Ptp&M013 Npte 2

PHYSICAL THERAPY PRINCIPALS & METHODS
PTP&M:013/2 Revision: 02 Page: 1 of 92
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“MEDICINE” IS A NOBLE PROFESSION, IT SERVES HUMANITY
1
PASSAGE TO THE USA, VIA CAPE OF NPTE.
NATIONAL PHYSIOTHERAPY EXAMINATION-PART-2
SPEC. BY: Abdulrehman S. Mulla
DATE: 03/21/2009
REVISION HISTORY
REV. DESCRIPTION CN No. BY DATE
01 Initial Release PT0013 ASM 04/25/2009
02/02 Replace the Front cover poster PT0014 ASM 05/04/2009

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TABLE OF CONTENTS PAGE
11.0 PHYSICAL AGENTS AND MODALITIES: ....................................................................................................................................................... 6
11.1 THERAPEUTIC MODALITIES: ................................................................................................................................................................. 6
11.1.1 THERMAL AGENTS: ................................................................................................................................................................ 7
A. CRYOTHERAPY:...................................................................................................................................................................... 7
B. THERMOTHERAPY:................................................................................................................................................................. 8
I. CONTRAINDICATIONS FOR HEAT MODALITIES:......................................................................................................... 8
D. ELECTRICAL MODALITIES: .................................................................................................................................................... 8
I. ELECTRIC STIMULATION: .............................................................................................................................................. 9
II. ELECTRIC STIMULATION / ULTRASOUND COMBO:.................................................................................................. 10
11.1.2 ACROMIOCLAVICULAR SPRAIN REHABILITATION PROGRAM:....................................................................................... 10
11.1.3 SHOULDER DISLOCATION REHABILITATION PROGRAM:................................................................................................ 14
11.1.4 ADULT WHEELCHAIR MEASUREMENTS: ........................................................................................................................... 20
11.1.5 WOUND STAGING: ................................................................................................................................................................ 21
A. ULCERS:................................................................................................................................................................................. 21
B. PRESSURE ULCERS:............................................................................................................................................................ 22
I. PREVENTION:................................................................................................................................................................ 23
II. MAKE SURE: .................................................................................................................................................................. 23
III. TIPS FOR PROPER POSITIONING AND MOVEMENT IN CHAIRS: ............................................................................ 24
C. ORAL ULCER: ........................................................................................................................................................................ 25
I. SYMPTOMS:................................................................................................................................................................... 25
II. CAUSES:......................................................................................................................................................................... 25
III. TREATMENT: ................................................................................................................................................................. 26
D. PEPTIC ULCER: ..................................................................................................................................................................... 26
I. CAUSES:......................................................................................................................................................................... 26
II. PREVENTION:................................................................................................................................................................ 27
III. DIAGNOSIS: ................................................................................................................................................................... 27
IV. TREATMENT: ................................................................................................................................................................. 28
E. CORNEAL ULCER:................................................................................................................................................................. 28
I. CAUSES:......................................................................................................................................................................... 28
III. DIAGNOSING CORNEAL ULCERS: .............................................................................................................................. 29
IV. TREATMENT FOR CORNEAL ULCERS:....................................................................................................................... 29
F. VENOUS ULCERS:................................................................................................................................................................. 30
I. CAUSES:......................................................................................................................................................................... 30
II. SYMPTOMS:................................................................................................................................................................... 30
III. DIAGNOSIS: ................................................................................................................................................................... 30
IV. TREATMENT: ................................................................................................................................................................. 31
V. RISK FACTORS FOR VENOUS SKIN ULCERS:........................................................................................................... 31
G. DIABETIC FOOT ULCERS: .................................................................................................................................................... 32
I. PERIPHERAL NEUROPATHY: ...................................................................................................................................... 32
II. CHARCOT FOOT DEFORMITY: .................................................................................................................................... 33
III. MICROVASCULAR DISEASE: ....................................................................................................................................... 33
IV. TREATMENT: ................................................................................................................................................................. 33
H. GENITAL ULCER:................................................................................................................................................................... 33
I. GENITAL HERPES SIMPLEX: ....................................................................................................................................... 33
II. SYPHILIS: ....................................................................................................................................................................... 35
III. CHANCROID:.................................................................................................................................................................. 35
IV. UNCOMMON CONDITIONS:.......................................................................................................................................... 35
I. PREVENTION AND TREATMENT OF PRESSURE ULCERS:.............................................................................................. 35
11.1.6 ELECTRONIC, ELECTRICAL MODALITIES: .............................................................................................................................. 37
A. ULTRASONIC: ........................................................................................................................................................................ 37
I. CONTRAINDICATIONS:................................................................................................................................................. 37
II. UV RADIATION THERAPY:............................................................................................................................................ 37
III. INDICATIONS: ................................................................................................................................................................ 37
IV. CONTRAINDICATIONS:................................................................................................................................................. 37
B. SHORT-WAVE DIATHERMY:................................................................................................................................................. 38
C. LASER THERAPY:.................................................................................................................................................................. 38
D. LONGWAVE THERAPY (FOR PAIN RELIEF):....................................................................................................................... 38
E. MFC (Medium Frequency Currents):....................................................................................................................................... 38
F. CONTRAINDICATIONS: ......................................................................................................................................................... 38

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11.1.7 PHYSIOTHERAPY MODALITIES IN RHEUMATOID ARTHRITIS: ........................................................................................ 39
A. COLD/HOT APPLICATIONS:.................................................................................................................................................. 39
I. PARAFFIN WAX BATH (P.W.B.): ................................................................................................................................... 40
B ELECTRICAL STIMULATION: ................................................................................................................................................ 40
I. ELECTRICAL CURRENTS: ............................................................................................................................................ 40
II. TENS (TRANSCUTANEOUS NERVE STIMULATOR):.................................................................................................. 40
C. HYDROTHERAPY: ................................................................................................................................................................. 41
I. WHIRLPOOL TREATMENT:........................................................................................................................................... 41
II. TEMPERATURE OF WHIRLPOOL:................................................................................................................................ 41
III. CONTRAINDICATIONS FOR WHIRLPOOL:.................................................................................................................. 41
D. BALNEOTHERAPY:................................................................................................................................................................ 42
I. INDICATIONS FOR BALNEOTHERAPY:....................................................................................................................... 42
II. CONTRAINDICATIONS:................................................................................................................................................. 43
III. CAUTIONS:..................................................................................................................................................................... 43
E. VACUUM ASSISTED WOUND CLOSURE:............................................................................................................................ 43
F. HYPERBARIC MEDICINE: ..................................................................................................................................................... 43
G. MASSAGE THERAPY:............................................................................................................................................................ 44
I. MODES OF THERAPEUTIC MASSAGE:....................................................................................................................... 44
II. ADVANTAGES FROM MASSAGE THERAPY: .............................................................................................................. 45
III. WHERE NOT TO MASSAGE?........................................................................................................................................ 45
12.0 FUNCTIONAL TRAINING AND ORTHOTIC, PROSTHETIC AND SUPPORTIVE DEVICES: ...................................................................... 46
12.1 ADULT UPPER LIMB PROSTHETIC TRAINING:................................................................................................................................... 46
12.1.1 POSTOPERATIVE THERAPY PROGRAM: ........................................................................................................................... 46
A. PROMOTE WOUND HEALING: ............................................................................................................................................. 47
B. CONTROL INCISIONAL AND PHANTOM PAIN: ................................................................................................................... 47
C. MAINTAIN JOINT RANGE OF MOTION:................................................................................................................................ 47
D. EXPLORE THE FEELINGS OF THE PATIENT AND FAMILY: .............................................................................................. 47
E. FINANCIAL SPONSORSHIP: ................................................................................................................................................. 48
12.1.2 PREPROSTHETIC THERAPY PROGRAM: ........................................................................................................................... 48
A. RESIDUAL LIMB SHRINKAGE AND SHAPING:.................................................................................................................... 49
B. RESIDUAL LIMB DESENSITIZATION:................................................................................................................................... 49
C. MAINTENANCE OF JOINT RANGE OF MOTION:................................................................................................................. 49
D. INCREASING MUSCLE STRENGTH: .................................................................................................................................... 49
E. INSTRUCTION IN PROPER HYGIENE OF THE LIMB: ......................................................................................................... 50
F. MAXIMIZING INDEPENDENCE: ............................................................................................................................................ 50
G. MYOELECTRIC SITE TESTING:............................................................................................................................................ 50
H. ORIENTATION TO PROSTHETIC OPTIONS: ....................................................................................................................... 50
12.1.3 DETERMINING THE PROSTHETIC PRESCRIPTION:.......................................................................................................... 51
A. FABRICATION AND TRAINING TIME:................................................................................................................................... 51
12.1.4 ADULT UPPER-LIMB PROSTHETIC TRAINING: .................................................................................................................. 52
A. INITIAL ASSESSMENT:.......................................................................................................................................................... 52
B. STATUS OF THE OPPOSITE UPPER LIMB: ·....................................................................................................................... 52
C. INITIAL VISIT: ......................................................................................................................................................................... 52
D. ORIENTATION TO PROSTHETIC COMPONENT TERMINOLOGY:..................................................................................... 53
E. PROSTHETIC WEARING SCHEDULE: ................................................................................................................................. 53
F. CARE OF THE RESIDUAL LIMB AND PROSTHESIS:.......................................................................................................... 53
G. BODY CONTROL MOTIONS:................................................................................................................................................. 54
H. PROSTHETIC EVALUATION: ................................................................................................................................................ 54
I. PROSTHETIC CONTROLS TRAINING:................................................................................................................................. 55
J. CONTROLS PRACTICE: ........................................................................................................................................................ 55
K. FUNCTIONAL USE TRAINING:.............................................................................................................................................. 56
I. CUTTING FOOD:............................................................................................................................................................ 57
II. USING SCISSORS: ........................................................................................................................................................ 57
III. DRESSING:..................................................................................................................................................................... 57
IV. OPENING A JAR OR BOTTLE: ...................................................................................................................................... 57
V. WASHING DISHES:........................................................................................................................................................ 57
VI. HAMMERING A NAIL AND USING TOOLS: .................................................................................................................. 57
VII. DRIVING A CAR: ............................................................................................................................................................ 58
VII. VOCATIONAL ACTIVITIES:............................................................................................................................................ 58
IX. HOME INSTRUCTIONS:................................................................................................................................................. 59
X. FOLLOW-UP ISSUES:.................................................................................................................................................... 59

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12.2 PHYSIOTHERAPYMANAGEMENT OF ADULT LOWER-LIMB AMPUTEES:........................................................................................ 61
12.2.1. PRESURGICAL MANAGEMENT:........................................................................................................................................... 62
A. INITIAL PATIENT CONTACT:................................................................................................................................................. 62
12.2.2. POSTSURGICAL MANAGEMENT & EVALUATION: ............................................................................................................. 62
A. PAST MEDICAL HISTORY:.................................................................................................................................................... 62
B. MENTAL STATUS:.................................................................................................................................................................. 62
C. RANGE OF MOTION: ............................................................................................................................................................. 62
D STRENGTH:............................................................................................................................................................................ 63
E. SENSATION:........................................................................................................................................................................... 63
F. BED MOBILITY: ...................................................................................................................................................................... 63
G. BALANCE/COORDINATION:.................................................................................................................................................. 63
H. TRANSFERS:.......................................................................................................................................................................... 63
I. WHEELCHAIR PROPULSION:............................................................................................................................................... 63
J. AMBULATION WITH ASSISTIVE DEVICES WITHOUT PROSTHESIS: ............................................................................... 63
K. CARDIAC PRECAUTIONS FOR AMPUTEES:....................................................................................................................... 64
12.2.3 PATIENT EDUCATION: LIMB MANAGEMENT:..................................................................................................................... 65
A. LIMB CARE: ............................................................................................................................................................................ 65
I. PROBLEM DETECTION/SKIN CARE: ........................................................................................................................... 65
II. PROSTHETIC MANAGEMENT: ..................................................................................................................................... 65
III. SOCK REGULATION:..................................................................................................................................................... 65
IV. DONNING AND DOFFING OF THE PROSTHESIS; ...................................................................................................... 65
V. RESIDUAL-LIMB WRAPPING: ....................................................................................................................................... 66
12.2.4 PREPROSTHETIC EXERCISE:.............................................................................................................................................. 69
A. STRENGTHENING: ................................................................................................................................................................ 69
I. RANGE OF MOTION: ..................................................................................................................................................... 70
II. FUNCTIONAL ACTIVITIES:............................................................................................................................................ 71
III. GENERAL CONDITIONING: .......................................................................................................................................... 71
IV. BED MOBILITY: .............................................................................................................................................................. 71
V. TRANSFERS:.................................................................................................................................................................. 71
VI. NOTE FOR THE PT (TRANSFERRING A PATIENT) .................................................................................................... 72
VII. WHEELCHAIR PROPULSION:....................................................................................................................................... 75
VIII. UNSUPPORTED STANDING BALANCE: ...................................................................................................................... 75
IX. AMBULATION WITH ASSISTIVE DEVICES: ................................................................................................................. 76
12.2.5 PREGAIT TRAINING: ............................................................................................................................................................. 76
A. BALANCE AND COORDINATION:......................................................................................................................................... 76
12.2.6 ORIENTATION TO THE CENTER OF GRAVITY AND BASE OF SUPPORT: ...................................................................... 77
A. SINGLE-LIMB STANDING:..................................................................................................................................................... 77
12.3 GAIT-TRAINING SKILLS:........................................................................................................................................................................ 79
12.3.1 SOUND LIMB AND PROSTHETIC LIMB TRAINING:............................................................................................................. 79
A. PELVIC MOTIONS:................................................................................................................................................................. 79
12.3.2 VARIATIONS:.......................................................................................................................................................................... 82
12.3.3 ADVANCED GAIT-TRAINING ACTIVITIES:........................................................................................................................... 83
A. STAIRS: .................................................................................................................................................................................. 83
B. STEP BY STEP:...................................................................................................................................................................... 83
C. STEP OVER STEP: ................................................................................................................................................................ 83
D. TRANSTIBIAL AMPUTEES: STEP OVER STEP: .................................................................................................................. 83
E. CRUTCHES: ........................................................................................................................................................................... 84
F. CURBS:................................................................................................................................................................................... 84
G. UNEVEN SURFACES:............................................................................................................................................................ 84
H. RAMPS AND HILLS:............................................................................................................................................................... 84
I. SIDESTEPPING:..................................................................................................................................................................... 85
J. BACKWARD WALKING: ......................................................................................................................................................... 85
K. MULTIDIRECTIONAL TURNS: ............................................................................................................................................... 85
L. TANDEM WALKING:............................................................................................................................................................... 86
M. BRAIDING: .............................................................................................................................................................................. 86
N. SINGLE-LIMB SQUATTING:................................................................................................................................................... 86
O. FALLING: ................................................................................................................................................................................ 86
XV. FLOOR TO STANDING: ................................................................................................................................................. 86
P. RUNNING SKILLS: ................................................................................................................................................................. 87
Q. RECREATIONAL ACTIVITIES:............................................................................................................................................... 88
13.0 PROFESSIONAL ROLES AND MANAGEMENT:.......................................................................................................................................... 90

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13.1 PATIENT CARE ACTIVITIES:................................................................................................................................................................. 90
13.1.1 DIRECT PATIENT CARE:....................................................................................................................................................... 90
13.1.2 INDIRECT PATIENT CARE ACTIVITIES:............................................................................................................................... 90
13.2 NON-PATIENT CARE ACTIVITIES:........................................................................................................................................................ 90
13.3 THE ROLE OF THE PHYSIOTHERAPIST:............................................................................................................................................. 91
13.3.1 EXPECTED PROVISIONS FROM THE PHYSIOTHERAPIST BY THE PATIENT:................................................................ 91
A. RESPONSIBILITIES TO THE CLIENT: .................................................................................................................................. 91
13.3.2 DIFFERENT TYPES OF PHYSIOTHERAPY:......................................................................................................................... 92

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11.0 PHYSICAL AGENTS AND MODALITIES:
11.1 THERAPEUTIC MODALITIES:
 Contemporary Use of Therapeutic Modalities
 Psychological Aspects of Rehabilitation
 Tissue Injury, Inflammation, and Repair
 Pain and Pain Relief
 Persistent Pain and Chronic Pain
 Impact of Injury and Pain on Neuromuscular Control
 Evidence-Based Application of Therapeutic Modalities
 Cold and Superficial Heat
 Principles of Electrotherapy
 Clinical Uses of Electrical Stimulation
 Ultrasound, Diathermy, and Electromagnetic Fields
 Low Level LASER Therapy
 Mechanical Energy
 Treatment Plans for Acute Musculoskeletal Injuries
 Neuromuscular Control and Biofeedback
 Clinical Management of Persistent and Chronic Pain
Stroking - Relaxation; start and end of session
Kneading - Loosening adhesions and increasing venous return
Tapotement - Nerve stimulation or lung decongestion
Friction - Perpendicular muscle fibbers: stretch scars, loosen adhesions due to inflammation
process
What are therapeutic modalities? It's the treatment or application of some form of stress to the body for the
purpose of eliciting an adaptive response. The stress must be conducive to the healing process. They fall
into four categories:
 Thermal
 Mechanical
 Electrical
 Chemical
Although modalities from all four categories are used in the training room at Gettysburg College, we will
only be looking at the thermal and electrical modalities.
The goal of therapeutic modalities is to provide an optimal healing environment. Many modalities rely on
the Gate Control Theory. We use therapeutic modalities to override the perception of pain. For example,
when you bang your shin, your first response is to rub it. This is an example of the sensory stimulation
overriding pain perception.
Stroking Kneading Tapotement Friction
therapeutic_modaliti
es.pdf

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11.1.1 THERMAL AGENTS:
 Thermal agents are the application of heating or cooling modalities to treat disease and other
traumatic injuries. Its main objective is to produce cellular and vascular changes with
variations in heating and cooling. Cryotherapy is the use of cold, while thermo therapy is the
use of heat.
 To provide an optimal healing environment through the use of thermal agents, one of four
modes can be utilized:
 Conduction is when there is heat loss or gain through direct contact, such as an ice pack.
 Convection is heat loss or gain through the movement of water molecules across the skin,
such as a whirlpool.
 Conversion is changing from one energy form into another, and will be discussed under
ultrasound.
 Evaporation is when thermal energy is removed when there is a change from the liquid state
to the gaseous state, such as a vapocoolant spray.
A. CRYOTHERAPY:
Cold is a relative state characterized by decreased molecular motion. The temperature
ranges from 32 to 65 degrees, and the body reacts with a series of Local and systemic
effects.
Indications to use cold modalities:
1. Acute injuries or inflammation
2. Acute or chronic pain
3. Small, superficial first degree burns
4. Post surgical pain and edema
5. In conjunction with rehabilitation exercises
6. Spasticity accompanying CNS disorders
7. Acute or chronic muscle spasm
Contraindications, when you don't want to use cold modalities:
1. Cardiac or respiratory involvement (because there is a decrease in HR and
respiratory rate)
2. Uncovered open wounds (slows the healing process)
3. Circulatory insufficiency (decrease in metabolic rate - be careful of diabetic patients)
4. Cold allergy
5. Superficial nerves (peroneal/ulnar)
6. Raynaud's Phenomenon
There are a variety of clinical applications for cryotherapy:
1. Ice Packs
2. Ice Massage
3. Ice Immersion
4. Cryostretch
5. Cold Whirlpool
Cryokinetics is the use of cold and exercise together during treatment. The athlete would
exercise while using a cold modality or post modality. The majority is performed in the
whirlpool. An example is an ankle in the whirlpool doing ROM exercises, and post
whirlpool performing manual resistance exercises. The advantage to doing this is there is
decreased pain and spasm leading to improved motion and strength in subacute and
chronic situations. A disadvantage is that the athlete's proprioception is lower, so he is
limited in his selection of exercises. In addition, the athlete may be working through pain
that is performing a protective function.

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B. THERMOTHERAPY:
Heating modalities result in an increase in molecular vibration and cellular metabolic rate.
It is divided into two categories, superficial and deep heating modalities. It is further
divided into chemical, electric, or magnetic. Temperatures range from 105 to 170
degrees. Superficial modalities include infrared lamps, moist heat packs, paraffin baths,
and warm whirlpools. Deep heating modalities include microwave diathermy, short wave
diathermy, and ultrasound. The body reacts with a series of local and systemic effects.
Indications f or heat modalities:
1. Subacute or chronic inflammatory conditions
2. When there is pain at the subacute and chronic levels
3. Chronic muscle spasm
4. When there is decreased ROM
5. Reduction of joint contractures
I. CONTRAINDICATIONS FOR HEAT MODALITIES:
1. Acute injuries
2. Circulatory problems
3. Poor thermal circulation
4. Areas of the body that are anesthetic
The following are some of the more commonly used thermo therapy modalities
utilized in the athletic training room:
1. Moist Heat Packs
2. Paraffin Bath
3. Warm Whirlpool
4. Ultrasound
D. ELECTRICAL MODALITIES:
Electrical stimulation is used for acute, subacute, and chronic injuries. There are many
indications and contraindications for electric stimulation. There are three basic set-ups for
pad placement: monopolar, bipolar, and quadripolar. Monopolar is one electrode running
from one channel, bipolar is two electrodes running from one channel, and quadripolar is
four electrodes running from two channels. If you are treating a smaller area, bipolar or
monopolar should be used. If the area being treated is large with more muscle mass
(such as the thigh), the quadripolar set-up should be used.
Some clinical applications of electrical stimulation are for creating muscle contraction
through nerve or muscle stimulation, stimulating sensory nerves to help in treating pain,
creating an electrical field in biological tissues to stimulate or alter the healing process,
and creating an electrical field on the skin surface to drive ions beneficial to the healing
process into or through the skin.
As electricity passes through the body, changes in the physiologic functioning can occur
at various levels:
1) Cellular
2) Tissue
3) Segmental
4) Systematic
Circulatory problems

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Cellular Level (Five major effects)
1. Excitation of nerve cells
2. Changes in cell membrane permeability
3. Protein synthesis
4. Stimulation of fibroblasts, osteoblasts
5. Modification of microcirculation
Tissue Level (Multiple cellular events)
1. Skeletal muscle contraction
2. Smooth muscle contraction
3. Tissue regeneration
Segmental Level (Regional effect from cellular and tissue levels)
1. Modification of joint mobility
2. Muscle pumping action to change circulation and lymphatic activity
3. Alteration of the micro vascular system to associated with muscle pumping
Systemic Effects
1. Analgesic effects as endogenous pain suppressors are released and act at different
levels to control pain
2. Analgesic effects from the stimulation of certain neurotransmitters to control neural
activity in the presence of pain stimuli
I. ELECTRIC STIMULATION:
When setting up your athlete, you always want to make sure they are in the most
comfortable position. When you place the electrodes on the athlete, ask him where
he feels the most pain and place the electrodes accordingly. Keep in mind that the
farther apart the electrodes are, the deeper the penetration.
There are three basic programs that can be used to apply stim to various injuries.
For an acute or subacute injury, the programs used are interferential and
premodulated. These two types of ES are high frequency, sensory level currents that
can be used to override the Gate Control Theory of pain. For chronic pain, you want
to use the Russian Stimulation program. This is a low frequency, motor unit stimulus
that produces a contraction in the muscle. The program can be used for muscle re-
education, muscle strengthening, or to produce a muscle pumping action to reduce
edema.
If the unit you are using has a dispersive pad to ground the patient that must be
set up. The first thing to do is wet a paper towel to place on the dispersive pad. This
aids as a conductor. Let's say you are treating a quad injury. With the athlete sitting
with his legs straight out on a table, the dispersive pad would be placed underneath
the hamstrings.
When choosing interferential, you want to use the quadripolar set-up. With this,
the electrodes are set up in a diagonal pattern. For this type of setup, you want to
place the red electrodes diagonal of each other and the black electrodes diagonal of
each other. With the premodulated setup, you can choose between monopolar,
bipolar, and quadripolar. You will use the same high frequency setup as the
interferential program.
If you choose interferential, the next step you want to do is to pick the frequency.
For pain control, you should choose 80-150 MHz, for 15 minutes. The premodulated
Quadripolar
setup
Stim and Ice

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setup for a high frequency program will also give you the choice of 80-150 MHz for
15 minutes. After you select the program, push the start button.
The next step is to turn up the intensity. As you turn up the intensity, tell the
athlete that he will feel a tingling sensation. Ask your athlete to let you know when he
starts to feel the tingling. When they tell you, you can then ask them to let you know
when to stop increasing the intensity as it reaches a comfortable level. Once this is
set, come back every five minutes to check on the athlete and to increase the
intensity if it isn't as strong.
Electrical stimulation can be used in conjunction with other treatments, such as
ice or stim. Both of these treatments work together to override the Gate Control
Theory of pain. Using two treatments at once saves time for both you and the athlete.
II. ELECTRIC STIMULATION / ULTRASOUND COMBO:
Ultrasound and electric stim can be used together to override the Gate Control
Theory. When setting up this treatment, place the electrodes in a bipolar set up. Put
the ultrasound transmission gel over the area of pain, and set up the parameters for
the ultrasound, followed by those for electric stim. The parameters remain the same
as previously explained. Once the treatment has been started and the intensity set at
a comfortable level, tell the athlete that they will feel a motor impulse as the
ultrasound head passes a trigger point within the muscle. Treatment time is set for 5
minutes.
11.1.2 ACROMIOCLAVICULAR SPRAIN REHABILITATION PROGRAM:
Phase I - Control Inflammation (1-2 days for Grade I sprain, 2-3 days for Grade II)
Goals:
Control Inflammation and Pain
Reduce Swelling
Rehab:
1) Cryotherapy
A: Ice for 20 minutes
2) Modalities
A: Interferential Stim (can be used with ice at the same time)
3) NSAIDS
A: Ibuprofen/Advil - 4 times a day for 3 days (only if no allergies)
Phase II - Restore Range of Motion (2-4 days for Grade I sprain, 3-7 days for Grade II sprain)
Goals:
 Passive and active range motion is within 80% of normal in the unaffected arm
 Joint flexibility in affected limb is restored
 Cardiovascular endurance is maintained at preinjury level
 Range of motion exercises performed pain free
Rehab:
1. Heat Therapy
A: Hot pack for 20 minutes
2. Modalities
A: Pulsed ultrasound for 5 minutes
3. Flexibility Exercises

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A: Hold involved arm across the chest at the involved elbow, pushing slightly posterior until a str
is felt
B: Hold sides of a doorway with hand behind you. Let arms straighten as you lean forward. Rep
with hands in front of you as you lean backward.
4. Codman's Exercises
* Perform without free weights (pain-free)
A: Stand with body bent forward at the waist 90 degrees, or lie on your stomach on a table with t
involved arm dangling in front of you.
B: Stabilize the scapula with a belt by wrapping it around the upper body and scapula.
C: Between 60 and 90 degrees flexion or scaption, move the involved arm in a swinging motion
going forwards and backwards, side to side, and in circles.
5. Wall Crawls (Flexion and abduction)
A: Place hand on wall and have fingers crawl up the wall until end of range of motion. Repeat go
down the wall.
B: Start by facing a wall, repeat exercise again by facing sideways to the wall
6. Shoulder Wheel
A: Place hand on grip of shoulder wheel and move wheel around until maximal range of motion i
reached. Repeat going the opposite way.
7. Pulley
A: Place hands on both ends of pulley and have the affected limb pull downward. Repeat again
unaffected limb pulling downward.
8. Cane Exercises
A: Shoulder flexion - hold cane with hands palm down at waist height.
Raise the wand overhead leading with the uninvolved arm until a stretch is felt in the involved
shoulder.
B: Shoulder abduction - hold cane with involved arm palm up, uninvolved arm palm down. Push
cane sideways and upward toward the involved side with the uninvolved arm until a stretch is
in involved shoulder.
C: Shoulder adduction - reverse hand positions from the previous exercise. Pull the cane toward
uninvolved side until a stretch is felt in the involved shoulder.
D: Shoulder internal/external rotation - keep hands palms down on ends of cane at waist level.
Move cane upward toward the head, and then return to the waist level.
9. Cardiovascular Endurance
A: Bike for 20 minutes
10. Cryotherapy
A: Ice after for 20 minutes
Phase III - Strength Training (5-7 days for Grade I sprain, 7-14 days for Grade II sprain)
Goals:
 Range of Motion and flexibility of affected arm equals unaffected arm
 Muscular Strength is equal between affected and unaffected arm
 Cardiovascular endurance maintained at preinjury level
 Range of Motion and Strength Exercises performed without pain
Rehab:
1. Heat Therapy/Flexibility
A: Continue heat and ultrasound therapy
B: Continue flexibility exercises
2. Codman's Exercises with Free Weights
Progress through free weights as tolerated (pain-free)

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A: Stand with body bent forward at the waist 90 degrees, or lie on your stomach on a table
with the involved arm dangling in front of you.
C: Between 60 and 90 degrees flexion or scaption, move the involved arm in a swinging
motion, going forwards and backwards, side to side, and in circles.
3. Theraband
A: Flexion - Grip theraband in front of you with the elbow extended. Pull theraband upward
until maximal range of motion is reached and lower downward.
B: Extension - Start in same position as flexion. Pull theraband backward until maximal
range of motion is reached and bring back to starting position.
C: Internal Rotation - Stand in front of theraband board with affected arm facing it. Rotate
arm inward across body while gripping the unattached end of theraband.
D: External Rotation - Stand in front of theraband board with unaffected arm facing It. Rotate
arm outward away from the body while gripping the unattached end of theraband.
E: Abduction - Stand in front of codman with affected arm facing it. Start with arm across the
body and pull away from side.
F: Adduction - Stand in front of codman with affected arm facing it. Grab the theraband and
pull arm toward the buttocks.
G: Horizontal Abduction - Stand in front of theraband board with unaffected arm facing it.
Bring shoulder up to 90 degrees of flexion so that it is parallel to the floor. Pull arm
across body toward the opposite shoulder.
H: Horizontal Adduction - Stand in front of theraband board with affected arm facing it. Bring
shoulder to 90 degrees of flexion so that it is parallel to the floor. Pull arm across body
towards the opposite shoulder.
I: As strength is gained, progress up to different colors of tubing.
4. Proprioception (Cat Stretch-Starting Position)
A: Start in a non-weight bearing position (knees flexed) on a floor
B: As patient gains strength, incorporate the following progressions:
 Body movement - static (still) to dynamic (moving)
 Amount of arms involved - bilateral (2 arms) to unilateral (1 arm) Surface - stable
(floor or wall) to unstable (single and multilane boards)
C: Perform 3-5 stances, holding 15-20 seconds
5. Open Kinetic Chain Exercises
A: Weight Training (Starting position - place weight in affected hand)
 Flexion: Bring it forward and towards the ceiling until maximal range of motion is
reached. Lower downward.
 Extension: Bring weight backward towards the ceiling until maximal range of motion
is reached. Lower downward.
 Abduction/Adduction: Raise weight to the side until maximal range of motion is
reached. Lower downward and continue to lift towards the other side. Lower down
to starting position.
 Horizontal Abduction/Horizontal Adduction: Lift weight up to 90 degrees of flexion.
Bring the weight in front of you towards the other shoulder. Continue in the opposite
direction towards the side until maximal range of motion is reached. Bring weight
back to starting position.
 Internal/External Rotation: Flex elbow of effected limb and bring it close to the side of
the body near the waistline. Bring weight in towards the stomach and continue into
the opposite direction until maximal range of motion is reached.

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6. Closed Kinetic Chain Exercises
A: Wall Presses (push ups against a wall)
B: Standing Shoulder Flexion/Extension
 Stand with hands shoulder width apart on a chair. Rock forward over hands and back.
A: Bike or Stairmaster for 30 minutes
8. Cryotherapy
Phase IV - Return to Activity (approx 14 days)
Goals:
 Normal function and sports specific patterns restored to injured extremity
 Muscular strength, endurance, and power in affected arm is equal to unaffected arm
 Normal coordination and balance
 Cardiovascular endurance is equal to preinjury level
1. Heat therapy/modalities
A: Continue head therapy, ultrasound, and flexibility
2. Strength exercises
A: Perform all exercises with minimal or no pain
3. Sports Specific Exercises
A: Baseball/softball - perform overhand throwing
B: Football - throw a spiral, catch a throw (depending on position)
C: Volleyball/tennis - perform a serve
D: Soccer - practice a throw in
E: Basketball - practice shooting and passing drills
4. Taping/Padding
A: Make an orthroplast pad to prevent further injury and hold in place with an ace wrap
5. Cryotherapy

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11.1.3 SHOULDER DISLOCATION REHABILITATION PROGRAM:
Phase I - Control Inflammation (1-2 days)
Goals:
 Control Inflammation and Pain
 Reduce Swelling
Rehab:
Cryotherapy
Modalities
A: Interferential Stim (can be used with ice at the same time)
NSAIDS
A: Ibuprofen/Advil - 4 times a day for 3 days (only if no allergies)
Phase II - Restore Range of Motion (2-7 days)
Goals:
 Passive and active range motion is within 80% of normal in the unaffected arm
 Joint Flexibility in affected limb is restored
 Cardiovascular Endurance is maintained at preinjury level
 Range of Motion exercises performed pain free
Rehab:
1. Heat Therapy
A: Hot pack for 20 minutes
2. Modalities
A: Pulsed ultrasound for 5 minutes
3. Flexibility Exercises
A: Hold involved arm across chest at the involved elbow, pushing slightly posterior until a
stretch is felt
B: Hold sides of a doorway with hand behind you. Let arms straighten as you lean
forward. Repeat with hands in front of you as you lean backward.
4. Codman's Exercises without a Free Weight
5. Wall Crawls (Flexion and abduction)
A: Place hand on wall and have fingers crawl up the wall until end of range of motion.
Repeat going down the wall.
B: Start by facing a wall, repeat exercise again by facing sideways to the wall
6. Shoulder Wheel
A: Place hand on grip of shoulder wheel and move wheel around until maximal range of
motion is reached. Repeat going the opposite way.
7. Pulley
A: Place hands on both ends of pulley and have the affected limb pull downward. Repeat
again with unaffected limb pulling downward.
8. Cane Exercises
A: Shoulder flexion - hold cane with hands palm down at waist height.

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Raise the cane to 90 degrees, leading with the uninvolved arm until a stretch is felt in
the involved shoulder.
B: Shoulder abduction - hold cane with involved arm palm up, uninvolved arm palm down.
Push cane sideways and upward toward the involved side with the uninvolved arm until
a stretch is felt in involved shoulder.
C: Shoulder adduction - reverse hand positions from the previous exercise.
Pull the cane toward uninvolved side until a stretch is felt in the involved shoulder.
D: Shoulder internal/external rotation - keep hands on ends of the cane, elbows flexed at
90 degrees. Keep elbows at your side while keeping upper arms still. Move the cane
side to side using only the forearms.
A: Bike for 20 minutes
10. Cryotherapy
A: Ice after for 20 minutes
Shoulder Exercise:
Extension from 45°
Shoulder Exercise:
Extension from 90°
Shoulder Exercise:
Extension from full
Shoulder
Exercise:
Extension to
Hyperextension
overhead
Shoulder Exercise:
External Rotation in
Horizontal "Rotator Cuff"
overhead
Shoulder
Exercise:
External
Rotation in
Neutral
overhead

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Shoulder
Exercise:
Flexion from
135°
overhead
Shoulder Exercise:
Flexion from Neutral
Shoulder Exercise:
Horizontal Abduction
Shoulder Exercise:
Horizontal Flexion Abduction
Shoulder Exercise:
Internal Rotation from Neutral
Shoulder Exercise:
Internal Rotation from Neutral
Shoulder Exercise:
Neutral Abduction

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Phase III - Strength Training (1-3 weeks)
Goals:
 Range of motion and flexibility of affected arm equals unaffected arm
 Muscular strength is equal between affected and unaffected arm
 Cardiovascular endurance maintained at preinjury level
 Range of motion and strength exercises performed without pain
 Mobility upon stability
Rehab:
1. Heat Therapy/Flexibility
A: Continue heat and ultrasound therapy
B: Continue flexibility exercises
2. Scapular Stabilizations / Strengthening
A: Depression - minidips or provide manual resistance while the athlete pushes his fist
towards the ground
B: Elevation - shoulder shrugs either against manual resistance or while holding a weight
C: Protraction - manual resistance while the athlete rolls his shoulders towards the front
D: Retraction - rows
3. Isometric Resistance
A: Stay below 90 degrees, and pain-free ROM
B: In each of the following positions, push your fist against a wall, desk, or any other
stationary item every 15 degrees throughout the range of motion.
 Push arm straight up in front of you
 Push arm straight out to the side
C: With elbow flexed at 90 degrees, push the outside of your fist against a wall every 15
degrees up to 45/50 degrees, and do the same with the inside of the fist
4. Codman's Exercises
Progress through free weights as tolerated (pain-free)
5. Theraband
A: Flexion - Grip theraband in front of you with the elbow extended. Pull the theraband
upward until maximal range of motion is reached and lower downward.
B: Extension - Start in same position as flexion. Pull theraband backward until maximal
range of motion is reached and bring back to starting position.
C: Internal Rotation - Stand in front of theraband board with affected arm facing it.
Rotate arm inward across body while gripping the unattached end of theraband.
D: External Rotation - Stand in front of theraband board with unaffected arm facing it.
Rotate arm outward away from the body while gripping the unattached end of
theraband.
E: Abduction - Stand in front of codman with affected arm facing it. Start with arm across
the body and pull away from side.
F: Adduction - Stand in front of codman with affected arm facing it. Grab the theraband
and pull arm toward the buttocks.

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G: Horizontal Abduction - Stand in front of theraband board with unaffected arm facing it.
Bring shoulder up to 90 degrees of flexion so that it is parallel to the floor. Pull arm
across body toward the opposite shoulder.
H: Horizontal Adduction - Stand in front of theraband board with affected arm facing it.
Bring shoulder to 90 degrees of flexion so that it is parallel to the floor. Pull arm across
body towards the opposite shoulder.
I: As strength is gained, progress up to different colors of tubing.
6. Proprioception (Cat Stretch-Starting Position)
A: Start in a non-weight bearing position (knees flexed) on a floor
B: As patient gains strength, incorporate the following progressions:
 Body movement - static (still) to dynamic (moving)
 Amount of arms involved - bilateral (2 arms) to unilateral (1 arm)
 Surface - stable (floor or wall) to unstable (single and multiplane boards)
C: Perform 3-5 stances, holding 15-20 seconds
7. Open Kinetic Chain Exercises
A: Weight Training (Starting position - place weight in affected hand)
 Flexion: Bring it forward and towards the ceiling until maximal range of motion is
reached. Lower downward.
 Extension: Bring weight backward towards the ceiling until maximal range of
motion is reached. Lower downward.
 Abduction/Adduction: Raise weight to the side until maximal range of motion is
reached. Lower downward and continue to lift towards the other side. Lower down
to starting position.
 Horizontal Abduction/Horizontal Adduction: Lift weight up to 90 degrees of flexion.
Bring the weight in front of you towards the other shoulder. Continue in the
opposite direction towards the side until maximal range of motion is reached. Bring
weight back to starting position.
 Internal/External Rotation: Flex elbow of effected limb and bring it close to the side
of the body near the waistline. Bring weight in towards the stomach and continue
into the opposite direction until maximal range of motion is reached.
8. Closed Kinetic Chain Exercises
A: Wall Presses (push ups against a wall)
B: Standing Shoulder Flexion/Extension
 Stand with hands shoulder width apart on a chair. Rock forward over hands and back.
A: Bike or Stairmaster for 30 minutes
10. Cryotherapy
Phase IV - Return to Activity (approx 14 days)
Goals:
 Normal function and sports specific patterns restored to injured extremity
 Muscular strength, endurance, and power in affected arm is equal to unaffected arm
 Normal coordination and balance
 Cardiovascular endurance is equal to preinjury level
1. Heat therapy/modalities
A: Continue head therapy, ultrasound, and flexibility
2. Strength exercises
Closed Kinetic Chain Exercises

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A: Perform all exercises with minimal or no pain
3. Sports Specific Exercises
A: Baseball/softball - perform overhand throwing
B: Football - throws a spiral, catch a throw (depending on position)
C: Volleyball/tennis - perform a serve
D: Soccer - practice a throw in
E: Basketball - practice shooting and passing drills
4. Taping/Padding
A: Make an orthroplast pad to prevent further injury and hold in place with an ace wrap
5. Cryotherapy

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11.1.4 ADULT WHEELCHAIR MEASUREMENTS:
15" - Low forward reach, minimum from floor
24" to 26" - Width chair, from rim to rim
24" - Maximum side reach
29" to 30" - height armrest to floor
32" - Minimum clear width for doorways and halls
36" - Height push handles to floor
36" Turning space (90degr)
36" - Ideal clear width for doorways and halls
42" to 43" - Chair length
48" - High forward reach maximum
Ramp ratio 1:12 2.2.2 Skin disorders and colour changes
Fore more info on the dimensions, visit
http://www.access-board.gov/ufas/ufas-html/figures.htm
Minimum Clear Width for
Single Wheelchair
Minimum Clear Width for Two Wheelchairs
Graphic Conventions

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11.1.5 WOUND STAGING:
Stage I: Redness, heat and edema involving the epidermis (non-blanchable erythema of
intact skin), reversible with decreased pressure, dermis is not involved
Stage II: Partial thickness skin loss with tear in epidermis, both epidermis/dermis are
involved, infection and/or necrosis may be present
Stage III: Full thickness skin loss involving damage or necrosis of subcutaneous tissue that
may extend down to but not through underlying fascia, infection and/or necrosis may be
present
Stage IV: Full thickness skin loss with extensive destruction, tissue necrosis or damage to
muscle, bone and supporting structures
A. ULCERS:
 Pressure Ulcer (dermatology), a discontinuity of the skin
 Oral ulcer, an open sore inside the mouth
 Peptic ulcer, a discontinuity of the gastrointestinal mucosa (stomach ulcer)
 Corneal ulcer, an inflammatory or infective condition of the cornea
 Venous ulcer, a wound thought to occur due to improper functioning of valves in the
veins
 Diabetic foot ulcers
 Genital ulcer, an ulcer located on the genital area

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B. PRESSURE ULCERS:
 A pressure ulcer is an injury to the skin as a result of constant pressure due to
impaired mobility. The pressure results in reduced blood flow and eventually causes
cell death, skin breakdown and the development of an open wound. Pressure ulcers
can occur in persons who are wheelchair-bound or bed-bound, sometimes even after
a short time (two to six hours). If the conditions leading to the pressure sore are not
rapidly corrected, the localized skin damage will spread to deeper tissue layers
affecting muscle, tendon and bone. Common sites include the sacrum (tailbone),
back, buttocks, heels, back of the head and elbows. If not adequately treated, open
ulcers can become a source of pain, disability and infection.
 People at greater risk of getting pressure ulcers are those who spend a lot of time in
a bed, chair, or wheelchair. Others at risk include:
 People who cannot move or change positions without someone else’s help, including
those who are in a coma, paralyzed, or have had a hip fracture
 People who have problems controlling their bowel or bladder functions
 People who do not eat a balanced diet
 People who have a lowered mental awareness caused by a medical condition,
medicines or anesthesia. (When mental awareness is lowered, a person might not be
able to act to prevent the development of pressure ulcers.)
 People who have a lowered overall health status
 Where on the body do pressure ulcers usually form?
 Pressure ulcers occur more often over bony parts of the body because there is more
pressure on the skin over these bony areas and less fat to cushion the area. The
illustrations on the right show these most common body sites. You and your
caregiver should pay attention to these areas when inspecting your skin for signs of
pressure ulcers.
Pressure Ulcers

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I. PREVENTION:
 Keep the skin clean: Use a gentle cleanser made for this purpose (not soaps,
which dry the skin). Dry the skin by patting — not rubbing — Before anyone
treats or touches the skin/wound area, make sure the person washes his or her
hands.
 Keep the skin from drying out: Apply a cream moisturizer (for example, Eucerin,
Neutrogena) immediately after a bath or shower to seal in the moisture from
bathing.
 Eat healthy foods: Proper nutrition is vital to healing. Poor eating habits result
in delayed healing, increased length of hospital stay, and increased risk of
infection. Your body, in fact, requires extra calories to help heal wounds. Eating
foods high in calories and protein — such as cheese, peanut butter, chicken,
beef, and fish — is important. In addition to a balanced diet, talk with your health
care providers (doctors, nurse, dietitian) about the need for vitamins, extra
minerals, or other nutritional supplements.
 Protect the skin from too much moisture: When skin gets too wet — a condition
called maceration — it is more likely to break down. Skin can become too moist
when sweat, urine, feces, or wound drainage remain in direct contact with the
skin. If your moisture problem is caused by a bowel or bladder control problem,
II. MAKE SURE:
The skin is cleaned as soon as it becomes soiled with urine or stool
A moisture barrier cream is used to protect the skin from body fluids
Absorbent pads or underwear with a quick-drying surface are used to help keep
moisture away from the skin

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 If pressure ulcers do form, they do not have to get worse. Treatment of pressure
ulcers consists of relieving the pressure that caused the sore, treating the sore
itself, and improving eating habits and other conditions to help the sore heal.
 Tips for proper positioning and movement in bed
 If you must stay in bed:
 Inspect your skin at least once a day.
 Change position at least every two hours. (If you are unable to change positions
by yourself, ask for assistance.)
 Keep a written "turning schedule" to record when your body position was last
changed as well as a note of your last position.
 Shift your weight slightly every 15 minutes, if you can.
 Use your arms to lift yourself rather than dragging yourself onto the bed or chair.
If in a hospital bed, use the trapeze bar to help lift your body to reposition.
 Avoid lying directly on your hipbone when lying on your side. A 30 degree side-
lying position is best. To accomplish this, tuck pillows under one side so that your
weight rests on the fleshy part of your buttock instead of your hip bone.
 Raise the head of the bed as little as possible (no more than 30 degrees from
horizontal) for as short a time as possible to avoid sliding down in the bed. The
head of the bed can be raised during meals to prevent choking. Return the head
of the bed to a horizontal or semi-reclining position one hour after eating.)
 When lying on your back, keep your heels up off the bed by placing a thin foam
pad or pillow under your legs from the middle of your calf to your ankle.
 Position the pillow length-wise, as shown.
 Do NOT place the pad or pillow directly–and only–under the knees because this
could reduce blood flow to the lower leg.
 Use pillows or small foam wedge pads to keep knees and ankles from touching
each other.
 Keep linens as wrinkle-free as possible.
 Let your health care provider know if the bed linens are soiled so that they can be
changed.
III. TIPS FOR PROPER POSITIONING AND MOVEMENT IN CHAIRS:
If you must stay in a chair or wheelchair:
Inspect your skin at least once a day.
Always use a seat cushion designed to relieve pressure on sitting surfaces. Ask your
health care provider about proper foam or air cushion product(s) to use. (Avoid
donut-shaped cushions, since these reduce blood flow to the tissue, causing tissue to
swell.)
Change position every hour. (If you are unable to change positions by yourself, ask
for assistance or have someone help you back to bed so you can change positions.)
Lift yourself up off the chair every 15 minutes. Depending on your strength, use one
of the three methods described below (listed from most to least preferred) and holds
the position for at least a slow count of five to 10 seconds:
1. Place your hands on the arm rest and lift your body off the chair.
2. Press your elbow on the arm rest to lift that side of your body off the chair; repeat
on opposite side, or do both sides at the same time.
3. Shift your weight by leaning far over to one side and repeat on the opposite side.

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Keep the top of your thighs slightly sloping forward and use pillows or foam cushions
to keep knees and ankles from touching each other.
Rest your feet comfortably on the floor or on the footrest.
Rest your elbows, forearms, and wrists on the chair arm supports.
If a pressure ulcer forms, how long does it last?
Pressure ulcers should always be treated by trained health care personnel. With
proper care and treatment, a pressure ulcer should begin healing within two weeks.
Where can I get more information about pressure ulcers?
The skin around the area will be red and shiny or dark purple. (In dark-skinned
people, the area might simply become darker than normal.)
The skin might be warm to the touch compared with nearby tissue.
The area might also be swollen or hard, and might lack feeling
Note: Skin reddening that disappears after pressure is removed is normal and is not
a pressure ulcer. Discoloration of the skin that is constant might be a pressure ulcer.)
C. ORAL ULCER:
An oral ulcer (/ˈʌl-sɚ/, from Latin ulcus) is the name for the appearance of an open sore
inside the mouth caused by a break in the mucous membrane or the epithelium on the
lips or surrounding the mouth. The types of oral ulcers are diverse, with a multitude of
associated causes including: physical or chemical trauma, infection from microorganisms,
medical conditions or medications, cancerous and nonspecific processes. Once formed,
the ulcer may be maintained by inflammation and/or secondary infection. Two common
oral ulcer types are aphthous ulcers (canker sores) and cold sores (aka fever blisters).
Cold sores around the lip are caused by the herpes simplex virus
I. SYMPTOMS:
 The symptoms preceding the ulcer may vary according to the cause of the
ulcerative process.
 Some oral ulcers may begin with a sharp stinging or burning sensation at the site
of the future mouth ulcer. In a few days, they often progress to form a red spot or
bump, followed by an open ulcer. Sometimes this takes a little bit longer,
depending on the cause of the ulcer.
 The oral ulcer appears as a white or yellow oval with an inflamed red border.
Sometimes a white circle or halo around the lesion can be observed. The gray,
white, or yellow colored area within the red boundary is due to the formation of
layers of fibrin, a protein involved in the clotting of blood. The ulcer, which itself is
often extremely painful, especially when agitated, may be accompanied by a
painful swelling of the lymph nodes below the jaw, which can be mistaken for
toothache.
II. CAUSES:
There are many processes, which can lead to ulceration of the oral tissues. In some
cases they are caused by an overreaction by the body's own immune system.
Factors that appear to provoke mouth ulcers include stress, fatigue, illness, injury
from accidental biting, hormonal changes, menstruation, sudden weight loss, food
allergies and deficiencies in vitamin B12, iron and folic acid.

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III. TREATMENT:
Treatments based on antibiotics and steroids are reserved for severe cases, and
should be used only under medical supervision.
Some doctors may also prescribe local anesthetic, such as lidocaine, for cases of
multiple or severe oral ulcers.
Some people benefit from using the over-the-counter topical gel Bonjela, which
contains choline salicylate -- choline salicylate is a local analgesic that helps to
reduce the pain and inflammation associated with oral ulcers.
D. PEPTIC ULCER:
Peptic ulcers are raw spots or sores that can occur anywhere on the lining of the
stomach (where they are called gastric ulcers) or the duodenum (where they are called
duodenal ulcers).
Peptic ulcers are craterlike erosions in the lining of the stomach, the duodenum (the part
of the small intestine just past the stomach), and rarely, the esophagus. Duodenal ulcers
are about three times more common than stomach (gastric) ulcers. Normally, glands in
the stomach secrete acid and the enzyme pepsin (hence the name peptic ulcer) that help
to break down foods in the digestive process. The stomach and duodenum meanwhile
secrete mucus to protect them against harm from pepsin and gastric acid. In peptic ulcer
disease the digestive tract's defensive mechanisms break down, often as a result of
infection with the bacterium Helicobacter pylori. Consequently, even small amounts of
stomach acid can cause corrosion. Each year, about 1 percent of Americans develop
peptic ulcers, and overall, up to 10 percent of the population will have an ulcer at some
point during their lives. All ages may be affected (including children), although ulcers
most often affect those over 30. Ulcers commonly recur: even after an ulcer has healed,
new ones often arise throughout the patient's lifetime, either in the original location or
elsewhere. Therefore, current ulcer drugs, which mostly act to reduce levels of stomach
acids, must often be taken on a long-term basis. The development of newer, short-term
drug regimens directed against H. pylori may significantly lower the high rate of ulcer
recurrence. Although peptic ulcers are rarely a major health threat, they sometimes lead
to serious complications, such as bleeding, obstruction of the digestive tract due to
scarring, or the creation of a hole or tear (perforation) in the digestive tract, which can
lead to severe, life-threatening infection of the abdominal cavity (peritonitis). In addition,
in a small percentage of cases a persistent stomach ulcer may be cancerous. The same
is not true for duodenal ulcers. For most ulcers, treatment is highly effective in controlling
symptoms and preventing serious complications.
I. CAUSES:
At least 80 percent of ulcers are believed to be caused by infection of the digestive
tract with H. pylori bacteria. It's not known how the infection spreads, although it may
be transmitted orally. H. pylori infests about 60 percent of Americans by age 60, but
most of those infected do not develop ulcers. Rather, the bacteria merely increase
the chances of developing an ulcer by weakening the stomach's protective
mechanisms and making the lining of the digestive tract susceptible to erosion by
stomach acids. Once an ulcer has developed, various secondary factors can
aggravate it, including alcohol, caffeine, dietary factors, smoking, and stress.
In the past, excessive production of stomach acid was thought to be the primary
cause of ulcers. It is now recognized that many people with ulcers actually have

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normal or even slightly less-than-normal amounts of stomach acid. However,
because mechanisms that protect the digestive tract lining are weakened, even small
amounts of stomach acid can cause (or delay the healing of ) ulcers. The exception is
ulcers caused by certain kinds of pancreatic or duodenal tumors, which secrete the
hormone gastrin and cause massive amounts of acid secretion (Zollinger-Ellison
syndrome).
Long-term use of aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs),
such as ibuprofen or naproxen, can lead to ulcers primarily in the stomach by
irritating its lining.
Hereditary factors also appear to play a role.
II. PREVENTION:
Avoid long-term use of aspirin or nonsteroidal anti-inflammatory drugs if possible.
Anyone who must take these drugs on a long-term basis, such as those with arthritis,
may benefit from the prescription drug misoprostol. Or your doctor may recommend
one of the newer anti-inflammatory drugs called cylooxygenase-2 (COX-2) inhibitors,
such as celecoxib and rofecoxib, which have been shown to have decreased
gastrointestinal side effects compared to other nonsteroidal drugs.
Taking ulcer medications as prescribed, and avoiding smoking and foods or drinks
that have aggravated ulcers in the past, can help prevent ulcer recurrence.
III. DIAGNOSIS:
Patient history and physical examination are needed.
An upper GI series (which involves swallowing a solution containing barium to create
a clear image of the digestive tract on x-ray) may show active ulcers or scarring
caused by past ulcers.
Endoscopy (in which a flexible scope is guided down the throat and into the stomach
and duodenum) allows ulcers to be viewed directly. Endoscopy also allows the doctor
to take a small sample of the ulcer (biopsy); this sample is then tested for cancer.
Biopsies can also detect the presence of H. pylori, but this method is invasive and
expensive. Quick office tests for the detection of this bacterium are becoming
available.
STOMACH ULCER

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IV. TREATMENT:
 For those with mild disease (one or two periods of symptoms a year),
prescription drugs that reduce secretion of stomach acid (cimetidine, ranitidine,
famotidine, nizatidine, or omeprazole) or that coat the lining of the stomach
(sucralfate) usually relieve pain within a week, although ulcers take about eight
weeks to heal. Antacids may also help, although they may interfere with the
actions of the prescription drugs if both are taken in close succession.
 Antibiotics directed against H. pylori bacteria are generally reserved for those
with more serious disease who do not respond to other ulcer medications, as the
long-term effectiveness and side effects of this approach are still being
evaluated. A combination of two antibiotics (usually metronidazole and
tetracycline) is usually taken for at least two weeks, along with a bismuth-
containing antacid (such as Pepto- Bismol). Antacids or medications that reduce
acid secretion may also be given. Combination antibiotic regimens prevent ulcer
recurrences in about 90 percent of cases.
 Surgery may be needed for bleeding, obstruction or perforation of the digestive
tract, or intractable pain from ulcers.
 Eat a well-balanced diet rich in fiber. Many dietary measures advocated in the
past—such as eating bland foods, eating many small meals a day, or drinking
milk—do not appear to help. Indeed, milk may actually increase stomach acid
production, although one or two glasses a day is usually not harmful. Coffee, tea,
and caffeinated sodas can increase acid secretion. Avoid excessive alcohol
consumption.
E. CORNEAL ULCER:
The front portion of the eye is covered with a thin, transparent membrane called the
cornea, which protects the interior of the eye. If there is a break or defect in the surface
layer of the cornea, called the epithelium, and damage to the underlying stroma, a
corneal ulcer results. The ulcer is usually caused by microorganisms, which gain access
to the stroma through the break in the epithelium.
Corneal ulcers generally heal well if treated early and aggressively. However if neglected,
corneal clouding and even perforation (a hole in the cornea) may develop, resulting in
serious loss of vision and possibly loss of the eye. Corneal ulcers are a serious vision-
threatening condition and require prompt medical attention.
Symptoms of corneal ulcers:
 Watery eyes
 Acute pain
 Sensitivity to light
 Blurry vision
 The feeling that there's something in your eye
 Discharge from the eye
I. CAUSES:
 Infection
 Wearing contact lenses for excessive periods of time
 Inadequate contact lens sterilization
 Eye injury

NPTE
29
 Lack of tear production
 Complications of herpes simplex keratitis, neurotrophic keratitis, chronic
blepharitis, conjunctivitis, trachoma, bullous keratopathy and cicatricial
pemphigoid
 Vitamin A deficiency or protein malnutrition
 Eyelid abnormalities
III. DIAGNOSING CORNEAL ULCERS:
Corneal ulcers are a serious vision-threatening condition and require prompt medical
attention. If left unattended, corneal ulcers may penetrate the cornea allowing
infection to enter the eyeball, which can cause permanent loss of vision and possible
loss of the eye. Your eye doctor can identify corneal ulcers by examining your eyes
with magnifying instruments and performing a culture study to identify infection. Your
doctor will check your eye, including under your eyelid, to make sure there are no
foreign materials present. Depending on the initial exam, fluorescein dye may be
used to identify the corneal defects. A test called the Seidel test (painting the wound
with dye and observing for leakage) may be performed to uncover possible deeper
injuries.
IV. TREATMENT FOR CORNEAL ULCERS:
If treated early, corneal ulcers are usually curable in two to three weeks. They are
typically treated with antibiotic eye drops. Sometimes, topical steroids will also be
used to decrease the risk of scarring and inflammation.

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