e c t


o n

The Profession

Chapter 1
Who are Physical Therapists,
and What Do They Do?

Definition of Physical Therapy Scope of Practice Education and Qualifications Practice Settings
Home Health Care
School System
Private Practice

Plan of Care (POC)
Coordination of Care
Progression of Care
Discharge Plan


Coordination/Communication/ Documentation
APTA Guidelines for Documentation
Basic Principles of Clinical

Clinical Education of Students Models of Disablement The Five Elements of Patient/ Client Management
Patient History Observation Systems Review Tests and Measures Pain

Patient/Client-Related Instruction Procedural Interventions
Choosing an Intervention Strategy

Outcomes Discharge/Discontinuation of Intervention Prevention and Promotion of Health, Wellness, and Fitness Members of the Health Care Team
Physical Therapy Director
Staff Physical Therapist
Physical Therapist Assistant
Physical Therapy/Occupational
Therapy Aide





Physical Therapy and Physical Therapist Assistant Student Physical Therapy Volunteer Home Health Aide

Chapter 2 Administration
The United States Health Care System
Overview Cost Containment Increased Requirements and Justification The Funding of Health Care
Publicly Funded Plans

Certified Occupational Therapist Assistant Speech-Language Pathologist (Speech Therapist) Certified Orthotist Certified Prosthetist Respiratory Therapist Respiratory Therapy Technician Certified (CRRT) Primary Care Physician (PCP) Physician's Assistant (PA) Physiatrist Chiropractor Registered Nurse Rehabilitation (Vocational) Counselor Audiologist Athletic Trainer (ATC) Social Worker Massage Therapist Acupuncturist

Quality of Care
Current Concerns About Quality of Care

Budgets-Fiscal Responsibilities
The Operating Budget The Capital Budget Budget Calendar Zero-Base Budget

Accounts Payable
Accounts Receivable

Health Care Regulations
Fiscal Regulations Certificate of Need (CON) Regulations Patient Self-Determination Act of 1990

Risk Management
Measurement and Assessment Strategies

Quality Assurance/Quality

Quality Assurance (QA) Continuous Quality Improvement (CQI) Utilization Review Quality Regulations Health Professionals Regulation Health Insurance Regulation
Access-Related Insurance Regulations Americans with Disabilities Act

Program Development
Professional Standards

Guide for Professional Conduct of the Physical Therapist Interpreting Ethical Principles
Principle Principle Principle Principle Principle Principle Principle Principle Principle Principle Principle 1 2 3 4 5 6 7 8 9 1I) 11

Cost-Related Insurance

Voluntary Accreditation
Voluntary Accrediting Agencies
Joint Commission on Accreditation of Healthcare Organizations UCAHO) Accreditation Council for Services for Mentally Retarded and Other Developmentally Disabled Persons (AC-MRDD) Commission on Accreditation of Rehabi Iitation Faci Iities (CARF)

Standards of Practice for Physical Therapy and the Criteria
Preamble Legal/Ethical Considerations Administration of the Physical Therapy Service Patient/Client Management



Comprehensive Outpatient Rehabilitation Facility (CORF)

The Typical JCAHO Accreditation Process Health Care Insurance: Reimbursement
Private Health Insurance Industry
Private Health Insurance Managed Health Care Systems Health Maintenance Organizations (HMOs) Point-of-Service (POS) Plans Preferred Provider Organizations (PPOs) Point-of-Purchase Plans Primary Care Networks

Incident/Occurrence Reporting Sentinel Event Reporting Illegal Practice and Malpractice

Informed Consent
Statutory Laws
Licensure laws
Workers' Compensation Acts

Chapter 3 Research
Populations and Samples Variables and Types of Data Data Collection and Sampling Techniques Graphical Representation of Organized Data Data Description
Measures of Central Tendency Measures of Variation Measures of Position

Government Health Insurance
Medicare Medicaid Balanced Budget Act of 1997 (BBA) Health Care Financing Administration (HCFA)

Worker's Compensation Personal Payment and Free Care Consumer-Driven Health Care Programs Health Insurance and Portability Accountability Act (HIPAA)
HIPAA Privacy Rule
HIPAA Terminology

The Normal Distribution
Confidence Intervals

Confidence Intervals for the Mean Confidence Intervals for Variances and Standard Deviations

Hypothesis Testing
Type I Errors Type II Errors Significance Level Probability (p) Value The Power of a Hypothesis Test z-Test t-Test

Medical Records
Threats to Medical Record Privacy Current Protections

Personnel Supervision/ Management of the Department Management and Leadership Theories
Bass Theory of Leadership
Four-Framework Approach
Managerial Grid

Chi-Square and Analysis of Variance (ANOVA)
Analysis of Variance (ANOVA)
Analysis of Covariance (ANCOVA)
Intraclass Correlation Coefficient

Management Styles
Managers Versus Leaders

Meetings Job Descriptions Performance Appraisal
Rating Systems
Completing a Performance

Choosing the Correct Statistical Test

Research Design
Control Group
Experimental Group
Placebo Effect
Random Assignment

Staff Motivation Professional Growth Policy and Procedure Manuals Material Safety Data Sheet (MSDS)



Use of Evidence-Based Practice (EBP) Scientific Rigor by Type of Research Design Instrumentation-Gold Standard Sensitivity and Specificity Validity
Construct Val idity Face Validity Content Validity External Validity Internal Validity Criterion-Referenced Validity Prediction Value Likelihood Ratio

Muscle Tissue
Muscle Function Pathology of Muscle Joint Classification Arthrokinematics Osteoki nematics Degrees of Freedom Close-Packed and Open-Packed Positions of the Joint Capsular and Noncapsular Patterns of Restriction End-Feels Arc of Pain Measuring Range of Motion Grading Accessory Movements Hypomobility, Hypermobility, and Instabi Iity

Reliability Threats to Validity and Reliability
Chapter 4 Education
Maslow's Hierarchy of Needs
Learning Theories
Domains of Learning
Educational Activities Decision-Making Problem-Solving Sensory Motor Learn ing

Kinesiology General Principles of Biomechanics Directional Terms Movements of the Body Segments
Planes of the Body
Axes of the Body

Physiology Physiology of Exercise
Energy Systems Measures of Energy Expenditure

Learning Styles
Analytical Learner Intuitive/Global Learner Inductive Versus Reasoning: Deductive Reasonings Initiative: Active Versus Passive Learning

Body Mass Index (BM/) Bioelectrical Impedance Analysis The Metabolic Equivalent (MET) Nutrients
Vitamins and Minerals

Improving Compliance with Learning and Participation Community and Staff Education Using Visual Aids Cultural Influences

Nerve and Muscle Physiology
Resting Membrane Potential (RMP) Action Potential The Synapse Neurotransmitters The Neuromuscular Junction

Chapter 5 Fundamentals and Core Concepts
Tissues of the Body Epithelial tissue
Nervous Tissue
Connective Tissue

Connective Tissue Proper Tendons and Ligaments Bone Cartilage Tissue Bursae Connective Tissue Disorders

Thermoregu lation Conservation and Production
of Body Heat
The Immune System T-Lymphocytes
Organs of the Immune System
The Healing Process Wound Healing
Muscle Healing



Destruction Phase
Repair Phase
Remodeling Phase

Positron (PET) Emission Tomography

Ligament and Tendon Healing
Phase I: Hemorrhagic Phase II: Inflammatory Phase III: Proliferation Phase IV: Remodeling Maturation


Articular Cartilage Healing
Meniscal Healing

Extrinsic Pathway
Intrinsic Pathway

Bone Healing Imaging Studies Radiography
Conventional Radiography Stress Radiograph Contrast-Enhanced Radiography

Magnetic Resonance Imaging Diagnostic Ultrasound Radionucleotide Scanning Fluoroscopy Transcranial Magnetic Stimulation (TMS) Magnetoencephalography (MEG) Miscellaneous Information Standard and Transmission-Based Precautions The Intensive Care Unit Environment Airways Lines Miscellaneous Equipment

Who are Physical Therapists, and What Do They Do?

The Guide to Physical Therapist Practice referred to hereafter as The Guide was developed by tlle American Physical Ther"py Association (APTA) "to encourage a uniform approach to physical therapist practice
and to explain Lo the world the nature of thaL prnctice."l 'Ibe Guide is

divided into two parts:
~ ~

Part 1 delineates the physical therapist's scope of practice and
describes patient management by physical therapist. (PTs).
Part 2 describes each of the di>lgnostic preferred practice pat­
terns of patients typically treated by PTs.

The Guide defines physical therapy as follows:
Physical therapy includes diagnosis and management qf movement dys­
function and enhancement q(physical andfunctiona/ abilities; restora­
tion, maintenance, and promotion ofoptimal physicalfuncttotl, ('PUmal
fitness and weI/ness, and optimal quality of life as it relates 10 movement
and health: and pret!(mtion of the onset, symptoms, and pTORression of
impairments, fi~nctional limitations, and disabilities that may result

/rum dil>eases, disorders, conditif.J1/s, or injuries,

Physical therapy is defmed as the care and services provided by or
under the direction and snpervi'iion of a physical therapist.:l
~ ~

Physical therapbts are the only professionals who provide
physical therapy.
Physical fuerapist assistmt. (PTAs)-unUcr tlle direaion and super­

vision of the physical therapi....,t-are the only pamprofessionaL.,
who assL~ in the provision of physical theiJ.py interventions.




PTs are professionally educated at the college or university level and are required to be licensed in the state (or states) in which they prac­ tice. Education programs for the preparation of physical therapists have been recognized in some manner ~ince 1928, when the APTA Brst published a list of approved programs'>
~ ~


Study Pearl
and PTA education
sitional£IDd.:,r ~PhYsic;rl Jh

Graduates from 1926 to 1959 completed physical therapy cur­ ricula approved by appropriate accreditation bodies. Graduates from 19(";0 to the present have successfully com­ pleted professional physical therapist education programs accredited by the CommL.,sion on Accreditation in Physical Therdpy Education CCAPTE). CAPTE also makes autonomous decisions concerning the accreditation status of continuing education programs for the physical therapists and physical therapist assistants.

:programs, which arE! consi.

profeSsional Pro~aI]K. ••

The APTA house of delegates first authorized the education of physical therapist assistants at the 1%7 Annual Conference.

Physical therapists praCTice in a broad range of inpatient, outpatient, and conununity-based settings, including those described in the next sections and listed in Table 1-1.

Hospitals may be classified in a number of ways, including by,




Length of stay (short-term or long-term) Acute-<eare (short-term hospital): An acute-care hospital can be defined as a facility that provides hospital care to patients who generally require a stay of up to 7 days, and whose focus is on a physical or mental condition requiring immediate intervention and constant medical attention, equipment, and personnel. Following a stay in the acute-<:are hospital, the patient is typically discharged to home or to another he-dlth-care facility. Suhacute: Medical care is prOVided to patients who require more than 7 but less than '\0 days' stay in a hospital, and who have a more stable condition than those receiving acute care. Teaching or nonteaching. Teaching A hospital that serves as a teaching site for medicine, dentistry, allied health, nursing program<;, or medical residency programs. Nonteaching: A hospital that has no teaching responsibilities or one that serves as an elective site for health-relat{xJ. programs. Major types of services: general, or specialities such as psychi­ atric, tubef<..."Ulosis, maternity) pediatrk, and ear, nose and throat CENT) Type of ownership or control: federal, state, or local b"wemrnent; for-profit and nonprofit.









Secondary care

Tertiary care (tertiary healrh care)

Transitional care unit

Skilled nursing faciHty (SNF)

A ho...;;pital is <in institution whose primary function is [Q provide inpatient diagno...<;tic and thempeutic services for a wide variety of medical, surgical and nonsurgical conditions. In addition, mo..;;! hospitals provide some outpatient servkes, p'Jrticularly emergency care. ... Bask: or entry-level health care, which includes diagnostic, thempeutic, or preventive services. ... Care is proVided on an outpatient ha.5is by primary-care physicians, including family practice physicians, internists, and p<;::uiatricians. ... Services provided by medical specialists, such as cardiologists, urologists, and dennatologists, who generally do not have fIrs! contact with [he patients. ... This level of <-'are may require inpatient hospitalization or ambulatory same-day surgery. to- HigWy specialized care that is given to patients in a hospital setting who are in danger of dis<Jbility Or death (organ tnmsplants. major .'Ilurgical procedures). ... Services provided often require sophistkaLed tedmologies (e.g.. neurosurgeons or interu;ivc care units). ... Specialized care usually provided occ<fuse of <f referral from primary or secondary medical care personnel. ... Nonmedkally based facility, which may be in group horne Of part of a continuum of rehabilitation center. ... Typical stay is 4 to 8 months. ... Greater focus placed on compen'llation versus restoration. ... A free-standing facility, or part of a hospital, that is licensed and approved hy the state (Medicare certified), where eligible individuals receive skilled nursing care and appropriate rchahilitative and restorative services. ... Sometimes referred to as an e:r:tf?nded carefacility. ... Accepts p<Jtients in need of rehabilitation and medical care tilltt is of a lesser intensity than that received in the acute GUt" .serting of a hospital. .. Provides skilled nursing, rehabili~Hion. and various other health services on a daily basis. ... Medicare defines daily as seven days a week of skilled nursing care and t1ve days a week of skilled therapy. .. Physician orders must be rewritten every 60 cLys.

Refer to text.

The physical therapist serves a supportive role for the primary care teams: providt:s examination, evaluation, diagnoses, prognosis, and intervention for musculoskelecal and neuromuscular dysfunctions . Physical therapy involvement is minirI41l.

Physical therapy may be consulted on an as··needed basis.

Physk<Jl therapy emphasiS is on improVing functional skills for maximum independence to prepare a patit.'nl for community reentry or for tran.sfer to an a'llsisted-living/skilled nursing facility .

An SNF musl be able to provide 24-hour nursing

Acute rehabilitation facility

.. Usually based in a mcdic<JI sening ... Provides early rehahilitation, .social, and vocational services as SOOn as the patient is medically stable.

covef'"Jge, :md the availability of physical, occupational, and speech therapy. Minimum u:'Ha .'set (MDS): federal data collection system for as...'ie..."o.'>ing nursing home patients. .. The MDS for nursing facility residents is a comprehensive resideD[ assessment iru;uumenl (RAT) that measures functional scatus~ mental health status, and beilltvioml stalUS 10 identify chronic care patient needs and fomlaJize a care plan in response to 18 re'llident assessment protocols (RAPs). .. Under federal regulation, assessments arc conducted at a time of aJmjssion into a nursing facility, upon reUlm. from a 72-hollf hospital admission, whenever there is a significant change in status, 4uarterly, and annually. Physical therapist involved in the c-oordiruued services of medical, social, educational, vocational, and the other rehabilitative services (OT, speech).




Chronic care facility

Comprehensive outpatient rehahilitation
facility (CORF)

Custodial care facility

Hospice cut:'

... Primary emphasis is to provide intensive physiCll and cognitive restorative services in the early months to disabled persons to facilitate their return to maximum functional capacity. ... Typical stay is .'i to 4 months (short term). ... Long-tem1 care facility that is facility or commullit~r' based. ... Sometimes refcncd to 3-<; extended rehabilitation. ... Designed for patients with permanent or residual disabilities caused by a nonreversible pathologic health condition. Also L1sed for patients who demonstrate slower than expected progress. ... Used as a placement f:-lcili[y--60 days or longer, but not for permanent stays. ... CORPs must provide coordinated outpatient diagnostic, therapeutic, and restorath·'e senlices, at a Single fi..'C.ed loc'atiun, to outpatienrs for the rehabilitation of injunxl, tlisabled, or sick individuals. ... CORFs are surveyed every 6 years at a minimum. ... Provides medical or nonmedical serv"ices, which do not seek to cure but are necessary for patients who are unable to care for themselves. ... Provided during periods when the medical condition of the patient is not changing. ... Patient does not reqUire the continued a<.lminllitration of medical care by qualified medical personnel. ... This type of care is not lL'iually covered under managed-care plans. ... A facility or program that is licensed, certil1ed, or otherwise authorized by law, which provides supportive care for the terminally ill. ... Focuses on the physical, spiritual, emotional, psychological, financial, and legal neetls of the dying patient and the family. ... Services provided by an inrerdisciplinary team of professionals and perhaps volunteers in a variety of settings, including hospitals, free-standing facilities, and at home, ... Medicare and Medicaid require that at least 8a:Vo of hospice care is provided at home. Eligibility for reimbursement includes: Medicare eligibility.

The faciHty has a full range of rehabilitation
services (physical, occupational, and speech
therapy) available .

Physical therapy (~md occupational therapy and
speech-Iangu:lge pathology services) may he
provided in an off-site location.

Physical therdpy involvement is minimal.

Physical therapy may be consulted on an as-needed basis. Occupational therapy more commonly

Pl'csuna) care

Ambulatory care (outpatient care)

Certification of terminal illness (k~s than or equal to 6 months of life) by physician. ... Optional Medicaid benefit that allows a state to pro"ide services to assist func1ionally impaired individuals in performing the activities of daily living (e.g., bathing, dressing, feeding, grooming). ... Includes outpatient prevcmative, diagnostic, and treatment services that arc provided at medical offices, surgery centers, or outpatient clinics (induding private pmctice phy·sical therapy clinics, outpatient satellites of institutions or hospitals). ... Designed tor patients who do not require overnight hospitalization. ... More cost-effective than inpatiem care, and therefore favored by managed-care plans.

Physical therapy mlY be consulted on an as-needed lYJsi5.

Physical therapy may be consulted on an as-needed basis.



Home health care involves the provision of medical or health care by a Home Health Agency (HHA), which may be governmental, volun­ tary, or private; nonprofit or for-profit. Home care services were intro­ duced to reduce the need for hospitalization and its associated costs. An HHA provides part-time and intermittent skilled and nonskilled services and other therapeutic services on a visiting basis to persons of all ages in their homes. Patient eligibility includes:





Any patient who is homebound or who has great difficulty leav­ ing their home. A person may leave home for medical treatment or short infrequent nonmedical absences such as a religious serv­ ice. Medicaid waiver clients. The Medicaid Waiver for the Elderly and Disabled (E&D Waiver) program is designed to provide services to seniors and the disabled whose needs would other­ wise require them to live in a nursing home. The goal is for clients to retain their independence by providing services that allow them to live safely in their own homes and communities for as long as it is appropriate. A patient who requires skilled care from one of the following disciplines: nursing, physical therapy, occupational therapy, or speech therapy. Physician certification. In the case of an elderly patient, recertifi­ cation by Medicare is required every 62 days. Medicare only pays for skilled home health services that are proVided by a Medicare-certified agency. At the time of writing, Medicare defines intermittent as skilled nursing care needed or given on fewer than 7 days each week, or less than 8 hours per day over a period of 21 days (or less) with some exceptions in special circumstances. Patients who continue to demonstrate potential for progress.

The physical therapy focus includes:
~ ~


Environmental safety including adequate lighting, securing scatter rugs, handrails, wheelchair ramps, raised toilet seats. Early intervention (refer to the "School System" section). Addressing equipment needs: Equipment ordered in the hospital is reimbursable. Most adaptive equipment ordered in the home is not reim­ bursable. Exceptions include items such as wheelchairs, com­ modes, and hospital beds. Observing for any evidence of substance abuse or physical abuse:
Substance abuse should be reported immediately to the physician.
Physical abuse should be immediately communicated to the
proper authorities (varies from state to state).


The major goal of physical therapy intervention in the school is to enhance the child's level of function in the school setting.




The physical therapist serves as a consultant to teachers working with children with disabilities in the classroom. Recommendations are made for adaptive equipment to facilitate improved posture, head control, and function. Early Intervention Program (EIP). National program designed for infants and toddlers with disabilities and their families. EIP was created by Congress in 1986 under the Individuals with Disabilities Education Act (IDEA)-refer to Chapter 16. To be eligible for services, children must be under 3 years of age and have a confirmed disability or established developmental delay, as defmed by the state, in one or more of the following areas of development: physical, cognitive, communication, social-emo­ tional, and adaptive.

Therapeutic and support services include:
~ ~ ~

~ ~ ~




Family education and counseling, home visits, and parent sup­ port groups. Special instruction. Speech pathology and audiology. Occupational therapy. Physical therapy. PT can provide direct interventions within the classroom or other inclusion settings depending on the ElP. Psychological services. Service coordination. Nursing services. Nutrition services. Social work services. Vision services. Assistive technology devices and services.


Private practice settings are privately owned and free-standing independ­ ent physical therapy practices.

Practice settings vary from physical therapy and orthopedic clin­ ics, to rehabilitation agencies. Documentation is required for every visit (refer to Documen­ tation section later). Re-examinations are required by Medicare every 30 days.

The term clinical education refers to the supervised practice of pro­ fessional skills in a clinical setting. The purpose of clinical education is to provide student clinicians with opportunities to:
~ Observe and work with a variety of patients under professional

supervision and in diverse professional settings, and to inte­ grate knowledge and skills at progressively higher levels of per­ formance and responsibility.




Work in situations where they can practice interpersonal skills and develop characteristics essential to productive working relationships. Develop clinical reasoning skills and management skills, as well as master techniques that develop competence at the level of a beginning practitioner.

Clinical education is arranged by negotiation between the staff of the respective academic unit (Academic Coordinator of Clinical Education, or ACCE) and the director of the individual clinical setting (Center Coordinator of Clinical Education, or CCCE). In most cases, for­ mal agreements are signed between the academic institution and the placement facility.

Instruction and supervision of PT/PTA students are provided by clinical instructors during scheduled clinical education experiences. The clinical instructor (CO, in addition to carrying out specific roles within the department, performs the role of teacher, facili­ tator, coordinator, and professional role model, and evaluates the student on a regular basis. The nature of the assessment varies across academic institutions, but usually includes a stu­ dent evaluation by both the clinical instructor and the student; the satisfactory completion of a specified number of hours; and a variety of assignments including case studies, essays, and ver­ bal presentations. Students are expected to take an active responsibility for their own education by identifying their own learning needs, assist­ ing in the planning and implementation of the learning experi­ ences, being familiar with and adhering to procedures and rules of the academic institution and the affiliating center, and evalu­ ating their own performance.

Study Pearl

Study Pearl
Impairrhf.mt Loss or .abnormality of anatomic, physiologic, or psychologic stru r function. Not all impair. y physical ther­ ments apy' ents cause activity d participation res

A disablement model is designed to detail the functional consequences and relationships of disease, impairment, and functional limitations. The physical therapist's understanding of the process of disablement and the factors that affect its development is crucial to achieving the goal of restoring or improving function and redUcing disability in the indi­ vidual. Many disablement models have been proposed over the years (Table 1-2). The Guide to Physical Therapist Practice3 employs termino­ logy from the Nagi disablement model,4 but also describes its frame­ work as being consistent with other disablement models (the model Person with a Disability and the Rehabilitation Process [National Center for Medical Rehabilitation Research, National Institutes of Health, 1993]),5 In 2001 the Executive Board of the World Health Organization approved the International Classification of Functioning, Disability, and Health (ICF). The ICF emphasizes "components of health" rather than "consequences of disease" (i.e., participation rather than disability), and environmental and personal factors as important determinants of health. 6


level of
hysical action,






Disease The intrinsic pathology or disorder Impairment Loss or abnormality of psychological, physiologic, or anatomic structure or function Disability Restriction or lack of ability to perform an activity in a normal manner

PathologylPathophysiology Interruption or interference with normal processes and efforts of an organism to regain normal state Impairment Anatomic, physiologic, mental, or emotional abnormalities or loss

Pathophysiology Intenuption with normal physiologic developmental processes or structures Impairment Loss of cognitive, emotional, physiologic, or anatomic structure or function



Body Functions and Structure


Functional Umltation Limitation in performance at the level of the whole organism or person

Functional Umltation Abnormality of or restriction or lack of ability to perform an action in the manner or range consistent with the purpose of an organ or organ system

Activities Activity limitations can cause secondary impairments

Handicap Disadvantage or disability that limits or prevents fulfillment of a normal role (depends on age, sex, sociocultural factors for the person)

Disability Limitation in performance of socially defmed roles and tasks within a sociocultural and physical environment

Disability Limitation or inability in performing tasks, activities, and roles to levels expected within physical and social contexts

Participation Is context dependent (environmental and personal factors). Is one aspect of health-related quality of life

Functional Limitation ~ Physical function component, which includes basic activities of daily living (BADLs) and instrumental activities of daily living (IADLs) ~ Psychological compo­ nent, which includes the various cognitive, perceptual, and personality traits of a person ~ Social component, which involves the interaction of the person within a larger social context or strncture Disability

Societal Umitation Restriction attributed to social policy or barriers that limit fulftIlment of roles. Examples include lack of accessibility and funding

Contextual, Environmental Personal Factors

Data from World Health Organization: International Classification of Impairments, Disabilities, and Handicaps. Geneva, Switzerland, 1993 (IClDH).



The physical therapist integrates the five elements of patient/client man­ agement, which are: 1. Examination of the patient. 2. Evaluation of the data and identification of problems. 3. Determination of the diagnosis. 4. Determination of the prognosis and plan of care (POC). 5. Implementation of the POC (intervention).3

The examination is an ongoing process that begins with the patient referral or initial entry and continues throughout the course of rehabili­ tation. The process of examination includes gathering information from the chart, other caregivers, the patient, the patient's family, caretakers, and friends in order to identify and define the patient's problem(s).7 The examination consists of three components of equal importance: patient history, systems review, and tests and measures. 3 These com­ ponents are closely related in that they often occur concurrently. One further element, observation, occurs throughout.

Study Pearl

Patient History. The patient history (refer to Chapter 6) involves the information gathered from a review of the medical records and interviews with the patient, family members, caregiver, and other inter­ ested persons, about the patient's history and current functional and health status. s The patient history usually precedes the systems review (see Chapter 6) and the tests and measures components of the examina­ tion, but it may also occur concurrently. The medical record provides detailed reports from members of the health care team. Observation. Much can be learned from a thorough observation. Throughout the history, systems review, and tests and measures, col­ lective observations form the basis for diagnostic deductions. The observation includes, but is not limited to, an analysis of posture, struc­ tural alignment or deformity, scars, crepitus, color changes, swelling, muscle atrophy, and the presence of any asymmetry. Systems Review. The systems review (see Chapter 6) is a brief or limited examination that provides additional information about the general health (GH) and the continuum of patient/client care through­ out the lifespan.
The tests and measures portion of the examination involves the physical examination of the patient. The test and measures portion provides objective data to accurately determine the degree of specific function and dysfunction. s There are a number of rec­ ognized tests and measures that are commonly performed by PTs. However, not all are used every time-the physical examination may be modified based on the history and the systems review. The clinician should resist the temptation to gather excessive and extraneous data, as too much data can make clinical decision-making more difficult.

Study Pearl


Study Pearl

Tests and Measures.




Dyspnea (shortness of breath, breathlessness) Fatigue (weakness) Syncope Chest pain or discomfort Irregular heartbeat Cyanosis Intermittent claudication Pedal edema

There may be other reasons why the tests and measures must be mod­ ified. For example, the examination of an acutely injured patient dif­ fers greatly from that of a patient in less discomfort or distress, the examination will be affected by the cognitive status of a patient, and the examination of a child differs in some respects from that of an adult. The tests and measures for the various systems are described in the relevant chapters. Examples of those aspects not always included in the test and measures include basic biometric measurements and the taking of vital signs (Table 1-3; see also Chapter 11).

Anthropometries. Anthropometrics are measurable physiologic characteristics and include height and weight.
Height. Height is the anthropometric longitudinal growth of an individual. Weight. Weight is the anthropometric mass of an individual. A scale is

used to measure weight. Body mass index (BM!) is used to calculate the relationship between healthy height and weight and obesity or being ovetweight or undetweight (see Chapter 5).

Study Pearl

Pain. The assessment of pain is very important to the overall well­ ness of the patient. Clinically pain can be measured using a wide variety of different scales. For example, the FACES scale, which is a series of faces assigned a value from 0 (no pain at all, showing a nor­ mal happy face) to 5 (the worst pain ever experienced by the patient), can be used. There is also a visual analog scale from 0 to a maximum of 10.

Following the history, systems review, and the tests and measures, an evaluation is made based on an analysis and organization of the col­ lected data and information. 1O An evaluation is the level of judgment necessary to make sense of the fmdings in order to identify a relationship between th~ symptoms reported and the signs of disturbed function,u According to BOD P11-05-20-49 published by the APTA,12 the evalua­ tion includes the ability to: • Synthesize available data on a patient/client expressed in terms of the disablement model to include impairment, functional limitation, and disability participation restrictions. • Use available evidence in interpreting the examination fmdings. • Verbalize possible alternatives when interpreting the examina­ tion findings. • Cite the evidence (patient/client history, lab diagnostics, tests and measures, and scientific literature) to support a clinical decision. The evaluation process may also identify possible problems that require consultation with, or referral to, another provider. A number of frameworks have been applied to clinical practice over the past 2 decades for guiding clinical decision making. 13- 18 Although the early frame­ works were based on disablement models, the more recent models have focussed on enablement perspectives.



A physical therapy diagnosis, which includes a prioritization of the identified impairments, functional limitations, and disabilities, can only be made when all potential causes for the symptoms have been ruled out. In order to form a diagnosis, the clinician must be able to:


Integrate the examination findings to classify the patient/client problem in terms of a human movement dysfunction (i.e., prac­ tice pattern). Identify and prioritize impairments to determine a specific dys­ function toward which the intervention will be directed. 12

The physical therapy diagnosis is a label ascribed to a cluster of signs and symptoms. The patient can be placed in a diagnostic cate­ gory as well as in one or more of the practice patterns listed in the Guide to Physical Therapist Practice. Examples of preferred practice patterns are given in Table 1-4. Most of the time, these patterns do not occur in isolation, as a patient often presents with a mixture of signs and symptoms that indicate one or more possible problem areas. If more than one practice pattern is applicable, the therapist indicates which practice pattern is primary.

The prognosis is the predicted level of function that the patient will attain and an identification of the barriers that may impact the achieve­ ment of optimal improvement (age, medication(s), socioeconomic sta­ tus, comorbidities, cognitive status, nutrition, social support, and envi­ ronment) within a certain time frame. lO This prediction helps guide the intensity, duration, frequency, and type of intervention, in addition to providing justifications for the intervention. Factors used in determin­ ing the prognosis include knowledge of the severity of an injury, the age and physical and health status of a patient, and the healing processes of the various tissues involved.

The plan of care (POC), which outlines anticipated patient manage­ ment, involves the setting of goals, coordination of care, progression of care, and discharge. The POC:



Is based on the examination, evaluation, diagnosis, and prog­
nosis, including the predicted level of optimal improvement.
Includes statements that identify anticipated goals and the
expected outcomes. Describes the specific interventions to be used, and the pro­ posed frequency and duration of the interventions that is required to reach the anticipated goals and expected out­ comes. Includes documentation that is dated and appropriately authenti­ cated by the physical therapist who established the plan of care. Includes plans for discharge of the patient/client taking into consideration achievement of anticipated goals and expected outcomes, and provides for appropriate follow-up or referral,2





Musculoskeletal Pattern 4A Pattern 4B Pattern 4C Pattern 4D
Pattern 4E Pattern 4F Pattern 4G Pattern 4H Pattern 41 Pattern 4J

Primary prevention/risk factor reduction for skeletal demineralization Impaired posture Impaired muscle performance Impaired joint mobility, motor function, muscle performance, and range of motion associated with connective tissue dysfunction Impaired joint mObility, motor function, muscle performance, and range of motion associated with localized inflammation Impaired joint mObility, motor function, muscle performance, and range of motion, or reflex integrity secondary to spinal disorders Impaired joint mobility, motor function, muscle performance, and range of motion associated with fracture Impaired joint mobility, motor function, muscle performance, and range of motion associated with joint arthroplasty Impaired joint mobility, motor function, muscle performance, and range of motion associated with bony or soft tissue surgical procedures Impaired motor function, muscle performance, range of motion, gait, locomotion, and balance associated with amputation Primary prevention/risk reduction for loss of balance and falling Impaired neuromotor development Impaired motor function and sensory integrity associated with nonprogressive disorders of the central nervous system--congenital origin or acquired in infancy or childhood Impaired motor function and sensory integrity associated with nonprogressive disorders of the central nervous system-acquired in adolescence or adulthood Impaired motor function and sensory integrity associated with progressive disorders of the central nervous system Impaired peripheral nerve integrity and muscle performance associated with peripheral nerve injury Impaired motor function and sensory integrity associated with acute or chronic polyneuropathies Impaired motor function, peripheral nerve integrity, and sensory integrity associated with nonprogressive disorders of the spinal cord Impaired arousal, range of motion, and motor control associated with coma, near coma, and vegetative state

Neuromuscular Pattern 5A Pattern 58 Pattern 5C/D
Pattern 5D Pattern 5E Pattern 5F Pattern 5G Pattern SH Pattern 51

Cardiovascular/ Pulmonary Pattern 68 Pattern 6c
Pattern 6D Pattern 6E Pattern 6F Pattern 6H Integumentary Pattern 78 Pattern 7C Pattern 7D

Impaired aerobic capacity/endurance associated with deconditioning Impaired ventilation, respiration/gas exchange, and aerobic capacity/endurance associated with airway clearance dysfunction Impaired aerobic capacity endurance associated with cardiovascular pump dysfunction or failure Impaired ventilation and respiration/gas exchange associated with ventilatory pump dysfunction or failure Impaired ventilation and respiration/gas exchange associated with respiratory failure Impaired circulation and anthropometric dimensions associated with lymphatic system disorders Impaired integumentary integrity associated with superficial skin involvement Impaired integumentary integrity associated with partial-thickness skin involvement and scar formation Impaired integumentary integrity associated with full-thickness skin involvement and scar formation

Data from Guide to PbysicalTberapist Practice. Pbys Tber. 2001;81:513-595.



To design a POC, the clinician must:

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Write measurable functional goals Cshort- and long-term) that are time-referenced with expected outcomes. Consult patient/client and/or caregivers to develop a mutually agreed to plan of care. Identify patient/client goals and expectations. Identify indications for consultation with other profeSSionals. Make referral to resources needed by the patient/client. Select and prioritize the essential interventions that are safe and meet the specified functional goals and outcomes in the plan of care (identify precautions and contraindications, provide evi­ dence for patient-centered interventions that are identified and selected, define the specificity of the intervention Ctime, inten­ sity, duration, and frequency), and set realistic priorities that consider relative time duration in conjunction with family, care­ givers, and other health care professionals). Establish criteria for discharge based on patient goals and func­ tional statusY


rrladein tl1emearfutl..lre. Long-terlUgoals (LT indj(;ateho"YJg~~.i~

ates. / ShorFterrn goal$(ST~r~reused to indic~tewhat pr~~~~ss is.ro.M

veotiQnis. tobeterminat


Coordination of Care. The purpose of the coordination of
care 12 is to:
I. Identify who needs to collaborate in the plan of care. 2. Identify additional patient/client needs that are beyond the scope of physical therapist practice, level of experience and expertise, and warrant referral. 3. Refer and discuss coordination of care with other health care professionals. 4. Articulate a specific rational for a referral. 5. Advocate for patient/client access to services.

Progression of Care. The purpose of the progression of care12 is to:
1. Identify outcome measures of progress relative to when to progress the patient further. 2. Measure patient/client response to intervention. 3. Monitor patient/client response to intervention. 4. Modify elements of the plan of care and goals in response to changing patient/client status, as needed. 5. Make ongoing adjustments to interventions according to out­ comes including the physical and social enVironments, med­ ical therapeutic interventions, and biological factors. 6. Make accurate decisions regarding intensity and frequency when adjusting interventions in the plan of care.

Discharge Plan. The purpose of the discharge plan12 is to:
I. Re-examine the patient/client if not meeting established crite­

ria for discharge based on the plan of care. 2. Differentiate between discharge of the patient/client, discon­ tinuation of service, and transfer of care with re-evaluation. 3. Prepare needed resources for patient/client to ensure timely discharge, including follow-up care.



4. Include patient/client and family/caregiver as a partner in discharge planning. 5. Discontinue care when services are no longer indicated. 6. When services are still needed, seek resources and/or consult with others to identify alternative resources that may be available. 7. Determine the need for equipment and initiate requests to obtain.


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The Guide! defines an intervention as "the purposeful and skilled inter­ action of the physical therapist and the patient/client and, when appro­ priate, with other individuals involved in the patient/client care, using various physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis." A physical therapy intervention is most effectively addressed from a problem-oriented approach, based on the evaluation, the patient's functional needs, and mutually agreed-upon goals. lO The most suc­ cessful intervention programs are those that are custom designed from a blend of clinical experience and scientific data, with the level of improvement achieved related to goal-setting and the attainment of those goals. The various intervention categories are listed in Table A-I of the Appendix.

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Ie with diagnosed impair­ nat limitations. hoare not necessari Iy impairments or func­ limitations, but seek servkes for n or promotion of health, wetl­ ,5, and fitness. '

Coordination, communication, and documentation!2 may include the following:
A. Addressing reqUired functions: 1. Establish and maintain an ongoing collaborative process of

decision-making with patients/clients, families, or care­ givers prior to initiating care and throughout the provision of services. 2. Discern the need to perform mandatory communication and reporting (e.g., incident reports, patient advocacy, and abuse reporting). 3. Follow advance directives. B. Admission and discharge planning. C. Case management. D. Collaboration and coordination with agencies, including: 1. Home care agencies. 2. Equipment suppliers. 3. Schools. 4. Transportation agencies. 5. Payer groups. E. Communication across settings, including: 1. Case conferences. 2. Documentation. 3. Education plans. F. Cost-effective resource utilization.



G. Data collection, analysis, and reporting of: 1. Outcome data. 2. Peer review findings. 3. Record reviews. H. Documentation across settings, following APTA's Guidelines for Physical Therapy Documentation, including: 1. Elements of examination, evaluation, diagnosis, prognosis, and intervention. 2. Changes in impairments, functional limitations, and disabilities. 3. Changes in interventions. 4. Outcomes of intervention. 1. Interdisciplinary teamwork: 1. Patient/client family meetings. 2. Patient care rounds. 3. Case conferences. J. Referrals to other professionals or resources.

Documentation in health care includes any entry into the patient/client record. The SOAP (Subjective, Objective, Assessment, Plan) note format has traditionally been used to document the examination and inter­ vention process.
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Subjective: Information about the condition from patient or family member. Objective: Measurement a clinician obtains during the physical examination. Assessment: Analysis of problem including the long- and short­ term goals. Plan: A specific intervention plan for the identified problem.

More recently, the Patient/Client Management Model has been used by those clinicians familiar with the Guide to Physical Therapist Practice.7 The Patient/Client Management Model described in The Guide has the following components:
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History: Information gathered about the patient's history. Systems review: Information gathered from performing a brief examination or screening of the patient's major systems addressed by physical therapy. Also includes information gath­ ered about the patient's communication, affect, cognition, learning style, and education needs. Tests and measures: Results from specific tests and measures performed by the therapiSt. Diagnosis: Includes a discussion of the relationship of the patient's functional deficits to the patient's impairments and/or disability. The relevant practice pattern(s) may also be included, as well as a discussion of other health care profes­ sionals to which the therapist has referred the patient or believes the patient should be referred. Prognosis: Includes the predicted level of improvement that the patient will be able to achieve and the predicted amount of time to achieve that level of improvement. The prognosis




should also include the PT's professional opinion of the patient's rehabilitation potential. Plan of care: Includes the expected outcomes Clong-term goals), anticipated goals (short-term goals), and interventions, including an education plan for the patient or the patient's care­ givers or significant others.

The purposes of documentation are as follows:



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To document what the clinician does to manage the individual patient's case. Records examination findings, patient status, intervention provided, and the patient's response to treatment. This documentation, considered a legal document, becomes a part of the patient's medical record. To communicate with all other members of the health care team, which helps provide consistency among the services pro­ vided. This includes communication between the physical ther­ apist and the physical therapist assistant. To provide information to third-party payers, such as Medicare and other insurance companies who make decisions about reimbursement based on the quality and completeness of the physical therapy note. To help the physical therapist organize the thought processes involved in patient care. To be used for quality assurance and improvement purposes and for issues such as discharge planning. To serve as a source of data for quality assurance, peer and uti­ lization review, and research.7

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Students in PTorprA programs may Qocument when the record is addition­ aUyauthenticatedhy the PT or, when permissible by law, documentation by PTAst~dents may be authenticated

APIA Guidelines for Documentation. To help develop and improve the art and science of PT, including practice, education, and research, the APTA board of directors has approved a number of guidelines for PT documentation. It is recognized that these guidelines do not reflect all of the unique documentation requirements associated with the many specialty areas within the PT profession. Applicable for both handwritten and electronic documentation systems, these guide­ lines are intended as a foundation for the development of more specific documentation guidelines in clinical areas, while at the same time pro­ viding guidance for the PT profession across all practice settings. 10 The PTA or certified occupational therapy assistant (COTA) reads the initial documentation of the examination, evaluation, diagnosis, prognosis, anticipated outcomes and goals, and intervention plan, and is expected to follow the plan of care as outlined by the PT/OT in the initial patient note.7 After the patient has been seen by the PTA or COTA for a time (the time varies according to the policies of each facil­ ity or health care system and state law), the PTA or COTA must write a progress note documenting any changes in the patient's status that have occurred since the therapist's initial note was written.7 Also, after dis­ cussion with the PT/OT about the diagnosis and prognosis, expected outcomes, anticipated goals, and interventions, the assistant rewrites or responds to the previously written expected outcomes and documents the revised plan of care accordingly.7 In many facilities (according to the policies of each facility or health care system and state law), the



PT/OT then cosigns the assistant's notes, indicating agreement with what is documented?

Initial Examination/Evaluation. Documentation of the initial encounter is typically called the "initial examination," "initial evalua­ tion," or "initial examination/evaluation." The examination/evaluation is typically completed by the end of the first visit, but may require sev­ eral visits. Visit/Encounter. Documentation of a visit or encounter, often called a progress note or daily note, documents sequential implementation of the plan of care established by the physical therapist, including changes in patient/client status and variations and progressions of specific interven­ tions used. Also may include specific plans for the next visit or visits. Re-examination. Documentation of re-examination includes data from repeated or new examination elements and is provided to evaluate progress and to modify or redirect intervention. Discharge or Discontinuation Summary. Documentation is required follOWing conclusion of the current episode in the physical therapy intervention sequence, to summarize progression toward goals and discharge plans. Evaluation. Evaluation is a thought process that may not include for­ mal documentation. However, the evaluation process may lead to doc­ umentation of impairments, functional limitations, and disabilities using formats such as:
• A problem list. • A statement of assessment of key factors (e.g., cognitive factors, co­ morbidities, social support) influencing the patient/client status.

Diagnosis. Documentation of a diagnosis determined by the physical therapist may include impairment and functional limitations. Prognosis. Documentation of the prognosis is typically included in the plan of care. Visit/Encounter. Documentation of each visit/encounter shall include the following elements:
• Patient/client self-report (as appropriate). • Identification of specific interventions provided, including fre­ quency, intensity, and duration as appropriate. For example, "knee extension, three sets, ten repetitions, 10# weight," or "transfer training bed to chair with sliding board." • Equipment provided. • Changes in patient/client impairment, functional limitation, and disability status as they relate to the plan of care. • Response to interventions, including adverse reactions, if any. • Factors that modify frequency or intensity of intervention and progression goals, including patient/client adherence to patient/ client-related instructions.


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Communication/consultation with providers/patient/client/ family/significant other. Documentation to plan for ongoing provision of services for the next visit(s), suggested to include, but not be limited to, the interventions with objectives, progression parameters, and pre­ cautions if indicated.

Re-examination. Documentation of re-examination shall include the
following elements:

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Documentation of selected components of examination to update impairment, function, and/or disability status. Interpretation of fmdings and, when indicated, revision of goals. When indicated, revision of plan of care, as directly correlated with goals as documented.

Discharge/Discontinuation Summary. Documentation of discharge or discontinuation shall include the following elements:
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Current physicaVfunctional status. Degree of goals achieved and reasons for goals not being achieved. Discharge/discontinuation plan related to the continuing care. Examples include: • Home program. • Referrals for additional services. • Recommendations for follow-up physical therapy care. • Family and caregiver training. • Equipment provided.

Basic Principles of Clinical Documentation



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Never record falsely, exaggerate, guess at, or make up data.7 All documents must be legible and should be written in black or blue ink, typed and/or transcribed. Keep the information objective and clear. Each episode of treatment must be documented, and each entry must be dated and signed with first and last name and professional designation (PT, PTA). Professional license num­ ber may also be included, but is optional. The patient's name and ID number should be on each page. To avoid the potential for falsification, empty lines should not be left between one entry and another, nor should empty lines be left within a single entry. Avoid vague terminology. Information should be stated concisely. Abbreviations can help with brevity, but only medically approved abbreviations or symbols can be used. Incorrect spelling, grammar, and punctuation can be mislead­ ing. Any mistake should be crossed out with a single line through the error, initialed, and dated by the clinician. Correction fluid/tape or similar products should never be used to correct text in medical records.



Patient/client-related instruction may include instruction, education, and training of patients/clients and caregivers regarding:
1. Current condition (pathology/pathophysiology [disease, di<;order, or condition], impainnents, functional limitations, or disabilities). 2. Enhancement of performance. 3. Plan of care: Risk factors for pathology/pathophysiology (disease, disor­ der, or condition), impairments, functional limitations, or dis­ abilities. Preferred interventions, alternative interventions, and alterna­
tive modes of delivery.
Expected outcomes.
4. Health, wellness, and fitness programs (management of risk factors). 5. Transitions across settings.t 2

Patient/client-related management forms the cornerstone of every patient visit. During the physical therapy visits, the clinician and the patient work to alter the patient's perception of their functional capa­ bilities. Together, the patient and clinician discuss the parts of the patient's life that he or she can and cannot control and then consider how to improve those parts that can be changed. It is imperative that the clinician spends time educating patients as to their condition, so that they can fully understand the importance of their role in the rehabilitation process, and become educated consumers. The aim of patient educa­ tion is to create independence, not dependence, and to foster an atmos­ phere of learning in the clinic. Patient/client education in its broadest sense involves informing, educating, or training patients/ clients, fam­ ilies, significant others, and caregivers in order to promote and opti­ mize physical therapy services. to Failure to identify the relevance of the presented material will promote disinterest and decreased compliance. Instruction should be proVided across all settings for all patients/clients on promoting understanding of:
1. Current condition, impairments, functional limitations, and

disabilities. 2. Anticipated goals and expected outcomes, the plan of care, specific intervention elements, and self-management strategies. 3. The elements necessary for the smooth transition to home or an alternate setting, work, and community. 4. Individualized family service plans or individualized educa­ tion plans. 5. Safety awareness, and risk factor reduction and prevention.

Procedural interventions can be broadly classified into three main groups: • Restorative interventions: directed toward remediating or improving the patient's status in terms of impainnents, functional





limitations, and recovery of function. These strategies are particu­ larly applicable for treating secondary impairments that con­ tribute to functional limitations and that are likely to improve with treatment. For example, impaired lower extremity strength is associated with functional loss; strength training can improve gait. Compensatory interventions: directed toward promoting opti­ mal function using residual abilities. Examples include training patients with subtle left neglect to consciously attend to the left side of space, using a cane for patients with impaired balance control that persists despite intervention, and functional train­ ing for patients with complete spinal cord transection. Preventative interventions: direct to toward minimizing poten­ tial impairments, functional limitations, and disabilities and maintaining health. 8 ,17

Interventions are chosen on the basis of the data obtained, diagnosis, prognosis, anticipated goals, and expected outcomes. 8 The goal of improving functional ability must be foremost in the clinician's reasoning when determining the intervention strategy. When deciding which intervention strategy to use, the clinician must weigh:


The likelihood that the underlying impairments will improve (e.g., through natural recovery from the injury, through neural plasticity) versus the requirements for immediate functional recovery despite the underlying impairments. The contributions of risk factors: • Functional performance factors. • Demographic, social lifestyle, behavioral, psychological, and environmental factors . • Physiologic impairments. • Comorbidities. • Anatomic impairments.




The process of identifying meaningful, achievable functional goals should be a collaborative effort between the clinician and the patient, the patient's family, or the patient's significant other. 1O To identify func­ tional goals, Randall and McEwen 19 recommend the following steps:
1. Determine the patient's desired outcome of the intervention. 2. Develop an understanding of the patient's self-care, work, and leisure activities and the environments in which these activi­ ties occur. 3. Establish goals with the patient that relate to the desired out­ comes (Table 1-5),19

1. If you were to concentrate your energies on

one thing for yourself, what would it be?
2. What activities do you need help with that

you would rather perform yourself? 3. What are your concerns about returning to work, home, school, or leisure activities? 4. What about your current situation would you like to be different in about 6 months? What would you like to be the same?
Data from Randall KE, McEwen IR. Writing patient­ centered goals. Phys 1ber. 2000;80:I197-1203, and Winton PJ, Bailey DB. Communicating with families: examining practices and facilitating change. In: Simeonsson JP, Simeonsson RJ, eds. Children with Special Needs: Family, Culture, and Society. Orlando: Harcourt Brace Jovanovich; 1993.

Once the goals have been agreed upon, the clinician must write the goals so that they contain the following elements:
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Who (the patient).
Will do what (activities).
Under what conditions (the home or work environment),



How well (the amount of assistance, or number of attempts required for successful completion). By when (target date).19,20

The last step12 is ongoing and involves continuous re-examination of the patient and a determination of the efficacy of treatment. 8
1. Summarize re-examination fmdings and evaluation of the patient's

abilities in terms of the anticipated goals and expected outcomes set forth in the POe. 2. Make determination as to whether the goals and outcomes are reasonable given the patient's diagnosis and progress made. If the patient attains the desired level of competence for the stated goals, revisions in the POC are indicated. If the patient attains the desired level of competence for the expected outcomes, discharge is considered. If the patient progresses more rapidly or slowly than expected, revisions in the POC are indicated. If the patient fails to achieve the stated goals or outcomes, the therapist must determine why. For example, were the goals and outcomes realistic given the database? Were the interven­ tions selected at an appropriate level to challenge the patient? Were any intervening and constraining factors identified?

Discharge planning, which is initiated dUring the data-collection phase, is the process of ending physical therapy services that have been pro­ vided during a single episode of care, when the anticipated goals and expected outcomes have been achieved. 2 Components of an effective discharge plan include:

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Patient, family, or caregiver education.
Plans for appropriate follow-up care or referral to another agency.
Instruction in a home exercise plan (HEP).
Evaluation and modification of the home environment to assist
the patient returning home. 8

Discontinuation may occur for any of the following reasons:
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The patient/client, caregiver, or legal guardian declines to con­ tinue intervention. The patient/client is unable to continue to progress toward anticipated goals and expected outcomes because of medical or psychosocial complications or because financiaVinsurance resources have been exhausted. The physical therapist determines that the patient/client will no longer benefit from physical therapy. 2



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Primary-Prevention of disease in a susceptible or potentially susceptible population through specific measures such as gen­ eral health promotion offers. 1 Secondary-Efforts to decrease duration of illness, severity of disease, and sequelae through early diagnosis and prompt intervention. 1 Tertiary-Efforts to decrease the degree of disability and promote rehabilitation and restoration of function in patients with chronic and irreversible diseases. 1


The director of physical therapy is typically a physical therapist who has demonstrated qualifications based on education and experience in the field of physical therapy and who has accepted additional admin­ istrative responsibilities. lO The director of a physical therapy depart­ ment must:



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Establish guidelines and procedures that delineate the func­ tions and responsibilities of all levels of physical therapy per­ sonnel in the service and the supervisory relationships inher­ ent to the functions of the service and the organization (see Chapter 2).10 Ensure that the objectives of the service are efficiently and effectively achieved within the framework of the stated pur­ pose of the organization and in accordance with safe physical therapist practice. Interpret administrative policies.
Act as a liaison between line staff and administration.
Foster the professional growth of the staff.


The Commission on Accreditation in Physical Therapy Education (CAPTE) serves the public by establishing and applying standards that assure quality and continuous improvement in the entry-level prepara­ tion of physical therapists and physical therapist assistants. All states require physical therapists to obtain a license to practice.


A physical therapist assistant (PTA) works under the supervision of a physical therapist. Care provided by a PTA may include teaching patients/clients exercise for mobility, strength, and coordination; train­ ing for activities such as walking with crutches, canes, or walkers; and the use of adjunctive interventions (see Chapter 18). A PTA may mod­ ify an intervention only in accordance with changes in patient status



and within the established plan of care developed by the physical therapist (see "Professional Standards" section in this chapter). Typically, a PTA has an associates degree from an accredited PTA program and is licensed, certified, or registered in most states.


Physical therapy aides are considered support personnel who may be involved in support services. Physical therapy aides receive on-the-job training under the on-site direction and supervision of a physical ther­ apist or in some cases a physical therapist assistant. The duties of a physical therapist aide are limited to those methods and techniques that do not require clinical decision making or clinical problem solving by a physical therapist or a physical therapist assistant.


The PT or PTA student can perform duties commensurate with their level of education. The PT clinical instructor (el) is responsible for all actions and duties of the affiliating student, and can supervise both physical therapy and physical therapist assistant students (a PTA may only supervise a PTA student-not a PT student).

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within theirrigntstorefoseetreafment by astuoont practitioner..


A volunteer is usually a member of the community who has an interest in assisting physical therapists with departmental activities. Responsibilities of a volunteer include:
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Taking phone messages. Basic nonclinicaVsecretarial duties.

Volunteers may not provide or setup patient treatment, transfer patients, clean whirlpools, or maintain equipment.


Home health aides provide health-related services to the elderly, dis­ abled, and ill in their homes. Their duties include performing house­ keeping tasks, assisting with ambulation or transfers, and promoting personal hygiene. The registered nurse, physical therapist, or social worker caring for the patient may assign specific duties to, and super­ vise, the home health aide.


Occupational therapists (OTs) assess function in activities of every­ day liVing, including dressing, bathing, grooming, meal preparation, writing, and driVing, which are essential for independent living. In making treatment recommendations, the OT addresses a number of fac­ tors including, but not limited to, (1) fatigue management; (2) upper



body strength, movement, and coordination; (3) adaptations to the home and work environment, including both structural changes and special­ ized equipment for particular activities; and (4) compensatory strate­ gies for impairments in thinking, sensation, or vision. The minimum educational requirements for the registered occupational therapist are described in the current Essentials and Guidelines of an Accredited Educational Program for the Occupational 1berapist. 21 All states require an OT to obtain a license to practice.


A certified occupational therapy assistant (COTA) works under the direction of an occupational therapist. COTAs perform a variety of rehabilitative activities and exercises as outlined in an established treat­ ment plan. The minimum educational requirements for the COTA are described in the current Essentials and Guidelines of an Accredited Educational Program for the Occupational1berapy Assistant. 22


A speech-language pathologist evaluates speech, language, cognitive­ communication, and swallowing skills of children and adults. Speech­ language pathologists are required to possess a masters degree or equivalent. The vast majority of states also require speech language pathologists to obtain a license to practice.


Certified orthotists (CO) design, fabricate, and fit orthoses (braces, splints, collars, corsets) prescribed by physicians for patients with dis­ abling conditions of the limbs and spine. A CO must have successfully completed the examination by the American Orthotist and Prosthetic Association.

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A certified prosthetist (CP) designs, fabricates, and fits prostheses for patients with partial or total absence of a limb. A CP must have suc­ cessfully completed the examination by the American Orthotist and Prosthetic Association.


Respiratory therapists evaluate, treat, and care for patients with breath­ ing disorders. The vast majority of respiratory therapists are employed in hospitals. Patient care activities include performing bronchial drainage techniques, measuring lung capacities, administering oxygen and aerosols, and analyzing oxygen and carbon dioxide concentra­ tions. Education programs for respiratory therapists are offered by hos­ pitals, colleges and universities, vocational-technical institutes, and the military. Most states require a respiratory therapist to obtain a license to practice.




A respiratory therapy technician certified (CRRT) is a skilled technician who:



Holds an associates degree from a 2-year trammg program accredited by the Committee in Allied Health Education and Accreditation. Has passed a national examination to become registered. Administers respiratory therapy as prescribed and supervised by a physician, including: • Pulmonary function tests. • Treatments consisting of oxygen delivery, aerosols, and nebulizers. • Maintenance of all respiratory equipment.


A primary care physician (PCP) is a practitioner, usually an internist, general practitioner, or family medicine physician, providing primary care services and managing routine health care needs. Most PCPs serve as gatekeepers for the managed-care health organizations, providing authorization for referrals to other specialty physicians or services, including physical therapy.

A physicion's assistant (PA) is a medically trained professional who can provide many of the health care services traditionally performed by a physician, such as taking medical histories and doing physical exami­ nations, making a diagnosis, and prescribing and administering thera­ pies (see also "Registered Nurse,").

A physiatrist is a physician specializing in physical medicine and reha­ bilitation, who has been certified by the American Board of Physical Medicine and Rehabilitation. The primary role of the physiatrist is to diagnose and treat patients with disabilities involving musculoskeletal, neurological, cardiovascular, or other body systems.

A chiropractor (DC) is a doctor trained in the science, art, and philosophy of chiropractic. A chiropractic evaluation and treatment is directed at providing a structural analysis of the musculoskeletal and neurologic systems of the body. According to chiropractic doctrine, abnormal function of these two systems may affect function of other systems in the body. In order to practice, chiropractors are usually licensed by a state board. Patients may see a chiropractor and physical therapist at the same time.
An individual who is licensed by the state to provide nursing services

after completing a course of study that results in a baccalaureate degree



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and who has been legally authorized or registered to practice as a reg­ istered nurse eRN) and use the RN designation after passing examina­ tion by a state board of nurse examiners or similar state authority. A registered nurse may:
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Make referrals to other services under a physician's direction. Supervise other levels of nursing care. Administer medication, but cannot change drug dosages. Communicate to the supervising physician any change in the patient's medical or social condition.

Rehabilitation counselors help people deal with the personal, physical, mental, social, and vocational effects of disabilities resulting from birth defects, illness or disease, accidents, or the stress of daily life. The role of the rehabilitation counselor includes:
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An evaluatation of the strengths and limitations of individuals.


Providing personal and vocational counseling. Arranging for medical care, vocational training, and job placement.

Rehabilitation counselors interview both individuals with disabilities and their families, and confer and plan with physicians, psychologists, occupational and physical therapists, and employers to determine the capabilities and skills of the individual. Conferring with the client, they develop a rehabilitation program that often includes training to help the person develop job skills and to increase the client's capacity to live independently.

Audiologists evaluate and treat individuals of all ages with the symp­ toms of hearing loss and other auditory, balance, and related sensory and neural problems.

The certified athletic trainer is a professional specialiZing in athletic health care. In cooperation with the physician and other allied health personnel, the athletic trainer functions as an integral member of the athletic health care team in secondary schools, colleges and universi­ ties, sports medicine clinics, professional sports programs, and other athletic health care settings. Certified athletic trainers have, at minimum, a bachelor's degree, usu­ ally in athletic training, health, physical education, or exercise science.

The role of the social worker is to offer a broad range of services from emotional support to referrals for community resources that can assist in enhancing adaptation to acute, chronic, and terminal conditions. Social workers may intervene by providing individual, couple, or family counseling, offering group education or support, and by working with



community groups in the development of resources to assist patients in meeting their own needs. A bachelor's degree is often the mini­ mum requirement to qualify for employment as a social worker; how­ ever, in the health field, the master's degree is often required. All states have licensing, certification, or registration requirements for social workers.

Massage therapy is a regulated health profession with a growing num­ ber of states and provinces now requiring a license. Registered mas­ sage therapists must uphold specific standards of practice and codes of ethics in order to hold a valid license. In order to become a licensed or registered massage therapist, most states and provinces require the applicant to pass specific government board examinations, which con­ sist of a written and a practical portion.

An acupuncturist treats symptoms by inserting very fme needles, some­

times in conjunction with an electrical stimulus, into the body's surface to, theoretically, influence the body's physiologic functioning. Typical sessions last between 30 minutes and an hour. At the end of the session, the acupuncturist may prescribe herbal therapies for the patient to use at home. Some acupuncturists work alone, while others work as part of a larger team of health care profeSSionals. At the time of writing, 32 states and the District of Columbia use the National Certification Commission for Acupuncture and Oriental Medicine (NCCAOM) certification as the main examination criteria for licensure, which takes 3 to 4 years to achieve. Each state may also choose to set additional eligibility criteria (usually additional academic or clinical hours). A small number of states have additional jurispru­ dence or practical examination requirements such as passing the CNT (clean needle technique) exam.

In general, risk management refers to the process of measuring or assessing risk and then developing strategies to manage that risk.

Traditional risk management focuses on risks stemming from physical or legal causes (e.g., natural disasters or fires, accidents, death, and lawsuits). Ideally, risk management involves a process of prioritiza­ tion that initially identifies those risks with the greatest potential for loss (patient or employee injury, property damage) and the greatest probability of occurring, followed by the identification of those risks with lower probability of occurrence and lower loss. Types of risk include:
~ ~

Knowledge risk: occurs when deficient knowledge is applied. Relationship risk: occurs when collaboration ineffectiveness occurs.



.. Process-engagement risk: occurs when operational ineffective­ ness occurs. The level of risk can be significantly reduced by the following: .. Scheduling regular (biannual) equipment inspections and maintenance. .. Safety training for staff in the use and care of the equipment. .. Creating and adhering to policies and procedures addressing the cleaning and maintenance of exercise equipment, whirlpool cleaning, treatment table cleaning, and spill procedures. .. Review of incident reports. .. The prompt identification of risk factors in patient care. .. Annual certification/recertification of staff in cardiopulmonary resuscitation.

In general, tile strategies employed to address risk include the following: .. .. .. .. Transferring the risk to another party (insurance policies).
Avoiding the risk.
Reducing the negative effect of the risk.
Accepting some or all of the consequences of a particular risk.

Program development is a systematic process, based on the results from a needs assessment, to plan, execute, and carry out an evaluation of a program. Programs are designed to meet the needs of a specific population or group. Program development can be broken down into four phases: 1. Needs assessment. A needs assessment can be used to deter­ mine how well a department is currently meeting the needs of the community and the types of resources and services it can provide in the future. A needs assessment can be in the form of a survey, community forum, or analysis of social indicators. Information can also be gathered by interviewing key inform­ ants. Key informants of the community are people who hold socially responsible positions (such as educators, public offi­ cials, and business representatives), or are active in commu­ nity events. To complete the needs assessment process, a determination must be made as to who will conduct the study, what kind of information needs to be collected (physical, social, cultural, and economic factors of the community), what is the target audience (demographics, perceived needs, real needs), how the information will be collected, and how the information will be used. 2. Program planning. In order to make use of the information collected, the results have to be interpreted. To interpret the data, some statistical analyses are often applied to identify what the majority of the community feels are tile most impor­ tant needs. An important feature of the results should be a



reflection of whether the current goals of the department are meeting the needs of the community. When the data analysis is complete, it should be possible to produce a rank-ordered list of the most important changes identified by the commu­ nity, which can be used to set budget priorities and to deter­ mine whether the program is viable. 3. Program implementation. At the end of the planning process, a time-frame should be set for implementation. At this stage, it is a gcxxi idea to share the plans with the community or target population. 4. Program evaluation. During this phase, a determination is made as to whether the program should be continued, modi­ fied, or discontinued.

The Guide for Profe:ssional Conduct was issued by the Ethics and Judicial Committee of the American Physical Therapy Association in 1981 and last amended in January 2004. The Guide lO is intended to serve the physical therapist in interpreting the code of ethics of the American Physical Therapy Association in matters of professional conduct. The Code and The Guide apply to all physical therapists.

INTERPRETING ETHICAL PRINCIPLES The interpretations expressed in The Guide reflect the opinions, deci­ sions, and advice of the Ethics and Judicial Committee. The interpreta­ tions are intended to assist a physical therapist in applying general eth­ ical principles to specific situations. They should not be considered inclusive of all situations that could evolve.

Principle 1. A physical therapist shall respect the rights and dignity of all individuals and shall provide compassionate care.
A. A physical therapist shall recognize individual differences and shall respect and be responsive to those differences. B. A physical therapist shall be guided by concern for the physi­ cal, psychological, and socioeconomic welfare of patients/ clients. C. A physical therapist shall not harass, abuse, or discriminate against others.

Principle 2. A physical therapist shall act in a trustworthy manner toward patients/clients, and in all other aspects of physical therapy practice.
2.1. Patient/Physical Therapist Relationship
A. To act in a trustworthy manner the physical therapist shall act

in the patient/client's best interest. Working in the patient/ client's best interest requires knowledge of the patient/client's



needs from the patient/client's perspective. Patients/clients often come to the physical therapist in a vulnerable state and will rely only on the physical therapists advice, which they per­ ceive to be based on superior knowledge, skill, and experi­ ence. The trustworthy physical therapist acts to ameliorate the patient's/client's vulnerability, not to exploit it. B. A physical therapist shall not exploit any aspect of the physical therapist-patient relationship. C. A physical therapist shall not engage in any sexual relationship or activity, whether consensual or nonconsensual, with any patient while the physical therapist-patient relationship exists. D. The physical therapist shall encourage an open and collabora­ tive dialogue with the patient!client. E. In the event the physical therapist or patient terminates the phys­ ical therapist-patient relationship while the patient continues to need physical therapy services, the physical therapist should take steps to transfer the care of the patient to another provider. 2.2. Truthfulness. A physical therapist shall not make statements that he or she knows or should know are false, deceptive, fraudulent, or unfair. See Section 8.2.C and D. 2.3. Confidential Information A. Information relating to the physical therapist-patient relation­ ship is confidential and may not be communicated to a third party not involved in that patient's care without the prior con­ sent of the patient, subject to applicable law. B. Information derived from peer review shall be held confiden­ tial by the review unless the physical therapist who was reviewed consents to the release of the information. C. A physical therapist may disclose information to appropriate authorities when it is necessary to protect the welfare of an individual or the community or when required by law. Such disclosure shall be in accordance with applicable law. 2.4. Patient Autonomy and Consent A. A physical therapist shall respect the patient/client's right to make decisions regarding the recommended plan of care, including consent, modification, or refusal. B. A physical therapist shall communicate to the patient/client the findings of his or her examination, evaluation, diagnosis, and prognosis. C. A physical therapist shall collaborate with the patient/client to establish the goals of treatment and the plan of care. D. A physical therapist shall use sound professional judgment in informing the patient/client of any substantial risks of the rec­ ommended examination and intervention. E. A physical therapist shall not restrict patients' freedom to select their provider of physical therapy.

Principle 3. A physical therapist shall comply with rules and reg­ ulations governing physical therapy and shall strive to effect changes that benefit patients/clients.



3.1. Professional Practice. A physical therapist shall comply with
laws governing the qualifications, functions, and duties of a physical therapist.

3.2. Just Laws and Regulations. A physical therapist shall abdi­
cate the adoption of rules, regulations, and policies by providers, employers, third-party payers, legislatures, and regulatory agencies to provide and improve access to necessary health care services for all individuals.

3.3. Unjust Laws and Regulations. Next, a physical therapist shall
endeavor to change unjust laws, regulations, and policies that govern the practice of physical therapy. See Section 10.2.

Principle 4.

A physical therapist shall exercise sound professional

4.1. Professional Responsibility
A. A physical therapist shall make professional judgments that are

in the patient/client's best interests. B. Regardless of practice setting, a physical therapist has primary responsibility for the physical therapy care of the patient and shall make independent judgments regarding that care consis­ tent with accepted professional standards. See Section 2.4. C. A physical therapist shall not provide physical therapy services to a patient/client while his or her ability to do so safely is impaired. D. A physical therapist shall exercise sound professional judgment based upon his or her knowledge, skill, education, training, and experience. E. Upon accepting a patient/client for physical therapy services, a physical therapist shall be responsible for the examination, evaluation, and diagnosis of that individual; the prognosis and intervention; re-examination and modification of the plan of care; and the maintenance of adequate records, including progress reports. A physical therapist shall establish the plan of care and shall prOVide and/or supervise and direct the appro­ priate interventions. See Section 2.4 and 6.1. F. If the diagnostic process reveals fmdings that are outside the scope of the physical therapist's knowledge, experience, or expertise, the physical therapist shall so inform the patient/ client and refer to an appropriate practitioner. G. When the patient has been referred from another practitioner, the physical therapist shall communicate the findings and/or information to the referring practitioner. H. A physical therapist shall determine when a patient/client will no longer benefit from phYSical therapy services. See Section 7.1.D.

4.2. Direction and Supervision
A. The supervising physical therapist has primary responsibility

for the physical therapy care rendered to a patient/client. B. A physical therapist shall not delegate to a less qualified person any activity that requires the unique skill, knowledge, and judg­ ment of the physical therapist.



4.3. Practice Arrangements A. Participation in a business, partnership, corporation, or other entity does not exempt physical therapists, whether employers, partners, or stockholders, either individually or collectively, from the obligation to promote, maintain, and comply with the ethical principles of the Association. B. A physical therapist shall advise his/her employer (s) of any employer practice that causes a physical therapist to be in con­ flict with the ethical principles of the American Physical Therapy Association. A physical therapist shall seek to elimi­ nate aspects of his or her employment that are in conflict with the ethical principles of the Association. 4.4. Gifts and other Considerations A. A physical therapist shall not invite, or accept, gifts, monetary incentives, or other considerations that affect or give an appear­ ance of affecting his or her professional judgment. B. A physical therapist shall not offer or accept kickbacks in exchange for patient referrals. See Sections 7.1.F and G and 9.1.D.

Principle 5. A physical therapist shall achieve and maintain pro­ fessional competence.
5.1. Scope of Competence. A physical therapist shall practice within the scope of his or her competence and commensurate with his or her level of education, training, and experience. 5.2. Self-assessment. A physical therapist has a lifelong professional responsibility for maintaining competence through ongoing self-assess­ ment, education, and enhancement of knowledge and skills. 5.3. Professional Development. A physical therapist shall partici­ pate in educational activities to enhance his or her basic knowledge and skills. See Section 6.1.

Principle 6. A physical therapist shall maintain and promote high standards for physical therapy practice, education, and research.
6.1. Professional Standards. A physical therapist's practice shall be consistent with accepted professional standards. A physical therapist shall continuously engage in assessment activities to determine com­ pliance with the standards. 6.2. Practice A. A physical therapist shall achieve and maintain professional competence. See Section 5. B. A physical therapist shall demonstrate his or her commitment to quality improvement by engaging in peer and utilization review and other self-assessment activities. 6.3. Professional Education A. A physical therapist shall support high-quality education in academic and clinical settings.



B. A physical therapist participating in the educational process is responsible to the students, the academic institutions, and the clinical settings for promoting ethical conduct. A physical ther­ apist shall model ethical behavior and provide student with information about the Code of Ethics, opportunities to discuss ethical conflicts, and procedures for reporting unresolved ethical conflicts. See Section 9.

6.4. Continuing Education
A. A physical therapist providing continuing education must be

competent in the content area. B. When a physical therapist provides continuing education, he or she shall ensure that the course content, objectives, faculty credentials, and responsibilities of the instructional staff are accurately stated in the promotional and instructional course materials. C. A physical therapist shall evaluate the efficacy and effectiveness of information and techniques presented in continuing educa­ tion programs before integrating them into his or her practice.

6.5. Research
A. A physical therapist participating in research shall abide byeth­ ical standards governing protection of human subjects and dis­ semination of results. B. A physical therapist shall support research activities that con­ tribute knowledge for improved patient care. C. A physical therapist shall report to appropriate authorities any acts in the conduct or presentation of research that appear unethical or illegal. See Section 9.

Principle 7. A physical therapist shall seek only such remunera­ tion as is deserved and reasonable for physical therapy services.
7. 1. Business and Employment Practices
A. A physical therapist's business/employment practices shall be consistent with the ethical principles of the Association. B. A physical therapist shall never place his or her own financial interests above the welfare of individuals under his or her care. C. A physical therapist shall recognize that third-party payer con­ tracts may limit, in one form or another, the provision of phys­ ical therapy services. Third-party limitations do not absolve the physical therapist from making sound professional judgments that are in the patient's best interest. A physical therapist shall avoid underutilization of physical therapy services. D. When a physical therapist judgment is that the patient will receive negligible benefit from physical therapy services, the physical therapist shall not provide or continue to proVide such services if the primary reason for doing so is to further the financial self-interest of the physical therapist or his or her employer. E. Fees for physical therapy services should be reasonable for the service performed, considering the setting in which it is pro­ vided, practice costs in the geographic area, judgment of other organizations, and other relevant factors.



F. A physical therapist shall not directly or indirectly request,

receive, or participate in the dividing, transferring, assigning, or rebating of an unearned fee. See Sections 4.4.A and B. G. A physical therapist shall not profit by means of credit or other valuable consideration, such as unearned commission, dis­ count, or gratuity, in connection with the furnishing of physical therapy services. See Sections 4.4.A and B. H. Unless laws impose restrictions to the contrary, physical thera­ pists who provide physical therapy within a business entity may pool fees and monies received. Physical therapists may divide or apportion these fees and monies in accordance with the business agreement. 1. A physical therapist may enter into agreements with organiza­ tions to provide physical therapy services if such agreements do not violate the ethical principles of the Association or appli­ cable laws.

7.2. Endorsement of Products or Services
A. A physical therapist should not exert influence on individuals under his or her care or their families to use products or serv­ ices based on the direct or indirect financial interest of the physical therapist in such products or services. Realizing that these individuals will normally rely on the physical therapist's advice, their best interest must always be maintained, as must their right of free choice relating to the use of any product or service. Although it cannot be considered unethical for a phys­ ical therapist to have a financial interest in the production, sale, or distribution of products/services, they must act in accor­ dance with law and make full disclosure of the interest when­ ever individuals under their care use such products/services. B. A physical therapist may receive remuneration for endorsement or advertisement of products or services to the public, physical therapists, or other health care professionals provided he or she discloses any fmancial interest in the production, sale, or distri­ bution of said products or services. C. When endorsing all advertising products or services, a physical therapist shall use sound professional judgment and shall not give the appearance of Association endorsement unless the Association has formally endorsed the products or services.

7.3. Disclosure. A physical therapist shall disclose to the patient if
the referring practitioner derives compensation from the provision of physical therapy.

Principle 8. A physical therapist shall provide and make available accurate and relevant information to patients/clients about their care and to the public about physical therapy services.
8.1. Accurate and Relevant Information to the Patient
A. A physical therapist shall provide the patient!client information about his or her condition and plan of care. See Section 2.4. B. Upon the request of the patient, the physical therapist shall pro­ vide, or make available, the medical records to the patient or a patient designated third party.

C. A physical therapist shall inform patients of any known finan­


cial limitations that may affect their care. D. A physical therapist shall inform the patient when, in his or her judgment, the patient will receive negligible benefit from fur­ ther care. See Section 7.1.C

8.2. Accurate and Relevant Information to the Public
A. A physical therapist shall inform the public about the societal

benefits of the profession and who is qualified to provide physi­ cal therapy services. B. Information given to the public shall emphasize that individual problems cannot be treated without individualized examina­ tion and plans/programs of care. C. A physical therapist may advertise his or her services to the public. See Section 2.2. D. A physical therapist shall not use, or participate in the use of, any form of communication containing a false, plagiarized, fraudulent, deceptive, unfair, or sensational statement or claim. See Section 2.2. E. A physical therapist who places a paid advertisement shall identify it as such unless it is apparent from the context that it is a paid advertisement.

Principle 9. A physical therapist shall protect the public and the profession from unethical, incompetent, and illegal acts.
9.1. Consumer Protection
A. A physical therapist shall proVide care that is within the scope of practice as defined by the state practice act. B. A physical therapist shall not engage in any conduct that is unethical, incompetent, or illegal. C. A physical therapist shall report any conduct that appears to be unethical, incompetent, or illegal. D. A physical therapist may not participate in any arrangements in which patients are exploited due to the referring sources' enhancing their personal incomes as a result of referring for, describing, or recommending physical therapy. See Sections 2.1.B, 4, and 7.

Principle 10. A physical therapist shall endeavor to address the health needs of society.
10.1. Pro Bono Services. A physical therapist shall render pro bono publico (reduced or no fee) services to patients lacking the ability to pay for services, as each physical therapist's practice permits. 10.2. Individual and Community Health
A. A physical therapist shall be aware of the patient health-related needs and act in a manner that facilitates meeting those needs. B. A physical therapist shall endeavor to support activities that benefit the health status of the community. See Section 3.



Principle 11. A physical therapist shall respect the rights, knowl­ edge, and skills of colleagues and other health care professionals.
11.1. Consultation. A physical therapist shall seek consultation whenever the welfare of the patient will be safeguarded or advanced by consulting those who have special skills, knowledge, or experience. 11.2. Patient/Provider Relationships. A phYSical therapist shall not undermine the reiationshipCs) between his or her patient and other health care professionals. 11.3 Disparagement. Physical therapist shall not disparage col­ leagues and other health care professionals. See Sections 9 and 2.4.A. The guide for conduct of the physical therapist assistant is pro­ vided in Table A-2 of the Appendix.

The physical therapy profession's commitment to society is to promote optimal health and function in individuals by pursuing excellence in practice. The American Physical Therapy Association attests to this commitment by adopting and promoting the following Standards of Practice for Physical Therapy.1O These standards are the profession's statement of conditions and performances that are essential for provi­ sion of high-quality professional service to society and provide a foun­ dation for assessment of physical therapy practice.

1. Legal considerations. a. A physical therapist complies with all the legal requirements of jurisdictions regulating the practice of physical therapy. b. The physical therapist assistant complies with all the legal requirements of jurisdictions regulating the work of the assistant. 2. Ethical considerations. a. The physical therapist practices in accordance with the Code of Ethics of the American Physical Therapy Association. b. The physical therapist assistant complies with the Standards of Ethical Conduct of the Physical Therapist Assistant of the American Physical Therapy Association.

1. Statement of mission, purposes, and goals. a. The physical therapy service has a statement of mission, pur­ poses, and goals that reflect the needs and interests of the patients and clients served, the physical therapy personnel affiliated with the service, and the community.



2. Organizational plan. a. The physical therapy service has a written organizational plan. 3. Policies and procedures. a. The physical therapy service has written policies and pro­ cedures that reflect the operation of the service and that are consistent with the Association's standards, mission, policies, positions, guidelines, and Code of Ethics. 4. Administration. a. A physical therapist is responsible for the direction of the physical therapy service. 5. Fiscal management. a. The director of the physical therapy service, in consultation with physical therapy staff and appropriate administrative personnel, participates in planning for, and allocation of, resources. Fiscal planning and management of the service is based on sound accounting principles. 6. Improvement of quality of care and performance. a. The physical therapy service has a written plan for continuous improvement of quality of care and performance of services. 7. Staffing. a. The physical therapy personnel affiliated with the physical therapy service have demonstrated competence and are suf­ ficient to achieve the mission, purposes, and goals of the services. b. The physical therapy service has a written plan that pro­ vides for appropriate and ongoing staff development. S. Physical setting. a. The physical setting is designed to proVide a safe and acces­ sible environment that facilitates fulfillment of the mission, purposes, and goals of the physical therapy service. The equipment is safe and sufficient to achieve the purposes and goals of the service. 9. Collaboration. a. The physical therapy service collaborates with all appropriate disciplines.

1. Patient/client collaboration.

a. Within the patient/client management process, the physical therapist and patient/client establish and maintain an ongo­ ing collaborative process of decision-making that exists throughout the provision of services. 2. Initial examination!evaluation!diagnosis/prognosis. a. A physical therapist performs an initial examination and evaluation to establish a diagnosis and prognosis prior to intervention. 3. Plan of care. a. The phYSical therapist establishes a plan of care and man­ ages the needs of the patient/client based on the examina­ tion, evaluation, diagnosis, prognosis, goals, and outcomes of the planned interventions for identified impairments, functional limitations, and disabilities.



b. The physical therapist involves the patient/client and appropriate others in the planning, implementation, and assessment of the plan of care. c. The physical therapist, in consultation with appropriate disci­ plines, plans the discharge of the patient client taking into con­ sideration achievements of anticipated goals and expected out­ comes, and provides for appropriate follow-up or referral. 4. Intervention. a. The physical therapist provides, or directs and supervises, the physical therapy interventions consistent with the results of the examination, evaluation, diagnosis, prognosis, and plan of care. 5. Re-examination. a. The physical therapist re-examines the patient/client as nec­ essary during an episode of care to evaluate progress or change in the patient/client status to modify the plan of care accordingly or discontinues physical therapy services. b. The physical therapists re-examination. 1) Identifies ongoing patient/client needs. 2) May result in recommendations for additional services, discharge, or discontinuation of physical therapy needs. 6. Discharge/discontinuation of intervention. a. The physical therapist discharges the patient/client from phys­ ical therapy services when the anticipated goals or expected outcomes for the patient/client have been achieved. b. The physical therapist discontinues intervention when the patient/client is unable to continue to progress toward goals or when the physical therapist determines that the patient/client will no longer benefit from physical therapy. 7. Communication!coordination!documentation. a. The physical therapist communicates, coordinates, and docu­ ments of aspects of patient/client management including the results of the initial examination and evaluation, diagnosis, prognosis, plan of care, interventions, response to interventions, changes in patient/client status relative to the interventions, reexamination, and discharge/discontinuation of intervention and other patient/client management activities. 8. Education. a. The physical therapist is responsible for individual profes­ sional development. The physical therapist assistant is responsible for individual career development. b. The physical therapist and the physical therapist assistant, under the direction and supervision of the physical thera­ pist, participate in the education of the students. c. The physical therapist educates and provides consultation to consumers and the general public regarding the purposes and benefits of phYSical therapy. d. The physical therapist educates and proVides consultation to consumers and the general public regarding the roles of the phYSical therapist, the physical therapist assistant, and other support personnel. 9. Research. a. The physical therapist applies research findings to practice and encourages, participates in, and promotes activities that establish the outcomes of patient/client management pro­ vided by the physical therapist.



10. Community responsibility. a. The physical therapist demonstrates community responsi­ bility by participating in community and community agency activities, educating the public, formulating public policy, or providing pro bono physical therapy services.


a. Client-an individual who is not necessarily sick or injured but who can benefit from a physical therapist's consultation, pro­ fessional advice, or services. A client also is a business, a school system, or other entity that may benefit from specific recommendations from a physical therapist. b. Diagnosis-both the process and the end result of the eval­ uation of information obtained from the patient examination. The physical therapist organizes the evaluation informa­ tion into defined clusters, syndromes, or categories to deter­ mine the most appropriate intervention strategies for each patient. c. Evaluation-a dynamic process in which the physical therapist makes clinical judgments based on data gathered during the examination. d. Examination-the process of obtaining a history, forming the relevant systems reviews, and selecting and administering spe­ cific tests and measures. e. Intervention-the purposeful and skilled interaction of the physical therapist with the patient or client. Intervention has three components: direct intervention; instruction of the patient or client and of the family; and coordination, communication, and documentation. f. Patient-an individual who is receiving direct intervention for an impairment, functional limitations, disability, or changing physical function and health status resulting from injury, disease, or other causes; an individual receiving health care services. g. Physical therapist patient management model-the model on which physical therapist based management of the patient throughout the episode of care, including the following ele­ ments: examination, evaluation and re-evaluation, diagnosis, prognosis, and intervention leading to the outcome. h. Plan of care-a plan that specifies the long-term and short­ term outcomes/goals, the predicted level of maximal improve­ ment, the specific interventions to be used, the duration and frequency of the intervention required to reach the outcomes/ goals, and the criteria for discharge. i. Prognosis-the determination of the level of maximal improvement that might be attained by the patient and the amount of time needed to reach that level. j. Treatment--Dne or more interventions used to ameliorate impairments, functional limitations, or disability or otherwise produce changes in the health status of the patient; the sum of all interventions provided by the physical therapist to a patient during an episode of care.



1. APTA Guide to Physical Therapist Practice. 2nd ed. American Physical Therapy Association. Phys Ther. 81:1-746;2001. 2. APTA Guide to Physical Therapist Practice. 2nd ed. American Physical Therapy Association. Phys Ther. 81:9-746;2001. 3. APTA Guide to Physical Therapist Practice: revisions. American Physical Therapy Association. Phys Ther. 79:623-9;2001. 4. Nagi S. Disability concepts revisited: implications for prevention. In: Pope A, Tartov A, eels. Disability in America: Toward a National Agenda for Prevention. Washington, DC: National Academy Press; 1991, 309-327. 5. Brandt EN, Jr., Pope AM. Enabling America: Assessing the Role of Rehabilitation Science and Engineering. Washington, DC: Institute of Medicine, National Academy Press; 1997. 6. Palisano RJ, Campbell SK, Harris SR. Evidence-based decision­ making in pediatric physical therapy. In: Campbell SK, Vander Linden DW, Palisano RJ, eds. Physical Therapy for Children. St. Louis, MO: Saunders, 2006, 3-32. 7. Kettenbach G. Background Information. In: Kettenbach G ed. Writing SOAP Notes with Patient/Client Management Formats, 3rd ed. Philadelphia, PA: FA Davis; 2004, 1-5. 8. O'Sullivan SB. Clinical decision-making, in O'Sullivan SB, Schmitz 1J. eels. Physical Rehabilitation, 5th ed. Philadelphia, PA: FA Davis; 2007,3-24. 9. Goodman CC, Snyder TK. Introduction to the interviewing process. In: Goodman CC, Snyder TK, eds. Differential Diagnosis in Physical Therapy. Philadelphia, PA: Saunders, 1990, 7-42. 10. APTA Guide to Physical Therapist Practice. Phys Ther. 81:S13-S95;2001. 11. Grieve GP. Common Vertebral joint Problems. New York, NY: Churchill Livingstone Inc; 1981. 12. APTA BOD. Minimum Required Skills ofPhysical Therapist Graduates at Entry-Level, BOD P11-05-20-49. Alexandria, VA: APTA 2004. 13. Rothstein JM, Echternach JL, Riddle DL. The Hypothesis-Oriented Algorithm for Clinicians II (HOAC II): a guide for patient manage­ ment. Phys Ther. 83:455-70;2003. 14. Echternach JL, Rothstein JM. Hypothesis-oriented algOrithms. Phys Ther.69:559-64;1989. 15. Rothstein JM, Echternach JL. Hypothesis-oriented algorithm for cli­ nicians. A method for evaluation and treatment planning. Phys Ther.66:1388--94;1986. 16. Schenkman M, Butler RB. A model for multisystem evaluation treatment of individuals with Parkinson's disease. Phys Ther. 69:932-43; 1989. 17. Schenkrnan M, Butler RB. A model for multisystem evaluation, interpretation, and treatment of individuals with neurologic dys­ function. Phys Ther. 69:538-47;1989. 18. Schenkrnan M, Donovan J, Tsubota J, et al. Management of indi­ viduals with Parkinson's disease: rationale and case studies. Phys Ther.69:944-55;1989. 19. Randall KE, McEwen IR. Writing patient-centered goals. Phys Ther. 80:1197-1203;2000. 20. O'Neill DL, Harris SR. Developing goals and objectives for handi­ capped children. Phys Ther. 62:295-298;1982.



21. American Occupational Therapy Association. Essentials and guide­ lines for an accredited educational program for the occupational therapist. Am] Occup Tber. 45:1077-1084;1991. 22. American Occupational Therapy Association. Essentials and guide­ lines for an accredited educational program for the occupational therapy assistant. Am] Occup Tber. 45:1085-1092;1991.



Comprehension Questions
1. A patient comes into your outpatient clinic without aphysician's prescription asking to be treated. Whether you can examine and treat this patient depends upon: A. Ethical principles. B. State licensure laws. C. Departmental procedures. D. Whether the patient has medical insurance. 2. What was developed to "encourage a uniform approach to physical therapist prac­ tice and to explain to the world the nature of that practice"? A. State licensure laws. B. The Guide to Physical Therapist Practice. C. The National Physical Therapy Examination. D. The Medicare Act of 1973. 3. True or false: Physical therapists are the only professionals who provide physical therapy. A. True. B. False. 4. What is the function of the Commission on Accreditation in Physical Therapy Education (CAPTE)? A. To design policies and procedures with regard to physical therapy. B. To make autonomous decisions concerning the accreditation status of continu­ ing education programs for physical therapists and physical therapist assistants. C. To design questions for the National Physical Therapy Examination. D. To oversee state licensing laws. 5. A home health agency (HHA) may be: A. Governmental. B. Voluntary. C. Private. D. Nonprofit or for-profit. E. All of the above. 6. What is the Medicaid Waiver for the Elderly and Disabled (E&D Waiver) program?

7. What is the Early Intervention Program?
8. The purpose of clinical education is to provide student clinicians with opportunities to: A. Observe and work with a variety of patients under professional supervision and in diverse professional settings, and to integrate knowledge and skills at progres­ sively higher levels of performance and responsibility. B. Take a break from schoolwork. C. Develop clinical reasoning skills and management skills, as well as to master techniques that develop competence at the level of a beginning practitioner. D. A and C.



9. A loss or abnormality of anatomic, physiologic, or psychologic structure or function is a description of which category of the disablement model? A. Impairment. B. Functional limitation. Disability. D. None of the above.


10. Which element of patient/client management includes gathering information from the chart, other caregivers, the patient, the patient's family, caretakers, and friends in order to identify and define the patient's problem(s)? A. The evaluation. B. The intervention. The examination. D. The test and measures.


11. What is the purpose of the re-examination? A. Allows the therapist to evaluate progress and modify interventions as appropriate. B. Provides the insurance companies with justification for payment. All of the above. D. None of the above.


12. Which component of the examination includes an analysis of posture, structural alignment or deformity, scars, crepitus, color changes, swelling, muscle atrophy, and the presence of any asymmetry? A. Palpation. B. Observation. Patient history. D. None of the above.


13. What are anthropometrics? A. Measurable physiological characteristics, including height and weight. B. Studies involving the history of man. A form of laboratory test. D. None of the above.


14. Which of the elements of patient/client management attempts to identify a relation­ ship between the symptoms reported and the signs of disturbed function? A. Test and measures. B. Patient history. Examination. D. None of the above.


15. Which element of patient/client management determines the predicted level of func­ tion that the patient will attain, and identifies the barriers that may impact the achievement of optimal improvement (age, medications, socioeconomic status, co­ morbidities, cognitive status, nutrition, social support, and environment) within a certain time frame? A. The evaluation. B. The examination.



C. The prognosis.
D. The diagnosis. 16. Which of the following statements are true about the plan of care? A. It is based on the examination, evaluation, diagnosis, and prognosis, including the predicted level of optimal improvement. B. It describes the specific interventions to be used, and the proposed frequency and duration of the interventions, required to reach the anticipated goals and expected outcomes. C. It includes plans for discharge of the patient/client, taking into consideration achievement of anticipated goals and expected outcomes, and provides for appropriate follow-up or referral. D. All of the above. 17. Which of the elements of patient/client management can be defined as "the pur­ poseful and skilled interaction of the physical therapist and the patient/client and, when appropriate, with other individuals involved in patient/client care, using vari­ ous physical therapy procedures and techniques to produce changes in the condition consistent with the diagnosis and prognosis." A. Examination. B. Prognosis. C. Intervention. D. Evaluation. 18. What is the major difference between a client and a patient? 19. What are the four components of the traditional SOAP note? 20. True or false: Correction flUid/tape can be used to correct text in medical records. A. A. True. B. B. False. 21. Which of the following patient attributes would not impact the clinician's choice of an intervention? A. Cornorbidities. B. Physiological impairments. C. Anatomic impairments. D. Race. 22. In atypical physical therapy department, which staff member ensures that the objec­ tives of the service are efficiently and effectively achieved within the framework of the stated purpose of the organization? A. Staff physical therapist. B. Physical therapy director. C. Department secretary. D. None of the above. 23. True or false: A PTA may modify an intervention only in accordance with changes in patient status and within the established plan of care developed by the physical therapist.



A. True.
B. False. 24. The following are all job responsibilities of the PT volunteer, except: A. Taking phone messages. B. Cleaning the whirlpool. C. Performing secretarial functions. D. All of the above are the job responsibilities of the PT volunteer. 25. All of the following are considered categories of the operating budget, except: A. Salaries and wages. B. Travel expenses. C. Continuing education. D. Office party expenses. 26. What type of costs can be identified specifically with a particular project, instruc­ tional activity, service, or other institutional activity, or can be directly assigned to such activities relatively easily with a high degree of accuracy? A. Indirect. B. Direct. C. Contingency. D. Escalation.

27. You are the director of the physical therapy department and will be conducting a job
interview for an opening. Which of the following questions would not be appropriate to ask a candidate at ajob interview? A. What is your level of experience? B. Why do you want to join this company? C. Do you have any children? D. What salary range are you interested in? 28. As the physical therapy director of afacility, you have been asked to write apolicy on retention and preservation of clinical records following patient discharge. Of the fol­ lowing, which is not an example of apolicy on retention and preservation of clinical records? A. The records are accessible to all personnel. B. The records will be maintained for a period of 5 years following discharge. C. The records will be stored in a locked cabinet during nonworking hours. D. The records of a minor will be retained for a period of 3 years after the patient comes of age. 29. As the physical therapy director of afacility, you have been asked to write an action plan to identify deficiencies, implement corrective action(s) to improve performance, and monitor the corrective actions to ensure that quality of care has been enhanced. In which of the following are you likely participating? A. Peer review. B. Quality assurance. C. Program evaluation. D. Utilization review.



30. As the physical therapy director of afacility, you have been asked to write aprogram that assures proper use of the faci Iity's funds and personnel. In which of the follow­ ing are you likely participating? A. Peer review. B. Quality assurance. C. Program evaluation. D. Utilization review. 31. Which of the following are included in the APTA Code of Ethics? A. A physical therapist shall exercise sound professional judgment. B. A physical therapist shall achieve and maintain professional competence. C. Aphysical therapist shall respect the rights and dignity of all individuals and shall provide compassionate care. D. A and C. E. All of the above. 32. You are a physical therapist assigned a physical therapy student who is performing his first clinical internship. Which of the following would be the most appropriate goals for this physical therapy student? A. To be able to perform an orthopedic examination on all patients. B. To perform all aspects of examination and treatment using correct body mechanics. C. To correctly evaluate all patient problems. D. To perform all patient care duties assigned. 33. Which of the following duties cannot be performed legally by a physical therapist assistant? A. Call aphysician about a patient's status. B. Add 3 pounds to a patient's current exercise protocol. C. Allow apatient to increase in frequency from 2 times/week to 3 times/week. D. Perform ultrasound on apatient. 34. A physical therapist decides to buy two electrical stimulation units from a sales representative. The representative offers the therapist afree dinner at a local restau­ rant as a token of appreciation. What is the best course of action for the physical therapist? A. Decline the dinner gracefully. B. Accept the offer gracefully. C. Offer to buy more units. D. Take the sales representative out to dinner. 35. CORF is an acronym for which of the following? A. Certified owner of a rehabilitation facility. B. Certified outpatient rehabilitation facility. C. Control organization for rehabilitation facilities. D. None of the above.



36. A patient with adiagnosis of carpal tunnel syndrome presents with aprescription for occupational therapy at an outpatient rehabilitation facility. The occupational thera­ pist informs the physical therapist that the patient's insurance will not reimburse for occupational therapy services. What is the best course of action? A. Allow the OT to treat the patient and the PT to sign off on his or her work. B. Inform the patient that he or she will be billed for the OT services. C. Call the doctor's office and obtain an order for PT, then proceed to treat the patient. D. Tell the patient to return to his or her doctor to obtain a prescription for physical therapy. 37. As the treating physical therapist, when should you begin discharge planning for a patient admitted to a rehabilitation unit who is status post-total hip replacement? A. At the first team meeting. B. At the last team meeting. C. Two weeks before discharge. D. After the initial evaluation. 38. A physical therapist is performing achart review and discovers that lab results reveal that the patient has malignant cancer. When evaluating the patient, the physical ther­ apist is asked by the patient, "Did my lab results come back?" The appropriate response for the physical therapist is: A. To inform the patient about the results and contact the social worker to assist in consultation of the family. B. To inform the patient that it would be inappropriate for you to comment on the lab results before the physician has assessed the lab results and spoken to the patient. C. To inform the patient that he or she has a malignant cancer. D. To tell the patient the results are in, but that physical therapists are not allowed to comment on the results. 39. You instruct aPT assistant to teach apatient on how to ascend and descend the front steps of her home. After first exercising the patient at her home, the PT assistant calls you from the home and informs you that, because of the patient's increased size and severe dynamic balance deficits, training on the steps is unsafe at this time. Which of the following is your best course of action? A. You should instruct the assistant to continue the step training, but cautiously. B. You should instruct the assistant to recruit the family members to assist with step training. C. You should instruct the assistant to discontinue step training until both of you can be present. D. You should contact the physician and seek further instructions. 40. A physical therapist is instructing a PT student in documentation using a SOAP note. Where should the following phrase be placed in a SOAP note-The patient reports wanting to return to playing soccer in 5 weeks? A. Subjective. B. Objective. C. Assessment. D. Plan.



1. The answer is B. 2. The answer is B. 3. The answer is A. This statement is true. 4. The answer is B. 5. The answer is E. 6. Aprogram designed to provide home care services to seniors and the disabled whose needs would otherwise require them to live in a nursing home. 7. A national program designed for infants and toddlers with disabilities and their families. 8. The answer is D. 9. The answer is A. 10. The answer is C. 11. 12. 13. 14. 15. The answer is A. The answer is B. The answer is A. The answer is D. The answer is C.

16. The answer is D. 17. The answer is C. 18. Apatient has a diagnosed impairment or functional limitation, whereas aclient is not necessarily diagnosed with impairments or functional limitations, but seek services for prevention or promotion of health, wellness, and fitness. 19. Subjective, objective, assessment, and plan. 20. The answer is B. This statement is false. 21. The answer is D. 22. The answer is B. 23. The answer is A. This statement is true. 24. The answer is B. 25. The answer is D. 26. The answer is B. 27. The answer is C. 28. The answer is A.



29. The answer is B. 30. The answer is D. 31. The answer is E. 32. The answer is B. 33. The answer is C. 34. The answer is A. 35. The answer is B. 36. The answer is C. 37. The answer is D. 38. The answer is B. 39. The answer is C. 40. The answer is A.


Administration, according to the Guide to Physical Therapist Practice, is "the planning, directing, organizing, and managing of human, techni­ cal, environmental, and fmancial resources effectively and efficiently."] Examples of administrative activity in which the physical therapist may engage in during his or her career include the following.]
~ ~ ~ ~ ~ ~

Ensuring fiscally sound reimbursement for services rendered. Budgeting for physical therapy services. Managing staff resources, including the acquisition and devel­ opment of clinical expertise and leadership abilities. Monitoring quality of care and clinical productivity. Negotiating and managing contracts. Supervising physical therapist assistant, physical therapy aides, and other support personnel (refer to Chapter 1).

lhe fIrst major change in the delivery of health care in the United States occurred in 1965, when the Medicare and Medicaid Acts were passed during the administration of President Johnson. Before that time, almost exclusively, individual health care providers delivered health care serv­ ices on a fee-for-service basis. In 1973, in response to the rapid rise in health care costs in both the private sector and Medicare, Congress passed the Health Maintenance Organization (HMO) Act, which provided the opportunity for the devel­ opment of HMOs.

Today the United States has several types of privately and publicly funded health insurance plans that provide health care services. During the 1980s, the HMOs began to exert a major influence in the delivery of health care in an effort to contain costs and spending. The most




common HMO model involves the appointment of a physician (pri­ mary care physician, or PCP) who serves as a gatekeeper for the insur­ ance company by being responsible for the authorization of specialty services, and who receives bonuses based on how much he or she conserves medical resources. However, due to the number of com­ plaints from patients about restricted health care, and from PCPs about the adversarial role they had with their patients, the gatekeeper model for the delivery of health care began to unravel in the 1990s.

Physical therapists have long been vulnerable in their abilities to demon­ strate direct cause--effect relationships between their interventions and the outcomes in relation to their patient's problems. The drive toward evi­ dence-based practice is aimed at addressing this issue (see Chapter 3).

The traditional model had health insurance provided in one of three ways:
~ ~ ~

As a benefit of employment, either directly, or through a union, with continued benefits available to retirees. Through government-funded programs, such as Medicaid and Medicare (see Publicly Funded Plans). Through private purchase of health insurance (generally for self-employed individuals).

This model has been eroded in recent years. Now, a growing number of employers offer no health benefits to their employees, have reduced benefits, or have withdrawn benefits from retirees. In most cases, employment-based plans that were once fully funded by employers now require employee contributions and copayments. The u.s. Census Bureau reports that in 2003, 60.4% of the population was covered by employment-based health insurance, 26.6% was covered by government-based insurance, while 15.6% had no health insurance at all (this total is higher than 100% because of the way the survey is takenY-4

Publicly Funded Plans.
care include:

The publicly funded plans for health


Medicare (for people over 65), which is administered by the federal government (see also Health Care Insurance: Reimbursement) Medicare is funded by a special payroll tax, under the Federal Insurance Contributions Act (FICA). Medicaid, which is administered by the states: Provides coverage for low-income earners, including the aged (over 65), people of limited resources, the blind, ancVor disabled. Is jointly funded by the federal government and the individ­ ual states.
Because the states set the rules, there are differences in both eli­
gibility and services provided, and these are subject to change.






Sends payments directly to the health care providers, not the
patient. The patient may be responsible for a copayment for some services.
The State Children's Health Insurance Program (SCHIP):
Created in 1997.
Provides insurance coverage for children of the working poor,
for people with full-time jobs, which do not offer employment­
based insurance, and for those who earn too much for
Medicaid but not enough to afford private insurance.
Because eligibility is at the discretion of the states, different
rules apply, and several have tightened eligibility or capped
the program.
The Ryan White Act: Signed into law on August 18, 1990.
Designed to help states pay for medications for uninsured
people with HN/ AIDS.
Although the number of uninsured people is high, these peo­ ple do have some recourse to emergency treatment:
Hospital emergency rooms (those that receive tax-exemption,
federal Hill-Burton grants, or loans) are not allowed to turn
away patients because of inability to pay. However, care is lim­
ited to emergency care only, and does not include routine care.
The costs incurred by this population are covered by a sur­ charge on insurance payments.

Study Pearl

The American Hospital Association lists over 6000 hospitals in the United States, the majority of which are not-for-profit hospitals, where about 75% of all hospitalized patients are treated. For-profit hospitals and governmental hospitals each account for the remaining hospitals and patients treated. Patients in the United States who have adequate insur­ ance, and who live in an appropriate location, can receive the best health care in the world. However, there is no uniformity, and the quality of care may vary according to type of insurance and to location:


Patients in rural areas face shortages of all types of health care
personnel. (About 20% of the U.S. population lives in areas that
have a shortage of primary health care professionals.)5-7
Patients who have no or inadequate insurance coverage get
care below the national standard. Uninsured patients may have
access to emergency care, but unless they require immediate
hospitalization, may get little or no follow-up care.

As health care costs have risen, efforts, both by government and pri­ vate entities, to control costs have focused on a number of areas:


Increasing the caseload size.
Decreasing costs.
The use of lower-eost paraprofessionals, resulting in an increased
sharing of the workload being performed by aides and technicians.



Problems faced by health care providers include:

~ ~

Shortages in qualified personnel (physicians, pharmacists, physical therapists nurses). An increasingly aging population. Lack of drug control. Although drugs used in the United States must be approved for safety and efficacy, there are no constraints on either therapeutic duplication or price (see Chapter 19). Any drug that obtains approval from the Food and Drug Administration (FDA) may be marketed in the United States, and the distribu­ tor has full discretion over the price charged.


A budget is a financial document in which the costs associated with operating a business are estimated for a specific time period, usually for 1 year. Included in the budget is a projection of expected rev­ enues and specific expenses. A number of budget plans or types are available.

The Operating Budget


One of the most commonly used types of budgeting and one of the simplest and easiest ways to setup an effective, easy-to­ follow plan of expenses and income. Comprised of a plan for current costs of the day to day opera­ tion of a business and the future means of financing them. Categories include: Salaries, benefits (including sick days, vacation, short- and long­
term disability).
Medical and office supplies.
Utilities (gas, electricity, phone).
Continuing education.
Travel expenses.

The Capital Budget
~ ~


The second most common type of budget. Details expenditures for the purchase of more expensive equip­ ment (i.e., over $300 to 5(0) with a lifespan of 3 to 5 years, repair needs, plans for purchasing buildings, and the means to finance each over lengthy time periods. Similar to the operating budget except it is more higWy detailed and focused on individual purchasing or business needs.

Budget Calendar

The schedule of events needed to occur and a period of time in which the preparation, review, and adoption of a budget takes place-the amount of time in which a business needs to and can implement a successful plan of operation.



Zero-Base Budget

An approach where the spending amount for each line item

~ ~

gets examined in its entirety annually, regardless of previous costs. Unjustifiable items often face eradication. Primarily used for essential cost planning.


Business expenses/costs can be divided into direct, indirect, fixed, variable, contingency, and escalation costs:


~ ~




Direct costs: those that can be identified specifically with a particular project, an instructional activity, a specific service or any other institutional activity, or that can be directly assigned to such activities relatively easily with a high degree of accuracy. The basic principle is that direct costs must be allocable (have a direct benefit and be directly attributable to the activity), allowable, reasonable, and necessary. Examples include: The salaries of professional staff. MedicaVsurgical supplies (ultrasound gel, iontophoresis pads,
and so on).
Educational courses.
Indirect costs: those necessary for the general operation of a business and the conduct of activity, or those costs that are not deemed as direct costs. Examples include: Utilities (heating, phones, electricity).
Building maintenance.
Fixed costs: those that are not responsive to patient volume levels. Examples include property rental. Variable costs: those that increase and decrease in proportion to patient volume levels. By definition, a variable cost is one that will total out at zero if there is no patient volume. Examples include medical/surgical and office supplies. Contingency costs: the amount of additional money, above and beyond the base cost, that is required to ensure a project's success. Discretionary costs are not stictly necessary for the provision of physical therapy service but correspond to strategic goals. Examples include advertising and community events. Escalation costs: the expenses or costs that may be added to proposal budgets in consideration of the effects of price/cost inflation on current-year costs.


Accounts payable refers to the unpaid bills of the business--the money owed to the suppliers and other creditors of the business for goods or services received. The sum of the amounts owed is listed as a current lia­ bility on the business balance sheet.




Accounts receivable refers to unpaid customer invoices, and any other money owed to the business by the customers/insurance companies/ patients. The sum of all the customer accounts receivable is listed as a current asset on the business balance sheet.

In the United States, health care regulation is undertaken to improve performance and quality through an enormous variety of different gov­ ernmental and nongovernmental agencies. These entities have varying statutory authority, scope, approaches, and outcomes, resulting in a complex, overlapping, duplicative, and sometimes contradictory regu­ latory environment.

Regulatory controls within the U.S. health care system include the fraud and abuse provisions included in the Health Insurance Portability and Accountability Act (HIPAA) of 1996; the 1997 Balanced Budget Act; and the regulations listed in Table 2-1.

TABLE 2-1. FISCAL REGULATIONS WllHIN lHE U.S. HEALlH CARE SYSTEM REGULATION False Claims Act of 1863 DESCRIPTION First signed into law in 1863. Underwent significant changes in 1986. Allows citizens to bring suits against groups or other individuals that are defrauding the government through programs, agencies, or contracts (overbilling for services, "upcoding"). Stipulates that an individual who knowingly and willfully offers, pays, solicits, or receives any remuneration in exchange for referring an individual for the furnishing of any item or service (or for the purchasing, leasing, ordering, or recommending of any good, facility, item, or service) paid for in whole or in part by Medicare or a state health care program (Le., Medicaid) shall be guilty of a felony. Often referred to as the "antikickback" statute. Authorizes the SecretaIY of Health and Human Services to impose civil money penalties, an assessment, and program exclusion for various forms of fraud and abuse involving the Medicare and Medicaid programs. Also known as Stark I and II. The first Self-Referral Prohibitions (Stark I) prohibited physicians from referring specimens obtained from Medicare patients to clinical laboratories with which the physician or an immediate family member of the physician had a financial relationship. In addition, any clinical laboratoIY that received a Medicare referral from a physician with which it had a fmancial relationship, could not bill Medicare for the performance of that procedure. A financial relationship is defined as either an ownershiplinvestment interest or a compensation relationship. The expanded Physician Self-Referral prohibitions (Stark II), introduced in 1995, prohibit self­ referrals (Medicaid and Medicare) of not only lab services but also many other designated health services including physical therapy. A scheme that ensures that the national health system has access to good quality branded medicines at reasonable prices, and promotes a healthy, competitive pharmaceutical industIY. Includes federal average wholesale price restrictions for Medicaid and state pharmaceutical regulations.

Medicare and Medicaid antifraud statutes

The Civil MonetaIY Penalties Law (CMPL) Federal self-referral prohibitions

Pharmaceutical price regulation scheme



Certificate of need (CON) laws are intended to regulate major capital expenditures, which may adversely impact the cost of health care serv­ ices, to prevent the unnecessary expansion of health care facilities, and encourage the appropriate allocation of resources for health care pur­ poses. CON laws became part of almost every state by 1978 after the 1974 National Health Act was passed.



The Patient Self-Determination Act (PSDA) requires many Medicare and Medicaid providers (hospitals, nursing homes, hospice programs, home health agencies, and HMOs) to give adult individuals, at the time of inpatient admission or enrollment, certain information about their rights under state laws governing advance directives, including the following: 1. 2. 3. 4. The right to participate in and direct their own health care decisions. The right to accept or refuse medical or surgical treatment. The right to prepare an advance directive. Information on the proVider's policies that govern the utiliza­ tion of these rights.

Study Pearl
An advance directive is a writt~n instructio;n, such as a li g Will or a Durabte Power of AU r Health Care, that provides i . s for the provision of med' atment in anticipation of those en the individual executing t no longer has decision­ pacity.

The act also prohibits institutions from discriminating against a patient who does not have an advance directive.

Quality assurance (QA) is an interactive management process designed to objectively ensure the appropriateness and effectiveness of patient care. It includes identifying deficiencies, implementing corrective action(s) to improve performance, and monitoring the corrective actions to ensure that quality of care has been enhanced. In the broadest sense, this ongoing process should involve the medical and profes­ sional staff, the administration, and the governing body of the health care facility.

Continuous quality improvement (CQ!) is a continuous process that identifies problems in health care delivery, examines solutions to those problems, and regularly monitors the solutions for improvement.

A utilization review (UR) is an evaluation of the correctness of the use of hospital services and resources, including the appropriateness of the admission, length of stay, and ancillary services. The review



may be conducted prospectively, concurrently, retrospectively, or in combination.
~ ~


Uses objective clinical criteria to ensure that the services are/were medically necessary and provided at the appropriate level of care. Can be conducted by the hospital for its own quality assurance and risk management system (peer review), using norms, crite­ ria, and standards adopted by its medical staff. Reports summa­ rizing the findings and action taken as a result of the process are regularly provided to the hospital board. These types of reviews tend to be educational rather than punitive.

Hospitals conduct and comply with multiple delegated and non­ delegated UR systems simultaneously.


Delegated utilization review: An entity external to the hospital under contract to the payer to review services. The norms, cri­ teria, and standards may be those adopted by the hospital med­ ical staff, or the external agency may require that its own pro­ tocols be used. The hospital must report its patient-specific findings to the entity; it may also be required to summarize overall findings from its internal UR process. Nondelegated utilization review: An entity external to the hos­ pital, which is under contract to the payer, and which reviews services using its own norms, criteria, and standards. This entity relies upon its own personnel to obtain clinical information from clinicians, the patient, family, medical records, or claims information submitted for payment after patient discharge. The review may be conducted concurrently or retrospectively, in person or on the hospital premises, by telephone, or by review of documentation.

A number of regulations exist in the United States that attempt to ensure quality of care. These include:

Study Pearl
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and~~~tth (NJO$HJisthefesearc;h
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foc:usiflgonergQnQmic~ (see~~tlP~rf).



Hospital accreditation and licensure, which includes Medicare conditions of participation (COP), and Joint Commission on Accreditation of Health Care Organizations (TCAHO) (see "Voluntary Accreditation" section in this chapter). State accreditation and licensure, including the Department of Health. Nursing home accreditation and licensure (including JCAHO, COP, the Nursing Home Reform Act, part of the Omnibus Budget Reconciliation Act of 1987, and state regulations). Licensure for all other health facilities (see "Voluntary Accreditation" section in this chapter). Peer review, encompassing Quality Improvement Organizations and the Health Care Quality Improvement Act of 1986. The Clinical Laboratory Improvement Act of 1967, as amended. FDA regulation of blood banks. Blood-borne pathogen requirements imposed by the Occupational Safety and Health Administration (OSHA). Health outcomes reporting systems mandated by states.



HEALTH PROFESSIONALS REGULATION Under the federal system of government in the United States, each state regulates health care professionals' practice. Health professional practice acts are statutory laws that establish licensing agencies, regulatory agen­ cies, or boards to generate rules that regulate medical practice. State licensing statutes establish the minimum level of education and experi­ ence required to practice, defme the functions of the profession, and limit the performance of these functions to licensed persons.

HEALTH INSURANCE REGULATION Health insurance regulation occurs at both the federal and state levels. Such regulations cover the gamut, regulating Blue Cross and Blue Shield carriers (which, if not-for-profit, are often regulated somewhat differently than their commercial counterparts); commercial insurance companies; self-insured plans; and various flavors of managed care, including health maintenance organizations (HMOs) and preferred provider organizations (PPOs). These entities write group coverage for employers, associations, or similar groups, as well as individual coverage.

Access-Related Insurance Regulations. A number of regu­ lations monitor the accessibility of health care. These include:




Health Maintenance Organization Act of 1973. Federal Emergency Medical Treatment and Active Labor Act. The federal Emergency Medical Treatment and Active Labor Act (EMTALA), also known as the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986 or the Patient Anti-Dumping Law, is primarily but not exclusively a nondiscrimination statute. The statute governs when and how a patient may be (1) refused treatment or (2) transferred from one hospital to another when he is in an unstable medical condition. Anti-discrimination restrictions (including the Rehabilitation Act of 1973, Pregnancy Discrimination Act of 1978, Americans with Disabilities Act of 1990, and Child Abuse Prevention and Treatment Act Amendments of 1984). Continuation of coverage requirements (including COBRA and state rules). Mandated health benefits (including mandated standards of care such as bone marrow transplants). There are at present three federally mandated health insurance benefits: The Mental Health Parity Act of 1996. Newborns' and Mothers' Protection Health Act of 1996. Women's Health and Cancer Rights Act of 1998.

Americans with Disabilities Act. The Americans with
Disabilities Act (ADA) of 19898 marked the first explicit national goal of achieving equal opportunity, independent living, and economic self­ sufficiency for individuals with disabilities. 9 To qualify as a person with disability, the individual must have a physical or mental impairment that substantially limits the performance of one or more major life activities (Table 2-2).



Social/Emotional ~ Interaction with others (e.g., speech difficulties such as pressured speech, lack of clarity, withdrawal, or responding with difficulty or too quickly; self absorption; inability to relate to or listen to others, including inability to relate due to paranoia, delusions, hal­ lucinations, obsessive compulsive ideation, negativity; inability to regulate mood and anxiety; inability to maintain appropriate dis­ tance from others) ~ Forming and maintaining relationships with others ~ Communication with others (e.g., answering questions, folloWing directions, using intelligible speech, recogniZing and expressing emotions appropriately, expressing needs, following a sequence) Cognitive ~ Concentration (as a major life activity itself and also resulting in limitations on other major life activities, such as interaction with others, self-care) ~ Making decisions ~ Complex thinking (e.g., planning, reconciling perceptions from different senses [seeing and hearingJ, sorting relevant from irrelevant details, problem solVing, changing from one task to another) ~ Abstract thinking (e.g., difficulty generaliZing or transferring learning from one setting to another, such as difficulty transferring skill of cooking in one kitchen to another kitchen)
~ Memory (long- or short-term)
~ Attention
~ Perception
~ Distinguishing real from unreal events
~ Initiating and completing actions
~ Processing information
Physical ~ Taking care of personal needs, such as eating, dressing, toileting, bathing, hygiene, household chores, managing money, follOWing medication or treatment regimens, following safety precautions ~ Eating (e.g., inability to regulate amounts appropriately or to maintain appropriate diet; need for strict eating schedule) ~ Sleeping (e.g., inability to fall asleep, obtain restful sleep, or sleep without interruption; excessive sleeping) ~ Reproduction ~ Sexual activity ~ Traveling

The ADA secures equal opportunity for individuals with disabilities in employment, public accommodations, transportation, state and local government services, and telecommunications. Title III of the ADA applies to public accommodations (Table 2-3), some examples of which follow:





Restaurants. Hotels. Theaters. Retail stores and shopping centers. Grocery stores. Parks that are not owned by the government. Hospitals, doctor's offices, and outpatient clinics. Law offices.

Public accommodations must make reasonable modifications in policies, practices, and procedures that deny equal access to individu­ als with disabilities. However, a public accommodation does not have to modify a policy if it would greatly alter its goods, services, or opera­ tions. Other impacts of the ADA include the following:

Employers may not ask job applicants about medical information or require a physical examination prior to offering employment.



TABLE 2-3. ACCESSIBILITY REQUIREMENTS Ramps Grade: ~ 8.3% Minimum width of 36 inches Must have handrails on both sides. 12 inches of length for each inch of vertical rise Handrails required for a rise of 6 inches or more or for horizontal runs of 72 inches or more Minimum width of 32 inches MaxinlUm depth of 24 inches Less than % inch for sliding doors Less than liz inch for other doors Requires I/rinch pile or less 36-inch width 6O-inch width 78-inch length Low-reach 15 inches High-reach 48 inches Reach over obstruction to 24 inches Not less than 29-inch height Not greater than 40 inches from floor to bottom of mirror or paper dispenser 17 inches minimum depth under sink to back wall 17 to 19 inches from floor to top of toilet Not less than 36-inch grab bars Grab bars should be 1 1/ 4 to }lIz inches in diameter l l / z-inch spacing between grab bars and wall Grab bar placement 33 to 36 inches up from floor level Approximately 2% of total rooms must be accessible 96 inches wide 240 inches in length Adjacent aisle must be 60 inches by 240 inches Approximately 2% of the total spaces must be accessible

DoolWays Thresholds Carpet Hallway clearance Wheelchair turning radius (U-turn) FOlWard reach in wheelchair Side reach in wheelchair Bathroom sink

Bathroom toilet

Hotels Parking spaces



After employment is offered, an employer can only ask for a medical examination if it is required of all employees holding similar jobs. If someone is turned down for work based on the results of a medical examination, the employer must prove that it is physi­ cally impossible for that person to do the work required.


Cost-related insurance regulations include the following:
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The Employee Retirement Income Security Act of 1974. Health Insurance Portability and Accountability Act (HIPAA} administrative simplification and privacy regulation (see "Health Insurance Portability and Accountability Act" section in this chapter). Medicare-as-secondary-payer rules passed in 1980.



.. Medigap (health insurance sold by private insurance compa­ nies to fill the "gaps" in Original Medicare Plan coverage) min­ imum standards enacted in 1990. .. General health insurance/HMO regulation (which focuses on solvency regulation and rate justification).

Accreditation of health care institutions is a voluntary process by which an authorized agency or organization evaluates and recognizes health services according to a set of standards describing the structures and processes that contribute to desirable patient outcomes. Accreditation is not new to the health system. The first initiative toward accreditation was taken in the United States as early as 1910. VOLUNTARY ACCREDITING AGENCIES Voluntary accrediting agencies include the ]CAHO, AC-MRDD, and/or CARP and CORF.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO). The ]CAHO is a private organization
created in 1951 to provide voluntary accreditation to hospitals. Many states rely on ]CAHO accreditation as a substitute for their own inspec­ tion programs. In 1964, the ]CAHO began charging hospitals for the surveys it per­ formed. The ]CAHO has high standards of quality assurance and a rigor­ ous process of evaluation, which makes it a much-esteemed agency for accreditation. Health services certified by the ]CAHO are given "deemed status" (in 1965, Congress passed amendments to the Social Security Act stating that hospitals accredited by the ]CAHO are "deemed" to be in compliance with most of Medicare's "Conditions of Participation for Hospitals" and therefore are able to participate in Medicare and Medicaid and are eligible for millions of federal health care dollars). Over a period of time after several experiments, the Joint Commission on Accreditation of Healthcare Organization (JCAHO), a national accreditation program, established itself as an esteemed accreditation body by 1987. In the 1990s, the ]CAHO revised its stan­ dards to reflect the changing functions of hospitals, seeking to move away from departments and toward patient experience of hospital sys­ tems. Recently, the ]CAHO has moved toward trying to find standards that reflect the integration of hospital services rather than examining them in isolation, and has begun to examine outcome measures instead of simple process standards for good practice. The ]CAHO accredits more than 80% of the nation's hospitals. It also accredits skilled nursing facilities, hospices, health plans, and other care organizations that provide home care, mental health care, laboratory, ambulatory care, and long-term services.

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Commission on e Organi­ ts is mat in health care every 12 months.

.. Hospitals pay for ]CAHO surveys, and more than 70% of ]CAHO's revenue comes directly from the organizations it is supposed to inspect. .. Hospitals and other health care providers were notified weeks or months in advance that a ]CAHO survey team will be arriving­




giving the provider plenty of time to make cosmetic changes, prepare staff to answer questions, update patient and personnel records, and increase staff levels. However, After two years of preparation, in 2004, JCAHO began piloting a new accreditation process called "Shared Visions-New Pathways." Beginning in 2006, all regular accreditation surveys were conducted on an unannounced basis. "Shared Visions--New Pathways" shifts the focus from survey preparation to continuous improvement of operational systems that directly affect the quality and safety of patient care. Although the JCAHO encourages workers to speak with survey­ takers, most workers do not have legal protection from retalia­ tion if they do so.

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Accreditation Council for Services for Mentally' Retarded and Other Developmentally Disableil Persons (AC-MRDD). AC-MRDD is a voluntary agency that
accredits programs or agencies that serve persons with developmental disabilities.

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Commission on Accreditation of Rehabilitation Facilities (CARF). CARF is a nonprofit organization designed to rec­
ognize standards of excellence in rehabilitation programs across the nation. CARF accreditation standards were developed with the input of consumers, rehabilitation professionals, state and national organizations, and third­ party purchasers. It is designed to establish standards of quality for free­ standing rehabilitation facilities and the rehabilitative programs of larger hospital systems in the areas of behavioral health, employment (work hard­ ening), and community support services (e.g., assisted living residences, supported living, child and youth services, adult day services, and blind rehabilitation services) and medicaVphysical rehabilitation (spinal cord injury, pain managemenO, and to determine how well an organization is serving its patient'l, consumers, and the community. Programs accredited by CARP have demonstrated that they meet the national standards for rehabilitation programs.

Comprehensive Outpatient Rehabilitation Facility (CORF). A CORF is a nonresidential facility established and oper­
ated exclusively for the purpose of providing diagnostic, therapeutic, and restorative services for the rehabilitation of injured, disabled, or sick persons, at a single fixed location, by or under the supervision of a physician. At minimum, these facilities must provide physician's services, physical therapy, and social or psychological services. With the excep­ tion of physical therapy, speech pathology services, and occupational therapy, services must be proVided on the facility's premises. However, one visit to the patient's home is covered to evaluate the home envi­ ronment in relation to the patient's treatment plan. A CORF must have only one location. If other institutions, such as hospitals, establish a CORF, it must be functionally and operationally independent. The CORF accreditation group conducts certification surveys for compliance with federal and state regulations and investigates any complaints filed against one of these proViders. Certification is achieved by adherence to federal requirements including:




Submission of a complete application.
Required documentation.
Successful completion of a survey.

In accordance with federal directives, up to 16.6% of CORFs are surveyed annually. Each CORF must be surveyed for certification as directed by the Centers for Medicare and Medicaid Services (CMS). An application for certification includes submission of a com­ pleted application, required documentation, and successful completion of a survey. There are no fees and no renewal applications required for certification. There are no state licensing requirements imposed by the agency.

1. Organization submits an application for review. 2. Survey conducted by the accrediting agency. 3. The organization conducts a self-study or self-assessment to examine itself based on the accrediting agency standards. 4. An individual reviewer or surveyor, or a team visiting the organization, conducts an on-site review. 5. The whole staff of the organization is involved in the accreditation and re-accreditation process. Tasks include document prepara­ tion, hosting site visit team, and interviews with the accreditors. 6. Accreditation surveyor or team issues a report granting or denying accreditation. ~ If accredited, the organization undergoes periodic review, typically every 3 years. ~ Some accrediting bodies may perform unannounced or unscheduled site surveys to ensure ongoing compliance.

In the private health insurance industry within the United States, there

are three types of fInns.



Commercial stock companies: private stockholder owned cor­ porations that operate in the national marketplace. Examples include Aetna, Travelers, and Connecticut General. Mutual companies: these also operate in the national market­ place and have private holders, but differ because the policy­ holders are also the owners. Examples include Mutual of Omaha, Prudential, and Metropolitan Life. Nonprofit insurance plans: these are granted exclusive franchises to geographical areas and to a particular line of insurance. Examples include Blue Cross, Blue Shield, and Delta Dental.

Private Health Insurance. Private health insurance includes commercial insurance, fee-for-service or traditional indemnity plans, or employers who are self-insured.
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Preauthorization may not be needed.
Patients have the freedom to choose their own providers.



The number of physical therapy visits should be usual, customary, and reasonable, which are often contractually defined in the insurance policy.

Managed Health Care Systems. Managed health care sys­ tems are organized programs by third-party payers ("gatekeepers") designed to control access (usually through the primary care physician or PCP) to inpatient and ambulatory health services by directing patients to certain proViders. Some features of managed health care systems include the folloWing:



Ensuring the medical necessity of the proposed service and the delivery of the service (pre-admission or pre-treatment certifica­ tion, second surgical opinion programs, concurrent reviews, indi­ vidualllarge case management, financial incentives, or penalties). Failure to comply with managed care requirements or decisions usually reduces health benefit coverage for claims. The penal­ ties may affect both the patient and the provider. Per diem rate: a set price for one day of hospital care, includ­ ing all ancillary services, excluding separately billed physician services. Monitoring services so that they are at the most efficient and cost-effective level of care while being consistent with high quality (related to favorable patient outcomes).


Managed care is essential to the structure of alternative delivery and fmancing systems, such as health maintenance organization (HMO) and preferred provider organization (PPO) arrangements (Table 2-4).

Capitation: a system whereby providers are paid a certain amount per case no matter how many visits are rendered Co-payment: insured's charge for the covered service-made at time of service and usually a preset amount Co-insurance: insured's share of the cost of the covered service-expressed as a percentage, e.g., 800A! paid by insurance company and 200A! paid by insured The provider is at fmandal risk (shared risk) if services are over-utilized





Health Maintenance Organizations. A health maintenance organization (HMO) is a form of managed care that offers prepaid, comprehensive health coverage for both hospital and physician services with specific health care providers using a fixed structure or capitated rates.
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Employers contract for these services as a benefit to their employees. Employees are locked into using the system of member health care providers and affiliating facilities. Some of these organizations allow patients to seek care "out of
network," but at a higher, or additional cost to the patient.
Employees may have to pay a small fee to visit (co-pay), such
as $10 per visit. The primary care physicians (PCPs) act as gatekeepers for any medical care required beyond their scope of practice. For example, the PCP must authorize physical therapy services before they can be provided. Most organizations base the number of allowed physical ther­ apy visits on the diagnosis.

Point-Of-Service Plans. A point-of-service (POS) plan is an insurance plan where members need not choose how to receive serv­ ices until the time they need them. This is also known as an open­ ended HMO.



Preferred Provider Organizations. In a preferred provider organization (PPO), a group of providers, usually hospitals or physi­ cians, provide health care services to employers at a negotiated, often discounted, price.
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Patients are not locked into PPO providers, but receive finan­ cial incentives to use services with the PPO network. Preauthorization is needed before services can be provided. Most plans limit the number of physical therapy visits accord­ ing to the diagnosis. An employer can offer its employees a traditional health-care plan, HMO, or PPO.

Point-of-Purchase Plans. The pOint-of-purchase plan is a bene­ fit plan that expands enrollee options to choose providers. It usually con­ sists of two or more delivery and financing options including an alterna­ tive delivery system, such as an HMO or PPO, and another plan such as traditional fee-for-service coverage. The participant is not locked in but may change coverage options each time care is obtained. The scope of benefits and payment provisions are structured to provide incentives for greater use of the alternative delivery system option. Primary Care Networks. A primary care network is similar to an HMO that provides health services for a fixed price, relying on par­ ticipating primary care physicians to serve as gatekeepers to control patient access to institutional services and specialty care. The primary care physician determines the patient's need for specialty care and any resulting referrals.
Medicare, Medicaid, and the Federal Employees Health Benefit Plans represent the government health plans.

Medicare. Medicare is administered by the federal government. ­
Center for Medicare and Medicaid services (CMS)--an agency within the U.S. Department of Health and Human Services, through the exten­ sion of title XVIII of the Social Security Act, 1965 (Law that created Medicare, Medicaid, and other federal programs). The Health Insurance Portability and Accountability Act of 1996 (HIPAA) required the CMS to adopt standards for coding systems that are used for report­ ing health care transactions. Medicare:


Provides basic health care and limited long-term care for retirees (65 years or older) and certain disabled individuals (with permanent kidney failure and other long-term disabili­ ties) without regard to income level. Beneficiaries must pay premiums, deductibles, and coinsurance.

There are three different varieties (Table 2-5), or parts:

Part A: Medicare hospital insurance that helps pay for medically necessary inpatient hospital care (limits the number of hospital days), and, after a hospital stay, and limited inpatient care in a



TABLE 2-5. MEDICARE TERMINOLOGY Medicare bonus payment Medicare cost HMO or contract Medicare cost report (MCR) Medicare insured group (MIG) Medicare Payment Advisory Commission (MedPAC) Medicare provider analysis and review file (MedPAR) Medicare risk contract Medicare secondary payer Medigap
An additional 10% payment to the physician above the allowed charge for services delivered to Medicare

beneficiaries in designated health professional shortage areas Prospective payment for acute and primary health care (monthly fee per patient with settlement annually based on actual costs). Primarily used in rural areas where full capitation is not feasible An annual report required of all institutions participating in the Medicare program. The MCR records each institution's total costs and charges associated with providing services to all patients, the portion of those costs and charges allocated to Medicare patients, and the Medicare payments received Employer (or union) groups receiving a capitated rate from Medicare in exchange for integrating Medicare covered services into the employers own traditional retiree health plan A nonpartisan congressional advisory body charged with providing policy advice and technical assistance concerning the Medicare program and other aspects of the health system. It conducts independent research, analyzes legislation, and makes recommendations to Congress. The Physician Payment Review Commission (PPRC) has been merged with the Prospective Payment Assessment Commission (ProPAC) to create MedPAC An HCFA data file that contains charge data and clinical characteristics, such as diagnoses and procedures, for every hospital inpatient bill submitted to Medicare for payment A contract between Medicare and a health plan under which the plan receives monthly capitated payments to provide Medicare-covered services for enrollees, and thereby assumes insurance risk for those enrollees. A plan is eligible for a risk contract if it is a federally qualified HMO or a competitive medical plan Is implemented when rates are set higher than actual costs to recover unreimbursed costs from government, uninsured, underinsured and other payers A policy guaranteeing to pay a Medicare beneficiary's co-insurance, deductible, and co-payments and one that will provide additional health plan or non-Medicare coverage for services up to a predefmed benefit limit. In essence, the product pays for the portion of the cost of services not covered by Medicare A form of Medigap insurance that allows insurers to experiment with the provision of supplemental benefits through a network of providers. Coverage is often limited to those services furnished by the participating network providers and emergency out-of-area care A Medicare + Choice (Part C) pOint-of-service option that allows enrollees in a Medicare risk HMO to go out of plan at a higher cost See Medigap Section of the Social Security Amendments of 1972 allowing the federal government to waive Medicare payment rules and allow alternative payment methods including capitation

Medicare Select

Medicare self-referral option Medicare supplement policy Medicare waiver (222)


skilled nursing facility, for limited home health care, or hospice care. • Provides basic protection against the cost of health care. • Does not cover all medical expenses or the cost of long-term care. • Provides coverage for patients who have been on Social Security disability for 24 months. • Annual deductible fees paid by the patient. Part B: Medicare medical insurance. Helps pay for: • Medically necessary physician services. • Outpatient hospital services and supplies that are not covered by the hospital insurance (laboratory tests and x-rays), • Ambulance transportation. • Outpatient physical and occupational therapy services (hos­ pital and private practice). The CMS has issued instructions that provide additional limitations on outpatient therapy serv­ ices, consistent with the provisions of the Deficit Reduction Act of 2005 Section 5107 requires limitations on outpatient therapy services, for the purpose of identifying and eliminating improper payments. Certain services are limited to certain




numbers of units per day for physical therapy, occupational therapy and speech-language pathology, separately to con­ trol inappropriate billing. • Home health care provided by a physical therapist in inde­ pendent practice. • Durable medical equipment (e.g., wheelchairs, canes, walk­ ers) determined to be "medically necessary" by the physician. • Medical supplies that the hospital insurance does not cover. • Each patient must pay a monthly premium. • The physician responsible for the care of the patient referred for physical therapy must certify the plan of care minimally every 30 days. • Medicare reimburses only physical therapy care that is con­ sidered to be skilled and necessary and certified by a refer­ ring physician. Part C: Medicare + Choice. A Medicare program under which eli­ gible Medicare enrollees can elect to receive benefits through a managed care program that places providers at risk for those benefits.

World Health Organization's Ninth Revision, International Classification of Diseases. The International Classification of

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Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is based on the World Health Organization's Ninth Revision, International Classification of Diseases (ICD-9). ICD-9-CM is the official system of assigning codes to diagnoses and procedures associated with hospital utilization in the United States. Only a physician can provide a medical diagnosis when referring a patient for therapy. This diagnosis mayor may not provide the reason why the patient requires skilled therapy services. Depending on state and/or local laws, a treatment/therapy diagnosis may be provided by the therapist based on the results of the evaluation. This treatment diagnosis should provide the reason the patient requires skilled therapy (may be the same as the medical diag­ nosis provided by the physician).

Healthcare Common Procedure Coding System. For Medicare and other health insurance programs to ensure that claims are processed in an orderly and consistent manner, standardized coding systems are essential. The Healthcare Common Procedure Cooling System (HCPCS) is used for this purpose. The HCPCS is divided into two principal subsys­ tems, referred to as level I and level II of the HCPCS.

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Level I of the HCPCS is comprised of CPT (Current Procedural Terminology), a numeric coding system maintained by the American Medical Association (AMA)-See the next section. Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office. Level III HCPCS were developed and used by Medicaid State agencies, Medicare contractors, and private insurers in their specific programs or local areas of jurisdiction. For purposes of Medicare, level III codes were also referred to as local codes.



Current Procedural Terminology Codes. The CPT is a uniform coding system consisting of descriptive terms and identifying codes that are used primarily to identify medical services and procedures fur­ nished by physicians and other health care professionals. These health care professionals use the CPT to identify services and procedures for which they bill public or private health insurance programs. Decisions regarding the addition, deletion, or revision of CPT codes are made by the AMA. The CPT codes are republished and updated annually by the AMA. Rehabilitation services are billed based on CPT codes that can be either visit based (untimed) or timed. Examples of untimed codes include the initial evaluation, group therapy, and unattended electric stimulation. Most therapy-based timed codes are measured in I5-minute increments. Examples include therapeutic exercise, and neuromuscular re-education. Per Medicare regulations, therapists will charge a I5-minute unit for treat­ ment greater than or equal to 8 minutes. Time intervals for I5-minute units, per Medicare, are as follows:
1 unit: >8 minutes-22 minutes 2 units: >23 minutes-37 minutes 3 units: >38 minutes-52 minutes 4 units: >53 minutes-67 minutes 5 units: >68 minutes-82 minutes 6 units: >83 minutes-97 minutes 7 units: >98 minutes-I12 minutes 8 units: >113 minutes-I27 minutes The pattern remains the same for treatment times in excess of 2 hours. According to these regulations, when only one service is provided in a day, providers should not bill for services performed for less than 8 minutes. For any single timed CPT code in the same day measured in I5-minute units, providers bill a single I5-minute unit for treatment greater than or equal to 8 minutes through and including 22 minutes. If the duration of a single modality or procedure in a day is greater than or equal to 23 minutes through and including 37 minutes, then 2 units should be billed. If a service represented by a I5-minute timed code is performed in a single day for at least 15 minutes, that service shall be billed for at least one unit. If the service is performed for at least 30 minutes, that service shall be billed for at least two units, etc. It is not appropriate to count all minutes of treatment in a day toward the units for one code if other serv­ ices were performed for more than 15 minutes. The following examples indicate how to count the appropriate number of units for the total therapy minutes provided. Example 1 24 minutes of neuromuscular reeducation (CPT code 97112)
23 minutes of therapeutic exercise (CPT code 97110)
Total timed code treatment time is 47 minutes.
The 47 minutes falls within the range for 3 units = 38 to 52 minutes.
Appropriate billing for 47 minutes is only 3 timed units. Each of the
codes is performed for more than 15 minutes, so each shall be billed
for at least 1 unit. The correct coding is 2 units of code 97112 and
one unit of CPT code 97110, assigning more timed units to the serv­
ice that took the most time.

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Example 2
20 minutes of neuromuscular reeducation (97112)
20 minutes therapeutic exercise (97110)
40 total timed code minutes.
Appropriate billing for 40 minutes is 3 units. Each service was per­
formed for at least 15 minutes and should be billed for at least one
unit, but the total allows 3 units. Since the time for each service is
the same, choose either code for 2 units and bill the other for 1 unit.
Do not bill 3 units for either one of the codes.

Medicaid. Medicaid is a joint state and federal program mandated by title XIX of the Social Security Act, which pays for medical and other services on behalf of certain groups of low-income persons (the poor, elderly, and disabled who do not receive Medicare) regardless of age.
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Benefits vary from state to state. Preauthorization is needed by a physician before treatment can begin. Individual states can determine the scope, duration, and amount of services provided. Many states have adopted HMO-like models to manage their Medicaid program. Medicaid (HCBS-Section 1915 (c)) Waivers: Exceptions to the usual requirements of Medicaid granted to a state by CMS. Target populations for 1915 (c) waivers include older adults, persons with disabilities, persons with mental retardation, per­ sons with chronic mental illness, and persons with AIDS. The Waivers allow states to: • Waive provisions of Medicaid law to test new concepts that are consistent with the goals of the Medicaid program. System-wide changes are possible under this provision. Frequently used to establish Medicaid managed care programs. • Waive freedom of choice. States may require that beneficiar­ ies enroll in HMOs or other managed care programs, or select a physician to serve as their primary care case manager. • Waive various Medicaid requirements to establish alternative, community-based services for (j) individuals who would other­ wise require the level of care provided in a hospital or skilled nursing facility, and/or (ij) persons already in such facilities who need assistance returning to the community. • Limit expenditures for nursing facility and home- and community-based services for persons 65 years and older so that they do not exceed a projected amount, determined by taking base year expenditure (last year before the waiver), and adjusting for inflation. Also eliminates requirements that programs be statewide and be comparable for all target pop­ ulations. Income rules for eligibility can also be waived.

Primary Care Case Management (PCCM). Section 1915(b) Managed Care/Freedom of Choice waivers allow states to implement managed care delivery systems, or otherwise limit individuals' choice of provider under Medicaid. Each participant is assigned to a single



primaty care provider who must authorize most other services such as specialty physician care before they can be reimbursed by Medicaid. Medicaid Prudent Pharmaceutical Purchasing Act (MPPPA). Enacted as part of the COBRA, MPPPA provides that Medicaid must receive the best-discounted price of any institutional purchaser of pharmaceuticals. In doing so, drug companies provide rebates to Medicaid equal to the difference between the discounted price and the price at which the drug was sold. This bill has resulted in cost shifting throughout the health industty.

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Balanced Budget Act of 1997 (BBA). The Balanced Budget
Act of 1997 made sweeping changes in the Medicare and Medicaid programs. Several of the significant provisions of the BBA were pay­ ment reductions to health care providers, new prospective payment systems for health care providers, and reduction of coverage of health care services by the Medicare and Medicaid programs.

long-term settings.

Health Care Financing Administration (HCFA). The Health Care Financing Administration is the previous name for the Center for Medicare and Medicaid services (CMS), described earlier.
WORKER'S COMPENSATION Worker's compensation programs were established and are regulated by state law to provide medical benefits and compensation for injuries and diseases that occur in the course of employment.
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Financed by covered employers, insured or self-insured. Some states limit the number of visits to a diagnosis, ancl/or require a pre-approval process be followed for reimbursement. Other states require the total number of visits or total number of weeks (duration) and the number of treatments per week (frequency) to be usual, customaty, and reasonable. All large employers 00 or more employees) or high-risk employers must contribute to Worker's Compensation.

An estimated 34 million Americans do not have health insurance. 10 Of

these, 56% are workers, 280/0 are children, and 16.5% are nonworking adults. lO Eighty-three percent of workers have private health insurance. lO


Individuals who cannot pay for health care can receive pro bono or free care through philanthropic donations and services. Hill-Burton Act: Federal legislation enacted in 1947 to support the construction and modernization of health care institutions. Hospitals that receive Hill-Burton funds must provide specific levels of charity care.

CONSUMER-DRIVEN HEALTH CARE PROGRAMS Consumer-driven health (CDH) care is a new paradigm for health care delivety. Defined narrowly, consumer-driven health care refers to health plans in which individuals have a personal health account, such



as a health savings account (HSA) or a health reimbursement arrange­ ment (HRA), from which they pay medical expenses directly. The phrase is sometimes used more broadly to refer to defmed contribution health plans, which allow employees to choose among various plans, often with a fIxed dollar contribution from an employer. The charac­ terisitics of CDH include:

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Those who opt for plans with high benefit levels may have to contribute a signifIcant amount of their own money in addition to an employer's contribution. Those with more basic coverage contribute less of their own money. More choice and greater control over one's health plan are characteristics of a consumer-driven health care marketplace. People with personal health accounts have economic incen­ tives to better manage their own care-they realize economic rewards for making good decisions and bear economic penal­ ties for making ill-advised ones. These economic incentives make patients more likely to seek information about medical conditions and treatment options, including information about prices and quality. By contrast, most patients have less incen­ tive to be prudent consumers of medical services in the current health care system. Up to one-quarter of physician visits are for conditions patients could easily have treated themselves, according to employee benefIts experts.

The main types of plans under consideration in consumer-driven health care are:




Full-defined contribution-the employee is responsible for finding and purchasing individual medical coverage. The employer proVides funding through either direct compensation or a voucher. Tiered networks-the employer offers employees a choice of medical plans, which include medical systems of varying costs. Managed competition-the employer provides a subsidized basic medical plan with buy-up options. Plans can be from the same or multiple insurers. Health savings accounts--current options include medical sav­ ings accounts, flexible spending accounts, and health reim­ bursement arrangements. Other options are still under con­ gressional consideration. Menu-driven--employers provide online information to help employees customize their own benefIt plan by selecting co­ pays, deductibles, and so forth. Although each of the above plans has its own particular benefIts and drawbacks, menu­ driven plans offer consumers the most options for customization.

HEALTH INSURANCE AND PORTABILITY ACCOUNTABILITY ACT The purpose of the Health Insurance and Portability Accountability Act (HIPAA) was to provide a mechanism to spread the risk of unforeseen medical expenditures across a broad base to protect the individual from personal expenditures.



The 1996 Federal legislation makes long-term care insurance pre­ miums tax deductible if nonreimbursable medical expenses, including part or all of long-term care premiums, exceed 7.5% of an individual's gross income. HIPAA also excludes long-term care insurance benefits from taxable income. Not all long-term care insurance coverage qualifies for this benefit.

HIPAA Privacy Rule. The u.s. Department of Health and Human Services (HHS) issued the Privacy Rule to implement the requirement of the HIPAA Act of 1996.


The Privacy Rule standards address the use and disclosure of individuals' health information-ealled "protected health infor­ mation" by organizations subject to the Privacy Rule-ealled "covered entities," as well as standards for individuals' privacy rights to understand and control how their health information is used. A major goal of the Privacy Rule is to assure that individuals' health information is properly protected while allowing the flow of health information needed to provide and promote high-quality health care and to protect the public's health and well-being. • The Privacy Rule applies to those who transmit health infor­ mation in electronic form in connection with transactions. • The Privacy Rule protects all "individually identifiable health information" (protected health information [PHI]) held or transmitted by a covered entity (health plans, health care clearinghouses, and to any health care provider) or its busi­ ness associate (limited to legal, actuarial, accounting, consult­ ing, data aggregation, management, administrative, accredita­ tion, or financial services), in any form or media, whether electronic, paper, or oral.

HI PAA Terminology


Protected health information (PHI): Information, including demographic data, that relates to: • The individual's past, present, or future physical or mental health or condition. • The provision of health care to the individual. • The past, present, or future payment for the provision of health care to the individual, and that identifies the individual or for which there is a reasonable basis to believe that it can be used to identify the individual. • Individually identifiable health information includes many com­ mon identifiers (e.g., name, address, birth date, Social Security number). Required disclosures: A covered entity must disclose protected health information in only two situations: • To individuals (or their personal representatives) specifically when they request access to, or an accounting of disclosures of, their protected health information. • To Health and Human services (HHS) when it is undertak­ ing a compliance investigation or review or enforcement action.



Permitted uses and disclosures: A covered entity is permitted, but not required, to use and disclose protected health informa­ tion, without an individual's authorization, for the following purposes or situations: • To the individual (unless required for access or accounting of disclosures). • Treatment, payment, and health care operations. • Opportunity to agree or object. • Incident to an otherwise permitted use and disclosure. • Public interest and benefit activities; and Office for Civil Rights (OCR) Privacy Rule Summary. • Limited data set: for the purposes of research, public health, or health care operations. • Covered entities may rely on professional ethics and best judg­ ments in deciding which of these permissive uses and disclosures to make. ~ Workforce training and management. Workforce members include employees, volunteers, and trainees, and may also include other persons whose conduct is under the direct con­ trol of the entity (whether or not they are paid by the entity). A covered entity must train all workforce members on its privacy policies and procedures, as necessary and appropriate for them to carry out their functions. A covered entity must have and apply appropriate sanctions against workforce members who violate its privacy policies and procedures or the Privacy Rule. ~ Data safeguards: A covered entity must maintain reasonable and appropriate administrative, technical, and physical safe­ guards to prevent intentional or unintentional use or disclosure of protected health information in violation of the Privacy Rule and to limit its incidental use and disclosure pursuant to other­ wise permitted or required use or disclosure. For example, such safeguards might include shredding documents containing pro­ tected health information before discarding them, securing med­ ical records with lock and key or pass code, and limiting access to keys or pass codes. ~ . Documentation and record retention: A covered entity must main­ tain, until 6 years after the later of the date of their creation or last effective date, its privacy policies and procedures, privacy prac­ tices notices, disposition of complaints, and other actions, activities, and designations that the Privacy Rule requires to be documented. ~ Criminal penalties: A person who knowingly obtains or discloses individually identifiable health information in violation of HIPAA faces a fme of $50,000 and up to 1 year imprisonment. The criminal penalties increase to $100,000 and up to 5 years imprisonment if the wrongful conduct involves false pretenses, and to $250,000 and up to 10 years imprisonment if the wrongful conduct involves the intent to sell, transfer, or use indiVidually identifiable health information for commercial advantage, personal gain, or malicious harm.


Medical records contain sensitive information, and increasing computeriza­ tion and other policy factors have increased threats to their privacy. Besides information about physical health, these records may include



infonnation about family relationships, sexUal behavior, substance abuse, and even the private thoughts and feelings that come with psychotherapy.








Administrative actions. This includes errors that release, mis­ classify, or lose information. This includes compromised accu­ racy, misuse by legitimate users, and uncontrolled access. Computerization. Although in some situations computerization increases privacy protection (for example, by adding pass­ words to sensitive areas), it may also decrease privacy protec­ tion for the following reasons: • Computerization enables storage of large amounts of data in small spaces. Thus when an intruder gains access, it is access not just to certain discrete amount of data, but also to larger collections, and perhaps keys to even further information. • Networked information is accessible from anywhere at any time, allowing a larger number of people access. This increases the possibility of mistakes or other problems such as misuse or leaks of data. • New databases and different types of datasets are more easily created. This both drives demand for new information and makes possible its creation. • Information is easily gathered, exchanged, and transmitted. Thus the potential for dissemination is theoretically limitless. • Access by unrelated parties. Insurance companies. They may either check records before approving treatment or may check records before extending coverage. Financial institutions. The federal Gramm-Leach-Bliley Act (GLB) allows financial companies such as banks, brokerage houses, and insurance companies to operate as a single entity. Drug companies. These companies may have deals with doc­ tors and hospitals, and may use the list for marketing. Employers. Court subpoenas. Often a patient will be unaware when his or her records have been subpoenaed. Even worse, unnecessary information is often included when the records are not ade­ quately screened. Legislative risks to medical record privacy: • A national medical records databank without adequate privacy safeguards. • Medical ID cards. These are problematic because of the backup databank necessary.

~ ~


Medical ethics. The privacy portion of the Hippocratic Oath: "Whatsoever I shall see or hear in the course of my intercourse with men, if it be what should not be published abroad, I will never divulge, holding such things to be holy secrets." The 1992 AMA statement, which states that medical information must be confidential to the greatest possible degree.



Laws and other legal protection. • The Privacy Act of 1974, as previously mentioned, which states that no federal agency may disclose information without the consent of the person. Agencies must also meet certain require­ ments for protecting the information. • Other federal laws. These laws only cover federal agencies, such as Medicare and Medicaid. • State laws. Various, inconsistent, and often ineffectual state laws cover the bulk of medical records. • Tort law. This may include defamation, breach of contract, and other privacy-related torts.

Direction and supelVision are essential administrative responsibilities for the provision of high-quality physical therapy. The degree of direc­ tion and supelVision necessary for ensuring high-quality physical ther­ apy depends on many factors, including the education, experience, and responsibilities of the parties involved; the organizational structure in which the physical therapy is provided; and applicable state law.!

Leadership is a process by which a person influences others to accom­ plish an objective and directs the organization in a way that makes it more cohesive and coherent. Leaders carry out this process by apply­ ing their leadership attributes, such as beliefs, values, ethics, character, knowledge, and skills. There are a number of leadership theories. 11 -22

Bass theory of leadership 23,24 states that there are three basic ways to explain how people become leaders:


Trait theory. Some personality traits may lead people naturally into leadership roles. Great events theory. A crisis or important event may cause a person to rise to the occasion, which brings out extraordinary leadership qualities in an ordinary person. Transformational leadership theory. People can choose to become leaders and can learn leadership skills.


The four-framework approach 25 suggest that leaders display leadership behaviors in one of four types of frameworks:

Structural framework. Structural leaders focus on structure, strategy, environment, implementation, experimentation, and adaptation.

CHAPTER 2. ADMINISTRATION • In an effective leadership situation, the leader is a social


architect whose leadership style is analysis and design.
• In an ineffective leadership situation, the leader is a petty auto­



crat whose leadership style is details. Human resource framework. Human resource leaders believe in people and communicate that belief; they are visible and accessible; they empower, increase participation, support, share information, and move decision-making down into the organization. • In an effective leadership situation, the leader is a catalyst and servant whose leadership style is support, advocacy, and empowerment. • In an ineffective leadership situation, the leader is a pushover, whose leadership style is abdication and fraud. Political framework. Political leaders clarify what they want and what they can get; they assess the distribution of power and interests; they build linkages to other stakeholders, use persuasion first, and then use negotiation and coercion only if necessary. • In an effective leadership situation, the leader is an advocate, whose leadership style is coalition and building. • In an ineffective leadership situation, the leader is a hustler, whose leadership style is manipulation. Symbolic framework. Symbolic leaders view organizations as a stage or theater to play certain roles and give impressions; these leaders use symbols to capture attention; they try to frame experience by providing plausible interpretations of experi­ ences; they discover and communicate a vision. • In an effective leadership situation, the leader is a prophet, an inspirational leader. • In an ineffective leadership situation, the leader is a fanatic or fool, whose leadership style is smoke and mirrors.

The Blake and Mouton managerial grid 26 (Fig. 2-1) uses two axes: 1. "Concern for people" is plotted using the vertical axis. 2. "Concern for results" is plotted along the horizontal axis. The managerial grid graphic is a very simple framework that ele­ gantly defines the basic styles that characterize workplace behavior and the resulting relationships based on how two fundamental con­ cerns (concern for people and concern for results) are manifested at varying levels whenever people interact. Most people fall somewhere near the middle of the two axes, but people who score on the far end of the scales can be categorized into five types of leaders:

Controlling (produce or perish) (9 on task [high task]), 1 on people [low relationship]). People who get this rating are very much task oriented and are hard on their workers (autocratic). There is little or no allowance for cooperation or collaboration. Heavily task-oriented people display these characteristics: they are very strong on schedules; they expect people to do what they are told without question or debate; when something goes







... .e ...




4 3















Concern for results


Controlling (direct and dominate) Accommodating (yield and comply) Middle of the road (balance and compromise) . ... Indifferent (evade and elude) ... • . Team leader (contrtbute and commit) ;'if". 'z·.cl 19

Figure 2-1. Blake and Mouton managerial grid.





wrong they tend to focus on who is to blame rather than con­ centrate on exactly what is wrong and how to prevent it; and they are intolerant of what they see as dissent, so it is difficult for their subordinates to contribute or develop. Team leader (9 on task [high taskl, 9 on people [high relation­ shipD. This type of person leads by positive example and endeavors to foster a team environment in which all team members can reach their highest potential, both as team mem­ bers and as people. They encourage the team to reach team goals as effectively as possible, while also working tirelessly to strengthen the bonds among the various members. They nor­ mally form and lead some of the most productive teams. Accommodating (country club) (l on task, 9 on people). This person uses predominantly reward power to maintain dis­ cipline and to encourage the team to accomplish its goals. Conversely, they are almost incapable of employing the more punitive coercive and legitimate powers. This inability results from fear that using such powers could jeopardize relationships with the other team members. Indifferent (impoverished) (l on task, 1 on people). A leader who uses a "delegate and disappear" management style. Because they are not committed to either task accomplishment or maintenance; they essentially allow their team to do whatever it wishes and prefer to detach themselves from the team process by allowing the team to suffer from a series of power struggles. Middle of the road (5 on task, 5 on people). Managers using this style try to balance between company goals and workers' needs. By giving some concern to both people and production, managers who use this style hope to achieve acceptable per­ formance.



Although it may appear that the most desirable place for a leader to be would be a 9 on task and a 9 on people (team leader), certain sit­ uations might call for one of the other four to be used at times.

A number of management styles have been recognized (Table 2-6),

A distinction is often made between being a manager and being a leader (Table 2-7).

The most effective tool for accomplishing communication objectives within a department is the staff meeting (Table 2-8). Staff meetings can be used to:
~ ~


Chart progress. Keep staff informed of all office activities. Coordinate between offices and departments. Determine how close the department is to meeting the goals of the strategic plan.


Managers see themselves primarily as employee trainers Management by coaching and development Individuals and groups within the organization compete against one another to achieve the Management by competitive edge best results Management by consensus Managers allow for the individual input of the employees Management by decision models Decisions are based on projections generated by constructed situations Management by exception Managers delegate as much responsibility and activity as possible intervening only when absolutely necessary Management by information Managers depend on data generated to help them increase efficiency systems Management by Emphasizes communication as well as integration of all human aspects (mental, emotional, physical, and spiritual) interaction Management by matrices Managers study variables to discern their interrelatedness, and cause and effect Management by objectives Managers set objectives for each employee based on the objectives of the organization. This method eliminates communication problems through the establishment of regular meetings, emphasiZing results, and being an ongoing process where new objectives are established and old objectives are modified as necessary according to changes in conditions Management by organizational Managers constantly seek to improve employee relations and communications development Management by performance Managers through motivation and employee relations Management by styles Managers adjust their approaches to meet situational needs Managers walk around the company, stopping to talk and to listen. This management style is Management by walking around based on the Hewlett-Packard (HP) Way developed by entrepreneur Dave Packard, co-founder ofHP Management by work Managers constantly seek ways to simplify processes and reduce expenses simplification



TABLE 2-7. MANAGEMENT VERSUS LEADERSHIP TRAITS MANAGEMENT TRAITS Does not ensure imagination, inventiveness, or ethical behavior Rationally analyzes and builds a systematic selection of targets and objectives Directs energy toward purposes, resources, and organization structure, and constructs a list of problems to resolve Can perpetuate group conflicts Becomes anxious when there is relative disorder Uses an accumulation of concerted experience to effectively make decisions Innovates by modifying existing practices Sees the world as relatively impersonal and passive Influences people through reason, details, and rationale Views work as an enabling process, incorporating a merger of plans, skills, timing, and staff Has a low level of emotional involvement in their occupation Relates to personnel by the role they play in the decision-making process Focuses on how tasks require completion Focuses attention on the process Forms moderate and widely distributed personal attachments with others Feels threatened by open challenges to their ideas, and are troubled by aggressiveness LEADERSHIP TRAITS Uses personal power to affect the plans and endeavors of others Intuitive, enigmatic understanding of what is essential Directs energy toward guiding people toward practical solutions

Works to develop compatible interpersonal relationships Works best when circumstances are somewhat uncontrolled Often jumps to conclusions, without a logical progression of concepts or fact Innovates through perception or intuition Sees the world as rich in color, constantly blending into new situations Influences people through altering moods, evoking images and anticipation Views work as making new approaches to old problems, or discovering new options for old issues Takes in emotional signals from others, making them mean something in the connection with an individual; often passionate about their career Relates to people intuitively and empathically Focuses on what needs to be done, leaVing determinations to the personnel involved Focuses on the determination to be made Forms comprehensive one on one relationships, which may be of short duration; often has mentors Able to tolerate aggressive interchanges, encouraging emotional involvement with others

TABLE 2-8. TIPS FOR EFFECTIVE STAFF MEETINGS Designate a meeting facilitator. Have a clear purpose and written agenda for the meeting. ~ Establish a starting and ending time for the meeting. ~ Inform staff ahead of time of their responsibilities for the meeting (bringing their calendars, briefing other staff on relevant issues, note-taking, etc.). ~ Encourage staff to participate but not to dominate. ~ If certain issues or projects require extensive planning or discussion, schedule another meeting for the relevant staff rather than discussing it with the full group. ~ Do not use staff meetings to discuss the performance of individuals, except for giving them a word of praise. ~ Close the meeting with a bang-and a plan.




A job is a collection of tasks and responsibilities that an employee is responsible to conduct. Jobs have titles. Job descriptions (JDs) are lists of the general tasks, or functions, and responsibilities of a position. A task is typically defined as a unit of work, that is, a set of activities needed to produce some result (e.g., completing an examination, writing a physician memo). Complex positions in the organization may include a large number of tasks, which are sometimes referred to as functions. A responsibility is the relationship between the value of a job out­ come and the worker's input of effort; the employee's situation within, and their impact to the organization. A role is the set of responsibilities or expected results associated with a job. A job usually includes several roles. Typically, JDs also include to whom the position reports, specifi­ cations such as the qualifications (necessary skills and experience required). needed by the person in the job, salary range for the position, and so on. To avoid age discrimination, experience should not include an upper limit. JDs are usually developed by conducting a job analysis, which includes examining the tasks and sequences of tasks necessary to per­ form the job. The analysis looks at the areas of knowledge and skills needed by the job. A JD should indicate the scope of the job, its responsibilities and duties and essential functions, and clearly indicate what contribution the position makes to the organization (Table 2-9). The JD is usually not all inclusive, and includes a statement at the end to indicate ". other duties as assigned."


Begin sentences with action verbs, to give a concise and consistent style. ~ Focus on major or critical actiVities, with dis­ tinctions made between minor activities that are done daily and major ones that might occur less frequently.

The performance appraisal (performance review, performance evalua­ tion, personnel rating, merit rating, employee appraisal, or employee evaluation) is any personnel decision that affects the status of employ­ ees regarding their retention, termination, promotion, transfer, salary increase or decrease, or admission into a training program. The performance appraisal is a vehicle to:
~ ~

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Validate and refine organizational actions and practices, or institute new ones. Provide feedback to employees with an eye on improving future performance. Although employees vary in their desire for improvement, generally workers want to know how well they are performing. People need positive feedback and vali­ dation on a regular basis. Once an employee has been selected, few management actions can have as positive an effect on worker performance as encouraging affirmation.


A list of the various types of rating systems follows.

Behavioral anchored rating scales: a performance rating that focuses on specific behaviors or sets as indicators of effective or










ineffective performance, rather than on broadly stated adjectives such as "average, above average, or below average." Other variations are: Behavioral observation scales.
Behavioral expectations scales.
Numerically anchored rating scales.
Checklists: a set of adjectives or descriptive statements. If the rater believes the employee possesses a trait listed, the rater checks the item. If the rater does not believe the employee possesses a trait listed, the rater leaves the item blank. Critical incident technique: a method of performance appraisal that makes lists of statements of very effective and very ineffective behavior for employees. The lists are usually combined into categories, which vary with the job. Once the categories have been developed and statements of effective and ineffective behavior have been provided, the evaluator prepares a log for each employee. During the evaluation period, the evaluator records examples of critical behaviors in each of the categories, and the log is used to evaluate the employee at the end of the evaluation period. Forced choice method: developed to prevent evaluators from rating employees too high. Using this method, the evaluator has to select from a set of descriptive statements that apply to the employee. The statements are weighted and summed to form an effectiveness index. Forced distribution: an appraisal system similar to grading on a curve. The evaluator is asked to rate employees in some fixed distribution of categories. Graphic rating scale: the oldest and most widely used perform­ ance appraisal method. The evaluators are given a graph and asked to rate the employees on a list of characteristics. The number of characteristics can vary from 1 to 100. Narrative or essay evaluation: the evaluator is asked to describe strengths and weaknesses of an employee's behavior. Paired comparison: an appraisal method for ranking employ­ ees. The names of the employees to be evaluated are first placed on separate sheets in a predetermined order, so that each person is compared with all other employees to be evalu­ ated. The evaluator then checks the person he or she feels has been the better of the two on the criterion for each comparison. The number of times a person has been preferred is tallied, and the tally developed is an index of the number of preferences compared to the number being evaluated.



Translate organizational goals into individual job objectives. Communicate expectations regarding an employee performance. Provide feedback to the employee about job performance in light of departmental objectives.

~ ~ ~



Coach the employee on how to achieve job objectives/ requirements. Diagnose the employee's strengths and weaknesses. Determine what kind of development activities might help the employee better utilize his or her skills to improve performance on the current job (developmental plan). Complete formal documentation of the performance appraisal and developmental plan (if necessary).

Some of the most effective ways for managers to motivate staff include giving praise, recognition, positive feedback, and the passing on of feedback from more senior managers. If staff feel that their decisions are generally supported, and when genuine mistakes are made they will be guided in the right direction, then they will be more positive, confident, and prepared to take on responsibility and decision-making. Finally, when staff are shown clear expectations and when they are valued, trusted, encouraged, and motivated, they will be more likely to give their best.

It is the responsibility of the physical therapy director/manager/

supervisor to provide ongoing educational program activities for the rehabilitation staff in order to enhance professional growth. Educational programs may occur during work time, in the evenings, or on weekends. In addition, staff members should be encouraged to attend professional and educational development classes, including those outside of the organization, based on financial constraints.



Policy manual. The purpose of a policy manual is to familiarize employees with the specific mission, culture, expectations, and benefits of the department/organization. Procedure manual. Procedure manuals differ from policy manuals in that they are used to assist employees in dealing with situations that may arise during the daily operations of the practice (e.g., charge entry, patient scheduling and registration processes, answering the telephone, and appro­ priate handling of referrals to physicians or other health care professionals).

Although these manuals, which are often combined into one binder, are not a legal contract, they do help to provide a clear, com­ mon understanding of departmentaVorganizational goals, benefits, and policies, as well as what is expected with regard to performance



and conduct. A typical policy and procedure manual has approxi­ mately eight sections, including the following:

~ ~ ~ ~ ~ ~ ~

Introduction. Employment. Employment status and records. Employee benefit programs. Timekeeping/payroll. Work conditions and hours. Leaves of absence. Employee conduct and disciplinary action.

The policy and procedure manual must be guided by various state and federal legislation, such as Equal Employment Opportunity (EEO)-protected classes, the Americans with Disabilities Act (ADA), the Family and Medical Leave Act (FMLA), and the Fair Labor Standards Act (FLSA)-exempt versus nonexempt. Table 2-10 provides a brief description of each of these laws. A yearly review of the policies is recommended.

TABLE 2-10. VARIOUS STATE AND FEDERAL LEGISLATIONS LEGISLATION Equal Employment Opportunity Act (EEO) Family and Medical Leave Act (FMLA) EXPLANATION Prohibits discrimination on the basis of race or color, national origin, sex, ancIJor religion. Requires employers with 50 or more employees to allow up to 12 work-weeks of unpaid leave in any 12-month period for the birth, adoption, or foster care placement of a child, or serious health condition of the employee, spouse, parent, or child, provided the leave is taken within 12 months of such event. Intermittent leave is allowed if there is a medical need for the leave. Intermittent leave is leave taken in separate blocks of time due to a single illness or injury, rather than in one continuous period. The employers must pay overtime to their workers whenever they work more than 40 hours in any week. Under Pennsylvania's state wage and hour laws, individuals employed in a bona fide executive, administrative, or professional capacity (salaried) are exempt from the overtime provisions of the law. Prohibits employment discrimination based on race, color, sex, religion, and national origin. Prohibits employers from discriminating against persons from 40 to 70 years of age in any area of employment. Prohibits employment discrimination based on disability in federal executive agencies, and full institutions receiving Medicare, Medicaid, and other federal support. Prohibits discrimination against "qualified individuals with disabilities." • An individual is considered to have a disability if he or she has a physical or mental impair­ ment that substantially limits one or more major life activities, has a record of such impair­ ment, or is regarded as having such impairment. • Persons discriminated against because they have a known association, or relationship with, an individual with a disability are also protected. • Discrimination is prohibited in all employment practices, including job application proce­ dures, hiring, firing, advancement, compensation, training, and other terms, conditions, and privileges of employment. • Discrimination applies to recruitment, advertising, tenure, layoff, leave, fringe benefits, and all other employment-related activities. • The ADA applies to employers with 15 or more employees.

Fair Labor Standards Act (FLSA)

Civil Rights Act of 1964 The Age Discrimination and Employment Act of 1967 1973 Rehabilitation Act American with Disabilities Act (ADA)



The purpose of the Occupational Safety and Health Administration (OSHA) Hazard Communication Standard is to ensure that the level of hazard of all chemical substances is known and communicated. Mixtures produced or imported are evaluated, and any hazard information is communicated by means of a written document called the Material Safety Data Sheet (MSDS). The MSDS must be written in English and contains certain required information including the chemical identity or common name, health hazards, emergency and first-aid procedures, and safety precautions.

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cywithintheU.S. r that is responsi­ .' uidelines to promote.' the workplace.. ..

The purpose of incident/occurrence reporting is to understand the underlying or contributing conditions that led to the occurrence of a safety incident, identify appropriate corrective actions that must be taken to address these conditions, and implement timely and effective cor­ rective actions. An incident/occurrence report typically contains the following information.
~ ~ ~ ~ ~ ~ ~ ~

Name or description of the incident/occurrence. Attention should be placed on making the report Simple, clear, and inclusive. Time and date of incident/occurrence. Brief description of the incident/occurrence location. A simple, chronological narrative works best. Brief description of incident. First and last names and titles of persons involved, if appropriate. What's being done and/or will be done next. Other departments involved or to become involved in the inci­ dent (emergency services, physician, etc.). The name and title of the person submitting the report.

A sentinel event is an adverse health event that may have been avoided through appropriate care or alternative interventions. Examples of a sentinel event are provided in Table 2-11. Health care providers are required to alert the JCAHO and often state licensing authorities of all

Any patient death, paralysis, coma, or other major permanent loss of function associated with a medication error. Any suicide of a patient in a setting where the patient is housed around-the-clock, including suicides following elopement from such a setting. ~ Any elopement, that is, unauthorized departure, of a patient from an around-the-clock care setting resulting in a temporally related death (suicide or homicide) or major permanent loss of function. ~ Any procedure on the wrong patient, wrong side of the body, or wrong organ. ~ Any intrapartum (related to the birth process) maternal death. ~ Any perinatal death unrelated to a congenital condition in an infant having a birthweight greater than 2500 g. ~ Assault, homicide or other crime resulting in patient death or major permanent loss of function. ~ A patient fall that results in death or major permanent loss of function as a direct result of the injuries sustained in the fall. ~ Hemolytic transfusion reaction involving major blood group incompatibilities




sentinel events, including a review of risk factors, preventative meas­ ures, and case analyses.


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According to the United States Public Health Service, malpractice can be viewed as a dereliction from professional duty or a failure to exercise an accepted degree of professional skill or learning by one rendering professional services that results in injury, loss, or damage. Malpractice also encompasses an injurious, negligent, or improper practice. Physical therapists are personally responsible for negligence and other acts that result in harm to a patient through professional- patient rela­ tionships. Negligence is defined as failure to do what reasonably com­ petent practitioners would have done under similar circumstances. To find a practitioner negligent, harm must have occurred to the patient. Examples involving physical therapy could include:
~ ~ ~ ~ ~

A burn caused by a hot pack.
Using defective exercise or electrical equipment.
Failing to prevent a patient from falling.
Causing an injury to a patient through improper prescription of
exercises. Performing any action or inaction that is inconsistent with the Code of Ethics, or the Standards of Practice.

Informed consent is the process by which a fully informed individual can participate in choices about his or her health care. It originates from the legal and ethical right that patients have to direct what hap­ pens to their own bodies, and from the ethical duty of the practitioner to involve the patient in his or her health care. The most important goal of informed consent is that the patient must have an opportunity to be an informed participant in his or her health care decisions. Basic consent entails explaining to the patient what you would like to do and asking for his permission to proceed. The more formal process should include a discussion of the follow­ ing elements:
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The nature of the decision/procedure.
Reasonable alternatives to the proposed intervention.
The relevant risks, benefits, and uncertainties related to each
alternative. Assessment of patient understanding. The acceptance of the intervention by the patient.

Statutes are defmed as laws that are passed by Congress and the various state legislatures. These statutes are the basis for statutory law. The leg­ islature passes statutes that are later put into the federal code of laws or



pertinent state code of laws. Statutory law consists of the acts of leg­ islatures declaring, commanding, or prohibiting something; a particu­ lar law established by the will of the legislative department of govern­ ment. A number of statutory laws impact physical therapy. These are described in the following sections.

Professional licensing laws are enacted by all states. These laws:

Are designed to protect the consumer against professional incompetence and exploitation by opportunists. Make a determination as to the minimal standards of education. In the case of physical therapy, the minimal standards required include: Graduation from an accredited program or its equivalent in physical therapy. Successful completion of a nationallieensing examination (NPTE).

Licensure examination and related activities are the responsibility of the Federation of State Boards of Physical Therapy. All states belong to this association. Ethical and legal standards relating to continuing practice of phys­ ical therapy. All phYSical therapists must have a license to practice. Each state determines criteria to practice and issue a license.

The rules and regulations of individual state's workers' compensation systems are the primary factors influencing the provision of physical therapy seIVices for patients with work-related injuries. Workers' com­ pensation laws are designed to ensure that employees who are injured or disabled on the job are provided with ftxed monetary awards, elim­ inating the need for litigation. The laws provide a no-fault system that pays all medical benefits and replaces salary (usually at 66%) until recovery occurs. In turn, employees forfeit the right to sue their employers for damages. These rules and regulations also provide ben­ eftts for dependents of those workers who are killed because of work­ related accidents or illnesses. Some of the rules and regulations also protect employers and fellow workers by limiting the amount an injured employee can recover from an employer and by eliminating the liability of coworkers in most accidents. State workers' compensation statutes establish this framework for most employment. Federal statutes are limited to federal employees or those workers employed in some significant aspect of interstate commerce. The laws vary from state to state, but most states identify four types of disability:


Temporary partial: the injured worker is able to do some work but is still recuperating from the effects of the injury, and is thus temporarily limited in the amount or type of work which can be performed compared to the pre-injury work. Temporary total: the injured worker is unable to work during a period when he or she is under active medical care and has not yet reached what is called "maximum medical improvement."



.. Permanent partial: the injured worker is capable of employ­ ment, but is not able to return to the former job. Benefits are usually paid according to a prescribed schedule for a fixed number of weeks. .. Permanent total: the injured worker cannot return to any gain­ ful employment, and lifetime benefits are provided to the employee.

Over the last 200 years, trade unions 27 -31 have developed into a num­ ber of forms, with differing political and economic climates influencing them. The immediate objectives and activities of trade unions vary, but may include: .. Provision of benefits to members. Early trade unions often pro­ vided a range of benefits to insure members against unem­ ployment, ill health, old age, and funeral expenses. In many developed countries, these functions have been assumed by the state; however, the provision of legal advice and represen­ tation for members remains an important benefit of trade union membership. .. Collective bargaining. Where trade unions are able to operate openly and are recognized by employers, they may negotiate with employers over wages and working conditions. .. Industrial action. The inability of both parties to reach an agree­ ment may lead to industrial action, culminating in either strike action or management lockout in furtherance of particular goals. In extreme cases, violent or illegal activities may develop around these events. .. Political activity. Trade unions may promote legislation favorable to the interests of their members or workers as a whole. To this end, they may pursue campaigns, undertake lobbying, and finan­ cially support individual candidates or parties for public office. .. Sectional organization. Unions may organize a particular sec­ tion of skilled workers (craft unionism), a cross-section of workers from various trades (general unionism), or attempt to organize all workers within a particular industry (industrial unionism). These unions are often divided into "locals," and united in national federations.

1. APTA. Guide to Physical Tberapist Practice. Phys Tber. 81:S13-S95, 2001. 2. Leigh JP, Waehrer G, Miller JR, et al. Costs of occupational injury and illness across industries. Scand J Work Environ Health. 30: 199-205;2004. 3. Liu]H, Etzioni DA, O'Connell]B, et al. The increasing workload of general surgery. Arch Surg. 139:423--8;2004. 4. Shi L, Macinko J, Starfield B, et al. The relationship between primary care, income inequality, and mortality in US States, 1980-1995. J Am Board Fam Pract. 16:412-22;2003.



5. Garrett N, Martini EM. The boomers are coming: a total cost of care model of the impact of population aging on the cost of chronic conditions in the United States. Dis Manag. 10:51-60;2007. 6. Hootman JM, Helmick CG. Projections of US prevalence of arthritis and associated activity limitations. Arthritis Rheum. 54:226-9;2006. 7. Uphold CR, Rane D, Reid K, et al. Mental health differences between rural and urban men living with HIV infection in various age groups.] Community Health. 30:355-75;2005. 8. Americans with Disabilities Act of 1989: 104 Stat 327. 101-336, 42 USC 12101 s2 (a) (8), 1989. 9. Waddell G, Waddell H. A review of social influences on neck and back pain disability. In: Nachemson AL, Jonsson E, eds. Neck and Back Pain: The Scientific Evidence ofCauses, Diagnosis, and Treatment. Philadelphia, PA: lippincott, Williams and Wilkins, 2000, 13-55. 10. Quadagno]. Why the United States has no national health insur­ ance: stakeholder mobilization against the welfare state, 1945-1996. ] Health Soc Behav. 45:25-44;2004. 11. Aaron 1. Program director satisfaction with leadership skills. Radiol Techno!' 78:104-12;2006. 12. Alimo-Metcalfe B. Leadership. Peak practice. Health Serv]. 116: 28-9;2006. 13. Ausman]I. Leadership vs. consensus. Surg Neura!. 66:548-9;2006. 14. Friedman PK. Mentoring: leadership, learning, legacy.] Mass Dent Soc. 55:16-8;2006. 15. Garman AN, Butler P, Brinkmeyer 1. Leadership.] Healthc Manag. 51:360--4;2006. 16. Gifford WA, Davies B, Edwards N, et al. Leadership strategies to influence the use of clinical practice guidelines. Can] Nurs Leadersh. 19:72-88;2006. 17. Hohne K. The principles of leadership.] Trauma Nurs. 13:122-5;2006. 18. Kerfoot K. Authentic leadership. Medsurg Nurs. 15:319-20;2006. 19. Naylor CD. Leadership in academic medicine: reflections from administrative exile. Clin Med. 6:488-92;2006. 20. Redman RW. Leadership strategies for uncertain times. Res Theory Nurs Pract. 20:273-5;2006. 21. Sternberg R]. A systems model of leadership: WICS. Am Psychol. 62:34-42; discussion 43-7;2007. 22. Zaccaro S]. Trait-based perspectives of leadership. Am Psychol. 62:6-16; Discussion. 43-7;2007. 23. Bass B. Stogdill's Handbook ofLeadership: A Survey of Theory and Research. New York: Free Press; 1989. 24. Bass B. From transactional to transformational leadership: learning to share the vision. Organ Dyn. 18:19-31;1990. 25. Bolman L, Deal T. Reframing Organizations. San Francisco, CA: Jossey-Bass; 1991. 26. Blake RR, Mouton JS. The Managerial Grid IlL The Key to Leadership Excellence. Houston, TX: Gulf Publishing Co.; 1985. 27. Roelofs C. Trade unions and cleaner production: perspectives and proposals for action. New Solut. 9:277-95; 1999. 28. Cohen P. Trade unions. United fronts? Nurs Times. 89:40-1;1993. 29. Johansson M, Partanen T. Role of trade unions in workplace health promotion. Int] Health Servo 32:179-93;2002. 30. Myers ML. Professional trade unions. Hospitals. 44:80-3;1970. 31. O'Shea P. Nurses and trade unions: an uneasy relationship. World Ir Nurs. 5:12-4;1997.



Comprehension Questions

1. Give three examples of the administrative activity in which the physical therapist may engage in during his or her career. 2. What is HMO an acronym for? 3. In an HMO setup, which individual serves as a gatekeeper for the insurance com­ pany by being responsible for the authorization of specialty services, and who receives bonuses based on how much they conserve medical resources? 4. True or false: Medicare and Medicaid are government-funded programs. A. True. B. False. 5. True or false: Medicare is funded by special contributions by members of the U.S. Senate. A. True. B. False. 6. What is the State Children's Health Insurance Program (SCHIP)? 7. Who does the Ryan White Act provide funds for to cover the cost of medications? 8. What is the purpose of the certificate of need (CON) laws? 9. What is an advance directive? 10. Which act secures equal opportunity for individuals with disabilities in employment, public accommodations, transportation, state and local government services, and telecommunications? 11. The WorkAgain Center, specializing in work hardening and conditioning, is sched­ uled for an accreditation survey. The appropriate agency to conduct this program is the: A. Commission on Accreditation of Rehabilitation Facilities (CARF). B. Joint Comrnission on Accreditation of Healthcare Organizations UCAHO). C. Occupational Safety and Health Administration (OSHA). D. Department of Health and Human Services. 12. How often does the Joint Commission on Accreditation of Healthcare Organizations UCAHO) survey hospitals? A. Once per year. B. Every 2 years. C. Every 3 years. D. Every 5 years. 13. What is a per diern rate?



14. Which of the following is a correct statement about Medicare? A. Medicare Part A is only for patients over 85 years old. B. Medicare Part Bis only for patients 65 to 84 years old. e. Medicare Part A is only for inpatient treatment. D. Medicare Part Bis only for use in long-term facilities.

15. Under what part of Medicare are outpatient physical therapy services reimbursed?
A. Part A. B. Part B. e. Parte. D. Part D.

16. Which Act resulted in payment reductions to health care providers, new prospective
payment systems for health care providers, and reduction of coverage of health care services by the Medicare and Medicaid programs?

17. What was the purpose of the Health Insurance and Portability Accountability Act

18. True or false: A major goal of HIPAA's privacy rule is to assure that individuals' health
information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public's health and well-being. A. True. B. False. 19. Which type of health insurance plan allows individuals to have a personal health account, such as a health savings account (HSA) or a health reimbursement arrange­ ment (HRA), from which they pay medical expenses directly?

20. The supervisor of a rehabilitative facility insists on a weekly meeting to discuss
reductions in productivity. The supervisor appears unconcerned with the increased demand placed on the already overworked employees. According to Blake and Mouton's managerial grid, what is the best classification of this manager? A. 5,5. B. 9,9. e. 1,9. D. 9,1. 21. True or false: Job descriptions are lists of the general tasks, or functions, and respon­ sibilities of a position. A. True. B. False. 22. Which of the following is an example of a policy in a physical therapy clinic? A. The clinic dress code. B. The correct way to accept a telephone referral. e. The operational hours of the clinic. D. A and e.



23. Which clinic document contains information about the chemical identity or com­ mon name of materials used in the clinic and the health hazards, emergency and first aid procedures, and safety precautions associated with those materials? 24. According to the Joint Commission on Accreditation of Healthcare Organizations UCAHO), what is a sentinel event? A. A patient who is seriously injured at a facility. B. An employee who is seriously injured at a facility. C. A JCAHO surveyor who finds a major error in a facility's billing policies. D. None of the above. 25. Define malpractice. 26. True or false: Every individual (PT, PTA, student PT, or student PTA) is liable for his or her own negligence. A. True. B. False. 27. How often does the Joint Commission on Accreditation of Healthcare Organizations UCAHO) require that all electrical equipment in hospitals be inspected? A. Every 3 months. B. Every 6 months. C. Every 12 months. D. Every 3 years. 28. All of the following criteria would designate a patient as homebound and allow for home physical therapy services to be approved by Medicare except: A. Being dependent on relatives for all transportation needs. B. Inability to safely leave home unattended. C. Ambulation for short distances causes dyspnea and chest pain. D. Leaving the home three times a week to receive dialysis. 29. A 50-year-old steelworker, who is married with 4 children, has been laid off his job for the last year. The family is currently on welfare. While cutting his grass he has a stroke and is admitted to the hospital. In this case, the third-party payer that would provide assistance is: A. Medicaid. B. Worker's compensation. C. Medicare part A. D. Social Security. 30. When billing Medicare, Medicaid, and many other third-party payers, providers are required to use the appropriate: A. CPT and common procedural coding system procedure codes. B. Current procedural terminology (CPT) procedure codes. C. Common procedural coding system of Center for Medicare and Medicaid Services (CMS). D. Resource-based relative value scale (RBRVS).




1. Ensuring fiscally sound reimbursement for services rendered; budgeting for physical therapy services; and managing staff resources, including the acquisition and devel­ opment of clinical expertise and leadership abilities. 2. Health maintenance organization.

3. The primary care physician (PCP).
4. The answer is A. This statement is true. 5. The answer is B. This statement is false. Medicare is funded by payroll tax, under the Federal Insurance Contributions Act (FICA). 6. Aprogram that provides insurance coverage for children of the working poor, for peo­ ple with full-time jobs that do not offer employment-based insurance, and for those who earn too much for Medicaid but not enough to afford private insurance.

7. Uninsured individuals with HIV/AIDS.
8. To regulate major capital expenditures, which may adversely impact the cost of health care services; to prevent the unnecessary expansion of health care facilities; and encourage the appropriate allocation of resources for health care purposes. 9. A written instruction, such as a living will or a durable power of attorney for health care, that provides instructions for the provision of medical treatment in anticipation of those times when the individual executing the document no longer has decision­ making capacity. 10. The Americans with Disabilities Act (ADA). 11. The answer is A. 12. The answer is C. 13. A set price for one day of hospital care, including all ancillary services, excluding separately billed physician services. 14. The answer is C. 15. The answer is B. 16. The Balanced Budget Act of 1997. 17. To provide a mechanism to spread the risk of unforeseen medical expenditures across abroad base to protect the individual from personal expenditures. 18. A. This statement is true. 19. Consumer-driven health care plans. 20. The answer is D. 21. The answer is A. This statement is true.



22. The answer is D. 23. Material data safety sheet (MSDS). 24. The answer is A. 25. A failure to exercise an accepted degree of professional skill or learning by one ren­ dering professional services that results in injury, loss, or damage. 26. The answer is A. This statement is true. 27. The answer is C. 28. The answer is A. 29. The answer is A. 30. The answer is A.


Research involves a controlled, systematic approach to obtain an answer to a question. 1 A number of research types are recognized. researcfi)involves the manipulation of a variable and measuring the effects of this manipulation. 1 ~ ~experimental researc!0does not manipulate the environ­ ment, but may describe the relationship between different vari­ ables, obtain information about opinions or policies, or describe current practice. 1 ~(j§sic researcto generally thought of as laboratory-based research in which the researcher has control over nearly all ~ects of the environment and subjects. 1 ~ (Clinical or appljed research;') refers to scientific study and research that seeks to solve practical problems. Applied research is used to fmd solutions to everyday problems, cure ill­ ness, and develop innovative technologies.
~ LEXperimentaJ

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fi~e;it. sh~~ldinf?lyd?aIlPoss jbl~ al"lsY"€!rabl€lrespon~~,. ••..• <.... <... .

exclusive; .norespondent•• shot,rId be able to have two attributes simqltaneously, . . . ..



Statistics is a branch of applied mathematics concerned with finding patterns in data and inferring connections between events. 2 Statistics is sometimes divided into two main areas, depending on how the data are used:

~(QescriptiveJoescriptive statistics describe what is or what the data shows. Descriptive statistics include the collection, organ­ ization, summarization, and presentation of data. 2 ~ @erentiaI]Inferential statistics are used to try to reach conclu­ sions that extend beyond the immediate data alone. Inferential statistics include making inferences from samples to popula­ tions, estimations and hypothesis testing, determining relation­ ships, and making predictions. 2 Inferential statistics are based on probability theory.2 Probability deals with events that occur by chance.



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There are two basic types of statistical studies: observational studies and experimental studies.

A population consists of all subjects (human or othetwise) that are being studied.

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Prevalence: the proportion of a population that has a particular disorder or condition at a specific point in time. Incidence: a rate of development of new cases of a disorder in a particular at-risk population over a given period of time. Parameter: a characteristic or measure obtained by using all the data values from a specific population.

A sample is a group of subjects selected from a population.

Statistic: a characteristic or measure obtained by using all the data values from a sample.


To gain knowledge about seemingly haphazard events, statisticians col­ lect information for variables, which describe the event. Data are the values (measurements or observations) that the variables can assume. Variables can be classified as qualitative or quantitative:

~ A rqii'ilitative variable'lcan be placed into a distinct category ~ according to some cQaracteristic or attribute (e.g., gender). ~ Ac§uantitative variable) numeric and can be ordered or ranked (e.g., age, height, weight). Quantitative variables can be further classified into two groups, discrete and continuous: 2 Discrete variables can assume only certain values that are countable (e.g., number of children in a family).
Continuous variables can assume an infinite number of pos­
sible values in an interval between any two specific values
(e.g., temperature).

In addition to being classified as qualitative and quantitative, vari­ ables can be classified by how they are categorized, counted, or meas­ ured. This type of classification uses measurement scales. The four classic scales (or levels) of measurement include 2 : (1lassificatory, categorical). Classifies data into mutu­ ally exclusive, exhausting categories in which no order or rank­ ing can be imposed. Examples include arbitrary labels (e.g., zip codes, \eligion, marital status). ~ c9rdinalj(ranking). Classifies data into categories that can be ranked, although precise differences between the ranks do not exist (e.g., letter grades [A, B, C, etc.], body builds [small, medium, large]). ~(ft1terv~nks data and precise differences between units of "--measUre do exist, although there is no meaningful zero. Examples include temperature (degrees centigrade, degrees Fahrenheit), IQ, and calendar dates.

~ ~minal



~/fuitio.\Possesses all the characteristics of interval measurement,
~ true zero exists. Examples include length, weight, age,
and salary.
DATA COLLECTION AND SAMPLING TECHNIQUES Researchers use samples to produce a representative segment of the target population. To avoid any biasing of the collected information, samples must be collected in a systematic fashion. Four basic methods of sampling are employed.

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~ ~dom sampli~all items have some chance of selection that

can be calculated, t~reby minimiZing sampling bias.
~ @tematic sampling) sometimes referred to as interval sam­
pling, means that there is a gap, or interval, between each
selection (e.g., every 20th person).
~ ~atified sampling; sometimes called proportional or quota
random sampling, involves dividing the population into homo­
geneous subgroups called strata, and then taking a simple ran­ dom sample in each subgroup. Stratified sampling assures that not only will the overall population be represented, but also the ~ subgroups of the population. ~ Cluster samplingJrnvolves dividing the population into groups or clusters (such as geographic boundaries), and then ran­ domly selecting sample clusters and using all members of the selected clusters as subjects of the samples. GRAPHICAL REPRESENTATION Of ORGANIZED DATA The most convenient method of organizing data is to construct a fre­ quency distribution. 3 Two types of frequency distributions are 3 :


Categorical frequency distribution. Used for data that can be placed in specific categories, such as nominal- or ordinal-level data (e.g., political affiliation). Grouped frequency distribution. Used when the range of data is large.

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tendenCy toC{)~si~~i
or ovetestimateatru
Bias) msyst~rnati~~rr~r

Data can be presented by constructing statistical charts and graphs. The choice of which chart/graph to use is determined by the type and breadth of the data, the audience it is directed to, and the questions being asked (Table 3- 1). The three most commonly used graphs in research include the histogram, frequency polygon, and cumulative frequency graph (ogive) (Fig. 3-1). In addition to these, the Pareto chart, the times series graph, and the pie graph are also used (Fig. 3-1). In those cases where the researchers are interested in deter­ mining if a relationship between two variables (independent and depend­ ent) exists, a scatter plot or scatter diagram can be used. DATA DESCRIPTION

Measures of Central Tendency. When populations are small, it is not necessary to use samples, because the entire population can be used to gain information. Measures found by using all the data values in the population are called parameters. Measures of central tendency


DISADVANTAGES Hard to quantify partial icons.
Icons must be of consistent size.
~ Best for only 2 to 6 categories.
~ Very simplistic.


Pictograph Uses an icon and key to represent a quantity of data values in order to decrease the size of the graph. UnePlot A line plot can be used as an initial record of discrete data values. The range determines a number line, which is then plotted with Xs for each data value. Pie Chart Displays data as a percentage of the whole. A total data number should be included.



Easy to read.
Visually appealing.
Handles large data sets easily


~ ~

Quick analysis of data. Shows range, minimum and maximum, gaps and clusters, and outliers easily. ~ Exact values retained.

~ ~

Not as visually appealing.
Best for under 50 data values.
Needs small range of data.

Visually appealing. Shows percent of total for each category.


~ ~ ~

No exact numerical data.
Hard to compare two data sets.
"Other" category can be a problem.
Best for 3 to 7 categories.
Used only with discrete data.
Needs limited categories.
No exact numerical values.
Color key can skew visual
interpretation. Cannot read exact values because datais grouped into categories. More diffia.J1t to compare two data sets. Used only with continuous data. Graph categories can be reordered to emphasize certain effects Used only with discrete data

Map Chart

Displays data by shading sections of a map, and must include a key and total data number.
Histogram Displays continuous data in ordered columns. Categories are of continuous measure such as time, inches, temperature, etc.

~ ~

Good visual appeal. Overall trends show well.

~ ~ ~


Visually strong. Can compare to normal curve. ~ Usually vertical axis is a frequency count of items falling into each category.


~ ~

Bar Graph Displays discrete data in separate columns. A double bar graph can be used to compare two data sets. Categories are considered unordered and can be rearranged alphabetically, by size, etc. Line Graph Plots continuous data as points and then joins them with a line. Multiple data sets can be graphed together, but a key must be used. Frequency Polygon Can be made from a line graph by shading in the area beneath the graph.
Scatterplot Displays the relationship between two factors of the experiment. A trend line is used to determine positive, negative, or no correlation Stem and Leaf Plot Record data values in rows, and can easily be made into a histogram.


Visually strong. Can easily compare two or three data sets.



Can compare multiple continuous data sets easily. Interim data can be inferred from graph line. Visually appealing.


Used only with continuous data.



~ ~
~ ~ ~ ~ ~

Anchors at both ends may imply zero as data points. Used only with continuous data. Hard to visualize results in large data sets. Flat trend line gives inconclusive results. Data on both axes should be continuous. Not visually appealing. Does not easily indicate measures of centrality for large data sets.

Shows a trend in the data relationship. Retains exact data values and sample size. Shows minimum/maximum and outliers. Concise representation of data. Shows range, minimum and maximum, gaps and clusters, and outliers easily. Can handle extremely large data sets.


~ ~ ~

Box Plot A concise graph showing the five point summary. Multiple box plots can be drawn side by side to compare more than one data set.


Shows 5-point summary and outliers. Easily compares two or more data sets. ~ Handles extremely large data sets easily.

~ ~

Not as visually appealing as other graphs. Exact values not retained.

Adapted with permission from Dr. Elaine Young at http://scLtarnucc.edu/-eyoung/1351/stat..,graph_advantage.htmi.



(II HlstOQram: frequency pOlygon; OQIve
Used wilen the data are contained In agrouped frequency distribution.

(hi Pareto chart Used to show !requendes for nominal or quali1a11v8 variables.

(el TIme series graph
Used to show 8 pattern or Inlnd that occurs over a peltod of time.

(dl Pie graph

Used to show the relationship
between the parts and the whole.
(Most often uses pen:entages.)

Figure 3-1. Summary of graphs and uses of each. (Reproduced, with permission, from Bluman A. Elementary Statistics: A Step by Step Approach. 6th ed. New York: McGraw-Hili; 2007:73.)

are measures of the location of the middle or the center of a distribution, where data tends to cluster. Multiple metries are used to describe this clustering, including the mean, median, and mode.



Mean. The arithmetic mean is what is commonly called the average. When the word "mean" is used without a modifier, it can be assumed that it refers to the arithmetic mean. The mean of a sample is typically denoted as x. The mean is the sum of all the scores divided by the number of scores. Median. The median is the middle of a distribution-half the scores are above the median and half are below the median. The median is less sensitive to extreme scores than the mean, and this makes it a better measure than the mean for higWy skewed distributions. Mode. The mode is the most frequently occurring score in a dis­ tribution. The advantage of the mode as a measure of central tendency is that its meaning is obvious. Further, it is the only measure of central tendency that can be used with nominal data.

Frequency distributions can assume many shapes. The three most important shapes are positively skewed, symmetric, and negatively skewed (Fig. 3-2).4

~ ~

Positively skewed: the majority of the data values fall to the left of the mean and cluster at the lower end of the distribution; the "tail" is to the right. Symmetric: the data values are evenly distributed on both sides of the mean. Negatively skewed: the majority of the data values fall to the right of the mean and cluster at the upper end of the distribu­ tion; the "tail" is to the left.




Mode Median Mean (a) Positively skewed or right-skewed



(b) Symmetric

Mean Median Mode

(c) Negatively skewed or left-skewed

Figure 3-2. Types of distributions. (Reproduced, with permission, from Bluman A. Elementary Statistics: A Step by Step Approach. 6th ed. New York: McGraw-Hili; 2007:115.)

Measures of Variation. Although measures of central tendency locate only the center of a distribution, other measures, such as a deter­ mination of the spread of a group of scores, are often needed to describe data. To examine the spread or variability of a data set, three measures are commonly used. 4

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Range: the most elementary measure of variation, which is defined as the difference between the highest and lowest val­ ues (the highest value minus the lowest value). Variance: the average of the squares of the distance that each value is from the mean. Standard deviation (a, SD): a determination of the spread of a group of scores-the average deviation of values around the mean. The SD is based on the distance of sample values from the mean, and provides information about how tightly all the various examples are clustered around the mean in a set of data. When the examples are pretty tightly bunched together and the belb;baped curve is steep, thrsrandard deviation is small.~~n the examples are spread apart and the 15~..<=.ti[ve~~-L~-llat, this indicates a r~~y large st~d...-de.Yia1ion. Mathematically, the standard devrariDn equals the square root of the mean of the square deviation, or the square root of the variance. The range can be used to



approximate the standard deviation by dividing the range value by 4.

Measures of Position. In addition to measures of central ten­ dency and measures of variation, there are measures of position, which are used to locate the relative position of a data value in the data set. 4 One of the most common measures of position is the percentile. Percentiles divide the data set into 100 equal groups. The Nth per­ centile is defined as the value such that N percent of the value lie below it. For example, a score in the 95th percentile represents the top 5% of scores.
~ ~ ~

The lower quartile is defmed as the 25th percentile-75% of the measures are above the lower quartile. The middle quartile is defined as the 50th percentile-is the median of all the measures. The upper quartile is defined as the 75th percentile-25% of the measures are above the upper quartile.


Probability can be defined as the chance of an event occurring. The classic theory of probability states that the chance of a particular out­ come occurring is determined by the ratio of the number of favorable outcomes (or successes) to the total number of outcomes. An event consists of a set of outcomes of a probability experiment. Probabilities can be expressed as fractions, decimals, or-where appropriate-percentages. 5



Probability sampling. Any method of sampling that utilizes some form of random selection, and uses a process or proce­ dure that assures that the different units in the population have equal probabilities of being chosen. Nonprobability sampling: does not require random selection or the parameters of the population to be identified. This type of sampling is often utilized in physical therapy due to the increased difficulty of meeting the more rigid requirements of probability sampling.

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Random variables can be either discrete or continuous. Many continuous variables have distributions that are bell shaped, and these are called approximately normally distributed variables. 6 Normal distributions are a family of distributions that have a sym­ metrical and general shape with values that are more concentrated in the middle than in the tails (Fig. 3-3). No variable fits a normal distribution perfectly, because a normal distribution is a theoretical distribution. 6 The mean, median, and mode of a normal distribution have the same value due to the symmetry of the bell-shaped distribution (Fig. 3-4). The curve has no boundaries and only a small fraction of the values fall outside of three standard

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The standard normal distribution is a normal distribution with a mean of 0 and a standard deviation of 1.



deviations (a measure of how spread out a distribution is) above or below the mean:

Normal distribution for the population

~ ~

Figure 3-3. Histogram showing a normal dis­ tribution. (Reproduced, with permission, from Bluman A. Elementary Statistics: A Step by Step Approach. 6th ed. New York: McGraw-Hili; 2007:283.)

One standard deviation away from the mean in either direction on the horizontal axis accounts for approximately 68% of the people in the group (Fig. 3-5). Two standard deviations away from the mean account for approximately 95% of the people (Fig. 3-5). Three standard deviations account for about 99% of the people (Fig. 3-5).

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The z value is actually the number of standard deviations that a particular x value is away from the mean. If the left tail (the tail at the small end of the distribution) is more pronounced than the right tail (the tail at the large end of the distribu­ tion), the function is said to have negative skewness (Fig. 3-6). If the reverse is true, it has positive skewness (Fig. 3-7). If the two halves of the curve are symmetrical (mirror images), the data distribution has zero skewness (Fig. 3-4).

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The sample mean will be, for the most part, somewhat different from the population mean due to sampling error. 7 An interval estimate of the parameter is an interval or a range of values used to estimate the param­ eter. This estimate mayor may not contain the value of the parameter being estimated. 7 In interval estimates, the parameter is specified as being between two values. The selection of a confidence level for an interval determines the probability that the CI produced will contain the true parameter value. Common choices for the confidence level Care 0.90, 0.95, and 0.99. These levels correspond to percentages of the area of the normal den­ sity curve. For example, a 95% confidence interval covers 95% of the normal curve--the probability of observing a value outside of this area is less than 0.05. 8•9

Mean Median Mode Normal

Figure 3-4. Normal distribution in relation to the mean, median, and mode. (Reproduced, with permission, from Bluman A. Elementary Statistics: A Step by Step Approach. 6th ed. New York: McGraw-Hili; 2007:283.)







I I '---- About 68% ---1

About 95% About 99.7%


IL+ 1u


+ 2u



Figure 3-5. Areas under a normal distribution curve. (Reproduced, with per­ mission, from Bluman A. Elementary Statistics: A Step by Step Approach. 6th ed. New York: McGraw-Hili; 2007:286.)

Mean Median Mode Negatively skewed

Figure 3-6. Negatively skewed distribution. (Reproduced, with permission, from Bluman A. Elementary Statistics: A Step by Step Approach. 6th ed. New York: McGraw-Hili; 2007:283.)

Mode Median Mean Positively skewed

Figure 3-7. Positively skewed distribution. (Reproduced, with permission, from Bluman A. Elementary Statistics: A Step by Step Approach. 6th ed. New York: McGraw-Hili; 2007:283.)



Figure 3-8. The tfamily of curves. (Reproduced, with permission, from Bluman A. Elementary Statistics: A Step by Step Approach. 6th ed. New York: McGraw-Hili; 2007:358.)

Confidence Intervals for the Mean. When the standard deviation is known and the variable is normally distributed, or when the standard deviation is unknown and the sample size is ~30, the stan­ dard normal distribution is used to find confidence intervals for the mean 7. However, in many situations, the population standard deviation is not known and the sample size is less than 30. In such situations, the standard deviation from the sample can be used in place of the popula­ tion standard deviation for confidence intervals. A somewhat different distribution, called the t distribution (Fig. 3-8), must be used when the sample size is less than 30 and the variable is normally or approximately normally distributed (Table 3-2). Confidence Intervals for Variances and Standard Deviations. To calculate these confidence intervals, 7 the chi-square
distribution is used. The chi-square variable is similar to the t variable in that its distribution is a family of curves based on the number of degrees of freedom. Several of the distributions are shown in Figure 3-9.


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Researchers are interested in answering many types of questions. These types of questions can be addressed through statistical hypothesis testing, which is a decision-making process for evaluating claims about a population. 10 Every hypothesis-testing situation begins with a state­ ment of a hypothesis. There are two types of statistical hypotheses of each situation: the null hypothesis (HJ and the alternative hypothesis (H A).


Null hypothesis (HJ: a statistical hypothesis that states that there is no difference between a parameter and a specific value, or that there is no difference between two parameters. 10 Alternative hypothesis (HA): a statistical hypothesis that states the existence of a difference between a parameter and a spe­ cific value, or states that there is a difference between two parameters. 10


Bell shaped Symmetric about the mean The mean, median, and node are equal to 0 and are located at the center of the distribution The curve never touches the x-axis

The variance is greater than one The key distribution is actually a family of curves based on the concept of degrees of freedom, which is related to sample size" As the sample size increases, the t distribution approaches the standard normal distribution

• The degrees of freedom are the number of values that are free to vary after a sample statistic has been computed, and they tell a researcher which specific code to use when a distribution consists of a family of curves. For example, if the mean of 5 values is 10, then 4 of the 5 values are free to vary. But once 4 values are selected, the fifth value must be a specific number to get a sum of 50, since 50 -;- 5 = 10. Hence, the degrees of freedom are 5 ­ 1 = 4, and this value tells the researcher which t curve to use. Reproduced, with permission, from Bluman AG. Confidence intervals and sample size. In: Bluman AG, ed. Elementary Statistics: A Step by Step Approach. 4th ed. New York: McGraw-Hill; 2008:343-385.



Figure 3-9. The chi-square family of curves. (Reproduced, with permis­ sion, from Bluman A. Elementary ~tatistics: A Step by Step Approach. 6th ed. New York: McGraw-Hili; 2007:374.)

Although the above definitions of null and alternative hypothesis use the word "parameter," these definitions can be extended to include other terms such as "distributions" and "randornness."l0 In statistical hypothesis testing, the null hypothesis (HJ is initially believed to be true, and the researcher sees if the data provide enough evidence to abandon the belief in Ho in favor of the alternative hypothesis HA . For example, in a julY trial there is a presumption of innocence (e.g., the population means of a control group and experimental group are not different from each other). The null hypothesis is assumed to be true (the defendant is innocent) at the outset of inferential statistical analy­ sis. The null hypothesis is only rejected in favor of the alternative hypothesis (e.g., the two means differ) when the data provide the basis for "reasonable doubt about innocence"-when based upon the experimental data, it is more likely that the control and experimental groups do not represent the same population---that is, that they are dif­ ferent from each other. In the most common use of hypothesis testing (Table 3-3), one must construct a test statistic, and evaluate it with respect to its
1. Make a claim: A hypothesis that is assumed to be/is correct---the research hypothesis. For example, the research hypothesis could

be "I wonder whether sleep deprivation would have an effect on mental performance." 2. State the null hypothesis and the alternative hypothesis: The null hypothesis (denoted He! is a statement about the value of a population parameter that MUST contain equality (=, :S, ~). For example, in the sleep deprivation study, the null hypothesis could be that sleep deprivation will have no effect on mental performance. The alternative hypothesis (denoted HI) is the oppo­ site statement---the one that must be true if the null hypothesis is false. The alternative hypothesis is a statement of what a statistical hypothesis test is set up to establish. In this example, the alternative hypothesis would be that sleep deprivation would have a pos­ itive or negative effect on mental performance. The goal is to ascertain a correct inference about the population that is being sam­ pled with the experimental technique. 3. Decide on the appropriate test statistic. A test statistic is a quantity calculated from the sample of data and is determined by the assumed probability model and the hypotheses under question. Its value is used to decide whether or not the null hypothesis should be rejected in the hypothesis test. 4. Find the critical value for the test statistic and determine the critical region (see text). 5. Perform the calculations and state the conclusion.



H true o

H false o

sampling distribution under the assumption that the null hypothesis is true. A null hypothesis is put fOlWard and it is determined whether the hypothesis or its opposite is true (Figure 3-10). In a hypothesis test, a type I error occurs when the null hypothesis is rejected when it is in fact true; that is, Ho is wrongly rejected. For example, in a clinical tria1 of a new drug, the null hypothesis might be that the new drug is no better, on average, than the current drug; that is Ho-there is no difference between the two drugs on aver­ age. A type I error would occur if we concluded that the two drugs pro­ duced different effects when in fact there was no difference between them (Fig. 3-11). A type I error is often considered to be more serious, and therefore more important to avoid, than a type II error (described next). The hypothesis test procedure is therefore adjusted so that there is a guaranteed "low" probability of rejecting the null hypothesis wrongly; this probability is never O. In a hypothesis test, a type II error occurs when the null hypothesis Ho is not rejected when it is in fact false. For example, in a clinical trial of a new drug, the null hypothesis might be that the new drug is no better, on average, than the current drug; that is Ho: there is no difference between the two drugs on average. A type II error would occur if it was concluded that the two drugs produced the same effect, that is, there is no difference between the two drugs on average, when in fact they produced different ones (Fig. 3-11). A type II error is fre­ quently due to sample sizes being too small. Nothing can be proved absolutely. Likewise, the decision to reject or not reject the null hypothesis does not prove anything-the only way to prove anything statistically is to use the entire population. 1o The question as to how large the difference is necessary to reject the null hypothesis is answered somewhat using the level of significance. The level of significance (denoted a) is the maximum probability of wrongly rejecting t4e null hypothesis Ho' when it is in fact true (committing a type I error). In simple terms, a is the preset risk one is willing to take in committing a type I error with


H o

Correct decision

Type I Errors.

not reject

Correct decision

H o

Figure 3-10. Possible outcomes of a hypoth­ esis test. (Reproduced, with permission, from Bluman A. Elementary Statistics: A Step by Step Approach. 6th ed. New York: McGraw-Hili; 2007:392.)

Type II Errors.

Significance Level.

Ho The defendant is innocent. : H1: The defendant is not innocent.

Hotrue (innocent)

Hofalse (not innocent)

The results of atrial can be shown as follows: Reject (convict)

Correct decision

not reject Ho (acquit) Correct decision


Figure 3-11. Hypothesis testing and a jury trial. (Reproduced, with per­ mission, from Bluman A. Elementary Statistics: A Step by Step Approach. 6th ed. New York: McGraw-Hili; 2007:393.)



Study Pearl
Noncritical reg ion



Figure 3-12. Critical and noncritical regions for a = 0.01 (right-tailed test). (Reproduced, with permission, from Bluman A. Elementary Statistics: A Step by Step Approach. 6th ed. New York: McGraw-Hili; 2007:395.)

an inferential statistical test-it is the bar over which the data need to jump in order to reject the null hypothesis and be considered statisti­ cally significant. By convention, statisticians use three arbitrary signifi­ cance levels (a)--O.lO, 0.05, and am levels (although it can be any level, depending on the seriousness of the type I error).l0 That is, if the null hypothesis is rejected, the probability of a type I error will be 10010, 5%, or 1%, d~pending on which level of significance is used. For example, if the acceptable risk of committing a type I errror is 5%, a is set to 0.05 (indicates that the expected difference due to chance is only 5 times out of every 100). While decreasing the a value reduces the risk of a type I error, decreasing it too much increases the chances of obtaining a type II error (symbolized by [3). After a significance level is chosen, a critical value is selected from a table for the appropriate test. The critical value determines the critical and noncritical regions. The critical value for any hypothesis test depends on the signifi­ cance level at which the test is carried out, whether the test is one­ tailed or two-tailed, and on the degrees of freedom (described later). The critical value can be on the right side of the mean or on the left side of the mean for one-tailed test-its location depends on the inequality signed of the alternative hypothesis. To obtain the critical value, the researcher must choose an alpha level (Fig. 3-13).

0.0 0.1 0.2 0.3 0







Find this area in table as shown


2.1 2.2 2.3 2.4 0.4901 Closest value to 0.4900

(a I The cr~ical region

(b) The critical value from Table E

Figure 3-13. Finding the critical value for a = 0.01 (right-tailed test). (Reproduced, with permission, from Bluman A. Elementary Statistics: A Step by Step Approach. 6th ed. New York: McGraw-HilI; 2007:395.)



Study Pearl


. indi11itest~~tt/len4!l • n¥POthesissh°uld Qereje(j¢d'vVn~ntAe testvalue is in ~~1riticq~.regionononesid~ the of mean;theregiorJ< otrejectionis ertir;elywithinone tatl ()fthe Prob­ ahi Iity ··.diStr~bution. .A(}ne-taited test.is~ithera . rigllt4aile<j~est or a le~-taited •. test; <depet1~i~gOfl the direetionof the/inequaJity of the alternative••hypothesis. 2'f\t'vVq-tail;d(two-~ided) test indi­ 9ates~~~tthe<~uIl hypothesis ·~an ~n~;e¢tedwhenthereis a<signif­
a~¥e .or<below·· the metin;· the



Probability (p) Value. The probability value (p-value) is used in statistics to describe the probability of something happening. A study will generally give a value of p for any conclusions it reaches. The p­ value is the probability of getting a sample statistic (such as the mean) or one more extreme sample statistic in the direction of the alternative hypothesis when the null hypothesis is true-the risk of committing a type I error if the null hypothesis is rejected. Small p-values suggest a vel)' unusual observation under H o indi­ cating that the null hypothesis is unlikely to be true. The smaller the p-value, the more convincing is the rejection of the null hypothesis. H o is rejected when the p-value is less than a. The p-value indicates the strength of evidence for, say, rejecting the null hypothesis H o' rather than simply concluding "reject H o" or "do not reject H o'" For example, if a statistical test is run and yields p = 0.25, statistical significance is defined as a statistical test yielding a p-value that is less than a, that is, less than 0.05 (less than 5% chance of com­ mitting a type I error). The Power of a Hypothesis Test. The power of a statistical hypothesis test measures the test's ability to reject the null hypothesis when it is actually false-that is, to make a correct inference.

fegi~nof r.ejectionisJocateG . in ~ither <(}~Jnet~ crlt'ical.regions (Fi~73 ;,14l.An.extremet\eSt.• statis­ ticifl<eitner tail of the distribution (fositiv~()rnegati\felwill lead to the rej~~iongftpe null hypothesis of nodiff~r~nce.

The choiC~)between·a one-si~edand a two-sjdedt~st.is.determin~d by the purpose ofthe investigation or prior reasons for using a .one-sided test. In mostscientifi cinvestigations, a con­ servative approach is used, Where the problem is formulated with. a two­ sided alternative hypothesis, allowing the data to determine precisely how the null hypothesis might be false.

The power of a hypothesis test is the probability of not committing a type II error. It is calculated by subtracting the probability of a type II error from 1. The maximum power a test can have is 1, whereas the mini­ mum is O. Ideally a test should have a high power, close to 1.

z-Test. The z-test is a statistical test of the mean of a population. It can be used when the sample size is ;::::30, or when the population is normally distributed and the standard deviation is known. For exam­ ple, a z-test could be used if exam scores from a class of students is compared to a different class that took the same exam (when the pop­ ulation mean and standard deviation are known).

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e conclusion of a study finds tnat terventlon is better than the con­ h p <0.00001, that is a very strong conclusion indeed. If, however, tAe conclusion is with p <0.25, then there is a tS% chance of committing a ty~ I.error iHhe null hypothesis is rejected; this is considered too/high a risk; too weak to rely on.

Noncritical region




Figure 3-14. Critical and non-critical regions for a = 0.01 (two-tailed test). (Reproduced, with permission, from Bluman A. Elementary Statistics: A Step by Step Approach. 6th ed. New York: McGraw-Hili; 2007:396.)



t-Test. The t-test is the most commonly used method to evaluate the differences in means between two groups when the standard deviation is unknown, the sample size is <30, and the distribution of the variable is approximately normal. The groups can be independent (e.g., blood pressure of patients who were given a drug vs. a control group that received a placebo) or dependent (e.g., blood pressure of patients "before" vs. "after" they received a drug).

Study Pearl
··It is important to remember t •does not know if a type I or error has been committe(Hn cal inferential decision; rat and p-values provide in · about the probability that error occurred, or the Iikeli such an error has occurred.

Chi-Square. In addition to using the chi-square distribution to find a confidence interval for a variance for standard deviation and to test the hypothesis about a single variance or standard devi­ ation, the chi-square can also be used to see whether a frequency distribution fits a specific pattern, and test the homogeneity of pro­ portions (Table 3-4). Analysis of Variance. When an F test (a test used to compare
two sample variances to determine whether they are equal) is used to test the hypothesis concerning the means of three or more populations, the technique is called analysis of variance (ANOVA). ANOVA is a use­ ful tool that helps the user to identify sources of variability from one or more potential sources, sometimes referred to as "treatments" or "fac­ tors." ANOVA is used rather than performing multiple t-tests because it protects against an inflation of ex that would otherwise result from mul­ tiple t-tests. By varying the factors in a predetermined pattern and ~nalyzing the output, one can use statistical techniques to make an accurate assessment as to the cause of variation in a process. There are two common types of ANOVA:

Study Pearl
whether The t-test and AN the difference(s) e means of two (Hest) or rno samples (ANOVA) could be due to random sampli .. At-test ent variable with there are two group trol versus experimental}. .. ANOVA is used when there is one independent vari more levels there are two or variables.

The one-way ANOVA is a method of analysis that requires mul­ tiple experiments or readings to be taken from a source that can take on two or more different inputs or settings. The one-way ANOVA performs a comparison of the means of a number of replications of experiments performed where a single input factor is varied at different settings or levels. The object of this comparison is to determine the proportion of the variability of the data that is due to the different treatment levels or factors as opposed to variability due to random error. Basically, rejection of the null hypothesis indicates that variation in the outcome is due to variation between the treatment levels and not due to


Pearson's chi-square Chi-square goodness-of-fit test Likelihood ratio chi-square Mantel-Haenszel chi-square

A nonparametric test of statistical significance for bivariate tabular analysis (also known as cross breaks) in the form of frequency counts occurring in two or more mutually exclusive categories. A different use of the Pearson chi-square. Used to test if an observed distribution conforms to any other distribution, such as one based on theory or one based on some other known distribution. An alternative procedure to test the hypothesis of no association of columns and rows in nominallevel tabular data. An ord.inal measure of significance that is preferred when testing the significance of linear relationship between two ordinal variables




random error. If the null hypothesis is rejected, there is a dif­ ference in the outcome of the different treatment levels at a sig­ nificance a and it remains to be determined between which treatment levels the actual differences lie. The two-way analysis of variance is an extension to the one-way analysis of variance, in which comparisons can be made between two or more population means with two or more inde­ pendent variables (hence the name two-way) called factors.


Analysis of Covariance (ANCOVA). ANCOVA is a test used to compare means of a continuous outcome variable among two or more treatment groups or conditions after controlling for the effects of intervening variables (covariates). For example, two groups of subjects are compared on the basis of diet parameters using two different types of exercises; the subjects in one group are male and the subjects in the second group are female; sex then becomes the covariate that must be controlled during statistical analysis. Intraclass Correlation Coefficient. The intraclass correlation coefficient (ICC) is a reliability coefficient calculated with variance esti­ mates obtained through an analysis of variance (ANOVA) (Table 3-5).11 The ICC has been advocated as a statistic for assessing agreement or consistency between two methods of measurement, in conjunction with a significance test of the difference between means obtained by the two methods. The advantage of the ICC over correlation coeffi­ cients is that it does not require the same number of raters per subject, and it can be used for two or more raters or ratings. I 1

<0.75 >0.75 >90

Poor to moderate agreement Good agreement Reasonable agreement for clinical measurements

Data from Portney L, Watkins MP. Foundations of Clinical Research: Applications to Practice. Norwalk, Cf: Appleton & Lange; 1993.

Study Pearl

The choice of which statistical test to use depends on the question being asked. I





If the design is to learn about the association between two vari­ ables (e.g., what is the relationship between arm girth and elbow flexor strength?), a correlation coefficient should be calculated. If the question deals with prediction (e.g., if the patient has a knee range of motion of 10 to 50 degrees on the second post­ operative day, how many days will the patient likely remain in the hospital?), a regression analysis is appropriate. If the question is whether a treatment has an effect, or shows a difference (e.g., does spinal traction reduce the signs and symptoms of a cervical root compression?), a chi-square, analy­ sis of variance (ANOVA), or t-test is appropriate. For a correlation study to determine the degree of association, a Spearman rho is used for ordinal data, whereas a Pearson cor­ relation coefficient is calculated for interval data. If the question is whether two groups differ on the dependent variable, and the data are normally distributed with equal vari­ ances, a t-test is appropriate.

There are a number of primary types of research designs (Table 3-6).



Controlled trials Uncontrolled trials Single-blind study Double-blind study

These require the experimental procedure to be compared with a placebo or another previously accepted procedure. Controlled studies are more likely than uncontrolled studies to determine whether differences are due to the experimental treatment or to some of the extraneous factors. These involve the investigators describing their experience with an experimental procedure; however, the experimental procedure is not formerly compared with a placebo or another previously accepted procedure A study in which the investigator does not know if the subject is in the treatment or the control group. A study in which neither the investigator nor the subject knows if the subject is in the treatment or the control group.

Ideally, the researcher should attempt to remove the influence of any variable other than the independent variable in order to evaluate its effect on the dependent variable. An experimental design has the pur­ pose of minimizing or contolling the effects on extraneous variables so that the relationship between the independent variable(s) and the dependent variable(s) can be ascertained.

The control group is used as a standard for comparison with experi­ mental groups in terms of age, abilities, race, and so on. For example, a particular study may divide participants into two groups-an "experi­ mental group" and a "control group." The experimental group is given the experimental treatment under study, while the control group may be given either the standard treatment for the illness or a placebo. At the end of the study, the results of the two groups are compared.

Study participants in the experimental group receive the drug, device, treatment, or intervention under study. In some studies, all participants are in the experimental group. In "controlled studies," participants will be assigned either to an experimental group or to a control group.

The placebo effect is the measurable, observable, or felt improve­ ment in health not attributable to treatment. Experimental research uses placebos (usually sugar or starch pills) to test the effect of a medication-an inactive substance that looks like medicine but con­ tains no medicine and has no treatment value (a placebo) is adminis­ tered to the patient. While participants in the control group are given the placebo, the other members of the study are given the actual medication.

Random assignment is assignment by chance, like flipping a coin or pulling numbers out of a hat. This method is sometimes used to deter­ mine who is in the experimental group and who is in the control group.



Study Pearl

For example, in a study with random assignment to one of two groups, participants have a 50% chance of being assigned to either group.

A number of statistical terms and defmitions are outlined in Table 3-7.

Evidence-based practice (EBP) is the integration of three key elements: best research evidence, clinical expertise, and patient values. It is hav­ ing an increasing impact on the profession of physical therapy. When integrating evidence into clinical decision-making, an understanding of how to appraise the quality of the evidence offered by clinical studies is important. Judging the strength of the evidence becomes an important part of the decision-making process.

Unfortunately, many of the experimental studies that deal with physical therapy topics are not well-designed trials. Awareness of the distinction between efficacy and effectiveness is important for therapists attempt­ ing to translate evidence to practice.

Efficacy: refers to outcomes of interventions provided in a con­ trolled setting under experimental conditions. When attempt­ ing to apply the results of an efficacy study, a therapist must



A summary of the paper, usually between 100 and 500 words, that describes the most important aspects of the study, including:
~ ~ ~

The The The The

problem investigated. subjects and instruments involved. design and procedures. major findingslconclusions.

Conclusion Empirical methods Hawthorne effect Parameter Peer review


The conclusion responds to the original research question and hypothesis to describe what the study showed. It should bring coherence to the study. Research methods and data-gathering techniques supported by measurable evidence, not opinion or speculation. An untreated subject experiences a change simply from participating in a research study. Similar to the placebo effect. Numerical measurements describing some characteristic of the population. A process by which research studies are examined by an independent panel of researchers for review. The purpose of such is to open the study to examination, criticism, review, and replication by peer investigators and ultimately incorporate the new knowledge into the field The population of a study refers to the group of people represented in a study. For example, if a researcher took a nationally representative sample of 1500 fourth-grade students, the sample is the 1500 fourth-grade students, but the population of the study would be fourth graders in general.




~ ~


Type of Study

Randomized controlled trial

Cohort study

~ ~


Nonrandomized trial with concurrent or historical controls Case study Study of sensitivity and specificity of a diagnostic test Population-based descriptive study

Cross-sectional study Case series Case report


Expert consensus Clinical experience

Data from Sackett DL. Rules of evidence and clinical recommendations on the use of antithrombotic agents. Chest. 1986;89:2S-3S.


consider whether subject characteristics and the manner in which intervention was provided generalize to patients on their caseloads and how to adapt the intervention to constraints within their practice settings. 14 Effectiveness: refers to outcomes of interventions provided within the scope of clinical practice.

Sackett15 proposed a five-level system that relates the experimental design to levels of evidence and grades of recommendation (Table 3-8). A grade A recommendation (the randomized controlled trial, Table 3-9), indicates that outcomes are supported by at least one level I study. A grade B recommendation indicates outcomes are supported by at least one level II study. A grade C recommendation indicates that outcomes are supported by level III, IV, or V studies. The Oxford Center for Evidence-Based Medicine has elaborated on Sackett's levels of evidence (Table 3-10).

Study Pearl

TABLE 3-9. THE RANDOMIZED CONTROLLED TRIAL (RCI) An experimental design in which subjects are randomly aSSigned to an experimental or control group permitting the strongest

inferences about cause and effect. Typically volunteers agreed to be randomly allocated to groups receiving one of the following:
~ ~

Treatment and no treatment. Standard treatment and standard treatment plus a new treatment. Two alternate treatments.

The common feature is that the experimental group receives the treatment of interest and the control group does not. At the end of the trial, outcomes of subjects in each group are determined-the difference in outcomes between groups provides an estimate of the size of the treatment effect.
~ ~ ~

Less exposed to bias.
Ensures comparability of groups.
Provides evidence of efficacy

Data from Maher CG, Herbert RD, Moseley AM, et al. Critical appraisal of randomized trials, systematic reviews of radomized trials and clinical prac­ tice guidelines. In: Boyling ]0, ]ull GA, eds. Grieve's Modern Manual Therapy: The Vertebral Column. Philadelphia: Churchill Livingstone; 2004:603--614; Petticrew M. Systematic reviews from astronomy to zoology: myths and misconceptions. BM]. 2001;322:98-101; Palisano R], Campbell SK, Harris SR. Evidence-based decision-making in pediatric physical therapy. In: Campbell SK, Vander Linden OW, Palisano R], eds. Physical Therapy for Children. St. Louis: W.B. Saunders; 2006:3-32.













2c 3a


SR (with homogeneity") SR (with homogeneity") SR (with homogeneity") SR (with homogeneity") SR (with of level I diagnostic of RCTs of inception cohort of prospective cohort homogeneity") studies; CDRt studies; CDRt with Ib studies of level I validated in different studies from different economic studies populations clinical centers Individual RCT (with Individual inception Validating·· cohort study Prospective cohort Analysis based on cohort study with with goodm reference study with good narrow confidence clinically sensible interval*) >80% follow-up; standards; or CDRt follow-up···· costs or CDRt validated in a tested within one alternatives; single population clinical center systematic review(s) of the evidence; and including multiway sensitivity analyses Allor none! Allor none case-series Absolute SpPins and Allor none Absolute SnNouts (see text) case-series better-value or worse-value analyses tm SR (with homogeneity") SR (with homogeneity") SR (with homogeneity·) SR (with homogeneity") SR (with of either retrospective of level >2 diagnostic of 2b and better homogeneity") of cohort studies studies studies of level >2 cohort studies or untreated control economic studies groups in RCTs Analysis based on Retrospective cohort Exploratory"· cohort Individual cohort Retrospective cohort study (including study or follow-up clinically sensible study with goodm study, or poor low quality RCT; of untreated control reference standards; follow-up costs or alternatives; limited review(s) patients in an RCT; CDRt after derivation, e.g., < 80% follow-up) derivation of CDRt or validated only on of the evidence, split-sample!!! or or validated on or single studies; split-sample!!! only and including databases multiway sensitiv­ ity analyses "Outcomes" research; "Outcomes" Research Ecologic studies Audit or outcomes ecological studies research SR (with homogeneity") SR (with homogeneity") SR (with homogeneity") SR (with of case-control homogeneity") of of 3b and better of 3b and better studies studies studies 3b and better studies Individual Nonconsecutive study; or Nonconsecutive Analysis based case-control study without consistently cohort study, or on limited very limited alternatives or applied reference standards population costs, poor quality estimates of data, but including sen­ sitivity analyses incorporating clinically sensible variations.




TABLE 3-10. OXFORD CENTER FOR EVIDENCE-BASED MEDICINE LEVELS OF EVIDENCE (Continued) DIFFERENTIAL DIAGNOSIS/ SYMPTOM PREVALENCE SruDY Case-series or superseded reference standards Expert opinion without explicit critical appraisal, or based on physiology, bench research or "tlrst principles"


THERAPY/ PREVENTION, ETIOLOGY/HARM Case-series (and poor quality cohort and case-control studies!! ) Expert opinion without explicit critical appraisal, or based on physiology, bench research, or "tlrst principles"

PROGNOSIS Case-series (and poor quality prognostic cohort studies''') Expert opinion without explicit critical appraisal, or based on physiology, bench research or "first principles"

DIAGNOSIS Case-control study, poor or nonindependent reference standard Expert opinion without explicit critical appraisal, or based on physiology, bench research or "first principles"

ECONOMIC AND DECISION ANALYSES Analysis with no sensitivity analysis



Expert opinion without explicit critical appraisal, or based on economic theory or "first principles"

Users can add a minus-sign to denote the level of that fails to provide a conclusive answer because of:


EITHER a single result with a wide confidence interval (such that, for example, an ARR in an Ref is not statistically significant but whose confidence intervals fail to exclude clinically important benefit or harm). OR a systematic review with troublesome (and statistically significant) heterogeneity. Such evidence is inconclusive, and therefore can only generate grade D recommendations.

·By homogeneity we mean a systematic review that is free of worrisome variations (heterogeneity) in the directions and degrees of results between
individual studies. Not all systematic reviews with statistically significant heterogeneity need be worrisome, and not all worrisome heterogeneity need
be statistically significant. As noted above, studies displaying worrisome heterogeneity should be tagged with a minus sign at the end of their designated
tClinical decision rule. (These are algorithms or scoring systems which lead to a prognostic estimation or a diagnostic category.)
IMet when all patients died before the Rx became available, but some now survive on it; or when some patients died before the Rx became avail­
able, but none now die on it.
IIBy poor quality cohort study we mean one that failed to clearly define comparison groups and/or failed to measure exposures and outcomes in the
same (preferably blinded), objective way in both exposed and nonexposed individuals and/or failed to identify or appropriately control known con­
founders and/or failed to carry out a sufficiently long and complete follow-up of patients. By poor quality case-control study we mean one that failed to
clearly define comparison groups and/or failed to measure exposures and outcomes in the same (preferably blinded), objective way in both cases and
controls and/or failed to identify or appropriately control known confounders.
lllSplit-sample validation is achieved by collecting all the information in a single tranche, then artificially dividing this into "derivation" and "validation"
ttAn "absolute SpPin" is a diagnostic finding whose specificity is so high that a positive result rules in the diagnOSiS. An "absolute SnNout" is a diag­
nostic finding whose sensitivity is so high that a negative result rules out the diagnosis.
flGood, better, bad, and worse refer to the comparisons between treatments in terms of their clinical risks and benefits.
tttGood reference standards are independent of the test, and applied blindly or objectively applied to all patients. Poor reference standards are hap­
hazardlyapplied, but still independent of the test. Use of a nonindependent reference standard (where the "test" is included in the "reference," or
where the "testing" affects the"reference") implies a level 4 study.
ttt!Better-value treatments are clearly as good but cheaper, or better at the same or reduced cost. Worse-value treatments are as good and more expen­
sive, or worse and equally or more expensive.
··Validating studies test the quality of a specific diagnostic test, based on prior evidence. An exploratory study collects information and trawls the
data (e.g., using a regression analysis) to find which factors are "significant."
···By poor quality prognostic cohort study we mean one in which sampling was biased in favor of patients who already had the target outcome, or the
measurement of outcomes was accomplished in <80% of study patients, or outcomes were determined in an unblinded, nonobjective way, or there
was no correction for confounding factors.
····Good follow-up in a differential diagnosis study is >80%, with adequate time for alternative diagnoses to emerge (e.g., 1---6 months acute, 1-5
years chronic).
Grades A B C D of Recommendation Consistent level 1 studies Consistent level 2 or 3 studies or extrapolations from level 1 studies Level 4 studies or extrapolations from level 2 or 3 studies Level 5 evidence or troublingly inconsistent or inconclusive studies of any level

Data produced by Phillips B, Ball C, Sackett D., et al. from Oxford Center for Evidence-Based Medicine Levels of Evidence. www.cebm.net/ index.aspx?0=1025, November 1998.




Systematic reviews


Reviews of the literature conducted in a way that is designed to minimize bias--"a study of studies." Recently published reviews can be used to assess the effects of health interventions, the accuracy of diag nostic tests, or the prognosis for a particular condition. Usually involve criteria to determine which studies will be considered, the search strategy used to locate studies, the methods for assessing the quality of the studies, and the process used to synthesize the find­ ings of individual studies. Particularly useful for busy clinicians who may be unable to access alI the relevant trials in an area and may otherwise need to rely upon their own incomplete surveys of relevant trials. NB: A systematic review is only as good as the quality of each study. A mathematical synthesis of the results of two or more research reports. A meta-analysis can be performed on studies that used reliable and valid measures and report some type of inferential statistic (e.g., t-test,

Data from Maher CG, Herbert RD, Moseley AM, et al. Critical appraisal of randomized trials, systematic reviews of radomized trials and clinical prac­ tice guidelines. In: Boyling JD, Jull GA, eds. Grieve's Modern Manual Therapy: The vertebral Column. Philadelphia: Churchill Livingstone; 2004:603---D14; Petticrew M. Systematic reviews from astronomy to zoology: myths and misconceptions. EM]. 2001;322:98-101; Palisano RJ, Campbell SK, Harris SR. Evidence-based decision-making in pediatric physical therapy. In: Campbell SK. Vander Linden DW, Palisano RJ, eds. Physical Therapy for Children. St. Louis: W.E. Saunders; 2006:3-32.

Study Pearl
critically app provides a form summarize the from a literature s, part of clinical appraised mary of' clinical

Evidence-based practice is a four-step process: 1. A clinical problem is identified and an answerable research question is formulated. 2. A systematic literature review is conducted and evidence is collected. 3. The research evidence is summarized and critically analyzed. 4. The research evidence is synthesized and applied to clinical practice. Practice guidelines are systematically developed statements to assist patient and practitioner decisions about management of a health condition (Table 3-12).14 In general, practice guidelines include rec­ ommendations for the following: 14

~ ~


Who should receive the intervention? Expected outcomes. Documentation including selection of reliable and valid tests and measures. Utilization of services (frequency and duration, number of visits). Procedural interventions. Coordination of care. Discharge planning.


Recommendations for management of a particular clinical condition. Intended to provide current standards for quality practice in order to improve effectiveness and efficiency of health care. Involve compilation of evidence concerning needs and expectations of recipients of care, the accuracy of diagnostic tests, effects of therapy, and prognosis. Usually necessitate the conduct of one, or sometimes several, systematic reviews. May be presented as clinical decision algorithms. Can provide a useful framework upon which clinicians can build clinical practice.
Data from Maher CG, Herbert RD, Moseley AM, et al. Critical appraisal of randomized trials, systematic reviews of radomized trials and clinical prac­ tice guidelines. In: Boyling JD, Jull GA, eds. Grieve's Modern Manual Therapy: The Vertebral Column. Philadelphia: Churchill Livingstone; 2004:603-ti14.



In 1998 an international group of researchers and policymakers formed the AGREE (Appraisal of Guidelines for Research and Evaluation) collaboration in order to improve the quality and effec­ tiveness of clinical practice guidelines. 14

The instrumentation-gold standard can be defined as an instrument with established validity that can be used as a standard for assessing or comparing other instruments.

Sensitivity represents the proportion of a population with the target dis­ order, which has a positive result with the diagnostic test. A test that can correctly identify every person who has the target disorder has a sensi­ tivity of 1.0. SnNout is an acronym for when Sensitivity of a symptom or sign is high, a negative response rules out the target disorder. Thus, a "high" sensitive test helps rule out a disorder. Specificity represents the proportion of the study population with­ out the target disorder, in whom the test result is negative (Table 3-13). 8 A test that can correctly identify every person who does not have the tar­ get disorder has a specificity of 1.0. SpPin is an acronym for when specificity is extremely high, a positive test result rules in the target dis­ order. Thus, a 'high' specific test helps rule in a disorder or condition. A test with a very high sensitivity, but low specificity, and vice versa, is of little value, and the acceptable levels are generally set at between 50% (unacceptable test) and 100% (perfect test), with an arbi­ trary cutoff of about 80%.8 There are several types of validity, including construct validity, face validity, content validity, external validity, con­ current validity, and criterion-referenced validity.

Validity is defined as the degree to which a test measures what it pur­ ports to be measuring, and how well it correctly classifies individuals with or without a particular diseaseY-19 Validity is directly related to the notion of sensitivity and specificity.

Construct Validity. Construct validity refers to the ability of a test to represent the underlying construct (the theory developed to organ­ ize and explain some aspects of existing knowledge and observations). Construct validity refers to overall validity.

TABLE 3-13. CONCEPTS AND DEFINITIONS OF SENSITIVIlY, SPECIFICIlY, AND PREDICTIVE VALUES CONCEPT Sensitivity Specificity Positive predictive value (PPV) Negative predictive value DEFINITION Proportion of patients with a disease who test positive. Proportion of patients without the disease who test negative. Proportion of patients who actually have the disease who test positive. If the target disease is uncommon, there are many more false-positive results and the PPV goes down. Proportion of patients who do not actually have the disease and who test negative.



Face Validity. Face validity refers to the degree to which the ques­ tions or procedures incorporated within a test make sense to the users. The assessment of face validity is generally informal and nonquantita­ tive and is the lowest standard of assessing validity-it is based on the notion that the finding is valid "on the face of it." For example, if a weighing scale indicates that a normal-sized person weighs 2000 pounds, that scale does not have face validity. Content Validity. Content validity refers to the assessment by
experts that the content of the measure is consistent with what is to be measured. Content validity is concerned with sample-population representativeness-that is, the knowledge and skills covered by the test items should be representative to the larger domain of knowledge and skills. In many instances, it is difficult if not impossible to administer a test covering all aspects of knowledge or skills. Therefore, only sev­ eral tasks are sampled from the population of knowledge or skills. In these circumstances, the proportion of the score attributable to a par­ ticular component should be proportional to the importance of that component to total performance. In content validity, evidence is obtained by looking for agreement in judgments by judges. In short, one person can determine face validity, but a panel should confirm content validity.

External Validity. External validity deals with the degree to which study results can be generalized to different subjects, settings, and times. n ,2o Internal Validity. Internal validity can be defmed as the degree to which the reported outcomes of the research study are a consequence of the relationship between the independent and dependent variables and not the result of extraneous factors. Criterion-Referenced Validity. Criterion validity is determined by comparing the results of a test to those of a test that is accepted as a "gold-standard" test (a test that is accepted as being close to 1000A! valid).8 There are three types of criterion-referenced validity: concurrent, predic­ tive, and discriminant.
Concurrent Validity. The degree to which the measurement being validated agrees with an established measurement standard adminis­ tered at approximately the same time. Concurrent validity is a form of criterion validity. Predictive Validity. Predictive validity is the extent to which test scores are associated with future behavior or performance. Discriminant Validity. Discriminant validity is the ability of a test to distinguish between two different constructs, and is evidenced by a low correlation between the results of the test and those of tests of a different construct. Diagnostic tests are used for the purpose of discovery, confirma­ tion, and exclusion. 21 Tests for discovery and exclusion must have high sensitivity for detection, whereas confirmation tests require high speci­ ficity (Table 3-13).22 The sensitivity and specificity of any physical test



to discriminate relevant dysfunction must be appreciated to make mean­ ingful decisions. 23 Other points used in testing include the prediction value, confidence interval, and likelihood ratio.

Prediction Value. The prediction value of a positive test indicates that those members of the study population who have a positive test outcome will have the condition under investigation (Table 3-13).8 The diagnostic power of the negative test outcome relates to those of the study population with a negative test outcome who do not suffer from the condition under investigation. 8 Likelihood Ratio. The likelihood ratio is the index measurement that is considered to combine the best characteristics of sensitivity, specificity, positive predictive value, and negative predictive value. Likelihood ratios are expressed as odds and are calculated from values used to calculate sensitivity and specificity. The likelihood ratio indi­ cates how much a given diagnostic test result will lower or raise the pretest probability of the target disorder. 8,9

Reliability is defined as the extent to which repeated measurements of a relatively stable phenomenon are close to each other. 24 Test­ retest reliability is the consistency of repeated measurements that are separated in time when there is no change in what is being meas­ ured. Any difference between the two sets of scores represents measurement error, which can arise from a number of factors includ­ ing intrarater variability, interrater reliability, or a lack of consistency of results. Reliability may be measured as repeatability between measurements performed by the same examiner (intrarater reliabil­ ity), or between measurements by different examiners (interrater reliability). Instrument reliability deals with the tool used to obtain a measurement. Reliability is quantitatively expressed by way of an index of agree­ ment, with the simplest index being the percentage agreement value. 'The percentage agreement value is defmed as the ratio of the number of agreements to the total number of ratings made. 25 However, because this value does not correct for chance agreement, it can provide a mis­ leadingly high estimate of reliability.18,25-27 The results of an examination are of limited value if they are not consistently repeatable.17,18 The kappa statistic (K) is a chance-corrected index of agreement that overcomes the problem of chance agreement when used with nominal and ordinal data (Table 3-14).28 However, with higher-scale data such as ordinal and parametric data, it tends to underestimate reliability, in which case a weight kappa (ranked) or ICC (parametric) should be usedY 'Theoretically K can be negative if agree­ ment is worse than chance. Practically in clinical reliability studies, K usually varies between 0.00 and 1.00.12 The K statistic does not differ­ entiate among disagreements; it assumes that all disagreements are of equal significance. 12 A number of calculations, including the Pearson product moment correlation coefficient and the intraclass correlation coefficient, can be used to assess reliability.


<40 40-60



Poor to fair agreement Moderate agreement Substantial agreement Excellent agreement Perfect agreement

Data from Portney L, Watkins MP. Foundations ofClinical Research: Applications to Practice. Norwalk, Cf: Appleton & Lange; 1993.




The most common threats to validity and reliability are:


~ ~ ~ ~

~ ~ ~

Ambiguity: when correlation is taken for causation.
Errors of measurement: random errors or systematic errors.
History: when some critical event occurs between pretest and
posttest. Instrumentation: when the researcher changes the measuring device. Maturation: when people change or mature over the research period. Mortality: when people die or drop out of the research. Regression to the mean: a tendency toward middle scores. The John Henry effect: when groups compete to score well. Sampling bias: the tendency of a sample to exclude some members of the sampling universe and over-represent others. Setting: something about the setting or context contaminates the study. The Hawthorne effect: a tendency of research subjects to act atyp­ ically as a result of their awareness of being studied.

1. Underwood FB. Clinical research and data analysis. In: Placzek JD, Boyce DA, eds. Orthopaedic Physical Therapy Secrets. Philadelphia: Hanley & Belfus; 2001: 130-139. 2. Bluman AG. The nature of probability and statistics. In: Bluman AG, ed. Elementary Statistics: A Step by Step Approach. 4th ed. New York: McGraw-Hill; 2008: 1-32. 3. Bluman AG. Organizing data. In: Bluman AG, ed. Elementary Statistics: A Step by Step Approach. 4th ed. New York: McGraw­ Hill; 2008: 33-100. 4. Bluman AG. Measures of central tendency. In: Bluman AG, ed. Elementary Statistics: A Step by Step Approach. 4th ed. New York: McGraw-Hill; 2008: 101-176. 5. Bluman AG. Probability and counting rules. In: Bluman AG, ed. Elementary Statistics: A Step by Step Approach. 4th ed. New York: McGraw-Hill; 2008: 177-242. 6. Bluman AG. The normal distribution. In: Bluman AG, ed. Elementary Statistics: A Step by Step Approach. 4th ed. New York: McGraw-Hill; 2008: 281-341. 7. Bluman AG. Confidence intervals and sample size. In: Bluman AG, ed. Elementary Statistics: A Step by Step Approach. 4th ed. New York: McGraw-Hill; 2008: 343-385. 8. Van der Wurff P, Meyne W, Hagmeijer RHM. Clinical tests of the sacroiliac joint, a systematic methodological review. Part 2: validity. Man Ther. 2000;5: 89-96. 9. Jaeschke R, Guyatt G, Sackett DL. Users guides to the medical lit­ erature. III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? lAMA. 1994;27:703-707.



10. Bluman AG. Hypothesis testing. In: Bluman AG, ed. Elementary Statistics: A Step by Step Approach. 4th ed. New York: McGraw-Hill; 2008: 387-455. 11. Huijbregts PA. Spinal motion palpation: a review of reliability studies. j Man Manip Ther. 2002;10: 24-39. 12. Portney L, Watkins MP. Foundations ojClinicalResearch: Applications to Practice. Norwalk, CT: Appleton & Lange; 1993. 13. Sackett DL, Strauss SE, Richardson WS, et al. Evidence Based Medicine: How to Practice and Teach EBM. 2nd ed. Edinburgh: Churchill Livingstone; 2000. 14. Palisano RJ, Campbell SK, Harris SR. Evidence-based decision­ making in pediatric physical therapy. In: Campbell SK, Vander Linden DW, Palisano RJ, eds. Physical Therapy jor Children. St. Louis: Saunders; 2006: 3-32. 15. Sackett DL. Rules of evidence and clinical recommendations on the use of antithrombotic agents. Chest. 1986;89:25-3S. 16. Fetters L, Figueiredo EM, Keane-Miller D, et al. Critically appraised topics. Pediatr Phys Ther. 2004;16:19-21. 17. Feinstein AR. Clinimetrics. Westford, MA: Murray Printing Company; 1987. 18. Marx RG, Bombardier C, Wright JG. What do we know about the reliability and validity of physical examination tests used to exam­ ine the upper extremity? j Hand Surg. 1999;24A:185-193. 19. Roach KE, Brown MD, Albin RD, et al. The sensitivity and speci­ ficity of pain response to activity and position in categorizing patients with low back pain. Phys Ther. 1997;77:730--738. 20. Domholdt E. Physical Therapy Research: Principles and Applications. Philadelphia: Saunders; 1993. 21. Feinstein AR. Clinical biostatistics XXXI: on the sensitivity, speci­ ficity & discrimination of diagnostic tests. Clin Pharmacol Ther. 1975;17:104-116. 22. Anderson MA, Foreman n. Return to competition: functional rehabilitation. In: Zachazewski JE, Magee DJ, Quillen WS, eds. Athletic Injuries and Rehabilitation. Philadelphia: Saunders; 1996: 229-261. 23. Jull GA. Physiotherapy management of neck pain of mechanical origin. In: Giles LGF, Singer KP, eds. Clinical Anatomy and Management oj Ceroical Spine Pain. The Clinical Anatomy oj Back Pain. London: Butterworth-Heinemann; 1998: 168--191. 24. Wright JG, Feinstein AR. Improving the reliability of orthopaedic measurements. j Bone joint Surg. 1992;74B:287-291. 25. Haas M. Statistical methodology for reliability studies. j Manip Physiol Ther. 1991;14:119-132. 26. Cooperman JM, Riddle DL, Rothstein JM. Reliability and validity of judgments of the integrity of the anterior cruciate ligament of the knee using the Lachman's test. Phys Ther. 1990;70:225-233. 27. Shields RK, Enloe LJ, Evans RE, et al. Reliability, validity, and respon­ siveness of functional tests in patients with total joint replacement. Phys Ther. 1995;75:169. 28. Laslett M, Williams M. The reliability of selected pain provocation tests for sacroiliac joint pathology. Spine. 1994;19:1243-1249.



Comprehension Questions

1. Explain the differences between a sample and a population. 2. In the following statement, determine whether adescriptive or inferential statistic has
been used. In the year 2010,148 million Americans will be enrolled in an HMO. 3. In the following statement, determine whether adescriptive or inferential statistic has been used. The national average annual medicine expenditure per person is $1058.

4. Classify each of the following as nominal-level, ordinal-level, interval-level, or ratio­ level measurements: pages in the city of Pittsburgh telephone book, weights of air humidifiers, ages of students in a classroom.

5. Which of the following variables is qualitative? A. Number of cars sold in one year by a local dealer.
B. limes it takes to perform an ultrasound. C. Colors of theraband in a PT department. D. Capacity in cubic feet of Hubbard tank. 6. Which of the following variables is continuous? A. Water temperatures of three whirlpools in the PT department. B. Number of ultrasound treatments provided each day by the physical therapy department. C. The number of staff members in the department. D. Whether the members of staff are male or female.

7. Name the four basic sampling methods.
8. In the following example, name the type of sampling that is being used: every seventh patient entering a physical therapy department. 9. True or false: Probability is used as a basis for inferential statistics. A. True. B. False. 10. The number of absences per year that a worker has is an example of what type of data? 11. A researcher divided subjects into two groups according to gender and then selected members from each group for his sample. What sampling method was the researcher using? 12. What is the name of the graph that is used to investigate whether or not two variables are related? 13. True or false: Frequency distributions can aid the researcher in drawing charts and graphs. A. True. B. False.



14. True or false: Data collected over a period of time can be graphed by using a pie graph. A. True. B. False. 15. What is another name for the ogive? 16. What graph should be used to show the relationship between the parts and the whole? 17. Data such as blood types can be organized into what type of frequency distribution? 18. For the situation where the most typical case is desired, which measure of central tendency-meaning, median, or mode-should be used? 19. If the mean of five values is 64, find the sum of the values. 20. Find the mean of 10, 20, 30, 40, and 50. 21. What is the relationship between variance and standard deviation? 22. True or false: In a data set, the mode will always be unique. A. True. B. False. 23. Why is the standard normal distribution important in statistical analysis? 24. What is the total area under the standard normal distribution curve? 25. What percentage of the area falls below the mean? Above the mean? 26. About what percentage of the area under the normal distribution curve falls within one standard deviation above and below the mean? 27. You decide to use agroup of healthy college student volunteers to study the effects of BAPS board exercises on ankle ROM and balance scores. Twenty volunteers partici­ pate in the 20-minute exercise sessions 3 times a week for 6 weeks. Measurements are taken at the beginning and end of the sessions. At the conclusion of the study, significant differences were found in both sets of scores. Based on this research design, you conclude that: A. The validity of the study was threatened with the introduction of sampling bias. B. BAPS board exercises are an effective intervention to improve ankle stability fol­ lowing chronic ankle sprain. C. The reliability of the study was threatened with the introduction of systematic error of measurement. D. The Hawthorne effect may have influenced the outcome of the study. 28. A valid informed consent for research purposes must include all of the following ele­ ments except: A. A statement ensuring the subject's commitment to participate for the duration of the study. B. An understandable explanation of the purpose and procedures to be used. C. All reasonable and foreseeable risks and discomforts. D. All potential benefits of participation.



29. A study of the local population was necessary to determine the need for a new phys­ ical therapy center in the area. The researchers performing the study divided the pop­ ulation by sex and selected a random sample from each group. This is an example of what type of random sample? A. Systematic random sample. B. Random cluster sample. C. One-stage cluster sample. D. Stratified random sample. 30. You read a clinical study investigating the relationship between ratings of perceived exertion (RPE) and type of exercise: arm isokinetics versus leg isokinetics. The study reports a correlation of 0.55 with the arm isokinetics and a correlation of 0.80 with the leg isokinetics. From these findings, you could determine: A. Leg isokinetic exercises are highly correlated with RPE while arm isokinetic exer­ cises are only moderately correlated. B. Both arm and leg isokinetic exercises are only moderately correlated with RPE. C. Both arm and leg isokinetic exercises are highly correlated with RPE. D. The common variance of both types of testing is only 25%.

1. A population is the totality of all subjects possessing certain common characteristics that are being studied. A sample is a group of subjects selected from apopulation.
2. Inferential.

3. Descriptive.
4. All are ratio-level measurements-they are measured relative to atrue zero point, as opposed to an arbitrary zero point. 5. The answer is C. 6. The answer is A.

7. Random, systematic, stratified, and cluster.
8. Systematic.

9. The answer is A. This statement is true.
10. Discrete. 11. Nominal. 12. Scatter plot or scatter diagram.

13. The answer is A. This statement is true.
14. The answer is B. This statement is false. 15. Cumulative frequency graph. 16. Pie graph.



17. 18. 19. 20. 21.



25. 26. 27. 28. 29. 30.

Categorical. Mode. 320. 30. The square root of the variance is the standard deviation. The answer is B. This statement is false. Many variables are normally distributed, and the distribution can be used to describe these variables. 1, or 100%. 50% of the area lies below the mean, and 50% of the area lies above the mean. 68%. The answer is A. The answer is A. The answer is D. The answer is A.


There are probably as many ways to teach as there are to learn. Learning refers to the ways people acquire, process, store, and apply new infor­ mation. To identify realistic goals, instructors must be skilled in assessing a patient's readiness or a patient's progress toward goals.

One of the most important basic learning principles to understand is that motivation plays a critical role, and that success is more predictably motivating than failure (Table 4-1). Basic principles of motivation exist that are applicable to learning in any situation.




The environment can be used to focus the patient's attention on what needs to be learned. Interesting visual aids, such as booklets, posters, or practice equip­ ment, motivate learners by capturing their attention and curiosity. Incentives, including privileges and receiving praise from the educator, motivate learning. Both affiliation and approval are strong motivators. Internal motivation is longer lasting and more self-directive than is external motivation, which must be repeatedly reinforced by praise or concrete rewards. However, some individuals have lit­ tle capacity for internal motivation and must be guided and reinforced constantly. Learning is most effective when an individual is ready to learn, that is, when one wants to know something.

Maslow's hierarchy of needs is based on the concept that there is a hier­ archy of biogenic and psychogenic needs that humans must progress through. Maslow hypothesizes that the higher needs in this hierarchy only come into focus once all the needs that are lower down in the



1. Landa

TIIEORY Algo-heuristic

PRINCIPLE ELEMENTS Identifying the mental processes (conscious and subconscious) that underlie expert learning, thinking and performance in any area. All cognitive activities can be analyzed into operations of an algorithmic, semi-algOrithmic, heuristic, or semi-heuristic nature. Teaching students how to dL~cover processes is more valuable than providing them already formulated. Adults need to know why they need to learn something. Adults need to learn experientially. Adults approach learning as problem-solving. Adults learn best when the topic is of immediate value.

STRATEGIES Once discovered, the operations and their systems can serve as the basis for instructional strategies and methods.

CLINICAL APPLICATION Performing a task or solving a problem always requires a certain system of elementary knowledge of units and operations.

Androgeny (adult learning)

Adult learning

Integrates other theoretical frameworks for adult learning such as andragogy (Knowles), experiential learning (Rogers), and lifespan psychology. Consists of two classes of variables: personal characteristics (aging, life phases, and developmental stages) and situational characteristics (part-time versus full-time learning, and voluntary versus compulsory learning).

There is a need to explain why specific things are being taught (e.g., certain commands, functions, operations, etc.). Instruction should be task-oriented instead of memorization; learning activities should be in the context of common tasks to be performed. Instruction should take into account the wide range of different backgrounds of learners; learning materials and activities should allow for different levels/types of previous experience with computers. Since adults are self-directed, instruction should allow learners to discover things for themselves, providing guidance and help when mistakes are made. The three dimensions of personal characteristics (affect, cognition, and behavior) must be taken into consideration. Aging results in the deterioration of certain sensory-motor abilities (e.g., eyesight, hearing, reaction time) while intelligence abilities (e.g., decision-making skills, reasoning, and vocabulary) tend to improve.

M. Knowles

Can be applied to any form of adult learning. Has been used extensively in the design of organizational training programs.

K.P. Cross

Adult learning programs should capitalize on the experience of participants. Adult learning programs should adapt to the aging limitations of the participants. Adults should be challenged to move to increasingly advanced stages of personal development. Adults should have as much choice as possible in the availability and organiza­ tion of learning programs.

Learning is a function of a change Behaviorist (stimulus-response in overt behavior. theory)--operant Changes in behavior are the result of an conditioning individual's response to events (stimuli) and their consequences that occur in the environment. The response of one behavior becomes the stimulus for the next response. Learning occurs when an individual engages in specific behaviors in order to receive certain consequences (learned association). Behavior can be controlled or shaped by operant conditioning. Desired or correct behaviors are identified so that frequent and scheduled reinforcements (positive reinforcement) can be given to reinforce the desired behaviors. Negative behaviors are ignored (negative reinforcement) so that these behaviors become weakened to the pOint where they disappear (extinction). First model of learning to be studied Classical conditioning in psychology. Demonstrate the environment's control over behavior. Type of associative learning. Relates the capacity of animals/humans to learn new stimuli and connect them to natural reflexes, allowing non-natural cues to elicit a natural reflex. The conditioned stimulus, or conditional stimulus, is an initially neutral stimulus that elicits a response-known as a conditioned response­ that is learned by the organism. Conditioned stimuli are associated psychologically with conditions such as anticipation, satisfaction (both immediate and prolonged), and fear. The relationship between the conditioned stimulus and conditioned response is known as the conditioned (or conditional) reflex. The process by which an individual learns to associate an unconditional stimulus with a conditional stimulus but receives no benefit from doing so.

Positive reinforcement is used through the use of rewards that are meaningful to the individual. Timing of Reinforcement ~ Continuous reinforcement: a behavior is reinforced every time it occurs. ~ Partial reinforcement: a behavior is reinforced intermittently. ~ Fixed interval: the period of time between the occurrences of each instance of reinforcement is fixed or set. ~ Variable interval: the period of time between the occurrences of each instance of reinforcement varies around a constant average.

B.P. Skinner, G. Watson

Limited clinical use: behavior modification techniques may be used when working with adults with impaired or limited cognitive abilities or young children. Repetition is a necessary prerequisite for learning.

Therapies associated with classical conditioning are aversion therapy, flooding, systematic desensitization, and implOSion therapy. Much of what we like or dislike is a result of classical conditioning.

I. Pavlov, ].B. Watson

These techniques have been criticized for being unethical since they have the potential to cause trauma. Perhaps the strongest application of classical conditioning involves emotion. Common experience and careful research both confirm that human emotion conditions vary rapidly and easily, particularly when the emotion is intensely felt or negative in direction; then it will condition quickly.







THEORY Cognitive dissonance

PRINCIPLE ELEMENTS There is a tendency for individuals to seek consistency among their cognitions (i.e., beliefs, opinions). When there is an inconsistency between attitudes or behaviors (dissonance), something must change to eliminate the dissonance. In the case of a discrepancy between attitudes and behavior, it is most likely that the attitude will change to accommodate the behavior. Focuses on the nature of learning in complex and ill-structured domains. Emphasis is placed upon the presentation of information from multiple perspectives and use of many case studies that present diverse examples. Effective learning is context-dependent. Stresses the importance of constructed knowledge; learners must be given an opportunity to develop their own representations of information in order to properly learn. Learning happens best under conditions that are aligned with human cognitive architecture. The contents of long-term memory are sophisticated structures (schema) that permit us to perceive, think, and solve problems, rather than a group of rote learned facts. Schemas are acquired over a lifetime of learning, and may have other schemas contained within themselves. The difference between an expert and a novice is that a novice hasn't acquired the schemas of an expert.


CLINICAL APPLICATION Dissonance theory is especially relevant to decision-making and problem-solving.

Cognitive flexibility

Cognitive load

Constructivist theory

Learning is an active process in which learners construct new ideas or concepts based upon their current/past knowledge.

There are three ways to eliminate L. Festinger dissonance: 1. Reduce the importance of the dissonant beliefs. 2. Add more consonant beliefs that outweigh the dissonant beliefs. 3. Change the dissonant beliefs so that they are no longer inconsistent. Learning activities must provide R. Spiro, multiple representations of content. P. Feltovitch, Instructional materials should avoid R. Coulson oversimplifying the content domain and support context-dependent knowledge. Instruction should be case-based and emphasize knowledge construction, not transmission of information. Knowledge sources should be highly interconnected rather than compartmentalized. Change problem-solving methods J. Sweller to use goal-free problems or worked examples. Eliminate the working memory load associated with having to mentally integrate several sources of information by physically integrating those sources of information. Eliminate the working memory load associated with unnecessarily processing repetitive information by reducing redundancy. Increase working memory capacity by using auditory as well as visual information under conditions where both sources of information are essential (i.e., nonredundant) to understanding. Instruction must be concerned with J. Bruner the experiences and contexts that make the student willing and able to learn (readiness).

Limited: cognitive flexibility theory is especially formulated to support the use of interactive technology.

Cognitive load theory has many implications in the design of learning materials such as handouts and home exercise programs.

Much of this theory is linked to child development.

Cognitive structure (Le., schema, mental models) provides meaning and organization to experiences and allows the individual to "go beyond the information given."

Experiential learning

Two types of learning: 1. Cognitive (meaningless): academic knowledge such as learning vocabulary or multiplication tables. 2. Experiential (significant): applied knowledge such as personal change and growth.

Genetic epistemology

Cognitive structures (i.e., development stages) are patterns of physical or mental action that underlie specific acts of intelligence and correspond to stages of child development. There are four primary cognitive structures: 1. Sensorimotor stage (0-2 years): intelligence takes the form of motor actions. 2. Preoperation period (3--7 years): intelligence is intutive in nature. 3. Concrete operational stage (8-11 years): cognition is logical but depends upon concrete referents. 4. Formal operations (12-15 years): thinking involves abstractions.

Modes of learning

Three modes of learning: 1. Accretion: the addition of new knowledge to existing memory. The most common form of learning. 2. Structuring: involves the formation of new conceptual structures or schema. 3. Tuning: the adjustment of knowledge to a specific task, usually through practice. The slowest form of learning. Accounts for expert performance.

Instruction must be structured so that it can be easily grasped by the student (spiral organization). Instruction should be designed to facilitate extrapolation and or fill in the gaps (going beyond the information given). Significant learning takes place when the subject matter is relevant to the personal interests of the student. Learning that is threatening to the self (e.g., new attitudes or perspectives) is more easily assimilated when external threats are at a minimum. Learning proceeds faster when the threat to the self is low. Self-initiated learning is the most lasting and pervasive. Children will provide different explanations of reality at different stages of cognitive development. Cognitive development is facilitated by providing activities or situations that engage learners and require adaptation (i.e., assimilation and accomodation). Learning materials and activities should involve the appropriate level of motor or mental operations for a child of given age; avoid asking students to perform tasks that are beyond their current cognitive capabilities. Use teaching methods that actively involve students and present challenges. Instruction must be designed to accommodate different modes of learning. Practice activities affect the refmement of skills but not necessarily the initial acquisition of knowledge.

C. Rogers

Applies primarily to adult learners and adult learning.

J. Piaget

The theory has been applied extensively to teaching practice and curriculum design in elementary education.

D. Rumelhart, Multiple applications to D. Norman physical therapy­ general model for human learning.









TI-lEORY Humanist

PRINCIPLE ELEMENTS Emphasis placed on personal freedom and dignity of the individual and the learner's needs and feelings during the learning process. The learner experiences unconditional positive regard, acceptance, and understanding. Promotes active learning rather than passive. Social learning theory emphasizes the importance of observing and modeling the behaviors, attitudes, and emotional reactions of others. Social learning theory explains human behavior in terms of continuous reciprocal interaction between cognitive, behaVioral, and environmental influences.

STRATEGIES Teacher must function as a facilitator and resource finder. Learning must address relevant problems and issues. The highest level of observational learning is achieved by first organiZing and rehearsing the modeled behavior symbolically and then enacting it overtly. Coding modeled behavior into words, labels, or images results in better retention than simply observing. Individuals are more likely to adopt a modeled behavior if it results in outcomes they value, or if the model is similar to the observer and has admired status and the behavior has functional value.

CLINICAL APPLICATION Used in clinical situations that emphasize self­ discovery, self­ appropriated learning, and experimental learning.

Social learning

A. Bandura

Applied extensively to the understanding of aggression and psychological disorders, particularly in the context of behavior modification.



pyramid are mainly or entirely satisfied. Maslow's hierarchy is often depicted as a pyramid consisting of five levels (Fig. 4-1). The lower lev­ els (from bonom to top: physiologic and safety needs) are referred to as defiCiency needs, while the top three levels (from bonom to top: lovelbelonging, status, and self-actualization needs) are referred to as a being needs. According to Maslow, in order for an individual to progress up the hierarchy to the being needs, his or her deficiency needs must be met. Growth forces create upward movement in the hierarchy, whereas regressive forces create downward movement in the hierarchy.

5. Actualization 4. Status (esteem)
3. Love/belonging 2. Safety 1. Physiological (biological needs)

The following provides a synopsis on the various theories of learning.

Figure 4-1. Maslow's hierarchy of needs.


Educational Activities. Bloom! identified three domains of
educational activities:

Cognitive: mental skills (knowledge). Involves knowledge and the development of intellectual skills. Includes the recall or recognition of specific facts, proce­ dural panerns, and concepts that serve in the development of intellectual abilities and skills. There are six major categories (degrees of difficulties) starting from the simplest behavior to the most complex, with the first one having to be mastered before the next one can take place (Table 4-2).

TABLE 4-2. COGNITIVE DOMAIN CATEGORY Knowledge: Recall data or information. EXAMPLES AND KEYWORDS Able to recite a poem; quote prices from memory. Keywords: defmes, identifies, labels, lists, matches, recalls, recognizes, reproduces, selects. Able to rewrite a policy and procedures manual; can explain the steps for performing a complex task. Keywords: comprehends, distinguishes, estimates, interprets, paraphrases, predicts, summarizes. Can use a manual to set up a DVD player can apply the laws of statistics to evaluate a research study. Keywords: applies, computes, constructs, demonstrates, manipulates, modifies, operates, prepares, produces, relates, shows, solves. Can fix a piece of exercise equipment by using logical deduction; can gather information and select the required tasks for staff training. Keywords: analyzes, breaks down, compares, contrasts, differentiates, distinguL~hes, identifies, illustrates, infers, outlines, separates. Can design or revise a process to perform a specific task; is able to integrate training from several sources to solve a problem. Keywords: categorizes, combines, compiles, composes, creates, devises, designs, generates, modifies, rearranges, reconstructs, reorganizes, summarizes. Can select the most effective solution; hire the most qualified candidate; explain and justify a new budget. Keywords: appraises, compares, concludes, contrasts, critiques, discriminates, interprets, justifies, summarizes.

Comprehension: Understand the meaning, translation, interpolation, and interpretation of instructions and problems. Application: Use a concept in a new situation or unprompted use of an abstraction. Apply what was learned in the classroom into novel situations in the workplace. Analysis: Separate material or concepts into component parts so that the organizational structure may be understood. Distinguish between facts and inferences. SynthesL~: Build a structure or pattern from diverse elements. Put parts together to form a whole, with emphasL~ on creating a new meaning or structure. Evaluation: Make judgments about the value of ideas or materials.

Data from www.nwlink.com/-donclarklhrdlbloom.html.



TABLE 4-3. AFFECTIVE DOMAIN: THE FIVE MAJOR CATEGORIES (LISTED FROM THE SIMPLEST BEHAVIOR TO THE MOST COMPLEX) CATEGORY Receiving phenomena: Awareness, willingness to hear, selected attention. EXAMPLE AND KEYWORDS Able to listen to others with respect; listens for and remember the names of newly introduced people. Keywords: chooses, describes, follows, identifies, locates, names, points to, selects. Is an active participant in discussions; able to present an inservice; asks many questions about new ideas and concepts in order to fully understand them. Keywords: answers, assists, complies, conforms, discusses, labels, performs, practices, reads, recites, reports, tells, writes. Is sensitive towards individuals and the various cultural differences; informs management on matters that one feels strongly about. Keywords: completes, demonstrates, differentiates, initiates, invites, joins, justifies, proposes, reports, selects, shares. Able to recognize the need for balance between freedom and responsible behaVior; accepts professional ethical standard~; prioritizes time effectively to meet the needs of the organization, family, and self. Keywords: adheres, alters, arranges, combines, compares, completes, defends, generalizes, identifies, integrates, modifies, organizes, relates, synthesizes. Demonstrates self-reliance and can work independently, but also cooperates in group activities as a team player; uses an objective approach in problem-solving; values people for what they are, not how they look. Keywords: discriminates, displays, influences, listens, modifies, performs, proposes, qualifies, questions, revises, solves, verifies.

Responding to phenomena: Active participation on the part of the learner. Learning outcomes may emphasize compliance in responding, willingness to respond, or satisfaction in responding (motivation). Valuing: The worth or value a person attaches to a particular object, phenomenon, or behavior.

Organization: Organizes values into priorities by contrasting different values, resolving conflicts between them, and creating a unique value system.

InternaliZing values (characterization): Has a value system that controls their behavior. The behavior is pervasive, consistent, predictable, and most importantly, characteristic of the learner. Instructional objectives are concerned with the patient's general patterns of adjustment (personal, social, emotional).
Data from www.nwlink.com/-donclarklhrd/bloom.html.



Affective: growth in feelings or emotional areas (attitude) (Table 4-3), Includes the manner in which matters are dealt with from an emotional aspect. Includes feelings, values, appreciation, enthusiasms, motiva­ tions, and attitudes. Psychomotor: manual or physical skills (skills). Includes physical movement, coordination, and use of the motor-skill areas. Development of these skills requires practice and is measured in terms of speed, precision, distance, procedures, or tech­ niques in execution. The seven major categories listed the Simplest behavior to the most complex (Table 4-4).

Decision-Making. Both at a personal level and in the context of organizations, decision-making skill strongly affects the quality of life and success. A major focus of research on decision-making is the fre­ quent departure from purely rational choices. Most theories accept the idea that decision-making consists of a number of steps or stages such as recognition, formulation, the generation of alternatives, an information search, and then selection and action. Furthermore, it is well recognized that routine cognitive processes such as memory,



TABLE 4-4. PSYCHOMOTOR DOMAIN CATEGORY Perception: The ability to use sensory cues to guide motor activity. EXAMPLES AND KEYWORDS Able to detect nonverbal communication cues; can estimate where a moving ball will land and can move to the correct location to catch the ball. Keywords: chooses, detects, differentiates, distinguishes, identifies, isolates, relates, selects. Knows and acts upon a sequence of steps in a construction process; is able to recognize own abilities and limitations. Keywords: initiates, displays, explains, proceeds, reacts, states, volunteers. Can perform an exercise as demonstrated; follows instructions well. Keywords: copies, traces, follows, reproduces. Can use a personal computer effectively; able to perform simple DIY projects at home; can drive a car. Keywords: assembles, calibrates, constructs, dismantles, fixes, manipulates, measures, mends, organizes. Can parallel park a car into a tight spot; displays skill and competence while playing sports. Keywords: the same as for Mechanism, except that the performance is quicker, better, more accurate, etc. Responds effectively to unexpected experiences; able to modify instructions to meet the needs of the learners. Keywords: adapts, alters, changes, rearranges, reorganizes, revises, varies. Able to independently develop a new and comprehensive training program, or exercise protocol. Keywords: arranges, builds, combines, composes, constructs, creates, deSigns, initiates.

Set: Readiness to act; includes mental, physical, and emotional sets. Guided response: The early stages in learning a complex skill that includes imitation and trial and error. Mechanism: The intermediate stage in learning a complex skill.

Complex overt response: The skillful performance of motor acts that involve complex movement patterns in a quick, accurate, and highly coordinated manner and with a minimum expenditure of energy. Adaptation: Skills are well developed and the individual can modify movement patterns to fit special requirements. Origination: Can create new movement patterns to fit a particular situation or specific problem.

Data from www.nwlink.com/-donclarklhrdlbloom.html.

reasoning, and concept formation play a primary role in decision­ making. The study of attitudes, creativity, and problem-solving is closely associated with decision-making. In addition, decision-making behavior is affected (usually adversely) by anxiety and stress.

Problem-Solving. Problem-solving skills appear to be related to many other aspects of cognition such as schema (the ability to remem­ ber similar problems), pattern recognition (recognizing familiar prob­ lem elements), and creativity (developing new solutions). The issue of transfer is highly relevant to problem-solving. Sensory Motor Learning. Motor skills can be classified as con­ tinuous (e.g., tracking), discrete, or procedural movements (e.g., typing). Behavioral psychology emphasizes practice variables in sensory-motor skills such as massed (concentrated--eoncentrating the learning or practice in a short period of time) versus spaced (distributed-spreading out the learning or practice over a longer period of time) practice; part versus whole task learning; and feedback/reinforcement schedules. Long-term retention of motor skills depends upon regular practice; however, continuous responses show less forgetting in the absence of practice than discrete or procedural skills. Repetition after task profi­ ciency is achieved (overtraining) and refresher training reduce the



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effects of forgetting. Unlike verbal learning, sensory-motor learning appears to be the same under massed and spaced practice. Learning and retention of sensory-motor skills is improved by both the quantity and quality of feedback (knowledge of results) during training. Two ways in which learning/teaching of motor skills can be facil­ itated include: 1. Slowing down the rate at which the information is presented. 2. Reducing the amount of information that needs to processed. There is evidence that mental rehearsal, especially involving imagery, facilitates performance. This may be because it allows addi­ tional memory processing related to physical tasks (e.g., the forma­ tion of schema) or because it maintains arousal or motivation for an activity.

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There are several different theories regarding learning styles, including those proposed by lung, Witkin, Kolb and Barbe, and Swassing. Litzinger and Osif2 briefly describe each theory. However, as the authors point out, it would be impossible to incorporate every learning theory into every session, and therefore each clinician might choose to focus on one. Litzinger and Osif focus mainly on the 4MAT theory of David Kolb as adapted by Bernice McCarthy:




Accommodators. This type of learner looks for the significance of the learning experience. These learners enjoy being active participants in their learning, and will ask many questions such as "What ill" and "Why not?" Divergers. This type of learner is motivated to discover the relevancy of a given situation, and prefers to have infor­ mation presented in a detailed, systematic, and reasoned manner. Assimilator. This type of learner is motivated to answer the question, "what is there to know?" They like accurate, organ­ ized delivery of information and they tend to respect the knowledge of the expert. These learners are perhaps less "instructor intensive" than some other learning styles. They will carefully follow prescribed exercises, provided a resource per­ son is clearly available and able to answer questions. Convergers are motivated to discover the relevancy or "how" of a situation. The instructions given to this type of learner should be interactive, not passive.

Another series of learning styles that are used frequently was devised by Taylor,3 who proposed that there are three common learn­ ing styles:


Visual. As the name suggests, the visual learner assimilates infor­ mation by observation, using visual cues and information such as pictures, anatomic models, and physical demonstrations. Auditory. Auditory learners prefer to learn by having things explained to them verbally.



Tactile. Tactile learners, who learn through touch and interac­ tion, are the most difficult of the three groups to teach. Close supervision is required with this group until they have demon­ strated to the clinician that they can perform the exercises cor­ rectly and independently. PNF techniques, with the emphasis on physical and tactile cues, often work well with this group.

Bicknell-Holmes and Hoffman4 describe a variety of teaching methods that would appeal to most learning styles. These techniques involve active or discovery learning-the patient is able to actively par­ ticipate in the learning process, which is in direct contrast with a teach­ ing method like lecturing, where the patient is a passive observer. Discovery learning has certain attributes:
~ ~


Emphasizes learning over content.
Uses failure as an opportunity to learn.
More is learned by doing than by watching.
Involves patients in higher levels of cognitive processing.

Some of the methods of discovery learning include the following.








Case-based learning: a fairly common active learning strategy in which the patients are able to participate in the decision­ making or problem-solving process. Incidental learning: learning is linked to game-like scenarios. Learning by exploring: a collection of questions and answers on a particular topic are organized into a system and patients can explore the various topics at their own pace. Learning by reflection: a type of active learning that involves higher-level cognitive skills. Patients are expected to model certain skills or concepts that they have acquired through their instructor or through another system of learning. Simulation-based learning: the clinician creates an artificial environment in which patients can practice skills or apply con­ cepts that they have learned, without the pressure of a real­ world situation. Real-life examples: using real-life problems and examples in a variety of scenarios (buying a house!car, using a bus schedule, etc.). Relevant instruction: instruction should be practical and the examples and exercises should be important and meaningful to the patients, because patients often need to know why they need to learn a particular skill or concept, or how it will be use­ ful to them in their everyday lives. Humor: to help keep the patients engaged and interested and to make their sessions more enjoyable.

Analytical Learner. The analytical/objective learner processes
information in a step-by-step order, perceives information in an objec­ tive manner, and is able to use facts and easily understand the rela­ tionships between them. This type of learner perceives information in an abstract, conceptual manner; information does not need to be related to personal experience. As this type of learner may have diffi­ culty comprehending the big picture, a step-by-step learning process with some form of structure is recommended.



Intuitive/Global Learner. The intuitive/global leaner processes information all at once, and not in an ordered sequence. Global learn­ ers are spontaneous and intuitive, and tend to learn in layers, absorbing material almost randomly without seeing connections, and then sud­ denly "getting it." The learning of this type reflects personal life expe­ riences and is thus subjective. As this type of learner tries to relate the subject matter to things he or she already knows, information needs to be presented in an interesting manner using attractive materials. Reasoning: Inductive Versus Deductive Reasoning. Inductive and deductive reasoning are two methods of logic used to arrive at a conclusion based on information assumed to be true. Both are used in research to establish hypotheses.
1. Deductive reasoning: involves a hierarchy of statements or truths and the arrival at a specific conclusion based on generalizations. 2. Inductive reasoning: inductive reasoning is essentially the opposite of deductive reasoning. It involves trying to create general principles by starting with many specific instances.

Initiative: Active Versus Passive Learning
1. Active/aggressive learner: exhibits initiative, actively seeks information; may reach conclusions qUickly before all infor­ mation is gathered. 2. Passive learner: often exhibits little initiative; responds best to direct learning.

A number of factors have been outlined to improve compliance, including the following. 5­ 7
~ ~

~ ~

~ ~ ~

Involving the patient in the intervention planning and goal setting. Realistic goal setting for both short- and long-term goals. Promoting high expectations regarding final outcome. Promoting perceived benefits. Projecting a positive attitude. Providing clear instructions and demonstrations with appro­ priate feedback. Keeping the exercises pain-free or with a low level of pain. Encouraging patient problem-solving.

The strengths and weaknesses of various teaching methods when pre­ senting community education programs, or when educating staff, are outlined in Table 4-5.

A number of guidelines when using visual aids are outlined in Table 4-6.




STRENG1HS Presents factual material in direct, logical manner. Contains experience that inspires. Useful for large groups.
~ ~ ~

WEAKNESSES Experts are not always good teachers. Audience is passive. Learning is difficult to gauge. Communication is one way. Time may limit discussion period. Quality is limited to quality of questions and discussion. Experts may not be good speakers. Personalities may overshadow content. Subject may not be in logical order. Can be unfocused. Needs to be limited to 5 to 7 minutes. People may have difficulty getting away from known reality. If not facilitated well, criticism and evaluation may occur.
~ ~

PREPARATION Needs clear inrroduction and summary. Needs time and content limit to be effective. Should include examples, anecdotes. Requires that questions be prepared prior to discussion.




Lecture with discussion

Panel of experts




Small group discussion

Involves audience, at least after the lecture. ~ Audience can question, clarify, and challenge. ~ Allows experts to present different opinions. ~ Can provoke better discussion than a one-person discussion. ~ Frequent change of speaker keeps attention from lagging. ~ Listening exercise that allows creative thinking for new ideas. ~ Encourages full participation because all ideas equally recorded. ~ Draws on group's knowledge and experience. ~ Spirit of congeniality is created. ~ One idea can spark off other ideas. ~ Entertaining way of teaching content (colorful) and raising issues. ~ Keep group's attention. ~ Looks professional. ~ Stimulates discussion. ~ Demonstrates three­ dimensional movement. ~ Pools ideas and experiences from group. ~ Effective after a presentation, mm, or experience that needs to be analyzed. ~ Allows everyone to participate in an active process. ~ Allows participation of everyone. ~ People often more comfortable in small groups. ~ Can reach group consensus.


~ ~ ~ ~



Facilitator coordinates focus of panel, introduces, and summarizes. Briefs panel.

~ ~ ~

~ ~

Facilitator selects issue. Must have some ideas if group needs to be stimulated.



~ ~

Can raise too many issues to have a focused discussion. Discussion may not have full participation. Only as effective as following discussion. Can be expensive. Not practical with more that 20 people. Few people can dominate. Others may not participate. Is time consuming. Can get off the track.



Need to set up equipment. Effective only if facilitator prepares questions to discuss after the show.

~ ~

~ ~

Requires careful planning by facilitator to guide discussion. Requires question outline.



Needs careful thought as to purpose of group. Groups may get side tracked.


Need to prepare specific tasks or questions for group to answer.





STRENGTIlS Introduces problem situation dramatically. ~ Provides opportunity for people to assume roles of others and thus appreciate another point of view. ~ Allows for exploration of solutions. ~ Provides opportunity to practice skills. ~ Develops analytic and problem-solving skills. ~ Allows for exploration of solutions for complex issues. ~ Allows patient to apply new knowledge and skills. ~ Personalizes topic. ~ Breaks down audience's stereotypes.

WEAKNESSES People may be too self­ conscious. Not appropriate for large groups. People may feel threatened.

PREPARATION Trainer has to defme problem situation and roles clearly. Trainer must give very clear instructions.


Case studies



People may not see relevance to own situation. Insufficient information can lead to inappropriate results. May not be a good speaker.

~ ~

Case must be clearly defined in some cases. Case study must be prepared.

Guest speaker



Contact speakers and coordinate. Introduce speaker appropriately.

Data from http://honolulu.hawaiLedu/intranet!committees/facdevcomiguidebk!teachtip!comteach.htm.

TABLE 4-6. GUIDELINES FOR TIlE USE OF VISUAL AIDS OVERHEADS Use the most professional lettering available. ~ Use transparencies of one color only and secure transparencies to cardboard frames (if available). ~ Number each transparency. ~ Prior to the session, check overheads for readability of type size by audience at far end of room. Printing should be no smaller than 1/4 inches high. Information should be placed on the top two-thirds of the transparency. ~ Be familiar with the operation of the projector and make sure projector works. Have extra bulbs available. ~ While presenting, be certain neither you nor the projector blocks anyone's view. ~ Use a pencil rather than a finger to note a detail on the transparency. ~ If you have a list of points, black out all but the first point, and then move the cover sheet and one point at the time.
~ ~ Choose

FLIPCHARTS a chart size that is appropriate for the design, your height, and the size of the audience. ~ Draw the art to fit the vertical shape of the chart. ~ Make the lettering dark enough and large enough to be read by everyone in the audience. ~ During preparation, leave several blank pages between each one to allow for corrections and additions. For the fmal presentation, remove all but one blank page at the beginning so that you can turn to that blank page when there is no relevant visual. ~ Securely attach charts to the easel and adjust the easel height for the presentation. ~ When writing on the flipchart, don't speak to the chart.

SLIDES Slides should be used instead of flipcharts if the group is large. Design the visuals for continuous Viewing and as notes. continuity: have all slides horizontal or vertical, not mixed.

~ Maintain

Allow sufficient production time. Place no more than 15 words per slide. ~ Use black or blue background with bright colors. ~ Check the position and order of the slide in the carousel or tray. ~ Use a conventional pointer. ~ Keep on as many lights as possible.




It is important that clinicians are sensitive to cultural issues in their inter­

actions with patients. Cultural influences shape the framework within which people view the world, define and organize reality, and function in their everyday life. In many cases, individuals group themselves on the basis of cul­ tural similarities, and as a result form cultural groups. Cultural groups share behavioral patterns, symbols, values, beliefs, and other charac­ teristics that distinguish them from other groups. At the group level, cultural differences are generally variations of differing emphasis or value placed on particular practices.

1. Bloom BS. Taxonomy ofEducational Objectives, Handbook I The Cognitive Domain. New York: David McKay; 1956. 2. Litzinger ME, Osif B. Accommodating diverse learning styles: designing instruction for electronic information sources. In: Shirato L, ed. What is Good Instruction Now? Library Instruction for the 90s. Ann Arbor: Pierian Press; 1993. 3. Taylor ]A. A practical tool for improved communications. Supervision. 1998;59: 1&-19. 4. Bicknell-Holmes T, Hoffman PS. Elicit, Engage, Experience Explore: Discovery Learning in Library Instruction. Ref Serv Rev. 2000; 28:313-322. 5. Blanpied P. Why won't patients do their home exercise programs? ] Orthop Sports Phys Ther. 1997;25:101-102. 6. Chen CY, Neufeld PS, Feely CA, et al. Factors influencing compli­ ance with home exercise programs among patients with upper extremity impairment. Am] Occup Ther. 1999;53:171-180. 7. Friedrich M, Cermak T, Madebacher P. The effect of brochure use versus therapist teaching on patients performing therapeutic exer­ cise and on changes in impairment status. Phys Ther. 1996;76: 1082-1088.



Comprehension Questions
1. Maslow's hierarchy of needs is based on what concept? 2. What is the lowest need according to Maslow? 3. What is the highest need according to Maslow? 4. According to the 4MAT theory, how do accommodators learn? 5. According to the 4MAT theory, how do convergers learn? 6. What are the three learning styles devised by Taylor?

7. Outline three factors that can be used to improve patient compliance
8. You have just returned from an inservice offering new treatment techniques in wound care and would like to share the information with interested members of the hospital staff. What is the best way to share this information? A. Prepare a handout and give it to the members of the hospital staff. B. Schedule a mandatory inservice during lunch for those hospital staff that partici­ pate in wound care. C. Post bulletins in view of all hospital staff and send memos to the department heads inviting everyone to attend an inservice during lunch. D. None of the above.

1. That there is a hierarchy of biogenic and psychogenic needs that humans must progress through. 2. Physiologic need. 3. Self-actualization. 4. This type of learner looks for the significance of the learning experience. 5. Convergers are motivated to discover the relevancy or "how" of a situation. 6. Visual, auditory, and tacti Ie.

7. Involving the patient in the intervention planning and goal setting, setting realistic short- and long-term goals, and promoting high expectations regarding final outcome.
8. The answer is C.

Fundamentals and Core Concepts

Based on morphology and function, the tissues of the body are classified into four basic kinds: epithelial, nervous, connective, and muscle tissue.!

Epithelial tissue is found throughout the body in two forms: membra­ nous and glandular.


Membranous epithelium forms such structures as the outer layer of the skin, the inner lining of the body cavities and lumina, and the covering of visceral organs. Glandular epithelium is a specialized tissue that forms the secretory portion of glands.


Nervous tissue helps coordinate movements via a complex motor con­ trol system of prestructured motor programs and a distributed network of reflex pathways mediated throughout the CNS.2

Connective tissue (CT) is found throughout the body and serves to pro­ vide structural and metabolic support for other tissues and organs of the body. Connective tissue includes bone, cartilage, tendons, liga­ ments, and blood tissue. The CT types are differentiated according to the extracellular matrix that binds the cells!:

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Embryonic CT. Connective tissue proper. • Loose CT. • Dense regular CT.



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• Dense irregular CT. • Elastic CT.
Reticular CT.
Adipose CT.
Cartilage and bone tissue.
• Hyaline cartilage. • Fibrocartilage. • Elastic cartilage.
Blood (vascular) tissue.

Connective Tissue Proper. Connective tissue proper (crP) has a loose, flexible matrix, called ground substance. The most common cell within CTP is the fibroblast. Fibroblasts produce collagen, elastin, and reticulin fibers. Collagen and elastin are vital constituents of the musculoskeletal system.
Collagen. The collagens are a family of extracellular matrix proteins that play a dominant role in maintaining the structural integrity of var­ ious tissues and in providing tensile strength to tissues. The major forms of collagen are outlined in Table 5-1. 4 Elastin. Elastic fibers are composed of a protein called elastin. As its name suggests, elastin provides the tissues in which it is situated with elastic properties. Elastin fibers can stretch, but they normally return to their original shape when the tension is released. The elastic fibers of elastin determine the patterns of distension and recoil in most organs including the skin, lungs, blood vessels, and CT. Arrangement of Collagen and Elastin. Collagenous and elastic
fibers are sparse and irregularly arranged in loose CT, but are tightly packed in dense CT. 5

Fascia is an example of loose CT.

~ Tendons and ligaments are examples of dense regular CT. 6

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Fascia. Fascia is viewed as the CT that provides support and protec­ tion to the joint, and acts as an interconnection between tendons aponeurosis, ligaments, capsules, nerves, and the intrinsic components of muscle. 7 •B This type of CT may be categorized as fibrous or nonfi­ brous, with the fibrous components consisting mainly of collagen and elastin fibers, and the nonfibrous portion consisting of amorphous ground substance, which is a viscous gel composed of long chains of carbohydrate molecules (GAG) bound to a protein and water. 9
Histologically, tendons and ligaments are similar in composition-they are densely packed CT structures that consists largely of directionally oriented, high tensile strength colla­ gen. lO Due to their function as supporting cables in an environment of high tensile forces, ligaments and tendons must be relatively inextensi­ ble to minimize transmission loss of energy. The collagen structural organization of tendons and ligaments is similarY Both are mostly type I collagenY The fibers are arranged in a quarter-stagger arrangement, which gives collagen its characteristic band­ ing pattern and provides high strength and stability. A loose connective­ tissue matrix surrounds the bundles of collagen fibrils. Bundles of

Tendons and Ligaments.



collagen and elastin combine to form a matrix of CT fascicles. This matrix is organized within the primary collagen bundles as well as between the bundles that surround them. 13


Tendons. Tendons are cordlike structures that function to attach mus­ cle to bone and to transmit the forces generated by muscles to bone in order to achieve movement or stability of the body in space. 13 The thickness of each tendon varies and is proportional to the size of the muscle from which it originates. Within the fascicles of tendons, the collagen components are uni­ directionally oriented. The fascicles are held together by a loose CT called endotenon. Endotenon contains blood vessels, lymphatics, and nerves, and permits longitudinal movements of individual fascicles when tensile forces are applied to the structure. The CT surrounding groups of fascicles and/or the entire structure is called the epitenon.


Bone, skin, ligament, and tendon Cartilage, nucleus pulposus Blood vessels, gastrointestinal tract Basement membranes

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Gliding tendons, such as the flexor tendons of the hand, are enclosed by a tendon sheath with discrete parietal (inside sur­ face of the sheath) and visceral (epitenon or outside layer of the tendon) synovium layers. These tendons receive vascular access only through vincula-small loose, flexible strips of CT that connect with the mesotenon and paratenon, the loose con­ nective tissues around the sheath. 13 Vascular tendons are surrounded by a peritendinous CT paratenon, which is connected to the epitenon. If there is syn­ ovial fluid between these two layers, the paratenon is called tenosynovium; if not, it is termed tenovagium. 13

As the tendon joins the muscle, it fans out into a much wider and thinner structure. The site where the muscle and tendon meet is called the myotendinous junction (MTJ). Despite its viscoelastic mechanical characteristics, the MTJ is very vulnerable to tensile failure. 14,15 Tendon injuries. Tendon injuries account for up to half of all sports­ related injuries. Both extrinsic and intrinsic forces can cause injuries to tendons.


Extrinsic factors may include training errors, training surfaces, environmental conditions, footwear, and improper or faulty equipment. Intrinsic causes are due to an athlete's body alignment, muscle imbalances, or structural deformities.

Tendonitis is an inflammatory condition characterized by pain at tendinous insertions into bone. More specifically, it is the sympto­ matic degeneration of the tendon with vascular disruption and inflam­ matory repair. Tendonopathy is the current umbrella term applied to sports-related tendon injuries that cause pain, swelling, and impaired performance. Common sites of tendonopathy include the rotator cuff of the shoulder e.g., supraspinatus, bicipital tendons), insertion of the wrist extensors (e.g., lateral epicondylitis, tennis elbow) and flexors (e.g., medial epicondylitis) at the elbow, patellar and popliteal tendons and iliotibial band at the knee, insertion of the posterior tibial tendon in the leg (e.g., shin splints), and the Achilles tendon at the heel.



TABLE 5-2. MAJOR LIGAMENTS OF TIlE UPPER QUADRANT JOINT Shoulder complex Glenohumeral LIGAMENT Coracoclavicular Costoclavicular Coracohumeral Glenohumeral ("Z") Coracoacromial Annular Ulnar (medial) collateral Radial (lateral) collateral FUNCTIOI\ Fixes the clavicle to the coracoid process Fixes the clavicle to the costal cartilage of the fir.;t Ii> Reinforces the upper portion of the joint capsule Reinforces the anterior and inferior aspect of the joinI. c:apsuIe Protects the superior aspect of the coracoacromial joinI. Maintains the relationship between the head of the r.ldius and the humerus and ulna Provides stability against valgus (medial) stress, pamcularly in the range of 20-130 degrees of flexion and extension Provides stability against varus (lateral) stress and functions to maintain the ulnohumeral and radiohumeral joints in a reduced position when the elbow is loaded in supination Provides the majority of the wrist stability Serves as rotational restraint, binding the proximal carpal row into a unit of rotational stability Binds the carpal bones together Prevent displacement of the interphalangeal joints



Extrinsic palmar Intrinsic Interosseous Volar and collateral interphalangeal


Typically, repeated loading causes partial rupture of the fibrils, which leads to tendon fatigue and microscopic destruction. When this microscopic destruction exceeds the tendon's reparative capacity, cumulative microtrauma occurs. As the metabolic rate of tendons is low, the increased demand for collagen and matrix production is eas­ ily exceeded and pathologic changes occur (cell atrophy, calcium deposits [i.e., calcific tendinitis]). Inadequate repair will set off a vicious cycle of tenocyte death with further reduction of reparative capacity and subsequent predis­ position to injury. The end result of this overload mechanism or failed healing response is the formation of a tendinosis zone within the tendon.

Ligaments. Skeletal ligaments are fibrous bands of dense cr that con­ nect bones across joints (Tables 5-2 and 5-3). Ligaments contribute to the stability of joint function by preventing excessive motion,20 acting as guides to direct motion, and by providing proprioceptive information for joint function. 21 Inman 22 feels that the ligaments are more important as checkreins than as providers of stability during movement. The cellular organization of ligaments makes them ideal for sus­ taining tensile load. 23 Small amounts of elastin are present in ligaments, with the exception of the ligamentum flavum and the nuchal ligament of the spine. The collagen has a less unidirectional organization in lig­ aments than it does in tendons, but its structural framework still pro­ vides stiffness (resistance to deformation). 11
Pathology of the ligament. See Table 5-4.

Bone. Bone, the most rigid of the connective tissues, is a highly vas­ cular form of cr, composed of collagen, calcium phosphate, water, amorphous proteins, and cells. Despite its rigidity, bone is a dynamic tissue, which undergoes constant metabolism and remodeling. A dif­ ferent cell, the osteoblast, produces the collagen of bone in the same



TABLE 5-3. MAJOR LIGAMENTS OF THE SPINE AND LOWER QUADRANT JOINT Spine LIGAMENT Anterior longitudinal ligament Posterior longitudinal ligament FUNCTION






Functions as a minor assistant in limiting anterior translation, and vertical separation of the vertebral body Resists vertical separation of the vertebral body Resists posterior shearing of the vertebral body Acts to limit flexion over a number of segments Provides some protection against intervertebral disk protrusions Ligamentum flavum Resists separation of the lamina during flexion Resists separation of the spinous processes during flexion Interspinous Iliolumbar (lower lumbar) Resists flexion, extension, axial rotation, and side bending of L5 on Sl Creates greater sciatic foramen Sacrospinous Resists forward tilting of the sacrum on the hip bone during weight bearing of the vertebral column Creates lesser sciatic foramen Sacrotuberous Resists forward tilting of the sacrum on the hip bone during weight bearing of the vertebral column Resists anterior and inferior movement of the sacrum Interosseous Dorsal sacroiliac (long) Resists backward tilting of the sacrum on the hip bone dUring weight bearing of the vertebral column Transports nutrient vessels to the femoral head Ligamentum teres Limits hip extension Iliofemoral Limits anterior displacement of the femoral head Ischiofemoral Pubofemoral Limits hip extension Medial collateral Stabilizes medial aspect of tibiofemoral joint against valgus stress Stabilizes lateral aspect of tibiofemoral joint against varus stress Lateral collateral Resists anterior translation of the tibia and posterior translation of the femur Anterior cruciate Resists posterior translation of the tibia and anterior translation of the femur Posterior cruciate Medial collaterals Provides stability between the medial malleollus, navicular, talus, and calcaneus against (deltoid) eversion Static stabilizers of the lateral ankle especially against inversion Lateral collaterals Provides indirect plantar support to the calcaneocuboid joint, by limiting the amount of Long plantar flattening of the lateral longitudinal arch of the foot Bifurcate Supports the medial and lateral aspects of the foot when weight bearing in a plantar flexed position Provides plantar support to the calcaneocuboid joint and possibly helps to limit flattening Calcaneocuboid of the lateral longitudinal arch

TABLE 5-4. LIGAMENT INJURIES GRADE First degree (mild) SIGNS Minimal loss of structural integrity No abnormal motion Little or no swelling Localized tenderness Minimal bruising Significant structural weakening Some abnormal motion Solid end-feel to stress More bruising and swelling Often associated hemarthrosis and effusion Loss of structural integrity Marked abnormal motion Significant bruising Hemarthrosis IMPLICATIONS Minimal functional loss Early return to training-some protection may be necessary

Second degree (moderate)

Tendency to recurrence Need protection from risk of further injury May need modified immobilization May stretch out further with time Needs prolonged protection Surgery may be considered Often permanent functional instability

Third degree (complete)

Reproduced, with pennission, from Reid DC. Sports Injury Assessment and Rehabilitation. New York: Churchill Iivingstone; 1992. Copyright © Elsevier.



TABLE 5-5. GENERAL STRUCTURE OF BONE SITE Epiphysis COMMENT Mainly develops under pressure Apophysis forms under traction Forms bone ends Supports articular surface Epiphyse~growth plate Respong(ye to ~rowth and sex hormones Vulnerable prior to growth spurt Mechanically weak Remodeling expanded bone end Cancellous bone heals rapidly Vulnerable to osteomyelitis Affords ligament attachment Forms shaft of bone Large surface for muscle origin Significant compact cortical bone Strong in compression CONDITIONS Epiphyseal dysplasias Joint surface trauma Overuse injury Damaged blood supply Physeal dysplasia Trauma Slipped epiphysis Osteomyelitis Tumors Metaphyseal dysplasia Fractures Diaphyseal dysplasias Healing slower than at metaphysis Sequestrum formation Altered bone shape Distorted growth Able to remodel angulation Cannot remodel rotation Involucrum with infection Dysplasia give altered density and shape RESULT Distorted joints Degenerative changes Fragmented development Avascular necrosis Short stature Deformed or angulated growth or growth arrest




Reproduced, with permission, from Reid DC. Sports Injury Assessment and Rehabilitation. New York: Churchi11 Livingstone; 1992. Copyright © Elsevier.

manner as that of ligament and tendon. 5 At the gross level, each bone has a distinct morphology comprising both cortical bone and cancel­ lous bone.
~ ~

Cortical bone is found in the outer shell. Cancellous bone is found within the epiphyseal and metaphy­ seal regions of long bones as well as throughout the interior of short bones (Table 5-5).14

The function of bone is to provide support, enhance leverage, protect vital structures, provide attachments for both tendons and liga­ ments, and to store minerals, particularly calcium. Bones may also serve as useful landmarks during the palpation phase of the examina­ tion. The strength of a bone is related directly to its density.

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Fractures. A fracture is commonly defined as a break in the continu­ ity of a bone. A number of types of fractures exist (Table 5-6). The risk for a fracture and the pattern of the fracture depend largely on the nature of the applied force, the properties of the bone, age, race, and the presence of any co-morbidities (e.g., osteoporosis). A fracture may arise when the force is applied repetitively over time or from a single application of force. 24 Regardless of where force is applied, the stress generated may be compressive, tensile, or shear in nature or a combi­ nation. 24 Fractures may be classified according to direction, mecha­ nism, whether the skin is broken or not, and location (Table 5-7). With indirect trauma, a fracture may be caused when a bending or twisting stress is applied at a distance from the resultant fraction. For exam­ ple, an inversion stress at the ankle may result in a fIfth metatarsal fracture. Although the length of time for fracture healing varies, there is a typical rate at which fractures heal and some predictable variability based on the location and nature of the fracture and the type of fixa­ tion (see "Bone Healing" later in this chapter).24



TABLE 5-6. TYPES OF FRACTURES TYPES OF FRACTIJRE Avulsion Closed Comminuted Complete Complex Compound (open) Compression DESCRIPTION
An avulsion fracture is an injury to the bone where a tendon or ligament pulls off a piece of the bone. When there is a closed fracture there is no broken skin. The fracture ends do not penetrate the skin (but may be seen under the skin) and there is no contusion from external trauma. A comminuted fracture has more than two fragments of bone that have broken off. It is a higWy unstable type of bone fracture. A fracture in which the bone has been completely fractured through its own width. This type of fractured bone severely damages the soft tissue that surrounds the bone A fracture that involves fragments of the bone penetrating through the internal soft tissue of the body and breaking through the skin from the inside. This type of fracture carries a high risk of infection. This type of bone fracture occurs when the bone is compressed beyond its limits of tolerance. These fractures generally occur in the vertebral bodies as a result of a flexion injury or without trauma in patients with osteoporosis. Compression fractures of the calcaneus are also common when patients fall from a height and land on their heels. A fracture of the epiphysL~ and physis--growth plate. These injuries are classified using the Salter-Harris classification. An incomplete fracture in which only one side of the bone has been broken. The bone usually is "bent" and only broken at the outside of the bend. It is mostly seen in children and is considered a stable fracture due to the fact that the whole bone has not been broken. This incomplete bone fracture involves minimal trauma to the bone and surrounding soft tissues. It has no significant bone displacement, and is considered a stable fracture, as the crack only extends into the outer layer of the bone but not completely through the entire bone. It is also known as a fissure fracture. Occurs when one fragment is driven into another. This type of fracture is common in tibial plateau fractures. A fracture that goes at an angle to the axis to the bone. This type of fracture occurs when a bone breaks in an area that is weakened by another disease process. Causes of weakened bone include tumors, infection, and certain inherited bone disorders. In this pattern a bone has been broken due to a twisting-type motion. It is higWy unstable. These fractures may extend through all or only part of the bone. Stress fractures are common in soldiers or runners and are far more common in women. They often occur in the spine and lower extremity (most often in the fibula, tibia, or metatarsals). Stress fractures occur in a variety of age groups, rang­ ing from young children to elderly persons. Stress fractures do not necessarily occur in association with a history of increased activity. Therefore, it is important to remember that the absence of a his­ tory of trauma or increased activity does not eliminate the possibility of stress or insufficiency fracture as a cause of musculoskeletal pain.

Epiphyseal Greenstick


Impaction Oblique Pathologic Spiral Stress

Pathology of Bone
Skeletal demineralization. Skeletal demineralization refers to a loss of mass and calcium content from the bones. Skeletal demineralization can vary in severity:
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Less severe bone loss: osteopenia. More severe bone loss: osteoporosis.

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Skel et~r~emineraIJztltiQntsa(jS€d by an imbaf.ance.:~~ween .bQ~~forma: tiORtlnd .bOfle:~rp}i?nlimay.bfiJ.a. primal)'. djsorderarn1aybesepood· disorders.. sucb:asQsteomafaciaand hyperparathyrojdism. L _
ary to~vafiety • ofi(1t~erdjsea~fiJ~ot

Osteoporosis. Osteoporosis 25 - 35 is a systemic skeletal disorder characterized by decreased bone mass and deterioration of bony microarchitecture. Osteoporosis results from a combina­ tion of genetic and environmental factors that affect both peak bone mass and the rate of bone loss. These factors include med­ ications, diet, race, sex, lifestyle, and physical activity. Osteoporosis may be either primary or secondary.



TABLE 5-7. SALTER-HARRIS CLASSIFICATION OF FRACfURES Salter I Epiphysis separate from shaft and metaphysis-through the physis Most common in newborns and young children Prognosis excellent Like Salter I, through the physis with separation of physis from metaphysis, but with a small IIlCI:apbjtW ~ bJure Most common overall epiphyseal fracture Prognosis excellent although joint instability is possible Intra-articular fracture through epiphysis Uncommon Open reduction internal fIxation (ORIF) is often necessary Intra-articular: through epiphysis, growth plate, and metaphysics Poor prognosis, lost blood supply Needs perfect reduction Crushing of physis Poor prognOSis Early radiograph negative Rarely occurs Portion of growth plate sheared off Typically occurs with penetrating injuries

Salter II

Salter III

Salter IV

Salter V

Salter VI (Rare)

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Study Pearl
ow bone densi as radiographic always noticeab 30% of bone. mineral is IOSt. 36


Primary osteoporosis is subdivided into types 1 and 2­ • Type 1, or postmenopausal osteoporosis, is thougbllO result from gonadal (estrogen, testosterone) deficiency, resuDng in accelerated bone loss. An increased recruitment and respon­ siveness of osteoclast precursors and an increase in bone resorption, which outpaces bone formation, oca.us. After menopause, women experience an accelerated bone loss of 1% to 5% per year for the ftrst 5 to 7 years. The end result is a decrease in trabecular bone and an increased risk of CoDes' and vertebral fractures. • Type 2, or senile osteoporosis, occurs in women and men because of decreased formation of bone and decreased renal production of 1,25(OH)2 D3 occurring late in life. The conse­ quence is a loss of cortical and trabecular bone and increased risk for fractures of the hip, long bones, and vertebrae. Secondary osteoporosis, also called type 3, occurs secondary to medications, especially glucocorticoids, or other conditions that cause increased bone loss by various mechanisms.

Osteoporosis can occur in either a generalized or a regional form. The cardinal feature is a fracture, and the clinical picture depends on the fracture site. Vertebral fracture often manifests as acute back pain after bending, lifting, or coughing or as asymptomatic progressive kyphosis with loss of height. Most vertebral fractures occur in the mid to lower thoracic or upper lumbar spine. The pain is described variably as sharp, nagging, or dull; movement may exacerbate pain; and some­ times pain radiates to the abdomen. Acute pain usually resolves after 4 to 6 weeks. In the setting of multiple fractures with severe kyphosis or dowager hump, the pain may become chronic. When kyphosis becomes severe, the patient may develop a restrictive pattern of respi­ ratory impairment. Forearm, hip, and proximal femoral fractures usually occur after falls, with forward falls often resulting in Colles' fractures and backward



falls resulting in hip fractures. Rib fractures are most often associated with osteoporosis secondary to corticosteroid use or Cushing's syn­ drome, but they can also be observed with other etiologies. To definitively diagnose osteoporosis, one must perform some type of quantitative imaging study on the bone in question. Medical and screening tests of bone mineral density are available:

Study Pearl
Cushing's syndrome is a hormonal disorder caused by proloogedexpo­ sure of the body's tissues to high levels of the hormone cortisol. Symptoms vary, but most peopl~ have upper body obesity, rounded (moon) face, increased fat aroundlhe neCk, and thinning arms and legs. In addi­ tion, Cushing's syndrome is associated with severe fatigue, hypertension, and increased risk of fracture.

Screening tests include finger densitometry and heel (calcaneal) ultrasonography. Medical tests include single-photon absorptiometry (SPA) and dual-energy x-ray absorptiometry (DXA). Radiographs may show fractures or other conditions, such as osteoarthritis, disk disease, or spondylolisthesis. Osteopenia (low bone density) may be apparent as radiographic lucency but is not always noticeable until 30% of bone mineral is lost.

BMD testing is the best predictor of fracture risk. Although meas­ urement at any site can be used to assess overall fracture risk, meas­ urement at a particular site is the best predictor of fracture risk at that site. According to guidelines from the National Osteoporosis Foundation, BMD should be measured in the following people:


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Postmenopausal women older than 65 years. Although preven­ tive measures may no longer be effective, these women are at risk and should be treated if they have osteoporosis. Postmenopausal women younger than 65 years who have one or more risk factors. Postmenopausal women who present with fragility fractures. Women who are considering therapy in which BMD will affect that decision. Women who have been on hormone replacement therapy (HRT) for prolonged periods. Men who experience fractures after minimal trauma. People with evidence of osteopenia on radiographs or a dis­ ease known to place them at risk for osteoporosis.

Study Pearl
Effective medical therapy is available to help prevent and treat osteo­ porosis, including gonadal hormone replacement, calcitonin, selective estrogen-receptor modulators, and bis­ phosphonates. 34 However, these agents reduce bone resorption with little, if any, effect on bone formation. 34

BMD is reported as a T-score, which compares the patient's BMD to that of a healthy young adult. Osteomalacia. Osteomalacia is characterized by incomplete mineral­ ization of normal osteoid tissue following closure of the growth plates. Rickets is defined as the failure of osteoid to calcify in a growing per­ son or animal. Failure of osteoid to calcify in the adult is called osteo­ malacia. Normal bone mineralization depends on interdependent fac­ tors that supply adequate calcium and phosphate to the bones. Clinically, osteomalacia is manifested by progressive generalized bone pain, muscle weakness, hypocalcemia, and pseudofractures. In its late stages, osteomalacia is characterized by a waddling gait. 38 Physical therapy role in skeletal demineralization. Risk factors for skele­ tal demineralization include those that are modifiable and those that are nonmodifiable (Table 5-8). Because anyone can be at risk for develop­ ing osteopenia or osteoporosis, every patient should be questioned regarding family history of bone disease and risk factors for low peak bone mass. In addition, the examination of the patient should include

Study Pearl
Vitamin 0 maintains calcium and
phosphate homeostasis through its
action on bone, the GI tract, kidneys,
and parathyroid glands. Vitamin 0
may be supplied in the diet or pro­
duced from a sterol precursor in the
skin following exposure to ultraviolet
light. Sequential hydroxylation then is
required to produce the metabolically
active form of vitamin D.


- - - -




Gender Race Age Family history Body size Early menopause

Use of specific medications Low calcium intake Low vitamin D Estrogen deficiency Excessive alcohol intake Cigarette smoking Physical inactivity Prolonged overuse of thyroid hormone

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Age, sex, and race. Questions about current and past medication use. Cyclosporine, thyroid hormone, glucocorticoids, and some of the chemother­ apeutic medications can cause loss of bone density.39,40 Questions about reproductive factors, especially with regard to early menopause and estrogen replacement therapy, Questions about lifestyle factors associated with decreased bone density, such as strenuous exercise (as occurs in marathon runners) that results in amenorrhea, Questions about dietary factors, especially calcium and vita­ min D intake (important because deficiencies of both increase osteoporosis risk), and eating disorders such as anorexia nervosa. Review of the cardiovascular and pulmonary systems, includ­ ing aerobic capacity and endurance. Review of the integumentary system. Posture examination (refer to Chapter 7): increased or increas­ ing thoracic kyphosis may be a sign of multiple painless verte­ bral compression fractures, which may be associated with osteoporosis, Vision and balance assessment-assess risk for falls.
Height measurements.
Range of motion: may be decreased as a result of changes in
posture. Muscle performance: patients with skeletal demineralization also have weak muscles.
Function: gait, locomotion, and balance.

The physical therapy intervention for skeletal demineralization includes


Weight-bearing and aerobic exercise, which have been shown to have a positive effect on BMD, although the exact mecha­ nism is not known. 33 ,41,42 Regular exercise should be encour­ aged in all patients, including children and adolescents, in order to strengthen the skeleton during the maturation process. In addition, exercise also improves agility and balance, thereby reducing the risk of falls. Postural correction and training: should address walking, standing, and sitting,



Pain control methods: use of adjunctive intelVentions (see Chapter 18).

Osteochondritis dissecans. Osteochondritis dissecans (OCD)43-50 is a term for osteochondral fracture. An osteochondral fragment may be present in situ, incompletely detached, or completely detached. A completely detached fragment is a loose body. The pathology of OCD may be described in three stages.
1. Thickened and edematous intra-articular and periarticular soft

tissues are obselVed. Often, the adjacent metaphysis reveals mild osteoporosis resulting from active hyperemia of the metaphysis. 2. On radiography, the epiphysis may demonstrate fragmenta­ tion. The epiphysis reveals an irregular contour and a thinning of the subcortical zone of rarefaction. Blood vessels within the epiphysis are incompetent because of thrombosis or microfractures of the trabeculae, which results in poor healing. 3. The period of repair in which granulation tissue gradually replaces the necrotic tissue. Necrotic bone may lose its struc­ tural support, which results in compressing and flattening of the articular surface. Osteomyelitis. Osteomyelitis51- 55 is an infectious process of the bone and its marrow. The term can refer to infections caused by pyogenic microorganisms, but can also be used to describe other sources of infection such as tuberculosis, or specific fungal infections (mycotic osteomyelitis), parasitic infections (Hydatid disease), viral infections, or syphilitic infections (Charcot arthropathy). Hematogenous spread from a primary source of infection is the commonest route of infection. The pyogenic form usually results from a pelvic inflammatory disease, but can be the result of a spread from the skin or pulmonary sites. In addition, the infection can result from sur­ gery, a penetrating wound, or poor dental hygiene. The tuberculosis infection spreads to bone from the lungs or uri­ nary tract. The proximal tibia is the most common site. Findings at physical examination may include the following:
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Fever or no fever. Edema. Warmth. Tenderness to palpation. Reduction in the use of the extremity.

Paget's disease. Paget's disease (osteitis deformans)56-65 of bone is an osteometabolic disorder. The disease is described as a focal disorder of accelerated skeletal remodeling that may affect one or more bones. This produces a slowly progressive enlargement and deformity of mul­ tiple bones. Despite intensive studies and widespread interest, its etiology remains obscure. The pathologic process consists of three phases:

Phase I-an osteolytic phase characterized by prominent bone resorption and hypelVascularization. Phase II-a sclerotic phase reflecting previously increased bone formation but currently decreased cellular activity and vascularity.



Phase III-a mixed phase with both active bone resorption and compensatory bone formation, resulting in a disorganized skeletal architecture. The bones become sponge-like, weakened, and deformed.

Complications include pathologic fractures, delayed union, pro­ gressive skeletal deformities, chronic bone pain, neurologic compromise of the peripheral and central nervous systems with facial or ocular nerve compression and spinal stenosis, and pagetic arthritis. Involvement of the lumbar spine may produce symptoms of clin­ ical spinal stenosis. Involvement of the cervical and thoracic spine may predispose to myelopathy. Although this disorder may be asymptomatic, when symptoms do occur, they occur insidiously. Paget's disease is managed either med­ ically or surgically.

Study Pearl
Proteoglycans are •. macromolecules that consist of a protein backbone to which are attached many extended polysaccharide units caIJedgly­ eosaminoglycans; of whkh·.there are two types: chondroitin sulfate and keratin sulfate.6l;!,69 A simple way to visualize. the proteoglycan molecule is to consider a test tube brusb with the stem representing the protei ncore and the glycosaminoglyeansrepre-, senti ng the bristles,zO,71 ProteogIycan structureinfl uenees the mechanical. properties of tissue indudingcompressive stiffness; sheer stiffness; osmotic pressure, and regu­ lation of hydration.

The development of bone is usually preceded by the formation of cartilage tissue. Cartilage tissue consists of cartilage cells called chondrocytes. Chondrocytes are specialized cells that are responsible for the development of cartilage and the maintenance of the extracellular matrix. 66 The extracellular matrix also contains pro­ teoglycans, lipids, water, and dissolved electrolytes. It is the concen­ tration of proteoglycans in solution that are responsible for the vis­ coelastic properties of cartilage. 67 Chondrocytes produce aggrecan, link protein, and hyaluronan, all of which are extruded into the extracellular matrix, where they aggre­ gate spontaneously.69 The aggrecans form a strong, porous-permeable, fiber-reinforced composite material with collagen. Cartilage tissue exists in three forms: hyaline, elastic, and fibro­ cartilage.

Cartilage Tissue.

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Hyaline cartilage. The normal articular surface of synovial joints consists of hyaline cartilage, commonly called gristle, which covers the ends of long bones and, along with the synovial fluid that bathes it, provides a smoothly articulating surface. Hyaline cartilage is composed of cells Cchondrocytes) sur­ rounded by an extracellular matrix that includes various macro­ molecules, most importantly proteoglycans and collagen. Articular cartilage plays a vital role in the function of the mus­ culoskeletal system by protecting the underlying subchondral bone through the distribution of large loads, the maintenance of low contact stresses, and the reduction of friction at the joint. Adult articular cartilage is an avascular and noninnervated structure. Hyaline cartilage is the most abundant cartilage within the body. Most of the bones of the body form fIrst as hyaline cartilage, and later become bone in a process called endochondral ossification. Elastic cartilage is a very specialized CT primarily found in loca­ tions such as the outer ear, and portions of the larynx. Fibrocartilage functions as a shock absorber in both weight­ bearing, and non-weight-bearing joints. Its large fiber content, reinforced with numerous collagen fibers, makes it ideal for bearing large stresses in all directions. Examples of fibrocarti­ lage include the symphysis pubis, the intervertebral disc, and the menisci of the knee.



Pathology of Cartilage. The terms arthritis, rheumatism, and
rheumatoid disease are generic references to an array of more than 100 diseases that are divided into 10 classification categories. 72 Two major forms of arthritis are considered in this section: osteoarthritis (OA), also referred to as degenerative joint disease (DJD), and rheumatoid arthritis (RA).
Osteoarthritis. Historically, osteoarthritis has been divided into pri­ mary and secondary forms.
Primary. Primary osteoarthritis (OA) is an idiopathic phenomenon, occurring in previously intact joints, with no apparent initiating factor. It is related to the aging process and typically occurs in older individu­ als. Most investigators believe that degenerative alterations primarily begin in the articular cartilage, as a result of either excessive loading of a healthy joint or relatively normal loading of a previously disturbed joint. These alterations appear to occur in the following sequence:
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~ ~





External forces accelerate the catabolic effects of the chondro­ cytes and disrupt the cartilaginous matrix. Enzymatic destruction increases cartilage degradation, which is accompanied by decreased proteoglycans and collagen synthesis. Changes in the proteoglycans render the cartilage less resistant to compressive forces in the joint and more susceptible to the effects of stress. The decreased strength of the cartilage is compounded by adverse alterations of the collagen. Elevated levels of collagen degradation place excessive stresses on the remaining fibers, eventually leading to mechanical failure. The diminished elastic return and reduced contact area of the cartilage, coupled with the cyclic nature of joint loading, causes the situation to worsen over time. Microscopically, flaking and fibrillations develop along the nor­ mally smooth articular cartilage surface. The loss of cartilage results in the loss of the joint space. Progressive erosion of the damaged cartilage occurs until the underlying bone is exposed. Bone denuded of its protective cartilage continues to articulate with the opposing surface. Eventually, the increasing stresses exceed the biomechanical yield strength of the bone. The subchondral bone responds with vascular invasion and increased cellularity, becoming thickened and dense (eburnation) at areas of pressure. Furthermore, the traumatized subchondral bone may undergo cystic degeneration, due to either osseous necrosis secondary to chronic impaction or the intrusion of synovial fluid. At nonpressure areas along the articular margin, vascularization of subchondral marrow, osseous metaplasia of synovial CT, and ossifying cartilaginous protrusions lead to irregular out­ growth of new bone (osteophytes). Fragmentation of these osteophytes or of the articular cartilage itself results in intra­ articular loose bodies (joint mice).

Primary OA occurs most commonly in the hands, particularly in the distal interphalangeal (DIP) joints, proximal interphalangeal (PIP) joints, and first carpometacarpal joints. Deep achy joint pain exacer­ bated by extensive use is the primary symptom. Also, reduced range of



Study Pearl

visible. Heberden nodes, which represent palpable osteophytes in the
motion and crepitus are frequently present. Joint

may be

The .• .• 1... •1'is.O·.f•. .•. . .• • . •
toi dar'thr!tis ilJcluQ~: . ~ Systemic:manif~~ta~ions: morn· 3...and•.n fatigue.• :: .: •.••••....• .• . w•.•..• . .e..• • .•i. •.•g•...• • .ht:.•. •. I.O5•..5.•. •.'.

.•:•.•. . .r.. • • .•a" "'Arthritis •oi30r rnOrefo.i(lt~r~as: the 14 morecomf11onJ}':jnV()l~ed joints.indtlde the~ight.or.leftf>l~ tyiCf} wrists,elbovv,kn~,an~l~, a,pdMTP joints.. In the ~and;rpany




DIP joints, are characteristic in women but not men. (Heberden nodes are features of OA, not rheumatoid arthritis, and they have no known association with glenohumeral disease or inguinal lymphadenopathy.) Inflammatory changes are typically absent or at least not pronounced in primary OA.


Secondary. Secondary OA is a degenerative disease of the synovial joints that results from some predisposing condition, usually trauma, that has adversely altered the articular cartilage and/or subchondral bone of the affected joints. Secondary OA often occurs in relatively young individuals.
Rheumatoid arthritis. Rheumatoid arthritis (RA) is a disease that affects the entire body and the whole person. The cycle of stretching, healing, and scarring that occurs as a result of the inflammatory process seen in rheumatoid arthritis causes Significant damage to the soft tissues and periarticular structures. Clinically, the differential diagnosis of RA is predicated upon the patient's signs and symptoms and careful exclu­ sion of other disorders.7 2 The physical therapy examination of the patient with suspected rheumatoid arthritis involves 72


such asulnardeviaHonof.ilieMCP ion of thecaf· IQck,· bOtllonniere wanneckdeformi-


Positive laboratory tests: elevated erythrocyte sedimentation rate (ESR) or C~reactive protein; synovial fluid analysis. Radiographi



~ ~



Measurement of joint range of motion. Goniometric measure­ ment of passive range of motion (PROM) is indicated at all affected joints following a gross range of motion screening. Measurement of strength: application of standard manual mus­ cle tests to determine strength and pain at various points in the range. Measurement of independence with functional activities. Functional measures may include ADL, work, and leisure activ­ ities. The choice of a functional instrument is influenced by sev­ eral factors including the characteristics and needs of the indi­ vidual patient, the level and depth of information required, and its predictive value in gauging the efficacy of treatment. Measurement of joint stability: the ligamentous laxity of any affected joint should be fully investigated. Measurement of mobility and gait (Chapter 7). Measurement of sensory integrity. Measurement of psychological status. Determination of level of impairment, including decondition­ ing, pain, weakness, cardiopulmonary complications, neuro­ logic manifestations, environmental barriers, and fatigue.

Based on the pathomechanics of the rheumatoid process, the fol­ lowing concepts form the foundation of any intetvention to manage RA72 :

~ ~ ~ ~

Decrease pain. Control the inflammation. Increase or maintain the ROM of all joints sufficient for functional activities. Focus on joint systems rather than isolated joints. Increase or maintain muscle strength sufficient for functional activities. Increase joint stability and decrease by biomechanical stresses on all affected joints.



The clinician should target functional activities that require spe­ cific techniques of joint protection.

~ ~

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Increase endurance for all functional activities. Promote independence in all ADL, including bed mobility and transfers. Improve efficiency and safety of gait pattern. Establish patterns of adequate physical activity or exercise to maintain or improve musculoskeletal and cardiovascular fitness and general health. Educate the patient, family, and other personnel to promote the individual's capacity for self-management. Consider the type of rheumatoid disease: • The type in which scarring outweighs the articular damage. Patients with stiff joints because of scarring do poorly after soft-tissue surgery. Patients in this group require aggressive and sustained therapy, often for 3 to 4 months. • The type in which joint laxity and tissue laxity become diffi­ cult to stabilize after soft-tissue procedures. The patients in this group require careful treatment and control of the ROM and the direction of motion by the use of splints for many months after surgery.

Juvenile rheumatoid arthritis. Refer to Chapter 16.

Bursae. Bursae are closed, round, flattened sacs that are lined by synovium and separate bare areas of bone from overlapping muscles (deep bursae) or skin and tendons (superficial bursae). They occur at areas of friction or possible impingement. Deep bursae develop in fetal life, whereas superficial bursae form within months to several years after birth, suggesting that direct pres­ sure and friction may be necessary to stimulate their development. The synovial cells of the bursa secrete a fluid rich in collagen and proteins that acts as a lubricant when parts of the body move and help reduce friction between moving parts of the body, such as in the shoul­ der, elbow, hip, knee, and heel.
Pathology of the Bursa. Bursitis is defined as inflammation of a bursa and occurs when the synovial fluid becomes infected by bacte­ ria or irritated because of too much friction or direct trauma. When inflamed, the synovial cells increase in thickness and may show villous hyperplasia. Symptoms of bursitis include localized tenderness, warmth, edema, erythema of the skin (if superficiaD, and loss of function. Common forms of bursitis include

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Subacromial (subdeltoid) bursitis. Olecranon bursitis. Iliopsoas bursitis. Trochanteric bursitis. Ischial bursitis. Prepatellar bursitis. Infrapatellar bursitis. Anserine bursitis.

Trochanteric bursitis. Trochanteric bursitis is the second most frequent cause of lateral hip pain.73



The histOly may reveal complaints of lateaI . . . . . . . . . 3Dd gluteal pain, especially when lying on the involved a" the pain is typically local to the hip region, it can I3diIIr j ID the knee and the lower leg. Objectively, the clinical fit.: • . . . . .
5 T


The reproduction of pain with palpation. .a n - C the iliotibial band (ITB) across the greater hO t wilt hip adduction, or the extremes of internal or ex""",". • .. WI ""5 ~ Resisted abduction, extension, or external JGCiiIIii:&" _ hip are also painful. ~ There is often associated tightness of the hip . ' "-_. wIIich cause the patient's feet to cross midline, iM:. a .. d stress on the trochanteric bursa.



Differential diagnosis should include:


~ ~

~ ~


Tendopathy of the gluteus medius or maximus mol'M"lrs w1I:h O£ without calcification. 76 )7 Inguinal and femoral hernia. An irritation of the L 4-5 nelVe root. Meralgia paresthetica. A "snapping" hip. Lower spinal neoplasm. Pelvic tumor. Hip infection. Avascular necrosis. Stress fracture of the femur. Bone or soft-tissue tumor.

There is very little research evidence on physical ~ inIer­ vention for trochanteric bursitis.78 The traditional intelVention usually consists of the removal of the causative factors by stretching the soft tis­ sues of the lateral thigh, especially the iliotibial band. Other inlen-eo­ tions include heat, ultrasound, NSAlDs, and injections. Transverse fric­ tion massage has also been advocated.7 9 Orthotics may be pre5Cribed if there is a biomechanical fault in the kinetic chain due to an ankle/f()(){ dysfunction.

Reactive Arthritis. Reactive arthritis80-M , formerly known as Reiter syndrome, refers to acute nonpurulent arthritis complicating an infec­ tion elsewhere in the body. Reactive arthritis falls under the rheumatic disease category of seronegative spondyloarthropathies, which include ankylosing spondylitis, psoriatic arthritis, and arthritis associated with inflammatory bowel disease. Reactive arthritis is triggered following enteric or urogenital infections. The symptoms, which generally appear within 1 to 3 weeks from onset of an inciting episode of urethritis/cervicitis or diarrhea, include eye inflammation, fatigue, fever (usually low grade), malaise, asymmetric joint stiffness (primarily involving the knees, ankles, and feet), enthesopathy, and cutaneous lesions. Sjogren's Syndrome. Sjogren's syndrome (SS)85-9 1 is an autoimmune disorder primarily characterized by lymphocytic infiltrates in the exocrine glands. Typically, most patients present with sicca symptoms,

Connective Tissue Disorders



such as xerophthalmia (dry eyes), xerostomia (dry mouth), and parotid gland enlargement. Additional features include arthralgia, arthritis, Raynaud phenomenon, myalgia, pulmonary disease, gastrointestinal disease, leukopenia, anemia, lymphadenopathy, neuropathy, vasculi­ tis, renal tubular acidosis, and lymphoma. SS is sometimes called primary SS when no other underlying rheu­ matic disorder is present, whereas SS is sometimes called secondary SS if it is associated with another underlying rheumatic disease, such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), or scle­ roderma (ScD. The pathogenesis of SS is not known.


Muscle tissue is responsible for the movement of materials through the body, the movement of one part of the body with respect to another, and locomotion. There are three types of muscle tissue: smooth, car­ diac, and skeletal tissue (Table 5-9). Human skeletal tissue is described here. The class of tissue labeled skeletal muscle consists of individual muscle cells or fibers. A single muscle cell is called a muscle fiber or myofiber (Fig. 5-1). Individual muscle fibers are wrapped in a CT enve­ lope called endomysium. Bundles of myofibers, which form a whole muscle (fasciculus), are encased in the perimysium. The perimysium is continuous with the deep fascia. Groups of fasciculi are surrounded by a connective sheath called the epimysium. Under an electron micro­ scope, it can be seen that each of the myofibers consists of thousands of myofibrils, which extend throughout its length. Myofibrils are com­ posed of sarcomeres arranged in series. 92 One of the most important roles of CT is to mechanically transmit the forces generated by the skeletal muscle cells to provide movement. Each muscle cell contains many fibers called myofilaments, which run parallel to the myofibril axis (Fig. 5-1). The myofilaments are made up of two protein filaments: actin (thin) and myosin (thick). The most dis­ tinctive feature of skeletal muscle fibers is their striated (striped) appearance. This cross-striation is the result of an orderly arrangement within and between structures called sarcomeres and myofibrils. 93 The sarcomere is the contractile machinery of the muscle. The stria­ tions are produced by alternating dark (A) and light (1) bands that appear to span the width of the muscle fiber. The A bands are com­ posed of myosin filaments, whereas the I bands are composed of actin filaments. The actin filaments of the I band overlap into the A band, giving the edges of the A band a darker appearance than the central region (H band), which contains only myosin. At the center of each I band is a thin, dark Z line. A sarcomere represents the distance between each Z line. Each muscle fiber is limited by a cell membrane called a sar­ colemma. The protein dystrophin plays an essential role in the mechanical strength and stability of the sarcolemma. 94 Dystrophin is lacking in patients with Duchenne muscular dystrophy. When a muscle contracts isotonically, the distance between the Z lines decreases, the I band and H bands disappear, but the width of the A band remains unchanged. 93 This shortening of the sarcomeres is not produced by a shortening of the actin and myosin filaments, but by a sliding of actin filaments over the myosin filaments, which pulls the Z lines together.

Striated (skeletal) Smooth Cardiac

Spanning joints and attached to bones via tendons Walls of hollow internal organs Heart muscle

Study Pearl
Jhe graded ·.cot)t(a()tj()n~()f~~I~ . muscles occur ·becausetbenum~r~t fibers participati . action Varies. lncreasi~ move­ ment .is ach ie .'.. . '.' . ' . r:tS more cells if'lto<::ooperat n.





Sarcomere MYOfilOmen~




on d


A bond I


I - . bond l Myosin crossbridge




= ~(] = r;j
Myosin thick filament


Myosin myofilament

Figure 5-1. Parts of a muscle. (Reproduced, with permission, from Prentice WE, Voight MI. Techniques in Musculoskeletal Rehabilitation. New York: McGraw-Hili; 2001 :31.)



Structures called cross-bridges serve to connect the actin and myosin filaments. The myosin filaments contain two flexible, hinge like regions, which allow the cross-bridges to attach and detach from the actin filament. During contraction, the cross-bridges attach and undergo power strokes, which provide the contractile force. During relaxation, the cross-bridges detach. This attaching and detaching is asynchronous, so that some are attaching while others are detaching. Thus, at each moment, some of the cross-bridges are pulling while oth­ ers are releasing. The regulation of cross-bridge attachment and detachment is a function of two proteins found in the actin fIlaments: tropomyosin and troponin. Tropomyosin attaches directly to the actin filament, whereas troponin is attached to the tropomyosin rather than directly to the actin filament. Tropomyosin and troponin function as the switch for muscle contraction and relaxation. In a relaxed state, the tropomyosin physi­ cally blocks the cross-bridges from binding to the actin. For contraction to take place, the tropomyosin must be moved. Each muscle fiber is innervated by a somatic motor neuron. One neuron and the muscle fibers it innervates constitute a motor unit, or functional unit of the muscle. Each motor neuron branches as it enters the muscle to innervate a number of muscle fibers. The area of contact between a nerve and a muscle fiber is known as the motor end plate, or neuromuscular junction. The release of a chemical acetylcholine from the axon terminals at the neuromuscular junctions causes electri­ cal activation of the skeletal muscle fibers. When an action potential propagates into the transverse tubule system (narrow membranous tunnels formed from and continuous with the sarcolemma), the voltage sensors on the transverse tubule membrane signal the release of Ca H from the terminal cisternae portion of the sarcoplasmic reticulum (a series of interconnected sacs and tubes that surround each myofibril).93 The released Ca H then diffuses into the sarcomeres and binds to tro­ ponin, displacing the tropomyosin, and allowing the actin to bind with the myosin cross-bridges. At the end of the contraction (the neural activity and action potentials cease), the sarcoplasmic reticulum actively accumulates CaH and muscle relaxation occurs. The return of CaH to the sarcoplasmic reticulum involves active transport, requiring the degradation of adenosine triphosphate (ATP) to adenosine diphos­ phate (ADP)".93 Because sarcoplasmic reticulum function is closely associated with both contraction and relaxation, changes in its ability to release or sequester CaH markedly affect both the time course and magnitude of force output by the muscle fiber. 95 Activation of varying numbers of motor neurons results in grada­ tions in the strength of muscle contraction. The stronger the electrical impulse, the stronger the muscle twitch. Whenever a somatic motor neuron is activated, all of the muscle fibers that it innervates are stimu­ lated and contract with all-or-none twitches. Although the muscle fibers produce all-or-none contractions, muscles are capable of a wide variety of responses. Together, CT and skeletal muscle tissue form the musculoskeletal system. The musculoskeletal system functions intimately with nervous

• The most readily available energy for skeletal muscle cells is stored in the form of ATI' and phosphocreatine (see the Physiology of Exercise section). Through the activity of the enzyme ATI'ase, ATI' promptly releases energy when required by the cell to perform any type of work, whether it is electrical, chemical, or mechanical.



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For thepurposeofatl()rthopedic examination, Cyriaxsubdivided mus" culoskeletal tissues into those consid· eredto be 1Jcotltractile" and those considered as·1Iinert" (noncontractile).97 ..Contractile. Contractile tissue, as defined by Cyriax,isabit of a mis­ nomer, asthe only true contractile tissue in the . body is the muscle fiber,··HoWever, included underthis term are themusc[ebelly, the ten­ doni the tenoperiosteal junction, the submuscularltendinous bursa, and bone>(ten()4)s.seousjunction}, as all are stre~ed to some·degree with a musdecOntraction. ~ Inert tissue. Inert tissue as definedby Cyriax includes .thejointc<ipsule, the .ligaments, the bursa,. thearocu­ lar .surfaces of the joint,tnesyn­ ovium, the dura,>bone,andfilscia.. The teno-osseous junction and the bursae are placed in each of the sub~ divisions due to their close proximity toconWictile tissue and thei r capacity to be compressed or .stretched during movement.

tissue to produce coordinated movement and to provide adequate joint stabilization and feedback during sustained positions and movements. Based on contractile properties, four different types of skeletal muscle fibers have been recognized (see also Table 17-1): Type Type Type Type I (slow-twitch red oxidative). lIa (fast-twitch red oxidative). lIb (fast-twitch white glycolytic). lIc (fast-twitch intermediate).

Human muscles contain a genetically determined mixture of both slow and fast fiber type. In humans, most limb muscles contain a rela­ tively equal distribution of each muscle fiber type, while the back and trunk demonstrate a predominance of slow twitch fibers. The use of specific muscle fibers is dependent on the desired activity. Although the two fiber types generally produce the same amount of force per contraction, the fast-twitch fibers produce that force at a higher rate (they fire more rapidly-hence their name). Thus, activities that require a limited amount of time to generate maximal force use a predomi­ nance of fast-twitch fiber recruitment. Activities that involve repeated and extended muscle contractions such as those required for endurance events entail more involvement of the slow-twitch fibers. Based on function, ]anda% further subdivided skeletal muscles into two groups: postural or tonic muscles (Table 5-10).

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Most muscles span qnJy one jOint. However, there are many mtlsdes in the body that cross two or morej()ints. Examples of these includeth~erector spinae,lhebicepsbrachii, the long heap ofthe triceps brachii, the ham. strings, the rectus femoris,andanum­ ber of muscles crossing the wristand fi nger joints.

Muscle Function. There are approximately 430 muscles in the body, each of which can be considered anatomically as a separate organ. About 75 pairs of muscle provide the majority of body move­ ments and posture. 98 Muscles around a joint typically function as pairs, referred to as agonists and antagonists. An agonist muscle contracts to produce the desired movement, while the antagonist muscle opposes the desired movement. Antagonists resist the agonist movement by relaxing and lengthening in a gradual manner to ensure that the desired motion occurs, and that it does so in a coordinated and con­ trolled fashion. Muscle groups that work together to produce a desired movement are called synergists. 99 The effectiveness of a muscle to produce movement is dependent on a number of factors (see Chapter 17), These include the location and orientation of the muscle's attachment relative to the joint (Tables 5-11 and 5-12), the tightness or laxity present in the musculotendinous unit, and the actions of other muscles that cross the joint. 98 Pathology of Muscle.
See Table 5-13.

Myosistis Ossificans. Myositis ossificanslOQ.-104 is an aberrant repara­ tive process that causes benign heterotopic (i.e., extraskeletal) ossifi­ cation in soft tissue. Myositis ossificans manifests in two forms.

Myositis ossificans circumscripta: it can develop either in response to soft-tissue injury (e.g., blunt trauma, stab wound, fracture/dislocation, surgical incision) or can occur without known injury. Proposed mechanisms for atraumatic myositis ossificans include nondocumented trauma, repeated small mechanical injuries, and nonmechanical injuries caused by ischemia or inflammation.

TABLE 5-10. FUNCTIONAL DMSION OF MUSCLE GROUPS MOVEMENT GROUP Primarily type IIa Prone to develop tightness Prone to develop hypertonicity Dominate in fatigue and new movement situations Generally cross two joints STABILIZATION GROUP Primarily type I Prone to develop weakness Prone to muscle inhibition Fatigue easily Primarily cross one joint


Examples Gastrocnemius/soleus Tibialis posterior Short hip adductors Hamstrings Rectus femoris Tensor fascia latae Erector spinae Quadratus lumborum Pectoralis major Upper portion of trapeZius Levator scapulae Sternocleidomastoid Scalenes Upper limb flexors

Examples Fibularis group Tibialis anterior Vastus medialis and lateralis Gluteus maximus, medius, minimus Serratus anterior Rhomboids Lower portion trapezius Short and deep cervical flexors Upper limb extensors Rectus abdominis

Reproduced, with permission, from Jull GA, Janda V. Muscle and motor control in low back pain. In: Twomey LT, Taylor JR, eds. Physical Therapy of the Low Back: Clinics in Physical Therapy. New York: Churchill Livingstone; 1987:258. Copyright © Elsevier.

Most (80%) ossifications arise in the thigh or arm. Other sites
include intercostal spaces, erector spinae, pectoralis muscles,
glutei, and the chest.
.. Myositis ossificans progressive: an autosomal dominant genetic
disorder with complete penetrance and variable expression. Overexpression of bone morphogenetic protein 4 and its mes­ senger ribonucleic acid (RNA) occurs. If diagnosed, the body part is immediately immobilized for about
2 to 4 weeks. Following the immobilization, a regime of gradually
increased exercise is initiated to promote a greater range of motion.
While myositis ossificans progressiva has no proven medical therapy,
patients with this condition may be administered cortisone and adreno­
corticotropin during acute episodes. Pain medications may be indi­
cated, as are other supportive measures, especially occupational therapy,
to facilitate functioning.

Joint Classification. Joints may be classified as diarthrosis,
which permit free bone movement, and synarthrosis, in which very
limited or no motion occurs (Table 5-14).

TABLE 5-11. COMMON MUSCLE ATTACHMENTS OF THE UPPER EXTREMI1Y ATTACHMENT SITE Greater tuberosity of the humerus Lesser tuberosity of the humerus Medial epicondyle of humerus Lateral epicondyle of humerus MUSCLE Supraspinatus, infraspinatus, teres minor Subscapularis Common flexor tendon origin Common extensor tendon origin



TABLE 5-12. COMMON MUSCLE ATTACHMENTS OF mE LOWER EXTREMITY ATTACHMENT SITE Greater trochanter Lesser trochanter Ischial tuberosity Pubic ramus MUSCLE Gluteus minimus, gluteus medius, piriformis, obturator internus, inferior and superior gemelli Psoas major Semitendinosus, semimembranosus, biceps femoris, adductor magnus Pectineus, adductor magnus, gracilis, adductor brevis

TABLE 5-13. CLASSIFICATION OF MUSCLE INJURY TYPE RELATED FACTORS Increased activity Unaccustomed activity Excessive eccentric work Viral infections Secondary to muscle cell damage Onset at 24-48 hours after exercise Sudden overstretch Sudden contraction Decelerating limb Insufficient warm-up Lack of flexibility Increasing severity of strain associated with greater muscle fiber death, more hemorrhage, and more eventual scarring Steroid use or abuse Previous muscle injury Collagen disease Direct blow, associated with increasing muscle trauma and tearing of fiber proportionate to severity Specific sites vulnerable May be complication of stress fractures Osteoporosis Skeletally immature but well developed muscle strength Associated with steroid injection or generalized collagen disorders

Exercise-Induced Muscle Injury (delayed muscle soreness)

Strains First degree (mild): minimal structural damage; minimal hemorrhage; early resolution

Second degree (moderate): partial tear; large spectrum of injury; significant early functional loss Third degree (severe); complete tear; may require aspiration; may require surgery

Contusions Mild, moderate, severe Intramuscular vs. intermuscular Avulsions Bony Apophyseal Muscle

Reproduced, with permission, from Reid DC. Sports InjUry Assessment and Rehabilitation. New York: Churchill Livingstone; 1992. Copyright © Elsevier.

TABLE 5-14. JOINT TYPES TYPE Diarthrosis CHARACTERISTICS Generally unites long bones and has great mobility Fibroelastic joint capsule, which is ftlled with a lubricating substance called synovial fluid-referred to as synovial joints United by bone tissue EXAMPLES Hip, knee, shoulder, and elbow joints

Synarthrosis Synostosis

Synchondrosis Syndesmosis

Joined by either hyaline or fibrocartilage Joined together by an interosseous membrane

Sutures of the skull and gomphoses (the teeth and their corresponding sockets in the mandible/ maxilla) The epiphyseal plates of growing bones and the articulations between the first rib and the sternum The symphysis pubis Articulation between the tibia and fibula



Diarthrosis (Synovial). Evel)' synovial joint contains at least one "mating pair" of articular surfaces--one convex and one concave. If only one pair exists, the joint is called simple; more than one pair is called compound; and if the disk is present, the joint is termed complex. Synovial joints have five distinguishing characteristics: joint cavity, articular cartilage, synovial fluid, synovial membrane, and a fibrous capsule. Four types of synovial joint are recognized (Fig. 5-2):
.. Nonaxial joint. These joints have no planes of motion or pri­ mal)' axes, and only permit sliding or gliding motions. Examples include the carpal joints. .. Uniaxial joint. These joints allow one motion around a single axis and in one plane of the body. Two types are recognized: • Hinge (ginglymus)-the elbow joint. • Pivot joint (trochoid)-the atlantoaxial joint. .. Biaxial joint. These joints allow movement in two planes and around two axes based on their convex/concave surfaces. Two types are recognized: • Condyloid----Dne bone may articulate with another by one surface or by two, but never more than two. If two distinct surfaces are present, the joint is called condylar, or bicondy­ lar. Example: metacarpophalangeal joint of the finger.

Nonaxlal (0 axes)
Plane joint

Uniaxial (1 axis)
Hinge joint

Biaxial (2 axes)
Condyloid joint

Triaxial (3 axes)
8all and socket joint

Carpal joints

lL ~j ~ ~

Metacarpal-phalangeal joints Elbow
Pivot joint Saddle joint


Atlantoaxial joint

Thumb Planes of motion None Sagittal OR Transverse Bilateral OR Longitudinal Flexion/Extension OR Rotation Pronation/Supination

Sagittal AND Frontal Bilateral AND Anteroposterior Flexion/Extension Abduction/Adduction




Sagittal Frontal Transverse Bilateral Anteroposterior Longitudinal Flexion/Extension Abduction/Adduction Rotation

Primary axes



Sliding or gliding

Figure 5-2. Joint classifications. (Reproduced, with permission, from Luttgens K, Hamilton N.
Kinesiology: Scientific Basis of Human Motion. 10th ed. New York: McGraw-Hili; 2002:27.)




• Sellar (saddle}-if a section is taken through a sellar surface in one plane, the joint surface can be seen to be convex and the CUIYatllre of the joint in the opposite plane is concave. Example: carpometacarpal joint of the thumb. Multiaxial joint. These joints allow movement in three planes and around three axes. Two subtypes are recognized: • Plane (gliding}-carpal joints. • Ball and socket-hip joint.

Synarthrosis (Fibrous). There are three major types of synarthroses based on the type of tissue uniting the bone surfaces (Table 5-14).105 Mechanoreceptors. All synovial joints of the body are provided with an array of corpuscular (mechanoreceptors) and noncorpuscular (nociceptors) receptor endings imbedded in articular, muscular, and cutaneous structures with varying characteristic behaviors and distri­ butions depending on articular tissue. Freeman and Wyke categorized these mechanoreceptors into four different types (Table 5_15).106-108 These articular mechanoreceptors are stimulated by mechanical forces (soft-tissue elongation, relaxation, compression, and fluid tension) and mediate proprioception. 106,108,I09 They include Pacinian corpuscles, Ruffini endings, the muscle spindle, and Golgi tendon organ (GTO)­ like endings (see Chapter 9). The mechanoreceptors translate mechanical deformation into electrical signals that provide information concerning joint motion and positionyo-1l4 Sensory information provided by the receptors travels

~ Important

FUNCTION in signaling actual joint position or changes in joint positions ~ Contribute to reflex regulation of postural tone, to coordi­ nation of muscle activity, and to a perceptional awareness of joint position ~ An increase in joint capsule tension by active or passive motion, posture, or by mobilization or manipulation causes these receptors to discharge at a higher frequency ~ Sense joint motion and regulate motor-unit activity of the prime movers of the joint ~ Type II receptors are entirely inactive in immobile joints and become active for brief periods at the onset of move­ ment and during rapid changes in tension ~ The type II receptors fire during active or passive motion of a joint, or with the application of traction ~ Detect large amounts of tension. These receptors only become active in the extremes of motion or when strong manual techniques are applied to the joint ~ Inactive in normal circumstances but become active with marked mechanical deformation or tension ~ Also active in response to direct mechanical or chemical irritation

I-Small Ruffini endings, The joint capsule, and in ligaments Slow-adapting, low-threshold stretch receptors

II-Pacinian corpuscles. Rapidly adapting, low-threshold receptors

In adipose tissue, the cruciate ligaments, the anulus fibrosus, ligaments and the fibrous capsule

III-Large Ruffini. Slowly adapting, high-threshold receptors IV-Nociceptors. Slowly adapting, high-threshold free nerve endings

Ligaments and the fibrous capsule


Data from Wyke BD. The neurology of joints: a review of general principles. C/in Rheum Dis. 1981;7:223-239; and Wyke BD. Articular neurology and manipulative therapy. In: Glasgow EF, Twomey LT, Scull ER, et aI., eds. Aspects of Manipulative Therapy. 2nd ed. New York: Churchill Livingstone; 1985:72-77.



TABLE 5-16. CHARACTERISTICS OF MECHANORECEPTORS AND NOCIOCEPTORS RECEPTOR TYPE Mechanoreceptors TYPE OF STIMULUS AND EXAMPLE Pressure Movement of hair in a hair follicle Light pressure Deep pressure Touch Pain (stretch) Distension Length changes Tension changes Temperature changes Cold Heat RECEPTOR TYPE


Nociceptors Proprioceptors

Afferent nerve fiber (base of hair follicles)
Meissner's corpuscle (skin)
Pacinian corpuscle (skin)
Merkel's touch corpuscle (skin)
Free nerve endings (wall of gastrointestinal tract, skin)
Ruffini corpuscles (skin and capsules in joints and ligament~)
Muscle spindles (skeletal muscles)
Golgi tendon organs (between muscles and tendons)
Krause's end bulbs (skin)
Ruffini corpuscles (skin and capsules in joints and ligaments)


through afferent pathways to the central nervous system (CNS), where it is integrated with information from other levels of the nervous sys­ tem. 1l5 The CNS, in turn, elicits efferent motor responses (neuromus­ cular control) vital to mediate proprioception and influence muscle tone and function. In addition to providing restraint at the extremes of joint range motion, the capsuloligamentous structures function to guide and direct normal movements. l11 However, ligaments alone are incapable of total control under situations of high load demands, and require the assis­ tance of active muscle. 116,117 Other receptors found in the joint include proprioceptors (Table 5-16).

Arthrokinematics. The small motion available at musculoskele­ tal joint surfaces is referred to as accessory or arthrokinematic motion. Normal arthrokinematic motions must occur for full-range physiologic motion to take place. A restriction of arthrokinematic motion results in a decrease in osteokinematic (see next section) motion. The three types of movement that occur at the articulating surfaces include:
Roll. A roll occurs when the points of contact on each joint sur­ face are constantly changing (Fig. 5-3). This type of movement is analogous to a tire on a car as the car rolls forward. The term "rock" is often used to describe small rolling motions. Slide. A slide is a pure translation. It occurs if only one point on the moving surface makes contact with varying points on the opposing surface (Fig. 5-3). This type of movement is analo­ gous to a car tire skidding when the brakes are applied sud­ denly on a wet road. This type of motion is also referred to as translatory or accessory motion. While the roll of a joint always occurs in the same direction as the swing of a bone, the direc­ tion of the slide is determined by the shape of the articulating surface (Fig. 5-4). This rule is often referred to as the concave­ convex rule: If the joint surface is convex relative to the other surface, the slide occurs in the opposite direction to the osteokinematic motion (Fig. 5-4). If, on the other hand, the joint




,, ,




, ,









Figure 5-3. Joint movements. A. roll and slide occurring with knee extension with a stationary tibia. B. Roll and slide occurring with knee extension with a staionary femur. (Reproduced, with permission, from Dutton M. Manual Therapy of the Spine. New York: McGraw-Hili; 2002:43.)

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surface is concave, the slide occurs in the same direction as the osteokinematic motion. Spin. A spin is defmed as any movement in which the bone moves but the mechanical axis remains stationary. A spin involves a rotation of one surface on an opposing surface around a lon­ gitudinal axis (Fig. 5-3). This type of motion is analogous to the pirouette performed in ballet. Spin motions in the body include internal and external rotation of the glenohumeral joint when the humerus is abducted to 90°; and at the radial head during forearm pronation and supination. Most anatomic joints demonstrate composite motions involving a roll, slide, and spin.


;:::;1 G'-"\~\'


r ,\~ g..­ ,.~·K- ~r--~••




Figure 5-4. Gliding motions. A. Glides of the convex segment should be in the direction opposite to the restriction. B. Glides of the concave segment should be in the direction of the restriction. (Reproduced, with permission, from Dutton M. Manual Therapy of the Spine. New York: McGraw-Hili; 2002:44.)



Can both spin and glide on their convex partners. Convex surfaces can both spin and glide on their concave partner. Spin and glides of the joint are combined in
In addition, convex surfaces can roll upon the concave surface and rolling is the primary movement of a convex surface. joints with 1 degree of freedom (DOF).·
Spin and glides can occur independently in a
Rolling is always accompanied by gliding except at the beginning and joint with 2 degrees! or 3 degrees of freedom*
termination of the movement. Can roll on the convex surface except when the
Rolling does not occur in the close pack position. joint is in the closed pack position.
Rolling always takes place in the same direction as the swing of the bone. Rolling is accompanied by gliding except at the
Gliding always takes place in the opposite direction of the rolling movement. beginning and termination of a movement. Since the convex surface is always larger than the concave surface, the gliding movement in the opposite direction prevents the convex surface Rolling and gliding occur in the same direction, which is also the same direction as the sWing of the bone. from rolling off of the concave surface Rolling causes the leading edge of the concave surface to approximate the convex surface and the trailing edge to lift up from the convex surface. Rolling supplement gliding, the larrer of which is the primary movement of the concave surface and makes for economy of articular cartilage.
'1 DOP: a joint that can swing in one direction or can only spin. An examples is the proximal interphalangeal joint.
12 DOP: a joint that can swing in two directions or swing in one direction and spin. Examples include the tibiofemoral joint, temporomandibular joint,
proXimal and distal radio-ulnar joints, subtalar joint, and talocalcaneal joint.
13 DOP: A bone that can spin and also swing in two distinct directions. Examples include ball-and-socket joints such as the shoulder and hip.

An articulating surface can be either Concave (female) or convex (male) in shape (ovoid), or a combination of both shapes (sellar) (Table 5-17).

Osteokinematics. Osteokinematics is defined as the study of bone motion. All human body segment motions involve osteokine­ matic motions. Visualization of bone movement can be made easier if one can imagine the bone is replaced by a rod that coincides with a mechanical axis of the bone, and that the rod has a mechanical axis that runs through its center, and also has thickness of movement at the point on its surface can be described. Actual bone movement is a com­ bination of one or more basic movements:

Study Pearl
Although sellar surfaces follow the same rules as ovid surfaces, because of the nature of the curvature of their joint surfaces, the direction of the swing and its correspondingroll/glipe is determined bythe~hap~?f_the joi nt surfaces. Forexampter atth "irst carpometacarpal-joint~ • the•• f{)J.loWi('1g biomechanicsare•. i?v~tved: ~ Flexionlextensiorl of metacarp.1}l: the movi ngsurface is concave. The swing of the bone OCCurS in an anteromediallposterolateral direction. The base glides and rolls in an anterornediallposterolateri'll direction. ~ Abductibnladduction of metacatpal: the movingsurfacets cbnvex. The swing of the bone ocCurs-in ail anterolateraflposteromedialditec­ tion. The base glidesin the opposite direction to the swing, .and. rolls in the same direction as the swing.


Spin-the motion of the chosen point is only rotation around the mechanical axis of the bone (pure spin). For example, inter­ nal and external rotation of the radius during pronation and supination. Swing-any motion of the point other than pure spin. • Pure swing: also known as a cardinal swing. A pure swing involves nO spin. The point moves from its initial position to the final position along the shortage path possible, with the path (chord) corresponding to a meridian of latitude or lon­ gitude, or a straight line on a flat surface. • Impure swing: also known as an arcuate swing. An impure swing is a combination of swing and spin. The point moves along a path (arc) other than the shortest possible distance.


Degrees of Freedom. The number of independent modes of motion at a joint is called the degrees offreedom (DOF). When referring to degrees of freedom, the swings must be cardinal and the axis of swing must be at a 90-degree angle to the other swing axes (Table 5-17).





Close-Packed and Open-Packed Positions of tile )Dint.
Joint movements are usually accompanied by a relati\-e iiisxl (approximation) or distraction (separation) of the 0J>P0L!iIii« sur­ faces. These relative compression or distractions affect the lewd of aRI­ grnity of the opposing surfaces. The position of maximmn of the opposing joint surfaces is termed the close-packed pusiIii:a of me joint. The position of least congruity is termed the open-pa::J!ll!Jll p0si­ tion. Thus, movements toward the close-packed posiIioo of a joint involve an element of compression, whereas moveIDeIJIS 0Ul of Ibis position involve an element of distraction.


Close-Packed Position. The close-packed position of a , . . fi joint position that results in:
Maximal tautness of the major ligaments.
Maximal surface congruity.
~ The least transarticular pressure.
~ The minimal joint volume.
~ The maximal stability of the joint.

~ ~


Once the close-packed position is achieved, no further motion in that direction is possible. This is the often-cited reason why IDOSl frac­ tures and dislocations occur when an external force is applied (0 a joint that is in its close-packed position. The close-packed positions for the various joints are depicted in Table 5-18.

Open-Packed Position. In essence, any position of the joinl adler than the close-packed position could be considered an open-packed

TABLE 5-18. CLOSE-PACKED POSITION OF THE JOINTS JOINT Zygapophysial (spine) Temporomandibular Glenohumeral Acromioclavicular Sternoclavicular Ulnohumeral Radiohumeral Proximal radioulnar Distal radioulnar Radiocarpal (wrist) Metacarpophalangeal Carpometacarpal Interphalangeal Hip Tibiofemoral Talocrural (ankle) Subtalar Midtarsal Tarsometatarsal Metatarsophalangeal Interphalangeal POSITION Extension Teeth clenched Abduction and external rotation Arm abducted to 90 degrees Maximum shoulder elevation Extension Elbow flexed 90 degrees; forearm supinated 5 degrees 5 degrees of supination 5 degrees of supination Extension with radial deviation Full flexion Full opposition Full extension Full extension, internal rotation, and abduction Full extension and external rotation of tibia Maximum dorsiflexion Supination Supination Supination Full extension Full extension



TABLE 5-19. OPEN-PACKED (RESTING) POSITION OF THE JOINTS JOINT Zygapophysial (spine) Temporomandibular Glenohumeral Acromioclavicular Sternoclavicular Ulnohumeral Radiohumeral Proximal radioulnar Distal radioulnar Radiocarpal (wrist) Carpometacarpal Metacarpophalangeal Interphalangeal

POSITION Midway between flexion and extension Mouth slightly open (freeway space) 55 degrees of abduction, 30 degrees of horizontal adduction Arm resting by side Arm resting by side 70 degrees of flexion, 10 degrees of supination Full extension, full supination 70 degrees of flexion, 35 degrees of supination 10 degrees of supination Neutral with slight ulnar deviation Midway between abduction-adduction and flexion-extension Slight flexion Slight flexion 30 degrees of flexion, 30 degrees of abduction, slight lateral rotation 25 degrees of flexion 10 degrees of plantar flexion, midway between maximum inversion and eversion Midway between extremes of range of movement Midway between extremes of range of movement Midway between extremes of range of movement Neutral Slight flexion

Tibiofemoral Talocrural (ankle) Subtalar Midtarsal Tarsometatarsal Metatarsophalangeal Interphalangeal

position. The open-packed pOsItion, also referred to as the loose­ packed position of a joint, is the joint position that results in:

~ ~ ~

The slackening of the major ligaments of the joint.
Minimal surface congruity.
Minimal joint surface contact.
Maximal joint volume.
Minimal stability of the joint.

The open-packed position permits maximal distraction of the joint surfaces. Because the open-packed position causes the brunt of any external force to be borne by the joint capsule or surrounding liga­ ments, most capsular or ligamentous sprains occur when a joint is in its open-packed position. The open-packed positions for the various joints are depicted in Table 5-19.

Study Pearl




Capsular and Noncapsular Patterns of Restriction.
Broadly speaking, there are two patterns of range of motion used in the interpretation of joint motion:


A capsular pattern of restriction is a limitation of pain and movement in a joint specific ratio, which is usually present with arthritis, or following prolonged immobilization (Table 5-20). A noncapsular pattern of restriction is a limitation in a joint in any pattern other than a capsular one, and may indicate the presence of either a derangement, a restriction of one part of the joint capsule, or an extra-articular lesion, that obstructs joint motion.



TABLE 5-20. CAPSULAR PATTERNS OF RESTRICTION JOINT Glenohumeral Acromioclavicular Sternoclavicular Humeroulnar Humeroradial Superior radioulnar Inferior radioulnar Wrist (carpus) Radiocarpal Carpometacarpal Midcarpal First carpometacarpal Carpometacarpal 2-5 Metacarpophalangeal 2-5 LIMITATION OF MOTION (PASSIVE ANGULAR MOTION) External rotation> abduction> internal rotation (3:2: I) No true capsular pattern. Possible loss of horizontal adduction, pain (and sometimes sIigm Iais of end range) with each motion See above: acromioclavicular joint Flexion> extension (± 4:1) No true capsular pattern. Possible equal limitation of pronation and supination No true capsular pattern. Possible equal limitation of pronation and supination with pain at end ranges No true capsular pattern. Possible equal limitation of pronation and supination ~ith pain at end ranges Flexion = extension See above (carpus)

Retroposition Fan> fold Flexion> extension (± 2:1) Flexion> extension (± 2: I) Internal rotation > flexion > abduction = extension> other motions Flexion> extension (± 5: I) No capsular pattern: pain at end range of translatory movements Plantar flexion> dorsiflexion Varus > valgus Inversion (plantar fleXion, adduction, supination) > dorsiflexion Extension> flexion (± 2: I) Flexion ~ extension Flexion Flexion
~ ~

Interphalangeal Proximal (PIP) Distal (DIP) Hip Tibiofemoral Superior tibiofibular Talocrural Talocalcaneal (subtalar) Midtarsal Talonavicular calcaneocuboid 1st Metatarsophalangeal Metatarsophalangeal 2-5 Interphalangeal 2-5 Proximal Distal

extension extension

Data from Cyriax J. Textbook of Orthopaedic Medicine: Diagnosis of Soft Tissue Lesions. 8th ed. London: Bailliere Tindall; 1982.

End-Feels. End-feels can be defined as the quality of resistance at
end range. The end-feel can indicate to the clinician the cause of the motion restriction (Tables 5-21 and 5-22).

Study Pearl

Arc of Pain. The term "painful arc" is used to describe an occur­ rence of temporary pain during active or passive motion that disap­ pears before the end of the movement. The presence of a painful arc indicates that some structure is being compressed. Measuring Range of Motion Overview. The term "goniometry" is derived from two Greek words:
gonia, meaning angle, and metron, meaning measure. Thus, a goniometer is an instrument used to measure angles. Within the field of physical therapy, goniometry is used to measure the total amount of available motion at a specific joint. Goniometry can be used to meas­ ure both active and passive range of motion.





CAUSE Produced by bone-to-bone approximation

CHARACTERISTICS AND EXAMPLES Abrupt and unyielding with the impression that further forcing will break something Examples Normal: elbow extension Abnormal: cervical rotation (may indicate osteophyte) Stretch with elastic recoil and exhibits constant-length phenomenon. Similar to Capsular (see below). Further forcing feels as if it will snap something Examples Normal; wrist flexion with finger flexion, the straight leg raise, and ankle dorsiflexion with the knee extended Abnormal; decreased dorsiflexion of the ankle with the knee flexed A very forgiving end-feel that gives the impression that further normal motion is possible if enough force could be applied Examples Normal: knee flexion, elbow flexion in extremely muscular subjects Abnormal; elbow flexion with the obese subject. Various degrees of stretch without elasticity. Stretch ability is dependent on thickness of the tissue ~ Strong capsular or extracapsular ligaments produce a hard capsular end-feel while a thin capsule produces a softer one ~ The impression given to the clinician is, if further force is applied something will tear Examples Normal: wrist flexion (soft), elbow flexion in supination (medium), and knee extension (hard), Abnormal: inappropriate stretch ability for a specific joint. If too hard, may indicate a hypomobility due to arthrosis; if too soft, a hypermobility


Insufficiency: produced by the muscle­ tendon unit May occur with adaptive shortening 2. Slow guarding: resistance that is felt, slowly releases with sustained force

Soft-tissue approximation

Produced by the contact of two muscle bulks on either side of a flexing joint where the joint range exceeds other restraints


Produced by capsule or


Goniometers are produced in a variety of sizes and shapes and are usually constructed of either plastic or metal. The two most common types of instruments used to measure joint angles are the bubble incli­ nometer and the traditional goniometer. Bubble goniometer. The bubble goniometer, which has a 360-degree rotating dial and scale with fluid indicator, can be used for flexion and extension; abduction and adduction; and rotation in the neck, shoul­ der, elbow, wrist, hip, knee, ankle, and spine. Traditional goniometer. The traditional goniometer, which can be used for flexion and extension; abduction and adduction; and rotation in the shoulder, elhow, wrist, hip, knee, and ankle, consists of three parts; A body. The body of the goniometer is designed like a protractor and may form a full or half circle. A measuring scale is located around the body. The scale can extend either from 0 to 180 degrees and 180 to 0 degrees for the half-circle models, or from 0 to 360 degrees and from 360 to 0 degrees on the full-circle models. The intervals on the scales can vary from 1 to 10 degrees.




CAUSES Produced by the articular surface rebounding from an intra-articular meniscus or disc. The impression is that if forced further, something will collapse Produced by viscous fluid (blood) within a joint

CHARACTERISTICS AND EXAMPLES A rebound sensation as if pushing off from a Sorbo rubber pad Examples Normal: axial compression of the cervical spine Abnormal: knee flexion or extension with a displaced meniscus A "squishy" sensation as the joint is moved toward its end range. Further forcing feels as if it will burst the joint



Fast guarding (spasm)

Produced by reflex and reactive muscle contraction in response to irritation of the nociceptor predominantly in articular structures and muscle. Forcing it further feels as if nothing will give

Examples Normal: none Abnormal: hemarthrosis at the knee An abrupt and "twangy" end to movement that is unyielding while the structure is being threatened, but disappears when the threat is removed (kicks back) With joint inflammation, it occurs early in the range, especially toward the close pack position to prevent further stress With an irritable joint hypermobility it occurs at the end of what should be normal range as it prevents excessive motion from further stimulating the nociceptor Spasm in grade II muscle tears becomes apparent as the muscle is passively lengthened and is accompanied by a painful weakness of that muscle Note: muscle guarding is not a true end-feel as it involves a co-contraction Examples Normal: none Abnormal: significant traumatic arthritis, recent traumatic hypermobility, grade II muscle tears The limitation of motion has no tissue resistance component and the resistance is from the patient being unable to tolerate further motion due to severe pain. It is not the same feeling as voluntary guarding but rather it feels as if the patient is both resisting and trying to allow the movement simultaneously Examples Normal: none Abnormal: acute subdeltoid bursitis, sign of the buttock A light resistance as from a constant light muscle contraction throughout the latter half of the range that does not prevent the end of range being reached. The resistance is unaffected by the rate of movement Examples Normal: none Abnormal: spinal facilitation at any level



Produced solely by pain. Frequently caused by serious and severe pathologic changes that do not affect the joint or muscle and so do not produce spasm. Demonstration of this end-feel is, with the exception of acute subdeltoid bursitis, de facto evidence of serious pathology. Further forcing simply increases the pain to unacceptable levels Not truly an end-feel, as facilitated hypertonicity does not restrict motion. It can, however, be perceived near the end range

A stationary arm. The stationary arm is structurally a part of the body and therefore cannot move independently of the body. A moving arm. The moving arm is attached to the fulcrum in the center of the body by a rivet or screw-like device that allows the moving arm to move freely on the body of the device. In some instruments, the screw-like device can be tightened to fix the mov­ ing arm in a certain position or loosened to permit free movement.



The correct selection of which goniometer device to use depends on the joint angle to be measured. The length of arms varies among instru­ ments and can range from 3 to 18 inches. Extendable goniometers allow varying ranges from 91/ 2 to 26 inches. The longer-anned goniometers, or the bubble inclinometer, are recommended when the landmarks are fur­ ther apart, such as when measuring hip, knee, elbow, and shoulder movements. In the smaller joints such as the wrist and hand and foot and ankle, a traditional goniometer with a shorter arm is used.

Procedure. The patient is positioned in the recommended testing position. While stabilizing the proximal joint component, the clinician gently moves the distal joint component through the available range of motion until the end-feel is determined. An estimate is made of the available range of motion and the distal joint component is returned to the starting position. The clinician palpates the relevant bony landmarks and aligns the goniometer (Tables 5-23 and 5-24). A record is made of the starting measurement. The goniometer is then removed and the patient moves the joint through the available range of motion. Once the joint has been moved through the available range of motion, the goniometer is replaced and realigned, and a measurement is read and recorded.

Grading Accessory Movements. The range of motion at a joint is defined as the available range, not the full range, and is usually in one direction only (Fig. 5-5). Each joint has an anatomic limit (AL), which is determined by the configuration of the joint surfaces and the surrounding soft tissues. The point of limitation (Pi) is that point in the range which is short of the anatomic limit and which is reduced by either pain or tissue resistance. Maitland advocated five grades of accessory movements at a joint, each of which falls within the available range of motion that exist'> at the joint-a point somewhere between the beginning point and the anatomic limit (Fig. 5-5). These grades can be used to assess arthrokine­ matic motion of the joint (see the next section in the chapter). Hypomobility, Hypermobility, and Instability. If a joint moves less than what is considered normal, or when compared to the same joint on the opposite extremity, it may be deemed hypomobile. Hypomobility may be caused by a number of factors including con­ tracture of cr. A joint that moves more than considered normal when compared to the same joint on the opposite extremity may be deemed hypermobile. Hypermobility may occur as a generalized phenomenon or be localized to just one direction of movement-the result of dam­ aged CT. The term stability, specifically related to the joint, has been the subject of much research. 1l9- 134 In contrast to a hypermobile joint, an unstable joint involves a disruption of the osseous and ligamentous structures of that joint, and results in a loss of function. Joint stability may be viewed as a factor of joint integrity, elastic energy, passive stiff­ ness, and muscle activation:

Study Pearl
Caution musti~eused Wh~f1~~sing clinical judgments Qn.th.e.resultsof accessoryl'l'lotion testing because feIN studies have·.• exarl"dn~dthe validity and reliabHityofaccessory motion testlng. of the spine or extremities. ~.?~ little lsknQwnabou~~~yalidityof these tests for most inferences. l1B

Study Pearl
~ The . presence. ofhYPPn1pbHitY"'in

tire absence of contraind15ations is an indication for jointTobiJiz.1. tionsasthe intervention of choice. ~ The presence of hypermobil1tyis a contralndicati()nt()joiritmobi~ Iizations.

Joint integrity. Joint integrity is enhanced in those ball- and­ socket joints with deeper sockets or steeper sides as opposed to those with planar sockets and shallower sides. Joint integrity



TABLE 5-23. GONIOMETRIC TECHNIQUES FOR THE UPPER EXTREMITY JOINT Shoulder MOTION Flexion AXIS Acromion process STATIONARY ARM Midaxillary line of the thorax MOVABLE AR\i Lateral midline of the humerus using the lateral epicondyle of the humerus for reference Lateral midline of the humerus using the lateral epicondyle of the humerus for reference Medial midline of the humerus


Acromion process

Midaxillary line of the thorax

Abduction Adduction Internal rotation External rotation Flexion

Anterior aspect of the acromion process Anterior aspect of the acromion process Olecranon process Olecranon process Lateral epicondyle of the humerus Lateral epicondyle of the humerus Lateral to the ulnar styloid process Medial to the ulnar styloid process Lateral aspect of the wrists over the triquetrum Lateral aspect of the wrists over the triquetrum Over the middle of the dorsal aspect of the wrist over the capitate Over the middle of the dorsal aspect of the wrist over the capitate Over the palmar aspect of the first carpo­ metacarpal joint Over the palmar aspect of the first carpometacarpal joint Over the lateral aspect of the radial styloid process









Radial deviation

Parallel to the midline of the anterior aspect of the sternum Medial midline of the humerus Parallel to the midline of the anterior aspec1 of the sternum Ulna using the olecranon process Parallel or perpendicular to and ulnar styloid for reference the floor Ulna using the olecranon process Parallel or perpendicular to and ulnar styloid for reference the floor Lateral midline of the radius Lateral midline of the humerus using the center of the using the radial head and radial acromion process for reference styloid process for reference Lateral midline of the humerus Lateral midline of the radius using using the center of the the radial head and radial acromion process for reference styloid process for reference Parallel to the anterior midline Dorsal aspect of the forearm, just proximal to the styloid of the humerus process of the radius and ulna Parallel to the anterior midline Ventral aspect of the forearm, just proximal to the styloid of the humerus process of the radius and ulna Lateral midline of the ulna Lateral midline of the fifth using the olecranon and metacarpal ulnar styloid process for reference Lateral midline of the fifth Lateral midline of the ulna using the olecranon and metacarpal ulnar styloid process for reference Dorsal midline of the forearm Dorsal midline of the third using the lateral epicondyle metacarpal of the humerus for reference Dorsal midline of the forearm using the lateral epicondyle of the humerus for reference Ventral midline of the radius using the ventral surface of the radial head and radial styloid process for reference Ventral midline of the radius using the ventral surface of the radial head and radial styloid process for reference Lateral midline of the second metacarpal using the center of the second metacarpal or phalangeal joint for reference Dorsal midline of the third metacarpal

Ulnar deviation


Carpometacarpal flexion

Ventral midline of the first metacarpal

Carpometacarpal extension

Carpometacarpal abduction

Ventral midline of the first metacarpal Lateral midline of the first metacarpal using the center of the first metacarpal or phalangeal joint for reference



TABLE 5-23. GONIOMETRIC TECHNIQUES FOR THE UPPER EXTREMITY (Continued) JOINT MOTION Carpometacarpal adduction AXIS Over the lateral aspect of the radial styloid process Over the dorsal aspect of the metacarpo­ phalangeal joint Over the dorsal aspect of the metacarpophalangeal joint Over the dorsal aspect of the metacarpo­ phalangeal joint Over the dorsal aspect of the metacarpo­ phalangeal joint Over the dorsal aspect of the proximal interphalangeal joint Over the dorsal aspect of the proximal interphalangeal joint Over the dorsal aspect of the proximal interphalangeal joint Over the dorsal aspect of the proximal interphalangeal joint STATIONARY ARM Lateral midline of the second metacarpal using the center of the second metacarpal or phalangeal joint for reference Over the dorsal midline of the metacarpal Over the dorsal midline of the metacarpal Over the dorsal midline of the metacarpal Over the dorsal midline of the metacarpal Over the dorsal midline of the proximal phalanx Over the dorsal midline of the proximal phalanx Over the dorsal midline of the middle phalanx Over the dorsal midline of the middle phalanx MOVABLE ARM Lateral midline of the first metacarpal using the center of the first metacarpal or phalangeal joint for reference Over the dorsal midline of the proximal phalanx Over the dorsal midline of the proximal phalanx Over the dorsal midline of the proximal phalanx Over the dorsal midline of the proximal phalanx Over the dorsal midline of the middle phalanx Over the dorsal midline of the middle phalanx Over the dorsal midline of the distal phalanx Over the dorsal midline of the distal phalanx


Metacarpophalangeal flexion Metacarpophalangeal extension Metacarpophalangeal abduction Metacarpophalangeal adduction Proximal interphalangeal flexion Proximal interphalangeal extension Distal interphalangeal flexion Distal interphalangeal extension




is also dependent on the attributes of the supporting structures around the joint, and the extent of joint disease. Elastic energy. Connective tissues are elastic structures, and as such are capable of storing elastic energy when stretched. This stored elastic energy may then be used to help return the joint to its original position when the stresses are removed. Passive stiffness. Individual joints have passive stiffness that increases toward the joint end range. An injury to these passive structures causing inherent loss in the passive stiffness results in joint laxity .135 Muscle activation. Muscle activation increases stiffness, both within the muscle and within the joint(s) it crosses. 136 However, the synergists and antagonist muscles that cross the joint must be activated with the correct and appropriate activation in terms of magnitude or timing. A faulty motor control system can lead to inappropriate magnitudes of muscle force and stiffness, allowing for a joint to buckle or undergo shear translation. 136

Pathologic breakdown of the above factors may result in instabil­ ity. Two types of instability are recognized: articular and ligamen­ tous.-Articular instability can lead to abnormal patterns of coupled and translational movements. 137-Ligamentous instability may lead to multiple planes of aberrant joint motion. l38



TABLE 5-24. GONIOMETRIC TECHNIQUES FOR THE LOWER EXTREMITY JOINT Hip MOTION Flexion AXIS Over the lateral aspect of the hip joint using the greater trochanter of the femur reference Over the lateral aspect of the hip joint using the greater trochanter of the femur reference Over the anterior superior iliac spine (ASIS) of the extremity being measured Over the anterior superior iliac spine (ASIS) of the extremity being measured Anterior aspect of the patella STATIONARY ARM Lateral midline of the pelvis MOVABLE ARM Lateral midline of the femur
using the lateral epicondyle
for reference
Lateral midline of the femur using the lateral epicondyle for reference Anterior midline of the femur using the midline of the patella for reference Anterior midline of the femur using the midline of the patella for reference Anterior midline of the lower leg using the crest of the tibia and a point midway between the two malleoli for reference Anterior midline of the lower leg using the crest of the tibia and a point midway between the two malleoli for reference Lateral midline of the fibula using the lateral malleolus and fibular head for reference Lateral midline of the fibula using the lateral malleolus and fibular head for reference Parallel to the lateral aspect of the fifth metatarsal Parallel to the lateral aspect of the fifth metatarsal


Lateral midline of the pelvis



Internal rotation

Aligned with imaginary horizontal line extending from one ASIS to the other ASIS Aligned with imaginary horizontal line extending from one ASIS to the other ASIS Perpendicular to the floor or parallel to the supporting surface

External rotation

Anterior aspect of the patella

Perpendicular to the floor or parallel to the supporting surface



Lateral epicondyle of the femur

Lateral midline of the femur using the greater trochanter for reference Lateral midline of the femur using the greater trochanter for reference Lateral midline of the fibula using the head of the fibula for reference Lateral midline of the fibula using the head of the fibula for reference Anterior midline of the lower leg using the tibial tuberosity for reference Anterior midline of the lower leg using the tibial tuberosity for reference Posterior midline of the lower leg Posterior midline of the lower leg


Lateral epicondyle of the femur



Lateral aspect of the lateral malleolus Lateral aspect of the lateral malleolus

Plantar flexion


Anterior aspect of the ankle midway between the malleoli

Anterior midline of the second metatarsal


Anterior aspect of the ankle midway between the malleoli

Anterior midline of the second metatarsal


Inversion Eversion

Posterior aspect of the ankle midway between the malleoli Posterior aspect of the ankle midway between the malleoli

Posterior midline of the calcaneus Posterior midline of the calcaneus




Grade I Grade II

Grade III Grade IV at limit of range


Grade V

(Beginning point in range of motion)

(Point of limitation)

(Anatomic limit)

Figure 5-5. Maitland's five grades of motion. (PL, point of limitation; AL, anatomic limit.) (Reproduced, with permission, from Dutton M. Manual Therapy of the Spine. New York: McGraw-Hili; 2002:44.)

GENERAL PRINCIPLES OF BIOMECHANICS The science of biomechanics involves the application of mechanical principles in the study of the structure and function of movement. For the physical therapist designing and supervising rehabilitation pro­ grams, a working knowledge of biomechanics is essential: a funda­ mental skill of the physical therapist is to identify, analyze, and solve problems related to human movement. When describing joint movements it is necessary to have a start­ ing position as the reference position. This starting position is referred to as the anatomic reference position. The anatomic reference posi­ tion for the human body is described as the erect standing position with the feet just slightly separated and the arms hanging by the side, the elbows straight, and with the palms of the hand facing forward (Fig. 5-6).

DIRECTIONAL TERMS Directional terms are used to describe the relationship of body parts or the location of an external object with respect to the body.139 The fol­ lowing are commonly used directional terms: Superior or cranial--doser to the head.
Inferior or caudal----eloser to the feet.
Anterior or ventral-toward the front of the body.
Posterior or dorsal-toward the back of the body.
Medial-toward the midline of the body.
Lateral-away from the midline of the body.
Proximal----eloser to the trunk.
Distal-away from the trunk.
Superficial-toward the surface of the body.
Deep--away from the surface of the body in the direction of the
inside of the body.




Figure 5-6. Standing positions. A. Funda­ mental standing position. B. Anatomic stand­ ing position. (Reproduced, with permission, from Luttgens K, Hamilton N. Kinesiology: Scientific Basis of Human Motion. 10th ed. New York: McGraw-Hili; 2002:38.)



Movements of the body segments occur in three dimensions along imaginary planes and around various axes of the body.

Planes of the Body. There are three traditional planes of the body corresponding to the three dimensions of space: sagittal, frontal, and transverse (Fig. 5-7).139


Sagittal. The sagittal plane, also known as the anterior-posterior
or median plane, divides the body vertically into left and right
halves of equal size
Frontal. The frontal plane, also known as the lateral or coronal
plane, divides the body equally into front and back halves
Transverse. The transverse plane, also known as the horizontal
plane, divides the body equally into top and bottom halves.

Three reference axes are used to describe human motion: frontal, sagittal, and longitudinal. The axis around which the movement takes place is always perpendicular to the plane in which it occurs.
~ ~ ~

Axes of the Body.

Frontal. The frontal axis, also known as the transverse axis, is perpendicular to the sagittal plane
Sagittal. The sagittal axis is perpendicular to the frontal plane
Longitudinal. The longitudinal axis, also known as the vertical
axis, is perpendicular to the transverse plane.

(" .. .. ,




!) : /',




: 1



"-<\ ). ,I


\! "\



.. ~.J:!;;.,
·'("c_ ••••



Figure 5-7. The planes of the body. A. Sagittal, or anteroposterior, plane. B. Frontal, or lateral, plane. C. Horizontal, or transverse, plane. (Reproduced, with permission, from Luttgens K, Hamilton N. Kinesiology: Scientific Basis of Human Motion. 10th ed. New York: McGraw-Hili; 2002:36.)



The planes and axes for the more common planar movements are described here
~ ~



Flexion, extension, hyperextension, dorsiflexion, and plantar flexion occur in the sagittal plane around a frontal-horizontal axis. Abduction, adduction; side flexion of the trunk; elevation and depression of the shoulder girdle; radial and ulnar deviation of the wrist; and eversion and inversion of the foot occur in the frontal plane around a sagittal-horizontal axis. Rotation of the head, neck, and trunk; internal rotation and external rotation of the arm or leg; horizontal adduction and abduction of the arm or thigh; and pronation and supination of the forearm occur in the transverse plane around the longitudi­ nal axis. Arm circling and trunk circling are examples of circumduction. Circumduction involves an orderly sequence of circular move­ ments that occur in the sagittal, frontal, and intermediate oblique planes, so that segment as a whole incorporates a com­ bination of flexion, extension, abduction, and adduction. Circumduction movements can occur at biaxial and triaxial joints. Examples of these joints include the tibiofemoral, radio­ humeral, hip, glenohumeral, and spinal joints.

Biomechanical levers can be defined as rotations of a rigid surface about an axis. For simplicity's sake, levers are usually described using a straight bar which is the lever, and the fulcrum, which is the point on which the bar is resting. The effort force attempts to cause movement of the load. That part of the lever between the fulcrum and the load is load arm. There are three types of levers:

First class: when two forces are applied on either side of an axis and the fulcrum lies between the effort and the load (Fig. 5-8), like a seesaw. Examples in the human body include the contraction of the triceps at the elbow joint, or tipping of the head forward and backward.






Effort Axis or fulcrum Resistance or weight




Figure 5-8. Levers. A. A lever of the first class. B. A lever of the sec­ ond class. C. A lever of the third class. (Reproduced, with permission, from Luttgens K, Hamilton N. Kinesiology: Scientific Basis of Human Motion. 10th ed. New York: McGraw-Hili; 2002:350.)




Second class: when the load (resistance) is applied between the fulcrum and the point where the effort is exerted (Fig. 5-8). This has the advantage of magnifying the effects of the effort so that it takes less force to move the resistance. Examples of second-class levers in everyday life include the nutcracker and the wheelbarrow-with the wheel acting as the fulcrum. There are a few examples of second-class levers in the human body. One possible example is weight-bearing plantarflexion (rising up on the toes). Another would be an isolated contraction of the brachioradialis to flex the elbow, which could not occur without the other elbow flexors being paralyzed. Third class: when the load is located at the end of the lever (Fig. 5-8) and the effort lies between the fulcrum and the load (resistance), like a drawbridge or a crane. The effort is exerted between the load and the fulcrum. The effort expended is greater than the load, but the load is moved a greater distance. Most movable joints in the human body function as third-class levers-flexion at the elbow.

The extensibility and habitual length of CT is a factor of the demands placed upon it. The examination of flexibility is performed to deter­ mine if a particular structure, or group of structures, has sufficient extensibility to perform a desired activity. A decrease in the length of the soft-tissue structures, or adaptive shortening, is very common in postural dysfunctions. Adaptive shortening can also be produced by:
~ ~ ~


Restricted mobility.
Tissue damage secondary to trauma.
Prolonged immobilization.
Hypertonia: the muscle will feel hard and may stand out from
those around it.


Energy Systems. Muscles are metabolically active and must gen­ erate energy to move. The creation of energy occurs initially from the breakdown of certain nutrients from foodstuffs. This energy is stored in a compound called adenosine triphosphate (ATP). ATP is produced in the muscle tissue from blood glucose or glycogen. Fats and proteins can also be metabolized to generate ATP. Glucose not needed imme­ diately is stored as glycogen in the resting muscle and liver, but can later be converted back to glucose and transferred to the blood to meet the body's energy needs. If the duration or intensity of the exercise increases, the body relies more heavily on fat stored in adipose tissue to meet its energy needs. {During rest and submaximal exertion, both fat and carbohydrates} are used to provide energy in approximately a 60% to 40% ratio. The energy demands for each activity depend on the intensity and duration of the activity. Different processes can meet the various energy demands. Two of the most important energy-generating



systems that function in muscle tissue include the anaerobic and aero­ bic metabolism, both of which produce ATP.

Anaerobic Metabolism. This process metabolites glucose to gener­ ate small amounts of ATP energy without the need for oxygen.




ATP-PCr system: used for ATP production during high-inten­ sity, short-duration exercise. Phosphocreatine (PCr) decom­ poses and releases a large amount of energy that is used to construct ATP. The short-term energy system provides energy for muscle con­ traction for up to 15 seconds. Anaerobic glycolysis (glycolytic system): a major supply of ATP during high-intensity, short-duration activities. • Muscle glycogen is the initial substrate. Stored glycogen is split into glucose, and through glycolysis, split again into pyruvate acid, and lactic acid is the end product, with no oxygen being directly involved. The energy released during this process forms ATP. • While unable to produce as much energy per unit time as the phosphocreatine system (i.e., unable to sustain maximum sprinting speed), it lasts considerably longer before intensity must be further reduced. The intermediate energy system provides the majority of energy for a sustained performance lasting between 20 seconds and 2 minutes (sprinting 400 or 800 meters).

Aerobic Metabolism (Oxidative System). If exercise continues
beyond a certain point, the body can no longer rely solely on anaero­ bic metabolism and has to switch to this more complex form of carbo­ hydrate and fat metabolism in order to generate ATP. The long-term energy system. Ultimately, all exercise has an oxygen cost, and the faster this can be met during recovery, the better the preparation for the next high-intensity exercise bout. Delivery of oxygen to the fatigued muscles replenishes stores of creatine phosphate and lowers levels of lactic acid. This means the aer­ obic system must not be overlooked during rehabilitation. In most activities, both aerobic and anaerobic systems function simultaneously, with the ratio being determined by the intensity and duration of the activity. In general, high-intensity activities of short duration rely more heavily on the anaerobic system, whereas low intensity activities of longer duration rely more on the aerobic system. The normal and abnormal responses to exercise, and the signs and symptoms of exercise intolerance, are described in Chapter 11.

Measures of Energy Expenditure
The Calorie. The energy value of the food we eat can be quantified in terms of the calorie. A kilocalorie (kcal) is the amount of heat nec­ essary to raise 1.0 kg of water by 1.0 C C. Oxygen Consumption
~ ~

Oxygen consumption may be abbreviated as V0 2 • Oxygen is used in all metabolically active tissue.



The Basal Metabolic Rate. The basal metabolic rate (BMR), the sum total of cellular activity in all metabolically active tissues while under basal conditions, is the minimal amount of oxygen utilized in order to support life.
~ ~

A person's BMR varies according to overall body size, gender, age, fat-free mass, and endocrine function. In general, the BMR tends to be 5% to 10% lower in women than men. There is a decline in BMR of 2% to 3% per decade of life, which is most likely due to the reduction in physical activ­ ity associated with aging.


Study Pearl

Body mass index (BM!) is a measure of body fat based on height and weight. Body fat can be divided into two types:
~ ~

.mass (FfM).. indl{d~~· . ootJ;sde, skil\ bone,and ...4s¢.erq.

Essential fat: necessary for normal physiologic function, serving as a source of energy and a storage site for some vitamins. Storage fat: stored in adipose tissue.

Study Pearl

Separate calculations are used for boys and girls aged 2 to 20 (Figs. 5-9 and 5-10) and for adult men and women (Table 5-25). Further subdivisions can be made according to gender for adults (Tables 5-26 and 5-27). The limitations of relying on the BMI include:
~ ~

TOe . . standiJ1:~t:ltror ··witn..·.estiryYating

It may overestimate body fat in athletes and others who have a

~,,(jef:ltfaJwi~hthe.· BMl is ·app"oxj~ rii~~el~SPf6, .

muscular build.
It may underestimate body fat in older persons and others who

have lost muscle mass.


Bioelectrical impedance analysis (BIA) measures body composition by sending a low, safe electrical current through the body flUids contained mainly in the lean and fat tissue. BIA measures the impedance or oppo­ sition to the flow of this electric current. The impedance of a biologic tissue comprises two components, the resistance and the reactance. The conductive characteristics of body fluids provide the resistive com­ ponent, whereas the cell membranes, acting as imperfect capacitors, contribute a frequency-dependent reactive component. Impedance is low in lean tissue, where intracellular fluid and elec­ trolytes are primarily contained. Impedance is high in fat tissue. Impedance is thus proportional to body water volume (TBW). In prac­ tice, a small constant current, typically 800 uA at a fixed frequency, usually 50 kHz, is passed between electrodes spanning the body and the voltage drop between electrodes provides a measure of imped­ ance. Prediction equations, previously generated by correlating imped­ ance measures against an independent estimate of TBW, may be used subsequently to convert a measured impedance to a corresponding estimate of TBW. Lean body mass is then calculated from this estimate using an assumed hydration fraction for lean tissue. Fat mass is calcu­ lated as the difference between body weight and lean body mass.



2 to 20 years: Girls Body mass index-for-age percentiles
Date Age Weight Stature 8MI' Comments





35­ 34­ 33­ 32­ 31­ 30­

·To Calculate 8MI: Weight (kg) , Stature (em) , Slature (em) x 10,000 or Weighl (Ib) , Slature (in) , Stature (in) x 703

29­ 28­ 27­





85=F='- 26­




- 21
- 20
- 19
- 18
- 17
- 16
- 15



20­ 19­ 18­
17­ 16­ 15­ 14­ 13­















19 20

Published May 30, 2000 (modified 10/16/00). SOURCE: Developed by the National Center lor Health Statistics in collaboration wilh the National Center for Chronic Disease Prevention and Health Promolion (2000). http://www.cdc.gov/growthcharts


Figure 5-9. Body mass index for age percentiles: girls 2 to 20 years.

BIA can be a useful technique for body composition analysis in healthy individuals and in those with a number of chronic conditions such as mild to moderate obesity, diabetes mellitus, and other medical conditions in which major disturbances of water distribution are not prominent. BIA values are affected by numerous variables including body position, hydration status, consumption of food and beverages, ambi­ ent air and skin temperature, recent physical activity, and conductance



2 to 20 years: Boys Body mass index-far-age percentiles
Date Age Weight Stature





35­ 34­ 33­ 32­ 31­
*To Calculate 8MI: Weight (kg) + Stature (em) + Stature (em) x 10,000 or Weight (Ib) + Stature (in) + Stature (in) x 703


30­ 29­ 28­



27 26


26­ 25­ 24­



I- 24

23 22


23­ 22­ 21­
20 19­

I- 21


20 19



18­ 17­ 16­ 15­ 14­ 13­ 12­

I- 17 I- 16

15 14

I- 13

f- 12




















PUblished May 30, 2000 (rnodified 10116100). SOURCE: Developed by the National Center for Health Statistics in collaboration with the National Center for Chronic Disease Prevention and Health Promotion (2000). hUp:/Iwww.cdc.gov/growthcharts



Figure 5-10. Body mass index for age percentiles: boys 2 to 20 years.



TABLE 5-25. BMI CALCULATIONS MEASUREMENT UNITS Kilograms and meters (or centimeters) FORMULA Formula: weight (kg)/ [height (m)F CALCULATION Calculation: [weight (kg)/height (cm)/height (em)] x 10,000 With the metric system, the formula for BMI is weight in kilograms divided by height in meters squared. Since height is commonly measured in centimeters, an alternate calculation formula, dividing the weight in kilograms by the height in centimeters squared, and then multiplying the result by 10,000, can be used. Calculation: [weight (lb)/height (in)/height (in)] X 703 When using English measurement~, ounces (oz) and fractions must be changed to decimal values. Then, calculate BMI by diViding weight in pounds (lbs) by height in inches (in) squared and multiplying by a conversion factor of 703.

Pounds and inches

Formula: weight (lb)/ [height (in)F x 703

BMI Categories Underweight = <18.5 kg/m2 Normal weight = 18.5-24.9 kg/m2 Overweight = 25-29.9 kg/m2 Grade I obesity = 30-34.9 kg/m2 Grade II obeSity = 35-39.9 kg/m 2 Grade III obesity = >40 kg/m2

TABLE 5-26. MEDIAN BMI VALUES FOR MEN AGE (YEARS) 20-29 Median BMI 24.5 30-39 25.9 40-49 26.8 50-59 27.2


TABLE 5-27. MEDIAN BMI VALUES FOR WOMEN AGE (YEARS) 20-29 Median BMI 24.4 30-39 26.4 40-49 27.8 50-59 28.4




of the examining table. Reliable BrA requires standardization and con­ trol of these variables. The typical protocol consists of:
~ ~ ~ ~ ~

No alcohol consumption for 48 hours prior to test. Avoidance of intense exercise for 12 hours prior to test. Avoidance of all diuretics (coffee, tea, caffeinated soda) for at least 12 hours prior to test. Avoidance of eating or drinking 4 hours prior to test. Emptying the bladder 30 minutes before test. Menstruating women should ensure they are at the same stage of their menstrual cycle for each test.

A metabolic equivalent unit, or MET, is defined as the energy expendi­ ture for sitting quietly, talking on the phone, or reading a book, which for the average adult approximates 35 mL of oxygen uptake per kilo­ gram of body weight per minute 05 mL O/kg/min)-l.2 kcallmin for a 70-kg individual). METs are defined as multiples of resting energy metabolism. For example, a 2-MET activity requires two times the metabolic energy expenditure of sitting quietly. The harder the body works during the activity, the higher the MET. In order to quantify the amount of exercise that the physical therapist prescribes to a patient, the use of MET units allows exercises to be graded from a level of low intensity to one of a higher intensity. Any activity that burns 3 to 6 METs is considered moderate-intensity physical activity. Any activity that burns more than 6 METs is considered vigorous-intensity physical activity (Table 5-28).

All of the foods that we consume consist of carbon, hydrogen, and oxy­ gen. Nutrients used to power exercise include carbohydrates, fats, and proteins. These nutrients, together with Vitamins, minerals, and water, are essential for the maintenance of optimum health.

Carbohydrates. Carbohydrates consist of carbon, hydrogen, and oxygen, with the ratio of hydrogen to oxygen always being 2: l. Carbohydrates serve a variety of important roles in normal body function:
~ ~ ~ ~

The primary fuel source of the body. A necessary adjunct for the catabolism of fats. The principal fuel for the CNS. A protective function for protein.

Fats. Fats, like carbohydrates, consist of carbon, hydrogen, and oxy­ gen. Fat'; differ from carbohydrates in that the ratio of hydrogen to oxy­ gen is much higher. There are three main groups of fats: simple lipids, compound lipids, and derived lipids.

Simple lipids. An example of the simple lipid is the triglyceride. Fat is stored in the body as triglyceride. Compound lipids. Lipoproteins are an example of a compound lipid. Lipoproteins consist of a protein core and an outer shell containing free cholesterol, phospholipid, and a regulatory



TABLE 5-28. GENERAL PHYSICAL ACTIVITIES DEFINED BY LEVEL OF INTENSITY IN ACCORDANCE WIlli CDC AND ACSM GUIDELINES MODERATE ACTIVITY 3.0 TO 6.0 METs (3.5 TO 7 kcal!min) Walking at a moderate or brisk pace of 3 to 4.5 mph on a level surface inside or outside, such as, ~ Walking to class, work, or the store ~ Walking for pleasure ~ Walking the dog ~ Walking as a break from work Walking downstairs or down a hill Racewalking-less than 5 mph Using crutches Hiking Roller skating or in-line skating at a leisurely pace Bicycling 5 to 9 mph, level terrain, or with few hills Stationary bicycling-using moderate effort Aerobic dancing-low impact Water aerobics VIGOROUS ACTIVITY GREATER THAN 6.0 METs (MORE THA1'i 7 kcal!min) Racewalking and aerobic walking-5 mph or faster Jogging or running Wheeling your wheelchair Walking and climbing briskly up a hill Backpacking Mountain climbing, rock climbing, rapelling Roller skating or in-line skating at a brisk pace

Bicycling more than 10 mph or bicycling on steep uphill terrain Stationary bicycling-using vigorous effort Aerobic dancing-high impact Step aerobics Water jogging Teaching an aerobic dance class Calisthenics-push-ups, pull-ups, vigorous effort Karate, judo, tae kwon do, jUjitsu Jumping rope Performing jumping jacks Using a stair climber machine at a fast pace Using a rowing machine-with moderate effort Using an arm cycling machine-with vigorous effort

Calisthenics-light Yoga Gymnastics General home exercises, light or moderate effort, getting up and down from the floor Jumping on a trampoline Using a stair climber machine at a light-to-moderate pace Using a rowing machine-with vigorous effort Weight training and bodybuilding using free weights, Nautilus- or Universal-type weights Boxing-punching bag Ballroom dancing Line dancing Square dancing Folk dancing Modern dancing, disco Ballet Table tennis-competitive Tennis-doubles Golf, wheeling or carrying clubs Softball-fast pitch or slow pitch Basketball-shooting baskets Coaching children's or adults' sports

Circuit weight training Boxing-in the ring, sparring Wrestling-competitive Professional ballroom dancing--energetically Square dancing--energetically Folk dancing--energetically Clogging

Tennis-singles Wheelchair tennis Most competitive sports Football game Basketball game Wheelchair basketball Soccer Rugby Kickball Field or rollerblade hockey Lacrosse




protein. The high-density lipoproteins (HDLs), which possess the highest amount of protein and the lowest amount of choles­ terol, are popularly called "good cholesterol." The low-density lipoproteins (LDLs) contain large amounts of cholesterol, which they transport to arterial walls, thus contributing to ath­ erosclerosis, or hardening of the arteries. Derived lipids. Perhaps the best-known of these is cholesterol. Cholesterol is found exclusively in animal tissue. It is both con­ sumed in the food we eat and produced by the body, mainly in the liver. A high cholesterol level in the blood is an independ­ ent risk factor for the development of heart disease.

Fats have a number of benefits. Fats:

~ ~ ~

Have the highest energy yield of any of the substrates in the body. Provide a layer of insulation for the body that helps maintain body temperature. Serve a protective function by surrounding the body organs and protecting them from injury. Act as a carrier for the fat-soluble vitamins A, 0, E, and K. Have an impact on the satiety center of the brainstem, produc­ ing feelings of fullness.

Proteins. Proteins, which contain carbon, hydrogen, and oxygen, make up about 15% of the mass of the average person. The major components of proteins are the amino acids, of which there are 20 dif­ ferent ones in the human body. Nine of these twenty are considered to be essential amino acids. Protein is used primarily for tissue mainte­ nance, repair, and growth and is the primary constituent of actin and myosin, the contractile elements of skeletal muscle tissue. Protein is a poor fuel source and excess protein, like carbohy­ drate, gets converted to fat. Vitamins and Minerals. Refer to Chapter 19.
Nerves and muscles are both excitable tissues. This excitability is dependent on the cell's membrane, which regulates the interchange of substances between the inside of the cell and the environment outside the cell. The potential difference between electrical charges on the inside and outside of the cell membrane is known as the resting mem­ brane potential (-60 mV to -90 mV for excitable cells).

Resting Membrane Potential. All cells under resting condi­ tions have an electrical potential difference across the plasma mem­ brane (resting membrane potential or RMP) so that the inside of the cell is negatively charged with respect to the outside. The resting mem­ brane potential is determined mainly by two factors:
~ ~

The differences in ion concentration of the intracellular and extracellular fluids. The permeabilities of the plasma membrane to the different ion species.



Both electrical and chemical gradients are established along the cell membrane with a greater concentration of diffusible positive ions on the outside of the membrane than on the inside. Thus:




The cell membrane is more permeable to potassium (K+) as compared to sodium (Na +) and negatively charged proteins (anions). An electrical potential is generated across the cell mem­ brane due to the high concentration of K+ and anions on the inside of the cell relative to the concentration of Na + on the outside. A negative charge is produced within the cell and a positive charge develops on the outside of the cell as the positively charged K+ diffuses from the cell. The RMP is maintained by an active sodium-potassium pump that takes in K+ and extrudes Na+.

To create transmission of an impulse in the nerve tissue, the RMP must be reduced below a threshold level, thereby causing a change in the membrane's permeability. These changes create an action potential that will propagate the impulse along the nerve in both direc­ tions from the location of the stimulus.

Action Potential. An action potential (AP) is a stimulus that causes the cell membrane to become more permeable to Na+ ions. Not all stimuli are effective in causing an action potential. To be an effective agent, a stimulus must have:

Study Pearl



An adequate intensity and amplitude to cause the membrane potential to be lowered sufficiently to reach threshold levels. Since a single excitatory synaptic event (excitatory postsy­ naptic potential or EPSP) does not bring the postsynaptic membrane to its threshold level, further depolarization is necessary before the initial EPSP has died away. This further depolarization can occur at different times (temporal sum­ mation) or simultaneously from different sources (spatial summation). A rapid enough rise of the current peak intensity to prevent accommodation, which is the rapid adjustment of the mem­ brane to stimuli to prevent depolarization. Sufficient duration to produce depolarization of the cell membrane.

Study Pearl

When the transmembrane potential reaches a critical threshold level (-55 mY), the voltage-sensitive Na+ and K+ channels open widely.
~ ~

Na+ permeability increases rapidly. K+ permeability increases slowly.

During depolarization, the transmembrane potential might rise as high as +35 mY. The flow of ions produces a characteristic charge:
~ ~

A positive charge is generated inside the cell. A negative charge is produced outside of the cell.



The K+ channels are fully open about the time the Na+ channels are closed. Thus:
~ ~ ~

K+ rushes rapidly out of the cell, making the transmembrane potential progressively more negative (repolarization). The K+ channels remain open long enough to repolarize the membrane 00 to 20 mV below RMP)-hyperpolarization. The K+ channels close and passive diffusion of the ions rapidly returns the RMP to its initial level.

Following excitation and propagation of the impulse along the nerve fiber, there is a brief period during which an ordinary stimulus is not able to generate another impulse. This brief period is termed the refractory period. The refractory period consists of two phases, the absolute refractory period and the relative refractory period.

Propagation of the Action Potential. The opening of the Na+ and K+ channels and voltage changes that produce an AP at one segment of the membrane triggers successive depolarizations in adjacent regions of the nerve, muscle, or membranes. Movement of the AP occurs along the surface of the nerve or muscle cell.


Unmyelinated nerve: AP movement is generated by a sequen­ tial depolarization along neighboring sites in the membrane. Speed of conduction is slow due to the greater internal resist­ ance in the small-diameter fibers. Myelinated nerve: AP movement is generated by saltatory con­ duction, which occurs at discrete junctures in the myelin sheath that surrounds the nerve called nodes of Ranvier. Myelin is an excellent insulator with a high resistance to current flow. Because myelin is absent over the nodes of Ranvier, current flows from one node to the next. The Na+ and K+ ion exchange and current flow is concentrated at these nodes, with the impulse jumping from node to node at speeds greater than those in the smaller unmyelinated nerve fibers.

A synapse 140 is the functional connection between a neuron and a second cell. In the PNS, the other cell may be either a neuron or effector cell within a muscle or gland. In the CNS the other cell is another neuron. Neuron-neuron synapses usually involve a con­ nection between the axon of one neuron and the dendrites, cell body, or axon of a second neuron. In almost all synapses, transmission is in one direction only: from the axon of the first (or presynaptic) neuron to the second (or postsynaptic) neuron. Synaptic transmission can be either electrical or chemical.

The Synapse.


Electrical synapses: in order for two cells to be electrically cou­ pled, they must be joined by areas of contact with low electri­ cal resistance. Adjacent cells that are electrically coupled are joined together by gap junctions. Gap junctions are present in cardiac muscle, some smooth muscles, and in various regions of the brain, although the functional significance in the latter is presently unknown. Chemical synapses: transmission across the majority of synapses in the nervous system is one way and occurs



through the release of chemical neurotransmitters from presy­ naptic axon endings called axon terminals. The presynaptic endings are separated from the postsynaptic cell by a synap­ tic cleft. The neurotransmitter molecules within the presynaptic neuron endings are contained within many small, membrane-enclosed synap­ tic vesicles. Voltage-regulated calcium (Ca2+) channels are located in the axon terminal adjacent to the docking sites. The arrival of action potentials at the axon terminal open these voltage-regulated Ca2+ chan­ nels and it is the inward diffusion of Ca2+ that triggers the rapid fusion of the synaptic vesicle with the axon membrane and the release of neu­ rotransmitter through a process called exocytosis. Once the neurotransmitter molecules have been released from the presynaptic axon terminals, they diffuse rapidly across the synaptic cleft and reach the membrane of the postsynaptic cell, where they bind to specific receptor proteins that are located within the postsynaptic membrane. Receptor proteins have high specificity for their neuro­ transmitter, which is the ligand of the receptor protein, and binding of the neurotransmitter ligand to its receptor protein causes ion channels to open in the postsynaptic membrane. The opening of ion channels often produces a depolarization called an excitatory postsynaptic potential (EPSP), which in turn stim­ ulate the postsynaptic cell to produce an action potential. In other cases a hyperpolarization occurs, called an inhibitory postsynaptic potential (IPSP), which antagonizes this effect.


S:: ~arl

_ _ _ to

Neurotransmitters Acetylcholine. Those neurons that use acetylcholine as a neuro­
transmitter140 are called cholinergic neurons. Acetylcholine (Ach) is used as an excitatory neurotransmitter by some neurons in the CNS and by somatic motor neurons at the neuromuscular junction. At auto­ nomic nerve endings, ACh may be even excitatory or inhibitory, depending on the organ involved. The varying responses of the post­ synaptic cells to acetylcholine occurs because different postsynaptic cells have different subtypes of acetylcholine receptors. These include nicotinic and muscarinic receptors.

Monoamines. The regulatory molecules epinephrine, norepineph­ rine, dopamine, and serotonin are in the chemical family known as monoamines. Of these, only epinephrine is not a transmitter, it is a hor­ mone. Although norepinephrine is also a hormone, it also functions as a neurotransmitter. As with acetylcholine, monoamine neurotransmit­ ters are released by exocytosis from presynaptic vesicles, diffuse across the synaptic cleft, and interact with specific receptor proteins in the membrane of the postsynaptic cell. The inhibition of monoamine action occurs in one of three ways:


Reuptake of monoamines into the presynaptic neuron endings. Enzymatic degradation of monoamines in the presynaptic neu­ ron endings by monoamine oxidase (MAO). Drugs that act as MAO inhibitors have been found to aid people suffering from clinical depression (refer to Chapter 19). The enzymatic degradation of catecholamines in the postsy­ naptic neuron by catechol-O-methyltransferase (COMT).



Serotonin. Serotonin is used as a neurotransmitter by neurons with cell bodies in the raphe nuclei that are located along the midline of the brainstem. Physiologic functions attributed to serotonin include a role in the regulation of mood and behavior, appetite, and cerebral circula­ tion. Drugs that block the reuptake of serotonin into the presynaptic axons (selective serotonin reuptake inhibitors [SSRIs]) have been developed in the treatment of depression (refer to Chapter 19). Dopamine. Neurons that use dopamine as a neurotransmitter are called dopaminergic neurons. The cell bodies of dopaminergic neu­ rons are highly concentrated in the midbrain and their axons can be subdivided into two systems:


Nigrostriatal system: the cell bodies of this system are located in a part of the midbrain called the substantia nigra, which send fibers to the caudate nucleus and the putamen (centers for motor control that are part of the basal nuclei). There is much evidence that in Parkinson's disease there is degeneration of these neurons in the substantia nigra. Mesolimbic system: involves neurons that originate in the mid­ brain and send axons to structures in the forebrain that are part of the limbic system. The dopamine release by these neurons may be involved in behavior and reward. Research has impli­ cated one subtype of these receptors in alcoholism. Addictive drugs including cocaine, morphine, and amphetamines are also known to activate dopaminergic pathways via the nucleus accumbens of the forebrain.

Norepinephrine. Norepinephrine is used as a neurotransmitter in both the PNS (smooth muscles, cardiac muscle, and glands) and CNS (general behavioral arousal). Mental arousal can be elicited by amphet­ amines and other such drugs that stimulate pathways in which norep­ inephrine is used as a neurotransmitter (refer to Chapter 19).

Amino Acids



Glutamic acid and aspartic acid: function as excitatory neuro­ transmitters in the CNS. Glutamic acid has been implicated in the physiology of memory. Gamma-aminobutyric acid (GABA); a derivative of glutamic acid, this is the most prevalent neurotransmitter in the brain (as many as one-third of all the neurons in the brain use GABA as a neurotransmitter). GABA, which has an inhibitory function, is involved in motor control. A deficiency of GABA-releasing neurons is responsible for the uncontrolled movements seen in people with Huntington's chorea. Glycine: inhibitory neurotransmitters that have very important functions in the spinal cord, where they help in the control of skeletal movements.

Peptides/Neuropeptides. More than 25 peptides of various sizes
are found in the synapses of the brain and are often called neuropep­ tides (Table 5-29).



TABLE 5-29. CHEMICAL NEUROTRANSMITTERS CATEGORY Monoamines CHEMICALS Epinephrine Norepinephrine Dopamine Serotonin Melatonin Adenosine Adenosine triphosphate (ATP) Aspartic acid GABA (gamma-aminobutyric acid) Glutamic acid Glycine Angiotensin II Bradykinin Glucagon Insulin Somatostatin Substance P Angiotensin II Endogenous opioids/opioid peptides (enkephalins and endorphins) Vasopressin Nitrogen monoxide (Nitric oxide) Carbon monoxide

Purines Amino acids



Data from Van de Graaff KM, Fox 51. Functional organization of the nervous system. In: Van de Graaff KM, Fox 51, eds. Concepts ofHuman Anatomy and Physiology. New York: WeB/McGraw-Hill; 1999:371-406.

As the nerve impulse reaches its effector organ or another nerve cell, the impulse is transferred between the two at a motor end plate or synapse. At this junction, a transmitter substance is released from the nerve, which causes the other excitable tissue to discharge (Fig. 5-11). Most of the axons of peripheral nerves terminate on muscle cells. Whereas terminals of autonomic nerve fibers do not come in intimate contact with smooth muscle or gland cells, terminals of motor fibers form large synapses with muscle fibers, called neuromuscular junctions or motor end plates--the point of contact between the motor nerve and the muscle. All skeletal muscle contains a neuromuscular junction. The polarization at the presynaptic motor nerve increases the entry of calcium ion', through voltage-gated calcium channels, causing fusion of acetyl­ choline (ACh)-containing vesicles with the presynaptic membrane. The nerve terminal releases ACh into the synapse. ACh diffuses across the synapse, activating the postsynaptic ACh receptor, and thus opening sodium channels with resultant depolarization of muscle membrane, release of calcium from the sarcoplasmic reticulum, and muscle contrac­ tion. Normally, the ACh released is more than is needed for activation of all of the receptors, providing a margin of safety in the neuromuscular junction transmission. Disease-related loss of the safety margin provides the basis for clinical testing of neuromuscular junction function.

The Neuromuscular Junction.









Figure 5-11. Ultrastructure of the neuromuscular junction and the mechanism of muscle contraction. (Reproduced, with permission, from Junqueira LC, Carneiro J. Basic Histology: Text and Atlas. 10th ed. New York: McGraw-Hili; 2003:203.)

The purpose of the thermoregulatory system is to maintain a relatively constant internal body temperature. The thermoregulatory system con­ sists of three primary components 141 : .. Thermoreceptors: provide input to the temperature-regulating center located in the hypothalamus. Peripheral and central thermoreceptors provide afferent temperature input to the reg­ ulating center. • Peripheral receptors: composed primarily of free nerve end­ ings, and have a high distribution in the skin. Also located in the abdominal organs and nervous system. • Central receptors: located in the hypothalamus and sensitive to temperature changes in blood perfusing the hypothalamus. .. Regulating center: dependent on information from thermore­ ceptors to achieve constant temperatures. Once this informa­ tion reaches the regulatory center, it is compared with a set point standard or optimal temperature value and, depending on the contrast between set value and incoming information, mechanisms may be activated either to conserve or dissipate heat.



Effector organs: respond to both increases and decreases in temperature. The primary effector systems include vascular, metabolic, skeletal muscle responses (shivering), and sweating.

When body temperature is lowered, the following mechanisms are activated to conserve heat and increase heat productionl41 :



~ ~

Vasoconstriction of blood vessels: the hypothalamus activates sympathetic nerves, resulting in vasoconstriction of cutaneous vessels throughout the body, thereby reducing the amount of heat loss to the environment. Decrease (or abolition) in sweat gland activity: reduces or pre­ vents heat loss by evaporation. Piloerection: although less significant in humans, this mecha­ nism functions to trap a layer of insulating air near the skin and decrease heat loss. Shivering: the primary motor center for shivering is located in the posterior hypothalamus. Hormonal regulation: serves to increase cellular metabolism, which subsequently increases body heat.

Study Pearl
For the P'-lrposes ofestiiblishing ba~~.
Hne data in determining response to
treatment, physical therapists gener­
ally measure body temperature using
a thermometer (refer to Chapter 11).
A variety of thermometer desjgns
exi5t141 :
.. Glass mercury.
.. Electronic.
~ Disposable single use.
~ Temperature-sensitive strips.
.. Tympanic membrane (infrared).

Excess heat is dissipated from the body through four primary methods:
~ ~ ~

Radiation: the transfer of heat by an electromagnetic waves from one object to another. Conduction: the transfer of heat from one object to another through a liquid, solid, or gas. Convection: the transfer of heat by movement of air or liquid (water). Evaporation: dissipation of body heat by the conversion of a liquid to a vapor.

Together with a number of physical barriers (the skin, mucous mem­ branes, tears, earwax, mucus, and stomach acid), the immune system defends the body against foreign or hazardous substances that infiltrate it (Table 5-30). Such substances include microorganisms (bacteria, viruses, and fungO, parasites (such as worms), cancer cells, and even transplanted organs and tissues. Antigens are entities within or on bacte­ ria, viruses, other microorganisms, or cancer cells that stimulate an immune response in the body. Antigens may also exist independently­ for example, as pollen or food molecules. A normal immune response consists of recognizing a foreign antigen, mobilizing forces to defend against it, and attacking it. Disorders of the immune system occur when:
~ ~

The body produces an immune response against itself (an autoimmune disorder). The body cannot produce suitable immune responses against invading microorganisms (an immunodeficiency disorder).



Antibody (immunoglobulin)

DEFINITION A protein that is produced by B-lymphocytes and that interacts with a specific antigen. Any substance that can stimulate an immune response. A white blood cell that releases histamine (a substance involved in allergic reactions) and that produces substances to attract neutrophils and eosinophils to a trouble spot. The smallest unit of a living organism, composed of a nucleus and cytoplasm surrounded by a membrane. The process of attracting cells by means of a chemical substance. A group of proteins with various immune functions, such as killing bacteria and other foreign cells, making foreign cells easier for macrophages to identify and ingest, attracting macrophages and neutrophils to a trouble spot, and enhancing the effectiveness of antibodies. The immune system's messengers, which help regulate an immune response. A white blood cell that usually resides in tissues and that helps T-lymphocytes recognize foreign antigens. A white blood cell that can ingest bacteria and other foreign cells, that may help immobilize and kill parasites, that participates in allergic reactions, and that helps destroy cancer cells. A white blood cell that helps B-lymphocytes recognize and produce antibodies against foreign antigens. Literally, compatibility of tissue; determined by human leukocyte antigens (the major histocompatibility complex) and used to determine whether a transplanted tissue or organ will be accepted by the recipient. A group of molecules that are located on the surface of cells and that are unique in each organism, enabling the body to distinguish self from nonself; also called the major histocom­ patibility complex. The reaction of the immune system to an antigen. A synonym for antibody.
A type of cytokine secreted by some white blood cells to affect other white blood cells.
A lymphocyte that attaches to foreign or abnormal cells and kills them. A white blood cell, such as a monocyte, a neutrophil, an eosinophil, a basophil, or a lymphocyte. The white blood cell responsible for specific immunity, including producing antibodies (by B-lymphocytes) and distinguishing self from nonself (by T-lymphocytes). A large cell that is derived from a white blood cell called a monocyte, that ingests bacteria and other foreign cells, and that helps white blood cells identify microorganisms and other foreign substances. A synonym for human leukocyte antigens. A cell in tissues that releases histamine and other substances involved in allergic reactions. A group of atoms chemically combined to form a unique chemical substance. A type of lymphocyte that, unlike other lymphocytes, is formed ready to kill certain microorganisms and cancer cells. A white blood cell that ingests and kills bacteria and other foreign cells. A cell that ingests and kills invading microorganisms, other cells, and cell fragments. The process of a cell ingesting an invading microorganism, another cell, or a cell fragment. A molecule on a cell's surface or inside the cell that allows only molecules that fit precisely to it-as a key fits in its lock-to attach to it. A white blood cell that helps end an immune response.

Antigen Basophil Cell Chemotaxis Complement system

Cytokines Dendritic cell Eosinophil Helper T-cell Histocompatibility

Human leukocyte antigens

Immune response Immunoglobulin Interleukin Killer (cytotoxic) T-cell Leukocyte Lymphocyte Macrophage

Major histocompatibility complex (MHC) Mast cell Molecule Natural killer cell Neutrophil Phagocyte Phagocytosis Receptor Suppressor T-cell


A normal immune response to foreign antigens damages nor­ mal tissues (an allergic reaction).

The body's first line of protection against invaders is through mechanical or physical barriers: the skin; the cornea of the eye; and the membranes lining the respiratory, digestive, urinary, and reproductive tracts. As long as these barriers remain unbroken, many invaders



cannot penetrate them. A break in any of these barriers increases the chance of contamination-for example, an extensive burn damages much of the skin, leaving it prone to contamination. In addition, secre­ tions containing enzymes that can destroy bacteria defend the barriers. Examples are tears in the eyes and secretions in the digestive tract and vagina. The next line of protection includes white blood cells (leukocytes) that travel through the bloodstream and into tissues, seeking and attacking microorganisms and other invaders. This protection has two parts:


Nonspecific (innate) immunity: the first step, which involves different types of leukocytes that on most occasions act on their own to destroy invaders. Specific (adaptive) immunity: the second step, which involves leukocytes working together to destroy invaders. Some of these cells do not destroy invaders themselves but enable other white blood cells to recognize and destroy invaders.

Nonspecific immunity and specific immunity interact with and impact each other either directly or through substances that attract or activate other cells of the immune system. These substances include cytokines (the messengers of the immune system), antibodies, and complement proteins (a part of the complement system). These sub­ stances dissolve in a body fluid, such as plasma, the liquid part of blood. To be effective, the immune system must be able to distinguish what is nonself(foreign) from what is self. Identification molecules on the exterior of all human cells-human leukocyte antigens (HLA), or the major histocompatibility complex (MHC)-make this distinction possible. Each individual has unique human leukocyte antigens. Any cell with molecules on its surface that are not identical with those of the body's own cells provokes an attack from the immune system.

T-lymphocytes provide the surveillance part of the immune system. They travel through the bloodstream and lymphatic system (see Chapter 11), looking for foreign substances (antigens) in the body. However, unless an antigen undergoes processing into antigen frag­ ments by another white blood cell, called an antigen-presenting cell, a T-lymphocyte cannot recognize it. Antigen-presenting cells consist of dendritic cells (which are the most effective), macrophages, and B-lymphocytes. A special molecule called a T-cell receptor, found on the exterior of a T-lymphocyte, recognizes the antigen fragment when an HLA mol­ ecule presents it. The T-cell receptor then attaches to the part of the HLA molecule presenting the antigen fragment, fitting in it as a key fits in a lock.

The immune system includes several organs as well as cells scattered throughout the body classified as primary or secondary lymphoid organs.




Primary: the thymus gland and bone marrow-the sites of white blood cell production. • Production and preparation of the T-lymphocytes (necessary for specific immunity) occur in the thymus gland. • The bone marrow produces several types of white blood cell, including neutrophils, monocytes, and B lymphocytes. Secondary: spleen, tonsils, liver, appendix, and Peyer's patches in the small intestine. These organs trap microorganisms and other foreign substances and provide a place for mature cells of the immune system to collect, interact with one another and with the foreign substances, and produce a specific immune response.

In immunodeficiency, the immune response is absent or depressed. Autoimmune diseases manifest as a self-destructive immune system response directed against normal tissue. Autoimmune diseases can develop according to involvement:


Organ specific: for example, Hashimoto's thyroiditis, Addison's disease, Crohn's disease, diabetes mellitus, and ulcerative colitis. Nonorgan specific (systemic): for example, systemic lupus ery­ thematosus (SLE), fibromyalgia, ankylosing spondylitis, multi­ ple sclerosis, psoriasis, Reiter's syndrome, and sarcoidosis.

The etiology of autoimmune diseases is often unknown. Possible causes include a genetic predisposition, hormonal changes, and envi­ ronmental, viral infection, or stress. Added risk factors include immuno­ compromised patients, those individuals with poor physiologic and psychological health, the elderly, or those who have a coexistence of other diseases or conditions. The main causes of immunodeficiency can be grouped into primary, secondary, or iatrogenic disorders:

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Primary disorders: a defect involving T-cells, B-cells, NK cells, phagocytic cells, complement proteins, or lymphoid tissues. Genetically determined immunodeficiency can cause increased susceptibility to infection, autoimmunity, and increased risk of cancer. Secondary disorders: result from an underlying disease or cause that depresses or blocks the immune response. These include: • Leukemia or Hodgkin's disease. • Nonspecific deficiencies in the immune system, which occur because of viral and other infections, malnourishment, alcoholism, cancer, chronic disease, chemotherapy, and radiation. • Autoimmune disease, diabetes mellitus, renal disease. • Acquired immunodeficiency syndrome (AIDS). • Organ transplantation-graft versus host disease. Iatrogenic disorders: induced by immunosuppressive drugs, or radiation therapy. Examples of immunosuppressive drugs include corticosteroids, cyclosporine, and cytotoxic drugs.



With the exception of bone tissue, all other tissues of the body can be referred to as soft tissue. Injuries to the soft tissues can be classified as primary or secondary:





Primary injuries can be self-inflicted, caused by another indi­ vidual or entity, or caused by the environment. Primary injuries can be subclassified into acute, chronic, or acute on chronic: • Acute. Acute injuries occur as the result of a sudden over­ loading of the musculoskeletal tissues (macrotrauma). Macrotraumatic injuries include fractures, and dislocations, which are outside the scope of practice for a physical ther­ apist; and subluxations, sprains (acute injury to a ligamenO, and strains (injury to a muscle), which make up the major­ ity of conditions seen in the physical therapy clinic. In addi­ tion, the clinician may also treat contusions that result from excessive compression to the soft tissues with resultant dis­ ruption of the muscle fibers and intramuscular bleeding. 142 Excessive tension to the soft tissues is borne by the colla­ gen within the tissue. While collagen fibers have the abil­ ity to elongate, if stretched sufficiently, sequential failure occurs. • Chronic. Chronic, or overuse injuries occur as the result of a cumulative repetitive overload, incorrect mechanics, and/or frictional resistance (microtrauma). These microtrau­ matie injuries include tendinitis, tenosynovitis, bursitis, and synovitis. • Acute on chronic. This type of injury presents as a sudden rupture of a previously damaged tissue and can occur when the load applied to a tissue is too great for the level of tissue repair or remodeling. Secondary injuries are essentially the inflammatory response that occurs with the primary injury. 3 A number of factors can have an impact on healing. These include the following. Local factors: • The degree of tissue damage. • The type and size of wound. • The type of tissue involved. • The presence of swelling. • The presence of infection. • The blood supply to the injured site. • The amount of stress applied to tissue. • The degree of wound stabilization.
Systemic factors:
• Age. • Comorbidities. • Nutritional state. • Obesity.
Extrinsic factors:
• Medications. • Temperature. • Humidity.



Fortunately, the majority of soft-tissue injuries heal without complica­ tion in a predictable series of events. However, when healing abnor­ malities occur, due to such complications as infection, compromised circulation, and neuropathy, they can cause great physical and psy­ chological stress to the involved patients and their families. Wounds are conventionally classified as superficial or deep:


Superficial. As their name suggests, superficial wounds 143 involve those tissues close to the skin surface. The healing of superficial wounds involves only the replacement of the ger­ minating layer by re-epithelialization. Deep. Damage to deeper tissues,143 including a surgically induced wound, triggers a more complicated chain of events involving both physical and chemical activities. This chain of events can be conveniently divided into stages or phases (Table 5-31): • Coagulation and inflammation. This stage is initiated almost immediately following injury and represents the normal immune system reaction to injury-a series of defensive events that involves the recognition of a pathogen and the mounting of a reaction against it. o Coagulation. Involves temporary repair. Apart from an initial period of vasoconstriction lasting for 5 to 10 minutes, tissue injury causes vasodilation, the disruption of blood vessels, and extravasation of blood constituents. 144 Extravasated blood contains platelets, which secrete substances that attract and activate macrophages and fibroblasts. 14~ Coagulation and platelet release results in the excretion of platelet-derived growth factor (PDGF),146 platelet fac10r 4,147 transforming growth factor-a (TGF_a),148 and transforming growth factor-[3 (TGF-[3).149 The main functions of a cell­ rich tissue exudate are to proVide cells capable of produc­ ing the components and biologic mediators necessary for the directed reconstruction of damaged tissue while dilut­ ing microbial toxins and removing contaminants present in the wound. 150 o Inflammation. Inflammation is mediated by chemotactic substances, including anaphylatoxins. Anaphylatoxins serve to attract neutrophils and monocytes:


Coagulation and inflammation (acute) Migratory and proliferative (subacute) Remodeling (chronic)

Area is red, warm, swollen, and painful Pain is present without any motion of involved area Usually lasts 48-72 hours, but can last as long as 7-10 days Pain usually occurs with activity or motion of involved area Usually lasts 10 days to 6 weeks Pain usually occurs after activity Usually lasts 6 weeks to 12 months



Neutrophils. Neutrophils are white blood cells of the poly­ morphonuclear (PMN) leukocyte subgroup (the others being eosinophils and basophils) that are filled with gran­ ules of toxic chemicals (phagocytes) that enable them to bind to microorganisms, internalize them, and kill them. Monocytes. Monocytes are white blood cells of the mononuclear leukocyte subgroup (the other being lym­ phocytes). The monocytes migrate into tissues and develop into macrophages, and provide immunologic defences against many infectious organisms. Macrophages serve to orchestrate a "long-term" response to injured cells subse­ quent to the acute response. l5l The white blood cells of the inflammatory stage serve to clean the wound of foreign substances, increase vascular permeability, and promote fibroblast activity.l5l The extent and severity of the inflammatory response depends on the size and the type of the injury, the tissue involved, and the vascularity of that tissue.152-156 Local vasodilation is pro­ moted by biologically active products of the complement and kinin cascades. 150 The complement cascade involves 20 or more proteins that circulate throughout the blood in an inactive form. 150 After tissue injury, activation of the complement cascade pro­ duces a variety of proteins with activities essential to healing. The kinin cascade is responsible for the transformation of the inactive enzyme kallikrein, which is present in both blood and tissue, to its active form, bradykinin. Bradykinin also contributes to the production of tissue exudate through the promotion of vasodilation and increased ves­ sel wall permeability.157 • Migratory and proliferative stage. This stage, which begins within days and includes the major processes of healing, is responsible for the development of wound tensile strength. A collagenous matrix facilitates angiogenesis by providing time and protection to new and friable vessels. The process of neovascularisation during this phase provides a granular appearance to the wound due to the formation of loops of capillaries and migration of macrophages, fibroblasts, and endothelial cells into the wound matrix. • Remodeling. The remodeling phase of wound healing involves a conversion of the initial healing tissue to scar tis­ sue. This lengthy phase of contraction, tissue remodeling, and increasing tensile strength in the wound lasts for up to a year.144.154,161-164 The application of controlled stresses to the new scar tissue must occur during this stage to help prevent it from shortening. 144,156 If the healing tissues are kept immo­ bile, the fibrous repair is weak, and there are no forces influ­ encing the collagen. Scarring that occurs parallel to the line of force of a structure is less vulnerable to reinjury than a scar, which is perpendicular to those lines of force. 165 Whereas simplification of the complex events of healing into these separate categories may facilitate understanding of the phenomenon, in reality these events occur as an amalgamation of different reactions,

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Inflammatory stage of healing iscl1ar~; acteriled by swellin& redness, heat, and impairment or loss of fu ·1l.The edema is due to an incre permeability of the venules, proteins, and leukocytes, whi into the site of injury.158,159 Ustially there is pain at rest or withaetive moti~j or when specific stress is applied to the injured structure. The pain, if severe enough, can result in muscle. guarding is and a loss of function . .If this.. Ii> interrupted or delayeg, ·chronlc am~ mation can result,lastingfrorrlrnot'1thsto years.

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Upon progressing to migratory and proliferative stage, the "active" effu­ sion and local erythema of the inflam· matory stage are usually no longer present. However, residual effusion may still be present at this time and resist resorption. 2o,16o



TABLE 5-32. THE EFFECT OF HORMONES ON HEALING HORMONE Glucocorticoids Calcitonin Thyroid hormone Parathyroid hormone Growth hormone EFFECT ON HEALING Negative
MECHANISM Decreased callus proliferation Decreased osteoclastic activity Increases rate of bone remodeling Increases rate of bone remodeling Increases amount of callus

Reproduced, with permission, from Frenkel SR, Koval KJ. Fracture healing and bone grafting. In: Spivak ]M, Di Cesare PE, Feldman DS, et aI., eds. Orthopaedics: A Comprehensive Study Guide. New York: McGraw-Hill; 1999:23--28.

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both spatially and temporally.150 Certain factors appear to determine the prognosis for healing (Tables 5-32 and 5-33).14 The most important factor regulating the regional time line of healing is sufficient blood flow. 144

Skeletal muscle has considerable regenerative capabilities, and the process of skeletal muscle regeneration after injury is a well-studied cascade of events. 167-169 The capacity for regeneration is based prima­ rily upon the type and extent of injury.142,170 The essential process of muscle regeneration is similar irrespective of the cause of injury, but the outcome and time course of regeneration vary according to the type, severity, and extent of the injury.167 Broadly speaking, there are three phases in the healing process of an injured muscle: the destruction phase, the repair phase, and the remodeling phase. 171

Destruction Phase. The muscle fibers and their CT sheaths are totally disrupted and a gap appears between the ends of the ruptured muscle fibers when the muscle fibers retract,169 This phase is charac­ terized by the necrosis of muscle tissue, degeneration, and an infiltra­ tion by PMN leukocytes as hematoma and edema form at the site of injury.

TABLE 5-33. PROGNOSTIC FACTORS FOR MUSCLE INJURY PARAMETER Site Severity POSITIVE PROGNOSTIC FACTORS Belly tears Intermuscular contusions Partial tears (first degree plus mild second degree) First injury Minimal loss of range Minimal swelling Little pain Usually preserved function Compartment syndrome rare Myositis ossificans less likely Often complete resolution Early resolution expected NEGATIVE PROGNOSTIC FACTORS Musculotendinous junction tears Intramuscular contusions Complete tears (severe second-degree and third-degree tears) Retear Significant loss of range Obvious tense swelling Extreme pain Loss of function Compartment syndromes with large hemorrhages Myositis ossificans more prevalent Tendency for recurrent tears Prolonged disability possible

Clinical signs


Reproduced, with pennission, from Reid DC. SPOrls Injury Assessment and Rehabilitation. New York: Churchill Uvingstone; 1992. Copyright © Elsevier.



Repair Phase. The repair phase usually involves the following
steps: • Hematoma formation. The gap between the ruptured ends of the fibers is at first filled by a hematoma. During the first day, the hematoma is invaded by inflammatory cells including phagocytes, which begin disposal of the blood clot. 169 • Matrix formation. Blood-derived fibronectin and fibrin cross­ link to form a primary matrix, which acts as a scaffold and anchorage site for the invading fibroblasts. 168,169 The matrix gives the initial strength for wound tissue to withstand the forces applied to it. 172 Fibroblasts begin to synthesize proteins of the extracellular matrix. • Collagen formation. The production of type I collagen by fibroblasts increases the tensile strength of the injured muscle. An excessive proliferation of fibroblasts can rapidly lead to an excessive formation of dense scar tissue, which creates a mechanical barrier that restricts or considerable delays com­ plete regeneration of the muscle fibers across the gap.169,171 During the first week of healing, the injury site is the weakest point of the muscle-tendon unit. This phase also includes regeneration of the striated muscle, production of a connective-tissue scar, and cap­ illary ingrowth. The regeneration of the myofibers begins with the acti­ vation of satellite cells, located between the basal lamina and the plasma membrane of each individual myofiber. 173 Satellite cells, myoblastic precursor cells, proliferate to reconstitute the injured area. 170 During muscle regeneration, it is presumed that trophic substances released by the injured muscle activate the satellite cells. 174 Unlike the multinucleated myofibers, these mononuclear cells maintain mitotic potential and respond to cellular signals by entering the cell cycle to provide the substrate for muscle regeneration and growth. 173 The satellite cells proliferate and differentiate into multinucleated myotubes and eventually into myofibers, which mature and increase in length and' diameter to span the muscle injury. Many of these myoblasts are able to fuse with existing necrosed myofibers and may prevent the muscle fibers from completely degenerating. 173 The final stage in the regenerative process involves the integration of the neural elements and the formation of a functional neuromuscular junction. 175 ,176 Provided that the continuity of the muscle fiber is not dis­ rupted and the innervation, vascular supply, and extracellular matrix are left intact, muscle will regenerate with no loss of normal tissue archi­ tecture and functiony7

Remodeling Phase. In this phase, the regenerated muscle matures and contracts with reorganization of the scar tissue. There is often incomplete restoration of the functional capacity of the injured muscle. The pathology of skeletal muscle damage varies depending upon the initiating cause. Muscle damage can occur during the prolonged immobility of hospitalization or from external sources such as mechan­ ical injury.178 One of the potential consequences of immobility is atro­ phy. The amount of muscle atrophy that occurs depends on the usage prior to bed rest and the function of the muscle. 178 Antigravity muscles



(such as the quadriceps) tend to have greater atrophy than antagonist muscles (such as the hamstrings). Research has shown that a single bout of exercise protects against muscle damage, with the effects last­ ing between 6 weeks 179 and 9 months. 180 Muscle resistance to damage may result from an eccentric exercise-induced morphologic change in the number of sarcomeres connected in series. l8l This finding appears to support initiating a reconditioning program with gradual progres­ sion from lower-intensity activities with minimal eccentric actions to protect against muscle damageY8,182

The process of ligament and tendon healing is complex. Healing of lig­ aments and tendons generally can be broken down into four overlap­ ping phases.

Phase I: Hemorrhagic. After disruption of the tissue, the gap is filled quickly with a blood clot. PMN leukocytes and lymphocytes appear within several hours, triggered by cytokines released within the clot. The PMN leukocytes and lymphocytes respond to autocrine and paracrine signals to expand the inflammatory response and recruit other types of cells to the woundy6 Phase II: Inflammatory. Macrophages arrive by 24 to 48 hours and are the predominant cell type within several days. Macrophages perform phagocytosis of necrotic tissues, and also secrete multiple types of growth factors that induce neovascularization and the forma­ tion of granulation tissue. By the third day after injury, the wound con­ tains macrophages, PMN leukocytes, lymphocytes, and multipotential mesenchymal cells, and platelets. Platelets have been shown to release PDGF, TGF-/3, and EGF. Macrophages produce bFGF, TGF-a, TGF-/3, and PDGF. These growth factors are not only chemotactic for fibrob­ lasts and other cells, but also stimulate fibroblast proliferation and the synthesis of types I, III, and V collagen and noncollagenous proteins. 183,184 Phase III: Proliferation. The last cell type to arrive within the wound is the fibroblast. Although debate continues, it currently is thought that fibroblasts are recruited from neighboring tissue and the systemic circulation. 18s These fibroblasts have abundant rough endo­ plastic reticulum and begin producing collagen and other matrix pro­ teins within 1 week of injury. By the second week after disruption, the original blood clot becomes more organized because of cellular and matrix proliferation. Capillary buds begin to form. Total collagen con­ tent is greater than in the normal ligament or tendon, but collagen con­ centration is lower and the matrix remains disorganized. Phase IV: Remodeling and Maturation. Phase IV is marked by a gradual decrease in the cellularity of the healed tissue. The matrix becomes denser and longitudinally oriented. Collagen turnover, water content, and the ratio of collagen types I to III begin to approach normal levels. 186 An integrated sequence of biochemical and biomechanical signals is critical to ligament remodeling. These signals regulate the expression of structural and enzymatic proteins, including degradation enzymes such as collagenase, stromolysin, and plasminogen



activator. 183 1he healed tissue continues to mature for many months, but will never attain normal morphologic characteristics or mechanical properties. Ligament injuries can take as long as 3 years to heal to the point of regaining near-normal tensile strength,187 although some ten­ sile strength is regained by about the fifth week follOWing injury, depending on the severity. 163.18&-190 A ligament may have 50% of its nor­ mal tensile strength by 6 months after injury, 80% after 1 year, and 100% only after 1 to 3 years.191-193 Forces applied to the ligament dur­ ing its recovery help it to develop strength in the direction that the force is applied.191-195

It is well known that the capacity of articular cartilage for repair is lim­

ited. Cartilage cells, or chondrocytes, are responsible for the mainte­ nance of the cartilage matrix. The repair response of articular cartilage varies with the depth of the injury. Injuries of the articular cartilage that do not penetrate the sub­ chondral bone become necrotic and do not heal. These lesions usually progress to the degeneration of the articular surface. 196 Although a short-lived tissue response may occur, it fails to proVide sufficient cells and matrix to repair even small defects.197.198 Injuries that penetrate the subchondral bone undergo repair due to access to the bone's blood supply. These repairs are usually char­ acterized as fibrous, fibrocartilaginous, or hyaline-like cartilaginous, depending on the species, the age of the animal, and the location and size of the injury.199 However, these reparative tissues differ from normal hyaline cartilage both biochemically and biomechanically. 1hus, by 6 months, fibrillation, fissuring, and extensive degenerative changes occur in the reparative tissues of approximately half of the full-thickness defects. 200 ,201 Similarly, the degenerated cartilage seen in osteoarthrosis does not usually undergo repair but progressively deteriorates. 196 Current surgical treatment for damaged cartilage may consist of debridement or removal of loose flaps or pieces of cartilage, abrasion! burr arthroplasty at the site of the lesion, or subchondral drilling. An experimental technique undergoing active investigation is the transplantation of chondrocytes or chondrogenic cells. 202 ,203

Two pathways for healing in response to a tear in the periphery of the meniscus are described: extrinsic and intrinsic.

Extrinsic Pathway. Once a meniscal tear occurs, a fibrin dot forms within its margins, creating a scaffold into which angiogenesis develops from the perimeniscal capillary plexus. The fibrin dot con­ tains factors, such as platelet-derived growth factor and fibronectin, that act as chemotactic and mitogenic agents for reparative cells to migrate and develop. Undifferentiated mesenchymal cells also migrate into the dot and a fibrovascular scar develops, gradually sealing the lesion. Further inflammatory response and angiogenesis result in heal­ ing of the lesion in about 10 weeks in the dog. It may take months or even years for the scar tissue to change into fibrocartilage resembling that of the meniscus. Differences between the



newly formed fibrocartilage and mature fibrocartilage are recognizable and include increased cellularity and, at times, increased vascularity in the repair tissue.

Intrinsic Pathway. The chondroeytes within the meniscus have an inherent capability to generate a healing response, even in the avas­ cular region. Chondrocytes are assisted by the fibrin clot, which not only acts as a scaffold but also provides the chemotactic and mitogenic stimuli to promote healing.
Bone healing is a complex physiologic process. The striking feature of bone healing, compared to healing in other tissues is that repair is by the original tissue, not scar tissue. Regeneration is perhaps a better descriptor than repair. This is linked to the capacity for remodeling that intact bone possesses. Like other forms of healing, the repair of bone fracture includes the processes of inflammation, repair, and remodel­ ing; however, the type of healing varies depending on the method of treatment. In classic histologic terms, fracture healing has been divided into two broad phases: primary fracture healing and secondary fracture healing.


Primary healing, or primary cortical healing, involves a direct attempt by the cortex to reestablish itself once it has become interrupted. In primary cortical healing, bone on one side of the cortex must unite with bone on the other side of the cortex to reestablish mechanical continuity. Secondary healing involves responses in the periosteum and external soft tissues with the subsequent formation of a callus. The majority of fractures heal by secondary fracture healing.

Within these broader phases, the process of bone healing involves a combination of intramembranous and endochondral ossification. These two processes participate in the fracture repair sequence by at least four discrete stages of healing: the hematoma formation (inflam­ mation or granulation) phase, the soft callus formation (proliferative) phase, the hard callus formation (maturing or modeling) phase, and the remodeling phase. 204


Hematoma formation (inflammation or granulation) phase. This phase is characterized by the release of a variety of prod­ ucts, including fibronectin, platelet-derived growth factor (PDGF), and transforming growth factor (TGF), by the acti­ vated platelets. These products trigger the influx of inflamma­ tory cells. Soft callus formation (proliferative) phase. This phase is char­ acterized by the formation of connective tissues, including car­ tilage, and formation of new capillaries from preexisting vessels (angiogenesis). During the first 7 to 10 days of fracture healing, the periosteum undergoes an intramembranous bone forma­ tion response and histologic evidence shows formation of woven bone opposed to the cortex within a few millimeters from the site of the fracture. By the middle of the second week,





abundant cartilage overlies the fracture site and this chondroid tissue initiates biochemical preparations to undergo calcifica­ tion. Thus, the callus becomes a three-layered structure con­ sisting of an outer proliferating part, a middle cartilagenous layer, and an inner portion of new bony trabeculae. The car­ tilage portion is usually replaced with bone as the healing progresses. Hard callus formation (maturing or modeling) phase. This phase is characterized by the production of woven bone. The calcification of fracture callus cartilage occurs by a mechanism almost identical to that which takes place in the growth plate. This can occur either directly from mesenchymal tissue (intramembranous) or via an intermediate stage of cartilage (endochondral or chondroid routes). Osteoblasts can form woven bone rapidly, but it is randomly arranged and mechani­ cally weak. Nonetheless, bridging of a fracture by woven bone constitutes "clinical union." Once cartilage is calcified, it becomes a target for the ingrowth of blood vessels. Remodeling phase. By replacing the cartilage with bone, and converting the cancellous bone into compact bone, the callus is gradually remodeled. During this phase, the woven bone is remodeled into stronger lamellar bone by the orchestrated action of osteoclast bone resorption and osteoblast bone formation.

Radiologically, or histologically, fracture gap bridging occurs by three mechanisms 204 :



Intercortical bridging (primary cortical union). This occurs when the fracture gap is reduced by normal cortical remodel­ ing under conditions of rigid fixation. This mode of healing is the principle behind rigid internal fixation. 205 External callus bridging by new bone arising from the perios­ teum and the soft tissues surrounding the fracture. Small degrees of movement at the fracture stimulate external callus formation. 206 This mode of healing is the aim in functional bracing 207 and intrameduallary OM) nailing. Intramedullary bridging by endosteal callus.

Normal periods of immobilization following a fracture range from as short as 3 weeks for small bones to around 8 weeks for the long bones of the extremities. During the period of casting, submaximal iso­ metrics are initiated, and once the cast is removed it is important that controlled stresses continue to be applied to the bone, as the period of bone healing continues for up to a year. 208,209 According to Wolff's law, bone remodels along lines of stress. 2lO Bone is constantly being resorbed and replaced as the resorption of circumferential lamellar bone is accomplished by osteoc!asts, and replaced with dense osteonal bone by osteoblasts. 2l1 Some fractures heal more slowly than expected or fail to heal at all. Slow healing is known as delayed union, and failure to heal is known as nonunion. When a fracture fails to heal, college or fibrocar­ tilage forms over the fracture surfaces (pseudoarthrosis) and a cavity between the fracture surfaces fills with fluid that resembles normal joint or bursal fluid. 24



The two key determinants of if and how a fracture will heal are the blood supply and the degree of motion experienced by the fracture ends. .. Blood supply: Angiogenesis is the outgrowth of new capillaries from existing vessels. The degree of angiogenesis that occurs depends on well-vascularized tissue on either side of the gap and sufficient mechanical stability to allow new capillaries to suxvive. Angiogenesis leads to osteogenesis. .. The amount of movement that occurs between fracture ends can be stimulatory or inhibitory depending on their magnitude. Excessive interfragmentary movement prevents the establish­ ment of intramedullary blood vessel bridging. However, small degrees of micromotion have been shown to stimulate blood flow at the fracture site and stimulate periosteal callus. 212 A frac­ ture that is rigidly internally fixed produces no periosteal callus, and heals by a combination of endosteal callus and primary cortical union. 204 An 1M nail blocks endosteal healing but allows enough movement to trigger periosteal callus. 204 External fixation, particularly with fine wires in a circular fixa­ tor, is least damaging to the medullary blood supply.204 This type of fixation may provide enough stability to allow rapid endosteal healing without external callus. 213

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delayed frac~ fudetUabetes melJi­ ptechl stemid use, antlr'fOflamrnat<;>rydrugs (NS1\I~)af)(iQtf'1erme<:tica,~lpns, and

The role of diagnostic imaging in physical therapy is rapidly evolving, although the availability or access to diagnostic images varies greatly depending on the practice setting. Diagnostic imaging should not be used as a substitute for the normal procedures of patient management, but instead as an adjunct and in context with the results from the tests and measures. Although the ordering of imaging studies is not within the scope of physical therapy practice (with the exception of PTs in the u.s. Army who have primary care physical therapy provider credentials), clini­ cians frequently receive imaging study reports (Table 5-34). Thus, it is important for the clinician to know what relevance to attach to these reports, and the strengths and weaknesses of the various imaging tech­ niques. In general, imaging tests have a high sensitivity (few false neg­ atives) but low specificity (high false-positive rate).

Radiographs may show fractures or other conditions, such as osteoarthritis, disk disease, or spondylolisthesis. Radiograph findings depend somewhat on technique and exposure. X-rays, which use ion­ izing radiation to produce an image on specialized film, are part of the electromagnetic spectrum and have the ability to penetrate through body tissues of varying densities. Limiting exposure to ionizing radia­ tion is an important aspect of diagnostic radiology. Body parts that will be exposed to radiation but are of no interest regarding the differential diagnosis should be adequately shielded with lead garments. Selection of the appropriate view can also help limit radiation exposure. The amount of beam that is absorbed is dependent on the density of the tissue. The f1lm plate is positioned to capture the particles of the beam



TABLE 5-34. STRENGlliS AND WEAKNESSES OF VARIOUS IMAGING STUDIES IMAGING STUDY Plain-fIlm, or conventional radiograph ADVANTAGES Helpful in detecting fractures and subluxations in patients with a history of trauma. Highlights the presence of degenerative joint disease. Helpful in assessing spinal mobility and stability in the spine. Outlines the soft-tissue structures of a joint that would otherwise not be visible with a plain-film radiograph. Good for detecting internal derangements. Provides image of the spinal cord, nerve roots, dura mater, and the spinal canal. Provides good visualization of the shape, symmetry, and position of structures by delineating specific areas. Quicker scan than MRI. Better detail of bone than MRl. Excellent tissue contrast. No streak artifacts. Ability to provide cross-sectional images. Noninvasive nature. Complete lack of ioniZing radiation. Can take images of any plane. Readily available. Noninvasive. Much less expensive than CT or MRl. Can be used in any plane (sagittal, coronal, axial, and at any obliquity). Can detect soft-tissue injuries, tumors, bone infectiOns, bone mineral density, and arthropathy. DISADVANTAGES Does not proVide an image of soft-tissue structures such as muscles, tendons, ligaments, and intervertebral disks. Patient may not tolerate stress pOSition. Mildly invasive. May require imaging guidance to place the needle. Potential for a post-myelogram headache. Potential for seizure (rare). Generally limited to axial plane. Soft-tissue contrast not as good as MRl.

Stress radiograph Arthrogram

Myelography Computed tomography (CD

Magnetic resonance imaging (MRl)

Diagnostic ultrasound

Expensive. Time consuming. Poor visualization of cortical bone detail or calcifications. Limited spatial resolution compared with CT. Not a sharp, clear image compared to images produced by other radiologic modalities. Because of the degrees of obliquity, one cannot easily tell what one is looking at without knowledge of cross-sectional anatomy; sonographer identifies anatomic segment. Visualization of structures limited by bone and gas (lung, bowel).

that are not absorbed by the tissues of the body. Tissues of greater den­ sity allow less penetration of the x-rays. Exposure to the x-ray particles causes the fUm to darken, whereas areas of absorption appear lighter on the ftlm. The denser a tissue is, the lighter it appears on the flim. The following structures are listed in order of descending density: metal, bone, soft tissue, water or body fluid, fat, and air. Because air is the least dense material in the body, it absorbs the least amount of x-ray particles, resulting in the darkest portion of the film. Bone can have varying densities within the body. For example, cancellous bone is less dense than cortical bone and thus appears lighter than the cortical bone on the radiograph. When evaluating radiographs, the clinician should use a system­ atic method. One such system uses the mnemonic ABCS 167 :
.. A: Architecture or alignment. The normal shape of each bone

should be apparent. The outline of each bone should be smooth and continuous. Breaks in continuity usually represent fractures.



Study Pearl
mineral density (BMO) is con­
.best predictor of fracture
risk. Although measurement at any
site can be used to assess overall frac­
ture riskl measurement at a particular site is the best predictor of ·fracture risk at that site.. BMO is reported as a . T-score, which compares tl BMO to that of a hea criteria proposed by the Organization (WHO), a mal value is within 1 s deviation (SO) of a young adu greater than -1 SO. • T-score of -1 to -2.5 SO-By def­ inition indicates osteopenia. • T-score of less than -2.5 SO-By definition indicates osteoporosis. • T-score of less than - 2.5 SO with fragility fracture(s)-By definition indicates severe osteoporosis.

• B: Bone density. The cortex of the bone should appear denser than the remainder of the bone. Subchondral bone becomes sclerosed in the presence of stress in accordance with Wolffs law214 and increases its density. • C: Cartilage spaces. Each joint should have a well-preserved joint space between the articulating surfaces. A decreased joint space typically indicates osteoarthritis. • S: Soft tissue evaluation. Trauma to soft tissues produces abnormal images, resulting from effusion and distention.

Conventional Radiography. Plain-film, or conventional, radi­
ographs are relatively inexpensive and give an excellent view of corti­ cal bone. They are thus very helpful in detecting fractures and sublux­ ations in patients with a history of trauma. 215 For example, in patients with cervical trauma, the physician often orders lateral, anterior-posterior, and oblique views, together with an open-mouth view (Table 5-35). Radiographs also may be used to highlight the presence of degenera­ tive joint disease, which is characterized by an approximation of the joint surface on the radiograph. However, radiographs do not provide an image of soft tissue structures such as muscles, tendons, ligaments, and intervertebral disks. • Plain radiography is not as accurate as bone mineral density (BMD) testing for diagnosing or detecting osteoporosis. • Radiographs may be more specific than MRI in differentiating potential causes of bony lesions because of the proven ability to characterize specific calcification patterns and periosteal reactions. However, plain radiographs are not considered sensItive to the early changes associated with tumors, infections, and some fractures. 216

Stress Radiograph. Flexion and extension views can be helpful
in assessing spinal mobility and stability in the rest of the spine and should be ordered in the acutely injured athlete when there is a high degree of suspicion of spine injury. Greater than 2 mm of motion at any segment would suggest instability and warrant further examination. A stress radiograph is a procedure using radiographs taken while the stress is applied to a joint. An unstable joint demonstrates widening of the joint space when the stress is applied.

Contrast-Enhanced Radiography. Contrast-enhanced radi­
ography procedures involve the use of a contrasting agent to highlight different structures. These agents may be administered orally, rectally, or by injection. Different contrast media may be used and include radiopaque organic iodides and radiotranslucent gases. Contrast­ enhanced radiography procedures include: • Arthrography-the study of structures within an encapsulated joint using a contrast medium, with or without air that is injected into the joint space. The contrast medium, such as iodide, dis­ tends the joint capsule. This type of radiograph is called an arthrogram. An arthrogram outlines the soft-tissue structures of a joint that would otherwise not be visible with a plain-film radiograph. Arthrography is most often conducted at the wrist,

TABLE 5-35. RADIOGRAPHIC VIEWS, STRUCTURES IMAGED, AND TYPICAL PATHOLOGIC CONDITION BY BODY REGION REGION Cervical spine RADIOGRAPHIC VIEW AP open mouth STRUCTURES IMAGED Odontoid process, body of axis, lateral masses of atlas and atlantoaxial joint COMMON PATHOLOGIC CONDITION Fractures of the upper cervical spine, asymmetrical location of the dens between the lateral masses indicating ligamentous stretching or injury Fractures of C3 to C7; disk space changes and pathology of the uncovertebral joint Fractures, dislocations, postural curves and contour lines, alignment changes, spondylitic changes Unstable joint segments from ligamentous injury Narrowing and degenerative changes of the intervertebral foramina and apophyseal joint Fractures of C7 to T2 Fractures of the proximal humerus and glenoid; changes in humeral head position from rotator cuff tears or glenohumeral dislocations; osteoarthritis, calcific tendinitis, or bursitis Hill-Sachs lesion Compression fracture of the humeral head usually associated with posterior dislocation Anterior and posterior glenohumeral dislocations; fractures of the proximal humerus and scapula Anterior and posterior glenohumeral dislocations; pathology of the anterior inferior glenoid Ligamentous instability of the AC joint or SC joint; fractures of the clavicle Fractures of the scapula Fractures of the scapula Fractures of the humerus; myositis ossificans of the anterior compartment Fractures of the proximal humerus Fractures of the distal humerus and proximal radius and ulna; dislocations of the elbow; ligamentous avulsions with bony attachment; varus and valgus deformities; heterotopic bone formations (Continued)

AP Lateral (standing, seated, or supine cross table) Lateral flexion-extension Obliques Swimmer's view AP

C3 to C7 spinous processes and vertebral bodies Occiput to C7


Occiput to C7 in active flexion and active extension Intervertebral foramina, facet joints, pedicles, and uncovertebral joints Best view of C7 to TI, prevents obstruction by shoulders Proximal humerus, lateral claVicle, AC joint, superior lateral aspect of the scapula

AP standing with arm in internal rotation AP standing with arm in external rotation Axillary, oblique West Point view Acromioclavicular (AC) joint Scapula AP bilateral with and without weight AP, lateral scapula Transcapular or Y view AP, lateral humerus Transthoracic lateral view AP

Humeral head in relation to the glenoid Humeral head in relation to the glenoid and the anterior inferior rim of the glenoid Both AC joints, both sternoclavicular joint~, clavicles Entire scapula, body of scapula Entire scapula; best view for comminuted and displaced fractures of the scapula Entire humerus True lateral view of the proximal humerus Distal humerus, proximal radius and ulna






TABLE 5-35. RADIOGRAPHIC VIEWS, STRUCTIJRES IMAGED, AND lYPICAL PATHOLOGIC CONDITION BY BODY REGION (Continued) REGION RADIOGRAPHIC VIEW Lateral STRUCTURES IMAGED Distal humerus, proximal radius and ulna COMMON PATHOLOGIC CONDITION Supracondylar fractures of the distal humerus, radial head fractures; fat pad sign; elbow dislocations Fractures of the coronoid process and medial epicondyle Fractures of the radial head, neck, tuberosity, and lateral epicondyle Fractures of the radial head, capitellum, coronoid process; joint abnormalities Fractures of the radius, ulna, wrist, and elbow Fractures of the wrist and hand; rheumatoid arthritis and osteoarthritis; avascular necrosis of the lunate or scaphoid; carpal instability Fractures of the vertebral bodies, posterior elements, and ribs; pneumothorax Fractures of the vertebral bodies and posterior elements; changes in postural alignment from scoliosis, fractures, and ligamentous disruptions; pedicle obliteration from tumors Fractures of the lamina and facets Fractures of the sternum and ribs; costosternal disruptions Fractures of the ribs Fractures of the vertebral bodies, end-plates, and posterior elements; disk space abnormalities Fractures of vertebral bodies, endplates, and posterior elements; vertebral alignment; disk space abnormalities Fractures of the vertebral bodies, endplates, and posterior elements; vertebral alignment; disk space abnormalities Fractures and defects in the pars interarticularis and articular facets Degenerative changes, ankylosis Fractures of the proximal femur, acetabulum, pubic rami, and ischial tuberosities; hip joint dislocations; slipped capital femoral epiphysis; Legg-ealve-Perthes disease; osteoarthritis Fractures of the femoral head and neck, greater and lesser trochanters

Internal oblique External oblique Radial head-capitellum Forearm Hand AP, lateral PA or dorsovolar, oblique, lateral AP

Best view of coronoid process Best view of radial head, neck, and tuberosity Best view of radial head, capitellum, and coronoid process Entire radius and ulna, wrist, elbow Distal radius and ulna to phalanges

Thoracic spine


T1-T12 vertebral end-plates, pedicles, and spinous processes; intervertebral disk spaces; costo­ vertebral joints; medial aspect posterior ribs Tl-Tl2 vertebral bodies, pedicles, and spinous processes; intervertebral disk spaces and foramina Facet joints, pedicles, and the pars interarticularis Sternum, axillary portion of the ribs Anterior and posterior aspects of the ribs Vertebral bodies and end-plates, transverse processes, intervertebral disk spaces, pedicles, and spinous processes Vertebral bodies, end-plates, and posterior elements; intervertebral disk spaces Vertebral bodies, end-plates, and posterior elements of L5 and Sl; L5-S1 intervertebral disk space Facet joints, lamina AP images bilateral SI]; obliques image unilateral SI] Acetabulum, femoral head and neck, greater trochanter, angle of inclination of the femoral neck to the shaft of the femur Femoral head and neck, proximal third of femur, acetabulum

Posterior oblique Anterior oblique (right) Ribs Lumbar spine AP, PA, AO, PO, PA chest AP


Coned down lateral spot

Obliques Sacroiliac joint (SIJ) AP axial, obliques Hip and pelvis AP unilateral or entire pelvis

Frog-leg lateral



Distal femur, proximal tibia, head of the fibula, tibiofemoral joint space

AP with valgus or varus stress Lateral with AP or PA stress Lateral

Relation of distal femur to proximal tibia Relation of distal femur to proximal tibia Relation of patella to femur; length of patella patellar ligament Intercondylar fossa, notch of popliteal tendon, tibial spines, intercondylar eminence, posterior aspects of the distal femur and proximal tibia, intercondylar eminence of tibia Patellar, femoral condyles Patellar, femoral condyles Shaft of tibia and fibula Distal tibia and fibula, body of the talus, tibiotalar joint Joint space between distal fibula and talus, ankle mortise Ankle mortise Distal tibia and fibula, calcaneus, tibiotalar and subtalar articulations Lateral malleolus, anterior tibial tubercle, distal tibiofibular syndesmosis, talofibular joint Medial and lateral malleoli, tibial plafond, dome of the talus, tibiotalar jOint, tibiofibular syndesmosis Talus, navicular, cuboid, cuneiforrns, metatarsals, phalanges Calcaneocuboid and talonavicular articulations, calcaneus, talus, subtalar joint Midtarsal joints to the phalanges

Notch or tunnel

Fractures of the patellar, tibial plateau, femoral condyles, distal femur, and proximal fibula; osteochondral fragments; osteoarthritis and rheumatoid arthritis; varus and valgus alignment Ligamentous instability; changes in articular cartilage thickness Ligamentous instability Osteochondral fractures, tibial apophysitis, quadriceps tendon ruptures, patellar ligament tears Osteochondral defects and loose bodies, fractures of the tibial spines

Sunrise axial Merchant axial Lower leg Ankle AP, lateral AP AP mortise

AP with inversion or eversion stress Lateral External oblique

Relation of patella to femoral condyles, subluxation and dislocation of the patellar, patellar fractures Preferred view of articular surface of the patellar, subtle dislocations Fractures and dislocations of the tibia and fibula Fractures of the distal tibia, fibula, and talus; dislocations and subluxations of the tibiotalar joint; osteoarthritis Fractures of the distal tibia and fibula; fractures of the talus Fractures and subluxations, mortise instability Fractures and dislocations of the distal tibia and fibula, talus, and calcaneus; osteoarthritis Fractures of the lateral malleolus, talus, and tuberosity of the calcaneus; disruptions of the distal tibiofibular syndesmosis Best view of pathology of the tibial plafond; fractures of the medial malleolus Fractures and dislocations of the foot Fractures and dislocations of the foot, heel spurs, osteoarthritis Fractures of the foot

Internal oblique Foot AP Lateral Oblique

Reproduced, with permission, from Deyle G. Diagnostic imaging in primary care physical therapy. In: Boissonnault WG, ed. Primary Care for the Physical Therapist: Examination and Triage. St. Louis: Elsevier W.B. Saunders; 2005:323--347. Copyright © Elsevier.

t-.l t-.l







shoulder, elbow, and ankle regions and is primarily used when MRI is contraindicated or when the details of intra-articular pathologic conditions such as a labral tear and articular carti­ lage lesions are desired. Myelography-the radiographic study of the spinal cord, nerve roots, dura mater, and spinal canal. The contrast medium is injected into the subarachnoid space, and a radiograph is taken. This type of radiograph is called a myelogram. Myelography is used frequently to diagnose intervertebral disk herniations, spinal cord compression, stenosis, nerve root injury, or tumors. The nerve root and its sleeve can be observed clearly on direct myelograms. When myelography is enhanced with computed tomography (Cn scanning, the image is called a CT myelogram. This modality produces axial cross-sectional images of the spine and enhances the distinction between the dural sac and its surrounding structures. 216 Diskography-the radiographic study of the intervertebral disk. A radiopaque dye is injected into the disk space between two vertebrae, into the nucleus pulposus. A radiograph is then taken. This type of radiograph is called a diskogram. An abnor­ mal dye pattern between the intervertebral disks indicates a rupture of the disk. The symptoms produced with the injection of the contrast material are often of greater diagnostic value than the images produced. 216 Angiography-the radiographic study of the vascular system. A water-soluble radiopaque dye is injected either intra-arterially (arteriogram) or intravenously (venogram). A rapid series of radiographs is then taken to follow the course of the contrast medium as it travels through the blood vessels. Angiography is used to help detect injury to or partial blockage of blood vessels.

Computer-assisted tomography (CT scans), also known as conven­ tional tomography, uses a fanlike beam of x-rays to provide an almost three-dimensional, or tomographic, image. The CT scan provides good visualization of the shape, symmetry, and position of structures by delineating specific areas. The images are usually sequentially taken through parallel planes until the desired area has been adequately imaged, and because the radiographic tube can move in complex angles and arcs it provides impressive imaging detail. Tomography per­ mits more accurate visualization of lesions too small (down to 1 mm) to be noted on conventional radiographs and can demonstrate anatomic detail obscured by overlying structures.This information can be helpful in the examination of acute fractures, aneurysms, infections, hematomas, cysts, and tumors. CT provides excellent cortical and tra­ becular definition that allows for detection and characterization of the complex geometry of triplane fractures as well as those fractures with suspected intra-articular extension. 217 Other uses for CT include inves­ tigating suspected visceral organ injuries, spine and extremity imaging, and head injuries. 216

Positron Emission Tomography (PET). A technique in which a radioactively labeled (positron-emitting isotope) molecule is used. One of these isotopes is incorporated into a biologically relevant



molecule and injected into or inhaled by the subject. It then concen­ trates in brain areas according to the molecule's chemistry and the brain's metabolic and blood flow demands. 218 These areas are detected when a positron is emitted from the molecule. Because a wide range of molecules can be used, PET can provide measurements of blood flow, blood volume, brain metabolism (especially glucose), and neu­ roreceptor or neurotransmitter chemistry. 218

Magnetic resonance imaging (MRI)216 uses the magnetic characteristics of the body's tissues rather than ionizing radiation to produce an image so that the resulting image is the result of the interaction of body tissues with electromagnetic forces. Patients are positioned in the scanner within a strong magnetic field that produces changes in the body's atoms. The ability of MRI to image of various parts of the body depends on the intrinsic spin of atoms with an odd number of neutrons or protons, thereby producing a magnetic moment. The atomic nuclei of tissues placed within the field align along the direc­ tion of the magnetic field. Stronger magnets are generally associated with better images, although there are some exceptions. The signal intensity refers to the strength of the radio waves at a tissue. The strength of the radio wave (RF) produces either bright (high) signal intensity or dark (low) signal intensity images. Signal intensity in a specific tissue will depend on the concentration of hydrogen ions as well as the Tl and T2 relaxation times. MR images are subsequently referred to as Tl or T2 weighted:


Tl images are obtained with RF pulses that have a short rep­ etition time and a short echo time. The Tl image, or longitu­ dinal relaxation, is used to describe the return of protons back to equilibrium after the application and removal of the RF pulse. • Shows subacute hemorrhage, fat, bone, and flUids contained in abscesses or cysts that contain high levels of protein as a bright intensity. • Useful for delineating the architecture of soft tissue such as marrow, fascia, and anatomic planes. The T2 image, or transverse relaxation time, is used to describe the associated loss of coherence or phase between individual protons immediately after the application of the RF pulse. • Fluid-containing structures such as bursae, inflamed ten­ dons, tumors, and abscesses, have a bright appearance on T2-weighted images.

The advantages of MRI include its excellent tissue contrast, abil­ ity to provide cross-sectional images, noninvasive nature, and com­ plete lack of ioniZing radiation. MRI provides an excellent view of anatomic and physiologic tissues. It commonly is used to assess the CNS and soft-tissue injuries. However, MRI studies are expensive and offer poor visualization of cortical bone compared to CT scans; CT scans also accurately analyze bone mineral content, proViding valu­ able information for the diagnosis and treatment of metabolic bone diseases. Contraindications for MRI include metal implants, such as pacemakers.



Ultrasound is a modality based on the transmission of sound waves through tissue and the time it takes for the waves to be reflected back to the transducing probe. Different tissues transmit sound waves at dif­ ferent velocities and, therefore, create different images. Ultrasound is readily available, noninvasive, and inexpensive. Operator skill is a large factor in the diagnostic utility of ultrasound images. Although initially used primarily for abdominal imaging, ultra­ sound imaging is rapidly becoming appreciated for its musculoskeletal applications. Power Doppler ultrasound imaging currently is used to help detect soft-tissue injuries, tumors, bone infections, and arthropa­ thy; and to evaluate bone mineral density. It also may be used to assess the degree and quality of fracture healing, and in the detection of syn­ ovitis and wood and plastic foreign bodies. Depending on operator skill, power Doppler ultrasound may be as sensitive as MRI and may be particularly useful in distinguishing chronic tendinitis from acute tendinitis and rotator cuff tears. 216

Radionucleotide scanning studies involve the diagnostic use of radioactive material or isotopes. These materials are administered orally or intravenously. The most common radionuclide scanning test is the bone scan (scintigraphy). Hours after the injection, the skeletal system is scanned to detect particular areas of abnormal metabolic (osteoclastic and osteoclastic) activity within a bone. The abnormality shows up as a so-called hot spot, which appears darker on the scan than normal tissue. Bone scans are considered sensitive, but not spe­ cific, for changes in bone associated with tumor, avascular necrosis, bone infection (osteomyelitis), Paget's disease, or recent fracture, including stress fractures-bone scans can detect sites of stress fracture in a bone before a conventional radiograph shows any abnormality, and often before they are symptomatic.

Fluoroscopic procedures involve the use of x-rays to demonstrate motions in joints or to guide injections. Because of the high exposure of radiation with this technique, it is used only rarely.

A technique used to investigate function in the human brain that uses

a magnetic field to induce an electric current in underlying brain tissue. The technique can be used to map brain function, elucidate brain areas involved in task performance by manipulating brain activity, or poten­ tially provide treatment as a therapeutic intervention. 218 The principal drawback of this technique is the direct stimulation of the brain, which carries the unlikely but still notable risk of a seizure. 218

A technique that relies on the naturally occurring magnetic fields in liv­

ing organisms and that is designed to provide a direct measure of cel­ lular activity. Sensors are arranged on the surface of the head in a fixed



helmet design. The measurements made by each sensor reflect the syn­ chronous activity of thousands of neurons contained in the brain areas under the sensor. The MEG technique allows for a wide variety of behavioral tests encompassing visual, auditory, somatosensory, and motor studies and has been used in studies of stroke and aphasia. 2t9,22o

See Tables 5-36 and 5-37

TABLE 5-36. STANDARD PRECAUTIONS Hand-washing 1. Wash hands after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. 2. Wash hands immediately after removing gloves, between patient contact~, and when otherwise indicated to reduce transmission of microorganisms. 3. Wash hands between tasks and procedures on the same patient to prevent cross-contamination of different body sites. 4. Use plain (non-antimicrobial) for routine hand washing. 5. An antimicrobial agent or a waterless antiseptic agent may be used for specific circumstances (hyperendemic infections) as defined by infection control. Gloves 1. Wear gloves (clean, unsterile gloves are adequate) when touching blood, body fluids, secretions, excretions, and contaminated items; put on clean gloves just before touching mucous membranes and nonintact skin. 2. Change gloves between tasks and procedures on the same patient after contact with materials that may contain high concentrations of microorganisms. 3. Remove gloves promptly after use, before touching uncontaminated items and environmental surfaces, and before going on to another patient; wash hands immediately acted love removal to avoid transferred of microorganisms to other patients or environments. Mask And Eye Protection or Face Shield 1. Wear a mask and eye protection as a stay shield to protect mucous membranes of the eyes, nose, and then join procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions. Gown 1. Wear a gown (a clean, unsterile gown L~ adequate) to protect skin and prevent soiling of clothing dUring procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions. 2. Select a gown that is appropriate for the activity and the amount of fluid likely to be encountered. 3. Remove a soiled gown as soon as possible and wash hands to avoid transfer of microorganisms to other patients or environments. Patient Care Equipment 1. Handle used patient care equipment soiled with blood, body fluids, secretions, and excretion in a manner that prevents skin and mucous membrane exposures, contamination of clothing, and transfer of microorganisms to other patients or environments. 2. In sure that reusable equipment is not used for the care of another patient until it has been cleaned and reprocessed appropriately. 3. In sure that single use items are discarded properly. Environmental Control 1. Follow hospital procedures for the routine care, cleaning and disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces. linen 1. Handle, transport, and process used linen soiled with blood, body fluids, secretions, and excretion in a manner that prevents skin and mucous membrane exposures and contamination of clothing, and avoids transfer of microorganisms to other patient~ or environments. Occupational Health and Blood-Borne Pathogens 1. Prevent injuries when using needles, scalpels, and other sharp instruments or devices; when handling sharp instruments and procedures; when cleaning used instruments; and when disposing of used needles. 2. Never recap used needles, or otherwise manipulate them using both hands, or use any other technique that involves directing the point of the needle toward any part of the body; rather, use either a one-handed "scoop" technique or mechanical device designed for holding the needle sheath. 3. Do not remove used needles from disposable syringes by hand, and do not bend, break, or otherwise manipulate used needles by hand. 4. Place used disposable syringes and needles, scalpel blades, or other sharp items in appropriate puncture-resistant container for transport to the reprocessing area. 5. Use mouthpieces, resuscitation bags, or other ventilation devices as an alternative to mouth-to-mouth resuscitation. Patient Placement 1. Use a private room for a patient who contaminates the environment or who does not (or cannot be expected to) assist in maintaining appropriate hygiene or environmental control. 2. Consult Infection Control if private room is not available.

From Centers for Disease Control, Hospital Infection Control Practices Advisory Committee. Recommendations jar Isolation Precautions in Hospitals. February 1997.




Airborne Precautions In addition to Standard Precautions, use Airborne Precautions, or the equivalent with all patients known or suspected to be infected with serious illness transmitted by airborne droplet nuclei (small-particle residue) that remain suspended in the air and that can be dispersed widely by air currents within a room or over long-distance (for example, Mycobacterium tuberculosis, measles virus, chickenpox virus). 1. Respiratory isolation room. 2. Wear respiratory protection (mask) when entering room. 3. Limit movement and transport of patient to essential purposes only. Mask patient when transporting out of area. Droplet Precautions In addition to Standard Precautions, use Droplet Precautions, or the equivalent, for patients known or suspected to be infected with serious illness microorganisms transmitted by large particle droplets that can be generated by the patient during coughing, sneezing, talking, or the performance of procedures (for example, mumps, rubella, pertussis, influenza). 1. Isolation room. 2. Wear respiratory protection (mask) when entering room. 3. Limit movement and transport of patient to essential purposes only. Mask patient when transporting out of area.

Contact Precautions In addition to Standard Precautions, use Contact Precautions, or the equivalent, for specified patients known or suspected to be infected or colonized with serious illness transmitted by direct patient contact (and or skin to skin contact) or contact with items in patient environment. 1. Isolation room 2. Wear gloves when entering room; change gloves after having contact with infective material; remove gloves before leaving patient's room; wash hands immediately with an antimicrobial agent or waterless antiseptic agent. After glove removal and hand washing, ensure that hands do not touch contaminated environmental items. 3. Where a gown when entering room if you anticipate your clothing will have substantial contact with the patient, environmental surfaces, or items in the patient's room, or if the patient is incontinent or has diarrhea, ileostomy, colostomy, or wound drainage not contained by dressing. Remove gown before leaving patient's room; after gown removal, ensure that clothing does not contact potentially contaminated environmental surfaces. 4. Single patient use equipment. 5. Limit movement and transport of patient to essential purposes only. Use precautions when transporting patient to minimize risk of transmission of microorganisms to other patients and contamination of environmental surfaces or equipment.

Data from Siegel JD, Rhinehart E, Jackson M, Chiarello L, and the Healthcare Infection Control Practices AdvisOly Committee, 2007. Guidelinefor Isolation Precautions: Preventing Transmission ofInfectiOUS Agents in Healtbcare Settings, June 2007. www.cdc.gov/ncidoclldhqp/pdflisolation2007.pdf

A working knowledge of leu equipment is important for the clinician so that interventions may be performed with the least disruption to the patient's care.



Endotracheal tube: artificial airway inserted into a patient who is unable to oxygenate/ventilate on his or her own. The tube may be placed in the mouth or the nose. Verification of cor­ rect placement is done by x-ray, and once correctly placed must not be moved unless there is a written order from the physician. Tracheostomy tube: artificial airway inserted into a patient who is unable to oxygenate/ventilate on his or her own. This type of tube is usually not placed unless the patient has had an endo­ tracheal tube in for an extended period of time and is unable to be weaned from the ventilator. Other instances in which the tra­ cheostomy tube may be inserted include facial trauma and dif­ ficulty placing the standard endotracheal tube.







Arterial line: a catheter inserted to monitor arterial pressure at all times. Also used for drawing arterial blood gases. May be inserted into one of four arteries: radial, femoral, pedal, and axillary. Arterial lines are usually changed every 4 to 5 days to decrease the risk of infection. Triple lumen: a venous catheter that is placed in the femoral vein, internal jugular vein, or subclavian vein to monitor central venous pressure (CVP). The tip of the catheter is usually placed in the superior vena cava. PA catheter (Swan-Ganz): very large venous catheter placed in either the subclavian vein, the internal jugular vein, or the femoral vein (rarely). The catheter is inserted into the pul­ monary artery via the heart. Uldall catheter (not strictly an N): a venous catheter used for dialysis and continuous renal replacement therapy. Can be placed in the same areas as triple-lumen and PA catheters.

Study Pearl





~ ~

Chest tube: placed by a physician into the pleural space for drainage of fluid or air. The chest tube is connected to a large bottle, which is responsible for collecting air/fluid without per­ mitting the lung to collapse. If the tube is accidentally dislodged or disconnected from the bottle, the patient's lung will collapse completely. Pigtail catheter: small catheter inserted into the pleural space for drainage of fluid only. The catheter may also be inserted into the peritoneum to drain ascites in a patient with liver dis­ ease. The catheter is connected to a drainage bag for collection of fluid. T-tube: placed into the common bile duct in order to drain bile after liver transplantation to assess if liver is producing bile adequately. Jackson-Pratt: placed in a patient after liver transplantation to drain fluid and blood. ICP drain: inserted to remove excess fluid from the ventricles of the brain. Extreme care must be taken with patients who have an ICP inserted, as raising (increases the drainage, thereby low­ ering the ICP) or lowering (increases the ICP) the head of the bed can significantly change the ICP.

1. Van de Graaff KM, Fox SI. Histology. In Van de Graaff KM, Fox SI, eds. Concepts of Human Anatomy and Physiology. New York: WCB/McGraw-Hill; 1999:130-158. 2. Williams GR, Chmielewski T, Rudolph KS, et al. Dynamic knee stability: Current theory and implications for clinicians and scien­ tists. ] Orthop Sports Phys Ther. 2001;31:546-566. 3. Prentice WE. Understanding and managing the healing process. In Prentice WE, Voight ML, eds. Techniques in Musculoskeletal Rehabilitation. New York: McGraw-Hill; 2001:17-41.



4. Burgeson RE. New collagens, new concepts. Ann Rev Cell BioI. 1988;4:551-577. 5. Engles M. Tissue response. In: Donatelli R, Wooden MJ, eds. Orthopaedic Physical Therapy. 3rd ed. Philadelphia: Churchill Livingstone; 2001:1-24. 6. Ham AW, Cormack DH. Histology. 8th ed. Philadelphia: Lippincott; 1979. 7. Barnes J. Myofascial Release: A Comprehensive Evaluatory and Treatment Approach. Paoli, PA: MFR Seminars; 1990. 8. Smolders JJ. Myofascial pain and dysfunction syndromes. In: Hammer WI, ed. Functional Soft Tissue Examination and Treatment by Manual Method~The Extremities. Gaithersburg, MD: Aspen; 1991:215-234. 9. Ellis JJ, Johnson GS. Myofascial considerations in somatic dys­ function of the thorax. In: Flynn TW, ed. The Thoracic Spine and Rib Cage: Musculoskeletal Evaluation and Treatment. Boston: Butterworth-Heinemann; 1996:211-262. 10. Clancy WG Jr. Tendon trauma and overuse injuries. In: Leadbetter WE, Buckwalter JA, Gordon SL, eds. Sports-Induced Inflammation. Park Ridge, IL: American Academy of Orthopaedic Surgeons; 1990:609-{)18. 11. Arniel D, Kleiner JB. Biochemistry of tendon and ligament. In: Nimni ME, ed. Collagen. Boca Raton: CRC Press; 1988:223-251. 12. Amiel D, Woo SL-Y, Harwood FL. The effect of immobilization on collagen turnover in connective tissue: a biochemical-biomechanical correlation. Acta Orthop Scand. 1982;53:325-332. 13. Teitz CC, Garrett WE, Jr., Miniaci A, et al. Tendon problems in ath­ letic individuals. j Bone joint Surg. 1997;79-A: 138-152. 14. Reid DC. Sports Injury Assessment and Rehabilitation. New York: Churchill Livingstone; 1992. 15. Garrett W, Tidball J. Myotendinous junction: Structure, function, and failure. In: Woo SL-Y, Buckwalter JA, eds. Injury and Repair of the Musculoskeletal Soft Tissues. Rosemont, IL: AAOS; 1988. 16. Garrett WE, Jr. Muscle strain injuries: clinical and basic aspects. Med Sci Sports Exerc. 1990;22:436-443. 17. Garrett WE. Muscle strain injuries. Am j Sports Med. 1996;24: S2-S8. 18. Safran MR, Seaber AV, Garrett WE. Warm-up and muscular injury prevention: an update. Sports Med. 1989;8:239-249. 19. Huijbregts PA: Muscle injury, regeneration, and repair. j Man Manip Ther. 2001;9:9-16. 20. Safran MR, Benedetti RS, Bartolozzi AR III, et al. Lateral ankle sprains: a comprehensive review. Part 1: etiology, pathoanatomy, histopathogenesis, and diagnosis. Med Sci Sports Exerc. 1999;31: S429-437. 21. Smith RL, Brunolli J. Shoulder kinesthesia after anterior gleno­ humeral dislocation. Phys Ther. 1989;69:106-112. 22. Inman VT. Sprains of the ankle. In: Chapman MW, ed. AAOS Instructional Course Lectures. Rosemont, 11: AAOS; 1975: 294-308. 23. Woo SL-Y, An K-N, Arnoczky SP, et al. Anatomy, biology, and bio­ mechanics of tendon, ligament, and meniscus. In: Simon S, ed. Orthopaedic Basic Science. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1994:45-87.



24. PI)'de JA, Iwasaki DH. Fractures. In: Cameron MH, Monroe LG, eds. Physical Rehabilitation: Evidence-Based Examination, Evaluation, and Interoention. St Louis: Saunders/Elsevier; 2007: 194-218. 25. Bukata SV, Rosier RN. Diagnosis and treatment of osteoporosis. Curr Opin Orthop. 2000;11:336-340. 26. Lane JM, Russell L, Khan SN. Osteoporosis. CUn Orthop. 2000; 372:139-150. 27. Eisman JA. Genetics of osteoporosis. Endocrine Rev. 1999;20: 788--804. 28. Scheiber LB, Torregrosa 1. Early intervention for postmenopausal osteoporosis. j Musculoskel Med. 1999;16:146-157. 29. Lane JM, Riley EH, Wirganowicz PZ. Osteoporosis: diagnosis and treatment. j Bone joint Surg. 1996;78A:618-D32. 30. Block J, Smith R, Black D, et al. Does exercise prevent osteo­ porosis? JAMA. 1987;257:345. 31. NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy. Osteoporosis prevention, diagnosis, and therapy. JAMA. 2001;285:785-795. 32. Sran MM, Khan KM. Is spinal mobilization safe in severe second­ aI)' osteoporosis? A case report. Man Tber. 2005;29:29. 33. Shea B, Bonaiuti D, Iovine R, et al. Cochrane Review on exercise for preventing and treating osteoporosis in postmenopausal women. Eura Medicophys. 2004;40:199-209. 34. O'Connell MB. Prescription drug therapies for prevention and treatment of postmenopausal osteoporosis. j Manag Care Pharm. 2006;12:S10-S19;quiz S26-28. 35. Compston]. Does parathyroid hormone treatment affect fracture risk or bone mineral density in patients with osteoporosis? Nat CUn Pract Rheumatol. 2007;1:1. 36. Cummings SR. A 55-year-old woman with osteopenia. JAMA. 2006;296:2601-2610. 37. Dupree K, Dobs A. Osteopenia and male hypogonadism. Rev Urol. 2004;6:S30-S34. 38. Basha B, Rao DS, Han ZH, et al. Osteomalacia due to vitamin D depletion: a neglected consequence of intestinal malabsorption. Am j Med. 2000; 108:296-300. 39. Briot K. Non-corticosteroid drug-induced metabolic bone dis­ ease. Presse Med. 2006;35:1579-1583. 40. Wolinsky-Friedland M. Drug-induced metabolic bone disease. Endocrinol Metab CUn North Am. 1995;24:395-420. 41. Bonaiuti D, Shea B, Iovine R, et al. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database Syst Rev. 2002;3. 42. Marcus R. Role of exercise in preventing and treating osteoporo­ sis. Rheum Dis CUn North Am. 2001;27:131-141. 43. Ronga M, Zappala G, Cherubino M, et al. Osteochondritis disse­ cans of the entire femoral trochlea. Am j Sports Med. 2006;34: 1508-1511. Epub Mar. 27, 2006. 44. Crawford DC, Safran MR. Osteochondritis dissecans of the knee. jAm Acad Orthop Surg. 2006;14:90-100. 45. Fortier LA, Nixon A]. New surgical treatments for osteochondritis dissecans and subchondral bone cysts. Vet CUn North Am Equine Pract. 2005;21:673-690.



46. Debeer P, Brys P. Osteochondritis dissecans of the humeral head: clinical and radiological findings. Acta Orthop Belg. 2005;71: 484-488. 47. Johnson MP. Physical therapist management of an adult with osteochondritis dissecans of the knee. Phys Ther. 2005;85: 665--675. 48. Campos PS, Freitas CE, Pena N, et al. Osteochondritis dissecans of the temporomandibular joint. Dentomaxillofac Radiol. 2005; 34:193-197. 49. Flynn JM, Kocher MS, Ganley TJ. Osteochondritis dissecans of the knee. ] Pediatr Orthop. 2004;24:434-443. 50. Schenck RC, Jr., Goodnight JM. Osteochondritis dissecans.] Bone Joint Surg Am. 1996;78:439-456. 51. Kankate RK, Selvan TP. Primary haematogenous osteomyelitis of the patella: a rare cause for anterior knee pain in an adult. Postgraduate Med]. 2000;76:707-709. 52. Dich VQ, NelsonJD, Haltalin KC. Osteomyelitis in infants and chil­ dren: a review of 163 cases. Am] Dis Child. 1975;129:1273-1278. 53. Roy DR. Osteomyelitis of the patella. Clin Orthop Rei Res. 2001; 389:30-34. 54. Lew DP, Waldvogel FA. Osteomyelitis. Lancet. 2004;364:369-379. 55. Lew DP, Waldvogel FA. Osteomyelitis. N Engl ] Med. 1997;336: 999-1007. 56. Siris ES, Lyles KW, Singer FR, et al. Medical management of Paget's disease of bone: indications for treatment and review of current therapies.] Bone Miner Res. 2006;21Csuppl 2):94-98. 57. Bone HG. Nonmalignant complications of Paget's disease.] Bone Miner Res. 2006;21Csuppl 2):64--68. 58. Shankar S, Hosking DJ. Biochemical assessment of Paget's dis­ ease of bone.] Bone Miner Res. 2006;21Csuppl 2):22-27. 59. Langston AL, Campbell MK, Fraser WD, et al. Clinical determi­ nants of quality of life in Paget's disease of bone. CalcifTissue Int. 2007;80:1-9. Epub Jan. 4, 2007. 60. Griz L, Caldas G, Bandeira C, et al. Paget's disease of bone. Arq Bras Endocrinol Metabol. 2006;50:814-822. 61. Palkar S, Mohan V. Paget's disease in diabetic subjects. ] Assoc Physicians India. 2006;54:585. 62. Bhatt K, Balakrishnan C, Mangat G, et al. Paget's disease of the bone: a report of three cases. ] Assoc Physicians India. 2006;54: 571-574. 63. Klein GR, Parvizi J. Surgical manifestations of Paget's disease.] Am Acad Orthop Surg. 2006;14:577-586. 64. Takata S, Hashimoto J, Nakatsuka K, et al. Guidelines for diagno­ sis and management of Paget's disease of bone in Japan.] Bone Miner Metab. 2006;24:359-367. 65. Whyte MP. Clinical practice. Paget's disease of bone. N Eng!] Med. 2006;355:593--600. 66. Mankin HJ, Mow VC, Buckwalter JA, et al. Form and function of articular cartilage. In: Simon SR, ed. Orthopaedic Basic Science. Rosemont, 11: American Academy of Orthopaedic Surgeons; 1994:1-44. 67. Woo SL-Y, Buckwalter JA. Injury and Repair of the Musculoskeletal Tissue. Park Ridge, 11: American Academy of Orthopaedic Surgeons; 1988.



68. Buckwalter ]A, Mankin H]. Articular cartilage. Part I: tissue design
and chondrocyte-matrix interactions.]Bonejoint Surg. 1997;79A:
69. Muir H. Proteoglycans as organizers of the extracellular matrix.
Biochem Soc Trans. 1983;11:613-622.
70. ]unqueira LC, Carneciro], Kelley RO. Basic Histology. Norwalk, CT: Appleton & Lange; 1995. 71. Lundon K, Bolton K. Structure and function of the lumbar inter­ vertebral disk in health, aging, and pathological conditions. j Orthop Sports Phys Tber. 2001;31:291-306. 72. Guccione AA, Minor MA. Arthritis. In: O'Sullivan SB, Schmitz T], eds. Physical Rehabilitation. 5th ed. Philadelphia: Davis; 2007: 1057-1085. 73. Roberts WN, Williams RE. Hip pain. Primary Care. 1988;15: 783-793. 74. Traycoff RB. Pseudotrochanteric bursitis: the differential diagno­ sis of lateral hip pain. j Rheumatol. 1991;18:1810-1812. 75. Hammer WI. The use of transverse friction massage in the man­ agement of chronic bursitis of the hip or shoulder. j Man Physiol Tber. 1993;16:107-111. 76. Gordon E]. Trochanteric bursitis and tendinitis. Clin Orthop. 1961; 20: 193-202. 77. Buckingham RE. Bursitis and tendinitis. Compr Tber. 1981;7: 52-57. 78. Cibulka MT, Delitto A. A comparison of two different methods to treat hip pain in runners. j Orthop Sports Phys Ther. 1993;17: 172-176. 79. Hammer WI. Friction massage. In: Hammer WI, ed. Functional soft Tissue Examination and Treatment by Manual Methods. Gaithersburg, MD: Aspen; 1991:235-249. 80. Leirisalo-Repo M. Reactive arthritis. Scand j Rheumatol. 2005;34: 251-259. 81. Colmegna I, Espinoza LR. Recent advances in reactive arthritis. Curr Rheumatol Rep. 2005;7:201-207. 82. Toivanen A, Toivanen P. Reactive arthritis. Best Pract Res Clin Rheumatol. 2004;18:689-703. 83. Kohnke S]. Reactive arthritis. A clinical approach. Orthop Nurs. 2004;23:274-280. 84. Childs SG. Reactive arthritis. Immune-mediated synovitis or joint infection. Orthop Nurs. 2004;23:267-273. 85. Haga H], Peen E. A study of the arthritis pattern in primary Sjogren's syndrome. Clin Exp Rheumatol. 2007;25:88--91. 86. Binard A, Devauchelle-Pensec V, Fautrel B, et al. Epidemiology of Sjogren's syndrome: where are we now? Clin Exp Rheumatol. 2007;25:1--4. 87. Amarasena R, Bowman S. Sjogren's syndrome. Clin Med. 2007;7: 53-56. 88. Mitsias DI, Kapsogeorgou EK, Moutsopoulos HM. Sjogren's syn- • drome: why autoimmune epithelitis? Oral Dis. 2006;12:523-532. 89. Garcia-Carrasco M, Fuentes-Alexandro S, Escarcega RO, et al. Pathophysiology of Sjogren's syndrome. Arch Med Res. 2006;37: 921-932. 90. Fox RI, Liu AY. Sjogren's syndrome in dermatology. Clin Dermatol. 2006;24:393--413.



91. Mavragani CP, Moutsopoulos NM, Moutsopoulos HM. The man­ agement of Sjogren's syndrome. Nat Clin Pract Rheumatol. 2006; 2:252-261. 92. Jones D, Round D. Skeletal Muscle in Health and Disease. Manchester: Manchester University Press; 1990. 93. Van de Graaff KM, Fox SI. Muscle tissue and muscle physiology. In: Van de Graaff KM, Fox SI, eds. Concepts ofHuman Anatomy and Physiology. New York: WCB/McGraw-Hill; 1999:280-305. 94. Armstrong RB, Warren GL, Warren JA. Mechanisms of exercise­ induced muscle fibre injury. Med Sci Sports Exerc. 1990;24:436-443. 95. Williams JH, Klug GA. Calcium exchange hypothesis of skeletal muscle fatigue. A brief review. Muscle Neroe. 1995;18:421. 96. Janda V. Muscle Function Testing. London: Butterworths; 1983. 97. Cyriax J. Textbook of OrthopaediC Medicine, Diagnosis of Soft Tissue Lesions. 8th ed. London: Bailliere Tindall; 1982. 98. Hall SJ. The biomechanics of human skeletal muscle. In: Hall SJ, ed. Basic Biomechanics. New York: McGraw-Hill; 1999:146-185. 99. MacConnaii MA, Basmajian]V. Muscles and Movements: A Basis for Human Kinesiology. New York: Krieger; 1977. 100. Beauchesne RP, Schutzer SF. Myositis ossificans of the piriformis muscle: an unusual cause of piriformis syndrome. A case report. ] Bone]oint Surg Am. 1997;79:906-910. 101. Weider D. Treatment of traumatic myositis ossificans with acetic acid iontophoresis. Phys Ther. 1992;72:133--137. 102. Waller SL, Porter DE, Huntley JS. Myositis ossificans progressiva. Br] Hosp Med (Lond). 2006;67:606-607. 103. Hendifar AE, Johnson D, Arkfeld DG. Myositis ossificans: a case report. Arthritis Rheum. 2005;53:793--795. 104. Waldridge BM, Beard D, Livesey LC. What is your diagnosis? Myositis ossificans.] Am Vet Med Assoc. 2004;225:1533--1534. 105. Junqueira LC, Carneciro J. Bone. In: Junqueira LC, Carneciro J, eds. Basic Histology. 10th ed. New York: McGraw-Hill; 2003: 141-159. 106. Freeman MAR, Wyke BD. An experimental study of articular neu­ rology.] Bone]oint Surg. 1967;49B:185. 107. Wyke BD. The neurology of joints. Ann R Coli Surg Engl. 1967;41:25-50. 108. Wyke BD. The neurology of joints: a review of general principles. Clin Rheum Dis. 1981;7:223--239. 109. Chusid JG. Correlative Neuroanatomy and Functional Neurology. 19th ed. New York: Appleton-Century-Crofts; 1985:144-148. 110. Grigg P. Peripheral neural mechanisms in proprioception.] Sport Rehabil. 1994;3:1-17. 111. Grigg P, Hoffmann AH. Properties of Ruffini afferents revealed by stress analysis of isolated sections of cat knee capsule. ] Neurophysiol. 1982;47:41-54. 112. Borsa PA, Lephart SM, Kocher MS, et al. Functional assessment and rehabilitation of shoulder proprioception for glenohumeral instability.] Sport Rehabil. 1994;3:84-104. 113. Clark R, Wyke BD. Contributions of temporomandibular articular mechanoreceptors to the control of mandibular posture: an experimental study.] Dent Assoc S Africa. 1974;2:121-129. 114. Skaggs CD. Diagnosis and treatment of temporomandibular dis­ orders. In: Murphy DR, ed. Ceroical Spine Syndromes. New York: McGraw-Hill; 2000:579--592.



115. Lephart SM, Pincivero DM, Giraldo]1, et al. The role of proprio­ ception in the management of and rehabilitation of athletic injuries. Am] Spons Med. 1997;25:130-137. 116. Wojtys EM, Wylie BB, Huston L]. The effects of muscle fatigue on neuromuscular function and anterior tibial translation in healthy knees. Am] Spons Med. 1996;24:615. 117. Abbott LC, Saunders JBDM, Bost FC, et al. Injuries to the liga­ ments of the knee joint.] BoneJoint Surg. 1944;26:503-521. 118. Riddle DL. Measurement of accessory motion: critical issues and related concepts. Phys Tber. 1992;72:865-874. 119. Answorth AA, Warner JJP. Shoulder instability in the athlete. Onhop Glin Nonh Am. 1995;26:487-504. 120. Bergmark A. Stability of the lumbar spine. Acta Onhop Scand. 1989;60:1-54. 121. Boden BP, Pearsall AW, Garrett WE Jr, et al. Patellofemoral insta­ bility: evaluation and management. ] Am Acad Onhop Surg. 1997;5:47-57. 122. Callanan M, Tzannes A, Hayes KC, et aI. Shoulder instability. Diagnosis and management. Aust Fam Physician. 2001;30: 655-661. 123. Cass JR, Morrey BF. Ankle instability: current concepts, diagnosis, and treatment. Mayo Glin Proc. 1984;59:165-170. 124. Clanton TO. Instability of the subtalar joint. Onhop Glin Nonh Am. 1989;20:583-592. 125. COX JS, Cooper PS. Patellofemoral instability. In: Fu FH, Harner CD, Vince KG, eds. Knee Surgery. Baltimore: Williams & Wilkins; 1994:959-962. 126. Freeman MAR, Dean MRE, Hanham IWF. The etiology and pre­ vention of functional instability of the foot. ] Bone Joint Surg. 1965;47B:678-685. 127. Friberg O. Lumbar instability: a dynamic approach by traction­ compression radiography. Spine. 1987;12:119-129. 128. Grieve GP. Lumbar instability. Physiotherapy. 1982;68:2. 129. Hotchkiss RN, Weiland A]. Valgus stability of the elbow.] Onhop Res. 1987;5:372-377. 130. Kaigle A, Holm S, Hansson T. Experimental instability in the lum­ bar spine. Spine. 1995;20:421--430. 131. Kuhlmann IN, Fahrer M, Kapandji AI, et al. Stability of the normal wrist. In: Tubiana R, ed. Tbe Hand. Philadelphia: Saunders; 1985: 934-944. 132. Landeros 0, Frost HM, Higgins Cc. Post traumatic anterior ankle instability. Glin Onhop. 1968;56:169-178. 133. Luttgens K, Hamilton N. The center of gravity and stability. In: Luttgens K, Hamilton N, eds. Kinesiology: Scientific Basis of Human Motion. 9th ed. Dubuque, IA: McGraw-Hill; 1997: 415--442. 134. Wilke H, Wolf S, Claes L, et al. Stability of the lumbar spine with different muscle groups: a biomechanical in vitro study. Spine. 1995;20:192-198. 135. Panjabi MM. The stabilizing system of the spine. Part 1. Function, dysfunction adaption and enhancement.] Spinal Disord. 1992;5: 383-389. 136. McGill SM, Cholewicki ]. Biomechanical basis for stability: an explanation to enhance clinical utility.] Onhop Spans Phys Tber. 2001;31:96-100.



137. Gertzbein SD, Seligman J, Holtby R, et al. Centrode patterns and segmental instability in degenerative disc disease. Spine. 1985;10: 257-261. 138. Cholewicki J, McGill S. Mechanical stability of the in vivo lumbar spine: implications for injury and chronic low back pain. Clin Biomech. 1996;11:1-15. 139. Hall S]. Kinematic concepts for analyzing human motion. In: Hall SJ, ed. Basic Biomechanics. New York: McGraw-Hill; 1999:28-89. 140. Van de Graaff KM, Fox SI. Functional organization of the nervous system. In: Van de Graaff KM, Fox SI, eds. Concepts of Human Anatomy and Physiology. New York: WCB/McGraw-Hill; 1999: 371-406. 141. Schmitz T]. Vital signs. In: O'Sullivan SB, Schmitz TJ, eds. Physical Rehabilitation. 5th ed. Philadelphia: Davis; 2007:81-120. 142. Zarins B. Soft tissue injury and repair: biomechanical aspects. Int ] Sports Med. 1982;3:9-11. 143. Clancy J, McVicar A. Wound healing: a series of homeostatic responses. BrJ Theatre Nurs. 1997;7:25-34. 144. Singer AJ, Clark RAF. Cutaneous wound healing. N EnglJ Med. 1999;341:738--746. 145. Heldin C-H, Westermark B. Role of platelet-derived growth factor in vivo. In: Clark RAF, ed. The Molecular and Cellular Biology of Wound Repair. 2nd ed. New York: Plenum; 1996:249-273. 146. Katz MH, Kirsner RS, Eaglstein WH, et al. Human wound fluid from acute wounds stimulates fibroblast and endothelial cell growth. ] Am Acad Dermatol. 1991;25:1054-1058. 147. Deuel TF, Senior RM, Chang D, et al. Platelet factor 4 is a chemo­ taxtic factor for neutrophils and monoeytes. Proc Natl Acad Sci. 1981;74:4584-4587. 148. Schultz G, Rotatari DS, Clark W. EGF and TGFa in wound healing and repair. ] Cell Biochem. 1991;45:346-352. 149. Sporn ME, Roberts AB. Transforming growth factor beta: recent progress and new challenges. ] Cell Bioi. 1992;119:1017-1021. 150. Wong MEK, Hollinger JO, Pinero G]. Integrated processes responsible for soft tissue healing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1996;82:475-492. 151. Sen CK, Khanna S, Gordillo G, et al Oxygen, oxidants, and antioxidants in wound healing: an emerging paradigm. Ann NY Acad Sci. 2002;957:239-249. 152. Kellett]. Acute soft tissue injuries: a review of the literature. Med Sci Sports Exerc. 1986;18:5. 153. Amadio Pc. Tendon and ligament. In: Cohen IK, Diegelman RF, Lindblad WJ, eds. Wound Healing: Biomechanical and Clinical Aspects. Philadelphia: Saunders; 1992:384-395. 154. Hunt TK. Wound Healing and Wound Infection: Theory and Surgical Practice. New York: Appleton-Century-Crofts; 1980. 155. Peacock EE. Wound Repair. 3rd ed. Philadelphia: Saunders; 1984. 156. Ross R. The fibroblast and wound repair. Bioi Rev. 1968;43:51-96. 157. McAllister BS, Leeb-Lunberg LM, Javors MA, et al. Bradykinin receptors and signal transduction pathways in human fibroblasts: integral role for extracellular calcium. Arch Biochem Biophys. 1993;304:294-301. 158. Evans RB. Clinical application of controlled stress to the healing extensor tendon: a review of 112 cases. Phys Ther. 1989;69: 1041-1049.



159. Emwemeka CS. Inflammation, cellularity, and fibrillogenesis in regenerating tendon: implications for tendon rehabilitation. Phys Tber. 1989;69:816-825. 160. Safran MR, Zachazewski ]E, Benedetti RS, et al. Lateral ankle sprains: a comprehensive review. Part 2: treatment and rehabili­ tation with an emphasis on the atWete. Med Sci Sports Exerc. 1999;31:S438-S447. 161. Oakes BW. Acute soft tissue injuries: nature and management. Austr Fam Physician. 1982;10:3-16. 162. Van der Mueulin ]HC. Present state of knowledge on processes of healing in collagen structures. Int] Sports Med. 1982;3:4-8. 163. Clayton ML, Wier GJ. Experimental investigations of ligamentous healing. Am] Surg. 1959;98:373-378. 164. Mason ML, Allen HS. The rate of healing of tendons. An experi­ mental study of tensile strength. Ann Surg. 1941;113:424-459. 165. Farfan HE The scientific basis of manipulative procedures. Glin Rheum Dis. 1980;6:159-177. 166. Orgill D, Demling RH. Current concepts and approaches to wound healing. Grit Gare Med. 1988;16:899. 167. Allbrook DB. Skeletal muscle regeneration. Muscle Neroe. 1981; 4:234-245. 168. Hurme T, Kalimo H. Activation of myogenic precursor cells after muscle injury. Med Sci Sports Exerc. 1992;24:197-205. 169. Hurme T, Kalimo H, Lehto M, et al. Healing of skeletal muscle injury: an ultrastructural and immunohistochemical study. Med Sci Sports Exerc. 1991;23:801-810. 170. Kasemkijwattana C, Menetrey], Bosch P, et al. Use of growth fac­ tors to improve muscle healing after strain injury. Glin Orthop. 2000;370:272-285. 171. Kalimo H, Rantanen], Jarvinen M. Soft tissue injuries in sport. In: Jarvinen M, ed. Balliere's Glin Orthop. 1997:2:1-24. 172. Lehto M, Duance VJ, Restall D. Collagen and fibronectin in a heal­ ing skeletal muscle injury: an immunohistochemical study of the effects of physical activity on the repair of the injured gastrocne­ mius muscle in the rat.] Bone]oint Surg. 1985;67-B:820-828. 173. Menetrey], Kasemkijwattana C, Day CS, et al. Growth factors improve muscle healing in vivo. ] Bone Joint Sur Br. 2000;82B: 131-137. 174. Alameddine HS, Dehaupas M, Fardeau M. Regeneration of skele­ tal muscle fibers from autologous satellite cells multiplied in vitro: an experimental model for testing cultured cell myogenicity. Muscle Neroe. 1989;12:544-555. 175. Barlow Y, Willoughby J. Pathophysiology of soft tissue repair. Br Med Bull. 1992;48:698-711. 176. Frank CB, Bray RC, Hart DA, et al. Soft tissue healing. In: Fu F, Harner CD, Vince KG, eds. Knee Surgery. Baltimore: Williams & Wilkins; 1994:189-229. 177. Injeyan HS, Fraser IH, Peek WD. Pathology of musculoskeletal soft tissues. In: Hammer WI, ed. Functional Soft Tissue Examination and Treatment by Manual Methods. Gaithersburg, MD: Aspen; 1991:9-23. 178. Kasper CE, Talbot LA, Gaines ]M. Skeletal muscle damage and recovery. AAGN Clin Issues. 2002;13:237-247. 179. Byrnes WC, Clarkson PM, White ]S, et al. Delayed onset muscle soreness following repeated bouts of downhill running. ] Appl Physiol. 1985;59:710.



180. Nosaka K, Sakamoto K, Newton M, et al. How long does the pro­ tective effect on eccentric exercise-induced muscle damage last. Med Sci Sports Exerc. 2001;33:1490-1495. 181. Lynn R, Talbot ]A, Morgan DL. Differences in rat skeletal muscles after incline and decline running.] Appl Physiol. 1998;85:98-104. 182. Nosaka K, Clarkson P. Influence of previous concentric exercise on eccentric exercise-induced muscle damage.] Sports Sci. 1997;15:477. 183. Murphy PG, Loitz B], Frank CB, et al. Influence of exogenous growth factors on the expression of plasminogen activators by explants of normal and healing rabbit ligaments. Biochem Cell Bioi. 1993;71:522-529. 184. Pierce GF, Mustoe TA, Lingelbach], et al. Platelet-derived growth factor and transforming growth factor-13 enhance tissue repair activities by unique mechanisms.] Cell Bioi. 1989;109:429-440. 185. Woo SL-Y, Suh]K, Parsons 1M, et al. Biological intervention in lig­ ament healing effect of growth factors. Sports Med Arthrosc Rev. 1998;6:74-B2. 186. Steenfos HH. Growth factors in wound healing. Scand] Plast Hand Surg. 1994;28:95-105. 187. Booher ]M, Thibodeau GA. The body's response to trauma and environmental stress. In: Booher ]M, Thibodeau GA, eds. Athletic Injury Assessment. 4th ed. New York: McGraw-Hill; 2000:55-76. 188. Frank G, Woo SL-Y, Arniel D, et al. Medial collateral ligament healing. A multidisciplinary assessment in rabbits. Am] Sports Med. 1983;11:379. 189. Balduini FC, Vegso]], Torg]S, et al. Management and rehabilitation of ligamentous injuries to the ankle. Sports Med. 1987;4:364-380. 190. Gould N, Selingson D, Gassman J. Early and late repair of lateral ligaments of the ankle. Foot Ankle. 1980;1:84-B9. 191. Vailas AC, Tipton CM, Mathes RD, et al. Physical activity and its influence on the repair process of medial collateral ligaments. Connect Tissue Res.1981;9:25-31. 192. Tipton CM, Matthes RD, MaynardJA, et al. The influence of phys­ ical activity on ligaments and tendons. Med Sci Sports Exerc. 1975;7:165-175. 193. Tipton CM, James SL, Mergner W, et al. Influence of exercise in strength of medial collateral knee ligaments of dogs. Am]Physiol. 1970;218:894-902. 194. Laban MM. Collagen tissue: implications of its response to stress in vitro. Arch Phys Med Rehabil. 1962;43:461. 195. McGaw WT. The effect of tension on collagen remodelling by fibroblasts: a stereological ultrastructural study. Connect Tissue Res. 1986;14:229. 196. Wakitani S, Goto T, Pineda SJ, et al. Mesenchymal cell-based repair of large, full-thickness defects of articular cartilage.] Bone Joint Surg. 1994;76A:579-592. 197. Fuller ]A, Ghadially FN. Ultrastructural observations on surgically produced partial-thickness defects in articular cartilage. Clin Orthop. 1972;86:193-205. 198. Ghadially FN, Thomas I, Oryschak AF, et al. Long-term results of superficial defects in articular cartilage: a scanning electron­ microscope study.] Pathol. 1977;121:213-217. 199. Convery FR, Akeson WH, Keown GH. The repair of large osteo­ chondral defects. An experimental study in horses. Clin Orthop. 1972;82:253-262.



200. Coletti JM Jr, Akeson WH, Woo SL-Y. A comparison of the physi­ cal behavior of normal articular cartilage and the arthroplasty surface. j Bonejoint Surg. 1972;54-A:147-160. 201. Furukawa T, Eyre DR, Koide S, et al. Biochemical studies on repair cartilage resurfacing experimental defects in the rabbit knee. j Bonejoint Surg. 1980;62-A:79-89. 202. Chu CR, Convery FR, Akeson WH, et al. Articular cartilage trans­ plantation. Clinical results in the knee. Clinical Orthop. 1999;360: 159-168. 203. Perka C, Sittinger M, Schultz 0, et al. Tissue engineered cartilage repair using cryopreserved and noncryopreserved chondroeytes. Clin Orthop. 2000;378:245-254. 204. Marsh DR, Li G. The biology of fracture healing: optimising out­ come. Br Med Bull. 1999;55:856-869. 205. Muller ME. Internal fixation for fresh fractures and nonunion. Proc R Soc Med. 1963;56:455-460. 206. McKibbin B. The biology of fracture healing in long bones.] Bone joint Surg. 1978;60B:150-161. 207. Sarmiento A, Mullis DL, Latta LL, et al. A quantitative comparative analysis of fracture healing under the influence of compression plating vs. closed weight-bearing treatment. Clin Orthop. 1980;149:232-239. 208. Bailey DA, Faulkner RA, McKay HA. Growth, physical activity, and bone mineral acquisition. In: Hollosky JO, ed. Exercise and Sport Sciences Reviews. Baltimore: Williams & Wilkins; 1996:233-266. 209. Stone MH. Implications for connective tissue and bone alterations resulting from rest and exercise training. Med Sci Sports Exerc. 1988;20:S162-168. 210. Monteleone GP. Stress fractures in the athlete. Orthop Clin North Am. 1995;26:423. 211. Hockenbury RT. Forefoot problems in athletes. Med Sci Sports Exerc. 1999;31:S448-S458. 212. Wallace AL, Draper ER, Strachan RK, et al. The vascular response to fracture micromovement. Clin Orthop. 1994;301:281-290. 213. Marsh D. Concepts of fracture union, delayed union, and nonunion. Clin Orthop. 1998;355:S22-S30. 214. Wolff J. The Law of Remodeling. Maquet P, Furlong R, trans. Berlin: Springer-Verlag; 1986 (1892). 215. Schutter H. Intervertebral disc disorders. Mendlewicz J, Schulman CC, Wilmotte J. Clinical Neurology. Philadelphia: Lippincott-Raven; 1995:chap. 41. 216. Deyle G. Diagnostic imaging in primary care physical therapy. In: Boissonnault WG, ed. Primary Care for the Physical Therapist: Examination and Triage. St Louis: Elsevier Saunders; 2005: 323-347. 217. Minz D. Imaging of sports injuries. Phys Med Rehabil Clin North Am. 2000;11:435-469. 218. Kimberley TJ, Lewis SM. Understanding neuroimaging. Phys Ther. 2007;11:670-683. 219. Forss N, Hietanen M, Salonen 0, et al. Modified activation of somatosensory cortical network in patients with right-hemisphere stroke. Brain. 1999;122:1889-1899. 220. Meinzer M, Elbert T, Wienbruch C, et al. Intensive language train­ ing enhances brain plasticity in chronic aphasia. BMC Bioi. 2004;2:20.



Comprehension Questions

1. What are the two major types of epithelial tissue? 2. True or false: Connective tissue (CT) is found throughout the body and serves to pro­
vide structural and metabolic support for other tissues and organs of the body. A. True. B. False.

3. What are the three types of cartilage and bone tissue?

4. True or false: Crimp is the slack in collagen tissue, which serves as the tissue's first
line of response to stress. A. True. B. False. 5. What is the primary mechanism used by ligaments, capsules, and muscle, to increase their length? 6. True or false: Fascia is an example of dense regular C1 A. True. B. False. 7. Give three exarnples of a CT disorder. 8. What are the three phases of soft-tissue healing? 9. True or false: A bursa is a synovial membrane-lined sac. A. True. B. False.

10. All of the following functions are true of the living skeleton except: A. It supports the surrounding tissues.
B. It assists in body movement. C. It provides a storage area for mineral salts. D. It determines the individuals developing somatotype.

11. What is the type of cartilage found in synovial joints called? 12. How does tendinitis differ from tendinosis? 13. Approximately how many bones are there in the human body? 14. True or false: Hyaline and elastic cartilage has no nerve supply, while fibrocartilage
is well innervated. A. True. B. False.

15. What is the shaft of a long bone called? 16. Which area of the bone is responsible for increasing the bone length during growth? 17. What are the three stages of bone healing?



18. How does Wolff's law apply to bone healing? 19. Adrenal cortex hypersecretions can result in many diseases. In this particular one, obesity is the most common feature in the face, trunk, and dorsal spinal region. The patient often has a "moonface," hypertension, and osteoporosis. Which of the dis­ eases listed below does the above description define? A. Cushing's syndrome. B. Pravda syndrome. e. Acromegaly. D. Pott's disease. 20. What are the three types of muscle tissue? 21. Which structure separates each muscle fiber from its neighbor? 22. Which type of muscle fiber is activated during moderate-intensity, long-duration exercise? 23. What is the function of a tendon? 24. Give three areas in the body that are prone to tendonopathy. 25. True or false: Bone is a highly vascular form of CT. A. True. B. False. 26. Give four functions of bone. 27. What are the three anatomical planes called? 28. What is the difference between a sprain and a strain? 29. The resting potential of a cell may be defined as: A. A refractory period in which the cell cannot respond to stimuli. B. The inherent ability of the cell to suspend protein synthesis. e. Selective membrane permeability to potassium, resulting in an electronegative potential within the cell. D. The result of a strong influx of sodium ions through the cell membrane. 30. The net movement of water across a cell membrane, which occurs because of the difference in water concentrations on the two sides of the membrane, is defined as: A. Homeostasis. B. Diffusion. e. Osmosis. D. Passive transport. 31. An action potential is generated when: A. Ionic fluxes reach equilibrium. B Sodium ions move inward and potassium ions move out of the cell in a rapid exchange. e. Any form of stimulus is applied to the cell. D. Potassium activation through exchange channels across the membrane.



32. The absolute refractory period of a nerve fiber is: A. The variable length of time between any two successive stimuli. B. The conduction immediately following the relative refractory period. C. The period immediately after depolarization when no strength of stimulus can elicit asecond impulse. D. The period in which the nerve is most sensitive to further stimuli. 33. The neuron is comprised of which of the following: A. Axon. B. Dendrite. C. Cell body. D. All of the above. 34. The smallest organized unit of the contractile mechanism of skeletal muscle is the: A. Myofilament. B. Actin. C. Myosin. D. Sarcomere. 35. Cardiac muscle is physiologically dilterent from skeletal muscle in that: A. It has no fibrous or bony attachments. B. Actin and myosin filaments produce adifferent type of striation. C. It does not develop a length-tension relationship. D. It functions as a syncytium divided into atrial and ventricular portions. 36. All of the following are attributes of smooth muscle except: A. It usually surrounds hollow viscera. B. It may have connective tissue fibers, but no tendons. C. It is arranged in antagonistic pairs. D. Is has no striations. 37. All of the following are attributes of cardiac muscle except: A. It has specially increased diameters and internal structures for abundant seques­ tration of calcium ions. B. It has a mechanism of excitation-contraction coupling. C. It has amuch slower conduction velocity of the action potential than is found in skeletal muscle fibers. D. The duration of contractions of cardiac muscle is mainly afunction of the dura­ tion of the action potential. 38. All of the following terms are used to describe fractures except: A. Greenstick. B. Comminuted. C. Pathologic. D. Tangential.

39. All of the following are true about the epiphyseal plate except: A. It is formed from cartilage. B. It serves as the site of progressive lengthening in long bones. C. It is located between the epiphysis and the diaphysis. D. It is found in all bones.



40. The prime energy source for active muscle is: A. Protein. B. Fat. Glucose or glycogen. D. None of the above.


41. All of the following substrates are involved with anaerobic production of ATP except: A. Acetic acid. B. Pyruvic acid. Glycogen. D. Glucose.


42. Venous return during exercise is augmented by all of the following except: A. Venoconstriction. B. Muscle contractions. e. Abdominothoracic pumping mechanisms. D. Intestinal motility. 43. All of the following are complications associated with a fracture except: A. Infection. B. Fat embolism. e. Crush syndrome. D. Volkmann's ischemic contracture.
44. Hyaline cartilage is nourished through the: A. Vessels from the periosteum. B. Haversian canals. Joint fluid. D. Nutrient arteries.


45. Myositis ossificans is characterized by: A. Pathologic fractures. B. Osteochondritis of bone tissue. A fibrous dysplasia of bone. D. Transformation of soft-tissue structures into bony consistency.


46. A disease in which there is deficiency in mineralization of bone matrix is: A. Osteogenesis irnperfecta. B. Osteitis deformans. Osteomalacia. D. Osteoporosis.


47. What condition is characterized by an incomplete mineralization of normal osteoid tissue following closure of the growth plates?
48. The condition described as Paget's disease is also called: A. Osteosclerosis. B. Osteitis deformans. Myositis ossificans. D. None of the above.




49. The epiphysis of a bone is located: A. Directly adjacent to the periosteum. B. Directly above the diaphysis. C. Directly below the metaphysis. D. Directly adjacent to the joint. SO. All of the following are considered modifiable risk factors for developing skeletal demineralization except: A. Use of specific medications. B. Estrogen deficiency. C. Physical inactivity. D. Early menopause.

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

8. 9. 10. 11. 12. 13.

15. 16. 17.

Membranous and glandular. The answer is A. This statement is true. Hyaline cartilage, elastic cartilage, and fibrocartilage. The answer is A. This statement is true. Viscoelasticity. The answer is B. This statement is false. Any three of the following: rheumatoid arthritis, spondyloarthropathies (e.g., anky­ losing spondylitis, reactive arthritis), polymyalgia rheumatica, polymyositis, der­ matomyositis, scleroderma, Sjogren's syndrome, crystal-induced arthropathies (e.g., gout), and juvenile rheumatoid arthritis. Inflammatory phase, proliferative phase, and remodeling phase. The answer is A. This statement is true. The answer is D. Hyaline. Tendinitis is a microscopic tear at the muscle-tendon junction. Tendinosis usually results from a degenerative process. 206. The answer is A. This statement is true. Diaphysis. The epiphyseal plate. Inflammatory phase, reparative (callus) phase, and remodeling phase. The law describes the ability of bone to adapt by changing size, shape, and structure depending on the mechanical stresses applied to bone.



19. The answer is A. 20. Smooth, skeletal, and cardiac. 21. Endomysium.

22. Slow twitch, type 1 fibers.
23. To attach muscle to bone. 24. Any three from the following: the rotator cuff of the shoulder (e.g. supraspinatus, bicipital tendons), insertion of the wrist extensors (i.e., lateral epicondylitis, tennis elbow) and flexors (e.g., medial epicondylitis) at the elbow, patellar and popliteal tendons, and iliotibial band at the knee, insertion of the posterior tibial tendon in the leg (e.g., shin splints), and the Achilles tendon at the heel. 25. The answer is A. This statement is true. 26. Any four of the following: provide support, enhance leverage, protect vital structures, provide attachments for both tendons and ligaments, and store minerals, particularly calcium. 27. Sagittal, frontal, transverse. 28. A sprain is an acute injury to the ligament, whereas a strain is an injury to the muscle. 29. The answer is C. 30. The answer is C. 31. The answer is B. 32. The answer is C. 33. The answer is D. 34. The answer is D. 35. The answer is B. 36. The answer is C. 37. The answer is B. 38. The answer is D. 39. The answer is D. 40. The answer is C. 41. The answer is A. 42. The answer is D. 43. The answer is C. 44. The answer is C.



45. The answer is D. 46. The answer is D. 47. 48. 49. 50. Osteomalacia. The answer is B. The answer is D. The answer is D.

s e c t


o n

Tests and Measures

Chapter 6 The History and Systems Review The History
Medical Screening
General Demographics Social History Occupation, Employment, and Work Environment Functional Status, Activity Level, and Current Level of Fitness Growth and Development Living Environment

Systems Review
The Scanning Examination for
Neuromusculoske/etal Conditions

Chapter 7 Gait, Posture, Ergonomics, and Occupational Health

The Gait Cycle
Stance Period
Swing Period
Gait Cycle Duration

History of Current Condition
Onset Intensity Pain Perception Quality of Symptoms Frequency and Duration Aggravating and Easing Factors Location Behavior of Symptoms Nature of the Symptoms Past History of Current Condition

Characteristics of Normal Gait
Joint Motions During Gait

Trunk and Upper Extremities
Foot and Ankle

Muscle Actions
Spine and Pelvis
Foot and Ankle

Past Medical and Surgical History Family History and General Health Status Medications

Influences on Gait




Flexibility and the Amount of Available Joint Motion Endurance-Economy of Mobility Base of Support Interlimb Coordination Leg-Length Inequality Gender Pregnancy Obesity Age Lateral and Vertical Displacement of the Center of Gravity Properly Functioning Reflexes Vertical Ground Reaction Forces

Chairs Workstation Design Environmental Barriers Work-Related Musculoskeletal Disorders

Specific Deviations of Individual Joints
Hip Knee Foot and Ankle

Principle: Management of Lost Time and Minimization of Disability Principle: Management of Neuromusculoske/etallnjury Principle: Facilitation of Timely and Appropriate Referrals Principle: Minimization of InjurylReinjury Incident Rate Personal Protective Equipment Functional Capacity Evaluation
Definitions Specific to FCE FCE Protocols Reporting Process and Format

Abnormal Gait Syndromes
Antalgic Gait Equinus Gait Gluteus Maximus Gait Plantar Flexor Gait Quadriceps Gait Spastic Gait Ataxic Gait Steppage Gait Trendelenburg Gait Parkinsonian Gait Hysterical Gait

Work Conditioning and Work Hardening Programs
Introduction Operational Definitions Work Hardening Providers Work Conditioning Guidelines Provider Responsibility Program Content Program Termination Management Model

Clinical Examination of Gait Observational Gait Analysis
Anterior View Lateral View Posterior View

Examination Diagnosis and Prognosis Interventions Outcomes

Quantitative Gait Analysis
Gait Analysis Profiles and/or Scales Posture

Chapter 8 Musculoskeletal Physical Therapy
Functional Anatomy and Biomechanics of Specific Joints Shoulder Complex Bursae Biomechanics GH Joint The Scapulohumeral Rhythm Sternoclavicular (SC) and Acromioclavicular (AC) Joints Nerve Supply Blood Supply Elbow Complex Muscles

Lateral Curvature of the Spine Posture at Work
Posture for Standing, Sitting in Office Chairs, or Driving

Driving Posture The Examination of the Environment Test and Measures Environmental Impact Posture Range of Motion Muscle Performance Gait, Locomotion, and Balance Ergonomics and Body Mechanics



Nerve Supply
Blood Supply

Wrist and Hand
Distal Radioulnar Joint
The Wrist
The Carpals
Midcarpal Joints

Intercuneiform and Cuneocuboid Joints Metatarsophalangeal Joints Interphalangeal (lP) Joints

Craniovertebral joints
Occipito-Atlantal (OA) Joint Atlanto-Axial Joint Craniovertebral Ligaments Craniovertebral Muscles Nerve Supply Blood Supply Biomechanics

Metacarpophalangeal Joints of the Second Through Fifth Fingers Carpometacarpal Joints First Carpometacarpal Joint Metacarpophalangeal Joint of the Thumb Interphalangeal Joints Palmar Aponeurosis Extensor Hood Synovial Sheaths Flexor Pulleys

Cervical Spine
Muscle Control

Temporomandibular joint
Supporting Structures
Nerve Supply

Muscles of the Wrist and Forearm
Anatomic Snuff Box Neurology , Vasculature of the Wrist and Hand Biomechan ics Movement of the Hand on the Forearm Flexion and Extension Movements of the Wrist Frontal Lateral Movements of the Wrist Thumb Movements

Thoracic Spine and Rib Cage
Biomechanics Respiration Posture Lumbar Spine The Global Muscle System The Local Muscle System

Sacroiliac joint

Examination of the Musculoskeletal System
Patient History and Systems
Tests and Measures

Observation Palpation Range of Motion Manual Muscle Testing Interpretation of Findings Accessory Joint Motion

Vascular Supply

Knee joint Complex
Tibiofemoral Joint Patellofemoral Joint Biomechanics The Quadriceps Angle Patella-Femur Contact and Loading Patellar Tracking Open- and Closed-Kinetic Chain Activities

Neurologic Testing
Special Tests of the Upper Extremity Special Tests of the Lower Extremity Special Tests of the Spine and SU Special Tests of the Cervical Spine and TMJ Upper Limb Tension Tests

Ankle and Foot joint Complex
Biomechanics Distal Tibiofibular Joint Talocrural Joint Subtalar Joint Midtarsal (Transverse Tarsal) Joint Complex Cuneonavicular Joint

Intervention Principles for Musculoskeletal Injuries
Control Pain and Inflammation
Promote and Progress Healing

Common Orthopedic Conditions
Achilles Tendinitis Acromioclavicular joint Injuries



Adhesive Capsulitis Ankle Sprains
Lateral Ankle (Inversion) Sprain

Orthopedic Surgical Repairs
Spinal Surgery
Lumbar Discectomy Laminectomy Vertebroplasty Kyphoplasty Foraminotomy

Avascular Necrosis of the Femoral Head Bursitis Carpal Tunnel Syndrome DeQuervain's Tenosynovitis Dupuytren's Contracture Epicondylitis
Lateral Epicondylitis (Tennis Elbow)

Lower Extremity
Total Joint Replacement

Meniscal Repair
Upper Extremity

Rotator Cuff Repair Flexor Tendon Repair

Medial Epicondylitis (Golfer's Elbow) Finger Injuries
Boutonniere Deformity Swan-Neck (Recurvatum) Deformity Mallet Finger Rupture of the Terminal Phalangeal Flexor Uersey Finger)

Chapter 9 Neuromuscular Physical Therapy Basic Anatomy and Physiology
Nervous System Organization Myelin Central Nervous System
Brain Meninges of the Central Nervous System

Fractures Groin Pain Hallux Valgus Lumbar Herniated Nucleus Pulposus Iliotibial Band Friction Syndrome (lTBFS) Little Leaguer's Elbow Meniscallnjuries Osteoarthritis Patella Tendinitis Patellofemoral Dysfunction Plantar Fasciitis Rheumatoid Diseases
Gout Ankylosing Spondylitis Systemic Lupus Erythematosus Psoriatic Arthritis

The Spinal Cord
Dorsal Root Fibers Gray Matter White Matter Blood Supply

Peripheral Nervous System
Autonomic Nervous System Cranial Nerves The Spinal Nerves Peripheral Nerves Cervical Nerves Thoracic Nerves Lumbar Plexus Femoral Nerve (L2-4) Obturator Nerve (L2-4)

Rotator Cuff Tendinitis Scaphoid Fracture Spinal Stenosis (Degenerative) Spondylolysis/Spondylolisthesis Temporomandibular Joint Disorders Thoracic Outlet Syndrome Tibiofemoral Joint Instability Torticollis Tumors Volkmann's Ischemic Contracture Wrist Fractures
Colles' Fracture
Smith's Fracture
Barton's Fracture
Buckle Fracture

Sacral Plexus
Collateral Branches of the Posterior Division Collateral Branches of the Anterior Division Pudendal and Coccygeal Plexuses

Monosynaptic Reflex Superficial Reflexes Babinski's Sign Primitive Reflexes Patterned Behavioral Reflexes Supraspinal Reflexes Cervico-ocu lar and Vestibu 10­ ocular Reflexes Protective Reflexes

Zygapophyseal Joint Dysfunction



Neuromuscular Control
Proprioception Balance Position and Movement Sense

Assessment of Postural Control
Visual system
Somatosensory System
Vestibular System

The Transmission of Pain
The Control of Pain

Neurologic Examination

Review of Systems
Tests and Measures

Observation Examination of Cognition Assessment of Speech and Language Assessment ofVisiospatial Function Mini-Mental State Examination (MMSE) Levels of Cognitive Function: Rancho Los Amigos Cognitive Functioning Scale Assessment of Righting Reactions Assessment of Equilibrium Reactions Standardized Tests for Functional Balance Assessment of Protective Reactions Examination of Comatose Patients Signs and Symptoms of Cerebral Edema and Increased Intracranial Pressure

Assessment of Aerobic Capacity/Endurance Examination of Autonomic Nervous System Function Diagnostic Procedures
Cerebral Angiography
Computed Tomography (CT Scan)
Electroencephalography (EEG)
Electromyogram (EMG)
Evoked Potential (EP)
Lumbar Puncture (LP)
Magnetic Resonance Imaging (MRI)
Magnetic Resonance Angiography
Nerve Conduction Velocity (NCV)
Positron Emission Tomography (PET)
Ventricu lography

Neurologic Dysfunction

Upper Motor Neuron Lesion
Nystagmus Dysphasia Wallenberg's Syndrome Ataxia Spasticity Drop Attack Wernicke's Encephalopathy Vertical Diplopia Dysphonia Hemianopia Ptosis Miosis Horner's Syndrome Dysarthria

Cranial Nerve Examination
CN I-The Olfactory Nerve CN II-The Optic Nerve CN III-Oculomotor; CN IV­ Trochlear; CN VI-Abducens Reflex Testing Oppenheim Clonus Hoffmann's Sign ~ Supraspinal Reflex Testing

Examination of Motor Function Examination of Coordination Assessment of Gait Neurodynamic Mobility Examination of Sensory Function
Description of Tests Pain Temperature Pressure Vibration Position Sense (Proprioception) Movement Sense (Kinesthesia) Stereognosis Graphesthesia Two-Point Discrimination Equilibrium Reactions

Lower Motor Neuron Lesion
Infectious Diseases

Encephal itis

Cerebral Vascular Accident
Transient Ischemic Attack
Cerebral Aneurysm
Traumatic Brain Injury
Spinal Cord Injury

Complications Associated with Spinal Cord Injury Physical Therapy Examination Physical Therapy Intervention

Cauda Equina Syndrome



Neurodegenerative and
Inflammatory Disorders

Alzheimer Disease
Multiple Sclerosis
Myasthenia Gravis
Cerebellar Disorders
Vestibular Disorders

Chapter 10 Pulmonary Physical Therapy
Anatomy and Physiology Lungs
Physical Properties of the Lungs

Muscles of Respiration

The Diaphragm Intercostal Muscles Accessory Muscles of Inspiration

Basal Ganglia Disorders
Parkinson Disease
Huntington Chorea

Pulmonary System Physiology
Terminology Mechanics of Breathing Controls of Venti lation

Cranial and Peripheral Nerve

Bell's Palsy Peripheral Nerve Injury

Closed Injuries
Nerve Repair

Nerve Graft
Nerve Transfer

Central and Peripheral Chemoreceptor Mechanisms Gas Exchange Gas Transport Intrapulmonary Shunt The Cough Mechanism

Peripheral Nerve Entrapments
Herpes Zoster
Trigeminal Neuralgia
Spinal Muscular Atrophy
Guillain-Barre Syndrome

Amyotrophic Lateral Sclerosis

Physical Therapy Examination History
Tests and Measures

Auscultation Examining the Muscles of Breathing Examining Vital Signs Chest Percussion Exercise Tolerance Tests Pulmonary Function Tests Imaging Studies Laboratory Tests

Postpolio Syndrome Neurologic Rehabilitation Recovery
Theories of Neurological

Constraint-Induced Movement Therapy Task-Oriented Approach Impairment-Focused Interventions The Brunnstrom Approach: Movement Therapy in Hemiplegia Integrated Approach Cognitive Rehabilitation

Pulmonary Pathology Obstructive Diseases
Chronic Obstructive Pulmonary Disease

Nonseptic Obstructive Pulmonary Diseases
Asthma Chronic Bronchitis Emphysema u1-Antitrypsin Deficiencyl

Management Strategies for Specific Conditions Strategies to Manage Hypertonia
Serial Casting Indications for Serial Casting Nerve Blocks Intrathecal Baclofen (ITB) Surgical Management Functional Electrical Stimulation Thermotherapy and Cryotherapy Sensory Stimulation

Septic Obstructive Pulmonary Diseases
Cystic Fibrosis

Infectious and Inflammatory Diseases
Bronchiolitis Pneumonia Mycobacterium Tuberculosis

Strategies to Manage Hypotonia
Therapeutic Exercise

Restrictive Lung Disease
Interstitial Lung Disease/Pulmonary Fibrosis Systemic Sclerosis

Vestibular Rehabilitation Therapy
Specific Exercises



Chest Wall Disease or Injury
Environmental and Occupational Diseases

Anatomy and Physiology of Blood
Production and Degradation of Blood

Parenchymal Disorders
Atelectasis Acute Respiratory Distress Syndrome

Peripheral Circulation - Blood Vessels

Pulmonary Oncology Pulmonary Vascular Disease
Pulmonary Embolism and Infarct

Pulmonary Hypertension Pulmonary Edema Pleural Diseases and Disorders

Transport of Oxygen
Lymphatic System
The Heart and Circulation

The Heart Coronary Circulation and the Cardiac Cycle

Pleural Effusion Central Disorders of the Pulmonary System
Sleep-Disordered Breath ing Physical Therapy Intervention

Electrical Conduction System of the Heart
Sinoatrial Node
Atrioventricular Node
Refractory Period
Chemical and Physical Influences

Physical Therapy Associated with Primary Prevention, Risk Reduction, and Deconditioning
Therapeutic Exercise Functional Training

on the Heart
Parasympathetic (Cholinergic) Stimulation Sympathetic (Adrenergic) Stimulation Atrial Natriuretic Factor Bainbridge Reflex

Physical Therapy Associated with Airway Clearance Dysfunction
Breathing Strategies and Exercises for Airway Clearance

Normal Exercise Response Blood Pressure Examination of the Cardiovascular System

Positioning for Airway Clearance Postural Drainage with Chest Percussion, Vibration, and Shaking
Chest Percussion ShakingNibration

Health History
Presence of Risk Factors

Physical Therapy Associated with Respiratory Failure and Ventilatory Pump Dysfunction and Failure
Manual Therapy Techniques Breathing-Assist Technique Squeezing Assistive Devices Medical Management of

Tests and Measures

Basic Biometrics Chest Expansion Vital Signs Pain Temperature Pulse Examination of Respiration Examination of Heart Sounds Examination of the Heart Rhythm Examination of Blood Pressure Relevance of Blood Pressure to Rehabi Iitation Exercise Tolerance Testing Step Tests Cycle Ergometry Tests Treadmill Tests Walk Tests Special Tests Diagnostic Tests

Respiratory Failure Special Considerations for Certain Patient Populations
Neurologic Spinal Cord Injury

Medical and Surgical Intervention for Pulmonary Disorders

Chapter 11 Cardiovascular Physical lherapy
Overview Anatomy and Physiology of the Cardiovascular System



Chest Radiograph Myocardial Perfusion Imaging Continuous Hemodynamic Monitoring (Swan-Ganz Catheter) Echocardiography Electrocardiogram (EKG) Laboratory Tests and Values

Physical Therapy Associated with Impaired Aerobic Capacity/ Endurance Associated with Cardiovascular Pump Dysfunction or Failure
Cardiac Rehabilitation

Cardiovascular Conditions Risk Factors Associated with Cardiovascular Dysfunction Peripheral Arterial and Vascular Disease
Arterial Disease Hypertension Hypotension Venous Insufficiency KI ippel-Trenau nay-Weber Syndrome Thrombophlebitis

Physical Therapy Associated with Impaired Circulation and Anthropometric Dimensions Associated with Lymphatic System Disorders
Lymphedema Venous Insufficiency

Management of Peripheral Vascular Disorders
Arterial Disease
Venous Disease

Kawasaki Disease
Heart Failure

Congestive Heart Failure

Chapter 12 Pathology, Gynecology, and Psychology
Pathology Infectious Disease
Types of Microorganisms

Fungus Bacteria Prions Parasites Virus Centers for Disease Control Guidelines for Isolation Precautions

Cor Pulmonale
Congenital Lesions
Valvular Disease
Coronary Artery Disease
Angina Pectoris

Myocardial Infarction

Inflammatory Conditions of the Heart Hematopoietic System Disorders
Sickle-Cell Disease
The Thalassemias
Fanconi's Anemia
Gaucher's Disease

Hematologic (Blood) Disorders
Disorders of Iron Absorption Disorders of Erythrocytes Hemostasis Disorders Hemophilia Thrombocytosis Thrombocytopenia The Thalassemias Histiocytosis X Physical Therapy Intervention for Hemostasis Disorders

Lymphatic Disease
Lymphedema Surgical Interventions for

Cardiovascular Conditions

Heart Valve Surgery Percutaneous Transluminal Coronary Angioplasty Coronary Artery Bypass Graft Cardiac Transplantation Transmyocardial Revascularization

Staging and Grading Physical Therapy Intervention

Genitourinary System Disorders
Water Balance Regulation of Fluids and Electrolytes Acid-Base Imbalances Urinary Tract Disorders Urinary Tract Infections Interstitial Cystitis (lC) Urinary Incontinence Renal Disorders

Cardiovascular Physical Therapy Physical Therapy Associated with Primary Prevention, Risk Reduction, and Deconditioning
Exercise Prescription



Endocrine System Disorders
Diabetes Mellitus
Thyroid Disorders
Parathyroid Disorders
Adrenal Disorders

Metabolic Disorders
Paget's Disease
Complex Disorders

Anger Acknowledgment Acceptance Adjustment Elizabeth Kubler-Ross Model of Grief Stages Physical Therapy Approach During the Grieving Process

Psychosocial Pathologies
Affective Disorders Bipolar Disorder Neuroses Dissociative Disorders Somatoform Disorders Schizophrenia Disorders Personality Disorders

Chronic Fatigue Syndrome Fibromyalgia Syndrome Myofascial Pain Syndrome Complex Regional Pain Syndrome Physical Therapy Role in Complex Disorders Gynecology Physiologic Changes That Occur During Pregnancy
Endocrine System Musculoskeletal System Neurologic System Gastrointestinal System Respiratory System Cardiovascu lar System Metabolic System Renal and Urologic Systems

Physical Therapy Intervention Empathy versus Sympathy

Chapter 13 Integumentary Physical Therapy
Skin or Integument Epidermis Dermis Accessory Structures of the Skin Hair
Vascular Supply Examination of the Integumentary System Patient/Client History and Systems Review Related to the Integumentary System Observation Signs and Symptoms of Skin Disorders Pruritis
Documentation of Skin Lesions Examination of a Skin Wound Common Skin Disorders or
Primary Skin Disorders Macule Papule Plaque Nodule Wheal

Complications Associated with Pregnancy
Hypertension Symphysis Pubis Dysfunction (SPD) and Diastasis Symphysis Pubis (DSP) Low Back Pain Coccydynia Gestational Diabetes Diastasis Recti Abdominis Cesarean Childbirth Hyperemesis Gravidarum Supine Hypotension Psychiatric Changes

Physical Therapy Examination Physical Therapy Intervention Psychology Anxiety Acute Stress Disorder (ASD) and Post-Traumatic Stress Disorder (PTSD) Coping/Defense Mechanisms Depression The Grief Process
Shock, Numbness, Denial, and Disbelief Bargaining Depression




Burn Healing and Management
Initial Evaluation and Resuscitation Initial Wound Excision and Biological Closure Definitive Wound Closure Rehabi Iitation, Reconstruction, and Reintegration Postdischarge Surgical Intervention

Secondary Skin Disorders
Vascular Skin Lesions
Eczema and Dermatitis

Exogenous (Contact) Dermatitis Endogenous (Constitutional) Dermatitis

Bacterial Infections
Bacterial Infections Localized to Hair Generalized Bacterial Skin Infections

Wound Care
Wound Dressings Negative-Pressure Wound Therapy Selective Debridement Nonselective Debridement

Viral Infections
Herpes Simplex Herpes Zoster (Shingles) Plantar Warts

Fungal Infections

Parasitic Infections Melanin Pigmentation Disorders
Hypopigmentation and Depigmentation Hyperpigmentation

Factors Influencing Wound Healing Scar Management Therapeutic Exercise Functional Training Manual Lymphatic Drainage Electrotherapeutic Modalities Physical Agents and Modalities

Non-Physical Therapy Interventions
Hyperbaric Oxygen Therapy (HBO)

Benign Dermatoses
Psoriasis Systemic Sclerosis Discoid Lupus Erythematosus

Chapter 14 Geriatric Physical Therapy
Theories of Aging Definitions
Life Expectancy
Component Age Croups

Autoimmune Skin Disorders
Polymyositis (PM)

Pressure Ulcers Arterial Insufficiency (Ischemic) Ulcers Neuropathic Ulcers Venous Insufficiency U leers

Skin Cancer
Benign Tumors
Premalignant Tumors
Malignant Tumors

Physiologic Changes and
Adaptations in the Old Adult

Impaired Strength
Impaired Balance

Intervention Strategies for Impaired Balance

Superficial Burn Superficial Partial-Thickness Burn Deep Partial-Thickness Burn Full-Thickness Burn Subdermal Burn Electrical Burn Burn Extent Complications of Burn Injury

Impaired Coordination
Impaired Cognition

Dementia Intervention Strategies for Impaired Cognition

Pathologic Conditions Associated with the Elderly
Musculoskeletal Disorders and Diseases

Physical Therapy Intervention for Impaired Integumentary Integrity
Patient/Client-Related Instruction



Neurologic Disorders and Diseases Cerebrovascular Accident (Stroke)

Physical Therapy Examination Physical Therapy Intervention
Degenerative Diseases Parkinson's Disease Alzheimer's Disease Cognitive Disorders Delirium and Dementia Depression Cardiovascular Disorders and Diseases Hypertension Coronary Artery Disease Pulmonary Disorders and Diseases Chronic Bronchitis/Chronic Obstructive Pulmonary Disease (COPD) Asthma Pneumonia Lung Cancer Integumentary Disorders and Diseases Decubitus Ulcers Metabolic Pathologies Diabetes Mellitus

Postoperative Period Postoperative Dressings Postoperative Physical Therapy Postoperative Intervention

lower limb Prosthetic Designs
Partial Foot Amputations Phalangeal Amputations Transphalangeal (Toe Disarticulation) Transtibial (Below the Knee) Transfemoral (Above the Knee) Hip Disarticulation Hemipelvectomy Hemicorporectomy Prosthetic Components Shanks
Foot Socket Designs
Knee Socket Designs
Hip Joints Hip Flexion Bias System Littig Hip Strut

lower limb Prosthetic Training
Proprioceptive Training
Gait Examination and Training
Abnormal Transtibial Gait Abnormal Transfemoral Gait

Ethical and legal Issues
The Living Will (Advanced Care Medical Directive) Refusal of Treatment "Do Not Resuscitate" (DNR) Orders Health Care Proxy Informed Consent

Upper limb Prosthetic Devices
Levels of Upper Limb Amputation Terminal Devices Hooks Hands Wrist Units Transradial Sockets Hinges Transradial Harness and Controls Elbow Units Use of the Prosthesis

Common Functional Problem Areas in the Geriatric Population
Immobility-Disability Physical Therapy Intervention Falls and Instability Evaluation of the Elderly Patient Who Falls Physical Therapy Intervention Polypharmacy and Medication Errors Nutritional Deficiency Physical Therapy Role

General Concepts Lower Limb Orthoses: Components/ Terminology Shoe Components Foot Orthoses Shoe Modifications Ankle-Foot Orthoses Knee-Ankle-Foot Orthoses Knee Orthotics Hip-Knee-Ankle-Foot Orthoses Reciprocal Gait Orthosis Standing Frame and Swivel Walker Parapodium Thoracic and Lumbosacral Orthoses Rigid

General Principles of Geriatric Rehabilitation

Chapter 15 Prosthetics, Orthotics, and Assistive Devices
Levels of Amputation



Cervical Orthoses Upper Limb Orthoses
Hand and Wrist Orthoses Elbow Orthoses

Infant Assessment Tools
Brazelton Neonatal Behavioral Assessment Scale (BNBAs) General Movement Assessment Dubowitz Neurologic Assessment of the Preterm and Full-Term Infant Movement Assessment of Infants Alberta Infant Motor Scales (AIMS) Harris Infant Neuromotor Test

Athletic Taping Skin Preparation Application Complications Transfer Training Levels of Physical Assistance Types of Transfers
Dependent Transfers Assisted Transfers

Comprehensive Developmental Assessment
Bayley Scales of Infant Development-II

Assistive Devices Canes Crutches Walkers Levels of Weight Bearing Gait Training with Assistive Devices
Two-Point Pattern Three-Point Gait Pattern Four-Point Pattern Sit to Stand Transfers Using Assistive Devices Stand to Sit Transfers Using Assistive Devices Stair and Curb Negotiation Instructions

Motor Assessments
Peabody Development Motor Scales-2 (PDMs-2) Bruininks Oseretsky Test of Motor Proficiency

Assessments Designed for Children with Disabilities
Gross Motor Function Measure
Pediatric Evaluation of Disability
Inventory (PED!)
Functional Independence Measure
for Children (WEEFIM)

Other Tests
School Function Assessment Pediatric Clinical Test of Sensory Interaction for Balance (PCTSIB)

Wheelchair Measurements Wheelchair Components Specialized Wheelchairs Wheelchair Training

Chapter 16 Pediatric Physical Therapy
Motor Control Motor Development Motor Development Theories
Neural-Maturationist Cognitive Theories

Pediatric Examination and Interventions for Specific Conditions Systems Review
Tests and Measures
Plan of Care
Conditions Related to the Neonate Prematurity
In Uterus Substance Exposure

Fetal Alcohol Syndrome Cocaine Exposure

Congenital Central Hypoventilation Syndrome Head Trauma in Newborns
Caput Succedaneum
Cepha Ihematoma

Prenatal Development Developmental Milestones Approximate Ages of Epiphyseal Closures Automatic Postural Responses Motor Programming Motor Learning Motor Learning Theories Primitive Reflexes Pediatric Screening and Diagnostic Tools .

Birth Trauma
Pulmonary System

Cyanosis Choanal Atresia Acute Respiratory Distress Syndrome Atelectasis Bronchopulmonary Dysplasia Bronchiolitis



Periventricular Leukomalada (PVL)
Legg-Calve-Perthes Disease Periventricular Hemorrhage­
Physical Therapy Role Osgood-Schlatter Disease Intraventricular Hemorrhage
Physical Therapy Role Idiopathic Scoliosis Cardiovascular System

Patent Ductus Arteriosus (PDA) Tetralogy of Fallot Physical Therapy Role

Cerebral Palsy
Physical Therapy Role

Musculoskeletal System
Congenital Muscular Torticollis Talipes Equinovarus (Club Foot) Congenital (Developmental) Hip Dysplasia Osteogenesis Imperfecta

Physical Therapy Role

Down Syndrome (Trisomy 21)
Physical Therapy Role

Brain Injury
Traumatic Brain Injury
Near-Drown ing
Brain Tumors

Neurologic System
Hydrocephalus Arthrogryposis Brachial Plexus Injury Spina Bifida Prader-Willi Syndrome

Seizure Disorders Duchenne Muscular Dystrophy
Physical Therapy Role

The Role of the Physical Therapist in the Special Care Nursery
Developmental Interventions Discharge Planning

Spinal Muscular Atrophy
Physical Therapy Role

Wilms Tumor
Bone Tumors
Physical Therapy Role in
Oncology Cases

Physical Therapy Roles for Specific Pediatric Pathologies
Asthma (Hyperreactive Airway Disease)
Physical Therapy Role

Cystic Fibrosis
Physical Therapy Role

Nursemaid's Elbow Torsional Conditions Slipped Capital Femoral Epiphysis
Physical Therapy Role

Rheumatology: Juvenile Rheumatoid Arthritis Hematopoietic System: Hemophilia

The History and Systems Review

The history (Table 6-1) usually precedes the systems review and the tests and measures components of the examination, but it may also occur concurrently. The clinician must record the history in a system­ atic fashion so that no subject areas are neglected. The purpose of the history is to:
1. Develop a working relationship with the patient, and to estab­

Study Pearl
It is.irnportantto.remembertha~;~,¥rnp­ tom!ican be experieoced~ithoutthe presence (}fTecog~ized . cIinical signs, anQ that 5igrtscan~.pr~sent;inthe abs~rtceot~ymptol1J~'Theformer~ce'­ nario .·15 morer9o~~?n,butrt~~latter can· occur, <fl1)rex~O'lpte, ifni situttti.ons

lish lines of communication with the patient.
2. Elicit reports of potentially dangerous symptoms, or red flags that require immediate medical referral (Table 6-2).1

3. Determine the chief complaint, its mechanism of injury, its severity, and its impact on the patient's function. 4. Ascertain the specific location, and nature of the symptoms. 5. Determine the irritability of the symptoms. 6. Establish a base line of measurements. 7. Elicit information on the history and past history of the current condition. 8. Gather information about the patient's past general medical and surgical history. While this information is not always related to the presenting condition, it does afford the clinician some insight as to the impact the information may have on the patient's tolerance or response to the planned intervention. 9. Determine the goals and expectations of the patient from the physical therapy intervention, and the functional demands of a specific vocational or avocational activity to which the patient is planning to return.
MEDICAL SCREENING Performing a medical screen is an inherent step in making a diagnosis for the purpose of deciding whether a patient referral is warranted, but the medical screen performed by the physical therapist is not synony­ mous with differential diagnosis.

When a.pathol.og~c reft~){ror po~itive

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or it

(;(;>u .Id;b.ea false-pl1)sitive;cesult, could oo;prQgllostic.z

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.~·iffer~Iltial·di~?n(}sis.·.ihvQlvest~.e.abi.l~ ity.. ·t(,).qulckIYi.cj.iffere~tiate.problems of
e){arnjmttjon.~r.oblemsofa .serious

aseriouso,atur~Jromth.osethatare f:l()tiLJ.~~ng,lhe history7(lnd;pAysical

naturejnclyde,. but are not limited to!

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History of Current Condition Did the condition begin insidiously or was trauma involved?
How long has the patient had symptoms?
Where are the symptoms?
How does the patient describe symptoms? Reports about numbness and tingling suggest neurologic compromise. Reports of pain
suggest chemical or mechanical irritant. Pain needs to be carefully evaluated in terms of its site, distribution, quality, onset, fre­ quency, nocturnal occurrence, aggravating factors, and relieving factors. Past History of Current Condition Has the patient had a similar injury in the past?
Was it treated or did it resolve on its own? If it was treated, how was it treated and did intervention help?
How long did the most recent episode last?
Past Medical/Surgical History How is the patient's general health? Does the patient have any allergies? Medications Patient Is Presently Taking Do the prescribed medications indicate a pathology not mentioned by the patient? Do the prescribed medications have any known side effects or contraindications? Other Tests and Measures Has the patient had any imaging tests such as x-ray, MRI, CT scan, bone scan? Has the patient had an EMG test, or a nerve conduction velocity test, which would suggest compromise to muscle tissue and/or neurologic system? Social Habits (Past and Present) Does the patient smoke? If so, how many packs per day?
Does the patient drink alcohol? If so, how often and how much?
Is the patient active or sedentary?

Social History Is the patient married, living with a partner, single, divorced, widowed? Is the patient a parent or single parent? Family History Is there a family history of present condition?
Growth and Development Is the patient right- or left-handed? Were there any congenital problems? living Environment What type of home does the patient live in with reference to accessibility?
Is there any support at home?
Does the patient use any extra pillows or special chairs to sleep?
Occupational/Employment/School What does the patient do for work?
How long has he or she worked there?
What does the job entail in terms of physical requirements?
What level of education did the patient achieve?
Functional Status/Activity Level How does the present condition affect the patient's ability to perform activities of daily living?
How does the present condition affect the patient at work?
How does the patient's condition affect sleep?
Is the patient able to drive? If so, for how long?

CT, computed tomography; EMG, electromyogram; MRI, magnetic resonance imaging.
Data from Clarnette RG, Miniaci A. Clinical exam of the shoulder. Med Sci Spons Exerc. 1998;30:1-6.



Recent unexplained weight changes

Malaise or fatigue

Unexplained nausea or vomiting Dizziness

Unilateral, bilateral, or quadrilateral paresthesias

Shortness of breath Bowel or bladder dysfunction Night pain Pain following eating Weakness

A gradual increase in the intensity of the pain Radicular pain Numbness

Systemic problem (infection, cancer, disease). Increased sweating can have a myriad of causes ranging from increased body temperature due to exer­ tion, fever, apprehension, and compromise to the autonomic system. Night sweats are of particular concern as they can often indicate the presence of a systemic problem. An unexplained weight gain could be due to congestive heart failure, hypothyroidism, or cancer. An unexplained weight loss could be due to a gastrointestinal disorder, hyperthyroidism, cancer, or diabetes. Systemic disease. Thyroid disease. Iron deficiency. Never a good sign. Although most causes of diZZiness can be relatively benign, dizziness may signal a more serious problem, especially if the dizziness is associated with trauma to the neck or head, or with motions of cervical rotation and exten­ sion (vertebral artery compromise). The clinician must ascertain whether the symptoms result from vertigo, nausea, giddiness, unsteadiness, fainting, etc. Vertigo requires that the patient's physician be informed, for further investigation. However, in itself it is not usually a contraindication to the continuation of the examination. The seriousness of the paresthesia depends upon its distribution. Quadrilateral paresthesia always indicates the presence of central nervous system involvement. Systemic problem. Bowel and bladder dysfunction may indicate involvement of the cauda equina. Malignancy. Gastrointestinal problems. Any weakness should be investigated by the clinician to determine whether it is the result of spinal nerve root compression, a peripheral nerve lesion, disuse, inhibition due to pain or swelling, an injury to the contractile or inert tissues (muscle, tendon, bursa, etc.), or a more serious pathology such as a fracture. Radiating pain refers to an increase in pain intensity and distribution. Radiating pain typically travels distal from the site of the injury. Nerve root irritation. Numbness that is a dermatomal pattern indicates spinal nerve root compression.

Data from D'Ambrosia R. Musculoskeletal Disorders: Regional Examination and Differential Diagnosis. 2nd ed. Philadelphia: Lippincott; 1986; and Goodman CC, Snyder TEK. Differential Diagnosis in Physical Tberapy. Philadelphia: W.B. Saunders; 1990.

The purpose of the medical screen is to confirm (or rule out) the need for physical therapy intervention, the appropriateness of the referral, whether there are any red-flag findings, red-flag risk factors, or clusters of red-flag signs and/or symptoms, and whether the patient's condition falls into one of the four categories of conditions outlined by The Guide. 3 Boissonnault and Bass4 noted that screening for medical disease includes communicating with a physician regarding a list or pattern of signs and symptoms that have caused concern, but not to suggest the presence of a specific disease. s According to The GUide,6 the components of the patient history include the topics covered in the follOWing sections.

General Demographics. This includes information about the patient's age, height, weight, marital status, primary language spoken,



and so forth. 6 Certain conditions are related to age, race, and gender. For example:
~ ~ ~ ~



~ ~

One in every 600 African Americans in the United States has sickle-cell anemiaJ Basal cell carcinoma and melanoma are more common in the white population. Degenerative and overuse syndromes are more frequent in the over-40 age group. The onset of ankylosing spondylitis often occurs between the ages of 15 and 35 years. s Both osteoporosis and osteoarthritis are associated with the older population. Prostate cancer has a higher incidence in men older than 50 years. 9 The male-to-female ratio of bladder cancer is 2:1 to 4:1, and the disease is twice as common in white American men as in black American men.IO,l! Among American women, breast cancer is the most frequently diagnosed cancer and the second leading cause of cancer­ related deaths. 12 Melanoma is the leading cause of cancer death in women aged 25 to 36 years old. 13 Anterior knee pain due to patellofemoral syndrome is most com­ mon in young teenage girls, and also in young men in their 20S.I 4

Social History. The clinician should procure information about the patient's social history, including support systems, family and care­ giver resources, and cultural beliefs and behaviors. 6 An individual's response to pain and dysfunction is, in large part, determined by his or her cultural background, social standing, educational and economical status, and anticipation of functional compromise. I5 Occupation, Employment, and Work Environment. The clinician should acquire information about the patient's occupation, employment, and work environment, including current and previous community and work activities. 6 The clinician must determine the patient's work demands, the activities involved, and the activities or pos­ tures that appear to be aggravating his or her condition. F!Jnctional Status, Activity Level, and Current Level of Fitness. The clinician must obtain information about the patient's
current and prior level of function, with particular reference to the type of activities performed and the percentage of time spent performing those activities.

Growth and Development. This section includes information about the patient's developmental background, and hand or foot dom­ inance. Examples of developmental or congenital disorders that the cli­ nician should note include such conditions as Legg-ealve-Perthes dis­ ease, cerebral palsy, Down syndrome, spina bifida, scoliosis, and congenital hip dysplasia. Living Environment. The clinician should be aware of the living situation of the patient, including entrances and exits to the house, the number of stairs, and the location of bathrooms within the house.



This portion of the history taking can prove the most challenging, and involves the gathering of both positive and negative findings, followed by the dissemination of the information into a working hypothesis. An understanding of the patient's history of the current condition can often help determine the prognosis and guide the intervention. The clinician should determine the circumstances and man­ ner in which the symptoms began, and the progression of those symp­ toms. 16 The mode of onset, or mechanism of injury, can be either trau­ matic (macrotraumatic) or atraumatic (microtraumatic), and can give clues as to the extent and nature of damage caused.

Study Pearl
Constant pain" following an inJlJI'y contiOtles .lJntil the heaJing pr(,')<;ess ha~ suffidehtlyreducedthe<;oncenr tratioflof nox;iou$irrltants~


Study Pearl
The achl ng ,type of pain, associated with degenerative arthritis and rhtlscle disorders, is often accentuated by activ­ ity and lessened by rest Painlb~tis not alleviated by rest, thatis notassociated with ",acute trauma/may'indicate· tbe presence ofaserious disorder such as a tumor or aneurysm. This pain is>o£ten described as deep,tQMstant~l1db()r­ ing, and is apt to be more noticeable and more intense at night}9
L _

Intensity. One of the simplest methods to quantify the intensity of pain is to use a lO-point visual analogue scale. The visual analog scale (VAS) is a numerically continuous scale that requires the pain level be identified by making a mark on a 100-mm line. 17 The patient is asked to rate his or her present pain compared with the worst pain ever experienced, with 0 representing no pain, 1 representing minimally perceived pain, and 10 representing pain that requires immediate attention. 18 Pain Perception. It is important to remember that pain perception is highly subjective. Pain is a broad and significant symptom that can be described using many descriptors. The symptoms of chronic pain typically behave in a mechanical fashion, in that they are provoked by activity or repeated movements, and reduced with rest, or a movement in the opposite direction. Quality of Symptoms. The quality of the symptoms depends on the type of receptor being stimulated.
~ ~ ~

Study Pearl
Patients' with chroQkpi:lln may be more prone to ,depression' and dis­ rupted ihterpersonal relationships.20-23

Stimulation of the cutaneous A-delta nociceptors leads to prick­ ing pain. 24 Stimulation of the cutaneous C nociceptors results in burning or dull pain. 25 Activation of the nociceptors in muscle by electrical stimulation produces aching pain. 26 Electrical stimulation of visceral nerves at low intensities results in vague sensations of fullness and nausea, but higher intensi­ ties cause a sensation of pain. 27

Peripheral neuropathies can manifest as abnormal, frequently unpleasant sensations, which are variously described by the patient as numbness, pins and needles, and tingling. 28 When these sensations occur spontaneously without an external sensory stimulus, they are called paresthesias (Table 6-3).28 Patients with paresthesias typically demonstrate a reduction in the perception of cutaneous and proprio­ ceptive sensations. Motivational-affective circuits can also mimic pain states, most notably in patients with anxiety, neurotic depression, or hysteria. 22 The MADISON mnemonic outlines the behavioral indicators that suggest motivational-affective pain 29 ,30:


tudY Pearl
Because motorand sensory axonsruh in thesameMerves,disord~rsof the P,eri P'"heral nerves (neuropathies) usu~ , ally affect both motor and sensory functions.



TABLE 6-3. CAUSES OF PARESTHESIA PARESTHESIA LOCATION Lip (perioral) Bilateral lower or bilateral upper extremities All extremities simultaneously One half of body Segmental (in dermatomal pattern) Glove-and-stocking distribution Half of face and opposite half of body PROBABLE CAUSE Vertebral artery occlusion Central protrusion of disk impinging on spine Spinal cord compression Cerebral hemisphere lesion Disk or nerve root Diabetes mellitus neuropathy, lead or mercury poisoning Brainstem impairment

Study Pearl

Multiple complaints, including complaints about unrelated body
Authenticity claims in an attempt to convince the clinician the
symptoms exist.
Denial of the negative effect the pain is having on function.
Interpersonal variability, manifested by different complaints to dif­
ferent clinicians or support staff.
Singularity of symptoms, where the patient requests special con­
sideration due to their type and level of pain.
Only you, where the clinician is placed at a special level of expertise. Nothing works.

Frequency and Duration. The frequency and duration of the patient's symptoms can help the clinician to classify the injury accord­ ing to its stage of healing: acute (inflammatory), subacute (migratory and proliferative), and chronic (remodeling) (see Table 5-31). Aggravating and Easing Factors. Of particular importance are the patient's chief complaint and the relationship of that complaint to specific aggravating activities or postures. Musculoskeletal condi­ tions are typically aggravated with movement and alleviated with rest (Table 6-4). If no activities or postures are reported to aggravate the symptoms, the clinician needs to probe for more information. Nonmechanical events that provoke the symptoms could indicate a nonmusculoskeletal source for the pain32 :

Night pain. Pain at night, unrelated to movement, that disturbs or prevents sleep may indicate a malignancy. Eating. Pain that increases with eating may suggest gastroin­ testinal involvement.

TABLE 6-4. DIFFERENTIATION BETWEEN MUSCULOSKELETAL AND SYSTEMIC PAIN MUSCULOSKELETAL PAIN Usually decreases with cessation of activity Generally lessens at night Aggravated with mechanical stress Usually continuous or intermittent
Reproduced, with permission, from Meadows York: McGraw-Hili; 1999.

SYSTEMIC PAIN Reduced by pressure Disturbs sleep Not aggravated by mechanical stress Usually constant or in waves

J. Orthopedic Differential Diagnosis in Physical Therapy. New

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Stress. An increase in overall muscle tension prevents muscles from resting. Cyclical pain. Cyclical pain can often be related to systemic events, as with menstrual pain. If aggravating movements or positions have been reported, they should be tested at the end of the tests and measures, to avoid any overflow of symptoms, which could confuse the clinician.

Study Pearl

location. The clinician should determine the location of the symp­ toms, as this can indicate which areas need to be included in the physi­ cal examination. Information about how the location of the symptoms has changed since the onset can indicate whether a condition is wors­ ening or improving. In general, as a condition worsens the symptom dis­ tribution becomes more Widespread and distal (peripheralizes). As the condition improves, the symptoms tend to become more localized (cen­ tralized). A body chart may be used to record the location of symptoms. It must be remembered that the location of symptoms for many musculoskeletal conditions is quite separate from the source, espe­ cially in those peripheral joints that are more proximal, such as the shoulder and the hip. The term referred pain is used to describe those symptoms that have their origin at a site other than where the patient feels the pain. If the extremity appears to be the source of the symp­ toms, the clinician should attempt to reproduce the symptoms by load­ ing the peripheral tissues. If this proves unsuccessful, a full investiga­ tion of the spinal structures must ensue. Behavior of Symptoms. The behavior of the symptoms aids the clinician in determining the stage of healing and the impact it has on the patient's function. Whether the pain is worsening, improving, or unchanging provides information on the effectiveness of an interven­ tion. In addition, a gradual increase in the intensity of the symptoms over time may indicate to the clinician that the condition is worsening or is nonmusculoskeletal in nature. 16.32 Maitland33 introduced the concept of the degree of irritability. An irritable structure has the following characteristics:

Study Pearl



A progressive increase in the severity of the pain with move­ ment or a specific posture. An ability to reproduce constant pain with a specific motion or posture indicates an irritable structure. Symptoms increased with minimal activity. An irritable struc­ ture is one that requires very little to increase the symptoms. Increased latent response of symptoms. Symptoms do not usually resolve within a few minutes following a movement or posture.

According to McKenzie and MaY,31 the intervention for the ortho­ pedic patient whose symptoms have a low degree of irritability, and are gradually resolving, should focus on only education initially. However, if the improvement ceases, a mechanical intervention may then be necessary,3l

Nature of the Symptoms. The clinician must determine whether pain is the only symptom, or whether there are other symptoms that accompany the pain, such as dizziness, bowel and bladder changes, tin­ gling (paresthesia), radicular pain/numbness, weakness, and increased sweating.


~ ~


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Dizziness (discussed later). Bowel or bladder dysfunction usually indicates a compromise (compression) of the cauda equine. Paresthesia. The seriousness of the paresthesia depends upon its distribution. While complaints of paresthesia can be the result of a relatively benign impingement of a peripheral nerve, the reasons for its presence can vary in severity and seriousness (Table 6-3). Radicular pain is produced by nerve root irritation. This type of pain is typically sharp, or shooting. Numbness that is a der­ matomal pattern indicates spinal nerve root compression. Radiating pain refers to an increase in pain intensity and distri­ bution. Radiating pain typically travels distal from the site of the injury. Weakness. Any weakness should be investigated by the clinician to determine whether it is the result of a neurological lesion (e.g., cerebral hemisphere lesion, spinal nerve root compression, or a peripheral nerve lesion), disuse, inhibition due to pain or swelling, an injury to the contractile or inert tissues (muscle, ten­ don, bursa, etc.), or a more serious pathology such as a fracture.

Past History of Current Condition. It is important for the clinician to determine whether the patient has had successive onsets of similar symptoms in the past, as recurrent injury tends to have a detri­ mental affect on the potential for recovery. If it is a recurrent injury, the clinician should note how often, and how easily, the injury has recurred, and the success or failure of previous interventions.
The patient's past medical history (PMH) can be obtained through a questionnaire (Table 6-5). The PMH can provide information with regard to allergies, childhood illnesses, and previous trauma. In addi­ tion, information on any health conditions such as cardiac problems, high blood pressure, or diabetes, should be elicited, as these may impact exercise tolerance (cardiac problems, high blood pressure) and speed of healing (diabetes). If the surgical history (Table 6-5) is related to the current problem, the clinician should obtain as much detail about the surgery as possi­ ble from the surgical report, including any complications, precautions, or postsurgical protocols.

Certain diseases, such as rheumatoid arthritis, diabetes, cardiovascular disease, and cancer have familial tendencies. The general health status refers to a review of the patient's health perception, physical and psychological function, as well as any specific questions related to a particular body region or complaint. 6

Although the dispensing of medications is out of the scope of practice for a physical therapist, questioning patients about their prescribed medications can reveal medical conditions that the patient might not

CHAPTER 6. THE HISTORY AND SYSTEMS REVIEW TABLE 6-5. SAMPLE MEDICAL HISTORY QUESTIONNAIRE General Information Date: Last Name First Name The information requested may be needed if you have a medical emergency. Person to be notified in emergency Phone Are you currently working? (Y) or (N) If not, why? Type of work General Medical History Please check ('1/) if you have been treated for: ( ) Heart problems () Lung disease/problems ( ) Arthritis ( ) Fainting or dizziness ( ) Swollen and painful joints ( ) Shortness of breath ( ) Calf pain with exercise ( ) Irregular heartbeat ( ) Severe headaches ( ) Stomach pains or ulcers ( ) Pain with cough or sneeze ( ) Recent accident ( ) Back or neck injuries ( ) Head trauma/concussion ( ) Diabetes ( ) Muscular weakness ( ) Stroke(s) () Cancer ( ) Joint dislocation(s) ( ) Balance problems ( ) Muscular pain with activity ( ) Broken bone ( ) Difficulty sleeping ( ) Swollen ankles or legs ( ) Frequent falls ( ) Jaw problems ( ) Unexplained weight loss ( ) Circulatory problems () Tremors ( ) Epilepsy/seizures/convulsions ( ) High blood pressure (hypertension) ( ) Chest pain or pressure at rest ( ) Allergies (latex, medication, food) ( ) Kidney disease ( ) Constant pain unrelieved by rest ( ) Liver disease ( ) Pregnancy ( ) Weakness or fatigue ( ) Hernias ( ) Night pain (while sleeping) ( ) Blurred vision ( ) Nervous or emotional problems ( ) Bowellbladder problems ( ) Any infectious disease (TE, AIDS, hepatitis) ( ) Difficulty swallowing ( ) Tingling, numbness, or loss of feeling. If yes, where? ( ) A wound that does not heal ( ) Constant pain or pressure during activity ( ) Unusual skin coloration Do you use tobacco? (Y) or (N) If yes, how much? Are you presently taking any medications or drugs? (Y) or (N) If yes, what are you taking them for?
1. Pain
On the line provided, mark where your "pain status" is today.




No pain


Most severe pain


2. Function. On a scale of 0 to 10, with 0 being able to perform all of your normal daily activities, and 10 being unable to perform
any of your normal daily activities, give yourself a score for your current ability to perform your activities of daily living.
Please list any major surgery or hospitalization:
Hospital: _ Approx. Date: _ Reasons: Hospital: _ Approx. Date: _ Reasons: Have you recently had an x-ray, MRI, or CT scan for your condition? (Y) or (N) Facility: Approx. date: _ Findings: Please mention any additional problems or symptoms you feel are important: Have you been evaluated and/or treated by another physician, physical therapist, chiropractor, osteopath, or health care practitioner for this condition? (Y) or (N) If yes, please circle which one.



consider related to his or her present problem.! Medications can also have an impact on clinical findings and the success of an intervention (see Chapter 19).34

The purpose of the systems review is to:


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Help determine the anatomic and physiologic status of all systems (i.e., musculoskeletal, neurologic, cardiovascular, pulmonary, integumentary, gastrointestinal, urinary, and reproductive; see the discussion later in this chapter).35 Provide information about communication skills, affect, cogni­ tion, language abilities, education needs, and learning style of the patient.35 Narrow the focus of subsequent tests and measures.
Define areas that may cause complications or indicate a need for
precautions during the examination and intervention processes. Screen for physical, sexual, and psychological abuse. Make a determination of the need for further physical therapy services based on an evaluation of the information obtained. Identify problems that require consultation with, or referral to, another health care provider.

With the majority of states now permitting direct access to physical therapists, many physical therapists now have the primary responsibility for being the gatekeepers of health care and for making medical refer­ rals. In light of the APTA's movement toward realizing Vision 2020, an operational definition of autonomous practice and the related term autonomous physical therapist practitioner is defined by the APTA's Board as follows:


Autonomous physical therapist practice is practice character­ ized by independent, self-determined professional judgment and action. An autonomous physical therapist practitioner within the scope of practice defined by the Guide to Physical Therapist Practice, provides physical therapy services to patients who have direct and unrestricted access to their services, and may refer as appropriate to other health-care providers and other profes­ sionals and for diagnostic tests. 36

Through the history and physical examination, physical therapists diagnose and classify different types of conditions for use in their clinical reasoning and intervention. 5 The Guide clearly articulates the physical therapist's responsibility to recognize when a consultation with, or referral to, another health care provider is necessary.6 The systems review, in addition to the scanning examination (see Table 6-6 and the discussion later in this chapter), is the critical part of the examination that identifies possible health problems that require consultation With, or referral to, another health care provider. 6 The sys­ tems review is based on the clinician's knowledge of body system physiology so that malfunctions of the various systems can be detected through comprehensive questioning.



Willingness to move, ROM, integrity of contractile and inert tissues, pattern of restriction (capsular, or noncapsular), quality of motion, and symptom reproduction Integrity of inert and contractile tissues, ROM, end-feel, sensitivity Integrity of contractile tissues (strength, sensitivity) Integrity of inert tissues (ligamentous/disc stability) Dural mobility Nerve conduction Afferent pathway (sensation) Efferent pathway (strength, fatigability) Afferent-efferent pathways, and central nervous systems

All patients should be questioned about their general health. This is usually obtained using a patient self-report questionnaire (Table 6-5). The self-report questionnaire should be designed to address such issues as 37 :


Fatigue: complaints of feeling tired or run down are extremely common, and therefore often only become significant if the patient reports that tiredness interferes with the ability to carry out typical daily activities and when the fatigue has lasted for 2 to 4 weeks or longer. Many serious illnesses can cause fatigue (Table 6-7). Malaise: a sense of uneasiness or general discomfort that is often associated with conditions that generate fever.

TABLE 6-7. CONDITIONS PRESENTING AS CHRONIC FATIGUE Psychological Depression Anxiety Somatization disorder Hypothyroidism Diabetes mellitus Pituitary insufficiency Addison's disease Chronic renal failure Hyperparathyroidism Endocarditis Tuberculosis Mononucleosis Hepatitis HIV infection Occult malignancy Congestive heart failure Chronic obstructive pulmonary disease Rheumatic disorders Sleep apnea Esophageal reflux



Neoplasms Cardiopulmonary Connective tissue disease Sleep disturbances Allergic rhinitis

Reproduced, with permISSIon, from Boissonnault WG. Review of Systems. In: Boissonnault WG, ed. Primary Care for the Physical1berapist: Examination and Triage. St. Louis: Elsevier W.B. Saunders; 2005:87-104. Copyright © Elsevier.







Feverlchills/sweats: these are signs and symptoms that are most often associated with systemic illnesses such as cancer, infections, and connective tissue disorders such as rheumatoid arthritis. To qualify as a red flag, the fever should have some longevity (2 weeks or longer). Unexpected weight change: a sensitive but nonspecific finding that can be a normal physiologic response, but may also be associated with depression, cancer, or gastrointestinal disease. Nausea/vomiting: persistent vomiting is an uncommon com­ plaint reported to a physical therapist, as the physician will have already been contacted. However a low-grade nausea, which can be caused by systemic illness or an adverse drug reaction, may be reported. Dizziness/lightheadedness: dizziness (vertigo) is a nonspecific neurologic symptom that requires a careful diagnostic workup. A report of vertigo, although potentially problematic, is not a contraindication to the continuation of the examination. Differential diagnosis includes primary central nervous system diseases, vestibular and ocular involvement, and more rarely, metabolic disorders. 38 Careful questioning can help in the dif­ ferentiation of central and peripheral causes of vertigo. Dizziness provoked by head movements or head positions could indicate an inner ear dysfunction. Dizziness provoked by certain cervical motions, particularly extension or rotation, also may indicate vertebral artery compromise. Paresthesia/numbness/weakness (Table 6-3). Change in mentation/cognition: can be a manifestation of mul­ tiple disorders including delirium, dementia, head injury, stroke, infection, fever, and adverse drug reactions. The clini­ cian notes whether the patient's communication level is age appropriate, whether the patient is oriented to person, place, and time, and whether emotional and behavioral responses appear to be appropriate to circumstances.

The systems review includes an assessment of the anatomic and physiologic status of all systems (Le., musculoskeletal, neurologic, car­ diovascular, pulmonary, integumentary, gastrointestinal, urinary, and reproductive), including the following. 35

For the cardiovascular/pulmonary system, the assessment of heart rate, respiratory rate, blood pressure, and edema. The four so-called vital signs, which are standard in most medical settings, include temperature, heart rate and blood pressure, and respiratory rate. Pain is considered by many to be the fifth vital sign (see Chapter 9 ).39--48 The clinician should monitor at least heart rate and blood pressure in any person with a history of cardiovascular disease or pulmonary disease, or those at risk for heart disease. 49 The equipment needed to assess these vital signs is a thermometer, a blood pressure (BP) cuff with a stethoscope (or an automatic BP machine), and a watch or clock. • Temperature. Body temperature is one indication of the metabolic state of an individual; measurements provide infor­ mation concerning basal metabolic state, possible presence or



absence of infection, and metabolic response to exercise. 50 "Normal" body temperature of the adult is 98.6°F (37°C). (Great Britain uses 98.4°F l36.9°Cl as "normal"). However, temperatures in the range of 965°F (35.8°C) to 99.4°F (37.4°C) are not at all uncommon. Fever or pyrexia is a tem­ perature exceeding lOO°F (37.7°C).51 Hyperpyrexia refers to extreme elevation of temperature above 41.1°C or lO6°F. 50 Hypothermia refers to an abnormally low temperature (below 35°C or 95°F). The temperature is generally taken by placing the bulb of a thermometer under the patient's tongue for 1 to 3 minutes depending on the device. In most individ­ uals there is a diurnal (occurring every day) variation in body temperature of 05° to 2°F. The lowest ebb is reached during sleep. Menstruating women have a well-known temperature pattern that reflects the effects of ovulation, with the temper­ ature dropping slightly before menstruation, and then drop­ ping further 24 to 36 hours prior to ovulation.51 Coincident with ovulation, the temperature rises and remains at a some­ what higher level until just before the next menses. It is also worth noting that in adults over 75 years of age and in those who are immunocompromised (e.g., transplant recipients, corticosteroid users, persons with chronic renal insufficiency, or anyone taking excessive antipyretic medications), fever response may be blunted or absent. 50 • Heart rate. In most people, the pulse is an accurate meas­ ure of heart rate. The heart rate or pulse is taken to a contain information about the resting state of the cardiovascular sys­ tem and the system's response to activity or exercise and recovery. 50 It is also used to assess patency of the specific arteries palpated, and the presence of any irregularities in the rhythm50 (see Chapter 11). • Respiratory rate. The normal chest expansion difference between the resting position and the fully inhaled position is 2 to 4 cm (females > males). The clinician should compare measurements of both the anterior-posterior diameter and the transverse diameter during rest and at full inhalation. Normal respiratory rate is between 8 and 14 per minute in adults, and slightly qUicker in children. The examination of breathing patterns is described in Chapter 10. • Blood pressure. Blood pressure is a measure of vascular resistance to blood flow (see Chapter 12).50 • Edema. Edema is an observable swelling from fluid accu­ mulation in certain body tissues. Edema most commonly occurs in the feet and legs, where it also is referred to as peripheral edema. Swelling or edema may be localized at the site of an injury or diffused over a larger area due to a sys­ temic disorder (e.g., congestive heart failure or renal dis­ ease). In general, the amount of swelling is related to the severity of the condition. The swelling occurs as a result of changes in the local circulation and an inability of the lym­ phatic system to maintain equilibrium, which causes an accumulation of excess fluid under the skin in the interstitial spaces or compartments within the tissues that are outside of the blood vessels.



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The more serious reasons for swelling include fracture, tumor, congestive heart failure, and deep vein thrombosis. See Chapters 11 and 12 for more details regarding the lym­ phatic system and the various types of edema. For the integumentary system, the assessment of skin integrity, skin color, and presence of scar formation (see Chapter 13). For the musculoskeletal system, the assessment of gross sym­ metry, gross range of motion, gross strength, weight, and height (see Chapter 8). For the neuromuscular system, a general assessment of gross coordinated movement (e.g., balance, locomotion, transfers, and transitions). In addition, the clinician observes for peripheral and cranial nerve integrity (see Chapter 9) and notes any indication of neurologic compromise such as tremors or facial tics. For communication ability, affect, cognition, language, and learning style, it is important to verify that the patient can com­ municate his or her needs. The clinician should determine whether the patient has a good understanding about his or her condition, the planned intervention, and the prognosis. The cli­ nician should also determine the learning style that best suits the patient.

Finally, it is well worth investigating the possibility that the pre­ senting signs and symptoms are because of an adverse drug reaction (Table 6-8).

Designed by Cyriax,52 the scanning (screening) examination for the orthopedic patient traditionally follows the history and is often incor­ porated as part of the systems review. Although two studies 53 ,54 ques­ tioned the validity of some aspects of the selective tissue tension exam­ ination, no defmitive conclusions were drawn from these studies. The scarcity of research to refute the work of Cyriax would suggest that its principles are sound, and that its use should be continued. The purpose of the scanning examination is to help rule out the possibility of symptom referral from other areas, and to ensure that all possible causes of the symptoms are examined. In addition, the scan­ ning examination helps narrow the search for the source(s) of symp­ toms to a specific body region and to identify any red flags that were alluded to during the history or physical examination. It was Grieve 55 who coined the term masqueraders to indicate those conditions that may not be musculoskeletal in origin and that may require skilled inter­ vention elsewhere (Table 6-9). The scanning examination is divided into two examinations: one for the lower quarter/quadrant (Table 6-10) and the other for the upper quarter/quadrant (Table 6-11). The tests that comprise the scanning examination are designed to detect neurologic weakness, the patient's ability to perceive sensations, and the inhibition of the deep tendon reflexes (DTR) and other reflexes by the central nervous system.



TABLE 6-8. MEDICATION SIDE EFFECTS AND SUBJECTIVE SYMPTOMS SIDE EFFECfS AND SUBJECTIVE SYMPTOMS Gastrointestinal distress (dyspepsia, heartburn, nausea, vomiting, abdominal pain, constipation, diarrhea, bleeding) MEDICATIONS (IN ORDER OF MOST COMMON OCCURRENCE) Salicylates Nonsteroidal anti-inflammatory drugs (NSAlDs) Opioids Corticosteroids Beta-blockers Calcium-channel blockers Skeletal muscle relaxants Diuretics Angiotensin-converting enzyme (ACE) inhibitors Digoxin Nitrates Cholesterol-lowering agents Antiarrhythmic agents Antidepressants (tricyclic antidepressants, monoamine oxidase inhibitors, lithium) Neuroleptics Antiepileptic agents Oral contraceptives Estrogens and progestins Theophylline Salicylates NSAlDs Opioids Beta-blockers ACE inhibitors NSAlDs Skeletal muscle relaxants Opioids Corticosteroids Beta-blockers Calcium-channel blockers Nitrates ACE inhibitors Digoxin Antianxiety agents Antidepressants (tricyclic antidepressants, monoamine oxidase inhibitors) Neuroleptics Antiepileptic agents Oral contraceptives Estrogens and progestins NSAlDs Corticosteroids Beta-blockers Opioids Calcium-channel blockers ACE inhibitors Nitrates Cholesterol-lowering agents Antiarrhythmic agents Antidepressants (monoamine oxidase inhibitors, lithium) Oral contraceptives Estrogens and progestins Antiepileptics
( Continued)

Pulmonary (bronchospasm, shortness of breath, respiratory depression)

Central nervous system (dizZiness, drowsiness, insomnia, headaches, hallucinations, confuSion, anxiety, depression, muscle weakness)

Dermatologic (skin rash, itching, flushing of face)



SIDE EFFECTS AND SUBJECTIVE SYMPTOMS Musculoskeletal (weakness, fatigue, cramps, arthritis, reduced exercise tolerance, osteoporosis) MEDICATIONS (IN ORDER OF MOST COM,\10N OCCURRENCE) Corticosteroids Beta-blockers Calcium-channel blockers ACE inhibitors Diuretics Digoxin Antianxiety agents Antiepileptic agents Antidepressants Neuroleptic agents Opioids Diuretics Beta-blockers Calcium-channel blockers Digoxin Antiarrhythmic agents Tricyclic antidepressants Neuroleptics Oral antiasthmatic agents NSAIDs Corticosteroids Diuretics Beta-blockers Calcium-channel blockers ACE inhibitors Nitrates Antidepressants (tricyclic antidepressants, monoamine oxidase inhibitors) Neuroleptics Oral contraceptives Estrogens and progestins Opioids Diuretics Beta-blockers Antiarrhythmic agents Antidepressants (tricyclic antidepressants, monoamine oxidase inhibitors) Neuroleptics Oral contraceptives Estrogens and progestins Salicylates NSAIDs Opioids Skeletal muscle relaxants Beta-blockers Nitrates Calcium-channel blockers ACE inhibitors Digoxin Antiarrhythmic agents Antianxiety agents Antidepressants (tricyclic antidepressants, monoamine oxidase inhibitors) Antiepileptic agents

Cardiac (bradycardia, ventricular irritability, AV block, congestive heart failure, PVCs, ventricular tachycardia)

Vascular (claudication, hypotension, peripheral edema, cold extremities)

Genitourinary (sexual dysfunction, urinary retention, urinary incontinence)

Head, eyes, ears, nose, and throat (tinnitus, loss of taste, headache, light-headedness, dizziness)

Reproduced, with permission, from Boissonnault WG. Review of systems. In: Boissonnault WG, ed. Primary Care for the Physical Therapist: Examination and Triage. Sr. Louis: Elsevier W.B. Saunders; 2005:87-104; and Data from Cain SO, Janos sc. Clinical pharmacology for the physical therapist. In: Boissonnault W, ed. Examination in Physical Therapy Practice: Screening for Medical Disease. 2nd ed. New York: Churchill Livingstone; 1995:350-351. Copyright © Elsevier.



TABLE 6-9. EXAMINATION FINDINGS AND TIfE POSSIBLE CONDITIONS CAUSING THEM FINDINGS Dizziness Quadrilateral paresthesia Bilateral upper limb paresthesia Hyperreflexia Babinski or clonus sign Consistent swallow on transverse ligament stress tests Nontraumatic capsular pattern Arm pain lasting> 6--9 mo Persistent root pain < 30 yr Radicular pain with coughing Pain worsening after 1 mo > 1 level involved (cervical region) Paralysis Trunk and limb paresthesia Bilateral root signs and symptoms Nontraumatic strong spasm Nontraumatic strong pain in elderly patient Signs worse than symptoms Radial deviator weakness Thumb flexor weakness Hand intrinsic weakness and/or atrophy Horner's syndrome Empty end-feel Severe post-traumatic capsular pattern Severe post-traumatic spasm Loss of range of motion post-trauma Post-traumatic painful weakness POSSIBLE CONDITION Upper cervical impairment, vertebrobasilar ischemia, craniovertebral ligament tear; may also be relatively benign Cord compression, vertebrobasilar ischemia Cord compression, vertebrobasilar ischemia Cord compression, vertebrobasilar ischemia Cord compression, vertebrobasilar ischemia Instability, retropharyngeal hematoma, rheumatoid arthritis Rheumatoid arthritis, ankylosing spondylitis, neoplasm Neoplasm Neoplasm Neoplasm Neoplasm Neoplasm Neoplasm or neurologic disease Neoplasm Neoplasm Neoplasm Neoplasm Neoplasm Neoplasm Neoplasm Neoplasm, thoracic outlet syndrome, carpal tunnel syndrome Superior sulcus tumor, breast cancer, cervical ganglion damage, brainstem damage Neoplasm Fracture Fracture Fracture Fracture

Reproduced, with permission, from Meadows J. Orthopedic Differential Diagnosis in Physical Therapy. New York: McGraw-Hill; 1999.

TABLE 6-10. THE LOWER QUARTER SCANNING MOTOR EXAMINATION MUSCLE ACTION Hip flexion Knee extension Hamstrings Dorsiflexion with inversion Great toe extension Ankle eversion Ankle plantarflexion Hip extension Iliopsoas Quadriceps Biceps femoris, semimembranosus, and semitendinosus Tibialis anterior Extensor hallicus longus Fibularis (peroneus) longus and brevis Gastrocnemius and soleus Gluteus maximus MUSCLE TESTED ROOT LEVEL 11-L2 L2-L4 L4-S3 Primarily L4 Primarily L5 Primarily 51 Primarily SI L5-S2 PERIPHERAL NERVE Femoral to iliacus and lumbar plexus to psoas Femoral Sciatic Deep peroneal Deep fibular (peroneal) nerve Superficial fibular (peroneal) nerve Tibial Inferior gluteal nerve



TABLE 6-11. TIlE UPPER QUARTER SCANNING MOTOR EXAMINATION RESISTED ACTION Shoulder abduction Elbow flexion Elbow extension Wrist extension Wrist flexion Finger flexion MUSCLE TESTED Deltoid Biceps brachii Triceps brachii Extensor carpi radialis longus, brevis, and extensor carpi ulnaris Flexor carpi radialis and flexor carpi ulnaris Flexor digitorum superficialis, flexor digitorum profundus, and lumbricales Dorsal interossei ROOT LEVEL Primarily C5 Primarily c6 Primarily C7 Primarily c6 Primarily C7 Primarily C8 PERIPHERAL NERVE Axillary Musculocutaneous Radial Radial Median nerve for radialis and ulnar nerve for ulnaris Median nerve superficialis, both median and ulnar nerve for profundus and lumbricales Ulnar

Finger abduction

Primarily T1

The tests used in the scanning examination (Table 6-6) produce a medical diagnosis, rather than a physical therapy one. 56 Those diag­ noses can include: Fracture. Neurologic pathology, which can either be treated (mechanical netve root compression from a disc protrusion, or inflamma­ tion), or is out of the scope of a physical therapist (tumor, upper motor neuron impairment, and cauda equina impairment) (Table 6-2). ~ Tendinitis, bursitis, muscle tear. ~ Tendon avulsion.

If a diagnosis is rendered from the scan, an intetvention may be initiated using the guidelines outlined in Table 6-12. The scan and/or history may also have indicated to the clinician that the patient's con­ dition is in the acute stage of healing. While this is not a diagnosis in the true sense, it can be used for the purpose of the intetvention plan. Often the scanning examination does not generate enough signs and symptoms to formulate a working hypothesis or a diagnosis. In this case, further testing with the tests and measures is required in order to proceed.

TABLE 6-12. SCAN FINDINGS AND INTERVENTIONS CONDITIONS Intervertebral disk protrusion, prolapse, and extrusion Anterior-posterior instability of vertebral segment Arthritis FINDINGS Severe pain, all movements reduced Flexion and extension reduction greater than rotation Hot capsular pattern PROTOCOL Gentle manual traction in progressive extension Traction and/or traction manipulation in extension PRICEMEM (Protection, Rest, Ice, Compression, Elevation, Medication Electrotherapeutics, Manual therapy) Exercises in pain-free direction Exercises in pain-free direction

Subluxation of vertebral segment Arthrosis of vertebral segment

One direction restricted
All directions restricted



1. Boissonnault WG. Examination in Physical Therapy Practice: Screening for Medical Disease. New York: Churchill Livingstone; 1991. 2. Meadows J. Orthopedic Differential Diagnosis in Physical Therapy. New York: McGraw-Hill; 1999. 3. Boissonnault W, Goodman C. Physical therapists as diagnosticians: drawing the line on diagnosing pathology. ] Orthop Sports Phys Ther. 2006;36:351-353. 4. Boissonnault WG, Bass C. Medical screening examination: not optional for physical therapists. ] Orthop Sports Phys Ther. 1991; 14:241-242. 5. OuVall RE, Godges J. Introduction to physical therapy differential diagnosis: the clinical utility of subjective examination. In: Wilmarth MA, ed. Medical Screening for the Physical Therapist. Orthopaedic Section Independent Study Course 14.1.1 La Crosse, WI: Orthopaedic Section, APTA; 2003:1-44. 6. American Physical Therapy Association. Guide to physical thera­ pist practice. Phys Ther. 2001;81:S13-S95. 7. Steinberg MH. Management of sickle cell disease. N EnglJ Med. 1999;340:1021-30. 8. Haslock 1. Ankylosing spondylitis. Baillieres Gin Rheumatol. 1993; 7:99. 9. Potosky AL, Feuer EJ, Levin OL. Impact of screening on incidence and mortality of prostate cancer in the United States. Epidemiol Rev. 2001;23:181-186. 10. Wingo PA, Tong T, Bolden S. Cancer statistics, 1995. CA Cancer ] Clin. 1995;45:8. 11. Parkin OM, Muir CS. Cancer incidence in five continents. Comparability and quality of data. /ARC Sci Pub. 1992;66:45. 12. Ries LAG, Eisner MP, Kosary CL, et al. SEER Cancer Statistics Review, 1973-1997. Bethesda: National Cancer Institute; 2000. 13. Martinez JC, Otley Cc. The management of melanoma and non­ melanoma skin cancer: a review for the primary care physician. Mayo Clin Proc. 2001;76:1253-1265. 14. McKenzie R, May S. Mechanical diagnosis. In: McKenzie R, May S, eds. The Human Extremities: Mechanical Diagnosis and Therapy. Waikanae, New Zealand: Spinal Publications; 2000:79-88. 15. Judge RD, Zuidema GO, Fitzgerald FT. The medical history and physical. In: Judge RD, Zuidema GO, Fitzgerald FT, eds. Clinical Diagnosis. 4th ed. Boston: Little, Brown; 1982:9-19. 16. Maitland G. Vertebral Manipulation. Sydney: Butterworth; 1986. 17. Huskisson EC. Measurement of pain. Lancet. 1974;2:127. 18. Halle JS. Neuromusculoskeletal scan examination with selected related topics. In: Flynn TW, ed. The Thoracic Spine and Rib Cage: Musculoskeletal Evaluation and Treatment. Boston: Butterworth-Heinemann; 1996:121-146. 19. Judge RD, Zuidema GO, Fitzgerald FT. Musculoskeletal system. In: Judge RD, Zuidema GO, Fitzgerald FT, eds. Clinical Diagnosis. 4th ed. Boston: Little, Brown; 1982:365-403. 20. Bonica JJ. Neurophysiological and pathological aspects of acute and chronic pain. Arch Surg. 1977;112:750-761.



21. Burkhardt CS. The use of the McGill Pain Questionnaire in assess­ ing arthritis pain. Pain. 1984;19:305. 22. Chaturvedi SK. Prevalence of chronic pain in psychiatric patients. Pain. 1987;29:231-237. 23. Dunn D. Chronic regional pain syndrome, type 1: part 1. AORN]. 2000;72:421. 24. Konietzny F, Perl ER, Trevino D, et al. Sensory experiences in man evoked by intraneural electrical stimulation of intact cutaneous afferent fibers. Exp Brain Res. 1981;42:219-222. 25. Ochoa J, Torebjork E. Sensations evoked by intraneural micros­ timulation of C nociceptor fibres in human skin nerves. ] Physiol. 1989;415:583-599. 26. Torebjork HE, Ochoa JL, Schady W. Referred pain from intraneural stimulation of muscle fascicles in the median nerve. Pain. 1984;18:145-156. 27. Ness TJ, Gebhart GF. Visceral pain: a review of experimental stud­ ies. Pain. 1990;41:167-234. 28. Rowland LP. Diseases of the motor unit. In: Kandel ER, Schwartz JH, Jessell TM, eds. Principles of Neural Science. 4th ed. New York: McGraw-Hill; 2000:695-712. 29. Goldstein R. Psychological evaluation of low back pain. Spine: State of the Art Rev. 1986;1:103. 30. Norris TR. History and physical examination of the shoulder. In: Nicholas JA, Hershman EB, Posner MA, eds. The Upper Extremity in Sports Medicine. 2nd ed. St Louis, MO: Mosby Year-Book; 1995:39-83. 31. McKenzie R, May S. History. In: McKenzie R, May S, eds. The Human Extremities: Mechanical Diagnosis and Therapy. Waikanae, New Zealand: Spinal Publications; 2000:89-103. 32. Goodman CC, Snyder TEK. Differential Diagnosis in Physical Therapy. Philadelphia: Saunders; 1990. 33. Maitland G. Peripheral Manipulation. 3rd ed. London: Butterworth; 1991. 34. Magarey ME. Examination of the cervical and thoracic spine. In: Grant R, ed. Physical Therapy ofthe Cervical and Thoracic Spine. 2nd ed. New York: Churchill Livingstone; 1994:109-144. 35. American Physical Therapy Association. Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:1-746. 36. American Physical Therapy Association. Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:9-746. 37. Boissonnault WG. Review of systems. In: Boissonnault WG, ed. Primary Care for the Physical Therapist: Examination and Triage. St. Louis, MO: Elsevier Saunders; 2005:87-104. 38. Mohn A, di Ricco L, Magnelli A, et al. Celiac disease-associated vertigo and nystagmus. ] Pediatr Gastroenterol Nutr. 2002;34: 317-318. 39. Davis MP, Walsh D. Cancer pain: how to measure the fifth vital sign. Cleve Clin] Med. 2004;71:625-632. 40. Salcido RS. Is pain a vital sign? Adv Skin Wound Care. 2003;16:214. 41. Sousa FA. Pain: the fifth vital sign. Rev Lat Am Enfermagem. 2002; 10:446-447. 42. Lynch M. Pain: the fifth vital sign. Comprehensive assessment lead., to proper treatment. Adv Nurse Pract. 2001;9:28-36. 43. Lynch M. Pain as the fifth vital sign.] Intraven Nurs. 2001;24:85-94.



44. Merboth MK, Barnason S. Managing pain: the fifth vital sign. Nurs Clin North Am. 2000;35:375-383. 45. Torma 1. Pain-the fifth vital sign. Pulse. 1999;36:16. 46. Newman, BY Pain as the fifth vital sign. ] Am Optom Assoc. 1999;70:619-620. 47. Joel LA. The fifth vital sign: pain. Am] Nurs. 1999;99:9. 48. McCaffery M, Pasero CL. Pain ratings: the fifth vital sign. Am] Nurs. 1997:97:15-16. 49. Frese EM, Richter RR, Burlis TV. Self-reported measurement of heart rate and blood pressure in patients by physical therapy clin­ ical instructors. Phys Ther. 2002;82: 1192-2000. 50. Bailey MK. Physical examination procedures to screen for serious disorders of the low back and lower quarter. In: Wilmarth MA, ed. Medical Screening/or the Physical Therapist. Orthopaedic Section Independent Study Course 14.1.1. La Crosse, WI: Orthopaedic Section, APTA; 2003:1-35. 51. Judge RD, Zuidema GD, Fitzgerald FT. Vital signs. In: Judge RD, Zuidema GD, Fitzgerald FT, eds. Clinical Diagnosis. 4th ed. Boston: Little, Brown; 1982:49-58. 52. Cyriax]. Diagnosis of soft tissue lesions. In: Cyriax]. Textbook 0/ Orthopaedic Medicine. 8th ed. London: Bailliere Tindall; 1982. 53. Hayes KW. An examination of Cyriax's passive motion tests with patients having osteoarthritis of the knee. Phys Ther. 1994:74:697. 54. Franklin ME. Assessment of exercise induced minor lesions: the accuracy of Cyriax's diagnosis by selective tissue tension para­ digm. ] Orthop Sports Phys Ther. 1996;24: 122. 55. Grieve GP. The masqueraders. In: Boyling JD, Palastanga N, eds. Grieve's Modern Manual Therapy. 2nd ed. Edinburgh: Churchill Livingstone; 1994:841-856. 56. Meadows JTS. Manual Therapy: Biomechanical Assessment and Treatment, Advanced Technique. Calgary: Swodeam Consulting; 1995.



Comprehension Questions

1. Give three reasons for taking a patient history. 2. Information about the patient's age, height, weight, marital status, and primary lan­ guage spoken is covered by which component of the history according to The Guide? 3. Which component of the history, according to The Guide, is concerned about the patient's developmental background and hand or foot dominance? 4. True or false: Pain that is not alleviated by rest, and that is not associated with acute trauma, may indicate the presence of aserious disorder such as atumor or aneurysm. A. True. B. False.

5. What do the letters in the MADISON mnemonic represent, and what type of patient does the mnemonic help detect?
6. True or false: Symptoms that are distal and superficial are more difficult for the patient to specifically localize than those that are proximal and deep. A. True. B. False. 7. What are the three characteristics of an irritable structure? 8. Radicular pain is produced by what? 9. Which portion of the examination helps determine the anatomic and physiologic sta­ tus of all systems (i.e., musculoskeletal, neurologic, cardiovascular, pulmonary, integumentary, gastrointestinal, urinary, and genital reproductive)? 10. Give five examples of red flags during an examination. 11. What are the four vital signs? 12. What is the purpose of the upper and lower quarter scanning examinations?

1. To elicit reports of potentially dangerous symptoms, or red flags that require an immediate medical referral; to determine the chief complaint, its mechanism of injury, its severity, and its impact on the patient's function; and to gather information about the patient's past general medical and surgical history. 2. General demographics. 3. Growth and development. 4. The answer is A. This statement is true. 5. Multiple complaints, including complaints about unrelated body parts; Authenticity claims in an attempt to convince the clinician the symptoms exist; Denial of the



negative effect the pain is having on function; Interpersonal variability, manifested by different complaints to different clinicians or support staff; Singularity of symptoms, where the patient requests special consideration due to his or her type and level of pain; Only you, where the clinician is placed at a special level of expertise; and Nothing works. The mnemonic is used to help detect patients with motivational­ affective pain. 6. The answer is B. This statement is false.

7. A progressive increase in the severity of the pain with movement or a specific pos­ ture, syrnptoms increased with minimal activity, and increased latent response of syrnptoms.
8. Nerve root irritation 9. Systems review. 10. Examples include fever (for more than 2 weeks), unexpected weight loss, night sweats, changes in cognition, dizziness, and vomitting. 11. Temperature, heart rate, blood pressure, and respiratory rate. 12. To help rule out the possibility of symptom referral from other areas, and to ensure that all possible causes of the symptoms are examined.

Gait, Posture, Ergonomics, and Occupational Health

Normal human gait is a method of bipedal locomotion involving the complex synchronization of the neuromuscular and cardiovascular sys­ tems.! The major requirements for successful walking include 2 :
~ ~

~ ~ ~

Support of body mass by the lower extremities. Production of locomotor rhythm. For the most part, the loco­
motor rhythm relies on reflexes-the stretch reflex and the
extensor thrust. 3 The stretch reflex is involved in the
extremes of joint motion, while the extensor thrust may facil­
itate the extensor muscles of the lower extremity during
weight bearing. 4
Dynamic balance control of the moving body.
Propulsion of the body in the intended direction.
Adaptability of locomotor responses to changing task and envi­
ronmental demands.

The major elements of physical therapy intervention that comprise locomotor training are outlined in Table 7-1.

Study Pearl

The gait cycle is defined as the interval of time between any of the repetitive events of walking. Such an event could include the point when the foot initially contacts the ground, to when the same foot con­ tacts the ground again. s The gait cycle consists of two periods: stance and swing (Fig. 7-1):

The stance period. This period constitutes approximately
60% of the gait cycle,6,7 and describes the entire time the foot
is in contact with the ground and the limb is bearing weight.
The stance period begins with the initial contact of the foot on
the ground, and concludes when the ipsilateral foot leaves the




TABLE 7-1. mE MAJOR COMPONENTS OF LOCOMOTOR TRAINING FUNCTIONAL COMPONENT Preparation INSTRUCTION AND TRAINING IN Bridging/pelvis elevation Hands on knees and quadruped Kneeling Half kneeling Sitting and sitting balance Modified plantigrade (position involving large base of support and high center of mass) Moving from sitting to standing and reverse with and without assistive device Supported standing and weight shifting with and without assistive device Standing with progressively diminishing base of support Stepping, sidestepping, cross-stepping Use of appropriate gait pattern, forward progression, and turning Indoor Forward progression and turning
Walking backward
Sidestepping, cross-stepping, and braiding
Stair climbing
Falling techniques (for individuals who are active ambulators)
Outdoor Opening doors and passing through thresholds Curb climbing; negotiating ramps, stairs, and sloped surfaces Entering/exiting transportation vehicles Walking on even and uneven surfaces Walking with imposed timing requirements Use of open community environments (use of elevators, revolving doors etc.) Walking on treadmill using body weight support progressing to no body weight support Slow speed progressing to faster speeds Dynamic balance control of the moving body Reciprocal stepping patterns: assisted movements to unassisted Short duration to longer durations

Parallel bar progression

Overground progression (with and then without assistive device) with appropriate gait pattern

Body weight support

Data from Schmitz 1J. Locomotive training. In: O'Sullivan SB, Schmitz 1J, eels. PhYSical Rehabilitation. 5th ed. Philadelphia: FA Davis; 2007:523-560.


The swing period. The swing period constitutes approXimately 40% of the gait cycle,6,7 and describes the period when the foot is not in contact with the ground. The swing period begins as the foot is lifted from the ground and ends with initial contact with the ipsilateral foot. 5

Stance Period. Within the stance period, two tasks and four inter­ vals are recognized. 6,8,9 The two tasks include weight acceptance and single limb support. The four intervals include loading response, mid­ stance, terminal stance and pre-Swing (Fig. 7-1).9 Initial contact and toe-off are instantaneous events. The initial contact, which occurs when one foot makes contact with the ground, takes place at the beginning of the stance period and represents the first 0% to 2% of the gait cycle. As the initial contact of one foot is occurring, the contralat­ eral foot is preparing to come off the floor.
Weight Acceptance. The weight acceptance task occurs during the first 10% of the stance period.



Double support


J - - - - . . . . . L - - - Stance (60%) ----L-------J-----Stance (40%) ------...,~

10% Loading response

30% Terminal stance






Initial swing


Terminal swing

Toe-off Initial contact Initial contact
1... - - - - - - - - - - - - - S t r i d e ( 1 0 0 % ) - - - - - - - - - - - - - - - I - / 4

Figure 7-1. Approximate values for the two phases of gait. (Reproduced, with permission, from Dutton M. Orthopaedic Examination, Evaluation, and Intervention. New York: McGraw­ Hill; 2004:374.)

The Loading Response. The loading response interval begins as one limb bears weight while the other leg begins to go through its swing period. This interval may be referred to as the initial double stance period, and consists of the first 0% to 10% of the gait cycle.9 Single Leg Support. The middle 40% of the stance period is divided
equally into mid-stance and terminal stance. Stability during single limb support arises primarily from the action of the calf muscles, which restrain excessive forward collapse of the tibia. 1O In addition, move­ ment of the subtalar joint into inversion functions to lock the midtarsal joints, creating a rigid forefoot lever over which the body weight can progress. 10

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Mid-Stance. The mid-stance interval, representing the first half of the single limb support task, begins as one foot is lifted, and continues until the body weight is aligned over the forefoot. 9 The mid-stance interval comprises the 10% to 30% phase of the gait cycle. 9 Terminal Stance. The terminal stance interval is the second half of the single limb support task. It begins when the heel of the weight­ bearing foot lifts off the ground and continues until the contralateral foot strikes the ground. Terminal stance comprises the 30% to 50% phase of the gait cycle.9 In the late single limb support, movement of the subtalar joint into inversion functions to lock the midtarsal joints and create a rigid forefoot over which body weight can progress. 10 Limb Advancement
Pre-Swing. The pre-swing interval represents the 50% to 60% phase of the gait cycle. The pre-swing interval refers to the last 10% of the stance period. This interval begins with initial contact of the contralateral limb and ends with ipsilateral toe-off. As both feet are on the floor at the same time during this interval, double support occurs for the second

A number of ta{:tors contribute to shock absorption during weight acceptance. These include Hl: ... Eccentric control of knee flexion to 15 degrees allow$ the dissipation of forces generated by the abrupt transfer of body weight onto the limb. . . ... Movement of the foot into 4 to 6
degrees of ever$ion functions to
unlock the midtarsal joints (talon­
avicular and calcaneocuboid), cre­
ating a more flexible foot that· is
able to adapt to uneven surfaces.•



time in the gait cycle. This last portion of the stance period is therefore referred to as the terminal double stance. Each interval of double stance lasts about 0.11 seconds. Timing for the phases of stance is 100/0 for each double stance interval and 400/0 for single limb support, so that the period of single limb support of one limb equals the period of swing for the other. 9

Swing Period. Gravity and momentum are the primary sources of motion for the swing period. 4 Within the swing period, one task and four intervals are recognized. 6,8,9 The task involves limb advancement. The four intervals include pre-swing, initial SWing, mid-SWing, and terminal sWing. 9
Limb Advancement. The swing period involves the forward motion
of the non-weight-bearing foot. The four intervals of the swing period are described in the next sections. 9

Pre-Swing. In addition to representing the final portion of the stance period and single limb support task, the pre-swing interval is consid­ ered as part of the swing period. Initial Swing. This interval begins with the lift of the foot from the floor, and ends when the swinging foot is opposite the stance foot. It represents the 600/0 to 730/0 phase of the gait cycle. 9 Knee flexion to 60 degrees (owing to passive and active factors) assists in clearing the limb. 1o Mid-Swing. This interval begins as the swinging limb is opposite the stance limb, and ends when the swinging limb is forward and the tibia is vertical. It represents the 730/0 to 870/0 phase of the gait cycle. 9 Terminal Swing. This interval begins with a vertical tibia of the swing leg with respect to the floor, and ends the moment the foot strikes the floor. It represents the last 870/0 to 1000/0 of the gait cycle.

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Hip flexion to 25 degrees, in.combina­ tion with~rlkle dor?iflexion ton~utral, is necessatJ'tp achieve foot c1earance,10

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As gait speed increases, it develops

into jogging and then running, with changes occurring with each of the intervals. For example, as speed increases, the stance period decreases and the terminal double stance phase disappears altogether. This produces a double unsupported phase. 12
~ ~

Gait Cycle Duration. The precise duration of the gait cycle intervals depends on a number of factors, including age, impairment, and the patient's walking velocity.


Normal free gait velocity on a smooth and level surface aver­ ages about 82 m/min for adults, with men being about 50/0 faster than womenY Walking velocity declines with age at a rate of 30/0 to 110/0 in healthy adults > 60 years oldY

The primary determinants of gait velocity are the repetition rate (cadence), physical conditioning, and length of the person's stride. ll

Cadence. Cadence is defined as the number of separate steps taken in a certain time. Normal cadence is between 90 and 120 steps per minute, with an average of 113 steps per minute. 13,14 The cadence of women is usually 6 to 9 steps per minute slower than that of men. 14 Cadence is also affected by age, with




cadence decreasing from the age of 4 to the age of 7, and then again in advancing years. 15 Step length/stride length. Step length is measured as the distance between the same point of one foot on successive footprints (ipsilateral to the contralat­ eral foot fall). Stride length, on the other hand, is the distance between suc­ cessive points of foot-to-floor contact of the same foot. A stride is one full lower extremity cycle. • Two step lengths added together make the stride length. • The average stride length for normal individuals is 1.41 meters,u • Typically, the stride length does not vary more than a couple of inches between tall and short individuals. • Men typically have longer stride lengths than women. • Stride length decreases with age, pain, disease, and fatigue. 16 It also decreases as the speed of gait increasesY A decrease in stride length may also result from a forward-head posture, a stiff hip, or a decrease in the availability of motion at the lum­ bar spine. The decrease in stride length that occurs with aging is thought to be the result of the increased likelihood of falling during the swing period of ambulation due to diminished con­ trol of the hip musculature. 18 This lack of control prevents the aged person from being able to intermittently lose and recover the same amount of balance that the younger adult can lose and recover. 18


Cadence (steps/min) = velocity (m/sec) x 120/stride length (m) Stride length (m) = velocity (m/sec) x 120/cadence (steps/min) Velocity (m/sec) = cadence (steps/min) x stride length (m)/120
Reproduced, with permission, from Levine D, Whittle M. Gait Analysis: The Lower Extremities. La Crosse, WI: Orthopaedic Section, APTA, Inc.; 1992.




A mathematical relationship exists

between cadence, stride length, and velocity, such that if two of them are directly measured, the third maybe derived by calculation (Table 7-2).5

Although the presence of symmetry in gait appears to be important, asymmetry in of itself does not guarantee impairment. It must be remembered that the definition of what constitutes "normal" gait is elu­ sive. Perry, and Gage and associates, list five priorities of normal gait I3 ,15:

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~ ~ ~ ~

Stability of the weight-bearing foot throughout the stance period. Clearance of the non-weight-bearing foot during the swing period. Appropriate prepositioning (during terminal swing) of the foot for the next gait cycle.
Adequate step length.
Energy conservation.


In order for gait to be efficient and to conserve energy, the center of gravity (COG) must undergo minimal displacement. The three-dimensional excursion of the center of gravitylbody mass is minimized through the intricate interactions of the segments of the lower extremity, especially at the knee and pelvis. 15 During the gait cycle, the COG is displaced both vertically and laterally:

The COG of the. body is located approximately midline in the frontal < . plane and slightly anterior to the sec­ ond sacral vertebra· in the sagittal plane. The COG in men is at a point that corresponds to 56.18% of their height. In women the COG is. at a point that corresponds to 55044% of theirheight. 19

Vertical displacement of the whole trunk occurs twice during each cycle-the lowest in double support, and the highest around mid-stance and mid-swing. 5 This vertical displacement




of the COG is minimized through pelvic rotation, flexion, and extension movements at the hip and knee, and rotation of the tibia and subtalar joint. 20 Lateral displacement of the COG occurs during the left and right stance periods. 5 Under normal conditions, the lateral dis­ placement of the COG occurs in a sinusoidal manner.

During the gait cycle, the swing of the arms is out of phase with the legs. As the upper body moves for­ ward, the trunk twists about a vertical axis. The thoracic spine and the pelvis rotate in opposite directions to each other to enhance stability and balance. In contrast, the lumbar spine tends to rotate with the pelvis. The shoulders and trunk rotate out of phase with each other during the gait cycle. 20 Unless they are restrained, the arms tend to swing in opposition to the legs, the left arm swinging forward as the right leg swings forward, and vice versa. 4 Maximum flexion of both the elbow and shoulder joints occurs at initial contact interval of the opposite foot and maximum extension occurs at initial contact of the foot on the same side. 21 Although the majority of the arm swing results from momentum, the pendular actions of the arms are also produced by gravity and muscle action. 4 ,22
~ ~

Trunk and Upper Extremities.

The posterior deltoid and teres major appear to be involved during the backward swing, The posterior deltoid serves as a braking mechanism at the end of the forward swing. The middle deltoid is active in both the forward and backward swing, perhaps to prevent the arms from brushing against the sides of the body during the swing.

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ess, the latter Trendelenburg enburg sign is lvis lists toward side during


Pelvis. The pelvis serves the double function of weight transfer and of acetabulum placement during gait. For normal gait to occur, the pelvis must both rotate and tilt. This combination of rotation and tilting serves to prevent excessive motion of the trunk. The rotation of the pelvis (approximately 4 degrees to each side) normally occurs about a vertical axis in the transverse plane toward the weight-bearing limb. 15 In addition to decreasing the lateral deviation of the COG, the pelvic rotation also results in a relative lengthening of the femur, and thus step length, during the termination of the swing period. 9 During the swing period, there is a slight pelvic tilt to the unsup­ ported leg (approximately 5 degrees). The downward tilting of the pelvis occurs in the frontal plane on the contralateral side of the stance limb. The pelvic tilt results in a relative adduction of the weight-bearing limb and a relative abduction of the non-weight-bearing limb. 9,20 Hip.

Hip motion occurs in all three planes during the gait cycle. Hip rotation occurs in the transverse plane. The hip rotates approx­ imately 40 to 45 degrees in the sagittal plane during a normal stride. 23 The hip begins in internal rotation during the loading response. Maximum internal rotation is reached near mid-stance.





The hip externally rotates during the swing period, with maxi­
mal external rotation occurring in terminal swing. 24
The hip flexes and extends once during the gait cycle, with the
limit of flexion occurring at the middle of the swing period, and
the limit of extension being achieved before the end of the
stance period (Table 7-3). At the point of initial contact, the hip
is in approximately 35 degrees of flexion, where it begins to
extend. Maximum hip flexion of 30 to 35 degrees occurs in late
swing period at about 85% of the gait cycle; maximum exten­
sion of approximately 10 degrees is reached near toe-off at
approximately 50% of the cycle 23--2S (Table 7-3).
In the coronal plane, hip adduction occurs throughout early
stance and reaches a maximum at 40% of the cycle. 2s Hip
adduction totaling 5 to 7 degrees occurs in the early swing
period, which is followed by slight hip abduction at the end of
the swing phase, especially if a long stride is taken. 4•23 ,2s

The movements of the thigh and lower leg occur in conjunction with the rotation of the pelvis. The pelvis, thigh, and lower leg nor­ mally rotate toward the weight-bearing limb at the beginning of the swing period. 20

Knee. The knee flexes twice and extends twice during each gait cycle: once during weight bearing and once during non-weight bear­ ing (Table 7-3). It is fully extended before initial contact, flexes early in the stance period, extends again around mid-stance, then starts flexing again, reaching a peak early in the swing period. The flexion occurs so that the lower limb can be advanced during the swing period with min­ imum vertical displacement of the COG. During weight-bearing activities such as gait, the tibiofemoral joint is subject to constant large muscular loads, bending, and rotational moments. These forces become particularly significant during sports activities, which place additional stresses on the joint. The knee flexes to about 20 degrees during the loading response interval, and this serves to act as a shock-absorbing mechanism. The knee then begins to extend and, as the heel rises during the terminal stance interval, it is almost fully extended, but flexes again as the swing period begins. It then continues to flex as the leg moves into the swing period, before extending again prior to initial contact. s In normal walk­ ing, about 60 degrees of knee motion is required for adequate clearance of the foot in the swing period. The peak flexion is required during ini­ tial swing, right after toe-off, because at that point in the gait cycle, the toe is still pointed toward the ground. IS Tibiofemoral joint reaction forces increase to 5 to 6 times the body weight for running and stair climbing, and 8 times body weight with downhill walking. 26-28 A loss of knee extension, which can occur with a flexion defor­ mity, results in the hip being unable to extend fully, which can alter the gait mechanics. Foot and Ankle. Ankle joint motion during the gait cycle occurs primarily in the sagittal plane (Table 7-3). During normal gait, the initial contact with the ground is made by the heel. In individuals with poor

Study Pearl


TABLE 7-3. JOINT MOTIONS AND MUSCLE ACTIVITY AT lHE HIP AND KNEE, AND JOINT POSITIONS AND MOTIONS OF lHE TIBIA, FOOT, AND ANKLE DURING GAIT PHASE Heel strike HIP Gluteus maximus and hamstrings work eccentrically to resist flexion moment at the hip. Erector spinae working eccentrically to control trunk flexion. The hip begins to extend from a position of 20 to 40 degrees of flexion. Reaction force anterior to the hip joint creating a flexion moment. Hip positioned in slight adduction and external rotation. Gluteus maximus and hamstrings contract concentrically to move hip toward extension. Hip moving into extension, adduction, and internal rotation. Hip moves through neutral position. Pelvis rotates posteriorly. Reaction force now posterior to hip joint creating an extension moment. Iliopsoas contracting eccentrically to resist hip extension. Gluteus medius creating reverse action to stabilize opposite pelvis. Hip positioned in 10 to 15 degrees of hip extension, abduction and external rotation. Iliopsoas activity continuing. Extension moment decreases after double-limb support begins. Hip moving toward 10 degrees of extension, abduction, and external rotation. Continued decrease of extension moment. Iliopsoas activity continuing. Adductor magnus working eccentrically to control pelvis. KNEE Positioned in full extension before heel contact, but flexing as heel makes contact. Reaction force behind knee causing flexion moment. Quadriceps femoris contracting eccentrically to control knee flexion. TIBIA Slight external rotation ANKLE Moving into plantarflexion FOOT Supination

Foot flat


In 20 degrees of knee flexion, moving toward extension. Flexion moment. After foot is flat, quadriceps femoris activity becoming concentric to bring femur over tibia. In 15 degrees of flexion, moving toward extension. Maximum flexion moment. Quadriceps femoris activity decreasing.

Internal rotation

Plantarflexion to dorsiflexion over a fixed foot

Pronation, adapting to support surface

Neutral rotation

3 degrees of dorsiflexion



In 4 degrees of flexion, moving toward extension. Maximum flexion moment. Quadriceps femoris activity decreasing. Moving from near full extension to 40 degrees of flexion. Reaction forces moving posterior to knee as knee flexes. Flexion moment. Quadriceps femoris contracting eccentrically.

External rotation


External rotation

15 degrees of dorsiflexion toward plantarflexion Maximum dorsiflexion moment 20 degrees of plantarflexion Dorsiflexion moment

Supination as foot becomes rigid for push-off




control of dorsiflexion (e.g., hemiplegics), the initial contact is made with the low part of the heel and forefoot simultaneously. Ibis is usu­ ally accompanied by a toe drag during the swing period. The ankle is usually within a few degrees of the neutral position at the time of initial contact, with the heel slightly inverted and the sub­ talar joint slightly supinated. 30 The initial impact is taken through the lateral tubercle of the calcaneus, a structure unique to humans and designed to tolerate the shock of heel strike via the calcaneal fat pad. As the heel contacts the ground, its forward momentum comes to an abrupt halt. During the loading response interval, plantar flexion occurs at the talocrural joint, with pronation occurring at the subtalar joint.30 The pronation of the subtalar joint unlocks the foot and allows maximal range of motion of the midtarsal joint, which brings the artic­ ulating surfaces of the cuboid and navicular to a position relatively par­ allel to the weight-bearing surface and allows the forefoot to become supple. 31 ,32 This increase in midtarsal joint mobility enhances the abil­ ity of the foot to adapt to uneven terrain. At the end of the mid-stance interval, the talocrural joint is maxi­ mally dorsiflexed, and the subtalar joint begins to supinate. During the latter part of the stance period, the foot must become a rigid lever. From the mid-stance to the terminal stance interval, the foot is in supination (plantar flexion of the ankle, external rotation of the tibia, dorsiflexion and abduction of the talus, and inversion of the calca­ neus)Y Supination at the subtalar joint locks the foot into a rigid lever30 ,33 by promoting supination at the midtarsal joint, which results in the articulating surfaces of the cuboid and calcaneus adopting a position that is perpendicular to one another, thus stabi­ liZing their articulation. 32 The fixed cuboid acts as a fulcrum for the fibularis (peroneus) longus muscle, facilitating plantar flexion of the first metatarsal in push-offY Once the ankle is fully close-packed, the heel is lifted by a com­ bination of passive force and contraction from the taut gastrocnemius, and the soleus, The lifting of the heel accentuates the force applied to the mid- and forefoot, and reinforces the close packing of this area, while simultaneously unclose packing the ankle joint. As ankle plantar flexion reaches its peak at the end of the terminal stance interval, the first metatarsophalangeal joint is extended. The dorsiflexion of the first MTP places tension on the plantar fascia and helps to elevate the medial longitudinal arch through the windlass mechanism of the plantar fascia. This windless mechanism creates a dynamic stable arch and hence a more rigid lever for push-oEfY While the forefoot is on the ground and the heel is off, the heel is inverted and the foot is supinated. 30 The heel rise coincides with the opposite leg swinging by the stance legY Approximately 40% of the body weight is borne by the toes in the final stages of foot contact. 35 ,36 Muscle activity during push-off is designed to initiate propulsionY From initial contact to early mid-stance, the tibia moves anteriorly, internally rotating within the ankle mortise, and prodUcing talar adduc­ tion and plantar flexion, and calcaneal eversion (weight-bearing pronation of the subtalar joint)Y The forward tibial advancement requires approximately 10 degrees of ankle joint dorsiflexion to pre­ vent excessive pronation at the subtalar and oblique midtarsal joints,7,32,37

Study Pearl
An .arlaptiyeJYsho#t~nedg~str()cne, mius.rnosclemayprodufeffiByement impairment{)}' restriQting.n.()rmal.dor3 siflexion .of the.ankJe fr(.jmoccurring duriJjlg·the . m'd3stancT.toh~?I·raise


compensated·rot·· b~increased.prona­ tionof·the· subt~la' .'...• ycre~ intertlalrota~ionoft . . > . y an~~sult. ant '''-in the Io1w j<>in\.F""'PIex. :'-.J

portio~orthe gaitcyde'1lli~m()ti(}nis




During the swing period, the ankle must dorsiflex in order for the forefoot to clear the ground. The ankle adopts a neutral position in terms of dorsiflexion and plantar flexion prior to the next initial contact.

The ankle and hip muscles are responsible for the majority of positive work performed during walking (54% of the hip and 36% of the ankle).38 The knee contributes the majority of the negative work (56%). 38 The muscle actions that occur dUring the stance period of gait are depicted in Tables 7-3 and 7-4. During the swing period, the semispinalis, rotatores, multifidus, and external oblique muscles are active on the side toward which the pelvis rotates. 4 The erector spinae and internal oblique abdominal muscles are active on the opposite side. The psoas

Spine and Pelvis.


Heel Strike to Weight Acceptance Anterior tibialis Extensor hallucis longus Extensor digitorum
Posterior tibialis Soleus Gastrocnemius

Eccentric--control pronation of subtalar joint Eccentric---clecelerate plantar flexion and posterior shear of tibia on talus Eccentric---clecelerate pronation of subtalar joint and internal rotation of the tibia

Mid-stance Posterior tibialis Soleus Flexor hallucis longus Flexor digitorum longus
Posterior tibialis Soleus Gastrocnemius

Eccentric---clecelerate fOIWard movement of tibia

Concentric-supinate subtalar and midtarsal joints

Push-off and Propulsion Peroneus longus Abductor hallucis
Peroneus brevis Flexor digitorum longus Extensor hallucis longus and brevis Abductor hallucis Abductor digit quinti Flexor hallucis brevis Flexor digitorum brevis Extensor digitorum brevis Interossei, lumbricals

Concentric-plantar flexion of first ray Antagonist to supinators of subtalar and midtarsal joints Concentric-stabilize toes against ground Concentric-stabilize first metatarsophalangeal joint Concentric-stabilize midtarsal and forefoot, raise medial arch of foot in push-off

Data from Norkin CC: Examination of gait. In: O'Sullivan SB, Schmitz T], eels. Physical Rehabilitation. 5th ed. Philadelphia: FA Davis; 2007:317-363.



major and quadratus lumborum help to support the pelvis on the side of the swinging limb, while the contralateral hip abductors also provide support.

Hip. During the early to mid portion of the swing phase, the iliop­ soas is the prime mover with assistance from the rectus femoris, sarto­ rius, gracilis, adductor longus, and possibly the tensor fascia latae, pectineus, and the short head of the biceps femoris during the initial swing interval. Perry notes the adductor longus muscle to be "the first and most persistent hip flexor."9 In terminal swing, there is no appre­ ciable action of the hip flexors when ambulating on level ground. Instead, the hamstrings and gluteus maximus are strongly active to decelerate hip flexion and knee extension. 23.25 Both these superficial muscles and their deeper counterparts, such as the hip adductors, the gemelli, and the short rotators, certainly contribute. 39 In rapid walking, there is increased activity of the sartorius and the rectus femoris dUring the swing period. 4 During initial contact, the gluteal muscles and the hamstrings contract isometrically with moderate intensity. The loading response interval is accompanied by hamstrings and gluteus maximus activity, which aid hip extension.23.25.41 The adductor magnus muscle supports hip extension and also rotates the pelvis externally toward the for­ ward leg. In mid-stance, coronal plane muscle activity is greatest as the abductors stabilize the pelvis. 42 --46 The muscle activity initially is eccentric as the pelvis shifts laterally over the stance leg. The gluteus medius and minimus remain active in terminal stance for lateral pelvic stabilization. The iliacus and anterior fibers of the tensor fas­ ciae latae are also active in the terminal stance and pre-swing inter­ vals. 23 ,25 Notable, but inconsistent, muscle activity of the rectus femoris is described by several authors. 23 ,25.41 The only muscles of the hip that contract significantly during the last part of the stance period are the adductor magnus, longus, and possibly brevis. 4
Knee. During the swing period, there is very little activity from the knee flexors. The knee extensors contract slightly at the end of the swing period prior to initial contact. During level walking the quadriceps achieve peak activity dUring the loading response interval (25% maxi­ mum voluntary contraction) and are relatively inactive by mid-stance as the leg reaches the vertical position and "locks," making quadriceps con­ traction unnecessary.47-50 Hamstring involvement is also important to normal knee function. The hamstrings provide dynamic stability to the knee by resisting both medial-lateral and anterior translational forces on the tibia. 27 The coactivation of the antagonist muscles about the knee during the loading response aids the ligaments in maintaining joint sta­ bility, by equalizing the articular surface pressure distribution and con­ trolling tibial translation. 51 ,52 The hamstrings also demonstrate activity at the end of the stance period. Hamstring activity during graded walking and increased speed demonstrates increased activity and for a longer duration. 4 Foot and Ankle. During the beginning of the swing period, the tibialis anterior, extensor digitorum longus (EDL), extensor hallucis

Study Pearl
The passive hip extension moment at initial contact has been calculated to be approximately 60% to 100% of the total moment occurring during the stance period, suggesting that passive elastic energy is stored and released during gait. 40


Study Pearl
Electromyographic activity of the hamstrings during level walking has shown that the hamstrings decelerate the leg prior to heel contact and then act synergistically with the quadri­ ceps during the stance period to sta­ bilize the knee. 49,53



Study Pearl
In the presence of calf muscle weak­ ness there is an inability to control forward advancement of the tibia, resulting in excessive dorsiflexion during single limb support and a lack of heel rise during late stance. 10

Study Pearl
During the stance period, three ankle rocker periods are recognized. 1. The first rocker occurs between the initial contact and when the foot is fJat on the floor. This rocker involves the ankle dorsiflexors working eccentrically to gradually permit the foot to come into full contact with the ground. 2. During the second rocker, the foot remains flat on the ground while the tibia advances. This motion is due to the plantar flexors working eccentrically to control the· ankle dorsiflexion that occurs. 3. The third rocker is the push-off required for advancement of the limb. This is the period of power generation. Thus, the first two rockers are decel­ eration rockers, where the perspective muscles are working eccentrically by undergoing a lengthening contraction with energy absorption. The third rocker is an acceleration rocker and aids in propulsion.

longus (EHL), and possibly the fibularis (peroneus) tertius contract concentrically with slight to moderate intensity tapering off during the middle of the swing period. 4,54,55 As the swing period begins, the fibu­ laris (peroneus) longus also contracts concentrically to evert the entire foot and bring the sole of the foot parallel with the substrate. At the point where the leg is perpendicular to the ground during the swing period, the tibialis anterior, EDL and EHL group of muscles contract concentrically to dorsiflex and invert the foot in preparation for the ini­ tial contact,4,54,55 There is very little activity, if any, from the plantar flexors during the swing period. Following initial contact, the anterior tibialis works eccentrically to lower the foot to the ground during the loading response intervaP4,55 Calcaneal eversion is controlled by the eccentric activity of the poste­ rior tibialis, and the anterior movement of the tibia and talus is limited by the eccentric action of the gastrocnemius and soleus muscle groups as the foot moves toward mid-stance. 56 Pronation occurs in the stance period to allow for shock absorption, ground terrain changes, and equilibrium. 32 ,57 The triceps surae become active again from mid­ stance to the late stance period, contracting eccentrically to control ankle dorsiflexion as the COG continues to move forward. In late stance period, the Achilles tendon is stretched as the triceps surae contracts and the ankle dorsiflexes. 58 At this point the heel rises off the ground and the action of the plantar flexors changes from one of eccentric contraction to one of concentric contraction. The energy stored in the stretched tendon helps to initiate plantar flexion and the initiation of propulsion.58 The fibularis (peroneus) longus provides important stability to the forefoot during propulsion.


Pain. Refer to "Abnormal Gait Syndromes" later in this chapter. Posture. The patient's posture is examined for the presence of asymmetry, or any deviations in the relaxed standing stance (see the discussion of posture later in this chapter). Good alignment of the weight-bearing segments of the body:
~ ~

Study Pearl
The consequences of a triple arthrodesis on gaitfunction include 10 ; ~ Loss of subtalar joint motion, resulting in reduced shock absorp­ tion during weight acceptance. ~ An inability to supinate in terminal stance, diminishing the forefoot rocker effect. .. Compromised ability to progress beyond the supporting foot. .. Diminished stride fength,

Reduces the likelihood of strain and injury by reducing joint friction and tension in the soft tissues. Improves the stability of the weight-bearing limb and the bal­ ance of the trunk. The stability of the body is directly related to the size of the base of support. In order to be stable, the inter­ section of the line of gravity with the base of support should be close to the geometric center of the base. 59 Reduces excess energy expenditure.

Flexibility and the Amount of Available Joint Motion.
A decrease in flexibility and/or joint motion may result in an increase in "internal resistance" and an increase in the energy expenditure required.

Endurance-Economy of Mobility. Economy of mobility is a measurement of submaximal oxygen uptake (submax VO) for a



given speed. 60 ,6l A decline in functional performance may be evi­ denced by an increase in submax V0 2 for walking. 62 This change in economy of mobility may be indicative of an abnormal gait pattern. 62 Some researchers have reported no gender differences for economy of mobility,6.}--<)5 while others suggest that men are more economical, or have lower energy costs than women at the same absolute work. 66-<J8 Age-related declines in economy of mobility have also been reported in the literature, with differing results. Some researchers reported that older adults were less economical than younger adults while walking at various speeds. 60 ,69,70 Conversely, economy of mobility appears to be unaffected by aging for individuals who maintain higher levels of physical aetivity.71-73

Study Pearl
The cardiovascular h/1lo~fits'geri\l'oo

from increasesingait s~edl1'la¥be
acceptable fora normal P9P~lationpr • in advancedrehabilitatioo,butsooul.cl' be used cautiously witnpo$tsurgical patients.?4

Base of Support. The size of the base of support (BOS) and its relation to the center of gravity (COG) are important factors in the maintenance of balance and thus the stability of an object. The COG must be maintained over the BOS if equilibrium is to be maintained. The BOS includes the part of the body in contact with the supporting surface and the intervening area. 75 The normal BOS is considered to be between 5 and 10 cm. Larger than normal bases of support are observed in individuals who have muscle imbalances of the lower limbs and trunk as well as those who have problems with overall static dynamic balance.76 As the COG moves forward with each step, it briefly passes beyond the anterior margin of the BOS, and a temporary loss of balance occurs.75 This temporary loss of equilibrium is coun­ teracted by the advancing foot at initial contact, which establishes a new BOS. The base width should decrease to around zero with increased speed. If the base width decreases to a point below zero, cross-over occurs, where one foot lands where the other should, and vice versa. The presence of cross-over can lead to alterations in gait,77 Interlimb Coordination. Different patterns of interlimb coor­ dination between arms and legs have been observed within the human walking mode.78,79 At lower walking speeds the arms are syn­ chronized to the stepping frequency (2:1 ratio arm: leg), whereas at higher walking velocities the arms are synchronized to the stride fre­ quency 0:1 ratio arm: leg). These results also suggest that at lower speeds the resonant frequency of the arms dominates the interlimb coupling, whereas at higher speeds the resonant frequency of the legs is dominant. 8o leg-length Inequality. Limb-length inequality is a common clinical finding, with one study finding as many as many as 70% of 1000 consecutive nonselected adult men with some degree of dis­ crepancy.8l Some authors have claimed that a limb-length discrepancy leads to mechanical and functional changes in gait82 and increased energy expenditure. 83 Intervention has been advocated for discrepancies of less than 1 cm to discrepancies greater than 5 cm,82-B4 but the rationale for these rec­ ommendations has not been well defined, and the literature contains little substantive information regarding the functional significance of these discrepancies. 85 For example, Gross found no noticeable functional

Study Pearl

... .....

Assistive devices<stlch as crutches or walkers may be considere(f. as-exten­ sions .of body parts. Usedcorredly, these devices serve to . increase the BOS. and therefore en hancestabt.lity.




or cosmetic problems in a study of 74 adults who had less than 2 cm of discrepancy and 35 marathon runners who had as much as 2.5 cm of discrepancy.84

Gender. Compared with males, females generally have narrower shoulders, greater valgus at the elbow, greater varus at the hip, and greater valgus at the knee. 86 Females also have a smal1er Achilles tendon, a narrower heel in relationship to the forefoot, and a foot that is narrower than a man's in length. As the body attempts to maintain its COG, the wider female pelvis may contribute to an increase in varus at the hip, which in turn leads to increased pronation at the hindfoot. 86 As women get older, their feet become larger, flatter, and stiffer. 86 The intrinsic muscles of the feet, which are important for balance, can become weak and atrophic from years of wearing constricting shoewear. Other con­ ditions, such as peripheral neuropathy, poor vision, arthritis, and gen­ eral deconditioning, can also cause gait changes. 86 Pregnancy. It is widely presumed that pregnant women exhibit marked gait deviations. The results of one study appears to refute that notion. 87 The study concluded that velocity, stride length, and cadence during the third trimester of pregnancy were similar to those measured one year postpartum, and that only small deviations in pelvic tilt and hip flexion, extension, and adduction were observed during preg­ nancy.87 The study found significant increases (p < 0.05) in hip exten­ sor, hip abductor, and ankle plantar flexor kinetic gait parameters, which suggests an increased use of hip extensor, hip abductor, and ankle plantar flexor muscles to compensate for increases in body mass and changes in body-mass distribution during pregnancy. These increases keep speed, stride length, cadence, and joint angles relatively unchanged. 87 These compensations may result in overuse injuries to the muscle groups about the pelvis, hip, and ankle including low-back, pelvic, and hip pain; calf cramps; and other painful lower-extremity musculoskeletal conditions associated with pregnancy.87 It was unclear from this study whether the women examined had gained normal amounts of weight associated with pregnancy. It would seem obvious that obesity associated with pregnancy may have differing effects on gait.
Obesity is associated with a number of comorbidities, such as coronary artery disease, type II diabetes, gallbladder disease, and sleep apnea. Given a normal body-mass index (defined as the weight in kilograms divided by the square of the height in meters) ranging from 18.5 to 24.9, 34% of the adult population is overweight (body-mass index 25 to 29.9) and another 27% is obese (body-mass index ~ 30).88 The gait deviations caused by obesity are perhaps clinically insignificant compared with its other associated health risks. However, as obesity is becoming more common, the clinician needs to be aware of its effects on the normal gait pattern to help discriminate compensa­ tory patterns as opposed to pathologic manifestations. The gait used by the obese patient is often described as a waddling gait. Depending on the degree of obesity, the waddling gait is characterized by increased lateral displacement, pelvic obliquity, hip circumduction, an increase in knee valgus, an external foot progression angle, over-pronation, and




increases in the normalized dynamic base of support. The changes in the natural alignment of the weight-bearing segments may result in musculoskeletal dysfunction including overuse injuries such as ten­ donitis and bursitis and eventual osteoarthritis of the hip and/or knee.
As the body ages, there may be some decrease in both strength and flexibility (see Chapter 14). As vision may also diminish, balance may become a concern. Consequently, although the cadence of gait may remain unchanged, the step length is typically shorter, the width of the base of support is wider, and the time spent in the double support phase is increased.

Age. Age may be a factor in gait variations.

Lateral and Vertical Displacement of the Center of Gravity. Rotation of the trunk may be excessive or lacking.
Excessive trunk rotation may result from a restricted or exaggerated arm swing. A pelvic drop (excessive descent of the ipsilateral or con­ tralateral pelvis) may occur on one side. The reasons for this differ according to whether the drop is ipsilateral or contralateral89 :


Ipsilateral: due to a short ipsilateral limb (including a leg length discrepancy or a knee flexion contracture), contralateral hip abductor weakness, calf muscle weakness, and scoliosis. Contralateral: due to gluteus medius insufficiency, hip adductor contracture/spasticity, contralateral hip abductor contracture, and scoliosis.

A pelvic hike (excessive elevation of the ipsilateral side of the pelvis) may result during the swing period to help with foot clearance in the presence of inadequate hip or knee flexion or excessive planter flexion of the ankle. 89 As discussed, an increase in lateral displacement may also occur with obesity.

Properly Functioning Reflexes. One study demonstrated that joint moments dUring gait are reduced in patients with lumbar disc herniations, and that the changes in moments are related to the level of the lesion. 90 Patients with upper motor neuron lesions can display a wide variety of gait disturbances--see the section on Abnormal Gait Syndromes. Vertical Ground Reaction Forces. Newton's third law states that for every action there is an equal and opposite reaction. During gait, vertical ground reaction forces (VGRF) are created by a combina­ tion of gravity, body weight, and the fIrmness of the ground. It is well established that joint angles and GRF components increase with walk­ ing speed. 91 This is not surprising, since the dynamic force components must increase as the body is subject to increasing deceleration and acceleration forces with walking speed increases.

Hip. The major problems that occur at the hip during gait are inad­ equate power, inadequate or inappropriate range of motion, and malrotation. is



Inadequate Power. Weakness of the hip flexors is best seen during the pre-swing and initial swing intelVals. Weakness of the hip abduc­ tors is noted during the single support phase of stance, as the hip abductors are required to prevent collapse of the pelvis toward the unsupported side. Weakness of the hip extensors is usually seen at ini­ tial contact and during loading response. Inadequate or Inappropriate Range of Motion. As the flexors, adductors, and internal rotators of the hip are dominant over their antagonists, flexion, adduction, and internal rotation deformities tend to be the rule. Malrotation. Malrotation of the hip is usually due to such conditions as femoral anteversion.

Knee. The common problem at the knee during the stance period is excessive flexion. During the swing period, the most common error is due to inadequate motion. If there is excessive flexion at the knee in mid-stance, the ground reaction force moves posteriorly to the knee and generates a flexion rather than an extension moment. This change in the moment requires the quadriceps and, to some degree, the hip extensors to maintain the stability. Excessive flexion at the knee results in excessive flexion occurring at the hip. This in turn increases the magnitude of the load on both the hip and knee joints. 92 Foot and Ankle. There are three broad types of errors of the foot and ankle in the stance and swing periods:
1. Malrotation. 2. Varus or valgus deformity. 3. Abnormal muscle moments. In the stance period, these deviations may interfere with number 1 and 4 of Perry's priorities of gait (stability in stance and adequate step length). In the swing period, these deviations may interfere with prior­ ities 2 and 3 (clearance of the foot in swing, and pre-positioning of the foot in terminal swing). The malrotation in stance rotates the plane of the foot outside of the plane of progression, resulting in the COG prematurely passing out­ side of the base of support, which results in a shortening of the con­ tralateral step length. In addition, if the foot is malrotated significantly into external rotation a valgus moment and an external rotation moment are introduced at the knee. Varus and valgus deformities produce a loss of stability through­ out the stance period because they introduce large external moments in the coronal plane that must be balanced by large muscle moments if stability is to be maintained. Abnormal muscle moments during the stance period can manifest as weakness of the tibialis anterior, resulting in a foot slap at initial con­ tact during the first rocker. Weakness of the triceps surae allows the tibia to progress too rapidly during the second rocker, causing the ground reaction force to fall behind the knee and induce knee flexion.



Abnormal muscle moments during the swing period include excessive activity of the plantar flexors or insufficient strength of the dorsiflexors, resulting in a drop foot and poor foot clearance.

Each of the attributes of normal gait described under characteristics of normal gait are subject to compromise by disease states, particularly neuromuscular conditions (Table 7_5).38 .93 In general, gait, deviations fall under four headings: those caused by weakness, those caused by abnormal joint position or range of motion, those caused by muscle contracture, and those caused by pain. IS



Weakness implies that there is an inadequate internal joint moment or loss of the natural force couple relationship. Neuromuscular conditions may be associated with abnormali­ ties of muscle tone, the timing of muscle contractions, and pro­ prioceptive and sensory disturbances, the latter of which can profoundly affect reflex postural balance. Abnormal joint position can be caused by an imbalance of flex­ ibility and strength around a joint or by contracture. Contractures--changes in the connective tissue of muscles, lig­ aments, and the joint capsule-may produce changes in gait. If the contracture is elastic, the gait changes are apparent in the swing period only. If the contraetures are rigid, the gait changes are apparent during the swing and the stance periods. Pain can alter gait as the patient attempts to use the position of minimal articular pressure (see the following section on antalgic gait). Pain may also produce muscle inhibition and eventual atrophy.

Antalgic Gait. The antalgic gait (Table 7-6) is characterized by a decrease in the stance period on the involved side in an attempt to eliminate the weight from the involved leg and use of the injured body

TABLE 7-5. GAIT DEVIATIONS RELATED TO DISEASE DEVIATION Ataxic Cerebellar Double step Equinus Festinating Gluteal Hemiplegic Scissor Spastic Steppage Tabetic Waddling CHARACTERISTICS Characterized by staggering and unsteadiness Manifested by staggering movements Characterized by alternate steps of a different length or at a different rate Characterized by high steps due to foot drop A gait that starts slowly, increases in speed, and may continue until the patient grasps an object in order to stop. Common feature of Parkinson's disease Characterized by a leaning of the trunk to the affected side while walking as a result of gluteus medius weakness Abduction and circumduction of the paralyzed limb in order to move the foot forward Crossing of the legs in midline upon advancement Characterized by stiff movements, toes seeming to catch and drag, hips and knees joined slightly flexed, and legs held together Gait in which elevation of the feet and toes appears exaggerated Slapping of the feet on the ground associated with high-stepping Characterized by feet that are wide apart. Associated with coax vara



TABLE 7-6. SOME CAUSES OF ANTALGIC GAIT Bone disease Fracture Infection Tumor Avascular necrosis (Legg--ealve disease, Osgood-Schlatter's disease, Kohler's disease) Traumatic rupture, contusion Cramp secondary to fatigue, strain, malposition, or claudication Inflammatory myositis Traumatic arthritis Infectious arthritis Rheumatoid arthritis Crystalline arthritis (gout, pseudogout) Hemarthrosis Bursitis Lumbar spine disease with nerve root irritation or compression Hip, knee, or foot trauma Corns, bunions, blisters, ingrown toenails

Muscle disorder

Joint disease

Neurologic disease Other

Data from Judge RD, Zuidema GD, Fitzgerald IT. Musculoskeletal system. In: Judge RD, Zuidema GD, Fitzgerald IT, eds. Clinical Diagnosis. 4th ed. Boston: Little, Brown and Company; 1982:365-403.

part as much as possible. In the case of joint inflammation, attempts may be made to avoid positions of maximal intra-articular pressure and to seek the position of minimum articular pressure94 :


Minimum articular pressure occurs at the ankle at 15 degrees of plantar flexion. Minimum articular pressure occurs at the knee at 30 degrees of flexion. With a painful knee, the gait is characterized by a decrease in knee flexion at initial contact and the loading response interval, and an increase in knee extension during the remainder of the stance period. Minimum articular pressure occurs at the hip at 30 degrees of flexion.

Study Pearl

Equinus Gait. Spastic diplegia is the most common pattern of motor impairment in patients with cerebral palsy CCP).95 In these patients, motor impairment is due to a number of deficits, including poor muscle control, weakness, impaired balance, hypertonicity, and spasticity.96 However, reduced joint motion as a consequence of the spasticity is perhaps the most noticeable and recorded impairment. As a consequence, muscle-tendon units frequently become con­ tracted over time, contributing to malalignment of the extremity dur­ ing gait. Toe-walking may be a primary gait deviation, which is the consequence of excessive myostatic contracture of the triceps surae, excessive dynamic contraction of the ankle plantarflexors, or a com­ bination of both factors. Additionally, toe-walking may be a compen­ satory deviation for myostatic deformity or dynamic overactivity of the ipsilateral hamstring muscles, which directly limit knee alignment and secondarily compromise foot and ankle position during the stance phase.



Associated gait deviations are frequently seen at the knees, hips, and pelvis in children with CP who are walking on their toes 98 :


Deviations seen at the knees include increased flexion in stance phase at initial contact and in mid-stance, and delayed and diminished peak knee flexion in swing phase. The hips often show diminished extension in the sagittal plane at terminal stance. A common deviation seen at the pelvis in children with CP who are toe-walking is increased anterior tilt.

Gluteus Maximus Gait. The gluteus maximus gait, which results from weakness of the gluteus maximus, is characterized by a posterior thrusting of the trunk at initial contact in an attempt to main­ tain hip extension of the stance leg. The hip extensor weakness also results in forward tilt of the pelvis, which eventually translates into a hyperlordosis of the spine to maintain posture. Plantar Flexor Gait. This type of gait is characterized by walk­ ing on the toes but is distinguished from the equinus gait seen in chil­ dren with CPo The plantar flexor gait demonstrates premature firing of the calf muscle in the swing phase of gait with EMG.99 A toe-walking gait pattern describes dynamic ankle deviations that include98 :

~ ~

A loss of heel strike at initial contact, with disruption of the first ankle rocker. Inversion of the second rocker, with ankle plantar flexion (instead of dorsiflexion) occurring at mid-stance. Variable disruption of the third rocker in terminal stance. Variable ankle alignment during swing phase.

It is not unusual for normal children to display intermittent tip­ toe gait when they first begin to walk; however, a more mature heel­ toe gait pattern should become consistent by age 2 years. lOG Older children with persistent tiptoe gait are often labeled idiopathic toe walkers (ITWs). Toe walking that begins after a mature heel-toe gait pattern has been established may signify muscular dystrophy, diastematomyelia, peroneal muscular atrophy, or spinal cord tumor. Toe walking has been associated with premature birth, developmen­ tal delay, schizophrenia, autism, and various learning disorders. 101

Quadriceps Gait. Quadriceps weakness can result from a peripheral nerve lesion (femora!), a spinal nerve root lesion, from trauma, or from disease (muscular dystrophy). Quadriceps weakness requires that forward motion be propagated by circumdueting each leg. The patient leans the body toward the other side to balance the center of gravity, and the motion is repeated with each step. Spastic Gait. A spastic gait may result from either unilateral or bilateral upper motor neuron lesions.
Spastic Hemiplegic (Hemiparetic) Gait. This type of gait results from a unilateral upper motor neuron lesion (see Chapter 9). This type



is frequently seen following a completed stroke. There is spasticity of all muscles on the involved side, but is more marked in some muscle groups. During gait, the leg tends to circumduct in a semicircle, rotating outward, or is pushed ahead and the foot drags and scrapes the floor. The upper limb, held adducted at the shoulder and flexed at the elbow and wrist, with the fist closed, is typically carried across the trunk for balance.

Spastic Paraparetic Gait. This type of gait results from bilateral upper motor neuron lesions (e.g., cervical myelopathy in adults and cerebral palsy in children). The gait is characterized by slow, stiff, and jerky movements. There is spastic extension at the knees with adduc­ tion at the hips (scissors gait).

Ataxic Gait. The ataxic gait is seen in two principal disorders: cerebellar disease (cerebellar ataxic gait) and posterior column disease (sensory ataxic gait).
Cerebellar Ataxic Gait. The nature of the gait abnormality with a cerebellar lesion is determined by the site of the lesion. In vermal lesions, the gait is broad-based, unsteady and staggering with an irreg­ ular sway. The patient is unable to walk in tandem or in a straight line. The ataxia of gait worsens when the patient attempts to stop suddenly or to turn sharply, with a tendency to fall. In hemispherallesions, the ataxia tends to be less severe, but there is persistent lurching or deviation toward the involved side. Sensory Ataxic Gait. With this type of ataxia, because the patient is unaware of the position of the limbs, the gait is broad-based, and the patient tends to lift the feet too high and slap on the floor in an unco­ ordinated and abrupt manner. The patient tends to watch the floor and the feet to maximize attempts at visual correction, and may have diffi­ culty walking in the dark.

Steppage Gait. This type of gait occurs in patients with a foot
drop. A foot drop is the result of weakness or paralysis of the dorsi­ flexor muscles due to an injury to the muscles, their peripheral nerve supply, or the nerve roots supplying the muscles. 90 The patient lifts the leg high enough to clear the flail foot off the floor by flexing exces­ sively at the hip and knee, and then slaps the foot on the floor.

Trendelenburg Gait. This type of gait is due to weakness of the hip abductors (gluteus medius and minimus). The normal stabilizing effect of these muscles is lost, and the patient demonstrates an exces­ sive lateral list in which the trunk is thrust laterally in an attempt to keep the center of gravity over the stance leg. A positive Trendelen­ burg sign is also present. Parkinsonian Gait. The parkinsonian gait is characterized by a flexed and stooped posture with flexion of the neck, elbows, metacar­ pophalangeal joints, trunk, hips, and knees. The patient has difficulty initiating movements and walks with short steps with the feet barely clearing the ground. This results in a shuffling type of gait with rapid



steps. As the patient gets going, the patient may lean forward and walk progressively faster as though chasing his or her center of gravity (propulsive or festinating gait). Less commonly, deviation of the center of gravity backward may cause retropulsion. There is also a lack of associated arm movement during the gait as the arms are held stiffly.

Hysterical Gait.

The hysterical gait is nonspecific and bizarre.

It does not conform to any specific organic pattern, with the abnor­

mality varying from moment to moment and from one examination to another. There may be ataxia, spasticity, inability to move, or other types of abnormality. The abnormality is often minimal or absent when the patient is unaware of being watched or when distracted. However, while all hysterical gaits are bizarre, all bizarre gaits are not hysterical.

The clinical examination of gait can be performed using a number of methods ranging from observation to computerized analysis. Computerized gait analysis measures gait parameters more precisely than is possible with clinical observation alone,102.103 and is widely used in the evaluation and treatment planning for patients with gait abnormalities. 104 However, computerized gait analysis is often cost­ prohibitive and thus not practical for most clinicians, who must there­ fore rely on their powers of observation. The reliability and agreement both between and within raters for gait problems detected by observa­ tion alone has been reported. Krebs and associates 103 found moderate reliability within and between physical therapists observing children's gait from videotape. Eastlack and coworkers 105 found only slight to moderate reliability between raters in the assessment of deviations at a single joint from a videotape. 104 The most commonly used gait analysis chart is the one designed by the Rancho Los Amigos Medical Center (Fig. 7-2), which allows the clinician to determine deviations and their effect on gait in a user­ friendly format.

Study Pearl
Barefoot walking provides information regarding foot function without sup­ port, and can highlight compensations such as excessive pronation, and foot deformities such as claw toes. lOG Having the patient walk with footwear can provide information about the effectiveness of the footwear to coun­ teract the compensations.

The Rancho Los Amigos Observational Gait Analysis (OGA) system, probably the most common system used by physical therapists, involves a systematic examination of the movement patterns of the fol­ lowing body segments at each point in the gait cycle: ankle, foot, knee, hip, pelvis, and trunk. Observational analysis of gait should focus on one gait interval at a time. For example, one should observe the pattern of initial contact with the floor and then, in turn study the actions throughout the initial contact at the ankle, knee, hip, pelvis, trunk, and upper extremities. A paper walkway, approximately 25-feet long, on which the patient's footprints can be recorded, is very useful for gait analysis in the outpatient population. 107,108 To assess gait, knowledge of what is deemed abnormal and the reasons for those abnormalities is a prereq­ uisite (Table 7-7), Where appropriate, the patient should be asked to walk on the toes, and then on the heels. An inability to perform either of these could be the result of pain, weakness, or a motion restriction.

Study Pearl
Metatarsalgia is indicated if the metatarsal heads are made more painful with barefoot walking. Pain at initial contact may indicate a heel spur, bone contusion, calcaneal fat pad injury, or bursitis.



Trunk: Major Deviation Minor Deviation Lean: B/F Lateral Lean: RlL Rotates: B/F Single Limb Support MSt

Major Problems

Weight Acceptance


Hikes Tilt: PIA Lacks Forward Rotation Lacks Backward Rotation Excess Forward Rotation Excess Backward Rotation Ipsilateral Drop Contralateral Drop Flexion: Limited Excess Inadequate Extension Past Retract Rotation: IRIER Ad/Abduction: Ad/Ab


Single Limb Support


Flexion: Limited Excess Inadequate Extension Wobbles Hyperextend Extension Thrust VarusNalgus: VrNI Excess Contralateral Flex Forefoot Contact Foot-Flat Contact Foot Slap Excess Plantar Flexion Excess Dorsiflexion Inversion/Everson: Iv/Ev Heel Off No Heel Off Drag Contralateral Vaulting

Swing Limb Advancement


Excessive UE Weight Bearing



Toes: Up Inadequate Extension Clawed


Figure 7-2. Rancho Los Amigos gait analysis chart. (Reproduced, with permission, from Dutton M. Orthopaedic Examination, Evaluation, and Intervention. New York: McGraw-Hili; 2004:388.)

The patient's footwear is examined for patterns of wear. The greatest amount of wear on the sole of the shoe should occur beneath the ball of the foot, and in the area corresponding to the fIrst, second, and third MTP joints, and slight wear to the lateral side of the heel. The upper portion of the shoe should demonstrate a transverse crease at the level of the MTP joints. A stiff first MTP joint can produce a crease line that runs obliquely, from forward and medial to backward and lateral. 109 Scuffing of the shoe might indicate tibialis anterior weakness or adap­ tively shortened heel cords. 106



TABLE 7-7. SOME GAIT DEVIATIONS AND THEIR CAUSES GAIT DEVIATIONS REASONS Generalized weakness Pain Joint motion restrictions Poor voluntary motor control

Slower cadence than expected for person's age

Shorter stance phase on the involved side and a decreased swing phase on the uninvolved side Shorter stride length on the uninvolved side Decrease lateral sway over the involved stance limb Decrease in cadence Decrease in velocity Use of an assistive device Stance phase longer on one side

Antalgic gait, resulting from a painful injury to the lower limb and pelvic region

Pain Lack of trunk and pelvic rotation Weakness of lower limb muscles Restrictions in lower limb joints Poor muscle control Increased muscle tone

Lateral trunk lean The purpose is to bring the center of gravity of the trunk nearer to the hip joint

Ipsilateral lean-hip abductor weakness (gluteus medius/ Trendelenburg gait) Contralateral lean-decreased hip flexion in swing limb Painful hip Abnormal hip joint (congenital dysplasia, coxa vara, etc.) Wide walking base Unequal leg length Weak or paralyzed knee extensors, or gluteus maximus Decreased ankle dorsiflexion Hip flexion contracture Weak or paralyzed hip extensors, especially the gluteus maximus (gluteus maximus gait) Hip pain Hip flexion contracture Inadequate hip flexion in swing Decreased knee range of motion Inability to extend the hip, usually due to a flexion contracture or ankylosis Contralateral gluteus medius weakness Adaptive shortening of quadratus lumborum on the swing side Contralateral hip adductor spasticity

Anterior trunk leaning Occurs at initial contact to move the line of gravity in front of the axis of the knee Posterior trunk leaning Occurs at initial contact to bring the line of the external force behind the axis of the hip

Increased lumbar lordosis Occurs at the end of the stance period Pelvic drop during stance

Excessive pelvic rotation
Adaptively shortened/spasticity of hip flexors on same side Limited hip joint flexion

Circumducted hip Ground contact by the swinging leg can be avoided if it is swung outward (in order for natural walking to occur, the leg that is in its stance phase needs to be longer than the leg which is in its swing phase in order to allow toe clearance of the swing foot)

Functional leg length discrepancy Arthrogenic stiff hip or knee




GAIT DEVIATIONS REASONS Functional leg length discrepancy Inadequate hip flexion, knee flexion, or ankle dorsiflexion Hamstring weakness Quadratus lumborum shortening Functional leg length discrepancy
Vaulting occurs on the shorter limb side

Hip hiking The pelvis is lifted on the side of the swinging leg, by contraction of the spinal muscles and the lateral abdominal wall Vaulting The ground clearance of the swinging leg will be increased if the subject goes up on the toes of the stance period leg Abnormal internal hip rotation Produces a "toe-in" gait

Adaptive shortening of the iliotibial band Weakness of the hip external rotators Femoral anteversion Adaptive shortening of the hip internal rotators Adaptive shortening of the hip external rotators Femoral retroversion Weakness of the hip internal rotators Spasticity or contracture of ipsilateral hip adductors Ipsilateral hip adductor weakness Coxa vara Hip flexion contracture Iliotibial band contracture Hip flexor spasticity Pain Arthrodesis (surgical or spontaneous ankylosis) Loss of ankle dorsiflexion Hip flexor weakness Hip joint arthrodesis

Abnormal external hip rotation Produces a "toe-out" gait

Increased hip adduction (scissor gait) Results in excessive hip adduction during swing (scissoring), decreased base of support, and decreased progression of opposite foot Inadequate hip extension/excessive hip flexion Results in loss of hip extension in mid-stance (forward leaning of trunk, increased lordosis, and increased knee flexion and ankle dorsiflexion) and late stance (anterior pelvic tilt), and increased hip . flexion in swing Inadequate hip flexion Results in decreased limb advancement in swing, posterior pelvic tilt, circumduction, and excessive knee flexion to clear foot Decreased hip swing through (psoatic limp) Manifested by exaggerated movements at the pelvis and trunk to assist the hip to move into flexion Excessive knee extension/inadequate knee flexion Results in decreased knee flexion at initial contact and loading response, increased knee extension dUring stance, and decreased knee flexion during swing

Legg-ealve-Perthes disease Weakness or reflex inhibition of the psoas major muscle Pain Anterior trunk deviation/bending Weakness of the quadriceps. The hyperextension is a compensation and places the body weight vector anterior to the knee Spasticity of the quadriceps. This is noted more during the loading response and during the initial swing intervals Joint deformity Knee flexion contracture resulting in decreased step length, and decreased knee extension in stance Increased tone/spasticity of hamstrings or hip flexors Decreased range of motion of ankle dorsiflexion in swing period Weakness of plantar flexors resulting in increased dorsiflexion in stance Lengthened limb

Excessive knee flexion/inadequate knee extension At initial contact or around mid-stance. Results in increased knee flexion in early stance, decreased knee extension in mid-stance and terminal stance, and decreased knee extension during swing




Inadequate dorsiflexion control ("foot slap") during initial contact to mid-stance
Weak or paralyzed dorsiflexors Lack of lower limb proprioception

Steppage gait during the acceleration through deceleration of the swing phase Exaggerated knee and hip flexion are used to lift the foot higher than usual, for increased ground clearance resulting from a foot drop Increased walking base ( > 20 cm)

Weak or paralyzed dorsiflexor muscles Functional leg length discrepancy

Deformity such as hip abductor muscle contracture Genu valgus Fear of losing balance Leg length discrepancy

Decreased walking base


10 cm)
Hip adductor muscle contracture Genu varum

Excessive eversion of calcaneus during initial contact through mid-stance
Excessive tibia vara (refers to the frontal plane position of the distal 1/3 of the leg as it relates to the supporting surface) Forefoot varus Weakness of tibialis posterior Excessive lower extremity internal rotation (due to muscle imbalances, femoral anteversion)

Excessive pronation during mid-stance through terminal stance
Insufficient ankle dorsiflexion (less than 10 degrees) Increased tibial varum Compensated forefoot or rearfoot varus deformity Uncompensated forefoot valgus deformity Pes planus Long limb Uncompensated medial rotation of tibia or femur Weak tibialis anterior

Excessive supination during initial contact through mid-stance
Limited calcaneal eversion Rigid forefoot valgus Pes cavus Uncompensated lateral rotation of the tibia or femur Short limb Plantar flexed first ray Upper motor neuron muscle imbalance

Excessive dorsiflexion
Compensation for knee flexion contracture Inadequate plantar flexor strength Adaptive shortening of dorsiflexors Increased muscle tone of dorsiflexors Pes calcaneus deformity

Excessive plantar flexion
Increased plantar flexor activity Plantar flexor contracture




Excessive varus
Contracture Overactivity of the muscles on the medial aspect of the foot

Excessive valgus
Weak invertors Foot hypermobility

Decreased or absence of propulsion (plantar flexor gait)
Inability of plantar flexors to perform function resulting in a shorter step length on the involved side.
Data from Giallonardo LM. Clinical evaluation of foot and ankle dysfunction. Phys Ther. 1988;68:1850--1856; Epler M. Gait. In: Richardson JK, 19larsh ZA, eds. Clinical Orthopaedic Physical Therapy. Philadelphia: Saunders; 1994:602--625; Hunt GC, Brocato RS. Gait and foot pathomechanics. In: Hunt GC, ed. Physical Therapy o/the Foot and Ankle. Edinburgh: Churchill Livingstone; 1988; Krebs DE, Robbins CE, Lavine L, et al. Hip biomechanics dUring gait. J Orthop Sports Phys Ther. 1998;28:51-59; Larish DD, Martin PE, Mungiole M. Characteristic panerns of gait in the healthy old. Ann NY Acad Sci. 1987;515:18--32; Levine D, Whinle M. Gait Analysis: The Lower Extremities. La Crosse, WI, Orthopaedic Section, APTA, Inc. 1992; Perry J. Gait Analysis: Normal and Pathological hmction. Thorofare, NJ: Slack; 1992; and Song KM, Ha1liday SE, Linle DG. The effect of limb-length dis­ crepancy on gait. J BoneJoint Surg. 1977;79A:1690--1698.

The patient's foot is also examined for callus formation, blisters, corns, and bunions. Callus formation on the sole of the foot is an indicator of dysfunction and provides the clinician with an index to the degree of shear stresses applied to the foot, and clearly outlines abnormal weight-bearing areas llO Adequate amounts of calluses may provide protection, but in excess amounts they may cause pain. Callus formation under the second and third metatarsal heads could indicate excessive pronation in a flexible foot, or Morton's neuroma if just under the former. A callus under the fifth, and sometimes the fourth, metatarsal head may indicate an abnormally rigid foot. The patient is then asked to walk in his or her usual manner and at his or her usual speed. The clinician begins the gait assessment with an overall look at the patient while he or she walks, noting the cadence, stride length, step length, and velocity. The arm swing during gait should also be observed. If an individual has a problem with the foot and/or ankle on one side, the opposite arm swing is often decreased. 34 The patient is observed from head to toe and then back again, from the side, from the front, and then from the back. In addition to observing the patient walking at his or her normal pace, the clinician should observe the patient walking at varying speeds, as appropriate. This can be achieved on a treadmill by adjust­ ing speed, or by asking the patient to change his or her walking speed. Once an overall assessment has been made of the patient's gait, the clinician can focus attention on the various segments of the kinetic chain of gait, including the trunk, pelViS, lumbar spine, hip, knee, and ankle and foot (Table 7-3). Attempts are made to determine the pri­ mary cause of any gait deviations or compensations (Table 7-7).

Anterior View. When observing the patient from the front, the cli­
nician can note the following;



~ ~ ~


~ ~



~ ~




The subject's head should not move too much during gait in a lateral or vertical direction, and should remain fairly stationary during the gait cycle. The amount of lateral tilt of the pelvis.
The amount of lateral displacement of the trunk and pelvis.
Whether there is excessive swaying of the trunk or pelvis.
The amount of vertical displacement. Vertical displacement can
be assessed by observing the patient's head. A "bouncing gait" is characteristic of adaptively shortened gastrocnemii, or increased tone of the gastrocnemius and soleus. The reciprocal arm swing. Movements of the upper trunk and limbs usually occur in the opposite directions to the pelvis and the lower limbs. Whether the shoulders are depressed, retracted, or elevated.
Whether the elbows are flexed or extended.
The amount of hip adduction/abduction that occurs. Causes of
excessive adduction include an excessive coxa vara angle, hip abductor weakness, hip adductor contracture or spasticity, or contralateral hip abduction contracture. Excessive hip abduc­ tion may be caused by an abduction contracture, a short leg, obeSity, impaired balance, or hip flexor weakness. 1lI The amount of valgus or varus at the knee. During gait, there may be an obvious varus-extension thrust. According to Noyes and aSSOciates, this gait pattern is characteristic of chronic injuries to the posterolateral structures of the knee. ll2 The width of the base of support. The degree of toe out. The term toe-out refers to the angle formed by the intersection of the foot's line of progression and the line extending from the center of the heel through the second metatarsal. The normal toe-out angle is approximately 7 degrees, which decreases as the speed of gait increases. lLl Whether any circumduction occurs. Hip circumduction can indicate a leg length discrepancy, decreased ability of the knee to flex, or hip abductor shortening or overuse. Whether any hip hiking occurs. Hip hiking can indicate a leg length discrepancy, hamstring weakness, or quadratus lumbo­ rum shortening. Evidence of thigh atrophy. The degree of rotation of the whole lower extremity. Because positioning the lower extremity in external rotation decreases the stress on the subtalar joint complex, an individual with a foot/ankle problem will often adopt this position during gaitY Excessive internal or external rotation of the femur can indicate adaptive shortening of the medial (anteversion) or lateral ham­ strings (retroversion).

Lateral View
~ ~

The amount of thoracic and shoulder rotation. Each shoulder and arm should swing reciprocally with equal motion. Orientation of trunk. The trunk should remain erect and level during the gait cycle as it moves in the opposite direction to the pelvis. Compensation can occur in the lumbar spine for a loss of motion at the hip. A backward lean of the trunk may result from weak hip extensors or inadequate hip flexion. A forward lean of the trunk may result from pathology of the hip, knee, or










ankle, abdominal muscle weakness, decreased spinal mobility, or hip flexion contracture. Forward leaning dUring the loading response and early mid-stance intelVals may indicate hip exten­ sor weakness. 89 Orientation of the pelVic tilt. An anterior pelvic tilt of 10 degrees is considered normal. Excessive anterior tilting can be due to weak hip extensors, a hip flexion contracture, or hip flexor spasticity. Excessive posterior pelvic tilting during gait usually occurs in the presence of hip flexor weakness. Degree of hip extension. Causes of inadequate hip extension and excessive hip flexion contracture, iliotibial band contrac­ ture, hip flexor spasticity, or pain. 111 Causes of inadequate hip flexion may include hip flexor weakness or a hip joint arthrodesis. lll Knee flexion and extension. The knee should be extended dur­ ing the initial contact intelVal, followed by slight flexion during the loading response intelVal. During the swing period there must be sufficient knee flexion. Causes of excessive knee flex­ ion and inadequate knee extension include inappropriate ham­ string activity, knee flexion contracture, soleus weakness, or excessive ankle plantar flexion. Causes of inadequate flexion and excessive extension at the knee include quadriceps weak­ ness, pain, quadriceps spasticity, excessive ankle plantar flex­ ion, hip flexor weakness, or knee extension contracturesY4 Individuals with genu reculVatum may have a functional strength deficit in the quadriceps muscle or gastrocnemius that allows knee hyperextension. lIS Ankle dorsiflexion and plantar flexion. During the mid-stance, the ankle dorsiflexes, and the body pivots over the stationary foot. At the end of the stance period, the ankle should be seen to plantarflex to raise the heel. At the beginning of the swing period the ankle is plantarflexed, moving into dorsiflexion as the swing period progresses, reaching a neutral position at the time of heel contact at the termination of the swing. Excessive plantar flexion in mid-swing, initial contact, and loading response may be due to pretibial (especially the anterior tib­ ialis) weakness. Excessive plantar flexion may also be due to a plantar flexion contracture, soleus and gastrocnemius spastic­ ity, or weak quadricepsy6 Excessive dorsiflexion may be due to soleus weakness, ankle fusion, or persistent knee flexion during the mid-stance period. 89 The stride length of each limb. Cadence. The cadence should be normal for the patient's age (Table 7-7). Heel rise. An early heel rise indicates an adaptively short­ ened Achilles tendon. 34 Delayed heel rise may indicate a weak gastrocnemius-soleus complex. Heel contact. A low heel contact during initial contact may be due to a plantar flexion contracture, tibialis anterior weakness, or premature action by the calf muscles. 116 Pre-swing. An exaggerated pre-swing is manifested by the patient walking on his or her toes. The causes for this include pes equines deformity, adaptive shortening or increased tone of the triceps surae, weakness of the dorsiflexors, and knee flex­ ion occurring at mid-stance. A decreased pre-swing is often




characterized by a lack of plantar flexion at terminal stance and pre-swing. The causes for this can be ankle or foot pain or weakness of the plantar flexor muscles.

Posterior View


~ ~

~ ~

The amount of subtalar inversion (varus)/eversion (valgus). Excessive inversion and eversion usually relate to abnormal muscular control. Generally speaking, varus tends to be the dominant dysfunction in spastic patients, while valgus tends to be more common with flaccid paralysis. 116 Base of support.
Pelvic list.
Degree of hip rotation. As in standing, excessive femoral inter­
nal rotation past the mid stance of gait will accentuate genu recurvatum. Causes of excessive external hip rotation may include gluteus maximus overactivity and excessive ankle plan­ tar flexion. III Cause of excessive internal hip rotation include medial hamstring overactivity, hip adductor overactivity, ante­ rior abductor overactivity, or quadriceps weakness. 1 11 The amount of hip adduction/abduction. The amount of knee rotation.

Quantitative gait analysis (Table 7-8) is used to obtain information on spatial and temporal gait variables, as well as motion patterns. 1l7 Imaging-based systems are the most sophisticated and expensive methods of obtaining quantitative data.

Gait Analysis Profiles and/or Scales

Functional ambulation profile (FAP). DeSigned to examine gait skills on a continuum from standing balance in the parallel bars to independent ambulation. 118 A more recent version of the FAP, which incorporates five environmental challenges that the individual may negotiate with or without use of orthotics or assistive devices, is called the Emory Functional Ambulation Profile (EFAP).

TABLE 7-8. GAlT VARIABLES FOR QUANTITATIVE GAlT ANALYSIS VARIABLE Speed Cadence Velocity Acceleration Stride time Step time Stride length Swing time Step width Foot angle DESCRIPTION A scalar quantity that has magnitude but not direction The number of steps taken by a patient per unit of time A measure of a body's motion in a given direction The rate of change of velocity with respect to time The amount of time that elapses during one stride. Both stride times should be measured The amount of time that elapses between consecutive right and left foot contacts (heel strikes). Both right and left step times should be measured The linear distance between two successive points of contact of the same foot The amount of time during the gait cycle that one foot is off the ground The width of the walking base (base of support) L~ the linear distance between one foot and the opposite foot The angle of foot placement with respect to the line of progression (degree of toe-out or toe-in)

Data from Norkin Cc. Examination of gait. In: O'Sullivan SB, Schmitz T], eels. Physical Rehabilitation. 5th ed. Philadelphia: FA Davis; 2007:317-363.



Functional independence measure (FIM)y9-122 A multidimen­ sional scale that assesses locomotion as one dimension of over­ all functional status. The FIM has two domains of function: motor (self-care, sphincter control, ability to transfer, and loco­ motion) and cognitive (communication and social cognition). The scoring criteria for the ambulation component of the loco­ motion subscale are summarized in Table 7-9. ~ Iowa Level of Assistance Scale. Examines four functional tasks (one of which involves gait): getting out of bed, standing from bed, ambulating 15 feet (4.57 m), and walking up and down three steps. ~ Gait Abnormality Rating Scale (GARS).123 Designed to iden­ tify patients living in nursing homes who were at risk for falling. The Modified GARS (GARS-M) is a modified seven-item version. ~ Fast Evaluation of Mobility Balance and Fear (FEMBAF). An instrument designed to identify risk factors, functional per­ formance, and factors that hinder mobility. ~ Functional ambulation classification (FAC) .124.1 2 Six functional 5 categories are defined: 1. Nonfunctional ambulation. 2. The assistance of another for support and balance is required. 3. Light touch assistance is required. 4. The patient needs verbal cueing for occasional safety assistance. 5. Patient is independent in ambulation on level surfaces. 6. Patient is independent in ambulation on all surfaces, includ­ ing stairs and inclines. ~ Timed up and go. 126--130 Patients are asked to rise from a seated position in a standard high chair, walk 3 meters on a level sur­ face, turn, walk back to the chair, and return to a seated posi­ tion, moving as quickly as they are safely able. Performance is based on total time to complete the task. 117









Able to walk at least 150 feet (50 m) completely independently, without any type of assistive device or wheelchair, safely and within a reasonable (functional) period of time Able to walk at least 150 feet (50 m) independently but requires an assistive device (orthosis, prosthesis, wheelchair, special shoes, cane, crutches, walker), or takes more than reasonable time, or has safety concerns Requires stand by supervbion, cueing, or coaxing to walk or propel wheelchair at least 150 feet (50 m) Requires minimum contact assistance (patient contributes 75% effort) to walk or propel wheelchair at least 150 feet (50 m) Requires moderate assistance (patient contributes 50% to 74% effort) to walk or propel wheelchair a minimum of 150 feet (50 m) Requires maximal assistance of one person (patient contributes 2'i% to 49% effort) to walk or propel wheelchair 'i0 feet (17 m) Requires total assistance (patient contributes less than 25% effort), or requires assistance of more than one helper, or is unable to walk or propel wheelchair at least 50 feet (17 m)

Dam from Dickson HG, Kohler F. FumIiunal independence measure (FIM). Scand] RehabilMed. 1999:31:63-64: Grey N, Kennedy P. The Functional Independence Measure: a comparative study of clinician and self ralings. Paraplegia. 1993:31:457--461; Hamilton BB, Laughlin ]A, Fiedler RC, ela1. Intenater reliability of the 7-level functional independence measure (FIM). Scand] Rehabil Med. 1994;26:115-119: and Keith RA, Granger CV, Hamilton BB, el OIL The functional independence measure: a new 1001 for rehabilitation. Adv Clin Rehabil. 1987;1:6-18.



Posture describes the relative positions of different joints at any given moment,131 Like "good movement," "good posture" is a subjective term based on what the clinician believes to be correct based on ideal models. Over the course of time, various definitions have been put forward to describe the attributes of good posture. 25 ,13 2- 1 36 Postural control is fundamental to movement, allowing an indi­ vidual to 137 : .. .. .. .. Maintain a position.
Move into and out of positions.
Recover from instability.
Anticipate and prepare for instability.

Study Pearl

system to perform ,actions ,requiring

the least amount of ~nergy to achieve
the desired effect."132 "" ,

Postural control is described under three conditions 137 : .. Steady-state adjustments: require movement strategies that con­ trol a stable, quiet position in which the center of body mass is kept within the base of support. .. Anticipatory adjustments: require movement strategies that recover stability in response to a planned, voluntary movement. .. Reactive adjustments: require strategies that recover stability in response to an unexpected, external disturbance. The postural examination may be assessed statically, when the body is at rest, or dynamically with the body in motion. The clinician observes the patient from the front, back, and sides, ideally with a patient standing near a plumbline for vertical reference for each view and with the clinician positioned to be able to see the patient's entire body: .. Standing: when observing from the anterior or posterior view, the plumbline should be aligned with a point midway between the feet and should divide the patient equally into the left: and right halves. When observing the patient from the side, the plumbline should be aligned slightly anterior to the lateral malleolus. .. Dynamic: refer to "Clinical examination of Gait" earlier in this chapter. The postural assessment gives an overall view of the patient's muscle function in both chronic and acute pain states. The examina­ tion enables the clinician to differentiate between possible provocative causes, such as structural variations, altered joint mechanics, muscle imbalances, and/or the residual effects of pathology. Skeletal malalignment may be defined as either abnormal joint alignment or deformity within a bone. Abnormal, or nonneutral, align­ ment is defined as "positioning that deviates from the midrange posi­ tion of function.,,138 To be classified as abnormal, nonneutral alignment must produce physical functional limitations. Nonneutral alignment may produce neuromusculoskeletal pathology at adjacent or distal

Study Pearl

ext1ernal auditory meatus, acromio­ clavicular joints, greater trochanters, and lateral malleoli. .. In the anteroposterior view, approx­ imate skeletal symmetry allows division of the body into symmetri­ cal halves with bisection of the fol­ lowing points: glabella, frenulum, episternal notch, xiphoid process, symphysis pubis, and a point mid­ way between the medial malleoli of the ankle joints.



Study Pearl


antag()nis~.~hang~s):,with· one ·a(lopt..

r~~ti?? .'eng~~:.~f~~~gonist • . an~~h.Y

in~as~orer restinglen?th than nor­ m~ll~ndthe other a~9Ptin~a.tonger resting length than norrnal.T~~.inert tissues,. suc:h as the ligaments and joint c:apsules, reatt in asirnilar fash­ ion, therehy alteringjoinrpl.ay, which in turn alters arthrokinernatic:func:tion aridforc:e transmission as. thernusdes around that joint..\llit~~·,their length in an attempt to mini:mi.ze the stresses at that Joint. 139 ,144,145


Study Pearl
WhiTe most dinidatls tan apprec:iate
that repeated movement patterns per­
formed In a Jherapeutic manner can
beR~nen¢j(l,l,jtmust als.? berernern:'
beredthat repeatedl)'lotions per­
formed.erroneously can ··produce
changes in l)'I1,lsdetension, muscle
strength, length,.andsliffness. 15o

Study Pearl
A sustained change in muscle length
is postulated toinfJuence the informa­ tion sent hy the proprioceptors,which can c.ause alterations in recruitment patterns and the domihanee of one synergist over andther. 150,152

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Postural imbalances involve the entire body, as should any corrections. It is important to remember. that prior to any intervention an appropriate exam­ . ination must take place.

joints through compensatory motions or postures. Nonneutral alignment, whether maintained statically, or performed repetitively, appears to be a key precipitating factor in soft-tissue and neurologic pain. 139 This may be due to an alteration in joint load distribution or the force transmis­ sion of the muscles. Nonneutral alignment can occur in the frontal (scoliosis, a leg length discrepancy) and sagittal planes (forward head, anteriorly rotated pelvis, a decrease in the lumbar lordosis, knee recurvatum, shoulder protraction), and can progress to a somatic dysfunction. 14 o­ 142 Sustained postures can also produce muscle imbalances and pain, especially if the joint is held at the end of its range. 143 It is theorized that if a muscle lengthens as part of a compensation, muscle spindle activity increases within that muscle, producing recip­ rocal inhibition of that muscle's functional antagonist, and resulting in an alteration in the normal force-couple and arthrokinematic relation­ ship, thereby effecting the efficient and ideal operation of the move­ ment system. 146-150 The pain from sustained positions is thought to result from ischemia of the isometrically contracting muscles, localized fatigue, or an excessive mechanical strain on the structures. Intramuscular pres­ sure can compress the blood vessels and prevent the removal of metabolites, and the supply of oxygen, either of which can cause tem­ porary painy,l It is quite normal for muscles to frequently change their lengths during movements. However, this change in resting length becomes pathologic when it is sustained through incorrect habituation, or as a response to pain. Muscles maintained in a shortened or lengthened position will eventually adapt to their new positions. Although these muscles are initially incapable of producing a maximal contraction in the newly acquired positions,153 changes at the sarcomere level allow the muscle to eventually produce maximal tension at this new length. 150 While this may appear to be a satisfactory adaptation, the changes in length produce changes in tension development, as well as changes in the angle of pull,1'i4 For example, a passively insufficient muscle is acti­ vated earlier in a movement than a normal muscle, and has a tendency to be more hypertonic, thereby producing a reflex inhibition of the antagonists. 146,147,155,156 For the vast majority of people, static postures are a rarity, while dynamic postures are more functional. JulP56 and Janda157 developed a system that characterized muscles based on common patterns of kinetic chain dysfunction into two functional divisions: a movement group, and a stabilization group (Table 7-10). More recently, Sahrmannl'iO has stressed the importance of obser­ vation along both directions of the kinetic chain, and the importance of examining joints proXimal to the site of the disorder, or symptomology, to determine the mechanical cause of the symptoms rather than iden­ tifying the painful tissues. Once the mechanical source is identified, the focus of the intervention is the simultaneous retraining of the muscles, by contracting the lengthened muscle when it is in a shortened posi­ tion, and stretching the shortened muscle. 150 Common lower limb skeletal malalignments and possible cor­ related and compensatory motions or postures are compiled in Table 7-11. Common postural deformities of the thoracic region include l'i8:




Examples Gastrocnemius/soleus Tibialis posterior Short hip adductors Hamstrings Rectus femoris Tensor fascia lata Erector spinae Quadratus lumborum Pectoralis major Upper portion of trapezius Levator scapulae Sternocleidomastoid Scalenes Upper limb flexors Characteristics Primarily type IIa muscle fibers Prone to adaptive shortening Prone to develop hypertonicity Dominate in new movement situations Generally cross two or more joints

Examples Peronei Tibialis anterior Vastus medialis and lateralis Gluteus maximus, medius, minimus Serratus anterior Rhomboids Lower portion trapezius Short/deep cervical flexors Upper limb extensors Rectus abdominis

Characteristics Primarily type I muscle fibers Prone to develop weakness and muscle inhibition Dominate in postural or sustained activities Primarily cross one joint

Reproduced. with permission, from .lull GA, Janda V. Muscle and motor control in low back pain. In: Twomey LT, Taylor JR, cill,. Physicallberapy a/the Low Back: Clinics in Physical Therapy. New York: Churchill Livingstone; 1987:258. Copyright © Elsevier.


~ ~

Dowager's hump. 'nus deformity is characterized by a severely
kyphotic upper dorsal region, which result'> from multiple anterior
wedge compression fractures in several vertebrae of dle middle to
upper moracic spine, usually caused by postmenopausal osteo­
porosis or long-term corticosteroid merapy (specificity, 0.99).159
Hump back. This deformity is a localized, sharp, posterior
angulation, called gibbus, produced by an anterior wedging of
one of two thoracic vertebra as a result of infection (tuberculo­
sis), fracture, or congenital bony anomaly of the spine 160
Round back. This deformity is characterized by decreased
pelvic inclination and excessive kyphosis.
Flat hack. This deformity is characterized by decreased pelVic
inclination, increased kyphosis, and a mobile thoracic spine.

Other deformities associated with this region include:



Barrel chest. In this deformity, a forward and upward project­
ing sternum increases the anteroposterior diameter. The barrel
chest results in respiratory difficulty, stretching of the inter­
costal and anterior chest muscles, and adaptive shortening of
the scapular adductor muscles.
Pigeon chest. In this deformity, a forward and downward project­
ing sternum increases me anteroposterior diameter. The pigeon
chest results in a lengthening of dle upper abdominal muscles and
an adaptive shortening of me upper intercostal muscles.
Funnel chest. In this deformity, a posterior-projecting sternum
occurs secondary to an outgrowili of dle ribs. 161 The funnel chest
results in adaptive shortening of me upper abdominals, shoulder
adductors, pectoralis minor, and intercostal muscles, and in length­
ening of me moracic extensors and middle and upper trapezius.




Ankle and Foot

POSSIBLE COMPENSATORY MOTIONS OR POSTURES Hypermobile first ray Subtalar or midtarsal excessive pronation Hip or knee flexion Genu recurvatum Excessive internal rotation along the lower quarter chain Hallux valgus Plantar flexed first ray Functional forefoot valgus Excessive or prolonged midtarsal pronation Excessive external rotation along the lower quarter chain Functional forefoot varus Plantar flexed first ray Hallux valgus Excessive midtarsal or subtalar pronation or prolonged pronation Excessive tibial; tibial and femoral; or tibial, femoral, and pelvic internal rotation, or all with contralateral lumbar spine rotation Excessive midtarsal or subtalar supination Excessive tibial; tibial and femoral; or tibial, femoral, and pelvic external rotation, or all with ipsilateral lumbar spine rotation

Ankle equinus

Rearfoot varus Excessive subtalar supination (calcaneal valgus)

Tibial; tibial and femoral; or tibial, femoral, and pelvic external rotation

Rearfoot valgus Excessive subtalar pronation (calcaneal valgus) Forefoot varus

Tibial; tibial and femoral; or tibial, femoral, and pelvic internal rotation Hallux valgus Subtalar supination and related rotation along lower quarter

Forefoot valgus

Hallux valgus Subtalar pronation and related rotation along lower quarter Hallux valgus Internal tibial torsion Flat foot

Metatarsus adductlis

Hallux valgus

Forefoot valgus Subtalar pronation and related rotation along the lower quarter33 Pes planus Excessive subtalar pronation External tibial torsion Lateral patellar subluxation Excessive hip adduction Ipsilateral hip excessive internal rotation Lumbar spine contralateral rotation Excessive lateral angulation of tihia in frontal plane; (tibial varum); (tihia vaw) Internal tibial torsion Ipsilateral hip external rotation Excessive hip abduction Ankle plantar flexion Excessive anterior pelvic tilt

Excessive tibial; tihial and femoral; or tibial, femoral, and pelvic external rotation, or all with ipsilateral lumbar spine rotation Forefoot varus Excessive suhtalar supination to allow lateral heel to contact ground In-toeing to decrease lateral pelvic sway during gait Ipsilateral pelvic external rotation

Knee and Tibia Genu valgus

Genu varus

Forefoot valgus Excessive subtalar pronation to allow medial heel to contact ground Ipsilateral pelvic internal rotation

Genu recUlvatum

Posterior pelvic tilt Flexed trunk posture Excessive thoracic kyphosis



TABLE 7-11. SKELETAL MALALIGNMENT OF THE LOWER QUARTER AcI\lD CORRELATED AND COMPENSATORY MOTIONS OR POSTURES (Continued) POSSIBLE CORRELATED MOTIONS OR POSTURES Out-toeing Excessive suhtalar supination with related rotation along lower quarter In-toeing Metatarsus adductus Excessive subtalar supination with related rotation along lower quarter Genu recurvatum

MALALIGNMENT External tibial torsion

POSSIBLE COMPENSATORY MOTIONS OR POSTImES Functional forefoot varus Excessive suhtalar pronation with related rotation along lower quarter Functional forefoot valgus Excessive subtalar pronation with related rotation along lower quarter

Internal tibial torsion

Excessive tibial retroversion (posterior slant of tibial plateaus) Inadequate tibial retrotorsion (posterior deflection of proximal tibia due to hamstrings pull) Inadequate tibial retroflexion (bowing of the tibia) Bowleg deformity of tibia (tibia vard, tibial varum)

Flexed knee posture

Altered alignment of Achilles tendon causing altered associated joint motion Internal tibial torsion

Forefoot valgus Excessive subtalar pronation Excessive external tibial torsion Excessive knee external rotation Excessive tibial; tibial and femoral; or tibial, femoral, and pelvic external rotation; or all with ipsilateral lumbar spine rotation Excessive knee internal rotation Excessive tibial; tibial and femoral; or tibial, femoral, and pelvic internal rotation; or all with contralateral lumhar spine rotation Excessive ipsilateral subtalar pronation Excessive contralateral subtalar supination Contralateral plantar flexion Ipsilateral genu recurvatum Ipsilateral hip or knee flexion Ipsilateral forward pelvis with contralateral lumbar spine rotation Excessive ipsilateral suhtalar supination Excessive contralateral subtalar pronation Ipsilateral plantar flexion Contmlateral genu recurvatum Contralateral hip or knee flexion Ipsilateral backward pelvic rotation with ipsilateral lumhar spine rotation

Hip and Femur Excessive femoral anteversion (anteversion)

In-toeing Excessive suhtalar pronation Lateral patellar subluxation

Femoral retrotorsion (retroversion)

Out-toeing Excessive suhtalar supination

Excessive femoral neck to shaft angle (coxa valga)

Decreased femoral neck to shaft angle (coxa vara)

Long ipsilateral lower limb and correlated motions or postures of a long limh Posterior pelvic rotation Supinated subtalar joint and related external rotation along the lower quarter Pronated subtalar joint and related internal rotation along lower quarter Short ipsilateral lower limb and correlated motions or postures along lower quarter; anterior pelvic rotation

Reproduced, with permission, from Riegger-Krugh C, Keysor JJ. Skeletal malalignments of the lower quarter: correlated and compensatory motions and postures. J Orthop Sports Phys Ther. 1996;23:164-170. With permission of the Orthopaedic and Sports Physical Therapy Section of the American Physical Therapy Association.




Two terms, scoliosis and rotoscoliosis, are used to describe the lateral curvature of the spine. Scoliosis is the older term and refers to an abnormal side bending of the spine, but gives no reference to the coupled rotation that also occurs. Rotoscoliosis is a more detailed definition, used to describe the curve of the spine by detailing how each vertebra is rotated and side flexed in relation to the vertebra below. For example, with a left lumbar convexity, the L5 vertebra would be found to be side flexed to the right and rotated to the left in relation to the sacrum. The same would be true with regard to the relation between L4 and L5. This rotation, toward the convexity, con­ tinues in small increments until the apex at L3. L2, which is above the apex, is right rotated and right side-flexed in relation to L3. The small increments of right rotation continue up until the thoracic spine, where the side bending and rotation return to the neutral position. Lateral curvature of the spine can be described as being structural or functionaI 162 ,163:

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The curve patterns are named accord­ ing to the level of the apex of the curve. For exam, p. Ie'1 a right thora~ic' c' Il't~e, ,h,as a convexIty toward ,the fight; and '(he apex .of the cut'VIO'isin the thoracic spine. ' •'


Functional: this type of scoliosis is classified as postural, which disappears on foward bending; and compensatory, which is most conunonly due to a short leg. Structural: may be genetic, congenital, or idiopathic, producing a structural change to the bone and a loss of spinal fleXibility. With a structural scoliosis, the vertebral bodies rotate toward the convexity of the curve (the spinous processes deviate toward the concave side), producing a distortion, called a rib hump.164 The rib hump occurs on the convex side of the curve. Persistent scoliosis during forward bending (Adam's sign) is indicative of a structural curve.

The curvature results in an adaptive shortening of the intrinsic trunk muscles on the concave side, and lengthening of the intrinsic muscles on the convex side. A number of radiographic classification systems exist to describe the types of scoliotic curves, including: Ponseti-Friedman classification.16S-l67 There are five types: I. A Single major lumbar curve at Tll-L3 with an apex at 11-2. II. A single major dorsolumbar curve at T6-7 to 11-2 with an apex at Tll-12. III. Combined thoracic and lumbar with a dorsal curve on the right side at T5-6 or TlO-ll and an apex at T7-8 and a lum­ bar curve on the left side at TIO-ll to L3-4 with an apex at 11-2. IV. A single major thoracic curve at T5-6 to Tll-12 with an apex at T8-9. V. Cervicothoracic at C7-Tl or T4-5 with an apex at T3. ~ King-Moe classification. 16B There are four types: I. Lumbar dominant and S-shaped. II. Thoracic dominant and S-shaped. III. Thoracic where the thoracic and lumbar curves do not cross the midline. IV. Long thoracic or double thoracic with Tl tilted into the upper curve.



Lenke classification. 169,170 There are three components: • Type of curves: I. Primary thoracic. II. Double thoracic scoliosis. III. Double major scoliosis. IV. Triple major scoliosis. V. Dorsolumbar-lumbar scoliosis. • Lumbar modifier: based on the relationship of the central sacral vertical line to the apex of the lumbar curve. Classified into A, B, and C categories. • Sagittal thoracic modifier: the sagittal curve measurement from T5-12. Designations are: - for less than 10 degrees, N for 10 to 40 degrees, and + for greater than 40 degrees.

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The significant incidence of scoliosis in' toe, ,adolescent popl,ll~tion' has prompted the creation,of ,. school s~reenihg programs in aliSO states. From the fifth grade onward/ children ",s,hould be, seree.ned, ,approximately e\'lery 6 to 9 months.

A number of techniques, measures, and indices are used to assess scoliosis. These include the Cobb-Webb technique, the Ferguson tech­ nique, the Greenspan method, the Nash-Moe technique of measuring vertebral rotation, the Cobb method of assessing vertebral rotation, the Risser index, the observation for ossification of the vertebral ring apophysis, the difference in the rib-vertebral angle, the Perdriolle method, and the Lytilt method. There is no literature that examines why patients and/or their sur­ geons choose surgical versus nonsurgical treatment. Parameters to consider include preoperative risks, radiographic measures, clinical symptoms, functional limitations and appearance, and social issues. The conservative approach for scoliosis runs the gamut from bracing to monitoring.

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ical stimulation of muscles for the rrection f scoliosis has not been found to e in preventing sco­ liosis progression, 71


Posture for Standing, Sitting in Office Chairs, or Driving
It is important to maintaining the natural curve of the spine when standing. The patient should be advised to:
~ ~ ~

Standing Posture.

~ ~

Keep the head directly over the shoulders and the shoulders over the pelvis. Tighten the abdominal muscles and tuck in the buttocks. Place the feet slightly apart with one foot in front of the other and knees slightly flexed. Use a railing or box to prop one foot up while standing. Wear shoes with good support and cushioning. A rubber mat can ease the pressure and enhance favorable ergonomic conditions. Change feet positions every 20 minutes.

Sitting Posture. Many of the problems associated with sitting may be avoided by a combination of the following techniques.

Provide support for the lumbar spine. Maintaining a similar lumbar lordosis in sitting as one maintains in standing is gener­ ally thought to be better than either a reduced lordosis or a kyphotic lumbar spine posture.m,173



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~ ~


gthaJ11nmiqql~~i~iJ1g,·and tn<it pressu~e in middlesitti~,in turn, W<i~)~~~atenhan in posterio~)!>itti ng. 174

p~~S~l,!re was. b!g~~riin •anteriw

ModifY the sitting position. As with standing, there are many potential sitting postures, although three are commonly described: • Anterior (forward) sitting: involves either an anterior rotation of the pelvis or increased kyphosis of the spine so that more than 25% of the body's weight is transmitted through the feet to the floor and the center of gravity is anterior to the ischial tuberosities. • Middle (erect) sitting: involves sitting with the center of grav­ ity directly over the ischial tuberosities, with approximately 25% of the body's weight transmitted through the feet to the floor. • Posterior sitting: involves sitting so that less than 25% of the body's weight is transmitted through the feet to the floor and the center of gravity is posterior to the ischial tuberosities. Take stretch breaks from sitting in office chairs or standing for long periods of time. Make the workstation as consistent and comfortable as pOSSible (see Ergonomics and Body Mechanics later). • Choose the surface height for the desk (standing, sitting or semi-seated) best for the task to be performed. For example, architects and draftsman may want a higher surface for draw­ ing while computer entry workers could be seated or stand­ ing, depending on the need to use other tools or references. • Adjust the seat of the ojfice chair so that the work surface is "elbow high" (see Ergonomics and Body Mechanics later), The legs should be positioned so that the individual's fist should be able to pass easily behind his or her calf and in front of the seat edge to provide enough space for the legs. Two fingers should slip easily under the thighs. If not, a cou­ ple of telephone books or a footrest can be used to raise the knees level with the hips. The backrest of the office chair should push the lumbar spine slightly anteriorly. A rolled up towel or a commercial back support can be placed at the back of the seat for added support. • Fit the height of the computer screen. Ask the individual to sit comfortably in his or her office chair, and to close the eyes and relax. Ask the individual to slowly reopen the eyes and see whether the center of the screen is level with his or her gaze.

The individual should be advised to sit with the knees level with the hips. A rolled up towel or a commercial back support can be placed at the back of the seat for added support. As reaching increases the pressure on the lumbar and cervical spines, shoulder, and wrist, the individual should be advised to sit as close to the steering wheel as possible.

The Guide to Physical Therapist Practice includes examination of enVironmental, home, and work (job/school/play) barriers among the list of categories of test and measures that may be used by physical



therapists. 175 Treating the injured worker requires that the physical therapist must be knowledgeable regarding the following 176 :

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Environmental barriers: defined as physical impediments to prevent individuals from functioning opti~ maUy in their surroundings. Include safety hazards, access problems, and home or workplace design difficulties. 175 ~ Accessibility: the degree to which an environment affords use of its resources with respect to an indi­ vidual's level, of function_ , ~ Universal design (lifespan design): this design concept emphasizes' social inclusion by creating envi­ ronments that are usable by a wide range of individuals of different ages, stature, sizes,· and ~bHities, , and also address,es the changing needs of human beings acro5sthe lifespan. 177


An understanding of all aspects of the patient's community, home, and work. This includes the physical environment in which an individual functions, including both built and natural objects. This aspect of the examination may entail the clinician visiting the patient's home or worksite. Detailed information about the patient's work history and available resources at the worksite may also be obtained from the company representa­ tive responsible for implementing change on the worker's behalf. The psychosocial issues and cultures of the patient's environment The most appropriate avenues for minimizing loss of function while maximizing recovery for a specific patient and workplace.


Environmental Impact. A variety of instruments have been developed that address the impact of environmental determinants on function. These include 177:




The Physical Activity Resource Assessment (PARA)Ys Designed to examine and document the available resources that promote activity within the neighborhood or community environment. Home and Community Environment (HACE).179 A self-report instrument used to identify features of the patient's home or community that may impact level of function. Safety Assessment of Function and the Environment for Rehabilitation (SAFER) tool. 180 A comprehensive functional and environmental examination tool designed for use with the elderly. Environmental analysis of mobility questionnaire (EAMQ).181,182 A self-report instrument that examines the impact of the envi­ ronment on community mobility.

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Posture. The postural examination (see also the "Posture" section earlier in this chapter) should include the patient's posture while per­ forming functional tasks in the home, community, and workplace. Ideally, prolonged postures should keep all joints in midrange (neutral position) to maximize muscle leverage, efficiency, and performance while minimizing strain on soft tissues and joints. 183 In addition, the cli­ nician should check if any environmental barriers, such as low-hanging lights, a high or low seat, or a high or low work surface, compromise the patient's ability to maintain neutral positioning. 183 Range of Motion. Functional range of motion rather than indi­ vidual joint motion is generally most relevant to the examination of environmental barriers. Muscle Performance. Functional muscle testing-such as determining whether the individual has the strength to handle tools,
Most products are designed to work well for people within the 5th to 95th percentile of the general population of nondisabled individuals. f84--188 The cli­ nician should measure the patient's height, reach, depth, hlp, shoulder, and hand width to identify individuals who do not fit within the typicalrange.



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The multidirectional reach test, an expanded version of the functional reach test, is an effective test of func­ tional range of motion. 189,190 Another measure of functional ROM is a map of the patient's reach zones, which look like semicircles extending in front of and to the side of the patient. 183 These items can be classi­ fied as primary, . secondary, or tertiary. Objects are then placed in the zoneS accordingt9frequencyof use.• .. Primary:.zone: frequently used objects,which can be used while keeping e.lbows at the side of the .. . body. .. Secondary zone: all objects that .are used 4 to 10 times an hour and that can be reach~d without the elbow moving further forward than the anterior portion of the rib cage. " Tertiary zone: infrequently used objects, which can be reached with­ out exceeding full elbow extenSion or 90 degrees of shoulder flexion


operate levers and lifts, and cany, push, and pull objects as required by the expected roles--can be more useful than examination of strength by measurement of individual muscle performance with manual muscle test or other approaches. 183

Gait, Locomotion, and Balance. The patient's movement patterns and balance should be observed throughout the environmen­ tal assessment, including how the patient moves in and out of the vehi­ cle or other equipment, climbs steps, traverses uneven surfaces, antic­ ipates and maneuvers trip hazards, stands and sits while talking, and balances when sitting and standing, as well as how fatigue impacts these motions. 183 Ergonomics and Body Mechanics. This involves an exami­ nation of the efficiency of task performance, the impact of environ­ mental variables, and how the task challenges maintenance of neutral postures. 183
To give departmental guidance in selecting office furniture and setting up workstations, the following guidelines are from the American National Standards Institute and the Environmental Health and Safety Center.


See Tables 7-12 and 7-13.

Workstation Design. Correct workstation height depends upon the user of a workstation and upon the chair and other factors that interact with the user and table (Tables 7-14 and Table 7-15). Ideally, the worker should be able to sit at the workstation with the keyboard in place and be able to easily maintain a 90- to 100-degree elbow angle and straight wrists while keying.
Height. The height of an adjustable keyboard support should adjust between 23 and 28 inches to accommodate most-but not all-users. 26 inches is a recommended compromise position while leg clearance must still be considered. Leg Room. Knee spaces should allow a worker to feel uncrowded and to allow some changes of position even with the keyboard support lowered to the correct level for use. The knee space should be at least 30 inches wide by 19 inches deep by 27 inches high to comply with the requirements of the Americans with Disabilities Act. For those using a footrest, clearance must be calculated with the legs in place on the footrest. Likewise, depth of the "clearance envelope" for both legs and toes should be evaluated while the workstation user is in a normal working position at the workstation (determined by the design of the seating system and the way the user sits). Drawers and support legs (for furniture) should not go where human legs need to fit.

Workstation Top. The workstation top should be big enough to
allow space not only for all computer-related necessary equipment, but also for paperwork, books, and other materials needed while working at the computer. Working with materials on chairs and at odd angles



TABLE 7-12. CHAIR DIMENSIONS Seat height Seat height should be pneumatically adjusted while seated. A range of 16 to 20.5 inches off the floor should accommodate most users. Thighs should be horizontal, lower legs vertical, feet flat on the floor, or on a footrest. The seat height should be 3 to 5 cm below the knee fold when the lower leg is vertical. Seat height should also allow a 90-degree angle at the elbows for typing. A seat width of 17 to 20 inches suffices for most people and should be deep enough to permit the back to contact the lumbar backrest without cutting into the backs of knees (there should be approXimately 10 cm between the back of the lower leg and the seat). The front edge should be rounded and padded. Avoid bucket-type seats. The seat should swivel easily. The seat slope should be adjustable (0 to 5 degrees is ideal). A forward slope is required for raised seats and semi-sitting. A backward slope of 5 degrees is suggested for normal sitting. The backrest should offer firm support, especially in the lumbar region.
Should be convex top to bottom; concave side to side.
Should be 12 to 19 inches Wide, and should be easily adjustable both in angle and height, while sitting.
The optimum angle between seat and back should permit a working posture of at least 90 degrees between the spine and thighs. Seat pan angle and backrest height and angle should be coordinated to allow for the most comfortable weight load on the spinal column. A chair seat and back should be padded enough to allow comfortable circulation. If a seat is too soft, the muscles must always adjust to maintain a steady posture, causing strain and fatigue The seat fabric should "breathe" to allow air circulation through clothes to the skin. Armrests are optional, depending on user preference and task performed. They should not restrict movement or impede the worker's ability to get close enough to the work surface. If the width between the armrests is too wide, the user must raise the shoulders and abduct the arms. The worker should not rest his or her forearms while keying. When using the armrests, shoulder abduction angle should be 15 to 20 degrees or less and shoulder flexion angle should be 25 degrees or less.

Seat width and depth

Seat slope


Seat material


TABLE 7-13. ERGONOMIC CHAIR CHECKLIST Chair has wheels or castors suitable for the floor surface. Chair swivels. Backrest is adjustable for both height and angle. Backrest supports the inward curve of the lower back. Chair height is appropriate for the individual and the work surface height. Chair is adjusted so there is no pressure on the backs of the legs, and feet are flat on the floor or on a footrest. 7. Chair is adjustable from the sitting position. 8. Chair upholstery is a breathable fabric. 9. Footrests are used if feet do not rest flat on the floor. 1. 2. 3. 4. 5. 6. Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No

TABLE 7-14. WORK STATION ACCESSORIES Footrest Document holder Situations will arise in which a user is perfectly adjusted for keyboard use and with the monitor at a correct angle, but his or her feet do not rest flat on the floor. A footrest may be used to correct this problem. Use a document holder instead of resting copy on the tabletop. This helps to eliminate strain and discomfort by keeping the copy close to the monitor and at the same height and distance from the user's face as the screen. Wrist rests should only be used to support the wrist in pauses between typing if this is comfortable for the individual. Placing the wrists on a wrist rest while typing can create a bend in the wrists and pressure on the carpal tunnel. Wrist rests should have rounded, not sharp, edges and should provide a firm but soft cushion.

Wrist rests



TABLE 7-15. VDT CHECKLIST Keyboard height (home row above floor): 71---B7 cm. Top surface of the keyboard space bar is no higher than 2.5 inches above the work surface. During keyboard use, the forearm and upper arm form an angle of 90-100 degrees with the upper arm almost vertical, the wrist is relaxed and not bent, wrist rests are available. If used primarily for text entry, keyboard is directly in front of the operator. If used primarily for data entry, keyboard is directly in front of the keying hand. Top of screen is at eye level or slightly lower (center above floor should be 92-116 cm). Viewing distance (eye to screen): 61-93 cm. Viewing angles (eye to screen center): +2 to -26 degrees. Screen is free of glare or shadows. Images on the screen are sharp, easy to read, and do not flicker. Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No

has the potential for neck and other body strain. Frequently used items should be kept close to avoid long reaches. A general recommendation is that the work area top should be at least as big as the standard office desk-30 inches by 60 inches. A depth of at least 30 inches allows flex­ ibility in use/reuse of the work area. Usable space may be maximized by good wire/cable management. The thickness of the work surface should be 1 inch.

Environmental Barriers. This includes an assessment of exte­
rior and interior barriers.

Exterior Barriers


Exterior access routes: includes consideration of the frequency and mode of transportation typically used to reach the destina­ tion, parking, lighting in the parking area, and safely traveling to the entrance. Stairs: steps should have a maximum height of 7 inches and depth of at least 11 inches and should not have tread lip projections. 191 Ramps: if the patient has to use a ramp for home or work, the clinician should ensure that the patient can safely ascend and descend it and that it is soundly built. For safety and ease of use, a ramp should ideally have an incline of at least I-foot length for each inch of rise (1:12 ratio). For example a 6-inch­ step leading into the homelbuilding requires a 6-foot ramp.183 Handrails: particularly important for those who ambulate with difficulty, and for those with impaired balance, especially on stairs and ramps.



Interior Barriers
.. Interior access routes: should be checked to ensure that there is enough space for basic mobility in and out of rooms with any assistive device the patient requires. .. Floor surface: type and resistance of floor covering should be appropriate. ~ Doorways: a door must be at least 32 inches wide for a standard wheelchair to pass, and ideally 1 to 2 inches wider than this to account for inaccurate maneuvering and the usual oblique approach to doors. 183




Lighting: check that lighting in all areas is bright enough for safe task performance and that light switches can be reached by the patient or that the lights come on automatically as the patient enters the environment. 183 Seating: examine the height, Width, depth, and stability of all seating (refer to "Ergonomics and Body Mechanics" earlier in this chapter).


Work-related musculoskeletal disorders (WMSDs) represent a wide range of disorders involving dysfunction of the neuromusculoskeletal system caused or made worse by the work environment, which can differ in severity from mild periodic symptoms to severe chronic and debilitating conditions. Examples of WMSDs include carpal tunnel syndrome, tenosynovi­ tis, tension neck syndrome, and low back pain (Table 7-16). WMSDs can cause symptoms such as pain, numbness, and tin­ gling; reduced worker productivity; lost time from work; temporary or permanent disability; inability to perform job tasks; and an increase in workers compensation costs. The Occupational Safety and Health Administration (OSHA) has issued directives to minimize risk for WMSDs in the form of the Ergonomic Programs Rule.I92-194 The following is adapted from Physical Tberapist Management of the Acutely Injured Worker, BOD G03-01-17-56 (Program 32), retitled Occupational Health Guidelines: Physical Therapist Management of the Acutely Injured Worker, amended BOD 03-00-25-61; BOD 03-99­ 16-51; BOD 03-98-11-32; initial BOD 03-97-26-68.

Study Pearl


Repetitive, forceful, or prolonged exertions of the hands; frequent or . heavy lifting, pushing, pulling, or qu­ rying of heavy objects;· .prolonged awkward postures; and v.rbration con­ tribute. to WMSDs.


The global outcomes of effective physical therapist management of the injured worker are to optimize work performance and minimize the devel­ opment of work-related occupational disability. Effective and timely man­ agement of the injured worker is enhanced by participation in some form of productive duty, and access to on-site or convenient off-site service. The physical therapist may recommend making accommodations to normal duty or providing alternative or transitional duty work. The physical ther­ apist needs to have a working knowledge of the critical work demands obtained through a job-Site analysis, video analysis, or written physical job demands analysis, or through communication with the employer.

Carpal tunnel syndrome Tendinitis ~ Tenosynovitis ~ Ganglion cysts ~ Bursitis ~ Myositis ~ Synovitis ~ Fibromyalgia ~ Osteoarthritis ~ Raynaud's syndrome ~ Complex regional pain syndrome


The physical therapist has unique qualifications to facilitate optimal functional outcomes through:

Diagnosis of the neuromusculoskeletal condition and applica­ tion of interventions to specific systems and tissues affected by the injury.





Determination of safe work activity that will not compromise medical stability. The design of safe, progressive rehabilitation programs that aggressively recondition the injured worker. These programs are specific to the workers' job demands and are within their functional and medical limitations. Minimization of lost work time, through aggressive clinical management and promotion of productive work.

PRINCIPLE: FACILITATION Of TiMELY AND ApPROPRIATE REfERRALS The physical therapist facilitates timely and appropriate referrals for other necessary intervention-that is, to physician specialists or other providers-through the constant monitoring of neuromusculoskeletal signs, symptoms, medical stability, and progress. Injured workers are directed through the employer's health system working interdepend­ ently with physicians and other health care providers. PRINCIPLE: MINIMIZATION Of INjURY/RflNjURY INCIDENT RATE The physical therapist's role in minimizing injury recurrence is in mak­ ing sound and practical ergonomic recommendations for workstation design, work performance, and worker training to improve knowledge of personal responsibilities for fatigue control. For the injured worker, these recommendations may be specific to the worker's neuromuscu­ loskeletal condition. Ideally, physical therapist services are provided on-site or in close proximity to the workplace. Workers with potentially disabling neuro­ musculoskeletal signs or symptoms are directed early to the physical therapist service. Supervisors are trained to detect signs of cumulative trauma disorders, thus facilitating early referral. The physical therapist should be knowledgeable of workplace duties, physical job requirements, equipment, and pertinent company policies and procedures. If the neuromusculoskeletal problem is not satisfactorily resolved within a limited number of visits, a referral for further examination and evaluation by another health care professional may be indicated. As soon as medically prudent, the injured worker is referred again to the physical therapist. The injured worker is then progressed, as above, to a self-paced program with the worker assuming, as possible via appropriate education and training, the responsibility for continued improvement. Clear, concise, functionally relevant information about the injured worker's physical therapist management and recovery progress must be documented and conveyed in a timely manner to all team members. A comprehensive "team" may include the physician, the physical ther­ apist, employer representative (such as human resources, safety man­ agement, and department contact person), the injured worker, the worker's supervisor, insurance carrier, and the occupational health nurse. The management of neuromusculoskeletal problems can be divided into four phases. The admission of an injured worker to a particular phase



of care is based upon the physical therapist's examination!evaluation! diagnosis/prognosis of the worker's functional and neuromusculoskele­ tal status. Progression from one phase to the next is based on objective functional tests and measures. The level of physical activity required by the job, if a reasonable alternative job placement is not available, influ­ ences the duration of a treatment phase.




Acute phase (immediate post-trauma). Patient management focused on the control and reduction of localized inflammatory response, joint and soft-tissue swelling or restriction, and the stabilization and containment of the injury. Postacute phase. Involvement of the injured worker in more active/functional activities. Graduated therapeutic exercises to increase muscle performance, improvement of joint integrity and mobility, and improvement of motor function (motor control and motor learning). Functional training to increase ability to perform physical tasks related to community and work reintegration. Reconditioning phase. More vigorous therapeutic exercises emphasiZing daily functional and work activities and improved endurance. The injured worker's neuromusculoskeletal status is in the end phase of physiologic healing and ready for restora­ tion of objectively measured functional capacities. Return-to-work phase. This phase is indicated for worker's who have progressed satisfactorily through the reconditioning phase but are not yet ready to return to work because of iden­ tifiable physical, functional, behaVioral, or vocational deficits. An objective functional capacity evaluation may be used as a basis for entry into this phase. This examination and evaluation serves with a review of previous treatment progression to inform the entry into an appropriate work conditioning or work hardening program. The ultimate anticipated goal is the restoration of the injured worker's physical and functional capacity for a safe and expeditious return-to-work.

Inherent in the management of all of the phases is frequent and open communication between the physical therapist and the injured worker, his or her supervisor, and the other members of the employee health care team. The ongoing emphasis on injury prevention educa­ tion, including proper body mechanics, self-responsibility, worker compliance with physician's and physical therapist's instructions, safe workplace practices, and workstation modifications, is essential.

The Occupational Safety and Health Administration (OSHA) requires the use of personal protective equipment (PPE) to reduce employee expo­ sure to hazards when engineering and administrative controls are not feasible or effective in reducing this exposure to acceptable levels. Employers are required to determine if PPE should be used to protect their workers. Personal protective equipment may include gloves, masks, protective guards, protective clothing, or goggles. If PPE is to be used, a PPE program should be implemented. This program should address the hazards present; the selection, mainte­ nance, and the use of the PPE; the training of employees; and moni­ toring of the program to ensure its ongoing effectiveness.



Study Pearl

The purpose of a functional capacity evaluation (FCE) is to provide performance-based measures of a worker's safe functional abilities compared to the physical demands of work. In an effort to provide more objectivity to the diagnoses and prognoses of work-related injuries, occupational therapists and then physical therapists have developed a battery of tasks that involve the testing and measurement of physical work functions (lifting, carry­ ing, pushing and pulling, activities or positions required). These measurements of function are used to make return-to-work/activity decisions, disability determinations, or to generate a rehabilitation plan.

Definitions Specific to FeE
.. Capacity: the ability of the client to work safely at maximal or submaximallevels over a selected period of time. .. Functional activity: any physical activity that generically or specifically simulates a work or practical task. Functional activ­ ities as defined by the Department of Labor may include, but are not limited to, balancing, carrying, climbing, crawling, kneeling, lifting, pulling, pushing, reaching, sitting, standing, stooping, and walking. • Job modification: change in a task to allow the demands of the job to match the abilities of the patient/client. .. Medically stable: medical stability is defined as that state in which primary healing is complete, or the progression of pri­ mary healing is not compromised. • Clinically, medical stability refers to the consistent presence of a set of signs and symptoms. Consistent means that the location of the symptoms and the presence of the signs have reached a plateau. • The intensity of the symptoms may vary with activity or intervention/treatment, but the location or pattern of change of symptoms remains consistent. • Categories of work demands include sedentary, light, medium, heavy, and very heavy. • The frequency of work demands is classified as never, occa­ sional' frequent, and constant. • Functional capacity evaluation provider: a provider is someone licensed in the jurisdiction in which the services are performed, who is able to demonstrate evidence of education, training, and competencies specific to the delivery of FCEs. .. Physical demands of the workplace: those physical abilities required to perform work tasks successfully. Physical demands include work postures (positions), body movements, forces applied to the worker, repetition of the work tasks, and other work stressors and hazards as defined by OSHA. For safe FCE administration and useful interpretation, the FCE provider should have adequate knowledge in the following areas: • Administration of FCEs and interpretation of test results. • Evaluation of physical demands of the workplace. • Identification of patient/client behaviors that interfere with physical performance. • Biomechanical components of safe work practices.



• Relevant laws and regulations, including, but not limited to: o Americans with Disabilities Act (ADA). o Code of federal regulations. o Occupational Safety and Health Administration (OSHA). o Social Security Disability Administration. o Workers' compensation. • Admission criteria.

FeE Protocols. A standard protocol includes tests and measures consistently applied to all patients/clients undergoing a functional capacity evaluation. Some clinics use their own approach, whereas others purchase a commercially available FCE system. A job-specific protocol includes tests and measures consistently applied to a patient/client undergoing a functional capacity evaluation with reference to a specific, identified job. The test length can range from one hour to multiple weeks. The five recommended test components of the FCE are:
~ ~

~ ~


Intake interview. Subjective test. Neuromusculoskeletal evaluation. Baseline functional test. Work-specific test.

It is important to remember that injury can occur dUring an FCE as

a result of exceeding the patient's musculoskeletal, cardiovascular, or neurologic system tolerances. Specific decision-making criteria help to standardize the process and protect the patient from overexertion. Controversy exists surrounding the safety of isometric lift testing due to the potential of generating significant amounts of force. Applications and indications for an FCE in work injury manage­ ment include:
~ ~ ~ ~ ~ ~

Determination of work function or work level with non-work­ related illnesses and injuries. Determination of work function or work level with workrelated illnesses and injuries. Return to work and job placement decisions and programs. Disability evaluation and rating. Determination of function in nonoccupational settings. Medical and rehabilitation treatment intervention and planning. Case management and case closure. The primary elements of the

Reporting Process and Format.
report should include 176 :

1. The patient's overall level of work, ranging from sedentary to

very heavy. 2. Abilities on specific tasks within that overall level. 3. Tolerance for an 8-hour day. During an FCE, each physical demand of work is typically assessed for a brief period, usu­ ally no more than 5 to 10 minutes. Based on his or her brief assessment, the clinician must determine the duration that this level of demand could be performed by the worker.



4. Level of cooperation with the testing or sincerity of effort. This is one of the most challenging and controversial aspects of the FCE. Patients who perceive secondary financial gain to the worker's compensation system may exaggerate their symp­ toms and limitations. 5. Comparison of the patient's abilities with the job demands or former occupation. 6. Conclusion/summary/recommendation. For FCE tests to be reliable and valid, the following FCE criteria must be met:






Objectivity: objectivity refers to the indication that the test and measurement are relatively unbiased by either the participant or the evaluator. Objectivity in testing can be increased when the testing procedures and practices for observation and scor­ ing are clearly defined and documented. Reliability: reliability refers to consistency in measurement and scoring. The test measures and scores must be consistent across evaluators, participants, and the date or time of test administra­ tion. Inter-rater and intra-rater reliability have been noted to be the most two important forms of reliability in FCE test adminis­ tration and evaluation. Practicality: refers to the reasonableness of the testing proce­ dure. The test must be practical to administer. The direct and indirect costs of the evaluation procedure must be reasonable and appropriate. Safety: refers to the level of risk in performing the test. The test must be safe to administer and must not be expected to lead to injury. Utility: refers to the test being useful. The evaluation proce­ dure must meet the needs of, and provide useful information to, the participant, the evaluator, the referral source, and the payor. Validity: a measurement of how real the test results are. Without validity testing, there is no way of knowing whether or not the results are truly accurate and meaningful.

The following is adapted from Guidelines: Occupational Health Physical Therapy: Work Conditioning and Work Hardening Programs, BOD G03-01-17-58 (Program 32), retitled Occupational Health Guidelines: Work Conditioning and Work Hardening Programs, amended BOD 03-00-25-62; BOD 03-99-16-49; BOD 11-94-33-109; initial BOD 11-92-29-134.

Introduction. Injured workers benefit from physical therapist services from the onset of injury through their return to work. Early physical therapy intervention consists of treatment for acute neuro­ musculoskeletal problems and other injuries. Many patient/clients who receive appropriate early care return to their job without additional rehabilitation services.



For those who are not able to return to work because of unre­ solved physical problems following acute care, the treatment focus changes to restoration of work-related function. Defined as work con­ ditioning, these programs address the physical issues of flexibility, strength, endurance, coordination, and work-related function for the global outcome of return to work. For the limited number of patient/clients with behavioral and vocational dysfunction, work hardening may be indicated. Work hard­ ening programs are interdisciplinary and address the physical, func­ tional, behavioral and vocational needs of the injured worker, with the global outcome of return to work. Physical therapists provide the phys­ ical and functional components within both of these programs. The following guidelines identify work conditioning and work hardening as separate and distinct programs for injured workers. These guidelines describe program elements that should be used to develop and guide practice. The guidelines serve the following purposes:
~ ~


For physical therapists: to design, implement, and evaluate structured programs for injured workers. For medical referral sources: to facilitate appropriate referral to structured programs. For insurance companies and managed care organizations: to develop appropriate methods of program authorization, moni­ toring, and payment. For departments of labor and industry: to utilize as definitions and guidelines for worker compensation patients. For managed care organizations, regulators, and providers: to serve as resource documents.

Operational Definitions
Work Conditioning. Work conditioning is an intensive, work­ related, goal-oriented conditioning program designed specifically to restore systemic neuromusculoskeletal functions (e.g., joint integrity and mobility), muscle performance (including strength, power, and endurance), motor function (motor control and motor learning), range of motion (including muscle length), and cardiovascular/pulmonary functions (e.g., aerobic capacity/endurance, circulation, and ventilation and respiration/gas exchange). The objective of the work conditioning program is to restore physical capacity and function to enable the patient/client to return to work. Work Conditioning Examination and Evaluation. Examination includes history, systems review, and selected tests and measures reqUired to identify the patient/client's individual work-related, sys­ temic, neuromusculoskeletal restoration needs. Evaluation of examina­ tion data is used to identify eligibility, design a plan of care, monitor progress, and plan for discharge and return to work. A work conditioning provider should ideally be a licensed physical therapist, although the APTA recognizes that other profeSSionals may function as work conditioning providers. Work Hardening. Work hardening refers to a highly structured, goal­ oriented, individualized intervention program designed to return the patient to work. Work hardening programs, which are multidisciplinary



in nature, use real or simulated work activities designed to restore phys­ ical, behavioral, and vocational functions. Work hardening addresses the issues of productivity, safety, physical tolerances, and worker behaviors.

Work Hardening Examination and Evaluation. Multidisciplinary examination includes history, systems review, and selected tests and measures required to identify the patient/client's individual restoration needs related to physical, functional, behaVioral, and vocational status. The initial multidisciplinary evaluation of examination data is used to identify patient/client eligibility, design a plan of care, monitor progress, and plan for discharge and return to work.
Work Hardening Providers. Work hardening providers include physical therapists, occupational therapists, psychologists, and vocational specialists (Table 7-17). Work Conditioning Guidelines Patient/Client Eligibifity. To be eligible for work conditioning, a
patient/client must:



Have a job goal. Have stated or demonstrated willingness to participate. Have identified systemic neuromusculoskeletal phYSical and functional deficits that interfere with work.

Work conditioning generally follows acute medical care or may begin when the patient/client meets the eligibility criteria. Work condi­ tioning should not begin after 365 days have elapsed following the injury without a comprehensive multidisciplinary examination and evaluation.

Provider Responsibility
~ ~

~ ~

The employer and/or carrier should be notified prior to initia­ tion of the program. The need for a program should be established by a work con­ ditioning provider based on the results of a work conditioning examination and evaluation. The program should be provided by or under the direction and supervision of a work conditioning provider. The work conditioning provider should document all exami­ nations, evaluations, and services provided, patient progress, and discharge plans. Information should be available with


Addresses phYliical and functional needs; may be provided by one discipline (single-discipline model) Requires work conditioning examination and evaluation Utilizes physical conditioning and functional activities related to work Provided in multi-hour sessions up to: 4 hours/day 5 days/week 8 weeks

Addresses physical, functional, behavioral, vocational needs within a multidisciplinary model Requires work hardening examination and evaluation Utilizes real or simulated work activities Provided in multi-hour sessions up to: 8 hours/day 5 days/week 8 weeks



appropriate authorization to the patient/client, employer, other
providers, insurance carriers, and any referral source.
.. The work conditioning provider should develop and utilize an
outcome assessment system designed to evaluate, at a mini­
mum, achievement of goals and outcomes, and program effec­
tiveness and efficiency.
.. The work conditioning providers should be appropriately
familiar with job expectations, work enVironments, and skills
required of the patient/client through means such as site visita­
tion, videotapes, and functional job descriptions.

Program Content
.. Development of program goals in relation to job skills and job
.. Interventions to improve strength, endurance, movement, flex­
ibility, motor control, and cardiovascular/pulmonary capacity
related to the performance of work tasks.
.. Practice, modification, and instruction in work-related activities.
.. Education related to safe job performance and injury prevention.
.. Promotion of patient/client responsibility and self-management.

Program Termination. The patient/client should be discharged from the work conditioning program when the goals and outcomes for the patient/client have been met. Work conditioning may be discontinued when any of the follow­ ing occur:
.. The patient/client is unable to continue to progress toward
goals and outcomes because of medical or psychosocial com­
plications or because financial/insurance resources have been
.. The patient/client declines to continue intervention.
.. The patient/client fails to comply with the requirements of
.. The physical therapist determines that the patient/client will no
longer benefit from physical therapy.
When the patient/client is discharged or discontinued from the work conditioning program, the work conditioning provider should notify the employer, insurance carrier, and/or any referral source, and include the following information: .. .. .. .. Reasons for program termination.
Clinical and functional status.
Recommendations regarding return to work.
Recommendations for follow-up services.

The following is adapted from Guidelines: Occupational Health

Physical Therapy: Work-Related Injury/Illness Prevention and Ergonomics, BOD G03-01-17-57 (Program 32), retitled Occupational Health Physical Therapy Guidelines: Prevention of Work-Related Injury/Illness; initial BOD 11-99-25-71.



Physical therapists, in their management of individual patients/ clients, integrate five elements in the management scheme: examina­ tion, evaluation, diagnosis, prognosis, and intervention(s). These ele­ ments are incorporated in a manner designed to maximize anticipated outcomes. This approach is also successfully employed by physical therapists in the development, implementation, and management of workplace injury/illness prevention programs.

When investigating the potential for injury/illness prevention and ergonomics programs, the first step is to take a complete history of the client company's injury/illness experience. The first tests and measures to be performed relate to individual work sites and workstations. Ergonomic tests and measures examine the environment, site, tools, equipment, materials, and machinery; individual work flow; general production processes, rate, quality, and production demands; physical demands; physical stressors; and task rotation. ~ Environmental factors include noise, ambient temperature, humidity, light, and air quality. All may contribute to potential injury/illness during performance of occupational tasks. • Physical characteristics of the work site and workstation, including surfaces, work station area size and configuration, and seating, also may contribute to potential injury/illness dur­ ing performance of occupational tasks. • Individual aspects of occupational tasks that may contribute to potential injury/illness may include tools, equipment, materials, machinery, individual work sequencing and pacing, general production processes, rate, quality, and production demands. ~ Specific physical demands placed on individuals during occu­ pational tasks may include force, repetition, postures and motions, vibration, and surface temperature of materials. The second tests and measures to be performed relate to individ­ uals who will perform occupational tasks. • Examination of each worker and the work force includes anthropometrics, including age and gender, examination of the individual worker, evaluation of the physical capacities of the worker, and assessment of work and health habits, risk behav­ iors, and worker/work force characteristics. • Health habits should include nutrition, exercise, and smoking history.

Reports relating to the evaluation and diagnosis of work sites or work stations, with respect to preventing injury or illness, should include data analysis; work analysis; evaluation of worker/work force, safety, behavior, and compliance; identification of at-risk employees; identifi­ cation of at-risk work processes/workstations; and identification of solutions. Reports relating to prognosis of work sites or workstations, with respect to preventing injury/illness, should include an estimate of goals and outcomes for all interventions.



INTERVENTIONS Successful injury/illness prevention and ergonomics programs address the needs of both individual workers and employers. The dynamic nature of these programs mandates careful analysis and balancing of relevant components of intervention. There are two major areas of intervention. The fIrst area of interven­ tion includes those aspects of prevention programs where physical ther­ apists take primary leadership roles. Procedural intervention components include monitoring at-risk employees and work processes, ergonomics, education and training, health promotion, return-to-work case manage­ ment, and occupational health committee/team development. The second area of intervention includes those aspects of injury/illness prevention and ergonomics programs in which physical therapists most often participate as team members. Participatory inter­ vention components include involvement as a team member in work assignment, human resources management, compensation and bene­ fits, labor relations, corporate values and work culture, and design and production standards. A comprehensive occupational health injury/illness prevention and ergonomics program developed, implemented, and managed by a physical therapist will explicitly define the (1) scope of the program, program plan, relevant policies and procedures; (2) authorities, responsibilities, accountabilities of those participating in the program; 0) surveillance strategy, benchmark, baseline, and triggering indica­ tors, and intervention protocols; (4) content and process of report gen­ eration and report distribution; (5) maintenance of the program; and (6) methods of program evaluation and improvement through meas­ ures that determine actual outcomes.

OUTCOMES Generating, analYZing, and interpreting data related to injury/illness prevention and ergonomics is performed by physical therapists using of the full range of statistical and epidemiologic methods, and appro­ priate application of such methods.

1. Mann RA, Hagy JL, White V, et al. The initiation of gait. j Bone joint Surg. 1979;61A:232-239. 2. Schmitz TJ. Locomotor training. In: O'Sullivan SB, Schmitz TJ, eds. Physical Rehabilitation. 5th ed. Philadelphia: Davis; 2007: 523-560. 3. Burnett CN, Johnson EW. Development of gait in children; 1. Method; II. Results. Dev Med Child Neurol. 1971;13:196. 4. Luttgens K, Hamilton N. Locomotion: solid surface. In: Luttgens K, Hamilton N, eds. Kinesiology: Scientific Basis ofHuman Motion. 9th ed. Dubuque, IA: McGraw-Hill; 1997:519-549. 5. Levine D, Whittle M. Gait Analysis: The Lower Extremities. La Crosse, WI: OrthopaediC Section, APTA; 1992. 6. Mann RA, Hagy J. Biomechanics of walking, running, and sprint­ ing. Am j Sports Med. 1980;8:345-350.



7. Murray MP. Gait as a total pattern of movement. Am) Phys Med. 1967;46:290. 8. Scranton J, P.E., Rutkowski R, Brown TD. Support phase kine­ •matics of the foot. In: Bateman JE, Trott AW, eds. The Foot and Ankle. New York: Decker; 1980:195-205. 9. Perty J. Gait cycle. In: Perty J, ed. Gait Analysis: Normal and Pathological Function. Thorofare, N]: Slack; 1992:3-7. 10. Powers CM, Burnfield JM. Normal and pathologic gait. In: Placzek JD, Boyce DA, eds. Orthopaedic Physical Therapy Secrets. Philadelphia: Hanley & Belfus; 2001:9&-103. 11. Perty J. Stride analysis. In: Perty J, ed. Gait Analysis: Normal and Pathological Function. Thorofare, N]: Slack; 1992:431-441. 12. Mann RA, Moran GT, Dougherty SE. Comparative electromyogra­ phy of the lower extremity in jogging, running and sprinting. Am ) Sports Med. 1986;14:501-510. 13. Perry J. Gait Analysis: Normal and Pathological Function. Thorofare, N]: Slack; 1992. 14. Rogers MM. Dynamic foot mechanics.) Orthop Sports Phys Ther. 1995;21:306-316. 15. Gage JR, Deluca PA, Renshaw TS. Gait analysis: principles and applications with emphasis on its use with cerebral palsy. Inst Course Lect. 1996;45:491-507. 16. Ostrosky KM, Van SweringenJM, Burdett RG, et a1. A comparison of gait characteristics in young and old subjects. Phys Ther. 1994; 74:637-646. 17. Adelaar RS. The practical biomechanics of running. Am) Sports Med. 1986;14:497-500. 18. Basmajian]V. Therapeutic Exercise. 3rd ed. Baltimore: Williams & Wilkins; 1979. 19. Croskey MI, Dawson PM, Luessen AC, et a1. The height of the cen­ ter of gravity in man. Am) Physiol. 1922;61:171-185. 20. Richardson JK, Iglarsh ZA. Gait. In: Richardson JK, Iglarsh ZA, eds. Clinical Orthopaedic Physical Therapy. Philadelphia: Saunders; 1994:602-625. 21. Murray MP, Sepic SB, Barnard EJ. Patterns of sagittal rotation of the upper limbs in walking. Phys Ther. 1967;47:272-284. 22. Hogue RE. Upper extremity muscular activity at different cadences and inclines dUring normal gait. Phys Ther. 1969;49:963-972. 23. Perry ]. The hip. In: Gait Analysis: Normal and Pathological Function. Thorofare, N]: Slack; 1992:111-129. 24. Giannini S, Catani F, Benedetti MG, et al. Terminology, parame­ terization and normalization in gait analysis. In: Gait Analysis: Methodologies and Clinical Applications. Washington, DC: lOS Press; 1994:65-88. 25. Oatis CA. Role of the hip in posture and gait. In: Echternach J, ed. Clinics in Physical Therapy: Physical Therapy ofthe Hip. New York: Churchill Livingstone; 1983:165-179. 26. Reinking MF. Knee anatomy and biomechanics. In: Wadsworth C, ed. Disorders of the Knee-Home Study Course. La Crosse, WI: Orthpaedic Section, APTA; 2001. 27. Norkin C, Levangie P. Joint Structure and Function: A ComprehenSive Analysis. Philadelphia: Davis; 1992. 28. Kuster MS, Wood GA, Stachowiak GW, et al. Joint load consider­ ations in total knee replacement. ) Bone Joint Surg. 1997;79B: 109-113.



29. Dillon P, Updyke W, Allen W. Gait analysis with reference to chon­ dromalacia patellae. ] Orthop Sports Phys Yber. 1983;5:127-131. 30. Hunt Gc. Functional biomechanics of the subtalar joint. In: Orthopaedic Physical Yberapy Home Study Course 92-1: Lower Extremity. La Crosse, WI: Orthopaedic Section, APTA; 1992. 31. Donatelli R. Normal anatomy and pathophysiology of the foot and ankle. In: Wadsworth C, ed. Contemporar)! Topics on the Foot and Ankle. La Crosse, WI: Orthopedic Section, APTA; 2000. 32. Root M, Orien W, Weed J. Clinical Biomechanics: Normal and Abnormal Function ofthe Foot. Los Angeles: Clinical Biomechanics; 1977. 33. Inman VT, Ralston HJ, Todd F. Human Walking. Baltimore: Williams & Wilkins; 1981. 34. Mann RA. Biomechanical approach to the treatment of foot prob­ lems. Foot Ankle. 1982;2:205-212. 35. Mann RA, Hagy JL. The function of the toes in walking, jogging and running. Clin Orthop. 1979;142:24. 36. BOjsen-Moller F, Lamoreux L. Significance of dorsiflexion of the toes in walking. Acta Orthop Scand. 1979;50:471--479. 37. Perry J. The mechanics of walking: a clinical interpretation. In: Perry J, Hislop HJ, eds. Principles of Lower Extremi(v Bracing. New York: American Physical Therapy Association; 1967:9-32. 38. Dee R. Normal and abnormal gait in the pediatric patient. In: Dee R, Hurst LC, Gruber MA, et al., eds. Principles of Orthopaedic Practice. 2nd ed. New York: McGraw-Hill; 1997:685-692. 39. Krebs DE, Robbins CE, Lavine L, et al. Hip biomechanics during gait. ] Orthop Sports Phys Yber. 1998;28:51-59. 40. Yoon YS, Mansour JM. The passive elastic moment at the hip ] Biomech. 1982;15:905-910. 41. Lehmkuhl LD, Smith LK. Brunnstrom's Clinical Kinesiology. Philadelphia: Davis; 1983:361-390. 42. Neumann DA, Cook TM. Effects of load and carry position on the electromyographic activity of the gluteus medius muscles during walking. Phys Yber. 1985;65:305-311. 43. Neumann DA, Cook T.M. Sholty RL, et al. An electromyographic analysis of hip abductor activity when subjecl<; are carrying loads in one or both hands. Phys Yber. 1992;72:207-217. 44. Neumann DA, Hase AD. An electromyographic analysis of the hip abductors during load carriage: implications for joint protection. ] Orthop Sports Phys Yber. 1994;19:296-304. 45. Neumann DA, Soderberg GL, Cook TM. Comparisons of maximal isometric hip abductor muscle torques between sides. Phys Yber. 1988;68:496-502. 46. Neumann DA, Soderberg GL, Cook TM. Electromyographic analysis of the hip abductor musculature in healthy right-handed persons. Phys Yber. 1989;69:431--440. 47. Adler N, Perry J, Kent B, et al. Electromyography of the vastus medialis oblique and vasti in normal subjects during gait. Electromyogr Clin Neurophysiol. 1983;23:643-649. 48. Arsenault AB, Winter DA, Marteniuk RG. Is there a "normal" pro­ me of EMG activity in gait? Med BioI Eng Comput. 1986;24: 337-343. 49. Battye CK, Joseph J. An investigation by telemetering of the activ­ ity of some muscles in walking. Med BioI Eng Comput. 1966;4: 125-135.



50. Dubo HIC, Peat M, Winter DA, et a1. Electromyographic temporal analysis of gait: Normal human locomotion. Arch Phys Med Rehabil. 1976;57:415-420. 51. Baratta R, Solomonow M, Zhou BH, et a1. Muscular coactivation: the role of the antagonist musculature in maintaining knee stabil­ ity. Amj Sports Med. 1988;16:113-122. 52. Draganich LF, Jaeger RJ, Fralj AR. Coactivation of the hamstrings and quadriceps during extension of the knee. j Bone joint Surg. 1989;71A:1076-1081. 53. Molbech S. On the paradoxical effect of some two-joint muscles. Acta Morphol Neerl Scand. 1965;6: 171. 54. Basmajian]V, Deluca C]. Muscles Alive: Their Functions Revealed by Electromyography. Baltimore: Williams & Wilkins; 1985. 55. Rose J, Gamble JG. Human Walking. Baltimore: Williams & Wilkins; 1994. 56. Donatelli RA. Normal anatomy and biomechanics. In: Donatelli RA, ed. Biomechanics of the Foot and Ankle. Philadelphia: Saunders; 1990:3-31. 57. Mann RA. Biomechanics of running. In: AAOS Symposium on the Foot and Leg in Running Sports. St. Louis: Mosby; 1982:30-44. 58. Teitz CC, Garrett WE Jr, Miniaci A, et a1. Tendon problems in ath­ letic individuals. j Bone joint Surg. 1997;79A: 138-152. 59. Luttgens K, Hamilton N. The standing posture. In: Luttgens K, Hamilton N, eds. Kinesiology: SCientific Basis ofHuman Motion. 9th ed. Dubuque, IA: McGraw-Hill; 1997:445-459. 60. Martin PE, Rothstein DE, Larish DD. Effects of age and physical activity status on the speed-aerobic demand relationship of walking. j Appl Physiol. 1992;73:200-206. 61. Prampero PE. The energy cost of human locomotion on land and in the water. Intj Sports Med. 1982;7:55-72. 62. Davies MJ, Dalsky GP. Economy of mobility in older adults. J Orthop Sports Phys Ther. 1997;26:69-72. 63. Daniels J, KrahenbuW G, Foster C, et a1. Aerobic responses of female distance runners to submaximal and maximal exercise. Ann NY Acad Sci. 1977;301:726-733. 64. Pate RR, Barnes CG, Miller CA. A physiological comparison of performance-matched female and male distance runners. Res Q Exerc Sport. 1985;56:245-250. 65. Wells CL, Hecht LH, Krahenbuhl GS. Physical characteristics and oxygen utilization of male and female marathon runners. Res Q Exerc Sport. 1981;52:281-285. 66. Bransford DR, Howley ET. Oxygen cost of running in trained and untrained men and women. Med Sci Sports Exerc. 1977;9:41-44. 67. Daniels J, Daniels N. Running economy of elite male and females runners. Med Sci Sports Exerc.1992;24:483-489. 68. Howley ET, Glover ME. The caloric costs of running and walking one mile for men and women. Med Sci Sports Exerc. 1974;6:235-237. 69. Larish DD, Martin PE, Mungiole M. Characteristic patterns of gait in the healthy old. Ann NY Acad Sci. 1987;515:18-32. 70. Waters RL, Hislop HJ, Perry J, et a1. Comparative cost of walking in young and old adults.] Orthop Res. 1983;1:73-76. 71. Allen W, Seals DR, Hurley BF, et a1. Lactate threshold and distance running performance in young and older endurance athletes. j Appl Physiol. 1985;58:1281-1284.



72. Trappe SW, Costill DL, Vukovich MD, et al. Aging among elite dis­ tance runners: a 22-year longitudinal study.] Appl Physiol. 1996; 80:285-290. 73. Wells CL, Boorman MA, Riggs DM. Effect of age and menopausal status on cardiorespiratory fitness in masters women runners. Med Sci Sports Exerc. 1992;24:1147-1154. 74. Lange GW, Hintermeister RA, Schlegel T, et al. Electromyographic and kinematic analysis of graded treadmill walking and the impli­ cations for knee rehabilitation.] Orthop Sports Phys Ther. 1996;23: 294-301. 75. Luttgens K, Hamilton N. The center of gravity and stability. In: Luttgens K, Hamilton N, eds. Kinesiology: SCientific Basis of Human Motion. 9th ed. Dubuque, IA: McGraw-Hill; 1997:415-442. 76. Epler M. Gait. In: Richardson ]K, Iglarsh ZA, eds. Clinical OrthopaediC Physical Therapy. Philadelphia: Saunders; 1994: 602-625. 77. Subotnick S1. Variations in angles of gait in running. Phys Sports Med. 1979;7:110-114. 78. Craik R, Herman RM, Finley FR. 1be human solutions for locomo­ tion: interlin1b coordination. In: Herman RM, Grillner S, Stein PS, eds. Neural Control ofLocomotion. New York: Plenum; 1976:51-63. 79. Wagenaar RC, Van Emmerik RE. Dynamics of pathological gait: stability and adaptability of movement coordination. Hum Mov Sci. 1994;13:441-471. 80. Van Emmerik RE, Wagenaar RC, Van Wegen EE. Interlimb cou­ pling patterns in human locomotion: are we bipeds or quadrupeds? Ann NY Acad Sci. 1998;860:539-542. 81. Rush WA, Steiner HA. A study of lower extremity length inequal­ ity. Am] Roentgenol. 1946;56:616-623. 82. Moseley CF. Leg-length discrepancy. In: Morrissy RT, ed. Lovell and Winter's Pediatric OrthopaediCS. 3rd ed. Philadelphia: Lippincott; 1990:767--813. 83. Beaty JH. Congenital anomalies of lower extremity. In: Crenshaw AH, ed. Campbell's Operative OrthopaediCS. 8th ed. St. Louis: Mosby-Year Book; 1992:2126--2158. 84. Gross RH. Leg length discrepancy: how much is too much? Orthopedics. 1978;1:307-310. 85. Song KM, Halliday SE, Little DG. The effect of limb-length dis­ crepancy on gait.] Bone]oint Surg. 1997;79A:1690-1698. 86. Frey C. Foot health and shoewear for women. Clin Orthop ReI Res. 2000;372:32-44. 87. Foti T, Davids JR, Bagley A. A biomechanical analysis of gait dur­ ing pregnancy.] Bone Joint Surg. 2000;82A:625-632. 88. National Center for Health Statistics. Prevalence of Overweight and Obesity Among Adults: United States. Hyattsville, MD: NCHS; 2000. 89. Perry J. Pelvis and trunk pathological gait. In: Gait Ana(vsis: Normal and Pathological Function. Thorofare, NJ: Slack; 1992: 265-279. 90. Morag E, Hurwitz DE, Andriacchi TP, et al. Abnormalities in mus­ cle function during gait in relation to the level of lumbar disc her­ niation. Spine. 2000;25:829--833. 91. Andriacchi TP, Ogle JA, Galante JO. Walking speed as a basis for normal and abnormal gait measurements. ] Biomech. 1977;10: 261-268.



92. Gage ]R. Gait Analysis in Cerebral Palsy. London: MacKeith Press; 1991. 93. Rengachary SS. Gait and station: examination of coordination. In: Wilkins RH, Rengachary SS, eds. Neurosurgery. 2nd ed. New York: McGraw-Hill; 1996:133-137. 94. Eyring E], Murray W. The effect of joint position on the pressure of intra-articular effusion. j Bone joint Surg. 1965;47A:313-322. 95. Blair E, Stanley F. Issues in the classification and epidemiology of cerebral palsy. Mental Retard Deuel Disab Res Rev. 1997;3:184-193. 96. Baddar A, Granata K, Damiano DL, et al. Ankle and knee cou­ pling in patients with spastic diplegia: effects of gastrocnemius­ soleus lengthening. j Bone joint Surg. 2002;84A:736-744. 97. Abel MH, Damiano DL, Pannunzio M, et al. Muscle-tendon surgery in diplegic cerebral palsy: functional and mechanical changes. j Pediatr Orthop. 1999;19:366-375. 98. Davids ]R, Foti T, Dabelstein], et al. Voluntary (normal) versus obligatory (cerebral palsy) toe-walking in children: a kinematic, kinetic, and electromyographic analysis. j Pediatr Orthop. 1999; 19:461--469. 99. Griffin PP, Walter WW, Shiavi R, et al. Habitual toe walkers: a clin­ ical and EMG gait analysis. j Bonejoint Surg. 1977;59A:97-101. 100. Statham L, Murray MP. Early walking patterns of normal children. Clin Orthop. 1971;79:8-24. 101. Stricker S], Angulo ]C. Idiopathic toe walking: a comparison of treatment methods. j Pediatr Orthop. 1998; 18:289-293. 102. Kadaba MP, Ramakrishnan HK, Wootten ME, et al. Repeatability of kinematic, kinetic, and electromyographic data in normal adult gait. j Orthop Res. 1989;7:849--860. 103. Krebs DE, Edelstein ]E, Fishman S. Reliability of observational kinematic gait analysis. Phys Tber. 1985;65:1027-1033. 104. Skaggs DL, Rethlefsen SA, Kay RM, et al. Variability in gait analy­ sis interpretation. j Pediatr Orthop. 2000;20:759-764. 105. Eastlack ME, Arvidson], Snyder-Mackler L, et al. Interrater relia­ bility of videotaped observational gait-analysis assessments. Phys Tber. 1991;71:465--472. 106. Appling SA, Kasser RJ. Foot and ankle. In: Wadsworth C, ed. Current Concepts of Orthopedic Physical Tberap~Home Study Course. La Crosse, WI: Orthopaedic Section, APTA; 2001. 107. Boeing DD. Evaluation of a clinical method of gait analysis. Phys Tber. 1977;57:795-798. 108. McPoil TG, Schuit D, Knecht HG. A comparison of three positions used to evaluate tibial varum. jAm Podiat Med Assn. 1988;78: 22-28. 109. Hertling D, Kessler RM. Management ofCommon Musculoskeletal Disorders: Physical Tberapy Principles and Methods. 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 1996. 110. Reid DC. Sports InjUry Assessment and Rehabilitation. New York: Churchill Livingstone; 1992. 111. Perry J. Hip Gait deviations. In: Gait Analysis: Normal and Pathological Function. Thorofare, NJ: Slack; 1992:245-263. 112. Noyes FR, Dunworth lA, Andriacchi TP, et al. Knee hyperexten­ sion gait abnormalities in unstable knees. Am j Sports Med. 1996; 24:35--45. 113. Murray MP, Drought AB, Kory RC. Walking patterns of normal men. j Bone joint Surg Am. 1964;46A:335-360.



114. Perry J. Knee abnormal gait. In: Gait Analysis: Normal and Pathological Function. Thorofare, NJ Slack; 1992:223-243. 115. Stauffer RN, Chao EYS, Gyory AN. Biomechanical gait analysis of the diseased knee joint. Glin Orthop. 1977;126:246-255. 116. Perry J. Ankle and foot gait deviations. In: Gait Analysis' Normal and Pathological Function. Thorofare, N]: Slack; 1992:185-220. 117. Norkin Cc. Examination of gait. In: O'Sullivan SB, Schmitz TJ, eds. Physical Rehabilitation. 5th ed. Philadelphia: Davis; 2007:317-363. 118. Nelson AJ. Functional ambulation profile. Phys Ther. 1974;54: 1059-1065. 119. Dickson HG, Kohler F. Functional independence measure (FIM). ScandI Rehabil Med. 1999;31:63-64. 120. Grey N, Kennedy P. The functional independence measure: a comparative study of clinician and self ratings. Paraplegia. 1993; 31:457-461. 121. Hamilton BB, LaughlinJA, Fiedler RC, et al. Interrater reliability of the 7-level functional independence measure (FIM). Scand I Rehabil Med. 1994;26:115-119. 122. Keith RA, Granger CV, Hamilton BB, et al. The functional inde­ pendence measure: a new tool for rehabilitation. Adv Glin Rehabil. 1987;1:6-18. 123. Wolfson L, Whipple R, Amerman P, et al. Gait assessment in the elderly: a gait abnormality rating scale and its relation to falls. I Gerontol. 1990;45:M12-19. 124. Holden MK, Gill KM, Magliozzi MR. Gait assessment for neuro­ logically impaired patients. Standards for outcome assessment. Phys Ther. 1986;66:1530-1539. 125. Holden MK, Gill KM, Magliozzi MR, et al. Clinical gait assessment in the neurologically impaired. Reliability and meaningfulness. Phys Ther. 1984;64:35-40. 126. Mathias S, Nayak US, Isaacs B. Balance in elderly patients: the "get-up and go" test. Arch Phys Med Rehabil. 1986;67:387-389. 127. Kristensen MT, Foss NB, Kehlet H. Timed "up & go" test as a pre­ dictor of falls within 6 months after hip fracture surgery. Phys Ther. 87:24-30. Epub Dec 1, 2007. 128. Large J, Gan N, Basic D, et al. Using the timed up and go test to stratify elderly inpatients at risk of falls. Glin Rehabil. 2006;20: 421-428. 129. Ng SS, Hui-Chan CWo The timed up & go test: its reliability and association with lower-limb impairments and locomotor capaci­ ties in people with chronic stroke. Arch Phys Med Rehabil. 2005; 86:1641-1647. 130. Podsiadlo D, Richardson S. The timed "up & go": a test of basic functional mobility for frail elderly persons. I Am Geriatr Soc. 1991;39:142-148. 131. Goodman CC, Snyder TEK. Differential Diagnosis in Physical Therapy. Philadelphia: Saunders; 1990. 132. Ayub E. Posture and the upper quarter. In: Donatelli RA, ed. Physical Therapy of the Shoulder. 2nd ed. New York: Churchill Livingstone; 1991:81-90. 133. Janda V. On the concept of postural muscles and posture in man. AustI Physiother. 1983;29:83--84. 134. Turner M. Posture and pain. Phys Ther. 1957;37:294. 135. Kendall FP, McCreary EK, Provance PG. Muscles: Testing and Function. Baltimore: Williams & Wilkins; 1993.



136. Greenfield B, Catlin P, Coats P, et a!. Posture in patients with shoulder overuse injuries and healthy individuals. j Otthop Spotts Phys Ther. 1995;21:287-295. 137. Clayton-Krasinski D, Klepper S. Impaired neuromotor develop­ ment. In: Cameron MH, Monroe LG, eds. Physical Rehabilitation: Evidence-Based Examination, Evaluation, and Intervention. St. Louis: Saunders/Elsevier; 2007:333-366. 138. Putz-Anderson V. Cumulative Trauma Disorders: A Manual for Musculoskeletal Diseases ofthe Upper Limbs. Bristol, PA: Taylor & Francis; 1988. 139. Keller K, Corbett J, Nichols D. Repetitive strain injury in computer keyboard users: pathomechanics and treatment principles in indi­ vidual and group intervention. j Hand Ther. 1998;11:9-26. 140. KOIT 1M, Wright HM, Thomas PE. Effects of experimental myofas­ cial insults on cutaneous patterns of sympathetic activity in man. j Neural Transm. 1962;23:330-355. 141. Travell JG, Simons DG. Myofascial Pain and Dysfunction-The Trigger Point Manual. Baltimore: Williams & Wilkins; 1983. 142. Beal Me. The short leg problem. jAOA. 1977;76:745-751. 143. Wilder DG, Pope MH, Frymoyer JW. The biomechanics of lumbar disc herniation and the effect of overload and instability. j Spinal Disord. 1988;1:16. 144. Kiser DM. Physiological and biomechanical factors for understand­ ing repetitive motion injuries. Semin OccupMed. 1987;2:11-17. 145. Greenfield B. Upper quarter evaluation: structural relationships and interindependence. In: Donatelli R, Wooden M, eds. Otthopedic Physical Therapy. New York: Churchill Livingstone; 1989:43-58. 146. Janda V. Muscle strength in relation to muscle length, pain and muscle imbalance. In: Harms-Ringdahl K, ed. Muscle Strength. New York: Churchill Livingstone; 1993:83. 147. Janda V. Muscle Function Testing. London: Butterworths; 1983. 148. Lewit K. Manipulative Therapy in Rehabilitation of the Motor System. 3rd ed. London: Butterworths; 1999. 149. Lewit K, Simons DG. Myofascial pain: relief by post-isometric relaxation. Arch Phys Med Rehabil. 1984;65:452-456. 150. Sahrmann SA. Diagnosis and Treatment of Movement Impairment Syndromes. St. Louis: Mosby; 2001. 151. Smith A. Upper limb disorders: time to relax? Physiotherapy. 1996;82:31-38. 152. Babyar SR. Excessive scapular motion in individuals recovering from painful and stiff shoulders: causes and treatment strategies. Phys Ther. 1996;76:226-247. 153. Tardieu C, Tabary JC, Tardieu G, et a!. Adaptation of sarcomere numbers to the length imposed on muscle. In: Guba F, Marechal G, Takacs 0, eds. Mechanism of Muscle Adaptation to Functional ReqUirements. Elmsford, NY: Pergamon Press; 1981:99. 154. Seidel-Cobb D, Cantu R. Myofascial treatment. In: Donatelli RA, ed. Physical Therapy of the Shoulder. 3rd ed. New York: Churchill Livingstone; 1997:383-401. 155. Janda V. Muscles, motor regulation and back problems. In: Korr IM, ed. The Neurological Mechanisms in Manipulative Therapy. New York: Plenum; 1978:27. 156. Jull GA, Janda V. Muscle and Motor control in low back pain. In: Twomey LT, Taylor JR, eds. Physical Therapy of the Low Back: Clinics in Physical Therapy. New York: Churchill Livingstone; 1987:258.



157. Janda V. Muscles and motor control in cervicogenic disorders: assessment and management. In: Grant R, ed. Physical Therapy of the Cervical and Thoracic Spine. New York: Churchill Livingstone; 1994:195-216. 158. Wiles P, Sweetnam R. Essentials of Orthopedics. London: ].A. Churchill; 1965. 159. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268:760-765. 160. Bland JH. Diagnosis of thoracic pain syndromes. In: Giles LGF, Singer KP, eds. Clinical Anatomy and Management of the Thoracic Spine. Oxford: Butterworth-Heinemann; 2000:145-156. 161. Sutherland ID. Funnel chest. j Bone joint Surg. 1958;40B: 244-251. 162. Bradford S. Juvenile kyphosis. In: Bradford DS, Lonstein JE, Moe JH, et aI., eds. Moe's Textbook of Scoliosis and Other Spinal Deformities. Philadelphia: Saunders; 1987:347. 163. McKenzie RA. Manual correction of sciatic scoliosis. NZ Med]. 1972;76:194-199. 164. Keirn HA. The Adolescent Spine. New York: Springer-Verlag; 1982. 165. Ponseti IV, Friedman B. Prognosis in idiopathic scoliosis. j Bone joint Surg Am. 1950;32A:381-395. 166. Ponseti IV, Pedrini V, Wynne-Davies R, et al. Pathogenesis of sco­ liosis. Clin Orthop Relat Res. 1976;120:268-280. 167. Weinstein SL, Ponseti IV. Curve progression in idiopathic scolio­ sis. ] Bone joint Surg Am. 1983;65:447--455. 168. Lowe T, Berven SH, Schwab FJ, et al. The SRS classification for adult spinal deformity: building on the King/Moe and Lenke clas­ sification systems. Spine. 2006;31:S119-S125. 169. Lenke LG. Lenke classification system of adolescent idiopathic scoliosis: treatment recommendations. Instr Course Lect. 2005;54: 537-542. 170. Lenke LG, Edwards CC II, Bridwell KH. The Lenke classification of adolescent idiopathic scoliosis: how it organizes curve patterns as a template to perform selective fusions of the spine. Spine. 2003;28:S199-S207. 171. Durham JW, Moskowitz K, Whitney]. Surface e1cetrical stimula­ tion versus brace in treatment of idiopathic scoliosis. Spine. 1990; 15:888-892. 172. Andersson BJ, Ortengren R, Nachemson AL, et aI. The sitting pos­ ture: an electromyographic and discometric study. Orthop Clin North Am. 1975;6:105-120. 173. Williams MM, Hawley JA, McKenzie RA, et al. A comparison of the effects of two sitting postures on back and referred pain. Spine. 1991;16:1185-1191. 174. Nachemson A. Towards a better understanding of low-back pain: a review of the mechanics of the lumbar disc. Rheumatol Rehabil. 1975;14:129-143. 175. American Physical Therapy Association. Guide to Physical Therapist Practice. 2nd ed. Phys Ther. 2001;81:1-746. 176. Lechner D, Daly J, Maltchev K, et al. The work-injured popula­ tion. In: Boissonnault WG, ed. Primary Care for the Physical Therapist: Examination and Triage. St. Louis: Elsevier Saunders; 2005:271-287. 177. Schmitz T]. Examination of the environment. In: O'Sullivan SB, Schmitz n, eds. Physical Rehabilitation. 5th ed. Philadelphia: Davis; 2007:401--467.



178. Lee RE, Booth KM, Reese-Smith JY, et al. The Physical Activity Resource Assessment (PARA) instrument: evaluating features, amenities and incivilities of physical activity resources in urban neighborhoods. Int] Behav Nutr Phys Act. 2005;2: 13. 179. Keysor J, Jette A, Haley S. Development of the home and commu­ nity environment (HACE) instrument.] Rehabil Med. 2005;37:37--44. 180. Oliver R, BlathwaytJ, Brackley C, et al. Development of the Safety Assessment of Function and the Environment for Rehabilitation (SAFER) tool. Can] Occup Ther. 1993;60:78-82. 181. Shumway-Cook A, Pacla A, Stewart AL, et al. Assessing environ­ mentally determined mobility disability: self-report versus observed community mobility.] Am Geriatr Soc. 2005;53:700-704. 182. Shumway-Cook A, Pacla A, Stewart A, et al. Environmental com­ ponents of mobility disability in community-living older persons. ] Am Geriatr Soc. 2003;51:393-398. 183. Paterson M, Mets T. Environmental assessment: home, commu­ nity, and work. In: Cameron MH, Monroe LG, eds. Physical Rehabilitation: Evidence-Based Examination, Evaluation, and Intervention. St. Louis: Saunders/Elsevier; 2007:918-936. 184. Gen F, Marcus M, Monteilh C, et al. A randomised controlled trial of postural interventions for prevention of musculoskeletal symptoms among computer users. Occup Environ Med. 2005;62:478-487. 185. Dainoff MJ, Cohen BG, Dainoff MH. The effect of an ergonomic intervention on musculoskeletal, psychosocial, and visual strain of VDT data entry work: the United States part of the international study. Int] Occup Sa! Ergon. 2005;11:49--63. 186. Moise A, Atkins MS: Design requirements for radiology worksta­ tions.] Digit Imaging. 2004;17:92-99. Epub 2004 Apr 19, 2004. 187. Ong CN, Chia SE, Jeyaratnam J, et al. Musculoskeletal disorders among operators of visual display terminals. Scand] Work Environ Health. 1995;21:60--64. 188. Horii sc. Electronic imaging workstations: ergonomic issues and the user interface. Radiographies. 1992;12:773-787. 189. Mackenzie M. A simplified measure of balance by functional reach. Physiother Res Int. 1999;4:233-236. 190. Duncan PW, Weiner DK, Chandler J, et al. Functional reach: a new clinical measure of balance.] Gerontol. 1990;45:M192-197. 191. Schmitz TJ. Examination of the environment. In: O'Sullivan SB, Schmitz TJ, eds. Physical Rehabilitation. 5th ed. Philadelphia: Davis; 2007:401--468. 192. Nelson A, Matz M, Chen F, et al. Development and evaluation of a multifaceted ergonomics program to prevent injuries associated with patient handling tasks. Int] Nurs Stud. 2006;43:717-733. Epub Oct 25, 2006. 193. Punnett 1. Commentary on the scientific basis of the proposed Occupational Safety and Health Administration Ergonomics Program Standard.] Occup EnViron Med. 2000;42:970-981. 194. Hadler NM. Comments on the "Ergonomics Program Standard" proposed by the Occupational Safety and Health Administration. ] Occup EnViron Med. 2000;42:951-969.



Comprehension Questions

1. Give three of the major requirements for successful walking.

2. Define the gait cycle.
3. What are the functional tasks associated with normal gait?

4. What are the two periods of the gait cycle?
5. What are the four intervals of the stance phase called? 6. What are the four intervals of the swing phase called?

7. What are the three gait parameters that are the most meaningful to measure in the clinic?
8. What are the three primary determinants of gait velocity? 9. What is the average normal cadence in adults without pathology? 10. Where is the center of gravity (COG) of the body located? 11. True or false: During the gait cycle, the COG is displaced both vertically and posteriorly. A. True. B. False. 12. True or false: During the gait cycle, the thoracic spine and the pelvis rotate in the same direction as each other to enhance stability and balance. A. True. B. False. 13. Describe the characteristics of a positive Trendelenburg sign. 14. Which of the following muscles is active throughout the entire gait cycle? A. Tibialis anterior. B. Soleus. C. Hamstrings. D. Quadriceps. 15. List three effects that a weak tibialis anterior could have on gait. 16. During the normal gait cycle, when do the hamstrings have their maximum activity? 17. Paralysis or marked weakness of the pretibial muscle group produces: A. Foot drop during swing phase. B. Excessive foot eversion. C. Excessive foot inversion. D. None of the above.



18. During locomotion, the adductor muscles of the thigh: A. Have peak activity just before toe-off. B. Have a high activity level in the early stance phase. C. Have a high activity level in late stance phase. D. None of the above. 19. During locomotion, erector spinae muscles: A. Have peak activity just before toe-off. B. Have a low activity level in the swing phase. C. Have a high activity level in late stance phase. D. None of the above. 20. During the stance phase of gait: A. The calf muscles become active. B. The quadriceps are active. C. The hip abductors are active. D. All of the above. 21. A positive Trendelenburg sign results from paralysis of: A. Hip flexors. B. Hip abductors. C. Hip extensors. D. Hip adductors. 22. You are performing a gait analysis of a patient. The patient lurches backward during the stance phase. What type of gait is the patient demonstrating? A. Wide-based gait. B. Antalgic gait. C. Gluteus medius gait. D. Extensor gait.

23. An individual demonstrates a steppage gait pattern during ambulation activities. Steppage gait is characterized by excessive: A. Knee and hip extension. B. Knee and hip flexion. C. Knee and ankle flexion. D. Knee and ankle extension. 24. At which point in the normal gait cycle is there maximum activity of the gluteus medius and minimus?
25. At what point in the gait cycle is the center of gravity the lowest? 26. Weakness of which muscle can cause aTrendelenburg gait pattern?



27. While observing the gait of a 67-year-old man with arthritis of the left hip, the phys­ ical therapist observes aleft lateral trunk lean. Why does the patient present with this gait deviation? A. To increase the joint compression force of the involved hip by moving the weight toward it. B. To decrease the joint compression force by moving the weight toward the involved hip. e. To bring the line of gravity closer to the involved hip joint. D. Because his right leg is shorter. 28. During a gait analysis you observe a patient demonstrating a significant posterior trunk lean at initial contact. Which is the most likely muscle that you will need to focus on during the exercise session in order to minimize this gait deviation? 29. Which three orthopedic conditions could be associated with quadriceps avoidance? 30. A patient who has a recent fracture of the right tibia and fibula has developed foot drop of the right foot during gait. Which nerve is causing this loss of motor function? 31. Following a hip fracture that is now healed, your patient presents with weak hip flex­ ors (2/5), with all other muscles within functional limits. During gait, which gait characteristic wou Id you expect to see? 32. Which three types of adjustments are a prerequisite for postural control? 33. Which deformity does aseverely kyphotic upper dorsal region that results from mul­ tiple anterior wedge compression fractures in several vertebrae of the middle to upper thoracic spine characterize? 34. Which chest deformity does a forward and downward projecting sternum that increases the anteroposterior diameter characterize? 35. Which type of scoliosis is classified as postural and compensatory? 36. When performing scoliosis screening in a school setting, what is the optimal age to begin screening? 37. You are examining a patient with excessive subtalar pronation in standing. What other postural adaptations are you likely to notice at the tibia, femur, and pelvis? 38. Define a functional capacity evaluation. 39. You are mapping apatient's reach zones as part of their worksite analysis. In which zone would you place all objects that are used 4 to 10 times an hour and that can be reached without the elbow moving further forward than the anterior portion of the rib cage? 40. For safety and ease of use, what is the ratio of length to rise in a ramp? 41. What is the minimum width for adoorway in order for a standard wheelchair to pass through? 42. Give three examples of work-related musculoskeletal disorders. 43. What types of equipment are categorized as personal protective equipment (PPE)? 44. What is the purpose of a functional capacity evaluation (FeE)? 45. Distinguish between work conditioning and work hardening.



1. Support of body mass by the lower extremities, production of locomotor rhythm, and dynamic balance control of the moving body.

2. The interval of time between any of the repetitive events of walking. 3. Weight acceptance, single limb support, and swing limb advancement.

4. Stance and swing. 5. Loading response, mid-stance, terminal stance and pre-swing.
6. Pre-swing, initial swing, mid-swing, and terminal swing. 7. Gait velocity, stride length, and cadence. 8. The repetition rate (cadence), physical conditioning, and the length of the person's stride. 9. 113 steps/min. 10. Approximately midline in the frontal plane and slightly anterior to the second sacral vertebra in the sagittal plane. 11. The answer is B. This statement is false. Displacement is vertically and laterally. 12. The answer is B. This statement is false. Rotation is in the opposite direction to each other. 13. A positive Trendelenburg sign is indicated when the pelvis lists toward the non-weight-bearing side during single-limb support. 14. The answer is A. 15. Foot slap immediately after initial contact, foot drop during swing, and excessive hip and knee flexion during swing. 16. During the end of the swing phase. 17. The answer is A. 18. The answer is A. 19. The answer is B.

20. The answer is D. 21. The answer is B.
22. The answer is D. 23. The answer is B.

24. Mid-stance.
25. Double support. 26. Gluteus medius. 27. The answer is C.



28. Gluteus maximus. 29. Quadriceps weakness (due to inhibition, swelling, or pain), patel lofemoraI pain, and anterior cruciate ligament deficiency. 30. Deep fibular (peroneal). 31. Circumduction of the hip. 32. Steady-state adjustments, anticipatory adjustments, and reactive adjustments. 33. Dowager's hump. 34. Pigeon chest. 35. Functional. 36. 10 to 12 years. 37. Tibial, femoral, and pelvic internal rotation. 38. An objective measure of a worker's safe functional abilities compared to the physi­ cal demands of work. 39. Secondary lone. 40. A ramp should ideally have an incline of at least 1-foot length for each inch of rise (1 :12 ratio). 41. 32 inches wide. 42. Carpal tunnel syndrome, tenosynovitis, and tension neck syndrome. 43. Gloves, mask, protective guards, protective clothing, and goggles. 44. An FCE measures the ability of an individual to perform functional or work-related tasks and predicts the potential to sustain these tasks over a defined time-frame. 45. According to the APTA, work conditioning is an intensive, work-related, goal­ oriented program that focuses on joint integrity and mobility, strength, endurance, flexibility, and cardiovascular/pulmonary functions. Work hardening is a broader­ based rehabilitation program designed to restore physical, behavioral, and voca­ tional functions and addressing the issues of productivity, safety, physical tolerances, and worker behaviors.

Muscu loskeletal Physical Therapy

The musculoskeletal system includes bones; muscles with their related tendons and synovial sheaths; bursa; and joint structures such as carti­ lage, menisci, capsules, and ligaments.

The shoulder complex (Fig. 8-1) is composed of four articulations:

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The The The The

glenohumeral (GH) joint. acromioclavicular (AC) joint. sternoclavicular (SC) joint. scapulothoracic pseudoarticulation.

A fifth "articulation"-the subacromial articulation between the coracoacromial arch (a rigid structure above the humeral head and rota­ tor cuff tendons) and the rotator cuff tendons-is included by some.!

Bursae. Approximately eight bursae are distributed throughout the shoulder complex. The subdeltoid-subacromial bursae, collectively referred to as the subacromial bursa, are the most significant with rela­ tion to pathology. The subacromial bursa proVides two smooth serosal layers, one of which adheres to the overlying deltoid muscle and the other to the rotator cuff lying beneath. This bursa is also connected to the acromion, greater tuberosity, and coracoacromial ligament. As the humerus elevates, it permits the rotator cuff to slide easily beneath the deltoid muscle.
Complete movement at the shoulder girdle involves a complex interaction between the glenohumeral, AC and SC complex, scapulothoracic (pseudojoint), upper thoracic, costal and sternomanubrial joints, and the lower cervical spine.

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!njury to the long thoracic nerve leads to is of the serratus anterior mu ultlng in medial scapular wingi



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Snapping scapolais attributed to fric­ tion between the mObile ~apula and its attached soft tissues and the relatively stable tho~aci~ wall. Anatomic expla­ nations forsnapping~~apula include thickened bursa, bone spurs on the scapula or a rib, and osl'eqchondroma.


Figure 8-1. Anterior view of right shoulder joints. (Reproduced, with permission, from Luttgens K, Hamilton N. Kinesiology: Scientific Basis of Human Motion. 10th ed. New York: McGraw-Hili; 2002:104.)

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Scaption refers to the forward eleva­ tion of the internally rotated arm in the scapular plane with the thumb


GH Joint
The convex humeral head articulates with the concave glenoid fossa of the scapula (Fig. 8-1) around a variety of planes and axes (Table 8-1). • The glenoid fossa is retroverted approximately 7 degrees. It faces anteriorly at an angle of approximately 45 degrees to the coronal plane, as it sits on the chest wall. The depth of the glenoid fossa is enhanced by the glenoid labrum, which can contribute up to 50% of the fossa's depth. • The humeral head is retroverted 20 to 30 degrees. • The longitudinal axis of the head is 135 degrees from the axis of the neck. .. The scapula is a flat triangular bone, situated over the second to seventh ribs. The glenOid fossa is located on the lateral angle of the scapula and faces anteriorly, laterally, and superiorly. This orientation places true abduction at 30 degrees anterior to the frontal plane. .. The GH joint is relatively unstable: • Static stability for the joint is provided by: A fibrous rim of tissue-the labrum-that surrounds and deepens the glenoid. A variety of ligaments (Table 8-2). • The joint capsule: Attaches medially to the glenoid margin, glenoid labrum, and coracoid process. Attaches laterally to the humeral anatomical neck, descend­ ing approximately 1 em on the shaft. Support provided to the capsule by rotator cuff muscles and glenohumeral ligaments. • Dynamic stability for the joint is afforded by the muscular dynamic stabilizers, in particular the rotator cuff, the biceps tendon, and the muscles of scapular motion (Table 8-3 to Table 8-5).

pointed to the floor.·

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E\ntf~l'ior afld poste­ nor (~'-"f\Y)les,ons most often .result from a sudden downward force orr a supinated ()lJ~tretched upper extremity

. orfrdlti a fa If on tne lateral shoulder.

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.The five layers Qf the rotator cuff are 1 : ~ A superficial portion of the coraeo­

hl,Hl1eral Hsament A closely p;;u::ked bundle of para 1­ leI collagen fibers, running from
the' muscle bellies

. .tuberosity. .., . '" Smaller fascicles with .a more ran­ . . .dam orientation: . • Loose connective tissue and bands of collagen that run, perpendicular to the longitudinal or.ientati6nof

the cufhendon.

True capsular layer.



TABLE 8-1. GLENOHUMERAL JOINT MOTIONS AND THEIR APPROPRIATE AXIS AND ACCESSORY MOTIONS PLANE/AXIS OF MOTION Sagittal/medial-lateral Coronal/anterior-posterior Transverse/longitudinal PHYSIOLOGIC MOTION Flexion/extension Abduction Adduction Internal rotation External rotation ACCESSORY MOTION Spin Inferior glide of humeral head Superior glide of humeral head Posterior glide of humeral head Anterior glide of humeral head

TABLE 8-2. LIGAMENTS OF THE SHOULDER LIGAMENT DESCRIPTION Comprised of the conoid and trapezoid ligaments. Runs between the acromion process and the clavicle. Comprised of anterior and posterior ligaments. Connects the superior-medial sternal ends of each clavicle with the capsular ligaments and the upper sternum. The strongest of the sternoclavicular ligaments. Distinct capsular thickenings limiting excessive rotation and translation of the humeral head by reinforcing the connection between the glenoid fossa and the humerus. Complex: parts include the anterior band, axillary pouch, and the posterior band. Strongest of the glenohumeral ligaments. FUNCTION Reinforces the connection between the coracoid process Stabilizes the acromioclavicular joint. Reinforces the connection between the acromion and the clavicle. Reinforces the connection between the sternum and the clavicle. Strengthens the articular capsule.

Clavicular ligaments Coracoclavicular ligament

Acromioclavicular ligament

Sternoclavicular ligaments Sternoclavicular ligament
Interclavicular ligament

Costoclavicular ligament

Reinforces the connection between the first rib amI the clavicle and stabilizes the joint.

Glenohumeral ligaments

Inferior glenohumeral ligament

Provides anterior stabilization, especially during abduction of the arm. Provides anterior stabilization during the combined motion of external rotation and 45 degrees of abduction. Works in conjunction with the coracohumeral ligament to provide inferior stabilization during adduction. Provides anterior support by tightening with flexion. Maintains the long head of the biceps muscle in the intertubercular groove. Reinforces the connection between the coracoid process and the medial border of the scapular notch. Reinforces the connection between the lateral aspect of the root of the spine of the scapula and the margin of the glenoid fossa. Reinforces the connection between the coracoid process and the acromion, stabiliZing the joint.

Middle glenohumeral ligament

Superior glenohumeral ligament

Runs from glenoid rim to anatomic neck. Runs from the lateral end of the coracoid process and inserts either side of the greater and lesser tuberosities. Traverses the bicipital groove.

Coracohumeral ligament

Transverse humeral ligament

Intrinsic ligaments of the Scapula Superior transverse scapular Attached by one end to the base of the ligament coracoid process, and by the other to the medial end of the scapular notch. An inconstant fibrous band that passes Inferior transverse scapular from the lateral border of the spine of ligament the scapula to the posterior margin of the glenoid cavity. Runs from the coracoid process to the Coracoacromial ligament anterior-inferior aspect of the acromion, with some of its fibers extending to the AC joint.




Scapular Abductors Trapezius
Serratus anterior (upper fibers)
Scapular Adductors Levator scapulae Rhomboids Scapular Flexors Serratus anterior (lower fibers) Scapular Extensors Pectoralis minor Scapular External Rotators Trapezius Rhomboids Shoulder flexors Coracobrachialis Short head biceps Long head biceps Pectoralis major Anterior deltoid

Shoulder Extensors The triceps Posterior deltoid Teres minor Teres major Latissimus dorsi Shoulder Abductors Supraspinatus Deltoid Shoulder Adductors Subscapularis Pectoralis major Latissimus dorsi Teres major Teres minor Shoulder Internal Rotators Pectoralis major and minor Serratus anterior Subscapularis Pectoralis major

Latissimus dorsi Teres major

Shoulder External Rotators Infraspinatus Supraspinatus Deltoid Teres minor

TABLE 8-4. NORMAL STRENGm RATIOS OF mE SHOliLDER Internal to external rotation: 3 to 2 Adduction to abduction: 2 to 1 Extension to tlexion: 5 to 4

TABLE 8-5, RESTRAINTS ABOUT THE GLENOHUMERAL JOINT PASSIVE (STATIC) Capsule Labrum Coracohumeral ligament Superior glenohumeral ligament Middle glenohumeral ligament Inferior glenohumeral ligament GeolIletry of humeral articular surface Geometry of glenoid articular surface Coracoacromial ligament Articular cartilage compliance Joint cohesion Supraspinatus Infraspinatw; Subscapularis Teres minor Pectoralis major Latissimus dorsi Biceps (long head) Triceps Deltoid Teres major Serratus anterior latissimus dorsi Trapezius Rhomboids levator scapulae Pectoralis minor ACTIVE (DYNAMIC)


Humeral stabilizers

Movers of glenohumeral joint


Movers of scapula

I{eproduced, with permission, from Magee DJ. Reid DC. Shoulder injuries. In: Zachazewski JE, Magee DJ. Quillen WS. eds. Atbletic InjUries and R"'Hlbilitutlon. PhilacJdphLt: W.B. Saunders; 1996:509-542. Copyright © Elsevier.



Available ranges of motion of the shoulder complex, end-feels, and potential causes of pain are listed in Table 8-6.


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The Scapulohumeral Rhythm. The scapula provides a mobile base for humeral motions in all directions. Scapular motion occurs in all three cardinal planes:
~ ~


Rotation in the transverse plane is called internal rotation. The scapula externally rotates from a starting point of approxi­
mately 33 degrees internal rotation to 20 degrees internal rotation
as the arm is elevated from 0 to 140 degrees in the scapular
Tilting of the scapula involves rotation in the sagittal plane.




Elevation-Flexion Peripheral nelVes involved: lateral and medial pectoral, axillary, musculocutaneous.


Tissue stretch. Motion limited by posterior band of the coracohumeral ligament, inferoposterior joint capsule. Tissue stretch. Motion limited by coracohumeral ligament, anterior joint capsule.

Suprahumeral impingement. Stretching of glenohumeral, acromioclavicular, sternoclavicular joint capsule. Triceps tendon jf elbow tlexed. Stretching of glenohumeral joint capsule Severe suprahumeral impingement. Biceps tendon jf elbow extended.

Extension Peripheral nelVes involved: axillary, lower subscapularis, thoracodorsal, lateral, and medial pectoral.


Elevation-Abduction Peripheral nelVes involved: axillary, suprascapular.


Tissue stretch. Suprahumeral impingement. Acromioclavicular arthritis Motion limited by inferior joint capsule, glenohumeral at terminal abduction. ligament, approximation of grated tuberosity and glenoid labrum. Tissue stretch. Motion limited by anterior capsule, glenohumeral ligament. Tissue stretch. Motion limited by posterior capsule. Anterior glenohumeral instability.

External Rotation Peripheral nelVes involved: lateral and medial pectoral, axillary, thoracodorsal, lower subscapularis, upper and lower subscapularis. Internal Rotation Peripheral nelVes involved: suprascapular, axillary.



Suprahumeral impingement. Posterior glenohumeral instability.



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Scapular dyskinesia (also referred to as abnormal scapulohumeral rhythm, winging, and scapular dys­ a) describes abnormal or atypical movement of the scapula during active motion tasks. The find­ is common in patients with an table glenohumeral joint and patients wit~i.mpingement syndrome. A scapular dyskinesia may occur as primary or secondary to. shoulder impingement and instability.

r-­ "I'


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tion between· .the . head of the humerus andthegJerioid. Can occur posteriorly or, more commonlyi i!l.oterJoriy. .The most commonly injuredherve.Withan anteriOrsh6ul­ derdislocationis the al(illarynerve. .. Rill~SiilcI15Iesion: a compression fr~<:wr~of the poster laterafaspect ofthehut'neralhead,wnich results frqm •impact all lhe .anteroinferior tim of the.. gJenoi<.idufinga.~ •. ante­ riordislocationof the shoulder. .•.. jll- ReverSE? HimSi1chs. lesion: a com­ pression fracture of the anterome­ diarhome~aJhfiladas the result of a posteriprdisJocation. .. Bankartlesion:an avulsion or deti.l~hrJ1ent· of the anterior portion oftfiejnferlor gl enonu metal. liga­ rTIentcompJex and glenoid labrum of tneanteriorfimof the glenpid. Bankart Jesi6nsc:an contribute to



~... Sh6uld~tdlslocation:a. true separa­

Figure 8-2. Normal scapulohumeral rhythm. (Reproduced, with per­ mission, from Brukner P, Khan K. Clinical Sports Medicine. 3rd ed. Sydney, Australia: McGraw-Hili; 2007:64.)

During elevation of the arm in the scapular plane, the scapula rotates upwardly, externally rotates, and tilts posteriorly. The combi­ nation and synchronization of the motions that occur between the scapula and the humerus dUring elevation is termed "scapulohumeral rhythm" (Fig. 8-2). With 180 degrees of abduction there is an approx­ imately 2:1 ratio of movement between the two structures-120 degrees of movement occurs at the GH joint, with 60 degrees of motion occurring at the scapulothoracic joint. The scapulohumeral rhythm decreases the potential for shear and translatory forces at the GH joint by actively positioning the scapula in relation to the moving humerus, thereby providing a stable base of muscle origin for the rotator cuff muscles. By allowing the glenoid to stay centered under the humeral head, the strong tendency for a downward dislocation of the humerus is resisted and the glenoid is maintained within a physiologically tolera­ ble range. At full abduction, the glenoid completely supports the humerus.


Shoulder sUbluxation: excessive O1ove.ment of the humeral head Wlthiespect to the glenpid, but not trueseparafion. Sh(Julderseparation: disruption of theAC joint.

Sternoclavicular (SC) and Acromioclavicular (AC) Joints

.. sc joint the clavicle, which is convex in a superior/inferior direc­
tion and concave in an anterior/posterior direction, articulates with the reciprocal shape of the sternum in a fibrocartilaginous




joint (Table 8--7). The SC joint is the only joint that directly attaches the upper extremity to the thorax. The allowed move­ ments are elevation and depression, protraction and retraction, and rotation. AC joint: a plane joint, but also described as diarthrodial, with fibrocartilage surfaces--a convex clavicle and a concave acromion. Contains an intra-articular fibrocartilaginous disc, which degenerates during the third and fourth decades of life.

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Nerve Supply. The shoulder complex is embryologically derived from C5 to C8, except the AC joint, which is derived from C4. 2-4 The sympathetic nerve supply to the shoulder originates primarily in the thoracic region from T2 down as far as T8. 5 Blood Supply. The vascular supply to the shoulder girdle is pri­ marily provided by branches off the axillary artery (including the tho­ racoacromial artery, subscapular artery, and the anterior and posterior circumflex humeral arteries), which begins at the outer border of the first rib as a continuation of the subclavian artery.
The elbow is composed of three articulations:

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Humeroulnar: the concave ulna articulates with the convex dis­ tal humerus (trochlea). This hinged articulation permits motion in a single plane, allowing for flexion and extension of the elbow. Humeroradial (radiocapitellar) joint: the concave head of the radius articulates with the capitellum, which is the convex lat­ eral articular surface of the distal humerus. This joint permits the radius to rotate to any degree of t1exion or extension of the humeroulnar joint, and this rotation allows supination and pronation of the forearm, in association with the proXimal radioulnar joint (the third articulation of the elbow). Proximal radioulnar joint: the proximal or superior radioulnar joint is a uniaxial pivot joint formed between the periphery of the convex radial head and the fibrous osseous ring formed by the concave radial notch of the ulna (Fig. 8-3), which lies distal to the trochlear notch, and the annular ligament. The proximal and distal radioulnar joints together form a bicondylar joint. An interosseous membrane located between the radius and ulna serves to help distribute forces throughout the forearm and pro­ vide muscle attachment.


Details about the muscles of the elbow and forearm are provided in Table 8-8.

Ligaments. The articular and ligamentous contributions to elbow stability are outlined in Table 8-9.
Medial (Ulnar) Collateral Ligament. There are three distinct com­ ponents of the medial collateral ligament (MCL): anterior bundle,




Protraction (Sagittal Plane: Clavicle Glides Posteriorly, Acromion Glides Anteriorly) Muscles performing motion: serratus anterior, pectoralis The distal clavicle moves minor. approximately 10 em. Peripheral nerves involved: long thoracic, lateral and medial pectoral. Retraction (Transverse Plane: Clavicle Glides Anteriorly, Acromion Glides Posteriorly) Muscles performing motion: trapezius, rhomboids. Peripheral nerves involved: spinal accessory, dorsal scapular. Elevation (Frontal Plane: Clavicle Glides Superiorly, Only Slight Angular Motion OCcurs at AC Joint) Muscles performing motion: upper trapeZius, levator scapulae. Peripheral nerves involved: spinal accessory, directly via C3-4 and dorsal scapular. Depression (Frontal Plane: Clavicle Glides Inferiorly, only Slight Angular Motion Occurs at AC JoInt) Muscles performing motion: serratus anterior (lower ponion), pectoralis minor. peripheral nerves involved: long thoracic, lateral and medial pectoral Rotation (Transverse Plane) Muscles performing motion: upper trapeZiUS, serratus anterior Clower portion). peripheral nerves involved: spinal accessory, long thoracic.

Anterior SC ligament, costoclavicular ligament (posterior portion), anterior capsule of the SC joint.

Distal clavicle moves approximately 3 em.

Posterior SC ligament, costoclavicular ligament (anterior portion), posterior capsule of the SC joint.

The distal clavicle moves approximately 10 em.

Costoclavicular ligament, inferior capsule of the SC joint.

Distal clavicle moves approximately 3 em.

Interclavicular ligament, SC ligament, articular disk of SC joint, superior capsule of SC joint.

30 degrees at AC joint, then 30 degrees at SC joint.

SC: anterior and posterior sternoclavicular ligament, interclavicular ligament, costoclavicular ligament. AC: acromioclavicular ligament, coracoclavicular ligament (conoid [limits backward rotation], trapezoid [limits forward rotation]).

transverse bundle, and posterior bundle. The fan-shaped MCL is func­ tionally the most important ligament in the elbow for providing stabil­ ity against valgus stress. 6.7

Lateral Collateral Ligament. The radial or lateral collateral liga­ ment (LCL, Fig. 8-4) consists of the annular ligament, the fan-like radial collateral ligament that originates from the lateral humerus at the center of the trochlea and capitellum, the accessory collateral lig­ ament, and the lateral ulnar collateral ligament. The LCL functions to maintain the ulnohumeral and radiohumeral joints in a reduced posi­ tion when the elbow is loaded in supination. B,9 Secondary restraints of the lateral elbow consist of the bony articulations, the joint capsule, and the extensor muscles with their fascial bands and intermuscular septa. Annular Ligament.
The annular ligament functions to maintain the relationship between the head of the radius and the humerus and ulna.



Medial epicondyle

Semilunar notch

Coronoid process TUberoSIty



,/ Radial styloid process


I, ~

•••_ Ulnar styloid process

Figure 8-3. The bony structures of the elbow and radioulnar joints. (Reproduced, with permission, from Luttgens K, Hamilton N. Kinesiology: Scientific Basis of Human Motion. 10th ed. New York: McGraw-Hili; 2002:128.)


There are numerous bursae in the elbow region:

... Olecranon bursa: the main bursa of the elbow complex. Lies posteriorly between the skin and the olecranon process. ... Deep intratendinous bursa and deep subtendinous bursa: pres­ ent between the triceps tendon and olecranon. • Bicipitoradial bursa: separates the biceps tendon from the radial tuberosity. • Subcutaneous medial epicondylar bursa. • Subcutaneous lateral epicondylar bursa.

TABLE 8-8. MUSCLES OF THE ELBOW AND FOREARM ACTION Elbow flexion MUSCLES Brachialis (workhorse of elbow flexion) Biceps brachii Brachioradialis Triceps Anconeus Supinator Biceps brachii Pronator quadratus Pronator teres NERVE Musculocutaneous Musculocutaneous Radial Median Radial Radial Posterior interosseous (radial) Musculocutaneous Anterior interosseous (median) Median NERVE ROOT C5-C6, (C7) C5-C6 CS--e6, (C7) C6--e7 C7-C8 C7--e8, (Tn Cs--e6 C5-C6 C8, T1 C6--e7

Elbow extension Forearm supination Forearm pronation



TABLE 8-9. ARTICULAR AND LIGAMENTOUS CONTRIBUTIONS TO ELBOW STABILITY STABILIZATION Valgus stability ELBOW EXTENDED Anterior capsule UCL and bony articular (proximal half of sigmoid notch) equally divided Anterior capsule (32%) Joint articulation (55%) RCL (14%) Anterior oblique ligament Anterior joint capsule Trochlea-olecranon articulation (minimal) Anterior capsule Radial head against the capitellum Coracoid against the trochlea Anterior capsule (85%) RCL (5%) UCL (5%) Triceps, biceps, brachialis, brachioradialis, and forearm muscles ELBOW FLEXED 90 DEGREES UCL proves 55%
()O/O anterior capsule and bony articulation
(proximal half of sigmoid notch) Joint articulation (75%) Anterior capsule (13%) RCL (9%)

Varus stability

Anterior displacement

Posterior displacement


RCL 10% UCL 78% Capsule 8%

Reproduced, wirh permission, from Sobel ], Nirschl RP. Elbow injuries. In: Zachazewski ]E, Magee D], Quillen WS, eds. Athletic Injuries and Rehahilitation. Philadelphia: W.B. Saunders; 1996:543-583. Copyrighr © Elsevier.


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The elbow also has complex innervation

(Table 8-10).

Blood Supply. The elbow complex receives iL<; blood supply from the brachial artery, anterior ulnar recurrent artery, posterior ulnar recurrent arery, radial recurrent artery, and middle collateral branch of the arteria profunda brachii.
Biomechanics Humeroulnar Joint. The motions that occur at the humeroulnar
joint involve impure t1exion and extension, which are primarily the result of rotation of the ulna about the trochlea. The range of t1ex­ ion-extension is from 0 to 150 degrees, with about 10 degrees of hyperextension being available. Full active extension in the normal elbow is some 5 to 10 degrees short of that obtainable by forced extension, due to passive muscular restraints (biceps, brachialis, and supinator) and tension on the ulnar collateral ligament and anterior capsule. lO ,ll Passive extension is limited by the impact of the olecranon process on the olecranon fossa. 12 ... Passive flexion is limited by bony structures (the head of the radius against the radial fossa, and the coronoid process against the coronoid fossa), tension of the posterior capsular ligament, and passive tension in the triceps (Table 8-9).12 Most activities of daily living usually can be accomplished with an elbow range of motion of 30 to 130 degrees of flexion, 50 degrees of supination, and 50 degrees of pronation.




Study Pearl
... The norma,I . carrying angle of. the
elbow varies With flexionatld

extension, raoging from 6 degrees of . varus wit 'to13 degree~ of ~algus in sion the mean v ee. 14 degrees (full extension}. Women.
Figure 8-4. The lateral aspect of the elbow joint showing ligaments. (Reproduced, with permission, from Luttgens K, Hamilton N. Kinesiology: Scientific Basis of Human Motion. 10th ed. New York: McGraw-Hili; 2002:129.) .tend to have a larger carrying aru~le, with an average valwe between 13 and 16 degrees~ .. The resting, or open-pac the humerouInar joint is flexion with 10 degrees of forean:n" supination. . ' .". .... . .•. , . ' ... The c1osed-packpositil?n 15ful1 extension and maximWn:l••. forearm supination. ' ,.'., " ". . ... The capsular pattern is much more limited in flexion than in ex_te_n_s_io_n_'_1

Humeroradial Joint. The motions occurring at this joint include flexion and extension of the elbow. Some supination and pronation also occurs at this joint due to a spinning of the radial head. Proximal Radioulnar Joint. At the proximal radioulnar joint, one
degree of freedom exists, permitting pronation and supination. Pronation and supination involve the articulations at the elbow as well as the distal radioulnar joint and the radiocarpal articulation. Joint motion at the elbow is primarily gliding for both flexion and extension. Rolling occurs in the final 5 to 10 degrees of range of motion for both flexion and extension.


Study Pearl



Distal Radioulnar Joint. The distal radioulnar joint (DRUJ) is a double pivot joint that unites the distal radius and ulna, and an articu­ lar disc. The articular disc, known as the triangular fibrocartilaginous complex (TFCC), assists in binding the distal radius and is the main stabilizer of the distal radioulnar joint as it improves joint congruency and cushions against compressive forces. A number of ligaments orig­ inate from the TFCC and provide support to it. The articular capsule, which attaches to the articular margins of the radius and ulna and to the disc, enclosing the inferior radioulnar joint, is lax. Palmar and dorsal radioulnar ligaments strengthen the cap­ sule anteriorly and posteriorly. Supination tightens the anterior capsule while pronation tightens the posterior part, adding to the overall sta­ bility of the wrist. The Wrist.
The wrist joint is comprised of the distal radius and ulna, eight carpal bones, and the bases of five metacarpals (Fig. 8-5).

Study Pearl
stability can be wing ma"ner: intercalated segment bility(OISI): results from disruption betw@f'n the s and lunate, • allowing the to rot.aW into volar flexion. The remaiinjnlg com nents of the proxim row to dorsi ion because of nn t.o the scaphoid. Volar interc ent insta­ bi Iity (VIS!): res of t.he Iigamentou triquetrum and Iu volar rotation of the extension of thet.riquetru .

The Carpals. The carpal bones lie in two transverse rows. The prox­ imal row contains (radial to ulnar) the scaphoid (navicular), lunate, tri­ quetrum, and pisiform. The distal row holds (radial to ulnar) the trape­ zium, trapezoid, capitate, and hamate.








FUNCTIONAL LOSS Pronation weakness.
Wrist flexion and abduction
weakness. Loss of radial deviation at wrist. Inability to oppose or flex thumb. Thumb abduction weakness. Weak grip. Weak or no pinch (ape hand deformity). Pronation weakness, especially at 90 degrees elbow flexion. Weakness of opposition and thumb flexion. Weak finger flexion. Weak pinch (no tip-to-tip). Weak wrist flexion. Loss of ulnar deviation at wrist. Loss of distal flexion of little finger. Loss of abduction and adduction of fingers. Inability to extend second and third phalanges of little and ring fingers (benediction hand deformity) Loss of thumb adduction.
Loss of supination.
Loss of wrist extension (wrist
drop). Inability to grasp. Inability to stabilize wrist. Loss of finger extension. Inability to abduct thumb.

Median nerve (C6-C8, Tl)

Passes through the two heads of the pronator teres, which is a potential site of entrapment.

Anterior interosseous nerve (branch of median nerve)

As the median nerve passes through

Ulnar nerve (C7-C8, TI)

the cubital fossa, the anterior interosseous nerve CAIN) branches off the median nerve, as it passes through the two heads of the pronator teres muscle. Passes along the medial arm and posterior to the medial epicondyle through the cubital tunnel, a likely site of compression.

Pronator teres Flexor carpi radialis Palmaris longus Flexor digitorum superficialis Flexor pollicis longus Lateral balf of flexor digitorum profundus Pronator quadratus Thenar eminence Lateral two lumbricals Flexor poUicis longus Lateral balf of flexor digitorum profundus Pronator quadratus Thenar eminence muscles Lateral two lumbricals Flexor carpi ulnaris Medial balf of flexor digitorum profundus Palmaris brevis Hypotbenar eminence Adductor pollicis Medial two lumbricals All interossei

Palmar aspect of hand with thumb, index, middle, and lateral half of ring fmger. Dorsal aspect of distal third of index, middle, and lateral half of ring finger.


Dorsal and palmar aspect of little and medial half of ring finger.

Redial nerve (C5-C8, Tl)

Divides into the superficial (sensory) branch and the deep (motor, or posterior interosseous) branch. The deep branch must then pass through the arcade of Frohse, a fibrous arch formed by the proximal margin of the superficial head of the supinator muscle, where it is most susceptible to injury. Approximately 3 cm proximal or distal to the elbow joint, the radial nerve branches into a deep mixed nerve (posterior interosseous nerve [PIND and a superficial sensory branch

Posterior interosseous nerve (branch of ulnar nerve)

Anconeus Brachioradialis Extensor carpi radialis longus and brevis Extensor digitorum Extensor pollicis longus and brevis Abductor pollicis longus Extensor carpi ulnaris Extensor indices Extensor digiti minimi Extensor carpi radialis brevis Extensor digitorum Extensor pollicis longus and brevis Abductor pollicis longus Extensor carpi ulnaris Extensor indices Extensor digiti minimi

Dorsum of hand (lateral two thirds). Dorsum and lateral aspect of thumb. Proximal two-thirds of dorsum of index, middle, and half of ring finger.


Weak wrist extension. Weak finger extension. Difficulty stabiliZing wrist. Difficulty with grasp. Inability to abduct thumb.

Reproduced, with permission, from Magee DJ. Orthopedic Physical Assessment. Philadelphia: W.B. Saunders; 2002. Copyright © Elsevier.






MU~~~g~~um...... p' ..~i - .~ (~(" I~


~ ~\ ttl''~~ ~~"~caPitatum
\~1:' (~\-.~ \:-~~
r 3

Triquetrum .••...­ Hamatum

1 \ ~I . (2 Multangulum t major

4 _'. •...•-..•••••. Metacarpals



• Also called trapezoid.

t Also called trapezium,

Figure 8-5. Bones of the wrist, anterior view. (Reproduced, with per­ mission, from Luttgens K, Hamilton N. Kinesiology: Scientific Basis of Human Motion. 10th ed. New York: McGraw-Hili; 2002:137.)

Midcarpal Joints. The midcarpal joint lies between the two rows of carpals. It is referred to as a "compound" articulation because each row has both a concave and convex segment. Wrist flexion, extension, and radial deviation are mainly midcarpal joint motions. Approximately 50% of the total arc of wrist flexion and extension occurs at the midcarpal level with more flexion (66%) occurring than extension (34%).13,14 The proximal row of the carpals is convex laterally and concave medially.
.. The scaphoid, lunate, trapezium, trapezoid, and triquetrum present with a concave surface to the distal row of carpals. .. The scaphoid, capitate, and hamate present a convex surface to a reciprocally arranged distal row,


StUdY" Pearl
, Ascaphol plet!'EO ":tear

'Mel1'tI;' ';which may, n injury.

nd supi te ra scaphoid tilts into fie
and ulnar deviation (see

Carpal Ligaments. Migration of the carpal bones is prevented by Slrong ligaments, and by the ulnar support provided by the TFCC. The major ligaments of the wrist include the palmar intrinsic ligaments, the volar extrinsic, and the dorsal extrinsic and intrinsic ligaments. &Jdiocarpal Joint. The radiocarpal joint is formed by the large artic­ ,alar concave surface of the distal end of the radiUS, the scaphoid, and , blate of the proximal carpal row, and the TFCC. Antebrachial Fascia. The