PCE - Physiotherapy Competency Exam

Describe the 3 stages of tissue healing. What are their general durations?

1. Inflammatory: 1-7 days post-injury.

2. Proliferative / Repair: 5-28 days post-injury.

3. Remodelling / Maturation: 28+ days to months/years.

Describe 3 contraindications to resistance exercise.

1. Acute inflammation.

2. Joint effusion.

3. Fracture.

4. Joint/muscle pain during AROM.

5. Bony metastasis / cancer.

Describe 3 contraindications to stretching.

1. Acute infection / inflammation.

2. Fracture.

3. Joint effusion.

4. Recent corticosteroid injection.

5. Hypermobility / instability in the direction being stretched.

Describe 3 items in your treatment for a patient with spinal stenosis.

1. Lumbar spine flexion exercises.

2. Lumbar traction.

3. Core stabilization to prevent lumbar flexion.

4. Aerobic exercise in a position allowing lumbar spine flexion.

5. Education on posture and ergonomics.

1. What is the most common type of lumbar disc herniation?

2. What is the most common age category for lumbar disc herniation?

1. Postero-lateral.

2. 30-50 years old.

Describe 2 signs and symptoms of a lumbar disc herniation.

1. Radiculopathy - neuropathic pain following a dermatomal distribution.

2. Myotomal weakness.

3. Low back / leg pain with weightbearing activities.

4. +ve SLR.

5. +ve Slump.

Describe 2 items in your treatment plan for lumbar disc herniation.

1. Graduated extension protocol.

2. Traction.

3. Lumbar stabilization exercises.

4. Education on duration of healing time, what healing process may look like.

5. Education to avoid prolonged flexion.

Describe 3 signs and symptoms of greater trochanteric pain syndrome.

1. TOP greater trochanter.

2. Pain w/ abduction and/or external rotation of hip.

3. Pain with prolonged standing.

4. Trendelenburg sign.

5. Decreased time in single-leg stance.

What clinical features would lead you to suspect septic hip bursitis over greater trochanteric pain syndrome?

1. Swelling.

2. Redness and warmth over lateral hip.

3. Fever and systemic symptoms.

What clinical features would lead you to a diagnosis of piriformis syndrome?

1. Macro/micro trauma to buttocks.

2. Absence of neurological signs.

3. Hx of sports involving hip flexion, internal rotation, adduction

4. Pain / irritiation with crossed legs

5. Deep and diffuse hip/buttock pain.

6. TOP over piriformis

Relating to tissue healing, what does the acronym "PRICE" stand for?

Protection.

Rest.

Ice (15-20 minutes every 2-3 hours during the first 48 hours after injury)

Compression.

Elevation.

Relating to tissue healing, what does the acronym "HARM" stand for?

Heat.

Alcohol.

Running.

Massage.

Describe the "swipe test" of the quadriceps and its utility.

The test is used to confirm the presence of edema.

1. Swipe upwards x2-3 on the medial aspect of the knee.

2. Then, swipe downwards x2-3 laterally.

3. Watch for fluid returning medially.

What are the 3 ligaments of the sacroiliac joint?

1. Anterior sacro-iliac ligament.

2. Interosseous.

3. Posterior (overlies the interosseous).

What are the ligaments of the lateral pelvic walls?

1. Sacrospinous ligament.

2. Sacrotuberous ligament.

*Together, these structures create both the greater and lesser sciatic foramen.

What are the origin and insertion of the iliopsoas?

Origin: iliac fossa, vertebrae T12-L5.

Insertion: lesser trochanter of femur.

Actions: hip flexion, external rotation.

What are the orign, insertion, innervation, and actions of the sartorius?

Origin: ASIS.

Insertion: Pes anserinus.

Innervation: Femoral n. (L2-4).

Actions: Hip F, ABD, ER; Knee F.

What are the orign, insertion, innervation, and actions of the pectineus?

Origin: pubis; pectineal line.

Insertion: inferior to lesser trochanter; pectineal line.

Innervation: femoral n. OR obturator n.

Action: Hip F, ADD, IR

What are the orign, insertion, innervation, and actions of the rectus femoris?

Origin: AIIS

Insertion: quadriceps tendon

Innervation: femoral n.

Action: hip F, knee E

What artery supplies the anterior compartment of the knee?

Femoral artery.

Describe 3 signs and symptoms of arterial insufficiency due to peripheral vascular disease.

1. Diminished or absent pulse in affected area.

2. Decreased capillary refill.

2. Shiny, thin, hairless skin.

3. Intermittent claudication: pain, aching, or cramping in affected area during activity.

4. Mild edema

Describe 3 signs and symptoms of venous insufficiency due to peripheral vascular disease.

1. Significant edema

2. Pruritis, "tightness"

3. Brown or eczema-presenting skin

4. Pain that is worse at the end of the day.

5. Pain improves with exercise.

What are common signs and symptoms of a deep venous thrombosis?

1. Dull ache in affected extremity

2. Tightness, heaviness

3. Localized swelling, edema, redness

4. Pain with calf dorsiflexion

What is the main difference between heparin and warfarin?

Heparin: fast acting, injection, short-term use

Warfarin: slow acting, long-term use

How should a physiotherapist approach treating a patient with a recent DVT?

1. Check with physician to determine if adequate anti-coagulation is achieved; activity orders.

2. Proceed with mobilization.

What are signs and symptoms of a pulmonary embolism?

1. SUDDEN dyspnea, chest pain

2. Bloody sputum, cough

3. Tachycardia

4. Syncope

5. Decreased oxygen saturation

How should a physiotherapist react when they suspect that a patient has a pulmonary embolism?

1. Halt mobilization.

2. Seek emergency medical assistance.

3. If possible, oxygenation (if you are rostered)

What magnitude of a drop in blood pressure would lead you to suspect orthostatic hypotension?

Systolic: >20 mmHg

Diastolic: >10 mmHg

What is the optimal positioning for a patient who is acutely experiencing orthostatic hypotension?

Supine

For how long should patients avoid strenous activity following heart surgery?

6-10 weeks

What blood pressure is considered hypertensive?

SBP >139

DBP >89

What is considered uncontrolled hypertension and a contraindication to exercise?

SBP >180

DBP >110

What is considered dangerously hypotensive?

SBP <90

DBP <60

What is heart rate reserve?

The difference between someone's maximum heart rate and their resting heart rate.

At what intensity (using heart rate reserve) do you want to prescribe aerobic exercise for cardiac patients?

40-70% heart rate reserve

(HR Reserve x % intensity) + resting HR = exercise HR

Describe 3 resistance training principles for cardiac patients.

1. NO valsalva

2. NO isometric / static exercises

3. Lower resistance + higher reps

4. Slower rate of progression; don't increase more than one of FITT each week.

Describe 2 precautions when mobilizing a patient with a chest tube.

1. Do NOT lift chest tube above the site of insertion to avoid backflow.

2. Do NOT lay or roll onto chest tube.

3. If connected to wall suction, check with medical team if the patient is able to be disconnected.

What are some unique considerations for femoral ART lines compared to brachial or radial?

1. NO hip flexion >80 degrees

2. When removed, no coughing for 2 hours. Patient must lie flat for 4-6 hours.

What is normal intracranial pressure? Dangerously elevated?

Normal ICP = 0-10 mmHg

Dangerous ICP = >20 mmHg

In what position are patients with elevated intracranial pressure treated?

What is one treatment consideration for those with elevated ICP?

Head of bed elevated 15-30 degrees.

Further, these patients require procedures such as suctioning or manual techniques to be limited.

What is the difference between a step and a stride?

Step: one leg moving forward; right heel strike to left heel strike.

Stride: when one step of each the left and right leg occur in succession; one gait cycle

During gait, what percentage is spent in the stance phase? In swing phase?

Stance: 60%

Swing: 40%

What are the sub-categories of the stance phase of gait? How much of a total gait cycle do we spend in each?

Initial Contact: 0% (double support)

Loading Response: 0-10% (double support)

Midstance: 10-30%

Terminal Stance: 30-50%

Pre-Swing: 50-60% (double support)

What are the sub-categories of the swing phase of gait? How much of a total gait cycle do we spend in each?

Initial Swing: 60-73%

Midswing: 73-87%

Terminal Swing: 87-100%

Define "midstance" in the gait cycle

Elevation of opposite limb until both ankles are aligned in the frontal plane

Define "terminal stance" in the gait cycle.

After both ankles are aligned; when the supporting heel rises from the ground until the opposite heel touches the ground.

Define "pre-swing" in the gait cycle

Initial contact of opposite limb to just prior to elevation of ipsilateral limb.

Define "initial swing" in the gait cycle

From the elevation of the foot off of the ground until the point of maximal knee flexion.

Define "Mid-swing" in the gait cycle

Following the point of maximal knee flexion to the point where the tibia is vertical

Define "terminal swing" in the gait cycle

From the point where the tibia is vertical to just prior to initial contact with the ground

What are the 3 main tasks of gait?

1. Weight acceptance

2. Maintenance of stability during single leg support

3. Limb advancement

Describe what causes trendelenburg gait and how the cause affects overall gait pattern.

Weak abductors cause the contralateral hip to drop

Patient will likely lean their trunk towards the weak side.

What are the highest and lowest heart rates that you should mobilize someone with?

High: >130 BPM

Low: <40 BPM

What gait aid(s) are most appropriate for non-weightbearing and feather-weightbearing?

What type of gait pattern is used?

1. Standard Walker

2. Crutches

Gait Pattern: 3-point

What gait pattern would a patient who is partial-weightbearing use?

1. 3-point

2. 4-point

What type of gait pattern(s) are used for patients who are WBAT or full-weightbearing?

1. 2-point

2. 4-point

What does an order of "supervision" mean?

Patient does not require physical help, but might require cues or someone nearby for potential assistance.

What does an order of "minimal assistance" mean?

Patient performes at least 75% of the activity

What does an order of "moderate assistance" mean?

Patient performs at least 50% of the activity

What does an order of "maximal assistance" mean?

Patient performs less than 25% of an activity

After a hip or knee replacement, which leg should lead during gait?

Operated lower extremity.

What are the typical hip precautions?

1. No hip flexion >90 degrees

2. No internal rotation of the hip

3. No adduction past midline

*WBAT

What is the hierarchy for inherent balance strategies - small to large perturbations in balance?

1. Ankle

2. Hip

3. Step

If you suspect that your patient is experiencing a transient ischemic attack or a stroke, what should you do?

1. Stop treatment

2. Ensure patient safety (lying with head slightly elevated)

3. Call emergency services

4. Monitor the patient

5. Avoid giving food or drink

Relating to strokes, what does the acronym "FAST" stand for?

Face drooping

Arm weakness

Speech difficulty

Time to call emergency services

What are some factors supporting a positive prognosis post-stroke?

1. Younger age

2. Ischemic type stroke

3. Absence of severe deficits (e.g. aphasia, visospatial deficits, incontinence)

4. Early mobility

In what timeframe do we expect the majority of neurological recovery to occur post-stroke? Functional recovery?

Neuro: 12 weeks

Functional: 14-15 weeks

*More severe strokes have a more protracted recovery period

How does treatment differ for thrombolytic vs. hemorrhagic strokes?

Thrombo: TPA within 3-4 hours. If after 6, mechanical thromectomy

Hemo: endovascular procedures, surgery

Define "diaschisis" and what your treatment priority would be.

Temporary reduction of neural activity in intact brain regions due to a loss of input from an anatomically connected injured area of the brain. Presents as flaccid limbs.

Treatment: produce any type of movement (voluntary / reflexive) that you can.

Does strengthening exercise exacerbate spasticity in stroke patients?

NO

What is "visual agnosia"?

Impairment in recognition of visually presented objects.

What is prosopagnosia?

Inability to recognize faces or pictures of familiar people.

What is anosognosia?

Patient does not recognize the presence or severity of their impairment; may believe that their affects limbs belong to someone else.

What are some treatment principles for neglect?

1. Therapist should stand and sit on neglect side to encourage attention to that side.

2. Stimulate affected side with sensory stimulation

3. Incorporate involved side into activities that involve crossing midline

4. Teach visual scanning strategies.

What are common characteristics of RIGHT CVA strokes?

1. Left-sided weakness

2. Visual/spatial problems

3. Neglect

4. Visual agnosia

*Non-verbal / artistic brain

What are common characteristics of LEFT CVA strokes?

1. Right-sided weakness

2. Aphasias (Broca's, Wernicke's, etc.)

3. Apraxia (difficulty planning and executing motor tasks)

What is Broca's aphasia?

Lesion to left frontal lobe resulting in impaired production of speech.

Auditory comprehension is intact.

What is Wernicke's aphasia?

Lesion to left temporal lobe resulting in impaired auditory comprehension of speech.

Spontaneous speech is preserved, intentional speech will not make sense.

In a patient with an acute stroke with a clearly affected side, which side would you transfer towards? Would this change as the patient progresses through rehab?

Acute: transfer towards strong side for increased safety.

Sub-Acute: transfer towards affected side for therapeutic benefit.

What are some considerations for constraint-induced movement therapy?

1. Must be completed for 90% of waking hours

2. Patient must be CMSA III or higher

3. Practice should be task-oriented.

What are some treatment principles for a flaccid, subluxed shoulder in a stroke patient?

1. Avoid positioning the shoulder in internal rotation

2. Ensure that the GH joint remains supported

3. Encourage weight-bearing as tolerated through the arm for joint loading

4. Proper shoulder positioning (slight abduction + ER)

5. Use of NMES

6. Education to family

7. Safe PROM

What are some facilitation strategies to use when treating stroke patients with little voluntary muscle activation?

1. Tactile cues (e.g. tapping, vibration, joint compression)

2. Stimulation (e.g. electrical)

3. Stretching

4. Ice

What are some inhibitory strategies to use with stroke patients who are more spastic?

1. Prolonged stretching

2. Tendon pressure

3. Prolonged cold

4. Compression

What might an infact of the anterior cerebral artery result in?

1. Motor / sensory loss in LOWER LIMBS (contralateral)

2. Emotional / personality changes (frontal lobe)

What might an infarct of the middle cerebral artery result in?

1. Motor / sensory loss in face, throat, HANDS, and/or ARMS (contralateral)

2. Perceptural deficits (parietal lobe)

3. Aphasia

What might an infarct of the posterior cerebral artery result in?

1. Vision difficulties

2. Abnormal involuntary movements

3. Memory impairments (temporal lobe)

What is Wallenberg's Syndrome?

Lesion of vertebral or posterior inferior cerebellar artery (PICA); causes loss of pain and temperature to contralateral trunk, loss of pain and temperature to ipsilateral face.

What is Horner's Syndrome?

Lesion to nerves of sympathetic trunk; results in ipsilateral ptosis, miosis, dry + red face

What innervates the muscles of mastication?

What are the main muscles of mastication?

Cranial nerve V (trigeminal)

Masseter, temporalis, medial + lateral pterygoid

What are the 4 joints of the shoulder complex?

sternoclavicular, acromioclavicular, glenohumeral, scapulothoracic

What clinical features would indicate plantar fasciopathy?

1. Pain over plantar fascia and calcaneal tuberosity

2. Most pain with first few steps in the morning / after a period of rest

3. Decreased dorsiflexion

4. Recent increase in activity

What clinical features would indicate medial tibial stress syndrome?

1. Pain over medial aspect of tibia (TOP)

2. Pain with resisted plantarflexion

3. Pain can improve or worsen with exercise, but is usually worst at the beginning of an exercise bout

4. One leg hop test to rule out stress # (unable to hop with #)

5. Pes Planus

Lateral ankle sprain: what is the typical MOI and what are the typical affected ligaments?

MOI: inversion and plantarflexion

Ligaments: ATFL, CFL

Syndesmosis / High Ankle Sprain: what is the typical MOI

MOI: excessive DF and ER of the leg when it's planted

What tests would you use to assist in the diagnosis of a high ankle sprain / syndesmosis?

1. Squeeze test

2. Kleiger test

What is the Royal London Hospital test?

Used to assist in the diagnosis of achilles tendinopathy.

Dorsiflexion decreases pain.

What is the ARC sign for achilles tendinopathy?

Palpation of achilles tendon during plantarflexion / dorsiflexion - can tendon be felt moving? Any thickening?

What are some common techniques used to assist in determining the presence of a knee meniscal pathology?

1. McMurray's Test

2. Thessaly's Test

3. Apley's test

4. Joint line tenderness

What is the most common MOI for the "unhappy triad" of the ACL, medial meniscus, and medial collateral ligament?

Plant + twist / dynamic valgus

Forceful rotation of the knee combined with flexion

What is the origin and insertion of the ACL?

Origin: posterio-medial aspect of lateral femoral condyle

Insertion: antero-medial tibial head