MSP Exam 1

• Imaging ABCS should be known
• Spondylitis, gout, spondylolisthesis, and rheumatoid arthritis should be considered; including their manifestation and symptoms.
• Lifestyle factors for treating gout should be known, i.e., weight loss, hydration, and reducing alcohol intake.
• Comparison of CT vs X-ray images should be studied
• Ability to identify an ultrasound picture is expected
• MRI, used for post-traumatic knee (ligament or meniscal tears, soft tissue damage), should be known.
• Side effects of taking bisphosphonates (GERD) should be known; patients should be positioned in supine.
• Red flags/yellow flags/constitutional symptoms require review
• DVT Diagnosis with case scenarios may be tested

Pathophysiologic Responses

• Increased workloads require pathophysiologic responses
• Smoking induces a range of pathophysiologic responses
• Responses are primarily centered around endothelial dysfunction, inflammation, oxidative stress, and platelet activation
• Can lead to atherosclerosis and contribute to cardiovascular diseases, lung damage, and cancer
• Mechanisms include impaired vascular function, increased blood clotting tendency, and direct cellular damage derived from toxic chemicals in tobacco smoke.

Tissue Healing Phases

• Phases include inflammatory, fibroplasia/repair, and remodeling/maturation.

Inflammatory Phase

• Includes the five cardinal signs of swelling: redness, swelling, heat, pain, and loss of function.

Wound Healing

• Acute phase: 0-48 hours
• Subacute phase: up to 2-4 weeks

Skin Healing

• Up to 3 days (most within first 48 hours) for the inflammatory phase
• Day 4 to Day 14 for fibroplasia/repair
• 10-14 days to several months for remodeling/maturation

Bone Healing

• Up to 3 days (most within first 48 hours) for inflammatory response
• Day 4 to 40 days (consider stable vs. unstable) for fibroplasia/repair
• 40+ days to months or years for remodeling

Cartilage Healing

• Up to 3 days (most within first 48 hours) during inflammation
• Acute (AC) Low potential for repair, fibroplasia phase: FC - Day 4 to day 28
• Remodeling/Maturation phase: FC-21-28 days to 1 year

Tendon & Ligament Healing

• Inflammatory response up to three days (most within first 48 hours)
• Fibroplasia/Repair 4 days to 28 days
• Remodeling 21 to 28 days to 1 year

Causes of Cell/Tissue Injury

• Types include reversible and irreversible injuries:
• Ischemia: Insufficient or absent blood flow (hypoxia or anoxia)
• Infection:
  • Bacterial leading to inflammatory response, causing cell injury/death
  • Viral infection directly and/or indirectly causes a cytopathic effect (RNA and DNA)
• Immune reactions due to hypersensitivities or autoimmune disorders.
• Chemical factors: Carbon monoxide, ammonia, heavy metals, alkylating agents in pharmaceutical drugs, and free radicals
• Physical/Mechanical factors:
  • Physical (blunt trauma, temperature (hypo/hyperthermia), radiation, electricity)
  • Mechanical (tissue tolerance, age, utilization, load factors involving compression, friction, torsion, or shear forces based on property of tissue, and magnitude: high load or repeated bouts of moderate load)
• Nutritional factors:
  • Vitamin B12 deficiency (neuropathy), calcium deficiency (decreased bone quality)
  • Protein malnutrition (edema, weight loss, diminished functional capacity)
• Fear, tension, anxiety, depression, isolation.
• Aging: Progressive decline in homeostasis balance that leads to pathology.
• Irreversible Cell Injury:
  • Cell death
  • Necrosis (end point of a pathological process), including coagulation, liquefaction, gas, fat, fibrin
  • Apoptosis (programmed cell death)

Bone, Tendinous & Ligamentous Injuries

• Includes associated phases of healing

Tendons Intrinsic healing

• Via vascular internal vascular response resulting in fibroblast proliferation from intrinsic blood supply.
• Fibroblasts are found in connective tissue: Proliferation a rapid increase, rapidly increase cells for tissue repair.

Tendons Extrinsic Healing

• Via-vascular-inflammatory-cellular response from adjacent tissue cells.
• Degree of healing depends on injury severity, surgical repair (or not), amount of mobilisation-immobilization.

Stages of Tendon Healing

• Acute: Hemostasis, Inflammatory phase
• Subacute: Repair and Healing
• Chronic: Maturation and Remodeling

Detrimental Tendon Healing

• Occurs when the tendon is unloaded completely
• Can occur from temporary paralysis, or when it is overloaded by active mobility or exercise

Tendon Healing by Cast Immobilization

• Beneficial for tendon to bone healing
• Detrimental for flexor tendon healing

Tendon Healing by Passive Motion

• Beneficial for flexor tendon healing
• Detrimental for tendon to bone healing

Tendon Recovery

• Controlled stress to develop tensile strength of the tendon is needed.
• Tendons can heal without surgery, (incomplete injuries): Suture repair to help minimize scar formation by closing the gap

Strength of Tendon Repairs

• Weakest at day 7-10 days
• Regaining strength at day 21-28days
• Near full strength at 6 months

Ligaments: Healing or Remodeling

• Torn ligament ends must be in contact with each other
• Progressive controlled stress must be applied to the healing tissues to orient scar tissue formation
• Ligaments must be protected against excessive forces during remodeling.
• Intra Articular ligaments DO NOT heal spontaneously, extra Articular ligaments heal in the order:
  • Inflammatory phase (inflammation and Hemostasis)
  • Repair (fibroplasia and cell proliferation)
  • Remodeling (maturation)

Intra Articular Ligaments

ligamnets that stabilize joints and are within the joint capsule ACL, PCL.

Extra Articular Ligaments

• located Outside the joint capsule MCL, LCL

Hallmark Signs & Risk Factors

• Osteoarthritis (OA) vs RA on radiograph and risk factors, management and presentation of these conditions should be understood.

Osteoarthritis (OA) Hallmark Signs:

• Joint Space Narrowing (asymmetrical, typically affecting weight-bearing surfaces)
• Osteophytes (bone spurs)
• Subchondral Sclerosis (increased bone density beneath cartilage)
• Subchondral Cysts
• Malalignment & Joint Deformity (late-stage)

Rheumatoid Arthritis (RA)️ Hallmark Signs:

• Symmetrical Joint Space Narrowing
• Periarticular Osteopenia (loss of bone density)
• Erosions (especially at the margins of joints, “bare area")
• Soft Tissue Swelling
• Joint Subluxation & Deformities

Osteoarthritis (OA) Risk Factors:

• Age (strongest predictor, usually >50 years)
• Obesity (especially for knee OA)
• Joint Trauma (post-traumatic OA)
• Repetitive Stress (occupational, sports-related)
• Genetics
• Female Sex (higher risk for knee/hand OA)

Rheumatoid Arthritis (RA) Risk Factors:

• Genetic Predisposition
• Female Sex (3:1 ratio)
• Smoking (strongest modifiable risk factor)
• Infections (potential triggers)
• Hormonal Factors Protective effects of pregnancy, worsens postpartum

Osteoarthritis (OA): Presentation

Morning Stiffness (<30 minutes, improves with activity)

• Worsens with Use (pain increases throughout the day)
• Asymmetrical Joint Involvement
• Commonly Affected Joints:
  • Knee (most common)
  • Hip
  • Hands (DIP, PIP, 1st CMC – Heberden's & Bouchard's nodes)
  • Spine (cervical & lumber)

Rheumatoid Arthritis (RA): Presentation

• Morning Stiffness >1 Hour (improves with movement)
• Worse with Rest, Better with Use
• Symmetrical Polyarthritis
• Commonly Affected Joints:
  • MCP & PIP (not DIP)
  • Wrist
  • Elbow
  • Shoulder
  • Knee & Ankle
  • Cervical Spine (C1-C2 instability, no lumbar involvement)
• Systemic Symptoms: Fatigue, weight loss, fever
• Extra-Articular Involvement: Rheumatoid nodules, interstitial lung disease, vasculitis, pericarditis

Osteoarthritis (OA): Management

• Non-Pharmacologic:
  • Weight Loss (most effective)
  • Physical Therapy & Exercise (low-impact activities)
  • Surgery
• Pharmacologic:
  • Acetaminophen (first-line for mild-moderate OA)
  • NSAIDs (effective pain control in moderate to severe OA)
  • DMOADS (Slows or reverse OA Pathology) (viscosupplementation [hyaluronic sulfate] or glucosamine and confronting sulfate

Rheumatoid Arthritis (RA): Pharmacologic

• Non-Pharmacologic:
  • Physical Therapy & Occupational Therapy, smoking cessation
• DMARDs (Disease-Modifying Anti-Rheumatic Drugs) (start ASAP):
  • Methotrexate (First-line)
  • Leflunomide, Hydroxychloroquine, Sulfasalazine (alternative DMARDs)
  • Biologic DMARDs (TNF inhibitors: Etanercept, Infliximab, Adalimumab)
  • NSAIDs & Glucocorticoids For symptomatic relief but not disease-modifying

Radiographical Assessment ABCS

• Alignment:
  • General issues (supernumerary bones, deformed Bones, Paget's disease)
  • Contour of bone (shape and cortical outline (fractures...))
  • Bones relative to other bones (subluxation, Dislocation)
• Bone Density:
  • General bone density (osteoporosis?), contrast in density, cortical v. cancellous bone, bone v. soft tissue
  • Abnormal texture change in trabecular Structure local changes in Bone density (osteoblastic or osteolytic activity)
• Cartilage:
  • Joint space width (indicates the thickness of intervening cartilage)
  • Epiphyseal plates - they are bounded with smooth margin with zn adjacent sclerotic band
• Soft Tissue: -Muscles/soft Tissue outlines - gross wasting?, Hematoma
  • Fat pads/lines - displaced indicates swelling.
  • Periosteal reactions

Imaging

• T2 vs T1 MRI vs CT vs Ultrasound vs Conventional Radiograph: pros/cons should be known
• Recognition for each one if shown.
• MRI has different sequences (protocols) that target different tissues, sequences often referred to as TI- or T2-weighted.
  • TI weighted (greater anatomical detail, emphasize fat, bone marrow)
  • T2 weighted (less anatomical detail, emphasize fluid/ edema/inflammation)
• CT has true presentation of tissue density.
• Ultrasound does not penetrate the cortex, Bone-soft tissue interface = bright echo, theoretically has no signal from subcortical bone.

Radiograph: Radio-dense/radiopaque substances:

• Cancellous bone =>cortical bone=> heavy metal
• Increased molecular weight increases radiodensity, increase in radiodensity=increases radiopaque
• Radiodense has High-density structures and appears bright
• Radiolucency has low density structures and appears dark structures that are not dense appear bright if they are thick enough or superimposed on other structure
  • Fracture healing and stages has three phases that overlap, there are:
    • Inflammation (10% total healing time)
    • Reparative (40% of healing time)
    • Remodeling (70% of healing time)

Strain and Sprain

• Strain: is stretching or a tearing of the musculotendinous unit, injury of the ligamentous structure around a joint with classifications:
  • First degree is minor tearing without integrity loss
  • Second degree is a partial tearing and a clear loss of function
  • Third degree is a severe tear with a complete loss of integrity
  • Rupture is vulnerable with tension causing emotional overlay which causes, anxiety, depression, panic disorder, symptoms out of proportion to the injury, symptoms persist beyond the expected time to heal, any position is uncomfortable ,the patient may not be aware that they are exaggerating pain

General Signs Of Pain Include:

• Individual may demonstrate a variety of behaviors
• Guarding is having stiff movements
• Bracing has fully extended limp with weight acceptance
• Rubbing on hand
• Grimacing when narrowing eyes
• Sighing or exaggerated air, by falling and rising

Interviewing Patients

• Remembering constitutional signs and symptoms is vital: -Fever -Diaphoresis (unexplained) -Sweats any time, night or day -Nausea -Vomiting -Diarrhea -Pallor -Dizziness / Syncope (Fainting) -Fatigue / Weakness -Unintentional Weight Loss
• Common sites should be known of visceral and review Kehr’s sign caused by upper L quadrant

Red Flags Factors

• History of cancer, recent trauma/infection and immunosupression
• Presention: symptoms lasting longer and worsens, weight loss, changes over time
• Symptoms: pain at night, unable to reproduce, and a change

Routes of Administration

• Includes pros/cons and first path
• The two main routes are enteral and pareteral -Enteral -Oral: convenient, but slow onset, affected by food -Sublingual: rapid, bypasses first pass -Buccal: like sublingual, but slower onset
• Pareteral -IV: Direct, precise control -IM: Faster than oral, bypasses first pass
  • SubQ: easier than IM, slow absorption
  • Topical: direct action -Transdemal: Prolonged release, slow

Pharmacokinetics

• Major aspects are general for: -Absorption: transfer of drug -Distribution is how leave stream -Metabolois/Biotransformation is chemical change -Excretion: removal of drug
• Bioavailabilty is percent of the body, only oral undergoes first-pass effect:
  • Clear of all -_1/2 is concentration that decreases og

Osteoporosis

• Signs/Symptoms: -Lower Back -Fractures -Changes
• Primary occurs in male and women, secondary is because other: -Age. Race, -Non modifiable or inactivity

Intermittent Claudication

• Key Signs. Symptoms and screening -Pain, weak pulse, test such as ABI, palpatation

DVT ( Deep Vein Thrombosis)

• Leg sweat
• Redness
• Dilated superficial veins Wells DVT, Homan sign
• Arterial, changes in aging, or vascular

Quizzes

• Red flags: A change or reaccurent pain
• First step: If no physical therapist and need to determine if PT is okay
• Check index.
• Safe effective drug in index
• Causes: CO. Free readicals
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• Sclerotic would be fracture
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