L33: Written Exam Lecture (Practice Questions) Flashcards
Jerry is a 55 year old sales manager with acute LBP (1 week history). His symptoms are aggravated by sitting, bending and lifting, and relieved with lying down and getting out of sitting to walk around.
Question 1:
Using evidence from research, outline ONE potential finding from the subjective interview that would indicate that Jerry requires immediate medical attention and/or referral for an MRI (1 mark).
- Cauda Equina symptoms – any 1 symptom (needs to be explicitly named)
- He has worsening neurological symptoms History of significant trauma
- Constant, unremitting night pain
- Spinal cord injury symptom (needs to be explicitly named)
- Any other symptom that would indicate a red flag
Jerry is a 55 year old sales manager with acute LBP (1 week history). His symptoms are aggravated by sitting, bending and lifting, and relieved with lying down and getting out of sitting to walk around.
Question 2
Outline THREE evidence based approaches in your initial management of Jerry that could be used to reduce his acute pain. Provide the approach, outline what you will do and provide an appropriate reassessment (6 marks)
- Education – to reduce cognitive threat and reduce fear avoidant behaviours - goal would be that he increases his activity. This would be explaining symptoms, what has happened and/or the importance of active recovery and/or providing reassurance that he has not sustained a serious injury and/or addressing his concerns he has.
- Reassessment: Teach back approach – ask Jerry what he now understands has happened with his back and what his plan over the next few days are or what he understands OR ask him to outline what his plan over next few days is.
- Directional preference exercise – if Jerry has a directional preference to extension, I will prescribe him with regular extension exercises in prone and/or standing. I will also encourage him to take regular breaks from flexion based positions (for example sitting) and promote increasing periods of walking. I would reassess if this is effective through VAS OR functional activities/PSFS OR ROM.
- Manual Therapy – rotation mobilisation and/or PA and/or unilateral PA and/or segmental reverse lateral flexion and/or HVT. Reassessment – ROM or reassess a functional task Also accepted answers = Providing reassurance Providing advice and strategies to remain active Taping (only in very short term) Gentle ROM exercises and/or any other exercises to improve confidence to move Massage (only if used with exercise) Postural/activity modification – advising around how to modify things at work Correcting lateral shift Advising other exercise or strategies that he has already found helps his symptoms NOT accepted Motor control exercises TA/MF etc as the question asks about reducing acute pain.
Brian is a 32 year old builder with increasing episodes of acute LBP. His symptoms are aggravated by flexion related tasks including sitting, bending and lifting
Using evidence from research outline THREE potential findings from the subjective interview that would indicate that Brian would benefit from an exercise approach that focuses on motor control retraining (3 marks)
ANY OF THE FOLLOWING
- High score (>9) of 15 item clinical instability questionnaire
- I feel like my back is going to “give way” or “give out” on me
- I feel the need to frequently pop my back to reduce the pain
- I have frequent times when my pain occurs throughout the day
- I have a past history where my back catches or locks when I twist or bend my spine
- I have pain when I sit to stand or stand to sit
- I have a lot of pain when I sit up from lying down if I don’t rise up the right way
- My pain is sometimes increased with quick, unexpected, or mild movements
- I have difficulty sitting without a back support such as a chair and feel better with a supportive backrest
- I cannot tolerate prolonged positions when I can’t move •It seems like my condition is getting worse over time
- I have had this problem a long time
- I sometimes get temporary relief with back brace or corset
- I have many occasions when I get muscle spasms
- I sometimes am fearful to move because of my pain ALSO
- A patient who has a history of pain with repeated end range loading
- A patient who we demonstrate can change symptoms with modifying position
Brian is a 32 year old builder with increasing episodes of acute LBP. His symptoms are aggravated by flexion related tasks including sitting, bending and lifting You consider using manipulation (high velocity thrust/Grade 5) to reduce Brian’s acute pain.
Outline TWO findings from the subjective and/or physical examination that would indicate that Brian is likely to benefit from this approach (2 marks)
- Acute LBP less than 16 days
- Able to tolerate position of technique
- No symptoms below the knee
- Low fear avoidance behaviours OR low score on FABQ
- Positive response to manual therapy technique
- Can include hip ROM
Brian is a 32 year old builder with increasing episodes of acute LBP. His symptoms are aggravated by flexion related tasks including sitting, bending and lifting List FOUR contraindications to manipulation (high velocity thrust/Grade 5) in the lumbar spine (4 marks)
- Positive Neurological symptoms that are worsening
- Bleeding disorders
- Bone weaking disorders
- Structural abnormalities
- Surgical fusion
- Cauda Equina
- Any other red flags
Brian is a 32 year old builder with increasing episodes of acute LBP. His symptoms are aggravated by flexion related tasks including sitting, bending and liftingAfter your first 2 weeks of initial management, Brian has regained full pain-free range of movement. From your assessment and his history you determine that he has a flexion control impairment.
Outline TWO appropriate motor control exercises that you would prescribe as part of his exercise program that are appropriate for this stage in his recovery. Include patient positioning and instructions (6 marks).
ANSWERS
- Forward lean in sit
- Forward lean in standing
- Pelvic tilt in sitting (lumbo-pelvic dissociation)
- 4 point kneel – finding neutral spine OR sit to heels keeping neutral spine
- Squat
- Hip hinge or deadlift
- Sit to stand keeping neutral spine
- Also accepted – transversus abdominus OR MF in supine/prone
For full 3 marks for both exercises must include:
- Name of technique (1 mark)
- Positioning and instructions to patient (1 mark) – consider using diagram
- “Prescription” ie frequency and reps (1 mark) – this can be standard or you could reason how many the patient should do based on the assessment
- NOTE – if the student says the ‘wrong’ exercise, they still get marks for positioning and prescription if correct.
Adrian is a 42 year old with a 4 month history of LBP relating to an injury at work which has worsened over the last 3 weeks. His GP has referred him through Work-Cover for Physiotherapy as he is now unable to work due to pain. His imaging findings demonstrate mild degeneration at L4/5 and L5/S1. His symptoms are consistent with L5/S1 non-specific LBP with psychosocial risk factors. He has a score of 35 on the work scale of the FABQ and a high risk score on the Start Back Screening Tool.
Question 2
On your assessment you find that Adrian is reluctant to bend forward in standing and you observe that he keeps his back straight and holds his breath. Outline and describe TWO ways in which you could improve his confidence or ability to perform lumbar flexion (4 marks)
ANSWERS
- Increasing cognitive awareness of his behaviours (for example making him aware that he is bracing/breath holding)
- Patient education regarding pain to reduce cognitive threat (this could be a number of things)
- Breathing through movement
- Flexion in supine – pulling knees to chest
- Flexion in side lying – pulling knees to chest
- Pelvic tilts in sitting or supine or on wall
- Flexion in 4 point kneel (cat camel)
- Relaxed breathing in sitting or lying MWMs
- Doing any other exercise (swimming, walking etc) that helps relax his back
Adrian is a 42 year old with a 4 month history of LBP relating to an injury at work which has worsened over the last 3 weeks. His GP has referred him through Work-Cover for Physiotherapy as he is now unable to work due to pain. His imaging findings demonstrate mild degeneration at L4/5 and L5/S1. His symptoms are consistent with L5/S1 non-specific LBP with psychosocial risk factors. He has a score of 35 on the work scale of the FABQ and a high risk score on the Start Back Screening Tool. Question 3 During your physiotherapy sessions with Adrian, outline and describe THREE key messages for your advice and education that you will be focussing on and what you are trying to achieve with each of these educational priorities (6 marks).
ANSWERS
- Addressing patient concerns
- Addressing unhelpful beliefs or addressing the MRI findings
- Reassuring around what the condition is
- Discussing importance of movement and/or exercise
- Any pain neurophysiology education (this may or may not be use of metaphors)
- Discuss and develop plan for return to work
- Giving prognostic information
- Self-management plan including exercise management
- Creating long term exercise plan
- Importance of work, exercise, social things etc
NOTE – the student should only get a full two marks for these if they state the message and what they are trying to achieve.
Adrian is a 42 year old with a 4 month history of LBP relating to an injury at work which has worsened over the last 3 weeks. His GP has referred him through Work-Cover for Physiotherapy as he is now unable to work due to pain. His imaging findings demonstrate mild degeneration at L4/5 and L5/S1. His symptoms are consistent with L5/S1 non-specific LBP with psychosocial risk factors. He has a score of 35 on the work scale of the FABQ and a high risk score on the Start Back Screening Tool.
Question 4
Outline your course of action if Adrian does not improve with physiotherapy management (1 mark).
- Referral for psychological intervention
- Referral to pain clinic
- Referral to GP
- Referral to multidisciplinary management
- ½ mark if referral for other Physio
- No marks for imaging (as he has had imaging and has no reason for imaging)
- No marks for another professional where there is no recommendations in guidelines or evidence
