Pocket Book For Physiotherapist

The Pocketbook for
PHYSIOTHERAPISTS
The Pocketbook for
PHYSIOTHERAPISTS
Gitesh Amrohit
BPT (Intern.)
Pt. JNM Medical College
Raipur (Chhattisgarh)
India
JAYPEE BROTHERS
MEDICAL PUBLISHERS (P) LTD
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The Pocketbook for Physiotherapists
© 2007, Jaypee Brothers Medical Publishers
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system,
or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or
otherwise, without the prior written permission of the author and the publisher.
This book has been published in good faith that the material provided by author is original. Every
effort is made to ensure accuracy of material, but the publisher, printer and author will not be
held responsible for any inadvertent error(s). In case of any dispute, all legal matters to be settled
under Delhi jurisdiction only.
First Edition: 2007
ISBN 81-8448-108-X
Typeset at JPBMP typesetting unit

Printed at Ajanta Press
Preface
I was the undergraduate student of physiotherapy in
the year 2002-2006. During this period me 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
posting’s, 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 this book.
Wishing and praying for your bright future and all
the success in your life.
Gitesh Amrohit
Acknowledgements
To complete any project, it has the blessing of a big
group of people. This blessing was also, there in my
project Pocketbook for Physiotherapists, i.e. why first
of all; I would like to give a healthy thanks to all the
students of physiotherapy of Pt. JNM Medical College,
Raipur (CG), who were there with me in my each step.
I am also thankful to Dr. Bindu Abraham and
Dr. Prafulla Bani, who encouraged me in every task.
I would also like to thank Niketa Pawar, Amit
Pansari, Tejaswi Verma, Saurabh Gupta, Md. Javed
Qureshi, Anshul Parhad, and Piyush Dubey; who
timely took me out of problems.
I am able to do all this by the guidance of my
mother and father Smt. Shruti Amrohit and Dr RD
Amrohit and my twin brothers Jitesh-Jivesh, whose
love and support was always there with me.
Between all this Dinesh Wagde, Nagpur Branch,
Jaypee Brothers Medical Publishers (P) Ltd. and
Mr. Shravan Kumar; Mr. Khomlal Chandeshwar; SK
Medical Book House, Raipur (CG), also supported and
encouraged me to keep moving. It was not possible for
me to publish this book without their support.
Thanks one and all, I need your help too, to
continue my achievement.
Contents
Chapter 1 Pharmacology ............................. 1
Drug classes in alphabetical orders
Prescription abbreviations
Chapter 2 Electrotherapy ............................ 19

Interferential
Short wave diathermy
Ultra-violet radiations
Laser therapy
Ultrasound
TENS
Infrared radiation
Paraffin wax bath
NMES
Microwave diathermy
Cryotherapy
Hot packs
Whirlpool bath
Contrast bath
Sauna bath
SD curve
Motor points
Chapter 3 Cardiorespiratory ..................... 43

Cardiorespiratory anatomy illustrations
Surface marking of the lung
CONTENTS
x
Respiratory volumes and capacities
Differences between central and peripheral cyanosis
Sputum analysis
Chest X-ray readings
Abnormal ECG findings
Percussion note
Auscultation
Palpation of pulses
Apgar scoring method
Postural drainage
Manual chest clearance techniques
Suctioning
Forced expiratory techniques
Tracheostomies
Aerosol therapy
Humidity
Lung function test
AMBU bag
Manual hyperinflation
Cardiorespiratory monitoring
Ventilations
Cardiorespiratory pathologies
Normal values
Blood values and their interfering factors
Respiratory assessment
Glossary of cardiorespiratory terms
Chapter 4 Neurology ................................. 107

Neuroanatomy illustrations
Clinical manifestations of cerebrovascular lesions
Localisation of lesion and their signs of impairment
Myotomes
CONTENTS
xi
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
Differences of upper motor neuron and lower motor
neuron lesions
Glasgow Coma scale
Modified ashworth scale for grading spasticity
Neurological pathologies
Neurological assessment
Glossary of neurological terms
Chapter 5 Musculoskeletal ....................... 157

Alphabetical listing of muscles
Joint range of movement
Common musculoskeletal tests
Musculoskeletal pathologies
Grades of sprain and treatment
Stages of fracture healing
Fracture with eponyms
Musculoskeletal assessment
Chapter 6 Miscellaneous .......................... 287

National immunization schedule
Spinal traction
Proprioceptive neuromuscular facilitation (PNF)
Common sports injuries
CONTENTS
xii
Types of aphasia
Gait terminology/deviations
Levels of amputations
Abbreviations
Normal reference/lab values
References ......................................................... 323
Index ................................................................... 325

PHARMACOLOGY
1
1
CHAPTER
CHAPTER 1
Pharmacology
Drug classes in alphabetical orders
Prescription abbreviations
PHARMACOLOGY
2
CHAPTER ACETA ZOLAMIDE
1 Type: Diuretics.
Uses: Glaucoma, epilepsy, acute mountain,
sickness, periodic paralysis, UTI.
Side effects: Hypokalemia, drowsiness, acidosis,
abdominal discomfort.
ADENOSINE
Class: Anti-arrhythmic.
Uses: Tachycardias.
Side effects: Nausea, bronchospasm, dyspnoea.
ALBENDAZOLE
Type: Antihelmintics.
Uses: Filariasis, hydatid disease, trichinosis, tape
worms.
Side effects: Diarrhoea, nausea, abdominal pain.
ALLOPURINOL
Class: Anti-gout.
Uses: Gout, kidney stones.
Side effects: Nausea, itching, rash.
AMIODARONE
Class: Anti-arrhythmic.
PHARMACOLOGY
3
Uses: Ventricular and supraventricular tachy- CHAPTER
1
cardias.
Side effects: Liver damage, reversible corneal
depositions.
AMLODIPINE
Class: Ca++ channel blocker.
Uses: Congestive heart failure, angina.
Side effects: Ankle oedema, flushing, palpitation,
headache, hypotension.
AMOXICILLIN
Please refer ampicillin.
AMPICILLIN
Class: Antibiotic.
Uses: UTI, RTI, meningitis, gonorrhoea, typhoid
fever, bacillary dysentery, bacterial endocarditis,
septicaemias, cholecystitis.
Side effects: Diarrhoea, rashes, lymphatic leukemia.
ALPRAZOLAM
Type: Benzodiazepines.
Uses: Anxiety, depression.
Side effects: Sedation, light headedness, vertigo.
Confusion, psychomotor and cognitive
impairment.
PHARMACOLOGY
4
CHAPTER ASPIRIN
1 Type: NSAIDs and antipyretic.

Uses: As analgesic, antipyretic, acute rheumatic
fever, RA, OA, post-myocardial infarction and
post-stroke.
Side effects: Nausea, vomiting, epigastric distress,
rhinorrhoea.
ATENLOL
Type: B-antiadrenergic.
Uses: Arrhythmias, angina, hypertension, MI,
congestive heart failure.
Side effects: Cold hand and feet, bradycardia,
hypotension, fatigue.
ATROPINE
Type: Antimuscarinic.
Uses: Corneal ulcers, peptic ulcers, pulmonary
embolism, preanaesthetic medication, brady-
cardia, motion sicknes.
Side effects: Dry mouth, difficulty in swallowing
and talking. Blurring of near vision.
CALCITONIN
Class: Hormone.
PHARMACOLOGY
5
Uses: Hypercalcaemia, bone pain, osteoporosis. CHAPTER
Side effects: Vomiting, nausea.
1
CARBAMAZEPINE
Type: Antiepileptic.
Uses: Partial and tonic–clonic seizures, trigeminal
neuralgia.
Side effects: Drowsiness, epigestric pain, nausea,
confusion, blurred vision.
CHLORAMPHENICOL
Class: Broad spectrum antibiotics.
Uses: Enteric fever, anaerobic infections, intra-
ocular infections, H. influenzae, meningitis.
Side effects: Nausea, vomiting, diarrhoea, gray
baby syndrome, bone marrow depression.
CHLORPROMAZINE
Type: Antipsychotic.
Uses: Schizophrenia, mania, organic brain
syndrome, arxiety tetanus alcoholic hallucinosis.
Side effects: Dry mouth, blurring vision, consti-
pation, parkinsonion symptoms, dystonic, jaun-
dice, akathisia, malignant neuroleptic syndrome
symptoms.
PHARMACOLOGY
6
CHAPTER CHLOROQUINE
1 Type: Antimalarial drug.

Uses: Malaria.
Side effects: Hypotension, vision loss, hearing
deficit, nausea, vomiting, anorexia, itching.
CIPROFLOXACIN
Class: Prototype antibacterial.
Uses: UTI, gonorrhoea, bacterial gastroenteritis,
typhoid, gynaecological disease, tuberculosis,
meningitis, respiratory infections.
Side effects: Nausea, vomiting, anorexia, bad taste
dizziness, headache, rashes, urticaria.
CLOFAZIMINE
Please refer dapsone.
DAPSONE
Type: Antileprotic drug.
Uses: Leprosy.
Side effects: Haemolytic anaemia, gastric intole-
rance, rashes, headache, lepra reactions, nausea,
vomiting.
DEXAMETHASONE
Please refer prednisolone.
PHARMACOLOGY
7
DIAZEPAM CHAPTER
Type: Benzodiazepines.
Uses: Anxiety, sleep disturbances, alcoholism and 1
as muscle relaxants.
Side effects: Unsteadiness, drowsiness, dizziness.
DICLOFENAC
Type: NSAIDs and antipyretic.
Uses: RA, OA, ankylosing spondylitis, post-
traumatic and postoperative inflammatory
conditions.
Side effects: Epigastric pain, nausea, rashes,
headache, dizziness.
DILTIA ZEM
Please refer amlodipine.
DOBUTAMINE
Class: Inotropic sympathomimetic.
Uses: Heart failure.
Side effects: Tachycardias.
DOPAMINE
Class: Inotropic sympathomimetic.
Uses: Shock, heart failure.
Side effects: Nausea, vomiting, tachycardia.
PHARMACOLOGY
8
CHAPTER DOXYCYCLINE
1 Please refer tetracyclines.
ERYTHROMYCIN
Class: Macrolide antibiotic.
Uses: Inflammation, diphtheria, syphilis, gonor-
rhoea.
Side effects: Gastrointestinal discomfort, rashes,
fever.
FERROUS SULPHATE
Class: Iron salt.
Uses: Iron defeciency anaemia.
Side effects: Constipation, epigastric discomfort,
darkening of faeces.
FLUCLOXACILLIN
Please refer penicillin.
GATIFLOXACIN
Please refer ciprofloxacin.
GENTAMICIN
Type: Aminoglycoside antibiotics.
Uses: Pseudomonas, Proteus, Klebsiella infections,
respiratory infection’s meningitis.
PHARMACOLOGY
9
Side effects: Vestibular disturbances, auditory loss, CHAPTER
1
nausea, vomiting.
HEPARIN
Class: Anticoagulant.
Uses: Pulmonary embolism, DVT.
Side effects: Thrombocytopenia, haemorrhage.
HYDROCORTISONE
Please refer prednisolone.
IBUPROFEN
Class: Non-steroidal anti-inflammatory.
Uses: Pain, stiffness, swelling, OA,RA, soft tissue
injuiries, headache, dental pain.
Side effects: Indigestion heart burn.
INSULIN
Class: Peptide hormone.
Uses: Insulin dependent and maturity onset
diabetes mellitus.
Side effects: Irritation over injection site, hypo-
glycaemia, weakness.
INTERFERON
Class: Antiviral and anticancer.
PHARMACOLOGY
10
CHAPTER Uses: Leukaemia, multiple sclerosis, granualo-
1
matous disease.
Side effects: Lethargy, chills, myalgia, fatigue,
rashes, fever, headache.
ISONIAZID
Type: Anti-tubercular drug.
Uses: Tuberculosis.
Side effects: Paresthesia, numbness, convulsions,
mental disturbances, hepatitis.
ISOSORBIDE MONONITRATE
Type: Antianginal drug.
Uses: Congestive heart failure, angina.
Side effects: Throbbing headache, flushing,
sweating, palpitation, dizziness, fainting.
KETAMINE
Type: General anaesthetics (IV).
Uses: As anaesthetics agent (not use in head and
neck surgery).
Side effects: Tachycardia, hallucinations, increased
blood pressure.
LACTULOSE
Class: Osmotic laxative.
PHARMACOLOGY
11
Uses: Constipation, hepatic encephalopathy. CHAPTER
Side effects: Diarrhoea, stomach cramps, flatulence.
1
LEVODOPA
Type: Dopamine precursar.
Uses: Parkinson’s disease.
Side effects: Nausea, vomiting, postural hypo-
tension, cardiac arrhythmias, alteration in taste
sensation, behavioural changes, abnormal
movements.
LIGNOCAINE
Class: Na+ channel blocker.
Uses: As anaesthetic and antiarrhythmic.
Side effects: Dizziness, nausea, vomiting.
LIQUID PARAFFIN
Class: Laxatives.
Uses: Constipation, before surgery night.
Side effects: Dehydration, lipid pneumonia.
MANNITOL
Class: Osmotic diuretic.
Uses: Glaucoma, head injury, stroke.
Side effects: Nausea, diarrhoea, headache.
PHARMACOLOGY
12
CHAPTER METHYLDOPA
1 Class: β adrenergic blocker.

Uses: High blood pressure.
Side effects: Sedation, lethargy, disturbed mental
capacity.
METHOTREXATE
Class: Cytotoxic and immunosuppressive.
Uses: Leukaemia, lymphoma.
Side effects: Diarrhoea, bone marrow suppression,
vomiting, inflammation.
METRONIDAZOLE
Type: Antiamoebic drugs.
Uses: Giaridiasis, amoebiasis, trichomonas vigi-
nitis, enterocolitis, gingivitis bacterial infections
Side effects: Nausea, vomiting, anorexia, headache,
glossitis, rashes, dizziness.
MORPHINE
Class: Opioid analgesic.
Uses: Ventricular failure, pain.
Side effects: Nausea, vomiting, constipation,
dizziness, drowsiness, rerpiratory depression.
NORFLOXACIN
Please refer ciprofloxacin.
PHARMACOLOGY
13
OMEPRAZOLE CHAPTER
Class: Proton pump inhibitors.
Uses/Side effects: Please refer ranitidine. 1
OXYTETRACYCLINE
Please refer tetracycline.
PANCURONIUM
Please refer vecuronium.
PARACETAMOL
Class: Non-opoid analgesic.
Uses: Pain, fever.
Side effects: Liver failure.
PENICILLIN–G
Class: Benzyl penicillin.
Uses: Streptococcal, pneumococcal, meningococcal
infections, gonorrhoea, syphilis, diptheria.
Side effects: Pain at inj. Site, nausea, rash. Itching,
urticaria, shock, exfoliative dermatitis.
PETHIDINE
Class: Opioid analgesic.
Uses: Severe pain, pain during labour, anxiety,
during anaesthesia.
PHARMACOLOGY
14
CHAPTER Side effects: Nausea, vomiting, constipation,
1
drowsiness.
PHENYTION
Class: Anti-convulsant.
Uses: Epilepsy.
Side effects: Nausea, vomiting, confusion,
headache, dizziness, ache, increased body hair.
PREDNISOLONE
Type: Glucocorticoid.
Uses: Adrenal insufficiency, adrenogenital,
syndrome, anthritides, collagen disease, asthma,
lung and eye disease, malignancies, intestinal and
skin disease.
Side effects: Peptic ulcer, osteoporosis, glaucoma,
growth retardation, fetal abnormalities, muscular
weakness, cushing’s habitus, fragile skin, psychia-
tric disturbances.
PROPRANOLOL
Class: Na+ channel blocker.
Uses: Sinus tachycardia, atrial and nodal ESs.
Side effects: Dizziness, nausea, vomiting.
RANITIDINE
Class: H2 blocker, for peptic ulcer.
PHARMACOLOGY
15
Uses: Duodenal ulcer, gastric ulcer, gastritis, CHAPTER
1
Zollinger-Ellison syndrome, GERD.
Side effects: Nausea, loose stool, muscle and joint
pain, dizziness, abdominal pain.
RIFAMPICIN
Type: Antitubercular drug.
Uses: Tuberculosis, leprosy, meningitis.
Side effects: Nausea, vomiting, malaise, bone pain,
purpura, breathleness.
SALBUTAMOL
Type: B2 agonist.
Uses: Asthma, chronic bronchitis, emphysema.
Side effects: Weakness, tremors, drowsiness,
nervousness.
SALCATONIN
Please refer calcitonin.
SENNA
Class: Stimulant laxative.
Uses/Side effects: Please refer lactulose.
STREPTOMYCIN
Class: Aminoglycoside antibiotics.
PHARMACOLOGY
16
CHAPTER Uses: Tuberculosis, plague, bacterial endocarditis,
1
tularemia.
Side effects: Vestibular disturbances, auditory loss
paresthesia.
TETRACYCLINE
Class: Actinomycettes, broad spectrum antibiotics.
Uses: Infections, pneumonia, plague, rickettsial
infection, cholera, UTI. Acne, lung disease.
Side effects: Nausea, vomiting, epigastric pain,
diarrhoea.
TINIDAZOLE
Please refer metronidazole.
VECURONIUM
Class: Muscles relaxants.
Uses: During general anaesthesia, convulsions,
trauma, tetanus, status epilepticus.
Side effects: Respiratory failure, muscle soreness,
hypotension.
WARFARIN
Please refer heparin.
PHARMACOLOGY
17
LIST OF PHARMACOLOGY ABBREVIATIONS CHAPTER
Abbreviation Meaning
ac
ad lib
before bed
as desired
1
bd twice daily
cap capsule
IM intermuscular
IV intravenous
LA local anaesthetic
Liq liquid
oc oral contraceptive
od once daily
om in the mornings
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
19
CHAPTER 2 CHAPTER
Electrotherapy 2
Interferential
Short wave diathermy
Ultra-violet radiations
Laser therapy
Ultrasound
TENS
Infrared radiation
Paraffin wax bath
NMES
Microwave diathermy
Cryotherapy
Hot packs
Whirlpool bath
Contrast bath
Sauna bath
SD curve
Motor points
ELECTROTHERAPY
20
INTERFERENTIAL
INDICATIONS
• Arthritis
CHAPTER • Neuritis
2 •
•
•
Neuralgia
Muscle sprain
Muscle weakness
• Sports injury
• Circulatory disorders
• Rheumatism.
CONTRAINDICATIONS
• Cardiac diseases
• Haemorrhage
• Abdomen during pregnaney
• Pacemaker.
PRESCRIPTION WRITING
• Electrode type—Small/medium/large
• Type of current—Dipole/isoplaner vector filed
• Frequency
• Base frequency
• Spectrum
• Spectrum mode—Rectangular/triangular/
trapezoidal
• Treatment time
• Intensity
• Sessions
• Remarks.
ELECTROTHERAPY
21
SHORT WAVE DIATHERMY
INDICATIONS
• Gynaecology—Pelvic endometriosis
• Traumatology—Sprains, muscular pain CHAPTER
•
•
Rheumatology—Neuralgia, inflammatory
pain arthritis.
Respiratory—Asthma, emphysema
2
• Neurology—Anti spasmodic action
• Others—Raynauds diseases, visceral pain,
automatic dystonia.
CONTRAINDICATIONS
• Metal implants
• Pace maker
• Deep X-ray therapy recently
• Circulatory deficiency
• Pregnancy and menstruation
• Local or general infection’s
• Diminished thermal sensation
• Deep vein thrombosis
• Severe swelling
• Acute traumatic or inflammatory lesions
• Malignancy.
• Patient position
• Electrode type—Pad/disc/wire coil
• Electrode placement—Coplanar/contro-
planar/crossfire
• Spacing—Medium/narrow
ELECTROTHERAPY
22
• Dosage
– Acute—Subthermal
– Subacute—Mild thermal
– Chronic—Thermal.
CHAPTER
• Duration
2 – Acute 10-15 min

– Subacute 15-20 min
– Chronic 20-30 min
• Session
• Specific precaution
• Supplementary therapy
• Remarks.
ULTRAVIOLET RADIATION
INDIACTIONS
• Wounds
• Acne vulgaris
• Alopecia
• Pressure sores
• Rickets
• Counter irritation
• Psychological benefit.
CONTRAINDIACATIONS
• Deep X-ray or cobalt therapy
• Recent skin grafting
• Hypersensivity to sun rays
• Arteriosclerosis
• Cardiac, hepatic or renal failure
ELECTROTHERAPY
23
• Diabetes
• Hyperthyroidism.
CHAPTER
• Patients positioning
•
•
Spectrum
Distance 2
• Dosage
Base
Wall For infected ulcers
Floor
• Focusing point
• Duration
• Session
• Special precaution
• Remarks.
LASER THERAPY
INDICATIONS
• Wounds
• Tensile strength of scar tissues pain
• Musculoskeletal conditions (tendonitis/bursi-
tis)
• Fractures (for healing).
CONTRAINDICATIONS
• Cardiac conditions
• Pregnancy
• Over the eye
ELECTROTHERAPY
24
• Haemorrhage
• Cancers.
CHAPTER • Patient’s position
2 •
•
•
Therapist position
Dosage
Duration
• Session
• Remarks.
ULTRASOUND
INDICATIONS
• Bursitis
• Capsulitis
• Tendinits
• Epicondylitis
• Ankylosing spondylitis
• Scar tissue
• Haematoma
• Keloid tissue
• Joint stiffness
• Dupuytren’s contracture
• Plantar fasitis
• Chronic indurate oedema
• Myalgia
• Herpes zoster
• Brachial neuritis, lumbago, sciatica intercostals
neuritis (for reduction of pain), varicose ulcers
and pressure sores
• Plantas warts.
ELECTROTHERAPY
25
CONTRAINDICATIONS
• Thrombophelebitis
• Haemorrhage
• Ischaemic tissue
CHAPTER
Pregnant uterus
2
•
• Malignancy
• Anaesthetic area
• All intra-tissue prosthetic and metallic
substances
• Recent grafts
• Defective skin sensation
• Deep X-ray therapy
• Acute infection
• Over cardia area (in advanced cardiac disease).
• Patient’s positioning
• Mode
• Method—Direct/water bag
• Duration
• Intensity
• Phonophoretic agent (if used)
• Session
• Remarks.
TRANSCUTANEOUS ELECTRICAL NERVE

STIMULATION (TENS)
INDICATIONS
• Post-surgical pain
• Obstetric pain
ELECTROTHERAPY
26
• Phantom limb pain
• Sciatic pain
• Periarthritic pain
• Reflex sympathetic dystrophy
CHAPTER
• Low backache
2 •
•
Pain due to scoot tissue
Cervical spondylosis (with neurological invol-
vement).
CONTRAINDICATIONS
• Cardiac pacemakers
• First trimester of pregnancy
• Haemorrhagic conditions
• Open wounds
• Over carotid sinus, mouth and near eyes
• Epilepsy.
• Type—High/low TENS
• Frequency
• Pulse width
• Intensity
• Duration
• Session
• Remarks.
INFRARED RADIATION
INDICATIONS
• Pain relief
• Muscle relaxation
ELECTROTHERAPY
27
• Oedema
• Elimination of waste products
• Superficial wounds.
CONTRAINDICATION CHAPTER
•
•
•
Vascular insufficiency
Arterial diseases
Haemorrhage
2
• Anaesthetic area
• Pregnancy and during menstruation
• Skin diseases, e.g. psoriasis, eczema
• Thermal hypothesia
• Deep X-rays therapy.
• Apparatus type—Luminous/Nonluminous
• Generator type—Lamp/tunnel bath
• Distance
• Focus point
• Wave-length
• Frequency
• Duration
• Session
• Special precaution
• Remarks.
PARAFFIN WAX BATH

INDICATIONS
• Joint stiffness
ELECTROTHERAPY
28
• Osteoarthritis
• Adhesions
• Scars
• Rheumatoid arthritis.
CHAPTER
2 CONTRAINDICATIONS
• Skin rashes
• Allergic conditions
• Open wounds
• Diminished skin sensation
• Defective arterial supply.
• Patient’s position
• Temperature
• Method—Pouring/brushing/dipping/
bandaging
• Duration
• Session
• Remarks.
NEUROMUSCULAR ELECTRICAL
STIMULATION, NMES (STIMULATOR)
INDICATIONS
• Foot drop
• Bell’s palsy
• Paraplegia
• Hemiplegia
ELECTROTHERAPY
29
• Quadriplegia
• Radial nerve injury (wrist drop)
• Mediun nerve injury (claw hand )
• Erb’s paralysis
CHAPTER
• Deltoid and quadriceps inhibition.
CONTRAINDIACATIONS 2
• Sensory deficit
• Hypertension
• Open wounds
• Pace makers
• Malignant tissue
• Epilepsy
• Hyperpyrexia
• Active tissue infections
• Deep X-rays therapy
• Peripheral vascular disease
• Over the excessive adipose tissue
• Mentally retarded.
• Instruction for patients
• Current type—Faradic/galvanic/others
• Pulse
• Frequency
• Duration
• Session
• Remarks.
ELECTROTHERAPY
30
MICROWAVE DIATHERMY
INDICATIONS
• Pain relief
CHAPTER • Trapezius spasm
2 • Arthritic conditions.
CONTRAINDICATIONS
• Malignancy
• Tuberculosis
• Deep X-ray therapy
• Non-pitable oedema
• Hypersensitive areas
• Anaesthetic areas
• Psychic patients
• Paralytic patients
• Recent injury.
• Type of applicator—Small/large circular/
rectangular
• Distance
• Frequency
• Intensity
• Duration
• Session
• Remarks.
ELECTROTHERAPY
31
CRYOTHERAPY (COLD THERAPY)
INDICATIONS
• Spastisity
• Swelling CHAPTER
•
•
•
Pain
Ligament sprain
Muscle strain.
2
CONTRAINDICATIONS
• Cryoglobinaemina
• Peripheral nerve injury
• Cardiac diseases
• Vascular diseases
• Cold sensitivity
• Cold urticaria
• Psychic patient’s.
• Patient’s position-
• Type of application—Ice massage/towels/
immersion/cold packs/evaporative colling/
excitatory cold
• Duration
• Session
• Remarks.
ELECTROTHERAPY
32
HOT PACKS ( HYDROCOLLATOR PACKS)/
ELECTRIC HEATING PAD
INDICATIONS
CHAPTER • Muscle spasm
2 •
•
Pain
Joint stiffness.
CONTRAINDICATIONS
• Impaired skin sensation
• Open wounds
• Allergic conditions
• Haemorrhage
• Impaired circulation.
• Layers of towel
• Types of packs—Small/large/contoured
• Duration
• Session
• Remarks.
WHIRLPOOL BATH
INDICATIONS
• Rheumatic conditions
• Stiffness
• Joint pain
• Fatigue.
ELECTROTHERAPY
33
CONTRAINDICATIONS
• Skin allergy
• Skin infections
• Open wounds
CHAPTER
Haemorrhage.
2
•
• Temperature
• Duration
• Session
• Remarks.
CONTRAST BATH
INDICATIONS
• Oedema
• Circulatory disorders.
CONTRAINDICATIONS
• Skin infections
• Open wounds
• Haemorrhage
• Skin allergy.
• Temperature
– Warm
– Cold
ELECTROTHERAPY
34
• Timing in
– Warm
– Cold
• Repetition
CHAPTER
• Session
2 • Remarks.
SAUNA BATH
INDICATIONS
• Weight reduction
• Pain
• Relaxation
• Psoriasis.
CONTRAINDICATIONS
• Psychic conditions
• Loss of skin sensations
• Dehydration.
• Temperature of hot chamber
• Expanded time in
– Sweating phase
– Colling phase
• Pause between two phases
• Duration (total)
• Session
• Remarks.
ELECTROTHERAPY
35
STRENGTH-DURATION CURVE
SHAPE OF THE CURVE
CHAPTER
Fig. 2.1: Normally innervated muscle:

In constant current
Fig. 2.2: Normally innervated muscle:

In constant voltage
ELECTROTHERAPY
36
NORMALLY INNERVATED MUSCLE
CHAPTER
Fig. 2.3: Complete denervated muscle:

In constant voltage
Fig. 2.4: Complete denervated muscle:

In constant current
ELECTROTHERAPY
37
CHAPTER
Fig. 2.5: Partially denervated muscle
MOTOR POINTS
Fig. 2.6: Motor points of the muscles supplied by

the facial nerve
ELECTROTHERAPY
38
CHAPTER
Fig. 2.7: Motor points of the back

ELECTROTHERAPY
39
CHAPTER
Fig. 2.8: Motor points of the posterior aspect of the

right arm
ELECTROTHERAPY
40
CHAPTER
Fig. 2.9: Motor points of the anterior aspect of the

right arm
ELECTROTHERAPY
41
CHAPTER
Fig. 2.10: Motor points of the anterior

aspect of the right leg
ELECTROTHERAPY
42
CHAPTER
Fig. 2.11: Motor points of the posterior aspect of

right leg
CARDIORESPIRATORY
43
CHAPTER 3
Cardiorespiratory
CHAPTER
Cardiorespiratory anatomy illustration

Surface marking of the lung
3
Respiratory volumes and capacities
Differences between central and peripheral
cyanosis
Sputum analysis
Chest X-ray readings
Abnormal ECG findings
Percussion note
Auscultation
Palpation of pulses
Apgar scoring method
Postural drainage
Manual chest clearance techniques
CARDIORESPIRATORY
44
Suctioning
Forced expiratory techniques
Tracheostomies
Aerosol therapy
Humidity
CHAPTER
3 Lung function test

AMBU bag
Manual hyperinflation
Cardiorespiratory monitoring
Ventilations
Cardiorespiratory pathologies
Normal values
Blood values and their interfering factors
Respiratory assessment
Glossary of cardiorespiratory terms
CARDIORESPIRATORY
45
CARDIORESPIRATORY ANATOMY
ILLUSTRATIONS
CHAPTER
Fig. 3.1: Surface marking of the fissures and lobes

of the right lung
CARDIORESPIRATORY
46
CHAPTER
3
Fig. 3.2: The bronchial tree
Fig. 3.3: The bronchopulmonary segments

(lateral aspect)
CARDIORESPIRATORY
47
SURFACE MARKING OF THE LUNGS
APEX
• Anteriorly 2.5 cm above the medical 1/3rd of
clavicle.
• Posteriorly 2 cm lateral to C7 spinous process.
ANTERIOR BORDER OF RIGHT LUNG CHAPTER

• Sternoclavicular joint
• Midline in the sternal angle
• Above the xyphoid process in the midline.
3
INFERIOR BORDER OF RIGHT LUNG.
• 6th rib in the mid clavicular line
• 8th rib in the mid axillary 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.
INFERIOR AND POSTERIOR BORDER OF

LEFT LUNG
• Same as the right lung
CARDIORESPIRATORY
48
FISSURES
Oblique
• 7.5 cm lateral to mid line in 6th rib
• Mid axillary line in 5th rib
• T3 spinous process.
CHAPTER
Horizontal
3 • Costal cartilage 4th rib

• 5th rib, mid axillary line
• T3 spinous process posteriorly.
TRACHEAL BIFURCATION
• Anterior—Manubriosternal junction
• Posterior—T4 vertebra.
DIAPHRAGM
Left
• 6th rib anteriorly
• T10 posteriorly
• 8th rib mid axillary.
Right
• 5th rib anteriorly
• T9 posteriorly
• 8th rib mid axillary.
CARDIORESPIRATORY
49
RESPIRATORY VOLUMES AND CAPACITIES
LUNG VOLUMES
Tidal Volume (TV)
Volume of the air moved into or out of the lunges
during quiet breathing at rest.
Value—500 ml. CHAPTER
Inspiratory Reserve Volume (IRV)

Maximum amount of air that can be inspired
3
following a normal tidal inspiration.
Value—3000 ml.
Expiratory Reserve Volume (ERV)

Maximum amount of air that can be exhaled
following a normal tidal expiration.
Value—1000 ml.
Residual Volume (RV)

Volume of air remaining in the lungs after a
maximum expiration.
Value—1500 ml
Minimal Volume (MV)

The amount of air that would remain when the
lungs collapsed.
Value—30-120 ml.
CARDIORESPIRATORY
50
LUNG CAPACITIES
It is the combination of two or more lung volumes.
Total Lung Capacity (TLC)

Total volume of air in the lungs after a maximal
inspiration.
TLC = VT+IRV+ERV+RV
CHAPTER
3
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
51
DIFFERENCES BETWEEN CENTRAL AND
PERIPHERAL CYANOSIS
Central Peripheral
Mechanism Dimininshed arterial Diminished flow of
oxygen saturation blood to the local part
Sites On skin and On skin only
mucous membranes CHAPTER
3
e.g. tongue, lips,
cheeks etc.
Clubbing and Usally 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
CARDIORESPIRATORY
52
Characteristic Associated features Interpretation
Mucopurulent Initially the sputum Bronchiectasis,
is mucoid and later Cystic fibrosis,
slightly discoloured Lung abscess
Foul smelling Long standing Bronchiectasis
and copious lung diseases
Haemoptysis Old blood Infection or chest
CHAPTER trauma
3
Cardiac disease
Black Black specks in Smoke inhalation
mucoid secretions
Frothy Pink or white Pulmonary oedema,
Heart failure
MILLER’S GRADING SYSTEM OF SPUTUM

M1 Mucoid with no suspicion of pus.
M2 Predominantly mucoid with suspicion of
pus.
P1 1/3 purulent, 2/3 mucoid
P2 2/3 purulent, 1/3 mucoid
P3 More than 2/3 purulent
READINGS OF CHEST X-RAYS

INDICATIONS
• Any type of sign and symptoms, which are
related to respiratory or cardiovascular
diseases
• To indentify the tumours
CARDIORESPIRATORY
53
• Preoperative evalution of patient’s for intra-
thoracic surgery
• Follow-up and monitoring of patient’s with
life support devices.
DATABASE
Patient’s name, Patient’s identification number,
CHAPTER
No. given by radiologist, Date, Time, Side
markings L or Rt (L= left, R = right)
3
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 (specially breast shadows
in women).
VIEWS
Posteroanterior (PA)
It means that the X-rays have entered the chest
from the posterior chest wall. The X-rays should
be ideally viewed from a distance of 3-4 feet.
CARDIORESPIRATORY
54
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.
CHAPTER Lateral
3 Lateral view helps to easily indentify smaller

lesions. The main problem in this view is
positioning the arms out of the X-rays field.
Lateral Decubitus
Lateral decubitus view may help to identify the
free fluid or air in the pleural cavity.
Apicogram or Lardotic
It is useful to demonstrate the calcifications,
nodules azygos lobe and middle lobe collapse.
Expiratory Film
The view is taken during expiration. By the help
of this view pulmonary hydatid cyst. Azygos vein
and vascular lesions are easily demonstrated.
Trendelenburg
The view is taken with Trendelenburg position.
It is mainly help to demonstrate the movement
of the fungal ball in cavity.
CARDIORESPIRATORY
55
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. CHAPTER
3
• Posterior portions of the ribs should be
horizontally and the anterior portions should
be oblique.
• Trachea lies centrally and vertical.
• The left hilum should be at a higher level than
the right.
• The right dome of diaphragm is about 2 cm
higher than the left, because the right lobe of
liver is situated directly underneath.
• The diameter of heart is usually less than half
the total diameter of the thorax.
• Both lung fields should be equally translucent
and should not have any other shadows.
COSTOPHRENIC ANGLE: It is a angle where the
diaphragms meets the ribs.
CARDIAOPHRENIC ANGLE: It is a angle where
the diaphragm meets the heart.
SILHOULTE SIGN: Broder of the adjacent organ
will be blurred, if there is any lesion contiguous
with the organ.
CARDIORESPIRATORY
56
COMMAN ABNORMALITIES IN X-RAYS
Lobar collapse—Homogenous opacity
Consolidation—Patchy opacity
Pleural effusion—Dense opacity
Pneumothorax—No lung marking is present
Lung abscess—Rounded opacity
Pulmonary tuberculosis—Soft confluent shadow
CHAPTER
calcification
3 Bronchiectasis—Multiple ring shadows.
ABNORMAL ECG FINDINGS

Lt. atrial enlargement — Wide, notched P wave
(lead II)
Rt. atrial enlargement — Tall p wave (lead II)
Ventricular — Wide QRS, ST
hypertrophy depression
Atrial tachycardia — Abnormally shaped P
waves
Atrial flutler — P wave replaced by
saw tooth baseline
Atrial fibrillation — No P waves visible
Sinoatrial block — P wave fails
Atrioventricular — Prolongation of PR
block interval
Bunde branch block — QRS interval abnormal,
ST segment depressed,
T wave inverted
Myocardial infarction — ST segment elevated,
T wave inverted
CARDIORESPIRATORY
57
Mitral valve disease — Bifid, broad P waves
Myocardial ischaemia — ST segment depressed
(Posterior MI)
Hyper kalaemia, — Tall T waves
acute MI
Hypokalaemia, — Small T waves
hypothyroidism,
pericardial effusion CHAPTER
Pericardial effusion — Small QRS complex
WOLF—Parkinson
white (wpw) syndrome — Short PR intervals, less
3
than 0.12 sec.
PERCUSSION NOTE
Evalution 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
pleximeter finger. All areas of the chest are
percussed.( front, back, and both axillae)
The pitch of the note is determined by whether
the lungs contain air, solid or fluid and will either
sound normal or abnormal.
CARDIORESPIRATORY
58
Abnormalties 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
CHAPTER
3
Skodaic resonance Empty cavity and pleural effusion
(boxy note)
Hyper resonance Pneumothorax, large cavity bullae
formation, chronic bronchitis,
congential 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.
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 sound are heard:
CARDIORESPIRATORY
59
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.
ABNORMAL BREATH SOUNDS CHAPTER
Causes
1. Abnormal generation—Abnormality in larger
3
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 pt’s with cavity, consolida-
tion, pleural effusion, partial collapse of lungs
and open pneumothorax.
2. Absence of lung tissue sounds, occurs when
transmission of sounds is impeded (e.g. in
pneumothorax, lung tissue collapse, pleural
effusion, asthma).
VOCAL RESONANCE
These are the sound heard through the
stethoscope, when the pt’s is asked to say “99” or
“aah.”
CARDIORESPIRATORY
60
Normal
The sound can be clearly heard, over the trachea
and are muffled and softer over lung tissue.
Abnormal
Broncophony—“99” can be clearly heard over lung
CHAPTER tissue.
3 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 usally indicative of
bronchial asthma, chronic bronchitis, lung
tumours, COPD’s, 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
CARDIORESPIRATORY
61
3. End of inspiration—Small airways and lung
tissue.
Crackles are indicative of bronchitis. Lt. heart
failure, pneumonia, lung abscess, bronchiec-
tasis, pulmonary oedema, pulmonary fibrosis
and other obstructive respiratory diseases.
Pleural Rub CHAPTER
It is due to roughening of the pleural surfaces as

in pleuisy. Pleural surfaces rub together and
creating a cracking or grating sound.
3
Stridor
Loud sound, heard during inspiration due to
obstraction of the respiratory track. It indicates a
serious condition. Laryngeal stridor is a high
pitched sound heard over the larynx due to
laryngeal obstraction, with foreign body,
diptheria, etc. whereas tracheal stridor is a low
pitched sound heard over the trachea due to
trached obstruction.
PALPATION OF PULSES
Pulse is palpated under following headings:
Rate
Rhythm
Volume
Force
Tension—(pulsus mollis/pulsus durus)
CARDIORESPIRATORY
62
Contour—(rise/summit/fall)
Equality
Condition of arterial wall (hard/musclar/tube
like)
Any abnormal character.
COMMON LOCATIONS
CHAPTER
Radial: Slightly medical to the styloid process.
3 Brachial: Cubital fossa.

Carotid: Upper end of the thyroid cartilage along
the medical broder of the sternomastoid muscles.
Femoral: Groin region.
Popliteal: Popliteal fossa.
Posterior tibial: Groove between the medical
malleolus and tendo-achilles.
Dorsalis pedis: Lateral to the extensor hallucis
tendon.
Axillary: Groove behind coraco-brachialis.
Anterior tibial: Between tibialis anterior and
extensor hallucis longus tendon, above the level
of ankle joint.
Temporal: Temple directly in front of ear.
Ulnar: Little finger side of wrist.
CARDIORESPIRATORY
63
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
CHAPTER
3
Reflex irritability No Grimace Cry
response
Colour Blue Pink Completely
pink
SCORE
Under 7—Resuscitation require.
7 or over—Normal
Between 5 and 7—Clearing air way and O 2
therapy require.
POSTURAL DRAINAGE
Positioning the patient to allow gravity to assist
the drainage of the secretions from specific areas
of lungs.
CARDIORESPIRATORY
64
CHAPTER
3
Fig. 3.4: Apical segments of both upper lobes
Fig. 3.5: Posterior segment of right upper lobe
Fig. 3.6: Posterior segment of the left upper lobe

CARDIORESPIRATORY
65
Fig. 3.7: Anterior segments of both upper lobes
CHAPTER
3
Fig. 3.8: Lateral and medial segments of middle
lobe
Fig. 3.9: Superior and inferior segments of the

lingula lobe
Fig. 3.10: Apical segments of both lower lobes

CARDIORESPIRATORY
66
CHAPTER
3 Fig. 3.11: Anterior basal segments of both lower

lobes
Fig. 3.12: Posterior segments of both lower lobes
Fig. 3.13: Lateral basal segment of the left lower lobe

and the medial basal segment of the right lower lobe
CARDIORESPIRATORY
67
CHAPTER
Fig. 3.14: Lateral basal segment of the right lower lobe
ALTERNATIVE METHOD OF POSTURAL DRAINAGE

3
Fig. 3.15: Postural drainage over towles
Fig. 3.16: Postural drainage over chair

CARDIORESPIRATORY
68
CHAPTER
3 Fig. 3.17: Postural drainage over foam wedge
CONTRAINDICATIONS
• Head injuries including cerebral vascular
accidents
• Hypertension
• Haemoptysis
• Aortic aneurysms
• Pulmonary oedema
• Surgical emphysemas
• Tension pneumothorax
• Eye operation
• 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.
CARDIORESPIRATORY
69
MANUAL CHEST CLEARANCE TECHNIQUES
Percussion, vibration and shaking along with
postural drainage is called manual chest clearance
technicque.
AIM
• To mechanically loosen the secretions CHAPTER
3
• 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
MODIFICATIONS OF TECHNIQUES FOR

PAEDIATRICS PATIENT’S
Inspite of hand percussion, we may use:
• Bell of stethoscope
• Face mask for babies
• Small medicine cup (30 ml.)
• Tenting finger.
PRECAUTIONS
Rib fracture
Burns
Pain
Surgical emphysema
CARDIORESPIRATORY
70
Flial chest
Haemoptysis
Pulmonary embolism
Acute infections
Metastatic conditions
Unstable cardiovascular conditions
Recent skin graft or flap
CHAPTER Severe clotting disorder.
3 SUCTIONING
The removal of bronchial secretions through a
suction catheter is called suctioning.
INDICATIONS
• Very sick spontaneously breathing patient
• Patient unwilling to cough voluntarily
• Patient who have no cough reflex
• All intubated patient’s.
CONTRAINDICATION
• Pulmonary oedema
• Stridor
• CSF leakage
• Bronchospasm.
MODES OF ENTRY
• Nose (nasopharyngeal)
• Mouth (oropharyngeal)
CARDIORESPIRATORY
71
• Via tracheostomy
• Via endotracheal tube.
PRECAUTIONS
• Lung transplant
• Pneumonectomy
• Recent oesophagectomy
CHAPTER
• Clotting disorders.
HAZARDS 3
• Infections
• Mucosal trauma
• Hypoxia
• Atelectasis
• Pneumothorax
• Bronchospasm
• Raised ICP
• Cardiac arrhythmias.
FORCED EXPIRATORY TECHNIQUES

It consists of one or two huffs from mid lung
volume to low lung volume followed by a period
of relaxed diaphragmatic breathing.
INDICATIONS
• Cystic fibrosis
• Chronic lung diseases
• After surgery (sometimes)
CARDIORESPIRATORY
72
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 uder general anaesthesia
in which a horizontal incision is made in neck.
CHAPTER
3
FUNCTIONS
• Increase alveolar ventilation
• Provide alternate pathway for breathing
• Protection of the airway from oral and gasteric
secretions.
INDICATIONS
• Respiratory obstruction
• Respiratory insufficiency
• Retained secretion.
TYPE OF TRACHEOSTOMY
• Emergency—To save the life of patient
• Permanent—When lesion of upper airway or
oesophagus.
TYPES OF TUBE
1. Metal or plastic
2. Cuffed or uncuffed
3. Single or double lumen.
CARDIORESPIRATORY
73
COMPLICATIONS
• Tracheal irritation, necrosis, ulceration
• Haemorrhage
• Pneumothorax
• Secretions occluding tube
• Surgical emphysema
• Tracheo-oesophageal fistula
• Infection of tracheostomy site CHAPTER
• Stenosis of trachea.
3
AEROSOL THERAPY
Actual particulate matter suspended in a gas is
called as aerosol. It act as a liquifire and mobilizer
of pulmonary secretions in the respiratory tract.
Only 0.15 μ-0.25 μ particle shows the greater
deposition in the alveoli.
The device that produceses an aersol 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.
CARDIORESPIRATORY
74
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 recieve vibra-
tional energy and aerosol effect is created. The
nebulus is then transmitted via the buffle to the
CHAPTER
patients 0.5 to 3 μ sizes of particles is generated.
3 PATIENT’S POSITION
Sitting or half lying.
USES
It is mainly used in delivery of drugs specially
bronchodilator.
HAZARDS
Bronchospasm, shortness of breath because of
swelling of secretions, cross contamination.
HUMIDITY
Adequate humidity is necessary for proper
respiratory function. The device which deliver a
maximum amount of water vapour to respiratory
that is called humidifier.
INDICATIONS
• Ventilated
• Intubated
CARDIORESPIRATORY
75
• Recieving supplemental oxygen
• New born babies
• Patient’s with severe chest injury
• COPD, asthma, pneumonia, atelectasis
• Thermal respiratory burns.
METHODS
• Systemic hydration—By oral or intravenous CHAPTER
•
•
•
Water bath
Nebulizers
Instillation/infusion
3
• 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 acess the degree of respiratory failure.
TESTS
a. Airways function test: All volumes and capa-
cities are assessed by spirometery.
CARDIORESPIRATORY
76
b. Blood gas analysis: PaO 2 and PaCO 2 is
assessed by blood gas analysier.
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
CHAPTER minute ventilation and oxygen consumption
3 are measured.
In field
Test
• 12 minutes, 6 minutes, 2 minutes, walk test
• Endurance walking test
• Step test
• Shuttle test.
In Laboratory
• Treadmill
• Cycle ergometer.
TEST PROTOCOLS
• Bruce
• Modified bruce or Sheffield
• Cornell
• Balkeware
• ACIP and MACIP
• Naughton
• Ware
CARDIORESPIRATORY
77
• Modified Sheffield
• Northwick park.
AMBU BAG
(AMBULATORY MANUAL BREATHING UNIT)
This is the apparatus used for mouth to mouth
respiration, by the help of face mask, endo- CHAPTER
3
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
foam rubber insert causes the bag to inflate
automatically. The chest recoil causes air to leave
the lung by an expiratory valve protected by wire
guaze. 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 anaesthetic
rebreathing bag is used for it. The maximum peak
airway pressure is 40 cm H2O.
CONTRAINDICATIONS
• Undrained pneumothorax
• Bullae
• Surgical emphysema
CARDIORESPIRATORY
78
• Severe bronchospasm(if pap > 40 cm H2O).
• Acute head injury
• Cardiovascular instability
• Recent pneumonectomy
• Recent lobectomy
• Haemoptysis
• Patient at risk of barotrauma.
CHAPTER
3 ADVERSE EFFECTS
• Barotrauma
• Cardiac arrhythmia
• Reduced oxygen saturation
• Reduced respiratory drive
• Raised intracanial pressure
• Bronchospasm
• Haemodynamic 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 mmHg.
Range—110 to140 mmHg.
Diastolic pressure: minimum pressure during
diastole of heart, i.e. 80 mmHg.
CARDIORESPIRATORY
79
Range—60 to 90 mmHg
Pulse pressure: Difference between systolic and
diastolic pressure, i.e. 40 mmHg.
Mean arterial pressure: Diastolic blood pressure
plus one-third pulse pressure:
DBP + 1/3 PP, i.e. 93 mmHg.
CHAPTER
CARDIAC OUTPUT
Amount of blood pumped from each ventricles.
CO = Stroke volume × heart rate
3
Normal value = 50 to 6 L/min
Average = 5.5 L/min/ventricles.
STROKE VOLUME
The amount of blood pumped out by each
ventricle during each beat.
Normal value = 70 ml (60 to 80 ml).
MINUTE VOLUME
Amount of blood pumped by each ventricle in one
minute.
Normal value 5-6 L/min.
CARDIAC INDEX
This is the minute volme 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.
CARDIORESPIRATORY
80
HEART RATE
The number of time the heart contracts in a
minute.
Normal 50-100 bpm
Tachycardia > 100 bpm at rest
Brady cardia < 50 bpm at rest.
CHAPTER
3
CENTRAL VENOUS PRESSURE
This is the pressure found in the veins emerging
in heart.
Normal value—3-6 mmHg or 3-15 cmH2O
CEREBRAL PERFUSION PRESSURE (CPP)

Pressure required to ensure adequate blood
supply to the brain.
CPP = MAP-ICP
Normal value > 70 mmHg.
INTRACRANIAL PRESSURE
Pressure exerted by the brain tissue, CSF of blood
volume with in the skull of meninges.
Normal value - 0-10 mmHg
PULMONARY ARTERY PRESSURE (PAP)

It is measure of pressures of the vena cava, right
atrium and right Ventricle.
Normal value—15-25/8-15 mmHg.
Mean value—10-20 mmHg.
CARDIORESPIRATORY
81
RESPIRATORY RATE
Number of breathes taken in a minute.
Normal value—12-16 breaths/min
Tachypnoea > 20 breaths/min
Bradypnoea < 10 breaths/min.
EJECTION FRACTION
CHAPTER
3
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%.
VENTILATIONS
SYNCHRONIZED INTERMITTENT MANDATORY
VENTILATION (SIMV)
Mandatory breaths are delivered in synchrony
with the patient’s breathing. The patient may
breath on his own but the mandatory breaths will
be delivered at a time in the ventilatory cycle, that
is covenient 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.
CARDIORESPIRATORY
82
CONTINUOUS POSITIVE AIRWAY
PRESSURE (CPAP)
Oxygen is delivered in a positive pressure
throughout inspiration and expiration during
spontaneous breathing. It decrease the work of
breathing, O 2 consumption but increases the
forced respiratory capacity and PaO2.
CHAPTER
3 POSITIVE END EXPIRATORY PRESSURE (PEEP)

PEEP is used when pao2 is < 200 mmHg. Gene-
rally PEEP is used of minimum 5 cm water in all
mechanically ventilated patient’s. It prevent the
alveolar collapse and increases the forced
rerspiratory cycle.
INTERMITTENT POSITIVE PRESSURE

BREATHING (IPPB)
It is a mechanical device that augment gas flow.
IPPB maintains positive airway pressure through-
out inspiration with airway pressure returing 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.
CARDIORESPIRATORY
83
BIPHASIC POSITIVE AIRWAY PRESSURE (BIPAP)
BiPAP is a single ventilation mode which permits
spontaneous breathing not only during expiration
but also during manadatory breaths. It reduces
atelectasis, less sedation higher inspiratory drive
and maintained and spontaneous brathing.
HIGH FREQUENCY VELTILATION (HFV) CHAPTER
It delivers low tidal volume or equal to anatomical
dead space volume at high respiratory frequencies
vary between 60 and 300 breaths/minute.
3
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.
CARDIORESPIRATORY
84
PRESSURE SUPPORT (PS)
During PS tidal volume, respiratory rate and flow
rate is controlled by patient himself through his
inspiratory efforts.
NON-INVASIVE VENTILATION (NIV)

CHAPTER NIV is the ventilatory support used without
3 intubation through a mask. It is rarely used.

Positive pressure devices are pressure, volume or
time controlled. The modes which are used are
pressure support ventilation, control/assist
ventilation, controlled mechanical ventilation,
BiPAP, CPAP and proportional assist ventilation.
RESPIRATORY PATHOLOGIES
ACUTE RESPIRATORY DISTRESS

SYNDROME (ARDS)
Progressive breathlessness and respiratory failure
caused by a variety of acute diffuse lung injuries.
Causes
Shock, burns, severe non-thoracic trauma, septi-
cemia, aspiration, pneumonia, fat embolism,
overdoses of drugs likely to damage pulmonary
circulation.
CARDIORESPIRATORY
85
C/F
Dyspnoea, tachypnoea, crackles and wheezes
sound, shock, septicemia, renal failure, liver
failure, CNS depression.
ARDS tends to reach its maximum initial
severity over next 24-48 hours and may be rapidly
fatal if severe.
CHAPTER
ATELECTASIS OF LUNG
Loss of volume in one or more segments or lobes
3
of the lungs.
Causes
Bronchical obstraction, carcinoma of bronchus,
aneurysm, enlarge glands.
C/F
Fever, tachycardia, tachypnoea, 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.
CARDIORESPIRATORY
86
C/F
Cough, wheeze, chest tightness, dyspnoea.
These symptoms can range from mild to
severe; and may even result in death.
BRONCHIECTASIS
CHAPTER Chronic permanent dialatation of one or more
3
bronchi, which impairs the drainage of bronchial
secretions and leads to persistent infection in the
affected segment or lobe.
Causes
I Congenital: kartagener syndrome, cystic fibrosis,
hypogammaglobulinemia with respiratory infec-
tion.
II Acquired
• Infections—Measles, whooping cough and
influenza, pneumonia, lung disease, tuber-
culosis, bronchopulmonary aspergillosis
• Obstraction—Foreign body, bronchial stenosis,
bronchial carcinoma.
Types
I Saccular: Affects proximal bronchi.
II Cylindrical: Affect distal bronchi.
III Varicose: Intermediate between saccular and
cylindrical.
CARDIORESPIRATORY
87
C/F
Productive cough, fever with chills, weakness,
lassitude, anorexia, loss of weight, pleuritic pain
and night sweats.
BRONCHITIS
Types CHAPTER
Acute bronchitis: Acute infection of mucous
membrane of trachea and bronchi produced by
viruses, bacteria or external irritants.
3
Chronic bronchitis: Condition associated with
mucous production amounting to cough and
expectoration for more than 3 months in a year and
for 2-3years consecutively with other causes rules
out.
C/F
Malaise, fever, palpitation, sweating, productive
cough, wheezing, dyspnoea.
Because of irreversible narrowing of the
airway, patient leads to develop dysponea,
cyanosis, hypoxia, hypercapnia and some times
heart failure occurring. This condition is called
‘blue bloaters.’
CHRONIC OBSTRUCTIVE PULMONARY DISEASE

(COPD)
COPD mainly associated with emphysema and
chronic bronchitis.
CARDIORESPIRATORY
88
Risk factors: Smoking, recurrent infections,
pollution, genetics.
C/F
Chest tightness, cough, dyspnoea, excessive
mucus production.
CHAPTER CYSTIC FIBROSIS
3 A progressive genetic disorder of the mucus—

secreting glands of the lungs. Pancreas, mouth,
gastrointestinal tract and sweat glands.
C/F
Recurrent respiratory infection, poor growth
malnutrition, abnormal heart.
Rhythms, dyspnoea, malabsorption.
Complication: 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.
C/F
Dyspnoea, productive cough, wheeze, recurrent
respiratory infection, weight loss, hyperinflated
chest.
CARDIORESPIRATORY
89
These patient’s are often called as “pink
puffers” who may hyperventilate typically over-
using their accessory respiratory muscles, and
breath with pursed lips in order to maintain
airway pressure to decrease the amount of airway
collapse.
EMPYSEMA CHAPTER
An accumulation of pus in the pleural cavity

following nearby lung infection. 3
C/F
Chest pain (increasing or inspiration, coughing,
sneezing, laughing, etc.) dyspnoea, fever,
anorexia, malaise, weight loss.
HAEMOTHORAX
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.
C/F
Absent breath sounds on affected side, reduced
chest expansion, dullness to percussion. If
bleeding continue, feauters of shock develops.
CARDIORESPIRATORY
90
LUNG ABSCESS
Circumscribed suppurative inflammation of lung
by pyogenic organisms leading to cavitation and
necrosis.
C/F
CHAPTER Fever, pleuritic chest pain, cough, foetid breath,
3
hemoptysis, clubbing of fingers, loss of weight,
anorexia.
PLEURAL EFFUSION
Pleural effusion is a collection of serous fluid in
the pleural space.
Types
I. Acute pleural effusion—Trauma, pancrea-
titis, pulmonary infraction.
II. Purulent effusion—Pyogenic infections,
septicemia, penetrating wound of chest
III. Hemorrhagic effusion—Tumor, tuberculo-
sis, pulmonary infaraction, bleeding.
IV. Tuberculous pleural effusion.
V. Milky effusion (chylous, opalescent).
VI. Iatrogenic.
VII. Recurrent.
VIII. Bilateral.
IX. Phantom.
CARDIORESPIRATORY
91
C/F
Pleuritic pain, dysponea, toxemia.
PLEURISY: INFLAMMATION OF PLEURA

Causes
Infection, infarction of lung, lung cancer injury to
chest wall rheumatoid arthritis. CHAPTER
C/F 3
Pain on respiration, unproductive cough, rapid
shallow breathing, chilly sensations, fever.
PNEUMONIA
Inflammation of lung parenchyma involving
respiratory bronchioles and alveolar unit distal to
the conduction zone.
Type
I. Anatomical
a. Lobar
b. Segmental
c. Lobular.
II. Clinical
a. Primary
b. Secondry (associated with any disease).
III. Etiological
a. Bacterial (E. coli, Klebsiella, Pseudo-
monas)
CARDIORESPIRATORY
92
b. Atypical (viral, mycoplasmal)
c. Protozoal (E. histolytica)
d. Fungal (actinomycosis, aspergillosis)
e. Allergic
f. Radiation
g. Collagenosis
h. Chemical.
CHAPTER
3 C/F
Dry and painful cough, pleuritic pain, fever,
fatigue, after few days. Purulent with blood in
sputum.
PNEUMOTHORAX
Pneumothorax is air in the pleural cavity. Air may
enter the pleural cavity through the chest wall,
mediastinum or diaphragm or from a puncture
of the visceral pleura covering the lung.
Causes
I. Primary spontaneous—Idiopathic.
II. Secondry 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. Fre-
quently affected tall, thin young men,
especially smokers.
CARDIORESPIRATORY
93
III. Traumatic and iatrogenic: Stab wounds,
fractured ribs, crush injury, lung biopsy,
faulty tracheostomy, cardiothoracic surgery.
IV. Artificial: Because of an antitubercular
drugs.
Types
CHAPTER
Closed—The opening in the lungs is very small
and rapidly heals. Thus allowing the lung to re-
expand. 3
Open —The opening remains patent and pressure
in the pleural cavity is equal to that of the
atmosphere.
Tension—The opening is valvular –air enters the
pleural space during inspiration but cannot
escape during expiration so that a positive
pressure occurs in the pleural cavity.
C/F
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.
CARDIORESPIRATORY
94
C/F
Dyspnoea, chest pain, haemoptysis
Risk factors: Prolonged sitting, femur fracture,
surgery.
PULMANARY OEDEMA
CHAPTER An increase in the fluid content of the extra-
3
vascular tissues of the lung.
Cause
Myocardial infarction, LV failure, mitral stenosis,
shock, infections, fluid overload, etc.
C/F
Wheezing, shortness of breath sweating tachy-
cardia, short and copious frothy cough.
PULMONARY TUBERCULOSIS
A chronic infectious disease caused by myco-
bacterium tuberculosis that is spread via the
circulatory system or the lymphnodes.
Sites: lungs, lymph nodes, bones, gastrointestinal
tract, kidney, skin, and meninges.
Types
a. Millary tuberculosis: The lungs are studded
with firm white tubercles about 1 mm in
diameter.
CARDIORESPIRATORY
95
b. Chronic fibrocaseous: Firstly cavities are
formed at the apex.
c. Acute tuberculous caseous pneumonia: Lesion
ulcerate through bronchial walls.
C/F
Cough, haemoptysis, weight loss, fatigue, fever,
CHAPTER
night sweats.
RESPIRATORY FAILURE 3
Condition when normal blood gas pressures
cannot be maintained at rest.
Type
I. Hypoxaemic respiratory failure—A decrea-
sed PaO2 with a normal or low PaCO2
Causes: Chronic bronchitis, emphysema,
ARDS
PaO2 < 8 kPa (60 mmHg)
II. Ventilatory failure: A decreased PaO2 with
an increased PaCO2.
Causes: Muscular dystrophy, lung disease,
Guillain-Barré.
PaO2 < 8 ka (60 mmHg)
PaCO2 > 6.7 kPa (50 mmHg)

CARDIORESPIRATORY
96
C/F
Central cynosis, loss of judgment, fatigue, dizzi-
ness, dimness of vision, headache.
Arterial Blood Gas Calssification of

Respiratory Failure
pH PaCO2 HCO3-
CHAPTER
3
Acute Decreased Increased Normal
Chronic Normal Increased Increased
Acute on chronic Decreased Increased Increased
SARCOIDOSIS
Granulomatous disease involving several organs.
Comman Site: Mediastinal, lymph nodes, lungs,
liver, spleen, skin, eyes.
C/F
Lymph node enlargement, fever, weight loss, dry
cough, uveitis arrhythmias.
SLEEP APNOEA
There is recurrent collapse of upper airway due
to which there is difficulty or obstruction in
breathing for more than 10 sec leading to distur-
bed sleep.
C/F
Restlessness, reduced sleep, reduced muscle tone,
enlarged tonsils or adenoids, abnormal use of
accessory respiratory muscle.
CARDIORESPIRATORY
97
Complication
Pulmonary hypertension, respiratory or heart
failure.
It occurs due to loss of muscle tone of pharynx
or abnormal central nerous system.
NORMAL VALUES CHAPTER
Age group Heart rate

mean (range)
(beats/min.)
Respiratory
rate range
(breaths/
Blood
pressure
systolic/
3
min.) diastolic
(mmHg)
Preterm 150(100-200) 40-60 39-59/16-36
New born 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 mmHg)
PaCO2 4.7-6.0 kPa (35-45 mmHg)
HCO3- 22-26 mmol/L
Base excess –2 to +2
CARDIORESPIRATORY
98
VENOUS BLOOD
pH 7.31-7.41 [H+] 46-38 nmol/L
pO2 5.0-5.6 kPa (37-42 mmHg)
pCO2 5.6-6.7 kPa (42-50 mmHg)
VENTILATION/PERFUSION
CHAPTER Alveolar : Arterial oxygen gradient A—
3
aPO2
Breathing air : 0.7-2.7 kPa (5-20 mmHg)
Brathing oxygen : 100% 3.3-8.6 kPa
(25-65 mmHg)
PRESSURES
mmHg 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 cmH2O
pressure
Intracranial
pressure (ICP) <10 mmHg (<1.3 kPa)
CARDIORESPIRATORY
99
mmHg kPa
Peak inspiratory Male 103-124 cmH2O
mouth pressure
(pi max) Female 65-87 cmH2O
(Case
dependent)
Peak expiratory Male 185-233 cmH2O
mouth pressure
(pe max.) Female 128-152 cmH2O CHAPTER
(Case
dependent) 3
BLOOD VALUES AND THEIR INTERFERING
FACTORS
WHITE BLOOD CELL (WBC)
Increase—Food, exercise, emotions, pain, mens-
trution, pregnancy, fever, anaesthesia prolonged
cold bath, infections, haemorrhage.
Decrease—Bone marrow depression, viral
infection, hypersplenism.
NEUTROPHIL
Increase—Infection.
Decrease—Viral infection, influenza, mumps,
anaemia, thyrotoxicosis.
EOSINOPHIL
Increase—Lung and bone cancer parasitic diseases,
Hodgkin’s disease.
CARDIORESPIRATORY
100
Decrease—Pyogenic infection, congestive heart
failure hypersplenism.
RED BLOOD CELLS (RBCs)

Increase—Dehydration, poisoning, diarrhoea,
polycythemia vera.
CHAPTER Decrease—Anaemia, bone marrow diseases,
3
rheumatic fever, endocarditis.
ESR
Increase—Anaemia, burns, MI, infections, gout,
rheumatoid arthritis, leukaemia, sarcoidosis
Decrease—Polycythemia vera, congestive cardiac
failure.
BLOOD UREA NITROGEN (BUN)

Increase—Shock, dehydration, diabetes, MI,
impaired renal function.
Decrease—Malnutrition, liver failure, nephrotic
syndrome.
URIC ACID
Increase—Metastatic cancer, shock, diabetic
ketosis, leukaemia.
Decrease—After drugs, ACTH phenothiazenes.
CARDIORESPIRATORY
101
RESPIRATORY ASSESSMENT
DATABASE
Reg No
Name
Age/sex DOA.
Address
Occupation CHAPTER
Referred by (consultant) and Hospital
Consultant’s probable diagnosis
Type of operation/illness 3
DOD
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.
CARDIORESPIRATORY
102
FROM CHART’S
Blood pressure
Heart rate
Temperature
Oxygen requirement
Oxygen saturation’s
Respiratory rate
CHAPTER
Peak flow
3 Urine output
Mode of ventilations
FiO2
Pressure support/volume control
Airway pressure
CVP
ABG’s.
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).
CARDIORESPIRATORY
103
— Nature (shooting or dull pain)
Course
• Radiation (if any)
• Towards (Rt/Lt) UL
Intensity of pain (constant or intermittent)
Aggravating/relieving factors.
On palpation
Oedema (pitting or non-pitting) CHAPTER
Inflammatory signs ( present/absent)
Wasting of muscle
Tracheal shift.
3
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’s
Sputum examination
ECG
Echo-cardiography
CARDIORESPIRATORY
104
Pulmonary function test
Stress test
Scanning.
On examination
Pulse rate
Respiratory rate
Temperature
CHAPTER Blood pressure.
3
Measurments
Chest expansion
Spirometry
Dysponea 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 catheteri-
zation 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.
CARDIORESPIRATORY
105
Apnoea: 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.
Bradycardia: Abnormally slow heart rate.
CHAPTER
3
Bradypnea: Decrease rerpiratory 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.
Dyspnoea: Laboured, uncomfortable breathing.
Dysrhythmia: Disturbance of rhythm.
Fibrillation: Rapid unco- ordinated contractions
of the cardiac muscle.
Haemodynamics: The study of forces governing
blood flow.
Haemoptysis: The presence of blood in the
sputum.
Hypercarbia: Excess of CO2 in the blood.
CARDIORESPIRATORY
106
Hypercapnia: An increase in the amout of CO
within the arterial blood.
Hyperinflation: An abnormal increase in the
amount of air in the lung tissue.
Hypocapnea: A decrease in the amount of CO2
in arterial blood.
CHAPTER Hypoapnea: Dimination of tidal volume.
3 Hypoventilation: An increase in the amount of

CO2 in arterial blood due to a decrease in alveolar
ventilation.
Hypovolaemia: Low blood volume.
Hypoxaemia/Hypoxia: Reduction of O2 supply to
the tissues.
Ischaemia: O2 starvation of the tissues due to a
lack of blood supply.
Orthopnoea: 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
107
CHAPTER 4
Neurology
Neuroanatomy illustrations
Clinical manifestations of cerebrovascular CHAPTER
4
lesions
Localisation 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
NEUROLOGY
108
Differences of upper motor neuron and lower
motor neuron lesions
Glasgow coma scale
Modified ashworth scale for grading spasticity
Neurological pathologies
Neurological assessment
Glossary of neurological terms
CHAPTER
4
NEUROLOGY
109
NEUROANATOMY ILLUSTRATIONS
ARTERIAL SUPPLY OF THE CEREBRAL
HEMISPHERE
Fig. 4.1: Supralateral surface CHAPTER
Fig. 4.2: Medial surface

NEUROLOGY
110
CHAPTER
4 Fig. 4.3: Circular arteriosus
CLINICAL MANIFESTATIONS OF
CEREBROVASCULAR LESSIONS
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 contical area Wernicke’s aphasia
(dominant hemisphere)
NEUROLOGY
111
Parietal lobe (non dominant Perceptual problems
lobe)
Optic radiation in internal Homonymous hemianopia
capsule
Parietal lobe Contralateral limb(s)
ataxia
ANTERIOR CEREBRAL ARTERY

CHAPTER
4
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)
Superior forntal gyrus Urinary incontinence
Corpus callosum Apraxia
Uncertain localisation 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
NEUROLOGY
112
Calcarine sulcus and lingual Prosopagnosia
gyrus (non dominant occipital
lobe)
Ventral posterolateral nucleus Thalamic syndrome:
of thalamus sensory impairments,
spontaneous pain,
dysethesias
Cerebral peduncle of mid Weber’s syndrome—
brain and III cranial nerve contralateral hemiplegia,
occulomotor nerve palsy
CHAPTER Subthalamic nucleus Contralateral hemiballism
4 LOCALISATION OF LESION AND

THEIR SIGNS OF IMPAIRMENT
Prefrontal area Dementia, stage of catatonic
stupor, incontinence of urine
Precentral area Jacksonion march (in irritation),
UMN type of paralysis (in
destruction)
Parietal lobe Paraesthesia (in irritation),
sensory ataxia, sensory loss
(in destruction)
Temporal lobe Visual and auditory hallucination,
uncinate fits, homonymous
superior quadrantic hemianopia
Occipital lobe Vision hallucination, convulsions
(in irritation),visual agnosia, visual
sensory aphasia (in destruction)
NEUROLOGY
113
BASAL GANGLIA
Nuclei
1. Putamen
2. Caudate
3. Globus pallidus.
Clinical Manifestations
Bradykinesia
Rigidity
Tremors CHAPTER
4
Akinesia
Chorea
Athetosis
Choreo-athetosis
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
L2 Hip flexion
NEUROLOGY
114
L3 Knee extension
L4 Dorsiflexion
L5 Great toe extension
S1 Planter flexion
S2 External rotation
DERMATOMES
CHAPTER
Fig. 4.4: Dermatomes of the whole body

NEUROLOGY
115
PERIPHERAL NERVOUS SYSTEM
AXILLARY NERVE (C5, C6)
Innervation of muscle—deltoid, teres minor.
Sensory distribution—lateral arm over lower
portion of deltoid.
Clinical features—loss of shoulder abduction, also
affect the lateral rotation of shoulder.
MUSCULOCUTANEOUS NERVE (C5, C6)

CHAPTER
Innervation of muscle—coracobrachialis biceps
brachialis
Sensory distribution—anterolateral surface of
4
forearm
Clinical features—loss of elbow flexion, also affect
supination
RADIAL NERVE (C6, C7, C8, T1)

Innervation of muscle
1. Before the radial groove—long and medial heads
of triceps
2. 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
NEUROLOGY
116
• After piercing the supinator
Other extensor muscles of the forearm and
hand.
Sensory distribution—posterion aspect of arm,
forearm and radial side of posterior hand.
Clinical feauters—wrist drop (loss of elbow, wrist,
finger and thumb extension).
MEDIAN NERVE (C6, C7, C8, T1)

Innervation of muscle
CHAPTER
4
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 opposi-
tion, flexion and abduction).
ULNAR NERVE (C8, T1)

Innervation of muscles
In the farearm
Proximal 1/3—flexor carpi ulnaris, medial half
of flexor digitorum profundus.
Distal 1/3—nil.
NEUROLOGY
117
In the hand
Superficial branch—hypothenar muscles.
Deep branch—adductor pollicis, all interossei
and medial two lumbricals.
Sensory distribution: Fourth finger (medial portion),
fifth finger.
Clinical features: Loss of wrist ulnar deviation.
Also affect flexion of wrist and finger pope’s
blessing—weakened fourth and fifth finger
flexion, thumb abduction loss, claw hand.
CHAPTER
FEMORAL NERVE (L2,L3,L4)
Innervation of muscle—iliopsoas, sartorius,
pectineus, quadriceps femoris.
4
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.
NEUROLOGY
118
Sensory distribution—nil.
Clinical features—loss of knee flexion, also affect
hip extension.
TIBIAL NERVE (L4, L5, S1, S2, S3)

Innervation of muscle—popliteus, ankle plantar
flexors tibialis posterior, intrinsics muscles of foot.
Sensory distribution:
Clinical features: loss of toe flexion and ankle
plantar flexion, also affect ankle inversion.
CHAPTER
4 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
119
VERTEBRAE AND CORRESPONDING SPINAL
SEGMENT RELATIONSHIP
Vertebrae Spinal segments
C1 to C4 (upper cervical) Same
C4 to C7 (lower cervical) +1
T1 to T7 +2
T7 to T9 +3
T10 L1,L2
T11 L3, L4
T12 L5 S1
L1 Sacral and CHAPTER
DESCENDING TRACTS
coccygeal nerve
4
Corticospinal tract—voluntary movements,
finger finer movements.
Rubrospinal tract—inhibits extensor muscles,
facilitates flexors movements.
Vestibulospinal tract—inhibits flexiors, facilitates
extensors.
Reticulospinal tract: Control muscle activity.
Tectospinal tract—vision reflex.
ASCENDING TRACTS
Medial lemniscus—kinesthetic, touch and
vibration sense.
Lateral spinothalamic—temperature, pain.
Anterior spinothalamic—crude touch, pressure.
NEUROLOGY
120
Spinocerebellar—kinesthetic sensation
Spino-olivary—carries message to fascia, tendon
and ligaments.
Spinoreticular—works on conscious level.
Spinotectal—vision.
NEUROLOGICAL TESTS
ALTER NOSE TO FINGER TEST
Test: Keep your finger away about an arm’s length
CHAPTER from the patient. Ask the patients to touch your
4
finger with his index finger and then touch his
nose. Repeat the movement.
Response: Patient missing your finger or intention
tremor.
Indicates: Possible cerebellar dysfunction.
FINGER TO NOSE TEST

Test: 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

Test: Keep the patient both shoulders in 90°
abduction with the elbow extension. Ask the
NEUROLOGY
121
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

Test: Patient lying down. Ask him to place one heel
on the opposite knee and then drug the heel down
CHAPTER
or the shin towards the ankle and back again.
Response: Inability to keep the heel on the shin or
unco-ordinated movement or intention tremor.
4
ALTERNATE HEEL TO KNEE TEST

Test: With supine position, ask the patients to
touch the knee and big toe alternately, with the
heel of opposite extremity.
Response: Unco-ordinated movement or intention
tremor.
JOINT POSITION SENSE (KINESTHESIA)

Test: The test is generally performed at distal joint
of the limb. Demonstrate the movement with
patient’s eye open. Then ask the patients to close
NEUROLOGY
122
his eyes to test. Crasp the joint to be tested between
two fingers and move it up and down. Ask the
patients to identify the direction of movement.
Response: Inability to identify.
Indicates: Loss of proprioception.
LIGHT TOUCH
Test: Take a wisp of cotton wool. Demonstrate the
procedure with the patient’s eye open. Then ask
the patient to close his eyes. Stroke the patient’s
CHAPTER skin with the cotton wool at random point, ask
4 him to indicate every time, he feel the touch.

Response—inability to indicate every time.
Indicates—altered touch sensation.
PIN PRICK (PAIN)

Test: 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.
TEMPERATURE
Test: Take cold and warm water and ask the
patients to distinguish between the two sensation.
Or
NEUROLOGY
123
A cold tunning 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
Test: Ask the patient to close his eyes. Put the
vibrating tunning fork (128 hz) over bony
prominence. CHAPTER
Response: Unable to report the feeling of vibration.
Indicates: Altered vibration sense.
4
TWO POINT DISCRIMINATION
Test: Demonstrate the procedure with patient’s
eye opened. Ask the patient to close his eyes,
with either one prong or two touch the patients
alternately and reduces space between two
prongs.
Response: Inability to discriminate.
Indicates: Indicates sensory dysfunction.
ROMBERG TEST
Test: Patient stand with feet parallel to each other
with a normal width between the feet and then
close eyes for 20-30 seconds.
NEUROLOGY
124
Response: Excessive postural sway or loss of
balance.
Indicates: Propriceptive or vestibular deficit
SHARPENED ROMBERG TEST

Test: 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.
CHAPTER
4
Indicates: Propriceptive or vestibular deficit.
OTHER BALANCE TESTS

One leg stance, Timed stance, Postural sway test,
Functional reach test, Nudge test, Getup 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
TYPES OF NERVE
Motor III, IV, VI, XI, XII
Sensor I, II, VIII
Mixed V, VII, IX, X
Name Function Assessment Abnormal sign’s
I Olfactory Smell Tested by use of non irritating Inability to detect smell
volatile oils or liquids
II Optic Vision - Tested for visual acuity by Loss of visual acuity
snellen chart (distance vision)
and jaeger’s (near vision)
- Tested for colour vision by Colour blindness
ishihara’s chart
- Tested for visual field by peri- Defects visual fields
metery or comfrontation test
NEUROLOGY
III Oculomotor Pupil constriction Test pupillary light reflex Pupillary dilatation
accommodation
of lens, movement Test accommodation reflex Loss of accommodation
of eyeball and reflex
eyelid Test eyeball and eyelid Diplopia, ptosis, squint
movements
4
125
CHAPTER
4
126
CHAPTER
IV Trochlear Movement of eyeball Assess the eye movement Diplopia,
in upward direction adductor paralysis
V Trigeminal Mastication, Ask the patient to clench Weakness and
somatosensation: jaws, hold against resistance wasting of mastication
face cornea, test sensation: forehead, muscle, loss of
anterior tongue cheeks, chin test corneal sensation in eye face,
reflex sinusers and teeth,
trigeminal neuralgia
VI Abducent Movement of Test eye movement Diplopia with gaze
eyeball in palsy, convergent
outward direction strabiamus
VII Facial Facial movement, Ask the patients to raise eye
NEUROLOGY
tearing-lacrimal frows, show teeth, smile,

gland, close eyes, tightly puff cheeks.
Salivary secretions-
submandibular,
sublingual,
Taste for anterior Test for taste-sweet, salty, Bells palsy, loss of
two thirds of tongue, sour, bitter taste, inability to close
somatosensation eye
VIII Hearing Test for hearing: Deafness,
Vestibulococ Rinne (sensorineural) and Tinnitus
hlear weber test (conduction)
Equilibrium Assess the balance, nystagmus Vertigo,
and eye head co-ordination nystagmus
IX Glosso- Elevation of pharynx Assess taste—sweet, salty, Dysphagia,
pharyngeal Salivary secretion: sour, bitter drymouth,
parotid, sensation loss of toung
of test for posterior sensation and taste,
third of tongue dysphonia
NEUROLOGY
reflexes Test gag reflex

X Vagus Phonation and Assess phonation and articulatin Dysphonia,
deglutition, secretion Observe movement of soft palate dysphagia
of digestive fluid,
cardiac depressor,
Reflexes, Somato- Test gag reflex Loss of gag reflex
sensations Test for pharyngeal sensation
4
127
CHAPTER
4
128
CHAPTER
XI Accessory Deglutition and
phonation,
movement of Test for muscle strength Muscle weakness
sternocleidomastoid and tone
and trapezius
(spinal part)
NEUROLOGY
XII Movement of Test for strength of tongue Dysphagia,

Hypoglossal tongue movement dysarthria,
wasting of tongue
DEEP TENDON REFLEXES
REFLEX NERVE MODE OF RESPONSE

ELICITATION
REFLEXES
Biceps C5-6 Musculocutaneous Striking over the Elbow flexion

biceps tendon
Supinator C5-6 Radial Striking over the Forearm flexion
brachioradialis tendon with supination
at the distial end
of radius
Triceps C7-8 Radial Striking over the Arm extension
tendon of triceps
NEUROLOGY
Finger flexion C7-8 Median and ulnar Striking over the Finger and
palmar surface of thumb flexion
the semiflexed fingers
Knee L2-4 Femoral Striking over the tendon Knee extension
of quadriceps
Ankle S1-2 Sciatic Striking over the Ankle plantar
tendocalcaneous flexion
4
129
CHAPTER
NEUROLOGY
130
SUPERFICIAL REFLEXES
Reflex Mode of elicitation Response

Plantar S1 Flexior response- All toes flexion
slightly scratching
the lateral border
of the sole
Extensor response- Small toe
slightly scratching fanning, ankle
the lateral border and big toe
of the sole dorsiflexion
Abdominal Slightly scratching Homolateral
CHAPTER T6-12 the abdomen with contraction of
4 blunt object the abdominal

muscles,
retraction of
linea alba and
umbilicus
Cremasteric Slightly scratching Cremasteric
L1 the skin on the muscle
upper, inner aspect contraction
of the thigh from with
above downwards homolateral
with a blunt object elevation of
testicle
Bulbocavernous Pressing the glans Bulbocavernous
S2-4 penis muscle
contraction
Anal S4-5 Pricking the skin External anal
on mucous sphincter
membrane in the muscle
perianal region contraction
NEUROLOGY
131
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 footpad fanning
Clonus Sudden dorsiflexion of Three or more then
(UMN foot passively three rhythmic
Lesion) contraction of
plantor flexions
DIFFERENCES OF UPPER MOTOR NEURON CHAPTER

AND LOWER MOTOR NEURON LESIONS
UMNL LMNL
4
Origin Cerebral cortex Cranial nerve
motor nuclei or
spind cord
anterior horm
Termination Cranial nerve nuclei Motor unit of
or spinal cord skeleted muscle
anterior horm
Affects Muscle group Individual muscle
Muscle tone Increased Decreased
Paralysis Spastic Flaccid
Wastage Do not occur Occur
of muscle
Involuntary Flexor spasms Fasciculation
movements sometimes sometimes
Superficial Lost Lost
reflexes
NEUROLOGY
132
UMNL LMNL
Deep reflexes Exaggerated Lost
Plantar reflex Abnormal
(Babinski’s sign) Lost
Clonus Present Lost
Electrical Normal Absent
activity
Fasciculation Absent Present
twitch in EMG
Speech Aphasia, Normal, unless
CHAPTER aphonia Laryngeal
4
Muscles are
affected
Posture Hemiplegic or High stepping
and gait scissoring
Palpation Hard Soft
GLASGOW COMA SCALE

EYE OPEN
Spontaneous 4
To speech 3
To pain 2
None 1
BEST VERBAL RESPONSE

Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible sound 2
None 1
NEUROLOGY
133
BEST MOTOR RESPONSE
Obeys commands 6
Localise the pain 5
Withdrawal to pain 4
Flexion to pain 3
Extension to pain 2
None 1
SCORE
Total 15
Minimum 3
CHAPTER
Coma 7 or less then 7
MODIFIED ASHWORTH SCALE FOR

GRADING SPASTICITY
4
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 increases, passive
movement difficult
4 Affected part is rigid in flexion or extension
NEUROLOGY
134
NEUROLOGICAL PAHTOLOGIES
ALZEIMER’S DISEASE
This is the commonest form of dementia charac-
terised by slow, progressive mental deterioration.
Neuritic plaques in parietal lobes and neuro-
fibrillary angles are present.
C/F
Memory loss both in short and long term apraxia,
CHAPTER aphasia, visuo spatial impairment, aggressive
4
behaviour
ARACHNOIDITIS
This is the chronic inflammation of the nerve root
sheaths in the spinal canal with or without nerve
root symptoms.
Chronic arachnoiditis occurs as a resultant of
meningitis, myelography or spinal surgery.
C/F
Severe low back pain, radicular pain, leg weak-
ness, gait disorder, incontinence.
ANTERIOR CORD SYNDROME

This occurs due to the flexion injury at the cervical
region resulting into damage of anterior portion
of spinal cord or its vascular supply.
NEUROLOGY
135
C/F
• Loss of motor function
• Loss of sense of pain and temperature
BELL’S PALSY
It occurs due to lower motor neurone paralysis
due to viral infection or exposure to extreme cold.
There is inflammation over the stylomastoid
foramen. Usually unilateral.
C/F CHAPTER
Asymmetry of face, weakness or paralysis of facial

muscle, unable to close eye of affected side
4
difficulty in chewing, drooling of saliva from
affected side, verbal communication is affected.
BROCA’S APHASIA
Caused due to lesion or damage of broca’s area
on the inferior frontal cortex.
C/F
Difficulty in speaking, non-fluent speech,
difficulty in writing, reducing word output.
BROWN SEQUARD SYNDROME

It occurs due to damage to one side of the
spinalcord commonly caused by stab injuries.
NEUROLOGY
136
C/F
Loss of sensory sensation on same side, loss of
sense of pain and temperature.
BULBAR PALSY
Occurs due to lower motor neurone lesion may
be unilateral or bilateral. the nerve supplying the
bulbar muscles of head and neck are mainly
affected.
CHAPTER C/F
4 Paralysis or weakness of muscles of face, jaw,

pharynx, larynx and palate, impairement in
swallowing, coughing speaking and gag reflex.
CEREBRAL PALSY
It is a group of condition characterised by motor
dysfunction due to non progressive brain damage
early in life classified into various types:
1. According to limb involvement (quadri, para,
di, monoplegia).
2. According to area of involvement (spastic,
athetoid, ataxic, floppy, mixed).
C/F
Retarded development, the performance of
various movement in pattern, there will be
persistence of infantile behaviour in all function
including primitive reflexes.
NEUROLOGY
137
CENTRAL CORD SYNDROME
It occurs from hyperextension injury to the
cervical region. Associated with congential or
degenerative narrowing of spinal canal. Resulting
due to compressive force causing haemmorrhage
and oedema.
C/F
Sensory impairment, neurological deficit of upper
and lower extremity.
CHAPTER
4
CHARCOT-MARIE-TEETH DISEASE
This is a progressive disorder of peripheral nerve
which is hereditary. This is also known as
hereditary motor sensory neuropathy (HMSN).
C/F
Difficulty in running, foot deformity, muscle
wasting, lower extremity weakness.
DISSEMINATED ENCEPHALOMYELITIS
It 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).
C/F
Neurological and motor dysfunction, limb
weakness.
NEUROLOGY
138
GUILLAIN-BARRÉ SYNDROME (GBS)
It is an acute post infective polyneuritis or
polyneuropathy. It occurs after one month of
febrile episodes of respiratory or GIT infections.
There is distruction of myelin sheath and inflam-
matory cell. Infiltration of nerve mostly affects the
proximal part of nerve root, that is why also
known as radicular neuropathy.
C/F
CHAPTER Neurological dysfunction, lower limb weakness
4 difficulty in walking muscle weakness, facial

paralysis.
HEMIPLEGIA
It is the 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, haemor-
rhage, hypertension, intracranial infections,
trauma or hysteria.
C/F
Upper and lower limb weakness, facial paralysis,
in some causes there may be sensory loss.
HORNER’S SYNDROME
There are the group of symptoms occurring due
to lesion of the sympathetic pathways in the
NEUROLOGY
139
brainstem, spinal cord, hypothalamus, cervical
ganglion or C8-T2 ventral spinal roots.
C/F
Pupil constrictions of same side, loss of facial
sweating on affected side of face, drooping of the
upper eyelid.
HUNTINGDON’S DISEASE
This is a disease caused by defect in chromosome
IV, that can be transmitted by either of the parent. CHAPTER
It can be hereditary in nature.
C/F
4
Chorea, progressive dementia, change in
behaviours.
HYDROCEPHALUS
This occurs due to deposition of excessive
cerebrospinal fluid in head due to which there is
dilatation of ventricles of brain. This is classified
into two types: communicating and non-
communicating. Causes may be congenital,
intrauterine infection, intracranial bleeding,
haemorrhage, congenital malformation.
C/F
Vomiting, nausea, irritability, behavioural
changes, bradycardia, delayed milestone develop-
ment, drowsiness, papilloedema.
NEUROLOGY
140
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
demyelinating diseases, vascular diseases.
C/F
Inability in speaking, difficulty in hearing.
MENINGITIS
CHAPTER
It is the inflammation of the leptomeninges and
4 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 meningococcial, pneumococcal
haemophilus influenzae, gram-negative menin-
gitis, chronic neoplasm infection, AIDS, syphilis.
C/F
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
NEUROLOGY
141
horn cell of spinal cord, motor nuclei of medulla
and the cortico-spinal tracts.
C/F
Wasting of muscles especially upper limbs and
those innervated from the medulla, combined
with symptoms of cortico-spinal tract degene-
ration various types are:
Anyotropic lateral sclerosis: Occur due to lower
motor neurone lesion. There is weakness of limbs
and face muscular atrophy may also be seen. CHAPTER
Progressive bulbar palsy: Caused due to damage of

motor nuclei is area of brainstem. There is pain
4
and spasm, dyspnoea, dysphagia, sore eyes and
dysarthria, paralysis of muscles of face, larynx and
pharynx and muscle wasting.
MULTIPLE SCLEROSIS
This is a slow progressive CNS disease charac-
terised by disseminated patches of demyelination
in the brain and spinal cord resulting in multiple
and varied neurologic symptoms and signs with
remission and exacerbation. Women are affected
more; age of onset is 20 to 40 years.
C/F
Ataxia, motor and sensory, disturbance, visual
disturbances, fatigue, bowel and bladder
NEUROLOGY
142
dysfunction, pain and spasm, behavioural
changes, bulbar dysfunction.
MUSCULAR DYSTROPHY
This is a group of inherited and progressive
muscle disorder. There is selective distribution of
weakness. Muscle fibers are replaced by fat and
connective tissue. Commonly, affected boys below
of the 4 years classified as:
• Duchenne dystrophy
CHAPTER • Becker muscular dystrophy
4 • Fascio-scapulo humeral muscular dystrophy

• Limb girdle musclar dystrophy.
C/F
Pseudohypertrophy of proximal muscles,
difficulty in walking, postural abnormalities
diminished reflexes, Gower’s sign.
MYASTHENIA GRAVIS
A progressive inability to sustain a maintained or
repeated contraction of striated muscles or
characteristic pattern of progressively reduced
muscle strength with repeated use of muscle and
recovery of muscle strength, following a period
of rest. Male: female is 2:3. Age of onset, neonates,
20-30 years or 50 years.
NEUROLOGY
143
C/F
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 50-60 years. Syndrome is characterised CHAPTER
by tremor, muscular rigidity, bradykinesia,
postural instability. 4
C/F
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 5 year of age. It is caused by 3 types of
poliovirus. It enters faeco-oral route. It destroys
the motor neuron of arterior horn, showing the
symptoms of lower motor neuron lesion. Divided
into various stages according to the involvement.
They are acute stage/pre-paralytic/paralytic stage/
convalescent stage/stage of early/recovery residual
stage/post polio residual phase.
NEUROLOGY
144
C/F
Weakness or paralysis of lower limb more than
upper limb, difficulty in speaking and
swallowing, respiratory complications due to
paralysis of muscles of thorax and abdomen.
POSTERIOR CORD SYNDROME

It is very rare and occurs when there is any deficits
in function served by posterior column. This is
usually seen with tabes dorsalis, a late stage
CHAPTER
syphillis condition.
4 C/F
Loss of proprioception and two point discrimi-
nation of stereognosis. Gait pattern is wide
based.
POST POLIO SYNDROME

This is the persistance of symptom like paralysis
or weakness after 2 years of illness. In this the
symptoms progresses after the recovery from
acute paralytic stage.
C/F
Pain in muscles and joints, neurological dys-
functions, progressive muscular weakness, severe
fatigue.
NEUROLOGY
145
PSEUDOBULBAR PALSY
It occurs when the cortiomotor neuron pathways
are affected due to upper motor neuron lesion
resulting in spasticity and weakness of the
pharyngeal and oral musculature.
C/F
Dysphagia and slurring of speech, emotional
incontinence inability to control the expressions
like laughing or crying.
CHAPTER
SACRAL SPARING
This is an incomplete lesion in it the centrally
4
located sacral tracts are preserved or remains
unaffected. The differing level of innervations
remains intact.
C/F
Loss of acute contraction of toe flexors supplied
by sacral nerve, cutaneous sensation is lost, Rectal/
sphincter contraction is affected, perianal
sensation is lost.
SPINAL MUSCULAR ATROPHIS (SMA)

This is a group of degenerative disorders of the
anterior horn cells, that are inherited and caused
muscle atrophy. This is classified according to the
age of onset and it is of three types:
NEUROLOGY
146
SMA I: Also known as werdnig-hoffman disease.
This is the most severe, one in onset and cause
weakness and hypotonia.
SMA II: Intermediate type. It progresses a bit slower
and has same features age of onset is 6-15 months.
SMA III: Wohlfart-kugelberg-welander disease
has late onset leads to progressive limb weakness
and occurs between 1 year.
STROKE/CEREBROVASCULAR ACCIDENT
CHAPTER It is an acute onset of neurological dysfunction,
4 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—ischaemic and
haemmorrhagic. Major risk factors causing stroke
are atherosclerosis, hypertension, smoking,
endocarditis, cardiac disease.
C/F
Headache, nausea, vomiting, dizziness, papillo-
edema, shallow respiration, increased heart rate.
TRANSVERSE MYELITIS
It is a syndrome not a disease in which acute
inflammation affectes gray and white matter in
one or more adjacent thoracic segments. Aetiology
is unknown, but in some cases there is viral
infection, vasculitis.
NEUROLOGY
147
C/F
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
It occurs when the sensory division of the trigemi-
nal nerve gets demyelinated and is characterised
by severe stabbing facial pain when eating and
shaving. CHAPTER
WERNICKE’S DYSPHASIA 4
This occurs due to the lesion of posterolateral left
temporal and inferior parietal region of the left
cortex, i.e. the wernicke’s area. The person
suffering from unaware of the language problem.
C/F
Nonsencial but fluent speech impairment of
comprehension and writing.
NEUROLOGICAL ASSESSMENT
Reg. No.
Name
Age/sex
Date of admission
Address
Occupation
NEUROLOGY
148
Referred by (consultant) and hospital
Type of operation/illness
Date of discharge
Discharge summary
Subjective examination
History of present condition
Drug history
CHAPTER Social situation
4
Normal daily routine.
GENERAL EXAMINATION
Pulse rate
Respiratory rate
Temperature
Blood pressure
State of conciousness—Glasgow Coma Scale.
On Observation
Attitude of lims
Facial expression
Deformity
Posture
Lying
Sitting
Standing
NEUROLOGY
149
Pain
Type
Onset
Nature
Radiation
Intensity
Aggravating/relieving factor
Associated symptoms
Severity—visual analogue scale.
On Palpation CHAPTER
4
Temperature
Tenderness
Oedema—pitting/non pitting
Inflammatory sign
Muscle wasting
Contractures.
On Examination
Range of movement
Muscle girth
Limb length
End feel—Capsular
Noncapsuar
Differential tests
Gait
Pattem
Distance
Velocity
NEUROLOGY
150
Walking aids
Orthoses
MMT
Reflexes
Superficial
Deep.
STATE OF HIGHER FUNCTION

Orientation
Consciousness
CHAPTER Behaviour
4
Memory
Intelligent capacity
Counting and calculation
Speech
Reading and writing
Vision
Speech and articulation
Cranial nerve examination
Muscle tone
Spasticity
Rigidity
Flaccidity.
SENSORY ASSESSMENT
Pain
Temperature
Vibration
Touch— Light
Crude
NEUROLOGY
151
Pressure
Two point discrimination
Spine: Tenderness
Deformity
Limb attitude
Lying
Sitting
Standing
Co-ordination (UL/LL)
Balance
Bladder and bowel CHAPTER
Dermatomes and myotomes
Exercise tolerance test
Specific investigations/blood test/X-rays/CT
4
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
NEUROLOGY
152
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
Ataxia: Incoordinated voluntary movements
Athetosis: Involuntary writhing movements
CHAPTER
4
Bradykinesia: Slowed voluntary movements
Catatonia: Freezing of movements
Charcot’s joint: Damaged joints with neurological
involvement
Chorea: Jerky, irregular, involuntary movement
Clonus: Rhythmic rapid repetitive muscle
contraction associated with increased tone
Dementia: Loss of mental function
Diplegia: Weakness and spasticity, affecting all
limbs but legs more than arms
Diplopia: Double vision
Dysaesthesia: Abnormal burning or aching
sensations
Dysarthria: Difficulty in articulating speech
Dysdiadochokinesia: Impaired ability to perform
rapid alternating movement
NEUROLOGY
153
Dysemetria: Impaired ability to judge the distance
Dysphagia: Difficulty in swallowing
Dysphasia: Difficulty in understanding language
Dysphonia: Diffculty in producing the voice
Dyspraxia: Inability to perform skilled move-
ments
Dyssynergia: Impaired abilityto complex move-
ments
Dystonia: Abnormal postural movements caused
by mainly co-contraction of agonists and CHAPTER
antagonists group of muscles.
Embolism: Cerebral-blood clot in the circulation
blocking an artery in the brain
4
Encephalopathy: Disorder of brain substances
Ependymoma: Tumor of brain and spinal card
Euphoria: An exaggerated felling of well being
Fasciculation: Visible involuntary contraction of
bundles of muscle fibres
Fibrillation: Involuntary contraction of individual
muscle fibrers
Glioma: One type of brain tumor
Gliosis: Proliferation of neuroglial tissue
Graphesthesia: Inability to recognize number,
figures or letter traced onto the skin with blunt
object
NEUROLOGY
154
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
Hyperacusis: Increased sensitivity to sound
Hyperreflexia: Increased reflexes
CHAPTER Hypertonia: Increased muscles tone
4 Hypertrophy: Increased size

Hypotonia: Decreased muscles tone
Kinaesthesian: Perception of body position and
movements
Miosis: Constraction 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
Paraesthesia: Tingling sensation
Paraparesis: Weakness of both legs
NEUROLOGY
155
Paraphasia: Inappropriate or incorrect word in
speeching
Paraplegia: Paralysis of both legs
Paresis: Muscles weakness
Photophobia: Intolerance to light
Prosopagnosia: Inability to recognise the person
Ptosis: Drooping of upper eyelid
Quadrantanopia: Loss of quarter then normal
visual field CHAPTER
4
Quardriparesis: 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: Quiverning or continuous shaking
Vertigo: Sensation of movements of one’s body
or of object’s moving about or spinning.
MUSCULOSKELETAL
157
CHAPTER 5
Musculoskeletal
Alphabetical listing of muscles
Joint range of movement
Common musculoskeletal tests
Musculoskeletal pathologies CHAPTER
Grades of sprain and treatment
Stages of fracture healing
5
Fracture with eponyms
Musculoskeletal assessment
MUSCULOSKELETAL
158
ALPHABETICAL LISTING OF THE MUSCLES
ABDUCTOR DIGITI MINIMI (FOOT)
Origin: Calcaneal tuberosity, planter aponeurosis,
intermuscular septum.
Insertion: Lateral side of base of proximal phalanx
of fifth toe.
Nerve: Lateral planter nerve (S1-S3).
Action: Abducts fifth toe.
ABDUCTOR DIGITI MINIMI (HAND)

Origin: Pisiform, tendon of flexor carpi ulnaris,
pisohamate ligament.
CHAPTER
Insertion: Ulnar side of base of proximal phalanx
5 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 show grade III power.
ABDUCTOR HALLUCIS
Origin: Flexor retinaculum, calcaneal tuberosity,
planter aponeurosis, intermuscular septum.
Insertion: Medial side of the base of proximal
phalanx of great toe.
Nerve: Medial planter nerve (S1, S2).
MUSCULOSKELETAL
159
Action: Abduct and flexes great toe.
MMT: Stand erect with equal body weight on both
legs. Try to abduct the great toe. Full abduction
show 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.
CHAPTER
MMT: Put your palm in mid prone position over
a table, abduct your thumb. Full abduction show
grade III power. 5
ABDUCTOR POLLICIS LONGUS
Origin: Upper part of posterior surface of ulna,
middle third of posterior surface of radius,
interosseous membrance.
Insertion: Radial side of 1st MC base, trapezium.
Nerve: Posterior interosseous nerve (C7, C8).
Action: Abducts and extends thumb, abducts
wrist.
MMT: Put your palm in mid-prone position over
a table, try to abduct and extend your thumb. Full
range of motion shows grade III power.
MUSCULOSKELETAL
160
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 lie 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
CHAPTER the medial aspect of the right thigh.
5 ADDUCTOR HALLUCIS
Origin: Oblique head—base of second to fourth
metatarsal, sheath of peroneus longus tendon;
transverse head-planter metatarsophalangeal
ligaments of lateral three toes.
Insertion: Lateral side of base of proximal phalanx
of great toe.
Nerve: Lateral planter nerve (S2, S3).
Action: Adducts great toe.
MMT: Stand erect over a platform with your great
toe in abducted position. The therapist keep his
index finger at the lateral side of the toe and resist
MUSCULOSKELETAL
161
your adduction of great toe. Full range of motion
shows grade III power.
ADDUCTOR LONGUS
Origin: Front of pubis.
Insertion: Middle third of linea aspera.
Nerve: Anterior division of obturator nerve (L2-L4).
Action: Adducts thigh.
MMT: Patients in side lying. Upper most limb in
25° abduction supported by examiner. Therapist
standing behind patient at knee level his hand
give resistance to the lower most limb at the
medial surface of distal femur, just proximal to
CHAPTER
the knee resistance is directed straight downward
towards the table.
Full range of action against gravity shows
grade III power while against resistance show
5
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.
Nerve: Obturator nerve and tibial division of
sciatic nerve (L2-L4).
Action: Adducts thigh.
MMT: Same as above.
MUSCULOSKELETAL
162
ADDUCTOR POLLICIS
Origin: Oblique head—palmer ligaments of
carpus, flexor carpiradialis tendon, base of second
to forth metacarpals, capitate, transverse head-
palmer 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 metacarpals of the four
finger by grasping the patient’s hand around the
CHAPTER ulnar side, ask patient to adduct the thumb. Full
5
range of motion with no resistance show grade
III power.
ANCONEUS
Origin: Posterior surface of lateral epicondyle of
humerus.
Insertion: Lateral surface of olecranon, upper
quarter of pasterior surface of ulna.
Nerve: Radial nerve (C6-C8).
Action: Extends elbow.
MMT: Patients prone on table with arm in 90°
abduction and forearm flexed and hanging
vertically over the side of the table. Therapist
provide support just above the elbow. Patients
MUSCULOSKELETAL
163
extends elbow to end of available range. Full
range of motion with no resistance show 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
comman flexior origin.
Nerve: Musculocutaneous nerve (C5, C6).
Action: Flexes shoulder and elbow, supinate
forearm. CHAPTER
MMT: Patient in short sitting, with forearms at
side and testing forearm in supination. Therapist
cups the test elbow. Patient flexes elbow through
5
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
wrist, then elbow and upto shoulder till a stretch
is felt over anterior arm.
BICEPS FEMORIS
Origin: Long head: Ischial tuberosity, sacro-
tuberous ligament.
MUSCULOSKELETAL
164
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: Scliatic nerve (L5-S2)
Long head—tibial division.
Short head—commonperoneal 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
CHAPTER
toward examiner).
5 Full range of motion without resistance show

grade III power.
BRCHIALIS
Origin: Lower half of anterior surface of humerus,
intermuscular septum.
Insertion: Coronoid process and tuberosity of ulna.
Nerve: Musculocutaneous nerve (C5, C6) redial
nerve (C7).
Action: Flexes elbow.
MMT: All is same as for biceps brachii expect
forearm in pronation.
Stretching: Same as for biceps brachii.
MUSCULOSKELETAL
165
BRACHIO-RADIALIS
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 expect fore-
arm in mid-position between pronation and
supination.
CORACO BRACHIALIS
Origin: Apex of coracoid process. CHAPTER
Insertion: Midway along medial border of
humerus. 5
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.
Patient flexes shoulder to 90°. Complete test range
(90°) shows grade III power.
DELTOID
Origin: Clavicle (anterior superior border of lateral
1/3 of shaft).
Insertion: Humerus (deltoid tuberosity on shaft).
Nerve: Axillary nerve (C5, C6).
MUSCULOSKELETAL
166
Action: Anterior fibres: Flex and medially rotate
shoulder.
Middle fibres: Abduct shoulder;
Posterior fibres: 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 fibres-hand in side way and
action is extension upto 90° with lateral
rotation
CHAPTER
• Full range (test range 90°) of function show
5 grade III power.

DIAPHRAGM
Origin: Posterior surface of xiphoid process, lower
six costal cartilages and adjoining ribs on each
side, medial and lateral arcuate ligament,
anterolateral aspect of bodies of lumbar vertebrae.
Insertion: Central tendon.
Nerve: Phrenic nerve (C3-C5).
Action: Draw central tendon inferiorly, changes
volume and pressure of thoracic and abdominal
cevities.
MMT: Patient lie supine. Therapist standing next
to patient at approximately waist level. One hand
MUSCULOSKELETAL
167
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 show grade III power.
DORSAL INTEROSSEI (FOOT)

Origin: Proximal half of sides of adjacent
metatarsals.
Insertion: Bases of proximal phalanges and dorsal
digital expansion (first attaches medially to
second toe; second, third and fourth attach
laterally to second, third and fourth toes
respectively). CHAPTER

Action: Abducts toes, flexes metatarsophalangeal
5
joints.
DORSAL INTEROSSEI (HAND)

Origin: Adjacent side of two metacarpal bones
(four bipennate muscles).
Insertion: Bases of proximal phalanges and dorsal
digital expansions (first attaches laterally to index
finger; second and third attach to both sides of
middle finger; fourth attaches medially to ring
finger).
MUSCULOSKELETAL
168
Action: Abducts index, middle and ring fingers,
flexes metacarpo phalangeal 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.
CHAPTER MMT: Patient in short sitting. Elbow is flexed,
5
forearm is fully pronated, and both are support
on the table.Therapist support the patient’s
forearm. The patient then extends and abducts the
wrist. Completion of full range of motion with no
EXTENSOR CARPI RADIALIS LONGUS

Origin: Lower third of lateral supracondylar ridge
of humerus, intermuscular septa.
Insertion: Posterior surface of base of second meta
carpal.
Action: Extends and abducts wrist.
MUSCULOSKELETAL
169
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 expect that patient with extend the wrist
with ulnar deviation.
CHAPTER
EXTENSOR DIGITI MINIMI
tendon, intermuscular septa.
5
Insertion: Dorsal digital expansion of fifth digit.
Action: Extends fifth digit and wrist.
MMT: Patient’s forearm in pronation, wrist in
neutral, MP joints and IP joints are in relaxed
flexion position. Therapiat stabilize the wrist in
neutral. Patient extends the MP joint of 5th digit.
Complete active range with no resistance show
grade III power.
MUSCULOSKELETAL
170
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 digitiminimi,
patient extends MP joint (all finger simulta-
neously), allowing the IP joints to be inslight
flexion. Complete active range, with no resistance
CHAPTER show grade III power.
5 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).
Action: Extends great toe and adjacent three toes.
MMT: Patient in short sitting, with foot on exami-
ner’s lap. Alternate position supine. Ankle in
neutral position, therapist sitting on low stool
infront of patient, or standing beside table near
MUSCULOSKELETAL
171
the patient’s foot. One hand stabilizes the
metatarsals with the fingers on the planter surface
and the thumb on the dorsum of foot. If patients
can extends the toes to complete range without
resistance it shows grade III power.
EXTENSOR DIGITORUM LONGUS

Origin: Upper three quarter of medical surface of
fibula, interosseous membrance, lateral tibial
condyle.
Insertion: Middle and distal phalanges of four
lateral toes.
CHAPTER
MMT: Same as for extensor digitorum longus.
EXTENSOR HALLUIS LONGUS 5

Origin: Fibula (shaft, middle ½ of medial aspect),
interosseous membrane.
Insertion: Hallux (distal phalanx, dorsal aspect of
bases), expansion to proximal phalanx.
Nerve: Deep peroneal nerve (L5).
Action: Extends great toe, ankle dorsiflexor.
MMT: Patient’s and therapist position is same as
for extensor digitorum longus and brevis.
Therapist stabilize the metatarsal area by
contouring the hand around the planter surface
of the foot, with the thumb curving around to the
MUSCULOSKELETAL
172
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 show
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.
CHAPTER MMT: Patient’s forearm in pronation, wrist in
5
neutral, MP joint and IP joint are in relaxed flexion
posture. Therapist stabilize 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.
Insertion: Dorsolateral base of maximal phalanx of
thumb.
Action: Extends thumb and wrist, abducts wrist.
MUSCULOSKELETAL
173
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
stabilize the first metacarpal firmly, allowing
motion to occur only at the MP joint. If the patient
move 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. CHAPTER
5
Action: Extends thumb and wrist, abducts wrist.
MMT: Same as for extensor pollicis brevis.
EXTERNAL OBLIQUE
Origin: Ribs 5-12 (inter digitating on external and
inferior surface).
Insertion: Iliac (rest outer border) thoraco lumbar
fascia, linea alba, aponeurosis from 9th costal
cartilage to ASIS, both sides meet at midline to
form linea alba, public symphysis (upper border).
Nerve: Ventral rami of lower six thoracic nerve (T7-
T12).
Action: Flexes, laterally flexes and rotates trunk.
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MMT: Patient in supine with arms outstretched
above plane of body. Ask the patient lift your head
and shoulders from the table taking your right
elbow toward your left knee. Then lift your and
shoulder from the table, taking your left elbow
toward your 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.
CHAPTER Nerve: Median (C6, C7).
5 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 support the patient’s forearm under the
wrist. The patient flexes the wrist in radial
deviation. full range of motion without resistance,
show grade III power.
FLEXOR CARPI ULNARIS

Origin: Humeral head: medial epicondyle via
commen flexor tendon.
Ulnar head: Medial border of olecranon and
upper 2/3rd of border of ulna.
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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 position same as for
flexor carpi radialis. Patient flexes the wrist in
ulnar deviation. Full range of motion without
resistance, shows grade III power.
FLEXOR DIGITI MINIMI BREVIS (FOOT)

Origin: Planter aspect of base of fifth metatarsal,
sheath of peroneus longus tendon.
Insertion: Lateral side of base of proximal phalanx CHAPTER
of fifth toe.
Nerve: Lateral planter nerve (S2, S3). 5
Action: Flexes fifth meta tarsophalangeal joint,
support lateral longitudinal arch.
FLEXOR DIGIT MINIMI BREVIS (HAND)

Origin: Hook of hammate, flexor retinaculum.
Insertion: Ulnar side of base of proximal phalanx
of little finger.
Nerve: Ulnar nerve (C8,T1).
Action: Flexes little finger.
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FLEXOR DIGITORUM ACCESSORIUS
Origin: Medial head-medial tubercle of calcaneus,
lateral head—lateral tubercle of calcaneus and
long planter ligament.
Insertion: Flexor digitorum longus tendon.
Nerve: Lateral planter nerve (S1 –S3).
Action: Flexes distal phalanges of lateral fourth
toes.
FLEXOR DIGITORUM BREVIS

Origin: Calcaneal tuberosity, planter aponeurosis,
intermuscular septa.
CHAPTER Insertion: Tendons divide and attach to the both
5
sides of the middle phalanges of second to fifth
toes.
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
proximal phalanges or digital phalanges. Patient
is asked to flex the toes. Full range of flexion
without resistance show grade III power.
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FLEXOR DIGITORUM LONGUS
Origin: Medial part of posterior surface of tibia,
deep transverse fascia.
Insertion: Planter aspect of base of distal phalanges
of second to fifth toes.
Nerve: Tibial nerve (L5-S2).
Action: Flexes lateral four toes, planter flexes
ankle.
MMT: Same as for flexor digitorum brevis.
FLEXIOR DIGITORUM PROFUNDUS

Origin: Ulna (proximal 3/4th of anterior and
medial shaft, medial coracoid process), intero- CHAPTER
sseous membrane (ulnar).
Insertion: Four tendons to digits 2-5 (distal 5
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
stabilze middle phalanx in extension by grasping
in on either side. Patient flexes distal phalanx of
each finger individually. Full range of motion
without resistance, show grade III power.
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FLEXOR DIGITORUM SUPERFICIALIS
Origin: Humero-ulnar head—humerus(medial
epicondyle via common flexior tendon).
Ulna (medial collateral ligament of elbow
joint); coronoide process (medial side).
Intermuscular septum
Radial head—radius (oblique line on anterior
shaft).
Insertion: Four tendon arranged in two pairs:
Superfacial pair-middle and ring fingers (side
of the middle phalanges).
Deep pair—index and little fingers (side of
middle phalanges).
CHAPTER Nerve: Median (C8, T1).
5 Action: Flexes fingers and wrist.

MMT: Patient’s forearm supinated, wrist a
neutral, finger to be tested is in slight flexion at
the MP joint. Therapist hold all fingers (except one
being tested) in extension at all joints. Isolation of
the index finger may not be complete. Each of four
finger 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 flexor digitorum
profundus is not active; that is the DIP joint goes
into extension. The distal phalanx should be
floppy. Ask the patient “ bend your index [then
MUSCULOSKELETAL
179
long, ring or little] finger, hold it. Full range of
motion without resistance shows grade III power.
FLEXOR HALLUCIS BREVIS

Origin: Medial side of planter surface of cuboid,
lateral cuneiform.
Insertion: Medial and lateral side of base of
proximal phalanx of great toe.
Action: Flexes metatarsophalangeal joint of great
toe.
MMT: Patient in short sitting, with legs hanging
over edge of table. Ankle is in neutral position,
CHAPTER
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
5
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).
Lateral head–femur (lateral surface of lateral
condyle).
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180
Insertion: Posterior surface of calcaneus.
Nerve: Tibial nerve (S1, S2).
Action: Plantar flexes ankle, flexes knee.
MMT: The patient stand over testing limb with
one or two fingers support over a table patient
attempt to raises heal from base consecutively
through full range of planter flexion. Ask him to
“stand on your right leg. Go up on your tiptoes.
Now down repeat this 20 times”. If the patient
completes between nine and one heal raise
correctly with no rest or fatigue it show grade III
power.
Stretching: Standing on the steps with the ball of
CHAPTER
the toes.
5 GEMELLUS INFERIOR
Origin: Upper part of ischial tuberosity.
Insertion: With obturator internus tendon into
medial surface of greater trochanter.
Nerve: Nerve to quadratus famoris (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
aspect). Patient attempt of externally rotate the
hip. If the patient can holds the end position is
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181
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 grasping the lower
leg. Therapist perform medial rotation.
GEMELLUS SUPERIOR
Origin: Ischial spine (gluteal surface).
Insertion: Greater trochanter (with obturator
internus tendon into medial surface).
Nerve: Nerve to obturator interus (L5, S1).
Action: Laterally rotates hip. CHAPTER
MMT and stretching: Same as G. inferior.
GLUTEUS MAXIMUS
5
Origin: Illium (posterior gluteal line, posterior
border, adjacement 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).
Action: Extends, laterally rotates and abducts hip.
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MMT: Patient is on prone lying.Therapist stand
at side of testing limb at he level of pelvis. Ask
patient to lift the leg towards ceiling. If the patient
can hold the full range of motion, it show grade
III power.
Stretching: (Passive): Patient lie supine. Therapist
stand beside the patient and facing the limb.
Therapist 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: Kneel sitting.
CHAPTER
Procedure: Patient flexing hip and knee himself, in
5 supine with his hand maintains a good stretch.
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
upper most position. The therapist stands behind
patient. For palpating the muscle he put his hand
just proximal to the greater trouchanter of the
femur. Ask him to abduct hip through complete
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183
range of motion without flexed hip or rotation.
Full range of motion and holds at end position,
Stretching: Patient lie supine. Therapist stand
beside the patient and faces the hip joint.
Therapist left hand stabilizes the opposite leg of
patient, while his right hand grasing 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. CHAPTER
Nerve: Superior gulteal nerve (L4-S1).

Action: Abducts and medially rotates hip.
5
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.
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184
Stretching: Patient in supine lying. Therapist stand
beside the patient and facing the hip joint. His left
hand stabilizes the opposite leg, while his right
hand grasping the lower thigh and the leg is
placed on the therapist forearm. Leg is pulled
apart by the therapist’s right hand.
ILIACUS
Origin: Iliacus fossa (superior 2/3), iliac crest
(inner lip), ala of sacrum, sacroiliac and iliolumbar
ligaments.
Insertion: Blends with insertion of psoas major into
lesser trochanter.
CHAPTER Nerve: Femoral nerve (L2, L3).
5 Action: Flexes hip and trunk.

MMT: Patient in short sitting with thigh over table
and leg hanging at the edge. Therapist stand 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.
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185
ILIOCOSTALIS CERVICIS
Origin: Angles of third to sixth ribs.
Insertion: Posterior tubercles of transverse process
of C4 to C6.
Nerve: Dorsal rami.
Action: Extends and laterally flexes vertebral.
MMT: Patient in prone with head off at the edge
of table. Therapist put one hand below patient’s
forehead. Ask patient to extends neck without
tilting chin, or looking up full range of motion,
ILIOCOSTALIS LUMBORUM CHAPTER

Origin: Sacral crest (medial and lateral) spines of
T11, T12 and lumber vertebrae and their supra-
spinous ligament, medial part of iliac crest.
5
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 stand 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.
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186
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.
ILIOCOSTALIS THORACIS
Origin: Angle of lower six ribs.
Insertion: Angle of upper six ribs, transverse
process of C7.
Nerve: Dorsal rami.
Action: Extend and laterally flexes vertebral
column.
MMT: Same as for illocostalis lumborum.
CHAPTER
5 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 grater
tubercle), shoulder joint (posterior aspect of
capsule).
Nerve: Supra scapular nerve (C5, C6).
Action: Laterally rotates shoulder.
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187
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
at the edge. Ask patient to move forearm upward
through the range of external rotation. Full range
of motion, shows grade III power.
Stretching: Patient in supine lying. Therapist
stands beside patients and faces the limb. The
therapist now grasp 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.
CHAPTER
5
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 lie supine. Therapist stands at the
side. Tape measure placed lightly arounf thorax
at level of xiphoid. Ask patient to holds maximal
inspiration for measurement and then holds
maximal expiration for a second measurement.
The difference between the two measurment is
record as chest expansion.
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188
INTERCOSTALIS INTERNI
Origin: Lower border of costal cartilage and costal
groove of rib above.
Insertion: Upper border of rib below.
Nerve: Intercostals nerves.
Action: Draw ribs downwards to decrease thoracic
cavity volume for expiration.
MMT: Same as for I. Externi.
INTERNAL OBLIQUE
Origin: Inguinal ligament (lateral 2/3), iliac crest
(anterior 2/3 of intermediate line), thoracolumbar
fascia.
CHAPTER
5
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 supine with arms out stretched 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 lie 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 opposide side of the
muscle will feel stretch.
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189
INTERSPINALIS
Origin and insertion: Extend between adjacent
spinous processes.
Nerve: Dorsal rami of spinal nerves.
Action: Extend and stabilize vertebral Column.
MMT: Same as for iliocostalis muscles.
INTERTRANSVERSALIS
Origin: Cervical and lumbar verterbrae
(transverse process).
Insertion: Transverse process of vertebra, superior
to origin.
CHAPTER
Nerve: Ventral and dorsal rami of spinal nerve.
Action: Laterally flex lumber and cervical spine,
stabilize vertebral column.
5
ISCHIOCAVERNOSUS
In the female
Origin: Ischium (tuberosity [linner surface] and
ramus), crus clitoriditis (surface).
Insertion: Aponeurosis inserting into side and
inferior surface of crus clitoriditis.
Nerve: Pudendal nerve (S2-S4).
Action: Compress crus clitoris, retarding venous
return and thus assisting erection.
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190
In the males
Origin: Ischium (tuberosity, medial aspect dorsal
to crus penis and ischial rami).
Insertion: Aponeurosis into the sides and under
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).
CHAPTER
5
Insertion: Arytenoid cartilage on same side (front
of muscular process).
Nerve: Vagus (X) nerve (recurrent laryngeal
branch).
Action: Closes glottis by rotating arytenoid
cartilages medially, approximating (adducting)
the vocal flods 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.
MUSCULOSKELETAL
191
Nerve: Thoracodorsal nerve (C6—C8).
Action: Extends, adducts and medially rotates
shoulder.
MMT: Patient prone with head turned to one side.
Arms at side; test arm is internally rotated (palm
up). Therapist stand at test side. Ask the patient
to push his arm toward 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 CHAPTER
therapist forearm. Therapist right hand apply
opposite force on the scapular region to prevent
scapular movement. Stretch force is given
5
towards the flexion of the shoulder with the
therapist 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.
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192
LONGISSIMUS CAPITIS
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 rotated head.
MMT: Patient prone 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 your forehead from my
hand and keep looking at he floor. Full range of
motion, shows grade III power.
CHAPTER
5
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
lumber vertebrae and thoracolumbar fascia.
Insertion: Transverse processes of T1-T12 and lower
nine or ten ribs.
MUSCULOSKELETAL
193
Nerve: Dorsal rami.
column.
MMT: Same as for iliocostalis thoracic.
LONGUS CAPITIS
Origin: Occipital bone.
Insertion: Anterior tubercles of transverse
processes of C3-C6.
Nerve: Anterior primary rami (C1-C3).
Action: Flexes neck.
MMT: Patient in supine with head supported on
CHAPTER
table. Arm at side. Therapist stands at head of
table facing patient. Ask patient to tuck his chin
into his neck. Do not raise his head from table. 5
If patient completes available ROM without
resistance, it shows grade III power.
LONGUS COLLI
Origin: T 1-T 2/3 (inferior oblique part, front of
bodies).
T1-T3 and C5-C7 (vertical intermediate part
front of bodies).
C 3 –C 5 (superior oblique part-anterior
tubercles of transverse process).
Insertion: C5 and C5 (inferior oblique part-anterior
tubercles of transverse process), C2-C4 (vertical
MUSCULOSKELETAL
194
intermediate part: front of bodies); superior
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
CHAPTER of proximal phalanx of lateral four toes.
5 Nerve: I lunbrical-medial planter nerve (S2, S3),

Lateral 3 lumbricals-lateral planter 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, show grade III power.
MUSCULOSKELETAL
195
LUMBRICALS (HAND)
Origin: Tendons of flexor digitorum profundus.
Insertion: Lateral margin of dorsal digital
expansion of extensor digitorum.
Nerve: I and II—median nerve (C8, T1).
III and IV—ulnar nerve (C8, T1).
Action: Flexes metacarpophalangeal joint and
extends interphalangeal joints of fingers.
MMT: Patient short sitting with forearm in
supination. Wrist is maintained in neutral. The
MP joint are flexed. Therapist stabilize the
metacarpals proximal to the MP joints resistance
is given on the palmer surface of the proximal row CHAPTER
5
of phalanges in the direction of MP extension. Ask
patient to simultaneously flex the MP joint and
extends the IP joints. If the patient completes both
motion correctly and simultaneously without
resistance, it show grade III power.
MULTIFIDUS
Origin: Back of sacrum, aponeurosis of erector
spinae, posterior superior illac 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.
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196
Action: Extends, rotates and laterally flexes
vertebral column.
MMT: Same as for interspinales and intertrans-
versaril.
OBTURATOR EXTERNUS
Origin: Outer surface of obturator membrane and
adjacent bone of public 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
CHAPTER low stool or kneels beside limb to be tested. Ask
5 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: Neve to obturater internus (L5, S1).
MMT: Same as for O. externus.
OPPONENS DIGITI MINIMI

Origin: Hook of hamate; flexor retinaculum.
MUSCULOSKELETAL
197
Insertion: Medical border of fifth metacarpal.
Nerve: Ulnar nerve (C8 T1).
Action: Abducts fifth digit, pull it forwards and
rotates it laterally.
MMT: Patient’s forearm supinated, wrist in
neutral. He raise 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 show grade III power.
OPPONENS POLLICIS
CHAPTER
5
Origin: Flexor retinaculum, tubercles of scaphoid
and trapezium, abductor pollices 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 stabilize 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.
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198
PALMAR INTEROSSEI
Origin: Shaft of metacarpal of digit on which it
acts.
Insertion: Dorsal digital expansion and base of
proximal phalanx of same digit.
Nerve: Ulnar nerve (C8,T1).
Action: Adducts thumb, index, ring and little
finger.
MMT: Patient’s forearm pronated, wrist in neutral
and fingers extended and adducted. MP joints are
neutral; avoid flexion. Ask patient to hold his
fingers together. If the patient can adducts finger
CHAPTER towards middle finger, but cannot hold against
5
PALMARIS LONGUS
Origin: Medial epicondyl via common flexor
tendon.
Insertion: Flexor retinaculum, palmar aponeurosis.
Nerve: Median (C7, C8).
Action: Flexes wrist.
Stretching: Patients 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 grasp
the palm and fingers.The therapist extends the
wrist of the patients with his right hand.
MUSCULOSKELETAL
199
PECTINEUS
Origin: Pecten pubis, iliopectineal eminence,
public tubercle.
Insertion: Along a line from leser trochanter to
linea aspera.
Nerve: Femoral nerve (L2,3) occassionally 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 CHAPTER
attachment—anterior surface of manubrium,
body of sternum, upper six costal cartilages, sixth
rib, aponeurosis of external oblique muscle.
5
Insertion: Lateral lip of inter tubercular sulcus of
humerus.
Nerve: Medial and lateral pectoral nerve (C5-T1).
Action: Adducts medially rotates, flexes and
extends shoulder.
MMT: Patient lie supime, shoulder at 90° of
abduction and elbow 90° of flexion. Therapist
stand at side of testing shoulder. For testing both
heads of P. major ask the patienbt to move his arm
across his chest and hold it. Full range of motion,
without resistance show grade III power.
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PECTORALIS MINOR
Origin: Outer surface of third to fifth ribs and
adjoining intercostal fascia.
Insertion: Upper surface and medial border of
coracoid process.
Nerve: Medial and lateral pectoral nerves (C5-T1).
Action: Protracts and medially rotates scapula.
PERONEUS BREVIS
Origin: Lower 2/3 of lateral surface at fibula,
intermuscular septa.
Insertion: Lateral side of base of fifth metatarsal.
CHAPTER
5
Nerve: Superficial peroneal nerve (L5, S1).
Action: Everts and planter 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 but tolerates
no resistance.
Stretching: Assisted full range of inversion in
sitting or supine position.
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PERONEUS LONGUS
Origin: Lateral tibial condyle, upper 2/3 of lateral
surface of fibula, intermuscular septa.
Insertion: Lateral side of base of first meta tarsal,
medial cuneiform.
Nerve: Superficial peroneal nerve (L5, S1).
Action: Everts and planter 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. CHAPTER

Action: Everts and dorsiflexes ankle.
5
MMT: Same as for peroneus longus.
PIRIFORMIS
Origin: Front of second to fourth sacral segment,
gluteal surface of ilium, pelvic surface of sacro-
tuberous 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.
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PLANTAR INTEROSSEI
Origin: Base and medial side of lateral three toes.
Insertion: Medial side of base of proximal phalanx
of same toes and dorsal digital expansions.
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.
CHAPTER Nerve: Tibial nerve (S1 S2).
5 Action: Plantarflexes 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 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, he
pushes the knee joint towards himself and with
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203
his right hand, he attempts to pull the leg away
from him and rotate it upwards, so that the toes
faces towards ceiling.
PRONATOR QUADRATUS
Origin: Ulna (lower quarter of anterior surface).
Insertion: Radius (lower quarter of arterior
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
CHAPTER
supination. Therapist standing at side or in front
of patient. Support the elbow ask the patients to
turn your palm down and hold it. If the patient 5
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).
Action: Pronates forearm, flexes elbow.
MMT: Same as for pronator quadratus.
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PSOAS MAJOR
Origin: Bodies of T12 and all lumbar vertebrae,
bases of transverse processes of all lumber
vertebrae, lumbar intervertebral discs.
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 discs.
CHAPTER
Insertion: Pecten pubis, iliopubic eminence, iliac-
5 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).
MMT: Same as for obturator and pirformis.
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QUADRATUS LUMBORUM
Origin: Iliolumbar ligament, posterior part of iliac
crest.
Insertion: Lower border of 12th rib, transverse
process of L1-L4.
Nerve: Ventral rami of T12 and L1-L3,4.
Action: Laterally flexes trunk, extends lumbar
vertebrae, steadies 12th rib during deep inspiration.
MMT: Same as for interspinales lumborum.
RECTUS ABDOMINIS
Origin: Symphysis pubis, pubic crest.
Insertion: 5th-7th costal cartilages, xiphoid process. CHAPTER
Nerve: Central rami T6,7-T12.

Action: Flexes trunk.
5
MMT: Patient supine with arms out stretched 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.
RECTUS CAPITIS ANTERIOR

Origin: Anterior surface of lateral mass of atlas
and root of its transverse process.
Insertion: Occipital bone.
Nerve: Anterior primary rami (C1,C2).
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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).
CHAPTER
Insertion: Occipital bone (lateral part of inferior
5 nuchal line).
Action: Extends and rotates neck.
MMT: Same as for longissimus capitis.
RECTUS CAPITIS POSTERIOR MINOR

Origin: Atlas (posterior tubercle).
Insertion: Medial part of inferior nuchal line of
occipital bone.
Action: Extends neck.
MMT: Same as for longissimus capitis.
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RECTUS FEMORIS
Origin: Straight head-anterior inferior iliac spine;
Reflected head—Area above acetabulum, capsule
of hip joint.
Insertion: Base of patella, then forms part of
patellar ligaments.
Nerve: Femoral nerve (L2-L4).
Action: Extends knee, flexes hip.
MMT: MMT of rectus femoris is carried out jointly
as for quadriceps femoris.
Patient in short sitting place wedge under the
distal thigh to maintain the femur in the
horizontal position. Patient should learn CHAPTER
backward to relive hamstring muscle tension.
Therapist standing at side of testing limb. Ask
patient to extend his knee through available range
5
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
over pelvis to stabilize and one hand to support
the knee. He then gradually pulls the limb in
backward direction till a stretch is felt over
anterior part of the thigh.
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208
RHOMBOID MAJOR
Origin: T2-T5 [spines and supraspinous ligaments].
Insertion: Medial border of scapula between root
of spine and inferior angle.
Nerve: Dorsal scapular nerve [C4, C5].
Action: Retracts and medially rotates scapula.
MMT: Patient on prone lying. Shoulder is
internally rotated and arm is adducted across the
back with elbow flexed and hand resting on the
back. Ask the patient to lift his hand and hold it.
Full range of motion’ show grade III power.
RHOMBOID MINOR
CHAPTER
5
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.
Insertion: Lamina of vertebra above.
Action: Extends vertebral column and rotates
thoracic region.
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209
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
show,grade III power.
CHAPTER
5
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.
MMT: Patient supine lying with head on table.
Ask the patient to bring your head off the table,
keeping your eyes on ceiling. Keep your shoulders
completely on the table. Full range of motion
without resistance, show grade III power.
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210
SCALENUS MEDIUS
Origin: Atlas and axix [transverse process], C3-C7
[posterior tubercles of transverse processes].
Insertion: Upper surface of first rib.
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
CHAPTER
5
SCALENUS POSTERIOR
Origin: C4-C6 [posterior tubercles of transverse
process].
Insertion: Outer surface of second rib.
Action: Laterally flexes neck, raises second rib
during respiration.
MMT: Same as for scalenus medius.
SEMIMEMBRANOSUS
Origin: Ischial Tuberosity

Insertion: Posterior aspect of medial tibial condyle.
Nerve: Tibial division of Sciatic nerve [L5-S2].
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211
Action: Flexes knee, extends hip and medially
MMT: Patient in prone lying. Therapist stand
beside the patient. Ask the patient to lift your leg
off the table, as high as you can without bending
your knee. If the patient completes full range of
motion and hold the position without resistance,
it shows grade III power.
stand beside the patient and facing the hip joint.
Therapist grasp lower leg region of the patient
with his right hand, while his left hand grasp the
patient’s knee.He flexes the patients hip and knee
with his both hands. CHAPTER
SEMISPINALIS CAPITIS 5
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.
MMT: Patients prone with head off end of table.
Arm at sides.
Therapist standing next to patients head with
one head supporting (or ready to support the
forehead). Ask the patient to look at the wall in
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212
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 your forhead from
CHAPTER my head and keep looking at floor. If the patient
5
completes the full range without resistance, it
SEMISPINALIS THORACIS
Origin: T6-T10 (transverse processes).
Insertion: C6-T4 spinous processes.
Action: Extends and rotates vertebral column.
MMT: Prone with arm at sides. Therapist standing
at side of table. Lower extremities are stabilized
just above the ankle. Ask the patient to raise your
head arm and chest from the table as high as you
can.
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213
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
intercostals fascia. CHAPTER
Insertion: Costal surface of medial border of

scapula.
Nerve: Long thoracic nerve (C5-C7).
5
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
web space along with the thumb and index finger
to palpate the edges of the scapula at he inferior
angle and along the vertebral and axillary borders.
Ask the patient to raise your arm forward over
your head keep your elbow straight; hold it do
not let me push your arm down. If patient’s scapula
moves through full range of motion without
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214
winging but can tolerate no resistance other than
the weight of the arm.
SOLEUS
Origin: Soleal line and middle third of medial
broder of tibia, posterior surface of head and
upper quarter of fibula, fibrous arch between tibia
and fibula.
Insertion: Posterior surface of calcaneus.
Nerve: Tibial nerve (S1, S2).
Action: Planter flexes ankle.
MMT: Patient standing on testing limb with knee
CHAPTER slightly flexed. Use one or two finger for balance
5 assist. Therapist standing or sitting with clear

lateral view of test limb. Ask patient to stand on
your right leg with your knee bent. Keep your
knee bent and go up and down on your toes
atleast 20 times. If the patient complete between
nine and one correct heel rises, with the knee
flexed then it shows grade III power.
standing beside the patient. The therapist holds
the lower thigh region with his left hand and
flexing the knee. The therapist’s right hand holds
the heel in neutral position. Slowly dorsiflex the
ankle to full range.
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215
SPINALIS (CAPITIS, CERVICS, 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 cervicrs are
poorly developed and blend and adjacent
muscles. So test is done for only spinalis thorcis.
The test is same as for semi spinalis thoracis.
SPLENIUS CAPITIS
CHAPTER
5
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.
SPLENIUS CERVICALS
Origin: T3 T6 (spinous processes).
Insertion: Posterior tubercles of transverse pro-
cesses of C1-C3/4.
MUSCULOSKELETAL
216
Nerve: Dorsal rami (C5-C7).
Action: Laterally flexes, rotates and extends neck.
MMT: Same as for semi spinalis cervices.
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).
CHAPTER Action: Laterally flexes and rotates neck; anterior
5 fibres flex neck, posterior fibres 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).
Action: Medially rotates shoulder.
MMT: Patient prone with head turned toward test
side. Shoulder is abducted to 90° with folded towel
placed under distal arm and forearm hanging
MUSCULOSKELETAL
217
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 grasp the lower arm of patient with
his left hand while his right hand grasping the
wrist of the patient and applying the stretch force
toward lateral rotation.
SUPERIOR OBLIQUE
Origin: Atlas (upper surface of transverse process).
CHAPTER
Insertion: Superior and inferior nuchal lines of
occipital bone.
5
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.
Action: Supinates forearm.
MUSCULOSKELETAL
218
MMT: Patient in short sitting. Arm at side and
elbow flexed to 90° forearm in pronation.
Therapist stand at side and support 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 left hand stabilizing the anterior aspect
of proximal humerus of the patient. Therapist
right hand grasping the lower forearm, wrist and
hand of the patient and elbow is in 90° flexed
position. Therapist right hand supinates and
pronates the forearm and stretches the structures.
CHAPTER
5 SUPRASPINATUS
Origin: Supraspinous fossa (medial 2/3) and
supra spinous 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 your
arm out to the side to shoulder level and hold it.
If the patient complete the range of motion (90°),
MUSCULOSKELETAL
219
TENSOR FASCIA LATA
Origin: Outer lip of iliac crest between iliac
tubercle and anterior superior iliac spine.
Insertion: Iliotibial tract.
Nerve: Superior gluteal nerve (L4-S1).
Action: Extends knee, abducts and medially
rotates hip.
MMT: Patient in side-lying, with testing limb in
upper side and flexed to 45° and lies across the
lower most limb with the foot resting on the table.
Ask the patient to lift your leg and hold it. If the
patient complete the movement and hold it
without resistance. Then it show grade III power.
CHAPTER
TERES MAJOR
Origin: Dorsal surface of inferior scapular angle.
5
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
(palm up). Ask the patient to lift your arm as high
as you can. If the patient completes available
range of motion without resistance, it shows grade
III power.
MUSCULOSKELETAL
220
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
thrapist 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
CHAPTER
shoulder joint.
5 Nerve: Axillary nerve (C5, C6).

Action: Laterally rotates shoulder.
MMT: Same as for infraspinatous.
Therapist grasp the lower arm of the patient with
his left hand and his right hand grasp the wrist
and applying the stretch force towards the medial
rotation.
TIBIALIS ANTERIOR
Origin: Lateral tibial condyle and upper 2/3 of
lateral surface of tibia, interosseous membrane.
MUSCULOSKELETAL
221
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 your foot up
and in 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 grasp the lower leg
CHAPTER
region and his right hand palm holding the heel
of the patient. Therapist’s right hand planter
flexes the ankle and stretches the tightened 5
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.
Nerve: Tibial nerve (L4,5).
Action: Planter flexes and inverts ankle.
MUSCULOSKELETAL
222
MMT: Patient in short sitting with ankle in slight
planter 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 able to invert the
foot through the full available range of motion,
Stretching: Patient in supine lying therapist is
standing beside the patient and facing the ankle
joint. He then grasp the ankle joint of the patient
with his left hand while his right hand grasp the
foot region. Therapist’s right hand is applying
stretch force towards the inversion and eversion
CHAPTER
movement and stretches the tightened structure.
5 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: Compress abdominal contents, rasises
intra-abdominal pressure.
MUSCULOSKELETAL
223
TREPEZIUS
Origin: Medial 1/3 of superior nuchal line,
external occipital protuberance, ligament nuchae,
C7 spine, T1-T12 spines, corresponding supra-
spinous ligament.
Insertion: Upper fibres—posterior border of lateral
third of clavicle; middle fibres-medial border of
acromion, superior lip of crest of spine of scapula;
lower fibres-tubercle at medial end of spine of
scapula.
Nerve: Accessory nerve (XI) vertral rami (C3,C4).
Action: Upper fibers elevate scapula, middle
retract scapula, lower fibers depress scapula.
CHAPTER
MMT:
1. For upper fibres: patient in short sitting over
end of table hands relaxed on lap. Ask patient
to raise his shoulder towards his ear.
5
2. For middle fibres: patient in prone lying with
shoulder at he edge of table and 90° abducted
elbow is flexed to 90°. Ask patient to lift your
elbow towards ceiling and hold it.
3. For lower fibres: patient in prone with arms
over head to about 145° of abduction. Forearm
is in midposition with the thumb pointing
towards the ceiling. Therapist stand 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
MUSCULOSKELETAL
224
patient to raise your arm from the table as high
as possible and hold it. If the patient complete
the available ROM in all above 3 test, 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
CHAPTER
of forearm.
5
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 he edge of the table. Ask
patient to straighten your elbow and hold it. If the
patient complete the available ROM with no
resistance it shows grade III power.
Stretching: Patient in supine lying or sitting.
Therapist is standing beside the patient. Therapist
left hand hold’s the patient hand and flexes the
elbow after the hand reaches the shoulder.
Therapist left hand stabilizes the shoulder also.
Therapist right hand grasping the elbow, lifts up
to gain shoulder flexion.
MUSCULOSKELETAL
225
VASTUS INTERMEDIUS
Origin: Upper 2/3 of anterior and lateral surface
of femur, lower part of lateral intermuscular
septum.
Insertion: Deep surface of quadriceps tendon,
lateral border of patella, lateral tibial condyle.
Action: Extends knee.
MMT: Done along with quadriceps femoris.
Stretching: Done along with quadriceps femoris.
VASTUS LATERALIS
Origin: Inter trochanteric line, greater trochanter, CHAPTER
gluteal tuberosity, lateral lip of linea aspera.
Insertion: Tendon of rectus femoris, lateral border
of patella.
5
Nerve: Femoral nerve (L2, L4).
VASTUS MEDIALIS
Origin: Intertrochanteric line, spiral line, medial
lip of linea aspera, medial supra condylar line,
medial intermuscular septum, tendon of adductor
longus and adductor magnus.
MUSCULOSKELETAL
226
Insertion: Tendon of rectus femoris, medial broder
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.
CHAPTER
Schenkar).
5
3. Pendulum goniometer (by Mr. Fox and van
Breemen).
4. Electrogoniometer (by Mr. Karpovich and
Karpovich).
RANGE OF MOTION FOR VARIOUS JOINT’S

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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227
Elbow
Flexion 0-130° (120°-150°)
Extension 135°-0
Forearm
Supination 0-90°
Pronation 0-90°
Wrist
Flexion 0-90° (10°-90°)
Extension 0-70° (50°-70°)
Ulnar deviation 0-40° (25°-40°)
Radial deviation 0-20° (15°-25°)
CHAPTER
MCP
Flexion 0-90° 5
Extension 0-20° (15°-30°)
Abduction 0-20°
Adduction 0
PIP
Flexion 0-110° (90°-120°)
Extension 0
DIP
Flexion 0-90°
Extension 0
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Thumb
MCP flexion 0-45°
HIP
Flexion 0-120° (110°-130°)
Extension 0-35° (25°-40°)
Abduction 0-55°
Adduction 0
External rotation 0-45° (35°-50°)
Internal rotation 0-35° (30°-45°)
Knee
Flexion 0-120°
CHAPTER Extension 0
5 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°
Intrphalangeal
Flexion 0-60° (50°-70°)
Extension 0
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Cervical Spine
Flexion 0-45°
Extension 0-45°
Lateral flexion 0-45°
Rotation 0-60°
Thoracic and Lumbar Spine

Flexion 0-80°
Extension 0-25°
Lateral flexion 0-35°
Rotation 0-45°
Note
MCP—Metacarpophalangeal joint, PIP-proximal
interphalangeal joint. CHAPTER
DIP—Distal interphalangeal joint.
MEASURING PROCEDURES
5
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.
MUSCULOSKELETAL
230
Abduction
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.
CHAPTER Elbow Joint
5 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.
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231
Supination
Axis: Ulnar styloid process.
Fixed arm: Perpendicular to the movable arm
without any body contact.
Moving arm: Posterior aspect of wrist.
Wrist Joint
Flexion and extention
Axis: Medial margin of wrist.
Fixed arm: Lateral midline of forearm.
Moving arm: Lateral midline of little finger.
Ulnar and radial deviation CHAPTER
Axis: Middle of the posterior aspect of wrist.
Fixed arm: Middle of posterior aspect of forearm. 5
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.
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232
Extension
Axis: Middle of the anterior aspect of the joint line
of MCP.
Fixed arm: Midline of the anterior aspect of wrist
and forearm.
Movable arm: Midline of the anterior aspect of the
metacarpal and phalanx.
Abduction and adduction
Axis: Middle of the posterior aspect of the joint
line of the MCP.
Fixed arm: Midline of the posterior aspect of wrist
and forearm.
CHAPTER
Moving arm: Midline of the posterior aspect of the
metacarpal.
5 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.
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233
Fixed arm: Midline of the lateral aspect of lower
trunk.
Moving arm: Midline of the lateral aspect of thigh.
Extension
Axis: Greater trochanter of femur.
Fixed arm: Midline of the lateral aspect of lower
trunk.
Moving arm: Midline of lateral aspect of the thigh.
Adduction
Axis: Two inches below the ASIS.
Moving arm: Midline of the anterior aspect of the
thing. CHAPTER
Fixed arm: 90° to the movable arm.
Medial and lateral rotation 5
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.
MUSCULOSKELETAL
234
Ankle Joint
Plantar and dorsiflexion
Axis: Tip of medial malleolus.
Fixed arm: Midline of the medial aspect of the leg.
Moving arm: 90° to stable arm.
Subtalor Joint
Inversion
Axis: Medial joint line of the head of the 1st
metatarsal.
Fixed arm: Parallel to the medial aspect of the ankle
and lower leg.
CHAPTER
5
Moving arm: Perpendicular to the fixed arm.
Eversion
Axis: Lateral aspect of the head of the 5th
metatarsal.
Fixed arm: Parallel to the lateral aspect of the lower
leg.
Moving arm: Perpendicular to the fixed arm.
Cervical Spine
Atlanto—occipital and atlanto axil joint
Flexion—extension
Axis: External auditory meatus.
Fixed arm: Perpendicular to the ground.
Moving arm: Base of nares.
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235
Lateral flexion
Axis: Spinous process of C7 vertebrae.
Moving arm: Midline of head.
Rotation
Axis: Center of cranial aspect of head.
Fixed arm: Parallel to the line joining both
acromion process.
Moving arms: Along the line of the tip of the nose.
Thoraco-lumbar Spine
Flexion/Extension
1. Measure distance between C7 and S1 spinous CHAPTER
process and then ask the patient to bend
forward.
2. Again take measurment and calculate diffe-
5
rence between firstly and final measurment.
Lateral flexion
Axis: Posterior aspect of S1 spinous process.
Moving arm: Parallel to the spin 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.
MUSCULOSKELETAL
236
Moving arm: Parallel to the imaginary line
between acromion process.
COMMON MUSCULOSKELETAL TESTS

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

Patient position: Sitting or supine lying.
Procedure: Examiner passively takes patients head
and neck in extension and side.
Flexion and rotation, hold it for 30 seconds.
Positive sign: Dizziness, nausea, headache nystag-
mus.
Romberg’s Test
Tests: Cervical neuropathy, UMNL.
Patient position: Standing.
Procedure: Asked to the patient close his eyes and
hold the position for 20-30 seconds.
Positive sign: Body sways, patients looses balance.
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237
Sharp-Purser Test
Tests: Cervical instability (sub-luxation).
Procedure: Examiners 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.
CHAPTER
Procedure: Neck of unaffected side in side flexion,
apply gentle pressure on the top of patient’s head.
Test is repeated on affected side. 5
Positive sign: Onset or increase in pain radiating
into shoulder or arm on fixed side.
Upper Limb Tention 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
MUSCULOSKELETAL
238
• Wrist extension
• Finger and thumb extension
• Contralateral side flexion of cervical spine.
ULTT 2
• Elbow extension
• Wrist extension
• Shoulder lateral rotation
ULTT 3
CHAPTER • Elbow extension
5
• 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
• Contra lateral side flexion of crvical spine.
Positive sign: Radiculating pain and stress over the
nerve of brachial plexus.
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239
THORACIC SPINE
Slump Test
Tests: Dural stretch.
Procedure
1. Patient sits on table, slump so that spine flexes,
shoulder sags forward examiner hold the chin
and head erect. If no symptoms then in
continuation.
2. Examine flexes patients neck and helds the
head down, if again no symptom their in
continuation.
3. Examiner passively extends patients knee and
dorsiflex the foot. CHAPTER
Positive sign: Sciatic pain, impigment of dura and

spinal cord or nerve roots.
5
LUMBAR SPINE
Brudzinski-Kernig Test
Tests: Neurodynamic dysfunction.
Patient 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.
MUSCULOSKELETAL
240
Farfan Torsion Test
Tests: Lumbar instability.
Patient position: Prone.
Procedure: Examiner stabilizes ribs and spine by
a hand and other hand on ilium.
Anteriorly pulls the ilium backward, result in
rotation of spine on opposite side.
Positive sign: Reproduce all the symptoms in
patient.
Quadrant Test
Tests: Joint dysfunction.
CHAPTER Procedure: Patient standing with examiner
5 standing behind. Patient extends spine, patient

holds the occiput on her/his shoulder and take
weight of head. Over pressure is applied, when
patient side flexes and rotates.
Positive sign: Pain in the back and sometimes stress
fracture.
Slump Test
Procedure
ST 1: Supine lying
• Cervical spine flexion
• Thoracic and lumbar spine flexion
• Hip flexion (90°)
MUSCULOSKELETAL
241
• Knee extension
• Ankle dorsiflexion.
ST 2: Supine lying
• Thoracic and lumbar flexion
• Hip (90°), abduction
• Knee extension
ST 3: Side lying
• Thoracic and lumber spine flexion
• Knee flexion
• Ankle plantar flexion.
CHAPTER
5
ST4: Long sitting
• Cervical spine flexion, rotation
• Thoracic and lumbar spine flexion
• Knee extension
Positive sign: Reproduce the patient’s symptoms,
cause discomfort or pain on neurological tissues.
Straight Leg Raise Test
Patient position: Supine lying.
Procedure: Stabilize the unaffected leg, patient
actively raise the leg (hip flexion, with knee
extension and ankle neutral).
MUSCULOSKELETAL
242
Positive sign: Pain and stretch below the range of
65°-70°.
SHOULDER JOINT
Anterior Drawer Test
Tests: Anterior shoulder instability.
Patients position: Supine.
Procedure: Hold shoulder in 80°-120° abduction,
0-20° forward flexion and 0-30° lateral rotation.
Perform flexion with stabilized scapula.
Positive sign: Click sound or/and apprehension.
Clunk Test
CHAPTER
Tests: Ligament injury/tear of glenoid labrum.
5 Patient position: Supine.

Procedure: Ask patient to abduct shoulder over his
head. Apply anterior force to posterior aspect of
humeral head, while lateral rotation.
Positive sign: Clunk or grinding sound and/or
apprehension of instability present anteriorly.
Crank (Anterior Apprehension) Test

Tests: Anterior shoulder instability.
Procedure: Slowly abduct the shoulder to 90° with
lateral rotation.
Positive sign: Apprehension.
MUSCULOSKELETAL
243
Droparm Test/Codman’s Test
Tests: Supraspinatus tendon rupture.
Procedure: Examiner on side put one hand on
shoulder girdle and other on forearm. Passively
abduction of arm to 90° in prone. Patient lower
down the abducted arm.
Positive sign: Pain and lack of motor control.
Duga’s Test
Tests: Shoulder dislocation.
Patient position: Standing both arms hanging by
side. CHAPTER
Procedure: Patient is asked to touch the opposite
shoulder by flexing the shoulder and elbow of the
affected arm.
5
Positive sign: Patient is unable to touch the
opposite shoulder.
Empty Can Test

Test: Pathology of supraspinatus tendon.
Patients position: Sitting or standing.
Procedure: Shoulder abduction 90°; horizontal
flexion 30° and medially rotate the thumb
pointing downwards.
Positive sign: Weakness or reappearance of
symptoms.
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244
Hamilton Ruler Test
Tests: Inferior shoulder instability.
Procedure: Examiner places straight ruler over
affected arm and check whether the acromion
process and lateral epicondyle are touched by the
ruler at the same or not.
Positive sign: If the ruler do not touch both at the
same time, indicates instability.
Hawkins Kennedy Test

Tests: Supraspinatus tendon impingement.
CHAPTER Patients position: Sitting or standing.
5 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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245
Neer Impingement Test
Tests: Biceps or supraspinatus tendon impinge-
ment.
Patient position: Sitting or standing.
Procedure: Forward flex arm and medially rotate
it passively.
Positive sign: Reappearence of symptoms.
Posterior Drawer Test

Tests: Posterior shoulder instability.
Procedure: Place shoulder in 100°-120° abduction,
CHAPTER
elbow flexed to 120° and shoulder in 20°-30°
forward flexion. Medial rotation and forward
flexion of shoulder up to 60°-80° with scapula 5
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.
MUSCULOSKELETAL
246
Sulcus Sign
Tests: Inferior shoulder instability.
Patients 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.
CHAPTER
5 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 paraesthesia in ulnar
nerve distribution.
MUSCULOSKELETAL
247
Jug Test
Test: Lateral epicondylitis.
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
CHAPTER
pronation and flexion fingers and wrist while
palpating lateral epicondyle.
Method 2: Resist extension of middle finger 5
distal to PIP joint.
Positive sign: Pain over lateral epicondyle and
reappearance of symptoms.
Pinch Grip Test

Tests: Median (anterior introsseous) nerve
intrapment.
Procedure: Patient pinches the tip of index finger
and thumb together.
Positive sign: Inability to pinch tip to tip.
MUSCULOSKELETAL
248
Valgus Stress Test
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.
CHAPTER
Procedure: Stabilize upper arm. Elbow flexion in
5 20°-30° and humerus in medial rotation.

Positive sign: Excessive laxity or reappearance of
symptoms.
WRIST JOINT AND HAND

Finkelstein Test
Tests: Tensosynovitis of abductor pollicis longus
and extenor pollicis brevis tendons (de Quervain’s
tenosynonvits).
Procedure: Ask the patient, to make a fist with thumb
inside. Move wrist into ulnar deviation passively.
Positive sign: Reappearance of symptoms.
MUSCULOSKELETAL
249
Liniburg’s Test
Test: Tendon pathology between flexor pollicis
longus and flexor indices.
Procedure: Flex thumb towards hypothenar
eminence and extend index finger.
Positive sign: Limited extension and reappearance
of symptoms.
Lunotriquetral Ballottement (Reagan’s Test)

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

Tests: Median nerve pathology, carpal tunnel
syndrome
MUSCULOSKELETAL
250
Procedure: Place the hands together from its dosral
aspect with wrist in flexion. Hold it for 1 minute.
Positive sign: Tingling sensation in distribution.
Reverse Phalen’s Test

Tests: Median nerve pathology.
Patient position: Sitting
Procedure: Place the palm of both hand together
with wrist extension.
Positive sign: Tingling sensation over median
nerve distribution.
CHAPTER
5 Sweater Finger Sign

Tests: Rupture of flexer profundus tendon.
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.
Procedure: Hold piece of paper between thumb
and index finger. Pull the paper away.
MUSCULOSKELETAL
251
Positive sign: As the paper is pulled away, the IP
joint of thumb flexes.
Tinel’s Sign
Tests: Median nerve pathology, carpal tunnel
syndrome.
Procedure: Tap over carpal tunnel.
Positive sign: Tingling sensation or paraesthesia
over median nerve distribution.
Waston (Scaphoid Shift) Test

Tests: Instability of scaphoid.
CHAPTER
5
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.
Procedure: Push right and left ASIS apart.
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252
Gaenslen’s Test
Tests: Sacroiliac joint involvement, hip pathology
or L4 nerve root lesion.
Patient position: Side lying on normal side, with
leg flexed against chest.
Procedure: Affected leg is 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.
CHAPTER Patient position: Standing.
5 Procedure: Palpate PSIS and sacrum. Patients

performs hip flexion and knee on side to be tested
(palpated), while standing on opposite leg. Repeat
the test and compare it both side.
Positive sign: If the PSIS does not move downward
to sacrum on side tested, it shows hypomobility
of that side.
Hibbs Test
Tests: Movement of sacroiliac joint, stress of
posterior sacroiliac ligament.
Patient position: Prone.
Procedure: Pelvis is stabilized and patients
performs 90° flexion on the knee, hip is medially
MUSCULOSKELETAL
253
rotated, while palpating sacroiliac joint on that
side. Repeat the test and compare it with other
side.
Positive sign: Range of opening and quality of
movement at each sacroiliac joint differ.
Laguere’s Sign
Tests: Sacroiliac joint involvement, hip pathology.
Procedure: Examiner flexes, abducts and laterally
rotate the patients hip to be tested. Over pressure
is applied at end range. Pelvis is stabilized. Repeat
the test on others side and compare both sides.
CHAPTER
5
Positive sign: Pain on SI joint or hip.
Piedallu’s Sign’s (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.
MUSCULOSKELETAL
254
Patient position: Side lying or supine.
Procedure: Push left and right ASIS towards each
other.
Standing Flexion
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
CHAPTER side.
5 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 of the
changing position of malleoli is noted.
Positive sign: One leg moves up more than other.
HIP/JOINT
Anterior Labral Tear Test
Tests: Ligament or labrum tear or injury.
Patients position: Supine.
MUSCULOSKELETAL
255
Procedure: Full flexion at hip, lateral rotation and
full abduction. Examiners extends, medially rotate
and adduct the hip.
Positive sign: Pain, reappearance of symptom with/
without click.
Ober’s Sign
Tests: Tensor fascia lata and iliotibial band
contractures.
Patient position: Side lying with lower leg flexed.
Procedure: Pelvis stabilized. Abduct and extend
upper leg with knee extension or flexion to 90°
passively and allow it to drop towards plinth.
CHAPTER
Positive sign: Upper leg remains abducted and
does not lower to plinth.
5
Patrick’s (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.
MUSCULOSKELETAL
256
Procedure: Full flexion at hip, adduction and lateral
rotation. Examiner extends, abduct and laterally
rotate the hip.
Positive sign: Resist extension of middle finger
distal to PIP joint.
Rectus Femoris Contracture Test

Tests: Rectus femoris contracture.
Procedure: Knee flexed to 90° over edge of plinth.
Patient takes other knee to chest.
CHAPTER Positive sign: Knee extends over edge of plinth.
5 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 hip abductors, stability of hip.
Procedure: Patient is made to stand on one leg.
Positive sign: Pelvis of opposite side drops.
MUSCULOSKELETAL
257
KNEE JOINT
Abduction (Valgus) Stress Test
Tests: Full knee extension ligament injury (ACL,
MCL, POL, PCL), quadriceps and semimembra-
nosus expansion.
Patient’s position: Supine.
Procedure: Ankle is stabilized and medial pressure
is applied on knee joint at 0° and then at extension
in 20°-30°.
Positive sign: Excessive movement is seen as
compared to opposite knee.
Adduction (Varus) Stress Test

CHAPTER
5
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.
MUSCULOSKELETAL
258
Procedure: Foot is stabilized, posteroanterior force
is applied on tibia.
Positive sign: Movement of tibia move than 6 mm
on femur.
Apley’s Test
Tests: Compress for meniscus injury and
distraction for ligamentous injury.
Patient’s position: Prone with 90° knee flexion.
Procedure: Medial and lateral rotation of tibia, first
with distraction and then with compression.
Positive sign: Pain.
CHAPTER
5
Brush Test
Tests: Mild effusion.
Patient’s position: Long sitting.
Procedure: Stroke the patella on medial side, below
joint line upto supra patellar 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.
MUSCULOSKELETAL
259
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.
Fairbank’s Apprehension Test

Tests: Patellar subuxation or dislocation.
Procedure: 30° flexion at knee and relaxed quads.
Lateral glide to patella passively.
Positive sign: Excessive movement. CHAPTER
Hughston Plica Test

Tests: Inflammation of suprapatellar plica.
5
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.
MUSCULOSKELETAL
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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.
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
CHAPTER rotation at knee.
5 Positive sign: Click are 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)
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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.
Procedure: 45° flexion at hip and 90° flexion at
knee, foot is placed in 30° medial rotation and
stabilized, posteroanterior force is applied on
tibia.
Positive sign: Excessive movement on lateral side, CHAPTER
5
when compared with other knee.
Slocum Test for Anterolateral Rotory Instability

Tests: Ligament injury (MLC,POL ACL)
Procedure: 45° hip flexion, 90° knee flexion, foot
is placed in 15° lateral rotation and stabilize it and
than 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.
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Patient’s position: Prone.
Procedure: Flexion at knee, posteroanterior force
is applied on talus with dorsiflexion on ankle and
then plantar flexion.
Positive sign: If movement on one side only
(ligament on the affected side). If excessive
anterior movement (both ligaments are affected).
Squeeze Test of Leg

Tests: Syndesmosis injury (fracture, contusion or
compartment syndrome).
CHAPTER Procedure: Examiner grasps leg at mid calf level
5
and squeeze 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.
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263
Thompson’s Test
Tests: Achilles tendon rupture.
Patient’s position: Prone.
Procedure: Feet is placed over edge of plinth and
then calf muscle is squeezed.
Positive sign: Absence of plantar flexion.
MUSCULOSKELETAL PATHOLOGIES
ACHONDROPLASIA
It is a condition which occurs because of failure
of normal ossification of bones, specially the long
bones, turning into dwarfism. It is a disease with
CHAPTER
auto somal dominant inheritance, but may also
occur by a fresh gene mutation.
C/F: Flat nose, short limbs, lumbar lordosis, large
5
skull with bulged vault and forehead, stubby
fingers
ALBERS-SCHONBERG 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 immo-
bilisation, hormonal imbalance, nutritional
deficiency.
C/F: Fracture resulting by minimal injury or
pressure, weak bone, reduced gaps between bone.
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264
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 affect
the age group of 15-30 years. M:F-10:1. There may
occur cartilage destruction and synovitis.
C/F: 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 non progressive condition in which the
CHAPTER infant born with multiple deformities, joint
5
stiffness and soft tissues contractures.
Types
Neurogenic—Due to degeneration of anterior horn
cells in certain segments of spinal card.
Myogenic—Due to replacement of muscles by
fibrofatty tissue.
C/F: Flexion, abduction at hips, flexion at knees,
equinovarus feet, congenital hip dislocation, joint
contractures, genurecurvatum, calcaneovalgus
feet, webs skins.
BAKER’S CYST
This is associated with rheumatoid arthritis and
MUSCULOSKELETAL
265
osteoarthritis. These occurs a cyst or a mass or a
fluid filled sac at back of knee joint.
C/F: Popliteal bursa gets distended, associated with
herniation of synovial membrane of knee joint.
BURSITIS
This is the inflammation of bursa. This occurs
because of bacterial infection or mechanical
irritation. Because of which the bursitis may be
infective or irritative caused by excessive pressure
or friction. also sometime due to gouty deposit.
C/F: Pain, swelling, redness, reduced joint range
of motion.
CHAPTER
5
CONGENITAL TALIPES EQUINO VARUS (CTEV)
This is the commonest congenital feet deformity
also known as clubfoot. The aetilogy is unknown,
hence two types idiopathic and secondary. The
talus neck gets angulated facing downwards and
medially, i.e. in inversion.
C/F: Postural equniovarus, as age increases
difficulty in walking, head is small in size,
bilateral foot deformity, creases on back of heel,
foot is slight convex.
CARPAL TUNNEL SYNDROME

This syndrome occurs when the median nerve get
compressed while passing through flexor retina-
culum. The causes of this may be inflammatory,
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266
post-traumatic, endocrine, idiopathic, the patient
affect is usually middle aged.
C/F: 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 this may affect the blood supply to nerves
and muscles resulting in compartment syndrome.
This injury lead to swelling resulting into reduced
blood supply furthers resulting in muscle
ischaemia.
CHAPTER C/F: Necrosis, nerve damage, fibrosis, contractures
5 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 disorder in western countries. The
factors responsible for this are hereditary, trauma,
breech malposition, hormonal changes during
pregnancy. F:M-6:1.
C/F: Asymmetry creases on groin, reduces range
of motion on the affected side, click sound is heard
everytime when movement occurs, child walks
with a peculiar gait, i.e. Trendelenburg or
waddling gait.
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267
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.
C/F: Tenderness on radial styloid process, pain
aggravates by adducting the thumb.
Thickned 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. CHAPTER
The ring finger is commonly affected.
C/F: Thickening felt at bases of ring and little
5
finger, flexion deformity of fingers.
FIBROSITIS
This is the inflammation of the fibrous tissue.
There are nodules (firm) mostly on trapezius and
spinal muscles. The nodules are mainly the trigger
points, responds to ultrasonic therapy and local
steroids.
C/F: Tenderness, nodules (small, firm), pain,
affected movement, reduced range of motion.
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268
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.
C/F: Pain, tenderness, fatigue, disturbed sleep,
anxiety, depression, morning stiffness.
GOLFER’S ELBOW (MEDIAL EPICONDYLITIS)

This is the condition in which there is
inflammation at the origin of flexor tendon, i.e.
at the medial epicondyle of the humerus.
CHAPTER C/F: Pain, tenderness, swelling, reduced range of
5 motion.
MYOSITIS OSSIFICANS
In this there is formation of haematoma around
a joint due to fracture or severe soft tissue injury,
mainly around elbow. It may also congenital.
C/F: 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.
MUSCULOSKELETAL
269
C/F: 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 type of
Osteochondritis are:
Perthes’ Disease
Also known as coxaplana, pseudocoxalgia.
Mainly affects the femoral head or femoral
epiphysis affecting the young boys. Occurs due
CHAPTER
to recurrent episodes of ischaemia and necrosis.
The bone becomes soft and fragmented due to
which it appears large than original size. 5
Osgood-Schlatters Disease
Mainly affect the tibial tubercle seen in teen age.
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.
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270
Scheuermann’s Disease
Mainly affect 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 type of vitamin D.
Due to this, there is softening of bone, because of
uncomplete calcification. Due to which they
become weak and get easily fractured. Mainly
seen in long bones.
C/F: Soft fragmented bone, pain, tenderness
CHAPTER 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.
C/F: Pain, tenderness, swelling, weight loss, fever.
PAGET’S DISEASE
This is a disease characterized by excessive
tendency of bony breakdown, get thickened and
spondy. Tibia is affected most commonly.
MUSCULOSKELETAL
271
Diseases becomes after 40 year of age. this occurs
due to osteoclast dysfunction.
C/F: 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
cells causing inflammation and necrosis. All the
organs or parts of the body supplied by blood or
arteries are affected due to impaired blood supply.
C/F: Fever, renal failure, hypertension, neuritis,
weight loss, muscle and joint pain, skin lesion.
POLYMYALGIA RHEUMATICA CHAPTER

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
5
pain and stiffness.
C/F: 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 aetiology. The muscle
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.
MUSCULOSKELETAL
272
C/F: Pain, tender to touch, difficulty in weight
bearing.
RHEUMATOID ARTHRITIS
This is an autoimmune disorder affecting several
joint at same times. There is destruction of
articular cartilage, capsule, ligament and tendons,
leads to deformity. The joints are symmetrically
affected. There are nodules, the disease is
common in young to middle aged women.
C/F: Pain, swelling, morning stiffness, loss of
movement and function.
SPONDYLOLISTHESIS
CHAPTER
5
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
interaarticularis due to overuse
III. Degenerative: Osteoarthritis
IV. Traumatic: Acute fracture
V. Pathological: Weakening of the pars intra–
articularis by a tumour, osteoporosis,
tuberculosis or Pagets’ disease.
C/F: Pain, tenderness, difficulty in bending, sitting
and lying down, affected movement.
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273
SPONDYLOLYSIS
This is the defect in the pars interarticularis of the
lumbar vertebrae resulting due to fatigue fracture.
It can be both uni and bilateral and it may or may
not progress to spondylolisthesis.
C/F: 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 CHAPTER
5
the bladder also. The vertebral artery may also be
involved.
C/F: 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 % are women.
C/F: Anaemia, hypertension, vasculitis, renal
disease, pleurisy, alopecia, polyarthritis vasculitis,
butterfly rash on face, Raynaud’s disease.
MUSCULOSKELETAL
274
SYSTEMIC SELEROSIS
This is an autoimmune disorder of the connective
tissue that causes increase in metabolism of
collagen. Excessive collagen deposits damages the
microscopic blood vessels in skin and other organs
leads to fibrosis and degeneration. Middle age
women are most commonly affected.
C/F: Oedema of hands and feet, alteration 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
CHAPTER
of the lateral epicondyle.
5 C/F: Pain, tenderness, affected movement of
extension.
TENOSYNOVITIS
This is the inflammation of the synovial lining of
the tendon sheath caused due to mechanical
irritation or infection. It may also occur due to
overuse and repetitive movements.
C/F: Pain, tenderness, swelling, redness affected
movement and function.
THORACIC OUTLET SYNDROME

Characterized by compression of neurovascular
bundle comprising of subclavian artery/vein,
MUSCULOSKELETAL
275
axillary artery/vein and brachial plexus at the
thoracic outlet (space between first rib, clavicle
and scalene muscles) causes include due to
hypertrophy of the existing muscles or due to any
other causes like trauma, congential, etc.
C/F: Pain, weakness, oedema, pallor, paraesthesia,
venous engorgement, cynosis 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.
CHAPTER
5
Grade II—Moderate pain and disability, weight
bearing difficult.
GradeIII—Severe pain, swelling and dislocation,
no weight bearing possible.
TREATMENT
PRICES
P—prevention from further injury
R—rest to the part
I—icing
C—compression
E—elevation of the part
S—support
MUSCULOSKELETAL
276
STAGES OF FRACTURE HEALING
HAEMATOMA FORMATION
• Duration: Less then 7 days
• Essential features: Deposition of blood at the
site of fracture, which sensitizes the precursor
cells.
CELLULAR PROLIFERATION
• Duration: Upto 2-3 weeks
• Essential features: It has two sub stages
a. Endosteal cellular proliferation-formation
of cell in endosteam
b. Periosteal cellular proliferation—formation
CHAPTER of cell on surface of medullary cavity.
5 STAGE OF CALCIFICATION
This stage include deposition of lime salt, mainly
calcium and phosphorus.
NEW BONE FORMATION

• Duration: 4-12 weeks
• Essential features: It has three sub stages
a. Stage of callus formation—Deposition
appear as slit callus, it occurs after 2-3
weeks of trauma.
Callus—It is a new bone formation/
calcification shich bridges the fracture site,
responsible for healing of fracture.
MUSCULOSKELETAL
277
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 get disturbed.
— It require 8-10 weeks for slit alignment
of trabecular pattern.
— This alignment is not anatomically
satisfactory.
— It appear to be slit deformed as normal CHAPTER
5
one. The bone get bended.
— To correct it, next stage occur.
REMODELING STAGE
• Duration: 1-2 years
• Essential features: It occurs till the correction
of bending.
• After 6 month 90% alliptable bone is
formed.
Note
1. Angulation and over-riding is not accepted
since
• It have longer period of remodeling.
• Movement of limb is affected.
• Bone may be fixed in rotated position.
MUSCULOSKELETAL
278
2. When fracture is united on bending with
remodeling in few months it is accepted.
3. One of the very important clinical finding
of nature 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
CHAPTER It is the fracture of distal articular surface of the
5
radius which extends to either its anterior or
posterior corticles. It is thus divided into 2 types
a. Volar Varton’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.
COLLES’ FRACTURE
It is define as the fracture at the distal end of the
radius, at its cartico-cancellous junction with
typical displacement in adults such as:
1. Dorsal tilt
2. Dorsal displacement
MUSCULOSKELETAL
279
3. Fragment impaction
4. Lateral tilt
5. Lateral displacement
6. Supination
Common injuries associated Colles’
• 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 conservatilvely. Undisplaced
type of fracture is immobilized in a below-elbow
plater cast for 6 weeks. Displaced fracture are
CHAPTER
treated by manipulative reduction and immobili-
zation in Colles’ cast.
5
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.
• It shows a typical displacement, i.e. the radius
fracture is angulated medially and anteriorly.
The distal radioulnar joint is disrupted which
results in dorsal dislocation of the distal end
of the ulna.
Treatment: In children it is treated with closed
reduction in a conservative manner. In elder
MUSCULOSKELETAL
280
person 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
CHAPTER
fracture angulates anteriorly and the radial
5
head dislocates arteriorly.
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 3-4 weeks.
Open reduction and internal fixation using a
plate is performed in case where a reduction is
not possible or if redisplcaement occurs.
MUSCULOSKELETAL
281
SMITH’S FRACTURE
It is also seen as reverse of Colles’ fracture where
the distal fregment displace ventrally and tilts
ventrally.
It is important to differentiating it from the
commoner Colles’ fracture which occur at the
same site.
It is treated by closed reduction and plaster
cast immobilization for six weeks.
BENNETT’S FRACTURE—DISLOCATION
It is a type of an oblique intra-articular fracture
of the base of the first metacarpal with
subluxation or dislocation of the metacarpal. CHAPTER
5
• 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
• Closed reduction and percutaneous fixation
under X-ray control using, and image inten-
sifier.
• Open reduction and internal fixation with a
K-wire or a screw.
MUSCULOSKELETAL
282
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.
Some time 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 immobilising
the DIP joint in hyper extension with help of
CHAPTER
an aluminium splint or plaster cost.
5 ROLADO’S FRACTURE
This is the frature 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 immo-
bilization in a thumb spica for three weeks.
BUMPER FRACTURE
It is actually the fracture of condyle of tibia.
Mechanism of injury is direct trauma to the
upper end of tibia, or an indirect force more often
results in unicondylar (by a varus/valgus bending
MUSCULOSKELETAL
283
force) or infra-condylear 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 motor-car strikes the
lateral side of the knee.
Treatment
It is treated clinically by reduction under
anesthesia, followed by below knee skin traction
for 3 weeks. The knee is mobilized as the fracture
becomes stickly, few cases need open reduction
and joint reconstruction.
CHAPTER
5
MUSCULOSKELETAL ASSESSMENT
Reg. No.
Name
Age/sex
Date of admission
Address
Occupation
Referred by (consultant) and hospital
Type of operation/illness
Date of discharge
Discharge summary
History of present illness
MUSCULOSKELETAL
284
ADL activity
Personal history
Social history
Family history
ON OBSERVATION
Attitude of limb
Facial expression
Deformity
Posture: Lying
Sitting
Standing
Pain:
Type
CHAPTER
Onset
5 Nature
Radiation
Intensity
Aggravating factor
Relieving factor
Severity (visual analoguel scale)
Associated symptoms
ON PALPATION
Temperature
Tenderness
Oedema—pitting/non-pitting
Inflammatory sign
Muscle wasting
Contractures
MUSCULOSKELETAL
285
ON EXAMINATION
Range of movement
Active
Passive
Joint effusion measurment
Muscle girth
Limb length
End feel: Capsular
Noncapsular
Differential test
Gait assessment
MMT
Neurological test
Dermatomes
CHAPTER
Reflexes
Myotomes
Special tests 5
Investigation—Blood/X-ray/CT scan/MRI.
MISCELLANEOUS
287
CHAPTER 6
Miscellaneous
National immunization schedule
Spinal traction
Proprioceptive neuromuscular facilitation
(PNF)
Common sports injuries
Types of aphasia
CHAPTER
Gait terminology/deviations
Levels of amputations 6
Abbreviations
Normal reference lab values
MISCELLANEOUS
288
NATIONAL IMMUNIZATION SCHEDULE
TIME VACCINE
Birth BCG and OPV zero dose (for institutional
deliveries)
6 weeks BCG (if not given at birth) DPT-1 and
OPV-1
10 weeks DPT-2 and OPV-2
14 weeks DPT-3 and OPV-3
9 month Measles
18-24 months DPT and OPV (1 booster)
5 year DT
10 year and TT
16 years
For pregnant Early in pregnancy TT-1, after 1
women month TT-2
SPINAL TRACTION
CHAPTER It is the stretching force applied in a longitudinal
6
direction of the spine.
TYPES
1. Continuous
2. Sustained
3. Intermittent.
EFFECTS
1. It increases the nutrition of the intervertebral
disc by separation of verterbral bodies, which
improves fluid flow.
MISCELLANEOUS
289
2. Because of stretching of tight fibrous tissue,
increases the mobility.
3. During traction, sliding movement occurs in
facet joints, which facilitates synovial sweep.
It acts as a lubricator.
4. Reduces the inflammation by increasing blood
circulation.
INDICATIONS
1. Intervertebral disc prolapse
2. Nerve root compression
3. Low back pain
4. Joint dysfunction.
CONTRAINDICATIONS
Pregnancy
Osteomyelitis
CHAPTER
Joint instability
Acute muscle spasm
Hiatus hernia
Claustrophobic patients
6
Abdominal or pelvic surgeries.
PROPRIOCEPTIVE NEUROMUSCULAR
FACILITATION (PNF)
TECHNIQUE
To strengthen muscles
1. Slow reversals
MISCELLANEOUS
290
2. Repeated contractions
3. Rhythmic stabilizations
To gain relaxation/lengthening of muscles
1. Hold—relax
2. Contract—relax
3. Rhythmic stabilizations
To improve co-ordination
1. Slow reversals
2. Repetitive movements.
COMMON SPORTS INJURIES

SHOULDER JOINT AND ARM
Rotator cuff tear — Javelin, swimming, volley-
ball, baseball
Glenohumeral — Gymnastic, weight lifting,
CHAPTER ballers
6 Glenohumeral
dislocation
— Boxing, hockey.
ELBOW AND FOREARM

Medical epicondylitis — Golf
Lateral epicondylitis — Tennis
Valgus extension — Javelin.
WRIST AND HAND

Tendon ligament — Volleyball, basket-
ball, boxing
MISCELLANEOUS
291
Ulnar tunnel syndrome — Cycling
Carpel tunnel — Rock-climbing,
tennis, golf.
HIP AND THIGH

Quadriceps and hamstring injuries—Runners
Adductor injuries—Horse riders
Fracture of pelvis/hip-dislocation—footballer.
KNEE AND LEG

Collateral ligament injury—Football
Meniscal injury—Football, kabaddi
Cruciate ligament injury—Long-jump
Knee dislocation—Kick boxing
IT band syndrome—Long and high jumpers CHAPTER
Compartment syndrome—Runner and cyclists.
ANKLE AND FOOT

6
Sprain—Basketball, football, baseball
Achilles tendonitis and bursitis—Runners
TA rupture—Running, football
Metatarsalgia—Runners
Stress fracture—Walkers
MISCELLANEOUS
292
TYPES OF APHASIA
Fluency Comprehension Repetition

1. Global - - -
2. Isolation - - +
3. Broca’s - + -
4. Transcortical - + +
motor
5. Wernicke’s + - -
6. Transcorticial + - +
sensory
7. Conduction + + -
8. Normal + + +
- Absent, + present
GAIT TERMINOLOGY
Traditional Rancho los amigos
Stance phase
CHAPTER Heel strike Intial contact
6
Foot flat Loading response
Mid stance Mid stance
Hee off Terminal stance
Toe off Preswing
Swing phase
Acceleration Initial swing
Mid swing Midswing
Deceleration Terminal swing
MISCELLANEOUS
293
GAIT DEVIATIONS
Ataxic—Staggering and unsteadiness
Hemeplegic—Rigid lower limb is stiffly dragged
sideways and forwards in semi circular fashion.
Spastic—Toes scraping the floor with pelvis lifting
from side to side.
Scissor—Crossed leg pattern
Shuffling (parkinsonian, festinant, festinating
gait)—Walking on toes but rapid shuffling steps
High steppage gait—Prancing gait pattern
Jaunty gait—Jerky and dancing pattern
Waddling—Oscillatory pattern
Kinesia paradoxa—Run better then walks
Tandem walking—Heel to toe pattern
CHAPTER
Gluteal—Leaning of the trunk to the affected side.
6
MISCELLANEOUS
294
LEVELS OF AMPUTATIONS
CHAPTER
6
Fig. 6.1: Levels of amputation in lower limb
MISCELLANEOUS
295
CHAPTER
Fig. 6.2: Levels of amputation in upper limb 6

MISCELLANEOUS
296
ABBREVIATIONS
AAA abdominal aortic aneurysm
Ab antibody
ABG arterial blood gases
ABPA allergic bronchopulmonary
aspergillosis
ACBT active cycle of breathing technique
ACE angiotensin-converting-enzyme
ACT activated clotting time
ACTH adrenocorticotropic hormone
AD autogenic drainage
ADH anti-diuretic hormone
ADL activities of daily living
A-aDO2 alveolar-arterial oxygen gradient
ADR adverse drug reaction
AE air entry
AEA above elbow amputation
CHAPTER AF atrial fibrillation
6 AFB
AFO
Ag
acid fast bacillus
ankle foot orthosis
antigen
AGN acute glomerulonephritis
AHRF acute hypoxaemic respiratory
failure
Ai aortic insufficiency
AIDS acquired immunedeficiency
syndrome
AKA above knee amputation
AL acute leukemia
ALD alcoholic liver disease
MISCELLANEOUS
297
ALI acute lung injury
AMBER advance multiple beam
equalization radiography
AML acute myeloid leukemia
AP anterior posterior
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 analogue scale CHAPTER
6
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
MISCELLANEOUS
298
BIVAD biventricular device
BKA below knee amputation
BM blood glucose monitoring
BMi body mass index
BO bowels open
BP blood pressure
BPD bronchopulmonary
dysplasia
BPF bronchopleural fistula
Bpm beats per minute
BS bowel sound/breath sound
BSA body surface area
BSO bilateral salpingo—oophorectomy
BVHF bi-ventricular heart failure
C/O complains of
C/W consistant with
Ca carcinoma
CHAPTER CABG coronary artery-bypass graft
6
CAD coronary artery disease
CAH chronic active hepatitis
CAL chronic airflow limitation
CAO chronic airways obstruction
CAPD continous arterial venous
haemofiltration
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
MISCELLANEOUS
299
CF cystic fibrosis
CFA cryptogenic fibrosing alveolitis
CFMS cerebral function monitors
CHD coronary heart disease
CHF chronic heart failure
Ci chest infection
CK creating kinase
CL lung compliance
CLD chronic lung disease
CML chronic myeloid leukemia
CMV controlled mandatory ventilation/
cytomegalovirus
CNS central nervous system
CO carbon monoxide
CO cardiac output
CO2 carbon dioxide
COAD chronic obstructive airways disease
CoP completion of plaster CHAPTER
6
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
MISCELLANEOUS
300
CRP conditioning rehabilitation
programme
CRQ chronic respiratory disease
questionnaire
C-section cesarean section
CSF cerebrospinal fluid
CT computed tomography
CVA cerebrovascular accident
CVI cerebrovascular incident
CVP central venous pressure
CVS cardiovascular system
CVVHF continuous veno-venous
hemofiltration
CXR chest X-rays
D&C dilation and curettage
D/C discharge
D/W discussed with
CHAPTER DBE deep breathing exercises
6
DDD degenerative disc disease
DDH developmental dysplasia of the hips
DH drug history
DHS dynamic hip screw
DIB difficulty in breathing
DIC disseminated intravascular
coagulopathy
DIOS distal intestinal obstruction
syndrome
Dish diffuse idiopathic skeletal
hyperostosis
Dl deciliter
MISCELLANEOUS
301
DLCO diffusing capacity for carbon
monoxide
DM diabetes mellitus
DMARD Disease modifying anti-rheumatic
drug
DMD Duchenne’s 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 CHAPTER
ECG
ECMO
removal
electrocardiogram
extracorporeal membrane
6
oxygenation
EECP enhanced external
counterpulsation
EEG electroencephalogram
EIA exercise induced asthma
ETT exercise tolerance test
EMG electromyography
ENT ear, nose and throat
EOR end of range
MISCELLANEOUS
302
Ep epilepsy
EPAP expiratory positive airway pressure
EPP equal pressure points
ERCP endoscopic retrograde,
cholangiopancreatography
ERV expiratory reserve volume
ESR erythrocyte sedimentation rate
ESRF end stage renal failure
ETCO2 end–tidal carbon dioxide
ETT endotracheal tube
EUA examination under anaesthetic
FB foreign body
FBC full blood count
FDP fibrin degradtion product
FET forced expiration product
FEV1 forced expiratory volume in 1
second
CHAPTER FFD fixed flexion deformity
6
FG French gauge
FGF fibroblast growth factor
FH family history
FHF fulminating hepatic failure
FiO2 fractional inspired oxygen
concentration
FRC functional residual capacity
FROM full range of movement
Ft feet
FVC forced vital capacity
FWB full weight bearing
G gram
MISCELLANEOUS
303
GA general anaesthetic
GAW airway conductance
GBS Guillain-Barre syndrome
GCS Glasgow Coma scale
GH general health
GI gastrointestinal
GIT gastrointestinal tract
GOR gastro-oesophageal reflux
GPB glossopharyngeal breathing
GTN glycerol trinitrate
GU gastric ulcer/genitourinary
H+ hydrogen ion
H2 hydrogen
HASO hip abduction spinal orthosis
Hb haemoglobin
HC head circumference
Hct haematocrit
HD haemidialysis CHAPTER
6
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
MISCELLANEOUS
304
HI head injury
HIV human immunodeficiency virus
HLA human leucocyte antigen
HLT heart-lung transplantation
HME heat and moisture exchanger
HPC history of presenting condition
HPOA hypertrophic pulmonary
osteoarthropathy
HR heart rate
HRR heart rates reserve
HT hypertension
HZ hertz
IABP intra-aortic balloon pump
IBS irritable bowel syndrome
IC inspiratory capacity
ICC intercostal catheter
ICD intercostal drain
CHAPTER ICP intracranial pressure
6
ICU intensive care unit
IDC indwelling catheter
IDDM insulin dependent diabetes mellitus
IF interferential therapy
Ig immunoglobulin
IHD ischaemic heart disease
ILD interstitial lung disease
IM intramedullary
IM/i.m. intramuscular
IMA interanal mammary artery
IMV intermittent mandatory
ventilation
MISCELLANEOUS
305
INH inhalation
INR international normalized ratio
IPAP inspiratory positive airway pressure
IPPB intermittent positive pressure
breathing
IPPV intermittent positive pressure
ventilation
IPS inspiratory pressure support
IRQ inner range quadriceps
IRV inspiratory reverse volume
IS incentive spirometry
ITU intensive therapy unit
IV/i.v. intravenous
IVB intervertebral block
IVC inferior vena cava
IVH intraventricular haemorrhage
IVI intravenous infusion
IVOX intravenacaval oxygenation CHAPTER
6
IVUS intravenacaval ultrasound
J joule
JVP jugular venous pressure
KAFO knee ankle foot orthosis
KCO transfer coefficient
KO knee orthosis
KPa kilopascal
LA local anaesthetic
LAP left atrial pressure
LBBB left bundle branch block
LBP low back pain
LCL lateral collateral ligament
MISCELLANEOUS
306
LDL low density lipoprotein
LED light-emitting diode
LFA low friction arthroplasty
LFT liver function test/lung function
test
LFT × 2 lung or liver function test
LL lower limb/lower lobe
LOC level of consciousness
LP lumbar puncture
LRTD lower respiratory tract disease
LSCS lower segment cesarean section
LTOT long-term oxygen therapy
LVAD left ventricular assist device
LVEF left ventricular ejection fraction
LVF left ventricular failure
LVRS lung volume reduction surgery
M meter
CHAPTER MAOI monoamine oxidase inhibitor
6
MAP mean airway pressure/mean
arterial pressure
MAS minimal access surgery
MC&S microbiology, culture and
sensitivity
MCH mean corpuscular haemoglobin
MCL medical collateral ligament
MCV mean corpuscular volume
MDI multidisciplinary team
MDI metered dose inhaler
ME metabolic equivalents/myalgic
encephalomyelitis
MISCELLANEOUS
307
MEFV maximum expiratory flow
volume
METs metabolic equivalents
MHz megahertz
MI myocardial infraction
MIFV maximum inspiratory flow
volume
ML middle lobe
MM muscle
MMAD mass median aerodynamic
diameter
MMHG millimeter of mercury
MMV mandatory minute volume
MND motor neurone disease
MOW meals on wheels
Mph miles per hour
MRI magnetic resonance imaging
MRSA methicillin—resistant CHAPTER
6
staphylococcus aureus
Ms millisecond
MS mitral stenosis/multiple sclerosis
MSU midstream urine
MUA manipulation under anaesthetic
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
MISCELLANEOUS
308
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
NEPV negative extrathoracic pressure
ventilation
NFR note for resuscitation
NG nasogastric
NH nursing home
NICU neonatal intensive care unit
NIDDM non-insulin dependent diabetes
mellitus
NIPPV non-invasive intermittent positive
CHAPTER pressure ventilation
6
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
MISCELLANEOUS
309
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
OB obliterative bronchiolitis
Occ occasional
OD over dose
Oe objective examination
OGD oesophagogastroduodenoscopy
OHFO oral high-frequency oscillation
OI oxygen index
°JACCOL No jaundice, anaemia, clubbing,
cyanosis, oedema
°LKKS No liver, kidney, kidney, spleen CHAPTER
6
OLT orthotopic liver transplantation
OPD outpatient department
ORIF open reduction and interal fixation
OT occupational therapist
P.R. per rectum
PA posterior anterior
PA pernicious anaemia/
posteroanterior/pulmonary artery
PACO2 partial pressure of carbon dioxide
in alveolar gas
PaCO2 partial pressure of carbon dioxide
in arterial blood
MISCELLANEOUS
310
PADL personal activities of daily living
PAIVM passive accessory intervertebral
movement
PAO2 partial pressure of oxygen in
alveolar gas
PaO2 partial pressure of oxygen in arterial
blood
PAP pulmonary artery pressure
PAWP pulmonary artery wedge pressure
PBC primary biliary cirrhosis
PC presenting condition/pressure
control
PCA patient-controlled analgesia
PCD primary ciliary dyskinesia
PCIRV pressure-controlled inverte ratio
ventilation
PCP pneumocystis carinii pneumonia
CHAPTER PCPAP periodic continuous positive
6
airway pressure
PCV packed cell volume
PCWP pulmonary capillary wedge
pressure
PD parkinson’s disease/peritoneal
dialysis/postural drainage
PDA patent ductus arteriosus
PE pulmonary embolus
PEEP positive end-expiratory pressure
PEF peak expiratory flow
PEFR peak expiratory flow rate
PEG percutaneous endoscopic
gastrostomy
MISCELLANEOUS
311
PeMax peak expiratory mouth pressure
PEME pulsed electromagnetic energy
PEP positive expiratory pressure
PERLA pupils equal and reactive to light
and accommodation
PFC persistant foetal circulation
PFO persistent foramen ovale
PFY patellofemaral 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 CHAPTER
6
revascularization
PN percussion note
PND paroxysmal nocturnal dyspnea
POMR problem-oriented medical record
POP plaster of paris
PPIVM passive physiological
intervertebral movement
PROM passive range of movement
PS pressure support/pulmonary
stenosis
PTB pulmonary tuberculosis
PTCA percutaneous transluminal
coronary angioplasty
MISCELLANEOUS
312
PTFE polytetrafluoroethylene
PTT partial thromboplastin time
PU passed urine
PVC polyvinyl chloride
PVD peripheral vascular disease
PVH periventricular haemorrhage
PVL periventricular leukomalacia
PVR pulmonary vascular resistance
PWB partial weight-bearing
Px prescribing
QOL quality of life
R/O removal of
RA rheumatoid arthritis/room air
RAP right atrial pressure
Raw airway resistance
RBBB right bundle-branch block
RBC red blood cell
CHAPTER RDS respiratory distress syndrome
6
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
MISCELLANEOUS
313
RSV respiratory syncytial virus
RTA road traffic accident
RV residual volume
RVF right ventricular failure
S.C. Subcuticular
SA sinoatrial
SAB Subacromial bursa
SAH subarachnoid haemorrhage
SALT speech and language therapist
SaO2 arterial oxygen saturation
SB sinus bradycardia
SBE subacute bacterial endocarditis
SCI spinal cord injury
SDH subdural haematoma
SFL/SFR side flex left/right
SGAW specific airway conductance
SH social history
SHO senior house officer CHAPTER
6
SIJ sacroiliac joint
SIMV synchronized intermittent
mandatory ventilation
SL sublingual
SLAP superior labrum, anterior and
posterior
SLE systemic lupus erythematosus
SMA spinal muscular atrophy
SN swedish nose
SNAG sustained natural apophyseal glide
SOA swelling of ankles
SOB shortness of breath
MISCELLANEOUS
314
SOBAR short of breath at rest
SOBOE short of breath on exertion
SOOB sit out of bed
SpO2 pulse oximetry arterial oxygen
saturation
SpR special registrar
SPS single point stick
SR sinus rhythm
SRAW specific airway resistance
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
CHAPTER SVO2 mixed venous oxygen saturation
6
SVR systemic vascular resistance
SVT supra ventricular 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
MISCELLANEOUS
315
TBI traumatic brain injury
TCCO2 transcutaneous carbon dioxide
TCO2 transcutaneous oxygen
TED thromboembolic deterrent
TEE thoracic expansion exercises
TENS transcutaneous electrical nerve
stimulation
TFA transfemoral arteriogram
TFT thyroid function test
TGA transposition of 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 CHAPTER
6
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
tumour
MISCELLANEOUS
316
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
μm micrometer
URTI upper respiratory tract infection
μs microsecond
USS ultrasound scan
UTI urinary tract infection
V ventilation
V/p shunt ventricular peritoneal shunt
V/Q ventilation-perfusion ratio
CHAPTER VA alveolar ventilation/alveolar
6
volume
VAD ventricular assist device
VAS visual analogue scale
VATS video-assisted thoracoscopy
surgery
VBG venous blood gas
VC vital capacity/volume control
Vd dead space
VE minute ventilation
VE ventricular ectopics
VEGF vascular endothelial growth
factor
MISCELLANEOUS
317
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
OTHER IMPORTANT TERMINOLOGIES

Acr—across O—outward
Med—medical Tow—towards CHAPTER
Hor—horizontal
Incl—inclined
Betw—between
Lat—lateral
Obl—oblique
Und—under
6
L—left Beh—behind
B—backward Movt—movement
D—downward Sup—support
W/c—with Tog—together
Alt—alternate J—jump
Rhythm—rhythmically Spr—spring
Pend—pendulum Ass—assited
Stat—stationary Pass—passive
Opp—opposite Wd—wide
MISCELLANEOUS
318
Foll—Follwed Rev—reverse
Cont—continuously Reb—rebound
Rep—repeat Bal—balance
Res—resisted <—less than
>-more than o—no
#—frature —diagnosis
—circumduction
!!—parallel —abdomen
H—head Frh—forehead
N—neck B—back
T—trunk S—side
Abd—abdomen P—pelvis
Sh.bl—shoulder blades Sh—shoulders
A—arms Elb—elbows
Wr—wrists Hnd—hands
Fing—fingers L—legs
K—knees Hl—heels
CHAPTER F—feet Ank—ankles
6 Fra—forearm
Ly—lying
Yd—yards
St—standing
Wg—Wing
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
MISCELLANEOUS
319
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.
NORMAL REFERENCE/LAB VALUES

HEMATOLOGY
Male Female Units
Activated partial 35-45 35-45 Second
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
CHAPTER
6
Hemoglobin hb 13-18 11-16 G/dl
Hematocrit pcv 40-55 35-48 %
Mean MCH 28-32 28-32 Pg
corpuscular
hemoglobin
Mean MCHC 31-36 31-36 G/dl or %
corpuscular
hemoglobin
concentration
Mean MCV 78-98 78-98 FL
corpuscular
volume
Platelet count 1.5-4.0 1.5-4.0 Lakhs/cumm
Contd...
MISCELLANEOUS
320
Contd...
Male Female Units

Prothrombin 11-14 11-14 Seconds
time 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
(mean 50) (mean 18) Ug/ml
Total iron binding Tibc 250-450 250-450 Ug/dl
capacity
Total leucocyte TLC 4000- 4000- Million/cumm
count 11000 11000
Transferring 30-35 30-35 %
saturation
CHEMICAL PATHOLOGY
S –seurm, b-blood, p—plasma
CHAPTER
6
Investigation Reference value Units
S. alanine ALAT 5-35 U/l
Aminotransferase SGPT
P.ammonia 47-65 Umol/l
S.amylase 30-170 U/l
S aspartate ASAT
aminotransferase SGOT 5-40 U/l
P.bicarbonate 21-28 mmol/l
S. bilirubin Total 0.2-1.0 mg/dl
S. bilirubin conjugated 0.1-0.2 mg/dl
S.calcium Total 9.0-11.0 mg/dl
P. calcium 2.3-2.7 mmol/L
Contd...
MISCELLANEOUS
321
Investigation Reference value Units
B. CO2 content 19-24 mmol/L
S. chloride 95-105 meq/L
S.cholestrol 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 (post-
prandial 2 hours) <140 mg/dl
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 Upto 4 Units/L
S.phosphatase alkaline 40-100 Units/L
4-12 Ka units/dl
S. proteins total 5.5-8 Gm/dl CHAPTER
6
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.
MISCELLANEOUS
322
OTHER BODY FLUIDS
Reference value
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
Faecal fat excretion <6.0 g/day
Occult blood negative (<2 ml blood/
day)
Urobilinogen 40-200 mg/day
Cerebrospinal Fluid (CSF)

CHAPTER
6
CSF volume 120-150 ml
CSF pressure 60-150 mm water
Body volume
Total 50-70%
Intracellular 33%
Extracellular 27%.
323
References
1. Textbook of Electrotherapy, 1st edition 2005,
Jagmohan Singh, Jaypee Brothers.
2. Practical Medicine, 7th edition 2005, P.J. Mehta’s,
National Book Depot.
3. Chest X-rays, 1st edition 2006 P.A. Mahesh, B
Vidyasagar, B S Jayaraj, Orient Longman.
4. Physiotherapy for Respiratory and Cardiac
Problem 3rd edition 2004. Jennifer A pryor, S
ammani prasad, Churchill Livingstone.
5. Textbook of Therapeutic Exercises, 1st edition
2005, S lakshmi narayan, Jaypee Brothers.
6. Tidys Physiotherapy, 12th edition 1991, Ann
Thomson, Alison Skinner, Joan Piercy, Varghese
Publication.
7. Essential of Medical Pharmacology, 5th edition
2003, K.D. Tripathi, Jaypee Brothers.
8. Medicine for Students 14th edition 1988, A.F.
Golwalla, S.A. Golwalla.
9. Textbooks of Rehabilitation, 2nd edition 2002, S.
Sunder. Jaypee Brothers.
10. Physiotherapy in Neuro Conditions, 1st edition
2006, Glady Samuel raj, Jaypee Brothers.
11. Muscle testing, 7th edition 2002 helen J. Hislop,
Jacqueline Montgomey Harcount (INDIA) Private
Ltd.
12. Cash’s Textbook of Neurology for Physiotherapy,
4th edition, Jaypee Brothers.
REFERENCES
324
13. Cash’s Textbook of Cardiorespi for Physio-
therapy, 4th edition, Jaypee Brothers.
14. Cash’s Textbook of Orthopaedics for Physio-
therapy, 4th edition, Jaypee Brothers.
15. Goel’s Physiotherapy (vol III), Dr. R.N.Goel, 1st
edition 2006, Shubham Publication.
16. Physical Rehabilitation: Assessment and
Treatment, 4th edition 2001 O’ Sullivan, Thomas
J. Schmitz, Jaypee Brothers.
17. Dictionary of Physiotherapy, 2nd edition 2005,
Lakhau, Sujata, Pramod, Abhishek, AITBS
publishers.
18. Human Anatomy Regional and Applied, 3rd
edition 1995, 1, 2 and 3rd volume. B.D. Chaurasia,
CBS Publishers and Distributors.
Index
A C
Abductor digiti minimi (foot) Carbamazepine 5
158 Cardiorespiratory
Abductor digiti minimi monitoring 78
(hand) 158 Chloramphenicol 5
Abductor hallucis 158 Chloroquine 6
Abductor pollicis brevis 159 Chlorpromazine 5
Abductor pollicis longus 159 Ciprofloxacin 6
Acetazolamide 2 Clofazimine 6
Adductor brevis 160 Common musculoskeletal
Adductor longus 161 tests 236
Adductor magnus 161 Common sports injuries 290
Adductor pollicis 162 Contrast bath 33
Aerosol therapy 73 Coracobrachialis 165
Albendazole 2 Cranial nerves 124
Allopurinol 2 origination of nerve 124
Ambu bag 77 types of nerve 124
Amlodipine 3 Cryotherapy (cold therapy)
Amoxicillin 3 31
Anconeus 162
Aspirin 4
Atropine 4 D
Dapsone 6
Deltoid 165
B Diaphragm 166
Biceps brachii 163 Diazepam 7
Blood values and their inter- Diclofenac 7
fering factors 99 Diltiazem 7
Brachialis 164 Dobutamine 7
INDEX
326
Dopamine 7 Bennett’s fracture—
Dorsal interossei (foot) 167 dislocation 281
Dorsal interossei (hand) 167 Colles’ fracture 278
Doxycycline 8 Galeazzi fracture
dislocation 279
Mallet fracture 282
E Monteggia’s fracture
Extensor carpi radialis brevis dislocation 280
168 Rolado’s fracture 282
Extensor carpi radialis longus Smith’s fracture 281
168
Extensor carpi ulnaris 169
Extensor digiti minimi 169 G
Extensor digitorum brevis Gait terminology 292
170 Gatifloxacin 8
Extensor digitorum longus Gemellus inferior 180
171 Gentamicin 8
Extensor hallucis longus 171 Glasgow coma scale 132
Glossary of cardiorespiratory
terms 104
F Gluteus maximus 181
Flexor carpi radialis 174 Gluteus medius 182
Flexor digiti minimi brevis Gluteus minimus 183
(foot) 175 Gracilis 183
Flexor digiti minimi brevis Grades of sprain and
(hand) 175 treatment 275
Flexor digitorum accessorius
176
Flexor digitorum brevis 176 H
Flexor digitorum profundus Heparin 9
177 Hot packs (hydrocollator
Flexor hallucis brevis 179 packs)/electric heating
Flucloxacillin 8 pad 32
Fractures with eponyms 278 Humidity 74
Barton’s fracture 278 Hydrocortisone 9
INDEX
327
I M
Iliacus 184 Mannitol 11
Iliocostalis cervicis 185 Manual chest clearance
Iliocostalis lumborum 185 techniques 69
Iliocostalis thoracic 186 Manual hyperinflation 77
Infrared radiation 26 Methotrexate 12
Intercostalis externi 187 Microwave diathermy 30
Intercostalis interni 188 Miller’s grading system of
Interferential 20 sputum 52
Internal oblique 188 Modified ashworth scale for
Interspinalis 189 grading spasticity 133
Ischiocavernosus 189 Musculoskeletal assessment
Isoniazid 10 283
Isosorbide mononitrate 10 Musculoskeletal pathologies
263
J achondroplasia 263
Albers-Schonberg
Joint range of movement 226 disease 263
ankylosing spondylitis
K 264
Ketamine 10 arthrogryposis multiplex
congenita 264
types 264
L
bursitis 265
Laser therapy 23 carpal tunnel syndrome
Lateral cricoarytenoid 190 265
Latissimus dorsi 190 compartment syndrome
Levator scapulae 191 266
Levels of amputations 294 congenital dislocation of
Levodopa 11 hip 266
Lignocaine 11 congenital talipes equino
Longissimus capitis 192 varus (CTEV) 265
Longissimus cervicis 192 de Quervain’s disease
Lumbar spine 239 267
Lumbricals (hand) 195 Dupuytren’s contracture
Lung function test 75 267
INDEX
328
fibromyalgia 268 Charcot-Marie-Teeth
fibrositis 267 disease 137
Golfer’s elbow (medial disseminated ence-
epicondylitis) 268 phalomyelitis 137
myositis ossificans 268 Gullain Barre syndrome
osteoarthritis 268 (GBS) 138
osteochondritis 269 hydrocephalus 139
osteomalacia 270 locked in syndrome 140
osteomyelitis 270 motor neuron disease
Paget’s disease 270 140
polyarteritis nodosa 271 muscular dystrophy 142
polymyalgia rheumatica myasthenia gravis 142
271 parkinsonism 143
polymyositis 271 poliomyelitis 143
rheumatoid arthritis 272 posterior cord syndrome
spondylolisthesis 272 144
spondylosis 273 postpolio syndrome 144
systemic lupus pseudobulbar palsy 145
erythematous 273 sacral sparing 145
tennis elbow 274 Neurological tests 120
tenosynovitis 274 alter nose to finger test
thoracic outlet syndrome 120
274 alternate heel to knee test
121
N finger to nose test 120
joint position sense
National immunization (kinesthesia) 121
schedule 288 other balance tests 124
Neurological pathologies 134 temperature 122
Alzheimer’s disease 134 two point discrimination
anterior cord syndrome 123
134 vibration sense 123
arachnoiditis 134 Neuromuscular electrical
bulbar palsy 136 stimulation 28
central cord syndrome Norfloxacin 12
137 Normal reference values 319
cerebral palsy 136 chemical pathology 320
INDEX
329
O R
Obturator externus 196 Ranitidine 14
Omeprazole 13 Rectus abdominis 205
Opponens pollicis 197 Rectus capitis anterior 205
Oxytetracycline 13 Reflexes 129
pathological reflexes 131
P superficial reflexes 130
Respiratory assessment 101
Palpation of pulses 61
Respiratory pathologies 84
Pectoralis major 199
Respiratory volumes and
Pectoralis minor 200
Percussion note 57 capacities 49
technique 57 lung capacities 50
Peripheral nervous system lung volumes 49
115 Rhomboid major 208
axillary nerve 115 Rhomboid minor 208
common peroneal nerve Rifampicin 15
118
femoral nerve 117
median nerve 116
S
musculocutaneous nerve Salcatonin 15
115 Sauna bath 34
obturator nerve 117 Scalenus anterior 209
radial nerve 115 Scalenus posterior 210
sciatic nerve 117 Semimembranosus 210
tibial nerve 118 Semispinalis capitis 211
ulnar nerve 116 Semispinalis thoracis 212
Peroneus brevis 200 Semitendinosus 213
Peroneus longus 201 Senna 15
Peroneus tertius 201 Serratus anterior 213
Pethidine 13 Short wave diathermy 21
Postural drainage 63 Soleus 214
technique 289 Spinal traction 288
contraindications 289
Q effects 288
Quadratus femoris 204 indications 289
Quadratus lumborum 205 types 288
INDEX
330
Stages of fracture healing 276 Thoracic spine 239
cellular proliferation 276 Tibialis anterior 220
haematoma formation Tibialis posterior 221
276 Tinidazole 16
remodeling stage 277 Tracheostomies 72
stage of calcification 276 functions 72
Sternocleidomastoid 216 indications 72
Subscapularis 216 Transversus abdominis 222
Suctioning 70 Trapezius 223
contraindication 70 Triceps brachii 224
indications 70
modes of entry 70
Surface marking of the lungs U
47 Ultrasound 24
anterior border of left Ultraviolet radiation 22
lungs 47
anterior border of right
lung 47 V
apex 47 Vastus intermedius 225
diaphragm 48 Vastus lateralis 225
fissures 48 Vastus medialis 225
inferior and posterior Vecuronium 16
border of left lung 47 Ventilations 81
inferior border of right Vertebrae and
lung 47 corresponding spinal
posterior border of right segment relationship
lung 47 119
tracheal bifurcation 48 ascending tracts 119
descending tracts 119
T
Tensor fascia lata 219
W
Teres major 219 Warfarin 16
Teres minor 220 Whirlpool bath 32

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Pocket Book For Physiotherapist

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The Pocketbook for

The Pocketbook for Physiotherapists

© 2007, Jaypee Brothers Medical Publishers

First Edition: 2007

Typeset at JPBMP typesetting unit

Chapter 2 Electrotherapy ............................ 19

Chapter 3 Cardiorespiratory ..................... 43

Chapter 4 Neurology ................................. 107

Chapter 5 Musculoskeletal ....................... 157

Chapter 6 Miscellaneous .......................... 287

References ......................................................... 323

Index ................................................................... 325

1 Type: NSAIDs and antipyretic.

1 Type: Antimalarial drug.

1 Please refer tetracyclines.

1 Class: β adrenergic blocker.

2 – Acute 10-15 min

TRANSCUTANEOUS ELECTRICAL NERVE

PARAFFIN WAX BATH

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 aspect of the

Fig. 2.9: Motor points of the anterior aspect of the

Fig. 2.10: Motor points of the anterior

Fig. 2.11: Motor points of the posterior aspect of

Cardiorespiratory anatomy illustration

3 Lung function test

Fig. 3.1: Surface marking of the fissures and lobes

Fig. 3.3: The bronchopulmonary segments

ANTERIOR BORDER OF RIGHT LUNG CHAPTER

POSTERIOR BORDER OF RIGHT LUNG

ANTERIOR BORDER OF LEFT LUNGS

INFERIOR AND POSTERIOR BORDER OF

3 • Costal cartilage 4th rib

Inspiratory Reserve Volume (IRV)

Expiratory Reserve Volume (ERV)

Residual Volume (RV)

Minimal Volume (MV)

Total Lung Capacity (TLC)

Vital Capacity (VC)

Inspiratory Capacity (IC )

Functional Residual Capacity (FRC)

Characteristic Associated features Interpretation

MILLER’S GRADING SYSTEM OF SPUTUM

READINGS OF CHEST X-RAYS

3 Lateral view helps to easily indentify smaller

NORMAL CHARACTERISTICS OF A CHEST

3 Bronchiectasis—Multiple ring shadows.

ABNORMAL ECG FINDINGS

ABNORMAL BREATH SOUNDS CHAPTER

3 Whispering pectoriloquy: The whispered “99” can

Pleural Rub CHAPTER

It is due to roughening of the pleural surfaces as

3 Brachial: Cubital fossa.

Fig. 3.5: Posterior segment of right upper lobe

Fig. 3.6: Posterior segment of the left upper lobe

Fig. 3.7: Anterior segments of both upper lobes

Fig. 3.9: Superior and inferior segments of the