Macquarie University CHIR8513 Functional Rehabilitation (2021S1) Past Exam Paper PDF

SEAT NUMBER: ……….… ROOM:..………………. FAMILY NAME:………….....…………………………. This question paper must be...

SEAT NUMBER: ……….… ROOM:..………………. FAMILY NAME:………….....…………………………. This question paper must be returned. OTHER NAMES:……..…….…………………..…….. Candidates are not permitted to remove any part of it from the examination room. STUDENT NUMBER:…..…….………..…………….. FORMAL EXAMINATION PERIOD: SESSION 1, JUNE 2021 Unit Code: CHIR8513 Unit Name: FUNCTIONAL REHABILITATION Duration of Exam 2 HOURS plus 10 MINUTES (reading time) (including reading time if applicable): Total No. of Questions: 81 Total No. of Pages 25 (including this cover sheet): GENERAL INSTRUCTIONS TO STUDENTS: Students are required to follow directions given by the Final Examination Supervisor and must refrain from communicating in any way with another student once they have entered the final examination venue. Students may not write or mark the exam materials in any way during reading time. Students may only access authorised materials during this examination. A list of authorised material is available on this cover sheet. All watches must be removed and placed at the top of the exam desk and must remain there for the duration of the exam. All alarms, notifications and alerts must be switched off. Students are not permitted to leave the exam room during the first hour (excluding reading time) and during the last 15 minutes of the examination. If it is alleged you have breached these rules at any time during the examination, the matter may be reported to a University Discipline Committee for determination. EXAMINATION INSTRUCTIONS: Total Number of Questions: 81 questions (Total 100 Marks) Section A: Multiple Choice (80 Marks) Section B: Short Answer (20 Marks) Instructions: ANSWER ALL QUESTIONS Section A: Answer all questions on the provided multiple choice marking sheet Section B: Answer questions in the space provided in the pink examination paper AIDS AND MATERIALS PERMITTED/NOT PERMITTED: Dictionaries: Paper-based translation dictionaries permitted Calculators: No calculators permitted Other: Closed book – No notes or textbooks permitted Copyright © Macquarie University. Copying or distribution of part or all of the contents in any form is prohibited. SECTION A: MULTIPLE CHOICE QUESTIONS INDICATE THE MOST CORRECT ANSWER TO EACH OF THE QUESTIONS IN THE SEPARATE MARKING SHEET 1. What is commonly considered the best predictor for endurance performance? a) Anaerobic threshold b) Ventilatory threshold c) Onset blood lactate accumulation d) All the above 2. EQI – eccentric quasi-isometric contractions, could be utilised to aid rehabilitation at the end- range of joint motion. a) True b) False 3. In 1936 Hans Solo introduced the General Adaptation Syndrome - the GAS principle, that described the physiological response to stress. a) True b) False 4. Affective reassurance relies on: a) Empathy b) Patient rapport c) Both (a) and (b) d) Neither (a) or (b) 2 5. A systematic review by Dr Aron Downie in BMJ reported that spinal malignancy and vertebral fractures are the most common serious pathologies to affect the spine, occurring approximately: a) less than 1% and 4% respectively b) less than 2% and 5% respectively c) less than 10% and 14% respectively d) less than 11% and 15% respectively 6. Trunk antalgia, pain rising from a chair, little to no sensitivity on prone lumbar spine P-A springing and sensitivity on the slump test with neck flexion, may all indicate which structure as a likely pain generator: a) Facet joint b) Sacroiliac joint c) Discogenic (annulus fibrosis) d) Ligamentous 7. Who was responsible for the emergence of the biopsychosocial model? a) Gordon Waddell b) George Engel c) Craig Liebenson d) Vladimir Janda 3 8. Which component of the biopsychosocial model appears to be most neglected? a) Biological b) Social c) Psychological d) All the above e) None of the above 9. A limitation of the biopsychosocial model (despite 3 clear domains), is its inability to show clinicians which interventions should be implemented. a) True b) False 10. From the patient’s perspective, which reason listed below is most likely to be a barrier to performing exercise. a) Difficulty finding the time to exercise b) Discipline required to complete exercises c) Problems prioritising time to complete exercises d) All the above 11. Exercises which target stability, mobility and flexibility are valued more by the patient, than exercise being enjoyable, motivational and confidence building. a) True b) False 4 12. A pilot randomised controlled trial lead by Gardner et al in 2016, identified which patient led goal to be the most important: a) Physical activity b) Workplace tolerance c) Coping skills d) Relationships, sleep and energy 13. Private consultation rooms, clinic cleanliness, natural lighting, low noise levels, convenient clinic hours, location, ease of parking and approachable staff are all examples of contextual effects that could impact the outcomes associated with physical therapy? a) True b) False 14. The outcome of pain can be expressed through our health, as the brain is interpreting information from multiple output systems. This can include changes to the: a) Limbic system b) Endocrine system c) Sympathetic system d) All the above 15. Although patients expect a structural diagnosis, practitioners should aim to adopt a more behavioural approach, where they could discuss (with their patients): a) Sleep patterns b) Physical activity engagement c) Work commitments d) All the above 5 16. A published systematic review by Aker and Martel on Maintenance care in 1996, described this controversial topic as: a) A politically incorrect topic b) Lacking scientific evidence it improves health status c) Only having sparse and anecdotal evidence d) All the above e) None of the above 17. Eklund et. al.’s randomised controlled trial compared chiropractic maintenance care (MC) vs. symptom guided care for recurrent & persistent low back pain (LBP). Which statement is correct with respect to the trial results? a) MC group had 33 fewer days with activity limiting LBP b) MC group had 23 fewer days with activity limiting LBP c) MC group had 13 fewer days with activity limiting LBP d) MC group had 3 fewer days with activity limiting LBP 18. In a secondary analysis of the maintenance care randomised controlled trial by Eklund et al, which sub-group fared worse with maintenance care? a) Interpersonally distressed b) Dysfunctional c) Adaptive copers d) All the above e) None of the above 6 19. Evidence suggests few Australians meet the physical activity guideline recommendations. One particular age group is children aged 2–17. Which subgroup of children is least likely to engage in physical activity? a) Children aged 2–5 b) Children aged 15-17 c) Children aged 6-12 d) Children aged 13–17 20. Please identify the famous middle-aged Aussie sedentary specimen who often appeared on TV in the late 70’s and early 80’s. He resisted all invitations to exercise, and was affectionately known as: a) Bob b) John c) Norm d) Alf e) Roger 21. Anecdotally chiropractors can influence patients’ long-term health & wellbeing through physical activity prescription. However (compared to physiotherapy), there is limited evidence to suggest this is the case. a) True b) False 7 22. Medical guidelines focus on single conditions for complex patient populations, such as our older population. This is further complicated by: a) Polypharmacy in elders b) Multiple health appointments c) Increased hospital admissions d) All the above e) None of the above 23. A progressive condition involving loss of skeletal muscle mass and subsequent function is known as: a) Osteoporosis b) Sarcopenia c) Paget’s disease d) None of the above e) All the above 24. With respect to bone loss, there is an accelerated loss in women, 5-10 years after menopause due to reduced testosterone. a) True b) False 25. Challenging balance exercises are recommended for beneficial effects on balance and subsequent falls reduction. a) True b) False 8 26. Australian researchers, including Hodges and Richardson (and others), throughout the late 1990’s discovered changes in the transverse abdominus and multifidus muscles in chronic low back pain patients This was related to: a) Delayed muscle firing b) Muscle weakness c) Inhibition of these muscles d) None of the above e) All the above 27. Given the deep multifidus attachments to the vertebrae, these muscles are known to control and sense intervertebral motion. They are also likely to have a proprioceptive role, rather than generating torque. a) True b) False 28. The ipsilateral latissimus dorsi, contralateral gluteus maximus and biceps femoris all form the: a) Oblique anterior sling b) Lateral system c) Oblique posterior sling d) Deep Longitudinal System e) None of the above 29. Numerous recent systematic reviews on motor control / spinal stabilisation exercises show these exercises (in the long-term) are more effective than other forms of active exercise. a) True b) False 9 30. A recent systematic review in 2020 showed the McKenzie method - mechanical diagnosis and therapy method (MDT) - is no more effective than other active or passive physical therapy treatments for chronic non-specific low back pain? a) True b) False 31. Robin McKenzie believed 2 key lifestyle factors predisposed an individual to low back pain. a) Frequency of extension and poor sitting posture b) Frequency of flexion and poor sitting posture c) Frequency of flexion and upright sitting posture d) None of the above 32. In the McKenzie Method symptoms that occur during the movement or at end-range are typical of the a) Derangement Syndrome b) Dysfunctional Syndrome c) Postural Syndrome d) None of the above e) All the above 33. Robin McKenzie advocated brief and minimal forces with respect to a ‘hands on’ approach to manual therapy (i.e. mobilisation). a) True b) False 10 34. The local twitch response associated with trigger points is similar to the patient Jump Sign, i.e. an entire body jump. a) True b) False 35. The most frequently used clinical findings, as part of the criteria used for the diagnosis of myofascial trigger points in a review of randomised trials (2020), include: a) Spot tenderness b) Referred pain c) Local twitch response d) All the above 36. The use of a vapocoolant spray, often applied to the affected muscle after it has been placed in passive stretch, is one way (that is traditionally) used to treat trigger points? a) True b) False 37. Trigger point referral associated with the lateral pterygoid muscle can characteristically refer to the: a) Zygomatic bone b) Mandible bone c) Nasal bone d) None of the above e) All the above 11 38. Extrinsic risk factors implicated in the development of tendinopathy include: a) A sudden increase in activity volume and/or intensity b) Poor recovery c) Poor workplace ergonomics d) Medication use (i.e., statins) e) All the above 39. Heavy strength exercises are one of a number of ways to manage tendinopathy? a) True b) False 40. Microscopically, tendinopathy includes production of type I collagen fibres, micro-vasculature and sensory nerve innervation, extracellular matrix disruption and inflammatory mediators. a) True b) False 41. Australian tendinopathy researchers Cook and Purdam describe a 3-stage pathological model of tendinopathy. They’ve recently added a 4th component. This is known as: a) Reactive tendinopathy b) Tendon dysrepair c) Degenerative tendinopathy d) Reactive on degenerative e) None of the above 12 42. Tendons become compromised when unloaded (to assist recovery). An example includes the use of a cast to help mend a broken ankle. In this instance the Achilles tendon is unloaded and potentially compromised once the individual returns to load activity. a) True b) False 43. Whilst examining the hip, which orthopaedic test yields the best information when it is negative? a) FADDIR (flexion, adduction, internal, rotation) b) Log roll test c) Fabere (Patricks) d) Obers test e) Thomas test 44. Kicking, directional change and overuse are typical causative factors associated with a) Iliopsoas strain b) Adductor strains c) Both (a) and (b) d) Neither (a) and (b) 45. FAI – femoroacetabular impingement syndrome - can refer into the lateral hip, sacroiliac joint and anterior thigh? a) True b) False 13 46. With respect to FAI, evidence suggests males can have larger femoral heads and females are more prone to the pincer presentation. Yet, both these structural findings can present with no pain (despite these bony changes). a) True b) False 47. The extensor carpi radialis brevis (ECRB) muscle in tennis elbow is the most affected tendon in almost ___ of cases. a) 70% b) 80% c) 90% d) 100% 48. Almost 50% of asymptomatic elbows show tendinopathic change. a) True b) False 49. The use of ice is not recommended for the management of tennis elbow. However, the positive response to the application of ice for 30 seconds may indicate cold hyperalgesia, which suggests a poorer prognosis or outcome, especially if a visual analogue scale of pain - VAS -is greater than 6/10 during the physical examination. a) True b) False 14 50. Functionally, elbow extension range of motion (ROM) appears more critical than elbow flexion ROM? a) True b) False 51. A volar plate and/or collateral ligament injury to the finger is typically know as a: a) Goose neck b) Swan neck c) Pelican neck d) All the above e) None of the above 52. A study by Reid et al, titled: ‘Adding mobilisation with movement to exercise and advice hastens the improvement in range, pain and function after non-operative cast immobilisation for distal radius fracture: a multicentre, randomised trial in 2020’, showed that adding mobilisation with movement (supination and wrist extension) did not alter outcomes after immobilisation for a distal radius fracture. a) True b) False 53. A patient presents with neck pain that has been present for 2-months. This would be best defined as: a) Acute pain b) Subacute pain c) Chronic pain d) Chronic inflammation 15 54. Which stage of healing is a patient most likely in after an isolated lateral ankle sprain if they have pain on ankle eversion and plantarflexion, tenderness on moderate palpation of the anterior talofibular ligament, but no visible swelling? a) Acute inflammation b) Repair c) Remodelling d) Chronic inflammation 55. A patient presents with low back pain and you determine that they are in the acute inflammatory stage. What would be the most appropriate advice for them? a) Rest until the inflammation subsides b) Keep moving but avoid any lifting or bending movements or any movement that increases pain c) Keep moving in comfortable ranges, but don’t worry if some movements hurt a bit d) Keep moving as much as possible, even if the movement causes significant pain 56. When a patient has developed chronic pain, the primary aim of treatment is to: a) Provide passive care to treat the underlying tissue damage causing the pain b) Make the patient understand that there is no tissue damage causing the pain, and the pain is ‘in their head’ c) Help the patient to manage their pain levels during everyday activities d) Refer the patient for psychological assessment 16 57. A score of 5 on the STaRT back test indicates: a) Low risk of developing persistent low back pain b) Medium risk of developing persistent low back pain c) High risk of developing persistent low back pain d) The patient may need more aggressive treatment than simple advice 58. Chronic inflammation is: a) Inflammation that persists for longer than 2 weeks b) Inflammation that persists for longer than 12 weeks s c) Inflammation that persists due to tissue damage occurring at the same time as healing d) The primary cause of chronic pain 59. Passive insufficiency means that: a) A joint cannot be moved back to a centrated position b) A joint cannot be actively moved back to a centrated position c) The ligamentous structures around a joint are damaged d) The stabilising muscles around a joint are weak or underactive 60. Dynamic instability means that: a) A joint cannot be moved back to a centrated position b) A joint cannot be actively moved back to a centrated position c) The ligamentous structures around a joint are damaged d) The stabilising muscles around a joint are weak or underactive 17 61. The upright posture begins to develop when a child: a) Begins to walk b) Is born c) Begins to crawl d) Starts to consciously lift their head or limbs 62. Which of the following exercises to improve mid-thoracic mobility would be most appropriate for a patient with limited shoulder abduction and flexion? a) Lewit’s wall lean b) Yoga sphinx on hands c) Active prayer stretch d) Wall slide 63. You note knee flexion and limited hip extension when a patient performs the hip extension movement pattern. Which plane of movement would this indicate dysfunction in? a) Sagittal plane b) Coronal plane c) Transverse plane d) Combined coronal and transverse planes 18 64. The anterior oblique muscle chain includes which abdominal muscles? a) Internal oblique and contralateral external oblique b) Internal oblique and ipsilateral external oblique c) External oblique and transversus abdominus d) Rectus abdominus and internal oblique 65. A weak gluteus medius muscle is associated with: a) Knee abduction b) Foot supination c) Leg external rotation d) Hip abduction 66. Which exercise would be the best to address primary dysfunctions in both the hip extension movement pattern and Vleeming’s active straight leg raise? a) Bridge track b) Quadruped track c) Dead bug track d) Squats 19 67. A positive shoulder abduction movement pattern primarily indicates a weakness in which muscle? a) Upper trapezius b) Serratus anterior c) Rhomboid major d) Lower trapezius 68. Which of the following dysfunctions would be the least likely to be associated with shoulder impingement syndrome? a) Reduced thoracic extension b) Weak ipsilateral lower trapezius c) Weak ipsilateral gluteus maximus d) Hypertonic and short ipsilateral latissimus dorsi 69. The WHO definition of rehabilitation: a) is person-centred b) includes interventions that aim to improve function c) includes interventions that aim to reduce impairments d) include assistive devices e) all the above 70. True or false? The International Classification of Function (ICF) characterises individuals according to functioning and disability, and contextual factors. a) True b) False 20 71. What is NOT a function-based/impairment classification subcategory for patellofemoral pain (PFP), reported in a recent clinical practice guideline? a) Overuse/overload without other impairment b) Anterior knee pain impairments c) Muscle performance deficits d) Movement coordination deficits e) Mobility impairments 72. True or false? Preference to knee-targeted exercise over hip-targeted exercise may be given in the early stages of treatment of patellofemoral pain (PFP). a) True b) False 73. What statement is incorrect regarding specific modes of exercise therapy for patellofemoral pain (PFP)? a) Clinicians should include exercise therapy with combined hip- and knee-targeted exercises to reduce pain and improve patient-reported outcomes and functional performance in the short, medium, and long term. b) Hip-targeted exercise therapy should target the posterolateral hip musculature. c) Knee-targeted exercise therapy includes either weight-bearing (resisted squats) or non–weight- bearing (resisted knee extension) exercise, as both exercise techniques target the knee musculature. d) Open kinetic chain exercises are preferential in the early stages of treatment for PFP as they reduce shear forces across joints. e) Overall, the combination of hip- and knee-targeted exercises is preferred over solely knee- targeted exercises to optimise outcomes in patients with PFP. 74. True or False? Regarding “subacromial shoulder pain”, shoulder exercises are as effective as both shoulder surgery and injections, and are less expensive and unlikely to generate negative side effects. They also offer the general health benefits of exercise. a) True b) False 21 75. A reasonable rehabilitation programme to address scapular dyskinesis could: a) start with standing low-load/low-activation exercises with the arm below shoulder level, to meaningfully activate the scapular retractors (>20% maximal voluntary isometric contraction) without putting the arm in an impingement position b) progress to prone and side-lying exercises that increase the load, but still emphasise lower trapezius and serratus anterior activation over upper trapezius activation. c) Add loads and activations by integrating ipsilateral and contralateral kinetic chain movements and adding distal resistance d) Optimisation of activation can occur through weight training emphasising proper retraction and stabilisation e) All of the above 76. True or false? Regarding rehabilitation of scapular dyskinesis, restoration of the scapular muscle force couples requires core strength and facilitation by kinetic chain activation? a) True b) False 77. A randomised controlled trial conducted by Bleakley et al and published in BMJ 2010 concluded that the accelerated exercise protocol they were testing: a) Impaired ankle function during the first week after ankle sprain b) Improved ankle function during the first week after ankle sprain c) Had no impact on ankle function during the first week after ankle sprain d) Was contraindicated in the first week after ankle sprain 78. According to Chen et el published in Current Sports Medicine Reports in June 2019 the percentage of patients who sustain an ankle sprain who go on to develop persistent symptoms is: a) Up to 10% b) Up to 20% c) Up to 40% d) Up to 80% 22 79. Ankle sprains are a common sports injury. All the following have been proposed to be useful in the treatment of ankle sprain. Which of the following is likely to offer the most effective approach? a) Compression bandages b) Cryotherapy (ice) c) Early mobilisation and weight bearing d) Non-steroidal anti-inflammatory drugs (NSAIDs) 80. Many of the modern approaches to functional rehabilitation of ankle sprains can be traced back to concepts introduced by Freeman in the mid-1960s. Which of the following consequences of ankle joint injury is most suspected of hindering functional recovery? a) Proprioceptive deficits b) Scar tissue formation c) Grade II ligamentous injury causing instability d) Grade II muscular tears causing strength deficits 23  SECTION B: SHORT ANSWER QUESTIONS PLACE THE ANSWERS TO QUESTIONS 81 IN THE SPACE PROVIDED ON THIS PINK EXAMINATION PAPER. 81. Jarrah, a 16-year-old state level baseball player, presents with anterior right shoulder pain. He has noticed pain on throwing for two weeks now. (20 marks total) a) List 3 tissue in lesion differential diagnoses (3 marks) Supraspinatus Tendonitis/Tear This is a common injury in overhead throwing athletes and can cause anterior shoulder pain. Biceps Tendonitis Inflammation of the biceps tendon, particularly the long head, which can cause pain in the anterior shoulder. Labral Tear (SLAP Lesion) A Superior Labrum fromfurther b) What Anterior to Posterior investigation tear may be can occur required (1 in throwing athletes due to repetitive stress. mark) MRI Scan This imaging modality is crucial for detailed visualization of soft tissues, including tendons, muscles, and the c) MRI scans reveal a supraspinatus tear which you successfully manage with cross- friction, ultrasound and mobilisation. List two active care activities that your patient would simultaneously be prescribed. (2 marks) Rotator Cuff Strengthening Exercises Example: Internal and external rotation exercises with resistance bands to strengthen the supraspina Scapular Stabilization Exercises Example: Scapular retraction exercises such as rows to enhance scapular stability and support shou d) As the patient enters the subacute phase you consider which functional assessments you would perform. List 4 relevant tests, related to the chief complaint; (4 marks) Hawkins-Kennedy Test This test helps identify subacromial impingement, which is common in throwing athletes. Neer’s Test Another impingement test to check for pain caused by the supraspinatus tendon being pinched und Empty Can Test This test isolates the supraspinatus muscle to assess its integrity and function. Apprehension Test This test helps identify anterior shoulder instability, which can be a contributing factor to shoulder p 24  e) The wall angel is positive. Describe two possible positive findings. (2 marks) Inability to Keep the Low Back Flat Against the Wall This indicates poor thoracic extension or tightness in the lumbar region. Inability to Keep the Arms and Wrists Flat Against the Wall This suggests tightness in the pectoral muscles, latissimus dorsi, or weakness in the shoulder stab f) List a joint restriction that may be present? (1 mark) Thoracic Spine Restriction Limited thoracic mobility can affect shoulder function and may be present in athletes with anterior shoulder p g) If the hand(s) were unable to reach the wall. Name a muscle that may require a lengthening procedure. (1 mark) Pectoralis Minor h) Describe the PIR procedure necessary to lengthen that muscle (3 marks) Positioning Place the patient supine with the arm abducted and externally rotated to stretch the pectoralis minor. Isometric Contraction Ask the patient to gently push the arm against your resistance (as if they are trying to bring the arm back tow Relaxation and Stretch After the contraction, have the patient relax and then gently increase the stretch on the pectoralis minor for a i) You decide to add resistance training to help build Jarrah’s shoulder strength. Please outline 3 key exercise principles for success. (3 marks) Progressive Overload Gradually increase the resistance or intensity of the exercises to continually challenge the muscles Specificity Focus on exercises that target the muscles and movements specific to throwing, such as rotator cu Consistency Ensure regular and consistent training sessions to build strength over time and avoid periods of ina a) List 3 tissue lesion differential diagnoses (3 marks) (Gemini) Supraspinatus tendinitis/tear Biceps tendinitis (long head) Labral tear (SLAP lesion) b) What further investigation may be required (1 mark) MRI scan (magnetic resonance imaging) c) MRI scans reveal a supraspinatus tear which you successfully manage with cross-friction, ultrasound and Rotator cuff strengthening exercises (e.g., internal & external rotation with resistance bands)25 Scapular stabilization exercises (e.g., rows) d) As the patient enters the subacute phase you consider which functional assessments you would perform. Hawkins-Kennedy Test (impingement)