PMR 14 - industrial rehabilitation

Question 1

Which workers’ compensation act was enacted in 1970/1971?
a. The Employers’ Liability Law
b. The Occupational Safety and Health Act (OSHA)
c. The Code of Hammurabi
d. No-fault insurance

Answer 1

B) OSHA was passed in 1970 in part to provide consistency and regulation of states’ workers’ compensation systems. The Code of Hammurabi is one of the earliest recorded legal codes; it regulated the society of ancient Babylon, including specifying compensation for employment and services rendered.

Question 2

A 38-year-old woman “clocked out” at work and was getting into her car in the parking lot when she slipped, twisting her ankle. Should this injury be covered under workers’ compensation?
a. Yes, because it arose out of the course of her employment
b. Yes, because it was her own fault that she slipped
c. No, because it was not her fault that the surface was slippery
d. No, because the minor injury will probably heal on its own

Answer 2

A) Injuries or illnesses are typically covered under workers’ compensation laws when they
“arise out of and in the course of employment.” Many state workers’ compensation systems exclude coverage for injuries sustained while an employee is commuting to and from work. There are many exceptions to this rule, such as where the scope of the employee’s duties includes travel.

Question 3

Which of the following is the lowest risk factor for occupational injury claims?
a. Job dissatisfaction
b. Low educational status
c. Smoking
d. Low income

Answer 3

D) Job dissatisfaction, smoking, and low education are all factors influencing the reporting of low back pain. Low income can be a risk factor as well, but it is less so than the others.

Question 4

Which of the following statements is true according to a National Academy of Sciences study?
a. A large percentage of injured workers account for a small percentage of costs
b. A small percentage of injured workers account for a small percentage of costs
C. A small percentage of injured workers account for a large percentage of costs
d. A large percentage of injured workers account for a large percentage of costs

Answer 4

C) This is the correct answer, as it illustrates the importance of a small vet costly group. It has been estimated that 25% of the cases of work-related back injuries account for around 90% (87-93%) of the costs.

Question 5

Once inured workers agree to receive
Workers’ Compensation benefits:
a. They can sue their employer for negligence
b. They cannot sue third parties who are involved
c. They can sue their employer and third parties
d. They forgo their right to sue their emplover

Answer 5

D) Workers’ Compensation laws are by definition “no fault.” In exchange for the employer’s assumption of responsibility, the worker surrenders the privilege to litigate against the employer as a result of the injury.

Question 6

Ways to improve functional outcomes in occupational injuries include all the following except:
a. Early intervention correlates with earl resolution
b. Evaluations and treatment should ideally occur in more than one location
c. The worker should remain at work as much as possible
d. Initial and subsequent visits should be brief and problem-focused

Answer 6

B) Ideally, care should be rendered in one location.

Question 7

Which of the following statements is true for an inured worker?
a. The direct costs of medical care exceed the indirect costs
b. Low back pain is not a significant source of disability in young workers
c. The indirect costs of medical care exceed the direct costs
d. The National Academy of Sciences found that musculoskeletal iniuries are a trivial cause of health care costs

Answer 7

C) The cost of medical care (direct costs) for the inured worker is far less than the cost of lost productivity and wages, not to mention the administrative costs associated with Workers’ Compensation claims (indirect costs).

Question 8

All the following are true except:
a. Many treatments such as splinting, surgery, and ointments date back 5,000 years
b. The Code of Hammurabi specified physician fees and monetary damages for those who harm others
c. The United States developed workers’ compensation laws before the European nations
d. The 18th century physician and author Bernardino Ramazzini is considered the father of occupational medicine

Answer 8

C) The United States lagged behind Europe in adopting policies to protect workers injured on the job. In fact, Chancellor Otto von
Bismarck of Germany was the first to adopt a system of compensation for injured workers in 1884. In the late 1800s, the Industrial Revolution had created unsafe work conditions in factories throughout the USA.
Both adults and children were being maimed and killed on the job, and employers routinely dodged liability for workers’ accidents.
Inured workers had little recourse but to sue employers for compensation, and few employees could afford to do this. Employers had powerful defenses against employee lawsuits: assumption of risk, comparative negligence, and fellow employee negligence.
In 1908, the US Federal Employers’ Liability Act was passed. Applying to railroad workers, it removed contributory negligence and the voluntary assumption of risk by workers as an employer’s defense. In 1917, the US Supreme Court affirmed that workers’ compensation laws were constitutional, and by 1920, forty-two states had adopted such laws.

Question 9

Under the current US workers’ compensations system:
a. The injured worker can sue a third party involved in the injury
b. The injured worker needs to pay his or her own medical bills
c. The injured worker is not paid for time off
d. The injured worker must sue his employer to regain lost earnings

Answer 9

A) Employees can sue a third party if they believe that party is somehow responsible for their injury. In turn, that third party may sue the employer if it believes the employer is legally liable for the accident. If this occurs, the employer’s liability coverage would pay any damages awarded by the court to the third party to compensate for the bodily injury to the employee.

Question 10

All of the following are true regarding workers’ compensation except:
a. The injured worker does not need to prove that the employer is at fault for her or his injury
b. Lost income is generally only partially replaced by workers’ compensation income and does not cover 100% of lost wages
c. Workers’ compensation varies little from state to state because it is governed by federal law.
d. Workers’ compensation provides both medical payments and supplemental lost wages while the injured worker recovers

Answer 10

C) While OSHA provides national guidelines for workers’ compensation policy, each state has an administrative agency that governs employee safety, workers’ benefits,
“employers’ behaviors, and procedures for appeal. For this reason, there are state to state variations in compensation rate, coverage, and duration of benefits.

Question 11

All of the following are true, except:
a. An injury refers to a specific event that occurred
b. An occupational illness mav arise gradually, and not necessarily after a particular event
c. Cumulative trauma disorder refers to a specific medical diagnosis and helps clarify the pathoanatomic event
d. Carpal tunnel syndrome is a type of cumulative trauma disorder

Answer 11

C) The term cumulative trauma disorder actually applies to many clinical entities affecting diverse tissues. A cumulative trauma disorder is generally caused by repetitive stresses applied at sufficient force or frequency to result in tissue damage.
Cumulative trauma disorders are more common in the upper limbs. At-risk jobs are those that require rapid speed or high force of movement, use of poorly designed tools, static or overhead work positions, and vibration.

Question 12

Which of the following is not a known physical risk factor for occupational injury claims?
a. Contact stress
b. Inadequate sleep
c. Whole body vibration
d. Forceful movement

Answer 12

B) Although inadequate sleep has received much attention lately for its association with medical error, it is not known to be a physical risk factor for occupational injury claims.

Question 13

Which of the following is true regarding emplovment evaluations?
a. Preemployment evaluations should be done before interviewing a potential employee
b. Preplacement evaluations have been determined to be illegal under current federal law
c. Ergonomists can help evaluated work site modifications
d. Job site analyses rely solely on job descriptions for their recommendations

Answer 13

C) The field of ergonomics endeavors to enhance the interaction between a person and his or her work environment. An ergonomic evaluation can help identify specific job-related position and equipment needs and may lead to worksite modifications to improve the worker’s productivity and reduce the risk of workplace injury.

Question 14

The maximum amount that should be lifted on an occasional basis during medium duty is:
a. 10 lb
b. 20 lb
c. 50 lb
d. 100 lb

Answer 14

C) A person with the functional ability to do medium work can lift 50 lb on an occasional basis.

Question 15

Which of the following is not true of independent medical examinations (IMEs)?
a. The reader is often a lay person who needs clarifying information regarding the examinee
b. Because the examination is performed by a physician, a doctor-patient relationship is started at that time
c. The report will often need to address issues of causation, impairment, and functional ability
d. The IME doctor should not order treatment for the examinee

Answer 15

B) Physicians who perform an IME are providing a service to an insurer, employer, or attorney by evaluating the claimant and medical records and then rendering specific opinions related to diagnosis, causation, medical tests and treatment, fitness for duty, maximal medical improvement, and permanent partial impairment. There is no physician-patient treating relationship when an IME is performed. The physician completing the IME does not assume the role of the treating physician and does not provide any treatment recommendations directly to the patient.

Question 16

The maximum that should be lifted on an occasional basis during light duty is:
a. 10 lb
b. 20 lb
c. 50lb
d. 100 lb

Answer 16

B) Workers on light duty can lift up to 20 lb on an occasional basis and up to 10 lb on a frequent basis.

Question 17

The following are all true statements about occupational rehabilitation except:
a. Job matching can help select a particular job for a worker with specific abilities
b. Functional capacity evaluations can help assess validity and functional ability to clarify appropriate work restrictions
c. Work conditioning may improve the worker’s strength and cardiovascular fitness after a period of prolonged inactivity
d. Positive Waddell signs on examination indicates a musculoskeletal nidus for pain

Answer 17

D) The Waddell signs are nonorganic findings often discovered in the evaluation of low back pain. The presence of three of the five signs is clinically significant, although not necessarily for malingering. When a patient exhibits such findings, it indicates that disturbances other than physical pathology might be contributing to the patient’s condition.

Question 18

A reasonable degree of medical certainty indicates:
a. Less likely than not
b. Greater than or equal to 51% certain
c. Greater than or equal to 95% certain
d. Within the realm of possibility

Answer 18

B) The phrase reasonable degree of medical certainty is a medicolegal term meaning “more likely than not.” In other words, if there is a preponderance of evidence supporting a conclusion, the phrase
“reasonable degree of medical certainty” can be applied.

Question 19

In the medico-legal workers’ compensation context, an aggravation refers to:
a. A permanent worsening of a prior condition by a particular event
b. Signs or symptoms of a prior illness or injury occurring in the absence of a new provocative event
c. A temporary worsening of a prior condition by an injury
d. An injury causing a latent disease process to appear

Answer 19

A) In the medico-legal arena, an exacerbation is a temporary worsening. To establish aggravation of a condition, the physician must document that an actual permanent worsening of the condition has occurred. Occasionally, this applies if the emplovee has a medical condition unrelated to work that is aggravated by a work injury.

Question 20

An impairment is:
a. The loss or abnormality of body structure or of a physiological or psychological functión
b. The nature and extent of functioning at the level of the person
c. The nature and extent of a person’s involvement in life situations in relation to activities, health conditions, and contextual factors, and may be restricted in nature, duration, and quality
d. Invariably associated with a disability and a correlated handicap

Answer 20

A) An impairment is the loss or abnormality of body structure, and can be physiological or psychological. Answer choice B is the definition of activity, and C the definition of participation, both of which can represent a dimension of disablement in the biopsychosocial model of the World Health Organization paradigm. Impairment is not invariably associated with a disability or handicap.

Question 21

Estimates of the percentage of disabled individuals in the United States range from:
a. 3% to 5%
b. 5% to 10%
c. 15% to 20%
d. 25% to 30%

Answer 21

C) Multiple sources, including the US
Census Bureau and the International Center for the Disabled, have conducted surveys, which indicate that 15% to 20% of the population have at least some level of disability. Most frequently, this disability required the use of a gait aid for ambulation, or help with activities of daily living.

Question 22

The condition associated with the highest prevalence of individuals with activity limitations is:
a. Mental retardation
b. Diabetes mellitus
c. Heart disease
d. Visual disorders

Answer 22

C) Heart disease, because of the prevalence of the condition itself and the chance that it will cause a disability, results in the highest prevalence of individuals with activity limitations.

Question 23

Which condition is associated with the highest risk, for a given individual, of having a significant disability?
a. Rheumatoid arthritis
b. Multiple sclerosis
c. Cerebrovascular disease
d. Emphysema

Answer 23

B) Multiple sclerosis, although not as common as the other conditions listed, carries a far greater risk of causing an individual to have a significant disability.

Question 24

Direct expenditures related to disability include:
a. Medical and personal care
b. Assistive technology
c. Income support
d. All of the above

Answer 24

D) All of the above. Disability frequently results in the impoverishment of the individual, and income support programs remain a huge expense for society. Indirect costs of disability are the loss of income or homemaker potential experienced by the individual.

Question 25

Vocational rehabilitation is an example of:
a. An ameliorative program
b. A corrective program
c. Both
d. Neither

Answer 25

B) Vocational rehabilitation is an example of a corrective program. Corrective programs are designed to facilitate the individual’s ability to return to work and to reduce or remove the disablement. An ameliorative program provides payment for income support and medical care directly.

Question 26

The Rehabilitation Act of 1973:
a. Extended civil rights protection to persons with disabilities
b. Included antidiscrimination and affirm ative action in employment
c. Was broadened by the
Rehabilitation Act Amendments of 1978 to include independent living programs, under the responsibility of the Rehabilitation Services Administration
d. All of the above

Answer 26

D) All of the above.

Question 27

Funding for state vocational rehabilitation agencies is primarily supplied by:
a. The federal government
b. The state government
c. Both, equally
d. Charitable organizations

Answer 27

A) The federal government supplies approximately 80% of the funding for vocational rehabilitation agencies. The states supply the remaining 20%.

Question 28

Vocational rehabilitation principles include:
a. Placing the individual back with a previous employer if a position is available
b. Assessing the premorbid skills of a client to see if a suitable position exists
c. Vocational testing if neither of the above is feasible
d. All of the above

Answer 28

D) If the client was employed prior to the onset of the disability, resuming employment with a previous employer always holds the most potential.

Question 29

Vocational testing assesses:
a. General intelligence
b. Aptitudes, interests, and work skills
c. Aptitude for specific occupations, as listed in the Dictionary of Occupational Titles
d. All the above

Answer 29

D) When the above have been completed, a job search is undertaken by the counselor.

Question 30

The Valpar Component Work Sample
Series is an example of the work sample approach to vocational testing, which measures:
a. Motor responses
b. General intelligence and academic performance
c. Occupational interests
d. None of the above

Answer 30

A) Motor responses are measured in this very practical testing, which includes a series of tasks such as drill press operation, circuit board assembly, or bench assembly.
Aptitudes and intelligence are not the focus of this testing.

Question 31

On-the-job training programs:
a. Can include tax incentives for potential emplovers.
b. Mandate that employers retain § employees after the program has been completed
C. Guarantee that the counselor will place the newly trained individual if the employer does not retain him or her
d. None of the above

Answer 31

A) Tax incentives are frequently offered to provide an incentive to potential employers.
Participating employers frequently retain the employee they have trained, but are not mandated to do so. Similarly, no guarantees are made that another position will be found, but the success rate of these programs is substantial.

Question 32

Which of the following programs has been clearly superior in returning disabled individuals to gainful, nonsheltered emplovment?
a. Sheltered workshops
b. Day programs
c. Home-based programs
d. None of the above

Answer 32

D) Sheltered workshops are certified by the US Department of Labor to pay
“subminim um” wages to disabled individuals with diminished earning capacity. An example of this type of public, nonprofit organization is Goodwill. Day programs primarily provide supervised day activities and are not designed to lead to productive employment.
Home-based programs help to set the disabled individual up with employment such as telephone soliciting that can be done at home. None of these programs have resulted in significant reintegration of their disabled clients into competitive community employment.

Question 33

The presence of a job coach is a unique feature of which type of employment program?
a. Transitional employment
b. Projects with industry
c. Supported employment
d. Sheltered workshops

Answer 33

C) Supported employment is a very intensive approach to returning the most severely disabled individuals to work. A job coach accompanies the client for as long as 6 months, at least on a part-time basis, assisting with job modifi cations, relationships with coworkers, and even performance of the job, as needed. Supported employment has succeeded in returning individuals with severe disabilities to productive employment.

Question 34

Disincentives for vocational rehabilitation include:
a. Fear on the part of disabled individuals that their cash and medical benefits will be jeopardized if they demonstrate that they can work, even on a part-time basis
b. Stereotypes that characterize the disabled as inevitably unproductive members of society
c. Employers’ attitudes toward the disabled
d. All of the above

Answer 34

D) Until they are assured that they would be able to feasibly support themselves, many individuals remain leery of demonstrating that they can work at all. Stereotypes and prejudice still abound and further limit the disabled in obtaining employment

Question 35

Which of the following sources of income is included in the benefit cap for Social Security Disability payments (i.e., counts against the beneficiary’s payments)?
a. Veterans’ payments
b. Disability pensions from government iobs
c. Workers’ compensation benefits
d. All the above

Answer 35

C) Workers’ compensation benefits count against the individual’s payments. The other sources of income listed above do not.

Question 36

The expenses that a business might incur to comply with the provisions of the Americans with Disabilities Act in hiring a disabled worker can be partially mitigated by:
a. An “access” tax credit for eligible expenses against income taxes
b. The Targeted Jobs Tax Credit (TJTC)
c. Holding a bake sale
d. None of the above

Answer 36

A) The access tax credit was created to ease the burden of compliance with the Americans with Disabilities Act on small businesses. The TJTC is an incentive for employers to hire the “hardcore” unemployed, those on SSI.

Question 37

General principles of disability prevention include:
a. Primary prevention efforts designed %.to prevent worsening of an
impairment
b. Secondary prevention efforts to identify and treat a pathologic condition and reduce the risk factors for further disablement
c. Tertiary prevention efforts to limit the restriction of a person’s participation in an area, such as employment, by actively facilitating such or by removing a barrier
d. All of the above

Answer 37

d. All of the above are general principles of disability prevention.

Question 38

What is the most common cause of disability in workers below the age of 45:
a. Neck pain
c. Low back pain
b. Shoulder pain
d. Knee pain

Answer 38

C) In workers younger than 45 years, low back pain is the most common cause of disability. Low back pain affects 2% to 4% of the working population annually. 80% of the working population will likely have an episode of low back pain on at least one occasion.

Question 39

Musculoskeletal injuries generally resolve and can be considered chronic by:
a. 1 month
b. 3 months
c. 6 months
d. 1 year

Answer 39

B) Musculoskeletal injuries generally resolve within 12 weeks. A condition is considered chronic if it persists beyond the expected normal healing time.

Question 40

The FABER test evaluates for:
a. Possible pathology in the knee
b. Possible pathology in the sacroiliac joint and hip
c. Cervical stenosis
d. Evidence of radiculopathy

Answer 40

B) FABER is an acronym for flexion-abduction-external rotation. This is also known as Patrick test. It is also sometimes referred to as FABERE (indicating extension after the flexion, abduction, and external rotation, to elicit pain). It is a stress maneuver to detect hip and sacroiliac pathology. It is performed by placing the affected hip in flexion, abduction, and external rotation with the foot placed on the opposite knee. The pelvis is stabilized with the examiner’s hands on the contralateral anterior superior iliac spine. The test is positive if there is pain in the ipsilateral hip or sacroiliac region.

Question 41

All of the following are true about neck pain except:
a. Most people with neck pain experience complete resolution of symptoms
b. Between 50% and 85% of the population who experience neck pain at some initial point will report neck pain again within 1 to 5 years
c. Findings are similar in the general population, workers, and patient’s following motor vehicle accidents
d. A normal neurologic exam is common

Answer 41

A) Most people with neck pain do not experience a complete resolution of symptoms. Between 50% and 85% of people experiencing neck pain at some initial point will report neck pain again 1 to 5 years later.
The numbers in the general population appear to be similar compared with workers and with patients following motor vehicle crashes.

Question 42

Permanent worsening of a previous condition by a particular event is called:
a. Aggravation
b. Precipitation
c. Exacerbation
d. Recurrence

Answer 42

A) Aggravation is a permanent worsening of a previous condition by a particular event.
Exacerbation is a temporary worsening of previous condition by injury. Recurrence is defined as signs and symptoms of a previous illness or injury occurring in the absence of a new provocative event.

Question 43

Functional capacity evaluations (FCEs):
a. Evaluate a worker’s ability to perform a particular type of job
b. Do not evaluate a worker’s tolerance for performing selected job tasks
c. Usually take less than 30 minutes to complete
d. Do not require specially trained therapists

Answer 43

A) The purpose of an FCE is to estimate a worker’s capability to perform a job task.
FCEs emphasize validity and consistency and identify poor effort by using a set of objective task-based measurements. There is much debate about the value of FCE testing, but there is agreement that FCE tests a worker’s tolerance to perform selected job tasks.

Question 44

Waddell’s nonorganic signs include:
a. Point tenderness with palpation
b. Loss of sensation representing the distribution of a specific nerve root or peripheral nerve
c. No complaints of low back pain with axial simulation
d. Negative-seated straight leg raise test while the patient is distracted and findings of increased pain with formal supine straight leg raise testing

Answer 44

D) Dr. Waddell described nonorganic signs of low back pain. If two or more of the tests, including subjective evaluation, are positive, the examiner should be concerned about issues other than peripheral nociception (organic pain) creating the pain behavior. Four tests comprising Waddell signs include nonorganic tenderness with light superficial palpation, axial simulation by applying light downward pressure on the patient’s head, distraction while performing seated straight leg raising, and regional sensory loss with sensory examination testing. Behavioral signs can also be revealed with muscle testing. Muscles may give way after briefly exerting normal strength, and strength exerted may be variable if testing rapid alternating strength.

Question 45

Low back pain and back injuries occurring in the work force:
a. Are uncommon in workers between ages 30 and 60 years
b. Become chronic and last more than 90 days in most cases
c. Are a primary cause of absenteeism from work
d. Do not require a complete medical history and physical examination

Answer 45

C) Low back pain affects 60% to 70% of adults at some time in their lives. Low back pain and back injuries commonly occur in workers from ages 30 to 60. Back injuries are a primary cause of absenteeism from work.
Most individuals with low back pain experience near complete resolution of symptoms within 30 days.

Question 46

When evaluating a patient with an acute onset of low back pain, identifiable red flags requiring further workup include all of the following except:
a. Night pain that interrupts sleep
b. Pain that is relieved by rest
c. History of trauma
d. Unexplained weight loss
e. History of prolonged use of steroids

Answer 46

B) Red flags are indicative of potentially serious conditions. These include (but are not limited to) maior trauma from a motor vehicle accident or fall from a height; minor trauma or strenuous lifting in older patients; history of cancer; history of fevers, chills, or unexplained weight loss; urinary retention; urinary frequency or overflow incontinence; saddle anesthesia; and severe progressive neurologic deficits in the lower extremity.

Question 47

Regarding the straight leg raise test:
a. The test is positive if the patient complains of axial pain
b. The test is positive if there is pain below the knee with greater than 70° of straight leg raising
C. The test is positive if pain is relieved by dorsiflexing the ankle
d. The test is positive if pain in the affected leg occurs with straight leg raising the patient’s unaffected extremity

Answer 47

D) Crossover pain (pain when the contralateral limb is raised) is a stronger indication of nerve root compression than pain elicited from raising the ipsilateral (affected) limb. Straight leg raising is positive if there is pain below the knee with more than 30° and less than 70° straight leg raising.
When straight leg raising is positive, the pain U is increased by dorsiflexing the ankle and relieved by plantar flexing the ankle.

Question 48

Initial care in a patient with acute onset of nonspecific low back pain (with no serious conditions noted on initial assessment)
includes:
a. Nonsteroidal anti-inflammatory drugs (NSAIDs), if not contraindicated
b. Use of narcotic medication for primary pain control
c. Valium to control muscle spasm
d. Bed rest for 2 weeks

Answer 48

A) The patient should be assured that rapid recovery can be expected if the initial assessment reveals no evidence of a serious condition. Nonprescription analgesics will provide sufficient pain relief for most patients with acute back pain. Most patients will not require bed rest. Bed rest greater than 4 days has the potential to cause debilitating effects.

Question 49

If fingertips are more than 10 cm from the floor with testing maximum trunk flexion, the following reasons should be considered except:
a. Symptom amplification
b. Nerve root compression
c. Tightness of the quadriceps
d. Paraspinal muscle spasm

Answer 49

C) Evaluation of normal lumbar flexion should reveal fingertips no greater than 10 cm from the floor. Reasons for limited lumbar flexion include nerve root irritation from possible disc herniation, tight hamstrings, and spasm of the paraspinal muscles.
Symptom amplification should also be considered, and in these situations, it is prudent to retest several times to determine whether there is significant variability.

Question 50

Heel walking tests motor strength of the ankle dorsiflexors and involves the following nerve roots):
a. S1
b. L4-5
C. L3-4
d. L1-2

Answer 50

B) Heel walking and toe walking are utilized to evaluate muscle strength and spinal innervation. Heel walking is a quick screen for L4-5 aggravation, and toe walking is a screen for S1 innervation.

Question 51

Testing extensor hallucis longus (EHL)
strength provides information about which of the following nerve root:
a. L1
b. L2
C. L3
d. L5

Answer 51

D) EHL strength correlates with the L5 nerve root. Gastrocsoleus strength correlates with S1 nerve root. Quadriceps strength relates to the L3-4 nerve root. Hip flexor strength reflects to the L1-2 nerve root.

Question 52

Which of the following is not a known risk factor for occupational injury claims?
a. Smoking
b. Job dissatisfaction
c. High educational level
d. Deconditioning

Answer 52

C) Risk factors for occupational injuries include smoking, low educational level, job dissatisfaction, lower socioeconomic status, deconditioning, and previous history of iniuries or disabilities.

Question 53

Work hardening focuses on improving a worker’s:
a. Strength and flexibility
b. Conditioning
c. Functional ability for a specific job
d. All of the above

Answer 53

D) Work hardening prepares a worker for a specific job by improving strength, conditioning, flexibility, and overall functional ability. This differs from work conditioning, which is typically needed after prolonged period of reduced activity to improve an injured worker’s strength and cardiovascular fitness. Work conditioning is not tailored to a specific job.

Question 54

Spurling’s test is used to help evaluate for:
a. Cervical disk herniations
b. Lumbar spondylosis
c. Injury to the brachial plexus
d. Lumbar disk herniations

Answer 54

A) Spurling’s test is used to help diagnose cervical disc herniations or cervical spondylosis. This test should be performed cautiously. While in the seated position, the patient is asked to rotate and laterally flex the head to the unaffected side first, followed by the affected side. The examiner uses one hand to lightly compress downward on the head to axially load the cervical spine. If this is tolerated well, then include extension of the neck, which narrows the neural foramen and reproduces radicular arm pain that can be associated with a cervical disc herniation or cervical spondylosis (foraminal stenosis).

Question 55

Clinical symptoms of cauda equina syndrome include all of the following except:
a. Radicular pain and numbness involving both legs
b. Loss of perineal sensation/saddle anesthesia
c. Unaffected gait pattern
d. Urinary frequency, urinary retention or incontinence

Answer 55

C) Cauda equina typically involves radicular pain and numbness involving both legs, although symptoms may be more severe in one extremity. Leg weakness may present with foot drop, stumbling gait, or difficulty getting up from a chair. Pain in the lower extremities may diminish as the paralysis progresses. There may be difficulty voiding or loss of urinary or anal sphincter control.
Saddle anesthesia/loss of perineal sensation is typical.

Question 56

Cumulative trauma disorders is a term that primarily refers to which of the following conditions?
a. Carpal tunnel syndrome
b. Recurrent low back pain
c. Patella tendinitis
d. Plantar fasciitis

Answer 56

A) Cumulative trauma disorders primarily refer to carpal tunnel syndrome, but may also include lateral epicondylitis, cubital tunnel syndrome, de Quervain’s tenosynovitis, myofascial pain, and rotator cuff tendinitis.
These disorders are the result of a repetitive movement that results in tissue damage.

Question 57

Which position causes the highest lumbar intradiscal pressure?
a. Standing
b. Walking
c. Lying supine
d. Sitting

Answer 57

D) Research has shown that sitting increases intradiscal pressure more than any other sedentary position. Provision of a chair with a supported backrest, armrests, and back support may reduce intradiscal pressure.

Question 58

All of the following are goals of a causality examination except:
a. Confirming the original diagnosis was correct and due to injury, event, or exposure
b. Confirming a person’s current complaints and findings has not been confounded by sickness behavior (conscious or unconscious)
c. Identifying the most appropriate form of treatment intervention
d. Verifying current symptoms and physical examination findings is consistent with a diagnosis and are not indicative of an unrelated new diagnosis

Answer 58

C) The causality exam consists of review of records, interview, physical examination, test results, and conclusions. Objective findings on examination should carry a greater weight of evidence than subjective findings in supporting the diagnosis. Goals of the causalitv examination do not include identifying the most appropriate form of treatment intervention.

Question 59

What is the definition of the term
“symptom magnification”?
a. Perceived (subconscious) concern with body integrity and body function
b. Conscious attempt to deceive for social rewards
c. Conscious or subconscious self-destructive socially reinforced behavioral response pattern
d. Anger related to a specific job-related injury

Answer 59

C) Dr. Leonard Matheson defined symptom magnification as “a conscious or unconscious self-destructive socially reinforced behavioral response pattern consisting of reports or displays of symptoms which function to control the life circumstances of the sufferer.”

Question 60

Maximal medical improvement is achieved once a condition:
a. Resolves
b. Is stable and no further change is expected
c. Requires no further diagnostic testing or intervention
d. All of the above

Answer 60

D) Maximal medical improvement (MMI)
occurs once the medical condition has resolved or has become stable with no further changes expected. Further diagnostic testing intervention is not recommended. The injured worker is not expected to significantly change in the near term with regard to pain level or functional ability. An impairment rating might be appropriate once MMI has been obtained.

Question 61

Establishing a diagnosis for a patient with complaints of low back pain before considering a referral for spine surgery is based on:
a. MRI findings
b. Subiective history
c. Objective findings on examination
d. All of the above

Answer 61

D) It is essential to match a patient’s subjective complaints, objective findings on examination, and diagnostic testing before considering a referral for spine surgery. A diagnosis based on MRI, in the absence of objective clinical findings, may not be the cause of a patient’s pain. This could potentially lead to an attempt at operative correction with resulting chronic low back pain and disability. Diagnostic testing should not be done routinely for nonspecific low ‹ back pain.

Question 62

Which of the following is true concerning epidural steroid injections?
a. Provide permanent relief of persistent lumbar radiculopathy
b. Markedly reduce functional impairment
c. Primarily indicated for axial back pain
d. Provide temporary relief for patients presenting with lumbar radiculopathy

Answer 62

D) Epidural steroid injections provide temporary pain relief in patients with persistent lumbar radiculopathy. The injections have no proven effect on functional impairment, need for surgery, or pain relief lasting more than 3 months. Epidural steroid injections are not indicated for patient’s presenting with axial (nonradicular) back pain only.

Question 63

Indications for spine surgery include all of the following except:
a. Cauda equina syndrome
b. History and examination findings that are not consistent with imaging results and/or EMG n
c. Progressive neurologic deficits
d. Certain types of fractures, tumors, and infections

Answer 63

B) Cauda equina syndrome, progressive neurologic deficits, certain types of fractures, infections, and tumors are all indications for spinal surgery. Surgery may also be indicated for patients with consistent history, examination findings, and diagnostic imaging.
Patients with documented leg and back pain secondary to a herniated disc, stenosis, or spondylolisthesis with poor response to conservative treatment (typically lasting at least 3 months) may also be surgical candidates. Surgical indications for patients presenting with purely axial back pain remain controversial.

Question 64

The risk of using an acute care model for a patient presenting with a chronic problem
64. includes all of the following except:
a. Potentially overlooks psychosocial issues that may be contributing
b. Provides unnecessary expectations that there will be a “quick fix”
c. Empowers patients and addresses multiple dimensions of care issues
d. Does not necessarily consider occupational and lifestyle issues

Answer 64

C) Using an acute care model for chronic illness provides patients with expectations that a medication, injection, or surgery will cure the problem. The risk is that psychosocial, occupational, and lifestyle issues and the importance of utilizing a multidimensional biopsychosocial approach will be overlooked.

Question 65

Workplace factors associated with an increased risk of neck pain include:
a. Use of chairs with armrests
b. Low levels of psychological job strain
c. Using telephone headsets
d. Working with the cervical spine in flexion for prolonged periods

Answer 65

D) Workplace factors associated with increased neck pain include repetitive and precision work, prolonged sedentary work positions, working with the cervical spine in flexion for prolonged periods of time, keyboard poorly positioned too close to the desktop edge, mouse position requiring flexion of shoulders of more than 25 degrees, use of chairs without armrests, using telephone shoulder rests, using a computer monitor requiring poor head posture (e.g., a head tilt of more than 3 degrees), high levels of psychological job strain, low coworker social support, and job insecurity.

Question 66

Illness behaviors are most often seen in which phase of injury?
a. Acute
b. Subacute
c. Chronic
d. Same in all phases

Answer 66

C) Illness behaviors are often seen in patients with a chronic pain syndrome.
Symptoms become the central focus of the patient’s life. Behaviors include grimacing, loud sighing, inconsistency on examination, slow movements, and overly involved family members.

Question 67

Principles of managing patients with neck pain include:
a. Electrodiagnostic testing performed within the first week of symptoms
b. Imaging tests done as soon as possible
c. Use of appropriately selected nonsteroidal anti-inflammatory drugs (NSAIDs) or nonprescription medication as a first-line treatment for pain
d. Strict bed rest

Answer 67

C) The American College of Occupational and Environmental Medicine recommends that the initial assessment of patients with cervical spine problems focuses on identifying the presence of “red flags” such as fever, serious neurologic involvement, or major trauma. In the absence of red flags, imaging and other tests are not recommended in the first 4 to 6 weeks of neck pain, as it almost never results in a meaningful change in clinical management. Electrodiagnostic testing should not be performed until 3 weeks after injury tests are usually negative within the first 3 weeks. Nonprescription medication or an appropriately selected nonsteroidal anti-inflammatory medication, appropriate adjustment of physical activity (if necessary), and the use of thermal modalities such as heat and/or ice can be used to relieve discomfort.