Essentials of Orthopaedics and Applied Physiotherapy 3rd Edition PDF

https://telegram.me/aedahamlibrary https://telegram.me/aedahamlibrary Essentials of Orthopaedics and Applied Physiotherapy THIRD EDITION Jayant Joshi Ex-Superintendent, Physiotherapy, All India Institute of Medical Sciences, Ex-Consultant, Physiotherapy and Rehabilitation, Sitaram Bhartia Institute of Science and Research, New Delhi, INDIA Prakash Kotwal MBBS, MS (Ortho), FAMS, FIMSA, Senior Consultant and Head, Department of Orthopaedics, Pushpawati Singhania Research Institute, New Delhi Formerly, Professor and Head, Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India https://telegram.me/aedahamlibrary Table of Contents Cover image Title page Copyright Dedication Preface to the third edition Preface to the first edition Contributor 1. Orthopaedics and physiotherapy Bibliography Physiotherapy as applied to orthopaedics Chest physiotherapy 2. The bones and the joints https://telegram.me/aedahamlibrary 3. Inflammation and soft tissue injuries References Inflammation Soft tissue injury Musculoskeletal disorders 4. Fractures (general) Bibliography 5. Injuries around the shoulder 6. Injuries of the arm 7. Injuries of the elbow 8. Injuries of the forearm 9. Injuries of the wrist 10. Injuries of the hand 11. Injuries of the spine Bibliography 12. Injuries of the pelvis https://telegram.me/aedahamlibrary 13. Injuries of the hip Lower extremity 14. Injuries of the thigh 15. Injuries of the knee 16. Injuries of the leg 17. Injuries of the ankle and the foot Bibliography 18. Common paediatric and adolescent musculoskeletal disorders and fractures Bibliography 19. Prevention of fractures 20. Emergency management of a polytrauma patient 21. Infections of the bones and joints 22. Metabolic bone diseases 23. Bone tumours 24. Arthrodesis, arthroplasty and osteotomy https://telegram.me/aedahamlibrary References Total hip replacement arthroplasty (thr) Girdlestone arthroplasty Total knee replacement arthroplasty Arthroplasty of ankle Arthroplasty of shoulder Arthroplasty of hand 25. Amputations Bibliography 26. Lesions of the brachial plexus 27. Peripheral nerve injuries Bibliography Brachial plexus lesions Peripheral nerve injury 28. Poliomyelitis Bibliography 29. Arthritides Bibliography Rheumatoid arthritis Haemophilia https://telegram.me/aedahamlibrary 30. Deformity Bibliography 31. Locomotion and gait Bibliography 32. Spine Bibliography Spina bifida Cervical syndrome Low back pain Lumbar spondylolisthesis 33. Regional orthopaedic soft tissue lesions of the shoulder, elbow, forearm, wrist and hand Bibliography 34. Hand Bibliography 35. Regional orthopaedic conditions at the hip Bibliography 36. Regional orthopaedic conditions at the knee Bibliography 37. Regional orthopaedic conditions at the ankle and foot https://telegram.me/aedahamlibrary Bibliography 38. Yoga, yoga asanas and physiotherapy Bibliography 39. Sports medicine Bibliography Index https://telegram.me/aedahamlibrary Copyright RELX India Pvt. Ltd. Registered Office: 818, 8th Floor, Indraprakash Building, 21, Barakhamba Road, New Delhi 110001 Corporate Office: 14th Floor, Building No. 10B, DLF Cyber City, Phase II, Gurgaon-122002, Haryana, India Essentials of Orthopaedics and Applied Physiotherapy, 3e, Jayant Joshi (Late) and Prakash Kotwal Copyright © 2017, by RELX India Pvt. Ltd. First Edition 1999 Reprinted 1999, 2000, 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008 Second Edition 2011 All rights reserved. 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Manager—Content Strategy: Nimisha Goswami Sr Manager—Education Solutions: Shabina Nasim https://telegram.me/aedahamlibrary Content Development Specialist: Subodh Kumar Project Manager: Ranjjiet Varhmen Sr Operations Manager: Sunil Kumar Sr Production Executive: Ravinder Sharma Sr Cover Designer: Milind Majgaonkar Typeset by GW India Printed in India by https://telegram.me/aedahamlibrary Dedication Dr Jayant Joshi left for his heavenly abode on 2 Februaruy 2015. He had completed the work on the third edition manuscript just 4 days before his death. https://telegram.me/aedahamlibrary Preface to the third edition Prakash Kotwal It is indeed a pleasure to present the third edition of the book Essentials of Orthopaedics and Applied Physiotherapy. Bringing out a new edition provides an opportunity to update the book in accordance with the recent advances in the subject. This is exactly what has been done with this edition of the book. Most of the chapters have been revamped with addition of new/better photographs and tables for better understanding. This edition contains 39 chapters, against the 26 in the second edition. The bigger chapters have been split into multiple chapters, organized region wise in body, with a view to update the chapters and easy accessibility to a topic. The project of writing this book was conceptualized with the intention of providing knowledge about orthopaedic conditions and procedures to the physiotherapy students, practising physiotherapists and orthopaedic surgeons alike. The book was also meant to discuss the physiotherapy protocols after an orthopaedic procedure or treatment. To take this intention further, selected physiotherapy procedures/manoeuvres are being provided along with this edition of the book. The videos of the physiotherapy procedures have proper citations in the text. The videos comes at no extra cost, demonstrating the correct methods of physiotherapy procedures/manoeuvres. I take this opportunity to pay homage to my co-author, Mr Jayant Joshi, who passed away a few months back. He was the main inspiration behind starting this book project. His passion and dedication for this book was so great that he completed the majority of the manuscript just before he passed away. https://telegram.me/aedahamlibrary I would like to express my gratitude to all those who helped me in the preparation of the manuscript of this book. I thank Mrs Kanchan Mittal for accepting the task of completing the physiotherapy part of the book. My friends Siddharth and Reena Mishra deserve a special mention and thanks for undertaking the clinical photography job with a professional finesse. I would like to thank my colleagues Dr Bhavuk Garg, Prof. Shah Alam Khan, Dr Md Tahir Ansari and Dr Abhinav Agarwal for providing certain clinical photographs for this book. I am also grateful to Dr Vivek Shankar for his extensive help at various stages of the preparation of manuscript. I owe my life to my parents, Shri P.D. Kotwal and Mrs Usha Kotwal, and career to Mr P.S. Samvatsar and Mrs Sushma Samvatsar. Last, but not the least, special thanks to my wife, Arundhati, for the encouragement, patience and the unconditional support in my professional pursuit. https://telegram.me/aedahamlibrary Preface to the first edition Jayant Joshi Prakash Kotwal Physiotherapy has come of age and is now an integral part of orthopaedic practice. In fact, orthopaedics per se is incomplete in the management of a patient without physiotherapy. Orthopaedic physiotherapy is one of the major specialities of the science of physiotherapy and plays a significant role in restoring full function at the earliest. There are a large number of books on orthopaedics and physiotherapy but each deals with the subjects as a separate entity. As such, it is not always convenient to refer to them to get an overall view of the total therapeutic management. Therefore, a need was felt to bring out a book with an interspeciality therapeutic approach to get the overall picture of the total therapeutic management. We sincerely hope that this book, the first of its kind, would fill this gap and would provide useful guidance not only to the students of physiotherapy and practising physiotherapists but also to the orthopaedic surgeons, physiatrists and others engaged in the rehabilitation of the physically handicapped. Most of the chapters in this book start with a treatise on relevant applied anatomy, predisposing factors, clinical features, diagnosis and comprehensive orthopaedic and https://telegram.me/aedahamlibrary physiotherapeutic management of all the common orthopaedic conditions including fractures and dislocations. A large number of line diagrams and photographs have been used to describe the various aspects of diagnosis and treatment of a particular condition. Some of the latest research works have also been included in the References for further reading on the subject. Tables have been used, wherever necessary, to present the matter in a concise or comparative form. We are grateful to Professor P Chandra and Professor PK Dave for their constant guidance and encouragement during the preparation of this book. Our special thanks are due to our spouses, who tolerated our passion for this book, supported and assisted us while we were working on the manuscript. We are also thankful to Mr Viney Patil, Mr Kamalakar Patil, Ms Sweta, Mr Tara, Mr Tiwari, Mr Anil and others for their co-operation and assistance. https://telegram.me/aedahamlibrary Contributor Kanchan Mittal, Superintendent of Physiotherapy, Department of Orthopedics, All India Institute of Medical Sciences, New Delhi https://telegram.me/aedahamlibrary CHAPTER 1 Orthopaedics and physiotherapy OUTLINE ◼ Goal and role of both the sciences ◼ Orthopaedic disorders ◼ Systematic approach ◼ Principal methods of orthopaedic management ◼ Orthopaedic physiotherapy and cardiopulmonary conditioning ◼ Chest physiotherapy ◼ Cardiopulmonary resuscitation or ABC of life support The term orthopaedics is derived from two Greek words orthos and pedios. Orthos means straightening and pedios means child. Originally the field of orthopaedics was limited to manipulating and correcting the deformed limbs in children. The age-old definition of this science is grossly wrong. Nowadays, the remarkable spurt of advancements in the technology has revolutionized the whole process of orthopaedic management; from correcting deformities in children, it has progressed to the level of organ replantation. Similarly, the field of physiotherapy which used to be limited to massage and simple movements to the joints following fracture has developed into an independent specialty of medical sciences. Its nonpharmacological exercise-oriented approach and multidisciplinary https://telegram.me/aedahamlibrary applicability has widened its horizons tremendously. Besides therapy, its preventive role is being recognized all over the globe. However, the science of physiotherapy has a special hand-and-glove relationship with orthopaedics, as it plays a predominant role in the management of the whole gamut of orthopaedic sciences. To quote one of the reputed orthopaedic surgeons of India, Late Prof P Chandra, Emeritus Professor, All India Institute of Medical Science, New Delhi, ‘The success of orthopaedic treatment depends largely on a physiotherapist. The surgeon should never pick up the knife unless he/she has a competent physiotherapist.’ Goal and role of both the sciences The ultimate goal of orthopaedic treatment as well as orthopaedic physiotherapy is to restore the maximum possible physical independence to a patient, in performing the physical tasks involved in the activities of daily routine (ADR) and occupation (before injury or altered occupation after rehabilitation) within the limits of disability or the disorder (Fig. 1-1). https://telegram.me/aedahamlibrary FIG. 1-1 Goal and role of orthopaedics and physiotherapy. Orthopaedic management provides the basic structural stability to the body, whereas physiotherapy works towards achieving the maximum functional restoration. Orthopaedic disorders The disorders in orthopaedics are broadly classified into two categories: 1. Traumatic (Table 1-1) and 2. Nontraumatic (Table 1-2) https://telegram.me/aedahamlibrary Table 1-1 Major Traumatic Orthopaedic Disorders Bone Injuries Soft Tissue Injuries Fractures Injury to the Subluxations Muscles Dislocations Ligaments Multiple trauma involving multiple fractures, injury to the soft Blood vessels tissue and visceral organs (e.g., caused by RTA, earthquake) Nerves Skin Fascia Other connective tissues like joint capsule, synovium, bursae Abbreviation: RTA, road traffic accident. Table 1-2 Major Nontraumatic Orthopaedic Disorders Disorder Aetiology Example Pathological fractures Occur as a result of weakening of the Fracture due to 1. bone due to generalized or localized metastatic lesion, a bone disease fracture through the bone cyst, or due to osteoporosis, etc. Congenital anomalies Mostly developed during intrauterine Congenital absence of 2. period bones CTEV, scoliosis, congenital dysplasia, etc. Developmental Developed due to faulty development Achondroplasia 3. disorders of bone or cartilage Paget disease Osteochondritis Infective diseases As a result of infection by Osteomyelitis 4. microorganisms Tuberculosis Septic arthritis Metabolic diseases As a result of imbalances in mineral Rickets 5. exchange between the bone reservoir Osteoporosis and intracellular fluid regulated by Hyperparathyroidism hormones and local factors Endocrinal disorders As a result of hormonal imbalances Hypothyroidism 6. (cretinism) Hypopituitarism (dwarfism) Inflammatory disorders Inflammation which progresses to the Rheumatoid arthritis 7. bones and joints systemic soft tissue Ankylosing spondylitis from diseases Neoplasia (tumours) Development of benign or malignant Osteoma (benign) 8. tumours of the bone Osteosarcoma (malignant) https://telegram.me/aedahamlibrary Degenerative joint Wear and tear of the joint cartilage Osteoarthritis 9. disorders Spondylosis 10. Neuronal and muscular Could be congenital, acquired, Cerebral palsy disorders developmental, infective or due to Neuropathy compressive pathology Poliomyelitis 11. Regional Soft tissue lesions due to Sports injuries musculoskeletal Overuse of specific muscles and joints, Cervical spondylosis conditions of the neck, or trauma Low back pain spine, upper and lower Wrong postural habits Adhesive capsulitis limbs Lack of exercise, etc. (frozen shoulder) Abbreviation: CTEV, congenital talipes equino varus. Some common traumatic disorders are listed below. ◼ Fracture: When there is discontinuity at the outermost hard layer of the bone (cortex). ◼ Subluxation: When a joint is only partially displaced from its compact original position with the retention of some articular contact. ◼ Dislocation: When a joint is displaced from its compact natural anatomic configuration with partial or complete disruption of the joint capsule and the ligaments. ◼ Strain: When a muscle or a ligament is torn as a result of excess violence. ◼ Stress: When the ligaments protecting the joint are injured due to sudden excessive twisting violence to the joint. Systematic approach Correct diagnosis is the key to the successful management of a patient. The following criteria help to arrive at the diagnosis: 1. Sound basic knowledge of the subject including the latest developments in the field 2. Critical clinical and physical examination and objective evaluation of the patient provide definite clues to a provisional diagnosis https://telegram.me/aedahamlibrary 3. Correct interpretation of the results of evaluation including investigations confirms the diagnosis 4. Appropriate patient-oriented therapy 5. Educating the patient on preventing the recurrence of the disorder or disease as well as wilful acceptance of healthy exercising lifestyle Steps in the process of evaluation towards diagnosis (tables 1-3 and 1-4) 1. Observational analysis 2. History taking 3. Collection of subjective data from a patient 4. Objective clinical data, through physical examination and evaluation 5. Functional evaluation Table 1-3 Steps in Orthopaedic and Physiotherapeutic Evaluation 1. Observational To observe the patient for obvious Overall physical status analysis physical discrepancies, e.g., posture, gait, Areas of major physical deformity when the patient is ambulatory disability 2. History of Offers broad classification of the present Identification of the major onset and episode and possible pathology, e.g. category of disorder: course of the Is it traumatic or nontraumatic? Traumatic or nontraumatic disorder or Is it congenital or acquired? Congenital or acquired disease Is it associated with Infective disorder Fever, chill, rigors, sweating (possible Inflammatory disorder infective pathology) Metabolic disorder Seasonal variation (possible inflammatory Endocrinal disorder pathology) Certain orthopaedic disorders Constitutional symptoms like rapid are commonly encountered at weight loss, anorexia (e.g. neoplasia) certain age groups and related to Hormonal imbalance (e.g. sex hypothyroidism, hypopituitarism) Joint pain at advanced age (degenerative disorder) https://telegram.me/aedahamlibrary Age and sex (certain orthopaedic diseases are common at certain age groups and sex) Developmental diseases Occur later during the growing period 3. Subjective data Information from the patient regarding To guide physical collection Occupation rehabilitation, schedule Subjective perception of the present To decide therapeutic episode and its overall impact approach 4. Objective To evaluate and record the informative Provide objective data to examination data through physical examination Plan therapeutic programme and evaluation Inspection Judge therapeutic response of Carefully inspect skin health, wounds, the patient and the prognosis of scars, stretchability, sensation, etc. recovery Objective evaluation of tenderness, swelling, deformity, atrophy Palpation For temperature difference, anatomical integrity of the bones and joints, interrelationship of the bony prominences and soft tissues (e.g., presence of nodules) Movements: Evaluation of passive as well as active ROM at the joints Muscle functions: Critical evaluation of strength, endurance, flexibility, tone, movement control and coordination Sensory status: Critical evaluation of the sensations, kinaesthetic and proprioceptive, touch, pinprick and the reflexes Joints: Examine the joints for stability, integrity, musculoskeletal stretchability, ROM and deformity 5. Functional To critically assess the physical efficacy of Provides guidance in evaluation performing the various activities of daily formulating individualized routine (ADR) therapeutic prescription – to Detailed evaluation of the improve deficient functional neuromusculoskeletal deficiencies hindering performance the ADRs Abbreviations: ADRs, activities of daily routine; ROM, range of motion. Table 1-4 Specific Orthopaedic and Physiotherapy Examinations to Reach Final Diagnosis Specific Orthopaedic Examination to Reach the Final Specific Physiotherapy Examination to Plan Therapeutic Programme Diagnosis Radiography Body structure, body weight, height and body composition To evaluate skeletal integrity Overall physical capacity to withstand exercise and any It could be contraindications Plain radiography Accurate goniometric measurement of ROM, deformities, etc. Contrast radiography Detailed assessment of muscle functions (e.g., arthrography) Muscle power (strength), especially of the functional groups CT scan: Provides detail of Endurance https://telegram.me/aedahamlibrary the skeletal lesion (with 3- Flexibility dimensional reconstruction) Tone (hypertonia, hypotonia or atonia) MRI: Provides better Examination of the joints delineation of the soft Details of the movement patterns, movement control and tissues and to some extent, coordination and balance changes in the bone Neuromuscular integrity by EMG, stimulation, RD test Angiography, biopsy and Gait pattern analysis other relevant diagnostic Diagnostic physical tests to identify the site and extent of the soft laboratory tests tissue or neuronal injury (e.g., musculotendinous complexes, Radioisotope bone scan ligaments, lesions of the central nervous system and peripheral PET scan nerves Open or closed biopsy (FNAC) Abbreviations: CT, computed tomography; EMG, electromyogram; FNAC, fine-needle aspiration cytology; PET, positron emission tomography; RD, reaction of degeneration; ROM, range of motion. It not only provides definite clues to the final diagnosis but also greatly assists in formulating the therapeutic procedures. Functional evaluation ◼ Evaluation of the whole body’s efficacy to perform ADR and occupation-related physical tasks, recording specific deficiencies blocking a particular activity ◼ Detailed neuromusculoskeletal evaluation of the individual- deficient segment obstructing the function, e.g., range of motion (ROM), muscle functions, movement control and coordination, balance, sensorium and ambulatory status, gait pattern and efficacy in managing slopes, stairs Note: Extensive stepwise evaluation is not always necessary or possible. A single step may be adequate to arrive at the diagnosis. Principal methods of orthopaedic management Basically the following two principal methods are used in the treatment: ◼ Conservative https://telegram.me/aedahamlibrary ◼ Surgery Conservative method Appropriate pharmacological agents: ◼ To reduce pain ◼ To control inflammation ◼ To control infection by microorganisms ◼ To control reflex muscular spasm ◼ Rest to the injured area by proper positioning of the injured limb ◼ To immobilize the injured or diseased area by ◼ Strapping ◼ Plaster of Paris (POP) slab/cast ◼ Orthosis ◼ Skin or skeletal traction ◼ Graded manipulation and serial POP casting to correct deformity ◼ Joint manipulation under GA to mobilize stiff joint ◼ Closed reduction and manipulation with or without GA to correct anatomical alignment of broken bones (fractures) or dislocated joints Surgery ◼ Open reduction and internal fixation (ORIF) to fix fractured bones https://telegram.me/aedahamlibrary ◼ Replacement of fractured or diseased bones or joints by artificial components, e.g., arthroplasty ◼ Bone grafting to fill up a gap, strengthening the bone or to stimulate the growth of bone in fractures nonunions ◼ Osteotomy – producing fracture to correct bony deformity, or malalignment of a joint ◼ To adjust the line of weight bearing or to correct limb length disparity ◼ Arthrodesis – fusion of the joint in a functional position when no alternative is available to facilitate function ◼ Reconstructive surgery – to repair the damaged soft tissues like nerve, muscle, fasciae, etc. ◼ Vertebroplasty – use of bone cement to fill up the gap and strengthen the diseased or broken vertebrae ◼ Replantation – reattachment of the severed part of the limb (e.g., hand, digits) Preventive role of physiotherapy 1. Preventive: Primary and secondary prevention (Table 1-5) 2. Restorative: To restore the near-normal functional status (Table 1-6) 3. Rehabilitative: To restore the maximum possible functional independence within the limits of the disease and the disability (Table 1-7) Primary prevention and secondary prevention: Mainly it refers to the prevention of traumatic lesions and life-threatening conditions like coronary heart disease (CHD), hypertension and https://telegram.me/aedahamlibrary hypercholesterolaemia. Secondary prevention and/or better control of the disease: Development of complications is common not only following fractures but even after contacting any disease, which has adverse effects on the progress of recovery. These hazards can be effectively dealt with by critical regular monitoring and taking instant controlling measures. Table 1-5 Preventive Role of Physiotherapy in Orthopaedics Primary prevention of Methods Fracture Exercise training (endurance) to optimize physical Dislocation fitness Subluxation Concentrated musculoskeletal conditioning of the Strains, sprains areas susceptible to injury Common soft tissue disorders Guidance on correct body mechanics Guidance to control or avoid activities susceptible to injury Sports- and occupation-related musculoskeletal conditioning Guidance on the work as well as rest-related wrong postural attitudes Secondary prevention of Rest, adequate support and frequent monitoring Expected common complications for the signs and symptoms of the expected following injury – fractures, dislocations, complications subluxation, etc. Guidance to the patient on the signs and Complications due to rigid symptoms of the possible complications immobilization (e.g. POP cast, skeletal traction) Complications due to prolonged Full ROM exercise and passive stretching at the recumbency suspected sites Soft tissue tightness, contractures Frequent positional changes in bed, skin care, Joint stiffness protection of pressure points Pressure sores Gradually progressive exercise Generalized weakness and muscular Chest physiotherapy atrophy Early initiation of progressive functional activities, Reduced respiratory efficiency PRE, earliest introduction of ambulatory training Generalized detoning of all the systems of Emphasis and guidance to continue exercises as the body taught Recurrence of the earlier disorder Table 1-6 Restorative Role of Physiotherapy in Orthopaedics Reduction and Methods https://telegram.me/aedahamlibrary control of Comfortable positioning, rest and appropriate physiotherapy modality Pain and tenderness Early cryotherapy Swelling Limb elevation compression bandage Reflex muscular Pain-free early isometrics and active repetitive movements to the distal spasm joints, cryotherapy Early initiation of Formulating exercise training prescription to improve functional restoration Muscle functions Joint ROM must restore functional ROM earliest Neuromuscular coordination and joint control–movement coordination Motivation of a patient to perform functional activities independently or with assistive aids Using suitable modality as per the needs (e.g., massage, SWD, ultrasonic therapy) Monitoring progress with regular re-evaluation Providing necessary guidance to prevent recurrence Use of specialized exercise techniques like PNF, manipulation and mobilization and manual therapy as per the needs Restore the preinjury physical status Abbreviations: PNF, proprioceptive neuromuscular facilitation; ROM, range of motion; SWD, shortwave diathermy. Table 1-7 Rehabilitative Role of Physiotherapy in Orthopaedics For patients suffering from severe Methods involvement or irreversible systemic Improving the strength and the function of the damages, e.g., quadriplegics, paraplegics paretic muscle groups and neuronal diseases like cerebral palsy: Identify and strengthen muscle groups to To provide maximum functional compensate for the weaker or paralysed muscles and independence within the limits of the introduce functional training at the earliest disease and the disability Strengthen the compensatory mechanisms to substitute or assist the functional activity Early provision of assistive aids and devices to assist function Concentrate on functional training with aids Training on the alternative mode for performing function, e.g., when ambulation is not feasible, preparing and teaching the patient on wheelchair ambulation Use of specialized exercise techniques like PNF and Bobath to improve movement control, posture, balance, movement coordination, motor and sensory re-education, transfers, balance, ambulation and self- sufficiency in performing the activities of daily routine and the activities involved in the occupation or work Abbreviation: PNF, proprioceptive neuromuscular facilitation. Moreover, physiotherapy has emerged as great asset due to its exercise-oriented approach. Its salutary effect helps in https://telegram.me/aedahamlibrary 1. increasing the efficiency of all the organs and the systems of the body. 2. increasing the immune responses of the body. 3. positively influencing the psychological status. Role of physiotherapy in orthopaedics Combination of all these benefits with physical fitness plays a key role as a preventive specialty. Planning of physiotherapeutic programme After critical evaluation, depending upon the expected role (i.e., preventive, restorative or rehabilitative), a comprehensive physiotherapy prescription is formulated to adequately meet the individual needs of a patient. A large number of physiotherapeutic modalities are available to pick and choose from. However, exercise remains the basic mode of treatment. Assistive modalities provide assistance in the relief from pain and swelling and help in movement re-education and functional restoration (Table 1-8). Besides, specialized exercise techniques like proprioceptive neuromuscular facilitation (PNF), Bobath Brunnstrom and Maitland, and specialized techniques like manipulation and mobilization and manual therapy are initiated. Table 1-8 Planning of Physiotherapeutic Programme Basic Mode of Treatment Assistive Mode of Treatment Exercise a: To improve Massage (a) Joint functions Cryotherapy Static and dynamic stability Thermotherapy Achieving normal or functional ROM Electrical stimulation (b) Muscle functions Interferential currents Strength Ultrasonic therapy Endurance TENS Flexibility Maintenance and use of orthotic, prosthetic and Tone functionally assistive devices to support, protect, hasten (c) Movement the process of recovery or to perform functional Character activities https://telegram.me/aedahamlibrary Control Coordination (single and multiple joints) Sensory motor re-education (d) Balance Static and dynamic balance (e) Functional training: To achieve self- sufficiency in performing the ADR at home and at work place with or without aids Abbreviations: ADR, activities of daily routine; ROM, range of motion; TENS, transcutaneous electrical nerve stimulation. aExercise is a multifactorial common entity and varies from life-saving manoeuvres like ABC of life support and emergency chest physiotherapy to functional restoration and rehabilitation. However, the success of a therapeutic programme heavily depends upon how efficiently patients perform exercise on their own. Exercise specificity Our inborn lethargy towards exercise even in normal health is compounded further by pain, weakness and depression. Moreover, therapeutic exercise for benefits needs to be done several times. Under such circumstances, motivating and educating a patient to perform exercise efficiently and repetitively calls for certain must-be observed principles: ◼ Spend enough time in explaining the why and how of exercises. Being exercise-oriented professionals, somehow we tend to forget – that the patient also knows about exercises as well as we do. ◼ Ideally use the better part or normal limb or use a method of ‘SELF- DEMONSTRATION’, audiovisual media, diagrams, etc., for the patient to understand the correct methodology of exercise. ◼ Always begin with the simplest possible exercise. ◼ Select exercise in a preferential order as per the demand of the patient’s condition. ◼ Select minimum number of very specific exercises and teach only one exercise at each sitting till a patient grasps it and performs it https://telegram.me/aedahamlibrary with maximum efficiency. ◼ Always check the specificity of previously taught exercise before proceeding to the next exercise. ◼ As far as possible, the exercise regimen should be competitive and based on the functional ADRs. ◼ To break the monotony of exercise but, at the same time, to ensure several repetitions, teach one exercise in the different fundamental positions of the body (e.g., exercise of knee flexion–extension can be performed in all the fundamental postures of the body (Fig. 1-2). https://telegram.me/aedahamlibrary https://telegram.me/aedahamlibrary https://telegram.me/aedahamlibrary FIG. 1-2 Performance of same movement (e.g. knee flexion) in various body postures: (A) supine, (B) low sitting (C) high sitting, (D) prone lying, (E) standing. It helps to break the monotony of exercise and encourages repetitions. By this approach, a patient’s acceptance of exercise is ensured. General plan of physiotherapeutic management in orthopaedics A. Acute multitrauma: prehospital care https://telegram.me/aedahamlibrary ◼ Make a quick assessment of the patient’s general condition by reviewing the vital signs. ◼ If needed, immediately start emergency measures to save life, e.g. ABC of life support (cardiorespiratory resuscitation). ◼ Control bleeding. ◼ Provide temporary support splinting to an injured limb and measures to prevent further damage. ◼ Arrange for immediate safe transfer of a patient to the nearest hospital or emergency management facility. B. Routine cases treated conservatively ◼ Perform critical evaluation to assess the degree of major physical problems. ◼ Formulate exercise prescription on an individual basis. ◼ Initiate educating a patient on simple but specific exercise training as well as functional training programme. ◼ Cultivate interest in exercise lifestyle emphasizing its health benefits. ◼ Monitor the conducting of the exercise training and the efficiency of patient’s performance, and use special exercise techniques. ◼ Plan a weekly or biweekly goal of expected improvement https://telegram.me/aedahamlibrary and review the progress critically by objective and subjective evaluation. ◼ Educate the patient on the don’ts and teach to prevent recurrence. C. Cases treated by surgery ◼ Make preoperative assessment and conditioning (in preplanned surgical patients). ◼ Make preoperative evaluation and education – on the postoperative exercise training sessions and functional training schedules. ◼ Prescribe necessary orthotic devices or aids needed for postsurgical functional training. ◼ Plan weekly goal of expected recovery. ◼ Review at regular intervals to ensure recovery. ◼ Cultivate patient’s interest in accepting exercise lifestyle as a disease preventive entity. Planning of physiotherapeutic management Due to the great variety of modalities and specialized treatment techniques, it is extremely difficult to generalize the therapeutic programme of physiotherapy. It is further complicated by the severity of the dysfunction, prognosis of recovery and individual variations. Based on the expected duration of rehabilitation, patients are broadly classified into the following three categories (Table 1-9): Table 1-9 https://telegram.me/aedahamlibrary Classification of Patients on the Basis of the Approximate Time Required for Rehabilitation 1. Short duration (3–6 weeks) Simple neuromusculoskeletal disorders or undisplaced uncomplicated fractures 2. Intermediate duration (12–30 Fractures and/or dislocations of major bones and joints weeks) Crush injuries; with complications Early detected bone diseases 3. Long duration (30–52 week or Conditions needing long periods of recumbency more) Patients with low physical capacity Patients with irreversible neuronal damages or bone diseases Recurrent systemic diseases like rheumatoid arthritis Loosening of the artificial implants needing revision or multiple surgeries Delay in reporting for treatment after developing complications Failure in motivating patients even with uncomplicated disorders Short-duration rehabilitation patients: This includes patients with simple, reversible neuromusculoskeletal dysfunctions, mostly involving soft tissues or simple fractures. The dysfunction is completely resolved within 3–6 weeks by appropriate physiotherapy measures. ◼ Control of pain and swelling by selecting appropriate modality ◼ Provide adequate supporting aid to prevent further damage, and pain due to movement at the injured area ◼ Encouraging pain-free isometrics progressing gradually to full ROM exercise against resistance ◼ Effective home management programme, postural guidance and guidance to avoid recurrence ◼ Correct use of aids and appliances whenever prescribed Intermediate-duration rehabilitation patients: This includes fractures or fracture dislocations of major bones and joints associated with complications, repetitive surgery, or not so complicated fractures, but patients have associated diseases (e.g., rheumatoid arthritis, pathological fractures, tumours). Functional independence in such a patient may require 12–30 weeks. https://telegram.me/aedahamlibrary The basic physiotherapy remains same as mentioned for short- duration patients, however, with the following modifications. Considering the complexities involved, there are more chances of slow rate of progress, difficulties in the performance of exercise and greater chances of developing soft tissue or joint contractures. The following treatment programme is instituted: ◼ Educate patients on simple but selective specific exercises. ◼ Provide support splint to prevent contractures and stiffness of functionally important joints or soft tissues. ◼ Provide functional training like changing position in bed, sitting up, shifting, transfers, standing and ambulation. ◼ Prescribe assistive aids as early as possible. ◼ Provide all the possible encouragement to put in hard efforts towards self-sufficiency. Long-duration rehabilitation patients: This category includes patients with extensive irreversible damages with prognosis of poor recovery. These patients require extensive long duration rehabilitative physiotherapy to bring them to the level of achieving functional independence. It may take 30–52 weeks or even more and sometimes, the patient may still remain dependent on physical assistance, particularly patients with irreversible neuronal damage, congenital anomalies, etc. Concept of total rehabilitation: ‘To bring a patient to the level of self-sufficiency in vocational, socioeconomic and psychological status, through restoration of physical independence in performing the occupational tasks and ADRs within the limits of the disease and the disability.’ How is physiotherapy the mainstay of total rehabilitation of a severely handicapped patient? https://telegram.me/aedahamlibrary Physiotherapy not only contributes significantly to achieving physical (functional) independence but also indirectly promotes vocational potentials which, in turn, augment the psychological status of a patient leading to the attainment of socioeconomic security (Fig. 1-3). FIG. 1-3 Role of physiotherapy in the total rehabilitation of a severely handicapped patient. Role of physiotherapy in total health care A. Primary prevention: Structured exercise training and its regularity have been proved to play a significant role in the primary prevention of contacting serious injuries and diseases like: ◼ Coronary artery disease (CAD), cardiovascular disease (CVD) https://telegram.me/aedahamlibrary ◼ Certain cancers ◼ Hypertension ◼ Fractures and soft tissue injuries ◼ NIDDM ◼ Obesity It is mainly through achieving optimal level of physical fitness and overall increase in the body’s immunity. B. Secondary prevention: When the disease has already occurred, regular structured exercise programme has been proved to assist in the arrest of its progression and improve responses to its basic therapy (e.g. antihypertensive drugs). Education and integration of exercise lifestyle Physical inactivity and wayward eating habits are the major causative factors in inviting all these diseases; therefore, educating, emphasizing and integrating an exercise lifestyle in every orthopaedic patient is the responsibility of the physiotherapist. Why is it ideal to integrate orthopaedics with an exercise-oriented lifestyle? ◼ Longer duration of recumbency or immobilization of the lower limbs for injuries or disease ◼ Longer periods of reporting to the department for treatment ◼ Home visits for treatment ◼ Most importantly, exercise-oriented therapy https://telegram.me/aedahamlibrary Today’s physiotherapy approach demands major emphasis on integrating and educating the patient on an exercise-oriented lifestyle (ELS) without giving an opportunity to say ‘I HAVE NO TIME’ or any other excuse. Areas needing special consideration for earlier and better results ◼ Avoid late referral: Irrespective of the mode of orthopaedic management employed, the patient should be referred for physiotherapy on the same day and regularly thereafter to avoid preventable complications like swelling, joint pain and stiffness, and generalized detoning. ◼ Preoperative education: Educating a patient on the postoperative care, and the exercise regimen on the contralateral normal limb or by self-demonstration greatly enhances the recovery. ◼ Early weight bearing and ambulation: The present trend of early ambulation may lead to fear complex, discomfort and limp. Instead, efforts should be made to achieve prerequisites of ease in ambulation like adequate ROM, muscle strength, balance and coordination. Considering the advantages of erect upright posture, well-supported graduated sustained standing, weight transfers, practising stepping, i.e., practising forward and backward stepping in supported static standing should be encouraged as early as possible. However, independent ambulation should not be enforced in a hurry before achieving adequate pain-free stability. ◼ Cardiorespiratory endurance: Considering the tremendous increase in the incidence and magnitude of RTAs, cardiovascular, metabolic, neoplastic disorders and obesity, integration of cardiorespiratory conditioning training is ideal as well as inescapable. Therefore, every physiotherapist is duty bound to impart lifestyle exercise along with orthopaedic care. Orthopaedic physiotherapy and https://telegram.me/aedahamlibrary cardiopulmonary conditioning Cardiopulmonary conditioning (CPC) is an exercise-oriented procedure which results in the improvement of endurance of cardiac and pulmonary systems. It works on the principle of overload, allowing adequate intake of oxygen and its transport efficiently to the working muscles. CPC has been proved to be a major contributory factor in the primary as well as secondary prevention of cardiovascular diseases. However, the overall benefits of CPC are of much greater significance to us. The benefits of CPC are as follows: 1. It improves all the physiological parameters of the cardiopulmonary system (Table 1-10). 2. It provides a wide range of benefits to the various systems of the body (Table 1-11). 3. It also greatly influences the neuromusculoskeletal systems of the body with salutary influences on the psychological status of the patient (Table 1-12). Table 1-10 Influence of CPC on Cardiovascular Parameters Increases Decreases Blood supply to heart and stroke volume Resting heart rate and BP Oxygen uptake and utilization Exercise HR and BP.RPP (double product) Beneficial blood cholesterol (HDL) Harmful blood cholesterol (LDL) Exercise tolerance and functional Oxygen demands of the heart and psychic capacity stress Abbreviations: BP, blood pressure; HDL, high-density lipoprotein; HR, heart rate; low-density lipoprotein; RPP, rate pressure product. Table 1-11 Overall Benefits of CPC Improves https://telegram.me/aedahamlibrary Haemodynamics Hormonal production Metabolism Glucose tolerance Thyroid and lung functions Table 1-12 Benefit of CPC Closely Related to Routine Physiotherapy Improvement in Neuromusculoskeletal system Muscular strength and endurance Flexibility of the joints and muscles Neuromuscular coordination Exercise tolerance, functional capacity and joie de vivre Psychological status Considering the overall benefits, integration of CPC in routine orthopaedic physiotherapy will certainly be instrumental in providing early and better results besides preventing musculoskeletal and cardiovascular problems. To integrate CPC in routine orthopaedic physiotherapy, it is not necessary to alter the basic regime planned for an orthopaedic dysfunction. It only needs certain modifications in the exercise regime to incorporate the principles of CPC. Methodology and principles of CPC 1. Preliminary screening 2. Clinical examination and evaluation 3. Formulating specific exercise prescription Preliminary screening Preliminary screening is done to ensure safety to the patient. Firstly, the medical history and the investigation reports are scrutinized to identify the presence of any serious cardiovascular disease. Secondly, https://telegram.me/aedahamlibrary the patient should be carefully observed for the presence of any potential risk factors for cardiovascular disease – CVD (Table 1-13). Such patients should first be referred for medical clearance. When no such problem is present, the patient can safely be included for CPC. Table 1-13 Potential Risk Factors (RF) for CVD Lifestyle RF Obesity, smoking, sedentary lifestyle, excessive use of alcohol and stressful personality Medical RF Diabetes, hypertension, hyperlipidaemia, rheumatic fever or congenital heart disease Hereditary Family history of heart disease RF Clinical examination and evaluation (a) Assessment of cardiopulmonary parameters is done at rest, during exercise and also during recovery: Monitoring heart rate, blood pressure and double product (HR × systolic BP) assesses the cardiac response to exercise with a rough estimate of myocardial oxygen consumption. (b) Exercise tolerance: As the requirements of the conditioning involve vigorous exercise to be continued for a longer period, it is imperative to evaluate the functional capacity or the exercise tolerance of the patient. It can be evaluated by various simple tests in nonrisk patients and is ideally monitored by graded exercise tests (GXT) like treadmill test, bicycle ergometry and arm crank ergometry for patients with cardiopulmonary disease or with present risk factors. The exercise puts physiological stress on the cardiopulmonary system and puts volume load on the left ventricle, quickly increasing the oxygen uptake by lungs with rapid increase in the heart rate. Systolic BP is also increased with increased cardiac output. Diastolic BP usually remains steady with increasing energy requirements. Simple tests: These are called performance, field or fitness tests. Broad estimation of aerobic capacity, cardiopulmonary https://telegram.me/aedahamlibrary status and exercise tolerance can be done by these tests. Distance test: The distance covered in a 12-min walk, jog or run is measured. The heart rate is checked at 2, 6 and 9 min during the full 12-min protocol. Time test: Time taken by an individual to cover 2–4 km is recorded. Both these tests can be done on a wheel chair in patients with weakness or paralysis of the lower extremities. Crompton test: In this test, the pulse is recorded after 3 min of rest in a supine position. Pulse is rerecorded immediately on standing. The difference indicates overall simple heart performance. The difference of 4 beats is an indicator of total fitness, whereas the difference of more than 20 is an indicator of poor cardiovascular fitness. Step test: After 3 min of relaxation in a chair, the pulse is recorded. Then the subject is made to step up and down a 16-inch step. The patient begins with the left leg up, then the right leg is stepped up; after that, the left leg is brought down, to be followed by the right leg; this completes one step. The speed of stepping is kept at 1 step every 3 s or 20 steps in a minute (in 80 counts/min). This is done continuously for 2 min. Then the subject relaxes in a chair and the pulse is re-recorded after 1 min rest. Excellent to good capacity is assumed if the difference between the pulse rates is within 10 counts, but the difference of more than 40 beats is an indicator of poor fitness. https://telegram.me/aedahamlibrary GXT: These are more specific tests than the tests described earlier. Here the load is gradually increased with equal grades. The cardiovascular response to the increasing load is monitored to a certain level. This level could be till the heart rate reaches up to 85% of the age-predicted maximal heart rate; then it is known as submaximal graded exercise test (submax. GXT). When the test is continued till the patient attains the level of age-predicted maximal heart rate (e.g., totally fit person), it is called maximal graded exercise test (max. GXT). This test can be performed by using simple wooden steps of varying height. However, more precise monitored graded tests are performed with treadmill, ergocycle or arm crank ergometry, etc. Graded step test: This test is done as described earlier; only the step height is increased gradually from level stepping to a 16-inch step (Fig. 1-4) and the test is conducted for 3 min at each level (Table 1-14) followed by 1-min rest at each level – when the pulse rate and BP are monitored (American Heart Association Publication, 1979, 1989). https://telegram.me/aedahamlibrary https://telegram.me/aedahamlibrary https://telegram.me/aedahamlibrary https://telegram.me/aedahamlibrary FIG. 1-4 Graded step test. (A) Left foot over the step at count one. (B) Right foot over the step at count two. (C) Left foot back to the floor at count three. (D) Right foot back to the floor at count four. Table 1-14 Graded Step Test Stepping Time/Rest Stage Steps/min Counts on Ratio I Level 3:1 min 20 80 II 4-inch step 3:1 min 20 80 https://telegram.me/aedahamlibrary III 8-inch step 3:1 min 20 80 IV 12-inch 3:1 min 20 80 step V 16-inch 3:1 min 20 80 step The test is to be monitored carefully and the exercise, heart rate and BP are recorded at the end of each of five stages of the test as indicated in Table 1-14. The test is continued till the desired level (age-predicted maximal or submaximal) is reached. It should be conducted carefully and should be discontinued if any signs of intolerance appear. Termination of the test: The test must be terminated, immediately, if the following symptoms or signs appear: 1. Progressive angina or chest discomfort 2. Progressive drop in the systolic blood pressure or heart rate 3. Undue dyspnoea 4. Raised BP – systolic from 230 to 250 mm Hg and diastolic exceeding 130 mm Hg or falls below the resting level 5. Undue fatigue 6. Musculoskeletal pain and discomfort 7. Pale and clammy skin (signs of vasoconstriction) 8. Feeling of dizziness 9. Atrial fibrillation 10. Atrial tachycardia 11. Progressive ST changes (elevation, widening of the QRS complex) 12. Ventricular tachycardia (30 or more consecutive beats). Before testing, it is absolutely essential to identify patients who are https://telegram.me/aedahamlibrary vulnerable and need special precautions 13. Patient’s request to stop Vulnerable Group ◻ Patients with risk factors ◻ Asymptomatic but with abnormal exercise test ◻ Dysrhythmias induced or aggravated with activity ◻ Patients with significant hypertension and with low functional capacity Special Precaution Group ◻ Anaemia with haemoglobin below 10 mg/100 mL ◻ Uncontrolled metabolic diseases like diabetes, thyrotoxicosis and myxoedema ◻ Uncontrolled congestive heart failure (classes III and IV) ◻ Acute myocarditis or cardiomyopathy within past 1 year ◻ Uncontrolled hypertension ◻ Dysrhythmias ◻ Significant cardiac enlargement ◻ Moderate-to-severe valvular disease https://telegram.me/aedahamlibrary ◻ Recent pulmonary embolism (PE) ◻ Inappropriate BP response to exercise ◻ Painful limbs, as the test involves vigorous exercise, it can be administered only to the normal or near normal limbs (Table 1-15) Table 1-15 Physical Disability and the Exercise Tolerance Test Normal or Near Normal Test Extremities Graded step test Lower extremities Stationary bicycle ergometer Lower extremities 12-min run, jog, walk test Lower extremities Climbing and descending 40 Lower extremities steps Arm crank ergometer Upper extremities 12-min wheelchair propelling Upper extremities Recovery: At the conclusion of the test, heart rate (HR), BP and ECG are monitored during the recovery. These should return to near resting level within 2–8 min. Abrupt increase in BP, HR or ST changes during recovery indicate abnormality. (c) Evaluation of pulmonary function: Estimation of the vital capacity (VC) and 1-s forced expiratory volume (FEV1) can be done by a simple spirometer test. Nonforced expiration of air through the mouth (clamping the nose) which is followed by maximum inhalation gives the measure of VC. For measuring FEV1, the breath is held briefly following maximal inhalation, the subject exhales as hard and as fast as possible. These tests can provide the initial evidence for early cardiopulmonary disorders, especially in individuals complaining of unexplained dyspnoea on exertion. Note: The conditioning or target range begins at 60% of maximal HR https://telegram.me/aedahamlibrary and is safe up to 75% of MHR. Ideal training range is between 70% and 85% of MHR or the range of oxygen uptake between 57% and 78% of maximal aerobic capacity (VO2 max). Exercise tolerance can adequately be assessed by the patient’s own subjective rating of the perceived exertion – RPE (Table 1-16), where each grade corresponds near to the level of HR (e.g., grade 11 on the RPE scale corresponds close to the HR of 110; (Borg, 1970). Table 1-16 Borg Scale of Perceived Exertion Perception of Grade Exertion 6–7 Very, very light 8–9 Very light 10–11 Fairly light 12–13 Somewhat hard 14–15 Hard 16–17 Very 18–19– Very, very hard 20 After assessing the haemodynamic cardiorespiratory response to the exercise test and the overall exercise tolerance, suitable exercise prescription is formulated on an individual basis. Principles of formulating exercise prescription Certain basic principles need to be followed while planning an exercise prescription for CPC. They are as follows: (i) Education on the self-determination of HR: The HR is determined by counting the radial pulse manually for 10 s. It is then multiplied by 6 to get the HR (beats) per minute. The patient needs to be educated on this important aspect to monitor the HR during rest as well as exercise. (ii) Calculating the range of target HR: The predicted maximum HR can be calculated by deducting the age of the patient from 220. https://telegram.me/aedahamlibrary However, whenever stress test is available, the accurate exercise HR can be calculated by the Karvonen equation: https://telegram.me/aedahamlibrary https://telegram.me/aedahamlibrary To calculate age-predicted maximum heart rate, subtract patient’s age from 220. Thus, for a 60-year-old patient, maximum heart rate would be 220 – 60 = 160 beats/min. The target range of exercise heart rate for a 60-year-old person can be calculated as follows: 60% of the maximum heart rate will be 75% of MHR will be 120. 85% of the MHR will be 136. The target heart rate range for the 60-year old patient will be from 96 to 136 (60–85% of MHR). The target range of heart rate for various age groups is illustrated in Table 1-17 and Fig. 1-4. (iii) Exercise specificity: This is concerned with the three important factors of the exercise programme: ◼ Intensity: The prerequisite for the CPC is to overload the oxygen transport system to the heart. This is possible only when the exercise is continuous and the target HR range is maintained throughout the stimulus phase of the exercise. The intensity should exceed the usual mild demands, but must fall short of producing excessive fatigue. The appropriate level of training leads to exertion with perspiration. There is an increase in the rate of breathing but the patient will not be out of breath (talk test). There is a feeling of pleasant tiredness but not an unpleasant fatigue. ◼ Duration: The duration of conditioning exercises should be brief to begin with, increasing gradually. It could be https://telegram.me/aedahamlibrary begun at 15 min and increased gradually to 30–45 min. Minimum total time should be 3 h a week. ◼ Frequency: The frequency of exercise sessions should be at least three sessions a week. It should not be done on successive days. This frequency of three times a week provides an option to concentrate on the orthopaedic problem on the remaining 4 days of the week. (iv) Mode of exercises: Isotonic or dynamic mode is the best mode of exercise. The movements should be continuous rhythmic involving the larger muscle groups. Continuous mode can be changed to intermittent mode but the interval has to be very brief and activity at a slower pace is continued even during this brief interval. Slow-paced activity reduces physiological demand, and the levels of lactic acid, thereby reducing muscle fatigue. This, in turn, facilitates stronger effort when vigorous exercise is begun again, allowing extra resistance at reduced physiological demand. It also slows down the rate of respiration reducing breathlessness, which is particularly useful in patients with respiratory insufficiency. Table 1-17 Agewise Target Heart Rate Avg. max. HR Target Zone Age HR 60% 70% 75% 80% 85% 90% 20 200 120 140 150 160 170 180 25 195 117 136 146 156 165 175 30 190 114 133 142 152 161 171 35 185 111 130 138 148 157 166 40 180 108 126 135 144 153 162 45 175 105 122 131 140 148 157 50 170 102 119 127 136 144 153 55 165 99 115 123 132 140 148 60 160 96 112 120 128 136 144 65 155 93 108 116 124 131 139 70 150 90 105 113 120 127 135 Isokinetic mode of exercise is ideal as resistance is accommodated https://telegram.me/aedahamlibrary according to the force of muscular contraction. Isometric mode of exercise is generally contraindicated or done with caution. Isometrics provoke Valsalva manoeuvres, rhythm alterations and pressor responses. Therefore, it is contraindicated in patients with hypertension or done carefully, monitoring the BP responses. The exercise programme should be directed to involve larger muscle groups to facilitate augmentation of the heart rate. To avoid fatigue to one particular limb or muscle group, it should alternate between the lower limbs, upper limbs and the trunk. Unilateral limb exercise is not adequate; therefore, simultaneous movements of either the upper limbs or the lower limbs are necessary. Phases of conditioning exercise Conditioning exercises are to be done in three different phases: Warm-up phase: This phase is the initial phase of conditioning. It facilitates the necessary adaptations of myocardium, joints, skeletal muscles, tendons and ligaments to prepare the body for the vigorous conditioning phase. The efficiency of muscular contraction is greatly improved due to increased circulation; the raised temperature decreases the viscosity of blood. It also helps to reduce the chances of musculoskeletal injury. Continuous rhythmic aerobics or calisthenic movements are used to gradually increase the heart rate close to the level of 60% of MHR. Warm up can be given for 5 min. Stimulus, endurance or conditioning phase: This is the most important phase of conditioning. It is a progression over the warm- up phase as the heart rate is increased to the training level from 60% to 70%, 75% or even 85% of MHR. This phase needs careful monitoring to maintain the training range of heart rate as well as vigilance for any adverse symptoms. It consists of more vigorous dynamic exercises alternating the movements and the body segments with very brief intervals. This could be begun for 10–15 min initially, gradually increased to 30–40 min. Exercise equipment can be used to attain and maintain the target range. https://telegram.me/aedahamlibrary Cool-down phase: It is the phase of gradually tapering down the intensity of the exercise. Exercises at low level help maintain sufficient cardiac output following vigorous exercise. It helps to transport and remove the waste products of metabolism by augmenting the venous drainage. Abrupt termination of exercise may lead to excessive demand of myocardial oxygen consumption thus elevating the heart rate. Increased hypotension may result in the decrease of blood supply to the brain leading to light headedness, dizziness or even fainting. Eliminating lactic acid along with metabolic wastes also reduces the chances of developing muscular soreness. Slowing the pace of conditioning exercise and the movements of slow stretching of the musculotendinous complexes are ideal. It is to be done for 5 min. Ideally, relaxation techniques should follow the cool-down phase. Besides, inducing an overall feeling of betterment, these techniques are instrumental in reducing heart rate, blood pressure and even cardiac dysrhythmias. Integration of CPC The detailed physical evaluation of the orthopaedic problem should be analysed in relation to the prerequisites of conditioning. Warm-up phase: According to the CPC needs of this phase, weak or involved limb/limbs can be included in the exercise programme, as the exercises during this phase are to be performed with lower intensity. Stimulus or conditioning phase: This phase needs continuous, intensive and vigorous exercise. Therefore, stronger components of the body should form the basis during this phase. Cool-down phase: This phase involves active slow stretching procedures of the musculoskeletal structures of the involved limb. It can be used advantageously either alone or in association with the contralateral limb. https://telegram.me/aedahamlibrary However, exercise planning for conditioning needs to be done on an individual basis and therefore no rigid procedures can be enlisted. Example of integration For the planning of a therapeutic programme, the basic needs of the patient’s therapy are important. A young man with traumatic paraplegia will need the following: Strength – in the upper extremities to ease transfer activities and ambulation Endurance – to propel wheelchair, and ambulation with aids and appliances Flexibility – to facilitate self-care All these basic needs should be incorporated as per the requirements of the CPC as follows: Warm-up phase (5 min) ◼ Neck and trunk movements ◼ Arm movements with light dumbbells ◼ Passive bilateral hip, knee flexion Stimulus or conditioning phase (beginning with a 10-min exercise session and working up gradually to at least 30 min, only three times a week) ◼ Pulley weights ◼ Prone push-ups ◼ Arm crank ergocycle https://telegram.me/aedahamlibrary ◼ Ambulatory activities with wheelchair or ambulatory aids (Fig. 1-5) ◼ Rowing ◼ Wheelchair push-ups (Fig. 1-6) Cool-down phase (5 min) ◼ Back stretch – prone and supine ◼ Leg stretch ◼ Arm stretch https://telegram.me/aedahamlibrary FIG. 1-5 Arm crank ergometry in a paraplegic to assess exercise tolerance. https://telegram.me/aedahamlibrary FIG. 1-6 Six- or 12-min wheelchair propelling test, to assess exercise tolerance in a paraplegic. Therefore, incorporation of CPC in routine orthopaedic physiotherapy procedures for a mild neuromusculoskeletal dysfunction and gradually progressing to a major physical handicap assumes high priority. Every effort should be made, whenever possible, to practise such an integrated approach. https://telegram.me/aedahamlibrary Chest physiotherapy Chest physiotherapy has a vital role to play not only in medical or surgical chest conditions but also in surgical procedures involving spine, pelvis, extremities and abdomen. Chest physiotherapy also plays a significant role in the prevention of common postoperative complications, or in reducing their severity when they occur. It is also instrumental in the early return of the patient to his/her preoperative status. Objectives of chest physiotherapy 1. To help remove secretions Percussion – Cupped hands are applied rhythmically to the thorax. Precautions include rib fractures, costo chondritis, haemoptysis, blood coagulation problems, dysrhythmias, pain, severe dyspnoea, pneumothorax and increased bronchospasm. Shaking – Following inspiration, a ‘bouncing’ or ‘thumping’ manoeuvre is applied to the rib cage. Vibration – Isometric cocontraction of the arms is applied to the thorax; it is usually used in conjunction with shaking, percussion and postural drainage positioning. 2. To help clear the airway Cough – Forcefully expelling air following a deep inhalation and closing of the glottis to expel mucus. Forced expiration technique – One or two forced expirations with relatively low lung volumes, the glottis is not closed. https://telegram.me/aedahamlibrary Ideal for patients with chronic obstructive pulmonary disease (COPD). Huffing – Similar to a cough with an open glottis. Patient may say Ha, Ha during expiration. Assisted coughing – Similar to the Heimlich manoeuvre done during expiration. 3. To improve gaseous exchange and increase lung volume Three breathing exercise techniques are useful: 1. Diaphragmatic breathing 2. Segmental breathing 3. Pursed lip breathing Physiotherapeutic approach The approach of a physiotherapist should basically be problem oriented, to prevent or minimize the expected complications following surgery. Early identification of patients who are at risk of developing complications is of primary importance. This is done by preoperative observations and assessment of various parameters in relation to the patient’s condition, planned surgical procedure and the patient’s physical work requirements for job as well as for hobbies. Risk factors likely to cause postoperative complications ◼ Preexisting history of respiratory disorder, CV disorder, haemophilia, circulatory insufficiency (e.g., varicose veins, venous stasis) https://telegram.me/aedahamlibrary ◼ Malignant disease ◼ Diabetes ◼ Poor nutritional status ◼ Obesity ◼ Alcoholism ◼ Smoking ◼ Low breathing capacity due to acquired or congenital musculoskeletal deformity or diseases like scoliosis, kyphosis, pectus carinatum (pigeon chest), pectus excavatum (funnel chest), barrel chest and ankylosing spondylitis ◼ Delayed prothrombin time Subjective assessment In subjective evaluation, it is important to know the duration, severity, pattern and factors associated with the following when present: ◼ Dyspnoea or breathlessness ◼ Orthopnoea or breathlessness while lying flat ◼ Paroxysmal or nocturnal dyspnoea ◼ Cough ◼ Sputum and haemoptysis ◼ Type of chest pain: pleuritic, tracheitic, musculoskeletal, angina or pericarditis ◼ The chief disturbing factors as expressed by the patient https://telegram.me/aedahamlibrary Objective assessment It is vital to record other relevant information about the symptoms, past and present medical history, clinical and laboratory investigations and also physiotherapeutic evaluation. ◼ Respiratory rate (normal adult: 12–16 breaths/min) ◼ Chest expansion (normal adult: 3–5 cm) ◼ Breath sounds: Auscultation with stethoscope during inspiration is useful in detecting sputum retention. The opening of the alveoli and small airways during inspiration produces sharp crackling sound or continuous musical sound. These added breath sounds indicate alveolar narrowing and mucus retention. It helps in localizing the area of retention, its detachment and elimination. It can be correlated with the other signs of retention (Table 1-18). ◼ Forced vital capacity (FVC) ◼ Forced expiratory volume in 1 s (FEV1): Measurement of FVC and FEV1 can be done by spirometry. The ratio of FEV1 to FVC provides a direct measure of the degree of airway obstruction. The ratio of less than 75% is graded as mild, less than 60% graded as moderate and less than 40% is graded as severe (American Thoracic Society, 1986). ◼ Peak expiratory flow (PEF) ◼ Values of arterial blood gases: Normal values in adults: ◼ pH = 7.35–7.45 ◼ PaO2 = 80–100 mm Hg ◼ PaCO2 = 35–45 mm Hg https://telegram.me/aedahamlibrary ◼ HCO3 = 22–26 mmol ◼ Base excess = –2 to +2 ◼ Flow volume curves ◼ Chest radiograph ◼ Strength and endurance of the muscles of respiration ◼ Pattern of respiration including the efficiency of diaphragm or the degree of substitution by the accessory muscles of respiration ◼ Range of body temperature (normal adult 36.5–37.5°F) ◼ Heart rate (normal adult between 60 and 100 beats/min) ◼ Blood pressure (normal adult between 95/60 and 145/90) ◼ Body weight (normal adult BMI = 20–25 kg/m2) ◼ Exercise tolerance – tested by 6-min distance walk test (SMD) or 12- min walk test Table 1-18 Signs of Sputum Retention Auscultation Localized or scattered short and sharp interrupted crackles, which may move with coughing A continuous musical sound or wheeze may be present or absent Sputum Thick, more viscid of any colour Other signs Pyrexia, ineffective coughRespiratory muscle weakness Besides these, observation of fingertips for clubbing, colour of eyes, cyanosis, jugular venous pressure (JVP) and peripheral oedema provide important clues. Assessment of patients in ICCU https://telegram.me/aedahamlibrary ◼ Measurement of central venous pressure (CVP), pulmonary artery pressure (PAP) and intracranial pressure (ICP) is important ◼ Mode of ventilation (e.g., supplemental oxygen positive airway pressure, intermittent positive pressure ventilation) ◼ Route of ventilation (e.g., mask, endotracheal tube tracheostomy) Depending upon the correct and critical interpretation of assessment, therapeutic regime is to be planned on an individual basis. After assessment, the physiotherapy has two basic functions: (a) Preoperative guidance and training (b) Postoperative management Before dealing with these two aspects, it is important to know the possible postoperative complications. Common complications following general anaesthesia 1. (a) Excessive bronchial secretions and their stagnation (b) Reduction of lung volume (c) Reduction of functional residual capacity (FRC) 2. Postoperative pain 3. Deep vein thrombosis (DVT) 4. PE 1. Reduction of the lung volume and FRC, and accumulation of secretions ◼ General anaesthesia provokes irritation of the bronchial https://telegram.me/aedahamlibrary mucosa, inhibits ciliary movement and promotes excessive bronchial secretions and their retention. There is impairment in the movement of mucus. This mucus plugging may lead to regional hypoventilation, airway obstruction and may even cause collapse of the lung tissue distal to the obstructed airway, or may even precipitate infection. ◼ There is marked reduction in the lung volume. ◼ The FRC may be reduced between 18% and 30%. ◼ There is respiratory depression and the efficiency of collateral ventilation is decreased markedly. ◼ Abdominal distension may be present limiting the excursion of the diaphragm. ◼ The pleural cavity may also be reduced due to gas or fluid. All these factors result in marked deficiency in the whole process of the normal respiratory cycle. 2. Postoperative pain Persistent postoperative pain causes reduction in the lung volume, inhibits the clearance of bronchial secretions and may even cause spasm of the trunk muscles. All these factors also result in marked inefficiency of the mechanism of respiration, as it adversely affects the patient’s active cooperation to perform exercise to eliminate secretions. 3. DVT (Fig. 1-7) https://telegram.me/aedahamlibrary The DVT or PE may occur as a result of damage to the vessel wall, venous stasis or changes in the blood clotting factors. A clot or thrombus may be formed in the deep veins of the pelvis or in the calf vein-plexus in the soleus muscle. Patients with earlier history of DVT, varicose veins, venous stasis, obesity, malignant disease, hypercoagulability of blood and advanced age are more prone to develop DVT. Therefore, such patients need critical monitoring following surgery of abdomen, pelvis and lower extremity. A thrombus formed in the deep vein may produce local inflammatory changes or may migrate to the lung resulting in PE. The thrombus formation becomes obvious only by the end of a week or 10 days following surgery. Early signs of inflammation are pain, tenderness and warmth over the calf region with a mild rise in the body temperature. The positive sign of DVT is the increase of pain on passive dorsiflexion of the foot (Homans sign). Treatment: Accurate diagnosis of DVT in the suspected patients is possible with venography or phlebography. Anticoagulant therapy and aspirin, with graduated elastic stockings, are the effective measures to treat DVT. Embolectomy, by using cardiopulmonary bypass, and heparin followed by oral anticoagulant therapy are the measures to control PE. Vigorous ankle, foot and toe movements, elastic stockings, ambulation at the earliest, mechanical electrical stimulation of the calf muscle during surgery and special boots to https://telegram.me/aedahamlibrary accelerate venous return which produce intermittent pressure on the limb could be helpful in the prevention of these complications. Therefore, active vigorous movements of toes with limb elevation, whenever possible, should be concentrated throughout the period of two weeks following surgery as an effective preventive measure. 4. PE The signs of PE: ◼ Central chest pain or pleuritic pain ◼ Severe breathlessness, haemoptysis or cyanosis. Pulmonary angiography or scan can confirm the diagnosis of PE FIG. 1-7 Deep vein thrombosis (DVT) (longitudinal section of a vein): development site of DVT inside the vein.. https://telegram.me/aedahamlibrary Physiotherapeutic management 1. Preoperative guidance and training After evaluation and planning of a type of surgical procedure, the physiotherapist must apprise the patient about the detrimental effects of general anaesthesia. The patient should be made aware of the procedures to minimize the ensuing complications during immediate and late postoperative phases. Ideally, sessions on sequentially progressive postsurgical therapeutic regime should be taught during this preoperative period. 2. Postoperative physiotherapeutic management The basic function of physiotherapy is firstly to improve breathing control by training of normal tidal breathing, making it relaxed and least exerting, and secondly, to eliminate postsurgical secretions. This is achieved by (a) positioning of the patient and (b) teaching and practising active cycle of breathing techniques (ACBT). (a) Positioning of the patient: To increase FRC as well as preventing lung collapse, upright erect posture should be assumed as early as feasible. The ambulation is resumed at the earliest possible opportunity; it could be assisted and well supported. (b) Breathing techniques: The basic techniques of chest physiotherapy are known as the ACBT. Components of ACBT are (a) breathing control or normal https://telegram.me/aedahamlibrary relaxed breathing, (b) thoracic expansion technique or inspiratory control technique and (c) forced expiration technique or expiratory control technique. (a) Breathing control technique: It is a technique of relaxed, smooth, normal tidal breathing, primarily using the lower chest. Formerly known as diaphragmatic breathing technique, it is actually accomplished by the coordinated activity of the abdominals, external and internal oblique muscles, the scalene muscles and the diaphragm. Advantages - Improves inspiratory control - Minimizes the work of breathing - Helps to relieve breathlessness at rest and on exertion - Facilitates return of the normal patterns of breathing - Improves ventilation of the bases of lungs preventing collapse, hyperventilation and fatigue Technique: The patient is positioned in a relaxed sitting position, with back, head and shoulders fully supported and the abdominal wall fully relaxed. It can be performed even in the high side lying position. Hands are placed on the anterior costal margins. The patient is taught to breathe out as quietly as possible sinking down the lower ribs and the abdomen without any force. It must be remembered that forced or prolonged expiration will increase the work https://telegram.me/aedahamlibrary of breathing and may even increase air flow obstruction. This is followed by a gentle, active phase of deep inspiration through the nose. Passage of air through the nose allows the air to be warm, humidified and filtered before it reaches the upper airway. During this phase of inspiration, the abdomen should bulge out to its fullest extent. A careful watch is needed to ensure that the upper chest and the accessory muscles (e.g. sternomastoid, trapezius) are not over-used as this may result in early fatigue due to increased oxygen consumption caused by the excessive work of the accessory muscles of respiration. (b) Thoracic expansion technique or inspiratory control technique: It is a technique of deep breathing with effort and emphasis on active inspiration as against relaxed effortless techniques of breathing control. Advantages - Assists in losing of excessive bronchial secretions - Facilitates the movement of secretions - Assists in the re-expansion of the lung tissue - Improves lung volume and mobilizes the thoracic cage, promoting air flow through the collateral ventilatory channels, thus getting air exactly behind bronchial secretions - Improves ventilation–perfusion relationship https://telegram.me/aedahamlibrary - Prevents collapse of the lung tissue Technique: After deep inspiration with maximum expansion of the thoracic cage, air is held for 3 s like in pranayama (Chapter 38). This is followed by relaxed passive expiration. As it is a tiring procedure, there should be a pause for relaxation after four to five deep breaths. The patient may feel dizzy owing to hyperventilation. Ideally, every four to five expansion exercises should be followed by a pause for relaxation by repeating the breathing control technique. This technique can be performed in half-lying position with the knees slightly flexed over a pillow or sitting on an upright chair or stool. This technique is specially important during early postoperative phase to prevent lung collapse, facilitate mobilization of secretions and decrease atelectasis (Ward, Danziger, Bonica, Allen & Bowes, 1966). The clearance of secretions can be facilitated further by performing the technique in an appropriate postural drainage position (Table 1-19). Whenever feasible, chest clapping, shaking and vibrations may be incorporated for more effective drainage of the secretions. The manoeuvres of chest clapping, shaking and vibrations are contraindicated or done very carefully in patients with the following: ◻ Osteoporosis of ribs https://telegram.me/aedahamlibrary ◻ Metastatic deposits affecting the ribs or vertebral column ◻ Haemoptysis ◻ Acute pleuritic pain ◻ Active pulmonary infections (e.g., tuberculosis) Contraindications for postural drainage: ◻ Recent severe haemoptysis ◻ Hypertension ◻ Cerebral oedema ◻ Aortic and cerebral aneurysms ◻ Acute asthma, emphysema, or dyspnoea (c) Forced expiration technique or expiratory control technique: Excessive bronchial secretions are eliminated by this technique of forceful expiration. It is a combination of one or two forceful expirations (huffs or coughs) followed by intermittent periods of breathing control to prevent possible occurrence or sudden increase in the bronchial spasm. The important part of the clearance mechanism by huff or cough is the narrowing, dynamic compression and collapse of the airways towards the mouth (West, 1992). The technique may incorporate chest percussion and/or vibratory chest shaking. https://telegram.me/aedahamlibrary To mobilize and clear peripheral secretions, huffing or coughing is initiated from the mid-lung volume, i.e., following a medium-size inspiration. Air is squeezed out forcefully by using the abdominal and chest wall with the mouth open. However, it should be longer to reach and loosen the secretions from the peripheral airways. To clear the secretions that have already reached to the more proximal airways, huffing or coughing has to be initiated from the high lung volume, i.e., following full deep inspiration. A rapid flow of secretions results when a forced expiratory effort is made with coughing against a closed glottis which raises intrathoracic pressure. Then, when the glottis opens abruptly there occurs a large pressure gradiant between the alveolar pressure and the upper tracheal pressure, resulting in rapid flow of secretions. To produce a huff, a forced expiratory effort is made with the glottis remaining open. This compresses the intrathoracic trachea and bronchi, dislodging and moving the mucus up the bronchial tree. Technique: To produce effective elimination of secretions by huff or cough, it is mandatory to take a deep breath before coughing. Strong contractions in the abdominal muscles are needed to produce effective cough. A single continuous huff down the same lung volume or a series of huffs and coughs without intermittent inspirations could be used. After one or two huffs or coughs there should be a pause of varying durations of 5–20 s for relaxation or relaxed https://telegram.me/aedahamlibrary breathing (breathing control). Gravity-assisted postural drainage positions may be valuable in patients with excessive secretions (Hofmyer, Webber & Hodson, 1986). Modifications in the ACBT: Although ACBT constitutes (a) breathing control, (b) thoracic expansion and (c) forced expiration techniques, this sequence may not always be adequate if the secretions are not lost enough to be eliminated. In such a situation, it may become necessary to perform additional or more than one manoeuvre of thoracic expansion technique (Fig. 1-8). It must be remembered to add breathing control techniques in between thoracic expansion and forced expiration technique. Reassessment and revision of breathing techniques for evaluation of its efficacy and to maintain patient’s compliance are necessary at regular intervals. ACBT done in gravity-assisted positions is also an alternative method of clearing secretions, and can be safely used if the ACBT is not productive. If the cause of reduced lung volume is atelectasis or lobar collapse due to retained secretions, the patient may fail to respond to ACBT. It may be necessary to adopt measures like antibiotics, oxygen therapy or mechanical adjuncts like periodic continuous positive airway pressure (PCPAP), intermittent positive pressure breathing (IPPB) or positive expiratory pressure (PEP) mask. Incentive spirometry may be considered along with the ACBT in gravity-assisted positions. https://telegram.me/aedahamlibrary 3. Postoperative pain 1. Adequate doses of analgesics should be given to control pain and its effects on respiratory efficiency. If not successful, inhalation of Entonox (mixture of nitrous oxide and oxygen in equal amounts) in sitting posture with manual hyperinflation or IPPB. It facilitates ACBT. 2. TENS: Low-intensity, high-frequency transcutaneous electric nerve stimulation (TENS) inhibits transmission of pain via small diameter nociceptive fibres, through the activation of large diameter A fibres (e.g., pain following fracture of ribs). 3. Passive movements to the joints away from the immobilized joints can also be used to provide pain relief. 4. Relaxation techniques and relaxing postures like Shavasana or TM may also help in reducing the intensity of pain. https://telegram.me/aedahamlibrary FIG. 1-8 Active cycle of breathing techniques. Table 1-19 Gravity-Assisted Postural Drainage Positions Lobe Position Upper 1, Apical 1 Sitting upright lobe 2 bronchus, https://telegram.me/aedahamlibrary Posterior bronchus (a) Right 2(a) Lying on the left side horizontally, turned 45° on to the face, resting against a pillow, with another supporting the head (b) Left 2(b) Lying on the right side, turned 45° on to the face, with three pillows arranged to lift the shoulders 30 cm (12 inches) from the horizontal Lingula 3 Anterior 3 Lying supine with the knees flexed bronchus 4 Superior 4 Lying supine with the body one quarter turned to the right maintained by bronchus and a pillow under the left side from shoulder to hip 5 5 Inferior The chest is tilted downwards to an angle of 15°; foot end of the bed bronchus raised to 35 cm (14 inches) Middle 4 Lateral 4 Lying supine with the body one quarter turned to the left maintained by a lobe bronchus and pillow under the right side from shoulder to hip 5 5 Medial The chest is tilted downwards to an angle 15°; foot end of the bed raised bronchus to 35 cm (14 inches) Lower 6 Apical 6 Lying prone with a pillow under the abdomen lobe bronchus 7 Medial basal 7 Lying on the right side with the chest tilted downwards to an angle of (cardiac) 20°; foot end of the bed raised to 45 cm (18 inches) bronchus 8 Anterior basal 8 Lying supine with the knees flexed, buttocks resting on a pillow and the bronchus chest tilted downwards to an angle of 20°; foot end of the bed raised to 45 cm (18 inches) 9 Lateral basal 9 Lying on the opposite side with pillow under the hips, the chest tilted bronchus downwards to an angle 20°; foot end of the bed raised to 45 cm (18 inches) 10 Posterior basal 10 Lying prone with a pillow under the hips and chest tilted downwards to bronchus an angle of 20°; foot end of the bed raised to 45 cm (18 inches) Alternative breathing techniques as adjuncts to chest physiotherapy 1. Autoassisted positive pressure breathing or glossopharyngeal breathing (GPB) This breathing technique is a form o

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