Jeopardy, Part II

PGY-2

100

Which of the following factors is the strongest predictor for the development of chronic, disabling low back pain? a. severity of pain b. physical examination findings c. psychosocial factors d. duration of pain

What is (c) Psychosocial factors and emotional distress are stronger predictors of low back pain than physical examination findings, severity of pain, or duration of pain. Specific psychosocial factors that may predict poorer outcomes in cases of low back pain include presence of depression, passive coping strategies,job dissatisfaction, higher disability levels, disputed compensation claims, and somatization. Reference(s)Chou R, et al. Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from theAmerican College of Physicians and the American Pain Society. Ann Intern Med. 2007;147 (7): 478-91.

200

A 35-year-old patient with chronic, axial low back pain indicates that the back pain has worsened significantly in the last few weeks. The pain is no longer being managed by physical therapy exercises and pain medications. The patient acknowledges increased irritability and poor sleep. The physical examination is stable. Which of the following actions is the most appropriate next step in managing the patient's care? a. obtaining a lumbar MRI b. evaluating for presence of depression c. ordering additional physical therapy d. starting a long-acting opioid medication

What is (b) Optimal treatment of chronic pain frequently requires a multidisciplinary approach. Illness exists within a complex matrix of biological, psychological and social issues. A patient may have a structural injury that acts as a nidus for development of chronic pain syndrome but psychological issues such as anxiety and/or depression can compound the presentation. The resulting pain syndrome may fail to respond to standard medical treatment unless all the contributors are addressed. When secondary psychological or social issues become the predominant factors, management must shift to include these factors. Reference(s) Barbuto, et al. Chronic pain: second, do no harm. Am J Phys Med Rehabil 200887:78– 83.

300

Which scenario is typical of patients with spinal stenosis and neurogenic claudication? a. Worsening leg pain with downhill walking b. Pain relief with standing still after a long walk c. Worsening leg pain with lumbar flexion d. Pain relief with increased anterior pelvic tilt

What is (a) Lumbar extension, created when walking downhill, decreases spinal canal diameter and worsens neurogenic claudication symptoms. Neurogenic claudication is classically improved when a person changes from a standing or walking position to a seated position. Lumbar flexion (forward trunk lean) with uphill walking may improve leg pain because lumbar flexion increases spinal canal diameter. Anterior pelvic tilt is associated with lumbar extension and increased pain. Reference(s)Vo AN. Kamen LB. Shih VC. Bitar AA. Stitik TP. Kaplan RJ. Rehabilitation of orthopedic andrheumatologic disorders. 5. Lumbar spinal stenosis. Arch Phys Med Rehabil 2005;86(3 Suppl 1):S69-76.

400

A 40-year-old man with a history of severe asthma and alcohol abuse complains of progressive right groin pain and a decline in mobility for the past 5 years. Acetaminophen and nonsteroidal anti-inflammatory drugs are not helpful. He has also tried physical therapy and the use of a cane without improvement. On physical examination, he has an antalgic gait and limited right hip range of motion, especially with internal rotation. Which procedure would best help the patient's pain and function? a. Total hip replacement b. Lumbar epidural steroid injection c. Radiofrequency rhizotomy d.Hip injection of platelet rich plasma

What is (a) This patient has osteonecrosis or avascular necrosis of the femoral head. Risk factors include glucocorticoid, alcohol, and tobacco use. When pain limits mobility and conservative management has failed, total hip replacement is indicated. Platelet rich plasma is still experimental for its primary indications of lateral epicondylitis, patellar tendinopathy, and Achilles tendinopathy.

500

What innervates the L4-5 facet joint? Name the nerve and level(s)

What is the medial branch from primary dorsal ramus. L4 and L3 innervate the L4-5 facet joint.

PGY-3

100

Which of the following is true regarding eccentric, as opposed to concentric, muscle contractions? a. Muscle length is shortened b. Less force is generated. c. Metabolic cost is higher. d. Tissue microtrauma is increased

What is (d) Eccentric muscle contractions involve muscle lengthening. Fast eccentric contractions generate the greatest force and may cause more tissue destruction. There is a low metabolic cost therefore, it is more energy efficient. Reference(s)Strax TE, Gonzalez P, Cuccurullo S. Physical Modalities, therapeutic exercise, extended bedrest, andaging effects. In: Cuccurullo, SJ editor. Physical Medicine and Rehabilitation Board Review. New York:Demos Medical Publishing 2004. p 573

200

When performing electromyography, which of the following muscles is helpful in differentiating an upper trunk brachial plexus injury from a cervical radiculopathy? a. biceps brachii b. deltoid c. rhomboid d. supraspinatus

What is (c) The rhomboid muscles are innervated by the dorsal scapular nerve and arise from the C4-C5 roots. The dorsal scapular nerve arises proximal to the upper trunk of the brachial plexus. The muscles are infrequently sampled when performing the needle examination, however, findings in the rhomboids may help differentiate a cervical radiculopathy (C4-C5) from a more distal upper trunk brachial plexopathy. The biceps brachii is innervated by the C5-6 roots and the musculocutaneous nerve (MCN). The MCN is a terminal branch from the lateral cord of the brachial plexus. The triceps muscles are innervated by theC6-C7-C8 roots and radial nerve(RN). The radial nerve is a terminal branch from the posterior cord of the brachial plexus. The supraspinatus muscle is innervated by the C5-6 roots and the suprascapular nerve(SN). The SN is a branch off of the upper trunk of the brachial plexus. Reference(s)Preston DC, Shapiro BE. Brachial plexopathy . In: Preston DC, Shapiro BE, editors. Electromyographyand neuromuscular disorders: clinical-electrophysiologic correlations, 2nd ed. Philadelphia: Butterworth-Heinemann; 2005. p.479-482.

300

What nerve(s) innervates the intervertebral discs?

What is branches from the ventral ramus from the spinal nerve.

400

Name at least 2 types of femoroacetabular impingement. Describe or draw pictures.

What is Cam and Pincer. Cam: Femoral head does not have uniform roundness, precludes smooth rotation within acetabulum Pincer: Overgrowth of rim around edge of acetabulum

500

Draw the Brachial Plexus with all roots, trunks, cords and Peripheral nerves. Extra 500 points if all innervated muscles and their root levels are also included.

draw on board

PGY-4

100

A warehouse worker routinely lifts a heavy object from the floor. The techniques that causes the most stress on the lumbar spine is lifting with the a. back straight and knees bent. b. back forward-flexed and the knees straight. c. object close to the body. d. object far away from the body.

What is (b) The activity of the lumbar muscles correlates well with intradiskal pressures (ie, when back muscles contract, an associated increase in disk pressure occurs). These pressures change depending on spine posture and the activity undertaken. Adding rotation to the already flexed posture increases the disk pressure substantially. Comparing lifting maneuvers, researchers showed a significant difference in disk pressure when lifting with the legs (ie, back straight, knees bent) versus lifting with the back (ie, forward-flexed back, straight legs). What decreases the forces on the lumbar spine is lifting the load close to the body because the farther the load is from the chest, the greater the stress on the lumbar spine.

200

A patient with chronic low back pain is referred for diagnostic lumbar medial branch blocks. The patient has been taking long-term warfarin (Coumadin) at a stable therapeutic level due to a history of atrial fibrillation. Which of the following is the next best step? a. Proceed with the blocks. b. Advise patient to stop warfarin. c. Bridge with low-molecular weight heparin. d. Pretreat the patient with vitamin K.

What is (a) To date, there are no reports of spinal complications following medial branch blocks in a patient taking anticoagulants. The risk of paraspinal hematoma is far outweighed by the risk of stopping the anticoagulant. Reference(s)Anticoagulants. In: Bogduk N, editor. International Spine Intervention Society: Practice Guidelines forSpinal Diagnostic and Treatment Procedure. 2nd ed. San Francisco: 2013. p 133-34

300

What is the best predictor of fractures in a person with osteoporosis? (a)Low body weight (b)Recent falls (c)Low physical activity (d)Prior fractures

What is (d) The best predictor of future fractures is prior fractures.Low body weight is also a major risk factor. Recent falls and low physical activity are additional risk factors

400

A 23-year-old woman with C7 ASIA B tetraplegia resulting from an accident 8 months ago is complaining of nausea for several days and has vomited non-bloody, non-bilious food particles the last 3 evenings when placed back to bed after dinner. She also reports some abdominal tightness and bloating. Her symptoms are relieved when lying on the left side. Her bowel training program is going well, resulting in regular, effective bowel movements. She recently lost 25 pounds and appears quite thin on exam. Which study will confirm this patient’s most likely diagnosis? (a)Abdominal x-ray (b)Head computed tomography (CT) scan (c)Serum calcium level (d)Upper gastrointestinal (GI) series

What is (d) Superior mesenteric artery (SMA) syndrome is a condition in which the third segment of the duodenum is compressed between the SMA and the aorta. Although it occurs rarely, it is more common in people with tetraplegia, especially if the person lost weight and is immobilized in the supine position. An upper GI series confirms the diagnosis with an abrupt cessation of barium in the third part of the duodenum. In addition to lying on the left side, some individuals get relief with metoclopramide (Reglan). A serum calcium level could be used to diagnose immobilization hypercalcemia, which is a common cause of nausea and vomiting in patients with tetraplegia. Hypercalcemia is not, however, alleviated with positioning and it usually occurs within the first few months after injury. Abdominal x-ray could identify chronic constipation, but since her bowel program is going well, constipation is not likely to be the cause of her symptoms. Although hydrocephalus would be identified by means of a head CT scan, it is the least likely diagnosis in this case

500

In less than one minute (yes, this will be timed), name 4 muscles with dual innervation. Additional 250 points for every additional muscle named after 4.

What is Pectoralis major: Medial pectoral, Lateral pectoral nerve Brachialis: Musculocutaneus nerve, Radial nerve Flexor digitorum profundus: Median nerve (AIN), Ulnar nerve Lumbricals: Median nerve, Ulnar nerve Flexor pollicis brevis: Median nerve, Ulnar nerve Pectineus: Femoral nerve, Obturator nerve Adductor magnus: Sciatic nerve (tibial portion), Obturator nerve Biceps femoris: Sciatic nerve (tibial portion), Sciatic nerve (peroneal portion)

Back

100

A patient with medical history of osteoporosis and a new vertebral compression fracture has a serum25(OH)D concentration of 15ng/mL. What of the following is the most appropriate treatment recommendation? a. diet modification without vitamin supplementation b. calcium carbonate 500 mg twice a day for 6 weeks c. daily multivitamin with 400 international units of vitamin D3 for 6 weeks d. 50,000 international units of vitamin D2 weekly for 6 weeks

What is (d) The patient is considered a high-risk individual given her age, gender, and diagnosis of osteoporosis. Abnormal serum 25(OH)D serum concentration is 30ng/mL or above. For patients whose 25(OH)Dconcentration is between 20-30 ng/mL, supplementation of 600-800 international units of Vitamin D3 isappropriate. The recommendation for repletion in a high-risk individual with serum 25(0H)D concentration of less than 20 is for weekly ergocalciferol or cholecalciferol at 50,000 units for six to eight weeks.

200

A patient's dual-energy x-ray absorptiometry (DXA) scan shows a T score of -1.5 at the lumbar spine, -2.0 at the femur, and -1.2 at the radius. This patient has a. normal bone density. b. osteopenia. c. osteomalacia. d.osteoporosis.

What is (b) The T score is the number of standard deviations above or below the mean bone mineral density of normal young adults. Normal bone density is less than 1 standard deviation below the mean. Osteopenia is defined by the World Health Organization as -1 to -2.5 standard deviations below the mean. Osteoporosis is -2.5 or more standard deviations below the mean. Osteomalacia is a softening of bone from decreased mineralization, frequently from vitamin D deficiency

300

Which patient is most likely to be treated conservatively? a. A young man who fell from roof and is experiencing bladder incontinence, numbness and tingling in the sacral distribution b. A woman with T12 compression fracture following a motor vehicle collision c. A person with chronic low back pain, grade 3 spondylolisthesis and neurological symptoms d.A 40-year-old woman with progressive foot drop and herniated disc L4-L5

What is (b) Compression fractures are most often treated conservatively. The man who fell from the roof has cauda equina syndrome, an absolute surgical indication. Progressive motor loss, such as the woman with the herniated disc, is also an absolute indication for surgical intervention. Relative indications for surgery include intractable pain and static motor loss, and surgery is often considered in these cases following failed conservative treatments. A grade 3 spondylolisthesis may be treated conservatively when no neurological symptoms are present. Although most discogenic low back pain can be treated conservatively, progressive neurological deficits are treated surgically.

400

A 25-year-old man comes to your office for evaluation of low back pain. As part of the physical examination, you mark a point at the L5 vertebral body and another point midline 10cm above. You ask him to flex forward maximally while keeping his knees extended and measure the distance between the two points. This distance is 13.5 cm. You suspect he may have what diagnosis? (a)Lumbar spondylolisthesis (b)Scheuermann disease (c)Lumbar herniated disc (d)Ankylosing spondylitis For 200 extra points: What is the above test called? For 300 extra points: Define Scheuermann disease

What is (d) The Schober test is used to assess restricted range of motion seen in ankylosing spondylitis as the disease progresses. The distance between the 2 points with forward flexion Page 14of 23exceeds 15cm in normal individuals.This clinical test is not used for the assessment of lumbar spondylolisthesis, Scheuermann disease, or lumbar herniated discs

500

Define spondylosis, spondylolysis, spondylolisthesis. For extra 250: What x-ray angle optimizes the spondylolysis "scotty dog" view? For extra 250: How is spondylolisthesis graded?

What is Spondylosis: degenerative cascade of changes involving the spine Spondylolysis: vertebral defect involving pars interarticularis Spondylolisthesis: slippage of one vertebral body (anterior or posterior) in relation to the vertebra it sits upon Spondylolysis scotty dog view: Oblique x-ray Spondylolisthesis: Graded 0-4, by percentage of vertebral body slippage

Misc

100

A 68-year-old woman asks what kind of exercise would be beneficial for her osteopenia. A physician replies that at least 3 days of the week, she should a. do stationary bicycling for 30 minutes. b. swim for 30 minutes in a warm pool. c. walk for 45 minutes. d. perform sit-ups for 10 minutes.

What is (c) Weight-bearing exercise, such as walking, is osteogenic. Persons with osteopenia should limit the load lifting to less than 20 pounds. Walking 45 minutes, 3 days per week, or 30 minutes daily is recommended. Swimming and bicycling can fulfill cardiovascular benefits, but are not helpful in stimulating bone remodeling. Spinal flexion exercises should be avoided due to the risk of compression fractures

200

Hyperreflexia after an upper motor neuron lesion can result from a. increased spinal inhibition from brain centers. b. hypoexcitability of alpha-motor neurons. c. peripheral nerve demyelination. d. increased gamma-fiber activity

What is (d) Hyperreflexia can result from a number of mechanisms including decreased spinal inhibitory mechanisms from brain centers, hyperexcitability of alpha-motor neurons, peripheral nerve sprouting, and increasedgamma-fiber activity. Reference(s)Nance PW, Satkunam L, Ethans K. Spasticity Management. In: Braddom RL, Chan L, Harrast MA,Kowalske KJ, Matthews DJ, Ragnarsson KT, Stolp KA, editors. Physical medicine and rehabilitation. 4thed. Philadelphia: Elsevier

300

Which of the following is the most likely cause of claw-toe deformity with callus in a patient with long-standing diabetic neuropathy? a. footwear b. vascular insufficiency c. muscle weakness d. weight gain

What is (c) A callus on the metatarsal head is a sign of increased forefoot pressure. In a patient with neuropathy, this is caused by weakness on the intrinsic foot muscles, leading to unbalanced pull of the long toe flexors and extenders resulting in a claw foot deformity. In a patient with claw foot deformity, the metatarsals are more prominent and the pad is often displaced. With ambulation, the pressure over the metatarsal heads is higher and this can result in callus and eventually ulcer formation. While the other answers listed all contribute to development of diabetic foot ulcers, they would not directly be the cause of a metatarsal callus. Reference(s)Salcido R, Ahn C, Wu S, Goldman R. Prevention and management of chronic wounds. In: Braddom RL,editor. Physical medicine and rehabilitation. 4th ed. Philadelphia: Elsevier Saunders 2011. p 700-1

400

A 59-year-old man had a stroke 6 months ago and has residual expressive aphasia and weakness of the right upper limb with only slight voluntary contractions at the shoulder and elbow. He would like to try constraint-induced movement therapy (CIMT). You inform him that you do not think CIMT will help him because a. CIMT is only effective if initiated within the first 3 months after a stroke. b. his aphasia prohibits him from effectively understanding the treatment protocol. c. he does not have adequate motor control in the right upper limb to participate. d. the medical literature has shown poorer outcomes with CIMT than conventional treatment.

What is (c) Constraint-induced movement therapy (CIMT) is a relatively recently developed type of therapy based on the current concepts of neuroplasticity. Patients must have adequate proximal limb control and at least partial wrist and finger extension, as well as sufficient balance during limb restraint. There is emerging support for the effectiveness of CIMT in acute, subacute, and chronic phases of stroke recovery, and outcomes have compared favorably to conventional treatment. Expressive aphasia would not be prohibitive of participation in a CIMT protocol. Logistic and cost considerations have limited the availability of CIMT, as has the candidacy of patients with only mild to moderate unilateral limb paresis. Reference(s)(a) Harvey RL, Roth EJ, Yu DT, Celnik P. Stroke syndromes. In: Braddom RL, editor. Physical medicineand rehabilitation. 4th ed. Philadelphia: Elsevier Saunders; 2011. p 1194. (b) Stein J, Brandstater ME.Stroke rehabilitation. In: Frontera WR, editor. DeLisa’s physical medicine and rehabilitation: principlesand practice. 5th ed. Philadelphia: Lippincott Williams &Wilkins; 2010. p 566. (c) Winstein CJ, Wolf SL.Task-oriented training to promote upper extremity recovery. In: Stein, J, editor. Stroke recovery andrehabilitation. New York: Demos; 2009. p 270-71

500

Name at least 3 seronegative spondyloarthrtopathies Extra 500 points for naming 4

What is 1. Psoriatic Arthritis 2. Ankylosing spondylitis 3. Reactive Arthritis (Reiter's) 4. Spondyloarthropathy associated GI conditions (Enteropathic arthritis)