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1
Q
  1. The Henneman size principle of therapeutic
    exercise says motor units are recruited in order of
    (A) increasing size, decreasing contraction
    strength, and diminishing fatigue
    (B) increasing size, increasing contraction
    strength, and diminishing fatigue
    (C) increasing size, increasing contraction
    strength, and escalating fatigue
    (D) decreasing size, increasing contraction
    strength, and diminishing fatigue
    (E) none of the above
A
  1. (C) Smaller, less powerful, fatigue resistant motor
    units, which contain slow-twitch muscle fibers,
    have the lowest firing threshold and are recruited
    first. Demands for larger forces are met by the
    recruitment of increasingly larger, more powerful,
    fatigable motor units. The largest motor units
    that contain the fast-twitch B fibers have the
    highest threshold and are recruited last.
2
Q
950. What is an example of an open kinetic chain
exercise?
(A) Leg press
(B) Knee extensions
(C) Push up
(D) Treadmill
(E) Bench press
A
  1. (B) Open kinetic chain exercises are typically
    performed where the foot/leg or hand/arm is
    free to move, and non-weight bearing, with the
    movement occurring at the peripheral joint.
    Examples of these exercises would be knee
    extensions, straight leg raises, and biceps curl. In
    closed kinetic chain (CKC) exercise, the distal
    part of the limb-upper or lower, is fixed to the
    ground or to the wall or plate. Examples include
    leg press, push up, and running exercises. In
    bench press, the foot is on the floor so this too is
    a CKC exercise. CKC exercises are felt to be more
    “functional”, since these exercises may mimic
    what patients do throughout the day or in an
    employment setting and thus are often favored.
    However, a mix of both types of exercises typically
    recommended.
3
Q
951. Which type of therapy has been found to
reduce the risk of falls in the elderly?
(A) Tai chi
(B) Pilates
(C) Yoga
(D) Strength training
(E) None of the above
A
  1. (A)
    A. Tai chi is an internal Chinese martial art often
    practiced with the aim of promoting health
    and longevity. Training consists of slow
    motion routines that groups of people
    practice together every morning in parks
    around the world, particularly in China.
    Many medical studies support its effectiveness
    as an alternative exercise and a form of
    martial arts therapy. Tai chi improves balance
    in persons of all ages.
    B. Pilates is a physical fitness system developed
    in the early 20th century by Joseph
    Pilates. Pilates called his method “contrology,”
    because he believed his method uses the
    mind to control the muscles. The program
    focuses on the core postural muscles which
    helps keep the body balanced and which are
    essential for providing support for the spine.
    C. Yoga is a group of ancient spiritual practices
    originating in India. Yoga involves flexibility
    exercise combined with strength training,
    but also traditional chants and relaxation
    techniques that relax the mind and the body.
    D. Strength training has been found to be
    effective in elderly patients but does not
    specifically reduce falls.
4
Q
952. Direct participants in interdisciplinary comprehensive
pain management include all of the
following, EXCEPT
(A) vocational counselor
(B) physical therapist
(C) psychologist
(D) general internal medicine physician
(E) occupational therapist
A
  1. (D) While a family physician is important to provide
    medical information to the team, the team
    leader is most often a physician with sub-specialty
    qualifications in pain management. The team
    consists of professionals from a variety of therapeutic
    groups that work together with the patient
    to help them improve their function and manage
    their chronic pain. All of the above except the primary
    care physician can readily be found among
    the interdisciplinary team.
5
Q
  1. Which of the following is true regarding aerobic
    training?
    (A) Persons placed on bedrest will experience
    a decrease in resting heart rate
    (B) Oxygen consumption (VO2) increases in
    proportion to the intensity of the exercise
    (C) For training to be effective, the duration
    of aerobic training must be at least
    10 minutes at a stretch
    (D) Intensity of training must be within 40%
    to 85% of maximal VO2 (VO2 max) to be
    considered aerobic training
    (E) Patients placed at bedrest will experience
    an increase of VO2 max after 3 weeks
A
  1. (D) When placed at bedrest, many detrimental
    changes occur to the cardiovascular system.
    People placed on bedrest will experience an
    increase in resting heart rate. Oxygen consumption
    (VO2) decreases in proportion to the
    intensity of the exercise. Patients will experience
    a 25% decrease in VO2 max after 3 weeks of
    bedrest. Additionally, during bedrest muscle
    breakdown occurs, osteoporosis occurs, and
    joint contractures can set in. Therefore, during acute pain episodes, it is imperative that patients
    are encouraged not to lie in bed for 24 hours.
6
Q
954. All of the following are examples of core
strengthening programs for spine rehabilitation,
EXCEPT
(A) lumbar stabilization
(B) pilates training
(C) yoga
(D) abdominal exercises
(E) all of the above
A
  1. (C)
    A. Lumbar stabilization is a type of exercise
    that attempts to strengthen muscles in the
    abdomen and posterior spine (multifidus)
    by cocontracting the muscles in a position of
    “neutral spine.” Neutral spine is a position
    where the spine hurts the least so exercise
    can take place.
    B. Pilates is an exercise designed by Joseph
    Pilates to use machines to assist with
    strengthening of muscles of the abdomen
    and spine—the core muscles.
    C. Yoga is an exercise of the mind and body.
    Positions are attempted that achieve maximum
    body stretch and relaxation. Strengthening
    is not a part of the program.
    D. Abdominal muscles are part of the core.
    The core defined as muscles between the
    chest (nipple line) and the waist.
7
Q
  1. Atypical exercise precaution that should be followed
    with a patient who has chronic osteoarthritis
    would be
    (A) no exercise in patients with osteoarthritis
    of three or more joints
    (B) no weight bearing on a limb with knee
    pain of 2 years’ duration
    (C) no ice when knee effusion occurs after
    exercise
    (D) only low-impact exercises in a patient
    with severe osteoarthritis of both knees
    awaiting joint replacement surgery
    (E) no stretching of a lower limb in a
    patient with osteoarthritis of the ankle
    who has a tight calf muscle
A
  1. (D) The exercise program in patients with
    osteoarthritis must be adjusted to their tolerance
    level. Many patients are functionally
    impaired, obese, and are at high risk for developing
    medical complications such as type-2
    diabetes or cardiovascular disease because of
    their inactivity. Thus, even if a patient is awaiting
    joint replacement because of chronic pain
    from osteoarthritis a period of physical activity
    before their surgery is warranted. Often protected
    weight-bearing, low-impact exercises, or
    exclusively aquatic exercises can allow the
    patient to tolerate sessions of physical therapy
    they otherwise could not tolerate.
8
Q
  1. A patient presents to your office with T6 paraplegia.
    He was living independently until severity
    of neuropathic pain in his legs increased to
    10/10. Now he can no longer go to work because
    the pain is so severe that he cannot concentrate
    at work. The fact that this patient cannot work is
    considered as
    (A) impairment
    (B) disability
    (C) handicap
    (D) physical capacity
    (E) none of the above
A
  1. (C)
    A. The American Medical Association Guides
    to the Evaluation of Permanent Impairment
    define impairment as “a loss, loss of use, or
    derangement of any body part, organ system,
    or organ function.” Thus in this case,
    the impairment would be the T6 injury.
    B. The American Medical Association Guides
    to the Evaluation of Permanent Impairment
    define disability as “an alteration of an individual’s
    capacity to meet personal, social,
    or occupational demands or statutory or
    regulatory requirements because of an
    impairment.” Thus, the inability to walk
    would be a disability. Another example
    might be a finger injury. A lawyer might
    have no vocational disability but a pianist
    might have 100% disability from the same
    impairment.
    C. Impairment is the functional consequence
    of the disability. Thus the inability to
    work, play a sport, or pay the rent would
    all be disabled.
    D. Physical capacity is just the capacity of the
    body to operate.
9
Q
  1. A patient presents to the office with 2-week
    history of leg pain consistent with S1 radiculopathy.
    Magnetic resonance imaging (MRI)
    reveals a paracentral L5-S1 disc herniation. The
    pain is worsened with bending forward, driving,
    and lifting objects. Aproper type of physical
    therapy exercise would be
    (A) McKenzie method of physical therapy
    with extension exercises
    (B) yoga
    (C) Williams method of physical therapy
    with flexion exercises
    (D) stationary bike
    (E) no therapy
A
  1. (A)
    A. Although individualized exercises also are
    performed, McKenzie exercises are most
    well known as a set of spinal extension exercises.
    The goal is to off-load the disk compression
    on the spinal nerve and reduce the
    pain in the leg. Often the pain “centralizes”
    to the lower back where is can be improved
    by other therapy methods. Although often
    practiced, little is written and even fewer
    studies have been performed to prove the
    effectiveness of the therapy. The study referenced
    above found improvement in leg
    pain in the short term (0-3 months) compared
    to other treatments but after 3 month,
    the benefit was no longer seen.
    B. Yoga is a form of exercise where bending forward
    often occurs. This might worsen the
    symptoms. For chronic back pain, yoga has
    been found to be effective in a recent study.
    C. Williams exercises are a set of flexion based
    exercises. Persons with acute paracentral
    disc herniations might get worse leg pain
    with flexion-type exercises. Flexion spine
    exercises can be beneficial in cases of stenosis
    or lateral disc herniations where flexion
    can result in offloading of neural structures.
    D. Stationary bike is a flexion exercise. This can
    result in more pressure on the disc increasing
    the leg pain.
    Although some studies suggest that physical
    therapy has no effect on painful disc herniations,
    many other studies find that therapy
    has a significant beneficial effect.
10
Q
  1. Which of the following is false regarding
    muscle tightness in the lower extremity?
    (A) Gluteus maximus inflexibility may
    decrease lumbar lordosis causing
    increased forces on the lumbar spine
    (B) The Ely test evaluates rectus femoris
    tightness
    (C) Lumbar lordosis can be increased in
    iliopsoas tightness
    (D) Anterior pelvic tilt may cause stress on
    the lumbar spine and can be caused by
    rectus femoris or hamstring tightness
    (E) The Thomas test assesses tightness of
    the iliopsoas muscle
A
  1. (D)
    A. Gluteus medius and hamstring inflexibility
    can lead to posterior pelvic tilt, decreasing
    lumbar lordosis.
    B. The Ely test evaluates the rectus femoris.
    C. Rectus femoris and iliopsoas tightness can
    cause anterior pelvic tilt, increasing lumbar
    lordosis.
    D. Increasing or decreasing lumbar lordosis
    can put stress on the lumbar spine.
    E. The Thomas test evaluates for iliopsoas
    muscle tightness while the Ely test evaluates
    the rectus femoris.
11
Q
  1. Which of the following statements regarding
    central pain is not correct?
    (A) Patients with central pain are usually
    affected by a change in temperature
    (B) More than 10% of patients with a stroke
    report significant central pain within the
    first year
    (C) Central pain caused by a thalamic
    infarction is often a burning pain that
    may be described as agonizing and is on
    the side contralateral to the lesion
    (D) Almost 90% of all central pain is caused
    by cerebral vascular accidents
    (E) No singular pharmacologic, surgical or
    other treatment has been proven to be
    helpful in the long term
A
  1. (B) Ninety percent of all cases of central pain
    are caused by cerebral vascular accidents but
    only 8% of all stroke patients will report central
    pain within the first year. The pain may be constant
    (85%) or intermittent (15%) and is primarily
    burning, prickling, aching, and lancinating.
    Thalamic strokes cause agonizing burning pain
    contralateral to the side of the lesion. Central
    pain is almost always affected by change in
    temperature and no one treatment has been
    found to be efficacious in the long term.
12
Q
  1. Achilles tendinosis is a chronic source of pain
    in many active adults. Which of the following
    interventions has been found to be helpful in
    the treatment of pain for this disease process?
    (A) Nonsteriodal anti-inflammatory drugs
    (B) Corticosteroid injections of the tendon
    (C) Heel pads
    (D) Topical laser therapy
    (E) Ultrasonography
A
  1. (A) Despite the controversy over the presence
    or lack of inflammation in Achilles tendonosis,
    there is weak evidence to support the use of
    oral nonsteroidal drugs for pain control. On
    the other hand there is weak evidence of lack
    of effect for heel pads, topical laser, heparin
    injections, and peritendinous corticosteroid
    injections. There is no well-designed study
    confirming the efficacy of ultrasound in treatment
    of this disease. Eccentric loading has
    been shown to be helpful.
13
Q
  1. Chronic pain from fibromyalgia is characterized
    by the following statements, EXCEPT
    (A) fibromyalgia affects women more often
    than men
    (B) there is a suggestion that genetic factors
    contribute to the etiology of fibromyalgia
    (C) mood and anxiety disorders are significant
    comorbidities in fibromyalgia
    (D) patients with fibromyalgia may experience
    a range of other symptoms including
    irritable bowel or bladder
    syndromes
    (E) cognitive disturbances are never part of
    fibromyalgia and suggest that there is
    an organic cause for the problem
A
  1. (E) Fibromyalgia affects about 2% of the general
    population, affecting 3.4% of women and 0.5%
    of men. The symptoms include sleep disturbances,
    stiffness, anxiety, depression, cognitive
    disturbances, irritable bowel and bladder syndromes,
    headaches, paresthesias, and other less
    common symptoms. Fibromyalgia aggregates
    in families and congregates with major mood
    disorders in families, suggesting genetic factors
    may be involved in the etiology of fibromyalgia.
14
Q
  1. The use of physical therapy that includes
    “directional preference” in the treatment of low back pain has not been shown to
    (A) decrease the need for surgery
    (B) decrease the use of medications
    (C) be associated with greater improvements
    in pain control
    (D) be as good as intensive dynamic
    strengthening
    (E) be better than nondirectional exercises
A
  1. (A) McKenzie based exercises are often called
    directionally based exercises and have been
    thought to be better than regular physical therapy
    in the treatment of low back pain. Not all studies
    have agreed. Several large studies have evaluated
    this paradigm. In one case, intensive
    dynamic strengthening was found to be as good
    as the McKenzie method for treatment of subacute
    and chronic low back pain. Another large
    study showed directional preference exercises
    can decrease medication consumption by threefolds
    and give rapid significant pain control when
    compared to nondirectional therapy and opposite
    directional therapy. No study has evaluated the
    use of directional therapy in avoiding surgery.
15
Q
  1. Evaluation and treatment of anterior knee pain
    that is insidious in onset, bilateral, peripatellar,
    and most often problematic in repetitive loadbearing
    movements includes all the following,
    EXCEPT
    (A) hamstring strengthening
    (B) activity modification
    (C) closed chain kinetic exercises
    (D) patellar taping
    (E) evaluation for apophysitis at the tibial
    tuberosity in adolescents
A
  1. (A) Patellofemoral pain syndrome (PFPS) is usually
    insidious in onset and often bilateral. It is
    most often associated with load-bearing exercises
    and repetition of the exercise. It is relatively
    benign, but in adolescents, one must consider
    the presence of a traction apophysitis of the tibial
    tuberosity. Closed kinetic chain exercises, patellar
    taping, and activity modification along with
    nonsteroidal anti-inflammatory drugs are the
    mainstays of treatment. Strengthening of the
    vastus medialis obliquus and other quadriceps
    muscles are important in the treatment and not
    strengthening of the hamstrings.
16
Q
964. Which of the following is true regarding phantom
limb sensations?
(A) Body parts that are sparsely innervated
are most commonly represented
(B) Phantom sensations are unpleasant with
burning and jabbing
(C) The incidence of phantom sensations
decreases with age.
(D) The amputated limb phantom may feel
shortened
(E) Phantom limb sensations require
peripheral input
A
  1. (D) Phantom limb sensation is an almost universal
    occurrence at some time during the first
    month following surgery.
    A. The strongest sensations come from body
    parts with the highest brain cortical representation,
    such as the fingers and toes. These
    highly innervated parts are also the areas of
    most persistent phantom limb sensation.
    B. Phantom sensations are either normal in
    character or as pleasant warmth and tingling.
    These are not painful.
    C. The incidence of phantom limb sensation
    increases with the age of the amputee. In children
    who have amputation before 2 years
    of age, the incidence of phantom limb sensation
    is 20%; the incidence of phantom
    limb sensation is nearly 100% when amputation
    occurs after 8 years of age.
    D. The phantom limb may undergo the phenomenon
    known as telescoping, in which
    the patient loses sensations from the mid
    portion of the limb, with subsequent shortening
    of the phantom. Telescoping is most
    common in the upper extremity. During
    telescoping, the last body parts to disappear
    are those with the highest representation
    in the cortex, such as the thumb, index
    finger, and big toe. Only painless phantoms
    undergo telescoping, and lengthening of
    the phantom may occur if the pain returns.
    Thus, patients may feel that the amputated
    phantom limb shortened.
    E. Phantom limb sensations do not appear to
    require peripheral nervous system input.
    Phantom limb sensations may be an attempt
    to preserve the self image and minimize distortion
    of the self image or may be a permanent
    inherited neural memory of postural
    patterns.
17
Q
  1. Which of the following physical examination
    maneuvers are not found to correlate with
    sacroiliac joint pain as confirmed by pain ablation
    with diagnostic injection with lidocaine
    under fluoroscopy, with at least 90% specificity?
    (1) Patrick test
    (2) Gaenslen test
    (3) Compression test
    (4) Distraction tests
A
  1. (E) Multiple published studies and meta-analysis
    of studies has found that the highest level of sensitivity
    and specificity for any physical examination
    test is 60%. The specific tests are as follows:
  2. Patrick test—The hip is externally rotated,
    the foot is placed on the opposite knee, and
    gentle pressure is applied to the foot and ipsilateral
    anterior superior iliac spine (ASIS).
    Pain can then occur in either of the affected
    sacroiliac joint. Also called the flexion, abduction,
    and external rotation (FABER).
  3. The goal of the Gaenslen test is to apply torsion
    to the joint. With one hip flexed onto the
    abdomen, the other leg is allowed to dangle
    off the edge of the table. Pressure should
    then be directed downward on the leg in
    order to achieve hip extension and stress the
    sacroiliac joint.
  4. Apply compression to the joint with the
    patient lying on his or her side. Pressure is
    applied downwards to the uppermost iliac
    crest (iliac compression test).
  5. Distraction can be performed to the anterior
    sacroiliac ligaments by applying pressure to
    the anterior superior iliac spine (iliac gapping
    test).
18
Q
  1. In pain management, tissue structures are
    warmed via which of the following mechanism(
    s)?
    (1) Conduction
    (2) Convection
    (3) Conversion
    (4) Radiation
A
  1. (A)
  2. Conduction is the transfer of heat from on
    surface to another directly. Examples include
    heat packs or paraffin.
  3. Convection in the most general terms refers
    to the movement of currents within fluids
    (ie, liquids, gases, and rheids). This would
    suggest movement of air or water across
    body surfaces. Examples include hydrotherapy
    or fluidotherapy.
  4. Conversion is the transfer of heat via a change
    in energy which occurs with ultrasound,
    infrared lamps, and microwave treatments.
  5. Radiation is energy in the form of waves or
    moving subatomic particles but is not used
    in therapy for pain management.
19
Q
  1. The SAID principle (specific adaptation to
    imposed demand) of therapeutic exercise for
    pain management includes the following:
    (1) Stronger muscles develop with strength
    training
    (2) Oxidative capacities of skeletal muscle
    decrease with aerobic training
    (3) Pliability of connective tissue increases
    with flexibility exercises
    (4) Circulation to the brain increases with
    aerobic training
A
  1. (B)
  2. Many studies show muscle hypertrophy
    does occur with specific strength training.
  3. Oxidative capacities of skeletal muscle
    increase with aerobic training.
  4. Stretching exercises work to enhance flexibility
    and reduce stress on painful areas.
  5. Brain function is not part of the SAID
    principle.
20
Q
968. Strength training consists of which type(s) of
muscle contraction?
(1) Isometric
(2) Isotonic
(3) Isokinetic
(4) Isoconcentric
A
  1. (A)
  2. Isometric exercise refers to contraction that
    does not result in movement at the joint.
    Often these exercises are used in the acute
    injury setting when movement of the joint
    or spine causes extreme pain increase.
  3. Isotonic exercise refers to an equivalent
    amount of weight being lifted throughout
    the range of motion (ROM) of the joint when
    contracting the muscle. This is the “traditional”
    exercise strength training that patients and
    nonpatients participate in. Machines such as
    nautilus or free weights may be used.
  4. Isokinetic exercise or “equal speed” exercise
    is when the speed of movement remains constant.
    This goal is for maximum tension to be
    applied throughout the entire ROM of the
    joint/muscle contraction. Machines must be
    used for this type of exercise.
  5. Concentric exercise is a shortening
    contraction—all three of the above exercises
    are examples of concentric exercise.
21
Q
969. Which of these statements is (are) true regarding
lumbosacral (LSO) supports?
(1) There was moderate evidence that LSO
supports were effective for primary low
back pain prevention
(2) There was moderate evidence that LSO
supports were ineffective for primary
low back pain prevention
(3) Lumbar supports are less effective in
reducing back pain than no treatment
(4) Lumbar supports are more effective in
reducing back pain than no treatment
A
  1. (C) The Cochrane back review systematically
    examined 13 trials. Five were randomized preventative
    trials. Two were nonrandomized
    trials. Six were randomized therapeutic trials.
    There was moderate evidence that LSO supports
    were ineffective for primary low back
    pain prevention. Although there was limited
    evidence that LSO supports were more effective
    than no treatment, there was no evidence
    that LSO supports were better than other treatments
    for low back pain.
22
Q
970. Acomprehensive, inpatient chronic pain treatment
program advertises that they are CARF
accredited treatment center. CARF is
(1) Commission on Activity with
Rehabilitation Focus
(2) a certification for centers to show that
they have better outcomes for pain
reduction
(3) a certification for centers to show that
they have better outcomes for return to
work
(4) the rehabilitation accreditation
commission
A
  1. (D) CARF (Commission on Accreditation of
    Rehabilitation Facilities) accredits a rehabilitation
    center if those services meet the standards
    outlined in the CARF standards manual. The
    CARF accreditation process certifies that the
    center meets the highest standards of quality
    but does not discuss or look at patient outcomes.
    A CARF accredited center meets certain
    minimum criteria set out to ensure that
    patients receive quality care expected in an
    interdisciplinary rehabilitation center.
23
Q
  1. Which of these statements regarding exercise is
    false?
    (1) Several studies indicate an increase in
    all-cause mortality with long-term
    regular exercise participation
    (2) Physical activity is considered a major
    risk factor for the development of cardiovascular
    disease
    (3) Both acute and chronic exercise can
    increase blood pressure in the long-term
    (4) Most studies indicate that aerobic exercise
    training increases plasma triglycerides
    and may lower high-density
    lipoprotein (HDL) cholesterol
A
  1. (E)
  2. Several studies indicate a decrease in allcause
    mortality with long-term, regular
    exercise participation.
  3. Physical inactivity is considered a major
    risk factor for the development of cardiovascular
    diseases.
  4. Both acute and chronic exercise can decrease
    blood pressure in the long term.
  5. Most studies indicate that aerobic exercise
    training decreases plasma triglycerides and
    may increase HDL cholesterol.
24
Q
  1. Physical effects of aquatic therapy include
    (1) increase in cardiac output
    (2) decrease in stroke volume
    (3) offloading of immersed joints
    (4) increased psychological stress due the
    aquatic exercise
A
  1. (B)
  2. Water immersion results in lowering the pressure
    in the venous and lymphatic side of the
    circulatory system. This results in increased
    central venous pressure and right atrial distension.
    Thus with increase in central blood
    volume, the atrial pressure rises, the pulmonary
    arterial pressure rises, and the cardiac
    volume increases. These changes all lead to
    an increase in stroke volume and increase in
    cardiac output with aquatic exercise.
  3. Stroke volume increases with aquatic exercise.
  4. As the body immerses in water, the water is
    displaced, creating a progressive off-loading
    of the immersed joints. A person who is
    immersed up to the pelvis has effectively
    offloaded 40% of their body weight. This
    allows the patient with chronic pain who
    may not have been able to exercise because of
    severe joint pain to exercise for a much longer
    period of time and in an upright position. It is
    hoped that the gains seen in the water can
    translate to the land.
  5. The exercise program decreases stress on
    the mind and the body alike.
25
Q
  1. The use of muscle relaxants in the rehabilitation
    of acute and chronic pain is common. Which of
    the following statements is (are) true regarding
    these drugs?
    (1) Baclofen is a γ-aminobutyric acid
    analogue
    (2) The active metabolite of cyclobenzaprine
    is meprobamate, which is a schedule
    intravenous controlled substance
    (3) Tizanidine has been shown to be helpful
    in treating low back pain in several
    studies
    (4) Skeletal muscle relaxants, like metaxalone
    and cyclobenzaprine, exert their
    effects directly on the muscle contractile
    mechanism in skeletal muscle
A
  1. (B)
  2. Baclofen is a γ-aminobutyric acid agonist
    analog, and it inhibits synaptic transmission
    in the spinal cord.
  3. The active metabolite of carisoprodol, not
    cyclobenzaprine, is meprobamate, which is
    a schedule IV controlled substance.
  4. Several studies have shown the efficacy of
    tizanidine in patients with musculoskeletal
    back pain with drowsiness being the main
    reason for discontinuation.
  5. Skeletal muscle relaxants are poorly named
    as they have little or no effect on the skeletal
    muscle contractile mechanism.
26
Q
  1. In acute musculoskeletal injury, which of the
    following is (are) direct effect(s) of using cold as
    a modality for treatment?
    (1) Relieve pain
    (2) Increase tissue repair
    (3) Reduce hemorrhage
    (4) Decrease risk of chromic pain
A
  1. (B) In acute musculoskeletal injuries cold is
    often used as part of the PRICE (protection,
    rest, ice, compression, and elevation) method.
    The effects of cold applied directly to the site of
    injury are to reduce hemorrhage and vasodilation,
    decrease local inflammatory response and
    edema, and to reduce pain. It may also decrease
    spasm associated with the injury.
27
Q
  1. The following types of pain syndromes have
    been found to consistently respond to treatment
    with botulinum toxin A:
    (1) Myofascial pain
    (2) Chronic low back pain
    (3) Headache
    (4) Tennis elbow
A
  1. (C) Studies on the use of botulinum toxin A
    (BTX-A) have been performed for the treatment
    of multiple problems in pain management. Most
    of the trials have been open label. The trials for
    myofascial pain and headaches have been
    mixed. Some of the discrepancies may have
    been regarding dosing and injection site. There is no clear consensus for or against the use of
    BTX-A in either disease. Open label studies on
    chronic low back pain have been small but do
    seem to have a positive effect. Asmall report in
    1999 showed efficacy of BTX-A in tennis elbow,
    but little further research has addressed this.
28
Q
  1. Which of the following has been validated as
    effective in the treatment of neck pain?
    (1) Soft collar
    (2) Massage
    (3) Cervical traction, mechanical traction
    (4) Therapeutic exercises
A
  1. (D) In 2001, The Philadelphia Panel for Evidence
    Based Clinical Practice Guidelines on Selected
    Rehabilitation Interventions for Neck Pain
    reported on treatments for neck pain using the
    methods defined by the Cochrane collaboration.
    They found no evidence to include or exclude
    the use of thermotherapy, massage, electrical
    stimulation, mechanical cervical traction, and
    biofeedback in the treatment of neck pain. They
    did find that the only treatment with clinically
    important benefits was therapeutic exercises.
    Other studies have not found any benefit to any
    type of cervical orthosis for the treatment of
    neck pain.
29
Q
  1. In the treatment of a patient diagnosed with
    fibromyalgia syndrome, there is not a clear consensus
    on most therapies. Which of the following
    is (are) true regarding therapies for
    fibromyalgia?
    (1) Ultrasound and massage are effective
    treatments for the deep muscle aches of
    fibromyalgia
    (2) Recreational therapy can be an important
    aspect of return to socialization
    (3) Occupational therapy is less likely to
    help return a patient to function than
    other forms of therapy
    (4) Aerobic exercise is probably the most
    important therapeutic treatment for
    fibromyalgia
A
  1. (C)
  2. Active, not passive, treatments have been
    found to be occasionally helpful in treatment
    of fibromyalgia. Passive treatments such as
    ultrasound, diathermy, and/or massage
    have no long-lasting benefit.
  3. Often, recreational therapy is important to
    get the patient to move more freely and
    begin enjoying things again.
  4. Occupational therapy can help optimize
    ergonomics gait, work, sleep, and play postures.
    As such they are very helpful in
    returning to functional activities.
  5. Aerobic activity is the cornerstone of treatment
    for fibromyalgia. At least 20 minutes
    per day are recommended. The exact mechanism
    of its effectiveness is as of now unclear.
30
Q
  1. Which of the following regarding heat and cold
    therapies for pain is (are) true?
    (1) Both heat and cold have direct effects on
    the muscle spindle
    (2) Heat and cold are safe modalities and
    should be used extensively in the long
    term to get the best relief in chronic pain
    (3) Both heat and cold can be helpful in
    treatment of muscle spasm
    (4) Transcutaneous electrical nerve stimulation
    (TENS) has been consistently
    shown to be helpful in treating chronic
    muscle pains
A
  1. (B)
  2. and 3. Pain from muscle spasms can be
    treated by affecting the muscle spindle.
    Spindle firing rates are affected by both heat
    and cold. These changes are both direct and
    indirect. Use of these modalities may help the
    muscle return to its normal resting length, but
    the precise mechanism of alleviating muscle
    spasm is still under investigation.
  3. Heat and cold should be used with caution
    and to a limited extent in the rehabilitation
    of a chronic pain state.
  4. Studies of TENS, acupuncture, and cold laser
    have left questions about their usefulness in
    reducing discomfort associated with chronic
    pain.
31
Q
  1. Which of the following is (are) true regarding
    the treatment and rehabilitation of lateral epicondylitis
    (LE)?
    (1) The use of extra corporeal shock wave
    therapy in LE has been validated and
    should be used early on in the disease
    process for best results
    (2) Counterforce bracing in LE is a common
    treatment and has consistently been
    found to be of use
    (3) Cold therapy has been found to be a
    helpful adjunct to treatment of LE
    (4) Poor prognosis for recovery and return
    of function has been found with
    employment in manual jobs
A
  1. (D)
  2. Extra corporeal shock wave therapy has had
    conflict reports of efficacy by a Cochrane
    review.
  3. Counterforce bracing is the application of a
    non-elastic strap that supports the forearm
    in patients with LE. While some studies
    have shown efficacy in the treatment of LE,
    others have not.
  4. A meta-analysis of all therapy modalities
    showed no evidence for long-term benefit
    for any physical modality.
  5. Poor prognosis has been associated with
    high level of strain at work, high level of
    baseline pain, keyboarding, highly repetitive
    monotonous work, and manual jobs.