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Physiotherapy Practical Examination - Detailed Answers

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LONG CASE: Motor Point Stimulation for Muscles Supplied by the Anterior Tibial Nerve (Deep Peroneal Nerve)

Anatomy Recap

Indication

• Lower motor neuron (LMN) lesion affecting the deep peroneal nerve
• Foot drop (peroneal nerve palsy)
• Denervated or partially denervated muscles - to prevent atrophy and fibrosis
• Post-fracture immobilization with nerve involvement
• To maintain muscle bulk and circulation while awaiting reinnervation

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Patient Position

• Knee slightly flexed (small pillow or rolled towel under the knee)
• Ankle in neutral or slight plantarflexion to expose the anterior compartment
• Limb well-supported and relaxed
• The anterior compartment of the leg fully accessible to the therapist

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Equipment Required

• Electrical stimulator capable of delivering interrupted DC (IDC) or surged faradic current
• For denervated muscle: Interrupted Galvanic (DC) current is used (as denervated muscle does not respond to faradic/AC current)
• Active (small) electrode: pencil/point electrode
• Dispersive (large) pad electrode
• Conducting gel / saline-soaked pad
• Motor point chart for reference

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Parameters

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Procedure (Step-by-Step)

• Explain the procedure to the patient; obtain consent
• Inspect the skin for wounds, rashes, burns, or metallic implants
• Position the patient supine, leg supported comfortably
• Clean the skin with spirit swab and allow to dry; apply conducting gel

• Place the large dispersive (inactive) electrode over the lower back (lumbar region) or the posterior calf
• Identify the motor points using a motor point chart or by mapping with the active electrode at minimal current
• Apply the small active (pencil) electrode directly over the motor point of the target muscle (e.g., Tibialis Anterior first)

• Tibialis Anterior: 5 cm below the head of fibula, 2 cm lateral to the tibial crest
• Extensor Digitorum Longus: 8-10 cm below fibular head, just lateral to TA
• Extensor Hallucis Longus: 12-14 cm below fibular head, between TA and EDL
• Extensor Digitorum Brevis: Just anterior and inferior to the lateral malleolus on the dorsum of foot

• Switch machine ON; set parameters (start at 0 intensity)
• Slowly increase intensity until a visible muscle twitch or contraction is observed
• Stimulate each muscle 30-50 times (contractions) per session
• Move the active electrode sequentially from one motor point to the next
• Observe quality of contraction - slow sluggish response = denervated muscle (confirms IDC use)

• Reduce intensity to zero before removing electrodes
• Remove gel, inspect skin
• Document response, any skin reaction, patient tolerance

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Contraindications

• Absolute:
  • Cardiac pacemaker in situ
  • Malignancy in the treatment area
  • Over the carotid sinus (not applicable here but general rule)
  • Active infection or osteomyelitis of the limb
  • Thrombophlebitis or deep vein thrombosis
  • Open wounds or skin conditions at electrode site
• Relative:
  • Impaired sensation (risk of burns - reduce intensity, monitor closely)
  • Pregnancy (lower limb generally safe, but caution)
  • Severe arterial disease / ischemia
  • Hemorrhagic tendency or patient on anticoagulants
  • Epiphyseal growth plates in children (over bone)
  • Complete nerve degeneration where no response is expected after 1-2 years (fibrosis stage)

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SHORT CASE I: Interferential Therapy (IFT) for Osteoarthritis (OA) of Left Knee

What is IFT?

Indication

• OA knee - pain relief, reduction of joint swelling, improved circulation
• Chronic musculoskeletal pain
• Post-surgical knee rehabilitation

Patient Position

• Left knee in comfortable extension (a small pillow under the knee is acceptable for comfort)
• Quadriceps and periarticular structures relaxed
• Knee fully accessible from all four sides for electrode placement

Electrode Placement Methods

• One electrode on medial aspect, one on lateral aspect of the knee
• Simple but less deep penetration

• Circuit 1: One electrode on anteromedial + one on posterolateral aspect
• Circuit 2: One electrode on anterolateral + one on posteromedial aspect
• The two circuits cross at 90 degrees within the knee joint - maximum interference at the joint

Parameters for OA Knee

Procedure

1. Explain procedure; obtain consent
2. Check for contraindications, inspect skin around knee
3. Position patient supine; expose left knee
4. Apply electrodes using quadripolar technique with conducting gel or wet sponge in suction cups
5. Set parameters: carrier frequency, AMF 80-100 Hz, sweep if required
6. Increase intensity slowly until patient reports comfortable buzzing/tingling - not painful
7. Treat for 15-20 minutes
8. After session: reduce intensity to zero, remove electrodes, inspect skin, document

Contraindications

• Cardiac pacemaker
• Active malignancy near the knee
• Thrombosis (DVT) in the limb
• Open wounds at electrode placement sites
• Acute inflammation with fever
• Pregnancy
• Implanted metallic prosthesis within the treatment field (relative - some modern units considered safe but caution advised)
• Impaired skin sensation

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SHORT CASE II: Infrared Radiation (IRR) for Low Back Pain (Luminous)

What is IRR?

• Luminous (Near IR / NIR): 750 nm - 1500 nm - from special bulbs with a glowing filament; penetrates deeper (up to 10 mm into tissue)
• Non-luminous (Far IR / FIR): 1500 nm - 12,500 nm - from electrically heated elements with no glow; superficial penetration (1-3 mm)

Indication

• Chronic low back pain (muscle spasm, soft tissue pain)
• Muscle relaxation prior to exercises or manipulation
• Subacute to chronic musculoskeletal pain
• Preparation of tissue before massage
• Improves local circulation and reduces stiffness

Patient Position

• Abdomen supported (small pillow under abdomen is optional for comfort)
• Arms by sides, head turned to one side or forehead on folded hands
• Lower back (lumbar region) fully exposed
• Clothing removed from the treatment area

Equipment Setup

• Luminous infrared lamp (Sollux lamp or similar with red filter or tungsten filament)
• The lamp has a reflector to focus and direct heat
• Lamp is positioned perpendicular to the treatment area (at 90 degrees to the skin surface)
• Distance: 45-60 cm from the skin surface (adjust based on patient tolerance and lamp wattage)
• Wattage: typically 250-750 W for therapeutic lamps

Procedure (Step-by-Step)

• Warn the patient what to expect (warming sensation, not burning)
• Inspect skin - check for impaired sensation, recent scars, dry skin
• Conduct a simple thermal sensation test - hot and cold tubes applied to the lumbar area
• Remove clothing from the lumbar region; patient lies prone
• Cover any scar tissue or anesthetic areas with damp cloth or gauze

• Switch on the lamp 5 minutes before treatment to allow it to warm up and reach stable output
• Pre-warm at a distance of 60-75 cm initially
• Ensure the lamp is stable on its stand; no risk of tipping

• Position the luminous IRR lamp 45-60 cm above the lumbar spine
• Lamp head directed perpendicular (90 degrees) to the lumbar surface
• Use a ruler or arm's length guide to maintain consistent distance
• Screen adjacent areas if needed

• Patient should feel a comfortable warmth - NOT burning or stinging
• Check patient after the first 3-5 minutes
• Inspect skin for excessive erythema (mottling = burn risk - increase distance or stop)
• Ask the patient to report if it becomes too hot
• Treat for 15-20 minutes
• The therapist should NOT leave the patient unattended

• Switch off the lamp
• Inspect the skin for normal erythema (redness) - expected and normal
• Avoid applying any cold modality immediately after
• Document treatment parameters (distance, duration, wattage, patient response)

Erythema Grading (Important for Exam)

Contraindications

• Absolute:
  • Impaired or absent thermal sensation in the lumbar area (high risk of burns)
  • Areas with defective circulation / ischemia
  • Active hemorrhage or acute inflammation
  • Malignancy in the treatment field
  • Over areas of metal implants (relative heat concentration)
• Relative:
  • Recent scar tissue (cover with damp cloth)
  • Skin diseases (eczema, psoriasis flare)
  • Photosensitive individuals
  • Pregnancy (avoid over abdomen/lumbar area in first trimester)
  • Fever or systemic infection
  • Deep X-ray therapy (irradiated skin is sensitive)
  • Over the eyes (use goggles or closed eyes; never aim lamp at face)

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