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• With exercise the heart rate rises, stroke volume rises (then plateaus), cardiac output and systolic BP rise, systemic vascular resistance falls, ventilation increases, and the exercising muscle extracts more oxygen. Long-term training shifts the curve: lower resting HR, higher stroke volume, and a lower submaximal HR at the same workload.

KEYKey numbers the NPTE reuses

• 1 MET = 3.5 ml oxygen per kg per min (resting oxygen consumption); activity levels are graded in METs (e.g. light below 3, moderate 3-6, vigorous above 6).
• Rate-pressure product (RPP) = HR x systolic BP; it estimates myocardial oxygen demand. Keep RPP controlled with acute exertional angina or high-risk cardiac patients.
• Karvonen target HR = (max HR - resting HR) x intensity + resting HR; commonly 60-85% of heart-rate reserve.
• Maximum heart rate estimate = 220 - age.
• Borg RPE 6-20: 13 = somewhat hard, 15 = hard, 17 = very hard. Borg CR10: 5-6 is usually a vigorous level.
• Normal BP response: systolic rises roughly 10 mmHg per MET, diastolic stays stable. Failure to rise, or an exercise drop in systolic BP, is a red flag to stop.

Borg scales quick reference

• Vital-sign monitoring during exercise: HR (radial/apical or telemetry), BP (auscultatory, same arm each time), SpO2 (goal 90-94% general, 88-92% in COPD), and symptoms (dyspnea, chest pain, dizziness). The PT should know when to STOP and re-evaluate.

KEYStop signs for exercise (any ONE is enough)

• Angina or chest tightness (stop, rest, help the patient sit down, use prescribed nitroglycerin per protocol, get help if not relieved in ~5 min).
• Severe dyspnea disproportionate to effort, or SpO2 dropping below ~88%.
• Dizziness, lightheadedness, near-syncope, or feeling faint.
• Systolic BP that drops or fails to rise with increasing workload.
• New ECG changes (ST depression/elevation) or significant arrhythmia — on telemetry this is a hard stop.
• Pallor, cyanosis, confusion, or a sudden change in mental status.
• Patient asks to stop. Respect it.

KEYContraindications to exercise testing / programmed aerobic exercise

• Acute myocardial infarction within the first ~2-5 days (per supervising physician), unstable angina at rest or rapid crescendo.
• Severe aortic stenosis (syncope with exertion is classic).
• Acute myocarditis or pericarditis, acute pulmonary embolism or deep vein thrombosis, acute aortic dissection.
• Uncontrolled hypertension (very high resting BP per physician), or resting tachycardia with unknown cause.
• Fever, acute infection, or within a few hours of a recent high-intensity exercise bout for some tests.
• The key PT phrase: red flags and absolute contraindications belong to the physician to clear; the PT implements and monitors.

Rhythms PTs should recognize

• CAD is the build-up of atherosclerotic plaque in coronary arteries. Stable angina is predictable (same threshold, relieved by rest/nitroglycerin); unstable angina is new, more frequent, or occurs at rest — a medical emergency; variant (Prinzmetal's) angina is coronary spasm. MI occurs when plaque ruptures and occludes a vessel.

• Classic MI symptoms: substernal crushing chest pain/pressure radiating to left arm, jaw or back, diaphoresis, nausea, shortness of breath.
• Women and diabetic patients often have atypical symptoms: fatigue, dyspnea, epigastric or back discomfort, no classic chest pain. Do not dismiss new dyspnea or profound fatigue.
• Unstable angina and MI = emergency: stop activity, call for help per facility protocol, do not leave the patient alone.

KEYCardiac rehabilitation phases

Phases of cardiac rehab

KEYAngina protocol & monitoring

• If angina develops: STOP exercise, sit the patient down, note the time, administer the patient's prescribed nitroglycerin (typically 1 tablet/spray, may repeat every ~5 min per physician order, commonly up to 3 doses), and call for help if pain persists beyond ~5 minutes or is severe.
• Measure HR and BP during and ~2-5 minutes after exercise; the patient should recover toward baseline in a few minutes.
• Anticoagulants (warfarin, DOACs) raise bleeding risk — use padded/grated surfaces carefully, watch for bruising/bleeding, and communicate lab values (e.g. INR) with the team before aggressive techniques.
• Post-MI: exercise progression should follow physician clearance; typical early limits include keeping HR and RPP below prescribed ceilings and avoiding Valsalva.

• Heart failure is the inability of the heart to meet tissue demand. Heart failure with reduced ejection fraction (HFrEF) vs preserved ejection fraction (HFpEF) differ in pump function but overlap in symptoms: dyspnea on exertion, fatigue, exercise intolerance, peripheral edema, orthopnea, and paroxysmal nocturnal dyspnea (PND).

NYHA functional classification

KEYFluid overload flags (call the physician)

• Rapid weight gain more than about 2-3 lb (about 1-1.4 kg) in 24 hours or 5 lb in a week.
• Increasing leg/ankle edema, new or worsening orthopnea, PND, or sleeping on more pillows.
• New productive cough with pink frothy sputum or sudden dyspnea at rest — possible pulmonary edema; seek emergency care.

KEYExercise approach

• Exercise improves peak VO2, symptoms, and quality of life and is safe in compensated HF: use symptom-limited aerobic (walking, cycling) with RPE and HR guidance, plus low-load resistance.
• Avoid Valsalva and gripping heavy loads (raising BP and afterload).
• Monitor pre- and post-session weight and ask about overnight dyspnea — weight creeping up means the plan needs review.
• Pace sessions with rest intervals; monitor SpO2; if desaturation with exertion, communicate to the team for oxygen prescription.

• Hypertension is the most common cardiovascular condition encountered in practice. Classification context commonly tested: normal below 120/80, elevated 120-129/below 80, stage 1 at or above 130/80, stage 2 at or above 140/90 (verify current guideline wording).

• Regular aerobic exercise plus isometric resistance training (e.g. wall squats, handgrip) lowers BP by roughly 5-10 mmHg; medication may be needed additionally.
• For hypertensives, avoid heavy-load lifting with Valsalva and sudden maximal efforts, which spike BP acutely.
• Antihypertensives and PT: diuretics (monitor hydration/orthostasis), ACE inhibitors (watch for dry cough, hyperkalemia), ARBs similar, beta-blockers (blunt HR — use RPE), calcium channel blockers (ankle edema, flushing) — many cause orthostatic hypotension in the elderly; screen with lie-to-stand.

• PAD is atherosclerotic narrowing of arteries to the legs. Classic intermittent claudication: reproducible calf cramping pain with a consistent walking distance, relieved by rest within a few minutes. Critical ischemia adds rest pain, cool/pale foot, and tissue loss.

• ABI (ankle-brachial index): normal about 1.0-1.4; below 0.9 suggests PAD; above 1.4 suggests non-compressible (calcified) vessels, often diabetic.
• Exercise program: walking to moderate claudication pain, then rest until pain resolves, then repeat — interval walking is the proven approach, typically 30-45 min, 3-5 days/week, several months.
• Cautions: avoid leg elevation in severe PAD (worsens ischemia), inspect footwear/hygiene, and refer ulceration or rest pain promptly.

• COPD includes emphysema (alveolar destruction, loss of elastic recoil, air trapping) and chronic bronchitis (chronic cough with sputum for at least 3 months in 2 consecutive years, airway inflammation and mucus).
• Most patients have both.

Classic trait comparisons

KEYSpirometry & severity (verify with current GOLD guidelines)

• Obstructive pattern: FEV1/FVC below the normal cutoff (about 0.70) with reduced FEV1.
• GOLD severity by post-bronchodilator % predicted FEV1 (contextual): at or above 80% mild, 50-79% moderate, 30-49% severe, below 30% very severe.

KEYInterventions a PT uses

• Pursed-lip breathing: inhale through the nose, exhale slowly through pursed lips, extending expiration — reduces air trapping and dyspnea.
• Positioning: tripod (leaning forward with arms supported) and high-side-lying reduce dyspnea and improve ventilation-perfusion.
• Secretion clearance: active cycle of breathing (ACBT) — breathing control, thoracic expansion exercises, and huff cough — plus percussion/vibration and postural drainage per patient tolerance.
• Energy conservation and pacing for ADLs; walking aids (rollator) reduce oxygen cost of walking; exercise training improves exercise tolerance and quality of life.

Inhaled medications commonly tested

• Asthma is chronic airway inflammation with reversible bronchoconstriction and airway hyperresponsiveness.
• Exercise-induced bronchoconstriction (EIB) typically peaks 5-15 minutes after exercise ends and is worst in cold, dry air.

• Exercise strategy: 5-15 min warm-up, use prescribed pre-exercise reliever (SABA) if ordered, choose warm humid environments, gradual cool-down, keep reliever inhaler available at the session.
• Acute attack: stop activity, sit upright, give the patient their rescue inhaler, monitor symptoms/SpO2, and escalate to emergency care if not improving, breathing is labored, or the patient cannot speak in full sentences.
• Severe-attack warning signs (need urgent care): inability to speak in sentences, use of accessory muscles, silent chest (barely audible wheeze — danger), cyanosis, confusion, or SpO2 below ~90%.

• Restrictive disorders reduce lung volumes (low TLC, FVC, FEV1 with normal or high FEV1/FVC). Examples: interstitial lung disease/pulmonary fibrosis, neuromuscular weakness (ALS, GBS, SCI high levels), chest-wall restriction (kyphoscoliosis, ankylosing spondylitis), and obesity hypoventilation.

• IPF: progressive exertional dyspnea and dry cough, bilateral basilar 'Velcro' crackles, clubbing; no obstructive spirometry; exercise is limited by dyspnea.
• Obesity hypoventilation: daytime somnolence, morning headache (nocturnal CO2 retention), polycythemia/cyanosis; treat with weight loss and sometimes PAP — assess endurance with rest, upright positioning.
• Neuromuscular weakness: monitor decline in vital capacity; assist cough (quad cough / manual assistance), encourage secretion clearance, position for comfort, and report acute respiratory changes.

• Venous thromboembolism (DVT + PE) is a leading preventable hospital complication. Virchow's triad: venous stasis, endothelial injury, and hypercoagulability. Immobility, surgery, cancer, pregnancy, obesity, and oral contraceptives all raise risk.

KEYRecognizing DVT

• Unilateral calf/thigh swelling, warmth, tenderness, and red or darkened color; a positive Homan sign is NOT reliable — do not rely on it or provoke it.
• If you suspect DVT: stop the activity, do NOT massage or aggressively move the limb, notify the physician, keep the patient at rest.

KEYRecognizing PE (emergency)

• Sudden onset shortness of breath, pleuritic chest pain (worse with breath), tachycardia, cough, sometimes hemoptysis; severe cases with hypotension, cyanosis, or syncope.
• Response: stop all activity, sit the patient in a position of comfort, call for emergency help, monitor vitals. Do not return to the session.

Common O2 delivery devices (approximate FiO2)

KEYNotable rules

• Portable oxygen safety: no smoking/open flame nearby, secure the tank, use spares for long sessions, check the gauge before transfers.
• Ventilated patients in therapy: coordinate with the team, watch the ventilator tubing (do not tug), monitor SpO2 and patient synchrony, and report acute desaturation or distress immediately.

• Arterial blood gas normal ranges: pH 7.35-7.45, PaCO2 35-45 mmHg, PaO2 80-100 mmHg, HCO3 22-26 mEq/L. Primary change maps the disorder: CO2 is the respiratory component, HCO3 the metabolic component.

Acid-base map (match the pattern, not memorized rows)

• The skin has three layers: epidermis (outer barrier, renews constantly), dermis (collagen, blood vessels, nerves, glands), and hypodermis/subcutaneous tissue (fat, larger vessels). Injury depth determines healing and treatment.

Phases of wound healing (overlapping timeline)

KEYHealing by intention

• Primary intention: clean surgical edges approximated — minimal scar (e.g. sutured incision).
• Secondary intention: wound left open, fills with granulation from the base (e.g. deep pressure ulcer, contaminated wound).
• Tertiary intention (delayed primary): wound initially left open, then closed, often after infection is controlled (contaminated wounds).

KEYFactors impairing healing

• Diabetes (microvascular + immune), smoking (vasoconstriction, low oxygen), malnutrition (protein/vitamin C/zinc), infection, ongoing pressure/shear/friction, edema, corticosteroids, advanced age, anemia.
• Granulation tissue is beefy red and moist — a healthy sign; slough (yellow/white) and necrotic eschar (black) are barriers that must be removed for healing.

KEYTissue types visible in a wound

Tissue appearance and meaning

KEYExudate types

• Serous: clear, watery; sanguineous: bloody; serosanguinous: pink/watery blood; purulent: thick yellow-green, indicates infection.
• Match dressing to exudate: low exudate → hydrocolloid/hydrogel/film; moderate → foam; high → alginate.; always with moisture balance.

KEYMeasuring and documenting

• Measure length x width x depth (probe tunneling and undermining with a cotton swab), note edges, and photograph consistently (same position, light, ruler, and date stamp).
• Distinguish tunneling (from wound edge into tissue) vs undermining (pocketing under the wound edge).
• Culture only when clinical signs of infection exist — routine swabs of a dirty-looking but non-infected wound are not indicated.

• Pressure injury results from prolonged pressure, shear, or friction — most often over bony prominences (sacrum, heels, ischial tuberosities, trochanters). Intensity x duration of pressure matters; blood flow is compressed, tissue is damaged.

NPIAP staging of pressure injuries (staging is about visible depth)

KEYBraden Scale for risk

• Six subscales: sensory perception, moisture, activity, mobility, nutrition, friction/shear. Lower total = higher risk (a commonly cited cutoff for 'high risk' is at or below 18, with scores well below requiring full prevention).
• Reassess on admission, after major change in status, and periodically per facility policy.

KEYOffloading and prevention

• Reposition at least every 2 hours while in bed; use a 30-degree lateral tilt instead of 90-degree side lie; protect the heels by suspending them off the mattress.
• NEVER place pressure over an existing wound. Keep it off the surface with cushions, positioning devices, or specialty beds.
• Choose pressure-relief surfaces (alternating-pressure mattresses, air-fluidized beds) and prohibit 'donut' rings that raise venous pressure.
• Nutrition: adequate protein and calories are part of prevention and healing.

Burn depth classification

KEYExtent and fluids

• Rule of Nines (adult): head + neck 9%, each upper limb 9%, anterior trunk 18%, posterior trunk 18%, each lower limb 18%, perineum 1%.
• The patient's palm (with fingers) is about 1% TBSA — useful for small scattered burns.
• Parkland (adult) fluid formula: 4 ml x %TBSA x body weight (kg) in first 24 hours; give half in the first 8 hours, remainder over the next 16. This is physician-driven; PTs should understand severity context.

KEYBurn rehabilitation essentials

• ANTI-DEFORMITY POSITIONING to prevent contracture (learn the patterns): neck — avoid flexed 'pillow' position; axilla — shoulder abducted ~90-110 degrees; elbow and knee — avoid prolonged flexion (no pillow under the knee); ankle — neutral/dorsiflexed.
• Splinting, serial casting, and daily ROM protect joint function; start gentle ROM early per team protocol.
• Ambulation as soon as cleared; pressure garments (applied ~23-25 mmHg) and silicone sheets are used for scar management, worn nearly 24 hours a day (except wound care/hygiene) for months (often 6-12+ months).
• Massage and stretching desensitize and preserve motion; watch for contracture, heterotopic ossification, and hypertrophic scarring.

Dressing categories matched to wound needs

KEYDebridement methods

• Autolytic: your own enzymes under an occlusive/moist dressing — least painful, slower.
• Enzymatic: topical agents (e.g. collagenase) digest slough/eschar.
• Sharp/surgical: sterile scalpel/scissors — performed by trained providers.
• Mechanical (wet-to-dry): dressing adheres to tissue, removed dry — PAINFUL and removes healthy tissue; the NPIAP and best practice discourage routine use.
• Biological (maggot/larval) therapy is an option for infected sloughing wounds.

Key differentiators

KEYManagement rules

• VENOUS ulcers: elevation, exercise of calf pump, and COMPRESSION (multilayer bandaging or graduated stockings ~30-40 mmHg). Compression is the core treatment — but NEVER if there is a significant arterial component.
• ARTERIAL ulcers: no compression; position for comfort (dependent to improve flow), protect from trauma, and pursue revascularization evaluation. Elevating the leg above the heart can worsen ischemia.
• DIABETIC foot: OFFLOADING is the priority — total contact cast or removable walker, daily inspection, glucose control, and footwear screening. Loss of protective sensation makes unnoticed progressive ulcers likely.

• Lymphedema is chronic tissue swelling from impaired lymphatic drainage.
• Primary (congenital/inherited) or secondary (post-surgery node dissection — commonly breast cancer, radiation, infection).
• Characterized by non-pitting to pitting edema, fibrosis, and a positive Stemmer sign (inability to pinch the dorsal foot/toe skin).

KEYStages (contextual)

• Stage 0: latent, no visible swelling but fluid shifts with position. Stage 1: pitting edema, reduces with elevation. Stage 2: non-pitting with fibrosis, does not reduce with elevation alone. Stage 3: lymphostatic elephantiasis with skin changes.

KEYComplete Decongestive Therapy (CDT)

• Four components: manual lymph drainage (MLD), short-stretch bandaging and compression garments, therapeutic exercise with compression, and meticulous skin care.
• Exercise should be performed WITH compression on; relative rest for the limb is not the goal — controlled movement aids flow.
• Prevent complications: avoid blood draws/needlesticks in the affected limb (post-mastectomy risk), monitor for cellulitis, keep skin moisturized.

KEYOutcome measurement

• Serial limb circumference at marked landmarks (e.g. every 4 cm) and/or water displacement volume. Document consistently at the same landmarks and time of day.

Transmission precautions and PPE

KEYClean vs sterile technique

• Chronic, non-infected wounds: clean technique is usually acceptable (facility policy governs). Acute surgical wounds, burns, and immunocompromised patients often require sterile technique.
• Dressing change principle: change when soiled/saturated or per order, remove exudate, never disturb the healing base, and red-flag worsening signs.

KEYSpecial wounds

• Surgical incision: staples/sutures typically removed around post-op days 7-14 depending on site (per surgeon); monitor for dehiscence and infection.
• Amputation residual limb: keep the stump protected post-op, start desensitization (tapping, textures) and volume-management (shrinker sock, rigid dressing) as allowed, then prosthetic training.
• Needlestick: wash immediately with soap and water, report per policy, follow post-exposure prophylaxis guidance.

• Braden: pressure-injury risk scale (lower = higher risk).
• Bates-Jensen Wound Assessment Tool (BWAT): scores wound characteristics (size, depth, edges, tunneling, exudate, tissue type) — useful to track healing over time.
• Pressure mapping / mapping devices identify high-load areas on support surfaces.
• Goniometry documents joint motion and contracture risk around a wound site.
• ABI informs arterial involvement and compression decisions.

KEYSafe discharge / transfer criteria

• Wound healing/progressing (closing, no deepening), patient offloading as taught, and patient/caregiver able to perform or direct the dressing routine.
• Patient/family can list signs of wound infection and know who to call (red flags education).
• Plan communicated via documentation and handoff (e.g. SBAR) to the next provider.

• Fresh wound in the clinic: control bleeding with direct pressure, clean gently with sterile saline, cover with a sterile dressing, and refer for suturing/antibiotic indication per policy.
• Puncture wounds: higher infection risk (deep contamination); do not seal the puncture.
• Bite wounds and wounds with retained foreign bodies: physician evaluation, no primary closure unless directed, watch for infection.
• Wet dressings are changed when saturated; a dressing that stays dry on a highly exudative wound needs a different (more absorbent or NPWT) approach.
• Prevention of new wounds in at-risk patients: skin inspection daily, footwear that fits, moisture barriers for incontinence, and offloading during all sessions.

• Standard precautions apply to EVERY patient as the baseline: treat all blood and body fluids as potentially infectious. Transmission-based precautions add layers based on the suspected route.

Precaution types (memorize the pairings)

KEYHand hygiene & PPE practice

• Perform hand hygiene before and after every patient, and between dirty and clean tasks (the 'five moments').
• PPE donning order: gown, then mask/respirator, then goggles/face shield, then gloves. Doffing order (to avoid contamination): gloves, then goggles/face shield, then gown, then mask/respirator — with hand hygiene between steps.
• Needlestick/contaminated exposure: wash the area immediately with soap and water (eyes with saline/water), report to the supervisor and employee health without delay, and follow post-exposure prophylaxis protocol.
• Disinfect treatment tables, plinths, and shared equipment between patients; single-use items are never reused.
• Screen when history suggests rash, cough, fever, or known infection — postpone or protect per policy.

• Safe patient handling protects the patient AND the therapist — staff back injuries are a leading cause of PT work loss.
• Modern practice replaces manual lifting with equipment whenever possible.

• Use mechanical lifts (full-sling, stand-assist), ceiling lifts, slider boards, and gait belts for transfers; a single therapist should NOT attempt lifting heavy dependent patients alone.
• Before any transfer: lock the wheelchair/set up the destination, position the patient's feet, use a gait belt snugly, and coordinate (count of three).
• Use your legs and wide base of support, keep the load close to your body, avoid twisting, and do not depend on upper-body strength alone.
• Check equipment before use: wheelchair brakes and armrests, walker/cane tips, plinth straps, and pin locks.
• Clinical falls: ensure call light within reach, side rails per policy, bed/tilt alarms for high-risk patients, hourly rounding, and a fall-risk flag on the chart.

KEYLicensure & scope

• You practice under the state practice act; scope of practice, supervision requirements, and delegation rules vary by state — PTs should know their own act and endorse/compact privileges context.
• Practice outside your competence is an ethical and legal violation — refer or seek training.

KEYInformed consent

• Elements: explanation of the proposed treatment, its risks and benefits, reasonable alternatives, and the right to refuse or withdraw at any time — given to a patient who is competent and volitional.
• Who consents: the patient if competent; a surrogate/legal guardian for minors or incapacitated adults; emergency treatment may proceed under implied consent.
• Refusal of treatment does not end your duty — you reassess, explain consequences clearly, document the refusal, and offer alternatives.
• Advance directives and DNR must be respected during treatment unless a valid in-the-moment order directs otherwise.

KEYDocumentation as a legal record

Documentation rules

• HIPAA protects patient privacy: protected health information (PHI) must not be shared without authorization except for treatment, payment, and healthcare operations. The exam tests everyday scenarios, not legal trivia.

HIPAA quick facts

KEYOther communication duties

• Records released only with valid patient authorization or permitted purpose; verify identity before giving information over the phone.
• Use of interpreters: prefer trained/medical interpreters particularly for sensitive content; be cautious using family as interpreters for confidential matters.
• Health literacy: use teach-back (ask the patient to repeat instructions in their own words) and plain language.
• SBAR for handoffs: Situation, Background, Assessment, Recommendation — concise and complete.

Core bioethics principles

KEYResolving an ethical dilemma (process the exam likes)

• Identify the problem and who is affected; gather relevant facts; identify principles that conflict; generate options; weigh consequences; choose the best ethically-supported action; evaluate the outcome.
• Ethical vs legal vs moral: something can be legal but unethical (e.g. a policy that discriminates) or ethical but legally ambiguous — the exam distinguishes these axes.
• Cultural competence: respect values and beliefs, use appropriate interpreters, adapt communication without abandoning standard of care.

• Suspected abuse of children, elders, or vulnerable adults MUST be reported to the designated state agency — you do NOT need proof, and you do NOT confront the family first.
• Report signs: unexplained injuries, contradictory stories, neglect (dehydration, pressure ulcers, untreated medical needs), unusual fear or withdrawal.
• Impaired or incompetent colleagues suspected of endangering patients should be reported through facility and state channels.
• Duty to warn (Tarasoff): if a patient poses a serious, imminent threat of harm to a specific identifiable person, you may have a duty to warn that person/authorities — facility policy and state law govern the exact steps.
• Sexual misconduct and boundary violations are zero-tolerance: no romantic/sexual relationships with current patients, no exploitative gifts, and clear professional boundaries.

The delegation lines the exam loves

KEYSupervision rules to remember

• The PT remains responsible for the plan and its outcome even when a PTA delivers treatment — supervision requirements (on-site vs general) vary by state; know the difference and comply.
• A PTA communicates findings to the PT; any change that would alter the plan triggers a PT re-assessment.
• An aide/tech can help physically but never performs skilled care independently.
• Discharge is the PT's call; the PTA reinforces teaching but does not make the discharge decision.

Emergency drills PTs should master

• Know where the AED, first-aid kit, oxygen (if stocked), and emergency equipment are, and who to call (code blue / medical emergency) in your clinic.
• Incident reports after any adverse event: factual, objective, blame-free, timely — what happened, what you observed, what was done.
• Two identifiers (name + DOB, or per facility) before every treatment and transfer.

• Medicare Part A covers inpatient (hospital, SNF) care; Part B covers outpatient services including PT; therapy must be medically necessary and progress-capable.
• Documentation must support the billed codes: CPT codes describe the services, modifiers and units matter, and 'incident-to' billing has specific physician-supervision requirements.
• Fraud and abuse: upcoding (billing a higher service than given), unbundling (billing components separately to inflate payment), fabrication of records — all zero tolerance and grounds for exclusion from Medicare.
• Medical necessity and skilled care: sessions billed must be performed by an appropriately qualified provider and be necessary — maintenance 'only' programs require specific documentation rules.
• When you see a billing pattern that looks wrong, report through the facility compliance channel — silence makes you part of it.

• The NPTE increasingly tests functional, patient-centered thinking. The ICF (International Classification of Functioning) frames problems in three layers: body structure/function, activity, and participation — plus personal and environmental factors. Intervention goals are written to function, not just diagnosis.

KEYICF levels in action (know the label for each)

• Body structure/function: muscle strength 3/5, ROM limitation, pain intensity.
• Activity: walking distance, stair negotiation, ADL performance.
• Participation: returning to work, sports, community life.
• Contextual factors: home stairs, caregiver support, equipment, patient beliefs — they enable or barrier function.

KEYDocumentation & goals

• Write SMART goals: Specific, Measurable, Achievable, Relevant, Time-bound (e.g. 'ambulate 150 feet with a rolling walker, contact-guard assist, within 3 weeks').
• Document objective, functional measurements (gait speed, 6MWT, TUG, ROM/MMT) at baseline and intervals — outcomes justify the plan.
• Use outcome measures with known cutoffs (e.g. TUG greater than 13.5 seconds = fall risk; Berg balance below 45/56 = increased risk; gait speed below about 0.8 m/s = falls/mobility concern).
• Continue competence: CEUs, staying current with evidence-based practice, and honest referral when outside your expertise.

Precaution types and PPE at a glance

Four elements of negligence

PT vs PTA vs aide: who does what

• Rehabilitation assessment (康复评定) is the measurement and analysis of a patient’s function, impairments, activity limitations, and participation restrictions. It is the foundation of the rehab process: you assess first, then set goals, then plan and dose treatment, then re-assess to measure progress. “No assessment, no treatment goal; no re-assessment, no objective result.”
• The core assessment battery (核心评定组合) maps to body structure/function, activity, and participation. A complete evaluation typically covers: muscle strength, range of motion, muscle tone, balance, sensation, gait, cognition, and pain. Each domain has standard tools with known reliability, normal values, and reference ranges.

KEYAssessment drives every clinical decision

• Assess before treat — Never begin a program without baseline measures
• Set SMART goals — Specific, Measurable, Achievable, Relevant, Time-bound
• Re-assess objectively — Repeat the same measure to document change over time
• Match tool to domain — Mobility→10MWT/TUG, balance→Berg/DGI, ADL→FIM/Barthel

• Manual Muscle Testing (MMT / 徒手肌力检查) grades isolated voluntary muscle strength on a 0–5 (or O–V) scale. Correct technique requires: the proper starting position, fixation of the proximal segment, and isolation of the target muscle. Consistency between testers matters because MMT is inherently subjective.
• MMT grades: 0 = no contraction; 1 = trace, a flicker of contraction seen/palpated; 2 = movement with gravity eliminated; 3 = movement through full ROM against gravity; 4 = movement against gravity plus some resistance; 5 = normal strength against maximal resistance. Grades 4 and 5 are the most difficult to distinguish reliably.

KEYMMT grading at a glance (0–5)

MMT 0–5 grading scale

• Range of motion (ROM / 关节活动度) is measured with a goniometer (量角器) for most limb joints. Correct method: align the fulcrum over the joint axis, the stationary arm along the proximal segment, and the moving arm along the distal segment; read on the correct side (flat side toward the patient). Always compare to the uninvolved side.

KEYKey goniometric points

• Active vs passive — A-ROM = patient self-motion; P-ROM = examiner moves joint, assesses end-feel
• End-feel — Soft (soft-tissue approximation), firm (capsular/ligamentous), hard (bony)
• Hypomobility vs hypermobility — Distinguish restriction from instability; both alter exercise dosing
• Contracture — Fixed shortening of muscle/tendon/capsule; distinguish from spasticity
• Contracture types — Flexion contracture (most common), extension, abduction/adduction, rotational

• Muscle tone (肌张力) abnormalities are classified as spasticity, rigidity, or flaccidity. Spasticity (痉挛) is velocity-dependent resistance from an UMN lesion; rigidity (僵硬) is velocity-independent resistance (e.g., Parkinson’s gear/cogwheel), often with tremor; flaccidity (弛缓) is low tone from an LMN or acute lesion.

KEYBalance & sensation essentials

• Balance depends on — Support surface, base of support, center of gravity, stability limits
• Berg Balance Scale — 14 items, 0–56; score <45 → increased fall risk
• Sensation types — Superficial 浅 (pain/temp/touch), deep 深 (proprioception/vibration/pressure), composite 复合 (stereognosis/two-point)
• Sensory testing — Test dermatomes bilaterally; document level of sensory loss
• Rigidity vs spasticity — Rigidity = constant, plastic/cogwheel; spasticity = velocity-dependent catch-and-release

• Gait (步态) analysis divides the cycle into stance (支撑相, ~60%) and swing (摆动相, ~40%). Key sub-phases of stance: heel strike, loading response, mid-stance, terminal stance, pre-swing. Observational gait analysis assesses symmetry, cadence, step/stride length, base of support, and arm swing, with kinematic (motion) and kinetic (force/GRF) perspectives.

KEYCognition &amp; outcome measures

• Cognition domains — Agnosia 失认, aphasia 失语, attention 注意, memory 记忆, executive function 执行功能
• 10MWT — Community ambulation cutoff ≈ 0.8 m/s; measures gait speed
• TUG — Time to stand, walk 3 m, return, sit; >13.5 s = fall risk
• FIM / Barthel — ADL performance; FIM 18 items 1–7; Barthel 0–100 (>60 = independence)
• GBS / DGI / BBS — Gait abnormalities scale; Dynamic Gait Index; Berg Balance Scale

• A systematic assessment flow keeps you complete and consistent: (1) history &amp; subjective screen, (2) observation &amp; posture, (3) active/passive/accessory motion &amp; muscle tests, (4) specialized tests &amp; functional measures, (5) document findings, (6) set goals and plan, (7) re-assess progress.

KEYExam flow: stop, look, listen

• Screen first — Red flags (cauda equina, DVT, fracture) override the full battery
• Compare both sides — Symmetry is the fastest clue to a real impairment
• Document objectively — Numbers, not adjectives — record goniometer/MMT/scale scores
• Re-measure — Progress requires repeating the SAME measure at the SAME time of day

• Traditional Chinese Medicine (TCM / 中医) sees the body as an integrated whole governed by yin and yang (阴阳) — two opposing yet interdependent forces.
• Health is balance; disease arises from imbalance.
• Qi (气), blood (血) and body fluids (津液) are the functional bases that nourish and move the body.

KEYCore TCM concepts

• Yin 阴 — Cooling, nourishing, structural, night, inward; deficiency → heat signs (dry mouth, night sweats)
• Yang 阳 — Warming, activating, functional, day, outward; deficiency → cold signs (cold limbs, fatigue)
• Qi 气 — Vital energy that moves, warms, defends, and holds; qi deficiency → fatigue, shortness of breath
• Blood 血 — Nourishes organs/tissues; blood deficiency → pale, dizziness, poor sleep
• Body fluids 津液 — Moisten joints, skin, orifices; fluid-damp → swelling, heaviness, phlegm

• Meridians (经络) are the pathways through which qi and blood circulate.
• There are 12 regular meridians (十二正经), each paired with an organ system, plus 8 extraordinary vessels.
• Acupoints (穴位) are specific points on the meridians used in acupuncture (针灸), acupressure, and tuina (推拿) for pain relief and health management.

KEYCommon pain points in sports

• He Gu (LI4) 合谷 — First dorsal web of the hand; general pain/headache/cold
• Zu San Li (ST36) 足三里 — Below the knee, lateral fibula/ST; strengthens digestion &amp; immunity, fatigue
• San Yin Jiao (SP6) 三阴交 — Medial lower leg above the medial malleolus; gynecologic, damp-cold, lower-limb fatigue
• Tai Chong (LR3) 太冲 — Dorsum of the foot proximal to the 1st-2nd metatarsal; stress, anger, BP

Tuina (推拿) is manual therapy using rolling (滚法), kneading (揉法), pressing (按法), and stroking/grasping (拿法) techniques. It is widely used for muscle tension, sports recovery, and managing chronic pain. Contraindications overlap with Western manual therapy: acute fracture, infection, severe osteoporosis, skin lesions, and suspected DVT.

• Moxibustion (艾灸) applies heat from burning moxa (mugwort) near acupoints to warm and tonify yang, and is used for cold-pattern conditions and pain.
• Gua sha (刮痧) and cupping (拔罐) are surface therapies that stimulate blood flow and relieve muscle tension; they are common in sports recovery settings.

KEYWarm vs cold applications

• Moxibustion (warm) 艾灸 — Cold-pattern: chills, cold limbs, chronic pain eased by heat; tonifies yang
• Cold compress (cool) 冷敷 — Acute injury, swelling, inflammation; reduce blood flow
• Cupping 拔罐 — Negative pressure → local hyperemia, loosens fascia; leaves circular marks
• Gua sha 刮痧 — Scraping to the skin; treats stagnant qi/blood; petechiae expected

• TCM classifies people into constitutional types (体质) based on their stable physical and behavioral profile.
• The classic scheme distinguishes nine (九种体质).
• Health management (健康管理) uses the constitution to tailor diet, exercise, lifestyle, and seasonal care — a personalized, preventive approach that complements evidence-based practice.

KEYNine constitutions at a glance

Nine constitutional types (九种体质)

• TCM and evidence-based sports recovery share a common goal: restore homeostasis and performance after training. Practical integrations include: moxibustion/cupping for local myofascial tension, tuina for recovery between sessions, constitutional diet for fueling, and mind-body practices (太极/气功) for balance and stress reduction in rehabilitation.

KEYWhere they complement EBP

• Myofascial release — Cupping/gua sha/tuina overlap with foam rolling &amp; manual therapy goals
• Recovery scheduling — TCM favors rest and season-intelligence; evidence supports periodized recovery
• Mind-body — Taijiquan/qigong improve balance, flexibility, stress — supported by RCTs for older adults &amp; neuro
• Self-care literacy — Both empower the athlete to self-manage minor complaints

• An Emergency Action Plan (EAP) is a written, venue-specific plan stating who does what, with which equipment, and how EMS is activated — rehearsed before the season, not while a player lies unresponsive.
• The Chain of Survival (adult): ① recognize the emergency and call for help, ② start high-quality CPR immediately, ③ defibrillate early with an AED, ④ activate EMS/advanced life support, ⑤ post-cardiac-arrest care. Every link missed cuts survival.
• The golden rule: the time to rehearse an emergency is NOT during the emergency. Untrained, unprepared people freeze.

KEYEAP core components

• Clear roles — A designated team leader; a CPR/AED operator; one person solely for calling EMS; one to retrieve equipment; one to meet EMS at the gate.
• Venue map — Field/court orientation, EMS access points, exits, and where the AED and first-aid bag live. Post the numbers and the map.
• Rehearsal — Rehearse the full plan at least 1–2× per season for every venue, and update it when staff, location, or equipment changes.
• Equipment — AED, CPR mask, gloves, bleeding control kit (tourniquet, pressure dressings, hemostatic gauze), cold-water immersion tub, communication device.

• Sudden cardiac arrest (SCA) is the leading cause of on-field death in athletes. It is most often caused by structural or electrical heart disease (hypertrophic cardiomyopathy, anomalous coronary arteries, arrhythmogenic right ventricular cardiomyopathy, long QT syndrome, myocarditis) — and in youth athletes also by commotio cordis (a chest-wall blow).
• Compressions-first philosophy: for a witnessed collapse with normal bystander CPR + early AED, survival can exceed 70%. Defibrillation within ~3 minutes is the single most powerful intervention.
• Commotio cordis: a sharp, non-penetrating blow to the precordium during the vulnerable repolarization window (~10–30 ms before the T-wave peak) triggers ventricular fibrillation. It typically occurs in children/adolescents (flexible chest wall) and needs exactly the same treatment as any SCA: immediate CPR + early defib.

KEYHigh-quality CPR basics (adult)

• Recognize — Check responsiveness (tap, shout). No breathing / only gasping → it is arrest: call EMS, get the AED, start compressions.
• Compress — Push hard & fast: 100–120 compressions/min, depth ~5–6 cm (adult), allow full chest recoil, minimize interruptions. 30:2 single rescuer.
• Defibrillate — Turn on the AED, follow voice prompts, attach pads, let it analyze. V-Fib/V-Tach respond to defib; asystole/PEA still need continuous CPR.
• Continue & hand off — Do not stop effective CPR until the person wakes, EMS takes over, or you are exhausted. Smooth hand-off, no long pauses.

2024 HRS sports statement: after a confirmed SCA, the athlete should not return to play until evaluated by a cardiology team, and most survivors are cleared only after 3–6 months of evaluation, ICD decisions, and shared decision-making about sport. Automatic external defibrillators should be present and rehearsed at every venue where vigorous activity happens.

• The heat illness spectrum, in order of severity: heat cramps → heat syncope → heat exhaustion → exertional heat stroke (EHS). EHS is a true medical emergency requiring immediate whole-body cooling.
• 2025 SCCM heat-stroke guideline: cool fast — ≥0.155°C/min, goal core temperature <39°C within 30 minutes of collapse. Cold-water immersion (CWI) 1–5°C is the gold standard; cool first, transport second.
• EHS = hyperthermia (core temp usually >40.5°C / 105°F) plus central nervous system dysfunction (confusion, agitation, seizures, coma). Dry skin is typical but sweating may persist in exertional cases — do NOT rely on it.

Anti-inflammatory myths that fail: avoid NSAIDs and full-dose antipyretics — they do not treat exertional heat stroke and can worsen renal injury. Dantrolene is not indicated for classic heat stroke. The treatment is physical cooling, not pharmacology.

• Exsanguination can kill within minutes. In athlete settings the priorities are: call for help, apply direct pressure, pack deep wounds, and use a tourniquet for life-threatening limb bleeding.
• Anaphylaxis is a severe, rapid-onset systemic hypersensitivity reaction — bronchospasm, laryngeal edema, urticaria, hypotension. First-line treatment is intramuscular epinephrine given immediately; delay is the biggest killer.
• Airway/breathing: for an unresponsive athlete with a pulse, use head-tilt–chin-lift (or jaw-thrust if trauma), clear visible obstructions, and give rescue breaths; place unconscious persons in the recovery position.

• Exercise increases glucose demand and can drop blood sugar rapidly in an athlete with diabetes. Early signs: tremor, sweating, hunger, confusion, irritability, pallor; severe: altered consciousness, seizure, coma.
• The rule of 15: if conscious and able to swallow, give ~15 g fast-acting carbohydrate (glucose tabs, juice, sugared drink, or a small tube of glucose gel), recheck in 15 minutes, and repeat if still low (<3.9 mmol/L / 70 mg/dL).
• DO NOT give anything by mouth to an unconscious athlete — no food, no drink, no water in the mouth. Put them in the recovery position, call EMS, and if they carry a glucagon kit, use it per training.

• When the number of injured exceeds the rescuers, triage decides who gets care first. The standard adult field system is START (Simple Triage and Rapid Treatment) — sort by a 30-second assessment into four categories.
• START mnemonic RPM: Respiratory, Perfusion, Mental status.
• Triage is a dynamic label: re-triage as conditions change, and keep a running count of each category for EMS. The goal is the greatest good for the greatest number.