geri exam 1
Measurement with a flexicurve is performed. Which kyphotic value would indicate clinical kyphosis? 10 11.2 12.5 13.5
13.5 Reason: All values that are greater than 13 indicate a clinical kyphosis measure. Values below indicate a normal value.
A working definition of clinical proficiency is: A clinician who has exposure to a wide variety of typical situations, uses memorized principles to guide action, and is comfortable with evolving situations A clinician who relies on rules and analytic reasoning A clinician who has a deep level of commitment to work, is intensely motivated to continue improvement, and has a deeply reflective practice A clinician who has five years of practice or more
A clinician who has a deep level of commitment to work, is intensely motivated to continue improvement, and has a deeply reflective practice Reason: Years of practice do not ensure proficiency. Dependence on rules and analytic reasoning is a common strategy for a novice. Recognition of patterns and comfort with changing factors decscribes competence, but the deepest level of commitment, motivation, and reflection is typical of a master clinician. [Peña, A. (2010). The Dreyfus model of clinical problem-solving skills acquisition: A critical perspective. Medical Education Online, 15(1), 4846.]
A patient with dementia and a recent fall is seen for PT evaluation in the home health setting following an acute hospital stay for a congestive heart failure exacerbation. Past medical history includes congestive heart failure, peripheral vascular disease, and hypertension. The patient lives in a single-level home with an able-bodied spouse and previously was able to ambulate without an assistive device. The patient owns no equipment but does have prior experience with the use of a front-wheeled walker following a knee replacement eight years ago. Examination findings reveal: Gait speed of 0.5 meters/second without an assistive device 6-Minute Walk Test distance of 125 prior to needing to sit down, completing only 2 minutes and 30 seconds of the test Berg Balance Scale score of 24/56 Inability to rise to standing without upper extremity support from a dining room chair Furniture-walking throughout the home Given the examination findings, what assistive device would be BEST to recommend in this case? A four-wheeled rollator with hand brakes and a seat A front-wheeled walker A quad cane Bilateral walking poles
A front-wheeled walker Reason: The patient should be provided with a walker that she has previously used as her motor pattern for this skill may still be intact despite her memory impairments. A four-wheeled walker, walking poles, and a quad cane require that the patient learn a new sequence in order to ambulate safely, whereas a front-wheeled walker has less sequencing required with its use.
Cellulitis is: A rapidly spreading infection caused by an exogenous bacteria, typically occurring at a site where the skin has been broken A yeast infection most common in immunocompromised older adults Dryness of the skin leading to redness or cracking of the skin Due to a MRSA infection
A rapidly spreading infection caused by an exogenous bacteria, typically occurring at a site where the skin has been broken Reason: Candida is caused by yeast infections. Xerosis is the condition of dry skin. MRSA infections are a distinct condition of localized wound infections treated with topical agents. Cellulitis is a rapidly spreading infection caused by an exogenous bacteria.
In older adults, vestibular hypofunction is: A central dysfunction of cerebellar origin. A situation in which both inner ears have been partially or completely damaged. This is treated with adaptive and substitution exercises. Corrected with Dix-Hallpike. Limited to a visual disturbance.
A situation in which both inner ears have been partially or completely damaged. This is treated with adaptive and substitution exercises. Reason: Characteristics of vestibular hypofunction include visual problems, balance instability while standing, and difficulty walking in the dark, on compliant surfaces, or in a straight line. This is due to partial or complete loss of the vestibulospinal reflex.
Which of the following conditions provides examples of accountability as defined by APTA core values? Acknowledging and accepting consequences of actions; assuming responsibility for learning and change. Placing patients'/clients' needs above the physical therapist's needs, even if it means completing patient/client care and professional responsibility prior to personal needs. Providing pro bono services and physical therapy services to underserved and underrepresented populations. Providing patient/client services that go beyond expected standards of practice.
Acknowledging and accepting consequences of actions; assuming responsibility for learning and change. Reason: Accountability is active acceptance of the responsibility for the diverse roles, obligations, and actions of the physical therapist, including self-regulation and other behaviors that positively influence patient/client outcomes, the profession, and the health needs of society. These are seen as indicators in the correct answer. All other responses are examples of altruism.
Mandy is a 76-year-old Asian woman who fell while taking out her trash and fractured her R wrist. This is her third GLF since her husband died 10 months ago. She lives alone and spends most of her day knitting or reading. She has been depressed since her husband's passing and has lost 12 pounds. She drinks six cups of coffee a day and eats mostly canned goods or frozen entrees that she can heat up in the microwave. She has poor eyesight and no longer drives. Her neighbor takes her to the grocery store and other errands once weekly. Otherwise, she does not get out much. She has moderate kyphosis, forward head, and protracted shoulders, which she attributes to years of her sitting leisure activity. Her TUG score is 15 seconds, and her DGI is 18/24. She is referred to PT, now six weeks post ORIF R wrist for general deconditioning, impaired balance, and UE strengthening/ROM. Which factors in Mandy's case would lead you to be concerned about osteoporosis as a contributing factor to her UE fracture? Age, female, poor diet, sedentary lifestyle, postural changes, ethnicity History of three falls in less than a year Depression and weight loss Decreased functional mobility and dynamic balance
Age, female, poor diet, sedentary lifestyle, postural changes, ethnicity Reason: Mandy has several intrinsic and lifestyle factors that may contribute to low bone density. Her history of falls and decreased balance give her a greater risk of fall, but does not increase the risk of fracture due to fall without the other characteristics present.
In your answer to the previous question, which factors are nonmodifiable? Decreased balance Postural changes Age, gender Sedentary lifestyle
Age, gender Reason: Nonmodifiable factors are considered intrinsic and nonchangeable. Lifestyle, posture, balance, deconditioning, and diet are all modifiable.
Older learners: Have diminishing IQs with aging, so need to have instructions presented in very basic formats Have cognitive decline, which limits their ability to learn Are kinesthetic learners since visual and auditory impairments limit their ability to learn visually and auditorily Are a heterogeneous group
Are a heterogeneous group Reason: There is no single common characteristic about learning capacity in older adults that is dictated by their age. They are as heterogeneous as any other group of learners in capacity, learning styles, and influence of experiences.
Which of the following interventions is the best exercise to improve his gait deviation? Sidelying straight leg lifts Riding a recumbent bicycle Balance exercises emphasizing a level pelvis Supine bridge exercises
Balance exercises emphasizing a level pelvis Reason: This exercise is useful because it is weight-bearing and it mimics the hip abductors' function of stabilizing the pelvis during single-limb stance of gait. To answer this question correctly, one has to have a good understanding of the action of the hip abductors during the stance phases of gait and therapeutic exercise that will closely mimic that. Sidelying straight leg lifts will target the hip abductors, but it is non-weight-bearing and may not be the best choice to improve his gait deviation. Supine bridge exercises will target several muscles but do not isolate the hip abductors and do not necessarily correlate to the hip abductors' function during gait. A recumbent bicycle will not improve the strength of the hip abductors.
A physical therapist considers a patient's value system and formulates goals that are specific to that individual's perceptions of quality of life. This is a good example of which particular aspect of ethics in geriatric care? Pro bono care Beneficence Cultural sensitivity Autonomy
Beneficence Reason: Beneficience is one of the guiding biomedical principles in health care, defined as a moral obligation to act for the benefit of others. The principle of beneficence asserts the obligation to deliberate benefits, to prevent and remove harms, and to weigh and balance the possible goods against the cost and possible harms of an action.
In order to be considered homebound under the Medicare Part A home health benefit, all of the following would need to be considered EXCEPT: Functional impairment making it too difficult to access medical services as an outpatient Cognitive impairment making it too difficult to access medical services as an outpatient Leaving the home has been deemed medically contraindicated Beneficiary must be confined to his/her bed
Beneficiary must be confined to his/her bed Reason: The term homebound in the context of the qualifying criteria for home health under the Medicare Part A benefit is not limited to the concepts of a beneficiary being confined to his/her bed.
The drug category associated with the greatest risk for fall in older adults is: Glucocorticoids Diuretics Benzodiazepines Bronchodilators
Benzodiazepines Reason: Benzodiazepines such as Valium or Ativan are frequently prescribed for anxiety, muscle spasm, or sedation, and are associated with adverse effects of dizziness, sedation, impaired motor coordination, and postural disturbances. Benzodiazepine use alone increases falls, irrespective of polypharmacy.
An older adult at risk for falls has undergone a structured home-based exercise program that consisted of standing balance training and strengthening exercises. The measure that can BEST show improvement is: 6 minute walk test Berg balance scale Timed up and go Tinetti
Berg balance
You are evaluating Bernard, a 73-year-old patient with Parkinson's Disease who is struggling with function and safety in his current home environment. He has had a progression of his disease and is not yet managing well with a new medication regimen. Under Medicare Part A, Bernard will qualify for admission to an IRF (inpatient rehab facility) if: Bernard had a surgical procedure in the last 30 days Bernard has a history of stroke Bernard has a three-day qualifying hospital stay Bernard can participate in at least three hours of therapy per day at least five days per week and requires at least two therapy disciplines for treatment
Bernard can participate in at least three hours of therapy per day at least five days per week and requires at least two therapy disciplines for treatment Reason: Criteria for admission to an inpatient rehab facility include the prescriptive therapy services that the patient will require during their stay. A specific diagnosis or procedure may contribute to the reason the patient requires therapies but is not stand-alone justification. There is no qualification of a hospital stay for IRF admission; in fact, the patient can be referred directly from a community (outpatient) provider.
Carmen is an 84-year-old female who received a neuro consult for her tremor. Parkinson's disease (PD) was ruled out, and she was given a drug prescription, with directions to return for follow-up in 14 days to determine the effectiveness of the drug on her tremor. Carmen chose to NOT take the drug because she was afraid of the side effects and her current management strategies were working fine. Her primary concern was that she may have PD. Which of the following is true regarding Carmen's treatment? Carmen has the right to refuse recommended treatment Carmen should take the drug because her neurologist prescribed it Carmen does not need to be concerned about drug side effects or taking too many drugs Carmen must do whatever necessary to manage her tremor even if it means a new drug
Carmen has the right to refuse recommended treatment Reason: Patients have the right to make choices in their health care. In this case, Carmen's primary reason to seek a neurology consultation was because she was afraid the tremor was a sign of PD. Once PD was ruled out, she made a decision based on the risk versus benefit of initiating a new prescription.
In older adults, benzodiazepine use should be minimized due to increased risk of: Extrapyramidal effects, including tardive dyskinesiacognitive impairment, delirium, falls Hypertension and risk of stroke Cognitive impairment, delirium, falls Incontinence and hypotension
Cognitive impairment, delirium, falls Reason: Use of benzodiazapines alone or in combination with other drugs (polypharmacy) is associated with dizziness, sedation, impaired motor coordination, and postural disturbances, causing increase in falls in older adults. Benzodiazapines are also listed in the Beers List of inappropriate medications for older adults. [Richardson, K., Bennett, K., & Kenny, R. A. (2014). Polypharmacy including falls risk-increasing medications and subsequent falls in community-dwelling middle-aged and older adults. Age and Ageing, 44(1), 90-96.]
You are developing a plan of care for a 79-year-old patient with persistent chronic pain secondary to spinal stenosis. Your plan should include: Compensation and coping strategies to minimize stressors while improving physical activity and function Expectations for a rapid and sustained change in pain Weaning the patient from all drugs in order to accurately assess patient management results Enrolling the patient in cognitive /behavioral pain management program
Compensation and coping strategies to minimize stressors while improving physical activity and function Reason: The patient's successful pain management will depend on many factors, including the patient's ability to learn effective self-management strategies utilizing positioning, activity modification, stress management, and relaxation techniques, and appropriate conditioning and physical activity within the limits of the current condition to optimize health and wellness.
Your 91-year-old patient Bessie is a resident in long-term care and refuses to participate with physical therapy interventions because she thinks exercise will aggravate the joint pain she is experiencing due to the winter storm approaching. Attributes to consider when understanding Bessie's chronic pain include: Bessie's pain is acute today related to the weather change; she should take pain medication and rest. Contributing physical and limbic system factors may be synergistic, amplifying the effect of pain on function. Bessie is 91. The risk of increasing her pain with exercise is worse than the benefit the exercise may offer. Interventions directly addressing Bessie's symptoms, such as soft-tissue mobilization, therapeutic exercise, and orthotic or supportive devices will not be helpful since her pain is chronic and diffuse.
Contributing physical and limbic system factors may be synergistic, amplifying the effect of pain on function. Reason: Bessie may have several components contributing to her pain today, including past experience with weather changes, a long history of unresolved musculoskeletal pain, poor understanding of the effects of bed rest, and inactivity on her overall pain and health management. Depressed mood, hopelessness, and anxiety may also contribute to her current state. However, the benefits of addressing current physical, physiological, and mechanical approaches to effect a localized tissue response while encouraging overall physical activity/mobility related to whole-body factors is essential for consistent and effective pain management, today and every day.
Use of the American College of Sports Medicine's (ACSM) principles of exercise prescription includes all of the following parameters EXCEPT: Frequency of exercise Intensity of exercise Daily completion of exercise Type of exercise
Daily completion of exercise Reason: ACSM guidelines for individualized exercise prescription utilize the FITT principle: frequency, intensity, type, and time parameters based on the type and goal of the program.
Multiple sclerosis involves what clinical pathologic process? Demyelination of white matter within the central nervous system Immune-mediated inflammation causing demyelination of the peripheral nervous system Vascular ischemia to grey matter within the brain, cerebellum, and spinal cord Vascular ischemia to white matter within the brain and cerebellum
Demyelination of white matter within the central nervous system Reason: MS involves an immune-mediated inflammatory response causing demyelniation of the central nervous system, which includes the brain, cranial nerves, cerebellum, and spinal cord. Vascular ischemia is the pathology of an ischemic stroke. Demyelination of the peripheral nervous system would not be diagnosed as multiple sclerosis.
A family insists that a patient be treated in spite of repeated indicators of no improvement and associated reimbursement denials. They have agreed to pay for it out of pocket. The family has requested a conference with the facility administrators and rehab team. Discussion with the family and rehab team will require resolution to which of the following ethical principles? Respect for autonomy Ethical dilemma Ethical distress Locus of authority
Ethical distress Reason: This situation requires decision-making to resolve the conflict between the patient's rights and what is justifiable as skilled care. A problem in which the right course of action is known (discontinue PT) but where there is a barrier keeping the person from doing the best course of action (family's wishes) is known as ethical distress.
In aging, there is a relative decrease in lean body mass. This affects pharmacokinetics in the following way: Water soluble drugs fail to reach intended unit concentration Fat-soluble drugs have more tissue to spread through and thus increase their half-lives Protein-bound medications will have lower free drug levels at standard doses As lean body mass tends to decline proportionally with GFR, and medications eliminated by the kidney tend to have shorter half-lives
Fat-soluble drugs have more tissue to spread through and thus increase their half-lives Reason: Due to increase in fat mass and lower lean body mass, water-soluble drugs reach higher unit concentration. Protein-bound medications will have higher free drug levels at standard doses. As lean body mass tends to decline proportionally with GFR, creatinine may remain normal with major impairments. Medications eliminated by the kidney tend to have prolonged half-lives.
Which statement is true regarding fear of falling? No valid tool exists to effectively measure fear of falling It is not important; only an actual fall with injury is important in identifying future risk for fall Fear of falling and avoidance of activity is typically underreported Patients will typically have fear of falling only if they have experienced an injury from a fall
Fear of falling and avoidance of activity is typically underreported term-8Reason: Older adults who fall develop a fear of falling even if they sustain no injury. Fear of falling causes them to limit their activity, which in turn leads to reduced mobility and fitness and subsequent increase in fall risk. Fear of falling is strongly associated with future falls. Fear of falling is well validated with the Activities-Specific Balance Confidence Scale and the Falls Efficacy Scale. (See rehabmeasures.org)
The Montreal Cognitive Assessment (MoCA) is a standardized, clinically researched cognitive screening test designed: To diagnose Alzheimer's disease To replace the MMSI since it now requires a subscription to administer For detection of mild cognitive impairment For specific use with progressive neurological conditions only
For detection of mild cognitive impairment Reason: The MoCA, created in 1996, was designed to assist health professionals in detection of mild cognitive impairment. A thorough description is found in the introduction of the tool available in the Journal of the American Geriatrics Society. It can also be referenced on rehabmeasures.org. [Nasreddine, Z. S., Phillips, N. A., Bédirian, V. (2005). The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53, 695-699.]
What brain MRI finding would be considered normal in the older adult? Cerebellar enlargement Frontal lobe atrophy Lacunar infarct in the thalamus Midbrain demyelination
Frontal lobe atrophy Reason: The only normal age-related neurological change identified as an option is frontal lobe atrophy. Lacunar infarcts in the thalamus are pathologic changes related to vascular disease and therefore not normal. Cerebellar enlargement is not a normal age-related change. Midbrain demyelination would be a pathologic change as well.
What would be the MOST appropriate outcome measure to include to gain more information regarding the patient's balance deficits? 6-Minute Walk Test 10-Meter Walk Test Functional Gait Assessment Timed Up and Go Test
Functional Gait Assessment Reason: The Functional Gait Assessment is the best answer. The patient reported falling, particularly in a very dynamic environment such as the mall. The 6-Minute Walk Test is a test of activity tolerance. The patient did not mention endurance or fatigue being a factor in his falls. The 10-Meter Walk Test is a test of gait speed. Although this patient is demonstrating slowed speed, it most likely is not the main factor with his balance deficits and falls. The Timed Up and Go Test is a test of functional mobility but does not fully assess various gait activities that one would have to perform in a busy environment. The FGA tests many different dynamic gait activities one would have to do in a busy environment, such as speed changes, turning the head while walking to scan, turning around when walking, and stepping over obstacles.
Which of the following medications could contribute to vestibular balance impairment in the elderly? Heparin Baclofen Gentamicin Metoprolol
Gentamicin Reason: Gentamicin is used to treat certain serious infections that are caused by bacteria, such as meningitis and infections of the blood, abdomen, lungs, skin, bones, joints, and urinary tract. Gentamicin is in a class of medications called aminoglycoside antibiotics. It is known to be an ototoxic medication and may cause vestibular hypofunction, with complaints of visual and balance problems.
Your patient is homebound and living with her spouse in a coastal area where hurricanes may occur. All of the following recommendations are appropriate for helping this couple to prepare for an emergency, except: Have the spouse walk the patient, using the WC, to the neighbor's house if a storm is approaching Maintain an ample supply of medications and emergency supplies (dry goods, water, flashlight, batteries, radio) in a designated safe room in the home Store legal documents and records in a secure, waterproof container
Have the spouse walk the patient, using the WC, to the neighbor's house if a storm is approaching Reason: Depending on neighbors for safety may not be realistic. Walking next door is not wise if a storm is rapidly approaching. All of the other emergency preparedness guidelines are pertinent. Family, friends, and/or first responders should be notified ahead of time regarding what plans are in place. Ensure EMS can access the home via lockbox or key available in a previously designated location
Helen is an 86-year-old female currently receiving physical therapy services in a skilled nursing facility following a hip fracture requiring a total hip arthroplasty to repair. She lives alone and sustained a ground-level fall when she tripped over her small dog. You are working on mobility, gait, and balance skills, but Helen is having difficulty with compliance to her hip precautions. She has mild cognitive impairment. Helen will be discharged from the skilled nursing facility for a three-week stay with her daughter before returning to her assisted living apartment. Learning of hip precautions is best assessed by: The ability of Helen's daughter to correct her when she moves unsafely. Helen consistently performing transfers and ambulation with her walker using correct strategies as she practiced in therapy. This is observed by facility staff as well as during therapy sessions, without the need for cues or corrections.Helen knows there are some new rules for moving, and frequently asks if she is doing things correctly, but she often forgets to use her walker. Helen still has pain when she gets out of bed, so she is very careful in moving—slowing down and getting out on the opposite side of the bed.
Helen consistently performing transfers and ambulation with her walker using correct strategies as she practiced in therapy. This is observed by facility staff as well as during therapy sessions, without the need for cues or corrections. Reason: Return demonstration reflects new motor learning. Helen's compliance with hip precautions in functional mobility (without reminders or cues) demonstrates her achievement in learning hip precautions.
Martha's ability to manage safely at home is best predicted by: Her ability to demonstrate all of her mobility and exercises, and repeat back any specific precautions or instructions regarding her post-op status (e.g, monitoring the surgical site, pain management strategies, and activity restrictions dictated by the surgeon, such as driving) Her ability to walk 50 feet with her walker to manage household distances Her clear cognitive status so she can tell her husband what to do Her daughter's confidence that her dad will take care of her mom
Her ability to demonstrate all of her mobility and exercises, and repeat back any specific precautions or instructions regarding her post-op status (e.g, monitoring the surgical site, pain management strategies, and activity restrictions dictated by the surgeon, such as driving) Reason: Martha's performance of necessary tasks for successful discharge to home is indicative of her psychomotor learning, given the limitations of her current condition. Her ability to verbally recite pertinent information regarding her care also reflects learning in the cognitive domain.
Which of the following would not lead to a lower score for the Norton scale? Her poor physical condition Her bedfast status Her intact mental condition Her incontinence
Her intact mental condition Reason: The Norton scale was designed to score 5 risks: physical condition, mental condition, activity, mobility, and continence. This results in a score of 5-20, with lower scores indicating higher risk for ulcer development with correlation to poorer functional level.
A 72-year-old male recently underwent a right total hip arthroplasty with a posterior approach. His past medical history is significant for hypertension and high cholesterol, which are controlled with medications. He presents to an outpatient physical therapy clinic for an initial evaluation. He is no longer using an assistive device for ambulation. During the gait assessment, the physical therapist notes a significant right trunk lean during stance phases on the right. Based on the patient's gait assessment, which of the following muscle groups is likely weak? Hip flexors Hip extensors Knee extensors Hip abductors
Hip abductors
The benefits of early mobilization in the ICU include all of the following except: Preserved musculoskeletal and neuromuscular integrity Enhanced cardiovascular function Decreased chronic inflammation Impaired blood sugar homeostasis
Impaired blood sugar homeostasis
What sensory exam finding would be considered NORMAL for this patient? Absent proprioception of bilateral great toes Impaired proprioception at the great toes bilaterally Impaired sensation to light touch in the L5 distribution Absent pin prick in a stocking distribution of the bilateral lower extremities
Impaired proprioception at the great toes bilaterally Reason: Absent sensory modalities are not associated with Parkinson's disease or normal aging. With age-related changes and Parkinson's disease, we can expect to see reduction in accuracy of proprioception. It would not be consistent with PD pathology or normal aging to have dermatomal or cutaneous distribution patterned sensory loss.
Development of appropriate interventions for inclusion in the patient-centered therapy care plan should be based on: The judgment and expertise of the evaluating therapist due to their professional training and experience. Impairments in body structure or function that limit activities or restrict participation in normal roles/responsibilities. What local coverage determinations (LCDs) outline as those are interventions that are covered by the Medicare benefit. The inclusion of required interventions of exercise, balance, and gait.
Impairments in body structure or function that limit activities or restrict participation in normal roles/responsibilities. Reason: The APTA has adopted the International Classification of Functioning, Disability and Health (ICF) as the biopsychosocial framework for building the patient-client model for care planning. Care plans are individually developed based on the unique characteristics of the patient and the environment and social support system in which the client resides.
Which of the following characteristics are common for all low-vision conditions associated with aging? Easily treated with corrective lenses Impairments to safety and functional mobility are present Loss of optic nerve function Edema and increased fluid pressure is always present
Impairments to safety and functional mobility are present Reason: Symptoms and treatment of the eye vary according to etiology of pathology and age-related changes. However, a functional approach for all patients with low vision should address mobility and safety, which are hindered by this sensory change.
When treating a patient with dementia, it is appropriate to: Recommend placement for the patient in a specialized facility Include caregivers/family members in therapy treatment sessions Provide a written and illustrated home exercise program to ensure compliance Limit number of therapy visits to no more than six in one episode of care
Include caregivers/family members in therapy treatment sessions Reason: Treatment of dementia patients should provide assistance, training, and education to caregivers/family members. Medicare Part A does not limit the care based on diagnosis/condition, or require specific interventions be provided; skilled therapy is based on individual patient characteristics that are appropriate to improve or stabilize function.
Motor skills in healthy older adults: Are limited to habitual patterns Incorporate innumerable combinations of movement of head and neck, trunk, and upper and lower extremities Reverse to developmental patterns as the individual ages Occur segmentally without integration
Incorporate innumerable combinations of movement of head and neck, trunk, and upper and lower extremities Reason: In a healthy older adult, movement patterns are generated and controlled in the same fashion as a younger individual; however, functional movement may demonstrate diminished velocity, available range of motion, stability, or endurance due to normal musculoskeletal and neurological changes with aging.
Practicing reflection as a professional means: Incorporating self-awareness into clinical decision-making and practice Utilizing recall of methods and processes The act of thinking Reliance on rules and analytic reasoning
Incorporating self-awareness into clinical decision-making and practice Reason: The more proficient and expert clinician can apply higher evaluative and intuitive skills to clinical judgement about the validity, strength, and relevance of evidence. The more novice clinician relies on rules, pattern recognition, and memorized facts. Self-awareness and reflective practice are characteristics of the expert clinician.
An advantage of use of beta blockers for exercise performance is all of the following except: Increased exercise capacity in patients with angina Increased HR response to exercise Decreased exercise ischemia Decreased HR
Increased HR response to exercise Reason: Beta blockers blunt HR response to exercise, making it inappropriate to measure exercise response with measuring change in heart rate/pulse. It is recommended to use perceived rate of exertion (PRE) as a more accurate reflection of exercise intensity and response.
You are consulting with a patient who has DJD of the knees, hips, and low back that limits her ability to mobilize in and out of bed. She reports that she requires assist of one to help her out of bed and that she can then pivot to the bedside commode with standby assist. She is currently nonambulatory as a result of the pain. She has a longtime sacral ulcer that has visible subcutaneous fat but no bone present. Many normal signs of aging contribute to formation of wounds. Which of the following is not considered normal aging? Decreased pain perception through the skin Decreased sweat glands Decreased thickness of dermis and hypodermis Increased Langerhans and mast cells
Increased Langerhans and mast cells Reason: Normal skin changes associated with aging: decreased melanocytes, Langerhans cells, mast cells, sweat glands, subcutaneous fat, epidermal and dermal layers, and elastin and collagen in the dermis. Additionally, flattened epidermal rete pegs and dermal papillae, decreased thickness of dermis and hypodermis, and decreased pain perception. Langerhans and mast cells, portions of the immune and histamine response, decrease through normal aging, not increase.
Gait characteristics of low-functioning older adults include: Increased dual stance time Decreased dual stance time Increased DGI scores Decreased TUG scores
Increased dual stance time Reason: Low-functioning older adults have gait characteristics that typically increase dual stance time in order to create increased stability and safety. These characteristics may include slower gait velocity (walking speed and TUG performance), increased stance-to-swing ratio, decreased step length, and decreased stability in dynamic balance (DGI tasks).
Medication use in the older population exceeds that in younger adults because: Medicare pays for the drugs, so the consumer is free to use more Increased prevalence of disease and comorbidities Older adults rely on drugs because they don't understand how to self-manage symptoms Medication use is well tolerated in the elderly so it is a treatment of choice by physicians
Increased prevalence of disease and comorbidities Reason: Two of three older Americans have multiple chronic conditions. Older adults represent 13% of the population but consume 30% of all medications. For community-dwelling older adults age 57-85, 81% report at least one prescription, and 29% report at least five prescription meds.
What response to exercise would you expect as a result of her Hgb level? Not applicable—patient is not appropriate for exercise Normal response with SpO2 from 95% to 100% Increased shortness of breath and fatigue with SpO2 desaturating with minimal movements Increased shortness of breath and fatigue with SpO2 from 95% to 100%
Increased shortness of breath and fatigue with SpO2 from 95% to 100% Reason: The patient's low level of Hgb may be fully saturated with oxygen, but shortness of breath can persist. Intervention is not advised with levels less than 8 g/dL. [Malone, D. J., Bishop Lindsay, K. L. (2006). Physical therapy in acute care: A clinician's guide. Thorofare: Slack Inc. (pg 50).]
Mandy's UE fracture resulting from a ground-level fall: Is not a concern since she did not fracture a vertebra Is a result of her recent weight loss and deconditioning Increases the suspicion of osteoporosis Requires an MRI to determine osteoporosis
Increases the suspicion of osteoporosis Reason: A fragility fracture is defined as a fracture from low trauma, such as a fall from a standing height, lifting, sneezing, or coughing. Most healthy/asymptomatic bone can withstand forces between two and five times what they normally are subjected to in ADLs/habitual activity, even in the presence of aging. A fracture is often the first sign of the disease.
Following consultation with nursing regarding patient participation in therapy, what would be an appropriate intervention? Proprioceptive neuromuscular facilitation gait training with resistance at bilateral ASIS with progression of speed and resistance Therapy should be held for the day Active range of motion and gait training only Low-intensity progressive resistive exercise as tolerated by the patient
Low-intensity progressive resistive exercise as tolerated by the patient Reason: Normal platelet level is 140-400 × 10³/mm³. Based on the platelet level of 75 × 10³/mm³, the patient can participate in low-intensity progressive resistive exercise and aerobic exercise. When below 50 × 10³/mm³, only active ROM and walking are advised. When less than 20, therapy may be contraindicated.
Which statement is false regarding mild cognitive impairment (MCI)? Normal function in ADLs is preserved MCI is a precursor to Alzheimers disease within three years Is characterized by greater cognitive and memory decline than expected in normal aging Genetic testing may be effective in predicting conversion from MCI to Alzheimer's disease
MCI is a precursor to Alzheimers disease within three years Reason: Predictability of conversion from MCI to Alzheimer's disease is 10%-15% conversion in one year, 50% conversion after five years, and 90% conversion after 10 years.
Home health agencies are altruistically responsible to: Manage therapy utilization to meet the needs of the patient while managing the changes in regulatory payment methodologies Prioritize nursing visits and use therapy minimally Maximize therapy visits to maximize reimbursement Dictate number of therapy visits based on diagnostic codes regardless of the therapy evaluation and assessment/plan of care
Manage therapy utilization to meet the needs of the patient while managing the changes in regulatory payment methodologies Reason: In all reimbursement models, the purpose of home health services is to provide necessary medical and rehabilitative interventions in a collaborative multidisciplinary plan of care to maintain or improve self-care and mobility, safety, and function for homebound patients based on clinical needs identified by the OASIS. When acting for the benefit of all stakeholders, the needs of the patient are balanced with regulatory compliance to optimize opportunity for care as a beneficiary of the insurance system applied to the case.
Which upper extremity nerve is implicated with the upper limb tension test? Radial nerve Ulnar nerve Median nerve Musculocutaneous nerve
Median nerve Reason: Median nerve bias upper limb tension test has the components listed. Ulnar nerve requires elbow flexion. Radial nerve requires wrist, finger, and thumb flexion. The musculocuteanous nerve test requires ulnar deviation. Furthermore, the medial nerve can also be implicated due to the patient's cervical nerve root involvement.
A patient in the hospital with the diagnosis of chronic C. diff infection demonstrates the following lab values: pH 7.1, PaCO2 40 mmHg, and HCO3 15. She has active movement, with a Glascow Coma Scale score of 13. Her platelet level is 75 × 10³/mm³. Hemoglobin level is 10.1 g/dL. Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis
Metabolic acidosis Reason: Normal pH of the body is between 7.35 and 7.45. The pH of 7.1 ensures that you have an acidotic process present. Normal PaCO2 is 35-45 mmHg, and normal HCO3 is 22-28 mEq/L. Due to the normal PaCO2 and abnormal HCO3, we can deduce that the patient is presenting with metabolic acidosis, commonly present with chronic diarrhea, shock/sepsis, trauma, and renal failure. We can further deduce that it is not respiratory acidosis, based on the Glasgow Coma Scale score.
Ben is a 60-year-old man referred from neurology services to physical therapy to address myalgia and chronic debilitating pain. The medical diagnosis is somatic system disorder, and the MRI of the cervical and lumbar spine reports absence of spinal stenosis or cord compression. Ben reports full-body muscle pain, and stiffness that seems to originate from his back but is present in all major muscle groups at 6/10 pain most of the time. Additionally, Ben has painful peripheral neuropathy of his feet, characterized by burning pain that is worse at night. This has been progressive over the last two to three years, totally debilitating him and preventing him from occupational work, usual IADLs, and leisure/recreational activities. His pain usually worsens as the day goes on and is specifically aggravated by activities requiring bending forward, prolonged standing, or walking. When symptoms are aggravated by activity, it may take two to three days to recover. Relieving factors include totally reclining, use of his massage chair, or deep-pressure massage with a rolling pin across sore muscles. Ben remains independent in self care, with use of adaptive devices such as reachers and sock aids. He reports he is unable to get up off the floor and that he requires use of his hands to stand from a chair, requires use of a railing for stairs, and struggles with transfers in and out of the car. He does not have any regular fitness routine at this time. In the physical therapy assessment using the ICF category of physical limitation, what is the appropriate description of Ben's condition? Myofascial pain, deconditioning, and joint stiffness associated with chronic pain and several years of decreased physical activity Degenerative spine disease Generalized osteoarthritis Obesity
Myofascial pain, deconditioning, and joint stiffness associated with chronic pain and several years of decreased physical activity Reason: Three of the answers provide diagnostic categories of Ben's condition. However, the physical therapy assessment summarizes Ben's physical limitations and provides a treatment diagnosis.
When evaluating a new patient in your outpatient clinic, Andrea, age 84, mentions she has lost 12 pounds since her husband died three months ago. She is referred to physical therapy for generalized weakness and risk of fall. You are concerned about her health behaviors and inquire about her current eating habits. Following guidelines for adequate nutrition in healthy older adults, you ask specific questions about all of the following except: Maintaining adequate fluid consumption Avoiding excessive alcohol intake Eating well-balanced meals including lean proteins, fiber, and unprocessed fruits and vegetables Nevermind—she is just depressed about her husband's death and will bounce back soon
Nevermind—she is just depressed about her husband's death and will bounce back soon Reason: All of these issues may be points of discussion affecting Andrea's current weight loss and state of health, affecting her weakness and risk for fall. If you find significant challenges for Andrea to address these independently, a social services referral or a nutrition consultation may be indicated.
Which of the following is true about the OASIS document used in home health? OASIS is required for patients being seen under the Medicare Part B benefit OASIS is used to calculate how many visits a patient may receive OASIS must always be completed by a nurse OASIS is used to calculate outcome and process measures that are publicly reported
OASIS is used to calculate outcome and process measures that are publicly reported Reason: OASIS is not required for Medicare Part B, is not used to calculate any specific number of visits the patient will receive, and is not limited to completion always being done by a nurse.
Several challenges of pain management in older adults are listed below. Which statement is NOT true? The impact of pain on function and mobility is often great and debilitating More chronic health conditions may limit the range of analgesics options to manage multiple conditions Older adults may have difficulty with medication adherence or be fearful of addictive or adverse effects Older adults accept pain as part of the aging process
Older adults accept pain as part of the aging process Reason: Pain management is complex and multifactorial in older adults. Patients with nonresolving neuropathic and musculoskeletal complaints can be overwhelming and challenging. Even with optimal physical therapy manual and exercise skills to assess and treat these patients mechanically, their pain or function may not improve. A comprehensive approach including psychological support and management of psychosocial issues is often necessary.
Your patient Martha is getting ready to be discharged from a three-week sub-acute stay in skilled nursing following a hip fracture. Martha is ambulatory with a front wheeled walker for household distances, performs all ADLs with modified independence, and is cognitively intact. The home is accessible. Martha's husband is physically well but was recently diagnosed with mild cognitive impairment. Martha's daughter is a successful marketing executive and has had minimal interaction with her parents over the last 30 years. She lives out of state and does not have POA. The daughter insists that her mother will be fine at home and that it his her dad's duty to take care of her mother now. You have concerns that Martha will now need physical assistance in the home for shopping, cleaning, laundry, meal preparation, etc., which are all tasks that Martha's husband has never done in the past. You should: Have Martha's husband work a day with OT to learn household tasks. Orient Martha's husband to the current limitations of Martha's functional activity and encourage him to work with social services to identify resources to help with tasks he may be unfamiliar with or unwilling to do. Insist that Martha's daughter come stay with her parents for the first couple of weeks at home until Martha is able to take on her household chores. Send Martha home with her husband and hope for the best, assuming that Martha's daughter will convince him to do his part.
Orient Martha's husband to the current limitations of Martha's functional activity and encourage him to work with social services to identify resources to help with tasks he may be unfamiliar with or unwilling to do. Reason: Family dynamics need to be respected. Martha's daughter has expectations that may be unrealistic of her father's participation in household management tasks. She lives out of town and will not have any direct influence on the dynamics of this discharge to home. It is imperative that the rehab team work to identify the challenges of the discharge plan, addressing the limitations of Martha's husband to learn and/or manage essential household tasks. Resources need to be identified for a safe and successful discharge, including education and informing the daughter regarding details of the plan, which will be as Martha chooses.
Patients with history of solid organ transplant are at risk for which condition and why? Heart disease; the stress of transplant surgery often leaves patients with cardiovascular changes Frailty; patients with transplant often fail to recover to premorbid levels of function and are at risk for weakness, weight loss, and depression Neuropathy; chemotherapy post transplant causes peripheral neuropathy Osteoporosis; bone mineral density is negatively impacted by the antirejection drugs necessary long-term in patients with transplant
Osteoporosis; bone mineral density is negatively impacted by the antirejection drugs necessary long-term in patients with transplant Reason: Patients who undergo solid organ transplant receive significant doses of prednisone drugs acutely and are maintained on antirejection drugs for their remaining lifespan, such as Prograf or CellCept. These drugs have a negative impact on bone mineral density, placing patients at risk for osteoporosis even when this risk may have been low pretransplant.
The authority role of the provider, common to the curative model of health care, encourages a passive role of the patient and is called: Patient-centered care Mutual collaboration Patient autonomy Paternalism
Paternalism Reason: Paternalism is the term that reinforces the provider as the decision-maker in the traditional medical model, which uses authority and knowledge to act on the patient's behalf. The alternative terms are characteristic of the more contemporary care model of health care, which encourages patient participation in decision-making, and recognition of patients' rights and choices in their health care decisions.
You are one of the interdisciplinary team members providing care to a patient with a history of lung cancer. The patient has recently been diagnosed with bone metastases. She is a palliative care patient. Skilled physical therapy may be indicated for: Progressive mobility training to ensure that patient continues to be independently mobile. Pain management interventions to facilitate continued completion of self-care activities. Patient and family/caregiver training in positioning and transfers to optimize safety. None of the above. Physical therapy is not appropriate with terminal patients or palliative care.
Patient and family/caregiver training in positioning and transfers to optimize safety. Reason: The Medicare Part A home health benefit for coverage of physical therapy services is not based on diagnoses or opportunity for improvement. Due to the underlying condition, this patient is at risk for injury related to the status of pathological bone. Skilled physical therapy would be appropriate to promote safety in positioning and mobility/transfers.
Benign paroxysmal positional vertigo (BPPV) is classified as which type of vestibular dysfunction? Central Peripheral Hypofunction Vertebral artery occlusion
Peripheral Reason: BPPV is defined as an inaccurate transduction of sensory stimulation within the peripheral apparatus due to mechanical dysfunction.
In motor control theory, which of the following component problems reflect musculoskeletal contributions? Poor sequencing Delayed activation of postural response Motor adaptation problems Postural abnormalities
Postural abnormalities Reason: Postural abnormalities related to degenerative skeletal changes or muscle weakness are a direct musculoskeletal contribution to motor control dysfunction. The other choices are examples of neurological dysfunction.
Your therapy interventions for Mandy should include: Use of a corset to improve her posture, balance training, and hand exercises. Use of a four-wheeled walker for decreased fall risk, UE strengthening, and ROM s/p ORIF. Posture correction, back extensor strengthening, body mechanics and safe movement, balance training, addressing UE deficits. Encouraging her to begin a water aerobics program at the community gym (to increase her overall conditioning without risk of fall) and specific UE strengthening and ROM so she can return to knitting.
Posture correction, back extensor strengthening, body mechanics and safe movement, balance training, addressing UE deficits. Reason: In addition to the PT referral for deconditioning, impaired balance and UE rehab, a comprehensive program addressing Mandy's modifiable risk factors to decrease her risk for future vertebral or peripheral fracture is essential. It would additionally be appropriate to consult with Mandy's PCP or orthopedist regarding your concerns about osteoporosis. Only 20% of patients with fragility fracture are ever followed up to determine if osteoporosis is present. Bone density studies will help guide appropriate pharmaceutical treatment to further protect Mandy from future fracture.
A patient is referred to physical therapy after a fall injury (fractured left hip with operative reduction, internal fixation). Medical history reveals a diagnosis of Stage 1 Alzheimer's disease. At this stage, the behaviors the therapist would NOT expect are: Memory loss Irritability and mood changes Profound communication deficits Difficulty concentrating
Profound communication deficits Reason: Frequent word finding difficulty or misapplication of words may begin to occur earlier in the progression of dementia; however, profound communication deficits are common as a patient progresses to late stages (FAST stage 7) of Alzheimer's disease, where patients may speak only a few words per day.
A 67-year-old male presents to the physical therapy evaluation with significant balance deficits with onset approximately eight months ago. The patient reports he has had five falls since then. He reports that the falls are usually when he is ambulating in the community, particularly where there are many people and objects around him, such as at the grocery store or mall.Upon examination, the physical therapist finds truncal rigidity, slowed movement, and abnormal smooth pursuit, with particular difficulty when asked to look up. Coordination testing is normal. Gait is symmetric, but with shortened step length and slowed speed. Sensory testing is normal. Based on these clinical findings, which of the following is this patient MOST likely to have? Progressive supranuclear palsy Lewy body dementia Multiple system atrophy Parkinson's disease
Progressive supranuclear palsy Reason: Early onset of falls and early truncal rigidity are not a typical presentation of Parkinson's disease. Parkinson's disease is associated with unilateral symptoms (stage 1 of the Hoehn and Yahr scale) followed by bilateral symptoms. Balance deficits are not apparent until stage 3. Loss of vertigo gaze is also a typical symptom of PSP and is not seen in PD. Cerebellar involvement is evident in multiple-system atrophy as well as autonomic signs. Lewy body dementia presents with asymmetric gait, speed apraxia, and cortical sensory loss.
Interventions appropriate for management of Ben's pain may include: Massage therapy three days per week Pain meds such as Oxycontin Psychotherapy referral for somatic system disorder management TENS
Psychotherapy referral for somatic system disorder management Reason: Oxycontin is an opioid drug that is known for numerous side effects, particularly in older adults. TENS would be a difficult modality to use since Ben's pain is so diffuse. Massage may provide short-term benefit but would not help Ben manage his chronic pain on a global scale. In addition to physical therapy intervention to prescribe exercise/physical activity, the greatest opportunity for successful pain management from the choices provided would be a psychotherapy referral.
Functional tests that are appropriate for older adults and provide comparisons to normative data in assessment of endurance include: Walking speed, TUG 6-Minute Walk Test, 2-Minute Step Test DGI, FGA 5 Times Sit-to-Stand Test
Reason: All of the tests listed have good validity and normative-based references for performance; however, only the 6-Minute Walk Test and the 2-Minute Step Test are direct measures of endurance. A discussion of interpretation of these tests and their application to developing a plan of care is found in the article by Whetten and Struder. [Whetten, B. K., & Struder, M. T. (2011). Physical therapists as the pharmacists of exercise: Determining the appropriate dosage (intensity) for your patient. GeriNotes, 18(1), 27-30.] 6-Minute Walk Test, 2-Minute Step Test
How many days remain in this patient's episode of care? 60 days 80 days 90 days 75 days
Reason: The patient was admitted to the skilled nursing facility 10 days ago. The episode of care began with the admission to the skilled nursing facility. The skilled nursing facility is participating under a 90-day bundle, so 80 days remain in the episode of care.
James is 87 years old. He lives at home alone and has recent weight loss, insomnia, increased confusion, and a fall with UE fracture. He is referred to therapy for gait and balance following his ground-level fall. Your assessment and plan of care includes: Limit his care to rehabilitation of the UE fracture to maximize return to function for ADLs. Referral to speech therapy for a dysphagia study to address his weight loss. DGI, FGA, and BESTest to clarify balance and gait factors contributing to his fall and determine his need for an assistive device Recognition of his symptoms as geriatric syndrome, which will require a multidisciplinary approach to address his risk for further functional decline and morbidity in his current living situation.
Recognition of his symptoms as geriatric syndrome, which will require a multidisciplinary approach to address his risk for further functional decline and morbidity in his current living situation.
What recommendation would be MOST appropriate based on the screening results? Provide fall prevention education, and request that the patient continue home program and return for screening in three months Recommend that the patient initiate a treadmill walking program at the gym at 1.0 meters/second Recommend that the patient stop driving, and offer transportation options to community exercise programs Referral to physical therapy for comprehensive evaluation and treatment
Referral to physical therapy for comprehensive evaluation and treatment Reason: Based on the patient's reduced self-selected speed over ground, it would not be safe or appropriate to recommend that the patient attempt to walk at a forced rate on the treadmill. Given the presence of an ineffective posterior stepping response on the push/pull test, the patient does have evidence of postural instability. It would not be appropriate to recommend cessation of driving, as none of the essential elements of driving were completed as part of the annual screen. Although fall prevention education is necessary, the best answer is to refer to physical therapy for a comprehensive evaluation and individualized treatment secondary to multiple abnormalities found upon screening including: reduced gait speed, impaired postural responses, and increased possibility of depression.
Which treatment strategy is NOT correctly matched with the intervention example to address management of low vision for older adults? Compensation: rearrange the environment, provide alternative activity Adaption: magnification and lighting Remediation: use of a white cane Remediation: improve ocular motor function
Remediation: use of a white cane Reason: An intervention strategy is correctly matched with an example of this type of approach in all answers except option 3. Use of a white cane would be an additional example for adaption. Remediation utilizes methods to improve the necessary skill or physiological function.
What activity would be MOST effective at increasing sit-to-stand ability for this patient? Explicit training regarding sit-to-stand technique Mental practice of sit-to-stand transfers Repeated sit-to-stands from a height that allows 8-9 reps without upper extremity support Repeated sit-to-stands from a height that allows 1-2 reps without upper extremity support
Repeated sit-to-stands from a height that allows 8-9 reps without upper extremity support Reason: Options 1 and 2 are incorrect because the patient has a cognitive impairment that limits her ability to benefit from explicit instructions (verbal sequences and instructions). Additionally, her memory impairment will not allow her to effectively utilize mental practice or imagery effectively. The patient should practice sit-to-stands from a surface that allows her to complete the task without UE support, in order to achieve task specificity. The patient should be able to complete 8-9 reps in order to achieve strength gains in this range with this task. Option 4, or 1-2 reps, would be working close to the patient's 1-rep maximum, which is not ideal for promoting strength gains in the geriatric population.
The Medicare interpretation of skill in support of reimbursable therapy care: Is the same as "reasonable and necessary" care Requires patients to be able to improve their functional status Requires that the care provided must demonstrate unique interventions that can only be performed by a licensed clinician Is assumed by the presence of a physician's referral
Requires that the care provided must demonstrate unique interventions that can only be performed by a licensed clinician Reason: CMS definition of skilled care per the Medicare Benefit Policy Manual and subsequent transmittals.
Serum enzymes are a valuable lab value in initial assessment of critical illness because: Serum enzymes reflect risk for cardiovascular disease. Serum enzymes and markers are evidence of tissue breakdown or cellular damage. Serum enzymes define the coagulation profile of the patient's blood, an important consideration for patients with atrial fibrillation, mechanical heart valves, or recent trauma. Serum enzymes are not helpful in understanding the degree of critical illness in older adults
Serum enzymes and markers are evidence of tissue breakdown or cellular damage. Reason: Serum enzymes and markers reflect the extent of tissue involvement or dysfunction resulting from a cancer or medical event, such as MI, CHF, or liver dysfunction, as evidence of tissue breakdown or cellular damage.
Based on his past medical history, which additional special tests should you complete for patient safety prior to further treatment? Spurling Test Sharp-Purser Test 6-Minute Walk Test Neck flexor muscle endurance test
Sharp-Purser Test Reason: Due to the patient's history of RA, you want to check for stability of the ligaments. Ensuring ligamental stability prior to initiating traction is important in order to decrease patient symptoms. [Cook, C. E., Hegedus, E. J. (2013). Orthopedic Physical Examination Tests. Upper Saddle River, New Jersey: Pearson Education, Inc.]
What stage would the patients sacral wound fit into under the National Pressure Ulcer Advisory Panel (NPUAP)? Stage 1 Stage 2 Stage 3 Stage 4
Stage 3 Reason: "Stage 1: intact skin with nonblanchable erythema, usually over a bony prominence Stage 2: partial-thickness wounds with loss of dermis / shallow, open wounds with red/pink wound bed Stage 3: full-thickness tissue loss where the subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed or directly palpable. Undermining/tunneling may be present. Stage 4: exposed or directly palpable bone, tendon, or muscle. May have slough/eschar present. Undermining/tunneling are often present."
What is the correct Hoehn & Yahr classification based on screening findings? Stage 1 Stage 2 Stage 3 Stage 4
Stage 3 Reason: The Hoehn & Yahr scale is a widely used clinical rating scale to classify disease severity in PD. Stage 1 includes unilateral symptoms with minimal or no functional disability. Stage 2 Includes bilateral or midline involvement without impairment of balance. Stage 3 includes bilateral disease with mild to moderate disability and impaired physical reflexes, or impaired recovery on the pull test. Stage 4 includes severely disabling disease; still able to walk or stand without assistance of a helper. Although the case does not give information related to tremor, rigidity or reduced force production, the case does highlight the abnormal result on the pull test as well as independent walking ability on the 10 meter walk test. Therefore, the only correct answer is Stage 3.
Potential side effects of statin drugs seen in older adults include: Increased blood viscosity and clotting time Blunted heart rate response to exercise Decrease in time to claudication Statin-induced myopathy, weakness
Statin-induced myopathy, weakness Reason: This is the benefit of statins and the reason they are used (not a side effect). Statins block a substance your liver needs to make cholesterol. This causes your liver to remove cholesterol from your blood, reducing the risk of heart attack and stroke. However, up to 29 percent of the people who start taking statins report muscle pain (mayoclinic.org) and, in some cases, liver damage. Rhabdomyolysis can occur when taking statins in very high doses or in combination with certain drugs. Statins may affect not only the liver's production of cholesterol but also several enzymes in muscle cells that are responsible for muscle cellular turnover and metabolism. The effects of statins on these cells may be the cause of muscle aches.
The patient is a 71-year-old male. He was recently discharged from an inpatient rehabilitation facility after suffering a right closed femoral fracture due to a fall. He subsequently had an ORIF to his right femur. His past medical history is significant for a CVA with right hemiparesis. He was using an SPC prior to the fall. He currently is using an FWW with a right forearm platform for all ambulation. His weight-bearing orders are 25% on right lower extremity. He completed a 10-Meter Walk Test in 50 seconds (0.2 m/s). Which of the following would be the best therapeutic exercise intervention for the patient as part of his home physical therapy plan of care? part 1/2 bilat standing hip abduction marching mini squats supine straight leg rises
Supine straight leg raises
A 76-year-old community-dwelling patient with Parkinson's disease is seen for a PT screening in the annual Parkinson's disease wellness clinic. The following screening results are found: Gait speed of 0.9 meters/second during the 10-Meter Walk Test without an assistive device 5 Times Sit-to-Stand score of 12 seconds An 8-pound weight loss over the past year Participation in a moderate-intensity gym track walking program for 45 minutes a day, five times a week, as well as a SilverSneakers upper and lower body strength building class two times a week Ineffective posterior protective stepping response found on the pull test Score of 17 on the 30-Item Geriatric Depression Scale What additional test would be MOST useful to include in this annual screening program to predict risk for falls in this patient population? Montreal Cognitive Assessment 6-Minute Walk Test Timed Up and Go (TUG) and Timed Up and Go Cognitive (TUG Cog) Modified Clinical Test for Sensory Integration and Balance
TUG Reason: The Timed Up and Go and Timed Up and Go Cognitive are recommended by the APTA Neurology Parkinson's disease EDGE committee to be completed in patients with PD across all H&Y stages to assess dual-task ability. Patients with PD who also have dual-task impairments are at an increased risk for falls. The Timed Up and Go has the ability to predict falls in patients with PD. Although the MoCA is recommended for completion by the APTA PD EDGE, it is not specifically able to predict those with PD who will fall. The 6-Minute Walk Test is not a test of postural control, and the Modified Clinical Test for Sensory Integration and Balance does not have PD-specific fall prediction properties.
A common functional task that reflects difficulty with dual-tasking is: The Mini-Cog test Talking while walking Fast walking speed Standing with eyes closed
Talking while walking Reason: Stops walking when talking is a test in which conversation is initiated while the patient is walking. If the patient stops for at least one second to respond, it is indicative of challenge in performing simultaneous motor and cognitive tasks. This is a practical task to assess during any gait activity with your patients.
Which statement in not true of the incidence of benign paroxysmal positional vertigo (BPPV) in older adults? The most common cause is head injury The most common cause is idiopathic It is often associated with labyrinthitis It is the cause of >50% of all dizziness
The most common cause is head injury Reason: Head injury (concussive syndrome) is the most common cause of BPPV in younger adults under age 50.
What is the most accurate interpretation and most appropriate action based on the Geriatric Depression Scale score? Major depressive disorder and referral to psychiatric services The absence of depression and discussion of results with the patient The possibility of depression and notifying the referring physician The absence of depression and referral to Parkinson's disease support groups
The possibility of depression and notifying the referring physician Reason: The 30-item Geriatric Depression Scale is valid and reliable for use in patients with Parkinson's disease. Higher scores indicate the possibility of depression, with lower scores indicating less depression. Research has found that a cutoff score of 13 is able to discriminate depressed individuals with PD from nondepressed individuals with PD. However, it is outside the scope of PT practice to diagnoses depression. The correct response in this case is to refer to the physician for further evaluation and management.
The need for skilled therapy services in the home setting is defined by: Diagnosis of the patient Degree of functional impairment The potential of decline without skilled intervention The presence of a physician order for therapy
The potential of decline without skilled intervention Reason: Although the diagnosis, degree of functional impairment, and presence of a physician's order are all important considerations when determining the need for skilled care, they do not, in and of themselves, confirm that need. The therapist must be able to articulate a significant potential for the beneficiary to decline without specific skilled reasonable and necessary interventions.
Mr. Jones is an 86-year-old male patient on your home health schedule. Original admission to the hospital was 15 days ago for ORIF after left hip fracture from a fall at home. He was admitted to a skilled nursing facility from the hospital 10 days ago. Due to a fall with a question of displacement of the prior fracture, he was readmitted to the hospital and is now discharged to home with home health services. The hospital does not participate in a bundled payment demonstration project and is not in a comprehensive care for joint replacement metropolitan service area. The skilled nursing facility is a participant in a 90-day episode bundled payment for the DRG for which the patient was admitted to the hospital. Which provider is responsible for the quality and cost of care for this patient's episode of care?
The skilled nursing facility Reason: Under the Bundled Payment for Care Improvement demonstration project, the first provider participating in BPCI who admits the patient is responsible for the cost and quality of care for the patient. Since the admitting hospital is not participating in BPCI or CJR, the care provided by the hospital would be reimbursed under a traditional DRG payment model. The skilled nursing facility, the first provider in the episode of care participating in BPCI, would be responsible for the cost and quality of care for the entire episode of care.
Medicare will pay for therapy services provided in a long-term care setting when the care is reasonable and necessary and requires the performance or supervision of a therapist in the following circumstances: There is clear documentation that, because of special medical complications, a skilled therapist is required to perform or supervise the service Nursing staff in the care center do not have time to perform the assistance for ambulation required by the patient Certified nursing assistants are trained but are not willing to provide the necessary care for the patient The patient does not willingly participate in their daily walking program with facility staff other than the therapist
There is clear documentation that, because of special medical complications, a skilled therapist is required to perform or supervise the service Reason: Reasonable and necessary is defined in the Social Security Act Title 18, Section 1862 (a)(1) as: reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. Services that do not require the performance or supervision of a therapist are not considered reasonable or necessary services, even if they are performed or supervised by a therapist.
Mandy's posture is measured at occiput-to-wall distance of 4 cm, her rib-to-pelvis distance is 2 finger breadths, and she has lost 3 inches of height from her maximum adult height in her 20s. In what way does this data contribute to your assessment? In spite of these changes, Mandy would have back pain if there were a vertebral compression fracture All older adults lose height and have poor posture; there is no concern about her spine health Mandy's forward head and kyphosis are a result of her sedentary lifestyle of knitting and reading and are not of concern regarding osteoporosis This data suggests imaging is appropriate to rule out vertebral compression fractures
This data suggests imaging is appropriate to rule out vertebral compression fractures Reason: These objective measures all indicate possible VCF. Referral for spine X-ray would contribute to a more clear diagnosis and assist in directing appropriate care.
Manifestations of poor nutritional status often overlap normal aging and disease, facilitating their progression. This statement is false; most older adults are obese. This statement is false; disease is rarely complicated by undernutrition. This statement is false; normal aging is not confused with poor nutrition. This statement is true; physiological changes of aging and conditions of many diseases are often negatively impacted by poor nutrition.
This statement is true; physiological changes of aging and conditions of many diseases are often negatively impacted by poor nutrition. Reason: This statement is true. Physiological changes of aging (e.g., sarcopenia) and conditions of many diseases (e.g., diabetes) are often negatively impacted by poor nutrition. Although nutrition is not the cause of these conditions, undernutrition or inadequate nutrition management can accelerate or complicate changes of both aging and disease.
The role of hospice is: To prolong life at all costs To assist in patient access to management of complex care requirements Only available with advance directives in place Not paid for by Medicare
To assist in patient access to management of complex care requirements Reason: Hospice care is a model for delivery of end-of-life care designed to support the patient and family in an integrated approach of care management including comfort, pain management, and maintenance of patient choice and dignity. All of the other statements are false.
Based on her diagnosis of osteoporosis, you would anticipate that the bone most affected would be: Compact bone Cortical bone Trabecular bone Flat bone
Trabecular bone Reason: Flat bone is not an accurate term for bone structure. Cortical bones are the more dense bones, generally in the shafts of long bones. Trabecular bone is the "spongy-type" bone that is most impacted by osteoporosis, leading to hard, cortical bone on the outside of the vertebrae and shafts but weakened bone on the inner portion. This weak bone is primarily responsible for osteoporosis-related fractures.
A 74-year-old patient presents with report of increased cervical pain with three-week duration. He notes that he feels midline thoracic pain and suboccipital pain with headaches, associated with looking over his shoulder when driving, when reading for extended periods, and with doing the dishes. He presents with a positive upper limb tension test with shoulder joint abduction, supination, wrist and finger extension, and elbow extension on the right. He also had provocation of symptoms with C5/C6 posterior/anterior joint mobilizations, and decreased symptoms with manual distraction. Past medical history includes hypertension, rheumatoid arthritis, and type 2 diabetes. This patient fits into which treatment-based clinical prediction rule? Manual treatment Traction Manual treatment + exercise group Stretching exercise
Traction Reason: This patient fits within the clinical prediction rule for traction with cervical pain. While he has RA, with proper screening and gentle progression into traction, it would still be appropriate. Manual treatment, stretching, and exercise are appropriate but are not applicable for a clinical prediction rule. [Childs, J. D., Cleland, J. A., Elliott, J. M., et al. (2008). Neck pain: Clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the Orthopedic Section of the American Physical Therapy Association. Journal of Orthopaedic Sports Physical Therapy, 2008, 38(9), A1-A34.]
Ben and his wife are motivated and hopeful for improved function and quality of life. An optimal physical therapy exercise prescription to improve Ben's chronic pain condition may include all of the following, except: Treadmill walking Supine flexibility exercise addressing shoulder girdle, hips, and spine Pool exercise Journaling of activity and systemic response on pain, energy, and well-being
Treadmill walking Reason: Ben has already reported that prolonged standing or walking makes his pain worse. Given Ben's multiple comorbidities, including degenerative spine disease, generalized osteoarthritis, and obesity, Ben is not likely to tolerate treadmill walking well. It is important to design a program with which Ben can find success and move forward in self-management of his chronic pain.
An 84-year-old female presents for evaluation of imbalance. She has a history of osteoporosis, chronic obstructive pulmonary disease with longtime inhaler use, and peripheral artery disease. She additionally appears frail, and you suspect age-related sarcopenia. She presents with a kyphotic thoracic curve, weak proximal muscle strength, and a forward head. What muscle fibers would be most affected with sarcopenia? Type I Type II Type C Type IA
Type II Reason: Type C is not a muscle fiber but is a nerve fiber that is associated with the conduction of pain. Type I fibers are slow-twitch fibers which have a good blood supply and slow fatigue. Type II fibers are fast-twitch fibers that primarily use glycolytic metabolism for energy. There is no Type IA fiber. There are type IIA and type IIB fibers, but they are classified as the fast-twitch fibers.
Bracing following vertebral compression fracture: Unloads forces on the fractured segment, assisting with pain relief and allowing for early mobilization Must provide total contact both anteriorly and posteriorly for effectiveness Does not affect intra-abdominal pressure Is available off the shelf and rarely needs to be custom fitted
Unloads forces on the fractured segment, assisting with pain relief and allowing for early mobilization
When did the episode of care begin for this patient? Upon admission to the hospital Upon admission to the skilled nursing facility Upon readmission to the hospital Upon admission to the home health agency
Upon admission to the skilled nursing facility
For which of the following conditions is use of the Borg Scale appropriate to monitor exercise intensity? Use for patients on bronchodilators Use in self-monitoring of aerobic and/or resistance training Use if a pacemaker is present Use when the patient is on a benzodiazepine drug
Use in self-monitoring of aerobic and/or resistance training
You have incorporated gait training into your physical therapy care plan for a patient. The following documentation of care would reflect skilled therapy intervention for gait training in the home health setting: Use of neuromuscular reeducation of ankle dorsiflexors initiated during pre-swing phase of gait cycle on involved lower extremity Ambulation with use of a rolling walker and verbal cueing for patient to pick up feet for progressively increasing distances in 10-foot increments Providing a standard home exercise program that includes seated knee extension, ankle dorsi- and plantarflexion exercises for 3 sets x 10 repetitions All of the above documented interventions demonstrate the skilled need of a therapist for completion
Use of neuromuscular reeducation of ankle dorsiflexors initiated during pre-swing phase of gait cycle on involved lower extremity Reason: Medicare Part A home health documentation requirements outline that skilled interventions are those components of care that can only be provided by, or under the care of, a physical therapist or physical therapy assistant. A basic HEP and a progressive walking program fail to demonstrate skilled need.
Which BPPV test is paired with the INCORRECT test maneuver? Anterior canal: Dix-Hallpike Horizontal canal: roll test Vertical canal: roll test Posterior canal: Dix-Hallpike
Vertical canal: roll test Reason: There is not a vertical canal.
Which nutrient deficiency is incorrectly matched with physical manifestations as seen in older adults? Vitamin A deficiency: Bitot's spots (eyes), hair loss, impaired taste Protein deficiency: edema, enlarged liver, muscle wasting Vitamin B12 deficiency: mild dementia, peripheral sensory loss, optic neuritis, anorexia Calcium deficiency: pallor, atrophic tongue, spoon-shaped nails, pale conjunctivae
Vitamin B12 deficiency: mild dementia, peripheral sensory loss, optic neuritis, anorexia Calcium deficiency: pallor, atrophic tongue, spoon-shaped nails, pale conjunctivae Reason: Pallor, atrophic tongue, spoon-shaped nails, and pale conjunctivae are typical of iron deficiency, whereas calcium deficiency is characterized by poor reflexes, slow mental processing, depression, and low bone mineral density.
Caregiver training for Martha's husband should include: How to cook simple meals for Martha and do the laundry How to help Martha transfer in/out of the shower and use the commode Written instructions regarding any adverse S/S and what to do in case of emergency Just managing his own needs independently; Martha will get along OK
Written instructions regarding any adverse S/S and what to do in case of emergency Reason: Martha's husband has mild cognitive impairment. Any instructions should be written and very directive and explicit. Martha does not currently need help with her own mobility or self-care, so caregiver training to assist her is not necessary. Medicare will not pay for the husband's training to do household chores for the patient. There are several gaps that need to be addressed for this couple to fully manage at home, but caregiver training will not address these.
This patient's gait speed indicates which of the following? part 2/2 he is likely independent in his ADLs and IADLs he is able to cross a street safely due to his normal walking speed he is likely to be a community ambulatory he is less likely to have an adverse event, such as a fall
he is likely independent in his ADLs and IADLs
