Risky Stretches

The following stretches (many of which are commonly performed) are considered risky (M. Alter uses the term `X'-rated) due to the fact that they have a very high risk of injury for the athlete that performs them. This does not mean that these stretches should never be performed. However, great care should be used when attempting any of these stretches. Unless you are an advanced athlete, you can probably do without them (or find alternative stretching exercises to perform). Each of these stretches is illustrated in detail in the section X-Rated Exercises of M. Alter:

the yoga plough
In this exercise, you lie down on your back and then try to sweep your legs up and over, trying to touch your knees to your ears. This position places excessive stress on the lower back, and on the discs of the spine. Not to mention the fact that it compresses the lungs and heart, and makes it very difficult to breathe. This particular exercise also stretches a region that is frequently flexed as a result of improper posture.

the traditional backbend
In this exercise, your back is maximally arched with the soles of your feet and the palms of your hands both flat on the floor, and your neck tilted back. This position squeezes (compresses) the spinal discs and pinches nerve fibers in your back.

the traditional hurdler's stretch
This exercise has you sit on the ground with one leg straight in front of you, and with the other leg fully flexed (bent) behind you, as you lean back and stretch the quadricep of the flexed leg. The two legged version of this stretch is even worse for you, and involves fully bending both legs behind you on either side. The reason this stretch is harmful is that it stretches the medial ligaments of the knee (remember, stretching ligaments and tendons is bad) and crushes the meniscus. It can also result in slipping of the knee cap from being twisted and compressed.

straight-legged toe touches
In this stretch, your legs are straight (either together or spread apart) and your back is bent over while you attempt to touch your toes or the floor. If you do not have the ability to support much of your weight with your hands when performing this exercise, your knees are likely to hyperextend. This position can also place a great deal of pressure on the vertebrae of the lower lumbar. Furthermore, if you choose to have your legs spread apart, it places more stress on the knees, which can sometimes result in permanent deformity.

Torso twists
Performing sudden, intense twists of the torso, especially with weights, while in an upright (erect) position can tear tissue (by exceeding the momentum absorbing capacity of the stretched tissues) and can strain the ligaments of the knee.

Inverted Stretches
This is any stretch where you "hang upside down". Staying inverted for too long increases your blood pressure and may even rupture blood vessels (particularly in the eyes). Inverted positions are especially discouraged for anyone with spinal problems.

EXERCISES

BENDING THE WRIST TO A TARGET:
Physiotherapist`s aim:
To improve the ability to extend the wrist.
Client`s aim:
To improve your ability to straighten your wrist.
Physiotherapist`s instructions:
Position the patient in sitting with their forearm pronated and resting on a block on a table in front of them.
Place a cup in their hand, a sandbag on their forearm and tape a flexible straw to the dorsal surface of their forearm with the joint of the straw aligned with their wrist joint.
Instruct the patient to extend their wrist to touch the tip of the straw and then relax their wrist back into flexion.
Client`s instructions:
Position yourself sitting with your forearm resting on a block on a table in front of you and your palm facing down.
Place a cup in your hand, a sandbag on your forearm and tape a flexible straw to the top of your forearm so that the bend of the straw is over your wrist.
Practice straightening your wrist so that your hand touches the tip of the straw then relaxing your hand back down again.
Progressions and variations:
Less advanced: 1. Bend the straw down to decrease the range that the wrist needs to move through. 2. Hold a cup with a smaller diameter.
More advanced: 1. Bend the straw up to increase the range that the wrist needs to move through. 2. Hold a cup with a larger diameter. 3. Hold a cup that can deform.


BENDING THE WRIST WHILE HOLDING A CUP:
Physiotherapist`s aim:
To improve the ability to radially deviate the wrist.
Client`s aim:
To improve your ability to bend your wrist.
Physiotherapist`s instructions:
Position the patient in sitting with their hand grasping a cup and hanging over the edge of a table.
Instruct the patient to tilt the cup up by radially deviating their wrist.
Client`s instructions:
Position yourself sitting with your hand grasping a cup and hanging over the edge of a table. Practice tilting the cup up by bending your wrist.
Progressions and variations:
Less advanced: 1. Move the cup through a smaller range of motion. 2. Use a cup with a smaller diameter.
More advanced: 1. Move the cup through a larger range of motion. 2. Use a cup with a larger diameter. 3. Use a cup that can deform. 4. Add water to the cup.


BICEPS ELECTRICAL STIMULATION:
Physiotherapist`s aim:
To strengthen the elbow flexors.
Client`s aim:
To strengthen your biceps.
Physiotherapist`s instructions:
Place the electrodes over the muscle belly of the elbow flexors.
Client`s instructions:
Place the two electrodes over the muscle belly as shown.
Precautions:
1. Perform skin tests.


BILATERAL ANKLE PLANTORFLEXOR STRETCH USING A WEDGE WHILE STANDING AGAINST A WALL:
Physiotherapist`s aim:
To stretch or maintain length of the ankle plantarflexors.
Client`s aim:
To stretch or maintain range in your ankles.
Physiotherapist`s instructions:
Position the patient in standing with their back against a wall and both feet on a wedge.
Ensure that their knees are kept straight and both feet point forwards.
Client`s instructions:
Position yourself standing with your back against a wall and both feet on a wedge.
Ensure that you keep your knees straight and both feet point forwards.
Progressions and variations:
Less advanced: 1. Decrease the angle of the wedge.
More advanced: 1. Increase the angle of the wedge.
Precautions:
1. Impaired or absent sensation of stretch.


BILATERAL ANKLE PLANTORFLEXOR STRETCH USING A WEDGE WHILE STANDING AT A TABLE:
Physiotherapist`s aim:
To stretch or maintain length of the ankle plantarflexors.
Client`s aim:
To stretch or maintain range in your ankles.
Physiotherapist`s instructions:
Position the patient in standing with both feet on a wedge and a table in front.
Ensure that their knees are kept straight and both feet point forwards.
Client`s instructions:
Position yourself standing with both feet on a wedge and a table in front.
Ensure that you keep your knees straight and both feet point forwards.
Progressions and variations:
Less advanced: 1. Decrease the angle of the wedge.
More advanced: 1. Increase the angle of the wedge.
Precautions:
1. Impaired or absent sensation of stretch.


BILATERAL CALF RAISES:
Physiotherapist`s aim:
To strengthen the ankle plantarflexors.
Client`s aim:
To strengthen your calf muscles.
Physiotherapist`s instructions:
Position the patient in standing.
Instruct the patient to plantarflex their ankles.
Client`s instructions:
Position yourself standing with your feet together.
Start with your heels on the ground.
Finish with your heels off the ground.
Progressions and variations:
Less advanced: 1. Provide hand support for balance.
More advanced: 1. Progress using strength training principles.


BILATERAL CALF RAISES ON A BLOCK:
Physiotherapist`s aim:
To strengthen the ankle plantarflexors.
Client`s aim:
To strengthen your calf muscles.
Physiotherapist`s instructions:
Position the patient in standing on a step with their heels off the edge.
Instruct the patient to plantarflex their ankle.
Client`s instructions:
Position yourself standing on a step with your heels off the edge.
Lift your body weight up onto your toes.
Progressions and variations:
Less advanced: 1. Provide hand support for balance.
More advanced: 1. Wear a backpack with weights in it. 2. Progress using strength training principles.

EXERCISES.

ASCENDING A STEP USING A DOORWAY:
Physiotherapist`s aim:
To improve the ability to ascend a step in a wheelchair.
Client`s aim:
To improve your ability to ascend a step in your wheelchair.
Physiotherapist`s instructions:
Position the patient in their wheelchair below a step.
Instruct the patient to use the doorway to pull themselves up over the step.
Client`s instructions:
Position yourself in your wheelchair below a step.
Practice using the doorway to pull yourself up over the step.
Progressions and variations:
Less advanced: 1. Decrease the height of the step.
More advanced: 1. Increase the height of the step.
Precautions:
1. Caution required to prevent forward fall from wheelchair.


ATTAINING A WHEELSTAND:
Physiotherapist`s aim:
To improve the ability to attain a wheelstand.
Client`s aim:
To improve your ability to attain a wheelstand.
Physiotherapist`s instructions:
Position the patient in their wheelchair.
Instruct the patient to flip the wheelchair into a wheelstand.
Client`s instructions:
Position yourself in your wheelchair.
Practice flipping your wheelchair into a wheelstand.
Progressions and variations:
Less advanced: 1. Perform the task on a flat surface.
More advanced: 1. Manoeuvre the wheelchair in different directions while maintaining a wheelstand.
2. Perform the task on a slope.
3. Add a weighted bag to the front or back of the wheelchair.
Precautions:
1. Ensure that wheelchair does not flip backwards.


BALANCING ON A BALL:
Physiotherapist`s aim:
To improve the ability to sit unsupported.
Client`s aim:
To improve your ability to sit unsupported.
Physiotherapist`s instructions:
Position the patient in sitting on a large ball that is wedged between two plinths.
Instruct the patient to lift their hands up in the air without falling.
Client`s instructions:
Position yourself sitting on a large ball that is wedged between two plinths.
Practice lifting your hands up in the air without falling.
Progressions and variations:
Less advanced: 1. Sit on a plinth.
More advanced: 1. Change the size of the ball. 2. Add a concurrent task while sitting on the ball.


BALANCING ON A BALL WHILE LIFTING ONE LEG UP AND DOWN:
Physiotherapist`s aim:
To improve the ability to sit unsupported.
Client`s aim:
To improve your ability to sit unsupported.
Physiotherapist`s instructions:
Position the patient in sitting on a large ball with their feet on the floor.
Instruct the patient to lift then lower one leg.
Client`s instructions:
Position yourself sitting on a large ball with your feet on the floor.
Practice lifting one leg up and down.
Progressions and variations:
Less advanced: 1. Provide hand support for balance. 2. Decrease the height that the leg is lifted. More advanced: 1. Increase the height that the leg is lifted. 2. Increase the movement of the raised leg (eg. add knee extension or hip abduction).


BALANCING WHILE SITTING ON A MOVING OBJECT:
Physiotherapist`s aim:
To improve the ability to sit unsupported.
Client`s aim:
To improve your ability to sit unsupported.
Physiotherapist`s instructions:
Position the patient in sitting on a moveable object while holding onto a rope.
Instruct the patient to sit upright while getting towed across the floor.
Client`s instructions:
Position yourself sitting on a moveable object while holding onto a rope.
Practice sitting upright while getting towed across the floor.
Progressions and variations:
Less advanced: 1. Tow the patient in one direction only. 2. Tow at a slow speed.
More advanced: 1. Tow the patient in many directions. 2. Tow at a faster speed.


BEAR WALKING:
Physiotherapist`s aim:
To strengthen the shoulder and hip muscles.
Client`s aim:
To strengthen your shoulder and hip muscles.
Physiotherapist`s instructions:
Position the patient on their hands and feet with their bottom in the air.
Instruct the patient to `bear-walk` forwards along the floor.
Client`s instructions:
Position yourself on your hands and feet with your bottom in the air.
Practice `bear-walking` forwards along the floor.
Progressions and variations:
More advanced: 1. Practice `bear-walking` in different directions. 2. Increase speed of task.


BENCH PRESS:
Physiotherapist`s aim:
To strengthen the shoulder horizontal adductors and elbow extensors.
Client`s aim:
To strengthen the muscles at the front of your shoulder and chest.
Physiotherapist`s instructions:
Position the patient in supine with their shoulders abducted and elbows flexed.
Instruct the patient to lift the weights above their chest until their elbows are straight.
Client`s instructions:
Position yourself lying on your back with your shoulders out to the side and elbows bent.
Lift the weights above your chest until your elbows are straight.
Progressions and variations:
Progress using strength training principles.


BENDING AND STRAIGHTENING THE WRIST TO TARGETS:
Physiotherapist`s aim:
To improve the ability to flex and extend the wrist.
Client`s aim:
To improve your ability to bend and straighten your wrist.
Physiotherapist`s instructions:
Position the patient in sitting with a cylindrical object on a table in front of them and a sandbag on their forearm.
Draw two target lines on the table to serve as targets for wrist movement.
Instruct the patient to flex and then extend their wrist to the target lines while grasping the object.
Ensure that the forearm does not move.
Client`s instructions:
Position yourself sitting with a cylindrical object on a table in front of you and a sandbag on your forearm. :
Practice bending your wrist backwards and forwards to the target lines while grasping the object.
Ensure that your forearm does not move.
Progressions and variations:
Less advanced: 1. Decrease the distance from the wrist to the target lines. 2. Hold an object with a smaller diameter.
More advanced: 1. Increase the distance from the wrist to the target lines. 2. Hold an object with a larger diameter. 3. Hold an object that can deform. 4. Remove the sandbag holding the forearm in place.


BENDING THE KNEE IN SITTING:
Physiotherapist`s aim:
To improve the ability to flex the knee in preparation for standing.
Client`s aim:
To improve your ability to bend your knee in preparation for standing.
Physiotherapist`s instructions:
Position the patient in sitting with their toes on a line in front of their knee.
Instruct the patient to flex their knee so that their heel touches a line behind their knee.
Client`s instructions:
Position yourself sitting with your toes on a line in front of your knee.
Practice sliding your foot back so that your heel touches a line behind your knee.
Progressions and variations:
Less advanced. 1. Place the lines closer to the heel and toes. 2. Reduce the amount of friction under the foot by using a friction-reducing device (eg. a roller-skate or slidesheet).
More advanced. 1. Place the lines further away from the heel and toes.


BENDING THE KNEE IN SITTING USING A ROLLER SKATE:
Physiotherapist`s aim:
To improve the ability to flex the knee in preparation for standing.
Client`s aim:
To improve your ability to bend your knee in preparation for standing.
Physiotherapist`s instructions:
Position the patient in sitting with one foot strapped into a roller-skate and their other foot on a block.
Instruct the patient to flex and extend their knee so that the roller-skate rolls between the lines on the floor.
Client`s instructions:
Position yourself sitting with one foot strapped into a roller-skate and your other foot on a block. Practice bending and straightening your knee so that the roller-skate rolls between the lines on the floor.
Progressions and variations:
Less advanced. 1. Place the lines closer to the heel and toes.
More advanced. 1. Place the lines further away from the heel and toes.

EXERCISES.

ACTIVE CYCLE FOR UPPER LIMBS:
Physiotherapist`s aim:
To improve fitness.
Client`s aim:
To improve your fitness.
Physiotherapist`s instructions:
Position the patient in their wheelchair with their hands in the paddles of the active cycle. Instruct the patient to cycle with their hands.
Client`s instructions:
Position yourself sitting in your wheelchair with your hands in the paddles of the active cycle. Cycle with your hands.
Progressions and variations:
Less advanced: 1. Decrease the active resistance.
More advanced: 1. Increase the active resistance. 2. Increase duration of exercise.
Precautions:
1. Check for pressure marks in areas where sensation is absent or impaired.


ANKLE DORSIFLEXOR ELECTRICAL STIMULATION:
Physiotherapist`s aim:
To strengthen the ankle dorsiflexors.
Client`s aim:
To strengthen the muscles at the front of your ankle.
Physiotherapist`s instructions:
Place the electrodes over the muscle belly of tibialis anterior.


ANKLE DORSIFLEXOR STRENGTHENING IN LONG SITTING:
Physiotherapist`s aim:
To strengthen the ankle dorsiflexors.
Client`s aim:
To strengthen the muscles at the front of your ankle.
Physiotherapist`s instructions:
Position the patient in long sitting with a target held above their toes.
Instruct the patient to dorsiflex their ankles to touch the target with their toes.
Client`s instructions:
Position yourself sitting with your legs in front of you and a target held above your toes.
Practice bending your ankles to touch the target with your toes.
Progressions and variations:
Less advanced: 1. Decrease the distance to the target.
More advanced: 1. Increase the distance to the target.


ANKLE DORSIFLEXOR STRENGTHENING IN SITTING USING SANDBAG WEIGHTS:
Physiotherapist`s aim:
To strengthen the ankle dorsiflexors.
Client`s aim:
To strengthen the muscles at the front of your ankle.
Physiotherapist`s instructions:
Position the patient in sitting with a weight attached around their toes.
Instruct the patient to dorsiflex their ankle.
Client`s instructions:
Position yourself sitting with a weight attached around your toes.
Start with your toes on the floor.
Finish with your toes off the floor.
Progressions and variations:
Progress using strength training principles.


ANKLE DORSIFLEXOR STRENGTHENING IN SITTING WITHOUT WEIGHTS:
Physiotherapist`s aim:
To strengthen the ankle dorsiflexors.
Client`s aim:
To strengthen the muscles at the front of your ankle.
Physiotherapist`s instructions:
Position the patient in sitting with their feet flat on the floor and their knees relatively extended. Instruct the patient to dorsiflex the ankles.
Client`s instructions:
Position yourself sitting with your feet together in front of you.
Start with your feet flat on the floor.
Finish with your toes lifted up.
Ensure that you keep your heels on the ground.
Progressions and variations:
Less advanced: 1. Position the feet further forwards. 2. Place a bandage around the knees to hold them together.
More advanced: 1. Position the feet further back.


ANKLE DORSIFLEXOR STRENGTHENING IN STANDING BY KICKING A BALL BACKWARDS:
Physiotherapist`s aim:
To strengthen the ankle dorsiflexors.
Client`s aim:
To strengthen the muscles at the front of your ankle.
Physiotherapist`s instructions:
Position the patient in standing while holding onto a ball.
Instruct the patient to kick the ball over their head.
Ensure that their ankle dorsiflexes.
Client`s instructions:
Position yourself standing while holding onto a ball.
Practice kicking the ball over your head.
Ensure that your foot bends backwards.
Progressions and variations:
Less advanced: 1. Perform the exercise in sitting.
More advanced: 1. Kick the ball further behind.


ANKLE DORSIFLEXOR/PLANTARFLEXOR STRENGTHENING IN SIDELYING WITHOUT WEIGHTS:
Physiotherapist`s aim:
To strengthen the ankle dorsiflexors/plantarflexors.
Client`s aim:
To strengthen your ankle muscles.
Physiotherapist`s instructions:
Position the patient in sidelying.
Instruct the patient to dorsiflex and plantarflex their ankle.
Client`s instructions:
Position yourself lying on your side.
Start with your toes pointing down.
Finish with your toes pointing up.


ANKLE DORSIFLEXOR/PLANTARFLEXOR STRENGTHENING IN SITTING BY DRAWING CIRCLES WITH THE FOOT:
Physiotherapist`s aim:
To strengthen the ankle dorsiflexors/plantarflexors.
Client`s aim:
To strengthen your ankle muscles.
Physiotherapist`s instructions:
Position the patient in sitting.
Instruct the patient to draw circles in the air with their toes.
Ensure that only their ankle moves.
Client`s instructions:
Position yourself in sitting.
Practice drawing circles in the air with your toes.
Ensure that only your ankle moves.
Progressions and variations:
Less advanced: 1. Move the ankle up and down only. 2. Make smaller circles.
More advanced: 1. Make larger circles. 2. Vary the ankle movement (eg. write the alpabet).


ANKLE DORSIFLEXOR/PLANTARFLEXOR STRENGTHENING IN SUPINE WITHOUT WEIGHTS:
Physiotherapist`s aim:
To strengthen the ankle dorsiflexors/plantarflexors.
Client`s aim:
To strengthen your ankle muscles.
Physiotherapist`s instructions:
Position the patient in supine.
Instruct the patient to dorsiflex and plantarflex their ankle.
Client`s instructions:
Position yourself lying on your back.
Start with your toes pointing down.
Finish with your toes pointing up.
Progressions and variations:
Progress using strength training principles.


ANKLE EVERTOR STRENGTHENING IN SITTING WITH ASSISTANCE:
Physiotherapist`s aim:
To strengthen the ankle evertors.
Client`s aim:
To strengthen the muscles on the outside of the ankle.
Physiotherapist`s instructions:
Position the patient in sitting with their heel on the floor and your hand stabilising their knee. Instruct and encourage the patient to evert their ankle and bring their toes to touch a target object.
Client`s instructions:
Position the child in sitting with their heel on the floor and your hand stabilising their knee. Instruct and encourage the child to move their toes outwards and upwards to touch an object with the outside border of their foot.
Progressions and variations:
Less advanced: 1. Position the target object closer to the toes.
More advanced: 1. Position the target object further away from the toes.


ANKLE EVERTOR STRENGTHENING IN SITTING WITHOUT WEIGHTS:
Physiotherapist`s aim:
To strengthen the ankle evertors.
Client`s aim:
To strengthen the muscles at the outside of your ankle.
Physiotherapist`s instructions:
Position the patient in sitting with their knees together and ankles slightly apart.
Instruct the patient to evert their ankles and bring the medial malleoli to touch together.
Ensure that the knees are kept still.
Client`s instructions:
Position yourself sitting with your knees together and ankles slightly apart.
Start with your feet flat on the floor.
Finish with outside of your soles lifted off the floor and the inside part of your ankles touching together.
Ensure that your knees are kept still.
Progressions and variations:
Less advanced: 1. Place a bandage around the knees to hold them together.
More advanced: 1. Perform the exercise in standing.


ANKLE INVERTOR STRENGTHENING IN SITTING WITH ASSISTANCE:
Physiotherapist`s aim:
To strengthen the ankle invertors.
Client`s aim:
To strengthen the muscles on the inside of the ankle.
Physiotherapist`s instructions:
Position the patient in sitting with their heel on the floor and your hand stabilising their knee. Instruct and encourage the patient to invert their ankle and bring their toes to touch a target object.
Client`s instructions:
Position the child in sitting with their heel on the floor and your hand stabilising their knee. Instruct and encourage the child to move their toes inwards and upwards to touch a target object with the inside border of their foot.
Progressions and variations:
Less advanced: 1. Position the target object closer to the toes.
More advanced: 1. Position the target object further away from the toes.


ANKLE INVERTOR/EVERTOR STRENGTHENING IN SITTING WITHOUT WEIGHTS:
Physiotherapist`s aim:
To strengthen the ankle invertors and evertors.
Client`s aim:
To strengthen the muscles on the inside and outside of your ankle.
Physiotherapist`s instructions:
Position the patient in sitting.
Instruct the patient to invert and evert their ankle.
Client`s instructions:
Position yourself sitting with your feet on the floor.
Start with the soles of your feet facing in.
Finish with the soles of your feet facing out.
Ensure that your knees are kept still.
Progressions and variations:
Progress using strength training principles.


ANKLE PLANTARFLEXOR STRENGTHENING IN SITTING USING SANDBAG WEIGHTS:
Physiotherapist`s aim:
To strengthen the ankle plantarflexors.
Client`s aim:
To strengthen your calf muscles.
Physiotherapist`s instructions:
Position the patient in sitting with a weight attached to the top of their knee.
Instruct the patient to lift their heel off the floor by plantarflexing their ankle.
Client`s instructions:
Position yourself sitting with a weight attached to the top of your knee.
Start with your feet flat on the floor.
Finish with your heel off the floor.
Ensure that you keep your toes on the floor.
Progressions and variations:
Progress using strength training principles.


ANKLE PLANTORFLEXOR STRENGTHENING IN SITTING USING THERABAND:
Physiotherapist`s aim:
To strengthen the ankle plantarflexors.
Client`s aim:
To strengthen your calf muscles.
Physiotherapist`s instructions
Position the patient in sitting with their foot on a wedge and some theraband attached under the wedge and over the top of their knee.
Instruct the patient to lift their heel off the wedge by plantarflexing the ankle.
Client`s instructions:
Position yourself sitting with your foot on a wedge and some theraband attached under the wedge and over the top of your knee.
Start with your foot flat on the wedge.
Finish with your heel off the wedge.
Ensure that you keep your toes on the wedge.
Progressions and variations:
Less advanced: 1. Downgrade the colour of the theraband.
More advanced: 1. Upgrade the colour of the theraband.


ANKLE PLANTORFLEXOR STRENGTHENING IN SITTING WITHOUT WEIGHTS:
Physiotherapist`s aim:
To strengthen the ankle plantarflexors.
Client`s aim:
To strengthen your calf muscles.
Physiotherapist`s instructions:
Position the patient in sitting with their knees together.
Instruct the patient to lift their heels off the floor by plantarflexing the ankles.
Client`s instructions:
Position yourself sitting with your knees together.
Start with your feet flat on the floor.
Finish with your heels lifted off the floor.
Ensure that you keep your toes on the floor.
Progressions and variations:
Less advanced: 1. Place a bandage around the knees to hold them together.
More advanced: 1. Place a weight over the knees.


ANKLE PLANTORFLEXOR STRENGTENING IN STANDING USING A WEDGE:
Physiotherapist`s aim:
To strengthen the ankle plantarflexors.
Client`s aim:
To strengthen your calf muscles.
Physiotherapist`s instructions:
Position the patient in standing against a wall with their foot on a wedge and their other foot resting on a stool in front of them.
Instruct the patient to lift their heel off the wedge by plantarflexing their ankle.
Ensure that most of the weight is borne through the leg on the wedge, the knee is kept straight and the back remains against the wall.
Client`s instructions:
Position yourself standing against a wall with your foot on a wedge and your other foot resting on a stool in front of you.
Start with your foot flat on the wedge.
Finish with your heel lifted off the wedge and standing on your toes.
Ensure that most of your weight is borne through the leg on the wedge, your knee is kept straight and your back remains against the wall.
Progressions and variations:
Less advanced: 1. Move the stool closer. 2. Provide hand support for balance.
More advanced: 1. Move the stool further away.


ANKLE PLANTARFLEXOR STRETCH BY WALKING UP A STEEP SLOPE:
Physiotherapist`s aim:
To stretch or maintain length of the ankle plantarflexors.
Client`s aim:
To stretch or maintain range in your ankles.
Physiotherapist`s instructions:
Position the patient in standing on a steep slope such as a slippery slide.
Instruct the patient to walk slowly up the slope.
Ensure that the back heel remains down and the back leg is kept as straight as possible.
Client`s instructions:
Position yourself standing on a steep slope such as a slippery slide.
Practice walking slowly up the slope.
Ensure that your back heel remains down and your back leg is kept as straight as possible.
Progressions and variations:
Less advanced: 1. Decrease the incline of the slope. 2. Provide hand support for balance.
More advanced: 1. Increase the incline of the slope.
Precautions:
1. Impaired or absent sensation of stretch.


ANKLE PLANTORFLEXOR STRETCH IN STANDING:
Physiotherapist`s aim:
To stretch or maintain length of the ankle plantarflexors.
Client`s aim:
To stretch or maintain range in your ankle.
Physiotherapist`s instructions:
Position the patient in standing with one leg in front of the other and their hands resting on a wall.
Instruct the patient to lean forwards while keeping the back leg straight.
Ensure that both feet point forwards and the back heel remains on the ground.
Client`s instructions:
Position yourself standing with one leg in front of the other and your hands resting on a wall. Lean forwards while keeping your back leg straight.
Ensure that both feet point forwards and your back heel remains on the ground.
Progressions and variations:
Less advanced: 1. Decrease forwards lean.
More advanced: 1. Increase forwards lean.
Precautions:
1. Impaired or absent sensation of stretch.


ANTERIOR DELTOID ELECTRICAL STIMULATION:
Physiotherapist`s aim:
To strengthen the shoulder flexors.
Client`s aim:
To strengthen the muscles at the front of your shoulder.
Physiotherapist`s instructions:
Place the electrodes over the muscle belly of the anterior deltoid.
Client`s instructions:
Place the two electrodes over the muscle belly as shown.
Precautions:
Perform skin tests.

STROKE OR CVA

DEFINITION:
= A stroke is the sudden death of brain cells in a localized area due to inadequate blood flow.




DESCRIPTION:
# A stroke occurs when blood flow is interrupted to part of the brain.
# Without blood to supply oxygen and nutrients and to remove waste products, brain cells quickly begin to die.
# Depending on the region of the brain affected, a stroke may cause paralysis, speech impairment, loss of memory and reasoning ability, coma, or death.
# A stroke also is sometimes called a brain attack or a cerebrovascular accident (CVA).




INCIDENCE:
= more than one-half million people in the United States experience a new or recurrent stroke each year
= stroke is the third leading cause of death in the United States and the leading cause of disability
= stroke kills about 160,000 Americans each year, or almost one out of three stroke victims
three million Americans are currently permanently disabled from stroke
in the United States, stroke costs about $30 billion per year in direct costs and loss of productivity
= two-thirds of strokes occur in people over age 65 but they can occur at any age
strokes affect men more often than women, although women are more likely to die from a stroke
= strokes affect blacks more often than whites, and are more likely to be fatal among blacks
Stroke is a medical emergency requiring immediate treatment.
= Prompt treatment improves the chances of survival and increases the degree of recovery that may be expected.
= A person who may have suffered a stroke should be seen in a hospital emergency room without delay.
= Treatment to break up a blood clot, the major cause of stroke, must begin within three hours of the stroke to be effective.
= Improved medical treatment of all types of stroke has resulted in a dramatic decline in death rates in recent decades.
= In 1950, nine in ten died from stroke, compared to slightly less than one in three in the twenty-first century.
= However, about two-thirds of stroke survivors will have disabilities ranging from moderate to severe.
CAUSES:
# There are four main types of stroke.
# Cerebral thrombosis and cerebral embolism are caused by blood clots that block an artery supplying the brain, either in the brain itself or in the neck.
# These account for 70-80% of all strokes.
# Subarachnoid hemorrhage and intracerebral hemorrhage occur when a blood vessel bursts around or in the brain.
# Cerebral thrombosis occurs when a blood clot, or thrombus, forms within the brain itself, blocking the flow of blood through the affected vessel.
# Clots most often form due to "hardening" (atherosclerosis) of brain arteries.
# Cerebral thrombosis occurs most often at night or early in the morning.
# Cerebral thrombosis is often preceded by a transient ischemic attack, or TIA, sometimes called a "mini-stroke."
# In a TIA, blood flow is temporarily interrupted, causing short-lived stroke-like symptoms. #Recognizing the occurrence of a TIA, and seeking immediate treatment, is an important step in stroke prevention.
# Cerebral embolism occurs when a blood clot from elsewhere in the circulatory system breaks free.
# If it becomes lodged in an artery supplying the brain, either in the brain or in the neck, it can cause a stroke.
# The most common cause of cerebral embolism is atrial fibrillation, a disorder of the heart beat. # In atrial fibrillation, the upper chambers (atria) of the heart beat weakly and rapidly, instead of slowly and steadily.
# Blood within the atria is not completely emptied.
# This stagnant blood may form clots within the atria, which can then break off and enter the circulation.
# Atrial fibrillation is a factor in about 15% of all strokes.
# The risk of a stroke from atrial fibrillation can be dramatically reduced with daily use of anticoagulant medication.
# Hemorrhage, or bleeding, occurs when a blood vessel breaks, either from trauma or excess internal pressure.
# The vessels most likely to break are those with preexisting defects such as an aneurysm.
# An aneurysm is a "pouching out" of a blood vessel caused by a weak arterial wall.
# Brain aneurysms are surprisingly common. According to autopsy studies, about 6% of all Americans have them.
# Aneurysms rarely cause symptoms until they burst.
# Aneurysms are most likely to burst when blood pressure is highest, and controlling blood pressure is an important preventive strategy.
# Intracerebral hemorrhage affects vessels within the brain itself, while subarachnoid hemorrhage affects arteries at the brain's surface, just below the protective arachnoid membrane.
# Intracerebral hemorrhages represent about 10% of all strokes, while subarachnoid hemorrhages account for about 7%.
# In addition to depriving affected tissues of blood supply, the accumulation of fluid within the inflexible skull creates excess pressure on brain tissue, which can quickly become fatal. #Nonetheless, recovery may be more complete for a person who survives hemorrhage than for one who survives a clot, because the blood deprivation effects usually are not as severe.
# Death of brain cells triggers a chain reaction in which toxic chemicals created by cell death affect other nearby cells.
# This is one reason why prompt treatment can have such a dramatic effect on final recovery.



RISK FACTORS:
= Risk factors for stroke involve age, sex, heredity, predisposing diseases or other medical conditions, use of certain medications, and lifestyle choices:
= Age and sex. The risk of stroke increases with age, doubling for each decade after age 55. Men are more likely to have a stroke than women.
= Heredity. Blacks, Asians, and Hispanics have higher rates of stroke than do whites, related partly to higher blood pressure.
= People with a family history of stroke are at greater risk.
Diseases.
=Stroke risk is increased for people with diabetes, heart disease (especially atrial fibrillation), high blood pressure, prior stroke, or TIA.
= Risk of stroke increases tenfold for someone with one or more TIAs.
= Other medical conditions.
= Stroke risk increases with obesity, high blood cholesterol level, or high red blood cell count.
= Hormone replacement therapy.
= In mid-2003, a large clinical trial called the Women's Health Initiative was halted when researchers discovered several potentially dangerous effects of combined hormone replacement therapy on postmenopausal women.
= In addition to increasing the risk of some cancers and dementia, combined estrogen and progesterone therapy increased risk of ischemic stroke by 31% among study participants.
= Lifestyle choices. Stroke risk increases with cigarette smoking (especially if combined with the use of oral contraceptives), low level of physical activity, alcohol consumption above two drinks per day, or use of cocaine or intravenous drugs.




SYMPTOMS:
# Symptoms of an embolic stroke usually come on quite suddenly and are at their most intense right from the start, while symptoms of a thrombotic stroke come on more gradually. Symptoms may include:
# blurring or decreased vision in one or both eyes
# severe headache, often described as "the worst headache of my life"
# weakness,
# numbness,
# paralysis of the face, arm, or leg, usually confined to one side of the body
# dizziness,
# loss of balance or coordination, especially when combined with other symptoms.




DIAGNOSIS:
= The diagnosis of stroke is begun with a careful medical history, especially concerning the onset and distribution of symptoms, presence of risk factors, and the exclusion of other possible causes.
= A brief neurological exam is performed to identify the degree and location of any deficits, such as weakness, incoordination, or visual losses.
= Once stroke is suspected, a computed tomography scan (CT scan) or magnetic resonance imaging (MRI) scan is performed to distinguish a stroke caused by blood clot from one caused by hemorrhage, a critical distinction that guides therapy.
= Blood and urine tests are done routinely to look for possible abnormalities.
= Other investigations that may be performed to guide treatment include an electrocardiogram, = angiography,
= ultrasound,
= electroencephalogram.




EMERGENCY TREATMENT:
# Emergency treatment of stroke from a blood clot is aimed at dissolving the clot.
# This "thrombolytic therapy" currently is performed most often with tissue plasminogen activator, or t-PA. t-PA must be administered within three hours of the stroke event.
# Therefore, patients who awaken with stroke symptoms are ineligible for t-PA therapy, as the time of onset cannot be accurately determined.
# t-PA therapy has been shown to improve recovery and decrease long-term disability in selected patients.
# t-PA therapy carries a 6.4% risk of inducing a cerebral hemorrhage, and is not appropriate for patients with bleeding disorders, very high blood pressure, known aneurysms, any evidence of intracranial hemorrhage, or incidence of stroke, head trauma, or intracranial surgery within the past three months.
# Patients with clot-related (thrombotic or embolic) stroke who are ineligible for t-PA treatment may be treated with heparin or other blood thinners, or with aspirin or other anti-clotting agents in some cases.
# Emergency treatment of hemorrhagic stroke is aimed at controlling intracranial pressure. Intravenous urea or mannitol plus hyperventilation is the most common treatment. #Corticosteroids also may be used. Patients with reversible bleeding disorders, such as those due to anticoagulant treatment, should have these bleeding disorders reversed, if possible.
# Surgery for hemorrhage due to aneurysm may be performed if the aneurysm is close enough to the cranial surface to allow access.
#Ruptured vessels are closed off to prevent rebleeding.
# For aneurysms that are difficult to reach surgically, endovascular treatment may be used.
# In this procedure, a catheter is guided from a larger artery up into the brain to reach the aneurysm.
# Small coils of wire are discharged into the aneurysm, which plug it up and block off blood flow from the main artery.




REHABILITATION:
= Rehabilitation refers to a comprehensive program designed to regain function as much as possible and compensate for permanent losses.
= Approximately 10% of stroke survivors are without any significant disability and able to function independently.
= Another 10% are so severely affected that they must remain institutionalized for severe disability.
= The remaining 80% can return home with appropriate therapy, training, support, and care services.
= Rehabilitation is coordinated by a team of medical professionals and may include the services of a neurologist, a physician who specializes in rehabilitation medicine (physiatrist), a physical therapist, an occupational therapist, a speech-language pathologist, a nutritionist, a mental health professional, and a social worker.
= Rehabilitation services may be provided in an acute care hospital, rehabilitation hospital, long-term care facility, outpatient clinic, or at home.
= The rehabilitation program is based on the patient's individual deficits and strengths.
= Strokes on the left side of the brain primarily affect the right half of the body, and vice versa. = In addition, in left brain dominant people, who constitute a significant majority of the population, left brain strokes usually lead to speech and language deficits, while right brain strokes may affect spatial perception.
= Patients with right brain strokes also may deny their illness, neglect the affected side of their body, and behave impulsively.
= Rehabilitation may be complicated by cognitive losses, including diminished ability to understand and follow directions.
= Poor results are more likely in patients with significant or prolonged cognitive changes, sensory losses, language deficits, or incontinence.




PREVENTING COMPLICATIONS
# Rehabilitation begins with prevention of stroke recurrence and other medical complications. #The risk of stroke recurrence may be reduced with many of the same measures used to prevent stroke, including quitting smoking and controlling blood pressure.
# One of the most common medical complications following stroke is deep venous thrombosis, in which a clot forms within a limb immobilized by paralysis.
# Clots that break free often become lodged in an artery feeding the lungs.
# This type of pulmonary embolism is a common cause of death in the weeks following a stroke. # Resuming activity within a day or two after the stroke is an important preventive measure, along with use of elastic stockings on the lower limbs.
# Drugs that prevent clotting may be given, including intravenous heparin and oral warfarin.
# Weakness and loss of coordination of the swallowing muscles may impair swallowing (dysphagia), and allow food to enter the lower airway.
# This may lead to aspiration pneumonia, another common cause of death shortly after a stroke.
# Dysphagia may be treated with retraining exercises and temporary use of pureed foods.
# Depression occurs in 30-60% of stroke patients.
# Antidepressants and psychotherapy may be used in combination.
# Other medical complications include urinary tract infections, pressure ulcers, falls, and seizures.




TYPES OF REHABILITATIVE THERAPY
= Brain tissue that dies in a stroke cannot regenerate.
= In some cases, the functions of that tissue may be performed by other brain regions after a training period.
= In other cases, compensatory actions may be developed to replace lost abilities.
= Physical therapy is used to maintain and restore range of motion and strength in affected limbs, and to maximize mobility in walking, wheelchair use, and transferring (from wheelchair to toilet or from standing to sitting, for instance).
= The physical therapist advises on mobility aids such as wheelchairs, braces, and canes.
= In the recovery period, a stroke patient may develop muscle spasticity and contractures, or abnormal contractions.
= Contractures may be treated with a combination of stretching and splinting.
= Occupational therapy improves self-care skills such as feeding, bathing, and dressing, and helps develop effective compensatory strategies and devices for activities of daily living.
= A speech-language pathologist focuses on communication and swallowing skills.
= When dysphagia is a problem, a nutritionist can advise alternative meals that provide adequate nutrition.
= Mental health professionals may be involved in the treatment of depression or loss of thinking (cognitive) skills.
= A social worker may help coordinate services and ease the transition out of the hospital back into the home.
= Both social workers and mental health professionals may help counsel the patient and family during the difficult rehabilitation period.
= Caring for a person affected with stroke requires learning a new set of skills and adapting to new demands and limitations.
= Home caregivers may develop stress, anxiety, and depression.
= Caring for the caregiver is an important part of the overall stroke treatment program.
= Support groups can provide an important source of information, advice, and comfort for stroke patients and for caregivers.
= Joining a support group can be one of the most important steps in the rehabilitation process.




PROGNOSIS:
# Stroke is fatal for about 27% of white males, 52% of black males, 23% of white females, and 40% of black females.
# Stroke survivors may be left with significant deficits.
# Emergency treatment and comprehensive rehabilitation can significantly improve both survival and recovery.
# A 2003 study found that treating people who have had a stroke with certain antidepressant medications, even if they were not depressed, could increase their chances of living longer. #People who received the treatment were less likely to die from cardiovascular events than those who did not receive antidepressant drugs.




PREVENTION:
= Damage from stroke may be significantly reduced through emergency treatment.
= Knowing the symptoms of stroke is as important as knowing those of a heart attack.
= The risk of stroke can be reduced through lifestyle changes:
# quitting smoking
# controlling blood pressure
# getting regular exercise
# keeping body weight down
# avoiding excessive alcohol consumption
# getting regular checkups and following the doctor's advice regarding diet and medicines, particularly hormone replacement therapy.
# Treatment of atrial fibrillation may significantly reduce the risk of stroke.
# Preventive anticoagulant therapy may benefit those with untreated atrial fibrillation. #Warfarin (Coumadin) has proven to be more effective than aspirin for those with higher risk.
# A new drug called ximelagatran (Exanta) with fewer side effects has been introduced in Europe.
# The drug's manufacturer was applying for FDA approval to market the drug for use in preventing stroke and other thromboembolic complications in early 2004.
# In 2003, physicians at the Framingham Heart Study derived new risk scores to help physicians determine which patients with new onset of atrial fibrillation are at higher risk for stroke alone or for stroke or death.
# Screening for aneurysms may be an effective preventive measure in those with a family history of aneurysms or autosomal polycystic kidney disease, which tends to be associated with aneurysms.



KEY TERMS:
= Aneurysm:
# A pouchlike bulging of a blood vessel. Aneurysms can rupture, leading to stroke.


= Atrial fibrillation:
# A disorder of the heart beat associated with a higher risk of stroke.
# In this disorder, the upper chambers (atria) of the heart do not completely empty when the heart beats, which can allow blood clots to form.


=Cerebral embolism:
# A blockage of blood flow through a vessel in the brain by a blood clot that formed elsewhere in the body and traveled to the brain.


= Cerebral thrombosis:
# A blockage of blood flow through a vessel in the brain by a blood clot that formed in the brain itself.


= Intracerebral hemorrhage:
# A cause of some strokes in which vessels within the brain begin bleeding.


=Subarachnoid hemorrhage:
# A cause of some strokes in which arteries on the surface of the brain begin bleeding.


= Tissue plasminogen activator (tPA):
# A substance that is sometimes given to patients within three hours of a stroke to dissolve blood clots within the brain.

DEFINITION:
# Meningitis is an infection that causes inflammation of the membranes covering the brain and spinal cord.
# Non-bacterial meningitis is often referred to as "aseptic meningitis."
# Bacterial meningitis may be referred to as "purulent meningitis."




CAUSES, INCIDENCE, RISK FACTORS:
= The most common causes of meningitis are viral infections that usually resolve without treatment.
= However, bacterial infections of the meninges are extremely serious illnesses, and may result in death or brain damage even if treated.
= Meningitis is also caused by fungi, chemical irritation, drug allergies, and tumors.




TYPES:
# Meningitis - cryptococcal
Syphilitic aseptic meningitis
# Meningitis - H. influenza
# Meningitis - meningococcal
# Meningitis - pneumococcal
# Meningitis - staphylococcal
# Meningitis - tuberculous
# Aseptic meningitis
# Meningitis gram negative
# Carcinomatous meningitis (meningitis due to cancer)


= Acute bacterial meningitis is a true medical emergency, and requires immediate hospital-based treatment.
= Bacterial strains that cause meningitis include Streptococcus pneumoniae, Haemophilus influenzae, Neisseria meningitidis (meningococcus), Listeria monocytogenes, and many other types of bacteria.
= In the U.S. about 17,500 cases of bacterial meningitis occur each year.


= Viral meningitis is milder and occurs more often than bacterial meningitis.
= It usually develops in the late summer and early fall, often affects children and adults under 30.
= Seventy percent of the infections occur in children under the age of 5.
= Most viral meningitis is associated with enteroviruses, which are viruses that commonly cause intestinal illness.
= However, many other types of viruses can also cause meningitis.
= For example, viral meningitis may occur as a complication in people with genital herpes. =Recently, West Nile virus spread by mosquito bites has become a cause of viral meningitis in most of the U.S.
= In addition to causing viral meningitis, West Nile virus may cause encephalitis in some patients and a polio-like syndrome in others.




SYMPTOMS:
# Fever and chills
# Severe headache
# Nausea and vomiting
# Stiff neck (meningismus)
Sensitivity to light (photophobia)
# Mental status changes
= Additional symptoms that may be associated with this disease:
# Decreased consciousness
# Rapid breathing
# Agitation
Opisthotonos (severe neck stiffness, ultimately resulting in a characteristic arched posture-seen in infants or small children)
# Bulging fontanelles (the soft spots in a baby's skull may bulge)
# Poor feeding or irritability in children
# Meningitis is an important cause of fever in newborn children.
# For this reason, a lumbar puncture is often done on newborns who have a fever of uncertain origin.




SIGNS AND TESTS:
= Lumbar puncture with CSF glucose measurement and CSF cell count
= Gram-stain and culture of CSF (cerebral spinal fluid)
= Chest x-ray to look for other sites of infection
= Head CT scan looking for hydrocephalus, abscess or deep swelling




TREATMENT:
# Antibiotics will be prescribed for bacterial meningitis; the type will vary depending on the infecting organism.
# Antibiotics are not effective in viral meningitis.
# Treatment of secondary symptoms including brain swelling, shock, and seizures will require other medications and intravenous fluids.
# Hospitalization may be required depending on the severity of the illness and the needed treatment.



PROGNOSIS:
= Early diagnosis and treatment of bacterial meningitis is essential to prevent permanent neurological damage.
= Viral meningitis is usually not serious, and symptoms should disappear within 2 weeks with no residual complications.



COMPLICATIONS:
Hearing loss or deafness
Brain damage
Loss of vision
Hydrocephalus




PREVENTION:
# Haemophilus vaccine (HiB vaccine) in children will help prevent one type of meningitis.
# The pneumococcal conjugate vaccine is now a routine childhood immunization and is very effective at preventing pneumococcal meningitis.
# It is highly recommended that household contacts and people with close contact with individuals with meningococcal meningitis receive preventative antibiotics to avoid becoming infected themselves.
# Some communities conduct vaccination campaigns following an outbreak of meningococcal meningitis.
# Military recruits are routinely vaccinated against this form of meningitis because of its high rate of occurrence.
# The American Academy of Pediatrics and the American College Health Association encourage college students (particularly freshmen living in dormitories) to consider being vaccinated with the meningococcal vaccine.

CARPAL TUNNEL SYNDROME

Carpal tunnel syndrome
What is Carpal Tunnel Syndrome (CTS)?
Carpal tunnel syndrome is a painful disorder of the wrist and hand. CTS is classified as a cumulative trauma disorder. The carpal tunnel is a narrow tunnel formed by the bones and other tissues of your wrist. It is the area under a ligament (a tough, elastic band of tissue that connects bones and organs in place) in front of the wrist. This tunnel protects your median nerve. The median nerve, which passes through the carpal tunnel gives you feeling in your thumb, and index, middle and ring fingers. Repetitive movements of the hand and wrist can cause inflammation of structures (such as tendons and their coverings) that surround the median nerve. The inflammation may compress this nerve, producing numbness, tingling, and pain in the first three fingers and the thumb side of the hand-a condition known as carpal tunnel syndrome.
Symptoms of carpal tunnel syndrome
Numbness or tingling in your hand and fingers, especially the thumb and index and middle fingers.
Pain in your wrist, palm or forearm.
More numbness or pain at night than during the day. The pain may be so bad it wakes you up. You may shake or rub your hand to get relief.
More pain when you use your hand or wrist more.
Trouble gripping objects.
Difficulty gripping or making a fist, to dropping things.
Risk factors
Many activities outside of work may contribute to carpal tunnel syndrome: knitting, sewing, or needlepoint; cooking and housework; TV computer games and home computer work; playing sports or cards; and hobbies or projects like carpentry or using power tools for extended periods of time.
Work-related cumulative trauma of the wrist.
Diseases or conditions that predispose to the development of carpal tunnel syndrome include pregnancy, diabetes, rheumatoid arthritis and obesity.
Jobs require pinching or gripping with the wrist
People at risk include people who use computers, carpenters, grocery checkers, assembly-line workers, meat packers, violinists and mechanics.
Hobbies such as gardening, needlework, golfing and canoeing can sometimes bring on the symptoms.
Diagnosis
Physiotherapist will ask you about your, past medical history, symptoms, social history such as hobbies and occupation. They will then examine you by performing some special tests as following:
Tap the inside of your wrist. You may feel pain or a sensation like an electric shock.
Bend your wrist down for 1 minute to see if this causes symptoms.
Perform a nerve conduction test or an electromyography (EMG) test to see whether the nerves and muscles in your arm and hand
Prognosis
Carpal tunnel syndrome usually isn't serious. With treatment, the pain will usually go away and you'll have no lasting damage to your hand or wrist.
Approximately 1 percent of individuals with carpal tunnel syndrome develop permanent injury. The majority recover completely and can avoid re-injury by changing the way they do repetitive movements, the frequency with which they do the movements, and the amount of time they rest between periods when they perform the movements.
Treatment
Physical therapists can target and correct poor work habits and improper work designs, such as tools, furniture, equipment, and work space. They also can assess the risk potential of an individual and determine if that person is physically unsuited for a particular job. They work closely with employers to educate employees about CTS- what causes it and how to avoid it through proper use of the musculoskeletal system. Among their many responsibilities, physical therapists teach health awareness and job safety. A typical education program includes exercises employees can do at work and at home, adjustments to the overall work environment and individual work stations, plus early detection of symptoms to avoid painful and costly surgery.
A physical therapist will begin by observing how employees work and evaluating the ergonomics of the work environment. Ergonomics is the study and control of the effects of postures, stresses, motions, and other physical forces on the human body engaged in work. For instance, computer programmers may be sitting in a chair that forces them to slouch. Their computer screen may be too high, causing stress in the neck and shoulders, and the keyboard may be in a position that forces continued pressure on the wrist muscles. Factory workers standing on their feet all day may have to use tools that are designed for individuals with a larger grip. Their work station may be too high or too low, forcing them into an awkward body position. This action puts added strain on the neck, shoulders, and arms.
A physical therapist can show employees how to adjust their work area, handle tools, or perform tasks in a way that puts less stress on the body. They may teach employees a number of exercises to increase flexibility of their arm/hand region while they are at work. Frequent brief stretching and relaxation exercises can help reduce injuries and improve productivity in the workplace. Physical therapists also suggest short rest breaks after two hours of using the hands.
Prevention
Recent studies have shown that carpal tunnel syndrome, like all other cumulative trauma disorders, is on the rise while other workplace injuries have leveled off. Many companies are turning to physical therapists for help in designing and implementing health promotion and injury prevention programs to protect their employees from CTS.
You may need to wear a wrist splint at night, while playing sports, or when working at home. The wrist splint assists in maintaining the wrist in a neutral or straight position and allows the wrist to rest.
Avoid bending your wrists down for long periods.
Pop up your arm with pillows when you lie down.
Avoid using your hand too much.
Find a new way to use your hand by using a different tool.
Try to use the other hand more often.
Lose weight if you're overweight.
Get treatment for any disease you have that may cause carpal tunnel syndrome.
If you do the same tasks with your hands over and over, try not to bend, extend or twist your hands for long periods.
Don't work with your arms too close or too far from your body.
Don't rest your wrists on hard surfaces for long periods.
Switch hands during work tasks.
Make sure your tools aren't too big for your hands.
Take regular breaks from repeated hand movements to give your hands and wrists time to rest.
Don't sit or stand in the same position all day.
If you use a keyboard a lot, adjust the height of your chair so that your forearms are level with your keyboard and you don't have to flex your wrists to type
Your physical therapist will help you design an exercise program that allows you to enjoy daily activities at home. To begin with, your physical therapist will instruct you on exercises to stretch the forearm muscles to reduce tension on tendons that pass through the wrist. After swelling in the wrist decreases, your physical therapist will give you some isometric strengthening exercises that are correct for your particular injury.

International Physiotherapy Day

On Saturday 8 September 2007, physiotherapists all over the world will be celebrating International Physiotherapy Day. This day was created by the World Confederation of Physiotherapists to recognise the work that physiotherapists do for their patients and their community, and to support them in their efforts to promote the profession and to advance their clinical expertise. This day marks the unity and solidarity of the Physiotherapy community from 92 countries around the world. The message is exercise is beneficial for everyone, at all ages and health status.

FROZEN SHOULDER

7 Steps to Overcoming Your Frozen Shoulder.


Tip #1 -
= Support the affected arm during activities of daily living.
= This includes driving, typing at the computer, sitting in a chair and relaxing in your
lazy boy at home.
= Gravity pulls the arm down when it is unsupported, and this
increases strain on the rotator cuff.
= It is best to use a soft pillow or cushion when
available.
= By reducing the pull of gravity throughout the day, you will naturally lessen the pain
and inflammation in your shoulder.
= While it will take effort on your part to not
violate this rule, I promise you it will make a difference.


Tip #2 -
= Use ice and heat accordingly to relieve pain and decrease stiffness.
= Heat is a great way to start the day and reduce stiffness.
= Your best bet is a warm
shower.
= Another method is applying a heating pack.
= Regardless, this will feel good,
reduce stiffness and better prepare you to move the arm in your morning routine.
= With regard to ice, I always suggest a frozen bag of veggies or professional soft wrap
that conforms to the shape of the shoulder.
= Be sure to support the arm as
mentioned previously while icing.
= Keep the ice on for 15-20 minutes and then off for
an hour.
= You may ice more than once per day if desired based on pain.
= I usually suggest icing before bed to improve sleep.
= I know you are asking yourself why put ice on a stiff shoulder.
=Ice really is helpful because it reduces inflammation.
= Heat feels good, but does not dramatically affect
the inflammation.
= Ice should be used after periods of increased activity (e.g. work or
play).
= So, if you have not been icing, begin using it daily to reduce pain and aid
healing.


Tip #3 -
= Avoid forcing the arm to move in painful ranges of motion unless
absolutely necessary.
= With a stiff frozen shoulder, the rotator cuff gets compressed when the arm is
elevated, rotated or extended beyond the point of joint mobility due to abnormal
joint mechanics and this often further aggravates the symptoms.
= This is problematic with getting dressed, fastening the seat belt or placing carry-on baggage in a plane.
= Depending on your pain state (acute, sub-acute or chronic) you may have pain in
different parts of the range of motion.
= Any significant pain with movement is a bad
thing and you should try to minimize or avoid it altogether.
= Rest from this abusive
motion is absolutely critical to resolving your inflammation and returning to preinjury
levels.
= However, this does not mean you should stop moving the arm in those directions at
all as that can cause you to lose even more mobility.
= Use moderation as your guide
and pay attention to the pain levels day to day!


Tip #4 -
= Do not perform single arm or overhead heavy lifting during periods
of inflammation.
= This position coupled with external loads will prolong your pain and slow the recovery
process.
= It is common for people to unknowingly abuse their shoulder with daily
activities including overhead lifting, carrying laptops, hauling briefcases and even
lifting luggage (especially overhead).
= I know you are asking how to avoid these positions.
= The best answer is to switch
arms or use both arms to execute lifting maneuvers when possible.
= Believe it or not,
even small loads and movements can significantly increase pain and inflammation.
= Minimizing the number of such activities is necessary to allow the injured tissue to
heal.
= Use pain as your guide with daily tasks, but be careful to avoid pushing, pulling or
lifting heavy objects with the affected arm.
= Try to use both arms and keep them as
close to the body as possible.
= This measure alone will accelerate healing and reduce
your pain.


Tip #5 -
= Perform arm pendulums (clockwise and counterclockwise circles)
daily.
= This gentle motion stimulates receptors in the shoulder joint and helps to increase
joint space and reduce pain.
= This is also a good warm-up activity prior to shoulder
exercises.
= You can eventually add a small weight or soup can to increase the effect.
= It is important to let the motion of the body direct the shoulder and not to forcefully
move the shoulder in circles.
= The arm should hang as though it were limp and follow
the lead of the body.
= I generally recommend doing 20-30 repetitions of this exercise 1-2 times per day.
= If
it causes pain, then reduce the radius of the circles or simply wait until it can be
done pain free.
= This is even more effective if you perform it after a warm shower or
applying moist heat to the shoulder for 10-15 minutes.


Tip #6 -
= Use a pillow under the arm at night to better support the injured
arm.
= Propping the arm up as opposed to letting it hang down against the bed will actually
reduce pull and tension on the shoulder and rotator cuff itself.
= Proper positioning will
keep the shoulder in a neutral position in line with the body and should feel very
comfortable.
= I also recommend trying to sleep on the unaffected side if possible, as lying on the
sore side compresses the shoulder and will typically increase pain and wake you.
= I know you are thinking it is impossible to stay in one position at night.
= You are
probably right.
= But, I encourage you to at least try these options when you are in
significant pain, as I know for sure that compression of the shoulder will make your
symptoms worse.
= That also equals more pain and less sleep.
= So, use a small to moderate sized pillow that achieves the optimal position described
above.
= Even if you move during sleep, a little break from the bad positions should
still aid in your recovery.


Tip #7 -
= Perform daily stretching and range of motion exercises.
= What if your shoulder is really sore? How does exercise aid healing? Exercise will
increase blood flow to the tissues and doing specific exercises will not only prevent
further motion loss and stiffness, but actually help you recover lost function and
mobility in your shoulder.
= It is not acceptable to do just any exercises.
= They need to be specific to the problem
you have and target the tight tissue in your shoulder.
= They must also be done at a
certain frequency, intensity and volume to reduce your pain.
= I have determined a
clinically proven formula for doing just this.
= Lower intensity and longer duration stretches coupled with specific cane range of
motion exercises are essential to promote healing, reduce inflammation and return
you to pre-injury activity levels again.
= More importantly, effective rehab exercises
will prevent future injuries and more pain and suffering.
= While there is no magic pill
or quick fix for a frozen shoulder, these exercises are guaranteed to help you get
better.

VENTILATORS

Ventilators
Definition
A ventilator is a device used to provide assisted respiration and positive-pressure breathing.
Purpose
Ventilators are used to provide mechanical ventilation for patients with respiratory failure who cannot breathe effectively on their own. They are also used to decrease myocardial gas consumption or intracranial pressure, provide stability of the chest wall after trauma or surgery, and when a patient is sedated or pharmacologically paralyzed.
Description
Different types of ventilators can be programmed to provide several modes of mechanical ventilation. A brief overview of each type and mode follows.
Negative-pressure ventilators
The original ventilators used negative pressure to remove and replace gas from the ventilator chamber. Examples of these include the iron lung, the Drinker respirator, and the chest shell. Rather than connecting to an artificial airway, these ventilators enclosed the body from the outside. As gas was pulled out of the ventilator chamber, the resulting negative pressure caused the chest wall to expand, which pulled air into the lungs. The cessation of the negative pressure caused the chest wall to fall and exhalation to occur. While an advantage of these ventilators was that they did not require insertion of an artificial airway, they were noisy, made nursing care difficult, and the patient was not able to ambulate.
Positive-pressure ventilators
Postive-pressure ventilators require an artificial airway (endotracheal or tracheostomy tube) and use positive pressure to force gas into a patient's lungs. Inspiration can be triggered either by the patient or the machine. There are four types of positive-pressure ventilators: volume-cycled, pressure-cycled, flow-cycled, and time-cycled.
VOLUME-CYCLED VENTILATORS. This type delivers a preset tidal volume then allows passive expiration. This is ideal for patients with acute respiratory distress syndrome (ARDS) or bronchospasm, since the same tidal volume is delivered regardless of the amount of airway resistance. This type of ventilator is the most commonly used in critical care environments.
PRESSURE-CYCLED VENTILATORS. These ventilators deliver gases at a preset pressure, then allow passive expiration. The benefit of this type is a decreased risk of lung damage from high inspiratory pressures, which is particularly beneficial for neonates who have a small lung capacity. The disadvantage is that the tidal volume delivered can decrease if the patient has poor lung compliance and increased airway resistance. This type of ventilation is usually used for short-term therapy (less than 24 hours). Some ventilators have the capability to provide both volume-cycled and pressure-cycled ventilation. These combination ventilators are also commonly used in critical care environments.
FLOW-CYCLED VENTILATORS. Flow-cycled ventilators deliver oxygenation until a preset flow rate is achieved during inspiration.
TIME-CYCLED VENTILATORS. Time-cycled ventilators deliver oxygenation over a preset time period. These types of ventilators are not used as frequently as the volume-cycled and pressure-cycled ventilators.
Modes of ventilation
Mode refers to how the machine will ventilate the patient in relation to the patient's own respiratory efforts. There is a mode for nearly every patient situation; plus, many different types can be used in conjunction with each other.
CONTROL VENTILATION (CV). CV delivers the preset volume or pressure regardless of the patient's own inspiratory efforts. This mode is used for patients who are unable to initiate a breath. If it is used with spontaneously breathing patients, they must be sedated and/or pharmacologically paralyzed so they don't breathe out of synchrony with the ventilator.
ASSIST-CONTROL VENTILATION (A/C) OR CONTINUOUS MANDATORY VENTILATION (CMV). A/C or CMV delivers the preset volume or pressure in response to the patient's inspiratory effort, but will initiate the breath if the patient does not do so within a preset amount of time. This mode is used for patients who can initiate a breath but who have weakened respiratory muscles. The patient may need to be sedated to limit the number of spontaneous breaths, as hyperventilation can occur in patients with high respiratory rates.
SYNCHRONOUS INTERMITTENT MANDATORY VENTILATION (SIMV). SIMV delivers the preset volume or pressure and preset respiratory rate while allowing the patient to breathe spontaneously. The vent initiates each breath in synchrony with the patient's breaths. SIMV is used as a primary mode of ventilation as well as a weaning mode. (During weaning, the preset rate is gradually reduced, allowing the patient to slowly regain breathing on their own.) The disadvantage of this mode is that it may increase the effort of breathing and cause respiratory muscle fatigue. (Breathing spontaneously through ventilator tubing has been compared to breathing through a straw.)
POSITIVE-END EXPIRATORY PRESSURE (PEEP). PEEP is positive pressure that is applied by the ventilator at the end of expiration. This mode does not deliver breaths but is used as an adjunct to CV, A/C, and SIMV to improve oxygenation by opening collapsed alveoli at the end of expiration. Complications from the increased pressure can include decreased cardiac output, lung rupture, and increased intracranial pressure.
CONSTANT POSITIVE AIRWAY PRESSURE (CPAP). CPAP is similar to PEEP, except that it works only for patients who are breathing spontaneously. The effect of CPAP (and PEEP) is compared to inflating a balloon but not letting it completely deflate before inflating it again. The second inflation is easier to perform because resistance is decreased. CPAP can also be administered using a mask and CPAP machine for patients who do not require mechanical ventilation but who need respiratory support (for example, patients with sleep apnea).
PRESSURE SUPPORT VENTILATION (PSV). PS is preset pressure which augments the patient's spontaneous inspiration effort and decreases the work of breathing. The patient completely controls the respiratory rate and tidal volume. PS is used for patients with a stable respiratory status and is often used with SIMV during weaning.
INDEPENDENT LUNG VENTILATION (ILV). This method is used to ventilate each lung separately in patients with unilateral lung disease or a different disease process in each lung. It requires a double-lumen endotracheal tube and two ventilators. Sedation and pharmacologic paralysis are used to facilitate optimal ventilation and increase comfort for the patient on whom this method is used.
HIGH FREQUENCY VENTILATION (HFV). HFV delivers a small amount of gas at a rapid rate (as much as 60-100 breaths per minute). This is used when conventional mechanical ventilation would compromise hemodynamic stability, during short-term procedures, or for patients who are at high risk for lung rupture. Sedation and/or pharmacologic paralysis are required.
INVERSE RATIO VENTILATION (IRV). The normal inspiratory:expiratory ratio is 1:2, but this is reversed during IRV to 2:1 or greater (the maximum is 4:1). This method is used for patients who are still hypoxic, even with the use of PEEP. Longer inspiratory time increases
the amount of air in the lungs at the end of expiration (the functional residual capacity) and improves oxygenation by re-expanding collapsed alveoli. The shorter expiratory time prevents the alveoli from collapsing again. This method requires sedation and therapeutic paralysis because it is very uncomfortable for the patient.
Ventilator settings
Ventilator settings are ordered by a physician and are individualized for the patient. Ventilators are designed to monitor most components of the patient's respiratory status. Various alarms and parameters can be set to warn healthcare providers that the patient is having difficulty with the settings.
RESPIRATORY RATE. The respiratory rate is the number of breaths the ventilator will deliver to the patient over a specific time period. The respiratory rate parameters are set above and below this number, and an alarm will sound if the patient's actual rate is outside the desired range.
TIDAL VOLUME. Tidal volume is the volume of gas the ventilator will deliver to the patient with each breath. The usual setting is 5-15 cc/kg. The tidal volume parameters are set above and below this number and an alarm sounds if the patient's actual tidal volume is outside the desired range. This is especially helpful if the patient is breathing spontaneously between ventilator-delivered breaths since the patient's own tidal volume can be compared with the desired tidal volume delivered by the ventilator.
OXYGEN CONCENTRATION (FIO2). Oxygen concentration is the amount of oxygen delivered to the patient. It can range from 21% (room air) to 100%.
INSPIRATORY:EXPIRATORY (I:E) RATIO. As discussed above, the I:E ratio is normally 1:2 or 1:1.5, unless inverse ratio ventilation is desired.
PRESSURE LIMIT. Pressure limit regulates the amount of pressure the volume-cycled ventilator can generate to deliver the preset tidal volume. The usual setting is 10-20 cm H2O above the patient's peak inspiratory pressure. If this limit is reached the ventilator stops the breath and alarms. This is often an indication that the patient's airway is obstructed with mucus and is usually resolved with suctioning. It can also be caused by the patient coughing, biting on the endotracheal tube, breathing against the ventilator, or by a kink in the ventilator tubing.
FLOW RATE. Flow rate is the speed with which the tidal volume is delivered. The usual setting is 40-100 liters per minute.
SENSITIVITY/TRIGGER. Sensitivity determines the amount of effort required by the patient to initiate inspiration. It can be set to be triggered by pressure or by flow.
SIGH. The ventilator can be programmed to deliver an occasional sigh with a larger tidal volume. This prevents collapse of the alveoli (atelectasis) which can result from the patient constantly inspiring the same volume of gas.
Operation
Many ventilators are now computerized and have a user-friendly control panel. To activate the various modes, settings, and alarms, the appropriate key need only be pressed. There are windows on the face panel which show settings and the alarm values. Some ventilators have dials instead of computerized keys, e.g., the smaller, portable ventilators used for transporting patients.
The ventilator tubing simply attaches to the ventilator on one end and to the patient's artificial airway on the other. Most ventilators have clamps that prevent the tubing from draping across the patient. However, there should be enough slack so that the artificial airway isn't accidentally pulled out if the patient turns.
Ventilators are electrical equipment so they must be plugged in. They do have battery back up, but this is not designed for long-term use. It should be ensured that they are plugged into an outlet that will receive generator power if there is an electrical power outage. Ventilators are a method of life-support. If the ventilator should stop working, the patient's life will be in jeopardy. There should be a bag-valve-mask device at the bedside of every patient receiving mechanical ventilation so they can be manually ventilated if needed.
Maintenance
When mechanical ventilation is initiated, the ventilator goes through a self-test to ensure it is working properly. The ventilator tubing should be changed every 24 hours and another self-test run afterwards. The bacteria filters should be checked for occlusions or tears and the water traps and filters should be checked for condensation or contaminants. These should be emptied and cleaned every 24 hours and as needed.
Health care team roles
The respiratory therapist is generally the person who sets up the ventilator, does the daily check described above, and changes the ventilator settings based on the physician's orders. The nurse is responsible for monitoring the alarms and the patient's respiratory status. The nurse is also responsible for notifying the respiratory therapist when mechanical problems occur with the ventilator and when there are new physician orders requiring changes in the settings or the alarm parameters. The physician is responsible for keeping track of the patient's status on the current ventilator settings and changing them when necessary.
Training
Training for using and maintaining ventilators is often done via hands-on methods. Critical care nurses usually have a small amount of class time during which they learn the ventilator modes and settings. They then apply this knowledge while working with patients on the unit under the supervision of a nurse preceptor. This preceptorship usually lasts about six weeks (depending upon the nurse's prior experience) and includes all aspects of critical care. Nurses often learn the most from the respiratory therapists, since ventilator management is their specialty.
Respiratory therapists complete an educational program that specifically focuses on respiratory diseases, and equipment and treatments used to manage those diseases. During orientation to a new job, they work under the supervision of an experienced respiratory therapist to learn how to maintain and manage the ventilators used by that particular institution. Written resources from the company that produced the ventilators are usually kept in the respiratory therapy department for reference.
Physicians generally do not manage the equipment aspect of the ventilator. They do, however, manage the relation of the ventilator settings to the patient's condition. They gain this knowledge of physiology during medical school and residency.
KEY TERMS
Alveoli Saclike structures in the lungs where oxygen and carbon dioxide exchange takes place.
Bag-valve-mask device Device consisting of a manually compressible bag containing oxygen and a one-way valve and mask that fits over the mouth and nose of the patient.
Endotracheal tube Tube inserted into the trachea via either the oral or nasal cavity for the purpose of providing a secure airway.
Hemodynamic stability Stability of blood circulation, including cardiac function and peripheral vascular physiology.
Hypoxic Abnormal deficiency of oxygen in the arterial blood.
Intracranial pressure The amount of pressure exerted inside the skull by brain tissue, blood, and cerebral-spinal fluid.
Peak inspiratory pressure The pressure in the lungs at the end of inspiration.
Pharmacologically paralyzed Short-term paralysis induced by medications for a therapeutic purpose.
Tracheostomy tube Surgically created opening in the trachea for the purpose of providing a secure airway. This is used when the patient requires long-term ventilatory assistance.
Weaning The process of gradually tapering mechanical ventilation and allowing the patient to resume breathing on their own.
BOOKS
Marino, P. The ICU Book. Baltimore: Williams & Wilkins, 1998.
Thelan, Lynne, et al. Critical Care Nursing: Diagnosis and Management. St. Louis: Mosby, 1998.
OTHER
Puritan-Bennett 7200 Series Ventilator System Pocket Guide. Booklet. Mallinckrodt, 2000.
Abby Wojahn, R.N., B.S.N., C.C.R.N.

OSTEOARTHRITIS

Osteoarthritis (AH-stee-oh-ar-THREYE-tis) is the most common type of arthritis, especially among older people. Sometimes it is called degenerative joint disease or osteoarthrosis.
Osteoarthritis is a joint disease that mostly affects the cartilage (KAR-til-uj). Cartilage is the slippery tissue that covers the ends of bones in a joint. Healthy cartilage allows bones to glide over one another. It also absorbs energy from the shock of physical movement. In osteoarthritis, the surface layer of cartilage breaks down and wears away. This allows bones under the cartilage to rub together, causing pain, swelling, and loss of motion of the joint. Over time, the joint may lose its normal shape. Also, bone spurs--small growths called osteophytes--may grow on the edges of the joint. Bits of bone or cartilage can break off and float inside the joint space. This causes more pain and damage.
People with osteoarthritis usually have joint pain and limited movement. Unlike some other forms of arthritis, osteoarthritis affects only joints and not internal organs. For example, rheumatoid arthritis--the second most common form of arthritis--affects other parts of the body besides the joints. It begins at a younger age than osteoarthritis, causes swelling and redness in joints, and may make people feel sick, tired, and (uncommonly) feverish.

How Does Osteoarthritis Affect People?
Osteoarthritis affects each person differently. In some people, it progresses quickly; in others, the symptoms are more serious. Scientists do not know yet what causes the disease, but they suspect a combination of factors, including being overweight, the aging process, joint injury, and stresses on the joints from certain jobs and sports activities.
What Areas Does Osteoarthritis Affect?Osteoarthritis most often occurs at the ends of the fingers, thumbs, neck, lower back, knees, and hips.

Osteoarthritis hurts people in more than their joints: their finances and lifestyles also are affected.
Financial effects include:
-The cost of treatment
-Wages lost because of disability.

Lifestyle effects include:
-Depression
-Anxiety
-Feelings of helplessness
-Limitations on daily activities
-Job limitations
-Trouble participating in everyday personal and family joys and responsibilities.

Despite these challenges, most people with osteoarthritis can lead active and productive lives. They succeed by using osteoarthritis treatment strategies, such as the following:
-Pain relief medications
-Rest and exercise
-Patient education and support programs
-Learning self-care and having a "good-health attitude."


Fighting Osteoarthritis With Exercise
You can use exercises to keep strong and limber, extend your range of movement, and reduce your weight.Some different types of exercise include the following:
Strength exercises:
These can be performed with exercise bands, inexpensive devices that add resistance.Aerobic activities: These keep your lungs and circulation systems in shape.Range of motion activities: These keep your joints limber.Agility exercises: These can help you maintain daily living skills.Neck and back strength exercises: These can help you keep your spine strong and limber.

Ask your doctor or physical therapist what exercises are best for you. Ask for guidelines on exercising when a joint is sore or if swelling is present. Also, check if you should (1) use pain-relieving drugs, such as analgesics or anti-inflammatories (also called NSAIDs), to make exercising easier, or (2) use ice afterwards.
Rest and joint care:
Treatment plans include regularly scheduled rest. Patients must learn to recognize the body's signals, and know when to stop or slow down, which prevents pain caused by overexertion. Some patients find that relaxation techniques, stress reduction, and biofeedback help. Some use canes and splints to protect joints and take pressure off them. Splints or braces provide extra support for weakened joints. They also keep the joint in proper position during sleep or activity. Splints should be used only for limited periods because joints and muscles need to be exercised to prevent stiffness and weakness. An occupational therapist or a doctor can help the patient get a properly fitting splint.
Nondrug pain relief:
People with osteoarthritis may find nondrug ways to relieve pain. Warm towels, hot packs, or a warm bath or shower to apply moist heat to the joint can relieve pain and stiffness. In some cases, cold packs (a bag of ice or frozen vegetables wrapped in a towel can relieve pain or numb the sore area. (Check with a doctor or physical therapist to find out if heat or cold is the best treatment.) Water therapy in a heated pool or whirlpool also may relieve pain and stiffness. For osteoarthritis in the knee, patients may wear insoles or cushioned shoes to redistribute weight and reduce joint stress.
Weight control:
Osteoarthritis patients who are overweight or obese need to lose weight. Weight loss can reduce stress on weight-bearing joints and limit further injury. A dietitian can help patients develop healthy eating habits. A healthy diet and regular exercise help reduce weight.

Cardiopulmonary resuscitation (CPR): First aid

Cardiopulmonary resuscitation (CPR) is a lifesaving technique useful in many emergencies, including heart attack or near drowning, in which someone's breathing or heartbeat has stopped. CPR involves a combination of mouth-to-mouth rescue breathing and chest compression that keeps oxygenated blood flowing to the brain and other vital organs until more definitive medical treatment can restore a normal heart rhythm.

When the heart stops, the absence of oxygenated blood can cause irreparable brain damage in only a few minutes. Death will occur within eight to 10 minutes. Time is critical when you're helping an unconscious person who isn't breathing.

Remember the ABCs
Airway, Breathing and Circulation — to remember the steps explained below.
AIRWAY: Clear the airway
1. Put the person on his or her back on a firm surface.
2. Kneel next to the person's neck and shoulders.
3. Open the person's airway using the head tilt-chin lift. Put your palm on the person's forehead and gently push down. Then with the other hand, gently lift the chin forward to open the airway.
4. Check for normal breathing, taking no more than 10 seconds: Look for chest motion, listen for breath sounds, and feel for the person's breath on your cheek and ear. Do not consider gasping to be normal breathing. If the person isn't breathing normally or you aren't sure, begin mouth-to-mouth breathing.
BREATHING: Breathe for the person
Rescue breathing can be mouth-to-mouth breathing or mouth-to-nose breathing if the mouth is seriously injured or can't be opened.
1. With the airway open (using the head tilt-chin lift), pinch the nostrils shut for mouth-to-mouth breathing and cover the person's mouth with yours, making a seal.
2. Prepare to give two rescue breaths. Give the first rescue breath — lasting one second — and watch to see if the chest rises. If it does rise, give the second breath. If the chest doesn't rise, repeat the head tilt-chin lift and then give the second breath.
3. Begin chest compressions — go to "CIRCULATION" below.
CIRCULATION: Restore blood circulation
1. Place the heel of one hand over the center of the person's chest, between the nipples. Place your other hand on top of the first hand. Keep your elbows straight and position your shoulders directly above your hands.
2. Use your upper body weight (not just your arms) as you push straight down on (compress) the chest 1 1/2 to 2 inches. Push hard and push fast — give two compressions per second, or about 100 compressions per minute.
3. After 30 compressions, tilt the head back and lift the chin up to open the airway. Prepare to give two rescue breaths. Pinch the nose shut and breathe into the mouth for one second. If the chest rises, give a second rescue breath. If the chest doesn’t rise, repeat the head tilt-chin lift and then give the second rescue breath. That's one cycle. If someone else is available, ask that person to give two breaths after you do 30 compressions.
4. If the person has not begun moving after five cycles (about two minutes) and an automated external defibrillator (AED) is available, open the kit and follow the prompts. If you're not trained to use an AED, a 911 operator may be able to guide you in its use. Trained staff at many public places are also able to provide and use an AED. Use pediatric pads, if available, for children ages 1 to 8. If pediatric pads aren't available, use adult pads. Do not use an AED for infants younger than age 1. If an AED isn't available, go to Number 5 below.
5. Continue CPR until there are signs of movement or until emergency medical personnel take over.
To perform CPR on a child:
The procedure for giving CPR to a child age 1 through 8 is essentially the same as that for an adult. The differences are as follows:
 Perform five cycles of compressions and breaths on the child — this should take about two minutes — before calling 911 or the local emergency number, unless someone else can call while you attend to the child.
 Use only one hand to perform heart compressions.
 Breathe more gently.
 Use the same compression/breath rate as is used for adults: 30 compressions followed by two breaths. This is one cycle. Following the two breaths, immediately begin the next cycle of compressions and breaths. Continue until the victim moves or help arrives.
To perform CPR on a baby:
Most cardiac arrests in infants occur from lack of oxygen, such as from drowning or choking. If you know the infant has an airway obstruction, perform first aid for choking. If you don't know why the infant isn't breathing, perform CPR.
To begin, assess the situation. Stroke the baby and watch for a response, such as movement, but don't shake the child.
If there's no response, follow the ABC procedures below and time the call for help as follows:
 If you're the only rescuer and CPR is needed, do CPR for two minutes — about five cycles — before calling 911 or your local emergency number.
 If another person is available, have that person call for help immediately while you attend to the baby.
AIRWAY: Clear the airway
1. Place the baby on his or her back on firm, flat surface, such as a table. The floor or ground also will do.
2. Gently tip the head back by lifting the chin with one hand and pushing down on the forehead with the other hand.
3. In no more than 10 seconds, put your ear near the baby's mouth and check for breathing: Look for chest motion, listen for breath sounds, and feel for breath on your cheek and ear.
If the infant isn't breathing, begin mouth-to-mouth breathing immediately.
BREATHING: Breathe for the infant
1. Cover the baby's mouth and nose with your mouth.
2. Prepare to give two rescue breaths. Use the strength of your cheeks to deliver gentle puffs of air (instead of deep breaths from your lungs) to slowly breathe into the baby's mouth one time, taking one second for the breath. Watch to see if the baby's chest rises. If it does, give a second rescue breath. If the chest does not rise, repeat the head tilt-chin lift and then give the second breath.
3. If the chest still doesn't rise, examine the mouth to make sure no foreign material is inside. If the object is seen, sweep it out with your finger. If the airway seems blocked, perform first aid for a choking infant.
4. Begin chest compressions — go to "CIRCULATION" below.
CIRCULATION: Restore blood circulation
1. Imagine a horizontal line drawn between the baby's nipples. Place two fingers of one hand just below this line, in the center of the chest.
2. Gently compress the chest to about one-third to one-half the depth of the chest.
3. Count aloud as you pump in a fairly rapid rhythm. You should pump at a rate of about 100 times a minute.
4. Give two breaths after every 30 chest compressions.
5. Perform CPR for about two minutes before calling for help unless someone else can make the call while you attend to the baby.
6. Continue CPR until you see signs of life or until a professional relieves you.