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Most Important Topics in Exercise Therapy for MPT Entrance

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1. Foundations of Exercise Therapy

• Isotonic (concentric + eccentric), isometric, isokinetic - definitions, differences, clinical uses
• Open kinetic chain (OKC) vs. closed kinetic chain (CKC) - examples and when to use each
• Active, active-assisted, passive exercise - indications
• Resisted exercises - manual vs. mechanical
• Aerobic vs. anaerobic exercise - energy systems (ATP-PC, glycolytic, oxidative)

• Muscle strength, endurance, power, flexibility, coordination
• SAID principle (Specific Adaptation to Imposed Demands)
• Overload principle, reversibility, specificity, progression

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2. Muscle Strength & Manual Muscle Testing (MMT)

• MRC/Kendall grading scale (0-5 with criteria for each grade) - very frequently tested
• Grade 3 = movement against gravity (pivot point)
• Normal = Grade 5
• Testing positions for individual muscles
• Difference between MMT and dynamometry
• Factors affecting muscle strength: age, sex, fiber type, cross-sectional area

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3. Range of Motion (ROM) & Flexibility

• Normal ROM values for all major joints (shoulder, hip, knee, ankle, spine) - memorize these
• Goniometry: axis, stationary arm, movable arm placement for each joint
• End-feel types: bony, capsular, soft tissue, spasm, boggy, empty - Cyriax classification
• Stretching types: static, ballistic, dynamic, PNF (Hold-Relax, Contract-Relax, HVLAT)
• PNF stretching - autogenic inhibition vs. reciprocal inhibition mechanisms

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4. PNF (Proprioceptive Neuromuscular Facilitation)

• Diagonal patterns: D1 and D2 for upper and lower limb (flexion/extension components)
• PNF techniques: Rhythmic Initiation, Slow Reversal, Hold-Relax, Contract-Relax, Repeated Contractions, Rhythmic Stabilization
• Neurophysiological basis: Sherrington's law of irradiation, reciprocal inhibition, successive induction
• Indications: neurological conditions, post-surgical rehab, sports

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5. Therapeutic Exercise Progression

• FITT principle: Frequency, Intensity, Time, Type
• RICE/PRICE/POLICE protocol for acute injuries
• De Lorme and Watkins progressive resistive exercise (PRE):
  • 10 RM concept
  • Three sets: 50%, 75%, 100% of 10 RM
• Oxford technique (reverse of De Lorme)
• Daily Adjustable Progressive Resistance Exercise (DAPRE)
• Borg's RPE (Rating of Perceived Exertion) scale: 6-20

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6. Muscle Physiology (Applied)

• Sliding filament theory - actin, myosin, troponin, tropomyosin mechanism
• Motor unit recruitment - size principle (Henneman)
• Fiber types: Type I (slow twitch - fatigue resistant), Type II (fast twitch - IIa, IIx)
• Length-tension relationship and force-velocity relationship
• Muscle hypertrophy vs. hyperplasia
• Delayed Onset Muscle Soreness (DOMS) - cause, timeline (24-72 hours), management
• Muscle atrophy: disuse vs. denervation

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7. Joint Mobilization & Manipulation

• Maitland grading (Grades I-IV and V):
  • Grade I: small amplitude, beginning of range (pain)
  • Grade II: large amplitude, beginning/middle of range (pain)
  • Grade III: large amplitude, into resistance
  • Grade IV: small amplitude, into resistance (stiffness)
  • Grade V: thrust/manipulation
• Convex-concave rule (Arthrokinematics): Roll and glide directions
• Accessory movements: gliding, rolling, spinning, distraction, compression
• Cyriax capsular pattern vs. non-capsular pattern

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8. Balance, Proprioception & Coordination Exercises

• Frenkel's exercises - for sensory ataxia (tabes dorsalis)
• Romberg's test - positive indicates loss of proprioception or vestibular function
• Balance training progression: stable to unstable surface, eyes open to eyes closed
• Vestibular rehabilitation exercises
• Core stabilization: inner vs. outer core units

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9. Aquatic / Hydrotherapy

• Archimedes principle - buoyancy and its therapeutic uses
• Therapeutic pool temperature: 33-36°C (neutral warmth)
• Hydrostatic pressure, turbulence, viscosity effects
• Bad Ragaz ring method - patterns in water
• Halliwick concept (ten-point program)
• Indications and contraindications of hydrotherapy

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10. Breathing Exercises & Chest Physiotherapy

• Diaphragmatic breathing technique
• Pursed-lip breathing - used in COPD (increases PEEP)
• Incentive spirometry
• Postural drainage positions for each lung lobe
• ACBT (Active Cycle of Breathing Technique): Breathing Control - Thoracic Expansion Exercises - Forced Expiratory Technique
• Huffing vs. coughing
• Percussion, vibration, shaking - differences and applications

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11. Endurance Training & Cardiac Rehabilitation

• Target Heart Rate: 60-85% of max HR (220 - age)
• Karvonen formula: THR = [(HRmax - HRrest) x intensity%] + HRrest
• VO2 max - gold standard for cardiorespiratory fitness
• Phase I, II, III, IV cardiac rehabilitation programs
• METs (Metabolic Equivalents): 1 MET = 3.5 mL O2/kg/min
• RPE scale application in cardiac rehab

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12. Posture & Ergonomics

• Ideal posture - plumb line alignment: earlobe, shoulder, greater trochanter, lateral malleolus
• Common postural deviations: kyphosis, lordosis, scoliosis, forward head posture, flat back
• Kendall postural classification
• Muscle imbalance: Janda's upper and lower crossed syndromes (very commonly tested)

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13. Gait Analysis

• Normal gait cycle: stance phase (60%) vs. swing phase (40%)
• Phases: Initial contact, Loading response, Mid-stance, Terminal stance, Pre-swing, Initial swing, Mid-swing, Terminal swing
• Step length, stride length, cadence, walking speed - definitions
• Common gait deviations and their causes (Trendelenburg, antalgic, steppage, scissor, Parkinsonian)
• Muscle activity during gait: gluteus medius role (key)

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14. Commonly Tested Specific Techniques

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16. Quick-Fire High-Yield Facts

• Muscle strength testing is most reliable at Grade 3 level
• Isometric contraction = no joint movement, maximum tension
• Eccentric contraction = muscle lengthens while contracting (greatest tension generated, most DOMS)
• Concentric = shortening
• Isokinetic = constant velocity (Cybex machine)
• 1 MET = resting oxygen consumption
• VO2 max decreases ~1% per year after age 25
• Overtraining syndrome: decreased performance + increased RPE
• Maitland Grade V = manipulation (requires special training)
• Convex surface moves: roll and glide in opposite directions
• Concave surface moves: roll and glide in same direction
• PNF D1 Flexion UL: Shoulder flexion + adduction + ER, elbow flex, wrist flex-adduction
• PNF D2 Flexion UL: Shoulder flexion + abduction + ER, elbow flex, wrist ext-abduction
• Normal shoulder flexion = 180°, abduction = 180°, ER = 90°, IR = 70°
• Normal hip flexion = 120°, extension = 30°, abduction = 45°
• Normal knee flexion = 135°, dorsiflexion = 20°, plantarflexion = 50°

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Priority Study Order for MPT Entrance

1. MMT grading + ROM values (always 4-5 questions)
2. Types of exercise + muscle contraction types
3. PNF patterns and techniques
4. De Lorme PRE / FITT principles
5. Maitland grading + convex-concave rule
6. Breathing exercises / ACBT
7. Gait cycle phases and deviations
8. Williams vs. McKenzie
9. Frenkel's + balance training
10. Aquatic therapy principles

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COMPLETE EXERCISE THERAPY NOTES FOR MPT ENTRANCE

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TOPIC 1: FOUNDATIONS OF EXERCISE THERAPY

Types of Muscle Contraction

Isometric Contraction

• The muscle generates tension but does not change in length and there is no joint movement
• Example: pushing against a wall, holding a weight still in mid-air
• Produces maximum tension at the specific joint angle trained (angle-specific strength gain)
• Used early in rehab when joint movement is painful or contraindicated (e.g., post-fracture, immediately post-op)
• No cardiovascular burden (blood pressure rises, but metabolic demand is low)
• Disadvantage: strength gain is limited to the trained angle (only ±10° carry-over)

Isotonic Contraction

• The muscle changes length while the load (resistance) remains constant
• Two subtypes:

• Muscle shortens while contracting
• Example: biceps curl lifting phase
• Produces least tension among the three types
• Most common in daily functional activities
• Less DOMS (delayed onset muscle soreness)

• Muscle lengthens while contracting (controls movement against gravity)
• Example: biceps curl lowering phase, walking downstairs (quadriceps)
• Produces the greatest tension of all contraction types
• Uses fewer motor units for same force = very efficient
• Responsible for most DOMS (micro-tears in muscle fibers)
• Used in tendon rehab (Achilles tendinopathy - Alfredson protocol)
• Dangerous if done excessively in untrained individuals

Isokinetic Contraction

• Movement occurs at a constant (pre-set) velocity
• Resistance varies throughout ROM to accommodate the muscle's strength curve
• Requires a special machine: Cybex, Biodex
• Maximum resistance at every point of ROM = maximum training stimulus
• Used for testing and training after knee surgery, sports rehab
• Very expensive, not available in all clinics

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Open Kinetic Chain (OKC) vs. Closed Kinetic Chain (CKC)

Open Kinetic Chain (OKC)

• The distal segment moves freely (foot or hand is free in the air)
• Example: straight leg raise, knee extension machine, biceps curl
• Isolates specific muscles
• Used to target a single muscle group
• Creates more shear forces at joints (e.g., anterior shear at knee in terminal extension)
• Useful for muscle isolation in early rehab

Closed Kinetic Chain (CKC)

• The distal segment is fixed (foot or hand is in contact with a fixed surface)
• Example: squats, leg press, push-ups, step-ups
• Co-contraction of agonist and antagonist occurs simultaneously
• More functional (mimics real-world movement)
• Less shear at joints, more joint compression (safer for ACL rehab)
• Preferred in later stages of rehab and sports-specific training

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Active, Active-Assisted, and Passive Exercise

Passive Exercise

• Movement is produced entirely by an external force (therapist, machine, or gravity)
• Patient's own muscle generates zero effort
• Used when: paralysis, coma, pain prevention, maintaining ROM in immobilized patients
• Does NOT maintain or increase muscle strength
• Maintains joint nutrition, prevents contractures, maintains tissue mobility

Active-Assisted Exercise

• The patient initiates movement but requires assistance to complete the full range
• Used when muscle strength is Grade 2 (can move but cannot overcome gravity) or Grade 3 but fatigues quickly
• Assistance can be manual (therapist) or mechanical (suspension, hydrotherapy)
• Gradually reduce assistance as strength improves

Active Exercise

• Movement is produced entirely by the patient's own muscle contraction
• No assistance, no resistance
• Used when strength is at least Grade 3 (can move against gravity)
• Maintains joint ROM, maintains muscle tone, improves coordination
• Progression from here is to add resistance (resisted exercise)

Resisted Exercise

• Active exercise performed against an external resistance
• Resistance can be: manual (therapist's hand), weights, resistance bands, machines
• Increases muscle strength, power, and endurance depending on the program

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Training Principles

SAID Principle (Specific Adaptation to Imposed Demands)

• The body adapts specifically to the type of stress placed on it
• If you train for strength, you gain strength (not necessarily endurance)
• If you train one arm, only that arm gets stronger
• Explains why exercise programs must match the patient's functional goal

Overload Principle

• For adaptation to occur, the exercise stress must exceed the current capacity of the body
• If you always lift the same weight, no further improvement occurs
• Basis of progressive resistive exercise (increasing load over time)

Reversibility (Use it or lose it)

• Adaptations gained through exercise are lost when training stops
• Strength starts declining within 2-3 weeks of detraining
• Endurance declines faster than strength
• Explains why maintenance programs are needed

Specificity Principle

• Training effects are specific to the type of exercise, muscles used, velocity, and energy system
• Slow training makes you better at slow movements, not fast ones
• Aerobic training does not improve anaerobic capacity significantly

Progression Principle

• Exercise intensity, volume, or complexity must be gradually increased over time
• Too rapid = injury; too slow = no adaptation
• Must follow a logical rehabilitation progression

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Energy Systems

ATP-PC System (Phosphagen System)

• Immediate energy, no oxygen needed (anaerobic)
• Duration: 0-10 seconds
• Used in: sprinting, jumping, explosive lifting
• Phosphocreatine donates its phosphate group to regenerate ATP from ADP

Glycolytic (Lactic Acid) System

• Short-term energy, no oxygen (anaerobic)
• Duration: 10 seconds to 2 minutes
• Produces lactate (lactic acid) as a byproduct
• Used in: 400m run, intense interval training
• Lactate causes muscle burning sensation (not DOMS)

Oxidative (Aerobic) System

• Long-term energy, requires oxygen
• Duration: beyond 2 minutes
• Produces ATP from carbohydrates, fats, and proteins via Krebs cycle + electron transport chain
• Used in: marathon, cycling, swimming distance
• Most efficient - produces 36-38 ATP per glucose molecule

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TOPIC 2: MANUAL MUSCLE TESTING (MMT)

MRC Grading Scale (Most Tested)

• Grade 2 = gravity eliminated = patient positioned so the limb moves horizontally
• Grade 3 is the key benchmark - if a muscle can move against gravity, it passes Grade 3
• Difference between 4 and 5 is subjective (how much resistance is "full"?)
• Grades 4- and 4+ are sometimes used clinically to subdivide Grade 4

Gravity-Eliminated Testing Positions

• For hip flexors: patient lying on side, supported limb flexes forward
• For knee extensors: patient lying on side (not sitting), extends knee horizontally
• For shoulder abductors: patient lying on back, arm lifts in the horizontal plane

Factors Affecting Muscle Strength

• Age: peaks at 20-30 years, declines after 40
• Sex: males typically 30% stronger than females (more testosterone, larger cross-section)
• Muscle cross-sectional area: biggest predictor of strength
• Fiber type: Type II fibers produce more force
• Motivation/neural factors: CNS drive contributes significantly
• Fatigue: reduces strength acutely
• Pain: inhibits muscle activation (arthrogenic inhibition)

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TOPIC 3: ROM, FLEXIBILITY & STRETCHING

Normal ROM Values (Memorize These)

Goniometry

• Stationary arm: aligned with the proximal bone (stays still)
• Movable arm: aligned with the distal bone (moves with the limb)
• Axis (fulcrum): placed over the joint axis of motion
• Example for knee flexion: axis = lateral knee joint, stationary arm = femur (lateral), movable arm = fibula

End-Feel (Cyriax Classification)

Normal End-Feels:

• Bony: hard, abrupt stop. Example: elbow extension (olecranon hits fossa)
• Capsular (leathery): firm, slight give. Example: shoulder ER in mid-range
• Soft tissue approximation: soft, spongy. Example: full knee flexion (calf meets thigh)

Abnormal End-Feels:

• Spasm: muscle goes into spasm before end of range (acute injury, pain)
• Boggy (springy): spongy rebound - suggests fluid/effusion in joint
• Empty: patient stops you before end range due to pain (no physical barrier) - serious pathology (tumor, abscess, fracture)
• Springy block: rebound at end range - suggests loose body/meniscus tear

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Types of Stretching

Static Stretching

• Hold a stretch position for 15-60 seconds, no bouncing
• Mechanism: stress relaxation and creep in viscoelastic tissues
• Most common type in clinical settings
• Safe, reduces injury risk if done after warm-up
• Best for improving general flexibility

Ballistic Stretching

• Bouncing movements at the end of range
• Uses momentum to force the limb beyond its normal ROM
• High risk of injury (activates stretch reflex, causing muscle to contract)
• Not recommended in rehabilitation
• Used by some athletes for sport-specific movements

Dynamic Stretching

• Controlled movement through full ROM without bouncing
• Example: leg swings, arm circles, hip circles
• Improves flexibility while also warming up the neuromuscular system
• Preferred as a warm-up before sport/exercise
• Does not hold the end position

PNF Stretching (see Topic 4 for full detail)

• Most effective stretching technique for increasing ROM
• Uses neurophysiological mechanisms to achieve greater gains than static stretching

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TOPIC 4: PNF (PROPRIOCEPTIVE NEUROMUSCULAR FACILITATION)

Neurophysiological Basis

Autogenic Inhibition

• When a muscle is under sustained tension, the Golgi Tendon Organ (GTO) fires
• GTO sends inhibitory signals to the same muscle via Ib afferent fibers
• The muscle relaxes (inhibited)
• Used in: Hold-Relax and Contract-Relax techniques
• After contracting the tight muscle maximally, the GTO fires, causing relaxation, and greater stretch is possible

Reciprocal Inhibition

• When the agonist contracts, the antagonist is reflexively inhibited (via Ia afferents from muscle spindle)
• Sherrington's Law of Reciprocal Innervation
• Used in: Contract-Relax with Antagonist Contraction (CRAC)
• Example: contracting the quadriceps inhibits hamstrings, allowing greater hamstring stretch

Irradiation

• Resistance applied to a strong muscle group "irradiates" or overflow to weaker muscles
• Basis of using strong limb patterns to facilitate weak ones
• Used in stroke, neurological conditions

Successive Induction

• Contracting the antagonist first facilitates the subsequent contraction of the agonist
• After resisting flexion, extension becomes stronger

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PNF Diagonal Patterns

Upper Limb D1 Flexion

• Shoulder: Flexion + Adduction + External Rotation
• Elbow: Flexion or extension (varies)
• Wrist: Flexion + Radial deviation
• Fingers: Flexion + Adduction
• Function: like crossing to scratch opposite shoulder

Upper Limb D1 Extension (opposite)

• Shoulder: Extension + Abduction + Internal Rotation
• Wrist: Extension + Ulnar deviation
• Function: like a backhand tennis stroke

Upper Limb D2 Flexion

• Shoulder: Flexion + Abduction + External Rotation
• Elbow: Flexion or extension
• Wrist: Extension + Radial deviation
• Function: like combing hair (sword-drawing motion)

Upper Limb D2 Extension (opposite)

• Shoulder: Extension + Adduction + Internal Rotation
• Wrist: Flexion + Ulnar deviation
• Function: like reaching into opposite hip pocket

Lower Limb D1 Flexion

• Hip: Flexion + Adduction + External Rotation
• Knee: Flexion or extension
• Ankle: Dorsiflexion + Inversion

Lower Limb D2 Flexion

• Hip: Flexion + Abduction + Internal Rotation
• Ankle: Dorsiflexion + Eversion

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PNF Techniques

Hold-Relax (HR)

• Therapist moves limb to end of comfortable range
• Patient performs isometric contraction of the tight (shortened) muscle against therapist's resistance (holds, doesn't move)
• 6-10 second hold, then relax
• Therapist moves into the new range
• Mechanism: autogenic inhibition (GTO fires in tight muscle)

Contract-Relax (CR)

• Similar to Hold-Relax but the contraction is isotonic (the tight muscle moves through range with resistance)
• Therapist resists the movement
• After contraction, relax, then new stretch
• More intense than Hold-Relax

Slow Reversal (SR)

• Alternating isotonic contractions of agonist and antagonist
• Patient moves actively into range, then actively returns
• Builds strength through full range in both directions

Rhythmic Initiation

• Movement starts with passive, then progresses to active-assisted, then active, then resisted
• Used in patients with rigidity (Parkinson's), hypertonia, or poor motor initiation
• Teaches the movement pattern before resisting it

Rhythmic Stabilization

• Simultaneous isometric contractions of agonist and antagonist while therapist resists both
• Builds co-contraction and joint stability
• Used for stability of shoulder, knee, trunk

Repeated Contractions

• Repeated stretches at the beginning of range or at a point of weakness to stimulate more powerful contraction
• Uses the stretch reflex to facilitate weak muscles

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TOPIC 5: THERAPEUTIC EXERCISE PROGRESSION

De Lorme and Watkins Progressive Resistive Exercise (PRE)

• The maximum weight that can be lifted exactly 10 times with proper form
• First, determine the 10 RM for the target muscle

• Starts light (warm-up), progressively increases to maximal effort
• Re-test 10 RM weekly and adjust loads accordingly
• Based on: overload principle - the 3rd set at 100% provides the training stimulus

Oxford Technique

• Reverse of De Lorme
• Starts at 100% of 10 RM and decreases | Set | Load | |---|---| | Set 1 | 100% of 10 RM | | Set 2 | 75% of 10 RM | | Set 3 | 50% of 10 RM |
• Rationale: exercise when fresh (full capacity first)
• Less popular than De Lorme today

DAPRE (Daily Adjustable Progressive Resistance Exercise) - Knight

• More dynamic: adjusts load daily based on the patient's actual performance
• Uses 4 sets

• 0-2 reps: decrease weight by 5-10 lbs
• 3-4 reps: decrease weight by 0-5 lbs
• 5-6 reps: keep the same
• 7-10 reps: increase by 5-10 lbs
• 11+ reps: increase by 10-15 lbs

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FITT Principle (Exercise Prescription)

• For aerobic training (ACSM guidelines): F=3-5/week, I=55-90% HRmax, T=20-60 min
• For strength training: F=2-3/week (same muscle group), I=60-80% 1RM, 8-12 reps, 2-4 sets

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PRICE Protocol (Acute Injury Management)

• P = Protection (prevent further injury)
• R = Rest (relative rest, avoid aggravating activity)
• I = Ice (cold for 15-20 minutes, vasoconstriction, reduces inflammation)
• C = Compression (bandage to reduce swelling)
• E = Elevation (raise limb above heart level to drain fluid)

• "Optimal Loading" replaced "Rest" because early controlled loading speeds recovery

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Borg's RPE Scale (Rating of Perceived Exertion)

• Scale: 6 to 20 (developed by Gunnar Borg)
• 6 = no exertion at all (resting)
• 11 = light
• 13 = somewhat hard (moderate intensity)
• 17 = very hard
• 20 = maximal exertion
• Formula: RPE × 10 ≈ Heart Rate (e.g., RPE of 13 ≈ HR of 130 bpm)
• Used when HR monitoring is not possible (in cardiac patients with pacemakers, on beta-blockers)

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TOPIC 6: MUSCLE PHYSIOLOGY (APPLIED)

Sliding Filament Theory

• Actin (thin filament): has active sites, covered by tropomyosin and troponin complex at rest
• Myosin (thick filament): has cross-bridge heads that bind to actin

1. Motor neuron fires → action potential travels to neuromuscular junction (NMJ)
2. Acetylcholine (ACh) released from synaptic vesicles
3. ACh binds to receptors on motor end plate → generates end plate potential
4. Action potential spreads through T-tubules into muscle fiber
5. T-tubules stimulate sarcoplasmic reticulum → Ca²⁺ released
6. Ca²⁺ binds to troponin C on the actin filament
7. Troponin moves tropomyosin away from actin active sites → active sites exposed
8. Myosin head binds to actin → forms cross-bridge
9. Power stroke: myosin head pivots, pulls actin toward center of sarcomere (H-zone narrows)
10. ATP binds to myosin → cross-bridge detaches
11. ATP hydrolyzed → myosin re-cocks for next cycle
12. Cycle repeats as long as Ca²⁺ is present
13. When stimulation stops: Ca²⁺ pumped back into SR → troponin blocks active sites → relaxation

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Motor Unit Recruitment - Size Principle (Henneman)

• Motor units are recruited in order of increasing size (small → large)
• Small motor units (Type I fibers): recruited first, fatigue slowly, low force
• Large motor units (Type II fibers): recruited later, fatigue quickly, high force
• For low-intensity tasks (walking): only small motor units active
• For high-intensity tasks (sprinting, heavy lifting): all motor units recruited including large ones

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Muscle Fiber Types

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Length-Tension Relationship

• A muscle generates maximum force at its optimal (resting) length (slightly stretched, ~1.2x resting)
• At very short or very long lengths, force production decreases
• Clinical application: muscles work best near mid-range of their length

Force-Velocity Relationship

• Concentric: as velocity increases, force decreases (inverse relationship)
• Eccentric: as velocity increases, force also increases slightly
• Isometric is at zero velocity and has moderate force
• This is why isokinetic training at slow speeds produces more force than fast speeds (for concentric)

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DOMS (Delayed Onset Muscle Soreness)

• Definition: muscle pain and stiffness that peaks 24-72 hours after unaccustomed eccentric exercise
• Cause: micro-tears in muscle fibers and connective tissue, inflammatory response
• Mechanism: primarily caused by eccentric contractions
• Symptoms: stiffness, tenderness, reduced strength (temporary), slight swelling
• Management: light exercise (active recovery), gentle stretching, NSAIDs, massage, cold therapy
• Not to be confused with acute muscle soreness (during exercise from lactate)
• DOMS is NOT prevented by warm-up alone

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Muscle Atrophy

Disuse Atrophy

• From immobilization or inactivity
• Both Type I and Type II fibers shrink
• Type II fibers atrophy faster
• Reversible with retraining

Denervation Atrophy

• From damage to the motor nerve
• Muscle loses all neural input
• Develops faster and more severe than disuse atrophy
• Fibrillations and positive sharp waves on EMG
• If re-innervation occurs: recovery possible; if not: eventually replaced by fibrous tissue

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TOPIC 7: JOINT MOBILIZATION & MANIPULATION

Maitland Grading System (Grades I-V)

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Arthrokinematics (Joint Surface Motion)

Convex-Concave Rule (Kaltenborn)

• Shoulder (GH joint): Humeral head (convex) moves on Glenoid (concave)
  • When arm abducts (humerus rolls superiorly), the humeral head glides inferiorly (opposite)
  • Clinical: loss of inferior glide = restricted abduction → mobilize inferiorly
• Knee (tibiofemoral): Tibia (concave) moves on Femur (convex) during open chain
  • Tibia rolls anterior during extension → tibia also glides anterior (same direction)
  • Clinical: loss of anterior tibial glide = restricted knee extension

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Accessory Movements

• Gliding (translation): one surface slides over another (most common mobilization)
• Rolling: one surface rolls over another (like a ball on the floor)
• Spinning: rotation around a stationary axis
• Distraction (traction): surfaces pulled apart (relieves compression, reduces pain)
• Compression: surfaces pushed together

• Grade I: slack taken up (pain relief, neutralizes gravity)
• Grade II: tissue slack removed (stretching, pain relief)
• Grade III: tissue stretch (increases ROM)

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Cyriax Capsular vs. Non-Capsular Pattern

Capsular Pattern

• Restriction of ROM in a predictable ratio when the entire joint capsule is involved
• Indicates: capsulitis, arthritis, frozen shoulder
• Each joint has its own pattern:
  • Shoulder: ER > Abduction > IR most limited
  • Hip: IR > Flexion > Abduction most limited
  • Knee: Flexion > Extension most limited
  • Elbow: Flexion > Extension most limited

Non-Capsular Pattern

• Restriction that does NOT follow the capsular pattern
• Indicates: intra-articular pathology (loose body, meniscus), ligament sprain, bursitis, muscle lesion
• Example: a patient with knee meniscus tear may have full flexion but block at 90° on extension (springy end-feel)

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TOPIC 8: BALANCE, PROPRIOCEPTION & COORDINATION

Proprioception

• The sense of body position in space without looking
• Receptors: muscle spindles (dynamic + static position), GTOs, joint mechanoreceptors, skin receptors
• Two types:
  • Kinesthesia: sense of movement and change in joint angle
  • Position sense (joint position sense): awareness of static limb position

Romberg's Test

• Patient stands with feet together, arms at sides
• Phase 1: Eyes open → stable = normal
• Phase 2: Eyes closed → patient sways/falls = Romberg's positive
• Positive Romberg's = patient depends on vision to compensate for lost proprioception or vestibular function
• Indicates: sensory ataxia (posterior column lesion - dorsal column), peripheral neuropathy, vestibular disorder
• Differentiating: if unsteady with eyes OPEN too = cerebellar ataxia (not positive Romberg's - both eyes open and closed are unsteady)

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Frenkel's Exercises (for Sensory Ataxia)

• Designed for patients with sensory ataxia (loss of proprioception in lower limbs)
• Classic cause: Tabes Dorsalis (syphilis affecting posterior columns), multiple sclerosis, peripheral neuropathy
• Principles: uses vision to substitute for lost proprioception; exercises are done slowly, precisely, with full attention
• Performed in progression: lying → sitting → standing → walking
• Examples:
  • Lying: sliding heel up and down the leg to a mark
  • Sitting: placing foot on a marked spot
  • Standing: walking along a line marked on the floor
  • Walking: stepping over obstacles, turning

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Balance Training Progression

1. Bilateral stable surface, eyes open
2. Bilateral stable surface, eyes closed
3. Unilateral (single leg), stable surface, eyes open
4. Unilateral, stable surface, eyes closed
5. Bilateral unstable surface (foam pad, wobble board), eyes open
6. Bilateral unstable surface, eyes closed
7. Unilateral unstable surface, eyes open
8. Unilateral unstable surface, eyes closed
9. Add dual-task (cognitive + balance, e.g., counting backward while balancing)
10. Functional tasks: catching, throwing, sport-specific movements

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Core Stabilization

Inner Core (Local Stabilizers)

• Deep muscles that stabilize the spine directly
• Transversus abdominis (TA): deepest abdominal muscle, forms a corset around the spine
• Multifidus: deep spinal muscle, controls intersegmental stability
• Pelvic floor muscles
• Diaphragm
• These fire before limb movements (anticipatory postural activation)
• In people with chronic low back pain: TA activation is delayed (Hodges & Richardson research)

Outer Core (Global Stabilizers)

• Larger muscles that move the trunk and control large forces
• Rectus abdominis, obliques, erector spinae, gluteals
• Activated for high-load tasks

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Vestibular Rehabilitation

• For patients with vertigo, dizziness, vestibular hypofunction
• BPPV (Benign Paroxysmal Positional Vertigo): dislodged otoconia in semicircular canals
  • Treatment: Epley maneuver (canalith repositioning), Semont maneuver
• Cawthorne-Cooksey exercises: head and eye movements to habituate the vestibular system
• Gaze stabilization exercises: VOR (vestibulo-ocular reflex) training

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TOPIC 9: AQUATIC / HYDROTHERAPY

Archimedes' Principle

• Any object immersed in fluid experiences an upward buoyant force equal to the weight of fluid displaced
• A person immersed to the neck: body weight reduced to approximately 10% of normal
• Immersed to waist: approximately 50% body weight
• Immersed to chest/axilla: approximately 25-40% body weight
• Clinical use: allows early weight-bearing in water for patients who cannot bear full weight on land (post-fracture, post-arthroplasty, morbid obesity, osteoarthritis)

Properties of Water Used Therapeutically

Buoyancy

• Reduces effective body weight (see above)
• Can be used to assist, support, or resist movement
  • Buoyancy-assisted: moving limb toward water surface (upward)
  • Buoyancy-supported: moving limb horizontally at water surface
  • Buoyancy-resisted: moving limb downward against buoyancy

Hydrostatic Pressure

• Pressure exerted by water on all surfaces of an immersed body equally
• Increases with depth (deeper = more pressure)
• Effects: reduces edema, improves venous and lymphatic return, assists cardiac preload
• Pascal's Law: pressure at any point in fluid acts equally in all directions

Viscosity

• Water's resistance to flow creates drag
• Increases resistance to movement (good for strengthening)
• Faster movement = greater resistance (no need for weights in water)
• Turbulence increases resistance further

Thermal Properties

• Warm water (33-36°C): reduces pain, reduces muscle spasm, improves tissue extensibility
• Cold water: reduces inflammation, vasoconstriction (used in cryotherapy pools for athletes)

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Therapeutic Pool Temperature Guidelines

• Therapeutic/rehabilitation: 33-36°C (neutral warmth)
• Rheumatoid arthritis: 34-36°C (warm)
• Spasticity reduction: 37-40°C (hot)
• Athlete recovery: 12-15°C (cold)
• Contrast hydrotherapy: alternate hot/cold

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Halliwick Concept (Ten-Point Programme)

1. Mental adjustment
2. Sagittal rotation control
3. Transversal rotation control
4. Longitudinal rotation control
5. Combined rotation control
6. Upthrust (buoyancy - floating)
7. Balance in stillness
8. Turbulent gliding
9. Simple progression
10. Basic Halliwick movement (swimming)

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Bad Ragaz Ring Method

• Therapeutic technique using rings (floats) around neck, arms, pelvis, knees to keep patient horizontal in water
• Therapist provides fixed point or resistance; patient's body moves
• Adapted from PNF patterns (same diagonal movements performed in water)
• Used for: neurological rehab, spinal injuries, strengthening, relaxation

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Contraindications of Hydrotherapy

• Open wounds, skin infections (risk of contamination)
• Uncontrolled bowel/bladder (incontinence without waterproof protection)
• Severe cardiac or respiratory conditions (absolute)
• Epilepsy (relative, can be done with supervision)
• Severe fear of water
• Infectious diseases
• Uncontrolled hypertension

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TOPIC 10: BREATHING EXERCISES & CHEST PHYSIOTHERAPY

Diaphragmatic (Abdominal) Breathing

• Patient lies supine, one hand on chest, one on abdomen
• Inhale: diaphragm descends → abdomen rises (belly hand rises, chest hand should NOT rise much)
• Exhale: abdomen falls, diaphragm ascends
• Purpose: maximizes tidal volume, reduces respiratory rate, reduces work of breathing
• Used in: COPD, anxiety, post-surgical patients

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Pursed-Lip Breathing

• Inhale through nose (2 counts), exhale through pursed lips as if blowing a candle slowly (4 counts)
• Creates back-pressure in airways during expiration = auto-PEEP (positive end-expiratory pressure)
• Prevents dynamic airway collapse in COPD (where airways collapse during forced expiration)
• Slows breathing rate, reduces air trapping, improves O2 saturation
• Primary use: COPD, emphysema

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Incentive Spirometry

• Device with a ball or piston that rises when the patient inhales slowly and deeply
• Provides visual feedback for sustained maximal inspiration (SMI)
• Prevents post-operative atelectasis
• Used: post-surgery (especially thoracic/abdominal), pneumonia, mucus clearance
• Goal: reach and maintain target volume for 3-5 seconds

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ACBT (Active Cycle of Breathing Technique)

Phase 1: Breathing Control (BC)

• Gentle, relaxed, tidal breathing at normal rate
• Uses diaphragmatic breathing
• Purpose: relax bronchospasm, rest between other phases

Phase 2: Thoracic Expansion Exercises (TEE)

• 3-5 deep slow breaths with a 3-second hold at peak inspiration
• Allows collateral ventilation (air moves behind secretions through pores of Kohn)
• Loosens and mobilizes secretions

Phase 3: Forced Expiratory Technique (FET / Huffing)

• Huff: open glottis, medium-deep inspiration, then forced expiration with an open mouth (as if fogging a mirror) - "haaaa" sound
• Moves secretions from peripheral to central airways
• Lower effort than coughing, less bronchospasm
• Followed by breathing control, then cough to expectorate

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Huffing vs. Coughing

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Postural Drainage

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Percussion, Vibration, Shaking

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TOPIC 11: ENDURANCE TRAINING & CARDIAC REHABILITATION

Target Heart Rate (THR)

• Maximum HR (HRmax) = 220 - age (formula, not exact for everyone)
• Target Zone = 60-85% of HRmax
• Example: 40-year-old: HRmax = 180 bpm; THR = 108-153 bpm

• HRR (Heart Rate Reserve) = HRmax - HRresting
• THR = (HRR × desired intensity%) + HRresting
• More accurate as it accounts for resting HR (fitness level)
• Example: HRmax=180, HRrest=70, desired intensity=70%
  • HRR = 180-70 = 110
  • THR = (110 × 0.70) + 70 = 77 + 70 = 147 bpm

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VO2 Max (Maximal Oxygen Uptake)

• The maximum rate at which the body can consume oxygen during maximal exercise
• Gold standard for cardiorespiratory fitness
• Values: average male ≈ 40-50 mL/kg/min; trained athlete ≈ 60-80 mL/kg/min; sedentary female ≈ 27-35
• Declines approximately 1% per year after age 25 in sedentary individuals
• Exercise training can increase VO2 max by 15-30%
• Limited by: cardiac output (mainly), oxygen delivery to muscles, mitochondrial capacity

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METs (Metabolic Equivalents)

• 1 MET = resting metabolic rate = 3.5 mL O2/kg/min
• Used to quantify exercise intensity in a standardized way
• Examples:
  • Sleeping: 0.9 MET
  • Sitting: 1 MET
  • Walking 3 mph: 3.5 METs
  • Cycling: 6-10 METs
  • Running 6 mph: 10 METs
  • Maximum: 20+ METs in elite athletes
• Used in cardiac rehab to prescribe activities safely after MI or surgery

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Cardiac Rehabilitation Phases

Phase I (Inpatient/Acute)

• Setting: Hospital (CCU, cardiac ward)
• Starts 24-48 hours after MI if stable
• Activities: deep breathing, ankle pumps, sitting up, short walks in corridor
• Goal: prevent deconditioning, assess exercise tolerance, patient education
• Intensity: 1-2 METs, RPE < 11, HR < HRrest + 20 bpm

Phase II (Early Outpatient)

• Setting: Hospital outpatient department or cardiac rehab center
• Duration: 6-12 weeks
• Monitored exercise (ECG, BP, SpO2 monitoring)
• Progressive walking, cycling, light resistance training
• Patient education: risk factor modification, diet, smoking cessation, medication
• Intensity: progressively increased to 4-7 METs

Phase III (Community-Based)

• Setting: Community gym or home-based, supervised less intensively
• Maintains improvements from Phase II
• Patient becoming more independent
• Duration: 3-6 months or indefinite

Phase IV (Maintenance)

• Setting: Independent (unsupervised or minimally supervised)
• Long-term lifestyle physical activity
• Goal: sustain cardiorespiratory fitness, reduce risk of recurrent events

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TOPIC 12: POSTURE & ERGONOMICS

Ideal Posture - Plumb Line Alignment

• Lateral view: Earlobe → Shoulder (acromion) → Greater trochanter → Just anterior to lateral knee joint → Lateral malleolus
• Posterior view: Midline of skull → Spinous processes → Gluteal cleft → Midline between feet

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Common Postural Deviations

Kyphosis

• Excessive posterior curvature of the thoracic spine (hunchback)
• Common in: elderly (osteoporosis), Scheuermann's disease in adolescents
• Associated with: forward head posture, tight pectorals, weak mid-trapezius + rhomboids

Lordosis

• Excessive anterior curvature of the lumbar spine (swayback)
• Common in: pregnancy, obesity, psoas tightness
• Associated with: anterior pelvic tilt, tight hip flexors and lumbar extensors, weak abdominals + gluteals

Scoliosis

• Lateral curvature of the spine with vertebral rotation (in 3D)
• Structural vs. functional (postural)
• Cobb's angle: measured on X-ray to quantify severity
  • < 10°: normal variation
  • 10-25°: mild
  • 25-45°: moderate (brace)

  • 45-50°: severe (surgery)

Flat Back Posture

• Reduced lumbar lordosis (spine too straight)
• Posterior pelvic tilt
• Often caused by: tight hamstrings, weak hip flexors

Forward Head Posture

• Head protrudes forward of the plumb line
• For every 2.5 cm forward: head weight effectively increases by ~10 lbs on the cervical spine
• Associated with: upper cervical extension (suboccipital compression), lower cervical flexion

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Janda's Crossed Syndromes (Very Commonly Tested)

Upper Crossed Syndrome

• Tight (overactive): Upper trapezius, Levator scapulae, SCM, Pectorals (major + minor), Suboccipital muscles
• Weak (underactive): Deep neck flexors, Rhomboids, Middle trapezius, Serratus anterior, Lower trapezius
• Postural result: Forward head, elevated/protracted shoulders, rounded upper back
• X-pattern: tight muscles cross with weak muscles in an "X" pattern

Lower Crossed Syndrome

• Tight (overactive): Hip flexors (iliopsoas, rectus femoris), Lumbar erector spinae
• Weak (underactive): Gluteus maximus, Gluteus medius, Abdominals (especially TA)
• Postural result: Anterior pelvic tilt, increased lumbar lordosis, slight hip flexion during standing
• Gait deviation: reduced hip extension, increased lumbar extension

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TOPIC 13: GAIT ANALYSIS

Normal Gait Cycle

Time Distribution:

• Stance phase: 60% of gait cycle (foot on ground)
• Swing phase: 40% of gait cycle (foot in air)
• Double support (both feet on ground simultaneously): ~20% total (10% at beginning and 10% at end of stance)
• At walking speeds, there is always a period of double support
• At running speeds: no double support → instead there is a "float phase" where neither foot is on the ground

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Phases of Gait (RLA/Rancho Los Amigos Terminology)

Stance Phase (60%)

1. Initial Contact (Heel Strike): Heel contacts ground; hip is flexed ~30°, knee near full extension, ankle neutral
2. Loading Response (Foot Flat): Foot rolls to flat; controlled plantarflexion (tibialis anterior eccentrically controls); knee flexes 15-20° for shock absorption (vastus medialis active); weight transferred to stance limb
3. Mid-Stance: Center of mass rises; body weight over stance foot; full weight-bearing; hip extending, knee extending, ankle dorsiflexing; gluteus medius stabilizes pelvis
4. Terminal Stance (Heel Off): Heel rises; ankle plantarflexes; hip continues extending; forward progression of body
5. Pre-Swing (Toe Off): Toe leaves ground; hip begins flexing; preparation for swing

Swing Phase (40%)

1. Initial Swing: Limb lifts from ground; hip flexes; knee flexes; ankle dorsiflexes (tibialis anterior - most active in early swing)
2. Mid-Swing: Limb swings forward; clearance achieved; tibialis anterior holds foot up
3. Terminal Swing: Knee extends; hip decelerates; hamstrings control limb deceleration; prepares for next heel strike

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Spatial & Temporal Parameters

• Step: one foot to other foot (right heel strike to left heel strike)
• Stride: same foot to same foot (right heel strike to next right heel strike)
• Step length: distance between consecutive heel strikes of opposite feet (~35-40 cm/step)
• Stride length: ~70-80 cm (2x step length)
• Cadence: number of steps per minute (~100-120 steps/min in adults)
• Walking speed: stride length × cadence/2 (normal ≈ 1.2-1.4 m/s in adults)
• Base of support (step width): lateral distance between feet (~5-10 cm)

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Muscle Activity During Gait (Key Points)

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Common Gait Deviations

Trendelenburg Gait

• Cause: Weak gluteus medius on the stance side
• Pattern: The pelvis drops on the swing (non-weight-bearing) side during stance
• Compensated Trendelenburg: Patient leans trunk toward the weak side (to bring COG over hip) - appears like a "waddling" gait
• Seen in: hip abductor weakness, hip OA, superior gluteal nerve lesion

Antalgic Gait

• Cause: Pain in the weight-bearing limb
• Pattern: Shortened stance time on the painful limb; patient rushes off the painful limb quickly
• Seen in: any painful hip, knee, ankle, or foot condition

Steppage Gait (High-Stepping)

• Cause: Weak or paralyzed tibialis anterior (foot drop) → ankle stays plantarflexed during swing
• Pattern: Hip and knee flex excessively to clear the dropped foot
• Seen in: common peroneal nerve palsy, L4-L5 nerve root lesion, Charcot-Marie-Tooth disease

Scissor Gait

• Cause: Bilateral spastic hip adductors
• Pattern: Both legs cross midline (like scissors) due to adductor spasm
• Seen in: Cerebral palsy, bilateral upper motor neuron lesions

Parkinsonian Gait

• Features: Shuffling (reduced step length), festination (accelerating involuntarily), stooped posture, reduced arm swing, difficulty initiating, "freezing"
• Cause: Parkinson's disease (dopamine deficiency in basal ganglia)

Hemiplegic Gait (Circumduction)

• Cause: Spastic hemiplegia after stroke
• Pattern: Affected leg is circumducted (swung outward in a circle) because of inability to flex knee/hip
• Stiff, extended spastic limb - Wernicke-Mann posture

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TOPIC 14: SPECIFIC TECHNIQUES & QUICK-FIRE FACTS

Williams' Flexion Exercises

• Developed by Paul Williams in 1937
• Indication: Low back pain associated with lumbar lordosis, degenerative disc disease, facet joint arthritis
• Principle: Reduce lumbar lordosis, open the posterior intervertebral foramen, strengthen abdominals
• Exercises include:
  1. Pelvic tilt (flatten lumbar spine to floor)
  2. Single knee to chest
  3. Double knee to chest
  4. Partial sit-up (crunch)
  5. Hamstring stretch
  6. Half-squat
• Avoid in: acute disc herniation with neural tension signs (the flexion increases intradiscal pressure)

McKenzie Extension Exercises

• Developed by Robin McKenzie
• Indication: Disc herniation with posterior nuclear displacement (disc prolapse)
• Principle: Extension "centralizes" referred pain (pain moves from periphery toward the spine) → good sign
• "Centralization phenomenon" is the key concept - pain that moves centrally predicts good outcome with McKenzie
• Exercises:
  1. Lying prone (passive extension)
  2. Prone on elbows
  3. Press-ups (prone push-ups to lumbar extension)
  4. Standing extension
• Contraindicated in: spinal stenosis, spondylolisthesis (extension worsens these)

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Codman's Pendulum Exercises

• Also called Codman's circumduction or pendulum exercises
• Patient bends forward at waist, lets arm hang freely, performs small circles/pendulum swings using trunk motion
• The arm is passive - no muscle contraction in the shoulder
• Purpose: gentle distraction and mobilization of GH joint, reduces pain, maintains early ROM
• Indication: frozen shoulder (adhesive capsulitis), rotator cuff injuries, post-surgical shoulder
• Used in the very early (acute) phase when active motion is painful

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Short Arc Quadriceps Exercise

• Patient lies supine, a roll placed under the knee (knee slightly flexed ~30-45°)
• Patient extends knee from 30° flexion to full extension (terminal 30° arc)
• Purpose: Isolates vastus medialis oblique (VMO) - the medial quadriceps responsible for terminal extension
• Indication: Post-knee surgery (ACL reconstruction, total knee arthroplasty), patellofemoral syndrome
• Avoids full range because deep flexion compresses the patellofemoral joint and stresses healing ACL graft

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Wall Pulley Exercises

• Overhead pulley system attached to wall
• Patient uses the unaffected arm to assist the affected arm in elevation through the pulley mechanism
• Provides active-assisted movement for shoulder elevation (flexion and abduction)
• Indication: Limited shoulder ROM, post-surgical shoulder, frozen shoulder, rotator cuff repair
• Allows graded progression of range

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Heel-Toe Walking (Frenkel's Walking Exercises)

• Patient walks along a line marked on the floor, placing each foot precisely heel-to-toe
• Uses visual feedback to control coordination
• Part of Frenkel's exercise progression (see Topic 8)
• Used in: sensory ataxia, cerebellar ataxia rehabilitation

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Straight Leg Raise (SLR)

• In the exercise context (not the neurodynamic test):
• Patient lies supine, one knee bent, other leg straight
• Lift the straight leg to ~45° (contracts hip flexors and creates isometric quadriceps contraction)
• Purpose: Strengthens hip flexors (iliopsoas), quadriceps (isometric), and indirectly the core
• Indication: Early post-op knee (before full active knee extension is safe), quadriceps weakness

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COMPLETE QUICK-FIRE REVISION FACTS

Muscle Contraction

• Eccentric = greatest force production + most DOMS
• Concentric = least force production
• Isometric = no joint movement + angle-specific gain only
• Isokinetic = constant velocity, maximum resistance throughout (Cybex/Biodex)
• During eccentric: fewer motor units needed for same force = more efficient

MMT

• Grade 0 = no contraction
• Grade 1 = flicker/trace only
• Grade 2 = full ROM, gravity eliminated
• Grade 3 = full ROM, against gravity, NO resistance
• Grade 4 = against some resistance
• Grade 5 = normal, against full resistance

ROM Key Values

• Shoulder abduction = 180°, ER = 90°
• Hip flexion = 120°, extension = 30°
• Knee flexion = 135°
• Ankle dorsiflexion = 20°, plantarflexion = 50°

PNF

• D2 Flexion UL = shoulder flexion + abduction + ER (like combing hair)
• D1 Flexion UL = shoulder flexion + adduction + ER (like reaching across to scratch)
• Hold-Relax uses isometric contraction → autogenic inhibition (GTO)
• Contract-Relax uses isotonic contraction

Exercise Prescription

• 1 RM = maximum load for 1 repetition
• 10 RM = maximum load for exactly 10 reps
• De Lorme: 50% → 75% → 100% of 10 RM
• Oxford: 100% → 75% → 50% of 10 RM (reverse)
• DAPRE: daily adjusted based on last set reps

Maitland

• Grades I & II = pain (free range)
• Grades III & IV = stiffness (into resistance)
• Grade V = HVLAT manipulation

Arthrokinematics

• Convex on concave: glide OPPOSITE to roll
• Concave on concave: glide SAME as roll

Cardiac Rehab

• HRmax = 220 - age
• Karvonen = (HRmax - HRrest) × % + HRrest
• 1 MET = 3.5 mL O2/kg/min
• Phase I = inpatient hospital (1-2 METs)
• Phase II = monitored outpatient (6-12 weeks)
• Phase III = community-based
• Phase IV = independent maintenance

Aquatic Therapy

• Neck depth immersion ≈ 10% body weight
• Waist depth ≈ 50% body weight
• Pool temp for rehab = 33-36°C
• Archimedes = buoyancy = weight of fluid displaced

Breathing

• ACBT = BC → TEE → BC → FET → expectorate
• Pursed lip = auto-PEEP = prevents airway collapse in COPD
• DOMS peaks at 24-72 hours after eccentric exercise
• Frenkel's = for sensory ataxia (uses vision to compensate)

Gait

• Stance = 60%, Swing = 40%
• Gluteus medius = stance phase, prevents pelvis drop
• Trendelenburg = weak gluteus medius (pelvis drops on opposite side)
• Steppage = foot drop (weak tibialis anterior) = common peroneal nerve palsy
• Tibialis anterior = most active in swing phase

Key Formulas

• VO2 max declines ~1%/year after age 25
• Stride = heel to same heel; Step = heel to opposite heel
• Cadence = steps per minute (~100-120 normal)
• RPE × 10 ≈ Heart Rate

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