Common Conditions Requiring Physical Therapy

Comprehensive reference of conditions, presentations, interventions, and clinical considerations

About Musculoskeletal Conditions

Musculoskeletal conditions affect the body's movement or musculoskeletal system, including muscles, tendons, ligaments, nerves, discs, blood vessels, joints, and bones. These conditions are a leading cause of disability worldwide and often benefit from physical therapy interventions focused on improving function, reducing pain, and restoring mobility.

Low Back Pain

Common Presentation Pain in lumbar region, possible radiation to buttocks/legs, movement limitations, muscle spasm
Causes/Etiology Muscle strain, disc herniation, facet joint dysfunction, spinal stenosis, poor posture
Therapeutic Indications Therapeutic exercise, manual therapy, core stabilization, McKenzie method, pain modalities
Contraindications/Precautions Avoid flexion with disc herniation, extension with stenosis, aggressive manipulation with osteoporosis

Clinical Insights

  • Red Flags: Saddle anesthesia, bowel/bladder dysfunction, progressive neurological deficits, fever, unexplained weight loss, history of cancer
  • Classification: Acute (<4 weeks), Subacute (4-12 weeks), Chronic (>12 weeks)
  • Directional Preference: Identify movements that centralize symptoms and movements that peripheralize symptoms
  • Psychosocial Factors: Fear-avoidance beliefs, catastrophizing, depression can impact outcomes

Evidence-Based Interventions

  • Acute: Remain active, avoid bed rest, pain management, gentle directional exercises
  • Subacute: Progressive exercises, manual therapy, postural education, gradual return to activities
  • Chronic: Multimodal approach including exercise, manual therapy, cognitive-behavioral approaches, activity modification

Rotator Cuff Tendinopathy

Common Presentation Shoulder pain with overhead activities, weakness, night pain, painful arc of movement
Causes/Etiology Repetitive microtrauma, impingement, aging, poor scapular mechanics
Therapeutic Indications Progressive resistance training, scapular stabilization, manual therapy, postural correction
Contraindications/Precautions Avoid heavy loading in acute phase, painful end ranges, aggressive stretching early post-surgery

Clinical Insights

  • Most Common Tendon: Supraspinatus (most vulnerable during 60-120° abduction)
  • Impingement Tests: Neer test, Hawkins-Kennedy, painful arc, empty can test
  • Phases of Tendinopathy: Reactive, Dysrepair, Degenerative
  • Loading Principles: Isometric → Isotonic (concentric/eccentric) → Functional/Sport-specific

Treatment Progression

  • Acute Phase (1-2 weeks): Relative rest, pain control, passive ROM as tolerated
  • Intermediate Phase (2-6 weeks): Progressive loading, scapular stabilization, rotator cuff strengthening
  • Advanced Phase (6+ weeks): Sport/occupation-specific training, eccentric loading, continued scapulothoracic control

Osteoarthritis

Common Presentation Joint pain, stiffness, decreased ROM, crepitus, worse after inactivity, joint enlargement
Causes/Etiology Age-related cartilage degeneration, joint trauma, genetic factors, obesity
Therapeutic Indications Low-impact exercise, aquatic therapy, joint protection techniques, weight management, manual therapy
Contraindications/Precautions Avoid high-impact activities, excessive joint loading, aggressive end-range stretching during flare-ups

Common Locations

  • Knee: Medial compartment most common, varus deformity
  • Hip: Groin pain, limited internal rotation, antalgic gait
  • Hand: DIP/PIP joints, first CMC (base of thumb)
  • Spine: Facet joints, may cause stenosis symptoms

Evidence-Based Interventions

  • Exercise: Land-based or aquatic exercise for pain reduction and improved function
  • Weight Management: Each pound lost reduces knee joint forces by 4 pounds
  • Manual Therapy: Joint mobilization for pain modulation and ROM
  • Assistive Devices: Braces, walking aids, joint protection techniques
  • Modalities: Heat for stiffness, cold for acute inflammation

Plantar Fasciitis

Common Presentation Heel pain worst with first steps in morning or after rest, tenderness at plantar fascia insertion
Causes/Etiology Excessive pronation, tight Achilles tendon, sudden increase in activity, improper footwear
Therapeutic Indications Stretching of plantar fascia and calf, night splints, orthotic devices, taping, manual therapy
Contraindications/Precautions Avoid prolonged standing/walking, unsupportive footwear, excessive running on hard surfaces

Clinical Insights

  • Pathomechanics: Windlass mechanism dysfunction, excessive tensile forces
  • Differential Diagnosis: Fat pad atrophy, tarsal tunnel syndrome, stress fracture, Achilles tendinopathy
  • Risk Factors: Pes planus (flat feet), pes cavus (high arches), limited ankle dorsiflexion, obesity
  • Natural History: Most cases resolve within 12 months with conservative management

Evidence-Based Interventions

  • Stretching: Plantar fascia-specific and gastrocnemius/soleus stretches
  • Manual Therapy: Soft tissue mobilization, joint mobilization of foot/ankle
  • Taping: Low-Dye taping for temporary relief and support
  • Footwear: Proper supportive shoes with cushioned heels
  • Night Splints: Maintain dorsiflexion during sleep to prevent morning pain

Adhesive Capsulitis

Common Presentation Progressive shoulder stiffness and pain, restricted passive and active ROM in multiple planes
Causes/Etiology Immobilization, diabetes, thyroid disorders, trauma, post-surgery
Therapeutic Indications Gentle progressive stretching, joint mobilization, pain modulation, home exercise program
Contraindications/Precautions Avoid aggressive stretching in freezing phase, heavy resistance, painful manipulations

Clinical Stages

  • Freezing Phase (2-9 months): Painful, gradual loss of motion
  • Frozen Phase (4-12 months): Less painful but significant stiffness
  • Thawing Phase (5-24 months): Gradual return of motion

Treatment Approach by Phase

  • Freezing: Pain management, maintain ROM without exacerbating symptoms
  • Frozen: Progressive stretching, joint mobilization, low-load prolonged stretches
  • Thawing: Strengthening, functional activities, return to prior level of function

Key Examination Findings

  • Capsular Pattern: External rotation most limited, followed by abduction and internal rotation
  • Equal Limitation: Both active and passive motion equally restricted
  • ROM Assessment: Document in multiple positions (neutral, 90° abduction)

About Neurological Conditions

Neurological conditions involve dysfunction of the brain, spinal cord, nerves, or muscles. Physical therapy for these conditions focuses on promoting neuroplasticity, maximizing functional independence, and preventing secondary complications. Interventions are typically long-term and require continual adaptation to changing needs.

Stroke

Common Presentation Hemiparesis/hemiplegia, spasticity, impaired coordination, speech deficits, balance issues
Causes/Etiology Ischemic or hemorrhagic cerebrovascular event
Therapeutic Indications Task-specific training, constraint-induced movement therapy, balance training, gait training, functional electrical stimulation
Contraindications/Precautions Avoid excessive fatigue, activities that increase intracranial pressure early post-stroke, excessive passive stretching with severe spasticity

Recovery Phases

  • Acute (0-3 months): Significant neurological recovery, focus on preventing complications
  • Subacute (3-6 months): Continued neurological recovery, intensive rehabilitation
  • Chronic (>6 months): Neurological recovery plateaus, focus on compensation and adaptation

Evidence-Based Interventions

  • Task-Specific Training: Repetitive practice of functional tasks
  • Constraint-Induced Movement Therapy: Restraining unaffected limb while intensively training affected limb
  • Body Weight-Supported Treadmill Training: For gait retraining
  • Functional Electrical Stimulation: For muscle activation and movement
  • Motor Imagery and Action Observation: Mental practice to enhance motor learning

Outcome Measures

  • Functional Independence Measure (FIM): Assesses level of disability
  • Fugl-Meyer Assessment: Measures motor recovery
  • Berg Balance Scale: Assesses balance
  • Timed Up and Go (TUG): Mobility and fall risk
  • Modified Ashworth Scale: Measures spasticity

Parkinson's Disease

Common Presentation Bradykinesia, resting tremor, rigidity, postural instability, freezing gait
Causes/Etiology Degeneration of dopaminergic neurons in substantia nigra
Therapeutic Indications LSVT BIG, rhythmic auditory stimulation, balance training, aerobic exercise, resistance training
Contraindications/Precautions Avoid complex dual-tasking early in training, excessive resistance with poor form, treatment during "off" periods

Clinical Stages (Hoehn and Yahr Scale)

  • Stage 1: Unilateral involvement only
  • Stage 2: Bilateral involvement without balance impairment
  • Stage 3: Mild to moderate disease, some postural instability, physically independent
  • Stage 4: Severe disability, still able to walk or stand unassisted
  • Stage 5: Wheelchair bound or bedridden unless assisted

Evidence-Based Interventions

  • LSVT BIG: Intensive amplitude-based training program
  • Rhythmic Auditory Stimulation: External cues to improve gait parameters
  • Resistance Training: Progressive resistance exercises to maintain strength
  • Balance Training: Multi-directional stepping, perturbation training
  • Aerobic Exercise: Stationary cycling, treadmill walking with appropriate safety measures

Management Considerations

  • Medication Timing: Schedule therapy during "on" periods when possible
  • Attentional Strategies: External cueing, mental rehearsal, focusing on amplitude
  • Fall Prevention: Home assessment, environmental modifications, behavioral strategies
  • Caregivers: Education on transfers, mobility assistance, recognizing freezing triggers

Multiple Sclerosis

Common Presentation Fatigue, weakness, spasticity, ataxia, visual disturbances, sensory changes
Causes/Etiology Autoimmune demyelination of central nervous system
Therapeutic Indications Energy conservation, aquatic therapy, core strengthening, balance training, cooling strategies
Contraindications/Precautions Avoid overheating, excessive fatigue, aggressive stretching during exacerbations, high-intensity exercise in heat

Disease Courses

  • Relapsing-Remitting MS (RRMS): Clearly defined attacks with full or partial recovery
  • Secondary Progressive MS (SPMS): Initial relapsing-remitting course followed by progression
  • Primary Progressive MS (PPMS): Steadily worsening function from the beginning
  • Progressive-Relapsing MS (PRMS): Progressive from onset with acute relapses

Evidence-Based Interventions

  • Aerobic Exercise: Low to moderate intensity to improve cardiovascular fitness
  • Resistance Training: Moderate intensity to maintain/improve strength
  • Balance Training: Multi-sensory challenges to improve stability
  • Aquatic Therapy: Buoyancy reduces joint loading, water resistance provides training medium
  • Energy Conservation: Activity pacing, prioritization, environmental modifications

Temperature Sensitivity

  • Uhthoff's Phenomenon: Temporary worsening of symptoms with increased body temperature
  • Cooling Strategies: Pre-cooling before exercise, cooling vests, cold packs
  • Environmental Controls: Air conditioning, scheduling outdoor activities during cooler times
  • Hydration: Maintaining adequate fluid intake before, during, and after activity

Guillain-Barré Syndrome

Common Presentation Ascending symmetrical weakness/paralysis, sensory abnormalities, autonomic dysfunction
Causes/Etiology Autoimmune attack on peripheral nerves following infection
Therapeutic Indications Graded strengthening, respiratory care, positioning, gradual mobility progression, functional training
Contraindications/Precautions Avoid overexertion, excessive stretching in acute phase, activities that compromise respiratory function

Disease Progression

  • Acute Phase (1-3 weeks): Rapid deterioration, may require ventilatory support
  • Plateau Phase (2-4 weeks): Stabilization of symptoms
  • Recovery Phase (months to years): Gradual improvement, may have residual deficits

Treatment Approach by Phase

  • Acute: Positioning, passive ROM, respiratory monitoring, prevention of complications
  • Plateau: Active-assisted exercises, functional mobility, graded strengthening
  • Recovery: Progressive resistive exercises, balance training, gait training, endurance activities

Monitoring Parameters

  • Respiratory Function: Vital capacity, negative inspiratory force, oxygen saturation
  • Autonomic Function: Blood pressure, heart rate, temperature regulation
  • Fatigue: Use Rating of Perceived Exertion (RPE) scale, monitor for post-exertional malaise
  • Strength: Manual muscle testing, dynamometry when appropriate

Spinal Cord Injury

Common Presentation Motor/sensory deficits below level of injury, spasticity, autonomic dysreflexia, pressure injury risk
Causes/Etiology Trauma, vascular disorders, tumors, infection
Therapeutic Indications Transfer training, wheelchair mobility, gait training with assistive devices, respiratory care, pressure relief techniques
Contraindications/Precautions Monitor for autonomic dysreflexia, avoid triggering stimuli, monitor skin integrity, respect fatigue limits

Classification (ASIA Impairment Scale)

  • A - Complete: No sensory or motor function preserved in S4-S5 segments
  • B - Sensory Incomplete: Sensory but not motor function preserved below neurological level including S4-S5
  • C - Motor Incomplete: Motor function preserved below neurological level, majority of key muscles below level have grade less than 3
  • D - Motor Incomplete: Motor function preserved below neurological level, majority of key muscles below level have grade greater than or equal to 3
  • E - Normal: Sensory and motor function normal

Functional Expectations by Level

  • C1-C4: Requires ventilatory support, power wheelchair with specialized controls
  • C5-C6: Independent feeding with equipment, power or manual wheelchair with specialized rims
  • C7-C8: Independent transfers with equipment, manual wheelchair propulsion
  • T1-T6: Independent transfers, good wheelchair skills including wheelies
  • T7-L1: Standing with braces possible, functional ambulation unlikely
  • L2-S5: Functional ambulation potential with appropriate orthoses

Autonomic Dysreflexia

  • Presentation: Sudden hypertension, bradycardia, headache, sweating above level, goosebumps
  • Common Triggers: Bladder distension, bowel impaction, skin irritation, tight clothing
  • Management: Upright positioning, remove trigger, monitor blood pressure
  • Urgency: Medical emergency requiring immediate intervention

About Cardiopulmonary Conditions

Cardiopulmonary conditions affect the heart, lungs, and associated blood vessels. Physical therapy interventions focus on improving functional capacity, breathing mechanics, exercise tolerance, and quality of life. Treatment is guided by objective measures of cardiopulmonary function and careful monitoring during activity.

Chronic Obstructive Pulmonary Disease (COPD)

Common Presentation Dyspnea, productive cough, decreased exercise tolerance, barrel chest
Causes/Etiology Smoking, pollution, occupational exposure, genetic factors (alpha-1 antitrypsin deficiency)
Therapeutic Indications Breathing strategies, airway clearance, energy conservation, graded exercise, respiratory muscle training
Contraindications/Precautions Avoid exercise during exacerbations, supplement O2 if needed, monitor oxygen saturation, respect fatigue limits

Pathophysiology

  • Emphysema: Destruction of alveolar walls with airspace enlargement
  • Chronic Bronchitis: Inflammation and excessive mucus production in bronchial tubes
  • Airflow Limitation: Not fully reversible, progressive over time
  • Air Trapping: Hyperinflation due to premature airway closure during expiration

Evidence-Based Interventions

  • Breathing Strategies: Pursed-lip breathing, diaphragmatic breathing, active expiration
  • Airway Clearance: Active cycle of breathing, autogenic drainage, positive expiratory pressure
  • Exercise Training: Endurance and strength training, interval training for severe disease
  • Energy Conservation: Activity pacing, adaptive techniques, assistive devices
  • Respiratory Muscle Training: Inspiratory muscle training devices

Monitoring Parameters

  • Oxygen Saturation: Maintain SpO2 >88-90% during activity
  • Dyspnea: Modified Borg Scale (0-10) or Visual Analog Scale
  • Heart Rate: Monitor for excessive increase or dysrhythmias
  • Exercise Capacity: 6-Minute Walk Test, Shuttle Walk Test

Post-Cardiac Surgery

Common Presentation Sternal pain, decreased upper extremity mobility, fatigue, anxiety about movement
Causes/Etiology Coronary artery bypass grafting, valve replacement
Therapeutic Indications Progressive cardiac rehabilitation, sternal precautions, breathing exercises, gradual return to activities
Contraindications/Precautions Avoid sternal stress in early phase, monitor vital signs, stay within prescribed heart rate limits, watch for arrhythmias

Cardiac Rehabilitation Phases

  • Phase I (Inpatient): Early mobilization, sternal precautions education, breathing exercises
  • Phase II (Outpatient): Supervised exercise program, typically 4-12 weeks post-surgery
  • Phase III (Community): Maintenance program with decreasing supervision
  • Phase IV (Independent): Long-term maintenance of exercise and lifestyle changes

Sternal Precautions (Traditional Approach)

  • No lifting >5-10 lbs (2.3-4.5 kg): For 6-8 weeks post-surgery
  • No pushing/pulling with arms: Including pushing up from bed/chair with arms
  • No reaching behind back: Restricts excessive shoulder extension/internal rotation
  • No reaching overhead: May be restricted initially

STARR Precautions (Newer Approach)

  • Sternal precautions based on Symptoms
  • Technique modifications for ADLs
  • Active patient involvement
  • Realistic restrictions based on individual
  • Real-time feedback on activity performance

Congestive Heart Failure

Common Presentation Dyspnea, fatigue, peripheral edema, orthopnea, exercise intolerance
Causes/Etiology Coronary artery disease, hypertension, valve disorders, cardiomyopathy
Therapeutic Indications Monitored aerobic exercise, interval training, breathing techniques, education on energy conservation
Contraindications/Precautions Monitor vital signs, avoid Valsalva maneuver, respect RPE limits, avoid extreme temperatures

Classification (New York Heart Association)

  • Class I: No limitation of physical activity, no symptoms with ordinary activity
  • Class II: Slight limitation, comfortable at rest but ordinary activity results in symptoms
  • Class III: Marked limitation, comfortable at rest but less than ordinary activity causes symptoms
  • Class IV: Unable to carry out any physical activity without discomfort, symptoms at rest

Evidence-Based Interventions

  • Aerobic Exercise: Low to moderate intensity (40-80% of peak VO2)
  • Interval Training: Alternating periods of higher intensity with active recovery
  • Resistance Training: Low resistance, higher repetitions
  • Self-Monitoring: Daily weight, symptom tracking, activity logging
  • Education: Fluid/sodium restriction, medication adherence, activity pacing

Monitoring Parameters

  • Heart Rate: Typically maintain 20-30 beats below symptom threshold
  • Blood Pressure: Avoid excessive increases during exercise
  • Rating of Perceived Exertion (RPE): Target 11-14 on Borg 6-20 scale
  • Symptoms: Monitor for unusual dyspnea, dizziness, chest pain
  • Weight Changes: Sudden increase (>2 lbs in 24 hours) may indicate fluid retention

Pulmonary Fibrosis

Common Presentation Progressive dyspnea, dry cough, fatigue, exercise-induced hypoxemia, clubbing
Causes/Etiology Idiopathic, environmental/occupational exposures, radiation, medications
Therapeutic Indications Oxygen supplementation during exercise, energy conservation, paced breathing, interval training
Contraindications/Precautions Monitor oxygen saturation, modify activity based on desaturation, avoid excessive exertion

Pathophysiology

  • Interstitial Inflammation: Immune cell infiltration in alveolar walls
  • Fibroblast Proliferation: Excessive connective tissue production
  • Reduced Compliance: Stiff lungs require increased work of breathing
  • Gas Exchange Impairment: Thickened alveolar-capillary membrane

Exercise Considerations

  • Oxygen Therapy: Titrate to maintain SpO2 >88-90% during activity
  • Interval Training: Alternating activity with rest periods
  • Breathing Techniques: Pursed-lip breathing, paced breathing during activity
  • Exercise Intensity: Moderate (typically 60-70% of maximum capacity)
  • Modality Selection: Consider non-weight bearing options to reduce work

Disease Progression Monitoring

  • Pulmonary Function Tests: Forced vital capacity (FVC), diffusing capacity (DLCO)
  • Exercise Capacity: 6-minute walk distance, oxygen desaturation pattern
  • Dyspnea Scale: Modified Medical Research Council (mMRC) Dyspnea Scale
  • Quality of Life: St. George's Respiratory Questionnaire

About Orthopedic Surgical Conditions

Orthopedic surgical procedures require specialized rehabilitation protocols that balance protecting healing tissues with maintaining mobility and function. Physical therapy interventions are typically phased according to tissue healing timelines and guided by specific precautions established by the surgeon.

Total Knee Arthroplasty

Common Presentation Post-surgical pain, swelling, limited ROM, weakness, gait deviations
Causes/Etiology Severe osteoarthritis, rheumatoid arthritis, post-traumatic arthritis
Therapeutic Indications Early ROM, progressive strengthening, gait training, functional mobility, modalities for pain/swelling
Contraindications/Precautions Avoid excessive flexion early post-op (per protocol), high-impact activities, prosthesis-specific precautions

Rehabilitation Phases

  • Acute Phase (0-3 weeks): Pain/edema management, early ROM, basic strengthening, gait training with assistive device
  • Subacute Phase (3-6 weeks): Progressive strengthening, advanced gait training, functional mobility
  • Advanced Phase (6-12 weeks): Higher level strengthening, balance activities, reduced dependence on assistive devices
  • Functional Phase (3-6 months): Return to recreational activities, optimize movement patterns

Key Rehabilitation Goals

  • ROM: 0° extension to 110-120° flexion minimum for functional activities
  • Strength: Focus on quadriceps, hamstrings, hip abductors/extensors
  • Gait: Normal pattern without assistive device, ability to negotiate stairs and uneven surfaces
  • Function: Independence in transfers, ADLs, and recreational activities

Common Complications

  • Arthrofibrosis: Excessive scarring limiting ROM
  • Persistent Quadriceps Weakness: May require specialized strengthening approaches
  • Patellofemoral Complications: Pain, crepitus, or instability
  • Prosthetic Loosening: May present as activity-related pain or instability

Total Hip Arthroplasty

Common Presentation Post-surgical pain, limited ROM, weakness, gait deviations
Causes/Etiology Osteoarthritis, avascular necrosis, hip dysplasia, fracture
Therapeutic Indications Progressive weight-bearing, gait training, hip strengthening, functional mobility training
Contraindications/Precautions Observe hip precautions based on surgical approach, avoid dislocation positions, excessive early flexion

Hip Precautions by Approach

  • Posterior Approach: Avoid flexion >90°, internal rotation, and adduction past midline
  • Anterior Approach: Avoid hip extension and external rotation; fewer restrictions overall
  • Anterolateral Approach: Avoid extension and external rotation
  • Direct Lateral Approach: Avoid adduction past midline and sometimes external rotation

Rehabilitation Phases

  • Phase I (0-4 weeks): Precautions emphasis, early mobility, basic strengthening, assistive device
  • Phase II (4-8 weeks): Progressive strengthening, gait normalization, functional exercises
  • Phase III (8-12 weeks): Advanced strengthening, balance activities, reduced assistive device use
  • Phase IV (3-6 months): Return to higher level activities, recreational adaptations

Evidence-Based Interventions

  • Early Mobility: Mobilization within first 24 hours post-surgery when possible
  • Progressive Loading: Gradual weight-bearing as tolerated (approach-dependent)
  • Targeted Strengthening: Focus on gluteals, hip abductors, quadriceps
  • Proprioceptive Training: Weight-shifting, single-leg stance, perturbation
  • Functional Training: Task-specific practice of daily activities

ACL Reconstruction

Common Presentation Knee pain, swelling, instability, limited ROM, quadriceps weakness
Causes/Etiology Sports injuries, pivoting trauma, deceleration injury
Therapeutic Indications Phased rehabilitation: early ROM, progressive strengthening, neuromuscular training, sport-specific training
Contraindications/Precautions Avoid hyperextension, early pivoting/cutting, open chain exercises in early phases per protocol

Graft Types and Considerations

  • Patellar Tendon Autograft: Faster fixation, anterior knee pain risk
  • Hamstring Autograft: Less donor site morbidity, longer fixation time
  • Quadriceps Tendon Autograft: Good size, less anterior knee pain than patellar
  • Allograft: No donor site morbidity, slower incorporation, higher revision rate in young patients

Rehabilitation Phases

  • Phase I (0-2 weeks): Control pain/effusion, restore ROM, activate quadriceps, protect graft
  • Phase II (2-6 weeks): Normalize gait, progressive strengthening, maintain ROM
  • Phase III (6-12 weeks): Advanced strengthening, neuromuscular control, early proprioception
  • Phase IV (3-6 months): Running progression, advanced neuromuscular training
  • Phase V (6-9 months): Sport-specific training, return to sport testing

Return to Sport Criteria

  • Strength: Limb symmetry index >90% for quadriceps and hamstrings
  • Functional Tests: Single leg hop, triple hop, crossover hop, 6-meter timed hop >90% symmetry
  • Landing Mechanics: Normal frontal and sagittal plane alignment during drop jump
  • Psychological Readiness: ACL-Return to Sport after Injury scale score >56

Rotator Cuff Repair

Common Presentation Shoulder pain, weakness with overhead activities, limited ROM
Causes/Etiology Acute tear from trauma, chronic degenerative tear
Therapeutic Indications Phased rehabilitation: protected ROM, progressive strengthening, scapular stabilization
Contraindications/Precautions Respect tissue healing timeframes, avoid excessive load, abide by surgeon's protocol for ROM restrictions

Factors Affecting Rehabilitation

  • Tear Size: Small, medium, large, massive
  • Tear Location: Supraspinatus, infraspinatus, subscapularis, teres minor
  • Tissue Quality: Tendon degeneration, muscle atrophy, fatty infiltration
  • Repair Technique: Single row, double row, transosseous equivalent
  • Patient Factors: Age, comorbidities, work demands, compliance

Rehabilitation Phases

  • Phase I (0-6 weeks): Protection, passive ROM within limits, pendulums, scapular awareness
  • Phase II (6-12 weeks): Progressive ROM, active-assisted ROM, light isometrics
  • Phase III (12-20 weeks): Full active ROM, progressive strengthening, dynamic stabilization
  • Phase IV (20+ weeks): Advanced strengthening, plyometrics, sport/work-specific training

Common ROM Restrictions

  • Supraspinatus Repair: Limit abduction and flexion (typically 90° for 4-6 weeks)
  • Infraspinatus/Teres Minor Repair: Limit external rotation (typically 30° for 4-6 weeks)
  • Subscapularis Repair: Limit external rotation and extension (0° ER for 4-6 weeks)
  • Massive Repair: More conservative restrictions for all planes

About Pediatric Conditions

Pediatric physical therapy addresses developmental, neuromuscular, and musculoskeletal conditions in children. Interventions must consider the child's developmental stage, growth, family dynamics, and educational environment. Treatment often involves play-based approaches and family education.

Cerebral Palsy

Common Presentation Abnormal muscle tone, delayed motor milestones, movement disorders, posture abnormalities
Causes/Etiology Perinatal brain injury, developmental brain malformation, genetic disorders
Therapeutic Indications Neurodevelopmental treatment, adaptive equipment, gait training, functional mobility, tone management
Contraindications/Precautions Avoid painful stretching with high tone, monitor for hip subluxation, respect fatigue limits

Classification Systems

  • Topographical: Hemiplegia, diplegia, quadriplegia, monoplegia, triplegia
  • Gross Motor Function Classification System (GMFCS): Levels I-V based on functional mobility
  • Motor Type: Spastic, dyskinetic (athetoid, dystonic), ataxic, mixed
  • Manual Ability Classification System (MACS): Levels I-V based on hand function

Evidence-Based Interventions

  • Goal-Directed Training: Functional, task-specific practice
  • Constraint-Induced Movement Therapy: For hemiplegia
  • Strength Training: Progressive resistance exercises for functional muscle groups
  • Gait Training: Body weight-supported treadmill, overground practice with appropriate assistive devices
  • Orthotic Management: AFOs, KAFOs, SMOs for alignment and function

Associated Conditions

  • Hip Displacement: Progressive subluxation/dislocation, more common in GMFCS IV-V
  • Scoliosis: Neuromuscular curve development, often requiring monitoring and intervention
  • Contractures: Progressive joint limitations requiring stretching, positioning, orthoses
  • Feeding/Swallowing Issues: May require multidisciplinary approach

Developmental Delay

Common Presentation Delayed achievement of motor milestones, coordination difficulties
Causes/Etiology Prematurity, genetic syndromes, prenatal exposures, environmental factors
Therapeutic Indications Developmental activities, sensory integration, play-based therapy, parent education
Contraindications/Precautions Avoid frustrating activities, respect developmental readiness, modify based on cognitive level

Developmental Milestones (Motor)

  • 3 months: Head control, chest up in prone, brings hands to midline
  • 6 months: Rolling, sitting with support, weight bearing on legs
  • 9 months: Independent sitting, crawling, pulling to stand
  • 12 months: Cruising, standing independently, first steps
  • 18 months: Walking independently, squatting to play
  • 24 months: Running, kicking ball, climbing stairs with assistance

Assessment Tools

  • Alberta Infant Motor Scale (AIMS): 0-18 months
  • Peabody Developmental Motor Scales (PDMS-2): Birth to 5 years
  • Bayley Scales of Infant Development: 1-42 months
  • Movement Assessment Battery for Children (MABC-2): 3-16 years

Intervention Approaches

  • Activity-Based: Practicing functional skills in context
  • Environmental Modification: Adapting settings to encourage development
  • Family-Centered: Coaching parents as primary interventionists
  • Sensory Integration: Addressing sensory processing for motor planning
  • Positioning: Optimal alignment for skill development

Torticollis

Common Presentation Head tilt to one side, rotation preference, plagiocephaly, limited cervical ROM
Causes/Etiology Intrauterine positioning, birth trauma, congenital muscular fibrosis
Therapeutic Indications Gentle stretching, positioning strategies, strengthening of contralateral muscles, parent education
Contraindications/Precautions Rule out nonmuscular causes, avoid forceful stretching, monitor for plagiocephaly

Classifications

  • Postural: Positional preference without muscle contracture
  • Muscular: Contracted sternocleidomastoid muscle (SCM) with fibrosis
  • Ocular: Associated with visual disturbance
  • Klippel-Feil Syndrome: Associated with cervical vertebral anomalies

Assessment Parameters

  • Passive Cervical Rotation: Compare involved to uninvolved side
  • Passive Cervical Lateral Flexion: Compare involved to uninvolved side
  • SCM Palpation: Check for fibrotic mass ("olive sign")
  • Head Shape: Assess for plagiocephaly, brachycephaly
  • Positional Preferences: Observe spontaneous head position during activities

Evidence-Based Interventions

  • Manual Stretching: Gentle, prolonged rotation and lateral flexion away from involved side
  • Positioning: Environmental modifications to encourage turning to non-preferred side
  • Tummy Time: Supervised prone positioning while awake
  • Parent Education: Carrying positions, sleep positioning, environmental setup
  • Strengthening: Active exercises for contralateral muscles

Scoliosis

Common Presentation Spinal curvature, asymmetric shoulder/hip height, trunk rotation
Causes/Etiology Idiopathic (most common), congenital, neuromuscular, genetic
Therapeutic Indications Schroth method, core strengthening, posture training, bracing compliance (if prescribed)
Contraindications/Precautions Avoid activities that increase curve, monitor growth spurts, coordinate with orthopedic management

Classifications

  • Idiopathic: Infantile (0-3 years), Juvenile (4-10 years), Adolescent (10+ years)
  • Congenital: Present at birth due to vertebral anomalies
  • Neuromuscular: Secondary to neurological or muscular disorders
  • Syndromic: Associated with Marfan, Ehlers-Danlos, or other syndromes

Assessment Parameters

  • Cobb Angle: Radiographic measurement of curve magnitude
  • Trunk Rotation: Measured with scoliometer during Adam's forward bend test
  • Curve Pattern: Single, double, triple curves; thoracic, lumbar, thoracolumbar
  • Risser Sign: Iliac apophysis ossification indicating skeletal maturity
  • Functional Assessment: Posture, strength, flexibility, respiratory function

Management Approaches

  • Observation: Curves <20° with regular monitoring
  • Bracing: Typically for curves 20-40° in skeletally immature patients
  • Physical Therapy: Schroth method, Scientific Exercise Approach to Scoliosis (SEAS)
  • Surgical Intervention: Usually for curves >45-50° or progressive despite bracing

Juvenile Idiopathic Arthritis

Common Presentation Joint pain, swelling, morning stiffness, limited ROM, growth disturbances
Causes/Etiology Autoimmune dysfunction
Therapeutic Indications Low-impact exercise, aquatic therapy, ROM exercises, splinting if needed, pain management
Contraindications/Precautions Avoid high-impact activities during flares, exercise modification during acute inflammation

Subtypes

  • Oligoarticular: 4 or fewer joints in first 6 months, often knees and ankles
  • Polyarticular: 5 or more joints, similar to adult rheumatoid arthritis
  • Systemic: Arthritis with fever, rash, organomegaly, serositis
  • Enthesitis-Related: Arthritis with enthesitis, often in lower extremities
  • Psoriatic: Arthritis with psoriasis or specific features (dactylitis, nail changes)

Evidence-Based Interventions

  • Aquatic Therapy: Provides resistance with reduced joint loading
  • Range of Motion: Daily stretching to maintain joint mobility
  • Strengthening: Isometric during flares, progressive resistance during remission
  • Splinting: Resting splints to prevent contractures, functional splints for activities
  • Physical Activity: Swimming, cycling, modified sports as appropriate

Management Considerations

  • Growth Disturbances: Monitor for leg length discrepancies, micrognathia
  • Psychosocial Support: Address body image, school participation, peer interactions
  • Pain Management: Non-pharmacological approaches, modalities, coping strategies
  • School Accommodations: Modified PE, extended time between classes, ergonomic seating

About Vestibular and Balance Conditions

Vestibular and balance disorders involve dysfunction of the inner ear balance system, central processing, or sensory integration. Physical therapy for these conditions focuses on promoting vestibular adaptation, substitution of alternative strategies, and improving postural control and stability during functional activities.

Benign Paroxysmal Positional Vertigo (BPPV)

Common Presentation Brief episodes of vertigo with position changes, positive Dix-Hallpike test
Causes/Etiology Otolith displacement in semicircular canals
Therapeutic Indications Canalith repositioning maneuvers (Epley, Semont), habituation exercises, balance training
Contraindications/Precautions Avoid provoking maneuvers in severe nausea, cervical spine precautions, proper patient positioning

Canal Identification

  • Posterior Canal: Most common (80-90%), positive Dix-Hallpike with torsional upbeating nystagmus
  • Horizontal Canal: Second most common (5-15%), positive supine roll test with horizontal nystagmus
  • Anterior Canal: Least common (1-2%), positive Dix-Hallpike with torsional downbeating nystagmus
  • Multiple Canals: Can occur simultaneously or sequentially

Repositioning Maneuvers

  • Epley Maneuver: For posterior canal BPPV
  • Semont Maneuver: Alternative for posterior canal BPPV
  • Roll Maneuvers: Log roll, Lempert 360° for horizontal canal BPPV
  • Deep Head Hanging Maneuver: For anterior canal BPPV

Post-Maneuver Instructions

  • Traditional Approach: Avoid lying flat or on affected side for 24-48 hours
  • Current Evidence: Restrictions may not significantly affect outcomes
  • Home Exercise Program: Modified Epley or Brandt-Daroff exercises as appropriate
  • Follow-up: Re-assessment in 1-2 weeks, different approach if not resolved

Vestibular Neuritis

Common Presentation Acute severe vertigo, nausea/vomiting, horizontal nystagmus, balance disruption
Causes/Etiology Viral infection of vestibular nerve
Therapeutic Indications Vestibular adaptation exercises, gaze stabilization, balance training, habituation exercises
Contraindications/Precautions Respect symptoms, gradual progression, safety precautions during acute phase

Clinical Phases

  • Acute (1-3 days): Severe vertigo, spontaneous nystagmus, significant functional limitation
  • Subacute (1-2 weeks): Decreasing spontaneous symptoms, provoked symptoms with movement
  • Chronic (>2 weeks): Symptoms primarily with rapid head movements, possible incomplete compensation

Evidence-Based Interventions

  • Vestibular Adaptation: Gaze stabilization with head movement, visual-vestibular interaction
  • Habituation: Repeated exposure to provoking movements to reduce symptom intensity
  • Substitution: Alternative strategies using visual and somatosensory inputs
  • Balance Training: Progressive challenges to stability with varied sensory conditions
  • Activity Retraining: Gradual return to daily activities and exercise

Differentiation from BPPV

  • Duration: Vestibular neuritis - sustained symptoms; BPPV - brief episodes
  • Provocation: Vestibular neuritis - constant initially; BPPV - positional only
  • Nystagmus: Vestibular neuritis - unidirectional, horizontal-torsional; BPPV - direction-changing
  • Recovery: Vestibular neuritis - gradual over weeks; BPPV - immediate after repositioning

Peripheral Neuropathy

Common Presentation Distal sensory changes, proprioceptive loss, unsteadiness, positive Romberg test
Causes/Etiology Diabetes, chemotherapy, alcohol abuse, vitamin deficiencies, autoimmune
Therapeutic Indications Proprioceptive training, ankle strategy training, assistive devices, fall prevention, sensory integration
Contraindications/Precautions Monitor for skin integrity, pain response, adapt to sensory loss, ensure safety

Types of Neuropathy

  • Sensory: Numbness, tingling, loss of proprioception, positive Romberg test
  • Motor: Weakness, atrophy, decreased reflexes, foot drop
  • Autonomic: Orthostatic hypotension, anhidrosis, thermoregulatory dysfunction
  • Mixed: Combination of sensory, motor, and/or autonomic symptoms

Balance Rehabilitation Approach

  • Sensory Reweighting: Training to rely on remaining sensory systems
  • Ankle Strategy: Strengthening ankle musculature for postural control
  • Surface Challenges: Progressively challenging surfaces to improve adaptation
  • Multi-task Training: Combining balance tasks with cognitive challenges
  • Visual Integration: Use of visual cues to compensate for proprioceptive loss

Fall Prevention

  • Home Assessment: Remove tripping hazards, improve lighting, install grab bars
  • Footwear: Supportive shoes with good traction, consider high-top styles
  • Assistive Devices: Appropriate walking aid prescription and training
  • Sensory Substitution: Use of tactile cues, weighted devices, auditory feedback
  • Education: Fall recovery techniques, activity modification strategies

Post-Concussion Syndrome

Common Presentation Dizziness, balance issues, visual disturbances, headache, cognitive issues
Causes/Etiology Sports injury, falls, motor vehicle accidents
Therapeutic Indications Graded exercise, vestibular rehabilitation, vision therapy, balance training
Contraindications/Precautions Avoid symptom exacerbation, cognitive overload, return to play/work per protocol

Clinical Domains

  • Vestibular: Dizziness, visual motion sensitivity, imbalance
  • Ocular-Motor: Convergence insufficiency, accommodation dysfunction, saccadic abnormalities
  • Cognitive: Attention deficits, processing speed, memory issues
  • Cervical: Neck pain, headaches, reduced ROM, joint position error
  • Autonomic: Exercise intolerance, heart rate abnormalities, orthostatic intolerance

Vestibular-Ocular Assessment

  • Vestibular-Ocular Motor Screening (VOMS): Standardized provocation assessment
  • Dynamic Visual Acuity: Assessment of gaze stability during head movement
  • Near Point Convergence: Ability to maintain binocular vision with near targets
  • Saccades/Pursuits: Eye movement control and accuracy

Evidence-Based Interventions

  • Subsystem-Specific Rehabilitation: Target vestibular, ocular, cervical components
  • Graded Exertion: Buffalo Concussion Treadmill Test to identify threshold
  • Habituation: Gradual exposure to provoking movements/environments
  • Balance Rehabilitation: Progressive challenges to postural stability
  • Return to Activity: Staged progression based on symptom monitoring

Age-related Balance Deficits

Common Presentation Increased postural sway, fear of falling, reduced reaction time, multifactorial balance impairment
Causes/Etiology Sensory changes, musculoskeletal limitations, medication effects, central processing changes
Therapeutic Indications Multi-component balance program, strength training, tai chi, fall prevention strategies, home modifications
Contraindications/Precautions Consider comorbidities, medication effects, cardiac precautions, cognitive limitations

Risk Factors

  • History of Falls: Strongest predictor of future falls
  • Polypharmacy: Four or more medications, especially psychoactive drugs
  • Environmental Hazards: Poor lighting, obstacles, lack of grab bars
  • Sensory Deficits: Vision, vestibular, proprioceptive changes
  • Muscle Weakness: Particularly lower extremity and core

Evidence-Based Assessments

  • Timed Up and Go (TUG): >12 seconds indicates fall risk
  • Berg Balance Scale: 14-item scale, score <45 indicates fall risk
  • 5 Times Sit-to-Stand: >12 seconds indicates fall risk
  • Four Square Step Test: >15 seconds indicates fall risk
  • Functional Reach Test: <10 inches indicates fall risk

Evidence-Based Interventions

  • Multicomponent Exercise: Combining balance, strength, flexibility, endurance
  • Tai Chi: Particularly effective for reducing fall risk
  • Dual-Task Training: Balance activities with cognitive challenges
  • Home Hazard Modification: Systematic assessment and adaptation
  • Vestibular Rehabilitation: For those with vestibular component