FMH

Question 1

The student is able to describe the structure of a physiotherapeutic methodical approach

Answer 1

• Initial hypothesis
• Screening
• Anamnesis
• Adjusted hypothesis
• Physical examination
• Definitive hypothesis
• Physiotherapeutic diagnosis
• Treatment
• Eveluation

Question 2

The student is able to name the difference between screening and diagnosing

Answer 2

Screening is to exclude and only to recognize risk factors. When diagnosing you connect risk factors to the signs, symptoms and pathology.

Question 3

The student knows the concept of an ‘initial hypothesis’ , name the fundamental movement skills and PIPs/NPIPs.

Answer 3

Initial hypothesis: body region + fundamental movement skill, psychosocial, high prevalence pathology for that region.

Adjusted hypothesis: body region + fundamental movement skill + ADL activity. Adjusted hypothesis are tested in physical examination.

Fundamental movement skills:

1. Stability
2. Mobility (artrogenic/myogenic)
3. Strength
4. Endurance
5. Neurogenic

PIP= patient identified problem, what the patient tells you

NPIP= non-patient identified problem, what someone else tells you about patient. GP referral, opinion fysio, medical records.

Question 4

The student is able to describe the model by Cott.

Answer 4

Preferred movement capacity
Current movement capacity
Maximal achievable movement potential

Question 5

The student knows the contents of a physiotherapeutic diagnosis.

Answer 5

• Age
• Reason for contact (PIP/NPIP), request for help
• Health problems ICF
• Course
• Underlying medical factors
• External factors
• Personal factors
• Prognosis

Question 6

The student is able to identify the screening process and the different scenarios. The student is able to interpret the different alarm signals.

Answer 6

Different scenarios/patterns:

1. Recognizable pattern
2. Unfamiliar pattern
3. Familiar pattern but with one or more divergent symptoms
4. Familiar pattern but with divergent course
5. Presence of one or more red flags.

General red flags:

• recent, unexplained weight loss (>5kg/month)
• longterm use of corticosteroids
• constant pain, that doesn’t diminished in rest or changing position
• cancer in history
• general feeling of malaise
• night pain, that doesn’t diminished when changing position.

Question 7

The student is able to name the yellow flags for non-specific low back pain

Answer 7

Psychosocial flags:

• psychological and psychosocial stress
• pain related fears / avoidance behavior
• somatization
• depressive complaints

Question 8

The student knows the clinical prediction rules for the lumbar stabilisation.

Answer 8

Set of criteria that a patient should meet in order to be placed in a specific training group.
Hicks et al contains two groups : Success and improved.

Clinical prediction rule for inclusion success group:

• Age less than 40 years old
• SLR greater than 91 degrees
• Aberrant motion present ; instability catch, painfull arc, Gowers sign, reversal lumbo-pelvic motion
• Positive prone instability test

Clinical prediction rule for inclusion improved group:

• FABQ physical activity scale greater than 9 points
• Aberrant movements absent
• No lumbar hypermobility with prone spring testing
• Negative prone instability test

Question 9

The student is able to name the three phases of stability training.

Answer 9

Cognitive phase:
Isolated training local muscle system.

Associative phase:
Relearning specific sub-movements using global muscle system, and controlled co-contraction of local muscle system.

Autonome phase:
Specific movements ADL

Question 10

The student is able to describe the contents of the guideline for low back pain.
COURS

Answer 10

Normal: activity level and degree of participation gradually increase over time to the level present before the episode of low back pain. In many cases pain will also diminish.

Divergent: An abnormal course with delayed recovery is defined as no clear increase in activity level and reduction in participation restrictions after 3 weeks.

Question 11

The student is able to describe the contents of the guideline for low back pain.
Sub divisions

Answer 11

Non-specific low back pain: no specific cause, 90%, most obvious symptom is pain in lumbosacral region, pain may radiate to gluteal region and upper leg, patient has no general symptoms of disease, such as fever or weight loss, the pain may be continuous of occur in episodes.

Specific low back pain is divided into:

• Lumbosacrale radicular syndrome, characterised by radicular pain in one leg, which may or may not be associated with neurological deficits;
• Back pain resulting from a possibly serious underlying specific disorder, such as (osteoporotic) vertebral fractures, malignities, ankylosing spondylitis, severe forms of verte- bral canal stenosis, or severe forms of spondylolisthesis.

Question 12

The student is able to describe the contents of the guideline for low back pain.
RED FLAGS

Answer 12

Red flags are signs or symptoms that might, individually or collectively, indicate a possible (serious) specific cause of the low back pain, which would require supplementary diagnostics.

There is consensus about the following red flags:
• Onset of the low back pain after age 50 years, continuous
pain regardless of posture or movement, nocturnal pain, general malaise, history of malignancy, unexplained weight loss, elevated erythrocyte sedimentation rate (ESR) → malignity?

• Recent fracture (< 2 years ago), previous vertebral fracture, age over 60 years, low body weight (< 60 kg/ BMI < 20 kg/m2), older person with hip fracture, prolonged use of corticosteroids, local percussion pain, tenderness and axial pressure pain in the spinal column, marked height reduction, increased thoracic kyphosis → osteoporotic vertebral fracture?
• Onset of low back pain before age 20 years, male sex, iridocyclitis, history of unexplained peripheral arthritis or inflammatory bowel disease, pain mostly nocturnal, morning stiffness > 1 hour, less pain when lying down or exercising, good response to NSAIDs, elevated ESR → ankylosing spondylitis?
• Severe low back pain after trauma → vertebral fracture?

• Onset of low back pain before age 20 years, palpable
misalignment of the processi spinosi at the L4-L5 level → severe spondylolisthesis?

Question 13

The student is able to describe the contents of the guideline for low back pain.
Points of interest anamneses

Answer 13

• Identify complaints
• Screening
• Asses status praesens: severity and nature complaints ICF.
• Identify onset complaints : Level activity/ participation before, time of onset way of developing, possible influence of occupational factors.
• Assessing course complaints: previous treatment, previous info, presence of (psychosocial) factors impeding recovery.
• Additional info: comorbid conditions, current medication/other treatment/ advice or medical aid.
• Determine patients problem

Question 14

The student is able to describe the contents of the guideline for low back pain.
Recommended measurement instruments

Answer 14

• numeric rating scale
• PSK: patient specifieke complaints
• QBPDS: Quebec back pain disability scale

Beginning and end treatment

Question 15

The student is able to describe the contents of the guideline for low back pain.
Factors that may slow down recovery

Answer 15

Back pain-related factors:

• severe limitations of activities
• radiating pain
• widespread pain

Personal factors:

• older age
• poor general health status

Psychosocial factors:

• psychological and psychosocial stress
• pain-related fears / avoidance behavior
• somatization
• depressive complaints

Occupational factors:

• unsatisfactory relationships with colleagues
• physically heavy tasks

Question 16

Signs suggesting a lumbosacral radicular syndrome

Answer 16

• radicular pain radiating to the leg, and
• leg pain that is more prominent than low back pain.
• positive crossed straight leg raise
• finger to floor (positive >25cm)
• Muscle strength

Question 17

The student is able to describe the contents of the guideline for low back pain.
Patient profiles

Answer 17

Profile 1
Non-specific low back pain with normal course of recovery.

Profile 2
Non-specific low back pain with abnormal course, without dominant presence of psychosocial factors impeding recovery.

Profile 3
Non-specific low back pain with abnormal course, with dominant presence of psychosocial factors impeding recovery.

Question 18

Treatment plan encompasses

Answer 18

• the final objectives plus the time schedule;
• the interventions to be applied;
• the schedule for evaluations and the form of evaluation;
• the expected number of treatment sessions (exceeding the expected number of sessions should prompt an evaluation and a possible change of profile).

Question 19

Management strategy for normal course low back pain (profile 1)

Answer 19

• Reassure the patient.

• Explain that low back pain is not a serious condition, often resolves spontaneously, but may recur.
• Preferably do not recommend continuous bed rest.
Recommend a maximum of 2 days of bed rest if that is the only way for the patient to sufficiently control the pain; explain that the bed rest should thereafter be gradually phased out.

• Avoid recommendations that encourage the patient to remain passive, and recommend a physically active lifestyle.
• Explain that increased activity will not damage any structures in the patient’s back.
• Explain that (moderate and gradually increasing) exercise, gradually increasing activity levels, and continuing or resuming work (if necessary with temporarily adjusted workload) promotes recovery.
• Limit the number of treatments to 3 sessions.

Question 20

Management strategy for non-specific low back pain with abnormal course, without dominant presence of psychosocial factors impeding recovery (profile 2)

Answer 20

• Avoid recommendations that encourage the patient to
remain passive, and recommend a physically active lifestyle.

• Explain that an increase in pain is not associated with
damage to structures in the patient’s back.

• Encourage the patient to engage in (moderate and gradually increasing) exercise, gradually increase their activity levels, and continue or resume work (if necessary with temporarily adjusted workload).
• Design an exercise program that fits in with the patient’s needs and your own expertise and experience as a therapist.
• In case of impaired joint functionality, consider:
• joint mobilization or manipulation and/or
• massage or thermal therapy (limited duration) to reduce the pain.

• If the patient has been on sick leave for more than 4 weeks, ask them about any arrangements that have been made with the company doctor, and if necessary discuss the management strategy with the company doctor or company physical therapist.

If the treatment has had no effect after 3 weeks (in the sense of increased activity and participation levels), the therapist should contact the patient’s family doctor.

Question 21

Management strategy for non-specific low back pain with abnormal course, with dominant presence of psychosocial factors impeding recovery (profile 3)

Answer 21

• Advise the patient to keep exercising and explain to them that movements are not harmful and even speed up the recovery process.
• Emphasize that the patient’s psychosocial factors (depressive feelings, fear of movement, catastrophizing, etc) may have an adverse influence on their recovery.

• Recommend contacting the family doctor, company
doctor and/or psychologist if serious or persistent psychosocial factors are hampering the recovery, and discuss the management options.

• Discuss the management options with the patient’s company doctor, company physical therapist or the occupational health and safety service if the recovery process is being impeded by heavy physical work, prolonged sick leave or a labor dispute, or if collaboration is expected to promote the recovery.
• Encourage the patient to engage in (moderate and gradually increasing) exercise, gradually increase their activity levels, and continue or resume work (if necessary with temporarily adjusted workload).
• Prescribe a graded activities program.
• If the patient is on sick leave, try to match the targets of the exercise program to the targets for work resumption.
• Contact the patient’s family doctor if the treatment has had no effect (in the sense of increased activity and participation levels) after 3-6 weeks, and terminate the treatment.

Question 22

The student is able to describe the triage for the lower back and name the determining characteristics, signs, symptoms and tests for the different decisions to be taken in the triage.

Answer 22

Non specific low back pain 90%
Specific non serious → radiculopathie 8%
Specific serious 2%

Non specific: mobility vs stability
Mobility examination → insp/palp, ADL, active/passive
Mobility treatment → mobilizing, functional movement therapy

Stability examination → insp/palp, ADL, active, MCI
Stability treatment → MCI, functional movement therapy

Radiculopathy examination → crossed straight leg raise, prone knee bend test, slump, braggard, Neri.
sensitivity (dermatome) strength (myotome)
Radiculopathy treatment → McKenzie, activity participation.

Specific serious
Cauda equina
Bechterew
Fractuur
Spondylolisthesis

Symptoms non specific:

• Pain low back
• Sometimes radiation glutes, upper leg
• Sometimes worsened by some movements
• Morning stiffness

Symptoms radiculopathy:
Unilateral leg pain > back pain
• Pain generally radiates to foot/toes
• Not only discogenic in origin
• Paresthesia, sensory disturbance
• Neuromeningeal stimulation
o Test taken straight leg, slump.
• Motor, sensory or reflex function decrease
o Matching one segment

Question 23

The student is able to globally distinguish between different surgery techniques and corresponding rehabilitation treatment protocols of hip implants.

Answer 23

Forms of hip surgery:
Removal osteophytes → in case of impingement
Resurfacing → metal head and socket
Minimally invasive surgery → non cemented, bone saving (less deep that standard)
Standard uncemented THR
Standard cemented THR → elderly or revision. revision after this is harder
Revision THR

Approaches:

• Anterior → Limited damage, quick recovery
• Anterolateral → no exorotation first six weeks
• Posterolateral → no adduction and endorotation, >90° flexion first six weeks.
• Direct lateral → no exorotation first six weeks.

Physiotherapy preoperative:
• Strengthen muscle strength
• Walking with crutches (practice beforehand)
• Improve fitness
• Don’t mobilize because it yields little profit and it makes little sense because after the operation, the freedom of movement is much greater.

Physiotherapy post operative:
• Mobilise
• Strength training
• Endurance training
• Stability training

Question 24

The student is able to explain the terms tendinitis, tendinosis and tendinopathy.

Answer 24

• Tendinitis: inflammation of the tendon, generally the tendon is painful and swollen. Because the inflammatory factor is generally absent, this term is no longer used much, but the term tendinopathy is usually chosen in the event of long-term pain and tissue changes.
• Tendinosis: the quality of the tendon decreases. In general, a pt has long-lasting pain in tendinosis due to tissue change. That is why it was decided to use tendinopathy instead of tendinosis
• Tendinopathy: ‘diseased tendon’ this term is mainly used for long-term pain and tissue change

Question 25

The student is able to name the prognostic factors from the KNGF Guideline Meniscectomy.

Answer 25

Positive:
• participation sport (pre operative)
• good preparation before return to play (post)

Negative:
• complicated injury
• location resection
• amount of tissue removed
• financial compensation employer 
• previous knee operations
• pre operative pain

Question 26

Based on the KNGF Guideline Meniscectomy, the student is able to recognise the current treatment phase of a patient based on their timeline.
PHASE 1A

Answer 26

Acute 0-5 days postoperative

Signs and symptoms
• The knee is painful and swollen.
• There is a reduced range of motion.
• The patient cannot/does not yet fully rely on the
operated leg.

Treatment goals:

→ Functions/anatomical characteristics
• reduction of the consequences of surgery (swelling, inflammatory process)
• pain reduction
• balancing load and laudability of the knee
• prevention movement anxiety

→ Activities
• improvement limitations in adl activities (eg climbing stairs)
• learn to move in a controlled manner (possibly with crutches)

Actions:

→ Functions/anatomical characteristics
- Inform: nature and severity of the lesion
- Advise: level of laudability and load; cryo therapy, at most to relieve pain
- Exercise: functions of the
knee joint within the limits of loadability; active movement of the knee, coordination, standing balance

→ Activities

• Inform: walking guided by pain and swelling (possibly with crutches); dynamic movement
• Advise: dosed movement
• Exercise: ADL activities (possibly with crutches)

→ Participation
- Advice: sports (and some activities) could be too demanding

→ Personal, external, medical, other factors

• Inform: expected duration of recovery (and prognosis), reduce usage off the medication
• Advice: Take rest, movement improves rehabilitation, how to use crutches
• Coach: give crutches/devices

Question 27

Based on the KNGF Guideline Meniscectomy, the student is able to recognise the current treatment phase of a patient based on their timeline.
PHASE 1B

Answer 27

Subacute 5-10 days

Signs and symptoms:
• swelling and pain have decreased;
• active knee movement is possible;
• load capacity increases;
• quality of moving with crutches increases (50-100% load).

Treatment goals:

→ Functions/anatomical characteristics
• normalization of knee joint mobility, muscle length
• increase/normalization active stability knee, strength, coordination, endurance leg muscles
• reduction of movement anxiety
• going dynamic

→ Activities
• reduce walking with crutches
• improvement simpleadl activities
• walking and climbing stairs
• good quality of exercise
• transfers: sitting/standing

Actions:

→ Functions/anatomical characteristics

• Inform/advising: Load and load-ability
• Exercise: functions, building up in load; active muscular stability of the knee (strength, coordination, balance, proprioception)

→ Activities
- Exercise: adl activities building up in load (without crutches); quality of movement; activities related to fear of movement

→ Personal, external, medical, other factors

• Inform/advise: importance of exercising at home; tapering off medication; fear of moving/loading
• Coach: homework exercises

Question 28

Based on the KNGF Guideline Meniscectomy, the student is able to recognise the current treatment phase of a patient based on their timeline.
PHASE 2

Answer 28

To be able to start phase two, the patient needs to have a dynamic gait without using crutches

Treatment goals:

→ Functions/anatomical characteristics
• decrease in disorders that cause reduced quality of movement or limitation in activities
• recovery motion automation
• enforcement improvement gait pattern

→ Activities
• improvement complexreadl activities
• walking and turning, walking with a load
• rowing, cycling
• complex, multiple transfers
• improvement sports and work related activities

→ Participation
• promoting participation in work, hobbies, sports, recreation

Actions:

→ Functions/anatomical characteristics
- Exercise: functions related to problem

→ Activities
- Exercise: problem area activities; walking, kneeling, squatting, jumping; complex activities sports, hobby, and work-related activities

→ Participation
- Coach: return to play, hobby, work

→ Personal, external, medical, other factors

• Inform/advice: achievability end goals; importance daily exercising
• Coach: importance of homework exercises