Physiotherapist's Pocketbook Essential Facts at Your Fingertips THIRD EDITION. THIRD

The Physiotherapist’s Pocketbook
Content Strategist: Poppy Garraway

Content Development Specialist: Veronika Watkins
Senior Project Manager: Kamatchi Madhavan
Designer: Brian Salisbury
The Physiotherapist’s
Pocketbook
Essential facts at your fingertips
THIRD EDITION
Karen Kenyon MRes, BSc (Hons),

BA (Hons), MCSP
Sussex Partnership NHS Foundation Trust, UK
Jonathan Kenyon MSc, PGCert (NMP),

BSc (Hons), MMACP, MCSP
Sussex Partnership NHS Foundation Trust, UK
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2018

© 2018 Elsevier Limited. All rights reserved.
First edition 2004

Second edition 2009
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ISBN 978-0-7020-5506-5
e-book 978-07020-7798-2
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A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data

A catalog record for this book is available from the Library of Congress
Notices
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds or
experiments described herein. Because of rapid advances in the medical sciences, in
particular, independent verification of diagnoses and drug dosages should be made.
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Last digit is the print number: 9 8 7 6 5 4 3 2 1

Preface ix
CONTENTS
CONTENTS
SECTION 1 Neuromusculoskeletal Anatomy 1
Musculoskeletal anatomy illustrations 2
Nerve pathways 29
Brachial plexus 45
Lumbosacral plexus 46
Peripheral nerve motor innervation 47
Muscle innervation chart 53
Muscles listed by function 59
Alphabetical listing of muscles 62
References and Further Reading 89
SECTION 2 Neuromusculoskeletal Assessment 91

Peripheral nerve sensory innervation 93
Dermatomes 95
Myotomes 96
Reflexes 96
Key features of upper and lower motor neurone lesions 98
The Medical Research Council scale for muscle power 99
Common locations for palpation of pulses 100
Common musculoskeletal tests 101
Common vascular tests 120
Neurological tests 121
Neurodynamic tests 124
Cranial nerves 132
Glossary of terms used to evaluate clinical tests 136
Common postures 138
Trigger points 145
Normal joint range of movement 157
Average range of segmental movement 159
Close packed positions and capsular patterns for selected
joints 161
Classification of ligament and muscle sprains 162
Windows of achievement for gross motor developmental
milestones 163
Joint hypermobility assessment 164
Complex regional pain syndrome 166
Distribution of referred pain 167 vv
Red flags 168
CONTENTS
Psychosocial yellow flags 170

Musculoskeletal assessment 174
References and further reading 176
SECTION 3 Neurology 179
Neuroanatomy illustrations 180
Signs and symptoms of cerebrovascular lesions 185
Signs and symptoms of injury to the lobes of the brain 189
Signs and symptoms of haemorrhage to other areas of the
brain 192
Functional implications of spinal cord injury 194
Glossary of neurological terms 197
Modified Ashworth scale 202
Neurological assessment 202
SECTION 4 Respiratory 207
Respiratory anatomy illustrations 208
Respiratory volumes and capacities 212
Chest X-rays 215
Auscultation 218
Abnormal breathing patterns 220
Percussion note 221
Sputum analysis 221
Clubbing 222
Capillary refill test 224
Differential diagnosis of chest pain 224
Arterial blood gas analysis 228
Respiratory failure 230
Nasal cannula 231
Common modes of mechanical ventilation 231
Cardiorespiratory monitoring 234
ECGs 237
Biochemical and haematological studies 244
Treatment techniques 251
vi Tracheostomies 257
Respiratory assessment 260
CONTENTS
SECTION 5 Pathology 265
Alphabetical listing of pathologies 266
Diagnostic imaging 306
SECTION 6 Pharmacology 311
Drug classes 312
Prescription abbreviations 354
Further Reading 355
SECTION 7 Appendices 357
APPENDIX 1 359
Laboratory values 359
Conversions and units 361
APPENDIX 2 365
Acronyms and Abbreviations 365
Prefixes and suffixes 378
APPENDIX 3 383
National Early Warning Score (NEWS2) for the acutely ill or
deteriorating patient 383
Clinical response to the NEWS2 trigger thresholds 385
APPENDIX 4 387
Adult Basic Life Support Sequence 387
Paediatric Basic Life Support Algorithm 388
Index 389
vii
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Eighteen years ago we were newly qualified physiotherapists
Preface
Preface
working in busy London teaching hospitals when we came up
with an idea that would later become The Physiotherapist’s
Pocketbook. Like hundreds of physiotherapists before us, we
prepared for clinical placements and rotations by compiling
pocket-sized reference notes that we could access quickly and
easily when we needed to check something. As we made our
way through our rotations these “crib sheets” slowly grew into
a compendium of key information covering all the core areas
of physiotherapy, forming the basis of the Pocketbook.
When we first wrote the Pocketbook we never thought we
would be writing the third edition 14 years later. We have been
overwhelmed by the favourable response to the previous two
editions and have endeavoured to ensure this new edition provides
a relevant and up-to-date resource that is as comprehensive and
useful as possible to all clinicians. It is beyond the scope and size
of the book to cover the more specialist areas of physiotherapy,
but we hope that its sections on anatomy, neuromusculoskeletal
examination, neurology, respiratory, pharmacology and pathology
and the supporting appendices are broad enough to fulfil its
main purpose – to provide quick and easy access to essential
clinical information during everyday clinical practice.
A project of this size would not be possible without the support
of our publishing team at Elsevier who have guided us throughout
the writing and production process. In addition, we have been
fortunate to work alongside a large number of colleagues,
students and academics who have provided invaluable encourage-
ment and advice. If we could name them all this would definitely
not be a pocket-sized book, but we would like to say a special
thanks to all our colleagues and friends at East Sussex Healthcare
NHS Trust, Brighton and Sussex Hospital NHS Trust and The
Sussex Musculoskeletal Partnership (Central and East).
ixix
This book is dedicated to our wonderful children,
DEDICATION
CONTENTS
Jack and Eva, who have had to put up with more
“physio stuff” than any child should ever be
subjected to.
xixi
Neuromusculoskeletal
anatomy
SECTION
Musculoskeletal anatomy illustrations 2
Nerve pathways 29
Brachial plexus 45
Lumbosacral plexus 46
Peripheral nerve motor innervation 47
Muscle innervation chart 53
1
Muscles listed by function 59
Alphabetical listing of muscles 62
Musculoskeletal anatomy illustrations
SECTION
Sagittal
1 Cephalic (median) plane
Neuromusculoskeletal anatomy
Coronal
Superior
(frontal) plane
Transverse
(horizontal) plane
Inferior
erior
Late
ral r Post
Anterio
Med
ial
Dorsum of hand
Palmar surface
of hand
Dorsum
of foot Proximal
Caudad
Distal
Plantar surface of foot
Figure 1.1 Anatomical position showing cardinal planes and
directional terminology.
2
SECTION
1
Longus colli, Rectus capitis Longus Rectus
upper oblique anterior capitis capitis
part lateralis
Splenius capitis
Longus colli
vertical part
Transverse
Longus colli process of atlas
lower oblique
part Levator scapulae
Scalenus medius Scalenus medius
Scalenus Scalenus
posterior posterior
1st rib
Serratus Scalenus
anterior anterior
Figure 1.2 Anterior and lateral muscles of the neck.
3
SECTION
1
Semispinalis Vertebral Splenius

capitis artery capitis
Ligamentum
nuchae
Rectus capitis
Obliquus
posterior
capitis
minor
superior
Rectus capitis
posterior major
Obliquus
Spinous capitis inferior
process Semispinalis
of C2 cervicis
Semispinalis Longissimus
capitis capitis
Splenius
capitis
Figure 1.3 Posterior and lateral muscles of the neck.
4
SECTION
Levatores
costarum
breves
Spinalis
thoracis
External Iliocostalis
intercostal thoracis
Quadratus Longissimus
lumborum thoracis
Transversus, origin Iliocostalis

from thoracolumbar lumborum
fascia
Quadratus
Lateral lumborum
intertransverse Erector
muscle spinae
Multifidus
Figure 1.4 Deep muscles of the back.
5
SECTION
1
Semispinalis capitis Splenis capitis
Levator scapulae
Sternocleidomastoid Rhomboideus
Trapezius minor
Supraspinatus
Infraspinatus
Deltoid Teres minor
Latissimus Teres major
dorsi
Thoracolumbar Rhomboideus
fascia major
Serratus anterior
Obliquus
internus Serratus
posterior inferior
Obliquus
externus Obliquus internus
Fascia covering
gluteus medius Erector spinae
Fascia covering
gluteus maximus Gluteus maximus
Figure 1.5 Superficial muscles of the back, neck and trunk.
6
SECTION
Latissimus dorsi Digitations of
serratus anterior
Rectus abdominis
Obliquus internus
Intercostal internus
of 10th intercostal
space
Figure 1.6 Muscles of the right side of the trunk.
7
SECTION
1
Sternocostal part of pectoralis major
Clavicular part of pectoralis major

Costo-abdominal part of
pectoralis major
Deltoid
Serratus anterior
Latissimus dorsi
Coracobrachialis
Biceps
Brachialis
Triceps
Triceps
(long head)
Triceps
(medial head)
Brachioradialis
Figure 1.7 Superficial muscles of the anterior chest and arm. Left
side.
8
SECTION
1
Pectoralis minor
Subscapularis
Subclavius
Long head of biceps
Short head of biceps
Coracobrachialis
Latissimus dorsi
Teres major
Serratus anterior
Biceps
Brachialis
Figure 1.8 Deep muscles of the anterior chest and upper arm. Left
side.
9
SECTION
1
Teres minor Supraspinatus Deltoid (cut)
Greater
tuberosity Spine of scapula
Humerus
Quadrangular
Long head space
of triceps Triangular
space
Lateral head
of triceps Infraspinatus
Teres major
Latissimus dorsi
Olecranon
Figure 1.9 Muscles of the posterior scapula and upper arm. Left side.
10
SECTION
Medial
intermuscular
1
septum of arm Bicipital
aponeurosis
Flexor carpi
radialis Pronator teres
Palmaris longus
Brachioradialis
Flexor carpi
ulnaris Flexor digitorum
Flexor digitorum superficialis,
superficialis radial head
Flexor pollicis
longus
Tendon to
ring finger Flexor pollicis
brevis
Pisiform
Abductor pollicis
brevis
Flexor retinaculum
Adductor pollicis,
Palmar brevis transverse head
Palmar
aponeurosis
Second lumbrical
Figure 1.10 Superficial flexors of the left forearm.
11
SECTION
Triceps
1 Fascia from triceps
Brachialis
Brachioradialis
Olecranon
Extensor carpi
Anconeus radialis brevis
Flexor carpi ulnaris

Extensor digitorum
Extensor carpi ulnaris
Extensor carpi
Extensor digiti minimi radialis longus
Abductor pollicis
longus
Extensor pollicis
Radius brevis
Extensor retinaculum Extensor pollicis
longus
Extensor digiti minimi Extensor carpi
Abductor digiti minimi radialis longus
and brevis
First dorsal
interosseus
Figure 1.11 Superficial extensors of the right forearm.
12
SECTION
Iliacus 1
Tensor
fasciae latae
Psoas major
Pectineus
Sartorius
Adductor longus
Rectus femoris
Gracilis
Vastus lateralis Adductor magnus
Iliotibial tract
Vastus medialis
Ligamentum
patellae Tendon of
sartorius
Figure 1.12 Superficial muscles of the anterior right thigh.
13
SECTION
1
Gluteus maximus
Piriformis
Gemellus superior
Gluteus minimus
Obturator
internus tendon
Sacrotuberous
Gluteus medius
ligament
Gemellus inferior
Gluteus maximus
Quadratus femoris
Adductor magnus
Vastus lateralis
Gracilis Biceps femoris,

long head
Semitendinosus Biceps femoris,
short head
Semimembranosus
Popliteus
Figure 1.13 Muscles of the posterior right thigh.
14
SECTION
1
Patellar ligament
(quadriceps
tendon)
Insertion of sartorius
Tibialis anterior Gastrocnemius

Peroneus longus
Extensor digitorum
longus
Soleus
Extensor hallucis
longus
Upper extensor Medial malleolus

retinaculum
Tibialis anterior
Lateral malleolus
Extensor digitorum
Lower extensor longus
retinaculum
Extensor digitorum Extensor hallucis
brevis brevis
Extensor hallucis
Peroneus tertius longus
Figure 1.14 Muscles of the anterior right leg.
15
SECTION
1 Gracilis
Semitendinosus
Semimembranosus Biceps femoris
Sartorius Plantaris
Gastrocnemius
medial head Gastrocnemius
lateral head
Soleus
Peroneus brevis
Flexor digitorum
longus
Peroneus longus
Calcanean tendon
Calcaneus
Figure 1.15 Superficial muscles of the posterior right calf.
16
SECTION
1
Semitendinosus
Biceps tendon
Sartorius Gastrocnemius
lateral head
Gracilis
Plantaris
Semimembranosus
Popliteus
Gastrocnemius Soleus
medial head
Peroneus longus
Tibial posterior
Flexor hallucis
longus
Flexor digitorum Peroneus longus

longus
Peroneus brevis
Flexor retinaculum Superior peroneal

retinaculum
Figure 1.16 Deep muscles of the posterior right calf.
17
SECTION
1
Semimembranosus
Vastus medialis
Sartorius Semitendinosus
Gracilis
Pes anserinus Gastrocnemius

(Goose’s foot) medial head
Tibia
Tibialis anterior
Soleus
Extensor retinacula Tibialis posterior

Flexor digitorum longus
Flexor hallucis longus
Tendo calcaneus
Calcaneus
Abductor hallucis Flexor retinaculum

Figure 1.17 Muscles of the medial right leg.
18
SECTION
Superior longitudinal band Ends of membrane
of cruciform ligament tectoria (cut)
Anterior
edge of
foramen
magnum
Transverse
Alar ligament process of atlas
Transverse Capsule of
ligament of atlas atlantoaxial
joint
Inferior longitudinal Posterior
band of cruciform longitudinal
ligament ligament
Figure 1.18 Ligaments of the atlanto-axial and atlanto-occipital joints.
19
20
1
Coracoclavicular ligament SECTION
Acromioclavicular Coracoacromial Trapezoid Conoid

ligament ligament ligament ligament
Acromion process
Clavicle
Subacromial bursa
Transverse scapular
Supraspinatus ligament
tendon (cut)
Coracoid process
Coracohumeral
ligament Coracobrachialis tendon
Transverse Biceps (short head)

humeral ligament
Superior glenohumeral
Tendon sheath on ligament
tendon of long head
Middle glenohumeral
of biceps brachi
ligament
Subscapularis (cut) Inferior glenohumeral
Biceps brachii ligament
(long head) tendon Joint Triceps brachii
Humerus capsule (long head)
Figure 1.19 Ligaments of the glenohumeral joint.
SECTION
1
Annular
Interosseous ligament
membrane of radius Medial epicondyle
Anterior
band Ulnar
collateral
Posterior ligament
band
Oblique band
Medial view
Tubercle on Olecranon
A coronoid process
Capitulum
Head of radius
Lateral
epicondyle
Trochlear
notch
Lateral view
Radial collateral Annular ligament
B ligament of radius
Figure 1.20 Ligaments of the elbow joint. A Medial. B Lateral.
21
SECTION
1
Ulnar collateral Palmar radio-
ligament carpal ligament
Pisiform Radial collateral

ligament
Pisohamate
ligament Flexor carpi
radialis tendon
Pisometacarpal
ligament Tubercle of
trapezium
Deep transverse
Head of capitate metacarpal
ligaments
Radius
Dorsal Ulna
radiocarpal
ligament Ulna collateral
ligament
Deep transverse Pisometacarpal
metacarpal ligament
ligaments
B
Figure 1.21 Ligaments of the wrist and hand joints. A Anterior.
B Posterior.
22
SECTION
Short posterior
1
sacroiliac ligament
Long posterior
sacroiliac ligament
Greater sciatic
foramen
Sacrotuberous
ligament
A Obturator foramen
Iliolumbar ligaments
Anterior sacroiliac
ligament
Sacrotuberous
ligament
Sacrospinous
ligament
B
Figure 1.22 Ligaments of the sacroiliac joint. A Posterior. B Anterior.
23
SECTION
1 Anterior inferior
iliac spine
Iliopubic
eminence
Iliofemoral
ligament
Pubofemoral
ligament
Ischiofemoral
ligament
Figure 1.23 Ligaments of the hip joint. A Anterior. B Posterior.
24
SECTION
Anterior cruciate Posterior cruciate
ligament ligament 1
Deep medial
Popliteus tendon collateral ligament
Lateral collateral Semimembranosus
ligament
Superficial medial
Biceps femoris
collateral ligament
tendon
Transverse
Iliotibial tract ligament
Patellar ligament Gracilis
Interosseous Semitendinosus
membrane
A Sartorius
Superficial
medial collateral
ligament Anterior cruciate
ligament
Ligament of
Wrisberg Lateral collateral
ligament
Medial meniscus Popliteus tendon
Posterior Lateral meniscus

cruciate Ligament of
ligament Humphrey
B
Figure 1.24 Ligaments of the knee joint. A Anterior. B Posterior.
25
SECTION
Posterior tibiotalar
1 ligament
Tibiocalcaneal
Tibionavicular
ligament
ligament
Posterior
talocalcanean
ligament
Plantar
calcaneonavicular
A (spring) ligament
Posterior Anterior tibiofibular

talofibular ligament
ligament
Anterior talofibular
Calcaneo- ligament
fibular
ligament
Lateral
B talocalcanean ligament
Figure 1.25 Ligaments of the ankle joint. A Medial. B Lateral.
26
SECTION
1
Distal
phalanx
Middle
phalanx
Proximal
phalanx
Head of
metacarpal
Base of
metacarpal
Body of
metacarpal
Capitate
Hamate
Pisiform First
metacarpal
Triquetral
Lunate Trapezoid
Ulna Trapezium
Radius Scaphoid
Figure 1.26 Bones of the right hand.
27
SECTION
1
Calcaneus
Talus
Navicular
Medial
Cuboid
Intermediate Cuneiform
V Lateral
IV
Proximal phalanx III Base of metatarsal
II
I Shaft of metatarsal
Middle phalanx
Metatarsal bones (I–V)
Sesamoid bone
Distal phalanx Head of metatarsal
Base of proximal
phalanx
Proximal phalanx
Distal phalanx
Figure 1.27 Bones of the right foot.
28
Nerve pathways
Brachial plexus SECTION
1
Brachial plexus
Lateral cord
Medial cord
Tendon of pectoralis minor
Axillary artery
Musculocutaneous nerve
Coracobrachialis
Median nerve
Pectoralis minor
Brachial artery
Biceps
Lateral
cutaneous Ulnar
nerve of arm nerve
Figure 1.28 Brachial plexus.
29
30
1
Suprascapular nerve SECTION
Supraspinatus
Upper limb
Teres minor
Infraspinatus Deltoid
Quadrangular space Axillary nerve
Lower triangular space
Radial nerve
Teres major
Long head
Triceps brachii Lateral head
Lateral intermuscular septum
Medial head
Brachialis (lateral part)
Triceps tendon Brachioradialis

Medial epicondyle
Figure 1.29 Axillary and radial nerves.
SECTION
1
Lateral cord Medial cord
Musculocutaneous
nerve Median nerve
Brachial artery
Ulnar nerve
Medial intermuscular septum
Radial nerve
Medial epicondyle
Figure 1.30 Musculocutaneous, median and ulnar nerves.
31
SECTION
1 Biceps
Brachialis
Ulnar nerve
Median nerve
Brachioradialis
Supinator
Superficial
radial nerve
Extensor carpi Ulnar artery

radialis longus
Ulnar nerve
Pronator teres Flexor carpi
deep and ulnaris
superficial heads
Flexor digitorum
profundus
Radial artery
Flexor pollicis
longus
Figure 1.31 Ulnar and median nerves.
32
SECTION
Radial nerve
1
Superficial branch
Posterior interosseous nerve
Anconeus
Brachioradialis
Extensor carpi radialis longus
Supinator
Extensor carpi radialis brevis
Abductor pollicis longus
Extensor indicis
Extensor pollicis brevis
Superficial branch
of radial nerve
Figure 1.32 Radial nerve.
33
34
1
SECTION
T12
Rib 12
Iliohypogastric nerve L1
Ilioinguinal nerve L2 Subcostal nerve
Genitofemoral nerve
L3
Lateral cutaneous Iliohypogastric nerve
Lumbosacral plexus
nerve of thigh L4 Genitofemoral nerve
L5 Ilioinguinal nerve
Obturator nerve
Lateral cutaneous
nerve of thigh
Femoral nerve Femoral nerve
Lumbosacral trunk
Inguinal ligament
Figure 1.33 Lumbosacral plexus.
SECTION
Gluteus
maximus
(turned back)
Gluteus minimus
Sciatic nerve Piriformis
Obturator internus
Quadratus
femoris
Semitendinosus
Tensor fasciae latae
Adductor
magnus
Biceps femoris
Popliteal artery
and vein Common peroneal
nerve
Tibial nerve
Figure 1.34 Sciatic nerve.
35
SECTION
1 Femoral nerve
Inguinal ligament
Posterior division
Pectineus
Medial cutaneous nerve of thigh
Adductor longus
Intermediate cutaneous nerve
Adductor magnus
Gracilis
Saphenous nerve
Vastus lateralis
Rectus femoris
Vastus medialis
Sartorius
Pes anserinus
Saphenous nerve
Figure 1.35 Femoral nerve.
36
SECTION
L1
1
L2
L3
L4
L5
Anterior branch Obturator externus

of obturator
nerve
Posterior branch
of obturator nerve
Adductor brevis Adductor longus
Gracilis
Adductor
magnus
Figure 1.36 Obturator nerve.
37
SECTION
1 Semimembranosus Biceps femoris

Tibial nerve
Semitendinosus
Gastrocnemius (cut)
Popliteal artery
Common peroneal
nerve
Sural nerve
Soleus (cut)
Flexor digitorum
longus Tibialis posterior
Flexor hallucis
longus
Peroneus longus
Sural nerve
Medial calcanean
nerve
Figure 1.37 Tibial and common peroneal nerves.
38
SECTION
Biceps femoris 1
Common peroneal Extensor digitorum
nerve longus
Head of fibula
Deep peroneal
Superficial nerve
peroneal nerve
Tibialis anterior
Peroneus longus
Extensor digitorum
longus
Extensor hallucis
longus
Peroneus brevis
Medial dorsal Lateral branch

cutaneous nerve of deep peroneal
Intermediate dorsal nerve
cutaneous nerve
Medial branch of
deep peroneal
nerve
Superior extensor
retinaculum
Inferior extensor
retinaculum (cut)
Figure 1.38 Superficial and deep peroneal nerves.
39
Axillary
Origin: Posterior cord (C5–C6)
SECTION Course:
1 • Descends laterally posterior to axillary artery and anterior

to subscapularis
• Passes posteriorly at lower border of subscapularis
together with posterior circumflex humeral vessels via

quadrangular space
• Divides: anterior and posterior branches. Anterior branch
winds around surgical neck of humerus and supplies
anterior deltoid. Posterior branch supplies teres minor and
posterior deltoid. Continues as upper lateral cutaneous
nerve of the arm after passing around deltoid.
Musculocutaneous nerve
Origin: Large terminal branch of lateral cord (C5–C7)
Course:
• Descends from lower border of pectoralis minor, lateral to
axillary artery
• Pierces coracobrachialis and descends diagonally between
biceps and brachialis to lateral side of arm
• Pierces deep fascia of antecubital fossa and continues as
lateral cutaneous nerve of the forearm
• Divides: anterior and posterior branches
Ulnar nerve
Origin: Large terminal branch of the medial cord (C7, C8,
T1)
Course:
• Descends medial to brachial artery and anterior to triceps
as far as the insertion of coracobrachialis
• Penetrates medial intermuscular septum and enters
posterior compartment to continue descent anterior to
medial head of triceps
• Passes posterior to medial epicondyle
• Enters anterior compartment between humeral and ulnar
40 heads of flexor carpi ulnaris
• Descends medially, anterior to flexor digitorum profundus
and posterior to flexor carpi ulnaris
• Pierces deep fascia lateral to flexor carpi ulnaris and SECTION
proximal to flexor retinaculum
• Passes anterior to flexor retinaculum and lateral to
pisiform
1
• Crosses hook of hamate
• Divides: superficial and deep branches
Median nerve
Origin: Lateral cord (C5–C7) and medial cord (C8, T1)
Course:
• The two cords unite anterior to the third part of the
axillary artery at the inferior margin of teres major
• Descends lateral to brachial artery and posterior to biceps
passing medial and anterior to brachial artery at the
insertion of coracobrachialis
• Crosses front of elbow lying on brachialis and deep to
bicipital aponeurosis
• Dives between the two heads of pronator teres and
descends through flexor digitorum superficialis and
profundus
• Becomes superficial near the wrist passing between the
tendons of flexor carpi radialis (lateral) and flexor
digitorum superficialis (medial), deep to palmaris longus
• Passes through the carpal tunnel
• Divides: medial and lateral branches
Radial nerve
Origin: Posterior cord (C5–C8, T1)
Course:
• Descends posterior to axillary and brachial arteries and
anterior to tendons of subscapularis, latissimus dorsi and
teres major
• Enters posterior compartment via lower triangular space
together with profunda brachii artery
• Descends obliquely towards lateral humerus along spiral
groove lying between lateral and medial head of triceps 41
• Enters anterior compartment via lateral intermuscular
septum to lie between brachialis and brachioradialis
SECTION
• Divides: superficial radial nerve (sensory) and posterior
interosseous nerve (motor) anterior to lateral epicondyle
1
Posterior interosseous nerve
Course:
• Enters posterior compartment between two heads of

supinator
• Descends between deep and superficial groups of
extensors
• Ends in flattened expansion on interosseous membrane
Sciatic nerve
Origin: Ventral rami (L4–S3)
Course:
• Forms anterior to piriformis. Leaves pelvis via greater
sciatic foramen below piriformis
• Enters gluteal region approximately midway between
ischial tuberosity and greater trochanter
• Descends on top of superior gemellus, obturator internus,
inferior gemellus, quadratus femoris and adductor
magnus and under gluteus maximus and long head of
biceps femoris
• Divides: tibial and common peroneal nerves at
approximately distal third of thigh
Tibial nerve
Origin: Medial terminal branch of sciatic nerve (L4–S3)
Course:
• Descends through popliteal fossa, passing laterally to
medially across the popliteal vessels
• Passes under tendinous arch of soleus
• Descends inferomedially under soleus and gastrocnemius,
lying on tibialis posterior and between flexor digitorum
42 longus and flexor hallucis longus
• Passes through tarsal tunnel (formed by the flexor
retinaculum, which extends from the medial malleolus to
the medial calcaneus) SECTION
• Enters plantar aspect of foot
• Divides: medial and lateral plantar nerves 1
Common peroneal nerve
Origin: Lateral terminal branch of sciatic nerve (L4–S3)
Course:
• Descends along lateral side of popliteal fossa between
biceps femoris and lateral head of gastrocnemius
• Passes anteriorly by winding around the neck of the
fibula, deep to peroneus longus
• Divides: superficial and deep peroneal nerves
Superficial peroneal nerve

Course:
• Descends between extensor digitorum longus and
peroneus longus, anterior to the fibula
• Pierces deep fascia halfway down the leg to become
superficial
• Divides: medial and intermediate dorsal cutaneous nerves
that enter foot via anterolateral aspect of ankle
Deep peroneal nerve

Course:
• Passes inferomedially into anterior compartment deep to
extensor digitorum longus
• Descends on interosseous membrane deep to extensor
hallucis longus and superior extensor retinaculum
• Crosses ankle deep to inferior extensor retinaculum and
tendon of extensor hallucis longus and medial to tibialis
anterior
• Enters dorsum of foot between tendons of extensor
hallucis and digitorum longus
• Divides: medial and lateral branches 43
Obturator nerve
Origin: Anterior divisions of L2–L4
SECTION Course:
1 •
•
Anterior divisions unite in psoas major
Emerges from psoas major on lateral aspect of sacrum
• Crosses sacroiliac joint and obturator internus
•
Enters obturator canal below superior pubic rami

• Exits obturator canal above obturator externus in medial
compartment of thigh
• Divides: anterior and posterior branches (separated by
obturator externus and adductor brevis)
Femoral nerve
Origin: Posterior divisions of L2–L4
Course:
• Posterior divisions unite in psoas major
• Emerges from lower lateral border of psoas major
• Descends in groove between psoas major and iliacus, deep
to iliac fossa
• Passes posterior to inguinal ligament and lateral to
femoral artery
• Enters femoral triangle
• Divides: number of anterior and posterior branches
44
Brachial plexus
Terminal nerves Cords Divisions Trunks Roots (anterior rami)
Lateral pectoral Dorsal scapular

Musculocutaneous nerve Suprascapular nerve
nerve
C5
Contribution to
Lateral Anterior Superior phrenic nerve
Ant
e C6
Axillary rior
Median
r Nerve to
terio
Pos subclavius
Posterior Posterior Middle C7

Superior
Radial subscapular nerve Po
ste
Thoracodorsal nerve rio
r
Inferior subscapular nerve
C8
Medial Anterior Inferior
Ulnar T1
Medial pectoral
Medial cutaneous nerve of arm
Medial cutaneous nerve of forearm Long thoracic nerve
Figure 1.39 Schematic of brachial plexus.
45
1
SECTION
Lumbosacral plexus
SECTION
L4
1
Superior L5
gluteal
nerve
S1
Inferior Sacral
gluteal plexus
nerve
S2
Common
peroneal
S3
nerve
Tibial nerve
S4
S5 Coccygeal
Sciatic nerve
plexus
Co
Posterior femoral
cutaneous nerve
Pudendal nerve Nerve to levator ani,

coccygeus and external
anal sphincter
Figure 1.40 Schematic of lumbosacral plexus.
46
Peripheral nerve motor innervation (from
O’Brien 2010, with permission)
AXILLARY NERVE SECTION
Deltoid 1
RADIAL NERVE
UPPER CUTANEOUS
NERVE OF THE ARM
Teres minor
Figure 1.41 Axillary nerve. (From O’Brien 2010, Aids to the Examination
of the Peripheral Nervous System, 5e, with permission.)
AXILLARY NERVE
Triceps, long head
Triceps, lateral head
Triceps, medial head
Brachioradialis
RADIAL NERVE
Supinator POSTERIOR
INTEROSSEOUS
Extensor carpi ulnaris NERVE
Extensor digitorum (deep branch)
Extensor digiti minimi
SUPERFICIAL
Extensor pollicis longus RADIAL NERVE
Extensor indicis
Figure 1.42 Radial nerve. (From O’Brien 2010, Aids to the

Examination of the Peripheral Nervous System, 5e, with permission.) 47
SECTION
1
MEDIAN NERVE
Pronator teres ANTERIOR

Flexor carpi radialis INTEROSSEOUS
NERVE
Palmaris longus
Flexor digitorum
Flexor digitorum
profundus I & II
superficialis
Flexor pollicis
longus
Palmar
Pronator quadratus branch
Motor
Abductor pollicis brevis Flexor Sensory
Flexor pollicis brevis retinaculum
Opponens pollicis
First lumbrical
Second lumbrical
Figure 1.43 Median nerve. (From O’Brien 2010, Aids to the

Examination of the Peripheral Nervous System, 5e, with permission.)
48
SECTION
ULNAR NERVE
Sensory MEDIAL
CUTANEOUS
Dorsal cutaneous
NERVE OF
branch
THE ARM
Palmar cutaneous
branch
Deep motor branch
Superficial terminal
branches Flexor digitorum
profundus III & IV
MEDIAL
CUTANEOUS
NERVE OF THE
FOREARM
Motor
Adductor pollicis Abductor
Flexor pollicis brevis Opponens digiti
1st Dorsal interosseus Flexor minimi
1st Palmar interosseus
Third lumbrical Fourth lumbrical
Figure 1.44 Ulnar nerve. (From O’Brien 2010, Aids to the

Examination of the Peripheral Nervous System, 5e, with permission.)
49
SECTION
1 Coracobrachialis
MUSCULOCUTANEOUS
NERVE
Biceps
Brachialis
Lateral cutaneous nerve

of the forearm
Figure 1.45 Musculocutaneous nerve. (From O’Brien 2010, Aids

to the Examination of the Peripheral Nervous System, 5e, with
permission.)
50
SECTION
1
Iliacus OBTURATOR
NERVE
FEMORAL NERVE
Cutaneous branch
LATERAL CUTANEOUS MEDIAL CUTANEOUS
NERVE OF THE THIGH NERVE OF THE THIGH
Quadriceps femoris Adductor brevis
Rectus femoris Adductor longus
Vastus lateralis
Vastus intermedius Gracilis
Vastus medialis
INTERMEDIATE CUTANEOUS Adductor magnus
NERVE OF THE THIGH
COMMON PERONEAL
NERVE DEEP PERONEAL
SUPERFICIAL PERONEAL NERVE
NERVE
Tibialis anterior
Peroneus longus
Extensor digitorum
Peroneus brevis longus
LATERAL CUTANEOUS Extensor hallucis longus

NERVE OF THE CALF
Peroneus tertius SAPHENOUS NERVE
Extensor digitorum brevis
Figure 1.46 Anterior aspect of lower limb. (From O’Brien 2010,

Aids to the Examination of the Peripheral Nervous System, 5e, with
permission.)
51
SECTION
1 SUPERIOR GLUTEAL
Gluteus medius
Gluteus minimus
NERVE Tensor fasciae latae
Piriformis
INFERIOR GLUTEAL
SCIATIC NERVE NERVE
Gluteus maximus
Semitendinosus
POSTERIOR
Semimembranosus CUTANEOUS NERVE
Adductor magnus OF THE THIGH
Biceps, long head
Biceps, short head
TIBIAL NERVE
COMMON PERONEAL
NERVE
Gastrocnemius,
medial head
Soleus Gastrocnemius,
lateral head
Tibialis posterior
Flexor digitorum longus Flexor hallucis longus
TIBIAL NERVE
SURAL NERVE
CALCANEAL BRANCH
MEDIAL PLANTAR NERVE to: LATERAL PLANTAR
Abductor hallucis NERVE to:
Flexor digitorum brevis Abductor digiti minimi
Flexor hallucis brevis Flexor digiti minimi
Cutaneous branches Adductor hallucis
Interossei
Cutaneous branches
Figure 1.47 Posterior aspect of lower limb. (From O’Brien 2010,
Aids to the Examination of the Peripheral Nervous System, 5e, with
permission.)
52
Muscle innervation chart (data from Standring
2015, with permission)
SECTION
Upper limb
C1 C2 C3 C4 C5 C6 C7 C8 T1
1
Inferior
and
superior
oblique
Rectus
capitis
posterior
major
and
minor
Rectus capitis
anterior and
lateralis
Longus capitis
Longissimus cervicis
Longus colli
Levator
scapulae
Trapezius
Diaphragm
Splenius capitis
Scalenus medius
Rhomboid
major
Rhomboid
minor
Scalenus anterior
Longissimus capitis
Biceps brachii
Brachioradialis
53
C1 C2 C3 C4 C5 C6 C7 C8 T1
Deltoid
SECTION Infraspinatus
1 Subscapularis
Supraspinatus
Teres minor
Brachialis
Coracobrachialis
Serratus anterior
Splenius cervicis
Teres major
Pectoralis major
Pectoralis minor
Extensor
carpi radialis
longus
Flexor carpi
radialis
Pronator
teres
Supinator
Anconeus
Latissimus dorsi
Scalenus posterior
Triceps brachii
Abductor
pollicis
longus
Extensor
carpi
radialis
brevis
Extensor
carpi
54 ulnaris
C1 C2 C3 C4 C5 C6 C7 C8 T1
Extensor
digiti SECTION
minimi
Extensor 1
digitorum
Extensor
indicis
Extensor
pollicis
brevis
Extensor
pollicis
longus
Flexor
pollicis
longus
Palmaris
longus
Pronator
quadratus
Abductor
digiti
minimi
Abductor
pollicis
brevis
Adductor
pollicis
Dorsal
interossei
Flexor
digiti
minimi
brevis
Flexor
digitorum
profundus 55
C1 C2 C3 C4 C5 C6 C7 C8 T1
Flexor
SECTION digitorum
superficialis
1 Flexor
pollicis
brevis
Lumbricals
Opponens
digiti
minimi
Opponens
pollicis
Palmar
interossei
Lower limb
T12 L1 L2 L3 L4 L5 S1 S2 S3
Quadratus lumborum
Psoas
minor
Psoas major
Adductor
brevis
Gracilis
Iliacus
Pectineus
Sartorius
Adductor
longus
Adductor
magnus
Rectus
femoris
56
T12 L1 L2 L3 L4 L5 S1 S2 S3
Vastus
intermedius SECTION
Vastus
lateralis 1
Vastus
medialis
Obturator
externus
Gluteus
medius
Gluteus
minimus
Popliteus
Tibialis
anterior
Tibialis
posterior
Tensor fascia
lata
Extensor
hallucis
longus
Extensor
digitorum brevis
Extensor
digitorum longus
Gemellus inferior
Gemellus
superior
Obturator
internus
Peroneus brevis
Peroneus longus
Peroneus tertius
Quadratus
femoris 57
T12 L1 L2 L3 L4 L5 S1 S2 S3
Biceps femoris
SECTION Flexor digitorum longus
1 Flexor hallucis longus

Gluteus maximus
Piriformis
Semimembranosus
Semitendinosus
Abductor
hallucis
Flexor
digitorum
brevis
Flexor hallucis
brevis
Gastrocnemius
Plantaris
Soleus
Abductor digiti
minimi
Flexor digitorum
accessorius
Adductor
hallucis
Dorsal
interossei
Flexor
digiti
minimi
brevis
Lumbricals
Plantar
interossei
58
Muscles listed by function
Head and neck SECTION
Flexors: longus colli, longus capitis, rectus capitis anterior,
sternocleidomastoid, scalenus anterior 1
Lateral flexors: erector spinae, rectus capitis lateralis, scalenes
(anterior, medius and posterior), splenius cervicis, splenius
capitis, trapezius, levator scapulae, sternocleidomastoid
Extensors: levator scapulae, splenius cervicis, trapezius,
splenius capitis, semispinalis, superior oblique,
sternocleidomastoid, erector spinae, rectus capitis
posterior major, rectus capitis posterior minor
Rotators: semispinalis, multifidus, scalenus anterior, splenius
cervicis, sternocleidomastoid, splenius capitis, rectus
capitis posterior major, inferior oblique
Trunk
Flexors: rectus abdominis, external oblique, internal oblique,
psoas minor, psoas major, iliacus
Rotators: multifidus, rotatores, semispinalis, internal oblique,
external oblique
Lateral flexors: quadratus lumborum, intertransversarii,
external oblique, internal oblique, erector spinae, multifidus
Extensors: quadratus lumborum, multifidus, semispinalis,
erector spinae, interspinales, rotatores
Scapula
Retractors: rhomboid minor, rhomboid major, trapezius,
levator scapulae
Protractors: serratus anterior, pectoralis minor
Elevators: trapezius, levator scapulae
Depressors: trapezius
Lateral rotators: trapezius, serratus anterior
Medial rotators: rhomboid major, rhomboid minor, pectoralis
minor, levator scapulae
Shoulder
Flexors: pectoralis major, deltoid (anterior fibres), biceps
brachii (long head), coracobrachialis 59
Extensors: latissimus dorsi, teres major, pectoralis major,
deltoid (posterior fibres), triceps (long head)
SECTION
Abductors: supraspinatus, deltoid (middle fibres)
Adductors: coracobrachialis, pectoralis major, latissimus dorsi,
1 teres major
Medial rotators: subscapularis, teres major, latissimus dorsi,
pectoralis major, deltoid (anterior fibres)
Lateral rotators: teres minor, infraspinatus, deltoid (posterior

fibres)
Elbow
Flexors: biceps brachii, brachialis, brachioradialis, pronator
teres
Extensors: triceps brachii, anconeus
Pronators: pronator teres, pronator quadratus
Supinators: supinator, biceps brachii
Wrist
Flexors: flexor carpi ulnaris, flexor carpi radialis, palmaris
longus, flexor digitorum superficialis, flexor digitorum
profundus, flexor pollicis longus
Extensors: extensor carpi radialis longus, extensor carpi
radialis brevis, extensor carpi ulnaris, extensor digitorum,
extensor indicis, extensor digiti minimi, extensor pollicis
longus, extensor pollicis brevis
Ulnar deviation: flexor carpi ulnaris, extensor carpi ulnaris
Radial deviation: flexor carpi radialis, extensor carpi radialis
longus, extensor carpi radialis brevis, abductor pollicis
longus, extensor pollicis longus, extensor pollicis
brevis
Fingers
Flexors: flexor digitorum superficialis, flexor digitorum
profundus, lumbricals, flexor digiti minimi brevis
Extensors: extensor digitorum, extensor digiti minimi,
extensor indicis, interossei, lumbricals
Abductors: dorsal interossei, abductor digiti minimi, opponens
digiti minimi
60 Adductors: palmar interossei
Thumb
Flexors: flexor pollicis longus, flexor pollicis brevis
Extensors: extensor pollicis longus, extensor pollicis brevis, SECTION
abductor pollicis longus
Abductors: abductor pollicis longus, abductor pollicis brevis 1
Adductors: adductor pollicis
Opposition: opponens pollicis
Hip
Flexors: psoas major, iliacus, rectus femoris, sartorius, pectineus
Extensors: gluteus maximus, semitendinosus,
semimembranosus, biceps femoris
Abductors: gluteus maximus, gluteus medius, gluteus
minimus, tensor fascia lata, sartorius, piriformis
Adductors: adductor magnus, adductor longus, adductor
brevis, gracilis, pectineus
Medial rotators: gluteus medius, gluteus minimus, tensor
fascia lata
Lateral rotators: gluteus maximus, piriformis, obturator
internus, gemellus superior, gemellus inferior, quadratus
femoris, obturator externus, sartorius
Knee
Flexors: semitendinosus, semimembranosus, biceps femoris,
gastrocnemius, gracilis, sartorius, plantaris, popliteus
Extensors: rectus femoris, vastus lateralis, vastus intermedius,
vastus medialis, tensor fascia lata
Tibial lateral rotators: biceps femoris
Tibial medial rotators: semitendinosus, semimembranosus,
gracilis, sartorius, popliteus
Ankle
Plantarflexors: gastrocnemius, soleus, plantaris, peroneus
longus, tibialis posterior, flexor digitorum longus, flexor
hallucis longus, peroneus brevis
Dorsiflexors: tibialis anterior, extensor digitorum longus,
extensor hallucis longus, peroneus tertius
Invertors: tibialis anterior, tibialis posterior
Evertors: peroneus longus, peroneus tertius, peroneus brevis 61
Toes
Flexors: flexor digitorum longus, flexor digitorum accessorius,
SECTION flexor digitorum brevis, flexor hallucis longus, flexor
1 hallucis brevis, flexor digiti minimi brevis, interossei,

lumbricals, abductor hallucis
Extensors: extensor hallucis longus, extensor digitorum
longus, extensor digitorum brevis, lumbricals, interossei
Abductors: abductor hallucis, abductor digiti minimi, dorsal

interossei
Adductors: adductor hallucis, plantar interossei
Alphabetical listing of muscles

Abductor digiti minimi (foot)
Action: abducts fifth toe
Origin: calcaneal tuberosity, plantar aponeurosis,
intermuscular septum
Insertion: lateral side of base of proximal phalanx of fifth toe
Nerve: lateral plantar nerve (S1–S3)
Abductor digiti minimi (hand)

Action: abducts little finger
Origin: pisiform, tendon of flexor carpi ulnaris, pisohamate
ligament
Insertion: ulnar side of base of proximal phalanx of little
finger
Nerve: ulnar nerve (C8, T1)
Abductor hallucis
Action: abducts and flexes great toe
Origin: flexor retinaculum, calcaneal tuberosity, plantar
aponeurosis, intermuscular septum
Insertion: medial side of base of proximal phalanx of great
toe
Nerve: medial plantar nerve (S1, S2)
Abductor pollicis brevis

62 Action: abducts thumb
Origin: flexor retinaculum, tubercles of scaphoid and
trapezium, tendon of abductor pollicis longus
Insertion: radial side of base of proximal phalanx of thumb SECTION
Nerve: median nerve (C8, T1)

1
Action: abducts and extends thumb, abducts wrist
Origin: upper part of posterior surface of ulna, middle third of
posterior surface of radius, interosseous membrane
Insertion: radial side of first metacarpal base, trapezium
Nerve: posterior interosseous nerve (C7, C8)
Adductor brevis
Action: adducts hip
Origin: external aspect of body and inferior ramus of pubis
Insertion: upper half of linea aspera
Nerve: obturator nerve (L2, L3)
Adductor hallucis
Action: adducts great toe
Origin: oblique head – bases of second to fourth metatarsal,
sheath of peroneus longus tendon; transverse head –
plantar metatarsophalangeal ligaments of lateral three
toes
Insertion: lateral side of base of proximal phalanx of great toe
Nerve: lateral plantar nerve (S2, S3)
Adductor longus
Action: adducts thigh
Origin: front of pubis
Insertion: middle third of linea aspera
Nerve: anterior division of obturator nerve (L2–L4)
Adductor magnus
Action: adducts thigh
Origin: inferior ramus of pubis, conjoined ischial ramus,
inferolateral aspect of ischial tuberosity
Insertion: linea aspera, proximal part of medial supracondylar
line 63
Nerve: obturator nerve and tibial division of sciatic nerve
(L2–L4)
SECTION
Adductor pollicis
1 Action: adducts thumb
Origin: oblique head – palmar ligaments of carpus, flexor
carpi radialis tendon, base of second to fourth
metacarpals, capitate; transverse head – palmar surface of

third metacarpal
Insertion: base of proximal phalanx of thumb
Anconeus
Action: extends elbow
Origin: posterior surface of lateral epicondyle of humerus
Insertion: lateral surface of olecranon, upper quarter of
posterior surface of ulna
Nerve: radial nerve (C6–C8)
Biceps brachii
Action: flexes shoulder and elbow, supinates forearm
Origin: long head – supraglenoid tubercle of scapula and
glenoid labrum; short head – apex of coracoid process
Insertion: posterior part of radial tuberosity, bicipital
aponeurosis into deep fascia over common flexor
origin
Nerve: musculocutaneous nerve (C5, C6)
Biceps femoris
Action: flexes knee and extends hip, laterally rotates tibia on
femur
Origin: long head – ischial tuberosity, sacrotuberous ligament;
short head – lower half of lateral lip of linea aspera,
lateral supracondylar line of femur, lateral intermuscular
septum
Insertion: head of fibula, lateral tibial condyle
Nerve: sciatic nerve (L5–S2). Long head – tibial division; short
64 head – common peroneal division
Brachialis
Action: flexes elbow
Origin: lower half of anterior surface of humerus, SECTION
intermuscular septum
Insertion: coronoid process and tuberosity of ulna 1
Nerve: musculocutaneous nerve (C5, C6), radial nerve (C7)
Brachioradialis
Action: flexes elbow
Origin: upper two-thirds of lateral supracondylar ridge of
humerus, lateral intermuscular septum
Insertion: lateral side of radius above styloid process
Nerve: radial nerve (C5, C6)
Coracobrachialis
Action: adducts shoulder and acts as weak flexor
Origin: apex of coracoid process
Insertion: midway along medial border of humerus
Nerve: musculocutaneous nerve (C5–C7)
Deltoid
Action: anterior fibres – flex and medially rotate shoulder;
middle fibres – abduct shoulder; posterior fibres – extend
and laterally rotate shoulder
Origin: anterior fibres – anterior border of lateral third of
clavicle; middle fibres – lateral margin of acromion
process; posterior fibres – lower edge of crest of spine of
scapula
Insertion: deltoid tuberosity of humerus
Nerve: axillary nerve (C5, C6)
Diaphragm
Action: draws central tendon inferiorly. Changes volume and
pressure of thoracic and abdominal cavities
Origin: posterior surface of xiphoid process, lower six costal
cartilages and adjoining ribs on each side, medial and
lateral arcuate ligaments, anterolateral aspect of bodies of
lumbar vertebrae 65
Insertion: central tendon
Nerve: phrenic nerves (C3–C5)
SECTION Dorsal interossei (foot)
1 Action: abducts toes, flexes metatarsophalangeal joints
Origin: proximal half of sides of adjacent metatarsals
Insertion: bases of proximal phalanges and dorsal digital
expansion (first attaches medially to second toe; second,

third and fourth attach laterally to second, third and
fourth toes, respectively)
Dorsal interossei (hand)

Action: abducts index, middle and ring fingers, flexes
metacarpophalangeal joints and extends interphalangeal
joints
Origin: adjacent sides of two metacarpal bones (four
bipennate muscles)
Insertion: bases of proximal phalanges and dorsal digital
expansions (first attaches laterally to index finger; second
and third attach to both sides of middle finger; fourth
attaches medially to ring finger)
Erector spinae
See iliocostalis, longissimus and spinalis

Action: extends and abducts wrist
Origin: lateral epicondyle via common extensor tendon
Insertion: posterior surface of base of third metacarpal
Nerve: posterior interosseous branch of radial nerve (C7, C8)

Action: extends and abducts wrist
Origin: lower third of lateral supracondylar ridge of humerus,
intermuscular septa
Insertion: posterior surface of base of second metacarpal
66 Nerve: radial nerve (C6, C7)
Action: extends and adducts wrist
Origin: lateral epicondyle via common extensor tendon SECTION
Insertion: medial side of fifth metacarpal base
Nerve: posterior interosseous nerve (C7, C8) 1
Extensor digiti minimi
Action: extends fifth digit and wrist
Origin: lateral epicondyle via common extensor tendon,
intermuscular septa
Insertion: dorsal digital expansion of fifth digit
Extensor digitorum
Action: extends fingers and wrist
Origin: lateral epicondyle via common extensor tendon,
intermuscular septa
Insertion: lateral and dorsal surfaces of second to fifth digits
Nerve: posterior interosseous branch of radial nerve (C7, C8)
Extensor digitorum brevis
Action: extends great toe and adjacent three toes
Origin: superolateral surface of calcaneus, inferior extensor
retinaculum, interosseous talocalcaneal ligament
Insertion: base of proximal phalanx of great toe, lateral side of
dorsal hood of adjacent three toes
Nerve: deep peroneal nerve (L5, S1)
Extensor digitorum longus

Action: extends lateral four toes, ankle dorsiflexor
Origin: upper three-quarters of medial surface of fibula,
interosseous membrane, lateral tibial condyle
Insertion: middle and distal phalanges of four lateral toes
Extensor hallucis longus
Action: extends great toe, ankle dorsiflexor
Origin: middle half of medial surface of fibula, interosseous
membrane 67
Insertion: base of distal phalanx of great toe
Nerve: deep peroneal nerve (L5)
SECTION Extensor indicis
1 Action: extends index finger and wrist
Origin: lower part of posterior surface of ulna, interosseous
membrane
Insertion: dorsal digital expansion on back of proximal

phalanx of index finger

Action: extends thumb and wrist, abducts wrist
Origin: posterior surface of radius, interosseous membrane
Insertion: dorsolateral base of proximal phalanx of
thumb
Extensor pollicis longus

Action: extends thumb and wrist, abducts wrist
Origin: middle third of posterior surface of ulna, interosseous
membrane
Insertion: dorsal surface of distal phalanx of thumb
External oblique
Action: flexes, laterally flexes and rotates trunk
Origin: outer borders of lower eight ribs and their costal
cartilages
Insertion: outer lip of anterior two-thirds of iliac crest,
abdominal aponeurosis to linea alba stretching from
xiphoid process to symphysis pubis
Nerve: ventral rami of lower six thoracic nerves (T7–T12)
Flexor carpi radialis

Action: flexes and abducts wrist
Origin: medial epicondyle via common flexor tendon
Insertion: front of base of second and third
68 Nerve: median (C6, C7)
Action: flexes and adducts wrist
Origin: humeral head – medial epicondyle via common flexor SECTION
tendon; ulnar head – medial border of olecranon and
upper two-thirds of border of ulna 1
Insertion: pisiform, hook of hamate and base of fifth
metacarpal
Nerve: ulnar nerve (C7–T1)
Flexor digiti minimi brevis (foot)

Action: flexes fifth metatarsophalangeal joint, supports lateral
longitudinal arch
Origin: plantar aspect of base of fifth metatarsal, sheath of
peroneus longus tendon
Insertion: lateral side of base of proximal phalanx of fifth
toe
Flexor digiti minimi brevis (hand)

Action: flexes little finger
Origin: hook of hamate, flexor retinaculum
Insertion: ulnar side of base of proximal phalanx of little
finger
Flexor digitorum accessorius

Action: flexes distal phalanges of lateral four toes
Origin: medial head – medial tubercle of calcaneus; lateral
head – lateral tubercle of calcaneus and long plantar
ligament
Insertion: flexor digitorum longus tendon
Nerve: lateral plantar nerve (S1–S3)
Flexor digitorum brevis

Action: flexes proximal interphalangeal joints and
metatarsophalangeal joints of lateral four toes
Origin: calcaneal tuberosity, plantar aponeurosis,
intermuscular septa 69
Insertion: tendons divide and attach to both sides of base of
middle phalanges of second to fifth toes
SECTION
Nerve: medial plantar nerve (S1, S2)
1 Flexor digitorum longus

Action: flexes lateral four toes, plantarflexes ankle
Origin: medial part of posterior surface of tibia, deep
transverse fascia
Insertion: plantar aspect of base of distal phalanges of second
to fifth toes
Nerve: tibial nerve (L5–S2)
Flexor digitorum profundus

Action: flexes fingers and wrist
Origin: medial side of coronoid process of ulna, upper
three-quarters of anterior and medial surfaces of ulna,
interosseous membrane
Insertion: base of palmar surface of distal phalanx of second
to fifth digits
Nerve: medial part – ulnar nerve (C8, T1); lateral part –
anterior interosseous branch of median nerve (C8, T1)
Flexor digitorum superficialis

Action: flexes fingers and wrist
Origin: humeroulnar head – medial epicondyle via common
flexor tendon, medial part of coronoid process of ulna,
ulnar collateral ligament, intermuscular septa; radial head
– upper two-thirds of anterior border of radius
Insertion: tendons divide and insert into sides of shaft of
middle phalanx of second to fifth digits
Nerve: median (C8, T1)
Flexor hallucis brevis

Action: flexes metatarsophalangeal joint of great toe
Origin: medial side of plantar surface of cuboid, lateral
cuneiform
Insertion: medial and lateral side of base of proximal phalanx
of great toe
70 Nerve: medial plantar nerve (S1, S2)
Flexor hallucis longus
Action: flexes great toe, plantarflexes ankle
Origin: lower two-thirds of posterior surface of fibula, SECTION
interosseous membrane, intermuscular septum
Insertion: plantar surface of base of distal phalanx of great toe 1
Flexor pollicis brevis
Action: flexes metacarpophalangeal joint of thumb
Origin: flexor retinaculum, tubercle of trapezium, capitate,
trapezoid
Insertion: base of proximal phalanx of thumb
Nerve: median nerve (C8–T1). Sometimes also supplied by
ulnar nerve (C8–T1)
Flexor pollicis longus

Action: flexes thumb and wrist
Origin: anterior surface of radius, interosseous membrane
Insertion: palmar surface of distal phalanx of thumb
Nerve: anterior interosseous branch of median nerve (C7, C8)
Gastrocnemius
Action: plantarflexes ankle, flexes knee
Origin: medial head – posterior part of medial femoral condyle;
lateral head – lateral surface of lateral femoral condyle
Insertion: posterior surface of calcaneus
Nerve: tibial nerve (S1, S2)
Gemellus inferior
Action: laterally rotates hip
Origin: upper part of ischial tuberosity
Insertion: with obturator internus tendon into medial surface
of greater trochanter
Nerve: nerve to quadratus femoris (L5, S1)
Gemellus superior
Origin: gluteal surface of ischial spine 71
Insertion: with obturator internus tendon into medial surface
of greater trochanter
SECTION
Nerve: nerve to obturator internus (L5, S1)
1 Gluteus maximus
Action: extends, laterally rotates and abducts hip
Origin: posterior gluteal line of ilium, posterior border of ilium
and adjacent part of iliac crest, aponeurosis of erector

spinae, posterior aspect of sacrum, side of coccyx,
sacrotuberous ligament, gluteal aponeurosis
Insertion: iliotibial tract of fascia lata, gluteal tuberosity of
femur
Nerve: inferior gluteal nerve (L5–S2)
Gluteus medius
Action: abducts and medially rotates hip
Origin: gluteal surface of ilium between posterior and anterior
gluteal lines
Insertion: superolateral side of greater trochanter
Nerve: superior gluteal nerve (L4–S1)
Gluteus minimus
Action: abducts and medially rotates hip
Origin: gluteal surface of ilium between anterior and inferior
gluteal lines
Insertion: anterolateral ridge on greater trochanter
Gracilis
Action: flexes knee, adducts hip, medially rotates tibia on femur
Origin: lower half of body and inferior ramus of pubis,
adjacent ischial ramus
Insertion: upper part of medial surface of tibia
Nerve: obturator nerve (L2, L3)
Iliacus
Action: flexes hip and trunk
Origin: superior two-thirds of iliac fossa, inner lip of iliac crest,
72 ala of sacrum, anterior sacroiliac and iliolumbar ligaments
Insertion: blends with insertion of psoas major into lesser
trochanter
Nerve: femoral nerve (L2, L3) SECTION
Iliocostalis cervicis
Action: extends and laterally flexes vertebral column
1
Origin: angles of third to sixth ribs
Insertion: posterior tubercles of transverse processes of C4 to
C6
Nerve: dorsal rami
Iliocostalis lumborum
Origin: medial and lateral sacral crests, spines of T11, T12
and lumbar vertebrae and their supraspinous ligaments,
medial part of iliac crest
Insertion: angles of lower six or seven ribs
Nerve: dorsal rami
Iliocostalis thoracis
Origin: angles of lower six ribs
Insertion: angles of upper six ribs, transverse process of
C7
Nerve: dorsal rami
Inferior oblique
Action: rotates atlas and head
Origin: lamina of axis
Insertion: transverse process of atlas
Nerve: dorsal ramus (C1)
Infraspinatus
Action: laterally rotates shoulder
Origin: medial two-thirds of infraspinous fossa and
infraspinous fascia
Insertion: middle facet on greater tubercle of humerus,
posterior aspect of capsule of shoulder joint
Nerve: suprascapular nerve (C5, C6) 73
Intercostales externi
Action: elevate rib below toward rib above to increase thoracic
SECTION cavity volume for inspiration
1 Origin: lower border of rib above

Insertion: upper border of rib below
Nerve: intercostal nerves
Intercostales interni
Action: draw ribs downward to decrease thoracic cavity
volume for expiration
Origin: lower border of costal cartilage and costal groove of
rib above
Insertion: upper border of rib below
Nerve: intercostal nerves
Internal oblique
Action: flexes, laterally flexes and rotates trunk
Origin: lateral two-thirds of inguinal ligament, anterior
two-thirds of intermediate line of iliac crest,
thoracolumbar fascia
Insertion: lower four ribs and their cartilages, crest of pubis,
abdominal aponeurosis to linea alba
Nerve: ventral rami of lower six thoracic nerves, first lumbar
nerve
Interspinales
Action: extend and stabilize vertebral column
Origin and insertion: extend between adjacent spinous
processes (best developed in cervical and lumbar regions
– sometimes absent in thoracic)
Nerve: dorsal rami of spinal nerves
Intertransversarii
Action: laterally flex lumbar and cervical spine, stabilize
vertebral column
Origin: transverse processes of cervical and lumbar vertebrae
Insertion: transverse process of vertebra superior to origin
74 Nerve: ventral and dorsal rami of spinal nerves
Latissimus dorsi
Action: extends, adducts and medially rotates shoulder
Origin: spinous processes of lower six thoracic and all SECTION
lumbar and sacral vertebrae, intervening supra- and
interspinous ligaments, outer lip of iliac crest, outer 1
surfaces of lower three or four ribs, inferior angle of
scapula
Insertion: intertubercular sulcus of humerus
Nerve: thoracodorsal nerve (C6–C8)
Levator scapulae
Action: elevates, medially rotates and retracts scapula, extends
and laterally flexes neck
Origin: transverse processes of C1–C3/4
Insertion: medial border of scapula between superior angle
and base of spine
Nerve: ventral rami (C3, C4), dorsal scapular nerve (C5)
Longissimus capitis
Action: extends, laterally flexes and rotates head
Origin: transverse processes of T1–T4/5, articular processes
of C4/5–C7
Insertion: posterior aspect of mastoid process
Nerve: dorsal rami
Longissimus cervicis
Origin: transverse processes of T1–T4/5
Insertion: transverse processes of C2–C6
Nerve: dorsal rami
Longissimus thoracis
Origin: transverse and accessory processes of lumbar
vertebrae and thoracolumbar fascia
Insertion: transverse processes of T1–T12 and lower nine or
ten ribs
Nerve: dorsal rami 75
Longus capitis
Action: flexes neck
SECTION Origin: occipital bone
1 Insertion: anterior tubercles of transverse processes of C3–C6

Nerve: anterior primary rami (C1–C3)
Longus colli
Action: flexes neck

Origin: inferior oblique part – front of bodies of T1–T2/3;
vertical intermediate part – front of bodies of T1–T3 and
C5–C7; superior oblique part – anterior tubercles of
transverse processes of C3–C5
Insertion: inferior oblique part – anterior tubercles of
transverse processes of C5 and C6; vertical intermediate
part – front of bodies of C2–C4; superior oblique part –
anterior tubercle of atlas
Nerve: anterior primary rami (C2–C6)
Lumbricals (foot)
Action: flexes metatarsophalangeal joints and extends
interphalangeal joints of lateral four toes
Origin: tendons of flexor digitorum longus
Insertion: medial side of extensor hood and base of proximal
phalanx of lateral four toes
Nerve: first lumbrical – medial plantar nerve (S2, S3); lateral
three lumbricals – lateral plantar nerve (S2, S3)
Lumbricals (hand)
Action: flexes metacarpophalangeal joints and extends
interphalangeal joints of fingers
Origin: tendons of flexor digitorum profundus
Insertion: lateral margin of dorsal digital expansion of
extensor digitorum
Nerve: first and second – median nerve (C8, T1); third and
fourth – ulnar nerve (C8, T1)
Multifidus
Action: extends, rotates and laterally flexes vertebral
76 column
Origin: back of sacrum, aponeurosis of erector spinae,
posterior superior iliac spine, dorsal sacroiliac ligaments,
mamillary processes in lumbar region, all thoracic SECTION
transverse processes, articular processes of lower four
cervical vertebrae
Insertion: spines of all vertebrae from L5 to axis (deep layer
1
attaches to vertebrae above; middle layer attaches to
second or third vertebrae above; outer layer attaches to
third or fourth vertebrae above)
Obturator externus
Origin: outer surface of obturator membrane and adjacent
bone of pubic and ischial rami
Insertion: trochanteric fossa of femur
Nerve: posterior branch of obturator nerve (L3, L4)
Obturator internus
Origin: internal surface of obturator membrane and
surrounding bony margin
Insertion: medial surface of greater trochanter
Nerve: nerve to obturator internus (L5, S1)
Opponens digiti minimi

Action: abducts fifth digit, pulls it forward and rotates it
laterally
Origin: hook of hamate, flexor retinaculum
Insertion: medial border of fifth metacarpal
Opponens pollicis
Action: rotates thumb into opposition with fingers
Origin: flexor retinaculum, tubercles of scaphoid and
trapezium, abductor pollicis longus tendon
Insertion: radial side of base of proximal phalanx of
thumb
Nerve: median nerve (C8, T1) 77
Palmar interossei
Action: adducts thumb, index, ring and little fingers
SECTION Origin: shaft of metacarpal of digit on which it acts
1 Insertion: dorsal digital expansion and base of proximal

phalanx of same digit
Palmaris longus
Action: flexes wrist
Origin: medial epicondyle via common flexor tendon
Insertion: flexor retinaculum, palmar aponeurosis
Nerve: median (C7, C8)
Pectineus
Action: flexes and adducts hip
Origin: pecten pubis, iliopectineal eminence, pubic tubercle
Insertion: along a line from lesser trochanter to linea aspera
Nerve: femoral nerve (L2, L3), occasionally accessory
obturator (L3)
Pectoralis major
Action: adducts, medially rotates, flexes and extends
shoulder
Origin: clavicular attachment – sternal half of anterior
surface of clavicle; sternocostal attachment – anterior
surface of manubrium, body of sternum, upper six costal
cartilages, sixth rib, aponeurosis of external oblique
muscle
Insertion: lateral lip of intertubercular sulcus of humerus
Nerve: medial and lateral pectoral nerves (C5–T1)
Pectoralis minor
Action: protracts and medially rotates scapula
Origin: outer surface of third to fifth ribs and adjoining
intercostal fascia
Insertion: upper surface and medial border of coracoid
process
78 Nerve: medial and lateral pectoral nerves (C5–T1)
Peroneus brevis
Action: everts and plantarflexes ankle
Origin: lower two-thirds of lateral surface of fibula, SECTION
intermuscular septa
Insertion: lateral side of base of fifth metatarsal 1
Nerve: superficial peroneal nerve (L5, S1)
Peroneus longus
Action: everts and plantarflexes ankle
Origin: lateral tibial condyle, upper two-thirds of lateral
surface of fibula, intermuscular septa
Insertion: lateral side of base of first metatarsal, medial
cuneiform
Nerve: superficial peroneal nerve (L5, S1)
Peroneus tertius
Action: everts and dorsiflexes ankle
Origin: distal third of medial surface of fibula, interosseous
membrane, intermuscular septum
Insertion: medial aspect of base of fifth metatarsal
Piriformis
Action: laterally rotates and abducts hip
Origin: front of second to fourth sacral segments, gluteal
surface of ilium, pelvic surface of sacrotuberous
ligament
Insertion: medial side of greater trochanter
Nerve: anterior rami of sacral plexus (L5–S2)
Plantar interossei
Action: adduct third to fifth toes, flex metatarsophalangeal
joints of lateral three toes
Origin: base and medial side of lateral three toes
Insertion: medial side of base of proximal phalanx of same
toes and dorsal digital expansions
Nerve: lateral plantar nerve (S2, S3) 79
Plantaris
Action: plantarflexes ankle, flexes knee
SECTION Origin: lateral supracondylar ridge, oblique popliteal ligament
1 Insertion: tendo calcaneus

Popliteus
Action: medially rotates tibia, flexes knee

Origin: outer surface of lateral femoral condyle
Insertion: posterior surface of tibia above soleal line
Pronator quadratus
Action: pronates forearm
Origin: lower quarter of anterior surface of ulna
Insertion: lower quarter of anterior surface of radius
Nerve: anterior interosseous branch of median nerve
(C7, C8)
Pronator teres
Action: pronates forearm, flexes elbow
Origin: humeral head – medial epicondyle via common flexor
tendon, intermuscular septum, antebrachial fascia; ulnar
head – medial part of coronoid process
Insertion: middle of lateral surface of radius
Nerve: median nerve (C6, C7)
Psoas major
Action: flexes hip and lumbar spine
Origin: bodies of T12 and all lumbar vertebrae, bases of
transverse processes of all lumbar vertebrae, lumbar
intervertebral discs
Insertion: lesser trochanter
Nerve: anterior rami of lumbar plexus (L1–L3)
Psoas minor (not always present)
Action: flexes trunk (weak)
Origin: bodies of T12 and L1 vertebrae and intervertebral
80 discs
Insertion: pecten pubis, iliopubic eminence, iliac fascia
Nerve: anterior primary ramus (L1)
Quadratus femoris SECTION

Origin: ischial tuberosity
1
Insertion: quadrate tubercle midway down intertrochanteric crest
Nerve: nerve to quadratus femoris (L5, S1)
Quadratus lumborum
Action: laterally flexes trunk, extends lumbar vertebrae,
steadies twelfth rib during deep inspiration
Origin: iliolumbar ligament, posterior part of iliac crest
Insertion: lower border of twelfth rib, transverse processes of
L1–L4
Nerve: ventral rami of T12 and L1–L3/4
Rectus abdominis
Action: flexes trunk
Origin: symphysis pubis, pubic crest
Insertion: fifth to seventh costal cartilages, xiphoid process
Nerve: ventral rami of T6/7–T12
Rectus capitis anterior

Action: flexes neck
Origin: anterior surface of lateral mass of atlas and root of its
transverse process
Insertion: occipital bone
Nerve: anterior primary rami (C1, C2)
Rectus capitis lateralis

Action: laterally flexes neck
Origin: transverse process of atlas
Insertion: jugular process of occipital bone
Nerve: ventral rami (C1, C2)
Rectus capitis posterior major

Action: extends and rotates neck
Origin: spinous process of axis 81
Insertion: lateral part of inferior nuchal line of occipital bone
SECTION Rectus capitis posterior minor
1 Action: extends neck
Origin: posterior tubercle of atlas
Insertion: medial part of inferior nuchal line of occipital bone
Rectus femoris
Action: extends knee, flexes hip
Origin: straight head – anterior inferior iliac spine; reflected
head – area above acetabulum, capsule of hip joint
Insertion: base of patella, then forms part of patellar ligament
Nerve: femoral nerve (L2–L4)
Rhomboid major
Action: retracts and medially rotates scapula
Origin: spines and supraspinous ligaments of T2–T5
Insertion: medial border of scapula between root of spine and
inferior angle
Nerve: dorsal scapular nerve (C4, C5)
Rhomboid minor
Action: retracts and medially rotates scapula
Origin: spines and supraspinous ligaments of C7–T1, lower
part of ligamentum nuchae
Insertion: medial end of spine of scapula
Nerve: dorsal scapular nerve (C4, C5)
Rotatores
Action: extends vertebral column and rotates thoracic region
Origin: transverse process of each vertebra
Insertion: lamina of vertebra above
Sartorius
Action: flexes hip and knee, laterally rotates and abducts hip,
82 medially rotates tibia on femur
Origin: anterior superior iliac spine and area just below
Insertion: upper part of medial side of tibia
Nerve: femoral nerve (L2, L3) SECTION
Scalenus anterior
Action: flexes, laterally flexes and rotates neck, raises first rib
1
during respiration
Origin: anterior tubercles of transverse processes of C3–C6
Insertion: scalene tubercle on inner border of first rib
Nerve: ventral rami (C4–C6)
Scalenus medius
Action: laterally flexes neck, raises first rib during respiration
Origin: transverse processes of atlas and axis, posterior
tubercles of transverse processes of C3–C7
Insertion: upper surface of first rib
Scalenus posterior
Action: laterally flexes neck, raises second rib during
respiration
Origin: posterior tubercles of transverse processes of C4–C6
Insertion: outer surface of second rib
Semimembranosus
Action: flexes knee, extends hip and medially rotates tibia on
femur
Insertion: posterior aspect of medial tibial condyle
Nerve: tibial division of sciatic nerve (L5–S2)
Semispinalis capitis
Action: extends and rotates head
Origin: transverse processes of C7–T6/7, articular processes
of C4–C6
Insertion: between superior and inferior nuchal lines of
occipital bone
Nerve: dorsal rami of spinal nerves 83
Semispinalis cervicis
Action: extends and rotates vertebral column
SECTION Origin: transverse processes of T1–T5/6
1 Insertion: spinous processes of C2–C5

Semispinalis thoracis
Action: extends and rotates vertebral column

Origin: transverse processes of T6–T10
Insertion: spinous processes of C6–T4
Semitendinosus
Action: flexes knee, extends hip and medially rotates tibia on
femur
Insertion: upper part of medial surface of tibia
Nerve: tibial division of sciatic nerve (L5–S2)
Serratus anterior
Action: protracts and laterally rotates scapula
Origin: outer surfaces and superior borders of upper eight,
nine or ten ribs and intervening intercostal fascia
Insertion: costal surface of medial border of scapula
Nerve: long thoracic nerve (C5–C7)
Soleus
Action: plantarflexes ankle
Origin: soleal line and middle third of medial border of tibia,
posterior surface of head and upper quarter of fibula,
fibrous arch between tibia and fibula
Insertion: posterior surface of calcaneus
Spinalis (capitis*, cervicis*, thoracis)
Action: extends vertebral column
Origin: spinalis thoracis – spinous processes of T11–L2
Insertion: spinalis thoracis – spinous processes of upper four
84 to eight thoracic vertebrae
*Spinalis capitis and spinalis cervicis are poorly developed and
blend with adjacent muscles
Nerve: dorsal rami SECTION
Splenius capitis
Action: extends, laterally flexes and rotates neck
1
Origin: lower half of ligamentum nuchae, spinous processes
of C7–T3/4 and their supraspinous ligaments
Insertion: mastoid process of temporal bone, lateral third of
superior nuchal line of occipital bone
Nerve: dorsal rami (C3–C5)
Splenius cervicis
Action: laterally flexes, rotates and extends neck
Origin: spinous processes of T3–T6
Insertion: posterior tubercles of transverse processes of C1–
C3/4
Nerve: dorsal rami (C5–C7)
Sternocleidomastoid
Action: laterally flexes and rotates neck; anterior fibres flex
neck, posterior fibres extend neck
Origin: sternal head – anterior surface of manubrium sterni;
clavicular head – upper surface of medial third of clavicle
Insertion: mastoid process of temporal bone, lateral half of
superior nuchal line of occipital bone
Nerve: accessory nerve (XI)
Subscapularis
Action: medially rotates shoulder
Origin: medial two-thirds of subscapular fossa and tendinous
intramuscular septa
Insertion: lesser tubercle of humerus, anterior capsule of
shoulder joint
Nerve: upper and lower subscapular nerves (C5, C6)
Superior oblique
Action: extends neck
Origin: upper surface of transverse process of atlas 85
Insertion: superior and inferior nuchal lines of occipital bone
SECTION Supinator
1 Action: supinates forearm
Origin: inferior aspect of lateral epicondyle, radial collateral
ligament, annular ligament, supinator crest and fossa of
ulna
Insertion: posterior, lateral and anterior aspects of upper third
of radius
Supraspinatus
Action: abducts shoulder
Origin: medial two-thirds of supraspinous fossa and
supraspinous fascia
Insertion: capsule of shoulder joint, greater tubercle of
humerus
Nerve: suprascapular nerve (C5, C6)
Tensor fascia lata

Action: extends knee, abducts and medially rotates hip
Origin: outer lip of iliac crest between iliac tubercle and
anterior superior iliac spine
Insertion: iliotibial tract
Teres major
Action: extends, adducts and medially rotates shoulder
Origin: dorsal surface of inferior scapular angle
Insertion: medial lip of intertubercular sulcus of humerus
Nerve: lower subscapular nerve (C5–C7)
Teres minor
Action: laterally rotates shoulder
Origin: upper two-thirds of dorsal surface of scapula
Insertion: lower facet on greater tuberosity of humerus, lower
posterior surface of capsule of shoulder joint
86 Nerve: axillary nerve (C5, C6)
Tibialis anterior
Action: dorsiflexes and inverts ankle
Origin: lateral tibial condyle and upper two-thirds of lateral SECTION
surface of tibia, interosseous membrane
Insertion: medial and inferior surface of medial cuneiform, 1
base of first metatarsal
Nerve: deep peroneal nerve (L4, L5)
Tibialis posterior
Action: plantarflexes and inverts ankle
Origin: lateral aspect of posterior surface of tibia below soleal
line, interosseous membrane, upper half of posterior
surface of fibula, deep transverse fascia
Insertion: tuberosity of navicular, medial cuneiform,
sustentaculum tali, intermediate cuneiform, base of
second to fourth metatarsals
Nerve: tibial nerve (L4, L5)
Transversus abdominis
Action: compresses abdominal contents, raises intraabdominal
pressure
Origin: lateral third of inguinal ligament, anterior two-thirds
of inner lip of iliac crest, thoracolumbar fascia between
iliac crest and twelfth rib, lower six costal cartilages where
it interdigitates with diaphragm
Insertion: abdominal aponeurosis to linea alba
Nerve: ventral rami of lower six thoracic and first lumbar
spinal nerve
Trapezius
Action: upper fibres elevate scapula, middle fibres retract
scapula, lower fibres depress scapula, upper and lower
fibres together laterally rotate scapula. Also extends and
laterally flexes head and neck
Origin: medial third of superior nuchal line, external occipital
protuberance, ligamentum nuchae, spinous processes and
supraspinous ligaments of C7–T12 87
Insertion: upper fibres – posterior border of lateral third of
clavicle; middle fibres – medial border of acromion,
SECTION
superior lip of crest of spine of scapula; lower fibres –
tubercle at medial end of spine of scapula
1 Nerve: accessory nerve (XI), ventral rami (C3, C4)
Triceps brachii
Action: extends elbow and shoulder

Origin: long head – infraglenoid tubercle of scapula, shoulder
capsule; lateral head – above and lateral to spiral groove
on posterior surface of humerus; medial head – below and
medial to spiral groove on posterior surface of humerus
Insertion: upper surface of olecranon, deep fascia of forearm
Nerve: radial nerve (C6–C8)
Vastus intermedius
Action: extends knee
Origin: upper two-thirds of anterior and lateral surfaces of
femur, lower part of lateral intermuscular septum
Insertion: deep surface of quadriceps tendon, lateral border of
patella, lateral tibial condyle
Vastus lateralis
Origin: intertrochanteric line, greater trochanter, gluteal
tuberosity, lateral lip of linea aspera
Insertion: tendon of rectus femoris, lateral border of patella
Vastus medialis
Origin: intertrochanteric line, spiral line, medial lip of linea
aspera, medial supracondylar line, medial intermuscular
septum, tendons of adductor longus and adductor
magnus
Insertion: tendon of rectus femoris, medial border of patella,
medial tibial condyle
88 Nerve: femoral nerve (L2–L4)
References and Further Reading
Drake, R. L., Vogl, W., & Mitchell, A. W. M. (2014). Gray’s anatomy for stu-
dents. Philadelphia: Churchill Livingstone. SECTION
O’Brien, M. D. (2010). Guarantors of ‘Brain’ 2009–2010. Aids to the examina-
tion of the peripheral nervous system (5th ed.). Edinburgh: W B Saunders. 1
Palastanga, N., & Soames, R. (2012). Anatomy and human movement: structure
and function (6th ed.). Edinburgh: Churchill Livingstone.
Standring, S. (2015). Gray’s anatomy: the anatomical basis of clinical practice
(41st ed.). Elsevier.
Thompson, J. C. (2016). Netter’s concise orthopaedic anatomy (2nd ed.).
Philadelphia: Saunders.
89
Neuromusculoskeletal
assessment
SECTION
SECTION
Peripheral nerve sensory innervation 93
Dermatomes 95 2
Myotomes 96
Neuromusculoskeletal assessment
Reflexes 96
Key features of upper and lower motor neurone
lesions 98
2
The Medical Research Council scale for muscle
power 99
Common locations for palpation of pulses 100
Common musculoskeletal tests 101
Common vascular tests 120
Neurological tests 121
Neurodynamic tests 124
Cranial nerves 132
Glossary of terms used to evaluate clinical tests 136
Common postures 138
Trigger points 145
Normal joint range of movement 157
Average range of segmental movement 159
Close packed positions and capsular patterns for
selected joints 161
Classification of ligament and muscle sprains 162
Windows of achievement for gross motor
SECTION
developmental milestones 163
2 Joint hypermobility assessment 164
Complex regional pain syndrome 166
Distribution of referred pain 167

Red flags 168
Psychosocial yellow flags 170
Musculoskeletal assessment 174
92
Peripheral nerve sensory innervation
Supraclavicular Supraclavicular
nerve C3, C4 nerve C3, C4
Axillary (circumflex) Axillary (circumflex)

nerve C5, C6 nerve C5, C6
Radial nerve Radial nerve

C5, C6 C5, C6
Musculo- Musculo-
cutaneous Medial cutaneous
nerve C5, C6 cutaneous nerve nerve C5, C6
C8, T1
Radial nerve Radial nerve
C7, C8 C7, C8
Ulnar nerve
C8, T1
Median nerve Median nerve
C6, C7, C8 C6, C7, C8
Anterior view Posterior view
Figure 2.1 Cutaneous distribution of the upper limb.
93
2
SECTION
94
2
SECTION
Subcostal nerve T12 Subcostal nerve T12
Genitofemoral nerve L1, L2 Iliohypogastric nerve L1
Ilioinguinal nerve L1 Posterior rami L1, L2, L3

Posterior rami S1, S2, S3
Lateral cutaneous
nerve of thigh L2, L3 Lateral cutaneous
nerve of thigh L2, L3
Obturator L2, L3, L4
Obturator L2, L3, L4
Medial plantar
Medial and intermediate
cutaneous nerves L2, L3 Posterior cutaneous
Lateral plantar
nerve S1, S2, S3
Saphenous
Medial cutaneous
Lateral cutaneous nerve nerve L2, L3 Sural
of calf of leg L5, S1, S2
Tibial
Lateral cutaneous nerve B

Superficial peroneal of calf of leg L4, L5, S1
(musculocutaneous) nerve
L4, L5, S1 Saphenous
nerve L3, L4
Sural nerve L5, S1, S2
Sural nerve S1, S2
Deep peroneal nerve L4, L5
A Anterior view Tibial nerve S1, S2 Posterior view
Figure 2.2 Cutaneous distribution of (A) the lower limb and (B) the foot.
Dermatomes (from O’Brien 2010, with
permission)
C3 C3
C4 C4
C5 T2
T3 T2 C5
T3
T4 T4
T5 T5 SECTION
T2 T6 T2
2
T6
T7
T7 T8
C6 T1 T8 T9
T9 T10
T11 T1
T10 C6
T11 T12
T12 L1
L1 L2
C6 S3 C6
S3 S4
C8 S4 C8
L2 L2
C7 C7
S2
L3 L3
L5
S2
L4 L4 L5
S1
S1
L5
L5
Figure 2.3 Dermatomes of the whole body. The above illustration

is used extensively in clinical practice to define the body’s dermatomal
patterns. It represents the dermatomes as lying between clearly defined
boundaries with no overlap between areas. However, it is worth
noting that studies have shown that there is significant variability in the
pattern of segmental innervation and that the above dermatomes do
not always describe the patterns found in a large number of patients.
(From O’Brien 2010, Aids to the Examination of the Peripheral
Nervous System, 5e, with permission.) 95
Myotomes
Root Joint action Root Joint action

C1–C2 Cervical flexion T1 Finger abduction/adduction
C3 Cervical lateral T2–L1 No muscle test
flexion
SECTION C4 Shoulder girdle L2 Hip flexion
2 C5
elevation
Shoulder abduction L3 Knee extension
C6 Elbow flexion L4 Ankle dorsiflexion
C7 Elbow extension L5 Great toe extension
C8 Thumb extension S1 Ankle eversion/hip extension/

ankle plantarflexion/knee
flexion
S2 Knee flexion
Reflexes
Deep tendon reflex Root Nerve

Biceps jerk C5–C6 Musculocutaneous
Brachioradialis jerk C5–C6 Radial
Triceps jerk C7–C8 Radial
Knee jerk L3–L4 Femoral
Ankle jerk S1–S2 Tibial
When testing reflexes, the patient must be relaxed and the muscle
placed on a slight stretch. Look for symmetry of response between
reflexes on both sides, and ensure that both limbs are positioned
identically. When a reflex is difficult to elicit, a reinforcement
manoeuvre can be used to facilitate a stronger response. This is
performed while the reflex is being tested. Usually upper-limb
reinforcement manoeuvres are used for lower-limb reflexes and
vice versa. Examples of reinforcement manoeuvres include
96 clenching the teeth or fists, hooking the hands together by the
flexed fingers and pulling one hand against the other (Jendrassik’s
manoeuvre), crossing the legs at the ankle and pulling one ankle
against the other.
Reflexes may be recorded as follows, noting any asymmetry
(Petty and Dionne, 2018):
– or 0: absent
– or 1: diminished SECTION
+ or 2: average
+ + or 3: exaggerated 2
+ + + or 4: clonus
An abnormal reflex response may or may not be indicative
of a neurological lesion. Findings need to concur with other
neurological observations in order to be considered as significant
evidence of an abnormality.
An exaggerated response (excessively brisk or prolonged) may
simply be caused by anxiety. However, it may also indicate an
upper motor neurone lesion, i.e. central damage. Clonus is
associated with exaggerated reflexes and also indicates an upper
motor neurone lesion. A diminished or absent response may
indicate a lower motor neurone lesion, i.e. loss of ankle jerk
with lumbosacral disc prolapse.
Abnormal
response
(indicating
possible
upper motor
Other Normal neurone
reflexes Method response lesion)
Plantar Run a blunt Flexion of Extension of
(superficial object over lateral toes big toe and
reflex) border of sole fanning of other
of foot from the toes (Babinski
heel up towards response)
the little toe and
across the foot
pad
Continued 97
Abnormal
response
(indicating
possible
upper motor
Other Normal neurone
reflexes Method response lesion)
SECTION Clonus (tone) Apply sudden Oscillatory More than
2 and sustained
dorsiflexion to the
beats may
occur, but
three rhythmic
contractions
ankle they are not of the
rhythmic or plantarflexors
sustained
Hoffman reflex Flick distal phalanx No Reflex flexion
of third or fourth movement of distal phalanx
finger downwards of thumb of thumb
Key features of upper and lower motor

neurone lesions
Upper motor Lower motor

neurone neurone
Muscle tone Increased Decreased
Clonus Present Absent
Muscle fasciculation Absent Present
Tendon reflexes Increased Depressed or absent
Plantar response Extensor (Babinski’s Flexor (normal)
sign)
Distribution Extensor weakness in Weakness of muscle
upper limb and flexor groups innervated
weakness in lower by affected spinal
limb segment/root, plexus
Whole limb(s) or peripheral nerve
involved
98
Upper motor neurone
Origin: cerebral cortex
Terminates: cranial nerve nuclei or spinal cord anterior horn
Lower motor neurone

Origin: cranial nerve motor nuclei or spinal cord anterior
horn SECTION
Terminates: skeletal muscle motor unit
2
The Medical Research Council scale for
muscle power
Grade Response
0 No contraction
1 Flicker or trace of contraction
2 Active movement with gravity eliminated
3 Active movement against gravity
4 Active movement against gravity and resistance
5 Normal strength
In addition, Grade 4 movements may be subdivided into:

4−: movement against slight resistance
4: movement against moderate resistance
4+: movement against strong resistance
Medical Research Council 1976 Aids to the investigation of peripheral nerve

injuries. London: HMSO. Reproduced with kind permission of the Medical
Research Council. 99
Common locations for palpation of pulses
Right common
carotid
Vertebral Aortic arch
SECTION Subclavian Axillary
2 Ascending aorta
Descending Descending
abdominal aorta
aorta
Brachial
Common iliac
Radial
Ulnar
Palmar
arches
External Internal iliac
iliac
Deep femoral
Femoral
Femoral
Popliteal
Peroneal
Posterior tibial
Anterior
tibial
Dorsalis pedis
Plantar
arch
Figure 2.4 Pulse points.
100
Common carotid Between the trachea and the
sternocleidomastoid muscle
Axillary Lateral wall of axilla in the groove behind
coracobrachialis
Brachial (a) Between the humerus and biceps on the
medial aspect of arm
(b) Cubital fossa
SECTION
Radial Lateral to flexor carpi radialis tendon
Femoral In femoral triangle (sartorius, adductor longus
and inguinal ligament)
2
Popliteal In popliteal fossa. Palpated more easily in prone
position with the knee flexed about 45°
Anterior tibial Above level of ankle joint, between tibialis
anterior and extensor hallucis longus tendons
Posterior tibial Posterior aspect of medial malleolus
Dorsalis pedis Dorsum of foot, between first and second
metatarsal bones
Common musculoskeletal tests

The following section does not contain an exhaustive list of
musculoskeletal tests. The tests have been selected according to
the frequency of their use in clinical practice and their usefulness
in identifying the presence or absence of pathology according
to the evidence base. No test is 100% accurate, and interpretation
of test findings needs to consider the overall clinical picture.
A brief description of each test is given below. For a fuller
description of how each test is performed, please refer to a
musculoskeletal assessment textbook.
Shoulder
Active compression test (O’Brien)
Tests: labral pathology, acromioclavicular joint pathology.
Procedure: patient upright with elbow in extension and
shoulder in 90° flexion, 10–15° adduction and medial
rotation. Stand behind patient, and apply downward force
to arm. Repeat with arm in lateral rotation. 101
Positive sign: pain/increased pain with medial rotation and
decreased pain with lateral rotation. Pain inside the
glenohumeral joint indicates labral abnormality. Pain over
the acromioclavicular joint indicates acromioclavicular
joint abnormality.
Anterior drawer test

SECTION
Tests: anterior shoulder stability.
2 Procedure: patient supine. Place shoulder in 80–120°
abduction, 0–20° forward flexion and 0–30° lateral
rotation. Stabilize scapula. Draw humerus anteriorly.
Positive sign: click and/or apprehension.
Anterior slide test

Tests: labral pathology.
Procedure: patient upright with hands on hips, thumbs facing
posteriorly. Stand behind patient, and stabilize scapula and
clavicle with one hand. With the other hand, apply an
anterosuperior force to the elbow while instructing the
patient to gently push back against the force.
Positive sign: pain/reproduction of symptoms/click.
Apprehension and relocation test (Fowler’s sign)

Tests: glenohumeral joint stability.
Step 1 (Apprehension): patient supine. Abduct shoulder to
90°. Move it into maximum lateral rotation. If movement
well tolerated, apply a posteroanterior force to humeral
head.
Positive sign: apprehension and pain.
Step 2 (Relocation): At the point where the patient feels pain
or apprehension, apply an anteroposterior force to
humeral head.
Positive sign: Decrease in pain or apprehension and increased
lateral rotation.
Biceps load test I

Tests: superior labral pathology.
Procedure: patient supine with shoulder in 90° abduction,
102 elbow in 90° flexion and forearm supinated. Laterally
rotate shoulder until patient becomes apprehensive.
Maintain this position. Resist elbow flexion.
Positive sign: pain/apprehension remains unchanged or
increases during resisted elbow flexion.
Biceps load test II

Tests: superior labral pathology.
SECTION
Procedure: patient supine with shoulder in 120° abduction
and maximum lateral rotation, elbow in 90° flexion and
forearm supinated. Resist elbow flexion.
2
Positive sign: increased pain during resisted elbow flexion.
Clunk test
Tests: tear of glenoid labrum.
Procedure: patient supine. Abduct shoulder over patient’s
head. Apply anterior force to posterior aspect of humeral
head while rotating humerus laterally.
Positive sign: a clunk or grinding sound and/or apprehension
if anterior instability present.
Crank test
Tests: labral pathology.
Procedure: patient sitting or supine with shoulder in 160°
flexion in scapular plane. Hold elbow, and apply a
longitudinal compressive force to humerus while rotating
it medially and laterally.
Positive sign: pain/reproduction of symptoms, with or without
click, usually during lateral rotation.
Crossed-arm adduction test (Apley scarf test)

Tests: acromioclavicular joint pathology.
Procedure: patient upright. Horizontally adduct the arm as far
as possible.
Positive sign: pain around acromioclavicular joint.
Drop arm test (Codman’s test)

Tests: integrity of rotator cuff, particularly supraspinatus.
Procedure: patient standing. Abduct shoulder to 90°. Patient
slowly lowers arm to the side. 103
Positive sign: Inability to lower the arm slowly (i.e. it drops) or
severe pain during the movement. Indicates complete/
partial rotator cuff tear.
External rotation lag sign

Tests: infraspinatus and supraspinatus integrity.
Procedure: patient upright with shoulder passively elevated to
SECTION
20° abduction (in the scapular plane) with elbow in 90°
2 flexion. Passively move shoulder into full lateral rotation.
Support elbow, and ask patient to hold position.
Positive sign: arm drops into medial rotation.
Hawkins-Kennedy impingement test

Tests: impingement of supraspinatus tendon.
Procedure: patient sitting or standing. Forward flex shoulder to
90° and flex elbow to 90°. Apply passive medial rotation.
Positive sign: reproduction of symptoms.
Hornblower’s sign
Tests: teres minor integrity.
Procedure: Patient sitting or standing with arms by side.
Patient lifts hands up to mouth.
Positive sign: inability to lift the hand to the mouth without
abducting arm first (this compensatory manoeuvre on the
affected side is the hornblower’s sign).
Jerk test
Tests: posterior shoulder stability.
Procedure: patient sitting. Place shoulder in 90° forward
flexion and medial rotation. Apply longitudinal cephalad
force to humerus, and move arm into horizontal
adduction.
Positive sign: sudden jerk or clunk.
Lift-off test
Tests: subscapularis integrity.
Procedure: patient upright with arm medially rotated behind
back. Patient lifts hand away from back.
104 Positive sign: inability to lift arm indicates tendon rupture.
Load and shift test
Tests: anterior and posterior shoulder stability
Procedure: patient sitting. Stabilize scapula by fixing coracoid
process and spine of scapula. Grasp humeral head, and
apply a medial, compressive force to seat it in the glenoid
fossa (load). Glide the humeral head anteriorly and
posteriorly (shift). SECTION
Positive sign: increased anterior or posterior glide indicates
anterior or posterior instability. 2
Neer impingement test
Tests: impingement of supraspinatus tendon and/or biceps
tendon.
Procedure: patient sitting or standing. Passively elevate arm
through forward flexion and medial rotation.
Patte’s test
Tests: infraspinatus and teres minor integrity.
Procedure: patient sitting. Place shoulder in 90° flexion in the
scapular plane and elbow in 90° flexion. Patient rotates
arm laterally against resistance.
Positive sign: resistance with pain indicates tendinopathy.
Inability to resist with gradual lowering of the arm or
forearm indicates tendon rupture.
Posterior drawer test

Tests: posterior shoulder stability.
Procedure: patient supine. Place shoulder in 100–120°
abduction and 20–30° forward flexion with elbow flexed
to 120°. Stabilize scapula. Medially rotate and forward flex
shoulder between 60° and 80° while pushing head of
humerus posteriorly.
Positive sign: significant posterior displacement and/or patient
apprehension.
Speed’s test
Tests: biceps tendon pathology. 105
Procedure: patient sitting or standing. Forward flex shoulder,
supinate forearm and extend elbow. Resist patient’s
attempt to flex shoulder.
Positive sign: increased pain in bicipital groove.
Sulcus sign
Tests: inferior shoulder stability.
SECTION
Procedure: patient standing or sitting, arm by side. Grip arm
2 below elbow, and pull distally.
Positive sign: reproduction of symptoms and/or appearance of
sulcus under acromion.
Supraspinatus (empty can) test

Tests: supraspinatus tendon pathology; suprascapular nerve
neuropathy.
Procedure: patient sitting or standing. Abduct shoulder to 90°.
Horizontally flex to 30°, and medially rotate so thumbs
point downwards. Resist patient’s attempt to abduct.
Positive sign: reproduction of symptoms or weakness.
Yergason’s test
Tests: biceps tendon pathology; subacromial impingement.
Procedure: patient sitting or standing with elbow in 90°
flexion and forearm pronated. Resist patient’s attempts to
supinate.
Positive sign: increased pain in bicipital groove.
Elbow
Elbow flexion test
Tests: cubital tunnel (ulnar nerve) syndrome.
Procedure: patient standing or sitting. Fully flex elbows with
wrist extended. Hold for 5 minutes.
Positive sign: tingling or paraesthesia in ulnar nerve
distribution.
Tennis elbow test (resisted)

Tests: tendinopathy of the wrist extensors involving the
106 common extensor origin at the lateral epicondyle.
Procedure: patient sitting or standing with elbow in full
extension and wrist in full flexion and pronation. Resist
patient’s attempts to extend wrist while supporting the
arm under the elbow.
Tennis elbow test (passive)

SECTION
common extensor origin at the lateral epicondyle.
Procedure: passively extend elbow, pronate forearm and flex
2
wrist and fingers while palpating lateral epicondyle.
Tennis elbow test (resisted middle-finger extension)

common extensor origin at the lateral epicondyle.
Procedure: resist extension of middle finger distal to PIP
(proximal interphalangeal) joint.
Golfer’s elbow test (resisted)

Tests: tendinopathy of the wrist flexors involving the common
flexor origin at the medial epicondyle.
Procedure: patient sitting or standing with elbow in full
extension and wrist in full extension and pronation. Resist
patient’s attempts to flex wrist while supporting the arm
under the elbow.
Golfer’s elbow test (passive)

Tests: tendinopathy of the wrist flexors involving the common
flexor origin at the medial epicondyle.
Procedure: passively extend elbow, supinate forearm and extend
wrist and fingers while palpating medial epicondyle.
Pinch grip test

Tests: anterior interosseous (median) nerve entrapment. 107
Procedure: patient pinches tips of index finger and thumb
together.
Positive sign: inability to pinch tip to tip.
Posterolateral pivot shift test

Tests: posterolateral rotatory instability of the elbow and the
SECTION integrity of the lateral collateral ligament.
Procedure: patient supine with affected arm overhead and
2 elbow in 20° flexion and supinated. Stabilize forearm
distal to elbow. Apply a longitudinal compressive force to
the radius and ulna then a valgus stress to the forearm,
while maintaining supination.

Positive sign: apprehension and pain.
Tinel’s sign (at elbow)

Tests: point of regeneration of sensory fibres of ulnar
nerve.
Procedure: tap ulnar nerve in groove between olecranon and
medial epicondyle.
Positive sign: tingling sensation in ulnar distribution of
forearm and hand. Furthest point at which abnormal
sensation felt indicates point to which the nerve has
regenerated.
Varus stress test

Tests: stability of lateral collateral ligament.
Procedure: patient sitting. Stabilize upper arm with elbow in
20–30° flexion and humerus in full medial rotation. Apply
adduction/varus force to forearm.
Positive sign: excessive laxity or reproduction of symptoms.
Valgus stress test

Tests: stability of medial collateral ligament.
Procedure: patient sitting. Stabilize upper arm with elbow in
20–30° flexion and humerus in full lateral rotation. Apply
abduction/valgus force to forearm.
108 Positive sign: increased laxity or reproduction of symptoms.
Wrist and hand
Carpal compression test
Tests: aids diagnosis of carpal tunnel syndrome
Procedure: patient sitting with elbow in extension and
supination. Place thumb over course of median nerve, just
distal to wrist crease and press firmly for up to 2 minutes.
Positive sign: paraesthesia and pain in median nerve SECTION
distribution.
2
Finkelstein test
Tests: tenosynovitis of abductor pollicis longus and extensor
pollicis brevis tendons (de Quervain’s tenosynovitis).
Procedure: patient makes a fist with thumb inside. Passively
move wrist into ulnar deviation.
Froment’s sign
Tests: ulnar nerve paralysis.
Procedure: grip piece of paper between index finger and
thumb. Pull paper away.
Positive sign: flexion of IP (interphalangeal) thumb joint as
paper pulled away.
Hand elevation test

Tests: aids diagnosis of carpal tunnel syndrome.
Procedure: patient elevates arm as high as possible and holds
for up to 1 minute.
Positive sign: reproduction of symptoms (paraesthesia and/or
pain)
Ligamentous instability test for the fingers

Tests: stability of collateral ligaments.
Procedure: apply valgus and varus force to PIP (proximal
interphalangeal) or DIP (distal interphalangeal) joint.
Positive sign: increased laxity.
Lunotriquetral ballottement (Reagan’s) test

Tests: stability of lunotriquetral ligament. 109
Procedure: stabilize lunate, and apply posterior and anterior
glide to triquetrum and pisiform.
Positive sign: reproduction of symptoms, crepitus or laxity.
Phalen’s (wrist flexion) test

Tests: median nerve pathology; carpal tunnel syndrome.
Procedure: place dorsal aspect of hands together with wrists
SECTION
flexed. Hold for 1 minute.
2 Positive sign: tingling in distribution of median nerve.
Reverse Phalen’s test

Tests: median nerve pathology.
Procedure: place palms of hands together with wrists

extended. Hold for 1 minute.
Positive sign: tingling in distribution of median nerve.
Scaphoid shift (Watson’s) test

Tests: stability of scaphoid.
Procedure: hold wrist in full ulnar deviation and slight
extension. With other hand, apply pressure to scaphoid
tubercle (palmar aspect) and move wrist into radial
deviation and slight flexion.
Positive sign: pain and/or subluxation of scaphoid.
Sweater finger sign

Tests: rupture of flexor digitorum profundus tendon.
Procedure: patient makes a fist.
Positive sign: loss of DIP joint flexion of one of the fingers.
Tinel’s sign (at the wrist)

Tests: median nerve pathology; carpal tunnel syndrome.
Procedure: tap over carpal tunnel.
Positive sign: tingling or paraesthesia in median distribution in
hand. Furthest point at which abnormal sensation felt
indicates point to which the nerve has regenerated.
Thumb grind test

Tests: stability and/or degeneration of the first
110 trapeziometacarpal joint.
Procedure: stabilize wrist and apply longitudinal compressive
force to first metacarpal, then medial and lateral rotation.
Positive sign: pain, crepitus.
Triangular fibrocartilage complex (TFCC) load test

Tests: triangular fibrocartilage complex integrity.
Procedure: hold forearm. With other hand hold wrist in ulnar
SECTION
deviation, then move it through supination and pronation
while applying a compressive force.
Positive sign: pain, clicking, crepitus.
2
Wrist flexion and compression test
Tests: aids diagnosis of carpal tunnel syndrome.
Procedure: patient sitting with elbow in extension and
supination. Flex wrist to 60°, place thumb over course of
median nerve, just distal to wrist crease and press firmly
for up to 30 seconds.
Positive sign: reproduction of symptoms (paraesthesia and/or
pain).
Pelvis
Compression test
Tests: sprain of posterior sacroiliac joint or ligaments.
Procedure: patient supine or side lying. Push right and left
ASIS (anterior superior iliac spine) towards each other.
Gaenslen’s test
Tests: sacroiliac joint.
Procedure: patient supine with leg hanging over side of plinth.
Patient hugs contralateral knee to chest. Place one hand
above knee of extended leg and other hand over knee of
flexed leg. Apply an opposing force to each leg
simultaneously.
Positive sign: reproduction of pain.
Gapping test (distraction)

Tests: sprain of anterior sacroiliac joint or ligaments. 111
Procedure: patient supine. Push right and left ASIS apart.
Gillet’s test
Tests: sacroiliac joint dysfunction.
Procedure: patient standing. Palpate PSIS (posterior
superior iliac spine) and sacrum at same level. Patient
SECTION
flexes hip and knee on side being palpated while
2 standing on opposite leg. Repeat test on other side and
compare.
Positive sign: if the PSIS on the side tested does not move
downwards in relation to the sacrum, it indicates

hypomobility on that side.
Piedallu’s sign (sitting flexion)

Tests: movement of sacrum on ilia.
Procedure: patient sitting. Left and right PSIS are palpated
while patient forward flexes.
Positive sign: one side moves higher than the other, indicating
Shear test
Tests: sacroiliac joint
Procedure: patient prone. Apply downward and superior
pressure to sacral base.
Standing flexion
Tests: movement of ilia on sacrum.
Procedure: patient standing. Left and right PSIS are palpated
while patient forward flexes.
Positive sign: one side moves higher than the other, indicating
Supine to sit (long sitting) test

Tests: sacroiliac joint dysfunction caused by pelvic torsion or
rotation.
112
Procedure: patient supine. Note level of inferior borders of
medial malleoli. Patient sits up and relative position of
malleoli noted.
Positive sign: one leg moves up more than the other.
Thigh thrust test (femoral shear test)

Tests: sacroiliac joint.
SECTION
Procedure: patient supine. Place hip and knee in 90° flexion.
Place one hand on top of flexed knee and the other
under the sacrum. Apply longitudinal force down
2
femur.
Hip
FABER test (Patrick’s test)
Tests: hip joint or sacroiliac joint dysfunction; spasm of
iliopsoas muscle.
Procedure: patient supine. Place foot of test leg on opposite
knee. Gently lower knee of test leg.
Positive sign: knee remains above the opposite leg; pain or
spasm.
Leg length test

Tests: leg-length discrepancy.
Procedure: patient supine. Measure between the anterior
superior iliac spine and the medial or lateral malleolus.
Positive sign: a difference of more than 1.3 cm is considered
significant.
Ober’s sign
Tests: tensor fascia lata and iliotibial band contractures.
Procedure: patient side lying with hip and knee of lower leg
flexed. Stabilize pelvis. Passively abduct and extend upper
leg with knee extended or flexed to 90°, then allow it to
drop towards plinth.
Positive sign: upper leg remains abducted and does not lower
to plinth.
113
Quadrant test
Tests: intra-articular hip joint pathology.
Procedure: patient supine. Place hip in full flexion and
adduction. Abduct hip in a circular arc, maintaining
full flexion, while applying a longitudinal compressive
force.
SECTION Positive sign: pain, locking, crepitus, clicking, apprehension.
2 Thomas test
Tests: hip flexion contracture.
Procedure: patient supine. Patient hugs one knee to chest.
Positive sign: opposite leg lifts off plinth.
Modified Thomas test

Tests: flexibility of iliopsoas, rectus femoris and tensor fascia
lata/iliotibial band.
Procedure: patient lies supine towards the bottom edge of the
plinth allowing lower leg to hang off the end. Patient hugs
knees to chest, then lowers contralateral leg as far as
possible.
Positive sign: leg unable to reach neutral position (contact
with plinth): tightness of iliopsoas or rectus femoris. To
differentiate, passively flex knee: increased hip flexion
indicates rectus femoris; unchanged hip flexion indicates
iliopsoas. Increased hip abduction indicates tightness of
tensor fascia lata/iliotibial band.
Trendelenburg’s sign
Tests: stability of the hip, strength of hip abductors (gluteus
medius).
Procedure: patient stands on one leg.
Positive sign: pelvis on opposite side drops.
Weber-Barstow Manoeuvre
Tests: leg length asymmetry.
Procedure: patient supine with hips and knees flexed. Hold
patient’s feet palpating medial malleoli with thumbs.
114 Patient lifts pelvis off bed and returns to starting position.
Passively extend legs, and compare relative position of
medial malleoli.
Positive sign: leg length asymmetry.
Knee
Abduction (valgus) stress test
Tests: full knee extension: anterior cruciate ligament, medial SECTION
quadriceps expansion, semimembranosus muscle, medial
collateral ligaments, posterior oblique ligament, posterior 2
cruciate ligament, posteromedial capsule.
20–30° flexion: medial collateral ligament, posterior oblique
ligament, posterior cruciate ligament, posteromedial
capsule.
Procedure: patient supine. Stabilize ankle, and apply medial
pressure (valgus stress) to knee joint at 0° and then at
20–30° extension.
Positive sign: excessive movement compared with opposite
knee.
Adduction (varus) stress test

Tests: full knee extension: cruciate ligaments, lateral
gastrocnemius muscle, lateral collateral ligament,
arcuate-popliteus complex, posterolateral capsule, iliotibial
band, biceps femoris tendon.
20–30° flexion: lateral collateral ligament, arcuate-popliteus
complex, posterolateral capsule, iliotibial band, biceps
femoris tendon.
Procedure: patient supine. Stabilize ankle. Apply lateral
pressure (varus stress) to knee joint at 0° and then at
20–30° extension.
Positive sign: excessive movement compared with opposite
knee.
Anterior drawer test

Tests: anterior cruciate ligament, posterior oblique ligament,
arcuate-popliteus complex, posteromedial and
posterolateral capsules, medial collateral ligament,
iliotibial band. 115
Procedure: patient supine with hips flexed to 45° and knee
flexed to 90°. Stabilize foot. Apply posteroanterior force to
tibia.
Positive sign: tibia moves more than 6 mm on the femur.
Apley’s test
Tests: distraction for ligamentous injury; compression for
SECTION
meniscus injury.
2 Procedure: patient prone with knee flexed to 90°. Medially and
laterally rotate tibia – first with distraction and then
compression.
Positive sign: pain.
Brush test
Tests: mild effusion.
Procedure: patient supine with knee extended as much
as possible. Stroke medial side of patella from just
below joint line up to suprapatellar pouch two or three
times. Use opposite hand to stroke down lateral side of
patella.
Positive sign: fluid travels to medial side and appears as bulge
below distal border of patella.
External rotation recurvatum test

Tests: posterolateral rotary stability in knee extension.
Procedure: patient supine. Hold heel, and place knee in 30°
flexion. Slowly extend knee while palpating posterolateral
aspect of knee.
Positive sign: excessive hyperextension and lateral rotation
palpated.
Hughston plica test

Tests: inflammation of suprapatellar plica.
Procedure: patient supine. Flex and medially rotate knee
while applying medial glide to patella and palpating
medial femoral condyle. Passively extend and flex
knee.
Positive sign: popping of plica band over femoral condyle,
116 tenderness.
Lachman’s test
Tests: anterior cruciate ligament, posterior oblique ligament,
arcuate-popliteus complex.
Procedure: patient supine with knee flexed 0–30°. Stabilize
femur. Apply posteroanterior force to tibia.
Positive sign: soft end feel or excessive movement.
SECTION
McConnell test for chondromalacia patellae
Tests: chondromalacia patellae. 2
Procedure: patient high sitting with femur laterally rotated.
Isometric quad contractions are performed at 0°, 30°,
60°, 90° and 120° of knee flexion for 10 seconds. If pain
is produced with any of these movements, repeat test with
patella pushed medially.
Positive sign: decrease in symptoms with medial glide.
McMurray test
Tests: medial meniscus and lateral meniscus injury.
Procedure: patient supine with test knee completely flexed. To
test the medial meniscus, laterally rotate knee and
passively extend to 90° while palpating joint line. To test
the lateral meniscus, repeat test with the knee in medial
rotation.
Positive sign: a snap or click.
Patella apprehension (Fairbank’s) test

Tests: patellar subluxation or dislocation.
Procedure: patient supine with knee in 30° flexion and quads
relaxed. Passively glide patella laterally.
Positive sign: patient apprehension or excessive movement.
Patellofemoral grind test (Clarke’s sign)

Tests: whether the patellofemoral joint is the origin of pain.
Procedure: patient supine or long sitting with knees extended.
Place web space of thumb over superior border of patella.
Apply downward and inferior pressure to the patella as
the patient contracts quadriceps muscles.
Positive sign: reproduction of symptoms. 117
Pivot shift test
Tests: integrity of anterior cruciate ligament.
Procedure: patient supine. Place the hip in 45° flexion and
30° abduction, and flex the knee to 45°. One hand
supports the knee while applying a valgus force to the
proximal fibula. The other hand cradles the foot while
SECTION applying an internal rotation force to the tibia, using the
foot as a lever. As both forces are applied, slowly extend
2 the knee.
Positive sign: A ‘jerk’ or ‘clunk’ as the tibia reduces backwards
at approximately 30° flexion.
Note: this test is easier to perform and more accurate under

general anaesthetic.
Posterior drawer test

Tests: posterior cruciate ligament, arcuate-popliteus complex,
posterior oblique ligament, anterior cruciate ligament.
flexed to 90°. Stabilize foot. Apply anteroposterior force to
tibia.
Positive sign: excessive movement.
Posterior sag sign

Tests: posterior cruciate ligament, arcuate-popliteus complex,
posterior oblique ligament, anterior cruciate ligament.
flexed to 90° with feet on plinth.
Positive sign: tibia drops posteriorly.
Slocum test for anterolateral rotary instability

Tests: anterior and posterior cruciate ligaments, posterolateral
capsule, arcuate-popliteus complex, lateral collateral
ligaments, iliotibial band.
flexed to 90°. Place foot in 30° medial rotation and
stabilize. Apply posteroanterior force to tibia.
Positive sign: excessive movement on lateral side when
118 compared with opposite knee.
Slocum test for anteromedial rotary instability
Tests: medial collateral ligament, posterior oblique ligament,
posteromedial capsule, anterior cruciate ligament.
flexed to 90°. Place foot in 15° lateral rotation and
stabilize. Apply posteroanterior force to tibia.
Positive sign: excessive movement on medial side when SECTION
compared with opposite knee.
2
Weight-bearing/rotation meniscal test (Thessaly or
Disco test)
Tests: integrity of the menisci.
Procedure: patient standing on affected leg in slight knee
flexion (20°). Hold patient’s hands for support. Patient
rotates body from left to right several times.
Positive sign: pain, catching, locking or apprehension.
Ankle and foot

Anterior drawer sign
Tests: medial and lateral ligament integrity.
Procedure: patient prone with knee flexed. Apply
posteroanterior force to talus with ankle in dorsiflexion
and then plantarflexion.
Positive sign: excessive anterior movement (both ligaments
affected) or movement on one side only (ligament on that
side affected).
Syndesmosis squeeze test

Tests: integrity of interosseous membrane/ligaments.
Procedure: patient long sitting or supine. Squeeze the fibula
and tibia together above the midpoint of the calf.
Talar tilt
Tests: adduction: mainly integrity of calcaneofibular ligament
but also anterior talofibular ligament. Abduction: integrity
of deltoid ligament. 119
Procedure: patient prone, supine or side lying with knee flexed.
Tilt talus into abduction and adduction with patient’s foot
in neutral.
Positive sign: excessive movement.
Thompson’s test
Tests: Achilles tendon rupture.
SECTION
Procedure: patient prone with feet over edge of plinth. Squeeze
2 calf muscles.
Positive sign: absence of plantarflexion.
Common vascular tests

Adson’s manoeuvre
Tests: thoracic outlet syndrome.
Procedure: patient sitting. Patient turns head toward test arm
and extends head. Laterally rotate and extend shoulder
and arm while palpating radial pulse. Patient takes a deep
breath and holds it.
Positive sign: disappearance of radial pulse.
Elevated arm stress test (Ross test)

Procedure: patient stands and abducts arm to 90°, laterally
rotates shoulders and flexes elbow to 90°. Patient opens
and closes hands for 3 minutes.
Positive sign: inability to keep arms in starting position, pain,
heaviness or weakness in arm, tingling in hand.
Homan’s test
Tests: deep vein thrombophlebitis.
Procedure: patient supine. Passive dorsiflexion of ankle with
knee extended.
Positive sign: pain in the calf.
Provocation elevation test

120
Procedure: patient standing with arms above head. Patient
opens and closes hands 15 times.
Positive sign: fatigue, cramping, tingling.
Neurological tests
Finger-nose test SECTION
Hold your finger about an arm’s length from the patient. Ask
the patient to touch your finger with the index finger and then
2
touch the nose, repeating the movement back and forth. Patients
may demonstrate past pointing (missing your finger) or intention
tremor.
Indicates: possible cerebellar dysfunction.
Heel-shin test
With the patient lying down, ask the patient to place one heel
on the opposite knee and then run the heel down the tibial shaft
toward the ankle and back again. Patients may demonstrate
intention tremor, an inability to keep the heel on the shin or
uncoordinated movements.
Indicates: possible cerebellar dysfunction.
Hoffman reflex
Flick the distal phalanx of the patient’s third or fourth finger.
Look for any reflex flexion of the patient’s thumb.
Indicates: possible upper motor neurone lesion.
Joint position sense

Test the most distal joint of the limb, i.e. distal phalanx of the
index finger or interphalangeal joint of the hallux. With the
patient’s eyes open, demonstrate the movement. To test, ask
the patient to close the eyes. Hold the joint to be tested at the
sides between two fingers, and move it up and down. Ask the
patient to identify the direction of movement, ensuring that you
are not moving more proximal joints or brushing against the
121
neighbouring toes or fingers. If there is impairment, test more
proximal joints.
Indicates: loss of proprioception.
Light touch
Use a wisp of cotton wool. With the patient’s eyes open, dem-
SECTION onstrate what you are going to do. To test, ask the patient to
2 close the eyes. Stroke the patient’s skin with the cotton wool at
random points, asking the patient to indicate every time he or
she feels the touch.
Indicates: altered touch sensation.
Pin prick
Use a disposable neurological pin which has a sharp end and a
blunt end. With the patient’s eyes open, demonstrate what you
are going to do. To test, ask the patient to close the eyes.
Test various areas of the limb randomly using sharp and blunt
stimuli, and ask the patient to tell you which sensation he or
she feels.
Indicates: altered pain sensation.
Plantar reflex (Babinski)

Apply a firm pressure along the lateral aspect of the sole of the
foot and across the base of the toes, observing the big toe. If the
big toe flexes, the response is normal. If the big toe extends and
the other toes spread, it indicates a positive Babinski’s sign.
Indicates: A positive Babinski’s sign signifies a possible upper
motor neurone lesion.
Rapidly alternating movement

Ask the patient to hold out one hand palm up and then alternately
slap it with the palmar and then dorsal aspect of the fingers of
the other hand. Where there is a loss of rhythm and fluency, it
is referred to as dysdiadochokinesia. For the lower limbs, ask
the patient to tap first one foot on the floor and then the other.
122 Indicates: possible cerebellar dysfunction.
Romberg’s test
Patient stands with feet together and eyes open. Ask the patient
to close the eyes (ensuring that you can support the patient if he
or she falls). Note any excessive postural sway or loss of balance.
Indicates: proprioceptive or vestibular deficit if the patient falls
only when he or she closes the eyes.
SECTION
Temperature
A quick test involves using a cold object such as a tuning fork 2
and asking the patient to describe the sensation when applied
to various parts of the body. For more formal testing, two test
tubes are filled with cold and warm water, and patients are asked
to distinguish between the two sensations.
Indicates: altered temperature sensation.
Two-point discrimination
Requires a two-point discriminator, a device similar to a pair of
blunted compasses. With the patient’s eyes open, demonstrate
what you are going to do. Ask the patient to close the eyes.
Alternately touch the patient with either one prong or two.
Reduce the distance between the prongs until the patient can
no longer discriminate between being touched by one prong or
two prongs. Varies according to skin thickness, but normal young
patients can distinguish a separation of approximately 5 mm
in the index finger and approximately 4 cm in the legs. Compare
left with right.
Indicates: impaired sensory function.
Vibration sense
Use a 128-Hz tuning fork. Ask the patient to close the eyes. Place
the tuning fork on a bony prominence or on the fingertips or
toes. The patient should report feeling the vibration and not
simply the contact of the tuning fork. If in doubt, apply the
tuning fork and then stop it vibrating suddenly by pinching it
between your fingers, and see if the patient can correctly identify
when it stops vibrating.
Indicates: altered vibration sense. 123
Neurodynamic tests
Upper limb neurodynamic tests
When conducting upper limb neurodynamic tests (ULNTs), the
sequence of the test movements is relatively unimportant and
may be adapted to suit the patient’s condition. However, if the
SECTION tests are to be of value as an assessment tool, the order used for
a particular patient must be the same each time the patient is
2 tested.
For all the upper limb neurodynamic tests, you may wish to
place the patient’s head in contralateral cervical flexion before
you do the test and then instruct the patient to bring his or her
head back to midline at the end of the sequence.
ULNT 1: Median nerve bias

ULNT 1 (Fig. 2.5) consists of:
• Neutral position of patient on couch in supine
• Fixing shoulder to prevent shoulder elevation during
abduction [1]
• Shoulder joint abduction [2]
• Wrist and finger extension [3]
• Forearm supination [3]
• Shoulder lateral rotation [4]
• Elbow extension [5]
Sensitizing test: cervical lateral flexion away from the
symptomatic side [6].
Desensitizing test: cervical lateral flexion toward the
symptomatic side.
124
1 2
SECTION
2
3 4
5 6
Figure 2.5 (1–6) Upper limb neurodynamic test 1.
ULNT 2a: Median nerve bias

ULNT 2a (Fig. 2.6) consists of:
• Shoulder girdle depression [1, 2]
• Elbow extension [3]
• Lateral rotation of whole arm [4] 125
1 2
SECTION
2
3 4
5 6
Figure 2.6 (1–6) Upper limb neurodynamic test 2a.
• Wrist, finger and thumb extension [5]

• Abduction of shoulder [6]
126 symptomatic side.
Desensitizing tests: cervical lateral flexion toward the
symptomatic side or release of the shoulder girdle
depression.
ULNT 2b: Radial nerve bias

ULNT 2b (Fig. 2.7) consists of:
SECTION
•
•
Shoulder girdle depression [1]
Elbow extension [2]
2
• Medial rotation of whole arm [3]
• Wrist, finger and thumb flexion [4]
• Shoulder abduction
symptomatic side.
depression.
1 2
3 4
Figure 2.7 (1–4) Upper limb neurodynamic test 2b. 127

ULNT 3: Ulnar nerve bias
ULNT 3 (Fig. 2.8) consists of:
• Shoulder girdle stabilised [1]
• Wrist and finger extension [1]
• Forearm pronation [2]
SECTION • Elbow flexion [3]
2 •
•
Shoulder lateral rotation [4]
Shoulder abduction [5]
2
128 Figure 2.8 (1–5) Upper limb neurodynamic test 3.

symptomatic side.
depression.
Slump test (Fig. 2.9) SECTION

Starting position: patient sits upright with knee crease at the
edge of plinth and hands behind back [1]. The slump test 2
consists of:
•
Spinal slump [2]
• Cervical flexion [3]
• Knee extension [4]
• Release neck flexion [5]
1 2 3
4 5 6
Figure 2.9 (1–6) Slump test. 129

The steps can be performed in any order.
Additional movements: add dorsiflexion or plantarflexion
with knee extension; bilateral knee extension [6], hip
abduction (obturator nerve bias), hip medial rotation, hip
flexion.
Positive test: development of pain or discomfort in
SECTION mid-thoracic area, behind the knees or in the hamstrings;
2
restriction of knee extension while slumped with the neck
flexed; restriction of dorsiflexion while slumped with the
neck flexed. Release of neck flexion decreases pain or
increases range of knee extension and/or dorsiflexion.
Desensitizing test: a decrease in pain or increase in range of

knee extension and/or dorsiflexion with cervical extension.
Straight leg raise (Fig. 2.10)
Figure 2.10 Straight leg raise.
Starting position: patient lies supine. The test consists of

passive hip flexion with the knee in extension.
Normal response: feeling of stretch or tingling in posterior leg.
Altered responses can be determined by comparing one
130 side with the other.
Sensitizing tests: dorsiflexion, hip adduction, hip medial
rotation, neck flexion and trunk lateral flexion.
Additional sensitizing tests: Add ankle dorsiflexion and forefoot
eversion (tibial nerve bias), ankle plantarflexion and
forefoot inversion (common peroneal nerve bias),
dorsiflexion and inversion (sural nerve bias).
Passive neck flexion (Fig. 2.11) SECTION

Starting position: patient lies supine. The test consists of
passive neck flexion.
2
Normal response: full, pain-free movement.
Sensitizing tests: straight leg raise, upper limb neurodynamic
tests.
Figure 2.11 Passive neck flexion.
Femoral Nerve Slump Test (Fig. 2.12)

Starting position: patient in side lying with symptomatic side
uppermost. Holds bottom knee to chest and flexes neck.
Sensitizing tests: the uppermost knee is passively flexed and the
hip extended.
Positive test: reproduction of symptoms in anterior thigh.
Desensitizing test: cervical extension reduces symptoms.
Additional sensitizing tests: hip medial or lateral rotation and/
or hip abduction/adduction. 131
SECTION
2
Figure 2.12 Femoral nerve slump test.
Cranial nerves
The cranial nerves form part of the peripheral nervous system
and originate from the brain. Each nerve is named according
to its function or appearance and is numbered using Roman
numerals I to XII. The numbers roughly correspond to their
position as they descend from just above the brainstem (I and II),
through the midbrain (III and IV), pons (V to VII) and medulla
(VIII to XII).
132
Name Function Test Abnormal signs
Olfactory (I) Smell Identify a familiar odour, e.g. coffee, Partial or total loss of smell
orange, tobacco, with one nostril at Altered or increased sense of
a time smell
Optic (II) Sight Visual acuity: read with one eye Visual field defects, loss of visual
covered acuity, colour-blindness
Peripheral vision: detect objects or
movement from the corner of the eye
with the other eye covered
Oculomotor (III) Movement of eyelid and Follow the examiner’s finger, which Squint, ptosis, diplopia, pupil
eyeball, constriction of pupil, moves up and down and side to side, dilation
lens accommodation keeping the head in mid-position
Trochlear (IV) Movement of eyeball upwards As for oculomotor Diplopia, squint
Trigeminal (V) Mastication, sensation for eye, Test fascial sensation Trigeminal neuralgia, loss of
face, sinuses and teeth Clench teeth (the examiner palpates mastication and sensation in eye,
the masseter and temporalis muscles) face, sinuses and teeth
Continued
2
133
SECTION
134
SECTION

Abducens (VI) Movement of eyeball into As for oculomotor Gaze palsy
abduction, controls gaze
Facial (VII) Facial movements, sensation Test ability to move the face, e.g. close Bell’s palsy, loss of taste and
and taste for anterior two- eyes tightly, wrinkle brow, whistle, ability to close eyes
thirds of tongue, secretion of smile, show teeth
saliva and tears
Vestibulocochlear Hearing, balance Examiner rubs index finger and thumb Tinnitus, deafness, vertigo, ataxia,
(VIII) together noisily beside one ear and nystagmus
silently beside the other. Patient
identifies the noisy side
Glossopharyngeal Sensation and taste for Swallow Loss of tongue sensation
(IX) posterior third of tongue, Evoke the gag reflex by touching the and taste, reduced salivation,
swallow, salivation, regulation back of the throat with a tongue dysphagia
of blood pressure depressor
Vagus (X) Motor and sensation for As for glossopharyngeal Vocal cord paralysis, dysphagia,
heart, lungs, digestive tract loss of sensation from internal
and diaphragm, secretion of organs
digestive fluids, taste, swallow,
hiccups
Accessory (XI) Motor to soft palate, larynx, Rotate neck to one side and Paralysis of innervated muscles
pharynx, trapezius and resist flexion, i.e. contract
sternocleidomastoid sternocleidomastoid. Shrug shoulders
against resistance
Hypoglossal (XII) Tongue control and strap Stick out the tongue. Dysphagia, dysarthria, difficulty
muscles of neck Push tongue into the left and right masticating
side of the cheek
2
135
SECTION
Glossary of terms used to evaluate clinical tests
True positive
The patient has the disease, and the test is positive.
False positive
SECTION The patient does not have the disease, but the test is positive.
2 True negative
The patient does not have the disease, and the test is negative.
False negative
The patient has the disease, but the test is negative.
Sensitivity and specificity

The sensitivity of a clinical test refers to the ability of the test to
correctly identify those patients with the disease (true positive
rate). In other words, if the test is highly sensitive, then a negative
result will almost certainly mean that the patient does not have
the disease.
The specificity of a clinical test refers to the ability of the test
to correctly identify those patients without the disease (true
negative rate). In other words, if a test is highly specific, then a
positive result would indicate that the patient is likely to have
the disease.
A way of remembering this is by remembering the terms
Snout and Spin:
SnOut – in a sensitive (Sn) test, a negative (n) result rules Out
disease.
SpIn – in a specific (Sp) test, a positive (p) result rules In
disease.
Positive predictive value (PPV)

The PPV answers the question: “If the test result is positive,
what is the probability that the patient actually has the
disease?”
136
For example, if a test has a small positive predictive value
(i.e. PPV = 15%), it indicates that many of the positive results
from the testing procedure are false positives.
Negative predictive value (NPV)

The NPV answers the question: “If the test result is negative,
what is the probability that the patient does not have the
SECTION
disease?”
For example, if a test has a high negative predictive value
(i.e. NPV = 95%), we can be confident that the negative results
2
from the testing procedure are true negatives.
137
Common postures (from Kendall et al. 2005, with
permission of Williams & Wilkins)
SECTION
2
Abdominals
Back extensors
Rectus abdominis
External oblique
Hip flexors
Hip extensors
Psoas major
Gluteus
maximus Iliacus
Hamstrings Tensor fasciae

latae
Rectus femoris
Figure 2.13 Ideal alignment – side view.
138
Lateral trunk SECTION
muscles
Quadratus 2
lumborum
External
oblique
Internal Hip adductors
oblique
Gluteus medius
Tensor fasciae
latae
Iliotibial tract of
fascia latae
Adductors
Evertors Inverters
Peroneus longus
Tibialis posterior
Peroneus brevis
Flexor digitorum
longus
Flexor hallucis
longus
Figure 2.14 Ideal alignment – posterior view.
139
SECTION
2
Figure 2.15 Kyphosis-lordosis posture.
140
SECTION
Figure 2.16 Sway-back posture.
141
SECTION
2
Figure 2.17 Flat-back posture.
142
SECTION
Figure 2.18 Faulty alignment – posterior view.
143
Ideal alignment
Anteriorly, the abdominal muscles pull upward and the hip flexors
pull downward. Posteriorly, the back muscles pull upward and
the hip extensors pull downward. Thus, the abdominal and hip
extensor muscles work together to tilt the pelvis posteriorly; the
back and hip flexor muscles work together to tilt the pelvis
SECTION anteriorly.
2 Kyphosis-lordosis posture
Short and strong: neck extensors and hip flexors. The low back
is strong and may or may not develop shortness.
Elongated and weak: neck flexors, upper back erector spinae

and external oblique. Hamstrings are slightly elongated
but may or may not be weak.
Swayback posture
Short and strong: hamstrings and upper fibres of internal
oblique. Strong but not short: lumbar erector spinae.
Elongated and weak: one-joint hip flexors, external oblique,
upper back extensors and neck flexors.
Flat-back posture
Short and strong: hamstrings and often the abdominals.
Elongated and weak: one-joint hip flexors.
Faulty alignment: posterior view

Short and strong: right lateral trunk muscles, left hip
abductors, right hip adductors, left peroneus longus and
brevis, right tibialis posterior, right flexor hallucis longus,
right flexor digitorum longus. The left tensor fascia lata is
usually strong, and there may be tightness in the iliotibial
band.
Elongated and weak: left lateral trunk muscles, right hip
abductors (especially posterior gluteus medius), left hip
adductors, right peroneus longus and brevis, left tibialis
posterior, left flexor hallucis longus, left flexor digitorum
longus. The right tensor fascia lata may or may not be
144 weak.
Trigger points
TrP1
Sternal division Clavicular division

Trapezius Sternocleidomastoid
Suboccipital Semispinalis capitis Semispinalis cervicis
2
145
SECTION
146
SECTION
Upper Middle Middle
TrP2 TrP6 TrP5
7
Lower Lower
TrP3 TrP4
Splenius capitis
T12
Trapezius
Upper
TrP
Lower
TrP
Splenius cervicis Levator scapulae

SECTION
Scaleni
Sternal
section
Clavicular
section
Lateral
margin
Pectoralis major
147
SECTION
2
Pectoralis minor Serratus anterior
Latissimus dorsi
148
SECTION
Supraspinatus
Infraspinatus
149
SECTION
2
Teres minor Teres major
Subscapularis
150
SECTION
Rhomboideus
Extensor Extensor Extensor

carpi ulnaris carpi radialis carpi radialis
longus brevis
Middle finger Ring finger Extensor indicis

Finger extensors
151
SECTION
2
Supinator Pronator teres
Iliopsoas
152
SECTION
Superficial Deep
1 1
2 2
Quadratus lumborum
TrP1 TrP2 TrP3
Gluteus medius
153
TrP1
SECTION TrP2
2
Piriformis
Anterior
portion
Tensor fasciae latae
Gluteus medius
Adductor magnus
Adductor brevis
154
SECTION
Hamstring muscles
Peroneus
longus
Peroneus
brevis
Tibialis anterior Extensor digitorum

longus
155
TrP2
TrP4
TrP3
SECTION TrP1
2
Gastrocnemius
TrP2
TrP1
Soleus Flexor Flexor Tibialis

hallucis digitorum posterior
longus longus
156
Normal joint range of movement
Shoulder
Flexion 160–180°
Extension 50–60°
Abduction 170–180°
Medial rotation 70–90° SECTION
Lateral rotation 80–100°
2
Elbow
Flexion 140–150°
Extension 0°
Pronation 80–90°
Supination 80–90°
Wrist
Flexion 70–80°
Extension 60–80°
Radial deviation 15–25°
Ulnar deviation 30–40°
Hip
Flexion 120–125°
Extension 15–30°
Abduction 30–50°
Adduction 20–30°
Medial rotation 25–40°
External rotation 40–50°
157
Knee
Flexion 130–140°
Extension 0°
Ankle
Dorsiflexion 15–20°
SECTION Plantarflexion 50–60°
2 Inversion
Eversion
30–40°
15–20°
Normal ranges of movement vary greatly between individuals.

The above figures represent average ranges of movement.
158
Average range of segmental movement (from
Middleditch & Oliver 2005, with permission)
Flexion Extension
15º 10º 5º 0º 0º 5º 10º 15º
SECTION
C0/1
C1/2 2
C2/3
C3/4
C4/5
C5/6
C6/7
C7/T1
T1/2
T2/3
T3/4
T4/5
T5/6
T6/7
T7/8
T8/9
T9/10
T10/11
T11/12
L12/L1
L1/2
L2/3
L3/4
L4/5
L5/S1
15º 10º 5º 0º 0º 5º 10º 15º

Figure 2.19 Spinal flexion and extension. 159
Lateral flexion Rotation
10º 5º 0º 0º 5º 10º 15º 20º 25º 30º 35º
C0/1
SECTION
0º C1/2
2 C2/3
C3/4
C4/5
C5/6
C6/7
C7/T1
T1/2
T2/3
T3/4
T4/5
T5/6
T6/7
T7/8
T8/9
T9/10
T10/11
T11/12
L12/L1
L1/2
L2/3
L3/4
L4/5
L5/S1
10º 5º 0º 0º 5º 10º 15º 20º 25º 30º 35º

Figure 2.20 Spinal lateral flexion and rotation.
160
Close packed positions and capsular patterns for
selected joints
Close packed
Joint position Capsular pattern*
Temporomandibular Clenched teeth Opening mouth
Cervical spine Extension (also Side flexion and SECTION
applies to thoracic
and lumbar spine)
rotation equally
limited; flexion is full 2
but painful, extension
is limited
Glenohumeral Abduction and Lateral rotation then
lateral rotation abduction then medial
rotation
Humeroulnar Extension Flexion then
extension
Radiocarpal Extension with Flexion and extension
radial deviation equally limited
Trapeziometacarpal None Abduction and
extension, full flexion
Metacarpophalangeal Metacarpophalangeal Flexion then
interphalangeal Flexion (fingers) extension
Opposition (thumb)
Interphalangeal
Extension
Hip Extension and Flexion, abduction
medial rotation and medial rotation
(order may vary)
Extension is slightly
limited
Knee Extension and Flexion then
lateral rotation of extension
tibia
Talocrural Dorsiflexion Plantarflexion then
dorsiflexion
Subtalar Inversion Inversion
161
Close packed
Joint position Capsular pattern*
Mid-tarsal Inversion (also Dorsiflexion,
applies to plantarflexion,
tarsometatarsal) adduction and medial
rotation
First Metatarsophalangeal Extension then flexion
SECTION metatarsophalangeal Extension
2 Interphalangeal
Extension
*Movements are listed in order of restriction, from the most limited to
the least limited.

Data from Cyriax (1982) and Magee (2014).
Classification of ligament and muscle sprains

Ligament sprains
Grade I/mild sprain
Few ligament fibres torn, stability maintained.
Grade II/moderate sprain
Partial rupture, increased laxity but no gross instability.
Grade III/severe sprain
Complete rupture, gross instability.
Muscle strains
Grade I/mild strain
Few muscle fibres torn, minimum loss of strength and pain on
muscle contraction.
Grade II/moderate strain
Approximately half of muscle fibres torn, significant muscle
weakness and loss of function. Moderate to severe pain on
isometric contraction.
Grade III/severe strain
Complete tear of the muscle, significant muscle weakness
and severe loss of function. Minimum to no pain on isometric
162 contraction.
Windows of achievement for gross motor
developmental milestones
Motor activity Approximate age

Rolling 2–9 months
Sitting without support 4–9 months SECTION
Crawling/creeping 5–14 months
Pulling up to supported stand 8–12 months 2
Standing with assistance 5–12 months
Cruising (i.e. walking holding onto furniture) 8–12 months
Walking with assistance 6–14 months
Standing alone 7–17 months
Walking alone 8–18 months
Kicking/throwing a ball 2 years
Running 2 years
Jumping with both feet 2–3 years
Mounting/descending stairs alone 3–4 years
Riding a tricycle 3 years
Catching a ball 3–5 years
Balancing on one leg 3–5 years
Hopping 3–4 years
Skipping 4–5 years
Riding a bicycle 4–8 years
Date compiled from Dosman et al, 2012; Gallahue et al, 2012; Haibach
et al, 2011; WHO Multicentre Growth Reference Study Group, 2006.
163
164
SECTION
Joint hypermobility assessment
Beighton hypermobility score (Beighton et al 1973)
1 2
4 5
Figure 2.21 Beighton Score for joint hypermobility.
Nine-point Beighton hypermobility score
The ability to: Right Left

1 Passively extend the fifth metacarpophalangeal 1 1
joint to ≥90°
2 Passively appose the thumb to the anterior aspect 1 1
of the forearm SECTION
2
3 Passively hyperextend the elbow to ≥10° 1 1
4 Passively hyperextend the knee to ≥10° 1 1
5 Actively place the hands flat on the floor without 1
bending the knees
TOTAL 9
One point is given for each side for manoeuvres 1–4 so that the
hypermobility score will have a maximum of 9 points if all are
positive.
It is generally considered that hypermobility is present if 5
or more of the 9 possible points are scored. In children, a positive
score is at least 6 out of 9 points.
It is worth noting that the Beighton scoring system is useful
as a quick screening tool. However, it is limited to a small selection
of joints. Clinicians are advised to examine other joints (e.g.
shoulders, cervical and thoracic spine, toes and feet) for further
evidence of hypermobility.
Five-part questionnaire for identifying joint

hypermobility (Hakim & Graham 2003)
An answer of ‘Yes’ to two or more of the questions gives a high
prediction of the presence of hypermobility. It does not mean
that the person has hypermobility syndrome.
1. Can you now (or could you ever) place your hands flat on
the floor without bending your knees?
2. Can you now (or could you ever) bend your thumb to
touch your forearm?
3. As a child, did you amuse your friends by contorting
your body into strange shapes, OR could you do the
splits? 165
4. As a child or teenager, did your shoulder or kneecap
dislocate on more than one occasion?
5. Do you consider yourself double-jointed?
Complex regional pain syndrome
SECTION
Budapest criteria: clinical diagnostic criteria
for complex regional pain syndrome (Harden
2 et al 2007)
To make the clinical diagnosis, the following criteria must be
met:
1. Continuing pain, which is disproportionate to any inciting

event
2. Must report at least one symptom in three of the four
following categories:
• Sensory: Reports of hyperesthesia and/or allodynia
• Vasomotor: Reports of temperature asymmetry and/or
skin colour changes and/or skin colour asymmetry
• Sudomotor/oedema: Reports of oedema and/or sweating
changes and/or sweating asymmetry
• Motor/trophic: Reports of decreased range of motion
and/or motor dysfunction (weakness, tremor, dystonia)
and/or trophic changes (hair, nails, skin)
3. Must display at least one sign at time of evaluation in two
or more of the following categories:
• Sensory: Evidence of hyperalgesia (to pinprick)
and/or allodynia (to light touch and/or temperature
sensation and/or deep somatic pressure and/or joint
movement)
• Vasomotor: Evidence of temperature asymmetry (>1°C)
and/or skin colour changes and/or asymmetry
• Sudomotor/oedema: Evidence of oedema and/or
sweating changes and/or sweating asymmetry
• Motor/trophic: Evidence of decreased range of motion
and/or motor dysfunction (weakness, tremor, dystonia)
and/or trophic changes (hair, nails, skin)
4. There is no other diagnosis that better explains the signs
166 and symptoms.
Distribution of referred pain (Tortora & Derrickson 2017)
Lung and Liver and

Liver and diaphragm gallbladder
gallbladder
Heart
Stomach
Stomach
Gallbladder Pancreas Liver and
Small intestine Ovary gallbladder
Colon
Ovary
Urinary Kidney
Appendix
bladder
Kidney
Ureter
A Anterior view B Posterior view

Figure 2.22 A and B Common patterns of referred pain of visceral origin.
2
167
SECTION
Red flags
Cauda equina syndrome (from National Institute
for Health and Care Excellence, Clinical Knowledge
Summaries 2017, with permission)
• Severe or progressive bilateral neurological deficit of the
SECTION legs, such as major motor weakness with knee extension,
ankle eversion, or foot dorsiflexion.
2 • Recent-onset urinary retention (caused by bladder
distension because the sensation of fullness is lost) and/or
urinary incontinence (caused by loss of sensation when
passing urine).
• Recent-onset faecal incontinence (due to loss of sensation
of rectal fullness).
• Perianal or perineal sensory loss (saddle anaesthesia or
paraesthesia).
• Unexpected laxity of the anal sphincter.
Spinal fracture (from National Institute for

Health and Care Excellence, Clinical Knowledge
• Sudden onset of severe central spinal pain that is relieved
by lying down
• There may be a history of major trauma (such as a road
traffic collision or fall from a height), minor trauma, or
even just strenuous lifting in people with osteoporosis or
those who use corticosteroids
• Structural deformity of the spine (such as a step
from one vertebra to an adjacent vertebra) may be
present
• There may be point tenderness over a vertebral body
Cancer (from National Institute for Health and

Care Excellence, Clinical Knowledge Summaries
2017, with permission)
• The person being 50 years of age or more
168 • Gradual onset of symptoms
• Severe unremitting pain that remains when the person is
supine, aching night pain that prevents or disturbs sleep,
pain aggravated by straining (for example, when defecating,
or when coughing or sneezing), and thoracic pain.
• Localized spinal tenderness
• No symptomatic improvement after 4 to 6 weeks of
conservative low back pain therapy
SECTION
• Unexplained weight loss
• Past history of cancer –breast, lung, gastrointestinal,
prostate, renal, and thyroid cancers are more likely to
2
metastasize to the spine
Infection (such as discitis, vertebral osteomyelitis,
or spinal epidural abscess) (from National Institute
for Health and Care Excellence, Clinical Knowledge
• Fever
• Tuberculosis, or recent urinary tract infection
• Diabetes
• History of intravenous drug use
• HIV infection, use of immunosuppressants, or the person
is otherwise immunocompromised
Inflammatory disease (axial spondyloarthritis)

(from Spondyloarthritis in over 16s: diagnosis and
management 2017, with permission)
Inflammatory disease should be suspected if the person’s low
back pain started before 45 years of age, has lasted for longer
than 3 months and four or more of the following additional
criteria are also present:
• low back pain that started before 35 years of age (this
further increases the likelihood that back pain is due to
spondyloarthritis compared with low back pain that
started between 35 and 44 years of age)
• waking during the second half of the night because of
symptoms
• buttock pain
• improvement with movement 169
• improvement within 48 hours of taking nonsteroidal
anti-inflammatory drugs (NSAIDs)
• a first-degree relative with spondyloarthritis
• current or past arthritis
• current or past enthesitis
• current or past psoriasis
SECTION
2 Psychosocial yellow flags (Accident Compensation

Corporation 2004, with permission)
Attitudes and beliefs about back pain
• Belief that pain is harmful or disabling resulting in

fear-avoidance behaviour, e.g., the development of
guarding and fear of movement
• Belief that a pain must be abolished before attempting to
return to work or normal activity
• Expectation of increased pain with activity or work, lack
of ability to predict capability
• Catastrophizing, thinking the worst, misinterpreting
bodily symptoms
• Belief that pain is uncontrollable
• Passive attitude to rehabilitation behaviours
• Use of extended rest, disproportionate ‘downtime’
• Reduced activity level with significant withdrawal from
activities of daily living
• Irregular participation or poor compliance with physical
exercise, tendency for activities to be in a ‘boom-bust’
cycle
• Avoidance of normal activity and progressive substitution
of lifestyle away from productive activity
• Report of extremely high intensity of pain, e.g. above 10,
on a 0–10 visual analogue scale
• Excessive reliance on use of aids or appliances
• Sleep quality reduced since onset of back pain
• High intake of alcohol or other substances (possibly as
self-medication), with an increase since onset of back pain
• Smoking
170
Compensation issues
• Lack of financial incentive to return to work
• Delay in accessing income support and treatment cost,
disputes over eligibility
• History of claim/s due to other injuries or pain problems
• History of extended time off work due to injury or other
pain problem (e.g. more than 12 weeks) SECTION
• History of previous back pain, with a previous claim/s
and time off work
• Previous experience of ineffective case management
2
(e.g. absence of interest, perception of being treated
punitively)
Diagnosis and treatment
• Health professional sanctioning disability, not providing
interventions that will improve function
• Experience of conflicting diagnoses or explanations for
back pain, resulting in confusion
• Diagnostic language leading to catastrophizing and fear
(e.g. fear of ending up in a wheelchair)
• Dramatization of back pain by health professional
producing dependency on treatments, and continuation
of passive treatment
• Number of times visited health professional in last year
(excluding the present episode of back pain)
• Expectation of a ‘techno-fix’, e.g. requests to treat as if
body were a machine
• Lack of satisfaction with previous treatment for back pain
• Advice to withdraw from job
Emotions
• Fear of increased pain with activity or work
• Depression (especially long-term low mood), loss of sense
of enjoyment
• More irritable than usual
• Anxiety about and heightened awareness of body
sensations (includes sympathetic nervous system arousal)
• Feeling under stress and unable to maintain sense of control
171
• Presence of social anxiety or disinterest in social activity
• Feeling useless and not needed
Family
• Overprotective partner/spouse, emphasizing fear of harm
or encouraging catastrophizing (usually well-intentioned)
• Solicitous behaviour from spouse (e.g. taking over tasks)
SECTION
• Socially punitive responses from spouse (e.g. ignoring,
2 expressing frustration)
• Extent to which family members support any attempt to
return to work
• Lack of support person to talk to about problems
Work
• History of manual work, notably from the following
occupational groups:
• Fishing, forestry and farming workers
• Construction, including carpenters and builders
• Nurses
• Truck drivers
• Labourers
• Work history, including patterns of frequent job changes,
experiencing stress at work, job dissatisfaction, poor
relationships with peers or supervisors, lack of vocational
direction
• Belief that work is harmful; that it will do damage or be
dangerous
• Unsupportive or unhappy current work environment
• Low educational background, low socioeconomic
status
• Job involves significant biomechanical demands, such as
lifting, manual handling heavy items, extended sitting,
extended standing, driving, vibration, maintenance of
constrained or sustained postures, inflexible work schedule
preventing appropriate breaks
• Job involves shift work or working unsociable hours
• Minimal availability of selected duties and graduated
return to work pathways, with unsatisfactory
172 implementation of these
• Negative experience of workplace management of back
pain (e.g., absence of a reporting system, discouragement
to report, punitive response from supervisors and
managers)
• Absence of interest from employer
Remember the key question to bear in mind while conducting
these clinical assessments is ‘What can be done to help this person SECTION
2
experience less distress and disability?’
How to judge if a person is at risk for long-term

work loss and disability
A person may be at risk if:
• There is a cluster of a few very salient factors
• There is a group of several less important factors that
combine cumulatively
There is good agreement that the following factors are
important and consistently predict poor outcomes:
• Presence of a belief that back pain is harmful or
potentially severely disabling
• Fear-avoidance behaviour (avoiding a movement or
activity due to misplaced anticipation of pain) and
reduced activity levels
• Tendency to low mood and withdrawal from social
interaction
• An expectation that passive treatments rather than active
participation will help
Suggested questions (to be phrased in treatment provider’s
own words):
• Have you had time off work in the past with back pain?
• What do you understand is the cause of your back
pain?
• What are you expecting will help you?
• How is your employer responding to your back pain? Your
coworkers? Your family?
• What are you doing to cope with back pain?
• Do you think that you will return to work? When? 173
Musculoskeletal assessment
Patients present with a variety of conditions, and assessments
need to be adapted to suit their needs. It is important to under-
stand the patient’s perspective of the problem as well as his or
her expectations of physiotherapy. This section provides a basic
framework for the subjective and physical musculoskeletal
SECTION assessment.
2 Subjective examination
Body chart
Location of current symptoms

Type of pain
Depth, quality, intensity of symptoms
Intermittent or constant
Abnormal sensation (e.g. pins and needles, numbness)
Relationship of symptoms
Check other relevant regions
Behaviour of symptoms
Aggravating factors
Easing factors
Severity
Irritability
Daily activities/functional limitations
24-hour behaviour (night pain)
Stage of the condition
Special questions
Red flags
Dizziness or other symptoms of vertebrobasilar insufficiency
(diplopia, drop attacks, dysarthria, dysphagia, nausea)
General health (e.g. smoking, alcohol, physical activity)
History of present condition

Mechanism of injury
History of each symptomatic area
174
Relationship of onset of each symptomatic area
Change of each symptom since onset
Previous episodes of present complaint
Previous treatment and outcome
Recent X-rays or investigations
Past medical history

SECTION
Relevant medical history
THREAD (Thyroid disorders, Heart problems, Rheumatoid 2
arthritis, Epilepsy, Asthma or other respiratory problems,
Diabetes)
Osteoporosis
Family history
Drug history
Current medication
Steroids
Anticoagulants
Social history
Age and gender
Home and work situation
Dependents
Hobbies and activities
Exercise
Yellow flags
Physical examination
Observation
Posture
Function
Gait
Structural abnormalities
Muscle bulk and tone
Soft tissues
175
Active and passive joint movements
Joint integrity tests (i.e. valgus and varus stress test)
Muscle tests
Muscle strength
Muscle control and stability
SECTION Muscle length
Isometric muscle testing
2 Neurological tests
Integrity of the nervous system
• dermatomes
• reflexes
• myotomes
Sensitivity of the nervous system
• straight leg raise
• slump test
• slump knee bend
• passive neck flexion
• upper limb neurodynamic tests
Neurological tests (e.g. coordination, balance)
Other tests (e.g. vascular, cranial)
Palpation
Skin and superficial soft tissue
Muscle and tendon
Nerve
Ligament
Joint
Bone
Pulses
Passive accessory movements

Accident Compensation Corporation (2004). New Zealand acute low back
pain guide: Incorporating the guide to assessing psychosocial yellow flags in
176
acute low back pain. New Zealand: ACC. www.acc.co.nz.
Beighton, P. H., et al. (1973). Articular mobility in an African population.
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2
tor development: infants, children, adolescents, adults (7th ed.). New York:
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178
Neurology
SECTION
Neuroanatomy illustrations 180
Signs and symptoms of cerebrovascular lesions 185
Signs and symptoms of injury to the lobes of the
brain 189
Signs and symptoms of haemorrhage to other areas of SECTION
the brain 192 3

Functional implications of spinal cord injury 194
3 Neurology
Glossary of neurological terms 197
Modified Ashworth scale 202
Neurological assessment 202
Neuroanatomy illustrations
Postcentral
Postcentral gyrus Central
sulcus sulcus
Precentral
Parietal gyrus
lobe
Precentral
Occipital sulcus
lobe
Frontal
SECTION lobe
3
Preoccipital
notch Lateral
Neurology
sulcus
Temporal
sulci Temporal
Temporal gyri
lobe
Figure 3.1 Lateral view of right cerebral hemisphere.
Corpus Central Paracentral

callosum sulcus lobule
Parietal
Cingulate lobe
gyrus
Parieto-
occipital
Frontal sulcus
lobe
Occipital
lobe
Anterior
commissure Calcarine
sulcus
Limbic Temporal
lobe lobe
Uncus Thalamus
180 Figure 3.2 Medial view of right cerebral hemisphere.
Cingulate gyrus Formix
Corpus callosum
Anterior
commissure Choroid plexus
Optic
chiasma Thalamus
Pineal gland
Infundibulum
Cerebellum
Pituitary gland Midbrain SECTION
Pons Fourth ventricle
Brain stem Medulla
oblongata Spinal
3
cord
Neurology
Figure 3.3 Mid-sagittal section of the brain.
Caudate Corpus Lateral

nucleus callosum ventricle
(head) (frontal horn)
Lentiform
nucleus Anterior limb
internal
Globus capsule
pallidus
Putamen Third
ventricle
Posterior
limb
Thalamus internal
capsule
Splenium Lateral
ventricle
(inferior horn)
Calcarine
sulcus
Figure 3.4 Horizontal section through the brain. 181
Cingulate Body of
sulcus corpus Caudate
Body of callosum nucleus
lateral ventricle
Internal
Formix capsule
Thalamus Putamen
Insula
SECTION Globus
Claustrum pallidus
3 Temporal horn
of lateral Third Hippocampus
ventricle ventricle
Subthalamic
Neurology
nucleus
Pons Substantia
nigra
Figure 3.5 Coronal section of the brain.
Primary motor
Primary somatic cortex
sensory cortex
Supplementary
Primary auditory motor cortex
cortex
Primary
visual
cortex
Visual association Olfactory

cortex cortex
182 Figure 3.6 Lateral view of sensory and motor cortical areas.
Primary motor Primary somatic
Supplementary cortex sensory cortex
motor cortex
Visual
association
cortex
SECTION
Primary
Olfactory cortex visual
cortex 3
Figure 3.7 Medial view of sensory and motor cortical areas.
Neurology
Anterior
cerebral artery
Posterior cerebral Middle cerebral

artery artery
Figure 3.8 Lateral view of right hemisphere showing territories
supplied by the cerebral arteries. 183
ASCENDING DESCENDING
TRACTS TRACTS
Gracile fasciculus
Cuneate fasciculus Lateral
Posterior and corticospinal
anterior Medullary
spinocerebellar reticulospinal
SECTION
3 Lateral
spinothalamic Pontine
reticulospinal
Anterior
Vestibulospinal
Neurology
spinothalamic
Tectospinal
Anterior
corticospinal
Figure 3.9 Ascending and descending spinal cord tracts.
Ascending tracts Descending tracts

Gracile fasciculus – Lateral corticospinal – voluntary
proprioception and movements
discriminative touch in legs and Medullary retrospinal –
lower trunk locomotion and posture
Cuneate fasciculus – Pontine reticulospinal –
proprioception and locomotion and posture
discriminative touch in arms and
upper trunk Vestibulospinal – balance and
antigravity muscles
Posterior and anterior
spinocerebellar – reflex and Tectospinal – orientates head to
proprioception visual stimulation
Lateral spinothalamic – pain and Anterior corticospinal –

temperature voluntary movements
Anterior spinothalamic – light

184 touch
Signs and symptoms of cerebrovascular lesions
Middle cerebral artery (MCA)
SECTION
Neurology
Figure 3.10 Middle cerebral artery The middle cerebral artery
arises from the internal carotid artery. The proximal part supplies a
large portion of the frontal, parietal and temporal lobes. The deep
branches supply the basal ganglia (corpus striatum and globus pallidus),
internal capsule and thalamus.
Signs and symptoms Structures involved

Contralateral weakness/paralysis Motor cortex (precentral gyrus)
of face, arm, trunk and leg
Contralateral sensory Somatosensory cortex
impairment/loss of face, arm, (postcentral gyrus)
trunk and leg
Expressive aphasia (Broca’s Motor speech area of Broca
aphasia) (dominant frontal lobe)
Receptive aphasia (Wernicke’s Sensory speech area of Wernicke
aphasia) (dominant parietal/temporal
lobe)
Neglect of contralateral side, Parietal lobe (nondominant lobe)
dressing and constructional
apraxia, geographical agnosia,
anosognosia 185
Homonymous hemianopia Optic radiation – temporal fibres
(often upper homonymous
quadrantanopia)
Ocular deviation Frontal lobe
Gait disturbance Frontal lobe (usually bilateral)
Pure motor hemiplegia Posterior limb of internal capsule
and adjacent corona radiata
Pure sensory syndrome Ventral posterior nucleus of
thalamus
SECTION
3 Anterior cerebral artery (ACA)

Neurology
Figure 3.11 Anterior cerebral artery The anterior cerebral

artery arises from the internal carotid artery and is connected by
the anterior communicating artery. It follows the curve of the corpus
callosum and supplies the medial aspect of the frontal and parietal
lobes, corpus callosum, internal capsule and basal ganglia (caudate
nucleus and globus pallidus).

Contralateral hemiplegia/ Motor cortex
hemiparesis (lower limb > upper
186 limb)
Contralateral sensory loss/ Somatosensory cortex
impairment (lower limb > upper
limb)
Urinary incontinence Superior frontal gyrus (bilateral)
Contralateral grasp reflex Frontal lobe
Akinetic mutism, whispering, Frontal lobe (bilateral)
apathy
Ideomotor apraxia, tactile Corpus callosum
agnosia, agraphia of the left hand
Spastic paresis of lower limb Bilateral motor leg area SECTION
Pathological grasp reflex, alien- Supplementary motor area,
hand phenomenon corpus callosum, cingulate gyrus 3
Gait apraxia Corpus callosum, cingulate gyrus
(usually bilateral)
Neurology
Impaired memory, confabulation Basal forebrain
Posterior cerebral artery (PCA)
Figure 3.12 Posterior cerebral artery The posterior cerebral

artery arises from the basilar artery. It supplies the occipital and
temporal lobes, midbrain, choroid plexus, thalamus, subthalamic
nucleus, optic radiation, corpus callosum and cranial nerves III and IV.
The posterior communicating arteries connect the posterior cerebral
arteries to the middle cerebral arteries anteriorly. 187
Thalamic syndrome: hemisensory Posterior nucleus of thalamus
loss, chorea or hemiballism,
spontaneous pain and
dysaesthesias
Weber’s syndrome: oculomotor Cranial nerve III and cerebral
paralysis and contralateral peduncle
hemiplegia
Contralateral hemiballism Subthalamic nucleus
Contralateral homonymous Primary visual cortex or optic
hemianopia radiation
SECTION Cortical blindness/cortical visual Primary visual cortex
3 impairment
Bilateral homonymous Bilateral occipital lobe
hemianopia, visual hallucinations
Alexia, colour anomia, impaired Dominant corpus callosum
Neurology
memory, visual agnosia (occipital lobe)

Memory defect, amnesia Bilateral inferomedial portions of
temporal lobe
Prosopagnosia Calcarine sulcus and lingual gyrus
(nondominant occipital lobe)
Vertebral and basilar arteries

The vertebral arteries arise from the subclavian arteries at the
root of the neck and enter the skull through the foramen
magnum. Within the skull they fuse to form the basilar artery.
They supply the medulla, pons, midbrain and cerebellum.

Lateral medullary syndrome:
• vertigo, vomiting, nystagmus Vestibular nuclei
• ipsilateral limb ataxia Spinocerebellar tract
• ipsilateral loss of facial pain and Cranial nerve V
thermal sensation
• ipsilateral Horner’s syndrome Descending sympathetic
188 tract
• ipsilateral dysphagia, hoarseness, vocal Cranial nerves IX and X
cord paralysis and reduced gag reflex
• contralateral loss of pain and thermal Lateral spinothalamic
sensation in trunk and limbs tract
Ipsilateral tongue paralysis and Cranial nerve XII
hemiatrophy
Contralateral impaired tactile sensation Medial lemniscus
and proprioception
Diplopia, lateral and vertical gaze palsies, Cranial nerve VI, medial
pupillary abnormalities longitudinal fasciculus
SECTION
Bulbar palsy, tetraplegia, changes in Bilateral corticospinal
consciousness
Pseudobulbar palsy, emotional instability
tracts
Bilateral supranuclear
3
fibres, cranial nerves
IX–XII
Neurology
Locked-in syndrome Bilateral medulla or pons
Coma, death Brainstem
Signs and symptoms of injury to the lobes of

the brain (adapted from Lindsay et al 2010, with
permission)
Frontal lobe
Function Signs of impairment
Precentral gyrus (motor Contralateral hemiparesis/hemiplegia
cortex)
Contralateral movement:
face, arm, leg, trunk
Broca’s area (dominant Expressive aphasia (dominant)
hemisphere)
Expressive centre for speech
Supplementary motor Paralysis of contralateral head and
area eye movement
Contralateral head and eye
turning 189
Prefrontal areas (damage Three prefrontal syndromes are
is often bilateral) recognized:
‘Personality’, initiative Orbitofrontal syndrome – disinhibition,
poor judgement, emotional lability
Frontal convexity syndrome – apathy,
indifference, poor abstract thought
Medial frontal syndrome – akinetic,
incontinent, sparse verbal output
Prefrontal lesions are also associated
SECTION with primitive reflexes (e.g. grasp,
pout), disturbance of gait (gait
3 apraxia), resistance to passive
movements of the limbs (paratonia)
Paracentral lobule Incontinence of urine and faeces
Neurology
Cortical inhibition of bladder

and bowel voiding
Parietal lobe
Postcentral gyrus (sensory Hemisensory loss/disturbance:
cortex) postural, passive movement,
Posture, touch and passive localization of light touch,
movement two-point discrimination,
astereognosis, sensory
inattention
Supramarginal and angular
gyri
Dominant hemisphere (part Receptive aphasia
of Wernicke’s language area):
integration of auditory and visual
aspects of comprehension
Nondominant hemisphere: body Left-sided inattention, denies
image, awareness of external hemiparesis
environment, ability to construct Anosognosia, dressing
shapes, etc. apraxia, geographical agnosia,
190 constructional apraxia
Dominant parietal lobe Finger agnosia, acalculia, agraphia,
Calculation, using numbers confusion between right and left
Optic radiation Homonymous quadrantanopia
Visual pathways
Temporal lobe
Superior temporal gyrus Cortical deafness, difficulty
(auditory cortex) hearing speech – associated with SECTION
3
Hearing of language (dominant receptive aphasia (dominant),
hemisphere), hearing of sounds, amusia (nondominant), auditory
rhythm and music (nondominant) hallucinations
Middle and inferior temporal Disturbance of memory and
Neurology
gyri learning
Learning and memory
Limbic lobe Olfactory hallucinations,
Smell, emotional/affective aggressive or antisocial
behaviour behaviour, inability to establish
new memories
Optic radiation Upper homonymous
Visual pathways quadrantanopia
Occipital lobe
Calcarine sulcus
Primary visual/striate cortex: Cortical blindness (bilateral
Relay of visual information involvement), homonymous
to parastriate cortex hemianopia with or without macular
involvement
Association visual/parastriate Cortical blindness without awareness
cortex: (striate and parastriate involvement),
Relay of visual information inability to direct gaze associated
to parietal, temporal and with agnosia (bilateral parieto-
frontal lobes occipital lesions), prosopagnosia
(bilateral occipito-temporal lesions) 191
Signs and symptoms of haemorrhage to other
areas of the brain
Putamen
Part of basal ganglia Contralateral hemiplegia/hemiparesis,
Involved in selective contralateral hemisensory loss,
movement hemianopia (posterior segment),
contralateral gaze palsy (posterior
segment), receptive-type aphasia
(posterior segment, left side),
SECTION anosognosia (posterior segment, right
3 side), apathy, motor impersistence,

temporary unilateral neglect (anterior
segment), coma/death (large lesion)
Neurology
Thalamus
Thalamus Contralateral hemiparesis/
Receives motor and sensory hemiplegia, contralateral
inputs and transmits them to hemisensory loss, impaired
the cerebral cortex consciousness, ocular disturbances
(varied), aphasia (dominant),
contralateral neglect (nondominant)
Midbrain
Part of brainstem Ipsilateral ptosis, dilated
Plays an important role in the pupil, occulomotor nerve
control of eye movements weakness, Horner’s syndrome.
and coordination of auditory Contralateral hemiparesis
and visual reflexes. Contains including lower face and tongue,
descending motor pathways, contralateral sensory loss
ascending sensory pathways, the including face, contralateral
red nuclei and substantia nigra and ataxia and intention tremor
192 cranial nerve nuclei III and IV
Pons
Part of brainstem Coma/death (large bilateral lesions),
Contains descending locked-in syndrome (bilateral),
motor pathways, tetraplegia (bilateral), lateral gaze palsy
ascending sensory towards affected side, contralateral
pathways and cranial hemiplegia, contralateral hemisensory
nerve nuclei V–VIII loss, ipsilateral facial weakness/sensory
loss, ipsilateral ataxia, coarse intention
tremor
Cerebellum SECTION
Function Signs of impairment 3

Anterior lobe Hypotonia, postural reflex
(spinocerebellum) abnormalities
Neurology
Muscle tone, posture and
gait control
Posterior lobe Ipsilateral ataxia: dysmetria,
(neocerebellum) dysdiadochokinesia, intention tremor,
Coordination of skilled rebound phenomenon, dyssynergia,
movements dysarthria
Flocculonodular lobe Disturbance of balance, unsteadiness
(vestibulocerebellum) of gait and stance, truncal ataxia,
Eye movements and balance nystagmus, ocular disturbances
Medulla oblongata
Part of brainstem Contralateral hemiparesis and
Controls breathing, heart and sensory loss (with sparing of the
blood vessel function and face). Ipsilateral facial sensory
digestion. Contains descending loss (pain and temperature).
motor pathways (the lateral Ipsilateral Horner’s syndrome.
corticospinal tract crosses to Ipsilateral laryngeal, pharyngeal
the contralateral side within and palatal paralysis (loss of
the medulla), ascending sensory gag reflex) with dysarthria and
pathways and the lower cranial dysphagia. Ipsilateral ataxia and
nerve nuclei (IX, X, XI, XII) dysmetria. Nystagmus, nausea,
vomiting and vertigo 193
Neurology
194
SECTION
Functional implications of spinal cord injury
Level Motor control Personal independence Equipment Mobility

C1–C2 Swallow, talk, chew, Type, turn pages, use Hoist, respirator, mouthstick, reclining Wheelchair
blow (cough absent) telephone and computer powered wheelchair using breath/chin
control
C3 Neck control, weak As above Hoist, respirator, mouth/head stick, Wheelchair
shoulder elevation wheelchair as above
C4 Respiration, neck Feed possible Mouth/head stick, hoist, mobile arm Wheelchair
control, shoulder shrug supports, wheelchair as above
C5 Shoulder external Feed, groom, roll in Adapted feeding/grooming equipment Wheelchair
rotation, protraction, bed, weight shift, push and hand splints, mobile arm supports,
elbow flexion, wheelchair on flat, use powered wheelchair with hand
supination brake controls or lightweight manual with
grips
C6 Shoulder, elbow Tenodesis grip, drink, write, Adapted equipment and splints, Bed mobility, bed-
flexion, wrist personal ADL, transfers, transfer board, hand-controlled to-chair transfers,
extension, pronation. dress upper body, light car, lightweight manual wheelchair, wheelchair, car
Weak elbow domestic chores, push powered for short distances
extension, wrist flexion wheelchair on slope
and thumb control
C7 Elbow extension, finger Dress lower body, personal Bath board, shower chair, hand- All transfers,
flexion and extension, and skin care, showering, all controlled car, wheelchair as above wheelchair, car
limited wrist flexion transfers, pick up from floor,
wheelchair sports
C8 Wrist flexion, hand Bladder and bowel care Grab rails, standing frame, nonadapted Stand in frame
control wheelchair
T1–T5 Top half of intercostals Trunk support, improved Bilateral knee-ankle orthoses with Full wheelchair
and long back muscles balance, assisted cough, spinal attachment, standing frame/table independence,
negotiate kerbs with transfer floor to
wheelchair, routine chair, mobilize
domestic chores with assistance for
short distances
T6–T12 Abdominals Good balance, weak to Bilateral knee-ankle orthoses, crutches Mobilize
normal cough, improved or frame independently
stamina indoors, transfer
chair to crutches
L1–L2 Hip flexion Calipers Stairs, transfer
floor to crutches
Neurology
3
195
SECTION
Neurology
196
SECTION
L3–L5 Knee extension, Ankle-foot orthoses, crutches/sticks
weak knee flexion,
dorsiflexion and
eversion
S1–S2 Hip extension Improved standing balance Normal gait
without aids
S2–S4 Bladder, bowel and
sexual function
Autonomic dysreflexia
A potentially life-threatening syndrome that can develop in
individuals with a spinal cord lesion at or above T6. It is character-
ized by an abrupt onset of severe and sustained hypertension.
If not treated immediately it can lead to seizures, retinal haemor-
rhage, pulmonary oedema, myocardial infarction, cerebral
haemorrhage and, in some cases, death. Signs include headache,
flushed face, bradycardia, sweating above the level of injury,
goose bumps below the level of injury, nasal stuffiness and nausea.
Autonomic dysreflexia is triggered by a noxious or non-noxious
stimulus below the level of the injury. This could be due to irrita-
SECTION
tion of the bladder (urinary tract infection, blocked catheter),
bowel (distended or irritated bowel, constipation), skin (cuts,
burns, pressure sores, pinching), abdomen (ulcers, gastritis),
3
menstrual cramps or restrictive clothing.
Neurology
Glossary of neurological terms
Acalculia inability to calculate
Agnosia inability to interpret sensations
such as sounds (auditory agnosia),
three-dimensional objects by touch
(tactile agnosia) or symbols and letters
(visual agnosia)
Agraphia inability to write
Akinesia loss of the ability to initiate movement
and episodes of ‘freezing’ during
movement
Alexia inability to read
Allodynia a painful response to a non-noxious
stimulus
Amnesia total or partial loss of memory
Amusia impaired recognition of music
Aneurysm a bulge in a blood vessel (usually an
artery) caused by a weakness in the
vessel wall
Anomia inability to name objects
Anosmia loss of ability to smell 197
Anosognosia denial of ownership or the existence of
a hemiplegic limb
Aphasia inability to generate and understand
language whether verbal or written
Apraxia a motor planning disorder characterized
by an inability to perform learned
movements despite intact power,
sensation, coordination, perception
and understanding. Different forms
include ideomotor (inability to carry
out motor commands but able to
SECTION perform movements under different
3 circumstances) and ideational (inability

to carry out a sequence of movements,
each of which can be performed
separately), constructional (inability
Neurology
to build, assemble, or draw objects),

occulomotor (impaired voluntary eye
movement), dressing and gait.
Astereognosis inability to recognize objects by touch
alone, despite intact sensation
Ataxia shaky and uncoordinated voluntary
movements that may be associated with
cerebellar or posterior column disease
Athetosis involuntary writhing movements
affecting face, tongue and hands
Ballismus sudden, involuntary violent flinging
movements of limbs, usually unilateral
(hemiballismus)
Bradykinesia slowness of movement
Bulbar relating to or involving the medulla
oblongata
Chorea irregular, jerky, involuntary movement
Clonus more than three rhythmic contractions
of the plantarflexors in response to
sudden passive dorsiflexion
198
Decorticate rigidity characterized by bent arms held in
towards the chest, clenched fists and
extended lower limbs. Associated
with disinhibition of the red nucleus
(midbrain) and disruption of the lateral
corticospinal tract
Decerebrate rigidity characterized by extended and
internally rotated upper and lower
limbs, with the wrists in flexion, the
ankles in plantarflexion and the head in
extension. Usually indicates damage to
the brainstem, specifically lesions in the SECTION
Diplopia
midbrain and cerebellum
double vision 3
Dysaesthesia perverted response to sensory stimuli
producing abnormal and sometimes
Neurology
unpleasant sensation
Dysarthria difficulty articulating speech
Dysdiadochokinesia clumsiness in performing rapidly
alternating movements
Dyskinesia involuntary movements, e.g. tremor,
chorea, dystonia, myoclonus
Dysmetria under- or overshooting while reaching
towards a target
Dysphagia difficulty or inability to swallow
Dysphasia difficulty understanding language
(receptive dysphasia) or generating
language (expressive dysphasia)
Dysphonia difficulty in producing the voice
Dyssynergia clumsy, uncoordinated movements
Dystonia hypertonia associated with abnormal
postural movements caused by
cocontraction of agonists and
antagonists, usually at an extreme of
flexion or extension
199
Extrapyramidal refers to the neural network (principally
signs the basal ganglia) located outside the
pyramids of the medulla that modulates
and regulates pyramidal function (i.e.
movement).
Fasciculation small, local involuntary muscle
contraction (twitching)
Graphanaesthesia inability to recognize numbers or letters
traced onto the skin with a blunt object
Hemianopia loss of one-half of the normal visual field
Hemiparesis weakness affecting one side of the body
SECTION Hemiplegia paralysis affecting one side of the body
3 Homonymous affecting the same side, i.e. homonymous

diplopia
Hyperacusis increased sensitivity to sound
Hyperaesthesia increased sensitivity to any stimulus
Neurology
Hyperalgesia increased sensitivity to a noxious

stimulus
Hyperreflexia increased reflexes
Hypertonia increase in normal muscle tone
Hypertrophy abnormal increase in tissue size
Hypoaesthesia reduced sensitivity to any stimulus
Hypokinesia slowness in the initiation of movement
Hypotonia reduced muscle tone
Kinaesthesia perception of body position and
movement
Miosis pupil constriction
Monoparesis weakness affecting one limb
Monoplegia paralysis affecting one limb
Myoclonus brief, involuntary, shocklike jerks of a
muscle/group of muscles
Myotonia persistent muscle contraction after
cessation of voluntary contraction
Nystagmus involuntary, repetitive, oscillatory
movement of the eye in one direction,
alternating with a slower movement in
the opposite direction
Paraesthesia tingling sensation often described as
200 ‘pins and needles’
Paraphasia insertion of inappropriate or incorrect
words in a person’s speech
Paraplegia paralysis of both legs
Paresis muscle weakness
Photophobia intolerance to light
Prosopagnosia inability to recognize faces
Ptosis drooping of the upper eyelid
Pyramidal signs refers to the corticospinal tract that
travels from the motor cortex to
the brainstem and spinal cord via the
pyramids of the medulla. Injuries to the
corticospinal tract show characteristics SECTION
Rigidity
of an upper motor neurone lesion
hypertonia associated with increased 3
resistance to passive stretch that
is present at very low speeds of
Neurology
movement, is not velocity-dependent
and can affect agonists and antagonists
simultaneously and movements in both
directions. Subtypes are ‘cog-wheel’
(increased resistance that gives way in
little jerks) and ‘lead-pipe’ (sustained
resistance throughout the whole range
of movement).
Quadrantanopia loss of one-quarter of the normal visual
field
Quadraparesis weakness of all four limbs
Quadriplegia paralysis of all four limbs
Spasticity hypertonia associated with exaggerated
deep tendon reflexes and a
velocity-dependent increase in muscle
resistance in response to passive stretch
that varies with the direction of joint
movement. Subtypes are ‘clasp-knife’
(initial increased resistance to stretch
that suddenly gives way) and ‘clonus’
(repetitive rhythmic contractions in
response to a maintained stretch).
201
Stereognosis ability to identify common objects by
touch alone
Tetraplegia another term for quadriplegia
Tetraparesis another term for quadraparesis
Modified Ashworth scale
Grade Description
0 Normal tone, no increase in muscle tone
SECTION 1 Slight increase in muscle tone, manifested by a catch and
3 release or by minimal resistance at the end of the range

of motion (ROM) when the affected part(s) is moved in
flexion or extension
1+ Slight increase in muscle tone, manifested by a catch,
Neurology
followed by minimal resistance throughout the

remainder (less than one-half) of the ROM
2 More marked increase in muscle tone through most of
the ROM, but affected part(s) easily moved
3 Considerable increase in muscle tone, passive movement
difficult
4 Affected part(s) rigid in flexion or extension
Neurological assessment
need to be adapted to suit their needs. This section provides a
basic framework for the subjective and objective neurological
assessment of a patient.
Database
History of present condition
Past medical history
Drug history
Results of specific investigations (e.g. X-rays, CT scans, blood
tests)
202
Subjective examination
Social situation
• family support
• accommodation
• employment
• leisure activities
• social service support
Normal daily routine
Indoor and outdoor mobility
Personal care (e.g. washing, dressing)
Continence
SECTION
Vision
Hearing
Swallowing
3
Fatigue
Pain
Neurology
Other ongoing treatment
Past physiotherapy and response to treatment
Perceptions of own problems/main concern
Expectations of treatment
Physical examination
Posture and balance
Alignment
Neglect
Sitting balance (static and dynamic)
Standing balance (static and dynamic)
• Romberg’s test
Voluntary movement
Range of movement
Strength
Coordination
• finger-nose test
• heel-shin test
• rapidly alternating movement
Endurance
203
Involuntary movement
Tremor
Clonus
Chorea
Dystonia
Myoclonus
Ballismus
Associated reactions
Tone
Decreased/flaccid
SECTION Increased
3 • spasticity (clasp-knife or clonus)
• rigidity (cogwheel or lead-pipe)
Reflexes
Neurology
Deep tendon reflexes

• biceps (C5/6)
• triceps (C7/8)
• knee (L3/4)
• ankle (S1/2)
Plantar reflex (Babinski’s sign)
Hoffman’s reflex
Muscle and joint range
Passive range of movement
Sensory
Light touch
Pin prick
Two-point discrimination
Vibration sense
Joint position sense
Temperature
Vision and hearing
Functional activities
Bed mobility
204 Sitting balance
Transfers
Upper limb function
Mobility
Stairs
Gait
Pattern
Distance
Velocity
Use of walking aids
Orthoses SECTION
Assistance from others
3
Exercise tolerance/fatigue
Cognitive status
Neurology
Attention
Orientation
Memory
Emotional state

Bromley, I. (2006). Tetraplegia and paraplegia: A guide for physiotherapists
Davies, P. M. (2000). Steps to follow: The comprehensive treatment of patients
with hemiplegia (2nd ed.). Berlin: Springer Verlag.
Douglas, G., Nicol, F., & Robertson, C. (2013). Macleod’s clinical examination
Fuller, G. (2013). Neurological examination made easy (5th ed.). Edinburgh:
Kass, J. S., & Mizrahi, E. M. (2016). Neurology secrets (6th ed.). Elsevier.
Lennon, S., & Stokes, M. (2009). Pocketbook of neurological physiotherapy.
Edinburgh: Churchill Livingstone.
Lindsay, K. W., Bone, I., & Fuller, G. (2010). Neurology and neurosurgery
illustrated (5th ed.). Edinburgh: Churchill Livingstone.
Mtui, E., Gruener, G., & Dockery, P. (2016). Fitzgerald’s clinical neuroanatomy
and neuroscience (7th ed.). Elsevier.
Ropper, A. H., Samuels, M. A., & Klein, J. P. (2014). Adams and Victor’s
principles of neurology (10th ed.). New York: McGraw-Hill. 205
Ross, J. (2015). Crash course: Nervous system (4th ed.). Edinburgh:
Mosby.
Scadding, J. W., & Losseff, N. A. (2011). Clinical neurology (4th ed.). CRC
Press.
Stokes, M., & Stack, E. (2011). Physical management for neurological conditions
(3rd ed.). Churchill Livingstone.
SECTION
3
Neurology
206
Respiratory
SECTION
Respiratory anatomy illustrations 208
Respiratory volumes and capacities 212
Chest X-rays 215
Auscultation 218
Abnormal breathing patterns 220
Percussion note 221
Sputum analysis 221
4
SECTION
Clubbing 222
Capillary refill test 224 4
Differential diagnosis of chest pain 224
Respiratory
Arterial blood gas analysis 228
Respiratory failure 230
Nasal cannula 231
Common modes of mechanical ventilation 231
Cardiorespiratory monitoring 234
ECGs 237
Biochemical and haematological studies 244
Treatment techniques 251
Tracheostomies 257
Respiratory assessment 260
Respiratory anatomy illustrations
Right upper
lobe Manubriosternal
Horizontal junction
fissure
Left upper
Right lobe
middle
lobe
Oblique
Oblique fissure
fissure
SECTION Right lower Left lower

lobe
4 lobe
Figure 4.1 Lung markings – anterior view.

Respiratory
Left upper Right upper

lobe lobe
Oblique
fissure Oblique
fissure
Left lower
lobe Right lower
lobe
208 Figure 4.2 Lung markings – posterior view.
Useful lung markings*
Apex Anterior – 2.5 cm above medial one-third
of clavicles
Posterior – T1
Inferior border Anterior – sixth rib
Posterior – T10/11
Mid-axilla – eighth rib
Tracheal bifurcation Anterior – manubriosternal junction
Posterior – T4
Right horizontal fissure Anterior – fourth rib (above the nipple)
Oblique fissures Anterior – sixth rib (below the nipple)
Posterior – T2/3
Left diaphragm Anterior – sixth rib
Posterior – T10 SECTION
Right diaphragm
Anterior – fifth rib 4
Posterior – T9
Respiratory
*These lung markings are approximate and can vary among individuals.
Right lung Left lung
Apical Apical
Upper Posterior Posterior
lobe
Anterior Anterior Upper
Lingula lobe
Middle Lateral Apical
lobe lower Superior
Medial
Medial Inferior
basal
Anterior Anterior
Lower basal Posterior basal Lower
lobe basal lobe
Lateral Lateral
basal basal
Figure 4.3 Anterior view of brachial tree. 209
Right lung
Upper lobe
Apical
Posterior
Anterior
Horizontal fissure
Middle lobe
Lateral
Medial
SECTION
4 Oblique fissure
Lower lobe
Superior
Respiratory
Anterior basal
Lateral basal
Lateral view
Figure 4.4 Bronchopulmonary segments – lateral view of right lung.
210
Left lung
Upper lobe
Apicoposterior Superior
Anterior division
Superior Lingular
Inferior division
Oblique fissure
Lower lobe
Superior SECTION
Lateral basal
Anteromedial basal 4
Respiratory
Lateral view
Figure 4.5 Bronchopulmonary segments – lateral view of left lung.
211
Respiratory
212
SECTION
Respiratory volumes and capacities
5800
Total lung
capacity Vital
(TLC) capacity
5800 ml (VC) Inspiratory reserve
4600 ml volume (IRV)
3000 ml
Inspiratory
capacity (IC)
3500 ml
2800 Tidal volume (VT)
Volume (ml)
500 ml
2300
Expiratory reserve
volume (ERV)
Functional 1100 ml
residual
1200
capacity
Residual
(2300 ml)
volume (RV)
1200 ml
Minimal volume (MV) 30–120 ml
Figure 4.6 Respiratory volumes and capacities. Average volume in a healthy adult male.
Lung volumes
VT (tidal volume)
Volume of air inhaled or exhaled during a single normal breath
Men: 500 mL Women: 500 mL
IRV (inspiratory reserve volume)

Maximum amount of air that can be inspired on top of a normal
tidal inspiration
ERV (expiratory reserve volume)

Maximum amount of air that can be exhaled following a normal
tidal expiration
SECTION
RV (residual volume) 4
Volume of air remaining in the lungs after a maximal
expiration
Respiratory
MV (minimal volume)
Amount of air that would remain if the lungs collapsed
Men: 30–120 mL Women: 30–120 mL
Lung capacities
A capacity is the combination of two or more lung volumes.
213
TLC (total lung capacity)
Total volume of the lungs at the end of a maximal inspiration
TLC = VT + IRV + ERV + RV
VC (vital capacity)
Maximum amount of air that can be inspired and expired in a
single breath
VC = VT + IRV + ERV
IC (inspiratory capacity)
SECTION
Maximum volume of air that can be inspired after a normal
4 tidal expiration
IC = VT + IRV
Respiratory
FRC (functional residual capacity)

Volume of air remaining in the lungs at the end of a normal
tidal expiration
FRC = ERV + RV
214
Chest X-rays
SECTION
A
2
4
1
3
Respiratory
4 9
8
5
7
10 6
11 12
B
1 Air in the trachea 7 Right ventricle
2 Clavicle 8 Right hilum
3 1st rib 9 Left hilum
4 Aortic arch 10 Right hemidiaphragm
5 Right atrium 11 Costophrenic angle
6 Left ventricle 12 Gastric air bubble
Figure 4.7 A Normal posteroanterior chest X-ray. B Structures 215
normally visible on X-ray.
Analyzing chest X-rays
Adopt a systematic approach when analyzing X-rays. You should
check the following:
Patient’s details
• Name, date and time of X-ray
Left and right side
• Ensure that the side marker (left or right) is present and
indicates the correct side. The aortic arch, apex of the
heart and the gastric air bubble will generally be on the left.
Is it anteroposterior (AP) or posteroanterior (PA)?

Supine or erect?
SECTION • AP X-rays are usually taken using a mobile machine with
4 the patient supine. The heart appears larger, and the
scapulae overlie the lungs.
• PA X-rays are taken in the radiology department with the
patient standing erect. The quality is generally better, and
Respiratory
the scapulae are out of the way.

• Vertebral endplates are more visible in AP X-rays and the
laminae in PA X-rays.
Is the patient positioned symmetrically?

• The medial ends of the clavicle should be equidistant from
the margins or spinous process of the adjacent vertebral
body. If the patient is rotated, the position of the heart,
spine and rib cage may appear distorted.
Degree of inspiration
• On full inspiration the sixth or seventh rib should intersect
the midpoint of the right hemidiaphragm anteriorly or the
ninth rib posteriorly.
Exposure
• If the film appears too dark, it is overpenetrated
216 (overexposed).
• If the film appears too light, it is underpenetrated
(underexposed).
Think of toast: dark is overdone, and light is underdone.
• The spinous processes of the cervical and upper thoracic
vertebra should be visible, as should the outline of the
mid-thoracic vertebral bodies.
Extrathoracic soft tissues

• Surgical emphysema is often seen in the supraclavicular
areas, around the armpit and the lateral chest wall.
• Note breast shadows in women, which may obscure the
lateral wall of the chest.
Invasive medical equipment

• Note the position and presence of any tubes, cannulas, SECTION
electrodes, etc.
• The tip of the endotracheal tube should lie about 2 cm 4
above the carina.
Respiratory
Bony structures
• Check for fractures, deformities and osteoporosis.
Intercostal spaces
• Small intercostal spaces and steeply sloping ribs indicate
reduced lung volume.
• Large intercostal spaces and horizontal ribs indicate
hyperinflation.
Trachea
• Lies centrally with the lower one-third inclining slightly to
the right.
• Deviation of the trachea indicates mediastinal shift. It
shifts towards collapse and away from tumours, pleural
effusions and pneumothoraces.
• Bifurcation into the left and right bronchi is normally
seen. The right bronchus follows the line of the trachea,
whereas the left bronchus branches off at a more acute
angle. 217
Hila
• Composed of the pulmonary vessels and lymph nodes.
• The left and right hilum should be roughly equal in size,
though the left hilum appears slightly higher than the
right. Their silhouette should be sharp.
Heart
• On a PA film, the diameter of the heart is usually less than
one-half the total diameter of the thorax. In the majority
of cases, one-third of the cardiac shadow lies on the right
and two-thirds on the left, which should be sharply
defined. The density of both sides should be equal. The
heart may appear larger on an AP film or if the patient is
rotated.
SECTION
Diaphragm
4 • The right side of the diaphragm is about 2 cm higher than
the left because the right lobe of the liver is situated
directly underneath it. Both hemidiaphragms should be
Respiratory
dome shaped and sharply defined.

• The costophrenic angle is where the diaphragm meets the
ribs.
• The cardiophrenic angle is where the diaphragm meets
the heart.
Auscultation
Auscultation should be conducted in a systematic manner,
comparing the same area on the left and right sides while visual-
izing the underlying lung structures. Ideally patients should be
sitting upright and be asked to breathe through the mouth to
reduce nasal turbulence.
Breath sounds
Normal
More prominent at the top of the lungs and centrally, with the
218 volume decreasing towards the bases and periphery. Expiration
is shorter and quieter than inspiration and follows inspiration
without a pause.
Abnormal (bronchial breathing)

Similar to the breath sounds heard when listening over the
trachea. They are typically loud and harsh and can be heard
throughout inspiration and expiration. Expiration is longer than
inspiration, and there is a pause between the two. They occur
if air is replaced by solid tissue, which transmits sound more
clearly. Caused by consolidation, areas of collapse with adjacent
open bronchus, pleural effusion, tumour.
Diminished
Breath sounds will be reduced if air entry is compromised by
either an obstruction or a decrease in airflow. Caused by pneu-
mothorax, pleural effusion, emphysema, collapse with occluded SECTION
bronchus, atelectasis, inability to breathe deeply, obesity.
4
Added sounds
Crackles
Respiratory
Heard when airways that have been narrowed or closed, usually
by secretions, are suddenly forced open on inspiration. Usually
classified as fine (originating from small, distal airways), coarse
(from large, proximal airways), localized or widespread. They
can be further defined as being early or late, depending on when
they are heard on inspiration or expiration.
Early inspiratory – reopening of large airways (e.g.
bronchiectasis and bronchitis)
Late inspiratory – reopening of alveoli and peripheral airways
(e.g. pulmonary oedema, pulmonary fibrosis, pneumonia,
atelectasis)
Early expiratory – secretions in large airways
Late expiratory – secretions in peripheral airways
Wheeze
Caused by air being forced through narrowed or compressed
airways. Described as either high or low pitched and monophonic 219
(single note) or polyphonic (where several airways may be
obstructed). Airway narrowing can be caused by bronchospasm,
mucosal oedema or sputum retention. An expiratory wheeze
with prolonged expiration is usually indicative of bronchospasm,
while a low-pitched wheeze throughout inspiration and expiration
is normally caused by secretions.
Pleural rub
If the pleural surfaces are inflamed or infected, they become
rough and rub together, creating a creaking or grating sound.
Heard equally during inspiration and expiration.
Voice sounds
In normal lung tissue, voice sounds are indistinct and unintelligible.
When there is consolidation, sound is transmitted more clearly
SECTION and loudly and speech can be distinguished. Voice sounds can
4 be diminished in the presence of emphysema, pneumothorax

and pleural effusion. They can be heard through a stethoscope
(vocal resonance) or felt by hand (vocal fremitus). To test voice
sounds, patients can be asked to say or whisper ‘99’ repeatedly.
Respiratory
Abnormal breathing patterns

Pursed-lip breathing
Exhalation through tightly drawn lips. This maintains pressure
inside the airways, preventing them from collapsing. Often seen
in patients with severe airway disease, e.g. COPD.
Paradoxical breathing
This is where normal chest wall movement is reversed. The entire
chest wall moves inwards on inspiration and outwards on
expiration. Seen in patients with bilateral diaphragm weakness
or paralysis, e.g. high cervical spinal cord injury.
Hoover sign
Paradoxical movement of the lower rib cage during inspiration
where the lower ribs move inwards instead of outwards. Seen
220 in patients with severe hyperinflation of the lungs where the
diaphragm has become flattened and can no longer function as
normal.
Kussmaul breathing
A rapid, deep and laboured breathing pattern that is associated
with metabolic acidosis, particularly diabetic ketoacidosis and
renal failure.
Cheyne-Stokes breathing
Cycles of irregular breathing characterized by a few deep and
sometimes rapid breaths followed by gradually shallower breaths
often to the point of apnoea. Associated with congestive heart
failure, severe neurological insults, e.g. CVA, head injury,
brainstem tumours and narcotic or hypnotic drug overdose.
Apneustic breathing SECTION
4
Prolonged inspiration followed by a prominent pause before
expiration. Caused by an injury to the brainstem (pons).
Percussion note
Respiratory
Elicited by placing the middle finger of one hand firmly in the
space between the ribs and tapping the distal phalanx sharply
with the middle finger of the other hand.
The pitch of the note is determined by whether the lungs
contain air, solid or fluid and will either sound normal, resonant,
dull or stony dull.
Resonant = normal
Hyperresonant = emphysema (bullae) or pneumothorax
Dull = consolidation, areas of collapse, pleural effusion
Sputum analysis (Thomas et al 2016, with

permission)
Description Causes
Saliva Clear watery fluid
Mucoid Opalescent or white Chronic bronchitis
without infection, asthma 221
Description Causes
Mucopurulent Slightly discoloured, but Bronchiectasis, cystic
not frank pus fibrosis, pneumonia
Purulent Thick, viscous:
– yellow Haemophilus
– dark green/brown Pseudomonas
– rusty Pneumococcus, Mycoplasma
– redcurrant jelly Klebsiella
Frothy Pink or white Pulmonary oedema
Haemoptysis Ranging from blood Infection (tuberculosis,
specks to frank blood, bronchiectasis), infarction,
old blood (dark brown) carcinoma, vasculitis,
trauma, also coagulation
disorders, cardiac disease
SECTION Black Black specks in mucoid Smoke inhalation (fires,
4
secretions tobacco, heroin), coal dust
Respiratory
Clubbing
Clubbing is a deformity of the fingernails or toenails in which
the angle between the nail bed and nail is lost (the nail-fold or
Lovibond’s angle). It is usually bilateral, and the distal digital
segments can also become enlarged. It is associated with a
number of cardiorespiratory and gastrointestinal diseases
including lung cancer, bronchiectasis, cystic fibrosis, idiopathic
pulmonary fibrosis, congenital heart disease, endocarditis, Crohn’s
disease, ulcerative colitis and liver disease (primary biliary
cirrhosis).
Schamroth’s test and window sign

The nail-fold angle is examined by placing the distal phalanx
and nail of the same digit of both hands together so that they
face each other. Normally, a small diamond-shaped window
should appear; however, in digital clubbing this window is
222 obliterated.
A B
Figure 4.8 A Normal (negative Schamroth sign). B Clubbing (positive Schamroth sign).
Respiratory
4
223
SECTION
Capillary refill test
A quick test for assessing tissue hydration and blood flow to the
peripheral tissues. Position the patient’s hand at heart level or
above, then apply pressure on the nail bed until it turns white
(approximately 5 seconds). Remove the pressure, and measure
how long it takes for the colour to return to the nail bed.
Normal capillary refill time is usually less than 2 seconds.
A prolonged capillary refill time may be a sign of dehydration
or decreased peripheral perfusion, e.g. shock, peripheral vascular
disease, hypothermia.
Differential diagnosis of chest pain (data from

Thomas et al 2016, with permission)
SECTION Pleura (pleurisy)
4 Causes: pleural infection or inflammation of the pleura,
trauma (haemothorax), malignancy
Location: unilateral, often localized
Respiratory
Onset: rapid
Quality: sharp, stabbing
Intensity: often ‘catches’ at a certain lung volume
Aggravating factors: deep breaths (limits inspiration) and
coughing
Relieving factors: anti-inflammatory medication
Associated findings may include: fever, dyspnoea, cough,
crackles, pleural rub
Pulmonary embolus
Causes: DVT (secondary to immobilization, long-distance
travel)
Location: often lateral, on the side of the embolism but may be
central
Onset: sudden
Quality: sharp
Associated findings may include: dyspnoea, tachypnoea,
tachycardia, hypotension, hypoxaemia (not significantly
224 improved with oxygen therapy), haemoptysis if
pulmonary infarction occurs. Unilateral swollen lower leg
that is red and painful suggests DVT.
Pneumothorax
Causes: trauma, spontaneous, lung diseases (e.g. cystic
fibrosis, AIDS), iatrogenic (e.g. post–central line insertion)
Location: Lateral to side of pneumothorax
Onset: sudden
Quality: sharp
Intensity: severity depends on extent of mediastinal shift
Associated findings may include: dyspnea, decreased/absent
breath sounds on side of pneumothorax, increased
percussion note, tracheal deviation away from the side of
the pneumothorax, hypoxaemia
Tracheitis SECTION
Causes: bacterial infection (e.g. Staphylococcus infection)
Location: central 4
Quality: burning
Intensity: constant
Respiratory
Aggravating factors: breathing
Tumours
Causes: primary or secondary carcinoma, mesothelioma
Location: may mimic any form of chest pain, depending on
site and structures involved
Relieving factors: opiate and anti-inflammatory analgesia
Rib fracture
Causes: trauma, tumour, cough, fractures (e.g. in chronic
lung diseases, osteoporosis), iatrogenic (e.g. surgery)
Location: localized point tenderness
Onset: often sudden
Aggravating factors: increases with inspiration
Muscular
Causes: trauma, unaccustomed exercise, excessive coughing
during exacerbations of lung disease
Location: superficial 225
Aggravating factors: increases on inspiration and some body
movements
Relieving factors: rest, anti-inflammatory medication, ice or
heat
Costochondritis and Tietze syndrome

Causes: trauma, viral infection
Location: localized to one or more costochondral joints
Quality: with or without generalized, nonspecific chest
pain
Aggravating factors: sneezing, coughing, deep inspiration,
twisting of the chest, reproducible pain – especially at the
costochondral junctions
Relieving factors: anti-inflammatory medication, ice or heat
SECTION
Neuralgia
Causes: thoracic spine dysfunction, tumour, trauma, herpes
4 zoster (shingles)
Location: dermatomal distribution
Quality: sharp or burning or paraesthesia
Respiratory
Relieving factors: antiviral medications (if caused by herpes

zoster)
Acute coronary syndrome: angina/myocardial

infarction
Causes: ischaemic heart disease
Location: central, retrosternal with or without radiation to the
jaw or upper extremities, frequently on left
Onset: pain at rest is more suggestive of infarction
Quality: pressure, tightness, squeezing, heaviness, burning
Aggravating factors: angina is aggravated by exertion, exposure
to cold and psychological stress. It usually lasts less than
10 minutes. Myocardial infarction has variable duration
but often lasts more than 30 minutes.
Relieving factors: angina is relieved by nitro-glycerine;
myocardial infarction is not.
Associated findings: depending on the severity of the
ischaemia, they may include nausea, vomiting, dyspnea,
226 dizziness, hypotension, arrhythmias
Pericardium (pericarditis)
Causes: infection, inflammation, trauma, tumour
Location: retrosternal or towards cardiac apex; may radiate to
left shoulder
Quality: sharp – may mimic cardiac ischaemia or pleurisy
Relieving factors: may be relieved by sitting up and leaning
forwards
Associated findings: tachycardia, pericardial friction rub
Dissecting aortic aneurysm

Causes: trauma, atherosclerosis, Marfan syndrome
Location: anterior chest (often radiating to back, between
shoulder blades), poorly localized central chest pain
Onset: sudden onset of unrelenting pain
Quality: tearing or ripping sensation, knifelike
SECTION
Associated findings: dyspnea, unequal pulses or blood pressure
in both arms, hypotension, ischaemic leg pain, reduced
lower limb pulses
4
Oesophageal
Respiratory
Causes: oesophageal reflux, trauma, tumour, vomiting
(Boerhaave syndrome)
Location: retrosternal but can also be posterior in the lower
back
Quality: burning
Aggravating factors: reflux is aggravated by lying flat or
bending forwards after eating
Relieving factors: antacids
Associated findings: oesophageal tears – mediastinal or
subcutaneous air or pleural effusion may be seen on
CXR
Mediastinal shift
Causes: pneumothorax, rapid drainage of a large pleural
effusion
Location: poorly localized, central discomfort
Onset: sudden
Quality: severe 227
Arterial blood gas analysis
Arterial blood analysis Reference ranges in adults

pH 7.35–7.45 pH
PaO2 10.7–13.3 kPa (80–100 mmHg)
PaCO2 4.7–6.0 kPa (35–45 mmHg)
HCO3– 22–26 mmol/L
Base excess –2 to +2
Interpreting acid-base disorders

Assessing acid-base disorders involves examining the pH, PaCO2
and HCO3–:
• pH – a low pH (<7.4) indicates a tendency towards
SECTION acidosis, a high pH (>7.4) indicates a tendency towards
4 alkalosis
• PaCO2 – an increase in PaCO2 leads to acidosis, a decrease
to alkalosis
• HCO3– – an increase in HCO3– leads to alkalosis, a decrease
Respiratory
to acidosis
Assessment
PaCO2 is produced by cellular processes and removed by the
lungs. An increase or decrease in respiratory function will change
the levels of PaCO2.
HCO3– is produced by the kidneys. Changes in the ability of
the kidneys to produce HCO3– or remove hydrogen ions in the
body will affect the pH. The renal system reflects changes in
metabolic activity within the body.
Establish whether the patient’s pH is acidotic, alkalotic or normal.

If the pH is acidotic, establish whether this is due to:
• increased PaCO2 – indicating respiratory acidosis
• decreased HCO3– – indicating metabolic acidosis
If the pH is alkalotic, establish whether this is due to:
• decreased PaCO2 – indicating respiratory alkalosis
228 • increased HCO3– – indicating metabolic alkalosis
Compensation
In acid-base disorders, the body tries to maintain haemostasis
by bringing the pH back to its normal range. It does this by
increasing or decreasing levels of PaCO2 and HCO3–. Therefore,
if the pH is within normal range, the original abnormality can
be identified by comparing the pH to the PaCO2 and the
HCO3–.
• If the pH is below 7.4 (tending towards acid), then the
component that correlates with acidosis (increased PaCO2
or decreased HCO3–) is the cause and the other is the
compensation.
• If the pH is above 7.4 (tending towards alkaline), the
component that correlates with alkalosis (decreased
PaCO2 or increased HCO3–) is the cause and the other is
the compensation. SECTION
Simple acid-base disorders 4

pH PaCO2 HCO3–
Respiratory
Respiratory Acidosis
Uncompensated ↓ ↑ N
Compensated N ↑ ↑
Respiratory Alkalosis
Uncompensated ↑ ↓ N
Compensated N ↓ ↓
Metabolic Acidosis
Uncompensated ↓ N ↓
Compensated N ↓ ↓
Metabolic Alkalosis
Uncompensated ↑ N ↑
Compensated N ↑ ↑
↑ = decreased; ↓ = increased; N = normal.
229
Base excess
Allows assessment of the metabolic component of acid-base
disturbances and therefore the degree of renal compensation
that has occurred. A base deficit (less than –2) indicates a meta-
bolic acidosis, and a base excess (greater than +2) correlates
with metabolic alkalosis.
Respiratory failure
Broadly defined as an inability of the respiratory system to
maintain blood gas values within normal ranges. There are two
types:
Type I (hypoxaemic respiratory failure)

A decreased PaO2 (hypoxaemia) with a normal or slightly reduced
SECTION PaCO2 due to inadequate gas exchange. Causes include pneu-
4 monia, emphysema, fibrosing alveolitis, severe asthma and adult

respiratory distress syndrome.
Defined as PaO2 < 8 kPa (60 mmHg).
Respiratory
Type II (ventilatory failure)

A decreased PaO2 with an increased PaCO2 (hypercapnia) caused
by hypoventilation. Causes include neuromuscular disorders
(e.g. muscular dystrophy, Guillain-Barré syndrome), lung diseases
(e.g. asthma, COPD), drug-related respiratory drive depression
and injuries to the chest wall.
Defined as PaO2 < 8 kPa (60 mmHg), PaCO2 > 6.7 kPa
(50 mmHg).
Arterial blood gas classification of

respiratory failure
pH PaCO2 HCO3–
Acute ↓ ↑ N
Chronic N ↑ ↑
Acute on chronic ↓ ↑ ↑
230 ↓ = decreased; ↑ = increased; N = normal.
Nasal cannula
The following values are approximate as the patient’s flow rates,
ability to breathe through the nose, type of cannula and buildup
of nasal mucus may all affect the amount of oxygen received. As
a general rule, the FiO2 is raised by 3–4% for each litre of oxygen.
To convert litres of O2 to FiO2

RA ≈ 21% FiO2
1 L/min ≈ 24% FiO2
2 L/min ≈ 28% FiO2
3 L/min ≈ 32% FiO2
4 L/min ≈ 36% FiO2
5 L/min ≈ 40% FiO2
6 L/min ≈ 44% FiO2 SECTION
RA = room air.
4
Although nasal cannula may be used with oxygen flows of up
to 6 L/min, flow rates above 4 L/min may cause drying and
Respiratory
irritation of the nasal mucosa.
Common modes of mechanical ventilation

Continuous mandatory ventilation (CMV)
Delivers a preset number of time-controlled breaths to the patient
that can be pressure or volume targeted:
• In volume-targeted CMV (VC-CMV), the ventilator delivers
a preset tidal volume and flow rate, with airway pressure
being dependent on airflow resistance and compliance of
the respiratory system. A pressure limit can be set to limit
barotrauma.
• In pressure-targeted CMV (PC-CMV), the ventilator
delivers a preset pressure and flow rate, with tidal volume
being dependent on airflow resistance and compliance of
the respiratory system.
• In dual-control modes (PRVC: pressure-regulated volume
control), the ventilator delivers volume-targeted breaths 231
that are pressure controlled, with peak airway pressure
varying from breath to breath, allowing for continuous
adaptation to the patient’s airway resistance and lung
compliance.
The original form of CMV (in which the work of breathing
is fully controlled by the ventilator and the patient is unable to
breath spontaneously) has been surpassed by newer modes that
allow for patient-initiated breaths and can assist or control
ventilation dynamically. However, CMV does not allow spontane-
ous breathing between mandatory breaths.
Intermittent mandatory ventilation (IMV)

Delivers a preset number of time-controlled breaths to the patient
that can be pressure or volume targeted but allows the patient
to take spontaneous breaths between scheduled machine-delivered
SECTION
breaths. This mode has given way to synchronous intermittent
4 mandatory ventilation (SIMV).
Synchronized intermittent mandatory ventilation

(SIMV)
Respiratory
Synchronizes breaths from the ventilator with the patient’s

spontaneous breaths. If the patient fails to take a spontaneous
breath within a set time, the ventilator delivers a mandatory
breath that is pressure or volume targeted.
Pressure support (PS)

The patient breathes spontaneously, triggering the ventilator
to deliver a set level of positive pressure to assist air entry
and reduce the work of breathing. The patient controls the
tidal volume, respiratory rate and flow rate. Pressure support
can be added to SIMV to compensate for the resistance from
the endotracheal tube, making it easier for the patient to
breathe.
Complications of mechanical ventilation

Infections, e.g. ventilator-associated pneumonia
Barotrauma, including pneumothorax, interstitial
232 emphysema
Tracheal injuries
Ventilator-associated lung injury
Diaphragm atrophy
Oxygen toxicity
Decreased cardiac output
Noninvasive ventilation (NIV)

NIV is the provision of ventilatory support without intubation
to the upper airway, usually via a mask or similar device. Positive
pressure ventilation is the most common form, though negative
pressure ventilation is used in some situations. The most common
modes of NIV are CPAP and BiPAP.
Continuous positive airway pressure (CPAP)

A high flow of gas is delivered continuously throughout inspira-
tion and expiration during spontaneous breathing. The alveoli SECTION
and smaller airways are splinted open, increasing lung volume
at the end of expiration (i.e. the functional residual capacity).
4
The aim is to reverse atelectasis and improve gas exchange. It
also increases lung compliance and decreases the work of
Respiratory
breathing.
Bilevel positive airway pressure (BiPAP)

Similar to CPAP, positive airway pressure is delivered throughout
inspiration and expiration during spontaneous breathing,
but the level of positive airway pressure alters between
inspiration and expiration. A higher level is delivered during
inspiration and a lower level during expiration. The alteration
between pressure levels is synchronized with the patient’s
breathing.
Contraindications to NIV
• Facial trauma/burns
• Recent facial, upper airway or upper gastrointestinal
tract surgery
• Fixed obstruction of the upper airway
• Inability to protect airway
• Life-threatening hypoxaemia 233
• Haemodynamic instability requiring inotropes/pressors
(unless in a critical care unit)
• Severe comorbidity
• Confusion/agitation
• Vomiting
• Bowel obstruction
• Copious respiratory secretions
• Undrained pneumothorax
Cardiorespiratory monitoring
Arterial blood pressure (ABP)
Measured via an intra-arterial cannula which allows con-
tinuous monitoring of the patient’s blood pressure and also
SECTION provides an access for arterial blood sampling and blood gas
analysis.
4 Normal value: 95/60–140/90 mmHg in adults (increases
gradually with age)
Hypertension: >145/95 mmHg
Respiratory
Hypotension: <90/60 mmHg
Cardiac output (CO)

Amount of blood pumped into the aorta each minute.
CO = HR × SV
Normal value: 4–8 L/min
Cardiac index (CI)

Cardiac output related to body size. Body surface area is calculated
by using the patient’s weight and height and a nomogram. Allows
reliable comparison between patients of different sizes.
CI = CO ÷ body surface area
Normal value: 2.5–4 L/min/m2

234
Central venous pressure (CVP)
Measured via a central venous cannula inserted into the internal
or external jugular vein or subclavian vein with the tip resting
close to the right atrium within the superior vena cava. Provides
information on circulating blood volume, the effectiveness of
the heart to pump that volume, vascular tone and venous return.
Normal value: 3–15 cmH2O
Cerebral perfusion pressure (CPP)

Pressure required to ensure adequate blood supply to the brain.
CPP = MAP − ICP
Normal value: >70 mmHg

SECTION
Ejection fraction (EF)
The stroke volume (SV) as a percentage of the total volume of 4
the ventricle prior to systolic contraction, i.e. end-diastolic volume
(EDV).
Respiratory
EF = SV ÷ EDV
Normal value: 65–75%
Heart rate (HR)

The number of times the heart contracts in 1 minute.
Normal value: 50–100 beats/min
Tachycardia: >100 beats/min at rest
Bradycardia: <50 beats/min at rest
Intracranial pressure (ICP)

Pressure exerted by the brain tissue, cerebrospinal fluid and blood
volume within the rigid skull and meninges. Neurological insults
such as space-occupying lesions, cerebral oedema, hydrocephalus,
cerebral haemorrhage, hypoxia and infection cause this pressure
to rise, resulting in a decreased blood supply to the brain. When
treating patients with raised ICP, minimize handling and ensure
235
that the head is maintained in midline and raised 15–30° from
supine. A marked degree of hip flexion should be avoided to
ensure optimal circulation and prevent potential increase in ICP.
Normal value: 0–10 mmHg
Mean arterial pressure (MAP)

Measures the average pressure of blood being pushed through
the circulatory system. It relates to cardiac output and systemic
vascular resistance and reflects tissue perfusion pressure.
MAP = (diastolic BP × 2) + (systolic BP) ÷ 3

<60 mmHg indicates inadequate circulation to the vital
SECTION organs
4 Oxygen saturation (SpO2)

Arterial oxygen saturation is measured using noninvasive pulse
oximetry.
Respiratory
Normal value: 95–98%
Pulmonary artery pressure (PAP)

A pulmonary artery balloon catheter (Swan-Ganz) is inserted
via the CVP catheter route and floated into the pulmonary artery
via the right ventricle. The PAP measures pressures of the blood
in the vena cava, right atrium and right ventricle and provides
a measure of the ability of the right side of the heart to push
blood through the lungs and to the left side of the heart.
Normal value: 15–25/8–15 mmHg
Mean value: 10–20 mmHg
Pulmonary artery occlusion pressure (PAOP)

Similar to PAP, but the Swan-Ganz catheter is moved further
along until it wedges in a small pulmonary artery. The balloon
tip is inflated to occlude the artery in order to allow measurement
236 of the pressure in the pulmonary capillaries in front of it and
the left atrium. Previously know as pulmonary artery wedge
pressure (PAWP).
Respiratory rate (RR)

Number of breaths taken in 1 minute.
Normal value: 12–16 breaths/min
Tachypnoea: >20 breaths/min
Bradypnoea: <10 breaths/min
Stroke volume (SV)

The amount of blood ejected from the ventricles during each
systolic contraction. Affected by preload (amount of tension on
the ventricular wall before it contracts), afterload (resistance
SECTION
that the ventricle must work against when it contracts) and
contractility (force of contraction generated by the myocardium).
4
SV = (CO × 1000) ÷ HR
Respiratory
Normal value: 60–130 mL/beat
Systemic vascular resistance (SVR)

Evaluates the vascular component of afterload in the left ventricle.
Vasoconstriction will increase systemic vascular resistance,
whereas vasodilation will decrease it.
SVR = 80 × (MAP − CVP) ÷ CO
Normal value: 800–1400 dyn ⋅ s ⋅ cm–5
ECGs
ECGs detect the sequence of electrical events that occur during
the contraction (depolarization) and relaxation (repolarization)
cycle of the heart. Depolarization is initiated by the sinoatrial
(SA) node, the heart’s natural pacemaker, which transmits the
electrical stimulus to the atrioventricular (AV) node. From here,
the impulse is conducted through the bundle of His and along 237
Left atrium
Sinoatrial node
Bundle of His
Right atrium
Atrioventricular
node
Left branch
Right bundle bundle
branch
Left ventricle
Right ventricle
SECTION Purkinje fibres
4 Figure 4.9 Conduction system of the heart.
the bundle branches to the Purkinje fibres, causing the heart

to contract.
Respiratory
The atrioventricular (AV) node can also function as a

pacemaker when there is a dysfunction of the SA node, e.g.
failure to generate an impulse (sinus arrest), when the impulse
generated is too slow (sinus bradycardia) or when the impulse
is not conducted to the AV node (SA block, AV block).
ECGs are recorded on graphed paper that travels at 25 mm/s.
It is divided into large squares of 5-mm width, which represents
0.2 s horizontally. Each square is then divided into five squares
of 1 mm width (i.e. 0.04 s horizontally). Electrical activity is
measured in millivolts (mV). A 1 mV signal moves the recording
stylus vertically 1 cm (i.e. two large squares).
An ECG complex consists of five waveforms labelled with the
letters P, Q, R, S and T, which represent the electrical events that
occur in one cardiac cycle.
The P wave represents the activation of the atria (atrial
depolarization).
• P amplitude: <2.5 mm
238 • P duration: 0.06–0.12 s
1mm
RR interval
5mm QRS complex
T wave
1mV P wave ST segment
U wave
PR QRS
QT
0.2 s
(200 ms) 0.04 s
(40 ms)
1s
(1000 ms) SECTION
Paper speed = 25 mm/s
Figure 4.10 Normal ECG.
4
The PR interval represents the time between the onset of
Respiratory
atrial depolarization and the onset of ventricular depolarization,
i.e. the time taken for the impulse to travel from the SA node
through the AV node and the His-Purkinje system.
• PR duration: 0.12–0.20s
The QRS complex represents the activation of the ventricles
(ventricular depolarization).
• QRS amplitude: 5–30 mm
• QRS duration: 0.06–0.10s
The ST segment represents the end of ventricular depolariza-
tion and the beginning of ventricular repolarization.
The T wave represents ventricular repolarization.
• T amplitude: <10 mm (approximately more than one-
eighth but less than two-thirds of corresponding R wave)
The QT interval represents the total time for ventricular
depolarization and repolarization.
• QT duration: 0.35–0.45 s 239
The U wave represents repolarization of the His-Purkinje
system and is not always present on an ECG.
Examples of ECGs
Normal sinus rhythm
• Regular rhythms and rates (60–100 beats/min)
• Has a P wave, QRS complex and T wave; all similar in size
and shape
SECTION
Figure 4.11 Sinus rhythm.
4 Sinus bradycardia
Defined as a sinus rhythm with a resting heart rate of less than
Respiratory
60 beats/min.
• Heart rate <60 beats/min
• Regular sinus rhythm
Figure 4.12 Sinus bradycardia.
Causes include cardiomyopathy, acute myocardial infarction,

drugs (e.g. β blockers, digoxin, amiodarone), obstructive jaundice,
raised intracranial pressure, sick sinus syndrome, hypothermia,
hypothyroidism, electrolyte abnormalities.
Can be a normal finding in extremely fit individuals and
240 during sleep.
Sinus tachycardia
Defined as a sinus rhythm with a resting heart rate of more
than 100 beats/min.
• Heart rate >100 beats/min
• Regular sinus rhythm
Figure 4.13 Sinus tachycardia.
Causes include sepsis, fever, anaemia, pulmonary embolism,

SECTION
hypovolaemia, hypoxia, hyperthyroidism, phaeochromocytoma,
drugs (e.g. salbutamol, alcohol, caffeine).
Can occur as a response to increased demand for blood flow,
4
e.g. exercise or in high emotional states, e.g. fear, anxiety, pain.
Respiratory
Atrial fibrillation
Where rapid, unsynchronized electrical activity is generated in
the atrial tissue, causing the atria to quiver. Transmission of the
impulses to the ventricles via the AV node is variable and
unpredictable, leading to an irregular heartbeat.
• Absent P wave replaced by fine baseline oscillations (atrial
impulses fire at a frequency of 350–600 beats/min)
• Irregular ventricular complexes; RR interval irregular
• Ventricular rate varies between 100 and 180 beats/min
but can be slower
Figure 4.14 Atrial fibrillation. 241

Causes include hypertension, coronary artery disease, mitral
valve disease, post–cardiac surgery, sick sinus syndrome,
pneumonia, pulmonary embolism, hyperthyroidism, alcohol
misuse, chronic pulmonary disease.
Ventricular ectopics or premature ventricular

contractions (PVCs)
Early beats (ectopics) usually caused by electrical irritability in
the ventricular conduction system or myocardium. Can occur
in normal individuals and be asymptomatic. However, can indicate
impending fatal arrhythmias in patients with heart disease. Can
occur singly, in clusters of two or more or in repeating patterns
such as bigeminy (every other beat) or trigeminy (every third
beat).
SECTION
4
Respiratory
Figure 4.15 Ventricular ectopics and PVCs.
• Irregular rhythm during PVC; however, underlying

rhythm and rate is usually regular, i.e. sinus
• P wave absent, QRS complex wide and early, T wave in
opposite direction from QRS complex during PVC
Causes include acute myocardial infarction; valvular heart
disease; electrolyte disturbances; metabolic acidosis; medications
including digoxin and tricyclic antidepressants; drugs such as
cocaine, amphetamines and alcohol; anaesthetics and stress.
Ventricular tachycardia
Defined as three or more heartbeats of ventricular origin at a
rate exceeding 100 beats/minute. May occur in short bursts of
less than 30 seconds, and may terminate spontaneously with
242 few or no symptoms (nonsustained). Episodes lasting more than
30 seconds (sustained) lead to rapid deterioration and ven-
tricular fibrillation that requires immediate treatment to prevent
death.
Figure 4.16 Ventricular tachycardia.
• Ventricular rate 100–200 beats/min

• Ventricular rhythm is usually regular
• QRS complex is wide, P wave is absent SECTION
Causes include acute myocardial infarction, myocardial

ischaemia, cardiomyopathy, mitral valve prolapse, electrolyte
4
imbalance, drugs (digoxin, antiarrhythmics), myocarditis.
Respiratory
Ventricular fibrillation
Rapid, ineffective contractions of the ventricles caused by chaotic
electrical impulses resulting in no cardiac output. Unless treated
immediately, it is fatal.
Ventricular fibrillation is the most commonly identified
arrhythmia in cardiac arrest patients and the primary cause of
sudden cardiac death (SCD).
Figure 4.17 Ventricular fibrillation.
No recognizable pattern: irregular, chaotic, immeasurable. 243

Respiratory
244
SECTION
Biochemical and haematological studies
Blood serum studies
Test Function Interpretation
Albumin Most abundant plasma protein. Maintains Increased: relative increase with haemoconcentration,
36–47 g/L osmotic pressure of the blood. Transports where there is severe loss of body water
blood constituents such as fatty acids, Decreased: malnutrition, malabsorption, severe liver
hormones, enzymes, drugs and other disease, renal disease, gastrointestinal conditions causing
substances excessive loss, thyrotoxicosis, chemotherapy, Cushing’s
disease
Bilirubin Pigment produced by the breakdown of Increased: hepatitis, biliary tract obstruction, haemolysis,
2–17 mmol/L haem haematoma
Decreased: iron-deficiency anaemia
C-reactive Protein produced in the acute inflammatory Increased: pyrexia, all inflammatory conditions (e.g.
protein phase of injury. Index for monitoring disease rheumatoid arthritis, pneumococcal pneumonia), trauma,
<7 mg/L activity during late pregnancy
Calcium Nerve impulse transmission, bone and Increased (hypercalcaemia): hyperparathyroidism,
2.1–2.6 mmol/L teeth formation, skeletal and myocardial malignancy, Paget’s disease, osteoporosis, immobilization,
muscle contraction, activation of enzymes, renal failure
blood coagulation, cell division and repair, Decreased (hypocalcaemia): hypoparathyroidism, vitamin
membrane structure and absorption of D deficiency, acute pancreatitis, low blood albumin, low
vitamin B12 blood magnesium, large transfusion of citrated blood,
increased urine excretion, respiratory acidosis
Creatine kinase Enzyme found in heart, brain and skeletal Increased: heart (myocardial infarction, myocarditis, open
Men: 30–200 U/L muscle. Increased when one of these areas heart surgery), brain (brain cancer, trauma, seizure) and
is stressed or damaged. Testing for a specific skeletal muscle damage (intramuscular injections, trauma,
Women: creatine kinase isoenzyme indicates area of surgery, strenuous exercise, muscular dystrophy)
30–150 U/L damage (e.g. raised CK-MB indicates damage
to heart)
Creatinine End-product of normal muscle metabolism Increased: renal failure, urinary obstruction, muscle disease
55–150 mmol/L Decreased: pregnancy, muscle wasting
Glucose Metabolized in the cells to produce energy Increased: diabetes mellitus, Cushing’s disease, patients on
3.6–5.8 mmol/L steroid therapy
Decreased: severe liver disease, adrenocortical insufficiency,
drug toxicity, digestive diseases
Respiratory
4
245
SECTION
Respiratory
246
SECTION
Lactate Enzyme that converts pyruvic acid into Increased: tissue damage due to myocardial infarction,
dehydrogenase lactate. High levels found in myocardial and liver disease, renal disease, cellular damage in trauma,
230–460 U/L skeletal muscle, the liver, lungs, kidneys and hypothyroidism, muscular diseases
red blood cells
Magnesium Neuromuscular transmission, cofactor in Increased (hypermagnesaemia): renal failure, adrenal
0.7–1.0 mmol/L activation of many enzyme systems for insufficiency, excessive oral or parenteral intake of
cellular metabolism (e.g. phosphorylation of magnesium, severe dehydration
glucose, production and functioning of ATP), Decreased (hypomagnesaemia): excessive loss from
regulation of protein synthesis gastrointestinal tract (diarrhoea, nasogastric suction,
pancreatitis), decreased gut absorption, renal disease, long-
term use of certain drugs (e.g. diuretics, digoxin), chronic
alcoholism, increased aldosterone secretion, polyuria
Phosphate Bone formation, formation of high energy Increased (hyperphosphataemia): renal failure,
0.8–1.4 mmol/L compounds (e.g. ATP), nucleic acid synthesis, hypoparathyroidism, chemotherapy, excessive phosphorus
enzyme activation intake
Decreased (hypophosphataemia): hyperparathyroidism,
chronic alcoholism, diabetes, respiratory alkalosis,
excessive glucose ingestion, hypoalimentation, chronic use
of antacids
Potassium Nerve impulse transmission, contractility of Increased (hyperkalaemia): renal failure, increased intake
3.6–5.0 mmol/L myocardial, skeletal and smooth muscle of potassium, metabolic acidosis, tissue trauma (e.g.
burns and infection), potassium-sparing diuretics, adrenal
insufficiency
Decreased (hypokalaemia): potassium-wasting diuretics,
vomiting, diarrhoea, metabolic alkalosis, excess
aldosterone secretion, polyuria, profuse sweating
Sodium Regulates body’s water balance, maintains Increased (hypernatraemia): excessive fluid loss or salt
136–145 mmol/L acid-base balance and electrical nerve intake, water deprivation, diabetes insipidus, excess
potentials aldosterone secretion, diarrhoea
Decreased (hyponatraemia): kidney disease, excessive water
intake, adrenal insufficiency, diarrhoea, profuse sweating,
diuretics, congestive heart failure, inappropriate secretion
of ADH
Urea Waste product of metabolism Increased: renal failure, decreased renal perfusion because
2.5–6.5 mmol/L of heart disease, shock
Decreased: high-carbohydrate/low-protein diets, late
pregnancy, malabsorption, severe liver damage
Respiratory
4
247
SECTION
Respiratory
248
SECTION
Haematological studies
Test Assesses Interpretation

Red blood cell count (RBC) Blood loss, anaemia, Increased: polycythaemia vera, dehydration, cardiac and pulmonary
Men: 4.5–6.5 × 1012/L polycythaemia (increase disorders characterized by cyanosis, acute poisoning
Women: 3.8–5.3 × 1012/L in Hb concentration of Decreased: leukaemia, anaemia, fluid overload, haemorrhage
the blood)
White blood cell count Detects infection or Increased: leukaemia, tissue necrosis, infection
(WBC) inflammation. Decreased: bone marrow suppression
4.0–11.0 × 109/L Monitors response
to radiation and
chemotherapy
White blood cell Evaluates body’s ability to Increased:
differential resist infection. Detects Neutrophil – bacterial infection, noninfective acute inflammation,
Neutrophils: 1.5–7.0 × 109/L and classifies leukaemia tissue damage
Eosinophils: 0.0–0.4 × 109/L Eosinophil – allergic reaction, parasitic worm infection
Lymphocytes: 1.2–3.5 × 109/L
Lymphocyte – viral infection, chronic bacterial infection
Monocytes: 0.2–1.0 × 109/L
Basophils: 0.0–0.2 × 109/L Monocyte – chronic bacterial infection, malignancy
Basophil – myeloproliferative disorders
Packed cell volume Blood loss and fluid Increased: polycythaemia, dehydration
(PCV)/haematocrit (Hct) balance Decreased: anaemia, acute blood loss, haemodilution
Men: 0.40–0.54 L/L
Women: 0.35–0.47 L/L
Haemoglobin (Hb) Anaemia and Increased: polycythaemia, dehydration
Men: 130–180 g/L polycythaemia Decreased: anaemia, recent haemorrhage, fluid overload
Women: 115–165 g/L
Platelets (Plt) Severity of Increased: polycythaemia vera, splenectomy, malignancy
150–100 × 109/L thrombocytopenia Decreased: anaemias, infiltrative bone marrow disease, haemolytic
disorders, disseminated intravascular coagulopathy, idiopathic
thrombocytopenic purpura, viral infections, AIDS, splenomegaly,
with radiation or chemotherapy
Prothrombin time (PT) Measures extrinsic Increased: bile duct obstruction, liver disease, disseminated
12–16 s clotting time of blood intravascular coagulation, malabsorption of nutrients from
plasma and clotting gastrointestinal tract, vitamin K deficiency, warfarin therapy, factor
factor deficiencies I (fibrinogen), II (prothrombin),V,VII, X deficiency
Respiratory
4
249
SECTION
Respiratory
250
SECTION
Activated partial Measures intrinsic Increased: liver disease, disseminated intravascular coagulation,
thromboplastin time clotting time of blood factor XI,VIII (haemophilia A) and IX (haemophilia B) deficiency,
(APTT) plasma and clotting hypofibrinogenaemia, malabsorption from gastrointestinal tract,
30–40 s factor deficiencies heparin or warfarin therapy
International normalized Standardized measure Increased: indicates excessive bleeding tendencies
ratio (INR) of clotting time derived Decreased: indicates increased risk for thrombosis
0.89–1.10 from the PT. An INR of 1
is assigned to the time it
takes for normal blood
to clot
Erythrocyte The rate at which red Increased: autoimmune disease, malignancy, acute posttrauma,
sedimentation rate (ESR) blood cells settle in severe infection (mainly bacterial), myocardial infarction
Men: 1–10 mm/h a tube of blood over Decreased: heart failure, sickle cell anaemia, steroid treatment
1 hour. A nonspecific
Women: 3–15 mm/h test that screens for
significant inflammatory,
infectious or malignant
disease
Values vary from laboratory to laboratory, depending on testing methods used. These reference ranges should be used as a guide only.
All reference ranges apply to adults only; they may differ in children.
Data from Matassarin-Jacobs, with permission of WB Saunders
Treatment techniques
Positioning
Adult
Positioning the patient optimizes cardiovascular and cardio-
pulmonary function and thus oxygen transport. Correct position-
ing of the patient can maximize lung volume, lung compliance
and the ventilation/perfusion ratio. It can also reduce the work
of breathing and aid secretion removal and cough. This may
involve positioning adult patients with unilateral lung disease
in side lying with the affected lung uppermost to gain the greatest
benefit. The situation is reversed in ventilated adult patients,
when it is more beneficial for the unaffected lung to be
uppermost.
SECTION
Children and infants
Positioning small children and infants to maximize ventilation/ 4
perfusion – rather than for postural drainage and removal of
secretions – requires a different approach to adults. In nonven-
Respiratory
tilated children with unilateral lung disease, the unaffected lung
should be positioned uppermost. Conversely, ventilated babies
and small children should be positioned with the affected lung
uppermost to improve oxygenation.
Postural drainage
Positioning the patient according to the anatomy of the bronchial
tree in order to use gravity to assist drainage of secretions.
Contraindications and precautions for head-down

position (Harden et al 2009, with permission)
• Hypertension
• Severe dyspnoea
• Recent surgery
• Severe haemoptysis
• Nosebleeds
• Advanced pregnancy
• Hiatus hernia 251
• Cardiac failure
• Cerebral oedema
• Aortic aneurysm
• Head or neck trauma/surgery
• Mechanical ventilation
Posterior segment
right upper lobe
Apical segments
SECTION upper lobes Posterior segment
left upper lobe
4
Right middle
Respiratory
lobe
Anterior segments
upper lobes
Anterior basal
segments
Apical segments
lower lobes
Lateral basal segment

right lower lobe Lingula
Posterior basal Right medial basal

segments lower and left lateral basal
lobes segments lower lobes
252 Figure 4.18 Postural drainage positions.
Precautions
Diaphragmatic paralysis/weakness (adults)
Head-down position can cause reflux, vomiting and
aspiration, and splints the diaphragm reducing respiratory
effectiveness (child/baby)
Manual chest clearance techniques

These can be used while the patient is in a postural drainage
position to aid the clearance of secretions. Manual techniques
include percussion, vibrations and shaking.
Contraindications Precautions
Percussion Directly over rib Profound hypoxaemia
Rhythmic clapping fracture Bronchospasm SECTION
with cupped hands or Directly over surgical
4
Pain
soft-rimmed face mask incision or graft
(in babies) on the Osteoporosis
Frank haemoptysis
patient’s chest Bony metastases
Severe osteoporosis
Respiratory
Near chest drains
Hypoxia in children
and babies – Ensure baby’s head is
percussion can supported
exacerbate hypoxia,
especially in infants
Vibrations Directly over rib Long-term oral
Fine oscillations fracture steroids
applied to the chest Directly over surgical Osteoporosis
wall by the therapist’s incision Near chest drains
hands or fingertips Severe bronchospasm Rib fractures in
(in babies). Performed
during thoracic Premature infants children/babies
expansion exercises, on – causes brain Ensure head is
exhalation only injury if head is not supported in
supported children/babies
253
Contraindications Precautions
Shaking Directly over rib Long-term oral
Coarse oscillations fracture steroids
by compressing and Directly over surgical Osteoporosis
releasing the chest incision Bony metastases
wall. Performed Premature infants –
during thoracic Near chest drains
causes brain injury.
expansion exercises, on DO NOT USE. Severe bronchospasm
exhalation only Rib fractures in
children/babies
Ensure head is
supported in
children/babies
From Harden et al 2009, with permission.
SECTION
Active cycle of breathing technique (ACBT)
4 This consists of three different breathing techniques, namely
breathing control (normal tidal breaths), thoracic expansion
exercises (deep inspiratory breaths, usually combined with a 3-s
Respiratory
end-inspiratory hold) and forced expiration technique (forced

expirations following a breath in that can be performed at different
lung volumes), that are repeated in cycles in order to mobilize
and clear bronchial secretions. These can be used in different
combinations according to the patient’s needs and in conjunction
with other treatment techniques.
Contraindications
• None if technique(s) adapted to suit the patient’s
condition
Precautions
• Bronchospasm
Airway suction
The removal of bronchial secretions through a suction catheter
inserted via the nose (nasopharyngeal/NP) or mouth (oropharyn-
geal), or via a tracheostomy or endotracheal tube using vacuum
254 pressure (usually in the range 8.0–20 kPa/60–150 mmHg).
Contraindications
• CSF leak/basal skull fracture (applies to nasopharyngeal
approach only)
• Stridor
• Severe bronchospasm
• Acute pulmonary oedema
Precautions
• Severe CVS instability
• Anticoagulated patients or those with clotting disorders
• Recent oesophagectomy, lung transplant or
pneumonectomy
Adverse effects
• Tracheobronchial trauma SECTION
• Bronchospasm
• Atelectasis 4
• Pneumothorax
• Hypoxia
Respiratory
• Cardiac arrhythmias
• Raised ICP
Manual hyperinflation (MHI)

The use of a rebreathing bag to manually inflate the lungs in
order to improve lung volume and arterial oxygenation, aid the
removal of secretions and assess or improve lung compliance.
The peak airway pressure being delivered should not exceed 40
cmH2O.
Contraindications
• Bullae
• Surgical emphysema
• Cardiovascular instability/arrhythmias
• Patients at risk for barotrauma, e.g. emphysema, fibrosis
• Recent pneumonectomy/lobectomy (first 10 days)
• Severe bronchospasm 255
• Peak airway pressure >40 cmH2O when mechanically
ventilated
• High PEEP requirement >15 cm H2O. If PEEP requirement
>10 cm H2O, only use MHI if essential
• Unexplained haemoptysis
• Increased ICP above the set limits
Adverse effects
• Barotrauma
• Haemodynamic compromise – reduced or increased blood
pressure
• Cardiac arrhythmia
• Reduced oxygen saturation
• Raised intracranial pressure
• Reduced respiratory drive
SECTION • Bronchospasm
4
Considerations when treating patients with raised ICP
Respiratory
Minimize suction
Minimize manual techniques
Minimize manual hyperinflation (maintain hypocapnia)
Consider sedation/inotropic support if ICP increased or unstable
Monitor CPP: should be >70 mmHg
Intermittent positive pressure breathing (IPPB)

Assisted breathing using positive airway pressure to deliver
gas throughout inspiration until a preset pressure is reached.
Inspiration is triggered when the patient inhales and expiration is
passive.
Effects
• Increases tidal volume
• Reduces work of breathing
• Assists clearance of bronchial secretions
256 • Improves alveolar ventilation
Contraindications
IPPB should not normally be used when any of the following
conditions are present. If in doubt, medical advice should be
sought.
• Facial fractures
• Acute head injury
• Large bullae
• Lung abscess
• Severe haemoptysis
• Vomiting
• Cardiovascular instability
• Active tuberculosis
• Tumour or obstruction in proximal airways
• Surgical emphysema SECTION
• Recent lung and oesophageal surgery
4
Tracheostomies
Respiratory
A tracheostomy is an opening in the anterior wall of the trachea
to facilitate ventilation. It is sited below the level of the vocal
cords.
Indications
• Provide and maintain a patent airway when the upper
airways are obstructed.
• Provide access for the removal of tracheobronchial
secretions.
• Prevent aspiration of oral and gastric secretions in
patients who are unable to protect their own airways.
• Used in patients who need longer-term ventilation.
Types of tube
Metal or plastic
• Metal tubes are used for long-term tracheostomy patients
as they are more durable, inhibit bacteria growth, are
easier to clean and can be sterilized with heat or steam. 257
3 4 5
1
SECTION
4 1 Cuffed non-fenestrated 4 Unfenestrated inner tube

2 Cuffed fenestrated 5 Fenestrated inner tube
3 Obturator
Respiratory
Figure 4.19 Different types of tracheostomy tubes.
They are made of either stainless steel or sterling silver

and do not have connections for respiratory equipment,
e.g. a resuscitation bag. On some tubes an adaptor can be
attached.
• Plastic tubes are cheaper and therefore more disposable.
Cuffed or uncuffed
• Cuffed tubes have an air-filled sac at their distal end.
When inflated, a cuffed tube provides a seal between the
trachea and the tube. It protects the airway against
aspiration and allows positive pressure ventilation.
Patients cannot speak when the cuff is inflated, unless the
tube is fenestrated. To minimize the risk for tracheal wall
trauma or aspiration, the cuff pressure should be
258 regularly checked and maintained between 20 and
30 cmH2O (22 mmHg) or within locally agreed
protocols.
• Uncuffed tubes are suitable for long-term use in patients
who may still require suctioning to clear secretions. It is
essential that patients are able to protect their own
airways and have an effective cough and gag reflex to
prevent aspiration. In the event of a tracheostomy
becoming blocked, the patient may still be able to breathe
around the tube. There is less risk for tracheal damage,
and the tube is easier to replace.
Fenestrated
• Fenestrated tubes have an opening on the outer cannula.
This enables air to pass through the tube and over the
vocal cords, allowing speech. They can also be used as
part of the weaning process by allowing patients to SECTION
breathe through the tube and use their upper airways.
Single or double lumen

4
• Single-lumen tubes consist of a single cannula and are
Respiratory
used for invasive ventilation. They are for short-term use
only as they carry the risk of becoming blocked by
secretions and obstructing the airway. The advantage of
using a single lumen is that it maximizes the size of the
tube thereby decreasing airway resistance.
• Double-lumen tubes consist of an inner and outer
cannula. The inner cannula is removable and can be
cleaned to prevent the accumulation of secretions. To
allow speech, the inner tube and outer tube need to be
fenestrated. However, during suctioning the inner tube
must be replaced with an unfenestrated tube to prevent
the catheter passing through the fenestration. It must also
be in place if the patient is put on positive pressure
ventilation in order to maintain pressure.
Mini tracheostomy
• A small tracheostomy that is primarily indicated for
sputum retention as it allows regular suctioning. It does
not prevent aspiration and will only provide a route for 259
oxygenation in an emergency situation. Talking and
swallowing are unaffected.
Complications
• Haemorrhage
• Pneumothorax
• Tracheal tube misplacement
• End of tube blocked if pressed against carina or tracheal
wall
• Surgical emphysema
• Secretions occluding tube
• Herniation of cuff causing tube blockage
• Stenosis of trachea due to granulation
• Tracheo-oesophageal fistula
• Infection of tracheostomy site
SECTION • Tracheal irritation, ulceration and necrosis caused by
overinflated cuff or excessive tube movement
4
Respiratory assessment
Respiratory

need to be adapted to suit their needs. This section provides a
basic framework for the subjective and objective respiratory
assessment of a patient.
Database
• History of present condition
• Past medical history
• Drug history
• Family history
• Social history
– support at home
– home environment
– occupation and hobbies
– smoking
Subjective examination
• Patient’s main concern
260 • Symptoms
• shortness of breath
• cough (productive or nonproductive)
• chest pain
• wheeze
• sputum and haemoptysis
• Other associated symptoms
– fever
– headache
– fatigue
– palpitations
– nausea and vomiting
– gastrointestinal reflux
– urinary incontinence
• Functional ability/exercise tolerance
Objective examination SECTION

Charts
• Blood pressure
4
• Heart rate
• Temperature
Respiratory
• Oxygen requirement
• Oxygen saturation
• Respiratory rate
• Weight
• Peak flow
• Spirometry
• Fluid balance
• Urine output
• Medications
+ ITU/HDU charts
• Mode of ventilation
• FiO2
• Heart rhythm
• Pressure support/volume control
• Airway pressure
• Tidal volume
• I:E ratio 261
• PEEP
• MAP
• CVP
• GCS
• ABGs
• Blood chemistry
X-rays and other diagnostic imaging (e.g. MRI, CT)

Observation
• General appearance
• Position
• Oxygen therapy
• Humidification
• Lines and drains
• Presence of wheeze or cough
SECTION
• Sputum
4 – colour
– volume
– viscosity
• Quality of voice
Respiratory
• Ability to talk in full sentences

• Skin colour
• Jugular venous pressure
• Oedema
• Clubbing
• Flapping tremor
• Chest
– shape
– breathing pattern
– work of breathing
– chest wall movement
– respiratory rate
Palpation
• Chest excursion
• Chest wall tenderness or crepitus
• Skin hydration
262 • Trachea
• Percussion note
• Capillary refill
Auscultation
• Breath sounds
• Added sounds
• Voice sounds
Functional ability
Exercise tolerance

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solving approach (5th ed.). Edinburgh: Elsevier.
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paediatrics (5th ed.). Elsevier.
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anatomy and physiology (11th ed.). London: Pearson.
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paediatrics (5th ed., pp. 47–82). Elsevier.
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ed.). Edinburgh: Churchill Livingstone.
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(4th ed.). Chichester: John Wiley & Sons.
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care (8th ed.). St Louis: Elsevier.
263
Pathology
SECTION
Alphabetical listing of pathologies 266
Diagnostic imaging 306
5
SECTION
5
Pathology
Alphabetical listing of pathologies
Acute respiratory distress syndrome (ARDS)
ARDS can be caused by a wide variety of factors including
pneumonia, sepsis, smoke inhalation, aspiration, major trauma
and burns. As a result, the body launches an inflammatory
response that affects the alveolar epithelium and pulmonary
capillaries. In ARDS, the alveolar walls break down and the
pulmonary capillaries become more permeable allowing plasma
and blood to leak into the interstitial and alveolar spaces, while
at the same time the capillaries become blocked with cellular
debris and fibrin. The lungs become heavy, stiff and waterlogged,
and the alveoli collapse. This leads to ventilation/perfusion
mismatch and hypoxaemia, and patients normally require
mechanical ventilatory support to achieve adequate gas exchange.
Symptoms usually develop within 24–48 hours after the original
injury or illness but can develop 5–10 days later.
AIDs (acquired immunodeficiency syndrome)

SECTION Caused by infection with the human immunodeficiency virus
5 (HIV), which destroys a subgroup of lymphocytes and monocytes,
resulting in suppression of the immune system. The virus enters
the host cell and causes a mutation of its DNA so that the host
cell becomes an infective agent (known as the provirus). Signs
Pathology
and symptoms include fever, malaise, painful throat, swollen

lymph nodes and aching muscles in the initial period following
infection. After a variable period of latency (1–15 years), weight
loss, night sweats, long-lasting fever and diarrhoea occur as
AIDS itself develops, which eventually progresses to the acquisi-
tion of major opportunistic infections and cancers such as
pneumonia or Kaposi’s sarcoma (a malignant skin tumour
appearing as purple to dark brown plaques). Antiretroviral drugs
are used to prolong the lives of infected individuals, although
there is no cure or vaccine for the disease.
Alzheimer’s disease
A form of dementia that is characterized by slow, progressive
266 mental deterioration. Symptoms may start with mild forgetfulness,
difficulty remembering names and faces or recent events and
progress to memory failure, disorientation, speech disturbances,
motor impairment and aggressive behaviour. It is the most
common form of dementia and is distinguished by the presence
of neuritic plaques (primarily in the hippocampus and parietal
lobes), and neurofibrillary tangles (mainly affecting the pyramidal
cells of the cortex).
Ankylosing spondylitis (axial spondyloarthritis)
A chronic inflammatory autoimmune disease involving the
entheses (tendon, ligament and joint capsule insertions). The
spine and sacroiliac joints are primarily involved, although other
joints can be affected. The inflammatory process causes erosion
of adjacent bone followed by ossification of the affected enthesis
leading to progressively restricted joint movement. Over time, the
spine and sacroiliac joints can become fused. Initial symptoms
usually develop from the late teens to early 30s and include
low back pain (with prolonged early morning stiffness that
improves with movement), fatigue, buttock pain and nocturnal
pain (with improvement on getting up). Males and females are
equally affected. Can be associated with inflammation of the SECTION
eye (uveitis/iritis), bowel (ulcerative colitis/Crohn’s disease)
and skin (psoriasis), as well as an increased risk of developing
5
osteoporosis, vertebral fractures and cardiovascular disease. The
cause is unknown.
Asthma Pathology
A chronic inflammatory disease of the airways that makes them

hyperresponsive to a wide range of stimuli including allergens,
pollution, infection, exercise and stress. As a result, the airways
narrow, leading to coughing, wheezing, chest tightness and
difficulty breathing. These symptoms can range from mild to
severe and may even result in death.
Axonotmesis
A more serious peripheral nerve injury than neuropraxia,
involving axonal and myelin degeneration distal to the injury
(Wallerian degeneration) but with preservation of the Schwann
cell basement membrane. Axonal regeneration is possible with
nerve fibres regenerating at approximately 1 mm per day. 267
Baker’s cyst
Distension of the popliteal bursa, which may be accompanied
by herniation of the synovial membrane of the knee-joint capsule
forming a fluid-filled sac at the back of the knee. Associated
with rheumatoid arthritis and osteoarthritis.
Bell’s palsy
An acute, lower motor neurone paralysis of the face, usually
unilateral, related to inflammation and swelling of the facial
nerve (VII) within the facial canal or at the stylomastoid foramen.
Symptoms include inability to close the eye on the affected side,
hyperacusis and impairment of taste. Good recovery is common.
Boutonnière deformity
A flexion deformity of the proximal interphalangeal joint
combined with a hyperextension deformity of the distal inter-
phalangeal joint. Caused by a rupture of the central slip of the
extensor tendon at its insertion into the base of the middle
phalanx. This causes the proximal phalanx to push upwards
SECTION through the lateral slips. The most common causes are rheu-
5 matoid arthritis and direct trauma.
Broca’s aphasia
See Expressive aphasia.
Pathology
Bronchiectasis
Dilatation and destruction of the bronchi as a result of recurrent
inflammation or infection. It may be present from birth (con-
genital bronchiectasis) or acquired as a result of another disorder
(acquired bronchiectasis). Causes of infection include impaired
mucociliary clearance due to congenital disorders such as primary
ciliary dyskinesia or cystic fibrosis as well as bronchial obstruction
and impaired inflammatory response, either acquired after a
severe episode of inflammation or secondary to immunodeficiency.
The inability of the airways to clear secretions in the bronchi
leads to a vicious circle of infection, damage and obstruction of
the bronchi. Clinical features include productive cough, episodic
268 fever, pleuritic pain and night sweats. Patients may develop
pneumothorax, respiratory and heart failure, emphysema and
haemoptysis.
Bronchiolitis
A common respiratory problem affecting young infants. Caused
by inflammation of the bronchioles due to infection by the human
respiratory syncytial virus (RSV). Commonly occurs in winter.
Signs and symptoms are similar to those of the common cold
and include runny or blocked nose, temperature, difficulty feeding,
a dry cough, dyspnoea and wheeze. In severe cases, hypoxia,
cyanosis, tachypnoea and a refusal to eat may develop, and
hospitalization is necessary.
Bronchitis
An inflammation of the bronchi. Acute bronchitis is commonly
associated with viral respiratory infections, i.e. the common cold
or influenza, causing a productive cough, fever and wheezing.
Chronic bronchitis is defined as a cough productive of sputum
for 3 months a year for more than 2 consecutive years. It is
characterized by inflammation of the airways leading to per- SECTION
manent fibrotic changes, excessive mucus production and
thickening of the bronchial wall. This results in sputum retention
and narrowing and obstruction of the airways. In severe cases,
5
irreversible narrowing of the airways leads to dyspnoea, cyanosis,
Pathology
hypoxia, hypercapnia and heart failure. These patients are often
described as ‘blue bloaters’.
Brown-Sequard syndrome
A neurological condition that occurs when there is damage to
one-half of the spinal cord. Below the lesion, there is motor and
proprioception loss on the same side and loss of pain and
temperature on the opposite side.
Bulbar palsy
A bilateral or unilateral lower motor neurone lesion that affects
the nerves supplying the bulbar muscles of the head and neck.
Causes paralysis or weakness of the muscles of the jaw, face,
palate, pharynx and larynx leading to impaired swallow, cough,
gag reflex and speech. 269
Bursitis
Inflammation of the bursa caused by mechanical irritation or
infection. Bursas that are commonly affected include the prepatel-
lar, olecranon (can be associated with gout), subacromial, tro-
chanteric, semimembranosus and the ‘bunion’ associated with
hallux valgus. May or may not be painful.
Cauda equina syndrome

Caused by compression of the nerve roots in the lumbar spine
leading to a characteristic set of features that include bilateral
neurogenic sciatica, reduced perineal sensation, altered bladder
function, loss of anal tone and sexual dysfunction. Patients
presenting with symptoms of CES need immediate referral for
investigation as early diagnosis is essential to prevent long-term
bladder, bowel and sexual dysfunction, sensory and motor loss
in lower limbs and possible paralysis.
Carpal tunnel syndrome

Compression of the median nerve as it passes beneath the
SECTION flexor retinaculum. Often caused by inflammation due to rheu-
5 matoid arthritis, hypothyroidism, diabetes, trauma, repetitive
movements, pregnancy or during menopause. Characterized
by pain, numbness, tingling or burning sensation in the dis-
tribution of the median nerve (i.e. the radial three and a half
Pathology
fingers and nail beds and the associated area of the palm).
Symptoms are often worse at night. Patients also complain of
clumsiness performing fine movements of the hand, particularly
on waking.
Cerebral palsy
An umbrella term for a variety of posture and movement disorders
arising from permanent brain damage incurred before, during,
or immediately after birth. The disorder is most frequently
associated with premature births and is often complicated by
other neurological problems including epilepsy, visual, hearing
and sensory impairments, communication and feeding difficulties,
cognitive and behavioural problems. Common causes include
270 intrauterine infection, intrauterine cerebrovascular insult, birth
asphyxia, postnatal meningitis and postnatal cerebrovascular
insult. The most common disability is a spastic paralysis, which
can be associated with choreoathetosis (irregular, repetitive,
writhing and jerky movements).
Charcot-Marie-Tooth disease
A progressive hereditary disorder of the peripheral nerves that
is characterized by gradual progressive distal weakness and
wasting, mainly affecting the peroneal muscle in the leg. Early
symptoms include difficulty running and foot deformities. The
disease is slowly progressive, and in the late stages the arm muscles
can also be involved. Also known as hereditary motor sensory
neuropathy (HMSN).
Chondromalacia patellae
Refers to degeneration of the patella cartilage causing pain around
or under the patella. Common among teenagers and young
adults, especially girls, it is linked to structural changes and
muscle imbalance associated with periods of rapid growth. This
leads to excessive and uneven pressure on patella cartilage. May SECTION
also result from an acute injury to the patella.
5
Chronic fatigue syndrome
See Myalgic encephalomyelitis.
Pathology
Chronic obstructive pulmonary disease (COPD)
An umbrella term for respiratory disorders that lead to obstruction
of the airways. COPD is associated mainly with emphysema and
chronic bronchitis but also includes chronic asthma. Risk factors
include smoking, recurrent infection, pollution and genetics.
Symptoms include cough, dyspnoea, excessive mucus production
and chest tightness. Patients may also develop oedema and heart
failure.
Claw toe
A flexion deformity of both the proximal interphalangeal and
the distal interphalangeal joints combined with an extension
deformity of the metatarsophalangeal joint. 271
Coccydynia
Pain around the coccyx. Often due to trauma, such as a fall onto
the buttocks, or childbirth; however, the cause is often unknown.
Compartment syndrome
Soft-tissue ischaemia caused by increased pressure in a fascial
compartment of a limb. This increased pressure can have a
number of causes, but the main ones are swelling following
major trauma, a cast being applied too tightly over an injured
limb, or repetitive strain injury. Signs and symptoms are pain,
pale/plum colour, absent pulse, paraesthesia and loss of active
movement. If left untreated, it leads to necrosis of nerve and
muscle in the affected compartment, which is known as Volk-
mann’s ischaemic contracture.
Complex regional pain syndrome (CRPS)

An umbrella term for a number of conditions, usually affecting
the distal extremities, whose common features include unremit-
ting severe pain (often described as burning) and autonomic
SECTION changes in the affected region such as swelling, tenderness,
5 restriction of movement, increased skin temperature, sweating,
discoloration of the skin (usually blue or dusky red) and
osteoporosis. CRPS is subdivided into two groups:
Pathology
Group I – conditions in which minor or major trauma has

occurred but there is no identifiable nerve injury, e.g. after
Colles’ fractures
Group II – conditions in which there has been an injury to a
major peripheral nerve (e.g. sciatic nerve)
Contracted shoulder (Adhesive capsulitis)

A condition that affects the glenohumeral joint synovial capsule
and is characterized by a significant restriction of active and
passive shoulder movement.
The aetiology is unknown, but it has been linked to diabetes,
heart disease, shoulder trauma or surgery, inflammatory disease,
cervical disease and hyperthyroidism. The condition usually
272
affects middle-aged individuals, particularly women. It normally
follows three distinct phases, each lasting approximately 6–9
months (although this can be extremely variable):
Phase 1: increasing pain accompanied by increasing stiffness
Phase 2: decreasing pain with the stiffness remaining
Phase 3: decreasing stiffness and gradual return to normal
function
Also known as frozen shoulder.
Coxa vara
Any condition that affects the angle between the femoral neck
and shaft so that it is less than the normal 120–135°. It can
either be congenital (present at birth), developmental (manifests
clinically during early childhood and progresses with growth)
or acquired (malunited and nonunited fractures, a slipped upper
femoral epiphysis, Perthes’ disease and bone ‘softening’, e.g.
osteomalacia, Paget’s disease).
Cubital tunnel syndrome

SECTION
Compression of the ulnar nerve as it passes through the cubital
tunnel (between the medial epicondyle and the olecranon).
Symptoms include pain, weakness and dysaesthesia along the
5
medial aspect of the elbow, forearm and hand.
Cystic fibrosis Pathology

A progressive genetic disorder of the mucus-secreting glands of
the lungs, pancreas, gastrointestinal tract and sweat glands.
Chloride ion secretion is reduced and sodium ion absorption is
accelerated across the cell membrane resulting in the production
of abnormally viscous mucus. This thickened mucus lines the
intestine and lung leading to malabsorption, malnutrition and
poor growth as well as recurrent respiratory infections that
eventually lead to chronic lung disease. The increased concentra-
tion of sodium in sweat upsets the mineral balance in the blood
and causes abnormal heart rhythms. Other complications include
male infertility, diabetes mellitus, liver disease and vasculitis.
The disease is eventually fatal.
273
De Quervain’s syndrome
A painful condition affecting movement of the thumb that
involves the extensor pollicis brevis and abductor pollicis longus
tendons and sheaths within the first dorsal compartment of the
wrist. Although the exact cause is not known, it is usually
aggravated by activities involving repetitive movements of the
hand or wrist.
Dermatomyositis
A rare autoimmune connective-tissue disease related to poly-
myositis that mainly affects adults between 40 and 60 years of
age and children between 5 and 15 years of age. It is more
common in women than men. Symptoms include weak, tired
and inflamed muscles, swollen skin and a distinctive skin rash.
In severe cases the heart and lungs can be affected.
Developmental coordination disorder

A neurodevelopmental condition affecting fine and/or gross
motor coordination in children and adults. Early physical
SECTION developmental milestones may be delayed (e.g. self-care, writing,
5 riding a bike). However, a definitive diagnosis is not given
before 5 years of age since developmental rates vary widely.
Thought to be more common in boys and can be associated
with nonmotor difficulties including problems with planning
Pathology
and organization as well as memory, perception, processing,

articulation and speech. Often coexists with autism spectrum
disorder, attention deficit hyperactivity disorder and learning
and language disorders. Also known as dyspraxia.
Developmental dysplasia of the hip

Used to describe a spectrum of disorders causing hip dislocation
either at birth or soon afterwards. The acetabulum is abnormally
shallow so that the femoral head is easily displaced. Females
and the left hip are more commonly affected.
Diabetes insipidus
A condition that leads to frequent excretion of large amounts
274 of diluted urine. The symptoms of excessive thirst and urination
are similar to diabetes mellitus, but the two conditions are
unrelated. Urine excretion is governed by antidiuretic hormone
(ADH), which is made in the hypothalamus and stored in the
pituitary gland. Diabetes insipidus is caused by damage to the
pituitary gland or by insensitivity of the kidneys to ADH. This
leads to the body losing its ability to maintain fluid balance.
Diabetes mellitus
A chronic condition caused by the body’s inability to produce
or effectively use the hormone insulin to regulate the transfer
of glucose from the blood into the cells. This leads to higher
than normal levels of blood sugar. If not corrected, this can lead
to coma, kidney failure and ultimately, death. In the long term,
high levels of glucose can damage blood vessels, nerves and
organs leading to cardiovascular disease, chronic renal failure,
retinal damage and poor wound healing.
There are two types of diabetes:
Type I– little or no insulin is produced. Requires lifelong
treatment with insulin injections, diet control and lifestyle
adaptations. SECTION
Type II – the body produces inadequate amounts of insulin or
is unable to utilize insulin effectively. Mainly occurs in 5
people older than 40 years of age and is linked to obesity.
Diffuse idiopathic skeletal hyperostosis (DISH) Pathology

A condition that is characterized by widespread calcification
and ossification of ligaments, tendons and joint capsule insertions.
Mainly affects the spine with calcification of the anterior
longitudinal ligament, which radiologically gives the appearance
of candle wax dripping down the spine. Other joints may be
affected with ossification of ligament and tendon insertions.
Radiographically distinguishable from spondyloarthropathies
and degenerative disc disease in that underlying bone and disc
height are preserved and the facet joints are unaffected. It mainly
affects men older than 50 years of age and in most cases it is
asymptomatic, though some patients complain of stiffness and
mild pain. The cause is unknown. Also known as Forestier’s
disease. 275
Duchenne muscular dystrophy
See Muscular dystrophy.
Dupuytren’s contracture
Thickening and shortening of the palmar aponeurosis together
with flexion contracture of one or more fingers. The cause is
unknown.
Ehlers-Danlos Syndrome (EDS)

A group of heritable connective tissue disorders that arise from
genetic alterations in collagen. It is characterized by joint
hypermobility and often instability as well as fragility and
hyperextensibility (stretchiness) of skin and other tissues of the
body. There are 13 types of EDS, the most common being the
hypermobile form (hEDS). Rarer types include classical EDS and
vascular EDS. Clinical features of hEDS include painful and
clicking joints, joint sprains, subluxations, dislocations, fatigue,
cardiovascular symptoms, dysautonomia (tachycardia, hypoten-
sion, syncope), mechanical and neuropathic bowel dysfunction
SECTION (hernia, reflux, sluggish bowel, constipation, chronic inflamma-
5 tion), prolapse (mitral, rectal, uterine), myopia, astigmatism,
poor response to local anaesthetic, striae atrophicae and easily
bruised skin. Classical EDS is associated with greater skin
extensibility resulting in more obvious scarring and organ
Pathology
prolapse. Vascular EDS, considered to be the most serious form,

is associated with a greater risk for rupture of the blood vessels,
gut wall and uterus, which can be life threatening and life
shortening.
Emphysema
The walls of the terminal bronchioles and alveoli are destroyed
by inflammation and lose their elasticity. This causes excessive
airway collapse on expiration, which traps air in the enlarged
alveolar sacs. This irreversible airways obstruction leads to
symptoms of dyspnoea, productive cough, wheeze, recurrent
respiratory infection, hyperinflated chest and weight loss. These
patients are often described as ‘pink puffers’ who may hyper-
276 ventilate, typically overusing their accessory respiratory muscles,
and breathe with pursed lips in order to maintain airway pressure
to decrease the amount of airway collapse.
Empyema
A collection of pus in the pleural cavity following nearby lung
infection. Can cause a buildup of pressure in the lung, which
causes pain and shortness of breath.
Enteropathic arthritis
This form of chronic inflammatory arthritis is associated with
ulcerative colitis or Crohn’s disease, which are types of inflam-
matory bowel disease (IBD). It affects around one-fifth of IBD
sufferers. Although it predominantly affects the peripheral joints
such as the knees, ankles and elbows, it can also affect the
spine.
Expressive aphasia (Broca’s aphasia)

A lesion of Broca’s area, on the inferior frontal cortex, causing
nonfluent, hesitant speech that is characterized by poor grammar
and reduced word output while meaning is preserved. Persever- SECTION
ance can occur and writing may be impaired, but comprehension
remains relatively intact. Broca’s area is near the motor cortex 5
for the face and arm and so may be associated with weakness
in these areas.
Pathology
Fibromyalgia
A nonarticular rheumatological disorder associated with chronic,
widespread pain lasting 3 months or more. It is associated with
increased sensitivity to pain, fatigue, unrefreshing sleep and
cognitive/memory problems. Other problems associated with
fibromyalgia include depression, anxiety, morning stiffness and
headaches. The cause and pathogenesis of fibromyalgia is
unknown, but it can either develop on its own or together with
other conditions such as rheumatoid arthritis or systemic lupus
erythematosus.
Forestier’s disease
See Diffuse idiopathic skeletal hyperostosis. 277
Freiberg’s disease
Degenerative aseptic necrosis of the metatarsal head, usually
the second metatarsal head, which mainly affects athletic girls
10–15 years of age.
Functional neurological disorder

Characterized by neurological symptoms such as weakness,
tremor, movement disorders, sensory symptoms, dissociative
(nonepileptic) attacks and blackouts, which are due to a
problem with the functioning of the nervous system, rather
than neurological disease. Previously known as conversion
disorder.
Ganglion
An abnormal but harmless cystic swelling that often develops
over a tendon sheath or joint capsule, especially on the back of
the wrist.
Giant cell (temporal) arteritis

SECTION Characterized by inflammation of large- and medium-sized
5 arteries, usually in the head and neck, resulting in a reduction
in blood and oxygen supply to the target organ. It is sometimes
called temporal arteritis because the arteries around the temples
are usually affected. It only tends to develop in adults older
Pathology
than 50 years of age and is more common in women than

in men. Giant cell arteritis is closely linked with polymyalgia
rheumatica syndrome. Patients present with intractable throbbing
headache, jaw claudication (pain when chewing or talking),
vision loss and generalized muscle ache. Early diagnosis and
treatment with steroids is essential to prevent visual loss or
brainstem stroke, as well as to relieve the headache. The cause is
unknown.
Golfer’s elbow (medial epicondylitis)

Tendinopathy of the common origin of the forearm flexors causing
pain and tenderness at the medial aspect of the elbow and down
the forearm.
278
Gout
Characterized by attacks of acute joint inflammation secondary
to hyperuricaemia (raised serum uric acid) where monosodium
urate or uric acid crystals are deposited into the joint cavity. The
disease usually affects middle-aged men and mainly affects
the big toe. If the disease progresses, urates may be deposited
in the kidney (stones) or the soft tissues (tophi), especially the
ears. Further joint destruction can occur.
Guillain-Barré syndrome (GBS)

An acute inflammatory polyneuropathy that usually occurs
1–4 weeks after fever associated with viral infection or follow-
ing immunization. Thought to be an autoimmune disorder, it
leads to segmental demyelination of spinal roots and axons,
denervation atrophy of muscle and inflammatory infiltration
of the brain, liver, kidneys and lungs. Clinical features include
loss of sensation in the hands and feet, symmetrical progres-
sive ascending motor weakness, paralysis, muscle wasting,
diminished reflexes, pain and autonomic disturbances. In
severe cases, the respiratory and bulbar systems are affected SECTION
and ventilation/tracheostomy may be required. Recovery is
common.
5
Haemothorax
Blood in the pleural cavity. Commonly due to chest trauma but Pathology
also found in patients with lung and pleural cancer and in those
who have undergone thoracic or heart surgery.
Hallux valgus
A lateral deviation of the great toe at the metatarsophalangeal
joint. The metatarsal head becomes prominent (bunion) and,
along with the overlying bursa, may become inflamed.
Hammer toe
An extension deformity of the metatarsophalangeal joint,
combined with a flexion deformity of the proximal interphalangeal
joint. The second toe is the most commonly affected.
279
Herpes zoster
See Shingles.
Horner’s syndrome
A group of symptoms caused by a lesion of the sympathetic
pathways in the hypothalamus, brainstem, spinal cord, C8–T2
ventral spinal roots, superior cervical ganglion or internal carotid
sheath. It causes ipsilateral pupil constriction, drooping of the
upper eyelid and loss of facial sweating on the affected side of
the face.
Huntingdon’s disease
A hereditary disease caused by a defect in chromosome 4 that
can be inherited from either parent. Onset is insidious and occurs
between 35 and 50 years of age. Symptoms include sudden,
involuntary movements (chorea) accompanied by behavioural
changes and progressive dementia.
Hypermobility spectrum disorder (previously
known as joint hypermobility syndrome)
SECTION
Hypermobility describes a condition in which joint movement
5 is in excess of normal range. In some cases this poses no problem
to the individual, but in others it makes joints more susceptible
to soft-tissue injury and internal derangement, arthritis,
Pathology
arthralgias and myalgias. Hypermobility spectrum disorder is

used to describe those who are symptomatic due to their hyper-
mobility but do not have a heritable disorder of connective tissue,
such as EDS or Marfan syndrome. The clinical features and
number of joints affected are highly variable and may include
a history of dislocation, subluxation, sprains, tendonitis and
proprioceptive deficit.
Hyperparathyroidism
Occurs when overactivity of the parathyroid glands leads to
excessive secretion of parathyroid hormone (PTH), which regu-
lates levels of calcium and phosphorus. Overproduction of PTH
causes excessive extraction of calcium from the bones and leads
to hypercalcaemia. Symptoms include fatigue, memory loss,
280 renal stones and osteoporosis.
Hyperthyroidism
Occurs when the thyroid gland produces too much thyroxine,
a hormone that regulates metabolism. This increase in metabolism
causes most body functions to accelerate, and symptoms may
include tachycardia, palpitations, hand tremors, nervousness,
shortness of breath, irritability, anxiety, insomnia, fatigue,
increased bowel movements, muscle weakness, heat intolerance,
weight loss despite an increase in appetite, thinning of skin
and fine brittle hair. Also known as overactive thyroid or
thyrotoxicosis.
Hyperventilation syndrome
Breathing in excess of metabolic requirements, which causes
low arterial carbon dioxide levels, leading to alkalosis and changes
in potassium and calcium ion distribution. As a result, neuro-
muscular excitability and vasoconstriction occur. Clinical features
include lightheadedness, dizziness, chest pain, palpitations,
breathlessness, tachycardia, anxiety, paraesthesia and tetanic
cramps.
SECTION
Hypothyroidism
Occurs when the thyroid gland does not produce enough thy-
5
roxine, a hormone that regulates metabolism. This decrease in
metabolism causes most body functions to slow down, and
symptoms may include tiredness, weight gain, dry skin and hair, Pathology
cold intolerance, hoarse voice, memory loss, muscle cramps,
constipation and depression. Also known as underactive thyroid.
Interstitial lung disease

An umbrella term for a wide range of respiratory disorders
characterized by inflammation and, eventually, fibrosis of the
lung connective tissue. The bronchioles, alveoli and vasculature
may all be affected causing the lungs to stiffen and decrease in
size. Examples of interstitial lung disease include fibrosing
alveolitis, asbestosis, pneumoconiosis, bird fancier’s or farmer’s
lung, systemic lupus erythematosus, scleroderma, rheumatoid
disease, cryptogenic pulmonary fibrosis and sarcoidosis. Also
known as diffuse parenchymal lung disease. 281
Jones fracture
A stress fracture of the proximal end of the fifth metatarsal.
Köhler’s disease
A condition in which the navicular bone undergoes avascular
necrosis. It usually affects children between 1 and 10 years of
age (more commonly boys) with a peak between 3 and 7 years
of age. The cause is unclear, but the disease usually resolves over
time (1 month to 2 years) without any long-term consequences.
Locked-in syndrome
A rare neurological disorder characterized by total paralysis of
all voluntary muscles except those controlling eye movement
and some facial movements. It is caused by damage to the pons
(brainstem). This may be due to traumatic brain injury, vascular
disease, demyelinating diseases or overdose. Patients are unable
to speak or move, but sight, hearing and cognition are normal.
Prognosis for recovery is poor with most patients not regaining
function.
SECTION
Lung abscess
5 A pus-filled necrotic cavity within the lung parenchyma caused
by infection.
Mallet finger
Pathology
A flexion deformity of the distal interphalangeal joint due to

damage to the extensor tendon at its insertion into the distal
phalanx. The result is an inability to extend the distal phalanx.
March fracture
A stress fracture of the metatarsal. Usually affects the second
or third metatarsal, but it can affect the fourth and fifth. Initially
the fracture may not be visible on X-ray, but abundant callus is
seen on later X-rays.
Marfan syndrome (MFS)

A heritable disorder of connective tissue that is thought to result
from a mutation in the fibrillin gene. Patients present with a
282 distinct collection of features known as the marfanoid habitus,
which include a tall, slender body with long arms, hands, fingers,
legs, feet and toes, flexible joints and scoliosis. Other features
include pectus excavatum or carinatum, pes planus, mitral valve
prolapse, and dislocation of the ocular lens. MFS also carries
an increased risk for aortic aneurysm.
Meningitis
An acute inflammation of the meninges due to infection by
bacteria or viruses. Age groups most at risk are those younger
than 5, especially infants younger than 1, and adolescents
between 15 and 19 years of age. The most common causes of
bacterial meningitis in young children are Neisseria meningitidis
(meningococcal meningitis) and Haemophilus influenzae. The
classic triad of clinical features is fever, headache and neck
stiffness. Skin rash and septic shock may occur where septicaemia
has developed as a result of widespread meningococcal infection.
Other signs in adults include confusion and photophobia. Onset
of symptoms may be gradual or sudden; however, deterioration
is rapid, often requiring intensive supportive therapy.
Meralgia paraesthetica SECTION
Pain, numbness and tingling in the anterolateral thigh caused

by compression of the lateral cutaneous nerve as it passes under
5
the inguinal ligament. Pregnancy, obesity and tight clothing
Pathology
are associated risk factors. Usually responds well to conservative
treatment and resolves over time.
Morton’s neuroma (metatarsalgia)

A fibrous thickening of the digital nerve as it travels between
the metatarsals. Can be caused by irritation, trauma or compres-
sion. Usually occurs between the second and third metatarsal
or the third and fourth metatarsal. Symptoms include burning,
numbness, paraesthesia and pain in the ball of the foot. Also
known as plantar neuroma and plantar digital neuritis.
Motor neurone disease

A group of progressive degenerative diseases of the motor system
occurring in middle to late adult life, causing weakness, wasting
and eventual paralysis of muscles. It primarily affects the anterior 283
horn cells of the spinal cord, the motor nuclei of the brainstem
and the corticospinal tracts. There are four main types:
Progressive muscle atrophy
Starts early in life, typically before 50 years of age. Affects the
cervical region leading to atrophy of the muscles of the hand.
Involvement spreads to the arms and shoulder girdle and may
extend to the legs.
Amyotrophic lateral sclerosis
There are upper motor neurone changes as well as lower motor
neurone changes. Characterized by weakness and atrophy in
the hands, forearms and legs but may also spread to the body
and face.
Progressive bulbar palsy
Caused by damage to the motor nuclei in the bulbar region in
the brainstem, which results in wasting and paralysis of muscles
of the mouth, jaw, larynx and pharynx. General features include
pain and spasms, dyspnoea, dysphagia, dysarthria and sore eyes.
SECTION
Primary lateral sclerosis
5 Occurs rarely. Causes weakness in the leg muscles, and some
people may develop clumsiness in the hands or speech problems.
Multiple sclerosis
Pathology
A chronic, progressive disease characterized by multiple demy-

elinating lesions (plaques) throughout the central nervous system.
It predominantly affects young adults between 20 and 40 years
of age and is more prevalent in women. The disease is usually
characterized by recurrent relapses (attacks) followed by remis-
sions, although some patients follow a chronic, progressive course.
The plaques interfere with normal nerve impulses along the
nerve fibre and the site of the lesions, and the degree of inflam-
mation at each site leads to a variety of neurological signs and
symptoms. Common symptoms include visual disturbances,
ataxia, sensory and motor disturbances, bulbar dysfunction,
fatigue, bladder and bowel symptoms, cognitive and emotional
disturbances, pain and spasm.
284 There are four broad groups of MS:
Relapsing/remitting (RRMS)
Partial or complete recovery between relapses. The majority of
people with MS (around 80%) are diagnosed with this form.
Secondary progressive (SPMS)
Slowly progressive deterioration with or without relapses. Those
diagnosed with RRMS (about 50%) may go on to develop SPMS.
Benign (BMS)
One or two relapses with full recovery.
Primary progressive (PPMS)
Progression of neurological symptoms without relapses. Affects
10–15% of MS patients.
Muscular dystrophy
A group of genetically determined progressive muscle-wasting
diseases. Duchenne muscular dystrophy is the most common and
severe form among children, in which the affected muscle fibres
degenerate and are replaced by fat and connective tissue. The
condition affects boys between 3 and 5 years of age. Its clinical SECTION
features include difficulty walking, pseudohypertrophy of proximal
muscles, postural problems, diminished reflexes and difficulty 5
standing from squatting (Gower’s sign). Myotonic dystrophy
is the most common form in adulthood, usually in the second
Pathology
decade. There are two types, with type 1 being more severe than
type 2. Clinical features include myotonia (difficulty relaxing the
muscles), ptosis and slow, progressive weakness of the face, neck
and distal limb muscles. Cardiomyopathy with arrhythmias and
gastrointestinal disturbances can occur.
Myalgic encephalomyelitis
A condition in which patients complain of long-term, persistent
and debilitating fatigue along with other symptoms such as
muscle pain, joint pain, disordered sleep, gastric disturbances,
poor memory and concentration, headaches, sore throat and
tender lymph nodes in the armpit and neck, though patients
will not necessarily have all of them. Diagnosis is based on
symptoms and tests that rule out other causes. No single cause
of the disease has been established. 285
Myasthenia gravis
A disorder of the neuromuscular junction caused by an impaired
ability of the neurotransmitter acetylcholine to induce muscular
contraction, most likely due to an autoimmune destruction of
the postsynaptic receptors for acetylcholine. It predominantly
affects adolescents and young adults (mainly women) and is
characterized by abnormal weakness and fatiguing of some or
all muscle groups to the point of temporary paralysis. Onset
of symptoms is usually gradual and includes drooping of the
upper eyelid, double vision, dysarthria and weakness of other
facial muscles.
Myeloma (also known as multiple myeloma)
A malignant condition in which abnormal plasma cells build
up in the bone marrow. It can appear as both a tumour and/or
an area of bone loss and tends to affect the spine (vertebral
bodies), pelvis, ribs, skull, shoulder and hip girdles. It also
interferes with the production of red blood cells and white blood
cells and can lead to kidney damage. Because myeloma can occur
SECTION at a number of sites in the bone marrow, it is often referred to
as multiple myeloma. Symptoms include hypercalcaemia,
5 anaemia, kidney damage, fatigue, infections, bone pain, fractures
and weight loss. Older people (older than 50 years of age) are
primarily affected.
Pathology
Myositis ossificans
Growth of bone in the soft tissues near a joint that occurs after
fracture or severe soft-tissue trauma, particularly around the
elbow. Also occurs in a congenital progressive form, usually
leading to early death during adolescence.
Myotonic dystrophy
See Muscular dystrophy.
Neuropraxia
The mildest type of peripheral nerve injury characterized by a
transient and reversible loss of nerve conduction without struc-
tural damage to the axon. Causes include blunt trauma, traction-
286 ischaemia from fracture-dislocation, compression-ischaemia (e.g.
compartment syndrome), irradiation. Recovery occurs within
8–12 weeks.
Neurotmesis
The most serious peripheral nerve injury where the nerve and
nerve sheath is disrupted. Surgical repair is necessary, though
recovery is unpredictable.
Osgood-Schlatter’s disease
Seen mainly in teenagers (boys slightly more than girls), it affects
the tibial tubercle. Vigorous physical activity can cause the patellar
tendon to pull at its attachment to the tibial tuberosity resulting
in detachment of small cartilage fragments.
Osteoarthritis
A chronic disease of articular cartilage, associated with secondary
changes in the underlying bone, causing joint inflammation
and degeneration. Primarily affects the large, weight-bearing
joints such as the knee and hip, resulting in pain, loss of move-
ment and loss of normal function.
SECTION
Osteochondritis
An umbrella term for a variety of conditions in which there is 5
compression, fragmentation or separation of a piece of bone i.e.
Osgood-Schlatter’s disease, Osteochondritis dissecans, Perthes’
Pathology
disease, Scheuermann’s disease, Sever’s disease, Sinding-Larsen-
Johansson’s disease.
Osteochondritis dissecans
It occurs when a localized area of bone dies due to a lack of
blood supply. Consequently, there is gradual localized separation
of the cartilage and underlying bone. Can be caused by repetitive
strain or trauma and mainly affects children and adolescents.
The loose body can enter the joint space resulting in pain, swelling
and reduced movement. The knee, elbow and ankle are the most
commonly affected joints.
Osteogenesis imperfecta
A heritable disorder of connective tissue caused by an abnormal
synthesis of type I collagen. As a result, bone is susceptible to 287
fracture and deformity and connective tissue may also be affected.
There are several different forms, which vary in appearance and
severity. In its mildest form, features may include a history of
fractures (which mainly occur before puberty), lax joints, low
muscle tone, tinted sclera ranging from nearly white to dark
blue or grey and adult-onset deafness. Those with a more severe
form of the disease suffer short stature, progressive bone deformity
and frequent fractures. Some types of the disease can be fatal
in the perinatal period. Also known as brittle bone disease.
Osteomalacia
Softening of the bone caused by a deficiency in vitamin D from
poor nutrition, lack of sunshine or problems absorbing or
metabolizing vitamin D. A lack of vitamin D leads to incomplete
calcification of the bones so that they become weak and easily
fractured. This is particularly noticeable in the long bones, which
become bowed. When this affects children, it is called rickets.
Osteomyelitis
SECTION
An inflammation of the bone and bone marrow due to infection.
The most common causes are infection of an open fracture
5 or postoperatively after bone or joint surgery. The infection
is often spread from another part of the body to the bone via
the blood.
Pathology
Osteoporosis
A reduction in bone density which results from the body being
unable to form enough new bone or when too much calcium
and phosphate is reabsorbed back into the body from existing
bones. This leads to thin, weak, brittle bones that are susceptible
to fracture. Osteoporosis is common in postmenopausal women,
where a loss of ovarian function results in a reduction in oestrogen
production. It can also be caused by prolonged disuse and
non–weight bearing, endocrine disorders such as Cushing’s
disease, and steroid therapy.
Paget’s disease
Characterized by an excessive amount of bone breakdown
288 associated with abnormal bone formation causing the bones to
become enlarged, deformed and weak. Normal architecture of
the trabeculae is affected making the bones brittle. Paget’s disease
is usually confined to individual bones, although more than one
bone can be affected. The pelvis, femur, and lower lumbar
vertebrae are the most commonly affected. Also known as osteitis
deformans. The cause remains unknown.
Parkinson’s disease
A degenerative disease of the substantia nigra that reduces the
amount of dopamine in the basal ganglia. Depletion of dopamine
levels affects the ability of the basal ganglia to control movement,
posture and coordination and leads to the characteristic symptoms
of rigidity, slowness of voluntary movement, poor postural reflexes
and resting tremor. Parkinson’s has a gradual, insidious onset
and affects mainly those between 50 and 65 years of age. Early
symptoms of Parkinson’s disease include aches and stiffness,
difficulty with fine manipulative movements, slowness of walking,
resting tremor of head, hands (pill rolling) and feet. Later
symptoms may include shuffling gait, difficulties with speech,
a masklike appearance and depression. SECTION
Pellegrini-Stieda syndrome
Local calcification of the femoral attachment of the medial
5
collateral ligament (MCL), usually following direct trauma or a
Pathology
sprain/tear of the MCL. Signs and symptoms include chronic
pain and tenderness, difficulty extending and twisting the knee,
marked restriction of knee range of movement and a tender
lump over the proximal portion of the knee.
Peripheral nerve injury

See Neuropraxia, Axonotmesis, Neurotmesis
Perthes’ disease
A childhood condition which occurs when the blood flow to the
upper femoral epiphysis is compromised, causing parts of the
femoral head to become ischaemic and necrotic. The tissues of
the femoral head become soft and fragmented but eventually
reform over a period of several years as the blood vessels regrow.
The reformed head is flatter and larger than the original, which 289
can lead to deformity, shortening and secondary osteoarthritis.
The cause is unknown.
Piriformis syndrome
Refers to irritation of the sciatic nerve by the piriformis muscle.
Swelling of the muscle through injury or overuse is thought to
compress on the sciatic nerve resulting in pain, numbness or
tingling in the buttock that can extend along the posterior thigh
and calf.
Plantar fasciitis
An inflammatory or degenerative condition affecting the plantar
fascia. Pain is usually felt along the medial aspect of the calcaneal
tuberosity where the plantar aponeurosis inserts and may extend
down the proximal plantar fascia.
Pleural effusion
A collection of excess fluid in the pleural cavity which can be
caused by a number of mechanisms:
SECTION • Increased hydrostatic pressure, e.g. congestive heart
5 failure
• Decreased plasma-oncotic pressure, e.g. cirrhosis of the
liver, malnutrition
• Increased capillary permeability, e.g. inflammation of the
Pathology
pleura
• Impaired lymphatic absorption, e.g. malignancy
• Communication with peritoneal space and fluid, e.g.
ascites
The fluid can either be clear/straw-coloured and have a low
protein content (known as a transudate), indicating a disturbance
of the normal pressure in the lung, or it can be cloudy and have
a high protein content (known as an exudate), indicating
infection, inflammation or malignancy.
Pleurisy
Inflammation of the pleura causing severe pain as a result of
friction between their adjoining surfaces. Pain is focused at the
290 site of the inflammation and is increased with deep inspiration
and coughing. Most commonly caused by a viral infection as
well pneumonia, tuberculosis, rheumatic diseases and chest
trauma.
Pneumonia
An inflammation of the lung tissue, mostly caused by bacterial
or viral infection but also by fungi or aspiration of gastric contents.
Pneumonia can be divided into two types:
• Community-acquired pneumonia: most commonly caused
by the bacterium Streptococcus pneumoniae
• Hospital-acquired pneumonia: tends to be more serious as
patients are often immunocompromised and they may be
infected by bacteria resistant to antibiotics
The most common infective agents are bacteria such as
Pseudomonas, Klebsiella and Escherichia coli. Clinical features
include productive or dry cough, pleuritic pain, fever, fatigue
and, after a few days, purulent and/or blood-stained sputum.
Pneumothorax SECTION
A collection of air in the pleural cavity following a lesion in the
lung or trauma to the chest, which causes the lung to collapse. 5
Clinical features include acute pain, dyspnoea and decreased
movement of the chest wall on the affected side. Sometimes this
can lead to significant impairment of respiration and/or circula- Pathology
tion, known as a tension pneumothorax. This occurs when the
amount of air pressure within the pleural cavity increases due
to the formation of a one-way valve caused by damage to the
visceral pleura, allowing air to enter on inspiration but preventing
it from escaping on expiration. Clinical features include increased
respiratory distress, cyanosis, hypotension, tachycardia and
tracheal deviation. In severe cases, this can cause a mediastinal
shift, which impairs venous return, leading to respiratory and
cardiac arrest. Pneumothoraces are classified by how they are
caused and divided into three types:
• Primary spontaneous pneumothorax: occurs without a
known cause. Usually affects tall, thin young men,
especially smokers 291
• Secondary spontaneous pneumothorax: occurs in the
presence of underlying lung disease. Associated with
diseases such as COPD, asthma, emphysema, cystic fibrosis
and pneumonia
• Traumatic pneumothorax: caused by traumatic injury to
the chest, e.g. perforation of lung tissue by fractured ribs
or stab wound, or during medical procedures such as
insertion of central venous lines, lung biopsies or
mechanical ventilation
Poliomyelitis
Poliomyelitis is a highly contagious infectious disease caused by
one of three types of poliovirus. The extent of the disease varies,
with some people experiencing no or mild symptoms, while others
develop the paralytic form of the disease. It can strike at any
age, but affects mainly children younger than 5 years of age.
The poliovirus destroys motor neurones in the anterior horn.
The muscles of the legs are affected more often than those of the
arm, but the paralysis can spread to the muscles of the thorax
SECTION
and abdomen. In the most severe form (bulbar polio), the motor
5 neurones of the brainstem are attacked, reducing breathing
capacity and causing difficulty in swallowing and speaking.
Without respiratory support, bulbar polio can result in death.
Pathology
Polyarteritis nodosa
A vasculitic syndrome where small- and medium-sized arteries
are attacked by rogue immune cells causing inflammation and
necrosis. Tissue supplied by the affected arteries, most commonly
the skin, heart, kidneys and nervous system, is damaged by the
impaired blood supply. Common manifestations are fever, renal
failure, hypertension, neuritis, skin lesions, weight loss and muscle
and joint pain.
Polymyalgia rheumatica
A vasculitic syndrome associated with fever and generalized pain
and stiffness, especially in the shoulder and pelvic girdle areas.
Other symptoms include overwhelming tiredness, loss of appetite,
292 weight loss, anxiety and depression. Symptoms usually begin
abruptly, and it mainly affects women older than 50 years of
age.
Polymyositis
An autoimmune, inflammatory muscle disease of unknown
aetiology causing progressive weakness of skeletal muscle. The
muscles of the shoulder girdle, hip and pelvis are most commonly
affected, although, less commonly, the distal musculature or
swallowing can be affected. The muscles can ache and be tender
to touch. The disease sometimes occurs with a skin rash over
the upper body and is known as dermatomyositis.
Postpolio syndrome
A recurrence or progression of neuromuscular symptoms that
appears in people who have recovered from acute paralytic
poliomyelitis, usually 15–40 years after the original illness.
Symptoms include progressive muscle weakness, severe fatigue
and pain in the muscles and joints.
Postural (orthostatic) tachycardia syndrome (PoTS)

SECTION
A form of cardiovascular autonomic dysfunction associated with
excessive tachycardia on standing. It is defined as a heart rate
increase of 30 beats per minute or more or a heart rate of more
5
than 120 beats per minute within 10 minutes of standing, usually
Pathology
without an associated drop in blood pressure. It is often diagnosed
with a Tilt Table Test. Symptoms can vary from mild to severe
and included lightheadedness, fainting or almost fainting,
headaches, fatigue, vision problems, palpitations, nausea,
acrocyanosis (red/blue discoloration of the lower leg during
standing caused by excessive venous pooling). It is most common
in women between 13 and 50 years of age and is associated
with several conditions including hypermobile Ehlers-Danlos
syndrome, chronic fatigue syndrome, mast cell activation disorder,
Sjögren’s syndrome and antiphospholipid syndrome.
Primary ciliary dyskinesia

A genetic condition affecting the cilia causing abnormal ciliary
activity and consequently, poor mucociliary clearance. Can be
associated with situs inversus (the location of internal organs 293
on the opposite side of the body), and when the two conditions
exist together this is known as Kartagener’s syndrome. Sperm
can also be affected as they share a similar structure to cilia,
leading to infertility in men. Clinical features include recurrent
ear, sinus and chest infections, which can eventually lead to
bronchiectasis.
Pseudobulbar palsy
An upper motor neurone lesion that affects the corticomotorneu-
rone pathways and results in weakness and spasticity of the
oral and pharyngeal musculature. Leads to slurring of speech
and dysphagia. Patients also exhibit emotional incontinence.
They are unable to control their emotional expression and may
laugh or cry without apparent reason.
Psoriatic arthritis
A chronic inflammatory autoimmune disorder associated with
psoriasis (a skin condition characterized by red, itchy, scaly
patches) causing joints to become stiff, painful and swollen.
SECTION
Approximately 30% of people with psoriasis are affected, and
it can either precede or follow the onset of the skin disease.
5 Occasionally, psoriatic arthritis may occur in the absence of skin
disease. Males and females are affected equally, and it is most
common in middle age. Any joint can be involved, including the
Pathology
spine, though the most common pattern is for one large joint
to be affected along with a number of small joints in the fingers
or toes. Some people also develop psoriatic nail disease.
Pulmonary embolus
A blockage in the pulmonary artery most commonly caused by
a blood clot that originates from one of the deep veins in the
legs. This causes a ventilation/perfusion imbalance and leads
to arterial hypoxaemia. Risk factors include prolonged bed rest
or prolonged sitting (e.g. long flights), oral contraception, surgery,
pregnancy, malignancy and fractures of the femur.
Pulmonary oedema
Accumulation of fluid in the lungs. Usually caused by left
294 ventricular failure whereby a back pressure builds up in the
pulmonary veins, eventually causing fluid to be pushed from
the veins into the alveoli. Pulmonary oedema can also be caused
by myocardial infarction, damage to mitral or aortic valves, direct
lung injury, severe infection, poisoning or fluid overload. Symp-
toms include shortness of breath, wheezing, sweating, tachycardia
and coughing up white or pink-tinged frothy secretions.
Raynaud’s phenomenon
A vasospastic disorder affecting the arterioles of the hands and
feet, usually triggered by cold weather or emotional stress. The
affected digits first turn pale and cold (ischaemia), then blue
(cyanosis) and then bright red (reperfusion). The condition can
either be primary, with no known cause, or secondary to an
underlying disease such as systemic lupus erythematosus, poly-
myositis, rheumatoid arthritis and scleroderma.
Reactive arthritis
An inflammatory autoimmune disease that is caused by
gastrointestinal or genitourinary infections. The syndrome is
classically composed of joint pain, stiffness and swelling. It can SECTION
be associated with urethritis and conjunctivitis. The disease
usually resolves after 6 months, although in a small number of
cases it can persist or recur. Also known as Reiter’s syndrome.
5
Receptive aphasia (Wernicke’s aphasia)
A lesion of Wernicke’s area (posterolateral left temporal and Pathology
inferior parietal language region of the left cortex) that results
in an inability to process the meaning of spoken words and
sentences. Writing and comprehension are greatly impaired,
though the individual still has normal cognitive and intellectual
abilities unrelated to speech or language. Speech is often fluent
but nonsensical as the individual uses incorrect or made-up
words. The patient is unaware of the language problem.
Right hemisphere language disorders

A term used to describe a range of communication problems
associated with right hemisphere brain damage, i.e. CVA or
traumatic brain injury, which are more subtle than those
experienced by people with aphasia. Deficits include literal 295
interpretations (inability to understand jokes, metaphors, irony,
sarcasm, indirect requests and figurative language), difficulty
in making inferences and identifying relevant information,
inability to interpret body language and facial expressions, flat
affect (monotonous speech pattern) and problems with conver-
sational rules (i.e. turn-taking, verbosity).
Reiter’s syndrome
See Reactive arthritis
Rheumatoid arthritis
A chronic, inflammatory autoimmune connective tissue disease
involving the synovium. Can often affect several joints at the
same time leading to destruction of the joint capsule, articular
cartilage, bone, ligaments and tendons. Clinical features include
joint deformity, stiffness, pain, swelling, heat, loss of movement
and function. Other manifestations of the disease include sub-
cutaneous nodules, muscle weakness, fatigue and anaemia.
Can be associated with an increased risk for osteoporosis,
SECTION
vertebral fractures and cardiovascular disease. The disease is
more common in young to middle-aged women, and the cause is
5 unknown.
Rickets
Pathology
See Osteomalacia
Sarcoidosis
An autoimmune disease that is characterized by the formation
of nodules or lumps (granulomas) in one or more organs of the
body. It mainly affects the lungs, eyes, skin, and lymph glands
and may change how the organ functions. Patients commonly
present with dyspnoea, persistent dry cough, skin rashes, or eye
inflammation. They may also complain of being unwell or
fatigued, and suffer fever and weight loss. In some cases, the
patients are asymptomatic. The cause is unknown.
Scheuermann’s disease
A condition caused by an abnormality in vertebral bone growth
296 during adolescence resulting in the affected vertebrae becoming
wedge-shaped, leading to an increased kyphosis of the spine.
Degeneration of the intervertebral discs into the vertebral
endplates can also occur. The thoracic spine is primarily affected,
although it can sometimes affect the thoracolumbar and lumbar
spine. The severity of the disease can vary. Some people experience
little or no symptoms, while others experience severe pain, stiffness
and loss of function. Boys are affected slightly more than girls.
The cause is unknown.
Septic arthritis
An infection in the joint caused by bacteria (e.g. Staphylococcus
aureus) or, rarely, by a virus or fungus. Patients present with
pain, swelling, erythema, restricted movement and fever. In most
cases, it only affects one joint. Risk factors include recent joint
trauma, surgery or replacement, intravenous drug abuse,
immunosuppressants, bacterial infection and existing joint
conditions e.g. rheumatoid arthritis. Early diagnosis is essential,
as delay can result in joint destruction. Also known as pyogenic
arthritis and infective arthritis.
Sever’s disease SECTION
A painful inflammation of the calcaneal apophysis that mainly

affects growing, active children between 9 and 14 years of age.
5
The pull of the Achilles tendon at its insertion causes traction
Pathology
of the apophysis, resulting in localized pain and tenderness of
the heel. It is exacerbated by sports and activities like running
and jumping.
Shingles
An infection of a sensory nerve and the area of skin that it
supplies by the varicella/zoster virus (chickenpox). Following
chickenpox infection, the virus remains dormant in a sensory
nerve ganglion but can be reactivated later in life. Characterized
by pain, paraesthesia and the appearance of a rash along the
dermatomal distribution of the affected nerve. Mainly occurs
in the trunk, although the face and other parts of the body can
be affected. Occurs predominantly in the middle-aged and older
population as well as the immunocompromised. Also known as
herpes zoster. 297
Sickle-cell disease (Sickle-cell anaemia)
An inherited blood disorder characterized by atypical haemoglobin
molecules that distort red blood cells into a rigid, sickle (crescent)
shape. The affected blood cells break down prematurely leading to
anaemia. Clinical features include shortness of breath, jaundice
and delayed childhood growth. The cells can also stick to and
obstruct smaller vessels causing tissue and organ ischaemia and
subsequent damage. The lungs, kidneys, spleen and brain are
particularly at risk and, as such, life-threatening complications
such as stroke and pulmonary hypertension (leading sometimes
to heart failure) can occur. Other complications include leg
ulcers, retinopathy, avascular necrosis of the hip and other large
joints, chronic pain and increased susceptibility to infection,
particularly osteomyelitis. Although anyone can be a carrier
of sickle cell disease, the trait is more common in people of
African, Middle Eastern, Eastern Mediterranean and Indian
origin.
Sinding-Larsen-Johansson’s disease
SECTION Seen mainly in adolescents, it affects the inferior pole of the
patella. Most commonly occurs in running and jumping sports,
5 which cause the patella tendon to pull at its attachment at
the inferior patellar pole. Results in fragmentation of the
inferior patella and/or calcification in the proximal patellar
Pathology
tendon.
Sjögren’s syndrome
An autoimmune connective tissue disorder in which the body’s
immune system attacks the moisture-producing glands, such
as the salivary and tear glands. This produces the primary
features of dry eyes and dry mouth. It can be primary or
secondary to other autoimmune diseases such as rheumatoid
arthritis, systemic sclerosis, systemic lupus erythematosus and
polymyositis. Mainly affects women between 40 and 60 years
of age.
Sleep apnoea
A cessation of breathing for more than 10 seconds caused by
298 recurrent collapse of the upper airway leading to disturbed
sleep. This may occur as a result of loss of muscle tone in the
pharynx as the patient relaxes during sleep (obstructive sleep
apnoea) and is usually associated with obesity or enlarged
tonsils or adenoids. It may also be caused by abnormal central
nervous system control of breathing (central sleep apnoea) or
occur as a result of a restrictive disorder of the chest wall, e.g.
scoliosis or ankylosing spondylitis, where normal use of acces-
sory respiratory muscles is inhibited during sleep. Pulmonary
hypertension, respiratory and/or heart failure may develop in
severe cases.
Spina bifida
A developmental defect that occurs in early pregnancy in which
there is incomplete closure of the neural tube. The posterior
part of the affected vertebrae does not fuse, leaving a gap or
split. There are three main types:
Spina bifida occulta
Mild form in which there is no damage to the meninges or spinal
cord. The defect is covered with skin that may be dimpled,
pigmented or hairy. In the vast majority of cases, it presents SECTION
with no symptoms. However, in some cases the spinal cord may
become tethered against the vertebrae, with possible impairment
5
of mobility or bladder control.
Pathology
Spina bifida cystica
When a blisterlike sac or cyst balloons out through the opening
in the vertebrae. There are two forms:
Meningocele: the spinal cord and nerves remain in the spinal
canal, but the meninges and cerebrospinal fluid balloon
out through the opening in the vertebrae, forming a sac.
This is the least common form of spina bifida.
Myelomeningocele: the spinal cord and nerves are pushed
out through the opening, along with the meninges and
cerebrospinal fluid. The spinal cord at this level is
damaged leading to paralysis and loss of sensation
below the affected segment. This is the most serious and
more common form and is often associated with
hydrocephalus. 299
Spinal muscular atrophies (SMA)
A group of inherited degenerative disorders of the anterior horn
cell causing muscle atrophy. There are three main types, which
are classified by age of onset:
SMA I (Werdnig–Hoffman disease) is the most severe form,
with onset from preterm to 6 months of age. It causes
weakness and hypotonia (‘floppy’ babies) leading to death
within 3 years.
SMA II (intermediate type) usually develops between 6 and 15
months of age. It has the same pathological features as
SMA I but progresses more slowly.
SMA III (Wohlfart-Kugelberg-Welander disease) has a late onset,
between 1 year of age and adolescence, leading to
progressive, proximal limb weakness.
SMA IV (adult-onset SMA) develops in early adulthood. It is a
milder form of the condition and causes mild to moderate
muscle weakness.
Spinal stenosis
SECTION
Narrowing of the spinal canal, nerve root canals or intervertebral
5 foramina. May be caused by a number of factors, including loss
of disc height, osteophytes, facet hypertrophy, disc prolapse and
hypertrophic ligamentum flavum.
Pathology
Compression of the nerve root may lead to radiating leg or

arm pain, numbness and paraesthesia in the affected dermatome,
muscle weakness, neurogenic claudication and low back pain.
In severe cases, the spinal cord may be compromised.
Spondyloarthritis (also known as seronegative

spondyloarthropathy)
A group of inflammatory joint disorders that include ankylosing
spondylitis, psoriatic arthritis, reactive arthritis, enteropathic
arthritis, undifferentiated spondyloarthritis. They all share notable
characteristics: the spine is usually affected, though other large
joints are occasionally implicated; there is a strong link to human
leukocyte antigen HLA-B27; there is an absence of rheumatoid
factor in the blood; enthesopathy (inflammation of the ligaments
300
and tendon where they attach to bone) commonly occurs, and
onset is usually before 40 years of age.
Spondylolisthesis
A spontaneous forward displacement of one vertebral body upon
the segment below it (usually L5/S1). Displacement may be
severe, causing compression of the cauda equina, requiring
urgent surgical intervention. Spondylolisthesis is classified
according to its cause:
I Dysplastic – congenital
II Isthmic – fatigue fracture of the pars interarticularis due to
overuse
III Degenerative – osteoarthritis
IV Traumatic – acute fracture
V Pathological – weakening of the pars interarticularis by a
tumour, osteoporosis, tuberculosis or Paget’s disease
In rare cases, the displacement may be backwards, known as a
retrolisthesis.
Spondylolysis SECTION
A defect in the pars interarticularis of the lumbar vertebrae

(usually L5), often the result of a fatigue fracture. It can
5
be unilateral or bilateral and may or may not progress to
Pathology
spondylolisthesis.
Spondylosis
Degeneration and narrowing of the intervertebral discs leading
to the formation of osteophytes at the joint margin and arthritic
changes of the facet joints. The lowest three cervical joints are
most commonly affected causing neck pain and stiffness,
sometimes with radiation to the upper limbs, although the
condition may remain symptomless. Can also occur in the lumbar
and thoracic spine. In some cases, osteophytes may encroach
sufficiently upon an intervertebral foramen to cause nerve root
pressure signs, or, more rarely, the spinal canal to cause dysfunc-
tion in all four limbs and possibly the bladder. The vertebral
artery can also be involved.
301
Stroke/cerebrovascular accident (CVA)
A condition in which part of the brain is suddenly severely
damaged or destroyed as a consequence of an interruption to
the flow of blood in the brain. This interruption may be caused
by a blood clot (ischaemic stroke) or by a ruptured blood vessel
(haemorrhagic stroke), either within the brain (intracerebral) or
around the brain (subarachnoid). The most common symptoms
of stroke are numbness, weakness or paralysis on one side of
the body, contralateral to the side of the brain in which the
cerebrovascular accident occurred. Other symptoms include
dysphasia, dysphagia, dysarthria, dyspraxia, disturbance of vision
and perception, inattention or unilateral neglect, and memory or
attention problems. When symptoms resolve within 24 hours,
this is known as a transient ischaemic attack (TIA).
Swan neck deformity
A hyperextension deformity of the proximal interphalangeal
joint combined with a flexion deformity of the distal interphalan-
geal joints and, sometimes, a flexion deformity of the metacar-
SECTION pophalangeal joints due to failure of the proximal interphalangeal
joint’s volar/palmar plate. Usually seen in rheumatoid arthritis,
5 but can be a result of injury.
Syringomyelia
Pathology
A rare disorder in which a longitudinal cavity (syrinx) forms

within the central spinal cord. The condition can be congenital
or acquired following trauma (e.g. hyperextension injuries of the
neck) or secondary to a space-occupying lesion. The lower cervical
segments are usually affected, though the cavity can extend into
the brainstem (syringobulbia). Symptoms vary according to the
location and extent of the cavity but include dissociated sensory
loss (loss of temperature and pain with intact proprioception)
often occurring in a “capelike” distribution over the back, arms
and hands. Paralysis and weakness can also occur.
Systemic lupus erythematosus (SLE)
A chronic, inflammatory autoimmune connective tissue disorder
involving the skin, joints and internal organs. Clinical features
302 and severity can vary widely depending on the area affected but
may include butterfly rash on face, polyarthritis, vasculitis,
Raynaud’s disease, anaemia, hypertension, neurological disorders,
renal disease, pleurisy and alopecia. Of those affected by the
disease, around 90% are women.
Systemic sclerosis (scleroderma)
An autoimmune connective tissue disorder that causes an
increase in collagen metabolism. Excessive collagen deposits
cause damage to microscopic blood vessels in the skin (sclero-
derma) and other organs (systemic sclerosis), leading to fibrosis
and degeneration. Any organ can be affected, and its effects can
be localized or diffuse, as well as progressive. Middle-aged women
are most commonly affected. Clinical features include oedema
of hands and feet, contractures and finger deformities, alteration
of facial features and dry, shiny, tight skin.
Talipes equinovarus
A common deformity of the foot and ankle, often congenital,
where the foot is plantarflexed, adducted and supinated. This
deformity can either be fixed (structural talipes) or passively
corrected (positional talipes). Males are more commonly affected. SECTION
Also known as clubfoot.
5
Talipes calcaneovalgus
A deformity of the foot and ankle, usually postural, where the
Pathology
foot is dorsiflexed and everted, and is resistant to plantarflexion.
Common in breech births, and usually resolves within 12 weeks.
Can be associated with hip dysplasia and leg length discrepancy.
Tarsal tunnel syndrome
Compression of the posterior tibial nerve or its branches as it
passes through the tarsal tunnel (behind the medial malleolus).
Symptoms include pain, dysaesthesia and weakness in the medial
and plantar aspects of the foot and ankle. Can be confused with
plantar fasciitis.
Tennis elbow (lateral epicondylitis)
Tendinopathy of the common origin of the forearm extensors
causing pain and tenderness at the lateral aspect of the elbow
and down the forearm. 303
Tenosynovitis
Inflammation of the synovial lining of a tendon sheath caused
by mechanical irritation or infection, often associated with
overuse and repetitive movements.
Thoracic outlet syndrome

An umbrella term for a group of conditions that result from
compression of the neurovascular bundle in the cervicoaxillary
canal. Common sites of compression are the costoclavicular
space (between the first rib and the clavicle) and the triangle
between the anterior scalene, middle scalene and first rib. Causes
include muscle shortening and spasm, poor posture, stretching
of the lower trunk of the brachial plexus, traumatic structural
changes, or, more rarely, congenital anatomical abnormalities
such as an enlarged C7 transverse process, cervical rib or clav-
icular bony abnormality. Clinical features include paraesthesia,
pain, subjective weakness, oedema, pallor, discoloration or venous
engorgement involving the neck and affected shoulder and upper
SECTION limb.
5 Torticollis
Refers to the position of the neck in a number of conditions
(rotated and tilted to one side). From the Latin torti meaning
Pathology
twisted and collis meaning neck.
Congenital torticollis
Caused by injury, and possible contracture, of the sternocleido-
mastoid by birth trauma or malpositioning in the womb. Seen
in babies and young children.
Acquired torticollis
Acute torticollis (wry neck) is caused by spasm of the neck muscles
(usually trapezius and sternocleidomastoid) that often results
from a poor sleeping position. Usually resolves within a few days.
Spasmodic torticollis is a focal dystonia caused by disease of the
central nervous system which leads to prolonged and involuntary
304 muscle contraction.
Transverse myelitis
A demyelinating disorder of the spinal cord in which inflammation
spreads more or less completely across the tissue of the spinal
cord resulting in a loss of its normal function to transmit nerve
impulses. Paralysis and numbness affect the legs and trunk below
the level of diseased tissue. Causes include immune system
disorders, infection (viral, bacterial, fungal) and vascular disor-
ders. Some patients progress to multiple sclerosis. Recovery varies.
Trigeminal neuralgia
A condition that is characterized by brief attacks of severe, sharp,
stabbing facial pain in the territory of one or more divisions of
the trigeminal nerve (cranial nerve V). It can be caused by
degeneration or compression of the nerve, though the cause is
often unknown. Attacks can last for several days or weeks, after
which the patient may be pain-free for months.
Trigger finger
A condition that is characterized by catching, “popping” or
locking of one of the fingers when it is flexed or extended. This SECTION
is caused by inflammation and hypertrophy of the flexor tendon
sheath that restricts the motion of the flexor tendon. The ring
5
finger is the most commonly affected digit. It is more common
in people with Type 1 diabetes and is also associated with
rheumatoid arthritis and amyloidosis. Pathology
Tuberculosis
An infection caused by the bacterium Mycobacterium tuberculosis.
It is spread when an individual with the disease coughs or sneezes,
releasing the bacteria into the air, where it can be inhaled by
someone else. In most healthy people, the body’s natural defense
kills the bacteria and no symptoms develop. In other cases, the
body is unable to kill the bacteria, but it can prevent it spreading.
Although the bacteria remains in the body, there are no symptoms
and the person is not infectious to others. This is termed latent
TB.
If the body fails to kill the bacteria or prevent it spreading
it is termed active TB. Any tissue can be infected, but the lungs 305
are the most common site. Other sites of infection include
lymph nodes, bones, gastrointestinal tract, kidneys, skin and
meninges. Latent TB can develop into active TB if the body’s
immune system becomes weakened following infection, inad-
equate immunity and malnutrition. Clinical features include
persistent cough, haemoptysis, weight loss, fatigue, fever and
night sweats.
Wernicke’s aphasia
See Receptive aphasia
Diagnostic imaging
Plain radiography (X-rays)
An image formed by exposure to short wavelengths of electro-
magnetic radiation (X-rays) that pass through the body and hit
a photographic receptor (radiographic plate or film) placed behind
the patient’s body. The X-rays pass through soft tissue, such as
muscle, skin and organs, and turn the plate black, whereas hard
SECTION tissue, such as bone, blocks the X-rays leaving the film white.
5 Useful for detecting fractures, dislocations and many bony

abnormalities including degenerative joint disease, spondylolis-
thesis, infections, tumours, avascular necrosis and metabolic
bone diseases. Two views in planes at right angles to each other,
Pathology
usually anteroposterior and lateral, are usually required in order

to adequately examine a region.
Can be used in conjunction with the instillation of iodinated
contrast material into various structures of the body. These block
the X-rays and help visualize the structure:
Angiography (blood vessels): cerebral aneurysms, vascular
malformations and occluded or stenosed arteries and
veins
Arthrography (joints): internal derangements of joints
Discography (intervertebral disc space): disc pathology
Myelography (thecal sac): compressive lesions of the spinal
cord and cauda equina
Tenography (tendon sheath): tendon pathology and ligament
306 ruptures
Computed tomography (CT)
Involves scanning part of the body from several angles by
rotating a thin X-ray beam and detector around it. The data
from the X-rays are then compared and reconstructed by
computer to produce a cross-sectional image, which can be
manipulated to emphasize bony or soft-tissue structures.
Provides good detail of bony structures, especially corti-
cal bone, and is particularly useful for complex fractures
and dislocations as well as for osteochondral lesions, stress
fractures, loose bodies and certain spinal pathologies such as
stenosis and disc herniation. It can also be used for diagnosing
aneurysms, brain tumours and brain damage and detecting
tumours and abscesses throughout the body. As with plain
film radiography, it can also be used in conjunction with the
administration of iodinated contrast material into various
body structures to image the brain, neck, chest, abdomen
and pelvis.
Magnetic resonance imaging (MRI)

SECTION
A cross-sectional image is formed by placing the body in a
powerful magnetic field and using radiofrequency pulses to excite
hydrogen nuclei within tissue cells. The signals emitted by the
5
nuclei are measured and reconstructed by computer to create
Pathology
an image of soft tissue and bone. Different pulse sequences are
used to accentuate different characteristics of tissue. T1-weighted
images show good anatomical detail with fluid being dark and
fat being bright. T2-weighted images are better at identifying
soft tissue pathology, but anatomical detail is less clear. Fluid
appears bright.
MRI provides superior soft-tissue contrast in multiple
imaging planes and is used to examine the central nervous,
musculoskeletal and cardiovascular systems. MRI has no
known adverse physiological effects. It is often used with gado-
linium, an intravenous contrast agent, to improve diagnostic
accuracy (T1-weighted). Patients with a cardiac pacemaker,
brain aneurysm clip or other metallic implants with the excep-
tion of those attached to bone, i.e. prosthetic joints, cannot
undergo MRI. 307
Radionuclide scanning
Involves the administration of a radioactive label (radioisotope)
along with a biologically active substance that is readily taken
up by the tissue being examined, e.g. iodine for the thyroid gland.
The radioisotope emits a particular type of radiation that can
be picked up by gamma ray cameras or detectors as it travels
through the body. Highly active cells in the target organ will
take up more of the radionuclide and emit more gamma rays
resulting in ‘hot spots’. It is used to identify areas of abnormal
pathology. Bone scans detect areas of increased activity and can
pick up metastatic disease, infection (osteomyelitis) and fractures.
It can also be used to investigate kidney, liver and spleen function,
coronary blood flow and thyroid activity and to detect pulmonary
emboli in the lungs.
Dual-energy X-ray absorptiometry (DEXA) scanning

The most commonly used technique to measure bone mineral
density. Two low-dose photon (X-ray) beams of different energies
are transmitted through the bone being examined and are
SECTION measured by a detector on the other side of the patient. The
5 denser the bone, the fewer the X-rays that reach the detector.
Used to diagnose and grade osteoporosis and assess the risk of
a particular bone becoming fractured. The World Health Organiza-
tion has defined bone mass according to the DEXA scan’s T-scores,
Pathology
which are standard deviation (SD) measurements referenced to

the young adult mean.
Normal: not more than 1 standard deviation below the
average value
Osteopenia: more than 1 but less than 2.5 standard deviations
below the average value
Osteoporosis: more than 2.5 standard deviations below the
average value
Ultrasound
Involves high-frequency sound waves being directed into the body
via a transducer, which are then reflected back from different
tissue interfaces and converted into a real-time image. Can be
308 used to examine a broad range of soft-tissue structures, such
as the abdomen, peripheral musculoskeletal system, fetus in
pregnancy, thyroid gland, eyes, neck, prostate and blood flow
(Doppler). However, it cannot penetrate bone or deep structures.
Electrodiagnostic tests
Electroencephalography (EEG)
A technique that records the electrical activity of the brain via
electrodes attached to the scalp. Used in the diagnosis of epilepsy,
coma and certain forms of encephalitis.
Evoked potentials (EP)

A technique that studies nerve conduction of specific sensory
pathways within the brain by measuring the time taken for the
brain to respond to a stimulus. The stimulus may either be visual
(e.g. flashed light, which measures conduction in the occipital
pathways), auditory (e.g. click, which measures conduction in
the auditory pathways) or somatosensory (e.g. electrical stimula-
tion of a peripheral nerve, which measures conduction in the
parietal cortex). Used for detecting multiple sclerosis, brainstem
and cerebellopontine angle lesions (e.g. acoustic neuroma), SECTION
various cerebral metabolic disorders in infants and children as
well as lesions in the sensory pathways (e.g. brachial plexus
5
injury and spinal cord tumour).
Nerve conduction studies Pathology

Measures conduction along a sensory or motor peripheral nerve
following stimulation of that nerve from two different sites. The
conduction velocity is calculated by dividing the distance between
the two sites by the difference in conduction times between the
two sites. Useful in the diagnosis of nerve entrapments (e.g. carpal
tunnel syndrome), peripheral neuropathies, motor and sensory
nerve damage and multifocal motor neuropathy.
Electromyography (EMG)
Involves the insertion of a needle electrode into muscle to record
spontaneous and induced electrical activity within that particular
muscle. Used in the diagnosis of a broad range of myopathies
and neuropathies. 309
SECTION
Pharmacology
Drug classes 312
Prescription abbreviations 354
Further Reading 355
6 SECTION
6Pharmacology
Drug classes
ACE inhibitors
Angiotensin-converting enzyme (ACE) inhibitors allow blood
vessels to dilate by preventing the formation of angiotensin II,
a powerful artery constrictor. Used in the treatment of heart
failure, hypertension, diabetic nephropathy and post–myocardial
infarction.
Antibiotics
Used to treat bacterial disorders ranging from minor infections
to deadly diseases. Antibiotics work by destroying the bacteria
or preventing them from multiplying while the body’s immune
system works to clear the invading organism. There are different
classes of antibiotic, which include penicillins (amoxicillin,
ampicillin, benzylpenicillin, flucloxacillin), cephalosporins
(cefaclor, cefotaxime, cefuroxime), macrolides (clarithromycin,
erythromycin), tetracyclines (tetracycline), aminoglycosides
(gentamicin) and glycopeptides (vancomycin).
Antiemetics
Act by blocking signals to the vomiting centre in the brain, which
triggers the vomiting reflex. Used to prevent or treat vomiting
SECTION and nausea caused by motion sickness, vertigo and digestive
6 tract infection and to counteract the common side effects of

some drugs.
Antiepileptics
Pharmacology
Used to prevent or terminate epileptic seizures. There are several

types of epilepsy, each treated by a specific antiepileptic medica-
tion. It is therefore essential to classify the type of seizure in
order to treat it effectively and minimize common side effects.
Antiretrovirals
Used to treat the human immunodeficiency virus (HIV). Standard
antiretroviral therapy uses a combination of antiretroviral drugs
to suppress the HIV virus, slow down the progression of the
312 disease and prevent its transmission.
Antiretrovirals work in a number of different ways:
Reverse transcriptase inhibitors – reduce the activity of the
reverse transcriptase enzyme, which is vital for virus
replication. They are divided according to their chemical
structure into nucleoside reverse-transcriptase inhibitors
(NRTIs), nucleotide reverse-transcriptase inhibitors
(NtRTIs) and non-nucleoside reverse-transcriptase
inhibitors (NNRTIs).
Protease inhibitors – interfere with the protease enzyme and
interfere with virus replication.
Entry inhibitors – prevent the HIV virus from entering human
cells. They are divided according to their mechanism of
action into entry blockers and fusion inhibitors.
Integrase inhibitors – target the integrase enzyme, which is
essential for integrating viral DNA into the human cell.
To reduce the development of drug resistance, the drugs are
used in combination, known as HAART (highly active antiret-
roviral therapy). Current treatment aims to act at different phases
of the viral life cycle and is usually initiated with a combination
of two NRTIs plus an NNRTI or a protease inhibitor. Antiretro-
virals are not a cure for HIV, but they increase life expectancy
considerably. However, they are toxic, and treatment regimens
must be carefully balanced. SECTION
β-blockers 6
Prevent stimulation of the β-adrenoreceptors in the heart muscle
(mainly β1-receptors) and peripheral vasculature, bronchi,
Pharmacology
pancreas and liver (mainly β2-receptors). Used to treat hyperten-

sion, angina, myocardial infarction, arrhythmias and thyrotoxi-
cosis. Can also be used to alleviate some symptoms of anxiety.
Since blocking β-adrenoreceptors in the lungs can lead to constric-
tion of air passages, care needs to be taken when treating patients
with asthma or COPD.
Benzodiazepines
Increase the inhibitory effect of GABA, which depresses brain
cell activity in the higher centres of the brain controlling 313
consciousness. Used for anxiety, insomnia, convulsions, sedation
for medical procedures and alcohol withdrawal.
Bronchodilators
Dilate the airways to assist breathing when constricted or
congested with mucus. There are two main types:
Sympathomimetics (i.e. salbutamol) stimulate β2-

adrenoreceptors on the surface of bronchial smooth
muscle cells causing the muscle to relax.
Anticholinergics (i.e. ipratropium bromide) act by
blocking the neurotransmitters that trigger muscle
contraction.
Both are used to treat asthma and other conditions associated

with reversible airways obstruction such as COPD.
Calcium channel blockers

Interfere with the transport of calcium ions through the cell
walls of cardiac and vascular smooth muscle. Reduce the
contractility of the heart, depress the formation and conduction
of impulses in the heart and cause peripheral vasodilation. Used
to treat angina, hypertension and arrhythmias.
SECTION
6 Corticosteroids
Natural or synthetic hormones that act on metabolism and tissue
inflammation. They reduce inflammation by inhibiting the forma-
tion of inflammatory mediators, e.g. prostaglandins. Used to
Pharmacology
control many inflammatory disorders thought to be caused by

excessive or inappropriate activity of the immune system, e.g.
asthma, inflammatory bowel disease, rheumatoid arthritis, lupus,
eczema, as well as inflammation caused by strain and damage
to muscles and tendons.
The term corticosteroids refers to glucocorticoids and
mineralocorticoids, but they each have different effects. Glu-
cocorticoids’ primary role is to reduce inflammation, while
mineralocorticoids regulate the electrolyte and fluid balance of
314 the body.
Diuretics
Work on the kidneys to increase the amount of sodium and
water excreted. There are different types of diuretic that work
on the nephron:
Thiazides (bendroflumethiazide/bendrofluazide)
Loop (furosemide/frusemide, bumetanide)
Potassium-sparing (amiloride, spironolactone)
Osmotic (mannitol)
Carbonic anhydrase inhibitors (acetazolamide, dorzolamide)
Used to treat hypertension (thiazides), chronic heart failure
and oedema (loop diuretics, thiazides or a combination of both),
glaucoma (carbonic anhydrase inhibitors or osmotic), raised
intracranial pressure (osmotic).
Disease-modifying antirheumatic drugs (DMARDs)
A group of medicines commonly used to treat types of inflam-
matory disease such as rheumatoid arthritis, ankylosing
spondylitis, psoriatic arthritis, inflammatory bowel disease, plaque
psoriasis, systemic lupus erythematosus and juvenile idiopathic
arthritis. They work via different mechanisms to suppress disease
activity and reduce associated joint damage.
They can be broadly split into two categories:
Conventional DMARDs – refers to the traditional, SECTION
nonbiological drugs, such as methotrexate, sulfasalazine
and hydroxychloroquine. 6
Biological DMARDS – target particular molecules involved in
the pathological immune response such as tumour
Pharmacology
necrosis factor alpha (TNFα). Examples include etanercept

and adalimumab.
Inotropes
Work by increasing the contractility of the heart muscle. They
can be divided into three groups:
Cardiac glycosides (i.e. digoxin) assist activity of the heart
muscle by increasing intracellular calcium storage in
myocardial cells. Used for heart failure and
supraventricular arrhythmias. 315
Sympathomimetics (i.e. dobutamine, dopamine) stimulate
β1-receptors on the heart, which increase the rate and
force of myocardial contraction. Provide inotropic support
in infarction, cardiac surgery, cardiomyopathies, septic
shock and cardiogenic shock.
Phosphodiesterase inhibitors (i.e. milrinone) inactivate cyclic
AMP, which increases the force of myocardial contraction
and relaxes vascular smooth muscle. Used to treat
congestive heart failure.
Mucolytics
Reduce the viscosity of bronchopulmonary secretions by breaking
down their molecular complexes. Used to treat excessive or
thickened mucus secretions.
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Inhibit the production of prostaglandins, which are responsible
for inflammation and pain following tissue damage. They are
called nonsteroidals to distinguish them from corticosteroids,
which have a similar function. Used for inflammatory diseases,
pain and pyrexia.
Opioids
Have a strong analgesic effect and are used to treat moderate
SECTION to severe pain arising from surgery, cancer, acute trauma
6 and terminal illness. Opioids reduce pain by binding to opioid
receptors, which decreases nerve excitability, thereby reducing
the transmission of nociceptive impulses to the brain. Opioid
receptors are mainly found in the spinal cord, brain, peripheral
Pharmacology
sensory neurons and in the gastrointestinal tract. As well as their

analgesic effects, opioids can produce a state of relaxation and
euphoria, which can lead to abuse and addiction. Side effects
include nausea and vomiting, constipation, respiratory depression
and drowsiness.
A–Z of drugs
Abacavir (antiretroviral – NRTI)
Used in combination with other antiretroviral drugs to treat
316 HIV infection.
Common side effects: nausea, vomiting, loss of appetite, diarrhea,
headaches, fatigue, hypersensitivity reactions.
Acetylcysteine (mucolytic)
Reduces the viscosity of secretions associated with impaired or
abnormal mucus production. Also used as an antidote for
paracetamol overdose.
Common side effects: hypersensitivity-like reactions, rashes,
nausea, vomiting, anaphylaxis (in children).
Aciclovir (antiviral)
Used against infections caused by herpes virus (herpes simplex
and varicella-zoster).
Common side effects: rare.
Adalimumab (biological DMARD)

Used to treat moderate to severe rheumatoid arthritis, ankylosing
spondylitis, psoriatic arthritis, Crohn’s disease, ulcerative colitis,
uveitis and juvenile idiopathic arthritis. Given by subcutaneous
injection at two-weekly intervals.
Common side effects: headache, skin rash, antibody development,
injection site reaction (erythema, itching, pain, swelling), upper
respiratory tract infection.
SECTION
Adenosine (antiarrhythmic)
Reverses supraventricular tachycardias to sinus rhythm. 6
Common side effects: facial flushing, dyspnoea, headache, nausea,
lightheadedness, chest pain.
Pharmacology
Adrenaline/epinephrine (sympathomimetic agent)

Acts on both alpha and beta receptors and so can cause peripheral
vasodilation (a beta effect) or vasoconstriction (an alpha effect).
Also increases both heart rate and contractility (beta effect).
Used during cardiopulmonary resuscitation to stimulate heart
activity and raise low blood pressure. It is also used to treat
anaphylactic shock
Common side effects: tachycardia, palpitations, anxiety, headache,
eye irritation, watering of eyes, dizziness, lightheadedness, facial 317
flushing, headache, dry mouth, nausea, trembling, insomnia,
vomiting, fatigue.
Alendronic acid/Alendronate (bisphosphonate)

Inhibits the release of calcium from bone by interfering with
the activity of osteoclasts, thereby reducing the rate of bone
turnover. Used in the prophylaxis and treatment of postmeno-
pausal osteoporosis and corticosteroid-induced osteoporosis.
Often used in conjunction with calcium tablets.
Common side effects: abdominal distension, abdominal pain,
constipation, diarrhoea, dyspepsia, flatulence, headache,
oesophageal reactions, regurgitation.
Allopurinol (antigout)
A prophylactic for gout, uric acid and calcium oxalate kidney
stones and hyperuricaemia associated with cancer chemotherapy.
Common side effects: rash, nausea, vomiting.
Alteplase (fibrinolytic)
Dissolves thrombi by acting directly on the plasminogen entrapped
within the clot. Used to treat acute conditions featuring blood
clots, particularly ischaemic stroke within the first 4.5 hours of
the onset of symptoms. Also given after a myocardial infarct to
dissolve thrombi in the coronary arteries and for acute massive
SECTION pulmonary embolism.
6 Common side effects: superficial bleeding at puncture sites,
hypotension.
Amantadine (antiviral with dopamine activity)

Pharmacology
Used to treat mild Parkinson’s disease, usually in younger patients,

however other treatments are often preferred. Also used for
postherpetic neuralgia.
Common side effects: anxiety, dizziness, headaches, nausea,
loss of appetite, cognitive impairment, confusion, insomnia,
hallucinations.
Amiodarone (antiarrhythmic)
Slows nerve impulses in the heart muscle. Used to treat arrhyth-
318 mias including paroxysmal supraventricular, nodal and
ventricular tachycardias, atrial fibrillation and flutter, ventricular
fibrillation, and tachyarrhythmias associated with Wolff-Par-
kinson-White syndrome.
Common side effects: bradycardia, hyperthyroidism, hypo-
thyroidism, jaundice, nausea, persistent slate grey skin discolora-
tion, phototoxicity, pulmonary toxicity (including pneumonitis
and fibrosis), raised serum transaminases, reversible corneal
microdeposits (sometimes with night glare), sleep disorders, taste
disturbances, tremor, vomiting.
Amitriptyline (tricyclic antidepressant)

Initially developed for depressive illness but no longer recom-
mended. Main use is to treat neuropathic pain and migraine
prophylaxis. Also used for abdominal pain or discomfort in
patients who have not responded to laxatives, antispasmodics
or loperamide.
Common side effects: dizziness, drowsiness, dry mouth, orthostatic
hypotension, headache, sweating, weight gain, nausea, fatigue,
unpleasant taste, blurred vision.
Amlodipine (calcium channel blocker)

Used to treat hypertension and angina.
Common side effects: abdominal pain, dizziness, fatigue, flushing,
leg and ankle swelling, headache, nausea, oedema, palpitations, SECTION
sleep disturbances.
6
Amoxicillin (penicillin antibiotic)
Used to treat a variety of infections such as urinary tract infec-
Pharmacology
tions, otitis media, sinusitis, uncomplicated community-acquired

pneumonia, salmonellosis and oral infections.
Common side effects: anaphylaxis, angioedema, diarrhoea, fever,
hypersensitivity reactions, joint pain, rash, serum sickness–like
reaction, urticaria.
Ampicillin (penicillin antibiotic)

Used to treat a variety of infections such as bronchitis, urinary
tract infections, otitis media, sinusitis, uncomplicated community-
acquired pneumonia and salmonellosis. 319
Anastrozole (antineoplastic hormone)

Used in the treatment of oestrogen-receptor–positive breast cancer
in postmenopausal women.
Common side effects: hot flushes, headache, fatigue, dizziness,
joint pain, vaginal dryness, hair thinning, nausea, diarrhoea.
Aspirin (NSAID)
Used as an anti-inflammatory, as an analgesic and to reduce
fever. It also inhibits thrombus formation and is used to reduce
the risk for heart attack and stroke.
Common side effects: gastric irritation leading to dyspepsia and
bleeding, wheezing in aspirin-sensitive asthmatics.
Atenolol (β-adrenoceptor blocker)

Used to treat hypertension, angina and arrhythmias.
Common side effects: hypotension manifested as cold extremities,
constipation or diarrhea, sweating, dizziness, fatigue, headache,
nausea.
Atorvastatin (statin)
SECTION Lowers LDL cholesterol and is prescribed for those who have not
6 responded to diet and lifestyle modification to protect them from
cardiovascular disease. Used to prevent cardiovascular events
in patients with atherosclerotic cardiovascular disease or diabetes
mellitus.
Pharmacology
Common side effects: headache, nausea, gastrointestinal distur-

bances, insomnia, back and joint pain.
Atracurium (neuromuscular blocker)

Used as a muscle relaxant during surgery and intubation and
to facilitate intermittent positive pressure breathing in the
intensive care unit.
Common side effects: acute myopathy (after prolonged use in
intensive care), bronchospasm, hypotension, seizures, skin
320 flushing, tachycardia.
Atropine (antimuscarinic)
Relaxes smooth muscle by blocking the action of acetylcholine
and is used to treat irritable bowel syndrome. Can be used to
paralyze ciliary action and enlarge the pupils during eye examina-
tion. Also used to reverse excessive bradycardia, in cardio-
pulmonary resuscitation and for patients who have been poisoned
with organophosphorous anticholinesterase drugs.
Common side effects: constipation, dry mouth, photophobia,
reduced bronchial secretions, skin dryness, skin flushing, transient
bradycardia (followed by tachycardia, palpitation and arrhyth-
mias), urinary retention, urinary urgency.
Azathioprine (immunosuppressant)
Prevents rejection of transplanted organs by the immune system
and in a number of autoimmune and connective tissue diseases
(including Crohn’s disease, ulcerative colitis, rheumatoid arthritis,
polymyositis, systemic lupus erythematosus). Also used to treat
severe refractory eczema and myasthenia gravis.
Common side effects: nausea, vomiting, hair loss, loss of
appetite.
Azithromycin (macrolide)
A derivative of erythromycin, it is used to treat certain respiratory
tract, ear, skin and genital infections.
SECTION
Common side effects: abdominal discomfort, diarrhoea, nausea,
vomiting. 6
Baclofen (skeletal muscle relaxant)
Pharmacology
Acts on the central nervous system to reduce chronic severe

spasticity resulting from a number of disorders, including multiple
sclerosis, spinal cord injury, brain injury, cerebral palsy or stroke.
Common side effects: dizziness, nausea, drowsiness, muscle
fatigue/weakness, confusion.
Beclometasone (corticosteroid)
Given by inhaler and used to control asthma in those who do
not respond to bronchodilators alone. Also used in creams to
treat inflammatory skin disorders and to relieve and prevent
symptoms of vasomotor and allergic rhinitis. 321
Common side effects: nasal discomfort/irritation, cough, bruising,
sore throat/hoarseness, nosebleed.
Bendroflumethiazide (thiazide diuretic)

Used to treat hypertension and oedema.
Common side effects: gout, hypercalcaemia, hyperglycaemia,
hyperuricaemia, hypochloraemic alkalosis, hypokalaemia,
hypomagnesaemia, hyponatraemia, metabolic and electrolyte
disturbances, mild gastrointestinal disturbances, postural
hypotension.
Benzylpenicillin (penicillin antibiotic)

Used to treat otitis media, cellulitis, pneumonia, endocarditis,
meningitis and throat infections.
hypersensitivity reactions, joint pains, rashes, serum sickness–like
Bisoprolol (β-adrenoceptor blocker)

Used to treat hypertension, angina and heart failure.
Common side effects: dizziness, fatigue, cold hands and feet.
Botulinum toxin type A (neurotoxin)

Blocks transmission at the neuromuscular junction by inhibiting
SECTION acetylcholine release, thereby producing temporary weakness
6 or paralysis of the targeted muscles (approximately 2–3 months).
Used to relieve muscle overactivity associated with spasticity
and dystonia from various causes, e.g. stroke, multiple sclerosis,
cerebral palsy in children, torticollis, chronic migraine, bladder
Pharmacology
dysfunction. Administered via injection.

Common side effects: pain at site, local weakness.
Budesonide (corticosteroid)
Used as an inhaler in the prophylactic treatment of asthma and
COPD. Also given systemically in a controlled-release form for
Crohn’s disease and ulcerative colitis.
Common side effects: cough, nasal irritation, bruising, sore throat
(when used as an inhaler), diarrhea/constipation (when taken
322 orally).
Bumetanide (loop diuretic)
A powerful, fast-acting diuretic used to treat pulmonary oedema
due to left ventricular failure. It also reduces oedema and dyspnoea
associated with chronic heart failure.
Common side effects: increased urinary frequency and urine
volume, muscle cramps, dizziness, hypotension, headache, nausea.
Buprenorphine (opioid with agonist and antagonist

properties)
Used to treat moderate to severe pain as well as opioid dependence.
Can be administered by injection, sublingually or transdermally
(i.e. BuTrans® patch).
Common side effects: sedation, dizziness, nausea, headache,
itching at application site, rash, vomiting, constipation, dry
mouth.
Calcitonin (salmon) (bone resorption inhibitor)

Regulates bone turnover and is used to treat Paget’s disease of
bone and hypercalcaemia of malignancy. Also given for prophy-
laxis of bone loss due to sudden immobility.
Common side effects: abdominal pain, diarrhoea, dizziness,
fatigue, flushing, headache, musculoskeletal pain, nausea, taste
disturbances, vomiting.
SECTION
Captopril (ACE inhibitor)
Reduces peripheral vasoconstriction and is used to treat hyperten- 6
sion, congestive heart failure, post–myocardial infarction and
diabetic nephropathy.
Pharmacology
Common side effects: rash, gastrointestinal disturbance.
Carbamazepine (antiepileptic)
Used to reduce likelihood of generalized tonic-clonic seizures
and partial seizure and to relieve neuropathic pain associated
with trigeminal neuralgia and diabetic neuropathy. Also used for
prophylaxis of bipolar disorder and acute alcohol withdrawal.
Common side effects: dizziness, drowsiness, ataxia, fatigue, blood
disorders, rash, urticaria, nausea, vomiting, headache, blurred
vision, dry mouth, oedema, fluid retention, increased weight. 323
Carbimazole (antithyroid drug)
Used to treat hyperthyroidism by reducing the formation of
thyroid hormone.
Common side effects: arthralgia, fever, headache, jaundice,
malaise, mild gastrointestinal disturbances, nausea, itching,
rash, taste disturbances.
Carvedilol (α- and β-blocker)

Used to treat chronic heart failure, hypertension and angina.
Common side effects: fatigue, dizziness, diarrhoea, bradycardia,
rhinitis, back pain.
Cefaclor (cephalosporin antibiotic)

Used to treat a variety of infections including acute otitis media,
bronchitis, pharyngitis, tonsillitis, respiratory tract and lower
urinary tract infections.
Common side effects: oral and vaginal candidiasis, diarrhoea,
abdominal cramps.
Cefotaxime (cephalosporin antibiotic)

Used to treat a variety of infections including skin, genitourinary,
gynaecological, intraabdominal and lower respiratory tract
infections, septicaemia, meningitis and surgical prophylaxis.
SECTION Common side effects: oral and vaginal candidiasis, diarrhoea,
6 abdominal cramps.
Cefuroxime (cephalosporin antibiotic)

Used to treat a variety of infections including acute and chronic
Pharmacology
bronchitis, gonorrhoea, impetigo, early Lyme disease, otitis media,

pharyngitis, tonsillitis, sinusitis, surgical prophylaxis and skin
and urinary tract infections.
Common side effects: oral and vaginal candidiasis, diarrhoea,
abdominal cramps.
Celecoxib (NSAID)
Used to relieve the symptoms of osteoarthritis, rheumatoid
arthritis and ankylosing spondylitis. Has a relatively selective
324 action on the inflammatory response compared to other NSAIDs,
causing less gastrointestinal disturbances. However, it also
associated with a greater risk for adverse cardiovascular
effects.
Common side effects: dyspnoea, influenza-like symptoms.
Certolizumab pegol (biological DMARD)

Used to treat severe rheumatoid arthritis, psoriatic arthritis,
ankylosing spondylitis and non-radiographic axial spondyloar-
thritis when response to NSAIDs has been inadequate or not
tolerated. Given by subcutaneous injection at two-weekly
intervals.
Common side effects: hypertension, rash, sensory abnormalities.
Chlorpromazine (antipsychotic)
Has a sedative effect and is used to control the symptoms of
schizophrenia and to treat agitation without causing confusion
and stupor. Also used to treat nausea and vomiting in terminally
ill patients.
Common side effects: drowsiness/lethargy, weight gain, tremor/
Parkinsonism, blurred vision, dizziness, fainting.
Ciclosporin (immunosuppressant)
Used to prevent rejection of organ and tissue transplantation.
Also used to treat rheumatoid arthritis, and severe resist-
ant psoriasis and dermatitis when other treatments have SECTION
failed.
Common side effects: gum swelling, excessive hair growth, nausea,
6
vomiting, tremor, headache, muscle cramps.
Pharmacology
Cimetidine (anti-ulcer – H2-receptor antagonist)

Decreases gastric acid production and is used to treat gastric
and duodenal ulcers, and for gastrooesophageal reflux disease.
Common side effects: diarrhoea, dizziness, headache.
Ciprofloxacin (antibacterial)
Treats mainly gram-negative infection and some gram-positive
infections. Used for chest, intestine and urinary tract infections.
Common side effects: diarrhoea, dizziness, headache, nausea,
vomiting, rash/itching. 325
Citalopram (selective serotonin reuptake inhibitor)
Used to treat depressive illness and panic disorder.
Common side effects: constipation, diarrhoea, dyspepsia, nausea,
vomiting, indigestion, sexual dysfunction, anxiety, insomnia,
headache, tremor, dizziness, drowsiness, dry mouth, sweating.
Clarithromycin (macrolide antibiotic)

Used to treat a variety of infections including bacterial exacerba-
tion of bronchitis, otitis media, acute maxillary sinusitis,
pharyngitis, tonsillitis, community-acquired pneumonia, skin
and soft-tissue infections. Also used to eradicate Helicobacter
pylori, responsible for many peptic ulcers.
vomiting.
Clomipramine (tricyclic antidepressant)
Used for long-term treatment of depression, especially when
associated with phobic and obsessional states.
Common side effects: sexual dysfunction, dry mouth, drowsiness,
tremors, dizziness, headache, constipation, fatigue, nausea,
sweating, blurred vision, weight gain.
Clonidine (α2-adrenoceptor agonist)
Used in the prophylaxis of recurrent migraine and to treat
SECTION
hypertension.
6 Common side effects: dry mouth, drowsiness, dizziness, sedation,
constipation.
Clopidogrel (antiplatelet)
Pharmacology
Has a similar effect to aspirin on reducing platelet aggregation,

although its mechanism of action is different. Prevents arthero-
thrombotic events in patients with chronic peripheral arterial
disease, recent myocardial infarction or recent ischaemic stroke.
Common side effects: abdominal pain, bleeding disorders (includ-
ing gastrointestinal and intracranial), diarrhoea, dyspepsia.
Codeine (opioid analgesic)
A mild opioid analgesic that is similar to, but weaker than,
326 morphine. Used to treat mild to moderate pain and is often
combined with a nonopioid analgesic such as paracetamol (to
form co-codamol). Also used as a cough suppressant and for
the short-term control of diarrhoea.
Common side effects: constipation, nausea, vomiting, drowsiness,
dizziness.
Co-trimoxazole (antibacterial)
A combination of two antibacterial drugs: trimethoprim and
sulfamethoxazole. Used to treat serious urinary tract and respira-
tory infections which have not responded to other drugs. Also
used to treat toxoplasmosis, nocardiasis, typhoid fever and
Pneumocystis pneumonia and otitis media in children.
Common side effects: headache, nausea, diarrhoea, rash, itching.
Dexamethasone (corticosteroid)
A long-acting corticosteroid that suppresses inflammatory and
allergic disorders. Used to diagnose Cushing’s disease. Used to
treat cerebral oedema, congenital adrenal hyperplasia, nausea
and vomiting associated with chemotherapy and various types
of shock.
Common side effects: insomnia, facial oedema (moon face),
abdominal distention, indigestion, increased appetite, nervous-
ness, facial flushing, sweating.
Diazepam (benzodiazepine) SECTION

Has a wide range of uses. Most commonly used to reduce anxiety,
relax muscles, promote sleep and in the treatment of alcohol
6
withdrawal. Also used for febrile convulsions and status epilep-
ticus. Dependence develops with prolonged use.
Pharmacology
Common side effects: drowsiness, ataxia, dizziness, forgetfulness,

confusion.
Didanosine (antiretroviral – NRTI)

Prevents the replication of HIV and therefore the progression of
AIDS by blocking the action of the reverse transcriptase enzyme.
Usually used in combination with other antiretroviral drugs.
Common side effects: pancreatitis, peripheral neuropathy,
headache, insomnia, gastrointestinal upset, fatigue, breathless-
ness, cough, blood disorders, rash, liver damage. 327
Diclofenac (NSAID)
Used to relieve mild to moderate pain associated with inflam-
mation such as rheumatoid arthritis, osteoarthritis, ankylosing
spondylitis, menstrual pain, moderate headache and musculo-
skeletal disorders. Also used to treat acute gout and postoperative
pain.
Common side effects: headache, abdominal pain, constipation,
diarrhoea, nausea, dyspepsia.
Digoxin (cardiac glycoside)

Increases the heart’s force of contraction. Used to control
breathlessness, tiredness and fluid retention in people with heart
failure. Also used to treat supraventricular arrhythmias, par-
ticularly atrial fibrillation.
Common side effects: dizziness, headache, diarrhoea, rash, visual
disturbances, fatigue, nausea.
Dihydrocodeine (opioid analgesic)

Similar to, but weaker than, morphine and more potent than
codeine. Used to relieve moderate to severe acute and chronic
pain and is often combined with a nonopioid analgesic such as
paracetamol (to form co-dydramol).
Common side effects: constipation, nausea, vomiting, drowsiness,
SECTION dizziness, headache, dry mouth.
6 Diltiazem (calcium channel blocker)

Used to prevent and treat angina and to lower high blood
pressure.
Pharmacology
Common side effects: peripheral oedema (notably of ankles),

dizziness, headache, bradycardia, nausea, vomiting, dry mouth,
tiredness.
Docusate (stimulant laxative)

Softens faeces by promoting water penetration and retention.
Used to treat constipation.
Common side effects: abdominal cramps, diarrhoea (excessive
use), hypokalaemia, rash
328
Dobutamine (inotropic sympathomimetic)
Provides inotropic support in acute severe heart failure, cardiac
surgery, cardiomyopathies, septic shock and cardiogenic
shock.
Common side effects: tachycardias, hypertension.
Domperidone (antiemetic)
Used to control nausea and vomiting associated with gastroen-
teritis, chemotherapy or radiotherapy.
Common side effects: drowsiness, dry mouth, malaise.
Donepezil (anticholinesterase)
Inhibits the breakdown of acetylcholine. Used to improve cognitive
function in dementia due to Alzheimer’s disease, although the
underlying disease process is not altered.
Common side effects: gastrointestinal upset, fatigue, insomnia,
muscle cramps, urinary incontinence.
Dopamine (inotropic sympathomimetic)

Used to treat cardiogenic shock after myocardial infarction,
hypotension after cardiac surgery, acute severe heart failure and
to start diuresis in chronic heart failure.
Common side effects: chest pain, dyspnoea, headache, hypoten-
sion, nausea, palpitations, tachycardia, vasoconstriction, SECTION
vomiting.
6
Dornase alfa (mucolytic)
A synthetic version of a naturally occurring human enzyme
Pharmacology
that breaks down the DNA content of sputum. Used by inhalation

in cystic fibrosis to facilitate expectoration.
Common side effects: rare.
Dosulepin (tricyclic antidepressant)

Used for long-term treatment of depression, especially when
associated with agitation, anxiety and insomnia.
Common side effects: drowsiness, dry mouth, sweating, blurred
vision.
329
Doxapram (respiratory stimulant)
Used in hospital to treat acute exacerbations of COPD with type
II respiratory failure when ventilation is unavailable or
contraindicated.
Possible side effects: arrhythmias, bradycardia, bronchospasm,
chest pain, confusion, convulsions, cough, dizziness, dyspnoea,
extrasystoles, flushing, hallucinations, headache, hyperactivity,
hypertension, incontinence, laryngospasm, muscle spasms,
nausea, perineal warmth, pyrexia, tachycardia, urinary retention,
vomiting.
Doxazosin (α1-adrenoceptor antagonist)

Lowers blood pressure by blocking vasoconstrictor sympathetic
nerve supply to the small arteries. Used to treat hypertension
and to reduce urinary obstruction caused by benign prostatic
hyperplasia.
Common side effects: dizziness, tiredness, headache, oedema
(particularly ankles), nausea, drowsiness.
Duloxetine (serotonin-noradrenaline reuptake
inhibitor)
Used to treat major depressive disorder, generalized anxiety
disorder, diabetic neuropathy and stress urinary incontinence.
Common side effects: nausea, dry mouth, constipation, insomnia.
SECTION
6 Efavirenz (antiretroviral – nonnucleoside reverse

transcriptase inhibitor)
Used to treat HIV infection, specifically HIV type 1 (HIV-1) in
Pharmacology
combination with other antiretroviral drugs. Not effective for

HIV-2.
Common side effects: abdominal pain, abnormal dreams, anxiety,
depression, diarrhoea, dizziness, fatigue, headache, impaired
concentration, nausea, itching, rash, sleep disturbances, Stevens-
Johnson syndrome, vomiting.
Emtricitabine (Nucleoside reverse transcriptase
inhibitor)
330 HIV infection.
Common side effects: headache, rhinitis, rash, diarrhea, nausea,
cough, vomiting, abdominal pain, insomnia, depression, pares-
thesia, dizziness, peripheral neuropathy, dyspepsia, myalgia, body
fat redistribution.
Enalapril (ACE inhibitor)

Used in the treatment of hypertension, chronic heart failure
and in the prevention of recurrent myocardial infarction following
a heart attack.
Common side effects: headache, dizziness, rash, persistent dry
cough.
Enfuvirtide (antiretroviral – entry inhibitor)

drug-resistant strains of HIV infection. Administered via sub-
cutaneous injection.
Common side effects: acne, anorexia, anxiety, asthenia, con-
junctivitis, diabetes mellitus, dry skin, erythema, gastro-
oesophageal reflux disease, haematuria, hypertriglyceridaemia,
impaired concentration, influenza-like illness, injection-site
reactions, irritability, lymphadenopathy, myalgia, nightmares,
pancreatitis, peripheral neuropathy, pneumonia, renal calculi,
sinusitis, skin papilloma, tremor, vertigo, weight loss.
Epinephrine/adrenaline (sympathomimetic agent) SECTION

See Adrenaline.
6
Erythromycin (macrolide antibiotic)
Used to treat a variety of infections including genitourinary,
Pharmacology
respiratory tract, skin and oral infections. Also used for Lyme
disease and to prevent rheumatic fever. Commonly given to those
who are allergic to penicillin.
vomiting.
Estradiol (oestrogen for hormone replacement therapy)

A naturally occurring female sex hormone used to treat
menopausal and postmenopausal symptoms such as hot
flushes, night sweats and vaginal atrophy. Can also be used for 331
the prevention of osteoporosis in high-risk women with early
menopause.
Common side effects: withdrawal bleeding, sodium and fluid
retention, gastrointestinal upset, weight changes, breast enlarge-
ment, venous thromboembolism.
Etanercept (biological DMARD)

Used to treat moderate to severe rheumatoid arthritis, ankylosing
spondylitis, juvenile idiopathic arthritis and plaque psoriasis.
Given by injection once or twice weekly.
Common side effects: injection site reactions, nausea, abdominal
pain, fever, headache.
Etidronate (bisphosphonate)
Inhibits the release of calcium from bone by interfering with
the activity of osteoclasts, thereby reducing the rate of bone
turnover. Used to treat Paget’s disease. Also used together with
calcium tablets to treat and prevent postmenopausal osteoporosis
and corticosteroid-induced osteoporosis.
Common side effects: gastrointestinal upset, nausea, constipation,
increased bone pain in Paget’s disease.
Exenatide (antidiabetic)
Acts by mimicking the action of incretin, a natural hormone
SECTION that boosts insulin secretion and reduces glucagon secretion.
6 Used to treat inadequately controlled type 2 diabetes in combina-
tion with other antidiabetic drugs. Administered via subcutaneous
injection.
Common side effects: nausea, vomiting, diarrhoea, reduced
Pharmacology
appetite, weight loss, dizziness, headache, sweating.
Fentanyl (opioid analgesic)

Used to depress respiration in patients needing prolonged assisted
ventilation. Also used as an analgesic during surgery and to
enhance anaesthesia. Used transdermally to treat chronic
intractable pain as well as breakthrough pain in patients receiving
opioid therapy for chronic cancer pain.
Common side effects: drowsiness, nausea, vomiting, constipation,
332 dizziness, dry mouth, headache.
Ferrous sulphate (iron salt)
Used to treat iron-deficiency anaemia.
Common side effects: nausea, epigastric pain, constipation or
diarrhoea, darkening of faeces.
Flucloxacillin (penicillin antibiotic)

Used to treat staphylococcal infections including pneumonia,
ear infections, cellulitis, osteomyelitis, endocarditis, impetigo and
for surgical prophylaxis.
Fluoxetine (selective serotonin reuptake inhibitor)

More commonly known by its brand name, Prozac, it increases
serotonin levels and is used to treat depressive illness, obsessive-
compulsive disorder and bulimia nervosa.
Common side effects: headache, nervousness, insomnia, anxiety,
nausea, diarrhoea, decreased appetite.
Furosemide/frusemide (loop diuretic)

A powerful, fast-acting diuretic that is used in emergencies to
reduce acute pulmonary oedema secondary to left ventricular
failure. It reduces oedema associated with chronic heart failure SECTION
and certain lung, liver and kidney disorders. It is also used to
treat resistant hypertension. 6
Common side effects: increased urinary frequency/volume,
nausea, dizziness, muscle cramps, abdominal disturbances,
Pharmacology
headache, diarrhoea, constipation, electrolyte disturbances.
Gabapentin (anticonvulsant)
Used as an adjunct in the treatment of partial onset seizures,
with or without secondary generalization. Can also be
used to treat peripheral neuropathic pain and for migraine
prophylaxis.
Common side effects: drowsiness, dizziness, ataxia, nystagmus,
tremor, diplopia, gastrointestinal upset, peripheral oedema,
amnesia, paraesthesia. 333
Gentamicin (aminoglycoside antibiotic)
Used to treat a variety of serious infections including septicaemia,
meningitis, biliary-tract infection, acute pyelonephritis, endo-
carditis, pneumonia in hospital patients, prostatitis, eye and ear
infections, central nervous system infections and surgical
prophylaxis.
Common side effects: rare but could include colitis, electrolyte
disturbances, hypocalcaemia, hypokalaemia, hypomagnesaemia,
nausea, peripheral neuropathy, stomatitis, vomiting, auditory
damage, impaired neuromuscular transmission, irreversible
ototoxicity, nephrotoxicity, transient myasthenic syndrome,
vestibular damage.
Glatiramer (immunomodulator)
Reduces the frequency of relapse in relapsing-remitting multiple
sclerosis and is used to delay progression of disability. Also used
to treat the initial symptoms in patients at high risk for developing
multiple sclerosis. Administered via subcutaneous injection.
Common side effects: anxiety, arthralgia, asthenia, back pain,
chest pain, constipation, depression, dyspepsia, dyspnoea, flush-
ing, headache, hypersensitivity reactions, hypertonia, influenza-
like symptoms, injection-site reactions, lymphadenopathy, nausea,
oedema, palpitations, rash, sweating, fainting, tachycardia,
SECTION tremor.
6 Gliclazide (sulphonylurea)
Stimulates the production and secretion of insulin and lowers
blood sugar levels. Used to treat type 2 diabetes mellitus.
Pharmacology
Common side effects: feeling faint, confusion, weakness, tremor,

sweating, constipation, diarrhoea, dizziness.
Glyceryl trinitrate/GTN (organic nitrate)

A potent coronary and peripheral vasodilator that is used for
the prophylaxis and treatment of angina. Also used to control
hypertension, congestive heart failure, unstable angina and
myocardial ischaemia after cardiac surgery.
Common side effects: dizziness, postural hypotension, tachycardia,
334 throbbing headache.
Golimumab (biological DMARD)
Used to treat moderate to severe rheumatoid arthritis, psoriatic
arthritis, ulcerative colitis and ankylosing spondylitis. Given by
injection at four-weekly intervals.
Common side effects: tiredness, dizziness, dyspepsia, hypertension,
injection site reactions, upper respiratory tract infection.
Haloperidol (antipsychotic)
Used to control violent and dangerously impulsive behaviour
associated with psychotic disorders such as schizophrenia and
mania. Also used to control agitation and restlessness, motor
tics, intractable hiccups and Tourette’s syndrome.
Common side effects: Parkinsonism, acute dystonia, restlessness,
drowsiness, postural hypotension.
Heparin (anticoagulant)
Prevents the formation of, and aids the dispersion of, blood clots.
Used to treat deep vein thrombosis, pulmonary embolism, unstable
angina, and acute occlusion of peripheral arteries. Also used
for thromboprophylaxis in medical and surgical patients as well
as during haemodialysis.
Common side effects: haemorrhage, thrombocytopenia.
Hydrocortisone (corticosteroid)
SECTION
Given as replacement therapy for adrenocortical insufficiency
(Addison’s disease). Suppresses a variety of inflammatory and
allergic disorders (e.g. psoriasis, ulcerative colitis, eczema, acute
6
asthma, inflammatory bowel disease, angioedema).
Pharmacology
Common side effects: indigestion, weight gain, acne.

Hydroxychloroquine (conventional DMARD)
Used to treat systemic lupus erythematosus, rheumatoid arthritis
and dermatological conditions caused or aggravated by sunlight.
Common side effects: gastrointestinal disturbances, headache,
itching, rash, skin reactions.
Hyoscine (muscarinic antagonist)
Used to manage motion sickness, giddiness and nausea caused
by disturbances of the inner ear and reduce intestinal spasm in 335
irritable bowel syndrome. Used to treat excessive respiratory
secretions in palliative care.
Common side effects: drowsiness, dry mouth, blurred vision.
Ibuprofen (NSAID)
Used to reduce pain, stiffness and inflammation associated with
conditions such as rheumatoid arthritis, juvenile idiopathic
arthritis, osteoarthritis, sprains and other soft-tissue injuries.
Also used to treat postoperative pain, headache, migraine,
menstrual and dental pain, and fever and pain in children.
Common side effects: heartburn, indigestion, nausea,
vomiting.
Imipramine (tricyclic antidepressant)

Less sedating than some other antidepressants, it is used for
long-term treatment of depression and also for nocturnal enuresis
(bedwetting) in children.
Common side effects: drowsiness, sweating, dry mouth, blurred
vision, dizziness, fainting, palpitations, gastrointestinal upset.
Insulin (peptide hormone)

Lowers blood sugar and is given by injection to control type 1
(insulin-dependent) and sometimes type 2 (maturity-onset)
diabetes mellitus.
SECTION Common side effects: fat hypertrophy at injection site, local
6 reaction at injection site, transient oedema.
Ipratropium (antimuscarinic)
Bronchodilator that is used to treat reversible airways obstruction,
Pharmacology
particularly in chronic obstructive pulmonary disease. Also used

in acute bronchospasm and to treat severe or life-threatening
asthma.
Common side effects: constipation, cough, diarrhoea, dry mouth,
gastrointestinal motility disorder, headache, sinusitis.
Isosorbide mononitrate (organic nitrate)

A coronary and peripheral vasodilator. Used as a prophylaxis
and treatment for angina and as an adjunct in congestive heart
336 failure.
Common side effects: dizziness, postural hypotension, tachycardia,
headache.
Ivabradine (sinus node inhibitor)

Acts on the sinoatrial node to slow the heart and reduce myo-
cardial oxygen consumption. Used to treat angina in patients
with normal sinus rhythm and in mild to severe chronic heart
failure when β-blockers are contraindicated or not tolerated.
Common side effects: atrial fibrillation, blurred vision, brady-
cardia, dizziness, first-degree heart block, headache, phosphenes,
ventricular extrasystoles, visual disturbances.
Lactulose (osmotic laxative)

Used to relieve constipation and is also used to treat hepatic
encephalopathy.
Common side effects: abdominal discomfort, cramps, flatulence,
nausea, vomiting.
Lamivudine (nucleoside reverse transcriptase inhibitor)

One of the most common NRTIs for treating HIV infection in
combination with other antiretroviral drugs, owing to its excellent
tolerance profile. Also used in chronic hepatitis B.
Common side effects: headache, nausea, malaise, fatigue, nasal
disturbances, diarrhoea, cough, musculoskeletal pain, neuropathy,
insomnia, anorexia, dizziness, fever, chills. SECTION
Lansoprazole (proton-pump inhibitor) 6

Reduces the amount of acid produced by the stomach, and is
used to treat stomach and duodenal ulcers as well as gastro-
Pharmacology
oesophageal reflux and oesophagitis.

Common side effects: abdominal pain, constipation, diarrhoea,
flatulence, gastrointestinal disturbances, headache, nausea,
vomiting.
Leflunomide (conventional DMARD)

Used to treat moderate to severe rheumatoid arthritis and psoriatic
arthritis.
Common side effects: abdominal pain, alopecia, anorexia, tired-
ness, diarrhoea, dizziness, dry skin, headache, increased blood 337
pressure, leucopenia, nausea, oral mucosal disorders, paraes-
thesia, itching, rash, tenosynovitis, vomiting.
Levodopa/L-dopa (dopamine precursor)

Used to treat idiopathic Parkinson’s disease by replacing the
depleted dopamine in the brain. It is combined with an inhibitor
such as carbidopa (to form co-careldopa) or benserazide (to form
co-beneldopa) to prolong and enhance its action. It becomes
less effective with continued use.
Common side effects: nausea, vomiting, abdominal pain, anorexia,
postural hypotension, dysrhythmias, dizziness, discoloration of
urine and other bodily fluids, abnormal involuntary movements,
nervousness, agitation.
Levothyroxine (thyroid hormone)

Used in the treatment of hypothyroidism.
Common side effects: rare but at excessive dosage can cause
cardiac arrhythmias, tachycardia, anxiety, weight loss, muscular
weakness and cramps, sweating, diarrhoea.
Lidocaine/lignocaine (local anaesthetic, class I

antiarrhythmic agent)
Used as a local anaesthetic both topically and subcutaneously.
Also used for ventricular dysrhythmias, especially following
SECTION myocardial infarction.
6 Common side effects: injection site irritation.
Lisinopril (ACE inhibitor)

Vasodilator that is used to treat hypertension, congestive heart
Pharmacology
failure and following myocardial infarction. Also used to treat

renal complications of diabetes mellitus.
Common side effects: rash, dry cough, headache, dizziness,
postural hypotension.
Lithium (antimanic)
Used to prevent and treat mania, bipolar disorders, recurrent
depression and aggressive or self-harming behaviour.
Common side effects: increase in urine, thirst, nausea, fine
338 tremor.
Loperamide (antimotility)
Inhibits peristalsis and prevents the loss of water and electrolytes.
Used to treat acute and chronic diarrhoea and faecal incontinence.
Common side effects: dizziness, flatulence, headache, nausea.
Losartan (angiotensin-II receptor antagonist)

Shares similar properties to ACE inhibitors and is used to treat
hypertension, heart failure and diabetic neuropathy. Does not
cause a persistent dry cough, which commonly complicates ACE
inhibitor therapy.
Common side effects: dizziness, diarrhoea, headache.
Macrogols (osmotic laxative)

Softens faeces by increasing the amount of water in the large
bowel. Used to treat chronic constipation and faecal impaction.
Common side effects: abdominal distension and pain, nausea,
flatulence.
Mannitol (osmotic diuretic)

Reduces cerebral oedema and therefore intracranial pressure.
Used preoperatively to reduce intraocular pressure in glaucoma.
Also used in the treatment of cystic fibrosis as an adjunct to
standard care.
Common side effects: cough, haemoptysis, headache, pharyn- SECTION
golaryngeal pain, throat irritation, vomiting, wheezing.
6
Maraviroc (antiretroviral – entry inhibitor)
Used in the treatment of HIV infection. Used in combination
Pharmacology
with other antiretroviral drugs in patients who have a specific

drug-resistant strain (CCR5 tropic).
Common side effects: abdominal pain, anaemia, anorexia,
depression, diarrhoea, flatulence, headache, insomnia, malaise,
nausea, rash.
Meloxicam (NSAID)
Used to relieve the symptoms of rheumatoid arthritis, ankylosing
spondylitis, juvenile idiopathic arthritis, and acute episodes of
osteoarthritis. 339
Common side effects: gastrointestinal upset, headache, dizziness,
diarrhoea, constipation, rash.
Metformin (biguanide)
Used to treat type 2 diabetes mellitus by decreasing glucose
production, increasing peripheral glucose utilization and reducing
glucose absorption in the digestive tract.
Common side effects: abdominal pain, anorexia, diarrhoea,
nausea, taste disturbances, vomiting.
Methadone (opiate agonist)
Used to treat severe pain. Also used as an adjunct in the treatment
of opioid dependence.
Common side effects: drowsiness, nausea, constipation, dizziness.
Methotrexate (cytotoxic and immunosuppressive)

Inhibits DNA, RNA and protein synthesis leading to cell death.
Used to treat leukaemia, lymphoma and a number of solid
tumours. Also used to treat inflammatory conditions such as
rheumatoid arthritis, psoriatic arthritis and Crohn’s disease.
Common side effects: nausea, uterine cramps, vomiting, abdomi-
nal pain, diarrhoea, dizziness, sweating, tinnitus, bradycardia,
chest pain.
Metoclopramide (dopamine antagonist)
SECTION
Used to treat nausea and vomiting caused by radiotherapy,
6 chemotherapy, opioid treatment, migraines and following surgery.
Common side effects: drowsiness, restlessness, fatigue, lethargy.
Metoprolol (β-blocker)
Pharmacology
Used to treat hypertension, angina, arrhythmias and heart failure.

Also used in the treatment and prevention of migraine and as
an adjunct in the management of hyperthyroidism.
Common side effects: decreased sexual function, drowsiness,
insomnia, fatigue.
Metronidazole (antimicrobial)
Used to treat a variety of infections caused by anaerobic bacteria
and protozoa including Clostridium difficile, pelvic inflammatory
340 disease and eradication of Helicobacter pylori.
Common side effects: anorexia, aseptic meningitis, furred tongue,
gastrointestinal disturbances, nausea, optic neuropathy, oral
mucositis, taste disturbances, vomiting.
Midodrine (α1-adrenoceptor agonist)

Used for treating severe orthostatic hypotension due to autonomic
dysfunction.
Common side effects: chills, dyspepsia, flushing, headache,
nausea, paraesthesia, piloerection, itching, rash, stomatitis,
supine hypertension, urinary disorders.
Milrinone (phosphodiesterase inhibitor)

A positive inotrope with vasodilating properties, it increases
cardiac contractility and reduces vascular resistance. Used
to treat severe congestive heart failure and myocardial
dysfunction.
Common side effects: ectopic beats, headache, hypotension,
supraventricular arrhythmias, ventricular tachycardia.
Morphine (opioid analgesic)

Used to relieve severe pain. Also used to suppress cough in
palliative care, myocardial infarction and acute pulmonary
oedema.
SECTION
Common side effects: drowsiness, nausea, vomiting, constipation,
dizziness, dry mouth, respiratory depression. 6
Naloxone (opioid antagonist)
Pharmacology
Used for opioid overdose and to reverse respiratory depression

caused by opioid analgesics.
Common side effects: dizziness, headache, hypertension, hypoten-
sion, nausea, tachycardia, vomiting.
Naproxen (NSAID)
Used to relieve pain and inflammation in rheumatic disease and
musculoskeletal disorders. Also used to treat acute gout and
menstrual cramps.
Common side effects: gastrointestinal disturbances. 341
Nevirapine (antiretroviral – non-nucleoside reverse
Used to treat HIV infection in combination with other antiret-
roviral drugs.
Common side effects: abdominal pain, diarrhoea, fatigue,
fever, granulocytopenia, headache, hepatitis, hypersensitivity
reactions (may involve hepatic reactions and rash), nausea,
rash, Stevens-Johnson syndrome, toxic epidermal necrolysis,
vomiting.
Nicorandil (potassium-channel activator)

Used for the prevention and treatment of angina. Acts on both
the coronary arteries and veins to cause dilation, thus improving
blood flow.
Common side effects: headache, flushing, nausea.
Nifedipine (calcium channel blocker)

Used in the treatment and prevention of angina. Also used to
treat hypertension, Raynaud’s disease and hiccup in palliative
care.
Common side effects: tiredness, dizziness, gastrointestinal dis-
turbances, headache, hypotension, lethargy, oedema, palpitations,
SECTION vasodilatation.
6 Nimodipine (calcium channel blocker)

Relaxes vascular smooth muscle, acting preferentially on the
cerebral arteries. Used to treat ischaemic neurological defects
Pharmacology
following aneurysmal subarachnoid haemorrhage.

Common side effects: hypotension, peripheral edema, diarrhoea,
headache.
Noradrenaline/norepinephrine (sympathomimetic
agent)
Administered intravenously to constrict peripheral vessels to
raise blood pressure in patients with acute hypotension.
Common side effects: hypertension, headache, bradycardia,
342 arrhythmias, peripheral ischaemia.
Omeprazole (proton-pump inhibitor)
Reduces the amount of acid produced by the stomach, and is
used to treat stomach and duodenal ulcers as well as gastro-
oesophageal reflux and oesophagitis.
flatulence, gastrointestinal disturbances, headache, nausea,
vomiting.
Ondansetron (serotonin antagonist)

Used to treat nausea and vomiting associated with anticancer
drug therapy, radiotherapy and following surgery.
Common side effects: headache, flushing.
Orphenadrine (antimuscarinic)
Blocks the action of the neurotransmitter acetylcholine, and is
used to reduce rigidity and tremor (but not tardive dyskinesia)
in younger patients with Parkinsonism.
Common side effects: dry mouth/skin, constipation, blurred
vision, retention of urine.
Oxybutynin (antimuscarinic)
Reduces unstable contractions of the bladder, thereby increasing
its capacity. Used to treat urinary frequency, urgency and incon-
tinence, nocturnal enuresis and neurogenic bladder instability. SECTION
Common side effects: dry mouth and eyes, gastrointestinal upset,
difficulty in micturition, skin reactions, blurred vision. 6
Oxycodone (strong opioid analgesic)
Pharmacology
Used to treat moderate to severe pain.

Common side effects: drowsiness, dizziness, hypotension, anorexia,
diarrhoea, abdominal pain, respiratory depression.
Pancuronium (muscle relaxant)

Long acting, it is used as a muscle relaxant during surgical
procedures and to facilitate tracheal intubation. Also used on
patients receiving long-term mechanical ventilation.
Common side effects: acute myopathy (after prolonged use in
intensive care), hypertension, tachycardia. 343
Paracetamol (nonopioid analgesic)
Used to treat mild pain and reduce fever. Does not irritate the
gastric mucosa, and so can be used by those who have peptic
ulcers or can be used in place of aspirin for those who are
aspirin-intolerant.
Common side effects: rare but overdose can cause liver
failure.
Paroxetine (selective serotonin reuptake inhibitor)

Increases serotonin levels and is used in depression, obsessive-
compulsive disorder, panic disorder, social phobia, posttraumatic
stress disorder and generalized anxiety disorder.
dyspepsia, gastrointestinal effects, nausea, vomiting.
Phenytoin (anticonvulsant)
Used to treat generalized tonic-clonic seizures, focal seizures and
status epilepticus. Also used to prevent seizures associated with
severe head injury and neurosurgery.
Common side effects: acne, anorexia, coarsening of facial
appearance, constipation, dizziness, drowsiness, overgrowth of
gums, headache, increased hair growth, insomnia, nausea,
paraesthesia, rash, transient nervousness, tremor, vomiting.
SECTION
Piroxicam (NSAID)
6 Has a long duration of action, and is used to relieve the symptoms
of rheumatoid arthritis, osteoarthritis, ankylosing spondylitis
and for pain relief in musculoskeletal disorders.
Pharmacology
Common side effects: gastrointestinal upset, dizziness, headache.
Pizotifen (antimigraine)
Inhibits the action of histamine and serotonin on blood vessels
in the brain, and is used in the prevention of vascular head-
ache including classical and common migraines and cluster
headache.
Common side effects: dizziness, drowsiness, dry mouth, increased
appetite, nausea, weight gain.
344
Pramipexole (Non-ergot dopamine agonist)
Stimulates dopamine receptors in the striatum and substantia
nigra, and is used to treat Parkinson’s disease as well as restless
legs syndrome.
Common side effects: confusion, constipation, decreased appetite,
dizziness, drowsiness, dyskinesia, hallucinations, headache,
hyperkinesia, hypotension, nausea, peripheral oedema, postural
hypotension, restlessness, sleep disturbances, sudden onset of
sleep, visual disturbances, vomiting, weight changes.
Pravastatin (statin)
Lowers LDL cholesterol and is prescribed for those who have not
responded to diet and lifestyle modification to protect them from
cardiovascular disease.
Common side effects: gastrointestinal upset, headache, fatigue,
rarely myositis.
Prednisolone (corticosteroid)
A strong corticosteroid used to suppress inflammatory and allergic
disorders, e.g. asthma, chronic obstructive pulmonary disease,
eczema, inflammatory bowel disease, rheumatoid arthritis, giant
cell arteritis, polymyalgia rheumatica and systemic lupus
erythematosus. Also used to treat generalized myasthenia
gravis. SECTION
Common side effects: indigestion, acne, increased body hair,
moon face, hypertension, weight gain/oedema, impaired glucose 6
tolerance, cataract, glaucoma, osteoporosis, peptic ulcer, candida,
adrenal suppression.
Pharmacology
Pregabalin (anticonvulsant)
Used to treat neuropathic pain, generalized anxiety disorder
and also used as an adjunctive therapy for partial epileptic
seizures.
Common side effects: dizziness; drowsiness; ataxia; peripheral
oedema; weight gain; blurred vision; diplopia, difficulty with
concentration, attention, cognition; tremor; dry mouth; headache;
constipation; tiredness.
345
Propranolol (β-blocker)
Used to treat hypertension, angina, arrhythmias, hyperthyroidism,
migraine, anxiety and for prophylaxis after myocardial infarction.
Common side effects: fatigue, cold peripheries, bronchoconstric-
tion, bradycardia, heart failure, hypotension, gastrointestinal
upset, sleep disturbances.
Quinine (antimalarial)
Used for the treatment of malaria. Also used to prevent nocturnal
leg cramps.
Common side effects: tinnitus, headache, blurred vision, confu-
sion, gastrointestinal upset, rash, blood disorders.
Raloxifene (selective oestrogen receptor modulator –

SERM)
Used to prevent vertebral fractures in postmenopausal women
at increased risk for osteoporosis.
Common side effects: hot flushes, influenza-like symptoms, leg
cramps, peripheral oedema.
Raltegravir (antiretroviral – integrase inhibitor)

roviral drugs.
SECTION Common side effects: abdominal pain, abnormal dreams, asthenia,
6 depression, diarrhoea, dizziness, dyspepsia, flatulence, headache,
hyperactivity, hypertriglyceridaemia, insomnia, nausea, rash,
vomiting.
Pharmacology
Ramipril (ACE inhibitor)

Used to treat hypertension, heart failure and to preserve kidney
function in conditions such as diabetes mellitus. Also used to
treat heart failure following myocardial infarction.
Common side effects: nausea, dizziness, headache, dry cough,
dry mouth, taste disturbances.
Repaglinide (meglitinide)
Oral, short-acting, antidiabetic drug that lowers blood glucose
346 levels after eating. Used to treat type 2 diabetes mellitus.
nausea, vomiting.
Rifampicin (antituberculous agent)
Antibacterial used to treat tuberculosis, leprosy and other serious
infections such as Legionnaire’s disease and osteomyelitis. Used
as a prophylactic against meningococcal meningitis and Hae-
mophilus influenzae (type b) infection.
Common side effects: red-orange–coloured tears and urine.
Risperidone (antipsychotic)
Used for acute psychiatric disorders and long-term psychotic illness
such as schizophrenia, psychosis, mania and persistent aggression
in patients with moderate to severe Alzheimer’s dementia.
Common side effects: insomnia, agitation, anxiety, headache,
weight gain, difficulty in concentrating, tremor.
Ritonavir (antiretroviral – protease inhibitor)
HIV infection.
rash, liver dysfunction, blood disorders, muscle pain and weak-
ness, metabolic disturbances, cough, anxiety.
Rivastigmine (anticholinesterase)
SECTION
Used to improve cognitive function in mild to moderate dementia
due to Alzheimer’s disease and Parkinson’s disease.
Common side effects: abdominal pain, agitation, anorexia, an
6
xiety, bradycardia, confusion, diarrhoea, dizziness, drowsiness,
Pharmacology
dyspepsia, extrapyramidal symptoms, headache, increased

salivation, insomnia, malaise, nausea, sweating, tremor, urinary
incontinence, vomiting, weight loss, worsening of Parkinson’s
disease.
Ropinirole (Non-ergot dopamine agonist)
Stimulates the dopamine receptors in the basal ganglia to relieve
the symptoms of Parkinson’s disease, and has been found to be
particularly useful for younger patients. Also used to treat
moderate to severe restless legs syndrome.
Common side effects: nausea, dizziness, drowsiness. 347
Salbutamol (β2-agonist)
A bronchodilator that is used to treat and prevent asthma,
exercise- or allergen-induced bronchospasm and conditions
associated with reversible airways obstruction. It is also used in
premature labour to relax uterine muscle.
Common side effects: headache, restlessness, nervousness,
tremors, nausea, dizziness, throat dryness and irritation,
pharyngitis, hypertension, heartburn, transient wheezing.
Salmeterol (β2-agonist)
A bronchodilator that is used to treat asthma and prevent
exercise-induced bronchospasm. It is longer acting than salbu-
tamol and so is useful in preventing nocturnal asthma. It should
not be used to relieve acute asthma attacks as it has a slow onset
of effect.
Common side effects: headache, cough, tremor, dizziness, vertigo,
throat dryness/irritation, pharyngitis.
Saquinavir (antiretroviral – protease inhibitor)

roviral drugs.
Common side effects: gastrointestinal upset, anorexia, hepatic
dysfunction, pancreatitis, blood disorders, sleep disturbances,
SECTION fatigue, headache, dizziness, paraesthesia, myalgia, myositis, taste
6 disturbances, rash, itching, anaphylaxis, peripheral neuropathy

and mouth ulcers.
Senna (stimulant laxative)

Pharmacology
Used to treat constipation by increasing the response of the colon

to normal stimuli.
Common side effects: abdominal cramps, diarrhoea.
Sertraline (selective serotonin reuptake inhibitor)

Used to treat depressive illness, obsessive-compulsive disorder,
panic disorder, posttraumatic stress disorder and social anxiety
disorder.
348 dyspepsia, gastrointestinal effects, nausea, vomiting.
Simvastatin (statin)
Lowers LDL cholesterol, and is prescribed for those who have
not responded to diet and lifestyle modification to protect them
from cardiovascular disease.
Common side effects: gastrointestinal upset, headache, fatigue,
rarely myositis.
Sodium valproate (antiepileptic)
Used to treat all types of epilepsy.
Common side effects: temporary hair loss, weight gain, nausea.
Streptokinase (fibrinolytic agent)
An enzyme that dissolves blood clots by acting on the fibrin
contained within it. Due to its fast-acting nature, it is useful in
treating acute myocardial infarction. Also used to treat other
thromboembolic events such as deep-vein thrombosis, pulmonary
embolism, acute arterial thromboembolism and central retinal
venous or arterial thrombosis.
Common side effects: excessive bleeding, hypotension, nausea,
vomiting, allergic reaction.
Sulfasalazine (aminosalicylate)
Used as an antiinflammatory to treat ulcerative colitis and active
Crohn’s disease. Also found to help in the treatment of rheumatoid
SECTION
arthritis.
Common side effects: abdominal pain, diarrhoea, exacerbation
of symptoms of colitis, headache, hypersensitivity reactions,
6
nausea, rash, urticaria, vomiting.
Pharmacology
Sumatriptan (selective serotonin agonist)

Used to treat severe acute migraine and cluster headaches.
Common side effects: dizziness, drowsiness, dyspnoea, fatigue,
flushing, myalgia, nausea, sensory disturbances, transient
increase in blood pressure, vomiting, weakness.
Tamoxifen (anti-oestrogen)
Used in the treatment of oestrogen-receptor–positive breast
cancer. Also used in the treatment of infertility due to failure
of ovulation. 349
Common side effects: nausea, vomiting, hot flushes, hair loss,
irregular vaginal bleeding and discharge.
Tamsulosin (α-blocker)
Used to treat urinary retention due to benign prostatic
hypertrophy.
Common side effects: dizziness, postural hypotension, headache,
abnormal ejaculation, drowsiness, palpitations.
Temazepam (benzodiazepine)
Used as a short-term treatment for insomnia and as a premedica-
tion before surgery or investigatory procedures.
Common side effects: amnesia, ataxia, confusion, dependence,
drowsiness, lightheadedness, muscle weakness, paradoxical
increase in aggression.
Tenofovir (antiretroviral – NRTI)

HIV infection as well as chronic hepatitis B.
insomnia, fatigue, cough, blood disorders, rash, muscle and joint
pain.
Terbutaline (β2-agonist)
SECTION Acts as a bronchodilator, and is used to treat and prevent exercise-
6 induced bronchospasm, asthma and other conditions associated
with reversible airways obstruction. It is also used to delay
premature labour.
Common side effects: nausea, vomiting, fine tremor, restlessness,
Pharmacology
headache, anxiety.
Teriparatide (parathyroid hormone)

Stimulates osteoblast function, increasing bone density and
strength. Used in the treatment of osteoporosis in men and
postmenopausal women at increased risk for fractures as well
as corticosteroid-induced osteoporosis.
Common side effects: anaemia, arthralgia, tiredness, depression,
dizziness, dyspnoea, fatigue, gastrointestinal disorders,
350
haemorrhoids, headache, increased sweating, muscle cramps,
myalgia, nausea, palpitations, reflux, sciatica, vertigo.
Tetracycline (tetracycline antibiotic)

Used to treat a variety of infections including acne, rosacea,
diabetic diarrhoea, nongonococcal urethritis, chlamydia and
rickettsia.
Common side effects: nausea, vomiting, diarrhoea.
Theophylline (methylxanthine)
Acts as a bronchodilator, and is used to treat acute and chronic
asthma and reversible airways obstruction.
Common side effects: gastrointestinal disturbances, insomnia,
headache, nausea, vomiting, agitation.
Thiopental (barbiturate)
Used to induce general anaesthesia, as well as reducing intra-
cranial pressure in patients whose ventilation is controlled.
Common side effects: arrhythmias, cough, headache, hypersen-
sitivity reaction, hypotension, laryngeal spasm, myocardial
depression, rash, sneezing.
Tibolone (hormone replacement therapy)

SECTION
A synthetic steroid used as a short-term treatment for symptoms
of menopause, especially hot flushes. Has both oestrogenic and 6
progestogenic activity. Also used as a second-line preventative
treatment for postmenopausal osteoporosis.
Pharmacology
Common side effects: abdominal pain, facial hair, leucorrhoea,

vaginal bleeding, weight changes.
Timolol (β-blocker)
Used to treat hypertension, angina and for prophylaxis follow-
ing myocardial infarction. Also commonly administered as eye
drops for glaucoma and occasionally given for the prevention
of migraine.
Common side effects: lethargy, fatigue, cold peripheries.
351
Tizanidine (α2-adrenoceptor agonist)
Acts centrally to reduce muscle spasticity associated with multiple
sclerosis or spinal cord injury or disease.
Common side effects: altered liver enzymes, dizziness, drowsiness,
dry mouth, fatigue, gastrointestinal disturbances, hypotension,
nausea.
Tolterodine (antimuscarinic)
Reduces unstable contractions of the bladder, thereby increasing
its capacity. Used to treat urinary frequency, urgency and
incontinence.
Common side effects: dry mouth and eyes, gastrointestinal upset,
headache, drowsiness.
Tramadol (opioid analgesic)

Used to treat moderate to severe pain.
Common side effects: nausea, vomiting, dry mouth, tiredness,
drowsiness, dependence.
Trastuzumab (antineoplastic)
Used in the treatment of HER2 overexpressing breast cancer
and stomach cancer.
SECTION Common side effects: diarrhoea, weakness, abdominal pain, joint
and muscle pain, fever, shivering.
6 Trazodone (antidepressant)
Used to treat depression and anxiety, particularly when sedation
Pharmacology
is required.
Common side effects: drowsiness, dry mouth, lightheadedness,
dizziness, headache, blurred vision, nausea, vomiting.
Trihexyphenidyl (antimuscarinic)
Blocks the action of the neurotransmitter acetylcholine,
and is used to reduce rigidity and tremor. Not useful for
bradykinesia.
Common side effects: dry mouth/skin, constipation, blurred
352 vision, retention of urine.
Valsartan (angiotensin-II receptor antagonist)
Shares similar properties to ACE inhibitors, and is used to treat
hypertension, heart failure and myocardial infarction with left
ventricular failure or systolic dysfunction.
Common side effects: dizziness, renal impairment.
Vancomycin (glycopeptide antibiotic)

Administered intravenously for the treatment of serious infections
caused by gram-positive bacteria such as endocarditis, osteo-
myelitis, septicaemia and soft-tissue infections. Used to prevent
infection during surgery when there is a high risk for MRSA.
Given orally for the treatment of gastrointestinal infections,
notably pseudomembranous colitis caused by the Clostridium
difficile organism.
Common side effects: nephrotoxicity, ototoxicity (damage to the
auditory nerve), blood disorders, renal failure.
Venlafaxine (serotonin and noradrenaline reuptake

inhibitor)
Used to treat major depression as well as generalized anxiety
and social anxiety disorders.
Common side effects: nausea, dizziness, drowsiness, insomnia,
restlessness, constipation, weakness, sexual dysfunction, blurred
vision. SECTION
Verapamil (calcium channel blocker) 6

Used in the treatment of hypertension, angina, supraventricular
arrhythmias, paroxysmal tachyarrhythmias. Also used to prevent
Pharmacology
cluster headaches.
Common side effects: constipation.
Warfarin (oral anticoagulant)

Prevention and treatment of pulmonary embolism and deep
vein thrombosis. Decreases the risk for transient ischaemic attacks
as well as thromboembolism in people with atrial fibrillation,
rheumatic heart disease and following artificial heart valve
surgery.
Common side effects: haemorrhage, bruising. 353
Zidovudine (nucleoside and nucleotide reverse
HIV infection. Also used to prevent maternal-fetal HIV
transmission.
Common side effects: nausea, vomiting, diarrhoea.
Zopiclone (non-benzodiazepine hypnotic)

Used for short-term treatment of insomnia (up to 4 weeks).
Common side effects: taste disturbances.
Prescription abbreviations
Abbreviation Latin English

a.c. ante cibum before food
b.d. bis die twice a day
nocte nocte at night
o.d. omni die daily
o.m. omni mane in the mornings
o.n. omni nocte at night
p.c. post cibum after food
p.o. per os by mouth
SECTION
p.r. per rectum by rectum
6 p.r.n.
q.d.s.
pro re nata
quater die sumendum
when required
four times a day
stat. statim immediately
Pharmacology
t.d.s. ter die sumendum three times a day
354
Further Reading
Hitchings, A., Lonsdale, D., Burrage, D., & Baker, E. (2014). The top 100
drugs: Clinical pharmacology and practical prescribing (1st ed.). Churchill
Livingstone.
Joint Formulary Committee (2017). British National Formulary (74th ed.).
London: BMJ Group and Pharmaceutical Press.
Kizior, R. J., & Hodgson, K. J. (2018). Saunders Nursing drug handbook 2018.
St Louis: Elsevier.
O’Shaughnessy, K. M. (2015). BMA new guide to medicine and drugs (9th
ed.). London: British Medical Association.
Rang, H. P., Ritter, J. M., Flower, R. J., & Henderson, G. (2015). Rang and
Dale’s pharmacology (8th ed.). Edinburgh: Churchill Livingstone.
SECTION
6Pharmacology
355
Appendices
SECTION
7
Laboratory values
APPENDIX
Biochemistry
Alanine aminotransferase 10–40 U/L
(ALT)
Albumin 36–47 g/L
Alkaline phosphatase 40–125 U/L
Amylase 90–300 U/L
Aspartate aminotransferase 10–35 U/L
(AST)
Bicarbonate (arterial) 22–28 mmol/L
Bilirubin (total) 2–17 mmol/L
C-reactive protein <7 mg/L
Caeruloplasmin 150–600 mg/L
1
Calcium 2.1–2.6 mmol/L
Chloride 95–105 mmol/L
Cholesterol (total) Desirable level <5.2 mmol/L
Cholesterol (HDL)
Men 0.5–1.6 mmol/L
Women 0.6–1.9 mmol/L
Copper 13–24 mmol/L
Creatine kinase (total)
Men 30–200 U/L
Women 30–150 U/L
Creatinine 55–150 mmol/L
Globulins 24–37 g/L SECTION
Glucose (venous blood,
fasting)
3.6–5.8 mmol/L
7
Iron
Men 14–32 µmol/L
Appendix 1
Women 10–28 µmol/L
Iron-binding capacity, total 45–70 µmol/L
(TIBC)
Lactate (arterial) 0.3–1.4 mmol/L
Lactate dehydrogenase (total) 230–460 U/L
Lead (adults, whole blood) <1.7 µmol/L
Magnesium 0.7–1.0 mmol/L
Osmolality 275–290 mmol/kg
Phosphate (fasting) 0.8–1.4 mmol/L
Potassium (serum) 3.6–5.0 mmol/L
Protein (total) 60–80 g/L
Sodium 136–145 mmol/L
Transferrin 2–4 g/L
Triglycerides (fasting) 0.6–1.8 mmol/L
Urate
Urea 2.5–6.5 mmol/L
Uric acid
Vitamin A 0.7–3.5 µmol/L
Vitamin C 23–57 µmol/L
Zinc 11–22 µmol/L
Haematology
Activated partial thromboplastin 30–40 s
time (APTT)
Bleeding time (Ivy) 2–8 min
Erythrocyte sedimentation rate (ESR)
Adult men 1–10 mm/h
Adult women 3–15 mm/h
Fibrinogen 1.5–4.0 g/L
SECTION Folate (serum) 4–18 mg/L
7 Haemoglobin
Men 130–180 g/L
(13–18 g/dL)
Women 115–165 g/L
Appendix 1
(11.5–16.5 g/dL)
International normalized ratio (INR) 0.89–1.10
Mean cell haemoglobin (MCH) 27–32 pg
Mean cell haemoglobin 30–35 g/dL
concentration (MCHC)
360 Mean cell volume (MCV) 78–95 fL
Packed cell volume (PCV or
haematocrit)
Men 0.40–0.54 (40–54%)
Women 0.35–0.47 (35–47%)
Platelets (thrombocytes) 150–400 × 109/L
Prothrombin time (PT) 12–16 s
Red blood cells (erythrocytes)
Men 4.5–6.5 × 1012/L
Women 3.85–5.30 × 1012/L
Reticulocytes 4.5–6.5 × 1012/L
White blood cells (leukocytes) 4.0–11.0 × 109/L
Values vary from laboratory to laboratory, depending on testing

methods used. These reference ranges should be used as a guide
only. All reference ranges apply to adults only; they may differ
in children.
Conversions and units

Pounds/kg
lb kg
1 0.45
2 0.91
3 1.36
4 1.81
5 2.27 SECTION
7
6 2.72
7 3.18
8 3.63
9 4.08
Appendix 1
10 4.54
11 4.99
12 5.44
13 5.90
14 6.35 361
Stones/kg
Stones kg
1 6.35
2 12.70
3 19.05
4 25.40
5 31.75
6 38.10
7 44.45
8 50.80
9 57.15
10 63.50
11 69.85
12 76.20
13 82.55
14 88.90
15 95.25
16 101.60
17 107.95
18 114.30
Mass
1 kilogram (kg) = 2.205 pounds (lb)
1 pound (lb) = 454 milligrams (mg) = 16 ounces (oz)
1 oz = 28.35 grams (g)
SECTION
7 Length
1 inch (in.) = 2.54 centimetres (cm)
1 metre (m) = 3.281 feet (ft) = 39.37 in
Appendix 1
1 foot (ft) = 30.48 cm = 12 in
Volume
1 litre (L) = 1000 millilitres (mL)
1 pint ≈ 568 mL
362
Pressure
kPa mmHg
1 7.5
2 15
4 30
6 45
8 60
10 75
12 90
14 105
1 millimetre of mercury (mmHg) = 0.133 kilopascal (kPa)
1 kilopascal (kPa) = 7.5 mmHg
SECTION
7
Appendix 1
363
Acronyms and Abbreviations
APPENDIX
AAA abdominal aortic aneurysm
Ab antibody
ABGs arterial blood gases
ABI acquired brain injury/ankle-brachial index
ABPA allergic bronchopulmonary aspergillosis
ACBT active cycle of breathing technique
ACE angiotensin-converting enzyme
ACT activated clotting time/airway clearance
technique/acceptance commitment therapy
ACTH adrenocorticotrophic hormone
AD autogenic drainage
ADH antidiuretic hormone
2
ADL activities of daily living
ADR adverse drug reaction
AE air entry
AEA above elbow amputation
AF atrial fibrillation
AFO ankle-foot orthosis
Ag antigen
AGN acute glomerulonephritis
AHRF acute hypoxaemic respiratory failure
AI aortic insufficiency
AIDS acquired immune deficiency syndrome
AKA above knee amputation SECTION
AL
ALD
acute leukaemia
alcoholic liver disease 7
ALI acute lung injury/acute limb ischaemia
ALS amyotrophic lateral sclerosis
Appendix 2
AMI acute myocardial infarction

AML acute myeloid leukaemia
AP anteroposterior
APACHE acute physiology and chronic health evaluation
ARDS acute respiratory distress syndrome
ARF acute renal failure
AROM active range of movement
AS ankylosing spondylitis
ASD atrial septal defect
ATN acute tubular necrosis
AV atrioventricular
AVF arteriovenous fistula
AVR aortic valve replacement
AVSD atrioventricular septal defect
BC breathing control
BE bacterial endocarditis/barium enema/base excess
BEA below elbow amputation
BiPAP bilevel positive airway pressure
BiVAD biventricular assist device
BKA below knee amputation
BLS basic life support
BM blood glucose monitoring
BMI body mass index
BO bowels open
BOS base of support
BP blood pressure
BPD bronchopulmonary dysplasia
BPF bronchopleural fistula
bpm beats per minute
BS bowel sounds/breath sounds
BSA body surface area
BSO bilateral salpingo-oophorectomy
BVHF biventricular heart failure
Ca carcinoma
SECTION CABG coronary artery bypass graft
7 CAD
CAH
coronary artery disease
chronic active hepatitis
CAL chronic airflow limitation
CAO chronic airways obstruction
Appendix 2
CAPD continuous ambulatory peritoneal dialysis

CAVG coronary artery vein graft
CAVHF continuous arterial venous haemofiltration
CBD common bile duct
CBF cerebral blood flow
366 CCF congestive cardiac failure
CCU coronary care unit
CDH congenital dislocation of the hip
CF cystic fibrosis
CFA cryptogenic fibrosing alveolitis
CFI cardiac function index
CHD coronary heart disease, congenital heart disease
CHF chronic heart failure
CI chest infection, confidence interval
CLD chronic lung disease, chronic liver disease
CML chronic myeloid leukaemia
CMV controlled mandatory ventilation/
cytomegalovirus
CNS central nervous system
CO cardiac output
C/O complains of
COAD chronic obstructive airways disease
COLD chronic obstructive lung disease
COT continuous oxygen therapy
COPD chronic obstructive pulmonary disease
CP cerebral palsy
CPAP continuous positive airway pressure
CPK creatine phosphokinase
CPM continuous passive movements
CPN community psychiatric nurse
CPP cerebral perfusion pressure
CPR cardiopulmonary resuscitation
CRF chronic renal failure
CRPS complex regional pain syndrome
CRP C-reactive protein SECTION
CSF
CT
cerebrospinal fluid
computed tomography 7
CTEV congenital talipes equinovarus
CV closing volume
Appendix 2
CVA cerebrovascular accident

CVD cardiovascular disease
CVP central venous pressure
CVS cardiovascular system
CVVHF continuous veno-venous haemofiltration
CXR chest X-ray 367
D&C dilation and curettage
D/C discharge
D/W discussed with
DBE deep breathing exercises
DDH developmental dysplasia of the hips
DEXA dual-energy X-ray absorptiometry
DH drug history
DHS dynamic hip screw
DIB difficulty in breathing
DIC disseminated intravascular coagulopathy
DIOS distal intestinal obstruction syndrome
DLCO diffusing capacity of the lungs for carbon monoxide
DM diabetes mellitus
DM1 myotonic dystrophy type 1
DMD Duchenne muscular dystrophy
DN district nurse
DNA deoxyribonucleic acid/did not attend
DSA digital subtraction angiography
DU duodenal ulcer
DVT deep vein thrombosis
DXT deep X-ray therapy
EBV Epstein-Barr virus
ECG electrocardiogram/electrocardiography
ECMO extracorporeal membrane oxygenation
EEG electroencephalogram
EIA exercise-induced asthma
EMG electromyography
ENT ear, nose and throat
SECTION EOR end of range
7 Ep
EPAP
epilepsy
expiratory positive airway pressure
EPP equal pressure points
EP evoked potentials
Appendix 2
ERCP endoscopic retrograde

cholangiopancreatography
ERV expiratory reserve volume
ESR erythrocyte sedimentation rate
ESRF end-stage renal failure
368 ETCO2 end-tidal carbon dioxide
ET endotracheal
ETT endotracheal tube/exercise tolerance test
EUA examination under anaesthetic
FB foreign body
FBC full blood count/fluid balance chart
FDP fibrin degradation product
FES functional electrical stimulation
FET forced expiration technique
FEV1 forced expiratory volume in 1 second
FFD fixed flexion deformity
FG French gauge
FGF fibroblast growth factor
FH family history
FHF fulminant hepatic failure
FiO2 fraction of inspired oxygen, inspired oxygen
concentration
FITT frequency, intensity, time and type
fMRI functional magnetic resonance imaging
FRC functional residual capacity
FROM full range of movement
FSH fascioscapulohumeral muscular dystrophy
FVC forced vital capacity
FWB full weight-bearing
GA general anaesthetic/gestational age
GAP gravity-assisted positioning
GBS Guillain-Barré syndrome
GCS Glasgow Coma Scale
GH general health
GIT gastrointestinal tract SECTION
GOR
GPB
gastro-oesophageal reflux
glossopharyngeal breathing 7
GTN glyceryl trinitrate
GU gastric ulcer/genitourinary
Appendix 2
H+ hydrogen ion
[H+] hydrogen ion concentration
HAART highly active antiretroviral therapy
HASO hip abduction spinal orthosis
Hb haemoglobin
HC head circumference 369
HCP health-care professional
Hct haematocrit
HD haemodialysis, Huntington’s disease
HDU high-dependency unit
HEP home exercise programme
HF heart failure/haemofiltration
HFCWO high-frequency chest wall oscillation
HFJV high-frequency jet ventilation
HFO high-frequency oscillation
HFOV high-frequency oscillatory ventilation
HFPPV high-frequency positive pressure ventilation
HH hiatus hernia/home help
HI head injury
HIV human immunodeficiency virus
HLA human leukocyte antigen
HLT heart-lung transplantation
HME heat and moisture exchanger
HPC history of presenting condition
HPOA hypertrophic pulmonary osteoarthropathy
HR heart rate
HRR heart rate reserve
HT hypertension
I:E ratio ratio of inspiratory to expiratory time
IABP intra-aortic balloon pump
ICC intercostal catheter
ICD intercostal drain
ICP intracranial pressure
ICU intensive care unit
SECTION IDC indwelling catheter
7 IDDM
Ig
insulin-dependent diabetes mellitus
immunoglobulin
IHD ischaemic heart disease
ILD interstitial lung disease
Appendix 2
IM intramedullary
IM/i.m. intramuscular
IMA internal mammary artery
IMV intermittent mandatory ventilation
INR international normalized ratio
370 IPAP inspiratory positive airway pressure
IPPB intermittent positive pressure breathing
IPPV intermittent positive pressure ventilation
IPS inspiratory pressure support
IRV inspiratory reserve volume
IS incentive spirometry
ISQ no change
ITU intensive therapy unit
IV/i.v. intravenous
IVB intervertebral block
IVC inferior vena cava
IVH intraventricular haemorrhage
IVI intravenous infusion
IVOX intravenacaval oxygenation
IVUS intravascular ultrasound
JVP jugular venous pressure
KAFO knee-ankle-foot orthosis
KO knee orthosis
LA local anaesthetic
LAP left atrial pressure
LBBB left bundle branch block
LBP low back pain
LED light-emitting diode
LFT liver function test/lung function test
LL lower limb/lower lobe
LMN lower motor neurone
LOC level of consciousness
LOS length of stay
LP lumbar puncture
LRTD lower respiratory tract disease SECTION
LSCS
LTOT
lower segment caesarean section
long-term oxygen therapy 7
LVAD left ventricular assist device
LVEF left ventricular ejection fraction
Appendix 2
LVF left ventricular failure

LVRS lung volume reduction surgery
MAP mean airway pressure/mean arterial pressure
MAS minimal access surgery
MCH mean corpuscular haemoglobin
MC&S microbiology, culture and sensitivity 371
MCV mean corpuscular volume
MD muscular dystrophy
MDI metered dose inhaler
MDT multidisciplinary team
ME metabolic equivalents/myalgic encephalomyelitis
MEP maximal expiratory pressure
MHI manual hyperinflation
MI myocardial infarction
MIP maximal inspiratory pressure
ML middle lobe
MM muscle
MMAD mass median aerodynamic diameter
MND motor neurone disease
MOW Meals On Wheels
MRI magnetic resonance imaging
MRSA methicillin-resistant Staphylococcus aureus
MS mitral stenosis/multiple sclerosis
MSU midstream urine
MUA manipulation under anaesthetic
MVO2 myocardial oxygen consumption
MVR mitral valve replacement
MVV maximum voluntary ventilation
NAD nothing abnormal detected
NAI nonaccidental injury
NBI no bony injury
NBL nondirected bronchial lavage
NBM nil by mouth
NCPAP nasal continuous positive airway pressure
SECTION NEPV negative extrathoracic pressure ventilation
7 NFR
NG
not for resuscitation
nasogastric
NH nursing home
NICU neonatal intensive care unit
Appendix 2
NIDDM non–insulin-dependent diabetes mellitus

NIPPV noninvasive intermittent positive pressure
ventilation
NICU neonatal intensive care unit
NIV noninvasive ventilation
372 NNU neonatal unit
NO nitric oxide
NOF neck of femur
NOH neck of humerus
NOS not otherwise specified
NP nasopharyngeal
NPA nasopharyngeal airway
NPPV noninvasive positive pressure ventilation
NPV negative pressure ventilation
NR nodal rhythm
NREM non–rapid eye movement
N/S nursing staff
NSAID nonsteroidal antiinflammatory drug
NSR normal sinus rhythm
NWB non–weight-bearing
OA oral airway/osteoarthritis
OB obliterative bronchiolitis
OCD obsessive-compulsive disorder
OD overdose
O/E on examination
OGD oesophagogastroduodenoscopy
OHFO oral high-frequency oscillation
OI oxygen index
OLT orthotopic liver transplantation
OPD outpatient department
ORIF open reduction and internal fixation
OSA obstructive sleep apnoea
OT occupational therapist
PA pernicious anaemia/posteroanterior/pulmonary
artery SECTION
PACO2
PaCO2
partial pressure of carbon dioxide in alveolar gas
partial pressure of carbon dioxide in arterial 7
blood
PADL personal activities of daily living
Appendix 2
PAO2 partial pressure of oxygen in alveolar gas

PaO2 partial pressure of oxygen in arterial blood
PAP pulmonary artery pressure
PAWP pulmonary artery wedge pressure
PBC primary biliary cirrhosis
PC presenting condition/pressure control 373
PCA patient-controlled analgesia
PCD primary ciliary dyskinesia
PCIRV pressure-controlled inverse ratio ventilation
PCO2 partial pressure of carbon dioxide
PCP Pneumocystis carinii pneumonia
PCPAP periodic continuous positive airway pressure
PCV packed cell volume
PCWP pulmonary capillary wedge pressure
PD Parkinson’s disease/peritoneal dialysis/postural
drainage
PD&P postural drainage and percussion
PDA patent ductus arteriosus
PE pulmonary embolus
PEEP positive end-expiratory pressure
PEF peak expiratory flow
PEFR peak expiratory flow rate
PEG percutaneous endoscopic gastrostomy
PeMax peak expiratory mouth pressure
PEP positive expiratory pressure
PET positron emission tomography
PFC persistent fetal circulation
PFO persistent foramen ovale
PHC pulmonary hypertension crisis
PICC peripherally inserted central catheter
PICU paediatric intensive care unit
PID pelvic inflammatory disease
PIE pulmonary interstitial emphysema
PIF peak inspiratory flow
SECTION PIFR peak inspiratory flow rate
7 PiMax
PIP
peak inspiratory mouth pressure
positive inspiratory pressure
PMH previous medical history
PMR percutaneous myocardial revascularization
Appendix 2
PN percussion note
PND paroxysmal nocturnal dyspnea
PNS peripheral nervous system
PO2 partial pressure of oxygen
POMR problem-oriented medical record
374 POP plaster of Paris
PR pulmonary regurgitation; pulmonary
rehabilitation
PRN as required
PROM passive range of movement
PRVC pressure-regulated volume control
PS pressure support/pulmonary stenosis
PTB pulmonary tuberculosis
PTCA percutaneous transluminal coronary angioplasty
PTFE polytetrafluoroethylene
PTSD posttraumatic stress disorder
PTT partial thromboplastin time
PVC polyvinyl chloride
PVD peripheral vascular disease
PVH periventricular haemorrhage
PVL periventricular leucomalacia
PVR pulmonary vascular resistance
PWB partial weight-bearing
QOL quality of life
RA rheumatoid arthritis/room air
RAP right atrial pressure
RBBB right bundle branch block
RBC red blood cell
RDS respiratory distress syndrome
REM rapid eye movement
RFT respiratory function test
RH residential home
RhF rheumatic fever
RIP rest in peace
RMT respiratory muscle training SECTION
R/O
ROM
removal of
range of movement 7
ROP retinopathy of prematurity
RPE rating of perceived exertion
Appendix 2
RPP rate pressure product

RR respiratory rate
RS respiratory system
RSV respiratory syncytial virus
RTA road traffic accident
RV residual volume 375
RVF right ventricular failure
SA sinoatrial
SAH subarachnoid haemorrhage
SALT speech and language therapist
SaO2 arterial oxygen saturation
SB sinus bradycardia/spina bifida
SBE subacute bacterial endocarditis
SCI spinal cord injury
SDH subdural haematoma
SGAW specific airway conductance
SH social history
SIMV synchronized intermittent mandatory ventilation
SIRS systemic inflammatory response syndrome
SLAP superior labrum, anterior and posterior
SLE systemic lupus erythematosus
SLR straight leg raise
SMA spinal muscle atrophy
SN Swedish nose
SNS sympathetic nervous system
SOA swelling of ankles
SOAP notes subjective, objective, assessment, plan
SOB shortness of breath
SOBAR short of breath at rest
SOBOE short of breath on exertion
SOOB sit out of bed
SpO2 pulse oximetry arterial oxygen saturation
SpR special registrar
SPS single point stick
SECTION SR sinus rhythm
7 SS
ST
social services
sinus tachycardia
SV self-ventilating/stroke volume
SVC superior vena cava
Appendix 2
SVD spontaneous vaginal delivery

SVG saphenous vein graft
SVO2 mixed venous oxygen saturation
SVR systemic vascular resistance
SVT supraventricular tachycardia
376 SW social worker
T21 trisomy 21 (Down syndrome)
TAA thoracic aortic aneurysm
TAH total abdominal hysterectomy
TAVR tissue atrial valve repair
TB tuberculosis
TBI traumatic brain injury
TcCO2 transcutaneous carbon dioxide
TcO2 transcutaneous oxygen
TED thromboembolic deterrent
TEE thoracic expansion exercises
TENS transcutaneous electrical nerve stimulation
TFA transfemoral arteriogram
TGA transposition of the great arteries
THR total hip replacement
TIA transient ischaemic attack
TKA through knee amputation
TKR total knee replacement
TLC total lung capacity
TLCO transfer factor in lung of carbon monoxide
TLSO thoracolumbar spinal orthosis
TM tracheostomy mask
TMR transmyocardial revascularization
TMVR tissue mitral valve repair
TOP termination of pregnancy
TPN total parenteral nutrition
TPR temperature, pulse and respiration
TURBT transurethral resection of bladder tumour
TURP transurethral resection of prostate
TV tidal volume SECTION
TWB
Tx
touch weight-bearing
transplant 7
U&E urea and electrolytes
UAO upper airway obstruction
Appendix 2
UAS upper abdominal surgery

UL upper limb/upper lobe
UMN upper motor neurone
URTI upper respiratory tract infection
USS ultrasound scan
UTI urinary tract infection 377
V ventilation
Va alveolar ventilation/alveolar volume
VAD ventricular assist device
VAS visual analogue scale
VATS video-assisted thoracoscopy surgery
VBG venous blood gas
VC vital capacity/volume control
VCV volume control/cycled ventilation
VE minute ventilation
VE ventricular ectopics
VEGF vascular endothelial growth factor
VER visual evoked response
VF ventricular fibrillation/vocal fremitus
V/P shunt ventricular peritoneal shunt
V/Q ventilation/perfusion ratio
VR venous return/vocal resonance
VRE vancomycin-resistant enterococcus
VSD ventricular septal defect
VT tidal volume
VT ventricular tachycardia
VTE venous thromboembolism
WBC white blood count/white blood cell
WCC white cell count
WOB work of breathing
W/R ward round
SECTION Prefixes and suffixes

7 Prefix/suffix Definition Example
adeno- gland adenoma
-aemia blood hyperglycaemia
Appendix 2
-algia pain neuralgia

angio- vessel angiogram
ante- before antenatal
arteri- artery arteriosclerosis
378 arthro- joint arthroscopy
Prefix/suffix Definition Example
-asis condition homeostasis
atel- imperfect atelectasis
athero- fatty atherosclerosis
auto- self autoimmunity
baro- pressure barotrauma
bi- two, twice or double bilateral, biconcave
bili- bile bilirubin
-blast cell osteoblast
brachi- arm brachial artery
brady- slow bradycardia
carcin- cancer carcinogen
cardio- heart cardiology
carpo- wrist carpal tunnel
-centesis to puncture amniocentesis
cephal- head cephalad
cerebro- brain cerebrospinal fluid
cervic- neck cervical fracture
chol- bile cholestasis
chondro- cartilage chondromalacia
contra- against contraindicated
costo- rib costochondral
junction
cranio- skull craniotomy
cryo- cold cryotherapy
cut- skin cutaneous SECTION
cyano-
cysto-
blue
bladder
cyanosis
cystoscopy 7
cyto- cell cytoplasm
dactyl- finger dactylomegaly
Appendix 2
derm- skin dermatome

diplo- double diplopia
dors- back dorsum
dys- difficult dyspnoea
-ectasis dilatation bronchiectasis 379
ecto- outside ectoplasm
-ectomy excision appendectomy
encephalo- brain encephalitis
endo- within endochondral
entero- intestine enterotomy
erythro- red erythrocyte
extra- outside extrapyramidal
ferro- iron ferrous sulphate
gastro- stomach gastroenteritis
-genic producing iatrogenic
haem- blood haematoma
hepato- liver hepatectomy
hetero- dissimilar heterosexual
homo- same homosexual
hydro- water hydrotherapy
hyper- excessive hyperactive
hypo- deficiency hypoxaemia
iatro- medicine, doctors iatrogenic
idio- one’s own idiopathic
infra- beneath infrapatellar
inter- among interrater
intra- inside intrarater
iso- equal isotonic
-itis inflammation tendinitis
SECTION laparo- loins, abdomen laparotomy
7 lipo-
-lysis
fat
breakdown
liposuction
autolysis
macro- large macrodactyly
Appendix 2
mal- bad, abnormal malignant

-malacia softening osteomalacia
mammo- breast mammogram
mast- breast mastectomy
-megalo enlarged cardiomegaly
380
mening- membranes meninges
-morph form or shape ectomorph
myel- spinal cord, marrow myelitis
myo- muscle myotonic
naso- nose nasopharyngeal
necro- death necrosis
nephr- kidney nephritis
oculo- eyes monocular
-oid resembling marfanoid
oligo- deficiency oliguria
-oma tumour lymphoma
oophoro- ovaries oophorectomy
-opsy examine biopsy
-osis state, condition nephrosis
osseo- bone osseous
osteo- bone osteolysis
-ostomy to form an opening colostomy
oto- ear otalgia
-otomy to make a cut osteotomy
para- beside paraspinal
-penia deficiency thrombocytopenia
peri- around periosteum
phago- eat, destroy phagocytosis
pharyngo- throat pharyngoscope
-philia love of hydrophilia SECTION
phleb-
-phobia
vein
fear of
phlebitis
hydrophobia
7
-plasia formation hyperplasia
Appendix 2
-plasty moulding rhinoplasty

-plegia paralysis hemiplegia
pneum- breath, air pneumothorax
-pnoea breathing dyspnoea
poly- many polymyositis
381
pseud- false pseudoplegia
pyelo- kidney pyeloplasty
reno- kidneys renography
retro- behind retrograde
rhino- nose rhinitis
-rrhagia abnormal flow haemorrhage
salping- fallopian tube salpingostomy
sarco- flesh sarcoma
sclero- hardening scleroderma
-scopy examination endoscopy
somat- body somatic
spondyl- vertebrae spondylosis
-stasis stagnation haemostasis
steno- narrow stenosis
-stomy surgical opening colostomy
supra- above suprapubic
syn- united with syndesmosis
tachy- swift tachycardia
thoraco- chest thoracotomy
thrombo- clot thrombolytic
-tomy incision gastrostomy
trans- across transection
-trophy growth hypertrophy
uro- urine urology
SECTION vaso- vessel vasospasm
7 veno- vein venography

Appendix 2
382
National Early Warning Score (NEWS2) for the
acutely ill or deteriorating patient
APPENDIX
A clinical assessment tool used in acute and ambulance settings
to improve the detection of acute clinical illness, risk for deteriora-
tion and clinical response in adult patients, including those with
sepsis (developed for the National Health Service, UK). The NEWS2
should not be used for children (younger than 16 years of age),
pregnant women or those with spinal cord injury.
3
SECTION
7
Appendix 3
Appendix 3
384
SECTION
Physiological parameters 3 2 1 0 1 2 3
Resp rate (per min) ≤8 9–11 12–20 21–24 ≥25
SpO2 Scale 1 (%) ≤91 92–93 94–95 ≥96
SpO2 Scale 2 (%) ≤83 84–85 86–87 88–92 ≤93 93–94 95–96 ≥97
Use if target range is 88–92%, e.g. in hypercapnic on air on O2 on O2 on O2
respiratory failure, under the direction of a qualified
clinician.
Air or oxygen? O2 Air
Systolic BP (mmHg) ≤90 91–100 101–110 111–219 ≥220
Pulse (per min) ≤40 41–50 51–90 91–110 111–130 ≥131
Consciousness or new-onset confusion* Alert CVPU
Temperature ≤35.0 35.1–36.0 36.1–38.0 38.1–39.0 ≥39.1
The NEWS2 observation chart is normally colour coded, with scores of 3 coloured red, scores of 2 coloured orange, scores of 1 coloured yellow
and scores of 0 being neutral.
*AVPU is a basic assessment of consciousness that identifies the following levels of consciousness:
Alert – patient is awake
Voice – patient responds to verbal stimulation
Pain – patient responds to painful stimulus
Unresponsive – patient is completely unresponsive
On the NEWS2, the AVPU term has been amended to ACVPU, where ‘C’ represents new-onset confusion.
Clinical response to the NEWS2 trigger thresholds
NEWS Frequency of
score monitoring Clinical response
0 Minimum 12 Continue routine NEWS
hourly monitoring.
Total 1–4 Minimum 4–6 Inform registered nurse, who must
hourly assess the patient.
Registered nurse decides whether
increased frequency of monitoring
and/or escalation of care are
required.
3 in a single Minimum 1 Registered nurse to inform the
parameter hourly medical team caring for the patient,
who will review and decide whether
escalation of care is necessary.
Total 5 or Minimum 1 Registered nurse to immediately
more hourly inform the medical team caring for
Urgent the patient.
response Registered nurse to request urgent
threshold assessment by a clinician or team
with core competencies in the care
of acutely ill patients.
Clinical care in an environment with
monitoring facilities.
Total 7 or Continuous Registered nurse to immediately
more monitoring of inform the medical team caring for
Emergency vital signs the patient. This should be at least at
response Specialist Registrar level.
threshold Emergency assessment by a team SECTION
with critical care competencies,
including practitioner(s) with
advanced airway management skills.
7
Consider transfer of care to a level
Appendix 3
2 or 3 clinical care facility, i.e. HDU

or ITU.
Clinical care in an environment with
monitoring facilities.
Royal College of Physicians 2017 National Early Warning Score (NEWS)
2: Standardising the assessment of acute-illness severity in the NHS.
385
Updated report of a working party. London, RCP
Adult basic life support sequence
APPENDIX
Unresponsive and not
breathing normally
Call 999 and ask for an

ambulance
30 Chest compressions
2 Rescue breaths
4
Continue CPR 30:2
As soon as AED arrives

switch it on and follow
instructions
Figure A.1 Resuscitation Council (UK) Guidelines 2015 with

permission (www.resus.org.uk)
SECTION
7
Appendix 4
Paediatric basic life support algorithm
(healthcare professionals with a duty to respond)
Unresponsive
Shout for help
Open airway
Not breathing normally
5 Rescue breaths
No signs of life
2 Rescue breaths
Call resuscitation team

(1 min CPR first, if alone)
Figure A.2 Resuscitation Council (UK) Guidelines 2015 with

SECTION
permission (www.resus.org.uk)
7
Appendix 4
388
Index
Page numbers followed by “f” indicate figures, and “t” indicate

tables.
A Acquired torticollis, 304

Acromioclavicular ligament,
Abbreviations, 365–378 20f
Abducens nerve, 133t–135t Acromion process, 20f
Abductor digiti minimi, 12f, Acronyms, 365–378
49f Activated partial
of foot, 62 thromboplastin time,
of hand, 62 248t–250t, 360–361
Abductor hallucis, 18f, 52f, Active compression test,
62 shoulder, 101–102
Abductor pollicis brevis, 11f, Active cycle of breathing
48f, 62–63 technique, 254
Abductor pollicis longus, 12f, Acute bronchitis, 269
33f, 47f, 63 Acute coronary syndrome,
Abscess, lung, 282 226
ACA. see Anterior cerebral Acute respiratory distress
artery syndrome (ARDS),
Acalculia, 197t–202t 266
Accessory nerve, 133t–135t Acute torticollis, 304
ACE inhibitors. see ACV. see Assist/control
Angiotensin- ventilation
converting enzyme ACVPU, 384t
(ACE) inhibitors Adductor brevis, 37f, 51f, 63
Acetylcysteine, 317 trigger points, 145f–154f
Aciclovir, 317 Adductor hallucis, 63 INDEX
Acid-base disorders, 228 Adductor longus, 13f,
Acidosis, 228 36f–37f, 51f, 63
metabolic, 229t, 230 Adductor magnus, 13f–14f,
respiratory, 229t 35f–37f, 51f–52f,
Acquired immune deficiency 63–64
syndrome (AIDS), 266 trigger points, 145f–154f 389
Adductor pollicis, 64 Amyotrophic lateral sclerosis,
Adenosine, 317 284
Adhesive capsulitis, 272–273 Anastrozole, 320
Adrenaline, 317–318 Anatomical planes and
a1-adrenoceptor antagonist, directions, 2f
330 Anconeus, 12f, 33f, 64
Adson’s manoeuvre, 120 Aneurysm, 197t–202t
Adult basic life support dissecting aortic, 227
sequence, 387f Angina, 226
Afterload, heart, 237 Angiography, 306
Agnosia, 197t–202t Angiotensin-converting
Agraphia, 197t–202t enzyme (ACE)
AIDS. see Acquired immune inhibitors, 312, 323,
deficiency syndrome 331, 338, 346
Airway suction, 254–255 Angiotensin-II receptor
Akinesia, 197t–202t antagonist, 339
Alanine aminotransferase, Ankle, 61
359–360 Ankle joint, 26f
Alar ligament, 19f musculoskeletal tests,
Albumin, 244t–247t, 119–120
359–360 ranges of movement, 158,
Alendronate, 318 158t
Alexia, 197t–202t Ankylosing spondylitis,
Alkaline phosphatase, 267
359–360 Anomia, 197t–202t
Alkalosis, 228, 230 Anosmia, 197t–202t
alkalosis, 229t Anosognosia, 197t–202t
metabolic, 229t, 230 Anterior band, 21f
Allodynia, 197t–202t Anterior cerebral artery
Allopurinol, 318 (ACA), 183f, 186f,
Alteplase, 318 186t–187t
Alzheimer’s disease, Anterior commissure,
266–267 180f–181f
Amantadine, 318 Anterior cruciate ligament,
Aminoglycosides, 312, 334 25f
Amiodarone, 318–319 Anterior drawer tests
Amitriptyline, 319 ankle, 119–120
INDEX
Amlodipine, 319 knee, 115–116
Amnesia, 197t–202t shoulder, 102
Amoxicillin, 312, 319 Anterior inferior iliac spine,
Ampicillin, 312, 319–320 24f
Amusia, 197t–202t Anterior limb internal
390 Amylase, 359–360 capsule, 181f
Anterior sacroiliac ligament, Apprehension test
23f knee (Fairbank’s), 117
Anterior slide test, shoulder, shoulder, 102
102 Apraxia, 197t–202t
Anterior talofibular ligament, ARDS. see Acute respiratory
26f distress syndrome
Anterior tibiofibular ligament, Arm, upper cutaneous nerve
26f of, 47f
Anteroposterior chest X-rays, Arterial blood gases,
216 228–230, 228t
Anti-arrhythmics, Arterial blood pressure, 234
amiodarone, 318–319 Arteritis, giant cell
Anticholinergics, (temporal), 278
bronchodilators, 314 Arthrography, 306
Anticholinesterase, 329, 347 Aspartate aminotransferase,
Anticoagulants, 335 359–360
Antidepressants Aspirin, 320
fluoxetine, 333 Assist/control ventilation
tricyclic antidepressants, (ACV), 232
319 Astereognosis, 197t–202t
Antidiabetics, 332 Asthma, 267
Antidiuretic hormone, Ataxia, 197t–202t
274–275 Atenolol, 320
Antiemetics, 312, 329 Athetosis, 197t–202t
Antiepileptics, 312, 323, 333 Atlanto-axial joint, 19f
Antimanics, 338 Atlanto-occipital joint, 19f
Antimotility, 339 Atorvastatin, 320
Antimuscarinics, 343 Atracurium, 320
Antiplatelet, 326 Atrial fibrillation, 241–242,
Antipsychotics, 325, 335, 241f
347 Atropine, 321
Antiretrovirals, 312–313, Auscultation, lungs,
327, 330–331, 339 218–220
Antithyroid drug, 324 Autoimmune connective-
Antivirals, aciclovir, 317 tissue disease, 274
Aortic aneurysm, dissecting, Autonomic dysreflexia, 197
227 AVPU, 384t
INDEX
Aphasia, 197t–202t Axial spondyloarthritis, 267
Broca’s, 268, 277 Axillary artery, 29f
Wernicke’s, 295, 306 Axillary nerve, 30f, 40, 47f
Apley scarf test, 103 Axonotmesis, 267
Apley’s test, knee, 116 Azathioprine, 321
Apneustic breathing, 221 Azithromycin, 321 391
B Biochemistry, 359–360
serum, 244t–247t
Babinski reflex, 97t–98t, BiPAP. see Bilevel positive
122 airway pressure
Back muscles, 5f Bisoprolol, 322
Back pain, 170 Bisphosphonates, 318, 332
Baclofen, 321 Bleeding time, 360–361
Baker’s cyst, 268 b-blockers, 313–314, 320,
Ballismus, 197t–202t 340, 346
Base excess, base deficit, 228t, Blood gases, 228–230, 228t
230 Blood pressure, arterial, 234
Basilar artery, 188, mean, 236
188t–189t Blue bloaters, 269
Basophils, blood counts, Bone resorption inhibitor, 323
248t–250t Bones
Beclometasone, 321–322 foot, 28f
Beighton hypermobility score, hand, 27f
164–165, 164f, mineral density, DEXA, 308
165t Botulinum toxin type A, 322
Bell’s palsy, 268 Boutonnière deformity, 268
Bendroflumethiazide, 322 Brachial artery, 29f, 31f
Benzodiazepines, 313–314, Brachial plexus, 29, 29f, 45
327 schematic of, 45f
Benzylpenicillin, 312, 322 Brachialis, 8f–9f, 12f, 30f,
Bicarbonate, 359–360 32f, 50f, 65
Biceps brachii, 8f–9f, 20f, 29f, Brachioradialis, 8f, 11f–12f,
32f, 50f, 64 30f, 32f–33f, 47f, 65
Biceps brachii tendon, 17f Bradycardia
long head, 20f ECG, 240, 240f
Biceps femoris, 16f, 35f, rates, 235
38f–39f, 64 Bradykinesia, 197t–202t
Biceps femoris tendon, 25f Bradypnoea, respiratory rate,
Biceps load test I, shoulder, 237
102–103 Brain, 181f
Biceps load test II, shoulder, haemorrhage in, 192–193
103 lobe of, signs and
Bicipital aponeurosis, 11f symptoms of,
INDEX
Biguanide, 340 189–191
Bilevel positive airway Brain stem, 181f
pressure (BiPAP), Breath sounds, 218–219
233–234 abnormal, 219
Bilirubin, 244t–247t, diminished, 219
392 359–360 normal, 218–219
Breathing patterns, Capillary refill test, 224
abnormal, 220–221 Capitate, 27f
Brittle bone disease, 287–288 Capitulum, 21f
Broca’s aphasia. see Capsular patterns of joints,
Expressive aphasia 161
Bronchi Capsulitis, glenohumeral
anatomy, 209f joint, 272
chest X-rays, 217 Captopril, 323
Bronchial breath sounds, 219 Carbamazepine, 323
Bronchiectasis, 268–269 Carbonic anhydrase
Bronchiolitis, 269 inhibitors, 315
Bronchitis, 269 Cardiac glycosides, 315, 328
Bronchodilators, 314 Cardiac index, 234
Bronchospasm, chest Cardiac output, 234
auscultation, Cardiophrenic angle, 218
219–220 Carpal compression test, 109
Brown-Sequard syndrome, Carpal tunnel syndrome, 270
269 Carvedilol, 324
Brush test, 116 Cauda equina syndrome,
Budapest criteria, 166 168, 270
Budesonide, 322 Caudate nucleus, 181f–182f
Bulbar (term), 197t–202t Cefaclor, 312, 324
Bulbar palsy, 269 Cefotaxime, 312, 324
progressive, 284 Cefuroxime, 312, 324
Bumetanide, 323 Celecoxib, 324–325
Buprenorphine, 323 Central sulcus, 180f
Bursitis, 270 Central venous pressure, 235
Cephalosporins, 312, 324
Cerebellum, 181f, 193, 193t
C Cerebral hemisphere, 180f
Cerebral palsy, 270–271
Caeruloplasmin, 359–360 Cerebral perfusion pressure,
Calcanean tendon, 16f 235
Calcaneofibular ligament, 26f Cerebrovascular accident
Calcaneus, 16f, 18f, 28f (CVA), 302
Calcarine sulcus, 180f–181f Cerebrovascular lesions,
Calcitonin, 323 185–188, 185t–186t
INDEX
Calcium, 244t–247t, Certolizumab pegol, 325
359–360 Cervical spine, close packed
Calcium channel blockers, position and capsular
314, 319, 328, 342 pattern, 161t–162t
Calf muscles, 16f Charcot-Marie-Tooth disease,
Cancer, 168–169 271 393
Chest Clubfoot, 303
physiotherapy, 251–257 Clunk test, shoulder, 103
X-rays, 215–218, 215f CMV. see Controlled
analysing, 216–218 mechanical ventilation
Chest muscles, 8f Coccydynia, 272
Chest pain, 224–227 Coccygeal plexus, 46f
Cheyne-stokes breathing, Codeine phosphate, 326–327
221 Codman’s test, 103–104
Children, NEWS2 for, 383 Cognitive status, in
Chloride, 359–360 neurological
Chlorpromazine, 325 assessment, 205
Cholesterol, 359–360 Common peroneal nerve, 35f,
Chondromalacia patellae, 38f, 43, 46f
271 Community-acquired
Chorea, 197t–202t pneumonia, 291
Choreoathetosis, 270–271 Compartment syndrome,
Choroid plexus, 181f 272
Chronic bronchitis, 269 Compensation
Chronic fatigue syndrome, acid-base disorders, 229
271 issues, back pain, 171
Chronic obstructive Complex regional pain
pulmonary disease syndrome, 166, 272
(COPD), 271 Compression tests
Ciclosporin, 325 active shoulder, 101–102
Cimetidine, 325 pelvis, 111–113
Cingulate gyrus, 180f–181f wrist flexion, 111
Cingulate sulcus, 182f Computed tomography, 307
Ciprofloxacin, 325 Conduction studies, nerve,
Citalopram, 326 309
Clarithromycin, 326 Conduction system, heart,
Clarke’s sign, 117 238f
Claustrum, 182f Congenital torticollis, 304
Clavicle, 20f Conoid ligament, 20f
Claw toe, 271 Continuous positive airway
Clomipramine, 326 pressure (CPAP),
Clonidine, 326 ventilation, 233
Clonus, 97, 97t–98t, Contractility, heart, 237
INDEX
197t–202t Controlled mechanical
Clopidogrel, 326 ventilation (CMV),
Close packed positions of 231–232
joints, 161 Conversion disorder, 278
Clotting, tests, 248t–250t COPD. see Chronic obstructive
394 Clubbing, 222, 223f pulmonary disease
Copper, 359–360 D
Coracoacromial ligament,
20f Database
Coracobrachialis, 8f–9f, 20f, in neurological assessment,
29f, 50f, 65 202
Coracohumeral ligament, respiratory assessment,
20f 260
Corpus callosum, 180f–181f De Quervain’s syndrome, 274
Corticosteroids, 314, De Quervain’s tenosynovitis,
321–322, 335, 345 109
Costochondritis, 226 Decerebrate rigidity,
Costophrenic angle, 218 197t–202t
Co-trimoxazole, 327 Decorticate rigidity,
Coxa vara, 273 197t–202t
CPAP. see Continuous positive Deep medial collateral
airway pressure ligament, 25f
Crackles, chest auscultation, Deep motor branch, 49f
219 Deep peroneal nerve, 39f,
Cranial nerves, 132 43
Crank test, shoulder, 103 Deep transverse metacarpal
C-reactive protein, 244t– ligaments, 22f
247t, 359–360 Deep vein thrombophlebitis,
Creatine kinase, 244t–247t, Homan’s test, 120
359–360 Deltoid, 6f, 8f, 10f, 30f, 47f,
Creatinine, 244t–247t, 65
359–360 Dermatomes, 95, 95f
Crossed-arm adduction test, Dermatomyositis, 274, 293
shoulder, 103 Developmental coordination
Cubital tunnel syndrome, disorder, 274
273 Developmental dysplasia of
Cuboid, 28f hip, 274
Cuffs, tracheostomy tubes, DEXA. see Dual energy X-ray
258–259, 258f absorptiometry
Cuneiform, 28f Dexamethasone, 327
Cutaneous branch, 51f Diabetes insipidus, 274–275
Cutaneous distribution Diabetes mellitus, 275
dermatomes, 95, 95f Diagnosis and treatment, of
INDEX
foot, 94f back pain, 171
lower limb, 94f Diagnostic imaging, 306–309
upper limb, 93f Diaphragm, 65–66
CVA. see Cerebrovascular chest X-ray, 218
accident surface markings, 209t
Cystic fibrosis, 273 Diazepam, 327 395
Diclofenac, 328 Dual energy X-ray
Didanosine, 327 absorptiometry
Diffuse idiopathic skeletal (DEXA), 308
hyperostosis (DISH), Duchenne muscular
275 dystrophy. see
Diffuse parenchymal lung Muscular dystrophy
disease, 281 Dull percussion, chest, 221
Digoxin, 315, 328 Duloxetine, 330
Dihydrocodeine, 328 Dupuytren’s contracture,
Diltiazem, 328 276
Diplopia, 197t–202t Dysaesthesia, 197t–202t
Disco test, 119 Dysarthria, 197t–202t
Discography, 306 Dysdiadochokinesia, 122,
DISH. see Diffuse idiopathic 197t–202t
skeletal hyperostosis Dyskinesia, 197t–202t
Dissecting aortic aneurysm, Dysmetria, 197t–202t
227 Dysphagia, 197t–202t
Distal phalanx, 27f–28f Dysphasia, 197t–202t
Diuretics, 315 Dysphonia, 197t–202t
loop, 315, 333 Dyssynergia, 197t–202t
thiazide, 315
Dobutamine, 316, 329
Docusate, 328 E
Domperidone, 329
Donepezil, 329 ECG. see Electrocardiography
Dopamine, 316, 329, Ectopics, ventricular, 242
348 EDS. see Ehlers-Danlos
Dornase alfa, 329 syndrome
Dorsal cutaneous branch, EEG. see
49f Electroencephalography
Dorsal interossei Efavirenz, 330
of foot, 66 Ehlers-Danlos syndrome
of hand, 66 (EDS), 276
Dorsal radiocarpal ligament, Ejection fraction, 235
22f Elbow, 60
Dosulepin, 329 Elbow flexion test, 106
Double lumen tubes, Elbow joint, 21f
INDEX
tracheostomy, 259 musculoskeletal tests,
Doxapram, 330 106–108
Doxazosin, 330 ranges of movement, 157,
Drop arm test, shoulder, 157t
103–104 Electrocardiography (ECG),
396 Drug history, 175 237–243, 239f
Electroencephalography Expansion exercises, thoracic,
(EEG), 309 254
Electromyography, 309 Expiratory reserve volume
Elevated arm stress test, 120 (ERV), 212f, 213
Emotional factors, back pain, Exposure, chest X-rays,
171–172 216–217
Emotional state, in Expressive aphasia, 277
neurological Extensor(s), forearm, 12f
assessment, 205 trigger point, 145f–151f
Emphysema, 217, 276–277 Extensor carpi radialis brevis,
Empty can test, 106 12f, 33f, 47f, 66
Empyema, 277 trigger point, 145f–151f
Emtricitabine, 330–331 Extensor carpi radialis longus,
Enalapril, 331 12f, 32f–33f, 47f, 66
Endotracheal tube, correct trigger point, 145f–151f
position, 217 Extensor carpi ulnaris, 12f,
Enfuvirtide, 331 33f, 47f, 67
Enteropathic arthritis, 277 trigger point, 145f–151f
Entry inhibitors, 313 Extensor digiti minimi, 12f,
Eosinophils, blood counts, 47f, 67
248t–250t Extensor digitorum, 12f, 47f,
Epicondylitis 67
lateral, 303 Extensor digitorum brevis,
medial, 278 15f, 51f, 67
Epinephrine (adrenaline), Extensor digitorum longus,
317–318, 331 15f, 39f, 51f, 67
Equinovarus deformity, trigger point, 145f–155f
303 Extensor hallucis brevis, 15f
Erector spinae, 5f–6f, 66 Extensor hallucis longus, 15f,
ERV. see Expiratory reserve 51f, 67–68
volume Extensor indicis, 33f, 47f, 68
Erythrocyte sedimentation trigger point, 145f–151f
rate, 248t–250t, Extensor pollicis brevis, 12f,
360–361 33f, 47f, 68
Erythromycin, 312, 331 Extensor pollicis longus, 12f,
Estradiol, 331–332 47f, 68
Etanercept, 332 Extensor retinacula, 12f, 18f
INDEX
Etidronate, 332 External intercostal, 5f
Evoked potentials, 309 External oblique, 68
Excessive tolerance/fatigue, in External rotation lag sign,
neurological shoulder, 104
assessment, 205 External rotation recurvatum
Exenatide, 332 test, 116 397
Extrapyramidal signs, Flat-back posture, 142f, 144
197t–202t Flexor(s), forearm, 11f
Extrathoracic soft tissues, Flexor carpi radialis, 11f, 22f,
chest X-rays, 217 48f, 68
Exudate, pleural effusion, 290 Flexor carpi ulnaris, 11f–12f,
32f, 49f, 69
F Flexor digiti minimi, 49f
Flexor digiti minimi brevis
Faber’s test, 113 of foot, 69
Facial nerve, 133t–135t of hand, 69
Bell’s palsy, 268 Flexor digitorum accessorius,
Fairbank’s apprehension test, 69
117 Flexor digitorum brevis, 52f,
False negative, 136 69–70
False positive, 136 Flexor digitorum longus,
Family, back pain, 172 16f–18f, 38f, 52f, 70
Fascia covering gluteus trigger point, 145f–156f
maximus, 6f Flexor digitorum profundus,
Fascia covering gluteus 32f, 70
medius, 6f III & IV, 49f
Fasciculation, 197t–202t Flexor digitorum superficialis,
Faulty alignment, 144 11f, 48f, 70
posterior view, 143f Flexor hallucis brevis, 52f, 70
Femoral nerve, 34f, 36f, 44 Flexor hallucis longus,
Femoral nerve slump test, 17f–18f, 38f, 52f, 71
131, 132f trigger point, 145f–156f
Femoral shear test, 113 Flexor pollicis brevis, 11f, 48f,
Fenestrated tracheostomy 71
tubes, 258f, 259 Flexor pollicis longus, 11f,
Fentanyl, 332 32f, 48f, 71
Ferrous sulphate, 333 Flexor retinaculum, 11f,
Fibrinogen, 360–361 17f–18f, 48f
Fibromyalgia, 277 Flucloxacillin, 333
Fibula, head of, 39f Fluoxetine, 333
Finger-nose test, 121 Folate, 360–361
Fingers, 60 Foot
Finkelstein test, 109 bones, 28f
INDEX
First lumbrical, 48f musculoskeletal tests,
First metacarpal, 27f 119–120
First metacarpophalangeal nerves, cutaneous
joint, close packed distribution, 94f
position and capsular Forced expiration technique,
398 pattern, 161t–162t 254
Forearm muscles, 11f Gemellus inferior, 14f, 71
trigger point, 145f–151f Gemellus superior, 14f,
Forestier’s disease. see Diffuse 71–72
idiopathic skeletal Genitofemoral nerve, 34f
hyperostosis Gentamicin, 312, 334
Fornix, 181f–182f Giant cell (temporal) arteritis,
Fourth lumbrical, 49f 278
Fourth ventricle, 181f Gillet’s test, 112
Fowler’s sign, 102 Glatiramer, 334
Fractional inspired oxygen Glenohumeral joint, 20f
concentration (FiO2), adhesive capsulitis, 272
231t close packed position and
FRC. see Functional residual capsular pattern,
capacity 161t–162t
Freiberg’s disease, 278 Gliclazide, 334
Fremitus, vocal, 220 Globulins, 359–360
Froment’s sign, 109 Globus pallidus, 181f–182f
Frontal lobe, 180f, 189, Glossopharyngeal nerve,
189t–190t 133t–135t
Functional activities, in Glucose, 244t–247t,
neurological 359–360
assessment, 204–205 Gluteus maximus, 6f, 14f,
Functional neurological 35f, 52f, 72
disorder, 278 Gluteus medius, 14f, 52f, 72
Functional residual capacity trigger points, 145f–154f
(FRC), 214 Gluteus minimus, 14f, 35f,
Furosemide, 333 52f, 72
Glyceryl trinitrate (GTN),
334
G Glycopeptides, 312
Golfer’s elbow (medial
Gabapentin, 333 epicondylitis), 107,
Gaenslen’s test, 111 278
Gait, in neurological Gout, 279
assessment, 205 allopurinol for, 318
Ganglion, 278 Gower’s sign, 285
Gapping test, pelvis, 111–112 Gracilis, 13f–14f, 16f–18f,
INDEX
Gastrocnemius, 15f, 38f, 71 25f, 36f–37f, 51f,
lateral head, 16f–17f 72
medial head, 16f–18f Graphanaesthesia,
trigger point, 145f–156f 197t–202t
GBS. see Guillain-Barré Greater sciatic foramen, 23f
syndrome Greater tuberosity, 10f 399
Gross motor coordination, Heart
developmental chest X-ray, 218
coordination disorder, conduction system, 238f
274 monitoring, 234–237
Gross motor developmental Heart rate, 235
milestones, 163 Heel-shin test, 121
GTN. see Glyceryl trinitrate Hemianopia, 197t–202t
Guillain-Barré syndrome Hemiparesis, 197t–202t
(GBS), 279 Hemiplegia, 197t–202t
Heparin, 335
Hereditary motor sensory
H neuropathy (HMSN),
271
Haematocrit (packed cell Herpes zoster. see Shingles
volume), 248t–250t, High dependency care units,
360–361 charts, 261–262
Haematology, 248t–250t, Hila (lungs), 218
360–361 Hip, 61
Haemoglobin, 360–361 Hip joint, 24f
blood levels, 248t–250t close packed position and
Haemothorax, 279 capsular pattern,
Hallux valgus, 279 161t–162t
Haloperidol, 335 developmental dysplasia,
Hamate, 27f 274
Hammer toe, 279 musculoskeletal tests,
Hamstring muscles, trigger 113–115
point, 145f–155f ranges of movement, 157,
Hand 157t
bones, 27f Hippocampus, 182f
joints, 22f HMSN. see Hereditary motor
muscles, 11f sensory neuropathy
musculoskeletal tests, Hoffman reflex, 97t–98t, 121
109–111 Homan’s test, 120
Hand elevation test, 109 Homonymous (term),
Hawkins-Kennedy 197t–202t
impingement test, 104 Hoover sign, 220–221
HCO3- (bicarbonate), 228, Horizontal fissure, 208f
INDEX
228t Hormone replacement
respiratory failure, 230t therapy, 331–332
Head, 59 Hornblower’s sign, 104
Head-down position, Horner’s syndrome, 280
251–252 Hospital-acquired
400 Head of capitate, 22f pneumonia, 291
Hughston plica test, 116 Hypotension, blood pressure
Humeroulnar joint, close level, 234
packed position and Hypothyroidism, 281
capsular pattern, Hypotonia, 197t–202t
161t–162t Hypoxaemic respiratory
Humerus, 10f, 20f failure, 230
Humphrey, ligament of,
25f
Huntington’s disease, 280 I
Hydrocortisone, 335
Hydroxychloroquine, 335 Ibuprofen, 336
Hyoscine, 335–336 IC. see Inspiratory capacity
Hyperacusis, 197t–202t Ideal alignment, 139f
Hyperaesthesia, 197t–202t posterior view, 139f
Hyperalgesia, 197t–202t side view, 138f
Hypercalcaemia, 244t–247t Iliacus, 13f, 51f, 72–73
Hyperinflation, manual, Iliocostalis cervicis, 73
255–256 Iliocostalis lumborum, 5f, 73
Hyperkalaemia, 244t–247t Iliocostalis thoracis, 5f, 73
Hypermobility, 280 Iliofemoral ligament, 24f
Ehlers-Danlos syndrome, Iliohypogastric nerve, 34f
276 Ilioinguinal nerve, 34f
Hypermobility spectrum Iliolumbar ligaments, 23f
disorder, 280 Iliopsoas, trigger point,
Hypernatraemia, 244t–247t 145f–152f
Hyperparathyroidism, 280 Iliopubic eminence, 24f
Hyperreflexia, 197t–202t Iliotibial tract, 13f, 25f
Hyperresonant percussion, Ill/deteriorating patient,
chest, 221 NEWS2 for, 383
Hypertension, blood pressure Imipramine, 336
level, 234 Immunosuppressants, 321,
Hyperthyroidism, 281 325, 334
Hypertonia, 197t–202t Impingement tests, shoulder,
Hypertrophy, 197t–202t 104–105
Hyperventilation syndrome, IMV. see Intermittent
281 mandatory ventilation
Hypoaesthesia, 197t–202t Infection, 169
INDEX
Hypocalcaemia, 244t–247t Inferior extensor retinaculum,
Hypoglossal nerve, 39f
133t–135t Inferior glenohumeral
Hypokalaemia, 244t–247t ligament, 20f
Hypokinesia, 197t–202t Inferior gluteal nerve, 46f
Hyponatraemia, 244t–247t Inferior oblique, 73 401
Inflammatory bowel disease, Intracranial pressure,
enteropathic arthritis, 235–236
277 raised, chest physiotherapy
Inflammatory disease, in, 256t
169–170 Involuntary movement, in
Infraspinatus, 6f, 10f, 30f, 73 neurological
trigger point, 145f–149f assessment, 204
Infundibulum, 181f IPPB. see Intermittent positive
Inguinal ligament, 34f, 36f pressure breathing
Injury, spinal cord, NEWS2 Ipratropium, 336
for, 383 Ipratropium bromide, 314
Inotropes, 315–316 Iron (serum), 359–360
Inspiration, for chest X-rays, Iron salts, 333
216 IRV. see Inspiratory reserve
Inspiratory capacity (IC), 214 volume
Inspiratory reserve volume Ischiofemoral ligament, 24f
(IRV), 212f, 213 Isosorbide mononitrate,
Insula, 182f 336–337
Insulin, 336 Ivabradine, 337
Integrase inhibitors, 313
Intensive care units, charts,
261–262 J
Intercostal spaces, 217
Jendrassik’s manoeuvre,
Intercostales externi, 74
96–97
Intercostales interni, 74
Jerk test, shoulder, 104
Intermediate dorsal
Joint
cutaneous nerve, 39f
capsular patterns, 161
Intermittent mandatory
hypermobility assessment,
ventilation (IMV), 232
164–166
Intermittent positive pressure
position sense, 121–122
breathing (IPPB),
ranges of movement,
256–257
157–158
Internal capsule, 182f
Joint capsule, 20f
Internal oblique, 74
Joint hypermobility
International normalized
syndrome, 280
ratio (clotting time
Jones fracture, 282
measure), 248t–250t,
INDEX
360–361
Interosseous membrane, 21f, K
25f
Interspinales, 74 Kaposi’s sarcoma, 266
Interstitial lung disease, 281 Kartagener’s syndrome,
402 Intertransversarii, 74 293–294
Kinaesthesia, 197t–202t Lateral talocalcanean
Knee, 61 ligament, 26f
Knee joint, 25f Lateral ventricle, 181f
anterior drawer tests, Latissimus dorsi, 6f–10f, 75
115–116 trigger points, 145f–148f
close packed position and Lead, 359–360
capsular pattern, Leflunomide, 337–338
161t–162t Left lower lobe, 208f
musculoskeletal tests, Left upper lobe, 208f
115–119 Leg length test, 113
range of movement, 158, Leg muscles, 15f
158t Length, units, conversions,
Köhler’s disease, 282 362
Kussmaul breathing, 221 Lentiform nucleus, 181f
Kyphosis-lordosis posture, Levator scapulae, 3f, 6f, 75
140f, 144 trigger point, 145f–146f
Levatores costarum breves, 5f
Levodopa/L-dopa, 338
L Levothyroxine, 338
Lidocaine, 338
Laboratory values, normal Lift-off test, shoulder, 104
ranges, 359–360 Ligamentous instability test,
Lachman’s test, 117 fingers, 109
Lactate, 359–360 Ligaments, grading of
Lactate dehydrogenase, sprains, 162
244t–247t, 359–360 Ligamentum nuchae, 4f
Lactulose, 337 Ligamentum patellae, 13f
Lamivudine, 337 Light touch test, 122
Lansoprazole, 337 Lignocaine, 338
Lateral collateral ligament, Limbic lobe, 180f
25f Lisinopril, 338
Lateral cord, 29f, 31f Lithium, 338
Lateral cutaneous nerve of Load and shift test, shoulder,
thigh, 34f 105
Lateral epicondyle, 21f Locked-in syndrome, 282
Lateral epicondylitis, 303 Long posterior sacroiliac
Lateral intermuscular ligament, 23f
INDEX
septum, 30f Long sitting test, 112–113
Lateral intertransverse Longissimus capitis, 4f, 75
muscle, 5f Longissimus cervicis, 75
Lateral malleolus, 15f Longissimus thoracis, 5f, 75
Lateral meniscus, 25f Long-term work loss and
Lateral sulcus, 180f disability, risk for, 173 403
Longus capitis, 3f, 76 M
Longus colli, 3f, 76
lower oblique part, 3f Macrogols, 339
vertical part, 3f Macrolides antibiotic, 312,
Loop diuretics, 315, 323, 321, 326, 331
333 Magnesium, 244t–247t,
Loperamide, 339 359–360
Losartan, 339 Magnetic resonance imaging
Lower extensor retinaculum, (MRI), 307
15f Mallet finger, 282
Lower limb Mannitol, 339
anterior aspect of, 51f Manual chest clearance
muscles, 13f, 56, 56t techniques, 253
nerves, cutaneous Manual hyperinflation,
distribution, 94f 255–256
posterior aspect of, 52f Manubriosternal junction,
Lower motor neurone lesions, 208f
reflexes, 97, 98t, 99 Maraviroc, 339
Lower triangular space, 30f March fracture, 282
Lumbosacral plexus, 34f, 46, Marfan syndrome, 280,
46f 282–283
Lumbosacral trunk, 34f Mass, units, conversions,
Lumbricals 362
of foot, 76 McConnell test for
of hand, 76 chondromalacia
Lunate, 27f patellae, 117
Lungs McMurray test, 117
abscesses, 282 Mean arterial pressure, 236
bronchopulmonary Mean cell haemoglobin,
segments, 210f–211f 360–361
capacities (function tests), concentration, 360–361
213–214 Mean cell volume, 360–361
interstitial disease, 281 Medial calcanean nerve, 38f
physiotherapy techniques, Medial cord, 29f, 31f
251–257 Medial dorsal cutaneous
pneumonia, 291 nerve, 39f
surface markings, 208f Medial epicondyle, 21f,
INDEX
volumes (function tests), 30f–31f
212f, 213 Medial epicondylitis, 278
Lunotriquetral ballottement, Medial intermuscular septum,
109–110 31f
Lymphocytes, blood counts, Medial malleolus, 15f
404 248t–250t Medial meniscus, 25f
Median nerve, 29f, 31f–32f, Middle phalanx, 27f–28f
41, 48f Midodrine, 341
bias, neurodynamic test, Mid-tarsal joint, close packed
124–127 position and capsular
carpal tunnel syndrome, pattern, 161t–162t
270 Migraine, pizotifen for, 344
Mediastinal shift, 227 Milrinone, 316, 341
on X-ray, 217 Mini tracheostomy, 259–260
Medical research council Minimal volume (lungs), 213
scale, for muscle Miosis, 197t–202t
power, 99, 99t Mobile machines, chest
Medulla oblongata, 181f, X-rays taken with,
193, 193t 216
Meloxicam, 339–340 Modified Ashworth scale,
Meningitis, 283 202, 202t
Meningocele, 299 Modified Thomas test, 114
Meningococcal meningitis, Monitoring, cardiorespiratory,
283 234–237
Meralgia paraesthetica, 283 Monocytes, blood counts,
Metabolic acidosis, 229t, 230 248t–250t
Metabolic alkalosis, 229t, Monoparesis, 197t–202t
230 Monophonic wheeze,
Metacarpal 219–220
base of, 27f Monoplegia, 197t–202t
body of, 27f Morphine, 341
head of, 27f Morton’s neuroma
Metal, tracheostomy tubes, (metatarsalgia), 283
257–258 Motor activity, 163t
Metatarsal Motor neurone disease,
base of, 28f 283–284
head of, 28f MRI. see Magnetic resonance
shaft of, 28f imaging
Metformin, 340 Mucolytics, 316, 329
Methadone, 340 Multifidus, 5f, 76–77
Methotrexate, 340 Multiple myeloma, 286
Metoclopramide, 340 Multiple sclerosis, 284–285
Metoprolol, 340 Muscarinic antagonist,
INDEX
Metronidazole, 340–341 335–336
Midbrain, 181f, 192, 192t Muscle and joint range, in
Middle cerebral artery, 183f, neurological
185f assessment, 204
Middle glenohumeral Muscle innervation chart,
ligament, 20f 53–56, 53t 405
Muscle power, medical National Early Warning Score
research council scale (NEWS2)
for, 99 for acutely ill/deteriorating
Muscle relaxants, 321, patient, 383
343 clinical response to, 385,
Muscle strains, 162 385t
Muscle tests, 176 use for, 383
Muscles Navicular, 28f
alphabetical listing of, Neck, 59
62–88 muscles, 3f
anatomy, 3f passive flexion (test), 131,
listed by function, 59–62 131f
Muscular dystrophy, 285 Neer impingement test,
Muscular pain, 225–226 shoulder, 105
Musculocutaneous nerve, Negative predictive value
29f, 31f, 50f (NPV), 137
Musculoskeletal assessment, Nerve conduction studies,
174–176 309
Musculoskeletal nerve, 40 Nerve pathways, 29–44
Musculoskeletal tests, Neuralgia, 226
101–120 Neuroanatomy, 180
Myalgic encephalomyelitis, Neurodynamic tests,
285 124–131, 125f–128f
Myasthenia gravis, 286 Neurological assessment,
Myelography, 306 202–205
Myeloma, 286 Neurological terms, 197–202
Myelomeningocele, 299 Neurological tests, 121–123,
Myocardial infarction, 226 176
Myoclonus, 197t–202t Neurology, 179–206
Myositis ossificans, 286 Neuromuscular blocker, 320
Myotomes, 96, 96t Neuromusculoskeletal
Myotonia, 197t–202t anatomy, 1–89
Myotonic dystrophy. see Neuropraxia, 286–287
Muscular dystrophy Neurotmesis, 287
Neurotoxin, 322
Neutrophils, blood counts,
INDEX
N 248t–250t
Nevirapine, 342
Nail-fold angle, 222 Nicorandil, 342
Naloxone, 341 Nifedipine, 342
Naproxen, 341 Nimodipine, 342
Nasal cannula, FiO2 levels, NIV. see Noninvasive
406 231 ventilation
Noninvasive ventilation Obturator internus, 35f, 77
(NIV), 233 Obturator internus tendon,
Non-nucleoside reverse 14f
transcriptase Obturator nerve, 34f, 37f, 44
inhibitors, 313, 330, Occipital lobe, 180f, 191,
342 191t
Nonsteroidal Oculomotor nerve,
antiinflammatory 133t–135t
drugs (NSAIDs), 316, Oesophageal pain, 227
320, 324–325, 336, Oestrogens, 331–332
339–341 Olecranon, 12f, 21f
Noradrenaline, 342 Olfactory cortex, 182f–183f
Normal ranges, laboratory Olfactory nerve, 133t–135t
values, 359–360 Omeprazole, 343
NPV. see Negative predictive Ondansetron, 343
value Opioids, 316, 323, 326–328,
NSAIDs. see Nonsteroidal 332, 343
antiinflammatory Opponens digiti minimi, 49f,
drugs 77
Nucleoside reverse Opponens pollicis, 48f, 77
transcriptase Optic chiasma, 181f
inhibitors, 313, Optic nerve, 133t–135t
330–331, 337 Organic nitrate, 334,
Nystagmus, 197t–202t 336–337
Orphenadrine, 343
Osgood-Schlatter’s disease,
O 287
Osmolality, serum, 359–360
Ober’s sign, 113 Osmotic diuretics, 315, 339
Objective examination, Osmotic laxative, 337, 339
respiratory Osteoarthritis, 287
assessment, 261–262 Osteochondritis, 287
Oblique band, 21f Osteochondritis dissecans,
Oblique fissure, 208f 287
Obliquus capitis inferior, 4f Osteogenesis imperfecta,
Obliquus capitis superior, 4f 287–288
Obliquus externus, 6f Osteomalacia, 288
INDEX
Obliquus internus, 6f–7f Osteomyelitis, 288
O’Brien test, 101–102 Osteopenia, DEXA, 308
Obstructive sleep apnoea, Osteoporosis, 288
298–299 DEXA, 308
Obturator externus, 37f, 77 Overactive thyroid, 281
Obturator foramen, 23f Oxybutynin, 343 407
Oxygen Parathyroid hormone, 280
arterial tension (PaO2), Paresis, 197t–202t
228t Parietal lobe, 180f, 190,
fractional inspired 190t–191t
concentration (FiO2), Parietooccipital sulcus, 180f
231t Parkinson’s disease, 289
saturation (SpO2), 236 Paroxetine, 344
therapy, FiO2 levels, 231 Passive neck flexion test, 131,
131f
Past medical history, 175
P Patella apprehension test,
117
P wave (of ECG), 238 Patellar ligament, 15f, 25f
Packed cell volume, 248t– Patellofemoral grind test, 117
250t, 360–361 Pathology, 265–309
PaCO2 (arterial carbon Patient, ill/deteriorating,
dioxide tension), 228, NEWS2 for, 383
228t Patrick’s test, 113
respiratory failure, 230t Patterns of referred pain, of
Paediatric basic life support visceral origin, 167,
algorithm, 388 167f
Paget’s disease, 288–289 Patte’s test, 105
Palmar aponeurosis, 11f PCA. see Posterior cerebral
Palmar branch, 48f artery
Palmar brevis, 11f Pectineus, 13f, 36f, 78
Palmar cutaneous branch, Pectoralis major, 78
49f trigger point, 145f–147f
Palmar interossei, 78 Pectoralis minor, 9f, 29f, 78
Palmar radiocarpal ligament, trigger point, 145f–147f
22f Pellegrini-Stieda syndrome,
Palmaris longus, 11f, 48f, 78 289
Palpation, 176 Pelvis, musculoskeletal tests,
Pancuronium, 343 111–113
PaO2 (arterial oxygen Penicillins, 312, 322
tension), 228t Peptide hormone, 336
Paracentral lobule, 180f Percussion
Paracetamol, 344 chest clearance, 253t–254t
INDEX
Paradoxical breathing, 220 chest examination, 221
Paraesthesia, 197t–202t dull, 221
Parameters, physiological, hyperresonant, 221
384t resonant, 221
Paraphasia, 197t–202t Pericarditis (pericardium),
408 Paraplegia, 197t–202t 227
Pericardium (pericarditis), Pineal gland, 181f
227 Pink puffers, 276–277
Peripheral nerve injury. see Piriformis, 14f, 35f, 52f
Axonotmesis; trigger points, 145f–154f
Neuropraxia; Piriformis syndrome, 290
Neurotmesis Piroxicam, 344
Peripheral nerve motor Pisiform, 11f, 22f, 27f
innervation, 47 Pisohamate ligament, 22f
Peripheral nerves, cutaneous Pisometacarpal ligament, 22f
distribution Pituitary gland, 181f
foot, 94f Pivot shift test, 118
lower limb, 94f Pizotifen, 344
upper limb, 93f Plain radiography, 306
Peroneus brevis, 16f–17f, 39f, Planes, cardinal, 2f
51f, 79 Plantar calcaneonavicular,
trigger point, 145f–155f 26f
Peroneus longus, 15f–17f, Plantar fasciitis, 290
38f–39f, 51f, 79 Plantar reflex, 97t–98t, 122
trigger point, 145f–155f Plantaris, 16f–17f, 80
Peroneus tertius, 15f, 51f, 79 Plastic, tracheostomy tubes,
Perthes’ disease, 289–290 257–258
Pes anserinus, 18f, 36f Platelet counts, 248t–250t,
PH of blood, 228, 228t 360–361
respiratory failure, 230t Pleura (pleurisy), 224
Phalen’s test, 110 Pleural effusion, 290
Pharmacology, 311–355 Pleural rub, 220
Phenytoin, 344 Pleurisy, 224, 290–291
Phosphate, 244t–247t, Pneumonia, 291
359–360 Pneumothorax, 225,
Phosphodiesterase inhibitors, 291–292
316, 341 Poliomyelitis, 292
Photophobia, 197t–202t postpolio syndrome, 293
Physical examination, Polyarteritis nodosa, 292
175–176 Polymyalgia rheumatica,
in neurological assessment, 292–293
203–205 Polymyositis, 293
Physiological parameters, Polyphonic wheeze, 219–220
INDEX
384t Pons, 181f–182f, 193, 193t
Physiotherapy, techniques, Popliteal artery, 38f
251–257 Popliteal bursa, Baker’s cyst,
Piedallu’s sign, 112 268
Pin prick test, 122 Popliteus, 14f, 17f, 80
Pinch grip test, 107–108 Popliteus tendon, 25f 409
Position sense, joints, Postural (orthostatic)
121–122 tachycardia syndrome
Positioning of patient (PoTS), 293
lung physiotherapy, Posture and balance, in
251 neurological
raised intracranial assessment, 203
pressure, 235–236 Potassium, 244t–247t,
Positive predictive value 359–360
(PPV), 136–137 Potassium-sparing diuretics,
Postcentral gyrus, 180f 315
Postcentral sulcus, 180f PPV. see Positive predictive
Posterior band, 21f value
Posterior cerebral artery PR interval (of ECG), 239
(PCA), 183f, 187, Pramipexole, 345
187f, 188t Pravastatin, 345
Posterior cruciate ligament, Precentral gyrus, 180f
25f Precentral sulcus, 180f
Posterior drawer tests Prednisolone, 345
knee, 118 Prefixes and suffixes,
shoulder, 105 378–382
Posterior femoral cutaneous Pregnant women, NEWS2 for,
nerve, 46f 383
Posterior interosseous nerve, Preload, heart, 237
33f, 41–42 Premature ventricular
Posterior limb internal contractions, 242,
capsule, 181f 242f
Posterior longitudinal Preoccipital notch, 180f
ligament, 19f Prescription abbreviations,
Posterior sag sign, 118 354, 354t
Posterior talocalcanean Pressure, units, conversions,
ligament, 26f 363, 363t
Posterior talofibular ligament, Pressure-cycled SIMV, 232
26f Pressure support (PS),
Posterior tibiotalar ligament, ventilation, 232–233
26f Primary auditory cortex,
Posteroanterior chest X-rays, 182f
216 Primary ciliary dyskinesia,
INDEX
Posterolateral pivot shift test, 293–294
108 Primary lateral sclerosis, 284
Postpolio syndrome, Primary motor cortex,
293 182f–183f
Postural drainage, 251–253, Primary somatic sensory
410 252f cortex, 182f–183f
Primary spontaneous Pulmonary oedema,
pneumothorax, 291 294–295
Primary visual cortex, Pulses
182f–183f heart rate, 235
Progressive bulbar palsy, 284 locations of, 100, 100f,
Progressive muscle atrophy, 101t
284 Pursed-lip breathing, 220
Pronator quadratus, 48f, 80 Putamen, 181f–182f, 192,
Pronator teres, 11f, 48f, 80 192t
trigger point, 145f–152f Pyramidal signs, 197t–202t
Propranolol, 346
Prosopagnosia, 197t–202t
Protease inhibitors, 313, Q
347
QRS complex (of ECG), 239
Protein, total serum,
QT interval (of ECG), 239
359–360
Quadrangular space, 10f, 30f
Prothrombin time, 248t–
Quadrant test, 114
250t, 360–361
Quadrantanopia, 197t–202t
Proton-pump inhibitor, 337,
Quadratus femoris, 14f, 35f,
343
81
Provocation elevation test,
Quadratus lumborum, 5f, 81
120–121
trigger points, 145f–153f
Proximal phalanx, 27f–28f
Quadriplegia, 197t–202t
base of, 28f
Quinine, 346
Prozac (fluoxetine), 333
PS. see Pressure support
Pseudobulbar palsy, 294 R
Psoas major, 13f, 80
Psoas minor, 80–81 Radial artery, 32f
Psoriatic arthritis, 294 Radial collateral ligament,
Psychosocial yellow flags, 21f–22f
170–173 Radial nerve, 30f, 33f,
Ptosis, 197t–202t 41–42, 47f
Pubofemoral ligament, 24f Radial nerve bias,
Pudendal nerve, 46f neurodynamic test,
Pulmonary artery occlusion 127, 127f
pressure, 236–237 Radiocarpal joint, close
INDEX
Pulmonary artery pressure, packed position and
236 capsular pattern,
Pulmonary artery wedge 161t–162t
pressure, 236–237 Radionuclide scanning, 308
Pulmonary embolus, Radius, 12f, 22f, 27f
224–225, 294 Raloxifene, 346 411
Ramipril, 346 Respiratory tract, 207–263
Ranges of movement anatomy illustrations,
joints, 157–158 208
segmental, 159 assessment, 260–263
Rapidly alternating Resuscitation Council (UK)
movement, 122 Guidelines 2015,
Raynaud’s phenomenon, 295 387f–388f
Reactive arthritis, 295 Reticulocytes, 360–361
Reagan’s test, 109–110 Retrolisthesis, 301
Rebreathing bag, manual Reverse Phalen’s test, 110
hyperinflation, 255 Reverse transcriptase
Receptive aphasia, 295 inhibitors, 313
Rectus abdominis, 7f, 81 Rheumatoid arthritis, 296
Rectus capitis anterior, 3f, 81 Rhomboid major, 82
Rectus capitis lateralis, 3f, 81 Rhomboid minor, 82
Rectus capitis posterior major, Rhomboideus, trigger point,
4f, 81–82 145f–151f
Rectus capitis posterior minor, Rhomboideus major, 6f
4f Rhomboideus minor, 6f
Rectus femoris, 13f, 36f, 51f, Rib fracture, 225
82 Rickets. see Osteomalacia
Red blood cell counts, Rifampicin, 347
248t–250t, 360–361 Right hemisphere language
Red flags, spine, 168–170 disorders, 295–296
Reflexes, 96–97, 96t–98t Right lower lobe, 208f
in neurological assessment, Right middle lobe, 208f
204 Right upper lobe, 208f
Reinforcement manoeuvres, Rigidity, 197t–202t
reflexes, 96–97 Risperidone, 347
Reiter’s syndrome. see Ritonavir, 347
Reactive arthritis Rivastigmine, 347
Repaglinide, 346–347 Romberg’s test, 123
Residual volume (RV), 212f, Ropinirole, 347
213 Ross test, 120
Resonance, vocal, chest Rotatores, 82
auscultation, 220 RV. see Residual volume
Resonant percussion, chest,
INDEX
221
Respiratory acidosis, 229t S
Respiratory alkalosis, 229t
Respiratory failure, 230 Sacral plexus, 46f
Respiratory rate, 237 Sacroiliac joint, 23f
412 Respiratory stimulant, 330 Sacrospinous ligament, 23f
Sacrotuberous ligament, 14f, Semitendinosus, 14f, 16f–18f,
23f 25f, 35f, 38f, 52f, 84
Salbutamol, 314, 348 Senna, 348
Salmeterol, 348 Sensitivity, 136
Saphenous nerve, 36f Sensory, in neurological
Saquinavir, 348 assessment, 204
Sarcoidosis, 296 Septic arthritis, 297
Sartorius, 13f, 16f–18f, 25f, Seronegative
36f, 82–83 spondyloarthropathy,
Scaleni, trigger point, 300–301
145f–147f Serotonin-noradrenaline
Scalenus anterior, 3f, 83 reuptake inhibitor,
Scalenus medius, 3f, 83 330
Scalenus posterior, 3f, 83 Serratus anterior, 3f, 6f,
Scaphoid, 27f 8f–9f, 84
Scaphoid shift test, 110 trigger point, 145f–147f
Scapula, 59 Serratus posterior inferior, 6f
muscles, 10f Sertraline, 348
Schamroth’s test, 222, 223f Sesamoid bone, 28f
Scheuermann’s disease, Sever’s disease, 297
296–297 Shaking, for chest clearance,
Sciatic nerve, 35f, 42, 46f 253t–254t
Scleroderma, 303 Shear test, 112
Second lumbrical, 11f, 48f Shingles, 297
Secondary spontaneous Short posterior sacroiliac
pneumothorax, 292 ligament, 23f
Segmental movement, ranges, Shoulder, 59–60
159 adhesive capsulitis,
Segments, lungs, 210f–211f 272–273
Selective oestrogen receptor musculoskeletal tests,
modulators, raloxifene, 101–106
346 ranges of movement, 157,
Selective serotonin reuptake 157t
inhibitor, 326, 333, Sickle-cell anaemia, 298
344 Sickle-cell disease, 298
Semimembranosus, 14f, SIMV. see Synchronized
16f–18f, 25f, 38f, 52f, intermittent
INDEX
83 mandatory ventilation
Semispinalis capitis, 4f, 6f, 83 Simvastatin, 349
trigger points, 145f Sinding-Larsen-Johansson
Semispinalis cervicis, 4f, 84 disease, 298
trigger points, 145f Single lumen tubes,
Semispinalis thoracis, 84 tracheostomy, 259 413
Sinus node inhibitor, 337 Spinous process of C2, 4f
Sinus rhythm, 240, 240f Splenium, 181f
Sitting flexion, 112 Splenius capitis, 3f–4f, 6f, 85
Situs inversus, 293–294 trigger points, 145f–146f
Sjögren’s syndrome, 298 Splenius cervicis, 85
Sleep apnoea, 298–299 trigger points, 145f–146f
Slocum tests, 118–119 Spondyloarthritis, 300–301
Slump test, 129–130, 129f Spondyloarthropathy,
SMA. see Spinal muscular seronegative,
atrophies 300–301
Social history, 175 Spondylolisthesis, 301
Sodium, 244t–247t, Spondylolysis, 301
359–360 Spondylosis, 301
Sodium valproate, 349 Sputum, 221, 221t–222t
Soft-tissue ischaemia, 272 ST segment (of ECG), 239
Soleus, 15f–18f, 38f, 52f, 84 Standing flexion, 112
trigger point, 145f–156f Statins, 320, 345
Spasmodic torticollis, 304 Stereognosis, 197t–202t
Spasticity, 197t–202t Sternocleidomastoid, 6f,
Specificity, 136 85
Speed’s test, shoulder, cranial nerve test,
105–106 133t–135t
Spina bifida, 299 trigger points, 145f
Spina bifida cystica, 299 Stimulant laxative, 328
Spina bifida occulta, 299 Straight leg raise test,
Spinal cord, 181f 130–131, 130f
Spinal cord injury Streptokinase, 349
functional implications of, Stroke, 302
194t–196t Stroke volume, 237
NEWS2 for, 383 Subacromial bursa, 20f
Spinal cord tracts Subclavius, 9f
ascending, 184f, 184t Subcostal nerve, 34f
descending, 184f, 184t Subjective examination
Spinal muscular atrophies in neurological assessment,
(SMA), 300 203
Spinal stenosis, 300 respiratory assessment,
Spinalis, 84–85 260–261
INDEX
Spinalis thoracis, 5f Suboccipital trigger points,
Spine 145f
ankylosing spondylitis, 267 Subscapularis, 9f, 20f,
ranges of segmental 85
movement, 159f–160f trigger point, 145f–150f
414 red flags, 168–170 Substantia nigra, 182f
Subtalar joint, close packed Swan-Ganz catheter,
position and capsular 236–237
pattern, 161t–162t Swan neck deformity, 302
Subthalamic nucleus, 182f Sway-back posture, 141f, 144
Suction, airway, 254–255 Sweater finger sign, 110
Suffixes and prefixes, Sympathomimetics
378–382 adrenaline, 317–318
Sulcus sign, 106 bronchodilators, 314
Sulfasalazine, 349 inotropic, 329
Sulphonylurea, 334 Synchronized intermittent
Sumatriptan, 349 mandatory ventilation
Superficial branch, 33f (SIMV), 232
Superficial medial collateral Syringomyelia, 302
ligament, 25f Systemic lupus
Superficial peroneal nerve, erythematosus,
39f, 43 302–303
Superficial radial nerve, Systemic sclerosis, 303
32f Systemic vascular resistance,
Superficial terminal branches, 237
49f
Superior extensor
retinaculum, 39f T
Superior glenohumeral
ligament, 20f T wave (of ECG), 239
Superior gluteal nerve, 46f Tachycardia
Superior oblique, 85–86 ECG, 241, 241f
Superior peroneal heart rate, 235
retinaculum, 17f Tachypnoea, respiratory rate,
Supinator, 32f–33f, 47f, 86 237
trigger point, 145f–152f Talar tilt (test), 119–120
Supine to sit test, 112–113 Talipes calcaneovalgus, 303
Supplementary motor cortex, Talipes equinovarus, 303
182f–183f Talocrural joint, close packed
Suprascapular nerve, 30f position and capsular
Supraspinatus, 6f, 10f, 20f, pattern, 161t–162t
30f, 86 Talus, 28f
trigger point, 145f–149f Tamoxifen, 349–350
INDEX
Supraspinatus tendon tests, Tamsulosin, 350
104–106 Tarsal tunnel syndrome, 303
Sural nerve, 38f Temazepam, 350
Surface markings, lungs, Temperature sensation,
208f testing, 123
Surgical emphysema, 217 Temporal gyri, 180f 415
Temporal lobe, 180f, 191, Thoracic expansion exercises,
191t 254
Temporal sulci, 180f Thoracic outlet syndrome,
Temporomandibular joint, 120, 304
close packed position Thoracolumbar fascia, 6f
and capsular pattern, Thumb, 61
161t–162t Thumb grind test, 110–111
Tendo calcaneus, 18f Thyroid gland, disorders, 281
Tendon reflexes, deep, 96–97 Thyroid hormone, 338
Tennis elbow (lateral Thyrotoxicosis, 281
epicondylitis), Tibia, 18f
106–107, 303 Tibial nerve, 35f, 38f, 42–43,
Tenofovir, 350 46f
Tenography, 306 Tibialis anterior, 15f, 18f, 39f,
Tenosynovitis, 304 87
de Quervain’s, 109 trigger points, 145f–155f
Tension pneumothorax, Tibialis posterior, 17f–18f,
291–292 38f, 52f, 87
Tensor fasciae latae, 13f, 35f, trigger point, 145f–156f
52f, 86 Tibiocalcaneal ligament, 26f
trigger points, 145f–154f Tibionavicular ligament, 26f
Terbutaline, 350 Tibolone, 351
Teres major, 6f, 9f–10f, 30f, Tidal volume (VT), 212f, 213
86 Tietze syndrome, 226
trigger point, 145f–150f Timolol, 351
Teres minor, 6f, 10f, 30f, 47f, Tinel’s sign
86 elbow, 108
trigger point, 145f–150f wrist, 110
Teriparatide, 350–351 Tizanidine, 352
Tetracyclines, 312, 351 TLC. see Total lung capacity
Tetraparesis, 197t–202t Toes, 62
Tetraplegia, 197t–202t Tolterodine, 352
TFCC load test, 111 Tone, in neurological
Thalamus, 180f–182f, 192, assessment, 204
192t Torticollis, 304
Theophylline, 351 Total lung capacity (TLC),
Thessaly test, 119 214
INDEX
Thiazide diuretics, 315, 322 Touch (light) test, 122
Thigh muscles, 13f Trachea
Thiopental, 351 bifurcation, surface
Third ventricle, 181f–182f markings, 209t
Thomas test, 114 X-ray, 217
416 Thompson’s test, 120 Tracheitis, 225
Tracheostomies, 257–260 True negative, 136
Tramadol, 352 True positive, 136
Transferrin, 359–360 Trunk, 59
Transient ischaemic attack, Trunk muscles, 6f
302 T-scores, bone mineral
Transudate, pleural effusion, density, 308
290 Tubercle of trapezium, 22f
Transverse humeral ligament, Tuberculosis, 305–306
20f Tumours, 225
Transverse ligament, 25f Two-point discrimination,
Transverse myelitis, 305 123
Transverse scapular ligament,
20f
Transversus abdominis, 87 U
Trapezium, 27f
Trapezius, 6f, 87–88 U wave (of ECG), 240
trigger points, 145f–146f Ulna, 22f, 27f
Trapezoid, 27f Ulnar artery, 32f
Trapezoid ligament, 20f Ulnar collateral ligament, 22f
Trastuzumab, 352 Ulnar nerve, 29f, 31f–32f, 40,
Traumatic pneumothorax, 49f
292 bias, upper limb
Trazodone, 352 neurodynamic test,
Trendelenburg’s sign, 114 128–129, 128f
Triangular fibrocartilage cubital tunnel syndrome,
complex load test, 111 273
Triangular space, 10f Ultrasound, 308–309
Triceps brachii, 8f, 12f, 30f, Uncuffed, tracheostomy
88 tubes, 258–259
long head, 8f, 20f Uncus, 180f
medial head, 8f Underactive thyroid, 281
Triceps tendon, 30f Units, 361–363
Tricyclic antidepressants, Upper cutaneous nerve, of
319, 326, 329, 336 arm, 47f
Trigeminal nerve, 133t–135t Upper extensor retinaculum,
Trigeminal neuralgia, 305 15f
Trigger finger, 305 Upper limb, 53
INDEX
Trigger points, sites, 145 muscles, 8f
Triglycerides, 359–360 nerves
Trihexyphenidyl, 352 cutaneous distribution,
Triquetral, 27f 93f
Trochlear nerve, 133t–135t neurodynamic tests,
Trochlear notch, 21f 124–131, 125f–128f 417
Upper motor neurone lesions, Vibration sense, 123
reflexes, 97, 98t, 99, Vibrations, for chest
122 clearance, 253t–254t
Urate, 359–360 Visual association cortex,
Urea, 244t–247t, 359–360 183f
Uric acid, 359–360 Vital capacity (VC), of lungs,
214
Vitamin A, 359–360
V Vitamin C, 359–360
Voice sounds, chest
Vagus nerve, 133t–135t auscultation, 220
Valgus stress test Volkmann’s ischaemic
elbow, 108 contracture, 272
knee, 115 Volume, units, conversions,
Valsartan, 353 362
Vancomycin, 312, 353 Volume-cycled SIMV, 232
Varus stress test Voluntary movement, in
elbow, 108 neurological
knee, 115 assessment, 203
Vascular resistance, systemic,
237
Vascular tests, 120–121 W
Vastus intermedius, 51f, 88
Vastus lateralis, 13f–14f, 36f, Warfarin, 353
51f, 88 Watson’s test, 110
Vastus medialis, 13f, 18f, 36f, Weber-Barstow Manoeuvre,
51f, 88 114–115
VC. see Vital capacity Weight, units, conversions,
Venlafaxine, 353 361–362, 361t–362t
Ventilation, mechanical, Weight-bearing/rotation
231–234 meniscal test,
Ventilatory failure, 230 119
Ventricular ectopics, 242, Werdnig-Hoffman disease,
242f 300
Ventricular fibrillation, 243, Wernicke’s aphasia. see
243f Receptive aphasia
Ventricular tachycardia, Wheeze, chest auscultation,
INDEX
242–243, 243f 219–220
Verapamil, 353 White blood cell counts,
Vertebral artery, 4f, 188, 248t–250t, 360–361
188t–189t Window sign, 222
Vestibulocochlear nerve, Wohlfart-Kugelberg-Welander
418 133t–135t disease, 300
Women, pregnant, NEWS2 Y
for, 383
Work, back pain, 172–173 Yergason’s test, 106
Wrisberg, ligament of, 25f
Wrist, 60
Wrist joint, 22f Z
musculoskeletal tests,
109–111 Zidovudine, 354
ranges of movement, 157, Zinc, 359–360
157t Zopiclone, 354
X
X-rays, 306
chest, 215–218, 215f
analysing, 216–218
INDEX
419
Normal values
Arterial blood Venous blood
analysis Reference ranges analysis Reference ranges
pH 7.35–7.45 pH 7.31–7.41
PaO2 10.7–13.3 kPa/80–100 mmHg PO2 5.0–5.6 kPa/37–42 mmHg
PaCO2 4.7–6.0 kPa/35–45 mmHg PCO2 5.6–6.7 kPa/42–50 mmHg
HCO3− 22–26 mmol/L
Base excess –2 to +2
P/F ratio (PaO2 ÷ FiO2)

In kPa In mmHg
Normal >40 >300
Acute lung injury <40 <300
Acute respiratory <26 <200
distress syndrome
Urine
Urine output 1 mL/kg/hour
Age group Heart rate – mean (range) Respiratory rate Blood pressure
Preterm 150 (100–200) 40–60 39–59/16–36
Newborn 140 (80–200) 30–50 50–70/25–45
<2 years 130 (100–190) 20–40 87–105/53–66
>2 years 80 (60–140) 20–40 95–105/53–66
>6 years 75 (60–90) 15–30 97–112/57–71
Adults 70 (50–100) 12–16 95–140/60–90
Cardiorespiratory values
Cardiac index CI 2.5–4 L/min/m2
Cardiac output CO 4–8 L/min
Central venous pressure CVP 3–15 cmH2O
Cerebral perfusion pressure CPP >70 mmHg
Intracranial pressure ICP 0–10 mmHg
Mean arterial pressure MAP 80–100 mmHg
Pulmonary artery pressure PAP 15–25/8–15 mmHg
Pulmonary artery occlusion pressure PAWP 6–12 mmHg
Stroke volume SV 60–130 mL/beat
Systemic vascular resistance SVR 800–1400 dyn ● s ● cm–5
The Glasgow Coma Scale

Eye opening Best verbal response Best motor response
Spontaneous 4 Orientated 5 Obeys commands 6
To sound 3 Confused 4 Localising 5
To pressure 2 Words 3 Normal flexion 4
None 1 Sounds 2 Abnormal flexion 3
None 1 Extension 2
None 1
Total score 3–15

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The Physiotherapist’s Pocketbook

Content Strategist: Poppy Garraway

Karen Kenyon MRes, BSc (Hons),

Jonathan Kenyon MSc, PGCert (NMP),

Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2018

First edition 2004

No part of this publication may be reproduced or transmitted in any form or by

British Library Cataloguing in Publication Data

Library of Congress Cataloging in Publication Data

Last digit is the print number: 9 8 7 6 5 4 3 2 1

SECTION 2 Neuromusculoskeletal Assessment 91

Psychosocial yellow flags 170

Scalenus medius Scalenus medius

Semispinalis Vertebral Splenius

Transversus, origin Iliocostalis

Figure 1.5 Superficial muscles of the back, neck and trunk.

Clavicular part of pectoralis major

Long head of biceps

Short head of biceps

Teres minor Supraspinatus Deltoid (cut)

Figure 1.10 Superficial flexors of the left forearm.

Flexor carpi ulnaris

Figure 1.11 Superficial extensors of the right forearm.

Vastus lateralis Adductor magnus

Figure 1.12 Superficial muscles of the anterior right thigh.

Gracilis Biceps femoris,

Tibialis anterior Gastrocnemius

Upper extensor Medial malleolus

Figure 1.14 Muscles of the anterior right leg.

Semimembranosus Biceps femoris

Figure 1.15 Superficial muscles of the posterior right calf.

Flexor digitorum Peroneus longus

Flexor retinaculum Superior peroneal

Figure 1.16 Deep muscles of the posterior right calf.

Pes anserinus Gastrocnemius

Extensor retinacula Tibialis posterior

Abductor hallucis Flexor retinaculum

Acromioclavicular Coracoacromial Trapezoid Conoid

Transverse Biceps (short head)

Pisiform Radial collateral

Posterior Lateral meniscus

Posterior Anterior tibiofibular

Triceps tendon Brachioradialis

Figure 1.30 Musculocutaneous, median and ulnar nerves.

Extensor carpi Ulnar artery

Figure 1.31 Ulnar and median nerves.

Abductor pollicis longus

Extensor pollicis brevis

Figure 1.32 Radial nerve.

nerve of thigh L4 Genitofemoral nerve

Anterior branch Obturator externus

Figure 1.36 Obturator nerve.

1 Semimembranosus Biceps femoris

Figure 1.37 Tibial and common peroneal nerves.

Medial dorsal Lateral branch

Figure 1.38 Superficial and deep peroneal nerves.

1 • Descends laterally posterior to axillary artery and anterior

together with posterior circumflex humeral vessels via

• Enters posterior compartment between two heads of