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1

A physical therapist has just completed the initial examination of a 45-year-old female
patient who presented with a chief concern of right lumbosacral pain. She is currently unable to participate in her normal exercise routine, and while she can still perform her work duties as a human resources manager, she is limited in the amount of time she can spend sitting at her desk. This is her second episode of pain in the same area; the first episode occurred 6 months ago after moving to a new home, and resolved 80% after 3 weeks without treatment. Her pain has recently increased again after lifting boxes of books from her garage up into her attic, and she became worried that her pain was not settling on its own. She is very concerned she may have done some permanent damage that will limit her ability to return to her normal active lifestyle. The patient’s
symptoms are nonirritable, and following the physical examination, the physical therapist
concludes that she fits the criteria for application of the clinical prediction rule for spinal manipulation.

1. What further considerations need to be reasoned through by this therapist in order to
determine whether or not it is appropriate to include lumbar spinal manipulation as part
of this patient’s plan of care?
a. consideration of whether or not the patient is comfortable and amenable to trying this
type of intervention.
b. consideration of whether or not the patient is similar enough to the population in
which the rule has been validated.
c. no further considerations are necessary as the patient’s examination findings fit the
clinical prediction rule.
d. both a and b are correct

D

2

A physical therapist has just completed the initial examination of a 45-year-old female
patient who presented with a chief concern of right lumbosacral pain. She is currently unable to
participate in her normal exercise routine, and while she can still perform her work duties as a
human resources manager, she is limited in the amount of time she can spend sitting at her desk.
This is her second episode of pain in the same area; the first episode occurred 6 months ago after
moving to a new home, and resolved 80% after 3 weeks without treatment. Her pain has recently
increased again after lifting boxes of books from her garage up into her attic, and she became
worried that her pain was not settling on its own. She is very concerned she may have done some
permanent damage that will limit her ability to return to her normal active lifestyle. The patient’s
symptoms are nonirritable, and following the physical examination, the physical therapist
concludes that she fits the criteria for application of the clinical prediction rule for spinal
manipulation.

Which clinical reasoning strategies should be employed in order to develop a diagnostic
understanding of this patient, consistent with a biopsychosocial approach to practice?
a. diagnostic reasoning and narrative reasoning strategies. 
b. diagnostic reasoning and teaching as reasoning strategies.
c. predictive reasoning and interactive reasoning strategies.
d. procedural reasoning and narrative reasoning strategies

A

3

A physical therapist has just completed the initial examination of a 45-year-old female
patient who presented with a chief concern of right lumbosacral pain. She is currently unable to
participate in her normal exercise routine, and while she can still perform her work duties as a
human resources manager, she is limited in the amount of time she can spend sitting at her desk.
This is her second episode of pain in the same area; the first episode occurred 6 months ago after
moving to a new home, and resolved 80% after 3 weeks without treatment. Her pain has recently
increased again after lifting boxes of books from her garage up into her attic, and she became
worried that her pain was not settling on its own. She is very concerned she may have done some
permanent damage that will limit her ability to return to her normal active lifestyle. The patient’s
symptoms are nonirritable, and following the physical examination, the physical therapist
concludes that she fits the criteria for application of the clinical prediction rule for spinal
manipulation

What clinical reasoning error would this therapist be at risk of committing if, at the first
follow-up visit, she assumed her reasoning was of good quality based only on the
patient’s reports of improvement in symptoms with sitting at work? 
a. confirmation bias.
b. inadequate testing of hypotheses. c. outcome bias. 
d. overemphasis on experiential knowledge

C

4

A physical therapist has just completed the initial examination of a 45-year-old female patient who presented with a chief concern of right lumbosacral pain. She is currently unable to participate in her normal exercise routine, and while she can still perform her work duties as a human resources manager, she is limited in the amount of time she can spend sitting at her desk. This is her second episode of pain in the same area; the first episode occurred 6 months ago after moving to a new home, and resolved 80% after 3 weeks without treatment. Her pain has recently increased again after lifting boxes of books from her garage up into her attic, and she became worried that her pain was not settling on its own. She is very concerned she may have done some permanent damage that will limit her ability to return to her normal active lifestyle. The patient’s symptoms are nonirritable, and following the physical examination, the physical therapist concludes that she fits the criteria for application of the clinical prediction rule for spinal manipulation.

Which of the following questions should be considered by this therapist in order to facilitate critical reflection about the clinical reasoning processes used?


a. How did you empirically validate any cause and effect relationship you have
recognized? 
b. What do you think your assumptions are about the way this type of patient usually
presents?
c. What is your understanding of the patient’s perspective on her problem?
d. Will you think or do anything differently in the future based on this experience?

B is incorrect

5

A 52-year-old woman was seen in physical therapy approximately 3 months after the onset of shoulder pain when her dog pulled on the leash she was holding. Pain was minimal at first but approximately 3 weeks later she began to have difficulty sleeping and noticed progressive pain and loss of shoulder motion. The patient is a computer programmer and has been able to work without much difficulty. On examination the patient has active elevation of 120°, external rotation with the arm at the side is 30°, and functional internal rotation is to the sacrum. Passively, elevation is 110°, external rotation with the arm at the side is 20°, and functional internal rotation reach is to the level of L5 vertebra on the spine. All active and passive end ranges are painful. Resisted abduction and external rotation are strong with slight pain. Both Neer and Hawkins impingement signs are positive.

Which of the following is the most likely diagnosis?

a. biceps tendinitis.
b. frozen shoulder (adhesive capsulitis).
c. full thickness subscapularis tear.
d. full thickness supraspinatus tear.

B

6

A 52-year-old woman was seen in physical therapy approximately 3 months after the onset of shoulder pain when her dog pulled on the leash she was holding. Pain was minimal at first but approximately 3 weeks later she began to have difficulty sleeping and noticed progressive pain and loss of shoulder motion. The patient is a computer programmer and has been able to work without much difficulty. On examination the patient has active elevation of 120°, external rotation with the arm at the side is 30°, and functional internal rotation is to the sacrum. Passively, elevation is 110°, external rotation with the arm at the side is 20°, and functional internal rotation reach is to the level of L5 vertebra on the spine. All active and passive end ranges are painful. Resisted abduction and external rotation are strong with slight pain. Both Neer and Hawkins impingement signs are positive.

If symptoms worsened with physical therapy intervention, which of the following would be indicated?

a. acupuncture.
b. intraarticular glenohumeral corticosteroid injection.
c. long head of the biceps corticosteroid injection.
d. subacromial corticosteroid injection.

B

7

A 52-year-old woman was seen in physical therapy approximately 3 months after the onset of shoulder pain when her dog pulled on the leash she was holding. Pain was minimal at first but approximately 3 weeks later she began to have difficulty sleeping and noticed progressive pain and loss of shoulder motion. The patient is a computer programmer and has been able to work without much difficulty. On examination the patient has active elevation of 120°, external rotation with the arm at the side is 30°, and functional internal rotation is to the sacrum. Passively, elevation is 110°, external rotation with the arm at the side is 20°, and functional internal rotation reach is to the level of L5 vertebra on the spine. All active and passive end ranges are painful. Resisted abduction and external rotation are strong with slight pain. Both Neer and Hawkins impingement signs are positive.

 What stretching has been advocated to promote plastic deformation of the capsular tissue when working with a patient with frozen shoulder (adhesive capsulitis)?

high load brief stretching.
b. low load prolonged stretching.
c. manipulation.
d. shoulder thrust maneuvers.

B

8

A 52-year-old woman was seen in physical therapy approximately 3 months after the onset of shoulder pain when her dog pulled on the leash she was holding. Pain was minimal at first but approximately 3 weeks later she began to have difficulty sleeping and noticed progressive pain and loss of shoulder motion. The patient is a computer programmer and has been able to work without much difficulty. On examination the patient has active elevation of 120°, external rotation with the arm at the side is 30°, and functional internal rotation is to the sacrum. Passively, elevation is 110°, external rotation with the arm at the side is 20°, and functional internal rotation reach is to the level of L5 vertebra on the spine. All active and passive end ranges are painful. Resisted abduction and external rotation are strong with slight pain. Both Neer and Hawkins impingement signs are positive.

According to the capsular pattern description provided by Cyriax,322 which of the following best describes the typical capsular response to a frozen shoulder?


a. forward flexion is less limited than external rotation range of motion.
b. forward flexion is more limited in range of motion than internal rotation.
c. forward flexion is the most limited range of motion.
d. internal rotation is always the most limited range of motion

A

9

A 38-year-old male electrician complains of numbness and tingling into his hand with “clumsiness” holding and operating various tools of his profession. He recounts an insidious onset of symptoms. Now the symptoms have progressed to the point where they are interfering with his job tasks. He reports mild pain on the inside of his elbow and some “clicking” that is not painful. He is a smoker, mildly overweight, and states that he may have “hypertension.”

Observation reveals a well developed male with hypertrophy throughout the upper extremities, especially of the brachium and forearm. He exhibits a forward head posture, increased thoracic kyphosis, bilateral humeral internal rotation with forward positioning of the glenohumeral heads, and scapular abduction. Visually, there is atrophy at the medial aspect of the hand and hypothenar region. The resting position of the 5th digit is in mild abduction. You palpate subluxation of the ulnar nerve in the cubital tunnel during passive flexion and extension of the elbow.

9. In best practice, which of the following physical examination tests would demonstrate the greatest diagnostic accuracy for determining if this patient has ulnar nerve compression or neuritis?

a. elbow flexion test.
b. Froment sign.
c. pressure provocative test.
d. scratch collapse test.

C

10

A 38-year-old male electrician complains of numbness and tingling into his hand with “clumsiness” holding and operating various tools of his profession. He recounts an insidious onset of symptoms. Now the symptoms have progressed to the point where they are interfering with his job tasks. He reports mild pain on the inside of his elbow and some “clicking” that is not painful. He is a smoker, mildly overweight, and states that he may have “hypertension.”

Observation reveals a well developed male with hypertrophy throughout the upper extremities, especially of the brachium and forearm. He exhibits a forward head posture, increased thoracic kyphosis, bilateral humeral internal rotation with forward positioning of the glenohumeral heads, and scapular abduction. Visually, there is atrophy at the medial aspect of the hand and hypothenar region. The resting position of the 5th digit is in mild abduction. You palpate subluxation of the ulnar nerve in the cubital tunnel during passive flexion and extension of the elbow.

10. Which of the following is correct for patient education and activity modification in this case?


a. avoid elbow flexion or excessive wrist flexion/finger flexion. 
b. immobilize daily in full extension and forearm supination.
c. self massage of the compression sites of the ulnar nerve. 
d. stretch the pectoral muscles with the shoulder positioned in 90° abduction

A

11

A 38-year-old male electrician complains of numbness and tingling into his hand with “clumsiness” holding and operating various tools of his profession. He recounts an insidious onset of symptoms. Now the symptoms have progressed to the point where they are interfering with his job tasks. He reports mild pain on the inside of his elbow and some “clicking” that is not painful. He is a smoker, mildly overweight, and states that he may have “hypertension.”

Observation reveals a well developed male with hypertrophy throughout the upper extremities, especially of the brachium and forearm. He exhibits a forward head posture, increased thoracic kyphosis, bilateral humeral internal rotation with forward positioning of the glenohumeral heads, and scapular abduction. Visually, there is atrophy at the medial aspect of the hand and hypothenar region. The resting position of the 5th digit is in mild abduction. You palpate subluxation of the ulnar nerve in the cubital tunnel during passive flexion and extension of the elbow.

11. Which of the following is a key component of his initial visit?

a. discovery of possible underlying irritants of the nerve.
b. kinetic chain strengthening of the shoulder.
c. operative management should be recommended.
d. provide the patient with an elbow pad to protect the medial elbow

A

12

A 38-year-old male electrician complains of numbness and tingling into his hand with “clumsiness” holding and operating various tools of his profession. He recounts an insidious onset of symptoms. Now the symptoms have progressed to the point where they are interfering with his job tasks. He reports mild pain on the inside of his elbow and some “clicking” that is not painful. He is a smoker, mildly overweight, and states that he may have “hypertension.”

Observation reveals a well developed male with hypertrophy throughout the upper extremities, especially of the brachium and forearm. He exhibits a forward head posture, increased thoracic kyphosis, bilateral humeral internal rotation with forward positioning of the glenohumeral heads, and scapular abduction. Visually, there is atrophy at the medial aspect of the hand and hypothenar region. The resting position of the 5th digit is in mild abduction. You palpate subluxation of the ulnar nerve in the cubital tunnel during passive flexion and extension of the elbow.

12. The patient has noted a decrease in the frequency and intensity of his symptoms of numbness and tingling during daily tasks. The atrophy of the hypothenar region has maintained but has not progressed. Which of the following is most appropriate to advance the plan of care?

a. mobilization of the fascia of wrist flexors and pronators with the elbow in flexion. 
b. prescribe elastic band exercises into full shoulder external rotation with humerus at 0°
of adduction.
c. stretches of the pectoralis minor at the 90–90 position of the shoulder.
d. thoracic spine mobilizations in the posterior to anterior direction of grades III–IV.

C is incorrect

13

Your new patient is a 21-year-old right-hand dominant female who lacerated her index and long finger flexor digitorum superficialis and flexor digitorum profundus tendons in zone 2 with a knife while cooking 3 days ago. She is 2 days status post primary repair. She presents to the clinic in a postoperative dressing with a referral that says: “Evaluate and treat with flexor tendon protocol.”

13. Which of the following sutures allows light active range of motion throughout the recovery?

a. 2-strand core with a peripheral epitendinous suture.
b. 4-strand core with a peripheral epitendinous suture.
c. 6-strand core with a peripheral epitendinous suture.
d. 6-strand core without a peripheral epitendinous suture.

B

14

Your new patient is a 21-year-old right-hand dominant female who lacerated her index and long finger flexor digitorum superficialis and flexor digitorum profundus tendons in zone 2 with a knife while cooking 3 days ago. She is 2 days status post primary repair. She presents to the clinic in a postoperative dressing with a referral that says: “Evaluate and treat with flexor tendon protocol.”

14. What is the primary goal for this phase of the recovery?

a. a strong repair that glides freely.
b. extrinsic muscle flexibility.
c. restoration of grip strength.
d. scar mobilization.

A

15

Your new patient is a 21-year-old right-hand dominant female who lacerated her index and long finger flexor digitorum superficialis and flexor digitorum profundus tendons in zone 2 with a knife while cooking 3 days ago. She is 2 days status post primary repair. She presents to the clinic in a postoperative dressing with a referral that says: “Evaluate and treat with flexor tendon protocol.”

Prior to proceeding with the examination, the therapist should determine:
a. if there are any associated injuries (ie, nerve or artery repair).
b. the patient’s occupation.
c. the type of suture.
d. all of the above.

D

16

Your new patient is a 21-year-old right-hand dominant female who lacerated her index and long finger flexor digitorum superficialis and flexor digitorum profundus tendons in zone 2 with a knife while cooking 3 days ago. She is 2 days status post primary repair. She presents to the clinic in a postoperative dressing with a referral that says: “Evaluate and treat with flexor tendon protocol.”

16. The therapist contacts the physician and ascertains the Duran protocol is preferred in this case. Therefore, the first therapy visit should include:

a. application of a volar forearm splint with the wrist and digits held at neutral.
b. application of rubber band traction to hold the digit in flexion.
c. initiation of active proximal interphalangeal and distal interphalangeal joint motion
exercises with the metacarpophalangeal joints in slight flexion.
d. initiation of passive proximal interphalangeal and distal interphalangeal joint flexion
with the metacarpophalangeal joints in slight flexion.

D

17

DD is a 29-year-old female attorney who complains of the inability to open her mouth
upon awakening in the morning over several days. She needs to move her jaw around many
times to “pop it open.” She is worried that her mouth will not open without this maneuver. She also reports pain over her right temporomandibular joint and right ear, as well as constant
headaches.
The patient’s history revealed similar locking episodes in the past (about one year
earlier), and the symptoms were relieved by hot pack or cold pack application. DD also reports a
scooter accident a few years ago that resulted in her falling, with the right side of her face hitting
the ground. 
Objective assessment revealed limited mouth opening to 25 mm without deviation and
pain. However, the patient is able to open wide to 40 mm after moving her jaw around which
causes a “popping” of the joint. Intermittent opening clicks were audible through auscultation.
The patient also reports a softer closing click. Lateral deviation is 10 mm to the right, and 7 mm
to the left. Palpable tenderness was noted intraorally and extraorally around the right
temporomandibular joint area. DD is currently wearing a night splint to prevent clenching and
bruxing.
Using the information above, which of the following is the most likely diagnosis for
DD’s temporomandibular joint dysfunction?
a. anterior disk displacement without reduction.
b. anterior disk displacement with reduction.
c. myofascial pain disorder syndrome.
d. posterior disk displacement.

B

18

DD is a 29-year-old female attorney who complains of the inability to open her mouth upon awakening in the morning over several days. She needs to move her jaw around many times to “pop it open.” She is worried that her mouth will not open without this maneuver. She also reports pain over her right temporomandibular joint and right ear, as well as constant headaches.

The patient’s history revealed similar locking episodes in the past (about one year earlier), and the symptoms were relieved by hot pack or cold pack application. DD also reports a scooter accident a few years ago that resulted in her falling, with the right side of her face hitting the ground.

Objective assessment revealed limited mouth opening to 25 mm without deviation and pain. However, the patient is able to open wide to 40 mm after moving her jaw around which causes a “popping” of the joint. Intermittent opening clicks were audible through auscultation. The patient also reports a softer closing click. Lateral deviation is 10 mm to the right, and 7 mm to the left. Palpable tenderness was noted intraorally and extraorally around the right temporomandibular joint area. DD is currently wearing a night splint to prevent clenching and bruxing.

A physical therapy program was provided to DD with emphasis on postural correction, oral habit modification, modality treatment, and joint mobilization to the temporomandibular joint and upper cervical spine. After two weeks of treatment, DD reports a decrease in earaches and headaches. Her pain-free opening range has increased to 31 mm, yet she still complains of tenderness around her mandibular angle intraorally and extraorally.

18. To relieve tension in DD’s mandibular elevators, which of the following is the most beneficial exercise program?

a. condylar remodeling exercise.
b. isometric closing exercise against finger above chin.
c. isometric opening exercise against hand under chin.
d. therapeutic exercise for clicking due to anterior disk displacement with reduction

A

19

DD is a 29-year-old female attorney who complains of the inability to open her mouth upon awakening in the morning over several days. She needs to move her jaw around many times to “pop it open.” She is worried that her mouth will not open without this maneuver. She also reports pain over her right temporomandibular joint and right ear, as well as constant headaches.

The patient’s history revealed similar locking episodes in the past (about one year earlier), and the symptoms were relieved by hot pack or cold pack application. DD also reports a scooter accident a few years ago that resulted in her falling, with the right side of her face hitting the ground.

Objective assessment revealed limited mouth opening to 25 mm without deviation and pain. However, the patient is able to open wide to 40 mm after moving her jaw around which causes a “popping” of the joint. Intermittent opening clicks were audible through auscultation. The patient also reports a softer closing click. Lateral deviation is 10 mm to the right, and 7 mm to the left. Palpable tenderness was noted intraorally and extraorally around the right temporomandibular joint area. DD is currently wearing a night splint to prevent clenching and bruxing.

After 4 weeks of physical therapy, the patient’s condition is stabilized at a 34-mm opening, but she still has the urge to “pop” open her mouth to “unlock” her jaw. The reciprocal noise is no longer present, and the pain still persists. At this time, you recommend DD to have a consultation with an oral surgeon. After that, arthrocentesis was recommended and performed.

19. Following a successful outcome from surgery, you would expect to see DD’s condition improved with decreased pain and __________:

a. opening to two fingers’ width, lateral excursion is one-fourth of opening bilaterally.
b. opening to two fingers’ width, lateral excursion is one-third of opening bilaterally.
c. opening to 3 fingers’ width, lateral excursion is one-fourth of opening bilaterally.
d. opening to 3 fingers’ width, lateral excursion is one-third of opening bilaterally

C

20

DD is a 29-year-old female attorney who complains of the inability to open her mouth upon awakening in the morning over several days. She needs to move her jaw around many times to “pop it open.” She is worried that her mouth will not open without this maneuver. She also reports pain over her right temporomandibular joint and right ear, as well as constant headaches.

The patient’s history revealed similar locking episodes in the past (about one year earlier), and the symptoms were relieved by hot pack or cold pack application. DD also reports a scooter accident a few years ago that resulted in her falling, with the right side of her face hitting the ground.

Objective assessment revealed limited mouth opening to 25 mm without deviation and pain. However, the patient is able to open wide to 40 mm after moving her jaw around which causes a “popping” of the joint. Intermittent opening clicks were audible through auscultation. The patient also reports a softer closing click. Lateral deviation is 10 mm to the right, and 7 mm to the left. Palpable tenderness was noted intraorally and extraorally around the right temporomandibular joint area. DD is currently wearing a night splint to prevent clenching and bruxing.

Which of the following programs is most appropriate for postoperative management? 
a. modalities and condylar remodeling exercise.
b. modalities, myofascial release, joint mobilization, and stretching exercise.
c. modalities only, no exercise.
d. modalities, self stretching only.

B

21

A 39-year-old right-handed male patient is referred to physical therapy with a chief complaint of neck and arm pain. The pain is located on the left side of the neck and down the left arm. He describes the location on left lateral neck, left anterolateral shoulder, and lateral arm down to mid forearm. The pain is a constant, sharp shooting, radiating pain that he rates as an 8/10 on a numerical pain rating scale. He also states that he has numbness and tingling along the lateral arm and forearm. The physical therapist begins the examination with postural assessment. The physical therapist notices that the patient maintains a slightly side bent head to the right. The next step is a range of motion assessment. Flexion appears to be within normal limits with no change in the patient’s pain; extension is limited to 35° with increased pain in the neck, shoulder, and arm; rotation to the right is 78° with no change in symptoms; and rotation to the left is 49° with slight increase in symptoms. Neurological testing is performed and the patient has weakness in the left biceps brachii and extensor carpi radialis longus and brevis, absent sensation on the left distal thumb, and diminished deep tendon reflexes at the brachioradialis. All other areas tested normal. The Spurling test is performed and is positive on the left while negative on the right. An upper limb tension test with a median nerve bias is also performed on this patient. The results on the right show that the patient is able to get shoulder abduction to 100°, external rotation to 85°, full forearm pronation, ulna deviation, wrist extension, and elbow extension 20° from full extension. The left shows 100° shoulder abduction, external rotation to 60°, forearm pronation to 50°, full ulnar deviation and wrist extension, and elbow extension 45° from full elbow extension.

21. The physical therapist has completed his evaluation. Given the above findings, the physical therapist classified this patient into which category?

a. neck pain with headaches.
b. neck pain with mobility deficits.
c. neck pain with movement coordination deficits.
d. neck pain with radiating pain.

D

22

A 39-year-old right-handed male patient is referred to physical therapy with a chief complaint of neck and arm pain. The pain is located on the left side of the neck and down the left arm. He describes the location on left lateral neck, left anterolateral shoulder, and lateral arm down to mid forearm. The pain is a constant, sharp shooting, radiating pain that he rates as an 8/10 on a numerical pain rating scale. He also states that he has numbness and tingling along the lateral arm and forearm. The physical therapist begins the examination with postural assessment. The physical therapist notices that the patient maintains a slightly side bent head to the right. The next step is a range of motion assessment. Flexion appears to be within normal limits with no change in the patient’s pain; extension is limited to 35° with increased pain in the neck, shoulder, and arm; rotation to the right is 78° with no change in symptoms; and rotation to the left is 49° with slight increase in symptoms. Neurological testing is performed and the patient has weakness in the left biceps brachii and extensor carpi radialis longus and brevis, absent sensation on the left distal thumb, and diminished deep tendon reflexes at the brachioradialis. All other areas tested normal. The Spurling test is performed and is positive on the left while negative on the right. An upper limb tension test with a median nerve bias is also performed on this patient. The results on the right show that the patient is able to get shoulder abduction to 100°, external rotation to 85°, full forearm pronation, ulna deviation, wrist extension, and elbow extension 20° from full extension. The left shows 100° shoulder abduction, external rotation to 60°, forearm pronation to 50°, full ulnar deviation and wrist extension, and elbow extension 45° from full elbow extension.

22. What is the next physical examination test the physical therapist should conduct?

a. distraction test.
b. neck flexor endurance test.
c. radial nerve tension test.
d. Sharp-Purser test. 

A

23

A 39-year-old right-handed male patient is referred to physical therapy with a chief complaint of neck and arm pain. The pain is located on the left side of the neck and down the left arm. He describes the location on left lateral neck, left anterolateral shoulder, and lateral arm down to mid forearm. The pain is a constant, sharp shooting, radiating pain that he rates as an 8/10 on a numerical pain rating scale. He also states that he has numbness and tingling along the lateral arm and forearm. The physical therapist begins the examination with postural assessment. The physical therapist notices that the patient maintains a slightly side bent head to the right. The next step is a range of motion assessment. Flexion appears to be within normal limits with no change in the patient’s pain; extension is limited to 35° with increased pain in the neck, shoulder, and arm; rotation to the right is 78° with no change in symptoms; and rotation to the left is 49° with slight increase in symptoms. Neurological testing is performed and the patient has weakness in the left biceps brachii and extensor carpi radialis longus and brevis, absent sensation on the left distal thumb, and diminished deep tendon reflexes at the brachioradialis. All other areas tested normal. The Spurling test is performed and is positive on the left while negative on the right. An upper limb tension test with a median nerve bias is also performed on this patient. The results on the right show that the patient is able to get shoulder abduction to 100°, external rotation to 85°, full forearm pronation, ulna deviation, wrist extension, and elbow extension 20° from full extension. The left shows 100° shoulder abduction, external rotation to 60°, forearm pronation to 50°, full ulnar deviation and wrist extension, and elbow extension 45° from full elbow extension. 

What intervention will be the most beneficial for this patient?
a. cervical collar and stabilization exercises.
b. cervical manipulation and stretching.
c. cervical traction and thoracic manipulation
d. transcutaneous electrical nerve stimulation and ergonomic instruction

C

24

A 39-year-old right-handed male patient is referred to physical therapy with a chief complaint of neck and arm pain. The pain is located on the left side of the neck and down the left arm. He describes the location on left lateral neck, left anterolateral shoulder, and lateral arm down to mid forearm. The pain is a constant, sharp shooting, radiating pain that he rates as an 8/10 on a numerical pain rating scale. He also states that he has numbness and tingling along the lateral arm and forearm. The physical therapist begins the examination with postural assessment. The physical therapist notices that the patient maintains a slightly side bent head to the right. The next step is a range of motion assessment. Flexion appears to be within normal limits with no change in the patient’s pain; extension is limited to 35° with increased pain in the neck, shoulder, and arm; rotation to the right is 78° with no change in symptoms; and rotation to the left is 49° with slight increase in symptoms. Neurological testing is performed and the patient has weakness in the left biceps brachii and extensor carpi radialis longus and brevis, absent sensation on the left distal thumb, and diminished deep tendon reflexes at the brachioradialis. All other areas tested normal. The Spurling test is performed and is positive on the left while negative on the right. An upper limb tension test with a median nerve bias is also performed on this patient. The results on the right show that the patient is able to get shoulder abduction to 100°, external rotation to 85°, full forearm pronation, ulna deviation, wrist extension, and elbow extension 20° from full extension. The left shows 100° shoulder abduction, external rotation to 60°, forearm pronation to 50°, full ulnar deviation and wrist extension, and elbow extension 45° from full elbow extension.

The patient is a right-handed 39-year-old male. The treatment plan consists of manual therapy, intermittent cervical traction, and deep neck flexor exercises throughout the course of care. Which other factor will help predict a favorable outcome in this patient?

a. flexion does not worsen symptoms.
b. no numbness present.
c. normal deep tendon reflexes.
d. positive median nerve tension test.

A

25

A 43-year-old male reports to physical therapy with a chief complaint of lower thoracic
pain. He is employed as a police officer and enjoys golfing and jogging. His symptoms are
located in the right lower thoracic region. He denies radiating pain, numbness, tingling, and pain
that wakes him at night. His pain is increased with full inspiration, activities involving left trunk
rotation such as his golf swing, and sitting in his police cruiser for longer than one hour. His
symptoms are eased with lying down and ibuprofen. The symptoms began 3 weeks ago after he
lifted a heavy washing machine out of his basement. He experienced immediate sharp pain in the
right lower thoracic region that gradually worsened throughout the day. He went to his primary
physician a week later who prescribed ibuprofen, ordered thoracic spine radiographs, and
referred him to physical therapy. The radiographs were interpreted as normal. His past medical
history is unremarkable and this is his first episode of back pain. He has been able to continue his
work activities but has not been able to play golf since his injury. His goals are to reduce his pain
while sitting in the cruiser at work and return to playing golf. He rates his pain on average as
6/10.
 
25. Given the location of the patient's pain, which of the following nonmusculoskeletal
conditions is most likely?
a. bony metastasis.
b. cholecystitis.
c. kidney stone.
d. peptic ulcer.

C

26

A 43-year-old male reports to physical therapy with a chief complaint of lower thoracic pain. He is employed as a police officer and enjoys golfing and jogging. His symptoms are located in the right lower thoracic region. He denies radiating pain, numbness, tingling, and pain that wakes him at night. His pain is increased with full inspiration, activities involving left trunk rotation such as his golf swing, and sitting in his police cruiser for longer than one hour. His symptoms are eased with lying down and ibuprofen. The symptoms began 3 weeks ago after he lifted a heavy washing machine out of his basement. He experienced immediate sharp pain in the right lower thoracic region that gradually worsened throughout the day. He went to his primary physician a week later who prescribed ibuprofen, ordered thoracic spine radiographs, and referred him to physical therapy. The radiographs were interpreted as normal. His past medical history is unremarkable and this is his first episode of back pain. He has been able to continue his work activities but has not been able to play golf since his injury. His goals are to reduce his pain while sitting in the cruiser at work and return to playing golf. He rates his pain on average as 6/10.

26. Which of the following outcome measures is most appropriate for this patient?

a. Neck Disability Index.
b. Oswestry Disability Index.
c. Patient-Specific Functional Scale.
d. either b or c.

27

A 43-year-old male reports to physical therapy with a chief complaint of lower thoracic pain. He is employed as a police officer and enjoys golfing and jogging. His symptoms are located in the right lower thoracic region. He denies radiating pain, numbness, tingling, and pain that wakes him at night. His pain is increased with full inspiration, activities involving left trunk rotation such as his golf swing, and sitting in his police cruiser for longer than one hour. His symptoms are eased with lying down and ibuprofen. The symptoms began 3 weeks ago after he lifted a heavy washing machine out of his basement. He experienced immediate sharp pain in the right lower thoracic region that gradually worsened throughout the day. He went to his primary physician a week later who prescribed ibuprofen, ordered thoracic spine radiographs, and referred him to physical therapy. The radiographs were interpreted as normal. His past medical history is unremarkable and this is his first episode of back pain. He has been able to continue his work activities but has not been able to play golf since his injury. His goals are to reduce his pain while sitting in the cruiser at work and return to playing golf. He rates his pain on average as 6/10.

27. Which of the following musculoskeletal conditions is most likely?


a. mechanical thoracic spine pain.
b. thoracic compression fracture.
c. thoracic facet joint dysfunction.
d. thoracic herniated disk

A

28

A 43-year-old male reports to physical therapy with a chief complaint of lower thoracic pain. He is employed as a police officer and enjoys golfing and jogging. His symptoms are located in the right lower thoracic region. He denies radiating pain, numbness, tingling, and pain that wakes him at night. His pain is increased with full inspiration, activities involving left trunk rotation such as his golf swing, and sitting in his police cruiser for longer than one hour. His symptoms are eased with lying down and ibuprofen. The symptoms began 3 weeks ago after he lifted a heavy washing machine out of his basement. He experienced immediate sharp pain in the right lower thoracic region that gradually worsened throughout the day. He went to his primary physician a week later who prescribed ibuprofen, ordered thoracic spine radiographs, and referred him to physical therapy. The radiographs were interpreted as normal. His past medical history is unremarkable and this is his first episode of back pain. He has been able to continue his work activities but has not been able to play golf since his injury. His goals are to reduce his pain while sitting in the cruiser at work and return to playing golf. He rates his pain on average as 6/10.

The patient presents with a normal lower quarter neurological examination, an increased lower thoracic kyphosis, and 50% limitation in left thoracic rotation. His symptoms are reproduced with left trunk rotation and right unilateral posterior to anterior spring testing over T10-11.

Which of the following interventions is best indicated for this patient?

a. prone lower thoracic manipulation.
b. seated middle thoracic manipulation.  
c. seated thoracolumbar rotation manipulation.
d. supine middle thoracic manipulation.

C

29

The patient is a 33-year-old man who works in a factory where he is responsible for driving a fork-lift and lifting heavy cases of soft drinks several times throughout the day. He presents with a chief complaint of chronic low back pain that ranges from 3/10 at rest to 9/10 at the end of the day. His symptoms began several years ago when he tried to stop a pallet of soft drinks from falling off a truck. He felt a sudden “pop” in his back and indicates that it has not been “right” since that time. He has had several periods of lost work time due to low back pain and has currently been out of work on a Worker’s Compensation claim for one month. This patient has had 2 lumbar magnetic resonance imaging examinations that revealed mildly degenerative, bulging disks at L4-5 and L5-S1. His previous physical therapy treatment has been centered on pain control approaches using moist heat and ultrasound. He indicates that he was instructed in the performance of sit-up exercises but stopped doing them after a couple of days because they increased his pain. He has avoided physical activity and exercise since that time.

29. Which of the factors listed below is least likely to contribute to a poor prognosis for

a. a history of multiple episodes of lost work time.
b. a physically demanding job.
c. high pain intensity at the end of the day.
d. the presence of bulging disks

D

30

The patient is a 33-year-old man who works in a factory where he is responsible for driving a fork-lift and lifting heavy cases of soft drinks several times throughout the day. He presents with a chief complaint of chronic low back pain that ranges from 3/10 at rest to 9/10 at the end of the day. His symptoms began several years ago when he tried to stop a pallet of soft drinks from falling off a truck. He felt a sudden “pop” in his back and indicates that it has not been “right” since that time. He has had several periods of lost work time due to low back pain and has currently been out of work on a Worker’s Compensation claim for one month. This patient has had 2 lumbar magnetic resonance imaging examinations that revealed mildly degenerative, bulging disks at L4-5 and L5-S1. His previous physical therapy treatment has been centered on pain control approaches using moist heat and ultrasound. He indicates that he was instructed in the performance of sit-up exercises but stopped doing them after a couple of days because they increased his pain. He has avoided physical activity and exercise since that time.

What components of the patient’s history suggest the presence of yellow flags?
a. a history of multiple episodes of lost work time.
b. avoidance of exercise and physical activity.
c. current Worker’s Compensation claim.
d. the presence of chronic symptoms.

C is incorrect