1.PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 1 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 1 PASSAGE TO THE USA, VIA CAPE OF NPTE. NATIONAL PHYSIOTHERAPY EXAMINATION-PART-3 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

2. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 2 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 2 TABLE OF CONTENTS PAGE 14.0 EDUCATION & CONSULTATION:................................................................................................................................................................... 6 14.1 PEDIATRIC PHYSIOTHERAPY EDUCATION & CONSULTATION:........................................................................................................ 6 14.1.1 PAEDIATRIC PHYSIOTHERAPISTS DO: ................................................................................................................................ 6 14.1.2 PHYSIOTHERAPY INTERVENTIONS:..................................................................................................................................... 6 14.2 GERIATRIC PHYSIOTHERAPY EDUCATION & CONSULTATION:........................................................................................................ 7 14.2.1 PHYSIOTHERAPISTS ROLE:.................................................................................................................................................. 7 14.2.2 SCREENING: ............................................................................................................................................................................ 7 14.2.3 ASSESSMENT:......................................................................................................................................................................... 8 14.2.4 CARE PLAN DEVELOPMENT:................................................................................................................................................. 8 14.2.5 INTERVENTION:....................................................................................................................................................................... 8 14.2.6 DOCUMENTATION:.................................................................................................................................................................. 8 14.2.7 DISCHARGE/ TRANSFER:....................................................................................................................................................... 8 14.2.8 DATA:........................................................................................................................................................................................ 8 14.3 ORTHOPEDIC PHYSIOTHERAPY EDUCATION & CONSULTATION: ................................................................................................... 9 14.3.1 PHYSIOTHERAPISTS ROLE:.................................................................................................................................................. 9 14.3.2 SCREENING: ............................................................................................................................................................................ 9 14.3.3 ASSESSMENT:......................................................................................................................................................................... 9 14.3.4 CARE PLAN DEVELOPMENT:............................................................................................................................................... 10 14.3.5 INTERVENTION:..................................................................................................................................................................... 10 14.3.6 DOCUMENTATION:................................................................................................................................................................ 10 14.3.7 DISCHARGE/ TRANSFER:..................................................................................................................................................... 11 14.3.8 DATA:...................................................................................................................................................................................... 11 14.4 NEUROLOGICAL PHYSIOTHERAPY EDUCATION & CONSULTATION:............................................................................................. 11 14.4.1 PHYSIOTHERAPISTS ROLE:................................................................................................................................................ 11 14.4.2 SCREENING: .......................................................................................................................................................................... 11 14.4.3 ASSESSMENT:....................................................................................................................................................................... 12 14.4.4 CARE PLAN DEVELOPMENT:............................................................................................................................................... 12 14.4.5 INTERVENTION:..................................................................................................................................................................... 12 A. IMPAIRMENT SPECIFIC: ....................................................................................................................................................... 12 B. ACTIVITY SPECIFIC:.............................................................................................................................................................. 13 C. ADVANCED INTERVENTION:................................................................................................................................................ 13 14.4.6 DOCUMENTATION:................................................................................................................................................................ 14 14.4.7 DISCHARGE/ TRANSFER:..................................................................................................................................................... 14 14.4.8 DATA:...................................................................................................................................................................................... 15 A. PROSTHETIC TERMINOLOGY:............................................................................................................................................. 15 14.5 CARDIO-PULMONARY PHYSIOTHERAPY EDUCATION & CONSULTATION: ................................................................................... 17 14.5.1 PHYSIOTHERAPISTS ROLE:................................................................................................................................................ 17 14.5.2 SCREENING: .......................................................................................................................................................................... 17 A. IMPORTANCE OF MEDICAL EVALUATION:......................................................................................................................... 17 14.5.3 ASSESSMENT:....................................................................................................................................................................... 18 14.5.4 CARE PLAN DEVELOPMENT:............................................................................................................................................... 18 14.5.5 INTERVENTION:..................................................................................................................................................................... 18 14.5.6 DOCUMENTATION:................................................................................................................................................................ 19 14.5.7 DISCHARGE/ TRANSFER:..................................................................................................................................................... 19 14.5.8 DATA:...................................................................................................................................................................................... 19 14.6 LOCATIONS OF THE FISSURES AND LUNG LOBES AND SEGMENTS IN RELATION TO CHEST WALL LANDMARKS:.............. 20 14.6.1 THORACIC CONFIGURATION ABNORMALITIES: ............................................................................................................... 21 14.6.2 CHARACTERISTICS AND CAUSES OF ABNORMAL BREATHING PATTERNS:................................................................ 21 14.6.3 TECHNIQUES TO ACCESS LUNG PROBLEMS:.................................................................................................................. 22 A. TACTILE FREMITUS AND THE CAUSES OF INCREASED OR DECREASED FREMITUS (LOCAL AND DIFFUSE): ...... 22 B. ASSESSING THORACIC EXPANSION:................................................................................................................................. 22 C. ABNORMAL FINDING OF CREPITUS AND ITS SIGNIFICANCE UPON PALPATION OF THE SUBCUTANEOUS TISSUES: ................................................................................................................................................................................ 22 D. TECHNIQUE FOR PERCUSSION AND SOUNDS PRODUCED WHEN THE UNDERLYING TISSUES ARE AIR-FILLED, FLUID FILLED, OR SOLID:..................................................................................................................................................... 22 E. PULMONARY AND EXTRAPULMONARY ABNORMALITIES THAT ARE ASSOCIATED WITH THE THREE BASIC TYPES OF PERCUSSION NOTES: .................................................................................................................................................... 23 F. FOUR PARTS OF THE STETHOSCOPE AND THE SITUATIONS IN WHICH IT IS BEST TO LISTEN WITH THE DIAPHRAGM AND WHEN IT IS BEST TO LISTEN WITH THE BELL: .................................................................................. 23 3. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 3 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 3 G. SOUNDS NORMALLY HEARD OVER THE CHEST:............................................................................................................. 23 H. "ADVENTITIOUS" BREATH SOUNDS: .................................................................................................................................. 23 I. THE AIRWAY OR PARENCHYMAL ABNORMALITIES:........................................................................................................ 24 J. CONDITIONS IN WHICH A PATIENT MAY HAVE DIMINISHED OR ABSENT BREATH SOUNDS:.................................... 24 K. THE PITCH AND INTENSITY OF STRIDOR AND THE POINT IN THE RESPIRATORY CYCLE IN WHICH STRIDOR IS HEARD:................................................................................................................................................................................... 24 L. AIRWAY ABNORMALITIES ASSOCIATED WITH STRIDOR: ............................................................................................... 24 M. ADVENTITIOUS SOUNDS ASSOCIATED WITH THE FOLLOWING CONDITIONS:............................................................ 24 N. AUSCULTATION TECHNIQUES OF BRONCHOPHONY, EGOPHONY, AND WHISPERED PECTORILOQUOY AND ABNORMAL FINDINGS AND THE CONDITIONS ASSOCIATED WITH EACH: ................................................................... 25 O. PATHOPHYSIOLOGICAL CONDITIONS IN WHICH BRONCHIAL BREATH SOUNDS ARE HEARD IN AREAS OF THE CHEST WHERE NORMALLY VESICULAR BREATH SOUNDS ARE HEARD:..................................................................... 25 P. "POINT OF MAXIMAL IMPULSE........................................................................................................................................... 25 15.0 RESEARCH AND EVIDENCE-BASED PRACTICE:...................................................................................................................................... 26 15.1 EBP IS A FIVE-STEP PROCESS: .......................................................................................................................................................... 35 15.2 RESEARCH DESIGN:............................................................................................................................................................................. 37 15.2.1 HISTORICAL RESEARCH:..................................................................................................................................................... 37 15.2.2 DESCRIPTIVE RESEARCH: .................................................................................................................................................. 37 15.2.3 CORRELATIONAL RESEARCH:............................................................................................................................................ 38 15.2.4. EXPERIMENTAL:.................................................................................................................................................................... 39 A. DESIGNS: ............................................................................................................................................................................... 39 I. TRUE EXPERIMENTS:................................................................................................................................................... 39 II. COHORT DESIGN, QUASI-EXPERIMENTAL DESIGN:................................................................................................ 40 III. WITHIN SUBJECTS (REPEATED MEASURES) DESIGNS: ......................................................................................... 42 IV. MATCHED PAIRS DESIGNS:......................................................................................................................................... 42 V. BETWEEN SUBJECTS DESIGNS:................................................................................................................................. 42 VI. FACTORIAL DESIGNS:.................................................................................................................................................. 43 VII. SINGLE-SUBJECT RESEARCH: ................................................................................................................................... 43 VIII. THE AB DESIGN:............................................................................................................................................................ 43 IX. NPTE TYPE OF QUESTIONS EXAMPLE: ..................................................................................................................... 44 B. CAUSAL-COMPARATIVE:...................................................................................................................................................... 45 C. EPIDEMIOLOGY:.................................................................................................................................................................... 45 15.3 VARIABLES:........................................................................................................................................................................................... 46 15.4 HYPOTHESIS: ........................................................................................................................................................................................ 46 15.4.1 HYPOTHESIS TEST:.............................................................................................................................................................. 46 15.4.2 NULL HYPOTHESIS:.............................................................................................................................................................. 47 15.4.3 ALTERNATIVE HYPOTHESIS:............................................................................................................................................... 48 15.5 DATA TYPES: ......................................................................................................................................................................................... 48 15.5.1 DISCRETE DATA:................................................................................................................................................................... 48 15.5.2 CATEGORICAL DATA:........................................................................................................................................................... 48 15.5.3 NOMINAL DATA: .................................................................................................................................................................... 48 15.5.4 ORDINAL DATA:..................................................................................................................................................................... 48 15.5.5 INTERVAL SCALE:................................................................................................................................................................. 49 15.5.6 CONTINUOUS DATA:............................................................................................................................................................. 49 15.5.7 FREQUENCY TABLE: ............................................................................................................................................................ 49 A. PIE CHART: ............................................................................................................................................................................ 50 B. BAR CHART:........................................................................................................................................................................... 50 C. DOT PLOT: ............................................................................................................................................................................. 51 D. HISTOGRAM:.......................................................................................................................................................................... 51 E. STEM AND LEAF PLOT: ........................................................................................................................................................ 52 F. BOX AND WHISKER PLOT (OR BOXPLOT): ........................................................................................................................ 52 G. 5-NUMBER SUMMARY: ......................................................................................................................................................... 52 H. OUTLIER:................................................................................................................................................................................ 52 I. SYMMETRY: ........................................................................................................................................................................... 52 J. SKEWNESS:........................................................................................................................................................................... 53 K. SCATTER PLOT: .................................................................................................................................................................... 53 L. ILLUSTRATIONS: ................................................................................................................................................................... 53 M. SAMPLE MEAN: ..................................................................................................................................................................... 53 15.6 SAMPLING: ............................................................................................................................................................................................. 54 15.6.1 TARGET POPULATION:......................................................................................................................................................... 54 15.6.2 MATCHED SAMPLES:............................................................................................................................................................ 54 4. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 4 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 4 15.6.3 INDEPENDENT SAMPLING:.................................................................................................................................................. 54 15.6.4 RANDOM SAMPLING:............................................................................................................................................................ 54 15.6.5 SIMPLE RANDOM SAMPLING:.............................................................................................................................................. 54 15.6.6 STRATIFIED SAMPLING:....................................................................................................................................................... 55 15.6.7 CLUSTER SAMPLING: ........................................................................................................................................................... 55 15.6.8 QUOTA SAMPLING: ............................................................................................................................................................... 55 15.6.9 SPATIAL SAMPLING: ............................................................................................................................................................. 55 15.6.10 SAMPLING VARIABILITY:...................................................................................................................................................... 55 15.6.11 STANDARD ERROR:.............................................................................................................................................................. 55 15.6.12 BIAS: ....................................................................................................................................................................................... 56 15.6.13 PRECISION:............................................................................................................................................................................ 56 15.7 INSTRUMENTATION-GOLD STANDARD:............................................................................................................................................ 56 15.8 INFORMED CONSENT:.......................................................................................................................................................................... 56 15.9 PROBLEMS RELATED TO MEASUREMENT:....................................................................................................................................... 56 15.9.1 CONTROL:.............................................................................................................................................................................. 56 A. CONTROL GROUP:................................................................................................................................................................ 56 B. EXPERIMENTAL GROUP: ..................................................................................................................................................... 57 C. INTERVENING VARIABLE: .................................................................................................................................................... 57 15.9.2 VALIDITY: ............................................................................................................................................................................... 58 A. STATISTICAL CONCLUSION VALIDITY:............................................................................................................................... 58 B. INTERNAL VALIDITY:............................................................................................................................................................. 58 C. CONSTRUCT VALIDITY:........................................................................................................................................................ 58 D. EXTERNAL VALIDITY: ........................................................................................................................................................... 59 E. ECOLOGICAL VALIDITY:....................................................................................................................................................... 59 F. CONTENT VALIDITY: ............................................................................................................................................................. 60 G. FACE VALIDITY: ........................................................................................................................................................................ 60 H. CRITERION VALIDITY: .............................................................................................................................................................. 60 I. CONCURRENT VALIDITY:.......................................................................................................................................................... 60 J. PREDICTIVE VALIDITY: ............................................................................................................................................................. 60 K. CONVERGENT VALIDITY:......................................................................................................................................................... 60 L. DISCRIMINANT VALIDITY:......................................................................................................................................................... 60 15.9.3 THREATS TO VALIDITY:........................................................................................................................................................ 61 A. INTERNAL VALIDITY:............................................................................................................................................................. 61 B. EXTERNAL VALIDITY: ........................................................................................................................................................... 62 C. OTHER THREATS:................................................................................................................................................................. 62 15.9.4 RELIABILITY: .......................................................................................................................................................................... 63 15.9.5 THREATS TO RELIABILITY: .................................................................................................................................................. 64 15.9.6 OBJECTIVITY: ........................................................................................................................................................................ 64 15.9.7 SUBJECTIVITY: ...................................................................................................................................................................... 64 15.9.8 SENSITIVITY: ......................................................................................................................................................................... 65 A. FALSE POSITIVE: .................................................................................................................................................................. 65 B. FALSE NEGATIVE:................................................................................................................................................................. 65 C. A NEGATIVE (LOW SENSITIVITY) RESULT RULES OUT THE DIAGNOSIS (SNOUT): ..................................................... 65 15.9.9 SPECIFICITY: ......................................................................................................................................................................... 66 15.10 DATA ANALYSIS AND INTERPRETATION: ......................................................................................................................... 66 15.10.1 DESCRIPTIVE STATISTICS:..................................................................................................................................................... 66 A. MEASURES OF CENTRAL TENDENCY:............................................................................................................................... 66 I. MEAN:............................................................................................................................................................................. 66 II. MEDIAN: ......................................................................................................................................................................... 66 III. MODE:............................................................................................................................................................................. 66 B. MEASURES OF VARIABILITY: .............................................................................................................................................. 66 I. RANGE:........................................................................................................................................................................... 66 II. SD - STANDARD DEVIATION........................................................................................................................................ 66 C. NORMAL DISTRIBUTION: - ........................................................................................................................................... 67 I. PERCENTILES: ...................................................................................................................................................... 67 II. QUARTILES:........................................................................................................................................................... 67 15.10.2 INFERENTIAL STATISTICS: ..................................................................................................................................................... 68 A. DEGREES OF FREEDOM:..................................................................................................................................................... 68 I. ERRORS:........................................................................................................................................................................ 68 1. STANDARD ERROR: ............................................................................................................................................. 68 2. TYPE I ERROR:...................................................................................................................................................... 68 5. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 5 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 5 3. TYPE II ERROR:..................................................................................................................................................... 69 15.10.3 PARAMETRIC STATISTICS: (INTERVAL AND RATIO DATA).............................................................................................. 69 A. ASSUMPTIONS: ..................................................................................................................................................................... 69 B. T-TEST.................................................................................................................................................................................... 69 I. T-TEST FOR INDEPENDENT SAMPLES: ..................................................................................................................... 69 II. T-TEST FOR NONINDEPENDENT SAMPLES: ............................................................................................................. 70 III. ONE-TAILED T-TEST: .................................................................................................................................................... 70 IV. TWO-TAILED T-TEST:.................................................................................................................................................... 70 a. When is a one-tailed test appropriate? ................................................................................................................... 71 b. When is a one-tailed test not appropriate? ............................................................................................................ 71 C. ANOVA - ANALYSIS OF VARIANCE:..................................................................................................................................... 71 I. ONE-WAY ANOVA:......................................................................................................................................................... 72 II. WHY NOT JUST USE THE T-TEST? ............................................................................................................................. 72 D. ANCOVA - ANALYSIS OF COVARIANCE:............................................................................................................................. 72 I. WHAT IS THE DIFFERENCE BETWEEN ANOVA AND ANCOVA?.............................................................................. 73 E. NON-PARAMETRIC STATISTICS:......................................................................................................................................... 74 I. CHI SQUARE:................................................................................................................................................................. 74 F. CORRELATIONAL STATISTICS: ........................................................................................................................................... 75 G. PEARSON PRODUCT-MOMENT COEFFICIENT:................................................................................................................. 76 I. CORRELATION COEFFICIENT: .................................................................................................................................... 76 II. SPEARMAN'S RANK CORRELATION COEFFICIENT: ..................................................................................................... 76 III. COMMON VARIANCE: ................................................................................................................................................... 76 15.11 SAMPLE RESEARCH TEST:.................................................................................................................................................. 77 16.0 PATHOLOGICAL:........................................................................................................................................................................................... 80 16.1 PHYSIOTHERAPY IN HIV: ..................................................................................................................................................................... 80 16.1.1 ISSUES: .................................................................................................................................................................................. 80 16.1.2 DESCRIPTION:....................................................................................................................................................................... 80 16.1.3 RECOMMENDATIONS: .......................................................................................................................................................... 80 16.2 STRUCTURAL KNEE PROBLEMS:........................................................................................................................................................ 81 16.3 STRUCTURAL HIP PROBLEMS: ........................................................................................................................................................... 82 16.4 DISORDERS AND DISEASES:............................................................................................................................................................... 83 16.5 MEDS: 84 16.6 ALS AND MS:.......................................................................................................................................................................................... 85 16.7 DIABETES MELLITUS: ........................................................................................................................................................................... 85 17.0 SAMPLE NPTE QUESTIONS:........................................................................................................................................................................ 86 3.2 ANATOMY AND PHYSIOLOGY ONLINE LEARNING CENTER:........................................................................................................... 93 3.3 WOUND CARE DEFINITIONS FLASH CARDS:..................................................................................................................................... 93 3.4 WOUND CARE TIPS AND DRESSINGS:............................................................................................................................................... 93 6. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 6 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 6 14.0 EDUCATION & CONSULTATION: The physiotherapist will function as an educator and advocate to the clinical care team members, the patient and their families/care givers, health care professionals and students. Education will include but is not limited to: Physiotherapists are responsible for professional practice standards and evidence based practices; taking a mentoring role in the Department of Rehabilitation Services research activities; performing patient care functions within their practice area; and performing quality management, administrative, and group leadership functions within the Division of Physical Therapy. They are responsible for the development of programs and program evaluation; facilitating education programs and services within their practice area and performing other duties consistent with the classification as delegated by their place of work. 14.1 PEDIATRIC PHYSIOTHERAPY EDUCATION & CONSULTATION: Paediatric physiotherapists are primarily members of the child health multidisciplinary team, which includes occupational therapists, speech and language therapists, paediatricians and health visitors who have specialised in assessing and managing conditions in children. They are often required to advise educational and social services teams on children's needs in relation to their physical development, respiratory condition or musculoesketal condition. 14.1.1 PAEDIATRIC PHYSIOTHERAPISTS DO: Evaluate a child's ability in relation to his/her gross motor development and produce an assessment, advising parents and medical staff on the child's needs. Specific assessments are often requested by education as part of a child's "Assessment of special educational needs", or by social services "Children's with disability team" identifying a child's present needs in order to find suitable care takers or future needs to plan housing needs or alterations. Advise parents, care takers and the child, if old enough, on the condition and informing them on various physiotherapy options working in partnership with them on the most appropriate strategies to enable each child to achieve his/her potential. The physiotherapist will work closely with the child's care takers teaching through demonstration handling techniques to encourage the child's gross motor development or specific techniques to maintain the child's health. 14.1.2 PHYSIOTHERAPY INTERVENTIONS: Specific exercises to be practiced regularly at home or at school. These are often designed as games or play activities General advice to be incorporated into daily living activities Short intensive clinic based exercises Recommended specific equipment to meet the child's needs e.g. walking aids, postural care equipment Assessment of moving and handling needs of the child advising on strategies to minimise the risk to the child and the carer 7. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 7 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 7 14.2 GERIATRIC PHYSIOTHERAPY EDUCATION & CONSULTATION: Objective: To minimise the impact of disease and disability upon the personal independence and autonomy of older persons. This is achieved by the application of preventative measures, early intervention, comprehensive medical and social assessment, remedial and rehabilative procedures and integrated community support. A comprehensive geriatric evaluation is carried out by the Physiotherapist in which the multiple problems of the older person are uncovered, described and explained, if possible, and in which the resources and strengths of the person are catalogued, need for services assessed and a coordinated care plan developed to focus interventions on the persons problems. Comprehensive geriatric evaluation usually means evaluation of the patient in several domains, most commonly the physical, mental, social, economic, functional and environmental. 14.2.1 PHYSIOTHERAPISTS ROLE: It is the physiotherapists role to assess the physical function domains of balance, mobility and transfers, and how these impact on personal activities of daily living and instrumental activities of daily living. The physiotherapists role includes the assessment of bed skills, sit to stand, standing balance, indoor and outdoor mobility, ability to negotiate stairs and details of any gait aids Additional assessments may include neurological, respiratory and musculoskeletal as indicated. The physiotherapists shall determine what level of function is safe for discharge by taking into consideration the home environment (eg stairs, distances required to walk) and available level of assistance. The physiotherapists shall always compare the best level of recent premorbid physical function with that as a current inpatient to identify if there is any additional limitation of function associated with illness, treatment or hospitalisation. Identification of this functional gap will help determine if rehabilitative interventions are indicated. The Physiotherapist shall implement acute intervention for problems amenable to physiotherapy based on assessment findings and clinical reasoning. 14.2.2 SCREENING: The physiotherapist as to the need for physiotherapy assessment and management will screen patients. Some indicators for physiotherapy include; 1. Respiratory disorders, which respond to physiotherapy (productive pneumonia, infective exacerbation CAL, bronchiectasis) 2. Motor impairing neurological conditions (CVA, MS, MND, PD) 3. Gait disorders amenable to treatment 4. Falls 5. Musculoskeletal diseases and injuries, which impact on function 8. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 8 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 8 14.2.3 ASSESSMENT: Physiotherapy assessment shall include bed skills; sit to stand, standing balance, indoor and outdoor mobility (as required), ability to negotiate stairs and details of any gait aids. Additional assessments may include neurological, respiratory and musculoskeletal as indicated. 14.2.4 CARE PLAN DEVELOPMENT: The physiotherapist shall liase with medical officers, nursing staff and other relevant health professionals regarding the patients bed skills, mobility and transfer status, physiotherapy treatment plan and further management of patients. They shall assist the organization team in making admission / discharge / referral decisions. 14.2.5 INTERVENTION: Physiotherapists shall implement acute intervention for problems amenable to physiotherapy based on assessment findings and clinical reasoning. Physiotherapists shall prescribe and deliver a safe, effective and individualised exercise programme based on current research evidence. They shall incorporate education and prevention into the provision of the physiotherapy service. Physiotherapists shall prescribe gait and transfer aids as identified by assessment findings and clinical reasoning. They shall organise the provision of the equipment from the appropriate source. 14.2.6 DOCUMENTATION: Physiotherapists shall thoroughly document the assessment, management plans and progress of all patients seen. All medical record entries must comply with medicolegal requirements. Mobility status must be clearly documented and communicated to ward staff using standard terminology as described in the Communication of Ward Mobility and Functional Mobility for ADLs Policy. Mobility/ transfer status must be written on bedside communication board. This is to maximise patient and staff safety. 14.2.7 DISCHARGE/ TRANSFER: Physiotherapists shall ensure appropriate referral and handover to ongoing physiotherapy service, and inform the patient and carer of these arrangements. 14.2.8 DATA: Physiotherapists shall maintain timely and accurate data of physiotherapy interventions in CERNER. Departmental Activities (non patient related activities) stats entered into reports database. 9. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 9 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 9 14.3 ORTHOPEDIC PHYSIOTHERAPY EDUCATION & CONSULTATION: Orthopaedic Physiotherapy is oriented towards the treatment of Musculo Skeletal ailments. It involves regaining appropriate health and function of structures surrounding the Joint regions and normalizing the Biomechanics following any injury or Orthopaedic disease. The rehabilitation of orthopaedically disabled individuals is also a major area of function 14.3.1 PHYSIOTHERAPISTS ROLE: Impaired posture, Impaired Muscle functions Impaired Joint Mobility, Motor function, Muscle performance, and range of motion associated with Connective tissue dysfunctions Localized inflammation As in Muscle pain, strain Muscle tear 14.3.2 SCREENING: The physiotherapist as to the need for physiotherapy assessment and management will screen patients. Joint stiffness Fractures Ligament strain, sprain, tear Inability to walk Inflammation of tendons and bursa Joint pain, poor posture Joint inflammation in case of osteoarthritis or rheumatoid arthritis Care for persons with orthopaedic problems can be complex. Usually the first health care contact for such a condition is the family physician. More than 60% of the people who suffer from orthopaedic problems will seek attention from their family physician who will typically treat the patient with anti-inflammatory medications and advice on rest. However, family physicians may lack the background knowledge and sufficient contact time to comprehensively manage orthopaedic conditions, and patients may not respond to conservative treatment, leaving referral to a specialist as the typical course of action. 14.3.3 ASSESSMENT: Physiotherapy assessment shall include bed skills; sit to stand, standing balance, indoor and outdoor mobility (as required), ability to negotiate stairs and details of any gait aids. In order to address access to care issues, many countries, have begun to examine multidisciplinary collaborative models of care. Improved use of non-physician health care providers can have a positive impact on the cost of health care, on efficiency of the health care system in terms of human resources, on patient satisfaction with care, and on physician productivity and satisfaction with the work environment. In the health care system, the most obvious choice for collaborative care in the management of orthopaedic problems is the physiotherapist because they are experts in the conservative management of these conditions. Using physiotherapists to manage non- surgical orthopaedic patients in a front-line, clinic setting is not new. The model of care in which a physiotherapist assesses, triages and manages orthopaedic patients has been successfully implemented in other countries. 10. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 10 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 10 The new trend, particularly in hip and knee arthroplasty clinics, is for physiotherapists to assess and triage patients for orthopaedic surgical assessment, and to manage those patients who require conservative care with appropriate advice, or by referring them for other management, such as a dietician. Patients who do require a consultation with the surgeon are then prioritised for a visit within one, three or six months, allowing the surgeon to deal with the more urgent cases first. Physiotherapists can also perform regular check- ups of those patients who have been referred for arthroplasty but who have been deemed by the surgeon as inappropriate at the current time, thereby taking the patient off the surgeon's wait list. In addition, these Physiotherapists are able to manage postoperative arthroplasty patients, especially for the six- and 12-month follow-up visits. This again serves to reduce the number of clinic patients that orthopaedic surgeons are required to see. 14.3.4 CARE PLAN DEVELOPMENT: The physiotherapist shall liase with medical officers, nursing staff and other relevant health professionals regarding the patients bed skills, mobility and transfer status, physiotherapy treatment plan and further management of patients. They shall assist the organization team in making admission / discharge / referral decisions. These Physiotherapists work in hospitals and have delegated acts that allow them to order X-rays, blood work and other necessary tests in order to make appropriate care decisions about patients. They will typically work with the surgeons for a period of time before starting their own clinics in order to learn the criteria that each surgeon uses to judge the necessity for surgery, and to learn additional radiographic diagnostic skills. This period of time also familiarizes the surgeon with the capabilities of the physiotherapist so the surgeon can be confident in the abilities of the person with whom they will work collaboratively. 14.3.5 INTERVENTION: Physiotherapists can see patients in a timely manner and are able to identify those who require conservative management or who need to see the surgeon. This allows the orthopaedic surgeons to care for patients with conditions more amenable to surgical intervention. This collaborative model of care between physicians and physiotherapists has been shown to: Increase the number of patients seen in the outpatient orthopaedic clinics since only those who may require surgery see the surgeon; Improve patient and physician satisfaction by easing the burden of excessive wait times on both; May ultimately improve publicly-funded access to the appropriate care for orthopaedic problems 14.3.6 DOCUMENTATION: Physiotherapists shall thoroughly document the assessment, management plans and progress of all patients seen. All medical record entries must comply with medicolegal requirements. Mobility status must be clearly documented and communicated to ward staff using standard terminology as described in the Communication of Ward Mobility and Functional Mobility for policy. Mobility/ transfer status must be written on bedside communication board. This is to maximise patient and staff safety. 11. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 11 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 11 14.3.7 DISCHARGE/ TRANSFER: Physiotherapists shall ensure appropriate referral and handover to ongoing physiotherapy service, and inform the patient and carer of these arrangements. 14.3.8 DATA: Physiotherapists shall maintain timely and accurate data of physiotherapy interventions. Departmental Activities (non patient related activities) entered into reports database. 14.4 NEUROLOGICAL PHYSIOTHERAPY EDUCATION & CONSULTATION: 14.4.1 PHYSIOTHERAPISTS ROLE: A neurological physiotherapist works with patients/clients of all ages with disorders of, or damage to, the brain, spinal cord and neuromuscular system, or degenerative conditions affecting the brain, nerves or muscles. Neurological physiotherapists have a special interest in the management of patients/clients with movement disorders arising from disturbances of the motor or sensory systems. These conditions may include, but are not limited to, stroke, traumatic or other brain injury, spinal cord injury, Parkinsons disease and neurogenetic conditions as well as dizziness and balance disorders and falls management in older clients. Neurological physiotherapists have special expertise and training in the assessment of physical function and mobility in clients with neurological disorders/disease, and in planning/delivering treatment programs as well as offering preventative advice to optimise physical function, mobility and quality of life. Neurological physiotherapists work in a wide range of settings including inpatient, outpatient, private practice, private hospital and outreach services and rehabilitation in the home. Inpatient facilities include acute hospitals, comprehensive stroke and neurological units, rehabilitation hospitals and slow stream rehabilitation services. Outpatient settings include public hospitals, community health and rehabilitation centres and domiciliary care/home based services. In these varied settings, neurological physiotherapists work in collaboration with other allied health professionals, general practitioners and case coordinators, as well as families and care takers, to provide a seamless continuity of acute, rehabilitation and ongoing care. 14.4.2 SCREENING: Early treatment following onset of an acute neurological condition such as a stroke or traumatic brain injury can help to maximise recovery. Ongoing neurological rehabilitation will assist the client in achieving his or her best possible potential in the long term. In the case of degenerative conditions, such as Parkinsons disease or Motor Neurone disease, the focus of ongoing treatment is to minimise disability and to promote optimal function and independence at each stage of the disease. 12. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 12 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 12 14.4.3 ASSESSMENT: Physiotherapy assessment shall include Bed skills; Body structures/functions and impairments Muscle length and joint ROM Muscle stiffness/tone Muscle reflexes/spasticity Strength/weakness Motor Control (co-ordination and movement isolation) UMN dysfunction Sensation (e.g. proprioception, somatosensory, visual field) Perception (e.g. vertical and position in space) Secondary impairment Activities Transfers (bed mobility, between bed, chair, STS, SIT, on-off floor) Postural control sitting and standing Gait in closed environment* Reaching Grasp &/or Manipulation Cognitive deficits and effect on function Neuropathic pain Environment e.g. Home/Work/school Incontinence, contributions Autonomic NS considerations Impact of pathology on outcomes (predicting prognosis) 14.4.4 CARE PLAN DEVELOPMENT: The physiotherapist shall liase with medical officers, nursing staff and other relevant health professionals regarding the patients: TBI prioritising goals Suggesting trial of medication types Suggesting trial of botox Suggesting trial of other methods for managing hyperreflexia/tone Discharge planning with multiple community agencies Equipment for home, work or school Early planning for discharge Circuit classes, group work 14.4.5 INTERVENTION: A. IMPAIRMENT SPECIFIC: Strengthening programs Co-ordination/motor control programs Managing tone & hyperreflexia Motor impairments Sensory retraining Prevention of secondary adaptations 13. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 13 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 13 B. ACTIVITY SPECIFIC: Bed mobility/ Transfer retraining STS retraining Postural control retraining Gait Running/HL skills Management of CVA UL Group/class exercise Splinting for UL Splinting for LL Wheelchair prescription Gait aid prescription Use of hoists/harness/slide sheet Application of FES Use of biofeedback Aquatic therapy for neurology C. ADVANCED INTERVENTION: TBI spasm (hyperreflexia/tone) management, variety of options Bobath handling skills Perceptual problems Activating muscles in context of activity (facilitating activation through task) Retraining a complex gait pattern, facilitation of normal Retraining gait pattern with clonus Retraining gait in open environment Retraining running Retraining advanced postural control activities Safely stand and move a client unassisted, client has is dependent e.g. minimal unilateral lower limb activity Teaching families skills for transfers for client with minimal activity Teaching families of those with progressive muscular disorders skills for handling, assistance, exercise and positioning. Developing circuit based stroke group Application of spinal braces Application of FES Fitness testing with polar heart monitor Wheelchair and/or seating prescription Prescription of equipment for independent living Counselling for patients and families Teaching care takers how to maximise outcome Serial casting for upper and lower limbs 14. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 14 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 14 14.4.6 DOCUMENTATION: Physiotherapists shall thoroughly document the assessment, management plans and progress of all patients seen. All medical record entries must comply with medicolegal requirements. Mobility status must be clearly documented and communicated to ward staff using standard terminology as described in the Communication of Ward Mobility and Functional Mobility for Policy. Mobility/ transfer status must be written on bedside communication board. This is to maximise patient and staff safety. 14.4.7 DISCHARGE/ TRANSFER: Physiotherapists shall ensure appropriate referral and handover to ongoing physiotherapy service, and inform the patient and carer of these arrangements. 15. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 15 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 15 14.4.8 DATA: Physiotherapists shall maintain timely and accurate data of physiotherapy interventions. Departmental Activities (non patient related activities) entered into reports database. A. PROSTHETIC TERMINOLOGY: AE: Above elbow - "transhumeral." AK: Above knee -"transfemoral." Amelia: Absence or partial absence of limbs at birth. BE: Below elbow also referred to as transradial. Bilateral amputee: A person missing either both arms or both legs; a double amputee. BK: Below knee also referred to as transtibial. Bumper: A rubber like device inserted into a knee or ankle component as a resistance or extension aid. DAK: Double AK, also referred to as "bilateral transfemoral." ED: An amputation through the elbow joint. Edema: A local or generalized condition in which the bodys tissues contain an excess of fluid. Endoskeletal Prosthesis: A prosthesis built more like a human skeleton with support and components on the inside. Energy storing foot: A prosthetic foot designed with a flexible heel. Extension assist: A method of assisting the prosthetic to "kick forward" on the swing through phase to help speed up the walking cycle. Hip Disarticulation. Amputation that removes the leg at the hip joint, leaving the pelvis intact. Hemipelvectomy. An amputation where approximately half of the pelvis is removed. Hybrid prosthesis: A prosthesis that combines several prosthetic options in a single prosthesis. IPOP: "Immediate Post Operative Prosthesis." Knee Disarticulation-through the knee (TDK): Amputation of the leg through the knee. Liner: Suspension systems used to attach prosthesis to the residual limb and/or provide additional comfort and protection of the residual limb. Long's Line: A straight line from the head of the femur through the distal end of the femur down to the center of the heel of the prosthetic foot. Myoelectrics: muscle electronics used to control a prosthesis. Nylon sheath: A sock interface worn close to the skin on the residual limb to add comfort and wick away perspiration. Partial Foot Amputation: - "Choppart Amputation." - amputation on the front part of the foot. Phantom pain: Pain that seems to originate in the portion of the limb that was removed. Phantom sensation: The normal ghost image of the absent limb may feel normal at times and at other times be uncomfortable or painful. Pistoning: Refers to the residual limb slipping up and down inside the prosthetic socket while walking. 16. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 16 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 16 Ply: Thickness of stump sock material. PTB: Patellar Tendon Bearing. BK prosthesis where weight is on the tendon below the kneecap. Pylon: A rigid member, usually tubular, between the socket or knee unit and the foot that provides a weight bearing support shaft for an endoskeletal prosthesis. Quad Socket: A socket designed for an above the knee amputee that has four distinctive sides allowing the muscles to function as much as possible. Residual limb: The portion of the arm or leg remaining after the amputation. Some people refer to it as a "stump." Rigid Dressing: A plaster wrap over the residual limb, usually applied in the operating or recovery room immediately following surgery for the purpose of controlling edema (swelling) and pain. SACH Foot: Solid-Ankle Cushion Heel. Shock Pylon: A prosthetic pylon that dampens the vertical forces exerted on the residual limb and is used to cushion the impact when walking. Shoulder Disarticulation : Amputation through the shoulder joint. Shrinker: A prosthetic reducer made of elastic material and designed to help control swelling of the residual limb (edema) and/or shrink it in preparation for a prosthetic fitting. Single Axis Foot: A foot is based on an ankle hinge that provides dorsiflexion and plantarflexion, i.e. toe up and toe down. Socket: The portion of the prosthesis that fits around the residual limb/stump and to which the prosthetic components are attached. Stump Shrinker: An elastic wrap or compression sock worn on a residual limb to reduce swelling and shape the limb. Suction socket: A socket designed to provide suspension by means of negative pressure vacuum in a socket. Symes amputation: An amputation through the ankle joint that retains the fatty heel pad portion and is intended to provide end weight bearing. Variable Volume Socket: Lightweight and custom-made. The two-piece design makes it possible to don and doff the prosthesis without subjecting the dysvascular limb to unnecessary shear. 17. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 17 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 17 14.5 CARDIO-PULMONARY PHYSIOTHERAPY EDUCATION & CONSULTATION: 14.5.1 PHYSIOTHERAPISTS ROLE: Cardiopulmonary physiotherapists work with patients in a variety of settings. They treat acute problems like asthma, acute chest infections and trauma; they are involved in the preparation and recovery of patients from major surgery; they also treat a wide range of chronic cardiac and respiratory conditions like Chronic Obstructive Pulmonary Disease (COPD), cystic fibrosis (CF) and post-myocardial infarction (MI). They work with all ages from premature babies to older adults at the end of their life. Physiotherapists have pioneering new management techniques for non-organic respiratory problems like hyperventilation and other stress-related disorders as well as leading the development of cardio-pulmonary rehabilitation and non-invasive ventilation. Cardiopulmonary physiotherapists use physical modalities to treat people. This may involve using manual techniques to clear infected mucus from a person's chest, or using non- invasive ventilation to help a person breathe, or prescribing exercises to improve a patient's functional exercise capacity. 14.5.2 SCREENING: The physiotherapist should perform physical examination. Physical examination components such as body weight, body composition (percent body fat), neurological function test, including reflexes, auscultation of the lungs, palpation of cardiac apical; impulse, auscultation of lung, palpation of cardinal apical impulse, auscultation of the heart with specific attention to murmur, palpation and inspection of the lower extremities for oedema and presence of arterial pulse should be done. Blood pressure: Cholesterol and lipoprotein: Pulmonary function: Functional capacity test (Exercise Tolerance Test [ETT]): A. IMPORTANCE OF MEDICAL EVALUATION: Medical screening (evaluation) is a useful and important part of the exercise prescription. A comprehensive medical evaluation will help identify high risk individuals who should not exercise at all or should be restricted to exercising only under medical supervision. The information obtained in medical evaluation can be used to develop the exercise prescription. The valves obtained from certain clinical measures such as BP, body fat content and blood lipid levels can be used to motivate the person to adhere to the exercise programme. A comprehensive medical evaluation, particularly of healthy people can provide a baseline against which any subsequent charges in health status can be compared. Many illness and diseases such as cardiovascular diseases can be identified in their earliest stages when chances of successful treatment are much higher. For the identification of individuals with other special needs. 18. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 18 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 18 14.5.3 ASSESSMENT: Physiotherapy assessment shall include Measurement and Documentation History Pulmonary Function Tests Arterial Blood Gases Imaging of the Chest Electrocardiogram Identification Multisystem Assessment and Laboratory Investigations Special Tests Clinical Assessment of the Cardiopulmonary System Monitoring Systems in the Intensive Care Unit 14.5.4 CARE PLAN DEVELOPMENT: The physiotherapist shall liase with medical officers, nursing staff and other relevant health professionals regarding the patients bed skills, mobility and transfer status, physiotherapy treatment plan and further management of patients. They shall assist the organization team in making admission / discharge / referral decisions. 14.5.5 INTERVENTION: Cardiopulmonary Physiotherapy is an essential non-invasive medical intervention that can mitigate or reverse insults on oxygen transport. Relating Interventions to an Individual?s Facilitating Ventilation Needs Patterns and Breathing Strategies Mobilization and Exercise Exercise Testing and Training: Body Positioning Primary Cardiopulmonary Dysfunction Physiological Basis for Airway Clearance Techniques Exercise Testing and Airway Training: Secondary Cardiopulmonary Dysfunction Clearance Interventions: Clinical Application Respiratory Facilitating Airway Muscle Training Clearance with Coughing Techniques Complementary Therapies as Cardiopulmonary Physical Therapy Interventions Patient Education 19. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 19 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 19 14.5.6 DOCUMENTATION: Physiotherapists shall thoroughly document the assessment, management plans and progress of all patients seen. All medical record entries must comply with medicolegal requirements. Mobility status must be clearly documented and communicated to ward staff using standard terminology as described in the Communication of Ward Mobility and Functional Mobility for Policy. Mobility/ transfer status must be written on bedside communication board. This is to maximise patient and staff safety. 14.5.7 DISCHARGE/ TRANSFER: Physiotherapists shall ensure appropriate referral and handover to ongoing physiotherapy service, and inform the patient and carer of these arrangements. 14.5.8 DATA: Physiotherapists shall maintain timely and accurate data of physiotherapy interventions. Departmental Activities (non patient related activities) entered into reports database. 20. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 20 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 20 14.6 LOCATIONS OF THE FISSURES AND LUNG LOBES AND SEGMENTS IN RELATION TO CHEST WALL LANDMARKS: 21. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 21 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 21 ANTERIOR: o Top of lungs is 2-4 cm above middle of clavicles o Suprasternal notch is top of manubrium o Sternal angle (Angle of Louis) articulate of 2nd rib and bifurcation of trachea o Bottom of lungs 6th rib midclavicular and 8th rib midaxillary (at end of exhalation) POSTERIOR: o C-7 most prominent spinal process at base of neck o T-1 articulate 1st rib and top of lungs o T-4 level so tracheal bifurcation o T-8 inferior angle of scapulae o T-9 top of right dome of diaphragm and bottom of right lung o T-10 top of left dome of diaphragm and bottom of left lung SEGMENTS: o Transverse fissure 4th rib midclavicular o Oblique fissure at 5th rib midaxillary o Lung border at 8th rib midaxillary o Pleural border at 10th rib midaxillary 14.6.1 THORACIC CONFIGURATION ABNORMALITIES: May be seen upon inspection of the chest wall and the significance of these findings. Barrel Chest: abnormal increase in AP diameter where the normal 45-degree angle between the spine and the intercostal becomes almost horizontal, associated with emphysema. Pectus Carinatum: Abnormal protrusion of the sternum. Pectus Excavatum: Depression of part or all of the sternum, which will produce a restrictive lung defect. Kyphosis: Abnormal AP convex curvature of the thoracic spine. Scoliosis: abnormal lateral curvature that can cause respiratory compromise. Lordosis: exaggerated forward curvature of the lumbar and cervical regions of the vertebrae. 14.6.2 CHARACTERISTICS AND CAUSES OF ABNORMAL BREATHING PATTERNS:. Common causes of an increase in the work of breathing include: 1. Lung diseases that cause loss of lung volume such as pulmonary fibrosis and atelectasis which cause the patient to take rapid, shallow breaths. 2. Lung diseases that cause intrathoracic airways to narrow such as with asthma or bronchitis and cause the patient to have a long expiratory breath. 3. Respiratory disorders that cause the upper airway to narrow such as with croup or epiglotitis and cause the patient to have a long inspiratory breath. 22. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 22 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 22 14.6.3 TECHNIQUES TO ACCESS LUNG PROBLEMS: A. TACTILE FREMITUS AND THE CAUSES OF INCREASED OR DECREASED FREMITUS (LOCAL AND DIFFUSE): Palpation is used to evaluate vocal fremitis (vibrations created by the vocal cords during speech), estimate thoracic expansion, and assess the skin and subcutaneous tissues of the chest. To assess for tactile fremitis, ask the patient to repeat the word "ninety nine" while you palpate the thorax. Increased fremitis is caused by any condition that increases the density of the lung as with consolidation that occurs in pneumonia. Fremitis is reduced or absent in patients who are obese, or overly muscular. Also, when the pleural space lining the lung becomes filled with air (pneumothorax) or fluid (Pleural effusion). Lastly, people with emphysema have bilateral reduction in fremitis due to reduction of the density of lung tissue. B. ASSESSING THORACIC EXPANSION: This palpation technique can be done either by placing hand anteriorly on the chest with the thumbs extended along the costal margin toward the xiphoid process or posteriorly by positioning your hands over the posterolateral chest with the thumbs meeting at the T8 vertebrae. Instruct patient to exhale a maximum breath while you extend your thumbs to meet at the midline. Next, instruct the patient to take a full, deep breath and note the distance the tip of each thumb moves from the midline. Each thumb should move an equal distance of 3-4 cm. C. ABNORMAL FINDING OF CREPITUS AND ITS SIGNIFICANCE UPON PALPATION OF THE SUBCUTANEOUS TISSUES: Crepitus is when air leaks from the lung into the subcutaneous tissue causing fine bubbles to produce a crackling sound and sensation when palpated. This condition is called subcutaneous emphysema. D. TECHNIQUE FOR PERCUSSION AND SOUNDS PRODUCED WHEN THE UNDERLYING TISSUES ARE AIR-FILLED, FLUID FILLED, OR SOLID: Percussion is the art of tapping on a surface to evaluate the underlying structure. Percussion of the chest wall produces a sound and a palpable vibration useful in evaluating underlying lung tissue. The technique most often used in per cussing the chest wall is called mediate, or indirect percussion. If you are right handed, place the middle finger of your left hand firmly against the chest wall parallel to the ribs, with the palm and other fingers held off the chest. Use the tip of the middle finger on your right hand or the lateral aspect of your right thumb to strike the finger against the chest near the base of the terminal phalanx with a quick, sharp blow. Movement of the hand striking the chest should be generated at the wrist, not at the elbow or shoulder Percussion over normal lung is described as normal resonance. If you percuss over an increased density the sound is said to be dull as with a fluid filled pleural space. Overinflated lungs have an increased (hyperinflation) resonance. Percussion over muscle, fat or bone is characterized as flat. 23. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 23 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 23 E. PULMONARY AND EXTRAPULMONARY ABNORMALITIES THAT ARE ASSOCIATED WITH THE THREE BASIC TYPES OF PERCUSSION NOTES: Normal resonance signifies normal lung. Increased resonance can be detected with hyperinflated lungs as with pneumothorax, emphysema or severe asthma. Decreased resonance is due to increased lung tissue density such as pneumonia, atelectasis, tumor or pleural effusion. F. FOUR PARTS OF THE STETHOSCOPE AND THE SITUATIONS IN WHICH IT IS BEST TO LISTEN WITH THE DIAPHRAGM AND WHEN IT IS BEST TO LISTEN WITH THE BELL: The stethoscope has 1. A bell 2. A diaphragm 3. Tubing and 4. Earpieces. It is best to listen with the diaphragm to the lungs because they have a higher frequency. The bell detects low- pitched heart sounds best. G. SOUNDS NORMALLY HEARD OVER THE CHEST: Vesicular breath sounds are the slight rustling of air and are considered normal. The exact mechanism is not known but is believed to be produced mostly during inspiration by turbulent flow in the upper airway. They are heard mostly on inspiration and over all areas of the chest distal to the central airways. Bronchial (very similar to tracheal) breath sounds are harsher and higher pitch with approximately equal inspiratory and expiratory components. The sound is heard over a major bronchus during normal breathing. H. "ADVENTITIOUS" BREATH SOUNDS: Normal breath sounds have been traditionally divided into four types: Vesicular, tracheal, bronchial and bronchovesicular. Adventious breath sounds are the NOT normal sounds heard in the lungs. They are continuous and discontinuous and are called wheezes, rhonchi, crackles etc. They are abnormal sounds superimposed on the normal lung sounds. Types of breath sounds a. Rhonchi low pitched, continuous b. Wheeze high pitched, continuous, proximal airways, often expiratory c. Crackle or rale discontinuous, distal airways (bases), often inspiratory d. Friction rub lower pitch, longer duration then crackles, both I and E e. Stridor Heard in the throat area, usually inspiratory if mild Vesicular breath Adventious breath 24. PHYSICAL THERAPY PRINCIPALS & METHODS PTP&M:013/3 Revision: 02 Page: 24 of 96 NPTE NOTICE: This specification, and the subject matter disclosed therein, embody proprietary information which is the confidential property of Mullsons Health & Wellness, which shall be copied, reproduced, disclosed to others, published, and could be used in whole or part, for any purpose, without the express advance written permission of a duly authorized agent of the Company. This specification is subject to recall by Mullsons Health & Wellness at any time. MEDICINE: ItS A NOBLE PROFESSION, IT SERVES HUMANITY 24 I. THE AIRWAY OR PARENCHYMAL ABNORMALITIES: Rhonchi are thought to result from airway narrowing that initially causes rapid airflow past the site of obstruction.