The Pocketbook For PHYSIOTHERAPISTS 2nd Gitesh Amrohit Masud PDF

The Pocketbook for
PHYSIOTHERAPISTS
The Pocketbook for
PHYSIOTHERAPISTS
SECOND EDITION
Gitesh Amrohit MPT (Neuro)

Chief Consultant and Director
Amrohit Institute of Rehabilitation Sciences (AIRS)
Raipur, Chhattisgarh, India
President
Physiotherapist Association®
Managing Editor
Right Sehat
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specifically stated, all figures and tables are courtesy of the author. Where
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manufacturer of the drug or device.
The Pocketbook for Physiotherapists
First Edition: 2007

Second Edition: 2012
ISBN 978-93-5025-560-5
Printed at
Dedicated to
My parents
Dr Ramadhar Amrohit
Smt Shruti Amrohit
and
My dearest twin brothers
Jeetesh-Jeevesh
Preface to
the Second Edition
It gives me immense pleasure to present the second

edition of the book The Pocketbook for Physiotherapists.
In this edition, I have tried to expand it, without
compromising its pocket size. Additional contents have
been attached in every section and to make it easier to
find the relevant information for the students.
I hope that undergraduates, postgraduates and
professionals find this book useful and informative.
Wishing and praying for your bright future and all
the success in your life.
Gitesh Amrohit
Preface to
the First Edition
I was the undergraduate student of physiotherapy in

the year 2002-2006. During this period, I and my
classmates had to remember lots of normal values,
special tests, drugs, pathology, anatomy and various
others things and it was not possible to remember all
the things at the same time, because the textbook did
not used to be in our hand all the time and these
problems were solved by preparing notes of all those
stuffs. The main problem used to arise when we have
to know and confirm certain things, while assessing
and giving treatment to the patient and because of this;
we were bound to carry all those heavy textbooks.
Taking care of all these problems, The Pocketbook for
Physiotherapists is written. In this there are all the
important stuffs related to medical and physiotherapy
and they are explained by the help of graphs, tables
and text without modifying their original meaning.
This book cannot be the textbook, but it can be used
after a thorough study from the textbooks during the
postings, clinics and the classroom. It has taken hard
work to comprise all the medical and physiotherapy
topics in this small handbook. So that you can take
complete advantage of the book.
Wishing and praying for your bright future and all
the success in your life.
Gitesh Amrohit
Acknowledgments
First of all, I thank God for the gift of life and all the
blessings, He has poured on me.
I would like to heartily thank my irreplaceable staff,
who were there with me in every step from bottom of
my heart.
I would also like to acknowledge with thanks
Mr Shravan Kumar and Mr Khomlal Chandeshwar;
SK Medical Book House, who supported and kept
motivating me. It was not possible for me to publish
this book without their support.
Last but not least, I would like to thank the entire
team at M/s Jaypee Brothers Medical Publishers (P)
Ltd, New Delhi, India, especially Shri Jitendar P Vij
(Chairman and Managing Director), Mr Tarun Duneja
(Director-Publishing) and Mr Prasun Bhattacharya
(Manager-Nagpur Branch) for their unmatchable
contribution in bringing this book to present shape.
Contents
CHAPTER 1: PHARMACOLOGY .................. 1

Drug Classes in Alphabetical Order 1;
Acetazolamide 2; Acetylcysteine 2; Aciclovir 2;
Adenosine 2; Adrenaline/Epinephrine 3;
Albendazole 3; Alendronate 3; Alfentanil 3;
Allopurinol 4; Amiodarone 4; Aminophyline 4;
Amitriptyline 4; Amlodipine 5; Amoxicillin 5;
Ampicillin 5; Alprazolam 5; Alendronate 6;
Aspirin 6; Atenolol 6; Atracurium 6; Atropine
7; Azathioprine 7; Baclofen 7; Beclomethasone 7;
Bendroflumethiazide/Bendrofluazide 8; Budesonide
8; Calcitonin 8; Captopril 8; Carbamazepine 9;
Celecoxib 9; Chloramphenicol 9; Chlorpromazine
9; Chloroquine 10; Ciclosporin 10; Ciprofloxacin
10; Clofazimine 11; Clomipramine 11; Clonidine
11; Codeine Phosphate 11; Dapsone 11;
Dexamethasone 12; Diazepam 12; Diclofenac 12;
Didanosine 12; Digoxin 13; Dihydrocodeine/Df
118 13; Diltiazem 13; Dobutamine 13; Donepezil
13; Dopamine 14; Dornase Alfa 14; Dosulepin/
Dothiepin 14; Doxapram 14; Doxycycline 14;
Enalapril 15; Efavirenz 15; Erythromycin 15;
Etidronate 15; Fentanyl 16; Ferrous Sulphate 16;
Flucloxacillin 16; Furosemide/Frusemide 16;
Gabapentin 16; Gatifloxacin 17; Gentamicin 17;
THE POCKETBOOK FOR PHYSIOTHERAPISTS
xiv
Gliclazide 17; Haloperidol 17; Heparin 18;
Hydrocortisone 18; Ibuprofen 18; Insulin 18;
Interferon 19; Ipratropium 19; Isoniazid 19;
Isosorbide Mononitrate 19; Ketamine 20;
Lactulose 20; Levodopa/L-dopa 20; Lignocaine/
Lidocaine 20; Liquid Paraffin 21; Lisinopril 21;
Mannitol 21; Meloxiam 21; Metformin 21;
Methotrexate 22; Methyldopa 22; Metronidazole
22; Midazolam 22; Morphine 23; Naproxen 23;
Norfloxacin 23; Omeprazole 23; Ondansetron 24;
Orphenadrine 24; Oxybutinin 24; Oxytetra-
cycline 24; Pancuronium 25; Paracetamol 25;
Penicillin-g 25; Pethidine 25; Phenytoin 25;
Piroxicam 26; Prednisolone 26; Propranolol 26;
Quinine 27; Ramipril 27; Ranitidine 27;
Rifampicin 27; Salbutamol 28; Salcatonin 28;
Senna 28; Streptokinase 28; Streptomycin 28;
Sulfasalazine 29; Tetracycline 29; Theophylline
29; Timolol 29; Tinidazole 30; Tizanidine 30;
Tolterodine 30; Tramadol 30; Trazodone 30;
Trihexyphenidyl/Benzhexol 31; Vancomycin 31;
Vecuronium 31; Verapamil 31; Warfarin 32;
Zalcitabine 32; Zidovudine 32; List of Pharma-
cology Abbreviations 33
CHAPTER 2: ELECTROTHERAPY ............... 35

Principles of Electrotherapy Application 37;
Interferential 42; Short Wave Diathermy 43;
Ultraviolet Radiation 45; Laser Therapy 47;
Ultrasound 48; Transcutaneous Electrical Nerve
Stimulation (TENS) 50; Iontophoresis 51;
Infrared Radiation 52; Paraffin Wax Bath 53;
Neuromuscular Electrical Stimulation (NMES)
CONTENTS
xv
55; Microwave Diathermy 56; Cryotherapy (Cold
Therapy) 57; Hot Packs (Hydrocollator Packs)/
Electric Heating Pads 58; Whirlpool Bath 59;
Contrast Bath 60; Sauna Bath 61; Electromyo-
graphic Biofeedback 62; Fluidotherapy 64;
Intermittent Pneumatic Compression 65; Conti-
nuous Passive Motion 66; Traction 67; Strength
Duration Curve 68; Motor Points 71
CHAPTER 3: CARDIORESPIRATORY ........ 77

Cardiorespiratory Anatomy Illustrations 79;
Surface Marking of the Lungs 82; Respiratory
Volumes and Capacities 84; Differences between
Central and Peripheral Cyanosis 87; Sputum
Analysis 87; Readings of Chest X-rays 88;
Abnormal ECG Findings 93; Percussion Note 94;
Auscultation 95; Palpation of Pulses 100; Apgar
Scoring Method 101; Postural Drainage 101;
Manual Chest Clearance Technique 107;
Suctioning 108; Forced Expiratory Techniques
110; Tracheostomies 110; Aerosol Therapy 112;
Humidity 113; Lung Function Test 114;
Ambulatory Manual Breathing Unit (AMBU)
Bag 115; Manual Hyperinflation 116; Cardio-
respiratory Monitoring 117; Ventilations 120;
Respiratory Pathologies 123; Normal Values 136;
Blood Values and their Interfering Factors 138;
Respiratory Assessment 139; Glossary of
Cardiorespiratory Terms 143
CHAPTER 4: NEUROLOGY ........................ 147

Neuroanatomy Illustrations 149; Clinical
Manifestations of Cerebrovascular Lesions 153;
xvi
Localization of Lesion and their Signs of
Impairment 155; Peripheral Nervous System 158;
Splints Used for Various Nerve Injuries 162;
Vertebrae and Corresponding Spinal Segment
Relationship 163; Neurological Tests 164; Cranial
Nerves 169; Reflexes 173; Differences of Upper
Motor Neuron and Lower Motor Neuron
Lesions 175; Glasgow Coma Scale 177; Modified
Ashworth Scale for Grading Spasticity 178;
Neurological Pathologies 178; Neurological
Assessment 193; Glossary of Neurological
Terms 197
CHAPTER 5: MUSCULOSKELETAL ......... 203

Muscles Listed by Function 204; Manual Muscle
Testing Grading 209; Alphabetical Listing of the
Muscles 210; Joint Range of Movement 278;
Common Musculoskeletal Tests 288; Musculo-
skeletal Pathologies 315; Grades of Sprain and
Treatment 328; Stages of Fracture Healing 329;
Fractures with Eponyms 331; Musculoskeletal
Assessment 336
CHAPTER 6: MISCELLANEOUS ................ 339

Diagnostic/Electrodiagnostic Testing 340;
National Immunization Schedule 345; Propriocep-
tive Neuromuscular Facilitation (PNF) 345;
Common Sports Injuries 346; Types of Aphasia
348; Gait 348; Levels of Amputations 351; Abbre-
viations 353; Normal Reference/Lab Values 376
Index ..................................................................... 381

PHARMACOLOGY
1
1
CHAPTER
CHAPTER 1
Pharmacology
• Drug classes in alphabetical order
• Prescription abbreviations
2
CHAPTER DRUG CLASSES IN ALPHABETICAL ORDER
1 ACETAZOLAMIDE
Type: Diuretics.
Uses: Glaucoma, epilepsy, acute mountain sick-
ness, periodic paralysis, urinary tract infection.
Side effects: Hypokalemia, drowsiness, acidosis,
abdominal discomfort.
ACETYLCYSTEINE
Type: Mucolytic.
Uses: Reduces the viscosity of secretions, antidote
for paracetamol overdose.
Side effects: Bronchoconstriction, nausea, vomiting.
ACICLOVIR
Type: Antiviral.
Uses: Herpes simplex and varicella zoster
infection.
Side effects: Very rare.
ADENOSINE
Class: Antiarrhythmic.
Uses: Tachycardias.
Side effects: Nausea, bronchospasm, dyspnea, chest
pain, facial flush.
PHARMACOLOGY
3
ADRENALINE/EPINEPHRINE CHAPTER
Type: Sympathomimetic agent.
Uses: During cardiopulmonary resuscitation to 1
stimulate heart activity and raise low blood
pressure, anaphylactic shock, glaucoma, in eye
surgery.
Side effects: Dry mouth, anxiety, restlessness,
palpitations, tremor, blurred vision, headache,
hypertension, tachycardias.
ALBENDAZOLE
Type: Anthelmintics.
Uses: Filariasis, hydatid disease, trichinosis, tape-
worms.
Side effects: Diarrhea, nausea, abdominal pain.
ALENDRONATE
Type: Bisphosphonate.
Uses: Postmenopausal osteoporosis, cortico-
steroids induced osteoporosis, Paget’s disease.
Side effects: Gastrointestinal upset, esophageal
irritation and ulceration.
ALFENTANIL
Type: Opioid analgesic.
Uses: Respiratory depressant, during surgery.
4
CHAPTER Side effects: Drowsiness, nausea, vomiting,
1
constipation, dizziness, dry mouth.
ALLOPURINOL
Type: Antigout.
Uses: Gout, kidney stones.
Side effects: Nausea, itching, rash.
AMIODARONE
Type: Antiarrhythmic.
Uses: Ventricular and supraventricular tachycar-
dias.
Side effects: Liver damage, reversible corneal
depositions, thyroid disorders.
AMINOPHYLINE
Type: Bronchodilator.
Uses: Acute severe asthma, reversible airway
obstruction.
Side effects: Nausea, headache, insomnia, arrhyth-
mias, convulsions, palpitations, tachycardias.
AMITRIPTYLINE
Type: Tricyclic antidepressant.
Uses: Depression, nocturnal enuresis in children.
PHARMACOLOGY
5
Side effects: Sweating, dry mouth, blurred vision, CHAPTER
1
dizziness, drowsiness, fainting, palpitations,
gastrointestinal upset.
AMLODIPINE
Type: Ca++ channel blocker.
Uses: Congestive heart failure, angina.
Side effects: Ankle edema, flushing, palpitation,
headache, hypotension, gastrointestinal upset.
AMOXICILLIN
Please refer Ampicillin.
AMPICILLIN
Class: Antibiotic.
Uses: Urinary tract infection, respiratory tract
infection, meningitis, gonorrhea, typhoid fever,
bacillary dysentery, bacterial endocarditis,
septicemias, cholecystitis.
Side effects: Diarrhea, rashes, lymphatic leukemia.
ALPRAZOLAM
Type: Benzodiazepines.
Uses: Anxiety, depression.
Side effects: Sedation, light headedness, vertigo,
confusion, psychomotor and cognitive impairment.
6
CHAPTER ALENDRONATE
1 Type: Bisphosphonate.
Uses: Postmenopausal osteoporosis, cortico-
steroids induced osteoporosis, Paget’s disease.
Side effects: Esophageal irritations and ulceration,
gastrointestinal upset, increased bony pain
especially in Paget’s disease.
ASPIRIN
Type: NSAIDs and antipyretic.
Uses: As analgesic, antipyretic, acute rheumatic
fever, RA, OA, postmyocardial infarction and
post-stroke.
Side effects: Nausea, vomiting, epigastric distress,
rhinorrhea.
ATENOLOL
Type: B-antiadrenergic.
Uses: Arrhythmias, angina, hypertension, myocar-
dial infarction, congestive heart failure.
Side effects: Cold hand and feet, bradycardia,
hypotension, fatigue.
ATRACURIUM
Type: Nondepolarizing muscle relaxant.
Uses: As a muscle relaxant.
Side effects: Hypotension, flushing, skin rashes.
PHARMACOLOGY
7
ATROPINE CHAPTER
Type: Antimuscarinic.
Uses: Corneal ulcers, peptic ulcers, pulmonary 1
embolism, preanesthetic medication, bradycardia,
motion sickness.
Side effects: Dry mouth, difficulty in swallowing
and talking, blurring of near vision, constipation,
flushing, dry skin.
AZATHIOPRINE
Type: Immunosuppressant.
Uses: Autoimmune and collagen disease including
rheumatoid arthritis, polymyositis, systemic lupus
erythematosus.
Side effects: Nausea, vomiting, loss of hair, loss of
appetite, bone marrow suppression.
BACLOFEN
Type: Skeletal muscle relaxant.
Uses: For reducing spasticity.
Side effects: Nausea, urinary disturbances, drowsi-
ness.
BECLOMETHASONE
Type: Corticosteroid.
Uses: Asthma, allergic rhinitis, in vasomotor
symptoms.
8
CHAPTER Side effects: Nasal discomfort, irritation, horse
1
voice, cough, nosebleed, sore throat.
BENDROFLUMETHIAZIDE/BENDROFLUAZIDE
Type: Thiazide diuretic.
Uses: Hypertension, cardiac failure, resistant
edema, for reducing urinary calcium excretion.
Side effects: Hypokalemia, dehydration, postural
hypotension, gout, hyperglycemia.
BUDESONIDE
Uses: Asthma, COPD.
Side effects: Nasal discomfort, cough, sore throat.
CALCITONIN
Type: Hormone.
Uses: Hypercalcemia, bone pain, osteoporosis.
Side effects: Vomiting, nausea.
CAPTOPRIL
Type: ACE inhibitor.
Uses: Hypertension, congestive heart failure, post-
myocardial infarction, diabetic nephropathy.
Side effects: Persistent dry cough, rashes, loss of
taste sensation, reduces kidney function, postural
hypotension.
PHARMACOLOGY
9
CARBAMAZEPINE CHAPTER
Type: Antiepileptic.
Uses: Partial and tonic–clonic seizures, trigeminal 1
neuralgia.
Side effects: Drowsiness, epigastric pain, nausea,
confusion, blurred vision.
CELECOXIB
Type: NSAID.
Uses: Osteoarthritis, rheumatoid arthritis.
Side effects: Fluid retention, dizziness, hyper-
tension, headache, itching, insomnia.
CHLORAMPHENICOL
Type: Broad spectrum antibiotics.
Uses: Enteric fever, anerobic infections, intraocular
infections, H. influenzae, meningitis.
Side effects: Nausea, vomiting, diarrhea, gray baby
syndrome, bone marrow depression.
CHLORPROMAZINE
Type: Antipsychotic.
Uses: Schizophrenia, mania, organic brain
syndrome, alcoholic hallucinosis.
Side effects: Dry mouth, blurring vision, consti-
pation, parkinsonian symptoms, dystonic,
10
CHAPTER jaundice, akathisia, malignant neuroleptic
1
syndrome symptoms.
CHLOROQUINE
Type: Antimalarial drug.
Uses: Malaria.
Side effects: Hypotension, vision loss, hearing
deficit, nausea, vomiting, anorexia, itching.
CICLOSPORIN
Type: Immunosuppressant.
Uses: Used to prevent rejection of organ and tissue
transplantation. Rheumatoid arthritis, severe
resistant psoriasis, severe dermatitis when other
treatments have failed.
Side effects: Nephrotoxicity, hypertension, increa-
sed body hair, nausea, tremors, swelling of gums.
CIPROFLOXACIN
Type: Prototype antibacterial.
Uses: UTI, gonorrhea, bacterial gastroenteritis,
typhoid, gynecological disease, tuberculosis,
meningitis, respiratory infections.
Side effects: Nausea, vomiting, anorexia, bad taste
dizziness, headache, rashes, urticaria.
PHARMACOLOGY
11
CLOFAZIMINE CHAPTER
Please refer Dapsone.
1
CLOMIPRAMINE
Type: Tricyclic antidepressant.
Uses: Depression.
Side effects: Sweating, drowsiness, dryness of
mouth, blurring of vision, dizziness, fainting,
palpitations, gastrointestinal upset.
CLONIDINE
Type: Alpha 2 adrenoceptor agonist.
Uses: Migraine, menopausal flushing, hyper-
tension.
Side effects: Dryness of mouth, gastrointestinal
upset, headache, dizziness, rashes, sedation,
depression, bradycardia, retention of fluid,
nocturnal unrest.
CODEINE PHOSPHATE
Please refer Morphine.
DAPSONE
Type: Antileprotic drug.
Uses: Leprosy.
12
CHAPTER Side effects: Hemolytic anemia, gastric intolerance,
1
rashes, headache, lepra reactions, nausea,
vomiting.
DEXAMETHASONE
Please refer Prednisolone.
DIAZEPAM
Type: Benzodiazepines.
Uses: Anxiety, sleep disturbances, alcoholism and
as muscle relaxants.
Side effects: Unsteadiness, drowsiness, dizziness,
confusion in elderly. Dependence develops with
prolonged use.
DICLOFENAC
Type: NSAIDs and antipyretic.
Uses: Rheumatoid arthritis, osteoarthritis, ankylos-
ing spondylitis, post-traumatic and postoperative
inflammatory conditions.
Side effects: Epigastric pain, nausea, rashes,
headache, dizziness.
DIDANOSINE
Please refer Zalcitabine.
PHARMACOLOGY
13
DIGOXIN CHAPTER
Type: Cardiac glycoside.
Uses: Heart failure, supraventricular arrhythmias. 1
Side effects: Nausea, anorexia, vomiting, diarrhea,
visual disturbances, headache, tiredness,
palpitations.
DIHYDROCODEINE/DF 118
Please refer Morphine.
DILTIAZEM
Please refer Amlodipine.
DOBUTAMINE
Type: Inotropic sympathomimetic.
Uses: Heart failure.
Side effects: Tachycardias.
DONEPEZIL
Type: Anticholinesterase.
Uses: Dementia especially due to Alzheimer’s
disease.
Side effects: Insomnia, muscle cramps, fatigue,
gastrointestinal upset.
14
CHAPTER DOPAMINE
1 Type: Inotropic sympathomimetic.

Uses: Shock, heart failure.
Side effects: Nausea, vomiting, peripheral vaso-
constriction, hypotension, hypertension tachy-
cardia.
DORNASE ALFA
Type: Mucolytic.
Uses: Used by inhalation in cystic fibrosis to
facilitate expectoration.
Side effects: Laryngitis, pharyngitis, pain in chest.
DOSULEPIN/DOTHIEPIN
Please refer Clomipramine.
DOXAPRAM
Type: Respiratory stimulant.
Uses: COPD with type-II respiratory failure.
Side effects: Hypertension, cerebral edema,
hyperthyroidism, dizziness, sweating, confusion,
seizures, nausea, vomiting, tachycardia, perineal
warmth.
DOXYCYCLINE
Please refer Tetracyclines.
PHARMACOLOGY
15
ENALAPRIL CHAPTER
Uses: Hypertension, chronic heart failure. 1
Side effects: Rashes, dry cough, loss of taste,
postural hypotension, dizziness, headache, reduce
kidney function.
EFAVIRENZ
Please refer Zalcitabine.
ERYTHROMYCIN
Type: Macrolide antibiotic.
Uses: Inflammation, diphtheria, syphilis,
gonorrhea.
Side effects: Gastrointestinal discomfort, rashes,
fever.
ETIDRONATE
Type: Bisphosphonate.
Uses: Postmenopausal osteoporosis, corticosteroid
induced osteoporosis, Paget’s disease, bone
metastases in breast cancer.
Side effects: Ulceration and esophageal irritation,
gastrointestinal upset, increased bony pain in
Paget’s disease.
16
CHAPTER FENTANYL
1 Type: Opioid analgesic.

Uses: Mainly used to depress respiration in
patients needing prolonged assisted ventilation.
Side effects: Drowsiness, nausea, vomiting, consti-
pation, dizziness, dry mouth.
FERROUS SULPHATE
Type: Iron salt.
Uses: Iron deficiency anemia.
Side effects: Constipation, epigastric discomfort,
darkening of feces.
FLUCLOXACILLIN
Please refer Penicillin.
FUROSEMIDE/FRUSEMIDE
Type: Loop diuretic.
Uses: For reducing acute pulmonary edema
secondary to left ventricular failure.
Side effects: Hypokalemia, postural hypotension,
hyponatremia, hyperuricemia, gout, dizziness,
nausea.
GABAPENTIN
Type: Anticonvulsant.
PHARMACOLOGY
17
Uses: Epileptic seizures, neuropathic pain, CHAPTER
1
trigeminal neuralgia.
Side effects: Dizziness, drowsiness, ataxia, nystag-
mus, tremor, diplopia, gastrointestinal upset,
peripheral edema, amnesia, paresthesia.
GATIFLOXACIN
Please refer Ciprofloxacin.
GENTAMICIN
Type: Aminoglycoside antibiotics.
Uses: Pseudomonas, Proteus, Klebsiella infections,
respiratory infection’s meningitis.
Side effects: Vestibular disturbances, auditory loss,
nausea, vomiting.
GLICLAZIDE
Type: Sulphonylurea.
Uses: Type-II diabetes mellitus.
Side effects: Hypoglycemia, weight gain.
HALOPERIDOL
Type: Antipsychotic.
Uses: Used for controlling violent and
dangerously impulsive behavior associated with
psychotic disorders like as schizophrenia,
dementia and mania.
18
CHAPTER Side effects: Acute dystonia, akathisia, drowsiness,
1
postural hypotension, parkinsonism.
HEPARIN
Type: Anticoagulant.
Uses: Pulmonary embolism, DVT.
Side effects: Thrombocytopenia, hemorrhage.
HYDROCORTISONE
Please refer Prednisolone.
IBUPROFEN
Class: Nonsteroidal anti-inflammatory/NSAID.
Uses: For reducing pain, stiffness, swelling. Osteo-
arthritis, rheumatoid arthritis, soft tissue injuries,
headache, dental pain, operative pain.
Side effects: Indigestion, heart burn.
INSULIN
Type: Peptide hormone.
Uses: Insulin dependent and maturity onset
diabetes mellitus.
Side effects: Irritation over injection site, hypo-
glycemia, weakness, weight gain, sweating.
PHARMACOLOGY
19
INTERFERON CHAPTER
Type: Antiviral and anticancer.

Uses: Leukemia, multiple sclerosis, granulomatous
1
disease.
Side effects: Lethargy, chills, myalgia, fatigue,
rashes, fever, headache, anorexia, irritation.
IPRATROPIUM
Uses: COPD.
Side effects: Dry mouth and throat.
ISONIAZID
Type: Antitubercular drug.
Uses: Tuberculosis.
Side effects: Paresthesia, numbness, convulsions,
mental disturbances, hepatitis.
ISOSORBIDE MONONITRATE
Type: Organic nitrate.
Uses: Congestive heart failure, angina.
Side effects: Throbbing headache, flushing, sweat-
ing, palpitation, dizziness, fainting.
20
CHAPTER KETAMINE
1 Type: Intravenous anesthetic.

Uses: As anesthetics agent (not use in head and
neck surgery).
Side effects: Tachycardia, hallucinations, increased
blood pressure, increased muscle tone, apnea,
hypotension, other transient psychotic sequelae.
LACTULOSE
Type: Osmotic laxative.
Uses: Constipation, hepatic encephalopathy.
Side effects: Diarrhea, stomach cramps, flatulence,
belching.
LEVODOPA/L-DOPA
Type: Dopamine precursor.
Uses: Parkinson’s disease.
Side effects: Nausea, vomiting, postural hypo-
tension, cardiac arrhythmias, alteration in taste
sensation, behavioral changes, abnormal move-
ments, abdominal pain, dizziness, discoloration
of urine and other body fluids.
LIGNOCAINE/LIDOCAINE
Type: Na+ channel blocker.
Uses: As anesthetic and antiarrhythmic.
Side effects: Dizziness, drowsiness, nausea, vomiting.
PHARMACOLOGY
21
LIQUID PARAFFIN CHAPTER
Type: Laxatives.
Uses: Constipation, before surgery night. 1
Side effects: Dehydration, lipid pneumonia.
LISINOPRIL
Uses: Hypertension, congestive heart failure,
following myocardial infarction.
Side effects: Nausea, vomiting, cough, taste
alteration, hypotension.
MANNITOL
Type: Osmotic diuretic.
Uses: Glaucoma, head injury, stroke.
Side effects: Nausea, diarrhea, headache, fever.
MELOXIAM
Type: NSAID.
Uses: Rheumatoid arthritis, ankylosing spondy-
litis, osteoarthritis.
Side effects: Headache, gastrointestinal upset,
dizziness, vertigo, rashes.
METFORMIN
Type: Biguanide.
22
CHAPTER Uses: Type-II diabetes mellitus.
1 Side effects: Anorexia, nausea, vomiting, diarrhea.
METHOTREXATE
Type: Cytotoxic and immunosuppressive.
Uses: Leukemia, lymphoma, rheumatoid arthritis,
psoriatic arthritis.
Side effects: Diarrhea, bone marrow suppression,
vomiting, inflammation.
METHYLDOPA
Type: Antihypertensive.
Uses: High blood pressure.
Side effects: Sedation, lethargy, disturbed mental
capacity, impotence, postural hypotension.
METRONIDAZOLE
Type: Antiamebic.
Uses: Giardiasis, amebiasis, trichomonas vaginitis,
enterocolitis, gingivitis bacterial infections.
Side effects: Nausea, vomiting, anorexia, headache,
glossitis, rashes, dizziness.
MIDAZOLAM
Type: Benzodiazepine.
PHARMACOLOGY
23
Uses: Anxiety, mainly used during small proce- CHAPTER
1
dures under local anesthetic and in ITU units for
those on ventilator support.
Side effects: Hypotension, apnea, drowsiness,
headache, confusion, ataxia, amnesia, muscular
weakness.
MORPHINE
Uses: Ventricular failure, pain.
Side effects: Nausea, vomiting, constipation, dizzi-
ness, drowsiness, respiratory depression, dry
mouth.
NAPROXEN
Type: NSAID.
Uses: Rheumatoid arthritis, musculoskeletal
disorders in acute stage, gout, menstrual cramps.
Side effects: Gastrointestinal upset.
NORFLOXACIN
Please refer Ciprofloxacin.
OMEPRAZOLE
Type: Proton pumps inhibitor.
Uses/Side effects: Please refer Ranitidine.
24
CHAPTER ONDANSETRON
1 Type: Serotonin antagonist.

Uses: Used to treat nausea and vomiting associa-
ted with anticancer drug therapy, radiotherapy
and following surgery.
Side effects: Headache, constipation.
ORPHENADRINE
Uses: For reducing rigidity and tremor in younger
patients with parkinsonism.
Side effects: Dry mouth, dry skin, constipation,
blurred vision, retention of urine.
OXYBUTININ
Uses: Urinary frequency, urgency and inconti-
nence, nocturnal enuresis, neurogenic bladder
instability.
Side effects: Dry mouth, dry eye, gastrointestinal
upset, difficulty in micturation, skin reaction,
blurring of vision.
OXYTETRACYCLINE
Please refer Tetracycline.
PHARMACOLOGY
25
PANCURONIUM CHAPTER
Please refer Vecuronium.
PARACETAMOL
1
Type: Nonopioid analgesic.
Uses: Pain, fever.
Side effects: Very rare. Overdose is dangerous
causing liver failure.
PENICILLIN-G
Type: Benzyl penicillin.
Uses: Streptococcal, pneumococcal, meningococcal
infections, gonorrhea, syphilis, diphtheria.
Side effects: Pain at inj. Site, nausea, rash, itching,
urticaria, shock, exfoliative dermatitis.
PETHIDINE
Uses: Severe pain, pain during labor, anxiety,
during anesthesia.
Side effects: Nausea, vomiting, constipation,
drowsiness, confusion.
PHENYTOIN
Type: Anticonvulsant.
Uses: Epilepsy, trigeminal neuralgia.
26
CHAPTER Side effects: Nausea, vomiting, confusion,
1
headache, dizziness, ache, increased body hair.
PIROXICAM
Type: NSAID.
Uses: Rheumatoid arthritis, acute gout, osteo-
arthritis, acute musculoskeletal disorders.
Side effects: Gastrointestinal upset.
PREDNISOLONE
Uses: Adrenal insufficiency, adrenogenital,
syndrome, arthritides, collagen disease, asthma,
lung and eye disease, malignancies, intestinal and
skin disease.
Side effects: Peptic ulcer, indigestion, acne,
osteoporosis, glaucoma, growth retardation, fetal
abnormalities, muscular weakness, Cushing’s
habitus, fragile skin, psychiatric disturbances.
PROPRANOLOL
Type: Na+ channel blocker.
Uses: Sinus tachycardia, atrial and nodal ESs.
Side effects: Dizziness, nausea, vomiting, fatigue,
cold peripheries, bronchoconstriction, brady-
cardia, heart failure, hypotension, gastrointestinal
upset, sleep disturbances.
PHARMACOLOGY
27
QUININE CHAPTER
Type: Antimalarial.
Uses: Malaria. Also used to prevent nocturnal leg 1
cramps.
Side effects: Tinnitus, headache, blurred vision,
confusion, gastrointestinal upset, rashes, blood
disorders.
RAMIPRIL
Uses: Hypertension, congestive heart failure,
myocardial infarction.
Side effects: Nausea, vomiting, dizziness, headache,
cough, dry mouth, taste disturbance.
RANITIDINE
Type: H2 blocker.
Uses: Duodenal ulcer, gastric ulcer, gastritis,
Zollinger-Ellison syndrome, GERD.
Side effects: Nausea, loose stool, muscle and joint
pain, dizziness, abdominal pain.
RIFAMPICIN
Type: Antitubercular.
Uses: Tuberculosis, leprosy, meningitis, osteo-
myelitis.
28
CHAPTER Side effects: Nausea, vomiting, malaise, bone pain,
1
purpura, breathlessness.
SALBUTAMOL
Type: 2-agonist.
Uses: Asthma, chronic bronchitis, emphysema.
Side effects: Weakness, tremors, drowsiness,
nervousness, tension. Anxiety, restlessness.
SALCATONIN
Please refer Calcitonin.
SENNA
Type: Stimulant laxative.
Uses/Side effects: Please refer Lactulose.
STREPTOKINASE
Type: Fibrinolytic agent.
Uses: Pulmonary embolism, thrombosed arterio-
venous shunts.
Side effects: Excessive bleeding, hypotension,
nausea, vomiting, allergic reactions.
STREPTOMYCIN
Type: Aminoglycoside antibiotics.
Uses: Tuberculosis, plague, bacterial endocarditis,
tularemia.
PHARMACOLOGY
29
Side effects: Vestibular disturbances, auditory loss CHAPTER
1
paresthesia.
SULFASALAZINE
Type: Aminosalicylate.
Uses: Ulcerative colitis, Crohn’s disease, rheuma-
toid arthritis.
Side effects: Nausea, vomiting, loss of appetite,
headache, joint pain, abdominal discomfort,
anorexia.
TETRACYCLINE
Type: Alpha-adrenoceptor agonist.
Uses: For reducing spasticity associated with
multiple sclerosis or spinal card injury.
Side effects: Lethargy, fatigue, dry mouth, gastro-
intestinal upset, hypotension.
THEOPHYLLINE
Type: Methylxanthine.
Uses: Asthma, bronchitis, emphysema.
Side effects: Nausea, vomiting, palpitations.
TIMOLOL
Type: Beta blocker.
Uses: Hypertension, angina, prophylaxis of
myocardial infarction.
Side effects: Please refer Propranolol.
30
CHAPTER TINIDAZOLE
1 Please refer Metronidazole.
TIZANIDINE
Uses: For treating moderate to severe pain.
Side effects: Nausea, vomiting, dry mouth,
tiredness, drowsiness, dependence.
TOLTERODINE
Uses: Mainly used to treat urinary frequency,
urgency and incontinence. Also used for reducing
unstable contraction of the bladder.
Side effects: Headache, gastrointestinal upset, dry
eye, dryness of mouth.
TRAMADOL
Uses: For treating moderate to severe pain.
Side effects: Nausea, vomiting, dry mouth,
tiredness, drowsiness, dependence.
TRAZODONE
Type: Antidepressant.
PHARMACOLOGY
31
Uses: Depression, anxiety. CHAPTER
Side effects: Drowsiness.
TRIHEXYPHENIDYL/BENZHEXOL
1
Uses: For reducing rigidity and tremor in young
patients with Parkinsonism.
Side effects: Blurring of vision, urine retention,
constipation, dry skin, dryness of mouth.
VANCOMYCIN
Type: Glycopeptide antibiotic.
Uses: MRSA infections, endocarditis, gastro-
intestinal infection.
Side effects: Disorder of the blood, nephrotoxicity,
ototoxicity.
VECURONIUM
Type: Muscles relaxants.
Uses: During general anesthesia, convulsions,
trauma, tetanus, status epilepticus.
Side effects: Respiratory failure, muscle soreness,
hypotension.
VERAPAMIL
Type: Calcium channel blocker.
32
CHAPTER Uses: Hypertension, supraventricular dysrhyth-
1
mias.
Side effects: Nausea, vomiting, constipation,
headache, ankle swelling.
WARFARIN
Please refer Heparin.
ZALCITABINE
Type: Antiretroviral NRTI.
Uses: For prevention of AIDS (commonly used in
combination with other antiretroviral drugs).
Side effects: Peripheral neuropathy, headache,
insomnia, gastrointestinal upset, fatigue, liver
damage, oral and esophageal ulcer, blood
disorder, rashes, breathlessness, pancreatitis.
ZIDOVUDINE
Type: Antiretroviral NRTI.
Uses: Mainly used to prevent maternal-fetal HIV
transmission.
Side effects: Peripheral neuropathy, headache,
insomnia, gastrointestinal upset, fatigue, liver
damage, oral and esophageal ulcer, blood dis-
order, rashes, breathlessness, pancreatitis, itching,
chest pain, taste disturbance, anemia, increase
frequency of urine, influenza like symptoms.
PHARMACOLOGY
33
LIST OF PHARMACOLOGY ABBREVIATIONS CHAPTER
Abbreviation
ac
Meaning
Before bed
1
ad lib As desired
bd Twice daily
cap Capsule
IM Intramuscular
IV Intravenous
LA Local anesthetic
liq Liquid
OC Oral contraceptive
od Once daily
om In the morning
on At night
opv Oral poliomyelitis vaccine
ORS Oral rehydration salt
ORT Oral rehydration therapy
pc After food
prn When required
qid Four times a day
qqh Every four hours
si Sublingual
sos As required
stat Immediately
susp Suspension
syr Syrup
tab Tablet
tds Three times a day.
ELECTROTHERAPY
35
2
CHAPTER
CHAPTER 2
Electrotherapy
• Principles of electrotherapy application
• Interferential
• Short wave diathermy
• Ultraviolet radiations
• Laser therapy
• Ultrasound
• Transcutaneous electrical nerve stimulation
(TENS)
• Iontophoresis
• Infrared radiation
• Paraffin wax bath
• Neuromuscular electrical stimulation (NMES)
• Microwave diathermy
• Cryotherapy (Cold therapy)
• Hot packs/Electric heating pads
• Whirlpool bath
36
CHAPTER • Contrast bath
2 •
•
Sauna bath
Electromyographic biofeedback
• Fluidotherapy
• Intermittent pneumatic compression
• Continuous passive motion
• Traction
• Strength duration curve
• Motor points
ELECTROTHERAPY
37
PRINCIPLES OF ELECTROTHERAPY CHAPTER
2
APPLICATION
RECEIVING THE PATIENT
• Good morning sir/madam.
• Please be seated (Please take your seat).
• I am your therapist who is going to treat you.
• Do not worry; I will do my best for you.
CASESHEET READING
• Laboratory investigation reports.
• Assessment and diagnosis done by the
physician.
CHECKING GENERAL CONTRAINDICATIONS

• Hyperpyrexia
• Epilepsy
• Severe renal and cardiac problems
• Cardiac pacemakers
• Severe hypotension and hypertension
• Infections
• Pregnant women
• Metal implants
• Mentally retarded patients
• Mentally upset patients
• Malignancy
• Eyes.
38
CHAPTER ANTERIOR ASPECT OF NECK AND
2
CAROTID SINUS
Tray Preparation
Patient Tray or Skin Resistance Lowering Tray and
Skin Sensation Testing Tray
• Pillow
• Cotton
• Soap
• Towel
• Macintosh
• Kidney tray
• Petroleum jelly or vaseline
• Test tubes (hot and cold)
• U-pin (sharp and blunt)
• Clips
• Bowel of water
• IR lamp
• Hot and cold packs.
Treatment Tray
• Pillow
• Towel
• Bedsheet
• Cotton
• Adhesive tapes
• Straps
• Salt
• Powder
• Scissor
• Inch tape
ELECTROTHERAPY
39
• Paper CHAPTER
2
• Graph paper
• Pencil
• Eraser
• Scale
• Goggles
• Machine and accessories
• Sand bags
• Crepe bandages.
Checking Local Contraindications
• Open wounds
• Scars
• Local skin infections
• Cuts
• Abrasions
• Eczema
• Localized hemorrhagic spots
• Skin sensitivity (testing).
Apparatus Preparation
• The apparatus and accessories needed should
be assembled and suitably positioned.
• Visually check the electrodes, leads, cables,
plugs, power outlets, switches, controls, dials,
and indicator lights for cracks and breaks.
Apparatus Checking
• Check the apparatus in front of the patient.
• Demonstrate the treatment to the patient.
• Give an explanation of the treatment to the
patient.
40
CHAPTER • Explained about the type of sensation, which
2
will be experienced by the patient.
POSITIONING THE PATIENT

• The position of the part to be treated should
be completely relaxed.
• Patient should be made comfortable by using
maximum number of pillows and sand bags
for the support.
• Position of the patient should be such that all
the joints of the body are completely relaxed.
• If possible give the position in which patient
can see the treatment.
• Uncover the part to be treated.
• Use pillows, macintosh, and towel for
supporting and whipping off the water.
• Make use of soap and possible hot water as
it will make the skin surface warm.
PLACEMENT OF ELECTRODES
• Place electrodes properly.
• Use adhesive tapes or straps for placing the
electrodes.
• Apply electrode gel evenly on entire electrode.
• Maintain good contact between the skin and
the electrode.
• Tie the electrodes with even pressure.
• Wires or leads should not cross each other
during the treatment.
Again check all the connections.
ELECTROTHERAPY
41
INSTRUCTIONS AND WARNINGS CHAPTER
Instructions
• Do not move during the treatment.
2
• Do not sleep while the treatment is going on.
• Do not touch the cables, apparatus, therapist,
and any other metal nearby you.
Warnings
• As there are chances of getting a blister due
to excessive current or overheating, so please
inform me if the current is not comfortable or
heating is more.
• If there is any burning sensation, immediately
inform me, as it might lead to burn.
• Inform me, if the position is not comfortable.
TREATMENT
• Explain the examiner about my operations.
• Increase the intensity knob till it is comfortable
for the patient.
• Duration of the treatment is decided on the
basis of the condition.
• The patient must be observed throughout to
ensure that treatment is progressing satisfac-
torily and without adverse effects.
TERMINATION OF TREATMENT
• Switch off the machine and the main supply.
42
CHAPTER • Inspect the treated part for any adverse
2
reactions.
• If there is any mild erythema, apply powder.
• If it is too severe, advise him/her to go to the
physician.
• An accurate record of all parameters of
treatment including region treated, technique,
dosage, and the resultant effect must be made.
INTERFERENTIAL
INDICATIONS
• Arthritis
• Neuritis
• Neuralgia
• Muscle sprain
• Muscle weakness
• Sports injury
• Circulatory disorders
• Rheumatism
• Stress incontinence
• Contractures
• Gynecological conditions
• Migraine
• Asthma
CONTRAINDICATIONS
• Cardiac diseases
• Hemorrhage
ELECTROTHERAPY
43
• Pregnant uterus CHAPTER
2
• Artificial pacemakers
• During menstruation over the abdomen only
• Dermatological conditions
• Febrile conditions.
SKIN SENSATION TEST

Pin-prick test.
PRESCRIPTION WRITING
• Electrode type—Small/medium/large
• Site of application
• Type of current—Dipole/isoplaner vector
filed
• Frequency
• Base frequency
• Spectrum
• Spectrum mode—Rectangular/triangular/
trapezoidal
• Treatment time
• Intensity
• Sessions
• Specific precautions
• Remarks.
SHORT WAVE DIATHERMY

INDICATIONS
• Gynecology—Pelvic endometriosis
44
CHAPTER • Traumatology—Sprains, muscular pain
2
• Rheumatology—Neuralgia, inflammatory
pain, arthritis
• Respiratory—Asthma, emphysema
• Neurology—Anti spasmodic action
• Others—Reynaud’s diseases, visceral pain,
automatic dystonia
• Abscesses
• Carbuncles.
CONTRAINDICATIONS
• Metal implants
• Pacemaker
• Deep X-ray therapy recently
• Circulatory deficiency
• Pregnancy and menstruation
• Local or general infection’s
• Diminished thermal sensation
• Deep vein thrombosis
• Severe swellings
• Acute traumatic or inflammatory lesions
• Malignancy.
SKIN SENSATION TEST

Hot and cold.
• Patient position
ELECTROTHERAPY
45
• Electrode type—Pad/disc/wire coil CHAPTER
2
• Electrode placement—Coplanar/contro-
planar/crossfire
• Spacing—Medium/narrow
• Dosage:
Acute - Subthermal
Subacute - Mild thermal
Chronic - Thermal
• Duration:
Acute - 10-15 min
Subacute - 15-20 min
Chronic - 20-30 min
• Session
• Supplementary therapy
• Remarks.
ULTRAVIOLET RADIATIONS
INDICATIONS
• Wounds
• Acne vulgaris
• Alopecia
• Pressure sores
• Rickets
• Counter irritation
• Psoriasis
• Vitiligo
• Psychological benefits.
46
CHAPTER CONTRAINDICATIONS
2 •
•
•
Deep X-ray or cobalt therapy
Recent skin grafting
Hypersensitivity to sun rays
• Arteriosclerosis
• Cardiac, hepatic or renal failure
• Diabetes
• Hyperthyroidism
• Febrile disorders.
SKIN SENSATION TEST

Hot and cold.
• Patients position
• Spectrum
• Distance
• Dosage
}
Base
Wall For infected ulcers
Floor
• Focusing point
• Duration
• Session
• Remarks.
ELECTROTHERAPY
47
LASER THERAPY CHAPTER
INDICATIONS
• Wounds
2
• Tensile strength of scar tissues pain
• Musculoskeletal conditions (tendonitis/
bursitis)
• Fractures (for healing).
CONTRAINDICATIONS
• Cardiac conditions
• Pregnancy
• Over the eye
• Hemorrhage
• Cancers
• Photosensitized patients.
SKIN SENSATION TEST

Hot and cold.
• Therapist position
• Dosage
• Duration
• Session
• Remarks.
48
CHAPTER ULTRASOUND
2 INDICATIONS
• Bursitis
• Capsulitis
• Tendinitis
• Epicondylitis
• Ankylosing spondylitis
• Scar tissue
• Hematoma
• Keloid tissue
• Joint stiffness
• Dupuytren’s contracture
• Plantar fasciitis
• Chronic indurate edema
• Myalgia
• Herpes-zoster
• Brachial neuritis, lumbago, sciatica intercostals
neuritis (for reduction of pain), varicose ulcers
and pressure sores
• Plantar warts.
CONTRAINDICATIONS
• Thrombophlebitis
• Hemorrhage
• Ischemic tissue
• Pregnant uterus
• Malignancy
• Anesthetic area
ELECTROTHERAPY
49
• All intratissue prosthetic and metallic CHAPTER
2
substances
• Recent grafts
• Defective skin sensation
• Deep X-ray therapy
• Acute infection
• Over cardiac area (in advanced cardiac
diseases).
SKIN SENSATION TEST

Hot and cold.
• Mode
• Method—Direct/water bag/under water
bath
• Duration
• Intensity
• Pulsed ratio
• Attenuation
• Field
• Coupling media: Water/oil/liquid paraffin/
aqua sonic gel
• Size of head
• frequency
• Phonophoretic agent (if used)
• Session
50
CHAPTER • Specific precautions
2
• Remarks.
TRANSCUTANEOUS ELECTRICAL NERVE

STIMULATION (TENS)
INDICATIONS
• Postsurgical pain
• Obstetric pain
• Phantom limb pain
• Sciatic pain
• Periarthritic pain
• Reflex sympathetic dystrophy
• Low backache
• Pain due to scoot tissue
• Cervical spondylosis (with neurological
involvement).
CONTRAINDICATIONS
• First trimester of pregnancy
• Hemorrhagic conditions
• Open wounds
• Over carotid sinus, mouth and near eyes
• Epilepsy.
SKIN SENSATION TEST

Pin-prick test.
ELECTROTHERAPY
51
PRESCRIPTION WRITING CHAPTER
•
•
•
Type—High/low
Frequency
Pulse width
2
• Intensity
• Duration
• Session
• Remarks.
IONTOPHORESIS
INDICATIONS
• Inflammation
• Calcific tendonitis
• Myositis ossification
• Soft tissue adhesions
• Soft tissue pain and inflammation
• Muscle and joint pain
• Edema
• Skeletal muscle spasm
• Skin ulcers
• Hyperhidrosis.
CONTRAINDICATIONS
• Uncontrolled hypertension
• Pregnancy
52
CHAPTER • Osteoporosis
2
• Epilepsy
• Cancer
• Over the pharyngeal area.
SKIN SENSATION TEST

Pin-prick test.
• Drug/solutions
• Type of electrode—Small/medium/large
• Electrode placement
• Intensity
• Duration
• Session
• Remarks.
INFRARED RADIATION
INDICATIONS
• Pain relief
• Muscle relaxation
• Edema
• Elimination of waste products
• Superficial wounds.
ELECTROTHERAPY
53
CONTRAINDICATIONS CHAPTER
•
•
•
Vascular insufficiency
Arterial diseases
Hemorrhage
2
• Anesthetic area
• Pregnancy and during menstruation
• Skin diseases, e.g. psoriasis, eczema
• Thermal hypothesia
• Deep X-rays therapy.
SKIN SENSATION TEST

Hot and cold.
• Apparatus type—Luminous/Nonluminous
• Generator type—Lamp/tunnel bath
• Distance
• Focus point
• Wave-length
• Frequency
• Duration
• Session
• Remarks.
PARAFFIN WAX BATH

INDICATIONS
• Joint stiffness
54
CHAPTER • Osteoarthritis
2
• Adhesions
• Scars
• Rheumatoid arthritis.
CONTRAINDICATIONS
• Skin rashes
• Allergic conditions
• Open wounds
• Diminished skin sensation
• Defective arterial supply
• Open suture
• After taking analgesic drugs
• After application of liniments.
SKIN SENSATION TEST

Hot and cold.
• Temperature
• Method—Pouring/brushing/dipping/
bandaging
• Duration
• Session
• Remarks.
ELECTROTHERAPY
55
NEUROMUSCULAR ELECTRICAL CHAPTER
2
STIMULATION (NMES)
INDICATIONS
• Foot drop
• Bell’s palsy
• Paraplegia
• Hemiplegia
• Quadriplegia
• Radial nerve injury (wrist drop)
• Median nerve injury (claw hand)
• Erb’s paralysis
• Deltoid and quadriceps inhibition.
CONTRAINDICATIONS
• Sensory deficit
• Hypertension
• Open wounds
• Pacemakers
• Malignant tissue
• Epilepsy
• Hyperpyrexia
• Active tissue infections
• Deep X-rays therapy
• Peripheral vascular disease
• Over the excessive adipose tissue
• Mentally retarded.
SKIN SENSATION TEST

Pin-prick test
56
CHAPTER PRESCRIPTION WRITING
2 •
•
•
Patients position
Instruction for patients
Site of application
• Current type—Faradic/galvanic/others
• Pulse
• Frequency
• Duration
• Session
• Remarks.
MICROWAVE DIATHERMY
INDICATIONS
• Pain relief
• Trapezius spasm
• Arthritic conditions
• Abscesses
• Carbuncles.
CONTRAINDICATIONS
• Malignancy
• Tuberculosis
• Deep X-ray therapy
• Non-palpable edema
• Hypersensitive areas
• Anesthetic areas
• Psychic patients
ELECTROTHERAPY
57
• Paralytic patients CHAPTER
2
• Recent injury.
SKIN SENSATION TEST

Hot and cold.
• Type of applicator—Small/large circular/
rectangular
• Distance
• Frequency
• Intensity
• Duration
• Session
• Remarks.
CRYOTHERAPY (COLD THERAPY)

INDICATIONS
• Spasticity
• Swelling
• Pain
• Ligament sprain
• Muscle strain.
CONTRAINDICATIONS
• Cryoglobinemia
58
CHAPTER • Peripheral nerve injury
2
• Cardiac diseases
• Vascular diseases
• Cold sensitivity
• Cold urticaria
• Psychic patients.
SKIN SENSATION TEST

Hot and cold.
• Type of application—Ice massage/towels/
immersion/cold packs/evaporative cooling/
excitatory cold/cold gel/cold compression
• Duration
• Session
• Special precautions
• Remarks.
HOT PACKS (HYDROCOLLATOR PACKS)/

ELECTRIC HEATING PADS
INDICATIONS
• Muscle spasm
• Pain
• Joint stiffness.
ELECTROTHERAPY
59
CONTRAINDICATIONS CHAPTER
•
•
•
Impaired skin sensation
Open wounds
Allergic conditions
2
• Hemorrhage
• Impaired circulation.
SKIN SENSATION TEST

Hot and cold.
• Layers of towel
• Types of packs—Small/large/contoured
• Duration
• Session
• Remarks.
WHIRLPOOL BATH
INDICATIONS
• Rheumatic conditions
• Stiffness
• Joint pain
• Fatigue.
60
CHAPTER CONTRAINDICATIONS
2 •
•
•
Skin allergy
Skin infections
Open wounds
• Hemorrhage.
SKIN SENSATION TEST

Hot and cold.
• Temperature
• Duration
• Session
• Remarks.
CONTRAST BATH
INDICATIONS
• Edema
• Circulatory disorders
• Tight amputation stump
• Post-traumatic swelling
• Joint sprains.
CONTRAINDICATIONS
• Skin infections
• Open wounds
ELECTROTHERAPY
61
• Hemorrhage CHAPTER
2
• Skin allergy
• Diabetes.
SKIN SENSATION TEST

Hot and cold.
• Temperature:
– Warm
– Cold
• Timing in:
– Warm
– Cold
• Repetition
• Session
• Remarks.
SAUNA BATH
INDICATIONS
• Weight reduction
• Pain
• Relaxation
• Psoriasis.
CONTRAINDICATIONS
• Psychic conditions
62
CHAPTER • Loss of skin sensations
2
• Dehydration.
SKIN SENSATION TEST

Hot and cold.
• Temperature of hot chamber
• Expanded time in:
– Sweating phase
– Cooling phase
• Pause between two phases
• Duration (total)
• Session
• Remarks.
ELECTROMYOGRAPHIC BIOFEEDBACK
INDICATIONS
• Spinal card injury
• Hemiplegia
• Spasticity
• Dystonic conditions
• Recovering peripheral nerve injury
• Specific muscle activity training
• Balance control
• Weight-bearing control
• Incontinence control
ELECTROTHERAPY
63
• Joint angle control CHAPTER
2
• Practice of movement
• Control of posture
• Functional breathing disorder
• Hypertension
• Epilepsy
• Migraine
• Cardiac arrhythmias
• Raynaud’s disease
• Tension headache.
CONTRAINDICATION
Psychic conditions
SKIN SENSATION TEST

• Hot and cold
• Pin-prick test.
• Type of biofeedback devices—Myoelectrical/
postural/goniometric/force/pressure/oro-
facial control/toilet training/cardiovascular/
stress/temperature
• Treatment duration
• Type of electrode—Surface/needle
• Session
• Remarks.
64
CHAPTER FLUIDOTHERAPY
2 INDICATIONS
• Swelling
• Pain
• Relaxation
• Stiffness
• Muscle spasm.
CONTRAINDICATIONS
• Psychic conditions
• Loss of skin sensations
• Dehydration.
SKIN SENSATION TEST

Hot and cold.
• Area of treatment
• Temperature
• Exercise guidelines inside the unit
• Duration
• Session
• Remarks.
ELECTROTHERAPY
65
INTERMITTENT PNEUMATIC COMPRESSION CHAPTER
INDICATIONS
• Edema
2
• Lymphedema
• Arterial insufficiency
• Wound healing
• DVT
• Stump reduction in amputee limbs
• Venous stasis ulcer.
CONTRAINDICATIONS
• Acute pulmonary edema
• Congestive heart failure
• Recent DVT
• Acute fracture
• Acute skin allergy.
SKIN SENSATION TEST

Pin-prick test.
• Area of treatment
• Pressure
• Inflation time
• Deflation time
• Duration
• Session
66
CHAPTER • Specific precautions
2
• Remarks.
CONTINUOUS PASSIVE MOTION

INDICATIONS
• Decreased joint ROM after any surgical proce-
dure
• Joint stiffness
• Decreased joint ROM after fracture manage-
ment.
CONTRAINDICATIONS
• Large wound
• Excess pain
• Area of treatment—Knee/shoulder/elbow/
ankle
• Movement and range
Shoulder:
Abduction/adduction with synchronized
rotation
Abduction/adduction with fixed rotation
Rotation with fixed abduction/adduction
Flexion/extension
Elbow:
Extension/flexion
ELECTROTHERAPY
67
Extension/flexion with synchronized CHAPTER
2
pronation-supination
Knee:
Flexion/extension
Ankle:
Dorsiflexion/planter flexion
• Duration
• Session
• Remarks.
TRACTION
INDICATIONS
• Radiculopathy
• Tight soft tissues not muscle spasm.
CONTRAINDICATIONS
• Fracture, dislocation or subluxation of the
spine
• Cancer, RA, OA, osteoporosis or infection of
the spine
• Hiatal or abdominal hernia
• Spinal cord compression
• Hypertension
• Aortic aneurysm
• Pregnancy
• Temporomandibular joint pain or dysfunction
• Chronic obstructive pulmonary disease
(COPD).
68
CHAPTER PRESCRIPTION WRITING
2 • Position of the patient

• Position of the spine—Neutral/flexion/
extension
• Method—Mechanical/manual/positional/
gravity/inversion
• Type—Static/intermittent
• Magnitude of force
• Total treatment duration
• Duration of Hold
– Rest (if Intermittent)
• Remarks.
STRENGTH DURATION CURVE

(FIGS 2.1 TO 2.5)
Fig. 2.1: Normally innervated muscle:

In constant current
ELECTROTHERAPY
69
CHAPTER
Fig. 2.2: Normally innervated muscle:

In constant voltage
Fig. 2.3: Complete denervated muscle:

In constant voltage
70
CHAPTER
Fig. 2.4: Complete denervated muscle:

In constant current
Fig. 2.5: Partially denervated muscle

ELECTROTHERAPY
71
MOTOR POINTS (FIGS 2.6 TO 2.11) CHAPTER
Fig. 2.6: Motor points of the muscles supplied by

the facial nerve
Fig. 2.7: Motor points of the back

72
CHAPTER
Fig. 2.8: Motor points of the posterior

aspect of the right arm
ELECTROTHERAPY
73
CHAPTER
Fig. 2.9: Motor points of the anterior

aspect of the right arm
74
CHAPTER
Fig. 2.10: Motor points of the anterior

aspect of the right leg
ELECTROTHERAPY
75
CHAPTER
Fig. 2.11: Motor points of the posterior

aspect of right leg
CARDIORESPIRATORY
77
3
CHAPTER
CHAPTER 3
Cardiorespiratory
• Cardiorespiratory anatomy illustrations
• Surface marking of the lungs
• Respiratory volumes and capacities
• Differences between central and peripheral
cyanosis
• Sputum analysis
• Readings of chest X-ray
• Abnormal ECG findings
• Percussion note
• Auscultation
• Palpation of pulses
• Apgar scoring method
• Postural drainage
• Manual chest clearance technique
78
CHAPTER • Suctioning
3 •
•
Forced expiratory techniques
Tracheostomies
• Aerosol therapy
• Humidity
• Lung function test
• Ambulatory manual breathing unit (AMBU) bag
• Manual hyperinflation
• Cardiorespiratory monitoring
• Ventilations
• Respiratory pathologies
• Normal values
• Blood values and their interfering factors
• Respiratory assessment
• Glossary of cardiorespiratory terms

CARDIORESPIRATORY
79
CARDIORESPIRATORY ANATOMY CHAPTER
ILLUSTRATIONS
3
Fig. 3.1: Surface marking of the fissures and lobes

of the right lung
80
CHAPTER
Fig. 3.2: Lung markings—anterior view
Fig. 3.3: Lung markings—posterior view

CARDIORESPIRATORY
81
CHAPTER
Fig. 3.4: Bronchial tree
Fig. 3.5: Bronchopulmonary segments

(lateral aspect)
82
CHAPTER SURFACE MARKING OF THE LUNGS
3 APEX
• Anteriorly 2.5 cm above the medial 1/3rd of
clavicle.
• Posteriorly 2 cm lateral to C7 spinous process.
ANTERIOR BORDER OF RIGHT LUNG

• Sternoclavicular joint
• Midline in the sternal angle
• Above the xyphoid process in the midline.
INFERIOR BORDER OF RIGHT LUNG

• 6th rib in the midclavicular line
• 8th rib in the midaxillary line
• 10th rib laterally to errecter spinae muscle
• 2 cm lateral to spinous process of T10.
POSTERIOR BORDER OF RIGHT LUNG

• 2 cm lateral to T10 spinous process
• 2 cm lateral to C7 spinous process
ANTERIOR BORDER OF LEFT LUNGS

• Sternoclavicular joint
• Mid point in the sternal angle
• 3 cm from sternal margin in the 4th rib
• 4 cm lateral to midline in the 6th rib.
CARDIORESPIRATORY
83
INFERIOR AND POSTERIOR BORDER OF CHAPTER
3
LEFT LUNG
Same as the right lung
FISSURES
Oblique
• 7.5 cm lateral to midline in 6th rib
• Midaxillary line in 5th rib
• T3 spinous process.
Horizontal
• Costal cartilage 4th rib
• 5th rib, midaxillary line
• T3 spinous process posteriorly.
TRACHEAL BIFURCATION
• Anterior—Manubriosternal junction
• Posterior—T4 vertebra.
DIAPHRAGM
Left
• 6th rib anteriorly
• T10 posteriorly
• 8th rib midaxillary.
84
CHAPTER Right
3 • 5th rib anteriorly

• T9 posteriorly
• 8th rib midaxillary.
RESPIRATORY VOLUMES AND

CAPACITIES (FIG. 3.6)
LUNG VOLUMES
Tidal Volume (TV)

Volume of the air moved into or out of the lungs
during quiet breathing at rest.
Value—500 ml (0.5 liter).
Inspiratory Reserve Volume (IRV)

Maximum amount of air that can be inspired on
top of a normal tidal inspiration.
Value—3300 ml (3.3 liter).
Expiratory Reserve Volume (ERV)

Maximum amount of air that can be exhaled
following a normal tidal expiration.
Value—1000 ml (1 liter)
CARDIORESPIRATORY
85
Residual Volume (RV) CHAPTER
Volume of air remaining in the lungs after a
maximum expiration. 3
Value—1200 ml (1.2 liter)
Minimal Volume (MV)

The amount of air that would remain when the
lungs collapsed.
Value—30-120 ml.
Fig. 3.6: Lung volumes and capacities
LUNG CAPACITIES
It is the combination of two or more lung volumes.
86
CHAPTER Total Lung Capacity (TLC)
3 Total volume of air in the lungs after a maximal

inspiration.
TLC = VT + IRV + ERV + RV
Value—6000 ml
Vital Capacity (VC)

Maximum volume of air that can be expired after
a maximum inspiration.
VC = VT + IRV + ERV
Value—4500 ml
Inspiratory Capacity (IC)

Maximum volume of air that can be inspired from
the end point of quiet expiration at rest.
IC = VT + IRV
Value—3500 ml
Functional Residual Capacity (FRC)

Volume of the air remaining in the lungs at the
end of quiet expiration at rest.
FRC = ERV + RV
Value—2500 ml
Note: The values for the average female adult are
25% less.
CARDIORESPIRATORY
87
DIFFERENCES BETWEEN CENTRAL AND CHAPTER
3
PERIPHERAL CYANOSIS
Central Peripheral
Mechanism Diminished arterial Diminished flow of
oxygen saturation blood to the local part
Sites On skin and On skin only
mucous membranes,
e.g. tongue, lips,
cheeks, etc.
Clubbing and Usually associated Not associated
polycythemia
Temperature Warm Cold
of the limb
Local heat Cyanosis remains Cyanosis abolished
Breathing Cyanosis Cyanosis persists
pure oxygen decreased
SPUTUM ANALYSIS
Characteristic Associated features Interpretation

Saliva Clear, watery fluid Normal
Mucoid Clear and sticky Bronchial asthma,
Chronic bronchitis
Purulent Thick viscous
– Yellow Haemophilus,
– Dark green/brown Pseudomonas,
– Rusty Pneumococcus,
– Redcurrant jelly Mycoplasma,
Klebsiella
Mucopurulent Initially the sputum Bronchiectasis,
is mucoid and later Cystic fibrosis,
slightly discolored Lung abscess
88
CHAPTER Characteristic Associated features Interpretation
3 Foul smelling
and copious
Hemoptysis
Long standing
lung diseases
Old blood
Bronchiectasis
Infection or chest
trauma
Cardiac disease
Black Black specks in Smoke inhalation
mucoid secretions
Frothy Pink or white Pulmonary edema,
Heart failure
Sputum examination is noted in the terms of:

• Quantity
• Viscosity
• Color
• Odor
• Frequency
• Time of day
• Ease of expectoration.
READINGS OF CHEST X-RAYS

(FIGS 3.7A AND B)
DEFINITION
The X-rays are a form of invisible electromagnetic
radiation that can penetrate the body and produce
an image on an X-ray film.
INDICATIONS
• Any type of sign and symptoms, which are
related to respiratory or cardiovascular
diseases.
CARDIORESPIRATORY
89
CHAPTER
Figs 3.7A and B: (A) Normal PA chest X-ray,

(B) Structures normally visible on X-rays
90
CHAPTER • To identify the tumors.
3
• Preoperative evaluation of patient’s for
intrathoracic surgery.
• Follow-up and monitoring of patient’s with
life support devices.
• To detect the trauma to the rib cage or lungs,
see foreign bodies that may have been
swallowed or inhaled.
VIEW APPEARANCES
Air (In the lungs) - Black
Fat, skin, muscles (Soft tissues) - Gray
Bone - White
DATABASE
Patient’s name, Patient’s identification number,
given by radiologist, date, time, side markings L
or R (L = Left, R = Right).
CHECKLIST
• Skeletal frame, mainly rib’s, clavicle, scapulae,
costochondral junctions, vertebral column
• Lung field, fissures
• Lungs hilli
• Heart shadow
• Mediastinum
• Trachea and bronchial air shadow
• Costophrenic and cardiophrenic angles
• Domes of both the diaphragms and the space
beneath them
• Soft tissue shadows (especially breast shadows
in women).
CARDIORESPIRATORY
91
VIEWS CHAPTER
Posteroanterior (PA)
It means that the X-rays have entered the chest 3
from the posterior chest wall. The X-rays should
be ideally viewed from a distance of three to four
feet.
Anteroposterior (AP)
Anteroposterior view is generally taken, when the
clavicles are projected above the ribs and heart
appear enlarged. AP views are taken with the
patient erect but in ICU and casualty generally
taken with supine position.
Lateral
Lateral view helps to easily indentify smaller
lesions. The main problem in this view is posi-
tioning the arms out of the X-rays field.
Lateral Decubitus
Lateral decubitus view may help to identify the
free fluid or air in the pleural cavity.
Apicogram or Lardotic
It is useful to demonstrate the calcifications,
nodules azygos lobe and middle lobe collapse.
Expiratory Film
The view is taken during expiration. By the help
of this view pulmonary hydatid cyst. Azygos vein
and vascular lesions are easily demonstrated.
92
CHAPTER Trendelenburg
3 The view is taken with Trendelenburg position.

It is mainly help to demonstrate the movement
of the fungal ball in cavity.
Oblique
It is most often used to demonstrate the ribs,
assess the heart and aorta.
NORMAL CHARACTERISTICS OF
A CHEST X-RAY—PA VIEW
• No skeletal abnormalities.
• Posterior portions of the ribs should be
horizontally and the anterior portions should
be oblique.
• Trachea lies centrally and vertically.
• The left hilum should be at a higher level than
the right.
• The right dome of diaphragm is about 2 cm
higher than the left, because the right lobe of
liver is situated directly underneath.
• The diameter of heart is usually less than half
the total diameter of the thorax.
• Both lung fields should be equally translucent
and should not have any other shadows.
Costophrenic angle: It is a angle where the dia-
phragms meets the ribs.
Cardiophrenic angle: It is a angle where the dia-
phragm meets the heart.
CARDIORESPIRATORY
93
Silhouette sign: Border of the adjacent organ will CHAPTER
3
be blurred, if there is any lesion contiguous with
the organ.
COMMON ABNORMALITIES IN X-RAYS

Lobar collapse—Homogeneous opacity
Consolidation—Patchy opacity
Pleural effusion—Dense opacity
Pneumothorax—No lung marking is present
Lung abscess—Rounded opacity
Pulmonary tuberculosis—Soft confluent shadow
calcification
Bronchiectasis—Multiple ring shadows.
ABNORMAL ECG FINDINGS

Left atrial — Wide, notched P wave
enlargement (lead II)
Right atrial — Tall P wave (lead II)
enlargement
Ventricular — Wide QRS, ST
hypertrophy depression
Atrial tachycardia — Abnormally shaped P
waves
Atrial flutter — P wave replaced by
saw-tooth baseline
Atrial fibrillation — No P waves visible
Sinoatrial block — P wave fails
Atrioventricular — Prolongation of PR
block interval
94
CHAPTER Bundle branch block — QRS interval abnormal,
3
ST segment depressed,
T wave inverted
Myocardial infarction — ST segment elevated,
(MI) T wave inverted
Mitral valve disease — Bifid, broad P waves
Myocardial ischemia — ST segment depressed
(Posterior MI)
Hyperkalemia, — Tall T waves
acute MI
Hypokalemia, — Small T waves
hypothyroidism,
pericardial effusion
Pericardial effusion — Small QRS complex
Wolf-Parkinson-
White (WPW) — Short PR intervals, less
syndrome than 0.12 sec.
PERCUSSION NOTE
Evaluation technique designed to assess the lung
density, specifically the air to solid ratio in the
lungs.
TECHNIQUE
The middle finger of the left hand (pleximeter
finger) is placed in close contact with the chest
wall in the intercostals space, a firm sharp tap is
then made by the middle finger of the right hand
(plexor finger), kept at right angle to the
CARDIORESPIRATORY
95
pleximeter finger. All areas of the chest are CHAPTER
3
percussed (front, back, and both axillae).
The pitch of the note is determined by whether
the lungs contain air, solid or fluid and will either
sound normal or abnormal.
Abnormalities Conditions
Impaired note Decreasing amount of air in alveoli
(consolidation, collapse, fibrosis)
Dull note Consolidated lung area or area
of collapse
Strong dull note Pleural effusion
Tympanic note Pneumothorax, emphysema
Skodaic resonance Empty cavity and pleural effusion
(boxy note)
Hyper-resonance Pneumothorax, large cavity bullae
formation, chronic bronchitis,
congenital lung cyst
BELL TYMPANY
Metallic type of sound heard in case of massive
pneumothorax. Coin is placed on one side of chest
and percussed with another coin. Bell-like sound
is heard on opposite side of chest through a
stethoscope or ear.
AUSCULTATION
Stethoscope is used to determine the quality,
character and intensity of breath sounds, vocal
resonance and adventitious sound (Fig. 3.8).
96
CHAPTER
Fig. 3.8: Stethoscope position
BREATH SOUNDS
More prominent at the top of the lungs and
centrally, with the volume decreasing towards the
bases and periphery. The stethoscope diaphragm
is placed near the root of the neck. Two lungs
sounds are heard:
1. On inspiration: A window through stress sound
heard.
2. On expiration: Low pitched sound. There is no
pause between the two and they are rustling
in quality. It is also called as vesicular breath
sound.
CARDIORESPIRATORY
97
CHAPTER
Fig. 3.9: Location of normal breath sounds
ABNORMAL BREATH SOUNDS (FIG. 3.9)
Causes
1. Abnormal generation—Abnormality in larger
airways.
2. Abnormal transmission—Abnormality at the
level of alveoli.
There are two types of abnormal breath
sounds:
1. Tracheal breath sound heard over lung tissue
areas (also called as bronchial breathing).
Sound is heard in patients with cavity, consoli-
dation, pleural effusion, partial collapse of
lungs and open pneumothorax.
98
CHAPTER 2. Absence of lung tissue sounds, occurs when
3
transmission of sounds is impeded (e.g. in
pneumothorax, lung tissue collapse, pleural
effusion, asthma).
VOCAL RESONANCE
These are the sound heard through the stetho-
scope, when the patients is asked to say “99” or
“aah.”
Normal
The sound can be clearly heard, over the trachea
and are muffled and softer over lung tissue.
Abnormal
Bronchophony—”99" can be clearly heard over
lung tissue.
Whispering pectoriloquy: The whispered “99” can
be heard over lung tissue.
Both of these are due to consolidation.
ADVENTITIOUS SOUNDS
Rhonchi or Wheezes
These sound are either high or low pitched and
monophonic (single notes) or polyphonic (where
several airways may be obstructed).
These sound indicate obstruction or narrowing
airways. These sounds is usually indicative of
CARDIORESPIRATORY
99
bronchial asthma, chronic bronchitis, lung CHAPTER
3
tumors, COPDs, cardiac failure, etc.
Crepitation or Crackles
Heard when airways that have been narrowed or
closed, are suddenly forced open on inspiration.
This sound can help to determine the site of
abnormally as follows:
1. Start of inspiration—Large airways
2. Mid inspiration—Medium smaller airways
3. End of inspiration—Small airways and lung
tissue.
Crackles are indicative of bronchitis. Left heart
failure, pneumonia, lung abscess, bronchiectasis,
pulmonary edema, pulmonary fibrosis and other
obstructive respiratory diseases.
Pleural Rub
It is due to roughening of the pleural surfaces as
in pleurisy. Pleural surfaces rub together and
creating a cracking or grating sound.
Stridor
Loud sound, heard during inspiration due to
obstruction of the respiratory track. It indicates a
serious condition. Laryngeal stridor is a high
pitched sound heard over the larynx due to laryn-
geal obstruction, with foreign body, diphtheria, etc.
whereas tracheal stridor is a low pitched sound
heard over the trachea due to trached obstruction.
100
CHAPTER PALPATION OF PULSES
3 Pulse is palpated under following headings:

Rate
Rhythm
Volume
Force
Tension (pulsus mollis/pulsus durus)
Contour (rise/summit/fall)
Equality
Condition of arterial wall (hard/muscular/
tube like)
Any abnormal character.
COMMON LOCATIONS
Radial: Slightly medical to the styloid process.
Brachial: Cubital fossa.
Carotid: Upper end of the thyroid cartilage along
the medial border of the sternomastoid muscles.
Femoral: Groin region.
Popliteal: Popliteal fossa.
Posterior tibial: Groove between the medial
malleolus and tendo Achilles.
Dorsalis pedis: Lateral to the extensor hallucis
tendon.
Axillary: Groove behind coracobrachialis.
CARDIORESPIRATORY
101
Anterior tibial: Between tibialis anterior and CHAPTER
3
extensor hallucis longus tendon, above the level
of ankle joint.
Temporal: Temple directly in front of ear.
Ulnar: Little finger side of wrist.
APGAR SCORING METHOD
Sign 0 1 2
Heart rate Absent Below100 Over 100
Respiratory effort Absent Weak cry Strong cry
Muscle tone Limp Flexion of Active
extremities movements
Reflex irritability No Grimace Cry
response
Color Blue Pink Completely
pink
SCORE
Under seven—Resuscitation require.
Seven or over—Normal
Between five and seven—Clearing airway and O2
therapy require.
POSTURAL DRAINAGE
Positioning the patient to allow gravity to assist
the drainage of the secretions from specific areas
of lungs (Figs 3.10 to 3.20).
102
CHAPTER
Fig. 3.10: Apical segments of both upper

lobes—sitting upright
Fig. 3.11: Posterior segment of right upper lobe—

left side lying, towards 45° turned prone
Fig. 3.12: Posterior segment of the left upper lobe—

right side lying turned 45° towards prone, shoulder
raised 30 cm
CARDIORESPIRATORY
103
CHAPTER
3
Fig. 3.13: Anterior segments of both upper lobes—
supine position
Fig. 3.14: Lateral and medial segments of middle

lobe—supine, quarter turned to left. Foot end of bed
raised 35 cm
Fig. 3.15: Superior and inferior segments of the lingual

lobe—supine, quarter turned to right. Foot end of bed
raised 35 cm
104
CHAPTER
3
Fig. 3.16: Apical segments of both lower lobes—
prone, head turned to side
Fig. 3.17: Anterior basal segments of both lower

lobes—supine, foot end of bed raised 46 cm
Fig. 3.18: Posterior segments of both lower lobes—

prone, head turned to side, foot end of bed raised
46 cm
CARDIORESPIRATORY
105
CHAPTER
3
Fig. 3.19: Lateral basal segment of the left lower lobe
and the medial basal segment of the right lower lobe—
right side lying, foot end of bed raised 46 cm
Fig. 3.20: Lateral basal segment of the right lower

lobe—left side lying, foot end of bed raised 46 cm
ALTERNATIVE METHOD OF POSTURAL DRAINAGE

(FIGS 3.21 TO 3.23)
Fig. 3.21: Postural drainage over towels

106
CHAPTER
Fig. 3.22: Postural drainage over chair
Fig. 3.23: Postural drainage over foam wedge
CONTRAINDICATIONS
• Head injuries including cerebral vascular
accidents
• Hypertension
• Hemoptysis
• Aortic aneurysms
CARDIORESPIRATORY
107
• Pulmonary edema CHAPTER
3
• Surgical emphysemas
• Tension pneumothorax
• Eye operations
• Facial burns
• Filling cycle of peritoneal dialysis
• Hiatus hernia
• Cardiac arrhythmias
• Pregnancy.
Note: In recent neurosurgery, head down posi-
tioning may cause increased intracranial pressure;
if PD is required modified positions can be used.
MANUAL CHEST CLEARANCE TECHNIQUE

Percussion, vibration and shaking along with
postural drainage are called manual chest
clearance technique.
AIM
• To mechanically loosen the secretions
• To improve the distribution of ventilations
• To assist the movement of secretions in larger
airways.
PERCUSSION RATE
• 100-460 times/min manually
• Force: 58-65 N
108
CHAPTER MODIFICATIONS OF TECHNIQUES FOR
3
PEDIATRICS PATIENTS
In spite of hand percussion, we may use:
• Bell of stethoscope
• Facemask for babies
• Small medicine cup (30 ml)
• Tenting finger.
PRECAUTIONS
• Rib fracture
• Burns
• Pain
• Surgical emphysema
• Flail chest
• Hemoptysis
• Pulmonary embolism
• Acute infections
• Metastatic conditions
• Unstable cardiovascular conditions
• Recent skin graft or flap
• Severe clotting disorder.
SUCTIONING
The removal of bronchial secretions through a
suction catheter is called suctioning.
INDICATIONS
• Very sick spontaneously breathing patient
• Patient unwilling to cough voluntarily
CARDIORESPIRATORY
109
• Patient who have no cough reflex CHAPTER
3
• All intubated patients.
CONTRAINDICATIONS
• Pulmonary edema
• Stridor
• CSF leakage
• Bronchospasm.
MODES OF ENTRY
• Nose (nasopharyngeal)
• Mouth (oropharyngeal)
• Via tracheostomy
• Via endotracheal tube.
PRECAUTIONS
• Lung transplant
• Pneumonectomy
• Recent esophagectomy
• Clotting disorders.
HAZARDS
• Infections
• Mucosal trauma
• Hypoxia
• Atelectasis
• Pneumothorax
• Bronchospasm
110
CHAPTER • Raised ICP
3
• Cardiac arrhythmias.
FORCED EXPIRATORY TECHNIQUES

It consists of one or two huffs from midlung
volume to low lung volume followed by a period
of relaxed diaphragmatic breathing.
INDICATIONS
• Cystic fibrosis
• Chronic lung diseases
• After surgery (sometimes).
TRACHEOSTOMIES
It is an operation performed on the anterior wall
of trachea to facilitate ventilation. Surgery is
performed at the level of 2nd and 3rd or 3rd and
4th tracheal rings done under general anesthesia
in which a horizontal incision is made in neck.
FUNCTIONS
• Increase alveolar ventilation
• Provide alternate pathway for breathing
• Protection of the airway from oral and gastric
secretions.
INDICATIONS
• Respiratory obstruction
• Respiratory insufficiency
• Retained secretion.
CARDIORESPIRATORY
111
CONTRAINDICATION CHAPTER
Anaplastic carcinoma thyroid.
TYPES OF TRACHEOSTOMY
3
• Emergency—To save the life of patient
• Permanent—When lesion of upper airway or
esophagus.
Types of Tube
1. Metal or plastic
2. Cuffed or uncuffed
3. Single or double lumen.
Complications
• Tracheal irritation, necrosis, ulceration
• Hemorrhage
• Pneumothorax
• Secretions occluding tube
• Tracheoesophageal fistula
• Infection of tracheostomy site
• Stenosis of trachea.
Advice at Discharge
Tracheostomy done after laryngectomy is
permanent. Patient should learn to use metal
tracheostomy, cleaning the tubes, etc.
112
CHAPTER AEROSOL THERAPY
3 Actual particulate matter suspended in a gas is

called as aerosol. It act as a liquifire and mobilizer
of pulmonary secretions in the respiratory tract.
Only 0.15 to 0.25 μ particle shows the greater
deposition in the alveoli.
The device that produces an aerosol is known
as nebulizer.
TYPES OF NEBULIZER
Pneumatic Jet
Consist of a water reservoir and a capillary tube
submerged into water. A high velocity gas flow
is introduced into the system, which cause the
water from the reservoir to advance upward
through the tube. This creates fine mist of particles
which are inturn move into the baffle. Aerosol
particles hit the baffle and are broken down into
smaller particle. It produces 3-5 μ size of particles.
Ultrasonic
Electrical energy is converted by a piezo-electric
transducer to mechanical or vibrational energy
with an ultra-high frequency of 1.35 mega cycle
per second. The nebulizer chamber receive
vibrational energy and aerosol effect is created.
The nebulus is then transmitted via the buffle to
the patients 0.5 to 3 μ sizes of particles is
generated.
CARDIORESPIRATORY
113
PATIENT’S POSITION CHAPTER
Sitting or half lying.
USES
3
It is mainly used in delivery of drugs specially
bronchodilator.
HAZARDS
Bronchospasm, shortness of breath because of
swelling of secretions, cross contamination.
HUMIDITY
Adequate humidity is necessary for proper
respiratory function. The device which deliver a
maximum amount of water vapour to respiratory
that is called humidifier.
INDICATIONS
• Ventilated
• Intubated
• Receiving supplemental oxygen
• Newborn babies
• Patient’s with severe chest injury
• COPD, asthma, pneumonia, atelectasis
• Thermal respiratory burns.
METHODS
• Systemic hydration—By oral or intravenous
• Water bath
114
CHAPTER • Nebulizers
3
• Instillation/infusion
• Heat and moisture exchangers/condensors.
HAZARDS
• Bronchoconstriction
• Infections.
LUNG FUNCTION TEST

USES
Understand clearly the type of functional
disorder:
• To measure progression or regression
• To decide on feasibility of thoracic operation
• To access the degree of respiratory failure.
TESTS
a. Airways function test: All volumes and
capacities are assessed by spirometry.
b. Blood gas analysis: PaO2 and PaCO2 is assessed
by blood gas analyzer.
c. Blood acid/alkaline reaction
Normal pH—7.4
pH— a low pH (< 7.4 )—acidosis
a high pH (> 7.4 )—alkalosis.
d. Exercise tolerance test: During these test minute
ventilation and oxygen consumption are
measured.
CARDIORESPIRATORY
115
In Field CHAPTER
Test
• 12 minutes, 6 minutes, 2 minutes, walk test
• Endurance walking test
3
• Step test
• Shuttle test.
In Laboratory
• Treadmill
• Cycle ergometer.
TEST PROTOCOLS
• Bruce
• Modified bruce or Sheffield
• Cornell
• Balkeware
• ACIP and MACIP
• Naughton
• Ware
• Modified Sheffield
• Northwick park.
AMBULATORY MANUAL BREATHING UNIT

(AMBU) BAG
This is the apparatus used for mouth to mouth
respiration, by the help of face mask, endo-
tracheal tube or tracheostomy, the air is driven
into the patient’s lung by squeezing the bag.
When the pressure is released a self-restoring
116
CHAPTER foam rubber insert causes the bag to inflate
3
automatically. The chest recoil causes air to leave
the lung by an expiratory valve protected by wire
gauze. Bages without this filters are very
dangerous since they allow bits of deteriorated
rubber spong to enter the lungs.
MANUAL HYPERINFLATION
The technique of giving deep breaths manually
to fully expand the lungs of loosen the secretions
increasing the lung compliance of an anesthetic
rebreathing bag is used for it. The maximum peak
airway pressure is 40 cm H2O.
CONTRAINDICATIONS
• Undrained pneumothorax
• Bullae
• Severe bronchospasm (if PAP > 40 cm H2O).
• Acute head injury
• Cardiovascular instability
• Recent pneumonectomy
• Recent lobectomy
• Hemoptysis
• Patient at risk of barotrauma.
ADVERSE EFFECTS
• Barotrauma
• Cardiac arrhythmia
CARDIORESPIRATORY
117
• Reduced oxygen saturation CHAPTER
3
• Reduced respiratory drive
• Raised intracranial pressure
• Bronchospasm
• Hemodynamic variations—Reduced or
increased flow pressure.
CARDIORESPIRATORY MONITORING
ARTERIAL BLOOD PRESSURE (ABP)
It is the lateral pressure exerted by the contained
column of blood on the wall of arteries. ABP is
expressed in different terms.
Systolic pressure: Maximum pressure during
systole of heart, i.e. 20 mm Hg.
Range—110 to 140 mm Hg.
Diastolic pressure: minimum pressure during
diastole of heart, i.e. 80 mm Hg.
Range—60 to 90 mm Hg
Pulse pressure: Difference between systolic and
diastolic pressure, i.e. 40 mm Hg.
Mean arterial pressure: Diastolic blood pressure
plus one-third pulse pressure:
DBP + 1/3 PP, i.e. 93 mm Hg.
CARDIAC OUTPUT
Amount of blood pumped from each ventricles.
CO = Stroke volume × heart rate
118
CHAPTER Normal value = 50 to 6 L/min
3
Average = 5.5 L/min/ventricles.
STROKE VOLUME
The amount of blood pumped out by each
ventricle during each beat.
Normal value = 70 ml (60 to 80 ml).
MINUTE VOLUME
Amount of blood pumped by each ventricle in one
minute.
Normal value = 5-6 L/min.
CARDIAC INDEX
This is the minute volume expressed in relation
to square meter of body surface is called CI.
CI = CO + body surface area.
Normal value = 2.5-4 L/min/m2.
HEART RATE
The number of time the heart contracts in a
minute.
Normal = 50-100 bpm
Tachycardia > 100 bpm at rest
Bradycardia < 50 bpm at rest.
CENTRAL VENOUS PRESSURE

This is the pressure found in the veins emerging
in heart.
Normal value—3-6 mm Hg or 3-15 cm H2O
CARDIORESPIRATORY
119
CEREBRAL PERFUSION PRESSURE (CPP) CHAPTER
Pressure required to ensure adequate blood
supply to the brain.
CPP = MAP-ICP
3
Normal value > 70 mm Hg.
INTRACRANIAL PRESSURE
Pressure exerted by the brain tissue, CSF of blood
volume with in the skull of meninges.
Normal value = 0-10 mm Hg
PULMONARY ARTERY PRESSURE (PAP)

It is measure of pressures of the vena cava, right
atrium and right ventricle.
Normal value = 15-25/8-15 mm Hg.
Mean value = 10-20 mm Hg.
RESPIRATORY RATE
Number of breathes taken in a minute.
Normal value = 12-16 breaths/min
Tachypnea > 20 breaths/min
Bradypnea < 10 breaths/min.
EJECTION FRACTION
It is the ratio of stroke volume (i.e. blood ejected
from left ventricle during systole) to the end
diastolic volume (EDV).
EF = SV/EDV
Normal value = 65-75%.
120
CHAPTER VENTILATIONS
3 SYNCHRONIZED INTERMITTENT MANDATORY

VENTILATION (SIMV)
Mandatory breaths are delivered in synchrony
with the patient’s breathing. The patient may
breath on his own but the mandatory breaths will
be delivered at a time in the ventilatory cycle, that
is convenient for the patient.
INTERMITTENT MANDATORY VENTILATION (IMV)

Breaths are delivered at a respiratory rate and
tidal volume that are determined by adjusting the
ventilator controls, but patient may breath
spontaneously between the mandatory breaths.
CONTINUOUS POSITIVE AIRWAY

PRESSURE (CPAP)
Oxygen is delivered in a positive pressure
throughout inspiration and expiration during
spontaneous breathing. It decreases the work of
breathing, O 2 consumption but increases the
forced respiratory capacity and PaO2.
POSITIVE END EXPIRATORY PRESSURE (PEEP)

PEEP is used when PaO2 is < 200 mm Hg. Gene-
rally PEEP is used in minimum 5 cm water in all
mechanically ventilated patient’s. It prevents the
alveolar collapse and increases the forced
respiratory cycle.
CARDIORESPIRATORY
121
INTERMITTENT POSITIVE PRESSURE CHAPTER
3
BREATHING (IPPB)
It is a mechanical device that augment gas flow.
IPPB maintains positive airway pressure through-
out inspiration with airway pressure returning to
atmospheric pressure during expiration.
Model—Bird mak7, Bennett
Contraindications: Facial fracture, undrained
pneumothorax, lung abscess, head injury,
vomiting.
CONTROLLED MECHANICAL VENTILATION (CMV)

At a preset tidal volume, pressure and flow rate,
CMV delivers a preset number of breaths to the
patient.
BIPHASIC POSITIVE AIRWAY PRESSURE (BiPAP)

BiPAP is a single ventilation mode which permits
spontaneous breathing not only during expiration
but also during mandatory breaths. It reduces
atelectasis, less sedation, higher inspiratory drive
and maintained spontaneous breathing. BiPAP is
most commonly used as a partial ventilatory
support device, to reduce the workload of
breathing in acute exacerbations of COPD. It can
also be used as a step down measure leading up
to weaning of mechanical ventilatory support.
122
CHAPTER HIGH FREQUENCY VENTILATION (HFV)
3 It delivers low tidal volume or equal to anatomical

dead space volume at high respiratory frequencies
varing, between 60 and 300 breaths/minute.
Types
a. High frequency positive 60-110 breaths/min.
pressure ventilation
b. High frequency jet 110-600 breaths/
ventilation (HFJV) min.
c. High frequency 600-3000 breaths/
oscillation (HFO) min.
ASSIST—CONTROL MODE VENTILATION

(A/C MODE)
In this, breathing is initiated by a patient during
ventilatory cycle and ventilator delivers gas at a
preset tidal volume or preset pressure.
PRESSURE CONTROLLED VENTILATION (PCV)

During PCV, all breaths are pressure limited and
time cycled. There is no possibility for patient
triggering.
PRESSURE SUPPORT (PS)

During PS tidal volume, respiratory rate and flow
rate is controlled by patient himself through his
inspiratory efforts.
CARDIORESPIRATORY
123
NONINVASIVE VENTILATION (NIV) CHAPTER
NIV is the ventilatory support used without
intubation through a mask. It is rarely used.
Positive pressure devices are pressure, volume or
3
time controlled. The modes which are used are
pressure support ventilation, control/assist
ventilation, controlled mechanical ventilation,
BiPAP, CPAP and proportional assist ventilation.
RESPIRATORY PATHOLOGIES
ACUTE RESPIRATORY DISTRESS
SYNDROME (ARDS)
Progressive breathlessness and respiratory failure
caused by a variety of acute diffuse lung injuries.
Causes
Shock, burns, severe nonthoracic trauma, septi-
cemia, aspiration, pneumonia, fat embolism,
overdoses of drugs likely to damage pulmonary
circulation.
Clinical Features
Dyspnea, tachypnea, crackles and wheezes
sound, shock, septicemia, renal failure, liver
failure, CNS depression.
ARDS tends to reach its maximum initial
severity over next 24 to 48 hours and may be
rapidly fatal if severe.
124
CHAPTER ATELECTASIS OF LUNG
3 Loss of volume in one or more segments or lobes

of the lungs.
Causes
Bronchial obstruction, carcinoma of bronchus,
aneurysm, enlarged glands.
Clinical Features
Fever, tachycardia, tachypnea, ineffectual cough,
weakness of respiratory muscle.
BRONCHIAL ASTHMA
Increased responsiveness of trachea and bronchi
to various stimuli and manifested by acute,
recurrent or chronic attacks of widespread
bronchial-bronchiolar narrowing.
Types
Extrinsic and intrinsic asthma.
Clinical Features
Cough, wheeze, chest tightness, dyspnea.
These symptoms can range from mild-to-
severe; and may even result in death.
BRONCHIECTASIS
Chronic permanent dilatation of one or more
bronchi, which impairs the drainage of bronchial
CARDIORESPIRATORY
125
secretions and leads to persistent infection in the CHAPTER
3
affected segment or lobe.
Causes
Congenital: Kartagener’s syndrome, cystic fibrosis,
hypogammaglobulinemia with respiratory
infection.
Acquired
• Infections: Measles, whooping cough and
influenza, pneumonia, lung disease, tuber-
culosis, bronchopulmonary aspergillosis
• Obstruction: Foreign body, bronchial stenosis,
bronchial carcinoma.
Types
Saccular: Affects proximal bronchi.
Cylindrical: Affect distal bronchi.
Varicose: Intermediate between saccular and
cylindrical.
Clinical Features
Productive cough, fever with chills, weakness,
lassitude, anorexia, loss of weight, pleuritic pain
and night sweats.
BRONCHITIS
Types
Acute bronchitis: Acute infection of mucous
membrane of trachea and bronchi produced by
viruses, bacteria or external irritants.
126
CHAPTER Chronic bronchitis: Condition associated with
3
mucous production amounting to cough and
expectoration for more than three months in a
year and for two to three years consecutively with
other causes rules out.
Clinical Features
Malaise, fever, palpitation, sweating, productive
cough, wheezing, dyspnea.
Because of irreversible narrowing of the
airway, patient leads to develop dyspnea,
cyanosis, hypoxia, hypercapnia and some times
heart failure. This condition is called blue bloaters.
CHRONIC OBSTRUCTIVE PULMONARY

DISEASE (COPD)
COPD is mainly associated with emphysema and
chronic bronchitis.
Risk factors: Smoking, recurrent infections,
pollution, genetics.
Clinical Features
Chest tightness, cough, dyspnea, excessive mucus
production.
CYSTIC FIBROSIS
A progressive genetic disorder of the mucus—
secreting glands of the lungs. Pancreas, mouth,
gastrointestinal tract and sweat glands.
CARDIORESPIRATORY
127
Clinical Features CHAPTER
Recurrent respiratory infection, poor growth
malnutrition, abnormal heart.
Rhythms, dyspnea, malabsorption.
3
Complications: Vasculitis, liver disease, diabetes
mellitus, infertility.
This is a fatal disease.
EMPHYSEMA
Enlargement of the airspaces distal to the terminal
bronchioles, either from dilatation or destruction
of their walls.
Clinical Features
Dyspnea, productive cough, wheeze, recurrent
respiratory infection, weight loss, hyperinflated
chest.
These patients are often called as pink puffers
who may hyperventilate typically by over-using
their accessory respiratory muscles, and breath
with pursed lips in order to maintain airway
pressure to decrease the amount of airway
collapse.
EMPYEMA
An accumulation of pus in the pleural cavity
following nearby lung infection.
128
CHAPTER Clinical Features
3 Chest pain (increasing or inspiration, coughing,

sneezing, laughing, etc.) dyspnea, fever, anorexia,
malaise, weight loss.
HEMOTHORAX
An accumulation of blood in pleural cavity. It
results from injury to internal mammary artery,
intercostals artery and also found in patient’s with
lung and pleural cancer or in those who have
undergone thoracic or heart surgery.
Clinical Features
Absent breath sounds on affected side, reduced
chest expansion, dullness to percussion. If
bleeding continue, features of shock develops.
LUNG ABSCESS
Circumscribed suppurative inflammation of lung
by pyogenic organisms leading to cavitation and
necrosis.
Clinical Features
Fever, pleuritic chest pain, cough, fetid breath,
hemoptysis, clubbing of fingers, loss of weight,
anorexia.
CARDIORESPIRATORY
129
PLEURAL EFFUSION CHAPTER
Pleural effusion is a collection of serous fluid in
the pleural space. 3
Types
I. Acute pleural effusion: Trauma, pancreatitis,
pulmonary infraction.
II. Purulent effusion: Pyogenic infections,
septicemia, penetrating wound of chest
III. Hemorrhagic effusion: Tumor, tuberculosis,
pulmonary infarction, bleeding.
IV. Tuberculous pleural effusion.
V. Milky effusion (chylous, opalescent).
VI. Iatrogenic.
VII. Recurrent.
VIII. Bilateral.
IX. Phantom.
Clinical Features
Pleuritic pain, dyspnea, toxemia.
PLEURISY: INFLAMMATION OF PLEURA
Causes
Infection, infarction of lung, lung cancer injury to
chest wall, rheumatoid arthritis.
Clinical Features
Pain on respiration, unproductive cough, rapid
shallow breathing, chilly sensations, fever.
130
CHAPTER PNEUMONIA
3 Inflammation of lung parenchyma, involving

respiratory bronchioles and alveolar unit distal to
the conduction zone.
Types
I. Anatomical
a. Lobar
b. Segmental
c. Lobular.
II. Clinical
a. Primary
b. Secondary (associated with any disease).
III. Etiological
a. Bacterial (E. coli, Klebsiella, Pseudo-
monas)
b. Atypical (viral, mycoplasmal)
c. Protozoal (E. histolytica)
d. Fungal (actinomycosis, aspergillosis)
e. Allergic
f. Radiation
g. Collagenosis
h. Chemical.
Clinical Features
Dry and painful cough, pleuritic pain, fever,
fatigue, after few days purulent with blood in
sputum.
CARDIORESPIRATORY
131
PNEUMOTHORAX CHAPTER
Pneumothorax is air in the pleural cavity. Air may
enter the pleural cavity through the chest wall,
mediastinum or diaphragm or from a puncture
3
of the visceral pleura covering the lung.
Causes
I. Primary spontaneous: Idiopathic.
II. Secondary spontaneous: Caused by ruptured
emphysematous bullae or due to ulceration
of active tuberculous lesion through the
pleura or rupture of local emphysematous
area from old tuberculous scarring.
Frequently affected are tall, thin young men,
especially smokers.
III. Traumatic and iatrogenic: Stab wounds,
fractured ribs, crush injury, lung biopsy,
faulty tracheostomy, cardiothoracic
surgery.
IV. Artificial: Because of an antitubercular
drugs.
Types
Closed: The opening in the lungs is very small and
rapidly heals. Thus allowing the lung to re-
expand.
Open: The opening remains patent and pressure
in the pleural cavity is equal to that of the
atmosphere.
132
CHAPTER Tension: The opening is valvular –air enters the
3
pleural space during inspiration but cannot
escape during expiration so that a positive
pressure occurs in the pleural cavity.
Clinical Features
Increased respiration distress, hypotension,
cyanosis, tachycardia, decreased movement of
chest wall.
PULMONARY EMBOLISM
Blockage of the pulmonary vasculature by blood
clots, venous thrombi, fat, air, foreign bodies or
fragment of malignant tumors.
Clinical Features
Dyspnea, chest pain, hemoptysis
Risk factors: Prolonged sitting, femur fracture,
surgery.
PULMONARY EDEMA
An increase in the fluid content of the extra-
vascular tissues of the lung.
Cause
Myocardial infarction, LV failure, mitral stenosis,
shock, infections, fluid overload, etc.
CARDIORESPIRATORY
133
Wheezing, shortness of breath sweating tachy-
cardia, short and copious frothy cough. 3
PULMONARY TUBERCULOSIS
A chronic infectious disease caused by myco-
bacterium tuberculosis that is spread via the
circulatory system or the lymph nodes.
Sites: Lungs, lymph nodes, bones, gastrointestinal
tract, kidney, skin, and meninges.
Types
a. Miliary tuberculosis: The lungs are studded
with firm white tubercles about 1 mm in
diameter.
b. Chronic fibrocaseous: Firstly cavities are formed
at the apex.
c. Acute tuberculous caseous pneumonia: Lesion
ulcerate through bronchial walls.
Clinical Features
Cough, hemoptysis, weight loss, fatigue, fever,
night sweats.
RESPIRATORY FAILURE
Condition when normal blood gas pressures
cannot be maintained at rest.
134
CHAPTER Types
3 Hypoxemic respiratory failure: A decreased PaO2

with a normal or low PaCO2
Causes: Chronic bronchitis, emphysema, ARDS
PaO2 < 8 kPa (60 mm Hg)
Ventilatory failure: A decreased PaO2 with an

increased PaCO2.
Causes: Muscular dystrophy, lung disease,
Guillain-Barré syndrome.
PaO2 < 8 ka (60 mm Hg)
PaCO2 > 6.7 kPa (50 mm Hg)
Clinical Features
Central cynosis, loss of judgment, fatigue, dizzi-
ness, dimness of vision, headache.
Arterial Blood Gas Classification of

Respiratory Failure
pH PaCO2 HCO3-
Acute Decreased Increased Normal
Chronic Normal Increased Increased
Acute on chronic Decreased Increased Increased
CARDIORESPIRATORY
135
SARCOIDOSIS CHAPTER
Granulomatous disease involving several organs.
Common site: Mediastinal, lymph nodes, lungs,
3
liver, spleen, skin, eyes.
Clinical Features
Lymph node enlargement, fever, weight loss, dry
cough, uveitis arrhythmias.
SLEEP APNEA
There is recurrent collapse of upper airway due
to which there is difficulty or obstruction in
breathing for more than 10 sec leading to
disturbed sleep.
Clinical Features
Restlessness, reduced sleep, reduced muscle tone,
enlarged tonsils or adenoids, abnormal use of
accessory respiratory muscle.
Complication
Pulmonary hypertension, respiratory or heart
failure.
It occurs due to loss of muscle tone of pharynx
or abnormal central nervous system.
136
CHAPTER NORMAL VALUES
3 Age group Heart rate

mean (range)
Respiratory
rate range
Blood
pressure
(beats/min) (breaths/ systolic/
min) diastolic
(mm Hg)
Preterm 150 (100-200) 40-60 39-59/16-36
Newborn 140 (80-200) 30-50 50-70/25-45
< 2 years 130 (100-190) 20-40 87-105/53-66
> 2 years 80 (60-140) 20-40 95-105/53-66
> 6 years 75 (60-90) 15-30 97-112/57-71
Adults 70 (50-100) 12-16 95-140/60-90
ARTERIAL BLOOD
pH 7.35-7.45 [H+] 45-35 nmol/L
PaO2 10.7-13.3 kPa (80-100 mm Hg)
PaCO2 4.7-6.0 kPa (35-45 mm Hg)
HCO3– 22-26 mmol/L
Base excess –2 to +2
VENOUS BLOOD
pH 7.31-7.41 [H+] 46-38 nmol/L
pO2 5.0-5.6 kPa (37-42 mm Hg)
pCO2 5.6-6.7 kPa (42-50 mm Hg)
CARDIORESPIRATORY
137
VENTILATION/PERFUSION CHAPTER
Alveolar
Breathing air
: Arterial oxygen gradient A—
PaO2
: 0.7-2.7 kPa (5-20 mm Hg)
3
Breathing : 100% 3.3-8.6 kPa
oxygen (25-65 mm Hg)
PRESSURES
mm Hg kPa
Right atrial (RA) Mean –1 to +7 0.13 to 0.93
pressure
Right ventricular Systolic 15-25 2.0-3.3
(RV) pressure Diastolic 0-8 0-1.0
Pulmonary artery Systolic 15-25 2.0-3.3
(PA) pressure Diastolic 8-15 1.0-2.0
mean 10-20 1.3-2.7
Pulmonary Mean 6-15 0.8-2.0
capillary wedge
pressure (PCWP)
Central venous 3-15 cm H2O
pressure
Intracranial
pressure (ICP) <10 mm Hg (<1.3 kPa)
Peak inspiratory Male 103-124 cm H2O
mouth pressure
(pi max) Female 65-87 cm H2O
(Case
dependent)
Peak expiratory Male 185-233 cm H2O
mouth pressure
(pe max.) Female 128-152 cm H2O
(Case
dependent)
138
CHAPTER BLOOD VALUES AND THEIR
3 INTERFERING FACTORS
WHITE BLOOD CELLS (WBCs)
Increase: Food, exercise, emotions, pain, menstrua-
tion, pregnancy, fever, anesthesia prolonged cold
bath, infections, hemorrhage.
Decrease: Bone marrow depression, viral infection,
hypersplenism.
NEUTROPHIL
Increase: Infection.
Decrease: Viral infection, influenza, mumps,
anemia, thyrotoxicosis.
EOSINOPHIL
Increase: Lung and bone cancer parasitic diseases,
Hodgkin’s disease.
Decrease: Pyogenic infection, congestive heart
failure hypersplenism.
RED BLOOD CELLS (RBCs)

Increase: Dehydration, poisoning, diarrhea,
polycythemia vera.
Decrease: Anemia, bone marrow diseases,
rheumatic fever, endocarditis.
CARDIORESPIRATORY
139
ESR CHAPTER
Increase: Anemia, burns, MI, infections, gout,
rheumatoid arthritis, leukemia, sarcoidosis 3
Decrease: Polycythemia vera, congestive cardiac
failure.
BLOOD UREA NITROGEN (BUN)

Increase: Shock, dehydration, diabetes, MI,
impaired renal function.
Decrease: Malnutrition, liver failure, nephrotic
syndrome.
URIC ACID
Increase: Metastatic cancer, shock, diabetic ketosis,
leukemia.
Decrease: After drugs, ACTH phenothiazenes.
RESPIRATORY ASSESSMENT
Database
Reg No
Name
Age/sex DOA.
Address
Occupation
Referred by (consultant) and Hospital
Consultant’s probable diagnosis
Type of operation/illness
140
CHAPTER DOD
3
Discharge summary
Instruction for physiotherapist
History of present illness
Past medical history
Drug history
ADL activities
Personal history
Family history
Social history
• Support at home
• Home environment
• Hobbies.
Subjective Examination
Main symptoms:
• Shortness of breath
• Cough (productive or non-productive)
• Pain
• Wheeze.
FROM CHARTS
• Blood pressure
• Heart rate
• Temperature
• Oxygen requirement
• Oxygen saturations
• Respiratory rate
• Peak flow
CARDIORESPIRATORY
141
• Urine output CHAPTER
3
• Mode of ventilations
• FiO2
• Pressure support/volume control
• Airway pressure
• CVP
• ABGs.
ON OBSERVATION
• Built of the patient
• Cyanosis (central/peripheral)
• Breathing pattern
• Depth
• Type
• Use of accessory muscle
• Chest symmetry
• Facial expression
• Assessment of chest pain
– Site/side of pain
– Type of pain
– Mode of onset of pain (gradual/rapid).
– Nature (shooting or dull pain)
• Course
– Radiation (if any)
– Towards (Rt/Lt) UL
Intensity of pain (constant or intermittent)
Aggravating/relieving factors.
• On palpation
– Edema (pitting or non-pitting)
– Inflammatory signs (present/absent)
142
CHAPTER – Wasting of muscle
3
– Tracheal shift.
• Percussion
– Resonance (normal/hypo/hyper)
– Cardiac dullness
– Liver dullness
– Spleen dullness
– Shifting dullness
– Coin test.
• Auscultation
– Heart sounds
– Gallops
– Breath sounds
– Tactile vocal fremitus
– Pleural rub
– Abnormal lung sound (if any).
• Investigation
– X-ray
– Sputum examination
– ECG
– Echo-cardiography
– Pulmonary function test
– Stress test
– Scanning.
• On examination
– Pulse rate
– Respiratory rate
– Temperature
– Blood pressure.
CARDIORESPIRATORY
143
• Measurements CHAPTER
3
– Chest expansion
– Spirometry
– Dyspnea level.
• Posture deformity
– Chest
– Spinal.
• Functional ability/exercise tolerance.
GLOSSARY OF CARDIORESPIRATORY
TERMS
Alkalosis: A pathological state of raised pH
resulting from a loss of CO2.
Anoxia: Absence of O2 in the tissues despite an
adequate blood supply.
Angiogram: A component of left heart
catheterization in which a dye is injected into the
coronary arteries to assess blood flow of the
presence of occlusion.
Angle of Louis: Anatomical landmark on the
chest wall for the RA, the bony demarcation of
manubrium from the body of sternum.
Apnea: Cessation of respiration.
Arrhythmia: Disturbance of cardiac rhythm.
Asphyxia: Death due to lack of oxygen.
Autoregulation: A type of vascular regulation
that occurs at the local level.
144
CHAPTER Bradycardia: Abnormally slow heart rate.
3 Bradypnea: Decrease respiratory rate.

Bruit: Turbulence or an abnormal murmur in a
vessel heard on auscultation.
Compliance: Change in lung volume for unit
change in distending pressure.
Cor pulmonale: Right ventricular enlargement
from a primary pulmonary cause.
Cyanosis: Bluish discoloration or skin color
changes.
Dyspnea: Laboured, uncomfortable breathing.
Dysrhythmia: Disturbance of rhythm.
Fibrillation: Rapid uncoordinated contractions of
the cardiac muscle.
Hemodynamics: The study of forces governing
blood flow.
Hemoptysis: The presence of blood in the
sputum.
Hypercarbia: Excess of CO2 in the blood.
Hypercapnia: An increase in the amount of CO
within the arterial blood.
Hyperinflation: An abnormal increase in the
amount of air in the lung tissue.
Hypocapnia: A decrease in the amount of CO2 in
arterial blood.
CARDIORESPIRATORY
145
Hypoapnea: Diminution of tidal volume. CHAPTER
Hypoventilation: An increase in the amount of
CO2 in arterial blood due to a decrease in alveolar
ventilation.
3
Hypovolemia: Low blood volume.
Hypoxemia/Hypoxia: Reduction of O2 supply to
the tissues.
Ischemia: O2 starvation of the tissues due to a lack
of blood supply.
Orthopnea: Difficulty in breathing when lying.
Paradoxical movement/breathing: Inward
drawing of the lower ribs on inspiration with
relaxation on expiration.
Tachycardia: Rapid heart rate.
Tachypnea: Rapid respiratory rate.
Ventilation: The act of moving air in and out of
the lungs.
NEUROLOGY
147
4
CHAPTER
CHAPTER 4
Neurology
• Neuroanatomy illustrations
• Clinical manifestations of cerebrovascular
lesions
• Localization of lesion and their signs of
impairment
• Myotomes
• Dermatomes
• Peripheral nervous system
• Splints used for various nerve injuries
• Vertebrae and corresponding spinal segment
relationship
• Descending tracts/ascending tracts
• Neurological tests
• Cranial nerves
• Reflexes
148
CHAPTER • Differences of upper motor neuron and lower
4
motor neuron lesions
• Glasgow coma scale
• Modified Ashworth scale for grading spasticity
• Neurological pathologies
• Neurological assessment
• Glossary of neurological terms
NEUROLOGY
149
NEUROANATOMY ILLUSTRATIONS CHAPTER
ARTERIAL SUPPLY OF THE CEREBRAL

HEMISPHERE (FIGS 4.1 TO 4.8) 4
Fig. 4.1: Lateral view of right cerebral hemisphere
Fig. 4.2: Medial view of right cerebral hemisphere

150
CHAPTER
Fig. 4.3: Mid sagittal section of the brain
Fig. 4.4: Coronal section of the brain

NEUROLOGY
151
CHAPTER
Fig. 4.5: Anterior cerebral artery
Fig. 4.6: Middle cerebral artery

152
CHAPTER
Fig. 4.7: Posterior cerebral artery
Fig. 4.8: Circular arteriosus

NEUROLOGY
153
CLINICAL MANIFESTATIONS OF CHAPTER
4
CEREBROVASCULAR LESIONS
MIDDLE CEREBRAL ARTERY
Involved structures Clinical features

Internal capsule and Contralateral paresis of
primary motor cortex face, arm, trunk, and leg
Internal capsule and primary Sensory impairment of
sensory cortex the contralateral face,
arm and leg
Broca’s cortical area Motor speech disorder
(dominant hemisphere)
Wernicke’s cortical area Wernicke’s aphasia
(dominant hemisphere)
Parietal lobe (nondominant Perceptual problems
lobe)
Optic radiation in internal Homonymous hemianopia
capsule
Parietal lobe Contralateral limb(s)
ataxia
ANTERIOR CEREBRAL ARTERY

Motor cortex Paresis of opposite foot
and leg to a lesser extent
the arm
Unknown Mental impairment
Somatosensory cortex Sensory impairments
(lower limb>upper limb)
Contd...
154
CHAPTER Contd...
4
Superior frontal gyrus Urinary incontinence
Corpus callosum Apraxia
Uncertain localization Abulia, slowness, lack

of spontaneity
POSTERIOR CEREBRAL ARTERY

Optic radiation or primary Contralateral homony-
visual cortex mous hemianopia
Inferomedial portions of Amnesia
temporal lobe bilaterally
Calcarine sulcus and lingual Prosopagnosia
gyrus (non dominant occipital
lobe)
Ventral posterolateral nucleus Thalamic syndrome:
of thalamus sensory impairments,
spontaneous pain,
dysesthesias
Cerebral peduncle of mid Weber’s syndrome—
brain and III cranial nerve contralateral hemiplegia,
occulomotor nerve palsy
Subthalamic nucleus Contralateral
hemiballismus
NEUROLOGY
155
LOCALIZATION OF LESION AND CHAPTER
4
THEIR SIGNS OF IMPAIRMENT
Prefrontal area Dementia, stage of catatonic

stupor, incontinence of urine
Precentral area Jacksonion march (in irritation),
UMN type of paralysis
(in destruction)
Parietal lobe Paraesthesia (in irritation),
sensory ataxia, sensory loss
(in destruction)
Temporal lobe Visual and auditory hallucination,
uncinate fits, homonymous
superior quadrantic hemianopia
Occipital lobe Vision hallucination, convulsions
(in irritation),visual agnosia, visual
sensory aphasia (in destruction)
CLINICAL MANIFESTATIONS OF HEMORRHAGE

TO OTHER AREAS OF THE BRAIN

Parts of basal ganglia Contralateral hemiparesis/
hemiplegia, contralateral
hemisensory loss,
hemianopia
(posterior segment),
Somatosensory cortex Sensory impairments
(lower limb>upper limb)
Superior frontal gyrus Urinary incontinence
Corpus callosum Apraxia
Uncertain localization Abulia, slowness, lack
of spontaneity
156
CHAPTER BASAL GANGLIA
4 Nuclei
• Putamen
• Caudate
• Globus pallidus.
Clinical Manifestations
• Bradykinesia
• Rigidity
• Tremors
• Akinesia
• Chorea
• Athetosis
• Choreoathetosis
• Hemiballismus
• Dystonia.
MYOTOMES
Root Action to be tested
C1 Flexion of upper cervical
C2 Extension of upper cervical
C3 Side flexion of cervical
C4 Elevation of shoulder girdle
C5 Shoulder abduction
C6 Elbow flexion
C7 Elbow extension
C8 Ulnar deviation
T1 Digits—abduction, adduction
NEUROLOGY
157
L2 Hip flexion CHAPTER
4
L3 Knee extension
L4 Dorsiflexion
L5 Great toe extension
S1 Planter flexion
S2 External rotation
DERMATOMES (FIG. 4.9)
Fig. 4.9: Dermatomes of the whole body

158
CHAPTER UPPER QUARTER SCREEN
4 C2
C3
C4
Occipital protuberance
Supraclavicular fossa
Acromioclavicular joint
C5 Lateral antecubital fossa
C6 Thumb
C7 Middle finger
C8 Little finger
T1 Medial antecubital fossa
T2 Apex of axilla
LOWER QUARTER SCREEN

L1 Upper anterior thigh
L2 Mid anterior thigh
L3 Medial femoral condyle
L4 Medial malleolus
L5 Dorsum 3rd MTP joint
S1 Lateral heel
S2 Popliteal fossa
S3 Ischial tuberosity
S4 Perianal area
PERIPHERAL NERVOUS SYSTEM

AXILLARY NERVE (C5, C6)
Innervation of muscles: Deltoid, teres minor.
Sensory distribution: Lateral arm over lower
portion of deltoid.
NEUROLOGY
159
Clinical features: Loss of shoulder abduction, also CHAPTER
4
affect the lateral rotation of shoulder.
MUSCULOCUTANEOUS NERVE (C5, C6)

Innervation of muscles: Coracobrachialis biceps
brachialis.
Sensory distribution: Anterolateral surface of
forearm.
Clinical features: Loss of elbow flexion, also affect
supination.
RADIAL NERVE (C6, C7, C8, T1)

Innervation of muscle
• Before the radial groove: Long and medial heads
of triceps.
• After the radial groove
Before crossing the elbow: Lateral head of triceps,
anconeus brachioradialis, external carpi
radialis longus.
• After crossing the elbow
Before piercing the supinator: Extensor carpi
radialis brevis, supinator.
After piercing the supinator
Other extensor muscles of the forearm and
hand.
Sensory distribution: Posterior aspect of arm,
forearm and radial side of posterior hand.
160
CHAPTER Clinical features: Wrist drop (loss of elbow, wrist,
4
finger and thumb extension).
MEDIAN NERVE (C6, C7, C8, T1)

Innervation of muscle:
In the forearm
Proximal 1/3: All flexor muscles of the forearm
(except the flexor carpi ulnaris and medial half of
the flexor digitorum profundus).
Distal 1/3: Nil.
In the hand: Flexor pollicis brevis, opponens
pollicis, abductor pollicis, first two lumbricals.
Sensory distribution: Palmar aspect of thumb,
second, third and fourth (radial half) fingers.
Clinical features: Ape hand (loss of thumb
opposition, flexion and abduction).
ULNAR NERVE (C8, T1)

Innervation of muscles
In the forearm
Proximal 1/3: Flexor carpi ulnaris, medial half
of flexor digitorum profundus.
Distal 1/3: Nil.
In the hand
Superficial branch: Hypothenar muscles.
Deep branch: Adductor pollicis, all interossei
and medial two lumbricals.
NEUROLOGY
161
Sensory distribution: Fourth finger (medial portion), CHAPTER
4
fifth finger.
Clinical features: Loss of wrist ulnar deviation.
Also affect flexion of wrist and finger Pope’s
blessing—weakened fourth and fifth finger
flexion, thumb abduction loss, claw hand.
FEMORAL NERVE (L2, L3, L4)

Innervation of muscle: Iliopsoas, sartorius,
pectineus, quadriceps femoris.
Sensory distribution: Anterior and medial thigh,
medial leg and foot.
Clinical features: Loss of knee extension, also affect
hip flexion.
OBTURATOR NERVE (L2, L3, L4)

Innervation of muscle: Hip adductors, obturator
externus.
Sensory distribution: Medial thigh (middle part)
Clinical features: Loss of hip adduction, also affect
lateral rotation of hip.
SCIATIC NERVE (L4, L5, S1, S2, S3)

Innervation of muscle: Hamstring.
Sensory distribution: Nil.
Clinical features: Loss of knee flexion, also affect
hip extension.
162
CHAPTER TIBIAL NERVE (L4, L5, S1, S2, S3)
4 Innervation of muscle: Popliteus, ankle plantar

flexors tibialis posterior, intrinsics muscles of
foot.
Sensory distribution: Medial side of ankle.
Clinical features: Loss of toe flexion and ankle
plantar flexion, also affect ankle inversion.
COMMON PERONEAL NERVE (L4, L5, S1, S2)

Innervation of muscle:
Superficial branch: Peroneals.
Deep branch: Tibialis anterior, toe extensors.
Sensory distribution: Anterolateral aspect of leg and
foot.
Clinical features: Foot drop (loss of ankle dorsi-
flexion). Loss of toe extension and ankle
eversion.
SPLINTS USED FOR VARIOUS NERVE

INJURIES
Nerve injured Splint
Axillary nerve Shoulder abduction splint
Radial nerve palsy Cock-up splint
Ulnar nerve palsy Knuckle-bender splint
Sciatic nerve palsy Foot drop splint
NEUROLOGY
163
VERTEBRAE AND CORRESPONDING CHAPTER
SPINAL SEGMENT RELATIONSHIP
Vertebrae Spinal segments
C1 to C4 (upper cervical) Same
4
C4 to C7 (lower cervical) +1
T1 to T7 +2
T7 to T9 +3
T10 L1,L2
T11 L3, L4
T12 L5 S1
L1 Sacral and
coccygeal nerve
DESCENDING TRACTS (FIG. 4.10)

Corticospinal tract: Voluntary movements, finger
finer movements.
Rubrospinal tract: Inhibits extensor muscles,
facilitates flexors movements.
Vestibulospinal tract: Inhibits flexors, facilitates
extensors.
Reticulospinal tract: Control muscle activity.
Tectospinal tract: Vision reflex.
ASCENDING TRACTS (FIG. 4.10)

Medial lemniscus: Kinesthetic, touch and
vibration sense.
Lateral spinothalamic: Temperature, pain.
Anterior spinothalamic: Crude touch, pressure.
164
CHAPTER
Fig. 4.10: Ascending and descending

spinal cord tracts
Spinocerebellar: Kinesthetic sensation
Spino-olivary: Carries message to fascia, tendon
and ligaments.
Spinoreticular: Works on conscious level.
Spinotectal: Vision.
NEUROLOGICAL TESTS
ALTERNATE NOSE-TO-FINGER TEST
Procedure: Keep your finger away about an arm’s
length from the patient. Ask the patients to touch
NEUROLOGY
165
your finger with his index finger and then touch CHAPTER
4
his nose. Repeat the movement.
Response: Patient missing your finger or intention
tremor.
Indicates: Possible cerebellar dysfunction.
FINGER-TO-NOSE TEST
Procedure: Keep the patient shoulder in 900
abduction with elbow extension. Ask the patient
to touch the tip of the nose with the help of the
tip of the index finger.
Response: Patient missing your finger or intention
tremor.
FINGER-TO-FINGER TEST
Procedure: Keep the patient both shoulders in 90°
abduction with the elbow extension. Ask the
patients to bring both the hand towards the
midline and approximate the index fingers from
opposing hand.
Response: Patients missing your finger or intention
tremor.
HEEL-SHIN TEST
Procedure: Patient lying down. Ask him to place
one heel on the opposite knee and then drag the
166
CHAPTER heel down or the shin towards the ankle and back
4
again.
Response: Inability to keep the heel on the shin or
uncoordinated movement or intention tremor.
ALTERNATE HEEL-TO-KNEE TEST

Procedure: With supine position, ask the patients
to touch the knee and big toe alternately, with the
heel of opposite extremity.
Response: Uncoordinated movement or intention
tremor.
HOFFMANN REFLEX
Procedure: Flick the distal phalanx of the patient’s
third or fourth finger.
Response: Reflex flexion of the patient’s thumb.
Indicates: Possible upper motor neuron lesion.
JOINT POSITION SENSE (KINESTHESIA)

Procedure: The test is generally performed at distal
joint of the limb. Demonstrate the movement with
patient’s eye open. Then ask the patient to close
his eyes to test. Grasp the joint to be tested
between two fingers and move it up and down.
Ask the patient to identify the direction of
movement.
NEUROLOGY
167
Response: Inability to identify. CHAPTER
Indicates: Loss of proprioception.
LIGHT TOUCH
4
Procedure: Take a wisp of cotton wool. Demons-
trate the procedure with the patient’s eye open.
Then ask the patient to close his eyes. Stroke the
patient’s skin with the cotton wool at random
point, ask him to indicate every time they feel the
touch.
Response: Inability to indicate every time.
Indicates: Altered touch sensation.
PIN-PRICK (PAIN)
Procedure: Demonstrate the procedure with
patient’s eyes open. Then ask him to close his
eyes. Test random areas of limb by using sharp
end object and ask the patient to tell, which
sensation they feel.
Response: Inability to identify the type of sensation
of pain.
Indicates: Altered pain sensation.
RAPIDLY ALTERNATING MOVEMENT

Procedure: Ask the patients to hold out one hand
palm up and then alternately slap it with the
palmar and then dorsal aspects of the fingers of
the other hand.
For the lower limbs get the patient to tap first
one foot on the floor and then the other.
168
CHAPTER Response: Loss of rhythm.
4 Indicates: Possible cerebellar dysfunction.
TEMPERATURE
Procedure: Take cold and warm water and ask the
patients to distinguish between the two sensation.
Or
A cold tuning fork is taken and ask the patient
to identify the sensation, when applied to various
parts of the body.
Response: Inability to differentiate the temperature.
Indicates: Altered temperature sensation.
VIBRATION SENSE
Procedure: Ask the patient to close his eyes. Put
the vibrating tuning fork (128 Hz) over bony
prominence or on the finger tips or toes.
Response: Unable to report the feeling of vibration.
Indicates: Altered vibration sense.
TWO-POINT DISCRIMINATION
Procedure: Demonstrate the procedure with
patient’s eye open. Ask the patient to close his
eyes, with either one prong or two touches the
patient alternately and reduces space between two
prongs.
Response: Inability to discriminate.
Indicates: Indicates sensory dysfunction.
NEUROLOGY
169
ROMBERG’S TEST CHAPTER
Procedure: Patient stand with feet parallel to each
other with a normal width between the feet and
then close eyes for 20-30 seconds.
4
Response: Excessive postural sway or loss of
balance.
Indication: Proprioceptive or vestibular deficit.
SHARPENED ROMBERG’S TEST

Procedure: Ask the patient to stand with the feet
in a tandem stance with arm folded across the
chest and stand for about a minute.
Response: Excessive postural sway or loss of
balance.
Indication: Proprioceptive or vestibular deficit.
OTHER BALANCE TESTS

One leg stance, timed stance, postural sway test,
functional reach test, nudge test, get up and go
test, Berg balance test.
CRANIAL NERVES
ORIGINATION OF NERVE
Forebrain I, II
Midbrain III, IV
Pons V, VI, VII, VIII
Medulla IX, X, XI, XII
170
CHAPTER TYPES OF NERVE
4 Motor
Sensor
Mixed
III, IV, VI, XI, XII
I, II, VIII
V, VII, IX, X
Name Function Assessment Abnormal
signs
I Smell Tested by use Inability to
Olfactory of non irritating detect smell
volatile oils or
liquids
II Optic Vision – Tested for Loss of
visual acuity visual acuity
by Snellen’s
chart (distance
vision) and
Jaeger’s (near
vision)
– Tested for color Color
vision by blindness
Ishihara’s chart
– Tested for Defects
visual field by visual fields
perimetry or
comfrontation
test
III Oculo- Pupil Test pupillary Papillary
motor constriction light reflex dilatation
accommo-
dation of Test accommo- Loss of
lens, dation reflex accommoda-
movement tion reflex
of eyeball Test eyeball Diplopia
and eyelid and eyelid Ptosis, squint
movements
Contd...
NEUROLOGY
171
Contd...
CHAPTER
4
signs
IV Movement Assess the Diplopia,
Trochlear of eyeball eye movement Adductor
in upward paralysis
direction
V Tri- Mastication, Ask the patient Weakness
geminal Somatosen- to clench jaws, and wasting
sation: hold against of mastica-
face resistance test tion muscle,
cornea, sensation: fore- loss of
anterior head, cheeks, sensation in
tongue chin test corneal eye face,
reflex sinuses and
teeth, trigemi-
nal neuralgia
VI Abdu- Movement Test eye Diplopia with
cent of eyeball movement gaze palsy,
in outward convergent
direction strabismus
VII Facial Ask the patients
Facial movement, to raise eye
Tearing- frows, show
lacrimal teeth, smile, close
gland eyes, tightly puff
Salivary cheeks
secretions-
Submandi-
bular,
Sublingual
Taste for Test for taste- Bells palsy,
anterior sweet, salty, loss of taste,
two-thirds sour, bitter inability to
of tongue close eye
Somato-
sensation
Contd...
172
Contd...
CHAPTER
4
sign
VIII Hearing Test for hearing: Deafness,
Vesti- Rinne (sensori- Tinnitus
buloco- neural) and Weber
chlear test (conduction)
Equilibrium Assess the Vertigo,
balance, nystag- nystagmus
mus and eye
head co-ordination
IX Elevation Assess taste— Dysphagia,
Glosso- of pharynx sweet, salty, sour, Dry mouth,
pharyn- Salivary bitter loss of tongue
geal secretion: sensation
parotid, and taste,
sensation dysphonia
of test for
posterior
third of
tongue Test gag reflex
reflexes
X Vagus Phonation Assess phonation Dysphonia
and and articulation
deglutition, Observe move- Dysphagia
secretion ment of soft
of digestive palate
fluid,
cardiac Test gag reflex Loss of gag
depressor, Test for pharyn- reflex
reflexes, geal sensation
somato-
sensations
XI Acces- Deglutition Test for muscle Muscle
sory and pho- strength and weakness
nation, tone
Movement
Contd...
NEUROLOGY
173
Contd...
CHAPTER
4
sign
of sterno- Test for muscle Muscle
cleidomas- strength and tone weakness
toid and
trapezius
(spinal
part)
XII Hypo- Movement Test for strength Dysphagia,
glossal of tongue of tongue dysarthria,
movement wasting of
tongue
REFLEXES
DEEP TENDON REFLEXES
Reflex Nerve Mode of Response

elicitation
Biceps Musculo- Striking over Elbow flexion
C5-6 cutaneous the biceps
tendon
Supinator Radial Striking over Forearm
C5-6 the Brachio- flexion with
radialis tendon supination
at the distal
end of radius
Triceps Radial Striking over Arm extension
C7–8 the tendon of
triceps
Finger Median Striking over Finger and
flexion and ulnar the palmar thumb flexion
C7-8 surface of the
semiflexed
fingers
Contd...
174
Contd...
CHAPTER
4
Reflex Nerve Mode of Response
elicitation
Knee Femoral Striking over Knee
L2-4 the tendon of extension
quadriceps
Ankle Sciatic Striking over Ankle plantar
S1-2 the tendocal- flexion
caneous
SUPERFICIAL REFLEXES
Reflex Mode of elicitation Response

Plantar S1 Flexor response— All toes flexion
slightly scratching
the lateral border of
the sole
Extensor response— Small toe fanning,
slightly scratching ankle and big toe
the lateral border of dorsiflexion
the sole
Abdominal Slightly scratching Homolateral
T6-12 the abdomen with contraction of the
blunt object abdominal
muscles, retraction
of linea alba and
umbilicus
Cremasteric Slightly scratching Cremasteric
L1 the skin on the upper, muscle contraction
inner aspect of the with homolateral
thigh from above elevation of testicle
downwards with a
blunt object
Contd...
NEUROLOGY
175
Contd...
CHAPTER
4
Reflex Mode of elicitation Response
Bulbocaver- Pressing the glans Bulbocavernous
nous S2-4 penis muscle contraction
Anal S4-5 Pricking the skin on External anal
mucous membrane in sphincter muscle
the perianal region contraction
PATHOLOGICAL REFLEXES
Reflex Mode of elicitation Positive response

Babinski Scratching the lateral Big toe extension
(UMN border of sole of foot and other toes
Lesion) and across the fanning
footpad
Clonus Sudden dorsiflexion Three or more
(UMN of foot passively then three
Lesion) rhythmic
contraction of
plantar flexors
DIFFERENCES OF UPPER MOTOR NEURON

AND LOWER MOTOR NEURON LESIONS
UMNL LMNL
Origin Cerebral cortex Cranial nerve
motor nuclei or
spinal cord
anterior horn
Termination Cranial nerve nuclei Motor unit of
or spinal cord anterior skeletal muscle
horn
Contd...
176
Contd...
CHAPTER
4
UMNL LMNL
Affects Muscle group Individual muscle
Muscle tone Increased Decreased
Paralysis Spastic Flaccid
Wastage of Do not occur Occur
muscle
Involuntary Flexor spasms Fasciculation
movements sometimes sometimes
Superficial Lost Lost
reflexes
Deep Exaggerated Lost
reflexes
Plantar Abnormal Lost
reflex (Babinski’s sign)
Clonus Present Lost
Electrical Normal Absent
activity
Fasciculation Absent Present
twitch in
EMG
Speech Aphasia, aphonia Normal, unless
Laryngeal
Muscles are
affected
Posture and Hemiplegic or High stepping
gait scissoring
Palpation Hard Soft
NEUROLOGY
177
GLASGOW COMA SCALE CHAPTER
EYE OPEN
Spontaneous 4
4
To speech 3
To pain 2
None 1
BEST VERBAL RESPONSE

Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sound 2
None 1
BEST MOTOR RESPONSE

Obeys commands 6
Localize the pain 5
Withdrawal to pain 4
Flexion to pain 3
Extension to pain 2
None 1
SCORE
Total 15
Minimum 3
Coma 7 or less than 7
178
CHAPTER MODIFIED ASHWORTH SCALE FOR
4
GRADING SPASTICITY
0 No increase in muscle tone

1 Slight increase in muscle tone manifested by a
catch and release or by a minimal resistance at
the end of the range of motion when the affected
part or parts are moved in flexion or extension
1+ Slight increase in muscle tone manifested by a
catch, followed by minimal resistance through the
reminder (less then half) of the ROM, but affected
parts are easily moved
2 Marked increase in muscle tone through most of
the ROM, but affected parts are easily moved
3 Considerable muscle tone passive increases,
passive movement difficult
4 Affected part(s) rigid in flexion or extension
NEUROLOGICAL PATHOLOGIES
ALZHEIMER’S DISEASE
Commonest form of dementia characterized by
slow, progressive mental deterioration. Neuritic
plaques (primarily in the hippocampus and
parietal lobes) and neurofibrillary tangles (mainly
affecting the pyramidal cells of the cortex) are
present.
Clinical Features
Memory loss both in short and long-term apraxia,
aphasia, visuospatial impairment, aggressive
behavior.
NEUROLOGY
179
ARACHNOIDITIS CHAPTER
Chronic inflammation of the nerve root sheath in
the spinal canal with or without nerve root symp-
toms. Chronic arachnoiditis occurs as a result of
4
meningitis, myelography or spinal surgery.
Clinical Features
Severe low back pain, radicular pain, leg weak-
ness, gait disorder, incontinence.
ANTERIOR CORD SYNDROME

Occurs due to the flexion injury at the cervical
region resulting into damage of anterior portion
of spinal cord or its vascular supply.
Clinical Features
Loss of motor function, loss of sense of pain and
temperature.
BELL’S PALSY
Lower motor neuron paralysis of the face, related
to inflammation and swelling of the facial nerve
(VII) within the facial canal or at the stylomastoid
foramen. Usually unilateral. Good recovery is
common.
Clinical Features
Asymmetry of face, weakness or paralysis of facial
muscle, unable to close eye of affected side,
180
CHAPTER difficulty in chewing, drooling of saliva from
4
affected side, verbal communication is affected.
BROCA’S DYSPHASIA
Caused due to lesion or damage of Broca’s area
on the inferior frontal cortex. Broca’s area is near
the motor cortex for the face and arm and so may
be associated with weakness in these areas.
Clinical Features
Difficulty in speaking, non-fluent speech, diffi-
culty in writing, reducing word output.
BROWN-SEQUARD SYNDROME
It occurs due to damage to one side of the spinal
cord commonly caused by stab injuries.
Clinical Features
Loss of sensory sensation on same side, loss of
sense of pain and temperature on the opposite
side.
BULBAR PALSY
Occurs due to lower motor neuron lesion, may be
unilateral or bilateral. The nerve supplying the
bulbar muscles of head and neck are mainly
affected.
NEUROLOGY
181
Paralysis or weakness of muscles of face, jaw,
pharynx, larynx and palate, impairment in
swallowing, coughing, speaking and gag reflex.
4
CEREBRAL PALSY
Group of condition characterized by motor
dysfunction due to nonprogressive brain damage
early in life classified into various types:
1. Topographical classification: Quadriplegia,
triplegia, paraplegia, diplegia, hemiplegia
monoplegia
2. According to types: Spastic, athetoid, ataxic,
floppy, mixed
Common causes include intrauterine cerebro-
vascular insult, intrauterine infection, birth
asphyxia, postnatal meningitis and postnatal
cerebrovascular insult.
Clinical Features
Retarded development, the performance of
various movements in pattern, there will be
persistence of infantile behaviour in all function
including primitive reflexes.
CENTRAL CORD SYNDROME

Occurs from hyperextension injury to the cervical
region, associated with congenital or degenerative
narrowing of spinal canal, resulting due to
182
CHAPTER compressive force causing hemorrhage and
4
edema.
Clinical Features
Sensory impairment, neurological deficit of upper
and lower extremity.
CHARCOT-MARIE-TOOTH DISEASE
Progressive disorder of peripheral nerve which is
hereditary, characterized by gradual progressive
distal weakness and wasting, mainly affecting the
peroneal muscle in the leg. In the later stages arm
muscles can also be involved. This is also known
as hereditary motor sensory neuropathy (HMSN).
Clinical Features
Difficulty in running, foot deformity, muscle
wasting, lower extremity weakness.
DISSEMINATED ENCEPHALOMYELITIS
Occurs due to prevascular CNS demyelination
resulting due to viral infection. Myelin loss is
followed by axonal degeneration and then by cell
body degeneration (irreversible).
Clinical Features
Neurological and motor dysfunction, limb
weakness.
NEUROLOGY
183
GUILLAIN-BARRÉ SYNDROME (GBS) CHAPTER
An acute or subacute symmetrical predominantly
motor neuropathy involving more than one
peripheral nerve, frequently it may involve the
4
facial and other cranial nerve, does not have any
known etiology, and reaches a peak of disability
by one to four weeks. There is distruction of
myelin sheath and inflammatory cell. Infiltration
of nerve mostly affects the proximal part of nerve
root. In most of the cases, onset of symptoms is
preceded by a mild gastrointestinal or respiratory
infection. GBS usually ends up with recovery.
Clinical Features
Neurological dysfunction, lower limb weakness,
difficulty in walking, muscle weakness, facial
paralysis, diminished reflexes, pain and autono-
mic disturbances. In severe cases, respiratory
problems are seen.
HEMIPLEGIA
Paralysis of half side of the body, i.e. it affects both
upper and lower limbs of same side. It may be due
to thrombosis, embolism, hemorrhage, hyperten-
sion, intracranial infections, trauma or hysteria.
Clinical Features
Upper and lower limb weakness, facial paralysis,
in some cases there may be sensory loss.
184
CHAPTER HORNER’S SYNDROME
4 A group of symptoms occurring due to lesion of

the sympathetic pathways in the brainstem, spinal
cord, hypothalamus, superior cervical ganglion,
internal carotid sheath or C8-T2 ventral spinal
roots.
Clinical Features
Pupil constrictions of same side, loss of facial
sweating on affected side of face, drooping of the
upper eyelid.
HUNTINGTON’S DISEASE
Disease caused by a defect in chromosome IV,
which can be transmitted by either of the parent.
It can be hereditary in nature. Onset is insidious
and occurs between 35 and 50 years of age.
Clinical Features
Chorea, progressive dementia, changes in
behavior.
HYDROCEPHALUS
An increase in cerebrospinal fluid (CSF) volume,
usually resulting from impaired absorption, rarely
from excessive secretion. Classified into two types:
communicating and non-communicating. Causes
includes congenital, intrauterine infection,
NEUROLOGY
185
intracranial bleeding, hemorrhage, congenital CHAPTER
4
malformation, etc.
Clinical Features
Vomiting, nausea, irritability, behavioural changes,
bradycardia, delayed milestone development,
drowsiness, papilledema.
LOCKED-IN SYNDROME
This is a neurological disorder in which there
occurs total paralysis of all the voluntary muscles
except those of face. Caused due to trauma of
demyelinating diseases and vascular diseases.
Clinical Features
Inability in speaking, difficulty in hearing.
MENINGITIS
It is the inflammation of the leptomeninges and
underlying subarachnoid C and F, caused by
bacteria or viral infections, commonly occurs in
children under 5 years of age and adults over 15
years of age. Classified into acute and chronic
meningitis.
Acute due to meningococcal, Pneumococcal
Haemophilus influenzae, gram-negative meningitis,
chronic neoplasm infection, AIDS, syphilis.
186
4 Headache, high fever, cold hands and feet,

lethargy, change in level of alertness, respiratory
distress, apnea, cyanosis.
MOTOR NEURON DISEASE

This is a pathological progressive degenerative
disease. Changes are more marked in anterior
horn cell of spinal cord, motor nuclei of medulla
and the corticospinal tracts.
Clinical Features
Wasting of muscles especially upper limbs and
those innervated from the medulla, combined
with symptoms of corticospinal tract degeneration
various types are:
Amyotrophic lateral sclerosis: Occur due to lower
motor neuron lesion. There is weakness of limbs
and face muscular atrophy may also be seen.
Progressive bulbar palsy: Caused due to damage of
motor nuclei is area of brainstem. There is pain
and spasm, dyspnea, dysphagia, sore eyes and
dysarthria, paralysis of muscles of face, larynx,
pharynx and muscle wasting.
MULTIPLE SCLEROSIS
This is a slow progressive CNS disease characte-
rized by disseminated patches of demyelination
in the brain and spinal cord resulting in multiple
NEUROLOGY
187
and varied neurologic symptoms and signs with CHAPTER
4
remission and exacerbation. Women are affected
more; age of onset is 20 to 40 years.
Clinical Features
Ataxia, motor and sensory disturbance, visual
disturbances, fatigue, bowel and bladder dysfunc-
tion, pain and spasm, behavioural changes, bulbar
dysfunction.
MUSCULAR DYSTROPHY
This is a group of inherited and progressive
muscle disorder. There is selective distribution of
weakness. Muscle fibers are replaced by fat and
connective tissue. Commonly affected are boys
below four years of age and the disease is further
classified as:
• Duchenne’s muscular dystrophy
• Becker’s muscular dystrophy
• Facioscapulohumeral muscular dystrophy
• Limb girdle muscular dystrophy.
Clinical Features
Pseudohypertrophy of proximal muscles, diffi-
culty in walking, postural abnormalities
diminished reflexes, Gower’s sign.
MYASTHENIA GRAVIS
A disorder of the neuromuscular junction caused
by an impaired ability of the neurotransmitter
188
CHAPTER acetylcholine to induce muscular contraction,
4
most likely due an autoimmune destruction of the
post synaptic receptors for acetylcholine. Male:
female ratio is 2:3. Age of onset – neonates, 20-
30 years or 50 years.
Clinical Features
Muscle weakness, ptosis in bulbar muscle,
respiratory distress,weakness of facial muscles
and jaw-slack, face expressionless.
PARKINSONISM
This is the degenerative disease of substantia
nigra, because of which there is decreased amount
of dopamine in the basal ganglia. It has a gradual
and incidious onset that affects the age group
between 50 to 60 years. Syndrome is characterized
by tremor, muscular rigidity, bradykinesia,
postural instability.
Clinical Features
Poor posture reflexes, resting tremor, depression,
mask like face, shuffling gait, difficulty in
speaking, slowness of voluntary movements.
POLIOMYELITIS
Is an infectious disease usually affecting children
under five year of age. It is caused by three types
of poliovirus. It enters feco-oral route. It destroys
NEUROLOGY
189
the motor neuron of anterior horn, showing the CHAPTER
4
symptoms of lower motor neuron lesion. Divided
into various stages according to the involvement.
They are acute stage/pre-paralytic/paralytic
stage/convalescent stage/stage of early/recovery
residual stage/post-polio residual phase.
Clinical Features
Weakness or paralysis of lower limb is more than
upper limb, difficulty in speaking and swallow-
ing, respiratory complications due to paralysis of
muscles of thorax and abdomen.
POSTERIOR CORD SYNDROME

It is very rare and occurs when there is any deficits
in function served by posterior column. This is
usually seen with tabes dorsalis, a late stage
syphilis condition.
Clinical Features
Loss of proprioception and two point discrimi-
nation of stereognosis. Gait pattern is wide
based.
POSTPOLIO SYNDROME
Persistence of symptom like paralysis or weakness
after two years of illness. In this the symptoms
progresses after the recovery from acute paralytic
stage.
190
4 Pain in muscles and joints, neurological dysfunc-

tions, progressive muscular weakness, severe
fatigue.
PSEUDOBULBAR PALSY
It occurs when the corticomotor neuron pathways
are affected due to upper motor neuron lesion
resulting in spasticity and weakness of the
pharyngeal and oral musculature.
Clinical Features
Dysphagia and slurring of speech, emotional
incontinence, inability to control the expressions
like laughing or crying.
SACRAL SPARING
Incomplete lesion in it the centrally located sacral
tracts are preserved or remains unaffected. The
differing level of innervations remains intact.
Clinical Features
Loss of acute contraction of toe flexors supplied
by sacral nerve, cutaneous sensation is lost, rectal/
sphincter contraction is affected, perianal
sensation is lost.
NEUROLOGY
191
SPINAL MUSCULAR ATROPHIS (SMA) CHAPTER
Degenerative disorders of the anterior horn cells,
that are inherited and cause muscle atrophy. This
is classified according to the age of onset and is
4
of three types:
SMA I: Also known as Werdnig-Hoffmann
disease. This is the most severe, one in onset and
cause weakness and hypotonia.
SMA II: It is of intermediate type. It progresses
a bit slower and has same features age of onset
of 6 to 15 months.
SMA III: Wohlfart-Kugelberg-Welander disease
has late onset, leads to progressive limb weakness
and occurs between one year.
STROKE/CEREBROVASCULAR ACCIDENT
It is an acute onset of neurological dysfunction,
because of abnormality in circulation in cerebral
area with resulting signs and symptoms and it
also involves the focal areas of brain. Two
mechanisms resulting in stroke—ischemic and
hemorrhagic. Major risk factors causing stroke are
atherosclerosis, hypertension, smoking,
endocarditis and cardiac disease.
Clinical Features
Headache, nausea, vomiting, dizziness, papill-
edema, shallow respiration and increased heart
rate.
192
CHAPTER TRANSVERSE MYELITIS
4 It is a syndrome not a disease in which acute

inflammation affectes gray and white matter in
one or more adjacent thoracic segments. Etiology
is unknown, but in some cases there is viral
infection, vasculitis.
Clinical Features
Ascending weakness and numbness of feet and
legs, sensorimotor, paraplegia below the lesion,
urinary retention and loss of bowel control, local
back pain, headache and stiff neck.
TRIGEMINAL NEURALGIA
Characterized by paroxysmal attack of severe,
short, sharp, stabbing pain affecting one or more
divisions of the trigeminal nerve. It can be caused
by degeneration of the nerve or compression on
it, though often the cause is unknown. Paroxys-
mal attacks last for several days or weeks, they
are often superimposed on a more constant ache.
When the attacks settle, the patient may remain
pain free for many months.
Clinical Features
Chewing, speaking, washing the face, tooth-
brushing, cold winds or touching a trigger point,
e.g. upper lip or gum, may all precipitate an attack
of pain.
NEUROLOGY
193
WERNICKE’S DYSPHASIA CHAPTER
Occurs due to the lesion of posterolateral left
temporal and inferior parietal region of the left
cortex, i.e. the Wernicke’s area. The person suffer-
4
ing from unaware of the language problem.
Clinical Features
Fluent but nonsensical speech, impairment of
comprehension and writing.
NEUROLOGICAL ASSESSMENT
Reg. No.
Name
Age/sex
Date of admission
Address
Occupation
Referred by (consultant) and hospital
Date of discharge
Discharge summary
Instruction for physiotherapist
Subjective examination
History of present condition
Drug history
Social situation
Normal daily routine
194
CHAPTER GENERAL EXAMINATION
4 •
•
•
Pulse rate
Respiratory rate
Temperature
• Blood pressure
• State of consciousness—Glasgow Coma Scale
On Observation
• Attitude of limbs
• Facial expression
• Deformity
• Posture
– Lying
– Sitting
– Standing
• Pain
– Type
– Onset
– Nature
– Radiation
– Intensity
– Aggravating/relieving factor
– Associated symptoms
– Severity: Visual analog scale
On Palpation
• Temperature
• Tenderness
• Edema: Pitting/non-pitting
NEUROLOGY
195
• Inflammatory sign CHAPTER
4
• Muscle wasting
• Contractures
On Examination
• Range of movement
• Muscle girth
• Limb length
• End feel
– Capsular
– Noncapsular
• Differential tests
• Gait
– Pattern
– Distance
– Velocity
– Walking aids
– Orthoses
• MMT
• Reflexes
– Superficial
– Deep
STATES OF HIGHER FUNCTION

• Orientation
• Consciousness
• Behavior
• Memory
• Intelligent capacity
196
CHAPTER • Counting and calculation
4
• Speech
• Reading and writing
• Vision
• Speech and articulation
• Cranial nerve examination
• Muscle tone
– Spasticity
– Rigidity
– Flaccidity
SENSORY ASSESSMENT
• Pain
• Temperature
• Vibration
• Touch
– Light
– Crude
• Pressure
• Two-point discrimination
• Spine
– Tenderness
– Deformity
• Limb attitude
– Lying
– Sitting
– Standing
• Co-ordination (UL/LL)
• Balance
NEUROLOGY
197
• Bladder and bowel CHAPTER
4
• Dermatomes and myotomes
• Exercise tolerance test
• Fatigue
• Specific investigations/blood test/X-rays/CT
scan/MRI
GLOSSARY OF NEUROLOGICAL TERMS

Acalculia: Inability to calculate
Agnosia: Inability to interpret sensations (types—
auditory, tactile, visual)
Agraphia: Inability to write
Akinesia: Difficulty in initiating movement
Alexia: Inability to read
Amnesia: Partial or total loss of memory
Amusia: Impaired recognition of music
Amyotrophy: Muscle wasting
Aneurysm: An expanded segment of an artery
Anomia: Inability to name objects
Anosmia: Loss of ability to smell
Anosognosia: Existence of a hemiplegic limb
Aphasia: Inability to generate and understand
language
Astereognosis: Inability to perceive shape by
touch
198
CHAPTER Ataxia: Incoordinated voluntary movements
4 Athetosis: Involuntary writhing movements

Bradykinesia: Slowed voluntary movements
Catatonia: Freezing of movements
Charcot’s joint: Damaged joints with neurological
involvement
Chorea: Jerky, irregular, involuntary movement
Clonus: Rhythmic, rapid, repetitive muscle con-
traction associated with increased tone
Dementia: Loss of mental function
Diplegia: Weakness and spasticity, affecting all
limbs but legs more than arms
Diplopia: Double vision
Dysesthesia: Abnormal burning or aching
sensations
Dysarthria: Difficulty in articulating speech
Dysdiadochokinesia: Impaired ability to perform
rapid alternating movement
Dysmetria: Impaired ability to judge the distance
Dysphagia: Difficulty in swallowing
Dysphasia: Difficulty in understanding language
Dysphonia: Difficulty in producing the voice
Dyspraxia: Inability to perform skilled move-
ments
NEUROLOGY
199
Dyssynergia: Impaired ability to complex CHAPTER
4
movements
Dystonia: Abnormal postural movements caused
by mainly co-contraction of agonists and
antagonists group of muscles.
Embolism: Cerebral-blood clot in the circulation
blocking an artery in the brain
Encephalopathy: Disorder of brain substances
Ependymoma: Tumor of brain and spinal cord
Euphoria: An exaggerated felling of wellbeing
Fasciculation: Visible involuntary contraction of
bundles of muscle fibers
Fibrillation: Involuntary contraction of individual
muscle fibers
Glioma: One type of brain tumor
Gliosis: Proliferation of neurological tissue
Graphesthesia: Inability to recognize number,
figures or letter traced onto the skin with blunt
object
Hemianopia: Loss of half of field of vision
Hemiballismus: Violent involuntary movements
of a limb
Hemiparesis: Weakness of one side of the body
Hemiplegia: Paralysis of one side of the body
Homonymous: Affecting the same side
200
CHAPTER Hyperacusis: Increased sensitivity to sound
4 Hyperreflexia: Increased reflexes

Hypertonia: Increased muscles tone
Hypertrophy: Increased size
Hypotonia: Decreased muscles tone
Kinesthesia: Perception of body position and
movements
Miosis: Contraction of pupil
Monoparesis: Weakness of one limb
Myoclonus: Brief shock like involuntary muscular
contraction
Myopathy: Disorder of muscle
Myotonia: State of persistence of muscle
contraction
Nystagmus: Jerk, involuntary movement of eye
Paresthesia: Tingling sensation
Paraparesis: Weakness of both legs
Paraphasia: Inappropriate or incorrect word
during speech
Paraplegia: Paralysis of both legs
Paresis: Muscles weakness
Photophobia: Intolerance to light
Prosopagnosia: Inability to recognize the person
Ptosis: Drooping of upper eyelid
NEUROLOGY
201
Quadrantanopia: Loss of quarter than normal CHAPTER
4
visual field
Quadriparesis: Weakness of all four limbs
Quadriplegia: Paralysis of all four limbs
Scotoma: Area of defective vision
Stereognosis: Tactile perception of shape
Tetraparesis: Quadriparesis
Tetraplegia: Quadriplegia
Tremor: Quivering or continuous shaking
Vertigo: Sensation of movements of one’s body
or of object’s moving about or spinning.
MUSCULOSKELETAL
203
5
CHAPTER
CHAPTER 5
Musculoskeletal
• Muscles listed by function
• Manual muscle testing grading
• Alphabetical listing of the muscles
• Joint range of movement
• Common musculoskeletal tests
• Musculoskeletal pathologies
• Grades of sprain and treatment
• Stages of fracture healing
• Fractures with eponyms
• Musculoskeletal assessment
204
CHAPTER MUSCLES LISTED BY FUNCTION
5 SHOULDER
Flexors: Pectoralis major, deltoid (anterior fibers),
biceps brachii (long head), coracobrachialis.
Extensors: Latissimus dorsi, teres major, pectoralis
major, deltoid (posterior fibers), triceps (long
head).
Abductors: Supraspinatus, deltoid (middle fibers).
Adductors: Coracobrachialis, pectoralis major,
latissimus dorsi, teres major.
Medial rotators: Subscapularis, teres major, latissi-
mus dorsi, pectoralis major, deltoid (anterior
fibers).
Lateral rotators: Teres minor, infraspinatous,
deltoid (posterior fibers).
ELBOW
Flexors: Biceps brachii, brachialis, brachioradialis,
pronator teres.
Extensors: Triceps brachii, anconeus.
Pronators: Pronator teres, pronator quadratus.
Supinators: Supinator, biceps brachii.
WRIST
Flexors: Flexor carpi radialis, flexor carpi ulnaris,
palmaris longus, flexor digitorum superficialis,
MUSCULOSKELETAL
205
flexor digitorum profundus, flexor pollicis CHAPTER
5
longus.
Extensors: Extensor carpi radialis brevis, extensor
carpi radialis longus, extensor carpi ulnaris,
extensor digitorum, extensor digiti minimi,
extensor pollicis longus, extensor pollicis brevis,
extensor indicis.
Radial deviation: Flexor carpi radialis, extensor
carpi radialis longus, extensor carpi radialis
brevis, abductor pollicis longus, extensor pollicis
longus, extensor pollicis brevis.
Ulnar deviation: Extensor carpi ulnaris, flexor carpi
ulnaris.
FINGERS
Flexors: Flexor digitorum profundus, flexor
digitorum superficialis, lumbricals, Flexor digiti
minimi brevis.
Extensors: Extensor digiti minimi, extensor digito-
rum, extensor indicis, lumbricals.
Abductors: Abductor digiti minimi, opponens
digiti minimi, dorsal interossei.
Adductors: Palmaris interossei.
THUMB
Flexors: Flexor pollicis longus, flexor pollicis
brevis.
206
CHAPTER Extensors: Extensor pollicis longus, extensor
5
pollicis brevis, abductor pollicis longus.
Abductors: Abductor pollicis longus, abductor
pollicis brevis.
Adductors: Adductor pollicis.
Opposition: Opponens pollicis.
HIP
Flexors: Psoas major, iliacus, rectus femoris,
sartorius, pectineus.
Extensors: Gluteus maximus, semitendinosus,
semimembranosus, biceps femoris.
Abductors: Gluteus maximus, gluteus medius,
gluteus minimus, sartorius, tensor fasciae latae,
piriformis.
Adductors: Adductor longus, adductor magnus,
adductor brevis, gracilis, pectineus.
Medial rotators: Gluteus medius, gluteus minimus,
tensor fasciae latae.
Lateral rotators: Gluteus maximus, piriformis,
gemellus superior, gemellus inferior, obturator
internus, obturator externus, sartorius.
KNEE
Flexors: Semitendinosus, semimembranosus,
biceps femoris, gastrocnemius, gracilis, sartorius,
plantaris, popliteus.
MUSCULOSKELETAL
207
Extensors: Rectus femoris, vastus medialis, vastus CHAPTER
5
lateralis, vastus intermedius, tensor fasciae latae.
Medial rotators: Semitendinosus, semimembran-
osus, sartorius, gracilis, popliteus.
Lateral rotators: Biceps femoris.
ANKLE
Dorsiflexors: Tibialis anterior, extensor digitorum
longus, extensor hallucis longus, peroneus tertius.
Plantar flexors: Gastrocnemius, soleus, plantaris,
peroneus longus, tibialis posterior, flexor digi-
torum longus, flexor hallucis longus, peroneus
brevis.
Invertors: Tibialis anterior, tibialis posterior.
Evertors: Peroneus longus, peroneus brevis,
peroneus tertius.
TOES
Flexors: Flexor digitorum longus, flexor digitorum
accessorius, flexor digitorum brevis, flexor
hallucis longus, flexor hallucis brevis, flexor digiti
minimi brevis, interossei, lumbricals, abductor
hallucis.
Extensors: Extensor hallucis longus, extensor
digitorum longus, extensor digitorum brevis,
lumbricals, interossei.
Abductors: Abductor hallucis, abductor digiti
minimi, dorsal interossei.
Adductors:Adductor hallucis, plantar interossei.
208
CHAPTER SCAPULA
5 Protractors: Serratus anterior, pectoralis minor.

Retractors: Rhomboid major, rhomboid minor,
trapezius, levator scapulae.
Elevators: Trapezius, levator scapulae.
Depressors: Trapezius.
Medial rotators: Rhomboid major, rhomboid
minor, pectoralis minor, levator scapulae.
Lateral rotators: Trapezius, serratus anterior.
HEAD AND NECK

Flexors: Longus colli, longus capitis, anterior
sternocleidomastoid, scalenus anterior.
Lateral flexors: Erector spinae, rectus capitis
lateralis. Scalene (anterior, middle and posterior),
splenius cervicis, splenius capitis, trapezius,
levator scapulae, sternocleidomastoid.
Extensors: Splenius cervicis, levator scapulae,
trapezius, splenius capitis, semispinalis, superior
oblique, sternocleidomastoid, erector spinae,
rectus capitis posterior major, rectus capitis
posterior minor.
Rotators: Semispinalis, multifidus, scalenus
anterior, splenius cervicis, sternocleidomastoid,
splenius capitis, rectus capitis posterior major,
inferior oblique.
MUSCULOSKELETAL
209
TRUNK CHAPTER
Flexors: Rectus abdominis, external oblique,
internal oblique, psoas major, psoas minor,
iliacus.
5
Rotators: Multifidus, rotatores, semispinalis,
internal oblique, external oblique.
Lateral flexors: Quadratus lumborum, intertrans-
versarii, external oblique, internal oblique, erector
spinae, multifidus.
Extensors: Quadratus lumborum, multifidus,
semispinalis, erector spinae, interspinales,
rotatores.
MANUAL MUSCLE TESTING GRADING
Grade Response
0 No movement
1 Flicker of contraction
2 Active movement with gravity eliminated
3 Active movement against gravity
4 Active movement against resistance but not to full
strength
5 Normal in power
Note
Grade 4 may be divided into
4 – Movements against slight resistance.
4 + Movements against strong resistance.
210
CHAPTER ALPHABETICAL LISTING OF THE MUSCLES
5 ABDUCTOR DIGITI MINIMI (FOOT)

Origin: Medial and lateral process of the calcaneal
tuberosity, plantar aponeurosis, intermuscular
septum.
Insertion: Lateral side of base of proximal phalanx
of fifth toe.
Nerve: Lateral plantar nerve (S1–S3).
Action: Abducts fifth toe.
ABDUCTOR DIGITI MINIMI (HAND)
Origin: Pisiform, tendon of flexor carpi ulnaris,

pisohamate ligament.
Insertion: Ulnar side of base of proximal phalanx
of little finger.
Nerve: Ulnar nerve (C8, T1).
Action: Abducts little finger.
MMT: Place the palm over a table and try to
abduct the little finger in full abduction without
resistance shows grade III power.
ABDUCTOR HALLUCIS
Origin: Flexor retinaculum, calcaneal tuberosity,

plantar aponeurosis, intermuscular septum.
Insertion: Medial side of the base of proximal
phalanx of great toe.
MUSCULOSKELETAL
211
Nerve: Medial plantar nerve (S1, S2). CHAPTER
Action: Abduct and flexes great toe.
MMT: Stand erect with equal body weight on both
legs. Try to abduct the great toe. Full abduction
5
shows grade III power.
ABDUCTOR POLLICIS BREVIS
Origin: Flexor retinaculum, tubercles of scaphoid

and trapezium, tendon of abductor pollicis
longus.
Insertion: Radial side of base of proximal phalanx
of thumb.
Nerve: Median nerve (C8, T1).
Action: Abducts thumb.
Manual muscle testing (MMT): Put your palm in
mid prone position over a table, abduct your
thumb. Full abduction shows grade III power.
ABDUCTOR POLLICIS LONGUS
Origin: Upper part of posterior surface of ulna,

middle third of posterior surface of radius,
interosseous membrane.
Insertion: Radial side of first metacarpal base,
trapezium.
Nerve: Posterior interosseous nerve (C7, C8).
Action: Abducts and extends thumb, abducts
wrist.
212
CHAPTER MMT: Put your palm in mid-prone position over
5
a table, try to abduct and extend your thumb. Full
range of motion shows grade III power.
ADDUCTOR BREVIS
Origin: External aspect of body and inferior ramus

of pubis.
Insertion: Upper half of linea aspera.
Nerve: Obturator nerve (L2, L3).
Action: Adducts hip.
MMT: Same as for adductor longus.
Stretching: Patient lies supine, therapist stand at
right side of patient with his left hand at patient’s
right hip and right hand over patient’s right ankle.
Then he abducts the leg with his right hand upto
a full range, where the person feels stretching at
the medial aspect of the right thigh.
ADDUCTOR HALLUCIS
Origin: Oblique head—base of second to fourth

metatarsal, sheath of peroneus longus tendon;
transverse head-plantar metatarsophalangeal
ligaments of lateral three toes.
of great toe.
Nerve: Lateral plantar nerve (S2, S3).
Action: Adducts great toe.
MUSCULOSKELETAL
213
MMT: Stand erect over a platform with your great CHAPTER
5
toe in abducted position. The therapist keep his
index finger at the lateral side of the toe and resist
your adduction of great toe. Full range of motion
ADDUCTOR LONGUS
Origin: Front of pubis.

Insertion: Middle third of linea aspera.
Nerve: Anterior division of obturator nerve (L2–L4).
Action: Adducts thigh.
MMT: Patients in side lying. Uppermost limb in
25° abduction supported by examiner. Therapist
standing behind patient at knee level, his hand
give resistance to the lowermost limb at the
medial surface of distal femur, just proximal to
the knee resistance is directed straight downward
towards the table.
Full range of action against gravity shows
grade III power while against resistance show
grade V power.
ADDUCTOR MAGNUS
Origin: Inferior ramus of pubis, conjoined ischial

ramus, inferolateral aspect of ischial tuberosity.
Insertion: Linea aspera, proximal part of medial
supracondylar line.
214
CHAPTER Nerve: Obturator nerve and tibial division of
5
sciatic nerve (L2–L4).
Action: Adducts thigh.
MMT: Same as above.
ADDUCTOR POLLICIS
Origin: Oblique head: Palmar ligaments of carpus,

flexor carpi radialis tendon, base of second to
fourth metacarpals, capitate, transverse head-
palmar surface of third metacarpal.
Insertion: Base of proximal phalanx of thumb.
Action: Adducts thumb.
MMT: Forearm in pronation, wrist in neutral and
thumb relaxed and hanging down in abduction.
Therapist stabilize the all metacarpals by grasping
the patient’s hand around the ulnar side, ask
patient to adduct the thumb. Full range of
motion with no resistance shows grade III power.
ANCONEUS
Origin: Posterior surface of lateral epicondyle of

humerus.
Insertion: Lateral surface of olecranon, upper
quarter of posterior surface of ulna.
Nerve: Radial nerve (C6–C8).
Action: Extends elbow.
MUSCULOSKELETAL
215
MMT: Patients prone on table with arm in 90° CHAPTER
5
abduction and forearm flexed and hanging
vertically over the side of the table. Therapist
provides support just above the elbow. Patients
extend elbow to end of available range. Full
range of motion with no resistance shows
grade III power.
BICEPS BRACHII
Origin: Long head: Supraglenoid tubercle of

scapula and glenoid labrum.
Short head: Apex of coracoid process.
Insertion: Posterior part of radial tuberosity,
bicipital aponeurosis into deep fascia over
common flexion origin.
Nerve: Musculocutaneous nerve (C5, C6).
Action: Flexes shoulder and elbow, supinate
forearm.
MMT: Patient in short sitting, with forearms at
side and testing forearm in supination. Therapist
cups the test elbow. Patient flexes elbow through
range of motion. Full range of motion without
Stretching: Patient in supine lying with right upper
limb fully extended and hanging by the side of
bed. Therapist right hand over the patient wrist
and left hand at back of elbow to prevent flexion
put the limb in the full extension starting from
216
CHAPTER wrist, then elbow and upto shoulder till a stretch
5
is felt over anterior arm.
BICEPS FEMORIS
Origin: Long head: Ischial tuberosity, sacrotuberous

ligament.
Short head: Lower half of lateral lip of linea
aspera, lateral supracondylar line of femur, lateral
intramuscular septum.
Insertion: Head of fibula, lateral tibia condyle.
Nerve: Sciatic nerve (L5–S2).
Long head—tibial division.
Short head—common peroneal division.
Action: Flexes knee and extends hip, laterally
rotates tibia on femur.
MMT: Prone with knee flexed to less than 90°. Leg
is in external rotation (toe pointing laterally).
Patient flexes knee, maintaining leg in external
rotation (heel away from examiner, toes pointing
toward examiner).
Full range of motion without resistance shows
grade III power.
BRACHIALIS
Origin: Lower half of anterior surface of humerus,

intermuscular septum.
Insertion: Coronoid process and tuberosity of ulna.
MUSCULOSKELETAL
217
Nerve: Musculocutaneous nerve (C5, C6) radial CHAPTER
5
nerve (C7).
Action: Flexes elbow.
MMT: All is same as for biceps brachii except
forearm in pronation.
Stretching: Same as for biceps brachii.
BRACHIORADIALIS
Origin: Upper two-third of lateral supracondylar

ridge of humerus lateral intermuscular septum.
Insertion: Lateral side of radius above styloid
process.
Nerve: Radial nerve (C5, C6).
Action: Flexes elbow.
MMT: All same as for biceps brachii except
forearm in mid-position between pronation and
supination.
CORACOBRACHIALIS
Origin: Apex of coracoid process.

Insertion: Midway along medial border of
humerus.
Nerve: Musculocutaneous nerve (C5–C7).
Action: Adducts shoulder and acts as weak flexor.
MMT: Patient in short sitting, arm at side with
elbow slightly flexed and forearm pronated.
218
CHAPTER Patient flexes shoulder to 90°. Complete test range
5
(90°) shows grade III power.
DELTOID
Origin: Clavicle (anterior superior border of lateral

1/3 of shaft).
Insertion: Humerus (deltoid tuberosity on shaft).
Nerve: Axillary nerve (C5, C6).
Action: Anterior fibers: Flex and medially rotate
shoulder.
Middle fibers: Abduct shoulder.
Posterior fibers: Extend and laterally rotate
shoulder.
MMT:
• For anterior deltoid, the test is same as for
coracobrachialis.
• For middle fibers—position of hand is side-
way and action is to abduct the shoulder upto
90°.
• For posterior fibers—hand in side way and
action is extension upto 90° with lateral
rotation.
• Full range (test range 90°) of function shows
grade III power.
DIAPHRAGM
Origin: Posterior surface of xiphoid process, lower

six costal cartilages and adjoining ribs on each
MUSCULOSKELETAL
219
side, medial and lateral arcuate ligament, antero- CHAPTER
5
lateral aspect of bodies of lumbar vertebrae.
Insertion: Central tendon.
Nerve: Phrenic nerve (C3–C5).
Action: Draw central tendon inferiorly, changes
volume and pressure of thoracic and abdominal
cavities.
MMT: Patient lies supine. Therapist standing next
to patient at approximately waist level. One hand
is placed lightly on the abdomen in the epigastric
area just below the xiphoid process. Patient
inhales with maximal effort and holds maximum
inspiration. Completion of maximal inspiratory
expansion shows grade III power.
DORSAL INTEROSSEI (FOOT)
Origin: Proximal half of sides of adjacent

metatarsals.
Insertion: Bases of proximal phalanges and dorsal
digital expansion (first attaches medially to
second toe; second, third and fourth attach late-
rally to second, third and fourth toes respectively).
Action: Abducts toes, flexes metatarsophalangeal
joints.
220
CHAPTER DORSAL INTEROSSEI (HAND)
5 Origin: Adjacent side of two metacarpal bones

(four bipennate muscles).
Insertion: Bases of proximal phalanges and dorsal
digital expansions (first attaches laterally to index
finger; second and third attach to both sides of
middle finger; fourth attaches medially to ring
finger).
Action: Abducts index, middle and ring fingers,
flexes metacarpophalangeal joints and extends
interphalangeal joints.
EXTENSOR CARPI RADIALIS BREVIS
Origin: Lateral epicondyle via common extensor

tendon.
Insertion: Posterior surface of base of third
metacarpal.
Nerve: Posterior interosseous branch of radial
nerve (C7, C8).
Action: Extends and abducts wrist.
MMT: Patient in short sitting. Elbow is flexed,
forearm is fully pronated, and both are supported
on the table. Therapist supports the patient’s
forearm. The patient then extends and abducts the
wrist. Completion of full range of motion with no
MUSCULOSKELETAL
221
EXTENSOR CARPI RADIALIS LONGUS CHAPTER
Origin: Lower third of lateral supracondylar ridge

of humerus, intermuscular septa. 5
Insertion: Posterior surface of base of second meta-
carpal.
Action: Extends and abducts wrist.
MMT: Same as for extensor carpi radialis brevis,
but the patient will only extend the wrist.
EXTENSOR CARPI ULNARIS
Origin: Lateral epicondyle via common extension

tendon.
Insertion: Medial side of fifth metacarpal base.
Action: Extends and adducts wrist.
MMT: All is same as for extensor carpi radialis
longus except that patient will extend the wrist
with ulnar deviation.
EXTENSOR DIGITI MINIMI

tendon, intermuscular septa.
Insertion: Dorsal digital expansion of fifth digit.
Action: Extends fifth digit and wrist.
222
CHAPTER MMT: Patient’s forearm in pronation, wrist in
5
neutral, MP joints and IP joints are in relaxed
flexion position. Therapist stabilizes the wrist in
neutral. Patient extends the MP joint of 5th digit.
Complete active range with no resistance shows
grade III power.
EXTENSOR DIGITORUM

tendon, intermuscular septa.
Insertion: Lateral and dorsal surface of second to
fifth digits.
Nerve: Posterior interosseous branch of radial
nerve (C7, C8).
Action: Extends fingers and wrist.
MMT: Position same as for extensor digiti minimi,
patient extends MP joint (all finger simulta-
neously), allowing the IP joints to be in slight
flexion. Complete active range, with no resistance
EXTENSOR DIGITORUM BREVIS
Origin: Calcaneus (anterior superolateral surface),

lateral talocalcaneal ligament. Extensor retina-
culum (inferior).
Insertion: Base of proximal phalanx of great toe,
lateral side of dorsal hood of adjacent three toes.
Nerve: Deep peroneal nerve (L5, S1).
MUSCULOSKELETAL
223
Action: Extends great toe and adjacent three toes. CHAPTER
MMT: Patient in short sitting, with foot on
examiner’s lap. Alternate position supine. Ankle
in neutral position, therapist sitting on low stool
5
in front of patient, or standing beside table near
the patient’s foot. One hand stabilizes the
metatarsals with the fingers on the plantar surface
and the thumb on the dorsum of foot. If patient
can extend the toes to complete range without
resistance, it shows grade III power.
EXTENSOR DIGITORUM LONGUS
Origin: Upper three quarter of medial surface of

fibula, interosseous membrane, lateral tibial
condyle.
Insertion: Middle and distal phalanges of four
lateral toes.
MMT: Same as for extensor digitorum brevis.
EXTENSOR HALLUCIS LONGUS
Origin: Fibula (shaft, middle ½ of medial aspect),

Insertion: Hallux (distal phalanx, dorsal aspect of
bases), expansion to proximal phalanx.
Nerve: Deep peroneal nerve (L5).
Action: Extends great toe, ankle dorsiflexor.
224
CHAPTER MMT: Patient’s and therapist’s position same as
5
for extensor digitorum longus and brevis.
Therapist stabilizes the metatarsal area by
contouring the hand around the plantar surface
of the foot, with the thumb curving around to the
base of the hallux. The other hand stabilizes the
foot at the heel. If the patient can extend the great
toe upto full range without resistance, it shows
grade III power.
EXTENSOR INDICIS
Origin: Lower part of posterior surface of ulna,

Insertion: Dorsal digital expansion on back of
proximal phalanx of index finger.
Action: Extends index finger and wrist.
MMT: Patient’s forearm in pronation, wrist in
neutral, MP joint and IP joint are in relaxed flexion
posture. Therapist stabilizes the wrist in neutral,
patient extends the MP joint of the index finger.
Complete range of extension shows grade III
power.
EXTENSOR POLLICIS BREVIS
Origin: Radius (posterior surface), interosseous

membrane.
MUSCULOSKELETAL
225
Insertion: Dorsolateral base of maximal phalanx of CHAPTER
5
thumb.
Action: Extends thumb and wrist, abducts wrist.
MMT: Patient’s forearm in mid-prone position
and wrist in neutral; CMC and IP joints of thumb
are relaxed and in slight flexion. The MP joint of
the thumb is in abduction and flexion. Therapist
stabilizes the first metacarpal firmly, allowing
motion to occur only at the MP joint. If the patient
moves proximal phalanx of the thumb through
full range of extension, it shows grade III power.
EXTENSOR POLLICIS LONGUS
Origin: Ulna (middle 3rd of posterior surface),

Insertion: Dorsal surface of distal phalanx of
thumb.
Action: Extends thumb and wrist, abducts wrist.
MMT: Same as for extensor pollicis brevis.
EXTERNAL OBLIQUE
Origin: Ribs 5–12 (interdigitating on external and

inferior surface).
Insertion: Iliac (rest outer border) thoracolumbar
fascia, linea alba, aponeurosis from 9th costal
226
CHAPTER cartilage to ASIS, both sides meet at midline to
5
form linea alba, pubic symphysis (upper border).
Nerve: Ventral rami of lower six thoracic nerve
(T7–T12).
Action: Flexes, laterally flexes and rotates trunk.
MMT: Patient in supine with arms outstretched
above plane of body. Ask the patient to lift your
head and shoulders from the table taking your
right elbow toward your left knee. Then lift the
shoulder from the table, taking your left elbow
towards right knee. The patient is able to perform
this at full range, it shows grade III power.
FLEXOR CARPI RADIALIS
Origin: Medial epicondyle via common flexor

tendon.
Insertion: Front of base of second and third
metacarpals.
Nerve: Median (C6, C7).
Action: Flexes and abducts wrist.
MMT: Patient in short sitting forearm is supported
on its dorsal surface in a table. To start, forearm
is supinated and wrist is in neutral position. The
therapist supports the patient’s forearm under the
wrist. The patient flexes the wrist in radial
deviation. Full range of motion without resistance
MUSCULOSKELETAL
227
FLEXOR CARPI ULNARIS CHAPTER
Origin: Humeral head: Medial epicondyle via

common flexor tendon. 5
Ulnar head: Medial border of olecranon and upper
2/3rd of border of ulna.
Insertion: Pisiform, hook of hamate and base of
fifth metacarpal.
Nerve: Ulnar nerve (C7–T1).
Action: Flexes and adducts wrist.
MMT: Patient’s and therapist’s position same as
for flexor carpi radialis. Patient flexes the wrist in
ulnar deviation. Full range of motion without
FLEXOR DIGITI MINIMI BREVIS (FOOT)
Origin: Plantar aspect of base of fifth metatarsal,

sheath of peroneus longus tendon.
of fifth toe.
Action: Flexes fifth metatarsophalangeal joint,
supports lateral longitudinal arch.
FLEXOR DIGITI MINIMI BREVIS (HAND)
Origin: Hook of hamate, flexor retinaculum.

Insertion: Ulnar side of base of proximal phalanx
of little finger.
228
CHAPTER Nerve: Ulnar nerve (C8, T1).
5 Action: Flexes little finger.
FLEXOR DIGITORUM ACCESSORIUS
Origin: Medial head—medial tubercle of

calcaneus, lateral head—lateral tubercle of
calcaneus and long plantar ligament.
Insertion: Flexor digitorum longus tendon.
Nerve: Lateral plantar nerve (S1–S3).
Action: Flexes distal phalanges of lateral fourth
toes.
FLEXOR DIGITORUM BREVIS
Origin: Calcaneal tuberosity, plantar aponeurosis,

intermuscular septa.
Insertion: Tendons divide and attach to the both
sides of the middle phalanges of second to fifth
toes.
Nerve: Medial plantar nerve (S1, S2).
Action: Flexes proximal interphalangeal joints and
metatarsophalangeal joints of lateral four toes.
MMT: Patients in short sitting with foot on
examiner’s lap or supine. Therapist sitting on
short stool in front of patient or standing at side
of table near patient’s foot. His one hand grasp
the anterior foot with the finger’s placed across
the dorsum of the foot and the thumb under the
MUSCULOSKELETAL
229
proximal phalanges or digital phalanges. Patient CHAPTER
5
is asked to flex the toes. Full range of flexion
without resistance shows grade III power.
FLEXOR DIGITORUM LONGUS
Origin: Medial part of posterior surface of tibia,

deep transverse fascia.
Insertion: Plantar aspect of base of distal phalanges
of second to fifth toes.
Nerve: Tibial nerve (L5–S2).
Action: Flexes lateral four toes, plantar flexes
ankle.
MMT: Same as for flexor digitorum brevis.
FLEXOR DIGITORUM PROFUNDUS
Origin: Ulna (proximal 3/4th of anterior and

medial shaft, medial coracoid process), inter-
osseous membrane (ulnar).
Insertion: Four tendons to digits 2–5 (distal
phalanges, at the base of palmar surface).
Nerve: Medial part—ulnar nerve (C8, T1).
Lateral part—anterior interosseous branch of
median nerve (C8,T1).
Action: Flexes fingers and wrist.
MMT: Patient’s forearm in supination, wrist in
neutral and PIP joint in extension. Therapist
stabilizes middle phalanx in extension by
230
CHAPTER grasping in on either side. Patient flexes distal
5
phalanx of each finger individually. Full range of
motion without resistance shows grade III power.
FLEXOR DIGITORUM SUPERFICIALIS
Origin: Humero-ulnar head—humerus (medial

epicondyle via common flexion tendon).
Ulna (medial collateral ligament of elbow joint);
coronoid process (medial side).
Intermuscular septum.
Radial head—radius (oblique line on anterior
shaft).
Insertion: Four tendon arranged in two pairs:
Superficial pair—middle and ring fingers (side of
the middle phalanges).
Deep pair—index and little fingers (side of middle
phalanges).
Nerve: Median (C8, T1).
Action: Flexes fingers and wrist.
MMT: Patient’s forearm supinated, wrist at
neutral, finger to be tested is in slight flexion at
the MP joint. Therapist holds all fingers (except
one being tested) in extension at all joints.
Isolation of the index finger may not be complete.
Each of four fingers is tested separately. Patient
flexes the PIP joint without flexing the DIP joint.
Do not allow motion of any joint of the other
fingers. Flick the terminal end of the finger being
tested with the thumb to make certain that the
MUSCULOSKELETAL
231
flexor digitorum profundus is not active; that is CHAPTER
5
the DIP joint goes into extension. The distal
phalanx should be floppy. Ask the patient “bend
your index [then long, ring or little] finger, hold
it. Full range of motion without resistance shows
grade III power.
FLEXOR HALLUCIS BREVIS
Origin: Medial side of plantar surface of cuboid,

lateral cuneiform.
Insertion: Medial and lateral side of base of proxi-
mal phalanx of great toe.
Nerve: Medial plantar nerve (S1, S2).
Action: Flexes metatarsophalangeal joint of great
toe.
MMT: Patient in short sitting, with legs hanging
over edge of table. Ankle is in neutral position,
therapist sitting on low stool infront of patient.
Test foot rests on examiner’s lap. One hand is
contoured over the dorsum, of the foot just below
the ankle for stabilization. The index finger of the
other hand is placed beneath the proximal
phalanx of the great toe alternatively, the tip of
the finger is placed up under the proximal
phalanx. Patient flexes great toe. Full range of
great toe flexion shows grade III power.
GASTROCNEMIUS
Origin: Medial head—femur (posterior part of
medial condyle).
232
CHAPTER Lateral head—femur (lateral surface of lateral
5
condyle).
Insertion: Posterior surface of calcaneus.
Nerve: Tibial nerve (S1, S2).
Action: Plantar flexes ankle, flexes knee.
MMT: The patient stands over testing limb with
one or two fingers supported over a table. Patient
attempts to raise heel from base consecutively
through full range of plantar flexion. Ask him to
“stand on your right leg. Go up on your tiptoes.
Now down. Repeat this 20 times”. If the patient
completes nine times or above and one heel raise
correctly with no rest or fatigue it shows grade
III power.
Stretching: Standing on the steps with the ball of
the toes.
GEMELLUS INFERIOR
Origin: Upper part of ischial tuberosity.

Insertion: With obturator internus tendon into
medial surface of greater trochanter.
Nerve: Nerve to quadratus femoris (L5, S1).
Action: Laterally rotates hip.
MMT: Patient is in short sitting. The therapist sit
over a low stool towards the testing limb. One
hand is contoured over the distal thigh (lateral
MUSCULOSKELETAL
233
aspect). Patient attempts to externally rotate the CHAPTER
5
hip. If the patient can hold the end position, it
Stretching: Patient is supine, lying with hip and
knee joint of testing limb in 90°. Therapist is
standing beside the patient and facing the hip
joint. His left hand stabilizes the thigh of the
patient, while his right hand is grasping the lower
leg. Therapist performs medial rotation.
GEMELLUS SUPERIOR
Origin: Ischial spine (gluteal surface).

Insertion: Greater trochanter (with obturator
internus tendon into medial surface).
Nerve: Nerve to obturator internus (L5, S1).
MMT and stretching: Same as G. inferior.
GLUTEUS MAXIMUS
Origin: Ilium (posterior gluteal line, posterior

border, adjacent part of iliac crest), aponeurosis
of erector spinae, sacrum (posterior aspect) side
of coccyx, sacrotuberous ligament, gluteal
aponeurosis.
Insertion: Iliotibial tract of fascia lata, femur
(gluteal tuberosity).
Nerve: Inferior gluteal nerve (L5–S2).
234
CHAPTER Action: Extends, laterally rotates and abducts hip.
5 MMT: Patient is on prone lying. Therapist stands

at side of testing limb at the level of pelvis. Ask
patient to lift the leg towards ceiling. If the patient
can hold the full range of motion, it shows grade
III power.
Stretching: (Passive): Patient lies supine. Therapist
stands beside the patient and facing the limb.
Therapists right hand grasping the ankle while his
left hand holds the knee posteriorly. The leg is
lifted with hip and knee flexed, towards the
cranial side of the patient.
Self-stretching
Position: Knee sitting.
Procedure: Patient flexing hip and knee himself, in
supine with the help of both hands.
GLUTEUS MEDIUS
Origin: Gluteal surface of ilium between posterior

and anterior gluteal line.
Insertion: Greater trochanter (anterolateral ridge).
Nerve: Superior gluteal nerve (L4–S1).
Action: Abducts and medially rotates hip.
MMT: Patient in side-lying with testing leg in
uppermost position. The therapist stands behind
patient. For palpating the muscle, he puts his
hand just proximal to the greater trochanter of the
femur. Ask him to abduct hip through complete
MUSCULOSKELETAL
235
range of motion without flexed hip or rotation. CHAPTER
5
Full range of motion and holds at end position,
Stretching: Patient lies supine. Therapist stands
beside the patient and faces the hip joint.
Therapist left hand stabilizes the opposite leg of
patient, while his right hand grasping lower thigh,
therapist right hand pushes the leg inside.
GLUTEUS MINIMUS
Origin: Ilium (gluteal surface between anterior

and inferior gluteal lines).
Insertion: Anterior lateral ridge on greater
trochanter.
Action: Abducts and medially rotates hip.
MMT and stretching: Same as G. medius.
GRACILIS
Origin: Pubis (interior ramus and lower half of

body), adjacent ischial ramus.
Insertion: Tibia (upper part of medial surface).
Nerve: Obturator nerve (L2, L3).
Action: Flexes knee, adducts hip, medially rotates
tibia on femur.
MMT: Same as for hip adductors.
Stretching: Patient in supine lying. Therapist stand
236
CHAPTER beside the patient and facing the hip joint. His left
5
hand stabilizes the opposite leg, while his right
hand grasping the lower thigh and the leg is
placed on the therapist forearm. Leg is pulled
apart by the therapist’s right hand.
ILIACUS
Origin: Iliacus fossa (superior 2/3), iliac crest

(inner lip), ala of sacrum, sacroiliac and iliolumbar
ligaments.
Insertion: Blends with insertion of psoas major into
lesser trochanter.
Nerve: Femoral nerve (L2, L3).
Action: Flexes hip and trunk.
MMT: Patient in short sitting with thigh over table
and leg hanging at the edge. Therapist stands at
the testing side. Ask the patient to lift off his leg.
Full range of motion, shows grade III power.
Stretching: Patient in side-lying. Therapist is
standing beside the patient, facing the hip joint.
Therapist’s left hand stabilizes the patient pelvis,
while his right hand grasping the upper thigh and
the leg is resting on the forearm of the therapist.
Patients thigh is lifted by the therapist’s right
hand and performing the extension movement of
the hip.
ILIOCOSTALIS CERVICIS
Origin: Angles of third to sixth ribs.

MUSCULOSKELETAL
237
Insertion: Posterior tubercles of transverse process CHAPTER
5
of C4 to C6.
Nerve: Dorsal rami.
Action: Extends and laterally flexes vertebral.
MMT: Patient in prone with head off at the edge
of table. Therapist puts one hand below patient’s
forehead. Ask patient to extend neck without
tilting chin, or looking up full range of motion,
ILIOCOSTALIS LUMBORUM
Origin: Sacral crest (medial and lateral) spines of

T 11 , T 12 and lumbar vertebrae and their
supraspinous ligament, medial part of iliac crest.
Insertion: Angle of lower six or seventh ribs.
Nerve: Dorsal rami.
Action: Extends and laterally flexes vertebral
column.
MMT: Patient in prone with arms at side.
Therapist stands at side of table, stabilizing lower
extremities just above the ankle. Ask patient to
raise his head, arms, and chest from the table as
high as he can. Full range of motion, shows
grade III power.
Stretching: Patient in long sitting. Ask him to put
his hands together in front of his foot and try to
cross the toes by his finger as much as he can,
looking towards his lower legs.
238
CHAPTER ILIOCOSTALIS THORACIS
5 Origin: Angle of lower six ribs.

Insertion: Angle of upper six ribs, transverse
process of C7.
Nerve: Dorsal rami.
Action: Extend and laterally flexes vertebral
column.
MMT: Same as for iliocostalis lumborum.
INFERIOR OBLIQUE
Origin: Lamina of axis.

Insertion: Transverse process of atlas.
Nerve: Dorsal ramus (C1).
Action: Rotates atlas and head.
INFRASPINATUS
Origin: Infraspinous fossa and its medial 2/3.

Insertion: Humerus (middle facet on greater
tubercle), shoulder joint (posterior aspect of
capsule).
Nerve: Suprascapular nerve (C5, C6).
Action: Laterally rotates shoulder.
MMT: Patient prone with head turned towards
test side. Abduct the shoulder to 90° with arms
supported on table. Forearm hanging vertically
over the edge. Place folded towel under the arm
MUSCULOSKELETAL
239
at the edge. Ask patient to move forearm upwards CHAPTER
5
through the range of external rotation. Full range
of motion, shows grade III power.
Stretching: Patient in supine lying. Therapist
stands beside patient and faces the limb. The
therapist now grasps the lower arm of the patient
with his left hand and with right hand grasping
the wrist and applying the stretch force towards
the medial rotation.
INTERCOSTALIS EXTERNI
Origin: Lower border of the rib above.

Insertion: Upper border of the rib below.
Nerve: Intercostal nerves.
Action: Elevate ribs below towards rib above to
increase thoracic cavity volume for inspiration.
MMT: Patient lies supine. Therapist stands at the
side. Tape measure placed lightly around thorax
at level of xiphoid. Ask patient to hold maximal
inspiration for measurement and then hold
maximal expiration for a second measurement.
The difference between the two measurements is
recorded as chest expansion.
INTERCOSTALIS INTERNI
Origin: Lower border of costal cartilage and costal

groove of rib above.
Insertion: Upper border of rib below.
240
CHAPTER Nerve: Intercostal nerves.
5 Action: Draw ribs downwards to decrease thoracic

cavity volume for expiration.
MMT: Same as for I. externi.
INTERNAL OBLIQUE
Origin: Inguinal ligament (lateral 2/3), iliac crest

(anterior 2/3 of intermediate line), thoracolumbar
fascia.
Insertion: Lower four ribs and their cartilages,
pubic crest, abdominal aponeurosis to linea alba.
Nerve: Ventral rami of lower six thoracic nerves,
first lumbar nerve.
Action: Flexes, lateral flexes and rotates trunk.
MMT: Patient is supine with arms outstretched
in full extension above the plane of body. Ask
patient to raise his head, shoulders and arm off
the table. Full range of motion, shows grade III
power.
Stretching: Patient lies prone on table. Ask him to
lift his head, shoulder and upper trunk as much
as possible and turn towards one side to look at
the ceiling of that side. The opposite side of the
muscle will feel stretch.
INTERSPINALIS
Origin and insertion: Extend between adjacent

spinous processes.
MUSCULOSKELETAL
241
Nerve: Dorsal rami of spinal nerves. CHAPTER
Action: Extend and stabilize vertebral column.
MMT: Same as for iliocostalis muscles. 5
INTERTRANSVERSARII
Origin: Cervical and lumbar vertebrae (transverse

process).
Insertion: Transverse process of vertebra, superior
to origin.
Nerve: Ventral and dorsal rami of spinal nerve.
Action: Laterally flex lumbar and cervical spine,
stabilize vertebral column.
ISCHIOCAVERNOSUS
In the female
Origin: Ischium (tuberosity and ramus), crus

clitoridis (surface).
Insertion: Aponeurosis inserting into side and
inferior surface of crus clitoridis.
Nerve: Pudendal nerve (S2–S4).
Action: Compress crus clitoridis, retarding venous
return and thus assisting erection.
In the male
Origin: Ischium (tuberosity, medial aspect dorsal

to crus penis and ischial rami).
242
CHAPTER Insertion: Aponeurosis into the sides and under
5
surface of the body of the penis.
Nerve: S 2–S 4 spinal nerves (pudendal nerve,
perineal branch, ventral rami).
Action: Compression of crus penis, maintaining
erection by retarding return of blood through the
veins.
LATERAL CRICOARYTENOID
Origin: Cricoid cartilage (cranial border of arch).

Insertion: Arytenoid cartilage on same side (front
of muscular process).
Nerve: Vagus (X) nerve (recurrent laryngeal
branch).
Action: Closes glottis by rotating arytenoid cartil-
ages medially, approximating (adducting) the
vocal folds for speech.
LATISSIMUS DORSI
Origin: Spinous process of lower six thoracic and

all lumbar and sacral vertebrae, intervening supra
and interspinous ligament, outer lip of iliac crest,
outer surface of lower three or four ribs, inferior
angle of scapula.
Insertion: Intertubercular sulcus of humerus.
Nerve: Thoracodorsal nerve (C6–C8).
MUSCULOSKELETAL
243
Action: Extends, adducts and medially rotates CHAPTER
5
shoulder.
MMT: Patient prone with head turned to one side.
Arms at side; test arm is internally rotated (palm
up). Therapist stands at test side. Ask the patient
to push his arm towards feet (reach down toward
your feet). If the patient completes full range of
motion, with no resistance, it shows grade III
power.
stands beside the patient and facing the limb.
Therapist left hand grasps the lower arm region
and the patient’s forearm resting over the
therapist forearm. Therapists right hand apply
opposite force on the scapular region to prevent
scapular movement. Stretch force is given
towards the flexion of the shoulder with the
therapists left hand.
LEVATOR SCAPULAE
Origin: C1–C3/C4 (transverse processes).

Insertion: Scapula (medial border between
superior angle and base of spine).
Nerve: Ventral rami (C3, C4) dorsal scapular nerve
(C5).
Action: Elevates, medially rotates and retracts
scapula, extends and laterally flexes neck.
244
CHAPTER LONGISSIMUS CAPITIS
5 Origin: T 1–T 4,5 (transverse process) articular

process of C4/5–C7.
Insertion: Posterior aspect of mastoid process.
Nerve: Dorsal rami.
Action: Extends, laterally flexes and rotates head.
MMT: Patient prone with head off the end of
table. Arm at side. Therapist standing next to
patient’s head with one hand supporting the
forehead.
Ask the patient to lift your forehead from my
hand and keep looking at the floor. Full range of
motion, shows grade III power.
LONGISSIMUS CERVICIS
Origin: Transverse process of T1–T4/5.

Insertion: Transverse process of C2–C6.
Nerve: Dorsal rami.
column.
MMT: Same as for L. capitis.
LONGISSIMUS THORACIS
Origin: Transverse and accessory process of

lumbar vertebrae and thoracolumbar fascia.
Insertion: Transverse processes of T1–T12 and lower
nine or ten ribs.
MUSCULOSKELETAL
245
Nerve: Dorsal rami. CHAPTER
column.
MMT: Same as for iliocostalis thoracic.
5
LONGUS CAPITIS
Origin: Occipital bone.

Insertion: Anterior tubercles of transverse
processes of C3–C6.
Nerve: Anterior primary rami (C1–C3).
Action: Flexes neck.
MMT: Patient in supine with head supported on
table. Arm at side. Therapist stands at head of the
table facing patient. Ask patient to tuck his chin
into his neck. Do not raise his head from table.
If patient completes available ROM without
LONGUS COLLI
Origin: T1–T2/3 (inferior oblique part, front of

bodies).
T1–T3 and C5–C7 (vertical intermediate part front
of bodies).
C3–C5 (superior oblique part—anterior tubercles
of transverse process).
Insertion: C5 and C5 (inferior oblique part–anterior
tubercles of transverse process), C2–C4 (vertical
246
CHAPTER intermediate part: front of bodies); superior
5
oblique part—anterior tubercle of atlas.
Nerve: Anterior primary rami (C2–C6).
MMT: Patient supine with arms at side. Patient
flexes neck, keeping eyes on the ceiling. If the
patient completes available range of motion, it
LUMBRICALS (FOOT)
Origin: Tendon of flexor digitorum longus.

Insertion: Medial side of extensor hood and base
of proximal phalanx of lateral four toes.
Nerve: First lumbrical-medial plantar nerve (S2,
S3), Lateral three lumbrical-lateral plantar nerve
(S2, S3).
Action: Flexes metatarsophalangeal joint and
extends interphalangeal joint of lateral four toes.
MMT: Patient short sitting with foot on
examiner’s lap. Therapist sitting on low stool in
front of patient, his hand grasps the dorsum of
the foot just below the ankle to provide
stabilization. The index finger of the other hand
is placed under the MP joints of the four lateral
toes to provide resistance to flexion. Ask the
patient to bend your toes over my finger. Full
range of motion without resistance, shows
grade III power.
MUSCULOSKELETAL
247
LUMBRICALS (HAND) CHAPTER
Origin: Tendons of flexor digitorum profundus.

Insertion: Lateral margin of dorsal digital expan-
5
sion of extensor digitorum.
Nerve: I and II—median nerve (C8, T1).
III and IV—ulnar nerve (C8, T1).
Action: Flexes metacarpophalangeal joint and
extends interphalangeal joints of fingers.
MMT: Patient short sitting with forearm in supi-
nation. Wrist is maintained in neutral. The MP
joints are flexed. Therapist stabilizes the meta-
carpals proximal to the MP joints, resistance is
given on the palmar surface of the proximal row
of phalanges in the direction of MP extension. Ask
patient to simultaneously flex the MP joint and
extend the IP joints. If the patient completes both
motions correctly and simultaneously without
MULTIFIDUS
Origin: Back of sacrum, aponeurosis of erector

spinae, posterior superior iliac spine, dorsal
sacroiliac ligaments, mamillary processes in
lumbar region, all thoracic transverse process,
articular process of lower four cervical vertebrae.
Insertion: Spines of all vertebrae from L5 to axis.
Nerve: Dorsal rami of spinal nerves.
248
CHAPTER Action: Extends, rotates and laterally flexes
5
vertebral column.
MMT: Same as for interspinales and intertrans-
versarii.
OBTURATOR EXTERNUS
Origin: Outer surface of obturator membrane and

adjacent bone of pubic and ischial rami.
Insertion: Trochanteric fossa of femur.
Nerve: Posterior branch of obturator nerve (L3, L4).
MMT: Patient in short sitting. Therapist sits on a
low stool or kneels beside limb to be tested. Ask
the patient to turn his leg in full range of motion,
OBTURATOR INTERNUS
Origin: Internal surface of obturator membrane
and surrounding bony margin.
Insertion: Medial surface of greater trochanter.
Nerve: Nerve to obturator internus (L5, S1).
MMT: Same as for O. externus.
OPPONENS DIGITI MINIMI
Origin: Hook of hamate; flexor retinaculum.

Insertion: Medial border of fifth metacarpal.
MUSCULOSKELETAL
249
Nerve: Ulnar nerve (C8, T1). CHAPTER
Action: Abducts fifth digit, pulls it forwards and
rotates it laterally.
MMT: Patient’s forearm supinated, wrist in
5
neutral. He raises the thumb away from the palm
and rotates it, so that its distal phalanx opposes
the distal phalanx of the little finger. Opposition
must be pad to pad. It the patient moves thumb
and 5th digit through full range of opposition
with no resistance, it shows grade III power.
OPPONENS POLLICIS
Origin: Flexor retinaculum, tubercles of scaphoid

and trapezium, abductor pollicis longus tendon.
Insertion: Radial side of base of proximal phalanx
of thumb.
Nerve: Median nerve (C8, T1).
Action: Rotates thumb into opposition with
fingers.
MMT: Patient forearm supinated, wrist in neutral
position, thumb in adduction with MP and IP
flexion. Therapist stabilizes the hand by holding
the wrist on the dorsal surface. If the patient
moves thumb and 5th digit through full range of
opposition with no resistance, it shows grade III
power.
250
CHAPTER PALMAR INTEROSSEI
5 Origin: Shaft of metacarpal of digit on which it

acts.
Insertion: Dorsal digital expansion and base of
proximal phalanx of same digit.
Action: Adducts thumb, index, ring and little
finger.
MMT: Patient’s forearm pronated, wrist in neutral
and fingers extended and adducted. MP joints are
neutral; avoid flexion. Ask patient to hold his
fingers together. If the patient can adduct finger
towards middle finger, but cannot hold against
PALMARIS LONGUS
Origin: Medial epicondyl via common flexor

tendon.
Insertion: Flexor retinaculum, palmar aponeurosis.
Nerve: Median (C7, C8).
Action: Flexes wrist.
Stretching: Patient is sitting on stool. Therapist is
standing beside the patient and facing his wrist.
Therapist left hand grasping the lower forearm of
the patient, while his right hand grasps the palm
and fingers.The therapist extends the wrist of the
patient with his right hand.
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251
PECTINEUS CHAPTER
Origin: Pecten pubis, iliopectineal eminence, pubic

tubercle. 5
Insertion: Along a line from lesser trochanter to
linea aspera.
Nerve: Femoral nerve (L2,3) occasionally accessory
obturator (L3).
Action: Flexes and adducts hip.
MMT: Same as for adductors of hip.
PECTORALIS MAJOR
Origin: Clavicular attachment—sternal half of

anterior surface of clavicle sternocostal attach-
ment—anterior surface of manubrium, body of
sternum, upper six costal cartilages, sixth rib,
aponeurosis of external oblique muscle.
Insertion: Lateral lip of intertubercular sulcus of
humerus.
Nerve: Medial and lateral pectoral nerve (C5-T1).
Action: Adducts, medially rotates, flexes and
extends shoulder.
MMT: Patient lies supine, shoulder at 90° of
abduction and elbow 90° of flexion. Therapist
stands at side of testing shoulder. For testing both
heads of P. major, ask the patient to move his arm
across his chest and hold it. Full range of motion,
without resistance shows grade III power.
252
CHAPTER PECTORALIS MINOR
5 Origin: Outer surface of third to fifth ribs and

adjoining intercostal fascia.
Insertion: Upper surface and medial border of
coracoid process.
Nerve: Medial and lateral pectoral nerves (C5–T1).
Action: Protracts and medially rotates scapula.
PERONEUS BREVIS
Origin: Lower 2/3 of lateral surface at fibula,

intermuscular septa.
Insertion: Lateral side of base of fifth metatarsal.
Nerve: Superficial peroneal nerve (L5, S1).
Action: Everts and plantar flexes ankle.
MMT: Patient in short sitting with ankle in neutral
position. Therapist sitting on low stool in front of
patient or standing at end of table, if patient is
supine.
His one hand grips the ankle just above the
malleoli for stabilization. Ask patient to turn your
foot down and out, hold it. If the patient
completes available range of eversion, it shows
grade III power.
Stretching: Assisted full range of inversion in
sitting or supine position.
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253
PERONEUS LONGUS CHAPTER
Origin: Lateral tibial condyle, upper 2/3 of lateral

surface of fibula, intermuscular septa. 5
Insertion: Lateral side of base of first metatarsal,
medial cuneiform.
Nerve: Superficial peroneal nerve (L5, S1).
Action: Everts and plantar flexes ankle.
MMT: Same as for peroneus brevis.
PERONEUS TERTIUS
Origin: Distal third of medial surface of fibula,

interosseous membrane, intermuscular septum.
Insertion: Medial aspect of base of fifth metatarsal.
Action: Everts and dorsiflexes ankle.
MMT: Same as for peroneus longus.
PIRIFORMIS
Origin: Front of second to fourth sacral segment,

gluteal surface of ilium, pelvic surface of
sacrotuberous ligament.
Insertion: Medial side of greater trochanter.
Nerve: Anterior rami of sacral plexus (L5–S2).
Action: Laterally rotates and abducts hip.
MMT: Same as for obturators internus and
externus.
254
CHAPTER PLANTAR INTEROSSEI
5 Origin: Base and medial side of lateral three toes.

Insertion: Medial side of base of proximal phalanx
of same toes and dorsal digital expansions.
Action: Adduct third to fifth toes, flex metatarso-
phalangeal joints of lateral three toes.
PLANTARIS
Origin: Lateral supra condylar ridge, oblique

popliteal ligament.
Insertion: Tendocalcaneus.
Action: Plantar flexes ankle, flexes knee.
POPLITEUS
Origin: Outer surface of lateral femoral condyle.

Insertion: Posterior surface of tibia above soleal
line.
Nerve: Tibial nerve (L4–S1).
Action: Medially rotates tibia, flexes knee.
Stretching: Patient on side lying, with testing limb
(right) upward. Therapist stands behind the
patient’s left hand over anterior thigh just
proximal to knee. His right hand just around the
posterior side of the ankle joint from his left hand,
MUSCULOSKELETAL
255
he pushes the knee joint towards himself and with CHAPTER
5
his right hand, he attempts to pull the leg away
from him and rotates it upwards, so that the toes
face towards ceiling.
PRONATOR QUADRATUS
Origin: Ulna (lower quarter of anterior surface).

Insertion: Radius (lower quarter of anterior
surface).
Nerve: Anterior interosseous branch of median
nerve (C7, C8).
Action: Pronates forearm.
MMT: Patient short sitting over a table. Arms at
side with elbow flexed to 90° and forearm in
supination. Therapist standing at side or in front
of patient. Support the elbow, ask the patient to
turn the palm down and hold it. If the patient
completes available range of motion it shows
grade III power.
PRONATOR TERES
Origin: Humeral head—medial epicondyle via

common flexor tendon, intermuscular septum,
antebrachial fascia, ulnar head—medial part of
coronoid process.
Insertion: Middle of lateral surface of radius.
Nerve: Median nerve (C6, C7).
256
CHAPTER Action: Pronates forearm, flexes elbow.
5 MMT: Same as for pronator quadratus.
PSOAS MAJOR
Origin: Bodies of T12 and all lumbar vertebrae,

bases of transverse processes of all lumbar
vertebrae, lumbar intervertebral disks.
Insertion: Lesser trochanter.
Nerve: Anterior rami of lumbar plexus (L1–L3).
Action: Flexes hip and lumbar spine.
MMT: Same as for iliacus.
PSOAS MINOR (NOT ALWAYS PRESENT)
Origin: Bodies of T12 and L1 vertebrae and inter-

vertebral disks.
Insertion: Pecten pubis, iliopubic eminence, iliac
fossa.
Nerve: Anterior primary ramus (L1).
Action: Flexes trunk (weak).
MMT: Same as for psoas major.
QUADRATUS FEMORIS
Origin: Ischial tuberosity.

Insertion: Quadrate tubercle midway down
intertrochanteric crest.
Nerve: Nerve to quadratus femoris (L5, S1).
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257
Action: Laterally rotates hip. CHAPTER
MMT: Same as for obturator and piriformis.
QUADRATUS LUMBORUM
5
Origin: Iliolumbar ligament, posterior part of iliac
crest.
Insertion: Lower border of 12th rib, transverse
process of L1–L4.
Nerve: Ventral rami of T12 and L1–L3,4.
Action: Laterally flexes trunk, extends lumbar
vertebrae, steadies 12th rib during deep inspi-
ration.
MMT: Same as for interspinales lumborum.
RECTUS ABDOMINIS
Origin: Symphysis pubis, pubic crest.

Insertion: 5th–7th costal cartilages, xiphoid
process.
Nerve: Central rami T6,7–T12.
Action: Flexes trunk.
MMT: Patient supine with arms outstretched in
full extension above plane of body. Instruct the
patient to raise your head, shoulders and arms off
the table. Full range of motion till inferior angle
of scapulae are off the table, shows grade III
power.
258
CHAPTER RECTUS CAPITIS ANTERIOR
5 Origin: Anterior surface of lateral mass of atlas

and root of its transverse process.
Insertion: Occipital bone.
Nerve: Anterior primary rami (C1, C2).
MMT: Same as for longus capitis.
RECTUS CAPITIS LATERALIS
Origin: Atlas (transverse process).

Insertion: Jugular process of occipital bone.
Nerve: Ventral rami (C1, C2).
Action: Laterally flexes neck.
MMT: Same as for rectus capitis anterior.
RECTUS CAPITIS POSTERIOR MAJOR
Origin: Axis (spinous process).

Insertion: Occipital bone (lateral part of inferior
nuchal line).
Action: Extends and rotates neck.
MMT: Same as for longissimus capitis.
RECTUS CAPITIS POSTERIOR MINOR
Origin: Atlas (posterior tubercle).

MUSCULOSKELETAL
259
Insertion: Medial part of inferior nuchal line of CHAPTER
5
occipital bone.
Action: Extends neck.
MMT: Same as for longissimus capitis.
RECTUS FEMORIS
Origin: Straight head—anterior inferior iliac spine;

Reflected head—area above acetabulum, capsule
of hip joint.
Insertion: Base of patella, then forms part of
patellar ligaments.
Nerve: Femoral nerve (L2–L4).
Action: Extends knee, flexes hip.
MMT: MMT of rectus femoris is carried out jointly
as for quadriceps femoris.
Patient in short sitting place wedge under the
distal thigh to maintain the femur in the horizon-
tal position. Patient should lean backward to
relieve hamstring muscle tension. Therapist
standing at side of testing limb. Ask patient to
extend his knee through available range of
motion, but not beyond 0°. If patient completes
available range of motion and holds the position
without resistance, its shows grade III power.
Stretching: Patient is in side lying with stretching
limb in side. Therapist stand behind the patient
at the level of his pelvis, keeping his one hand
260
CHAPTER over pelvis to stabilize and one hand to support
5
the knee. He then gradually pulls the limb in
backward direction till a stretch is felt over
anterior part of the thigh.
RHOMBOID MAJOR
Origin: T 2 –T 5 [spines and supraspinous

ligaments].
Insertion: Medial border of scapula between root
of spine and inferior angle.
Nerve: Dorsal scapular nerve [C4, C5].
Action: Retracts and medially rotates scapula.
MMT: Patient on prone lying. Shoulder is
internally rotated and arm is adducted across the
back with elbow flexed and hand resting on the
back. Ask the patient to lift his hand and hold it.
Full range of motion shows grade III power.
RHOMBOID MINOR
Origin: C7–T1 (spine and supraspinous ligaments),

lower part of ligamentum nuchae.
Insertion: Medial end of spine of scapula.
Nerve: Dorsal scapular nerve [C4, C5].
Action: Retracts and medially rotates scapula.
MMT: Same as for rhomboid major.
ROTATORES
Origin: Transverse process of each vertebra.

MUSCULOSKELETAL
261
Insertion: Lamina of vertebra above. CHAPTER
Nerve: Dorsal rami of spinal nerves.
Action: Extends vertebral column and rotates
thoracic region.
5
SARTORIUS
Origin: Anterior superior iliac spine and area just

below.
Insertion: Upper part of medial side of tibia.
Nerve: Femoral nerve [L2, L3].
Action: Flexes hip and knee, laterally rotates and
abducts hip, medially rotates tibia on femur.
MMT: Short sitting with thigh supported on table
and legs hanging over side. Ask Patient to side
your heel up the shin of your other leg. Complete
range of motion with hold at end position shows,
grade III power.
SCALENUS ANTERIOR
Origin: C3–C6 [anterior tubercles of transverse

process].
Insertion: Scalene tubercle on inner border of first
rib.
Nerve: Ventral rami [C4–C6].
Action: Flexes, laterally flexes and rotates neck,
raises first rib during respiration.
262
CHAPTER MMT: Patient supine lying with head on table.
5
Ask the patient to bring your head off the table,
keeping your eyes on ceiling. Keep your shoulders
completely on the table. Full range of motion
without resistance, show grade III power.
SCALENUS MEDIUS
Origin: Atlas and axix (transverse process), C3–C7

(posterior tubercles of transverse processes).
Insertion: Upper surface of first rib.
Nerve: Ventral rami (C3–C8).
Action: Laterally flexes neck, raises first rib during
respiration.
MMT: Patient supine with cervical spine in
neutral. Ask patient to turn your head and face
the ceiling and hold it. If the patient rotates head
through full range to both right and left without
SCALENUS POSTERIOR
Origin: C4–C6 [posterior tubercles of transverse

process].
Insertion: Outer surface of second rib.
Nerve: Ventral rami [C6–C8].
Action: Laterally flexes neck, raises second rib
during respiration.
MMT: Same as for scalenus medius.
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263
SEMIMEMBRANOSUS CHAPTER
Origin: Ischial tuberosity

Insertion: Posterior aspect of medial tibial condyle.
5
Nerve: Tibial division of sciatic nerve [L5–S2].
Action: Flexes knee, extends hip and medially
MMT: Patient in prone lying. Therapist stands
beside the patient. Ask the patient to lift the leg
off the table, as high as without bending the knee.
If the patient completes full range of motion and
hold the position without resistance, it shows
grade III power.
stands beside the patient and facing the hip joint.
Therapist grasps lower leg region of the patient
with his right hand, while his left hand grasps the
patient’s knee. He flexes the patients hip and knee
with his both hands.
SEMISPINALIS CAPITIS
Origin: C7–T6/7 (transverse process).

C4–C6 (articular process).
Insertion: Between superior and inferior nuchal
lines of occipital bone.
Nerve: Dorsal rami of spinal nerve.
Action: Extends and rotates head.
264
CHAPTER MMT: Patients prone with head off end of table.
5
Arm at sides.
Therapist standing next to patients head with
one head supporting (or ready to support the
forehead). Ask the patient to look at the wall in
front. If the patient completes range of motion, but
takes no resistance, it shows grade III power.
SEMISPINALIS CERVICIS
Origin: T1–T5/6 (transverse processes).

Insertion: Spinous process of C2–C5.
Action: Extends and rotates vertebral column.
MMT: Patient in prone lying with head off end
of table. Arm at side. Therapist standing next to
patient’s head with one hand supporting the
forehead. Ask the patient to lift forehead and keep
looking at floor. If the patient completes the full
range without resistance, it shows grade III
power.
SEMISPINALIS THORACIS
Origin: T6–T10 (transverse processes).

Insertion: C6–T4 spinous processes.
Action: Extends and rotates vertebral column.
MUSCULOSKELETAL
265
MMT: Prone with arm at sides. Therapist standing CHAPTER
5
at side of table. Lower extremities are stabilized
just above the ankle. Ask the patient to raise your
head arm and chest from the table as high as you
can.
SEMITENDINOSUS
Origin: Ischial tuberosity.

Insertion: Tibia (upper part of medial surface).
Nerve: Tibial division of sciatic nerve (L5–S2).
Action: Flexes knee, extends hip and medially
MMT: Same as for semimembranosus.
Stretching: Same as for semimembranosus.
SERRATUS ANTERIOR
Origin: Outer surface and superior border of

upper eight, nine or ten ribs and intervening
intercostal fascia.
Insertion: Costal surface of medial border of
scapula.
Nerve: Long thoracic nerve (C5–C7).
Action: Protracts and laterally rotates scapula.
MMT: Patient in short sitting over end or side of
table. Hands on lap. Therapist standing at test side
of patient. Hand giving resistance is on the arm
proximal to the elbow. The other hand uses the
266
CHAPTER webspace along with the thumb and index finger
5
to palpate the edges of the scapula at the inferior
angle and along the vertebral and axillary borders.
Ask the patient to raise arm forward over head,
keep the elbow straight; hold it, do not let push
your arm down. If patient’s scapula moves
through full range of motion without winging but
can tolerate no resistance other than the weight
of the arm.
SOLEUS
Origin: Soleal line and middle third of medial

border of tibia, posterior surface of head and
upper quarter of fibula, fibrous arch between tibia
and fibula.
Insertion: Posterior surface of calcaneus.
Action: Plantar flexes ankle.
MMT: Patient standing on testing limb with knee
slightly flexed. Use one or two finger for balance
assist. Therapist standing or sitting with clear
lateral view of test limb. Ask patient to stand on
right leg with knee bent. Keep knee bent and go
up and down on toes atleast 20 times. If the
patient completes between nine and one correct
heel rises, with the knee flexed then it shows
grade III power.
standing beside the patient. The therapist holds
MUSCULOSKELETAL
267
the lower thigh region with his left hand and CHAPTER
5
flexing the knee. The therapist’s right hand holds
the heel in neutral position. Slowly dorsiflex the
ankle to full range.
SPINALIS (CAPITIS, CERVICIS, THORACIS)
Origin: Spinalis thoracis-spinous processes of

T11–L2.
Insertion: Spinalis thoracis-spinous processes of
upper four to eight thoracic vertebrae.
Nerve: Dorsal rami.
Action: Extends vertebral column.
MMT: Spinalis capitis and spinalis cervicis are
poorly developed. So test is done for only spinalis
thoracis. The test is same as for semispinalis
thoracis.
SPLENIUS CAPITIS
Origin: Ligamentum nuchae (lower half), spinous

processes of C 7 –T 3/4 and their supraspinous
ligaments.
Insertion: Mastoid process of temporal bone,
lateral third of superior nuchal line of occipital
bone.
Nerve: Dorsal rami (C3–C5).
Action: Extends, laterally flexes and rotates neck.
MMT: Same as for semispinalis capitis.
268
CHAPTER SPLENIUS CERVICALS
5 Origin: T3 T6 (spinous processes).

Insertion: Posterior tubercles of transverse
processes of C1–C3/4.
Nerve: Dorsal rami (C5–C7).
Action: Laterally flexes, rotates and extends neck.
MMT: Same as for semispinalis cervicis.
STERNOCLEIDOMASTOID
Origin: Sternal head-anterior surface of manu-

brium sterni, calvicular head—upper surface of
medial third of clavicle.
Insertion: Mastoid process of temporal bone,
lateral half of superior nuchal line of occipital
bone.
Nerve: Accessory nerve (XI).
Action: Laterally flexes and rotates neck; anterior
fibers flex neck, posterior fibers extend neck.
MMT: Same as for scalenus anterior.
SUBSCAPULARIS
Origin: Medial 2/3 of subscapular fossa and

tendinous intramuscular septa.
Insertion: Lesser tubercle of humerus, anterior
capsule of shoulder joint.
Nerve: Upper and lower subscapular nerve
(C5, C6).
MUSCULOSKELETAL
269
Action: Medially rotates shoulder. CHAPTER
MMT: Patient prone with head turned towards
test side. Shoulder is abducted to 90° with folded
towel placed under distal arm and forearm
5
hanging vertically over edge of table. Ask patient
to move your forearm up and back and hold it.
If the complete range is achieved, it shows
grade III power.
Stretching: Patient is supine lying. Therapist is
standing beside the patient and facing the limb.
The therapist grasps the lower arm of patient with
his left hand while his right hand grasping the
wrist of the patient and applying the stretch force
towards lateral rotation.
SUPERIOR OBLIQUE
Origin: Atlas (upper surface of transverse process).

Insertion: Superior and inferior nuchal lines of
occipital bone.
Action: Extends neck.
SUPINATOR
Origin: Lateral epicondyle (inferior aspect), radial

collateral ligament, annular ligament, supinator
crest and fossa of ulna.
Insertion: Posterior, lateral and anterior aspects of
upper third of radius.
270
CHAPTER Nerve: Posterior interosseous nerve (C6, C7).
5 Action: Supinates forearm.

MMT: Patient in short sitting. Arm at side and
elbow flexed to 90° forearm in pronation.
Therapist stands at side and supports the elbow.
Ask patient to turn your palm up. If the patient
completes available range of motion without
Stretching: Patient in supine lying. Therapist is
Therapist’s left hand stabilizing the anterior
aspect of proximal humerus of the patient.
Therapist’s right hand grasping the lower
forearm, wrist and hand of the patient and elbow
is in 90° flexed position. Therapist’s right hand
supinates and pronates the forearm and stretches
the structures.
SUPRASPINATUS
Origin: Supraspinous fossa (medial 2/3) and

supraspinous fascia.
Insertion: Capsule of shoulder joint, greater
tubercle of humerus.
Nerve: Suprascapular nerve (C5, C6).
Action: Abducts shoulder.
MMT: Patient in short sitting with arm at side and
elbow slightly flexed. Ask the patietnt to lift arm
out to the side to shoulder level and hold it. If the
MUSCULOSKELETAL
271
patient completes the range of motion (90°), it CHAPTER
5
TENSOR FASCIAE LATAE
Origin: Outer lip of iliac crest between iliac

tubercle and anterior superior iliac spine.
Insertion: Iliotibial tract.
Action: Extends knee, abducts and medially
rotates hip.
MMT: Patient in side-lying, with testing limb in
upper side and flexed to 45° and lies across the
lowermost limb with the foot resting on the table.
Ask the patient to lift your leg and hold it. If
the patient completes the movement and holds it
without resistance, then it shows grade III power.
TERES MAJOR
Origin: Dorsal surface of inferior scapular angle.

Insertion: Medial lip of intertubercular sulcus of
humerus.
Nerve: Lower subscapular nerve (C5, C7).
Action: Extends, adducts and medially rotates
shoulder.
MMT: Patient in prone with head turned to one
side, arm at side, test arm is internally rotated
272
CHAPTER (palm up). Ask the patient to lift arm as high as
5
you can. If the patient completes available range
of motion without resistance, it shows grade III
power.
Stretching: Patient in supine lying, therapist is
The therapist grasps the lower arm region with
his left hand and the patient forearm resting over
the therapist forearm. Therapist right hand apply
opposite force on the scapular region to prevent
scapular movement. Stretch force is given
towards the flexion of the shoulder with the
therapist left hand.
TERES MINOR
Origin: Upper 2/3 of dorsal surface of scapula.

Insertion: Lower facet on greater tuberosity of
humerus, lower posterior surface of capsule of
shoulder joint.
Nerve: Axillary nerve (C5, C6).
Action: Laterally rotates shoulder.
MMT: Same as for infraspinatous.
Therapist grasps the lower arm of the patient with
his left hand and his right hand grasps the wrist
and applying the stretch force towards the medial
rotation.
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273
TIBIALIS ANTERIOR CHAPTER
Origin: Lateral tibial condyle and upper 2/3 of

lateral surface of tibia, interosseous membrane. 5
Insertion: Medial and inferior surface of medial
cuneiform, base of first metatarsal.
Nerve: Deep peroneal nerve (L4,5).
Action: Dorsiflexes and inverts ankle.
MMT: Patient in short sitting. Therapist sitting on
stool in front of patient with patient’s heel resting
on thigh. Ask the patient to bring foot up and
holds it. If the patient completes the available
range of motion and holds it, shows grade III
power.
standing beside the patient and facing the ankle
joint. The therapist left hand grasps the lower leg
region and his right hand palm holding the heel
of the patient. Therapist’s right hand plantar flexes
the ankle and stretches the tightened structures.
TIBIALIS POSTERIOR
Origin: Tibia (lateral aspect of posterior surface,

below soleal line, interosseous membrane, upper
half of posterior surface of fibula, deep transverse
fascia).
Insertion: Tuberosity of navicular, medial cunei-
form, sustentaculum tali, intermediate cuneiform,
base of second to fourth metatarsals.
274
CHAPTER Nerve: Tibial nerve (L4,5).
5 Action: Plantar flexes and inverts ankle.

MMT: Patient in short sitting with ankle in slight
plantar flexed. Therapist sitting on low stool in
front of patient or on side of test limb. One hand
is used to stabilize the ankle just above the
malleoli. Ask the patient to turn your foot down
and in and hold it. If the patient is able to invert
the foot through the full available range of motion,
it shows grade III power.
Stretching: Patient in supine lying, therapist is
standing beside the patient and facing the ankle
joint. He then grasps the ankle joint of the patient
with his left hand while his right hand grasps the
foot region. Therapist’s right hand is applying
stretch force towards the inversion and eversion
movement and stretches the tightened structure.
TRANSVERSUS ABDOMINIS
Origin: Lateral third of inguinal ligament, anterior

two-third of inner lip of iliac crest, thoracolumbar
fascia between iliac crest and 12th rib, lower six
costal cartilages where it interdigitates with
diaphragm.
Insertion: Abdominal aponeurosis to linea alba.
Nerve: Ventral rami of lower six thoracic and
lumbar spinal nerve.
Action: Compresses abdominal contents, raises
intra-abdominal pressure.
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275
TRAPEZIUS CHAPTER
Origin: Medial 1/3 of superior nuchal line,
external occipital protuberance, ligament nuchae,
C7 spine, T1–T12 spines, corresponding supra-
5
spinous ligament.
Insertion: Upper fibers—posterior border of lateral
third of clavicle; middle fibers—medial border of
acromion, superior lip of crest of spine of scapula;
lower fibers—tubercle at medial end of spine of
scapula.
Nerve: Accessory nerve (XI) ventral rami (C3, C4).
Action: Upper fibers elevate scapula, middle
retract scapula, lower fibers depress scapula.
MMT:
1. For upper fibers: Patient in short sitting over end
of table hands relaxed on lap. Ask patient to
raise his shoulder towards his ear.
2. For middle fibers: Patient in prone lying with
shoulder at the edge of table and 90° abducted
elbow is flexed to 90°. Ask patient to lift elbow
towards ceiling and hold it.
3. For lower fibers: Patient in prone with arms over
head to about 145° of abduction. Forearm is
in midposition with the thumb pointing
towards the ceiling. Therapist stands at test
side. His finger tip of one hand palpate below
the spine of scapula and across to the thoracic
vertebrae, following the muscle as it curves
down to the lower thoracic vertebrae. Ask
276
CHAPTER patient to raise your arm from the table as high
5
as possible and hold it. If the patient completes
the available ROM in all above 3 tests, then
the muscle is in grade III.
TRICEPS BRACHII
Origin: Long head: infraglenoid tubercle of

scapula, shoulder capsule.
Lateral head: Above and lateral to spiral groove
on posterior surface of humerus.
Medial head: Below and medial to spiral groove
on posterior surface of humerus.
Insertion: Upper surface of olecranon, deep fascia
of forearm.
Action: Extends elbow and shoulder.
MMT: Patient in prone on table. His shoulder of
testing limb is in 90° of flexion and forearm
hanging vertically at the edge of the table. Ask
patient to straighten your elbow and hold it. If the
patient completes the available ROM with no
Stretching: Patient in supine lying or sitting.
Therapist is standing beside the patient. Therapist
left hand hold’s the patient hand and flexes the
elbow after the hand reaches the shoulder.
Therapist left hand stabilizes the shoulder also.
Therapist right hand grasping the elbow, lifts up
to gain shoulder flexion.
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277
VASTUS INTERMEDIUS CHAPTER
Origin: Upper 2/3 of anterior and lateral surface

of femur, lower part of lateral intermuscular
septum.
5
Insertion: Deep surface of quadriceps tendon,
lateral border of patella, lateral tibial condyle.
Action: Extends knee.
MMT: Done along with quadriceps femoris.
Stretching: Done along with quadriceps femoris.
VASTUS LATERALIS
Origin: Intertrochanteric line, greater trochanter,

gluteal tuberosity, lateral lip of linea aspera.
Insertion: Tendon of rectus femoris, lateral border
of patella.
Nerve: Femoral nerve (L2, L4).
VASTUS MEDIALIS
Origin: Intertrochanteric line, spiral line, medial

lip of linea aspera, medial supracondylar line,
medial intermuscular septum, tendon of adductor
longus and adductor magnus.
278
CHAPTER Insertion: Tendon of rectus femoris, medial border
5
of patella, medial tibial condyle.
JOINT RANGE OF MOVEMENT

TYPES OF GONIOMETER
1. Universal goniometer (by Mr Moore)
2. Gravity depended or fluid goniometer (by
Mr Schenkar)
3. Pendulum goniometer (by Mr Fox and van
Breemen)
4. Electrogoniometer (by Mr Karpovich and
Karpovich)
RANGE OF MOTION FOR VARIOUS JOINTS
Shoulder
Flexion 0–180° (150°–180°)
Extension 0–45° (40°–60°)
Abduction 0–180° (150°–180°)
Adduction 0
Internal rotation 0–90° (70°–90°)
External rotation 0–90° (70°–90°)
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279
Elbow CHAPTER
Flexion
Extension
0–130° (120°–150°)
135°–0 5
Forearm
Supination 0–90°
Pronation 0–90°
Wrist
Flexion 0–90° (10°–90°)
Extension 0–70° (50°–70°)
Ulnar deviation 0–40° (25°–40°)
Radial deviation 0–20° (15°–25°)
MCP
Flexion 0–90°
Extension 0–20° (15°–30°)
Abduction 0–20°
Adduction 0
PIP
Flexion 0–110° (90°–120°)
Extension 0
DIP
Flexion 0–90°
Extension 0
280
CHAPTER Thumb
5 MCP flexion
HIP
0–45°
Flexion 0–120° (110°–130°)

Extension 0–35° (25°–40°)
Abduction 0–55°
Adduction 0
External rotation 0–45° (35°–50°)
Internal rotation 0–35° (30°–45°)
Knee
Flexion 0–120°
Extension 0
Ankle
Plantar flexion 0–45°
Dorsi flexion 0–20°
Inversion 0–45°
Eversion 0–15°
MTP
Flexion 0–40°
Extension 0–80° (10°–90°)
Abduction 0–15°
Intraphalangeal
Flexion 0–60° (50°–70°)
Extension 0
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281
Cervical Spine CHAPTER
Flexion
Extension
Lateral flexion
0–45°
0–45°
0–45°
5
Rotation 0–60°
Thoracic and Lumbar Spine

Flexion 0–80°
Extension 0–25°
Lateral flexion 0–35°
Rotation 0–45°
Note:
MCP: Metacarpophalangeal joint
PIP: Proximal interphalangeal joint
DIP: Distal interphalangeal joint
MEASURING PROCEDURES
Shoulder Joint
Flexion
Axis: Greater tuberosity of humerus
Moving arm: On the midline of lateral aspect of
arm
Fixed arm: Straight to the moving arm.
Extension
Axis: Greater tuberosity of humerus
Moving arm: Midline of the lateral aspect of arm
Fixed arm: Straight to the moving arm.
282
CHAPTER Abduction
5 Axis: One inch below the acromion process of the

scapula
Moving arm: Midline of the anterior aspect of arm
Fixed arm: Horizontally on the clavicle.
Medial and lateral rotation
Axis: Olecranon process of the ulna
Moving arm: Midline of the posterior aspect of
forearm
Fixed arm: Straight to moving arm.
Elbow Joint
Flexion
Axis: Lateral epicondyle of humerus
Fixed arm: Lateral midline of humerus
Moving arm: Lateral midline of forearm.
Radioulnar Joint
Pronation
Axis: Ulnar styloid process
Fixed arm: Perpendicular to the moving arm
without any body contact
Moving arm: Anterior aspect of wrist
Supination
Axis: Ulnar styloid process
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283
Fixed arm: Perpendicular to the movable arm CHAPTER
5
without any body contact
Moving arm: Posterior aspect of wrist.
Wrist Joint
Flexion and extension

Axis: Medial margin of wrist
Fixed arm: Lateral midline of forearm
Moving arm: Lateral midline of little finger.
Ulnar and radial deviation
Axis: Middle of the posterior aspect of wrist
Fixed arm: Middle of posterior aspect of forearm
Moving arm: Midline of posterior aspect of the
middle finger.
MCP
Flexion
Axis: Midline of the posterior aspect of the joint
line of the MCP
Fixed arm: Midline of the posterior aspect of wrist
and forearm
Moving arm: Midline of the posterior aspect of the
metacarpal.
Extension
Axis: Middle of the anterior aspect of the joint line
of MCP.
284
CHAPTER Fixed arm: Midline of the anterior aspect of wrist
5
and forearm
Movable arm: Midline of the anterior aspect of the
metacarpal and phalanx.
Abduction and adduction
Axis: Middle of the posterior aspect of the joint
line of the MCP
Fixed arm: Midline of the posterior aspect of wrist
and forearm
Moving arm: Midline of the posterior aspect of the
metacarpal.
PIP
Flexion and extension

Axis: Middle of the posterior aspect of the joint
line of the PIP
Fixed arm: Midline of the posterior aspect of the
MC, wrist and forearm
Moving arm: Midline of the posterior aspect of
phalanx.
Hip Joint
Flexion
Axis: Greater trochanter of the femur
Fixed arm: Midline of the lateral aspect of lower
trunk
Moving arm: Midline of the lateral aspect of thigh.
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285
Extension CHAPTER
Axis: Greater trochanter of femur
Fixed arm: Midline of the lateral aspect of lower
trunk
5
Moving arm: Midline of lateral aspect of the thigh.
Adduction
Axis: Two inches below the ASIS
Moving arm: Midline of the anterior aspect of the
thing
Fixed arm: 90° to the movable arm.
Medial and lateral rotation
Axis: Tip of patella
Moving arm: Midline of the anterior aspect of the
leg
Fixed arm: Straight to moving arm.
Knee Joint
Flexion
Axis: Lateral joint line
Moving arm: Midline of lateral aspect of leg
Fixed arm: Midline of the lateral aspect of thigh.
Ankle Joint
Plantar and dorsiflexion

Axis: Tip of medial malleolus.
286
CHAPTER Fixed arm: Midline of the medial aspect of the leg
5 Moving arm: 90° to stable arm.
Subtalar Joint
Inversion
Axis: Medial joint line of the head of the first
metatarsal
Fixed arm: Parallel to the medial aspect of the ankle
and lower leg
Moving arm: Perpendicular to the fixed arm.
Eversion
Axis: Lateral aspect of the head of the fifth meta-
tarsal
Fixed arm: Parallel to the lateral aspect of the lower
leg
Moving arm: Perpendicular to the fixed arm.
Cervical Spine
Atlanto-occipital and atlanto-axial joint

Flexion—Extension
Axis: External auditory meatus
Fixed arm: Perpendicular to the ground
Moving arm: Base of nares.
Lateral flexion
Axis: Spinous process of C7 vertebrae
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287
Fixed arm: Perpendicular to the ground CHAPTER
Moving arm: Midline of head.
Rotation 5
Axis: Center of cranial aspect of head
Fixed arm: Parallel to the line joining both
acromion process
Moving arms: Along the line of the tip of the nose.
Thoraco-lumbar Spine
Flexion—extension
1. Measure distance between C7 and S1 spinous
process and then ask the patient to bend
forward.
2. Again take measurement and calculate diffe-
rence between first and final measurement.
Lateral flexion
Axis: Posterior aspect of S1 spinous process
Fixed arm: Perpendicular to the ground
Moving arm: Parallel to the spine with reference
to the spinous process of C7 vertebra.
Rotation
Axis: Center of the cranial aspect of the head
Fixed arm: Parallel to the imaginary line between
the tubercles of the iliac crest
Moving arm: Parallel to the imaginary line
between acromion process.
288
CHAPTER COMMON MUSCULOSKELETAL TESTS
5 CERVICAL SPINE
Distraction Test
Tests: Nerve root compression.

Patient’s position: Sitting.
Procedure: Put one hand under chin and other
hand under occiput, then gently lift patient’s
head.
Positive sign: Relief or decrease in pain.
Quadrant Test
Tests: Vascular involvement in spine.

Patient’s position: Sitting or supine lying.
Procedure: Examiner passively takes patient’s head
and neck in extension and side.
Flexion and rotation, hold it for 30 seconds.
Positive sign: Dizziness, nausea, headache,
nystagmus.
Romberg’s Test
Tests: Cervical neuropathy, UMNL.

Patient’s position: Standing.
Procedure: Ask the patient to close his eyes and
hold the position for 20 to 30 seconds.
Positive sign: Body sways, patients looses balance.
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289
Sharp-Purser Test CHAPTER
Tests: Cervical instability (subluxation).

5
Procedure: Examiner’s one hand over forehead
while thumb of other hand over spinous process
of axis, patient is asked to flex his head.
Positive sign: The head slides backward during the
movement.
Spurling’s Test
Tests: Nerve root compression.

Procedure: Neck of unaffected side in side flexion,
apply gentle pressure on the top of patient’s head.
Test is repeated on affected side.
Positive sign: Onset or increase in pain radiating
into shoulder or arm on fixed side.
Upper Limb Tension Test
Tests: Brachial plexus tension.

Procedure: Test should be done in sequence given
below:
ULTT 1
• Depress and abduct (110°) shoulder
• Elbow extension
• Forearm supination
290
CHAPTER • Wrist extension
5
• Finger and thumb extension
• Contralateral side flexion of cervical spine.
ULTT 2
• Elbow extension
• Wrist extension
• Shoulder lateral rotation
ULTT 3
• Elbow extension
• Forearm pronation
• Wrist flexion and ulnar deviation
• Finger and thumb flexion
• Shoulder medial rotation
UTLL 4
• Depress and abduct (10°–90°) shoulder
• Elbow extension
• Wrist extension and radial deviation
• Shoulder lateral rotation
Positive sign: Radiculating pain and stress over the
nerve of brachial plexus.
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291
THORACIC SPINE CHAPTER
Slump Test
Tests: Dural stretch.
5
Procedure
1. Patient sits on table, slumps so that spine
flexes, shoulder sags forward, examiner holds
the chin and head erect. If no symptoms, then
in continuation.
2. Examiner flexes patient’s neck and holds the
head down, if again no symptoms then in
continuation.
3. Examiner passively extends patients knee and
dorsiflexes the foot.
Positive sign: Sciatic pain, impingement of dura
and spinal cord or nerve roots.
LUMBAR SPINE
Brudzinski-Kernig Test
Tests: Neurodynamic dysfunction.

Patient’s position: Supine.
Procedure: Hands cupped behind the head. Patient
actively flex the head onto chest. Patient raises the
extended leg with hip flexion until pain is felt,
patient then flexes the knee.
Positive sign: Pain disappears.
292
CHAPTER Farfan Torsion Test
5 Tests: Lumbar instability.

Patient’s position: Prone.
Procedure: Examiner stabilizes ribs and spine by
a hand and other hand on ilium.
Anteriorly pulls the ilium backward, results in
rotation of spine on opposite side.
Positive sign: Reproduce all the symptoms in
patient.
Quadrant Test
Tests: Joint dysfunction.
Procedure: Patient standing with examiner
standing behind. Patient extends spine, patient
holds the occiput on her/his shoulder and takes
weight of head. Over pressure is applied, when
patient side flexes and rotates.
Positive sign: Pain in the back and sometimes stress
fracture.
Slump Test
Procedure
ST1: Supine lying
• Cervical spine flexion
• Thoracic and lumbar spine flexion
• Hip flexion (90°)
MUSCULOSKELETAL
293
• Knee extension CHAPTER
5
• Ankle dorsiflexion.
ST2: Supine lying
• Thoracic and lumbar flexion
• Hip (90°), abduction
• Knee extension
ST3: Side lying
• Knee flexion
• Ankle plantar flexion.
ST4: Long sitting
• Cervical spine flexion, rotation
• Knee extension
Positive sign: Reproduce the patient’s symptoms,
cause discomfort or pain on neurological tissues.
Straight Leg Raise Test

Patient’s position: Supine lying.
Procedure: Stabilize the unaffected leg, patient
actively raise the leg (hip flexion, with knee
extension and ankle neutral).
294
CHAPTER Positive sign: Pain and stretch below the range of
5
65°–70°.
SHOULDER JOINT
Anterior Drawer Test

Tests: Anterior shoulder instability.
Procedure: Hold shoulder in 80°–120° abduction,
0–20° forward flexion and 0–30° lateral rotation.
Perform flexion with stabilized scapula.
Positive sign: Click sound or/and apprehension.
Clunk Test
Tests: Ligament injury/tear of glenoid labrum.
Procedure: Ask patient to abduct shoulder over his
head. Apply anterior force to posterior aspect of
humeral head, while lateral rotation.
Positive sign: Clunk or grinding sound and/or
apprehension of instability present anteriorly.
Crank (Anterior Apprehension) Test

Tests: Anterior shoulder instability.
Procedure: Slowly abduct the shoulder to 90° with
lateral rotation.
Positive sign: Apprehension.
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295
Droparm Test/Codman’s Test CHAPTER
Tests: Supraspinatus tendon rupture.
Patient’s position: Sitting. 5
Procedure: Examiner on side, put one hand on
shoulder girdle and other on forearm. Passively
abduction of arm to 90° in prone. Patient lowers
down the abducted arm.
Positive sign: Pain and lack of motor control.
Duga’s Test
Tests: Shoulder dislocation.
Patient’s position: Standing, both arms hanging by
side.
Procedure: Patient is asked to touch the opposite
shoulder by flexing the shoulder and elbow of the
affected arm.
Positive sign: Patient is unable to touch the
opposite shoulder.
Empty Can Test

Test: Pathology of supraspinatus tendon.
Patient’s position: Sitting or standing.
Procedure: Shoulder abduction 90°; horizontal
flexion 30° and medially rotate the thumb
pointing downwards.
Positive sign: Weakness or reappearance of symp-
toms.
296
CHAPTER Hamilton Ruler Test
5 Tests: Inferior shoulder instability.

Patient’s position: Standing.
Procedure: Examiner places straight ruler over
affected arm and checks whether the acromion
process and lateral epicondyle are touched by the
ruler at the same time or not.
Positive sign: If the ruler do not touch both at the
same time, indicates instability.
Hawkins-Kennedy Test
Tests: Supraspinatus tendon impingement.
Procedure: Ask the patient to forward flex shoulder
to 90° and elbow flexion 90°. Apply medial
rotation passively.
Positive sign: Reproduction of symptoms.
Jerk Test
Tests: Posterior shoulder instability.
Procedure: Hold shoulder in 90° forward flexion
and medial rotation.
Apply longitudinal cephalad force (from head)
to humerus and adduct the arm horizontally.
Positive sign: Sudden jerk or clunk.
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297
Neer Impingement Test CHAPTER
Tests: Biceps or supraspinatus tendon impinge-
ment.
5
Procedure: Forward flex arm and medially rotate
it passively.
Positive sign: Reappearance of symptoms.
Posterior Drawer Test

Tests: Posterior shoulder instability.
Procedure: Place shoulder in 100°–120° abduction,
elbow flexed to 120° and shoulder in 20°–30°
forward flexion. Medial rotation and forward
flexion of shoulder up to 60°–80° with scapula
stabilized.
Positive sign: Apprehension and/or significant
posterior displacement.
Speeds Test
Tests: Pathology of biceps tendon.
Procedure: Elbow extension, forearm supination
and shoulder forward flexion. Apply resistance
when patient performs shoulder flexion.
Positive sign: Increased pain in bicipital groove.
298
CHAPTER Sulcus Sign
5 Tests: Inferior shoulder instability.

Patient’s position: Standing or sitting.
Procedure: Arm by side. Hold arm below elbow
and pull distally.
Positive sign: Reappearance of symptoms and/or
apprehension of sulcus under acromion.
ELBOW JOINT
Cozen’s Test
Tests: Lateral epicondylitis.
Procedure: Grip the patient’s forearm distally and
ask the patient to make a firm fist and passively
flex the wrist.
Positive sign: Pain over lateral epicondyle and
reappearance of symptoms.
Elbow Flexion Test

Tests: Cubital tunnel syndrome.
Procedure: Elbow full flexion with extended wrist.
Hold it for 5 minutes.
Positive sign: Tingling or paresthesia in ulnar nerve
distribution.
MUSCULOSKELETAL
299
Jug Test CHAPTER
Test: Lateral epicondylitis.
Patient’s position: Standing. 5
Procedure: Ask him to lift a jug full of water
holding it from its mouth.
Positive sign: Pain and reappearance of symptoms.
Lateral Epicondylitis Test (Tennis Elbow)

Tests: Lateral epicondylitis.
Procedure
Method 1: Passive elbow extension, forearm
pronation and flexion fingers and wrist while
palpating lateral epicondyle.
Method 2: Resist extension of middle finger distal
to PIP joint.
Positive sign: Pain over lateral epicondyle and
reappearance of symptoms.
Pinch Grip Test

Tests: Median (anterior interosseous) nerve
intrapment.
Procedure: Patient pinches the tip of index finger
and thumb together.
Positive sign: Inability to pinch tip to tip.
300
CHAPTER Valgus Stress Test
5 Tests: Stability of medial collateral ligament.

Procedure: Stabilize upper arm with elbow flexion
in 20°–30° and lateral rotation of humerus in full
range. Apply force while abducting forearm.
Positive sign: Reappearance of symptoms or
increased laxity.
Varus Stress Test

Tests: Stability of lateral collateral ligament.
Procedure: Stabilize upper arm. Elbow flexion in
20°–30° and humerus in medial rotation.
Positive sign: Excessive laxity or reappearance of
symptoms.
WRIST JOINT AND HAND
Finkelstein’s Test
Tests: Tenosynovitis of abductor pollicis longus
and extensor pollicis brevis tendons (de
Quervain’s tenosynovitis).
Procedure: Ask the patient, to make a fist with
thumb inside. Move wrist into ulnar deviation
passively.
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301
Liniburg’s Test CHAPTER
Test: Tendon pathology between flexor pollicis
longus and flexor indices.
5
Procedure: Flex thumb towards hypothenar
eminence and extend index finger.
Positive sign: Limited extension and reappearance
of symptoms.
Lunotriquetral Ballottement Test (Reagan’s Test)

Tests: Stability of lunotriquetral ligament.
Procedure: Stabilize the triquetrum and lunate.
Apply posterior and anterior glide.
Positive sign: Reappearance of symptoms crepitus
or laxity.
Murphy’s Sign
Tests: Lunate dislocation.
Procedure: Patients makes a fist.
Positive sign: 3rd metacarpal lines up with 2nd and
5th metacarpal.
Phalen’s (Wrist Flexion) Test

Tests: Median nerve pathology, carpal-tunnel
syndrome.
302
CHAPTER Patient’s position: Sitting.
5 Procedure: Place the hands together from its dorsal

aspect with wrist in flexion. Hold it for one
minute.
Positive sign: Tingling sensation in distribution.
Reverse Phalen’s Test

Tests: Median nerve pathology.
Procedure: Place the palms of both hands together
with wrist extension.
Positive sign: Tingling sensation over median
nerve distribution.
Sweater Finger Sign

Tests: Rupture of flexor profundus tendon.
Patient's position: Sitting.
Procedure: Patient makes a fist.
Positive sign: Loss of flexion of DIP joint of one of
the finger.
Thoment’s Sign
Tests: Ulnar nerve paralysis.
Patient's position: Sitting or standing.
Procedure: Hold piece of paper between thumb
and index finger. Pull the paper away.
Positive sign: As the paper is pulled away, the IP
joint of thumb flexes.
MUSCULOSKELETAL
303
Tinel’s Sign CHAPTER
Tests: Median nerve pathology, carpal-tunnel
syndrome.
5
Procedure: Tap over carpal tunnel.
Positive sign: Tingling sensation or paresthesia
over median nerve distribution.
Waston (Scaphoid Shift) Test

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

Tests: Sprain of sacroiliac joint or ligaments.
Patient's position: Supine.
Procedure: Push right and left ASIS apart.
Gaenslen’s Test
Tests: Sacroiliac joint involvement, hip pathology
or L4 nerve root lesion.
304
CHAPTER Patient's position: Side lying on normal side, with
5
leg flexed against chest.
Procedure: Affected leg is hyper extended at hip
and pelvis is stabilized by examiner.
Positive sign: Pain on SI joint, while performing
movement.
Gillets Test
Tests: Sacroiliac joint dysfunction.
Patient's position: Standing.
Procedure: Palpate PSIS and sacrum. Patient
performs hip flexion and knee on side to be tested
(palpated), while standing on opposite leg. Repeat
the test and compare both sides.
Positive sign: If the PSIS does not move downward
to sacrum on side tested, it shows hypomobility
of that side.
Hibb’s Test
Tests: Movement of sacroiliac joint, stress of
posterior sacroiliac ligament.
Patient's position: Prone.
Procedure: Pelvis is stabilized and patient
performs 90° flexion on the knee, hip is medially
rotated, while palpating sacroiliac joint on that
side. Repeat the test and compare it with other
side.
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Positive sign: Range of opening and quality of CHAPTER
5
movement at each sacroiliac joint differ.
Laguere’s Sign
Tests: Sacroiliac joint involvement, hip pathology.
Procedure: Examiner flexes, abducts and laterally
rotates the patient’s hip to be tested. Over pressure
is applied at end range. Pelvis is stabilized. Repeat
the test on other side and compare both sides.
Positive sign: Pain on SI joint or hip.
Piedallu’s Signs (Sitting Flexion)

Tests: Movement of sacrum on ilia.
Procedure: As the patient forward flexes, palpate
the right and left PSIS.
Positive sign: Normal side moves higher than
other, indicates hypomobility on that side.
Posterior Gapping Test

Tests: Sprain of posterior sacroiliac joint or
ligament.
Patient's position: Side lying or supine.
Procedure: Push left and right ASIS towards each
other.
306
CHAPTER Standing Flexion
5 Tests: Movement of ilia on sacrum.

Procedure: Palpate PSIS of both sides, while patient
forward flexes the hip.
Positive sign: Normal side moves higher than
affected side, indicates hypomobility on affected
side.
Supine-to-Set (Long Sitting) Test

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

Tests: Ligament or labrum tear or injury.
Procedure: Full flexion at hip, lateral rotation and
full abduction. Examiner extends, medially rotates
and adducts the hip.
Positive sign: Pain, reappearance of symptom
with/without click.
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Ober’s Sign CHAPTER
Tests: Tensor fasciae latae and iliotibial band
contractures.
Patient's position: Side lying with lower leg flexed.
5
Procedure: Pelvis stabilized. Abduct and extend
upper leg with knee extension or flexion to 90°
passively and allow it to drop towards plinth.
Positive sign: Upper leg remains abducted and
does not lower to plinth.
Patrick’s Test (Faber’s Test)

Tests: Hip joints and SI joint dysfunction, spasm
of iliopsoas muscle.
Procedure: Foot of test leg is placed on opposite
knee. Slowly lower knee of test leg.
Positive sign: Pain or spasm, knee remains above
the opposite leg.
Posterior Labral Tear Test

Tests: Ligament injury or labrum tear.
Procedure: Full flexion at hip, adduction and lateral
rotation. Examiner extends, abducts and laterally
rotates the hip.
Positive sign: Resist extension of middle finger
distal to PIP joint.
308
CHAPTER Rectus Femoris Contracture Test
5 Tests: Rectus femoris contracture.

Procedure: Knee flexed to 90° over edge of plinth.
Patient takes other knee to chest.
Positive sign: Knee extends over edge of plinth.
Thomas Test
Tests: Hip flexion contracture.
Procedure: Patient takes knee on to chest.
Positive sign: Opposite leg lifts off plinth.
Trendelenburg’s Sign
Tests: Strength of hip abductors, stability of hip.
Procedure: Patient is made to stand on one leg.
Positive sign: Pelvis on opposite side drops.
KNEE JOINT
Abduction (Valgus) Stress Test

Tests: Full knee extension ligament injury (ACL,
MCL, POL, PCL), quadriceps and semimembra-
nosus expansion.
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Procedure: Ankle is stabilized and medial pressure CHAPTER
5
is applied on knee joint at 0° and then at extension
in 20°–30°.
Positive sign: Excessive movement is seen as
compared to opposite knee.
Adduction (Varus) Stress Test

Tests: Full extension ligament injury (LCL),
iliotibial band, biceps femoris tendon.
Procedure: Ankle is stabilized, lateral pressure is
applied on knee joint at 20° and then extension
at 20°–30°.
Positive sign: Excessive movement is seen as
compared to opposite knee.

Tests: Ligament injury (ACL, POL, MCL), iliotibial
band, posteromedial and posterolateral capsules.
Patient’s position: Supine with 45° hip flexion and
90° knee flexion.
Procedure: Foot is stabilized, posteroanterior force
is applied on tibia.
Positive sign: Movement of tibia, move than 6 mm
on femur.
310
CHAPTER Apley’s Test
5 Tests: Compress for meniscus injury and

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

Tests: Posterolateral rotatory stability in knee
extension.
Procedure: Place the knee in 30° flexion and hold
the heel. Extend knee slowly while palpating the
knee’s posterolateral aspect.
Positive sign: Excessive hyperextension and lateral
rotation can be palpated.
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311
Fairbank’s Apprehension Test CHAPTER
Tests: Patellar subluxation or dislocation.
Patient’s position: Supine. 5
Procedure: 30° flexion at knee and relaxed quads.
Lateral glide to patella passively.
Positive sign: Excessive movement.
Hughston Plica Test

Tests: Inflammation of suprapatellar plica.
Procedure: Knee is medially rotated and flexed.
Applying medial glide on patella and medial
femoral condyle is palpated. Extend and flex knee
passively.
Positive sign: Popping of plica band over femoral
condyle, tenderness.
Lachman’s Test
Tests: Ligament injury (ACL, POL), arcuate-
popliteus complex.
Patient’s position: Supine with 0–30° knee flexion.
Procedure: Femur is stabilized and posteroanterior
force on tibia is applied.
Positive sign: Soft end feel or excessive movement.
McMurray Test
Tests: Medial meniscus and lateral meniscus
injury.
312
CHAPTER Patient’s position: Supine.
5 Procedure: Complete knee flexion.

Test medial meniscus: Knee lateral rotation and 90°
extension passively, while palpating joint line.
Test lateral meniscus: Test is repeated with medial
rotation at knee.
Positive sign: Click or a snap.
Posterior Drawer Test

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

Tests: Ligament injury (PCL, POL, ACL)
Procedure: 45° flexion at hip and 90° flexion on
knee with feet on plinth.
Positive sign: Tibia drops posteriorly.
Slocum Test for Anterolateral Rotatory Instability

Tests: Ligament injury (ACL, PCL, LCL and
cruciate), iliotibial band.
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313
Procedure: 45° flexion at hip and 90° flexion at CHAPTER
5
knee, foot is placed in 30° medial rotation and
stabilized, posteroanterior force is applied on
tibia.
Positive sign: Excessive movement on lateral side,
when compared with other knee.
Slocum Test for Anterolateral Rotary Instability

Tests: Ligament injury (MLC, POL, ACL)
Procedure: 45° hip flexion, 90° knee flexion, foot
is placed in 15° lateral rotation and stabilize it.
Then posteroanterior force is applied on tibia.
Positive sign: Excessive movement on medial side,
when compared with other knee.
ANKLE JOINT AND FOOT
Tests: Medial and lateral ligament integrity.

Procedure: Flexion at knee, posteroanterior force
is applied on talus with dorsiflexion on ankle and
then plantar flexion.
Positive sign: If movement on one side only
(ligament on the affected side). If excessive
anterior movement (both ligaments are affected).
314
CHAPTER Squeeze Test of Leg
5 Tests: Syndesmosis injury (fracture, contusion or

compartment syndrome).
Procedure: Examiner grasps leg at mid calf level
and squeezes the tibia and fibula together.
Positive sign: Pain in the lower leg.
Talar Tilt
Tests:
Abduction: Integrity of deltoid ligament.
Adduction: Integrity of calcaneofibular ligament
and also anterior talofibular ligament.
Patient’s position: Prone, supine or side lying.
Procedure: Flexion at knee. Talus is tilted in
adduction and abduction and foot is in neutral
position.
Positive sign: Excessive movement.
Thompson’s Test
Tests: Achilles tendon rupture.
Procedure: Feet is placed over edge of plinth and
then calf muscle is squeezed.
Positive sign: Absence of plantar flexion.
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315
MUSCULOSKELETAL PATHOLOGIES CHAPTER
ACHONDROPLASIA
It is a condition which occurs because of failure
5
of normal ossification of bones, specially the long
bones, turning into dwarfism. It is a disease with
autosomal dominant inheritance, but may also
occur by a fresh gene mutation.
Clinical Features
Flat nose, short limbs, lumbar lordosis, large skull
with bulged vault and forehead, stubby fingers
ALBERS-SCHÖNBERG DISEASE
Also known as marble bone disease or osteo-
porosis. This is a disorder in which the bone are
brittle but dense and there is poor formation of
protein matrix. It may result due to immobili-
sation, hormonal imbalance, nutritional
deficiency.
Clinical Features
Fracture resulting by minimal injury or pressure,
weak bone, reduced gaps between bone.
ANKYLOSING SPONDYLITIS
This is a chronic disease showing progressive
inflammatory stiffening of joint. The SI joint is the
first to be involved, the manubrio-sternal, hip and
knee joints may also be involved. This mainly
316
CHAPTER affects the age group of 15–30 years. M:F—10:1.
5
There may occur cartilage destruction and
synovitis.
Clinical Features
Pain and stiffness (early morning), deformity of
hip and spine (kyphosis), peripheral joints may
also be involved, i.e. shoulder hip and knee.
ARTHROGRYPOSIS MULTIPLEX CONGENITA

It is a nonprogressive condition in which the
infant born with multiple deformities, joint
stiffness and soft tissues contractures.
Types:
Neurogenic—Due to degeneration of anterior horn
cells in certain segments of spinal cord.
Myogenic—Due to replacement of muscles by
fibrofatty tissue.
Clinical Features
Flexion, abduction at hips, flexion at knees,
equinovarus feet, congenital hip dislocation, joint
contractures, genu recurvatum, calcaneovalgus
feet, web skins.
BAKER’S CYST
This is associated with rheumatoid arthritis and
osteoarthritis. There occurs a cyst or a mass or a
fluid filled sac at back of knee joint.
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317
Popliteal bursa gets distended, associated with
herniation of synovial membrane of knee joint. 5
BURSITIS
This is the inflammation of bursa. This occurs
because of bacterial infection or mechanical
irritation. Because of which the bursitis may be
infective or irritative caused by excessive
pressure or friction. Also sometimes due to gouty
deposit.
Clinical Features
Pain, swelling, redness, reduced joint range of
motion.
CONGENITAL TALIPES EQUINOVARUS (CTEV)

This is the commonest congenital feet deformity
also known as clubfoot. The etiology is unknown,
hence two types: Idiopathic and secondary. The
talus neck gets angulated facing downwards and
medially, i.e. in inversion.
Clinical Features
Postural equinovarus, as age increases difficulty
in walking, head is small in size, bilateral foot
deformity, creases on back of heel, foot is slight
convex.
318
CHAPTER CARPAL-TUNNEL SYNDROME
5 This syndrome occurs when the median nerve

gets compressed while passing through flexor
retinaculum. The causes of this may be inflamma-
tory, post-traumatic, endocrine, idiopathic. The
patient affected is usually middle aged.
Clinical Features
Numbness, tingling, clumsiness in carrying fine
movements, absent in pulse conduction.
COMPARTMENT SYNDROME
A rise in pressure in compartments containing
muscles, bones, vessels, fascia, because of any
reason may affect the blood supply to nerves and
muscles resulting in compartment syndrome.
This injury leads to swelling resulting into
reduced blood supply, further resulting in
muscle ischemia.
Clinical Features
Necrosis, nerve damage, fibrosis, contractures
gangrene.
CONGENITAL DISLOCATION OF HIP
This is the sudden dislocation of hip occurring
before, during or after the birth. This is one of
the commonest disorders in western countries.
The factors responsible for this are hereditary,
trauma, breech malposition, hormonal changes
during pregnancy. F:M—6:1.
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319
Asymmetry creases on groin, reduces range of
motion on the affected side, click sound is heard
everytime when movement occurs, child walks
5
with a peculiar gait, i.e. Trendelenburg or
waddling gait.
DE QUERVAIN’S DISEASE
It results because of inflammation of the tendon
sheath of abductor pollicis longus and extensor
pollicis brevis at place where it crosses styloid
process of radius.
Clinical Features
Tenderness on radial styloid process, pain
aggravates by adducting the thumb.
Thickened sheath can be palpated.
DUPUYTREN’S CONTRACTURE
This is a condition occurring due to the flexion
deformity of one or more fingers because of
thickening and shortening of palmar aponeurosis.
The etiology is unknown, but it can be hereditary.
The ring finger is commonly affected.
Clinical Features
Thickening felt at bases of ring and little finger,
flexion deformity of fingers.
320
CHAPTER FIBROSITIS
5 This is the inflammation of the fibrous tissue.

There are nodules (firm) mostly on trapezius and
spinal muscles. The nodules are mainly the trigger
points, respond to ultrasonic therapy and local
steroids.
Clinical Features
Tenderness, nodules (small, firm), pain, affected
movement, reduced range of motion.
FIBROMYALGIA
This is disorder which is rheumatological and
non-articular in nature associated with joint and
myofascial pain. The etiology and pathology is
unknown, but it can occur itself or with some
other condition.
Clinical Features
Pain, tenderness, fatigue, disturbed sleep, anxiety,
depression, morning stiffness.
GOLFER’S ELBOW (MEDIAL EPICONDYLITIS)

This is the condition in which there is inflamma-
tion at the origin of flexor tendon, i.e. at the medial
epicondyle of the humerus.
Clinical Features
Pain, tenderness, swelling, reduced range of
motion.
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321
MYOSITIS OSSIFICANS CHAPTER
In this there is formation of hematoma around a
joint due to fracture or severe soft tissue injury,
mainly around elbow. It may also be congenital.
5
Clinical Features
Pain, tenderness, stiffness of joint.
OSTEOARTHRITIS
This is a degenerative joint disorder mainly
affecting the articular cartilage of the joint. It may
affect any age group after adolescent. Mainly
affects the large joint and the weight bearing
joints. Female are more affected than male.
Clinical Features
Pain, tenderness, swelling, morning stiffness,
reduced range of motion, joint effusion.
OSTEOCHONDRITIS
This is the disorder in which there is inflammation
of the joint and the cartilages. It may occur due
to compression, fragmentation or separation of
piece of bone. The various or common types of
osteochondritis are:
Perthes’ Disease
Also known as coxaplana, pseudocoxalgia.
Mainly affects the femoral head or femoral
epiphysis affecting the young boys. Occurs due
322
CHAPTER to recurrent episodes of ischemia and necrosis.
5
The bone becomes soft and fragmented due to
which it appears larger than original size.
Osgood-Schlatter Disease
Mainly affect the tibial tubercle seen in teenage
boys. Results in detachment of small cartilage, due
to vigorous physical activity.
Osteochondritis Dissecans
Mainly seen in adult boys. In this, there is
separation of fragment of bone and cartilage into
a joint. The commonest site are the capitulum of
humerus and medial femoral condyle.
Scheuermann’s Disease
Mainly affects the vertebral bodies resulting in
degeneration of the intervertebral disc into
vertebral end plate. Can also lead to kyphosis.
OSTEOMALACIA
Occurs due to deficiency of vitamin D, i.e. due to
poor nutrition, lack of various types of vitamin D.
Due to this, there is softening of bone, because of
incomplete calcification. Due to which they
become weak and get easily fractured. Mainly
seen in long bones.
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323
Soft fragmented bone, pain, tenderness, swelling,
redness, difficulty in weight bearing. 5
OSTEOMYELITIS
This occurs due to infection of the bones by the
micro-organisms. This results into destruction of
bone and production of inflammatory cells and
exudates. Seen commonly because of open
fracture or joint surgery. The infection may also
spread to other parts of body.
Clinical Features
Pain, tenderness, swelling, weight loss, fever.
PAGET’S DISEASE
This is a disease characterized by excessive
tendency of bony breakdown, gets thickened and
spondy. Tibia is affected most commonly.
Diseases mostly affects after 40 year of age. This
occurs due to osteoclast dysfunction.
Clinical Features
Dull pain, thickening of the affected bone.
POLYARTERITIS NODOSA
This is a vasculitic syndrome in which, the various
size of arteries are attacked by the rogue immune
324
CHAPTER cells causing inflammation and necrosis. All the
5
organs or parts of the body supplied by blood or
arteries are affected due to impaired blood supply.
Clinical Features
Fever, renal failure, hypertension, neuritis, weight
loss, muscle and joint pain, skin lesion.
POLYMYALGIA RHEUMATICA
This is a vasculitic syndrome, symptoms usually
begin at or over the age of 50 and mainly affects
women. This is associated with fever, generalized
pain and stiffness.
Clinical Features
Loss of vision, involvement of cranial arteries,
migraines, stroke.
POLYMYOSITIS
This is an autoimmune, inflammatory disease of
muscle. It causes progressive weakness of skeletal
muscle. It has an unknown etiology. The muscles
of pelvis, hip and shoulder girdle are mainly
affected. The disease occurs sometimes with a skin
rash over the body and is known as dermato-
myositis.
Clinical Features
Pain, tender to touch, difficulty in weight bearing.
MUSCULOSKELETAL
325
RHEUMATOID ARTHRITIS CHAPTER
This is an autoimmune disorder affecting several
joints at same times. There is destruction of
articular cartilage, capsule, ligament and tendons,
5
leads to deformity. The joints are symmetrically
affected. There are nodules, the disease is
common in young to middle aged women.
Clinical Features
Pain, swelling, morning stiffness, loss of move-
ment and function.
SPONDYLOLISTHESIS
This is the forward displacement of one vertebral
body over the vertebral body below it, commonly
seen in L5/S1, the displacement may be severe,
causes compression of cauda equina.
I. Dysplastic: Congenital
II. Isthmic: Fatigue fracture of the pars
interarticularis due to overuse
III. Degenerative: Osteoarthritis
IV. Traumatic: Acute fracture
V. Pathological: Weakening of the pars intra–
articularis by a tumor, osteoporosis, tuber-
culosis or Paget’s disease.
Clinical Features
Pain, tenderness, difficulty in bending, sitting and
lying down, affected movement.
326
CHAPTER SPONDYLOLYSIS
5 This is the defect in the pars interarticularis of the

lumbar vertebrae resulting due to fatigue fracture.
It can be both uni and bilateral and it may or may
not progress to spondylolisthesis.
Clinical Features
Pain, difficulty in bending, affected movement.
SPONDYLOSIS
This occurs due to degeneration and narrowing
of the intervertebral discs which leads to the
formation of osteophytes at joint margin and
arthritic changes of the facet joint, the cervical
joints are commonly affected. The spinal canal
causes dysfunction of all four limbs and may be
the bladder also. The vertebral artery may also be
involved.
Clinical Features
Neck pain, stiffness, radiating pain to upper limbs,
vertigo.
SYSTEMIC LUPUS ERYTHEMATOUS

This is a chronic inflammatory autoimmune
connective tissue disorder. It involves the skin,
joint and internal organs. Amongst the affected
people, 90 percent are women.
MUSCULOSKELETAL
327
Anemia, hypertension, vasculitis, renal disease,
pleurisy, alopecia, polyarthritis vasculitis,
butterfly rash on face, Raynaud’s disease.
5
SYSTEMIC SCLEROSIS
This is an autoimmune disorder of the connective
tissue that causes increase in metabolism of
collagen. Excessive collagen deposits damage the
microscopic blood vessels in skin and other organs
and leads to fibrosis and degeneration. Middle
age women are most commonly affected.
Clinical Features
Edema of hands and feet. Alterations of facial
features are dry, shiny, tight, skin contractures
and finger deformities.
TENNIS ELBOW
Also known as lateral epicondylitis, affecting the
common extensor origin due to the inflammation
of the lateral epicondyle.
Clinical Features
Pain, tenderness, affected movement of extension.
TENOSYNOVITIS
This is the inflammation of the synovial lining of
the tendon sheath caused due to mechanical
328
CHAPTER irritation or infection. It may also occur due to
5
overuse and repetitive movements.
Clinical Features
Pain, tenderness, swelling, redness affected move-
ment and function.
THORACIC OUTLET SYNDROME

It is characterized by compression of neurovascu-
lar bundle comprising of subclavian artery/vein,
axillary artery/vein and brachial plexus at the
thoracic outlet (space between first rib, clavicle
and scalene muscles). Causes include hyper-
trophy of the existing muscles or due to any other
cause like trauma, congenital, etc.
Clinical Features
Pain, weakness, edema, pallor, paresthesia,
venous engorgement, cyanosis involving mainly
neck, any affected side shoulder and upper
extremity.
GRADES OF SPRAIN AND TREATMENT

Grade I—Minimal pain and disability, weight
bearing not affected.
Grade II—Moderate pain and disability, weight
bearing difficult.
Grade III—Severe pain, swelling and dislocation,
no weight bearing possible.
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329
TREATMENT CHAPTER
Prices
P—Prevention from further injury
5
R—Rest to the part
I—Icing
C—Compression
E—Elevation of the part
S—Support.
STAGES OF FRACTURE HEALING

HEMATOMA FORMATION
• Duration: Less than 7 days
• Essential features: Deposition of blood at the site
of fracture, which sensitizes the precursor
cells.
CELLULAR PROLIFERATION
• Duration: Up to two to three weeks
• Essential features: It has two substages:
a. Endosteal cellular proliferation—formation
of cells in endosteam
b. Periosteal cellular proliferation—formation
of cells on surface of medullary cavity.
STAGE OF CALCIFICATION
This stage includes deposition of lime salt, mainly
calcium and phosphorus.
330
CHAPTER NEW BONE FORMATION
5 • Duration: Up to 4 to 12 weeks
• Essential features: It has three substages:
a. Stage of callus formation: Deposition appears
as slit callus, it occurs after two to three
weeks of trauma.
Callus—It is a new bone formation/
calcification which bridges the fracture site,
responsible for healing of fracture.
b. Stage of consolidation:
— This stage is characterized by more
callus formation which bridges the
fracture site.
— The callus appears to be firm or hard
on palpation. This callus consolidates
on parent bone.
c. Crossing of trabecular pattern:
— The trabecular pattern of the fractured
bone gets disturbed.
— It requires 8–10 weeks for slit alignment
of trabecular pattern.
— This alignment is not anatomically
satisfactory.
— It appear to be slit deformed as normal
one. The bone gets bended.
— To correct it, next stage occurs.
REMODELING STAGE
• Duration: One to two years
• Essential features: It occurs till the correction of
bending.
MUSCULOSKELETAL
331
• After 6 month, 90 percent bone is formed. CHAPTER
5
Note
1. Angulation and over-riding is not accepted
since:
• It has longer period of remodeling.
• Movement of limb is affected.
• Bone may be fixed in rotated position.
2. When fracture is united on bending with
remodeling in few months, it is accepted.
3. One of the very important clinical findings
of mature union is—no pain on applying
angulation force.
4. Radiological criteria to suggest mature
union are:
• Callus formation
• Crossing of trabeculae formation
• Remodeling.
FRACTURES WITH EPONYMS

BARTON’S FRACTURE
It is the fracture of distal articular surface of the
radius which extends to either its anterior or
posterior cortical. It is thus divided into two
types:
a. Volar Barton’s fracture (anterior marginal
type).
b. Dorsal Barton’s fracture (posterior marginal
type).
This type of fracture is treated by closed
manipulation and by a plaster cast. If it fails, the
open reduction and internal fixation is done.
332
CHAPTER COLLES’ FRACTURE
5 It is defined as the fracture at the distal end of the

radius, at its corticocancellous junction with
typical displacement in adults such as:
1. Dorsal tilt
2. Dorsal displacement
3. Fragment impaction
4. Lateral tilt
5. Lateral displacement
6. Supination.
Common Injuries Associated Colles’ Fracture

• Fracture of the styloid process of ulna
• Rupture of the ulnar collateral ligament
• Rupture of the interosseous radioulnar
ligament, resulting radioulnar subluxation.
Treatment
It is mainly treated conservatively. Undisplaced
type of fracture is immobilized in a below-elbow
plaster cast for six weeks. Displaced fractures are
treated by manipulative reduction and immobili-
zation in Colles’ cast.
GALEAZZI FRACTURE—DISLOCATION
This is characterized by fracture of the lower third
of the radius with dislocation or subluxation of
the distal radioulnar joint. The most common
cause is fall on outstretched hand.
MUSCULOSKELETAL
333
It shows a typical displacement, i.e. the radius CHAPTER
5
fracture is angulated medially and anteriorly. The
distal radioulnar joint is disrupted which results
in dorsal dislocation of the distal end of the ulna.
Treatment: In children, it is treated with closed
reduction in a conservative manner. In elder
persons, it is mostly treated by open reduction and
internal fixation of radius with a plate.
MONTEGGIA’S FRACTURE—DISLOCATION
It is defined as ‘ fracture of upper third of the ulna
with dislocation of the head of radius.’ Most
common cause is fall on outstretched hand with
forearm forced in excessive pronation.
Types
a. Extension type: Extension type is commoner
with the ulna fracture angulates anteriorly and
the radial head dislocates anteriorly.
b. Flexion type: Flexion type indicates that the
ulna fracture angulates posteriorly and the
radial head dislocates posteriorly.
Treatment
Since, it is very unstable injury, it redisplaces
frequently even if it has been reduced once. After
proper reduction, close watch is kept by weekly
check X-rays for initial three to four weeks.
334
CHAPTER Open reduction and internal fixation using a
5
plate is performed in case where a reduction is
not possible or if redisplacement occurs.
SMITH’S FRACTURE
It is also seen as reverse of Colles’ fracture where
the distal fragment displace ventrally and tilts
ventrally.
It is important to differentiate it from the
commoner Colles’ fracture which occurs at the
same site.
It is treated by closed reduction and plaster
cast immobilization for six weeks.
BENNETT’S FRACTURE—DISLOCATION
It is a type of an oblique intra-articular fracture
of the base of the first metacarpal with subluxa-
tion or dislocation of the metacarpal.
Most common cause is longitudinal force
applied to the thumb.
Treatment
As being an intra-articular fracture it requires
accurate reduction and reduction, otherwise it
leads to incongruity of the articular surface and
may prone the bone for osteoarthritis.
Mostly used methods are:
• Closed manipulation and plaster cast.
MUSCULOSKELETAL
335
• Closed reduction and percutaneous CHAPTER
5
fixation under X-ray control using an
image intensifier.
• Open reduction and internal fixation with
a K-wire or a screw.
MALLET FRACTURE
• It is also called as mallet finger or baseball
finger.
• This fracture is the result of sudden passive
flexion of the distal interphalangeal joint,
which causes avulsion of extensor tendon of
the distal interphalangeal (DIP) from its
insertion at the base of the distal phalanx.
Sometimes the avulsion is associated with
fragment of bone with it.
• It shows the clinical feature of slight flexion
of distal phalanx.
• Treatment of this fracture is by immobilizing
the DIP joint in hyperextension with help of
an aluminium splint or plaster cast.
ROLADO’S FRACTURE
This is the fracture of base of the first metacarpal,
extra-articularly. Being an extra-articular fracture,
its perfect reduction is not as important as in
Bennett’s fracture dislocation.
It is treated clinically by reduction and
immobilization in a thumb spica for three weeks.
336
CHAPTER BUMPER FRACTURE
5 It is actually the fracture of condyle of tibia.

Mechanism of injury is direct trauma to the
upper end of tibia, or an indirect force more often
results in unicondylar (by a varus/valgus bending
force) or infracondylar fracture (by a hyper-
extension force).
Bumper fracture is more accurately the
fracture of the lateral condyle of the tibia, when
the bumper of a motorcar strikes the lateral side
of the knee.
Treatment
It is treated clinically by reduction under
anesthesia, followed by below knee skin traction
for three weeks. The knee is mobilized as the
fracture becomes stickly, few cases need open
reduction and joint reconstruction.
MUSCULOSKELETAL ASSESSMENT
Reg. No.
Name
Age/sex
Date of admission
Address
Occupation
Referred by (consultant) and hospital
MUSCULOSKELETAL
337
Date of discharge CHAPTER
5
Discharge summary
Instructions for physiotherapist
History of present illness
Drug history:
Current medication
Steroids
Anticoagulants
allergies.
ADL activity
Personal history
Social history
Family history.
ON OBSERVATION
Attitude of limb
Facial expression
Deformity
Posture: Lying
Sitting
Standing.
Pain: Type
Onset
Nature
Radiation
Intensity
Aggravating factor
Relieving factor
338
CHAPTER Severity
5
Associated symptoms.
ON PALPATION
Temperature
Tenderness
Edema—pitting/non-pitting
Inflammatory signs
Muscle wasting
Contractures.
ON EXAMINATION
Range of movement:
Active
Passive.
Joint effusion measurement
Muscle girth
Limb length
End feel: Capsular
Noncapsular.
Differential test
Gait assessment
MMT
Neurological test:
Dermatomes
Reflexes
Myotomes.
Special tests
Investigations—Blood/X-ray/CT scan/MRI.
MISCELLANEOUS
339
6
CHAPTER
CHAPTER 6
Miscellaneous
• Diagnostic/electrodiagnostic testing
• National immunization schedule
• Proprioceptive neuromuscular facilitation
(PNF)
• Common sports injuries
• Types of aphasia
• Gait
• Levels of amputations
• Abbreviations
• Normal reference/lab values
340
CHAPTER DIAGNOSTIC/ELECTRODIAGNOSTIC
6
TESTING
COMPUTED TOMOGRAPHY (CT)
Imaging procedure where detailed information is
obtained from thin section in collimated X-rays.
Indications
• Evaluation of bony structure, especially
cortical bone.
• Useful for diagnosis in compound fracture,
dislocations, stress fracture and spinal
pathologies.
• Structural evaluation of lung, mediastinal
pathologies.
• Structural analysis of intracranial lesions.
• Evaluation and comparison of the normal
organ and abdominal tissues.
Contraindications
• Restless patient
• Pregnancy.
MAGNETIC RESONANCE IMAGING (MRI)

Cross sectional image is formed by certain atomic
nuclei, which possess unpaired protons or
neutrons, possess an inherent spin. Positive
charged nucleus generates a small magnetic field
MISCELLANEOUS
341
around itself, when it spins. Those signals emitted CHAPTER
6
by the nuclei are measured and reconstructed by
computer to create an image of soft tissue and
bone.
T1—Images show anatomical detail with fluid
being dark and fat being bright.
T2—Images show soft tissue pathology much
better with fluid being bright.
Advantages
• Noninvasive.
• Give high intrinsic contrast.
• No bony or air defect.
• No known biological hazards.
• Sagittal, transverse imaging are possible.
• It does not involve the use of ionizing
radiation.
Disadvantages
• Patients may produce artifacts, because
imaging time is long.
• Expansive.
• Require trained technical staff.
• Patient with a cardiac pacemaker, brain aneu-
rysm clip or other metallic implants with the
exception of those attached to the bone, i.e.
prosthetic joints cannot be scanned.
342
CHAPTER ULTRASOUND
6 Based on piezo-electric effect which is the

property of certain substances to convert electrical
energy to sound energy.These are the active
portions of the ultrasonic transducers. Can be
used to examine a broad range of soft tissue
structures.
Advantages
• Noninvasive.
• Cost-effective.
• Widely available.
• Also used in wards.
• Does not involve the use of ionizing radiation
and can therefore be safely used in a pregnant
women.
Disadvantages
• Limited in thorax.
• Cannot image the bone.
• Limited use in the abdomen when there is
gaseous distension.
RADIOGRAPHY
Oldest imaging technique, formed by exposure to
short wavelengths of X-rays that pass through the
body and hit a photographic receptor placed
behind the patient body.
MISCELLANEOUS
343
USES CHAPTER
•
•
•
In dentistry
Mammography
Chest examinations
6
• Diagnosis of fractures.
Hollow organ can be visualized by filling them
with a radiopaque substances. These block the
X-rays and visualize the structures.
Angiography: Visualization of the blood vessels.
Arthrography: Visualize the degenerations of the
joints.
Discography: Visualize the disc pathology.
Myelography: Visualize the compressive lesions of
the spinal cord and cauda equine.
Tenography: Visualize the tendon pathology and
ligaments ruptures.
ELECTROENCEPHALOGRAPHY (EEG)
Electroencephalography examines by means of
scalp electrode the spontaneous electrical activity
of the brain. Tiny electrical potentials, which
recorded, amplified and displayed on either 8 or
16 channels of a pen recorder. Mainly used in
diagnosis of coma, epilepsy and certain forms of
encephalitis.
ELECTROMYOGRAPHY (EMG)
Electromyography is a technique used in studying
the electrical activity of the muscles for the
344
CHAPTER diagnosis of neuromuscular disease. Used in the
6
diagnosis of a broad range of myopathies and
neuropathies.
NERVE CONDUCTION STUDIES (NCV)

Recording technique of a peripheral nerve
impulses at same location, which may distant
from the site from where the propagating action
potential is induced in that peripheral nerves.
Mainly used in the diagnosis of nerve entrap-
ments, peripheral neuropathies, motor and
sensory nerve damage and multifocal motor
neuropathies.
EVOKED POTENTIALS (EP)

An electrical response recorded from the brain,
the spinal cord or the peripheral nerve that is
evoked by various external stimuli such as visual
(e.g. flashing the light), auditory (click sound),
somatosensory (electrical stimulation), etc. The
recording electrodes are placed over the scalp,
neck or spine surface, which vary depending on
the type of stimulus modality to be tested. Mainly
used for detecting multiple sclerosis, brainstem
and cerebellopontine angle lesions, various
cerebral metabolic disorders in infants and
children.
MISCELLANEOUS
345
NATIONAL IMMUNIZATION SCHEDULE CHAPTER
Time
Birth
Vaccine
BCG and OPV zero dose (for
6
institutional deliveries)
6 weeks BCG (if not given at birth)
DPT-1 and OPV-1
10 weeks DPT-2 and OPV-2
14 weeks DPT-3 and OPV-3
9 months Measles
18-24 months DPT and OPV (1 booster)
5 years DT
10 year and 16 years TT
For pregnant women Early in pregnancy TT-1, after
1 month TT-2
PROPRIOCEPTIVE NEUROMUSCULAR
FACILITATION (PNF)
TECHNIQUE
To strengthen muscles:
1. Slow reversals
2. Repeated contractions
3. Rhythmic stabilizations
To gain relaxation/lengthening of muscles:
1. Hold—relax
2. Contract—relax
3. Rhythmic stabilizations
346
CHAPTER To improve coordination
6
1. Slow reversals
2. Repetitive movements.
COMMON SPORTS INJURIES

SHOULDER JOINT AND ARM
Rotator cuff tear — Javelin throwers, swim-
mers, volleyball players,
baseball players
Glenohumeral — Gymnasts, weight lifters,
ballers
Glenohumeral — Boxers, hockey players
dislocation
ELBOW AND FOREARM

Medial epicondylitis — Golf players
Lateral epicondylitis — Tennis players
Valgus extension — Javelin throwers
WRIST AND HAND

Tendon ligament — Volleyball players,
basketball players,
boxers
Ulnar tunnel syndrome — Cyclist
Carpel-tunnel syndrome — Rock-climbers,
tennis players, golf
players
MISCELLANEOUS
347
HIP AND THIGH CHAPTER
Quadriceps and hamstring injuries—Runners
Adductor injuries—Horse riders 6
Fracture of pelvis/hip-dislocation—Footballers
KNEE AND LEG

Collateral ligament injury—Footballers
Meniscal injury—Footballers, kabaddi players
Cruciate ligament injury—Long-jumpers
Knee dislocation—Kick boxers
IT band syndrome—Long and high jumpers
Compartment syndrome—Runners and cyclists
ANKLE AND FOOT

Sprain—Basketball player, footballers, baseball
players
Achilles tendonitis and bursitis—Runners
TA rupture—Runners, footballers
Metatarsalgia—Runners
Stress fracture—Walkers
348
CHAPTER TYPES OF APHASIA
6 1. Global
Fluency Comprehension Repetition
– – –
2. Isolation – – +
3. Broca’s – + –
4. Transcortical – + +
motor
5. Wernicke’s + – –
6. Transcortical + – +
sensory
7. Conduction + + –
8. Normal + + +
– Absent, + present
GAIT
GAIT TERMINOLOGY
Traditional Rancho los amigos
Stance phase
Heel strike Initial contact
Foot flat Loading response
Mid stance Mid stance
Heel off Terminal stance
Toe off Preswing
Swing phase
Acceleration Initial swing
Mid swing Mid swing
Deceleration Terminal swing
MISCELLANEOUS
349
GAIT ASSESSMENT CHAPTER
Under the headings of:
• Type of gait patterns and variations
• Length of step and width of base
6
• Abnormal leg movements
• Instability
• Associated postural movements
• Identification of cause
• Energy requirement in given pattern
• Determination of the functional ambulation
capacities.
ABNORMAL GAIT
Antalgic/Painful—Stance face on the affected leg
is shorter than that on the non-affected leg.
Atherogenic/Stiff hip or knee—Patient lifts the
entire leg higher than normal to clear the ground
because of stiff hip or knee.
Ataxic/Drunkers—Staggering and unsteadiness.
Patient walks with a wide base and swings the
leg unnecessarily and irregularly.
High stepping/Foot drop/Slapping—More of the
hip and knee flexion to clear the ground.
Lordotic—Walking with increased lumber
lordosis.
Hemiplegic/Circumductory—Rigid lower limb is
stiffly dragged sideways and forwards in semi-
circular fashion.
350
CHAPTER Spastic—Toes scraping the floor with pelvis
6
lifting from side to side.
Scissoring—Crossed leg pattern, walk on toes,
overactive arms to maintain balance, pelvic
waddle.
Shuffling (Parkinsonian, Festinant, Festinating
gait)—Walking on toes but rapid shuffling steps,
increased in cadence, lack of heel strike and toe
off, decreased arm swing.
Jaunty—Jerky and dancing pattern.
Waddling—Oscillatory pattern.
Kinesia paradoxa—Run better than walks.
Tandem walking—Heel-to-toe pattern.
Gluteal—Leaning of the trunk to the affected side.
Antalgic/Limping—Patient does not put his
complete weight on the affected lower limb, step
length is very small.
Calcaneal—Patient walks on the heel.
Hand to knee/Quadriceps—Knee has to be
forcibly extended during heel strike and this is
done by placing hand on thigh at midstance.
Talus/Equinous/Toe—Walks on toes.
Valgus—Walks on medial border of the foot and
knock knee is present.
Varus—Patient walks on the lateral border of the
foot and associated bow leg is present.
MISCELLANEOUS
351
LEVELS OF AMPUTATIONS CHAPTER
6
(FIGS 6.1 AND 6.2)
Fig. 6.1: Levels of amputation in lower limb

352
CHAPTER
Fig. 6.2: Levels of amputation in upper limb

MISCELLANEOUS
353
ABBREVIATIONS CHAPTER
AAA
Ab
ABG
Abdominal aortic aneurysm
Antibody
Arterial blood gas
6
ABPA Allergic bronchopulmonary asper-
gillosis
ACBT Active cycle of breathing technique
ACE Angiotensin-converting-enzyme
ACT Activated clotting time
ACTH Adrenocorticotropic hormone
AD Autogenic drainage
ADH Anti-diuretic hormone
ADL Activities of daily living
A-aDO2 Alveolar-arterial oxygen gradient
ADR Adverse drug reaction
AE Air entry
AEA Above elbow amputation
AF Atrial fibrillation or a febrile
AFB Acid fast bacilli
AFO Ankle foot orthosis
Ag Antigen
AGN Acute glomerulonephritis
AHRF Acute hypoxemic respiratory
failure
Ai Aortic insufficiency
AIDS Acquired immunodeficiency
syndrome
AKA Above knee amputation
AL Acute leukemia
ALD Alcoholic liver disease
354
CHAPTER ALI Acute lung injury
6
AMBER Advance multiple beam equali-
zation radiography
AML Acute myeloid leukemia
AP Anteroposterior
APACHE Acute physiology and chronic
health evaluation
A-aPO2 Alveolar-arterial oxygen gradient
ARDS Acute respiratory distress syndrome
ARF Acute renal failure
AROM Active range of movement
AS Ankylosing spondylitis
ASD Atrial septal defect
ATN Acute tubular necrosis
ATPS Ambient temperature and pressure
saturated
AVAS Absolute visual analog scale
AVF Arteriovenous fistula
AVR Aortic valve replacement
AVSD Atrioventricular septal defect
AXR Abdominal X-ray
B/slab Back slab
BCG Bacille Calmette-Guerin
BDI Baseline and transition dyspnea
index
BE Bacterial endocarditis/barium
enema/base excess
BEA Below elbow amputation
BiPAP Bilevel positive airway pressure
BIVAD Biventricular device
MISCELLANEOUS
355
BKA Below knee amputation CHAPTER
6
BM Blood glucose monitoring
BMi Body mass index
BO Bowels open
BP Blood pressure
BPD Bronchopulmonary dysplasia
BPF Bronchopleural fistula
Bpm Beats per minute
BS Bowel sound/breath sound
BSA Body surface area
BSO Bilateral salpingo-oophorectomy
BVHF Bi-ventricular heart failure
C/O Complains of
C/W Consistent with
Ca Carcinoma
CABG Coronary artery-bypass graft
CAD Coronary artery disease
CAH Chronic active hepatitis
CAL Chronic airflow limitation
CAO Chronic airways obstruction
CAPD Continuous arterial venous hemo-
filtration
CBC Complete blood cell count
CBD Common bile duct
CBF Cerebral blood flow
CCF Congestive cardiac failure
CCU Coronary care unit
CDH Congenital dislocation of hip
CF Cystic fibrosis
CFA Cryptogenic fibrosing alveolitis
356
CHAPTER CFMS Cerebral function monitors
6
CHD Coronary heart disease
CHF Chronic heart failure
Ci Chest infection
CK Creating kinase
CL Lung compliance
CLD Chronic lung disease
CML Chronic myeloid leukemia
CMV Controlled mandatory ventilation/
cytomegalovirus
CNS Central nervous system
CO Carbon monoxide
CO Cardiac output
CO2 Carbon dioxide
COAD Chronic obstructive airways disease
CoP Completion of plaster
COPD Chronic obstructive pulmonary
disease
CP Cerebral palsy
CPAP Continuous positive airway pressure
CPM Continuous passive movement
CPN Community psychiatric nurse
CPP Cerebral perfusion pressure
CPR Cardiopulmonary resuscitation
Crash team Cardiac arrest team
CRF Chronic renal failure
CRP C-reactive protein
CRP Conditioning rehabilitation
program
MISCELLANEOUS
357
CRQ Chronic respiratory disease ques- CHAPTER
6
tionnaire
C-section Cesarean section
CSF Cerebrospinal fluid
CT Computed tomography
CVA Cerebrovascular accident
CVI Cerebrovascular incident
CVP Central venous pressure
CVS Cardiovascular system
CVVHF Continuous veno-venous
hemofiltration
CXR Chest X-rays
D and C Dilation and curettage
D/C Discharge
D/W Discussed with
DBE Deep breathing exercises
DDD Degenerative disc disease
DDH Developmental dysplasia of the
hips
DH Drug history
DHS Dynamic hip screw
DIB Difficulty in breathing
DIC Disseminated intravascular
coagulopathy
DIOS Distal intestinal obstruction synd-
rome
DISH Diffuse idiopathic skeletal hyper-
ostosis
Dl Deciliter
DLCO Diffusing capacity for carbon
monoxide
358
CHAPTER DM Diabetes mellitus
6
DMARD Disease modifying anti-rheumatic
drug
DMD Duchenne muscular dystrophy
DN District nurse
DNA Deoxyribonucleic acid/did not
attend
DOA Dead on arrival/date of admission
DSA Digital subtraction angiography
DTs Delirium tremens
DU Duodenal ulcer
DVT Deep vein thrombosis
DXT Deep X-ray therapy
EBV Epstein-barr virus
ECCO2R Extracorporeal carbon dioxide
removal
ECG Electrocardiogram
ECMO Extracorporeal membrane oxyge-
nation
EECP Enhanced external counter pulsation
EEG Electroencephalogram
EIA Exercise induced asthma
ETT Exercise tolerance test
EMG Electromyography
ENT Ear, nose and throat
EOR End of range
Ep Epilepsy
EPAP Expiratory positive airway pressure
EPP Equal pressure points
MISCELLANEOUS
359
ERCP Endoscopic retrograde, cholangio- CHAPTER
6
pancreatography
ERV Expiratory reserve volume
ESR Erythrocyte sedimentation rate
ESRF End stage renal failure
ETCO2 End-tidal carbon dioxide
ETT Endotracheal tube
EUA Examination under anesthetic
FB Foreign body
FBC Full blood count
FDP Fibrin degradation product
FET Forced expiration product
FEV1 Forced expiratory volume in 1
second
FFD Fixed flexion deformity
FG French gauge
FGF Fibroblast growth factor
FH Family history
FHF Fulminating hepatic failure
FiO2 Fractional inspired oxygen concen-
tration
FRC Functional residual capacity
FROM Full range of movement
Ft Feet
FVC Forced vital capacity
FWB Full weight bearing
G Gram
GA General anesthetic
Gaw Airway conductance
GBS Guillain-Barré syndrome
360
CHAPTER GCS Glasgow coma scale
6
GH General health
GI Gastrointestinal
GIT Gastrointestinal tract
GOR Gastroesophageal reflux
GPB Glossopharyngeal breathing
GTN Glycerol trinitrate
GU Gastric ulcer/genitourinary
H+ Hydrogen ion
H2 Hydrogen
HASO Hip abduction spinal orthosis
Hb Hemoglobin
HC Head circumference
Hct Hematocrit
HD Hemodialysis
HDU High dependency unit
HF Heart failure
HFCWO High frequency chest wall
oscillation
HFJV High frequency jet ventilation
HFO High frequency oscillation
HFOV High frequency oscillatory
ventilation
HFPPV High frequency positive pressure
ventilation
HFV High frequency ventilation
HH Hiatus hernia/home help
HI Head injury
HIV Human immunodeficiency virus
HLA Human leukocyte antigen
MISCELLANEOUS
361
HLT Heart-lung transplantation CHAPTER
6
HME Heat and moisture exchanger
HPC History of presenting condition
HPOA Hypertrophic pulmonary osteo-
arthropathy
HR Heart rate
HRR Heart rates reserve
HT Hypertension
Hz Hertz
IABP Intra-aortic balloon pump
IBS Irritable bowel syndrome
IC Inspiratory capacity
ICC Intercostal catheter
ICD Intercostal drain
ICP Intracranial pressure
ICU Intensive care unit
IDC Indwelling catheter
IDDM Insulin dependent diabetes mellitus
IF Interferential therapy
Ig Immunoglobulin
IHD Ischemic heart disease
ILD Interstitial lung disease
IM Intramedullary
IM/im Intramuscular
IMA Internal mammary artery
IMV Intermittent mandatory ventilation
INH Inhalation
INR International normalized ratio
IPAP Inspiratory positive airway pressure
IPPB Intermittent positive pressure
breathing
362
CHAPTER IPPV Intermittent positive pressure
6
ventilation
IPS Inspiratory pressure support
IRQ Inner range quadriceps
IRV Inspiratory reverse volume
IS Incentive spirometry
ITU Intensive therapy unit
IV/i.v. Intravenous
IVB Intervertebral block
IVC Inferior vena cava
IVH Intraventricular hemorrhage
IVI Intravenous infusion
IVOX Intravenacaval oxygenation
IVUS Intravenacaval ultrasound
J Joule
JVP Jugular venous pressure
KAFO Knee ankle foot orthosis
KCO Transfer coefficient
KO Knee orthosis
KPa Kilopascal
LA Local anesthetic
LAP Left atrial pressure
LBBB Left bundle branch block
LBP Low back pain
LCL Lateral collateral ligament
LDL Low density lipoprotein
LED Light emitting diode
LFA Low friction arthroplasty
LFT Liver function test/lung function
test
MISCELLANEOUS
363
LFT × 2 Lung or liver function test CHAPTER
6
LL Lower limb/lower lobe
LOC Level of consciousness
LP Lumbar puncture
LRTD Lower respiratory tract disease
LSCS Lower segment cesarean section
LTOT Long-term oxygen therapy
LVAD Left ventricular assist device
LVEF Left ventricular ejection fraction
LVF Left ventricular failure
LVRS Lung volume reduction surgery
M Meter
MAOI Monoamine oxidase inhibitor
MAP Mean airway pressure/mean
arterial pressure
MAS Minimal access surgery
MC and S Microbiology, culture and sensi-
tivity
MCH Mean corpuscular hemoglobin
MCL Medical collateral ligament
MCV Mean corpuscular volume
MDI Multidisciplinary team
MDI Metered dose inhaler
ME Metabolic equivalents/myalgic
encephalomyelitis
MEFV Maximum expiratory flow volume
METs Metabolic equivalents
MHz Megahertz
MI Myocardial infraction
MIFV Maximum inspiratory flow volume
364
CHAPTER ML Middle lobe
6
MM Muscle
MMAD Mass median aerodynamic diameter
mmHg Millimeter of mercury
MMV Mandatory minute volume
MND Motor neuron disease
MOW Meals on wheels
Mph Miles per hour
MRI Magnetic resonance imaging
MRSA Methicillin-resistant staphylococcus
aureus
Ms Millisecond
MS Mitral stenosis/multiple sclerosis
MSU Midstream urine
MUA Manipulation under anesthetic
MV Minute volume
MVO2 Myocardial oxygen consumption
MVR Mitral valve replacement
MVV Maximum voluntary ventilation
MWM Mobilization with movement
N/S Nursing staff
NAD Nothing abnormal detected
NAG Natural apophyseal glide
NAI Non-accidental injury
NBI No bony injury
NBL Non-directed bronchial lavage
NBM Nil by mouth
NCPAP Nasal continuous positive airway
pressure
NEEP Negative end expiratory pressure
MISCELLANEOUS
365
NEPV Negative extra-thoracic pressure CHAPTER
6
ventilation
NFR Note for resuscitation
NG Nasogastric
NH Nursing home
NICU Neonatal intensive care unit
NIDDM Non-insulin dependent diabetes
mellitus
NIPPV Non-invasive intermittent positive
pressure ventilation
NITU Neonatal intensive care unit
NIV Non-invasive ventilation
Nm Nanometer
Nmol Nanomole
NMR Nuclear magnetic resonance
NO Nitric oxide
NOF Neck of femur
NOH Neck of humerus
NP Nasopharyngeal
NPA Nasopharyngeal airway
NPV Negative pressure ventilation
NR Nodal rhythm
NREM Non-rapid eye movement
NSAID Non-steroidal anti-inflammatory
drug
NSR Normal sinus rhythm
NWB Non-weight bearing
O/E On examination
O2 Oxygen
OA Oral airway/osteoarthritis
366
CHAPTER OB Obliterative bronchiolitis
6
Occ Occasional
OD Over dose
Oe Objective examination
OGD Oesophagogastroduodenoscopy
OHFO Oral high-frequency oscillation
Oi Oxygen index
°JACCOL No jaundice, anemia, clubbing,
cyanosis, edema
°LKKS No liver, kidney, kidney, spleen
OLT Orthotopic liver transplantation
OPD Outpatient department
ORIF Open reduction and internal
fixation
OT Occupational therapist
PR Per rectum
PA Posteroanterior
PA Pernicious anemia/postero-
anterior/pulmonary artery
PACO2 Partial pressure of carbon dioxide in
alveolar gas
PaCO2 Partial pressure of carbon dioxide in
arterial blood
PADL Personal activities of daily living
PAIVM Passive accessory intervertebral
movement
PAO2 Partial pressure of oxygen in
alveolar gas
PaO2 Partial pressure of oxygen in arterial
blood
MISCELLANEOUS
367
PAP Pulmonary artery pressure CHAPTER
6
PAWP Pulmonary artery wedge pressure
PBC Primary biliary cirrhosis
PC Presenting condition/pressure
control
PCA Patient-controlled analgesia
PCD Primary ciliary dyskinesia
PCIRV Pressure-controlled inverted ratio
ventilation
PCP Pneumocystis carinii pneumonia
PCPAP Periodic continuous positive airway
pressure
PCV Packed cell volume
PCWP Pulmonary capillary wedge pres-
sure
PD Parkinson’s disease/peritoneal
dialysis/postural drainage
PDA Patent ductus arteriosus
PE Pulmonary embolus
PEEP Positive end expiratory pressure
PEF Peak expiratory flow
PEFR Peak expiratory flow rate
PEG Percutaneous endoscopic gastro-
stomy
PeMax Peak expiratory mouth pressure
PEME Pulsed electromagnetic energy
PEP Positive expiratory pressure
PERLA Pupils equal and reactive to light
and accommodation
PFC Persistent fetal circulation
368
CHAPTER PFO Persistent foramen ovale
6
PFY Patellofemoral joint
PHC Pulmonary hypertension crisis
PID Pelvic inflammatory disease
PIE Pulmonary interstitial emphysema
PIF Peak inspiratory flow
PIFR Peak inspiratory flow rate
Pimax Peak inspiratory mouth pressure
PIP Peak inspiratory pressure
PMH Previous medical history
PMR Percutaneous myocardial revas-
cularization
PN Percussion note
PND Paroxysmal nocturnal dyspnea
POMR Problem-oriented medical record
POP Plaster of Paris
PPIVM Passive physiological intervertebral
movement
PROM Passive range of movement
PS Pressure support/pulmonary
stenosis
PTB Pulmonary tuberculosis
PTCA Percutaneous transluminal
coronary angioplasty
PTFE Polytetrafluoroethylene
PTT Partial thromboplastin time
PU Passed urine
PVC Polyvinyl chloride
PVD Peripheral vascular disease
PVH Periventricular hemorrhage
MISCELLANEOUS
369
PVL Periventricular leukomalacia CHAPTER
6
PVR Pulmonary vascular resistance
PWB Partial weight-bearing
Px Prescribing
QOL Quality of life
R/O Removal of
RA Rheumatoid arthritis/room air
RAP Right atrial pressure
Raw Airway resistance
RBBB Right bundle-branch block
RBC Red blood cell
RDS Respiratory distress syndrome
REM Rapid eye movement
RFT Respiratory function test
RH Residential home
RhF Rheumatic home
RIP Rest in peace
RMT Respiratory muscle training
ROM Range of movement
ROP Retinopathy of prematurity
RPE Rating of perceived exertion
RPP Rate pressure product
RR Respiratory rate
RS Respiratory system
RSV Respiratory syncytial virus
RTA Road traffic accident
RV Residual volume
RVF Right ventricular failure
SC Subcuticular
SA Sinoatrial
370
CHAPTER SAB Subacromial bursa
6
SAH Subarachnoid hemorrhage
SALT Speech and language therapist
SaO2 Arterial oxygen saturation
SB Sinus bradycardia
SBE Subacute bacterial endocarditis
SCI Spinal cord injury
SDH Subdural hematoma
SFL/SFR Side flex left/right
SGAW Specific airway conductance
SH Social history
SHO Senior house officer
SIJ Sacroiliac joint
SIMV Synchronized intermittent manda-
tory ventilation
SL Sublingual
SLAP Superior labrum, anterior and
posterior
SLE Systemic lupus erythematosus
SMA Spinal muscular atrophy
SN Swedish nose
SNAG Sustained natural apophyseal glide
SOA Swelling of ankle
SOB Shortness of breath
SOBAR Short of breath at rest
SOBOE Short of breath on exertion
SOOB Sit out of bed
SpO2 Pulse oximetry arterial oxygen
saturation
SpR Special registrar
SPS Single point stick
MISCELLANEOUS
371
SR Sinus rhythm CHAPTER
6
SRAW Specific airway resistance
SS Social services
ST Sinus tachycardia
SUF (c) E Slipped upper femoral (capital)
epiphysis
SV Self-ventilating
SVC Superior vena cava
SVD Spontaneous vaginal delivery
SVG Saphenous vein graft
SVO2 Mixed venous oxygen saturation
SVR Systemic vascular resistance
SVT Supraventricular tachycardia
SW Social worker
SWT Shuttle walk test
T21 Trisomy 21 (Down’s syndrome)
TA Tendon of Achilles
TAA Thoracic aortic aneurysm
TAH Total abdominal hysterectomy
TAR Total ankle replacement
TATT Tired all the time
TAVR Tissue atrial valve repair
TB tuberculosis
TBI Traumatic brain injury
TCCO2 Transcutaneous carbon dioxide
TCO2 Transcutaneous oxygen
TED Thromboembolic deterrent
TEE Thoracic expansion exercises
TENS Transcutaneous electrical nerve
stimulation
TFA Transfemoral arteriogram
372
CHAPTER TFT Thyroid function test
6
TGA Transposition of great arteries
TGV Thoracic gas volume
THR Total hip replacement
TIA Transient ischemic attack
TKA Through knee amputation
TKR Total knee replacement
TLC Total lung capacity
TLCO Carbon monoxide transfer factor
TLCO Transfer factor in lung of carbon
monoxide
TLSO Thoracolumbar spinal orthosis
TM Tracheostomy mask
TMR Transmyocardial revascularization
TMVR Tissue mitral valve repair
TOP Termination of pregnancy
TPN Total parenteral nutrition
TPR Temperature, pulse and respiration
TTO To take out
TURBT Transurethral resection of bladder
tumor
TURP Trans urethral resection of prostate
TV Tidal volume
TWB Touch weight-bearing
Tx Transplant
U and E Urea and electrolytes
UAO Upper airway obstruction
UAS Upper abdominal surgery
UL Upper limb/upper lobe
mm Micrometer
URTI Upper respiratory tract infection
MISCELLANEOUS
373
ms Microsecond CHAPTER
6
USS Ultrasound scan
UTI Urinary tract infection
V Ventilation
V/p shunt Ventricular peritoneal shunt
V/Q Ventilation-perfusion ratio
VA Alveolar ventilation/alveolar volume
VAD Ventricular assist device
VAS Visual analog scale
VATS Video-assisted thoracoscopy surgery
VBG Venous blood gas
VC Vital capacity/volume control
Vd Dead space
VE Minute ventilation
VE Ventricular ectopics
VEGF Vascular endothelial growth factor
VER Visual evoked response
VF Ventricular fibrillation/vocal
fremitus
VR Vocal response
VRE Vancomycin-resistance
Enterococcus
VSD Ventricular septal defect
VT Ventricular tachycardia
Vt Tidal volume
W Watt
W/R Ward round
WBC White blood count
WCC White cell count
WOB Work of breathing
ZEEP Zero end expiratory pressure
374
CHAPTER OTHER IMPORTANT TERMINOLOGIES
6 Acr—across
Med—medial
Hor—horizontal
O—outward
Tow—towards
Lat—lateral
Incl—inclined Obl—oblique
Betw—between Und—under
L—left Beh—behind
B—backward Movt—movement
D—downward Sup—support
W/c—with Tog—together
Alt—alternate J—jump
Rhythm—rhythmically Spr—spring
Pend—pendulum Ass—assisted
Stat—stationary Pass—passive
Opp—opposite Wd—wide
Foll—followed Rev—reverse
Cont—continuously Reb—rebound
Rep—repeat Bal—balance
Res—resisted <—less than
>-more than o—no
#—fracture —diagnosis
—circumduction
!!—parallel —abdomen
H—head Frh—forehead
N—neck B—back
T—trunk S—side
Abd—abdomen P—pelvis
Shbl—shoulder blades Sh—shoulder
A—arm Elb—elbow
Wr—wrist Hnd—hand
MISCELLANEOUS
375
Fing—fingers L—leg CHAPTER
6
K—knee Hl—heel
F—feet Ank—ankle
Fra—forearm St—standing
Ly—lying Wg—Wing
Yd—yards Kn—Kneeling
Gr—grasp Hg—Hanging
Wlk—walk Bd—Bend
Pr—prone Rst—rest
X—cross Cl—close
Crk—crook Lax—relaxed
Crch—crough Sitt—sitting
Pos—position Rch—Reach
Str—stretch Std—stride
Stp—stoop Lg—long
Flex—flexion Rot—rotation
Abd—abduction Ev—eversion
Inv—inversion Supin—supination
Pron—pronation R—right
Ext—extension F—forward
Add—adduction U—upward.
S—sideways
376
CHAPTER NORMAL REFERENCE/LAB VALUES
6 HEMATOLOGY
Male Female Units
Activated partial 35-45 35-45 Seconds
thromboplastics
time APTT (PTTK)
ESR
Westergren 0-10 0-20 mm/lst hr
Wintrobe 0-7 0-14 mm/lst hr
Eosinophil count 40-450 40-450 Cells/cumm
Hemoglobin Hb 13-18 11-16 G/dl
Hematocrit PCV 40-55 35-48 %
Mean corpuscular MCH 28-32 28-32 Pg
hemoglobin
Mean corpuscular MCHC 31-36 31-36 G/dl or %
hemoglobin
concentration
Mean corpuscular MCV 78-98 78-98 FL
volume
Platelet count 1.5-4.0 1.5-4.0 Lakhs/cumm
Prothrombin time 11-14 11-14 Seconds
(PT)
RBC count 4.5-5.5 3.8-5.2 million/cumm
Reticulocyte count 0.5-2.0 0.5-2.0 %
Serum iron 80-180 60-160 Ug/dl
Serum feritin 16-300 12-160 Ug/ml
(mean 50) (mean 18)
Total iron binding Tibc 250-450 250-450 Ug/dl
capacity
Total leukocyte TLC 4000- 4000- Million/cumm
count 11000 11000
Transferring 30-35 30-35 %
saturation
MISCELLANEOUS
377
CHEMICAL PATHOLOGY CHAPTER
6
S—Serum, B—Blood, P—Plasma
Investigation Reference value Units

S alanine ALAT 5-35 U/l
Aminotransferase SGPT
P ammonia 47-65 Umol/l
S amylase 30-170 U/l
S aspartate ASAT 5-40 U/l
aminotransferase SGOT
P bicarbonate 21-28 mmol/l
S bilirubin Total 0.2-1.0 mg/dl
S bilirubin Conjugated 0.1-0.2 mg/dl
S calcium Total 9.0-11.0 mg/dl
P calcium 2.3-2.7 mmol/l
B CO2 content 19-24 mmol/l
S chloride 95-105 mEq/l
S cholesterol 150-230 mg/dl
S copper 11-12 Umol /l
S creatinine 0.6-1.2 mg/dl
Creatinine clearance 70-120 ml/min
S fatty acid Total 9-15 mmol/l
B glucose fasting 65-100 mg/dl
B glucose PP <140 mg/dl
(postprandial 2 hours)
S lactate dehydrogenase LDH 50-150 Units/L
S lipids total 400-800 mg/dl
S phosphatase acid 1-5 Ka units/dl
2-10 units/L
Prostatic fraction Up to 4 units/L
Contd...
378
Contd....
CHAPTER
6
Investigation Reference value Units
S phosphatase alkaline 40-100 units/L
4-12 Ka units/dl
S proteins total 5.5-8 gm/dl
Albumin 3.5-6.0 gm/dl
Globulin 2.0-3.5 gm/dl
A/g ratio 1.5:1-3:1
S phosphorus 1.0-1.4 mmol/L
S potassium 3.8-4.8 mEq/L
S sodium 135-145 mEq/L
B urea 20-40 mg/dl
B urea nitrogen (BUN) 10-20 mg/dl
S uric acid 2-6 mg/dl
Values are only for adults and depending on testing methods used.
OTHER BODY FLUIDS
Urine Examination
Urine examination 24 hr volume 600-1800 ml
Specific gravity urine (random) 1.003-1.030
Protein excretion 24 hr urine <150 mg/day
Protein, qualitative urine negative
Glucose excretion 24 hr urine 50-300 mg/day
Glucose qualitative urine (random) negative
Porphobilinogen urine (random) negative
Urobilinogen 24 hr urine 1.0-3.5 mg/day
Stool Examination
Coproporphyrin 400-1000 mg/day
Fecal fat excretion <6.0 g/day
Occult blood negative (<2 ml blood/day)
Urobilinogen 40-200 mg/day
MISCELLANEOUS
379
Cerebrospinal Fluid (CSF) CHAPTER
Normally cerebrospinal fluid is clear, colorless
and faintly alkaline.
Production 100 ml/day
6
CSF volume 120–150 ml
CSF pressure 60–150 mm of water in horizontal
position
200–250 mm of water in sitting position
Leukocytes 0-4 lymphocytes/ul
pH 7.31–7.34
Glucose 50–80 mg/dl
Proteins 15–45 mg/dl
Calcium 5.7–6.8 mg%
Body Volume
Total 50–70%
Intracellular 33%
Extracellular 27%
380
NOTES
Index
Page numbers followed by f refer to figure
A Adenosine 2
Adventitious sounds 98
Abduction stress test 308
Aerosol therapy 112
Abductor
Albendazole 3
digiti minimi 210 Albers-Schönberg disease
hallucis 210
315
pollicis Alendronate 3, 6
brevis 211 Alfentanil 3
longus 211 Allopurinol 4
Abnormal Alphabetical listing of
breath sounds 97 muscles 210
ECG findings 93 Alprazolam 5
gait 349 Alternate
Acetazolamide 2 heel-to-knee test 166
Acetylcysteine 2 nose-to-finger test 164
Achondroplasia 315 Alternative method of
Aciclovir 2 postural drainage 105
Acute respiratory distress Alzheimer’s disease 178
syndrome 123 Ambulatory manual
Adduction stress test 309 breathing unit bag 115
Adductor Aminophyline 4
brevis 212 Amiodarone 4
hallucis 212 Amitriptyline 4
longus 213 Amlodipine 5
magnus 213 Amoxicillin 5
pollicis 214 Ampicillin 5
382
Anconeus 214 B
Ankle joint 285
Ankylosing spondylitis 315 Baclofen 7
Anterior Baker’s cyst 316
aspect of neck and carotid Barton’s fracture 331
sinus 38 Basal ganglia 156
border of Beclomethasone 7
left lungs 82 Bell’s palsy 179
right lung 82 Bendrofluazide 8
cerebral artery 151f, 153 Bendroflumethiazide 8
cord syndrome 179 Bennett’s fracture 334
drawer test 294, 309, 313 Benzhexol 31
gapping test 303 Biceps
labral tear test 306 brachii 215
Apgar scoring method 101 femoris 216
Apley’s test 310 Biphasic positive airway
Arachnoiditis 179 pressure 121
Arterial Blood
blood 136 urea nitrogen 139
gas classification of values 138
respiratory failure Body volume 379
134 Brachialis 216
pressure 117 Brachioradialis 217
supply of cerebral hemi- Breath sounds 96
sphere 149 Broca’s dysphasia 180
Arthrogryposis multiplex Bronchial asthma 124
congenita 316 Bronchiectasis 124
Ascending tracts 163 Bronchitis 125
Aspirin 6 Bronchopulmonary segments
Atelectasis of lung 124 81f
Atenolol 6 Brown-Sequard syndrome
Atracurium 6 180
Atropine 7 Brudzinski-Kernig test 291
Auscultation 95 Brush test 310
Axillary nerve 158 Budesonide 8
Azathioprine 7 Bulbar palsy 180
INDEX
383
Bumper fracture 336 Clunk test 294
Bursitis 317 Codeine phosphate 11
Codman’s test 295
C Cold therapy 57
Colles’ fracture 332
Calcitonin 8
Common
Captopril 8
musculoskeletal tests 288
Carbamazepine 9
peroneal nerve 162
Cardiac
sports injuries 346
index 118
Compartment syndrome 318
output 117
Computed tomography 340
Cardiorespiratory
Congenital
monitoring 117
dislocation of hip 318
Carpal-Tunnel syndrome 318
lung cyst 95
Celecoxib 9
talipes equinovarus 317
Cellular proliferation 329
Continuous
Central
passive motion 66
cord syndrome 181
positive airway pressure
venous pressure 118
120
Cerebral
Contrast bath 60
palsy 181
Controlled mechanical
perfusion pressure 119
ventilation 121
Cerebrospinal fluid 379
Coproporphyrin 378
Cervical spine 281, 286, 288
Coracobrachialis 217
Charcot-Marie-tooth disease
Coronal section of brain 150f
182
Corpus callosum 155
Chloramphenicol 9
Cozen’s test 298
Chloroquine 10
Cranial nerves 169
Chlorpromazine 9
Crank test 294
Chronic obstructive
Cryotherapy 57
pulmonary disease 126
Cystic fibrosis 126
Ciclosporin 10
Ciprofloxacin 10
Circular arteriosus 152f D
Clofazimine 11 Dapsone 11
Clomipramine 11 De Quervain’s disease 319
Clonidine 11 Deep tendon reflexes 173
384
Dermatomes 157 Electromyography 343
Descending tracts 163 Emphysema 127
Dexamethasone 12 Empyema 127
Diaphragm 83, 218 Enalapril 15
Diazepam 12 Erythromycin 15
Diclofenac 12 Etidronate 15
Didanosine 12 Evoked potentials 344
Digoxin 13 Expiratory reserve volume
Dihydrocodeine 13 84
Diltiazem 13 Extensor
Disseminated encephalo- carpi radialis
myelitis 182 brevis 220
Distraction test 288 longus 221
Dobutamine 13 carpi ulnaris 221
Donepezil 13 digiti minimi 221
Dopamine 14 digitorum 222
Dornase alfa 14 brevis 222
Dorsal interossei 219, 220 longus 223
Dosulepin 14 hallucis longus 223
Dothiepin 14 indicis 224
Doxapram 14 pollicis
Doxycycline 14 brevis 224
Droparm test 295 longus 225
Duga’s test 295 External rotation recurvatum
Dupuytren’s contracture 319 test 310
E F
Efavirenz 15 Faber’s test 307
Ejection fraction 119 Fairbank’s apprehension test
Elbow 204, 279 311
and forearm 346 Farfan torsion test 292
flexion test 298 Femoral nerve 161
joint 282, 298 Fentanyl 16
Electrodiagnostic testing 340 Ferrous sulphate 16
Electroencephalography 343 Fibromyalgia 320
INDEX
385
Fibrositis 320 Gillets test 304
Finger-to- Glasgow coma scale 177
finger test 165 Gliclazide 17
nose test 165 Gluteus
Finkelstein’s test 300 maximus 233
Flexor medius 234
carpi minimus 235
radialis 226 Golfer’s elbow 320
ulnaris 227 Gracilis 235
digiti minimi brevis 227 Guillain-Barré syndrome 183
digitorum
accessorius 228 H
brevis 228
Haloperidol 17
longus 229
Hamilton ruler test 296
profundus 229
Hawkins-Kennedy test 296
superficialis 230
Heart rate 118
hallucis brevis 231
Heel-Shin test 165
Flucloxacillin 16
Hematoma formation 329
Forced expiratory techniques
Hemiplegia 183
110
Hemothorax 128
Frusemide 16
Heparin 18
Functional residual capacity
Hibb’s test 304
86
High frequency ventilation
Furosemide 16
122
Hip joint 284, 306
G
Hoffmann reflex 166
Gabapentin 16 Horner’s syndrome 184
Gaenslen’s test 303 Hughston plica test 311
Gait terminology 348 Huntington’s disease 184
Galeazzi fracture 332 Hydrocephalus 184
Gastrocnemius 231 Hydrocortisone 18
Gatifloxacin 17
Gemellus
inferior 232 I
superior 233 Ibuprofen 18
Gentamicin 17 Iliacus 236
386
Iliocostalis K
cervicis 236
lumborum 237 Ketamine 20
Knee joint 285, 308
thoracis 238
Inflammation of pleura 129
Infrared radiation 52 L
Infraspinatus 238
Inspiratory Lachman’s test 311
capacity 86 Lactulose 20
reserve volume 84 Laguere’s sign 305
Insulin 18 Laser therapy 47
Intercostalis Lateral
externi 239 cricoarytenoid 242
interni 239 decubitus 91
Intermittent epicondylitis test 299
mandatory ventilation Latissimus dorsi 242
120 Levator scapulae 243
pneumatic compression Levels of amputation in
65 lower limb 351f
positive pressure upper limb 352
breathing 121 Lidocaine 20
Interspinalis 240 Lignocaine 20
Intertransversarii 241 Liniburg’s test 301
Intracranial pressure 119 Liquid paraffin 21
Iontophoresis 51 Lisinopril 21
Ipratropium 19 Location of normal breath
Ischiocavernosus 241 sounds 97f
Ishihara’s chart 170 Longissimus
Isoniazid 19 capitis 244
Isosorbide mononitrate 19 cervicis 244
thoracis 244
Longus
J
capitis 245
Jacksonion march 155 colli 245
Jerk test 296 Lower
Joint position sense 166 motor neuron 175
Jug test 299 quarter screen 158
INDEX
387
Lumbar spine 291 Monteggia’s fracture 333
Lung Morphine 23
abscess 128 Motor neuron disease 186
capacities 85 Multifidus 247
function test 114 Multiple sclerosis 186
volumes 84 Murphy’s sign 301
and capacities 85f Muscular dystrophy 187
Lunotriquetral ballottement Musculocutaneous nerve 159
test 301 Myasthenia gravis 187
Myositis ossificans 321
Myotomes 156
M
Magnetic resonance imaging
340 N
Mallet fracture 335 Naproxen 23
Manual National Immunization
chest clearance technique Schedule 345
107 Neer impingement test 297
hyperinflation 116 Nerve conduction studies
muscle testing grading 344
209 Neuromuscular electrical
McMurray test 311 stimulation 55
Medial epicondylitis 320 Neutrophil 138
Meloxiam 21 New bone formation 330
Meningitis 185 Noninvasive ventilation 123
Metformin 21 Norfloxacin 23
Methotrexate 22
Methyldopa 22
Metronidazole 22 O
Mid sagittal section of brain Ober’s sign 307
150f Obturator
Midazolam 22 externus 248
Middle cerebral artery internus 248
151f, 153f nerve 161
Modified Ashworth scale for Omeprazole 23
grading spasticity 178 Ondansetron 24
388
Opponens Pethidine 25
digiti minimi 248 Phalen’s test 301
pollicis 249 Phenytoin 25
Origination of nerve 169 Piedallu’s signs 305
Orphenadrine 24 Pinch grip test 299
Osgood-Schlatter disease 322 Piriformis 253
Osteoarthritis 321 Piroxicam 26
Osteochondritis 321 Plantar interossei 254
dissecans 322 Plantaris 254
Osteomalacia 322 Pleural rub 99
Osteomyelitis 323 Pleurisy 129
Oxybutinin 24 Pneumonia 130
Oxytetracycline 24 Pneumothorax 131
Poliomyelitis 188
P Polyarteritis nodosa 323
Polycythemia 87
Paget’s disease 323
Polymyalgia rheumatica 324
Palmar interossei 250
Polymyositis 324
Palmaris longus 250
Popliteus 254
Palpation of pulses 100
Positive end expiratory
Pancuronium 25
pressure 120
Paracetamol 25
Posterior
Paraffin wax bath 53
cerebral artery 152f, 154
Patrick’s test 307
cord syndrome 189
Pectineus 251
drawer test 297, 312
Pectoralis
gapping test 305
major 251
labral tear test 307
minor 252
sag test 312
Pelvis 303
Postpolio syndrome 189
Penicillin-G 25
Postural drainage 101
Peripheral nervous system
Prednisolone 26
158
Pressure controlled
Peroneus
ventilation 122
brevis 252
Pronator
longus 253
quadratus 255
tertius 253
teres 255
Perthes’ disease 321
INDEX
389
Propranolol 26 lateralis 258
Proprioceptive neuromus- posterior major 258
cular facilitation 345 posterior minor 258
Prothrombin time 376 femoris 259
Pseudobulbar palsy 190 contracture test 308
Psoas Red blood cells 138
major 256 Respiratory
minor 256 failure 133
Pulmonary pathologies 123
artery pressure 119 rate 119
edema 132 volumes and capacities
embolism 132 84
tuberculosis 133 Reverse Phalen’s test 302
Rheumatoid arthritis 325
Rhomboid
Q major 260
Quadrant test 288, 292 minor 260
Quadratus Rifampicin 27
femoris 256 Right cerebral hemisphere
lumborum 257 149f
Quinine 27 Rolado’s fracture 335
Romberg’s test 169, 288
R
Radial nerve 159
S
Radioulnar joint 282 Sacral sparing 190
Ramipril 27 Salbutamol 28
Ranitidine 27 Salcatonin 28
Rapidly alternating Sarcoidosis 135
movement 167 Sartorius 261
Readings of chest X-rays 88 Scalenus
Reagan’s test 301 anterior 261
Rectus medius 262
abdominis 257 posterior 262
capitis Scapula 208
anterior 258 Scheuermann’s disease 322
390
Sciatic nerve 161 Standing flexion 306
Semispinalis Stethoscope position 96f
capitis 263 Straight leg raise test 293
cervicis 264 Strength duration curve 68
thoracis 264 Streptokinase 28
Sensory Streptomycin 28
aphasia 155 Stroke volume 118
assessment 196 Subscapularis 268
ataxia 155 Subtalar joint 286
loss 155 Sulcus sign 298
Serratus anterior 265 Sulfasalazine 29
Sharpened Romberg’s test Superficial reflexes 174
169 Superior oblique 269
Sharp-Purser test 289 Supine-to-set test 306
Short wave diathermy 43 Supraspinatus 270
Shoulder joint 281, 294 Sweater finger sign 302
Skin sensation test 43, 46, Synchronized intermittent
49, 52, 55, 58, 61-65 mandatory ventilation
Sleep apnea 135 120
Slump test 291, 292 Systemic
Smith’s fracture 334 lupus erythematous 326
Speeds test 297 sclerosis 327
Spinal
cord tracts 165f
muscular atrophis 191 T
Splenius Talar tilt 314
capitis 267 Tennis elbow 299, 327
cervicals 268 Tenosynovitis 327
Spondylolisthesis 325 Tensor fasciae latae 271
Spondylolysis 326 Teres
Spondylosis 326 major 271
Spurling’s test 289 minor 272
Squeeze test of leg 314 Tetracycline 29
Stages of Theophylline 29
calcification 329 Thomas test 308
fracture healing 329 Thoment’s sign 302
INDEX
391
Thompson’s test 314 Types of
Thoracic aphasia 348
and lumbar spine 281 goniometer 278
outlet syndrome 328 nebulizer 112
spine 291 nerve 170
Thoracolumbar spine 287 tracheostomy 111
Tibial nerve 162 tube 111
Tibialis
anterior 273
posterior 273 U
Tidal volume 84 Ulnar nerve 160
Timolol 29 Ultraviolet radiations 45
Tinel’s sign 303 Upper
Tinidazole 30 limb tension test 289
Tizanidine 30 motor neuron 175
Tolterodine 30 quarter screen 158
Total Uric acid 139
iron binding 376 Urobilinogen 378
leukocyte 376
lung capacity 86
Tracheal bifurcation 83 V
Tracheostomies 110 Valgus stress test 300, 308
Tramadol 30 Vancomycin 31
Transcutaneous electrical Varus stress test 300
nerve stimulation 50 Vastus
Transverse myelitis 192 intermedius 277
Transversus abdominis 274 lateralis 277
Trapezius 275 medialis 277
Trazodone 30 Vecuronium 31
Trendelenburg’s sign 308 Venous blood 136
Triceps brachii 276 Ventilation/perfusion 137
Trigeminal neuralgia 192 Verapamil 31
Trihexyphenidyl 31 Vital capacity 86
392
W joint 283
and hand 300
Waston test 303
Wernicke’s dysphasia 193
Whirlpool bath 59 Z
White blood cells 138
Wrist Zalcitabine 32
flexion test 301 Zidovudine 32

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The Pocketbook for

Gitesh Amrohit MPT (Neuro)

JAYPEE BROTHERS MEDICAL

Jaypee Brothers Medical Publishers (P) Ltd.

© 2012, Jaypee Brothers Medical Publishers

Inquiries for bulk sales may be solicited at: jaypee@jaypeebrothers.com

The Pocketbook for Physiotherapists

First Edition: 2007

It gives me immense pleasure to present the second

I was the undergraduate student of physiotherapy in

CHAPTER 1: PHARMACOLOGY .................. 1

CHAPTER 2: ELECTROTHERAPY ............... 35

CHAPTER 3: CARDIORESPIRATORY ........ 77

CHAPTER 4: NEUROLOGY ........................ 147

CHAPTER 5: MUSCULOSKELETAL ......... 203

CHAPTER 6: MISCELLANEOUS ................ 339

Index ..................................................................... 381

1 Type: Inotropic sympathomimetic.

1 Type: Opioid analgesic.

Type: Antiviral and anticancer.

1 Type: Intravenous anesthetic.

1 Side effects: Anorexia, nausea, vomiting, diarrhea.

1 Type: Serotonin antagonist.

1 Please refer Metronidazole.

CHECKING GENERAL CONTRAINDICATIONS

POSITIONING THE PATIENT

SKIN SENSATION TEST

SHORT WAVE DIATHERMY

SKIN SENSATION TEST

SKIN SENSATION TEST

SKIN SENSATION TEST

SKIN SENSATION TEST

TRANSCUTANEOUS ELECTRICAL NERVE

SKIN SENSATION TEST

SKIN SENSATION TEST

SKIN SENSATION TEST

PARAFFIN WAX BATH

SKIN SENSATION TEST

SKIN SENSATION TEST

SKIN SENSATION TEST

CRYOTHERAPY (COLD THERAPY)

SKIN SENSATION TEST

HOT PACKS (HYDROCOLLATOR PACKS)/

SKIN SENSATION TEST

SKIN SENSATION TEST

SKIN SENSATION TEST

SKIN SENSATION TEST

SKIN SENSATION TEST

SKIN SENSATION TEST

SKIN SENSATION TEST

CONTINUOUS PASSIVE MOTION

2 • Position of the patient

STRENGTH DURATION CURVE

Fig. 2.1: Normally innervated muscle:

Fig. 2.2: Normally innervated muscle:

Fig. 2.3: Complete denervated muscle:

Fig. 2.4: Complete denervated muscle:

Fig. 2.5: Partially denervated muscle

Fig. 2.6: Motor points of the muscles supplied by

Fig. 2.7: Motor points of the back

Fig. 2.8: Motor points of the posterior

Fig. 2.9: Motor points of the anterior

Fig. 2.10: Motor points of the anterior