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Physiotherapy - Complete 15-Mark Answer Guide (BPT Degree Exam)

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1. Electrotherapy Modalities

A. TENS (Transcutaneous Electrical Nerve Stimulation)

• Definition: Application of low-voltage electrical current through skin electrodes to relieve pain.
• Mechanism: Based on the Gate Control Theory (Melzack & Wall) - stimulation of A-beta fibres "closes the gate" to pain signals carried by A-delta and C fibres. Also stimulates release of endorphins (opioid mechanism).
• Parameters: Frequency 1-150 Hz; pulse width 50-200 microseconds; intensity: comfortable tingling.
• Modes:
  • Conventional (high frequency, low intensity): immediate, short-lasting relief
  • Acupuncture-like (low frequency, high intensity): delayed but longer relief
  • Burst mode: combination of both
• Indications: Musculoskeletal pain, post-operative pain, neuropathic pain, labour pain.
• Contraindications: Cardiac pacemaker, over carotid sinus, pregnancy (over abdomen/lumbar), epilepsy, broken skin.

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B. Ultrasound Therapy

• Definition: Application of high-frequency sound waves (0.5-3 MHz) for therapeutic purposes.
• Effects:
  • Thermal: Increases tissue temperature, increases extensibility of collagen, vasodilation.
  • Non-thermal (Cavitation & Streaming): Micro-streaming of intracellular fluids, increases cell membrane permeability, enhances tissue repair.
• Modes:
  • Continuous: maximum thermal effect
  • Pulsed (1:1, 1:3, 1:4): predominantly non-thermal/mechanical effect
• Parameters: Frequency (1 MHz for deep tissues; 3 MHz for superficial); Intensity 0.5-3 W/cm²; ERA (Effective Radiating Area) of probe.
• Indications: Soft tissue injuries, tendinitis, bursitis, scar tissue, plantar fasciitis.
• Contraindications: Over malignancy, near pacemaker, open epiphyses, deep vein thrombosis, over spinal cord post-laminectomy.

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C. Shortwave Diathermy (SWD)

• Definition: Deep heating using high-frequency electromagnetic energy (27.12 MHz).
• Types:
  • Condenser (capacitance) method: Heats tissues with high water content (muscles).
  • Inductance (coil) method: Heats tissues with high ion content.
• Pulsed SWD: Non-thermal, used for acute inflammation/oedema reduction.
• Effects: Increases blood flow, reduces muscle spasm, promotes tissue healing, reduces pain.
• Indications: Sub-acute and chronic musculoskeletal conditions, pelvic inflammatory disease, sinusitis.
• Contraindications: Metal implants, pacemaker, active tuberculosis, haemorrhagic conditions, malignancy.

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D. Infrared Radiation (IRR)

• Types:
  • Near infrared (700-1500 nm): penetrates deeper, photochemical effects.
  • Far infrared (1500-12500 nm): superficial, heat mostly in skin.
• Effects: Superficial heating, pain relief, muscle relaxation, vasodilation, wound healing.
• Indications: Muscle spasm, joint stiffness, superficial wound healing.
• Contraindications: Acute inflammation, ischaemia, impaired sensation, photosensitivity.

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E. Laser Therapy (Low-Level Laser Therapy / LLLT)

• Properties: Monochromatic, Coherent, Collimated light.
• Mechanism: Biostimulation of cells (photobiomodulation); stimulates mitochondria, increases ATP production, promotes tissue repair.
• Indications: Wound healing, pain relief, tendinopathy, lymphoedema.

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2. Exercise Therapy

A. Types of Muscle Contraction

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B. Principles of Exercise Prescription

• FITT Principle: Frequency, Intensity, Time, Type
• SAID Principle: Specific Adaptation to Imposed Demands
• Overload Principle: Progressive increase in load for continued adaptation
• Reversibility: Gains lost if training stops

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C. Types of Therapeutic Exercises

1. Passive exercises: No patient effort; maintains ROM, prevents adhesions. Used in paralysis, unconscious patients.
2. Active-assisted exercises: Therapist assists when muscle power is < Grade 3.
3. Active exercises: Patient performs without assistance; builds strength (power Grade 3+).
4. Resisted exercises: Additional external resistance; strengthening (power Grade 4+).
5. Stretching exercises: Increase flexibility; static vs. dynamic; PNF stretching.
6. Proprioceptive/Balance exercises: Wobble board, single-leg standing, BAPS board.
7. Aerobic/Endurance exercises: Improve cardiovascular fitness; walking, cycling.
8. Breathing exercises: Diaphragmatic, pursed-lip, segmental breathing; used in COPD, post-surgery.

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D. Muscle Grading (MRC Scale)

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3. Manual Therapy

A. Joint Mobilization (Maitland Grades)

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B. Soft Tissue Mobilization (Massage)

• Effleurage: Long, gliding strokes; relaxation, venous/lymphatic return.
• Petrissage: Kneading; deeper muscle fibres, removes metabolites.
• Tapotement: Percussion; stimulates nerves, used in chest physio (clapping for mucus clearance).
• Friction massage (Cyriax): Deep transverse friction; breaks down scar adhesions in tendons/ligaments.
• Vibration: Fine tremor oscillations; relaxation or stimulation depending on speed.

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C. Proprioceptive Neuromuscular Facilitation (PNF)

• Principle: Uses diagonal and rotational movement patterns (Kabat patterns) that mimic functional movement.
• Techniques:
  • Hold-Relax: Isometric contraction of tight muscle, then passive stretch. Best for pain-limited ROM.
  • Contract-Relax: Isotonic contraction, then passive stretch. Best for stiffness-limited ROM.
  • Agonist-Contraction (Rhythmic Initiation): Used in paralysis/spasticity.
  • Rhythmic Stabilization: Co-contraction for stability.
• Clinical uses: Stroke rehab, spinal cord injury, sports injuries, post-surgical rehab.

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4. Hydrotherapy (Aquatic Therapy)

• Properties of water used:
  • Buoyancy: Reduces effective body weight (at neck level - 90% reduction). Allows exercise in weakened muscles.
  • Hydrostatic pressure: Reduces oedema, assists venous return.
  • Viscosity: Provides resistance to movement (strengthening).
  • Thermotherapy: Warm water relaxes muscle spasm.
• Contraindications: Open wounds, infections, incontinence, cardiac failure, fear of water.
• Uses: Rheumatoid arthritis, post-arthroplasty, spinal cord injury, neurological conditions.

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5. Chest Physiotherapy

Techniques:

1. Postural Drainage: Position patient so gravity assists secretion drainage from a specific lobe/segment.
2. Percussion (Clapping): Rhythmic clapping over chest wall with cupped hands; loosens secretions.
3. Vibration: Fine oscillations applied during expiration; moves secretions toward larger airways.
4. Directed Coughing & Huffing: Effective expectoration technique.
5. Active Cycle of Breathing Technique (ACBT): Breathing control + thoracic expansion exercises + forced expiration.
6. Incentive Spirometry: Visual feedback to encourage sustained slow deep breaths; prevents post-operative atelectasis.

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6. Neurological Physiotherapy

Key Approaches:

• Bobath (NDT) Approach: Inhibits abnormal tone and facilitates normal movement patterns; key handling technique.
• Brunnstrom Approach: Uses synergy patterns as stepping stones to recovery.
• Rood Approach: Uses sensory stimulation to facilitate/inhibit motor responses.
• Motor Relearning Program (Carr & Shepherd): Task-specific training for functional recovery.

Gait Re-education:

• Parallel bars → Walking frame → Crutches → Stick → Independent
• Address: weakness, spasticity, balance deficits, proprioception loss.

Spasticity Management:

• Stretching, positioning, splinting, electrical stimulation, ice therapy.

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7. Orthopaedic Physiotherapy

Post-fracture Rehabilitation:

• Phase 1 (Immobilization): Oedema control (elevation, ice), distal joint exercises, isometrics in cast.
• Phase 2 (Post-immobilization): ROM exercises, progressive strengthening.
• Phase 3 (Functional): Proprioception, sport-specific training.

Common Orthopaedic Conditions:

• Frozen shoulder (Adhesive Capsulitis): Pendulum exercises, mobilizations, ultrasound, stretching.
• Tennis Elbow (Lateral Epicondylitis): Eccentric exercise of wrist extensors, Cyriax deep friction massage, US therapy.
• Plantar Fasciitis: Stretching of calf and plantar fascia, orthotics, US, ice massage.
• Knee OA: Quadriceps strengthening (especially VMO), hydrotherapy, TENS for pain.

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8. Gait Analysis

Normal Gait Cycle:

• Stance Phase (60%): Initial contact → Loading response → Mid-stance → Terminal stance → Pre-swing
• Swing Phase (40%): Initial swing → Mid-swing → Terminal swing

Abnormal Gaits:

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9. Traction

• Cervical Traction: Relieves nerve root compression, disc herniation; manual or mechanical.
  • Force: 10-15 kg; angle: 10-25° flexion for disc problems.
• Lumbar Traction: For disc herniation with radiculopathy.
  • Force: Half to 2/3 of body weight.
• Types: Manual, mechanical (sustained/intermittent), autotraction, positional traction.
• Contraindications: Osteoporosis, fracture, cord compression signs, malignancy, RA of cervical spine.

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10. Splinting & Orthotics

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Quick-Revision Summary Table

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• Define the topic clearly (2 lines).
• Classify/categorize where possible (table or list).
• Include mechanisms, types, indications, and contraindications for each modality.
• Add a short clinical note or example.
• Write a brief conclusion (2 lines).