MOH Physiotherapy Licensure Exam (Jordan) cheat sheet

Muscle fiber types: type I is slow-twitch, oxidative, fatigue-resistant, high capillary and mitochondrial density; type IIa is fast-twitch oxidative-glycolytic; type IIx is fast-twitch glycolytic with the highest force and fastest fatigue.

Length-tension relationship: active tension peaks near resting sarcomere length (~2.0-2.2 µm in human muscle) where actin-myosin overlap is optimal; tension falls when the muscle is over-shortened or over-stretched.

Force-velocity relationship: concentric force decreases as shortening velocity rises; eccentric contractions generate greater force than isometric, which exceeds concentric at the same activation.

Muscle action depends on joint motion, not anatomy alone: a two-joint muscle can act as agonist at one joint and antagonist at another simultaneously (e.g., rectus femoris hip flexion with knee extension).

Open kinetic chain: distal segment free, joint motion independent; closed kinetic chain: distal segment fixed, joints move in a coupled, co-contraction-heavy pattern with greater joint approximation.

Gait cycle: stance is ~60% and swing ~40% of the cycle; double support occupies ~2 periods per cycle and increases with slower walking speed. Normal cadence is roughly 100-120 steps/min in adults.

Screw-home mechanism: terminal knee extension from ~20° to full involves ~10-15° of tibial external rotation relative to the femur, tightening the ACL and locking the joint.

Levers: first class = force and load on opposite sides of the fulcrum; second class = load between force and fulcrum (mechanical advantage); third class = force between fulcrum and load (most common in the body, favors speed and range).

Oxygen transport: cardiac output = heart rate × stroke volume; Fick principle states VO2 = cardiac output × arteriovenous oxygen difference.

Inflammation phases: acute (vasodilation, increased capillary permeability, neutrophil influx, minutes to days), subacute (macrophages, granulation tissue), chronic (fibrosis, lymphocyte and macrophage predominance, weeks to months).

Tissue healing timelines for soft tissue: inflammatory ~0-5 days, proliferative/fibroblastic ~5 days-6 weeks, remodeling/maturation up to 12 months or more; tendon and ligament healing is slower than muscle.

Fracture healing: hematoma and inflammation (~1 week), soft callus (~2-3 weeks), hard callus (~3-6 weeks), remodeling (months to years).

Bone stress injury: stress reaction precedes stress fracture; risk sites with poor blood supply and high tensile load include femoral neck, anterior tibial cortex, navicular, and fifth metatarsal base (Jones).

Red flags for serious pathology: unexplained weight loss, night pain unrelieved by rest, fever, history of cancer, progressive neurological deficit, bowel/bladder changes, saddle anesthesia, and age over 50 with new-onset pain.

Diabetes mellitus: peripheral neuropathy raises foot ulcer and Charcot risk; exercise-induced hypoglycemia risk is highest with insulin or sulfonylureas, so pre-exercise glucose and carbohydrate planning are required.

Osteoporosis: T-score ≤ -2.5 defines osteoporosis; -1.0 to -2.5 is osteopenia; avoid spinal flexion with loading, high-impact, and twisting exercises in severe osteoporosis; favor weight-bearing and progressive resistance.

Cardiac pathology: stable angina is predictable with exertion and relieved by rest; unstable angina occurs at rest or with changing pattern and is a contraindication to exercise testing until medically stabilized.

Respiratory pathology: obstructive disease (asthma, COPD) shows reduced FEV1/FVC ratio; restrictive disease (fibrosis, kyphoscoliosis) shows reduced FVC with a preserved or raised ratio.

Rotator cuff tendinopathy: painful arc 60-120° abduction, positive Neer and Hawkins-Kennedy tests; management emphasizes progressive loading, scapular control, and activity modification over passive modalities.

Carpal tunnel syndrome: median nerve distribution (thumb, index, middle, radial half of ring), positive Phalen and Tinel tests, nocturnal symptoms; thenar atrophy indicates advanced disease.

Lumbar disc herniation: radicular pain follows a dermatome, positive straight leg raise (sensitized by ankle dorsiflexion), and often improves with extension in central or lateral preference patterns.

Lumbar spinal stenosis: neurogenic claudication relieved by flexion (sitting, leaning forward) and worsened by extension and walking; bilateral symptoms are common.

Osteoarthritis: joint line tenderness, crepitus, morning stiffness under 30 minutes, reduced range; exercise and weight management are first-line, not rest.

Anterior cruciate ligament injury: non-contact pivot mechanism, immediate swelling (hemarthrosis), positive Lachman (most sensitive), pivot shift, and anterior drawer.

Achilles tendinopathy: pain 2-6 cm above the calcaneal insertion, morning stiffness, painful on loading; eccentric or heavy-slow resistance training is the evidence-based core.

Frozen shoulder: three phases (painful, frozen, thawing); capsular pattern is external rotation most limited, then abduction, then internal rotation; corticosteroid injection plus stretching in the painful phase.

Fracture management: relative stability and early controlled motion promote callus; absolute rest and prolonged immobilization increase stiffness and disuse atrophy.

Upper motor neuron lesion signs: hyperreflexia, spasticity, positive Babinski, clonus, and loss of fine dexterity; lower motor neuron signs: flaccidity, fasciculation, atrophy, and areflexia.

Stroke: middle cerebral artery infarct causes contralateral face and arm weakness greater than leg; anterior cerebral artery affects leg more than arm; posterior circulation causes ataxia, diplopia, and dysphagia.

Brunnstrom stages of motor recovery: 1 flaccidity, 2 synergy emergence, 3 synergy dominance, 4 partial voluntary movement out of synergy, 5 complex movement out of synergy, 6 near-normal, 7 normal.

Ashworth scale grades resistance to passive movement from 0 (none) to 4 (rigid); the Modified Ashworth adds 1+ for catch followed by minimal resistance through less than half the range.

Spasticity is velocity-dependent increased tone from hyperexcitable stretch reflex; rigidity is velocity-independent and constant (extrapyramidal, as in Parkinson disease).

Multiple sclerosis: Uhthoff phenomenon is transient worsening with heat; fatigue is the most common symptom; exercise should be scheduled in cooler conditions with pacing.

Guillain-Barré syndrome: ascending symmetric flaccidity with areflexia, autonomic instability, and risk of respiratory failure; monitor vital capacity and avoid overfatigue in the acute phase.

Parkinson disease: resting tremor, bradykinesia, rigidity, and postural instability; cueing (auditory, visual) and large-amplitude training improve gait and freezing.

Balance control: reactive strategies are ankle, hip, and stepping; sensory organization depends on vision, somatosensory, and vestibular input, so testing with eyes closed and on compliant surfaces isolates deficits.

Normal arterial blood gas: pH 7.35-7.45, PaCO2 35-45 mmHg, PaO2 80-100 mmHg, HCO3- 22-26 mEq/L; respiratory acidosis shows raised PaCO2 and low pH, metabolic acidosis shows low HCO3- and low pH.

Exercise prescription for cardiac rehabilitation: moderate intensity is 40-70% of heart rate reserve (Karvonen formula: target HR = resting HR + %intensity × (max HR - resting HR)) or 40-60% of VO2 reserve.

Rate of perceived exertion 11-13 on the 6-20 Borg scale corresponds to moderate intensity and is used when heart rate response is unreliable (beta-blockers, pacemakers).

Absolute contraindications to exercise testing: acute myocardial infarction within 2 days, unstable angina, uncontrolled arrhythmia, acute endocarditis or myocarditis, symptomatic severe aortic stenosis, and acute pulmonary embolism.

Airway clearance techniques: postural drainage, percussion, vibration, active cycle of breathing (breathing control, thoracic expansion, huffing), autogenic drainage, and positive expiratory pressure devices.

Pursed-lip breathing slows expiration, reduces dynamic hyperinflation, and improves dyspnea in COPD; diaphragmatic breathing targets reduced accessory muscle use.

Cystic fibrosis: airway clearance is daily and lifelong; exercise testing and sputum clearance before exercise improve tolerance; dehydration and salt loss in heat are risks.

Six-minute walk test: measures functional exercise capacity; a clinically important change is roughly 30 m in many cardiorespiratory populations; standardize encouragement, track, and rest breaks.

Orthostatic hypotension: drop of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing; manage with slow position changes, hydration, and compression.

Gross motor milestones: head control ~3-4 months, rolling ~5-6 months, independent sitting ~6-8 months, crawling ~8-9 months, pulling to stand ~9-10 months, independent walking ~12-15 months.

Red flags in infant development: persistence of primitive reflexes beyond 6 months, hand fisting after 4 months, asymmetry of movement, failure to bear weight, and loss of previously acquired skills.

Cerebral palsy: classified by tone (spastic, dyskinetic, ataxic) and distribution (hemiplegia, diplegia, quadriplegia); Gross Motor Function Classification System (GMFCS) levels I-V predict mobility prognosis.

Down syndrome: hypotonia, joint hypermobility (especially atlantoaxial), and developmental delay; screen for atlantoaxial instability before high-impact or contact activity.

Spina bifida: level of lesion predicts function; latex allergy precautions are standard; monitor for hydrocephalus and shunt malfunction signs (headache, vomiting, lethargy).

Geriatric falls: multifactorial assessment covers vision, medication review, orthostatic blood pressure, gait and balance (Timed Up and Go, Berg Balance Scale), home hazards, and fear of falling.

Sarcopenia: age-related loss of muscle mass and strength; progressive resistance training plus adequate protein intake are the primary interventions.

Fragility fracture prevention: weight-bearing and balance exercise reduce falls; hip protectors and vitamin D correction are adjuncts; avoid high-impact loading in severe osteoporosis.

Polypharmacy in older adults: sedatives, antihypertensives, and anticholinergics raise fall and delirium risk; deprescribing is a physiotherapy-relevant safety consideration.

SOAP note structure: Subjective (history, symptoms), Objective (measurements, tests), Assessment (clinical impression, differential), Plan (interventions, goals, review date).

SMART goals: Specific, Measurable, Achievable, Relevant, Time-bound; goals should be patient-centered and functional, not solely impairment-based.

Sensitivity is the proportion of true positives correctly identified; specificity is the proportion of true negatives correctly identified; a highly sensitive test is best for ruling out, a highly specific test for ruling in.

Likelihood ratios: positive LR = sensitivity / (1 - specificity); negative LR = (1 - sensitivity) / specificity; LR above 10 or below 0.1 substantially shifts post-test probability.

Intra- and inter-rater reliability: intraclass correlation coefficient (ICC) above 0.75 is generally good; measure the same variable with the same instrument and conditions to compare raters.

Range of motion: goniometry is the standard; measure active before passive; record in degrees with the axis, stationary arm, and moving arm landmarks stated for reproducibility.

Manual muscle testing grades 0-5: 0 no contraction, 1 trace, 2 movement with gravity eliminated, 3 movement against gravity, 4 against gravity with some resistance, 5 normal.

Clinical reasoning errors: anchoring on an early diagnosis, confirmation bias, and premature closure; systematic red-flag screening and re-assessment reduce diagnostic error.

Outcome measures should match the construct: Numeric Pain Rating Scale for pain intensity, Oxford Hip Score for hip function, DASH for upper limb, Berg Balance Scale for balance.

Cryotherapy: reduces tissue temperature, blood flow, and pain; apply 15-20 minutes with a barrier; contraindicated in cold hypersensitivity, Raynaud phenomenon, and over regenerating peripheral nerves.

Thermotherapy: increases collagen extensibility and blood flow; superficial heat 15-20 minutes; avoid over acute inflammation, impaired sensation, and malignancy.

Ultrasound: continuous mode for thermal effects (deep heating), pulsed for non-thermal; intensity 0.5-2.0 W/cm²; avoid over epiphyseal plates, pacemakers, and the eye.

TENS: conventional high-frequency (80-150 Hz, narrow pulse) for pain gating; low-frequency (2-4 Hz) for endorphin release; do not apply over the heart, carotid sinus, or pregnant abdomen.

Resistance training prescription: to build strength, use 60-80% of 1RM for 2-4 sets of 6-12 reps; for endurance, use lower loads (40-60% 1RM) with 15-25 reps; allow 48 hours recovery per muscle group.

Cardiorespiratory exercise: FITT-VP (frequency, intensity, time, type, volume, progression); adults need 150-300 minutes/week of moderate or 75-150 minutes/week of vigorous aerobic activity plus 2 days of strengthening.

Flexibility: static stretching 2-4 repetitions of 15-60 seconds per muscle, 2-3 days/week; dynamic stretching before activity, static stretching after.

Motor learning: practice should be task-specific, variable, and progressively challenging; feedback should be faded as skill improves; blocked practice early, random practice later.

Rehabilitation technology: functional electrical stimulation recruits fatigable motor units and is used for foot drop and hand function; exoskeletons and treadmill body-weight support enable high-intensity gait practice.

Informed consent requires capacity, disclosure of material risks and alternatives, comprehension, and voluntariness; consent must be obtained before assessment or treatment and documented.

Confidentiality: patient information may be shared only with consent or where required by law; disclose the minimum necessary information on a need-to-know basis.

Documentation: contemporaneous, dated, signed, and factual records; record objective findings, interventions, patient response, and any adverse events; never alter records retrospectively.

Scope of practice: a physiotherapist must practice within their training and competence; delegating to assistants requires supervision and retention of professional accountability.

Professional boundaries: sexual or exploitative relationships with patients are prohibited; dual relationships and gifts must be managed transparently.

Duty of care and negligence: four elements must be proven - duty, breach of the standard of care, causation, and damages.

Patient safety: identify patients at risk (falls, pressure injury, infection, medication), use standard precautions (hand hygiene, gloves), and follow safe patient handling and equipment checks.

Incident reporting: report adverse events and near misses through the organization's system without blame; disclose harmful errors to the patient honestly and promptly.

Mandatory reporting and legal duties vary by jurisdiction; when a legal or ethical duty conflicts, seek guidance from the regulator and document the reasoning.

Muscle fiber types: type I is slow-twitch, oxidative, fatigue-resistant, high capillary and mitochondrial density; type IIa is fast-twitch oxidative-glycolytic; type IIx is fast-twitch glycolytic with the highest force and fastest fatigue.

Length-tension relationship: active tension peaks near resting sarcomere length (~2.0-2.2 µm in human muscle) where actin-myosin overlap is optimal; tension falls when the muscle is over-shortened or over-stretched.

Force-velocity relationship: concentric force decreases as shortening velocity rises; eccentric contractions generate greater force than isometric, which exceeds concentric at the same activation.

Muscle action depends on joint motion, not anatomy alone: a two-joint muscle can act as agonist at one joint and antagonist at another simultaneously (e.g., rectus femoris hip flexion with knee extension).

Open kinetic chain: distal segment free, joint motion independent; closed kinetic chain: distal segment fixed, joints move in a coupled, co-contraction-heavy pattern with greater joint approximation.

Gait cycle: stance is ~60% and swing ~40% of the cycle; double support occupies ~2 periods per cycle and increases with slower walking speed. Normal cadence is roughly 100-120 steps/min in adults.

Screw-home mechanism: terminal knee extension from ~20° to full involves ~10-15° of tibial external rotation relative to the femur, tightening the ACL and locking the joint.

Levers: first class = force and load on opposite sides of the fulcrum; second class = load between force and fulcrum (mechanical advantage); third class = force between fulcrum and load (most common in the body, favors speed and range).

Oxygen transport: cardiac output = heart rate × stroke volume; Fick principle states VO2 = cardiac output × arteriovenous oxygen difference.

Inflammation phases: acute (vasodilation, increased capillary permeability, neutrophil influx, minutes to days), subacute (macrophages, granulation tissue), chronic (fibrosis, lymphocyte and macrophage predominance, weeks to months).

Tissue healing timelines for soft tissue: inflammatory ~0-5 days, proliferative/fibroblastic ~5 days-6 weeks, remodeling/maturation up to 12 months or more; tendon and ligament healing is slower than muscle.

Fracture healing: hematoma and inflammation (~1 week), soft callus (~2-3 weeks), hard callus (~3-6 weeks), remodeling (months to years).

Bone stress injury: stress reaction precedes stress fracture; risk sites with poor blood supply and high tensile load include femoral neck, anterior tibial cortex, navicular, and fifth metatarsal base (Jones).

Red flags for serious pathology: unexplained weight loss, night pain unrelieved by rest, fever, history of cancer, progressive neurological deficit, bowel/bladder changes, saddle anesthesia, and age over 50 with new-onset pain.

Diabetes mellitus: peripheral neuropathy raises foot ulcer and Charcot risk; exercise-induced hypoglycemia risk is highest with insulin or sulfonylureas, so pre-exercise glucose and carbohydrate planning are required.

Osteoporosis: T-score ≤ -2.5 defines osteoporosis; -1.0 to -2.5 is osteopenia; avoid spinal flexion with loading, high-impact, and twisting exercises in severe osteoporosis; favor weight-bearing and progressive resistance.

Cardiac pathology: stable angina is predictable with exertion and relieved by rest; unstable angina occurs at rest or with changing pattern and is a contraindication to exercise testing until medically stabilized.

Respiratory pathology: obstructive disease (asthma, COPD) shows reduced FEV1/FVC ratio; restrictive disease (fibrosis, kyphoscoliosis) shows reduced FVC with a preserved or raised ratio.

Rotator cuff tendinopathy: painful arc 60-120° abduction, positive Neer and Hawkins-Kennedy tests; management emphasizes progressive loading, scapular control, and activity modification over passive modalities.

Carpal tunnel syndrome: median nerve distribution (thumb, index, middle, radial half of ring), positive Phalen and Tinel tests, nocturnal symptoms; thenar atrophy indicates advanced disease.

Lumbar disc herniation: radicular pain follows a dermatome, positive straight leg raise (sensitized by ankle dorsiflexion), and often improves with extension in central or lateral preference patterns.

Lumbar spinal stenosis: neurogenic claudication relieved by flexion (sitting, leaning forward) and worsened by extension and walking; bilateral symptoms are common.

Osteoarthritis: joint line tenderness, crepitus, morning stiffness under 30 minutes, reduced range; exercise and weight management are first-line, not rest.

Anterior cruciate ligament injury: non-contact pivot mechanism, immediate swelling (hemarthrosis), positive Lachman (most sensitive), pivot shift, and anterior drawer.

Achilles tendinopathy: pain 2-6 cm above the calcaneal insertion, morning stiffness, painful on loading; eccentric or heavy-slow resistance training is the evidence-based core.

Frozen shoulder: three phases (painful, frozen, thawing); capsular pattern is external rotation most limited, then abduction, then internal rotation; corticosteroid injection plus stretching in the painful phase.

Fracture management: relative stability and early controlled motion promote callus; absolute rest and prolonged immobilization increase stiffness and disuse atrophy.

Upper motor neuron lesion signs: hyperreflexia, spasticity, positive Babinski, clonus, and loss of fine dexterity; lower motor neuron signs: flaccidity, fasciculation, atrophy, and areflexia.

Stroke: middle cerebral artery infarct causes contralateral face and arm weakness greater than leg; anterior cerebral artery affects leg more than arm; posterior circulation causes ataxia, diplopia, and dysphagia.

Brunnstrom stages of motor recovery: 1 flaccidity, 2 synergy emergence, 3 synergy dominance, 4 partial voluntary movement out of synergy, 5 complex movement out of synergy, 6 near-normal, 7 normal.

Ashworth scale grades resistance to passive movement from 0 (none) to 4 (rigid); the Modified Ashworth adds 1+ for catch followed by minimal resistance through less than half the range.

Spasticity is velocity-dependent increased tone from hyperexcitable stretch reflex; rigidity is velocity-independent and constant (extrapyramidal, as in Parkinson disease).

Multiple sclerosis: Uhthoff phenomenon is transient worsening with heat; fatigue is the most common symptom; exercise should be scheduled in cooler conditions with pacing.

Guillain-Barré syndrome: ascending symmetric flaccidity with areflexia, autonomic instability, and risk of respiratory failure; monitor vital capacity and avoid overfatigue in the acute phase.

Parkinson disease: resting tremor, bradykinesia, rigidity, and postural instability; cueing (auditory, visual) and large-amplitude training improve gait and freezing.

Balance control: reactive strategies are ankle, hip, and stepping; sensory organization depends on vision, somatosensory, and vestibular input, so testing with eyes closed and on compliant surfaces isolates deficits.

Normal arterial blood gas: pH 7.35-7.45, PaCO2 35-45 mmHg, PaO2 80-100 mmHg, HCO3- 22-26 mEq/L; respiratory acidosis shows raised PaCO2 and low pH, metabolic acidosis shows low HCO3- and low pH.

Exercise prescription for cardiac rehabilitation: moderate intensity is 40-70% of heart rate reserve (Karvonen formula: target HR = resting HR + %intensity × (max HR - resting HR)) or 40-60% of VO2 reserve.

Rate of perceived exertion 11-13 on the 6-20 Borg scale corresponds to moderate intensity and is used when heart rate response is unreliable (beta-blockers, pacemakers).

Absolute contraindications to exercise testing: acute myocardial infarction within 2 days, unstable angina, uncontrolled arrhythmia, acute endocarditis or myocarditis, symptomatic severe aortic stenosis, and acute pulmonary embolism.

Airway clearance techniques: postural drainage, percussion, vibration, active cycle of breathing (breathing control, thoracic expansion, huffing), autogenic drainage, and positive expiratory pressure devices.

Pursed-lip breathing slows expiration, reduces dynamic hyperinflation, and improves dyspnea in COPD; diaphragmatic breathing targets reduced accessory muscle use.

Cystic fibrosis: airway clearance is daily and lifelong; exercise testing and sputum clearance before exercise improve tolerance; dehydration and salt loss in heat are risks.

Six-minute walk test: measures functional exercise capacity; a clinically important change is roughly 30 m in many cardiorespiratory populations; standardize encouragement, track, and rest breaks.

Orthostatic hypotension: drop of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing; manage with slow position changes, hydration, and compression.

Gross motor milestones: head control ~3-4 months, rolling ~5-6 months, independent sitting ~6-8 months, crawling ~8-9 months, pulling to stand ~9-10 months, independent walking ~12-15 months.

Red flags in infant development: persistence of primitive reflexes beyond 6 months, hand fisting after 4 months, asymmetry of movement, failure to bear weight, and loss of previously acquired skills.

Cerebral palsy: classified by tone (spastic, dyskinetic, ataxic) and distribution (hemiplegia, diplegia, quadriplegia); Gross Motor Function Classification System (GMFCS) levels I-V predict mobility prognosis.

Down syndrome: hypotonia, joint hypermobility (especially atlantoaxial), and developmental delay; screen for atlantoaxial instability before high-impact or contact activity.

Spina bifida: level of lesion predicts function; latex allergy precautions are standard; monitor for hydrocephalus and shunt malfunction signs (headache, vomiting, lethargy).

Geriatric falls: multifactorial assessment covers vision, medication review, orthostatic blood pressure, gait and balance (Timed Up and Go, Berg Balance Scale), home hazards, and fear of falling.

Sarcopenia: age-related loss of muscle mass and strength; progressive resistance training plus adequate protein intake are the primary interventions.

Fragility fracture prevention: weight-bearing and balance exercise reduce falls; hip protectors and vitamin D correction are adjuncts; avoid high-impact loading in severe osteoporosis.

Polypharmacy in older adults: sedatives, antihypertensives, and anticholinergics raise fall and delirium risk; deprescribing is a physiotherapy-relevant safety consideration.

SOAP note structure: Subjective (history, symptoms), Objective (measurements, tests), Assessment (clinical impression, differential), Plan (interventions, goals, review date).

SMART goals: Specific, Measurable, Achievable, Relevant, Time-bound; goals should be patient-centered and functional, not solely impairment-based.

Sensitivity is the proportion of true positives correctly identified; specificity is the proportion of true negatives correctly identified; a highly sensitive test is best for ruling out, a highly specific test for ruling in.

Likelihood ratios: positive LR = sensitivity / (1 - specificity); negative LR = (1 - sensitivity) / specificity; LR above 10 or below 0.1 substantially shifts post-test probability.

Intra- and inter-rater reliability: intraclass correlation coefficient (ICC) above 0.75 is generally good; measure the same variable with the same instrument and conditions to compare raters.

Range of motion: goniometry is the standard; measure active before passive; record in degrees with the axis, stationary arm, and moving arm landmarks stated for reproducibility.

Manual muscle testing grades 0-5: 0 no contraction, 1 trace, 2 movement with gravity eliminated, 3 movement against gravity, 4 against gravity with some resistance, 5 normal.

Clinical reasoning errors: anchoring on an early diagnosis, confirmation bias, and premature closure; systematic red-flag screening and re-assessment reduce diagnostic error.

Outcome measures should match the construct: Numeric Pain Rating Scale for pain intensity, Oxford Hip Score for hip function, DASH for upper limb, Berg Balance Scale for balance.

Cryotherapy: reduces tissue temperature, blood flow, and pain; apply 15-20 minutes with a barrier; contraindicated in cold hypersensitivity, Raynaud phenomenon, and over regenerating peripheral nerves.

Thermotherapy: increases collagen extensibility and blood flow; superficial heat 15-20 minutes; avoid over acute inflammation, impaired sensation, and malignancy.

Ultrasound: continuous mode for thermal effects (deep heating), pulsed for non-thermal; intensity 0.5-2.0 W/cm²; avoid over epiphyseal plates, pacemakers, and the eye.

TENS: conventional high-frequency (80-150 Hz, narrow pulse) for pain gating; low-frequency (2-4 Hz) for endorphin release; do not apply over the heart, carotid sinus, or pregnant abdomen.

Resistance training prescription: to build strength, use 60-80% of 1RM for 2-4 sets of 6-12 reps; for endurance, use lower loads (40-60% 1RM) with 15-25 reps; allow 48 hours recovery per muscle group.

Cardiorespiratory exercise: FITT-VP (frequency, intensity, time, type, volume, progression); adults need 150-300 minutes/week of moderate or 75-150 minutes/week of vigorous aerobic activity plus 2 days of strengthening.

Flexibility: static stretching 2-4 repetitions of 15-60 seconds per muscle, 2-3 days/week; dynamic stretching before activity, static stretching after.

Motor learning: practice should be task-specific, variable, and progressively challenging; feedback should be faded as skill improves; blocked practice early, random practice later.

Rehabilitation technology: functional electrical stimulation recruits fatigable motor units and is used for foot drop and hand function; exoskeletons and treadmill body-weight support enable high-intensity gait practice.

Informed consent requires capacity, disclosure of material risks and alternatives, comprehension, and voluntariness; consent must be obtained before assessment or treatment and documented.

Confidentiality: patient information may be shared only with consent or where required by law; disclose the minimum necessary information on a need-to-know basis.

Documentation: contemporaneous, dated, signed, and factual records; record objective findings, interventions, patient response, and any adverse events; never alter records retrospectively.

Scope of practice: a physiotherapist must practice within their training and competence; delegating to assistants requires supervision and retention of professional accountability.

Professional boundaries: sexual or exploitative relationships with patients are prohibited; dual relationships and gifts must be managed transparently.

Duty of care and negligence: four elements must be proven - duty, breach of the standard of care, causation, and damages.

Patient safety: identify patients at risk (falls, pressure injury, infection, medication), use standard precautions (hand hygiene, gloves), and follow safe patient handling and equipment checks.

Incident reporting: report adverse events and near misses through the organization's system without blame; disclose harmful errors to the patient honestly and promptly.

Mandatory reporting and legal duties vary by jurisdiction; when a legal or ethical duty conflicts, seek guidance from the regulator and document the reasoning.

Muscle fiber types: type I is slow-twitch, oxidative, fatigue-resistant, high capillary and mitochondrial density; type IIa is fast-twitch oxidative-glycolytic; type IIx is fast-twitch glycolytic with the highest force and fastest fatigue.

Length-tension relationship: active tension peaks near resting sarcomere length (~2.0-2.2 µm in human muscle) where actin-myosin overlap is optimal; tension falls when the muscle is over-shortened or over-stretched.

Force-velocity relationship: concentric force decreases as shortening velocity rises; eccentric contractions generate greater force than isometric, which exceeds concentric at the same activation.

Muscle action depends on joint motion, not anatomy alone: a two-joint muscle can act as agonist at one joint and antagonist at another simultaneously (e.g., rectus femoris hip flexion with knee extension).

Open kinetic chain: distal segment free, joint motion independent; closed kinetic chain: distal segment fixed, joints move in a coupled, co-contraction-heavy pattern with greater joint approximation.

Gait cycle: stance is ~60% and swing ~40% of the cycle; double support occupies ~2 periods per cycle and increases with slower walking speed. Normal cadence is roughly 100-120 steps/min in adults.

Screw-home mechanism: terminal knee extension from ~20° to full involves ~10-15° of tibial external rotation relative to the femur, tightening the ACL and locking the joint.

Levers: first class = force and load on opposite sides of the fulcrum; second class = load between force and fulcrum (mechanical advantage); third class = force between fulcrum and load (most common in the body, favors speed and range).

Oxygen transport: cardiac output = heart rate × stroke volume; Fick principle states VO2 = cardiac output × arteriovenous oxygen difference.

Inflammation phases: acute (vasodilation, increased capillary permeability, neutrophil influx, minutes to days), subacute (macrophages, granulation tissue), chronic (fibrosis, lymphocyte and macrophage predominance, weeks to months).

Tissue healing timelines for soft tissue: inflammatory ~0-5 days, proliferative/fibroblastic ~5 days-6 weeks, remodeling/maturation up to 12 months or more; tendon and ligament healing is slower than muscle.

Fracture healing: hematoma and inflammation (~1 week), soft callus (~2-3 weeks), hard callus (~3-6 weeks), remodeling (months to years).

Bone stress injury: stress reaction precedes stress fracture; risk sites with poor blood supply and high tensile load include femoral neck, anterior tibial cortex, navicular, and fifth metatarsal base (Jones).

Red flags for serious pathology: unexplained weight loss, night pain unrelieved by rest, fever, history of cancer, progressive neurological deficit, bowel/bladder changes, saddle anesthesia, and age over 50 with new-onset pain.

Diabetes mellitus: peripheral neuropathy raises foot ulcer and Charcot risk; exercise-induced hypoglycemia risk is highest with insulin or sulfonylureas, so pre-exercise glucose and carbohydrate planning are required.

Osteoporosis: T-score ≤ -2.5 defines osteoporosis; -1.0 to -2.5 is osteopenia; avoid spinal flexion with loading, high-impact, and twisting exercises in severe osteoporosis; favor weight-bearing and progressive resistance.

Cardiac pathology: stable angina is predictable with exertion and relieved by rest; unstable angina occurs at rest or with changing pattern and is a contraindication to exercise testing until medically stabilized.

Respiratory pathology: obstructive disease (asthma, COPD) shows reduced FEV1/FVC ratio; restrictive disease (fibrosis, kyphoscoliosis) shows reduced FVC with a preserved or raised ratio.

Rotator cuff tendinopathy: painful arc 60-120° abduction, positive Neer and Hawkins-Kennedy tests; management emphasizes progressive loading, scapular control, and activity modification over passive modalities.

Carpal tunnel syndrome: median nerve distribution (thumb, index, middle, radial half of ring), positive Phalen and Tinel tests, nocturnal symptoms; thenar atrophy indicates advanced disease.

Lumbar disc herniation: radicular pain follows a dermatome, positive straight leg raise (sensitized by ankle dorsiflexion), and often improves with extension in central or lateral preference patterns.

Lumbar spinal stenosis: neurogenic claudication relieved by flexion (sitting, leaning forward) and worsened by extension and walking; bilateral symptoms are common.

Osteoarthritis: joint line tenderness, crepitus, morning stiffness under 30 minutes, reduced range; exercise and weight management are first-line, not rest.

Anterior cruciate ligament injury: non-contact pivot mechanism, immediate swelling (hemarthrosis), positive Lachman (most sensitive), pivot shift, and anterior drawer.

Achilles tendinopathy: pain 2-6 cm above the calcaneal insertion, morning stiffness, painful on loading; eccentric or heavy-slow resistance training is the evidence-based core.

Frozen shoulder: three phases (painful, frozen, thawing); capsular pattern is external rotation most limited, then abduction, then internal rotation; corticosteroid injection plus stretching in the painful phase.

Fracture management: relative stability and early controlled motion promote callus; absolute rest and prolonged immobilization increase stiffness and disuse atrophy.

Upper motor neuron lesion signs: hyperreflexia, spasticity, positive Babinski, clonus, and loss of fine dexterity; lower motor neuron signs: flaccidity, fasciculation, atrophy, and areflexia.

Stroke: middle cerebral artery infarct causes contralateral face and arm weakness greater than leg; anterior cerebral artery affects leg more than arm; posterior circulation causes ataxia, diplopia, and dysphagia.

Brunnstrom stages of motor recovery: 1 flaccidity, 2 synergy emergence, 3 synergy dominance, 4 partial voluntary movement out of synergy, 5 complex movement out of synergy, 6 near-normal, 7 normal.

Ashworth scale grades resistance to passive movement from 0 (none) to 4 (rigid); the Modified Ashworth adds 1+ for catch followed by minimal resistance through less than half the range.

Spasticity is velocity-dependent increased tone from hyperexcitable stretch reflex; rigidity is velocity-independent and constant (extrapyramidal, as in Parkinson disease).

Multiple sclerosis: Uhthoff phenomenon is transient worsening with heat; fatigue is the most common symptom; exercise should be scheduled in cooler conditions with pacing.

Guillain-Barré syndrome: ascending symmetric flaccidity with areflexia, autonomic instability, and risk of respiratory failure; monitor vital capacity and avoid overfatigue in the acute phase.

Parkinson disease: resting tremor, bradykinesia, rigidity, and postural instability; cueing (auditory, visual) and large-amplitude training improve gait and freezing.

Balance control: reactive strategies are ankle, hip, and stepping; sensory organization depends on vision, somatosensory, and vestibular input, so testing with eyes closed and on compliant surfaces isolates deficits.

Normal arterial blood gas: pH 7.35-7.45, PaCO2 35-45 mmHg, PaO2 80-100 mmHg, HCO3- 22-26 mEq/L; respiratory acidosis shows raised PaCO2 and low pH, metabolic acidosis shows low HCO3- and low pH.

Exercise prescription for cardiac rehabilitation: moderate intensity is 40-70% of heart rate reserve (Karvonen formula: target HR = resting HR + %intensity × (max HR - resting HR)) or 40-60% of VO2 reserve.

Rate of perceived exertion 11-13 on the 6-20 Borg scale corresponds to moderate intensity and is used when heart rate response is unreliable (beta-blockers, pacemakers).

Absolute contraindications to exercise testing: acute myocardial infarction within 2 days, unstable angina, uncontrolled arrhythmia, acute endocarditis or myocarditis, symptomatic severe aortic stenosis, and acute pulmonary embolism.

Airway clearance techniques: postural drainage, percussion, vibration, active cycle of breathing (breathing control, thoracic expansion, huffing), autogenic drainage, and positive expiratory pressure devices.

Pursed-lip breathing slows expiration, reduces dynamic hyperinflation, and improves dyspnea in COPD; diaphragmatic breathing targets reduced accessory muscle use.

Cystic fibrosis: airway clearance is daily and lifelong; exercise testing and sputum clearance before exercise improve tolerance; dehydration and salt loss in heat are risks.

Six-minute walk test: measures functional exercise capacity; a clinically important change is roughly 30 m in many cardiorespiratory populations; standardize encouragement, track, and rest breaks.

Orthostatic hypotension: drop of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing; manage with slow position changes, hydration, and compression.

Gross motor milestones: head control ~3-4 months, rolling ~5-6 months, independent sitting ~6-8 months, crawling ~8-9 months, pulling to stand ~9-10 months, independent walking ~12-15 months.

Red flags in infant development: persistence of primitive reflexes beyond 6 months, hand fisting after 4 months, asymmetry of movement, failure to bear weight, and loss of previously acquired skills.

Cerebral palsy: classified by tone (spastic, dyskinetic, ataxic) and distribution (hemiplegia, diplegia, quadriplegia); Gross Motor Function Classification System (GMFCS) levels I-V predict mobility prognosis.

Down syndrome: hypotonia, joint hypermobility (especially atlantoaxial), and developmental delay; screen for atlantoaxial instability before high-impact or contact activity.

Spina bifida: level of lesion predicts function; latex allergy precautions are standard; monitor for hydrocephalus and shunt malfunction signs (headache, vomiting, lethargy).

Geriatric falls: multifactorial assessment covers vision, medication review, orthostatic blood pressure, gait and balance (Timed Up and Go, Berg Balance Scale), home hazards, and fear of falling.

Sarcopenia: age-related loss of muscle mass and strength; progressive resistance training plus adequate protein intake are the primary interventions.

Fragility fracture prevention: weight-bearing and balance exercise reduce falls; hip protectors and vitamin D correction are adjuncts; avoid high-impact loading in severe osteoporosis.

Polypharmacy in older adults: sedatives, antihypertensives, and anticholinergics raise fall and delirium risk; deprescribing is a physiotherapy-relevant safety consideration.

SOAP note structure: Subjective (history, symptoms), Objective (measurements, tests), Assessment (clinical impression, differential), Plan (interventions, goals, review date).

SMART goals: Specific, Measurable, Achievable, Relevant, Time-bound; goals should be patient-centered and functional, not solely impairment-based.

Sensitivity is the proportion of true positives correctly identified; specificity is the proportion of true negatives correctly identified; a highly sensitive test is best for ruling out, a highly specific test for ruling in.

Likelihood ratios: positive LR = sensitivity / (1 - specificity); negative LR = (1 - sensitivity) / specificity; LR above 10 or below 0.1 substantially shifts post-test probability.

Intra- and inter-rater reliability: intraclass correlation coefficient (ICC) above 0.75 is generally good; measure the same variable with the same instrument and conditions to compare raters.

Range of motion: goniometry is the standard; measure active before passive; record in degrees with the axis, stationary arm, and moving arm landmarks stated for reproducibility.

Manual muscle testing grades 0-5: 0 no contraction, 1 trace, 2 movement with gravity eliminated, 3 movement against gravity, 4 against gravity with some resistance, 5 normal.

Clinical reasoning errors: anchoring on an early diagnosis, confirmation bias, and premature closure; systematic red-flag screening and re-assessment reduce diagnostic error.

Outcome measures should match the construct: Numeric Pain Rating Scale for pain intensity, Oxford Hip Score for hip function, DASH for upper limb, Berg Balance Scale for balance.

Cryotherapy: reduces tissue temperature, blood flow, and pain; apply 15-20 minutes with a barrier; contraindicated in cold hypersensitivity, Raynaud phenomenon, and over regenerating peripheral nerves.

Thermotherapy: increases collagen extensibility and blood flow; superficial heat 15-20 minutes; avoid over acute inflammation, impaired sensation, and malignancy.

Ultrasound: continuous mode for thermal effects (deep heating), pulsed for non-thermal; intensity 0.5-2.0 W/cm²; avoid over epiphyseal plates, pacemakers, and the eye.

TENS: conventional high-frequency (80-150 Hz, narrow pulse) for pain gating; low-frequency (2-4 Hz) for endorphin release; do not apply over the heart, carotid sinus, or pregnant abdomen.

Resistance training prescription: to build strength, use 60-80% of 1RM for 2-4 sets of 6-12 reps; for endurance, use lower loads (40-60% 1RM) with 15-25 reps; allow 48 hours recovery per muscle group.

Cardiorespiratory exercise: FITT-VP (frequency, intensity, time, type, volume, progression); adults need 150-300 minutes/week of moderate or 75-150 minutes/week of vigorous aerobic activity plus 2 days of strengthening.

Flexibility: static stretching 2-4 repetitions of 15-60 seconds per muscle, 2-3 days/week; dynamic stretching before activity, static stretching after.

Motor learning: practice should be task-specific, variable, and progressively challenging; feedback should be faded as skill improves; blocked practice early, random practice later.

Rehabilitation technology: functional electrical stimulation recruits fatigable motor units and is used for foot drop and hand function; exoskeletons and treadmill body-weight support enable high-intensity gait practice.

Informed consent requires capacity, disclosure of material risks and alternatives, comprehension, and voluntariness; consent must be obtained before assessment or treatment and documented.

Confidentiality: patient information may be shared only with consent or where required by law; disclose the minimum necessary information on a need-to-know basis.

Documentation: contemporaneous, dated, signed, and factual records; record objective findings, interventions, patient response, and any adverse events; never alter records retrospectively.

Scope of practice: a physiotherapist must practice within their training and competence; delegating to assistants requires supervision and retention of professional accountability.

Professional boundaries: sexual or exploitative relationships with patients are prohibited; dual relationships and gifts must be managed transparently.

Duty of care and negligence: four elements must be proven - duty, breach of the standard of care, causation, and damages.

Patient safety: identify patients at risk (falls, pressure injury, infection, medication), use standard precautions (hand hygiene, gloves), and follow safe patient handling and equipment checks.

Incident reporting: report adverse events and near misses through the organization's system without blame; disclose harmful errors to the patient honestly and promptly.

Mandatory reporting and legal duties vary by jurisdiction; when a legal or ethical duty conflicts, seek guidance from the regulator and document the reasoning.

Muscle fiber types: type I is slow-twitch, oxidative, fatigue-resistant, high capillary and mitochondrial density; type IIa is fast-twitch oxidative-glycolytic; type IIx is fast-twitch glycolytic with the highest force and fastest fatigue.

Length-tension relationship: active tension peaks near resting sarcomere length (~2.0-2.2 µm in human muscle) where actin-myosin overlap is optimal; tension falls when the muscle is over-shortened or over-stretched.

Force-velocity relationship: concentric force decreases as shortening velocity rises; eccentric contractions generate greater force than isometric, which exceeds concentric at the same activation.

Muscle action depends on joint motion, not anatomy alone: a two-joint muscle can act as agonist at one joint and antagonist at another simultaneously (e.g., rectus femoris hip flexion with knee extension).

Open kinetic chain: distal segment free, joint motion independent; closed kinetic chain: distal segment fixed, joints move in a coupled, co-contraction-heavy pattern with greater joint approximation.

Gait cycle: stance is ~60% and swing ~40% of the cycle; double support occupies ~2 periods per cycle and increases with slower walking speed. Normal cadence is roughly 100-120 steps/min in adults.

Screw-home mechanism: terminal knee extension from ~20° to full involves ~10-15° of tibial external rotation relative to the femur, tightening the ACL and locking the joint.

Levers: first class = force and load on opposite sides of the fulcrum; second class = load between force and fulcrum (mechanical advantage); third class = force between fulcrum and load (most common in the body, favors speed and range).

Oxygen transport: cardiac output = heart rate × stroke volume; Fick principle states VO2 = cardiac output × arteriovenous oxygen difference.

Inflammation phases: acute (vasodilation, increased capillary permeability, neutrophil influx, minutes to days), subacute (macrophages, granulation tissue), chronic (fibrosis, lymphocyte and macrophage predominance, weeks to months).

Tissue healing timelines for soft tissue: inflammatory ~0-5 days, proliferative/fibroblastic ~5 days-6 weeks, remodeling/maturation up to 12 months or more; tendon and ligament healing is slower than muscle.

Fracture healing: hematoma and inflammation (~1 week), soft callus (~2-3 weeks), hard callus (~3-6 weeks), remodeling (months to years).

Bone stress injury: stress reaction precedes stress fracture; risk sites with poor blood supply and high tensile load include femoral neck, anterior tibial cortex, navicular, and fifth metatarsal base (Jones).

Red flags for serious pathology: unexplained weight loss, night pain unrelieved by rest, fever, history of cancer, progressive neurological deficit, bowel/bladder changes, saddle anesthesia, and age over 50 with new-onset pain.

Diabetes mellitus: peripheral neuropathy raises foot ulcer and Charcot risk; exercise-induced hypoglycemia risk is highest with insulin or sulfonylureas, so pre-exercise glucose and carbohydrate planning are required.

Osteoporosis: T-score ≤ -2.5 defines osteoporosis; -1.0 to -2.5 is osteopenia; avoid spinal flexion with loading, high-impact, and twisting exercises in severe osteoporosis; favor weight-bearing and progressive resistance.

Cardiac pathology: stable angina is predictable with exertion and relieved by rest; unstable angina occurs at rest or with changing pattern and is a contraindication to exercise testing until medically stabilized.

Respiratory pathology: obstructive disease (asthma, COPD) shows reduced FEV1/FVC ratio; restrictive disease (fibrosis, kyphoscoliosis) shows reduced FVC with a preserved or raised ratio.

Rotator cuff tendinopathy: painful arc 60-120° abduction, positive Neer and Hawkins-Kennedy tests; management emphasizes progressive loading, scapular control, and activity modification over passive modalities.

Carpal tunnel syndrome: median nerve distribution (thumb, index, middle, radial half of ring), positive Phalen and Tinel tests, nocturnal symptoms; thenar atrophy indicates advanced disease.

Lumbar disc herniation: radicular pain follows a dermatome, positive straight leg raise (sensitized by ankle dorsiflexion), and often improves with extension in central or lateral preference patterns.

Lumbar spinal stenosis: neurogenic claudication relieved by flexion (sitting, leaning forward) and worsened by extension and walking; bilateral symptoms are common.

Osteoarthritis: joint line tenderness, crepitus, morning stiffness under 30 minutes, reduced range; exercise and weight management are first-line, not rest.

Anterior cruciate ligament injury: non-contact pivot mechanism, immediate swelling (hemarthrosis), positive Lachman (most sensitive), pivot shift, and anterior drawer.

Achilles tendinopathy: pain 2-6 cm above the calcaneal insertion, morning stiffness, painful on loading; eccentric or heavy-slow resistance training is the evidence-based core.

Frozen shoulder: three phases (painful, frozen, thawing); capsular pattern is external rotation most limited, then abduction, then internal rotation; corticosteroid injection plus stretching in the painful phase.

Fracture management: relative stability and early controlled motion promote callus; absolute rest and prolonged immobilization increase stiffness and disuse atrophy.

Upper motor neuron lesion signs: hyperreflexia, spasticity, positive Babinski, clonus, and loss of fine dexterity; lower motor neuron signs: flaccidity, fasciculation, atrophy, and areflexia.

Stroke: middle cerebral artery infarct causes contralateral face and arm weakness greater than leg; anterior cerebral artery affects leg more than arm; posterior circulation causes ataxia, diplopia, and dysphagia.

Brunnstrom stages of motor recovery: 1 flaccidity, 2 synergy emergence, 3 synergy dominance, 4 partial voluntary movement out of synergy, 5 complex movement out of synergy, 6 near-normal, 7 normal.

Ashworth scale grades resistance to passive movement from 0 (none) to 4 (rigid); the Modified Ashworth adds 1+ for catch followed by minimal resistance through less than half the range.

Spasticity is velocity-dependent increased tone from hyperexcitable stretch reflex; rigidity is velocity-independent and constant (extrapyramidal, as in Parkinson disease).

Multiple sclerosis: Uhthoff phenomenon is transient worsening with heat; fatigue is the most common symptom; exercise should be scheduled in cooler conditions with pacing.

Guillain-Barré syndrome: ascending symmetric flaccidity with areflexia, autonomic instability, and risk of respiratory failure; monitor vital capacity and avoid overfatigue in the acute phase.

Parkinson disease: resting tremor, bradykinesia, rigidity, and postural instability; cueing (auditory, visual) and large-amplitude training improve gait and freezing.

Balance control: reactive strategies are ankle, hip, and stepping; sensory organization depends on vision, somatosensory, and vestibular input, so testing with eyes closed and on compliant surfaces isolates deficits.

Normal arterial blood gas: pH 7.35-7.45, PaCO2 35-45 mmHg, PaO2 80-100 mmHg, HCO3- 22-26 mEq/L; respiratory acidosis shows raised PaCO2 and low pH, metabolic acidosis shows low HCO3- and low pH.

Exercise prescription for cardiac rehabilitation: moderate intensity is 40-70% of heart rate reserve (Karvonen formula: target HR = resting HR + %intensity × (max HR - resting HR)) or 40-60% of VO2 reserve.

Rate of perceived exertion 11-13 on the 6-20 Borg scale corresponds to moderate intensity and is used when heart rate response is unreliable (beta-blockers, pacemakers).

Absolute contraindications to exercise testing: acute myocardial infarction within 2 days, unstable angina, uncontrolled arrhythmia, acute endocarditis or myocarditis, symptomatic severe aortic stenosis, and acute pulmonary embolism.

Airway clearance techniques: postural drainage, percussion, vibration, active cycle of breathing (breathing control, thoracic expansion, huffing), autogenic drainage, and positive expiratory pressure devices.

Pursed-lip breathing slows expiration, reduces dynamic hyperinflation, and improves dyspnea in COPD; diaphragmatic breathing targets reduced accessory muscle use.

Cystic fibrosis: airway clearance is daily and lifelong; exercise testing and sputum clearance before exercise improve tolerance; dehydration and salt loss in heat are risks.

Six-minute walk test: measures functional exercise capacity; a clinically important change is roughly 30 m in many cardiorespiratory populations; standardize encouragement, track, and rest breaks.

Orthostatic hypotension: drop of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing; manage with slow position changes, hydration, and compression.

Gross motor milestones: head control ~3-4 months, rolling ~5-6 months, independent sitting ~6-8 months, crawling ~8-9 months, pulling to stand ~9-10 months, independent walking ~12-15 months.

Red flags in infant development: persistence of primitive reflexes beyond 6 months, hand fisting after 4 months, asymmetry of movement, failure to bear weight, and loss of previously acquired skills.

Cerebral palsy: classified by tone (spastic, dyskinetic, ataxic) and distribution (hemiplegia, diplegia, quadriplegia); Gross Motor Function Classification System (GMFCS) levels I-V predict mobility prognosis.

Down syndrome: hypotonia, joint hypermobility (especially atlantoaxial), and developmental delay; screen for atlantoaxial instability before high-impact or contact activity.

Spina bifida: level of lesion predicts function; latex allergy precautions are standard; monitor for hydrocephalus and shunt malfunction signs (headache, vomiting, lethargy).

Geriatric falls: multifactorial assessment covers vision, medication review, orthostatic blood pressure, gait and balance (Timed Up and Go, Berg Balance Scale), home hazards, and fear of falling.

Sarcopenia: age-related loss of muscle mass and strength; progressive resistance training plus adequate protein intake are the primary interventions.

Fragility fracture prevention: weight-bearing and balance exercise reduce falls; hip protectors and vitamin D correction are adjuncts; avoid high-impact loading in severe osteoporosis.

Polypharmacy in older adults: sedatives, antihypertensives, and anticholinergics raise fall and delirium risk; deprescribing is a physiotherapy-relevant safety consideration.

SOAP note structure: Subjective (history, symptoms), Objective (measurements, tests), Assessment (clinical impression, differential), Plan (interventions, goals, review date).

SMART goals: Specific, Measurable, Achievable, Relevant, Time-bound; goals should be patient-centered and functional, not solely impairment-based.

Sensitivity is the proportion of true positives correctly identified; specificity is the proportion of true negatives correctly identified; a highly sensitive test is best for ruling out, a highly specific test for ruling in.

Likelihood ratios: positive LR = sensitivity / (1 - specificity); negative LR = (1 - sensitivity) / specificity; LR above 10 or below 0.1 substantially shifts post-test probability.

Intra- and inter-rater reliability: intraclass correlation coefficient (ICC) above 0.75 is generally good; measure the same variable with the same instrument and conditions to compare raters.

Range of motion: goniometry is the standard; measure active before passive; record in degrees with the axis, stationary arm, and moving arm landmarks stated for reproducibility.

Manual muscle testing grades 0-5: 0 no contraction, 1 trace, 2 movement with gravity eliminated, 3 movement against gravity, 4 against gravity with some resistance, 5 normal.

Clinical reasoning errors: anchoring on an early diagnosis, confirmation bias, and premature closure; systematic red-flag screening and re-assessment reduce diagnostic error.

Outcome measures should match the construct: Numeric Pain Rating Scale for pain intensity, Oxford Hip Score for hip function, DASH for upper limb, Berg Balance Scale for balance.

Cryotherapy: reduces tissue temperature, blood flow, and pain; apply 15-20 minutes with a barrier; contraindicated in cold hypersensitivity, Raynaud phenomenon, and over regenerating peripheral nerves.

Thermotherapy: increases collagen extensibility and blood flow; superficial heat 15-20 minutes; avoid over acute inflammation, impaired sensation, and malignancy.

Ultrasound: continuous mode for thermal effects (deep heating), pulsed for non-thermal; intensity 0.5-2.0 W/cm²; avoid over epiphyseal plates, pacemakers, and the eye.

TENS: conventional high-frequency (80-150 Hz, narrow pulse) for pain gating; low-frequency (2-4 Hz) for endorphin release; do not apply over the heart, carotid sinus, or pregnant abdomen.

Resistance training prescription: to build strength, use 60-80% of 1RM for 2-4 sets of 6-12 reps; for endurance, use lower loads (40-60% 1RM) with 15-25 reps; allow 48 hours recovery per muscle group.

Cardiorespiratory exercise: FITT-VP (frequency, intensity, time, type, volume, progression); adults need 150-300 minutes/week of moderate or 75-150 minutes/week of vigorous aerobic activity plus 2 days of strengthening.

Flexibility: static stretching 2-4 repetitions of 15-60 seconds per muscle, 2-3 days/week; dynamic stretching before activity, static stretching after.

Motor learning: practice should be task-specific, variable, and progressively challenging; feedback should be faded as skill improves; blocked practice early, random practice later.

Rehabilitation technology: functional electrical stimulation recruits fatigable motor units and is used for foot drop and hand function; exoskeletons and treadmill body-weight support enable high-intensity gait practice.

Informed consent requires capacity, disclosure of material risks and alternatives, comprehension, and voluntariness; consent must be obtained before assessment or treatment and documented.

Confidentiality: patient information may be shared only with consent or where required by law; disclose the minimum necessary information on a need-to-know basis.

Documentation: contemporaneous, dated, signed, and factual records; record objective findings, interventions, patient response, and any adverse events; never alter records retrospectively.

Scope of practice: a physiotherapist must practice within their training and competence; delegating to assistants requires supervision and retention of professional accountability.

Professional boundaries: sexual or exploitative relationships with patients are prohibited; dual relationships and gifts must be managed transparently.

Duty of care and negligence: four elements must be proven - duty, breach of the standard of care, causation, and damages.

Patient safety: identify patients at risk (falls, pressure injury, infection, medication), use standard precautions (hand hygiene, gloves), and follow safe patient handling and equipment checks.

Incident reporting: report adverse events and near misses through the organization's system without blame; disclose harmful errors to the patient honestly and promptly.

Mandatory reporting and legal duties vary by jurisdiction; when a legal or ethical duty conflicts, seek guidance from the regulator and document the reasoning.

Muscle fiber types: type I is slow-twitch, oxidative, fatigue-resistant, high capillary and mitochondrial density; type IIa is fast-twitch oxidative-glycolytic; type IIx is fast-twitch glycolytic with the highest force and fastest fatigue.

Length-tension relationship: active tension peaks near resting sarcomere length (~2.0-2.2 µm in human muscle) where actin-myosin overlap is optimal; tension falls when the muscle is over-shortened or over-stretched.

Force-velocity relationship: concentric force decreases as shortening velocity rises; eccentric contractions generate greater force than isometric, which exceeds concentric at the same activation.

Muscle action depends on joint motion, not anatomy alone: a two-joint muscle can act as agonist at one joint and antagonist at another simultaneously (e.g., rectus femoris hip flexion with knee extension).

Open kinetic chain: distal segment free, joint motion independent; closed kinetic chain: distal segment fixed, joints move in a coupled, co-contraction-heavy pattern with greater joint approximation.

Gait cycle: stance is ~60% and swing ~40% of the cycle; double support occupies ~2 periods per cycle and increases with slower walking speed. Normal cadence is roughly 100-120 steps/min in adults.

Screw-home mechanism: terminal knee extension from ~20° to full involves ~10-15° of tibial external rotation relative to the femur, tightening the ACL and locking the joint.

Levers: first class = force and load on opposite sides of the fulcrum; second class = load between force and fulcrum (mechanical advantage); third class = force between fulcrum and load (most common in the body, favors speed and range).

Oxygen transport: cardiac output = heart rate × stroke volume; Fick principle states VO2 = cardiac output × arteriovenous oxygen difference.

Inflammation phases: acute (vasodilation, increased capillary permeability, neutrophil influx, minutes to days), subacute (macrophages, granulation tissue), chronic (fibrosis, lymphocyte and macrophage predominance, weeks to months).

Tissue healing timelines for soft tissue: inflammatory ~0-5 days, proliferative/fibroblastic ~5 days-6 weeks, remodeling/maturation up to 12 months or more; tendon and ligament healing is slower than muscle.

Fracture healing: hematoma and inflammation (~1 week), soft callus (~2-3 weeks), hard callus (~3-6 weeks), remodeling (months to years).

Bone stress injury: stress reaction precedes stress fracture; risk sites with poor blood supply and high tensile load include femoral neck, anterior tibial cortex, navicular, and fifth metatarsal base (Jones).

Red flags for serious pathology: unexplained weight loss, night pain unrelieved by rest, fever, history of cancer, progressive neurological deficit, bowel/bladder changes, saddle anesthesia, and age over 50 with new-onset pain.

Diabetes mellitus: peripheral neuropathy raises foot ulcer and Charcot risk; exercise-induced hypoglycemia risk is highest with insulin or sulfonylureas, so pre-exercise glucose and carbohydrate planning are required.

Osteoporosis: T-score ≤ -2.5 defines osteoporosis; -1.0 to -2.5 is osteopenia; avoid spinal flexion with loading, high-impact, and twisting exercises in severe osteoporosis; favor weight-bearing and progressive resistance.

Cardiac pathology: stable angina is predictable with exertion and relieved by rest; unstable angina occurs at rest or with changing pattern and is a contraindication to exercise testing until medically stabilized.

Respiratory pathology: obstructive disease (asthma, COPD) shows reduced FEV1/FVC ratio; restrictive disease (fibrosis, kyphoscoliosis) shows reduced FVC with a preserved or raised ratio.

Rotator cuff tendinopathy: painful arc 60-120° abduction, positive Neer and Hawkins-Kennedy tests; management emphasizes progressive loading, scapular control, and activity modification over passive modalities.

Carpal tunnel syndrome: median nerve distribution (thumb, index, middle, radial half of ring), positive Phalen and Tinel tests, nocturnal symptoms; thenar atrophy indicates advanced disease.

Lumbar disc herniation: radicular pain follows a dermatome, positive straight leg raise (sensitized by ankle dorsiflexion), and often improves with extension in central or lateral preference patterns.

Lumbar spinal stenosis: neurogenic claudication relieved by flexion (sitting, leaning forward) and worsened by extension and walking; bilateral symptoms are common.

Osteoarthritis: joint line tenderness, crepitus, morning stiffness under 30 minutes, reduced range; exercise and weight management are first-line, not rest.

Anterior cruciate ligament injury: non-contact pivot mechanism, immediate swelling (hemarthrosis), positive Lachman (most sensitive), pivot shift, and anterior drawer.

Achilles tendinopathy: pain 2-6 cm above the calcaneal insertion, morning stiffness, painful on loading; eccentric or heavy-slow resistance training is the evidence-based core.

Frozen shoulder: three phases (painful, frozen, thawing); capsular pattern is external rotation most limited, then abduction, then internal rotation; corticosteroid injection plus stretching in the painful phase.

Fracture management: relative stability and early controlled motion promote callus; absolute rest and prolonged immobilization increase stiffness and disuse atrophy.

Upper motor neuron lesion signs: hyperreflexia, spasticity, positive Babinski, clonus, and loss of fine dexterity; lower motor neuron signs: flaccidity, fasciculation, atrophy, and areflexia.

Stroke: middle cerebral artery infarct causes contralateral face and arm weakness greater than leg; anterior cerebral artery affects leg more than arm; posterior circulation causes ataxia, diplopia, and dysphagia.

Brunnstrom stages of motor recovery: 1 flaccidity, 2 synergy emergence, 3 synergy dominance, 4 partial voluntary movement out of synergy, 5 complex movement out of synergy, 6 near-normal, 7 normal.

Ashworth scale grades resistance to passive movement from 0 (none) to 4 (rigid); the Modified Ashworth adds 1+ for catch followed by minimal resistance through less than half the range.

Spasticity is velocity-dependent increased tone from hyperexcitable stretch reflex; rigidity is velocity-independent and constant (extrapyramidal, as in Parkinson disease).

Multiple sclerosis: Uhthoff phenomenon is transient worsening with heat; fatigue is the most common symptom; exercise should be scheduled in cooler conditions with pacing.

Guillain-Barré syndrome: ascending symmetric flaccidity with areflexia, autonomic instability, and risk of respiratory failure; monitor vital capacity and avoid overfatigue in the acute phase.

Parkinson disease: resting tremor, bradykinesia, rigidity, and postural instability; cueing (auditory, visual) and large-amplitude training improve gait and freezing.

Balance control: reactive strategies are ankle, hip, and stepping; sensory organization depends on vision, somatosensory, and vestibular input, so testing with eyes closed and on compliant surfaces isolates deficits.

Normal arterial blood gas: pH 7.35-7.45, PaCO2 35-45 mmHg, PaO2 80-100 mmHg, HCO3- 22-26 mEq/L; respiratory acidosis shows raised PaCO2 and low pH, metabolic acidosis shows low HCO3- and low pH.

Exercise prescription for cardiac rehabilitation: moderate intensity is 40-70% of heart rate reserve (Karvonen formula: target HR = resting HR + %intensity × (max HR - resting HR)) or 40-60% of VO2 reserve.

Rate of perceived exertion 11-13 on the 6-20 Borg scale corresponds to moderate intensity and is used when heart rate response is unreliable (beta-blockers, pacemakers).

Absolute contraindications to exercise testing: acute myocardial infarction within 2 days, unstable angina, uncontrolled arrhythmia, acute endocarditis or myocarditis, symptomatic severe aortic stenosis, and acute pulmonary embolism.

Airway clearance techniques: postural drainage, percussion, vibration, active cycle of breathing (breathing control, thoracic expansion, huffing), autogenic drainage, and positive expiratory pressure devices.

Pursed-lip breathing slows expiration, reduces dynamic hyperinflation, and improves dyspnea in COPD; diaphragmatic breathing targets reduced accessory muscle use.

Cystic fibrosis: airway clearance is daily and lifelong; exercise testing and sputum clearance before exercise improve tolerance; dehydration and salt loss in heat are risks.

Six-minute walk test: measures functional exercise capacity; a clinically important change is roughly 30 m in many cardiorespiratory populations; standardize encouragement, track, and rest breaks.

Orthostatic hypotension: drop of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing; manage with slow position changes, hydration, and compression.

Gross motor milestones: head control ~3-4 months, rolling ~5-6 months, independent sitting ~6-8 months, crawling ~8-9 months, pulling to stand ~9-10 months, independent walking ~12-15 months.

Red flags in infant development: persistence of primitive reflexes beyond 6 months, hand fisting after 4 months, asymmetry of movement, failure to bear weight, and loss of previously acquired skills.

Cerebral palsy: classified by tone (spastic, dyskinetic, ataxic) and distribution (hemiplegia, diplegia, quadriplegia); Gross Motor Function Classification System (GMFCS) levels I-V predict mobility prognosis.

Down syndrome: hypotonia, joint hypermobility (especially atlantoaxial), and developmental delay; screen for atlantoaxial instability before high-impact or contact activity.

Spina bifida: level of lesion predicts function; latex allergy precautions are standard; monitor for hydrocephalus and shunt malfunction signs (headache, vomiting, lethargy).

Geriatric falls: multifactorial assessment covers vision, medication review, orthostatic blood pressure, gait and balance (Timed Up and Go, Berg Balance Scale), home hazards, and fear of falling.

Sarcopenia: age-related loss of muscle mass and strength; progressive resistance training plus adequate protein intake are the primary interventions.

Fragility fracture prevention: weight-bearing and balance exercise reduce falls; hip protectors and vitamin D correction are adjuncts; avoid high-impact loading in severe osteoporosis.

Polypharmacy in older adults: sedatives, antihypertensives, and anticholinergics raise fall and delirium risk; deprescribing is a physiotherapy-relevant safety consideration.

SOAP note structure: Subjective (history, symptoms), Objective (measurements, tests), Assessment (clinical impression, differential), Plan (interventions, goals, review date).

SMART goals: Specific, Measurable, Achievable, Relevant, Time-bound; goals should be patient-centered and functional, not solely impairment-based.

Sensitivity is the proportion of true positives correctly identified; specificity is the proportion of true negatives correctly identified; a highly sensitive test is best for ruling out, a highly specific test for ruling in.

Likelihood ratios: positive LR = sensitivity / (1 - specificity); negative LR = (1 - sensitivity) / specificity; LR above 10 or below 0.1 substantially shifts post-test probability.

Intra- and inter-rater reliability: intraclass correlation coefficient (ICC) above 0.75 is generally good; measure the same variable with the same instrument and conditions to compare raters.

Range of motion: goniometry is the standard; measure active before passive; record in degrees with the axis, stationary arm, and moving arm landmarks stated for reproducibility.

Manual muscle testing grades 0-5: 0 no contraction, 1 trace, 2 movement with gravity eliminated, 3 movement against gravity, 4 against gravity with some resistance, 5 normal.

Clinical reasoning errors: anchoring on an early diagnosis, confirmation bias, and premature closure; systematic red-flag screening and re-assessment reduce diagnostic error.

Outcome measures should match the construct: Numeric Pain Rating Scale for pain intensity, Oxford Hip Score for hip function, DASH for upper limb, Berg Balance Scale for balance.

Cryotherapy: reduces tissue temperature, blood flow, and pain; apply 15-20 minutes with a barrier; contraindicated in cold hypersensitivity, Raynaud phenomenon, and over regenerating peripheral nerves.

Thermotherapy: increases collagen extensibility and blood flow; superficial heat 15-20 minutes; avoid over acute inflammation, impaired sensation, and malignancy.

Ultrasound: continuous mode for thermal effects (deep heating), pulsed for non-thermal; intensity 0.5-2.0 W/cm²; avoid over epiphyseal plates, pacemakers, and the eye.

TENS: conventional high-frequency (80-150 Hz, narrow pulse) for pain gating; low-frequency (2-4 Hz) for endorphin release; do not apply over the heart, carotid sinus, or pregnant abdomen.

Resistance training prescription: to build strength, use 60-80% of 1RM for 2-4 sets of 6-12 reps; for endurance, use lower loads (40-60% 1RM) with 15-25 reps; allow 48 hours recovery per muscle group.

Cardiorespiratory exercise: FITT-VP (frequency, intensity, time, type, volume, progression); adults need 150-300 minutes/week of moderate or 75-150 minutes/week of vigorous aerobic activity plus 2 days of strengthening.

Flexibility: static stretching 2-4 repetitions of 15-60 seconds per muscle, 2-3 days/week; dynamic stretching before activity, static stretching after.

Motor learning: practice should be task-specific, variable, and progressively challenging; feedback should be faded as skill improves; blocked practice early, random practice later.

Rehabilitation technology: functional electrical stimulation recruits fatigable motor units and is used for foot drop and hand function; exoskeletons and treadmill body-weight support enable high-intensity gait practice.

Informed consent requires capacity, disclosure of material risks and alternatives, comprehension, and voluntariness; consent must be obtained before assessment or treatment and documented.

Confidentiality: patient information may be shared only with consent or where required by law; disclose the minimum necessary information on a need-to-know basis.

Documentation: contemporaneous, dated, signed, and factual records; record objective findings, interventions, patient response, and any adverse events; never alter records retrospectively.

Scope of practice: a physiotherapist must practice within their training and competence; delegating to assistants requires supervision and retention of professional accountability.

Professional boundaries: sexual or exploitative relationships with patients are prohibited; dual relationships and gifts must be managed transparently.

Duty of care and negligence: four elements must be proven - duty, breach of the standard of care, causation, and damages.

Patient safety: identify patients at risk (falls, pressure injury, infection, medication), use standard precautions (hand hygiene, gloves), and follow safe patient handling and equipment checks.

Incident reporting: report adverse events and near misses through the organization's system without blame; disclose harmful errors to the patient honestly and promptly.

Mandatory reporting and legal duties vary by jurisdiction; when a legal or ethical duty conflicts, seek guidance from the regulator and document the reasoning.

Muscle fiber types: type I is slow-twitch, oxidative, fatigue-resistant, high capillary and mitochondrial density; type IIa is fast-twitch oxidative-glycolytic; type IIx is fast-twitch glycolytic with the highest force and fastest fatigue.

Length-tension relationship: active tension peaks near resting sarcomere length (~2.0-2.2 µm in human muscle) where actin-myosin overlap is optimal; tension falls when the muscle is over-shortened or over-stretched.

Force-velocity relationship: concentric force decreases as shortening velocity rises; eccentric contractions generate greater force than isometric, which exceeds concentric at the same activation.

Muscle action depends on joint motion, not anatomy alone: a two-joint muscle can act as agonist at one joint and antagonist at another simultaneously (e.g., rectus femoris hip flexion with knee extension).

Open kinetic chain: distal segment free, joint motion independent; closed kinetic chain: distal segment fixed, joints move in a coupled, co-contraction-heavy pattern with greater joint approximation.

Gait cycle: stance is ~60% and swing ~40% of the cycle; double support occupies ~2 periods per cycle and increases with slower walking speed. Normal cadence is roughly 100-120 steps/min in adults.

Screw-home mechanism: terminal knee extension from ~20° to full involves ~10-15° of tibial external rotation relative to the femur, tightening the ACL and locking the joint.

Levers: first class = force and load on opposite sides of the fulcrum; second class = load between force and fulcrum (mechanical advantage); third class = force between fulcrum and load (most common in the body, favors speed and range).

Oxygen transport: cardiac output = heart rate × stroke volume; Fick principle states VO2 = cardiac output × arteriovenous oxygen difference.

Inflammation phases: acute (vasodilation, increased capillary permeability, neutrophil influx, minutes to days), subacute (macrophages, granulation tissue), chronic (fibrosis, lymphocyte and macrophage predominance, weeks to months).

Tissue healing timelines for soft tissue: inflammatory ~0-5 days, proliferative/fibroblastic ~5 days-6 weeks, remodeling/maturation up to 12 months or more; tendon and ligament healing is slower than muscle.

Fracture healing: hematoma and inflammation (~1 week), soft callus (~2-3 weeks), hard callus (~3-6 weeks), remodeling (months to years).

Bone stress injury: stress reaction precedes stress fracture; risk sites with poor blood supply and high tensile load include femoral neck, anterior tibial cortex, navicular, and fifth metatarsal base (Jones).

Red flags for serious pathology: unexplained weight loss, night pain unrelieved by rest, fever, history of cancer, progressive neurological deficit, bowel/bladder changes, saddle anesthesia, and age over 50 with new-onset pain.

Diabetes mellitus: peripheral neuropathy raises foot ulcer and Charcot risk; exercise-induced hypoglycemia risk is highest with insulin or sulfonylureas, so pre-exercise glucose and carbohydrate planning are required.

Osteoporosis: T-score ≤ -2.5 defines osteoporosis; -1.0 to -2.5 is osteopenia; avoid spinal flexion with loading, high-impact, and twisting exercises in severe osteoporosis; favor weight-bearing and progressive resistance.

Cardiac pathology: stable angina is predictable with exertion and relieved by rest; unstable angina occurs at rest or with changing pattern and is a contraindication to exercise testing until medically stabilized.

Respiratory pathology: obstructive disease (asthma, COPD) shows reduced FEV1/FVC ratio; restrictive disease (fibrosis, kyphoscoliosis) shows reduced FVC with a preserved or raised ratio.

Rotator cuff tendinopathy: painful arc 60-120° abduction, positive Neer and Hawkins-Kennedy tests; management emphasizes progressive loading, scapular control, and activity modification over passive modalities.

Carpal tunnel syndrome: median nerve distribution (thumb, index, middle, radial half of ring), positive Phalen and Tinel tests, nocturnal symptoms; thenar atrophy indicates advanced disease.

Lumbar disc herniation: radicular pain follows a dermatome, positive straight leg raise (sensitized by ankle dorsiflexion), and often improves with extension in central or lateral preference patterns.

Lumbar spinal stenosis: neurogenic claudication relieved by flexion (sitting, leaning forward) and worsened by extension and walking; bilateral symptoms are common.

Osteoarthritis: joint line tenderness, crepitus, morning stiffness under 30 minutes, reduced range; exercise and weight management are first-line, not rest.

Anterior cruciate ligament injury: non-contact pivot mechanism, immediate swelling (hemarthrosis), positive Lachman (most sensitive), pivot shift, and anterior drawer.

Achilles tendinopathy: pain 2-6 cm above the calcaneal insertion, morning stiffness, painful on loading; eccentric or heavy-slow resistance training is the evidence-based core.

Frozen shoulder: three phases (painful, frozen, thawing); capsular pattern is external rotation most limited, then abduction, then internal rotation; corticosteroid injection plus stretching in the painful phase.

Fracture management: relative stability and early controlled motion promote callus; absolute rest and prolonged immobilization increase stiffness and disuse atrophy.

Upper motor neuron lesion signs: hyperreflexia, spasticity, positive Babinski, clonus, and loss of fine dexterity; lower motor neuron signs: flaccidity, fasciculation, atrophy, and areflexia.

Stroke: middle cerebral artery infarct causes contralateral face and arm weakness greater than leg; anterior cerebral artery affects leg more than arm; posterior circulation causes ataxia, diplopia, and dysphagia.

Brunnstrom stages of motor recovery: 1 flaccidity, 2 synergy emergence, 3 synergy dominance, 4 partial voluntary movement out of synergy, 5 complex movement out of synergy, 6 near-normal, 7 normal.

Ashworth scale grades resistance to passive movement from 0 (none) to 4 (rigid); the Modified Ashworth adds 1+ for catch followed by minimal resistance through less than half the range.

Spasticity is velocity-dependent increased tone from hyperexcitable stretch reflex; rigidity is velocity-independent and constant (extrapyramidal, as in Parkinson disease).

Multiple sclerosis: Uhthoff phenomenon is transient worsening with heat; fatigue is the most common symptom; exercise should be scheduled in cooler conditions with pacing.

Guillain-Barré syndrome: ascending symmetric flaccidity with areflexia, autonomic instability, and risk of respiratory failure; monitor vital capacity and avoid overfatigue in the acute phase.

Parkinson disease: resting tremor, bradykinesia, rigidity, and postural instability; cueing (auditory, visual) and large-amplitude training improve gait and freezing.

Balance control: reactive strategies are ankle, hip, and stepping; sensory organization depends on vision, somatosensory, and vestibular input, so testing with eyes closed and on compliant surfaces isolates deficits.

Normal arterial blood gas: pH 7.35-7.45, PaCO2 35-45 mmHg, PaO2 80-100 mmHg, HCO3- 22-26 mEq/L; respiratory acidosis shows raised PaCO2 and low pH, metabolic acidosis shows low HCO3- and low pH.

Exercise prescription for cardiac rehabilitation: moderate intensity is 40-70% of heart rate reserve (Karvonen formula: target HR = resting HR + %intensity × (max HR - resting HR)) or 40-60% of VO2 reserve.

Rate of perceived exertion 11-13 on the 6-20 Borg scale corresponds to moderate intensity and is used when heart rate response is unreliable (beta-blockers, pacemakers).

Absolute contraindications to exercise testing: acute myocardial infarction within 2 days, unstable angina, uncontrolled arrhythmia, acute endocarditis or myocarditis, symptomatic severe aortic stenosis, and acute pulmonary embolism.

Airway clearance techniques: postural drainage, percussion, vibration, active cycle of breathing (breathing control, thoracic expansion, huffing), autogenic drainage, and positive expiratory pressure devices.

Pursed-lip breathing slows expiration, reduces dynamic hyperinflation, and improves dyspnea in COPD; diaphragmatic breathing targets reduced accessory muscle use.

Cystic fibrosis: airway clearance is daily and lifelong; exercise testing and sputum clearance before exercise improve tolerance; dehydration and salt loss in heat are risks.

Six-minute walk test: measures functional exercise capacity; a clinically important change is roughly 30 m in many cardiorespiratory populations; standardize encouragement, track, and rest breaks.

Orthostatic hypotension: drop of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing; manage with slow position changes, hydration, and compression.

Gross motor milestones: head control ~3-4 months, rolling ~5-6 months, independent sitting ~6-8 months, crawling ~8-9 months, pulling to stand ~9-10 months, independent walking ~12-15 months.

Red flags in infant development: persistence of primitive reflexes beyond 6 months, hand fisting after 4 months, asymmetry of movement, failure to bear weight, and loss of previously acquired skills.

Cerebral palsy: classified by tone (spastic, dyskinetic, ataxic) and distribution (hemiplegia, diplegia, quadriplegia); Gross Motor Function Classification System (GMFCS) levels I-V predict mobility prognosis.

Down syndrome: hypotonia, joint hypermobility (especially atlantoaxial), and developmental delay; screen for atlantoaxial instability before high-impact or contact activity.

Spina bifida: level of lesion predicts function; latex allergy precautions are standard; monitor for hydrocephalus and shunt malfunction signs (headache, vomiting, lethargy).

Geriatric falls: multifactorial assessment covers vision, medication review, orthostatic blood pressure, gait and balance (Timed Up and Go, Berg Balance Scale), home hazards, and fear of falling.

Sarcopenia: age-related loss of muscle mass and strength; progressive resistance training plus adequate protein intake are the primary interventions.

Fragility fracture prevention: weight-bearing and balance exercise reduce falls; hip protectors and vitamin D correction are adjuncts; avoid high-impact loading in severe osteoporosis.

Polypharmacy in older adults: sedatives, antihypertensives, and anticholinergics raise fall and delirium risk; deprescribing is a physiotherapy-relevant safety consideration.

SOAP note structure: Subjective (history, symptoms), Objective (measurements, tests), Assessment (clinical impression, differential), Plan (interventions, goals, review date).

SMART goals: Specific, Measurable, Achievable, Relevant, Time-bound; goals should be patient-centered and functional, not solely impairment-based.

Sensitivity is the proportion of true positives correctly identified; specificity is the proportion of true negatives correctly identified; a highly sensitive test is best for ruling out, a highly specific test for ruling in.

Likelihood ratios: positive LR = sensitivity / (1 - specificity); negative LR = (1 - sensitivity) / specificity; LR above 10 or below 0.1 substantially shifts post-test probability.

Intra- and inter-rater reliability: intraclass correlation coefficient (ICC) above 0.75 is generally good; measure the same variable with the same instrument and conditions to compare raters.

Range of motion: goniometry is the standard; measure active before passive; record in degrees with the axis, stationary arm, and moving arm landmarks stated for reproducibility.

Manual muscle testing grades 0-5: 0 no contraction, 1 trace, 2 movement with gravity eliminated, 3 movement against gravity, 4 against gravity with some resistance, 5 normal.

Clinical reasoning errors: anchoring on an early diagnosis, confirmation bias, and premature closure; systematic red-flag screening and re-assessment reduce diagnostic error.

Outcome measures should match the construct: Numeric Pain Rating Scale for pain intensity, Oxford Hip Score for hip function, DASH for upper limb, Berg Balance Scale for balance.

Cryotherapy: reduces tissue temperature, blood flow, and pain; apply 15-20 minutes with a barrier; contraindicated in cold hypersensitivity, Raynaud phenomenon, and over regenerating peripheral nerves.

Thermotherapy: increases collagen extensibility and blood flow; superficial heat 15-20 minutes; avoid over acute inflammation, impaired sensation, and malignancy.

Ultrasound: continuous mode for thermal effects (deep heating), pulsed for non-thermal; intensity 0.5-2.0 W/cm²; avoid over epiphyseal plates, pacemakers, and the eye.

TENS: conventional high-frequency (80-150 Hz, narrow pulse) for pain gating; low-frequency (2-4 Hz) for endorphin release; do not apply over the heart, carotid sinus, or pregnant abdomen.

Resistance training prescription: to build strength, use 60-80% of 1RM for 2-4 sets of 6-12 reps; for endurance, use lower loads (40-60% 1RM) with 15-25 reps; allow 48 hours recovery per muscle group.

Cardiorespiratory exercise: FITT-VP (frequency, intensity, time, type, volume, progression); adults need 150-300 minutes/week of moderate or 75-150 minutes/week of vigorous aerobic activity plus 2 days of strengthening.

Flexibility: static stretching 2-4 repetitions of 15-60 seconds per muscle, 2-3 days/week; dynamic stretching before activity, static stretching after.

Motor learning: practice should be task-specific, variable, and progressively challenging; feedback should be faded as skill improves; blocked practice early, random practice later.

Rehabilitation technology: functional electrical stimulation recruits fatigable motor units and is used for foot drop and hand function; exoskeletons and treadmill body-weight support enable high-intensity gait practice.

Informed consent requires capacity, disclosure of material risks and alternatives, comprehension, and voluntariness; consent must be obtained before assessment or treatment and documented.

Confidentiality: patient information may be shared only with consent or where required by law; disclose the minimum necessary information on a need-to-know basis.

Documentation: contemporaneous, dated, signed, and factual records; record objective findings, interventions, patient response, and any adverse events; never alter records retrospectively.

Scope of practice: a physiotherapist must practice within their training and competence; delegating to assistants requires supervision and retention of professional accountability.

Professional boundaries: sexual or exploitative relationships with patients are prohibited; dual relationships and gifts must be managed transparently.

Duty of care and negligence: four elements must be proven - duty, breach of the standard of care, causation, and damages.

Patient safety: identify patients at risk (falls, pressure injury, infection, medication), use standard precautions (hand hygiene, gloves), and follow safe patient handling and equipment checks.

Incident reporting: report adverse events and near misses through the organization's system without blame; disclose harmful errors to the patient honestly and promptly.

Mandatory reporting and legal duties vary by jurisdiction; when a legal or ethical duty conflicts, seek guidance from the regulator and document the reasoning.

Muscle fiber types: type I is slow-twitch, oxidative, fatigue-resistant, high capillary and mitochondrial density; type IIa is fast-twitch oxidative-glycolytic; type IIx is fast-twitch glycolytic with the highest force and fastest fatigue.

Length-tension relationship: active tension peaks near resting sarcomere length (~2.0-2.2 µm in human muscle) where actin-myosin overlap is optimal; tension falls when the muscle is over-shortened or over-stretched.

Force-velocity relationship: concentric force decreases as shortening velocity rises; eccentric contractions generate greater force than isometric, which exceeds concentric at the same activation.

Muscle action depends on joint motion, not anatomy alone: a two-joint muscle can act as agonist at one joint and antagonist at another simultaneously (e.g., rectus femoris hip flexion with knee extension).

Open kinetic chain: distal segment free, joint motion independent; closed kinetic chain: distal segment fixed, joints move in a coupled, co-contraction-heavy pattern with greater joint approximation.

Gait cycle: stance is ~60% and swing ~40% of the cycle; double support occupies ~2 periods per cycle and increases with slower walking speed. Normal cadence is roughly 100-120 steps/min in adults.

Screw-home mechanism: terminal knee extension from ~20° to full involves ~10-15° of tibial external rotation relative to the femur, tightening the ACL and locking the joint.

Levers: first class = force and load on opposite sides of the fulcrum; second class = load between force and fulcrum (mechanical advantage); third class = force between fulcrum and load (most common in the body, favors speed and range).

Oxygen transport: cardiac output = heart rate × stroke volume; Fick principle states VO2 = cardiac output × arteriovenous oxygen difference.

Inflammation phases: acute (vasodilation, increased capillary permeability, neutrophil influx, minutes to days), subacute (macrophages, granulation tissue), chronic (fibrosis, lymphocyte and macrophage predominance, weeks to months).

Tissue healing timelines for soft tissue: inflammatory ~0-5 days, proliferative/fibroblastic ~5 days-6 weeks, remodeling/maturation up to 12 months or more; tendon and ligament healing is slower than muscle.

Fracture healing: hematoma and inflammation (~1 week), soft callus (~2-3 weeks), hard callus (~3-6 weeks), remodeling (months to years).

Bone stress injury: stress reaction precedes stress fracture; risk sites with poor blood supply and high tensile load include femoral neck, anterior tibial cortex, navicular, and fifth metatarsal base (Jones).

Red flags for serious pathology: unexplained weight loss, night pain unrelieved by rest, fever, history of cancer, progressive neurological deficit, bowel/bladder changes, saddle anesthesia, and age over 50 with new-onset pain.

Diabetes mellitus: peripheral neuropathy raises foot ulcer and Charcot risk; exercise-induced hypoglycemia risk is highest with insulin or sulfonylureas, so pre-exercise glucose and carbohydrate planning are required.

Osteoporosis: T-score ≤ -2.5 defines osteoporosis; -1.0 to -2.5 is osteopenia; avoid spinal flexion with loading, high-impact, and twisting exercises in severe osteoporosis; favor weight-bearing and progressive resistance.

Cardiac pathology: stable angina is predictable with exertion and relieved by rest; unstable angina occurs at rest or with changing pattern and is a contraindication to exercise testing until medically stabilized.

Respiratory pathology: obstructive disease (asthma, COPD) shows reduced FEV1/FVC ratio; restrictive disease (fibrosis, kyphoscoliosis) shows reduced FVC with a preserved or raised ratio.

Rotator cuff tendinopathy: painful arc 60-120° abduction, positive Neer and Hawkins-Kennedy tests; management emphasizes progressive loading, scapular control, and activity modification over passive modalities.

Carpal tunnel syndrome: median nerve distribution (thumb, index, middle, radial half of ring), positive Phalen and Tinel tests, nocturnal symptoms; thenar atrophy indicates advanced disease.

Lumbar disc herniation: radicular pain follows a dermatome, positive straight leg raise (sensitized by ankle dorsiflexion), and often improves with extension in central or lateral preference patterns.

Lumbar spinal stenosis: neurogenic claudication relieved by flexion (sitting, leaning forward) and worsened by extension and walking; bilateral symptoms are common.

Osteoarthritis: joint line tenderness, crepitus, morning stiffness under 30 minutes, reduced range; exercise and weight management are first-line, not rest.

Anterior cruciate ligament injury: non-contact pivot mechanism, immediate swelling (hemarthrosis), positive Lachman (most sensitive), pivot shift, and anterior drawer.

Achilles tendinopathy: pain 2-6 cm above the calcaneal insertion, morning stiffness, painful on loading; eccentric or heavy-slow resistance training is the evidence-based core.

Frozen shoulder: three phases (painful, frozen, thawing); capsular pattern is external rotation most limited, then abduction, then internal rotation; corticosteroid injection plus stretching in the painful phase.

Fracture management: relative stability and early controlled motion promote callus; absolute rest and prolonged immobilization increase stiffness and disuse atrophy.

Upper motor neuron lesion signs: hyperreflexia, spasticity, positive Babinski, clonus, and loss of fine dexterity; lower motor neuron signs: flaccidity, fasciculation, atrophy, and areflexia.

Stroke: middle cerebral artery infarct causes contralateral face and arm weakness greater than leg; anterior cerebral artery affects leg more than arm; posterior circulation causes ataxia, diplopia, and dysphagia.

Brunnstrom stages of motor recovery: 1 flaccidity, 2 synergy emergence, 3 synergy dominance, 4 partial voluntary movement out of synergy, 5 complex movement out of synergy, 6 near-normal, 7 normal.

Ashworth scale grades resistance to passive movement from 0 (none) to 4 (rigid); the Modified Ashworth adds 1+ for catch followed by minimal resistance through less than half the range.

Spasticity is velocity-dependent increased tone from hyperexcitable stretch reflex; rigidity is velocity-independent and constant (extrapyramidal, as in Parkinson disease).

Multiple sclerosis: Uhthoff phenomenon is transient worsening with heat; fatigue is the most common symptom; exercise should be scheduled in cooler conditions with pacing.

Guillain-Barré syndrome: ascending symmetric flaccidity with areflexia, autonomic instability, and risk of respiratory failure; monitor vital capacity and avoid overfatigue in the acute phase.

Parkinson disease: resting tremor, bradykinesia, rigidity, and postural instability; cueing (auditory, visual) and large-amplitude training improve gait and freezing.

Balance control: reactive strategies are ankle, hip, and stepping; sensory organization depends on vision, somatosensory, and vestibular input, so testing with eyes closed and on compliant surfaces isolates deficits.

Normal arterial blood gas: pH 7.35-7.45, PaCO2 35-45 mmHg, PaO2 80-100 mmHg, HCO3- 22-26 mEq/L; respiratory acidosis shows raised PaCO2 and low pH, metabolic acidosis shows low HCO3- and low pH.

Exercise prescription for cardiac rehabilitation: moderate intensity is 40-70% of heart rate reserve (Karvonen formula: target HR = resting HR + %intensity × (max HR - resting HR)) or 40-60% of VO2 reserve.

Rate of perceived exertion 11-13 on the 6-20 Borg scale corresponds to moderate intensity and is used when heart rate response is unreliable (beta-blockers, pacemakers).

Absolute contraindications to exercise testing: acute myocardial infarction within 2 days, unstable angina, uncontrolled arrhythmia, acute endocarditis or myocarditis, symptomatic severe aortic stenosis, and acute pulmonary embolism.

Airway clearance techniques: postural drainage, percussion, vibration, active cycle of breathing (breathing control, thoracic expansion, huffing), autogenic drainage, and positive expiratory pressure devices.

Pursed-lip breathing slows expiration, reduces dynamic hyperinflation, and improves dyspnea in COPD; diaphragmatic breathing targets reduced accessory muscle use.

Cystic fibrosis: airway clearance is daily and lifelong; exercise testing and sputum clearance before exercise improve tolerance; dehydration and salt loss in heat are risks.

Six-minute walk test: measures functional exercise capacity; a clinically important change is roughly 30 m in many cardiorespiratory populations; standardize encouragement, track, and rest breaks.

Orthostatic hypotension: drop of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing; manage with slow position changes, hydration, and compression.

Gross motor milestones: head control ~3-4 months, rolling ~5-6 months, independent sitting ~6-8 months, crawling ~8-9 months, pulling to stand ~9-10 months, independent walking ~12-15 months.

Red flags in infant development: persistence of primitive reflexes beyond 6 months, hand fisting after 4 months, asymmetry of movement, failure to bear weight, and loss of previously acquired skills.

Cerebral palsy: classified by tone (spastic, dyskinetic, ataxic) and distribution (hemiplegia, diplegia, quadriplegia); Gross Motor Function Classification System (GMFCS) levels I-V predict mobility prognosis.

Down syndrome: hypotonia, joint hypermobility (especially atlantoaxial), and developmental delay; screen for atlantoaxial instability before high-impact or contact activity.

Spina bifida: level of lesion predicts function; latex allergy precautions are standard; monitor for hydrocephalus and shunt malfunction signs (headache, vomiting, lethargy).

Geriatric falls: multifactorial assessment covers vision, medication review, orthostatic blood pressure, gait and balance (Timed Up and Go, Berg Balance Scale), home hazards, and fear of falling.

Sarcopenia: age-related loss of muscle mass and strength; progressive resistance training plus adequate protein intake are the primary interventions.

Fragility fracture prevention: weight-bearing and balance exercise reduce falls; hip protectors and vitamin D correction are adjuncts; avoid high-impact loading in severe osteoporosis.

Polypharmacy in older adults: sedatives, antihypertensives, and anticholinergics raise fall and delirium risk; deprescribing is a physiotherapy-relevant safety consideration.

SOAP note structure: Subjective (history, symptoms), Objective (measurements, tests), Assessment (clinical impression, differential), Plan (interventions, goals, review date).

SMART goals: Specific, Measurable, Achievable, Relevant, Time-bound; goals should be patient-centered and functional, not solely impairment-based.

Sensitivity is the proportion of true positives correctly identified; specificity is the proportion of true negatives correctly identified; a highly sensitive test is best for ruling out, a highly specific test for ruling in.

Likelihood ratios: positive LR = sensitivity / (1 - specificity); negative LR = (1 - sensitivity) / specificity; LR above 10 or below 0.1 substantially shifts post-test probability.

Intra- and inter-rater reliability: intraclass correlation coefficient (ICC) above 0.75 is generally good; measure the same variable with the same instrument and conditions to compare raters.

Range of motion: goniometry is the standard; measure active before passive; record in degrees with the axis, stationary arm, and moving arm landmarks stated for reproducibility.

Manual muscle testing grades 0-5: 0 no contraction, 1 trace, 2 movement with gravity eliminated, 3 movement against gravity, 4 against gravity with some resistance, 5 normal.

Clinical reasoning errors: anchoring on an early diagnosis, confirmation bias, and premature closure; systematic red-flag screening and re-assessment reduce diagnostic error.

Outcome measures should match the construct: Numeric Pain Rating Scale for pain intensity, Oxford Hip Score for hip function, DASH for upper limb, Berg Balance Scale for balance.

Cryotherapy: reduces tissue temperature, blood flow, and pain; apply 15-20 minutes with a barrier; contraindicated in cold hypersensitivity, Raynaud phenomenon, and over regenerating peripheral nerves.

Thermotherapy: increases collagen extensibility and blood flow; superficial heat 15-20 minutes; avoid over acute inflammation, impaired sensation, and malignancy.

Ultrasound: continuous mode for thermal effects (deep heating), pulsed for non-thermal; intensity 0.5-2.0 W/cm²; avoid over epiphyseal plates, pacemakers, and the eye.

TENS: conventional high-frequency (80-150 Hz, narrow pulse) for pain gating; low-frequency (2-4 Hz) for endorphin release; do not apply over the heart, carotid sinus, or pregnant abdomen.

Resistance training prescription: to build strength, use 60-80% of 1RM for 2-4 sets of 6-12 reps; for endurance, use lower loads (40-60% 1RM) with 15-25 reps; allow 48 hours recovery per muscle group.

Cardiorespiratory exercise: FITT-VP (frequency, intensity, time, type, volume, progression); adults need 150-300 minutes/week of moderate or 75-150 minutes/week of vigorous aerobic activity plus 2 days of strengthening.

Flexibility: static stretching 2-4 repetitions of 15-60 seconds per muscle, 2-3 days/week; dynamic stretching before activity, static stretching after.

Motor learning: practice should be task-specific, variable, and progressively challenging; feedback should be faded as skill improves; blocked practice early, random practice later.

Rehabilitation technology: functional electrical stimulation recruits fatigable motor units and is used for foot drop and hand function; exoskeletons and treadmill body-weight support enable high-intensity gait practice.

Informed consent requires capacity, disclosure of material risks and alternatives, comprehension, and voluntariness; consent must be obtained before assessment or treatment and documented.

Confidentiality: patient information may be shared only with consent or where required by law; disclose the minimum necessary information on a need-to-know basis.

Documentation: contemporaneous, dated, signed, and factual records; record objective findings, interventions, patient response, and any adverse events; never alter records retrospectively.

Scope of practice: a physiotherapist must practice within their training and competence; delegating to assistants requires supervision and retention of professional accountability.

Professional boundaries: sexual or exploitative relationships with patients are prohibited; dual relationships and gifts must be managed transparently.

Duty of care and negligence: four elements must be proven - duty, breach of the standard of care, causation, and damages.

Patient safety: identify patients at risk (falls, pressure injury, infection, medication), use standard precautions (hand hygiene, gloves), and follow safe patient handling and equipment checks.

Incident reporting: report adverse events and near misses through the organization's system without blame; disclose harmful errors to the patient honestly and promptly.

Mandatory reporting and legal duties vary by jurisdiction; when a legal or ethical duty conflicts, seek guidance from the regulator and document the reasoning.