What's the Big Idea(s)?: CWE Semester 4 study guide

Define pain.

an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage

What type of pain is described as "pain that arises from altered nociception, despite no clear evidence of actual or threatened damage causing the activation of peripheral nociceptors or evidence for disease/lesion of somatosensory system causing the pain?"
A. nociceptive
B. neuropathic
C. central
D. nociplastic

D. nociplastic

T/F Patients can have a combination of nociceptive and nociplastic pain.

true

Which dimension of pain turns pain into suffering?
A. sensory
B. emotional
C. cognitive

C. cognitive

Characteristics and examples of nociceptive pain

-due to activation of nociceptors
-inflammation, mechanical irritant, injury
Ex: ankle sprain, OA, RA

characteristics and examples of neuropathic pain

-due to a lesion or disease of the somatosensory system
-may present with loss of sensation or motor function and dysthesia
Ex: diabetic neuropathy, CTS, CRPS

characteristics and examples of central pain

-due to disturbances in central pain processing
-enhanced excitability, reduced inhibition
Ex: fibromyalgia, TMJ disorder, nonspecific LBP

Which of the following is NOT true about referred pain?
A. only common in chronic conditions
B. spontaneous pain perceived outside the area of injury
C. often follows a dermatome or spinal segmental area
D. can be referred to distant areas

A. only common in chronic condition s

Features of the neuromatrix theory

-evolved from gate control theory
-pain is a perception produced by characteristic "neurosignature" patterns of nerve impulses generated by a widely distributed neural network
-the "body-self neuromatrix" in the brain
-the output patterns of the body-self neuromatrix activate perceptual, homeostatic, and behavioral programs after injury, pathology, or chronic stress
-genetically determined and modified by sensory experience
-primary mechanism that generates the neural pattern and produces pain

1. examples of types of input to the neuromatrix
2. examples of types of outputs from the neuromatrix

1. cognitive-evaluative, sensory-discriminative, motivational-affective
2. pain perception, action programs, stress-regulation program

Nociception is defined as the process of

encoding and processing noxious stimuli

1. Define noxious stimulus.
2. Define nociceptive stimulus.

1. stimulus that is damaging or threatens damage to normal tissues; activates nociceptors
2. actual or potential tissue-damaging event transduced and encoded by nociceptors

Which of the following nerve fiber types has the fastest conduction velocity?
A. Ia
B. II (A-beta)
C. III (A-delta)
D. IV (C)

A. Ia

Which of the following is NOT a characteristic of peripheral sensitization?
A. higher activation threshold of nociceptors after the first one fires
B. increased firing rate
C. increased release of NTs in the dorsal horn
D. area of tissue damage is more sensitive to sensory stimuli

A. higher activation threshold of nociceptors after the first one fires

What is the difference btw primary and secondary hyperalgesia?

Primary: increased sensitivity of peripheral nociceptors in response to tissue damage
Secondary: incr sensitivity of dorsal horn neurons located in the spinal segments corresponding to the primary nociceptive source

Which type of stimulus has the LARGEST receptive field?
A. pain
B. warmth
C. vibration
D. touch

A. touch

What is the net effect that occurs with central sensitization?

previously SUBTHRESHOLD synaptic inputs are recruited to generate an increased or augmented action potential output, a state of facilitation, potentiation, or amplification

Which of the following is NOT a characteristic of central sensitization?
A. enhanced response to innocuous stimuli
B. response threshold to noxious stimuli increases
C. increase in spontaneous firing
D. enhanced response to noxious stimuli

B. response threshold to noxious stimuli increases

Which ascending tract is the MOST important for the transmission of nociceptive information?
A. corticospinal
B. corticobulbar
C. STT
D. DMSCT

C. STT

T/F Women may exhibit greater centrally mediated pain responses.

true

Which of the following is NOT a high priority gene linked to pain perception?
A. COMT gene
B. TRPV1
C. capsaicin (opioid receptor)
D. acetylcholine

D. acetylcholine

How does pain perception change with age?

-thresholds more frequently elevated (less sensitivity) in older adults
-advancing age may result in greater central sensitization
-nervous system may delay initial onset of pain reports, but then may take longer to resolved with older adults

Which questionnaire would be BEST if you wanted to assess a patient's pain experience through multidimensional aspects using pain-related words?
A. VAS
B. McGill Pain Questionnaire
C. painDETECT
D. Wong-Baker FACES Pain Scale

B. McGill Pain Questionnaire

Bob is a 70 y/o patient reporting LBP. You conduct a painDETECT questionnaire and Bob scores 27. What can you conclude?
A. the pain is unlikely to have a neuropathic pain component
B. the pain is likely to have a neuropathic pain component
C. results are inconclusive

B. the pain is likely to have a neuropathic pain component

You are conducting a pain assessment on a 6 y/o child. What method would be MOST appropriate?
A. ask if the pain is an "owie"
B. use a 3-level pain intesnity scale
C. use a 4 or 5 item scale
D. use the VAS

D. use the VAS

Which of the following is NOT a factor predicting poor outcomes in chronic pain?
A. shorter duration of pain
B. history of anxiety
C. multiple pain sites
D. low social support at time of diagnosis

A. shorter duration of pain

Which of the following is FALSE related to pain-related fear?
A. pain-related fear and avoidance is a normal response to unusual threatening information
B. motivational contexts modulate behavior
C. extinction of avoidance behavior is a slow process
D. evidence for graded exposure treatment is weak

D. evidence for graded exposure treatment is weak

components of self-management pain intervention

-pt edu on pain and disease and health literacy
-edu on increased movement, activity, and pacing
-development of pain management skills with nonpharmacological approaches
-development of coping skills - target stress reduction and pain relief: relaxation therapy, mindfulness, massage, therapeutic movement, motor imagery
-need to be pt specific, realistic/achievable goals, regularly modify goals
-graded exposure/pacing and strategies to optimize sleep
-understanding the protective function of pain

You are working with a patient to restore the accuracy and speed at identifying where a picture or body part is aligned relative to the body. Which component of a GMI program are you utilizing?
A. laterality reconstruction (implicit motor imagery)
B. motor imagery (explicit)
C. mirror therapy
D. cortical reorganization

A. laterality reconstruction (implicit motor imagery)

What is the recommended sequence of progression of a GMI program?

1. laterality reconstruction
2. motor therapy
3. mirror therapy

mechanism of actions of physical modalities for pain management

-stimulate A-beta afferent fibers
-decrease pain fiber transmission velocity
-decrease metabolic rate
-stimulate the release of endogenous opioids
-cognitive/emotional (motivation, relaxation techniques)

Would direct current or alternating current TENS be more appropriate when working with denervated muscles?

direct current

TENS stimulates afferent sensory fibers to elicit the production of

endogenous substances such as endorphins, enkephalins, and serotonin (i.e., gate theory)

Indications for TENS

-control chronic pain
-manage s/p pain
-reduce post-traumatic and acute pain

precautions with TENS

-can mask underlying pain
-burns or skin irritation
-prolonged use may result in muscle spasm/soreness
-caffeine intake may reduce effectiveness
-narcotics decrease effectiveness

T/F TENS works by increasing endogenous inhibition and reducing central excitability.

true

What form of TENS would be most appropriate if you were attempting to stimulate A-beta fibers with no muscle contraction?
A. high frequency TENS
B. low frequency/rate TENS
C. Brief-intense TENS
D. Russian

A. high frequency TENS

What form of TENS would be most appropriate for wound care management?
A. high frequency TENS
B. low frequency/rate TENS
C. Brief-intense TENS
D. Russian

C. brief-intense TENS

Low frequency/rate TENS

-controls pain via the release of endogenous opiates
-may produce muscle contractions/spasms
-stimulates A-delta fibers, activating the endogenous opioid mechanism and reducing transmission of noxious stimuli via other pathways

Which form of TENS would produce an "acupuncture"-type sensation?
A. high frequency TENS
B. low frequency/rate TENS
C. Brief-intense TENS
D. Russian

B. low frequency/rate TENS

Which is NOT a contraindication for electrotherapy?
A. cardiac arrhythmias
B. pregnancy
C. exposed metal implants
D. impaired cognition or sensation

D. impaired cognition or sensation

precautions for electrotherapy

-cardiac disease
-impaired cognition or sensation
-malignant tumors
-areas of skin irritation or open wounds
-iontophoresis following administration of other physical agents

T/F Placing electrodes further apart would deepen the current flow.

true

characteristics of small electrodes

-increases current density
-recruits fewer motor units
-more "uncomfortable"
-better for targeting small areas

characteristics of large electrodes

-decreases current density
-recruits more motor units
-more comfortable
-better for targeting larger areas

Which of the following is the ONLY modulation that uses gate control theory? (all the others use opiates)
A. acupuncture/low-frequency
B. burst mode
C. conventional/high frequency
D. modulated

C. conventional/high frequency

You want to select a modulation with short duration, high frequency, and a low to comfortable current amplitude. Which would be the MOST appropriate?
A. acupuncture/low-frequency
B. burst mode
C. conventional/high frequency
D. modulated

C. conventional/high frequency

You want to select a modulation with long pulse duration, low frequency, and a low to comfortable amplitude. Which is most appropriate?
A. acupuncture/low-frequency
B. burst mode
C. conventional/high frequency
D. modulated

A. acupuncture/low-frequency

You want to select a modulation with a long pulse duration, high frequency, and comfortable to tolerable amplitude. Which is MOST appropriate?
A. conventional TENS
B. acupuncture
C. brief intense
D. burst mode

C. brief intense

You want to select a modulation with random modulations of pulse duration, frequency, and current amplitude. Which is most appropriate?
A. modulated
B. burst mode
C. brief intense
D. low frequency

A. modulated

You are working with a patient following a meniscal repair and want to emphasize muscle strengthening and strong muscle contractions. Which TENS mode would be the BEST option?
A. high frequency
B. low frequency
C. modulated
D. "Russian" (burst mode)

D. "Russian"

Which parameters would be correct if you were utilizing sensory TENS (high rate)?
A. targeting A-beta fibers, 50-150 microsec, <20 Hz, 20-30 min treatment time
B. targeting A-delta fibers, 150-300 microsec, <20 Hz, 20-45 min every 4-5 hours
C. targeting A-beta fibers, 100-1000 microsec, high frequency, 30-60 sec for each area
D. targeting A-beta fibers, 50-150 microsec, 60-150 Hz, 20-30 min treatment

D. targeting A-beta fibers, 50-150 microsec, 60-150 Hz, 20-30 min treatment

Parameters for motor TENS (low-rate)

Mechanism: endorphin release
Target fiber: A-delta
Pulse duration: 150-300 microsec
Frequency: <20 Hz
Amplitude: muscle contraaction
Treatment time: 20-45 min, every 4-5 hours

What is the main benefit of IFC?

allows for use of higher frequency that can reach deeper tissues w/o the discomfort associated with lower frequency

Which of the following is NOT an indication for iontophoresis?
A. hypersensitivity to electrical currents
B. acute or chronic inflammation
C. arthritis
D. myofascial pain syndromes

A. hypersensitivity to electrical currents

You are working with a patient who presents with excessive palmoplantar sweating. Which modality would be the most beneficial?
A. high-frequency TENS
B. ice massage
C. iontophoresis
D. nonthermal ultrasound

C. iontophoresis

With ultrasound, use ______(1) frequencies for superficial tissues and _______(2) frequencies for deeper tissues.

1. higher
2. lower

Which modality would be useful for desensitizing the trapezius and infraspinatus trigger points?
A. iontophoresis
B. low-intensity US
C. high-intensity US
D. modulated NMES

B. low-intensity US

Benefits of massage

-reduces stress/cortisol levels
-alters NT release in CNS
-activates descending inhibitory pathways
-can alter gene transcription, promote healing and reduce inflammation
-INDIRECTLY produce pain-relieving effects by helping restore normal movement patterns

Massage would be an appropriate intervention for all of the following except:
A. LBP
B. fibromyalgia
C. mechanical neck pain
D. cervical radiculopathy

D. cervical radiculopathy

Acute pain

-often associated with inflammation and hyperalgesia
-often sensitive to noxious heat, mechanical, or thermal stimuli
-surgical pain related to nociceptor sensitization and sensitization of dorsal horn neurons in response to an incision

You are working with a patient who demonstrates increased pain after palpation, activity, and during sitting or standing. They also do not have an identified cause of pain, and there is no worsening of an underlying pathology. What type of pain is this?
A. acute
B. nociceptive
C. neuropathic
D. central

D. central

Principles related to manual contact for PNF

-stimulates skin and pressure receptors
-resistance on one surface only facilitates movement in the desired direction
-don't wrap hands around a joint
-lumbrical grip

You are performing a hip PNF technique and start in a position of extension, abduction, and internal rotation, Which PNF pattern/position are you demonstrating?
A. D1 hip extension
B. D2 hip extension
C. D1 hip flexion
D. D2 hip flexion

A. D1 hip extension

Describe a D1 shoulder PNF pattern

extension/abduction/IR to flex/ADD/ER

Describe a D2 shoulder pattern

shoulder ext/ADD/IR to flex/ABD/ER

Describe a hip D1 pattern

ext/abd/IR to flex/add/ER

Describe a hip D2 pattern

hip ext/add/ER to flex/abd/ER

Which is not a proper PNF technique?
A. stand in the correct diagonal
B. first establish available ROM
C. start at mid-range of position
D. begin with rhythmic initiation

C. start at mid-range position

Donna is a 45 y/o F with complaints of numbness in her right wrist/hand and pain that is worse at night. You perform a shaking hands test and Tinel's sign, both of which are positive. Which other exam finding would further support a diagnosis of CTS?
A. sensation loss in the 5th digit
B. reduced sensory capacity in the 1st digit
C. wrist-ratio index < 0.67
D. symptom severity scale < 1.9

B. reduced sensory capacity in the 1st digit

What type of nerve palsy would present as drop wrist deformity?
A. Erb's palsy
B. radial nerve palsy
C. median nerve palsy
D. ulnar nerve palsy

B. radial nerve palsy

Dan is a 55 y/o pt presenting to PT after a FOOSH injury. He demonstrates reduced grip, tenderness with palpation between the FCU tendon and the ulnar styloid process, and pain with axial loading. What motion would you expect to be the most limited?
A. supination
B. pronation
C. wrist flexion
D. wrist extension

A. supination (TFCC dysfunction)

Which two tendons are inflamed with deQuervain's disease?
A. EPB and APB
B. EPL and EDL
C. EPB and APL
D. FCU and FCR

C. EPB and APL

Martha is a 47 y/o F who recently started weightlifting after living a sedentary life. She reports pain/swelling over the radial wrist and on examination, you find a thickening on the tendon sheath and Finkelstein's test is positive. What is the likely diagnosis?
A. wrist fracture
B. carpal tunnel syndrome
C. deQuervain's disease
D. Dupuytren's contracture

C. deQuervain's disease

Which of the following is a s/s of CRPS?
A. loss of hair on feet
B. bilateral coldness in hands
C. shiny skin and brittle fingernails
D. hypoalgesia

C. shiny skin and brittle fingernails

You are treating a patient with CRPS. Which modality would NOT be appropriate?
A. TENS
B. thoracic mobilization
C. stress-loading program of action and compression
D. standing on an acupuncture mat

D. standing on an acupuncture mat

Resting position of the hand

-wrist: slight extension and slight UD
-thumb: slight flexion, slight ABD, slight opposition
-fingers: slight flexion of all joints

Carpal tunnel clinical prediction rule

1. shaking of hands for symptom relief
2. wrist-radio index > 0.67
3. symptom severity scale > 1.9
4. reduced median sensory field of digit 1
5. age > 45 yrs

Which of the following is a NEGATIVE predictor on the Amsterdam wrist rules for all wrist fractures?
A. sex (if male)
B. swelling in the anatomical snuff box
C. pain with radial deviation
D. pain with axial compression of the thumb

D. pain with axial compression of the thumb

predictors for distal wrist fractures

-age (per 10 yrs)
-swelling wrist
-visible deformation
-distal radius tender to palpation
-pain on palmar flexion
-pain on supination

John reports to PT with difficulty picking up his water bottle after playing a game of volleyball where the ball forced ABD of his thumb. Which of the following pathologies should be at the top of your differential diagnosis list?
A. carpal instability
B. UCL rupture of thumb ("Skier's" thumb)
C. Dupuytren's contracture
D. trigger finger

B. UCL rupture of thumb

At what point would a pt w/ Kienbock's disease need to consider a carpectomy of the proximal carpal row?
A. when there are RG sclerotic changes of the lunate
B. when pt is experiencing pain and stiffness w/ wrist motion
C. when joints adjacent to the lunate start being impacted

C. when joints adjacent to the lunate start being impacted

Which joint mobilization would be most appropriate for increasing wrist flexion?
A. radiocarpal AP (dorsal) glide
B. radiocarpal PA (volar) glide
C. distal RUJ dorsal glide
D. distal RUJ volar glide

A. radiocarpal AP (dorsal) glide

B = extension
C = supination
D = pronation

Which test would you NOT perform if you were assessing wrist stability?
A. press test
B. ulnomeniscotriquetral dorsal glide
C. ballottement test
D. scaphoid compression

D. scaphoid compression

Which intervention would not be appropriate post-op decompression of the carpal tunnel?
A. edema control
B. progressive ROM and strengthening
C. differential tendon glides
D. tensioners

D. tensioners

What is the most common complication of a Colles' fracture?
A. compartment syndrome
B. CRPS
C. malunion
D. scar hypersensitivity

D. scar hypersensitivity

Which is FALSE regarding general guidelines for wrist fracture management?
A. 8 weeks immobilization with external fixation
B. 2-6 week rehab if nondisplaced
C. flexion and supination usually the most limited
D. maintain ROM and strength of distal and proximal joints during immobilization

C. flexion and supination usually the most limited

characteristic of fibromyalgia

-generalized chronic MSk pain
-hyperalgesia and allodynia
-tender points
-women > men
-increases with age
-higher BMI (risk factor)

Which is NOT an appropriate intervention for someone with fibromyalgia?
A. use of therapeutic touch to stimulate release of endogenous opiates
B. pain neuroscience education
C. aquatic therapy
D. high intensity aerobic activity

D. high intensity aerobic activity

Which of the following s/s would lead you towards fibromyalgia vs. MPS?
A. local twitch response
B. responds to manual muscle therapies
C. diffuse pain
D. localized or regional pain

C. diffuse pain

What is true about the expected functions of nerves?
A. do not lengthen with movement
B. slide longitudinally or transversely to increase tension
C. be compressible by bone, tendon, muscle, fascia
D. all of the above

C. be compressible by bone, tendon, muscle, fascia

You are instructing a patient to perform an active ULNT glide. The pt starts with their arm at their side and they flex their wrist, turn their palm away and push their wrist towards the floor. Which nerve is being tensioned?
A. radial nerve
B. ulnar nerve
C. median nerve
D. sciatic nerve

A. radial nerve

Johnny comes to PT concerned with nerve issues, You find (+) active and passive ULNT for median, ulnar, and radial nerves. What is most likely causing these issues?
A. median cord compression in the cervical spinal cord
B. lateral cord compression in the cervical spinal cord
C. anterior cord compression in the cervical spinal cord
D. posterior cord compression in the cervical spinal cord

A. median cord compression in the cervical spinal cord

Which exam finding would support a diagnosis of lateral epicondylalgia?
A. pain with resisted wrist extension and RD
B. pain with resisted wrist flexion and UD
C. pain with wrist ext/RD PROM
D. (+) Golfer's elbow test

A. pain with resisted wrist extension and RD

Which muscle would NOT be involved with medial epicondylalgia?
A. pronator teres
B. FCR
C. ECRB
D. FCU

C. ECRB

Michael experienced a traumatic injury from a valgus force applied while his elbow was in flexion. Which ligament or structure was most likely injured?
A. MUCL
B. LUCL
C. joint space
D. joint capsule

A. MUCL

Which structure is at risk of partial avulsion with repeated valgus stress to the elbow ?
A. lateral epicondyle
B. olecranon
C. medial epicondyle
D. radial head

C. medial epicondyle

Joe comes to PT with complaints of sensory deficits in his lateral two digits, medial elbow pain. He sits at a desk for work during the day and demonstrates intrinsic muscle atrophy. Which diagnosis should be at the top of your list?
A. carpal tunnel syndrome
B. Little Leaguer's elbow
C. cubital tunnel syndrome
D. pronator teres syndrome

C. cubital tunnel syndrome

Which is NOT included in the "terrible triad" for elbow fractures?
A. posterior elbow dislocation
B. anterior elbow dislocation
C. radial head fracture
D. Type 1 coronoid fracture

B. anterior elbow dislocation

Which fracture is common in children and is described as a transverse fracture across the humerus, above the condyles?
A. transcondylar fracture
B. radial dislocation
C. supracondylar fracture
D. ulnar fracture

C. supracondylar fracture