13.5 Diagnostic Procedures: Imaging, MSK Ultrasound, Urodynamics & Neuropsych Assessment

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

13.5 Diagnostic Procedures: Imaging, MSK Ultrasound, Urodynamics & Neuropsych Assessment

Key Takeaways Explain This Topic AI

Diagnostic procedures in the foundational domain include gait analysis (Chapter 2.9), medical imaging, musculoskeletal ultrasound, urodynamics, neuropsychological evaluation, and laboratory studies—each selected by clinical question.

Imaging modalities differ by tissue: MRI best for soft tissue, spinal cord, and marrow; CT for bone detail and acute hemorrhage; radiographs for fractures and alignment; bone scan/SPECT for occult fracture/osteomyelitis; PET for oncologic/metabolic imaging.

Musculoskeletal ultrasound dynamically evaluates tendons, ligaments, and nerves (e.g., carpal tunnel median nerve cross-sectional area, rotator cuff tears) and guides injections without ionizing radiation.

Urodynamics characterizes bladder dysfunction (detrusor overactivity, poor compliance, detrusor-sphincter dyssynergia) guiding therapy; neuropsychological assessment quantifies cognition and guides rehabilitation planning after brain injury/stroke.

Last updated: July 2026

Diagnostic Procedures: Imaging, MSK Ultrasound, Urodynamics & Neuropsych Assessment

Diagnostic procedures form a Domain A sub-area (gait analysis is in Section 2.9). The physiatrist selects and interprets imaging, ultrasound, urodynamics, and neuropsychological testing to clarify diagnoses and direct rehabilitation.

Medical Imaging Selection

Modality Best For Rehab Use Example Limitation
Radiograph Bone cortex, alignment, fractures Fracture follow-up, prosthesis alignment Poor soft-tissue detail

CT Bone detail, acute hemorrhage, complex fractures Cervical spine fracture, heterotopic ossification extent Radiation; metal artifact

MRI Soft tissue, spinal cord, marrow, tendons/ligaments Spinal cord compression, rotator cuff, demyelinating plaques Contraindications (some implants), cost

Bone scan/SPECT Occult fracture, osteomyelitis, metastases Stress fracture, complex regional pain syndrome Nonspecific uptake

DEXA Bone mineral density Osteoporosis screening/monitoring Bone density only
Fluoroscopy Real-time procedures Spine injections (see pain chapter) Radiation, operator-dependent

US Tendon/ligament/nerve dynamic, fluid Tendon tears, effusions, guided injection Operator-dependent; limited for deep structures

Musculoskeletal Ultrasound

MSK ultrasound dynamically images tendons, ligaments, muscles, joints, and peripheral nerves. High-yield applications:

Rotator cuff : full- vs partial-thickness supraspinatus tears, tendinosis, bursal fluid.

Carpal tunnel : median nerve cross-sectional area at the wrist (>10-12 mm² supports CTS).

Lateral epicondyle : tendon thickening, neovascularity, tears.

Achilles and patellar tendons : tendinosis, neovascularity, partial tears.

Joint effusions and guided injections/aspirations .

Advantages include dynamic real-time assessment, no ionizing radiation, and image-guided interventions; limitations are operator dependence and limited penetration/deep-structure assessment. The AANEM and ACR acknowledge MSK US in physiatric and rheumatologic practice.

Urodynamics

Urodynamic studies characterize lower urinary tract function in neurogenic and non-neurogenic bladder dysfunction.

Component Measures / Detects
Uroflowmetry Peak flow rate, voiding pattern
Cystometry (CMG) Bladder sensation, capacity, compliance, detrusor overactivity
Pressure-flow study Bladder outlet obstruction vs impaired contractility

Leak point pressures Detrusor leak point (SCI above T6 risk high pressures), abdominal leak point (stress incontinence)

EMG of external sphincter Detrusor-sphincter dyssynergia (DSD; suprasacral SCI)

Findings guide therapy: detrusor overactivity → anticholinergics/beta-3 agonists/botulinum; DSD with high pressures → intermittent catheterization ± alpha-blockers; low compliance → early intervention to protect upper tracts (renal function monitoring, low bladder storage pressures).

Neuropsychological Assessment

Neuropsychological evaluation uses standardized batteries to quantify cognitive domains (attention, memory, language, executive function, visuospatial, processing speed) and emotional functioning after TBI, stroke, tumor, or neurodegenerative disease. It informs rehabilitation planning, return-to-work/school, capacity decisions, and outcome measurement. Functional scales (FIM, Glasgow Outcome Scale, Rancho levels) complement—but do not replace—formal neuropsychological testing. Neuropsychologists also help distinguish depression/pseudodementia from genuine dementia and identify functional cognitive overlay.

Laboratory Studies & Integration

Common labs support rehab diagnoses: CBC/anemia (exercise tolerance), renal function (NSAID/contrast dosing), vitamin D/B12, thyroid (myopathy/fatigue), HbA1c (wound healing), inflammatory markers (rheumatologic disease), and drug levels. The physiatrist integrates imaging, ultrasound, urodynamics, neuropsychological testing, and labs with the clinical exam to build a coherent rehabilitation plan.

Imaging Safety & Contrast Considerations

Imaging choice weighs diagnostic yield against risk: CT ionizing radiation (cumulative cancer risk, dose-reduction in children/pregnancy), MRI gadolinium retention (kidney function-dependent NSF risk), and contrast allergy/renal function. The physiatrist selects the lowest-yield-sufficient study, coordinates renal function and allergy precautions, and recognizes implants (pacemakers, clips, neurostimulators) that constrain MRI. Pre-procedural contrast protocols and metformin management around iodinated contrast are recurring exam points.

Electrodiagnosis as a Diagnostic Adjunct

While detailed electrodiagnosis is in Chapter 5, the foundational diagnostic-procedures domain includes recognizing when EMG/NCS complement imaging: radiculopathy (EMG myotomal pattern vs MRI structural), entrapment neuropathy (localizing conduction slowing), and distinguishing neurogenic from vascular TOS. The physiatrist sequences non-invasive tests (imaging, ultrasound, urodynamics, neuropsych) before invasive ones and integrates them with the clinical exam.

Urodynamics Interpretation Pearls

Pattern Finding Implication

Detrusor overactivity Uninhibited contractions during filling Urge/neurogenic; anticholinergic/beta-3/botulinum

Low compliance High pressure at low volume Upper-tract risk; reduce storage pressure early

Detrusor-sphincter dyssynergia EMG activity during detrusor contraction Suprasacral SCI; intermittent catheterization ± alpha-blocker

Outlet obstruction High detrusor pressure, low flow BPH, stricture; alpha-blocker/surgery
Areflexic bladder No detrusor contraction Sacral/conus; clean intermittent catheterization

Low-compliance bladders with high storage pressures risk upper-tract deterioration; detrusor leak point pressures >40 cm H2O historically flagged upper-tract risk, prompting early intervention. The physiatrist integrates urodynamics with renal function surveillance (creatinine, upper-tract imaging) for lifelong neurogenic bladder management.

Neuropsychology: Application & Limitations

Neuropsychological testing is most informative in stable (subacute-to-chronic) phases; acute confusional states and fluctuating deficits limit interpretability. Findings guide diagnosis (differential of dementia vs depression vs FND cognitive overlay), rehabilitation planning (strengths/weaknesses, compensatory strategies), capacity/legal questions, return to work/school, and outcome measurement. Limitations include practice effects with repeat testing, cultural/educational test bias, and effort/cognition interaction—formal effort testing is part of contemporary assessment. The physiatrist refers judiciously and integrates results into the multidisciplinary plan rather than treating the report in isolation.