Industrial Rehab

Question 1

What are the characteristics of cervical facet (zygapophyseal) joint mediated pain?

Answer 1

Localizing neck pain to the facet joints can be difficult because facet joint pain referral patterns can overlap diskogenic or myofascial pain patterns. Facet joint (zygapophyseal) pain is frequent in individuals with chronic cervical pain following whiplash injuries. Facet joint pain may be difficult to reproduce with palpation and is more common with cervical extension rather than cervical flexion. The referral pattern is typically to the neck and shoulders.

Question 2

Which of the following is a risk factor for plantar fasciitis?

Answer 2

Obesity is a risk factor for plantar fasciitis. Plantar fasciitis affects both men and women equally. It also most commonly occurs in people between the ages of 40 and 70 years. Factors that increase the tension on the plantar fascia, such as decreased subtalar
motion, pes cavus, pes planus, and a tight Achilles’ tendon, may contribute to plantar
fasciitis.

Question 3

Tramadol (Ultram) should be used with caution with which of the following medications?

Answer 3

Tramadol has rarely been associated with serotonin syndrome and seizures. There is increased risk of these side effects when Tramadol is taken with MAO inhibitors, selective serotonin reuptake inhibitors, tricyclic antidepressants and triptans used to treat migraine headaches.

Question 4

Which first line treatment for plantar heel pain is most effective?

Answer 4

Nineteen randomized trials of treatment of plantar heel pain were reviewed. Trial quality was noted to be generally poor. There was no evidence to support effectiveness of therapeutic ultrasound. There were no randomized trials evaluating surgery. There was limited evidence for the superiority of corticosteroid injections over orthotic devices. There are few studies demonstrating the effectiveness of ESWT, with systematic reviews demonstrating poor quality and no conclusive evidence in reducing night pain, resting pain, and pressure pain in the short term. In most patients with PF, conservative treatment usually is sufficient. Initially, a period of rest accompanied by anti-inflammatory agents (ice pack/heat, NSAID’s), stretching, and an orthosis is recommended. There is no difference in which types of orthosis is used, although plantar stretching seems to be more effective. If the patient remains symptomatic, corticosteroid injection and night splint (especially in patients with symptoms greater than 6 months in duration) may be reasonable. ESWT should be considered prior to any surgical intervention in patients with refractory PF.

Question 5

Which intervention for carpal tunnel syndrome has been shown to improve symptoms?

Answer 5

Both nocturnal and full-time splinting have been found to alleviate symptoms in carpal tunnel syndrome. According to the Cochrane Report current evidence shows significant short-term benefit from oral steroids, splinting, ultrasound, yoga and carpal bone mobilization. Use of nonsteroidal anti-inflammatory drugs, ergonomic keyboards, and short-term ultrasound have not been found helpful in controlled trials.

Question 6

Which cervical injection technique has been associated with acute catastrophic neurologic injury?

Answer 6

Recent reports of acute catastrophic neurologic injury have been associated with the transforaminal approach for epidural injection of particulate corticosteroids. These injuries were hypothesized to be secondary to intra-arterial injection of particulate solutions and subsequent infarction of the central nervous system. The vessels most likely involved are the vertebral artery and radicular arteries of the spinal cord. Techniques used to help avoid such events include the use of fluoroscopic guidance during injection of contrast to assess for vascular flow. Digital subtraction analysis may also be used to assess for vascular flow during injection. Intralaminar epidural steroid injection is also associated with complications and neurologic injury due to epidural hematoma, abscess, or direct puncture of the spinal cord; however, these injuries are usually subacute and rarely result in death if properly treated. The possibility of neurologic injury exists with cervical facet injections, but such injury is easily avoided with good technique, and there are no published reports of such injury. Paraspinal trigger point injections, if properly performed, are not likely to be associated with neurologic injury.

Question 7

Sacroiliac pain and dysfunction can most reliably be diagnosed by

Answer 7

Intra-articular injection of local anesthetic, with subsequent pain relief, is the only reliable means of diagnosing primary sacroiliac joint (SIJ) pain. Physical examination findings, imaging studies, and nuclear medicine studies may suggest SIJ abnormalities but do not establish the SIJ as a cause of pain. Referral patterns of SIJ pain overlap with other sources of lumbar and lower-limb pain, and differentiation is important to determine effective treatment.

Question 8

The most effective nonsurgical treatment for de Quervain’s tenosynovitis is

Answer 8

Local corticosteroid injection is proven effective as a treatment for de Quervain’s tenosynovitis, both with and without splinting. Injection alone produced an 83% cure rate, with injection plus splinting producing a 61% cure rate. Splinting alone produced a 14% cure rate, and rest and anti-inflammatories were of no benefit.

Question 9

The clinical practice of avoiding local corticosteroid injection into the Achilles’ tendon because of the risk of tendon rupture is based upon:

Answer 9

Case reports and case series - Review of the medical literature does not show a clear association between local corticosteroid injection and Achilles’ tendon rupture. Animal studies indicate decreased tendon strength associated with intratendinous injection of corticosteroid, with presumed increase in tendon rupture. Clinical studies of peritendinous injections did not show an increase in rupture rate. Some clinicians advocate for injection under fluoroscopic or ultrasound guidance to avoid intratendinous injection. Evidence is inadequate to support the use of local corticosteroid injections as a treatment for Achilles’ tendonitis.

Question 10

What does the term maximum medical improvement (MMI) mean?

Answer 10

No further tx is reasonably expected to improve the condition - Maximum medical improvement (MMI) is a term used to indicate that further significant recovery or deterioration of a condition is not anticipated to occur. The patient’s condition may remain clinically symptomatic, as resolution of the condition may or may not occur. Ongoing treatment (eg, maintenance treatment) may be required following MMI.

Question 11

A factory assembly line worker presents to your office with lateral elbow pain for 3 months. What condition is commonly associated with lateral epicondylitis?

Answer 11

Lateral epicondylitis, or proximal wrist extensor tendinopathy, is associated with smoking and obesity. It occurs equally among males and females. It is not associated with hypercholesterolemia.

Question 12

Which treatment is shown to improve the symptoms of carpal tunnel syndrome for up to 1 year?

Answer 12

Using a wrist/hand splint can improve the symptoms of carpal tunnel syndrome for up to 1 year. Therapeutic ultrasound and oral corticosteroids have been shown to provide only short-term relief. Tendon glide maneuvers have not been shown to affect the outcome of carpal tunnel syndrome.

Question 13

Repeatedly lifting the shoulder past which degree of flexion or abduction is associated with an increased prevalence of shoulder disorders?

Answer 13

Repeatedly lifting the shoulder past 60 degrees of flexion or abduction is associated with an increased prevalence of shoulder disorders.

Question 14

A 65-year-old file clerk presents with low back pain that occurred 6 months ago after he bent over to pick up a file at work. He saw his primary care physician, who ordered magnetic resonance imaging (MRI) of his lumbar spine and told him he had a bulging disc. He was subsequently referred to you because he is still symptomatic. The patient feels his bulging disc was caused by bending over to pick up the file at work. You tell him that his bulging disc:

Answer 14

Was likely present before the onset of h is low back pain - Bulging discs are seen commonly in 65-year-old individuals. In a study of asymptomatic individuals, 79% of those age 60 or older had bulging discs. Other studies have confirmed the finding that bulging discs occur more commonly in older individuals.

Question 15

A 38-year-old sheet metal worker with low back pain has difficulty sleeping so you prescribe medications, including cyclobenzaprine (Flexeril). You tell him that common side effects of cyclobenzaprine include sedation, lethargy and dry mouth. While the exact mechanism of action is unknown, cyclobenzaprine’s structure and side effect profile are similar to what class of drug?

Answer 15

Cyclobenzaprine (Flexeril) is structurally similar to tricyclic antidepressants and was first studied as an antidepressant. While its exact mechanism of action is unknown, it is presumed to work at the level of the brainstem or higher with a generalized sedative effect. Tizanidine (Zanaflex) is a central alpha2-adrenergic agonist. Orphenadrine (Norflex) is an antihistamine. Benzodiazepines, such as diazepam (Valium) and baclofen are g-aminobutyric acid agonists.

Question 16

Disability as defined by the Americans with Disabilities Act (ADA) is

Answer 16

The Americans with Disabilities Act defines disability as a physical or mental impairment that substantially limits 1 or more of a person’s major life activities. The person has a record of such impairment, or is regarded as having such impairment. Impairment is the actual physiologic, anatomic, or psychologic abnormality. Handicap refers to the barriers society places on an individual to perform function in the community. A permanent disability rating is used to determine financial compensation for an injury.

Question 17

An injured worker has a hip fracture after tripping over a cable at work. Work-up also demonstrates osteoporosis, which was unknown to the patient prior to the fall. The employer states the fall was not that traumatic and cites the osteoporosis as the primary problem. Your response to the employer:

Answer 17

Physicians may be asked to provide an opinion regarding causation and apportionment. Determination of causation requires investigation of an identifiable factor that results in a medically identifiable condition, and requires a synthesis of medical judgment with scientific analysis. While osteoporosis was present at the time of the fall, the fall itself was causative of the fracture (eg, the fracture would not have occurred if the patient had not tripped over the cable)

Question 18

A 54-year-old male with a prior history of a right L5 lumbar radiculopathy from a work injury status-post lumbar fusion presents with recurrent radicular symptoms in the same distribution. Which of the following is correct regarding apportionment of his condition?

Answer 18

When apportioning a condition, the provider must show that a prior condition or injury has contributed to the current impairment. Apportionment also requires documentation of a prior condition or injury. Employment status is not a factor in determining apportionment. Calculation of apportionment may vary from state to state.

Question 19

The Americans with Disabilities Act protects individuals from employment discrimination if they have physical or mental impairments that:

Answer 19

substantially limits a major life activity - Employment discrimination is prohibited against qualified individuals with disabilities. An individual is considered to have a disability if she or he has a physical or mental impairment that substantially limits one or more major life activities such as seeing, hearing, speaking, walking, breathing, performing manual tasks, learning, caring for oneself, and working. A qualified individual with a disability is a person who meets legitimate skill, experience, education, or other requirements of an employment position that she or he holds or seeks, and who can perform the essential functions of the position with or without reasonable accommodation. Reasonable accommodation is any modification or adjustment to a job or the work environment that will enable a qualified applicant or employee with a disability to participate in the application process or to perform essential job functions. Employers are not required to lower quality or quantity standards as an accommodation; nor are they obligated to provide personal use items such as glasses or hearing aids.

Question 20

Persistent physical, cognitive, and psychological symptoms after work-related mild TBI

Answer 20

In work-related and civil litigation in patients with mild TBI there is increased recognition of the influence of financial incentives. Estimates of persistent symptoms and disability after mild TBI vary between 5% and 10%, with conflicting reports in the medical literature regarding the etiology of ongoing symptoms. A growing consensus suggests that previous estimates of non-recovery in the 15%-20% range were likely inflated. There are numerous reports in the medical literature that note the non-specificity of cognitive, emotional, and physical symptoms that are commonly reported after mild TBI.
These symptoms are not unique to mild TBI and are seen in the normal population and have been found to occur at similar rates in both patients who report mild TBI and patients who report bodily injuries without mild TBI.

Question 21

Which of the following factors increases the chance of employment in an individual with a SCI?

Answer 21

Odds of being employed after SCI were greater for younger survivors, those who were not competitively employed before injury, those with higher levels of education before injury, those who were not married before injury, and those more remote in time after injury.

Question 22

The most common etiology of back pain in an injured worker is

Answer 22

Many conditions in the low back may cause back pain, including muscular or ligamentous injury, facet joint arthritis, disc damage, or vertebral endplate degeneration. Mechanical back pain is most common. However, in most patients, the anatomic cause of LBP cannot be determined with any degree of clinical certainty.

Mechanical low back pain refers to back pain that arises intrinsically from the spine, intervertebral disks, or surrounding soft tissues. This includes lumbosacral muscle strain, disk herniation, lumbar spondylosis, spondylolisthesis, spondylolysis, vertebral compression fractures, and acute or chronic traumatic injury.1 Repetitive trauma and overuse are common causes of chronic mechanical low back pain, which is often secondary to workplace injury. Most patients who experience activity-limiting low back pain go on to have recurrent episodes. Chronic low back pain affects up to 23% of the population worldwide, with an estimated 24% to 80% of patients having a recurrence at one year.

Question 23

The mechanism of whiplash injury creates which type of deformity in the cervical spine?

Answer 23

Whiplash injury was once thought of as occurring from simple hyperextension or hyperflexion of the cervical spine in the sagittal plane. But in fact, it is an S-shaped deformation in the sagittal plane of the cervical spine that results in whiplash injury. After impact there is abnormal lower cervical spine extension coupled with upper cervical spine flexion and axial compression.

Question 24

When faced with a patient presenting with vague hip and low back pain which of the following may prove most useful in identifying the pain generator?

Answer 24

Intraarticular HIP local anesthetic block - Minimally invasive diagnostic procedures including epidural nerve root or hip joint injections has proven to be invaluable in assessing the involvement of each area to the patient’s diagnosis. Fluoroscopically guided hip joint or nerve root injection can be safely employed affording diagnostic and therapeutic benefit.

Of note, with respect to treatment, Official Disability Guidelines recommends treating hip OA first as a likely contributor to low back complaints. “Severe OA of the hip joint may cause abnormal spinal sagittal alignment and difficulty in maintaining proper balance as well as a wobbling gait.”

Question 25

Independent Medical Examiners (IME) are independent contractors providing medical examinations within the realm of their specialties. They have obligations to:

Answer 25

IMEs are required to evaluate patients objectively and not be influenced by the preferences of the patient-employee, employer, or insurance company. They are to fully disclose that they are acting on behalf of a third party and disclose any perceived conflicts of interest. They are to administer an objective medical examination but are not required to monitor patients’ health over time. A limited
patient-physician relationship should be considered to exist and the physician has a responsibility to inform the patient of any important health information or abnormality that is discovered during the examination. The physician should ensure to the extent possible that the patient understands the problem or diagnosis, suggest that the patient seek care from a qualified physician, and if necessary provide reasonable assistance in securing follow-up care.

Question 26

In patients with rotator cuff tendinitis, sleeping with a pillow between the affected arm and the trunk decreases tension on which tendon?

Answer 26

With the arm in a slightly abducted position, there is less tension on the supraspinatus tendon and this will help prevent compromise of blood flow in the watershed area of the tendon.

Question 27

A Functional Capacity Evaluation (FCE) will help determine an injured worker’s

Answer 27

physical demand level related to job activity - A functional capacity evaluation (FCE) is a systematic measurement of a person’s ability to safely perform work activities. There are 2 general purposes of FCEs. First, they can be used to identify current limitations and levels of disability, to assist in treatment planning. Second, job-specific FCEs can be used to predict an injured worker’s safe functional abilities, so that the worker can make a successful return to employment. The results of an FCE yield a physical demand level (PDL), which is categorized into sedentary, light, medium, heavy, and very heavy, based upon criteria found in the U.S. Department of Labor’s Dictionary of Occupational Titles.

Question 28

Which of the following factors are likely to contribute to a decreased likelihood of employment and decreased stability of employment following discharge from a TBI rehabilitation program?

Answer 28

Minority Status - Obtaining and maintaining gainful employment after a TBI can be challenging. Research has shown that return-to-work outcomes after TBI can range from 29% to 88%. This rate is significant because employment is considered a primary indicator of community reintegration after injury and is substantially linked to a person’s well-being. The wide range of employment rates after TBI is influenced by a variety of factors. Some of the most common predictors include injury severity, cognitive functioning, neurobehavioral factors, and differences in patient demographics. Among the patient demo-graphic variables that affect return-to-work outcomes, minority subjects were 2-3.5 times more likely than white subjects to be unemployed or unstably employed within the first 3 years after TBI when adjusting for pre-injury employment status, age, marital status, education, cause of injury, total length of stay in acute care and rehabilitation hospitals, and DRS score (low score better than high score) at discharge.

Question 29

Seat belt use during motor vehicle collisions has reduced overall injury severity and mortality, but has not reduced incidence of spinal injuries associated with:

Answer 29

Thoracic and lumbar spine fracture patterns are influenced by the age of occupant and type and use of seat belts. Despite a reduction in overall injury severity and mortality, seat belt use is associated with an increased incidence of thoracic and lumbar spine fractures. Minor thoracic and lumbar spine fractures were associated with an increased likelihood of pelvic and abdominal injuries and higher Injury Severity Scores (ISS), demonstrating their importance in predicting overall injury severity. Extension injuries occurred in older obese individuals and were associated with a high fatality rate. Future advancements in automobile safety engineering should address the need to reduce thoracic and lumbar spine injuries in belted occupants.

Question 30

Low back pain patients who initially express concerns about their ability to maintain their current job can experience significant reduction in the risk for sick leave and significant improvement in physical function by arranging for:

Answer 30

Two short counseling sessions by an occupational physician combining advice on meeting workplace barriers and enhancing leisure-time physical activity had a substantial effect on important
prognostic factors, including pain, function, and sick leave, for low back pain patients with moderate to severe symptoms who had expressed concerns about the ability to maintain their current job.

Question 31

What is the most common musculoskeletal injury that is caused by exposure to an electrical shock?

Answer 31

The most common orthopedic injury after electrical shock is a posterior fracture-dislocation of the humeral head. Scapular fractures as a direct result of electrical shock have also been reported. Other fractures associated with electrically induced injury usually result from a fall at the time of injury. Spinal fractures caused by electric shock are very rare. The mechanism of fracture in electrical injury is postulated to be forceful muscle contraction. In shoulder dislocations, massive contraction of the infraspinatus and teres minor along with the deltoid, latissimus dorsi, and teres major force the humeral head superiorly and posteriorly against the acromion and medially against the glenoid fossa, causing the humeral head to lodge behind the glenoid rim. Similarly, forceful muscle contractions in the thoracic spine are likely the mechanism by which thoracic compression fractures occur as a result of low-voltage electrically induced injury

Question 32

According to the CDC’s National Institute for Occupational Safety and Health (NIOSH), which scenario is most likely to involve a nonfatal work-related injury?

Answer 32

Workers aged <25 years had the highest injury/illness rates. More than three fourths of all nonfatal workplace injuries/illnesses were attributed to contact with objects or equipment (e.g., being struck by a falling tool or caught in machinery), bodily reaction or exertion (e.g., a sprain or strain), and falls. No substantial reduction was observed in the overall number and rate of ED-treated occupational injuries/illnesses during 1996-2004. To reduce occupational injuries/illnesses, interventions should continue to target workers at highest risk and reduce exposure to those workplace hazards with the greatest potential for causing severe injury or death. More emphasis should be placed on prevention-
effectiveness studies and dissemination of successful interventions to reduce work-related injuries and illnesses.

Question 33

Which of the following factors predicts the severity of lower back pain events?

Answer 33

According to the study by Carragee et al, prior compensation claims was one of the factors that predicted the severity of lower back pain events. Age was not listed as a predictor. Minor disc bulges are present in a number of asymptomatic people and did not predict serious low back pain events. Minor trauma such as falling from a chair was also not a factor.

Question 34

Under the American with Disabilities Act (ADA), an individual is considered disabled if he/she:

Answer 34

The definition of disability according to the ADA is a physical or mental impairment that substantially limits a major life activity. This includes individuals who have a record of prior impairment but are not currently impaired as well as individuals who are regarded as having a disability, even if they do not actually have one. To be protected under this statute, an individual with a disability must meet legitimate skill, experience, education, or other requirements of an employment position that she or he holds or seeks, and must be able to perform the essential functions of the position with or without reasonable accommodation. Employers are not required to lower performance expectations of a job as an accommodation. A temporary (<6 months) minor condition like the flu or a cold is not considered a disability. Temporary severe conditions, like trauma to both lower limbs that prevents walking or back pain that prevents lifting of >20 lbs, are considered disabling conditions that qualify under ADA for accommodations by employers.

Question 34

According to the ADA, a reasonable accommodation by an employer occurs when:

Answer 34

The ADA considers a “reasonable accommodation” when an employer modifies the workplace or job duties to adhere to medical restrictions while the employee is still able to complete the essential job functions. The flu is considered a temporary, minor condition that is not a disability, and therefore, does not qualify for accommodation. ADA protections do not enable unqualified individuals who lack legitimate skill, experience, education, or other requirements of an employment position to receive alternate jobs within their qualifications. The last option is not an accommodation since the employee is unable to complete the essential job functions.

Question 35

Which of the following is an essential criterion for causality in determining whether an activity at work causes an injury?

Answer 35

Bradford-Hill criteria are often used to establish epidemiologic evidence for a causal relationship between a presumed cause and observed effect. These 9 criteria include:

(1) Temporal Relationship: Exposure always precedes the outcome; this is the only absolutely essential criterion.
(2) Strength: The stronger the association, the more likely it is causal, but a small association does not mean that there is not a causal effect.
(3) Dose-Response Relationship: An increasing amount of exposure increases the risk. This is strong evidence for a causal relationship, but the absence of a dose-response relationship does not rule out a causal relationship, for example, if a threshold exists above which a relationship may develop.
(4) Consistency: The association is consistent when results are replicated in studies in different settings using different methods. This strengthens the likelihood of an effect.
(5) Plausibility: The association agrees with currently accepted understanding of pathological processes. A plausible mechanism between cause and effect is helpful, but Hill noted that knowledge of the mechanism is limited by current knowledge.
(6) Consideration of Alternate Explanations: It is always necessary to consider multiple hypotheses before making conclusions about causal relationships.
(7) Experiment: The condition can be altered by an appropriate experimental regimen. The hypothesis can be tested.
(8) Specificity: This is established when a single putative cause produces a specific effect. This is the weakest of all the criteria, and absence of specificity in no way negates a causal relationship. Because outcomes are likely to have multiple factors influencing them, it is highly unlikely that a one-to-one cause-effect relationship exists.
(9) Coherence: The association should be compatible with existing theory and knowledge, but the lack of laboratory evidence cannot nullify the epidemiological effect on associations. (Hill, 1965)

Question 36

Which of the following conditions is strongly associated with use of a power stonecutting tool?

Answer 36

Vibrating power hand tools are associated with the diagnosis of hand-arm vibration syndrome (HAVS). Neck and lower back degenerative disc disease are not attributed to the operation of power hand tools. Elbow arthritis is also not associated with the use of power hand tools.

Question 37

According to the Americans with Disabilities Act (ADA), an individual with a complete T12 spinal cord lesion with a bachelor’s degree would be able to perform the essential job functions of which of the following positions without accommodation?

Answer 37

Accommodation would be needed for someone with paraplegia to work as a commercial truck driver. The individual presumably has no training as a plumber and would therefore be unable to work as plumber. An analyst is a sedentary clerical position that could be done by a person with paraplegia with readily available computer interface approaches. A warehouse clerk is a physically demanding job that would likely require some type of accommodation for a person with paraplegia (e.g., a robotic exoskeleton), if any were available.

Question 38

Which of the following statements describes maximal medical improvement (MMI), according to the American Medical Association’s Guides to the Evaluation of Permanent Impairment 5th Edition?

Answer 38

MMI is reached after all reasonable medical treatments have been offered and sufficient time has passed for any expected healing and recovery to occur. This does not, of course, imply that there has been complete resolution of the symptoms or condition, but rather that the patient has reached an effective clinical plateau beyond which significant improvement or decline is not anticipated. There is no duration of recovery provided in the definition. There is no statutory length of treatment.

Sufficient time has passed for the expected healing and recovery from treatment to occur. All reasonable medical treatment has been offered. The condition has reached clinical plateau.

Question 39

Work hardening incorporates which of the following components?

Answer 39

Work conditioning should restore the client’s physical capacity and function. Work hardening should be work simulation and not just therapeutic exercise, plus there should also be psychological support. Work hardening is an interdisciplinary, individualized, job specific program of activity with the goal of return to work. Work hardening programs use real or simulated work tasks and progressively graded conditioning exercises that are based on the individual’s measured tolerances. Work conditioning and work hardening are not intended for sequential use. They may be considered in the subacute stage when it appears that exercise therapy alone is not working and a biopsychosocial approach may be needed, but single discipline programs like work conditioning may be less likely to be effective than work hardening or interdisciplinary programs. (CARF, 2006) (Washington, 2006)

Therapeutic exercise, psychological support, and work simulation

Question 40

An individual complains of weakness with 5th finger abduction. Sensation on the dorsal aspect of the wrist is intact. Which occupation poses the highest risk for this condition?

Answer 40

The likely diagnosis is an ulnar nerve compressive neuropathy at the wrist (Guyon’s canal), which results in the loss of sensation in the ulnar nerve distribution as well as weakness in the ulnar nerve innervated muscles distal to the canal. Furthermore, sensation in the dorsal ulnar cutaneous nerve is spared. This type of injury is commonly associated with bike riding since they forcefully grip the handlebar with either radial or ulnar deviation. None of the other occupations are associated with this hand position.

Question 41

An electrodiagnostic evaluation reveals a normal EMG of the short head of the biceps femoris, an absent superficial peroneal SNAP, slowed conduction of the peroneal nerve across the fibular head, decreased CMAP of the EDB and tibialis anterior compared to the contralateral side. Which occupation would this individual most likely have?

Answer 41

The findings are consistent with a peroneal neuropathy with entrapment at the fibular head. Strawberry pickers are known to squat for a long period of time and develop peroneal neuropathies. The other positions are not associated with squatting or crossing their legs for long periods of time.

Question 42

Industries with the highest risk of upper limb disorders are characterized by:

Answer 42

Upper extremity pain disorders are typically associated with forceful repetition. Sedentary work and fine manipulation work can lead to these problems but not highest risk. Long recovery and short work cycles prevents injuries.

heavy manual handling and repetitive work.

Question 43

Which of the following is the best predictor of an individual’s ability to work?

Answer 43

Medical impairment, range of motion and strength have not been found to predict ability to work. Self-reported measures of function is the best choice since it reflects the individual’s perceived ability.

Question 44

The ADA requires that functional performance evaluations should

Answer 44

The ADA protects individuals with disabilities from discrimination. Therefore, it requires that age and gender not influence the results of testing. However, the remaining options are incorrect since impairment does not predict disability. A disabled person should not be compared to an able-bodied person for conclusions to be drawn. There is no comment on the length of performance evaluations.

Question 45

Work hardening programs are intended to

Answer 45

Work hardening should be considered if a high quality, reputable program is available. Treatment should be geared toward returning the patient to their specific job and should include a psychological component. Interdisciplinary treatment should use real or simulated job activities in a graded fashion according to patient tolerance (see Official Disability Guidelines, CARF accreditation literature). A general conditioning/strengthening program that tries to simulate job duties (without psychological component) would be a work conditioning program.

simulate specific job activities

Question 46

Which factor is a positive predictor for referral to a functional restoration program for workers compensation patients with chronic pain?

Answer 46

Official Disability Guidelines state “If a goal of treatment is to prevent or avoid controversial or optional surgery, a trial of 10 visits (80 hours) may be implemented to assess whether surgery may be avoided.” High job satisfaction, non-smoker and not having extended disability time are all listed in ODG as positive predictors of success. Negative predictors of program success include: “(1) a negative relationship with the employer/supervisor; (2) poor work adjustment and satisfaction; (3) a negative outlook about future employment; (4) high levels of psychosocial distress (higher pretreatment levels of depression, pain and disability); (5) involvement in financial disability disputes; (6) greater rates of smoking; (7) increased duration of pre-referral disability time; (8) higher prevalence of opioid use; and (9) elevated pre-treatment levels of pain. “ Option (a) is incorrect because pain management programs are not appropriate for patients who have successfully returned to work. Options (c) & (d) are incorrect because both have multiple “negative predictors” of success.

Question 47

For a patient with ongoing epicondylitis (elbow) due to repetitive work activities, which of the following modality treatments would be most appropriate to include with physical therapy orders?

Answer 47

There is weak but supportive evidence for including ultrasound treatments adjunctively with physiotherapy for medial and lateral epicondylitis. The other listed modality treatments have insufficient evidence to support their use (Official Disability Guidelines). Of note, low level (cold) laser therapy, when administered very specifically is also recommended per ODG “as an option for lateral epicondylitis using a narrowly defined LLLT regimen where lasers of 904 nm wavelength with low output (5–50 mW) are used to irradiate the tendon insertion at the lateral elbow using 2–6 points or an area of 5 cm2 and doses of 0.25–1.2 Joules per point/area.” Other frequencies and dosing regimens have not shown benefit.

Question 48

A 44-year-old, right-handed female presents for electrodiagnostic testing at the request of her primary care physician for chronic carpal tunnel symptoms of her dominant hand. Her symptoms have been moderate to severe for at least six months and NCS testing today reveals moderate to severe carpal tunnel findings without denervation on EMG testing. According to multiple guidelines on carpal tunnel syndrome, what is the most appropriate next treatment recommendation?

Answer 48

Multiple standard of care guidelines recommend surgical intervention for moderate to severe carpal tunnel syndrome that has persisted beyond 6 months, with or without prior non-surgical treatments. Option (b) is incorrect because hand therapy, including “nerve glide” exercises have not consistently demonstrated benefit. Option (c) is incorrect because corticosteroid injections offer only good short-term relief. Wrist splinting has only demonstrated utility for CTS that is less than 6 months in duration and is typically more successful for mild or moderate cases. Option (d) is incorrect since there are no identified psychosocial concerns.

Question 49

A 54-year-old, right-handed female presents for electrodiagnostic testing at the request of her primary care physician for mild and intermittent, nocturnal carpal tunnel symptoms of her dominant hand for 3 weeks. NCS testing today reveals mild carpal tunnel findings, including no denervation on EMG testing. Cervical radiculopathy has already been excluded. What is the most appropriate next treatment recommendation?

Answer 49

Multiple standard of care guidelines recommend education and splinting as first line treatment for mild carpal tunnel symptoms that have been present for less than one month. For symptoms that persist or worsen beyond one-month, other interventions including steroid injection and hand therapy could then be considered. Carpal tunnel release surgery should not be considered for mild carpal tunnel syndrome unless symptoms persist or worsen beyond 6 months.

Question 50

Which combination of physical exam maneuvers and patient complaints are the most sensitive and specific for diagnosing carpal tunnel syndrome?

Answer 50

According to Official Disability Guidelines, several traditional findings of carpal tunnel syndrome have limited specific diagnostic value. There is a broad range of sensitivity in the various tests for carpal tunnel syndrome, depending on the patient population. Clinicians should depend on more than one test.” The most sensitive screening combination (96% sensitive/99% specific) seems to be 1) an abnormal Katz hand diagram, 2) abnormal sensibility by Semmes-Weinstein testing, 3) a positive Compression test (such as the Durkan’s test), and 4) night pain.” Other tests, including Tinel’s, Phalen’s, “closed wrist sign”, thumb abductor weakness all have relatively low sensitivity but can have high specificity when present. Of note, “flick sign” (where shaking the affected hand improves symptoms) has been shown to have high sensitivity and specificity on its own. Finkelstein’s is a diagnostic test for DeQuervain’s tenosynovitis.

Question 51

Which of the following is a significant risk factor for developing carpal tunnel syndrome?

Answer 51

According to Official Disability Guidelines Carpal tunnel syndrome seems to be primarily attributable to CTS-prone personal characteristics (e.g., obesity, diabetes, female, rheumatoid arthritis), but symptoms may be associated with workplace activities. (Melhorn, 2008) (Lozano-Calderon, 2008) Some controversy continues about whether computer work is a risk factor for CTS, with current opinion that the keyboard is low risk and that the mouse may be mild risk. There is some evidence to conclude that CTS symptoms are associated with workplace activities, but current studies have not proven a causal relationship.

Occupations keyboard use?

Question 52

Which of the following treatments has demonstrated the most consistent efficacy in carpal tunnel syndrome?

Answer 52

Official Disability Guidelines recommends “at-home local applications of cold packs first few days of acute complaints; thereafter, applications of heat therapy.(Michlovitz, 2002) (Michlovitz, 2004)”. Option (a) is incorrect because per ODG, “Rarely used and recent systematic reviews do not recommend acupuncture when compared to placebo or control (O’Connor-Cochrane, 2003). The existing evidence is not convincing enough to suggest that acupuncture is an effective therapy for CTS. (Sim, 2011)” Options (b & c) are incorrect per ODG, “Manipulation has not been proven effective in high quality studies for patients with carpal tunnel syndrome, but smaller studies have shown comparable effectiveness to other conservative therapies. (Goodyear-Smith, 2004) Trials of magnet therapy, laser acupuncture, exercise or chiropractic care did not demonstrate symptom benefit when compared to placebo or control.”

Question 53

A 39-year-old female presents with 6 months of progressive right shoulder and upper arm pain, intermittent radial hand dysesthesia, poor fine manipulation with the right hand/fingers and generalized “weakness” complaints of the right arm. Which diagnosis is unlikely to demonstrate pathology on ultrasound?

Answer 53

Medial epicondylitis would NOT be expected to cause the described symptoms, and should demonstrate symptoms limited to the elbow and forearm. Ultrasound might demonstrate tears or thickening of the common extensor tendon. Options (a) (b) and (d) could have symptom profiles consistent with this patient’s presentation. Carpal tunnel syndrome (CTS) is a known cause of hand dysesthesia and can include pain up the arm to the shoulder. Cervical radicular syndromes commonly cause pain and dysesthesia into the arm and hand and C6 nerve root involvement can have significant overlap with CTS. Rotator cuff syndrome commonly causes upper arm and parascapular pain and weakness complaints and may be accompanied by intermittent distal dysesthesia symptoms. Ultrasound may reveal changes in nerve diameter or other pathology in carpal tunnel syndrome. Comprehensive shoulder joint ultrasound would reveal tendinopathy, impingement or bursitis associated with rotator cuff pathology. Cervical nerve roots are difficult to image with ultrasound, although some studies are beginning to suggest that nerve roots may be enlarged in some patients with radiculopathy. Nevertheless, EMG and physical exam remain the mainstay for diagnosis for cervical radiculopathy.

Question 54

Which of the following surveys/questionnaires is used to identify patients in the acute phase of recovery from a low back injury who are at increased risk of prolonged work loss and who may benefit from early supervised physical therapy?

Answer 54

From ODG: “Multiple studies have shown that patients with a high level of fear-avoidance do much better in a supervised physical therapy exercise program, and patients with low fear-avoidance do better following a self-directed exercise program. When using the Fear-Avoidance Beliefs Questionnaire (FABQ), scores greater than 34 predicted success with PT supervised care. While the formal questionnaire may not be used, it is recommended that providers be familiar with these principles. The issue of fear-avoidance is a concept, and not just a measurable entity requiring the Fear-Avoidance Questionnaire. It can be recognized in a mental health evaluation by a competent psychologist performing such assessment. (Fritz, 2001) (Fritz, 2002) (George, 2003) (Klaber, 2004) (Hicks, 2005) (Leeuw, 2007) The FABQ quantifies the level of fear of pain and beliefs about avoiding activity in patients with low back pain (LBP). The instrument consists of 16 items subdivided into 2 subscales, a 5-item physical activity subscale (e.g., “Physical activity might harm my back”) and an 11-item work subscale (e.g., “My work might harm my back”). Higher scores represent increased fear-avoidance beliefs. The FABQ has been associated with current and future disability and work loss in patients with chronic and acute LBP. Fear avoidance characteristics of patients with LBP should be recognized at an early stage. The presence of guarded motions, exaggerated affect, and inconsistent findings on physical performance assessments may suggest risk for chronicity and/or disability. As patients’ fear avoidance beliefs dominate their ability to confront their symptoms, they are much less likely to be active. This lack of activity, actual or perceived, can further contribute to progressive disability. (Hanney, 2009)”

Question 55

Which of the following surveys/questionnaires is commonly used as an outcome measure in research, measures patients’ self-perception of disability specifically for low back pain?

Answer 55

ODI is used to track patient perception of disability over the course of treatment, specifically for low back pain. In addition to being used as an outcome measure in research, physician offices are also utilizing this tool for outcome tracking.

Oswald Disability Index (ODI) questionaire

Question 56

Which of the following is a psychological questionnaire is often used to identify the existence of comorbid psychological problems present in chronic pain patients and to help tailor treatment?

Answer 56

Minnesota multiphasic personality inventory (MMPI)and its variants (version 2 and 2RF) are the most widely used psychometric tests for adult personality and psychopathology testing.

Question 57

Which of the following is commonly used as a research outcome measure to assess perception of physical and emotional functioning in patients with chronic pain?

Answer 57

The (SHORT FORM) SF-36® and the shorter SF-12® is a measure of quality of life with questions covering multiple domains. SF-36 Domains include “physical functioning; role limitations due to physical health; role limitations due to emotional problems; energy/fatigue; emotional well-being; social functioning; pain; general health”. These questionnaires are owned and marketed by Medical Outcomes Trust. They have a considerable research base and assess a broad range of activities of daily living relevant to disability.

Question 58

Which of the following factors predicted the highest risk for disability at one year following low back injury?

Answer 58

Per Official Disability Guidelines, “workers with more severe back injuries were more likely to be on disability after one year. Employees with pain spreading down into the leg indicating radiculopathy were at particularly high risk. Another significant predictor was the specialty of the first doctor seen after the back injury, and workers who saw a chiropractor were less likely to be disabled at one year. Certain job characteristics also affected disability risk, and risk was lower when employers offered modified duty. All of the significant factors were combined into a statistical model which was 88 percent accurate in identifying workers who would and would not be disabled after one year. In this study most of the psychological factors thought to contribute to chronic pain were not significant risk factors for disability. (Turner, 2008)”

Question 59

Which of the following non-medical factors predict a poor prognosis for return to work following low back injury?

Answer 59

Per Official Disability Guidelines, “Non-medical factors identified as being potentially associated with poorer return to work outcomes include: low worker educational levels, a pre-injury heavy manual job, older than 45 years, smoking, positive Waddell’s signs, less life satisfaction, receiving compensation, workplace climate (including bullying), prior absence history, abuse of drugs and alcohol, long commuting distance to/from work, attorney involvement, long hours worked, work overload and pressure, high unpaid workload (particularly with women), obesity, and blaming others for the injury. (Mills, 2008)”

Question 60

What are the chances of an individual with a work related low back injury returning to work after being off-work for 2 years?

Answer 60

At 700 days of missed work, less than 1% of injured workers will return to employment.

Question 61

A significant deviation, loss, or loss of use of any body structure or body function in an individual with a health condition, disorder, or disease is called:

Answer 61

According to the WHO ICF, impairments are problems at the level of bodily structures and function. Disability arises from impairments and can result in activity limitations and participation restrictions. Handicaps are disadvantages related to disability that result in reduced participation in normal life roles. The medical term “deficiency” describes a lack or shortage of something that may cause illness or impairment, e.g., limb deficiency, color vision deficiency, iron deficiency anemia.

Question 62

Describe the normal structure and biomechanics of the cervical spine in a healthy individual.

Answer 62

Disk herniation in the cervical spine occurs most commonly in the posterolateral aspect of the disk. Fifty percent of cervical flexion and extension occurs at the atlanto-occipital joint, and 50% of cervical spine axial rotation occurs at the atlantoaxial joint. The intervertebral disks in the cervical spine are more rigid and have a nucleus pulposus that is located more anterior compared with the lumbar spine. The foramina are largest proximally and smallest distally. Disk shape is larger anteriorly.

Question 63

Activity limitations and/or participation restrictions in an individual with a health condition, disorder, or disease is called:

Answer 63

According to the WHO ICF, impairments are problems at the level of bodily structures and function. Disability arises from impairments and can result in activity limitations and participation restrictions. Handicaps are disadvantages related to disability that result in reduced participation in normal life roles. The medical term “deficiency” describes a lack or shortage of something that may cause illness or impairment, e.g., limb deficiency, color vision deficiency, iron deficiency anemia.

Question 64

A 47-year-old injured worker with low back pain is near maximum medical improvement (MMI) and is referred for a functional capacity evaluation (FCE). What knowledge can be obtained from FCEs for injured workers with chronic low back pain?

Answer 64

Performance on the floor-to-waist lift are as predictive as the number of failed tasks in the entire FCE protocol. Limitations noted in an FCE apply to occupational and non-occupational (eg, recreational) activities. FCEs are used to estimate a patient’s functional abilities, whereas work-hardening programs are designed to increase a patient’s functional abilities. Following an FCE, 20% of patients experience back-related events within 1 year.