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🏥 PRACTICAL EXAMINATION GUIDE

Physiotherapy in Women's Health (BPT — CBCS)

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📋 OVERVIEW OF WHAT CAN BE ASKED

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✅ TOPIC 1: ASSESSMENT OF PELVIC FLOOR MUSCLES

What Can Be Asked:

"Demonstrate assessment of pelvic floor muscle strength" "How will you assess a patient presenting with urinary incontinence?"

Demonstration Steps:

• Chief complaint: type of leakage (stress/urge/mixed)
• Onset, duration, frequency
• Obstetric history: number of deliveries, type (normal/LSCS), birth weight
• Bladder diary: voiding frequency, nocturia, urgency
• Bowel habits, prolapse symptoms
• Pain during intercourse (dyspareunia)
• Red flag screening: blood in urine, pelvic mass

• Lumbar lordosis (increased = anterior pelvic tilt = PF weakness)
• Diastasis recti check — midline separation of rectus abdominis
  • Measure with fingers at umbilicus, 4.5 cm above, 4.5 cm below

  • 2 finger widths = significant diastasis

• Pad test (1-hour): Patient leaks urine during activity; pad weighed before and after
  • <1g = no incontinence; 1–10g = mild; 10–50g = moderate; >50g = severe
• Q-tip test: For urethrovesical junction hypermobility
• Cough stress test: Patient coughs with full bladder, observe for leakage

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✅ TOPIC 2: PELVIC FLOOR MUSCLE TRAINING (PFMT) / KEGEL EXERCISES

What Can Be Asked:

"Demonstrate pelvic floor muscle training for a patient with stress urinary incontinence" "Teach a postnatal patient Kegel exercises"

Demonstration Steps:

• Explain anatomy using diagram: pelvic floor = hammock of muscles from pubis to coccyx
• Functions: urinary/bowel control, sexual function, support of pelvic organs, trunk stability
• Explain difference between correct PFM contraction vs. wrong (gluteal squeeze, breath-holding, Valsalva)

• Instruct: "Imagine you are stopping the flow of urine and passing wind at the same time — squeeze and lift inward and upward"
• Visual cues: "elevator going up"
• Avoid: buttock squeeze, inner thigh squeeze, breath-holding, abdominal bracing

1. Crook lying (supine with knees bent) — easiest
2. Side lying
3. Sitting
4. Standing
5. Functional positions (during cough, squat)

• Hold contraction for 8–10 seconds
• Relax for equal time (10 seconds)
• 8–12 repetitions
• 3 sets/day

• Quick 1-second contractions
• 3–5 repetitions added after each slow set
• Important for stress incontinence (pre-contracts before cough/sneeze)

• Pre-contraction of PFM just before/during cough or sneeze
• Demonstrates to examiner you know functional application

• Increase hold time (from 4s → 10s)
• Increase repetitions
• Progress to upright/functional positions
• Add resistance: weighted vaginal cones (mention, don't demonstrate)

• 3 months minimum for measurable improvement
• Bladder diary review at 4–6 weeks

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✅ TOPIC 3: ANTENATAL EXERCISE PRESCRIPTION & DEMONSTRATION

What Can Be Asked:

"Demonstrate antenatal exercises for a 28-week pregnant woman with low back pain" "What exercises do you prescribe in each trimester?"

Key Principles to State First:

• Aim: maintain fitness, prepare for labor, prevent musculoskeletal disorders
• Avoid: supine position after 16 weeks (aortocaval compression), contact sports, high-impact activities, Valsalva maneuver
• Screen with PARmed-X for Pregnancy (mention this)

Exercises to Demonstrate:

• Ankle pumps and foot circles
• Pelvic floor exercises (start early)
• Diaphragmatic breathing
• Gentle walking program

• Pelvic tilting (supine → side lying → 4-point kneeling):
  • Patient in crook lying → flatten lumbar spine → hold 5–10 seconds
  • Reduces lumbar lordosis and LBP
• Cat-Camel stretch (4-point kneeling):
  • Arch back (cat) → hollow back (camel)
  • 10 repetitions
• Side-lying hip abduction:
  • Strengthens gluteus medius
  • Prevents SIJ pain / Trendelenburg gait
• Supported squats (wall squat):
  • Prepares for labor, strengthens quads
• Transverse abdominis activation:
  • Patient breathes out, gently draws lower abdomen in without bracing
  • "Hollowing" not bracing

• All supine exercises modified to left side-lying or semi-reclined
• Tailor sitting (cross-legged sitting): Opens pelvis, stretches adductors
• Supported wall squats with ball
• Pelvic rocking on birthing ball
• Breathing exercises: Lamaze technique
  • Slow deep breathing for early labor
  • Light accelerated breathing for active labor
  • Blow-pant-pant for transition phase
• Perineal massage (from 34 weeks): Reduces perineal tearing — mention to examiner

Labor Preparation Positions to Demonstrate:

• Upright walking — utilizes gravity
• All-fours (hands & knees) — posterior fetal rotation
• Squatting — widens outlet
• Side-lying — reduces perineal trauma

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✅ TOPIC 4: POSTNATAL PHYSIOTHERAPY EXERCISES

What Can Be Asked:

"What physiotherapy exercises will you prescribe in the first week after normal delivery?"

Day 1–3 (Immediate Postnatal):

• Foot & ankle pumps — DVT prevention
• Breathing exercises — diaphragmatic
• Gentle abdominal contractions — breathe out, gently tighten
• Pelvic floor exercises — even if episiotomy (promotes healing via circulation)

Day 4–7:

• Pelvic tilting (crook lying)
• Bridges (gluteal sets):
  • Crook lying → lift buttocks off bed → hold 5 sec → lower
  • Strengthens gluteals and lumbar extensors
• Knee rolling (rotational mobilization)

Week 2–6:

• Diastasis recti check (mandatory — if >2 fingers, no sit-ups, no oblique crunches)
• Heel slides — core activation
• Clam shells — hip external rotation, gluteus medius

After 6-Week Check (Cleared by Obstetrician):

• Return to full core strengthening
• Sit-ups, planks only if diastasis healed
• Return to aerobic exercise / swimming

Post-LSCS (Caesarean) Specific:

• Deep breathing + incentive spirometry (Day 1)
• Wound support during cough ("splinting the wound")
• Mobility exercises: early ambulation
• Scar mobilization from 6–8 weeks (once healed)

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✅ TOPIC 5: TREATMENT OF URINARY INCONTINENCE

What Can Be Asked:

"Demonstrate physiotherapy management of stress urinary incontinence" "Differentiate and treat stress vs. urge incontinence"

Classification (Must Know):

Bladder Retraining (for Urge Incontinence) — Demonstrate:

• Start with voiding every 1.5 hours (regardless of urge)
• Increase interval by 15–30 minutes each week
• Target: void every 3–4 hours
• Urge suppression technique:
  • "Stop, don't run to the toilet"
  • Squeeze PFM 3 times rapidly (inhibits detrusor via pudendal-detrusor reflex)
  • Distract attention (count backwards from 100)
  • Urge will pass in 30–60 seconds

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✅ TOPIC 6: ELECTROTHERAPY FOR PELVIC FLOOR — BIOFEEDBACK & NEUROMUSCULAR ELECTRICAL STIMULATION (NMES)

What Can Be Asked:

"How will you set up biofeedback for pelvic floor rehabilitation?" "Demonstrate NMES/TENS for urinary incontinence"

Biofeedback:

1. Explain procedure to patient, obtain consent
2. Patient positioned in semi-reclined or supine crook lying
3. Vaginal probe (perineometer) or surface EMG electrodes placed at perineum
4. Screen shows contraction trace in real-time
5. Patient aims to reach target line on screen with each contraction
6. Relaxation phase must return to baseline (teaches relaxation too)
7. 20–30 minute session, 2–3×/week
8. Progress threshold as strength improves

• EMG biofeedback: 0–100 μV range
• Goal: recruit correct muscles, avoid compensators

NMES (Neuromuscular Electrical Stimulation):

• Electrode placement: Two channels crossing at pelvic floor
• Frequency: 80–150 Hz (pain relief), 10–50 Hz (muscle stimulation)
• Used for: pelvic pain, dysmenorrhea, endometriosis pain

TENS for Dysmenorrhea:

• High TENS: 80–120 Hz, low intensity — pain gate mechanism
• Electrode placement: over lower abdomen / sacrum
• Session: 20–30 minutes during pain

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✅ TOPIC 7: DIASTASIS RECTI ASSESSMENT & TREATMENT

What Can Be Asked:

"Assess a postnatal patient for diastasis recti and demonstrate treatment"

Assessment:

1. Palpate along linea alba from xiphoid to pubis
2. Ask patient to do a mini curl-up (chin tuck)
3. Feel for gap with fingers — measure in finger widths at:
   • 2.5 cm above umbilicus
   • At umbilicus
   • 2.5 cm below umbilicus
4. Also assess tissue tension (inter-recti distance + depth of gap)

• ≤2 finger widths = normal

• 2 fingers = diastasis recti

• No sit-ups, planks, oblique crunches until healed

Treatment Exercises (Demonstrate):

1. Abdominal bracing with expiration: Breathe out, gently draw lower abdomen in
2. Heel slides: Supine, one heel slides along bed while maintaining neutral spine
3. Dead bugs: Arms and legs extend alternately while spine stays neutral
4. Bent knee fall-outs (clam)
5. Supported bridging
6. Taping / abdominal binder: Support linea alba

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✅ TOPIC 8: PHYSIOTHERAPY FOR LOW BACK PAIN IN PREGNANCY

What Can Be Asked:

"A 32-week pregnant woman presents with low back pain — assess and treat"

Assessment:

• Distinguish: lumbar LBP vs. posterior pelvic pain (PGP) vs. SPD
• Posterior Pelvic Pain Provocation (P4) test: Flex hip 90°, apply posterior force → positive if pain at posterior pelvis
• ASLR test (Active Straight Leg Raise): Assess lumbopelvic stability
• Patrick's FABER test: SIJ involvement

Treatment:

• Gentle lumbar mobilization (Maitland Grade I–II)
• SIJ manipulation (with care, low grade)
• Soft tissue release: piriformis, iliopsoas, QL

• Pelvic tilting, cat-camel
• Transverse abdominis activation
• Swimming / hydrotherapy (reduces axial load)

• Avoid prolonged standing
• Pillow between knees in side-lying
• Ergonomic advice for sitting/sleeping

• Demonstrates how to apply at level of greater trochanters
• Reduces SIJ stress by compressing the joint

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✅ TOPIC 9: BREAST CANCER REHABILITATION AFTER MASTECTOMY / LYMPHEDEMA

What Can Be Asked:

"Demonstrate post-mastectomy shoulder exercises" "How will you manage lymphedema of the upper limb after axillary node dissection?"

Post-Mastectomy Exercises (Demonstrate day-by-day):

• Elbow flexion/extension
• Wrist circumduction
• Hand gripping / finger exercises
• Deep breathing

• Shoulder pendulum exercises
• Shoulder shrugs and rolls

• Wall walking (finger ladder): Patient faces wall, fingers walk up incrementally
• Rope over door/shoulder pulley
• Wand exercises: Using a stick to assist glenohumeral movement
• Target: full shoulder ROM by 4–6 weeks

Lymphedema Management — CDT (Complete Decongestive Therapy):

1. Manual Lymphatic Drainage (MLD):
   • Light, rhythmic strokes toward functioning lymph nodes
   • Sequence: clear trunk first (axilla → neck), then distal to proximal on limb
   • Pressure: 30–45 mmHg (very light — NOT deep massage)
2. Compression Bandaging:
   • Short-stretch bandages (low resting pressure, high working pressure)
   • Applied distal to proximal
   • Worn day and night in intensive phase
3. Exercise (with compression):
   • Pumping action of muscles enhances lymph return
   • Shoulder, elbow, wrist, hand exercises
4. Skin Care:
   • Moisturize daily, avoid cuts/needle pricks in affected limb
   • Avoid heat, constriction, blood pressure on that arm

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✅ TOPIC 10: OSTEOPOROSIS — PREVENTION & PHYSIOTHERAPY

What Can Be Asked:

"What exercises will you prescribe for a post-menopausal woman with osteoporosis?"

Risk Screening:

• FRAX score (mention)
• DXA scan values: T-score ≤ –2.5 = osteoporosis; –1 to –2.5 = osteopenia

Physiotherapy Program:

• Walking, jogging, stair climbing
• High-impact: jumping — only if vertebral fracture excluded
• Low-impact: dancing, elliptical

• Progressive resistance to major muscle groups
• Especially: back extensors, hip extensors, shoulder girdle
• Back extensor strengthening: Prone lying, arms by side → lift chest off bed

• Tandem stance (heel-to-toe), single-leg stance
• Tai Chi
• Perturbation training on wobble board

• Chin tucks, scapular retraction
• Thoracic extension over rolled towel
• Reduce kyphosis

• Forward flexion of spine (sit-ups, toe-touching) — risk of vertebral compression fracture
• High-impact activities if established osteoporosis
• Heavy lifting

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✅ TOPIC 11: PHYSIOTHERAPY AFTER GYNAECOLOGICAL SURGERIES

What Can Be Asked:

"What is your physiotherapy role after hysterectomy?" "Post-surgical management after anterior/posterior colporrhaphy"

Early Post-op (Day 1–3):

• Deep breathing exercises / IPPB
• Incentive spirometry
• Cough support: Patient holds pillow over lower abdomen during cough
• DVT prophylaxis: ankle pumps, foot circles, TED stockings
• Early ambulation

Day 4–7:

• Gentle pelvic tilting
• Walking program (graduated)
• Avoid PFM exercises for 6 weeks post-pelvic floor repair (risk of dehiscence)

Week 6 onwards:

• PFM exercises resume
• Core stability program
• Scar tissue mobilization (from 6–8 weeks)
• Return to ADLs, lifting education

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✅ TOPIC 12: ASSESSMENT SCALES & OUTCOME MEASURES (MUST KNOW)

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📝 EXAMINER'S MOST COMMONLY ASKED PRACTICAL VIVAS

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🔑 GOLDEN RULES FOR PRACTICAL EXAM

1. Always start with subjective history before touching the patient — examiners specifically look for this
2. Obtain informed consent before any assessment or treatment
3. Explain to the patient what you are doing and why — communication is marked
4. State contraindications for every modality/exercise before demonstrating
5. Use correct terminology: PFMT, PERFECT, CDT, MLD, NMES — not vague terms
6. Demonstrate proper positioning — especially modified positions in pregnancy
7. Give a home program at the end of every management demonstration
8. Document and reassess — state you would review outcome measures at each session

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Practical Demonstrations That Can Be Asked — Women's Health (BPT)

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🔵 PELVIC FLOOR

1. Demonstrate Kegel / Pelvic Floor Muscle Training on a patient with stress urinary incontinence
2. Demonstrate PERFECT scheme assessment of pelvic floor muscles
3. Demonstrate the "Knack" maneuver (pre-contraction before cough/sneeze)
4. Demonstrate bladder retraining for urge urinary incontinence
5. Demonstrate urge suppression technique to a patient
6. Set up biofeedback (perineometer/EMG) for pelvic floor rehabilitation
7. Set up NMES for stress urinary incontinence (parameters + electrode placement)
8. Set up NMES for urge urinary incontinence
9. Demonstrate weighted vaginal cone therapy (explain + instruct)
10. Demonstrate a 1-hour pad test

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🔵 ANTENATAL

1. Demonstrate antenatal exercises for 1st trimester
2. Demonstrate antenatal exercises for 2nd trimester
3. Demonstrate antenatal exercises for 3rd trimester
4. Demonstrate pelvic tilting in pregnancy (supine / 4-point kneeling)
5. Demonstrate cat-camel stretch for a pregnant patient with LBP
6. Demonstrate transverse abdominis activation in pregnancy
7. Demonstrate Lamaze breathing technique (slow / accelerated / pant-blow)
8. Demonstrate labor positions (upright, all-fours, squatting, side-lying)
9. Demonstrate application of a pelvic girdle / trochanteric belt
10. Demonstrate tailor sitting and its benefits
11. Demonstrate perineal massage (explain procedure to patient)

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🔵 POSTNATAL

1. Demonstrate Day 1–3 postnatal exercises after normal vaginal delivery
2. Demonstrate postnatal exercises after LSCS (caesarean)
3. Demonstrate diastasis recti assessment (finger-width measurement during curl-up)
4. Demonstrate exercises for diastasis recti (heel slides, dead bug, bridge)
5. Demonstrate wound splinting technique during cough post-LSCS
6. Demonstrate incentive spirometry use post-operative
7. Demonstrate DVT prevention exercises (ankle pumps, foot circles)
8. Demonstrate postnatal core stabilization progression

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🔵 PREGNANCY-RELATED LOW BACK PAIN / PELVIC GIRDLE PAIN

1. Demonstrate P4 test (Posterior Pelvic Pain Provocation test)
2. Demonstrate ASLR test (Active Straight Leg Raise)
3. Demonstrate FABER / Patrick's test for SIJ
4. Demonstrate lumbar stabilization exercises for pregnancy LBP
5. Demonstrate postural correction and ergonomic advice to a pregnant patient
6. Demonstrate sleeping position advice in pregnancy

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🔵 BREAST CANCER REHABILITATION & LYMPHEDEMA

1. Demonstrate Day 1–7 post-mastectomy shoulder exercises (elbow, wrist, hand)
2. Demonstrate wall-walking (finger ladder) exercise
3. Demonstrate wand / stick exercise for shoulder ROM
4. Demonstrate shoulder pulley exercise
5. Demonstrate Manual Lymphatic Drainage (MLD) for upper limb lymphedema
6. Demonstrate short-stretch compression bandaging for lymphedema
7. Demonstrate circumferential limb measurement for lymphedema monitoring
8. Explain all 4 components of CDT (Complete Decongestive Therapy)
9. Demonstrate exercises with compression garment for lymphedema

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🔵 OSTEOPOROSIS

1. Demonstrate back extensor strengthening (prone lying, chest lift)
2. Demonstrate weight-bearing exercises for bone density
3. Demonstrate balance exercises (tandem stance, single-leg stance, wobble board)
4. Demonstrate postural exercises for kyphosis correction (scapular retraction, thoracic extension)
5. Demonstrate fall prevention program for elderly osteoporotic woman
6. State contraindications of exercise in osteoporosis (forward flexion, sit-ups — must know)

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🔵 GYNAECOLOGICAL SURGERY

1. Demonstrate early post-op physiotherapy after hysterectomy (breathing, ankle pumps, ambulation)
2. Demonstrate deep breathing exercises / IPPB post-gynaecological surgery
3. Demonstrate abdominal scar mobilization technique (from 6–8 weeks)
4. Demonstrate graduated walking program post-surgery
5. Demonstrate return-to-activity program after pelvic floor repair surgery

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🔵 ELECTROTHERAPY MODALITIES

1. Demonstrate TENS application for dysmenorrhea (electrode placement: lower abdomen / sacrum, parameters)
2. Demonstrate IFT (Interferential Therapy) for pelvic pain (4-pole technique, parameters)
3. Demonstrate TENS for perineal pain post-delivery
4. Demonstrate ultrasound therapy over episiotomy scar / perineal scar

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🔵 OUTCOME MEASURE DEMONSTRATIONS

1. Administer ICIQ-UI short form questionnaire to patient
2. Demonstrate Modified Oxford Scale grading explanation to examiner
3. Demonstrate VAS / NRS pain scale use
4. Record a bladder diary with a patient

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🏆 TOP 10 HIGHEST PROBABILITY DEMONSTRATIONS (Most Likely to Be Asked)

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Complete Practical Procedures + Demonstrations — Women's Health (BPT)

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🔴 PROCEDURE 1: PELVIC FLOOR MUSCLE ASSESSMENT (PERFECT SCHEME)

Examiner May Ask:

Procedure:

• Wash hands, wear gloves
• Explain procedure to patient, obtain verbal consent
• Ensure privacy, draw curtains
• Patient empties bladder before assessment

• Supine crook lying (knees bent, feet flat)
• Knees slightly apart
• Drape patient appropriately

• Observe perineum at rest
• Ask patient to "squeeze and lift" — observe inward lift of perineum
• Ask patient to cough — observe for downward descent (prolapse) or leakage

• Insert vaginal probe or use two gloved fingers
• Ask patient to squeeze and lift around your fingers
• Grade using Modified Oxford Scale (0–5)

• P = Power: Oxford grade (0–5)
• E = Endurance: seconds held at maximum contraction
• R = Repetitions: how many times max contraction repeated before fatigue
• F = Fast: number of 1-second fast contractions
• E = Elevation: is there visible/palpable inward lift?
• C = Co-contraction: does abdomen inappropriately brace?
• T = Timing: can patient pre-contract before cough?

• Record baseline PERFECT score
• Use to guide treatment plan

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🔴 PROCEDURE 2: PELVIC FLOOR MUSCLE TRAINING (PFMT)

Examiner May Ask:

Procedure:

• Explain PFM anatomy using diagram
• Explain difference: stress UI = leaks on cough/sneeze/exercise
• Tell patient what PFMT achieves and how long it takes (minimum 3 months)

• Say: "Imagine you are stopping the flow of urine and passing wind simultaneously — squeeze and lift inward and upward"
• Confirm patient is NOT squeezing: buttocks, thighs, abdomen
• Confirm patient is NOT holding breath

• Begin in crook lying (supine, knees bent) — gravity-eliminated

• Squeeze and hold for 8–10 seconds
• Fully relax for 10 seconds (relaxation equally important)
• Repeat 8–12 times
• 3 sets per day

• After each slow set, perform 3–5 quick 1-second contractions
• Fully relax between each
• This trains Type II fibers — active during sudden pressure rise

• Teach patient to pre-contract PFM just BEFORE coughing/sneezing
• Practice: patient counts "1-2-squeeze-cough"

• Week 1–2: Supine crook lying
• Week 3–4: Side lying
• Week 5–6: Sitting
• Week 7–8: Standing
• Week 9+: Functional positions (squatting, stair climbing)

• Written instruction card
• 3 sets/day, every day
• Review at 4 weeks with bladder diary

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🔴 PROCEDURE 3: BIOFEEDBACK SETUP FOR PELVIC FLOOR

Examiner May Ask:

Procedure:

• EMG biofeedback machine / perineometer
• Vaginal probe (disposable cover/condom over probe)
• Lubricant

• Explain procedure fully, obtain consent
• Patient empties bladder
• Supine crook lying, draped
• Wash hands, gloves on

• Apply lubricant to probe
• Insert vaginal probe gently
• Or place surface EMG electrodes on perineum (external option)
• Ground electrode on thigh

• Switch on machine
• Record resting EMG baseline (should be low — 2–4 μV)
• Elevated resting tone = hypertonic pelvic floor (note this)

• Ask patient to perform contraction
• Screen shows real-time contraction trace
• Patient aims to reach target line on screen
• Relaxation phase: trace must return fully to baseline
• Ensure no abdominal, gluteal co-activation (check with second channel)

• 20–30 minutes per session
• 2–3 sessions/week
• 6–8 week program

• Raise target threshold as strength improves
• Add fast-twitch protocol on machine
• Transition to home exercises without machine

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🔴 PROCEDURE 4: NMES (NEUROMUSCULAR ELECTRICAL STIMULATION) FOR URINARY INCONTINENCE

Examiner May Ask:

Procedure:

• Stress UI: PFM too weak to contract voluntarily (Oxford grade 0–2)
• Urge UI: Detrusor overactivity — need inhibition

• Pregnancy
• Pacemaker
• Active infection / vaginitis
• Malignancy in pelvic region
• First 6 weeks post-surgery
• Impaired sensation

• NMES machine with vaginal/anal probe
• Disposable probe cover + lubricant

• Semi-reclined or supine crook lying
• Draped for privacy

• Lubricate and insert probe
• Start intensity at zero, increase slowly until patient feels contraction
• For stress UI: visible PFM contraction required
• For urge UI: sensation only, not strong contraction (detrusor inhibition mode)

• Monitor for discomfort
• Record intensity used each session
• Reassess Oxford grade every 4 weeks

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🔴 PROCEDURE 5: TENS FOR DYSMENORRHEA / PERINEAL PAIN

Examiner May Ask:

Procedure:

• Confirm: primary dysmenorrhea (no pathology)
• Pain score on VAS
• Site of pain: lower abdomen, sacral, inner thighs

• Pregnancy
• Pacemaker
• Over abdomen in undiagnosed pelvic pathology
• Active DVT

• Option A: Two electrodes on lower abdomen (bilateral paramedian, T10–L1 dermatome)
• Option B: Two electrodes on sacrum (S2–S4 — pudendal nerve)
• Option C: Crossed: one anterior, one posterior (most effective)

• Start with High TENS (80–100 Hz) for immediate pain relief

• Skin preparation: clean, dry skin
• Apply electrodes with gel or self-adhesive pads
• Set frequency → pulse width → increase intensity to strong, comfortable, non-painful tingling
• Duration: 20–30 minutes

• VAS score after treatment
• Can use during menstruation as needed (home TENS unit advised)

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🔴 PROCEDURE 6: MANUAL LYMPHATIC DRAINAGE (MLD) — UPPER LIMB POST-MASTECTOMY

Examiner May Ask:

Procedure:

• MLD is a very light massage technique
• Moves lymph fluid from congested areas to healthy lymph nodes
• NOT deep tissue massage — pressure is like weight of a coin

• Patient supine, arm slightly elevated on pillow
• Therapist stands beside affected side

• Apply gentle circular strokes at left supraclavicular fossa (healthy side)
• Creates negative pressure to receive lymph

• Stimulate left axillary nodes first

• Stroke from right axilla (blocked) → across anterior chest → toward left axilla
• Or right axilla → upward to right neck nodes
• This reroutes lymph away from blocked area

• Upper arm → elbow → forearm → hand
• Direction: always toward proximal (toward body)
• Technique: stationary circles / scoop strokes (J-stroke)
• Pressure: 30–40 mmHg (very light)
• Speed: slow, rhythmic (1 stroke per second)

• 45–60 minutes per session
• Daily in intensive phase
• Then 2–3×/week in maintenance

• Always apply bandage immediately after MLD while tissues are decompressed

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🔴 PROCEDURE 7: COMPRESSION BANDAGING FOR LYMPHEDEMA

Examiner May Ask:

Procedure:

• Stockinette (tubular bandage)
• Padding foam (Artiflex / Reston foam)
• Short-stretch bandages (Comprilan): 6 cm, 8 cm, 10 cm widths

• Arterial insufficiency (check ABPI first if lower limb)
• Active infection (cellulitis) — treat infection first
• Cardiac edema — not primary lymphedema treatment

1. Apply stockinette finger to axilla
2. Pad each finger separately with foam
3. Apply finger bandages (2 cm wide)
4. Apply padding layer (Artiflex) from hand to axilla — smooth, no gaps, no wrinkles
5. Apply first short-stretch bandage (6 cm) at wrist — spiral technique, 50% overlap
6. Apply 8 cm bandage at forearm
7. Apply 10 cm bandage at upper arm
8. Each layer: apply with less tension as you go proximal (creates gradient — highest at distal)

• Check capillary refill at fingertips
• Ask patient: tingling, numbness, increased pain? If yes — remove and reapply
• Bandage should feel firm, not tight

• Worn 23 hours/day in intensive phase
• Removed only for MLD, bathing, exercises

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🔴 PROCEDURE 8: ANTENATAL EXERCISE SESSION (2ND TRIMESTER)

Examiner May Ask:

Procedure:

• Check gestational age, obstetric complications, BP
• Any contraindications: placenta previa, pre-eclampsia, PPROM, multiple gestation
• Screen with PARmed-X for Pregnancy

• Seated marching
• Ankle circles
• Shoulder rolls
• Neck side flexion stretches

• On hands and knees → arch lower back → flatten lower back
• 10 repetitions, hold 5 seconds

• Arch spine upward (cat) → hollow downward (camel)
• 10 repetitions, slow and controlled

• Breathe out → gently draw lower abdomen in (not bracing)
• Hold 10 seconds × 10 repetitions

• Crook lying → raise buttocks → hold 5 seconds → lower
• 10 repetitions
• Stop if dizziness or back pain

• Left side-lying → lift top leg to 30–40° → hold 2 sec → lower
• 10 repetitions each side (avoid supine after 16 weeks)

• Back against wall, feet 30 cm away, shoulder-width apart
• Lower to 60° knee flexion (not full squat)
• Hold 10 seconds, 5–8 repetitions

• 3 sets integrated into session

• Tailor sitting stretch
• Child's pose (modified — knees wide apart for bump)
• Deep diaphragmatic breathing

• Hydration: drink water throughout
• Stop if: dizziness, chest pain, vaginal bleeding, contractions, reduced fetal movement
• Wear supportive footwear, avoid overheating

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🔴 PROCEDURE 9: DIASTASIS RECTI ASSESSMENT + TREATMENT

Examiner May Ask:

ASSESSMENT Procedure:

• Patient supine, crook lying, arms by side

• Locate linea alba (midline, xiphoid to pubis)
• Palpate at:
  • 2.5 cm ABOVE umbilicus
  • AT umbilicus
  • 2.5 cm BELOW umbilicus

• Ask patient: chin tuck, then slowly lift head and shoulders (mini curl-up)
• Feel for ridge/gap with fingertips

• Count finger widths fitting in gap
• Normal = ≤ 2 fingers
• Significant = > 2 fingers
• Also assess depth (tissue tension/spring) — shallow gap with poor tension = worse

• Document: location, gap width in cm, tissue tension (good/poor)

TREATMENT Procedure:

• Breathe in → breathe out → gently draw lower abdomen inward
• Hold 10 seconds × 10 repetitions
• NO bracing, NO doming at midline

• TA activated → slowly slide one heel along bed until leg is straight → return
• Alternate sides, 10 each

• Both knees bent → lower one knee slowly to side → return
• Core activated throughout, 10 each side

• Resistance band around thighs → bridge up → maintain tension
• 10 repetitions

• Supine, arms up, knees 90° → extend opposite arm + leg → return
• Only when gap reduced to ≤ 2 fingers

• Sit-ups / crunches
• Oblique crunches
• Full plank
• Heavy lifting
• Any exercise causing "doming" or "coning" at midline

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🔴 PROCEDURE 10: POST-MASTECTOMY SHOULDER EXERCISES

Examiner May Ask:

Procedure:

• Deep breathing exercises
• Hand grip and release (squeezing soft ball)
• Wrist flexion/extension, circumduction
• Elbow flexion/extension
• Shoulder shrugs and rolls

• Shoulder pendulum: lean forward, arm hangs, swing in circles
• Supported shoulder AROM: flexion to comfortable range

• Patient faces wall
• Fingers walk up wall incrementally each session
• Mark daily progress with tape
• Goal: full elevation by 4–6 weeks

• Patient stands side-on to wall
• Fingers crawl laterally (abduction)

• Hold stick with both hands
• Unaffected arm assists affected arm through:
  • Flexion
  • Abduction
  • External rotation

• Pulley over door
• Unaffected arm pulls down to lift affected arm up
• Progress ROM daily

• Theraband resisted shoulder exercises
• Scapular retraction, depression
• Rotator cuff strengthening

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🔴 PROCEDURE 11: OSTEOPOROSIS EXERCISE PROGRAM

Examiner May Ask:

Procedure:

• T-score from DXA, vertebral fracture history
• Fall risk assessment: Berg Balance Scale / Timed Up & Go

• Forward spinal flexion (sit-ups, toe touch)
• High-impact jumping (if severe osteoporosis / vertebral fracture)
• Heavy overhead loading

• Brisk walking 30 minutes / day
• Stair climbing
• Low-impact dancing

• Hip extension in prone
• Bridging with progression to single-leg bridge
• Wall push-ups → floor push-ups
• Theraband rows
• Calf raises

• Prone chest lift: prone lying, arms by side → lift chest off mat → hold 5 sec
• Superman (prone arm + opposite leg lift)
• Seated thoracic extension over chair

• Tandem stance (heel to toe) — 30 seconds
• Single-leg stance — 10–30 seconds (near wall for safety)
• Walking heel-to-toe in straight line
• Stepping over obstacles
• Wobble board/balance board

• Chin tucks against wall
• Scapular retraction with theraband
• Wall angels
• Thoracic extension over foam roller

• Resistance: 2–3×/week
• Weight-bearing aerobic: 5×/week
• Balance: daily

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🔴 PROCEDURE 12: IFT (INTERFERENTIAL THERAPY) FOR PELVIC PAIN

Examiner May Ask:

Procedure:

• Chronic pelvic pain, dysmenorrhea, endometriosis pain, post-op pain

• Pregnancy
• Active menstruation (for internal probe)
• Malignancy
• Pacemaker
• DVT

• Channel 1: Two electrodes diagonally on lower abdomen
• Channel 2: Two electrodes crossing Channel 1 (forming X over painful area)
• Current crosses at pelvic floor = treatment zone

• Clean skin, apply dampened electrode pads
• Place in crossed diagonal pattern
• Start intensity at 0 → increase to strong, comfortable sensation
• Patient should feel deep tingling/buzzing at pelvic area, not skin surface

• Remove electrodes, check skin
• Reassess pain VAS
• 6–10 sessions recommended

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📌 QUICK REFERENCE: ALL PROCEDURES AT A GLANCE

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COMPLETE ASSESSMENT & MANAGEMENT GUIDE

Symphysis Pubis Dysfunction (SPD) | Pelvic Girdle Pain (PGP) | Pubic Diastasis

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📌 PART 1: ANATOMY & DEFINITIONS

Pubic Symphysis — Anatomy (Textbook)

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Definitions — Know the Difference

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📌 PART 2: SUBJECTIVE ASSESSMENT (HISTORY)

What to Ask — Complete History

Chief Complaint

• Exact location of pain: anterior (pubic area), posterior (sacral/SIJ), groin, inner thigh, perineum?
• Character: sharp, burning, aching, stabbing
• Severity: VAS/NRS (0–10)
• Onset: during pregnancy / after delivery / post-trauma

Aggravating Factors (Typical SPD/PGP Pattern)

• Turning over in bed (most common complaint)
• Going up/down stairs (step-to pattern vs. alternating)
• Walking, especially single-leg loading
• Getting in/out of car (abduction movement)
• Standing on one leg (dressing, stepping)
• Sexual intercourse (dyspareunia — groin/pubic pain)
• Prolonged sitting or standing
• Lifting / carrying

Relieving Factors

• Rest, symmetrical positions, support belt

Obstetric History

• Gestational age (if pregnant)
• Parity, previous deliveries, mode of delivery
• Birth weight, duration of labor, instrumental delivery (forceps)
• History of SPD in previous pregnancy

Red Flags (screen and exclude)

• Bladder/bowel dysfunction
• Saddle anesthesia
• Progressive neurological deficit
• Fever, night sweats (infection/malignancy)
• Trauma (pubic diastasis after delivery)

Functional Impact

• Pelvic Girdle Questionnaire (PGQ): Gold standard outcome measure for PGP
• Activities of daily living limitations

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📌 PART 3: OBJECTIVE ASSESSMENT

A. OBSERVATION

Standing Posture

• Increased lumbar lordosis → anterior pelvic tilt → increases stress on pubic symphysis
• Antalgic posture: lateral lean, hip hitching
• Trendelenburg sign: Pelvis drops on unaffected side when standing on affected leg — indicates gluteus medius weakness / SIJ instability

Gait Analysis

• Waddling gait / Penguin gait: Wide-based, short stride, lateral trunk sway — classic SPD
• Antalgic gait: Reduced stance phase on affected side
• Step-to pattern on stairs (cannot alternate legs)
• Observe for: hip drop, trunk rotation, pelvic obliquity

Skin

• Bruising over pubic symphysis (pubic diastasis post-delivery)
• Swelling, tenderness to palpation at pubic symphysis

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B. PALPATION

Pubic Symphysis Palpation

• Position: Supine crook lying
• Palpate directly over pubic symphysis (midline, just above genitalia)
• Positive: Point tenderness, or pain radiating to groins/inner thighs
• Note: tenderness over pubic tubercles = adductor tendinopathy component

SIJ Palpation

• Over posterior SIJ (just medial to PSIS)
• Compare bilateral tenderness

PSIS Level Assessment

• Place thumbs on both PSIS
• Note if one is higher/lower → pelvic obliquity / SIJ malalignment

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C. RANGE OF MOTION

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📌 PART 4: SPECIAL TESTS — ALL IN DETAIL

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🔬 TEST 1: ACTIVE STRAIGHT LEG RAISE (ASLR)

Purpose

Procedure

• Therapist compresses iliac crests together bilaterally (simulates sacroiliac belt)
• Ask patient to repeat ASLR
• If easier with compression → POSITIVE test → confirms SIJ instability, will benefit from compression belt

• Positive ASLR = impaired load transfer through SIJ/pelvis
• Indicates PGP of SIJ origin
• Most sensitive test for PGP (sensitivity 87%, specificity 94%)

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🔬 TEST 2: POSTERIOR PELVIC PAIN PROVOCATION TEST (P4 TEST / THIGH THRUST TEST)

Purpose

Procedure

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🔬 TEST 3: PATRICK'S TEST (FABER TEST)

Purpose

Procedure

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🔬 TEST 4: GAENSLEN'S TEST

Purpose

Procedure

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🔬 TEST 5: SACRAL THRUST TEST

Purpose

Procedure

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🔬 TEST 6: COMPRESSION TEST (SIJ COMPRESSION)

Purpose

Procedure

• Pain reproduced = SIJ compression provokes → pathology within joint
• Pain relieved = hypermobile SIJ → will benefit from compression belt

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🔬 TEST 7: DISTRACTION TEST (SIJ GAPPING TEST)

Purpose

Procedure

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🔬 TEST 8: MENNELL'S TEST (PUBIC SYMPHYSIS SHEAR TEST)

Purpose

Procedure

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🔬 TEST 9: MODIFIED TRENDELENBURG TEST

Purpose

Procedure

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🔬 TEST 10: ONE-LEG STANDING TEST (STORK TEST / GILLET TEST)

Purpose

Procedure

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🔬 TEST 11: LONG DORSAL SACROILIAC LIGAMENT TEST (LDL TEST)

Purpose

Procedure

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🔬 TEST 12: PIEDALLU'S TEST (SITTING FLEXION TEST)

Purpose

Procedure

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📌 PART 5: MEASUREMENT & GRADING

A. Symphysis Pubis Gap Measurement

• Imaging: Ultrasound or X-ray (flamingo view)
• Normal gap: 4–5 mm in non-pregnant
• Pregnant: up to 7–8 mm acceptable
• SPD diagnosis: >10 mm (or >7 mm with symptoms in pregnancy)
• Pubic diastasis: >10 mm gap post-delivery (some sources: >25 mm = severe diastasis)

B. Pain Severity

• VAS (Visual Analogue Scale): 0–10 cm line
• NRS (Numeric Rating Scale): 0–10 verbal

C. Functional Outcome Measures

D. ASLR Scoring

• Each leg scored 0–5
• Total = 0–10
• Score ≥2 = significant impairment
• Used as primary outcome measure in research

E. Flamingo View (X-ray) — For Pubic Diastasis

• Weight-bearing AP pelvis X-ray
• Patient stands on one leg alternately
• Measure vertical displacement of pubic symphysis

• 2 mm vertical displacement = abnormal (diastasis)

• 5 mm = significant instability

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📌 PART 6: CLUSTER OF TESTS — DIAGNOSTIC CRITERIA

European Guidelines (Vleeming et al.) — PGP Diagnosis:

1. P4 test (Posterior pelvic pain provocation)
2. ASLR test
3. Modified Trendelenburg
4. Long dorsal SIJ ligament palpation

SPD Specific Diagnosis:

• Pubic symphysis tenderness on palpation
• Mennell's shear test positive
• Pain with hip abduction/ER
• Imaging: gap >10 mm or >7 mm with symptoms

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📌 PART 7: PHYSIOTHERAPY MANAGEMENT

A. ACUTE PHASE (Pain Dominant)

1. Rest & Activity Modification

• Avoid: single-leg activities, stairs, prolonged standing, wide-leg opening (getting in/out of car, birth stirrups)
• Teach: "Keep knees together" rule — get in/out of bed as a unit
• Sleeping: pillow between knees in side-lying

2. Pelvic Support Belt / Trochanteric Belt

• Place belt at level of greater trochanters (NOT at iliac crest — that is a sacral belt)
• Tension: firm but not so tight as to restrict breathing
• Wear: during activity, not at night
• Mechanism: Increases SIJ force closure → reduces shear at pubic symphysis

3. Pain Relief Modalities

• TENS: 80–100 Hz over posterior SIJ (sacral electrodes) — safe in pregnancy
• Heat/Ice: Heat over SIJ / ice over pubic symphysis in acute phase
• Hydrotherapy: Pool exercises — offloads pelvic weight

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B. STABILIZATION PHASE — EXERCISE PROGRAM

Principle: Restore FORCE CLOSURE of pelvis

1. Transverse Abdominis (TA) Activation

• Breathe in → breathe out → gently draw lower abdomen in (below umbilicus)
• Hold 10 seconds × 10 repetitions
• NO bracing, NO breath-holding
• Progress to: heel slides, arm lifts while maintaining TA activation

2. Pelvic Floor Muscle Training

• Coordinate PFM contraction with TA
• They co-activate naturally — training one helps the other
• Protocol: PERFECT scheme (as described previously)

3. Gluteus Medius Strengthening (CRITICAL for SIJ stability)

• Side-lying, neutral spine
• Lift top leg to 30–40° (NOT beyond)
• Hold 3–5 seconds × 15 repetitions
• Add ankle weight / Theraband as progression

• Side-lying, hips 60° flexion, knees stacked
• Rotate top knee upward like a clamshell opening (DO NOT let pelvis roll back)
• 15–20 repetitions
• Critical: keep pelvis still, movement only at hip

4. Gluteus Maximus Strengthening

• Crook lying, knees together (not apart — avoids pubic shear)
• Tighten TA and PFM → lift buttocks → hold 5 seconds → lower
• 10–15 repetitions
• Standard bridging with knees apart is CONTRAINDICATED in SPD

• Prone lying → lift one straight leg off bed 10–15 cm
• Hold 3–5 seconds
• Avoid lumbar extension compensation

5. Multifidus Activation

• 4-point kneeling → alternate arm + opposite leg extension (bird-dog)
• Core neutral throughout
• Begin unilateral, progress to full extension

6. Adductor Strengthening (Important for pubic symphysis stability)

• Supine crook lying → squeeze pillow between knees
• Hold 10 seconds × 15 repetitions
• Gentle resistance

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C. FUNCTIONAL PHASE — PROGRESSION

Progression Criteria (Before advancing):

• Able to perform ASLR without difficulty
• VAS ≤ 2/10
• Can walk symmetrically for 10 minutes

Exercises:

• Sit-to-stand with neutral pelvis
• Mini wall squats (legs parallel, NOT wide stance)
• Step-ups (small step height)
• Lunges (when fully pain-free)
• Swimming / aqua aerobics (offloads pelvis)

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D. MANUAL THERAPY

1. SIJ Manipulation / Mobilization

• Maitland Grade I–II: Pain-relieving oscillations
• Grade III–IV: Stretching — use only when hypomobile SIJ identified
• CONTRAINDICATED in pregnancy with hypermobile SIJ — do not manipulate hypermobile joint

2. Muscle Energy Technique (MET) — For SIJ Malalignment

• Patient supine, hip flexed to 90°
• Therapist resists hip extension isometrically (patient pushes toward extension, therapist resists)
• 5-second hold × 3 repetitions
• After each contraction, move into new range

• Hip extended off table → patient resists hip flexion
• Corrects anteriorly rotated ilium

3. Soft Tissue Therapy

• Piriformis release (often tight with SIJ dysfunction)
• Hip flexor (iliopsoas) stretch — tight iliopsoas increases anterior pelvic tilt → increases SIJ/pubic shear
• Adductor release (adductor longus commonly tender with SPD)

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E. SPECIFIC MANAGEMENT: PUBIC DIASTASIS POST-DELIVERY

Immediate Management (Hospital):

• Compression: Apply trochanteric belt immediately
• Rest: Bed rest, minimal ambulation
• Log-rolling technique: Patient must roll to side as a unit to get out of bed — do NOT allow trunk rotation
• Commode at bedside: Avoid long walks
• Urinary catheter may be needed if walking to toilet painful

Positioning:

• Side-lying with pillow between knees
• Avoid lithotomy position, stirrups
• Avoid hip abduction beyond neutral

Physiotherapy Progression for Diastasis:

Surgical Management Indication (Refer):

• Diastasis >25 mm with severe instability
• Failed conservative treatment
• ORIF (Open Reduction Internal Fixation) with plate/screws — physiotherapy continues post-op

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📌 PART 8: PATIENT EDUCATION — WHAT TO TEACH

"10 Golden Rules for SPD/PGP" — Teach Patient:

1. Keep knees together when getting in/out of bed, turning over, getting in/out of car
2. Sit to put on underwear/trousers — do NOT stand on one leg
3. Take small equal steps when walking — avoid stride length difference
4. Sit to bottom of stairs, use rail, place both feet on each step
5. Avoid carrying on one hip
6. Do not push through pain — pain is a signal
7. Wear supportive footwear — no high heels
8. Sleep in side-lying with pillow between knees
9. Wear pelvic belt during activity — not at night
10. Avoid activities that open legs wide: swimming breaststroke, sitting cross-legged, squatting wide

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📌 PART 9: DIFFERENTIAL DIAGNOSIS

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📌 PART 10: SUMMARY TABLE — ALL SPECIAL TESTS

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📌 QUICK EXAM SUMMARY

1. ASLR (with compression modification)
2. P4 / Thigh Thrust
3. Mennell's Shear Test
4. Trendelenburg
5. FABER

1. TA activation
2. Clamshell (Gmed)
3. Bridging with knees together (NOT apart)
4. PFM training
5. Adductor squeeze