Gender Based Merged For Test

Obstetrics concerns itself with
pregnancy, labour, delivary &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.
Normal anatomy of female pelvis
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.
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
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.
Mechanical changes
 Apparent changes that occur due to an unbalanced
force.
 During pregnancy these mechanical changes are due
to the unbalanced force placed by the baby on the
mother’s body.
• Neuromechanical adaptations to pregnancy refer to
the change in gait, postural parameters, as well as
sensory feedback, due to the numerous anatomical,
physiological, and hormonal changes women
experience during pregnancy.
• One of the most noticeable alterations in pregnancy is
weight gain, The enlarging uterus, the growing foetus,
the placenta and amniotic fluid, the acquisition of fat
and water retention, all contribute to this increase in
weight. The weight gain varies from person to person
and can be anywhere from2.3 kg to over 45 kg.
Types of mechanical changes.
Postural
Lumbar lordosis
Postural stability
Gait
Low back pain
Posture
• The body's posture changes as the pregnancy
progresses.
• The pelvis tilts and the back arches to help keep
balance.
• Poor posture occurs naturally from the stretching of
the woman's abdominal muscles as the foetus grows,
these muscles are less able to contract and keep the
lower back in proper alignment.
• proper posture is crucial in preventing unnecessary
mechanical stress on the lower back
Posture
Lumbar lordosis
 To positionally compensate the additional load due to the
pregnancy, pregnant mothers often extend their lower backs.
 As the foetal load increases, women tend to arch their lower
backs, specifically in the lumbar region of their vertebral column
to maintain postural stability and balance.
 The arching of the lumbar region is known as lumbar lordosis,
which recovers the centre of mass into a stable position by
reducing hip torque.
 Unfortunately, while lumbar lordosis reduces hip torque, it also
exacerbates spinal shearing load, which may be the cause for the
common lower back pain experienced by pregnant women.
 The tendency to move the shoulders more posteriorly that
occurs during prolonged standing will increase lumbar lordosis.
Lumbar lordosis
Postural stability
• The weight added during the progression of pregnancy
also affects the ability to maintain balance.
• In biomechanics, balance refers to one’s ability to
maintain the centre of gravity within the base of
support with minimal postural sway.
• In other words, the moment generated by gravity
must be balanced by the ankle movement in order to
maintain postural stability.
• Although quiet standing appears to be static, it is
actually a process of rocking from the ankle in the
sagittal plane.
CONT….
• Oedema, or swelling, of the feet is common during
pregnancy, partly because the enlarging uterus compresses
veins and lymphatic drainage from the legs.
• Pregnant women have a decreased perception of balance

during quiet standing, which is confirmed by an increase in
anterior-posterior sway. This relationship heightens as
pregnancy progresses and significantly decreases post-
partum. To compensate for the decrease in balance stability
(both actual and perceived), stance width increases to
maintain postural stability.
•
The addition of mass, particularly around the torso,
naturally changes a pregnant mother's centre of mass
(COM). Which will require her to adjust her body to
Gait
• The pregnant woman has a different pattern of gait.
The step lengthens as the pregnancy progresses, due to
weight gain and changes in posture. On average, a
woman's foot can grow by a half size or more during
pregnancy. In addition, the increased body weight of
pregnancy, fluid retention, and weight gain lowers the
arches of the foot, further adding to the foot's length
and width.
• Certain skeletal joints such as the pubic symphysis
and sacroiliac widen or have increased laxity.
Cont..
• Gait in pregnant women often appear as a “waddle” – a
forward gait that includes a lateral component.
• However, research has shown that the forward gait
alone remains unchanged during pregnancy. It has
been found that gait parameters such as gait
kinematics, (velocity, stride length, and cadence)
remain unchanged during the third trimester of
pregnancy and 1 year after delivery.
Cont……
• These parameters suggest that there is no change
in forward movement. There is, though, a
significant increases in kinetic gait parameters,
which may be used to explain how gait motion
remains relatively unchanged despite increase in
body mass, width and changes in mass
distribution about the waist during pregnancy.
• These kinetic gait parameters suggest an
increased use of hip abductor, hip extensor, and
ankle plantar flexor muscle groups.
• To compensate for these gait deviations, pregnant
women often make adaptations that can result in
musculoskeletal injuries.
Low back pain
• Pregnancy related low back pain is a common
complaint that occurs in 60-70% of pregnancies and
can be defined as pain between the 12th rib and the
gluteal folds/pubic symphysis during the course of
pregnancy.
• This pain is not the result of a known pathology such
as disc herniation and can begin at any point during
pregnancy.
• Although most cases are mild, approximately one third
of women experience severe pain.
Cont…..
• Pregnancy related low back has been coined multiple
times and can be referred to as one of the following
patters:
 Low Back Pain (LBP),
 Peripartum Posterior Pelvic Pain (PPPP),
Pregnancy-related low back pain (PLBP) or
pregnancy-related pelvic girdle pain (PPGP) The last
two patterns can occur separately or combined
• proper posture, a regular exercise program, and
awareness of the low-back biomechanics that are most
ergonomic to alleviate any mechanical stress on the
lower back.
• Because of weight gain and hormonal changes, the
distribution of weight will be displaced and exert more
stress on the lower back and pelvis, and at the same
time, the ligaments and joints will become more lax.
• pregnant women should be taught how to maintain a
neutral spine posture-that is, how to avoid excessive
lumbar lordosis and excessive reversal of lumbar
lordosis--during all activities.
Physical therapy
• Stability, coordination and functional preservation
should be trained with active back exercises –
endurance training for back muscles stabilization.
Pelvic tilts, knee pull, straight leg raising, curl up,
lateral straight leg raising and water aerobics are
recommended because these exercises could relieves
lumbar pain in pregnancy. Relaxation exercises while
paying close attention to proper respiration also show
to be beneficial.
• Management includes specific interventions to
address pain, weakness, and mobility in the low back
region
1. Prenatal exercises
2. Preparation for labour
3. Postnatal exercises
Prenatal 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 musculosketal pathologies
Pre-natal exercises
 During pregnancy the body experiences dramatic
physiological changes that require a carefully designed
exercise program. These naturally occurring changes
are not permanent and the benefits of regular exercise
are many. Always check with the health care provider
for any limitations of activities before attempting any
exercises.
Benefits of exercise during
pregnancy
• Improved posture and appearance
• Relief of back pain
• Stronger muscles in preparation for labor and support for
loosened joints
• Improved circulation
• Increased flexibility
• Increased/maintained aerobic endurance
• Increased energy level and less fatigue
• Decreased muscle tension that promotes relaxation
• Promotion of feelings of well-being and a positive self-
image
How much exercise should I do?
• Exercise programs during pregnancy should be directed
toward muscle strengthening to minimize the risk of joint
and ligament injuries.
Frequency
• Daily: stretching, strengthening, Kegels, relaxation
• Three times a week: low or non-impact aerobic activity,
such as swimming or cycling, with appropriate warm-up
and cool-down
• Once a week: check for separation of abdominal muscles
(See section on Abdominal muscles).
Deep breathing exercises
• Breathe in deeply through your nose.
• Sigh out through your mouth.
• Repeat 5 times.
• Do this exercise 6 times a day.
Deep breathing exercises
• Breathe in deeply through your nose.
• Sigh out through your mouth.
• Repeat 5 times.
• Do this exercise 6 times a day.
• Foot and ankle exercises
• Keep your knees relaxed for both exercises.
• • Bend and stretch your ankles vigorously
• up and down for 30 seconds.
• • Circle both feet 10 times in each
• direction.
• • Repeat both of these exercises
• 10 times a day.
• They will help to reduce swollen ankles
and varicose veins.
Strengthen your pelvic floor
muscles during pregnancy
The floor of your pelvis is formed by very

elastic muscles which act like a small
trampoline to support your baby during
pregnancy. These muscles may become
weak leading to a leakage of urine when
you cough or sneeze. Many women have this
problem during pregnancy. Exercise now to
strengthen your pelvic floor, do at least
80 exercises each day.
How to do pelvic floor exercises
Sit with your knees apart.
• Don’t hold your breath.
• Don’t clench your buttocks.
Tighten your back passage as if you were trying to
stop passing wind. Now tighten the muscles you
would use to stop a flow of urine. Do both together
and you should feel your back passage, vagina and
front passage all lift and close at the same time. Now you
know what to do, you can do this
exercise while standing, sitting or lying down.
• Stand parallel to the back of a sturdy chair with the
hand closest to the chair resting on it, feet parallel and
hip-distance apart.
With your toes and knees turned out to 45 degrees,

pull your belly button up and in. Bend your knees,
lowering your torso as low as possible while keeping
your back straight. Straighten your legs to return to
starting position. Repeat for reps.
Strengthens: Quadriceps, hamstrings and butt.

Improves balance.
• Lie on your right side, head supported by your
forearm, right leg bent at a 45-degree angle and left leg
straight. Place your opposite arm on the floor for
stability. Lift left leg to about hip height and repeat for
reps.
Then, bend your left knee and rest it on top of pillows

for support. Straighten your right leg and lift it as high
as possible for reps [shown]. Switch sides and repeat
for reps.
Strengthens: Core and inner thighs

Side-Lying Inner
and Outer Thigh
 Get down on your hands and knees, wrists directly
under your shoulders. Lift your knees and straighten
your legs behind you until your body forms a straight
line. Don’t arch your back or let your belly sag
[shown].
Hold for 1 to 2 breaths, working up to 5 breaths.
Strengthens: Core, arms and back.

• The sword
• Stand with your feet wider than your hips, knees bent,
feet turned out comfortably and hands on your hips.
Bend your knees and sweep your right hand toward
your left knee as you look down [a]. Sweep your right
arm upward and to the right as if you were drawing a
sword out of a hip belt, looking up toward your hand
[b]. Complete reps, switch sides and repeat.
• Benefits: Strengthens legs, back and abs; improves
balance
• Thigh stretch
• Kneel on a mat or carpet, with your knees hip-width
apart and your abs pulled in (if necessary, place a
folded blanket or two under your knees for comfort)
[a]. Squeezing your butt, inhale as you lean back,
keeping hips up. Reach your arms up to shoulder
height, palms down [b]. Exhale, returning hips to the
upright position as you lower your arms.
• Benefits: Strengthens hips, buttocks, lower back and
abs
 Wag the tail
 Get down on all fours, making sure your wrists are
aligned under your shoulders. Draw your belly in and
lift your left knee up and to the side [a], making sure
your shoulders stay away from your ears (i.e., don’t
shrug your shoulders). Draw circles with your knee
while keeping your abs pulled in [b]. Complete reps
and switch sides.
 Benefits: Strengthens lower back and abs; increases
flexibility and stability
 General goals & plan for exercise programs
GOALS PLAN OF CARE
1.Improve posture & 1.Train & strengthen

correct body mechanics postural muscle
2. Teach correct body

mechanics in all position
2.Upper & lower 2. strengthening ex. of UL &

extremities strengthening LL
3. Prepare for circulatory 3. Stockings, stretching ex.
compromise
4. Improve awareness & 4. Pelvic floor muscle

control of pelvic floor strengthen
musculature
5. Maintain abdominal muscle 5. Abd. Muscle strengthen
function & correct diastesis ex.
recti
6. Provide information about 6. Prenatal & postnatal
preg. & associated problem information
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 preg. & 500 kcal./day for ex. during
lactation.
• low resistance & high repetitions ex. is recommended,

avoid valsalva maneuvers.
• stop ex. if any unusual symptoms occur.

Environment: Temperature regulation is
highly dependent on hydration and
environmental conditions. Exercising
pregnant women should ensure adequate
fluid intake before, during and after
exercise, wear loose-fitting clothing, and
avoid high heat and humidity to protect
against heat stress, especially during the
first trimester. Wear comfortable exercise
Foot wear that gives strong ankle
And arch support.
Growth and Development: The pregnant
woman should monitor her level of exercise
and adjust her dietary intake to ensure proper
weight gain. If pregnancy is not progressing
normally or if vaginal bleeding, persistent pain
or chronic fatigue are noted, exercise should
be stopped until a medical evaluation has
been completed. Also, if regular contractions
occur more than 30 minutes after exercise,
medical evaluation should be sought. This
may signify pre-term labor.
Mode: Weight-bearing and non-weight-bearing exercise are
thought to be safe during pregnancy. Non-weight-bearing
exercise such as swimming and cycling Improve maternal
fitness. Weight bearing exercises are similarly beneficial as
long as they are comfortable such as walking, jogging and
low-impact aerobics programs. Heavy weightlifting, or similar
activities that require straining, are to be discouraged.
Bicycle riding, especially during the second and third
trimesters, should be avoided because of changes in
balance and the risk of falling. Include relaxation and
stretching before and after exercise program. Stretching
should be gentle and static to maintain joint flexibility.
Intensity: Pregnancy is probably not
a time for serious competition. For
women who are continuing their
regular exercise regimen during
pregnancy, exercise intensity should
not exceed pre-pregnancy levels. The
intensity of exercise should be
regulated by how hard a woman
believes she is working. Moderate to
hard is quite safe for a woman who is
accustomed to this level of exercise.
Contraindications to exercise……….
1. ABSOLUTE CONTRAINDICATIONS
 Preg. Induced HTN BP >140/90 mmhg.

 Diagnosed heart disease IHD,RHD,CHF.
 Premature rupture of membrane.
 Placental abruption.
 History of preterm delivery.
 Recurrent miscarriage.
 Restrictive lung disease
 Persistent vaginal bleeding.
 Fetal distress.
 IUGR.
 Incomplete cervix
 Thrombophlebitis &pulmonary embolism.
 Pre-eclampsia
 polyhydraminos / oligohydraminos
 Acute infection
Restrictive lung disease
 Is the respiratory diseases that restrict lung expansion,

resulting in a decreased lung volume, an increased
work of breathing, and inadequate ventilation.
Incompetent cervix
 is a medical condition in which a pregnant
woman's cervix begins to dilate (widen) and efface
(thin) before her pregnancy has reached term.
 Cervical incompetence may cause miscarriage or
preterm birth during the second and third
trimesters.
Persistent 2nd and 3rd trimester
bleeding
 It is contraindicated because may cause miscarriage or

preterm birth.
 Most women have a decreased to lerance for bearing
exercises.
Placenta previa after 26 weeks of
gestation
 Placenta previa is a problem in pregnancy in which the
placenta grows in the lower part of the uterus and
covers all or part of the opening to the cervix.
 Pregnant women with placenta previa are advised to
reduce activities and must be in bed rest.
Ruptured membranes
 condition occurs when the membraned sac holding
the baby and the amniotic fluid breaks open before
you're actually in labor.
 It may be caused by over exercising, smoke during
pregnancy, have had a previous early membrane
rupture, or had vaginal bleeding during your
pregnancy.
2.RELATIVE CONTRAINDICATIONS
 Diabetes
 Anemia's or other blood disorders
 Thyroid disorder
 Dialated cervix
 Breech presentation during third trimester
 Multiple gastation
 Ex. induced asthma
 Peripheral vascular disease
 Pain of any kind.
Relative contraindications
 Chronic bronchitis
 Morbid obesity
 Extreme underweight(BMI<12)
 Poorly controlled hypertension
 Heavy smoking
 Orthopaedic limitations
 Poorly controlled seizure disorder
anaemia
 It is a decrease in red blood cells
 During exercise a person requires more oxygen causing
the heart to work faster, having to pump more blood
round it. Less red blood cells results in less oxygen
supply which cause the foetus to receive less oxygen.
Chronic bronchitis
 Inflammation of the bronchioles
 bronchitis increase difficulty in breathing, exercise
will increase work of breathing which will result in
decrease supply of oxygen to the foetus.
Morbid obesity
 Health condition that can interfere with basic physical
functions such as breathing and walking.
Poorly controlled hypertension
 Increase in blood pressure
 Exercises on hypertensive disorders of pregnancy are
associated with an increased risk of preterm delivery,
neonatal intensive care unit admission, and fetal death
Heavy smoking
• Smoking during pregnancy affects you and your baby's
health before, during, and after your baby is born. The
nicotine , carbon monoxide, and numerous other poisons
you inhale from a cigarette are carried through your
bloodstream and go directly to your baby. Smoking while
pregnant will:
 Lower the amount of oxygen available to you and your
growing baby.
 Increase your baby's heart rate.
 Increase the chances of miscarriage and stillbirth.
 Increase the risk that your baby is born prematurely and/or
born with low birth weight.
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 & levetor

scapulae
 Low back extensors
 Hip adductors [caution do not over stretch in
women with pelvic instability]
 Ankle planter flexor.

Self Scalen streching Scalens stretching by therapist
 Low back extensors stretching
Manual Back Stretch

Self Back Stretching
Hip adductor stretching : -
Tailor’s Sitting Position

Strengthening of Corner Press Out
External Rotators
ABDOMINAL EXERCISES: -
1. Corrective ex. for diastesis recti
 Head lift
 Head lift with pelvic tilt
Head Lift
2. Trunk curls
3. Leg sliding
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 ex 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 & Lower Limb
Exercise.
1. Modified push ups /standing pushups
2. Hip extension
a. supine bridging
b. All four leg raising
a.
Quadruple position with posterior pelvic tilt

b.
Leg is raised only until it is in line with the

trunk
3. Modified squatting
These are used

 To strengthen the hip &knee extensor.
 Stretch the peroneal area.
a. Supported squatting using a chair or wall.

b. Wall slide.
 Self stretching
PERINEUM & ADDUCTOR FLEXIBILITY
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 & BREATHING EX
 Relaxation & Breathing exercise.
Are given with the following objectives
1. To obtain rest during preg.
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”
PREPERATION 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.

 Preparation
Get into a comfortable position, side lying or semi-
sitting, supported by pillows. Don’t let your hands and
feet dangle; this makes your muscles work, increasing
tension. Ensure all body joints are slightly flexed. Have
a blanket ready, should you get cold. Create a
distraction-free environment; dim the lights, play
quiet, peaceful music.
Methods of Relaxing
• Progressive relaxation
This is focusing on one or more muscle group at a time
to relax your entire body. Tense each body part for
about six seconds and release (don’t hold your breath).
Slowly tour your body, consciously tensing and
releasing muscle groups, working down from facial
muscles to toes. Your partner or a taped voice can also
guide you through
Touch relaxation
 Your partner can apply the following techniques:

Apply a gentle, still touch over a tense area until that
area relaxes completely. Apply firm pressure to tense
areas with fingertips and/or palm of hand. Slowly
release tense area. Gently stroke tense area away from
centre of body, massaging tense muscles
Breathing
Our pace and rate of breathing changes constantly

depending on our emotional and medical status. Pain
or panic can cause rapid breathing or forceful exhaling,
resulting in the flushing of carbon dioxide out of our
system (hyperventilation). Hyperventilating causes a
sense of dryness, dizziness and lightheadedness
Greeting breath
• Recommended for any type of contraction, greeting

breath is also known as cleansing breath, relaxing
breath, in/out breath, refuelling breath, and complete
breath. Perform this type of breathing at the
beginning and end of a contraction.
Take a deep breath through your nose and out through
your mouth. (If you are congested, breathe through
mouth only.)
• Imagine breathing in energy and releasing tension.
• Combine stretching your body as you breathe in,
returning to starting position as you breathe out.
Slow-paced, rhythmical, full-
chest breathing
• This is for tolerable contractions (usually in the early stages
of labour).
Breathe slowly and effortlessly, half the pace of your regular
breathing patterns, or a rate of 6–10 breaths/minute.
• As you breathe in through your nose, you or your partner
can place your hands under the rib cage and observe the
rise and swell as air enters lungs. When you breathe out
through your mouth, observe how the chest falls and you
feel more relaxed.
• While your partner is timing the contractions, concentrate
on a focal point (an object or person in the room) or, with
eyes closed, in your imagination.
Benefits of applying good
breathing techniques
1. Air circulation will improve and will supply baby

and uterus with much needed
oxygen and nutrients, while excreting carbon dioxide.
2.Decreasing or avoiding breathlessness, which is
common in prenatal and labouring women.
3. Heart and lungs will be better prepared for
oncoming labour. Your partner/coach needs to learn
and follow your breathing pattern so that you can be
guided during labour. (Your breathing patterns may
differ if your contractions are artificially
augmented.)
Positioning During Labour
1st stage of labour –
In this stage uterus
anteverts
Forwards leaning
facilitates ante version
Woman should be
encouraged
To change position
during first stage of
labour
 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 LABOUR
 Once the labour begins, the of 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 2nd stage

stage
Easy Breathing to 1 or 2 deep breaths
prevent
breathing- a pushing in & out, then hold
little slower & “fairly deep making the
deeper then breathing” diaphragm “piston
usual. to move the go down” repeat
diaphragm
up &down when breath runs
together out, after a gulp of
with a sharp air.
blow out
through
relaxed lip
BREATHING & 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.
Perineal Massage
The perineum is the area of tissue between the vagina

and the anus. Performing perineal massage antenatally
helps to prepare the perineum to stretch more easily
during childbirth and reduce the need for stitches. It is
thought over 85% of women will have some degree of
tear during vaginal birth; therefore attempting to
minimise this trauma is an important part of preparing
for labour.
Cont…
 You can start perineal massage from 32-34 weeks of
pregnancy. It can be done by you or your partner if you
are both comfortable with this. It is a good idea to
perform after a bath because the perineum is softer. It
is recommended to use unscented, organic based oil,
such as olive, sweet almond or sunflower, which
lubricates the area and makes the massage more
comfortable.
Cont…
Get comfortable:
Place one or both thumbs on and just within the back
wall of the vagina, resting one or both forefingers on
the buttocks. Press down towards the rectum and
massage by moving the thumbs and forefingers
together in an upwards U movement. Aim to massage
for about 5 minutes at a time, each day or every
alternative day for most benefit. Do not do perineal
massage if you have vaginal herpes or any vaginal
infection. If you feel pain at any time, stop and try
another time.
Pelvic tilt or angry cat
This variation of the pelvic tilt, done on all fours, strengthens

the abdominal muscles and eases back pain during
pregnancy and labor.
Get down on your hands and knees, arms shoulder-width
apart and knees hip-width apart, keeping your arms
straight but not locking the elbows.
As you breathe in, tighten your abdominal muscles and
tuck your buttocks under and round your back.
Relax your back into a neutral position as you breathe out.
Repeat at your own pace, following the rhythm of your
breath.
Squat
This exercise strengthens your thighs and helps open your

pelvis.
Stand facing the back of a chair with your feet slightly
more than hip-width apart, toes pointed outward. Hold the
back of the chair for support.
Contract your abdominal muscles, lift your chest, and
relax your shoulders. Then lower your tailbone toward the
floor as though you were sitting down on a chair. Find your
balance — most of your weight should be toward your
heels.
Take a deep breath in and then exhale, pushing into your
legs to rise to a standing position.
Tailor or Cobbler Pose
This position can help open your pelvis and loosen

your hip joints in preparation for birth. It can also
improve your posture and ease tension in your lower
back.
Sit up straight against a wall with the soles of your feet
touching each other (sit on a folded towel if that's
more comfortable for you).
Gently press your knees down and away from each
other, but don't force them.
Stay in this position for as long as you're comfortable.
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.
POSTNATAL 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.
2. Early postnatal ex. - Include proper positioning.

INITIAL POSTNATAL EX.
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
EARLY POSTNATAL EX.
sitting standing
feeding
others
lying
CESAREAN CHILDBIRTH
• 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 Breathing ex. Coughing
function & decrease the &huffing.
risk of pneumonia
2.Decrease incisional 2. Postnatal TENS
pain associated with support incision with
coughing hands when coughing.
3. Friction massage & scar
3. Prevent postsurgical mobilization.
adhesion formation
4.Prevent postsurgical 4.Active leg ex. ,early
vascular complication ambulation
5.Correct posture & 5.Postural instruction
protected activities of &positioning for ADL
daily living
6. Pelvic floor ex.
6. Prevent pelvic floor
dysfunction
7. Abdominal ex.
7. Develop abdominal
strength
 SUGGESTED ACTIVITIES FOR THE PT. WITH A CS.
.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 then 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 GES PAINS
• Abd. Massage or kneading while lying on the left side.
• Pelvic tilting ex.
4.SCAR MOBILISATION
HIGH RISK PREGNANCY
 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 preg.
 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. Decrease stiffness 1. Positioning instruction
,joint motion at available
ROM.
2. Maintain muscle length & Stretching &
bulk to improve 2.
strengthening ex. Within
circulation. limits imposed by
physician.
3. Improve proprioception
3. Movement activities for
many body parts as
4. Improve posture within possible.
available limits.
4. modified posture
5. Stress management & instruction.
enhance relaxation .
5. relaxation tech.
6. Enhance postpartem
recovery. 6. Ex instruction &home
program for postpartum
period.
EX. 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 , fing. Flex. & extn. , 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. diastesis recti 1.Modified abdominal muscle
ex. With crossed hand
over the abdomen.
2. Lower back pain & pelvic
2.In acute condition bed rest
pain.
do’s or don’t
gentle heat & massage
pelvic tilting in croock lying
TENS if indicated
3. SI dysfunctioN 3. Modified ex. For SI pain
4. Nerve compression 4. Splinting
syndrome ice packs
- Carple tunnle syndrome elevation of the limb
TENS
- Brachial pluxus pain
- Meralgia paraesthetica
Posterior tibial nerve
-
compress
5.Circulatory problem 5. –prolonged standing
avoided
varicose vein of leg
ankle ex. ,calf stretching
vulval varicose vein
- raising foot end of standing
leg cramps should bed.
-thrombosis & deep kneading massage
- thromboembolism - 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.
Sitting posture in coccydynia
PHYSIOTHERAPY IN GYNAECOLOGICAL
CONDITIONS
INDICATIONS PT MANAGEMENT
1. INFECTIONS 1. in acute phase
-vulvitis -chemtherapy.
-vaginitis in chronic phase
- cervicitis pulsed or cont SWD
- salphingitis
- PID
2. CYST & NEW GROWTH 2. pulsed SWD /US for
softning of painful abd.
adhesion.
3..STRESS INCONTINENCE 3. pelvic floor ex.
4.GENITAL PROLAPSE 4. pelvic floor strength
-cystocele, urethrocele, - ening ex.
-rectocele, enterocele,
- uterine prolapse
5. MENSTRUAL DISORDER 5. primary type
-primary / spasmodic type pain coping strategies
- sec. /congestive
- dysmennoria relaxation & breathing
tech. & TENS
6. BACKACHE & ABD. 6. TENS
PAIN
THANKYOU
THANKS
Women’s Health and
Incontinence
Agenda
Basic anatomy
Causes of pelvic floor dysfunction
Pelvic floor dysfunctions
Pelvic floor muscle rehabilitation

Objectives
Identify and describe the basic anatomy of the

pelvic floor
Identify and describe the causes of pelvic floor
dysfunction
Identify and describe the various pelvic floor
dysfunctions
Apply the principles of exercises physiology to
the pelvic floor muscles
Identify and prescribe appropriate behavioural
modification and advice
Basic Anatomy
The Anatomy of the Pelvis includes:

Bony Pelvis - sacrum and innominates
Pelvic Organs - bladder, uterus and
rectum
Pelvic Floor – muscle and fascia upon
which all pelvic and
abdominal organs rest
Basic Anatomy
Bony Pelvis and Ligaments
Basic Anatomy
Pelvic Organs:
Basic Anatomy
Pelvic Floor: Muscles
Muscles of the pelvic floor consist of a

superficial and a deep layer.
The superficial muscles –
ischiocavernosus, bulbospongiosis and
superficial transverse perineal muscles.
The deep layer is known as the Levator
Ani – pubococcygeus, puborectalis,
iliococcygeus and coccygeus .
Basic Anatomy
Pelvic Floor Muscles: Superficial
PERINEUM & UROGENITAL

DIAPHRAGM FEMALE
SUPERFICIAL LAYER UROGENITAL TRIANGLE
(perineal muscles)
ISCHIOCAVERNOSUS
UROGENITAL
DIAPHRAGM
BULBOSPONGIOSUS
SUPERFICIAL ISCHIAL
TRANSV PERINEII TUBEROSITY
EAS PC PERINEAL
IC BODY
GM
ANAL TRIANGLE
Superficial layer - urogenital and anal triangles

muscles: ischiocavernosus, bulbospongiosus, superf transvers perinei, EAS
Basic Anatomy
Pelvic Floor Muscles: Deep Levator Ani
DEEP PELVIC FLOOR = LA

Pelvic Diaphragm
PC PUBOCOCCYGEUS
1 LA PR PUBORECTALIS
1
IC ILIOCOCCYGEUS
LEVATOR PLATE
COCCYGEUS
2
COCCYX
1+2 =
SACRUM
PELVIC DIAPHRAGM
Basic Anatomy
Pelvic Floor Muscles:
Levator Ani is a striated muscle
70% Type I slow twitch

30% Type II fast twitch
Nerve innervation: Pudendal nerve S2-S4

Basic Anatomy
Pelvic Floor: Endopelvic fascia
The Endopelvic fascia is a sheet-like band

of connective tissue that attaches the
pelvic organs to the side-walls of the
pelvis.
Basic Anatomy
Pelvic Floor: Endopelvic fascia
Functions of the Pelvic Floor Muscles
Supports abdominal and pelvic organs

Assists in maintaining both urinary and
faecal continence
Needed for normal sexual functioning
Forms part of the core stabilising muscles,
therefore important in pelvic and spinal
stability
Pelvic Floor Dysfunction
Types of Pelvic Floor Dysfunctions:
Urinary Incontinence
Anal Incontinence
Pelvic Organ Prolapse (POP)

Urinary Incontinence:
Urinary Incontinence (UI): complaint of
involuntary loss of urine
Types of UI:
– Stress urinary incontinence
– Urgency incontinence
– Mixed incontinence
Int Urogynecol J (2010) 21:5-26

Stress Urinary Incontinence:
Complaint of involuntary loss of urine on

effort or physical exertion (e.g. Sporting
activity), or on sneezing or coughing.

Stress Urinary Incontinence:
Urgency Incontinence:
Complaint of involuntary loss of urine

associated with urgency.
Urgency Incontinence is often associated
with the following symptoms:
– Frequency: complaint that micturition occurs
more frequently during waking hours (7x/day
normal)

Urgency Incontinence:
– Nocturia: interruption of sleep 1 or more times

because of the need to micturate, each void is
preceded and followed by sleep.
– Urgency: complaint of a sudden, compelling
desire to pass urine which is difficult to defer.
When all the above exist we refer to the

syndrome as an overactive bladder

Mixed Incontinence:
Complaint of involuntary loss of urine

associated with urgency and also physical
effort or physical exertion or on sneezing
or coughing

Anal Incontinence

Anal Incontinence:
Complaint of involuntary loss of faeces or

flatus

Anal Incontinence

Pelvic Organ Prolapse (POP):
Definition: The descent of one or more of

the anterior vaginal wall, posterior vaginal
wall, the uterus or apex of vagina (post
hysterectomy)

Pelvic Organ Prolapse (POP):
Symptom:
– A departure from normal sensation, structure or
function, experienced by the woman in reference to
the position of her pelvic organs.
– Symptoms generally worse (e.g. after long periods of
standing or exercise) and better when gravity not a
factor (e.g. lying).
– May be more prominent after abdominal straining.
– Complaint of vaginal bulging, heaviness and digitation

Prolapse: Anterior Wall (Bladder)
Prolapse: Posterior Wall (Rectum)
Prolapse: Uterine Prolapse
Causes of Pelvic Floor Dysfunction
Pregnancy
Childbirth
Prolonged increases intra-abdominal pressure-
Chronic Constipation, Obesity, Heavy Lifting
Surgery (abdominal and pelvic surgery)
Hormonal changes- menopause
Neurological diseases – multiple sclerosis
Aging
Pelvic Floor Muscle Rehabilitation
Principles of muscle training
Application
Teaching pelvic floor exercises
Behavioural modification
Principles of General Muscle Training:
Overload
Specificity
Reversibility
Principles of Pelvic Floor Muscle Training:
Overload
– Max contractions
– Longer sub-maximal contractions
– Postural adjustments
Specificity
– Get the correct muscle
– Assess (reduced strength, reduced endurance, both)
– Symptom specific
– Functional
Reversibility
– Continue exercise until goals achieved
– Appreciate weakening factors and compensate
Teaching Basic Pelvic Floor Exercises:
“Squeeze and lift the muscles between

your legs as if you want to stop urination
or defaecation”
10x squeeze and relax

10x holding for 10sec
5x / day
Teaching PF exercises: Coactivation of synergists
The PFM work with Transverse Abdominis

(TrA), lumbar multifidi and the diaphragm
to form the cylinder of support for the
spine.
Use pelvic floor to aid TrA contractions
and vice versa.
Principles used to train core stabilising
muscles apply to the pelvic floor
Behavioural Modification:
Understand what weakens pelvic floor or

worsens symptoms.
Education!
Behavioural Modification: Toiletting
Behavioural Modification: Toiletting
Toilet only with a sensation of an urge

Sit correctly
Relax
Bulge abdomen with urination/defaecation
Don’t strain
Thank you
MEMORANDUM
SEFAKO MAKGATHO HEALTH SCIENCES UNIVERSITY
SCHOOL OF HEALTH CARE SCIENCES
SUBJECT NAME: Principles of Physiotherapy III EXAMINATION: STANDARD
RE- EXAMINATION X
SUBJECT CODE : MPTF030
COURSE : BSc PHYSIOTHERAPY III PAPER NUMBER: 2/2
DATE OF EXAMINATION: 2018 DURATION : 3 HRS
NUMBER OF STUDENTS: TOTAL MARKS : 120
INTERNAL EXAMINERS PARTICULARS: 1. Dr Mtshali

Dr Cochrane
Mr Dawood
Ms Nkuna
Ms Sobantu
EXTERNAL EXAMINERS PARTICULARS: 1. Ms I du Plessis
THIS MEMORANDUM CONSISTS OF 9 PAGES INCLUDING COVER PAGE.
SIGNATURE OF HEAD OF DEPARTMENT : ______________________________________
SIGNATURE OF DIRECTOR OF SCHOOL : ______________________________________
1|Page
Section A: Gender-based Health
Question 1
1.1 Prescribe Physiotherapy management for a patient with stress incontinence.
(10)
• Pelvic muscle training exercise (1) to keep the urethral sphincter strong and
working (1).
• Some use vaginal cone with pelvic exercises (1)
• Biofeedback and electrical stimulation (1) may be useful for people doing
pelvic muscle training (1)
• Electrical stimulation therapy uses a low-voltage electrical current (1) to
stimulate and contract the correct group of muscles (1) this is done by anal or
vaginal probe (1)
• Treatment sessions usually last 20 min (1) and may be done every 1-4 days
(1).
1.2 Discuss the Physiotherapy treatment of a patient with erectile dysfunction.

(10)
Physiotherapy can help by:
• Removal of aggravating factors (1)
• Manual therapy treatment to your low back and pelvis, getting the joints
moving correctly (1)
• Trigger point therapy: Getting the muscles working properly and reduction of
the overactive parts in the low back muscles, hip muscles and pelvic floor
muscles. (1)The patient should be taught how to do this himself (1)
• Pelvic floor exercises to release the pelvic floor (1)
• Self-stimulation activities are essential. Using hot, cold, light and harder
touching of the penis can help with sensory reactivation. (1)If the nerves are
damaged after surgery then sensory reception will be compromised. (1) Such
activity can be done at home and often is better to do regularly(1)
• Specific hip, spine and pelvis exercises to get the patient and his pelvic floor
moving better(1)
2|Page
• Specialised breathing and relaxation work. Relaxation through breathing has
been found to be hugely beneficial for all types of conditions (1)
• Re-education of the pelvic floor, hip and abdominal musculature (1)
• General exercise (1)
Section total: 20 marks
Section B: Manual Therapy
Question 1
A 21 year old female model was on the runway when she flicked her hair
towards her right hand side and experienced a sharp pain in her neck. She
explains that she is now “stuck facing her right hand side and cannot look
straight ahead”. She also notes that she regularly suffers from headaches. Her
pain is a constant 4/10 and is aggravated to an 8/10 when she brings her neck
up from cervical lateral flexion into neutral. The patient eases up immediately
when she is in the “stuck” position.
1.1 Prioritise a list of three (3) possible diagnoses for this patient. (4)
Acute locked cervical joint (1 mark for the diagnosis and 1 mark for the priority)
Torticollis (1)
Any justifiable C-spine pathology (1)
1.2 Describe the manner in which you will determine the irritability of the patient’s
condition. (4)
Not irritable (1) – time to aggravate (1) – Time to ease (1) – Low Sin (1)
During the assessment you find that the patient has overactive, hypertrophic
mobilisers, in-active stabilisers and accompanying joint and soft tissue
restrictions.
1.3 Create a treatment plan to manage the most likely diagnosis for this patient.
Include the possible restrictions with their corresponding treatment techniques
as well as relevant Orthopaedic Manual Therapy treatment techniques. (17)
Selection of Acute cervical locked joint (1)
3|Page
Joint restriction type (1) – Lateral flexion (Symbol (1) Grade 3 or 4 (1) Time (1)
Dosage (1)
Soft tissue restriction (length and TP) – (2) mention headaches
Rx of above – MFR (1) Stretches (1)
Activation of deep cervical flexors (1) – Proper explanation of how to (1)
Global stabiliser retraining (1) - explanation of an exercise (1) – eccentric (1) –
Dosage (1) – Position (1) dissociation (1)
Student can use aids for their exercises (theraband, towel etc etc) and this will result
in marks for the explanation of the exercises
Section C: Neurology
Question 1
Mrs X sustained a stroke that affected her left side (right middle cerebral artery
infarct) four (4) weeks ago. She is currently unable to walk, although she can
perform sit-to-stand activities with moderate assistance. Her left arm is flaccid
and she cannot use the arm functionally at all.
1.1 Discuss the clinical differences between an anterior cerebral artery stroke and
a middle cerebral artery stroke. (5)
ACA: Blood supply to the frontal lobes (left and right) and primary motor cortex will
be affected (1). The patient will present with the following signs – Change in
personality, inability to plan movement sequences resulting in delayed
reaction times and the lower limb will be more severely affected that the upper
limb, resulting in a poor prognosis for gait (any sign will be given a mark).
MCA: Blood supply to the parietal lobes and secondary motor cortex (left and right)
will be affected.(1) The patient will present with the following signs and
symptoms – change in ability to perceive sensation – which indicates a poor
prognosis for sensory recovery (1). The upper limb will be more severely
affected than the lower limb, which indicates a poor prognosis for the upper
limb. The patient will struggle with initiation of movement, termination of
movement and execution of a movement sequence (1).
4|Page
1.2 Describe the precautions that should be considered during rehabilitation of
this patient. (5)
The arm should not be pulled on during rehabilitation – high risk of subluxation and
dislocation (1). The arm should be positioned at a 45º angle when the patient is in
supine, especially during rolling / bed mobility activities (1)
The patient might suffer from hemi-spatial neglect – the therapist should not leave
the patient unattended (1) and should remain on the affected side at all times during
treatment (1).
The affected foot must be positioned well to prevent sub-talar subluxation and to
optimize the position of the knee (especially during standing positions) (1).
1.3 Explain one (1) treatment position option in which the patient can be placed to
re-educate gait during rehabilitation. (5)
Any one of the following positions can be explained (up to five marks):
The patient should be treated in positions of weight bearing but with constraining the
joint that is not actively being exercised. The three best positions will be
asymmetrical. Position one: half kneeling with the one lower limb and two-point
kneeling with the opposite lower limb (see example of position below). The position
will allow the patient to prepare for taking weight on the affected side, but minimizes
the role of the knee and ankle - they only have to accommodate the body weight and
not ground reaction forces.
The second position will be with the patient in supported standing – either with their
backs against a wall with rollers on both sides for support or with a walking aid in
front of the patient. The patient will be asked to stand with the unaffected leg slightly
in front of the affected leg – if the stance phase of gait is being retrained and with the
unaffected leg slightly behind the affected leg if the swing phase of gait is being
exercised. The final position will be with one leg on a step and one leg moving up
and down the step – again, if the stance phase is being re-educated the affected leg
will be on the step and if the swing phase is being re-educated the affected leg will
be on the step.
5|Page
Question 2
2.1 Contrast the clinical findings that you would expect when assessing a patient
with a focal traumatic brain injury with a patient who sustained a diffuse
traumatic brain injury. (10)
Focal injuries will have localized fall-outs (1), i.e. the patient may have only one limb
affected or the patient may present like a hemiplegic patient with one half of the body
affected (1). The clinical signs will include sensory fall-outs, motor fall-outs, and
perceptual fall-outs (3) and may include ataxia and incoordination, but the fall outs
will be limited to the brain lobe that was injured in the attack / accident (1). A diffuse
injury will affect more than one limb (1) and there will be more than one fall-out (i.e.
motor- and perceptual- and ataxia and incoordination- fall-outs will be present) (1).
Irrespective of the other injuries, the patient will suffer from severe sensory fall-outs,
as the thalamus will be affected by a diffuse injury (1). The shearing forces
associated with diffuse brain injuries will also lead to slow improvement of patients
and they may not recover from the injury at all (1).
Section D: Orthopaedic Rehabilitation
Question 1
A healthy 30 year old male was involved in a motor vehicle accident two (2)
months ago. He sustained a severely comminuted proximal third fracture of
the left femur. An above knee amputation of the left femur was done on
admission.
1.1 Motivate if this patient will qualify for a prosthesis. (4)
Yes (1), he is young (1) strong (1) and no underlying diseases (1)
1.2 Describe the most likely contracture that this patient may develop as a result
of the amputation and the prevention thereof. (5)
Hip flexion and abduction contracture (1) due to the advantage of the hip flexors and
hip abductors (1)
Strengthening of the hip extensors (1) and hip adductors (1)
Advice on prone position of the patient (1)
6|Page
1.3 List five (5) aspects of the stump that has to be assessed during the objective
evaluation. (5)
Any of the following (up to five) will be marked as correct:
Swelling (1) muscle wasting (1) Girth (1), length of stump (1), ranges of movement of
the hip (1) muscle strength of muscles of the thigh (1), readiness for pressure (1)
The patient complains of phantom sensation.

1.4 List three (3) categories of this sensation that the patient may present with
and give an example of each.
(6)
Any of the following (up to six) will be marked as correct:
Kinesthetic sensations (1) – impressions of postural changes (1), length (1) and
volume of the residual limb (1)
Kinetic sensations (1) – perception of willed, spontaneous or associated movements
(1)
Exteroceptive sensations (1) – perceptions of touch (1), temperature (1), pressure
(1)
The Physiotherapist decides to perform dynamic stump exercises with the

patient.
1.5 Explain any five (5) aims of dynamic stump exercises. (5)
To accustom the stump to pressure (1) to decrease hypersensitivity (1) in
preparation for use of prosthesis (1)
To stretch the hip flexors (1) to prevent development of hip flexion contractures (1)
To improve strength of the hip extensors (1), hip adductors (1) to counteract the pull
of the hip flexors and abductors (1) and to allow easy use and control of the
prosthesis (1)
Re-educate proprioception (1)
Promote muscle tone (1)
Increase circulation (1)
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Section E: Sport Rehabilitation
Question 1
A 23 year old soccer player consulted a physiotherapist because he has
chronic pain in the groin. His pain got worse a week ago after playing the
Super 8 Tournament. The main activities that aggravate his symptoms are
rapid changes of direction and kicking.
1.1 Discuss the reasons why it is a challenge to manage groin pain in soccer
players. (9)
Overuse injury in the adductor region, player continues to play and gradually the pain
concentrates at the adductor longus insertion (1) at the inferior pubic bone. After a
period of continued play, the iliopsoas muscle (1) becomes painful as well. It
becomes tight (1) and develops trigger points. The tendon thickens (1). Pelvic
instability/ poor pelvic control develop because of muscle imbalance (1). This
becomes more pronounced at the later stages of match because of fatigue (1). The
athlete develops a small avulsion of the conjoint tendon which affects the inguinal
canal (1). This leads to signs of an incipient hernia (1). Poor conditioning, core
instability, dysfunction related to low back pain/ thoracolumbar region or the SIJ lead
to compensatory movements (1).
The patient is diagnosed with an adductor tendinopathy

1.2 Describe the clinical test that distinguishes adductor tendinopathy from other
groin conditions. (4)
Squeeze test (1) – pain with resisted adduction (1); supine lying with knees bent (1);
therapist puts fist between patient’s legs; instructs patient to squeeze his fist (1).
1.3 Discuss four (4) principles of Physiotherapy management for adductor

tendinopathies. (12)
Ensure the exercise is performed without pain (1)
Pain –free exercise is crucial (1); should be pain-free during and after exercise (1);
provocation test, squeeze test should be pain-free (1); promote healing process (1)
Identify and reduce the sources of increased load on the pelvis (1)
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Reduce adductor muscle tone (1) and guarding with soft tissue treatment (1); correct
iliopsoas muscle shortening: (1) neural stretching (1) and mobilization of upper
lumbar intervertebral joints (1); reduce gluteus medius muscle tone; identify and
correct hip joint abnormality; mobilize stiff intervertebral segments
Improve lumbopelvic stability (1)
Activation (1) and timing of transverses abdominis (1); application of pelvic belt (1) to
minimize pelvic instability (1)
Strengthen local musculature (1)
A graduated pain-free muscle strengthening program is started once pain has settled
and muscle shortening has been corrected (1); static (1) followed by dynamic
exercises (1)
Progress the patient’s level of activity on the basis of regular clinical assessment (1)
Aim to gradually increase the load on the pubic bones and surrounding tissue (1);
pain free walking is gradually increased in speed and distance (1).
GRAND TOTAL: 120 MARKS
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MEMORANDUM
X
RE- EXAMINATION
NUMBER OF STUDENTS: 52 TOTAL MARKS : 120

Dr Cochrane
Mr Dawood
Ms Nkuna
Ms Sobantu
1|Page
Question 1
A 70 year old female consults Physiotherapy complaining of back pain and
poor balance. She has had a pelvic fracture one (1) year ago and she has been
smoking cigarettes for 50 years. Her osteoporosis test results were positive.
1.1 Explain the Physiotherapy treatment aims for a patient with osteoporosis. (10)
To improve posture by use of exercises (1). These exercises improve your posture
and reduce rounded or “sloping” shoulders (1). They can help you decrease the risk
of breaking a bone, especially in the spine (1). To strengthen hip and back (spine) -
strengthening (1) exercises. These exercises can help you to strengthen the muscles
in your back and hips (1). To improve balance- exercises (1). These exercises
strengthen your legs and challenge your balance (1). They can decrease your
chance of falling (1). To improve the function (1) of the patient - functional exercises
(1). These exercises improve how well you move. They can help you in everyday
activities and decrease your chance of falling and breaking a bone. For example, if
you find it hard to get up from a chair or climb stairs, you should do these activities
as exercises (try standing up and sitting down several times until you are tired).
Question 2
A 28 year old female was diagnosed with stage three (3) breast cancer. She
had a mastectomy a month ago.
2.1 Discuss the cancer rehabilitation post-surgery for this patient. (10)
The goal of physical therapy after surgery and during cancer treatment (radiation,
chemotherapy) is to minimize the side effects and to optimize function (1). Physical
Therapy interventions include:
• Manual Therapy (1). Manual Therapy is defined as skilled hands on treatment
to the joints, muscles, fascia and scar (1). This can help with restricted range
of motion, pain and swelling (1).
• Lymphedema Treatment (1). This treatment includes manual lymphatic
drainage, compression bandaging, evaluation for garments, and instruction in
exercise and self-care (1).
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• Postural Training (1). Physical therapy will address the postural changes after
surgery with postural specific exercises and ergonomic assessments (1).
• Exercise (1). Exercise through all the phases (prior, during and after) is of vital
importance and has been proven to minimize, or eliminate the side effects of
treatment. Physical therapy will provide an individualized programs with
specific goals (1).
Question 1
A 32 year old male all center operator suffers from pins and needles and vague
pain from his right medial elbow, all the way down to his pinky finger. These
symptoms are occasionally accompanied by severe pain around his cervical
area. He has constant pain with a Numerical Pain Score (NPS) of 3/10. His
pain is exacerbated (to 10/10) when he answers a call and hold the phone with
his right hand. He reduces his pain to the resting level of pain by moving his
wrist and neck repeatedly for about a minute.
1.1 Compile a list of five (5) possible diagnoses for this patient (5)
Nerve root compression of C8 / T1 (1)
Neural immobility of the ulna nerve (1)
Any diagnosis affecting mechanical interfaces (1)
Ulnar Nerve neuritis (1)
1.2 Justify each diagnosis in Question 1.1 with reference to anatomy. (5)
Each diagnosis used should be justified with an anatomical description
1.3 Justify the type of objective evaluation that should be conducted on this
patient, with specific reference to irritability.
(5)
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Limited evaluation (1) – student then needs to justify the type (of limited evaluation
by means of discussing the behaviour of symptoms (1), irritability (1) and activity vs
time vs intensity principle (2)
1.4 Select the most likely nerve to be affected for the patient and analyse the
manner in which you will objectify the mobility of the selected nerve. Include a
description of a positive test and the interpretations thereof. (10)
Ulnar Nerve (1)
Test : ULNT (1)
Patient position: supine
Therapist position and hand holds: stride standing, close leg against couch, hand-on-
hand (palm on palm) holding fingers distally with your thumb, support arm with thigh,
knuckles of close hand on bed like MNT1 – (1)
Action:
Max comfortable Shoulder depression (1)
Wrist and finger extension/pronation (pronation of forearm and not hand) (1)
Elb fl (1)
G/H ext rot (reposition self before start with ext rot) – using thigh (1)
G/H abd (1)
Structural differentiation – release small amount of scapular depression by flexing
your wrist a small amount (for sh symptoms, control hand and release wrist ext while
maintaining elb fl) (1)
Analysis of the possible interpretations (1) and what they mean (1)
Question 1
1.1 Contrast cerebellar- and sensory ataxia under the following headings (you
may make use of a table). (8)
• Pathology
• Visual disturbances
• Motor impairments
Sensory Ataxia Cerebellar Ataxia
Pathology Lower motor neuron lesion that Upper motor neuron
affects the spinal cord after the lesion that affects the
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anterior horn cell (1) cerebellum and posterior
cord of the spinal cord (1)
Visual disturbances No nystagmus or visual Patient will suffer from
disturbances will be present (1) nystagmus (1)
Motor impairments • Titubation / tremors in the • Postural titubation and
extremities (1) tremors (1)
• Positive Rhomberg sign (1) • Negative Rhomberg
sign (1)
1.2 Discuss the different types of stimulation that should be provided to a patient
during the execution of Frenkel’s exercises for a patient with ataxia. (7)
Auditory input (1) – the therapists should count aloud as the patient is performing the
movement and the input should be rhythmical (1).
Tactile and proprioceptive input (1) – will be provided in two ways – the introduction
of friction, as the foot slides over the bed (1); and the touch-input of the therapist on
the patient’s affected lower limb(s) during the performance of movement (1).
Visual input (1) – markers should be placed on the bed where the patient is
performing the movement to provide a target for the patient’s foot to reach (1).
Question 2
A 69 year old female patient sustained a stroke two (2) days ago. She is
currently being managed in the ward and is medically stable. She presents
with significant muscle weakness and hypotonia in the left upper- and lower
limbs. Today is the first day that she is consulting a Physiotherapist.
2.1 Outline the impairment-level assessment that should be conducted on this
patient (in order of priority). (10)
Respiratory assessment (1) – should be prioritized because patient is still in the
acute phase of recovery and at a high risk of developing nosocomial infections (1).
Sensation assessment (1) – the order of priority for this patient is higher than other
acute injuries as the patient (left hemi) may suffer from hemi-spatial neglect (1).
Shoulder girdle / upper limb assessment (will also give a correct mark for pain
assessment) (1) – when there is severe hypotone in the upper limb the patient is
likely to subluxate / dislocate the joint or hurt the shoulder girdle in the acute phase,
which can result in shoulder-hand-syndrome later in rehabilitation (1).
Other assessment strategies (order of priority does not matter) are:
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Objective muscle tone assessment (1); range of motion assessment (1); muscle
activation assessment (1); visual assessment (1); proprioception assessment (1).

Question 1
A 45 year old patient was diagnosed with a right transverse mid-shaft femur
fracture and was managed with Open Reduction and Internal Fixation (ORIF)
three (3) days ago.
1.1 Explain the weight bearing status of this patient. (3)
Any of the following (up to three) will be marked as correct:
Full weight bearing (1) because the type of fracture is quite stable (1) and the
intramedullary nail is strong enough to support and reinforces the fracture during
weight bearing and promotes stability (1) weight bearing promotes callous formation
(1).
1.2 Discuss a holistic Physiotherapy management programme for the patient at

this stage of recovery. (20)
• Active ankle movements (1) with limb in elevation (1) to promote circulation
(1) and reduce swelling (1) since anesthesia causes sluggishness in blood
flow (1) to prevent development of DVT (1).
• Ice therapy (1) to reduce pain (1) and swelling around the knee and thigh (1).
• Patella mobilization (1) to prevent stiffness of the patella and the knee joint
(1).
• Assisted active movements of the knee joint (1) to improve knee flexion range
of motion (1) to prevent development of joint stiffness (1) and muscle
shortening (1).
• Hold relax technique for the quadriceps (1) to improve range of knee flexion in
the presence of pain (1).
• Active knee extension (1) to improve strength of quadriceps (1) since their
function will be inhibited by the injury and the operation (1) to prevent quads
atrophy (1).
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• Isometric quadriceps exercises (1) to promote strength of the quads at
terminal knee extension (1).
• Push-ups in long sitting (1) to maximise UL muscle strength (1) in preparation
for use of walking aids (1).
• Bridging (1) to promote strength of hip extensors (1) and use of bed pan when
the patient is not yet independent in walking with aids (1).
• Gait re-education (1) with a walking frame (1) FWB (1) to promote
independence out of bed (1).
Five (5) days following surgery, the patient complains of pain and swelling at
the back of the leg.
1.3 Name the possible diagnosis and the test that the Physiotherapist should use
to confirm the diagnosis. (2)
Deep vein thrombosis (1); Homan’s test (1)
Question 1
Shoulder instability is very common in overhead athletes. Physiotherapy
plays a pivotal role in the management of shoulder instability.
1.1 Describe the ‘AMBRI’ instability of the shoulder. (5)
AMBRI- Atraumatic (1) Multidirectional instability (1) that is bilateral (1). It responds
well to rehabilitation (1) but may require inferior shift of capsule if rehabilitation fails
(1).
1.2 Discuss five (5) principles of shoulder rehabilitation. (20)

Promote early pain reduction (1): pain is a major cause of altered function (1),
avoidance of painful positions causes sports people to abnormal positions of arm
and back (1). Pain causes muscle inhibition which alters muscle firing patterns (1).
Control pain by early mobilisation (1), encourage relative rest (1), decreased
throwing activities (1), avoid painful arcs of motion (1), administer NSAIDs (1).
- Integrate kinetic chain into rehabilitation (1): it is important to re-establish kinetic
chain early in the rehabilitation process, while shoulder is recovering trunk and leg
7|Page
exercises should be prescribed (1). This allows normal link sequencing to generate
velocity and force (1). Correct trunk muscle imbalance (1). Generate sport- specific
force and velocity from the lower extremity in a closed chain fashion (1).
- Promote stabilisation of the scapula (1): Scapula is the base on which all shoulder
activities rest (1). Selectively activate scapula stabilising muscles through early
achievement of abduction (1) and improved glenohumeral rotation (1). Most throwing
activities in sports demand 90º of shoulder abduction as throwing activities occur
between 85º and 110º of abduction and require a large arc of glenohumeral
abduction (1).
- Practice closed chain rehabilitation (1): Muscle activation around the shoulder
articulation is a closed chain activity emphasizing co-contraction force couples at the
scapulothoracic and glenohumeral joint (1). Exercises are started at levels below 900
of abduction. In the early phases to allow for healing of tissues (1). This results in a
proper scapulohumeral-rhythm and allows rotator cuff to work as compressor cuff
conferring concavity compression and a stable instant center of rotation (1).
- Introduce plyometrics (1): Most athletic activities involve development of power. For
most athletes, the time component is relatively rapid (1). Because these exercises
develop a large amount strain in the eccentric phase of the activity and force in the
concentric phase of the activity (1), they should be done when complete anatomical
healing has occurred. Full range of motion should be achieved before plyometric
exercises are started (1).
8|Page
MEMORANDUM
X
RE- EXAMINATION
NUMBER OF STUDENTS: 52 TOTAL MARKS : 120
INTERNAL EXAMINERS PARTICULARS: 1. Prof Maleka

Ms Kotsokoane
Ms Human
Mr Tshabalala
Ms Raphokwane
1|Page
Section A: Community Physiotherapy and Public Health
Question 1
Older adults experience one or more falls during their lifetime, irrespective of
where they reside.
1.1 Define the term older adult in the context of South Africa. (2)
An older adult is any person male or female (1) who is 60 years and above (1).
1.2 Explain five (5) ways in which Physiotherapists can prevent falls in the homes
of older adults. (10)
Any of the following (up to 10) will be marked as correct:
• Exercising (1) – strengthens the muscles generally, improve on proprioception
and reduce improve balance and reduce/delay falls in older adults (1).
• Arranging furniture well (1) – this creates room/space for safe mobility inside
the house (1).
• Should not use/ have loose mats (1) – the floor is free from hazards that can
predispose an older adult to falling (1).
• Electricity needs to be appropriate (no loose/hanging cords) (1)– if there is no
way of avoiding such, cords should be out of the way, under a carpet
otherwise older adults mat trip and fall (1).
• Sufficient lighting (1) – the rooms should be well lit to enable the older adult to
see clearly in each room. No clutter in the house should be kept (1).
• Be advised to avoid using alcohol or reduce the amount consumed (1) – older
adults should strive to remain in control and be able to interact with the
environment well without intoxication (experiencing adverse effects of alcohol
consumption) (1).
• Reporting any medication side effects early (1) – dizziness is one side effects
of chronic medication that older adults take. If reported, changes to
medication can be made timeously (1).
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1.3 List three (3) reasons why it is important to prevent falls in older adults. (3)
• Falls cause restricted activity and immobility (1)
• Falls are responsible for high medical costs (1)
• Fall can lead to death (1)
• Falls are preventable (1)
• Falls cause disability (1)
The number of older adults are on the increase globally but still experience
diverse social problems despite the rights they have as South African citizens.
1.4 Explain four (4) social problems that older adults are likely to experience
which mainly lead to institutionalization / residing in old age homes.
(8)
Any of the following (up to eight) will be marked as correct:
• Poverty (1) - No other source of income except government grants which
might not be enough (1).
• Poor housing or loss of accommodation (1) - Might lack shelter and live in the
street or cannot maintain the existing house and not be able to maintain it (1).
• Lack of heating (1) - Sources of energy might not be accessible to the patient.
E.g. high electricity bills, no strength to carry wood for fire (1).
• Loneliness/living alone (1) - Children are married, spouse passed on if
married and none one to share their lives with (1).
• Loss of status (1) - No longer seen as valuable/important, are ignored and not
given attention by the society (1).
1.5 Explain participation as a principles under the declaration of the rights of older
adults in South Africa. (7)
Older persons should remain integrated in the society (1); they are to participate
actively in the formulation (1) and implementation (1) of policies that directly affect
their wellbeing (1). They should share their knowledge (1) and skills (1) with the
younger generations (1). They should seek and develop opportunities for service to
the community (1) and to serve as volunteers in positions appropriate to their
interests and capabilities (1). They should be able to form movements or
associations of older persons and manage them (1).
3|Page
Section B: Cardiorespiratory Therapy
Question 1
A 40 year old male mine worker had undergone a Coronary Artery Bypass
Graft (CABG) a week ago and is referred for Physiotherapy.
1.1 Explain the underlying pathophysiology for this patient. (4)
Coronary Artery Disease (1) is an occlusion / obstruction (1) of the coronary arteries
(1) resulting from atherosclerosis (1).
1.2 Explain three (3) factors that may hinder maximum performance for this
patient during exercise.
(6)
An increase in systolic BP during exercises (1) to above 20 beats of the targeted
heart rate (1).
Chest pain (1) due to increased cardiac output work (1).
Feeling dizzy/dyspnea (1) due to unstable ECG wave during exercises (1).
1.3 Outline the goals of cardiac rehabilitation. (8)

To decrease cardiac morbidity (1) and relief of symptoms (1).
To promote risk modification (1) and secondary prevention (1).
Increase fitness (1) and resume normal activities (1).
To improve self- confidence (1) and knowledge (1).
The patient complicates and presents with signs of post-operative atelectasis.

Intermittent Positive Pressure Breathing (IPPB) is the treatment of choice.
1.4 Outline the purpose of IPPB. (5)
Increase alveolar ventilation (1)
Improve ventilation-perfusion ratio (1)
Mobilise and facilitate expectoration of thick secretions (1)
Decrease WOB (1)
Deliver aerosolized medication (1)
4|Page
1.5 Briefly describe the Physiotherapy management for the patient at this stage of
recovery. (7)
This will include chest Rx to clear airway of any accumulation of secretions (1)
E.g.: Nebulisation (1), Postural drainage (1), Gentle vibrations (1) and suction (1).
Breathing techniques (1) such as localised breathing exercises (1), Active cycle of
breathing technique (1) incentive spirometry (1).
Section C: Paediatric Rehabilitation – Cerebral Palsy
Question 1
A five year old boy is diagnosed with mild to moderate ataxia. He is seen by a
Physiotherapist to prepare him for school
1.1 Explain the differential diagnosis of ataxia. (3)
Ataxic disorders of children can be divided into acute (may be chemically induced)
(1), Chronic progressive (genetic disorders) (1) and Chronic non-progressive (CP
type) (1).
1.2 Explain three (3) clinical features of ataxia. (6)

• Postural tone is low, but some movement and a degree of postural control
against gravity is possible (1).
• Lack of co-contraction proximally (1) resulting in:
o inability to hold steady postures (1);
o inability to give stability to a moving part (1).
• Co-ordination of movement (1):
o patterns can appear normal (1);
o patterns are immature and tend to be more total (1);
o lack of selectivity (1);
o fine graded movements difficult to coordinate (1).
• Balance reactions (1):
o usually present but not adequate (1);
o often delayed, badly coordinated, excessive in range (1);
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o child cannot adapt to shift in COG quick enough and grade muscles
(1), thus child becomes fearful, and tends to move quickly (1).
• Disturbed reciprocal innervation (1) and manifest as:
o titubation of the head (1);
o truncal sway (1);
o intention tremor (1);
o dysmetria (1);
o nystagmus (1);
o jerkiness of movements (1).
1.3 Outline the Physiotherapy treatment principles for ataxia. (6)

• Increase and steady postural tone (1):
o sustained postural control: Pressure tapping (1);
o grading of movement: Alternate tapping (1).
• Facilitate active adaptation to being moved (1)
• Work for quality of movement (placing, reversing, grading and modulation of
force, timing and direction) (1)
• Regulate balance reactions (1)
• Facilitate selectivity of movements, and independence of limbs from trunk (1)
• Gain rotation about body axis (1).
6|Page
Section D: General Paediatric Rehabilitation
Question 1
A baby was born with myelomeningocele (L5/S1) and presented with
hydrocephalus at two (2) weeks of age. Both conditions were treated
surgically. Currently, the baby is four (4) weeks old.
1.1 Explain the association between myelomeningocele, hydrocephalus and
Arnold Chiari II.
(3)
Due to the tethering of the spinal cord and meninges (possibly due to surgery), there
might be increase downward “pulling” on the spinal cord, also due to the
myelomeningocele (1) Arnold Chiari II malformation (cerebellar hypoplasia), the
hindbrain/posterior part of the brain descends inferiorly (small posterior fossa) into
the foramen magnum and the brain can be underdeveloped/malformed(1). This
causes a blockage at the level of the 4th ventricle, causing hydrocephalus (non-
communicating/obstructive) (1).
1.2 Name the tests that should be used to determine if a new-born presents with
associated hip pathology, such as developmental dysplasia of the hip.
(2 x ½ = 1)
Barlow (1/2) and Ortolani (1/2) tests.
1.3 List two (2) signs and symptoms that parents have to look out for that might
indicate that the ventriculo-peritoneal (VP) shunt is malfunctioning. (2)
Any of the following (up to two) will be marked as correct:
Increase in head circumference (1); Sunsetting eyes (downward deviation of the
eyes) (1); Bulging fontanelles (soft spot on the head) (1); Nausea, vomiting (1);
Papilledema (1); Irritability (1); Sleepiness (1); Fever (1); Headache / pain /
discomfort (1); Altered speech/vision (1); Change in muscle tone (increase in tone)
(1); Cerebellar signs (balance and coordination influenced, clumsiness) (1); Sensory
changes (1); Weakness (1); Decrease in functional performance (1); Change in
personality (1); Change in cognitive ability (1); Bowel and bladder dysfunction (1);
Swelling and redness/tenderness around the shunt area (1); Decreased / impaired
7|Page
head control (which just started to develop at 3 months of age) (1); Stiffness of the
neck and shoulder muscles (1).
1.4 Provide an applicable and age-appropriate outcome measurement that can be
used to determine if the patient is experiencing pain or discomfort. (1)
FLACC scale (as the patient is younger than two years of age) (1)
1.5 Explain how the level of the defect might influence the patient’s prognosis
regarding functional mobility. (2)
The level of the lesion determines the patient’s functionality: the higher the site/lesion
the greater the extent of paralysis and motor function, the more assistance and
orthotics (e.g. AFO, later KAFO) might be needed for independent mobility (1). In this
case the patient should be able to mobilise with the assistance of a walking frame
and AFOs, therefore the prognosis is good (1).
1.6 Explain three (3) Physiotherapy treatment principles for the patient as an
infant and toddler.
(6)
The infant and toddler with myelomeningocele - The emphasis here will be more
passives and education of caregiver on how to take care of the child.
• Early intervention: prevention of contractures, skin breakdown (1)
• Maximising developmental skills (milestones) (1)
• Educate and support parents and caregivers (1)
• Positioning (contractures), minimise “frogged legs”, using aids, towel rolls etc
to position the child correctly (1).
• Health care activities; check shunt, medications, observe skin, address
feeding difficulties, bowel & bladder care (therefore parent support NB) (1).
• Interact with child, play therapy, balance & coordination, age appropriate play
& activities (1).
• Active play encourages UL & trunk strength, ROM (1)
• Watch out for decreased sensation, other complications such as osteoporosis
(1)
• Balance, coordination (1)
8|Page
• Protective devices, such as knee pads, long pants, protective shoes (minimise
skin abrasions) when patient tries to mobilise (1)
• Mobilise, change positions (1)
• ROM, strengthening muscles (1)
• Assistive technology (1)
• Confidence, skills, adaptive devices (1)
• Developmental activities (1)
• Respiratory and other medical management if required (1)
• Fit of assistive devices, orthosis (1)
• Group classes, activities (1)
• Communication+++ (1)
Section E: Professional Practice
Question 1
1.1 Explain the relationship between the International Classification of
Functioning, Disability and Health (ICF) and rehabilitation practice.
(6)
Student can illustrate their answer using the diagram below or narrate their answer
using the x and y axis components of the diagram below.
9|Page
Question 2
2.1 Explain the levels of evidence for qualitative research. (8)
In qualitative research the evidence is represented by the trustworthiness of the
study by assessing four main criteria
– Credibility (1)
• Refers to the presentation of accurate description or interpretation of human
experience that people who also share that experience would immediately
recognise the descriptions (1).
– Dependability (1)
• Refers to whether the findings would be consistent if the inquiry were
replicated with the same subjects or in a similar context (1).
– Transferability (1)
• Refers to the degree to which the findings can be applied to other contexts
and settings with other groups, it is the ability to generalise from the findings
to larger population (1).
– Confirmability (1)
10 | P a g e
• Refers to the degree to which the findings are a function solely of the
informants and conditions of the research and not of other biases, motivation
and perspectives (1).
Question 3
Mark is a third year student at Sefako Makgatho Health Sciences University
(SMU), who has just completed his community block at Winterveldt clinic. All
students were expected to keep a reflective diary. Day 5 in the block, he wrote
the following reflection in his reflective diary:
“This morning of the 14 April 2017 started a bit slow. Our supervisor arrived
late and shouted at us for not treating out-patients who were sitting in the
waiting area. It was not our fault, the secretary did not tell us that the patients
were waiting for us to treat. I was irritated by our supervisor. From then
onwards the situation got worse, as I was treating a patient, the supervisor
came into my cubicle and started asking me questions about my patient and
his condition. I was so terrified and could not answer my supervisor’s
questions. I mixed up my facts and my supervisor was not impressed with me.
This confirms what I have always assumed about our supervisor, that she not
like students.
The day was saved by our community outreach event, home visits. We drove
out to the first patient Mrs X. She is a 63 years old stroke survivor. According
to my assessment, this patient is doing extremely well because she is
improving well functionally but still not reintegrated in her community. I have
not used any outcome measure to assess her level of integration, so on my
way to her house, I thought of an outcome measure that Ms K taught us in
class. I am intending to use this outcome measure today. I wonder if there are
other outcome measures that I can use for my patient in order to assess her
level of integration. Maybe I must google when I get to the University this
afternoon or ask Mr T.
After our home visit, our supervisor, called us to reflect on our experiences on
the home visits. I was pleasantly surprised at how she guided our thinking in
this discussion. I only realised then that our supervisor want us to perform at
our best at all times and provide quality services. After the discussion with our
supervisor I learned that one must not make assumption and create
11 | P a g e
perceptions that are incorrect. This whole experience will help me be a good
supervisor in the future, and it is a great skill to have as person”.
3.1 Discuss the various levels of reflective writing and practice by using specific
quotations contained in the above reflective piece of writing. (16)
Naming and describing the level of reflective writing and practice using quotation
from the reflective piece of writing above as follows:
Descriptive writing (4 marks)
• What happened? Give lots of detail, it helps with understanding the
importance of context
Descriptive reflection (4 marks)
• Why was the incidence moving?
• Feelings: How did it make you feel?
• Identifying assumptions
Dialogue reflection (4 marks)
• Exploring and imagining alternatives.
• Challenging assumptions.
Critical reflection (4 marks)
• How has this incidence changed you professionally and personally?
– What was good or bad?
– What sense can you make out the situation? Lessons learnt.
– If it arose again, what would you do?
12 | P a g e
MEMORANDUM
RE- EXAMINATION X

Dr Cochrane
Mr Dawood
Ms Nkuna
Ms Sobantu
1|Page
Question 1
1.1 Prescribe Physiotherapy management for a patient with stress incontinence.
(10)
• Pelvic muscle training exercise (1) to keep the urethral sphincter strong and
working (1).
• Some use vaginal cone with pelvic exercises (1)
• Biofeedback and electrical stimulation (1) may be useful for people doing
pelvic muscle training (1)
• Electrical stimulation therapy uses a low-voltage electrical current (1) to
stimulate and contract the correct group of muscles (1) this is done by anal or
vaginal probe (1)
• Treatment sessions usually last 20 min (1) and may be done every 1-4 days
(1).
1.2 Discuss the Physiotherapy treatment of a patient with erectile dysfunction.

(10)
Physiotherapy can help by:
• Removal of aggravating factors (1)
• Manual therapy treatment to your low back and pelvis, getting the joints
moving correctly (1)
• Trigger point therapy: Getting the muscles working properly and reduction of
the overactive parts in the low back muscles, hip muscles and pelvic floor
muscles. (1)The patient should be taught how to do this himself (1)
• Pelvic floor exercises to release the pelvic floor (1)
• Self-stimulation activities are essential. Using hot, cold, light and harder
touching of the penis can help with sensory reactivation. (1)If the nerves are
damaged after surgery then sensory reception will be compromised. (1) Such
activity can be done at home and often is better to do regularly(1)
• Specific hip, spine and pelvis exercises to get the patient and his pelvic floor
moving better(1)
2|Page
• Specialised breathing and relaxation work. Relaxation through breathing has
been found to be hugely beneficial for all types of conditions (1)
• Re-education of the pelvic floor, hip and abdominal musculature (1)
• General exercise (1)
Question 1
A 21 year old female model was on the runway when she flicked her hair
towards her right hand side and experienced a sharp pain in her neck. She
explains that she is now “stuck facing her right hand side and cannot look
straight ahead”. She also notes that she regularly suffers from headaches. Her
pain is a constant 4/10 and is aggravated to an 8/10 when she brings her neck
up from cervical lateral flexion into neutral. The patient eases up immediately
when she is in the “stuck” position.
1.1 Prioritise a list of three (3) possible diagnoses for this patient. (4)
Acute locked cervical joint (1 mark for the diagnosis and 1 mark for the priority)
Torticollis (1)
1.2 Describe the manner in which you will determine the irritability of the patient’s
condition. (4)
Not irritable (1) – time to aggravate (1) – Time to ease (1) – Low Sin (1)
During the assessment you find that the patient has overactive, hypertrophic
mobilisers, in-active stabilisers and accompanying joint and soft tissue
restrictions.
1.3 Create a treatment plan to manage the most likely diagnosis for this patient.
Include the possible restrictions with their corresponding treatment techniques
as well as relevant Orthopaedic Manual Therapy treatment techniques. (17)
Selection of Acute cervical locked joint (1)
3|Page
Joint restriction type (1) – Lateral flexion (Symbol (1) Grade 3 or 4 (1) Time (1)
Dosage (1)
Soft tissue restriction (length and TP) – (2) mention headaches
Rx of above – MFR (1) Stretches (1)
Activation of deep cervical flexors (1) – Proper explanation of how to (1)
Global stabiliser retraining (1) - explanation of an exercise (1) – eccentric (1) –
Dosage (1) – Position (1) dissociation (1))
Student can use aids for their exercises (theraband, towel etc etc) and this will result
in marks for the explanation of the exercises
Question 1
Mrs X sustained a stroke that affected her left side (right middle cerebral artery
infarct) four (4) weeks ago. She is currently unable to walk, although she can
perform sit-to-stand activities with moderate assistance. Her left arm is flaccid
and she cannot use the arm functionally at all.
1.1 Discuss the clinical differences between an anterior cerebral artery stroke and
a middle cerebral artery stroke. (5)
ACA: Blood supply to the frontal lobes (left and right) and primary motor cortex will
be affected (1). The patient will present with the following signs – Change in
personality, inability to plan movement sequences resulting in delayed
reaction times and the lower limb will be more severely affected that the upper
limb, resulting in a poor prognosis for gait (any sign will be given a mark).
MCA: Blood supply to the parietal lobes and secondary motor cortex (left and right)
will be affected.(1) The patient will present with the following signs and
symptoms – change in ability to perceive sensation – which indicates a poor
prognosis for sensory recovery (1). The upper limb will be more severely
affected than the lower limb, which indicates a poor prognosis for the upper
limb. The patient will struggle with initiation of movement, termination of
movement and execution of a movement sequence (1).
4|Page
1.2 Describe the precautions that should be considered during rehabilitation of
this patient. (5)
The arm should not be pulled on during rehabilitation – high risk of subluxation and
dislocation (1). The arm should be positioned at a 45º angle when the patient is in
supine, especially during rolling / bed mobility activities (1)
The patient might suffer from hemi-spatial neglect – the therapist should not leave
the patient unattended (1) and should remain on the affected side at all times during
treatment (1).
The affected foot must be positioned well to prevent sub-talar subluxation and to
optimize the position of the knee (especially during standing positions) (1).
1.3 Explain one (1) treatment position option in which the patient can be placed to
re-educate gait during rehabilitation. (5)
Any one of the following positions can be explained (up to five marks):
The patient should be treated in positions of weight bearing but with constraining the
joint that is not actively being exercised. The three best positions will be
asymmetrical. Position one: half kneeling with the one lower limb and two-point
kneeling with the opposite lower limb (see example of position below). The position
will allow the patient to prepare for taking weight on the affected side, but minimizes
the role of the knee and ankle - they only have to accommodate the body weight and
not ground reaction forces.
The second position will be with the patient in supported standing – either with their
backs against a wall with rollers on both sides for support or with a walking aid in
front of the patient. The patient will be asked to stand with the unaffected leg slightly
in front of the affected leg – if the stance phase of gait is being retrained and with the
unaffected leg slightly behind the affected leg if the swing phase of gait is being
exercised. The final position will be with one leg on a step and one leg moving up
and down the step – again, if the stance phase is being re-educated the affected leg
will be on the step and if the swing phase is being re-educated the affected leg will
be on the step.
5|Page
Question 2
2.1 Contrast the clinical findings that you would expect when assessing a patient
with a focal traumatic brain injury with a patient who sustained a diffuse
traumatic brain injury. (10)
Focal injuries will have localized fall-outs (1), i.e. the patient may have only one limb
affected or the patient may present like a hemiplegic patient with one half of the body
affected (1). The clinical signs will include sensory fall-outs, motor fall-outs, and
perceptual fall-outs (3) and may include ataxia and incoordination, but the fall outs
will be limited to the brain lobe that was injured in the attack / accident (1). A diffuse
injury will affect more than one limb (1) and there will be more than one fall-out (i.e.
motor- and perceptual- and ataxia and incoordination- fall-outs will be present) (1).
Irrespective of the other injuries, the patient will suffer from severe sensory fall-outs,
as the thalamus will be affected by a diffuse injury (1). The shearing forces
associated with diffuse brain injuries will also lead to slow improvement of patients
and they may not recover from the injury at all (1).
Question 1
A healthy 30 year old male was involved in a motor vehicle accident two (2)
months ago. He sustained a severely comminuted proximal third fracture of
the left femur. An above knee amputation of the left femur was done on
admission.
1.1 Motivate if this patient will qualify for a prosthesis. (4)
Yes (1), he is young (1) strong (1) and no underlying diseases (1)
1.2 Describe the most likely contracture that this patient may develop as a result
of the amputation and the prevention thereof. (5)
Hip flexion and abduction contracture (1) due to the advantage of the hip flexors and
hip abductors (1)
Strengthening of the hip extensors (1) and hip adductors (1)
Advice on prone position of the patient (1)
6|Page
1.3 List five (5) aspects of the stump that has to be assessed during the objective
evaluation. (5)
Swelling (1) muscle wasting (1) Girth (1), length of stump (1), ranges of movement of
the hip (1) muscle strength of muscles of the thigh (1), readiness for pressure (1)
The patient complains of phantom sensation.

1.4 List three (3) categories of this sensation that the patient may present with
and give an example of each.
(6)
Kinesthetic sensations (1) – impressions of postural changes (1), length (1) and
volume of the residual limb (1)
Kinetic sensations (1) – perception of willed, spontaneous or associated movements
(1)
Exteroceptive sensations (1) – perceptions of touch (1), temperature (1), pressure
(1)
The Physiotherapist decides to perform dynamic stump exercises with the

patient.
1.5 Explain any five (5) aims of dynamic stump exercises. (5)
To accustom the stump to pressure (1) to decrease hypersensitivity (1) in
preparation for use of prosthesis (1)
To stretch the hip flexors (1) to prevent development of hip flexion contractures (1)
To improve strength of the hip extensors (1), hip adductors (1) to counteract the pull
of the hip flexors and abductors (1) and to allow easy use and control of the
prosthesis (1)
Re-educate proprioception (1)
Promote muscle tone (1)
Increase circulation (1)
7|Page
Question 1
A 23 year old soccer player consulted a physiotherapist because he has
chronic pain in the groin. His pain got worse a week ago after playing the
Super 8 Tournament. The main activities that aggravate his symptoms are
rapid changes of direction and kicking.
1.1 Discuss the reasons why it is a challenge to manage groin pain in soccer
players. (9)
Overuse injury in the adductor region, player continues to play and gradually the pain
concentrates at the adductor longus insertion (1) at the inferior pubic bone. After a
period of continued play, the iliopsoas muscle (1) becomes painful as well. It
becomes tight (1) and develops trigger points. The tendon thickens (1). Pelvic
instability/ poor pelvic control develop because of muscle imbalance (1). This
becomes more pronounced at the later stages of match because of fatigue (1). The
athlete develops a small avulsion of the conjoint tendon which affects the inguinal
canal (1). This leads to signs of an incipient hernia (1). Poor conditioning, core
instability, dysfunction related to low back pain/ thoracolumbar region or the SIJ lead
to compensatory movements (1).
The patient is diagnosed with an adductor tendinopathy

1.2 Describe the clinical test that distinguishes adductor tendinopathy from other
groin conditions. (4)
Squeeze test (1) – pain with resisted adduction (1); supine lying with knees bent (1);
therapist puts fist between patient’s legs; instructs patient to squeeze his fist (1).
1.3 Discuss four (4) principles of Physiotherapy management for adductor

tendinopathies. (12)
Ensure the exercise is performed without pain (1)
Pain –free exercise is crucial (1); should be pain-free during and after exercise (1);
provocation test, squeeze test should be pain-free (1); promote healing process (1)
Identify and reduce the sources of increased load on the pelvis (1)
8|Page
Reduce adductor muscle tone (1) and guarding with soft tissue treatment (1); correct
iliopsoas muscle shortening: (1) neural stretching (1) and mobilization of upper
lumbar intervertebral joints (1); reduce gluteus medius muscle tone; identify and
correct hip joint abnormality; mobilize stiff intervertebral segments
Improve lumbopelvic stability (1)
Activation (1) and timing of transverses abdominis (1); application of pelvic belt (1) to
minimize pelvic instability (1)
Strengthen local musculature (1)
A graduated pain-free muscle strengthening program is started once pain has settled
and muscle shortening has been corrected (1); static (1) followed by dynamic
exercises (1)
Progress the patient’s level of activity on the basis of regular clinical assessment (1)
Aim to gradually increase the load on the pubic bones and surrounding tissue (1);
pain free walking is gradually increased in speed and distance (1).
9|Page
MEMORANDUM
RE- EXAMINATION X
INTERNAL EXAMINERS PARTICULARS: 1. Prof Maleka

Ms Kotsokoane
Ms Human
Mr Tshabalala
Ms Raphokwane
1|Page
Section A: Community Physiotherapy and Public Health
Question 1
Respite care in South Africa is gradually introduced as part of management of
clients in the home setting.
1.1 Explain the role of Physiotherapy in respite care. (10)
Assess (1) and manage the caregiver (1) physical assessment and appropriate
management according to identified problems (1), e.g. can be taught how to assist
the patient in a correct manner while transferring the patient (1), particularly about
posture in order to avoid musculoskeletal disorders (1). Alleviate the burden from
the care giver (1) who should be encouraged to allow the patient to be more
independent (1). Teach the caregiver about respite care (1) can inform the caregiver
about respite care (1), the benefits thereof (1), the burden of care (financially,
emotionally and physical) and institutions where the services are offered (1).
Question 2
2.1 Describe disability according to the medical model of disability. (5)
Disability is an individual problem (1) the individual is assessed, diagnosed (1) and
given therapy (1) without considering the needs of the individual (1), the individual is
blamed for their disability (1)
Question 3
You are asked to participate in a health project initiated to conduct health
screening in a community.
3.1 Outline the purpose of screening. (3)
Identify diseases early (1), enabling early intervention and management (1) reduce
mortality (1) and suffering from a disease (1).
3.2 Describe the limitations of screening tests. (12)

Screening tests can incorrectly show positives (1) for those without disease (false
positives), negative (1) for those who have the disease (false negative), they are
costs involved in running and unnecessary investigation (1) and treatment of false
positives are a waste of valuable resources such as money (1).
2|Page
Among others and individuals who are deemed positive by a test falsely may suffer
adverse effects such as stress (1), anxiety (1), discomfort (1), exposure to radiation
and chemicals when not necessary (1) some of which are irreversible (1). There is a
delay in diagnosing those with the disease (1) because they are shown to be
negative falsely and they continue with a false sense of security (1) when they are
indeed ill and are not managed on time (1) leading to complications (1) which could
have been prevented or minimised (1).
Section B: Cardiorespiratory Therapy
Question 1
A 60 year old male was diagnosed with a pleural effusion. He underwent a
decortication through a right lateral thoracotomy two (2) days ago. Two (2)
intercostal drains were inserted on the right (anteriorly and posteriorly) as well
as a negative suction drain.
1.1 Define the term ‘pleural effusion’. (3)
Excess fluid (1) that accumulates between the two pleural layers (1), the fluid-filled
space that surrounds the lungs (1).
1.2 Describe how decortication will improve the patient’s condition. (7)
Pus in the pleural space (1) results in positive pressure (1). This prevents
extensibility / expansion of the lung (1) which causes lung collapse (1). Decortication
improves negative pressure (1) and increases air entry (1) into the lung thus
reducing work of breathing (1).
1.3 Explain an indication of a negative suction for this patient. (2)

Facilitate drainage (1) by reducing pressure during inspiration in case the patient has
a broncho-pleural fistula (1).
1.4 Outline the expected findings of an objective evaluation. (5)

• Pus in a form of a fluid level (1)
• Decreased air entry on the right lower lobe (1)
• Decrease chest expansion (1)
3|Page
• Pain on the incision site which will limit ROM of the right shoulder (1)
• Decreased exercise tolerance (1)
1.5 List three (3) precautions that should be followed during treatment. (3)
• Avoid reproducing pain with movements (1)
• ICD tube not to be stretched (1)
• Upper limb movements on the incision site should be done with caution (1)
1.6 Briefly discuss the treatment program for this patient. (10)
Any of the following (up to ten) will be marked as correct:
• To prevent accumulation of secretion in the lungs (1): this will be achieved by
chest physiotherapy e.g. gentle vibrations (1), postural drainage (1),
supported coughing (1).
• To improve and maintain lung compliance (1): this is achieved by doing
breathing exercises e. g. DBE’s (1), ACBT (1), incentive exercises (1) and
encouraging normal breathing pattern bilaterally esp. affected side (1).
• To improve (1) and maintain exercise tolerance (1): agility exercises (1).
Agility exercises also will facilitate drainage (1).
• Maintain joint range of motion to prevent joint stiffness (1): Thoracic mobility
exercises (1) to prevent stiffness of the thoracic cage (1) as well as upper limb
exercises of the affected side (1) to prevent frozen shoulder (1).
• Maintain correct posture (1): emphasise symmetry to prevent scoliosis (1).
4|Page
Section C: Paediatric Rehabilitation
Question 1
The most common neuromuscular diseases (NMD) seen in the paediatric
population are Duchenne muscular dystrophy (DMD) and spinal muscular
atrophy (SMA). Match the following statements with the correct definition.
Write only the question number and letter in your answer script (e.g. 1.1 J).
Fascio-
A. SMA I D. DMD G. scapulohumeral
dystrophy
Becker muscular Distal muscular
B. E. H. Myotonic dystrophy
dystrophy atrophy
Oculo-pharyngeal
C. F. SMA II
muscular dystrophy
1.1 This NMD is usually diagnosed in the first six (6) months of life and has a poor
prognosis. (1)
A
1.2 Patients might present with ptosis. (1)
C
1.3 On posture analysis, these patients often present with scapula winging,
increased kyphosis and shortened pectoralis muscles. (1)
H
1.4 This NMD has a similar distribution of weakness as peripheral neuropathy. (1)
E
1.5 Compare and contrast SMA type II and DMD. You may make use of a table.
(6)
Marks will be allocated for three facts that are compared / contrasted for both
conditions (3 x 2 = 6)
5|Page
SMA II DMD
Etiology: abnormality / mutation, Absence of cytoskeletal protein /
conversion, deletion of the SMN I/2 or dystrophin in the muscle caused by an
VAPB gene on chromosome 5. abnormality of the Xp21
Pathophysiology: Abnormality lies within Abnormality lies in the structure and
the anterior horn cell (motor neuron stability of the muscle (due to a lack of
disease) muscle dystrophy)
Onset of Sx / time of Dx: Early onset Later onset, usually diagnosed in 3-7
(infant / toddler) SMA II. Diagnosed 6- year olds
18 months
Ambulation: attains sitting; can’t stand Walking, regresses and usually
by 12 months and never walks wheelchair bound / non-ambulant by 12
years of age
Clinical presentation / signs: “Floppy” Gower’s sign (weakness in gluteus
baby or infant. APGAR score can also mm); clumsy, frequent falls
give an indication.
Oral / bulbar involvement: severe, Oral / bulbar control not as prominent /
swallowing problems, failure to thrive. severe. Decreased risk of aspiration.
Higher risk of aspiration.
Specific manifestations: Bell shaped Increased lumbar lordosis, waddling gait
chest (due to intercostal mm weakness (proximal weakness)
and relative sparing of diaphragm).
Overall, progressive muscle weakness Weakness of mainly proximal muscles
and atrophy. Including respiratory such as pectoralis, abdominals,
muscles as well. Starts with weakness quadriceps, hamstrings, tibialis anterior,
more proximally (IC mm > diaphragm). gastrocs /soleus. Also influences
respiratory muscles (diaphragm and IC
mm)
Prognosis: Poor to moderate; lifespan: Moderate; usually die in their early 20s.
2years to 30s.
Cause of death: respiratory failure more Cause of death: respiratory failure or
common. cardiomyopathy/cardiac complications.
Prevalence for SMA II and III is higher Most common NMD in childhood (more
(less severe than SMA I) common than Becker mm dystrophy)
1.6 Provide an applicable outcome measurement that can be used for the
following:
1.6.1 A DMD patient’s lower limb function (range of motion and functional
ability) that can indicate disease severity / progression. (1)
Vignos scale (1)
1.6.2 A nine (9) year old DMD patient’s health-related quality of life in the
domains: physical, emotional, social and school performance. (1)
PedsQL (1)
In the majority of boys living with DMD gluco-corticosteroids are prescribed.

6|Page
1.7 Outline the advantage of gluco-corticosteroid usage in these patients with
reference to their functional ability and lung function. (2)
One mark will be allocated for functional ability and one mark for lung function:
Fx ability: patients tend to mobilise/walk longer (before they become non-ambulant)
(1); OR relative preservation of mm strength (improves mobility and independence
for longer) (1)
Respiratory/lung function: Relative preservation of lung volumes (VC, FVC, FEV1)
(1); OR decrease in decline of respiratory mm weakness (1)
1.8 Some of the side-effects of long term steroid usage include decreased bone
density and overweight. Explain how gluco-corticoid-induced osteoporosis be
prevented in the older child. (1)
Any of the following (up to one) will be marked as correct:
Calcium and Vitamin D supplements
More recent developments: Bisphosphonate treatment
Weight bearing exercises, standing frame etc.
1.9 Explain the importance of cough augmentation in both DMD and SMA
patients and when will cough assistance be indicated.
(3)
Due to the decrease in respiratory mm (esp. expiratory mm) patients present with a
decrease in FEV1 and PECF / PEF (1) which leads to an ineffective cough,
accumulation of secretions, pulmonary complications and compromise (1). In order
to prevent morbidity and mortality in these patients it is important to improve
secretion clearance (expiratory flow) (1). In NMD population the indication for cough
augmentation is when the patient’s PECF < 270L/min (1).
7|Page
Question 2
A baby was born with a neural tube disorder, namely myelomeningocele (L4/5).
2.1 Advise the parents on how neural tube disorders can be prevented. (4)
Any of the following (up to four) will be marked as correct:
• Intake of folic acid in foods (1) such as asparagus, leafy vegetables, beans,
avocados or multivitamins. 0.4 mg per day recommended, for females at a
high risk: 4mg per day (1) OR Preferably 3 months prior to conception and
during the first trimester (1).
• Avoid the use of non-prescription drugs (1), alcohol and prescription drugs
such as anti-consultants (1)
• Avoid increased temperatures (hot baths, electrical blankets, and sauna) (1);
hyperthermia as well as hypothermia can increase the risk (1)
• Diabetes mellitus and obesity (mother) (1) has an increased risk (manage DM
with medication and obesity with lifestyle adaptations) (1)
• Genetic factors (1) (2-4% increased risk if parents had another child with
NTD) (!)
• Teratogens (1) (environmental substances that can cause abnormal
growth/development of fetal cells) (1).
2.2 The baby presents with latex sensitivity. Name two (2) precautions that
should be taken by the medical personnel.
(2)
Any of the following (up to two) will be marked as correct:
Latex is found in various medical products such as gloves and catheters (1).
Physiotherapists and other personnel should rather use non-latex gloves when
working with the patient (1), also caution must be taken if catheterisation is needed
(non-latex products should be used) (1).
2.3 Explain any three (3) ways in which nursing staff and parents can assist in
preventing pressure sores for the baby in the case study. (6)
• Keeping skin dry (change nappy & bedding regularly) (2)
8|Page
• Check the skin regularly (daily basis), especially on the high risk areas, such
as the heels, the sacrum, ilia, knee joints etc (lower limbs) for areas of
redness/irritation (2)
• Pressure relief important, the patient should not stay in the same position for a
long time. Change the baby’s position every 30 minutes (2)
• Treat abrasions, burns etc. immediately (1)
• Watch out for pressure areas caused by casts and orthotics such as AFOs,
POP (club feet) (1)
Section D: Professional Practice
Question 1
1.1 Using the International Classification of Functioning, Disability and Health
(ICF) as a framework for assessment and treatment (of any patient), list and
discuss three (3) outcome measures for all domains of the ICF.
(30)
Body structure and function: any three OM described clearly e.g. muscle testing-
Oxford grading (10).
Activity limitation: any three OM described clearly e.g. Functional Independence
Measure (FIM), Barthel Index (10).
Participation restriction: any three OM described clearly e.g. Maleka- Stroke
Community Reintegration Measure (M-SCRIM), Community Reintegration Measure
(CIM) (10).
9|Page

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Obstetrics concerns itself with

pregnancy, labour, delivary &the care of

Gynaecology is the study of disease

 Primary conditioning unrelated to pregnancy.

 Impairments related to physiological changes of

 Physical &physiological benefits.

• Changes in reproductive system.

• Urinary system -kidney increases by 1cm.

• Changes in pulmonary system.

b. Decrease in ligamentous tensile

c. Hyper mobility of joints due to

d. Pelvic floor drops as much as 2.5 cm.

a. COG shifts upwards & forwards.

• Pregnant women have a decreased perception of balance

The floor of your pelvis is formed by very

With your toes and knees turned out to 45 degrees,

Strengthens: Quadriceps, hamstrings and butt.

Then, bend your left knee and rest it on top of pillows

Strengthens: Core and inner thighs

Hold for 1 to 2 breaths, working up to 5 breaths.

Strengthens: Core, arms and back.

1.Improve posture & 1.Train & strengthen

2. Teach correct body

2.Upper & lower 2. strengthening ex. of UL &

4. Improve awareness & 4. Pelvic floor muscle

7. Improve relaxation skill 7. Relaxation tech.

• Each person should be individually evaluated for preexisting

• Exercise regularly, at least thrice a week

• Avoid ballistic movements & rapid change in directions.

• avoid an anaerobic pace.

• avoid prolong period of standing specially in third

• low resistance & high repetitions ex. is recommended,

• stop ex. if any unusual symptoms occur.

 Preg. Induced HTN BP >140/90 mmhg.

 Is the respiratory diseases that restrict lung expansion,

 It is contraindicated because may cause miscarriage or

 Gentle selective stretching

 Aerobic activities for CVS conditioning

 UL &LL strengthening ex.

 Pelvic floor ex.

 Relaxation /cool down activities

 Educational information [if any] & postpartum ex.

 Pelvic motion training & strengthening.

 Modified UL & LL strengthening.

 Perineum &adductor flexibility.

 Relaxation &breathing exercise

 Upper neck extensors & scalenes

 Scapular protractors, shoulder internal rotators & levetor

 Low back extensors

 Hip adductors [caution do not over stretch in

women with pelvic instability]

 Ankle planter flexor.

Manual Back Stretch

Tailor’s Sitting Position

Hook lying with posterior pelvic tilt

Maintain pelvic tilt as the feet slide along the

 Pt position – any position

Quadruple position with posterior pelvic tilt

Leg is raised only until it is in line with the

These are used

a. Supported squatting using a chair or wall.

2. Sitting – have the women sit on a short stool