February QoM:

OCS/SCS Super Bowl Edition

Peyton Manning and Cervical Radiculopathy

Imagine you’re working in clinic and your next evaluation is Peyton Manning.

He Says:

“I can’t feel anything in my fingertip. It’s crazy. Well I can probably manage, but when you’re a quarterback and it’s your right hand, you’re certainly concerned as far as being able to do your job.”

Your examination reveals

• Hypo reflexive deep tendon reflex
• Positive upper limb tension test
• Decreased force production when throwing a football.

What is the best physical therapy intervention for this patient?

A. Manipulation or mobilization of the cervical spine + chin tucks

B. Mechanical constant traction

C. Repeated cervical extension (at least 10 repetitions)

D. Mechanical intermittent traction

Which is not part of the cluster of tests used to rule in cervical radiculopathy?

A. Spurling’s

B. Distraction

C. Upper limb tension test A

D. Active cervical rotation less than 45 degrees

What visceral structure can cause radiculopathy in a C8-T1 nerve root distribution pattern?

A. Liver

B. Spleen

C. T4 Syndrome

D. Heart

FIND ANSWERS BELOW…..

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What is the best physical therapy intervention for this patient?

A. Manipulation or mobilization of the cervical spine + chin tucks

B. Mechanical constant traction

C. Repeated cervical extension (at least 10 repetitions)

You should always assess if your patient centralizes with various cervical movements, however, if you could only pick one answer this is not the best.  According the Clinical Practice Guidelines for Neck Pain published in JOSPT in 2008, centralization procedures  were given a grade C recommendation.  Centralization procedures for the spine have been more heavily studied in the lumbar spine rather than the cervical spine.  

D. Mechanical intermittent traction

What is the best physical therapy intervention for this patient?

A. Manipulation or mobilization of the cervical spine + chin tucks

Although manipulation and mobilization was given a grade A recommendation from the Clinical Practice Guidelines, this was in regards to patients with mechanical neck pain or headaches and not patients with radicular symptoms.  Again, this doesn’t suggest that you shouldn’t assess for the effects of your manual therapy techniques on the patient’s radicular symptoms.  

B. Mechanical constant traction

C. Repeated cervical extension (at least 10 repetitions)

D. Mechanical intermittent traction

What is the best physical therapy intervention for this patient?

A. Manipulation or mobilization of the cervical spine + chin tucks

B. Mechanical constant traction

For this patient, mechanical traction is indicated, however intermittent traction rather than constant traction.

C. Repeated cervical extension (at least 10 repetitions)

D. Mechanical intermittent traction

Answer choice D is correct.  

Which is not part of the cluster of tests used to rule in cervical radiculopathy?

A. Spurling’s

Spurling’s test is classically defined as passively side bending the cervical spine and providing a caudal force through the head. Reproduction of radicular symptoms is a positive test. This test is part of the cluster.

B. Distraction

Distraction of the cervical spine results in reduction of radicular symptoms, and is part of the cluster.

C. Upper limb tension test A

Upper limb tension test A puts tension on the nerve roots with a bias for the median nerve, and is part of the cluster.

D. Active cervical rotation less than 45 degrees

Answer choice D is the best answer. Although a patient with less than 45 degrees of cervical rotation would test positive for this aspect of the cluster, it’s actually active rotation less than 60 degrees to the affected side that’s part of the cluster. Active cervical rotation less than 45 degrees is important when deciding if a patient requires a radiograph with the Canadian C-Spine rules.

PubMed Citation: Childs JD, Cleland JA, Elliott JM, Teyhen DS, Wainner RS, Whitman JM, Sopky BJ, Godges JJ, Flynn TW; American Physical Therapy Association. 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. J Orthop Sports Phys Ther. 2008 Sep;38(9):A1-A34. Epub 2008 Sep 1. Erratum in: J Orthop Sports Phys Ther. 2009 Apr;39(4):297. PubMed PMID: 18758050.

Link to Article: http://www.ncbi.nlm.nih.gov/pubmed/18758050

What visceral structure can cause radiculopathy in a C8-T1 nerve root distribution pattern?

A. Liver

Answer choice A is incorrect because the liver may cause increased pain in the right upper quadrant of a patient and refer into neck.

B. Spleen

Answer choice B is unlikely to cause symptoms mimicking cervical radiculopathy. Patients with pancreatitis commonly present with back pain and upper abdominal pain.

C. T4 Syndrome

Answer choice C is characterized by pain in the thoracic spine and paresthesias in a stocking glove pattern.

D. Heart

Myocardial infarction can often mimic radicular symptoms into the arm, and should always be on the differential diagnosis of a clinician when evaluating a client with cardiac risk factors.

PubMed Citation: Sizer PS Jr, Brismée JM, Cook C. Medical screening for red flags in the diagnosis and management of musculoskeletal spine pain. Pain Pract. 2007 Mar;7(1):53-71. Review. PubMed PMID: 17305681.

Link to Article: http://www.ncbi.nlm.nih.gov/pubmed/17305681

Other notes:  As I was creating this post, it was interesting to find out more details about the oldest Manning brother.  Apparently he was just as stellar of an athlete as his younger brothers, but had to have surgery after experiencing numbness and atrophy in his right biceps.

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Take the Feburary OCS/SCS Mini-Quiz

QUESITONS:

1. A patient has been referred to physical therapy for cervical radiculopathy secondary to spondylosis at C5 and C6. She reports pain, paresthesias and weakness of her arm. She’s had this pain for about 4 months. Which of the following is the least likely alternative diagnosis

A. Parsonage Turner Syndrome

B. Neurogenic Thoracic Outlet Syndrome

C. Venous Thoracic Outlet Syndrome

D. Arterial Thoracic Outlet Syndrome

2. All of the following can cause Paget-Schroetter Syndrome except for what?

 A. Hypertrophic anterior scalene muscle

B. Hypertrophic subclavius muscle

C. Depression of first rib

D. Cervical first rib

3. In regards to Paget-Schroetter Syndrome, which vein is most commonly affected?

 A. Subclavian artery

B. Axillary artery

C. Subclavian vein

D. Axillary vein

4. What is the gold standard for detecting Paget-Schroetter Syndrome?

 A. Wright’s Test

B. Angiogram

C. Venous Duplex Ultrasound

D. Adson’s Test

5. What king of malignancy will most likely cause radiculopathy in a C8-T1 nerve root distribution?  

A.Tumor affecting the prostate

B. Tumor affecting the thyroid

C. Pancoast tumor affecting the lung

D. Wilm’s tumor affecting the kidney

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ANSWERS:

1. A patient has been referred to physical therapy for cervical radiculopathy secondary to spondylosis at C5 and C6. She reports pain, paresthesias and weakness of her arm. She’s had this pain for about 4 months and it has not changed. All of the following diagnoses are can occur except for what?

A. Parsonage Turner Syndrome

Neuritis involving the brachial plexus. Commonly involves the upper trunk of the brachial plexus but has been frequently reported in the literature in other parts of the plexus. It can mimic cervical radiculopathy or a peripheral neuropathy, however, a classic sign of this condition is that pain becomes abolished, but weakness persists.

B. Neurogenic Thoracic Outlet Syndrome

Very common type of thoracic outlet syndrome. Typically will result in weakness and paresthesias down the arm secondary to compression of the neurogenic structures in the interscalene triangle

C. Venous Thoracic Outlet Syndrome

Patient may report discoloration of the arm along with weakness and pain. Typically the venous structures will be compressed in the costoclavicular junction.

D. Arterial Thoracic Outlet Syndrome

This pathology can be caused my occlusion of the subclavian artery secondary to a cervical rib or scalene hypertrophy. The patient may experience pain and paresthesais down into the arm.

 Check these articles out:

Monteiro Dos Santos RB, Dos Santos SM, Carneiro Leal FJ, Lins OG, Magalhães C, Mertens Fittipaldi RB. Parsonage-Turner syndrome. Rev Bras Ortop. 2015 Apr 17;50(3):336-41. doi: 10.1016/j.rboe.2015.04.002. eCollection 2015 May-Jun. PubMed PMID: 26229940; PubMed Central PMCID: PMC4519651.

DeLisa LC, Hensley CP, Jackson S. Diagnosis of Paget-Schroetter Syndrome/Primary Effort Thrombosis in a Recreational Weight Lifter. Phys Ther. 2016 Sep 1. [Epub ahead of print] PubMed PMID: 27587803.

2. All of the following can cause of Paget-Schroetter Syndrome except for what?

A.Hypertrophic anterior scalene muscle

B. Hypertrophic subclavius muscle

C. Depression of first rib

D. Cervical first rib

Answer choices A, B and C can all cause symptoms suggestive of Paget-Schroetter Syndrome, which can compromise the subclavian vein. Typically a cervical rib will compromise the subclavian artery.

 Check this article out:

DeLisa LC, Hensley CP, Jackson S. Diagnosis of Paget-Schroetter Syndrome/Primary Effort Thrombosis in a Recreational Weight Lifter. Phys Ther. 2016 Sep 1. [Epub ahead of print] PubMed PMID: 27587803.

3. In regards to Paget-Schroetter Syndrome, which vein is most commonly affected?

 A. Subclavian artery

B. Axillary artery

C. Subclavian vein

Paget-Schroetter Syndrome is best described as a primary effort thrombosis that affects the subclavian vein. Most commonly affects weightlifters or upper extremity athletes.

D. Axillary vein

Check out this article:

DeLisa LC, Hensley CP, Jackson S. Diagnosis of Paget-Schroetter Syndrome/Primary Effort Thrombosis in a Recreational Weight Lifter. Phys Ther. 2016 Sep 1. [Epub ahead of print] PubMed PMID: 27587803.

4. What is the gold standard for detecting Paget-Schroetter Syndrome?

A. Wright’s Test

B. Angiogram

Angiogram is the gold standard for detecting an effort thrombosis. Answer choice C is a good second choice, and is usually the first test performed for patients with this condition. However, it is not the gold standard. Answer choices A and D are clinical examination techniques that can be utilized, but are not the gold standard.  

C. Venous Duplex Ultrasound

D. Adson’s Test

 Check this article out:

DeLisa LC, Hensley CP, Jackson S. Diagnosis of Paget-Schroetter Syndrome/Primary Effort Thrombosis in a Recreational Weight Lifter. Phys Ther. 2016 Sep 1. [Epub ahead of print] PubMed PMID: 27587803.

6. What king of malignancy will most likely cause radiculopathy in a C8-T1 nerve root distribution?

A. Tumor affecting the prostate

B. Tumor affecting the thyroid

C. Pancoast tumor affecting the lung

Metastases do not commonly occur in the cervical region compared to other areas of the spine. Common tumors that metastasize to the spine are tumors located in the prostate, breast, kidney, thyroid, and lungs. A good way to remember common tumors that metastasize to the spine is to memorize the pneumonic Lead Kettle (PB KTL). Pancoast tumor forms at the superior aspect of the lung and pushes on the C8-T1 nerve roots as it increases in size at the thoracic inlet. This tumor commonly occurs in individuals that are over 50 years old and have a history of smoking. Most will report shoulder pain and rarely have pulmonary symptoms. Often times it is misdiagnosed.

D. Wilm’s tumor affecting the kidney

Check this article out: 

Arcasoy SM, Jett JR. Superior pulmonary sulcus tumors and Pancoast’s syndrome. N Engl J Med. 1997 Nov 6;337(19):1370-6. Review. PubMed PMID: 9358132.

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Now for the QoM

• After working a full day, you sit on the couch and turn on the Discovery channel.
• The show The Deadliest Catch is on, and you see that one of the deckhands has collapsed to the ground.
• All of a sudden his elbows and wrists become locked into flexion and his hips and knees become extended.
• Refer to YouTube video by clicking here.

What is the best term of the posture the deckhand assumed?

A. Decorticate rigidity

B. Posture assumed with lower motor neuron injury

C. Decerebrate rigidity

D. Posture assumed with damage to midbrain or pons

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Scroll down to see the correct answer choice and explanation.

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• After working a full day, you sit on the couch and turn on the Discovery channel.
• The show The Deadliest Catch is on, and you see that one of the deckhands has collapsed to the ground.
• All of a sudden his elbows and wrists become locked into flexion and his hips and knees become extended.
• Refer to YouTube video by clicking here.

What is the best term of the posture the deckhand assumed?

A. Decorticate rigidity

• The posture in this case is suggestive of complications with the corticospnal tracts above the level of the midbrain causing flexion of the elbows and wrist, and extension of the lower extremities.  
• Damage to the corticospinal tracts is typically referred to as upper motor neuron syndrome.
• Check this video out of a soccer player experiencing decorticate rigidity after getting hit in the head by a soccer ball.  

B. Posture assumed with lower motor neuron injury

• The postures described in this case are more associated with an upper motor neuron injury rather than a lower motor neuron injury.
• Lower motor neuron deficits are typically characterized by weakness, decreased deep tendon reflexes, decreased tone, muscle atrophy, and fasciculations.

C. Decerebrate rigidity

• Brain stem damage at or below the level of the midbrain.
• Decerebrate rigidity typically occurs when there is a lesion of the brainstem above the vestibular nucleus.
• Head/neck, arms and legs will be extended and toes will point downward.
• Damage at this level will inhibit flexed postures from occurring and cause extension of both the upper and lower extremities.
• Check this video out of a football player experiencing decerebrate rigidity after scoring a touchdown.

D. Posture assumed with damage to midbrain or pons

• This is a potential answer choice, however answer choice A is more appropriate as lesions or complications tend to occur above the level of the midbrain when decorticate posture is identified.

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January 2017

 In 2014, Tiger Woods had his first lumbar micro discectomy. What is the most likely lumbar level(s) the surgery was performed at?

A. L1-L2 and/or L2-L3

B. L2-L3 and/or L3-L4

C. L3-L4 and/or L4-L5

D. L4-L5 and/or L5-S1

Scroll down for answer and details.

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In 2014, Tiger Woods had his first lumbar micro discectomy. What is the most likely lumbar level(s) the surgery was performed at?

A. L1-L2 and/or L2-L3

B. L2-L3 and/or L3-L4

C. L3-L4 and/or L4-L5

D. L4-L5 and/or L5-S1

The most common levels for a disc herniation to occur are at the L4-L5 and/or L5-S1 disc levels.

Dohrmann et al 2015

• Evaluated the literature in 2015 for all subjects who underwent an operation for lumbar disc herniation.
• Of 39,048 subjects, the most common level of disc herniation was L4-L5 and L5-S1, respectively.

The majority of lumbar disc herniations do not require surgery.

Indications for Lumbar Micro discectomy

• Cauda equina syndrome
• Significant motor weakness
• Intractable pain
• Failed conservative treatment
  • Nonsteroidal anti-inflammatory drugs
  • Physical therapy for 8-12 weeks
  • Epidural Injection

Tiger Woods had a discectomy in 2014, and return to play 12 weeks later.

Phases of Rehab after Lumbar Discectomy:

Phase 1: Post operative phase

• Activity modification
• Log roll transfers
• Abdominal setting
• Gluteal sets
• Ankle pumps

Phase 2: Protected Mobilization phase

• Abdominal and lumbar stabilization exercises in unloaded position
• Modalities
• Neural mobilization
• Decrease fear of movement

Phase 3: Neutral Stabilization

• Address muscle imbalances
• Progress exercises from unloaded to loaded position
• Initiate lumbar ROM

Phase 4: Dynamic stabilization

• LE strengthening
• Dynamic movements
• Progress stabilization exercises

Phase 5: Sports specifics activities

So what are the outcomes for other elite athletes?

A recent systematic review by Dr. Reiman and his colleagues in BJSM found that not all athletes return to sport at the same level of play as before surgery.

In another systematic review on elite athletes there was differences in performance levels after surgery based on the sport played.

Outcomes for Elite Athletes (CORR 2014)

• A systematic review was performed on outcomes for elite athletes after micro discectomy.
• 450 athletes were identified in various sports.
  • 36% were from the NFL
  • 16% from the NBA
  • 28% from NHL
  • 19% from the MLB,
  • Less than 1% of the 450 athletes included various Olympic athletes, martial artists, sailors and a ballerina.

Number of Years playing after Micro Discectomy

• 8 years for MLB players
• 1 years for NFL players
• 6 years for NHL players

 Games played after surgery

• 232 games for MLB players
• 36 games for NFL players
• 129 games for NHL players

 Difference between Non-op and Op for MLB players

• Non-operative treatment of disc herniation returned to play at 3.6 months
• Operative returned at 8.7 months.

 Performance

• Only 3 articles reported on performance measures after lumbar disc herniation
• Hockey players achieved 65%of performance measures from baseline after micro discectomy
• Where as football players had improved performance >100% of their baseline
• Earhart et al in 2012 found there was a sig. decrease in performance at 1 year after surgery in MLB.
• No difference was found between operative and non operative cohorts in the NBA

Studies in this systematic review consisted mainly of low level III and IV evidence, however it could help elite athletes make decisions on weather or not to pursue surgery.

Check out this link to the BJSM podcast discussing Tiger Woods.

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Post written by Cody J. Mansfield

January 2017

Harry Potter is flying fast on his Nimbus 2000 while being chased by a rogue bludger. After an endless pursuit, the rogue bludger slams into Harry’s arm, and an audible pop is heard. Harry then reaches out, catches the snitch and falls to the ground. You’re able to examine Harry before Gilderoy Lockhart is able to get there. Harry is unable to extend his arm fully, and he is tender to palpation at the proximal radial head.

What is the best answer choice?

A. Harry should be referred for radiographs due to the audible pop that was heard when the rogue bludger hit his arm.

B. Harry should be placed in a sling and referred for radiographs if not better within 72 hours.

C. Harry should be referred for radiographs because he is unable to extend his elbow.

D. Harry should be referred for radiographs based on the American College of Radiology Appropriateness Criteria due to the tenderness to palpation at the proximal radial head.

SCROLL DOWN TO SEE ASNWER AND EXPLANATION

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What is the best answer choice?

A. Harry should be referred for radiographs due to the audible pop that was heard when the rogue bludger hit his arm.

B. Harry should be placed in a sling and referred for radiographs if not better within 72 hours.

C. Harry should be referred for radiographs because he is unable to extend his elbow.

D. Harry should be referred for radiographs based on the American College of Radiology Appropriateness Criteria due to the tenderness to palpation at the proximal radial head.

Explanation: Answer choice C is correct because the inability to extend the elbow is a clinically useful test, and an extremely sensitive test.  If you cannot fully extend your elbow, a radiograph should be ordered to rule out a fracture.

See some links below to some great articles with short summaries:

Boyles, R. (2013). Posterior Dislocation of the Elbow. Journal of Orthopaedic & Sports Physical Therapy, 43(9), 673-673.

• This is a great article that describes a 23 year old with severe left elbow pain after falling on an outstretched hand, and highlights the importance of referring for imaging when a patient cannot extend elbow fully.

Appelboam A, Reuben AD, Benger JR, et al. Elbow extension test to rule out elbow fracture: multicentre, prospective validation and observational study of diagnostic accuracy in adults and children. BMJ. 2008;337:a2428.

• Methods
  • 5 EDs in Southwest England
  • 2127 adults presented with acute elbow pain
  • 1740 met inclusion criteria
  • 602 able to extend elbow
  • 17 had fracture
  • 1138 without full elbow extension
  • 521 fractures identified
• Results
  • SN 8% SP 48.5%
  • CI 95%
  • Negative Predictive value 4% (adults) 95.8% (children)
  • Negative LR .03 (adults) .11 (children)
• Conclusions
  • Those who cannot extend elbow should be referred for radiography
  • Nearly 50% increase in chance of fracture
  • Able to fully extend elbow; confident no olecranon fx
  • Defer radiograph
  • Return if symptoms do not resolve in 7-10 days

Docherty, M. A., Schwab, R. A., & John, O. (2002). Can elbow extension be used as a test of clinically significant injury?. Southern medical journal, 95(5), 539-542.

• 114 patients with acute elbow injury
• 110 underwent radiographic injury
• Unable to extend elbow
  • Bone injury
    • 37 of 38
  • Able to extend
    • Bone Injury
      • 1 of 54
    • SN 97% SP 69%

Jie KE, van Dam LF, Verhagen TF, Hammacher ER. Extension test and ossal point tenderness cannot accurately exclude significant injury in acute elbow trauma. Ann Emerg Med. 2014 Jul;64(1):74-8. doi: 10.1016/j.annemergmed.2014.01.022. PubMed PMID: 24530106.

• 2 EDs in Netherlands
• Passive Extension + point tenderness
• 587 patients included
• Normal extension in 174 pt.s
  • Normal ext. predicted absence of fx with SN 88% SP 55%
• Absence of point tenderness with normal extension
  • 24 patients
  • 3 had fracture
  • 1 required surgery
  • SN 98% SP 11%

Hoppes, C. W., & Jonson, S. R. (2015). Fracture Through an Enthesophyte on the Olecranon Process. Journal of Orthopaedic & Sports Physical Therapy, 45(2), 143-143.

A short case again highlighting the importance of referring for imaging.

• 54 y.o. man currently serving in the military
• Evaluated by PT in direct access capacity
• Chief complain of left elbow pain
• Onset: 3 weeks prior
• MOI: Forcefully hyperextending elbow while playing volleyball

Fat Pad Sign

• Click on the link and you will see a normal radiograph of an elbow without the fat pad sign where the anterior fat pad is just anterior to the coronoid and radial fossae, and the posterior fat pad is located deep within the concavity of the olecranon fossa.
• In the scenario where the radial head is fractured, fluid will fill the synovial cavity, which will elevate the fat pads within the coronoid and olecranon fossa. See the other picture highlighted in the link.
• The fat pad sign is useful to look for because a radial head fracture may not be well visualized on imaging.

What else can cause limited elbow extension?

• Heterotrophic ossification
• Edema
• Osteophytes
• Medial elbow tightness

The orthopedic certified specialty exam is a grueling 200 question, 6 hour multiple choice examination covering what is seemingly an endless universe of orthopedic physical therapy topics.

To ace the OCS exam it takes preparation and mastery of test taking strategies.

• Scroll to the very end of this post for links to videos of what Ryan Balmes DPT and Mike Reinold have to say about the OCS exam.

How to start the battle:

• Read the Ortho Current Concepts of Orthopaedic Physical Therapy
• Read the JOSPT Clinical Practice Guidelines
• Focus on self-identified weakness
• Develop a study plan
• Take practice questions

What do you do when confronted with the various vignettes and multiple choice questions the exam holds?

• My goal is to provide you with a brief review of test taking strategies and question make-up
• Help improve your comfort level with OCS type questions
• Help to guide you toward being able to answer questions you otherwise might have missed

The Three Test Taking Strategies to Ace The OCS Exam:

#1 Making sense of the question/ vignette

• Skim question – provides idea for what question the vignette will be answering
• Read vignette – pick out clues and avoid distractors
• Read question – Carefully
• Read all answers – Mark definite wrong answer choices to narrow options
• Answer question – Some you will just not know!

#2 Vignette Make-Up

• Clues – Information required to answer the question (i.e. age, gender, clinical patterns)
• Neutral Info – Not a distraction and not key information (i.e. fluff)
• Distractors – Objective info that should not change decision making (i.e. obscure clinical measures, evidence and data overload not needed for answering question)

#3 Deductive Reasoning: What happens if I just do not know the answer?

• Guessing leaves you with approximately 25% chance of answering correctly
• Deductive reasoning to narrow choices increases your odds
• Avoid absurd options (i.e. outside of practice, contraindicated action)
• Rule out similar options (there are not two correct answers)
• Watch out for degree of qualification (i.e. always or never)
• Go with your gut and do not change your answer, as second guessing tends to change a correct answer to a wrong answer
• Check questions to return to as you might stumble upon an answer during test

BONUS POINT: Get into the head of the item writers (Yes they are real people)

• Few clinicians answer / write questions in the same way due to practice variability
• Key words in language can guide the test taker to the perspective of the item writer (i.e. A MDT based practitioners may use terms like derangement, dysfunction, and postural syndromes)
• Take time to review the varying points of view and treatment approaches to help better understand these differences (i.e. McKenzie vs. Maitland vs. EBP in the spine)

Finally, take the time to take practice exams and answer sample questions similar to those found in Ortho PT Questions: Pass The Test Without Breaking The Bank.

In the words of Effie Trinket,

“May the odds be ever in your favor”

Post written by Ken Kirby, PT, DPT, OCS | @kkirbydpt

Still here?

Check out the sample questions from the Orthopaedic Specialist Certification Candidate Guide.

• Scroll to page 11 to take the 14 practice questions

See what Ryan Balmes DPT and Mike Reinold have to say about the OCS exam.

• Skip to to the 9 minute and 18 second mark for Mike Reinold’s video.
• Ryan Balmes discusses ways to prep for the OCS exam.
• Mike Reinold and his colleagues discuss the pathway to getting to the point of taking the OCS exam (i.e. residency or no residency).