Cardiorespiratory and Sports Phyisotherapy - Viresh

CARDIORESPIRATORY AND GENERAL PHYSIOTHERAPY
INDEX
SL.NO TITLE PAGE NO.
1 Management of wound and ulcers 2–7
2 Pulmonary Rehabilitation 8 – 18
3 Physiotherapy following lung surgeries 19 – 24
4 Introduction to ICU 25 – 39
5 Physiotherapy management following PVD 40 – 48
6 Cardiac Rehabilitation 49 – 61
7 Health fitness and Promotion 61 – 70

Treatment, Response to exercise and implication
8 71 – 76
of physiotherapy in disease condition
9 Abdominal surgeries 77 – 79
Physiotherapy intervention in the management
10 80 – 82
of medical, surgical and radiation
11 Physiotherapy in obstetrics and Gynaecology 83 – 123
Applied Yoga in cardio – respiratory
12 124 – 126
conditions
Home program and education of family
13 127
members in patient’s care
Respiratory failure – oxygen therapy and
14 128 – 131
mechanical ventilation
15 Burns management 132 – 148
16 ABG Analysis 149
17 Hematological and biochemical tests 150 – 151
18 Exercise tolerance testing 152 – 155
19
1 |Cardiorespiratory and General Physiotherapy – Viresh

CHAPTER 8: MANAGEMENT OF WOUND AND ULCERS
- An injury to the tissue can be simply called as a Wound.

- A pressure ulcer is a wound caused by unrelieved pressure on the dermis and underlying vascular structure,
usually between bone and support surface.
NORMAL WOUND HEALING: 3 overlapping phase

Inflammatory phase
• Characterized by vasodilatation, release of histamine
and stimulation of nociceptive receptors
• This can be correlated with redness, heat, swelling and
pain
Proliferative phase
• Characterized by the formation of granulation tissue
• Wound contraction starts
• Fibroblast in the wound develops in to collagen matrix
Maturation /remodeling phase
• Remodeling of the new epithelium
• It is an ongoing process even after wound closure takes
months to years
Patient intervention starts at this stage.
• In case of pressure wounds, when pressure is not relieved

damage happens which cannot be repair or recover on their
own
• When deeper vessels occluded decreased blood flow, leads
to cell death next to necrosis and finally a visible wound
• Superficial dermis can tolerate ischemia for 2-8hrs
• Deeper muscle, fat tissue etc. for 2 hours and less
• It occurs frequently who are immobilized for a long period of time
• Can occur at any age depends on the period
• It increases the risk of death in elderly individuals.
Clinical presentation
• First sign of pressure ulceration is blanchable erythema with increased skin
temperature
• Progression to superficial
abrasion, blister
• Full thickness skin loss -bleeding is minimal
• Main areas – sacrum, coccyx, greater trochanter, ischial
tuberosity, calcaneus and lateral malleolus.
Blanchable Erythema Superficial abrasion

Full thickness skin loss
Wound examination
History
- It is taken to determine the primary problems
- History should include queries like mechanism of injury, date of onset, progression
- How long has wound been present
- Treatment history to date
- What types of health-care providers have been involved in the management of the wound
- History of previous wounds
- Co-morbidities – Patient’s capacity to heal can be limited by specific disease effects on tissue like integrity
and perfusion, mobility, compliance, nutrition and risk for infection.
A. Diabetes
1. Abnormal glucose levels are not compatible with wound healing
2. Decreased sensation in feet cause high risk for breakdown
B. Vascular
1. Coronary Artery Disease – decreased circulating oxygen
2. Congestive Heart Failure – edema in lower extremities
3. Peripheral Vascular Disease – inadequate vascular support
4. Peripheral Arterial Disease – inadequate arterial support
C. Cancer
1. Radiation – high risk or may cause skin breakdown
2. Antineoplastic medications impair wound healing
Subjective examination
• It is to gather information about the current symptoms
• He should be questioned about behavior and characteristics of symptoms (pain associated with wound
or to any extremity, are there any certain positions which keep symptoms better or worse)
Objective examination
• Here observation is the important component of data gathering
• Typically includes-type of lesion (ischemic arterial ulcer, venous insufficiency ulcer, neuropathic,
rheumatoid ulcer etc.)
• Stage of wound (stage 1 to 4)
• Type of drainage- will check the amount, color, consistency, and odor, serous (clear, watery);
serosanguinous (clear red or reddish brown); purulent (thick, yellow, cloudy)
• Presence of edema.
(Cases: Ischemic arterial ulcer, Venous insufficiency ulcer, Neuropathic ulcer, Rheumatoid ulcer).
Aims of treatment
• Teach the patient self-care of wound management and identification of signs of infections
• Provide a moist wound healing environment
• Reduces the necrotic tissue at wound site
• Decrease pain associated with wound
• Decrease the risk of infection
• Improve physical functions (if decreased secondary to wound)
Intervention
• Physical therapy intervention for wound management includes verity of modalities and appropriate
wound dressing to promote healing
• The intervention plan should have a holistic view. Eg: Patient with signs and symptoms with venous
disease may also present with poor ankle ROMs.
• Wound must be cleansed and dressed but the limb should get compression for optimum healing.

Ultrasound therapy
• US can increase tissue temperature and it includes acceleration of metabolic rate, reduction or control of
pain and muscle spasm, increase circulation and increase soft tissue extensibility.
• It heats smaller and deeper areas than most superficial area. US heats tissue with high US absorption
coefficient- tissues with high collagen content like tendon ligament joint capsule but not for fat with
water content.
• US is not ideal for muscle heating because of low absorption but very effective in heating scar in muscle
area because of increased collagen content
• Application of ultrasound stimulates cell activity and it accelerate inflammatory process.
• The skin repair and wound contraction will be accelerated.
• US stimulates the collagen secretion and have an effect on elastin properties which strengthen scar tissue.
• Procedure is done by covering the wound by a hydrogel and deliver US by a hand - held applicator.
• Another option is applying US transmission gel over peri – wound area and treat from this region instead
of the wound bed.
• The parameters that have been found to be effective for healing wound is 20% duty cycle, 0.8 - 1.0
W/cm² intensity, 3MHz frequency, for 5 – 10 minutes
• Treatment duration depends on the area of the wound.
Electrical stimulation
• Electrical stimulation has effectiveness in facilitating healing in both acute and chronic wounds.
• It is used to eliminate bacterial load, promote granulation, reduce inflammation, edema, reduce wound
related pain
• Electric stimulation has a Galvano toxic effect on the cells needed for healing
• By using high volt pulsed current (HVPC) directly in the wound can create these changes –attraction
of neutrophils, macrophages, and epidermal cells which facilitate debridement and re –
epithelialization.
Method of application
• Direct method of application-it includes an ES unit treatment and non – treatment electrodes and a saline
soaked gauze or hydrogel dressing over wound bed to enhance electrical conductivity.
• Indirect method of application – here electrodes are placed around the peri – wound skin using gel.
Radiant heat
• Infrared red radiation increases local wound and skin temperature facilitating metabolic rate and
improving circulation to the wound site.
• This technique is effective in treating chronic wounds even in the presence of vascular compromise.
• Normothermia can be accomplished by warm up wound therapy system which includes, delivering moist
heat through a non – contact dressing.
• Using a warming card which is placed in a sleeve on top of the sterile wound cover giving warmth up to
38° C.
Negative pressure wound therapy (NPWT)
• NPWT is a wound healing technique used to facilitate wound closure in acute surgical and challenging
slow healing wounds.
• VAC or vacuum assisted closure is the device used to provide negative pressure treatment.
• An open cell foam dressing is placed in the wound and a suction tube is connected from the foam to the
portable pump, an air tight seal is created over the foam and suction tube with a film.
• A controlled amount of negative pressure (sub atmospheric) is applied through the foam to the wound
bed.
• For the first few days 48 hours pressure applied continuously via portable pump, after the withdrawal of
significant amount of wound fluids it is done intermittently.
• The foam is changed in every 12 hours (infected wounds).
Short wave diathermy
• PSWD and CSWD have been used to treat chronic open wounds
• It provides radio waves to produce thermal and non – thermal effect by facilitating one phase of healing
to next.

• PSWD heats superficial tissues and CSWD heats deep muscle and joint tissue
• It increases fibroblast proliferation, collagen formation and tissue perfusion
• Treatment is delivered usually without touching the skin, but with newer units’ pad can be placed over
the wound dressing, compression garments etc.
Ultraviolet radiation
• It is a form of energy between x – ray and visible light
• It is divided in to wavelength and bands
• Three bands useful for human skin are UVA, UVB and UVC
• It has bactericidal effects and it increases blood flow, enhance granulation tissue formation, stimulation
of vitamin D
• Procedure is done on a clean wound with dressing removed using UVB or UVC lamp
• Treatment distance dosage, frequency will vary on the status of the wound
Hyperbaric oxygen therapy
• HBO delivers 100% O2 to an individual who rest inside a sealed chamber at a pressure greater than
atmosphere (full body chamber)
• It increases the amount of O2 available for cell metabolism, increase O2 in hypoxic tissue
• Topical hyperbaric O2 therapy THBO is used now a days Instead of full body chamber, localized limb
chambers are used, so THBO delivered O2 directly to the surface of the wound through a portable unit.
• It is also used in combination therapy along with stimulation or with cold laser
Compression therapy
• The concept of compression therapy is based on a simple and efficient mechanical principle consisting
of applying an elastic garment around an area of the body to control edema
• Edema not only inhibit wound healing by affecting perfusion of the tissue but also inactivates the ability
of the skin to manage bacteria
• It should apply as soon as signs of swelling appears when leg wounds are present
Elevation
• It is not a compression technique but used to reduce some type of swelling (mild acute swelling) and
is a precursor to compression
• Proper positioning and active ROM exercise should teach the patient in corporate with other means of
swelling controlling technique like compression etc.
Four – layer bandage system
• Four-layer bandaging is a high-compression bandaging system (sub-bandage pressure 3540mmHg at
the ankle) that incorporates elastic layers to achieve a sustained level of compression over time. Since
the development of the four-layer system over 15 years ago.
• The four-layer bandage system is primarily used in the treatment of venous ulceration and achieves
healing in patients with both deep, superficial and combined venous incompetence. Four-layer
bandaging can also be used to prevent recurrence in patients who are unable to wear elastic stockings.
• The short-stretch, elastic effect noted in four-layer bandaging has made this a useful treatment.
Indications
Primary uses
• Treatment of venous ulceration
• Prevention of ulcer recurrence if hosiery is not tolerated
• Symptomatic relief of superficial thrombophlebitis
Other uses
• Traumatic wounds with local edema, for example pretibial lacerations
• Venous/lymphatic disorders
• Ulceration of mixed aetiology with an edematous component
Contraindications
• Patients with heart failure should not receive high compression therapy. In this instance high
compression will redistribute blood towards the centre of the body, thereby increasing the pre-load of
the heart and possibly causing further overload and death
• Patients with severe obliterative arteriosclerosis should not receive compression therapy.

Application
Layer 1: Orthopaedic wool: Orthopaedic wool provides a layer of padding that protects areas at risk of high
pressure
Layer 2: Crepe bandage: This is the least effective layer as it simply adds extra absorbency and smooths
down the orthopaedic layer prior to the application of the two outer compression bandages.
Layer 3: Elastic Extensible bandage: It is a highly extensible bandage that provides a sub-bandage pressure
of approximately 17mmHg when applied at 50% overlap using a figure-of-eight technique.
Layer 4: Elastic Cohesive bandage: A frequent misconception is that the outer cohesive layer within the four-
layer system is there simply to maintain the bandage position. In fact, this layer provides the higher level of
compression (sub-bandage pressure approximately 23mmHg)
Long and short stretch bandages
• This both bandages are used to control edema and provide compression to support the lymphatic system
• Long stretch bandages provide a high resting pressure means they constrict when the wearer is resting.
• They do not provide significant working pressure. they are readily available and easy to wear.
• Short stretch bandages provide low resting pressure but provide high working pressure
• They are less stretchy, provide rigid appearance after application and this make more appropriate for
edema treatment
• Working pressure increases the work of muscle like pumping activity and lower resting pressure make
bandage more tolerable
• It needs special training to apply like no: of layers, age condition and tension of the bandage etc.
Lymphedema bandage
• This is highly specialized bandage with multiple layers of padding materials and short stretch bandage
which provide support to the lymph edematous body part.
• It provides support to the tissues with elasticity loss and facilitates a mild tissue pressure to empty the
lymph vessels.
• It is applied to head and neck, chest, abdomen, genital area and back.
Compression garments
• It is widely used by clients all over the world, it is designed to venous blood flow in Les.
• Now it is designed to manage burns surgical scars to provide support to venous circulation and to
prevent re – accumulation of fluids It is not used as a treatment to remove excess fluids
• Another one is quilted garment which provide compression which is used by person who cannot apply
support garment and whose skin is fragile.
• Venous return and lymphatic drainage are attained by altering the stitching channels
Guidelines for compression bandaging

• Arterial wound- no compression or very light long stretch bandage in 12 – 25 mm hg is used
• Venous wounds-compression is essential, short stretch bandage with high working pressure 40 mmhg
• Neuropathic wounds-if no arterial involvement compression with short stretch wrap
• Lymphedema-short stretch compression wrap until limb reduction then moderate to high compression
20-30mmhg to 30 -40 mmhg
• Edema-same as lymphedema short stretch compression 23hours/day.
Wound dressing
• A dressing is an adjunct used by a person for application to a wound to promote healing or to prevent
further harm. A dressing is designed to be in direct contact with the wound, which makes it different
from a bandage.
• Choosing appropriate dressing should be on the basis of wound and peri – wound tissue. A product that
preserves wound hydration limit fluid loss is ideal
• In moist wound dressing the following wound characteristics must be considered.
• Infection-present /absent
• Necrosis-remove/not
• Drainage-dry, adequate or excessive
• Granulation-present/not
• Epithelialization - present/not
• Peri-wound area-intact/at risk
• Odor-minimal/need reduction
Primary dressing- that applied directly to the wound
Secondary dressing-that applied over primary one
Scar Tissue Mobilization

Scar tissue mobilization is a form of manual physical therapy where your licensed PT uses hands-on
techniques on your muscles, ligaments and fascia in order to break adhesions and optimize your muscle
function.
Adhesions are your body’s attempt to heal a soft tissue injury with a lengthy inflammation process, resulting
in long strands of collagenous scar tissue. These new tissues pull against one another, forming trigger points
of pain
Goals of Scar Tissue Mobilization:

• Break down or reduce adhesions
• Improve range of motion
• Lengthen muscles and tendons
• Reduce swelling and edema
• Decrease pain
• Restore functionality
Soft Tissue Mobilization Techniques

Specific techniques for scar tissue mobilization include:
Sustained pressure – pushing directly on the restricted tissue and holding
Unlocking spiral – pushing on the restricted tissue in alternating clockwise and counterclockwise rotating
motions
Direct oscillations – rhythmic pushing on the restricted tissue
Perpendicular mobilization – pushing on the myofascial tissue at right angles
Parallel mobilization – pushing along the seams of muscles
Perpendicular strumming – rhythmic pushing along muscle border, followed by rubber of top of muscle
Friction massage – pushing across the grain of the muscles, tendons and ligaments

CHAPTER 14: PULMONARY REHABILITATION
➢ Pulmonary rehabilitation is an evidence-based, multidisciplinary, and comprehensive intervention for

patients with chronic respiratory diseases who are symptomatic and often have decreased daily life
activities.
➢ Integrated into the individualized treatment of the patient, pulmonary rehabilitation is designed to
reduce symptoms, optimize functional status, increase participation, and reduce health care costs
through stabilizing or reversing systemic manifestations of the disease.
Rationale for Pulmonary rehabilitation

➢ Exercise intolerance - one of the main factors limiting participation in activities of daily living
➢ Reduction in symptoms like dyspnoea, fatigue
Factors Contributing to Exercise Intolerance in Chronic Respiratory Disease

➢ Ventilatory limitation
o Increased dead-space ventilation
o Impaired gas exchange
o Increased ventilatory demands
o Dynamic hyperinflation
➢ Gas exchange limitation
Hypoxia → directly/ indirectly → Exercise tolerance
➢ Cardiac dysfunction
o Increase in right ventricular afterload
o Hypoxic vasoconstriction
o Increase in pulmonary vascular resistance
Increase right ventricular afterload → Right hypertrophy → Right ventricular failure → Decrease left
ventricular fillings→ Decrease ability of heart to meet exercise demands.
➢ Skeletal muscle dysfunction

Peripheral muscle dysfunction
- Inactivity induced deconditioning
- Oxidative stress
- Corticosteroid use
- Reduced muscle mass
➢ Respiratory muscle dysfunction

o Diaphragm of patients with COPD is chronically over-loaded
o Show a greater resistance to fatigue
o Inspiratory muscle to generate more force
Respiratory Muscle Weakness:

- Hypercapnia
- Maximum respiratory pressure
- Dyspnea
- Exercise intolerance
➢ During exercise it has been shown that patients with COPD use a larger proportion of their maximal
inspiratory pressure than healthy subjects → More oxidative type 1 sarcomere develop, capillary
density increases → “Steal” effect of blood from peripheral muscles to diaphragm

Goals in Pulmonary Rehabilitation:
➢ Reduction in overall medical costs and hospitalisation
➢ Improvement in - cardiac status
- ventilation
- physical activity
➢ Control of respiratory infections
➢ Basic airway management
➢ Psychosocial support
➢ Occupational retraining and placement
➢ Patient and Family education, counseling and support
➢ Improvement in health – related behaviors

-Patient will stop tobacco use. Stop drug or alcohol misuse and company medical and rehab treatment.
➢ Improvement in clinical symptoms and progression of disease.

-Patient will learn to mobilize respiratory secretions.
-Employ strategies to relief shortness of breath and cough.
-Recognize the early sign of discomfort
-Decrease the frequency and severity of the respiratory exacerbation and obtain optimal O2 saturation
throughout the day and night.
➢ Improvement in function and daily activity tolerance.

-The patient will gain sufficient strength, flexibility and endurance.
-To accomplish the identity, the ADL and will learn to employ strategies to manipulate enrollment to
maximize physical functioning.
➢ Improvement in nutritional status

-The patient will obtain and maintain optimal body weight and composition and administrative
adequate growth and physical maturation.
➢ Improvement in mood, confidence, self – esteem and self – efficacy.

-Patient will become independent in all areas of care and how to contact appropriate resources for
assistance and learn behavior to maintain the goals.
Objectives in Pulmonary Rehabilitation:

➢ Development of:
▪ diaphragmatic breathing skills
▪ stress management
▪ relaxation techniques
➢ Involvement in a daily physical exercise regimen to condition both skeletal and respiratory muscles
➢ Adherence to proper hygiene, and nutrition
➢ Proper use of medications, oxygen, and breathing equipment
➢ Applications of airway clearance techniques
➢ Provisions for individual and family counseling
Indications
➢ Individuals with chronic respiratory disease resulting in:
▪ Anxiety
▪ Dyspnea
➢ Limitations with:
▪ Social activities
▪ ADL
➢ Moderate to severe obstructive lung disease
➢ Restrictive pulmonary and chest wall disease
➢ Other conditions
Contraindications
➢ Cor pulmonale
➢ Severe pulmonary hypertension
➢ Significant hepatic dysfunction
➢ Renal failure
➢ Severe cognitive deficit, and psychiatric disease.
➢ Physical limitations
Benefits of Pulmonary rehabilitation
➢ Reduction in
▪ Hospitalization days
▪ Sensation of dyspnea
▪ Exacerbations
▪ Anxiety and depression
➢ Improvement in
▪ Exercise tolerance
▪ Health related QOL
▪ Peripheral muscle strength
▪ Ability to perform ADL
TEAM MEMBERS:
1. The Patient:
The patient with pulmonary disease participating in the pulmonary rehabilitation program, the patient’s
spouse or family and the primary care provider play a central role on the team.
2. Medical Director:
The pulmonologist, who direct the rehabilitation programme is matter of overall policy, procedures
and medical care.
3. Program Director or Administrator:

This portion is the team leader directing day to day function of the pulmonary rehabilitation program.
4. Respiratory Care Specialist:

This can be nurse, physical therapist or respiratory therapist to provide patient care, services and
education regarding the managing respiratory symptoms and treatment.
5. Exercise Specialist:
This person can be a physical or occupational or respiratory therapist, nurse or exercise physiologist
who will be leading exercises progression for respiratory patient.
6. Nutritionist or Dietitian:
The key role of nutritionist to evaluate or monitor the over and under nourished condition of the
participant to maximize rehabilitation potential.
7. Behavioural Specialist:
May be a social worker or psychologist. This person should have skills in monitoring patient and
family member to adopt behaviour that support the life style changes. Recommended the rehabilitation
learning and to learn stress management.

Conditions that produce Candidates for Pulmonary Rehabilitation
Obstructive diseases Restrictive diseases Exposure to risks for Chest wall defects Pulmonary vascular Others
COPD conditions
-Emphysema -Idiopathic pulmonary -Cigarette Smoking -Neuromuscular -Pulmonary Emboli -Pre-lung
-Bronchitis fibrosis -Occupational exposure weakness -Idiopathic, occlusive transplant
-Bronchiectasis -Sarcoidosis -Air pollution -Chest deformities conditions -Post-lung
-Cystic fibrosis -Asbestosis -Infections of the lungs -Obesity -Pulmonary transplant
-Alpha-antitrypsin -Silicosis -Impaired immune -Spinal Deformities hypertension
deficiency -Adult respiratory defences -Chest Surgery
-Asthma distress syndrome
ASSESSMENT:
➢ Assessment - necessary for developing an appropriate, individualized plan of care.
➢ The Clinical history
▪ Cough (Duration, characteristic, timing, types, frequency)
▪ Sputum (color, consistency, quantity, odour, time)
▪ Hemoptysis (onset, appearance, amt, color, odour, associated symptoms)
▪ Dyspnea (sensation, onset, preceding event, Aggravating factor, reliving factor, associated
symptoms)
▪ Chest pain (type, onset, location, radiation, duration, aggravating factor, reliving factor)
➢ Examination
▪ Vital signs
➢ Inspection
▪ Head
▪ Neck
▪ Thorax
▪ Extremities
➢ Palpation
➢ Percussion
➢ Auscultation
▪ Breath sounds
▪ Heart sounds
➢ Review of investigations
▪ CBC
▪ WBC - 4500-11500/cu mm of blood
➢ Neutrophils - 40-75% of total WBC
➢ Eosinophil - 0-6% of total WBC
➢ Basophil - 0-1% of total WBC
➢ Lymphocytes - 20-45% of total WBC
➢ Monocytes - 2-10% of total WBC (largest)
▪ RBC- 4.8-5.5 million/cu mm
▪ Platelet- 140,000-440,000/mm3
▪ Pulmonary function testing (FVC, FEV)
➢ Baseline exercise capacity
» Submaximal exercise testing
▪ Modified Bruce Treadmill protocol
▪ Self - paced walking test
▪ 12 and 6 min walk test
▪ Modified shuttle walk test
▪ Bag and carry test
Other assessments:
➢ Measurements of respiratory muscle strength
▪ Max voluntary resp pressure
▪ Respiratory muscle endurance

▪ Max sustainable voluntary ventilation
▪ Incremental threshold loading
➢ Measures of peripheral muscle strength
➢ Assessments of ADL
➢ Health status, cognitive function
➢ Nutritional status/ body composition
▪ Depletion od FFM index (FFM/height2)
▪ Values: Males below 16kg/m2
▪ Females below 15kg/m2 (ATS 2006)
International classifications of patient – Specific outcome:

• Respiratory Impairment
➢ Is a loss or abnormality of psychologic, physiologic, or anatomic structure
or
Function resulting from the respiratory disease
or
Exteriorization of pathologic state
➢ Usually determined by laboratory measurement.
➢ For respiratory disease, impairment is reflected in
o Decreased FEV1
o Air trapping in pulmonary function testing
o Decreased quadriceps in force on peripheral muscle function testing
• Respiratory Disability
➢ Refers to inability to perform an activity in the manner within the normally expected range because of
lung disease
• Respiratory Handicap
➢ Represents the disadvantage resulting from an impairment or disability within the context of patient’s
ability to perform in society or fill the expected roles
SETTING:
Program setting:
1. Inpatient
2. Out patient
3. Home Based rehabilitation
INPATINET:
➢ Improve pulmonary hygiene
▪ Postural drainage
▪ FET, ACBT, Autogenic drainage
▪ Assisted coughing
➢ Breathing strategies
➢ Decrease incisional pain
➢ Incentive spirometry
➢ Maintain ROM and strength
➢ Progressive ambulation
➢ Initial self-care and ADLs
Inpatient Care:
➢ Acute care:
Mechanical ventilator - if respiratory failure
Ventilatory settings: Mode: CMV
Lower tidal volume 6-8ml/kg
Moderate RR

High inspiratory flow rate (70-100L/min)
➢ If patient can spontaneously take some breaths:
Mode: SIMV with pressure support
RR: 12-14 breaths/min
tidal volume: 6ml/kg
peak flow: 50l/min
pressure support: 20cmH20
➢ If patient is able to take all the breaths by himself:
Shift down to- CPAP
➢ If patient can breathe normally, t tube trial is done before weaning the patient
Additional Strategies to improve exercise performance:
Maximizing pulmonary function before starting exercise training:
» Noninvasive mechanical ventilation
» Oxygen therapy
➢ In hypoxemic patients:
▪ Resting PaO2 < 60 mmHg, or SaO2< 90%
▪ Complications: High concentrations – impair respiratory drive in acute hypercapnic COPD
▪ Thus, O2 therapy should be controlled by giving continuous O2 at 24% concentration
▪ Training with oxygen supplementation leads to significant improvement in exercise tolerance
and dyspnea compared with training at room air
➢ In non-hypoxemic patients:
▪ O2 therapy allowed higher training intensities and enhanced exercise performance in laboratory
setting
▪ The prescription of supplemental oxygen for mild hypoxemia did not show any increase in
exercise tolerance or HRQL
» Nebulization
➢ In acute cases, nebulization is prescribed 4-6 hourly
➢ Facilitates mucocilliary clearance
➢ Combination of bronchodilators used:
▪ 2ml ipratropium bromide + 1 ml salbutamol+ 2ml saline
▪ 1ml salbutamol + 3ml saline
▪ 2ml ipratropium bromide + 2ml saline
» Respiratory muscle training
» Long term oxygen therapy (LTOT)
» Prolongs survival in patients with COPD
» Near continuous O2 (18h/d) superior to O2 provided for 12-15 hours daily
» Neuropsychologic function improved to a significantly greater degree in pts receiving near
continuous O2.
» Breathing Retraining techniques:
» Chest physical therapy and breathing techniques
» For patients who have >30 mL sputum production -24 hours or have difficulty with sputum
expectoration:
» Bronchial hygiene therapy with or without PD
» Effective huffing techniques (FET), to enhance sputum expectoration
3 major breathing techniques include:
» Pursed lip breathing
» Posture technique
» Diaphragmatic breathing
➢ Posture technique
▪ Leaning forward postures frequently relieve dyspnoea in COPD pts by reducing respiratory effort
▪ Shifting of abdominal contents elevates the depressed diaphragm cranially, resulting in improved
performance
➢ Bed mobility exercises

▪ Start with exercises of lower extremity followed by the upper extremity
Inpatient rehabilitation:
➢ Best - suited for the sickest patient
➢ Advantages:
▪ closer medical monitoring
▪ intensive nursing available 24hours/day.
➢ Disadvantages:
▪ cost and potential difficulty with insurance coverage
▪ not suitable for patients with less severe respiratory or comorbid disease
▪ Transportation potentially difficult for family members
OUTPATIENT REHABILITATION:
➢ Main aim is to quantify patient’s capabilities
➢ To structure a rehab program that helps in achieving patient’s max effort
➢ After achieving a particular target progression is being made according to one’s environmental needs
➢ Advantages:
▪ Widely available
▪ Least costly
▪ Efficient use of staff resources
▪ Least intrusive to the family
Disadvantages:
▪ Potential transportation issues
▪ No opportunities to observe home activities
HOME BASED REHABILITATION/ LONG TERM REHAB
➢ Understanding environmental stress placed on patient
➢ Understanding architecture of home
➢ Structuring maintenance and progression accordingly
➢ Maintenance therapy:
▪ Improve cardiopulmonary endurance
▪ Increase general strength and mobility
▪ Continue breathing and coughing techniques
▪ LTOT, if required
▪ Energy conservation techniques and pacing
▪ Vaccination against influenza
➢ Advantages:
▪ Convenient to the patient
▪ Transportation not an issue
▪ Adaptation of the exercises to the familiar environment.
➢ Disadvantages:
▪ Cost and potential difficulty with insurance coverage.
▪ Lack of group support.
▪ Potential lack of full spectrum of multidisciplinary health personnel
▪ Limited access to exercise equipment.
PROGRAM COMPONENETS OF PULMONARY REHABILITATION:

1. GENERAL CARE:
Include initial physical examination to determine a specific diagnosis and assessment of severity of the
disease. After assessment is made therapeutic intervention often includes prescription off medications and
possible oxygen recommendation for prevention. Preventive care includes immunization and vaccinations,
smoking cessation, avoidance of environmental irritants. Adequate hydration and proper nutrition and weight
control.
Patient is assessed for activity or sleep related oxygen needs. To determine this pulse oximeter and serial
ABG measurements are used.

2. DYSPNOEA MANAGEMENT
➢ Preventing or reducing the intensity and distress of dyspnea, improves the QOL of patients with
pulmonary disease and is an important goal of pulmonary rehabilitation
Causes:
➢ Increased central respiratory drive
➢ Weakness of respiratory muscles
➢ Abnormal central perception of dyspnea
Measurement of Dyspnoea:
❑ Dyspnea component of St. George respiratory questionnaire
» 1- Most days a week
» 2- Several days a week
» 3- A few days a week
» 4- Only with chest infections
» 5- Not at all
Management of Dyspnoea:
➢ Reduce ventilatory demand
a) Reduce metabolic load
➢ Exercise training improves efficiency of CO2 elimination
➢ Activity modification and Energy conservation
➢ Supplemental oxygen therapy
b) Decrease central drive:
➢ Supplemental oxygen therapy
➢ Pharmacological therapy
➢ Improve efficiency of carbon dioxide elimination by altering breathing pattern
➢ Reduce ventilatory impedance
➢ Reduce/counterbalance lung hyperinflation
➢ Surgical volume reduction
➢ Improve inspiratory muscle function
➢ Nutrition
➢ Inspiratory muscle training
➢ Positioning
➢ Alter central perception
3. EXERCISE TRAINING:
➢ Frequency: 4-5 times/week
➢ Intensity: high intensity training
▪ 60-80% max. work capacity for LE
▪ 60% of max. work capacity for UE
➢ Type: Continuous/Interval
➢ Mode: combination of strength and endurance
➢ Duration: 25-30 minutes for 20 sessions
➢ At least 2 supervised session
➢ Borg Score of 4 to 6 for dyspnea or fatigue is usually a reasonable target
ENDURANCE TRAINING FOR EXTREMITIES:
Upper extremity Lower extremity
Frequency 3-4 sessions/week 3-4 sessions/week
▪ >12yrs, elderly, disease patients-mild to moderate
▪ Healthy individuals- progress from moderate to high
Intensity 60% max capacity 60-80% max capacity
Time 30 minutes Minimum 30 min with or without breaks
Type Supported arm exercise Stationary cycle
Unsupported arm exercise Treadmill

TheraBand Ground based walking
STRENGTH TRAINING:
» loads ranging from 50 to 85% of the one-repetition maximum greater increase in peripheral muscle
function
» 3 days/ week twice daily for 6-12weeks
» Machine weights or free weights
» Combination of strength and endurance training is supposed to have more beneficial effects
4. RESPIRATORY MUSCLE TRAINING:

» Inspiratory muscle function is compromised in COPD leading to dyspnea, exercise limitation, and
hypercapnia
» Respiratory muscle strength is commonly estimated by measuring maximal negative inspiratory
pressure (PI max)
» Two methods of inspiratory muscle training
❖ Threshold loading
❖ Resistive loading
Exercise prescription guidelines for RMT
➢ Frequency: at least 5 times per week
➢ Intensity: initiated at low intensity
Gradually increased to achieve >30% Pi max
➢ Duration: 30 min per day (continuous or 15 min twice a day)
➢ Breathing frequency of 12-15 breaths per minute is recommended
RMT IN PULMONARY REAHB

» Inspiratory muscle training
+
Standard exercise training in patients with poor initial inspiratory muscle strength →→ improves ex.
capacity more than exercise alone
» Inspiratory muscle training could be considered as adjunctive therapy in PR, primarily in patients with
suspected or proven respiratory muscle weakness.
Who all can be included?
➢ RMT may be considered in patients with COPD who remain symptomatic despite optimal therapy
➢ Severe dyspnea
➢ Highly motivated
➢ Reduced respiratory muscle strength (PI max)
➢ Moderate to severe respiratory impairment but not “end stage”, with severe hyperinflation and
flattening diaphragm
5. EDUCATION:
➢ With education patient become more skilled at collaborative self - management and have improved
compliance.
➢ Anatomy and Pathophysiology of disease, medical management easily detected and treatment of acute
illness use and misuse of oxygen and practical solutions to incorporate diet reform and activity into
daily life.
➢ It is a shared responsibility among the patient, family, primary care physician, specialist, and other
health care providers
Objective
➢ To encourage behavioral changes that lead to improved health and a commitment to long-term
adherence with self - assessment and management
➢ Brief idea about the condition, disease process
➢ Benefits of the rehabilitation program
➢ Decrease fear of activity and avoidance of activity
Self - management education
➢ Breathing strategies

➢ Bronchial hygiene
➢ Medications
➢ Self-assessment
➢ Activities of daily living and energy conservation
6. PSYCHOSOCIAL AND BEHAVIORAL INTERVENTION:

It is an integral part of pulmonary rehab because chronic diseases places stress on whole family coping
strategies. Stress reduction and management techniques support systems are necessary. Patient may also need
financial assistance and occasional rehab services.
Need for psycho-social intervention
➢ Increased risk of anxiety, depression
➢ Feeling of hopelessness & inability to cope
➢ Difficulty in solving common problems
➢ Failure to adhere to rehabilitation plan
Management:
» Regular patient education sessions
» Stress management
» Discussions about symptoms, concerns and problems during rehabilitation
» Group therapy
7. NUTRITION MANAGEMENT:
➢ High energy, protein rich diet
➢ Administration of 1.5 g protein/ kg per day
➢ Frequent smaller meals
8. PULMONARY CARE
Respiratory treatment techniques to remove secretions and relieving dyspnea includes Bronchial drainage.
Breathing techniques, cough facilitation, postures to improve breathing, relaxation techniques,
bronchodilators, respiratory assistance devices to rest the breathing muscles at night or during the exercise.
9. OUTCOME ASSESSMENT:
➢ Measurement of outcomes should be incorporated into every comprehensive pulmonary rehabilitation
program
➢ Minimal requirements include the assessment of the following measures of the patient’s recovery
before and after rehabilitation
➢ Dyspnea
➢ Direct Measures of Dyspnea
▪ Modified Borg Scale for Breathlessness
▪ Visual Analog Scale
➢ Indirect Measures of Dyspnea Targeted to Activities
▪ Baseline and Transitional Dyspnea Index (BDI&TDI)
▪ Chronic Respiratory Disease Questionnaire (CRQ)
➢ Other Relevant Questionnaires
▪ Pulmonary Functional Status and Dyspnea Questionnaire: PFSDQ
➢ Exercise ability
➢ Submaximal exercise tests
➢ Walking tests
➢ Health status
➢ Submaximal exercise tests
➢ Walking tests
➢ Activity levels
Performance log

➢ An important goal of rehabilitation is to improve the patient’s ability to engage in activities of
daily living
➢ Assessment of performance can be accomplished by direct observation or by patient report
Measures of quality of life

➢ A health related QOL instrument can assess the overall benefit of improvements in the patient’s
symptoms, disability, and handicap
➢ In rehabilitation, the following instruments have been used
▪ General health questionnaires, such as sickness impact profile
▪ Disease specific scales, such as the chronic respiratory disease questionnaire
PHARMACOTHERAPY IN PR:
DRUG THERAPY:
➢ Anticholinergic agents:
▪ Ipratropium bromide-
▪ Tiotropium
➢ Β2 adrenergic agonists:
▪ Salbutamol, fenoterol, terbutaline
▪ Salmeterol or formoterol)
➢ Combination therapy: inhaled ipratropium bromide and β2 adrenergic agonists is potentially more
effective and safer
➢ Corticosteroids:
▪ Prednisolone
➢ Antibiotics
➢ Mucolytic agents:
▪ N-Acetylcysteine,
GENERAL PHYSIOTHERAPY MANAGEMENT IN PULMONARY REHABILITATION:
1. Modified Bronchial drainage positions to facilitate the ease of assuming appropriate position. Independently
and compatibly firm, foam wedge, cushions, Trendelenburg’s position: foot end elevated: 15 – 30°.
2. Percussion or vibration to clear airway palm cups or mechanical precursors or vibrators can be employed.
Performance of exercise of deep breathing exercises, forced expiration and coughing and huff or Use of mask
that provides positive expiratory pressure. Breathing and coughing exercises may be done after bronchodilator
treatment.
3. Secretions remove in the morning that are accumulated over night or before and after each exercise sessions.
4. Sustained exercise can be given if the patient is tolerated.
5. To relieve the dyspnoea teach the patient controlling the breathing pattern, alternate position and relaxation
techniques pursed lip breathing may be help in patients with obstructive lung diseases.
Avoid breath holding, Valsalva manoeuvre and unnecessary talking during the task.
*Education: (Including patient and family members as well)

- Anatomy and Physiology (Breathing in and out); Pathology of the disease, Self-management, management
of breathlessness, inhalers and medications, nutrition (6-8 small meals, eat well plate); anxiety and depression;
exercise pacing, air way clearance techniques – ACBT, AD, coughing and huffing; Smoking cessation.

CHAPTER 15: PHYSIOTHERAPY FOLLOWING LUNG SURGERIES
A Thoracotomy is an incision into the thoracic cavity to gain access to lungs, bronchi, heart or oesophagus.
The position of the incision relative to the thorax may be lateral (Postero – lateral, antero - lateral) or anterior
(transverse, vertical).
A) Lateral incisions:
1. Posterolateral incisions:
This follows the vertebral border of the scapula and the line of a rib (Numbers 5, 6, 7 or 8) to the
anterior angle of costal margin. The muscles cut are Trapezius, latissimus dorsi, rhomboids, serratus anterior,
intercostals and erector spinae.
2. Anterolateral incisions:
This starts close to midline in front follows along the line of a rib below the breast to the posterior
axillary line. The muscles cut are pectoralis major and minor, serratus anterior, internal and external
intercostals. This incision is used for mitral valvotomy and pleurectomy.
B) Anterior Incisions:
1. Transverse (Sub – mammary)
This passes across from one side of the 4th intercostal space to the other. The muscles divided are
Pectoralis major, internal and external intercostals. The sternum is divided transversely. It is not very often
used.
2. Vertical (Median Sternotomy)

This involves splitting the sternum down the middle with no muscle cut other than the interweaving
aponeuroses of pectoralis major. This is used for open heart surgery.
3. Thoraco-laparotomy incision
This is along the line of the 7th or 8th rib and there may be an abdominal incision as well. It is used for
access to the oesophagus.
INDIACTIONS FOR SURGERY

1. Malignancy – Primary bronchial carcinoma
2. Trauma – Wounds from road traffic accidents, gun shots or knife stab.
3. Diseases/infections – Bronchiectasis, tuberculosis, lung abscess, large bullae
4. Degenerative conditions
5. Congenital conditions
TYPES OF OPERATIONS:
1. Pneumonectomy: It is the removal of the entire lung
2. Lobectomy: It is the removal of an entire lobe sometimes with a section of the thoracic wall
3. Segmental or wedge resection: It is the removal of a bronchopulmonary segment. Wedge resection is the
removal of a small part of the lung tissue.
COMPLIACTIONS OF LUNG SURGERIES:

1. Respiratory:
a. Infections of lung tissues
b. Consolidation/collapse of remaining lung tissue
c. Pneumothorax
d. Broncho – pleural fistula: This occurs when the stump of the bronchus from which the lung tissue has
been removed breaks down. Fluid from the space left by the removal of the section of the lung drains
into the bronchus.
Clinical features: Tachycardia, Spiky temperature and cough productive of filthy blood – stained fluid.
Treatment: Antibiotic, repair of the stump and/or insertion of a drainage tube into the cavity.

This means the patient is treated lying on the operated side and has to be taught to keep the unaffected
side uppermost.
2. Circulatory:
a. Deep Vein thrombosis
b. Cardiac arrhythmias
c. Tamponade
d. Haemorrhage
3. Wound
a. Infection
b. Failure to heal
c. Adherent scar
4. Joint Stiffness
a. Shoulder and Shoulder girdle
b. Thoracic spine
c. Costo – vertebral joints
5. Muscle weakness
a. Latissimus dorsi
b. Serratus anterior
c. Other divided muscles
d. Leg muscles if unexercised
6. Postural deformity:
Tendency to protect the scar leads to a scoliosis and forward flexion.
Fluid is removed after any surgery that has opened the thorax to prevent a consolidated pleural effusion except
after a pneumonectomy when the fluid fills in the space of the missing lung. Equipment used comprises a
tube, a bottle with sterile water and possibly a suction pump. The tube passes from th inside the pleural cavity
down through a tight – fitting cap at the neck of the bottle to below the level of the water. This constitutes an
underwater seal. Air may be allowed to escape freely from a second tube positioned high above the water in
the neck of the bottle or a suction machine may be attached t this tube. Points to be noted are:
1. Amount and type of drainage
2. Air leak
3. Swing of water
4. Suction
5. The tubes
6. Clamps
PNEUMONECTOMY
This involves the removal of an entire lung. A radical pneumonectomy includes excision of the
mediastinal glands with dissection from the chest wall or pericardium. There may be unavoidable damage to
the phrenic nerve resulting in paralysis of half od the diaphragm or to the recurrent laryngeal nerve. Both these
complications impair respiration and coughing.
Indications: Carcinoma, Bronchiectasis and tuberculosis
Incision: Postero-lateral thoracotomy
PRE – OPERATIVE PHYSIOTHERAPY

Aims:
1. Gain the confidence of the patient
2. Clear the lung fields
3. Teach respiratory control and inspiratory holding
4. To teach posture awareness
5. Teach arm, trunk and leg exercises
6. Teach mobility about the bed.
Confidence of the patient

Teaching the exercises to be undertaken post – operatively and answering the patient’s questions helps
to allay some of the fears of the operation.
Clearing lung fields

The patient must be discouraged from smoking. Shaking, clapping and vibrations with postural
drainage. If necessary must be used to clear secretions from the sound lung. This is used in preference to
coughing post – operatively. The patient is instructed on how to support the wound during coughing or huffing.
The arm of the unaffected side is placed across the front of the thorax and round the affected side just below
the incision site giving firm pressure with the forearm and hand.
Teaching respiratory control

The patient is asked to take a deep breath in, hold then breathe in a little further, hold, then breathe out.
Breathing control has to be practised after secretions have been cleared.
POST – OPERATIVE PHYSIOTHERAPY

Note whether the patient is on Oxygen therapy or no and check whether there is a drain in the thorax.
Aims:
1. Clear secretions from the remaining lung.
2. Retain full expansion of remaining lung tissue
3. Prevent circulatory complications
4. Prevent wound complications
5. Regain arm and spinal movements
6. Restore exercise tolerance.
Day of Operation (Day 0) (Surgery am, treat pm)
Patient in half – lying with pillows arranged behind the neck and back and possibly both forearms on
a pillow on the lap.
Expansion breathing exercises for all areas of the lung. Foot and ankle exercises.
Day 1: Post – operation
Half – lying – segmental expansion exercises, shaking or vibrations as necessary, huffing and
expectoration with wound support from the physiotherapist.
By the end of the day, the patient should be huffing with self-support. Foot and ankle exercises
(ATM’s). correct postures should be emphasised to prevent a scoliosis on the scar side.
During two of the sessions the arm on the affected side must be moved:
1. Into full extension
2. Hand behind head
3. Hand behind back
4. Hand touch opposite shoulder.
A rope ladder should be provided so that the patient can pull on it to move around in bed and sit up.
Day 2: Post – operation
Treatment is continued as above plus on two sessions:
1. Sitting on the edge of the bed:
a. Trunk turning
b. Trunk bending side to side
c. Trunk stretching backwards
2. Sitting in chair – bilateral breathing exercises
3. Walk round: Bed with trunk erect and arms swinging.
Day 3: Post – Operation
Breathing and huffing are continued as necessary. Other activities continue twice in the day. The
patient may join in group therapy.
Day 4: Post – Operation to discharge
The patient continues with group therapy, gets dressed, walks further and after the 7th day, practises
going up and down stairs with breathing control. Bilateral breathing trunk and arm exercises are essential.

Stitches come out usually 7 – 10 days after operation. Two weeks after the operation the patient is
generally discharged with strict instructions to continue the exercise regimen.
Modifications to this programme

• Postural drainage: Positioning the patient on the operation side. Tipping must not be used because of the
danger of a Broncho – pleural fistula due to the fluid bathing the bronchial stump.
• IPPB may be used to improve ventilation
• Oxygen therapy and humidification may be necessary.
• Breathing exercises and huffing should clear the secretions.
Incentive Spirometry
This technique used to encourage a patient to take a deep breath in when there is hypoventilation after thoracic
or high abdominal surgery due to pain or secretion retention.
Example: At low lung volume a plastic ball rises to the top of a column, at mid – lung volume a second ball
rises and at high volume a third ball rises.
Long – term Management

- Three monthly check – ups.
- Check exercise tolerance, posture, trunk and shoulder mobility so that the patient may have the home
activity programme adjusted.
- The patient continues thoracic mobility exercises on a regular daily basis, for at least this period of time.
LOBECTOMY
Indications:
1. Bronchiectasis
2. Tuberculosis
3. Lung abscess
4. Carcinoma
Incisions: Posterolateral or anterolateral thoracotomy at the level of the 5th or 7th rib.
Pre – Operative Physiotherapy

This begins 48 hours to a week before surgery and is the same as for pneumonectomy. The only
variation is that breathing exercises will be taught to expand the lung tissue on the affected side which will
still be present after the operation.
Post – Operative Physiotherapy

Treatment similar to that of pneumonectomy. The main difference is that the patient has two
underwater seal drains. Oxygen therapy and humidification are generally used for up to 24 hours.
Day of operation (Day 0) – given after analgesia

Half lying:
- Breathing exercises to expand all segments of remaining lung tissue
- Vibrations over the unopened side
- Huffing with the incision supported by the physiotherapist
- Foot and ankle exercises (ATM’s)
Day 1: (Treat 3 – 4 times as necessary)

1. Analgesia is given as necessary before treatment.
2. Inhalations may be given.
Half – lying:
3. Breathing exercises as above but add inspiratory holding.
4. Add vibrations to the operated side plus percussion as required.
5. Side – lying on the unoperated side.

When positioning the patient, check that the drains are free and that the upper arm is supported by a
pillow. The underneath shoulder should not be on the pillow supporting the head. It is often helpful for the
patient to have a pillow under the top knee.
Expansion breathing exercises are given for the remaining lung tissue with vibrations and percussion.
If necessary the foot of the bed may be raised to give postural drainage.
Return the patient to half lying and check the position so that the shoulders are level and weight is
taken equally on both buttocks.
Exercises for the arm on the operated side:

1. Assisted arm elevations.
2. Assisted arm movements to touch the back of the neck and opposite shoulder.
Leg exercises are given:

1. ATM’s
2. Quadriceps contractions
3. Alternate hip and knee bending and stretching.
During the afternoon the patient will sit out of bed and it is important to ensure that the drains are not in danger
of being kinked or blocked.
Day 2
1. As first day
2. And self – supported huffing.
3. Arm exercises should be full range – auto – assisted. Elevation should be practised hourly.
4. Add trunk exercises in sitting:
a. Hands on shoulders bend side to side
b. Hands on shoulders turn side to side
c. Abdominal contractions
Discourage the patient from sitting cross-legged because this occludes the popliteal artery and vein and may
result in a deep vein thrombosis.
Day 3 and 4
Treatments may be cut down to one or two per day
Trunk and arm exercises should be continued and walking extended. The patient should be encouraged to
dress in normal clothing and to go up and down stairs.
• Bilateral breathing exercises are encouraged. Stitches are taken out between 7 and 10 days.
• Discharge is between 10 and 12 days after operation.
Long – term management

The patient will have regular check – ups at which time it is helpful if the physiotherapist checks
thoracic mobility, ensures that the scar is not adherent and that all areas of the lungs are expanding.
THORACOPLASTY
This operation is performed to produce permanent collapse of a lung. It may be used in pulmonary
tuberculosis or chronic empyema and is very rare.
The operation consists of resection of a varying number of ribs, leaving the periosteum in position.
Four to ten ribs may be removed.
The two main complications of this operation are;
1. Deformity: Ex. Scoliosis
2. Paradoxical breathing: The flaccid area of the chest wall is sucked in on inspiration and blown out on
expiration. This can be prevented by strapping over a cotton – wool pad to support the chest wall until it has
become firmer.

Pre – operative Physiotherapy
The patient has to be taught breathing control, expanding the remaining ling, forced expiration
technique and coughing, posture correction, shoulder girdle and shoulder exercises.
Post – Operative Physiotherapy
Day of operation:
Treatment is given after analgesia. Half – lying. Breathing exercises to expand the lower areas of the
lungs are bilaterally. The physiotherapist applies firm pressure over the apical areas of the thorax, and the
patient is encouraged to cough or huff.
Day 1
Posture correction must be started with the physiotherapist instructing the patient to push the head
sideways against manual resistance, towards the affected side and push the shoulder down and back.
Active assisted arm movements are practised on both the sides.
Day 2
Continue breathing exercises and coughing. Posture correction is progressed so that patient has to align
the head and shoulder and thoracic spine with scapular retraction without the guidance of the physiotherapist.
Day 3
The patient will be up and about. Manually resisted exercises for the shoulder girdle and arm on the
affected side should be included.
Day 4
Trunk exercises in sitting are added.
Day 5 - 7
Trunk exercises in standing should be included. Posture correction in walking should be practised.
Day 8 to discharge from hospital

The patient must practise exercises to maintain trunk mobility, thoracic cage mobility and a good
posture which have to be continued at home for at least 3 months after discharge.
When the patient attends for check ups with the surgeon the physiotherapist should check the patient’s
posture and thoracic expansion.
OPERATIONS OF THE PLEURA

These are:
1. Pleurectomy:
Removal of the parietal layer of pleura from an area of the chest wall leaving a raw surface to which
the visceral layer sticks and is performed for pneumothorax.
2. Abrasion pleurodesis:
It is the insertion of a powder into the pleural cavity. This acts as an irritant to the pleural surfaces,
causing them to adhere to each other. It is performed for spontaneous pneumothorax or malignant pleural
effusions.
3. Decortication of the lung:

It is the stripping off of the layers of pleura that have become thickened due to chronic inflammation
from pleurisy which restricts movement of the chest wall and expansion of the lung.

CHAPTER 17: INTRODUCTION TO ICU
Introduction to ICU:
• Patients are admitted to an intensive care unit (ICU) for intensive therapy, intensive monitoring or
intensive support.
• They are at a risk of failure of one or more major organs.
• Their needs range from observation of vital signs after major surgery to total support of physiological
systems.
• Admissions usually depends on expectation of recovery.
ICU Monitoring:
• From the patient’s point of view, monitors bring both anxiety and reassurance.
• From the staff point of view, they are useful to record subtle changes in patient’s status.
• Monitoring implies regular observation and a systemic response if there is deviation from a specified
range.
Ventilator interactions:
• Ventilator graphics demonstrate flows, pressures and volumes that represent the patient’s response to
ventilator.
1. Pressure-time curve:
a) Peak airway pressure
b) Mean airway pressure
c) End-inspiratory plateau pressure
2. Flow-time curve:
a) Verifies presence of intrinsic PEEP
3. Pressure-volume loop:
a) Represents lung compliance.
b) Work of breathing can be calculated
4. Flow-volume loop:
a) It indicates patency of airways Figure 1: Flow - Volume Loop
b) Peak expiratory flow
c) Forced mid-expiratory flow
d) Forced vital capacity
e) Peak inspiratory flow.
Gas Exchange:
1. Arterial oxygen blood gases analysis
2. Arterial oxygen saturation:
a) >92% - normal
b) <90% - low (increase in CO to maintain Oxygen delivery)
c) Physiotherapy can upset gas exchange and if desaturation occurs, treatment should be stopped.
3. Capnography:
a) Displays expired CO2 concentration as waveform (capnogram).
a) It provides a non-invasive assessment of adequacy of ventilation.
b) Values at end-exhalation indicate end-tidal CO2, which approximates alveolar PCO2.
4. Transcutaneous monitoring:
a) Oxygen and CO2 diffuse across skin and can be measured by a sensor on the skin.
b) In haemodynamically stable patients, values relate to respiratory status.
Tidal volume:
• If it is not continuously monitored and displayed, it can be measured by attaching a Wright spirometer
to the tracheal tube and taking average of 5 breaths.

Fluid status:
• The fluid status chart gives an overview of fluid status.
• Keeping an eye on the UOP, thirst, dry mucus membranes(dehydration), edema(overhydration)
Haemodynamic monitoring:
• The heart and the vascular systems act as a continuous loop in which constantly shifting pressure
gradient keep the blood moving.
• CVS function can be gauged from clinical signs such as BP, HR, UOP and mental status.
• These are however unreliable in critical illness and invasive hemodynamic monitoring is then required.
The parameters are:

1. Blood pressure:
a) It can be monitored by an automated cuff that intermittently compresses the limb and senses
arterial pulsations.
b) An indwelling catheter gives beat to beat waveform display.
c) The most relevant reading is mean arterial pressure.
2. Right atrial pressure:
a) The central venous pressure is monitored by a water manometer through the central line
a) It reflects the pre-load of right ventricle.
b) Normal values are 3-12 cm H2O
c) A high value may indicate heart failure, pulmonary embolus, COPD, pneumothorax or over-
transfusion of fluid.
d) Gives early warning of cardiac tamponade (sudden rise) and hemorrhage (sudden drop).
3. Left atrial pressure:
a) A pulmonary artery catheter is passed along the CVP catheter route, floated through right
ventricle into pulmonary artery.
a) The pulmonary artery catheter monitors cardiac output, mean pulmonary artery pressure and
pulmonary artery wedge pressure.
b) PAP: normal- 10-20 mmHg. PAWP: normal- 5-15 mmHg.
c) PAP is raised in pulmonary HTN, pulmonary embolism, fluid overload.
d) PAWP is compromised if patient is severely hypovolemic, changes position or is subject to
high lung inflation pressures. Increased PAWP shows left ventricular failure.
Tissue oxygenation:
1. Mixed venous oxygenation:
a) Mixed venous blood in the pulmonary artery contains oxygen that is left after its journey and
reflects tissue perfusion and extraction level.
b) SvO2 is 65-75% and should be more than 10% below SaO2
c) A low value reflects:
i. Decreased oxygen delivery (suction anemia, low CO, hypoxemia, hemorrhage)
ii. Increased oxygen demand (suction exercise, fever, anxiety, labored breathing or pain.
2. Gastric tonometry:
a) It entails passing a saline filled balloon into the stomach and measuring the PCO2 that passes
across the membrane
b) Gastric mucosal pH can also be measured
c) Acidosis indicates hypoperfusion, which if not corrected may contribute to multisystem failure.
Cardiac Output:
1. Invasive measurement is by thermodilution a known quantity of cold saline solution is rapidly injected
into a channel of the pulmonary artery catheter. The temperature of blood when it reaches the
pulmonary artery indicates the speed with which solution has been warmed.
2. Non-invasively it can be assessed by transoesophageal doppler USG.
3. Reduced urine output is the simplest indicator of reduced CO.
Electrocardiography (ECG):
1. Disturbances such as hypoxia, physiotherapy, electrolyte imbalance, MI can cause disorders of HR.

2. These are picked up by ECG which is recording of electrical activity in heart comprising of waves,
complexes and intervals.
a) Sinus rhythm
b) Ventricular tachycardia
c) Nodal rhythm
d) Atrial fibrillation
e) Ventricular fibrillation
f) Heart block
Sinus rhythm: Ventricular tachycardia:
Ventricular fibrillation:
Atrial fibrillation: Atrial flutter:
Heart block (3rd Degree)
ADVANCED PULMONARY SUPPORT:

1. Intravascular oxygenation:
– It can be used if potentially damaging volumes and pressures are being delivered by ventilator.

2. Liquid ventilation:
– It eliminates the gas-liquid interface in the lung
by filling them with an inert colorless liquid
called perfluorocarbon
– This is twice as heavy as water, highly soluble
to respiratory gases and opaque to X-ray.
APPARATUS:
1. Monitor: Shows HR, BP, SpO2, ECG
2. Silicon pulse oximeter probes
3. ICU bed: Can be adjusted by levels for positioning
of patients.
4. Defibrillator: Usually kept in the crash cart.
5. Central venous pressure manometer.
6. Suction unit
7. Rigid suction catheter
8. Suction catheters: There are different sizes.
9. Inline suction catheter: It is closed suction catheter. It is extremely good in case of infectious patients
or patients with septicaemia.
10. Urinary catheter: Fowley’s catheter
11. Catheter bag
12. Venflon: very commonly used. Also known as channel or venous catheter.
13. Infusion set
14. Infusion pump: Delivers medicines like dopamine, analgesia, insulin etc. It gives controlled doses of
medicine over a particular period of time.
15. Central venous catheter: A central line. It has 3 sites: Subclavian, internal jugular and femoral veins.
16. Central line: after insertion of the catheter.
17. Tongue depressors: David – Boyne tongue depressors.
AIRWAYS AND TUBES:

1. Oropharyngeal tube
2. Endotracheal tube: It is used commonly for patients who are on oxygen support or on ventilator.
3. Ryle’s tube: Used for feeding the patients. It enters through the nose and passes to the oesophagus.
PHYSIOTHERAPY IN ICU:
Assessment:
1. Subjective assessment:
2. Charts
a) GCS score
b) Pain score
c) Sedation score
d) Temperature, BP, HR, RR, SpO2
e) CVS stable Y/N
f) ABGs
g) Fluid balance
h) Relevant medication
3. Ventilation
a) Self ventilating Y/N
b) Breathing pattern
c) NIV Y/N mode:
d) IPPV Y/N
e) Tidal volume
f) Mode SIMV/ other
g) PEEP
h) Patient triggering Y/N

i) Humidifier
j) CXR Date Radiology report/own interpretation
Clinical assessment:
1. Appearance
2. Auscultation breath sounds added sounds
3. Abdominal distention
4. Percussion note
5. Other
I. Indications to treat
II. Precautions/reasons not to treat
TREATMENT:
1. Pressure area care:
– Pressure sores distress people, kill people and are avoidable
– Risk factors are malnutrition, obesity, steroids, diabetes, restricted movement.
– It can be prevented by frequent turning and judicious positioning, pressure reducing cushions,
keeping pressure area dry, turning without friction, using water or air beds.
– It can be treated by cryotherapy.
2. Positioning:
– It is the main PT treatment for intensive care patients.
– Postioning helps in increasing ventilation, increases FRC, enhances gas exchange.
– It improves secretion removal by postural drainage.
– Factors that modify positioning are head injury, abnormal muscle tone, pain, SCI, fractures,
pressure sores, unstable BP.
3. Breathing exercises:
– If patients are breathing spontaneously, teaching them deep breathing exercises, segmental
breathing exercises, coughing, huffing.
– Suggest spirometry for post-surgical ICU patients.
– In cases of cardiac or thoracic surgery, teach patient supported breathing exercises.
4. Manual hyperinflation:
– Is helpful in clearing excess secretions and also for improving ventilation.
5. Postural drainage:
– Positioning of patients in various ways to enhance secretion clearance by using gravity.
– The precautions and contra indications should be kept in mind.
6. Manual techniques:
– Percussion and vibration are very commonly indicated in the ICU.
– Monitors should be closely observed while giving manual techniques.
– They help in moving the secretions from terminal bronchioles to main airways.
– These are always followed by suctioning.
7. Suction:
– It is performed if patient is unable to clear secretions by other means, secretions are
accessible to the catheter (crackles in the upper airway), secretions are detrimental to patient.
– Patients who are on ventilator, semiconscious, weak or neurologically impaired may require
suction.
– It is contraindicated if there is stridor, unstable CVS, undrained pneumothorax, hemoptysis,
acute head or neck injury.
– It aggravates bronchospasm n reduces SpO2 but they come back to normal in 2 mins.
– There may be difficulty in passing the catheter due to kinking of the tracheal tube, obstruction
by thick secretions or patient biting the tube.
– If secretions are mixed with blood, STOP.
– Saline instillation into lungs is sometimes done for mobilizing thick secretions. It helps
dislodge encrusted secretions.
– Saline is delivered distally by injecting it through suction catheter.
– After this perform a few MH breaths before suctioning.
8. Exercises:
– Activity required to maintain sensory input, comfort, joint mobility and healing ability
– Patients need active or passive exercises, including stretches.
– Precautions should be taken for patients who are paralysed, burns, fracture etc.
9. Mobilization:
– To prevent deconditioning, an attempt should be made to stand and walk all patients who are
not contraindicated.
– Sitting with legs dangling over edge of bed, using tilt-table, visit outside on wheel chair.
COMMON CONDIITIONS IN ICU:
TETANUS:
Pathophysiology:
• Tetanus bacillus produces one of the most lethal poisons known.
• It is a common resident of superficial soil and enters the body through a wound. It infects any dead
tissue and spreads to the CNS.
• This leads to muscle rigidity, autonomic instability, and sometimes convulsions.
Clinical presentation
1.Patient experiences pain
2.Stiffness
3.Inability to open their mouth (lock jaw)
Assessment
General assessment as mentioned earlier.
Muscle strength
ROM
Chest mobility
Regular assessment for pressure sores, tone and deformity should be done.
Management:
• Medical:
1. Intubation in case of spasm of larynx
2. IPPV for spasm of diaphragm
3. Sedation is sometimes needed
4. Muscle relaxants
• Physiotherapy:
1. Positioning
2. Passive and active stretching
3. Breathing exercises
4. Ankle-toe pumps
• Recovery occurs over 6 weeks but residual stiffness is common.

HEAD INJURY:
Introduction:
• Accurate assessment and final clinical judgment is very vital.
• Methods to control intracranial pressure and prevent lung problems may be in conflict and are often
complicated by other trauma.
• Head trauma may precipitate a process that converts a mild injury to a life threatening one.
• Primary damage at the time of impact is irreversible but secondary damage, which encompasses
every mishap that befalls thereafter can double mortality by reducing O2 delivery to brain.
Effect of head injury on respiratory system:
• Chest infection is only 2nd to intracranial hypertension as a cause of death following head injury.
• Damage to the respiratory centre may cause abnormal breathing. Hyperventilation can cause tissue
hypoxia, hypoventilation cause vasodilation and raised intracranial pressure. Cheyne-stokes or ataxic
breathing are signs of severe damage.
• Loss of protective pharyngeal reflexes in an unconscious patient may cause acute aspiration.
• Immobility, recumbency and depressed consciousness cause shallow breathing and impaired cough
• Associated trauma like facial injury, fractured ribs, hemopneumothorax or lung contusion
compromise the airway or impair gas exchange.
• Fluid restriction to reduce cerebral edema can lead hypotension and reduced oxygen delivery. Excess
fluid can cause pulmonary edema.
• Pneumonia is common in early stages if acute aspiration has occurred at the time of injury or
emergency intubation. It is less common in later stages.
• Later problems may arise like DIC because of fluid imbalance, multisystem failure or fat embolism.
Effect on brain:
• Primary injury is caused by bleeding, contusion and shearing forces.
• Secondary damage is caused by cerebral edema, raised ICP, hypoxemia, anaemia, hypo-,
hypertension, infection.
• The brain swells when damaged to a maximum after 24-48 hours of injury. Extreme intracranial
pressure may cause coning, in which the brain stem herniates through the foramen magnum.
• Cerebral perfusion rate is important for circulation in brain and must be maintained above 70 mm of
Hg.
Factors increasing ICP:
• Head down postural drainage increases arterial, venous and ICP because cerebral veins have no
valves.
• Turning the patient increases ICP because head movement obstructs drainage from the brain.
• Head movement, suction, coughing, MHI, vibrations, percussion can raise ICP
• Hypertension and in hypotension the CPP is reduced. Death by reduced CPP occur during admission
(internal bleeding) and during surgery (intentional low BP).
General Management:
1. Monitoring:
– CPP and ICP is monitored.
– GCS
– PaCO2 and PaO2
– Oximetry
2. Head elevation
– Commonly head is elevated to 15-35º in order to reduce ICP and encourage CSF outflow.
3. Fluid management:
– Normovolaemia is target, excess fluid increases cerebral edema and dehydration reduces
brain perfusion.
4. Nutrition:
– Energy expenditure is doubled for 4 wks.
– Enteral feeding should be started when possible.
5. Temperature control
6. Drug therapy
7. Mechanical ventilation
– Intubation may be needed to clear airway.
– IPPV given to regulate an unstable breathing pattern, ensure oxygenation or manage chest
complication.
Physiotherapy:
• Hallmark of physiotherapy is maximum involvement and minimum intervention.
• Involvement is by frequent assessment to assist decisions and supervision of handling to minimize
ICP disturbance.
• Intervention is unwise in presence of CVS instability, hypotension etc.
• Assessment:
1. SpO2
2. Chest complication
3. Observation of BP, ICP.
4. CSF leak from nose or ear
• Positioning:
1. Log-rolling.
2. Accurate positioning in side lying with neutral head positioning
3. Neck flexion must be avoided.
4. Calf pressure should be avoided as DVT is significant risk.
• MHI
• Manual techniques
1. Percussion should be rhythmic, smooth and gentle.
2. Vibrations should be fine and avoid affecting intra thoracic pressure.
3. Vibrator can be used.
• Suction:
1. Give rest from previous activity
2. 100% oxygen before and after treatment
3. Head kept in alignment
4. Tracheal tube stabilized throughout
• Exercise:
1. Extreme hip flexion avoided in acute stage.
2. If flaccidity is present, avoid movements in first few days.
3. If spasticity is developing, appropriate positioning should be maintained.
4. If increased tone or clonus is seen, immediate splinting should be done and stretching to
prevent contracture.
LUNG DISEASES:
Introduction:
➢ It includes- COPD and Asthma
➢ Chronic obstructive pulmonary disease:
• It is the common disease entity of chronic bronchitis and emphysema.
• It is a slowly progressive disease and most airways obstruction is fixed.
• It is caused by smoking, occupation related, childhood respiratory illness and in utero exposure to
smoking or malnutrition.
➢ Pathophysiology:
• Chronic bronchitis is a disease of airways, characterized by excess mucus secretion and productive
cough.
• There is inflammation of the airways leading to fibrotic changes and wheezing.
• Emphysema shares the same aetiology but is the disease of alveoli and smallest airways. It is caused
by damage to alveoli.
• There is loss of elastic tissue of the alveoli and the floppy walls collapse.
➢ Clinical features:
• Manifested as pink puffer or blue bloater
• Pink puffer is breathless, work of breathing is more, weight loss, labored breathing, soft tissue
recession.
• Blue bloater is less breathless, suffers from nocturnal hypoxemia, edematous.
• Barrel chest
• Forced expiration with purse lip breathing
• Cyanotic appearance
Medical Management:
• Oxygen therapy
• Bronchodilators like thiophylline
• Steroids for exacerbation
• Inhalers and nebulizers
• Hypnotic drug like zolpidem in case of disturbed sleep
• Surgery to remove giant bullae or lung volume reduction.
Physiotherapy:
• For exacerbation PT is required to clear to secretions and reduce WOB
• MHI
• Daily standing and walking are required unless contraindicated
• Bed exercises should be demonstrated
• Restoration and maintenance of exercise tolerance and basic self management.
• Pulmonary rehabilitation
➢ End stage:
➢ Invasive treatment is given
➢ Recognition of patient’s needs is done by physiotherapist for better palliation.
Asthma:
• More common, more serious, more manageable than thought.
• It is a chronic inflammatory condition of the airways, characterized by undue responsiveness to
stimuli that are normally innocuous i.e. hyper reactivity.
• Predisposing factors include poverty, smoking, in utero allergen sensitization.
➢ Patho physiology:
• It takes place in 2 phases:
• Sensitization phase in which there is exposure to allergens in fetal or early life.
• Hyperreactive phase in which there is continued exposure to allergens causing inflammation which
damages surface epithelial layer.
➢ Clinical features:
• Intermittent dry cough
• Wheezing
• Increased WOB
Severe risk indicators:
• Pallor or sweating
• Decreased response to bronchodilator.
• Decreased respiratory effort
• Loss of wheeze and silent chest on auscultation
• Cyanosis or altered consciousness
➢ Medical management:
• Mechanical ventilation
• Heliox for bronchospasm

• Continuous IV bronchodilating anaesthetic such as ketamine
➢ Physiotherapy management:
• Relaxed abdominal breathing
• Postural advice and emphasis on exhalation to reduce muscle tension and hyper inflated chest.
• Inspiratory muscle training
• Teaching effective coughing
• Aerobic exercises with appropriate precautions.
PULMONARY OEDEMA
Pathophysiology:
• Pulmonary edema is extravascular water in the lungs, usually caused by back pressure of failing left
heart.
• Non-cardiogenic pulmonary edema can be caused by fluid overload, systemic vasoconstriction,
pressure changes or increased capillary permeability due to toxins or inflammatory damage.
Signs and Symptoms:
1. Main symptom is breathlessness which is seen as orthopnea and PND.
2. Fatigue caused by reduced CO
3. Radiographic signs are enlarged heart, upper lobe division and bilateral fleecy opacities spreading
from the hila.
4. Crackles with or without wheeze on auscultation
5. In non-cardiogenic PE X-ray shows normal sized heart.
6. Frothy sputum (white or pink)
Management: Physiotherapy
1. Positioning for ease of breathing
2. Postural drainage to mobilize secretion.
3. Suction should be avoided as it does not help the condition and will remove the surfactant if
performed repeatedly.
MULTIPLE ORGAN FAILURE:
Aetiology:
1. Bacteremia: viable bacteria in blood
2. Infection: micro organisms
3. Septicaemia: systemic infection in which pathogen is present in blood
4. Endotoxin: toxin released by gram –ve bacteria.
5. Sepsis: systemic response to infection
6. Systemic inflammatory response syndrome: general inflammatory response.
7. Shock: failure of oxygen supply to meet oxygen demand.
Causes:
1. Prolonged hypotension
2. Sepsis
3. Aspiration
4. Over-transfusion
5. Smoke inhalation
6. Head injury
7. drowning
8. Fat –embolism
9. Lung contusion
10. Poisoning
11. Peritonitis
12. DIC
13. Immunosuppression following trauma or surgery
Management:

- Medical:
o Ventilatory support
o Inotropic support and vasodilators
o Sedation
o Packed red cell transfusion
o Haemofiltration to wash out circulating mediators.
o Fluid management
o Steroids if started early and in case of gram –ve septicemia.
- Physiotherapy:
1. Chest physiotherapy (with extreme precaution)
2. Splinting of hands if fingers are affected.
3. Positioning to optimize circulation and prevent contracture
4. Passive movements with extreme care to protect the skin.
a) DISSEMINATED INTRAVASCULAR COAGULATION:
• The normal response of tissue damage, i.e. controlled explosion of thrombin to initiate clotting and
limit blood loss, becomes uncontained after severe damage like burns, HI, SCI
• In this case, the thrombin activates uncontrolled coagulation and blocks blood vessels causing
ischemia and organ damage.
• Bleeding can occur from slightest trauma.
• Death Is Coming.
b) KIDNEY FAILURE:
• It occurs acutely in response to hypotension, hypoxia or multisystem falilure.
• It is suspected if UOP drops or urea creatinine levels rise.
• Treatment can be by continuous hemo filtration, intermittent hemo dialysis(access by AV fistula),
peritoneal dialysis.
• PT should be at end of emptying cycle to ensure diaphragmatic movement.
• Respect the renal vascular catheter as disconnection leads to major blood loss.
NEUROMUSCULAR DISORDERS:
Types:
• Guillian-Barré syndrome
• Acute quadriplegia
• Acute head injury
• Myasthenia gravis
• Botulism
• Tetanus
• Critical illness neuropathy
Physiotherapy management:
• GBS:
– Mainly prophylactic to prevent contractures
– Spinal movements
– Tilt table
– Hydrotherapy
• Ac. Quadriplegia:
– 3rd to 5th day- position change, percussion and assissted coughing.
– Positioning of limbs and ROM
– Mobilization and weight bearing
• Myasthenia gravis:
– ICU is needed after thymectomy, during crisis, in case of bulbar weakness.

– PT is mainly to clear excess bronchial secretions.
• Botulism:
– Bulbar and respiratory muscles paralysis may occur
– IPPV is needed for months.
• Critical illness neuropathy:
– PT is needed little and often to optimize musculoskeletal function without exhausting the
patient.
SMOKE INHALATION:
• It is the primary cause of fire-related deaths.
• Heat from inhaled smoke is filtered by the upper airways causing bronchospasm, mucosal swelling,
pulmonary edema, paralysis of cilia. The surfactant is destroyed and lung tissue is burnt.
• Upper airway obstruction is most treatable respiratory complication but if intubation is delayed,
asphyxia may occur from face n neck edema.
• 2nd ry damage is from the inflammatory response to injured tissue, CO inhalation and infection of
denuded airways.
Treatment:
• Pain management
• Fluid administration
• Humidified oxygen at 100%
Physiotherapy:
• Respiratory PT to maintain lung volume and clear thick secretion.
• Treatment should be little and often
• Percussion and vibration should be avoided. Vibrator may be used if very necessary.
• If suction is needed, it should be very gentle minimal and aseptic.
• In case of edema around head or neck, postural drainage is contraindicated.
• If hoarseness, voice change or stridor develops, nasopharyngeal suction is contraindicated.
• Two – hourly exercises are required for burned limbs esp. hands using some analgesia.
POSITIONING:
• Complications of poisoning include arrhythmias due to toxin or metabolic upset, fluid depletion due
to vomiting.
• Respiratory compromise due to ventilatory depletion, upper airways obstruction or pulmonary
edema.
• If gastric lavage is attempted, it can cause aspiration, distress and laryngeal spasm.
• These patients are at the extremes of depression or desperation.
• The professional approach is to withhold personal judgement and care for the patients in such a way
that s/he believes life to be worth living.
• The care they receive in the first few hours can have a profound impact on their grief.
ASPIRATION:
• Aspiration is common in NMD because of dysphagia and poor gag reflex.
• It is suspected in patients with lower lobe pneumonia, spiking temperature, feeding that is associated
with coughing or crackles.
• It can cause bronchospasm, bronchitis, pneumonia and abscess.
• Prevention is by:
– Head and chest elevation
– Upright sitting while eating
– Avoid feeding when patient is tired
– Avoidance of straws for drinking
– Avoidance of distraction while eating

– Suction equipment should be ready.
Management:
• Immediate physiotherapy by postural drainage
• Percussion
• Vibrations and shaking
• Cough or suction
• Medical management by intubation and suctioning
• Fluid replacement to compensate the loss of fluid aspirated.
NEAR - DROWNING:
• It is defined as submersion followed by survival for 24hrs, then deterioration.
• Death can occur from pulmonary complications, esp. in case of wet drowning, which leads to
pulmonary edema, inactivation of surfactant, bronchospasm, cerebral edema.
• If water is swallowed, there is vomiting leading to further aspiration.
• Frequent PT to clear the airways may be needed for at least 48 hrs to prevent atelectasis.
• Dry drowning is caused by laryngospasm in a panicking victim, leading to apnea and hypoxia.
• Hypothermia (core temperature <35ºC) occurs
• Resuscitation attempts should be prolonged and nobody should be considered dead until warm and
dead.
• Patients are given warmed humidified oxygen, warmed IV fluids, warm blankets.
ADULT RESPIARTORY DISTRESS SYNDROME:

Pathophysiology:
• It is injury to the lung parenchyma leading to alveolar-capillary membrane leak and pulmonary
edema.
• Lung tissue can be injured directly e.g. by aspiration, smoke inhalation etc. It can be indirectly by
toxins let loose by multisystem failure.
• The resulting alveolar-capillary membrane allows flooding of alveoli leading to massive pulmonary
edema. Vascular injury leads to hypertension which increases edema.
• The waterlogged and inflamed lungs become progressively and unevenly damaged.
Clinical Features:
• Respiratory distress
• PaO2 and PaCO2
• X-ray signs lag behind by 24-48 hours, there is fine consolidation with bilateral snowstorm
infiltrates.
• High PAP
• Tachypnea
• Hypoxemia
• Ventilated patient shows high airway pressure.
Physiotherapy:
• Mainly done to increase the lung volumes.
• Positioning from supine to prone and back
• MHI
• Medical management:
– NIV, PEEP, pressure control ventilation.
– Surfactant replacement
– ß2- agonists
– Steroids
– Oxygen therapy
SHOCK:

• Shock occurs when reserve capacity of tissue respiration is exhausted.
• Hypovolaemic shock is caused by loss of fluid like burns or hemorrhage. It is characterized by
increased HR, RR, decreased CVP, PAWP, SBP, UOP.
• Cardiogenic shock is caused by sudden heart failure as in MI. It is characterized by high CVP, low
CO and pulmonary edema.
• Septic shock occurs when sepsis induced hypotension is unresponsive to fluid resuscitation. There is
fever, high pulse rate and low BP.
• Other types of shocks are anaphylactic, an allergic reaction and neurogenic following NS damage.
DEALING WITH AN EMEREGENCY IN ICU:

Recognition and management of emergencies:
• The key to the successful management of emergencies is informed anticipation and recognition.
• Physiotherapists are not immersed in life-threatening events everyday so are advised to review
protocols regularly in order to maintain confidence and avoid indecision
• Some common emergencies seen in an ICU which need to be anticipated, recognised and managed
are discussed.
Cardiac Arrest:
• It is the sudden cessation of heart function. It is the commonest mechanism of old-fashioned process
but death. It is followed within seconds by loss of consciousness and then by loss of respiration.
• Anticipation:
– Before starting work in any new ward or unit, first task is to locate the crash trolley.
– The medical history will provide evidence of risky conditions such as IHD, severe respiratory
disease, drug overdose, arrhythmias or shock.
• Recognition:
– Warning signs are change in breathing, color, facial expression or mental function.
– Hypoventilation with altered consciousness is an ominous combination.
– Patient’s color may be pale ashen or blue.
– No carotid pulse can be felt
– Respiration is gasping then stops
– ECG shows ventricular fibrillation, tachycardia etc.
• Action:
– Time between collapse and initiation of resuscitation is critical and false alarm is better than a
dead patient.
– If suspicions are due to change in consciousness and color, feel the pulse.
– Call out to patient and if found unresponsive follow the following:
– Summon help by pressing crash button and by bellowing Cardiac arrest. If no one is available
and a telephone is nearby call crash team.
– Position patient supine, remove all pillows.
• Establish patent airways

• Keep airway open by correct head positioning, look, listen, and feel for breathing for 10 secs. If –nt
ventilate using face mask, resuscitation bag and oxygen at 15L/min.
• Kneel on bed and apply external chest compression.
• Stand clear when the crash team arrives.
• When no longer needed attend to other patients who may be distressed at witnessing the event.
Respiratory Arrest:
• Anticipation:

– Predisposing factors include exacerbation of COPD, airway obstruction or aspiration.
– Warning signs are inability to speak, and either violent respiratory efforts, laboured breathing
or drowsiness.
• Recognition:
– It is indicated by –nce of movement of chest, loss of airflow from the mouth and nose and
sometimes cyanosis.
– This progresses to loss of consciousness.
• Action:
– Call for help
– Establish patent airway
– If foreign body is there remove it
– Ventilate by bag-mask ventilation
– If patient starts breathing, turn him or her into recovery position because vomiting is
common.
SEIZURE:
• Anticipation:
– History of epilepsy
– Head injury, alcohol intoxication, fever in children.
• Recognition:
– It varies from transient loss of consciousness to major muscle activity, followed by
drowsiness.
• Action:
– Patients subject to frequent seizures should have bed kept low, side rails up and padded and
oxygen and suction available.
– If advance warning is there, insert airway. Don’t attempt it once seizure is underway.
– Protect patient’s head and body from injury. Loosen tight clothing, esp. around neck. Don’t
use restrains or hold patient down. Keep in side lying if possible.
– Afterwards ensure patient is in recovery position. Reassure him/her as consciousness returns
HEMORRHAGE:
• Anticipation:
– Uncontrolled bleeding can follow surgery, arterial line disconnection or trauma.
• Recognition:
– External bleeding is not easily missed.
– Internal bleeding is suspected if there is severe hypovolemia.
– Bleeding in closed space causes extreme pain.
• Action:
– Position patient supine.
– Apply pressure to bleeding point if accessible.
– Elevate affected part if possible.
– Request assistance.
– Explain patient what is being done.
MASSIVE HEMOPTYSIS:
• Anticipation:
– Predisposing factors are lung cancer, bronchiectasis, abscess or TB.
• Action:
– Patient should be positioned head down and laid on the affected side to prevent aspiration
into healthy lung.

– Patients with depressed consciousness or risk of asphyxiation need intubation and suction
• Equipment malfunction or disconnection:
a) Astute eyes and ears help pick up the slightest hiss of air leak from orchestra of alarms.
b) subtle changes in drowsy patient’s demeanour.
c) Alarms that are relevant for physiotherapist are high pressure alarm, low pressure alarm,
alarms for BP.
d) Arterial line or vascath disconnection.
e) Firm pressure is applied to the site, observe patient and monitors for hypovolemia.
f) Inform nurse.
CHAPTER 21: PHYSIOTHERAPY MANAGEMENT FOLLOWING PVD

 PVD is a generic term that encompasses vascular insufficiencies such as arteriosclerosis, arterial
stenosis, Raynaud’s phenomenon.
 Peripheral arteriosclerosis is common in the elderly and is often associated with hypertension and
hyperlipidemia.
➢ PVD is frequently observed in patients with CAD, diabetes, and a long-term history of
smoking.
 Also known as PAD or PAOD.
 Occlusive disease of the arteries of the lower extremity.
 Most common cause:
➢ Atherothrombosis
➢ Others: arteritis, aneurysm + embolism.
The FACTS:
1. The prevalence: >55 years is 10%–25%
2. 70%–80% of affected individuals are asymptomatic
3. Pt’s with PVD alone have the same relative risk of death from cardiovascular causes as those CAD
or CVD
4. PVD patient’s = 4X more likely to die within 10 years than patients without the disease.
5. The ankle–brachial pressure index (ABPI) is a simple, non-invasive bedside tool for diagnosing PAD
— an ABPI <0.9 = diagnostic for PAD
6. Patients with PAD require medical management to prevent future coronary and cerebral vascular
events.
Two types of PVD
 Functional
➢ Doesn’t have an organic cause.
➢ Doesn’t involve defects in blood vessels’ structure, usually short-term effects and come and
go.
➢ Ex: Raynaud’s disease.
 Organic
➢ Caused by structural changes in the blood vessels, such as inflammation.
➢ Ex: Peripheral artery disease, caused by fatty buildups in arteries.
Symptoms of PVD:
 Leg or hip pain during walking (intermittent claudication).
 The pain stops when you rest.
 Numbness, tingling or weakness in the legs.
 Burning or aching pain in feet or toes when resting.
 Sore on leg or foot that won’t heal.
 Cold legs or feet.

 Color change in skin of legs or feet.
 Loss of hair on legs.
The 5 P’s
 Peripheral signs of PVD are the classic 5 P’s
➢ Pulselessness
➢ Paralysis
➢ Paraesthesia
➢ Pain
➢ Pallor
Who is at risk for PVD?

 Over the age of 50
 Smokers
 Diabetics
 Overweight (especially with syndrome X or hyperinsulinism)
 Male sex
 Sedentary people
 People who have hypertension or high cholesterol
 Family history of heart or vascular disease
PAIN SCALE:
 A subjective grading scale for PVD pain is as follows:
➢ Grade 1: Definite discomfort or pain, but only of initial or modest levels (established, but
minimal).
➢ Grade 2: Moderate discomfort or pain from which the patient’s attention can be diverted, for
example by conversation.
➢ Grade 3: Intense pain (short of Grade 4) from which the patient’s attention cannot be
diverted.
➢ Grade 4: Excruciating and unbearable pain.
Anatomy and Physiology:
Arteries – walls are thicker due to greater smooth muscle, hence stronger & can withstand high pressure
PLAQUE DEPOSIT:

Progression of Occlusion:
Arterial Assessment:
Purpose: To determine adequate tissue perfusion
Guide lines
1. Compare upper & lower
2. Compare bilaterally
3. Compare distal & proximal
4. Supine (vs) dependent changes.
Major areas of assessment
1. Circulation – pulse means perfusion
2. Motion – muscles need oxygen
3. Sensation – pain, burning, proprioception, numbness
Circulation
Check pulse points: Carotid, Radial, Femoral, Dorsalis pedis, Posterior tibial & Capillary refill.
 Pulses are based on a scale: 0 to 4+

➢ 0 = NO PULSE
➢ 1+ = THREADY PULSE
➢ 2+ = NORMAL PULSE
➢ 3+ = BOUNDING PULSE
➢ 4+ = ANEURYSM
How to perform an ABI Exam?

 Performed with the patient
resting in the supine position
 All pressures are measured with
an arterial Doppler and
appropriately sized blood pressure
cuff (edge 1-2 inches above the
pulse; cuff width should be 40% of
limb circumference).
 Systolic pressures will be
measured in the right and left
brachial arteries followed by the
right and left ankle arteries.

ABI Procedure: →
THE ANKLE – BRANCHIAL INDEX

𝐿𝑜𝑤𝑒𝑟 𝑒𝑥𝑡𝑟𝑒𝑚𝑖𝑡𝑦 𝑠𝑦𝑠𝑡𝑜𝑙𝑖𝑐 𝑝𝑟𝑒𝑠𝑠𝑢𝑟𝑒
𝐴𝐵𝐼 =
𝐵𝑟𝑎𝑐ℎ𝑖𝑎𝑙 𝑎𝑟𝑡𝑒𝑟𝑦 𝑠𝑦𝑠𝑡𝑜𝑙𝑖𝑐 𝑝𝑟𝑒𝑠𝑠𝑢𝑟𝑒
• The ankle-brachial index is 95% sensitive and 99%

specific for PAD
➢ Establishes the PAD dAge less than 50 years with
diabetes, and one additional risk factor Age 50 to 69
years and history of smoking or diabetes
➢ Age 70 years and older
➢ Leg symptoms with exertion (suggestive of claudication) or ischemic rest pain
➢ Abnormal lower extremity pulse examination
➢ Known atherosclerotic coronary, carotid, or renal artery disease
ANKLE/BRACHIAL INDEX
NORMAL 0.9 - 1.2 RISK IS LOW
VASCULAR DISEASE 0.6 – 0.9 MODERATE
RISK EXISTS
SEVERE DISEASE < 0.5 VERY HIGH RISK EXISTS
Example: 0.6 -0.9 Moderate

Brachial Pressure = 120 mmHg
Ankle Pressure = 96 mmHg
Physical Examination:
 Inspection
 Expose the skin and look for:
 Thick Shiny Skin
 Hair Loss
 Brittle Nails
 Colour Changes (pallor)
 Ulcers
 Muscle Wasting
 Palpation
 Temperature (cool, bilateral/unilateral)
 Pulses: ?Regular?
 Capillary Refill
 Sensation/Movement
Auscultation
 Femoral Bruits
 Ankle Brachial Index (ABI)
= Systolic BP in ankle
Systolic BP in brachial artery
 Buerger’s Test
 Elevate the leg to 45° - and look for pallor
 Place the leg in a dependent position 90°& look for a red flushed foot before returning to normal
 Pallor at <20° = severe PAD.
Differential diagnosis of Leg Pain:
1. Vascular
a) DVT (as for risk factors)
b) PVD (claudication)
2. Neurospinal
a) Disc Disease
b) Spinal Stenosis (Pseudoclaudication)
3. Neuropathic
a) Diabetes
b) Chronic EtOH abuse
4. Musculoskeletal
a) OA (variation with weather + time of day)
b) Chronic compartment syndrome
Medical Management:
Thrombolytic therapy: Used to dissolve clots: Retavase, streptokinase
Surgical Management
1. Grafting – Bypass surgery
2. Endarterectomy – Removal of atherosclerotic plaque
3. Aorto/femoral/tibial bypass
Treatment of PVD:
 Severe lower extremity PVD is treated initially with cardiovascular disease risk factor modification:
➢ Exercise training
 Research has shown that regular exercise is the most consistently effective treatment
for PVD.
 Patients who have taken part in a regular exercise program for at least 3 months have
seen substantial increases in the distances they are able to walk without experiencing
painful symptoms.
Exercise Prescription:
 Training Intensity
➢ Initial
 Set by result of peak treadmill.

 Starting exercise work load brings on claudication pain.
➢ Subsequent
 Speed or grade increased if patient walks > 10 minutes.
 Grade increased first if speed > 2 mph.
 Speed increased first if < 2 mph.
➢ Duration
 Initial: 35 minutes (intermittent walking)
➢ Subsequent: Add 5 minutes every session until 50 minutes (intermittent walking) is possible
➢ Frequency: 3-5 times per week.
➢ Specificity of Activity: Treadmill walking is the recommended exercise.
➢ Medication
 Drugs that lower cholesterol or control high blood pressure.
 Decrease blood viscosity.
 Trental, Persantine, or Coumadin
 Antiplatlet agents: their primary long-term benefit is reduction in cardiovascular
events and mortality.
 ASA doses of 75 to 325mg QD have shown protective benefits.
 Ticlid and Plavix also have shown promise in disease prevention and in
therapy after vascular intervention.
➢ Diet
➢ Stop Smoking
 On average, smokers are diagnosed with PVD as much as 10 years earlier than non-
smokers.
 Stopping smoking now is the single most important thing you can do to halt the
progression of PVD or prevent it in the future.
➢ Interventional Radiology
 Angioplasty
 Balloon angioplasty catheter
 Inserted through an artery
 Balloon is inflated and compresses lesion
 Stents
 Thrombolytic Therapy
 Stent-Grafts
➢ Surgery
➢ Gene-Based Therapy
ARTERIAL DISORDERS
GOALS:
1. Improve peripheral arterial circulation with exercise.
Regular exercise such as walking increases circulation.
2. Prevent vascular compression.
Avoid restrictive clothing, crossing legs, sitting for prolonged periods.
3. Relieve pain.
Consider analgesics so patient can participate in activities
4. Maintain tissue integrity
• Avoid trauma, wear correct shoe gear (no bare feet!)
• Test water temp with hand not foot!
• Regular podiatry care

• Good nutrition
ARTERIAL DISEASES:
BUERGER’S DISEASE [TAO] (aka: Thromboangiitis Obliterans)

1. Disease is linked directly to smoking (required history for diagnosis)
2. Possible immunopathogenesis
3. Inflammation produces critical limb ischemia
4. Disease can progress proximally
RAYNAUDS DISEASE:
Vasospastic disorders:
1. Blood vessels (fingers & toes) go into spasm
2. Extreme sensitivity to temp changes (especially cold)
3. More common female > male
4. Color changes are red/white/blue.
Classified:
1. Raynaud’s disease = when symptoms are the only presenting factor
2. Raynaud’s phenomenon = when symptoms are secondary to another condition
Ex: RA, scleroderma, lupus, carpal tunnel syndrome, thoracic outlet syndrome
Prevention:
1. Protect from cold exposure
2. Avoid excessive emotional stress
3. Do not use vibrating tools.
ANEURYSM:
It is a localized abnormal dilation of a blood vessel.
Abdominal Aortic Aneurysm: Pathophysiology

Aneurysm - Permanent localized dilation of an artery
- Enlarges to 2x normal diameter
- Middle layer of artery is weakened
- HTN produces more tension and enlargement within the artery
Interventions:
 Nonsurgical
 Surgical- AAA Resection
- Endovascular stent graft
DISEASES OF VENOUS CIRCULATION:

 Phlebitis - Vein inflammation
 Phlebothrombosis: Clot develops due to venous stasis or “thick blood” hypercoaguability &
inflammation
 DVT- Deep Vein Thrombosis
 Thrombophlebitis: Inflammation of walls of veins with clot formation
VENOUS DISORDERS:
DEEP VENOUS THROMBOSIS (DVT)

Pathophysiology – Deep vein clot most common in lower leg (calf)
Undiagnosed DVT occurs in 50% of patients with pulmonary emboli

Assessment of DVT:
Signs & Symptoms:
- Calf or groin tenderness
- Pain that can be dull or aching, especially when walking
- Sudden onset of unilateral swelling of the leg
- Cyanosis of the affected extremity
- Slightly elevated temp
- General malaise
Homan’s Sign - Pain on dorsiflexion of foot

NO LONGER ADVISED - can increase the risk of detaching the thrombus as the calf muscle contract
Coagulation studies
D Dimer-increased values with venous thrombosis, PE, and Malignancy
Duplex Scan
Interventions:
1. Bedrest and leg elevation
2. Warm moist soaks may be used
3. Evaluate for PE
4. Anti-inflammatory drugs for superficial thrombophlebitis –NSAIDS
5. Heparin therapy
6. Warfarin (Coumadin)
Varicose Veins:
 Protruding veins that are darkened/tortuous are caused by weak vein walls, increased venous
pressure & incompetent valves
 Common in patients that stand for long periods
 Pregnancy
 Obesity
 Family history of varicose veins
 Systemic problems-heart disease
Assessment – Subjective and Objective data
 Severe, aching pain in leg
 Leg fatigue and heaviness
 Itching over the affected leg (statis dermatitis)
 Feelings of heat in the leg
 Visibly dilated veins
 Thin, discolored skin above the ankles
 Increased incidence of PE and thrombophlebitis
Diagnostic Tests:
 Tourniquet test
 Trendelenberg test
 Doppler ultrasound/ angiography
Medical Interventions:
 Elevate extremity
 Elastic Stockings
 Sclerotherapy-for small/limited # of veins
Surgical Interventions:
• Vein stripping or ligation

• EndoVenous Laser treatment
• RF (radio frequency) - vein is heated from inside.
Interventions:
 Monitor patient postop
 Assess circulation
 Elevate legs and perform active ROM
 Teach: avoidance of venous stasis, compression stockings, exercise, leg elevation.
LYMPHATIC SYSTEM:
Lymphatic System – works with circulatory system
a) Thoracic duct
b) Right lymphatic duct.
Drainage: Thoracic drains abdomen (r) drains head, neck & thorax
ANATOMY AND PHYSIOLOGY

Lymphatic fluid collects & returns to venous circulation by emptying into subclavian veins
When interstitial fluid pressure increases lymphatic flow increases when drainage is impaired edema ensues
(fluid collects).
CAUSES OF LYMPHEDEMA INCLUDE:

Lymphangitis
Cellulitis
Insufficient number of vessels
Secondary factors: Malignancy, trauma and surgical removal.
Assessment:
 Pain at site of injury
 Redness of skin
 Fever and chills
 Red streak on skin extending toward the lymph nodes
 Lymph nodes enlarged
 WBC, Blood & Wound cultures
 Lymphangiography - IV dye, X – Rays.
Interventions:
 Moist heat
 Elevation and immobilization of the extremity
 Elastic stockings
 Na restriction
 Antibiotics/antifungals for infection
 Diuretics
 Analgesics

CHAPTER 20: CARDIAC REHABILITATION
• AHA:
Cardiac rehabilitation is a comprehensive
exercise, education and behavioral modification
program designed to improve the physical and
emotional condition of patients with heart disease.
• AACVPR:
It is a process by which persons with
cardiovascular disease and their family system are
restored to and maintained at their optimal
physiological, psychological, social, vocational
and emotional status.
• WHO:
The sum of activities required to influence
favourably the underlying cause of the disease, as
well as the best possible physical, mental and
social conditions so that they may, by their own
efforts preserve or resume when lost, as normal a
place as possible in the community. (WHO 1993)
Cardiac rehabilitation team:

1. Patient
2. Cardiologist
3. Physiotherapist
4. Nurse
5. Dietitian
6. Occupational therapist
7. Pharmacist
8. Psychologist
9. Family Members and friends.
Goals:
• Increasing the functional capacity of the patient.
• Changing the natural history of the disease to reduce morbidity and mortality.
Indications:
• Post myocardial infarction
• Coronary artery bypass graft surgery
• Patient's with poor ventricular function

• Patient's with healthy ventricles
• Elderly patient’s
• Asymptomatic at risk-patients
Contraindications:
• Unstable angina
• Resting SBP>200mmHg or DBP>100mmHg
• Orthostatic BP drop of>20mmHg
• Moderate to severe aortic stenosis
• Uncontrolled atrial or ventricular dysrhythmias
• Uncontrolled sinus tachycardia
• Uncontrolled congestive heart failure
• Third degree A-V heart block
• Active myocarditis
• Recent embolism
• Thrombophlebitis
• Uncontrolled diabetes
• Orthopaedic problems
Effects of Exercise:
• On aerobic capacity
• On cardiac output
• On heart rate
• On stroke volume
• On myocardial oxygen consumption
Aerobic capacity O2
consumption
• Used to measure the work capacity of an individual.
• Represented by the maximum of O2 consumption (VO2max), expressed in
mm of O2 consumed/kg body wt/min
workload
Cardiac Output
• Cardiac output increases with work
• In early exercise, CO increases due to augmented SV via the Frank Starling
mechanism. CO
• In late exercise, CO is increased primarily through an increase in ventricular
rate.
VO2 max
Heart Rate: Age determined max
HR
VO2
Stroke Volume SV
• SV represents the quantity of blood pumped with each heartbeat.
• A major determinant of SV is the diastolic filling volume, which is inversely
related to the heart rate.
VO2 max

Myocardial Oxygen consumption:
• MVO2 is the actual O2 consumption of the heart, as opposed to the VO2, Anginal
which represents the O2 consumption of the whole body. threshold
• The Anginal Threshold is defined as the point where the myocardial O2 MVO2
demand exceeds the ability of the coronary circulation to meet that demand.
• It has been shown that the HR and SBP correlate well with the actual MVO2
and can be used as clinical guide. VO2 max
• The usual measure is the rate pressure product (RPP), which is calculated:
RPP=HR*SBP/100
AEROBIC TRAINING
• Refers to an exercise program that involves dynamic exercise with large muscle group and of a
sufficient intensity, duration and frequency to alter the cardiopulmonary response to exercise.
Principles of Aerobic Training:
• Intensity
• Duration
• Frequency
• Specificity
INTENSITY
Prescribed as % of functional capacity revealed on ETT, within a range of 40% to 85% depending
upon the initial level of fitness.
Heart Rate:
• HRmax = 220-age
• The Karvonen method:
Maximal HRR= HRmax – HRrest
• Metabolic Equivalent:
• The amount of O2 the body consumes is directly proportional to the energy expend during
physical activity.
• At rest, body uses approximately 3.5ml of O2/kg of body wt/min. this resting metaboolic rate
is referred to as 1.0 MET.

• Rate of perceived Exertion:
– This method requires
that a person
subjectively rates how
difficult the work is,
using a numerical scale
that is related to
exercise intensity.
– On the 15 point Borg
RPE scale a rating of
12-13 (or 3-4 on the
cardiac rehabilitation -
10[CR-10] scale)
corresponds to 60%
VO2 max or 60% of
HRR.
DURATION:
• Duration of each cycle in the typical aerobic training program is 20 to 30 minutes.
• A warm-up and cool-down period should be included.
FREQUENCY:
• Exercise 3 days/ week.
• Programs involving exercise at lower intensities should be performed at least 5days/ week.
EFFECTS OF AEROBIC TRAINING:

Post training
• Aerobic capacity:
– Increase in the VO2 max.
VO2 max Pre training
– Resting and sub maximal remains same.
Workload
• Cardiac Output:
– CO ay maximal exercise increases, the resting and
submaximal CO remains same. Post training
CO Pre training
VO2
• Stroke Volume:
– Is higher at rest, submaximal work and maximal work after aerobic training.
– This increase is due to a combination of increased blood volume and prolonged diastolic
filling time
Post training
SV Pre training
VO2

• Heart Rate:
– Is lower at rest and at any given submaximal workload but Age determined max
remains unchanged at maximal work.
Pre
HR Post
• Myocardial oxygen consumption:

VO2
– Decrease in MVO2 at rest and at any submaximal
workload, but there is no change in the max MVO2.
– Maximal level is determined by the anginal threshold.
Age determined max

Pre
MVO2 Post
VO2
Assessment of cardiac functions:

• History
– Chest pain
– Palpitation
– Syncope
– Edema
– Fatigue
– Cough
• Family history
• Social history
• Functional history
• Physical examination
Exercise tolerance testing:
• Essential first step in exercise training phase of any cardiac rehabilitation program.
• To create and individualized exercise prescription.
Exercise protocols
• Treadmill protocol
• Bicycle ergometry
• Upper extremity ergometry
CARDIAC REHABILITATION PROGRAM

Contents:
• Phase I
• Phase II
• Phase III
• Phase IV
• Divided into four phases:
1. The acute in hospital phase, beginning in the cardiac care unit. (0-8 days)
2. The convalescent phase. (8th day – 6 weeks)
3. The training phase. (6 weeks – 12 weeks)
4. The maintenance phase.

PHASE I:
• Duration: 5 to 7 days.
• Components:
– Medical evaluation
– Reassurance and education
– Correction of cardiac misconception
– Risk factor assessment
– Mobilization
– Discharge planning
Goals:
• Assessment of hemodynamic responses to self-care and progressive ambulation activities.
• Determination of the effectiveness of the patient’s medications in controlling abnormal physiological
or electrocardiographic responses to activity.
• Establishment of clinical data that contribute to the patient’s prognosis and thus to optimal medical
management.
• Early behavior modification and risk factor reduction.
• Family education.
Protocol:
• Based on the physical assessment and the evaluation and treatment procedures performed by the
cardiac rehabilitation team.
Day Protocol
1 Coronary care unit
2 (Stabilization)
3
4 Self-care evaluation
5 Monitored ambulation
6
7 Low-level exercise test
8 Discharge
ACTIVITY LEVELS:
1.
a) Complete bed rest
b) Independent morning care; wash hands, face, brush teeth with arms supported
c) Feed self, with arms supported
d) Complete bed bath
e) Bedside commode
2.
a) Complete bed bath
b) Teaching materials given to patient
c) Bedside commode
d) Up in chair, at bedside with feet elevated, 20 to 30 minute twice a day
e) Flat, sitting, and standing BP and apical pulse before moving to the chair on first day
f) Monitored self care evaluation
3.
a) In bed, patient bathes
b) Walk to bathroom with help. Flat, sitting, and standing BP and pulse before ambulation on
first day
c) Walk to chair and sit for 30 to 60 minutes three times a day

4.
a) Same as level 3
b) Up to bathroom as desired
c) Up in room and chair three times a day for 30 to 60 minutes
d) Monitored ambulation
5.
a) Sponge bath self, sitting in bathroom
b) Up in room and chair as desired
c) Continue progressive monitored ambulation
6.
a) Sit down shower
b) Walk in hall three times a day
7. Walk up and down one flight of stairs

8. Low-level treadmill test before discharge.
WENGER POTOCOL:
• Step 1- PROM, active ankle exercise, self-feeding, orientation to program
• Step 2- same exercise, legs dangling at the side of bed
• Step 3- AAROM, sitting in chair, bedside commode, more detailed explanation of the program, light
recreation
• Step 4- minimal resistance, increase sitting time, patient education, light craft activities
• Step 5- moderate resistance, unlimited sitting, sitting for meals, seated ADL, continued patient education
• Step 6- increase resistance, walking to bathroom, standing ADL, group meetings
• Step 7- standing warm-up exercise, walking 100 ft at comfortable pace, tub bath, walking to group
meeting
• Step 8-increase active standing exercise, increase ambulation, walk downstairs (take elevator up),
continue education program
• Step 9- increase exercise program, review energy-conservation and pacing techniques.
• Step 10- increase exercise with light weight and increase walking distance, increase craft activities,
discuss home exercise program
• Step 11- increase duration of each activity
• Step 12- increase walking downstairs to 2 flights, increase resistance used in exercise
• Step 13- continue same exercise
• Step 14- walk up 1 flight of stairs and downstairs, complete instructions for home exercise program and
pacing of activities
CRITERIA FOR MODIFYING OR TERMINATING PHASE I REHABILITATION:

• SBP>180mmHg, DBP>110mmHg
• Hypotensive SBP response (>10 to 15mmHg fall)
• Development of premature ventricular contractions and ventricular tachycardia
• Onset of severe fatigue or dizziness
At discharge:
• Patient is taken for a low-level stress test
• It is conducted with possible end points like 20 to 30 heart beats above the RHR
• METs 4 to 6
Low – level exercise test – 6MWT
• Performance based test.
• Assesses the sub-maximal level of functional capacity.

PHASE II:
• Is the immediate post-discharge phase
• Duration: 8th day to 6 weeks
• Components:
– Addresses health education
– Exercise
– Stress management
Goals:
• Increase exercise capacity and endurance in a safe and progressive manner
• Teach the patient to apply techniques of self-monitoring to home activities
• Relieve anxiety and depression
• Increase patient’s knowledge
Exercise Program:
• Frequency: 3-5 times/week
• Intensity: RHR+20 bpm; RPE<11; METs=4
• Time: 5-30 minutes; interspersed with rest periods and progress to about 30 minutes
• Type: sitting/standing functional activities; ROM exercises; walking
PHASE III:
• The patient has stabilized and requires ECG monitoring only if signs and symptoms necessitate.
• Duration: 6 weeks to 12 weeks
• Begins with symptom limited ETT.
• Result of this test are used to determine a target HR for exercise training
Goals:
• Improve and maintain physical fitness
• Provide professional supervision for exercise
• Continue with educational and behavioral program
Exercise Testing:
• An important tool in cardiac rehabilitation for the development of the exercise prescription, risk
stratification and determination of the level of monitoring required during the exercise program.
Types of training:
• Steady State Training:
– Is a sustained activity, where workload and HR are maintained at a constant sub-maximal
intensity.
– Jogging, walking, stepping and cycling.
• Interval Training:
– The exercise is followed by a rest interval.
– Is perceived to be less demanding than continuous
– High-intensity work can be achieved as there is appropriate spacing of work-relief intervals.
• Circuit Training:
– Employs a series of exercise activities. At the end of the last activity, the individual starts
from the beginning and again moves through the series.
– Improves strength and endurance by stressing both the aerobic and anaerobic systems.
• Circuit Interval Training:
– Involves a number of vigorous exercises that are often strength training in nature.
– Involves short duration bursts of activity interspersed with either rest periods, or activity of a
less intensive workload.
– Individualization can be achieved:
• Changing the duration at each station;
• Changing the length of rest periods between each station;
• Altering the amount of resistance employed;
• Altering the speed and range of movements.
– When CR classes use circuit training, patients work between cardiovascular (CV) stations
and active recovery (AR) stations.
Exercise Program:
• Frequency: 3-4 times/week
• Intensity: 60-70% maximal HR; 12-13 RPE; 40-60% of VO2 max
• Time: 20-60 minutes; inclusive of warm up and cool down
• Type: aerobic/endurance training
• Warm-up period:
– To increase in muscle temperature
– Increase need for oxygen
– Dilation of previously constricted capillaries with increase in circulation.
– Decreases susceptibility of the musculoskeletal system to injury by increasing flexibility.
• Cool-down period:
– Prevent pooling of the blood in the extremities by continuing to use muscles to maintain
venous return.
– Enhance recovery period with the oxidation of metabolic waste and replacement of the
energy stores
PHASE IV:
Goals:
• Continued improvement and maintenance of fitness.
• Minimal or unsupervised exercise program
• Self-exercise
• Long term behavioral modifications
Exercise program:
• Frequency: one session/day; 3-4 days/week
• Intensity: 60-80% of VO2; 70-85% of HRR; RPE 12-15
• Time: desired 30-60 minutes continuous workout
• Type: dancing, hill walking, resistance exercise.
General Exercises:
- Treadmill
- Stepper
- Wall push up’s
- Weight cuffs
- Squatting (with gym ball to the wall)
- Tera band exercises.
Encourage spirometry
Active exercises
Maintenance is by exercises.

CHAPTER 19: PHYSIOTHERAPY MANAGEMENT FOLLOWING CARDIAC SURGERIES
Cardiac Surgery:
Operations usually requiring the bypass machine are:
Indications:
1. Valve repairs or replacements.
2. Coronary artery bypass graft (CABG)
3. Grafting or repair of coarctation of the aorta.
4. Closure of atrial or ventricular septal defects.
5. Heart transplant.
Operations not normally requiring the bypass machine are:

1. Valvotomy
2. Pacemaker insertion.
3. Ligaturing of patient ductus arteriosus.
4. Blalock – Taussing operation
5. Pericardiectomy.
THE INCISIONS:
These are median sternotomy (or sternal split), lateral thoracotomy and sub-mammary.
Median Sternotomy
This is commonly used incision for heart operations and includes division of the sternum. No muscle fibres
are cut but the sternal attachment of the pectoralis major cab be impaired. The commonest postural fault with
this incision is shoulder girdle protraction.
Lateral thoracotomy
This incision goes through am intercostal space on one side of the thorax – for heart operations the level is
usually left fourth of fifth intercostal space. The muscles cut and postural fault is associated with it. A left
thoracotomy is usual, a right thoracotomy may be used for some heart operations.
Sub – mammary incision
This is an incision through the fourth intercostal space with the sternum divided transversely. The muscles cut
are the intercostal and pectoralis major. It is not very commonly used.
Complications:
1. Respiratory:
a) Infection of lung tissue.
b) Consolidation or collapse of whole or part of a lung.
c) Pneumothorax
d) Hemothorax
2. Cardiovascular
a) Deep vein thrombosis, with resultant danger of pulmonary embolus
b) Cardiac arrest
c) Tamponade – collection of blood in the pericardial cavity which compresses the heart, reducing its
capacity to fill with blood during diastole and leading to cardiac arrest.
d) Cardiac arrhythmias
e) Emboli from diseases valve may break off lodge in a cerebral vessel and cause a stroke.
3. Wound
a) Infected
b) Unhealed
c) Adherent

4. Joint Stiffness
a) Shoulder and shoulder girdle
b) Thoracic spine
c) Costovertebral joints
• The Shoulder/shoulder girdle complex is especially prone to stiffness unilaterally following a lateral
thoracotomy and bilaterally following a median sternotomy.
5. Muscle weakness
a) The muscles affected by the incision will be weak
b) Leg and abdominal muscles become weak during bed rest.
6. Postural deformity
a) Protraction (‘rounding’) of the shoulder after median sternotomy
b) Scoliosis, concave on the operation site after a lateral thoracotomy.
Lines, tubes and drains:

1. Endotracheal tube
2. Humidifier
3. Oxygen
4. Drainage tubes
5. Drip
6. Central venous pressure recording
7. Arterial pressure
8. Ryle’s tube
9. Pacemaker
10. Electrocardiography
11. Urinary catheter
PHYSIOTHERAPY IN CARDIAC SURGERY

Aims of the Physiotherapist:
1. To gain the patient’s confidence
2. To ensure that the lung fields are clear and that all areas of the thorax are expanding.
3. To explain where the incisions site will be and how it will be supported during coughing or moving.
4. To teach coughing or huffing.
5. To teach the patient general leg and trunk exercises.
6. To teach shoulder and shoulder girdle exercises.
7. To train position sense.
Procedure: Introduction, explanation:
- Explain the purpose of the physiotherapy that the patient will receive.
- Examine and assess the patient along the following lines:
o Check that all areas of the thoracic cage are expanding.
o Note the type of sputum the patient is producing – if any.
o Check that there is full range of movement at the joints of the spine, shoulder/shoulder girdle
and both lower limbs.
o Observe the patient’s posture, noting any deviation from normal, especially of trunk, neck
and shoulder girdle.
o Read the patient’s notes to determine results of test. E.g.: Exercise tolerance, Chest X – rays.
Lung fields and thoracic expansion

- Give breathing exercises, shaking, clapping, postural drainage and intermittent positive pressure breathing
modified to consider the condition of the patient’s heart.
- If the lungs are clear then the patient need only be taught. Expansion, breathing exercises for lower lateral
costal, anterior basal and posterior basal areas.
Incision site:
Support will be applied during moving, coughing or huffing.
Coughing and Huffing
The incision has to supported and the patient taught to cough at the beginning of expiration after a deep
inspiration.
Huffing should be taught so that the patient’s practiced in both methods of lung clearing. Relaxation
and diaphragmatic breathing are encouraged after coughing.
Exercises
It is important to teach the patient shoulder, trunk and leg exercises because these must be started on
the first day after the operation. The number of repetitions of each movement must be geared to the patient’s
tolerance.
Positions sense training
No breathing exercises, coughing, relaxation or exercises should be taught while the patient is out of
alignment.
Moving and turning
Postural drainage is contraindicated by cardiac arrhythmias or pulmonary edema.
POST – OPERATIVE TREATMENT

For the first 48 hours after cardiac surgery, the patient will be in an intensive care unit, because he can
be under continuous supervision and skilled personnel are immediately on hand to deal with any emergency.
Aims of physiotherapy
1. To maintain a clear airway
2. To prevent lung collapse and consolidation
3. To help the patient to maintain good posture
4. To ensure that mobility of the shoulder, neck, trunk and legs is maintained.
5. To prevent deep vein thrombosis later – i.e. after 48 hours up to 2 weeks.
6. To restore the patient’s confidence
7. To increase the patient’s exercise tolerance.
8. To teach the patient a home exercise plan.
Outline of an uncomplicated recovery following an operation using the cardiopulmonary bypass
machine
Day of operation:
Physiotherapist must note the position of drips, tubes and lines. She must check recordings such as
temperature, blood pressure, ECG, pulse rate, respiration rate, time of administration of analgesic drugs. Note
the complications during surgery.
If the patient does not require artificial ventilation and there are no excessive pulmonary secretions,
may be delayed until the endotracheal tube has been removed.
With the incision supported, the patient is encouraged to take three deep breaths and to try one or two
huffs. He is then repositioned in half – lying with full support for his head and trunk from pillows.
Day 1
Treatment given four times during the day. Diaphragmatic and bilateral basal breathing exercises are practiced
with huffing and then coughing when the patient can manage.
Position sense training is incorporated because the shoulders, head and neck should be aligned before
breathing exercises are performed and relaxation encouraged after coughing.
If the patient has had a lateral thoracotomy, the elevation of the operation side should be assisted into
elevation at two of the treatment sessions. Foot movements – five times in each direction must be encouraged
and one hip and knee bending and stretching should be performed 3 – 4 times at two of the treatment sessions.

Day 2
It is the same as the first day. A rope ladder may be tied to the end of the bed to enable the patient to
sit up himself, but not all patients like this after a median sternotomy. Arm movements should be full range
on the side of a lateral thoracotomy. Where the incision has been a median sternotomy, the patient may start
bilateral shoulder movements.
By the 4th treatment session the patient may be up to sit beside his be up to sit beside his bed, and
breathing exercises are given in this position.
Day 3
The patient will be clear of all drips, drains and lines. Breathing exercises and huffing should continue.
General arm and trunk exercises will be included in at least one session and the patient may be taken for a
short walk (within the ward) on another session. Posture correction and arm swinging should be incorporated
into the walking practice.
Day 4
The patient should be up and about independently and allowed to go to the toilet on his own. The
physiotherapist must assess chest expansion once at least. Arm, trunk and leg activities may be performed
with other patients in a ward class.
Day 5 - 14
Activities until the day of discharge – usually 2 weeks after the operation – must be geared to the
individual patient. Around days 5 – 7 the patient should be able to walk upstairs (about 8 – 10 stairs) and an
exercise programme may be developed along the lines of a patient recovering from a myocardial infarction.
Before discharge
The patient should be confident that he will be able to cope with his home situation, otherwise he may
go to recovery unit if the hospital has one. He must have full thoracic expansion and know how to practise
breathing exercises everyday. He must also have full joint mobility. The progression of length of walking and
daily activities.
Variations:
Ventilated patients
Some patients may be on a ventilator for the first 12 – 24 hours after cardiac surgery. Physiotherapy
may be required if there is evidence of collection of secretions in the patient’s lungs. Vibrations and suction
may then be given but the vigour and length of treatment are dictated by the patient’s overall condition,
especially in relation to the stability of the cardiovascular system.
General Management for all cardiac surgeries:

1. Auscultation
2. ATM
3. Active / Active assisted exercises
4. Patient is made to sit (Positioning)
5. Breathing exercises: Diaphragmatic and deep breathing
6. Slight percussion and vibration
7. ACBT (Effective) and Autogenic drainage (AD)
8. Incentive Spirometer

CHAPTER 28: HEALTH FITNESS AND PROMOTION
Fitness: Ability to do work without getting tired or to keep a healthy life.
Factors affecting Exercise performance:
I) EXTRINSIC FACTORS:
1. Temperature:
- Ideal temperature of the body: 40 – 70 °F (For exercise/performance)
* Below and above is difficult.
- Normal temperature of the body: 98.6 ° F/ 37° C
- High temperature leads to dehydration
- Warm blood animals: we can adopt to any climate but blood temperature should be maintained constant.
- Homeostasis – monitoring blood temperature (Normal).
* Hypothalamus (Serves internal temperature of the body) – thermoregulatory centre of the body →
maintains blood temperature. It serves 0.1 – 0.2° difference of temperature in the body.
- Skin – also serves temperature (External temperature of the body)
Serves 2 – 3 ° difference in the body.
Maintaining temperature in Blood:

In Hot conditions,
Sense through Skin (Sensation) → impulses to HYPOTHALAMUS → impulses to arteries → vasodilation
→increases blood supply → sweat (a lot) → water and electrolyte →cools down the skin (Evaporation) →
Heat loss/convention.
In Cold conditions,
Sensation of the skin → impulses to Hypothalamus → arteries → vasoconstriction →decrease blood supply
→shivering → muscle become active → metabolic rate increases →temperature also increases.
*Hormones also play an important role.
Will performance increase or decrease due to temperature?
HOT – More than 70 degree → Performance decreases = due to dehydration
→Water and electrolyte (increase performance and exercise).
COLD – Below 40 degree → Reduce blood supply and muscle activity decreases, muscles are stiff.
→Warmth should be given (to increase muscle activity and flexibility and performance).
2. Wind:
- Has positive and negative impact
- Wind against the person → Performance decreases
- Wind in the direction of the person (or with the person) → Performance increases.
3. Altitude:
- Oxygen supply decreases
- Temperature decreases
- Density of the air decreases
* Altitude Sickness: Happens when ascends or descends the hill.
Signs: eye block, nausea, dizziness, generalized weakness.
- Adaptation to which body adapts to altitude is “Acclamatation”. (Due to the variation in height).
- Up to 2300 metre extend above sea level, physiological changes happens and it takes at least 2 to 3
weeks for the body to get acclimatized.
- Above 2300 m, for every 610 metre 1 more week time is required for acclimatization.

Adaptations acquired in the body:
• Breathing/respiratory rate increase: Hyperventilation of the lungs.
• Metabolic rate increases than normal.
• Cardiac output also increases.
• Lung volumes alternation will be seen.’
• Hemoglobin (amount) in the blood increase more than normal →thereby increases the oxygen carrying
capacity.
• Increased in the capillaries (new capillaries are formed) to supply oxygen to the body.
• Acid – base balance: disturbances → by product + HCO3(Bi – carbonate)
Normal pH: 7.35 -7.45
- If a person is trained in a higher altitude, then if they come to normal, then the performance is best
(improves). Not easily fatigue, performance is good.
- If they come to sea level, the person trained in a higher altitude can keep their activity only for 2 – 3
weeks.
• Down to Up → decrease performance
• Up to up → Ok
• Up to down → increase performance.
4. Air Pollution:
- Contaminated air, carbon monoxide, respiratory diseases (problems) on long run, decreased lung
volume/capacity, reduced lung function.
- Major pollutants: CO (Carbon monoxide, Sulphur dioxide, Nitrogen oxides)
- Major pollutants are from the vehicles.
- Filters: Nasal hair, Mucous in nasal cavity, Cilia (mouth), sneezing and coughing.
Pollutants → respiratory cavity → (1) bronchospasm (narrowing of bronchus) → Shortness of breath →
Prolonged exposure → deposited in alveoli → secretions, inflammation, infections → lungs expansion is
affected → elasticity of lungs is affected.
*No gaseous exchange at the alveolar level
*In smokers much severe.
For Athlete: more affected than normal.
1. Grasps air through mouth (increase air pollutants) → No mechanism to filter the particles.
2. Increase respiratory rate → increase minute pollutants.
3. Diffusion is altered, Lung expansion not proper.
Other problems: dryness of mouth, dehydration, sweating, dry cough, chest pain (prolonged exposure) and
substernal pain.
Initial in the eye also can be seen.
Normal exercise they do.
5. Exercise surface/ Turf:
- Shoes and turf are more important.
Turf can be either open or artificial.
Performance in hilly area → uneven → affect.
1. Proper – not good foot wear decreases performance.
2. Uneven – good foot wear decreases performance.
3. Hilly area – up against gravity decreases performance.
• Climbing up is difficulty – against gravity.
• Climbing down is difficult.
o It requires more control (Balance, support, stability)
o Here, muscular work more eccentrical (Lengthening).
o Proper control of muscles.
• SHIN SPLINT: condition in which pain in the tibialis anterior (Micro damage - strain) muscle (pain on
anterior part of the leg - shin).
• TURF TOE: occurs in the great toe, people who help in the artificial toe.
Signs: Pain, swelling effusion, redness, tenderness, decreased ROM (Both Active and passive ROM).
Management: Proper foot wear/ shoe, Turf should be proper for exercising.
6. Diet:
- Before performance carbohydrate is important.
- All food should be taken properly in ‘Balanced diet’.
- Energy is supplied by carbohydrate (sugar).
- To increase Body weight: Rest, supplementation, gym, proper warm ups.
Carbohydrate Loading:
Protocol: 1 week before performance
Initial don’t take any carbohydrate foot. They take more of protein and lot of work out. Energy is needed,
carbohydrate stored in body is completely utilized.
Happens 4 to 5 days before performance.
3 or 4 days, they are loaded with carbohydrate as much as possible and reduce the activity.
Maintenance Principle:
After weight loss, then they do not work out then they gain their weight.
Minimal exercise must be done (maintain exercises).
- Here, minimal exercise should be done.
- All carbohydrate food should be taken on the day of performance.
- Increases the carbohydrate.
Disadvantages or Side effects of carbohydrate loading:
- Feel more thirsty
- 1 gm of glycogen → have 2.7 g of water
- Should not prolong for long time (It can cause deficiencies).
*Determines performance of person.
II) INSTRINSIC FACTORS
1. Age
- Adults and young people play well.
- Children perform well when training is given well.
- Elderly people reduces.
2. Sex:
- Male perform well than that of female
→ Increase muscular power and strength
→ Depends on training as well.
3. Body Surface Area/ Body Dimension
- Body weight and height
- BMI = Weight (Kg)/ Height (m2)
- No correlation of sex, weight, age and weight.
4. Genetics (Gene) / Race
- Train or not, performance is really well.
- It depends on the race also.
- Familial character

5. Capacity to work
- Depends on strength, power and endurance.
Strength: Shorter duration, big work Ex. Weight lifting
Power: Strength force along with speed (Speed + force) Ex. Punch in a boxing.
Endurance: how long we prolong, long duration of time. Ex. Marathon running.
- Not 1 can do all three things.
- Different conditions are required.
(i) Muscles: Bulk of muscle → strength → FG tibresane increases.
(ii) New capillaries formation → Endurance → More O2 (SO fibres increases in endurance training).
Capacity is termed by “Training factor”.
Sudden activity – Strengthening condition (ATP, CP → in muscles or body).
ASSESSMENT FOR PHYSICAL FITNESS

Aim:
- To find out capacity of individual and plan for training.
- Base line of each person should be known.
Energy System:
A) Immediate Energy System
- Short burst of activity (work) in few seconds only.
- Energy that is utilized for activity for less than 10 seconds.
- It is used from ATP and CP.
→ 5 millimoles of ATP and 15 millimoles of CP is present in 1 kg.
B) Short – term energy system
- Energy that is utilized for activity for maximum for 4 minutes.
- Activities that happen in rest and mild exercise is used here.
- Supplied by Glycolysis.
C) Long – term energy system
- Energy that is utilized for activity for more than 4 minutes.
- Used from Kreb’s cycle.
FITNESS EVALUATION:
I. AEROBIC CAPACITY OF A PERSON:
1. Spirometry (Actual method) → Open method and closed method (Compact room)
Open Method:
1. Mile walk/run test:
Time taken to complete 1 mile; Walk or run;
Time is taken as the Baseline of his fitness.
2. PACER (Progressive Assisted Cardiovascular Endurance Run)
- Two lines → Start point and ending point} → Distance = 20 minutes.
- Starting line make him run to and fro for how many ever he can do?
- Lapse are counted, Time is measured}→ important in this test.
- Same rhythm should be maintained, if lost test is stopped.
II. ABDOMINAL STRENGTH OR ENDURANCE TEST:
1. Curl – up’s test (Flexed Knee)
Crook lying position and lift head and shoulder touch the knees.
In 1 minute, number of repetitions are calculated.

2. Partial Curl – up test (Extend Knee)
Supine lying, head and shoulder are lifted and upper body
In 1 minute, Number of repetitions are calculated.
III. UPPER BODY STRENGTH OR ENDURANCE TEST
1. Push up’s: It needs of more spinal flexibility
Prone lying, hands on bed or mat, Push ups done in rhythmic fashion and repetitions are calculated.
Once, rhythm is lost, discontinue.
2. Pull ups – hanging
Standard tool: Bar – 1½ inch in diameter
Make person hang on the pool and chin is moved above the pool.
Number of repetitions in rhythmic fashion, once lost discontinue.
3. Flexed armed Hang
Flexed arm, chin can be below the pool
Number of repetitions are calculated, once lost discontinue.
IV. FLEXIBILTY TESTING
1. Sit and Reach test:
Long sitting and has to teach the toes. Spinal extension and hamstrings flexibility.
Count number of repetitions Check whether he is able to touch toe or no.
2. Back Saver Sit and Reach test:
Sit with back support and side movement of the trunk. Check lateral flexors.
3. V – Sit and Reach:
Keep legs apart in V position (Abduction).
Draw median line and make the person sit on the line.
Foot should be 8 -12 inches apart in between.
Bend out and touch the center line
Check for spine.
*Adipose tissue:
Fats:
1. Essential
Nervous system: Energy; It constitutes only 3% of body weight} depends on males/ females (varies).
2. Non – essential
Excess energy is stored under the skin and act like an insulator; Thick layer of fat.
V. COMPOSITION OF BODY (ANALYSIS OF BODY COMPOSITION)
Lean body mass: The mass of muscle without fat.
1. SKIN FOLD MEASUREMENT/ FAT FOLD MEASUREMENT
That is called as “Pincer – type caliper”.
Skin fold is held by two jaws and then measured.
1. Triceps – in between → Shoulder + elbow
2. Thigh – Hamstrings → upper 1/3rd or 2/3rd from knee cap.
3. Cuff’s – Upper 1/3rd
4. Abdomen – 1-inch right side umbilicus.
5. Suprailiac area – Just above iliac crest
6. Subscapular area – Just above the tip of scapula
Why you are finding out?
- Help in weight – reduction program
- For company one with another

2. MUSCLE GIRTH MEASUREMENT
Fat and muscle couldn’t be separated and measured.
1. Upper arm: Mid way between shoulder and elbow
2. Forearm: Upper 1/3rd (maximum girth) } → Measurement of girth of hand of right and left
3. Thighs: upper 1/3rd of thigh (more prominent area).
4. Cuff: upper 1/3rd of cuff (more prominent area).
5. Buttock area: Where the maximum prominent is there
6. Abdomen: 1-inch above the umbilicus is measured. (Near umbilical area)
7. Chest – upper – Axilla; middle – nipple level; lower – xiphoid process
3. BIOELECTRIC IMPEDANCE ANALYSIS:
Analysis for amount of fat present in body.
- Pass some electric current into the body by means of electrode (placed at dorsum of hand and placed at
dorsum of feet).
- Monitor measured the amount of impedance in the body.
- Calculation is done, to the amount of fat.
- They convert the amount of impedance to amount of fat.
- Here, it is not exact.
- Here, it also depends on hydration (Electrolytes).
- It is only done for rough analysis.
4. X – RAY ASSESSMENT:
- Thickness of the fat seen in the X – ray and the composition of fat present in the body.
- Using inch/metre scale is used to measure.
Purpose:
- Whether training muscle effective or not.
5. CT – SCAN: We can measure it.
6. HYDROSTATIC EVALAUTION METHOD
In which we find the density of human body
Swimming pool or Hydrostatic pool is required.
4 feet length * 4 feet depth * 5 feet height
It is expensive test
It is accurate method of body density
Under water method to calculate the density of body.
Density = Mass (m)/ Volume (l)
1. Measure the weight of a person in air.
2. Chair (made up of metal) is supported and supported by chair and a weighing machine is present.
Weight of person + chain + chair should be known
3. Immense person in water.
Note: After maximum exhibition he has to go into pool.
He has to hold 5 – 10 seconds of hid breath.
4. Amount of weight = Buoyant force.
Difference in weight is seen inside and outside also.
It is repeated, this for 8 to 10 times.
5. Water temperature is also maintained.
Temperature of the pool is 95° F (Should be maintained to that of the body).
𝑚𝑎𝑠𝑠 𝑜𝑓 𝑡ℎ𝑒 𝑝𝑒𝑟𝑠𝑜𝑛 𝑖𝑛 𝑎𝑖𝑟

FORMULA: 𝐷𝑒𝑛𝑠𝑖𝑡𝑦 = 𝑚𝑎𝑠𝑠 𝑖𝑛 𝑤𝑎𝑡𝑒𝑟
𝑚𝑎𝑠𝑠 𝑜𝑓 𝑡ℎ𝑒 𝑝𝑒𝑟𝑠𝑜𝑛 𝑖𝑛 𝑎𝑖𝑟− −𝑅𝑒𝑠𝑖𝑑𝑢𝑎𝑙 𝑉𝑜𝑙𝑢𝑚𝑒
𝑑𝑒𝑛𝑠𝑖𝑡𝑦 𝑜𝑓 𝑤𝑎𝑡𝑒𝑟

SKILLED RELATED FITNESS:
1. Agility:
Ability of player to move and change the direction under control (sudden change in direction quickly with
control).
Ex: Cone run, Figure of 8 run, Shuttle run, running with obstacles.
2. Balance training
Wobble board, multiangle balance board, standing on wobble board.
3 things:
1. LOG falling within BOS
2. BOS should be wider
3. COG should be as much as low.
3. Co – ordination
Frenkel’s exercise
- Any test to check co – ordination
- Comes only through practice.
4. Power
Ability to combine strength and speed.
Ex: Boxer’s punching → Punch bag, Golfer’s
5. Reaction time:
Time taken for sudden reaction
EVALUATION AND PRESCRIPTION OF EXERCISE FOR SPECIFIC GROUPS: WOMEN,

ELDERLY AND CHILDREN
I. Start with Warm up
- Mild stretching, repetitions of joints
- Slow movement, jogging, jumping.
→ To prevent injury (Blood supply increases – preparing muscles)
Duration: 5 – 10 minutes (To increase flexibility, increase BP [slightly])
2 Kinds of people: Fit people: Mild exercises to maintain
Normal people: High intensity exercises.
II. AEROBICS
- More specific for each one.
- For Elderly (very careful – above 45 -50 years) – No skipping or jogging.
It may cause muscle tear, ligament tear, sprain, strain, CV problems, osteoporosis (Women common),
cause problem’s in bone.
• Start with warm up
• Start slowly and increase the intensity of exercise
• First, walking in normal pace gradually increase the speed
• Progress on to “Brisk walking” → Jogging/Skipping → then more speed.
• But progression is not on one day.
“ADAPTATION/ ACCOMIDATION PRINCIPLE” in sports medicine.
Children: Anything but training properly
Women: A) Normal – all exercises
B) Pregnant – avoid exercises in the first trimester → then start slow exercises and in limit
C) Post – Menopausal – Joint problems (osteoporosis) → check problems
Pregnancy and Post – menopausal women:
Breathing exercises (for everyone), Walking (For all three categories of women) & brisk walking is also ok.

No jumping, Hydrotherapy or underwater exercises → check whether she is a swimmer. Don’t know
swimming then do walk in the water.
Cycling is the best (Static, Bicycle ergometer) & rowing seat.
Step jumping, skipping.
Factors:
1. Intensity of exercises
2. Frequency of exercise
Frequency: Aerobic Exercise should be started with 10 minutes initially, and increase gradually to 20
minutes minimum and 60 minutes maximum.
To be effective: 3 – 5 days a week should be done
• The frequency should be more initially when time is less; when the time increases the frequency can be
reduced.
Intensity:
(History – before prescribing exercises; problems and medications must be looked out).
1. Target Heart Rate: Vital signs.
Maximum Heart Rate = 220 – Age.
Target Heart Rate = 60-70% Maximum Heart Rate + Heart rate (at rest)
Karvonen Method: Exercise should be performed at the 60-70% HR(Max).
2. Metabolic Equivalence (MET’s)
Amount of energy utilized depending on the oxygen consumption.
1 MET = 3.5 ml of O2 consumption/kg weight
*Approximately, if we burn 5 calories = 1 litre of O2.
3. RPE Scale (Rate of Perceived Exertion)
- Subjective Scale, based on their intensity they had.
- Based on breathlessness.
*Borg’s Scale: 6-8: Very very light; 19-very very hard
* To be effective, RPE Scale = 12 – 13 which indicate fairly light exercise to 15 – 16 which represent hard
exercises.
III. STRETCHING/FLEXIBILITY EXERCISES
- It is important for gymnastic
- May or may not be done by everyone
- They can be mild stretching
- In cases on pregnant women, this can be done very well (cramps and pains).
- Also, for elderly men or women, they can do. (To maintain length of muscle and ROM).
Types: Active/Self stretch and passive stretch
- Self-stretching is taught when they are able to do by themselves/partners
- Maintained 10 seconds for stretch
- Ballistic or static stretch: injury can happen very much→ done in paralytic patients.
- Here, Static stretch is slow sustained.
Duration: maximum of 10 minutes.
Specific stretching based on their activity (like football) stretching is given for long time.
IV. RESISTANCE TRAINING/ STRENGTHENING/ RESISTED EXERCISES:

- Muscle bulk increases → Myofibrils increases, no. of fibres increases, no. of mitochondria present in cell
increases, increase in energy or strength.
- And protein in muscle increase
- It helps in DNA synthesis
- Even bone become strong when you do strengthening exercises.
Different types of strengthening exercises:
1. Progressive Resisted Exercise (Best way to strengthening exercises)
* 1 RM => 1 repetition maximum; initial start 50% of 1 – RM →60% →75% → 85% →95% → 100%
15 repetitions of 1 RM, then change weight, check 1 RM again.
2. Pulleys with weights
3. Tetra bands
4. Springs
*Careful about injury of muscles and bone.
“OVERLOADING PRINCIPLE”
Whenever you are increasing loads, increase it gradually; Start from 10 RM and gradually increase.
In Children: They can do as they can. But be careful for injuries they get.
Elderly: Can do but not too much.
Pregnancy: Not in first and last trimester. They should be very careful.
*For everyone, teach the proper way to lift up weight. While weight lifting, Squatting is important (if not –
disc problem can develop). Life span is increased; Hospitalization will be reduced.
Exercise should be done 2 – 3 days in a week.
Duration: Not specific because it depends on number of repetitions. You can calculate the Heart rate.
V. RECREATIONAL ACTIVITIES:
Depends upon the interest of the patient. Adds on benefits in the body.
Children: They are more involved.
Duration: At least 30 minutes, 5 days in a week.
VI. COOL DOWN: Relaxation of the body; Bringing down of BP and Heart Rate.
Duration: 5 minutes is enough
COMBINATION OF EXERCISES:
1. Circuit training
All activities can be performed in a cyclic manner. Squats, push-ups, pull-ups at a time one after the other.
2. Plyometrics
- It is a sudden stretching of muscle and followed by an immediate contraction without a pause.
Ex: Squat and jump up on a step; Skipping with high intensity, Hanging with high intensity
- Any sport activity which induced more power, we use plyometrics.
- Restricted for elderly men, pregnant and elderly women.
3. Calisthenics
- Rhythmic exercises done for large group of muscles without much use of equipments.
- Flexibility, endurance and strength cab be improved. Body weight acts as resistance. Jumping, kicking,
twisting body, swimming. It should be performed rhythmically.
- It is for young adults, not for elderly men or women.
Precautions Taken for Training Exercises
- No overdose; Not involved if any recent injury, no heavy weights.
- Vital signs should be monitored regularly (in the initial stage), Medicines they are taking.
- Food they take (exercises before food); No much gap between exercise and the time of food taken.
- Time of meal should be appropriate, time of exercises also matters; Time the person did exercises
(duration) should be noted down.
- Do proper warm up; should be well hydrated. Proper foot wear (well-fitting shoe), proper clothing.
- Don’t induce injection of insulin in the muscle you usually use; gel filled or silicone insoles can be used
to avoid force of friction.
- Maintenance exercises should be done (minimum exercises) – “Maintenance Principle”

CHAPTER 27: TREATMENT, RESPONSE TO EXERCISE AND IMPLICATIONS OF
PHYSIOTHERAPY IN DISEASE CONDITIONS
1. OBESITY
Cause: Heredity, Sedentary life style, over – eating, no physical activity
* Lot of fat deposition
* The amount of intake (calorie) = BMR + TEM + TEA
BMR = Body Mass Index (Energy required to do work at rest).
TEM = Thermic Effect of Meal (Metabolism due to food intake)
TEA = Thermic Effect of Activity (Activities and Exercises).
• Initially, the size of the cell → Hypertrophy of adipose cells (Fat cells) increases – 12 months
• After 12 months – increase number of fat cells “Hyperplasia”.
2 Types of Obesity
a) Male (Android body): Apple Shape – upper body weight increases
b) Female (Gynoid body): Pear Shape – lower body weight increases
*The waist – hip circumference
For Men = Waist/Hip = 1 HB
For Women = Waist/Hip = 0.8 HB
< No risk, > risk.
Calculate:
- BMI
- Roughly: Height in cm – 100 = Approximately.
Negative effects of being obesity
Inactivity, lazy, inactivity causes obesity.
Diabetes – Juvenile (Especially)
Work load is more, CV problems are common.
Musculoskeletal issues come, Breathing problems (respiratory), Psychological affects patients
Hormonal problem may also experience some reproductive issues.
What to do: Diet and exercise.
DIET: High fiber diet (fruits and vegetables); reduce fatty intake, Protein (can be added more in amount)
Amount of intake should be normal, Less carbohydrate or sugar.
* 3 – 4 times we should be taken that produce energy + water.
*Continuous exercises/workout should be there.
EXERCISE:
These should be recorded:
1. History of patient should be taken carefully
2. Vital sign should be recorded properly
3. Amount of food intake
1. Warm ups: 5 – 10 minutes
2. Aerobic
- Treadmill, running, jogging (only when no orthopaedic problems).
- Hydrotherapy and Swimming (For obese people)
- Walking and cycling
* Amount of calories burnt = depending on the muscles used.
- At least minimum of 5 days
- Do it continuously for 10 – 12 weeks (3 months)
- Weight that can reduced in 1 week: minimum: 0.45 kg & maximum: 0.95 kg (in week) not more than that.
- Duration at least 45 minutes to 60 minutes and it can be continued upto 90 minutes.
- For reducing 0.45 kg of fat, burn minimum 3500 kcal of energy.
- Intensity of the energy: For a minimum of 15 – 16 RPE scale and also the percentage of exercise should be
80 - 90% THR.
- MET depends on amount of calories burnt.
- It reduces bulk of the muscle and body weight.
3. Strengthening/Flexibility exercises
- It breaks down fat to some extend; 1 or 2 days a week it can be done.
4. Recreational activities
- Women and children and adults are mostly interested.
- Check vitals, breaks (initially short but generally reduce it), breathing pattern and sweating.
Life Style modifications:
- No immediate eating and sleeping should not be done
- Have dinner earlier
In Obesity: if hormonal problems, gynecologist advice should be taken along with weight.
2. HYPERTENSION
Cause: Stress increased, obesity, heart disease.
Normal BP = 120/80 mmHg
Hypertension > 140/90 mmHg
After activity, checking up – always high.
Do work or not in some people → always high
Advice: Regularly BP monitoring is advised; Constant same elevated then Hypertension then medication.
Risk factors: Salt, oily food, pickles, pappad, dry fish (Avoid all these).
Type A personality: People with always stress, excited, anxiety, tensed. (More chances of hypertension).
Type B personality: Cool person; Diet and avoid stress.
*If diastolic pressure is more, it is due to left ventricular hypertrophy, left atrium hypertrophy, cardiac
failure (Hypertension can lead to).
*Systolic pressure: can be due to people who have got stiffness of the artery of the walls.
- It can be due to vascular problems.
- Diabetic patients have high systolic pressure
- It can lead to stroke, heart disease and also chronic renal disease.
- Increase alcohol, increase cigarette smoking are the factors that lead to hypertension.
*Anti-hypertensive drugs
- Relaxation techniques: Jacob’s relaxation technique, Mitchell relaxation techniques.
- Yoga and medication
- Listening to melodious music or music therapy.
EXERCISES: Can be done on regular basis
Help in reducing BP;
Statistics done says that immediately after exercise BP increases.
But during rest, it gradually drops down to 10 to 20 mmHg
Don’t check BP immediately after the activity
1. Early morning walk and music → Mood changes: Hormonal activity increases
2. Aerobic Exercises: If BP goes up → monitoring
a. Warm up → Mild stretching, walking
Group therapy is much helpful; Stress becomes reduced.

b. Aerobic activity: It can be mild to moderate exercise on all days; 50 – 70% of THR
Minimum of 30 minutes and maximum of 60 minutes.
- If BP shoots up in between there can be 5 – 10 minutes gap in between.
*Work out should be done → between 11 to 12 RPE scale
Better to do all days.
• If need, flexible exercises cab be done (5 – 10 minutes).
• Anerobic exercises can be done.
Twice in a week and not helpful to reduce BP to greater extend.
• It is better in a circuit training 8 – 10 exercises with 8 – 10 repetitions of each exercise.
c. Recreational activities: Largely helps in reducing BP
d. Cool down:
Hypertension → reduce salt drinks, reduce carbonated drinks.
Pre – cautions:
- Symptoms like sweating, too much of breathlessness.
- Medications for BP regularly
- Check vital signs
- Isometric exercises: Systolic and diastolic pressure increases so it should be avoided or people with
Cardiac patients and Hypertension.
- Too much strenuous activity must be avoided.
- If checked, BP – Systolic pressure should not go more than 200 mmHg; Diastolic pressure not more than
105 mmHg.
- Patients who are b-blockers and diuretics, they will have thermoregulatory problems.
- They become more hypoglycemic
- Note for other symptoms like sweating, chest pain, pain in the jaw, giddiness.
- Proper foot wear and clothing is must.
- They should be proper and good, no uneven surface, inclined surface also should be avoided.
3. DIABETES MELITUS
Cause: impairment of b-cells of Langerhans of liver, Life style: food items, Stress, lack of physical activity,
Obesity, infections, hereditary from parents. *(Insulin – maintain glucose levels and transport it to cells).
TYPES:
i) IDDM (Type 1)
Insulin non – secreted (insufficiency), insulin taken before food
ii) NIDDM (Type 2)
Insulin present but body gets resisted (very common).
Symptoms: Frequent urination, fatigue, hungry, abnormal odor in urine, late wound healing.
Exercises:
A) Type 1:
- It can result to Hypoglycemic or Hyperglycemic.
- Check person time of meal, check the blood glucose level and medications.
- If blood glucose level is high, inject insulin better exercise session.
- If blood glucose level is less, give food and inject insulin and then perform exercise.
• If a person is on fast, the amino acids and fats are utilized.
• It gets converted into fatty acids and triglycerides.
• Even ketones accumulation increases because of this person goes to giddiness;
• If not checked properly, he may go to coma or even death.

Body has got enough glucose present in body.
Convert glycogen → glucose, it doesn’t happen to spread glucose to body, if not injected with insulin.
They become Hyperglycemic, Hypoglycemic.
- If insulin given then, moderate to vigorous exercises can be given to patients.
- Don’t give insulin, but can perform exercise then mild exercises are given.
Glucose can be utilized maximum if insulin is injected to him.
1. Warm up
2. Aerobic exercise
3. Stretching
4. Strengthening (very helpful in these changes)
- The area where we inject should be checked properly.
- Don’t inject on the muscle which you concentrate.
Diet: Low carbohydrate diet (Less sugar); vegetables can be eaten (underground vegetables should be cut
down), Millets can be added on. *Root vegetables contain high content of carbohydrate.
B) Type 2:
- Insulin is secreted by resisted, blood glucose increases
- Walking (exercise) increases sensitivity of insulin.
- Insulin is supplied in much in amount
- During exercises the glucose is utilized from the blood
- Minimum of 30 minutes: 5 days a week
Aerobics:
a) Warm up: 5 – 10 minutes: Mild jumps/stretching
b) Aerobics (Best): 30 minutes minimum and maximum depends on capacity of individual.
It is 70 – 90% THR; RPE Scale: minimum of 7 – 8 RPE or 9 – 10 RPE maximum depending on glucose
availability.
Strengthening exercises: Depends on person’s interest and involvement
- 2 – 3 days/week depending on RM
- 50% of 1 RM (starting) and increase slowly
- 8 – 10 repetitions with 3 sets of exercises.
Stretching Exercises: not much helpful
Recreational Activities
Cool Down
*Hypoglycemic: Risk factors: It happens in NIDDM
Pre – Cautions (in general):
- Proper meals should be taken.
- Note few things:
a) The previous time of meal
b) Check the level of blood glucose/sugar (Whether normal/high/low).
- If Hypoglycemic, no exercises: Give something to eat (Like sweets, snacks).
- Avoid injuries and open wounds
- Proper foot wear is a must
- Surface should be done is an even or proper surface
- Clothing should be comfortable.
- History of what medications and its side effects.

4. RENAL FAILURE
Cause: DM (prolonged time), CV problems, alcohol
More medications: especially analgesics and antibiotics taken on long run and Hard water.
Function of Kidney: Excretion, purification of blood, acid – base balance. It helps to control extracellular
fluids of the body.
Signs and Symptoms: Swelling in limbs.
Pre – Cautions:
- Take more amount of water (with less salt).
- Take medicines only when it is very necessary.
Associated with renal failure:
- Renal failure lead to BP, Dm, edema, anemia, renal osteodystrophy (may be caused).
- It is also caused ‘Proximal myopathy’.
- It also leads to peripheral neuropathy.
Things to do:
1. Diet:
- More fibers, less protein (boiled vegetables without salt).
- No: Food less in phosphorous, potassium (banana)
- Can’t take enough amount of water and food
- Diet should be with less fluid.
- No oil, no fat.
- It should be strictly followed.
These kinds of people will surely be on medications, if can’t be managed then “Dialysis”.
After renal transplant, then physiotherapy comes into play.
Patient is very tired and poor exercise tolerance and very sedentary life.
DIALYSIS PATIENT:
When Exercise given, they can’t reach Target Heart rate (THR).
Exercises:
2 Ways –
1. During dialysis (Best)
2. After dialysis (Routine one)
1. During dialysis
Beside cycle ergometry
- Blood can be good capacity of oxygen
- Capacity to perform increases.
* For every 5 minutes exercises, 1- or 2-minutes rest.
* Increase capacity of person during exercise only.
Aerobics: Mild aerobics depending on comfort of the patient; Check for BP and level of HR.
Mild Strengthening: Exercises are also done. For major muscles of Upper limb and Lower Limb.
Lower limbs:
Isometrics (No, if Hypertension), Mild techniques, Squat’s.
* Calculate Rm, and 25% of RM (Static) and increase it gradually.
* Muscle strengthening of ADL’s and mobility
* Stretching: mild and Flexibility exercises.
- They can get involved in re – creational activities.
* For other days (regular exercises + not affected muscle)
- Moderate aerobic exercises, breathing exercises also can be done; can go to 12 -13 RPE Scale (So what
hard)
- At least 3 – 5 days of anerobic is must.
- THR must be monitored.
- Metabolic Equivalence may be in appropriate.
- Strengthening exercises → increase muscle mass to greater extent
- Stretching (Slight/mild)
- Helps in decrease edema (Elevation of limb above heart level).
* Renal failure = Aerobic + strengthening exercises (1 or 2 a week) [Regularly] → If strength is very less
than 3 to 5 days/week or 1 week.
* Recreational activities (Like gardening)
Transplantation Patient:
- Exercises needed for general conditioning
- Help in maintain lipid profile
- Help in controlling blood glucose (sugar) level
- It also helps in maintaining/controlling BP
- Increase level of sensitivity of insulin
- Increases muscle mass and strength of muscle.
- It increases amount of hemoglobin in blood.
- Increases cardiovascular endurance
- It changes the mood of patient and relieves the mood of patient from depression.
1. Warm up: Mild stretching
2. Aerobic Exercises: Very important
- Start with mild to moderate and even severe exercises also.
- Check for any orthopaedic problems or not. In such cases, non – weight bearing exercises and
hydrotherapy.
- Endurance and capacity of the person increases.
- Starting from 12 – 13 to 16 -17 RPE Scale
- Check THR → Start with 70% of THR and go upto 90% of THR
- Progression time should be proper (Even time to accommodate).
*Muscle Strengthening Exercises:

- Major muscle must be strengthened.
- From 50 – 90% or full RM upto Maximum.
Stretching exercises
Recreational activities
Cool down.

CHAPTER 22: ABDOMINAL SURGERIES
The incisions used for exploring the abdominal
cavity can be classified as:
(A) Vertical incision: These may be
i. Midline incision
ii. Paramedian incisions
(B) Transverse and oblique incisions:
i. Kocher's subcostal Incision
ii. Transverse Muscle dividing incision
iii. Mc Burney’s Grid iron or muscle splitting incision
iv. Oblique Muscle cutting incision
v. Pfannenstiel incision
vi. Maylard Transverse Muscle cutting Incision
vii. Abdominothoracic incisions
Common Operations:
• Gastrectomy
• Cholecystectomy
• Appendectomy
• Colectomy
• Colostomy
• Ileostomy
• Herniotomy/ Herniorrhaphy/ plasty
• Nephrectomy
• Prostatectomy
• Cystectomy
• Mastectomy
• Hysterectomy
Pre – operative assessment
- Read the notes
- Assess the respiratory function
- Check for circulatory problems
- Detailed history of the patient
Respiratory Assessment
- Symmetry
- Rate
- Depth

- Chest expansion
- Dyspnea
- Accessory muscle involvement
- Measurement
Surgery notes reading
- Type of incision
- Type of anesthesia
- Duration
- Immediate complications/unwanted events/management.
Vital signs checking
- Tidal volume – 2 ml/kg body weight
- Minute volume – 100 ml/kg body weight
- FVC – 70 ml/kg
- FEV1 – 70-90% of FVC
- PaO2 – not less than 70 mm/hg
- PaCo2 – not more than 50 mm/hg
- RR – 12-16/min
- ABG analysis
- Pulse oximetry
- PR
- ECG
- Heart Sounds
- Systemic arterial blood pressure
- CVP
- TPR chart
- Ventilator support
Orientation Assessment
- Communication ability
- Alertness
- Perceptual ability to follow instructions
Objective assessment
- Respiratory
- Circulatory
- ROM/Muscle power
- Mobility/ Functional, etc.
Respiratory Assessment
- Painful breathing
- Difficulty in coughing
- Impaired respiration
- Accumulation of secretions
- Palpation
- Auscultation
Circulatory assessment
- Homan’s sign
- Edema
Posture and mobility
- Kyphoscoliosis
- Bed mobility

Post – operative assessments
Early movements can
• Prevents chest infection
• Prevents wound infection
• Decreases the risk of developing blood clots
• Increases muscle strength and endurance
• Promotes independence
1. To prevent chest complications:
- Breathing exercises
- Coughing/Cough support
- Inhalation, humidification and PD
- Breath control exercises with arm movements
2. To prevent circulatory complications
- Trendelenberg tilt (15-degree bed end elevation)
- Leg exercises
- Early ambulation
- Bed mobility
- Trunk and abdominal exercises
- Prevention by medical means
3. To prevent circulatory problems by medical means
- Blood thinners
4. Prevention of bad posture
- Firm back support
- Chair with arms
- Over correction
Deep Breathing Exercise
• Wound support and Supported Cough
• General Exercise After Abdominal Surgery
• Getting out of bed; Sitting Out of Bed
• Walking/ambulation as you are recovering, exercise need to be progressed on.
What not to do?
• Lift anything heavy
• Strain during toileting
• Forward bending
• Divining (3 – 6 months), Swimming (3 – 6 months).

CHAPTER 24: PHYSIOTHHERAPY INTERVENTION IN THE MANAGEMENT OF
MEDICAL, SURGICAL AND RADIATION
Common Symptoms of cancer:

• Fatigue / decreased energy levels - 70%
• Decreased muscle strength
• Decreased functional status
• Nausea
• Pain
• Body image problems
• Sleep disturbances
• Depression and anxiety - 20-50%
“Evidence is accumulating that exercise is beneficial for cancer sufferers”
Cancer Level of Evidence Strength of evidence
Colon High Strong
Rectal Medium No effect
Breast High Moderate
Lung Low Moderate
Prostate Medium Equivocal
Overall Medium Moderate
Others Low Equivocal
Where:
Palliative physiotherapy is found in: -
• Specific palliative care wards
• Nursing homes
• General wards
• Oncology wards
• Community rehabilitation (homes)
Objectives of treatment:
• To be as free as possible from unnecessary suffering (physical, emotional or spiritual);
• To maintain patient’s dignity and independence throughout the experience;
• To be cared for in the environment of choice;
• To have patient’s grief needs recognised and responded to;
• To be assured that family’s needs are also being met.
Physiotherapy
• Physiotherapy in palliative care is orientated to achieve the optimum quality of life as perceived by
the patient.
• Holistic & problem-solving approach to therapy
• Achieve maximum physical, psychological, social, vocational function
• Adapt traditional therapy to the patient’s changing function
• More beneficial if begins with diagnosis of cancer and continues as required through the various
stages - Preventative, Restorative, Supportive, Palliative
Preventative
• Aims at restricting or inhibiting the development of disability in the course of the disease or
treatment before disability occurs
• Education for patient and families commencing immediately after diagnosis
• Mobility and exercise programs.
• Availability of therapist as a resource for patients and families
Restorative
• Rehabilitation is the objective when no or little residual disability is anticipated for some time and
patients are expected to return to normal living styles
• Encouragement, education and treatment in achieving physical, work and lifestyle goals
• Specific treatments as required
Supportive
• Enhance independent functioning when residual cancer is present and progressive disability is
probable
• Encouragement, education and treatment in achieving physical, work and lifestyle goals
• Availability of therapist as a resource
Palliative
• Primarily directed at promoting maximum comfort
• Maintaining the highest level of function possible in the face of disease progression and impending
death
In Brief
• Prevent muscle shortening
• Prevent joint contractures
• Influence pain control
• Optimise independence and function
• Education and participation of the carer
Goals of Physiotherapy
• Determine the patient’s functional loss
• Estimate functional potential
• Implement a plan to progress from measured loss to full potential
• To improve quality of life
• To listen ‘actively and positively’ with an awareness of priorities as determined by the patient
• Achieve the best possible quality of life for patients and their families
• Availability as a resource for patient and families
Aims of Physiotherapy
1. Assess and optimise the patient’s level of physical function.
Take into consideration the interplay between the physical, psychological, social and vocational aspects of
function
Understand the patients underlying emotional, pathological and psychological condition.
Focus is the physical and functional consequences of the disease and/or its treatment, on the patient.
2) Restore the patient’s sense of self

Facilitate and optimise the patient's ability to function with safety and independence in the face of
diminishing resources.
Maintain optimum respiratory & circulatory function
Listen to patient
Set realistic goals with the patient
3) Prevent muscle shortening & joint contractures

Influence pain control
Educate in all aspects of physical function

Education and participation of the carer
Treat the patient with dignity – allowing them to “live until they die”.
Build a relationship of confidence and trust.
Differences in Palliative Physiotherapy Treatment

• Traditional physiotherapy treatments need to be modified to accommodate the irregular changing
needs of the patient
• Treatments are brief often less than 10 minutes and are repeated several times per day if possible
• Frequent rests are required
• Patient’s status can change suddenly and rapidly
• Requirement to balance ‘effort’ and ‘fatigue’
• Requirement to: -
- Monitor and respond appropriately to patient’s verbal & non-verbal expressions of pain
- Monitor patient very closely during and between treatments
• Timely communication to/with other team members is particularly important
• Changes in patient’s status
• Information given or obtained from patient
• Contribute to staff confidence with patient transfers by accurate assessment and reporting of patient’s
changing transfer abilities
• Coordinate & participate with nursing staff in transfers of patient
• Major issues the patient and therapist face
Fatigue, nausea, pain, weakness, lack of confidence, disparity between perceived & actual physical
ability, drug reactions, Cachexia (major weight loss), progressive, irregular decline in ability, muscle
wasting, disease progression, ascities, varying grief reactions.
Treatment:
• Assessment of patient’s physical, & transfer abilities
• Respiratory management/education
• Mobility towards maximum level independence – treatment & education
• Active &/or passive mobilization
• Pain & symptom management
• Exercise prescription
• Assessment & education in functional ADL
• Provision of walking aides
• Pain management – education – TENS
• Lymph management
• Massage
• Relaxation
• Hydrotherapy
• Home discharge planning with Occupational Therapist
- Home visit
- Education, patient & family
- Provision of aides
- Liaison with other palliative staff
• Multidisciplinary meetings
• Family meetings
• Listening and supporting

CHAPTER 26: PHYSIOTHERAPY IN OBSTETRICS
ANTENATAL CARE:
Goals of antenatal care
• To reduce maternal and perinatal mortality and morbidity rates.
• To improve the physical and mental health of women and children.
• To prepare the woman for labor, lactation, and care of her infant.
• To detect early and treat properly complicated conditions that could endanger the life or impair the
health of the mother or the fetus.
Signs of pregnancy
• Presumptive (subjective) signs of pregnancy:
These signs are least indicative of pregnancy; they could easily indicate other conditions. signs lead a
woman to believe that she is pregnant
▪ Amenorrhea.
▪ Breast changes and tangling sensation.
▪ Chlosma and linea nigra.
▪ Abdominal enlargement & striae gravidarum.
▪ Nausea & vomiting.
▪ Frequent urination.
▪ Fatigue
▪ Quickening: sensations of fetal movement in the abdomen. Firstly, felt by the patient at
approximately 16 to 20 weeks.
.
Probable signs (objective) of pregnancy:
They are more reliable than the presumptive signs, but they still are not positive or true diagnostic findings.
▪ Hegar’s sign (softening of the lower uterine segment). 6-8 weeks
▪ Goodell’s sign (softening of the cervix uterus, and vagina during pregnancy). 4-6 weeks
▪ Ballottement. dropping and rebounding of the fetus in its surrounding amniotic fluid in
response to a sudden tap on the uterus
▪ Positive pregnancy test.
▪ Braxton hicks’ contractions. more frequently felt after 28 weeks. They usually disappear with
walking or exercise.
▪ The uterus changes from a pear shape to a globe shape.
▪ Enlargement and softening of the uterus
▪ Chadwick’s sign---bluish discoloration of the cervix, vagina and labia during pregnancy as a result of
increased vascular congestion.
▪ Osiander`s sign (pulsation of fornices)
Positive signs of pregnancy:

▪ Fetal heart tones can be detected as early as 9 to 10 weeks from the last menstrual period (LMP) by
Doppler technology
▪ Fetal movement felt by the examiner. after about 20 weeks' gestation
▪ Visualization of the fetus by the ultrasound.
Antenatal Care:
Definitions
• It is a planned examination and observation for the woman from conception till the birth.
Or
• Antenatal care refers to the care that is given to an expected mother from time of conception is
confirmed until the beginning of labor

Goals and Objectives of Antenatal Care
Goals:
* To reduce maternal mortality and morbidity rates.
* To improve the physical and mental health of women and children.
* antenatal care aims to prevent, identify, and ameliorate maternal and fetal abnormality that can adversely
affect pregnancy outcome.
* To decrease financial recourses for care of mothers.
Objectives
Antenatal care support and encourage a family’s healthy psychological adjustment to childbearing
FACTORS AFFECTING MOTHERS UTILIZATION OF ANTENATAL CARE
• Demographic and Biological Factors
• Socioeconomic Factors
• Psychosocial Factors
• Health Services Factors
• Environmental Factors
Assessment and physical examination

• Component of antenatal care
Assessment:
1. The initial assessment interview can establish the trusting relationship between the nurse and the
pregnant woman.
2. Establishing rapport
3. Getting information about the woman’s physical and psychological health.
4. Obtaining a basis for anticipatory guidance for pregnancy.
During the first visit, assessment and physical examination must be completed. Including:
➢ History.
➢ Physical examination.
➢ Laboratory data.
➢ Psychological assessment.
➢ Nutritional assessment.
History
• Welcome the woman, and ensure a quiet place where she can express concerns and anxiety without
being overheard by other people.
• Personal and social history:
This include: woman’s name, age, occupation, address, and phone number. marital status, duration of
marriage, Religion, Nationality and language, Housing and finance
Menstrual history:
A compete menstrual history is important to establish the estimated date of delivery. It includes:
- Last menstrual period (LMP).
- Age of menarche.
- Regularity and frequency of menstrual cycle.
- Contraception method.
- Any previous treatment of menstrual
- Expected date of delivery (EDD) is calculated as followed:
1st day of LMP −3 months +7 days, and change the year.
Example: Calculate EDD if LMP was august 30, 2007 = June 6, 2008.

Current problems with pregnancy:
Ask the patient if she has any current problem, such as:
- Nausea & vomiting.
- Abdominal pain.
- Headache.
- Urinary complaints.
- Vaginal bleeding.
- Edema.
- Backache.
- Heartburn.
- Constipation.
Obstetrical history:
This provides essential information about the previous pregnancies that may alert the care provider to
possible problems in the present pregnancy. Which includes:
➢ Gravida, para, abortion, and living children.
➢ Weight of infant at birth & length of gestation.
➢ Labor experience, type of delivery, location of birth, and type of anesthesia.
➢ Maternal or infant complications.
Medical and surgical history:
Chronic condition such as diabetes mellitus, hypertension, and renal disease can affect the outcome of the
pregnancy and must be investigated.
Prior operation, allergies, and medications should be documented.
Previous operations such as cesarean section, genital repair, and cervical cerclagc.
Accidents involving injury of the bony pelvis
Family history:
Family history provides valuable information about the general health of the family, and it may reveal
information about patters of genetic or congenital anomalies.
Including:
- D.M.
- Hypertension.
- Heart disease.
- Cancer.
- Anemia.
Physical examination
Physical examination is important to:
✓ detect previously undiagnosed physical problems that may affect the pregnancy outcome.
✓ and to establish baseline levels that will guide the treatment of the expectant mother and fetus
throughout pregnancy.
General Examination
It should be started from the moment the pregnant woman walks into the examination room.
Examine general appearance:
Observe the woman for stature or body build and gait
The face is observed for skin color as pallor and pigmentation as chloasma.
Observe the eyes for edema of the eyelids and color of conjunctiva. Healthy eyes are bright and clear.
Vital signs:
▪ Blood pressure:
1. It is taken to ascertain normality and provide a baseline reading for a comparison throughout the
pregnancy.
2. In late pregnancy, raised systolic pressure of 30 mm Hg or raised diastolic pressure of 15 mm Hg
above the baseline values on at least two occasions of 6 or more hours apart indicates toxemia.

▪ Pulse:
The normal pulse rate = 60-90 BPM.
Tachycardia is associated with anxiety, hyperthyroidism, or infection.
▪ Respiratory rate:
The normal is 16-24 BPM.
Tachypnea may indicate respiratory infection, or cardiac disease.
▪ Temperature:
normal temperature during pregnancy is 36.2C to 37.6C.
Increased temperature suggests infection.
Cardiovascular system:
Venous congestion: Which can develop into varicosities, venous congestion most commonly noted in the
legs, vulva, and rectum.
Edema: Edema of the extremities or face necessitates further assessment for signs of pregnancy-induced
hypertension.
Musculoskeletal system
Posture and gait:
Body mechanics and changes in posture and gait should be addressed. Body mechanics during pregnancy
may produce strain on the muscles of the lower back and legs.
Height & weight:
An initial weight is needed to establish a baseline for weight gain throughout pregnancy.
Preconception:
➢ Wt. lower than 45kg, or Ht. under 150 cm is associated with preterm labor, and low birth weight
infant.
➢ Wt. higher than 90 kg is associated with increased incidence of gestational diabetes, pregnancy
induced hypertension, cesarean birth, and postpartum infection.
Recommendation for weight gain during pregnancy are often made based on the woman’s body mass index.
Pelvic measurement:
The bony pelvis is evaluated early in the pregnancy to determine whether the diameters are adequate to
permit vaginal delivery.
Observe the neck for enlarged thyroid gland and scars of previous operations.
* Observe complexion for presence of blotches.
* Ensure that the general manner of the woman indicates vigor and vitality.
* An anemic, depressed, tired or ill woman is lethargic, not interested in her appearance, and unenthusiastic
about the interview.
* Lack of energy is a temporary state in early pregnancy, a woman often feels exhausted and debilitated.
* Discuss the woman's sleeping patterns and minor disorders and give advice as necessary.
* Report any signs of ill health.
Abdomen:
▪ The size of the abdomen is inspected for:
- the height of the fundus, which determines the period of the gestation.
- multiple pregnancy.
The shape of the abdomen is inspected for:

- Fetal lie & position.
- The abdomen is longer if the fetal lie is longitudinal as occurs in 99.5% of cases.
- The abdomen is lower & broad if the lie is transverse.
- Fetal movement is inspected as evidence of fetal life and position.
- Fetal heart beat can be heard by stethoscope after the 20th week, or Doppler after 8th week. Normal fetal
heart rate is 120-160 beats/min.

1 – Inspection:
The nurse should look at the following:
• Skin changes such as linea nigra, striae gravidarum and scars of previous operations.
• The size of the abdomen is inspected for:
* Height of the fundus, which determines the period of gestation.
* Multiple pregnancy and polyhydramnios will enlarge both the length and breadth of the uterus.
* A large fetus increases only the length of the uterus.
Contour of the abdominal wall is observed for pendulous abdomen, lightening protrusion of umbilicus and
full bladder
The uterus may be higher than expected:

1. Large fetus, multiple pregnancy
2. Polyhydramnios
3. Mistaken date of last menstrual period
The uterus may be lower than expected:
1. small fetus, intrauterine growth restriction
2. oligohydramnios
3. mistaken date of last menstrual period.
Fundal palpation is performed to determine whether it contains the breech or the head. This will help to
diagnose the fetal lie and presentation.
Calculations:
Calculation of gestation using fundal height
McDonald’s method: Measure from symphysis pubis to top of fundus in cm.
Gestation is measurement + or – 2 weeks
12 weeks: The uterus fills the pelvis so that the fundus of the uterus is palpable at the symphysis pubis.
16 weeks: The uterus is midway between the symphysis pubis and the umbilicus.
20 weeks: It reaches the umbilicus
Methods for Determining Fetal Presentation: Leopold's maneuvers

• First maneuver: To determine fetal presentation (longitudinal axis) or the part of the fetus (fetal
head or breech) that is in the upper uterine fundus.
• Second maneuver: To determine the fetal position or identify the relationship of the fetal back and
the small parts to the front, back, or sides of the maternal pelvis.
*Determine what fetal body part lies on the side of the abdomen. Reverse the hands and repeat the
maneuver. If firm, smooth, and a hard - continuous structure, it is likely to be the fetal back; if smaller,
knobby, irregular, protruding, and moving, it is likely to be the small body parts (extremities).
• Third maneuver: To determine the portion of the fetus that is presenting.
The head will feel firm and globular. If not engaged into the pelvis, the presenting part is movable. If
immobile, engagement has occurred. This maneuver is also known as Pallach's maneuver or grip
• Fourth maneuver: To determine fetal attitude or the greatest prominence of the fetal head over the
pelvic brim
• If the cephalic prominence is felt on the same side as the small parts, it is usually the sinciput (fetus'
forehead), and the fetus will be in vertex or flexed position. If the cephalic prominence is felt on the
same side as the back, it is the occiput (or crown), and the fetus will be vertex or slightly extended
position.
• If the cephalic prominence is felt equally on both sides, the fetus' head may be in a military position
(common in posterior position). Then move the hands toward the pelvic brim. If the hands converge
(come together) around the presenting part, it is floating. If the hands diverge (stay/move apart), the
presenting part is either dipping or engaged in the pelvis.

• Neurological system
• Deep tendon reflexes should be evaluated because hyperreflexia is associated with complications of
pregnancy.
• Skin
• Pallor of the skin my indicate anemia.
• Jaundice may indicate hepatic disease.
• Chloasma and linea nigra related to pregnancy.
• Striae graviderum should be noted.
• Nail beds should be pink with instant capillary return.
Legs:
* Legs should be noted for edema.
* They should be observed for varicose veins
* The calf must be observed for reddened areas which may be caused by phlebitis and white areas which
could be caused by deep vein thrombosis.
* Ask the woman to report tenderness during examination.
* The legs should be observed for unequal length or muscle wasting which may be an indication of pelvic
abnormalities.
Breast
• Assess breast size, symmetry, condition of nipple, and the presence of colostrum.
• Gastrointestinal systems
• Mouth:
• The gum may be red, tender, edematous as a result of the effects of increased estrogen. Observe the
mouth for:
• Dryness or cyanosis of the lips.
• Gingivitis of the gums.
• Septic focus or caries of the teeth
• Intestine:
Assess for the bowel sound.

Assess for constipation or diarrhea.
Vaginal discharge:
* Ask the woman about any increase or change of vaginal discharge.
• Report to the obstetrician any mucoid loss before the 37th week of pregnancy.
Vaginal bleeding:
* Vaginal bleeding at any time during pregnancy should be reported to the obstetrician to investigate its
origin.
LABORATORY DATA
Test Purpose
Blood group To determine blood type.
Hgb & Hct To detect anemia.
(RPR) rapid plasma reagin To screen for syphilis
Rubella To determine immunity
Urine analysis To detect infection or renal disease. protein, glucose, and ketones
Papanicolaou (pap) test To screen for cervical cancer
Chlamydia To detect sexual transmitted disease.
Glucose To screen for gestational diabetes.
Stool analysis for ova and parasites
* Venereal disease tests To screen for syphilis
should be performed (VDRL)
Hepitits Bserface antigine To detect carrier status or active disease
• * Hemoglobin will be repeated:

• - At 36 weeks of gestation.
• - Every 4 weeks if Hb is<9g/dl.
• - If there is any other clinical reason.
• Ultrasound
Is performed to:
• estimate the gestational age.
• Check amniotic fluid volume.
• Check the position of the placenta.
• Detect the multifetal pregnancy.
• The position of the baby.
• Fetal kick count:
• The pregnant woman reports at least 10 movements in 12 hours.
* Absence of fetal movements precedes intrauterine fetal death by 48 hours.
• Schedual of antenatal care:
• A medical check up every four weeks up to 28 weeks gestation,
• Every 2 weeks until 36 weeks of gestation
• Visit each week until delivery
• More frequent visits may be required if there are abnormalities or complications or if danger signs
arise during pregnancy

➢ Services at subsequent visits:
• the nurse inquires about physical changes that are related directly to the pregnancy, such as the
woman’s perception of fetal movement, any exposure to contagious illness, medical treatment and
therapy prescribed for non-pregnancy problems since the last visit,
• prescribed medications that were not prescribed as a part of the women’s prenatal care.
health education:
• Follow up:
• Advice the mother to follow up according to the schedule of antenatal care that mentioned before,
advise the mother to follow up immediately if any danger sings appears, describe the important of
follow up to the mother.
Health teaching during pregnancy

Health promotion during pregnancy begins with reviewing health hare.
Hygiene:
• Daily all over wash is necessary because it is stimulating, refreshing, and relaxing.
• Warm shower or sponge baths is better than tub bath.
• Hot bath should be avoided because they may cause fatigue. &fainting
• Regular washing for genital area, axilla, and breast due to increased discharge and sweating.
• Vaginal douches should avoided except in case of excessive secretion or infection.
Danger signs of pregnancy
• Vaginal bleeding including spotting.
• Persistent abdominal pain.
• Sever & persistent vomiting.
• Sudden gush of fluid from vagina.
• Absence or decrease fetal movement.
• Severe headache.
• Edema of hands, face, legs & feet.
• Fever above 100 F (greater than 37.7C).
• Dizziness, blurred vision, double vision & spots before eyes.
• Painful urination.
Breast care:
• Wear firm, supportive bra with wide straps to spread weight across the shoulder.
• Wash breasts with clean tap water (no soap, because that could be drying). Daily to remove the
colostrum & reduce the risk of infection.
• It is not recommended to massage the breast, this may stimulate oxytocin hormone secretion and
possibly lead to contraction.
• advise the mother to be mentally prepared for breast feeding
• advise the pregnant woman to expresses colostrums during the last trimester of pregnancy to prevent
congestion.
Dental care:
• The teeth should be brushed carefully in the morning and after every meal.
• Encourage the woman the to see her dentist regularly for routine examination & cleaning.
• Encourage the woman to snack on nutritious foods, such as fresh fruit & vegetables to avoid sugar
coming in contact with the teeth.
• A tooth can be extracted during pregnancy, but local anesthesia is recommended.
Dressing:
• Woman should avoid wearing tight cloths such as belt or constricting bans on the legs, because these
could impede lower extremity circulation.
• Suggest wearing shoes with a moderate to low heel to minimize pelvic tilt & possible backache.
• Loose, and light clothes are the most comfortable.

Travel:
Many women have questions about travel during pregnancy.
• Early in normal pregnancy, there are no restrictions.
• Late in pregnancy, travel plans should take into consideration the possibility of early labor.
Sexual activity:
• Sexual intercourse is allowed with moderation, is absolutely safe and normal unless specific problem
exist such as: vaginal bleeding or ruptured membrane.
• If a woman has a history of abortion, she should avoid sexual intercourse in the early months of
pregnancy.
Exercises:
• Exercise should be simple. Walking is ideal, but long period of walking should be avoided.
• The pregnant woman should avoid lifting heavy weights such as: mattresses furniture, as it may lead
to abortion.
• She should avoid long period of standing because it predisposes her to varicose vein.
• She should avoid setting with legs crossed because it will impede circulation.
Purpose:
1. To develop a good posture.
2. To reduce constipation & insomnia.
3. To alleviate discomvortable, postural back ache& fatigue.
4. To ensure good muscles tone& strength pelvic supports.
5. To develop good breathing habits, ensure good oxygen supply to the fetus.
6. To prevent circulatory stasis in lower extremities, promote circulation, lessen the possibility of
venous thrombosis
Guide lines for exercises during pregnancy:

• Maintain adequate fluid intake.
• Warm up slowly, use stretching exercises but avoid over stretching to prevent injury to ligaments.
• Avoid jerking or bouncing exercises.
• Be careful of loose throw rugs that could slip& cause injury.
• Exercises on regular basis (three times per week).
• After first trimester, avoid exercises that require supine position.
Contraindications:
• Vaginal bleeding.
• Sever anemia.
• History of preterm labor,
• Extreme over or under weight.
• -Hypertension, heart, lung, thyroid diseases
Sleep:
• The pregnant woman should lie down to relax or sleep for 1 or 2 hours during the afternoon.
• At least 8 hours sleep should be obtained every night & increased towards term, because the highest
level of growth hormone secretion occurs at sleep.
• Advise woman to use natural sedatives such as: warm bath & glass of worm milk.
• A good sleeping position is sims’ position, with the top leg forward. This puts the weight of the fetus
on the bed, not on the woman, and allows good circulation in the lower extremities.
• avoid resting in supine position, as supine hypotension syndrome can develop.
Hazards
• Occupational hazards: lead, mercury, X ray s& ethylene oxide.
• Infection: rubella, toxoplasmosis, syphilis.
• Smoking & alcohol: increase risk for pregnancy, prematurity, fetal death, mental retardation &
congenital anomalies.
• Drugs: as sedative & analysis, anticoagulant, antithyrodism, hormones& antibiotics.

Diet:
• Daily requirement in pregnancy about 2500 calories.
• Women should be advised to eat more vegetables, fruits, proteins, and vitamins and to minimize their
intake of fats.
Purpose:
– Growing fetus.
– Maintain mother health.
– Physical strength & vitality in labor.
– Successful lactation.
• Managing the minor disorders of pregnancy
Nausea and vomiting
Occur between 4-6 weeks gestation
• Causes:
- hormonal influences: hcg, progesterone, estrogen.
- emotional factors like tension.
• Management:
- adequate rest and relaxation.
- eating small six meals a day rather than three large meals.
- solid food tolerated better than liquid food like: crackers or piece of dry toast.
- carbohydrate snacks at bedtime can prevent hypoglycemia which cause nausea & vomiting.
- Food should not have a strong odor, should not be either very hot or very cold, and fried or greasy foods
should be avoided.
Heartburn
• Causes:
- progesterone hormone relaxes the cardiac sphincter of the stomach and allows reflex or bubbling back of
gastric contents into the esophagus.
- the pressure of the growing uterus on the stomach from about 30-40 weeks.
• Management:
- avoid lying flat.
- sleeping with more pillows and lying on the right side.
- small frequent meals.
- take antacids.
- taking baking soda in a glass of water is contraindicated because of the possibility of retention of sodium
and subsequent edema
Avoid fried, spicy, and fatty food
Avoid citrus juices
Backache
• Cause:
Backache may be due to muscular fatigue and strain that accompany poor body balance.
• It may be due to increased lordosis during pregnancy in an effort to balance the body.
• •The pregnancy hormones sometimes soften the ligaments to such a degree that some support is
needed.
• Management:
- exercise.
- sit with knee slightly higher than the hips.
-The pregnant woman is reassured that once birth has occurred, the ligaments will return to their pre-
pregnant strength.

Urinary frequency
• Cause:
Occur due to the pressure of the growing uterus on the bladder.
• Management:
The problem will be resolved when the uterus rises into the abdomen after the 12th week.
Kegel exercises are sometimes recommended to help maintain the bladder.
Varicosities
• Causes:
- progesterone relaxes the smooth muscles of the veins and result in sluggish circulation. The valves of the
dilated veins become inefficient & varicose veins result.
- weight of the uterus partially compressed the veins returning blood from the legs.
• Management:
- lying flat on the bed with the feet elevated.
- moving the legs about is better than standing still.
Constipation
• Causes:
- intestinal motility decreased during pregnancy as a result of progesterone.
- iron supplementation.
• Management:
- the food should have amount of fruit & green vegetables which contain fibers.
- drinking a lot of water.
- exercise & walking.
- laxatives could prescribed by physician.
Physiotherapy in Obstetrics & Gynecology

Obstetrics concerns itself with pregnancy, labour, delivery &the care of the mother after child birth
Gynaecology is the study of disease associated with women which in effect means condition involving the
female genital tract.
Physiotherapy in obstetrics condition
From the moment of conception pregnancy profoundly alters the women physiology.
There is change in all body system to fulfill the requirement of the body.
Therapeutic exercises may be prescribed to pregnant women for several reasons:
• Primary conditioning unrelated to pregnancy.
• Impairments related to physiological changes of pregnancy, such as back pain, faulty posture, or leg
cramps.
• Physical &physiological benefits.
• Preventive measures
Physiological changes during pregnancy
• Pregnancy wt. gain - 9.70 to 14.55 kg.
• Changes in reproductive system.
• Urinary system -kidney increases by 1cm.
• Changes in pulmonary system.
• CVS.
Physiological changes during pregnancy
• Musculoskeletal system.
a. Stretching of abdominal muscles
b. Decrease in ligamentous tensile strength.

c. Hyper mobility of joints due to ligamentous laxity.
d. Pelvic floor drops as much as 2.5 cm.
Mechanical changes.
a. COG shifts upwards & forwards.
b. posture – shoulder girdle becomes rounded, scapular protraction, upper limb internal rotation,
increase in cervical lordosis, knee hyperextension, increase in lumber lordosis.
c. balance – pt. walks with wider BOS.
Exercises in Pregnancy
1. Prenatal exercises
2. Preparation for labour
3. Postnatal exercises
Pre – natal Exercise:

Potential impairments of pregnancy
• Development of faulty posture
• Upper & lower extremities stress
• Altered circulation, varicose vein LL edema
• Pelvic floor stress
• Abdominal muscle stretch & diastasis recti
• Inadequate relaxation skills necessary for labour & delivery
• Development of musculoskeletal pathologies
General goals & plan for exercise programs
GOALS PLAN OF CARE
1.Improve posture & correct body mechanics 1.Train & strengthen postural muscle
2.Upper & lower extremities strengthening 2. Teach correct body mechanics in all position
Strengthening ex. of UL & LL
3. Prepare for circulatory compromise 3. Stockings, stretching exercise.
4. Improve awareness & control of pelvic floor 4. Pelvic floor muscle strengthen
musculature
5. Maintain abdominal muscle function & 5. Abd. Muscle strengthen ex.
correct diastasis recti
6. Provide information about pregnant & 6. Prenatal & postnatal information
associated problem
7. Improve relaxation skill 7. Relaxation tech.
General Guidelines for Exercise Instruction

• Physical examination is must prior to engaging a pt. in an Exercise – Programme.
• Each person should be individually evaluated for preexisting Musculo -skeletal problems, posture &
fitness level
• Exercise regularly, at least thrice a week
• Avoid ballistic movements & rapid change in directions.
• Include warm-up & cool down session
• Avoid an anaerobic pace.
• Strenuous activities should be avoided.
• Avoid prolong period of standing specially in third trimester.
• Adequate caloric intake, increase to 300 kcal. /day for ex. during pregnancy & 500 kcal./day for ex.
during lactation.
• Low resistance & high repetitions ex. is recommended, avoid Valsalva maneuvers.
• Stop ex. if any unusual symptoms occur.

Contraindications to exercise:
1. ABSOLUTE CONTRAINDICATIONS
• Pregnancy induced HTN BP >140/90 mmhg.
• Diagnosed heart disease IHD, RHD, CHF.
• Premature rupture of membrane.
• Placental abruption.
• History of preterm delivery.
• Recurrent miscarriage.
• Persistent vaginal bleeding.
• Fetal distress.
• IUGR.
• Incomplete cervix
• Thrombophlebitis &pulmonary embolism.
• Pre-eclampsia
• Polyhydraminos / oligohydraminos
• Acute infection
2.RELATIVE CONTRAINDICATIONS
• Diabetes
• Anemia's or other blood disorders
• Thyroid disorder
• Dialated cervix
• Extreme obesity / underweight
• Breech presentation during third trimester
• Multiple gestation
• Ex. induced asthma
• Peripheral vascular disease
• Pain of any kind.
Suggested sequence of exercise:
• General rhythmic activities to warm-up.
• Gentle selective stretching
• Aerobic activities for CVS conditioning
• UL &LL strengthening ex.
• Abdominal ex
• Pelvic floor ex.
• Relaxation /cool down activities
• Educational information [if any] & postpartum ex. Education.
Selected exercise techniques
• Postural exercise.
• Abdominal exercise
• Stabilization exercise
• Pelvic motion training & strengthening.
• Modified UL & LL strengthening.
• Perineum &adductor flexibility.
• Relaxation &breathing exercise
Posture exercise:
Includes: -
• Strengthening exercise
• Stretching exercise
STRETCHING EXERCISES
• Upper neck extensors & scalenes.
• Scapular protractors, shoulder internal rotators & levator scapulae

• Low back extensors
• Hip adductors [caution do not over stretch in women with pelvic instability]
• Ankle planter flexor.
- Low back extensors
stretching
- Hip adductor stretching
Self-Scalene stretching Scalenes stretching by

therapist
Strengthening Exercise:
Strengthening of External Rotators Corner Press Out
ABDOMINAL EXERCISES:
1. Corrective ex. for diastesis recti
• Head lift
• Head lift with pelvic tilt.
2. Trunk curls
3. Leg sliding

Hook lying with posterior pelvic tilt
Maintain pelvic tilt as the feet slide along the floor away from the body
4. Quadruped pelvic tilt ex.
STABILIZATION EXERCISES:
• These exercises are progression for developing dynamic control of the pelvis &LL.
• These may be performed throughout the pregnancy & postpartum period.
• caution – the women to maintain a relaxed breathing pattern & exhale during the exertion phase of
each ex.
• Alternate hip & knee extension with one leg stationary on a mat.
• Progression is alternate hip & knee extension &flexion with both LL moving.
Pelvic floor exercises:

Isometric ex. / kegals ex.
• Pt position – any position
• Instruction – to tighten the pelvic floor as if attempting to stop urine, &hold for 3 to 5 sec.
• This ex is valuable in treating leaky bladder.
Modified Upper Limb and Lower Limb Exercises:

1. Modified push – ups /standing pushups
2. Hip extension
a. supine bridging
b. All four – leg raising

3. Modified squatting
These are used
• To strengthen the hip &knee extensor.
• Stretch the peroneal area.
a. Supported squatting using a chair or wall.
Quadruple position with posterior pelvic tilt b. Wall slide.
Leg is raised only until it is in line with the

trunk
PERINEUM AND ADDUCTOR FLEXIBILITY

Self-stretching
1. Women's position supine or side lying.
Instruct to abduct the hip &pull the knees towards the sides of her chest & hold the position for as long as
comfortable.
2. Sitting – have the women sit on a short stool with the hips abducted & feets flat on the floor.
Relaxation and Breathing Exercise:

Relaxation & Breathing exercise are given with the following objectives
1. To obtain rest during pregnancy.
2. To help the mother regain normal health afterwards by preventing unnecessary fatigue
3. Most common method of relaxation is MITCHELLS METHOD.
4. Patient position in kneeling forward on to one’s arm on a cushion placed on a seat of a chair.
5. In this position wt. of the fetus lies on the anterior abdominal wall & pelvic floor relaxes
6. In this position pt. take deep diaphragmatic breathing.
7. Other methods of relaxation are
a. mental imagery.
b. muscle setting – “Jacobson’s Method”
Preparation for Labour:

A prog. of labour training consist of
1. Body awareness & labour/ positioning during
labour.
2. Relaxation during labour.
3. Breathing during labour.
4. Massage during labour.
Positioning during labour:

1st stage of labour –
In this stage uterus anteverts

• Positions attended during 1st stage are
• Sitting with head &shoulder resting on a table.
• Standing leaning against a wall either facing or
with back support.
• Stride sitting across a chair resting the head &
arms on the back.
• On all four on floor supported by partner, standing,
resting head on his shoulder.
KEGALS EX. DURING 1ST STAGE OF

LABOUR
These are labour inducing exercise.
In 1st half an hour –supine to sitting every 5
min.
In 2nd half an hour – do supine to sitting every 4
min.
2. POSITIONING DURING 2ND STAGE OF LABOUR.

Commonly used positions are
• Lithotomy
• Dorsal (recumbent)
• Lateral & semirecument
Relaxation during Labor

• Once the labour begins, contraction of the uterus progress.
• Relaxation during contraction becomes more demanding.
• Provide the women with suggested tech. to assist in relaxation.
1.Moral support from family members.
2.Seek comfortable position including lying on pillows, gentle motions such as pelvic rocking.
3.Slow breathing with each contraction.
4.Visual imagery.
5. During transition there is often an urge to push. Use quick blowing tech. using the cheeks during push.
6. Local heat/ cold application.
7. Gentle touch provides relaxation.

BREATHING DURING LABOUR
According to Williams & Booth (1985)
1st stage Transitional stage 2nd stage

Easy breathing- a little Breathing to prevent pushing 1 or 2 deep breaths in & out,
slower & deeper then usual. “fairly deep breathing” to move then hold making the
the diaphragm up &down together diaphragm “piston go down”
with a sharp blow out through repeat when breath runs out,
relaxed lip after a gulp of air.
Breathing and Pushing:

• Ask the mother to place her index finger over epigastrium, take a breath in & feel the expansion in this
area.
• Fix the ribs & increase the intrathoracic pressure, with inspiration bear down & diaphragm will then act
as a piston directed downwards towards the fundus.
• Place the other hand on the waist feel it expand sideways & become aware of the forward bulging of the
lower abd. muscle & the relaxation of the pelvic floor open the door for the birth of baby”
• Relaxation of the jaws should explain to the patient.
• The direction of the push is downward under the pubic bone.
• Breath hold for only 6-7sec. To minimize any adverse effect on the fetus due to a prolonged pushing
maneuver.
• Several pushes may be necessary during contraction. b/w contraction sigh out, rest & relax.
Massage During labour

• It is helpful in pain relief during labour.
• soothing effect of massage activates “gate closing” mechanism at spinal level.
• tissue manipulation stimulates the release of endogeneous opiates.
• Massage is applied over-
1. BACK MASSAGE
2. ABDOMINAL MASSAGE
3. LEG MASSAGE
4. PERINEAL MASSAGE
BACK MASSAGE
1. It is helpful in prolong 1st stage of labour or when
the fetus is in the occipito post. Position.
2. Back pain experienced in lumbosacral region.
3. Stationary kneading is applied slowly & deeply to
the painful area.
4. Effleurage from sacrococcygeal area up & over the
iliac creast
5. Longitudinal stocking from occiput to coccyx.
6. Kneading with clenched fist directly over the SI
joint for severe pain.

ABDOMINAL MASSAGE
1. Pain experienced over the lower half of the abdomen in the suprapubic region.
2. light finger stroking over the site of pain.
LEG MASSAGE
1. Occasionally labour pain may be perceived in the thighs & cramps in the calf or foot.
2. effleurage or kneading relieve pain.
PERINEAL MASSAGE
1. It is done in 2nd stage of labour to encourage stretching of skin & muscle to prevent tearing/ episiotomy.
EXERCISES THAT ARE NOT SAFE DURING PREGNANCY

• Bilateral SLR.
• “Fire hydrant” ex.- this should be avoided by any women who has pre-existing SI joint symptoms.
• Unilateral wt. bearing activities.
• Several activities that have potential for high velocity impact may cause abdominal trauma should
be avoided. 1.Horse riding & driving.
2. Heavy wt. lifting.
3. Ice skating, etc.
POST NATAL EXERCISES
1. Ex. Can be started as soon as after delivery as the women feels able to ex.
2. All prenatal ex. Can be performed safely in postpartum period.
3. Before starting ex. Proper assessment of position & consistency of the fundus of the uterus should
be done.
4. Assessment of perineum & lochia.
5. Monitoring of lower limb edema, varicosities.
6. Care & advise on breast feeding & baby care.
POSTNATAL EXERCISES
1. Initial postnatal exercises.
Breathing Ex. Deep breathing for circulatory & relaxing effect
Leg exercise Foot ankle leg exercise
Abdominal exercise In crook line position combined with expiration
Pelvic tilting exercise Crook lying position, Tilt- Relax-Tilt – Relax Exercise

2. Early postnatal ex. - Include proper positioning.
CESAREAN CHILD BIRTH

It is an operative procedure whereby the fetuses after the end of 28th wk. are delivered through an incision
on the abdominal &uterine wall.
• Impairments /Problem Due to Cs
1. Risk of pneumonia
2. Postsurgical pain.
3. Risk of adhesion.
4. Formation at incisional site.
5. Risk of vascular complication.
6. Faulty posture.
7. Pelvic floor dysfunction.
8. Abdominal weakness
GOAL PLAN OF CARE
1. Improve pulmonary function & decrease the risk 1. Breathing ex. Coughing &huffing.
of pneumonia
2. Decrease incisional pain associated with 2. Postnatal TENS support incision with hands
coughing when coughing.
3. Prevent postsurgical adhesion formation 3. Friction massage & scar mobilization.
4. Prevent postsurgical vascular complication 4. Active leg ex., early ambulation
5.Correct posture & protected activities of daily 5.Postural instruction &positioning for ADL
living
6. Prevent pelvic floor dysfunction 6. Pelvic floor ex.

7. Develop abdominal strength 7. Abdominal ex.

SUGGESTED ACTIVITIES FOR THE PT. WITH ACS.
1. Exercises
• All prenatal ex. Should be done.
• The women should be instructed to begin preventive ex. As soon as possible during recovery period.
• Ankle pumping activities &early ambulation to prevent venous stasis.
• Pelvic floor ex. Kegals ex. &pelvic tilting ex.
• Abdominal ex. Should be progressed more slowly.
• Deep diaphragmatic breathing
• Women should wait at least 6 to 8 wk before resuming vigrous ex.
2. Coughing & Huffing
• Huffing is a forceful outward breath using the diaphragm rather than abdominal to push air out of
lungs.
• The abdominals are pulled up &in rather then pushed out causing decreased abdominal pressure &
less strain on the incision.
• Support the incision with pillows or hands during cuffing or huffing & say “HA” forcefully while
pulling in abdominal muscle.
3. Ex. to relieve intestinal pains
• Abd. Massage or kneading while lying on the left side.
• Pelvic tilting ex.
4. Scar Mobilization
HIGH RISK PREGANANCY

• A pregnancy that is complicated by disease or problem that put the mother or fetus at risk for illness
or death. Condition may be preexisting be induced by pregnancy or an abnormal physiological
reaction during pregnancy.
• The goal of medical intervention is to prevent preterm delivery, usually through use of bed rest,
restriction of activity &medications when appropriate.
GOAL PLAN OF CARE
1. 1. Decrease stiffness 1. 1. Positioning instruction, joint motion at available ROM.
2. 2. Maintain muscle length & bulk to improve2. 2. Stretching & strengthening ex. Within limits imposed
circulation. by physician.
3. 3. Improve proprioception 3. 3. Movement activities for many body parts as possible.
4. 4. Improve posture within available limits. 4. 4. Modified posture instruction.
5. 5. Stress management & enhance relaxation. 5. 5. Relaxation tech. 6. Ex instruction &home program for
6. 6. Enhance postpartem recovery. postpartum period.
Exercise program for high risk pregnancy

1. POSITIONING INSTRUCTION
• Left side lying position to prevent vena cava compression, enhance COP & lower extrimity edema.
• Pillow to support body parts & enhance relaxation.
• Supine position for short period with wedge placed under the rt. Hip to decrease IVC compression.
2. ROM INSTRUCTION
Slow active full ROM of all the joints.
Teach movement in gravity eleminated position.
3. SUGGESTED EX.
• Lying
- Supine or side lying with alternate knee to chest.
- Ankle pumping.
- Shoulder, elbow, finger Flex. & extension, reach to ceiling, arm circle.
- Unilateral SLR in supine & side lying position.
- Bilateral active ROM in diagonal pattern for UL & LL
- Pelvic tilt, bridging, isometrics for pelvic floor muscle.
• Sitting [may not be allowed]
- All UL joint movement in available ROM.
- Cervical movement in available ROM.
4. RELAXATION TECHNIQUE
5. BED MOBILITY & TRANSFER ACTIVITIES
• Moving up down side to side in bed.
• Rolling
• Supine to sitting assisted by arms.
6. PREPRATION FOR LABOUR
• Relaxation tech.
• Modified squatting supine, sitting or side lying with knee to chest.
• Breathing
PREGNANCY INDUCED PATHOLOGY

PATOHLOGY PT MANAGEMENT
1. Diastasis recti 1.Modified abdominal muscle ex. With crossed hand
over the abdomen.
2. Lower back pain & pelvic pain. 2.In acute condition bed rest.
Do’s or Don’t: Gentle heat & massage, Pelvic tilting
in crook lying, TENS if indicated
3. SI dysfunction 3. Modified ex. For SI pain
4. Nerve compression syndrome 4. Splinting, ice packs, elevation of the limb, TENS
Carpel tunnel syndrome, Brachial plexus pain and
Posterior tibial nerve compress
5.Circulatory problem varicose vein of leg vulval 5. Prolonged standing avoided, ankle ex., calf
varicose vein leg cramps; thrombosis & stretching, raising foot end of standing should bed.
thromboembolism. deep kneading massage, stocking & breathing ex.
6. Stress incontinence 6. Pelvic floor ex
7. Postural backache 7. Postural correction
8. Coccydynia 8. Ice packs, Heat, US, TENS, use of rubber ring to
relieve pressure in sitting.
PHYSIOTHERAPY IN GYNAECOLOGICAL CONDITIONS

INDICATIONS PT MANAGEMENT
1. Infections: 1. In acute Phase:
Vulvitis, vaginitis, cervicitis, salphingitis, PID Chemotherapy, in chronic phase – pulsed or const SWD
2. Cyst and New Growth 2. Pulsed SWD/US for softening of painful abdomen
adhesions.
3. Stress incontinence 3. Pelvic floor exercise
4. General Prolapse 4. Pelvic floor strengthening exercise.
-Cystocele, urethrocele, rectocele, enterocele,
uterine prolapse
5. Menstrual Disorders 5. Primary type
- Primary/ Spasmodic type - Pain coping strategies
- Secondary/ congestive - Relaxation and breathing techniques and TENS
- Dymennoria
6. Backache and Abdominal Pain 6. TENS

GYNECOLOGY & OBSTETRICS
Pelvic floor muscles:
Definition: It is sheath of musculofascial structure occupying the outlet of pelvis and it includes all the tissues
from the skin of perineum below to the superior fascia of levator ani muscle above.
Anatomy: It is pierced by three canals: - Urethra - Vagina - Anal canal
Structures of pelvic floor: - Skin of perineum - Urogenital region - Superficial perineal pouch
- Deep perineal pouch - Levator ani muscle
Nerve supply: 4th sacral nerve, pudendal nerve, inferior hemorrhoids nerve
Functions:
- Closure of pelvic outlet
- Support to the pelvic organs and viscera
- Helps in coughing, sneezing and lifting activities
- Helps in micturation, defection, parturition by raising the intra-abdominal pressure
- Controls the sphincteric action of urethra, vagina and rectum.
Pelvic floor exercises:

Pelvic floor muscle contractions can be confirmed by:
- Vaginal examination by physiotherapist - Self-examination by patient - Hand an perineum by
physiotherapist/patient - Perineometer - Stop and start midstream urine - Fole’s catheter/tampon
- During intercourse - EMG - Biofeedback
Teaching pelvic floor contractions:

a. Visualization:
- A large simple diagram of the pelvis, pelvic organs, levator ani muscles helps to show the three openings.
- It also helps to show the lifting and gripping action of muscles
b. Language:
Words and images are chosen which are easily understand ask the patient to:
- Stopping/passing urine
- Stopping/passing/breaking wind
- Blowing off/parking
- Stopping diarrhea/shit/poo
- Trying to stop from leaking/wetting your pants
- Gripping to stop with a tampon falling out
- Gripping your partners penis
c. Starting position: (for sensory feedback)

- Sitting on a hard chair, leaning forwards to support forearms on knees with thighs and feet together is the
initial starting position
d. Duration and repetition of contraction:

- During the 1st session the patient is asked to hold a contraction strongly until she feels the muscles weakening
- The duration is timed and recorded
- Then long and strong contractions are repeated on after the other.
- Also check for contractions of other muscles like gluteus, hip adductors, abdominal muscles.
e. General advise:
- The patient is advised to contract the pelvic floor before sneezing, coughing or laughing may cause a strong
desire to void.
- This is called as counter bracing
f. Contractions and relaxation:

- Ask the patient to contract the

- Pelvic floor during:
. Passage of urine. To stop/pass wind. To stop diarrhea
- Quick contraction of pelvic floor by hold and relax technique can be used
- Elevator exercises: Ask the patient to imagine going up in an elevator and contract her pelvic floor by
gradually increasing the intensity as the lift goes up by and floor and then to relax gradually as the lift comes
down by floor
- Pelvic tilting with rotations in supine position.
- About 8-12 fast contractions followed by 3-4 slow –short contractions can be done.
g. Pelvic muscles strengthening exercises:
a. Perineometer: - Kegel device is a pneumatic device which helps to measure the pressure inside the vagina
and to motivate the women to practice pelvic floor exercises - A compressible air-filled rubber cuff was
inserted into the vagina which is connected to a manometer by a rubber tubing - Ask the women to contract
her pelvic floor several times and note the highest reading in the dial. Also, note the length of time for which
she could hold her contractions. - It is useful as biofeedback and for motivation - Take care that intraabdominal
pressure is not measured rather than pelvic floor
b. Foley’s catheter/Tampon: - An air-filled catheter is inserted into the vagina and the patient is asked to
contract and hold the catheter against the traction given by the therapist
c. Vaginal cones:
- It consists of 5-9 small cones or cylinders ranging from 10 gm to 100 gm
- They are made up of lead coated with plastic and a nylon string is attached at one of the tapered ends
- It is a size of a tampon
- The lightest cone is inserted first and ask the patient to hold and walk for 15 min
- Once the cone is retained for 15 min without slipping progression is made to the next cone
- This helps to activate the motor units to support the cones and to increase woman’s awareness of her ability
to contract the pelvic floor muscles voluntarily.
d. Interferential therapy: (IFT)

- This improves the woman’s cortical awareness and the ability to perform voluntary contractions
- Position is in ½ lying position with hips and knees slightly flexed
- The electrode position should be such that the interference occurs at the pudendal and pelvic nerves
e. Low frequency muscle stimulation - Faradism (surged) is used in re-education of pelvic floor muscles -
Levator ani muscles can be contracted using vaginal or anal electrode - Pulse width: 0.1 – 7 m/s - Frequency:
0.5 – 40 Hz.
f. Pelvic tilting exercises:
- Pelvic rolling
- Pelvic rocking with circular motion
- Postural correction by pelvic tilting in standing
g. Lengthening of hip adductors:

- Contract-relax techniques in cross leg sitting by pushing the knees to the floor
- Modified squatting
- Stretching activities
PROLAPSED UTERUS
Definition: It is defined as the herniation or descent of the uterus through the vaginal wall through the
introitus. It may be associated with prolapse of other pelvic organs like:
- Prolapse of the bladder through the upper part of anterior vaginal wall called as cystocele
- Prolapse of the urethra through the lower part of anterior vaginal wall called urethrocele.
- Prolapse of Pouch of Douglas (POD) through the upper part of posterior vaginal wall is enterocele
- Herniation of the rectum through the posterior vaginal wall is called as rectocele

Etiology:
- Congenital weakness of pelvic floor muscles
- Multiple child birth
- Withdrawal child birth
- Withdrawal of hormonal support after menopause
- Improper care during and after surgery
- Raised intra-abdominal pressure during coughing, sneezing, etc.
- Following total or subtotal hysterectomy or vaginal hysterectomy may lead to vault prolapse
- Bulky uterus, cervical fibroids, uterine fibroids may pull down the uterus by weight or traction
- Chronic dysentery, heavy weight lifting
- Obesity
- Constipation
Degree of Prolapse:
1st degree: Cervix remains within the vagina.
2nd degree: The cervix appears at the perineum which descends or protrudes during straining and with
possibility of infection, damage of ulceration
3rd degree: (Providentia) The entire uterus comes outside the vagina causing total inversion of the vagina
Assessment:
1. Patient’s profile
2. History: - Present Medical history (onset, duration, severity, cause) - Past medical history - Any surgery
3. Chief complaint: - Patient complains of some mass coming down from vagina. - Frequency of micturation
- Difficulty in emptying the bladder or bowels - Constipation - Stress incontinence - Low backache - Post
menopausal bleeding
4. On observation: Observe the perineal region for:
- Redness
- Inflammation
- Discharge
- Degree of prolapse: 1st degree, 2nd degree, 3rd degree
- Incision
- Scaring
- Decubitus ulcers (this are ulcers developing at the cervix or at the lateral vaginal wall due to defective
circulation or friction between the thighs and clothes)
5. On examination: - Grading of pelvic floor muscles: 0: Nil 1: Poor 2: Fair 3: Good 4: Very good
- Vaginal digital examination
- Perineometer studies
- 3-point scale. Duration, Texture & Pressure
6. Investigation report:
- Hormonal level
- Ultrasound scanning
- Anorectal function report
Physiotherapy Management:
A. For 1st and 2nd degree prolapse:
1. Pelvic floor exercises:
- It can be done in any position and at any time
- Pubococcygeal lift is easier to activate and more effective
- Contraction and relaxation of pelvic floor muscles
- Hold and relax techniques
- During these exercises do not hold the abdominal, gluteus or hip adductor muscles.
- Perineometer can be used as a means of visual feedback
- Vaginal cones for strengthening of pelvic floor muscles

2. Electrotherapy: - IFT - Low frequency muscle stimulation by surged faradism is useful for muscle re-
education. Active pad: In perineal region Inactive pad: Over the lumbar or sacral region Thus, 10 contractions
can be given with 1-minute rest for 3 times a week
3. Integrated functional patterns:

i. Bracing: - For quick and sustained rise in intra-abdominal pressure. For e.g. wt lifters, furniture removers,
martial art players - It is used to counter the downward pull of pelvic floor muscles and organs - It also
maintains normal lumbar curve
ii. Abdominal Drawing: (for coughing and lifting)
- Draw in your abdomen at the bikiniline towards the lower back and hold
iii. Visceral Interaction:
- It is for an effective cough or sneezing effort
4. Urge control: The methods of detrusor inhibition are:

- Perineal pressure by hand
- Perineal pressure in sitting on the edge of a hand chair or on folded towel
- Leg crossing standing
- Strong gluteal muscle contractions in standing
5. Other methods: - Bladder retraining - Urethral plug device - Ring pessary - Enuresis alarms
B. For 3rd degree prolapse: (Post-operatively) Aims of treatment:

- To prevent circulatory complications
- To prevent respiratory complications
- To teach postural correction
- To strengthen weakened muscles
- To reduce pain, edema
- To improve circulation and promote healing
Means of treatment:
i. To relieve pain, edema and promote healing: - Heat therapy relieves pain and accelerates the healing
process - IFT for pain relief - IRR reduces pain, inflammation and edema
ii. To prevent circulatory complication:
- Ankle/toe movements
- Bandaging and stocking
- Elevation of lower limb over pillow or by slings
- Early ambulation
iii. To prevent respiratory complications:
- Coughing and huffing techniques
- The patient is taught to support the vaginal area using sanitary pad with a firm upward pressure while
coughing
- Postural drainage
- Removal of airway secretions
iv. Strengthen and retrain weakened muscles:
- Pelvic floor exercise
- Kegel/perinometer
- Vaginal cones
- Foley‘s catheter exercises
- Faradic stimulation
- Pelvic floor contractions
- Gradual progression to strengthening of back and abdominal muscles
- Pelvic rhythmic rocking/titling exercises

Uses:
- Prevent back and abdominal muscle spasm
- Reduce flatulence pain
- Helps to reduce pressure by the organs over the incision site
v. Postural correction: - Ask the patient to ―stand tall‖ - Using mirror as a means of biofeedback vi. General
instructions:
- Adequate rest
- Back care
- To teach correct lifting techniques
- Ergonomics
- Avoid lifting heavy wt for 0-8 weeks post-operatively
Surgical Procedures for Prolapsed Uterus:

1. Anterior Colporrhaphy: - For repair of vagina and cystocele
2. Posterior Colporrhaphy: - For repair of rectocele, enterocele, or repair of the perineum
3. Perineorrhaphy: - It is suturing of the perineum for repair of lacerations caused during child birth. It may
involve the anal sphincter.
4. Father gells/Manchester operation: - It is done in young females - Here, anterior and posterior
colporrhaphy is done along with cervical amputation and shortening of the Mackenrodt ligament
5. Salpingostomy: - It is a microsurgery for repair of fallopian tubes.
6. Gilliam’s ventrosuspension: - It is used to correct retroversion of uterus.
7. Hysterectomy: - It is done in elderly women after menopause where the uterus is been surgically removed.
INCONTINENCE OF URINE
Definition: Involuntary loss of urine which is objectively demonstrable and is a social or hygienic problem.
Urgency: It is a strong desire to void, accompanied by fear of leakage or fear of pain.
Frequency: It is a term which denotes that the person empties the bladder very frequently
Dysuria: It is pain on passing urine
Enuresis: It is any involuntary loss of urine
Types of urinary incontinence:

1. Extra-urethral incontinence: It is the loss of urine through channels other than the urethra Causes:
- Congenital abnormality
- Fistula between bladder and urethra or vagina
- Trauma surgeries like hysterectomy
2. Urge incontinence: - It is an involuntary loss of urine associated with a strong desire to void - The amount
lost is related to the intensity of the urgency and amount of urine in the bladder Causes:
- Sensory urgency due to hypersensitivity of bladder, urinary calculi, tumor
- Motor urgency due to overactivity of the detrusors
3. Overflow incontinence: Involuntary loss of urine associated with over distention of the bladder Causes:
- Impairment of nerve supply to detrusor
- Inability of detrusor to contract
- Any obstruction
4. Reflex incontinence: Loss of urine due to over activity of detrusor (detrusor hyper-reflexia) or due to
involuntary urethral relaxation
5. Nocturnal Enuresis: Incontinence during sleep or bed wetting
6. Giggle incontinence: Girls go through a giggling phase during puberty

7. Organism incontinence: - Sexual activity can cause urinary symptoms and lower urinary tract dysfunction
- Honeymoon cystitis or post-coital dysuria without infection is common in young women - Dysuria, urgency
and urinary tract infection is noted in post-menopausal women following intercourse 8.
Stress incontinence: It is defined as involuntary loss of urine due to stress/strain such as increased intra-
abdominal pressure on coughing, sneezing, lifting.
- Genuine stress incontinence is defined as the condition in which there is involuntary loss and in the absence
of detrusor activity, the intravesical pressure is greater than the maximum uretheral pressure
Etiology:
- Trauma or injury to the pubic symphysis due to fracture or following symphysiotomy
- Post-operative muscle weakness
- Pregnancy due to overstretch or damage of pelvic floor muscles and fascia
- Post-menopausal women due to atrophy of the supporting structure
- Urethral deformity
- Obesity
- Hormonal changes resulting in loss of elasticity of pelvic floor musculature.
Tests for incontinence:
1. Frequency/volume chart: - The women is asked to note the time and volume of urine voided each time
she goes to toilet - It is then recorded on a special chart - This helps to determine: - The actual frequency of
micturation - Degree of nocturia - Determine altered circadian cycle, i.e. whether she is voiding more during
night or day - How much fluid is drunk - Determines the bladder capacity - Incidents of urinary accidents
2. Visual Analog Scale: - It is mainly to determine the severity of symptoms during incontinence and pain
measurement 1 10 No pain - always wet No incontinence - total incontinence No problem - massive problem
3. Pad Test: It is an objective test used in urodynamic studies
Procedure:
- The test is started after the patient has voided
- A pre-weighed sanitary pad is worn and then the patient is asked not to void until the end of the test
- After drinking 1000 ml of fluid the patient rests for 45 mins
- The patient is then ask to do exercise for 30 min which includes walking, climbing, stairs, running, wasting
under running water, coughing vigorously
- The pad is then removed and re-weighed
- The difference in weight denotes the amount of fluid loss which is recorded
- Usually an increase in 1 gm weight is allowed on account of sweating, vaginal discharge etc
4. Biofeedback: - A vaginal probe is introduced into the vagina which is connected to a visual display. - The
women is then asked to contract the pelvic floor muscles - Electrical signals from the pelvic muscles are shown
denoting the intensity and duration of contraction
5. Manual grading of pelvic floor muscle contraction: - The therapist inserts his index finger into the vagina
and asks the patient to contract the pelvic floor muscles - Thus, the therapist determines the texture, intensity
of contraction or whether the finger is easily withdrawn
Aims:
- To restore the function of urethrovesicle muscles
- Strengthening the support of the uterus
- Advise obese patient to control diet
Means of treatment:
a. Pelvic floor contractions: Sitting position or leaning forward to support the forearm on knees e.g.
- Stopping passing urine - stopping passing breaking wind - Stopping yourself blowing off/farting - Fasting
and slow contractions - Bracing exercises
Duration: As long as the muscles becomes weak and fatigued.
b. Perinometer/Kegel’s exercise: - Kegel device is a pneumatic device which helps to measure the pressure
inside the vagina and to motivate the women to practice pelvic floor exercises - A compressible air filled

rubber cuff was inserted into the vagina which is connected to a manometer by a rubber tubing - Ask the
women to contract her pelvic floor several times and note the highest reading in the dial. Also, note the length
of time for which she could hold her contractions. - It is useful as biofeedback and for motivation - Take care
that intra-abdominal pressure is not measured rather than pelvic floor
c. Foley’s catheter: - An air-filled catheter is inserted into the vagina and the patient is asked to contract and
hold the catheter against the traction given by the therapist
d. Vaginal cones:
- It consists of 5-9 small cones or cylinders ranging from 10 gm to 100 gm
- They are made up of lead coated with plastic and a nylon string is attached at one of the tapered ends
- It is a size of a tampon
- The lightest cone is inserted first and ask the patient to hold and walk for 15 min
- Once the cone is retained for 15 min without slipping progression is made to the next cone
- This helps to activate the motor units to support the cones and to increase woman’s awareness of her ability
to contract the pelvic floor muscles voluntarily.
e. Elevator exercises: Ask the patient to imagine going up in an elevator and contract her pelvic floor by
gradually increasing the intensity as the lift goes up by and floor and then to relax gradually as the lift comes
down by floor
- Pelvic tilting with rotations in supine position.
- About 8-12 fast contractions followed by 3-4 slow –short contractions can be done.
f. General exercises: - Pelvic tilting - Pelvic rotation - Pelvic rocking - Functional training - Squatting exercise
- Postural correction exercise
g. Faradism: Faradism (surged) is used in re-education of pelvic floor muscles - Levator ani muscles can be
contracted using vaginal or anal electrode - Pulse width: 0.1 – 7 m/s - Frequency: 0.5 – 40 Hz h.
Interferential therapy: It improves patient’s cortical awareness and ability to perform voluntary contractions
For genuine stress incontinence parameters:
- Sweep: 10 -40 Hz
- Carrier wave: 2000 Hz
- Duration: 15 mins
- Intensity: maximally tolerable
Parameters for urge or frequent incontinence
- Sweep: 5 -10 Hz
- Carrier wave: 2000 Hz
- Duration: 30 mins
- Intensity: maximum
Four pole method:
- Two electrodes are applied on abdomen just above the lateral portion of inguinal ligament (A1, B1)
- Two electrodes are applied on medial to the ischial tuberosity on either side of the anus (A2, B2)
Two pole method:
- One medium size electrode over the anus covering the posterior fibers of levator ani muscle.
- 2nd small size electrode is placed centrally below the pubic symphysis.
i. Bladder retraining: - It is used in frequency urgency without leakage incontinence - Contract pelvic floor
muscles every time before voiding - Distraction by companion, games TV, music - Perineal pressure by hand
- Cross leg standing - Maximus gluteus contractions in standing
Physiological Changes in Pregnancy:
- During pregnancy there are progress anatomical and physiological changes.
- These changes does not only occur at the genital organs but also to all the system of the body.
- This is due to increasing demands of the growing fetus.
I. Changes in genital organs
1.Vulva: - It becomes edematous and hyperemic - The labia minora become pigmented and hypertrophied
2. Vagina: - It becomes hypertrophied vascular and edematous - The vaginal secretions becomes copious, thin
and curly white - The ph becomes more acidic.

3. Uterus: - There is increase in size of uterus - It measures 35 cms in length and 900-1000 gms - Changes
occurs in all the parts of uterus. - The uterine muscles undergo hypertrophied and hyperplasia. - The fondues
enlarged more than the body if the uterus. - The 3 distinct layers of uterus muscles can be made out. - In a turn
the uterus differentiates into an active upper segment which is more muscular and a passive lower segment
which is least muscular. - The cervix is deviated to the left side (levo-rotation), bringing it closer to the ureter
due to lateral obliquity.
II. Breast
- There is increase in the size of the breast due to hypertrophy and proliferation of the ducts alveoli.
- The vascularity increase which result in the appearance of bluish veins running under the skin.
- The nipples becomes larger, erectile and are deeply pigmented
- The sebaceous glands which remains invisible in the non-pregnant state becomes hypertrophied over the
areola during pregnancy and are called as Montgomery‘s tubercles
- Secondary areola is seen in the 2nd trimester
- Secretions may also been seen at about 12 weeks of pregnancy
- Breast weight is increased approximately to 500-800 gm
III. Endocrine system:

- Changes are brought about by progesterone, estrogen and relaxin hormones
a. Effects of progesterone: - Reduction in tone of smooth muscles resulting in nausea, reduced peristalsis,
constipation, bladder toned is decreased, dilation of veins and decreased diastolic pressure - Increase in body
temperature - Increased storage of fats - Development of breast, alveolar and glandular milk producing cells
b. Effects of estrogen: - Increased growth of uterus and breast ducts - Increased levels of prolactin for lactation
- Maternal calcium metabolism - Higher levels may result in increased vaginal glycogen resulting in ‗thrush‘.
c. Effects of relaxin: - Replacement of collage in pelvic joints, capsules, cervix, resulting in greater
extensibility and pliability - Inhibition of myometrial activity
- Helps in distension of uterus and provides additional supporting connective tissues - Has a role in cervix
ripening
IV. Cutaneous changes:

- There is formation of chlosma gravidarum or pregnancy mark in the form of pigmentation around the cheek
which is patchy or diffused and it disappears after delivery
- It also shows formation of linea nigra which is a brownish black pigmentation in the midline of the abdomen
stretching from the xiphisternum to the pubic symphysis. It usually disappears after delivery.
- Striae gravidarum are slightly depressed linear marks with varying length and breath. These are seen just
below the umbilicus
- These are pinkish during delivery which becomes glistening white after pregnancy and is then called as striae
albicans
V. Weight gain: - A pregnant lady puts on about 10-12 kg of weight - In early pregnancy the lady may loose
weight due to nausea and vomiting but later the weight gain is progressively increased to about 2 kg every
month
VI. CVS changes:

- Increase in blood volume by 40%
- Increase in plasma level than red cells and Hb level falls by 80%. This is called as dilution anemia or
physiological anemia due to pregnancy
- During 3rd trimester, the weight of fetus may compress the aorta and IVC against the lumbar spine in lying
position causing dizziness, unconsciousness and is called as pregnancy hypotensive syndrome.
- Increase in cardiac output by 40%
- Stroke volume increased by 30%
- Heart rate increased by 30%
- Heart rate increased by 15 beats/min

VII. Respiratory system:
- Respiratory rate increases from 15-18 breath/min (hyperventilation)
- Alveolar ventilation increases
- Tidal volume increases up to 40%
- Diaphragm is raised by 40 mm
- Chest diameter is increased by 20 mm
- CO2 tension is decreased
- PaO2 – 92 mm of Hg
- PaCO2 – 30 mm of Hg
VIII. GIT and urinary system:

- respiratory rate increases from 15 to 18 breath/min(Hyperventilation)
- Alveolar ventilation increases,.
- Tidal volume increases up to 40%
- Diaphragm is raised up to 40mm
- Chest diameter is increased by 2mm
- Co2 tension is decreased
- PaO2—92mm of Hg
- PaCo2 __ 30mm of Hg
VIII. GIT and Urinary system:

- Nausea and vomiting due to response by human chronic Gonadotrophin (H.C.G)
- Delayed gastric emptying and thus shows constipation
- Increased concentration of bile in gall bladder
- There is increased in the size and weight of kidney and dilation of the renal pelvis
- Dilation of uterus causes pooling and stagnation of urine resulting in U.T.I.
IX. Musculoskeletal system

- Increased joint laxity
- Increased lumbar lordosis due it change in COG and pelvic tilting
- The distance between the two rectus abdominal muscles widens and the linea alba may split under the strain
called as Diastasis Recti
- Edema of ankle due to water retention
- Compression of nerves causing carpel tunnel syndrome
X. Psychological and emotional changes: - Mood swings - Depression - Anxiety Complication in Pregnancy
I. Ectopic pregnancy - Here the fertilized ovum gets implanted out side the uterus - It is most commonly seen
in the fallopian tube a the ampulla or at the isthmus - As the pregnancy develops it results in pain, rupture of
the tube, bleeding, shock or maternal collapse
II. Eclampsia and pre eclampsia toxemia (P.E.T)
- It is defined by a threshold diastolic pressure of 90mm of Hg and proteinuria
- It is most common in prim gravid women and twin pregnancies
- The lady may shows:
- Increased cardinal signs
- Increase BP more than 140/90 mm of Hg
- Edema
- Proteinuria
- Eclampsia is life threatening characterized by:
- Epileptic fever - Cardiac arrest - Kidney damage - Maternal or fetus death
III. Ante-partum hemorrhage:
- It is defined as bleeding from the genital tract or placental site after 28 weeks of pregnancy but before the
baby is born

IV. Placenta Previa:
- When the placentas implanted partially or completely over the lower uterine segment, then it is called as
placenta previa
There are four stages:

Stage I: The major part of the placenta is in the upper uterine segment and vaginal delivery is possible Stage
II: A part of the placenta is in the lower uterine segment near the internal os, then vaginal delivery is possible
if the placenta is anterior
Stage III: The placenta is over the internal os but at one side. Hence vaginal delivery is not done.
Stage IV: The placenta is situated centrally over the internal os. Hence vaginal delivery is not allowed.
V. Intra-uterine growth retardation - It may results due to: - Impaired placental function - Toxemia -
Hypertension - Placental separation - Infractions - Premature reduction of placenta
VI. Intra-uterine death

- Placenta insufficiency and eclampsia may cause fetus death.
VII. Pulmonary embolism: Amniotic fluid embolism may cause the contents of amniotic fluid to enter the
uterine veins and reach the heart resulting in pulmonary embolism
- Thus the lady may show:
- ARDS, dyspnea
- Cyanosis
- Cardio-vascular shock
- Coma, sudden death
VIII. Diabetes Mellitus

- The baby born to diabetic mother may be large (macrosomic) weighing more than 3.5 kgs.
- The increased level of maternal sugar stimulates fetus insulin production causing
excessive fetus growth and fat deposition
- Diabetic mother have a high risk for fetus abnormalities, pre-edampsia, Intra uterine death.
IX. Post partum hemorrhage

- It is the bleeding from or into the genital tract following the birth of the baby.
- It may be:
Primary:
- Within 24 hrs following birth of baby
Secondary:
- Beyond 24 hrs and within 6 weeks following birth of the baby.
X. Multiple pregnancies: - There is increased strain on the mother following each pregnancy. - Due to
increasing growth of uterus after each delivery there is high risk of pre-mature labor
XI. Polyhydraminos and oligohydraminos:

- Presence of abnormally large amount of amniotic fluid resulting in uterus to become tense and distended is
called as polyhydraminos the amniotic fluid is reduced and milky.
XII. Other complications:

- Fibroid
- Uterine Inversion
- Hydaliform mole
- Chori carcinoma
- Abortion

- Anemia
- Hemolytic disease
- Hepatitis, jaundice
- Prolonged pregnancy, Prolonged labor
- Still birth
- Maternal obesity
- Stress incontinence
- Diastases Recti
- Back pain
EPISIOTOMY
Definition: It is a well-planned surgical incision involving the perineal muscle and posterior vagina wall to
widen the vaginal opening during labor. It is also called as perineotomy.
Indications:
- All prima gravida
- Before any instructional delivery
- To cut short the second stage of labor in case of cardiac disease or pregnancy induced hypertension
- Brach delivery
- Pubis delivery
- Fetal distress syndrome
- Large baby
- Preterm labor.
Purpose:
- To speed up the delivery
- To prevent overstretching of premium ad surrounding tissue
- To prevent damage to the fetal head
- To prevent complication
Types:
1. Mediolateral episiotomy: Here, the incision is made downwards and outwards from the midpoint of four
chetle either to the right or left directed diagonally in a straight line about 0-5 cm away from anus.
2. Lateral episiotomy:
- The incision starts 1 cm away from the centre of four chetle and extends laterally
3. Median episiotomy:
- The incision starts from the centre of four chetle and extends posteriorly along the midline for about 2.5 cm.
Aims:
- To relieve pain
- To promote healing
- To improve circulation
- To improve strength of pelvic floor muscles
- To prevent infection
Means of Treatment:
a. Pelvic floor exercises: - Contractions and relaxations . Passage of urine . Stop ad pass wind . To stop
diarrhea - Quick contraction
- Elevator exercises
- Pelvic tilting/rocking/rolling
- Perineometer/Kegel‘s exercises
- Vaginal cones
- Foley‘s catheter/tampon

Uses:
- Improves strength
- Reduces pain
- Decreases edema
- Improves venous and lymphatic return
- Removes transudates and traumatic exudates
b. Position: - Adequate positioning with proper pillow support

c. Ice Massage: - Crushed ice is packed in damp gauze or damp cloth and is placed over the site of incision
or at the site of edema for 5-10 min. - Ice massage can be done by the lady herself
d. Warm saline water: - To maintain perineal hygiene - Relieve pain and relaxation - To relieve burning
sensation
e. Ultrasound:
- It is done in crook lying position
- Pulsed mode is used
- Intensity is 0.5-1 W/cm2
- Frequency: 3 MHz for superficial structures
- Duration: 7-8 min
Uses:
- To relieve pain
- Remove traumatic exudates
- Promote healing
Care:
- The ultrasound head is washed with detergent and dipped in glutoraldehyde and dried after use
f. Pulsed electromagnetic energy:

- It is pulsed short wave diathermy
- ―No touch‖ mode is used
- 10-65 us pulse is used
g. Infrared radiations (IRR):
- In crook lying position
- Duration: 20 mins
- Distance: 50-70 cm
Uses:
- For pain relief
- Improves circulation
- Improves healing process
DIASTASIS RETII
Definition:
- It is defined as a split or separation of rectus abdominal muscles or a gap between two rectus abdominal
muscle in the line of linea alba is called as diastasis rectii.
- The width may range from 12 cm-20 cm longitudinally and 4.5 cm transversely.
Incidence:
- It is seen during pregnancy before the expulsion of the baby especially in the 2nd stage of labor
- It is absent in lady‘s with good abdominal tone prior to pregnancy
- It is see at the level, below or above the level of umbilicus
Risk factors:
- Multipara
- Women with narrow pelvis
- In case of large fetus
- Weak abdominal muscles
Significance:
1. Lady‘s with diastasis rectii have musculoskeletal problems like back pain due to insufficiency of abdominal
muscles to maintain posture and normal lumbar curvature
2. Anterior abdominal wall consists of skin, fascia, subcutaneous tissue, and peritoneum. Thus, has less
protection to fetus
3. The patient is unable to exert sufficient pressure in case of forceful expiratory events
4. In severe cases it may result in herniation by separation of the abdominal wall
Assessment:
1. Patient’s profile
2. History:
- Onset
- Duration
- Cause
- Mechanism
- Any previous associated problem
- Any medical/surgical treatment
3. Obstetrics and gynecology notes
4. Chief complaints:
- Inability to get up from lying to sitting
- Back pain
- Postural defect
- Herniation may be seen
5. On observation:
- Any bulge along the linea alba
- Position of limbs
- Posture of patient (in lying)
- Level: Below umbilicus . At the level of umbilicus . Above
- Edema or swelling
- Thinning of abdominal wall
6. On examination:
- Size and depth of separation
- Gap of separation
Diastasis rectii test: The patient lies in supine crook lying position - Place the fingers horizontally along the
longitudinal axis of linea alba - Ask the patient to raise the arm and shoulders till the spine of scapula is off
the floor - If the fingers sink in the depression between the two rectus abdominal, then it shows presence of
Diastasis rectii - The depth of which the fingers sink states the severity of diastasis rectii - The diastasis is
measured by the number of fingers that can be placed between the rectus muscles - In some women, gross
diastasis may be visible when they try to sit up or lie down. In such cases a wide range of bulging tissue
resembling a ―bowler’s hat‖ can be seen. This is seen mainly when the rectus muscle works against gravity
Corrective Exercises for Diastasis Rectii:
a. Head lift: - It is in supine crook lying position - Ask her to cross the hands over the midline of the diastasis
- Then ask her to exhale and lift the head off the floor and simultaneously to gently pull the rectus abdominal
muscles towards the midline - Then ask her to lower the head and relax - This exercises can be done 4-5 times
a day
b. Head lift with pelvic tilt: - The patient in hook lying position with hands crossed at the midline of the
diastasis - Ask her to exhale and raise the head slowly along with this ask her to simultaneously do a posterior
pelvic tilt.
- This helps to use only the rectus muscles and not the oblique muscles as well as minimizes intrabdominal
pressure

c. Leg sliding exercises: - Make her lie in the crook lying position with pelvis in posterior tilt - Ask her to
hold the pelvic tilt and slowly slide one leg along the floor to make it straight - Once she no longer can hold
the pelvic tilt ask her to slowly lift and bring back the leg to starting position - Repeat the same with other leg
- This can also be performed with both legs at the same time if the abdominal muscles can hold the pelvic tilt
d. Pelvic tilt exercise (cat and camel exercise): - Ask her to be in quadripod position and perform a posterior
pelvic tilt - Then ask her to draw in and tighten the abdomen. Note that the back should be kept straight - After
releasing the contraction ask her to perform an anterior pelvic tilt - This exercise can be modified by asking
her to flex her trunk in right or left side while tightening the abdomen - Proper re-assurance and gaining
patient‘s confidence and gaining patient‘s confidence is also essential
Abdominal muscles: - Rectus abdominis - Transverse abdominis - Internal oblique muscle - External oblique
muscle Functions: - Support abdominal contents - Helps in forceful expiratory techniques like coughing,
defection, micturation - Postural balance - To maintain intra-abdominal pressure - Support pelvic contents:
trunk flexion and rotation.
ANTE-NATAL EXERCISE:
It is the exercise program that the woman undergoes from the period of conception up to the birth of child.
Goals: - To promote and maintain physical and emotional health of the lady throughout pregnancy - To
identify and treat the medical and obstetric complications of pregnancy - To detect fetal abnormalities as early
as possible - To inform and prepare family of parents about pregnancy, labor, delivery and care of the baby -
Thus, the main aim should be healthy mother and healing infant
Physiotherapy Aims: - Antenatal education about physical and psychological changes during pregnancy -
Prepare the woman for delivery and prevent post-operative complications - Psychological support - Proper
fluid and nutrition intake - To teach leg, abdominal and pelvic floor exercises - Advise on back care and lifting
- Regular checkups and examination - To teach methods for controlling neuromuscular tension and prevent
circulatory complication - Adequate relaxation - To teach positions required for labor
Exercise Program:
A. Early bird classes: - To gain interest and motivation - Antenatal education - Mental preparation -
Prioritization towards pregnancy
B. Back are and posture:
i. Postural awareness in lying, starting, sitting. For e.g. standing erect, sitting erect with pillows
ii. Postural awareness during lifting, bending, and household activities - For e.g. while lifting objects floor
it is advisable to never stoop, feet should be apart to increased base of support and any object lifted must be
held close to the body. - Later during pregnancy patient is not advisable to climb on high stools or ladder due
to lack of balance.
iii. Postural muscles to be stretched - Neck extensors - Shoulder internal rotators - Scapular protractors -
Lumbar spine muscles - Hamstring - Calf muscles
vi. Postural muscles to be strengthened: Neck muscle - Scapular retractors - Spine extensors - Hip and knee
extensors - Dorsiflexors of ankle
C. Pelvic floor contractions and tilting exercises:
- Explanation: About the important of pelvic floor exercise for the preparation of pregnancy
- Instructions: Try stopping passing urine, Stopping/passing wind, hold and relax, vaginal cones exercises
- Contractions: 200 contractions/day
- Number of sessions: 3-4 sessions/day
- Pelvic tilting: By sitting at the edge of chair. In lying or prone kneeling. It helps in abdominal muscle
strengthening, maintains good posture and prevents backache Cat and camel exercise pelvic tilt in prone
kneeling
d. Exercise to improve circulation and prevent cramps:
- Explanation about the effect of circulation on pregnancy
- Women with sedentary jobs are advised to do more exercises
- Ankle dorsiflexion/plantar flexion (30 times)
- Foot circling (30-40 times/session)
- Avoid cross leg sitting
- To teach self-stretching in bed, with foot in dorsiflexion and not in plantar flexion to prevent calf cramps
- Warm water bath, pre-bed time walk, avoid sitting for long time, foot exercises in bed
before going to sleep also helps to relieve cramps during pregnancy

e. Relieve fatigue:
- Stress coping strategies
- Relaxation
- Reassurance
f. To relieve sacroiliac pain, pubic pain, lumbar pain by low grade mobilization, soft tissue kneading, pelvic
support
g. Advise on life style:
- Type of work and how long to continue
- Sports activities are encouraged
- Alteration in life style
h. Teaching neuromuscular control:
1. Mitchell’s Relaxation method:
- It is based on the physiological principle of reciprocal relaxation of muscles
- Here, one group of muscles contract while the other group relaxes
- The proprioceptors in the muscles and joints records the position of relaxation which is relayed and registered
in the cerebellum
- For e.g. For hunched shoulders: Pull your shoulders towards the feet-feel that the shoulders are away from
ear- thus your neck may feel longer
2. Jacobson’s (contrast) method:
- It involves alternatively contracting and relaxing various muscle groups throughout the body to develop a
recognition of difference between tension and relaxation
3. Touch and massage:
- Effleurage
- Stroking
- Kneading
4. Suggestions and visualization
i. Breathing Exercises:
- Takes care of postural hypotension, syncope and respiratory complications
- Positions for breathing
. High side lying . Long sitting . Arm lean sitting . Wall lean standing
j. Teaching positions for labor:
1. First stage (waiting for cervical dilation):
- Upright position with gravity assisting fetal descent
- Walking about
- Leaning forwards with support
2. Second stage (expulsive effort of giving birth):
- Explains assistive techniques for delivery (episiotomy, forceps delivery Cesarean section)
- Pain relief by TENS
- Modified squatting position or use of child birth chair
3. Third stage (expulsion of placenta, cord and membranes):
- Relaxation and breathing techniques
k. Swimming and water exercises:
- Aerobic exercises like sports, jogging, walking, swimming should be encouraged
- Encourage regular swimmers to continue swimming
Uses:
- Buoyancy of water supports the increasing weight of pregnant lady
- Tanning and muscle strengthening
- Improves physical fitness and endurance
- Yoga can also be done
l. General guidelines:
- Avoid jerky, buoyancy or ballistic movements

- Exercise at least 3-4 times a week
- Practice warm-up exercises and cool down exercises before and after an exercise program respectively
- Avoid strenuous activities in hot and humid weather
- Maternal heart rate should not exceed 140 beats/min
- Take adequate fluids, nutrition to prevent dehydration
- Exercises should be done within the physiological limits of pregnancy
POSTNATAL EXERCISE
Definition: It is the exercise program which the women undergo after pregnancy to maintain physical fitness
and prevent complications.
Physiotherapy Aims:
- Re-educate and strengthen pelvic floor muscles
- Care of perineum
- Relief pain in perineum
- To strengthen abdominal muscles
- To give advise on posture and back core
- Give instructions regarding the care of baby
- To prevent postoperative complications
I. Initial postnatal exercises:

1. Breathing exercises: - Deep breathing exercises - Diaphragmatic breathing - Lateral costal and posterior
basal expansion exercises - Helps in relaxation and circulation
2. Leg exercise’s: - Ankle foot exercises - Elevation and compression - Lower limb movements - Improves
circulation and prevents DUT
3. Pelvic floor exercises: - It can be given within 6 hrs of delivery
Uses:
- Regain strength of muscles
- Improve circulation
- Promote healing
- Relieve pain
- Remove inflammatory exudate
Techniques:
- Hold relax technique
- Sustained contractions
- Quick contractions
- To stop mid flow urine
- Interferential therapy
- Faradism
Contractions:
- 200 contractions/day
- Should be increased by 50 contractions/day
Note:
- Sutures can be supported by sanitary pad, towel till perineal pain subsides
- The pelvic floor muscles should be contracted every time the mother coughs, laughs, sneezes.
- It can be done in sitting, lying or standing with feet apart.
4. Pelvic tilting exercises:
- It can be done in side lying, crook lying or sitting at the edge of chair.
- Pelvic tilting in prone kneeling by cat and camel exercises
- Quick tilting relieves back pain
- Rhythmic gluteal contractions helps to relieve pain from hemorrhoids or bruising.
5. Abdominal muscle exercises:
Uses:
- After delivery the muscles becomes slack and intrabdominal pressure is reduced

- Prevent diastasis rectii
- Increased ligament laxity
- Decreases chances of spinal muscle strain after delivery
- For postural awareness
Exercises:
- Crook lying with pelvic tilting
- Crook lying with back flattening
- Crook lying with back flat and sliding the legs forwards and backwards
- Crook lying with tightening the abdominal muscles and lifting the head
- Half crook lying with hip hitching
- Sitting with trunk bending from side to side
- Sitting with trunk rotation side to side
- Crook lying with knees rolling from side to side
- Contraction of hip extensors and maintaining forward/backward pelvic tilt
- Prone lying with alternate leg raising and lowering
- Prone lying and tightening of buttocks
6. Care of perineum:
- Proper hygiene must be maintained to prevent infection
- Frequent bathing
- Changing of sanitary pods
- The area should be kept dry
- During bowel movements it should be supported by a clean folded sanitary towel
7. Relief of perineal pain:

- Sitting on a cushion or pillows relieves pain
- Side sitting or side lying for breast feeding
- Prone lying with pillows under knee and abdomen
- Ice massage, ice packs for 4-5 mins
- Pulsed electromagnetic energy
- Ultrasound
8. Episiotomy management Physiotherapy Management: Aims:

- To relieve pain
- To promote healing
- To improve circulation
- To improve strength of pelvic floor muscles
- To prevent infection
Means of Treatment: a. Pelvic floor exercises: - Contractions and relaxations . Passage of urine . Stop ad
pass wind . To stop diarrhea
- Quick contraction
- Elevator exercises
- Pelvic tilting/rocking/rolling
- Perineometer/Kegel‘s exercises
- Vaginal cones
- Foley‘s catheter/tampon
Uses:
- Improves strength
- Reduces pain

- Decreases edema
- Improves venous and lymphatic return
- Removes transudates and traumatic exudates
b. Position: - Adequate positioning with proper pillow support

c. Ice Massage: - Crushed ice is packed in damp gauze or damp cloth and is placed over the site of incision
or at the site of edema for 5-10 min. - Ice massage can be done by the lady herself
d. Warm saline water: - To maintain perineal hygiene - Relieve pain and relaxation - To relieve burning
sensation
h. Ultrasound:
- It is done in crook lying position
- Pulsed mode is used
- Intensity is 0.5-1 W/cm2
- Frequency: 3 MHz for superficial structures
- Duration: 7-8 min
Uses:
- To relieve pain
- Remove traumatic exudates
- Promote healing
Care:
- The ultrasound head is washed with detergent and dipped in glutoraldehyde and dried after use
i. Pulsed electromagnetic energy:

- It is pulsed short wave diathermy
- ―No touch‖ mode is used
- 10-65 us pulse is used
j. Infrared radiations (IRR):

- In crook lying position
- Duration: 20 mins
- Distance: 50-70 cm
Uses:
- For pain relief
- Improves circulation
- Improves healing process
II. Late postnatal exercises:

a. Ergonomic and postural awareness: - Adequate positioning in sitting, lying, standing, kneeling is taught
- Baby bathing - Nappy changing - Breast feeing - Appropriate use of carrying slings to avoid back problems
- Pram handles at correct height to carry the baby
b. Postnatal home exercises: - Daily walking with her baby by sling or pram - Pelvic floor muscles exercises
can be done at home - After diastasis rectii has healed abdominal exercises can be done . Side flexion . Rotation
. Curt downs
- Adequate rest and relaxation in bed or an easy chair
c. Return to sports and exercises: - Aerobic exercises - Jogging, cycling - Distance walking – Swimming
CESAREAN SECTION
Definition: It is a surgical procedure in which the delivery is conducted by making an abdominal incision
Incision: Pfannenstiel incision or bikini line incision
Indications:
- Contracted pelvis
- Diabetes mellitus
- Eclampsia
- Serious illness injury
- Previous cesarean section commonly called elective cesarean section
- Placenta previa
- Breach delivery
- Fetal /maternal stress
- Delayed labor
- Prolapse uterus
- Intrauterine death
Types:
1. Classical section:
- A longitudinal incision in the upper uterine segment - A paramedian incision is used
2. Lower segment section:
- A Pfannenstiel or bikini line incision and transverse incision into the lower uterine segment is used
- It has good cosmetic result
I. 1st Day:
- Huffing with pillow support
- Foot and leg exercises
- Bed mobility exercises
- Rolling side to side
- Feeding the baby in bed
II. 2nd Day:
- Pelvic floor exercises
- Abdominal exercises
- Pelvic tilting
- Deep breathing exercises
- Standing erect, postural awareness
- Buttocks tightening
- Wound healing, relieve pain
III. Late postnatal exercises:
- Stitches are removed on the 7the day
- Ergonomic training
- Posture and back care
- Care of the baby: lifting, Feeding, Bathing, Nappy changing
- Home exercise program
- Sports and yoga
IV. Immediate post-operative complications:
- Chest operative complications:
- DVT
- Wound infections
- Incontinence (late complications)
- Voiding dysfunction
(Explain PT management of all)

CHAPTER 29: APPLIED YOGA IN CARDIO – RESPIRATORY CONDITIONS:
- The word yoga means "union" in Sanskrit, the language of ancient India where yoga originated. We
can think of the union occurring between mind, body and spirit.
- What is commonly referred to as "yoga" can be more accurately described by the Sanskrit word
asana, which refers to the practice of physical postures or poses.
- Asana is only one of the eight "limbs" or types of yoga, the majority of which are more concerned
with mental and spiritual well-being than physical activity. Today, however, the words asana and
yoga have become almost synonymous.
Benefits of Yoga
There are many benefits of practicing yoga, here are ten to name a few:
• You'll feel more relaxed and learn to stay relaxed.
• Your overall muscle tone improves as well as alignment.
• You'll add vitality to your spine, improving all systems of the body, especially the glands and nerves.
• Digestion improves; gas and bloating lessen.
• Your lungs expand, increasing oxygen intake.
• You'll sleep better.
• You'll be less tired during the day with higher energy.
• Your immune system will strengthen.
• You'll learn to set aside time for yourself.
• You'll learn to trust yourself more.
Cardio – respiratory System
• Yoga practice leads to decrease in heart rate and blood pressure
• Yoga improves cardio-respiratory efficiency
• Yoga improves exercise tolerance
• Yoga balances Autonomic nervous system
• Yoga modifies coronary artery disease risk factors
• Reversal of Heart disease
Sukhasana - Sit/Easy Position

Easy Position Benefits
• A starting position that helps focus awareness on breathing and the body.
• Helps strengthen lower back and open the groin and hips.
Instructions
• Sit cross-legged with hands on knees. Focus on your breath. Keep your spine
straight and push the sit bones down into the floor. Allow the knees to gently lower.
• Take 5-10 slow, deep breaths.
• On the next inhale, raise your arms over your head.
• Exhale and bring your arms down slowly.
• Repeat 5-7 times.
Tadasana - Mountain
Mountain Benefits
• Improves posture, balance and self-awareness.
Instructions
• Breathe. Hold the posture, but try not to tense up. Breathe
• As you inhale, imagine the breath coming up through the floor, rising
through your legs and torso and up into your head
• Reverse the process on the exhale and watch your breath as it passes
down from your head, through your chest and stomach, legs and feet
• Hold for 5 to 10 breaths, relax and repeat

Uttanasana II: Forward Bend or Extension
Forward Bend Benefits
• Stretches the legs and spine
• Rests the heart and neck
• Relaxes mind and body
Instructions
• Begin standing straight in Mountain pose or Tadasana
• Either grasp your ankles or just leave your hands on the floor and breathe several times.
• Repeat 3-5 times. On your last bend, hold the position for 5 or 10 breaths
• Curl upward as if pulling yourself up one vertebra at a time, stacking one on top of another, and
leaving the head hanging down until last.
Trikonasana - the Triangle

Triangle Benefits
• Stretches the spine
• Opens the torso
• Improves balance and concentration
Instructions
• Inhale and raise both arms so they're parallel with the floor.
• Exhale, turn your head to the left and look down your left arm toward your outstretched fingers
Bhujangasana - The Cobra

Cobra Benefits
• Stretches the spine
• Strengthens the back and arms
• Opens the chest and heart
Instructions
• Inhaling, slowly raise your head and chest as high as it will go
• Only go as far as you are comfortable. Your pelvis should always remain on the floor. Breathe
several times and come down
Virabhadrasana II - Warrior II
Warrior II Benefits
• Strengthens legs and arms
• Improves balance and concentration
• Builds confidence
Instructions
• Begin in mountain pose with feet together and hands at side
• Raise your arms over head. Then slowly lower them until your left arm is pointing straight ahead and
your right arm is pointing back
• Concentrate on a spot in front of you and breathe
• Take 4 or 5 deep breaths, lower your arms, bring your legs together. Reverse the position
Ardha Sarvangasana – Half Shoulder stand

Half Shoulder Stand Benefits
• Promotes proper thyroid function
• Strengthens abdomen
• Stretches upper back
• Improves blood circulation
• Induces relaxation

Instructions
• Lie on your back and lift your legs up into air. Place your hands on your lower back for support,
resting your elbows and lower arms on the ground
• Breathe deeply and hold for at the posture for at least 5-10 breaths, increasing the hold over time.
• To come down, slowly lower your legs, keeping them very straight
Sethu Bandhasa - The Bridge

Bridge Benefits
• Increases flexibility and suppleness
• Strengthens the lower back and abdominal muscles
• Opens the chest
Instructions
• To begin, gently raise and lower your tail. Then, slowly, raise the tailbone and continue lifting the
spine, trying to move one vertebra at a time until your entire back is arched upward
• Take five slow, deep breaths.
• Come down slowly and repeat.
Savasana - The Corpse

Corpse Benefits
• Relaxes and refreshes the body and mind, relieves stress and
anxiety, quiets the mind
• Possibly the most important posture, the Corpse, also known as the Sponge, is as deceptively simple
as Tadasana, the Mountain pose.
Instructions
• Start with your feet, imagine the muscles and skin relaxing, letting go and slowly melting into the
floor
• Then simply breathe and relax
• Stay in the pose for at least 5-10 minutes.

CHAPTER 25:
HOME PROGRAM AND EDUCATION OF FAMILY MEMBERS IN PATIENT CARE
Education: (Explain each point in your own words).

Patient and family members are included:
1. Anatomy and Physiology (Breathing in and breathing out)
2. Pathology of disease
3. Self-management
4. Management of Breathlessness
5. Inhalers and medications (re - education)
6. Nutrition (6 – 8 small meals; eat – well plate).
7. Anxiety and Depression
8. Exercise and pacing
9. Airway clearance techniques – ACBT, AD
10. Smoking cessation.
Exercise:
Give exercise that are suitable for the appropriate condition of the patient.
- Include incentive spirometer
- Breathing techniques: Diaphragmatic and Deep breathing exercises
- Slight percussion and vibration
- Positioning of the patient in different positions.
- Relaxation positions
- Management of Breathlessness by appropriate positions.
Tips given to caregivers and family members:

• Help maintain the quality of life for the patient.
• Educate them about symptoms, treatments and progression of the disease.
• Keep track of medication schedule and exercise
• Offer love and support necessary to meet challenges
• Let the patient participate in daily activities on their own
• Set attainable goals for patient
• Improve communication with the patient
• Minimize patient illness and disability
• Take proper care of the diet of patient: Provide 6 – 8 small meals throughout the day instead of 3
heavy, large meals.
• Maximize patient’s potential and promote patient health.
• Nutritional status of the patient should be taken care of.
The elements of patient education interventions include the following:
1. Approach to educate:
Education is a central component of programme because, firstly, distress hampers recovery process
and secondly, morbidity and mortality caused by angina are not necessarily proportional to the number of
vessels involved:
The approves involves the general strategy for communication, information to patients. Approaches
may be standardized or individualized. This may target specific population (Eg. Older persons, those with
low education).
2. Mode of delivery:
This mode of delivery encompasses the medium or format for information delivery. Medium is the
process through which education is delivered and may include face to face or telephone contact, written
resources or audiovisual materials.
3. Dose:
Dose is the level at which an intervention is delivered and may be described as the number and
length of education sessions.

CHAPTER 16
RESPIRATORY FAILURE – OXYGEN THERAPY AND MECHANICAL VENTILATION
• It is a ventilation of the lungs by artificial means usually by a ventilator.

• A ventilator delivers gas to the lungs with either negative or positive pressure.
Ventilation: It is a machine used for breathing when the patient is not able to breathe spontaneously.
Purposes:
1. To maintain or improve ventilation and tissue oxygenation
2. To decrease the work of breathing and improve patient’s comfort.
INDICATIONS:
1. Acute respiratory failure due to
- Mechanical failure – includes neuromuscular diseases or Myasthenia gravis, Guillain Barre syndrome and
poliomyelitis (failure of normal respiratory, neuromuscular system).
- Musculoskeletal abnormalities such as chest wall trauma (flail chest).
- Infective disease of the lungs such as pneumonia, tuberculosis
- COPD
2. Abnormalities of pulmonary gas exchange as in
- Obstructive lung disease in the form of asthma, chronic bronchitis or emphysema
- Conditions such as pulmonary edema, atelectasis, Pulmonary fibrosis.
- Patient who has received general anesthesia as well as post cardiac arrest. Patients often requires
ventilatory support until they have recovered from the effects of the anesthesia or the insult of an arrest.
3. Trauma – Road traffic accidents (cervical, spinal cord, head injuries), Motor neuron disease, poisoning,
drowning, kyphosis, scoliosis and Kyphoscoliosis.
4. Chest deformities
5. Muscular dystrophy
Duration: Depends on the conditions
Clinical Indices of the Need for MV

Inadequate Ventilation
• RR > 30 breaths/min (Normal 10-20)
• VT < 5 ml/kg (Normal 5-7)
• VC < 15 ml/kg (Normal 65-75)
• PaCO2 > 60 mm Hg
• RR/VT > 100
• VD/VT ratio > 0.6 (Normal < 0.3)
• Paradoxical breathing.
Inadequate Gas Exchange

• PaO2 < 60 mm Hg on FiO2 > = 0.6.
Although all these indices are mentioned but most of the time the decision to ventilate is
clinical, based on the trends and the condition of the patient at that time.
Rapid Shallow Breathing Rate:
RSBR = RR/TV
Indication if increase 105 breaths m/l
Dead Space Ventilation: Normal: < 0.3
TV, Indication: >0.6
*Inadequate gas exchange
*fiO2 →Fraction of inspiration oxygen
Maximum = 6 litres – 44% (Because not more, causes irritation).

Physiological Effects of Ventilator:
• Decreased preload
— Positive alveolar pressure increases lung volume→ compression of the heart by the inflated
lungs→ the intramural pressure of the heart cavities rises (e.g., Increase RAP) --> venous return decreases
preload is reduced --> stroke volume decreases --> cardiac output and blood pressure may drop. This can
be minimized with i.v. fluid, which helps restore adequate venous return and preload.
— Patients who are very sensitive to change in preload conditions (e.g. presence of hypovolemia,
tamponade, PE, severe air trapping) are particularly prone to hypotension when PPV is initiated.
La – place Law
Forceful pushing of air inside.
Air pushed inside – Alveolar pressure increases – lung inflated – compress Heart → Intramural Pressure
(Increased – inside cavities) → Venous return decrease → Stroke Volume decreases → output decreases
→Hypotension (Hydration is given to manage the patient).
• Reduced afterload
– Lung expansion increases extramural pressure (which helps pump blood out of the thorax) and thereby
reduces LV afterload.
– When the cardiac performance is mainly determined by changes in afterload than in preload conditions
(e.g., hypervolemic patient with systolic heart failure), IPPV may be associated with an improved stroke
volume. IPPV is very helpful in patients with cardiogenic pulmonary edema, as it helps to reduce preload
(lung congestion) and afterload.
- It will decrease because of external pressure increases.
Weaving: It’s a process where mechanical ventilation removed when patient can breathe by his own.
Parameter checked.
A) Pulmonary Function indices:
Parameter Ventilation indicated Normal range
Respiratory rate (Breathe/min) >35 10 – 20
Tidal Volume ml/kg body weight <5 5–7
Vital capacity by ml/kg body weight <15 65 – 75
Maximum Inspiratory force (cm/HO2) <20 75 – 100
B) Arterial Blood gas
pH <7.25 7.35 – 7.45
PaO2 (mmHg) < 60 75 – 100
PaCO2 (mmHg) >50 35 -45
- RSBI – 105 (Rapid Shallow Breathing Index)
- Spontaneous Breathing Trail (SBT)
- Resolving of the patient complain during treatment
- Breathing control should be controlled
- Cough reflex should be good (Suctioning in coma patients).
TYPES OF MECHANICAL VENTILATION:
1. Negative Ventilator
2. Positive Ventilator
a) Volume ventilator b) Pressure ventilator c) High frequency ventilator
1. Volume Ventilator: Used in CIU, CCU,
Some amount of oxygen delivered to each breath. Peak inspiratory pressure.
2. Pressure Ventilator:
- The use of pressure ventilator is increasing in critical care unit.
- A typical pressure mode delivery a selected gas pressure to the patient early in inspiration and sustains the
pressure throughout the inspiratory phase.
- By meeting the patient’s inspiratory flow demand throughout inspiration patient effort is reduced and
comfort increased.

Positive Pressure ventilators Classification
Ventilation are classified according to how the inspiratory phase ends. The factor which terminates
the inspiratory cycle reflects the machine type.
They are classified as:
a) Pressure cycled ventilator: in which inspiration is terminated when a specific airway pressure has been
reached. The ventilator delivers a preset pressure; once this pressure us achieved, end inspiration occurs.
b) Volume cycled ventilator: Inspiration is terminated after a preset tidal volume has been delivered by the
ventilator. The ventilator delivers a present tidal volume (TV) and inspiration stops when the present tidal
volume is achieved.
c) Time cycled ventilator: In which inspiration is terminated when a preset inspiratory time has elapsed.
Time cycled machines are not used in adult critical care settings. They are used in pediatric intensive care
areas.
MODES OD MECHANICAL VENTIALTION:
a) Volume mode b) Pressure mode
Volume Modes:
1. Continuous/controlled Mandatory ventilation (CMV)
2. Assisted Controlled Mandatory Ventilation (ACMV)
- The ventilator provides the patient with a preset tidal volume at a pre – set rate.
- The patient may initiate a breath on his own, but the ventilator assists by delivering a specified tidal
volume to the patient. Clint can initiate breaths that are delivered at the preset tidal volume.
- Clint can breathe at higher rate than the preset number of breaths/minutes.
- The total respiratory rate is determined by the number of spontaneous inspirations initiated by patient plus
the number of breaths put on the ventilator.
- In assisted control mode, a modatory (or control) rate is selected.
- in the patient wishes to breathe faster he or she can trigger the ventilator and receive a full volume breath.
- Often used as initial mode of ventilation.
- When a patient in too weak to perform the work of breathing (E.g.: When emerging from anaesthesia).
Disadvantages: Hyperventilation, air can be trapped.
3. Intermittent Mandatory ventilation (IMV)
4. Synchronized Intermittent Mandatory Ventilation (SIMV)
- The ventilator provides the patient with a pre – set number of breaths/minutes at a specified tidal volume
and FiO2.
- In between the patient is able to breaths, the patient is able to breathe spontaneously at his own tidal
volume and rate with no assistance from the ventilator.
- The tidal volume of these breaths can vary drastically from the tidal volume set on the ventilator, because
the tidal volume is determined by the patient’s spontaneous effort.
- Adding pressure support during spontaneous breaths can minimize the risk of increased work of breathing.
- Ventilator breaths are synchronized with the patient spontaneous breaths (no fighting).
- Used to wean the patient from the mechanical ventilator.
- Weaning is accomplished by gradually lowering the set rate and allowing the patient to assume more work.
Pressure Modes:
1. Pressure Control Ventilation: in cases of ARDS, PEEP is more. It can be used with SIMV with
synchronizing. Both invasive and non – invasive method (it can be given)/
Disadvantage: It can be Hypoventilation, sometime air hangs.
2. Pressure Support Ventilation:
* CPAP (Continuous Positive Airway Pressure)
- Before weaning the patient, Spontaneous breathing trail, patient is monitored.
* FiO2 * PEEP * TV
* Triggering sensitivity (negative pressure triggers breathing). (CO2 strives for our breathing).
→ Respiratory centres stimulates in the brain
• - 2cm of water (Negative pressure required for breathing).

TIDAL VOLUME:
• The volume of air delivered to a patient during a ventilator breath.
• The amount of air inspired and expired with each breath.
• Usual volume selected is between 5 to 15 ml/ kg body weight)
• In the volume ventilator, Tidal volumes of 10 to 15 mL/kg of body weight were traditionally used.
• the large tidal volumes may lead to (volutrauma) aggravate the damage inflicted on the lungs
• For this reason, lower tidal volume targets (6 to 8 mL/kg) are now recommended.
PEAK FLOW/FLOW RATE:
• The speed of delivering air per unit of time, and is expressed in liters per minute.
• The higher the flow rate, the faster peak airway pressure is reached and the shorter the inspiration;
• The lower the flow rate, the longer the inspiration.
RESPIRATORY RATE/BREATH RATE/ FREQUENCY (F)
• The number of breaths the ventilator will deliver/minute (10-16 b/m).
• Total respiratory rate equals patient rate plus ventilator rate.
• The nurse double-checks the functioning of the ventilator by observing the patient’s respiratory rate.
For adult patients and older children: With COPD
- A reduced tidal volume - A reduced respiratory rate
For infants and younger children: -
- A small tidal volume - Higher respiratory rate
MINUTE VOLUME (VE)
• The volume of expired air in one minute.
• Respiratory rate times tidal volume equals minute ventilation. VE = (VT x F)
• In special cases, hypoventilation or hyperventilation is desired
In a patient with head injury,
• Respiratory alkalosis may be required to promote cerebral vasoconstriction, with a resultant decrease
in ICP.
• In this case, the tidal volume and respiratory rate are increased (hyperventilation) to achieve the
desired alkalotic pH by manipulating the PaCO2.
In a patient with COPD
• Baseline ABGs reflect an elevated PaCO2 should not hyperventilated. Instead, the goal should be
restoration of the baseline PaCO2.
• These patients usually have a large carbonic acid load, and lowering their carbon dioxide levels
rapidly may result in seizures.
I:E RATIO (INSPIRATION TO EXPIRATION RATIO)
• The ratio of inspiratory time to expiratory time during a breath (Usually = 1:2)
SIGH:
• A deep breath.
• A breath that has a greater volume than the tidal volume.
• It provides hyperinflation and prevents atelectasis.
• Sigh volume: Usual volume is 1.5 –2 times tidal volume.
• Sigh rate/ frequency: Usual rate is 4 to 8 times an hour.
PEAK AIRWAY PRESSURE
• In adults if the peak airway pressure is persistently above 45 cmH2O, the risk of barotrauma is
increased and efforts should be made to try to reduce the peak airway pressure.
• In infants and children, it is unclear what level of peak pressure may cause damage. In general,
keeping peak pressures below 30 is desirable.
PRESSURE LIMIT
• On volume-cycled ventilators, the pressure limit dial limits the highest pressure allowed in the
ventilator circuit.
• Once the high-pressure limit is reached, inspiration is terminated.
• Therefore, if the pressure limit is being constantly reached, the designated tidal volume is not being
delivered to the patient.

CHAPTER 18: BURNS MANAGEMENT
A burn is an injury caused by thermal, chemical, electrical, or radiation energy. A scald is a burn
caused by contact with a hot liquid or steam but the term 'burn' is often used to include scalds.
Most burns heal without any problems but complete healing in terms of cosmetic outcome is often
dependent on appropriate care, especially within the first few days after the burn. Most simple burns can be
managed in primary care but complex burns and all major burns warrant a specialist and skilled
multidisciplinary approach for a successful clinical outcome.
Risk factors
• Highest rates are seen in children under the age of 5 and the elderly over the age of 75.
• About 50% of burns and scalds occur in the kitchen.
Assessment
• Assess airway, breathing, circulation, disability, exposure (prevent hypothermia) and the need for
fluid resuscitation. Also, assess severity of burns and conscious level.
• Establish the cause: consider non-accidental injury.
• Assess for associated injuries: associated injuries may be sustained while the victim attempts to
escape the fire. Explosions may throw the patient some distance and result in internal injuries or
fractures.
• It is essential that the time of the burn injury be established.
• Burns sustained within an enclosed space suggest possible inhalation injury.
• Pre-existing illnesses, drug therapy, allergies and drug sensitivities are also important.
• Establish the patient's tetanus immunisation status.
• Body surface area - Rule of Nines
o The adult body is divided into anatomical regions that represent 9%, or multiples of 9%, of
the total body surface. Therefore 9% each for the head and each upper limb; 18% each for
each lower limb, front of trunk and back of trunk.
o The palmar surface of the patient's hand, including the fingers, represents approximately 1%
of the patient's body surface.
o Body surface area differs considerably for children - the Lund and Browder chart takes into
account changes in body surface area with age and growth.
o If not available:
▪ For children <1 year: head = 18%, leg = 14%.
▪ For children >1 year: add 0.5% to leg, subtract 1% from head, for each additional year
until adult values are attained.
• Depth of burn (previously described as first-degree, second-degree and third-degree burns). Burn
wounds are dynamic and need reassessment in the first 24-72 hours because depth can increase as a
result of inadequate treatment or superadded infection. Burns can be superficial in some areas but
deeper in other areas:
o Epidermal (superficial partial-thickness): red, glistening, pain, absence of blisters and brisk
capillary refill. Not life-threatening and normally heal within a week, without scarring.
o Superficial dermal: pale pink or mottled appearance with associated swelling and small
blisters. The surface may have a weeping, wet appearance and is extremely hypersensitive.
Brisk capillary refill. Heal in 2-3 weeks with minimal scarring and full functional recovery.
o Deep dermal: blistering, dry, blotchy cherry red, doesn't blanch, no capillary refill and
reduced or absent sensation. 3-8 weeks to heal with scarring; may require surgical treatment
for best functional recovery.
o Full-thickness (third-degree): dry, white or black, no blisters, absent capillary refill and
absent sensation. Requires surgical repair and grafting.
o Fourth-degree: includes subcutaneous fat, muscle, and perhaps bone. Requires reconstruction
and, often, amputation.
• Circumferential extremity burns: assess status of distal circulation, checking for cyanosis, impaired
capillary refilling or progressive neurological signs. Assessment of peripheral pulses in burn patients
is best performed with a Doppler ultrasound.
• Baseline determination for the major burn patient:
o Blood: FBC, type and crossmatch, carboxyhaemoglobin, serum glucose, electrolytes, and
pregnancy test in all females of childbearing age. Arterial blood gases.
o CXR. Other X-rays may be indicated for associated injuries.
o Cardiac monitoring: dysrhythmias may be the first sign of hypoxia and electrolyte or acid-
base abnormalities.
o Circulation: severely burned patients may have hypovolaemic shock:
▪ Blood pressure may be difficult to obtain and may be unreliable.
▪ Monitoring hourly urinary outputs reliably assesses circulating blood volume and so
an indwelling urinary catheter should be inserted.
Management of minor burns

• Clean burns with soap and water, or a dilute water-based disinfectant to remove loose skin.
• All blisters should be left intact to minimise the risk of infection.
• Larger blisters or those in an awkward position (in danger of bursting) should be aspirated under
aseptic technique.
• Non-adhesive dressing, with gauze padding is usually effective, but biological dressings are better,
especially for children.
• Dressings should be examined at 48 hours to reassess the burn, including depth.
• Dressings on superficial partial-thickness burns can be changed after 3-5 days in the absence of
infection.
• If infection occurs, daily wound inspection and dressing change is required. The patient should be
prescribed seven days of flucloxacillin first-line or erythromycin. Clarithromycin should be used if
the patient is intolerant of erythromycin.
• Ensure adequate analgesia and assess the need for tetanus prophylaxis.
Management of major burns

The initial treatment of burns needs to include the following possible injuries:
• Direct thermal injury producing upper airway oedema and/or obstruction.
• Inhalation of products of combustion (carbon particles) and toxic fumes, leading to chemical
tracheobronchitis, oedema, and pneumonia.
• Carbon monoxide (CO) poisoning.
Immediate management
• Airway:
o The airway above the glottis is very susceptible to obstruction because of exposure to heat.
The clinical presentation of inhalation injury may be subtle and often does not appear in the
first 24 hours.
o Clinical indications of inhalation injury include:
▪ Face and/or neck burns.
▪ Singeing of the eyebrows and around the nose.
▪ Carbon deposits and acute inflammatory changes in the oropharynx.
▪ Carbon particles seen in sputum.
▪ Hoarseness.
▪ History of impaired awareness, eg alcohol or head injury, and/or confinement in a
burning environment.
▪ Explosion, with burns to head and torso.
▪ Carboxyhaemoglobin level greater than 10% if the patient is involved in a fire.
o Management of acute inhalation injury:
▪ Early management may require endotracheal intubation and mechanical ventilation.
▪ Transfer to a burn centre.
▪ Stridor is an indication for immediate endotracheal intubation.
▪ Circumferential burns of the neck may lead to swelling of the tissues around the
airway and so require early intubation.
• Stop the burning process:
o Remove all clothing - adherent synthetic clothing and tar should be actively cooled with
water, and left for formal debridement.
o Dry chemical powders should be carefully brushed from the wound.

o Rinse the involved body surface areas with copious amounts of tap water. Cool the burn with
tepid water for up to 20 minutes. Great care is required, as cooling may cause hypothermia,
especially in children, and in those with extensive burns - and may worsen shock.
o Remove constricting clothing and jewellery before covering the patient with warm, clean and
dry linens, to prevent hypothermia.
• Breathing:
o Arterial blood gas determinations should be obtained as a baseline but arterial PO2 does not
reliably predict CO poisoning. Therefore, baseline carboxyhaemoglobin levels should be
obtained, and 100% oxygen should be administered.
o Elevation of the head and chest by 20-30° reduces neck and chest wall oedema. If a full-
thickness burn of the chest wall leads to severe restriction of the chest wall motion, chest wall
escharotomy (burn incised into subcutaneous fat and underlying soft tissue; no anaesthetic is
required) may be required.
o CO poisoning: has a much greater affinity than oxygen for haemoglobin and so displaces
oxygen.
▪ Assume CO exposure in patients burned in enclosed areas.
▪ Diagnosis of CO poisoning is made primarily from a history of exposure.
▪ Patients with CO levels of less than 20% usually have no physical symptoms.
▪ Higher CO levels may result in headache and nausea, confusion, coma and death.
▪ CO dissociates very slowly but this is increased by breathing high-flow oxygen via a
non-rebreathing mask.
• Intravenous access and fluid replacement:
o Large-calibre intravenous lines must be established immediately in a peripheral vein.
o Any adult with burns affecting more than 15% of the body surface area or a child with more
than 10% of body surface area affected requires fluid resuscitation.
o Resuscitation fluids required in the first 24 hours from the time of injury:
▪ Adults:
▪ 3-4 ml (3 ml in superficial or partial-thickness burns, 4 ml in full-thickness
burns or those with associated inhalation injury) of Hartmann's solution/kg
body weight/% total body surface area.
▪ Half of this calculated volume is given in the first eight hours and the other
half is given over the following 16 hours.
▪ Children:
▪ Resuscitation fluid as above plus maintenance (0.45% saline with 5%
dextrose) which should be titrated against nasogastric feeds or oral intake:
▪ 100 ml/kg for first 10 kg body weight plus 50 ml/kg for the next 10 kg body
weight plus 20 ml/kg for each extra kg.
• Ensure adequate analgesia: strong opiates should be used.
• Prevent hypothermia.
Management of the burns:
o Prompt irrigation with running cool tap water for 20 minutes provides appropriate cooling.
Very cold water should be avoided (causes vasoconstriction and worsens tissue ischaemia
and local oedema). Chemical burns may need longer periods of irrigation.
o Dressings help to relieve pain and keep the area clean but avoid circumferential wrapping, as
this can cause constriction.
o All patients with facial burns or burns in an enclosed environment should be assessed by an
anaesthetist for early intubation.
o For full-thickness circumferential burns, escharotomy may be required to avoid respiratory
distress or reduced circulation to the limbs as a result of constriction.
• Transfer to a burns centre or other appropriate care centre as indicated.
Referral to a specialist burns unit

All complex injuries should be referred - particularly:
• Age under 5 years or over 60 years.

• Site of injury: face, hands, perineum, any flexure (including neck or axilla) and circumferential
dermal burns or a full-thickness burn of the limb, torso, or neck.
• Inhalation injury.
• Mechanism of injury:
o Chemical burns affecting over 5% total body surface area (over 1% for hydrofluoric acid
burns) & Exposure to ionising radiation.
o High-pressure steam injury.
o High-tension electrical injury.
• Suspected non-accidental injury in a child.
• Large affected area:
o Age under 16 years: over 5% total body surface area affected.
o Age 16 years or older: over 10% total body surface area affected.
• Co-existing conditions, eg serious medical conditions, pregnancy or associated fractures, head injury,
or crush injuries.
Further management
• Circulatory insufficiency caused by a circumferentially burned limb is best relieved by escharotomy.
Escharotomies are usually not required within the first six hours of burn injury.
• Fasciotomy: seldom required, but may be necessary to restore circulation for patients with associated
skeletal trauma, crush injury, high-voltage electrical injury or burns involving tissue beneath the
investing fascia.
• Gastric tube insertion: if there is nausea, vomiting, abdominal distention, or if burns involve more
than 20% of the total body surface area.
• Analgesia and sedation:
o Severely burned patients may be restless and anxious from hypoxaemia or hypovolaemia
rather than pain. The patient then responds better to oxygen or increased fluid administration
rather than to narcotic analgesics or sedatives that may mask the signs of hypoxaemia or
hypovolaemia.
o Intravenous narcotic analgesics and sedatives may be administered in small, frequent doses.
• Wound care:
o Partial-thickness (second-degree) burns are painful when air currents pass over the burned
surface. Gently covering the burn with clean linen relieves the pain and deflects air currents.
o Do not break blisters or apply an antiseptic agent.
o Any applied medication must be removed before appropriate antibacterial topical agents can
be applied.
o Application of cold compresses may cause hypothermia. Do not apply cold water to a patient
with extensive burns.
• Antibiotics: should be reserved for the treatment of infection.
• Tetanus: determination of immunisation status is very important.
• Full-thickness burns: require excision and grafting unless they are less than 1 cm in diameter.
Grafting is required within three weeks in order to minimise scarring. Therefore, early referral is
essential.
• After healing:
o The area of healed burns should be moisturised and massaged to reduce dryness.
o A high-factor sun cream should be used to prevent further damage and pigmentation changes.
Chemical burns
• Can result from exposure to acidic, alkaline or petroleum products.
• Alkali burns tend to be deeper and more serious than acid burns.
• Immediately flush away the chemical with large amounts of water for at least 20 to 30 minutes
(longer for alkali burns). Alkali burns to the eye require continuous irrigation during the first eight
hours after the burn.
• If dry powder is still present on the skin, brush it away before irrigation with water.
Electrical burns
• Are often more serious than they appear on the surface.

• Rhabdomyolysis results in myoglobin release, which can cause acute renal failure. If the urine is
dark, start therapy for myoglobinuria immediately.
• Fluid administration should be increased to ensure a urinary output of at least 100 ml/hour in the
adult.
• Metabolic acidosis should be corrected by maintaining adequate perfusion and adding sodium
bicarbonate.
Complications
• Respiratory distress from smoke inhalation or a severe chest burn.
• Fluid loss, hypovolaemia and shock.
• Infection.
• Increased metabolic rate leading to acute weight loss.
• Increased plasma viscosity and thrombosis.
• Vascular insufficiency and distal ischaemia from a circumferential burn of limb or digit.
• Muscle damage from an electrical burn may be severe even with minimal skin injury;
rhabdomyolysis may cause renal failure.
• Poisoning from inhalation of noxious gases released by burning (eg cyanide poisoning due to
smouldering plastics).
• Haemoglobinuria and renal damage.
• Scarring and possible psychological consequences. Hypertrophic scarring is more common following
deeper burns treated by surgery and skin grafting than with superficial burns.
Prognosis
• Will depend on depth of burn and the body surface area affected.
• Superficial burns usually heal within two weeks without surgery.
• Risk factors for death include age over 60 years, more than 40% of body surface area affected and
inhalation injury.
• Death may result from severe extensive burns or electric shock.
Prevention
There are many important aspects of prevention of burns, including:
• Safety in the workplace.
• Safety in the home, including regularly checking smoke alarms.
• Good parenting to protect children.
• Care of the frail elderly and the socially isolated.
• Prevention of sunburn: appropriate duration and timing of sunbathing, sun protection creams, and
regulation of tanning booths.
Introduction to Burns:
- Partial thickness burn = involves epidermis.
- Deep partial thickness = involves dermis.
- Full thickness = involves all of skin.
Partial thickness burns:
◼ Sunburn is a very superficial burn.
◼ Expect blistering and peeling in a few days.
◼ Maintain hydration orally.
◼ Heals in 3-6 days- generally no scaring
◼ Topical creams provide relief.
◼ No need for antibiotics
Deeper partial thickness

◼ Blisters are typical of partial thickness burns.
◼ Don’t be in a hurry to break the blisters.
◼ Heals in 14-21 days
◼ Blisters provide biologic dressing and comfort.
◼ Once blisters break, red raw surface will be very painful.

Full thickness burns
◼ Yellow, “leathery” appearance; or charred
◼ Often have no sensation (nerve endings destroyed)
◼ Outer edges might be partial thickness.
◼ Initial management same as partial thickness.
◼ Later will need skin grafts.
Mixed Partial and Full thickness

◼ Central yellow area might be full thickness.
◼ Outer edges are probably partial thickness.
◼ Initial management is the same.
◼ Later will need skin grafts for the full thickness areas.
Zones of burn wounds:

- Zone of Coagulation
◆ devitalized, necrotic, white,
no circulation
- Zone of Stasis ‘circulation
sluggish’
◆ may covert to full thickness,
mottled red
- Zone of Hyperemia
◆ outer rim, good blood flow,
red
Estimate the size of the burn

◼ The patient’s own palm is about 1%
of his body surface area.
◼ “Rule of Nines”
Send these to a burn center

◼ Partial thickness burns >10% BSA
◼ Burns involving the face, hands,
feet, genitalia, perineum, or major
joints
◼ full thickness/3 degree burn
◼ Electrical, Chemical, and Inhalation
burns.
◼ In combat, all but the most superficial burn should be evacuated
Burn Care Products:
◼ < 20% TBSA 2nd degree – Silvadene (SVC) Cream BID
◼ Any > 20% TBSA-SVC and Sulfamylon (SMC) alt BID
◼ 3rd degree burn – SVC and SMC alt BID.
Care of small burns:
◼ Clean entire limb with soap and water (also under nails).
◼ Apply antibiotic cream
◼ Dress limb in position of function and elevate it.
◼ No hurry to remove blisters unless infection occurs.
◼ Give pain meds as needed (IM, or IV)
◼ Rinse daily in clean water; in shower is very practical.
◼ Gently wipe off with clean gauze.
Blisters:
◼ In the pre-hospital setting, there is no hurry to remove blisters.
◼ Leaving the blister intact initially is less painful and requires fewer dressing changes.

◼ The blister will either break on its own, or the fluid will be resorbed.
Silver – impregnated dressings (Silver Ion)
◼ Apply wet silver dressing directly on the burn.
◼ Creams or dressings under the silver dressing impede the antimicrobial action.
◼ Keep it moist!
◼ Remove it, rinse it out, replace it on the burn.
- Soak Silver dressings and gauze in water (not saline).

- Apply the silver dressing.
- Wrap with moist gauze. Secure with mesh, gauze or tape.
First few days:
◼ Moisten dressing with WATER every 12h or so.
◼ Remove outer gauze and silver dressing every day.
◆ Inspect the burn.
◆ Rinse exudate off burn.
◼ Rinse exudate off silver dressing with WATER.
◼ Return same silver dressing to the burn.
◼ Apply new outer gauze moistened with WATER.
After several days:
◼ Replace silver dressing
◆ Every 2 - 5 days
◆ Depending on amount of exudate, cellular debris
◼ First wet the silver dressing before removing it.
◼ Don’t pull on it if it’s stuck – moisten it more.
◼ Apply new moist silver dressing and gauze.
Burns of Special areas of the body:
◼ Face
◼ Mouth
◼ Neck
◼ Hands and feet
◼ Genitalia
FACE:
◼ Be VERY concerned for the airway!!
◼ Eyelids, lips and ears often swell alarmingly.
◼ In fact, they look even worse the next day.
◼ But they will start to improve daily after that.
◼ Cleanse eyes with warm water or saline.
◼ Apply antibiotic ointment or liquid tears until lids are no longer swollen.
◼ Bacitracin cream/ointment will serve.
Hands and feet:
- This is rather deep and might require grafting. Be
initial management is basic.
- Dressings should not impede circulation.
- Leave tips of fingers exposed.
- Keep limb elevated.
- Allow use of the hands in dressings by day.
- Splint in functional position by night.
- Keep elevated to reduce swelling.
- Fingers might develop contractures if active measures are not taken to prevent them.
Genitalia:
◼ Shower daily, rinse off old cream, apply new cream.
◼ Insert Foley catheter if unable to urinate due to swelling.

LARGE BURNS:
Causes of death in burn patients:
Airway
◆ Facial edema, and/or airway edema
◆ Breathing
◆ Toxic inhalation (CO)
◆ Respiratory failure due to smoke injury or ARDS
Edema Formation:
◼ Amount of edema can be immense (even without facial burns)
◼ Depression of mental status can worsen problem
◼ Edema peaks at 12 to 24 hours
◼ Pediatric patients even more concerning
Circulation: “Failure of resuscitation”
◆ Cardiovascular collapse, or acute MI
◆ Acute renal failure
◆ Other end organ failure
◆ Missed non-thermal injury
Patient’s with larger burns:
First assess
◼ CBA’s
◼ “Disability” (brief neuro exam)
◼ Expose
Later
◼ Examine rest of patient
◼ Calculate IV fluids
◼ Treat burn
Circulation:
◼ Record vital signs.
◼ Check distal pulses and nail beds.
◆ Keep him warm!
◆ Loss of skin impairs ability to retain heat and fluids.
◆ Being cold will cause vasoconstriction.
◼ Monitor urine output (in larger burns, insert Foley catheter for hourly urine output). 30/50cc/hr
◼ Monitor at least HCT and urine specific gravity.
◼ When available, monitor electrolytes.
Neuro Status:
◼ The burn itself does not alter the level of consciousness.
◼ If patient is not alert, think of other causes:
◆ Hypovolemia
◆ Carbon monoxide
◆ Head injury
◼ Don’t allow swollen eyelids to prevent you from examining the pupils.
◼ Test sensation and motion in burned extremities.
Expose:
◼ Undress the patient to examine the whole body.
◼ But burned patients lose body heat quickly, so keep them warm.
◼ To keep warm, use whatever means available: Blankets, heating lamps, bed frame and large box
covered with blankets
Calculate fluid requirements:
- Weight in kg x % burn x 2 - 4cc / kg / %
- 100 kg patient with 50% TBSA burn:
- 100 x 50 x 2 = 10,000cc = 10 liters
- This is calculated for the first 24 hours post-burn.
- Give half of this in first 8 hours.
- Half of 10,000cc = 5000cc in 8 hours = 400 cc / hour initially
- How do we know if this is too much fluid, or too little?
- Monitor at least:
Urine output - in adults, around 50 cc / hour
Decreasing urine output = need for more fluids.
Burn Size in small children
◼ The head accounts for about 18% (instead of 9%).
◼ The legs account for about 13% (instead of 18%).
Fluid requirements in children
◼ Use same formula for fluids to replace loss from burns.
◼ In children, add this amount to normal maintenance rate:
10 kg - about 40 cc / hour maintenance fluids
20 kg - about 60 cc / hour
30 kg - about 70 cc / hour
◼ Expected urine output for child: 1 cc / kg /hour
for infant: 2 cc/ kg / hour
- 20 kg child with 30% burn:
- 20 (kg) x 30(%) x 2 (cc/kg/%) = 1200 cc in 24 hours
- Half of this in first 8 hour = 600 cc in 8 hour = 75 cc / hours initially
- 75 cc / hour for burn loss + normal 60 cc / hour maintenance = 135 cc / hour initially
- How do you know if the patient is getting too much fluid or too little?
- Check urine output, urine specific gravity, HCT
Special types of burn

◼ Circumferential burn
◼ Burn requiring escharotomy
◼ Electrical burn
◼ Chemical burn
INHALATION BURNS
It occurs due to inhalation of
- Fascial burns
- Dry heat
- Smoke
- Fumes (toxic fumes of combustion)
- Hot gases
- CO poisoning
Clinical features:
- Damage to upper respiratory tract and air passages
- Laryngeal edema
- Pulmonary edema
- Tracheal edema
- Nasal congestion
- Pulmonary damage
- Acute respiratory distress syndrome (ARDS)
- Soot in nostril and mouth
- Sore throat
- Burning sensation
- Hypoxia

Complications:
- Pneumonia
- Pulmonary edema
- Tracheal damage
- Airway obstruction
Management: Proper assessment and diagnostic procedures must be carried out including bronchoscopy.
i. O2 therapy and analgesics:
- O2 is given in fascial masks (mild cases) and ventilators or tracheostomy in severe cases
- Analgesics is administered for pain relief
ii. Humidification
- Moistening of the gases or air is essential as the function of upper respiratory tract is damaged
- Thus, humidification helps in maintaining adequate air entry
- During inhalation
iii. Intermittent Positive Pressure Breathing (IPPB):
- It helps to maintain a positive pressure in the airways throughout inspiration and then returning back to
normal atmospheric pressure during expiration.
- Usually bird or Bennett device is used
iv. Suctioning
- It is very essential to maintain the lung field free of any secretions
- One therapist squeezes and releases AMBU bag and the other therapist performs shaking and vibration to
the chest
- Suctioning is done after 6-8 inflations
v. Nebulization
- Bronchodilators are administered by a nebulizer to maintain the airway
- It has to be given 2-3 times a day in early stages
vi. Breathing exercise
- It is of utmost importance in these patients and must be started within few hours of admission
vii. In severe cases tracheostomy is preferred over Endotracheal Tube Intubation (ETI)
viii. Movements of jaw
- Jaw movements must be initiated with the range of pain to prevent stiffness and loss of function
- Jaw opening, losing, protrusion, retraction is taught to the patient
ix. Proper positioning
- Positioning of head and neck must be done to prevent stiffness and contracture
- Rolled towel under the neck-pillow under the shoulder to maintain extension is incorporated.
x. Re-education
- Coughing techniques is taught to remove respiratory secretion
- Spirometry training
- Postural drainage
- Airways clearance techniques
Physiotherapy Management for burns in general:

I. Respiratory care:
- Postural drainage (tipping is contraindicated due to fascial edema)
- Percussion and shaking manipulation
- Huffing and cuffing
- In later stages chest wall stretching exercises, scar mobilization, chest expansion exercises, strengthening
of respiratory muscles
- Suctioning of humidification for ventilated patient.

II. Maintain ROM and prevent contractures deformity:
1. Positioning (supine or ½ lying position)
- Head and neck: A pillow or towel under the neck and shoulders to maintain extension.
- Shoulder: Abduction-external rotation
- Elbow: Slight extension
- Wrist: Slight extension
- MCP joint: In flexion
- IP joint: Extension
- Thumb: Abduction
- Hip: Extension and slight abduction
- Knee: Extension
- Ankle: 900 dorsiflexion
Do not place pillow under the knee as it may cause flexion contracture.
2. Splinting
It may be static or dynamic
- Static splints is used to hold the position of limb till the movement can start
- Usually, night splints are used until the scar is healed
- Dynamic splints helps in controlling the movements of joint.
For e.g:- A foam roll placed in the hand allows extension and flexion of the fingers thus allowing the
damaged extensor tendons in a limited range and preventing them to be overstretched. Collars may be used
to maintain the neck position and preventing drooping of neck Splint Anterior neck:
- Soft cervical collar
- Moulded cervical collar
- Halo neck splint
- Watusi collar
- Philadelphia collar
Ear: Semirigid O2 mask Mouth:

- MPA (microstoma prevention application)
- External traction hooks
- Orthodontic commissure application
Chest
- Airplane splint
- Abduction splint
- Clavicle strap
- Back/spinal support brace
Elbow and knee

- Gutter/throng
- 3-point
- 1K unformer
- Spiral extension splint
- Air splint
Foot:
- Posterior foot drop splint
- Posterior/anteroankle conformer
- High top gym shoe
- Moulder leather shoe

Toe
- Toe conformer
Hand and wrist:

- Antideformity splint
- Wrist splint
- Thumb spica
- Thumb web spacer
- Traction splint
- Plamar/dorsal extension splint
- Sandwich splint
Precautions during splinting:

- Proper positioning is important
- Unnecessary joints must not be included in the splints.
- They should be removed and cleaned regularly
- Tight bandaging of splint should be avoided
- Nerve compression should be avoided
- Padding is necessary over the bony prominences during splinting
- Dynamic splints should be used only when required
III. Exercises
- Active assisted and free exercise is incorporated through a full ROM
- Passive movements are contraindicated as it may lead to fibrous tissue formation.
- This helps to maintain joint ROM, reduces edema, prevents contractures and deformities
- Passive stretching exercises can be done to mobilize the scar tissue
IV. Muscle strengthening
- Isometric exercise
- Manual resistance exercises
- Each joint should be strengthened through a full ROM 2-3 times a day
V. Scar tissue mobilization: (only if healed)
It helps to reduces the size of scar and permit free ROM

- Passive stretching at the end range to stretch the scar
- Massage by thumb and finger kneading around the scar tissue
- Picking up, rolling, friction massage to improve soft tissue mobility
- Wax bath to improve skin texture and scar pliability
- Pressure garments must be worn for 24 hours a day for 8-18 months. This prevents hypertrophy of the
scars scarring
- Ultrasound elongates and mobilizes the scar tissue
- UVR to promote tissue formation and wound healing especially at the donor site in grafting
VI. General care:
- Use of creams and ointment to keep the skin moist
- Lubrication
- Prevent infection, electrolyte imbalance
- Proper dressing of wounds and bandaging
- Analgesics for pain relief
- Maintain cardiovascular endurance
- Case of pressure sores
VII. Regain maximum function:
- Focusing on ADL activities
- Promotion activities like bathing, toileting, clothing, walking

- Gait training exercises and improve gait pattern especially in lower limb burns
- Cycling, treadmill walking, steeper, skipping, jumping, ball bouncing activities
- Hydrotherapy
- Early ambulation
VIII. Home exercise program
IX. Prevention of complications
Escharotomy:
Indications
◼ Circulation to distal limb is in danger due to swelling.
◆ Progressive loss of sensation / motion in hand / foot.
◆ Progressive loss of pulses in the distal extremity by palpation or doppler.
◼ In circumferential chest burn, patient might not be able to expand his chest enough to ventilate and
might need escharotomy of the skin of the chest.
Complications
◼ Bleeding: might require ligation of superficial veins
◼ Injury to other structures: arteries, nerves, tendons
NOT every circumferential burn requires escharotomy.
◼ In fact, most DO NOT need escharotomy.
◼ Repeatedly assess neuro-vascular status of the limb.
◼ Those that lose circulation and sensation need escharotomy.
◼ Eschar = burned skin

◼ Escharotomy = cut burned skin to relieve underlying pressure
◼ Similar to bivalving a tight cast.
◼ Cut along inside and outside of limb from good skin to good skin
◼ Knife can be used, or cautery.
◼ Use local or no anesthesia. (Full-thickness burn should have no sensation, but underlying tissues do!)
Escharotomy of forearm:
◼ Incise along medial and/or lateral surfaces.
◼ Avoid bony prominences.
◼ Avoid tendons, nerves, major vessels.
Electrical Burn:
◼ Outer skin might not appear too bad.
◼ But heat was conducted along the bone.
◼ Causes the most damage.
◼ Burns from inside out.
◼ Usually requires fasciotomy.
Fasciotomy:
◼ Fascia = thick white covering of muscles.
◼ Fasciotomy = fascia is incised (and often overlying skin)
◼ Skin and fascia split open due to underlying swelling.
◼ Blood flow to distal limb is improved.
◼ Muscle can be inspected for viability.
HEALING AND GRAFTS:

1. Superficial dermal burns will heal within 10-14 days
2. Deep dermal burns will heal within 21-28 days
3. Any burn not healed after 21 to 28 days and larger than 3 cm in diameter may benefit from a skin graft
◼ Full thickness burns always require surgical closure (SSG, full thickness graft, pinch graft or flaps)
◼ Deep burns will need desloughing either by dressings with Eusol or by surgical debridement
◼ All burns requiring skin cover should be grafted as soon as possible, this reduces the chance of infection
& anaemia.

DEFINITIONS:
Graft: A skin graft is a tissue of epidermis and varying amounts of dermis that is detached from its own
blood supply and placed in a new area with a new blood supply.
Function:
- Closure of wound
- Healing process
- Prevent infection
- Prevent fluid loss
- Correct deformity
Indications:
- Full thickness burns
- Diabetic foot
- Cellulitis
- Fascial burns/injury
- Varicose ulcer
- Surgical excision of neoplasm
- Cosmetic requirements
Contraindications:
- Discomfort
- Weakness of muscles
- Stiffness
- Infection
Types:
a. Depending on the donor site
1. Autograft:
- It is taken from the patient’s own body.
- Less chances of rejection by immune reaction
2. Homograft/allograft
- It is taken from other person ‘s body or from a cadaver.
- It usually gets rejected within 4 weeks
3. Heterograft:
- It is taken from the body of other species e.g. pig
- It is also knows as xenograft
- It usually gets rejected in 3 weeks
4. Meshed skin
- Due to shortage of autograft in case of large burns, a large area can be covered by making a mesh of a split
thickness graft in a special machine.
- Here, the epithelium grows from the strands of a mesh to cover the intermittent base are.
b. Depending on thickness of graft:

- Free skin graft: Split thickness graft Whole thickness graft
- Flaps and pedicles
a. Free skin grafts:

- These consists of slices of skin removed from one part of body and applied to raw surface in another part
- It provides the simplest method of restoring the skin cover
- There are two types depending on the thickness:

I. Split thickness graft:
- It may include only the epidermis (think split) or both the epidermis and dermis (thick split)
- It is also called as thiersch grafts.
- The donor sites includes- thigh, buttocks or abdomen. It usually heals in 10-12 days
Advantages:
- More suitable for large and contaminated wounds
- Is excepted readily
- Less prone to infection
- Large grafts may be taken from the donor site
Disadvantage:
- Has a high tendency to contract during healing
II. Whole thickness grafts:

- It is also called as wolfe graft
- It consists of full thickness of skin up to the dermis but not the superficial fascia or fats
- These grafts are transferred without the blood supply
- For the 1st 48 hr the nutrition is obtained from free tissue fluid of the recipient site
- The capillaries grow into the graft and vascularization is complete after 48 hr
Advantages:
- Has more durability
- Better protection
- Less chances of contraction
- Provide better coloration and texture
- More suitable for small defects especially on the face
Disadvantage:
- Donor site does not heal spontaneously
- The donor site cannot be grafted again
b. Pedicle and flaps:

Flap: Any tissue used for reconstruction or wound closure that retains all or part of its original blood supply
after the tissue has been moved to the recipient location.
- Here, the skin to be transferred remains attached at one end to the donor area and the other end is attached
to the recipient site.
- The blood supply to these graft is preserved throughout the procedure.
- In case of free flaps the skin is transferred along with its blood vessels which is then anastomozed with the
vessels of the recipient area. It is temporarily used to transfer the tissues.
Grafts: Does not maintain original blood supply

Flap: Maintains original blood supply.
Classification of Grafts:
1. Autografts – A tissue transferred from one part of the body to another.
2. Homografts/Allograft – tissue transferred from a genetically different individual of the same species.
3. Xenografts – a graft transferred from an individual of one species to an individual of another species.
Types of Grafts:
Grafts are typically described in terms of thickness or depth.
Split Thickness (Partial): Contains 100% of the epidermis and a portion of the dermis. Split thickness grafts
are further classified as thin or thick.
Full Thickness: Contains 100% of the epidermis and dermis.

Requirements for survival:
◼ Bed must be well vascularized.
◼ The contact between graft and recipient must be fully immobile.
◼ Low bacterial count at the site.
Other factors that contribute to graft failure:
◼ Systemic Factors
◆ Malnutrition
◆ Sepsis
◆ Medical Conditions (Diabetes)
◆ Medications
⧫ Steroids
⧫ Antineoplastic agents
⧫ Vasonconstrictors (e.g. nicotine)
What are unsuitable sites for grafting?
◼ Bone
◼ Tendon
◼ Infected Wound
◼ Highly irradiated
Indications for Grafts:
◼ Extensive wounds.
◼ Burns.
◼ Specific surgeries that may require skin grafts for healing to occur.
◼ Areas of prior infection with extensive skin loss.
◼ Cosmetic reasons in reconstructive surgeries.
Split thickness:
Used when cosmetic appearance is not a primary issue or when the size of the wound is too large to use a
full thickness graft.
Donor Sites:
The ideal donor site would provide skin that is identical to the skin surrounding the recipient area.
Unfortunately, skin varies dramatically from one anatomic site to another in terms of:
- Color - Thickness - Hair - Texture
Pre-operative physiotherapy treatment:

- Gaining confidence of the patient
- Patient education about the grafting procedures
- Type of clothing
- Maximize ROM
- Increased muscle strength on the donor site.
Post-operative physiotherapy management:

- The aim is to soften and mobilize the grafted tissue, enable freedom of movement, improve nutrition and
restore the function.
- 14 days after surgery finger kneading around the edges of tissues is started to mobilize the tissues.
- Massage to decrease edema and with little pressure is applied.
- Maintain ROM in the involved joints.
- Isometrics exercises
- Active ROM and passive ROM in the involved joint
- Breathing exercises, huffing and cuffing for clearing respiratory secretions.
- Scar management
- Wearing of pressure garments to reduce hypertrophic scaring
- At donor are:- UVR to promote healing 3-4 days after operation and muscle strengthening.

Complications:
- Loss of graft/flap
- Hematoma
- Compression of arteries
- Extreme pain
- Severe edema
- Excessive scarring
Mobilization
Scar tissue mobilization is a form of manual physical therapy where your licensed PT uses hands-on
techniques on your muscles, ligaments and fascia in order to break adhesions and optimize your muscle
function.
Adhesions are your body’s attempt to heal a soft tissue injury with a lengthy inflammation process, resulting
in long strands of collagenous scar tissue. These new tissues pull against one another, forming trigger points
of pain
Goals of Scar Tissue Mobilization:

• Break down or reduce adhesions
• Improve range of motion
• Lengthen muscles and tendons
• Reduce swelling and edema
• Decrease pain
• Restore functionality
Soft Tissue Mobilization Techniques

Specific techniques for scar tissue mobilization include:
Sustained pressure – pushing directly on the restricted tissue and holding
Unlocking spiral – pushing on the restricted tissue in alternating clockwise and counterclockwise rotating
motions
Direct oscillations – rhythmic pushing on the restricted tissue
Perpendicular mobilization – pushing on the myofascial tissue at right angles
Parallel mobilization – pushing along the seams of muscles
Perpendicular strumming – rhythmic pushing along muscle border, followed by rubber of top of muscle
Friction massage – pushing across the grain of the muscles, tendons and ligaments

ARTERIAL BLOOD GAS ANALYSIS
Objective: Basic mechanism of acid or base
What is an ABG?
- It is an invasive procedure
- It is drawn from artery
Caution: Patient on anticoagulant
Part of diagnosis
ABG can be indicated for:
1. Patient’s oxygenation
2. Ventilatory status
3. Acid base status → for O2 therapy
4. During surgery
Site: Radial, Brachial and Femoral
Anatomy of a blood gas: pH/ pCO2/ pO2/ HCO3
Regulators of acid/base:
1. RS (Respiratory System)
2. Renal System
3. Buffers
Blood gas normal value:
pH pCO2 pO2 HCO3 Base Excess
Arterial 7.35 – 7.45 35 - 45 80 - 100 22 - 26 -2 – 12
Venous 7.30 – 7.40 43 – 50 ~ 45 22 – 26 -2 - 13
pH – Overall state
PaCO3 – Respiratory component
HCO3 – metabolic component
PaO2 – Partial pressure of O2 saturation
SaO2 – (96 – 100%) Arterial O2 saturation
B.E (Base Excess) – Amount of base present in blood
Base deficient – Amount of base when -2 in blood
Blood Gas Analysis

1. Determine if pH is acidic (decrease) or alkaline (increase).
2. Determine Cause
i) Respiratory
ii) Metabolic
iii) Mixed
For pH determination:
If pH → 7.5 (Alkaline)
pH → 7.4 (Normal)
pH → 7.3 (Acidic)
Alkalemia → Alkaline
Acidemia → Acidosis
3. Check oxygenation → PaO2.
4 diseases: Respiratory acidosis, Respiratory alkalosis, Metabolic acidosis and Metabolic alkalosis.
* When pH decreases then the HCO3- decreases → Metabolic

* When pH increases then the PaCO2 decreases → Respiratory

HEMATOLOGICAL AND BIOCHEMICAL TESTS
Cholesterol:
Cholesterol is a waxy, fat – like substance found in all cell surfaces in our bodies transported through our
blood.
What does cholesterol do?
Insulates nerves, makes hormones that send signals between cells and helps with the digestion of fats.
Where do we get cholesterol?
Our bodies make all the cholesterol we need. We also get cholesterol from foods we eat.
Blood Cholesterol levels increase by eating these products:
• Animal products
– Meat: Beef, poultry, fish, etc.
– Dairy: milk, eggs, cheese, yogurt, etc.
• Vegetable products contain:
– Saturated and
– Trans Fat Foods
• Vegetable shortening or hydrogenated fat
• Vegetable margarines
• Snack foods: Cookies, Crackers
• Frozen or other prepared foods
Why worry about Cholesterol?
• Blood cholesterol can stick to the sides of arteries.
• Blockages can form.
• It can lead to serious medical problems:
– Heart attack and
– Stroke.
Investigation: A blood test can tell you your blood cholesterol levels.
Who should be tested?
Anyone over the age of 20
– At least every five years
– More often as determined by your doctor
Types:
HDL: Good Cholesterol: Carries cholesterol away from your arteries
LDL: Bad Cholesterol: Builds up in arteries
Triglycerides: Fats: Builds up in arteries
Cholesterol Values:
Normal: Less than 200 mg/dl
Borderline High: 200 – 239 mg/dl
High: 240 mg/dl or higher
HDL Cholesterol:
Optimal: 60+ mg/dl for both males and females
At risk for heart disease: Women: Less than 50 mg/dl
Men: Less than 40 mg/dl
LDL Cholesterol:
Optimal: Less than 100 mg/dl
Near or above Optimal: 100 – 129 mg/dl
Borderline High: 130 – 159 mg/dl
High: 160 – 189 mg/dl
Very High: 190 + mg/dl
Triglycerides:
Normal: Less than 150 mg/dl
Borderline high: 150 – 199 mg/dl

High: 200 – 499 mg/dl
Very high: 500 + mg/dl
Improve your levels:

Exercise, improved diet, maintain a healthy weight, quit smoking, possibly cholesterol drugs.
Diet: Reduce your intake of fats and cholesterols.
• Increase your intake of fruits and vegetables.
• Add more fiber.
• Eat low-fat or fat-free dairy products.
• Avoid eating too many calories.
Exercise: 30 minutes a day, 4+ times a week
BLOOD TEST:
PARAMETER MALE FEMALE
Hemoglobin g/L 13.5 – 18 11.5 – 16
WBC x109/L 4.00 – 11.00 4.00 – 11.00
Platelets x109/L 1.50 – 4.00 1.50 – 4.00
MCV fL 78 – 100 78 – 100
PCV 0.40 – 0.52 0.37 – 0.47
RBC x1012/L 4.5 – 6.5 3.8 – 5.8
MCH pg 27.0 – 32.0 27.0 – 32.0
MCHC g/dl 31.0 -37.0 31.0 – 37.0
Neutrophils 2.0 – 7.5 2.0 – 7.5
Lymphocytes 1.0 – 4.5 1.0 – 4.5
Monocytes 0.2 – 0.8 0.2 – 0.8
Eosinophils 0.04 – 0.40 0.04 – 0.40
Basophils < 0.1 <0.1

EXERCISE TOLERANCE TESTING
SIX-MINUTE WALK TEST:
Purpose: This statement provides practical guidelines for the 6-minute walk test (6MWT).
INDICATIONS FOR THE SIX-MINUTE WALK TEST

Pretreatment and posttreatment comparisons
1. Lung transplantation
2. Lung resection
3. Lung volume reduction surgery
4. Pulmonary rehabilitation
5. COPD
6. Pulmonary hypertension
7. Heart failure
Functional status (single measurement)
1. COPD
2. Cystic fibrosis
3. Heart failure
4. Peripheral vascular disease
5. Fibromyalgia
6. Older patients
Predictor of morbidity and mortality
1. Heart failure
2. COPD
3. Primary pulmonary hypertension
REQUIRED EQUIPMENT
1. Countdown timer (or stopwatch)
2. Mechanical lap counter
3. Two small cones to mark the turnaround points
4. A chair that can be easily moved along the walking course
5. Worksheets on a clipboard
6. A source of oxygen
7. Sphygmomanometer
8. Telephone
9. Automated electronic defibrillator
PATIENT PREPARATION
1. Comfortable clothing should be worn.
2. Appropriate shoes for walking should be worn.
3. Patients should use their usual walking aids during the test (cane, walker, etc.).
4. The patient’s usual medical regimen should be continued.
5. A light meal is acceptable before early morning or early afternoon tests.
6. Patients should not have exercised vigorously within 2 hours of beginning the test.
MEASUREMENTS
1. Repeat testing should be performed about the same time of day to minimize intraday variability.
2. A “warm-up” period before the test should not be performed.
3. The patient should sit at rest in a chair, located near the starting position, for at least 10 minutes before the
test starts. During this time, check for contraindications, measure pulse and blood pressure, and make sure
that clothing and shoes are appropriate.
4. Pulse oximetry is optional. If it is performed, measure and record baseline heart rate and oxygen
saturation (SpO2) and follow manufacturer’s instructions to maximize the signal and to minimize motion
artifact. Make sure the readings are stable before recording. Note pulse regularity and whether the oximeter
signal quality is acceptable.

The rationale for measuring oxygen saturation is that although the distance is the primary outcome
measure, improvement during serial evaluations may be manifest either by an increased distance or by
reduced symptoms with the same distance walked. The SpO2 should not be used for constant monitoring
during the exercise. The technician must not walk with the patient to observe the SpO2. If worn during the
walk, the pulse oximeter must be lightweight (less than 2 pounds), battery powered, and held in place
(perhaps by a “fanny pack”) so that the patient does not have to hold or stabilize it and so that stride is not
affected. Many pulse oximeters have considerable motion artifact that prevents accurate readings during the
walk.
5. Have the patient stand and rate their baseline dyspnea and overall fatigue using the Borg scale
6. Set the lap counter to zero and the timer to 6 minutes. Assemble all necessary equipment (lap counter,
timer, clipboard, Borg Scale, worksheet) and move to the starting point.
7. Instruct the patient as follows:
“The object of this test is to walk as far as possible for 6 minutes. You will walk back and forth in this
hallway. Six minutes is a long time to walk, so you will be exerting yourself. You will probably get out of
breath or become exhausted. You are permitted to slow down, to stop, and to rest as necessary. You may
lean against the wall while resting, but resume walking as soon as you are able. You will be walking back
and forth around the cones. You should pivot briskly around the cones and continue back the other way
without hesitation. Now I’m going to show you. Please watch the way I turn without hesitation.”
Demonstrate by walking one lap yourself. Walk and pivot around a cone briskly. “Are you ready to do that?
I am going to use this counter to keep track of the number of laps you complete. I will click it each time you
turn around at this starting line. Remember that the object is to walk AS FAR AS POSSIBLE for 6 minutes,
but don’t run or jog. Start now, or whenever you are ready.”
THE BORG SCALE

0 Nothing at all
0.5 Very, very slight (just noticeable)
1 Very slight
2 Slight (light)
3 Moderate
4 Somewhat severe
5 Severe (heavy)
6
7 Very severe
8
9
10 Very, very severe (maximal)
8. Position the patient at the starting line. You should also stand near the starting line during the test. Do not
walk with the patient. As soon as the patient starts to walk, start the timer.
9. Do not talk to anyone during the walk. Use an even tone of voice when using the standard phrases of
encouragement. Watch the patient. Do not get distracted and lose count of the laps. Each time the participant
returns to the starting line, click the lap counter once (or mark the lap on the worksheet). Let the participant
see you do it. Exaggerate the click using body language, like using a stopwatch at a race.
After the first minute, tell the patient the following (in even tones): “You are doing well. You have 5
minutes to go.” When the timer shows 4 minutes remaining, tell the patient the following: “Keep up the
good work. You have 4 minutes to go.” When the timer shows 3 minutes remaining, tell the patient the
following: “You are doing well. You are halfway done.” When the timer shows 2 minutes remaining, tell the
patient the following: “Keep up the good work. You have only 2 minutes left.” When the timer shows only
1-minute remaining, tell the patient: “You are doing well. You have only 1 minute to go.” Do not use other
words of encouragement (or body language to speed up).
If the patient stops walking during the test and needs a rest, say this: “You can lean against the wall
if you would like; then continue walking whenever you feel able.” Do not stop the timer. If the patient stops
before the 6 minutes are up and refuses to continue (or you decide that they should not continue), wheel the
chair over for the patient to sit on, discontinue the walk, and note on the worksheet the distance, the time
stopped, and the reason for stopping prematurely. When the timer is 15 seconds from completion, say this:

“In a moment I’m going to tell you to stop. When I do, just stop right where you are and I will come to you.”
When the timer rings (or buzzes), say this: “Stop!” Walk over to the patient. Consider taking the chair if
they look exhausted. Mark the spot where they stopped by placing a bean bag or a piece of tape on the floor.
10. Post-test: Record the post-walk Borg dyspnea and fatigue levels and ask this: “What, if anything, kept
you from walking farther?”
11. If using a pulse oximeter, measure SpO2 and pulse rate from the oximeter and then remove the sensor.
12. Record the number of laps from the counter (or tick marks on the worksheet).
13. Record the additional distance covered (the number of meters in the final partial lap) using the markers
on the wall as distance guides. Calculate the total distance walked, rounding to the nearest meter, and record
it on the worksheet.
14. Congratulate the patient on good effort and offer a drink of water.
Factors reducing the 6MWD

1. Shorter height
2. Older age
3. Higher body weight
4. Female sex
5. Impaired cognition
6. A shorter corridor (more turns)
7. Pulmonary disease (COPD, asthma, cystic fibrosis, interstitial lung disease)
8. Cardiovascular disease (angina, MI, CHF, stroke, TIA, PVD, AAI)
9. Musculoskeletal disorders (arthritis, ankle, knee, or hip injuries, muscle wasting, etc.)
Factors increasing the 6MWD

1. Taller height (longer legs)
2. Male sex
3. High motivation
4. A patient who has previously performed the test
5. Medication for a disabling disease taken just before the test
6. Oxygen supplementation in patients with exercise-induced hypoxemia.
TREADMILL TESTING
Purpose: To check for cardiac efficiency during exercise.
Indications:
1. Angina (Chest pain) – pain during exercise or activity
2. Myocardial ischemia
3. Undiagnosed chest pain
4. Hypertension
Procedure:
- Supervised by trained physician – 1 in 2500 tests death can happen without a proper supervising physician
(if not observed).
- ECG, Heart rate and BP should be monitored carefully and recorded during each stage of exercise and during
- ST segment abnormalities and chest pain.
- Treadmill or bicycle ergometer can be used
Exercise end points:

Commonly terminated when patients reach and obituary percentage of predicted maximum Heart rate
Use of RPE scale in assessment of fatigue
Maximal Heart Rate = 220 – Age
Target Heart rate = MHR – 15% of max. HR
Fatigue assessment – Use Borg’s Scale

ABSOLUTE INDICATION _ STOP EXRECISE
- Stop if systolic pressure is increased by more than 10 mmHg
- Moderate to severe angina
- Increasing dizziness or syncope
- Signs of poor perfusion
- Subject’s desire to stop
- Sustained ventricular tachycardia
- ST segment elevation in ECG (Shows Myocardial ischemia)

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CARDIORESPIRATORY AND GENERAL PHYSIOTHERAPY

SL.NO TITLE PAGE NO.

1 Management of wound and ulcers 2–7

3 Physiotherapy following lung surgeries 19 – 24

5 Physiotherapy management following PVD 40 – 48

7 Health fitness and Promotion 61 – 70

16 ABG Analysis 149

17 Hematological and biochemical tests 150 – 151

18 Exercise tolerance testing 152 – 155

1 |Cardiorespiratory and General Physiotherapy – Viresh

- An injury to the tissue can be simply called as a Wound.

NORMAL WOUND HEALING: 3 overlapping phase

Patient intervention starts at this stage.

• In case of pressure wounds, when pressure is not relieved

Blanchable Erythema Superficial abrasion

2 |Cardiorespiratory and General Physiotherapy – Viresh

3 |Cardiorespiratory and General Physiotherapy – Viresh

4 |Cardiorespiratory and General Physiotherapy – Viresh

5 |Cardiorespiratory and General Physiotherapy – Viresh

Guidelines for compression bandaging

Scar Tissue Mobilization

Goals of Scar Tissue Mobilization:

Soft Tissue Mobilization Techniques

7 |Cardiorespiratory and General Physiotherapy – Viresh

➢ Pulmonary rehabilitation is an evidence-based, multidisciplinary, and comprehensive intervention for

Rationale for Pulmonary rehabilitation

Factors Contributing to Exercise Intolerance in Chronic Respiratory Disease

➢ Skeletal muscle dysfunction

➢ Respiratory muscle dysfunction

Respiratory Muscle Weakness:

8 |Cardiorespiratory and General Physiotherapy – Viresh

➢ Improvement in health – related behaviors

➢ Improvement in clinical symptoms and progression of disease.

➢ Improvement in function and daily activity tolerance.

➢ Improvement in nutritional status

➢ Improvement in mood, confidence, self – esteem and self – efficacy.

Objectives in Pulmonary Rehabilitation:

3. Program Director or Administrator:

4. Respiratory Care Specialist:

10 |Cardiorespiratory and General Physiotherapy – Viresh

11 |Cardiorespiratory and General Physiotherapy – Viresh

International classifications of patient – Specific outcome:

12 |Cardiorespiratory and General Physiotherapy – Viresh

13 |Cardiorespiratory and General Physiotherapy – Viresh

PROGRAM COMPONENETS OF PULMONARY REHABILITATION:

14 |Cardiorespiratory and General Physiotherapy – Viresh

15 |Cardiorespiratory and General Physiotherapy – Viresh

4. RESPIRATORY MUSCLE TRAINING:

RMT IN PULMONARY REAHB

16 |Cardiorespiratory and General Physiotherapy – Viresh

6. PSYCHOSOCIAL AND BEHAVIORAL INTERVENTION:

17 |Cardiorespiratory and General Physiotherapy – Viresh

Measures of quality of life

GENERAL PHYSIOTHERAPY MANAGEMENT IN PULMONARY REHABILITATION:

4. Sustained exercise can be given if the patient is tolerated.

*Education: (Including patient and family members as well)

18 |Cardiorespiratory and General Physiotherapy – Viresh

2. Vertical (Median Sternotomy)

INDIACTIONS FOR SURGERY

COMPLIACTIONS OF LUNG SURGERIES:

19 |Cardiorespiratory and General Physiotherapy – Viresh

PRE – OPERATIVE PHYSIOTHERAPY

Confidence of the patient

20 |Cardiorespiratory and General Physiotherapy – Viresh