LABORATORY MANUAL

COURSE CODE AND NAME PT-201(BPT)

ACADEMIC YEAR Jan-May 2024
SUBJECT NAME AND CODE EXERCISETHERAPY-II
(22PTH-202)
SEMESTER IV
DEPARTMENT PHYSIOTHERAPY(UIAHS)

Faculty Name- Dr. Monica Preet Kour (PT) Lab Assistant-Mr. Jaswant Singh

Assistant Professor

Physiotherapy (UIAHS)

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Table of Contents

1 University-Vision and Mission

2 Department-Vision and Mission

3 PEO

4 PO

5 PSO

6 Course Objectives

7 Course Outcomes

8 Mapping of COs/POs/PSOs

9 Syllabus (As approved in BOS) ---(If Any Changes required, Approval

Copy from DAA)

10 List of Experiments (Mapped with Cos)

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 UNIVERSITY VISION AND MISSION

Vision
To be globally recognized as a Centre of Excellence for Research, Innovation, Entrepreneurship and
disseminating knowledge by providing inspirational learning to produce professional leaders for serving
the society

Mission
Providing world class infrastructure, renowned academicians and ideal environment for Research,
Innovation, Consultancy and Entrepreneurship relevant to the society.

Offering programs & courses in consonance with National policies for nation building and meeting
global challenges.

Designing Curriculum to match international standards, needs of Industry, civil society and for
inculcation of traits of Creative Thinking and Critical Analysis as well as Human and Ethical values.

Ensuring students delight by meeting their aspirations through blended learning, corporate mentoring,
professional grooming, flexible curriculum and healthy atmosphere based on co-curricular and extra-
curricular activities.

Creating a scientific, transparent and objective examination/evaluation system to ensure an ideal

certification.

Establishing strategic relationships with leading National and International corporates and universities
for academics well as research collaborations.

Contributing for creation of healthy, vibrant and sustainable society by involving in Institutional Social
Responsibility (ISR) activities like rural development, welfare of senior citizens, women empowerment,
community service, health and hygiene awareness and environmental protection

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 PHYSIOTHERAPY- VISION

To emerge as an institute of global standards, with state-of-the-art facilities, that will meet the societal
requirements of competent and skilled allied health professionals through experiential learning, research
and innovation.

MISSION-

1. Establishing strategic relationship with leading national and international healthcare

institutions for high quality teaching, state of art research and creative activity.

2. Designing a curriculum that matches with the national and international universities of repute
and as demanded by health care industry.

3. Contributing for evolving a sustainable healthcare system by reinforcing collaboration with

academic health centers, government, communities and professional organizations.

4. Engaging students to learn patient- centered approach and evidence-based practice, as

part ofmulti-disciplinary healthcare team.

5. Engaging students to groom them as professional leaders in quality improvement and

service development for enhancing well-being of society.

6. To encourage future leaders with the commitment to accountable patient care.

7. Contributing for creation of healthy vibrant and sustainable society, by involving the students in
Community healthcare programs for awareness and hygiene.

Programme Educational Objectives (PEOs)

The faculty members of Division of Physiotherapy under University Institute of Applied Health
Sciences have formulated the Programme Educational Objectives (PEOs). These objectives are the
broad statements that the program of Bachelor of Physiotherapy is preparing its graduates to achieve
both academically and professionally. The PEOs of Bachelor of Physiotherapy Programme are as
follows:

PEO 1: FUTURE PROSPECTS: To Develop and create a competent physiotherapist who will utilize
and practice professional principles of physiotherapy in self-practice, hospitals, government and non-
government organizations, academics, research institutes and cooperate settings.

PEO 2: PROFESSIONAL COMPETENCE: Integrate knowledge of basic sciences and

physiotherapy in order to modify treatment approaches that reflect the breadth and scope of
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 physiotherapy practice and Demonstrate clinical competency in evaluation, treatment planning and
implementation.

PEO 3: LEADERSHIP QUALITY: To inculcate students with leadership skills with high level of
integrity for team building and also an ability to function professionally with ethical responsibility as an
individual as well as in multidisciplinary team with positive attitude.

PEO 4: CONTINUING PROFESSIONAL DEVELPOMENT (CPD):

The demand for quality, accountability and efficacy of practice has highlighted the need for
professionals to demonstrate that they are keeping abreast of new knowledge, techniques and
developments related to their professions.
PEO 5: CONTRIBUTION IN NATIONAL GROWTH: To equip students with broad based knowledge
to support the service industries, economic development and to address social and economic challenges
of the nation.
Programme Specific Outcomes (PSOs): The Programme Specific Outcomes (PSOs) pertains to
physiotherapeutic skills and knowledge that the student should possess upon completion of the graduation.
The PSOs of the Bachelor of Physiotherapy program perforate:
PSO1: The objectives are to acquaint future entrepreneurs with brand building techniques, innovative
marketing strategies and to equip them with skills and practice to be able to use it effectively in marketing
their clinical start up.
PSO2: These courses help students learn how to develop strategies and do the basic tasks of external
and internal communications. It explains key functions of organizational communication departments
within a corporation

PSO3: learn the key concepts, tools, and technologies related to Logistics Management, understand how
logistics is managed in global supply chains and what techniques are employed to make supply chains
learn, understand the warehousing, material handling, and transportation in detail and concepts and
practices related to logistical packaging

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Programme Outcomes (POs)

The Programme outcomes refer to the knowledge and capabilities that the student should acquire during
his graduation and what he will be to do after completion of the graduation. The POs of the Bachelor
of Physiotherapy program are as follows:

PO1. Problem analysis: Ability to asses, analyze and treat patients with various diseases anddisorders
in the field of Physiotherapy and Rehabilitation sciences.

PO2. Design/development of Treatment Protocol: Design and implement treatment protocol for
various disease and disorders according to the need of the patients with appropriate consideration of
functional and environmental needs.

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 PO3. Knowledge Application: Apply the concepts of Anatomy, physiology and kinesiology
in professional Physiotherapy Practice and select various exercise therapies and
Electrotherapeutic techniques for prevention and Treatment of various conditions.

PO4. Case studies and clinical Trial: An ability to design and conduct clinical trial, analyze
data andprovide well informed conclusions on a given study.

PO5. Evidence Based Practice: Employ critical thinking and evidence-based practice to
make clinical decisions about physical therapy services. Also collaborate with patients,
caregivers, and otherhealth care providers to develop and implement an evidence-based plan
of care that coordinates human and financial resources.

PO6. Professional conduct: Able to work professionally in the field of physiotherapy and
maintain good intrapersonaland interpersonal skills.

[Link] and team work: Function effectively as an individual as a member or

leader indiverse teams, and in multidisciplinary settings.

PO8. Ethics: Practice ethical principles and commit to professional ethics, responsibilities and
norms ofhealthcare industry.
[Link] skills: Ability to communicate effectively on different diseases and disorders
treated by physiotherapists, being able to comprehend and write effective reports and design
documentation, make effective presentations, give and receive clear instructions to the Patients
andfellow colleagues.
PO10. Environment and Sustainability: Understand the impact of professional practice and
health industry solutions in society and environmental contexts and demonstrate knowledge of and
need for sustainable development.

PO11. Use of Modern Technology/ Recent Advances: Apply scientific research and other
forms ofbest evidences in the practice of physiotherapy.

[Link] learning strategies: Demonstrate a commitment to professional growth and

ongoing learning to promote absorption and adoption of new knowledge and tools.

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SEMESTER IV
Syllabus
Course Name: Exercise Therapy L T P S C CH Course
COURSE DESCRIPTION
After the course on exercise therapy student will be able to understand the different types of
exercise for the benefit of patient in different situations and conditions both in health and
disease or disorder.
COURSE OBJECTIVES
In this course the student will learn the principles, methods, applications of therapeutic
exercises and assessment tools.
COURSE OUTCOMES
CO1 Student will able to learn different evaluation methods and application of physiotherapy.
CO2 Major emphasis of learning is towards Musculo-skeletal, cardio-respiratory and nervous
system.
CO3 Study and practice of Manual therapy.
CO4 Understand the different types of exercise for the benefit of patient in different situations
and conditions both in health and disease or disorder.
Syllabus
Unit-1 Introduction to Exercise Therapy Exercise regimens
a. Isotonic: deLormes, Oxford, MacQueen, Circuit weight training
b. Isometric: BRIME (Brief Resisted Isometric Exercise), Multiple Angle
c. Isometrics Isokinetic regimens
Proprioceptive Neuromuscular Facilitation
a. Definitions & goals
b. Basic neurophysiologic principles of PNF: Muscular activity, Diagonals patterns of movement: upper limb, lower
limb
c. Procedure: components of PNF
d. Techniques of facilitation
e. Mobility: Contract relax, Hold relax, Rhythmic initiation
f. Strengthening: Slow reversals, repeated contractions, timing for emphasis,
rhythmic stabilization Stability: Alternating isometric, rhythmic stabilization
g. Skill: timing for emphasis, resisted progression Endurance: slow reversals,
agonist reversal
Suspension Therapy
a. Definition, principles, equipment’s & accessories, Indications & contraindications, Benefits of suspension therapy
b. Types of suspension therapy: axial, vertical, pendular Techniques of suspension therapy for upper limb Techniques
of suspension therapy for lower limb
Functional Reeducation
a. Lying to sitting: Activities on the Mat/Bed, Movement and stability at floor level; Sitting activities and gait; Lower
limb and Upper limb activities
Aerobic Exercises
a. Definition and key terms; Physiological response to aerobic exercise, Examination and evaluation of aerobic
capacity – Exercise Testing, Determinants of an Exercise Program, The Exercise Program, Normal and abnormal
response to acute aerobic exercise, Physiological changes that occur with training, Application of Principles of an
Aerobic conditioning program for patients – types and phases of aerobic training.
Practical
1. Demonstrate the technique of measuring using goniometry
2. Demonstrate the PNF techniques
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3. Demonstrate to use the technique of suspension therapy for mobilizing strengthening joints and muscles
4. Demonstrate techniques for functional re-education
Unit-2 Manual Therapy
Stretching
a. Definition of terms related to stretching; Tissue response towards immobilization and elongation, Determinants of
stretching exercise, Effects of stretching, Inhibition and relaxation procedures, Precautions and contraindications of
stretching, Techniques of stretching.
Manual Therapy & Peripheral Joint Mobilization
a. Schools of Manual Therapy, Principles, Grades, Indications and Contraindications, Effects and Uses – Maitland,
Kaltenborn, Mulligan.
b. Biomechanical basis for mobilization, Effects of joint mobilization, Indications and contraindications, Grades of
mobilization, Principles of mobilization, Techniques of mobilization for upper limb, lower limb, Precautions.
Balance
a. Physiology of balance: contributions of sensory systems, processing sensory information, generating motor output
b. Components of balance (sensory, musculoskeletal, biomechanical)
c. Causes of impaired balance, Examination & evaluation of impaired balance, Activities for treating impaired balance:
mode, posture, movement, Precautions & contraindications, Types Balance retraining.
Coordination Exercise
a. Anatomy & Physiology of cerebellum with its pathways Definitions: Co-ordination, Inco-ordination
b. Causes for Inco-ordination, Test for co-ordination: equilibrium test, non-equilibrium test Principles of co-ordination
exercise.
c. Frenkel’s Exercise: uses of Frenkel’s exercise, technique of Frenkel’s exercise, progression, home exercise.
Posture
a. Definition, Active and Inactive Postures, Postural Mechanism, Patterns of Posture, Principles of re-education:
corrective methods and
techniques, Patient education.
Practical
1. Demonstrate the technique for muscle stretching
2. Demonstrate mobilization of individual joint regions
3. Demonstrate exercise for training co-ordination – Frenkel’s exercise
4. Assess and evaluate posture and gait
5. Demonstrate techniques for measuring limb length and body circumference
Unit-3 Musculoskeletal assessment and yoga
Walking aids
a. Types: Crutches, Canes, Frames; Principles and training with walking aids Basics in Manual Therapy &Applications
with Clinical reasoning
a. Examination of joint integrity
i. Contractile tissues
ii. Non contractile tissues
b. Mobility - assessment of accessory movement & End feel
c. Assessment of articular & extra-articular soft tissue status
i. Myofascial assessment
ii. Acute & Chronic muscle hold
iii. Tightness
iv. Pain-original & referred
d. Basic principles, Indications & Contra-Indications of mobilization skills for joints & soft tissues.
i. Maitland
ii. Mulligan
iii. Mckenzie
iv. Muscle Energy Technique
v. Myofascial stretching
vi. Cyriax
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vii. Neuro Dynamic Testing
Hydrotherapy
a. Definitions, Goals and Indications, Precautions and Contraindications, Properties of water, Use of special
equipment, techniques, Effects and uses, merits and demerits Individual and Group
a. Advantages and Disadvantages, Organization of Group exercises, Recreational Activities and Sports
Exercises
Practical
1. Assess and train for using walking aids
2. Demonstrate muscle strength using the principles and technique of MMT
3. Demonstrate the techniques for muscle strengthening based on MMT grading
4. Demonstrate the techniques of massage manipulations
5. Demonstrate techniques of strengthening muscles using resisted exercises.

Table of Content

1 Demonstrate the technique of measuring using goniometry

2 Demonstrate the PNF techniques.

. Demonstrate to use the technique of suspension therapy for mobilizing

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strengthening joints and muscles

4 Demonstrate techniques for functional re-education

5 Demonstrate the technique for muscle stretching

6 Demonstrate mobilization of individual joint regions

7 Demonstrate exercise for training co-ordination – Frenkel’s exercise

8 Assess and evaluate posture and gait

9 Demonstrate techniques for measuring limb length and body circumference

10 . Assess and train for using walking aids

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 [Link]

Aim: Demonstrate the technique of measuring using goniometry

Equipment's Required: Model, Couch, goniometer

Procedure:

Joint- Hip joint

Movement - Hip Flexion

Equipment Required - Goniometer.

Materials Required: Model, Goniometer.

Learning objectives
 To learn the detailed procedure of goniometric ROM measurement of hip joint.
 Acquire the knowledge regarding different techniques of application of goniometric
ROM measurement of hip joint

Procedure:
Patient position: Supine, with lower extremities in anatomical position (Fig. 4.1).

Stabilization: Over anterior aspect of ipsilateral pelvis (Fig.4.2).

Examiner action: After instructing patient in motion desired, stabilize ipsilateral pelvis with one
hand and flex patient's hip through available ROM with other hand. Ipsilateral knee should be
allowed to flex as well. Hip should not be flexed past the point at which pelvic motion begins to
occur (as detected by superior movement of ipsilateral ASIS under examiner's stabilizing hand).
Return limb to starting position. Performing passive movement provides an estimate of the ROMand
demonstrates to patient exact motion desired (see Fig.4.2).

Goniometer alignment: Palpate following bony landmarks (shown in Fig.4.1) and aligngoniometer
accordingly (Fig. 4.3).
Stationary arm: Lateral midline of pelvis and trunk.
Axis: Greater trochanter of femur.
Moving arm: Lateral midline of femur toward lateral femoral epicondyle.
Read scale of goniometer.

Patient/Examiner action: Perform passive, or have patient perform active, hip flexion (Fig.4.4).In
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 either case, hip flexion should not be allowed to continue past point at which pelvic motion is
detected (see Examiner action).

Confirmation of alignment: Repalpate landmarks and confirm proper goniometric alignment atend
of ROM, correcting alignment as necessary (see Fig. 4.4). Read scale of goniometer

Documentation: Record patient's ROM.

Precaution: Should hip be allowed to flex past point at which pelvic motion begins to occur, motion
measured will include both hip and lumbar flexion. In order to isolate hip flexion, pelvicmotion must
not be permitted.

Fig. 4.1. Starting position for measurement of hip flexion. Bony landmarks for goniometer
alignment (lateral midline of pelvis/trunk, greater trochanter, lateral femoral epicondyle) indicated
by orange lineand dots.

Fig. 4.2. End of hip flexion ROM, showing proper hand placement for stabilizing pelvis and
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detecting pelvic motion. Bony landmarks for goniometer alignment (lateral midline of pelvis/trunk,
greater trochanter, lateral femoral epicondyle) indicated byorange line and dots.

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 Fig. 4.3. Starting position for measurement of hip flexion, demonstrating proper initial alignment of
goniometer.

Required Result:
 The students will be able to apply goniometer for measurement of ROM of hip joint.
 When a patient has decreased range of motion, it will help to assess the joint before performing an
intervention, and continues to use the tool to monitor progress.

Joint- Knee joint

Movement – Knee Flexion
Equipment Required - Goniometer.

Materials Required: Model, Goniometer.

Learning objectives
a. To learn the detailed procedure of goniometric ROM measurement of knee joint.
b. Acquire the knowledge regarding different techniques of application of goniometricROM
measurement of knee joint

c. Procedure:

Patient position: Supine, with lower extremities in anatomical position; towel roll underipsilateral
ankle (Fig. 4.1.1).

Stabilization: Over anterior aspect of thigh (Fig. 4.1.2).

Examiner action: After instructing patient in motion desired, flex patient's knee through available
ROM by sliding patient's foot along table toward pelvis. Return to starting position. Performing
passive movement provides an estimate of the ROM and demonstrates to patient theexact motion
desired (see Fig. 12-2).

Goniometer alignment: Palpate following bony landmarks (shown in Fig. 4.1.1) and align
goniometer accordingly (Fig. 4.1.3).

Stationary arm: Lateral midline of femur toward greater trochanter.

Axis: Lateral epicondyle of femur

Moving arm: Lateral midline of fibula, in line with fibular head and lateral malleolus. Readscale of
goniometer.
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 Patient/Examiner action: Perform passive, or have patient perform active, knee flexion bysliding
foot toward pelvis (Fig. 4.1.4).

Confirmation of alignment: Repalpate landmarks and confirm proper goniometric alignmentat

end of ROM, correcting alignment as necessary (see Fig. 4.1.4).
Documentation: Read scale of goniometer.

Note: Knee flexion may be measured with patient in prone position, but knee flexion ROM inprone
may be limited owing to tightness of rectus femoris muscle.

Fig.4.1.1. Starting position for measurement of knee flexion. Towel roll under ipsilateral ankle to promotefull knee
extension. Bony landmarks for goniometer alignment (greater trochanter, lateral femoral epicondyle, lateral malleolus) indicated
by orange dots

Fig.4.1.2 End of knee flexion ROM, showing proper hand placement for stabilization of ipsilateral
thigh. Bony landmarks for goniometer alignment (greater trochanter, lateral femoral epicondyle,
lateral malleolus) indicated by orange dots

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 . Required Result:
 The students will be able to apply goniometer for measurement of ROM of knee joint.
 When a patient has decreased range of motion, it will help to assess the joint before performing an
intervention, and continues to use the tool to monitor progress.

Joint- Ankle joint
Movement – Ankle dorsiflexion and plantarflexion

Equipment Required - Goniometer.

Materials Required: Model, Goniometer.

Learning objectives
a. To learn the detailed procedure of goniometric ROM measurement of ankle joint.
b. Acquire the knowledge regarding different techniques of application of goniometric ROM
measurement of ankle joint

c. Procedure:

Patient position: Sitting in the end of the couch and the legs are kept hanging

Examiner action: After instructing patient in motion desired, dorsiflex patient's ankle through
availableROM. Return to starting position. Performing passive movement provides an estimate of
the ROM and demonstrates to patient the exact motion desired

Goniometer alignment: Palpate following bony landmarks) and aligngoniometer

accordingly

Stationary arm: It is placed over the midline of the medial aspect of the leg and is holding by the therapist’s left
hand

Axis: Tip of the medial malleolus is taken as the axis.

Moving arm: Movable arm is placed 90° to the movable arm and is holding by the therapist’s
right hand

Patient/Examiner action: Therapist’s right hand is performing the plantar and dorsiflexion movement of the hip
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.

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 Viva Questions:

 Define goniometer
 What is the use of goniometer
 What are the different types of goniometers
 Explain principles of goniometer.

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 [Link]

Aim: To study the pattern of PNF in Upper limb and Lower limb

Equipment's Required: Model, Couch

Procedure- Teach the patterns and sequences start to finish

1. Patient should look at the limb

2. Use verbal cues
3. Appropriate pressure is essential
4. Mechanics and body positioning are essential
5. Rotational movement is critical component
6. Distal movements occur first.

• Patterns - All patterns have three components:

– Flexion-extension
– Abduction-adduction
– Internal rotation-external rotation
 Upper and lower extremity have 2 diagonal patterns
 Trunk patterns are called chopping and lifting
 Neck patterns involve flexion/rotation to one side and extension/rotation to the other
 There are two diagonals of motion for each of the major parts of the body

• The head and neck,

• The upper trunk,
• The lower trunk
• The extremities.

Each diagonal is made up of two patterns that are antagonistic of each other
Each pattern has a major component of flexion or one of extension
Their being two flexion and two extension patterns of the major parts
Patterns
• D1 flexion
• D1 extension
• D2 flexion
• D2 extension

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Upper Extremity – D1 Flexion
• Starting position
– Shoulder extension, abduction and internal rotation; forearm
pronation; wrist extension and ulnar deviation; finger extension.
• Hand positions (for R side)
– L hand in palm of patient had, R hand on distal, anterior/ medial arm
• Movements
– Shoulder flexion, adduction and internal rotation; scapular elevation and
abduction; forearm supination; wrist flexion and radial deviation; finger flexion.

Flex-add – ER (D1 flex) Ext –abd- IR

Upper Extremity – D1 Extension

• Starting position
– Shoulder flexion, adduction and external rotation; forearm
supination; wrist flexion and radial deviation; finger flexion
• Hand positions (for R side)
– L hand on distal, posterior/lateral arm, R hand on dorsal/
ulnar aspect ofhand/fingers
• Movements
– Shoulder extension, abduction and internal rotation; scapular
depression andadduction; forearm pronation; wrist extension and ulnar
deviation; finger extension.
–
Ext-abduction - IR (D1 Ext ) Flex-add- ER

Caution (if any):

a) Diseases Affecting the Tissues Being Stretched.
b) Joint Instability. Joint instability can be the result of a prior dislocation, fracture, or sprain.
c) Acute Injury.
d) Vascular injury.
e) Infection
f) Excessive Pain When Stretching.
g) Inflammation or Joint Effusion.

Learning outcomes:
Effect of PNF
a) Muscle Strengthening
b) Neuro-Muscular Co-ordination
c) Increase range of motion.
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Viva Voice
a) Patterns of PNF
b) Principle of PNF
c) Diagonal Pattern

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 [Link]

Aim: Demonstrate to use the technique of suspension therapy for mobilizing strengthening joints and

muscles

Equipment's Required: Model, Couch

Procedure-

The Technique of Suspension Therapy

Shoulder Abduction and Adduction:

Muscles name:

 Abductor: 0-15 degrees: - Supraspinatus, 15-90 degrees: - Medial Deltoid, 90-180 degrees: -
Trapezius and serratus anterior.
 Adductor: Pectoralis major, Latissimus dorsi, and Teres major.

Position of the patient: Supine lying position.

Point of suspension: One inch below the acromion process of the scapula.

Accessories required:

 S-hooks: 3
 Three-ring sling: 1
 Single sling: 1
 Supporting rope with wooden clit: 2

Procedure:

 One inch below the acromion process of the scapula is assumed as the suspension point by the
primary supportive rope which is secured by the s-hook with the suspension frame.
 A secondary supporting rope is connected in the same s-hook.
 Three-ring sling is operated to sustain the wrist.
 A single sling is operated to reinforce the elbow.
 The primary supporting rope is connected to the wrist sling.
 A secondary supporting rope is connected to the elbow sling.
 The patient is recommended to execute the abduction and adduction activity of the shoulder.
 For intensifying the abductor medial motion of the axis is taken out, and vice versa for adductor
intensifying.

Shoulder Flexion and Extension

Muscles name:

 Flexor- Anterior deltoid, pectoralis major, and coracobrachialis.

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  Extensor- Latissimus dorsi, teres major and minor, and posterior deltoid muscles.

Position of patient– Side-lying.

Point of suspension: Greater tuberosity

Accessories required:

1. S-hooks: 3
2. Three-ring sling: 1
3. Single sling: 1
4. Supporting rope with wooden cleat: 2

Procedure:

 Greater tuberosity is assumed as the suspension point by connecting the supporting rope. Which is
hooked by the s-hook with the suspension frame.
 A secondary supporting rope is secured in the same s-hook.
 Three-ring sling is operated to support the wrist.
 A single sling is utilized to sustain the elbow.
 The primary supporting rope is connected to the wrist sling.
 A secondary supporting rope is hooked to the elbow sling.
 The patient is recommended to execute the flexion and extension motion of the shoulder.
 For reinforcing the power of the flexor posterior motion of the axis is accepted out and vice versa for
extensor strengthening.

Shoulder Medial and Lateral Rotation

Muscles name:

 Medial Rotation: Anterior Deltoid, Subscapulais, latissmus dorsi, Teres major.

 Lateral Rotation: Posterior Deltoid, Infraspinatus, Teres minor

Position of the patient: Supine lying.

Point of suspension: Olecranon process.
Accessories required:

 S-hook: 4
 Three-ring sling: 1
 Single sling: 1
 Supporting rope with wooden cleat: 2

Procedure:

 The shoulder is bent 90° with the elbow in 90° flexion the olecranon process is assumed as the
suspension point by a primary supporting rope which is secured by the s-hook with the suspension
frame.
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  The secondary rope is connected with the head side suspension frame by another s-hook in the
vertical suspension.
 Three-ring sling is operated to reinforce the wrist.
 A single sling is utilized to keep the arm.
 The primary supporting rope is connected to the wrist sling.
 A secondary supporting rope is connected to the arm sling.
 The patient is ordered to execute the medial and lateral rotation action of the shoulder.
 For intensifying the medial rotator, lateral shifting of the axis is dragged out, and vice versa for
lateral rotator strengthening.

Elbow Flexor and Extensor

Muscle name:

 Flexor: Biceps brachii, Brachioradialis, and Brachialis.

 Extensor: Anconeus and Triceps brachii.

Position of the patient: Sitting.

Point of suspension: Lateral epicondyle of the humerus bone.
Accessories required:

 S-hooks: 4
 Three-ring sling: 1
 Single sling: 1
 Supporting rope with wooden cleat: 2

Procedure:

 The shoulder is abducted at 90 degrees with the elbow in a 90 degrees flexed position the lateral
epicondyle is assumed as the suspension point by the primary supporting rope, which is secured by
the s-hook with the suspension frame.
 The secondary supporting rope is connected with the suspension frame by another s-hook in vertical
suspension.
 Three-ring sling is utilized to reinforce the wrist.
 A single sling is utilized to keep the arm.
 The primary supporting rope is connected to the wrist sling.
 A secondary supporting rope is connected to the arm sling.
 The patient is guided to execute the elbow flexion and extension motion.
 For boosting the strength of the flexor lateral shifting of the axis is dragged out and vice versa for
extensor strengthening.

Hip Flexion and Extension

Muscle name:

 Flexion: Iliopsoas, Rectus femoris, Pectineus, Sartorius, and Tensor fascia lata.
 Extension: Gluteus maximus, Biceps femoris, Semimembranosus, and Semitendinosus muscles.

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Position of the patient: Side-lying.
Point of suspension: Greater trochanter of the femur.
Accessories required:

 S-hooks: 3
 Three-ring sling: 1
 Single sling: 1
 Supporting rope with wooden cleat: 2

Procedure:

 The greater trochanter is assumed as the suspension point by a primary supporting rope which is
secured by the s-hook with the suspension frame.
 A secondary supporting rope is connected with the same s-hook.
 A single sling is utilized to support the knee.
 Three-ring sling is utilized to support the ankle.
 The primary supporting rope is connected to the ankle sling.
 A secondary supporting rope is connected to the knee sling.
 The patient is guided to execute the flexion and extension motion of the hip.
 For boosting the strength of the flexor posterior shifting of the axis is carried out and vice versa for
extensor strengthening.

Hip Abductor and Adductor

Muscles name:

 Abductor: Gluteus medius and Gluteus minimus

 Adductor: Adductor longus, Adductor magnus, and Adductor brevis muscles

Position of a patient: Supine lying with contrasting hip abducting to its full limit.

Point of suspension: 2 inches below the anterior superior iliac spine (ASIS)

Accessories required:

 S-hooks: 3
 Three-ring sling: 1
 Single sling: 1
 Supporting rope with wooden cleat: 2

Procedure:

 Two inches below the anterior superior iliac spine (ASIS) is accepted as the suspension point by the
primary supporting rope which is secured by the s-hook with the suspension frame.
 A secondary supporting rope is connected with the same s-hook.
 Three-ring sling is utilized to reinforce the foot and ankle.
 A single sling is utilized to support the knee.
 The primary supporting rope is connected to the ankle sling.

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  The secondary supporting rope is connected to the knee sling.
 The patient is guided to execute the abduction and adduction action of the hip.
 To improve the strength of the abductor medial shifting of the axis is dragged out and vice versa for
adductor strengthening.

Hip Medial and Lateral Rotation

Muscle name:

 Medial Rotator: Gluteus minimus and Tensor fascia lata.

 Lateral Rotator: Gluteus maximus, Piriformis, Superior gemellus, Inferior gemellus, Obturator
enternus, and Obturator externus,

Position of the patient: Supine lying.

Point of suspension: Apex of the patella bone.
Accessories required:

 S-hooks: 4
 Three-ring sling: 1
 Single sling: 1
 Supporting rope with wooden cleat: 2

Procedure:

 The apex of the patella is accepted as the suspension point by the primary supporting rope, which is
secured by the s-hook with the suspension frame.
 The secondary supporting rope is connected with the head side suspension frame by another s-hook.
 Three-ring sling is utilized to keep the ankle.
 A single sling is utilized to keep the thigh.
 The primary supporting rope is connected to the ankle sling.
 A secondary supporting rope is connected to the thigh sling.
 The patient is guided to execute the medial and lateral action of the hip.
 To improve the strengthening of the medial rotator medial shifting of the axis is dragged out and vice
versa for lateral rotator strengthening.

Knee Flexion and Extension

Position of the patient: Side-lying.

Point of suspension: Lateral joint line of the knee joint.

Accessories required:

 S-hooks: 4
 Three-ring sling: 1
 Single sling: 1
 Supporting rope with wooden cleat: 2
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Procedure:

 The lateral joint line is accepted as the suspension point by the primary supporting rope, which is
secured by the s-hook with the suspension frame.
 COG of the thigh is assumed as the suspension point by the secondary supporting rope. Which is
connected to the head side suspension by another s-hook in vertical suspension.
 Three-ring sling is utilized to reinforce the ankle.
 A single sling is utilized to support the thigh.
 The primary supporting rope is connected to the ankle sling.
 A secondary supporting rope is connected to the thigh sling.
 The patient is guided to execute the flexion and extension action of the knee.
 To improve the strength of the flexor posterior shifting of the axis is dragged out and vice versa for
extensor strengthening.

For Whole Body Suspension

whole body suspension

 The individual slings are suspending each limb in the vertical suspension with reinforcing ropes. The
upper trunk, lower trunk, head, and both upper extremities and lower extremities are balanced with
separate supporting ropes in the vertical suspension to set the entire body suspension.

Learning outcomes:
a) Effect of suspension
b) Uses of suspension for functional re-education

Viva Voice

a) Techniques of suspension
b) The procedure of applying suspension for different muscle group
c) Types of suspension
d) Principles of suspension

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 [Link]

Aim: Demonstrate techniques for functional re-education

Description - The mat program involves the patient in activities incorporating both
movement and stability. They range from single movements, such as unilateral scapula motions, to
complex combinations requiring both stabilization and motion, such as crawling or knee walking. The
activities are done in different positions, for function and to vary the effects of reflexes or gravity. The
therapist also chooses positions that can help control abnormal or undesired movements.

Equipment's Required: Model, Mat

Outline of Procedures

a) Rolling- For rolling to be effective, patient is required to learn to move the head, neck, upper limb,
lower limb and trunk in a balance manner. Rolling is needed to improve bed mobility and to change
position independently. Initially, rolling is taught to patient in mat but afterwards patient gets
confidence to perform it over bed.

Action to role prone from supine position:

1) Patient lies in supine position.

2) Patient flexes his head, neck and right shoulder.
3) Right arm is moved towards left side to create momentum.
4) The momentum of arm is transferred to trunk and lower limb.
5) The lower half of body will be rolled to prone position. Flexion of hip and knee will facilitate the
roll.
6) Patient takes his right shoulder at the back side by putting weight on left forearm and thus, weight is
distributed on both upper limb.
7) Patient lies prone.
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Rolling to prone can also be assisted by use of pillows under one side of pelvis or scapula if needed.
The number of pillows is decreased in progression.

b) Prone on elbow

This position on mat activities given to cervical lesion patient facilitates head and neck control
and strengthens serratus anterior and other scapular muscles. This position is very important to
train the patient to gain stability is quadruped and sitting position. Prone on elbow positionshould
be used carefully in lumbar injuries as this increases lumbar lordosis.

Action of patient:

1) Patient lies prone and places his elbows close to trunk.

2) Elbows are pushed down while lifting head and upper trunk.
3) Now, patient brings the elbow to the level of shoulder and body weight is shifted through elbows.

C) Quadruped Position

In this position, trunk lies horizontal to ground and body weight is distributed over both hands and
both knees. It is also called as prone kneeling position. This is the first sequence in mat activities
that allow weight bearing through hips.

This position helps to initiate control of muscle of lower trunk and hips. This position can either
be achieved from prone on elbow position or from long sitting position.

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To assume position from long sitting:

1) Patient in long sitting.

2) Body weight is bore through hands with extended elbows by rotating the trunk.
3) Now, from the side sitting position patient moves into quadruped position by shifting weight over
hands.
4) Position is achieved by available trunk strength and momentum from head and shoulders.

Learning outcomes:
c) Effect of rolling
d) Ffunctional re-education

Viva Voice

e) Techniques of functional re-education from standing to walking.

f) The procedure of bridging and its clinical implication.
g) The procedure of rolling and its clinical implication.

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 5. Experiment

Aim: Demonstrate the technique for muscle stretching

Learning objectives- To learn the detailed procedure of stretching the shoulder extensors & shoulder
flexors.

Outline of Procedures

Application of Manual Stretching Procedures

1. Move the extremity slowly through the free range to the point of tissue restriction.
2. Grasp the areas proximal and distal to the joint in which motion is to occur. The grasp should be
firm but not uncomfortable for the patient. Use padding, if necessary, in areas with minimal
subcutaneous tissue, reduced sensation, or over a bony surface.
3. Use the broad surfaces of your hands to apply all forces.
4. Firmly stabilize the proximal segment (manually or with equipment) and move the distal segment.
5. To stretch a multi joint muscle, stabilize either the proximal or distal segment to which the range-
limiting muscle attaches. Stretch the muscle over one joint at a time and then over all joints
simultaneously until the optimal length of soft tissues is achieved.
6. To minimize compressive forces in small joints, stretch the distal joints first and proceed
proximally.
7. Consider incorporating a pre-stretch, isometric contraction of the range-limiting muscle (the hold–
relax procedure) to relax the muscle reflexively prior to stretching it.
8. To avoid joint compression during the stretching procedure, apply gentle (grade I) distraction to
the moving joint.
9. Apply a low-intensity stretch in a slow, sustained manner. Remember, the direction of the
stretching movement is directly opposite the line of pull of the range-limiting muscle.
10. Ask the patient to assist you with the stretch or apply a passive stretch to lengthen the tissues.
11. Take the hypo-mobile soft tissues to the point of firm tissue resistance and then move just beyond
that point.
12. The force must be enough to place tension on soft tissue structures but not so great as to cause pain
or injure the structures.
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 13. The patient should experience a pulling sensation, but not pain, in the structures being stretched.
When stretching adhesion's of a tendon within its sheath, the patient may
14. experience a “stinging” sensation.
15. Maintain the stretched position for 30 seconds or longer.
16. During this time, the tension in the tissues should slowly decrease. When tension decreases, move
the extremity or joint a little farther to progressively lengthen the hypo-mobile tissues.
17. Gradually release the stretch force and allow the patient and therapist to rest momentarily while
maintaining the range-limiting tissues in a comfortably elongated [Link] repeat the
sequence several times.
18. If the patient does not seem to tolerate a sustained stretch, use several very slow, gentle,
intermittent stretches with the muscle in a lengthened position.
19. If deemed appropriate, apply selected soft tissue mobilization procedures, such as facial massage
or cross fiber friction massage, at or near the sites of adhesion during the stretching maneuver.

Flexion of the Shoulder

To increase flexion of the shoulder (to stretch the shoulder extensors)

FIGURE (A) Hand placement and stabilization of the scapula to stretch

the teres major and increase shoulder flexion.
FIGURE (B) Hand placement and stabilization of the pelvis to stretch
the latissimus dorsi and increase shoulder flexion.

Hand Placement and Procedure

Grasp the posterior aspect of the distal humerus, just above the elbow. Stabilize the
axillary border of the scapula to stretch the teres major, or stabilize the lateral aspect of the
thorax andsuperior aspect of the pelvis to stretch the latissimus dorsi. Move the patient’s arm
into full shoulder flexion to elongate the shoulder extensors.

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Hyperextension of the Shoulder
To increase hyperextension of the shoulder (to stretch the shoulder flexors).

FIGURE - Hand placement and stabilization of the scapula to increase extension of the shoulder
beyond neutral.
Patient Position
Place the patient in a prone position.

Hand Placement and Procedure

1. Support the forearm and grasp the distal humerus.
2. Stabilize the posterior aspect of the scapula to prevent substitute movements.
3. Move the patient’s arm into full hyperextension of the shoulder to elongate the
shoulder flexors.

Cautions –
1. Do not passively force a joint beyond its normal ROM.
2. Remember, normal (typical) ROM varies among individuals.
3. In adults, flexibility is greater in women than in men.
4. When treating older adults, be aware of age-related changes in flexibility.

Learning outcomes:
1. Effect of Stretching

2. Type of Stretching
Viva Voice

1. Active insufficiency
2. Discuss stretch reflex
3. Stretching of flexors

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Lower limb:
Materials Required: Model, Couch

Learning objectives
a. To learn the detailed procedure of application of stretching in lower limb

Outline of Procedures
A. Flexion of the Hip with Knee Extension
To increase flexion of the hip with the knee extended (stretch the hamstrings) (Fig. 4.25).

FIGURE 4.25 (A, B) Hand placement and stabilization of the opposite femur to stabilize the
pelvis and low back for stretching procedures to increase hip flexion with knee extension (stretch
the hamstrings) with the therapist standing by the side of the table or kneeling on the table.

Hand Placement and Procedure

With the patient’s knee fully extended, support the patient’s lower leg with your arm or shoulder.
Stabilize the opposite extremity along the anterior aspect of the thigh with your other hand or a
belt or with the assistance of another person. With the knee at 0 degree extension, and the hip in
neutral rotation, flex the hip as far as possible.

[Link] of the Hip

To increase adduction of the hip [stretch the tensor fasciae latae and iliotibial (IT) band] (Fig.
4.29).

Patient Position
Place the patient in a side-lying position with the hip to be stretched uppermost. Flex the bottom
hip and knee to stabilize the patient.

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 FIGURE 4.29 Patient positioned side-lying. Hand placement and procedure
to stretch the tensor fasciae latae and IT band.

Hand Placement and Procedure

Stabilize the pelvis at the iliac crest with your proximal hand. Flex the knee and extend the
patient’s hip to neutral or into slight hyperextension, if possible.
Let the patient’s hip adduct with gravity and apply an additional stretch force with your other
hand to the lateral aspect of the distal femur to further adduct the hip.

Cautions –
Do not passively force a joint beyond its normal ROM.
Remember, normal (typical) ROM varies among individuals.
In adults, flexibility is greater in women than in men.
When treating older adults, be aware of age-related changes in flexibility.

Learning outcomes:
Effect of Stretching
Type of Stretching

Viva Voice

1 Active insufficiency
2 Discuss stretch reflex
3 Stretching of flexors

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 6. Experiment

Aim: Demonstrate mobilization of individual joint regions

Learning objective: To learn the detailed procedure of stretching the shoulder joints.
Materials Required: Model, Couch, towel
Procedure-
A. Glenohumeral Distraction
Indications
Testing; initial treatment (sustained grade II); pain control (grade I or II oscillations); general
mobility (sustained grade III).

Patient Position
Supine, with arm in the resting position. Support the forearm between your trunk and elbow.

Hand Placement
Use the hand nearer the part being treated (e.g., left hand if treating the patient’s left shoulder) and
place it in the patient’s axilla with your thumb just distal to the joint margin anteriorly and fingers
posteriorly. Your other hand supports the humerus from the lateral surface.

Mobilizing Force
With the hand in the axilla, move the humerus laterally.

B. Glenohumeral Posterior Glide

Indications
To increase flexion; to increase internal rotation.

Patient Position
Supine, with the arm in resting position.

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 Therapist Position and Hand Placement
Stand with your back to the patient, between the patient’s trunk and arm. Support the arm against
your trunk, grasping the distal humerus with your lateral hand. This position provides grade I
distraction to the joint. Place the lateral border of your top hand just distal to the anterior margin
of the joint, with your fingers pointing superiorly. This hand gives the mobilizing force.

Mobilizing Force
Glide the humeral head posteriorly by moving the entire arm as you bend your knees.

Caution (if any):

i) Hyper mobile joint
ii) Acute trauma or fracture
iii) Burn
iv) Generalized Oedema
v) Skin disease
vi) Open wounds and sinuses

Effect of joint mobilization

 Muscle Strengthening
 Neuro-Muscular Co-ordination
 Increase range of motion

Viva Voice

a) Principal of peripheral joint mobilization

b) Indications of peripheral joint mobilization
c) Contraindications of peripheral joint mobilization

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 7 Experiment
Aim: Demonstrate exercise for training co-ordination – Frenkel’s exercise

Materials Required: Model.

Procedure:
Preparation of the Patient
• Patient is positioned in convenient posture normally half-lying posture by which the patient can watch the movement
performed by him.
• Selected range is decided and the distances between two points are marked in the couch by the chalk according the
agreed count. Normally, 4 counts are made, if the patient attains the range, the additional count will be added.
• Untreated parts should be covered by the blanket to protect privacy of the patient
• Proper demonstration about the exercise program to the patient. The patient must know the correct picture about the
exercise (Fig. 14.1)

Progression in the Exercise Program A polished re-education board or non-slippery surface is used for the exercise
Programme.
1. Dragging the limb on the board and touching the marked spot with the voluntary halt.
2. Dragging the limb on the board and touching the marked spot with the halt on command.
3. Limb unsupported movements.
4. Unsupported movements touching the marked spot with voluntary halt.
5. Limb unsupported touching the marked spot with the halt on command.
6. Limb supported touching the opposite side body specific points with the heel or finger by voluntary halt. (For
example, with the heel, touching the opposite side toes, ankle, shin, knee. With the finger, touching the opposite side
fingers, wrist, forearm, elbow, arm, shoulder).
7. Limb unsupported touching the opposite side body specific points with the heel or finger by halt on command. 8.
Touching the finger, which is placed in the air by the therapist.
9. Therapist placing finger in the air and moving here and there, the patient reaches the point. According to the grade
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of disability the exercise is started (Figs 14.2 and 14.3).

Lying Upper limb

• Half-lying—Abduction and adduction of shoulder.
• Half-lying—Wrist flexion, extension, ulnar and radial deviation.
• Side lying—Flexion and extension of elbow.
• Side lying—Flexion and extension of shoulder. Lower limb
• Half-lying—Abduction and adduction of hip.
• Side lying—Flexion and extension of hip.
• Side lying—Flexion and extension of knee.
• Half-lying—Flexion and extension of hip and knee. Sitting Lower limb
• Sitting—Knee flexion and extension.
• Sitting—Hip abduction and adduction.
• Sitting—Dragging the foot and placing over the marked point or numbered board half and halt on command

• Sitting—Foot unsupported and placing over the marks.

• Sitting—Unsupported foot and touching the therapist’s finger, which is placed in air.
• Sitting—Standing and sitting down.
• Sitting—From long sitting toilet training.
• Sitting—Hitching, hiking movements.
• Sitting—Walking on the buttocks.
• Sitting—Beginning stage sit with the upper limit support later without the upper limb support. Upper limb
• Sitting—Alternating the movements like supination and pronation, flexion and extension, closing and opening the
fist, touching the finger tips with the thumb.
• Sitting—Reaching the therapist’s finger, which is placing in the air.
• Sitting—Pegboard exercises.
• Sitting—Separating the same colored blocks from the box.
• Sitting—Constructing some objects with help of the blocks
. • Sitting—Transferring the ball from one hand to another hand.
• Sitting—Pushing and punching movements.
• Sitting—Elbow flexing and touching the shoulder with the palm.
• Sitting—Combing, drawing, tying the shoelace and normal household activities (Figs 14.5 and 14.6)

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Standing
• Standing with the support is practiced first.
• Walking training with help of the parallel bars.
• First train the walking with wider base later changed into narrow base.
• Frenkel’s mat is used to improve the walking skill.
1. Walking on the both side footprints by leaving the middle footprints with the “swing to” gait, i.e. right foot
forwards and left foot up to it.
2. As said above with the “swing through” gait, i.e. right foot forwards and left foot through and forwards. This type of
walking increases the base.
3. Walking on the middle and one-side footsteps to reduce the base with the ‘swing to’ gait, same like ‘swing through’
gait. Sideways walking can also be practiced.
4. Turning can be practiced with pivoting and lifting and placing on the footmarks.

Pivoting (Fig. 14.7): The turning is done towards the weak side. The weak side will be stable in one point and rotating
with the fixed axis and another leg is lifted and kept on the mark place, e.g. right side. Right foot is rotated or turned
90° and the left foot is raised and placed parallel to the right foot.
Lifting and Turning: This is the progression from the pivoting, e.g. right side. Right side is lifted and turned 90° and
placed on the floor and the left leg also lifted and placed parallel to it.

Viva Voice:
 What are coordination exercises, and how do you define them?
 Why is coordination important in various physical activities?
 What challenges might individuals face in coordination exercises?
 Provide examples of modifications for individuals with coordination difficulties

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 Experiment 8

1. Aim: Assess and evaluate posture and gait

2. Equipment’s Required: N.A

Materials Required: Plumb line, Couch, skeletal system

3. Learning objectives

A. To learn the normal posture of the human body.

B. Acquire the Knowledge of postural analysis.

4. Outline of Procedures

A. Model/Patient should be comfortable

B. Examining part to be exposed enough to see and palpate the structures

C. Identification of various parts of Body

D. Identification of various positions

5. Required Result: Parameters- The student will be able to elucidate the clinical findings.

6. Caution (if any): Bones and Models should be handled carefully.

7. Learning outcomes:

Posture is a position of greatest efficiency, around the center of gravity, with muscles on all
sides, exerting pull equally.
Correct postureis a “Position in which minimum stress is put oneach joint maintaining the
natural curves of the body
Faulty postureis any position that
increases stress on joints thus creating muscle imbalances, ligaments tension and circulatory
occlusion

CAUSES OF POOR POSTURE

• Positional factors/Habitual

• Appearance of increased height (social stigma)

• Muscle imbalances/contractures Pain e.g. ICD pleural effusion Respiratory conditions

• Structural factors
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• Congenital anomalies

• Developmental problems

• Trauma Disease

FACTORS AFFECTING POSTURAL ANALYSIS

• Subject must be minimally clothed

• The subject must assume a comfortable and relaxed posture

• Subjects who use orthotic or assistive devices should be assessed with and without them to
determine their effectiveness in correcting posture.

• relevant medical history and other information

NORMAL POSTURE

LATERAL VIEW
 Head and neck: The Plumb line falls through the ear lobe to the acromion process.
Common faults include: Forward head, Flattened lordotic cervical curve and Excessive
Lordotic curve
 Shoulder: The Plumb line falls through the acromion process. Common faults include:
Forward shoulders, Lumbar Lordosis, etc.
 Thoracic vertebraeThe Plumb line bisects the chest symmetrically. Common faults are
Kyphosis, Pectus excavatum (Funnel chest), Barrel chest, Pectus carinatum (Pigeon
chest), etc.
 Lumbar vertebrae: The Plumb line falls midway between the abdomen and back and
slightly anterior to the sacroiliac Joint. Common faults include Lordosis, Sway back,
Flat back, etc.
 Pelvis and hip: The Plumb line falls slightly anterior to the sacroiliac joint and posterior
to the hip joint, through the greater trochanter, creating an extension moment. Common
faults include Anterior pelvic tilt and Posterior pelvic tilt
 Knee: The Plumb line passes slightly anterior to the midline of the knee, creating
anextension moment. Common faults include recurvatum, Flexed knee, etc.
 Ankle: The Plumb line lies slightly anterior to the lateral malleolus, aligned
withtuberosity of 5th metatarsal. Common faults include Forward posture.

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Fig. 7.1 Analysis of posture in lateral view

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POSTERIOR VIEW
 Head and neck: The Plumb line bisects the head through the external occipital
protuberance; head is usually positioned squarely over the shoulders so that eyes remain
level. Common faults include Abducted scapulae, Winging of the scapulae.
 Trunk: The Plumb line bisects the spinous process of the thoracic and lumbar vertebrae.
Common faults include Lateral deviation (Scoliosis)
 Pelvis and hip: The Plumb line bisects the gluteal cleft and the posterior superior iliac
spines are on the same horizontal plane; the iliac crests, gluteal folds and greater
trochanters are level. Common faults include Lateral pelvic tilt, Pelvic rotation etc.
 Knee: The Plumb line lies, equidistant between the knees. Common faults include Genu
varum and Genu Valgum.
 Ankle: The Plumb line is equidistant from the malleoli. Common faults includePes
planus (Pronated) and Pes Cavus (supinated)

Fig. 7.2 Analysis of posture in posterior view

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ANTERIOR VIEW
 Head and neck: The Plumb line bisects the head at the midline into equal halves.
Common faults include Lateral Tilt, Rotation and Mandibular asymmetry.
 Shoulder: The Plumb line bisects the sternum and xiphoid process. It may be due to
Dropped or elevated shoulder, Clavicle and joint asymmetry, etc.
 Elbow: Common faults includeCubitus valgus, Elbow hyperextension, Cubitus varus, etc.
 Hip: Common faults include Lateral rotation and Medial rotation at hip.
 Knee: The legs are equidistant from a vertical line through the body. Common Faults
include External tibial torsion, Internal tibial torsion, etc.
 Ankle: Common Faults include Hallux valgus, Hammer toes, etc.

Fig.7.3 Analysis of posture in anterior view

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 Equipment’s Required: N.A

Materials Required: Marker, Camera, skeletal system

1. Learning objectives

A. To learn the normal gait of the human body.

B. Acquire the Knowledge of gait analysis.

2. Outline of Procedures

A. Model/Patient should be comfortable

B. Examining part to be exposed enough to see and palpate the structures

C. Identification of various parts of Body

D. Identification of various positions

3. Required Result: Parameters- The student will be able to elucidate the clinical findings.

Relationships to be determined - NA

Graphs/Plots-NA

Error Analysis-NA

4. Caution (if any): Bones and Models should be handled carefully.

5. Learning outcomes:

SAGITTAL PLANE ANALYSIS OF THE GAIT CYCLE

Heel Strike to Foot Flat

Hip Joint: Flexion

 The line of gravity is anterior

 The moment created is a flexion moment
 The desired motion is flexion
 Eccentric contraction happens at the hip extensors (Gluteus Maximus) to control
theamount of hip flexion.

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Knee Joint: Flexion

 The line of gravity is posterior

 The moment created is a flexion moment
 The desired motion is flexion
 Eccentric contraction happens at the knee extensors (quadriceps) to control the amount
ofknee flexion

Ankle Joint: Plantarflexion

 The line of gravity is posterior

 The moment created is a plantarflexion moment
 The desired motion is plantarflexion
 Eccentric contraction happens at the Tibialis Anterior to control the amount of ankle
plantarflexion

Fig.9.1 Sagittal Plane Analysis of gait cycle from heel strike to foot flat

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 Foot Flat to Midstance

Hip Joint: Flexion

 The line of gravity is anterior

 The moment created is a flexion moment
 The desired motion is extension
 Concentric contraction happens at the hip extensors (Gluteus Maximus) to do extension
ofthe hip joint

Knee Joint: Flexion

 The line of gravity is posterior

 The moment created is a flexion moment
 The desired motion is extension
 Concentric contraction happens at the knee extensors (quadriceps) to do extension of
theknee joint

Ankle Joint: Dorsiflexion

 The line of gravity moves anteriorly

 The moment created is a dorsiflexion moment
 The desired motion is dorsiflexion
 Eccentric contraction happens at the planter flexors (gastrocnemius) to control the
amount of ankle dorsiflexion

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 9 Experiment

Aim: Demonstrate techniques for measuring limb length and body circumference

Purpose

The purpose of this test is to assess leg length difference of leg length discrepancy (LLD).

Leg length discrepancies are usually classified into two groups: true and functional.

True LLD are those in which an actual bony asymmetry exists somewhere between the head of the
femur and the mortise of the ankle.

Functional LLD are those which occur as a physiological response to altered mechanics along the
kinetic chain anywhere from the foot to the lumbar spine giving the appearance of a short leg when a
bony asymmetry in the length of bones might not actually exis

Technique

Direct Method:

 Involves measuring limb length with a tape measure between 2 defined points, in the stand. Two
common points are the anterior iliac spine and the medial malleolus or the anterior inferior iliac
spine and lateral malleolus
 Be careful, however, because there is a great deal of criticism and debate surroundings the
accuracy of tape measure methods. If you choose this method, keep the following to pics and
possible errors in mind:
o Always use the mean of at least 2 or 3 measures
o If possible, compare measures between 2 or more clinicians
o Iliac asymmetries may mask or accentuate a limb length inequality
o Unilateral deviations in the long axis of the lower limb (e.g. Genu varum) may mask or
accentuate a limb length inequality
o Asymmetrical position of the umbilicus
o Joint contractures

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Indirect Method

 Palpation of bony landmarks, most commonly the iliac crests or anterior iliac spines, in
standing. These methods consist of detecting if bony landmarks are at (the horizontal) level or if
limb length inequality is present.
 Palpation and visual estimation of the iliac crest (or ASIS) in combination with the use of blocks
or book pages of known thickness under the shorter limb to adjust the level of the iliac crests (or
ASIS) appears to be the best (most accurate and precise) clinical method to asses limb
inequality.
 You should keep in mind that asymmetric pelvic rotations in planes other than the frontal plane
may be associated with limb length inequality. A review of the literature suggests, therefore,
that the greater trochanter major and as many pelvic landmarks should be palpated and
compared (left trochanter with right trochanter) when the block correction method is used.

The PALM (Palpation Meter)

 The PALM is a reliable and valid instrument for measuring pelvic height difference. It is
convenient, cost-effective, and is a good alternative to radiographic measurement [5].
 Measurement Procedure: 2 tape strips were placed on the ground, 15cm apart. The tape strips
mark the location on the floor where patients have to place their feet. The patients are asked to
walk for 10 steps and align the medial borders of their feet with the outside of the tape strips.
Patients have to stand fully erected (no knee or hip or spine bending). The PALM is placed on
the most superior aspect of the iliac crest. The distance between caliper heads is measured to the
nearest mm and the angle of inclination to the nearest half degree. The inclinometer ball is
designed to move towards the side of the shorter limb.

Standing on Blocks

 The patient is standing with feet 10 cm apart, knees extended and equal weight on both feet
 The clinician places his/her hands on a bilateral anatomical structure: Spina iliac posterior
superior, Spina iliac anterior superior, or crista iliac left and right. Now the clinician visually
assesses if there is a length inequality, and if so, places a wooden board of 0,5 cm under the foot
of the shorter side.
 Keep placing thicker planks under the shorter side until the equal length is reached, the
thickness of the plank is equal to the leg length difference.
 Although reliability is highly dependent on the accurate measurements of the clinician, this
method has shown excellent results in inter-examination results between highly trained
clinicians and medical students. Confounding variables reported by literature are pelvic
asymmetry, incorrect positioning of feet, obesity, joint contractures, scoliosis, and inaccurate
measurement.

Imaging Method:

A wide range of imaging methods can be used, including:

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  Plain Radiography:

1. Orthoroentogenogram
2. Scanogram
3. Teleoroentgenogram: a full-length standing AP radiograph of the lower extremity.

 Computed Radiography.
 Micro-dose Digital Radiography: another form of computer-aided imaging that substantially
reduces the radiation exposure to patients in comparison with conventional radiographic
techniques.
 Ultrasound: In this technique, the ultrasound transducer is used to identify the bony landmarks
at the hip, knee, and ankle joints.
 CT Scanogram: anteroposterior (AP) scout view of the bilateral femurs and tibias are obtained.

MRI Scan: MRI images were obtained using a T1 weighted spin echo sequence and the best coronal
images were selected for standardized assessment of femoral length using the classic bony landmarks
of the femoral head and medial femoral condyle

Viva Questions:

 Define leg length discrepancy (LLD) and its various forms.

 What are the common causes of leg length discrepancy?
 Explain different methods used to measure leg length discrepancy.
 How do you accurately measure leg length in a clinical setting?

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 10 Experiment

Aim: Assess and train for using walking aids

Purpose - Walking aids are useful to assist people who have difficulty in walking or people who
cannot walk independently. This include crutches, sticks and frames.

Types:

Axillary crutches: They are made of wood with an axillary pad, a hand piece
and a rubber ferrule.
The position of the hand piece and the total length are usually adjustable.
The axillary pad should rest beneath the apex of axilla and hand grip in slight flexion when

weight is not being taken. When weight is being taken through axillary pad, the elbow will go
into extension and weight is transmitted down the arm to hand piece.

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 Crutch Elbow crutch

Elbow crutches: They are made of metal and have a metal or plastic forearm band. Theyare
usually adjustable in length by means of a press clip or metal button and have a rubber
ferrule. These crutches are suitable for patients with good balance and strong arms. Weight is
transmitted exactly the same way as for axillary crutches.

Forearm crutches (gutter crutches): They are made of metal with a padded
forearm support and strap, an adjustable hand piece and a rubber ferrule.

WALKING AIDS
These are used for patients with rheumatoid disease for providing support. They
cannot take weight through hands, wrists and elbows because of deformity or
pain.

Forearm crutch
Preparation for crutch walking:

a. Arms: shoulder extensors, adductors and elbow extensors must be assessed and strengthened before the
patient starts walking. The hand grip must also be tested to see that the patient has sufficient power and
mobility to grasp hand piece.
b. Legs: the strength and mobility of both legs should be assessed and strengthened if necessary. Main
attention to the hip abductors and extensor, the knee extensors and the plantar flexors of the ankle should
be given.
c. Balance: sitting and standing balance must be tested.
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d. Demonstration: the physiotherapist should demonstrate appropriate crutch walking to the patient.

Crutch walking: During first time, when the patient is to stand and walk, the physiotherapist should have an
assistant for supporting the patient.

i. Non-weight bearing: patient should always stand with a triangular base [Link] either infront or
behind the weight bearing leg.

i. Partial weight bearing: the crutches and the affected leg are taken forward and
put down together. Weight is then taken through the crutches and the affected
leg, while the unaffected leg is brought through.

Sticks: sticks may be made up of either wood or metal with curved or straight
hand piece. Metal ores are adjustable while the wooden ones are non-adjustable.

Uses: sticks allow more weight to be taken through the leg than crutches. One
stick may be used on the unaffected side, so that the stick and affected leg are
placed forward together, taking some of the weight through the stick.

Tripod or Quadri pod: Metal sticks with three or four prolonged bases and gives
more stable support than stick.

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Tripod Quadripod

Viva Questions:

 What are walking aids, and what is their primary purpose?

 Can you list some common types of walking aids?
 Differentiate between canes, crutches, and walkers.
 When might someone require the use of a walking aid?
 What factors would you consider when assessing an individual's need for a walking aid?
 Explain the importance of assessing gait and stability before prescribing a walking aid.

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