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cd /home/daytona/workspace/attachments/b123633b-2d2a-4a66-888f-535d201356c1 && p…

cd /home/daytona/workspace/attachments/b123633b-2d2a-4a66-888f-535d201356c1 && p…

cd /home/daytona/workspace/attachments/b123633b-2d2a-4a66-888f-535d201356c1 && p…

cd /home/daytona/workspace/attachments/b123633b-2d2a-4a66-888f-535d201356c1 && p…

~/paper4_exam_notes/Paper4_Simple_Exam_Notes.md

# PAPER 4 - PHYSIOTHERAPY INTERVENTIONS IN MUSCULOSKELETAL DISORDER
## Simple Exam Notes

---

# UNIT 1: IMPAIRED MUSCLE PERFORMANCE

## Key Elements of Muscle Performance
- **Strength** - max force a muscle can generate
- **Power** - force x velocity (how fast the force is generated)
- **Endurance** - ability to sustain effort over time

## Factors Affecting Muscle Force Production
| Factor | Effect |
|--------|--------|
| Fiber type | Type II (fast twitch) = more force; Type I (slow twitch) = more endurance |
| Fiber diameter | Larger diameter = more force |
| Muscle size (cross-sectional area) | Larger = stronger |
| Force-velocity relationship | Slower contraction = more force |
| Length-tension relationship | Max force at optimal length |
| Muscle architecture | Pennate arrangement = more force |

## Causes of Decreased Muscle Performance (Remember: N-M-D-L-I-S-L)
1. **N**eurologic pathology (stroke, SCI)
2. **M**uscle strain
3. **D**isuse and deconditioning
4. **L**ength-associated changes
5. **I**schemia (e.g., Volkmann's Ischemic Contracture)
6. **S**carring (e.g., cut injuries)
7. **L**esion in brain/spinal cord → spastic paralysis
8. Lesion in Anterior Horn Cell → flaccid paralysis (e.g., polio)

## Exercise Dose Components (Remember: F-I-D-V-R)
- **F**requency - how often (days/week)
- **I**ntensity - how hard (% of 1 RM)
- **D**uration - reps or time
- **V**olume - total work done
- **R**est interval - recovery time between sets

## Ways to Progress Exercise Dosage
- Increase weight/intensity
- Change relationship to gravity
- Increase lever arm length
- Increase sets and reps
- Decrease rest interval
- Increase frequency

## Adaptations to Resistance Exercise
### Neural Adaptations (early - first 6-8 weeks)
- Increased motor unit recruitment
- Increased rate of firing
- Synchronized firing

### Skeletal Muscle Adaptations (long term)
- **Hypertrophy** - increase in muscle fiber size
- **Hyperplasia** - increase in number of muscle fibers (controversial)
- Vascular and metabolic adaptations

### Other System Adaptations
- **Bone:** Prevents bone mineral density loss; treats osteoporosis/osteopenia
- **Connective tissue:** Increases tensile strength of tendons and ligaments

---

# UNIT 2: TYPES OF MUSCLE CONTRACTIONS & RESISTANCE

## Types of Muscle Contraction
| Type | Description | Example |
|------|-------------|---------|
| Isometric | No joint movement, muscle contracts | Pushing wall |
| Isotonic Concentric | Muscle shortens, joint moves | Bicep curl up |
| Isotonic Eccentric | Muscle lengthens while contracting | Lowering a weight |
| Isokinetic | Constant speed, variable resistance | Cybex machine |

## Types of Resistance
- **Manual** resistance - therapist applies force
- **Mechanical** resistance - equipment (weights, bands)
- **Static** - isometric
- **Dynamic** - isotonic/isokinetic

## Resistance Training Methods
| Method | Key Points |
|--------|------------|
| DeLorme (Progressive Resistance Exercise) | 3 sets: 50%, 75%, 100% of 10 RM |
| Oxford Technique | Reverse of DeLorme: 100%, 75%, 50% of 10 RM (starts heavy, gets lighter) |
| DAPRE (Daily Adjustable Progressive Resistance Exercise) | 4 sets; adjusts weight daily |
| Circuit Training | Multiple stations, minimal rest |
| Plyometrics | Eccentric → concentric (stretch-shortening cycle); develops power |

## SAID Principle
**Specific Adaptation to Imposed Demands** - the body adapts specifically to the type of stress placed on it.

---

# UNIT 3: FLEXIBILITY & STRETCHING

## Types of Stretching
| Type | Description | When to Use |
|------|-------------|-------------|
| Static stretching | Hold at end-range for 15-60 sec | After exercise/cool-down |
| Dynamic stretching | Controlled movement through range | Before activity/warm-up |
| Ballistic stretching | Bouncing movements | Pre-activity (for athletes) |
| PNF stretching | Uses muscle contractions | Best for ROM gains |

## PNF Stretching Techniques (3 Types)
1. **Contract-Relax (CR):** Isotonic contraction of tight muscle → relax → stretch
   - Use when ROM is limited by muscle tightness
2. **Hold-Relax (HR):** Isometric contraction of tight muscle → relax → stretch
   - Use when there is pain with movement; also called Muscle Energy Technique
3. **Slow Reversal-Hold-Relax (SRHR):** Isotonic contraction of agonist → isometric contraction of antagonist → relax → stretch

## Mechanisms of PNF Stretching
- **Autogenic Inhibition:** GTO activation → inhibits the same muscle → allows stretch
- **Reciprocal Inhibition:** Contraction of agonist → inhibits antagonist → antagonist can be stretched

## Myofascial Release (MFR)
- Technique to release abnormal tightness in fascia
- Indirect: gentle pressure in the direction of ease
- Direct: pressure applied directly into restriction barrier
- J-stroke, perpendicular, and longitudinal techniques used

## Pilates Method
- Conditioning program improving flexibility, control, coordination, and strength
- Focuses on body as single integrated unit
- Emphasizes breathing, alignment, efficient movement
- Uses specialized equipment (reformer, cadillac)

---

# UNIT 4: BALANCE & PROPRIOCEPTION

## Proprioception
- Ability to sense body position, movement, and force
- Mediated by mechanoreceptors: muscle spindles, Golgi tendon organs, joint receptors
- Impaired after injury - must be retrained

## Neuromuscular Control
- Efferent motor response to sensory (proprioceptive) input
- Goal: Restore automatic, unconscious movement patterns

## Balance Training Progression (simple to complex)
1. Stable surface → unstable surface (wobble board, foam)
2. Eyes open → eyes closed
3. Static → dynamic
4. Double limb → single limb
5. No perturbation → external perturbation

## Types of Balance
- **Static balance:** Maintain position without movement
- **Dynamic balance:** Maintain balance during movement
- **Reactive balance:** Respond to unexpected disturbances

---

# UNIT 5: HYDROTHERAPY / AQUATIC THERAPY

## Properties of Water Used in Therapy
| Property | Effect |
|----------|--------|
| Buoyancy | Reduces effective body weight; unloads joints |
| Hydrostatic pressure | Reduces swelling/edema; supports circulation |
| Viscosity/Resistance | Provides resistance for strengthening |
| Thermodynamics | Warm water relaxes muscles |

## Whirlpool
- Tank with turbine motor controlling water/air movement
- Heat transfer by conduction and convection
- Effects: reduces swelling, muscle spasm, pain; allows active movement
- Indications: wounds, hand/foot conditions, pain management

## Contrast Bath
- Alternating hot and cold water immersion
- Produces pumping action (vasodilation → vasoconstriction)
- Used for: hand/foot conditions, chronic pain, improving circulation
- Typical protocol: start/end hot; ratio 3:1 or 4:1 (hot:cold)

## Hubbard Tank
- Full-body immersion
- Used for full-body burns, spinal conditions, extensive injuries

---

# UNIT 6: GAIT REHABILITATION

## Normal Gait Cycle
- **Stance phase (60%):** Heel strike → foot flat → mid-stance → heel off → toe off
- **Swing phase (40%):** Acceleration → mid-swing → deceleration

## Common Gait Deviations
| Deviation | Cause |
|-----------|-------|
| Trendelenburg gait | Weak gluteus medius |
| Steppage gait | Foot drop (weak dorsiflexors) |
| Antalgic gait | Pain - shortened stance on affected side |
| Scissor gait | Spastic hip adductors (CP) |
| Waddling gait | Bilateral gluteus medius weakness |

## Gait Aids (in order from most to least support)
1. Parallel bars (most support)
2. Walker (rollator > standard)
3. Axillary crutches
4. Forearm/Lofstrand crutches
5. Quad cane
6. Standard cane (least support)

## Crutch Walking Gaits
| Gait | Weight Bearing | Use |
|------|---------------|-----|
| 4-point | WB both | Slowest, most stable |
| 3-point | NWB one limb | Fracture, post-op |
| 2-point | WB both, alternating | Faster than 4-point |
| Swing-to | NWB both | Paraplegic |
| Swing-through | NWB both | Fastest, most advanced |

---

# UNIT 7: CORE STABILITY

## The "Core" - Definition
A box with:
- **Front:** Abdominals
- **Back:** Paraspinals + Gluteals
- **Roof:** Diaphragm
- **Bottom:** Pelvic floor + Hip girdle musculature
- **Sides:** Hip abductors and rotators

## Local vs. Global Core Muscles
| Type | Muscles | Function |
|------|---------|----------|
| Local (stabilizers) | Transversus abdominis, multifidus, pelvic floor, diaphragm | Segmental stabilization, continuous low-level activation |
| Global (mobilizers) | Rectus abdominis, external oblique, iliocostalis | Force production, large movements |

## Key Local Stabilizers (Important!)
- **Transversus abdominis (TrA):** Deepest abdominal; activates BEFORE limb movement (feedforward)
- **Multifidus:** Controls inter-segmental motion; most important for lumbar stability
- **Pelvic floor:** Works synergistically with TrA

## Core Stability Exercises - Progression
1. Finding neutral spine
2. Abdominal hollowing/bracing
3. Prone bridging (plank)
4. Lateral bridging (side plank)
5. Supine pelvic bridging
6. Quadruped (bird-dog)
7. Dead bugs
8. Balance board/labile surface exercises
9. Plyometrics
10. Sport-specific exercises

## Core Assessment Tests
| Test | Assesses |
|------|----------|
| Prone bridge (plank) | Anterior + posterior core |
| Lateral bridge | Lateral core |
| Torso flexion hold (60°) | Flexor endurance |
| Extensor endurance test | Back extensor endurance |

---

# UNIT 8: MANUAL THERAPY

## Joint Mobilization (Maitland Grades)
| Grade | Movement | Purpose |
|-------|----------|---------|
| Grade I | Small amplitude at beginning of range | Pain relief |
| Grade II | Large amplitude, does not reach end of range | Pain relief |
| Grade III | Large amplitude at end of range | Pain + stiffness |
| Grade IV | Small amplitude at end of range | Stiffness |
| Grade V | Thrust (manipulation) | Restore full range |

**Rule:** Grades I-II = pain dominant; Grades III-IV = stiffness dominant

## Kaltenborn's Grades
- **Grade I:** Traction (neutralize joint compression)
- **Grade II:** Traction (take up slack/"loosen")  
- **Grade III:** Actual stretch to mobilize

## Cyriax Approach (Selective Tissue Tension Testing)
- Identifies the structure at fault
- Inert tissue lesion: passive movement painful
- Contractile tissue lesion: resisted movement painful
- Deep Friction Massage (DFM): transverse friction across tissue fibers

## Muscle Energy Technique (MET)
- Developed by Fred Mitchell Sr. (1948)
- Uses the patient's own isometric muscle contractions to relax and lengthen muscles
- Based on autogenic inhibition (GTO activation) and reciprocal inhibition

### Types of MET
1. **Post Isometric Relaxation (PIR)** - Lewitt's technique
   - Submaximal (10-20%) contraction away from barrier × 5-10 sec
   - Relax → stretch further
2. **Post Facilitation Stretching (PFS)** - Janda's technique
   - Brief maximal contraction → rapid stretch
3. **Reciprocal Inhibition MET**
   - Contraction of antagonist → stretch agonist

## Myofascial Release (MFR)
- J-stroke technique, perpendicular release, longitudinal release
- Indirect: follow the path of least resistance
- Direct: engage the restriction directly

---

# UNIT 9: NEURODYNAMIC ASSESSMENT

## Upper Limb Tension Tests (ULTT)
Also called Brachial Plexus Tension Tests / Elvey Tests

| Test | Nerve Bias | Key Positions |
|------|-----------|---------------|
| ULTT 1 | Median | Shoulder dep → Abd → ER → Forearm Sup → Wrist/Finger Ext → Elbow Ext |
| ULTT 2A | Median | Shoulder dep → Elbow Ext → Lateral rotation → Wrist/Finger/Thumb Ext |
| ULTT 2B | Radial | Shoulder dep → Elbow Ext → Medial rotation → Wrist/Finger/Thumb Flex |
| ULTT 3 | Ulnar | Shoulder dep → Abd → ER → Wrist/Finger Ext → Elbow Flex |
| ULTT musculocutaneous | Musculocutaneous | Shoulder dep → Elbow Ext → Shoulder Ext → Ulnar deviation |

## Lower Limb Neurodynamic Tests
| Test | Nerve Bias |
|------|-----------|
| Straight Leg Raise (SLR) | Sciatic / L4-S1 |
| Slump Test | Sciatic / dural |
| Femoral Nerve Stretch Test | Femoral / L2-L4 |
| Prone Knee Bend | Femoral / L3-L4 |

## Positive Test Findings
- Reproduction of symptoms (pain, tingling, numbness)
- Sensitization by contralateral cervical side flexion
- Sensitization by ankle dorsiflexion (SLR)

---

# UNIT 10: PHYSIOTHERAPY ASSESSMENT

## SOAP Notes Format
- **S**ubjective: Patient's complaints, history, symptoms
- **O**bjective: Clinical findings, measurements, test results
- **A**ssessment: Diagnosis, problem list
- **P**lan: Treatment plan, goals

## Outcome Measures (Common ones)
| Measure | What it assesses |
|---------|-----------------|
| VAS / NRS | Pain intensity |
| WOMAC | Hip/knee osteoarthritis |
| Oswestry Disability Index | Low back pain disability |
| DASH | Upper limb disability |
| Modified Barthel Index | Functional independence |
| Berg Balance Scale | Balance |
| Timed Up and Go (TUG) | Mobility + fall risk |

---

# UNIT 11: ORTHOTICS & PROSTHETICS

## Orthosis - Definition and Purpose
An external device applied to the body to:
1. Rest a joint/fracture
2. Relieve compressive stress
3. Stabilize a joint
4. Correct/prevent deformity
5. Exercise muscles and joints
6. Control ROM
7. Transmit forces
8. Re-educate phasic muscle activity

## Orthosis Naming System (AAOP)
Named by the joints they span:
- **AFO** = Ankle-Foot Orthosis
- **KAFO** = Knee-Ankle-Foot Orthosis
- **HKAFO** = Hip-Knee-Ankle-Foot Orthosis
- **TLSO** = Thoraco-Lumbo-Sacral Orthosis
- **WHO** = Wrist-Hand Orthosis
- **SEWHO** = Shoulder-Elbow-Wrist-Hand Orthosis

## Foot Orthoses
| Type | Use |
|------|-----|
| UCBL (University of California Biomechanics Lab) | Subtalar control, flat foot |
| SMO (Supra-Malleolar Orthosis) | Ankle stability without dorsiflexion assist |
| Arizona AFO | Rigid, controls subtalar motion |

## Ankle-Foot Orthoses (AFO)
| Type | Indication |
|------|-----------|
| Posterior leaf spring (PLS) | Mild foot drop |
| Solid AFO | Severe spasticity, ankle instability |
| Articulated AFO | Allows dorsiflexion, blocks plantar flexion |
| Ground reaction AFO (GRAFO) | Crouched gait in CP |

## SACH Foot (Solid Ankle Cushion Heel)
- Most common prosthetic foot
- No moving parts; rubber heel compresses to simulate plantar flexion
- SAFE foot = variant with flexible endoskeleton

## Spinal Orthoses
| Orthosis | Level | Indication |
|----------|-------|-----------|
| Soft collar | Cervical | Minor neck pain/strain |
| Philadelphia collar | C2-T1 | Cervical fractures |
| Halo vest | C0-T2 | Unstable cervical fractures |
| TLSO (Boston brace) | T6-sacrum | Scoliosis (<45°), lumbar fractures |
| Milwaukee brace | T1-sacrum | Scoliosis (apex T8 or above) |
| Jewett brace | T6-L1 | Hyperextension fractures, limits flexion |
| Chairback brace | L1-sacrum | Low back pain, limits flexion |

## Milwaukee Brace
- Active corrective brace for scoliosis
- Components: pelvic girdle + head support + posterior uprights + corrective pads
- Exercises while wearing: postural balance, pelvic tilting, breathing exercises, spine extensor exercises

## Boston Brace (TLSO - Passive Supportive)
- Prefabricated polypropylene rear-opening girdle
- For scoliosis curves of 20-40 degrees

## Upper Limb Prosthetics
### Types of Wrist Units
- **Constant friction:** Simple rotation
- **Quick change wrist units:** Rapid terminal device exchange

### Types of Terminal Devices
- **Voluntary opening:** Hook opens when cable pulled; closes by rubber bands
- **Voluntary closing:** Stronger grip, hook closes with cable pull

## Principles of Orthotic Application (12 Key Points)
1. Adequate surface area (for pressure distribution)
2. Accurate contouring
3. Adaptation to change of position
4. Comfort (determined by surface area + joint position)
5. Joint design placement (close to anatomical axis)
6. Minimize adverse effects (pain, constriction)
7. Reshaping when needed
8. Conserve time and energy of patient
9. Durability
10. Maintenance (teach patient care)
11. Finishing (no weak points)
12. Cost control

---

# UNIT 12: MANUAL THERAPY - ADVANCED TECHNIQUES

## Physiotherapy for Specific Conditions

### Osteoarthritis Management
- Education and self-management
- Strengthening (quads for knee OA)
- Aerobic exercise
- Weight loss
- Orthotics/footwear modification
- TENS, ultrasound for pain
- Short-wave diathermy (pulsed PSWD) - increases blood flow, reduces synovial thickness

### Low Back Pain Management
- Active treatment preferred over passive
- McKenzie method (directional preference)
- Core stabilization program
- Manual therapy (manipulation/mobilization)
- Aerobic exercise
- Patient education/cognitive behavioral approach

### Neck Pain Management
- Cervical stabilization
- Cranio-cervical flexor training (deep neck flexors - longus colli, longus capitis)
- Manual therapy
- Postural correction
- Neurodynamics (ULTT as both diagnostic and therapeutic)

---

# UNIT 13: COGNITIVE BEHAVIORAL PHYSIOTHERAPY (CBP)

## Key Principles
- Addresses psychological components of chronic pain
- Challenges unhelpful thoughts and beliefs about pain
- Pain neuroscience education (PNE)
- Graded exposure (to feared activities)
- Goal-setting

## Components of CBP in Physiotherapy
1. Pain neurophysiology education
2. Graded activity and exposure
3. Activity pacing
4. Cognitive restructuring (challenging fear-avoidance beliefs)
5. Relaxation and stress management (deep breathing, PMR, mindfulness)
6. Group therapy (peer support)
7. Time management
8. Goal setting

---

# UNIT 14: SPLINTING

## Purposes of Splinting
1. Resting/positioning
2. Pain relief
3. Prevent contracture
4. Correct deformity
5. Protect healing structures
6. Assist function
7. Post-operative

## Common Upper Limb Splints
| Splint | Indication |
|--------|-----------|
| Resting hand splint | RA, burns, post-op |
| Wrist cock-up splint | Carpal tunnel, wrist weakness |
| Thumb spica | De Quervain's, scaphoid fracture |
| Mallet finger splint | Mallet finger (DIP held in extension) |
| Swan neck splint | Prevents PIP hyperextension |
| Boutonniere splint | PIP extension, DIP flexion |
| Cylinder cast | PIP joint injuries |

## Common Lower Limb Splints/Orthotics
| Device | Indication |
|--------|-----------|
| Knee immobilizer | Post-op, ligament injury |
| Hinged knee orthosis | Ligament instability with ROM |
| Patella stabilizing brace | Patellofemoral pain |
| Night splint (foot) | Plantar fasciitis |

---

# UNIT 15: SHOE MODIFICATIONS

## Shoe Modifications - External
| Modification | Purpose |
|-------------|---------|
| Heel wedge (medial) | Varus correction, lateral compartment OA |
| Heel wedge (lateral) | Valgus correction, medial compartment OA |
| Metatarsal bar | Offload metatarsal heads |
| Rocker sole | Reduce forefoot pressure, hallux rigidus |
| Extended steel shank | Stiffen sole, reduce toe dorsiflexion |
| Thomas heel | Flat foot, medial support |

## Common Foot Deformities
| Deformity | Description |
|-----------|-------------|
| Hallux valgus | Medial displacement of 1st metatarsal, lateral phalanges deviation |
| Hallux rigidus | Stiff 1st MTP joint |
| Pes planus | Flat foot |
| Pes cavus | High arch foot |
| Claw toes | MTP hyperextension, IP flexion |
| Hammer toe | PIP flexion, MTP and DIP extension |

---

# QUICK REVISION: MOST IMPORTANT POINTS

## Top 10 Things to Remember

1. **Muscle performance = Strength + Power + Endurance**
2. **Exercise dose = F-I-D-V-R** (Frequency, Intensity, Duration, Volume, Rest)
3. **PNF stretching = Contract-Relax / Hold-Relax / Slow Reversal-Hold-Relax**
4. **Maitland Grades I-II = pain; III-IV = stiffness; V = manipulation**
5. **Core = Abdominals (front) + Paraspinals (back) + Diaphragm (roof) + Pelvic floor (bottom)**
6. **TrA and multifidus = KEY local stabilizers** (activate before limb movement)
7. **ULTT 1 = Median nerve; ULTT 2B = Radial nerve; ULTT 3 = Ulnar nerve**
8. **DeLorme = 50-75-100% of 10RM; Oxford = 100-75-50% of 10RM**
9. **Milwaukee brace = active corrective; Boston brace = passive supportive**
10. **MET developed by Fred Mitchell Sr (1948) - uses patient's own isometric contraction**

## Common Exam Questions

**Q: What is the SAID principle?**
A: Specific Adaptation to Imposed Demands - body adapts specifically to the type of stress applied.

**Q: Difference between hypertrophy and hyperplasia?**
A: Hypertrophy = increase in muscle fiber SIZE; Hyperplasia = increase in fiber NUMBER.

**Q: What is autogenic inhibition?**
A: GTO activation inhibits the contracting muscle itself, allowing it to relax and stretch further.

**Q: What is reciprocal inhibition?**
A: Contraction of agonist causes reflex relaxation of the antagonist.

**Q: What does transversus abdominis do?**
A: Creates intra-abdominal pressure and thoracolumbar fascia tension; activates feedforward before limb movement; provides segmental spinal stability.

**Q: Maitland Grade V is what?**
A: High-velocity low-amplitude thrust (manipulation) at end of range.

**Q: Indication for Milwaukee brace?**
A: Scoliosis with curve apex at T8 or above (cervicothoracic/thoracic curves).

---

*End of Paper 4 Simplified Exam Notes*

cd /home/daytona/workspace/paper4_exam_notes && python3 -c " from reportlab.lib.…

ls /home/daytona/workspace/paper4_exam_notes/

cd /home/daytona/workspace/paper4_exam_notes && pandoc Paper4_Simple_Exam_Notes.…

ls /home/daytona/workspace/paper4_exam_notes/ && python3 -c " import os size = o…

python3 -c " from reportlab.lib.pagesizes import A4 from reportlab.lib import co…

~/paper4_exam_notes/make_flashcards.py

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.platypus import SimpleDocTemplate, Table, TableStyle, Paragraph, Spacer, HRFlowable, KeepTogether
from reportlab.lib.styles import ParagraphStyle, getSampleStyleSheet
from reportlab.lib.units import cm
from reportlab.lib.enums import TA_CENTER, TA_LEFT

W, H = A4  # 595 x 842 pts

# ── colour palette ──────────────────────────────────────────────
DARK_BLUE   = colors.HexColor('#1a237e')
MED_BLUE    = colors.HexColor('#1565c0')
LIGHT_BLUE  = colors.HexColor('#e3f2fd')
ACCENT_BLUE = colors.HexColor('#42a5f5')
GREEN       = colors.HexColor('#1b5e20')
LIGHT_GREEN = colors.HexColor('#e8f5e9')
ORANGE      = colors.HexColor('#e65100')
LIGHT_ORG   = colors.HexColor('#fff3e0')
PURPLE      = colors.HexColor('#4a148c')
LIGHT_PRP   = colors.HexColor('#f3e5f5')
RED         = colors.HexColor('#b71c1c')
LIGHT_RED   = colors.HexColor('#ffebee')
TEAL        = colors.HexColor('#004d40')
LIGHT_TEAL  = colors.HexColor('#e0f2f1')
GREY_BG     = colors.HexColor('#fafafa')
WHITE       = colors.white

# ── styles ───────────────────────────────────────────────────────
def S(name, **kw):
    base = ParagraphStyle(name, fontName='Helvetica', **kw)
    return base

PAGE_TITLE  = S('PT',  fontSize=18, textColor=WHITE,       alignment=TA_CENTER, spaceAfter=4, leading=22, fontName='Helvetica-Bold')
CARD_TITLE  = S('CT',  fontSize=10, textColor=WHITE,       alignment=TA_CENTER, leading=13,   fontName='Helvetica-Bold')
CARD_BODY   = S('CB',  fontSize=8,  textColor=colors.HexColor('#212121'), leading=12, spaceAfter=2)
CARD_BODY_W = S('CBW', fontSize=8,  textColor=WHITE,       leading=12, spaceAfter=2)
SMALL       = S('SM',  fontSize=7,  textColor=colors.HexColor('#424242'), leading=10)
SMALL_W     = S('SMW', fontSize=7,  textColor=WHITE,       leading=10)
BOLD_BODY   = S('BB',  fontSize=8,  textColor=colors.HexColor('#212121'), leading=12, fontName='Helvetica-Bold')

def p(text, style=CARD_BODY):
    """Convenience: make a Paragraph, bold **text** inline."""
    import re
    text = re.sub(r'\*\*(.*?)\*\*', r'<b>\1</b>', str(text))
    return Paragraph(text, style)

def card(title, bg_color, title_bg, rows, col_widths=None, note=None):
    """Build one flashcard as a KeepTogether block."""
    CARD_W = 17 * cm

    # title bar
    title_table = Table([[p(title, CARD_TITLE)]], colWidths=[CARD_W])
    title_table.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,-1), title_bg),
        ('TOPPADDING',    (0,0), (-1,-1), 5),
        ('BOTTOMPADDING', (0,0), (-1,-1), 5),
        ('LEFTPADDING',   (0,0), (-1,-1), 8),
        ('RIGHTPADDING',  (0,0), (-1,-1), 8),
        ('ROUNDEDCORNERS', [4, 4, 0, 0]),
    ]))

    # body table
    if col_widths is None:
        col_widths = [CARD_W]

    body_data = []
    for row in rows:
        if isinstance(row, list):
            body_data.append([p(c) if isinstance(c, str) else c for c in row])
        else:
            body_data.append([p(row) if isinstance(row, str) else row])

    body_table = Table(body_data, colWidths=col_widths)
    body_table.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,-1), bg_color),
        ('TOPPADDING',    (0,0), (-1,-1), 4),
        ('BOTTOMPADDING', (0,0), (-1,-1), 4),
        ('LEFTPADDING',   (0,0), (-1,-1), 7),
        ('RIGHTPADDING',  (0,0), (-1,-1), 7),
        ('VALIGN',        (0,0), (-1,-1), 'TOP'),
        ('GRID',          (0,0), (-1,-1), 0.3, colors.HexColor('#bdbdbd')),
        ('ROUNDEDCORNERS', [0, 0, 4, 4]),
    ]))

    note_elems = []
    if note:
        note_elems = [p(f'<i>* {note}</i>', SMALL)]

    return KeepTogether([title_table, body_table] + note_elems + [Spacer(1, 8)])

# ── two-column card layout helper ───────────────────────────────
def two_col_card(title, title_bg, bg, left_rows, right_rows):
    """Side-by-side two-column card."""
    CARD_W = 17 * cm
    half = CARD_W / 2

    title_table = Table([[p(title, CARD_TITLE)]], colWidths=[CARD_W])
    title_table.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,-1), title_bg),
        ('TOPPADDING',    (0,0), (-1,-1), 5),
        ('BOTTOMPADDING', (0,0), (-1,-1), 5),
        ('LEFTPADDING',   (0,0), (-1,-1), 8),
        ('RIGHTPADDING',  (0,0), (-1,-1), 8),
    ]))

    # build inner sub-tables
    def mini(rows, w):
        t = Table([[p(r) if isinstance(r, str) else r] for r in rows], colWidths=[w])
        t.setStyle(TableStyle([
            ('BACKGROUND', (0,0), (-1,-1), bg),
            ('TOPPADDING',    (0,0), (-1,-1), 3),
            ('BOTTOMPADDING', (0,0), (-1,-1), 3),
            ('LEFTPADDING',   (0,0), (-1,-1), 5),
            ('RIGHTPADDING',  (0,0), (-1,-1), 5),
            ('VALIGN',        (0,0), (-1,-1), 'TOP'),
        ]))
        return t

    outer = Table([[mini(left_rows, half - 4), mini(right_rows, half - 4)]], colWidths=[half, half])
    outer.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,-1), bg),
        ('TOPPADDING',    (0,0), (-1,-1), 0),
        ('BOTTOMPADDING', (0,0), (-1,-1), 0),
        ('LEFTPADDING',   (0,0), (-1,-1), 0),
        ('RIGHTPADDING',  (0,0), (-1,-1), 0),
        ('VALIGN',        (0,0), (-1,-1), 'TOP'),
        ('LINEAFTER',     (0,0), (0,-1), 0.5, colors.HexColor('#bdbdbd')),
    ]))

    return KeepTogether([title_table, outer, Spacer(1, 8)])

# ── section banner ───────────────────────────────────────────────
def section_banner(text, bg=DARK_BLUE):
    t = Table([[p(text, PAGE_TITLE)]], colWidths=[17*cm])
    t.setStyle(TableStyle([
        ('BACKGROUND', (0,0), (-1,-1), bg),
        ('TOPPADDING',    (0,0), (-1,-1), 7),
        ('BOTTOMPADDING', (0,0), (-1,-1), 7),
        ('LEFTPADDING',   (0,0), (-1,-1), 10),
        ('RIGHTPADDING',  (0,0), (-1,-1), 10),
        ('ROUNDEDCORNERS', [6, 6, 6, 6]),
    ]))
    return KeepTogether([t, Spacer(1, 8)])

# ════════════════════════════════════════════════════════════════
# BUILD DOCUMENT
# ════════════════════════════════════════════════════════════════
doc = SimpleDocTemplate(
    '/home/daytona/workspace/paper4_exam_notes/Paper4_Flashcards.pdf',
    pagesize=A4,
    rightMargin=2*cm, leftMargin=2*cm,
    topMargin=1.5*cm, bottomMargin=1.5*cm,
    title='Paper 4 - Quick Reference Flashcards',
    author='Orris Study Aid'
)

story = []

# ── COVER BANNER ────────────────────────────────────────────────
cover = Table([[p('PAPER 4: PHYSIOTHERAPY IN MSK\nQUICK REFERENCE FLASHCARDS', PAGE_TITLE)]], colWidths=[17*cm])
cover.setStyle(TableStyle([
    ('BACKGROUND', (0,0), (-1,-1), DARK_BLUE),
    ('TOPPADDING',    (0,0), (-1,-1), 18),
    ('BOTTOMPADDING', (0,0), (-1,-1), 18),
    ('ROUNDEDCORNERS', [8,8,8,8]),
]))
story += [cover, Spacer(1, 10)]

# ════════════════════════════════════════════════════════════════
# SECTION 1 – MUSCLE PERFORMANCE
# ════════════════════════════════════════════════════════════════
story.append(section_banner('1. MUSCLE PERFORMANCE', DARK_BLUE))

story.append(card(
    'KEY ELEMENTS', LIGHT_BLUE, MED_BLUE,
    [
        ['**STRENGTH**  Max force a muscle can generate',
         '**POWER**  Force × Velocity (rate of doing work)'],
        ['**ENDURANCE**  Sustain effort over time',
         '**SAID Principle**  Body adapts SPECIFICALLY to demands placed on it'],
    ],
    col_widths=[8.5*cm, 8.5*cm]
))

story.append(card(
    'CAUSES OF DECREASED MUSCLE PERFORMANCE', LIGHT_BLUE, MED_BLUE,
    [
        ['**Neurologic** - stroke, SCI (spastic paralysis)', '**Muscle strain** - direct injury'],
        ['**Disuse / deconditioning** - bed rest', '**Ischemia** - VIC (Volkmann\'s)'],
        ['**Lesion in AHC** - flaccid paralysis (polio)', '**Scarring** - cut injuries'],
        ['**Length-associated changes** - prolonged immobilisation', ''],
    ],
    col_widths=[8.5*cm, 8.5*cm]
))

story.append(card(
    'EXERCISE DOSE  ➜  F - I - D - V - R', LIGHT_GREEN, GREEN,
    [
        ['**F** requency', 'How often (days/week)'],
        ['**I** ntensity', '% of 1 RM (repetition maximum)'],
        ['**D** uration', 'Number of reps or time'],
        ['**V** olume', 'Total work = sets × reps × weight'],
        ['**R** est interval', 'Recovery time between sets'],
    ],
    col_widths=[5*cm, 12*cm]
))

story.append(card(
    'ADAPTATIONS TO RESISTANCE TRAINING', LIGHT_PRP, PURPLE,
    [
        ['**Neural (early 6-8 wks)**', 'More motor units recruited; faster firing; synchronised firing'],
        ['**Hypertrophy**', 'Increase in muscle fibre SIZE'],
        ['**Hyperplasia**', 'Increase in muscle fibre NUMBER (controversial)'],
        ['**Bone**', 'Prevents bone mineral density loss; treats osteoporosis'],
        ['**Connective tissue**', 'Increased tensile strength of tendons & ligaments'],
    ],
    col_widths=[4.5*cm, 12.5*cm]
))

story.append(card(
    'RESISTANCE TRAINING METHODS', LIGHT_ORG, ORANGE,
    [
        ['**DeLorme (PRE)**', '3 sets: **50% → 75% → 100%** of 10 RM'],
        ['**Oxford**',        '3 sets: **100% → 75% → 50%** of 10 RM (reverse)'],
        ['**DAPRE**',         '4 sets; weight adjusted daily based on performance'],
        ['**Plyometrics**',   'Eccentric → Concentric (stretch-shortening cycle); builds POWER'],
        ['**Circuit**',       'Multiple stations, minimal rest; builds endurance + strength'],
    ],
    col_widths=[4.5*cm, 12.5*cm]
))

# ════════════════════════════════════════════════════════════════
# SECTION 2 – STRETCHING & FLEXIBILITY
# ════════════════════════════════════════════════════════════════
story.append(section_banner('2. STRETCHING & FLEXIBILITY', MED_BLUE))

story.append(card(
    'TYPES OF STRETCHING', LIGHT_BLUE, MED_BLUE,
    [
        ['**Static**',    'Hold end-range 15-60 sec',    'After exercise / cool-down'],
        ['**Dynamic**',   'Controlled movement thru range','Before activity / warm-up'],
        ['**Ballistic**', 'Bouncing movement',            'Pre-activity (athletes)'],
        ['**PNF**',       'Uses muscle contractions',     'Best for ROM gains'],
    ],
    col_widths=[3.5*cm, 7.5*cm, 6*cm]
))

story.append(card(
    'PNF STRETCHING – 3 TECHNIQUES', LIGHT_GREEN, GREEN,
    [
        ['**Contract-Relax (CR)**',
         'Isotonic contraction of tight muscle → relax → stretch\n'
         'Use when: ROM limited by muscle tightness'],
        ['**Hold-Relax (HR)**',
         'Isometric contraction of tight muscle → relax → stretch\n'
         'Use when: pain limits movement; = Muscle Energy Technique'],
        ['**Slow Reversal-Hold-Relax (SRHR)**',
         'Isotonic agonist contraction → isometric antagonist contraction → relax → stretch\n'
         'Also called: contract-relax agonist contraction'],
    ],
    col_widths=[5*cm, 12*cm]
))

story.append(card(
    'INHIBITION MECHANISMS', LIGHT_PRP, PURPLE,
    [
        ['**Autogenic Inhibition**',
         'GTO fires when muscle contracts/stretches → inhibits SAME muscle → allows stretch\n'
         'Basis of: CR, HR, PIR techniques'],
        ['**Reciprocal Inhibition**',
         'Contraction of agonist → relaxes ANTAGONIST via muscle spindle\n'
         'Basis of: SRHR, RI-MET techniques'],
    ],
    col_widths=[5*cm, 12*cm]
))

# ════════════════════════════════════════════════════════════════
# SECTION 3 – CORE STABILITY
# ════════════════════════════════════════════════════════════════
story.append(section_banner('3. CORE STABILITY', colors.HexColor('#006064')))

story.append(card(
    'THE CORE "BOX"', LIGHT_TEAL, TEAL,
    [
        ['**FRONT**',  'Abdominals (transversus abdominis, obliques, rectus)'],
        ['**BACK**',   'Paraspinals + Gluteals'],
        ['**ROOF**',   'Diaphragm'],
        ['**BOTTOM**', 'Pelvic floor + Hip girdle musculature'],
        ['**SIDES**',  'Hip abductors and rotators'],
    ],
    col_widths=[3.5*cm, 13.5*cm]
))

story.append(card(
    'LOCAL vs GLOBAL MUSCLES', LIGHT_TEAL, TEAL,
    [
        ['**Type**', '**Muscles**', '**Role**'],
        ['Local (stabilizers)', 'TrA, Multifidus, Pelvic floor, Diaphragm',
         'Segmental stability; low-level continuous activation; FEEDFORWARD activation'],
        ['Global (mobilizers)', 'Rectus abdominis, External oblique, Iliocostalis',
         'Force production; large movements'],
    ],
    col_widths=[4*cm, 7*cm, 6*cm]
))

story.append(card(
    'CORE ASSESSMENT TESTS', LIGHT_GREEN, GREEN,
    [
        ['**Prone bridge (Plank)**',      'Anterior + posterior core endurance'],
        ['**Lateral bridge (Side plank)**','Lateral core endurance'],
        ['**Torso flexion hold at 60°**', 'Flexor endurance'],
        ['**Extensor endurance test**',   'Back extensor endurance (prone over table edge)'],
    ],
    col_widths=[6.5*cm, 10.5*cm]
))

story.append(card(
    'CORE EXERCISE PROGRESSION', LIGHT_BLUE, MED_BLUE,
    [
        p('**1** Neutral spine → **2** Abdominal hollowing/bracing → **3** Prone bridge → '
          '**4** Lateral bridge → **5** Supine pelvic bridging → **6** Quadruped (bird-dog) → '
          '**7** Dead bugs → **8** Labile surface (balance board) → **9** Plyometrics → '
          '**10** Sport-specific'),
    ],
    col_widths=[17*cm]
))

# ════════════════════════════════════════════════════════════════
# SECTION 4 – MANUAL THERAPY
# ════════════════════════════════════════════════════════════════
story.append(section_banner('4. MANUAL THERAPY', ORANGE))

story.append(card(
    'MAITLAND GRADES OF MOBILISATION', LIGHT_ORG, ORANGE,
    [
        ['**Grade**', '**Amplitude**', '**Position in Range**', '**Purpose**'],
        ['Grade I',   'Small',         'Beginning of range',    'Pain relief'],
        ['Grade II',  'Large',         'Does NOT reach end range','Pain relief'],
        ['Grade III', 'Large',         'At end of range',        'Pain + stiffness'],
        ['Grade IV',  'Small',         'At end of range',        'Stiffness'],
        ['Grade V',   'HVLAT thrust',  'End of range',           'Restore full range'],
    ],
    col_widths=[3*cm, 3*cm, 5.5*cm, 5.5*cm],
    note='I-II = pain dominant; III-IV = stiffness dominant; V = manipulation'
))

story.append(card(
    'MUSCLE ENERGY TECHNIQUE (MET)', LIGHT_GREEN, GREEN,
    [
        ['**Developer**', 'Fred Mitchell Sr, DO (1948)'],
        ['**Principle**', 'Patient\'s own isometric contraction relaxes + lengthens muscle'],
        ['**PIR**',       'Post Isometric Relaxation (Lewitt) – 10-20% submaximal contraction × 5-10 sec → stretch (Autogenic Inhibition)'],
        ['**PFS**',       'Post Facilitation Stretching (Janda) – maximal contraction → rapid stretch'],
        ['**RI-MET**',    'Reciprocal Inhibition – contraction of antagonist → stretch agonist'],
    ],
    col_widths=[2.8*cm, 14.2*cm]
))

story.append(card(
    'NEURODYNAMIC TESTS – UPPER LIMB (ULTT)', LIGHT_PRP, PURPLE,
    [
        ['**Test**',  '**Nerve**',        '**Key Positions**'],
        ['ULTT 1',   'Median nerve',      'Shoulder dep → Abd → ER → Forearm Sup → Wrist/Finger Ext → Elbow Ext'],
        ['ULTT 2A',  'Median nerve',      'Shoulder dep → Elbow Ext → Lateral rotation → Wrist/Finger/Thumb Ext'],
        ['ULTT 2B',  'Radial nerve',      'Shoulder dep → Elbow Ext → Medial rotation → Wrist/Finger/Thumb Flex'],
        ['ULTT 3',   'Ulnar nerve',       'Shoulder dep → Abd → ER → Wrist/Finger Ext → Elbow FLEX'],
    ],
    col_widths=[2.5*cm, 3*cm, 11.5*cm],
    note='Also called Elvey Test / Brachial Plexus Tension Test. Sensitiser = contralateral cervical side flexion'
))

story.append(card(
    'NEURODYNAMIC TESTS – LOWER LIMB', LIGHT_BLUE, MED_BLUE,
    [
        ['**SLR (Straight Leg Raise)**',      'Sciatic nerve / L4-S1; sensitiser = ankle dorsiflexion'],
        ['**Slump Test**',                    'Sciatic nerve / dural tension; sitting slump + neck flexion + knee extension'],
        ['**Femoral Nerve Stretch Test**',    'Femoral nerve / L2-L4; prone, knee flexion + hip extension'],
        ['**Prone Knee Bend**',               'Femoral nerve / L3-L4'],
    ],
    col_widths=[6*cm, 11*cm]
))

# ════════════════════════════════════════════════════════════════
# SECTION 5 – GAIT
# ════════════════════════════════════════════════════════════════
story.append(section_banner('5. GAIT REHABILITATION', RED))

story.append(card(
    'GAIT CYCLE', LIGHT_RED, RED,
    [
        [p('**STANCE PHASE (60%)**\nHeel strike → Foot flat → Mid-stance → Heel off → Toe off',
           CARD_BODY),
         p('**SWING PHASE (40%)**\nAcceleration → Mid-swing → Deceleration (terminal swing)',
           CARD_BODY)],
    ],
    col_widths=[8.5*cm, 8.5*cm]
))

story.append(card(
    'GAIT DEVIATIONS – QUICK RECALL', LIGHT_RED, RED,
    [
        ['**Trendelenburg**',  'Weak GLUTEUS MEDIUS – pelvis drops to opposite side'],
        ['**Steppage**',       'Foot drop – weak dorsiflexors (L4-L5)'],
        ['**Antalgic**',       'Pain – shortened stance phase on affected side'],
        ['**Scissor**',        'Spastic hip adductors (CP) – legs cross midline'],
        ['**Waddling**',       'Bilateral weak gluteus medius – body sways side to side'],
        ['**Festinating**',    'Parkinson\'s – shuffling, short steps, forward lean'],
    ],
    col_widths=[4*cm, 13*cm]
))

story.append(card(
    'CRUTCH WALKING GAITS', LIGHT_ORG, ORANGE,
    [
        ['**4-Point**',       'Both feet WB; alternating; SLOWEST, most stable'],
        ['**3-Point**',       'NWB one limb; both crutches + WB limb; fractures / post-op'],
        ['**2-Point**',       'Both feet WB; faster than 4-point'],
        ['**Swing-to**',      'Both NWB; swing to crutch level; paraplegia'],
        ['**Swing-through**', 'Both NWB; swing PAST crutches; FASTEST'],
    ],
    col_widths=[4.5*cm, 12.5*cm]
))

# ════════════════════════════════════════════════════════════════
# SECTION 6 – ORTHOTICS & PROSTHETICS
# ════════════════════════════════════════════════════════════════
story.append(section_banner('6. ORTHOTICS & PROSTHETICS', TEAL))

story.append(card(
    'SPINAL ORTHOSES', LIGHT_TEAL, TEAL,
    [
        ['**Orthosis**',          '**Level**',   '**Indication**'],
        ['Soft collar',           'Cervical',    'Minor neck pain/strain'],
        ['Philadelphia collar',   'C2-T1',       'Cervical fractures'],
        ['Halo vest',             'C0-T2',       'Unstable cervical fractures'],
        ['Milwaukee brace',       'T1-sacrum',   'Scoliosis apex T8 or ABOVE (active corrective)'],
        ['Boston brace (TLSO)',   'T6-sacrum',   'Scoliosis 20-40° (passive supportive)'],
        ['Jewett brace',          'T6-L1',       'Hyperextension fractures; limits FLEXION'],
        ['Chairback brace',       'L1-sacrum',   'Low back pain; limits flexion'],
    ],
    col_widths=[5*cm, 3.5*cm, 8.5*cm],
    note='Milwaukee = active corrective | Boston = passive supportive'
))

story.append(card(
    'ANKLE-FOOT ORTHOSES (AFO)', LIGHT_BLUE, MED_BLUE,
    [
        ['**Posterior Leaf Spring (PLS)**',  'Mild foot drop; flexible plastic'],
        ['**Solid AFO**',                    'Severe spasticity; no ankle movement'],
        ['**Articulated AFO**',              'Allows dorsiflexion; blocks plantar flexion'],
        ['**Ground Reaction AFO (GRAFO)**',  'Crouched gait in cerebral palsy; anterior shell'],
        ['**UCBL insert**',                  'Subtalar control; flat foot / pes planus'],
    ],
    col_widths=[6*cm, 11*cm]
))

story.append(card(
    'PROSTHETIC FEET', LIGHT_GREEN, GREEN,
    [
        ['**SACH foot**',         'Solid Ankle Cushion Heel – most common; no moving parts; rubber heel'],
        ['**SAFE foot**',         'SACH variant – flexible endoskeleton; more natural push-off'],
        ['**Dynamic response**',  'Energy storing (carbon fibre); running blades'],
    ],
    col_widths=[4.5*cm, 12.5*cm]
))

# ════════════════════════════════════════════════════════════════
# SECTION 7 – HYDROTHERAPY & MODALITIES
# ════════════════════════════════════════════════════════════════
story.append(section_banner('7. HYDROTHERAPY & PHYSICAL MODALITIES', PURPLE))

story.append(card(
    'WATER PROPERTIES IN THERAPY', LIGHT_PRP, PURPLE,
    [
        ['**Buoyancy**',           'Reduces effective body weight; unloads joints'],
        ['**Hydrostatic pressure**','Reduces swelling; supports venous return'],
        ['**Viscosity**',          'Provides resistance for strengthening'],
        ['**Thermodynamics**',     'Warm water = muscle relaxation; pain relief'],
    ],
    col_widths=[5*cm, 12*cm]
))

story.append(card(
    'HYDROTHERAPY MODALITIES', LIGHT_PRP, PURPLE,
    [
        ['**Whirlpool**',       'Tank + turbine; conduction + convection; reduces spasm, swelling, pain'],
        ['**Contrast bath**',   'Alternating hot/cold; pumping effect; use ratio 3:1 or 4:1 (hot:cold)'],
        ['**Hubbard tank**',    'Full body immersion; burns, spinal conditions, extensive injuries'],
        ['**Pool therapy**',    'Partial weight bearing; gait re-training; ROM exercises'],
    ],
    col_widths=[4*cm, 13*cm]
))

# ════════════════════════════════════════════════════════════════
# SECTION 8 – QUICK FIRE Q&A
# ════════════════════════════════════════════════════════════════
story.append(section_banner('8. EXAM Q&A – MUST KNOW', RED))

qna = [
    ('What is muscle performance?', 'Capacity of a muscle to do WORK (force × distance). Key elements: Strength, Power, Endurance'),
    ('DeLorme vs Oxford technique?', 'DeLorme = 50→75→100% of 10 RM (progressive). Oxford = 100→75→50% of 10 RM (regressive)'),
    ('What is the SAID principle?', 'Specific Adaptation to Imposed Demands – body adapts specifically to the type of stress applied'),
    ('Autogenic vs Reciprocal Inhibition?', 'Autogenic = GTO inhibits SAME muscle. Reciprocal = agonist contraction inhibits ANTAGONIST'),
    ('Who developed MET and when?', 'Fred Mitchell Sr, D.O. in 1948. Used isometric contractions + inhibition to lengthen muscle'),
    ('Maitland Grade V is?', 'High Velocity Low Amplitude (HVLA) THRUST (manipulation) at end of range'),
    ('Grades I-II vs III-IV Maitland?', 'I-II = pain dominant (early, gentle). III-IV = stiffness dominant (end range)'),
    ('ULTT nerve biases?', 'ULTT1 = Median | ULTT2A = Median | ULTT2B = RADIAL | ULTT3 = ULNAR'),
    ('Trendelenburg gait cause?', 'Weak GLUTEUS MEDIUS – pelvis drops to opposite (contralateral) side in stance'),
    ('Milwaukee vs Boston brace?', 'Milwaukee = ACTIVE corrective (apex T8 above). Boston = PASSIVE supportive (curves 20-40°)'),
    ('Local vs global core muscles?', 'Local (TrA, multifidus) = segmental stability + feedforward. Global (rectus, obliques) = movement'),
    ('Transversus abdominis key role?', 'Creates IAP + thoracolumbar fascia tension; activates BEFORE limb movement (feedforward mechanism)'),
    ('SACH foot full form and feature?', 'Solid Ankle Cushion Heel – most common prosthetic foot; no moving parts; rubber heel compresses for push-off'),
    ('Stance vs swing phase percentages?', 'Stance = 60% | Swing = 40% of the gait cycle'),
    ('PNF 3 techniques?', 'Contract-Relax (CR) | Hold-Relax (HR) | Slow Reversal-Hold-Relax (SRHR)'),
]

for q, a in qna:
    story.append(card(
        q, LIGHT_RED, RED,
        [p(f'<b>A:</b> {a}')],
        col_widths=[17*cm]
    ))

# ════════════════════════════════════════════════════════════════
# SECTION 9 – MEMORY AIDS
# ════════════════════════════════════════════════════════════════
story.append(section_banner('9. MEMORY AIDS & MNEMONICS', GREEN))

story.append(card(
    'TOP MNEMONICS', LIGHT_GREEN, GREEN,
    [
        ['**F-I-D-V-R**',
         'Exercise Dose: Frequency, Intensity, Duration, Volume, Rest'],
        ['**N-M-D-L-I-S-L**',
         'Causes of decreased muscle performance: Neurologic, Muscle strain, Disuse, Length changes, Ischemia, Scarring, Lesion (AHC)'],
        ['**S-P-D-P-B**',
         'Core box: Spine (paraspinals back), abdominals (front), Diaphragm (roof), Pelvic floor (bottom), abductors (sides)'],
        ['**1-2-3-4 = pain→stiff**',
         'Maitland: Grades 1-2 = pain; Grades 3-4 = stiffness; Grade 5 = manipulation'],
        ['**"Median-Median-Radial-Ulnar"**',
         'ULTT1, 2A, 2B, 3 nerve bias order'],
        ['**"DeLorme goes UP; Oxford goes DOWN"**',
         'DeLorme: 50→75→100%; Oxford: 100→75→50%'],
        ['**"Milwaukee is ACTIVE; Boston is PASSIVE"**',
         'Milwaukee brace corrects actively; Boston brace passively supports'],
    ],
    col_widths=[5.5*cm, 11.5*cm]
))

# footer note
story.append(Spacer(1, 6))
footer_style = ParagraphStyle('footer', fontSize=7, textColor=colors.grey, alignment=TA_CENTER)
story.append(Paragraph('Paper 4 – Physiotherapy Interventions in Musculoskeletal Disorder  |  Quick Reference Flashcards  |  For Exam Revision', footer_style))

doc.build(story)
print('Flashcard PDF created successfully!')

python3 /home/daytona/workspace/paper4_exam_notes/make_flashcards.py

~/paper4_exam_notes/make_flashcards.py

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/paper4_exam_notes/make_flashcards.py'

python3 /home/daytona/workspace/paper4_exam_notes/make_flashcards.py

python3 -c " import os size = os.path.getsize('/home/daytona/workspace/paper4_ex…