Hip Replacement Surgery Essay: Exercise And Treatment Protocol.

Exercises to Strengthen Hip Muscles

The patient Mr Smith had a hip replacement surgery and is currently on his 4^th week post-operation. He is walking with a stick following the WBAT protocol,placing only as much weight as feels comfortable on his legs. Thera-Band hip abductor helps to strengthen the outside of the hip muscles. Also hip extension Pilates exercises such as Butt firming exercises including side kick front/back exercises will be suggested. To strengthen the VMO, I will suggest lateral heel drop exercises. For that a stepper and a few light ankle weights will be needed. Sit to stand exercises with a sturdy chair, are required to help ease processes like getting up from bed, couch or toilet, after surgery. 

While supervising Mr Smith’s sessions I will strictly follow all the protocols. I will start him with the easy exercises like the sit and stand exercise, and gradually move towards the ones that requires more movement and activity. I may also alter the protocol according to his ability to follow up the processes. 

During the implementation of his exercise session, if Mr Smith experiences any discomfort I would ask for help from the physiotherapist allotted for Mr Smith. If he sprains any muscle or gets any soft tissue injury, I will seek prompt medical advice from the physiotherapist who will provide sound advice and encourage him to keep moving. 

During treatment I will keep asking Mr Smith both about his improvements and discomforts. If the exercises are being helpful for him, in his usual daily movements and if they are helping him to improve his posture. Also I would ask if he is having any trouble with the entire session. 

As the treatment nears completion I would ask Mr Smith to follow the exercise protocols more stringently. I will make sure he does all the allotted exercises for the duration that he is supposed to. I will chart out his improvement throughout the treatment procedures. I will look for any issues that he has had while in the treatment and make sure that he does not have any more inconveniences at home (MacKay-Lyons et al. 2013). After his treatment ends I will try to provide him as much assistance as possible so that he can continue exercising on his own at home. 

The followings are the exercises that I have been instructed to do with Mr Smith:

• Thera-Band hip abduction exercise: Thera-Band hip abductions strengthen the outside of the hip muscles, which help externally rotate and lift the legs out to the side. For doing this, I will wrap a Thera-Band around his both ankles and then keeping one leg static, I will lift up his other leg slowly and ask him to repeat this for 30 times, with each leg (Brandt et al.2013).
• Pilates exercises for hip extension: The set up for the side kick series is the same for all the pilates exercises. For effective outcome I will make sure that he is setting good alignment and maintaining it throughout the exercises.
• Lateral heel-drop exercises: This helps in strengthening the VMO and the lower back muscles so that Mr Smith can be able to perform lunges and squats properly without any pain in his knees. This is necessary to keep pushing off one knee from the steps, while the other knee will be contracted and controlling the descent during this exercise.
• Sit-to-stand exercise: The sit to stand exercise is necessary for the exact movement of the hips during regular change of stature while standing up from a chair or getting up from the bed. A sturdy chair is to be used making sure that it will not slide on the floor. 

I would document Mr Smith’s entire treatment session thoroughly, providing every minor detail like how many times he had done the exercises or for how long he has been able to do them and thus record his improvement day by day. I will also highlight any difficulties that he have had while in the treatment. 

If the client gets confused about the instructions given to him for home exercise, I will again describe him all the procedures in a lucid manner and provide him with a chart mentioned with all the details of the exercises. 

The hip joint is formed with the cup-shaped socket acetabulum which is laterally adjoined to the pelvis and with the head of the femur. The acetabulum is comprised of ilium, ischium and pubis. Extension of the hip-joint depends on this iliofemoral ligament.

Sit-to-Stand Exercises

The contraindications for the posterior approach at the hip, which is more commonly stated as the total hip arthroplasty (THA) approach. It does not has great complication and adheres to intraoperative potentials as well.

Activities that Mr Smith needs to avoid includes lifting heavy weights, walking for long hours, or even staying in the same posture for a long time. Also he must avoid crossing his legs at any time, or pull his knees towards his chest, lie on the side of his replaced hip and avoid leaning forward. 

Exercises to maintain Mrs Smith’s cardiopulmonary function will involve aerobic exercises, which will have a positive effect on her health outcomes. Exercises to strengthen her arms and legs will include calf raises which are simple yet effective, a few yoga exercises along with strength and aerobic exercises. Calf stretch, soleus stretch and achilles stretch exercises and foam roller exercise will be done to ensure her gastrocnemius muscle length is maintained on her injured leg. Overall the treatment will be based on stabilization, strengthening and motion exercises. 

I will have to consider her condition, especially her age and movement abilities. This can be made aware that her broken femur needs to be taken care of first. So that her instruction of bed rest will also be maintained. 

Resting night splint would be used for the purpose of stretching the plantar fascia ligament of her leg during sleep. It will help in relieving pain from the plantar fasciitis. 

This is an image of the type of splint that might be used for Mrs Smith: 

The indicators that the splint is causing a pressure area will be the skin or bones on the ankles which may get reddish and appear bruised. Even the temperature may change in that area too. 

Pillows or wedges can be used in the area of the pressure sores. 

The four main causes of pressure areas are as follows:

• Pressure: Pressure due to the splint can reduce blood flow to the feet, especially around the bony area of the ankle.
• Traction: Sheer force tractions can stretch the limbs while the patient is in inclined position, due to their anti-gravity posture.
• Friction: Continuous friction against the bed sheets or clothing can result in bedsores or pressure sores.
• Moisture: Excessive moisture tends to affect the outer layer of the skin, especially in older people.

The following is an image showing different layers of the skin:  

I would first get all the information about the patient. This would include the patient’s age, medical history, current medical condition and recommended treatments. Then I would allot a timing for the patient and inform the patient to come for treatment at that time. I would also make sure that the patient knows the details of the treatment that he/she is about to get through. I would give them a brief idea about the exercises I would need them to perform and ask for their cooperation. 

The WHS issues I need to be aware of include health and safety issues, manual handling, infection control, clearing hazards from the area around the bed, cleanliness and condition of equipment, identifying any foreseeable hazard, moving parts in machinery, toxic chemicals and manual handling tasks. 

I would warn the patient that before using crutches they must:

• Wear comfortable casual shoes
• Relax their arms and let them hang easily over the crutches
• Always adjust the crutches so that it separates the armpit from the crutch about two to four inches
• Also adjust the hand-grips on the crutches
• Lift their good leg up for the first step. 

The correct order to move up or down the stairs would be to place the crutch on the ground first and then lift the good leg up for the first step. 

The Hip Joint

If the client was having difficulty using the crutches I would help them adjusting the crutch length and help them to make the grip. I would also help them walk with it. 

If there is any fracture on the legs or the patient’s ankles cannot bear any weight on them then I would not suggest the use of crutches.

24 hour management is a mobility management program that ensures effective hip management and postural management interventions through its entire implementation. This approach considers all the relevant postures an individual can be able to adopt over 24 hours period of any given day. The three core postural orientations are lying, sitting and standing.When body posture is unequal between sides it is called postural asymmetry which can affect pelvic rotation, obliquity, dislocated hips and rib distortions and result in compromised health of the patient.   

The allied health assistant would be responsible for the 24 hour postural management equipment such as standing frames, wheelchairs, sleep systems, wedges or even special seating arrangements. The allied health assistant must be responsible for handling all the equipment and keep them functioning so that those can be used for providing postural care to all the patients. The equipment must be flexible and sustainable. These equipment are mostly used to help children and adults in maintaining their movements. 

Any surgery or damage may cause fluid build-up in the lymphatic tissues and nodes. This condition is known as lymphedema. After such fluid generation in the lymphatic system doctors suggest lymphoedema massages to the patient which helps them get rid of that extra fluid from the nodes and reduces the swelling. There are two stages of lymphoedema massage: clearing and reabsorption. Clearing creates a vacuum due to massaging with gentle pressure so that the fluid filled area is prepared to bring in more fluid, creating a flushing effect. 

With the permission of the physio, I would advise the patient to do:

• Elbow flexion exercise: This allows movement of the upper arms which are close to the axillary lymph nodes. The more these muscles move, the more fluid can be pumped back into the lymph nodes and help reduce the oedema.
• Light exercise: Light movement exercises will help prepare the patient for everyday tasks and encourage lymph fluid drainage
• Wrapping: Wrapping the arms may also help in fluid drainage
• Compression garments: Such clothing helps reduce chances of lymphoedema. 

If lymphoedema worsens it will result in the permanent changes in the tissues such as thickening or scarring. Although these changes cannot be undone the side effects can be reduced significantly with effective management. The exercise plans would include flexibility and stretching along with aerobic exercises. 

The factors that make up a successful fitness plan includes frequency, intensity, time and type. These factors make up the FITT formula which ensures how often a person exercises, how hard they exercise and the duration of exercise and the types of exercises they do. The frequency is measured by the days of each week a person exercises. This FITT principle helps monitor the exercise program of a patient or any athlete. The two biggest issues people face while going through an exercise program are concentrating on training too hard and secondly not doing a variety of exercise programs.

While doing an exercise program, the person must know the difference between muscle strength and muscle endurance exercises. Endurance means the ability to perform a muscular action for a long period such as running marathon, while muscle strength refers to the capability of exerting maximal force against a resistance for a short period of time like lifting a heavy box. People must do a variety of both strength and endurance exercises.  Strength exercises build muscle and endurance exercises round the participant’s training. Because, everyday tasks require both strength and endurance. There is a myth that lifting heavy weights builds muscles. This is not a practical thought. Heavy lifting tends to create more muscle mass in men rather than in women. This is due to the fact that women have lesser content of testosterone than men. Therefore, women have to work twice as hard as men to develop the same amount of muscle strength. The more muscles a person’s body contains the more calories they are able to burn throughout the day, and the more capable they are to perform any task and activities that may come their way. Muscular strength and endurance are quite significant for several reasons. A combination of strength and endurance exercise program not only helps in increasing the ability of doing many activities that require strength such as lifting heavy boxes or chopping woods without getting tired, but also reduces the chances of getting any kind of injury. They also help in keeping and maintaining a healthy body weight. When muscles are enabled to sustain repeated contractions against a resistance for a prolonged period of time, their endurance is quite high. This is one of the major components of overall muscular fitness, along with muscular strength and power. 

Contraindications for Total Hip Arthroplasty

Prime movers are muscles that are primarily responsible for generating and controlling a specific movement. Most movements require the action of a number of muscles in synergy. Prime movers or agonists are directly responsible for producing a particular movement. Examples include the quadriceps and hamstrings in the leg. 

Synergist muscles perform fixation at the moveable joints. Their function is the same as agonist muscles’. In the biceps brachioradialis and brachialis are the synergist muscles. 

Agonists are the muscles that contract in a movement. Examples are the biceps. 

Antagonist muscles are the ones that relax during a movement while the agonist muscle is contracted. Examples include the triceps.  

Eccentric strengthening refers to the cumulative lengthening of a muscle when it is tensed and is contracted to control the movement which is performed by a force from outside. Example include calf muscles, that shorten while rising the toes but lengthens during the descent of legs. 

Repetition is defined as a complete movement of any activity. Activities that compel the muscles to move a lot harder than any other tasks tend to make them stronger than before. The more muscles are built, the more toned the muscle are. Examples include push-up exercises. 

Sets, in combination with reps are the terms used to refer to the number of times an exercise is being performed. Reps define the number of times a particular exercise is performed and sets define the number of cycles of reps that are being done.   

Circuit is a form of exercise training program that strengthens the muscles and increases their power of endurance as well. It uses various high intensity exercises to build muscles and make them resisting towards endurance. The resistance exercises are performed without any break in between them. 

When muscles fail to generate sufficient force to finish or deal with a certain workload after continuous repetitions of a specific exercise, especially after simultaneous weight lifting training, then the muscle failure occurs. After such a training session the neuromuscular system fails to respond anymore. 

Matrix training involves complete focus on the repetition movements, fully or partially, within sets, that boost the growth of muscles and increases muscle mass. This training method is responsible for activating and working out muscles that are not usually worked out in an effective way. 

Progressive overload refers to the fact that for building up muscle, gaining muscle mass, to acquire strength, to improve performance and to increase the ratio of all these, one must start to adapt to a tension that is much greater than what they have experienced earlier.   

Adaptation is the principle that defines the process by which human body gets accustomed to a certain kind of exercise or training program by continuous and thorough exposure to it. By adapting to the program, muscles tend to adapt to the stress and fitness will be increased. 

Recovery refers to the period that involves numerous post-exercise regimes, depending on the type and intensity of the physical activity one was performing. The duration of this recovery period is directly related to the length, as well as intensity of the exercise which exerts an essential role in maintaining a healthy training program.   

Exercises to Maintain Cardiopulmonary Function

Specificity refers to the principle that implies that in order to become skilled at any exercise one must keep on performing that activity. This makes the person more focussed and efficient, so that they can achieve their desired target because the body gains power as it is exercised. 

Endurance training refers to the activities that stimulates heart rate and respiratory rate and helps keeping the cardiovascular, respiratory and the entire circulatory systems healthy. Such exercises include jogging, swimming cycling and walking. Higher level of endurance also helps to withstand tiredness, fatigue, stress and pain.   

Resistance training involves working against a form of object or machinery equipment that constantly resists the movement. This kind of training method is used to increase the strength of an individual. Besides its ability to build up muscle strength, it can lead to overall fitness of a person. 

Flexibility training has a significant role in preventing any kind of injury, but is also one of the most undervalued training program. This training method includes stretching exercises that lengthen the muscles, such as yoga or Tai chi. It enables the the joints to move effectively through different range of motions.   

When someone else does the activity, it is termed as passive exercise. But when a person does the work entirely on their own, and put all the energy behind the movements themselves, that is known as active exercise. Although when a person does a work with the help of another, then it is termed as active assisted exercise. Active assisted exercises are mainly performed by patients who have muscle weakness and need the assistance of an external force such as a person, therapist, or machinery like weight and pulley circuit, in order to exert an action. Whereas resisted exercise includes dynamic and static muscle contractions, which are resisted by mechanical force. 

The physiological parameters that could be monitored when conducting an exercise program include heart rate, respiratory rate and total calories burned. 

It is truly important to work on the movement of the knees post a surgery. The client should be available for doing knee bending and straightening exercises which would keep the knee in motion. 

A client, who lives alone at home, must be directed to do exercises that he or she can do without any requiring any assistance. In the outpatients department I would make sure that the client is properly instructed regarding the fitness regime. 

The client who attends school and is in need of a chest physiotherapy, must be addressed to exercises including chest percussion, chest vibration, turning and deep breathing exercises. The sole purpose of this session would be to get more oxygen into the patient’s body. 

Dementia is a condition associated with a severe lack of cognition and thoughtfulness resulting in serious decline in a person’s ability to perform daily activities. The symptoms include loss of memory, lack of focus, inability to speak properly with using correct words, increasing confusion, depression and social withdrawal (Borson et al. 2013). 

The problems related to a person with dementia may involve their decreased ability to focus on the given instructions, their inability to express their mind and lastly sometimes their incontinence or inability to hold urine. 

Resting Night Splints for Plantar Fasciitis

The three strategies that could be used to work effectively with a person who is suffering from dementia include pelvic floor exercise, electrical stimulation and bio feedback. 

Four signs of hypoglycaemia includes excessive sweating, hunger, fatigue and tremor. 

If the person I am working with shows any signs of hypoglycaemia, then I would immediately stop the training and give them some drink and food with high content of sugar (glucose).

The patient might feel dizzy due to postural hypotension a type of condition developed from low blood pressure. The dizziness or light-headedness may last for a few minutes. 

I would make them lie down immediately after they feel dizzy and eventually their symptoms would disappear. Then i would make sure that they stay hydrated to improve the condition. 

Nociceptive pain is a type of chronic pain that is caused due to severe tissue damage and may be described as sharp, throbbing ache at the place of injury (Khayambashi et al. 2014). It lasts for a while. This is a type of sensation that occurs due to the response of sensory nervous system. 

Neuropathic pain is defined as the type of pain that involves multiple nerves. In this type of pain each affected nerve sends a pain signal to the brain which then relays the signal by expressing sensations of burn, stab, shoot or ache as an electric shock. 

Psychogenic pain is defined as the type of pain that is caused by various factors associated with the psychology of the individual. Factors such as depression, mental behaviour, anxiety or emotional behaviour are involved in psychogenic pain (Yarnitsky 2015). Examples include back pain and head ache. 

Idiopathic pain is referred to as the kind of pain that is chronic, means it lasts for several months, but has no underlying cause that can be identifiable by the doctors or therapists (Forssell et al. 2015). The origin of the pain is often not recognisable. It is quite common and disabling. 

While working with a person who is suffering from pain, a PT aide will need to do mostly therapeutic exercises which includes ultrasound, taping and electrical stimulation that will help with the joints and soft tissue mobilisation (Gilron, Jensen and Dickenson 2013). These kinds of treatments can reduce the pain immediately and help restore normal functions of joints. 

Informed consent is a voluntary agreement form that entails all the details and risks of a procedure. It is essential to be signed by the participants before they go through the procedure. 

In physiotherapy contraindication refers to a specific situation in which a procedure is not used due to its harmful effects to the patient. Example: ultrasound in cancer. Precaution is a situation where the patient is at risk of experiencing an adverse event, therefore, treatment should proceed with caution and involve lower intensity and reduced duration. 

Hydrotherapy refers to the use of an environment of water for therapeutic purposes. The buoyancy, turbulence and drag- such properties of water are important for use in this therapy (Mortimer, Privopoulos and Kumar 2014). Hydrotherapy helps in achieving the functional goal through these properties of water. Although its affectivity is not yet widely acknowledged it is gaining popularity among physiotherapists. It reduces pain and increases function in a cost-effective way. During the session, turbulence provides resistance which aids in the rehabilitation, strengthening, and controls the balance of the session in a variety of ways. Consequently, turbulence helps in improving the balance, mobility and functional ability. 

Pressure Areas and WHS Issues

While conducting hydrotherapy sessions the following precautions must be taken:

• The temperature of the water must be near body temperature
• The water must be clean, to eliminate chances of any infection
• Constant supervision is a prerequisite
• Patients must be taken care of if they have increased risk of drowning
• Patients with cardiac instability must be treated specially
• Keep head above water and look out for any respiratory distress 

Heat treatments can be used in lower back pain, shoulder pain, back pain and any chronic pain. Ice treatment can be used for treating sprained injuries of ankle or palm, in acute arthritis and gouty arthritis. 

Ice treatment works by decreasing the temperature of the affected area and improves circulation by increasing the pumping action of the blood vessels. Heat treatment, on the other hand, dilates the vessels and increases the flow of oxygen and nutrients to the affected area, thus helps to heal the damaged tissues. 

8 Things that were wrong with the given scenario are as follows:

• First the patient has peripheral neuropathy, for which ice treatment is more effective than heat treatment
• She has diabetes and along with the heat treatment she is at greater risk of developing blisters
• Although the heat pad for back pain was justified, the legs should not be wrapped with heated packs since they are more prone to numbness and blistering
• The patient is told to lie on the packs, which should not be done. The packs must be changed within few minutes and not kept continuously for very long time
• The patient is very old and has trouble with vision, therefore the nurse should not leave her there.
• The used packs should not be left in the pan-room.
• The packs must be disposed of in the proper way right after they have been used
• The nurse should not wait two weeks for the physiotherapist to return

For setting up an interferential treatment the safety measures I need to be aware of includes the lead wires which degrade with time, need to be replaced every six month. The self-adhesive electrodes if gets overused, can lead to patient discomfort or injury. 

The instrument should be cleaned by washing the coverings thoroughly after every use and then drying them. Also the electrodes should be kept clean, before every use. 

If any fault in the equipment occurs, I would ask for a specialist to take care of the machine and repair it. 

MASS – the amount of mass in an object, measured in kilograms.

FORCE – that which causes matter to change its velocity

SPEED – (velocity) - the measure of the rate of motion, (distance/time)

ACCELERATION – the rate of change of the velocity of a moving body

WORK – the transfer of energy from one physical system to another, especially the transfer of energy to a body by the application of a force that moves the body in the direction of the force. It is calculated as the product of the force and the distance through which the body moves and is expressed in joules.

ENERGY – the capacity of a physical system to do work.

POWER – the rate at which work is done, expressed as the amount of work per unit time and commonly measured in units such as the watt and horsepower.

STRENGTH – (physical) – the ability of a body to exert force using muscles.

MOMENTUM – a measure of the motion of a body equal to the product of its mass and velocity.

TORQUE – the tendency of a force to produce rotation of an object around an axis (or fulcrum, or pivot). Just as a force produces a pull or a push, a torque can be thought of as a twist.

FORCE ARM – the distance between fulcrum and points of force

RESISTANCE ARM – the resistance arm is the side of the lever (from the centre to the load) that carries the load.
AXIS OF ROTATION – the axis around which something rotates

PULLEY - pulleys are usually used in sets designed to reduce the amount of force needed to lift a load. 

1. Movement of the top of the foot (toes) away from the lower leg plantar flexion
2. Rotation of the hand so that the palm faces forwards supination

• Movement of the foot so that the sole faces towards outward eversion

1. Straightening or increasing the angle between a joint extension
2. Rotation of the foot so that the sole faces inwards inversion
3. Rotation of the hand so thatthe palm faces backwards pronation

• A part of the body that is more towards the middle plane medial
• A part of the anatomy that is more towards the attachment proximal

1. Moving a body part away from the midline of the body abduction
2. Bending or decreasing the angle between a joint flexion
3. Moving a body part towards the midline of the body adduction

• inward turning or movement of a body around its axis internal rotation 

The  deltoid  abducts the shoulder.

The  Gluteus Maximus extends the hip

The Sternocleidomastoid  rotates the head in the opposite direction

The Vastus Medialis Oblique  locks in knee extension in the last 20⁰ of movement

The  Gastrocnemius plantarflexes the ankle

The Tibialis Anterior dorsiflexes the ankle

The triceps extends the elbow

The Rectus Abdominus flexes the trunk

Most of the musculo-skeletal system, including many of the muscles and bones of the body act as levers. Levers are classified as first-, second-, and third-class systems. Third-class levers are most common in the body, while first-class levers are least common. In the case of humans, Third-class lever system amplifies the motion of the limited muscle contractions and thus allows for larger and faster movement of the extremities. Example includes the movement of the forearm. An example of a second class lever in the human body is Achilles tendon which pushes or pulls across the heel of the foot.

References

Borson, S., Frank, L., Bayley, P.J., Boustani, M., Dean, M., Lin, P.J., McCarten, J.R., Morris, J.C., Salmon, D.P., Schmitt, F.A. and Stefanacci, R.G., 2013. Improving dementia care: the role of screening and detection of cognitive impairment. Alzheimer's & Dementia, 9(2), pp.151-159.

Brandt, M., Jakobsen, M.D., Thorborg, K., Sundstrup, E., Jay, K. and Andersen, L.L., 2013. Perceived loading and muscle activity during hip strengthening exercises: comparison of elastic resistance and machine exercises. International journal of sports physical therapy, 8(6), p.811.

Forssell, H., Jääskeläinen, S., List, T., Svensson, P. and Baad?Hansen, L., 2015. An update on pathophysiological mechanisms related to idiopathic oro?facial pain conditions with implications for management. Journal of oral rehabilitation, 42(4), pp.300-322.

Gilron, I., Jensen, T.S. and Dickenson, A.H., 2013. Combination pharmacotherapy for management of chronic pain: from bench to bedside. The Lancet Neurology, 12(11), pp.1084-1095.

Khayambashi, K., Fallah, A., Movahedi, A., Bagwell, J. and Powers, C., 2014. Posterolateral hip muscle strengthening versus quadriceps strengthening for patellofemoral pain: a comparative control trial. Archives of physical medicine and rehabilitation, 95(5), pp.900-907.

MacKay-Lyons, M., McDonald, A., Matheson, J., Eskes, G. and Klus, M.A., 2013. Dual effects of body-weight supported treadmill training on cardiovascular fitness and walking ability early after stroke: a randomized controlled trial. Neurorehabilitation and neural repair, 27(7), pp.644-653.

Mortimer, R., Privopoulos, M. and Kumar, S., 2014. The effectiveness of hydrotherapy in the treatment of social and behavioral aspects of children with autism spectrum disorders: a systematic review. Journal of multidisciplinary healthcare, 7, p.93.

Yarnitsky, D., 2015. Role of endogenous pain modulation in chronic pain mechanisms and treatment. Pain, 156, pp.S24-S31.

The patient Mr Smith had a hip replacement surgery and is currently on his 4^th week post-operation. He is walking with a stick following the WBAT protocol,placing only as much weight as feels comfortable on his legs. Thera-Band hip abductor helps to strengthen the outside of the hip muscles. Also hip extension Pilates exercises such as Butt firming exercises including side kick front/back exercises will be suggested. To strengthen the VMO, I will suggest lateral heel drop exercises. For that a stepper and a few light ankle weights will be needed. Sit to stand exercises with a sturdy chair, are required to help ease processes like getting up from bed, couch or toilet, after surgery.

While supervising Mr Smith’s sessions I will strictly follow all the protocols. I will start him with the easy exercises like the sit and stand exercise, and gradually move towards the ones that requires more movement and activity. I may also alter the protocol according to his ability to follow up the processes. 

During the implementation of his exercise session, if Mr Smith experiences any discomfort I would ask for help from the physiotherapist allotted for Mr Smith. If he sprains any muscle or gets any soft tissue injury, I will seek prompt medical advice from the physiotherapist who will provide sound advice and encourage him to keep moving. 

During treatment I will keep asking Mr Smith both about his improvements and discomforts. If the exercises are being helpful for him, in his usual daily movements and if they are helping him to improve his posture. Also I would ask if he is having any trouble with the entire session. 

As the treatment nears completion I would ask Mr Smith to follow the exercise protocols more stringently. I will make sure he does all the allotted exercises for the duration that he is supposed to. I will chart out his improvement throughout the treatment procedures. I will look for any issues that he has had while in the treatment and make sure that he does not have any more inconveniences at home (MacKay-Lyons et al. 2013). After his treatment ends I will try to provide him as much assistance as possible so that he can continue exercising on his own at home. 

The followings are the exercises that I have been instructed to do with Mr Smith:

• Thera-Band hip abduction exercise: Thera-Band hip abductions strengthen the outside of the hip muscles, which help externally rotate and lift the legs out to the side. For doing this, I will wrap a Thera-Band around his both ankles and then keeping one leg static, I will lift up his other leg slowly and ask him to repeat this for 30 times, with each leg (Brandt et al.2013).
• Pilates exercises for hip extension: The set up for the side kick series is the same for all the pilates exercises. For effective outcome I will make sure that he is setting good alignment and maintaining it throughout the exercises.
• Lateral heel-drop exercises: This helps in strengthening the VMO and the lower back muscles so that Mr Smith can be able to perform lunges and squats properly without any pain in his knees. This is necessary to keep pushing off one knee from the steps, while the other knee will be contracted and controlling the descent during this exercise.
• Sit-to-stand exercise: The sit to stand exercise is necessary for the exact movement of the hips during regular change of stature while standing up from a chair or getting up from the bed. A sturdy chair is to be used making sure that it will not slide on the floor. 

I would document Mr Smith’s entire treatment session thoroughly, providing every minor detail like how many times he had done the exercises or for how long he has been able to do them and thus record his improvement day by day. I will also highlight any difficulties that he have had while in the treatment. 

If the client gets confused about the instructions given to him for home exercise, I will again describe him all the procedures in a lucid manner and provide him with a chart mentioned with all the details of the exercises. 

The hip joint is formed with the cup-shaped socket acetabulum which is laterally adjoined to the pelvis and with the head of the femur. The acetabulum is comprised of ilium, ischium and pubis. Extension of the hip-joint depends on this iliofemoral ligament.

The contraindications for the posterior approach at the hip, which is more commonly stated as the total hip arthroplasty (THA) approach. It does not has great complication and adheres to intraoperative potentials as well.

Activities that Mr Smith needs to avoid includes lifting heavy weights, walking for long hours, or even staying in the same posture for a long time. Also he must avoid crossing his legs at any time, or pull his knees towards his chest, lie on the side of his replaced hip and avoid leaning forward. .

Exercises to maintain Mrs Smith’s cardiopulmonary function will involve aerobic exercises, which will have a positive effect on her health outcomes. Exercises to strengthen her arms and legs will include calf raises which are simple yet effective, a few yoga exercises along with strength and aerobic exercises. Calf stretch, soleus stretch and achilles stretch exercises and foam roller exercise will be done to ensure her gastrocnemius muscle length is maintained on her injured leg. Overall the treatment will be based on stabilization, strengthening and motion exercises. 

I will have to consider her condition, especially her age and movement abilities. This can be made aware that her broken femur needs to be taken care of first. So that her instruction of bed rest will also be maintained. 

Resting night splint would be used for the purpose of stretching the plantar fascia ligament of her leg during sleep. It will help in relieving pain from the plantar fasciitis. 

This is an image of the type of splint that might be used for Mrs Smith:  

The indicators that the splint is causing a pressure area will be the skin or bones on the ankles which may get reddish and appear bruised. Even the temperature may change in that area too. 

Pillows or wedges can be used in the area of the pressure sores. 

The four main causes of pressure areas are as follows:

• Pressure: Pressure due to the splint can reduce blood flow to the feet, especially around the bony area of the ankle.
• Traction: Sheer force tractions can stretch the limbs while the patient is in inclined position, due to their anti-gravity posture.
• Friction: Continuous friction against the bed sheets or clothing can result in bedsores or pressure sores.
• Moisture: Excessive moisture tends to affect the outer layer of the skin, especially in older people. 

I would first get all the information about the patient. This would include the patient’s age, medical history, current medical condition and recommended treatments. Then I would allot a timing for the patient and inform the patient to come for treatment at that time. I would also make sure that the patient knows the details of the treatment that he/she is about to get through. I would give them a brief idea about the exercises I would need them to perform and ask for their cooperation. 

The WHS issues I need to be aware of include health and safety issues, manual handling, infection control, clearing hazards from the area around the bed, cleanliness and condition of equipment, identifying any foreseeable hazard, moving parts in machinery, toxic chemicals and manual handling tasks. 

I would warn the patient that before using crutches they must:

• Wear comfortable casual shoes
• Relax their arms and let them hang easily over the crutches
• Always adjust the crutches so that it separates the armpit from the crutch about two to four inches
• Also adjust the hand-grips on the crutches
• Lift their good leg up for the first step. 

The correct order to move up or down the stairs would be to place the crutch on the ground first and then lift the good leg up for the first step. 

If the client was having difficulty using the crutches I would help them adjusting the crutch length and help them to make the grip. I would also help them walk with it. 

If there is any fracture on the legs or the patient’s ankles cannot bear any weight on them then I would not suggest the use of crutches. 

24 hour management is a mobility management program that ensures effective hip management and postural management interventions through its entire implementation. This approach considers all the relevant postures an individual can be able to adopt over 24 hours period of any given day. The three core postural orientations are lying, sitting and standing.When body posture is unequal between sides it is called postural asymmetry which can affect pelvic rotation, obliquity, dislocated hips and rib distortions and result in compromised health of the patient.   

The allied health assistant would be responsible for the 24 hour postural management equipment such as standing frames, wheelchairs, sleep systems, wedges or even special seating arrangements. The allied health assistant must be responsible for handling all the equipment and keep them functioning so that those can be used for providing postural care to all the patients. The equipment must be flexible and sustainable. These equipment are mostly used to help children and adults in maintaining their movements. 

Any surgery or damage may cause fluid build-up in the lymphatic tissues and nodes. This condition is known as lymphedema. After such fluid generation in the lymphatic system doctors suggest lymphoedema massages to the patient which helps them get rid of that extra fluid from the nodes and reduces the swelling. There are two stages of lymphoedema massage: clearing and reabsorption. Clearing creates a vacuum due to massaging with gentle pressure so that the fluid filled area is prepared to bring in more fluid, creating a flushing effect. 

With the permission of the physio, I would advise the patient to do:

• Elbow flexion exercise: This allows movement of the upper arms which are close to the axillary lymph nodes. The more these muscles move, the more fluid can be pumped back into the lymph nodes and help reduce the oedema.
• Light exercise: Light movement exercises will help prepare the patient for everyday tasks and encourage lymph fluid drainage
• Wrapping: Wrapping the arms may also help in fluid drainage
• Compression garments: Such clothing helps reduce chances of lymphoedema. 

If lymphoedema worsens it will result in the permanent changes in the tissues such as thickening or scarring. Although these changes cannot be undone the side effects can be reduced significantly with effective management. The exercise plans would include flexibility and stretching along with aerobic exercises. 

The factors that make up a successful fitness plan includes frequency, intensity, time and type. These factors make up the FITT formula which ensures how often a person exercises, how hard they exercise and the duration of exercise and the types of exercises they do. The frequency is measured by the days of each week a person exercises. This FITT principle helps monitor the exercise program of a patient or any athlete. The two biggest issues people face while going through an exercise program are concentrating on training too hard and secondly not doing a variety of exercise programs.

While doing an exercise program, the person must know the difference between muscle strength and muscle endurance exercises. Endurance means the ability to perform a muscular action for a long period such as running marathon, while muscle strength refers to the capability of exerting maximal force against a resistance for a short period of time like lifting a heavy box. People must do a variety of both strength and endurance exercises.  Strength exercises build muscle and endurance exercises round the participant’s training. Because, everyday tasks require both strength and endurance. There is a myth that lifting heavy weights builds muscles. This is not a practical thought. Heavy lifting tends to create more muscle mass in men rather than in women. This is due to the fact that women have lesser content of testosterone than men. Therefore, women have to work twice as hard as men to develop the same amount of muscle strength. The more muscles a person’s body contains the more calories they are able to burn throughout the day, and the more capable they are to perform any task and activities that may come their way. Muscular strength and endurance are quite significant for several reasons. A combination of strength and endurance exercise program not only helps in increasing the ability of doing many activities that require strength such as lifting heavy boxes or chopping woods without getting tired, but also reduces the chances of getting any kind of injury. They also help in keeping and maintaining a healthy body weight. When muscles are enabled to sustain repeated contractions against a resistance for a prolonged period of time, their endurance is quite high. This is one of the major components of overall muscular fitness, along with muscular strength and power.  

Prime movers are muscles that are primarily responsible for generating and controlling a specific movement. Most movements require the action of a number of muscles in synergy. Prime movers or agonists are directly responsible for producing a particular movement. Examples include the quadriceps and hamstrings in the leg. 

Synergist muscles perform fixation at the moveable joints. Their function is the same as agonist muscles’. In the biceps brachioradialis and brachialis are the synergist muscles. 

Agonists are the muscles that contract in a movement. Examples are the biceps. 

Antagonist muscles are the ones that relax during a movement while the agonist muscle is contracted. Examples include the triceps. 

Eccentric strengthening refers to the cumulative lengthening of a muscle when it is tensed and is contracted to control the movement which is performed by a force from outside. Example include calf muscles, that shorten while rising the toes but lengthens during the descent of legs.  

Repetition is defined as a complete movement of any activity. Activities that compel the muscles to move a lot harder than any other tasks tend to make them stronger than before. The more muscles are built, the more toned the muscle are. Examples include push-up exercises. 

Sets, in combination with reps are the terms used to refer to the number of times an exercise is being performed. Reps define the number of times a particular exercise is performed and sets define the number of cycles of reps that are being done. 

Circuit is a form of exercise training program that strengthens the muscles and increases their power of endurance as well. It uses various high intensity exercises to build muscles and make them resisting towards endurance. The resistance exercises are performed without any break in between them. 

When muscles fail to generate sufficient force to finish or deal with a certain workload after continuous repetitions of a specific exercise, especially after simultaneous weight lifting training, then the muscle failure occurs. After such a training session the neuromuscular system fails to respond anymore. 

Matrix training involves complete focus on the repetition movements, fully or partially, within sets, that boost the growth of muscles and increases muscle mass. This training method is responsible for activating and working out muscles that are not usually worked out in an effective way. 

Progressive overload refers to the fact that for building up muscle, gaining muscle mass, to acquire strength, to improve performance and to increase the ratio of all these, one must start to adapt to a tension that is much greater than what they have experienced earlier.   

Adaptation is the principle that defines the process by which human body gets accustomed to a certain kind of exercise or training program by continuous and thorough exposure to it. By adapting to the program, muscles tend to adapt to the stress and fitness will be increased. 

Recovery refers to the period that involves numerous post-exercise regimes, depending on the type and intensity of the physical activity one was performing. The duration of this recovery period is directly related to the length, as well as intensity of the exercise which exerts an essential role in maintaining a healthy training program.   

Specificity refers to the principle that implies that in order to become skilled at any exercise one must keep on performing that activity. This makes the person more focussed and efficient, so that they can achieve their desired target because the body gains power as it is exercised. 

Endurance training refers to the activities that stimulates heart rate and respiratory rate and helps keeping the cardiovascular, respiratory and the entire circulatory systems healthy. Such exercises include jogging, swimming cycling and walking. Higher level of endurance also helps to withstand tiredness, fatigue, stress and pain. 

Resistance training involves working against a form of object or machinery equipment that constantly resists the movement. This kind of training method is used to increase the strength of an individual. Besides its ability to build up muscle strength, it can lead to overall fitness of a person. 

Flexibility training has a significant role in preventing any kind of injury, but is also one of the most undervalued training program. This training method includes stretching exercises that lengthen the muscles, such as yoga or Tai chi. It enables the the joints to move effectively through different range of motions.  

When someone else does the activity, it is termed as passive exercise. But when a person does the work entirely on their own, and put all the energy behind the movements themselves, that is known as active exercise. Although when a person does a work with the help of another, then it is termed as active assisted exercise. Active assisted exercises are mainly performed by patients who have muscle weakness and need the assistance of an external force such as a person, therapist, or machinery like weight and pulley circuit, in order to exert an action. Whereas resisted exercise includes dynamic and static muscle contractions, which are resisted by mechanical force.

The physiological parameters that could be monitored when conducting an exercise program include heart rate, respiratory rate and total calories burned.

It is truly important to work on the movement of the knees post a surgery. The client should be available for doing knee bending and straightening exercises which would keep the knee in motion.

A client, who lives alone at home, must be directed to do exercises that he or she can do without any requiring any assistance. In the outpatients department I would make sure that the client is properly instructed regarding the fitness regime.

The client who attends school and is in need of a chest physiotherapy, must be addressed to exercises including chest percussion, chest vibration, turning and deep breathing exercises. The sole purpose of this session would be to get more oxygen into the patient’s body.

Dementia is a condition associated with a severe lack of cognition and thoughtfulness resulting in serious decline in a person’s ability to perform daily activities. The symptoms include loss of memory, lack of focus, inability to speak properly with using correct words, increasing confusion, depression and social withdrawal (Borson et al. 2013).

The problems related to a person with dementia may involve their decreased ability to focus on the given instructions, their inability to express their mind and lastly sometimes their incontinence or inability to hold urine.

The three strategies that could be used to work effectively with a person who is suffering from dementia include pelvic floor exercise, electrical stimulation and bio feedback.

Four signs of hypoglycaemia includes excessive sweating, hunger, fatigue and tremor.

If the person I am working with shows any signs of hypoglycaemia, then I would immediately stop the training and give them some drink and food with high content of sugar (glucose).

The patient might feel dizzy due to postural hypotension a type of condition developed from low blood pressure. The dizziness or light-headedness may last for a few minutes.

I would make them lie down immediately after they feel dizzy and eventually their symptoms would disappear. Then i would make sure that they stay hydrated to improve the condition.

Nociceptive pain is a type of chronic pain that is caused due to severe tissue damage and may be described as sharp, throbbing ache at the place of injury (Khayambashi et al. 2014). It lasts for a while. This is a type of sensation that occurs due to the response of sensory nervous system.

Neuropathic pain is defined as the type of pain that involves multiple nerves. In this type of pain each affected nerve sends a pain signal to the brain which then relays the signal by expressing sensations of burn, stab, shoot or ache as an electric shock.

Psychogenic pain is defined as the type of pain that is caused by various factors associated with the psychology of the individual. Factors such as depression, mental behaviour, anxiety or emotional behaviour are involved in psychogenic pain (Yarnitsky 2015). Examples include back pain and head ache.

Idiopathic pain is referred to as the kind of pain that is chronic, means it lasts for several months, but has no underlying cause that can be identifiable by the doctors or therapists (Forssell et al. 2015). The origin of the pain is often not recognisable. It is quite common and disabling.

While working with a person who is suffering from pain, a PT aide will need to do mostly therapeutic exercises which includes ultrasound, taping and electrical stimulation that will help with the joints and soft tissue mobilisation (Gilron, Jensen and Dickenson 2013). These kinds of treatments can reduce the pain immediately and help restore normal functions of joints.

Informed consent is a voluntary agreement form that entails all the details and risks of a procedure. It is essential to be signed by the participants before they go through the procedure.

In physiotherapy contraindication refers to a specific situation in which a procedure is not used due to its harmful effects to the patient. Example: ultrasound in cancer. Precaution is a situation where the patient is at risk of experiencing an adverse event, therefore, treatment should proceed with caution and involve lower intensity and reduced duration.

Hydrotherapy refers to the use of an environment of water for therapeutic purposes. The buoyancy, turbulence and drag- such properties of water are important for use in this therapy (Mortimer, Privopoulos and Kumar 2014). Hydrotherapy helps in achieving the functional goal through these properties of water. Although its affectivity is not yet widely acknowledged it is gaining popularity among physiotherapists. It reduces pain and increases function in a cost-effective way. During the session, turbulence provides resistance which aids in the rehabilitation, strengthening, and controls the balance of the session in a variety of ways. Consequently, turbulence helps in improving the balance, mobility and functional ability.

While conducting hydrotherapy sessions the following precautions must be taken:

• The temperature of the water must be near body temperature
• The water must be clean, to eliminate chances of any infection
• Constant supervision is a prerequisite
• Patients must be taken care of if they have increased risk of drowning
• Patients with cardiac instability must be treated specially
• Keep head above water and look out for any respiratory distress

Heat treatments can be used in lower back pain, shoulder pain, back pain and any chronic pain. Ice treatment can be used for treating sprained injuries of ankle or palm, in acute arthritis and gouty arthritis.

Ice treatment works by decreasing the temperature of the affected area and improves circulation by increasing the pumping action of the blood vessels. Heat treatment, on the other hand, dilates the vessels and increases the flow of oxygen and nutrients to the affected area, thus helps to heal the damaged tissues.

8 Things that were wrong with the given scenario are as follows:

• First the patient has peripheral neuropathy, for which ice treatment is more effective than heat treatment
• She has diabetes and along with the heat treatment she is at greater risk of developing blisters
• Although the heat pad for back pain was justified, the legs should not be wrapped with heated packs since they are more prone to numbness and blistering
• The patient is told to lie on the packs, which should not be done. The packs must be changed within few minutes and not kept continuously for very long time
• The patient is very old and has trouble with vision, therefore the nurse should not leave her there.
• The used packs should not be left in the pan-room.
• The packs must be disposed of in the proper way right after they have been used
• The nurse should not wait two weeks for the physiotherapist to return

For setting up an interferential treatment the safety measures I need to be aware of includes the lead wires which degrade with time, need to be replaced every six month. The self-adhesive electrodes if gets overused, can lead to patient discomfort or injury.

The instrument should be cleaned by washing the coverings thoroughly after every use and then drying them. Also the electrodes should be kept clean, before every use.

If any fault in the equipment occurs, I would ask for a specialist to take care of the machine and repair it.

MASS – the amount of mass in an object, measured in kilograms.

FORCE – that which causes matter to change its velocity

SPEED – (velocity) - the measure of the rate of motion, (distance/time)

ACCELERATION – the rate of change of the velocity of a moving body

WORK – the transfer of energy from one physical system to another, especially the transfer of energy to a body by the application of a force that moves the body in the direction of the force. It is calculated as the product of the force and the distance through which the body moves and is expressed in joules.

ENERGY – the capacity of a physical system to do work.

POWER – the rate at which work is done, expressed as the amount of work per unit time and commonly measured in units such as the watt and horsepower.

STRENGTH – (physical) – the ability of a body to exert force using muscles.

MOMENTUM – a measure of the motion of a body equal to the product of its mass and velocity.

TORQUE – the tendency of a force to produce rotation of an object around an axis (or fulcrum, or pivot). Just as a force produces a pull or a push, a torque can be thought of as a twist.

FORCE ARM – the distance between fulcrum and points of force

RESISTANCE ARM – the resistance arm is the side of the lever (from the centre to the load) that carries the load.
AXIS OF ROTATION – the axis around which something rotates

PULLEY - pulleys are usually used in sets designed to reduce the amount of force needed to lift a load.

1. Movement of the top of the foot (toes) away from the lower leg plantar flexion
2. Rotation of the hand so that the palm faces forwards supination

• Movement of the foot so that the sole faces towards outward eversion

1. Straightening or increasing the angle between a joint extension
2. Rotation of the foot so that the sole faces inwards inversion
3. Rotation of the hand so thatthe palm faces backwards pronation

• A part of the body that is more towards the middle plane medial
• A part of the anatomy that is more towards the attachment proximal

1. Moving a body part away from the midline of the body abduction
2. Bending or decreasing the angle between a joint flexion
3. Moving a body part towards the midline of the body adduction

• inward turning or movement of a body around its axis internal rotation

The  deltoid  abducts the shoulder.

The  Gluteus Maximus extends the hip

The Sternocleidomastoid  rotates the head in the opposite direction

The Vastus Medialis Oblique  locks in knee extension in the last 20⁰ of movement

The  Gastrocnemius plantarflexes the ankle

The Tibialis Anterior dorsiflexes the ankle

The triceps extends the elbow

The Rectus Abdominus flexes the trunk

Most of the musculo-skeletal system, including many of the muscles and bones of the body act as levers. Levers are classified as first-, second-, and third-class systems. Third-class levers are most common in the body, while first-class levers are least common. In the case of humans, Third-class lever system amplifies the motion of the limited muscle contractions and thus allows for larger and faster movement of the extremities. Example includes the movement of the forearm. An example of a second class lever in the human body is Achilles tendon which pushes or pulls across the heel of the foot.

References

Borson, S., Frank, L., Bayley, P.J., Boustani, M., Dean, M., Lin, P.J., McCarten, J.R., Morris, J.C., Salmon, D.P., Schmitt, F.A. and Stefanacci, R.G., 2013. Improving dementia care: the role of screening and detection of cognitive impairment. Alzheimer's & Dementia, 9(2), pp.151-159.

Brandt, M., Jakobsen, M.D., Thorborg, K., Sundstrup, E., Jay, K. and Andersen, L.L., 2013. Perceived loading and muscle activity during hip strengthening exercises: comparison of elastic resistance and machine exercises. International journal of sports physical therapy, 8(6), p.811.

Forssell, H., Jääskeläinen, S., List, T., Svensson, P. and Baad?Hansen, L., 2015. An update on pathophysiological mechanisms related to idiopathic oro?facial pain conditions with implications for management. Journal of oral rehabilitation, 42(4), pp.300-322.

Gilron, I., Jensen, T.S. and Dickenson, A.H., 2013. Combination pharmacotherapy for management of chronic pain: from bench to bedside. The Lancet Neurology, 12(11), pp.1084-1095.

Khayambashi, K., Fallah, A., Movahedi, A., Bagwell, J. and Powers, C., 2014. Posterolateral hip muscle strengthening versus quadriceps strengthening for patellofemoral pain: a comparative control trial. Archives of physical medicine and rehabilitation, 95(5), pp.900-907.

MacKay-Lyons, M., McDonald, A., Matheson, J., Eskes, G. and Klus, M.A., 2013. Dual effects of body-weight supported treadmill training on cardiovascular fitness and walking ability early after stroke: a randomized controlled trial. Neurorehabilitation and neural repair, 27(7), pp.644-653.

Mortimer, R., Privopoulos, M. and Kumar, S., 2014. The effectiveness of hydrotherapy in the treatment of social and behavioral aspects of children with autism spectrum disorders: a systematic review. Journal of multidisciplinary healthcare, 7, p.93.

Yarnitsky, D., 2015. Role of endogenous pain modulation in chronic pain mechanisms and treatment. Pain, 156, pp.S24-S31.v