GALGOTIAS UNIVERSITY

DEPARTMENT OF PHYSIOTHERAPY

LAB MANUAL
EXERCISE THERAPY PRACTICAL
BPT- 2005

III Semester

PREPARED BY:
Dr. Neha Chauhan
Revised by Dr. Sakshi Arora and Dr. Pooja
Kukreti
 List of Practicals.
1. To study the types and uses Goniometer.
2. To study the procedure of joint mobilization for Upper limb.
3. To study the procedure of joint mobilization for Upper limb.
4. To study the application of Goniometer for spine.
5. To study the application of Goniometer for Lower limb.
6. To study the application of Goniometer for Lower limb.
7. To study the rules and grading system of Joint mobilization.
8. To study the procedure of applying Manual Lumbar Traction.
9. To study the procedure of applying Manual Cervical Traction
10. To study the procedure of muscle re-education.
11. To study the application of Frankel’s exercises.
12. To study the various components of Suspension therapy Apparatus.
13. To study the application of suspension bed for lower extremity.
14. To study the application of suspension bed for upper extremity.
 PRACTICAL 1

INTRODUCTION TO GONIOMETRY

Aim: To study the types and uses of goniometer.

The term goniometry is derived from two greek words, gonio, meaning angle, and metron,
meaning measure. Therefore, goniometry refers to the measurement of angles, in particular the
measurement of angles created by human joints.

Procedure: To measure the range of motion at a joint, the center of the goniometer is positioned
at the axis of rotation of a joint, and the arms of the goniometer are aligned with the long axis of
the bones of the adjacent segments.

A goniometer is usually made of plastic and is often transparent. Occasionally goniometers are
made of metal. There are two "arms" of the goniometer: the stationary arm and the moveable
arm. Each arm is positioned at specific points on the body and the center of the goniometer is
aligned at the joint to be measured.

TYPES OF GONIOMETER

1. Universal goniometry: These are most commonly used instrument. The body of a
universal goniometer resembles a protractor and may from full or half circle.
Measurement scales are located on the body (0-180 or 0-360). It consists of two arms
stationary or fixed arm and movable arm. Stationary cannot be moved. Movable arm is
attached to the fulcrum which is the center of the body and it can be moved. It contain a
black line extend the length of the arm formeasuring the angle.
2. Fluid inclinometer: It has fluid filled circular chamber containing an air bubble. It is
similar to a carpenter’s level, but being circular, has a 360 degree scale.
3. Pendulum goniometer: It consists of a 360 degree protractor with a weighted pointer
hanging from the center of the protractor.
4. Electro goniometers: These are used primarily in research to obtain dynamic joint
measurements. It is similar to that of universal goniometer.
 PRACTICAL 2

GONIOMETRY UPPER LIMB

Aim: To study the application of Goniometer for upper limb.

Shoulder joint range of motion

1. Flexion
Recommended testing position: Supine lying.
Normal ROM: 0-180º
Fulcrum: Greater Tubercle process.
Movable arm: Middle line of humerus.
Fixed arm: Mid axillary line of thorax.

2.Extension
Recommended testing position: Prone lying
Normal ROM: 0-500
Fulcrum: Greater Tubercle process
Movable arm: Lateral midline of the humerus.
Fixed arm: Midaxillary line of thorax
3.Abduction
Recommended testing position: Supine lying
Normal ROM: 0-180
Fulcrum: Acromial process
Movable arm: Medial midline of humerus
Fixed arm: Parallel to the midline of the anterior aspect of the sternum.

4.Adduction
Recommended testing position: Supine lying
Normal ROM: 180-0.
Fulcrum: Acromial process
Movable arm: Medial midline of humerus
Fixed arm: Parallel to the midline of the anterior aspect of the sternum
5.Medial rotation
Recommended testing position: Supine lying, with the arm placed at 90 of abduction
Normal ROM: 0-80
Fulcrum: Olecranon process
Movable arm: Parallel to ulna
Fixed arm: Parallel or perpendicular to the floor

6.Lateral rotation
Recommended testing position: Supine lying, with the arm placed at 90 of abduction
Normal ROM: 0-90
Fulcrum: Olecranon process
Movable arm: Parallel to ulna
Fixed arm: Parallel or perpendicular to the floor
ELBOW

1. Flexion

Recommended testing position: Supine lying

Normal ROM: 0-1450
Fulcrum: Lateral epicondyle of humerus
Movable arm: Lateral midline of the humerus
Fixed arm: Midline of the humerus
 Fixed arm: Midline of the humerus

2.Extension
Recommended testing position: Supine lying
Normal ROM: 1450-0
Fulcrum: Lateral epicondyle of humerus
Movable arm: Lateral midline of the humerus
Fixed arm: Midline of the humerus

FOREARM

1. Supination
Recommended testing position: Sitting with upper arm at the side of the
body, elbow flexed to 90 and forearm
supported.
Normal ROM: 0-80
Fulcrum: Lateral to the ulnar styloid process
Movable arm: Ventral aspect of the forearm, proximal to styloid process
Fixed arm: Anterior midline of humerus
2. Pronation
Recommended testing position: Sitting with upper arm at the side of the
body, elbow flexed to 90 and forearm
supported
Normal ROM: 0-80
Fulcrum: Lateral to the ulnar styloid process
Movable arm: Dorsal aspect of the forearm, proximal to styloid process ofradius
Fixed arm: Anterior midline of humerus
WRIST

1. Flexion
Recommended testing position: Sitting next to a supporting
surface and hand facing the
ground.
Normal ROM: 0-80
Fulcrum: Lateral aspect of the wrist over the triquetrum
Movable arm: Lateral midline of the fifth metacarpal
Fixed arm: Lateral midline of the ulna

2. Extension
Recommended testing position: Sitting next to a supporting surface and hand
facing the ground.
Normal ROM: 0-70
Fulcrum: At the level of capitate
Movable arm: Volar midline of the third metacarpal
Fixed arm: Volar midline of the forearm
3. Radial deviation
Recommended testing position: Sitting next to a supporting surface and hand
facing the ground.
Normal ROM: 0-20
Fulcrum: At the level of capitate
Movable arm: Dorsal midline of the third metacarpal
Fixed arm: Dorsal midline of the humerus
 2. Ulnar deviation:
Recommended testing position: Sitting next to a supporting surface and hand
facing the ground.
Normal ROM: 0-30
Fulcrum: At the level of capitate
Movable arm: Dorsal midline of the third metacarpal Fixed arm: Dorsal midline of the humerus

MCP Joint
1.Flexion

Recommended testing position: Sitting next to a supporting surface and hand

facing the ground.
Normal ROM: 0-90
Fulcrum: Midline of posterior aspect of MCP joint
Movable arm: Mideline of posterior aspect of
metacarpal
Fixed arm: Mideline of posterior aspect of wrist
and forearm
 2.Extension

Recommended testing position: Sitting next to a supporting surface and hand

facing the ground.
Normal ROM: 0-20
Fulcrum: Midline of anterior aspect of MCP joint
Movable arm: Mideline of anterior aspect of
metacarpal and phalanx
Fixed arm: Mideline of anterior aspect of wrist
and forearm
 4.Adduction and Abduction.
Recommended testing position: Sitting next to a supporting surface and hand
facing the ground.
Normal ROM: Abduction - 0-20 & Adduction - 0
Fulcrum: Midline of posterior aspect of MCP joint
Movable arm: Mideline of posterior aspect of
metacarpal
Fixed arm: Mideline of posterior aspect of wrist and
forearm
 PRACTICAL 3

GONIOMETRY FOR SPINE

Aim: To study the application of Goniometer for spine.

Cervical spine forward bending (flexion)

Test Position
 Subject sitting with lumbar and
thoracic spines supported
 Stabilize lumbar and thoracic spines
 Flex cervical spine

 Goniometer Alignment
 Axis – external auditory meatus
 Stationary arm – vertical
 Moving arm – aligned with nostrils

Cervical spine backward bending (extension)

Test Position

 Subject sitting with lumbar and

Thoracic spines supported
 Stabilize lumbar and thoracic spines
 Mouth relaxed and slightly open
 Extend cervical spine

Goniometer Alignment
 Axis – external auditory meatus
 Stationary arm – vertical
 Moving arm – aligned with nostrils.

CERVICAL SPINE SIDEBENDING (lateral flexion)

 Test Position
 Subject sitting with lumbar and
Thoracic spines supported
 Stabilize lumbar and thoracic spines
 Side bend cervical spine

 Goniometer Alignment
 Axis – spinous process of C7
 Stationary arm – spinous processes of thoracic spine
 Moving arm – posterior midline of head at occipital protuberance

CERVICAL SPINE ROTATION

 Test Position
 Subject sitting with lumbar and thoracic
spines supported
 Stabilize lumbar and thoracic spines
 Rotate cervical spine

Goniometer Alignment
 Axis – center of superior aspect of head
 Stationary arm – aligned with acromion processes
 Moving arm – aligned with tip of nose

THORACO-LUMBAR SPINE FORWARD BENDING (flexion)

Test Position
 Subject standing
 Flex thoracic and lumbar spines

Tape Measure Alignment

 Spinous processes of C7 and S1

THORACO-LUMBAR SPINE BACKWARD BENDING (extenion)

 Test Position
 Subject standing
 Extend thoracic and lumbar spines

Tape Measure Alignment

 Spinous processes of C7 and S1
 PRACTICAL 4

GONIOMETRY LOWER LIMB

Aim: To study the application of Goniometer for lower limb.

HIP JOINT

1. Flexion
Recommended testing position: -Supine lying
Normal ROM: -0-120
Fulcrum: - Lateral aspect of the hip joint
Movable arm: - Lateral midline of the femur
Fixed arm: - Lateral midline of the pelvis

2. Extension
Recommended testing position: - prone lying
Normal ROM: -0-30
Fulcrum: - Lateral aspect of the hip joint
Movable arm: - Lateral midline of the femur
Fixed arm: - Lateral midline of the pelvis
3. Abduction
Recommended testing position: -Supine lying
Normal ROM: -0-45
Fulcrum: -Anterior superior iliac spine(ASIS) of the
extremity being measured
Movable arm: -Anterior midline of the femur
Fixed arm: -Horizontal line extending from one ASIS to
other ASIS.

4. Adduction
Recommended testing position: -Supine lying
Normal ROM: -0-30
Fulcrum: -Anterior superior iliac spine(ASIS) of the
extremity being measured
Movable arm: -Anterior midline of the femur
Fixed arm: -Horizontal line extending from one ASIS to
other ASIS.

5. Medial rotation and Lateral rotation

Recommended testing position: -Sitting on a supporting surface
Normal ROM: -0-45
Fulcrum: -Anterior of the patella
Movable arm: -Anterior midline of lower leg
Fixed arm: -Parallel to leg
KNEE JOINT

1. Flexion

Recommended testing position: -Prone lying

Normal ROM: -0-135
Fulcrum: -Lateral epicondyle of the femur
Movable arm: -Lateral midline of the femur
Fixed arm: -Lateral midline of the fibula

2. Extension

Recommended testing position: -Prone lying

Normal ROM: -135-0
Fulcrum: -Lateral epicondyle of the femur
Movable arm: -Lateral midline of the femur
 Fixed arm: -Lateral midline of the fibula

ANKLE JOINT

1. Dorsi flexion
Recommended testing position: -Sitting or supine
Normal ROM: -0-20
Fulcrum: -Lateral aspect of lateral malleolus
Movable arm: -Lateral aspect of fifth metatarsal
Fixed arm: -Lateral midline of the fibula

2. Plantar flexion
Recommended testing position: -Sitting or supine
Normal ROM: -0-50
Fulcrum: -Lateral aspect of lateral malleolus
Movable arm: -Lateral aspect of fifth metatarsal
Fixed arm: -Lateral midline of the fibula
3. Inversion
Recommended testing position: -Sitting with knee flexed to 90 and the lower
Legover the edge of supporting surface
Normal ROM: -0-35
Fulcrum: -Anterior aspect of the ankle midway
between the malleoli
Movable arm: -Anterior midline of the second metatarsal
Fixed arm: -Anterior midline of the lower leg

4. Eversion
Recommended testing position: -Sitting with knee flexed to 90 and the lower
Leg over the edge of supporting surface
Normal ROM: -0-15
Fulcrum: -Anterior aspect of the ankle midway
between the malleoli
Movable arm: -Anterior midline of the second metatarsal
Fixed arm: -Anterior midline of the lower leg
 PRACTICAL-5

JOINT MOBILISATION-INTRODUCTION

AIM: To study the Rules and Grading system of Joint mobilization.

 Passive skilled manual therapy techniques applied to joint & related soft tissue at varying
speeds & amplitudes using physiologic or accessory motion for therapeutic purpose.
 Indications :
i) Pain, spasm & muscle guarding
ii) Reversible joint hypomobility
iii) Positional faults
iv) Functional immobility
v) Progressive limitation
 Contraindication & precaution :
i) Hypermobility
ii) Joint effusion
iii) Inflammation
 Procedure :
 Examination
 Evaluation
 Grade or dosage of movement
o Gr I: small amplitude rhythmic oscillation performed at beginning of ROM
o Gr II: large amplitude rhythmic oscillation performed within range, not reaching
limit.
o Gr III: large amplitude rhythmic oscillation performed up to the limit of available
motion.
o Gr IV: small amplitude rhythmic oscillation performed at the limit of available
motion.
o Gr V: small amplitude, high velocity thrust to snap adhesions at limit of available
motion.
 PRACTICAL -6
JOINT MOBILIZATION UPPER EXTREMITY

Aim: To study the procedure of joint mobilization for Upper limb.

GLENOHUMERAL JOINT

Resting position : Shoulder is abducted 55o , horizontally adducted 30o and externally rotated so
that the forearm is in horizontal plane.

Treatment plane : In the glenoid fossa and moves with the scapula.

Stabilization : Fixate the scapula with a belt or have an assistant.

Glenohumeral Joint Traction / Distraction

 Subject Position : Supine, with arm in the resting position. Support the forearm between
your trunk and elbow.
 Hand Placement : Use the hand nearer the part being treated and place it in the subject’s
axilla with your thumb just distal to the joint margin anteriorly and fingers posteriorly. Your
other hand supports the humerus from the lateral surface.
 Mobilizing Force : With the hand in the axilla, move the humerus laterally.

Glenohumeral Caudal Glide

 Subject Position : Supine, with arm in the resting position. Support the forearm between
your trunk and elbow.
 Hand Placement : Place one hand in the subject’s axilla to provide a grade I distractqion.
The web space of your other hand is placed just distal to the acromion process.
 Mobilizing Force : With the superiorly placed hand, glide the humerus in an inferior
direction.
Glenohumeral Posterior Glide

 Subject Position : Supine, with the arm in resting position.

 Therapist Position and Hand Placement : Stand with your back to the subject, between
the subject’s trunk and arm. Support the arm against your trunk, grasping the distal
humerus with your lateral hand. This position provides grade I distraction to the joint. Place
the lateral border of your top hand just distal to the anterior margin of the joint, with your
fingers pointing superiorly. This hand gives the mobilizing force.
 Mobilizing Force : Glide the humeral head posteriorly by moving the entire arm as you
bend your knees.

Glenohumeral Anterior Glide

 Subject Position : Supine, with the arm in resting position over the edge of treatment table.
 Therapist Position and Hand Placement : Stand facing the top of the table with the leg
closer to the table in a forward stride position. Support the subject’s arm against your thigh
with your outside hand; the arm positioned on your thigh provides a grade I distraction.
Place the ulnar border of your other hand just distal to the posterior angle of the acromion
process, with your fingers pointing superiorly; this hand gives the mobilizing force.
  Mobilizing Force : Glide the humeral head in an anterior and slightly medial direction.
Bend both knees so the entire arm moves anteriorly.

ELBOW AND FOREARM COMPLEX

HUMEROULNAR JOINT

Resting Position: Elbow is flexed 70o, and forearm is supinated 10o.

Treatment Plane: The treatment plane is in the olecranon fossa, angled approximately 45 o from
the long axis of the ulna

Stabilization: Fixate the humerus against the treatment table with a belt or use an assistant to
hold it. The subject may roll onto his or her side and fixate the humerus with the contralateral
hand if muscle relaxation can be maintained around the elbow joint being mobilized.
Humeroulnar Distraction
 Subject Position : Supine, with the elbow over the edge of the treatment table or supported
with padding just proximal to the olecranon process. Rest the subject’s wrist against your
shoulder, allowing the elbow to be in resting position for the initial treatment.
 Hand Placement : Place the fingers of your medial hand over the proximal ulna on the volar
surface; reinforce it with your other hand.
 Mobilizing Force : Force against the proximal ulna at a 45 o angle to the shaft of the bone.
Humeroulnar Distal Glide
 Subject Position: Supine, with the elbow over the edge of the treatment table. Begin with
the elbow in resting position. Progress by positioning it at the end range of flexion.
 Hand placement: Place the fingers of your medial hand over the proximal ulna on the volar
surface; reinforce it with your other hand.
 Mobilizing Force: First apply a distraction force to the joint at a 45 o angle to the ulna, then
while maintaining the distraction, direct the force in a distal direction.

Humeroulnar Radial Glide

 Subject Position: Side-lying on the arm to be mobilized, with the shoulder laterally rotated
and the humerus supported on the table. Begin with the elbow in resting position; progress
to end-range flexion.
 Hand Placement: Place the base of your proximal hand just distal to the elbow; support the
distal forearm with your other hand.
 Mobilizing Force: Force against the ulna in a radial direction.
Humeroulnar Ulnar Glide
 Subject Position : Same as for radial glide except a block or wedge is placed under the
proximal forearm for stabilization (using distal stabilization). Initially, the elbow is placed in
resting position and is progressed to end-range extension.
 Mobilizing Force : Force against the distal humerus in a radial direction, causing the ulna to
glide ulnarly.

HUMERORADIAL JOINT

Resting Position : Elbow is extended, and forearm is supinated to the end of the available range.

Treatment Plane : The treatment plane is in the concave radial head perpendicular
to the long axis of the radius.

Stabilization : Fixate the humerus with one of your hands.

Humeroradial Distraction
 Subject Position : Supine or sitting, with the arm resting on the treatment table.
 Therapist Position and Hand Placement : Position yourself on the ulnar side of the
subject’s forearm so you are between the subject’s hip and upper extremity. Stabilize the
subject’s humerus with your superior hand. Grasp around the distal radius with the fingers
and thenar eminence of your inferior hand. Be sure your are not grasping around the distal
ulna.
 Mobilizing Force : Pull the radius distally (long-axis traction causes joint traction).

Humeroradial Dorsal / Volar Glides

 Subject Position : Supine or sitting with the elbow extended and supinated to the end of the
available range.
 Hand Placement : Stabilize the humerus with your hand that is on the medial side of the
subject’s arm. Place the palmar surface of your lateral hand on the volar aspect and your
fingers on the dorsal aspect of the radial head.
 Mobilizing Force : Move the radial head dorsally with the palm of your hand or volarly with
your fingers.

Humeroradial Compression
 Subject Position : Sitting or supine.
 Hand Placement : Approach the subject right hand to right hand, or left hand to left hand.
Place your thenar eminence against the subject’s thenar eminence (locking thumbs).
 Mobilizing Force : Simultaneously, extend the subject’s wrist, push against the thenar
eminence, and compress the long axis of the radius while supinating the forearm.
PROXIMAL RADIOULNAR JOINT

Resting Position : The elbow is flexed 70o and the forearm supinated 35o.

Treatment Plane : The treatment plane is in the radial notch of the ulna, parallel to the long axis
of the ulna.

Stabilization : Proximal ulna.

Dorsal/Volar Glides
 Subject Position : Sitting or supine, with the elbow and forearm in resting position. Progress
by placing the forearm at the limit of the range of pronation prior to administering the dorsal
glide or at the limit of the range of supination prior to administering the volar glide.
 Hand Placement : Fixate the ulna with your medial hand around the medial aspect of the
forearm. Place your other hand around the head of the radius with the fingers on the volar
surface and the palm on the dorsal surface.
 Mobilizing Force : Force the radial head volarly by pushing with your palm or dorsally by
pulling with your fingers.
DISTAL RADIOULNAR JOINT

Resting Position : The resting position is with the forearm supinated 10 o.

Treatment Plane : The treatment plane is the articulating surface of the radius, parallel to the
long axis of the radius.

Stabilization : Distal ulna.

Dorsal/Volar Glides
 Subject Position : Sitting, with the forearm on the treatment table. Begin in the resting
position and progress to end-range pronation or supination.
 Hand Placement : Stabilize the distal ulna by placing the fingers of one hand on the dorsal
surface and the thenar eminence and thumb on the volar surface. Place your other hand in the
same manner around the distal radius.
 Mobilizing Force : Glide the distal radius dorsally or volarly parallel to the ulna.
WRIST COMPLEX

RADIOCARPAL JOINT

Resting Position : The resting position is a straight line through the radius and third metacarpal
with slight ulnar deviation.

Treatment Plane : The treatment plane is in the articulating surface of the

radius perpendicular to the long axis of the radius.

Stabilization : Distal radius and ulna.

Radiocarpal Distraction
 Subject Position : Sitting, with the forearm supported on the treatment table, wrist over the
edge of the table.
 Hand Placement : With the hand closest to the subject, grasp around the styloid processes and
fixate the radius and ulna against the table. Grasp around the distal row of carpals with your
other hand.
 Mobilizing Force : Pull in a distal direction with respect to the arm.

Radiocarpal Joint General Glides

Dorsal glide to increase flexion ; volar glide to increase extension ; radial glide to increase ulnar
deviation; ulnar glide to increase radial deviation.
 Subject Position and Hand Placement : Sitting with forearm resting on the table in pronation
for the dorsal and volar techniques and in mid-range position for the radial and ulnar
techniques.
 Mobilizing Force : The mobilizing force comes from the hand around the distal row of
carpals.
 Progression : Progress by moving the wrist to the end of the available range and glide in the
defined direction. Specific carpal gliding techniques described in the next sections are used
to increase mobility at isolated articulations.

Dorsal glide

Volar glide
Ulnar glide
 PRACTICAL-7

JOINT MOBILIZATION LOWER EXTREMITY

Aim: To study the procedure of joint mobilization for lower limb.

HIP JOINT

Resting Position : The resting position is hip flexion 30o, abduction 30o, and slight external
rotation.

Stabilization : Fixate the pelvis to the treatment table with belts.

Hip Distraction of the Weight-Bearing Surface –

Caudal Glide
 Subject Position : Supine, with the hip in resting position and the knee extended.
 Therapist Position and Hand Placement : Stand at the end of the treatment table; place a belt
around your trunk, then cross the belt over the subject’s foot and around the ankle. Place your
hands proximal to the malleoli, under the belt. The belt allows you to use your body weight
to apply the mobilizing force.
 Mobilizing Force : Long-axis traction is applied by pulling on the leg as you lean backward.

Hip Posterior Glide

 Subject Position : Supine, with hips at the end of the table. The subject helps stabilize the
pelvis and lumbar spine by flexing the opposite hip and holding the thigh against the chest
 with the hands. Initially, the hip to be mobilized is in resting position; progress to the end of
the range.
 Therapist Position and Hand Placement : Stand on the medial side of the subject’s thigh.
Place a belt around your shoulder and under the subject’s thigh to help hold the weight of
the lower extremity. Place your distal hand under the belt and distal thigh. Place your
proximal hand on the anterior surface of the proximal thigh.
 Mobilizing Force : Keep your elbows extended and flex your knees; apply the force through
your proximal hand in a posterior direction.

Hip Anterior Glide

 Subject Position : Prone, with the trunk resting on the table and hips over the edge. The
opposite foot is on the floor.
 Therapist Position and Hand Placement : Stand on the medial side of the subject’s thigh.
Place a belt around your shoulder and the subject’s thigh to help support the weight of the
leg. With your distal hand, hold the subject’s leg. Place your proximal hand posteriorly on
the proximal thigh just below the buttock.
 Mobilizing Force : Keep your elbow extended and flex your knees; apply the force through
proximal hand in an anterior direction.

THE KNEE AND LEG

Resting Position : The resting position is 25o flexion.

Treatment Plane : The treatment plane is along the surface of the tibial plateaus; therefore, it
moves with the tibia as the knee angle changes.
Stabilization : The femur is stabilized with a belt or by the table.

TIBIOFEMORAL JOINT

Tibiofemoral Distraction, Long-Axis Traction

 Subject Position : Sitting, supine, or prone, beginning with the knee in the resting position.
 Hand Placement : Grasp around the distal leg, proximal to the malleoli with both hands.
 Mobilizing Force : Pull on the long axis of the tibia to separate the joint surfaces.

Tibiofemoral Distraction (sitting position)

 Tibiofemoral Distraction - above : supine lying
below : prone lying

Tibiofemoral Posterior Glide

 Subject Position : Supine, with the foot resting on the table. The position for the drawer test
can be used to mobilize the tibia either anteriorly or posteriorly, although no grade I
distraction can be applied with the glides.
 Therapist Position and Hand Placement : Sit on the table with your thigh fixating the
subject’s foot. With both hands, grasp around the tibia, fingers pointing posteriorly and
thumbs anteriorly.
 Mobilizing Force : Extend your elbows and lean your body weight forward; push the tibia
posteriorly with your thumbs.

Tibiofemoral Anterior Glide

 Subject Position : Prone, beginning with the knee in resting position; progress to the end of
the available range. The tibia may also be positioned in lateral rotation. Place a small pad
under the distal femur to prevent patellar compression.
 Hand Placement : Grasp the distal tibia with the hand that is closer to it and place the palm of
the proximal hand on the posterior aspect of the proximal tibia.
 Mobilizing Force : Force with the hand on the proximal tibia in an anterior direction. The
force may be directed to the lateral or medial tibial plateau to isolate one side of the joint.

PATELLOFEMORAL JOINT

Distal Glide
 Subject Position : Supine, with knee extended; progress to positioning the knee at the end of
the available range in flexion.
 Hand Placement : Stand next to the subject’s thigh, facing the subject’s feet. Place the web
space of the hand that is closer to the thigh around the superior border of the patella. Use the
other hand for reinforcement.
 Mobilizing Force : Glide the patella in a caudal direction, parallel to the femur.

Medial-Lateral Glide
 Subject Position : Supine with the knee extended. Side-lying may be used to apply a medial
glide.
 Hand Placement : Place the heel of your hand along either the medial or lateral aspect of the
patella. Stand on the opposite side of the table to position your hand along the medial border
and on the same side of the table to position your hand along the lateral border. Place the
other hand under the femur to stabilize it.
 Mobilizing Force : Glide the patella in a medial or lateral direction, against the restriction.

Lateral glide

TIBIOFIBULAR JOINT

Proximal Tibiofibular Articulation : Anterior (Ventral) Glide

 Subject Position : Side-lying, with the trunk and hips rotated partially toward prone. The top
leg is flexed forward so the knee and lower leg are resting on the table or supported on a
pillow.
 Therapist Position and Hand Placement : Stand behind the subject, placing one of your hands
under the tibia to stabilize it. Place the base of your other hand posterior to the head of the
fibula, wrapping your fingers anteriorly.
 Mobilizing Force : The force comes from the heel of your hand against the posterior aspect
of the fibular head, in an anterior-lateral direction.
Distal Tibiofibular Articulation : Anterior (Ventral) or Posterior (Dorsal) Glide
 Subject Position : Supine or prone.
 Hand Placement : Working from the end of the table, place the fingers of the more medial
hand under the tibia and the thumb over the tibia to stabilize it. Place the base of your other
hand over the lateral malleolus, with the fingers underneath.
 Mobilizing Force : Press against the fibula in an anterior direction when prone and in a
posterior direction when supine.

ANKLE JOINT

TALOCRURAL JOINT

Resting position : 10o plantarflexion.

Treatment Plane : In the mortise, in an anterior- posterior direction with respect to the leg.
Stabilization : The tibia is strapped or held against the table.

Talocrural Distraction
 Subject Position : Supine, with the lower extremity extended. Begin with the ankle in resting
position. Progress to the end of the available range of dorsiflexion or plantarflexion.
 Therapist Position and Hand Placement : Stand at the end of the table; wrap the fingers of
both hands over the dorsum of the subject’s foot, just distal to the mortise. Place your thumbs
on the plantar surface of the foot to hold it in resting position.
 Mobilization Force : Pull the foot away from the long axis of the leg in a distal direction by
leaning backward.

Talocrural Dorsal (Posterior) Glide

 Subject Position : Supine, with the leg supported on the table and the heel over the edge.
 Therapist Position and Hand Placement : Stand to the side of the subject. Stabilize the leg
with your cranial hand or use a belt to secure the leg to the table. Place the palmar aspect of
the web space of your other hand over the talus just distal to the mortise. Wrap your fingers
and thumb around the foot to maintain the ankle in resting position. Grade I distraction force
is applied in a caudal direction.
 Mobilizing Force : Glide the talus posteriorly with respect to the tibia by pushing against the
talus.
Talocrural Ventral (Anterior) Glide
 Subject Position : Prone, with the foot over the edge of the table.
 Therapist Position and Hand Placement : Working from the end of the table, place your
lateral hand across the dorsum of the foot to apply a grade I distraction. Place the web space
of your other hand just distal to the mortise on the posterior aspect of the talus and calcaneus.
 Mobilizing Force : Push against the calcaneus in an anterior direction (with respect to the
tibia); this glides the talus anteriorly.

SUBTALAR JOINT

Resting Position : The resting position is midway between inversion and eversion.

Treatment Plane : In the talus, parallel to the sole of the foot.

Subtalar Distraction
 Subject and Therapist Position : The subject is placed in a supine position, with the leg
supported on the table and heel over the edge. The hip is externally rotated so the talocrural
joint can be stabilized in dorsiflexion with pressure from your thigh against the plantar
surface of the subject’s forefoot.
 Hand Placement : The distal hand grasps around the calcaneus from the posterior aspect of
the foot. The other hand fixes the talus and malleoli against the table.
 Mobilizing Force : Pull the calcaneus distally with respect to the long axis of the leg.
Subtalar Medial Glide or Lateral Glide
Medial glide to increase eversion; lateral glide to increase inversion.
 Subject Position : Side-lying or prone, with the leg supported on the table or with a towel
roll.
 Therapist Position and Hand Placement : Align your shoulder and arm parallel to the bottom
of the foot. Stabilize the talus with your proximal hand. Place the base of the distal hand on
the side of the calcaneus medially to cause a lateral glide and laterally to cause a medial
glide. Wrap the fingers around the plantar surface.
 Mobilizing Force : Apply a grade I distraction force in a caudal direction, then push with the
base of your hand against the side of the calcaneus parallel to the planter surface of the heel.

Lateral glide (prone lying position)

Lateral glide (side lying position)
 PRACTICAL -8

MANUAL LUMBAR TRACTION

Aim: To study the procedure of applying Manual Lumbar Traction

Traction is the application of a mechanical force to the body in a way that separates or attempts
to separate the joint surfaces and elongate the surrounding soft tissues

Traction can be applied manually by the clinician or mechanically by a machine. Traction can
also be applied by the patient using body weight and the force of gravity to exert a force.
Traction can be applied to the spinal or peripheral joints.

Spinal traction can distract joint surfaces, reduce protrusions of nuclear discal material, stretch
soft tissue, relax muscles, and mobilize joints. Low-force traction of 10 to 20lb, applied for a
long duration, ranging from hours to a few days, can also be used to temporarily immobilize a
patient. All of these effects may reduce the pain associated with spinal dysfunction. The
stimulation of sensory mechanoreceptors that occurs with the application of traction may also
gate the transmission of pain along afferent neural pain pathways.

EFFECTS of Spinal Traction

 Joint Distraction
 Reduction of Disc Protrusion
 Soft tissue Stretching
 Muscle Relaxation
 Joint Mobilization
 Patient Immobilization

INDICATIONS for the use of Spinal Traction

 Disc bulge or Herniation

 Nerve root impingement
 Joint hypomobility
 Subacute Joint Inflammation
 Paraspinal Muscle spasm

CONTRAINDICATIONS for the use of Spinal Traction

 Where motion is contraindicated

 With an acute iniury or inflammation
 Joint hypermobility or instability
  Peripheralization of symptoms with traction
 Uncontrolled hypertension.

Precautions include:

 Structural diseases or conditions affecting the spine( e.g.. tumor, infection. Rheumatoid
arthritis, osteoporosis or prolonged systemic steroid use)

 When pressure of the belts may be hazardous (e.g. with pregnancy, hiatal hernia vascular
compromise, osteoporosis)

 Displacement of annular fragment

 Medial disc protrusion

 Severe pain fully relieved by traction

 Claustrophobia

 Patients who can’t tolerate prone or supine position

 Disorientation

 Temporomandibular joint (TM) problems

 Denture

APPLICATION TECHNIQUES

 Traction can be applied in a variety of ways. Treatment with traction at this time includes
the use of electric and weighted mechanical devices, self traction, positional traction. and
manual traction

 Manual Traction

 Manual traction is the application of force by the therapist in the direction of distracting
the joints. It can be used for the cervical and lumbar spine as well as for the peripheral
joints

MANUAL LUMBAR TRACTION

1. Position the patient in the position of least pain. This is usually supine, with the hips and
knees flexed.
 2. Position yourself. Kneel at the patient's feet, facing the patient.

3. Place your hands in the appropriate position, behind the patient's proximal legs, over the
muscle belly of the triceps surae.

4. Apply traction force to the patient's spine by leaning your body back and away from the
patient, keeping your spine in a neutral position.

Adjust the force of the traction according to the desired outcome and the patient's report. Manual
traction to the cervical spine may be static, of constant force, or intermittent of varying force.
 PRACTICAL -9

MANUAL CERVICAL TRACTION

Aim: To study the procedure of applying Manual Cervical Traction

PATIENT SUPINE

1. Position the patient supine.

2. Position yourself. Stand at the head of the patient, facing the patient

3. Place your hands in the appropriate position. Supinate your forearms so your hands are
faced up; place the lateral border of your second finger in contact with the patient's
occiput and your thumbs behind the patient's ears.

4. Apply traction. Apply force through the occiput by leaning back, keeping your spine in a
neutral position

PATIENT SITTING

1. Position the patient in the sitting position

2. Stand behind the patient.

3. Place your hands in the appropriate position. With your arms in a neutral position, place
your thumbs under the patient's occiput and the rest of your hands along the side of the
patient's face.

4. Apply traction. Apply traction through the patient's occiput by lifting up.
Adjust the force of the traction according to the desired outcome and the patient's report. Manual
traction to the cervical spine may be static, of constant force, or intermittent of varying force.

ADVANTAGES

 No equipment required.

 Short setup time

 Force can be finely graded.

 Clinicians present throughout treatment to monitor and asses the patient's response.

 Can be applied briefly, prior to setting up mechanical traction, to help determine if longer
application of traction will be beneficial.

 Can be used with patients who do not tolerate being placed in halters or belts.

DISADVANTAGES

 Limited maximum traction force, probably not sufficient to distract the lumbar facet
joints

 Amount of traction force cannot be easily replicated or specifically recorded.

 Cannot be applied for a prolonged period of time.

Requires a skilled clinician to apply

 PRACTICAL-10

MUSCLE RE-EDUCATION INTRODUCTION

Aim: To study the procedure of muscle reeducation.

In flaccid paralysis

1. The affected muscles must be protected over stretching by adequate support and splintage.
2. The circulation of area must be maintained to ensure adequate nutrition to the paralyzed
muscles by active exercise for other normal muscles in the area, contrast baths etc.
3. The range of movement in joints immobilized by the paralysis and extensibility of the affected
muscles must be maintained by passive movements.
4. Remembrance of pattern of movement must be stimulated and kept alive by passive
movement while active movement is impossible.
5. The strength and use of normal muscles in the area must be maintained by resisted exercise.

In spastic paralysis: It can be treated by proprioceptive neuromuscular facilitation

techniques, controlled sustained passive stretching, active or passive mobilization
may be preceded by massage or packing with ice.

THE INITIATION OF MUSCULAR CONTRACTION

Measures used to obtain initiation of contraction

1. Warmth. The area affected must be warm, as moderate warmth improves the quality of
the contraction. Any method designed to improve the circulation in the area is effective;
active exercise of unaffected muscles against strong resistance is the method of choice.
2. Stabilization. Stabilization of the bones of origin of the affected muscles and of joints
distal to those over which these muscles work, improves their efficiency.
3. Grip or Manual contact. The physiotherapist’s hand give pressure only in the direction
of the movement, to direct the patient’s effort and give sensory stimulation.
4. Stretch. Stimulation of the muscle spindles elicits reflex contraction of that muscle
provided the reflex arc is intact.
5. Irradiation. The use of resistance to functional movements of the opposite limbs which
normally produces fixator action or the other side can assist initiation of contraction in
the affected muscle.
STRENGTHENING METHODS

The art of training muscles lies in creating the conditions under which they are called upon to
work to full capacity against an ever-increasing resistance.

TREATMENT TO INCREASE MUSCULAR STRENGTH AND FUNCTION

Principles:

1. The affected muscle must be strengthened Progressively by resisted exercise , which are
specific for the group to which the muscles belong.
a) Range
b) Type of muscle work
c) Resistance
d) Speed
e) Duration
2. Full Function of the affected muscles as members of the Teams of Muscles which work
to produce skilled and co-ordinated movements, must be restored by free Activities,
Naturally and Skilled Movements.

TYPES OF EXERCISE USED TO STRENGTHEN MUSCLES AND RESTORE

FUNCTION

Assisted-resisted exercises: these are rarely used to strengthen muscles except in cases of
marked weakness.

Free exercises: free exercises are valuable as they can be practiced at regular and frequent
intervals and at home.

Resisted exercises: these exercises create the tension in muscles essential for increase in power
and hypertrophy.

Muscles Around Ankle Joint

Relaxed passive movements

Half lying with the patient’s knee bent over a firm pillow or across a

physiotherapist’s knee, leaving the heel unsupported. The physiotherapist places

one hand above the joint and other hand round the foot.
Assisted exercises for the foot

Manual assistance can be given using the same grasp as passive movements.

Self assistance given by means of a rope and pulley.

Free exercises

-Non-weight bearing exercises for ankle joint

1. Legs crossed sitting; foot dorsiflexion and plantarflexion.

1. Inclined long sitting; alternate foot dorsiflexion and plantarflexion.

2. Sitting; alternate heel and toe raising.

Leg cross sitting Inclined long sitting Sitting

Muscle Around Knee Joint

Relaxed passive movements

1. Hip and knee flexion and extension: patient in lying position, the physiotherapist

gives support under the thigh with one hand and other hand grasps

round the ankle. The hip and knee are then moved into flexion and extension.

Assisted and assisted-resisted exercises for knee joint

1. Knee flexion and extension: Manual assistance may be given for the

flexors or extensors of the knee from side lying with the limb supported

in the hands or on the surface of the plinth.

Free exercises for the knee joint

Non-weight bearing exercises

1. Lying; one hip and flexion and extension.

2. Side lying; one hip and knee flexion and extension.

3. Prone lying; alternate knee flexion and extension.

Partial weight bearing exercises

1. Bicycling on free or stationary bicycle.

2. Rowing on rowing machine.

3. Long sitting; receive and pass ball.

Weight bearing exercises

1. Crouch position; alternate leg stretching, with or without spring.

2. Prone kneeling; sit back on heels.

High sitting Bicycling

Prone lying.
Muscle Around Hip Joint
Relaxed passive movements
1. Hip abduction and adduction, medial and lateral rotation, flexion and extension: the leg which
is not to be moved is fully abducted and fixed, either by a sandbag or by bending the knee over
the side of the plinth, and the patient relaxes. With the forearm supinated, one of the
physiotherapist hands supports under the thigh, and with the other pronated she supports the
lower leg at the ankle joint. Traction is given and the leg is moved into abduction and adduction.
Medial and lateral rotation can be performed by giving traction on the heel and rolling the knee
inwards and outwards with a stroking movement.
Assisted exercises for hip joint
As the limb to be moved is heavy, suspension and the use of roller skates are valuable means of
assistance.

Free exercises
Non weight bearing exercises:
1. Grasp high half standing; leg swinging forwards and backwards.
2. Prone lying; leg medial and lateral rotation.
Partial weight bearing exercises
1. Heave grasp high half standing; arm stretching and one knee bending.
2. Crouch position; step or spring to stride prone falling.
Weight bearing exercises
1. Half kneeling; or step standing; forward pressing.
2. Stride standing; pelvis and trunk rotation.
 PRACTICAL- 11

Aim: To study the application of Frenkel's exercises.

FRENKEL’S EXERCISES

 Set of systematic & graduated exercise developed by Dr. H.S. Frenkel for treatment of inco-
ordination.
 It is an alternative method of control that aims to establish voluntary control of movement,
consists of :
i. concentration of attention
ii. precision
iii. repetition

Technique
1. Patient is positioned comfortably & suitably clothed so that he/she is able to see limbs
throughout the movement.
2. A concise explanation & demonstration is given before movement is attempted to give the
patient a clear mental picture.
3. Patient should give full attention to performance of exercise to make movement smooth &
accurate.
4. The speed of movement is dictated by physiotherapist by means of rhythmic counting,
movement of hand or use of suitable music.
5. Range of movement is indicated by marking the spot on which the foot or hand is to be
placed.
6. Exercise should be repeated many times till it is perfect & easy. Frequent rest periods must
be allowed as these exercises are tiring at first.
7. Progression is made alteration in speed, range & complexity of exercise initially. Later on,
alteration in speed of consecutive movements & interruptions involving stopping & starting
to command may be added.

Progression
 Progression is made by altering the speed, range and complexity of the exercise.
 Fairly quick movements require less control than slow ones. Later, alteration in the speed of
consecutive movements and interruptions which involve stopping and starting to command,
are introduced.
 According to the degree of disability, re-education exercises start in lying with the head
propped up and with the limbs fully supported and progress is made to exercises in sitting,
and then in standing.

Examples :

 Exercise for legs in lying position with head raised

o Hip abduction-adduction.
o 1 hip & knee flexion-extension (fig.1).
o 1 leg raising to place heel on a specified mark (fig.2).
o Hip and Knee flexion and extension, abduction and adduction.

Fig.1 Fig.2

 Exercise for the legs in sitting (fig.3)

o 1 leg stretching to slide heel to a position indicated by mark on floor.
o Alternate leg stretching & lifting to place heel/toe on specified mark.
o Stride sitting ; change to standing & sit down again.

Fig.3 Plan to show suitable marking on floor.

 Exercise for the legs in standing (fig.4)

o Stride standing; transference -of weight from Foot to Foot.
o Stride standing; walking sideways placing Feet on marks on the floor.
o Standing; walking placing feet on marks.
o Standing; turn round
 o Standing; walking and changing direction to avoid obstacles.

Fig.4 Exercise for the legs in standing.

 Exercises for the arms

o Sitting (one Arm supported on a table or in slings); Shoulder flexion or extension to
place Hand on a specified mark.
o Sitting; one Arm stretching, to thread it through a small hoop or ring.
o Sitting; picking up objects and putting them down on specified marks.

EXERCISES TO PROMOTE MOVEMENT AND RHYTHM

 All exercises are repeated continuously to a rhythmic count, or to suitable music.
a. Sitting; one hip flexion and adduction (to cross one thigh over the other), the movement
is then reversed and repeated.
b. Half lying; one Leg abduction to bring knee to side of plinth, followed by one knee
bending to put Foot on floor, the movement is then reversed and repeated (fig.5).
c. Sitting, lean forward and take weight on feet (as if to stand), then sit down again
(fig.6).
d. Standing; arm swing forwards and backwards (with partner, holding two sticks) (fig.7).
e. Standing or walking; bounce and catch, or throw and catch a ball.
 Marching to music, ballroom dancing or swimming, if possible, should be encouraged.

Fig. 5 Fig.6 Fig. 7

 PRACTICAL -12

Suspension Therapy - Introduction

Aim: To study the various components of Suspension therapy Apparatus

SUSPENSION

Suspension is the means whereby parts of the body are supported in slings and elevated by the
use of variable length ropes fixed to a point above the body. Suspension frees the body from the
friction of the material upon which body components may be resting and it permits free
movement without resistance. For suspension we need:

 a fixed point (hook) above the relevant part of the body and

 a suspensory unit which consists of

 a sling

 a supporting adjustable rope

 S- hook

 Dog clip / Karabiner hook

The Fixed Point

 Stainless steel or plastic covered 5 cm metal mesh or free-standing frame around the area
of a plinth. Hooks on the side of the frame allow lateral fixed points and can be used to
keep the small apparatus near at hand.

Suspensory Unit
Consisting of a rope and a sling.

The Supporting Ropes

Ropes should be of 3-ply hemp so that they will not slip, and they can be of three arrangements:

 a single rope,

 a pulley rope or

 a double rope.

Single Rope

A single rope has a ring fixed at one end, by which it is hung up. The other end of the rope
passes through one end of a wooden cleat, through the ring of a dog clip and through the other
end of the cleat and is then knotted with a half-hitch. The cleat is for altering the length of the
rope and should be held horizontally for movement and pulled oblique when supporting. The
rope then 'holds' on the cleat by frictional resistance. The dog clip should be on a pivot to allow
adjustments in position with minimum discomfort when the slings are attached. The total length
of rope required is 1.5 m.

Pulley Rope

A pulley rope has a dog clip attached to one end of the rope which then passes over the wheel of
a pulley. The rope then passes through the cleat and a second dog clip. Like the single rope this
rope is 1.5 m long. This arrangement is used for reciprocal pulley circuits; with one sling
supporting a limb, and the ends of the sling attached to the two dog clips, it is used for three-
dimensional movements of a limb, i.e. abduction or adduction with flexion or extension and
medial or lateral rotation (combined, oblique, rotatory movements).

Double Rope

A double rope consists of a ring and clip from which the rope is hung. The rope then passes
through one side of a cleat, round a pulley wheel at the lower end, to the case of which is
attached a dog clip, through the other end of the cleat and over the wheel of an upper pulley
which is attached to the compensating device. The rope then passes down again through a centre
hole in the cleat where it is knotted. This device gives a mechanical advantage of two as two
pulleys are used. The rope is shortened by pushing the cleat down, allowing the lifter to move
with gravity at the same time as it offers a mechanical advantage of two. Such a rope is used to
suspend the heavy parts of the body – the pelvis, thorax or heavy thighs when these are to be
supported together.
TYPES OF SUSPENSION :

Vertical Fixation

• The rope is fixed so that it hangs vertically above the centre of gravity of the part to be
suspended. The centre of gravity of each part of the body is, on the whole, at the junction
of the upper and middle third.

• Used for support as it tends to limit the movement of the part to a small-range pendular
movement on each side of the central resting point.

• Vertical fixation is used primarily to support, e.g. the abducted upper limb when the
elbow is to be moved

Axial Fixation

• When all the ropes supporting a part are attached to one 'S' hook which is fixed to a point
immediately above the centre of the joint which is to be moved.

• When such fixation is set up the movement of the limb will be on a flat plane level with
the floor. In this way pure angular movements are obtained.
 PRACTICAL -13

SUSPENSION FOR THE LOWER EXTREMITY

Aim: To study the application of suspension bed for lower extremity

Abduction and Adduction of HIP

• Position of the subject : lying with the opposite leg abducted to its limit.

• Fixation point : Immediately above the hip joint. One sling is put under the lower thigh
and one three-ring sling on the foot and ankle; each is attached to a rope hung from the
fixation point. The limb is lifted just clear of the plinth.

• Hip may be mobilized in abduction and adduction or the abductor or adductor muscles
may be especially worked with or without manual resistance

Flexion and Extension of HIP

• Position of the subject : side lying with the underneath leg flexed as far as possible.

• Fixation point : Over the hip joint, single sling is attached to the thigh and one is a three-
ring sling applied to the ankle and foot.

• During flexion both the hip and knee should be flexed together to overcome passive
insufficiency of hamstring muscle.

• When extension is performed the knee should be extended to overcome the active
insufficiency of hamstring muscle
THE KNEE

Flexion and Extension of KNEE

• Position of the subject : side lying with one or two pillows between the slightly flexed
thighs.

• Fixation point : Over the knee joint, single sling is attached to the thigh and one is a
three-ring sling applied to the ankle and foot.

• By keeping the hip slightly flexed on the trunk the foot can be seen each time the knee is
extended and part of the arc of movement is thus observed by the subject.

• This position may be used to mobilize the knee joint or to work the flexors or extensors
of the knee.
 PRACTICAL -14

SUSPENSION FOR THE UPPER EXTREMITY

Aim: To study the application of suspension bed for upper extremity .

THE SHOULDER

Abduction and Adduction of Shoulder

• Position of the subject : supine lying, quarter turned towards the arm which is to be
moved. Alternatively, the starting position is prone lying, quarter turned towards side
lying with a pillow under the trunk on the side of the arm which is to be moved.

• Fixation point : Over the shoulder joint, single sling is attached to the elbow and one is a
three-ring sling applied to the wrist and hand.

Shoulder abduction and adduction.

A: Quarter 15° turned from lying. B: Quarter 15° turned from prone lying.

THE ELBOW

• Position of the subject : sitting on a low backed chair.

• Fixation point : A single sling and rope supports the arm in vertical fixation, and a three-
ring sling and single rope fixed to point above the elbow joint.