Kuwait MOH Physiotherapist cheat sheet

Muscle contraction: excitation-contraction coupling begins with ACh release at the motor end plate; Ca2+ binds troponin C, displacing tropomyosin and exposing actin binding sites.

Muscle fiber types: Type I = slow, oxidative, fatigue-resistant; Type IIa = fast oxidative-glycolytic; Type IIx/IIb = fast glycolytic, fatigable.

Length-tension relationship: peak active tension occurs near resting sarcomere length (~2.0-2.2 micrometres) where actin-myosin overlap is optimal.

Force-velocity relationship: concentric force falls as shortening velocity rises; eccentric contraction generates the highest force at lower metabolic cost.

Hilton's law: the nerve supplying a joint also supplies the muscles moving that joint and the skin over the insertions.

Upper limb root values: shoulder abduction C5, elbow flexion C5-C6, wrist extension C6-C7, finger flexion C8, finger abduction T1.

Lower limb root values: hip flexion L2-L3, knee extension L3-L4, ankle dorsiflexion L4-L5, ankle plantarflexion S1-S2, anal wink S4-S5.

Gait cycle: stance is ~60% and swing ~40% of the cycle; double support occupies ~20% at normal walking speed and disappears in running.

NSAID mechanism: reversible inhibition of cyclooxygenase (COX-1 and COX-2), reducing prostaglandin synthesis; corticosteroids act via phospholipase A2 inhibition and gene transcription effects.

Ottawa ankle rules: X-ray indicated if pain in malleolar zone plus bone tenderness at posterior edge or tip of either malleolus, or inability to bear weight both immediately and in clinic.

Ottawa knee rules: X-ray if age >55, isolated patellar tenderness, fibular head tenderness, inability to flex to 90 degrees, or inability to bear weight four steps.

Rotator cuff: supraspinatus initiates abduction (empty can/Jobe test), infraspinatus and teres minor externally rotate (external rotation lag sign), subscapularis internally rotates (lift-off test).

ACL: anterior drawer and Lachman test anterior laxity (Lachman most sensitive, performed at ~20-30 degrees flexion); pivot shift indicates rotational instability.

Meniscal tears: McMurray test and joint-line tenderness; a locked knee with block to extension suggests displaced bucket-handle tear needing orthopaedic referral.

Total knee arthroplasty: early mobilisation and full weight-bearing within 24 hours where the surgeon permits; aim for full extension and knee flexion progression toward 90-120 degrees.

Hip fracture post-operative: avoid hip flexion beyond 90 degrees, adduction past midline, and internal rotation after posterior-approach arthroplasty to reduce dislocation risk.

Rheumatoid arthritis: morning stiffness >1 hour, symmetrical small-joint involvement, MCP and PIP swelling; exercise should be low-impact and graded during flares.

Osteoarthritis: pain worse with use and relieved by rest, brief morning stiffness <30 minutes, bony enlargement and crepitus; core treatment is exercise and weight management, not rest.

Stroke: thrombolysis window typically up to 4.5 hours from onset for selected patients; thrombectomy may extend to 24 hours in selected large-vessel occlusion.

MRC grading: 0 no contraction, 1 flicker, 2 movement with gravity eliminated, 3 movement against gravity, 4 against resistance, 5 normal.

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

Spinal cord injury: complete injury = no sensory or motor function in sacral segments S4-S5; ASIA A is complete, B sensory incomplete, C and D motor incomplete, E normal.

Autonomic dysreflexia occurs with lesions above T6; triggers include bladder distension and constipation; response is hypertension, bradycardia, headache, and sweating - sit the patient up and remove the stimulus.

Vestibular rehabilitation: BPPV is treated with canalith repositioning (Epley for posterior canal, Semont, or Barbecue roll for horizontal canal); unilateral hypofunction is managed with gaze stabilisation and habituation exercises.

Dix-Hallpike test provokes torsional upbeating nystagmus with latency and fatigue in posterior canal BPPV; the supine roll test identifies horizontal canal BPPV.

Parkinson's disease: cardinal features are bradykinesia, rigidity, resting tremor, and postural instability; physiotherapy targets cueing for freezing, amplitude-based training, and falls prevention.

Multiple sclerosis: exercise should avoid overheating; Uthoff phenomenon is transient worsening of symptoms with raised core temperature.

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

Type 1 respiratory failure: PaO2 <8 kPa with normal or low PaCO2; type 2 is PaO2 <8 kPa with PaCO2 >6 kPa.

Airway clearance techniques: active cycle of breathing, autogenic drainage, PEP and oscillating PEP, high-frequency chest wall oscillation, and postural drainage with gravity-assisted positioning.

Forced expiratory technique: one or two huffs from mid to low lung volume followed by relaxed controlled breathing and a cough to clear mobilised secretions.

Cardiac rehabilitation: exercise training typically begins at 40-60% of peak capacity and progresses; Borg RPE 11-13 is a common moderate-intensity target.

Six-minute walk test: measures functional exercise capacity; a change of about 30 m in chronic lung disease is generally considered clinically important.

ICU early mobilisation: assess sedation level, haemodynamics, and lines before mobilising; stop for mean arterial pressure drop, new arrhythmia, or desaturation below the set threshold.

Post-operative breathing exercises: incentive spirometry, deep breathing, and supported coughing reduce atelectasis after upper abdominal and thoracic surgery.

Manual hyperinflation delivers a slow larger-volume breath with a manual resuscitation bag, then a pause and release to mobilise secretions and re-expand lung units.

Gross motor milestones: head control ~3 months, sitting without support ~6-8 months, pulling to stand ~9 months, independent walking ~12-15 months.

Primitive reflexes: Moro disappears by ~4-6 months, asymmetric tonic neck reflex by ~6 months, palmar grasp by ~4-6 months; persistence suggests neurological delay.

Cerebral palsy classification: spastic (most common), dyskinetic, ataxic, and mixed; distribution is hemiplegic, diplegic, or quadriplegic.

GMFCS levels I-V describe self-initiated movement; level I walks without limitations, level V is transported in a manual wheelchair.

Cerebral palsy hip surveillance: serial hip radiographs with migration percentage measurement; migration percentage >30% warrants orthopaedic referral.

Spina bifida: level of lesion predicts function; thoracic lesions are usually non-ambulant, lumbar lesions may ambulate with orthoses, sacral lesions often ambulate independently.

Duchenne muscular dystrophy: X-linked dystrophin deficiency; Gowers' sign and calf pseudohypertrophy; avoid eccentric and high-resistance exercise, and monitor for cardiomyopathy.

Clubfoot (talipes equinovarus): Ponseti method uses serial casting, usually followed by Achilles tenotomy and foot abduction bracing to prevent relapse.

Torticollis: congenital muscular torticollis is managed with stretching and positioning; assess for plagiocephaly and hip dysplasia association.

SOAP format: Subjective (history, symptoms), Objective (examination findings), Assessment (clinical impression and differential), Plan (treatment, goals, review).

Red flags: unexplained weight loss, night pain unrelieved by rest, fever, history of cancer, progressive neurological deficit, bowel or bladder dysfunction, and saddle anaesthesia.

Cauda equina syndrome is a surgical emergency: saddle anaesthesia, urinary retention or incontinence, bilateral sciatica, and reduced anal tone require immediate referral.

Outcome measures: use validated, condition-specific tools such as the Oswestry Disability Index, DASH, Berg Balance Scale, and Numeric Pain Rating Scale.

SMART goals: Specific, Measurable, Achievable, Relevant, Time-bound; goals should be patient-centred and negotiated, not imposed.

Sensitivity is the proportion of true positives correctly identified; specificity is the proportion of true negatives correctly identified; high sensitivity suits screening, high specificity confirms diagnosis.

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

Differential diagnosis requires comparing onset, mechanism, aggravating and easing factors, and 24-hour symptom pattern rather than relying on a single test.

Exercise prescription FITT: Frequency, Intensity, Time, and Type; progressive overload drives adaptation and specificity determines the training effect.

Eccentric exercise is used for tendinopathy (e.g., Alfredson protocol for Achilles) and is characterised by controlled lengthening under load.

Ultrasound: continuous mode produces thermal effects at 1-3 MHz; pulsed mode is non-thermal; avoid over the pregnant uterus, malignant tissue, and epiphyseal plates in children.

TENS: conventional high-frequency (80-100 Hz) for pain gating; low-frequency or burst modes may engage endogenous opioid mechanisms; contraindicated with pacemakers and over the neck anteriorly.

Cryotherapy reduces tissue temperature, blood flow, and pain; apply for 10-20 minutes with a barrier to protect skin and monitor for cold hypersensitivity.

Thermotherapy increases tissue extensibility and blood flow; avoid over acute inflammation, impaired sensation, or vascular insufficiency.

Interferential current uses two medium-frequency currents producing a low-frequency beat; avoid across the thorax, over the heart, and in pregnancy.

Assistive devices: a cane is held in the hand opposite the affected limb; walkers and crutches reduce weight-bearing; assess fit and handgrip before prescription.

Traction: cervical traction is used for radicular symptoms; contraindicated with spinal instability, malignancy, or cord compression.

Informed consent requires capacity, adequate information, and voluntariness; document discussion of risks, benefits, and alternatives before intervention.

Infection control: hand hygiene is the single most effective measure; use standard precautions with all patients and transmission-based precautions for known infections.

Scope of practice: practise only within competence and training; refer or escalate when the condition exceeds the physiotherapist's scope.

Documentation should be contemporaneous, objective, dated, signed, and legible; record assessment findings, interventions, patient response, and advice given.

Confidentiality is a duty; disclosure without consent is limited to legal requirements, risk of serious harm, or public health obligations.

Kuwait MOH regulation: registration and licensure through the Ministry of Health are required to practise; maintain professional indemnity and comply with MOH standards.

Falls prevention: assess falls risk, environment, footwear, and medications; use gait belts and standby assistance for high-risk transfers.

Duty of care and negligence: a breach of the accepted standard of care causing harm establishes negligence; incident reporting is mandatory for adverse events.

Study designs: randomised controlled trial (causal inference), cohort (incidence and prognosis), case-control (rare diseases), cross-sectional (prevalence), and case series (hypothesis generation).

Levels of evidence: systematic reviews and meta-analyses of RCTs are highest; single RCTs, cohort studies, case-control, case series, and expert opinion descend in hierarchy.

Randomisation reduces selection bias; blinding reduces performance and detection bias; allocation concealment prevents foreknowledge of assignment.

P-value: probability of observing results as extreme as those found if the null hypothesis is true; it is not the probability that the null is true.

Confidence interval: a 95% CI means that 95% of similarly constructed intervals would contain the true parameter; a CI excluding the null value corresponds to statistical significance.

Number needed to treat = 1/absolute risk reduction; it indicates how many patients must be treated for one additional benefit.

Intention-to-treat analysis includes all randomised participants in their assigned groups, preserving randomisation and reducing attrition bias.

Minimal clinically important difference is the smallest change perceived as beneficial by patients; statistical significance does not imply clinical importance.

Sensitivity and specificity trade off with the chosen cut-off; ROC curves plot sensitivity against 1-specificity and the area under the curve quantifies diagnostic accuracy.