13.2 Rehabilitation Pharmacology & Medication Management

ABPMR Physical Medicine and Rehabilitation Board Exam Study Guide Exam

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1 Chapter 1: Introduction & Exam Overview

1.1 ABPMR Part I Exam Overview & Format 1.2 Board Review Strategy & Content Blueprint Breakdown

2 Chapter 2: Musculoskeletal Medicine

2.1 Shoulder & Upper Extremity Diagnostics 2.2 Knee, Hip & Lower Extremity Conditions 2.3 Spine Pathology, Radiculopathy & Myelopathy 2.4 Inflammatory Arthritis, Tendinopathies & Concussion 2.5 Bone Health, Osteoporosis & Metabolic Bone Disease 2.6 Thoracic Outlet Syndrome & Peripheral Nerve Entrapment 2.7 Fracture Rehabilitation & Immobilization Complications 2.8 Overuse Tendinopathies & Regenerative Medicine 2.9 Gait Analysis & Abnormal Gait Patterns

3 Chapter 3: Spinal Cord Injury Rehabilitation

3.1 ASIA Examination & Impairment Scale 3.2 Spinal Cord Injury Syndromes 3.3 Autonomic Dysreflexia & Acute Complications 3.4 Neurogenic Bladder, Bowel & Secondary Complications

4 Chapter 4: Stroke & Neuromuscular Rehabilitation

4.1 Stroke Vascular Syndromes & Acute Assessment 4.2 Stroke Motor Recovery & Hemiplegic Complications 4.3 Spasticity Assessment & Multimodal Management 4.4 ALS, GBS, CIDP & Neuromuscular Disease Rehab 4.5 Multiple Sclerosis & Demyelinating Disease Rehabilitation 4.6 Parkinsonism, Movement Disorders & Functional Neurologic Disorder

5 Chapter 5: Electrodiagnostics (EMG/NCS)

5.1 Nerve Conduction Studies Principles & Physics 5.2 Needle Electromyography & MUAP Analysis 5.3 Mononeuropathies & Radiculopathy Patterns 5.4 Neuromuscular Junction Disorders & Myopathies

6 Chapter 6: Traumatic Brain Injury

6.1 TBI Severity Classification, Glasgow Coma Scale, and Pathophysiology 6.2 Rancho Los Amigos Levels of Cognitive Functioning and Disability Rating Scale 6.3 Neurobehavioral Sequelae and Agitation Management 6.4 Concussion Evaluation, Vestibular-Ocular Dysfunction, and Return-to-Play/Work Protocols

7 Chapter 7: Chronic Pain & Interventional Spine

7.1 Fluoroscopic Spine Interventions 7.2 Opioid Stewardship & Controlled Substance Compliance 7.3 Complex Regional Pain Syndrome, Fibromyalgia & Myofascial Pain 7.4 Spinal Cord Stimulation & Intrathecal Therapy

8 Chapter 8: Amputee Rehabilitation & Prosthetics

8.1 Amputation Surgical Levels & Medicare K-Levels 8.2 Socket Designs & Suspension Systems 8.3 Prosthetic Feet & Microprocessor Knee Mechanisms 8.4 Post-Amputation Care, Residual Limb & Phantom Pain

9 Chapter 9: Pediatric Rehabilitation

9.1 Cerebral Palsy Classification & GMFCS 9.2 Spina Bifida & Myelomeningocele Management 9.3 Muscular Dystrophies & Neuromuscular Disease in Children 9.4 Pediatric Brachial Plexopathy & Congenital Disorders

10 Chapter 10: Prosthetics, Orthotics & Assistive Technology

10.1 Lower Limb Orthoses — AFOs & KAFOs 10.2 Spinal & Upper Extremity Orthoses 10.3 Upper Limb Prosthetics — Body-Powered vs Myoelectric 10.4 Wheelchairs, Seating Systems & Pressure Mapping

11 Chapter 11: Medical Rehabilitation & Outcomes

11.1 Dysphagia Assessment & Management 11.2 Neurogenic Bladder & Bowel Management 11.3 Pressure Injuries & Wound Management 11.4 Outcome Measures & Medical Complications 11.5 Cancer Rehabilitation & Oncologic Rehabilitation 11.6 Burns, Endocrine/Metabolic & Medical Complications Rehabilitation

12 Chapter 12: Cardiopulmonary Rehabilitation

12.1 Cardiac Rehabilitation Phases & Metabolic Equivalents 12.2 Pulmonary Rehabilitation & COPD Management

13 Chapter 13: Foundational Rehabilitation Concepts

13.1 Kinesiology, Biomechanics & Functional Anatomy 13.2 Rehabilitation Pharmacology & Medication Management 13.3 Research Methodology, Biostatistics & Evidence-Based Practice 13.4 Nutrition, Metabolism & Energy Expenditure in Rehabilitation 13.5 Diagnostic Procedures: Imaging, MSK Ultrasound, Urodynamics & Neuropsych Assessment

13.2 Rehabilitation Pharmacology & Medication Management

Key Takeaways Explain This Topic AI

Spasticity pharmacotherapy is tiered: oral baclofen, tizanidine, diazepam, and dantrolene for generalized tone; focal chemodenervation with onabotulinumtoxinA for focal spasticity; intrathecal baclofen for severe diffuse spasticity (especially SCI).

Neuropathic pain first-line agents include gabapentin/pregabalin (alpha-2-delta calcium channel), tricyclic antidepressants (nortriptyline), and SNRIs (duloxetine); opioids are not first-line for neuropathic pain.

Common rehab drug adverse effects include sedation/hypotension with baclofen and tizanidine, hepatotoxicity/weakness with dantrolene, anticholinergic effects with bladder medications, and NSAID renal/gastrointestinal risk.

Rehab-relevant interactions: baclofen potentiates CNS depression with alcohol/sedatives; warfarin INR shifts with NSAIDs/antibiotics; SSRIs increase bleeding risk with NSAIDs and QT considerations.

Last updated: July 2026

Rehabilitation Pharmacology & Medication Management

Pharmacology is a Domain A applied-science topic with high clinical yield. The physiatrist prescribes and coordinates medications for spasticity, pain, bladder/bowel, bone, and psychiatric comorbidity, recognizing adverse effects and interactions that affect rehabilitation.

Antispasticity Medications

Agent Mechanism Key Adverse Effects Notes

Baclofen (oral) GABA-B agonist Sedation, hypotension, dizziness; abrupt withdrawal → seizures, hallucinations First-line; ITB for severe diffuse (SCI)

Tizanidine Alpha-2 agonist Sedation, hypotension, dry mouth; hepatotoxicity (monitor LFTs) Less weakness than diazepam/dantrolene

Diazepam GABA-A agonist Sedation, dependence, cognitive impairment Useful at night; avoid in elderly (Beers)

Dantrolene Direct skeletal muscle relaxant (RyR) Weakness, hepatotoxicity (LFTs) Useful when sedation contraindicated

OnabotulinumtoxinA Blocks acetylcholine release at NMJ Local weakness, dysphagia (cervical), antibody-mediated nonresponse with frequent/high doses Focal spasticity/dystonia

Intrathecal baclofen screening trial precedes pump implant; withdrawal is a medical emergency (fever, spasticity rebound, rhabdomyolysis) managed with oral baclofen and supportive care.

Neuropathic Pain Agents First-line: Gabapentin/Pregabalin (alpha-2-delta Ca channel) OR TCA (nortriptyline) OR SNRI (duloxetine)

Second-line/adjunct: Topical lidocaine/capsaicin, tramadol, opioids (not first-line; risks)

Gabapentinoids : renal dose adjustment; sedation, dizziness, edema.

TCAs : anticholinergic, QT, sedation; nortriptyline preferred for fewer side effects than amitriptyline.

SNRIs (duloxetine): useful for diabetic neuropathy and fibromyalgia; monitor BP.

Opioids : not first-line; risks (dependency, OSA, hypogonadism) — opioid stewardship.

Bladder & Bowel Medications

Detrusor overactivity (urge/neurogenic) : anticholinergics (oxybutynin, tolterodine, solifenacin) — anticholinergic burden (cognition in elderly); beta-3 agonist (mirabegron) — less cognitive burden; intravesical botulinumtoxinA; intermittent catheterization when retention coexists.

Outlet incompetence (stress) : pseudoephedrine, duloxetine, or surgical sling.

Retention : bethanechol (post-op/postpartum), alpha-blockers (tamsulosin) for bladder outlet.

Bowel : stimulant (senna, bisacodyl), osmotic (polyethylene glycol, lactulose), stool softener; rectal stimulant for neurogenic bowel program.

Bone & Other

Bisphosphonates , denosumab , teriparatide , romosozumab for osteoporosis (see bone-health section).

NSAIDs : renal, GI, cardiovascular risk; combine with PPI in high-risk; avoid in CKD and late pregnancy.

Anticoagulants : warfarin, DOACs (apixaban, rivaroxaban) for VTE prophylaxis in immobilized patients; NSAIDs and antiplatelets increase bleeding risk.

Antidepressants/anxiolytics : SSRIs/SNRIs commonly; sedating agents impair rehab participation.

Drug Interactions & Withdrawal Cautions

Baclofen + alcohol/sedatives → profound CNS depression; abrupt baclofen withdrawal → seizures.

NSAIDs + warfarin/SSRIs → bleeding; NSAIDs + ACE inhibitors/diuretics → renal injury.

Prolonged QT drugs combined (e.g., TCAs + certain antiemotics) → arrhythmia risk.

Sudden corticosteroid cessation → adrenal insufficiency; taper prolonged courses.

Chemodenervation Dosing & Pitfalls

OnabotulinumtoxinA dosing balances efficacy and antibody formation; frequent, high-dose, "booster" injections increase neutralizing antibody risk and secondary nonresponse. Toxin choice matters: onabotulinumtoxinA, abobotulinumtoxinA, and incobotulinumtoxinA are not dose-equivalent (units differ by product). Common pitfalls include inadequate muscle selection (use EMG/ultrasound guidance), underdosing large muscles, and overlooking focal vs generalized spasticity patterns. Anterior neck injection risks dysphagia; limb injection risks excessive weakness impairing function—functional goals (hygiene, gait, pain) guide target selection, not tone reduction alone.

Intrathecal Baclofen: Screening & Emergency

ITB candidates undergo a screening bolus; a positive response (reduced tone/spasms) precedes pump implant. Complications: catheter breakage/kinking, pump malfunction, infection, CSF leak, and—critically—withdrawal (fever, spasticity rebound, rhabdomyolysis, autonomic instability) and overdose (hypotonia, respiratory depression, coma). ITB withdrawal is a medical emergency managed with oral baclofen/lorazepam and supportive care; overdose may require antidotal supportive care. Candidates should recognize the clinical patterns of ITB withdrawal and overdose.

Polypharmacy & Beers Criteria in Rehab

Rehab patients are often elderly with multiple medications. The Beers Criteria flag potentially inappropriate medications: benzodiazepines, first-generation antihistamines, anticholinergics, long-acting sulfonylureas, and NSAIDs in certain populations—each impairing rehab (sedation, falls, cognition, hypoglycemia, renal/GI bleeding). The physiatrist reconciles medications, deprescribes deliriogenic agents, and selects safer alternatives (e.g., mirabegron over oxybutynin in cognitively impaired elderly for bladder).

Medication Effects on Rehabilitation Participation

• Effect Implicated Agents Rehab Impact
• Sedation Baclofen, tizanidine, opioids, benzodiazepines ↓participation, falls
• Weakness Dantrolene, statins, steroid myopathy ↓strength gains
• Cognitive impairment Anticholinergics, opioids, benzodiazepines ↓learning, delirium
• Bleeding NSAIDs + anticoagulants/SSRIs ↓injection/manual safety
• Hypotension Tizanidine, antihypertensives Orthostasis, falls

Coordinating pharmacotherapy with rehabilitation goals—timing sedating agents at night, minimizing cognitive load, adjusting for renal/hepatic function—optimizes outcomes and is a high-yield physiatric competency.

Corticosteroids in Rehabilitation

Corticosteroids are used acutely for MS relapse (high-dose intravenous methylprednisolone), spinal cord injury, and many inflammatory and pain conditions, and the physiatrist must weigh their rehabilitation-relevant adverse effects: a proximal steroid myopathy that directly undermines strength and transfer goals, hyperglycemia, fluid retention, hypertension, mood and sleep disturbance, peptic-ulcer risk that rises sharply when combined with NSAIDs, increased infection susceptibility, and avascular necrosis. Prolonged courses suppress the hypothalamic-pituitary-adrenal axis and require tapering rather than abrupt cessation to avoid adrenal crisis; bone loss accrues with chronic use, warranting calcium, vitamin D supplementation, and DEXA surveillance. Short high-dose pulses for relapse are generally well tolerated and are coordinated with the neurology service. The physiatrist pairs steroid therapy with protective rehabilitation—counteracting myopathy with graded resistive exercise, monitoring glucose and blood pressure, and timing therapy activity to the dosing schedule to minimize participation loss.