Lakshmi NarayananTextbook of THERAPEUTIC EXERCISES masud.pdf · version 1

Textbook of THERAPEUTIC EXERCISES

Textbook of THERAPEUTIC EXERCISES S Lakshmi Narayanan PT Principal Navodaya College of Physiotherapy Mahaboobnagar (AP) JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD New Delhi

Published by Jitendar P Vij Jaypee Brothers Medical Publishers (P) Ltd EMCA House, 23/23B Ansari Road, Daryaganj New Delhi 110 002, India Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021, +91-11-23245672 Fax: +91-11-23276490, +91-11-23245683 e-mail: [email protected] Visit our website: www.jaypeebrothers.com Branches • 202 Batavia Chambers, 8 Kumara Krupa Road, Kumara Park East, Bangalore 560 001, Phones: +91-80-22285971, +91-80-22382956, +91-80-30614073 Tele Fax: +91-80-22281761 e-mail: [email protected] • 282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza Pantheon Road, Chennai 600 008, Phones: +91-44-28262665, +91-44-28269897 Fax: +91-44-28262331 e-mail: [email protected] • 4-2-1067/1-3, Ist Floor, Balaji Building, Ramkote Cross Road, Hyderabad 500 095, Phones: +91-40-55610020, +91-40-24758498 Fax: +91-40-24758499 e-mail: [email protected] • 1A Indian Mirror Street, Wellington Square Kolkata 700 013, Phone: +91-33-22451926 Fax: +91-33-22456075 e-mail: [email protected] • 106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital Parel, Mumbai 400 012, Phones: +91-22-24124863, +91-22-24104532, +91-22-30926896 Fax: +91-22-24160828 e-mail: [email protected] Textbook of Therapeutic Exercises © 2005, S Lakshmi Narayanan All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means: electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher. This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of material, but the publisher, printer and author will not be held responsible for any inadvertent error(s). In case of any dispute, all legal matters are to be settled under Delhi jurisdiction only. First Edition : 2005 ISBN 81-8061-469-7 Typeset at JPBMP typesetting unit Printed at Gopsons Papers Ltd. A-14 Sector 60, Noida

All to Lord Krishna

Acknowledgements I, first of all, express my gratitude and thank the people those worked hard with me to complete this project successfully in time. I don’t have the words to express my thanks to Dr KP Neeraja, Principal, Navodaya College of Nursing, Raichur who initiated and motivated me to start this project and encouraged to complete this project in time successfully. And I express my special thanks to my friends who spent their lots of time and guided me while editing this book. Dr Radhakrishnan MPT student, Navodaya College of Physiotherapy, Raichur with whom I spent 10 years of lifespan from my college days, guided and helped me a lot to the completion of the project. And I also extend my thanks to management, colleague, students and well-wishers of Navodaya College of Physiotherapy, Mahaboobnagar, Andhra Pradesh who encouraged, helped and guided to create one venture in my life. And also I thank the Publisher, Jaypee Brothers Medical Publishers (P) Ltd. and staff of Bangalore branch. Thanks one and all, I need your help too to continue my achievement.

6 TEXTBOOK OF THERAPEUTIC EXERCISES Preface Many of them told me that writing a book is not an easy thing, at last I came to know it is true. This project I bring to you is purely helpful for the beginners of exercise therapy. The books available on therapeutic exercises are above the level of the undergraduates and highly advanced one. This made me to select my project of exercise therapy. I believe that this book gives the basic knowledge in the field of exercise therapy. This book is the first venture and the future editions will be updated to the need and demand of the profession. I request the readers to comment, guide and express opinions on this book, which will be helpful for me to make perfect and qualitative in the next edition. Kindly send your comments to [email protected]. S Lakshmi Narayanan

GAIT 7 Contents 1. Mechanics ........................................................................................................................... 1 2. Introduction to Exercise Therapy ............................................................................... 14 3. Examinations ................................................................................................................... 27 4. Goniometry ....................................................................................................................... 40 5. Starting and Derived Positions ................................................................................... 52 6. Relaxation ........................................................................................................................ 70 7. Pelvic Tilt .......................................................................................................................... 73 8. Active and Passive Movements .................................................................................... 77 9. Relaxed Passive Movement ........................................................................................... 84 10. Peripheral Joint Mobilization ...................................................................................... 95 11. Stretching ....................................................................................................................... 159 12. Functional Re-education Training ............................................................................ 182 13. Suspension Therapy ..................................................................................................... 195 14. Incoordination (Asynergia) ........................................................................................ 204 15. Mobility Aids .................................................................................................................. 212 16. Gait ................................................................................................................................... 226 Bibliography ...................................................................................................................... 235 Index ................................................................................................................................. 237

1 CHAPTER Mechanics FORCE 2. The distance is represented by the direction of the arrow. Force is that which produces the motion or The force can be defined by the effect what modifies the motion of an object and moves it for a particular distance it is the alteration in it produces. the state of resting object or the motion created in the object to create the force one object has Linear Force to act on another, it may be pull or push. Force If the two forces are acting along the same line has the vector quantity, i.e. magnitude and and produces the straight-line motion is direction. referred on the linear force. Example: The force may act on two varieties of objects: a. When two forces are acting on an object in 1. Static 2. Dynamic. same direction produces the linear motion, the forces are said to be the pushing linear The force acts on the stable or the body, force (Fig. 1.1A). which is in equilibrium, the body may be in b. When the two forces pull an object in same rest or in contact motion. The force may be direction it produces the linear motion, the acting on the object, which in motion and it force is said to be the pulling linear force may be changing the state of motion. (Fig. 1.1B). c. When the two forces are acting opposite to Force = Mass × Acceleration, each other with the equal magnitude it where, force is measured in newton, mass in results in equilibrium (Fig. 1.1C). kilogram, acceleration in meter (m/s2). d. When the two forces are acting opposite to each other with unequal magnitude the Force is applied on the object particular movement occurs towards the greater weight to move it for particular distance. One magnitude side. newton is defined as the force applied on the 1 kg weight object and moves it for 1 meter Parallel Force distance. The two equal magnitudes are acting in the 1. The magnitude is represented by the length of the arrow.

2 TEXTBOOK OF THERAPEUTIC EXERCISES The children are applying the two forces in the end and the fulcrum gives the counter force to maintain the see-saw in neutral position. Rotational Force In the parallel forces any one of the forces is greater than other results the rotation that force is said to be the rotational force. or If the two different magnitude forces act on the different points of an object result in the rotation movement, i.e. twisting effect; the forces are said to be force couple (Fig. 1.3). Concurrent Force If the two forces are acting on the object in different directions is perpendicular to each other. The resultant force will be in between the two forces. It can be diagrammatically represented by the parallelogram method (Fig. 1.4). CENTER OF GRAVITY (COG) The center of gravity is a imaginary point at which the mass of the object is concentrated. The symmetrical objects will have the COG at the center of the object. It may depend on the size, shape, structure, weight, and portion of the particular object. In asymmetric object the COG is located in the heavier end where the mass is concentrated. In a rod the COG is located near to the upper end, if it is vertically placed and the same will be near to the ground if it is horizontally placed due to its height, weight difference, and the weight transmitted area (Fig. 1.5). Fig. 1.1: Linear force LINE OF GRAVITY (LOG) same direction and same plane with the counter The imaginary vertical line passes through the force in the middle (Fig 1.2). center of gravity is called as line of gravity. Normally, the center of gravity (COG) lies in Example: See-saw the second sacral vertebra in the human body

MECHANICS 3 Figs 1.2A and B: A. Parallel forces with same magnitude, B. Parallel forces with different magnitude Fig. 1.3: Rotational forces (Force couple)

4 TEXTBOOK OF THERAPEUTIC EXERCISES while erect bilateral standing posture. It will change with the positional changes. In the human body each and every segment of the body has its separate COG and the two or three segments together gives the different COG. For example, the arm, forearm and hand will be having its own separate COG but the upper limb as a whole gives some other different COG. Fig. 1.4: Concurrent force system BASE OF SUPPORT (BOS) The base of support means the area supported beneath the object. Whenever the base of support is more the stability will be more. Greater the BOS lower the COG of any object. 1 BOS α —C—OG— For example, the fundamental position of standing the BOS is lesser than the lying, so COG in the standing position it is in the higher level whereas in the lying posture it will be just near to the ground as a result lying posture is more stable than the any other fundamental position and also it can be maintained for the longer period. The stability is directly propor- tional to BOS and inversely proportional to COG (Fig. 1.6). Stability α BOS 1 Stability α —CO—G— EQUILIBRIUM Equilibrium is balancing or keeping in remain rest of the body even though the force is exerted on it (or) it is the state of an object where all the forces acting on it are equal in magnitude and opposite in direction. Fig. 1.5: COG and LOG Types of Equilibrium It is classified into the following three types: 1. Stable equilibrium 2. Unstable equilibrium 3. Neutral equilibrium.

MECHANICS 5 Fig. 1.7: Different types of equilibrium Fig. 1.6: A. Standing—COG in higher level, LOG is in Unstable Equilibrium highiest height, less BOS, B. Sitting—COG in lower The minimum force is enough to alter the level, LOG is in lesser height, BOS is more, C. Ly- equilibrium of an object is called as the unstable ing—COG near to floor, LOG is in very much lesser equilibrium. The BOS is less and the COG is in height, BOS is huge higher position. The object will be having the lesser equilibrium. Whenever the object is in resting position, it may not be having the tendency of moving Example: Pen is balanced to stand on the or rotating so the resultant force and movement floor. When the force is applied to the pen, it is equal to 0. alters its original state. Stable Equilibrium Neutral Equilibrium The object will restore in resting position even Even though the movement or position changes though the force alters its equilibrium. This in the object by the force exerted on it, there is called as the stable equilibrium. Generally, will not be any change in the COG of the object. the equilibrium will be more when the BOS is more and COG lies in the lower part of an object Example: Ball is rolling on the floor. (Fig. 1.7). LEVER Example: Book placed on the table. When A lever is defined as the rigid bar, which moves the force is applied on the book, the book about on some fixed point called fulcrum (F). regains its original state after the removal of To perform an activity or a movement, the the force. bone acts as the lever and the joints acts as the

6 TEXTBOOK OF THERAPEUTIC EXERCISES fulcrum (F). The movement will be created by Example in human body—Atlanto-occipital two types of forces, i.e. resistance (R), and effort joint. (E), in which the resistance (R) is the opposing force and the effort (E) is action achieving force. During the nodding movement of the head, The resistance may be the weight of the body the neck extensors act as the effort (E) Atlanto- parts and the effort may be the pull of the occipital joint as fulcrum and the facial part is muscle. The perpendicular distance between the resistance (R). the effort to the fulcrum is called as effort arm (EA) and the perpendicular distance between Second Order Lever the resistance to the fulcrum is called as The resistance (R) lies between the fulcrum (F) resistance arm (RA). and the effort (E), these levers are the lever of the strength but not the speed and ROM. These Achieving the ROM of the joints may some- types of levers are less seen in the human body. time depend on the strength of the muscles or the place of the insertion of the particular Example: Wheelbarrow. muscles. For example, if the two muscles are Example in human body—raising the body acting on the same joint for a same movement; on the toes. In which the ball of the toes are the effort (E) will be added more, as a result the the fulcrum (F) the tendo-Achilles tendon is the ROM will be so easier and also more faster the effort (E) and the body weight is passing through movement. Consider the equal powered two the middle part of the foot is the resistance (R). muscles are acting on the same joint for same This variety always having the mechanical action but their insertions are: (a) one is farther advantage. So that varieties of levers or called to the joint (fulcrum), (b) another is closer to the are the levers of the strength. joint (fulcrum). The muscle, which inserted closer to the joint produce stronger movement Third Order Lever than the farther inserted muscles The effort lies in between the fulcrum (F) and the resistance (R). These levers having mostly Types of Levers mechanical disadvantage. But the third order These are of three types. They are as under: levers are seen plenty in the human body. 1. First order lever (1°) 2. Second order lever (2°) Example: Bettle nut cutter, Chapatti press. 3. Third order lever (3°). Example in human body—flexing the elbow First Order Lever Fig. 1.8: Levers of various classes The fulcrum (F) is between the effort (E) and the resistance (R). Sometimes the fulcrum is situated closer to the resistance or effort. Example: See-saw, scissors, nail-cutter, etc. If the fulcrum is closer to the resistance (R) it produces more speed or ROM but with less strength. If the fulcrum is close to the effort (E) it produces the less speed or ROM but with more strength. There are less number of first order levers are seen in the human body and also the lesser mechanical advantage.

MECHANICS 7 in which the elbow is the fulcrum (F) biceps NEWTON’S LAWS OF FORCE insertion is the effort (E) and the forearm and There are three laws of motion given by hand is the resistance (R) (Fig. 1.8). Newton. 1. Law of inertia Mechanical Advantage 2. Law of acceleration The mechanical advantage of the lever depends 3. Law of action-reaction. on the few factors: force (F), resistance ( R) and its perpendicular distance, i.e. resisted arm Law of Inertia (RA) and effort arm (EA). If the RA and EA are The object remains at rest or of uniform motion in same length, there may not be any unless and until it is disturbed by an external mechanical advantage. The same effort force force. is necessary to oppose the resistance. Then the mechanical advantage (MA) = 1. For example, while traveling in the car the body is in motion suddenly if the break applies If the RA greater than the EA, then the the body will be moved forward, because the effort force should be more to oppose the body tends to be in motion. resistance, so it is difficult to perform the movement. Above said two varieties are not Law of Acceleration having the mechanical advantage. The rate of changing of velocity is called as acceleration. The velocity is directly propor- MA < 1 tional to the acceleration and inversely If the EA exceeds the RA, less effort is proportional to the mass of an object. required to oppose the force. This is called as the mechanical advantage. It can be achieved in all a= F/m the second order levers and the 1st order levers where, a is acceleration, f is force, and m is where the fulcrum is closer to the resistance (R). mass of the body. Mechanical Advantage—EA/RA It can also be written as When the effort arm (EA) is more than the F= ma resistance arm (RA) then the mechanical advantage will be more than 1. When the which is the Newton’s second law of motion. mechanical advantage is more than 1, less effort is required to perform the movement. Law of Action-Reaction For every action there is an opposite and equal EA > RA reaction. a. In first order levers there is no rule of The heavier the mass, lesser the movement mechanical advantage. EA may be greater, and the lesser the mass greater the movement. lesser or equal to RA. Among these, if the The strength of the action is equal to strength EA is greater than RA, it gives more of reaction. mechanical advantage. b. In all second order levers the mechanical Example: Recoil of the gun. advantage is greater than one. c. In all third order levers the mechanical PULLEY advantage is normally less than one. So, the Pulley is the grooved wheel, which moves effort should be more to produce the around an axis and the rope or the iron cable movement.

8 TEXTBOOK OF THERAPEUTIC EXERCISES Fig. 1.9: Pullies passing through the groove. Two categories of This type of pulley is used in the suspension pulley are seen as under: therapy units which makes easy to lift the body 1. Fixed. parts. This reduces the restricted force to half 2. Movable. and easy lifting the body parts. Fixed Pulley SPEED The pulley is attached to the fixed point, the Speed is the rate at which the object moves. It fixed pulley is acting as the first-order lever. does not take in account of the direction. The The weight (R) on one side and the effort (E) on normal speed of an object may vary depends another side with the fixed axis is fulcrum (F) on the hurdles it passes. The speed of an object in middle. This type of pulley is used to alter moving in one plane may vary between in each the direction of the force by which the resistance and every particular distance; even though we or the traction can be applied to the body parts. can calculate the average speed of that particular object. Example: Lateral malleolus acts as the pulley for the peroneus longer tendon to reduce WORK the resistance force of that muscle (Fig. 1.9). Work is defined as the force moves an object for a particular distance. It is measured in joules Movable Pulley or ergs. One end of the rope is attached to the fixed point and another end is passed through the Work = Force × Distance fixed pulley. The movable pulley is attached in where, work measured in joules, force in between the fixed point and the fixed pulley, newtons, and distance in meters the movable pulley acts like the second order lever. Generally, second order lever will have POWER the mechanical advantage. This movable pulley Power is the rate at which the work is done or reduces the restricted force into half. rate of energy expenditure. There is no second order lever seen in the human body.

MECHANICS 9 Power = Work × Direction. Where, Work in joules. Duration in seconds. ELASTICITY Elasticity is the capacity of regaining its original form after releasing the force exerted on it. Example: Springs, elastic rubber, sorbo rubber. Hook’s Law The stress and strain are directly proportional to each other. Stress α Strain SPRINGS Fig. 1.10: Springs Springs are used to assist or resist the move- ment in exercise therapy. Sometimes it is used ENERGY for the passive mechanical stretching of the soft Energy is the capacity to perform the work. It tissues. One end of the spring is attached in is mainly of two types namely: the beam another end is elongated by the force. • Potential energy • Kinetic energy Weight of the Spring Sometimes the springs are graded in the Potential Energy weights. It is the capacity of doing the work with the help of the stored energy. For example, the Example: 20 lbs, 40 lbs, 50 lbs, 75 lbs. The maximum flexion of the knee in the standing 20 lbs springs needs the 20 lbs of force to position has the potential to fall down with the elongate it. According to the pounds of the help of the gravity due to the position (Fig. 1.11). springs it requires the force to elongate it. Springs in Parallel If the two springs are used in parallel manner the weight of the springs are added and it requires the sum of the springs force to produce the maximum of elongation (Fig. 1.10). Springs in Series Fig. 1.11: Kinetic and potential energy If the two springs are added in the series manner that is equal to the single spring and the effort to elongate them is the sum of the two springs divided by two.

10 TEXTBOOK OF THERAPEUTIC EXERCISES Fig. 1.12: Rotational motion Kinetic Energy Fig. 1.13: Linear motion This is the work done by an object as a result of motion. The potential and kinetic energy can be explained with the pendulum. The potential energy is stored in either side of the pendulum while moving. The potential energy is changed into kinetic energy while falls with help of the gravitational force. TYPES OF MOTION To perform osteokinematic movement there should be an axis and a plane. Rotatory Motion (Fig. 1.12) • Otherwise called as angular motion. PLANES AND AXES • Movement of an object around a fixed axis Planes Planes are the space or surface where the known as rotatory motion. movements take place. • Each segment moves through the same angle, same time at a constant distance. Translatory Motion (Fig. 1.13) Axes • Each segment or object moves in straight Axes are the points by which the movements take place. The anatomical position (standing line. erect with the head, toes and the palm of the • Each segment moves through same distance hand facing forwards and the finger extended.) is the correct position to discuss about the at the same time in parallel path. planes and axes. The imaginary planes are • If the movement occurs in straight line is made to each other perpendicular in the human body. These are called as “Cardinal planes”. called as “linear motion”. • If it occur in curved pathway is called “curvilinear motion”.

MECHANICS 11 Fig. 1.14: Curvilinear motion Types 1. Frontal plane (Coronal plane) 2. Sagittal plane (A-P plane) 3. Transverse plane (Horizontal plane) (Fig. 1.15) Frontal Plane Fig. 1.15: Axes and planes • The plane, which divides the body into equal Transverse Plane front and back parts. • The plane, which divides the body into equal • This plane passes through the coronal upper and lower parts. suture of the skull. • Movement occurs in X-Z plane. • Movement occurs in X-Y plane. • Movements possible are medial and lateral • Movement occurs in sagittal axis or A-P rotation. axis. • Movement occurs in vertical axis. • Movements possible are abduction and MOVEMENT ARM adduction. Definition: This is the distance between the axis of the joint to the action line. Sagittal Plane • The plane, which divides the body into equal Rarely the movement arm comes in the line of the lever arm. Whenever the force is applied right and left parts. 90° to the lever arm, the perpendicular distance • Movement occurs in Y-Z plane. will fall on the lever arm and coincides. In • This plane passes through the sagittal human joint most of the line of forces parallel suture of the skull. • Movements possible are flexion and exten- sion. • Movement occurs in frontal axis or coronal axis.

12 TEXTBOOK OF THERAPEUTIC EXERCISES Fig. 1.16: Hamstring exerting the force on the leg. A. 45°, B. 90°, C. 125° flexion of knee Fig. 1.17: Movement arm in relation with gravitational force. A. 45°, B. 90°, C. 125° flexion of knee

MECHANICS 13 to the lever arm due to the muscular comes perpendicular to the lever arm and the arrangement, so the movement arm will have movement arm distance will be more and also the more short distance and also rarely some the movement arm coincides with the lever joint line of force comes perpendicular to the arm. lever arm (lever arm is the movable segment of the joint). So, whenever the force is applied During 45º and 125º, i.e. below and above 90° to the lever arm, the movement arm 90º of movement, the movement arm distance coincides with the lever arm. If the line of force reduces and comes closer. So, the torque is applied 90° to the lever arm, the torque created in the muscle will be very less. created in the muscle will be maximum. Variation in the angulations of the lever results in increasing or decreasing of the movement T = f × ⊥d arm. The application of the LOG also decides ⊥d = ma the ma of the lever. Generally, gravity acts T = f × ma vertically, so the LOG will be perpendicular to For example: Hamstring muscle action (Figs the lever arm. Whenever the lever is in 90º 1.16 and 1.17) position the gravity exerts more torque on the Generally, the lever arm will be constant lever. The muscular torque has to counteract and the line of force and the movement arm the gravitational torque to generate the changes depend on the arrangement of the movement over the lever. Whenever the movement. In 45º, 90º, 125º of flexion of knee gravitational torque is less, i.e. during below the torque created by the muscle will be more or above 90º angulations, there will be less during 90º. Because whenever the line of force muscular torque needed to generate the movement on the lever.

214 TEXTBOOK OF THERAPEUTIC EXERCISES CHAPTER Introduction to Exercise Therapy TYPES OF SKELETAL MUSCLE FIBERS Type IIa Fibers Skeletal muscles are the voluntary and striated They contain more amounts of myoglobin, mito- muscles. These skeletal muscles are responsible chondria and blood capillaries. But comparative for the activities or movements around a with type I, these are less pink in color. These particular joint. These skeletal muscles are not are fatigue-resisted fibers but not like Type I. having the same structure and function. There They split the ATP much faster, as the result are three types of skeletal muscles (Table 2.1). contraction velocity is also fast. These fibers a. Type I fibers also generate the ATP from aerobic system. b. Type IIa fibers c. Type IIb fibers. Oxidative—Fast Twitch—Pink Colored— Fatigue-resisted Muscle Fibers Type I Fibers Example: Leg muscles, which is responsible for These fibers contain more number of the mito- walking and running. chondria, myoglobin and the blood capillaries. Because of the more number of myoglobin and Type IIb Fibers blood vessels, the muscle fibers are red in color. They contain less numbers of mitochondria, It is having the capacity to generate the ATP myoglobin and blood capillaries. They generate from the aerobic system, so that it is called as the ATP from the anaerobic system, i.e. by the oxidative fibers. It is innervated by the less processes of glycolysis. They are large in number of nerve fibers. These muscle fibers diameter fibers and are fatigue earlier. The are in small diameter and fatigue-resisted contraction of these muscle fibers will be more fibers. rapid and strong. These muscle fibers also contain the glycogen, they are in white color. Slow Twitch—Fatigue-resisted—Red Colored— Glycolytic—Fast Twitch—Early Fatiguable— Oxidative Muscle Fibers White Muscle Fiber Example: Postural muscles like neck and trunk Example: The muscle responsible for rapid muscles. movement are—Shoulder flexors and abductors.

INTRODUCTION TO EXERCISE THERAPY 15 Characters Type I Table 2.1: Types of muscle fibers Type IIb Color Type IIa White Fatiguability Fast Myoglobin Red Pink Less Capillaries Very less Slow Less ATP Production More More Anaerobic system Velocity More More Fast of conduction Aerobic system Aerobic system Less Mitochondria Rapid contracting muscles Example Slow Medium Weight lifting, gymnastic Activity More More activities Postural muscles like Leg muscles neck muscles Walking, running, Maintaining posture jogging Normally, each and every muscle contains • Type IIa—Runner, athletes. the mixture of all the muscle fibers. Depending • Type IIb—Gymnastic people, body-builders. on the activity the muscle fibers are working and also depends on the proportionate of muscle ARRANGEMENT OF THE FASCICULI fibers in the muscle spindle determines the OF THE MUSCLES contraction of muscles. In postural muscles the The muscular fasciculi are arranged in three proportion of the type I fibers are more and in directions. rapid contraction muscles the type II b propor- 1. Parallel tion is more. During the minimal contraction 2. Oblique of the muscle, the Type I muscle fiber motor 3. Circular. fibers are stimulated as a result type I muscle fiber goes for contraction. If the more amount Parallel of contraction is needed, the Type II motor The fasciculi muscles having the strong action units will be stimulated. and also higher ROM capacity. These muscles are again divided into four varieties. They are: Sometimes depend on the exercise the type of the muscle fibers also changing. If the i. Strap strenuous activity is less, the type IIb fibers ii. Fusiform may be converted as type II a or type I. If the iii. Rhomboidal strenuous activity is more the type I fibers may iv. Triangular. become type IIa or type IIb. For example, the gymnastic people, who are Strap performing the rapid movements and exercise In this muscle, fasciculi are parallel with each will be having the more proportionate of the other and run total length of the muscles and white fibers (type IIb). The runners will be ends in flat tendon. having more proportionate of the pink fibers (type IIa). The normal people like housewife, Example: Sternomastoid, stylohyoid. clerks, company MDs will be having the more of red fibers (Type I). Fusiform • Type I—Housewife, those who are perfor- The fasciculi are parallel to each other and runs full length of the muscles and terminate in the ming the normal day-to-day activities.

16 TEXTBOOK OF THERAPEUTIC EXERCISES flat tendon. But the muscular part is more Oblique Muscle Fibers bulky in middle than the tendon. The muscles are having the strong fibers but less ROM capacity muscles. There are three Example: Biceps, brachioradialis. varieties. 1. Unipinnate Rhomboidal 2. Bipinnate These muscles are rhomboid shape or quadran- 3. Multipinnate gular in shape, the muscles having the broad attachment with the broad flat tendon. In this variety the fasciculi are short and the tendon runs maximum length of the muscle. Example: Rhomboidus major, pronator quadratus. Triangular Unipinnate The muscles having the spreaded fasciculi, The muscular fasciculi are arranged in the one which ends with the flat and small tendon, these side of the tendon. are triangular or fan-shaped. Example: Tibialis anterior, EDL, and semi- Example: Pectoralis major, temporalis (Fig. membranosus. 2.1). Fig. 2.1: Arrangement of fasciculi of muscles

INTRODUCTION TO EXERCISE THERAPY 17 Bipinnate • Plantar flexion: Bending the ankle in Fasciculi are arranged in both sides of the downward direction. tendon. • Protraction: Forward movement of the Example: Intraosseous muscles of the hand. mandible or shoulder girdle. Multipinnate • Retraction: Backward movement of the Many tendons are having both the side fasciculi mandible or shoulder girdle. arrangement. • Supination: Movement in which the palm Example: Deltoid. facing upwards. Circular Muscle Fibers • Pronation: Movement in which the palm Fasciculi are arranged in the circular manner facing downwards. and help to close an orifice. • Elevation: Upward movement of the body Example: Orbicularis oris, external anal part. sphincter. • Depression: Downward movement of the ANATOMICAL MOVEMENT body part. • Flexion: Bending movement reduces the RANGE OF MOTION (ROM) angle between the articular surfaces. Movement of the joint can be performed by the • Extension: Stretching movement, which internal or external force. The internal force can be produced by the muscles and the external force increases the angle between articular may be produced by manually or mechanically. surfaces. The movement of a joint results in angulations • Abduction: Bony segments move away from of that particular joint. The angulation of the the midline. movements are referred as the range of motion. • Adduction: Bony segment moves towards The ROM will be perfect in one joint if the soft the midline. tissues are intact. If any change occurs in any • Medial rotation: Rotational movement soft tissues results in disturbance or alteration occurs in the articular surface towards the of the range of motion. Generally, in the hypo- midline (Internal rotation). mobile joint the ROM will be less than the normal • Lateral rotation: Rotational movements prescribed ROM of that particular joint. In occur in the articular surface away from the hypermobile joint it is vise versa. This ROM can midline (External rotation). be measured with the help of goniometer. • Circumduction: Combination of flexion, extension and abduction, adduction and There are two types of ROM (i) Active, and medial rotation, lateral rotation. (ii) Passive • Inversion: Moving the sole of the foot 1. Active ROM: The ROM, which is achieved inwards so that each sole of the foot faces each other. without any external force, i.e. by the effort • Eversion: Moving the sole of the foot of his own called as active ROM. Generally, outwards. the Active ROM, will be less in the hypo- • Dorsiflexion: Bending the ankle in upward mobile joint. direction. 2. Passive ROM: The ROM which is achieved with the help of the external force is called as Passive ROM. Normally, by the Passive ROM we can achieve greater ROM than Active ROM. In hypomobile joint, the Passive ROM will be more than the Active

18 TEXTBOOK OF THERAPEUTIC EXERCISES ROM because the tightened structures will Abduction 0 °-55 ° be stretched by the passive force but it Adduction 0° cannot achieve actively. The ROM may be External rotation 0 °-45° (35°-50°) different from each and every joint. Internal rotation 0 °-35° (30°-45°) The ROM may be varying from each and • Knee 0 °-120 ° every joint and each and every individual Flexion 0° depends on the variety, size, and bony promi- Extension 0 °-45 ° nence. The same joint ROM may be differing • Ankle 0 °-20 ° from an individual to individual due to variation Plantar flexion 0 °-45 ° in muscle bulk and the bony prominence. Dorsi flexion 0 °-15 ° The prescribed ROM for each and every joint Inversion 0 °-40 ° in normal individual is given below: Eversion 0 ° 80 ° (10 °-90 °) • Shoulder • MTP 0 °-15 ° Flexion 0°-180° (150°-180°) Flexion 0 °-60° (50°-70°) Extension 0 °-45° (40°-60 °) Extension 0° Abduction 0°-180° (150°-180°) Abduction Adduction 0° • Interphalangeal Internal rotation 0 °-90° (70°-90°) Flexion External rotation 0°-90° (70°-90°) Extension • Elbow Flexion 0°-135° (120°-150°) Extension 0° RANGE OF MUSCLE WORK • Forearm Range of muscle work means the degree of the Supination 0 °-90 ° movement done by the muscle contraction. The Pronation 0 °-90 ° range of the movement can be measured by • Wrist the goniometer. To produce a movement, the Flexion 0 °-90° (70°-90°) group of muscles has to contract or stretch. Extension 0 °-70° (50°-70°) There are 4 types of ranges. Ulnar deviation 0 °-40° (25°-40°) 1. Full range: The muscle is moving the joint Radial deviation 0 °-20° (15°-25°) • MCP from the full stretched position to full Flexion 0 °-90 ° contracted position (Concentrically) or from Extension 0 °-20° (15°-30°) full contracted position to full stretched Abduction 0 °-20 ° position (Eccentrically). The full range of Adduction 0° movement rarely required in normal day- • PIP to-day activity. Full range exercises are Flexion 0 °-110° (90°-120°) required to perform by the patients to Extension 0° maintain the full ROM of the joints. • DIP 2. Inner range: The muscles move the joint Flexion 0 °-90 ° from the medium contracted position to the Extension 0° full contracted position (Concentrically) or • Thumb from minimum contracted position to MCP flexion 0 °-45 ° the full stretched position (Eccentrically). • HIP Extreme inner range movements are Flexion 0°-120° (110°-130°) difficult to perform and it requires the more Extension 0 °-35° (25°-40°) numbers of motor unit contractions.

INTRODUCTION TO EXERCISE THERAPY 19 3. Middle range: Muscle moves the joints very much difficult to perform. While perfor- between the minimal range to the medium ming the outer range movement, the angle range. There is no fully stretched or fully of pull will be adverse and some of the contracted muscles seen. This is the range energy is used for the compression of the which we use more in our day-to-day life. articular surface. The gravity also resists In this range the muscle has the maximum the movement, so that out range movement strength. Exercise in this range increases will be difficult to perform (Fig. 2.2). the muscle power, strength and tone. Muscle Action 4. Outer range: The muscles move the joint In normal action a single muscle cannot from the stretched position to the minimal produce the effective movement. Depends on contracted position (Concentrically) or from the function of the muscles they are named as: full contracted to the medium contracted (i) agonists, (ii) antagonists, (iii) synergists, and position. Outer range movements also are (iv) fixators. Agonists These are chief muscles, which produce the effective movement. These groups of muscles are called as prime movers. Example: For elbow flexion biceps and brachialis are helpful, but the brachialis has its major part in the contraction or movement. So, brachialis is called as the prime mover or agonists. Antagonists These are the muscles, which is acting against the agonists. Example: Triceps act as the antagonists to the brachialis while flexing the elbow. If the agonists contracts, the antagonist goes for relaxation by the neurological reflex. Same mechanism is used in the PNF techniques to reduce the spasm or the spasticity of the muscle group. Fig. 2.2: Hamstring eccentric and concentric Synergists (Syn-with) muscle work The name itself explains us the muscle acting with the other muscle. The synergists are acting with the agonists and making stronger the action of agonists. Example: Biceps acts as synergists to brachialis for the elbow flexion.

20 TEXTBOOK OF THERAPEUTIC EXERCISES Fixators elbow flexion to perform the push-ups. The Fixators are the muscle, which fixes the attach- shoulder joint moves towards the fixed wrist. ments of the agonists, antagonists and syner- gists. Open Kinematic Chain The movement occurring independently and Example: The muscles attached with the not in predictable manner. The distal joint shoulder girdle to the trunk acts as the fixator moving and the proximal joint will be fixed with- for the deltoid action. Fixators are not only out any motion. fixing the bony component while movement of Example: agonists, antagonists or synergists and also a. In shoulder 90° flexion, performing the have the dynamic properties. It is not only having the isometric contraction but also has elbow flexion and extension movement. isotonic in altering the pattern of movement. b. In standing posture, the leg is lifted from Fixator work is very much (nearly 75%) the ground and performing the knee flexion needed in normal day-to-day activities. and extension movement (Fig. 2.3). Example: Threading in the needle, throwing the ball. KINEMATIC CHAIN The movement of one joint may require the motion over the proximal and distal joints, and sometimes it may not be required. Two types of kinematic chains are present. 1. Closed kinematic chains 2. Open kinematic chains. Closed Kinematic Chain Figs 2.3i to iv: (i), (iii)—Closed kinematic chain, In human body the joints are having interlink and (ii), (iv)—Open kinematic chain with each other, so the motion occurs in one particular joint causes motion over the other joints in predictable manner. In the closed kinematic chain the proximal and distal joint will be moving to produce the movement over one particular joint. Example: (1) Performing the sit-ups and (2) performing the push-ups. In the first example the hip joint flexion and the ankle joint dorsiflexion occurs to produce the flexion over the knee to go for the sitting posture. The proximal joint (hip) is moving towards the distal (ankle) joint but the distal joint is fixed without any movement. In the second example the shoulder extension and wrist extension produce the

INTRODUCTION TO EXERCISE THERAPY 21 In the figure example elbow flexes without the motion of the shoulder and the distal joint (wrist) is free to do any motion. In the second example the knee is flexed without the movement of the hip and the ankle is free to do any movement. ACTIVE AND PASSIVE Fig. 2.4: Passive insufficiency INSUFFICIENCY around these joints in the given sequence, the muscle cannot go for further more lengthening In one joint muscle the movement may not be in the MCP, PIP and DIP. This phenomenon is restricted by the proximal or distal joint motion. called as passive insufficiency. If the agonist But it is not possible in the two or multi-joint muscle goes active insufficiency, the antagonist muscles, the ROM may be changing depends goes for the passive insufficiency. on the proximal and distal joint movement. If the muscles are crossing more than one joint, there is possibility for active and passive insufficient said by Brunnstrom. Active Insufficiency TYPES OF MUSCLE WORK The muscle cannot go for further shortening Muscle activity increases the intramuscular while performing the activity around the joints, tension and changes in the muscle length. The which the muscle crosses. It occurs to the muscle fibers are contracted and relaxed during agonists. the muscle work. We can categorize these muscle works by the change in the length and Example: Flexor compartment muscles of tone of the muscles into three varieties. the forearm. These muscles responsible for 1 Isotonic contraction elbow flexion, MCP flexion PIP and DIP flexion. 2 Isometric contraction If the above said movements are done in the 3 Isokinetic contraction. same sequence, the person feels difficult in flexing the MCP and finger after flexing the Isotonic Contraction elbow and wrist, because the muscles are Iso—equal, Tonic—tone. By changing the already shortened by the elbow and wrist length of the muscle, the same amount of flexion. So, further shortening is difficult, this tension is created throughout the contraction is called as active insufficiency (Tenodesis). is said to be isotonic contraction. There are two types of isotonic contractions. Passive Insufficiency • Concentric contraction The muscle cannot lengthen further while • Eccentric contraction. performing movement around more than two joints, which it crosses. It occurs in the anta- Concentric Contraction gonists (Fig. 2.4). Concentric—towards the center. This type of contraction is otherwise called as shortening Example: Extensor compartment muscles contraction. The muscle is isotonically shortens of the forearm. These muscles are responsible for elbow, wrist, MCP, PIP and DIP extension. While performing the opposite movement

22 TEXTBOOK OF THERAPEUTIC EXERCISES to produce the movement. The proximal and Fig. 2.5: Concentric contraction distal bones are drawn towards the center. A Bi Normally, one bony component is fixed and another will be moving to perform the Bii movement. If the proximal bony component is fixed the distal bony component will be pulled towards the center. Example: Lifting the dumb-bells. If the distal component is fixed the proximal bony component moves towards the center. Example: Push-ups. Insertion of the muscle moves towards the origin or origin the muscle moves towards the insertion of the muscles during the concentric contraction. The concentric contraction moves the bony lever through some distance in the direction of the muscle pull. So that it results in an action or muscle work (Figs 2.5 and 2.6). W=F×D where W = Work, F = Force, and D = Distance Force, i.e. tension is created inside the muscle that the tension pulls the bony compo- nent to some distance, so that it results in movement. Isotonic contractions are used to build up the muscle power and the muscle bulk and it requires more energy to perform. Normally, in the body-building exercise, the concentric contraction exercises are playing major role than the other varieties of contrac- tions. Resisted concentric contractions are mostly useful to increase the muscle power and bulk. Eccentric Contraction Figs 2.6A to Bii: A. Proximal component is fixed and Eccentric—from the center (Fig. 2.7). This is the distal component is moving, Bi,ii. Distal compo- otherwise called as lengthening contraction. nent is fixed and the proximal component is moving Here the proximal and distal bony components are pulled apart from the center. Eccentric muscular tension moves the bony lever through contraction lengthens the muscle and the a distance in the direction of the muscle pull. insertion of the muscle is pulled distally. The But the muscle work is said to be negative energy expenditure in this contraction is very muscle work. Normally, these eccentric less than the concentric contraction. The

INTRODUCTION TO EXERCISE THERAPY 23 Fig. 2.7: Eccentric contraction Isokinetic Contraction contractions are assisted by the gravitational Iso—equal, Kinetic—Force. In isokinetic con- force. The contraction occurs inside the muscle tractions the velocity, speed is same and the even though it lengthens. For example, carry- resistance is variable. This type of contraction ing a bucket by the hand and filling water from and the exercise can be done with the help of the tap. In this example the length of the muscle the special equipment such as Biodex, Cybex, is increased and the bony components are Orthron, Kincom. The speed and velocity is drawn apart in the direction of the muscle pull preset and the resistance is directly and the tension will be generated inside the proportional to the torque produced by the muscle and slowly increases with the filling of muscle. The speed is constant; if the patient the water in the bucket. wants to increase the speed also it is not possible. If the patient offers more force, the Isometric Contraction resistance exerted by the instrument will be Iso—equal, Metric—measurement.In isometric more. If the patient pushes less force there will contraction there is no changes in the length be less resistance by the instrument. For of the muscle but the tension. Intramuscular example, in concentric contraction. tension is created without changing the length of the muscle. There is no mechanical muscle While lifting the dumb-bells (e.g. 6 kg) with work occurs in isometric contraction because the hand, the resistance exerted by the dumb- the force (F) is generated, i.e. tension is created bells will be same throughout the movement. but is not moving the bony lever because both Normally in the middle range, muscle has more the proximal and distal bones are fixed here. strength than in the beginning and in the end These types of contractions are otherwise called range. If the resistance stays same throughout as static or holding contraction. Isometric the ROM, the muscle has to work harder in contractions are more easy and less energy beginning and in the end range, so that the expensive contraction. Isometric contraction speed also varies throughout the ROM. But in against resistance also can build up the muscle isokinetic exercise whatever the torque produ- bulk and the power. This type of isometric ced in the muscle same amount of resistance exercise can help to improve the muscle produced by the instrument. In the middle strength. Less fatiguability is also seen in this range the strength of the torque is more, so type of contraction. that the resistance given by the equipment also more. Sometime in the beginning and in end range is less. So, this advantage is not seen in the isotonic or isometric contraction and exercise. If the person feels pain he cannot stop the movement all of a sudden safely in the isotonic contraction or exercise. But it is possible in isokinetic contraction. The tension created inside the muscle changes depend on the type of muscle contrac- tion; the tension generated in the eccentric contraction is more than the other contraction (Fig. 2.8). Eccentric contraction > Isometric contraction > Concentric contraction.

24 TEXTBOOK OF THERAPEUTIC EXERCISES Oca2nanbde RBC supply to the acting muscles. This done by: • By increasing HR • By increasing BP • By increasing cardiac output • By increasing venous return • By reducing blood flow to the inactive muscles and non-vital organs • By redistributing the blood from the non- vital organ to vital organ. A BC Changes in Cardiovascular System Effect on Heart Figs 2.8A to C: A. Isometric, B. Concentric, A prolonged exercise causes the enlargement C. Eccentric contraction of heart. Generally, hypertrophy of the heart in athletes caused by the strenuous exercises. ENDURANCE This type of hypertrophic and enlarged heart is totally different from the diseased enlarged Endurance means performing an activity for a heart, i.e. cardiomegaly. What the athletes are prolonged period of time without any fatigue, having is the physiological change but the this is the fatiguability resistance exercises and diseased enlargement due to the diseased aerobic ttyhpeeeonferegxyericniseens.duTrhaenOce2 is used as a pathology. The athletes of hypertrophic heart fuel for exercises. It having the increased stroke volume but the is of two types namely, dilated diseased heart will not be having the 1. Muscular endurance, and strength to work harder. 2. General body endurance. Effect on Heart Rate Muscular Endurance The enormous increasing of the heart rate A group of muscles contracts for a prolonged observed at the beginning stage of the exercise period of time without fatigue. and after some time the raising ratio of heart rate comes down. During the early stage of the General Body Endurance exercise the raising of the heart rate due to This is otherwise called as cardiopulmonary the cerebral activation on the medullary cardiac endurance. Many groups of muscles of the body center. This heart rate raising differs from an performing an activity for a prolonged period individual to individual. The athletes having of time without fatigue. the reduced heart rate than the normal man while performing exercise, if the stamina Example: Walking, jogging, running. increases the heart rate decreases with the exercises. PHYSIOLOGICAL CHANGES DURING Effect on Cardiac Output EXERCISES (EXERCISE PHYSIOLOGY) The cardiac output tremendously increases with Increasing muscular activity needs the more the strenuous exercise. In athletes the cardiac

INTRODUCTION TO EXERCISE THERAPY 25 output may be 30 liters per minute but the same decreased in the abdominal organs, kidney and is 22 liters per minute for the normal man. other non-vital organ. Cardiac output increases with the increased stroke volume mostly observed in the athletes Changes in Respiration as said above (see effect on heart). Pulmonary Ventilation Effect on Venous Return Pulmonary ventilation is so stable up to the During the muscular exercise the venous severe exercise is done. The pulmonary ventila- return increase. It may be due to (1) continuous tion is not increasing with the increasing of muscular contraction which squeezes and consumption of the Op2ublymtohneamryusvcleenttiislsauteioonr pumps blood towards the heart, (2) reflex venous itnhcereOas2 elsacwki.thTthhies severe increasing of the constriction increases the venous return, and workload. (3) respiratory movement increases the sucking effect on the right heart, during the inspiration Respiratory Rate the intrathoracic pressure decreases and the abdominal pressure increases which causes the TinhcereOa2sedsemthaenrdesdpuirraintogrtyhreastteroefnaunouinsdeixveidruciasle, rapid return of the blood to the heart. it may be due to: 1. Increased production of the CO2 by the Effect on BP working muscles. The muscular exercise increases the systemic 2. Proprioceptive activation of the joint. BP. The raising of the BP due to the (1) Increa- 3. Reflex effect by the respiratory centers. sed HR (2) Increased COP (3) Increased vasocon- 4. Increases temperature. striction in the non-vital organ. The increasing 5. Adrenaline hypersecretion. of the HR and the cardiac and vasoconstrictor centers of the medulla stimulate the cerebral Effect on Second Wind cortex to increasing BP. In early stage of the strenuous exercise the person feels the distress, headache, throbbing Effect on Circulation pain, breathlessness and irregular pulse, but if the exercise continued, the distress comes During exercise blood supply to the active down. This sense of relief is called as second muscles and vital organ increases, it is found wind. During the second wind distress dis- that the blood supply increases 30 times during appears and the discomfort disappears. But the exercise than the normal state. While perfor- physiology of the second wind is not so clear. ming exercise, the workload of the heart increases with the need. In moderate exercise coronary flow increased depends SoonmtehtiemOes2 requirement of the cardiac muscles. Effect on O2 Exchange due to strenuous exercise the cardiac muscle minatyhantostibtueagteiottninthgethpeerssuofnfimcieanytfeaeml tohuenatnogf iOn2a, During the normal or moderate exercise the gaiOnon2cedrfsletouahwspeettadoor. ttT4ehhrleitee/mmsO.ui2Gnst.eceIlnnenessri,toahlnluelynrsa,geitvshaeenersdeOinet2hxsteehartehcuiaersalaevrtettioohilnesi pain. The muscular exercise increases the pulmonary circulation but the blood supply to the brain remain normal. While performing aOc2idwbilyl be lacking due to production of lactic exercise the blood flow to the active muscle, the active muscles. So, the lactic acid heart, and lung are increased but the same is

26 TEXTBOOK OF THERAPEUTIC EXERCISES quantity increases in the blood plasma and Effect on Kidney Functions active muscles. To reduce the lactic acid During the exercise the blood flow to the non- metabolism, excess amount of O2 is needed; this vital and the inactive muscles decreases. Due lack is called O2 debt. to the decreased blood flow to the kidney, there will be lacking of the urine formation and the Changes in Blood Cell increased secretion of the ADH, this ADH During the strenuous exercise the fluid enters increases the fluid reabsorption up to 1 or 2 into the tissue from the blood. So, the hemo- hours from cessation of the exercise there will concentration occurs but the prolonged exercise be reduced urine flow. Normally, the exercises may reduce the hemoconcentration by sending cause the increased amount of albumin in the back the fluid into the blood. Sometimes during urine. Sometimes physical exercise causes the the strenuous exercise the hemolysis may also red urine, which contain hemoglobin, it is due occur. The WBC count increases in any sort of to the breakdown of the RBC during the exercise. But the raising of the WBC may vary strenuous exercises. It also breaks the myog- between the normal people to the athletes; it lobin, which results in the black urine formation may be less for athletes while comparative with 24 to 48 hours after exercise. the common man. Changes in Blood Temperature Digestive System Muscular activity produces the heat, if the heat The mild exercise, like walking, increases the loss is less the body temperature goes up. gastric juice secretion and the motility of Normally, during exercise the body temperature stomach. But the strenuous exercise decreases goes up due to the temporary failure of the the gastric juice secretion and the stomach temperature regulation center activation. motility, but increasing after cessation of the exercise will compensate the same. Changes in Blood Fluid Endocrine Function During the muscular exercise, there will be the The endocrine function during the exercise has rapid loss of the water through sweating and not been fully studied. The growth hormone expired air. In early stage of exercise the fluid secretion increases with the strenuous exercise. enters into the tissue from the blood results in ADH also increases more as discussed earlier hemoconcentration and comes down by the but there is no change in the thyroid hormone. fluid back to the blood. So, the sweating The utilization of cortical hormone is increased observed during the early stage of exercises, if during the exercise. exercise prolonged the excessive sweating comes down.

3 CHAPTER Examinations CINICAL EXAMINATION OF MOTOR Quadriceps Muscle Bulk NERVOUS SYSTEM From the base of the patella three points are marked in the bulky area with a difference of The clinical examination of the motor nervous system consists of the following identities. It is as follows. Bulk of Muscles The state of nutrition is examined by inspection and palpation of various muscles, and comparing these on the two sides. In muscular atrophy, the muscle mass decreases and the muscle gives a soft and flabby feeling. Atrophy may be general, following a prolonged illness. Physical exercise increases the bulk (hypertrophy) of the muscles. In some diseases of the muscles (dystrophies), the muscle mass increases (pseudohypertrophy), but these bulky muscles are weak despite their size. Calf and buttock muscles are especially involved. Measurement of Muscle Bulk Figs 3.1 and 3.2: Measurements of quadriceps The muscular weakness or the atrophy leads muscle bulk with inch tape to the reduction of the muscle bulk. To measure the muscle bulk, the bulky area is selected. In general, muscle bulk measurements are done for the quadriceps and calf muscles.

28 TEXTBOOK OF THERAPEUTIC EXERCISES 2 or 3 inches. The circumference is measured 2 — Full range of movement in elimination of from all the three marked areas by the inch gravity position tape. The difference is compared with the normal side limb (Figs 3.1 and 3.2). 3 — Full range of movement in against gravity position Calf Muscle Bulk From the apex of the patella three points are 4 — Full range of movement in against gravity marked in the bulky area with a difference of position with minimal resistance 1 or 2 inches. The circumference is measured from all the three points, the difference is 5 — Normal. compared with the normal side. Second Method Sometimes circumference measurement is taken for the biceps and the brachioradialis 0 — No contraction muscles also. 1 — Flicker of contraction 1+— One-third of movement in eliminating Muscle Tone It is a state of sustained partial contraction of gravity position. the muscle, where it may be increased or 2¯— Two-thirds of movement in eliminating decreased during pathological condition. Tests for increased tone (hypertonia), or decreased gravity muscle tone (hypotonia), for checking the tones 2 — Full range of movement in eliminating are by passively moving the parts of the limb and assessing the resistance offered by the gravity muscles. 2+— One-third of movement in against gravity Strength of Muscles position It is the assessment for weakened or paralyzed 3¯— Two-thirds of movement in against gravity muscles. It enables to find out the strength of the muscle and its capacity of performing an position activity. The strength of the muscles are asses- 3 — Full range movement in against gravity sed manually and are graded into five stages 3+— One-third of movement in against gravity according to the medical research council. The manual muscle testing has developed by position with minimal resistance Wright and Lovett in 1912. But the Daniels 4¯— Two-thirds of movement in against gravity and Worthingham, Kendall and Kendall methods are most commonly used. Before position with minimal resistance entering into strengthening program one 4 — Full range of movement in against gravity should have the thorough knowledge about the manual muscle testing. position with minimal resistance 4+— One-third of movement in against gravity There are two methods of muscle grading. position with maximal resistance. First Method 5-— Two-thirds of movement in against gravity 0 — No contraction 1 — Flicker of contraction position with maximal resistance 5 — Full range of movement in against gravity position withmaximalresistanceornormal. CLINICAL EXAMINATION OF THE SENSORY NERVOUS SYSTEM Kinds of Sensations The sensory nervous system comprises diffe- rent kinds of sensations, which can be examined in different ways. There are different kinds of sensations, which are as follows:

EXAMINATIONS 29 Epicretic Sensation Crude Touch These are the mild or light sensations, which These are still heavier form of touch like a are perceived accurately. These are of different pressure type. Subject may be pressed by a types as follows: heavy pressure of the examiner’s thumb, tested a. Fine touch or tactile sensation for both sides. Sensations were perceived by b. Tactile localization pacinian corpuscles and its center is located in c. Tactile discrimination. sensory cortex. Abnormality causes anesthesia, paresthesia, and hyperesthesia and hypo- Protopathic Sensations esthesia, which is the increased and decreased These are the crude and primitive types of sensitivity of sensory stimuli. sensations. a. Pressure sensation Pain b. Pain sensation This sensation is tested by a pin or needle prick c. Temperature sensation. of the skin, on identical marks of both sides. This sensation is perceived by free nerve Deep Sensations endings and its center is located in sensory These are the sensations, which are arising cortex. Loss of this sensation leads analgesia from the deep structures. and other abnormality of hyperalgesia or a. Pallesthetic sensation paralgesia. b. Kinesthetic sensation (Conscious and sub- Temperature conscious) This sensation is tested by having the identical c. Visceral pain sensation. parts of both sides to be tested by hot water test tube and cold-water test tube alternatively. Special Sensations The subject is asked to say about the tempera- These are the special and complex sensations ture felt. This is perceived by Raffinis end like taste, vision, hearing, smell, etc. bulb for warmth sensation and Krause’s end bulb for cold sensation. The center is located The nervous pathways of the sensations are in sensory cortex. Loss of this sensation leads called the sensory pathways and carry the to thermic anesthesia. impulses from the receptors to the centers in brain, which are of two types like somato- Kinesthetic Sensations sensory system and viscerosensory system. These are the sensations by which a person becomes aware of the position and movements Methods of Testing of Different Sensations of different joints of the body. The impulses arise Fine Touch from muscles, tendons, joints, and ligaments. Test with a wisp of cotton, on identical points This is perceived by proprioceptors, muscles of the two sides of the body. Test for two points spindles and Golgi bodies. The center located in discrimination in addition to touch appreciation cerebellum. Loss of this kinesthetic sensation and localization. These have been perceived by leads to akinesia and loss of vibratory sense Meissner’s corpuscles and Merkel’s disc, and leadsto pallenesthesia.Lossofabilitytorecognize its center located in sensory cortex. Loss of all any known object with closed eyes due to loss of sensations and abnormal sensations results in cutaneous sensations called as astereognosis. anesthesia and paresthesia respectively.

30 TEXTBOOK OF THERAPEUTIC EXERCISES EXAMINATION OF REFLEXES segment of the spinal cord. The extensor The reflexes which are of importance in clinical plantar response or the Babinski’s sign is a neurology can be divided mainly into the pathology occurring in UMN lesions. There following groups: occurs a dorsiflexion of the big toe followed by 1. Superficial reflexes extension and fanning of the other toes. 2. Deep or tendon reflexes Babinski sign is a part of the mass flexor 3. Visceral reflexes of organic reflexes withdrawal reflex, which is seen in the cases of 4. Pathologic reflexes. spinal cord transection. The following points must be remembered The pathway for this reflex is afferent by in all reflexes: tibial nerve (L5, S1), efferent by L4, L5, center 1. Method of eliciting the reflexes is S1, S2. 2. Response or the result produced 3. Afferent and efferent pathway Epigastric Reflex 4. Centers for the reflexes Stroking the chest with a blunt point of the 5. Clinical significance of each reflex. needle, downwards from the nipple results in drawing in of the epigastrium on the same side. Superficial Reflexes Center is T7,T8. The stimulation of a particular part of skin or mucous membrane results in the contraction Superficial Abdominal Reflex of certain muscles. The reflex arc for skin A light stroking of the skin, preferably directed reflexes seem to be complex and long, and towards the umbilicus, results in brisk con- include a number of internuncial neurons. The traction of anterior abdominal muscles lying afferent impulses appear to be carried up directly under the stimulus. Centers are through the posterior white columns and T8, T9, T10, T11, T12. spinothalamic tracts and end in midbrain, thalamus or even the forebrain. From here, Cremastric Reflex the impulses are carried down by pyramidal Stroking the inner side of upper thigh results and extrapyramidal tracts to the anterior gray in drawing up of the testicle due to contraction column cells. The neural paths for deep of cremastric muscle. Center is L1, L2. reflexes, on the other hand, are simple and short, ending in the spinal cord itself. Mucous Membrane Reflex Corneal or Conjunctival Reflex Skin Reflexes Touching the cornea or conjunctiva with a wisp Plantar Reflex (Plantar Flexor Reflex) of cotton results in bilateral blinking. Afferent A scratch is given along the outer edge of the pathway is by ophthalmic division of 5th cranial sole of the foot with a pencil or the blunt point nerve, efferent pathway is by 7th nerve and of a needle, starting from the heel towards the center is in pons. little toe, and then, along the bases of the toes, medially. In healthy adults, there is a plantar Pharyngeal Reflex flexion of the toes, especially the big toe, and A touch upon the posterior pharyngeal wall the ankle is dorsiflexed and inverted. Stronger with a tongue depressor results in constriction stimuli may produce withdrawal of the limb. of pharynx. Afferent pathway is by 9th nerve, This reflex is mediated by the first sacral efferent by 10th nerve, center is in medulla.

EXAMINATIONS 31 Palate Reflex prone position of the forearm. Afferent and Touching the mucous membrane covering the efferent pathway is radial nerve, center is soft palate results in elevation of the palate. C6,C7,C8. Afferent by 9th nerve, efferent by 10th nerve, center is in medulla. Patellar Reflex or Knee Jerk In the high sitting position or when the leg is Deep Tendon Reflexes in the relaxed position tap the patellar tendon. If the tendon of a slightly stretched muscle is The response is extension at the knee joint. sharply tapped with percussion hammer, the Afferent and efferent pathway is by femoral muscle contracts immediately. Deep reflexes nerve, center is L3,L4. are ‘fractionated’ stretch reflexes. The stimulus that initiates the reflex is the stretch of the Ankle Jerk muscle spindles and not the tendon receptors. Dorsiflex the foot slightly with one hand and Impulses originating in the muscle spindles are strike the Achilles tendon with the percussion conducted to the CNS, and pass directly to the hammer, the response is plantar flexion of the motor neurons, which supply the same muscle. foot, afferent and efferent pathway is by tibial Elicit the deep reflexes on both sides, and nerve, and center is in S1, S2. compare their speed, amplitude, and the duration of contraction and relaxation of the Visceral Reflexes muscle in each case. These are the papillary reflexes, which are grouped into direct and indirect light reflexes. Maxillary Reflex Strike the middle of the chin with the tip of Light Reflex (Direct Light Reflex) middle finger when the mouth is slightly Examine each eye separately with the subject opened. The response is a sudden closure of in a shady, indirectly illuminated place. Shine a the jaw. Afferent and efferent pathway is by bright light into the eye being tested (bring the 5th nerve, and center is in pons. torch from the side of the eye and never from directly in front of the eye as the subject will Biceps Reflex reflexly close his eyes). There is constriction of Tap the tendon of the biceps, the response is pupil almost immediately; then it dilates a little, flexion of the elbow. Afferent and efferent and assumes a smaller size after undergoing a pathway is by musculocutaneous nerve, center few oscillations. Switch off the light; the pupil is C5,C6. quickly dilates to its previous size. The optic nerve is the afferent pathway; the center is in Triceps Reflex the midbrain (the concerned fibers leave the Tap the tendon of the triceps, with the elbow optic tract before the lateral geniculate body slightly flexed, the response is extension at the and end in the pretectal region of the midbrain elbow. Afferent and efferent pathway is by on the Edinger-Westphal nuclei of both sides). Radial nerve, and center is C6, C7. The efferent pathway is the oculomotor nerve. Radial Supinator Reflex (Brachioradialis) Consensual Light Reflex (Indirect Light Reflex) Flexion and supination of the forearm upon Place a hand between the two eyes and focus striking the styloid process of the radius in mid- light into one eye, observing the effect on the

32 TEXTBOOK OF THERAPEUTIC EXERCISES pupil of the unstimulated side. There is constric- where, there will be a dorsiflexion of the big tion of the pupil in the other eye (i.e., both toe followed by extension and fanning of the pupils constrict). The constriction of the pupil other toes along with dorsiflexion of the ankle on the unstimulated side is called the consen- and flexion of the knee and hip joint may also sual or indirect light reflex. This response is occur. This response has also been called due to crossing of some of the fibers in the optic ‘Babinski toe sign’, ‘up going toe’, and ‘positive chiasma and their termination on the oculo- Babinski reflex’. With slight lesions, this motor nuclei of both sides. Switch off the light response may be obtained only from the lateral and note that both pupils dilate. The consen- region while a normal response is obtained sually mediated reaction is more active than from the medial region of the sole of the foot. the direct reaction of a pupil in some lesions of Babinski sign is a part of the mass flexor reflex the optic nerve. Afferent pathway is by 2nd (withdrawal reflex) seen in cases of spinal cord nerve, efferent pathway is by oculomotor nerve, transection. and center is in midbrain. The other pathological signs are Gordon’s Accommodation Reflex leg sign, Oppenheim’s sign, Chaddok’s sign, When one looks at a near object the pupils Hoffmann’s sign. constrict, the eyes converge, and the lenses become more convex. These three responses CLINICAL EXAMINATION OF constitute accommodation reaction. Hold up CRANIAL NERVES your index finger close to the subject’s nose First or Olfactory Nerve and ask him to look at a distant object (or the Take small amount of oil of peppermint and oil far side of the room). Then ask him to quickly of cloves in two small test tubes. Bring these focus his eyes at your finger. As the eyes near each nostril separately, one after the converge the pupils constrict, if the patient is other, and ask the patient if he can identify the unable to see ask him to look at his finger held smell. Irritants such as ammonia and acetic in front of his eye. Afferent pathway is by 2nd acid should not be used as they also act through nerve, efferent pathway is by oculomotor nerve, the trigeminal nerve. It should be confirmed and center is in visual cortex. before the test that the patient is not suffering from common cold. Loss of sense of smell is Pathological Reflexes called anosmia. Ask the patient if he has any This group includes some primitive responses, hallucinations of smell. The olfactory area of which occur only with lesions of UMN. the cerebral cortex lies in the uncus of the Normally, they are suppressed by cerebral parahippocampal gyrus. inhibition. The reflexogenic area is widened in upper motor neuron lesions, and the Babinski- Second or Optic Nerve like response is obtained from widespread areas. To test the optic nerve first ask the patient if his vision is normal. Acuity (sharpness) of vision Babinski’s Sign can be tested by making the patient read letters It is otherwise called extensor plantar response; of various sizes printed on a ischiaras chart it was named extensor because the movement from a fixed distance. It must, of course, be of the toe is in extension according to anato- remembered that loss of acuity of vision can be mical terminology. This occurs in UMN lesions caused by errors of refraction, or by the presence of opacities in the cornea or the lens

EXAMINATIONS 33 (cataract). As part of a normal clinical exami- muscles, which move the eyes. The 6th nerve nation the field of vision can be tested by supplies the lateral rectus, the 4th nerve confronation test as follows. Ask the patient to innervates the superior oblique, and the 3rd sit opposite you (about half a meter away) and nerve supplies all the other extraocular look straight forwards at you. As one eye to be muscles, along with the sphincter pupilae, tested at a time ask the patient to place a hand ciliary muscle (the muscle of accommodation) on one eye so that he can see only with the and the levator superiors. other eye. Stretch out one of your arms laterally so that your hand is about equal distance from i. Ask the patient to look at your finger held your face and that of the patient. In this position at a distance of about 2 feet from his eyes. you will probably not be able to see your hand. Notice if there is any squint (strabismus). However, you may notice it if you move a finger. Ask the patient if he has double vision Keep moving your index finger and gradually (diplopia) or gets attacks of vertigo. bring the hand towards yourself until you can just see the movements of the finger. This gives ii. Test for pupillary light reflexes and the you an idea of the extent of your own visual convergence accommodation reflex. Notice field in that direction. By asking the patient to the size, shape, and mobility of the pupil. tell you as soon as he can see the moving finger you can get an idea of the patients field of vision iii. Fix the chin of the patient with left hand in the direction of your hand. By repeating the and ask him to follow the movements of test placing your hand in different directions a your right index finger with his eyes. Move good idea of the field of vision of the patient your finger in the cardinal directions. The can be obtained. If an abnormality is suspected eyes move normally 50º outwards, 50° detailed testing can be done using a procedure inwards, 33° upwards, and 50° downwards. called perimetry. Test the rotatory movements of the eyes also. Observe if there is any limitation of If there is any doubt about the integrity of movement in any direction. optic nerve the retina is examined using an ophthalmoscope. With this instrument we can Injury to these nerves leads to pathology of see the interior of the eye through the pupil of diplopia which means the double vision, squint the eye. The optic disc and blood vessels (strabismus) where two eyes are deviated from radiating from it can be see. the normal angle which are of two types— paralytic squint and concomitant squint, and Injuries to different parts of the visual skew deviation where one eye is directed pathway can produce various kinds of defects. upwards and the other downwards. Loss of vision in one-half (right or left) of the visual field is called hemianopia. If the same Fifth or Trigeminal Nerve half of the visual field is lost in both eyes the Both the motor and the sensory functions are defect is said to be homonymous and if different tested. halves are lost the defect is said to be heterony- mous. Motor Functions Ask the patient to clench his teeth—the Third, Fourth and Sixth Nerve (Oculomotor, masseter and temporal muscles contract, and Trochlear and Abducent Nerve) should become equally prominent on either The oculomotor (3rd nerve), trochlear (4th side. Confirm by placing your hands on the nerve), and the abducent (6th nerve) are tested muscles. The muscles will fail to become together as they innervate the external ocular prominent if there is paralysis on that side. Ask him to open his mouth—the jaw will deviate to

34 TEXTBOOK OF THERAPEUTIC EXERCISES the side of paralysis, the healthy lateral in the former and infranuclear lesions occur in pterygoid muscles pushing it to that side. the later in which both upper and lower parts of the face are equally affected. Loss of taste Sensory Functions sensation over the anterior two-thirds of the Test the sensations of touch, pain and tempera- tongue can be found. ture over the entire face and over posterior one-third of the tongue. Test the corneal reflex Eighth or Vestibulocochlear Nerve on both sides because the trigeminal nerve This nerve is responsible for hearing (cochlear forms the afferent path of this reflex. As already part) and for equilibrium (vestibular part). mentioned, loss of corneal reflex is one of the Normally, we test only the cochlear part. The early signs of 5th nerve lesion. hearing of the patient can be tested by using a watch. First, place the watch near one ear so Injury to this nerve causes paralysis of the that the patient knows what he is expected to muscles supplied by this nerve and referred hear. Next, ask him to close his eyes and say, pain, trigeminal neuralgia, mandibular nerve when he hears the ticking of the watch. The block. watch should be held away from the ear and then gradually brought towards it. The distance Seventh or Facial Nerve at which the sounds are first heard should be The facial nerve supplies the muscles of the compared with the other ear. face including the muscles that close the eyelids, and the mouth. The nerve is tested as In doing this test it must be remembered follows: that loss of hearing can occur from various causes such as the presence of wax in the ear, i. Ask the patient to close his eyes firmly. or middle ear disease. Nerve deafness can be In complete paralysis of the facial nerve, distinguished from deafness due to a conduction the patient will not be able to close the defect by noting the following: eye on the affected side. In partial paralysis the closure is weak and the examiner can i. Sounds can be transmitted to the internal easily open the closed eye with his fingers. ear through air, and can also be transmit- ted through bone. Normally, conduction ii. Ask the person to smile. In smiling the through air is better than through bone, normal mouth is more or less symmet- but in defects of conduction the sound is rical, the two angles moving upwards and better heard through bone. outwards. In facial paralysis the angle fails to move on the paralyzed side. ii. Air conduction and bone conduction can be compared by using a tuning fork iii. Ask the patient to fill his mouth with air. against an object so that it begins to Press the cheek with your finger and vibrate producing sound. Place the tuning compare the resistance (by the buccinator fork near the patients ear and then muscle) on the two sides. The resistance immediately put the base of the tuning is less on the paralyzed side. On pressing fork on the mastoid process. Ask the the cheek air may leak out of the mouth patient where he hears the sound better because the muscles closing the mouth (Rhinne’s test). In another test the base are weak. of a vibrating tuning fork is placed on the forehead. The sound is heard in both ears iv. The sensation of taste should be tested but is clearer in the ear with a conduction on the anterior two-thirds of the tongue. defect (Weber’s test). Injury to this nerve leads to facial palsy and Bell’s palsy, where supranuclear lesions occur

EXAMINATIONS 35 Defects in the vestibular apparatus or in the that on the affected side the vocal fold does vestibular nerve are difficult to test and such not move. It is fixed in a position midway cases need to be examined by a specialist. between adduction and abduction. In cases where the recurrent laryngeal nerve Ninth or Glossopharyngeal Nerve is pressed upon by a tumor it is observed Testing of this nerve is based on the fact that that nerve fibers that supply abductors are (a) the nerve carries fibers of taste from the lost first. posterior one-third of the tongue; and (b) that it provides sensory innervation to the pharynx. Eleventh or Accessory Nerve i. Sensations of taste can be tested by Put your hands on the right and left shoulders applying substances that are salty (salt), of the patient and ask him to elevate (shrug) sweet (sugar), sour (lemon), or bitter his shoulders. In paralysis the movement will (quinine) to the posterior one-third of the be weak on one side due to paralysis of the tongue. The mouth should be rinsed and trapezius. the tongue dried before the substance is applied. Ask the patient to turn his face to the opposite side against resistance offered by your ii. Touching the pharyngeal mucosa causes hand. In paralysis the movement is weak on reflex constriction of pharyngeal muscles. the affected side due to paralysis of the The glossopharyngeal nerve provides the sternoclidomastoid muscle. afferent part of the pathway for this reflex. Twelfth or Hypoglossal Nerve Tenth or Vagus Nerve This nerve has an extensive distribution but This nerve supplies muscles of the tongue. To testing is based on its motor supply to the soft test the nerve ask the patient to protrude the palate and to the larynx. tongue. In a normal person the protruded tongue lies in the midline. If the nerve is i. Ask the patient to open the mouth wide paralyzed the tongue deviates to the paralyzed and say ‘aah’. Observe the movement of side. the soft palate. In a normal person the soft palate is elevated. When one vagus Protrusion of the tongue is produced by the nerve paralysed the palate is pulled pull of the right and left genioglossus muscles. towards the normal side. When the nerve The origin of the right and left genioglossus is paralysed on both sides the soft palate muscles lies anteriorly and the insertion lies does not move at all. posteriorly. Each muscle draws the posterior part of the tongue forwards and medially. ii. In injury to the superior laryngeal nerve Normally, the medial pull of the two muscles the voice is weak due to paralysis of the cancels out, but when one muscle is paralyzed, cricothyroid muscle. At first there is it is this medial pull of the intact muscle that hoarseness but after some time the causes the tongue to deviate to the opposite side. opposite cricothyroid compensates for the deficit and hoarseness disappears. Deviation of the tongue should be assessed with reference to the incisor teeth, and not to iii. Injury to the recurrent laryngeal nerve the lips. Remember that in facial paralysis the also leads to hoarseness, but this hoarse- tongue may protrude normally, but may appear ness is permanent. On examining the to deviate to one side because of asymmetry of larynx through a laryngoscope it is seen the mouth.

36 TEXTBOOK OF THERAPEUTIC EXERCISES CLINICAL EXAMINATION OF THE in the rate less than 60/min represents brady- CARDIOVASCULAR SYSTEM cardia. A person suffering from heart disease may present with many symptoms, some of which Recording of the Blood Pressure may not appear to be apparently connected with This is done by auscultatory method, in which cardiovascular system. Heart disease may be subject’s blood pressure is measured by an detected during a routine clinical examination, apparatus called sphygmomanometer. Here though the patient may not complain of any subject’s hand is tied by the cuff present in the symptoms. Some symptoms are constantly apparatus around the elbow and pressure is encountered in heart diseases, which are raised by the hand pump. Then as the pressure dyspnea, palpitation, cardiac pain, GI symptoms, is being released the pulse beats have been respiratory symptoms, and urinary symptoms. auscultated with a stethoscope, noting down Clinical examination of the cardiovascular the appearance and disappearance of the sound. system undergoes through different processes This has been noted as the systolic and diastolic and it consists the following examinations: pressure. Normal blood pressure is 120/80 mm 1. Examination of the arterial pulses of Hg. Increase in this pressure leads to hyper- 2. Recording of the blood pressure tension and decrease in this pressure leads to 3. Inspection and palpation of the system hypotension. 4. Percussion 5. Auscultation. Inspection and Palpation The subject should be examined in good light, Examination of Arterial Pulses with chest bared, but without unnecessary The pulse is the lateral pressure exerted by exposure to chill, both in sitting and supine the walls of the blood vessels. It forms an elastic positions. Notice the shape of the chest and coiling and recoiling type. The pulse has been precardium and observe if there is any dyspnea felt by the tip of the three fingers ((index, and cyanosis. Subject should be examined for middle, and ring finger). Middle finger feels the the pulsations of the veins, pulsations in the pulse, index finger varies the pressure on the thoracic region, pulsations in the epigastrium, artery whereas ring finger is used to prevent apex beat and the thrills and murmurs. Thrill the retrograde pulsation from the palmar arch. is the palpable murmur. The examiner should notice for the rate, rhythm, volume, tension, and character of the Percussion pulse to find out the abnormal changes or may Place your left middle finger firmly in contact be of any pathology. with the skin. Strike its middle phalanx with the tip of the right middle finger 2-3 times. The The normal pulse rate is 70-80 beats/ percussing finger should be relaxed and should minute. not be lifted up more than 3 inches or so and the movement of the hand should be loose and The pulses were felt all over the body, which at the wrist and the finger joints and not at are of, carotid artery pulse, superficial tem- the elbow. Notice two things while percussing porary artery pulse, brachial artery pulse, radial (a) the feeling imparted to the percussed finger artery pulse, femoral artery pulse, posterior and (b) the sound produced, which differs both tibial artery pulse, popliteal artery pulse, quantitatively and qualitatively. dorsalis pedis, etc. Increase in pulse more than 100/min represents tachycardia and decrease

EXAMINATIONS 37 Auscultation length difference is less than one inch. It is The auscultation takes a major role in the considered as normal but the difference goes examination of the cardiovascular system. Here more than one and half inches is considered as the heart sounds were being auscultated with abnormal. It needs the proper corrective the help of stethoscope. These sounds were treatment. First, the reason for the leg length heard due to the closure and opening of the discrepancy is analyzed before the treatment valves present in the heart. is carried out. There are four heart sounds to be heard Causes and these sounds can be heard in four places 1. Congenital deficiency of limb, e.g. congenital around the heart. • Aortic area—2nd right intercostal space shortening of femur, phocomelia congenital shortening of tibia. close to sternum 2. Trauma, e.g. malunited fracture, premature • Pulmonary area—2nd left intercostal space epiphyseal closure in fracture, loss of bony fragment after open fracture close to sternum 3. Poliomyelitis • Tricuspid area—Apex or xiphoid process of 4. Pelvic tilt or drop 5. Scoliosis sternum 6. Gout disease like osteomyelitis • Mitral area—5th right intercostal space in 7. Soft tissue shortening or contracture 8. Bony abnormalities, e.g. coxa vara, coxa midclavicular line. valga, genu varum and genu valgum. The sounds are rhythmic in nature and, first and second sounds were heard close in a short Leg Length Measurement interval whereas, interval is long between the There are two types of leg length measurements: second and the first sounds. Third sound is 1. True shortening measurement heard immediately after the second sound, 2. Apparent shortening measurement which is not audible usually, and the fourth sound hears just before starting of the first True Shortening Measurement sound. The sounds which are heard is given To measure the true shortening of the limb, below as follows: the patient is positioned in supine lying. The • First sound (S1)—Louder and resembles legs are kept parallel to each other 15 to 20 cm LUBB sound heard during the closure of apart. The measurement is taken from ASIS AV valves in ventricular systole. to the medial or lateral malleolus of the patient • Second sound (S2)—Not louder resembles with the inch tape. DUBB sound heard during the closure of semilunar valves in ventricular diastole. To know the correct area of the leg discre- • Third sound (S3)—Not heard loud, occurs pancy the examiner has to measure. in rapid ventricular filling. • From ASIS to greater trochanter (for coxa- • Fourth sound (S4)—Not heard loud, occurs in atrial contraction. vara) Heart murmur is an abnormal sound that • From greater trochanter to lateral knee consists of a flow noise that is heard before, between, or after the normal heart sounds or joint line (for femoral shortening) that may mask the normal heart sounds. • From medial joint line of the knee to the LEG LENGTH DISCREPANCY medial malleolus (for tibial shortening) In normal individual itself we can observe the mild difference in the leg length. If the leg

38 TEXTBOOK OF THERAPEUTIC EXERCISES Apparent Shortening of the Leg Finger-to-Finger Test Even though the true shortening measurement Patient is asked to abduct both the shoulders shows nil difference in the leg length but the 90° with elbow in extension and ask the examiner may feel the height difference by patient to bring both the index fingers towards observation. That time the apparent shorten- midline and touch each other. Cerebellar ing has to be performed; by this method we diseased patient may touch each other by the can know the leg length difference due to spinal wavering and oscillating fashion. But the or pelvic problem. If any difference in the spinal posterior column diseased person can touch level or in the pelvic level, it cannot be measu- accurately with opened eyes, but not with closed red by the true length measurement. Apparent eyes. length measurement has to be made by positioning the patient in supine lying. The Rapid Alternating Movement measurement is taken from umbilicus or the The patient is asked to do the pronation and xiphoid sternum to the medial malleolus. supination movement alternatively. In cere- bellar lesion the patient feels difficulty in Spasticity Grading performing this movement, this phenomena is 0 — Normal muscle tone called as dysdiadochokinesia. 1 — Slight increasing in muscle tone catch Lower Limb when limb is moved Finger Toe Test 2 — More marked increased in muscle tone The therapist’s finger is pointed two feet above the patient’s great toe and instructs him to but limb easily flexed touch with the great toe. The cerebellar disease 3 — Considerable increase in muscle tone patient can touch the finger with the oscillatory 4 — Limb rigid in flexion or extension. or light bouncing movements. But it can be done accurately with the opened eyes but not MEASUREMENT OF THE PELVIC while closed, by the posterior column diseased ANGLE OF INCLINATION patient. See in the Chapter Pelvic Tilt (Chapter 7). TESTS FOR INCOORDINATION Upper Limb Heel-Shin Test Patient is asked to touch the knee with the Finger Nose Test opposite side heel and is sliding on the shin Patient is asked to touch the tip of the index towards the great toe. Same test is asked to finger of the one hand and the nose alterna- the patient to perform without rubbing on the tively with the index finger of another hand. In shin. In cerebellar disease, the heel is carried cerebellar disease, the patient touches the nose up to overshoot the knee. If the heel is carried with the wavy and oscillatory motion (here and down, it begins to execute an action tremor. In there) and finally touches the nose. In posterior posterior column disease the patient cannot column disease, the patient can touch the nose perform it due to the inability to recognize the accurately with eye-opening but he cannot position of the joint. touch with closed eyes.

EXAMINATIONS 39 Romberg’s Test TEST FOR JOINT RANGE OF MOTION Patient is made to stand straight with the eyes The fourth chapter (Goniometry) explains in opened. Then the patient is instructed to shut detail about the techniques of measuring the the eyes. Patient may begin to sway and may joint passive and active range of motion mea- even fall if he is not supported, it occurs the surement. patient with posterior column disease. But cerebellar diseased patient can stand even the eyes are closed also.

440 TEXTBOOK OF THERAPEUTIC EXERCISES CHAPTER Goniometry DEFINITION Body The instrument, which is used for measuring Body of the goniometer resembles like half or the range of motion of the joint, is called as full circle protractor. Normally, the half circle goniometer. The term goniometry is derived protractor contains 0º to 180º or 180º to 0º of from the Greek words Gonio—Angle and readings and the full circle protractor body Metron—Measurement. consists of 0º to 360º and 360º to 0º readings. In the middle of the body axis and fulcrum screw To measure a range of motion of a particular is present, it connects the stationary and joint the therapist should have the thorough movable arm. This axis of the goniometer knowledge on the range of motion of an placed over the axis of the joint, which has to individual joint, types of range of motion, osteo be measured. and arthrokinematic of the joint and axis and plane of the joint. Above said portions are mentioned in the Chapters 2 and 10. TYPES OF GONIOMETER 1. Universal goniometer 2. Gravity dependent goniometer or fluid goniometer 3. Pendulum goniometer 4. Electrogoniometer Universal Goniometer Fig. 4.1: Types of goniometer It is designed by Mr. Moore. This is very commonest variety. It is having stationary arm, Stable Arm movable arm, and body. This is the extension from the body of the goniometer. The stable arm does not have any

GONIOMETRY 41 motion. This will be aligned with the proximal • Therapist has to stand near to the patient segment of the measuring joint. and facing the joint, which has to be measured. Movable Arm This is the additional attachment with the body • Axis or the fulcrum of the goniometer is of the goniometer in the axis. Movable arm is placed over the axis of the joint to be aligned with the distal segment of the mea- measured. suring joint. • Stable arm is fixed with the proximal seg- Gravity Dependent Goniometer or ment of the joint. Fluid Goniometer It is otherwise called as pelvic inclinometer, it • Movable arm is fixed with the distal segment is designed by Schenkar in 1956. It is having of the joint. gravity effecting pointer and the fluid filled chamber with the air bubbles. It resembles like • Therapist has to move the distal segment the carpenter’s level meter. It is mostly used of the joint with the movable arm of the for measuring the pelvic tilt or drop. goniometer to measure the joint range. Pendular Goniometer SELECTION OF THE GONIOMETER It is designed by Fox and Van breemen in 1934. Selection of the goniometer is much more It consists of 360º protractor with the weighed important factor while measuring the range of pointer. motion of the joint. If the bony segments of the joints are big, the bigger size, i.e. bigger length movable and stable armed goniometer has to be used and for the smaller segment vise versa. Normally, the inclinometer is mostly used to measure the pelvic motion. Electrogoniometer POSITION OF THE PATIENT It is designed by Karpovich and Karpovich Position of the patient is another factor has to in 1959, it has two arms. One is attached with be noticed carefully while measuring the joint the proximal segment and another is attached range with the goniometer. Proper positioning with the distal segment of the measuring joint. of the patient itself is the competition of half of The potentiometer is connected with these two the procedure of measuring the joint range. arms. Changes in the joint position show the To measure the range of motion of one angulations in the potentiometer. It is mostly particular joint, the below mentioned factors used for the research purposes. has to be followed. • The joint structures have to be in relaxed PROCEDURE • Patient’s clothes are removed where the manner. • Joint should be in zero or starting position. joint measurement to be taken. • The complete range of motion of the joint • Position the patient in the relaxed manner has to be permitted. and the joint to be measured should be free • Proximal joint has to be fixed or stabilized from any obstructions like pillow, couch, etc. • Measuring joint has to be in 0º position. There is no proper recommended position • Total procedure should be explained to the to measure the range of motion with the gonio- patient. meter. It may vary depends on the creativity of an examiner. Only thing is, it should fulfill

42 TEXTBOOK OF THERAPEUTIC EXERCISES the above said condition with the convenient Muscle Bulk position for the patient as well the therapist. Increasing the muscle bulk may cause the reduction of the active and passive range of FACTORS AFFECTING THE JOINT motion. For example, for a common man the RANGE OF MOTION elbow flexion range of motion will be 125º to 135º but it is very much lower for the body- Soft Tissue Tightness builders due to their huge biceps muscle bulk. Joint soft tissues like muscle, ligament, capsule, cartilage, synovial membrane spasm or tight- Sex ness causes the reduction of range of motion of The range of motion may vary with the sex. the joint. The soft tissue tightness may be due For example, females will be having less hip to the prolonged immobilization of the joint, extension and hyper hip flexion after 25 years, injury around the joint or any joint diseases but the same is reverse in male. Generally, like osteoarthritis, rheumatoid arthritis, female will be having the more flexible increa- ankylosing spondylitis and TB arthritis. sed range of motion than the male. Adhesion Formation Age Adhesion formation of the joint reduces the The range of motion of joint will be more in ROM of the joint. Lack of mobility of the joint the infant and childhood due to nonfusion of leads to reduction in the flexibility and the the bones. Day by day the range of motion nourishment circulation around the joint struc- reduces with the age difference. While reaching tures. If the joint structures are immobilized the adulthood, the range of motion reduces for prolonged period reduces the extensibility, while comparing with the childhood and late formation of the adhesion and formation of the childhood. The range of motion again bit contraction of the soft tissue around the joint. increases in the old age due to the hypotonicity There will be increasing of the collagen fibers of the muscles and the reduction of the muscle and reduction of the elasticity property of the bulk. fibers of the connective and soft tissues of the joint. Nervous System Sometimes the range of motion may vary with Injuries or Inflammation around the Joint the pathological changes, i.e disease process in Any recent injuries, inflammatory condition the nervous system. Spasticity of the muscle, and the joint diseases like osteoarthritis, which is the result of the UMN lesion, will be rheumatoid arthritis, ankylosing spondylitis reducing the range of motion and the joint said and TB arthritis and psoriatic arthritis may to be hypomobile. The LMN lesion, which cause severe pain around the joint. As the causes the flaccidity, will result in hypermobile result of the pain patient may avoid performing joint. If the musculoskeletal disorder arises due the full range of movement. Sometimes due to to the lesion of any parts of the nervous system fear of pain also patient may not perform any like cerebellum, basal ganglion, cerebral cor- movement. So, as a result, there will be tex, thalamus, hypothalamus, internal capsule, reduction in the active and passive range of midbrain and pons result in the decreasing or movement. increasing the range of motion.

GONIOMETRY 43 MEASURING PROCEDURES Shoulder Joint Flexion Fig. 4.3: Measuring the shoulder extension movement with the goniometer Fig. 4.2: Measuring the shoulder flexion movement the patient’s body contact and is holding by with the goniometer the therapist’s right hand. • Procedure: Therapist’s left hand is perfor- • Position of the patient: Supine lying. ming the extension movement of the • Axis: Greater tuberosity of the humerus is shoulder joint with the goniometer and measuring the angle to see the passive range taken as the axis. of motion and the active ROM is measured • Movable arm: Movable arm is placed over by patient himself performing the movement. the midline of the lateral aspect of arm and Abduction is holding by the therapist’s right hand. • Position of the patient: Supine lying. • Stable arm: It is placed straight line to the • Axis: One inch below the acromion process movable arm and is kept in the air without the patient’s body contact and is holding by of the scapula is taken as the axis. the therapist’s left hand. • Procedure: Therapist’s right hand is per- forming the flexion movement of the shoul- der joint with the goniometer and measuring the angle to see the passive range of motion and the active ROM is measured by patient himself performing the movement. Extension Fig. 4.4 Measuring the shoulder abduction move- • Position of the patient: Prone lying. ment with the goniometer • Axis: Greater tuberosity of the humerus is • Movable arm: Movable arm is placed over taken as the axis. the midline of the anterior aspect of arm • Movable arm: Movable arm is placed over and is holding by the therapist’s right hand. the midline of the lateral aspect of arm and is holding by the therapist’s left hand. • Stable arm: It is placed straight line to the movable arm and is kept in the air without