Comprehensive Pharmacology Notes: Concepts and Applications

Posted on Feb 15, 2025 in Physical Education

General Pharmacology: Detailed Notes

1. Introduction & General Concepts

Definition of Pharmacology

Pharmacology is the branch of medical science that studies drugs, including their sources, chemical properties, biological effects, and therapeutic uses. It examines how drugs interact with biological systems and how the body processes these drugs.

Importance of Pharmacology

• Understanding drug actions and interactions.
• Ensuring safe and effective use of drugs.
• Aiding drug development, testing, and approval.
• Preventing adverse effects and toxicity.

Branches of Pharmacology

1. Pharmacokinetics – Study of what the body does to the drug (Absorption, Distribution, Metabolism, Elimination).
2. Pharmacodynamics – Study of what the drug does to the body (Mechanism of action, Therapeutic effects, Side effects).
3. Pharmacotherapeutics – Study of the clinical use of drugs in disease treatment.
4. Toxicology – Study of the harmful effects of drugs and poisons.
5. Chemotherapy – Study of drugs that kill or inhibit the growth of microorganisms, parasites, and cancer cells.
6. Clinical Pharmacology – Evaluates drug effects in humans, including safety, efficacy, and interactions.
7. Pharmacogenetics – Studies genetic influences on drug metabolism and effects.

Drug Nomenclature

Drugs have three types of names:

1. Chemical Name: Specifies molecular structure (e.g., N-acetyl-para-aminophenol for Paracetamol).
2. Generic Name: Official, internationally recognized name (e.g., Paracetamol).
3. Brand Name: Commercial name given by pharmaceutical companies (e.g., Tylenol, Panadol).

Sources of Drugs

• Natural: Plants (Morphine), Animals (Insulin), Minerals (Magnesium sulfate).
• Synthetic: Laboratory-made drugs (Aspirin, Paracetamol).
• Biotechnological: Genetically engineered drugs (Insulin, Monoclonal antibodies).

Classification of Drugs

1. Pharmacological Action: Antibiotics, Analgesics, Antihypertensives.
2. Therapeutic Use: Drugs for diabetes, asthma.
3. Mechanism of Action: Beta-blockers, Calcium channel blockers.
4. Chemical Nature: Steroids, Alkaloids, Peptides.
5. Legal Classification: Prescription drugs, Over-the-counter (OTC) drugs, Controlled substances.

2. Pharmacokinetics (What the Body Does to the Drug)

Routes of Drug Administration

1. Enteral (Digestive Tract): Oral, Sublingual, Rectal.
2. Parenteral (Bypassing Digestive Tract): Intravenous (IV), Intramuscular (IM), Subcutaneous (SC).
3. Topical: Application to skin, eyes, ears, or mucous membranes.
4. Inhalational: Direct absorption through the lungs (e.g., Asthma inhalers).

Drug Absorption

• Definition: The process by which a drug enters the bloodstream.
• Factors Affecting Absorption:
  • Route of administration.
  • Drug solubility and formulation.
  • Blood flow to absorption site.
  • pH and gastric emptying time.

Drug Distribution

• Definition: Movement of the drug from the bloodstream to tissues.
• Factors Affecting Distribution:
  • Plasma protein binding.
  • Tissue permeability.
  • Blood-brain barrier.

Drug Metabolism (Biotransformation)

• Occurs mainly in the liver through enzyme activity.
• Phase 1 Reactions: Modification via Oxidation, Reduction, Hydrolysis.
• Phase 2 Reactions: Conjugation with other molecules to enhance elimination.

Drug Elimination (Excretion)

• Renal (Kidneys): Most drugs excreted via urine.
• Hepatic (Liver & Bile): Some drugs excreted via the intestines.
• Pulmonary (Lungs): Anesthetic gases exhaled.
• Other Routes: Skin (sweat), Saliva, Breast milk.

3. Pharmacodynamics (What the Drug Does to the Body)

Mechanism of Drug Action

1. Receptor Interaction: Drugs bind to specific receptors to exert effects (e.g., beta-blockers block β-receptors in the heart).
2. Enzyme Inhibition: Drugs inhibit enzymes to alter biological reactions (e.g., aspirin inhibits COX enzymes to reduce inflammation).
3. Ion Channel Modulation: Drugs block or open ion channels (e.g., calcium channel blockers for hypertension).
4. Neurotransmitter Modulation: Drugs increase or decrease neurotransmitter activity (e.g., antidepressants).

Therapeutic & Side Effects of Drugs

• Therapeutic Effect: The intended beneficial effect of a drug.
• Side Effects: Unintended but mild effects (e.g., drowsiness from antihistamines).
• Adverse Effects: Harmful reactions requiring medical attention.
• Idiosyncratic Reactions: Rare, unpredictable responses unique to an individual.
• Allergic Reactions: Immune-mediated responses (e.g., penicillin allergy).

Drug Toxicity

• Dose-Dependent Toxicity: Higher doses increase toxicity risk (e.g., liver damage from paracetamol overdose).
• Carcinogenicity & Mutagenicity: Some drugs can cause cancer or genetic mutations.
• Teratogenicity: Some drugs cause fetal abnormalities (e.g., thalidomide).

Autonomic Nervous System (ANS)

The Autonomic Nervous System (ANS) is a part of the Peripheral Nervous System (PNS) that regulates involuntary physiological functions, including heart rate, blood pressure, digestion, and respiratory rate. It operates without conscious control and is divided into two main divisions:

1. Sympathetic Nervous System (SNS)
2. Parasympathetic Nervous System (PNS)

These two systems work in antagonistic fashion to maintain homeostasis.

1. Sympathetic Nervous System (SNS)

Functions (“Fight or Flight Response”)

The SNS prepares the body for stressful or emergency situations by:

• Increasing heart rate (tachycardia) and blood pressure
• Dilating bronchioles to enhance oxygen intake
• Increasing blood glucose levels (glycogenolysis)
• Redirecting blood to skeletal muscles (vasodilation)
• Inhibiting digestive secretions and peristalsis
• Dilating pupils (mydriasis)
• Increasing sweating (sudomotor activity)

Neurotransmitters & Receptors

• Primary Neurotransmitters: Norepinephrine (NE) & Epinephrine (Epi)
• Receptors: Adrenergic Receptors (α & β)
  • α1 (Vasoconstriction, increased BP)
  • α2 (Inhibitory, reduces NE release)
  • β1 (Increases heart rate & contractility)
  • β2 (Bronchodilation, vasodilation in muscles)
  • β3 (Lipolysis in adipose tissue)

Drugs Affecting SNS (Adrenergic System)

1. Adrenergic Agonists (Sympathomimetics)
   • Direct-acting: Epinephrine, Norepinephrine, Dopamine, Dobutamine
   • Indirect-acting: Amphetamines, Ephedrine
   • Mixed-acting: Pseudoephedrine
2. Adrenergic Antagonists (Sympatholytics)
   • α-blockers: Prazosin, Tamsulosin, Phentolamine (Used in hypertension, BPH)
   • β-blockers: Propranolol, Atenolol, Metoprolol (Used in hypertension, arrhythmias)

2. Parasympathetic Nervous System (PNS)

Functions (“Rest and Digest Response”)

The PNS conserves energy and maintains baseline body functions:

• Decreasing heart rate (bradycardia)
• Constricting bronchioles (bronchoconstriction)
• Stimulating digestive secretions & peristalsis
• Enhancing urination (micturition)
• Constricting pupils (miosis)
• Increasing glandular secretion (saliva, tears)

Neurotransmitters & Receptors

• Primary Neurotransmitter: Acetylcholine (ACh)
• Receptors: Cholinergic Receptors
  • Muscarinic (M1-M5)
    • M1 (CNS, gastric secretion)
    • M2 (Cardiac inhibition)
    • M3 (Smooth muscle contraction, glandular secretion)
  • Nicotinic (Nn, Nm)
    • Nn (Autonomic ganglia)
    • Nm (Neuromuscular junctions in skeletal muscles)

Drugs Affecting PNS (Cholinergic System)

1. Cholinergic Agonists (Parasympathomimetics)

   • Direct-acting: Pilocarpine (for glaucoma), Bethanechol (for urinary retention)
   • Indirect-acting: Neostigmine, Physostigmine (Acetylcholinesterase inhibitors)

2. Cholinergic Antagonists (Parasympatholytics)

   • Atropine (used in bradycardia, pupil dilation)
   • Scopolamine (used for motion sickness)
   • Ipratropium, Tiotropium (used in asthma, COPD)

Comparison of SNS vs. PNS

Pharmacological Interventions in ANS Disorders

1. Hypertension → β-blockers (Metoprolol, Propranolol), α-blockers (Prazosin)
2. Asthma, COPD → β2 agonists (Salbutamol), Anticholinergics (Ipratropium)
3. Glaucoma → Cholinergic agonists (Pilocarpine)
4. Bradycardia → Anticholinergics (Atropine)
5. Myasthenia Gravis → Acetylcholinesterase inhibitors (Neostigmine)
6. Parkinson’s Disease → Anticholinergics (Benztropine)
7. Shock, Anaphylaxis → Adrenergic agonists (Epinephrine, Dopamine)

Autonomic Nervous System (ANS) & Therapeutic Agents

The Autonomic Nervous System (ANS) regulates involuntary functions such as heart rate, blood pressure, respiration, digestion, and glandular secretion. ANS drugs are classified based on their effects on Sympathetic (Adrenergic) and Parasympathetic (Cholinergic) Nervous Systems.

1. Therapeutic Agents Acting on the Autonomic Nervous System

ANS drugs are categorized into two major classes:

A. Sympathetic (Adrenergic) Drugs

These drugs either stimulate (Sympathomimetics) or inhibit (Sympatholytics) the Sympathetic Nervous System (SNS).

B. Parasympathetic (Cholinergic) Drugs

These drugs either stimulate (Parasympathomimetics) or inhibit (Parasympatholytics) the Parasympathetic Nervous System (PNS).

2. Uses of ANS Therapeutic Agents in Clinical Practice

A. Cardiovascular Disorders

• Adrenergic Agonists (Epinephrine, Norepinephrine) → Used in shock, cardiac arrest (↑ BP, ↑ Heart rate).
• β-Blockers (Propranolol, Metoprolol) → Treat hypertension, arrhythmia, angina (↓ Heart rate, ↓ BP).
• α-Blockers (Prazosin) → Manage hypertension, Benign Prostatic Hyperplasia (BPH) (Vasodilation, Smooth muscle relaxation).

B. Respiratory Disorders

• β2-Agonists (Albuterol, Salmeterol) → Used in asthma, COPD (Bronchodilation).
• Anticholinergics (Ipratropium, Tiotropium) → COPD, Bronchospasm (Bronchodilation).

C. Neurological Disorders

• Cholinesterase Inhibitors (Neostigmine, Donepezil) → Myasthenia gravis, Alzheimer’s (↑ ACh, Muscle contraction).
• Anticholinergics (Benztropine) → Parkinson’s disease (↓ Tremors, ↓ Muscle rigidity).

D. Ophthalmology

• Pilocarpine (Cholinergic Agonist) → Used in Glaucoma (Pupil constriction, ↓ Intraocular pressure).
• Atropine (Anticholinergic) → Used in eye exams (Pupil dilation, Mydriasis).

E. Gastrointestinal & Urinary Disorders

• Bethanechol (Cholinergic Agonist) → Treats urinary retention (↑ Bladder contraction).
• Scopolamine (Anticholinergic) → Prevents motion sickness (↓ Nausea, ↓ Vomiting).

3. Effects of ANS Drugs on the Body

4. Interaction of ANS Drugs with Physical Therapy

Physical therapists should be aware of ANS drug effects to optimize patient safety and exercise performance.

A. Considerations in Cardiovascular Patients

• β-Blockers (Metoprolol, Propranolol) → May limit heart rate response during exercise; monitor fatigue and dizziness.
• Adrenergic Agonists (Epinephrine, Dopamine) → Increase heart rate and blood pressure, requiring close monitoring.

B. Respiratory Therapy

• β2-Agonists (Albuterol, Salmeterol) → Can increase heart rate, causing tremors and anxiety during exercise.
• Anticholinergics (Ipratropium, Tiotropium) → Improve exercise tolerance in COPD patients by reducing bronchospasm.

C. Neuromuscular Considerations

• Cholinergic Agonists (Neostigmine, Pyridostigmine) → Enhance muscle contraction in Myasthenia Gravis, improving therapy outcomes.
• Anticholinergic Drugs (Benztropine, Atropine) → Can cause dizziness and blurred vision, affecting balance training.

D. Pain Management & Muscle Spasticity

• Anticholinergics (Scopolamine, Atropine) → Reduce muscle spasms, but may cause dry mouth, dizziness.
• Adrenergic Agonists (Clonidine, Tizanidine) → Used for spasticity relief, but may induce sedation, fatigue.

5. Drug Interactions & Precautions in Physical Therapy

Conclusion

• ANS drugs significantly impact cardiovascular, respiratory, and neuromuscular function.
• Physical therapists should monitor side effects such as heart rate changes, dizziness, and fatigue.
• Exercise modifications and patient education are crucial for individuals on ANS-modulating drugs.

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Here are detailed notes on Pharmacology in the Cardiovascular System, covering drug classification, commonly used drugs, and their interaction with physical therapy.

Pharmacology of the Cardiovascular System

The cardiovascular system consists of the heart and blood vessels responsible for circulating blood, oxygen, and nutrients throughout the body. Cardiovascular pharmacology deals with drugs that manage hypertension, heart failure, arrhythmias, ischemic heart diseases, and thrombotic disorders.

1. Classification of Cardiovascular Drugs

Cardiovascular drugs are classified based on their mechanism of action and therapeutic use:

A. Antihypertensive Drugs (Used for Hypertension)

1. Beta-blockers (β-blockers) → Metoprolol, Propranolol, Atenolol
2. Calcium Channel Blockers (CCBs) → Amlodipine, Verapamil, Diltiazem
3. ACE Inhibitors (Angiotensin-Converting Enzyme Inhibitors) → Lisinopril, Enalapril
4. ARBs (Angiotensin II Receptor Blockers) → Losartan, Valsartan
5. Diuretics (Water Pills) → Hydrochlorothiazide, Furosemide, Spironolactone
6. Alpha-blockers → Prazosin, Doxazosin
7. Centrally Acting Agents → Clonidine, Methyldopa
8. Vasodilators → Hydralazine, Minoxidil

B. Antiarrhythmic Drugs (Used for Arrhythmias)

1. Class I (Sodium Channel Blockers) → Lidocaine, Quinidine
2. Class II (Beta-blockers) → Metoprolol, Esmolol
3. Class III (Potassium Channel Blockers) → Amiodarone, Sotalol
4. Class IV (Calcium Channel Blockers) → Verapamil, Diltiazem
5. Miscellaneous (Digoxin, Adenosine)

C. Drugs for Heart Failure

1. ACE Inhibitors → Lisinopril, Enalapril
2. ARBs → Losartan, Valsartan
3. Beta-blockers → Carvedilol, Metoprolol
4. Diuretics → Furosemide, Spironolactone
5. Cardiac Glycosides → Digoxin
6. Vasodilators → Hydralazine, Nitrates

D. Antianginal Drugs (Used for Angina)

1. Nitrates → Nitroglycerin, Isosorbide dinitrate
2. Beta-blockers → Atenolol, Metoprolol
3. Calcium Channel Blockers → Amlodipine, Verapamil
4. Ranolazine → Used in chronic angina

E. Anticoagulants (Blood Thinners)

1. Heparin & Low Molecular Weight Heparin (LMWH) → Enoxaparin, Dalteparin
2. Vitamin K Antagonists → Warfarin
3. Direct Oral Anticoagulants (DOACs) → Rivaroxaban, Apixaban

F. Antiplatelet Drugs

1. Aspirin (Acetylsalicylic Acid)
2. Clopidogrel, Ticagrelor, Prasugrel

G. Thrombolytic (Fibrinolytic) Drugs

1. Alteplase (tPA), Streptokinase, Tenecteplase → Used in stroke, MI, pulmonary embolism

H. Lipid-Lowering Agents (Used for High Cholesterol)

1. Statins → Atorvastatin, Simvastatin, Rosuvastatin
2. Fibrates → Gemfibrozil, Fenofibrate
3. Niacin (Vitamin B3) → Lowers LDL & triglycerides
4. Cholesterol Absorption Inhibitors → Ezetimibe

2. Commonly Used Cardiovascular Drugs & Their Interaction with Physical Therapy

Many cardiovascular drugs can affect exercise tolerance, heart rate, and blood pressure, which is important for physical therapists to consider.

3. Interaction of Cardiovascular Drugs with Physical Therapy

A. Exercise Tolerance & Performance

• Beta-blockers reduce maximum heart rate, so the usual heart rate-based intensity measures may not be accurate.
• Diuretics can cause dehydration and electrolyte imbalances, affecting muscle function and endurance.
• Nitrates may cause low BP during exercise, requiring close monitoring.

B. Orthostatic Hypotension

• ACE Inhibitors, ARBs, Vasodilators, and Diuretics may cause sudden drops in BP when moving from sitting to standing.
• Physical therapists should advise slow positional changes and monitor BP before and after therapy sessions.

C. Bleeding Risks

• Patients on anticoagulants (Warfarin, Heparin, DOACs) have higher bleeding risk.
• Avoid deep tissue massage, high-impact exercises, or activities with fall risks.

D. Muscle Weakness & Cramping

• Statins (for cholesterol) may cause muscle pain, weakness, or rhabdomyolysis.
• Diuretics (for hypertension, heart failure) can lead to potassium loss and muscle cramps.
• Encourage hydration and electrolyte balance.

E. Arrhythmias & Heart Rate Monitoring

• Antiarrhythmic drugs (Amiodarone, Digoxin) may cause dizziness, palpitations, or bradycardia.
• Monitor heart rate, avoid overexertion, and be aware of abnormal heart rhythms.

4. Key Takeaways for Physical Therapy & Cardiovascular Drugs

✅ Monitor heart rate and BP regularly, especially in patients taking beta-blockers, calcium channel blockers, and diuretics.
✅ Encourage gradual postural transitions to prevent dizziness (orthostatic hypotension).
✅ Avoid high-impact exercises in patients on anticoagulants to reduce bleeding risk.
✅ Modify exercise intensity in patients on beta-blockers, as their heart rate response is reduced.
✅ Ensure hydration and electrolyte balance in patients on diuretics.
✅ Watch for muscle pain or weakness in patients taking statins.

Notes on Glucocorticoids & Thyroxine: Uses, Side Effects, and Interaction with Physical Therapy

1. Glucocorticoids

A. Introduction

Glucocorticoids are steroid hormones produced by the adrenal cortex and play a vital role in metabolism, immune response, and inflammation control. Synthetic glucocorticoids are widely used in medical treatment for inflammatory, autoimmune, and allergic conditions.

B. Commonly Used Glucocorticoid Drugs

C. Uses of Glucocorticoids

1. Anti-inflammatory → Reduces swelling and pain (arthritis, asthma, allergies).
2. Immunosuppressive → Used in autoimmune diseases (lupus, rheumatoid arthritis, multiple sclerosis).
3. Replacement Therapy → Used in adrenal insufficiency (Addison’s disease).
4. Respiratory Conditions → Inhaled glucocorticoids (budesonide, fluticasone) are used for asthma and COPD.
5. Oncology → Helps in chemotherapy-induced nausea, reduces brain edema in brain tumors.
6. Skin Conditions → Used for eczema, psoriasis (topical formulations).

D. Side Effects of Glucocorticoids

1. Musculoskeletal System
   • Muscle wasting (steroid myopathy)
   • Osteoporosis (increased fracture risk)
   • Joint pain, weakness
2. Metabolic Effects
   • Hyperglycemia (increased blood sugar)
   • Weight gain & fluid retention (Cushingoid appearance)
3. Cardiovascular System
   • Hypertension (due to sodium retention)
   • Increased risk of atherosclerosis
4. Gastrointestinal System
   • Gastric ulcers
   • Increased risk of infections (due to immunosuppression)
5. Neurological & Psychological Effects
   • Mood swings, anxiety, depression
   • Insomnia, memory issues
6. Endocrine System
   • Adrenal suppression (long-term use)
   • Cushing’s syndrome (prolonged high doses)
7. Skin & Soft Tissues
   • Delayed wound healing
   • Skin thinning (atrophy), easy bruising

E. Interaction with Physical Therapy

2. Thyroxine (Thyroid Hormone)

A. Introduction

Thyroxine (T₄) is a thyroid hormone produced by the thyroid gland that regulates metabolism, energy production, and growth. Synthetic levothyroxine (T₄) is used for hypothyroidism.

B. Commonly Used Thyroid Drugs

C. Uses of Thyroxine (Levothyroxine)

1. Hypothyroidism Treatment → Primary (Hashimoto’s) & Secondary Hypothyroidism
2. Goiter Reduction → Helps reduce enlarged thyroid glands
3. Thyroid Cancer → Used post-surgery to suppress TSH & prevent recurrence
4. Myxedema Treatment → Severe hypothyroidism (life-threatening emergency)
5. Metabolism Regulation → Used to maintain normal growth & energy levels

D. Side Effects of Thyroxine

E. Interaction with Physical Therapy

3. Comparison: Glucocorticoids vs. Thyroxine

4. Key Takeaways for Physical Therapy

✅ Monitor muscle strength and joint stability in patients on glucocorticoids.
✅ Adjust exercise intensity in thyroxine therapy patients with heart rate abnormalities.
✅ Encourage weight-bearing exercises for osteoporosis risk in both drugs.
✅ Ensure hydration & cooling strategies in patients with thyroid hormone therapy.
✅ Monitor blood pressure, blood sugar, and fatigue for optimal therapy outcomes.

Pharmacology of the Central Nervous System (CNS): Anesthetic Agents

This document provides detailed notes on anesthetic agents, their uses, side effects, and interactions with physical therapy.

1. Introduction to Anesthetic Agents

Anesthetic agents are drugs used to induce a reversible loss of sensation and consciousness. They are classified based on their route of administration and duration of action into:

1. General Anesthetics – Cause complete unconsciousness.
2. Local Anesthetics – Block sensation in a specific area without affecting consciousness.

2. Classification of Anesthetic Agents

A. General Anesthetics (Induce Unconsciousness)

These drugs depress the CNS to cause loss of sensation and consciousness.

1. Inhalational Anesthetics (Gas & Volatile Liquids)

2. Intravenous (IV) Anesthetics

B. Local Anesthetics (Block Sensation in a Specific Region)

These drugs block sodium channels, preventing nerve conduction in localized areas.

1. Amide Local Anesthetics (Metabolized in Liver)

2. Ester Local Anesthetics (Metabolized in Plasma)

3. Uses of Anesthetic Agents

A. General Anesthetics

• Surgical Procedures → Induce and maintain unconsciousness.
• Sedation in ICU Patients → For ventilator support.
• Diagnostic Procedures → Endoscopy, MRI for uncooperative patients.
• Pain Management → Ketamine is used for chronic pain and burn injuries.

B. Local Anesthetics

• Minor Surgeries → Dental procedures, skin excisions.
• Regional Blocks → Epidurals for labor pain, spinal anesthesia for lower body surgeries.
• Chronic Pain Management → Nerve blocks for arthritis, post-surgical pain.
• Topical Use → Relief of burns, insect bites, and sore throat (Benzocaine).

4. Side Effects of Anesthetic Agents

A. General Anesthetics

B. Local Anesthetics

5. Interaction with Physical Therapy

Physical therapists must consider the effects of anesthetics on muscle function, pain perception, balance, and cardiovascular stability.

A. General Anesthetics & Physical Therapy

B. Local Anesthetics & Physical Therapy

6. Special Considerations in Physical Therapy

A. Post-Surgical Rehabilitation

• Patients recovering from general anesthesia may experience weakness, dizziness, and impaired coordination.
• Ensure fall prevention strategies and gradual mobilization.
• Post-spinal or epidural anesthesia → Patients may have temporary leg weakness.

B. Chronic Pain Management

• Nerve blocks (local anesthetics) can improve exercise tolerance.
• Caution: Pain relief may lead to overuse injuries if the patient overexerts.

C. Malignant Hyperthermia (Emergency Condition)

• Caused by inhalational anesthetics & succinylcholine.
• Symptoms: High fever, muscle rigidity, increased HR & BP.
• Requires immediate emergency treatment (Dantrolene sodium, cooling measures).

7. Key Takeaways for Physical Therapists

✅ Monitor for muscle weakness, dizziness, and cognitive impairment post-anesthesia.
✅ Gradually mobilize patients after surgery to prevent falls and hypotension.
✅ Assess strength and sensation before initiating therapy after local anesthetics.
✅ Encourage breathing exercises for respiratory depression post-general anesthesia.
✅ Educate patients on overuse injury risk after nerve blocks.
✅ Be alert for emergency signs of malignant hyperthermia.

Pharmacology of the Central Nervous System (CNS): Sedatives and Hypnotics

This document provides detailed notes on sedatives and hypnotics, including their uses, side effects, and interaction with physical therapy.

1. Introduction to Sedatives and Hypnotics

Sedatives and hypnotics are CNS depressants used to induce relaxation, drowsiness, and sleep.

• Sedatives: Reduce anxiety and agitation without causing sleep.
• Hypnotics: Induce sleep and are used for insomnia and sleep disorders.

2. Classification of Sedatives and Hypnotics

Sedatives and hypnotics are classified based on their mechanism of action and duration.

A. Benzodiazepines (BZDs)

• Mechanism: Enhance GABA (Gamma-Aminobutyric Acid), leading to CNS depression.
• Commonly Used Drugs:

  Drug Name	Duration of Action	Uses
  Diazepam (Valium)	Long-acting	Anxiety, muscle spasm, seizures
  Lorazepam (Ativan)	Intermediate	Insomnia, pre-anesthetic sedation
  Alprazolam (Xanax)	Short	Anxiety disorders, panic attacks
  Midazolam (Versed)	Ultra-short	Pre-surgical sedation

B. Non-Benzodiazepine Hypnotics (“Z-Drugs”)

• Mechanism: Bind to GABA-A receptors (like BZDs) but have a shorter duration.
• Commonly Used Drugs:

  Drug Name	Uses	Key Features
  Zolpidem (Ambien)	Insomnia	Short-acting, less daytime drowsiness
  Zaleplon (Sonata)	Insomnia	Very short half-life, used for sleep onset
  Eszopiclone (Lunesta)	Insomnia	Longer duration, used for sleep maintenance

C. Barbiturates

• Mechanism: Potentiate GABA, but more dangerous than benzodiazepines.
• Commonly Used Drugs:

  Drug Name	Uses	Key Features
  Phenobarbital	Seizure control	Long-acting, high addiction potential
  Thiopental	Induction of anesthesia	Ultra-short-acting, rapid sedation

D. Melatonin Receptor Agonists

• Mechanism: Mimic melatonin, regulating sleep-wake cycles.
• Commonly Used Drugs:

  Drug Name	Uses	Key Features
  Ramelteon (Rozerem)	Insomnia	Non-addictive, safe for long-term use

E. Orexin Receptor Antagonists

• Mechanism: Block orexin, a neurotransmitter responsible for wakefulness.
• Commonly Used Drugs:

  Drug Name	Uses	Key Features
  Suvorexant (Belsomra)	Insomnia	Reduces wakefulness, long duration

3. Uses of Sedatives and Hypnotics

1. Anxiety Disorders → Benzodiazepines (Diazepam, Lorazepam)
2. Insomnia → Zolpidem, Zaleplon, Eszopiclone, Ramelteon
3. Seizures → Phenobarbital, Clonazepam
4. Pre-Anesthetic Sedation → Midazolam, Thiopental
5. Muscle Spasms & Pain Management → Diazepam
6. Alcohol Withdrawal → Lorazepam, Diazepam

4. Side Effects of Sedatives and Hypnotics

A. Common Side Effects

B. Severe Side Effects

• Paradoxical Reactions → Increased anxiety, aggression, hallucinations (seen in elderly patients).
• Respiratory Depression → More common with barbiturates and high-dose benzodiazepines.
• Rebound Insomnia → Sudden withdrawal can worsen sleep problems.
• Dependence & Withdrawal → Long-term use leads to addiction and tolerance, especially with benzodiazepines and barbiturates.

5. Interaction with Physical Therapy

Physical therapists must consider the CNS effects, cardiovascular changes, and muscular effects of these drugs.

A. Sedatives & Physical Therapy

B. Hypnotics & Physical Therapy

6. Special Considerations for Physical Therapy

A. Fall Risk Management

• Patients on sedatives/hypnotics are at high risk for falls due to:
  • Impaired balance & coordination
  • Dizziness & drowsiness
• Interventions:
  • Balance training
  • Use of assistive devices
  • Supervised mobility exercises

B. Cognitive & Behavioral Monitoring

• Patients on long-term benzodiazepines may have memory loss and confusion.
• Therapists should use clear instructions and repetition in exercises.

C. Respiratory Support

• Barbiturates and benzodiazepines depress respiration.
• Deep breathing exercises and monitoring oxygen levels are crucial.

D. Sleep Hygiene Counseling

• Non-pharmacological approaches like exercise, relaxation techniques, and cognitive behavioral therapy (CBT) should be encouraged.

7. Key Takeaways for Physical Therapists

✅ Monitor for drowsiness, sedation, and delayed reaction times.
✅ Encourage gradual postural transitions to prevent dizziness and falls.
✅ Use assistive devices in patients with impaired coordination.
✅ Avoid scheduling therapy sessions when sedative effects are strongest.
✅ Educate patients on non-drug methods for anxiety and sleep improvement.
✅ Watch for signs of withdrawal in long-term users of benzodiazepines.

Pharmacology of the Central Nervous System (CNS): Anti-Epileptic Drugs (AEDs)

This document provides detailed notes on anti-epileptic drugs (AEDs), including their uses, side effects, and interaction with physical therapy.

1. Introduction to Anti-Epileptic Drugs (AEDs)

• Epilepsy is a neurological disorder characterized by recurrent seizures due to excessive electrical activity in the brain.
• Anti-epileptic drugs (AEDs) control seizures by stabilizing neuronal membranes and reducing excitability.

2. Classification of Anti-Epileptic Drugs (AEDs)

AEDs are classified based on their mechanism of action and types of seizures they treat.

A. Sodium Channel Blockers

These drugs inhibit sodium (Na⁺) channels, preventing excessive neuronal firing.

B. GABA Enhancers

These drugs enhance GABA (inhibitory neurotransmitter), reducing neuronal excitability.

C. Calcium Channel Blockers

These drugs inhibit calcium (Ca²⁺) channels, reducing neuronal overactivity.

D. Mixed Mechanism AEDs

These drugs act on multiple pathways, enhancing their effectiveness.

3. Uses of Anti-Epileptic Drugs

• Seizure Disorders (Epilepsy) → Used for generalized, focal, and absence seizures.
• Status Epilepticus → Benzodiazepines (Lorazepam, Diazepam) used for emergency seizure control.
• Neuropathic Pain & Fibromyalgia → Gabapentin, Pregabalin.
• Bipolar Disorder → Valproic acid, Lamotrigine, Carbamazepine.
• Migraine Prevention → Topiramate, Valproic Acid.

4. Side Effects of Anti-Epileptic Drugs

A. Common Side Effects

B. Severe Side Effects

1. Stevens-Johnson Syndrome (SJS) → Rare but life-threatening skin reaction (Carbamazepine, Lamotrigine).
2. Hepatotoxicity → Valproic Acid, Phenytoin.
3. Osteoporosis & Bone Loss → Phenytoin, Phenobarbital, Valproic Acid (long-term use).
4. Teratogenicity (Birth Defects) → Valproic Acid, Phenytoin (Pregnant women should avoid).

5. Interaction with Physical Therapy

Physical therapists must consider the neuromuscular, cognitive, and systemic effects of AEDs when planning rehabilitation.

A. Neuromuscular Effects

B. Cognitive & Behavioral Effects

C. Cardiovascular & Metabolic Effects

D. Seizure Management in Therapy

6. Special Considerations for Physical Therapy

A. Fall Risk Management

• Patients on AEDs may have poor coordination, muscle weakness, and dizziness.
• Interventions:
  • Balance training
  • Gait assessment
  • Use of assistive devices if needed

B. Cognitive & Behavioral Monitoring

• Memory loss, confusion, and mood changes may occur with AEDs.
• Therapists should provide simple instructions and monitor for depression.

C. Bone Health & Osteoporosis

• Weight-bearing exercises should be encouraged in long-term AED users to prevent bone loss.

D. Exercise & Seizure Threshold

• Intense exercise can sometimes trigger seizures.
• Patients should be monitored for signs of overexertion.

7. Key Takeaways for Physical Therapists

✅ Monitor for drowsiness, ataxia, and coordination issues.
✅ Encourage gradual position changes to prevent dizziness.
✅ Use balance training and assistive devices to prevent falls.
✅ Educate patients on proper medication adherence to avoid breakthrough seizures.
✅ Be prepared for emergency seizure management in therapy sessions.

1. 1 ©IPH&H 2020 UNIT 1:- Mechanical Anatomy of Motion and posture Types of Movement/Motion Movement takes place at joints and is brought about by either the patient’s muscular efforts or by the application of an external force. Movements may be classified as passive or active. Passive Passive movements are those brought about by an external force which in the absence of muscle power in the part may be mechanical or via the therapist: (1) Mechanical – the pull of gravity causing ‘flopping’. (2) The therapist performing movements. The therapist may produce accessory or anatomical movement at joints. Anatomical movements are those which the patient could perform if his muscles worked to produce that movement. Active These are performed by the patient either freely, assisted or resisted. (1) Freely – in which case mechanical factors will play a part offering either resistance or assistance. (2) Assisted – when the therapist adopts the grips as for passive movements and assists the patient to perform the movement. The disadvantage of assisted active movements is that it is impossible for either party to detect how much work is being performed by each of them. (3) Resisted – when mechanical or manual resistance is applied. The mechanical resistance may be in the form of weights, springs, water, auto loading or the mode of performance of the activity. Posture:- Posture is not just how you hold your neck or the slump of your shoulders and low back. Everything in the body is connected, and our posture is the coordinated workings of all the different mechanical parts of the body. The body’s motion system controls posture. Scientists call this system the neuro-musculo-skeletal system (NMS), and break it down into three subsystems. 2 ©IPH&H 2020 Unit 2:- Evaluation/Assessment:- Shoulder: Speed Test (Biceps or Straight Arm Test) – Bicipital Tendinitis Yergason’s Test – Bicipital Tendinitis Lippman’s Test – Bicipital Tendinitis Supraspinatus Test (Empty Can Test) – Supraspinatus Tear Drop Arm Test (Codman’s Test) – Rotator Complex Neer Impingement Test Supraspinatus & Biceps Tendon Roos Test – Thoracic Outlet Syndrome Wright Test – Thoracic Outlet Syndrome Adson Test – Thoracic Outlet Syndrome Allen’s Test – Thoracic Outlet Syndrome Upper Limb Tension Test (ULTT) ULTT 1 ULTT 2 ULTT 3 ULTT 4 – Median nerve & anterior interosseous nerve – C5, 6, 7, Median nerve, Musculocutaneous nerve & axillary nerve – Radial nerve – C8, T1, Ulnar nerve Apprehension Test – Anterior Shoulder Dislocation Rockwood Test – Anterior Shoulder Instability Dugas Test – Anterior Shoulder Dislocation Posterior Apprehension Test – Posterior Shoulder Dislocation Push Pull Test – Posterior Shoulder Dislocation Sulcus Test – Inferior Shoulder Instability Clunk Test – Labral Tear 3 ©IPH&H 2020 UNIT 3:- SPECIAL ORTHOPAEDIC TESTS EXERCISE OF SHOULDER AND HIP:- Exercises of Shoulder:- Active Shoulder Movements. Pendular Exercises:- Position of Patient:- Standing on the side of the table with the support of edge of it. Little bit bending forward. Procedure of Exercises:- Flexion and Extension: -Therapist will ask patient to move his/her hand in forward and backwards movement. It will be repeated for 10-15 times Abduction and Adduction: – Therapist will ask patient to move his/her hand in sideways movement. It will be repeated for 10-15 times Circumduction:- Therapist will ask patient to move his/her hand in Rotational movement . It will be repeated foe 10-15 times both clock wise and anti-clock wise Finger Ladder:- Flexion and Extension: – Position of Patient:- Standing in the front of the ladder Procedure of Exercises:-Therapist will ask patient to move his/her fingers in upward as we use to walk in steps. It will be repeated for 10 times Abduction and Adduction: – Position of Patient:- Standing in the side of the ladder Procedure of Exercises:-Therapist will ask patient to move his/her fingers in upward as we use to walk in steps. It will be repeated for 10 times 4 ©IPH&H 2020 Shoulder Wheel Flexion and Extension: – Position of Patient:- Standing in the side of the Shoulder Wheel Procedure of Exercises:-Therapist will ask patient to move his/her hand in Rotational movement and rotate the wheel. It will be repeated foe 10-15 times both clock wise and anti-clock wise Abduction and Adduction: – Position of Patient:- Standing in the front of the shoulder wheel Procedure of Exercises:-Therapist will ask patient to move his/her hand in Rotational movement and rotate the wheel. It will be repeated foe 10-15 times both clock wise and anti-clock wise Exercises of Hip:- Active Movements of Hip SLR:- Patient will be in supine lying position. Therapist will ask to do Hip Flexion and hold it at 30-40 degree angle and this procedure will be repeated for 10-15 times. Half Squats/ Chair Position:-Patient will be in standing position. Therapist will ask him/her to half squats or come in chair position, therapist will ask him/her to hold this position for 5- 6sec this procedure will be repeated for 10-15times. 5 ©IPH&H 2020 UNIT 4:- EXERCISE FOR FOOT AND HAND:- Exercises of Foot:- Ankle Pump:- Position of the Patient: -Supine Lying Procedure of Exercise: – Patients will be asked to do dorsiflexion and plantarflexion for ten times. Patients will be asked to do rotational movement clock and anti-clock wise for ten times. Toe Curling:- Position of the Patient: – Sitting Procedure of Exercise: – Patient is asked to do keep his/her foot on the towel and curl the toes in such a way that it decreases it. This procedure is done for 10-15 times. Picking up the Marble balls:- Position of the Patient: – Sitting Procedure of Exercise: – Patient is asked to do keep his/her foot on floor and asked to pick up the marbles of different sizes with toes. This procedure is done for 10-15 times. Ankle rolling over a bottel:- Position of the Patient: – Sitting Procedure of Exercise: – Patient is asked to do keep his/her foot on bottle and asked to move the ankle in to and fro motion so that ankle moves over the bottle. This procedure is done for 10-15 times. 6 ©IPH&H 2020 Exercise of Hand:- Active Ankle Movements Pressing up the Ball or Putty with all the fingers:- Position of the Patient: – Sitting Procedure of Exercise: – Patient is asked to hold ball or putty and asked to Press it with wrist and fingers in all the available movements. This procedure is done for 10-15 times. Pressing hand exerciser:- Position of the Patient: – Sitting Procedure of Exercise: – Patient is asked to Press it with fingers in Flexion and Extension movements. This procedure is done for 10-15 times. 7 ©IPH&H 2020 UNIT5:- EXERCISE FOR KNEE AND ELBOW:- Exercises of Knee:- Active Movement of knee. Isometric Quadriceps:- Position of the Patient:- Supine Lying Procedure:- A towel roll will be placed below the knee Joint. Therapist will ask him/her to press the roll with the force of the knee joint with ankle in dorsiflexion so that there is the production of contraction at Quadriceps. The created pressure will be hold for 5-6 sec, this procedure will be repeated for 10-15 times. Isometric Hamstrings:- Position of the Patient:- Supine Lying Procedure:- A towel roll will be placed below the Ankle Joint. Therapist will ask him/her to press the roll with the force of the ankle joint with ankle in dorsiflexion so that there is the production of contraction at Hamstrings. The created pressure will be hold for 5-6 sec, this procedure will be repeated for 10-15 times. Isometric Vastrus Medialis Oblique(VMO):- Position of the Patient:- Supine Lying with knee flexion Procedure:- A towel roll will be placed between the both knees. Therapist will ask him/her to press the roll with the force of both knees so that there is the production of contraction at VMO. The created pressure will be hold for 5-6 sec, this procedure will be repeated for 10-15 times. Dynamic Quadriceps:- Position of the Patient:- High Sitting on the edge of the table or chair Procedure:-Therapist will ask patient to do knee extension and at the end we will ask patient to do dorsiflexion. This position should be held for 5-6sec, this procedure will be repeated for 10-15 times. 8 ©IPH&H 2020 Exercises of Elbow:- Active Elbow movement:- Flexion & Extension. Unit 6:- Vicarious Motion (Trick Movement):- VARIOUS MOTIONS TRICK MOVEMENT The term ‘trick movements’ generally suggests unnatural movements, seen when muscles are either incapacitated or hindered – for instance, the hitching up of the shoulder by the trapezius when the supraspinatus ligament is kindled or the deltoid deadened. Grouping of trick movements: (1) Direct substitution of well-set muscles. (2) Accessory inclusion. (3) Tendon action. (4) Rebound. (5) Anomalous nerve supply. (6) Gravity. (1) Direct substitution of well-set muscles: Full snatching and rise of the shoulder is conceivable in spite of loss of motion of deltoid, by utilizing muscles which cross the shoulder-joint – the long head of biceps and triceps, the pectoralis major. (2) Accessory inclusion: The abductor pollicis brevis and the flexor pollicis brevis idle into the extensor development of the thumb. It is consequently conceivable to broaden the interphalangeal joint of the thumb when the spiral or back interosseus nerves are incapacitated. The abductor digiti minimi might be embedded into the volar part of the proximal phalanx and would thus be able to flex the metacarpophalangeal joint. (3) Tendon activity: This alludes to the shortening of a ligament when the rival contracts unequivocally; it happens in muscles which cross two joints and have regularly a constrained length. In this way, when there is loss of motion of the long flexors of the fingers, hyperextension of the wrist causes a ligament activity at the terminal interphalangeal joints because of the restricted length of the flexors. This may look as though the long flexors are contracting. (4) Rebound: This alludes to the wonder of an appearing constriction in the agonist when the rival contracts firmly and afterward unwinds rapidly. Solid constriction of the extensor pollicis longus and abrupt unwinding may look as though the long flexor is working. 9 ©IPH&H 2020 (5) Anomalous nerve supply: In 20 % of every single ordinary subject there is irregular nerve supply in the helpful gravity and along these lines the hand must be held with the ulnar outskirt up. The commonest inconsistencies are ulnar stockpile of the opponens, the second lumbrical and the flexor pollicis brevis. Signs of complete ulnar or finish middle stock of all the inborn have been portrayed. (6) Gravity: The elbow can without much of a stretch be reached out by gravity when the triceps is incapacitated given the shoulder is beneath 90 degrees. So as to stay away from the trick activity of gravity the shoulder must be held at 90 degrees or higher. UNIT 7:- JOINT MOTION ASSESSMENT:- GONIOMETRY Gonio =Angle, metron =measure It is a technique used to measure and document amount of available range of motion ofjoints. Both PROM and AROM canbe measured. Tests of muscle strength(MMT) and neurological function are used in conjunction withgoniometry Use of Goniometry To identify abnormal conditions related to muscles, tendons and joints. Such as: 1. Contractures 2. Decreased ROM due to disuse or injury Developing treatment goals For evaluating progress/lack of progress in rehabilitation treatment. Finding effectiveness of specific therapeutic technique, medication or surgical procedure. Type of Goniometer A standard (universal) goniometer Consists of : 1. Stationary arm: It is part of body, cannot move independently 2. Moving arm: Attached to fulcrum in the center of body 3. Body: A full circle on which 0o to 360o • Degrees are drawn. 10 ©IPH&H 2020 Degree of Freedom:- Joints are described in relation to Uniaxial: movement in only one plane Biaxial : movement in 2 planes Multiaxial: movement in 3 planes End Feel:- The feeling of a structure being a barrier for further motion at the end of joint range is called END FEEL. The types of structures limiting ROM These are of 2 types 1. Normal 2. Abnormal Procedure:- Ask the patient to acquire recommended Place the join in zero position (neutral position) Stabilize the proximal joint component. Before using goniometer, ask patient to move until end feel is determined Now palpate bony landmark Align the goniometer Read and record the measurement. Active ROM:- Joints are described in relation to number of planes that they can move in. movement in only one plane, E.g. elbow joint, knee joint : movement in 2 planes. E.g. wrist joint movement in 3 planes,e.g. shoulder joint The feeling of a structure being a barrier for further motion at the end of joint range is The types of structures limiting ROM have their own characteristic end feel. tient to acquire recommended testing position. Place the join in zero position (neutral position) Stabilize the proximal joint component. Before using goniometer, ask patient to move distal joint component to complete range, is determined. Now palpate bony landmark Read and record the measurement. planes that they can move in. The feeling of a structure being a barrier for further motion at the end of joint range is own characteristic end feel. component to complete range, 11 ©IPH&H 2020 Shoulder Joint Flexion Extension Abduction Internal rotation External rotation Range 0-180 0-40 0-180 0-80 0-90 12 ©IPH&H 2020 13 ©IPH&H 2020 Shoulder Medial Rotation 14 ©IPH&H 2020 Elbow Elbow Flexion Forearm Supination Normal ROM Elbow Extension Forearm Pronantion 15 ©IPH&H 2020 Manual Muscle Examination:- 1. Introduction During manual muscle testing (MMT), each muscle bunch is tried reciprocally. For show purposes, just one side is tried right now every one of the 6 muscle gatherings. One hand of the analyst applies opposition or palpates the muscle or ligament for compression while the other hand settles the furthest point being tried to keep it in the test position. The test is rehashed if the patient doesn’t comprehend the guidelines or isn’t having any significant bearing most extreme exertion. 2. Grading follows the Medical Research Council (MRC) system. shows a calculation for the MRC muscle quality scoring framework. On the off chance that the subject is feeling the loss of an appendage, has a cast, or can’t be put in the right testing position, muscle quality is evaluated as “unfit to survey”. In the event that the patient has a fixed contracture, however can in any case play out the test, the muscle is evaluated. Clinical gadgets, for example, catheters and channels, and mechanical ventilation as a rule don’t obstruct muscle testing, except if a joint is immobilized to guarantee legitimate working of a gadget. 3. Procedure 1. For each muscle tried, the analyst stands to the side being tried, and the patient is sitting upstanding and situated to permit full development of the joint against gravity. The inspector shows the ideal development against gravity. The inspector at that point demands the patient to rehash the movement. 2. In the event that the patient can move through the ideal scope of movement against gravity, the analyst endeavors to apply opposition in the testing position while expressing “Hold it, don’t let me push it down” or “Hold it, don’t let me twist it” (Figure 2). On the off chance that the patient endures no obstruction, the muscle score is Grade 3. In the event that the patient endures some opposition, the score is Grade 4, and full obstruction, Grade 5. 3. On the off chance that the patient can’t move against gravity, the patient is repositioned to permit development of the furthest point with gravity dispensed with. In the case of supporting the appendage, the inspector gives neither help nor protection from the patient’s willful development. This gravity-disposed of situating will shift for each muscle tried. On the off chance that the patient can’t finish at any rate halfway scope of movement with gravity wiped out, the muscle or ligament is watched or potentially palpated for compression. 16 ©IPH&H 2020 4. For a disabled patient who can’t sit up in a bed set in the seat position or on the edge of the bed, interchange positions for testing the lower furthest point are remembered for this convention. 4. Shoulder Abduction 1. Testing position – arm out from the side at shoulder level. The inspector exhibits the movement, at that point states “Lift your arm out to the side to bear level.” The hand giving obstruction is shaped over the patient’s arm simply over the elbow. The other hand balances out the shoulder over the shoulder joint. The analyst states “Hold it, don’t let me push it down.” To evaluate grades 3, 4, or 5, if you don’t mind see area 3.2 above. 2. If more weaker than Grade 3, the patient untruths recumbent with arms along the edge. The inspector underpins the arm simply over the elbow and at the wrist to guarantee that the shoulder doesn’t remotely pivot (turn outward). The patient endeavors to move the arm out to the side. The analyst states: “Attempt to move your arm out to the side”. Evaluation 2 is allocated if the patient moves with gravity killed. 3. If more weaker than Grade 2, the inspector states “Try to move your arm out to the side ” and palpates the center deltoid muscle, as illustrated, for withdrawal, and scores as Grade 1 or 0 as recently characterized. Shoulder MMT can be performed with central venous catheters (e.g., subclavian and jugular) in place, including those used for dialysis. (Figure 2) 4. The rest of the evaluations will be finished comparatively to above utilizing explicit test positions for the patient and inspector, and explicit directions for the patient’s development. 5. Elbow Flexion 1. Test position – lower arm supinated and flexed marginally in excess of 90 degrees. Verbal directions: “Curve your elbow somewhat in excess of 90 degrees”. The hand giving obstruction is shaped over the flexor surface of the lower arm proximal to the wrist. The analyst’s other hand applies counterforce by measuring the palm over the foremost unrivaled part of the shoulder. The analyst at that point states: “Hold it. Try not to let me push it down” and scores Grades 3, 4, or 5 as recently portrayed. 2. If more weaker than Grade 3, the shoulder is kidnapped to 90 degrees. The inspector underpins the arm under the elbow and, if fundamental, the wrist too. The lower arm is turned with the thumb confronting the roof. With the elbow expanded, the patient endeavors to flex the elbow. The inspector states: “Attempt to twist your elbow.” Grade 2 is allotted if the patient can flex the elbow. 17 ©IPH&H 2020 3. If more weaker than Grade 2, the lower arm is supinated and situated along the edge in around 45 degrees of elbow flexion. The analyst states “Attempt to twist your elbow”, palpates the biceps ligament and scores as either Grade 1 or 0.6. 6 Wrist Extension:- 1. Test position – arm along the edge, elbow flexed to 90 degrees with the lower arm pronated and the wrist completely expanded. Verbal directions: “Curve your wrist up beyond what many would consider possible.” The inspector’s hand giving opposition is set over the rear of the patient’s hand only distal to the wrist. The inspector’s other hand underpins the patient’s lower arm. The inspector at that point states: “Hold it. Try not to let me push it down” and scores Grades 3, 4 or 5. 2. If more weaker than Grade 3, the elbow is flexed to 90 degrees and lower arm turned with thumb confronting the roof. The lower arm and wrist are bolstered by the inspector. The inspector states: “Curve your hand toward me”. Evaluation 2 is allocated if the patient can broaden the wrist. 3. If more weaker than Grade 2, the inspector states “Twist your wrist toward me” and palpates the two extensor ligaments, one on each side of the wrist, as illustrated, and scores as Grade 1 or 0. The analyst is mindful so as not to palpate the ligaments in the wrist. 4. This test isn’t performed if there is an ipsilateral outspread blood vessel catheter set up. 7. Hip Flexion 1. Test position – sitting with the hip completely flexed and knee bend. The patient may put their hands on the bed or table for steadiness. Verbal directions: “Raise your knee up as high as it will go.” The inspector’s hand giving opposition is set on the thigh only proximal to the knee. The other hand gives security along the edge of the hip. The analyst at that point states: “Hold it. Try not to let me push it down” and scores Grades 3, 4 or 5. 2. If more weaker than Grade 3, the patient sets down as an afterthought not being tried. For instance, the patient lays on the correct side to test the left hip. The inspector remains behind the patient with one arm supporting the leg being tried with the hand supporting under the knee. The contrary hand keeps up arrangement of the storage compartment at the hip. The inspector states: “Bring your knee toward your chest.” Grade 2 is doled out if the patient can flex the hip. 3. If more weaker than Grade 2, the patient is prostrate. The inspector asks, “May I contact your leg here?” (highlighting the internal part of the hip joint). With the patient’s consent, the 18 ©IPH&H 2020 analyst states “Twist your hip” and palpates the iliopsoas ligament, as illustrated, and scores as Grade 1 or 0. 4. In an out of commission quiet, grades 5, 4, and 3 are tried with the bed in the seat position, or the leader of the bed raised beyond what many would consider possible. Pads are set under the knee to flex the hip to 90 degrees. The inspector guarantees that the foot is lifted off the bed when requesting that the patient raise the knee off the bed. Evaluations 2 and 1 are scored as recently depicted. 5. This test can be acted in patients with flawless and very much made sure about femoral intravascular catheters. 8. Knee Extension 1. Test position – sitting upright with the knee fully extended to 0 degrees. Avoid knee hyperextension. Verbal instructions; “Straighten your knee”. The hand giving resistance is contoured on top of the leg just proximal to the ankle. The other hand is placed under the thigh above the knee. The examiner then states “Hold it. Don’t let me bend it” and scores Grades 3, 4 or 5. 2. If weaker than Grade 3, the patient lays on the non-testing side. The examiner stands behind the patient at knee level. The leg not being tested may be flexed for stability. One arm cradles the leg being tested around the thigh with the hand supporting the underside of the knee. The other hand holds the leg just above the ankle. The examiner states: “Straighten your knee.” Grade 2 is assigned if the patient can extend the knee (Figure 3). 3. If weaker than Grade 2, the patient is supine and the examiner states:”Push the back of your knee down” or “Tighten your knee cap” and palpates the quadriceps tendon, and scores as Grade 1 or 0. 4. For the bedridden patient, in scoring Grades 3, 4,and 5, the patient is positioned in the same manner as for hip flexion and graded as described above for knee extension (Figure 4). 9. Ankle Dorsiflexion 1. Test position – sitting, with the heel on floor, foot in full dorsiflexion, and shoes and socks removed. Verbal instructions: “Bend your foot up as far as possible.” The toes are relaxed during the test. The hand giving resistance is cupped over the top of the foot proximal to the toes. The other hand is contoured around the front of the leg just proximal to the ankle. The examiner then states “Hold it, don’t let me push it down” and scores Grade 3, 4 or 5. 19 ©IPH&H 2020 2. If weaker than Grade 3, but there is partial range of motion against gravity, assign Grade 2. 3. If weaker than Grade 2, palpate the tibialis anterior tendon, and score as Grade 1or 0. 4. The bedridden patient is tested supine, with the leg extended and a pillow placed under the knee. 5. This test can usually be applied with an intact and secured pedal intravascular catheter. Be careful not to dislodge the catheter. Manual Muscle Test Grading System Grade Manual Muscle Test 5 Movement against gravity plus full resistance 4 Movement against gravity plus some resistance 3 Completes the available test range of motion against gravity, but tolerates no resistance 2 The patient completes full or partial range of motion with gravity eliminated 1 Slight contractility without any movement 0 No evidence of contractility (complete paralysis) 20 ©IPH&H 2020 UNIT 8:- THE THERAPEUTIC GYMNASIUM:- Finger Ladder The finger stepping stool, or divider climb, is an exercise based recuperation procedure that assists with reestablishing scope of movement to the shoulder after a physical issue, particularly to the rotator sleeve. It is likewise useful in mitigating constant rotator sleeve issue. The objective of the activity is to improve the scope of movement that a patient can accomplish without torment in the shoulder. Commonly, they comprise of plastic or wooden divider mounts that are designed in a grouping of “steps”, every one of which is level on top and cut at a 45-degree edge underneath. Along these lines, the patient is compelled to raise their finger to a specific tallness with each progression and can likewise follow progress by denoting the quantity of steps moved with each endeavor. Theraband Therabands are versatile exercise groups. They are about 20cm wide and very long and they are stretchy. Theraband obstruction groups are broadly utilized for restoration from muscle and joint wounds and for high impact exercise and general molding. Therabands are the main resistive exercise groups embraced by the American Physical Therapy Association (APTA). These 6″ wide latex groups come in various, shading coded opposition levels, recognized by the thickness of the band: Theraband Color Theraband Thickness Comparison: pounds of pull expected to extend a 12″ band length to 24″ Yellow Thin 2.5 lb Red Medium 4.5 lb Green Heavy 5.0 lb Blue additional overwhelming 7.5 lb Dark unique overwhelming 9.0 lb Silver overly overwhelming 15.0 lb DUMB-BELL 21 ©IPH&H 2020 A short bar with a weight at each end, used typically in pairs for exercise or muscle-building. Dumbbells are one of the most widely used weight-training equipment pieces. One dumbbell consists of two equal weights that are attached to a handle, and the weights can be fixed or removable. The main reason why people use dumbbells is to build and tone muscles, and they can be used to develop muscles in most parts of the body. Dumbbells come in many different weights and sizes, and they can be made of metal, concrete or other materials. Types of Dumbbells Presently, there are three main types of dumbbells:• adjustable dumbbells • fixed weight dumbbells • selectorized dumbbells Sand Bags Clinical Sand Bags are utilized for an assortment of uses in the clinical business, for example, persistent situating, restorative and recovery applications, and to help encourage hemostasis after surgeries. Sand Bags have been explicitly intended to give adjustment in a wide assortment of positions. They fit over the shoulders, or fold over a kid’s hand or lower leg for situating. They likewise fit over the knees, or around the pelvis for adjustment. The one of a kind stretched neck, saddlebag shape, and delicate “kneadable” substance offer agreeable help for a huge number of employments. Therapeutic Ball An exercise ball is a ball constructed of soft elastic with a diameter of approximately 35 to 85 centimeters (14 to 34 inches) and filled with air. The air pressure is changed by removing a valve stem and either filling with air or letting the ball deflate. It is most often used in physical therapy, athletic training and exercise. It can also be used for weight training. The ball, while often referred to as a Swiss ball, is also known by a number of different names, including balance ball, birth ball, body ball, ball, fitness ball, gym ball, gymnastic ball, physioball, pilates ball, Pezzi ball, sports ball, stability ball, Swedish ball, therapy ball, or yoga ball. Stretch, strengthen, balance, bounce or roll; the uses of the Therapy Balls are limitless. For exercises in a sitting position on the ball, the user should have the feet flat on the floor with the knees bent to 90o or less. The ball should be inflated to a size that is appropriate for the height of the user. Note: the size listed for each ball is the maximum inflation. Please allow for compression of the ball. When a user is between sizes, select the larger size as it can be under inflated slightly. These burst-resistant balls slowly deflate if punctured. They are packaged with a convenient foot operated air pump, instructions, a measuring tape, a plug, a plug remover and an air fill adapter. Medicine Ball 22 ©IPH&H 2020 A Medicine Ball alludes to a weighted ball that can be utilized for doing a wide scope of activities to improve wellness, quality and coordination just as help sportsmen recuperate from wounds. This sort of ball can be made of cowhide, nylon, vinyl, elastic, polyurethane and different materials, and it comes in a wide range of loads, going from 2 lb to 25 lb. The standard Medicine Ball has a measurement of 14 inches, however different sizes are additionally accessible. Parallel Bar The mechanical assembly comprises of two even bars set corresponding to one another in customizable upstanding backings, the floor by a metal supporting system. The bars are made out of wood or other material, with an external covering of wood. The utilization of Parallel Bars in rehabilitative and non-intrusive treatments is fundamentally significant in the social insurance calling. Parallel Bars are utilized to assist individuals with recovering their quality, balance, scope of movement, and freedom. For individuals recuperating from wounds, diseases, and other incapacitating conditions, Parallel Bars are significant things of nonintrusive treatment, restoration, and gym equipment. Shoulder Wheel Shoulder wheel is a restorative gadget utilized for recovery of upper appendage. Shoulder Wheel’s scope of-movement circular segment can be changed from 10 creeps to 39 crawls by moving handle, and the opposition gave can be fluctuated by turning the obstruction handle. The Shoulder Wheel’s tallness can alter 26 inches vertically to permit situated and standing treatment. This Shoulder Rehabilitation Wheel is perfect for medical clinics, centers, and exercise based recuperation offices. The advantages are: • Increase quality of upper appendage muscles. • Increase ROM • Increase dissemination 23 ©IPH&H 2020 UNIT 9:- EXERCISE IN WATER (AQUATIC THERAPY/ HYDROTHERAPY) Definition of AquaticExercise Aquatic exercise refers to the use of water (in multidepth immersion pools or tanks) that facilitates the application ofestablished therapeutic interventions, including stretching,strengthening, joint mobilization, balance and gait training,and endurance trainingMost patients easily tolerate aquatic exercise. However, thepractitioner must consider several physiological and psycho-logical aspects of immersion that affect selection of an aquaticenvironment. Physical Properties of Water The properties provided by buoyancy, hydrostatic pressure,viscosity, and surface tension have a direct effect on the body in the aquatic environment. Buoyancy Definition:- Buoyancy is the upward force that works opposite to gravity. Properties:- Archimedes’ principle states that an immersedbody experiences upward thrust equal to the volume of liquiddisplaced. Clinical significance:- The effects of buoyancy include thefollowing. • Buoyancy provides the patient with relative weightlessnessand joint unloading by reducing the force of gravity on the body. In turn, this allows the patient to perform activemotion with increased ease. • Buoyancy provides resistance to movement when an extremity is moved against the force of buoyancy. Thistechnique can be used to strengthen muscles. • The amount of air in the lungs will affect buoyancy of thebody. Buoyancy will be increased with fully inflated lungsand decreased with deflated lungs. 24 ©IPH&H 2020 • Body composition will also affect buoyancy. Obese patientswill have increased buoyancy due to fat tissue having alower specific gravity. Patients with increased bone densitywill have less buoyancy than those with decreased bonedensity. • Buoyancy allows the practitioner three-dimensional accessto the patient. Hydrostatic Pressure Definition:- Hydrostatic pressure is the pressure exerted bythe water on immersed objects. Properties:- Pascal’s law states that the pressure exerted byfluid on an immersed object is equal on all surfaces of the object. As the density of water and depth of immersion increase, so does hydrostatic pressure. Clinical significance:- The effects of hydrostatic pressure include the following. • Increased pressure reduces or limits effusion, assists venousreturn, induces bradycardia, and centralizes peripheralblood flow. • The proportionality of depth and pressure allows patientsto perform exercise more easily when closer to the surface. Viscosity Definition:- Viscosity is friction occurring between molecules of liquid resulting in resistance to flow. Properties:- Resistance from viscosity is proportional to thevelocity of movement through liquid. Clinical significance:- Water’s viscosity creates resistancewith all active movements. • Increasing the velocity of movement increases the resistance. • Increasing the surface area moving through water increasesresistance. Surface Tension Definition:- The surface of a fluid acts as a membraneunder tension. Surface tension is measured as force per unitlength. Properties:- The attraction of surface molecules is parallel to the surface. The resistive force of surface tension changesproportionally to the size of the object moving through thefluid surface. Clinical significance:-The effect of surface tension includesthe following. 25 ©IPH&H 2020 • An extremity that moves through the surface performsmore work than if kept under water. • Using equipment at the surface of the water increases theresistance. Goals and Indications for Aquatic Exercise The specific purpose of aquatic exercise is to facilitate functional recovery by providing an environment that augmentsa patient’s and/or practitioner’s ability to perform varioustherapeutic interventions. Aquatic exercise can be used to achieve the following specific goals: • Facilitate range of motion (ROM) exercise • Initiate resistance training • Facilitate weight-bearing activities • Enhance delivery of manual techniques • Provide three-dimensional access to the patient • Facilitate cardiovascular exercise • Initiate functional activity replication • Minimize risk of injury or reinjures during rehabilitation • Enhance patient relaxation Precautions and Contraindications to Aquatic Exercise Most patients easily tolerate aquatic exercise. However, thepractitioner must consider several physiological and psychological aspects of immersion that affect selection of an aquaticenvironment. • Fear of Water • Neurological Disorder • Respiratory Disorder • Cardiac Dysfunction 26 ©IPH&H 2020 UNIT 10:- RESISTANCE EXERCISES:- Definition: – • Resisted exercise is any form of active exercise in which dynamic or static muscle contraction is resisted by an outside force applied manually or mechanically. • Strength: Muscle strength is the greatest measurable force that can be exerted by a muscle or muscle group to overcome resistance during a single maximum effort. • Power: Muscle power is defined as work produced by the muscle per unit of time. Power= force X distance/time • Endurance: It is the ability to perform low intensity repetitive or sustained activities over a prolonged period of time. Types of muscle works: • Isometric muscle work: In this type of muscle work there is increase in tone of the muscle without any change in the muscle length.E.g. Isometric strengthening for neck extensors: the clasped hand behind the head is pushed back by the head. No movement of the head or neck occurs but the tone of neck extensors increases. • Isotonic muscle work: in this type of muscle work there is change in length of the muscle while it maintains an even tone throughout the contraction period. This is of two types • Concentric work: here the origin and insertions come closer and the muscle length shortens. E.g. getting up from a chair: knee and hip extensors contract concentrically to bring about extension in these two joints. • Eccentric work: here the origin and the insertion go away from each other and the muscle length increases.E.g. sitting on a chair from standing: knee and hip extensors contract eccentrically to bring about flexion in these two joints. Principles resistance exercise 27 ©IPH&H 2020 Principle of overload: If muscle performance is to improve , a load that exceed the metabolic capacity of the muscle must be applied; that is a muscle must be challenged to perform at a level greater than to which it is accustomed. • Overload can be applied by increasing the intensity or volume. In strength training the intensity is increased where as in endurance training the volume i.e. Frequency, repetitions and time is increased. SAID (Specific Adaptation to Imposed Demand) Principle: • Adaptations produced by the training are highly specific to the nature of the stimulus or overload applied. • SAID applies to all the systems of the body. • The adaptations are specific to strength, power, endurance, functional activity, joint angle, sequence of muscle activations, energy systems and virtually all other variable present. Principle of Reversibility: • The adaptations achieved through resistance exercise persist as long as the resistance exercise is performed regularly and go back gradually to the pre exercise levels once the training is stopped. This means the effects of resistance training are reversible. Inter individual variability: • Every individual responds to resistance exercise in a different way, thus similar stimuli may bring about a lot of improvement in one patient and no improvement in others. Group action of muscles:- 1. Prime movers/ agonists 2. Antagonists 3. Synergists 4. Fixators Prime movers: – They are the muscles who bring about the movement by contraction. They are responsible for most of the forces generated in the movement.E.g. for shoulder abduction deltoid is acting as the prime mover. Antagonists: – These are the muscles that are opposing group of prime movers. They relax and are lengthened (either passively or eccentrically) to allow controlled movement.E.g. shoulder adductors lengthen passively during abduction, knee extensors lengthen eccentrically during knee flexion in standing to sitting Synergists: – They work or relax to modify the movement of the prime movers. They may alter the direction of pull of prime mover or when a multijoint muscle is the prime mover, 28 ©IPH&H 2020 fix the joint where movement is not required in a position of advantage.E.g. rotator cuff in shoulder alters the pull of deltoid and creates abduction. Without them the deltoid would create an upward translation. INDICATIONS 1. Curative: • Muscle: weakness or paralysis • Bone: to increase density • Aerobic system: improves aerobic capacity • Other connective tissues: improve pliability and strength 2. Preventive: • To preserve muscle power in all the conditions where muscle weakness is anticipated. • To live a healthy life with high levels of fitness. Preparative: To prepare for some specific activity where the adaptations of resistance exercise will be useful, e.g training for arm muscles of a boxer will prepare him for a better performance. Recreative: Various form of resistance training is used as sports and recreation activity, like body building. DETERMINANTS OF RESISTANCE TRAINING • Frequency • Intensity • Time • Type • Alignment & Stabilization • Volume • Periodization • Rest interval • Sequencing • Integration to functional activities (FITT pas vir) • The determinants are interdependent for a successful regime Frequency • No. of exercise sessions per day or per week. • Depends on the goal or adaptation desired, should be set in accordance with intensity and volume. • Importance:Decides the rest time between two sessions of exercise. The rest is needed to recover from the fatigue and for the adaptations (e.g. protein sysntesis) to occur. 29 ©IPH&H 2020 • Higher the intensity and volume lower should be the frequency, as strong exercises creates microtrauma which needs time to recover. • In immediate post-surgery conditions short sessions of exercise is given several times a day whereas high intensity exercise for body building are usually performed 3-5 sessions a week. • Excessive frequency: progressive fatigue, decline in performance, overuse injury • Inadequate frequency: no or minimal adaptations Intensity/ exercise load/ training load • The intensity is the amount of resistance/ load imposed on the contracting muscles during each repetitions of an exercise. • 2 types: • Maximal:- Maximal intensity resistance of a muscle is the highest resistance a muscle can withstand, higher than maximal intensity being beyond the muscle’s capacity • Submaximal:- Submaximal intensity resistance is a resistance that is lower than the maximal intensity, usually some percent of the maximal intensity (between 30 to 80%) • Repetition Maximum (RM):- RM is a method of quantifying exercise intensity, given by Delorme Definition:A repetition maximum is defined as the greatest amount of weight a muscle can move through the available ROM a specific no of times. 1 RM for a muscle is the maximum weight (resistance) with which the muscle can contract through full/ available ROM for one time. The muscle will be unable to perform the repetition for a second time. 10 RM for a muscle is the maximum weight (resistance) with which the muscle can contract through full/ available ROM for 10 times. The muscle will be unable to perform an 11th repetition. Uses of RM:- To document a baseline measurement of dynamic strength of a muscle To identify an exercise load to be used during exercise To find out prognosis in reassessment and alter the exercise regime accordingly. How to measure 1RM Measured by repetitions to fatigue method using equations/ charts. Various equations and charts are available e.g. 1 RM= (No of reps/30+1) X weight used Example: if one lifts 15 kg for 20 times, 1RM=? 30 ©IPH&H 2020 For reps to fatigue the muscle is warmed up and stretched and then given a weight (preferably free weight) which can be performed comfortably over 5 repetitions. The no of repetition the candidate can perform before fatigue is noted. Training zone The amount of resistance to be used in a training program is usually a percentage of 1RM For sedentary: 30-40% of 1 RM For untrained healthy individual: 60-70% of 1 RM For highly trained: 80-95% of 1 RM Time/duration:- The duration of a resistance training regime is the total no of weeks or months during which the exercise program is carried out. Duration determines the adaptations: