RAT Cards Flashcards by Gabe Reardon

What is the single strongest clue of the following supporting a radiculopathy?

a) Repetitive cervical extension centralizes
b) Loss of vibratory sense in the little finger
c) Cervical compression causes arm pain
d) Patellar hyperreflexia
e) shoulder abduction relieves arm symptoms

a) loss of vibratory sense of little finger

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Which of the following would be the strongest indication of a radiculopathy?

a) shoulder abduction increases arm pain
b) Valsalva reproduces arm pain
c) SLR creates severe LBP
d) Achilles hyperreflexia
e) ankle clonus

b) Valsalva reproduces arm pain

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Your patient landed hard on her snow mobile after hitting a mogul and becoming airborne; she experienced immediate LBP which of the following would be on your DDX?

a) Disc derangement
b) Disc herniation with nerve root damage
c) Lumbar strain
d) Lumbar sprain
e) Facet syndrome

d) lumbar sprain

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Your patient has signs and symptoms of lumbar radicular syndrome. which of the following would be at the top of your DDX list?

a) disc derangement
b) spinal stenosis
c) metastatic bone cancer
d) facet syndrome
e) spurs lodged in IVF

b) spinal stenosis

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Based on the results of your history and physical your patient may have a spinal disease. what should be ordered first?

CRP, CBC, blood chemistry screen

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What two ancillary tests can actually confirm that nerve roots/nerves are damaged and not functioning properly?

Electromyelograph and nerve velocity (conduction) test

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Your patient has a low back flexion load sensitivity and has to sit all day at work. What are two recommendations you could suggest?

Perform hip hinging (abdominal bracing) and bruegger’s relief position [many others]

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What are two specific diagnosis to think of first when a pt has LBP w/o nerve symptoms after a high load flexion injury?

Lumbar sprain (posterior ligaments), compression fracture

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Excluding diseases what are three common SI injury diagnoses covered in class?

SI joint dysfunction, SI syndrome, SI sprain

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Your 68 year old patient has LBP, no leg symptoms but is getting progressive foot drop. What lumbar diagnosis are you most concerned about? what would be the first ancillary test to order?

The patient may have an SOL.

First order an x-ray and then order an MRI.

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Your pt landed hard on her snowmobile after hitting a mogul and becoming airborne; she experienced immediate low back pain. What are your top two dx concerns in the lumbar spine for this patient?

Compression fracture or a lumbar sprain

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Your pt has a low back extension load sensitivity. Based on the coursenotes, what are 3 specific activity modifications you could suggest?

Lower items in the shower, don’t wear high heels, no heavy lifting above the waist

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What are three specific diagnosis to think when your patient has LBP due to a high load flexion history?

Disc injury, sprain of posterior lumbar ligaments, compression fractures

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In an AS patient what two special spine related physical exams should be performed?

Schober’s test; Normal: at least 5cm of additional separation when two marks are placed on the spine 10 cm apart

Chest expansion; Normal is > or equal to 5cm

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Which of the following would suggest a possible radiculopathy in a patient with radicular arm pain?

a) Repetitive cervical extension centralizes the arm symptoms
b) Grade 4 muscle weakness of the biceps
c) Valsalva causes arm pain
d) Tricep hyperreflexia
e) Shoulder abduction relieves the arm symptoms

b) Grade 4 muscle weakness of the biceps

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What are the four more general categories of injury besides trauma?

repetitive/overuse, normal movement in an unstable spine, sudden unguarded motion, sustained postural loading

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What are the parts of the 5 item toolbox to determine neuropathic pain

Pain (distal/dermatomal, stab/electric, extremity worse than BP, affected by spinal loading)
paresthesia in a dermatomal distribution
Change in SMR
Nerve tension tests recreating pain
Spinal loading/positioning with immediate pain

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Your patient has a low back extension load sensitivity and he has a job where he has to stand most of the day. Based on the course notes, what are 2 specific activity modifications you could suggest?

Lean over the desk to create flexion in the low back

Stand with one leg perched on ledge or stool

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What are 2 specific diagnoses to think of when a patient lands hard on his buttock and now has LBP (but no leg symptoms)?

Lumbar sprain and compression fracture

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What are 5 diseases that cause sacroiliitis covered in this course?

What test would be most positive with all of these

AS, RA, Reiter’s syndrome, Psoriatic arthritis, enterpathic arthropathies (chron’s and ulcerative colitis)

HLA-B27

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You suspect that your patient may have a disease causing her LBP. What are the first 4 ancillary studies to consider ordering?

Plain film x-rays, ESR, CBC, Complete Metabolic Panel

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Beginning at what age would you want to x-ray a patient with sudden onset of spontaneous low back pain?

The patient may be osteoporotic with a spontaneous fracture

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At what age in men and women should you start to suspect an AAA as a cause of sudden spontaneous low back pain?

Men: 50-55 y/o
Women: 60-65 y/o

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What is the most common location for a compression fracture?

TLJ (T12-L1)

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What are all three physical exam findings from the 5 point checklist to detect neural damage in a patient with low back and leg pain?

Changes in SMR Pain recreated with nerve tension tests Change in symptoms with change in spinal loading

What are four major types of categories that should trigger ordering an MRI in a patient within the first few visits of managing a suspected disc herniation?

Muscle weakness is progressing or severe Signs of CES Suspected upper lumbar disc herniation Performed as part of a surgical consult

List 4 clues from the physical supporting a disc derangement. Which is strongest?

Flexion load sensitivity Pain centralizes with extension (strongest) Worse with sitting Painful or tender adjacent SP

What are 5 positive physical exam findings that support a cervical dis derangement

Neck flexion load sensitivity Pain centralizes with repetitive extension Pain with cervical compression Pain with Valsalva Pain is relieved with cervical distraction

Besides a hyperextension injury what are two other traumatic mechanisms that can directly damage a nerve root?

Fall on head laterally flexing head away and depressing arm. | Fall directly on head causing axial compression

Your patient has neck pain accompanied by sharp pain along the back of the triceps and a “numb” feeling in the 4th and 5th fingers. Neck AROM is severely limited in flexion due to neck pain. Cervical compression and Valsalva create neck pain and the shoulder abduction test decreases the finger numbness. SMR testing are all normal. Write a complete diagnosis for this case.

Mild traumatic C8 disc herniation with paresthesia to 4th and 5th finger

What is considered the gold standard test for a facet diagnosis?

Intra-articular anesthetic injections

For each of the following indicate whether the exam finding would support a sprain, strain or both. Pain with AROM Pain at end range during PROM Pain when initiating PROM

Both Both Sprain

Besides pain centralization with spinal loading, what are 3 other positive physical examination findings that would support a lumbar disc derangement over a facet syndrome?

Midline pain instead of facet pain, pain with flexion rather than extension (for a posterior derangement), valsalva is positive for disc derangement

What are the two most common types of trauma to create compression fracture in a healthy spine?

``` Fall in neutral Hyperflexion injury (compression) ```

Which of the SI orthopedic tests can suggest functional instability of the SI joint if it is positive?

ASLR | If positive then next try with abdominal bracing and check for pain

Your patient has chronic low back pain. Repetitive rotation decreases the leg pain (+LR 2.1 for discogenic pain). There are no signs of nerve involvement. What is the posttest probability that the patient may have a disc derangement?

40% +15% = 55%

In a 30 y/o patient what would be two types of trauma that could lead to a compression fracture?

Slip and fall/axial compression | Traumatic lifting injury with spine in flexion at end range

What are 3 major types of scenarios that should trigger ordering a radiograph for a patient with LBP?

Trauma Sufficient nerve damage Disease

One of the criterion for making a neuropathic pain diagnosis is key information about a patient’s extremity pain. What are 4 characteristics of that pain that suggest it is neuropathic?

Severity of pain (pain is greater in extremity than in back/neck Quality of pain (sharp, shooting, zinging) Pain is aggravated by spinal position Location (pain past elbow or knee)

Your patient appears to have a C7 radiculopathy. What are the 3 most common possible causes/diagnoses?

Disc herniation, stenosis, osteophytes | The A list

Your patient has neck pain accompanied by deep achy pain as far as the forearm. Neck AROM is severely limited in flexion due to neck pain. Cervical compression and Valsalva increase the neck pain, cervical distraction provides some relief. SMR testings are all normal. Write a complete diagnosis for this case.

Cervical disc derangement with deep referred pain to the forearm

Your patient has LBP and deep ache in his right calf. The back pain is aggravated by both flexion and extension. He cannot perform the bilateral active SLR due to pain. Valsalva and Kemp’s are negative. Sustained right rotation of the pelvis mildly aggravates the back pain but relieves the calf ache. He has no sensory, motor or reflex deficits and the SLR mildly aggravates the LBP. What is the most probable working diagnosis for this patient?

Lumbar disc derangement

Your patient has a traumatic cervical hyperflexion injury, posterior neck pain and no arm symptoms. Both active and passive cervical flexion are painful, especially at end range. Resisted isometric neck extension is the most aggravating test. Cervical compression, valsalva and extremity sensory, motor and reflex tests are all normal. Most probable working diagnosis for this patient is which of the following?

Cervical neck strain

What are the 3 key indications from the physical exam that would denote that a sprain was moderate to severe?

Generalized and marked tenderness and swelling Mild laxity - gross instability Moderate to marked ROM loss Pain on stress of tissue before end range

Your patient who is a janitor suffered a right rotational low back injury while riding his dirt bike. What are two specific, practical activity modifications that you could recommend?

If left handed then learn to use right hand for daily activities to avoid twisting and reaching to the right Avoid overreaching while cleaning

When testing a patient with neck and arm pain, besides cervical compression what are the other 4 orthopedic tests that are recommended to perform to screen for a radicular syndrome?

Cervical distraction, Shoulder abduction, ULTT - median nerve, valsalva

Your patient who works in a warehouse has a lumbar extension load sensitivity. What are three specific, practical activity modifications that you could recommend?

Avoid lifting items above the waist Lower shower items to not extend back Take breaks from standing for long periods of time

Which of the following would be the single strongest clue supporting a deranged disc? a) A positive SLR b) Repetitive lumbar rotation reduces the territory of the foot numbness c) Patellar hyperreflexia d) Positive Valsalva maneuver creates leg pain

b) Repetitive lumbar rotation reduces the territory of the foot numbness

Which of the following would generally be considered the most useful measure of the degree of severity of a patient’s acute low back condition? a) Palpatory segmental hypermobility b) Their PSFS rating c) Measuring AROM d) Severity of pain measured on a face scale e) Muscle testing their core stability muscles

b) Their PSFS rating

Which is a more helpful exam finding regarding Kemp’s test? a) Positive test for LBP helps to rule in a facet syndrome b) A negative test for LBP helps to rule out a facet syndrome c) Both positive and negative tests are equally helpful d) A positive test only supports a facet syndrome if it causes leg pain

b) A negative test for LBP helps to rule out a facet syndrome

Your patient has a traumatic hyperflexion injury, posterior neck pain and no arm symptoms. Both active and passive cervical flexion are painful at end range. Muscle tests in the arm are strong, but cervical extension muscle testing is painful and weak. Cervical distraction & compression, Valsalva, and extremity sensory and reflex tests are all normal. Palpation also reveal tender cervical thoracic junction locked into extension. What is your diagnosis (use the 4 part format)

Cervical paraspinal strain associated with a cervical thoracic junction joint dysfunction

For each of the following indicate whether the exam finding would support a) a sprain/joint injury, b) a strain, or c) could be either one: Pain with AROM Pain only at end range during PROM Pain with a resisted full ROM Pain starting at midrange PROM

C C C A

What are the best 3 key indications from the physical exam that would denote that a sprain or a collateral ligament in the knee was more moderate to severe? Choose what you think would be the strongest and most specific exam finding.

Laxity of ligaments with valgus or varus orthopedic stress tests Localized or extensive bruising of the knee (strongest and most specific since grade 1 sprain would not show any bruising in the medial knee) Palpable defect of the ligament

Give the best 3 PE findings to support a grade 2 muscle strain in the U.E.

Mild to moderate weakness with muscle testing Possible small defect in the muscle through palpation Moderate swelling and bruising of the muscle

Which condition would likely have the least promising prognosis for non-surgical care?

Spinal stenosis

Based on likelihood ratios, what are the two strongest clues from the physical exam that would support a lumbar spinal stenosis diagnosis?

Positive Romberg and wide stance

For lumbar spinal stenosis, indicate common or uncommon for each of the following: Positive straight leg raise Flexion exercises are prescribed Patient has symptoms of cauda equina syndrome

uncommon common uncommon

For isthmic spondylolisthesis indicate common or uncommon for each of the following: Positive straight leg raise Flexion more aggravating than extension Forward slippage at L4

uncommon uncommon uncommon

For patients with acute spondylolysis what are four key parts of treatment plan (aside from physical rehab exercises)?

Bracing the patient for 20-23 hrs/day for 3-6 months Avoid extension maneuvers Stop playing sports Ice the injury for 20 minutes 3-4 times a day and add in range of motion exercises that are not painful to them.

Your 65 year old patient has leg pain with walking. What two diagnoses would usually be at the top of your list?

Spinal canal stenosis and peripheral artery disease

For each of the following conditions, indicate the ancillary study that would usually be ordered. To confirm that a patient has suspected spinal stenosis To confirm an occult pars fracture that was not well visualized on x-ray To screen for PAD To confirm PAD

x-ray and then MRI (MRI is to A. confirm) CT Brachial ankle index MRA

Your patient has a traumatic cervical hyperflexion injury, posterior neck pain and no arm symptoms. Active and passive cervical flexion hurt throughout the range. Cervical distraction is painful. Cervical compression, Valsalva, neck muscle tests, and extremity SMR tests are all normal. Probable working diagnosis for this patient a) Cervical disc herniation b) Cervical disc derangement c) Cervical facet syndrome d) Cervical sprain e) Cervical strain

Cervical sprain

Which of the following is a positive prone lumbar instability test? a) Increased pain when pressing down on a SP with the feet lifted b) Decreased pain when pressing down on a SP with the feet lifted c) Increased sense of hypermobility when pressing down on a SP with feet lifted d) Decreased sense of hypermobility when pressing down on a SP with feet lifted

b) Decreased pain when pressing down on a SP with the feet lifted

Which of the following is an accurate description of an instability catch? a) Bending the knees and initiating the motion in the lumbar spine instead of at the pelvis when returning from touching the toes. b) Deviating into rotation while the patient is attempting to perform active flexion c) Placing hands on legs and “walking up one’s thighs” when returning from a flexed position d) Pain which may be accompanied by a painful catch while bending through just certain degrees of motion going down or coming back from toe touching.

b) Deviating into rotation while the patient is attempting to perform active flexion

Which of the following is least likely a signal of functional instability? a) Painful catch disappears when performing abdominal bracing b) There is immediate increased pain when sitting that is relieved by standing c) A loss of Achilles reflex d) Spine deviates from the vertical position when performing the single leg stand

c) A loss of Achilles reflex

Which of the following is most likely a signal of functional instability? a) Painful arc during active flexion and extension b) A positive Romberg test c) Pain centralization with repetitive lumbar extension d) 5mm of slippage on a lumbar flexion-extension studies

a) Painful arc during active flexion and extension

Your patient has severe LBP aggravated by reaching above his head. Active and passive lumbar extension, the 4-quadrant test, having a bowel movement, and bilateral active SLR are all painful. His LBP disappears if he lies on his back and hugs both legs to his chest for about 1 minute. He has no sensory, motor or reflex deficits and the SLR is negative. Most probable working diagnosis? a) Lumbar disc herniation b) Lumbar disc derangement c) Lumbar facet syndrome d) Lumbar sprain e) Lumbar joint dysfunction

b) Lumbar disc derangement

Besides aberrant movement, what are the other 3 components of the clinical prediction rule for lumbar stabilization exercises?

a) Age under 40 y/o b) SLR above 91º c) Positive prone lumbar instability test

For patients with isthmic (pars fracture) spondylolisthesis, indicate common or uncommon for each of the following: Positive SLR: Made worse by extension: Forward slippage at L4:

uncommon common uncommon

What are 5 clues from the Hx that would suggest that a patient has functional instability?

``` Triggered by trivial events Pain with sitting History of a catch Reduced response to treatment Temporary response to treatment ```

Which of the following are commonly abnormal in a patient with moderate DJD of the spine? a) Radiograph b) ESR c) CBC

Commonly abnormal NOT commonly abnormal NOT commonly abnormal

Which of the following one of the conditions would likely have the least promising prognosis for non-surgical care? a) Lumbar spinal stenosis b) Lumbar disc herniation c) Lumbar spondylolysis d) Lumbar spondylolisthesis e) Lumbar facet syndrome

a) Lumbar spinal stenosis

Aside from HVLA manipulation and treating MFTPs, what were 2 other main conservative therapeutic interventions for spinal stenosis contained in the CSPE protocol (be as specific as possible) a) Knees to chest exercises and flexion distraction therapy b) Prone extension exercises every two hours and CMT to lumbar spine c) Core stability exercises and encouraging the patient to try to walk further despite the leg pain d) Limit the amount of time sitting and soft tissue manipulation addressing a lower cross syndrome

a) Knees to chest exercises and flexion distraction therapy

Which of the following would usually not be considered a LBP complicator/contributor? a) Hypertonic hamstrings b) Lower cross syndrome c) Quadratus lumborum MFTP d) Shaking when attempting to do a sit up

c) Quadratus lumborum MFTP (because it is a pain generator)

For patient with lumbar spinal stenosis, indicate common (> 50%) or uncommon (< 5. 50%) for each of the following: Positive SLR: Positive Romberg test: Patient has symptoms of cauda equina syndrome:

Uncommon Uncommon Uncommon

What are 4 different ways that spinal degeneration can actually become the primary pain generator in a patient.

a) Spinal stenosis b) Instability c) Spondolytic compression of nerve root d) Osteoarthritis

RAT Cards Flashcards

(76 cards)