Baath University

College of Health Sciences

Department of Physical Therapy

English Medical Physical

Therapy

By Mr. Ghazi Salah

1
 ‫القسم األول‬

Physical Treatment
Rehabilitation
physical therapy,therapist PT
aoccupational OT
therapy,therapist
patient PT
Kine,kinesio
Motor/ mobility
sensory
mixed
Range of motion ROM
outerrange
innerrange
middlerange
contraction
Muscle action
exercise
Isotonic contraction
Concentric contraction
Eccentric contraction
Isometriccontraction
prime-movers (agonists)
antagonist

2
 synergistst
fixator
passive movement
Active movement
Active-Assistive Exc
cramp
contracture
muscle tone
Stretching
relaxe
inactive posture
Active posture
retract
elastic
losse
voluntary
balance
Equilibrium
Stability
forces
cravity
Levers
Anatomy position
Superior
Inferior
Posterior(dorsal)
Anterior(ventral)

3
 Medial
Lateral
distal
proximal
caudal
frontal-plane
sagittal-plane
horizontal-plane
sagittal-axis (z axis)
frontal axis (x axis)
longitudinal-axis (y axis)
flexion
Extension
hyperextension
Abduction
Adduction
internal-rotation
External-rotation
Circumduetion
-Lateral-flexion
Rotation
Inversion
Eversion
Drosi-flexion
Plantar-flexion
Palmar-flexion
Wrist-dorsar-flexion

4
 Ulnar-Odeviation
radial-deviation
Pronation
supination
horizontal-flexion
horizontal-extension
opposition
Retraction
Elevation
depression
elevation
depression
protraction
retraction
Push-up
Physical examination PE
examination
Past medical history PMH
primary
interview
signs
symptoms
Swelling
OEDEMA
Bulge
wapped
deep

5
 Compare side
synmetry
Deformity
Posture
temperature
Assess power
Hypertrophy
Atrophy
Hypothrophy
exaggerated
hardening
reflexes
deformity
stress
sweat
pallor
dizziness
clawlike
plana
Look for fixed joints
Goniometer
Disorders
Level
Changes
pelvimetry
systemic
Radicular

6
 Radiculopathy
refer pain
Frequency
Radiation
Tingling
numbness
Tremor
Precipitating
Blurred
Dull
aching
shooting
Compression
root
Sharp
Burning
colicky
heaviness
tightness
Intensity
Pattern
brittle
wheelchair
Traction
stability
Amputation
STUMP

7
 CONTRACTURE
adhesion
motivation
gait
PHASE
STANCE
SWING
walker
orthopedics
Splint
cast
immovable
arthroplasty
Arthroscope
Aspiration
curve
tilt
Bend
segmente
Firmly
Cutaneous
Somatic
Visceral
Neuropathic
Congenital
Referred
jugular

8
 Creatin kinase
glucosamine
Electromyography (EMG)
winging
Postoperative
Paralyasis
Bone defects
dystrophy
discolouration
Sprain
Subluxation
dislocation
avulsion
scoliosis
lordosis
Kyphosis
Kypholordosis
Round Back
Flat Back
Valgus
varus
recurvatumGenu
Genu valgum
Genu varnm
Talipes
flatfoot
Cuvus foot

9
 Hollow Chest
Funnel Chest = Pectus
Excevutum
Barrel Chest
Pigeon Chest = Pectus
Garinatum
Harrison's groove
Torticollis
Congenital Dislocation
Ankylosis
dyskinesia
Rheumatoid arthritis
Osteoarthritis OA
Ankylosing spondylitis
polyarthritis
degenerative
Chondromalacia
Meniscetomy
Herniated disk
sciatica
spondylolysis
spondylolisthesis
Exostosis
Calcify
Spondylosis
Rachischisis
Pott disease
Osteoporosis

10
 Osteomyelitis
osteodystrophy
osteogenesis
Osteo dystrophy
Dermatomyositis
Polymyositis
Chronic fatigue
Muscular dystrophy
Muscle weakness
Myasthenia gravis
Fibromyalgia syndrome
asterixis
ataxia
athetosis
Neurogenic arthropathy
Infections
Encephalitis
Bacterial meningitis
Viral meningitis
carsinoma
Sarcoma
Neoplasms
Neuroma
Chondroma
Ewing tumor
osteoma
osteochondroma

11
 Carpal tunnel syndrome
achondroplasia
Fracture
Obligue
Spiral
Impacted
Comminuted
Greenstick
Closed
open
Colles
Transverse
Compression
potts
Hallux valgus
Hammertoe
Heberden nodes
Hemarthrosis
radiculopathy
Band- like
redicular
Hemiplegia
embolism
Stroke
Stiff gait
Concussion
Parkinson

12
 multiple sclerosis
Cerebral Palsy
Polio
Decreased reflex
Alzheimer
Confusion
Epilepsy
Seizures
Urinary incontinence
Headaches
Hypertension
Atherosclerosis
Heart disease
Insomnia
vomiting
coughing
sneezing
hiccupping
rickets
Leg –calve-perthes disease
Reiter syndrome
bursitis
Paget disease
Gout

Diabetes mellitus
HIV

13
 Aneurysm

Hematoma
Multiple myeloma
cholecyslitis
Rectal lesion
Biliary colic
Renal colic
Small intrstine
Perforated duodenalulcer
Penetrating
duoddendluleer
Nausea
scotomas
Rabies
Skin rashes
Tuberculosis
thrombosis
emboli
articulations
Synovial joint
Asynovia
Wear and tear
tendons
bursa
Dense
Irregular
nourishes

14
 cushions
Concave
convex
Protect
Symphysis
Stress points
osteon
ossification
Osteoblast
osteoclast
calcified
Connective tissue
bursotomy
myeloblast
craniostosis
Radioactive
Paravertebral
blood
location
Reaction
Reduction of fracture
realignment
Pusforming
Wound
Invaded
Tract
Genitourinary

15
 trauma
Calcitonin
Arthroclasia
Auto graft
Allo graft/homo graft
Hetero graft
Myelogram
Prosthesis

secretes
secretions
metabolic
phagocyte
receptive aphasia
expressive aphasia
primitive
automatically
organs
heartbeat
digestion
Potential
conducting
threshold
swallowing
unmyelinated
Conscious
unaware

16
 ‫القسم الثاني‬
Pathology

Disorders
Heredity
Flight or flight
Rest and digest
Cerebral angiography
dissolve clot
Narcolepsy
process
peripheral
Giving way
merges
emerges
Interspinous
supraspinous
NERSING
Cigarette smoking
Tenorrhaphy
Cardiotonic
copper
controls

17
 functions
impulses
bilateral
Skeleton
Face (Facial)
Forehead (frontal)
Eye (ocular)
Mouth (oral)
Facial bones
Lacrimal
Hyoid
Grown
fovea
Cranium (Cranial)
Styloid process
Mastoid process
Occipital
Lambdoidal suture
Squamous suture
Coronal suture
sphenoid
parietal
nasal
Jows
maxilla
mandible
zygomatic

18
 Girdle
Appendicular
Upper extremity
Lower extremity
Clavicle
Scapula
Shoulder blade (scapular)
coraco
Sternoch

Arm
Forearm (antebrachial)
Humerus
Glenoid cavity
Shoulder joint
olecranon
Ulna
Radius
Carpals
Wrist
metacarpals
phalanges
Palm (palmar)
Fingers (phalangeal)
Pollucis
Indicis
Sternum

19
 Ribs
Costal cartilage
Costochondral
Chest (thoracic)
Trunk
Armpit (axillary)
Breast (mammary)
Navel (umbilical)
umbilicus
Groin (inguinal)
Ilium
pelvis
sacrum
coxa
Hip (iliac)
acetabulum
Glenoid fossa
Buttock (gluteal)
Femur
Thigh (femoral)
Trochanter
Tubercle
tuberostiy
genu
knee
Articular surface
Kneecap (patellar)

20
 kneecape
cartilage
Meniscus , menisci
Ligament
Cruciate ligaments
Toes (phalangeal)
Tibia
Fibula
malleolus
Tarsals
Ankle
Calcaneus
Talus
Foot (pedal)
Sole of foot (planter)
cuneiform
Spinal colum
spinal cord
Vertebral column
Cervical vertebrae
Thoracic vertebrae
Lumbar vertebrae
Sacral vertebrae
Coccygeal vertebrae
Atlas (1st cervical)
Axis (2nd cervical )
Cervical

21
 Thoracic
Lumbar
Sacral
Coccygeal
Atlas
Axis
Transverse process
Intervertebral disk
Body of vertebra
Process
Sinus
Spine
Spinous process
Foramen for spinal nerve
fibrocartilage
Annulus fibrosus
Nucleus pulpsus
Epicondyole
Facet
Foramen
Pedicle
flavum
Small of back (lumbar)
Long bone
Short bone
Epiphysis
Metaphysis

22
 diaphysis
Shaft
Spongy bone
Bone marrow
structure
Compact
Endo thelium
Periosteum
Larynx
Trachea
bronchi
Grove
lamella
Ridges
Fossa
Meatus
Notch
saddle
tuberosity
Fossa
Massive
border
ridge
tip
shallow
rim
underneath

23
 sperficial
Superficial
Over come
slope
Overlapping
broad
hiatus
Mass
gutter
Wedge
fused
Tall
tiny
Pillar
sleeve
Hiatus
Capsule
Arche
promontory
Laminae
Crest
tubercle
Smooth
Cardiac
Skeletal
Origins
insertion

24
 Orbicularis
Masseter
Orbicularis
Temporalis
Sternocleidomastoid
Serratus anterior
Trapezius
Spenius capitis
Rhomboid major and
minor
Deltoid
subscapula
Infraspinetior
Supraspinetior
Teres minor
Teres major
Rotator cuff
Pectoralis major
Biceps brachii
Triceps brachii
Brachioradialis
Flexor carpi
Extensor carpi
Internal oblique
Latissimus dorsi
Lumbodorsal
Rectus abdominis

25
 External oblique
Quadrates lumborum
Posas major
Iliacus
Gluteus maximus
Gluteus medius
Gluteus Minimus
Tensor facia latae
Quadriceps
Vastus Medialis
Vastus lateralis
Vastus intermedius
Rectus femoris
Adductors
sartorius
gracilis
Hamstring group
Biceps femoris
Semitendinosus
seminembranosus
Tibialis anterior
Peroneus longus
Extensor digitorum longus
Extensor digitorum brevis
Extensor hallucis longus
Peroneus longus
Peroneus linpus

26
 gastroxnemius
soleus
Tibialis posterior
Flexor hallucis longus
Flexor digitorum longus
Flexor digitorum brevis
Flexor hallucis longus
lumbricales
Dorsal interossei
abductor hallucis
Abductor digiti quinti
Thoracic cavity
Abdominal cavity
Abdominopelvic cavity
Pelvic cavity
Cranial cavity
Spinal cavity
Dorsal cavity
diaphragm
Right lumbar region
left lumbar region
Right iliac region
left iliac region
Right upper guadrant
Left upper guadrant
Right lower guadrant
Left lower guardant

27
 nervous system
Central nervous system (CNS)

peripheral nervous system

(PNS)
Cerebrum (Telencephalon)

Diencephalon

Brainstem
Cerebellum

Corpus cellosum
Pons
Medulla oblongata
Pineal gland
hemispheres
cerebral cortex
frontal lobe
parietal lobe

temporal lobe

occipital lobe

canals
ventricles
Lateral ventricles
third ventricle
Fourth ventrecle

28
 Brain Stem

sympathetic
parasympathetic
involuntary
cranial nerves
spinal nerves
Autonomic nerves

Olfactory
Optic
Oculomotor
Trochlear
Trigeminal
Abducens
Facial
Vestibulocochlear
Glossopharyngeal
Vagus
Accessory
Hypoglossal
Stimulates
gaps
Nodes of Ranvier
uninsulated
Synapse
Glial cells (neuroglia)

29
 insula
hippocampus
Neuron
Dendrite
Axon
Schwann cell
glial cell
myelin sheath
regeneration
Neurilemma
synapse
Dstrocytes
Microglial cells
oligodendroglia
Limbic System
subcortical
Meninges
Dura mater
Arachnoid
Pia mater
Ganglion
Hypothalamus
Pituitary gland
Pineal gland
supporting cells
Thalamus

30
 brain
cavities
Brachial plexus
Radial nerve
Median nerve
Ulnar nerve
Axillary nerve
Musculocutaneous nerve
Long thoracic nerve
Suprascapular nerve
Lateral pectoral nerve
Medial pectoral nerve
thoracodorsal nerve
Spinal accessory nerve
Femoral nerve
Obturator nerve
Superior gluteal nerve
inferior gluteal nerve
Sciatic nerve
Soma
Axon
dendrit
Axonotmesis
Rapture or Neurotmesis
Drop hand
Monkeys hand deformity
Scapula Alata

31
 Drop Foot
artery
carotid
Jugular
liver
peritoneum
biopsy BX

32
 ‫القسم الثالث‬

immediately STAT
quantity sufficient QS
keep vein open KVO
ambulatory AMP
Out of bed OOB
parallel
rectom
Serous
membrane
Extrathoracic
Intraabdominal
celiac
acro
acrodermatitis
brach
dactyl
polydactyly
ped
Circum
Peri
Intra
Epi

33
 Extra
Infra
Sub
Inter
Juxta
Para
Retro
supra
digit
epigastrium
hypochondrium
Lumen
Meatus
Orifice
Septum
Sphincter
Sinus
Fistula

Poly,multi
Quadr
Supra,super
Tri
Ultra
Ante,pre,pro
Brady
Tachy

34
 Post
Re
Con,syn,sym
Dys
Eu
neo
Acro
Aden/o
Aer/o
Angi/o,vas/o
Cardio
Carcin/o
Cephal/o
Cyt/o
Derm/o
Dextr/o
Fiber/o
Gastr/o
Gen/o
Gluc/o
Hem/o, hemat/o
Hydr/o
Leuk/o
Lip/o
Lith/o
Nas/o
Necr/o

35
 Orth/o
Oste/o
Path/o
Ped/o
Phob/o
hepat
A,an
Anti,contra
de
Ab
Circum, peri
Dia, trans
E,ec,ex,ecto,exo,extra
En,endo,intra
epi
Inter
Meso
Meta
Para
Retro
Sub,infra
Bi
Hemi,semi
Hyper
Hypo

Macro

36
 Micro

Mono,uni

Oligo

pan
Algia,dynia
Lysis
Megaly
Oid
Penia
Rrhea
Spasm
Cele
Ectasis
Emia
Iasis
It is
Malacia
Oma
Osis
phil
rrhage
Rrhexis
Desis

37
 Ectomy
Plasty
Tomy
Stomy
Tripsy
Ist
Meter
Poiesis
stasis
Thoracoplasty
Anphonia
anaerobic
Apnea
Anoxia
anorxia
anticogulant
contraception
decapitate
decompression
decongestant
Abnormal
Circumvascular
Periosteum
Dialysis
Edentia
Eccentric
Excise

38
 Ectopic
Exocrine
Extravascular
Encapsulate
Endoscope
Intradermal
Epidermal
Entercostal
Mesomorphic
Metastasis
Metamorphosis
Paramedic
Infraumbilical
Sublingual
Bilateral
Hemicephalic
Semilunar
Hyperlipemia
Hypothermia
Macrocyte
Microlith
Unilateral
oliguria
Hemogram
Hematology
hepatoma
Leukocyte

39
 Lipoid
Lithiasis
Necrocytosis
Oral
Orthostatic
Osteal
Pathology
Pediatrics
Pedal
hydrophobia
Tomy
Stomy
ectomy
Incision
excision
Polyphobia
Multicellular
Quadriplegia
Suprarenal
Triangle
Ultrasonic
Antepartum
Premature
Prognosis
Bradycardia
Tachycardia
Postoperative

40
 Reactive
Syndactylism
Congential
Dysphonia
dysphahia
Eugenic
neoplasia
Acrodynia
Acrophobia
Edenoma
Angioplasty
Vasectomy
Vascular
Carcinogenic
Cardiologist
Cephalic
Dermal
Cutaneous
Dextrocardia
Erythrocardia
Fibroma
Gastric
osteogenic
cephalagia
Cephalodunia
myalgialiga
Arthralgia

41
 Neuralgia
Causalgia
analgesia
Hemolysis
Hepatomegaly
Cardiomegaly
spleenomegaly
Lipoid
Vasospasm
Gastroxele
Angiectasis
Hyperlipemia
Hepatitis
Osteomalacia
carcinoma
Sclerosis
Lukocytosis
Basophil
Hepatorrhexis
Arthrodesis
Osteorrhaphy
herniorrhaphy
nephrorrhaphy
Laparotomy
Lithotripsy
mastectomy
pharmacist

42
 hemostasis
orthostasis

PT
PTA
diagnosis DX
H/o
Mm
MMT
C/O
LTG
PROM
ROM
Mobs
FIM score
CT
EMG
Rx
HOB
HP
E Stim
TENS
HVGS
Ex
Ther Ex
HEP
US

43
 ultraviolet UV
CPM
CTx
Tx
STM
PNF
W/c
KAFO
RICE
NSAID(s)
GHJ
C
T
L
S
CO
MCP
PIP
MTP
TMJ
PCL
MCL
LCL
I
CA
CNS
PNS

44
 NMS
CSF
ton
AP
LL
PA
RL
UE
LE
Flex
Abd
Add
Pro
Sup
ER
IR
PF
DF
Ev
Inv
SB
Rot
CKC
OKC
DJD
DVT
CTS

45
 CVA
BP
DM
Fx
MS
HTN
RA
OA
DJD
HNP
FX
THA
TKA
ORIF
Ortho
BMD
LM
HA
COG
AE
AK
BE
BK
BKA
CPR
CSF
ADL

46
 BP
BPM
ETOH
F
H/O
H&P
HR
I&O
IVDA
p
respiration R
rule out R/O
temperature T
TPR
vital signs VS
RX
b.i.d
d
a.c
p
h
h.s
noc
p.r.n
Qd
qh
Q2h

47
 t.i.d
q.i.d
Stat
Wk
Yr
Sl
p.o
Im
Iv
Id
Sc,so
p.r
p.v
Tab
Cap
Supp
Gt
Gtt
Elix
Ung
Susp
Ag
Lp
Sa

48
 Nervous system
By: N. AKHRASS, M.D.,
A.B.I.M.
Introduction
• The nervous system is a complex network of structures that activates & controls all
functions of the body and receives all input from the environment.

• It controls body functions with electric impulses.

• It has 2 types of cells : the neuron (the basic structure) & the neuroglia (the
supporting cells.

Anatomy – nervous system

• (CNS) central nervous system
 brain

 spinal cord

• (PNS) peripheral nervous system

 cranial nerves

 spinal nerves

 autonomic nerves

49
 CNS - The Brain
• Portion of CNS contained within the cranium.

• It is composed of :

 Cerebrum (Telencephalon)

 Diencephalon

 Brainstem

 Cerebellum

• Cerebrum
• Largest part of brain

• Composed mostly of white matter

• Also houses cerebral cortex

• Thin outer layer of gray matter

• Higher brain functions

• Divided into two hemispheres

• Deep groove separates hemispheres

50
 called longitudinal fissure

• On the surface of the cerebrum, nerve cells lie in sheets, called the cerebral cortex.

• Cerebral cortex has folds called gyri (s = gyrus) which are separated from each
other by grooves, known as sulci (s = sulcus).

• Each hemisphere is subdivided into four major lobes:

• frontal lobe

• parietal lobe

• temporal lobe

• occipital lobe

• The two cerebral hemispheres are interconnected by corpus callosum.

• In the middle of the cerebrum, there are spaces, or canals, called ventricles.

• The ventricles are four in number :

2 lateral ventricles 3rd ventricle 4th ventricle.

• The ventricles are interconnected cavities filled with cerebrospinal fluid ( CSF ).

• CSF is a clear fluid circulating in and around the brain & the spinal cord.

• CSF protects the brain and spinal cord – like a cushion.

• Ependymal cells are the cells which make CSF.

51
 The Diencephalon
Contains:

• Thalamus

• Hypothalamus

• Pituitary gland

• Pineal gland

• A region encircling the third ventricle

• Consists of hypothalamus and thalamus

• Hypothalamus forms floor of the third ventricle

• Thalamus consists of two masses of gray matter located in the sides and
roof of the third ventricle

• Also located in the diencephalon

• Secretes melatonin

• The hypothalamus is connected with the pituitary gland & it controls the
secretions of it.

• The pineal gland is also located in the diencephalon & it secretes melatonin.

52
 The brainstem
• It containst

 the midbrain

 the pons (the bridge)

 the medulla oblongata

The cerebellum
 Separated from the brainstem by the fourth ventricle

 Receives sensory input from the eyes, ears, joints, and muscles

 Sends motor impulses out the brainstem to the skeletal muscles

CNS - The Spinal Cord

• Extends from medulla oblongata to between 1st and 2nd lumbar vertebrae

• Consists of:

• Gray matter

• Central area surrounded by white matter

• White matter

• Contains tracts for impulses

53
 Meninges
• Set of three protective layers covering brain and spinal cord

• Dura mater

• Outermost layer

• Arachnoid

• Middle layer

• Pia mater

• Thin, vascular inner layer

• Attached directly to brain and spinal cord tissue

• Spaces between meninges are filled with cerebrospinal fluid

• Fluid is continuous with that of central canal of spinal cord and the ventricles of
the brain

Peripheral nervous system (PNS)

It contains :

 Cranial nerves

 Spinal nerves

 Autonomic nervous system

54
 Nerves
 Bundles of neuron fibers in PNS

 Ganglion = collection of cell bodies along nerve pathway

 Most nerves contain both sensory and motor fibers

Cranial nerves
12 pairs of nerves arising from the brain .

 I – Olfactory (sensory) : Smell .

 II – Optic (sensory) : Vision .

 III – Oculomotor : Eye movement & pupil

size.

 IV – Trochlear (motor) : Eye movement.

 V - Trigeminal :

o V.1 – Ophthalmic (sensory) : Face & scalp sensation .

o V.2 – Maxillary (sensory) : Mouth & nose sensation .

o V.3 – Mandibular (mixed) : Chewing .

 VI – Abducens (motor) : eye movement .

 VII – Facial (mixed) :

o Face & scalp movement

o Tongue taste sensation

o Ear pain & temperature

 VIII – Vestibulocochlear (sensory) : Hearing & balance

 IX – Glossopharyngeal (mixed) :

o Sensation in the ear

o Tongue & throat sensations

o Throat movement

 X – Vagus (mixed) :

55
 o Throat, voice box, chest, & abdominal sensations

o Voice box & throat movement

o Chest movement

 XI - Accessory (motor) : Neck muscle movement

 XII – Hypoglossal (motor): Tongue movement.

Spinal Nerves
 31 pairs of spinal nerves connect with spinal cord

 Grouped in segments:

• Cervical (8)

• Thoracic (12)

• Lumbar (5)

• Sacral (5)

• Coccygeal (1)

 Nerves joins cord by two roots:

• Posterior (dorsal)

 Carries sensory impulses into spinal cord

• Anterior (ventral)

 Carries motor impulses from spinal cord to muscle or gland

Autonomic nervous system

56
 • Regulates activity of cardiac and smooth muscle, and glands

• Divided into sympathetic and parasympathetic divisions

• Function automatically and usually in an involuntary manner

• Innervate all internal organs

• Utilize two neurons and one ganglion for each impulse

Sympathetic nervous system

• Originate from:

T1 – T12 &

L1 – L2 .

 Stimulates body responses:

• “Fight-or-flight” response

• Increased heart rate

57
 • Increased respiration rate

• Activates adrenal gland

• Delivers more blood to skeletal muscles

Parasympathetic
• Originate from the nuclei of :

cranial nerves III, VII, IX, X.

sacral nerves S2 – S4

 Parasympathetic nervous system :

• “Rest & digest”.

• Returns body to steady state.

• Stimulates maintenance activities.

• Promotes all internal responses associated with a relaxed state.

• Promotes digestion and retards heartbeat.

-------------------------------------------------------------------------------------------------------------------------

Nervous system
Histology
The Neuron
 Basic functional unit of nervous system

 Two types of fibers extend from cell body

• Dendrite

 Carries impulses toward cell body

• Axon

 Carries impulses away from cell body

 Some covered with myelin.

 Any long axon is also called a nerve fiber

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 Types of Neurons
• Motor Neurons
• Accept nerve impulses from the CNS

• Transmit them to muscles or glands

• Sensory Neurons
• Accept impulses from sensory receptors

• Transmit them to the CNS

• Interneurons
• Convey nerve impulses between various parts of the CNS

• Dendrite : microscopic branching fiber of a nerve cell that is the first part to
receive the nervous impulse.

• Cell body (soma) : part of a nerve cell that contains the nucleus.

• Axon : microscopic fiber that carries the nervous impulse along a nerve cell.

• Schwann cell :
• It is a variety of glial cell .

• Present only in PNS.

• Keeps peripheral nerves (both myelinated & unmyelinated) alive.

• Forms myelin sheath in myelinated axons.

• Supports nerve regeneration.

• Myelin sheath : fatty tissue that surrounds, protects, & insulates the axon of a
nerve cell.

this sheath increases the efficiency of nerve impulse transmission.

These sheaths are white in color (white matter).

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  Neurilemma (Neurolemma) :
• Etymology: G. = neuron + lemma = sheath.

• It is the thin membrane spirally enwrapping the myelin layer of myelinated

nerves or the axons of unmyelinated nerves.

• It is the plasma membrane of Schwann cell.

• Called also the sheath of Schwann.

• It has a role in the regeneration of peripheral nerves & the rapid

transmission of impulses.

 Nodes of Ranvier :
• Are the gaps between the myelin sheaths.

• Here, the axons are uninsulated & exposed to the interstitial space and
where voltage – dependent Na+ channels are clustered in the axonal
membrane.

 This allows action potentials to propagate rapidly by jumping from node to node
in a

process called saltatory conduction.

 Synapse :
o From the Greek synapsis, “ a point of contact ”.

o It is a structure specialized for information transfer from the axon to

muscle, to glands, or to another neuron.

o Synapses between neurons most often occur between axons and dendrites
but may occur between an axon and a cell body, between two axons, or
between two dendrites.

 Ganglion:

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 o Pleural : ganglia.

o It is a collection of nerve cell bodies in the peripheral nervous system.

Glial cells (neuroglia)

• Gli/o = glue.

• Cells in the nervous system that do not carry impulses but are supportive &
connective in function

• Examples are astrocytes, microglial cells & oligodendroglia.

• There are about 100 billion glial sells.

Astrocytes
• A glial cell

• serve a variety of metabolic, immunologic, structural, and nutritional support

functions required for normal function of neurons.

• Astrocytes express voltage and Ligand -gated ion channels and regulate K+ and Ca+
concentrations within the interstitial space.

• provide structural and trophic support for neurons.

• End-feet of astrocytic processes at blood vessels provide sites for release of

cytokines and chemoattractants during CNS injury .

• play an important role also in terminating neuronal responses to glutamate, the

most abundant excitatory neurotransmitter in the brain

Oligodendrocytes
• Form the myelin sheath covering axons in the CNS.

• Microglia A microglial cell is a phagocyte.

• activated by brain injury, infection, or neuronal degeneration.

• Ependymal cellA cell that lines the fluid – filled sacs of the brain & spinal cord.

Function
• Nervous system has three specific functions

• Receiving sensory input

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 • Performing integration

• Generating motor output

Functions of the parts of the brain

• Cerebrum : thinking, personality, sensations, movements, memory.

• Thalamus : relay station for sensory impulses ; pain.

• Hypothalamus : body temperature, sleep, appetite, emotions, control of the

pituitary gland.

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 Limbic System
• Complex network of tracts and “nuclei”

• Incorporates medial portions of

• The cerebral lobes,

• The subcortical basal nuclei, and

• The diencephalon.

• Integrates higher mental functions and primitive emotions

• Hippocampus

• Amygdala (fear)

• limbic system : (limbus = ring). A ring-shaped area in the centre of the brain
consisting of a number of connected clusters of nerve cells. The limbic system
plays a role in influencing the autonomic nervous system, which automatically
regulates body functions; the emotions; and the sense of smell. The system is
extensive, and contains various different substructures including the hippocampus,
the cingulate gyrus, and the amygdala.

• It is now known that the limbic system is a center for basic emotional drives.

• There are few synaptic connections between the cerebral cortex and the
structures of the limbic system, which perhaps helps to explain why we have so
little conscious control over our emotions.

Cerebellum
• Separated from the brain stem by the fourth ventricle

• Receives sensory input from the eyes, ears, joints, and muscles

• Sends motor impulses out the brain stem to the skeletal muscles

Function : coordination of voluntary movements & balance.

Brain Stem
Contains the midbrain, the pons, and the medulla oblongata

• Midbrain:

Acts as a relay station for tracts passing between the cerebrum, and The spinal cord or
cerebellum

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 • Pons
• Helps regulate breathing and head movements

• connects the cerebellum & cerebrum to the rest of the brain .

• nerves to the eyes and face.

• Medulla oblongata
• Contains reflex centers for vomiting, coughing, sneezing,
hiccupping, and swallowing .

• nerve fibers cross over, left to right & right to left .

• contains centers to regulate heart, blood vessels, and respiratory

system.

Spinal Cord
• The spinal cord has two main functions

• Center for many reflex actions

• Means of communication between the brain and spinal nerves

• The spinal cord is composed of gray matter and white matter

• Cell bodies and short unmyelinated fibers give the gray matter its color

• Myelinated long fibers of interneurons running in tracts give white matter

its color

Peripheral Nervous System

• Functionally is divided into :

• Somatic system

• Autonomic system

• Somatic system
• Contains cranial nerves and spinal nerves

• Gather info from sensors and conduct decisions to effectors

• Controls the skeletal muscles

• Conscious of its activity

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 • Autonomic system
• Controls the smooth muscles, cardiac muscles, and glands

• Usually unaware of its actions

• Divided into two divisions

• Sympathetic division

• Parasympathetic division

Autonomic System
• Regulates activity of cardiac and smooth muscle, and glands

• Divided into sympathetic and parasympathetic divisions

• Function automatically and usually in an involuntary manner

• Innervate all internal organs

• Utilize two neurons and one ganglion for each impulse

• Sympathetic and Parasympathetic Divisions

• Sympathetic division

• Especially important during fight or flight responses

• Accelerates heartbeat and dilates bronchi

• Parasympathetic division

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 • Promotes all internal responses associated with a relaxed state

• Promotes digestion and retards heartbeat

• Nerve Impulses:
Resting Potential
Resting Potential

• The membrane potential (voltage) when the axon is not conducting an

impulse

• The inside of a neuron is more negative than the outside -65 mV

• Due in part to the action of the sodium-potassium pump

Action Potential
• An action potential is generated only after a stimulus larger than the threshold

• Gated channel proteins

• Suddenly allows sodium to pass through the membrane

• Another allows potassium to pass through other direction

Propagation of Action Potentials

• In myelinated fibers, an action potential at one node causes an action potential at
the next node (Saltatory (jumping) Conduction).

• Conduction of a nerve impulse is an all-or-nothing event

Intensity of signal is determined by how many impulses are generated within a given
time span

Transmission Across a Synapse

• A synapse is a region where neurons nearly touch

• Small gap between neurons is the synaptic cleft

• Transmission across a synapse is carried out by neurotransmitters

• Sudden rise in calcium at end of one neuron

• Stimulates synaptic vesicles to merge with the presynaptic membrane

• Neurotransmitter molecules are released into the synaptic cleft

Synaptic Integration

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 • A single neuron is on the receiving end of

Many excitatory signals, and Many inhibitory signals

• Integration

• The summing of signals from Excitatory signals, and Inhibitory signals

-----------------------------------------------------------------------------------------------------------------

Pathology
Vascular Disorders
• Stroke or cerebrovascular accident

• Any occurrence of brain tissue not getting oxygen

• 3rd leading cause of death in developed world

• Leading cause of neurologic disability

• Risk factors:

• Hypertension

• Atherosclerosis

• Heart disease

• Diabetes mellitus

• Cigarette smoking

• Heredity

Thrombosis
• Formation of blood clot in vessel, often in carotid artery

• Sudden blockage caused by traveling obstruction termed embolism

• Diagnosed with:

• Cerebral angiography

• CT scans

• Other radiographic techniques

• Treatment

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 • Carotid endarterectomy

• Drugs to dissolve clot

Aneurysm
• Localized dilation of vessel

• May rupture and cause hemorrhage

• Causes:

• Congenital

• Atherosclerosis

• Hypertension

• May lead to:

• Aphasia

• Hemiplegia

Trauma
• Epidural hematoma
• Bleeding between dura mater and skull bone

• Usually results from blow to side of head

• Subdural hematoma
• Bleeding between dura mater and arachnoid

• Usually results from blow to front or back of head

• Concussion
• Can result from blow to head or fall

• May also encounter countercoup injury

Infections
• Bacterial meningitis

• Inflammation of meninges

• Common symptom is stiff neck

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 • Diagnosed with lumbar puncture

• Viral meningitis (another form)

• Encephalitis (inflammation of the brain)

• Also includes other viruses that affect CNS:

• Rabies

• Polio. HIV

Neoplasms
• Tumors originating in nervous system, usually involving neuroglia

• Called gliomas

• Symptoms are dependent on size and location:

• Seizures

• Headaches

• Vomiting

• Muscle weakness

• Interference with one of the senses (hearing, vision)

Degenerative Diseases
• Multiple sclerosis
• Patchy loss of myelin with hardening of tissue in CNS

• Symptoms:

• Vision problems

• Tingling, numbness in arms

• Urinary incontinence

• Tremor

• Stiff gait

• Exact cause is unknown

• Parkinson disease
• Failure of midbrain neurons to secrete dopamine

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 • Leads to:

• Tremors

• Muscle rigidity

• Flexion at joints

• Akinesia

• Emotional problems

• Treated with L-dopa

• Alzheimer disease
• Unexplained degeneration of neurons

• Atrophy of cerebral cortex

• May cause:

• Progressive loss of recent memory

• Confusion

• Mood changes

• Multi-infarct dementia
• Symptoms resemble those associated with AD

• Caused by multiple small strokes

Epilepsy
• Seizures caused by abnormal electric brain activity

• Seizures vary:

• Brief and mild (petit mal)

• Major (grand mal)

• Serious seizures result in loss of consciousness and convulsions

• Diagnosed with EEG revealing brain activity abnormalities

• Treated with antiepileptic and anticonvulsive drugs

Sleep Disturbances
• Dyssomnia = general term for sleep disorders

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 • Insomnia

• Insufficient or nonrestorative sleep

• Narcolepsy

• Brief, uncontrollable “attacks” of sleep

• Treated with:

• Stimulants

• Regulation of sleep habits

• Short daytime naps

• Sleep apnea

• Failure to breathe for brief periods during sleep

• Usually results from upper airway obstruction

• Diagnosed with:

• Physical examination

• Sleep history

• Log of sleep habits

• Details of sleep environment

• Consumed substances that may interfere with sleep

• Polysomnography

• Study in sleep laboratory

• Characterize two components of sleep

• Non-rapid eye movement (deep sleep stage)

• Rapid eye movement (dream stage)

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 Pain Types
By: N. AKHRASS, M.D.,
A.B.I.M.
Pain is often the primary symptom in many physical therapy practices.

Pain assessment is a key feature in the physical therapy interview.

Pain is now recognized as the "fifth vital sign“ along with blood pressure,
temperature, heart rate, and respiration

Recognizing pain patterns that are characteristic of systemic disease is a necessary

step in the screening process.

Understanding how and when diseased organs can refer pain to the
neuromusculoskeletal (NMS) system helps the therapist identify suspicious pain
patterns.

ASKING ABOUT PAIN

 Onset

 Location

 Duration

 Frequency

 Radiation

 Quality

 Quantity

 Precipitating

 factors

 Palliating factors

 Associated manifestations

 This information is then compared with presenting features of primary

musculoskeletal lesions that have similar patterns of presentation.

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  Pain patterns of the chest, back, shoulder, scapula, pelvis, hip, groin, and
sacroiliac joint are the most common sites of referred pain from a systemic
disease process

 A large component in the screening process is being able to recognize the

client demonstrating a significant emotional overlay.

 Pain patterns from cancer can be very similar to what we have traditionally
identified as psychogenic or emotional sources of pain. It is important to
know how to differentiate between these two sources of painful symptoms.

Referred pain

 Characteristics: a dull, deep, aching, and difficult to localize.

 Pathophysiology: The brain has difficulty distinguishing the true source of

pain when afferent nerve fibers from two separate sites converge, and so
pain is perceived vaguely in multiple areas

Axial pain

 Characteristics: Dull, deep, aching, localized.

 Pathophysiology: Stimulation of the nerve endings within the structure that is

also the source of pain.

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 Radicular pain

 Characteristics: Lancinating, shooting, electric, band-like.

 Pathophysiology: Compression of a dorsal root ganglion or inflammation of a

nerve root

Radiculopathy

 Characteristics: Weakness, numbness, tingling, decreased reflexes.

 Pathophysiology: Ischemia or compression of a nerve root.

ASSESSMENT OF PAIN
AND SYMPTOMS

 The interviewing techniques and specific questions for pain assessment must
be learned.

 The information gathered during the interview and examination provides a

description of the client that is clear, accurate, and comprehensive.

 easuring pain and assessing pain are two separate issues.

 A measurement assigns a number or value to give dimension to pain

intensity. A comprehensive pain assessment includes a detailed health
history, physical exam, medication history (including nonprescription drug
use and complementary and alternative therapies), assessment of functional
status, and consideration of psychosocial-spiritual factors.

 The portion of the core interview regarding a client's perception of pain is a

critical factor in the evaluation of signs and symptoms.

 Questions about pain must be understood by the client and should be

presented in a nonjudgmental manner.

 A record form may be helpful to standardize pain assessment with each client

 To elicit a complete description of symptoms from the client, the physical

therapist may wish to use a term other than pain.

 For example, referring to the client's symptoms or using descriptors such as

hurt or sore may be more helpful with some individuals.

 Burning, tightness, heaviness, discomfort, and aching are just a few examples
of other possible word choices.

Characteristics of Pain

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  It is very important to identify how the client's description of pain as a
symptom relates to sources.

 Many characteristics of pain can be elicited from the client during the
Interview to help define the source or type of pain in question

These characteristics include:

 • Location

 • Description of sensation

 • Intensity

 • Duration

 • Frequency and Duration

 • Pattern

 Other additional components are related to factors that aggravate the

pain, factors that relieve the pain, and other symptoms that may occur in
association with the pain.

 Keep in mind that an increase in frequency, intensity, or duration of

symptoms over time can indicate systemic disease.

Location of Pain

 The examiner may ask questions such as:

 Show me exactly where your pain is located.

 Do you have any other pain or symptoms

 anywhere else?

 If yes, what causes the pain or symptoms to occur in this other area?

Description of Pain

 The examiner may ask questions such as:

• What does it feel like?

• Is your pain/Are your symptoms:

 Knifelike, Dull, Boring, Burning, Throbbing, Prickly, Deep aching, or Sharp.

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  When a client describes the pain as knifelike, boring, colicky, coming in
waves, or a deep aching feeling, this description should be a signal to the
physical therapist to consider the possibility of a systemic origin of
symptoms.

 Dull, somatic pain of an aching nature can be differentiated from the aching
pain of a muscular lesion by squeezing or by pressing the muscle overlying
the area of pain.

 Resisting motion of the limb may also reproduce aching of muscular origin
that has no connection to deep somatic aching.

Intensity of Pain

 The level or intensity of the pain is an extremely important, but difficult,

component to assess in the overall pain profile.

 Psychologic factors may play a role in the different ratings of pain intensity.

 Some difference is observed between women and men.

 Likewise, pain intensity is reported

 as less when the affected individual has some means of social or emotional
support.

 Multiple scales are available.

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 Frequency and Duration of Pain

 The frequency of occurrence is related closely to the pattern of the pain, and
the client should be asked how often the symptoms occur and whether the
pain is constant or intermittent.

 Duration of pain is a part of this description.

 EX: How long do the symptoms last?

 pain related to systemic disease has been shown to be a constant rather than
an intermittent type of pain experience.

 Clients who indicate that the pain is constant should be asked:

• Do you have this pain right now?

• Did you notice these symptoms this morning immediately when you
woke up?

 pain of musculoskeletal origin usually can be reduced with rest or change in

position.

Pattern of Pain

 After listening to the client describe all the characteristics of his or her pain or
symptoms, the therapist may recognize a vascular, neurogenic,
musculoskeletal (including spondylogenic), emotional, or visceral pattern
(Table).

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  The following sequence of questions may be helpful in further assessing the
pattern of pain:

• Tell me about the pattern of your pain/ symptoms.

• When does your back/shoulder (name the involved body part) hurt?

• Describe your pain/ symptoms from first waking up in the morning

to going to bed at night.

• Have you ever experienced anything like this before?

• How does your pain/symptom(s) change with time?

• Are your symptoms worse in the morning or evening?

The pattern of pain associated with systemic disease is often a progressive pattern
with a cyclical onset (i.e., the client describes symptoms as being alternately worse,
better, and worse over a period of months).

When there is back pain, this pattern differs from the sudden sequestration of a
discogenic lesion that appears with a pattern of increasingly worse symptoms
followed by a sudden cessation of all symptoms. Such involvement of the disk occurs
without the cyclical return of symptoms weeks or months later, which is more typical
of a systemic disorder

Aggravating and Relieving Factors

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 A series of questions addressing aggravating and relieving factors must be included
such as:

• What brings your pain (symptoms) on?

• What kinds of things make your pain (symptoms) worse (e.g., eating, exercise,
rest, specific positions, excitement, stress)?

To assess relieving factors, ask:

• What makes the pain better?

Follow-up questions include:

• How does rest affect the pain/symptoms?

• Are your symptoms aggravated or relieved by any activities?

• If yes, what?

• How has this problem affected your daily life at work or at home?

• How has this problem affected your ability to care for yourself without assistance
(e.g., dress, bathe, cook, drive)?

Systemic pain tends to be relieved minimally, relieved only temporarily, or

unrelieved by change in position or by rest. However, musculoskeletal pain is often
relieved both by a change of position and by rest.

Associated Symptoms

 These symptoms may occur alone or in conjunction with the pain of systemic
disease.

The client may or may not associate these additional symptoms with the chief
complaint.

The physical therapist may ask:

• What other symptoms have you had that you can associate with this problem?

 If the client denies any additional symptoms, follow up this question with a
series of possibilities such as:

Burning, Heart palpitations, Numbness/Tingling, Difficulty in breathing,

Hoarseness, Problems with vision, Difficulty in swallowing, Nausea, Vomiting,
Dizziness, Night sweats, Weakness.

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 Whenever the client says "yes" to such associated symptoms, check for the presence
of these symptoms bilaterally. Additionally, bilateral weakness, either proximally or
distally, should serve as a red flag possibly indicative of more than a musculoskeletal
lesion.

 Blurred vision, double vision, scotomas (black spots before the eyes), or
temporary blindness may indicate early symptoms of multiple sclerosis or
may possibly be warning signs of an impending cerebrovascular accident.

The presence of any associated symptoms, such as those mentioned here, would
require contact with the physician to confirm the physician's knowledge of these
symptoms

 In summary, careful, sensitive, and thorough questioning regarding the

multifaceted experience of pain can elicit essential information necessary
when making a decision regarding treatment or referral.

SOURCES OF PAIN

 Physical therapists frequently see clients whose primary complaint is pain,

which often leads to a loss of function.

However, focusing on sources of pain does not always help us to identify the
causes of tissue irritation.

 Recently, there has been a move from classifying pain on the basis of disease,
duration, and body part or anatomy to a mechanism- based classification.

In this approach the major goal of assessment is to identify the pathophysiological

mechanism of the pain and use this information to plan appropriate intervention.

 The most effective physical therapy diagnosis will define the syndrome and
address the causes of pain rather than just identifying the sources of pain.
Usually, a careful assessment of pain behavior is invaluable in determining
the nature and extent of the underlying pathology.

 The clinical evaluation of pain usually involves identification of the primary

disease/etiological factor(s) considered responsible for producing or initiating
the pain.

The client is placed within a broad pain category usually labeled as nociceptive
(e.g., pinprick), inflammatory (e.g., tissue injury), or neuropathic pain

 We further classify the pain by identifying the anatomical distribution,

quality, and intensity of the pain.

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 Such an approach allows for physical therapy interventions for each identified
mechanism involved.

 From a screening perspective we look at the possible sources of pain and

types of pain.

When listening to the client's description of pain, consider these possible sources
of pain :

• Cutaneous

• Somatic

• Visceral

• Neuropathic

• Referred

Cutaneous Sources of Pain

 Cutaneous pain (related to the skin) includes superficial somatic structures

located in the skin and subcutaneous tissue.

The pain is well localized as the client can point directly to the area that "hurts."
Pain from a cutaneous source can usually be localized with one finger.

Somatic Sources of Pain

 Somatic pain can be superficial or deep.

 Superficial somatic structures involve the skin, superficial fasciae, tendons

sheaths, and periosteum.

 Deep somatic pain comes from pathologic conditions of the periosteum and
cancellous (spongy) bone, nerves, muscles, tendons, ligaments, and blood
vessels

 Deep somatic structures also include deep fasciae and joint capsules.

 When we talk about the "psycho-somatic" response, we refer to the mind-

body connection.

 Deep somatic pain is poorly localized and may be referred to the body
surface, becoming cutaneous pain. It can be associated with an autonomic
phenomenon, such as sweating, pallor, or changes in pulse and blood
pressure, and is commonly accompanied by a subjective feeling of nausea
and faintness.

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  Pain associated with deep somatic lesions follows patterns that relate to the
embryologic development of the musculoskeletal system.

This explains why such pain may not be perceived directly over the involved organ

 Parietal pain (related to the wall of the chest or abdominal cavity) is also
considered deep somatic. The visceral pleura (the membrane enveloping the
organs) is insensitive to pain, but the parietal pleura is well supplied with pain
nerve endings.

For this reason it is possible for a client to have extensive visceral disease (e.g.,
heart, lungs) without pain until the disease progresses enough to involve the parietal
pleura.

psychosomatic sources of pain occur when emotional or psychologic distress

produces physical symptoms

Visceral Sources of Pain

 Visceral sources of pain include the internal organs and the heart muscle.
This source of pain includes all body organs located in the trunk or abdomen,
such as those of the respiratory, digestive, urogenital, and endocrine
systems, as well as the spleen, the heart, and the great vessels.

Visceral pain is not well localized

 Visceral pain is well known for its ability to produce referred pain (i.e., pain
perceived in an area other than the site of the stimuli).

 For example, the heart is innervated by the C3- T4 spinal nerves. Pain of a
cardiac source can affect any part of the soma (body) also innervated by
these levels. This is one reason why someone having a heart attack can
experience jaw, neck, shoulder, mid-back, arm or chest pain and accounts for
the many and varied clinical pictures of myocardial infarction.

 More specifically, the pericardium (sac around the entire heart) is adjacent to
the diaphragm.

Pain of cardiac and diaphragmatic origin is often experienced in the shoulder

because the C5-6 spinal segment (innervation for the shoulder) also supplies the
heart and the diaphragm.

Neuropathic Pain

 Neuropathic or neurogenic pain results from damage to or pathophysiologic

changes of the peripheral or central nervous system.

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  Neuropathic pain can occur as a result of injury or destruction to the
peripheral nerves, pathways in the spinal cord, or neurons located in the
brain.

 Neuropathic pain can be acute or chronic depending on the timeframe.

 This type of pain is not elicited by the stimulation of nociceptors or

kinesthetic pathways as a result of tissue damage, but rather by malfunction
of the nervous system itself.

Disruptions in the transmission of afferent and efferent impulses in the periphery,

spinal cord, and brain can give rise to alterations in sensory modalities (e.g., touch,
pressure, temperature), and sometimes motor dysfunction.

 It can be drug-induced, metabolic based, or brought on by trauma to the

sensory neurons or pathways in either the peripheral or central nervous
system.

It appears to be idiosyncratic; not all individuals with the same lesion will have

pain.

 It is usually described as sharp, shooting, burning, tingling, or producing an

electric shock sensation.

The pain is steady or evoked by some

stimulus that is not normally considered noxious (e.g., light touch, cold). Some
affected individuals report aching pain. There is no muscle spasm in neurogenic pain

 Neuropathic pain is not alleviated by opiates or narcotics, although local

anesthesia can provide temporary relief. Medications used to treat
neuropathic pain include antidepressants, anticonvulsants, antispasmodics,
adrenergics, and anesthetics.

Many clients have a combination of neuropathic and somatic pain making it more
difficult to identify the underlying pathology.

Causes of Neuropathic Pain

 C e n t r a l n e u r o p a t h i c p a i n:

 Multiple sclerosis

 Headache (migraine)

 Stroke

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  Traumatic brain injury (TBI)

 Parkinson's disease

 Spinal cord injury (incomplete)

 Peripheral neuropathic pain:

 Poorly controlled diabetes mellitus (metabolic induced)

 Vincristine (Oncovin) (drug-induced; used in cancer treatment)

 Isoniazid (INH) (drug-induced; used to treat tuberculosis)

 Amputation (trauma)

 Crush injury/brachial avulsion (trauma)

 Herpes Zoster (Shingles, postherpetic neuralgia)

 Complex regional pain syndrome (CRPS2, causalgia)

 Nerve compression syndromes (e.g., carpel tunnel syndrome,

thoracic outlet syndrome)

 Paraneoplastic neuropathy (cancer-induced

 Cancer (tumor infiltration/compression of the nerve)

 Liver or biliary impairment (e.g., liver cancer, cirrhosis, primary

biliary cirrhosis)

 Leprosy

 Congenital neuropathy (e.g., porphyria)

 Guillain-Barre Syndrome

Referred Pain

 By definition, referred pain is felt in an area far from the site of the lesion,
but supplied by the same or adjacent neural segments.

Referred pain occurs by way of shared central pathways for afferent neurons and
can originate from any cutaneous, somatic, or visceral source.

 Referred pain is usually well localized (i.e., the person can point directly to
the area that hurts), but it does not have sharply defined borders. It can
spread or radiate from its point of origin. Local tenderness is present in the
tissue of the referred pain area, but there is no objective sensory deficit.

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 Referred pain is often accompanied by muscle hypertonus over the referred area
of pain

 Always ask one or both of these two questions in your pain interview as part
of the screening process:

• Are you having any pain anywhere else in your body?

• Are you having symptoms of any other kind that may or may not be related to
your main problem?

Differentiating Sources of Pain

 How do we differentiate somatic sources of pain from visceral sources? It can

be very difficult to make this distinction.

That is one reason why clients end up in physical therapy even though there is a
viscerogenic source of the pain

 The superficial and deep somatic structures are innervated unilaterally via
the spinal nerves, whereas the viscera are innervated bilaterally through the
autonomic nervous system via visceral afferents..

 The quality of superficial somatic pain tends to be sharp and more localized.
It is mediated by large myelinated fibers, which have a low threshold for
stimulation and a fast conduction time. This is designed to protect the
structures by signaling a problem right away.

 Deep somatic pain is more likely to be a dull or deep aching that responds to
rest or a non-weight bearing position.

Deep somatic pain is often poorly localized (transmission via small unmyelinated
fibers) and can be referred from some other site.

 Pain of a deep somatic nature increases after movement. Sometimes the

client can find a comfortable spot, but after moving the extremity or joint,
cannot find that comfortable spot again.

This is in contrast to visceral pain, which usually is not reproduced with

movement, but rather, tends to hurt all the time or with all movements.

 Pain from a visceral source can also be dull and aching, but usually does not
feel better after rest or recumbency.

Keep in mind pathologic processes occurring within somatic structures (e.g.,

metastasis, primary tumor, infection) may produce localized pain that can be

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 mechanically irritated. This is why movement in general (rather than specific
motions) can make it worse.

 Back pain from metastasis to the spine can become quite severe before any
radiologic changes are seen.

TYPES OF PAIN

Radicular Pain

 Radicular pain results from direct irritation of axons of a spinal nerve or

neurons in the dorsal root ganglion and is experienced in the musculoskeletal
system.

 Radicular, radiating, and referred pain are not the same things, although a
client can have radicular pain that radiates. Radiating means the pain spreads
or fans out from the originating point of pain. Whereas radicular pain is
caused by nerve root compression, referred pain results from activation of
nociceptive free nerve endings (nociceptors) of the nervous system in
somatic or visceral tissue.

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PHYSIOTHERAPY

 Management of the physical therapy of patients with musculoskeletal and

rheumatic diseases is a challenging task, even for the most astute clinician.

the treatment of patients with rheumatic diseases

A. Preventing disability.

B. Restoring function.

C. Relieving pain.

D. Educating the patient.

Evaluation

A. Functional assessment

1. Bed mobility. Observe the patient

a. Turn over from a supine position to the side and then to a prone position.

b. Move up and down in bed.

c. Move from a supine to a sitting position.

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 2. Transfer status.

Observe the patient transfer to and from various surfaces (i.e., bed, chair, and
toilet).

3. Gait analysis

a. Observational. Watch the patient ambulate with or without assistive devices

on level surfaces and stairs.

b. Instrumented, with a foot switch stride analyzer or computerized video

analysis

B. Range of motion (ROM) assessment of all joints

C. Strength assessment

1. Manual muscle test of trunk, neck, and proximal and distal muscles to determine
weak musculature.

2. Instrumental biomechanical muscle test.

3. Isometric/isokinetic objective strength measurement recorded to selected

muscle groups performed with an isokinetic dynamometer .

D. Posture assessment.

Observe the patient both standing and ambulating during functional activities.

E. Respiratory status.

Chest evaluation consists of the following:

1. Auscultation.

2. Chest expansion.

3. Description of cough.

4. Inspirometry.

Components of treatment.

 Once the physical therapy evaluation has been performed, the clinician has
baseline data for future comparison and a basis for determining treatment
goals. These specific goals are achieved through therapeutic exercise,

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 modalities, functional activities, and perhaps the most important aspect of
treatment, patient education

Therapeutic exercise

A. Goals of exercise

1. Maintain or improve ROM.

2. Strengthen weak muscles.

3. Increase endurance.

4. Enhance respiratory efficiency through breathing exercises.

5. Improve balance and coordination.

6. Enable joints to function better biomechanically.

Therapeutic exercises

1. Range of motion.

Excursion of a joint through available range.

2. Passive range of motion (PROM). Without active muscle contraction about the
joint. The joint is moved through available ROM by another person, object, or
other extremity

3. Active assisted ROM (AAROM).

The patient performs ROM exercises with the assistance of another person,
object, or extremity.

4. Active ROM (AROM). The patient performs ROM exercises without assistance.

5. Active resisted ROM (ARROM). The patient performs ROM exercises with some
form of resistance (manual or mechanical resistance, elastic bands, or weights).

6. Strengthening exercises

a. Static.

Isometric exercises in which the patient contracts or tightens the muscle around
the joint without producing any joint motion.

b. Dynamic. Some form of resistance is used, either manually or with an externally

applied load (i.e., weight).

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 1. Isotonic. Concentric or eccentric contractions of variable speed with use of a
set weight or resistance throughout the full ROM.

2. Isokinetic. A concentric or eccentric contraction at a set speed with use of a

set weight or resistance throughout the full ROM

General instructions to patients

1. Use pain as your guide.

Pain or discomfort should not last longer than 1 hour after exercise.

2. Make the exercise part of your daily routine.

3. Try to do a complete set of exercises at least twice a day at a time convenient to

you.

4. Prescribed medication and applications of heat or cold may precede exercises to

enhance relaxation and decrease pain.

5. Perform only those exercises given to you by your physician or therapist.

6. Perform exercises on a firm surface.

7. Exercise slowly with a smooth motion. Do not rush.

8. Avoid holding your breath while exercising.

9. Modify the exercise regimen during an acute attack, and contact your physician or
physical therapist if you have any complaints or problems with the exercises.

Physical agents (modalities

 Various modalities/treatments are employed by the physical therapist,

including the application of heat, cold, electrical stimulation, mechanical
traction, and mobilization/massage. These are generally provided as an
adjunct to a total rehabilitative program.

A. Superficial heating
B. 1. Hot packs contain a silica gel that absorbs water. These
packs are kept in thermostatically controlled water at 175°F.
The literature demonstrates that
C. hot-pack effectiveness reached at a depth of 1 cm
increases skin temperature by 10°C.

D. . Indications.

E. Relief of pain, muscle spasm, decreased ROM.

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 F. Contraindications.

G. Sensory involvement, open lesions, malignancy.

H. 2. Paraffin bath.

Paraffin wax is mixed with mineral oil and maintained at 118° to 126°F. It is
most useful in the treatment of hands. The wax mold conforms to the hand and
provides heat to all joint surfaces. The heating benefits are similar to those
obtained with hot packs.

a. Indications.

Relief of pain, muscle spasm, decreased ROM.

b. Contraindications.

Sensory involvement, open lesions

 3. Hydrotherapy

(whirlpool, therapeutic pool).

Water is maintained at 94° to 96°F. Coupled with its ability to eliminate the
effect of gravity (buoyancy), heated water can provide excellent moist heat and
exercise simultaneously. Whirlpools for individual limbs are also beneficial to
promote wound cleaning and

healing. Hydrotherapy is a related form of heat treatment

a. Indications

1. Muscle spasms, relief of pain, decreased ROM.

2. Whirlpool. Open lesions.

b. Contraindications

1. Patients with decreased heat tolerance.

2. Therapeutic pool. Open lesions, urinary tract infection, diarrhea; extreme

care should be taken in patients with cardiopulmonary involvement

4. Fluidotherapy

Is a dry application of heat. A bed of finely ground solids (e.g., glass beads
with an average diameter of 0.0165 in.) are blown with thermostatically
controlled warm air. This creates a warm, semifluid mixture for treatment of the
hand or foot. The temperatures are within the same ranges as the paraffin wax.

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 a. Indications.

Relief of pain, muscle spasm, decreased ROM.

b. Contraindications.

Sensory involvement, open lesions.

B. Deep heating

 Ultrasound. The application of high-frequency sound waves to the

musculoskeletal system causes a deep heating response. This response is
deeper than that induced by other physical agents, and it has been
demonstrated that the intraarticular temperature of the hip joint rises by
1.43°C after a properly applied therapeutic dose.

 Typical patient exposure is 1 to 2 W/cm 2 for 5 to 10 minutes. Ultrasound can

also be combined with electrical stimulation

 1. Indications.

 Pain relief, muscle spasm, and decreased ROM.

 2. Contraindications.

 Local malignancy, unstable vertebrae (after laminectomy), pregnancy,

spinal cord disease.

 ultrasound should not be applied directly over the eyes, brain, or spinal
cord.

C. Cold

 Cryotherapy is very effective in promoting vasoconstriction, thus decreasing

restricted joint ROM resulting from an inflammatory process and aiding with
pain relief. Cold modalities include ice packs, frozen gel packs (cold packs),
and ice massage.

 1. Indications.

 Swelling and inflammatory reactions, spasms, contusions, traumatic

arthritis.

 2. Contraindications.

 Decreased sensation, sensitivity to cold, Raynaud's phenomenon

 D. Mobilization

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  generally means moving joints, including spinal joints, through an ROM
designed to stretch the joint capsule and, in some instances, move the joint
beyond the norm of its associated muscles. The technique is primarily used in
patients with musculoskeletal pain.
 . Indications.
 Joint hypomobility, decreased proprioception, restriction of accessory joint
motion, ligamentous tightness, adhesions, joint dysfunction.
 2. Contrindications.
 Ligamentous laxity, unstable joints.
 E. Massage
 is a widely practiced modality. It is intended to relieve pain, soft-tissue
tightness, and muscle spasm. It is often used in conjunction with heat or cold
applications. Other forms of massage include acupressure, connective tissue
massage, postural integration (rolling), and deep friction massage.
 1. Indications.
 Muscle spasm, decreased extensibility of soft tissues.
 2. Contrindications.
 Cellulitis, malignancy, phlebitis
 F. Electrical stimulation
 is one of the oldest and most effective physical agents. Its purpose is to
contract or reeducate muscle, relax muscle spasms, stimulate nerves to
promote motion and pain relief, and generally improve circulation.

 A wide range of current types (AC and DC) and a wide variety of electrical
generators [low-volt, high-volt, biofeedback, transcutaneous electrical nerve
stimulation (TENS)] are available. No individual system or model is ideal for
all clinical situations, and the therapist's choice depends on the desired
therapeutic response
 1. Indications.
 Muscle reeducation, denervated muscles, pain relief, decreased general
circulation, decreased muscle strength during immobilization, decreased
ROM.
 2. Contraindications.
 Phlebitis, demand pacemakers, hemorrhage, recent fractures.
 G. Mechanical traction
 Intermittent traction is utilized for spinal disorders, generally in conjunction
with other modalities. The amount of traction prescribed depends on the area
being treated and on the patient's tolerance. Its effectiveness in promoting
relaxation through muscle stretching, relieving nerve compression, and
relieving pain has been demonstrated. Patients receive intermittent traction
two to three times per week on average for 20 minutes
 1. Indications.

Muscle spasm, mild nerve compression, vertebral osteoarthritis.

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  2. Contraindications.

Unstable vertebrae, local malignancy, spinal cord disease, osteoporosis,

osteomyelitis, pregnancy.

 Isometric:

A system of exercise without

body movement in which muscles build

up strength by working against resistance, provided by either a fixed object
or an opposing set of muscles.
 Isotonic:
A system of exercise, such as
weight lifting, in which muscle tension is
kept constant as the body works against
its own, or an external, weight.
It is a concentric or eccentric contractions of variable speed with use of a set
weight or resistance throughout the full ROM
 Isokinetic:
A concentric or eccentric contraction at a set speed with use of a set weight
or resistance throughout the full ROM

Hearing understanding, thought &

word finding voice production
articulation.

(N.B: Hearing & understanding = Listening)

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  No hearing Deafness
 No understanding Aphasia
 No thought or word finding Aphasia
 Poor voice production Dysphonia
 Poor articulation Dysarthria.

The Lobes of a Cerebral Hemisphere

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Luck and success ...
Mr. Ghazi Salah

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