general
Your patient is a 35 year old male with a primary complaint of right shoulder pain which has progressively worsened over the last several months. He is a painter and has had increased work while his partner is out. A Hawkins-Kennedy test is positive, and his pain is during a painful arc of 60-120 degrees of elevation. A drop-arm test is negative, and the infraspinatus strength is 3+. According to Neer, what stage of Impingement is your patient in?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
B.
Neer’s stages of impingement are 1. <25 years old, characterized by edema, and hemorrhage which is reversible. 2. 25-40 years old, characterized by fibrosis and tendinitis from repeated episodes of mechanical irritation. >40 years old, continued mechanical compression of the rotator cuff tendons which can result in full or partial rotator cuff tears and bone spurs. Neer did not discuss a stage 4.
Which of the following makes a clinical test best for “ruling in” a disorder
A. High sensitivity
B. High specificity
C. Low sensitivity
D. Low sensitivity
B.
Your patient was involved in a waterskiing accident and suffered axonotmesis of the posterior cord of the brachial plexus. What is true of this injury?
A. Surgery will be required for full functional return
B. There are sensory and motor deficits distal to the site of legion
C. There is no Wallerian degeneration
D. EMG shows lack of fibrillation potentials (FP) and positive sharp waves
B.
axonotmesis involves loss of the relative continuity of the axon and it’s covering of myelin, but preservation of the connective tissue framework of the nerve. There are motor and sensory deficits distal to the site of the lesion. Wallerian degeneration is present, and the patient can fully recover without surgery. However, if scar tissue forms surgery may be required.
What type of exercise program appears to optimize outcomes in patients with patellofemoral pain in the long term?
A. Weight-bearing quad strengthening
B. Open-chain quad strengthening
C. Posterolateral hip strengthening
D. Both hip and knee targeted exercise
D.
While more research is required to determine specifics of open vs. closed chain exercises, according to the Patellofemoral pain CPG in JOSPT, the combination of hip and knee targeted exercises is preferred over solely knee-targeted exercises to optimize in patients with PFP
Virginia is a 65 year old female who has been attending physical therapy for several months for right knee pain. Her symptoms came on gradually about 6 months ago, and despite treatment seem to be worsening and she is noting new symptoms over the last six weeks. She notes stiffness and pain upon awakening that lasts for about two hours before she starts to warm up enough to ambulate without pain. Her medical history is positive for history of smoking (1 pack per week for 30 years prior to quitting about 15 years ago) and obesity (BMI of 32). Her new symptoms include pain in both of her wrists which also feel stiff. She has also noted some generalized pain throughout her hands which, like her knees, seem to be worst first thing in the morning and primarily affect her MCP joints. Which of the following underlying pathologies is most likely to be present based on her presentation?
A. Osteoarthritis
B. Psoriatic arthritis
C. CPPD
D. Rheumatoid arthritis
D.
Rheumatoid arthritis is a polyarthritis (affecting more than 5 joints simultaneously) and commonly affects the MCP joints, though it can affect any joint. Rheumatoid arthritis can show up at any age, and most people develop this between the ages of 30 and 50. Despite this, about a third of people develop RA in older age and the overall prevalence of the disease is is most common in people aged 65-80. A history of smoking and obesity increase the risk of developing this disorder. Stiffness that lasts for over an hour is also indicative of inflammatory arthritis which makes osteoarthritis unlikely in this case. CPPD would be less likely, though it can resemble RA. This would be more likely to affect the weight-bearing joints, and is usually self-limiting (it resolves within days or weeks) and would not be likely to persist as long as it has in Virginia's case. Psoriatic arthritis is also less likely, as it affects fewer joints than RA and there are no red scaly rashes (though this is not always present with PSA)
You are evaluating a 30 year old female with a chief complaint of shoulder and neck pain. You suspect that her symptoms are caused by cervical radiculopathy. You consult the literature for interpretation of special tests for the cervical spine with the following results:
Spurling’s test has a 30% sensitivity and 94% specificity.
Neurodynamic testing of the median nerve has 72-83% sensitivity and 11-33% specificity. Considering only the above 2 tests, which of the following is true?
A. Neurodynamic testing will lead to very few false negatives
B. Neurodynamic testing will lead to very few false positives
C. Spurling’s test will lead to very few false negatives
D. Spurling’s test will lead to very few false positives
A.
Sensitivity indicates the probability that if the patient has the condition, the test will be positive. Because Neurodynamic testing has high sensitivity, it should pick up cervical radiculopathy readily, and there should be few false negatives
Which is the following would not be a test you would choose to assess a patient with low back pain who you suspect has a movement coordination impairment?
A. Prone instability test
B. Multifidus lift test
C. Abdominal bracing maneuver
D. Hip abduction test
C.
An abdominal bracing maneuver may be useful to assess spinal stiffness, but the other tests listed provide an assessment of movement coordination as it relates to multiplanar spinal activity
What is true regarding nociceptic pain and neuropathic pain?
A. Nociceptic pain acts to warn and protect individuals from possible or actual injury, while neuropathic pain does not serve as a warning mechanism
B. Nociceptic pain arises from tissue, and neuropathic pain arises from nerves
C. Nociceptic pain is frequently associated with central socialization
D. Nociceptic pain tends to be more severe than neuropathic pain
A.
neuropathic pain is pain due to the nervous system’s inappropriate response to stimuli. The initial stimuli can involve any body tissue. Neuropathic pain is frequently associated with central sensitization and is often more severe than nociceptic pain
Your patient is a 39 year old male who developed low back pain and posterior right thigh pain 10 days ago after shoveling his driveway following a snowstorm. He has had intermittent back pain in the past but never this long-lasting. He works as a lawyer and is having difficulty sitting through long court sessions. Working at his standing desk is not an issue. Physical examination shows hypertonicity of the lumbar paraspinals, poor reversal of the lumbar spine with forward bend, a hypomobile L4.5 segment, and hip IR of 0-42 on the right and 0-34 on the left. What would be your initial course of treatment?
A. Core stabilization exercises
B. Extension based exercise program
C. Lumbar manipulation
D. Flexion based exercise program
C.
The patient meets the criteria for the lumbar manipulation CPR which would be the most appropriate place to begin. He does demonstrate a directional preference for rotation, so an extension based exercise program may be subsequently coordinated into his care
A physical therapist is examining a patient with a suspected upper extremity nerve lesion due to weakness of the adductor pollicis. She asks the patient to hold an index card using a key pinch, but when she pulls the card away from the patient the IP joint flexes. Which nerve is likely damaged in this case?
A. Ulnar nerve
B. Anterior interosseous nerve
C. Posterior interosseous nerve
D. Median nerve
A.
a weak AP (with FPB) and positive Froment sign indicates an ulnar nerve pathology.
In terms of education for patients with low back pain, which of the following is true?
A. Patients should be encouraged to avoid movements that cause pain
B. A detailed anatomical explanation of pain generators helps the patient understand why they are having pain
C. Patients should be encouraged to focus more on improvement to their activity levels as opposed to just pain levels
D. Patients should be encouraged to utilize bed rest to protect their spine
C.
In the “low back pain CPG in JOSPT” in regards to patient education: patient education and counseling strategies for patients with low back pain should emphasize 1. The promotion of the understanding of anatomical strength inherent to the human spine 2. The neuroscience that explains pain perception 3. The overall favorable prognosis of lower back pain 4. The use of pain coping strategies that decrease fear and catastrophizing 5. The importance of improvement in activity level
Which of the following classification systems is most recommended for acute low back pain, according to the most recent CPG for low back pain published in JOSPT?
A. Mechanical diagnosis and therapy (MDT)
B. Cognitive functional therapy
C. Treatment based classification systems
D. Movement impairment syndromes
C.
pathoanatomical, MDT, and prognostic risk stratification have the highest recommendations for chronic low back pain (grade B evidence for each). For acute low back pain, however, the treatment based classification system is most recommended with grade B evidence. MDT has grade C evidence for acute low back pain. Cognitive functional therapy has grade C evidence for chronic low back pain.
Owen is a 64 year old who is 3 weeks post-op for a left sided total hip arthroplasty who presents to an outpatient orthopedic follow-up visit with reports of dizziness. This seems to be worst when changing body positions (such as sitting up in bed) or when walking. His medical history is significant for morbid obesity (BMI of 44), type 2 DM, and previously diagnosed chronic high blood pressure which is managed with Zestril. He is also currently taking a short acting opioid for pain related to his THA. Upon examination, he does not have pain in his LE over his deep venous system. He has pitting edema and mild swelling involving his left leg. His vital signs include a lower than usual blood pressure (110/60 at rest), slightly elevated HR (108 BPM with regular rhythm), and SPO2 of 92% on room air. What is the appropriate course of action for Owen?
A. Urgently refer Owen to the emergency room, call ahead and warn that you are suspicious of a CVA and request he can be worked up to rule this out
B. Urgently refer Owen to the emergency room, call ahead and warn that you are suspicious of a PE and request he can be worked up to rule this out
C. Continue to examine Owen for suspected orthostatic hypotension likely related to being overly medicated with Zestril and his opioids. After this exam, refer to his primary care provider for further examination.
D. Continue to examine Owen for suspected BPPV with the Dix-Hallpike maneuver. If this confirms the suspected diagnosis, initiate treatment in PT.
B.
he meets three of Wells' criteria for pulmonary embolism (heart rate >100, signs of DVT with the pitting edema in one leg, and previous surgery within 4 weeks). A pulmonary embolism is also arguably at least as likely as other possible diagnoses. This places him at a high risk of PE and he should proceed with a possible CT angiogram to rule this out before continuing with physical therapy. He would still score as at least having moderate risk even if PE was not considered the primary diagnosis. People with PE's do not necessarily always have signs and symptoms consistent with DVT at all. Morbid obesity also makes it more difficult to examine for DVT, but also moderately increases the risk of DVT/PE in general. It is not uncommon for pulmonary emboli to not cause significant SPO2 changes until later stages of the illness, and a gradually increasing heart rate with a decreasing blood pressure should increase the index of suspicion for PE. Pulmonary emboli also frequently cause dizziness rather than true shortness of breath. Orthostatic hypotension is also possible, but ruling out the worst possible diagnosis is more appropriate initially for this patient.
It is recommended to have a strong familiarity with the Wells' criteria for PE and for DVT prior to exam day.
What is the most common surgery used to treat cauda equina syndrome?
A. Lumbar microdiscectomy
B. Lumbar laminectomy
C. Lumbar fusion
D. None of the above
B.
Cauda equina syndrome is most frequently treated with me a lumbar laminectomy. In some cases, a microdiscectomy can be used but less frequently
Max presents to physical therapy with a grade 2 ankle sprain which occurred two days ago. There is swelling present and he reports moderate pain. Which of the following interventions should NOT be used after an acute lateral ankle sprain in Max's case?
A. Diathermy
B. Cryotherapy
C. Pulsed ultrasound
D. Low level laser therapy
C.
as the most recent CPG for lateral ankle sprains recommends AGAINST the use of pulsed ultrasound with grade A evidence. The other listed interventions have grade C evidence suggesting they may be used for acute lateral ankle sprains.