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Education

Undergraduate program:

A lecture (1 ½ hr) followed by a clinical demonstration of patients ( ½ hr)
Duration of each round: 3 weeks, 4 days/week, 2 hours/day
No lectures are given on Monday, Friday and Saturday.
The Students are divided into groups of about 130 per round.
The lectures include almost all of the important topics of Rheumatology required as basics for any graduated physician. 

General aims

The major emphasis of the undergraduate course is on clinical skills and competencies relating to the musculoskeletal system.  At the end of the course students should be able to assess, by appropriate history and examination, an adult patient with locomotor symptoms in terms of:

  • descriptive abnormality
• limited differential diagnosis
  • relevant investigations
  • disability and handicap

 

LEARNING OBJECTIVES

PHASE

DETAILS OF CONTENT

METHODS & RESOURCES

Competencies in clinical assessment and diagnosis

 

To identify normality and regional abnormality of the musculoskeletal system.

e.g., identifying abnormality (tenderness, swelling, deformity, muscle wasting, weakness, etc.)

Normal volunteers / students and patient's demonstration

 

To identify and characterise, through enquiry and regional examination the symptoms and signs of

  • arthropathy
  • common periarticular and soft tissue lesions (bursitis, tendinitis, etc.) of different joints
  • muscle disorders (inflammatory, non-inflammatory)
  • limb trauma

Enquiry to establish the characteristics of the symptoms, and other relevant features; and joint and regional examination to identify

  • Laxity, swelling, tenderness, deformity, atrophy, etc of different joints
  • Muscle weakness and atrophy
  • Neurological and vascular effects of trauma

Lectures / Slide shows / and
Patient demonstration in outpatient clinic and Inpatient ward

 

To identify, characterise and differentiate by patient enquiry, examination and limited investigation :

  • common mechanical neck/back pain (+ spinal cord or root entrapment)
  • inflammatory back pain (eg spondylitis)

Ability to take relevant history in the knowledge of the characteristics of the major conditions
Ability to examine neck, back and sacroiliac joints

Clinical cases:
A case of sciatica with imaging
Common back pain / neck pain

 

 

LEARNING OBJECTIVES

PHASE

DETAILS OF CONTENT

METHODS & RESOURCES

Competencies in clinical assessment and diagnosis (cont.)

To construct an appropriate differential diagnosis and plan of investigation and assessment for a patient presenting with :

  • Acute or chrovic monoarticular symptoms
  • Acute or chronic oligoarticular symptoms
  • polyarticular symptoms
  • Regional pain

Ability to manage a clinical situation including principles of differential diagnosis / algorithm, e.g., Age related conditions, Trauma related causes, Infections, etc.

 

Lectures / Slide shows / and
Patient demonstration in outpatient clinic and Inpatient ward

Knowledge of main characteristics and principles of management  and rehabilitation of specific conditions

To (1) specify the symptoms and signs, and (2) outline the investigation, assessment and principles of management of a patient with

  • Osteoarthritis
  • chronic inflammatory arthritis (rheumatoid, seronegative spondyloarthropathy, juvenile chronic arthritis)
  • Autoimmune musculoskeletal conditions (SLE, PM/DM)
  • crystal-associated arthritis (urate, pyrophosphate)
  • metabolic bone diseases (osteoporosis, osteomalacia)
  • infection associated arthritis (reactive, viral, rheumatic fever)
  • soft tissue lesion/enthesopathy
  • common mechanical neck/back pain
  • fibromyalgia / chronic generalised pain

detail of knowledge required for the different conditions

Lectures / Slide shows / and
Patient demonstration in outpatient clinic and Inpatient ward

 

To specify systemic conditions with musculoskeletal features; and to outline the systemic features of musculoskeletal conditions

e.g., malignancy, infections, psychiatric conditions, etc.

Lecture

 

To outline approach to request and interpretation of laboratory investigations in diagnosis and assessment of musculoskeletal conditions.

Interpretation of the full blood count, ESR, CRP, autoimmune screen (rheumatoid factor, ANA), and others.

Lectures and practical (case based)

 

 

LEARNING OBJECTIVES

PHASE

DETAILS OF CONTENT

METHODS & RESOURCES

Knowledge of main characteristics and principles of management  and rehabilitation of specific conditions (cont.)

To characterize and identify the principal imaging features of osteoarthritis, rheumatoid arthritis, ankylosing spondylitis and others.

Different radiological investigations

Practical

 

To outline the strategies available for the management of acute and chronic musculoskeletal disorders

General, medical, physical, and surgical, strategies for prevention and treatment

Lecture

 

To outline rehabilitation principles of musculoskeletal conditions

Basic concepts and various tools are shown (physical, orthosis, etc.)

Lecture / Slide show

 

To outline the major drugs used in the management of musculoskeletal conditions.

Analgesics, non-steroidal anti-inflammatory drugs, corticosteroids, hypo-uricaemic drugs, disease-modifying and cytotoxic drugs.

Lecture

 

To outline common operations for musculoskeletal conditions.

Arthroscopy, synovectomy, osteotomy, arthroplasty, arthrodesis
Back surgery

Lecture / Slide show

 

To specify strategies for the prevention of certain musculoskeletal conditions, e.g., osteoporosis, osteoarthritis, neck and back pain

Principals of prevention
Specific examples

Lecture / Slide show

 

  pdf core?recommendations?for?a?musculoskeletal?undergraduate?curriculum 32.70 Kb

 

 

THEME
LEARNING OBJECTIVES

PRIORITY & DEPTH OF COMPETENCY
A = core; B = optional; C = suitable for special study module ; 1 = to be able to apply; 2 = to be familiar with; 3 = to be aware of

Basic Competencies In Clinical Assessment And Diagnosis

HISTORY

To identify abnormality from normality (pain, displacement, dislocation stiffness, swelling and limitation of activities) by a history relevant to the musculoskeletal system.

  • To be able to apply a screening history as part of a general enquiry, for example using the PASS (Pain , limitation of Activities, Stiffness and  Swelling) screen.
  • To be able to take a relevant history in the knowledge of the characteristics of the major conditions of
  • Bone including fracture, malignancy, infection
  • Joints, including rheumatoid arthritis, other arthritides degenerative joint disease
  • Connective tissue,  including bursitis, tendinitis, tenosynovitis, enthesopathy
  • Nerve tissue, including entrapment, peripheral neuropathy, radiculopathy
  • Muscle tissue, including congenital, inflammatory, neurological
  • To be able to take an appropriate history in relation to high energy and low energy trauma and injury and its sequelae
  • To know how to assess acute and chronic pain in terms of its characteristics, severity, effects and modulating factors.
  • To understand the impact on the individual of a chronic musculoskeletal condition in terms of impairment of function, limitation of activities and restriction of participation (WHO ICF) (ref).

A1

EXAMINATION

To identify normality and abnormality by examination of the musculoskeletal system.

  • To be able to perform a screening examination as part of general examination, for example by using the GALS (Gait, Arms, Legs and Spine) screen  (ref)
  • To be able to perform an appropriate examination on musculoskeletal trauma (inspection, palpation, range of motion and  status distal to the trauma) (colour, circulation, sensibility, mobility).
  • To be able to perform an appropriate examination of major joints (hip, knee, humeroscapular) and small joints such as finger joints to be able to identify and characterise by examination pain, tenderness, swelling, dislocation, displacement, deformity, muscle wasting, weakness, abnormal movement and functional impairment.
  • To be able to perform an appropriate examination on of the neck, back and sacroiliac joints.

A1

ATTITUDE AND COMMUNICATION SKILLS

To obtain the appropriate attitude and communication skills for the management of people with acute and chronic musculoskeletal conditions

  • To have an understanding of the problems of people with musculoskeletal conditions and the full impact on the individual and their care givers (e.g. focus on chronic low back pain).
  • To have a holistic approach to the patient

A1


Assessment of Specific Problems
(specifically related to urgency, importance and / or frequency)

EMERGENCIES / RED FLAGS

To know when to immediately refer a patient with a condition that requires urgent specialist management.
This requires the ability to identify, characterise and differentiate through patient enquiry, examination and limited investigation, within the context of knowledge and outline management of:

  • Open fractures
  • Fractures with nerve or vascular compromise
  • Cauda equina compression
  • Compartment syndrome / vascular compromise
  • Joint infection
  • Soft tissue infection
  • Bone infection
  • Temporal arteritis

A1

EXTREMITY PROBLEMS:
TRAUMATIC

To identify, characterise and differentiate through patient enquiry, examination and limited investigation, within the context of knowledge:
Traumatic extremity problems
This requires the ability to

  • take a relevant history in the knowledge of the characteristics of trauma and fracture.
  • identify and characterise e.g. injuries that include fracture of long bones, fracture involving joints, joint dislocations, sprains and strains.
  • evaluate the energy of the trauma and its impact on type of injury (low energy trauma and fragility fracture, traffic accident and complicated fractures).

A1

EXTREMITY PROBLEMS:
NON-TRAUMATIC

To identify, characterise and differentiate through patient enquiry, examination and limited investigation, within the context of knowledge:
Non-traumatic extremity problems  
This requires the ability to:

  • take a relevant history in the knowledge of the characteristics of  major, non-traumatic extremity problems.
    • joint disorders (osteoarthritis, rheumatoid arthritis)
    • soft tissue disorders (bursitis, tendinitis, tenosynovitis, enthesopathy and nerve entrapment)
    • muscle disorders (congenital, inflammatory and neurological)
    • bone conditions (malignancy and infection)
  • identify and characterise, for example, conditions that include:
    • joint inflammation and/or damage such as osteoarthritis, rheumatoid arthritis
    • soft tissue conditions such as bursitis, tendinitis, tenosynovitis, enthesopathy and nerve entrapment
    • muscle conditions such as congenital, inflammatory and neurological
    • bone conditions such as malignancy and infection.

A1

SPINAL PROBLEMS

Spinal problems
This requires the ability to:

  • take a relevant history in the knowledge of the characteristics of the major conditions
  • mechanical neck/back pain (e.g. lumbago)
  • spinal cord or root entrapment (e.g. herniated lumbar disc)
  • vertebral fracture of traumatic orgin
  • vertebral fracture of osteoporotic origin
  • inflammatory back pain  (e.g. Mb Bechterew)
  • spinal deformity (e.g. scoliosis)
  • destructive (infectious and tumour-related) back pain (e.g. tuberculosis, metastasis, certain cancers)

A1

PROBLEM BASED SYMPTOMATIC APPROACH

To construct an appropriate differential diagnosis and plan of patient enquiry, examination, limited investigation and assessment for a patient presenting with

  • Musculoskeletal injury
  • Joint pain - poly, mono, and periarticular
  • Back pain
  • Regional pain or stiffness
  • Generalised pain or stiffness
  • Decrease or loss of motion or weakness
  • Altered sensation
  • Deformity
  • Mass

This should relate to mechanisms of conditions:

  • traumatic (e.g. low energy as in osteoporosis or occupational accidents)
  • vascular / ischaemic (e.g. compression or disruption of a vessel)
  • neurological (e.g. compression)
  • infectious (e.g. joint or bone)
  • degenerative (e.g. joint or spine)
  • auto-immune or immune-mediated (e.g. rheumatoid arthritis
  • metabolic / toxic (e.g. osteoporosis, gout)
  • inherited / developmental / congenital (e.g. scoliosis)
  • neoplastic (e.g. myeloma)

A1

 

 

 

 

 

- later discussed also in the context of knowledge

 

 

 

 


Knowledge of main characteristics and principles of management  and rehabilitation of common musculoskeletal conditions
(this is the theoretical background)o

FRACTURE / INJURY / TRAUMA

In theoretical terms, have the ability to:

  • specify the symptoms, signs and immediate complications
  • outline the assessment and appropriate investigation
  • outline the immediate and long term management of patient with
  • common adult fractures (A2)
  • joint dislocation (A2)
  • joint instability (B3) (eg knee, finger)
  • soft tissue injuries (A3)
  • acute spinal injury  (A2)
  • multiple injured patient (A3)

Clinical experience should be gained of all stages of injury and healing

 

 

 

 

 

 

(for example from emergency room to rehabilitation clinic)

JOINT AND SOFT TISSUE CONDITIONS

 

 

 

In theoretical terms, have the ability to:

  • specify the symptoms, signs and predisposing factors
  • outline the assessment and appropriate investigation
  • give a limited differential diagnosis and
  • outline the principles of management of a patient with
  • osteoarthritis (A1)
  • chronic inflammatory arthritis eg RA (A1), SpA (B2)
  • soft tissue lesion / enthesopathy e.g rotator cuff lesion and / or tennis elbow (A1) others (B2)
  • fibromyalgia / chronic generalised pain (B2)
  • polymyalgia rheumatica (B2)
  • crystal-associated arthritis (A1)
  • rheumatic fever (A2)
  • autoimmune connective tissue diseases eg SLE (A2)
  • viral arthritis( incl. HIV) (A2)

 

SPINE

In theoretical terms, have the ability to:
(1)   specify the symptoms and signs

  • outline the assessment and appropriate investigation
  • give a limited differential diagnosis and
  • outline the principles of management of a patient with
  • low back pain and sciatica (A1)
  • neck pain (B2)

 

TUMORS

In theoretical terms, have the ability to:

  • specify the symptoms, signs and predisposing factors
  • outline the assessment and appropriate investigation
  • outline the principles of management of a patient with
  • primary bone and soft tissue tumours (C1)
  • metastatic bone disease (A2)

 

BONE DISORDER

In theoretical terms, have the ability to:

  • specify the symptoms, signs and predisposing factors
  • outline the assessment and appropriate investigation
  • give a limited differential diagnosis
  • outline the principles of management of a patient with
  • Osteoporosis (A2)
  • Osteomalacia (A2)
  • Paget's Disease (B3)

 

PEDIATRIC

In theoretical terms, have the ability to:

  • outline the clinical features and
  • outline the principles of management of paediatric locomotor conditions including
  • common paediatric fractures (wrist/forearm, elbow, femoral shaft) (A3)
  • paediatric musculoskeletal infections (A1)
  • paediatric hip conditions eg DDH (A3)
  • chronic paediatric conditions that often require orthopaedic management (club foot, scoliosis, neuromuscular disorders) (B3)
  • juvenile chronic / idiopathic arthritis (A3)

 

RELATED KNOWLEDGE

To outline the relative prevalence, health and economic impact, major associations and expected prognosis / outcome of specific musculoskeletal conditions

  • Fracture - low and high energy
  • Neck and low back pain
  • Common soft tissue lesions such as rotator cuff lesions, tennis elbow.
  • Osteoarthritis - hip and knee
  • Rheumatoid arthritis

A2


Core knowledge supporting diagnosis and management

BASIC KNOWLEDGE

To identify the bones and joints within the articulated human skeleton
To specify the major muscle groups, their function and their root innervation
To specify major vessels and nerves related to the musculoskeletal problems.

A1

 

To outline the basic physiology and pathology relating to musculoskeletal conditions

  • This includes ageing, injury and disease states and repair of musculoskeletal tissues (bone, cartilage, synovium, muscle, entheses). (including mechanical, traumatic, metabolic, vascular, degenerative, inflammatory and immune-mediated conditions, neoplastic, inherited and developmental)

A1

Knowledge of methods for management and treatment

MANAGEMENT STRATEGIES

To outline the strategies available for the management, including rehabilitation, of acute and chronic musculoskeletal disorders (listed above) and for chronic musculoskeletal pain

  • This includes education, drug therapy, physical treatments, relaxation, self-efficacy, psycho-social interventions, social support, referral and shared care
  • To be familiar with factors that influence adherence to a management plan

A1

PHARMACOLOGY

To be familiar with the major indications, adverse effects, drug interactions and contra-indications of drugs commonly used in the management of musculoskeletal conditions.

  • Acute and chronic pain management
  • Disease-modifying therapy

This includes analgesics, non-steroidal anti-inflammatory drugs, antidepressants in pain management, corticosteroids, hypouricaemic drugs, disease-modifying and cytotoxic drugs.
There should be familiarity with the placebo effect and an awareness of special situations with these drugs, such as pregnancy.

A2

NON-SURGICAL TREATMENT FOR TRAUMA

To know the surgical principles of fracture and multiple trauma management in terms of:  Reduction - Fixation - Immobilisation

  • To be aware of the most common non-operative procedures for fracture and dislocation.  This includes closed reduction, the use of external fixation devices such as Plaster of Paris or elastic wraps.

 

(common injuries may include fracture of the wrist or proximal humerus, shoulder dislocation and ankle sprain)

SURGICAL TREATMENT

To know the surgical principles of fracture and multiple trauma management in terms of:   Reduction - Fixation - Immobilisation

  • This includes familiarity with the treatment of the most common fractures such as hip, wrist and ankle fractures
  • To be aware of the most common operative procedures for fracture and dislocation.  This includes open reduction, the use of internal and external fixation devices.

 

A2

A3 

 

To be aware of the most common operations for musculoskeletal conditions.
This includes

  • arthroscopy of the knee,
  • arthroplasty of hip and / or knee
  • back surgery (discectomy, spinal fusion)
  • amputation, synovectomy, osteotomy, arthrodesis, and carpal tunnel decompression

B2

 

To be familiar with the benefits and complications of large joint (hip, knee) replacement surgery

  • This includes the complications of DVT, infection and loosening and expected durability of implant

A2

REHABILITATION

To know the benefits of rehabilitation of musculoskeletal conditions

  • Rehabilitative interventions that should include physiotherapy and occupational therapy.
  • The different problems of lower versus upper limb amputation should be understood

A2

 

To be aware of common orthoses, limb prostheses and adaptive equipment for individuals with a musculoskeletal impairment

  • For example when to use: Plaster of Paris, sticks, cane, walker, corset, ADL equipment

B3

PREVENTION

To be aware of prevention strategies for common musculoskeletal conditions
To be aware of the principals of prevention.

  • Specific examples could include trauma, fractures, osteoporosis, osteoarthritis, osteoarticular infection, mechanical soft-tissue lesions, and neck or back pain

A3

Knowledge of methods to assist diagnosis and management

LABORATORY ASSESSMENT

To demonstrate an appropriate use and interpretation of laboratory investigations with respect to diagnosis and assessment of musculoskeletal conditions

  • full blood count (haemoglobin / white cells)
  • ESR  (erythrocyte sedimentation rate)
  • CRP (C-reactive protein)
  • rheumatoid factor
  • ANA
  • serum biochemistry  including calcium, alkaline phosphatase, creatine kinase, and albumen
  • synovial fluid analysis (white cells, glucose, culture,  crystals)

.

A2

IMAGING

To demonstrate the appropriate use of imaging for the diagnosis and assessment of musculoskeletal conditions

  • eg X-ray, CT scan, MRI, bone densitometry, bone scintigraphy, musculoskeletal ultrasound

A2

 

 

Postgraduate and residency program:

Postgraduate program: Lecture and clinical practice is provided for postgraduate students according to the schedule.
Residency program: in addition to the postgraduate program, residents are trained to examine and manage out-patient cases as well as inpatients. There is continuous guidance from all staff members regarding proper management.

Fellowship programs (not available)

 

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