MODULE LOCOMOTION 2010...1. GRAY'S Anatomy, the Anatomical Basis of Clinical Practice, Thirty-ninth edition, 2005. 2. Gross anatomy, 5 th ed. Kyung Won Chung. Lippincott Williams&Wilkins,

EUROPOS SĄJUNGAEuropos Socialinis Fondas

Programme of medical studies

MODULE

LOCOMOTION Second year

Third semester

Faculty of medicineKaunas university of medicine

Contents 1. General information2. General contents of the module3. Module objectives and tasks 4. Tutorials4.1. First problem. Sudden bone fracture

4.2. Second problem. Injury of the knee joint 4.3. Third problem. Degenerative changes of hip joint structural components 4.4. Fourth problem. The lumbar pain 4.5. Fifth problem. “Appe‘s hand” 4.6. Sixth problem. Muscle weakness

5. Lectures5.1. Structural and functional features of the knee and hip joint (2 hours)5.2. Peculiarities of the connective tissue (bones, cartilages); structure and metabolism of muscle protei(2hours) 5.3.Microscopic structure of the joint structural components (2 hours)5.4. Mechanism and regulation of the skeletal muscle contraction and relaxation (2 hours) 5.5. Clinical examination of the patients suffering from musculoskeletal system diseases Awareness of lower neuron lesion symptoms and examination. (2 hours)5.6. Arthropatic syndrome. Some aspects of fibrous tissue pathology. (2 hours).5.7. Radiological anatomy of bones, aging peculiarities. Osteoporosis radiologic diagnostics (2 hours) 5.8. Early, primary and secondary prevention of coxarthrosis and L4-L5 intervertebral disc hernia (2 hours)5.9. Initial assessment of an injured patient (2 hours)

6. Practical’s6.1. Functional anatomy of the vertebral column (3 hours)6.2. Functional anatomy of the knee and hip joints (3 hours)6.3. Functional anatomy of muscles of the upper extremity (3 hours) 6.4. Functional anatomy of muscles of the lower extremity (3 hours) 6.5. Functional anatomy of muscles of the trunk (3 hours)6.6. Aging changes of the structural components of the joints (3 hours). 6.7. Recording of the human electromyogram (3 hours)6.8. Regulation of the skeletal muscle force (3 hours)6.9. Principles of conservative and surgical therapy of degenerative bone changes (3 hours)6.10. Principles of diagnostics and management of joint injuries and bone fractures (3 hours)6.11. Immobilization for trauma patients. Wound dressings. (3 hours)

7. Seminars7.1. Duchenne muscular dystrophy (2 hours)7.2. Peculiarities of the bone tissue and cartilage molecular composition; bone mineralization and factors that influence this process. (3 hours)7.3. Clinical diagnostics of the musculoskeletal system. Arthropatic syndrome. (3 hours).7.4. Radiologic anatomy of bones, aging peculiarities: image analysis of x-ray, computerized tomography (CT), magnetic resonance imaging (MRI). Radiologic diagnostics of osteoporosis. Bone densitometry (1 hour)

7.5. Radiologic examination of the knee joint. (1 hour)7.6. Radiologic examination of the hip joint (1 hour)7.7. Radiologic examination of the vertebral column: x – ray, myelography, computerized tomography (CT), magnetic resonance imaging (MRI) (1 hour)7.8. Mechanism of action of the main medicaments used in osteoporosis treatment (4 hours)7.9. Principles of the knee joint traumas therapy (2 hours)7.10. Nonmedicamental implement and methods of improvement of joint function due to degenerative changes; nonsurgical implement and methods of restoration of function after the intervertebral hernia (3 hours)7.11. Duchenne sindrome: Nursing management (4 hours)7.12. Influence of factors of ergonomic occupational environment on lumbar pain occurrence ( 2val.) 7.13. Influence of factors of ergonomic occupational environment on median nerve compression syndrome development (2 hours)7.14 Principles of diagnostics and management of soft tissue injuries, joint injuries and bone fractures (2 hours)

8. Module exam questions8.1. Anatomy 8.2. Biology8.3. Biochemistry 8.4. Human histology and embryology 8.5. Physiology.8.6 Basis of medical diagnostics8.7. Rentgenology and radiology8.8. Pharmacology8.9. Orthopedia and traumatology8.10. Kinesiology8.11. Nursing8.12. Environmental and occupational medicine 8.13.General surgery

9. Appendixes

1. General information

The head of module: associated prof. Aušra Burkauskienė, institute of anatomy (ausra.burkauskiene@med. kmu.lt)

Coordinators of module: associated prof. Vytautas Gedrimas, institute of anatomy ([email protected]),

Associated prof. Rimvydas Miliauskas, department of physiology ([email protected])

Departments: Institute of Anatomy Department of Biology Department of Histology and Embryology Department of Physiology Department of Biochemistry Clinic of Internal Diseases Clinic of Radiology Department of Theoretical and Clinical Pharmacology Clinic of Orthopedia and Traumatology Department of Kinesiology and Sport medicine Department of Nursery and Care Environmental and Occupational Medicine Clinic of General surgery.

mailto:[email protected]

mailto:[email protected]

mailto:ausra.burkauskiene@med.%20kmu.lt

Subjects delivered and persons in charge:

Anatomy (associated prof. Aušra Burkauskienė, 327308, 868785510)Biology (prof. Algis Bertulis, 327366)Human histology and embryology (prof. Angelija Valančiūtė, 327210)Biochemistry (associated prof. Jūratė Burneckienė, 327220)Physiology (prof. Edgaras Stankevičius, 327257)Basis of medical diagnostics (associated prof. Palmyra Leišytė 306093)Radiology (associated prof. Eglė Monastyreckienė Jūratė 327005, 327001 )Pharmacology (associated prof. Arvydas Milašius, 327242)Orthopedia and traumatology (prof. Romas Jonas Kalesinskas 326282, 326697)Kinesiology (lect. Vidmantas Zaveckas, lect. Vytautas Poškaitis, 730580)Nursing (assistant Aušra Lekauskaitė, 327147)Environmental and occupational medicine (lect.Vidmantas Januškevičius, assistant Paulius Vasilavičius, 327293)General surgery (lecturer Juozas Juočas, 306059)

2. General thematic contents of the module

During the course students obtain the new skills in the following areas: Morphology and biomechanics of the musculoskeletal system; Biochemical structure and aging changes of bone, hyaline and fibrous cartilage Hyaline, fibrous cartilage and skeletal muscle remodeling; The bone growth and remodeling; Metabolism of striated muscular tissue; Signal transmission from the nerve to the skeletal muscle. Contraction and relaxation of the

muscle; Most common pathology and mechanisms of the musculoskeletal system; Basis of the musculoskeletal system examination; Prevention of the musculoskeletal system diseases, principles of therapy, rehabilitation,

nursing and their application to the further theoretical and practical studies.

3. Objective of the module and tasks

Objective – to help students to obtain knowledge and skills in order to be able to determine, analyze, relate and generalize theoretical and practical questions of the presented problems. Tasks:

• Master anatomy of the skeleton as a passive part of the musculoskeletal system, its histologic structure, biochemistry, biomechanics, the growth, remodeling, aging changes and most common pathology, pathogenesis, diagnostics of diseases that damage skeleton, therapy and prevention;

• Master anatomy of joints as moveable articulations, their histological structure, biochemistry, metabolism of the connective tissue, pathology of joints in relation to age, degenerative changes, traumas, mechanisms of pathologic changes, diagnostics, principles of therapy, rehabilitation and prevention;

• Master anatomical peculiarities of the vertebrae and their joints, the spine movements, functional anatomy of ligaments and muscles that stabilize the body, histologic structure, biohemistry of intervertebral discs, degenerative changes and their causes resulting in pathology of the spine, principles of diagnostics, therapy, rehabilitation and prevention;

• Master functional anatomy of striated musles as an active part of the musculoskeletal system, histologic and biochemical structures, metabolism, mechanisms and regulation of contraction and relaxation of the skeletal muscle;

• Master innervation of the trunk and extremities muscles (spinal nerves, their divisions, nerve plexuses: the cervical, the brachial, the lumbar, the sacral plexuses and peripheral nerves that emerge from these plexuses), histologic structure of a peripheral nerve, symptoms that arise from dysfunction of above mentioned innervation of muscles;

• Master to explain the origin and changes of striated muscle dystrophy that arise from gene mutation in muscle fibers due to Duchenne syndrome, functional groups of muscles that are damaged during this pathology, morphology, function, mechanisms of progressing changes in curvature of the spine and disorders of respiration, nursing management, methods of therapy and outcomes.

4. Tutorials

4.1. First problem. Sudden bone fracture

75-years-old pensionier woman A.G. lived on her own and was of small built (body height -

1,6 m and mass - 49 kg ) . She had been having a history of the continuing, gnawing lumbar pain

for the past 15 years. Due to this pain, the woman was having a diffulty in walking: she had cramp

pains in legs at night whenever she walked. Therefore, she tried to walk as little as possible and did

not visit her doctor. The only woman‘s entertainment was coffee drinking. In the evening being

unable to sleep because of pain, A.G. got up and went for her painkillers but stumbled over the

carpet and felt down. By falling she leaned on her hand that led to a sharp pain. The woman

observed that her hand involuntary moved outside, there also was an increase in the circumference

of the wrist region, accompanied by oedema and deformation. Next day A.G. was referred to a

traumatologist, who after examination and x-ray of the hand diagnosed a fracture of the radius.

What caused sudden fracture of the radius?

Was it possible to prevent this fracture?

What is a reason of the lumbar pain?

The main issue: degenerative age related changes of the bones. Clinical manifestations: The gnawing continuing lumbar pain, decreased ability to walk, cramp pain in the legs at night.

Objective

To be able to explain growth and regeneration of bones, age related bone tissue changes, mechanisms and factors of such bone tissue changes, pathogenesis of ostheoporosis and possible complications, diagnostic pattern and possibilities, way of treatment and prophylaxis

Tasks of the course and contents

After dealing with the problem students must know the following:

• The partition of the skeleton, anatomical features of vertebrae and long bones.

Subject – anatomyUnit – Institute of Anatomy

References: 1. Human Anatomy. Prives M., Lysenkov N., Bushkovch. Moscow, 1989, It., p.128-142,

217, 221-224, 227-231, 247-248, 252-254, 261-265.2. Atlases of Human Anatomy.

Supplementary reading: 1. GRAY'S Anatomy, the Anatomical Basis of Clinical Practice, Thirty-ninth edition,

2005. 2. Gross anatomy, 5 th ed. Kyung Won Chung. Lippincott Williams&Wilkins, 2005.3. Material of the Module of osteology, syndesmology and myology. Burkauskiene. A.,

Azelis V., Rutkauskas S. Kaunas, 2007.

• Features of structure, synthesis and metabolism of bone protein.Mineralization of bone tissue and factors that influence this process.

Subject - biochemistryUnit - Department of Biochemistry

References: 1. 1.Marks’ basic medical biochemistry. C.Smith, A.D.Marks, M.Lieberman. 2005, 2nd

ed., p. 905 -910, 912-915.2. Harper’s illustrated biochemistry. R,K.Murray et al. 2003. 26th ed. 535-539, 542-

555.Supplementary reading:

1. Biochemistry. P.C.Champe, R.A.Harvey, D.R.Ferrier. 2005, 3rd ed., p.43-49, 51.

• Microscopic structure of bones, their vascularization and regeneration.

Subject – human histology and embryology Unit – Department of Histology and Embryology

References:1. L.Jungeira , J.Carneiro. Basic Histology, 2005, p.135 -149t. Supplementary reading: 2. A.Stevens, Human Histology,. 2005, p.249 – 264.

• Methods and techniques of examination of the musculoskeletal system organs, pathological conditions of joints, the tissues around the joints and striated muscles.

Subject – basis of medical diagnostics Unit – Clinic of Internal Diseases

References: 1. Clinical Examination, second edition. Epstein, Owen at al. 2001,p.255-292.

Supplementary reading:1. Clinical Medicine, Fifth Editon. Kumar, Parveen Clark, Michael.. 2002.

• Anatomy of skeletal radiology, to locate osteoporosis in X-ray pictures and CT images, to evaluate the records of the bone density.

Subject – radiologyUnit – Department of Radiology

References: 1. Diagnosis of bone and joint disorders. 3rd edition. D.Resnick. 1995. p.1-4862. Orthopedic radiology. A practical approach. A.Greenspan. Philadelphia, 1988. p.1.1-1.53. Textbook of radiology and imaging. D.Sutton, 2003. p.1207-1212

Supplementary reading: 1. Skeletal radiology. D.Resnick, H.Pettersson. London, 1992.

• Potential of osteoporosis correction by pharmacological means, the most important groups of drugs used to treat and prevent osteoporosis, criteria of drug administration, drug-induced side effects, symptoms of overdose and first aid measures in a case of poisoning, the mechanism of these drugs action, indication, safety precausions and drug interaction associated with other medicaments.

Subject– pharmacology Unit – Department of Theoretical and Clinical Pharmacology

References: 1. Basic and Clinical Pharmacology. Bertram G. Katzung. 1998, p. 706 – 720. 2. Lippincott's Illustrated Reviews: Pharmacology, 2nd edition, 1997, p. 337 – 339.

Supplementary reading:

1. Pharmacology.Fifth edition. H.P.Rang ir kt. 2003.

• Principles of medicamental, nonmedicamental and surgical treatment of the radius fracture.

Subject– orthopedia and traumatologyUnit – Clinic of Orthopedia and Traumatology

References: 1. Charles A. Rockwood, Jr. And David P. Greeen: Fractures in adults 411-450 2. http://www.aofoundation.org/

• Joint contusion (contusio), joint distortion (distorsio), rupture of ligaments and menisci. Clinical signs, diagnostics, principles of management. Joint luxations. Causes. Classification. Principles of diagnostics and management. Bone fractures. Mechanisms of fractures. Types of fractures and bone dislocations. Principles of assessment of patients with bone fractures. First aid and principles of management.

Subject– general surgeryUnit - Clinic of General Surgery

References:1. Clinical surgery. Edited by Michael M. Henry, Jeremy N. Thompson. Second

Edition.1998, p. 677-689.Supplementary readings:

1. David L. Hamblen, Hamish Simpson. Adams's Outline of Fractures, Including Joint In-juries, 20th edition. Churchill Livingstone, 2007. p. 340.

2. 2. Essentials of General Surgery (4th edition). Peter F. Lawrence, Richard M. Bell, Merril T. Dayton, Mohammed I. Ahmed. Lippincott Williams & Wilkins, 2006, p 206-208.

http://www.bestwebbuys.com/Mohammed_I_Ahmed-author.html?isrc=b-compare-author

http://www.bestwebbuys.com/Merril_T_Dayton-author.html?isrc=b-compare-author

http://www.bestwebbuys.com/Richard_M_Bell-author.html?isrc=b-compare-author

http://www.bestwebbuys.com/Peter_F_Lawrence-author.html?isrc=b-compare-author

4.2 Second problem. Knee joint injury

A 26-year-old patient P.M., who had played football for 10 years, visited a doctor because of the pain in the left knee joint. During the match another player had kicked him in the inner side of the left knee. P.M. fell and turned his leg; he wanted to raise and leaned on the left leg. The patient felt a severe pain in the area of the left knee. The sportsman limping left the field. Despite the pain and oedema the patient did not visited a doctor but cooled the knee area, then fixed the joint region with elastic bandage and used antinflamatory painkillers. The pain subsided, oedema diminished but on the second day when P.M. began to walk oedema and the pain reoccurred accompanied by decreased motion of the knee joint. He decided to visit a doctor. Walking down the stairs P.M. felt a severe pain accompanied by a feeling of „locking“ of the left knee joint. After examination the doctor suspected the medial meniscus tear and administered clinical tests.

What was the cause of the pain and why did the patient felt „locking“ of the knee joint?

What is medical treatment and principles of joint restoration?

The main issue: knee joint traumatic injuries

Clinical manifestations: posttraumatic pain of the medial side of the left knee joint, oedema, decreased motion of the knee joint, „locking“of this joint.

Aim

To master morphology of the main elements and appendages of the knee joint, to be able to detect traumatic injuries using various techniques of diagnostics, to consider the principles of therapy and rehabilitation.


After dealing with the problem students must know:

• Anatomy of the main elements and appendages of the knee joint, innervation, features of biomechanics.

Subject– anatomyUnit – Institute of Anatomy


IIt., 266-276.2. Atlases of Human Anatomy.3. Supplementary reading: 4. GRAY'S Anatomy, the Anatomical Basis of Clinical Practice, Thirty-ninth edition,


Azelis V., Rutkauskas S. Kaunas, 2007.7. Features of bone and cartilage protein structure, synthesis and function.

Subject – biochemistryUnit – Department of Biochemistry

References: 1. Marks’ basic medical biochemistry. C.Smith, A.D.Marks, M.Lieberman. 2005, 2nd ed., p.

905 -910, 912-915.2. Harper’s illustrated biochemistry. R,K.Murray et al. 2003. 26th ed. 535-539, 542-555.

• Histologic structure of a joint capsule, ligaments, meniscs.

Subject – human histology and embryologyUnit – Department of Histology and Embryology

References: 1. L.Jungeira , J.Carneiro. Basic Histology, 2005, p.135 -149t

Supplementary reading: 1. A.Stevens, Human Histology,. 2005, p.249 - 264

• Screening indications of the joint knee.To locate common injuries to the knee joint in CT, arthrographic, MRI images.

Subject –radiologyUnit – Clinic of Radiology

References:1. Bone and joint imaging in rheumatic and orthopedic diseases. Francesco Priolo. p.357-

358, 360-3672. Diagnosis of bone and joint disorders. D.Resnick. 3rd edition, 1995. p.3253-32543. Practical musculoskeletal ultrasound. E.G.McNally, 2005. p.144-1604. Orthopedic radiology. A practical approach. A.Greenspan. Philadelphia, 1988. p.6.25-

6.315. Textbook of radiology and imaging. D.Sutton, 2003. p.1235-12376. Internal derangements of joints. Emphasis on MR imaging. D.Resnick, H.S.Kang.

p.595-635

• Most common traumas of the knee joint and types of meniscus tear. Arthroscopy as the method of diagnostics and therapy.

Subject – orthopedia and traumatologyUnit – Clinic of Orthopedia and Traumatology

References: 1. H. Crenshaw: Campbell’s operative orthopaedics 8th. ed.Volume I. 441-5092. http://www.nlm.nih.gov/medlineplus/ency/presentations/100117_1.htm3. http://orthoinfo.aaos.org/booklet/view_report.cfm?Thread_ID=8&topcategory=Knee4. http://cms.clevelandclinic.org/ortho/body.cfm?id=31#9

• Types and purposes of splints. Splinting of the injuries of soft tissues, joints and bone frac-tures. Types and purposes of wound dressings. Requirements for contemporary wound dressings. Various dressing techniques for managing injuries.

Subject– general surgeryUnit - Clinic of General Surgery.



1. Compendium Wounds and Wound Management. P. Hartmann AG. 1st Edition, 1999, p.88-112.

4.3 The third problem. Pain and reduction of mobility of the hip joint

A 70-year-old retired woman J.C. working as a plasterer until she was 62. She had an increased body mass (height – 1, 60m, weight- 88kg). The patient saw a doctor because of the pain in her right hip joint, stiffness in the morning and limited motions. She had done manual job all her life, had had a normal weight but after menopause her weight increased. First she felt the pain in the right hip joint 10 years ago. After few years the pain was brought on not only on exertion but also at night, or on the rest. The pain was accompanied by stiffness in the right hip joint in the morning and weakness in the muscles of the thigh. Recently, the patient began to suffer from severe pain, particularly on exertion. Being unable to sleep - the pain radiated to the thigh, groin, buttocks - the woman began to use the painkillers, which helped a little. The patient also complained of the cramp pain in the muscles around the right hip, increased siffeness in the morning, a limited amplitude of motions, „shortening“ of the right lower limb. After examination the doctor suspected the primary osteoarthrosis of the right hip joint.

What was the cause of the pain and why did dysfunction of the right hip joint occur? Explain the

mechanism of the development of these changes.

What is treatment, rehabilitation and prevention of this pathology?

The main issue: degenerative changes of the joint structural components.

Clinical manifestations: the continuing pain in the right hip, increased on exertion, pain radiating to the thigh, groin, buttocks, weakness and the cramp pain in the muscles around the joint, stiffness in the morning, limited amplitude of motions, shortening of the lower limb.

Aim

To master the features of morphology of the main elements and appendages of the hip joint, to detect degenerative changes of the joint using various diagnostic techniques and explain the mechanism of these changes, consider the principles of treatment, rehabilitation and prevention.



• Anatomy of the main elements and appendages of the hip joint, innervation, the peculiarities of biomechanics.

Subject – anatomyUnit–Institute of anatomy


IIt., 266-276.2. Atlases of Human Anatomy.




• Features of bone and cartilage protein structure, synthesis and function. Age-related bone and cartilage changes.


References: 1. Marks’ basic medical biochemistry. C.Smith, A.D.Marks, M.Lieberman. 2005, 2nd ed., p.

905 -910, 912-915.2. Harper’s illustrated biochemistry. R,K.Murray et al. 2003. 26th ed. 535-539, 542-555.

• Structure of the articular cartilage surface, age-related changes, regeneration.


References:1. L.Jungeira , J.Carneiro. Basic Histology, 2005, p.135 -149t

Supplementary reading: 1. A.Stevens, Human Histology,. 2005, p.249 - 264

Radiologic anatomy of the hip joint. To detect the signs of arthrosis using radiologic images.


References:1. Bone and joint imaging in rheumatic and orthopedic diseases. Francesco Priolo. p.59-73,

162-1672. Diagnosis of bone and joint disorders. 3rd edition. D.Resnick, 1995. p.1263-1289, 1320-

13343. Essentials of skeletal radiology. T.R.Yochum, L.J.Rowe. Baltimore, 1987. p.546-5504. Practical musculoskeletal ultrasound. E.G.McNally. 2005. p.136-1405. Orthopedic radiology. A practical approach. A.Greenspan. Philadelphia, 1988. p.10.4-

10.86. A short textbook of clinical imaging. D.Button, J.W.R. Young. London, 1990. p.377-3807. Textbook of radiology and imaging. D.Sutton. 2003.p.1222-1226

• Criteria of the choise of surgical therapies for the hip joint arthrosis that is caused by degenerative changes of the elements of the joint.

Subject – orthopedia and traumatologyUnit – Clinic of Orthopedia and Traumatology

References: 1. A. H. Crenshaw: Campbell’s operative orthopaedics 8th. ed.Volume III. 1787-1844

• The significance of an early and primary prevention for this disease; the main principles of the tertiary prevention of the hip joint osteoarthrosis (active rehabilitation); influence of coxarthrosis to locomotion, osteokinematics and arthrokinematics; to understand posibilities of return of function.

Subject – kinesiologyUnit – Department of Kinesiology and Sport Medicine

References :1. Osteoarthritis instructor manual. 2. EULAR Recommendations 2003: an evidence based approach to the management of

knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis. Jordan KM, Arden NK, Doherty M, Bannwarth B, Bijlsma JW, Dieppe P, et al. 2003, p.62:1145-55.

3. Non-surgical treatment of osteoarthritis: a half century of "advances". Ann Rheum Dis. Brandt KD. 2004, p. 63:117-22.

Supplementary reading:1. Osteoarthritis of the periferal joints. In: Bailliere´s Best Practice & Research - Clinical

Rheumatology: Elsevier. Petersson IF, Jacobsson LTH. 2002.

4.4 The fourth problem. The lumbar pain

A 40-year-old builder K. M. with an increased body mass (height - 1,78 m, weight - 105 kg) complained of the lumbar (low back) pain, which radiated to the right leg up to the foot, muscle weakness in the leg and muscles dysfunction. The patient had suffered from the continuing pain in his low back for 2 years. Exertion made the pain worse. A year ago, after exertion he felt a severe pain in his low back that made him unable to move. A doctor advised to decrease exertion and administered nonsteroid, ant inflammatory drugs, myorelaxants?. After acute phases of the disease physioteraphy, massage, exercises were administered. The pain subsided and the patient carried on with his daily work till the last excedent. Doctor saw patient‘s right hip and knee joints were kept in the flexion position, the right sole (foot) was pendent, patient cannot rise it, make extension (dorsal flexion) of the right sole and big toe. Patient cannot stand on the right heel. He felt a difference in medical style touching of both legs, difference of temperature in the right leg, lateral side of the sole and big toe. The doctor suspected inflammation of L5 spinal nerve root, as a sequence of the possible L4-L5 intervertebral disc hernia.

Why did the pain in the low back occur?

Which factors may cause intervetebral L4- L5 disc hernia?

Determine the groups of the muscles and innervation of muscles , which dysfunction involved in

intervetebral L4- L5 disc hernia formation

Determine principles of treatment of such pathology?

The main issue: Degenerative changes of the vertebral column and its bone joints.

Clinical manifestations: the severe pain in the low back, radiating to the right leg and the leg dysfunction after exertion, changes of the right lower limb sensations.

Aim

To master the features of morphology of the vertebrae and their joints, describe degenerative changes, using various diagnostic techniques, confirm intervertebral L4-L5 disc hernia, to explain the mechanism of dysfunction of the lower limb muscles, consider the principles of therapy, rehabilitation and prognosis of recovery and prevention.



• Anatomical features of the vertebrae and their joints, degenerative changes of spine bones, the muscular groups and muscles of the lower limb, function, innervation of muscles and dysfunction.

Subject – anatomyUnit – Institute of Anatomy

References: 1. Human Anatomy. Prives M., Lysenkov N., Bushkovch. Moscow, 1989, It.,p. 142-147,

355-379, p. IIt., 266-276.2. Atlases of Human Anatomy.




• Peculiarities of bone and cartilage protein structure, synthesis and function.


References:1. Marks’ basic medical biochemistry. C.Smith, A.D.Marks, M.Lieberman. 2005, 2nd ed., p.

905 -910, 912-915.2. Harper’s illustrated biochemistry. R,K.Murray et al. 2003. 26th ed. 535-539, 542-555

• Histologic structure of the peripheral nerve. Structure of the muscle contractile apparatus.


References:1. L.Jungeira , J.Carneiro. Basic Histology, 2005, p.155 –163, 182 202

Supplementary reading: 1. A.Stevens, Human Histology,. 2005, p71 –82, .85 -94

• Mechanism of signal transmission from a nerve to the skeletal muscle.

Subject – physiology Unit – Department of Physiology

References:1. Review of Medical Physiology. 22nd edition. Ganong W.F. Lange Medical Books, New

York, 2005, Ch. 4, p. 98-101, 116-118.2. Textbook of Medical Physiology. 11th edition. Guyton A.C. Saunders, 2005, Ch. 7, p.

85-91.

• The main radiologic signs of degenerative changes of the vertebral column.


References:1. Bone and joint imaging in rheumatic and orthopedic diseases. Francesco Priolo. p.75-

1342. Cerebral and spinal computed tomography. 3rd edition. T.Grumme, W.Kluge, K.Kretz-

schmar et al. p.229-2483. Diagnosis of bone and joint disorders. 3rd edition. D.Resnick. 1995. p.1372-14624. Differential Diagnosis in Conventional Radiology. F.A.Burgener, M.Kormano. New

York, 1991. p.192-1935. Essentials of skeletal radiology. T.R.Yochum, L.J.Rowe. Baltimore, 1987. p.273-3166. Orthopedic radiology. A practical approach. A.Greenspan. Philadelphia, 1988. p.8.37-

8.437. Textbook of radiology and imaging. D.Sutton. 2003. p.1226-12298. Whole body computed tomography. 2nd edition. O.H.Wegener. p.513-530

• Significance of early and primary preventive measures for disease occurrence; the main principles of tertiary prevention (active rehabilitation) of intervertebral L4-L5 disc hernia; influence of intervertebral L4-L5 disc hernia on the body posture and locomotion, osteokinematics and arthrokinematics. To understand the return of function.

Subject – kinesiologyUnit – Department of Kinesiology and Sport Medicine

References : 1. Kinesiology of the musculoskeletal system. Fundations for physical

rehabilitation.Mosby. Donald A. Neumann. 2004, p. 269 – 294.2. Exercise therapy for treatment of non-specific low back pain. The Cochrane

Collaboration, Issue 1. Published by JohnWiley & Sons. Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Copyright © 2007, p. 41 – 68.

3. Multidisciplinary biopsychosocial rehabilitation for subacute low-back pain among working age adults. Karjalainen K, Malmivaara A, van Tulder M, Roine R, Jauhiainen M, Hurri H, Koes B. Copyright © 2007 The Cochrane Collaboration, Issue 1. Published by JohnWiley & Sons, p. 1 – 19.

Supplementary reading: 1. Exercise therapy for treatment of non-specific low back pain. Copyright © 2007 The Co-

chrane Collaboration. Published by JohnWiley & Sons.2. Multidisciplinary biopsychosocial rehabilitation for sub acute low-back pain among

working age adults. Copyright © 2007 The Cochrane Collaboration. Published by JohnWiley & Sons.

• Factors (features of weight lifting and occupational environment, manual work, regulations of work and individual factors) that contribute to the back injuries and prevention.

Subject – environmental and occupational medicine Unit – Department of Environmental and Occupational Medicine

References:Supplementary reading:

1. T.C.AW, K. Gardiner, J.M. Harrington "Occupational health" 187-188 p.2. William Charney "Handbook of modern hospital safety" 701-742 p.3. Julia Smedley "Oxford handbook of Occupational health" 156-162 p

4.5 The fifth problem. “Appe’s hand”

A 54-year-old lecturer at medical university G.Č. has been preparing a manuscript of monograph and after long lasting writing began to feel intensive, especially in night, burning pain, edema, numbness of the right hand and I-III fingers. Patient has insomnia because of the pain and numbness of the hand, he tried to help himself making massage, walking in the bedroom. Thinking that all these disturbances were related to writing the patient did not seek medical advice and began to worry only when complains became stronger. Visually comparing both own hands he saw the changes and differences in relief of his right hand, the right thenar eminences became flat; the right hand was like the “appe’s hand” which image he had seen in medical atlas. G.Č. decided visited a doctor.

Examination in the clinic revealed hypotrophy of small muscles of the palmar surface of the lateral side of the right hand, atrophy of nuscles of thenar eminence of the right hand, skin dryness. Patient cannot successfully make fist (he cannot make flexion of I-III fingers), to keep paper list between I and II fingers, to move II finger on the table surface. Doctor found a decrease in skin sensation of I-III fingers and of the lateral side of the IV finger. A pain was intensified, when the flexion or extension of the hand in the radiocarpal joint was made. The doctor diagnosed median nerve compression in the right carpal canal. After nerve decompression surgery, nerve trunk compressing fibroid tissue bundles of tendons were removed, nerve is released in the carpal canal, skin sensation disorders and numbness disappeared, muscle atrophy did not progressed.

Why was median nerve compressed?

Why did the thenar eminence and other muscles of the lateral side of the palmar surface of the hand

waste away?

Why did after nerve compression parasthesia, numbness, pain, muscle weakness occur? Why did

these sensations become stronger after bending of the hand in the wrist joint?

The main issue: long-termed compression of the peripheral nerve stem and muscular atrophy. Clinical manifestations: skin sensation dysfunction, numbness, pain, muscular weakness and atrophy.

Aim:To master anatomy of the forearm and hand, the wrist and hand joints and ligaments,

the forearm and hand muscles and their tendons, the structure of the peripheral nerve, segmental innervations of skin and muscle of the forearm and hand, explain anatomic basis of median nerve compression, clinical manifestations of the median nerve compression.



• Anatomy of the upper extremity bones, joints and muscles, the nerve course of the hand, the characteristics of innervations and vascularization.

Subject – anatomyUnit –Institute of Anatomy

References: 1. Human Anatomy. Prives M., Lysenkov N., Bushkovch. Moscow, 1989, It.,p. 217-238,

335-355, IIt., p., 65-73, 256-264.2. Atlases of Human Anatomy.

Supplementary reading: 1. GRAY'S Anatomy, the Anatomical Basis of Clinical Practice,

Thirty-ninth edition, 2005. 2. Gross anatomy, 5 th ed. Kyung Won Chung. Lippincott Willi-

ams&Wilkins, 2005.3. Material of the Module of osteology, syndesmology and my-

ology. Burkauskiene. A., Azelis V., Rutkauskas S. Kaunas, 2007.

• Physical-clinical methods to return of medianus nerve functions, effectiveness of kinesiotherapy in return of medianus nerve functions.

Subject – kinesiologyUnit– Department of Kinesiology and Sport Medicine

References:1. Kinesiology of the musculoskeletal system. Foundations for physical rehabilitation.

Mosby Donald A. Neumann. 2004, p. 269 – 294.Supplementary reading:

1. Exercise therapy for treatment of non-specific low back pain. Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Copyright © 2007 The Cochrane Collaboration, Issue 1. Published by JohnWiley & Sons.

2. Multidisciplinary biopsychosocial rehabilitation for subacute low-back pain among working age adults. Karjalainen K, Malmivaara A, van Tulder M, Roine R, Jauhiainen M, Hurri H, Koes B. Copyright © 2007 The Cochrane Collaboration, Issue 1. Published by JohnWiley & Sons.

• Median nerve carpal syndrome provoking factors of occupational environment and work process, factors that increase tunnel syndrome risk, individual safety measures used to prevent this syndrome.

Subject – environmental and occupational medicine Unit – Department of Environmental and Occupational Medicine.

References: 1. Carl Zenz "Occupational medicine" 48-63 p. 2. http://www.assh.org/Content/NavigationMenu/PatientsPublic/HandConditions/CarpalTu

nnelSyndrome/Carpal_Tunnel_Syndr.htmSupplementary reading:

1. Encyclopaedia of occupational health and safety/ ILO, 1998. 2. National Institute for Occupational Safety and Health. Elements of Ergonomics

Programs. DHHS (NIOSH) Publication No.97-117,1997, Cincinnati, OH

4.6 The sixth problem. Progressing muscle weakness.

A 18-year-old school boy J. S. was admitted to hospital because of the history of breathlessness and muscle weakness at the quietness. Mother of J.S. noticed problems when a boy was 5 -years-old, had suffered from difficulty in standing up, walking, particularly in climbing stairs. At age of 7 years diagnosis of congenital wekness of the muscles was made. Weakness and atrophy of the muscles (especially muscles of the upper limb) advanced, amplitude of movements decreased, deformation of the spine (kypho-scoliosis) and contractures of the joints were found. He had locomotion problems and finally he was able to move only in a electric wheelchair. Mother of J.S. told that brother of this guy died he was 24-years – old and progress of disease was very alike.

Why did the skeletal muscles become weak?

Why did dyspnea occur?

Is it possible to help the patient?

The main issue: Degenerative changes of the skeletal muscles.

Clinical manifestations: Progressive muscle weakness, limited motions, curvature of the spine, respiratory disorders.

AimTo know functional groups of skeletal muscles that are damaged by the disease, muscles that belong to these groups, their morphology, function, degenerative changes, the mechanisms and course of curvature of the spine and progressing weakness of the muscles, nurse management.


After dealing with the problem the students must know:

• Functional groups of skeletal muscles that are damaged by the disease, their function, vascularization, innervation. The parts of diafragma, the peculiarities of function, vascularization, innervation. Courses of development and the mechanisms of curves of the spine (kyphosis, lordosis, scoliosis). The importance of these curves for the statics and dynamics of human body.

Subject– anatomyUnit – Institute of anatomy

References: 1. Human Anatomy. Prives M., Lysenkov N., Bushkovch.

Moscow, 1989, It.,p. 287-312, 331-355, IIt., p., 51-53, 61-75, 82-94, 104-118, 256-266.2. Atlases of Human Anatomy.

Supplementary reading: 1. GRAY'S Anatomy, the Anatomical Basis of Clinical Practice,

Thirty-ninth edition, 2005. 2. Gross anatomy, 5 th ed. Kyung Won Chung. Lippincott Willi-

ams&Wilkins, 2005.3. Material of the Module of osteology, syndesmology and my-

ology. Burkauskiene. A., Azelis V., Rutkauskas S. Kaunas, 2007.

• To explain the origin of muscular dystrophy and changes that result from gene mutation in the muscle fibers.

Subject – biologyUnit – Department of Biology

References:1. Principles of Medical Genetics. T.D.Gelehter, F. C. Collins, D Ginsburg.1997, p. 212 –


1. http://www.ygyh.org/dmd/whatisit.htm

• Proteins of the muscular tissue, the peculiarities of metabolism and their significance to movement.



863-879.2. Harper’s illustrated biochemistry. R,K.Murray et al. 2003. 26th ed. 556-566, 573-576.

• Mechanism and regulation of the skeletal muscle contraction and relaxation.

Subject – physiology Unit – Department of Physiology

References:1. Review of Medical Physiology. 22nd edition. Ganong W.F. Lange Medical Books, New

York, 2005, Ch. 3, p. 65-78.2. Textbook of Medical Physiology. 11 edition. Guyton A. C. Saunders, 2005, Ch. 6, p. 72-

84.

• Patient-based nursing measures during respiratory failure: patient‘s position, which decreases dyspnea, oxygen delivery supplies, breathing exercises. Patient-based nursing measures to promote lexibility of joints and diminish muscle weakness: the methods of exercises. Promotion of general wellbeing. Patient based nursing measures for prevention of pressure sores.

Subject – nursingUnit – Department of Nursing and Care

References:1. Basic Nursing. Patricia A. Potter, Anne Griffin Perry. St. Louis, 2003, p. 645-685, 822-

839.2. Clinical Nursing Skills. Sandra F. Smith, Donna . Duell, Barbara C. Martin. New Jersey,

2000, p. 257-260, 263-265, 478-479.3. Fundamentals of Nursing. Carol Taylor, Carol Lillis, Priscilla leMone. Philadelphia,

1993, p. 625-633.Supplementary reading:

Therapeutic Exercise. 5'11 edition. Basmajian John V., WolfSteven L. Williams&Wilkins, 1996.

5. Lectures

5.1 Structural and functional features of the knee and hip joint (2 hours)

Unit – Institute of Anatomy

In charge–doc. A.Burkauskienė

Description

Features of the hip joint elements: acetabulum (socket of the hip bone), the head of the femur, the

joint capsule and appendages, their significance to biomechanics of the joint. Age-related

peculiarities of joint structural components. Anatomic peculiarities of the knee joint main elements:

articulating surface of the tibia and the condyles of the femur, the capsule, (its elements), and

appendages of the articulation, their significance to biomechanics of the joint.

5.2 Peculiarities of the connective tissue (bone, cartilage), muscle protein structure and metabolism (2 hours).

Unit – Department of Biochemistry

In charge– doc. J. Burneckienė

Description

Connective tissue proteins, their biochemical characteristics.

Peculiarities and functions of the connective tissue (bone, cartilage) and muscle proteins. Collagen

– the most abundant protein in the body. Collagen structure and functions; peculiarities of collagen

synthesis. The role of vitamin C in formation of collagen structure. Collagen catabolism,

collagenases. Types of collagen. Biological signifficance of collagen. Peculiarities of elastin

structure and synthesis, its significance to ligament and tendon elasticity. Structure and functions of

proteoglycans. Peculiarities of proteoglycan structure in bone and cartilage. Muscle proteins and

peculiarities of their structure. Energy resources of muscle.

5.3 Microscopic structure of joints structural components (2 hours).

Unit – Department of Histology and Embryology

In charge – prof. A.Valančiūtė

Description

Classification of the joints, histologic structure of joint capsule layers, a joint cavity, stucture of a

synovial membrane and synovial fluid. Histological structure of fibrous joints, skull bones,

vertebral joints, the pubic symphysis, the hip and knee joints. Articulating surfaces of bones,

peculiarities of the cartilage and bone tissue, bone, cartilage and tight connective tissue

redistribution in relation to physiological conditions. Age- related changes of joint structures.

5.4 Mechanism and regulation of the skeletal muscle contraction and relaxation (2 hours).

Unit – Department of Physiology

In charge – prof. E.Stankevičius, doc. R. Miliauskas

Description

Signal transmission from a nerve to the skeletal muscle. Factors affecting the signal transmission in

a neuromuscular junction. Mechanism of the skeletal muscle contraction and cyclic work of myosin

cross-bridges. Mechanism of the skeletal muscle relaxation. The ways of regulation of the skeletal

muscle force.

5.5 Clinical examination of the patients suffering from musculoskeletal system diseases Awareness of lower neuron lesion symptoms and examination. (2 hours)

Unit – Department of Internal Diseases

In charge – assoc. prof. Palmyra Leišytė

Description

Examination of the patients suffering from the diseases of the skeletal muscular system by inter-

viewing, inspection (looking), palpation (touching and feeling). Laboratory and x – ray changes.

Examination of the joint and vertebral column function. Reflexes and senses in lower neuron le-

sion diagnosis.

5.6 Arthropatic syndrome. Some aspects of fibrous tissue pathology. (2 hours).

Unit – Clinic of Internal Disease

In charge – assoc. prof. Palmyra.Leišytė

Description

Degenerative and inflammatory arthropatic syndromes. Examination of the fibrous (surrounding

joints) tissue and striated muscles by interviewing, inspection, palpation. Most common symptoms

of pathology of tendons, their sheath and attachment sites, ligaments, periosteum, fascia, aponeur-

osis and muscles. Fibromialgia and myofascial pain syndromes.

5.7 Radiological anatomy of bones, aging peculiarities. Osteoporosis radiological diagnostics (2 hours).

Unit –Clinic of Radiology

In charge– associated prof. E.Monastyreckienė

Description

Radiological image of bone structure. Radiological image of aging peculiarities of bone

development: X – ray, computerized tomography (CT), magnetic resonance imaging (MRI).

Radiological diagnosis of osteoporosis. Quantative and qualitative evaluation of bone density using

radiology. Bone densitometry.

5.8 Early, primary and secondary prevention of coxarthrosis and intervertebral L5-S1 disc hernia (2 hours).

Unit – Department of Kinesiology and Sport Medicine

In charge–lect.V. Zaveckas

Description

Significance of early and primary prevention measures to development of coxarthrosis. The main

principles of the tertiary prevention (active rehabilitation) of the hip joint osteoarthrosis. Influence

of coxarthrosis on locomotion, osteokinematics and arthrokinematics. Possibilities to return of these

functions.

Significance of early and primary prevention measures to intervertebral disc hernia development.

The main principles of the tertiary prevention (active rehabilitation) of intervertebral L5-S1 disc

hernia. Intervertebral L4-L5 disc hernia influence on the body posture and locomotion,

osteokinematics and arthrokinematics. Possibilities to return of these functions.

5.9 Initial assessment of an injured patient (2 hours)

Unit - Clinic of General surgery.

In charge: lecturer J. Juočas

Description

Trauma and traumatism as a medical and social problem. Description. Trauma classification.

Trauma mechanisms. General and specific assessment of an injured patient. Post traumatic disease.

The main aspects of clinical signs, diagnostics and management of post traumatic disease. Blunt

soft tissue injuries. Blunt injuries of the chest and abdomen. Principles of diagnostics and

management.

6. Practicals

6.1 Functional anatomy of vertebra column (3hours)

Unit – Institute of AnatomyDescription

Peculiarities of the thoracic, lumbar, sacral curves of vertebral column that helps to perform its functions: movement, respiratory, protection. Significance of the vertebral canal and intervertebral foramens. Functional anatomy of the spine joints: intervertebral joints, ligaments between vertebral bodies and processes, intervertebral discs, the bone joints of the spine (sacrum). The spine curvatures (kiphosis, lordosis, scolosis) and their significance to the human body statics and dinamics

References: 1. Human Anatomy. Prives M., Lysenkov N., Bushkovch. Moscow, 1989, It., p.128-149.2. Atlases of Human Anatomy.




6.2 Functional anatomy of the knee and hip joints (2hours)

Unit – Institute of Anatomy Description

The knee joint as the largest synovial joint in the body. Characteristic of knee joint articuliation surfaces, peculiarities of configuration of these surfaces. Peculiarities of articular cartilage and importance in weight bearing. The peculiarities of the joint cavity, its aging changes. The peculiarities of a capsule attachment, articular capsula recesses, synovial folds, knee joint adiposal body, bursae. Structural peculiarities of meniscs and their significance. The main intraarticular ligaments of the knee joint: the cruciate ligaments, the transverse ligament, the tibial collateral ligament, the oblique popliteal ligament, patellar ligament, the attachement site and function. Peculiarities of the joint biomechanics that arise from shape of the articuliation surfaces, ligaments. Peculiarities of the hip joint that differ it from the others. Peculiarities of acetabulum structure and function. Structural peculiarities of the head of the femur.Peculiarities of a capsule attachment. Relaxation and stretching of the knee joint capsule according movements of the joint.

Significance of hip joint ligaments (ligament of the head of the femur, the illiofemoral, the ischiofemoral, the pubofemoral) in the body statics and dinamics. Peculiarities of joint biomehanics.

References: 1. Human Anatomy. Prives M., Lysenkov N., Bushkovch. Moscow, 1989, It., p. 249-252,

256-260.2. Atlases of Human Anatomy.


1. GRAY'S Anatomy, the Anatomical Basis of Clinical Practice, Thirty-ninth edition, 2005.

2. Gross anatomy, 5 th ed. Kyung Won Chung. Lippincott Williams&Wilkins, 2005.3. Material of the Module of osteology, syndesmology and myology. Burkauskiene. A.,


6.3. Functional anatomy of the upper extremity (2hours).


Muscles that make flexion, adduction, outer and inner rotation of the humerus in the shoulder joint, innervation. Muscles that make flexion, extension, supination and pronation of the forearm in the elbow joint, innervation. Muscles that flex, extend, adduct and abduct the hand and their innervation. Muscles that make flexion, extension, adduction and abduction of the hand in the radiocarpal joint, innervation.Muscles that flex, extend, adduct and abduct the phalanges in the carpometacarpal joints and innervation. Muscles that flex, extend, abduct, oppose the thumb in the I carpometacarpal joint and their innervation. Muscles that flex, extend the fingers in the interphalangeal joints and their innervation.


IIt., p. 256-264.2. Atlases of Human Anatomy.




6.4 Functional anatomy of the lower extremity (2hours)


Muscles that surround the hip joint (iliopsoas, gluteal - minimus,medius,maximus, tensor of the fascia lata, piriformis, outer and inner obturator, gemelli (twin) muscles, quadratus femoris muscles, innervation. Characteristic of the movements in the hip joint. Muscles responsible of knee joint movements, innervation. Muscles responsible for stability of the foot in walking, innervation.


IIt., 266-276.2. Atlases of Human Anatomy.355-377


1. GRAY'S Anatomy, the Anatomical Basis of Clinical Practice, Thirty-ninth edition, 2005.

2. Gross anatomy, 5 th ed. Kyung Won Chung. Lippincott Williams&Wilkins, 2005.3. Material of the Module of osteology, syndesmology and myology. Burkauskiene. A.,


6.5 Functional anatomy of the trunk muscles (3hours )


Muscles that participate in movements of the head and neck, innervation. Muscles that take part in the movements of the scapula and their innervation. Muscles that adduct and abduct the arm, after the adduction taking arm forward or backward in the shoulder joint, innervation. Muscles taking part in the extension, flexion, rotation of the trunk to the same and opposites side, innervation. Muscles that maintain intraabdominal pressure, innervation. Muscle that decrease volume of the abdomen, innervation. Muscles of respiration, innervation.


IIt., 253-269.2. Atlases of Human Anatomy.355-377,




6.6 Aging changes of joints (3 hours)

Unit - Department of Histology and Embryology Description

Review of micropreparations: Joints of a finger. To detect a joint capsule and joint cavity using small magnification of the microscope. To detect the synovial membrane, a developing bone amd formed the bone tissue using amplification of the little microscope. Vertebra cross sections. Attention to structure of the bone tissue and the sites of muscles attachments to a bone using amplification of the little microscope should be paid. Study structure of joints. Questions that will be discussed: Structure of the bone and cartilage tissue. Types of the bone and cartilage tissue. Development of the bone tissue and its redistribution during life and in relation to performed work. The synovial membrane cell structure and function. Composition of the synovial fluid. Structure of the capsule of the joint.

References: 1. L.Jungeira , J.Carneiro. Basic Histology, 2005, p.135 -149.

Supplementary reading: 1. A.Stevens, Human Histology,. 2005, p.249 – 264

6.7 Record of the human electromyogram (3 hours).

Unit - Department of PhysiologyDescription

Record of electromyogram (EMG) performing a relaxed extension of the wrist (dorsal extension). Record of EMG during a controlled dorsal extension of the wrist. Isometric contractions of flexors of the wrist under different loads. Determination of temporary dependence of EMG and wrist movement.

References : 1. Review of Medical Physiology. 22nd edition. Ganong W.F. Lange Medical Books, New

York, 2005, Ch. 3, p. 76.2. Textbook of Medical Physiology. 11th edition. Guyton A. C. Saunders, 2005, Ch. 54.

6.8 Regulation of the skeletal muscle force (3 hours).

Unit - Department of Physiology Description

Evaluation of summation of contractions of the fast and slow muscle. Evaluation of tetanic contractions of the fast and slow muscle. Evaluation of the fast and slow muscle fatigue.

References: 1. Review of Medical Physiology. 22nd edition. Ganong W.F. Lange Medical Books, New

York, 2005, Ch. 3, p. 65-78.2. Textbook of Medical Physiology. 11th edition. Guyton A. C. Saunders, 2005, Ch. 6, p.

72-84.

6.9 Principles of conservative and surgical therapy of degenerative bone changes (2 hours).

Unit – Clinic of Orthopedia and TraumatologyDescription

Conservative nonmedicament (principles of immobilization, kinesiotherapeutic and measures of rehabilitation), medicamental and surgical treatment (a short description of surgical technique) of fractures of the radius that occur in most cases ofosteoporosis. Review of control x-ray pictures. Principles of surgical treatment of degenerative changes of the hip (subtotal endoprosthesis, total endoprosthesis, arthrodesis). Review of control x-ray pictures.

References :

1. Charles A. Rockwood, Jr. And David P. Greeen: Fractures in adults 411-450 2. http://www.aofoundation.org/ 3. A. H. Crenshaw: Campbell’s operative orthopaedics 8th. ed.Volume III. 1787-

1844

6.10 Principles of diagnostics and management of joint injuries and bone fractures (3 hours)

http://www.aofoundation.org/


Description

Joint contusion (contusio), joint distortion (distorsio), rupture of ligaments and menisci. Clinical signs, diagnostics, principles of management. Joint luxations. Causes. Classification. Principles of diagnostics and management. Bone fractures. Mechanisms of fractures. Types of fractures and bone dislocations. Principles of assessment of patients with bone fractures. First aid and principles of management.



1. David L. Hamblen, Hamish Simpson. Adams's Outline of Fractures, Including Joint In-juries, 20th edition. Churchill Livingstone, 2007. p. 340.

2. Essentials of General Surgery (4th edition). Peter F. Lawrence, Richard M. Bell, Merril T. Dayton, Mohammed I. Ahmed. Lippincott Williams & Wilkins, 2006, p 206-208.

6.11 Immobilization for trauma patients. Wound dressings. (3 hours)


Description

Types and purposes of splints. Splinting of the injuries of soft tissues, joints and bone fractures. Types and purposes of wound dressings. Requirements for contemporary wound dressings. Various dressing techniques for managing injuries.



1. Compendium Wounds and Wound Management. P. Hartmann AG. 1st Edition, 1999, p.88-112.

7. Seminars

7.1 Duchenne muscular dystrophy (2 hours).

Unit – Department of BiologyDescription





Etiology and pathogenesis of Duchenne muscular dystrophy. Prevalence of disease. Duchenne muscular dystrophy in relation to sex. Origin and changes of striated muscular dystrophy due to gene mutation in muscle fibres (impairment of synthesis of muscle protein dystrophin due to gen Xp21 part deletion)Outcomes of therapy.

Reference:1. Principles of Medical Genetics. T.D.Gelehter, F. C. Collins, D Ginsburg.1997, p. 212 –


1. http://www.ygyh.org/dmd/whatisit.htm

7.2 Peculiarities of the bone and cartilage molecular composition; bone mineralization and factors that influence this process (3 hours).

Unit – Department of Biochemistry Description

Peculiarities of bone and cartilage molecular composition.The bone and cartilage in relation to age and sex. Bone mineralization and factors that influence this process: parathyroid hormon, vitamin D (calcitriol), calcitonin. Their structure, synthesis, target cells and mechanism of action. Significance of parathyroid hormon, vitamin D and calcitonin to re-gulation of calcium and phosphorus metabolism.Biochemical markers that reflect metabolism of bone and muscle.


905 -910, 912-915.2. Harper’s illustrated biochemistry. R,K.Murray et al. 2003. 26th ed. 445, 450, 463, 535-

539, 542-555.

7.3 Clinical diagnostics of the musculoskeletal system. Arthropatic syndrome. (3 hours).

Unit – Clinic of Internal DiseaseDescription

Examination of patients suffering from musculoskeletal system diseases: interviewing, inspection, palpation. Examination of joints, muscles and spine function. The most important syndromes of the musculoskeletal system diseases: joint damage syndrome (arthropatic), pain in the joint surrounding tissues and the striated muscles.

References: 1. Clinical Examination, second edition. Epstein, Owen at al. 2001,p.255-292.

Supplementary reading:1. Clinical Medicine, Fifth Editon. Kumar, Parveen Clark, Michael.. 2002.

http://www.ygyh.org/dmd/whatisit.htm

7.4 Radiologic anatomy of bones, aging peculiarities: image analysis of x – ray, computerized tomography (CT), magnetic resonance imaging (MRI). Radiologic diagnostics of osteoporosis. Bone densitometry (1 hours).

Unit – Clinic of RadiologyDescription – radiologic anatomy of bones; radiologic image of osteoporosis.

References:1. Bone and joint imaging in rheumatic and orthopedic diseases. Francesco Priolo. p.17-582. Diagnosis of bone and joint disorders. 3rd edition. D.Resnick. 1995. p.1-486

a. Orthopedic radiology. A practical approach. A.Greenspan. Philadelphia, 1988. p.1.1-1.5

b. Textbook of radiology and imaging. D.Sutton, 2003. p.1207-12123. Bone and joint imaging in rheumatic and orthopedic diseases. Francesco Priolo. p.256-2634. Diagnosis of bone and joint disorders. 3rd edition. D.Resnick, 1995. p.1783-18845. Differential Diagnosis in Conventional Radiology. F.A.Burgener, M.Kormano. New York,

1991. p.1-126. Essentials of skeletal radiology. T.R.Yochum, L.J.Rowe. Baltimore, 1987. p.1031-10407. Orthopedic radiology. A practical approach. A.Greenspan. Philadelphia, 1988. p.20.1-20.48. A short textbook of clinical imaging. D.Button, J.W.R. Young. London, 1990. p.327-3319. Textbook of radiology and imaging. D.Sutton, 2003. p.1351-1369

7.5 Radiologic examination of the knee joint (1 hour).

Unit – Clinic of Radiology Description

Ultrasound (US) and magnetic resonance imaging of the knee joint; (spectrum of uses of computerized tomography (CT) arthrography; analysis of radiologic images. Radiologic diagnostics of menisci and ligaments tear.

References: 1. Bone and joint imaging in rheumatic and orthopedic diseases. Francesco Priolo. p.357-

358, 360-3672. Diagnosis of bone and joint disorders. D.Resnick. 3rd edition, 1995. p.3253-32543. Practical musculoskeletal ultrasound. E.G.McNally, 2005. p.144-1604. Orthopedic radiology. A practical approach. A.Greenspan. Philadelphia, 1988. p.6.25-

6.315. Textbook of radiology and imaging. D.Sutton, 2003. p.1235-12376. Internal derangements of joints. Emphasis on MR imaging. D.Resnick, H.S.Kang.

p.595-635

7.6. Radiologic examinations of the hip joint (1 hour).

Unit – Clinic of Radiology Description

Radiologic anatomy of the hip joint, radiologic diagnostics of arthrosis: x –ray, computerized tomography (CT) and magnetic resonance imaging (MRI). Stadiums of arthrosis.

References:1. Bone and joint imaging in rheumatic and orthopedic diseases. Francesco Priolo. p.59-73,

162-1672. Diagnosis of bone and joint disorders. 3rd edition. D.Resnick, 1995. p.1263-1289, 1320-13343. Essentials of skeletal radiology. T.R.Yochum, L.J.Rowe. Baltimore, 1987. p.546-5504. Practical musculoskeletal ultrasound. E.G.McNally. 2005. p.136-1405. Orthopedic radiology. A practical approach. A.Greenspan. Philadelphia, 1988. p.10.4-10.86. A short textbook of clinical imaging. D.Button, J.W.R. Young. London, 1990. p.377-3807. Textbook of radiology and imaging. D.Sutton. 2003.p.1222-1226

7.7Radiologic examination of veterbral column: x – ray, myelography, computerized tomography (CT), magnetic resonance imaging (MRI) (1 hour).

Unit – Clinic of Radiology Descriptrion

The main radiologic signs of veterbral column degenerative damage. Interveterbral disc hernia. Stenosis of spine canal.

References: Cerebral and spinal computed tomography. 3rd edition. T.Grumme, W.Kluge, K.Kretz-

schmar et al. p.229-248Diagnosis of bone and joint disorders. 3rd edition. D.Resnick. 1995. p.1372-1462Differential Diagnosis in Conventional Radiology. F.A.Burgener, M.Kormano. New York,

1991. p.192-193Essentials of skeletal radiology. T.R.Yochum, L.J.Rowe. Baltimore, 1987. p.273-316Orthopedic radiology. A practical approach. A.Greenspan. Philadelphia, 1988. p.8.37-8.43Textbook of radiology and imaging. D.Sutton. 2003. p.1226-1229.Whole body computed tomography. 2nd edition. O.H.Wegener. p.513-530.

7.8 Pharmacology of medicinal products used for the prophylaxis and treatment of osteoporosis (4 hours).

Unit - Department of Basic and Clinical Pharmacology Description

The aim: To get knowledge on classification of medicinal products used for the prevention and treatment of osteoporosis, their pharmacological properties, therapeutic uses, adverse reactions, benefits and risks.

Contents: Principal and secondary endogenous regulators of bone mineral metabolism. Medicinal products used for the prevention and treatment of osteoporosis: classification, therapeutic indications, pharmacodynamics, adverse reactions, risk-benefit ratio. Drug-induced osteoporosis.

Tasks: to get knowledge on classification of medicinal products used for the prevention and

treatment of osteoporosis; to discuss pharmacological properties of medicinal products used for the prevention and

treatment of osteoporosis; to get knowledge on risks related to medicinal products used for the prevention and

treatment of osteoporosis, risk factors and risk minimization activities; to get insight into rationale of risk-benefit assessment of medicinal products used for the

prevention and treatment of osteoporosis; to get knowledge on medicinal products capable to induce osteoporosis and minimization of

its risk in chronic treatment. References: 1. Katzung BG. Basic and Clinical Pharmacology. 10th ed. Boston: McGraw-

Hill; 2007. p. 706-723.2. Mysek MJ, Harvey RA, Champe PC. Lippincott‘s Illustrated Reviews: Pharmacology. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2009. p. 299-303, 316, 343-344.

Supplementary readings:

1. Brunton LL. Goodman & Gilman’s Manual of Pharmacology and Therapeutics. New York: McGraw-Hill Companies, Inc; 2008. p. 1059-1074.2. Waller DG. Medical Pharmacology and Therapeutics. Edinburg: Harcourt Publishers Limited; 2001. p. 405-412.3. Trevor AG, Katzung BG, Masters CB. Katzung & Trevor’s Pharmacology: Examination & Board Review. New York: Lange Medical Books / McGraw-Hill; 2005. p. 355-360.

7.9 Principles of the knee joint traumas therapy (2 hours).

Unit – Clinic of Orthopedia and Traumatology Description

Most common knee injuries, their differentiation and principles of treatment. Types and mechanisms of the knee joint menisci tear. Principles of surgical treatment.

References:

1. H. Crenshaw: Campbell’s operative orthopaedics 8th. ed.Volume I. 441-5092. http://www.nlm.nih.gov/medlineplus/ency/presentations/100117_1.htm3. http://orthoinfo.aaos.org/booklet/view_report.cfm?Thread_ID=8&topcategory=Knee4. http://cms.clevelandclinic.org/ortho/body.cfm?id=31#9

7.10 Nonmedicament measures and methods of improvement of joint function due to degenerative damage. Nonsurgical measures and methods of intervertebral disc hernia return of function (3 hours).

Unit – Department of Kinesiology and Sport Medicine Description

Comparison of methods: prons and cons. Possibilities of return of impaired osteokinematics and arthrokinematics of joint by diminishing pain and improving of function. Possibilities of return of impaired osteokinamatics and arthrokinematics of veterbra by diminishing pain and improving of function. Evaluation of the low back pain and prognosis of patient functional ability by biopsychosocial aspect.

References: 1. Osteoarthritis instructor manual. Osteoartrito instruktorių ruošimo Lietuvoje pagal

LeonardoDaVinči projektą medžiaga (verčiama iš anglų kalbos). 2006, p.1- 20. 2. EULAR Recommendations 2003: an evidence based approach to the management of

knee osteoarthritis: Report of a Task Force of the Standing Committee for International Clinical Studies Including Therapeutic Trials (ESCISIT). Ann Rheum Dis. Jordan KM, Arden NK, Doherty M, Bannwarth B, Bijlsma JW, Dieppe P, et al. 2003, p.62:1145-55.

3. Osteoarthritis of the periferal joints. In: Bailliere´s Best Practice & Research - Clinical Rheumatology. Petersson IF, Jacobsson LTH. Elsevier; 2002.

4. Non-surgical treatment of osteoarthritis: a half century of "advances". Ann Rheum Dis. Brandt KD. 2004, p.7-22.

5. Kinesiology of the musculoskeletal system. Fundations for physical rehabilitation.Mosby.Donald A. Neumann. 2004, p.9 – 294.

6. . Exercise therapy for treatment of non-specific low back pain. Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Copyright © 2007 The Cochrane Collaboration, Issue 1. Published by JohnWiley & Sons, p. 68.

7. Multidisciplinary biopsychosocial rehabilitation for subacute low-back pain among working age adults. Karjalainen K, Malmivaara A, van Tulder M, Roine R, Jauhiainen M, Hurri H, Koes B. Copyright © 2007 The Cochrane Collaboration, Issue 1. Published by JohnWiley & Sons, p.1 – 19.

7.11 Duchenne syndrome: nursing management (4 hours).

Unit –Department of Nursing and CareDesription

Students are going to learn patient – based nursing measures in management of respiratory cases failure such as patient‘s positions that decrease breathlessness and improve respiration, body positions in the cases of lung drainage. They will be able to use various nursing care measures to promote joint flexibility and diminish muscle weakness. They will learn well-balanced diet, prevention of pressure sores.

References:1. Basic Nursing. Patricia A. Potter, Anne Griffin Perry. St. Louis, 2003, p. 645-685, 822-

839.2. Clinical Nursing Skills. Sandra F. Smith, Donna . Duell, Barbara C. Martin. New Jersey,

2000, p. 257-260, 263-265, 478-479.3. Fundamentals of Nursing. Carol Taylor, Carol Lillis, Priscilla leMone. Philadelphia,

1993, p. 625-633.Supplementary reading:

1. Therapeutic Exercise. 5'11 edition. Basmajian John V., WolfSteven L. Williams&Wilkins, 1996.

7.12 Influence of factors of ergonomic occupational environment on the lumbar pain occurrence (2 hours).

Unit – Department of Environmental and Occupational Medicine Description

During the course the common regulations of sorting, organization and performing of loads as well as factors (load – work environment characteristics, use of manual work, work regulations and individual factors) that may influence the spine injuries are studied.

References: 1. T.C.AW, K. Gardiner, J.M. Harrington "Occupational health" 187-188 p.2. William Charney "Handbook of modern hospital safety" 701-742 p.3. Julia Smedley "Oxford handbook of Occupational health" 156-162 p.

Supplementary reading: 1. Encyclopaedia of occupational health and safety/ ILO, 1998. 2. National Institute for Occupational Safety and Health. Elements of Ergonomics Pro-

grams. Cincinnati, OH DHHS (NIOSH) Publication No.97-117,1997.

7.13 Influence of factors of ergonomic occupational environment on tunnel syndrome development (2 hours).

Unit – Department of Occupational and Sport Medicine Description

Tunnel syndrome provoking factors of work environment and work processes, risk factors and individual safety measures to prevent this syndrome.

References: 1. Carl Zenz "Occupational medicine" 48-63 p.

2. http://www.assh.org/Content/NavigationMenu/PatientsPublic/HandConditions/CarpalTunnelSyndrome/Carpal_Tunnel_Syndr.htm

Supplementary reading: 1. Encyclopaedia of occupational health and safety/ ILO, 1998. 2. National Institute for Occupational Safety and Health. Elements of Ergonomics Pro-

grams. Cincinnati, OH DHHS (NIOSH) Publication No.97-117,1997.

7.14 Principles of diagnostics and management of soft tissue injuries, joint injuries and bone fractures (2 hours)

Unit - Clinic of General Surgery.Description

Mechanisms and outcomes of the soft tissue injuries, joint injuries and bone fractures. Assessment of the trauma patient. Physical examination, laboratory and radiological diagnostics. First aid and management.

References:1. David L. Hamblen, Hamish Simpson Adams's Outline of Fractures, Including Joint In-

juries, 20th edition. Churchill Livingstone, 2007, p.340.Supplementary readings:

1. Essentials of General Surgery (4th edition). Peter F. Lawrence, Richard M. Bell, Merril T. Dayton, Mohammed I. Ahmed. Lippincott Williams & Wilkins, 2006, p 189-198.

8. Module exam questions

8.1 Anatomy

Partition of the human skeleton. Peculiarities of the different parts of the vertebral column.

Main structural components and adnexa of the knee joint, biomechanic peculiarities of the knee

joint.

Main structural components and adnexa of the hip (coxal) joint, biomechanical peculiarities of

the hip joint.

Functional characteristic, vascularization and innervation of the respiratory muscles.

Morphofunctional description, vascularisation and innervation of the deep back muscles.

Morphofunctional description, vascularization and innervation of the abdominal muscles.

Axillary fossa, composition of the walls, foramena, content.

Muscles of the forearm, function, vascularization, innervation, topography.

Muscles of the hand (manus), function, vascularization, innervation, topography.

The wrist (carpal) canal, composition of the walls, content.





Muscles of the pelvis and thigh (femoral), function, vascularization, innervation.

The adductor canal of the thigh, composition of the walls, content.

Muscles of the leg and foot, function, vasculariz\ation, innervation, topography.

Popliteal fossa, muscles bounded fossa, content.

Cruropopliteal canal of the leg, composition of the walls, openings of the canal, content.

8.2 Biology

1. What is the cause of Duchenne syndrome?

2. How is Duchenne dystrophy inherited?

3. Manifestations of the Duchenne syndrome.

4. What are methods of Duchenne dystrophy therapy and their outcomes?

8.3 Biochemistry

Proteins of the connective tissue (bone, cartilage), their biochemical characteristics.

Peculiarities of collagen structure, synthesis and function.

Peculiarities of elastin structure, synthesis and function.

Structure and functions of proteoglycans.

Muscle proteins; peculiarities of their structure.

Factors that regulate homeostasis of calcium (hormones, vitamin D); their structure and mechanism of action.

8.4 Human histology and embryology

1. Types of bone tissue.

2. Cartilage tissue: structure, classification.

3. Histologic structure of joint ligaments and menisci.

4. Histologic structure of a peripheral nerve.

5. Contractile apparatus of muscles; its structure.

6. Synovial membrane and synovial fluid.

a. Physiology

1. Synaptic signal transmission from a nerve to the skeletal muscle: steps and

mechanisms.

2. Factors that affect the signal transmission in the neuromuscular junction.

3. Mechanism of the skeletal muscle contraction. Cycling of myosin cross-bridges.

4. Mechanisms of the skeletal muscles relaxation.

5. Electromechanical coupling in the skeletal muscle.

6. Types of motor units and skeletal muscle fibers.

7. Regulation of the skeletal muscle force: 1) by stimulation frequency and 2) by

recruitment of motor units.

8. Relations “muscle force – length“ and „muscle contraction velocity – force“.

8.6 Basis of medical diagnostics

1. Patients‘ suffering from musculoskeletal diseases complains, semiotic values.

2. Pathologic changes detected during patients’ suffering from musculoskeletal diseases

examination and palpation, semiotic values.

3. Joint damage syndrome: causes, clinical, laboratory and x-ray changes.

4. Common clinical signs of pathology of periarticular tisues.

5. Muscular pain syndrome: causes, clinical signs, values.

8.7 Radiology

1. Which radiologic examinations are used to detect intervertebral disc hernia?

2. What are the signs of x-ray pictures of deformation osteoarthrosis?

3. Which radiologic examinations are used to detect the knee joint meniscus tear?

4. The signs of x-ray pictures of osteoporosis.

8.8 Pharmacology

1. Vitamin D and parathyroid hormone as principal endogenous regulators of bone

mineral homeostasis.

2. Calcitonin, glucocorticoids and estrogens as secondary endogenous regulators of

bone mineral homeostasis.

3. Preparations of vitamin D and its metabolites. Teriparatide.

4. Preparations of estrogens. Selective estrogen-receptor modulators.

5. Bisphosphonates and fluoride. Drug-induced osteoporosis.

8.9 Orthopedia and traumatology

1. Principles of medicament and nonmedicament treatment of radius fractures.

2. Principles of surgical treatment of radius fractures.

3. Criteria of surgical treatment methods of the hip joint arthrosis that results from

degenerative changes of the joint.

4. Most common traumas of the knee joint and types of meniscus tear.

5. Arthroscopy - method of diagnostics and treatment.

8.10 Kinesiology

1. Early, primary and tertiary prevention of coxarthrosis; similarities and differences.

2. Possibilities of return of impaired osteokinematics and arthrokinematics of joint by

diminishing pain and improving of function.

3. Nonsurgical methods of restoring of intervertebral disc hernia; proms and cons of

these methods.

4. Evaluation of the lumbar pain and making prognosis of patient functional ability by

biopsychosocial aspect.

8.11. Nursing

1. Nursing care of a patient with the history of breathlessness.

2. Measures of nursing that promote flexibility of joints.

3. Measures of nursing that diminish muscle weakness.

4. Measures that strengthen general condition of the body in order to prevent infection.

8.12. Environment and work safety

1. What does manual sorting of loads mean?

2. Who and how is responsible for establishment of safe and healthy working?

8.13. General surgery

1. Assessment of an injured patient.

2. Soft tissue injuries: clinical signs, outcomes, first aid and principles of management.

3. Joint injuries: clinical signs, outcomes, first aid and principles of management.

4. Bone fractures: causes, classification, outcomes.

5. Principles of diagnostics and management of bone fractures.

Principles of splinting of bone fractures.

Purposes of wound dressings, properties of modern wound dressings.

9. Appendixes

Documents

MODULE LOCOMOTION 2010...1. GRAY'S Anatomy, the Anatomical Basis of Clinical Practice, Thirty-ninth edition, 2005. 2. Gross anatomy, 5 th ed. Kyung Won Chung. Lippincott Williams&Wilkins,