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Flashcards in Medical Rehab Deck (95)
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1

You are asked to consult on a 60-year-old cancer patient with an acute deep vein thrombosis (DVT) in the right upper limb, secondary to a long-standing central venous catheter. What therapy restrictions would you recommend for the patient?

(a) Bed rest for 10-12 days to allow for clot maturation.
(b) No activity restrictions, since upper limb DVTs have a low likelihood of causing a
pulmonary embolus.
(c) Begin resistive exercises 12-24 hours after the patient is therapeutic on an anticoagulant.
(d) Limit therapy to ambulation, balance, and ADL training if anticoagulation is medically
contraindicated

Answer: (d)
Commentary: Because patients with acute upper limb DVT who cannot safely be anticoagulated are at high risk for pulmonary emboli and death, their physical, occupational, or lymphedema therapy should be functional in nature (ie, ambulation, balance, ADL training). Resistive exercises should be deferred until 48 – 72 hours after a patient is therapeutic on an anticoagulant (low molecular weight heparin, unfractionated heparin, or Coumadin). Prolonged bed rest for clot maturation is no longer supported within the medical literature for lower extremity DVTs, since the initial recommendation was based on a single limited study. Although the timing of mobilization following an acute upper limb DVT and institution of therapy has not yet been defined in the literature, bed rest for 10-12 days is overly restrictive. However, placing no activity restrictions on the patient is potentially dangerous, since an immature clot may break off and embolize to the lungs.

Reference: (a) Stubblefield MD and O'Dell MW, editors. Cancer rehabilitation: principles and practice. New York: Demos Medical Publishing; 2009. (b) Stubblefield MD, Pearce CK. Rehabilitation of the cancer patient: identification, evaluation, and rehabilitation of patients with complications of cancer and its treatment from impending fracture to hematologic abnormalities. Paper presented at: American Academy of Physical Medicine and Rehabilitation Annual Assembly; 2011. (c) Kiser TS, Stefans VA. Pulmonary embolism in rehabilitation patientsrelation to time before return to physical therapy after diagnosis of deep vein thrombosis. Arch Phys Med Rehabil 1997;78(9):942-5.

2013

2

A 70-year-old man with COPD presents to your office for follow-up. His forced expiratory
volume in 1 second (FEV1) is 55% of predicted normative values. What would you expect the
patient’s functional limitations to be?

(a) No functional impairment; the patient is able to walk significant distances without
difficulty.
(b) Mild functional impairment; the patient is able to walk significant distances at a slower
speed.
(c) Moderate functional impairment; the patient requires intermittent rest when walking and
climbing stairs.
(d) Severe functional impairment; the patient is only able to ambulate for very short
distances.

Answer: (c)
Commentary: The World Health Organization’s Global Initiative for Chronic Obstructive Lung Disease classifies patients who have an FEV1 between 50%-79% of predicted values as moderately impaired. This equates to the FEV1 dropping between 1-2 liters. Functional impairment develops when the FEV1 falls below 3 liters. Patients with an FEV1 between 30%-49% of predicted values are severely impaired while those with an FEV1 less than 30% are the most impaired.

Reference: (a) Keyser RE, Chan L, Woolstenhulme JG, Kennedy M, Drinkard BE. Pulmonary rehabilitation. In: Braddom RL, editor. Physical medicine and rehabilitation. 4th ed. Philadelphia: Elsevier; 2011 p 744-5. (b) Manasian S. Pulmonary rehabilitation. In: Nesathurai S, Blaustein D, Editors. Essentials of inpatient rehabilitation. Blackwell Science;2001. p 42-43

2013

3

A 28-year-old male firefighter sustained deep dermal burns across his lower face, neck, anterior
chest, and shoulders. To help manage the formation of hypertrophic scars, you recommend

(a) corticosteroid injections directly into localized, early hypertrophic scars.
(b) compression garments to be worn 12 hours a day.
(c) topical silicone to large areas of hypertrophic scar.
(d) ultrasound treatments with passive stretching

Answer: (a)
Commentary: Corticosteroid injections directly into localized, early hypertrophic scars can be
useful, especially in highly cosmetic locations (face or neck) or in scars that are very pruritic.
Compression garments should be worn 23 hours a day until wound erythema begins to abate, usually about 12-18 months after injury. Topical silicone, applied as a sheet, is effective in themanagement of small areas of hypertrophic scar. In a prospective randomized double-blind study,
the effectiveness of ultrasound with passive stretching versus placebo ultrasound with passive stretching showed no difference in joint range of motion or perceived pain between the 2 treatment groups. This finding suggests that, although widely used, ultrasound may not have a beneficial effect on contractures that form secondary to hypertrophic scarring.

2013

4

When is the use of hyperbaric oxygen recommended for the treatment of diabetic foot ulcers?

(a) As first-line treatment
(b) If there are signs of infection
(c) If standard therapy is ineffective
(d) As prophylaxis after wound has healed

Answer: (c)
Commentary: Hyperbaric oxygen therapy is a treatment modality that can be considered for non-infected diabetic foot ulcers that have not responed to other therapies. Systematic review did show improved wound healing at 6 weeks with use of hyperbaric oxygen but no differences were noted at 1 year.

Reference: (a) Miller AO, Henry M. Update on diagnosis and treatment of diabetic foot ulcers

2013

5

A 59-year-old woman with metastatic breast cancer presents with painful swelling of her right
arm over the last year. She underwent a radical mastectomy two years ago followed by radiation
therapy. She describes an aching discomfort along with an ill-defined sensation of numbness and
tingling. Effective decongestive therapy for the treatment of secondary lymphedema requires

(a) long-stretch bandaging of the affected limb.
(b) truncal clearance to facilitate drainage of the affected limb.
(c) intermittent pneumatic compression devices.
(d) low-level laser therapy.

Answer: (b)
Commentary: Truncal clearance is necessary to facilitate lymphatic drainage from affected limbs
by promoting effective pressure gradients, reducing lymphatic network resistance, and
stimulating lymphatic contractility. Short-stretch bandaging is recommended to create large
functional dynamic pressures with low resting pressures helping to prevent circulatory
compromise. Adjuvant intermittent pneumatic compression devices have been found to
significantly reduce limb volume during both Phase 1 and Phase 2 of complete decongestive
therapy. However, the older generation, non-programmable pumps may generate higher pressures
than therapeutically necessary and risk the development of truncal or genital edema, as well as
produce fibrotic cuffs. Low-level laser therapy is still being investigated for the management of
secondary lymphedema, since the wavelength, pulse duration and frequency, dose and dose rate,
duration of treatment, and repetition of treatment must be further defined.

Reference: (a) A randomized, prospective study of a role for adjunctive intermittent pneumatic
compression. Cancer 2002;95(11):2260-7. (b) Mayrovitz HN. The standard of care for
lymphedema: current concepts and physiological considerations. Lymphatic Res Biol
2009;7(2):101-108. (c) Oremus M, Dayes I, Walker K, Raina P. Systematic review: Conservative
treatments for secondary lymphedema. BMC Cancer 2012;12(6):1-15. (d) Szuba A, Achalu R,
Rockson SG. Decongestive lymphatic therapy for patients with breast carcinoma-associated
lymphedema. Cancer 2002;95(11):260-7. http://www.ncbi.nlm.nih.gov/pubmed/12436430. Accessed July 20, 2012.

2013

6

Which clinical tool BEST measures and predicts the safety of ambulation in older adults?

(a) Berg Balance Scale (BBS)
(b) Braden Scale
(c) Timed Up and Go (TUG) test
(d) Katz Index

Answer: (c)
Commentary: The Berg Balance Scale (BBS) is a 56-point scale to evaluate performance during
14 common activities, such as standing, turning and reaching for an object on the floor. It does not rate walking. The Braden Scale is for predicting pressure sore risk, and is used to help determine the risk of skin breakdown or decubitus ulcer. In the Timed Up and Go (TUG) test, a patient is asked to rise from an armchair, walk 3 meters (10 feet), turn around, walk back to the chair, and sit down again (the score is the time in seconds it takes to complete these tasks). This
test has high interrater and content reliability, and predicts whether a patient can safely walk outside alone. The Katz Index is widely used to measure independence in activities of daily living (ADLs), but does not include measures of mobility, such as walking or stair climbing.

7

A 67-year-old man with chronic obstructive lung disease (COPD) is about to start a pulmonary
rehabilitation program. Which option is an appropriate breathing retraining technique for the
patient to learn?

(a) Diaphragmatic breathing
(b) Localized expansion exercises
(c) Rapid, shallow breathing
(d) Head up and bending backward postures


Answer: (b)
Commentary: Breathing retraining techniques for COPD include pursed lips breathing, head
down and bending forward postures, slow deep breathing, and localized expansion exercises (also
known as segmental breathing, wherein the patient is asked to inspire while the clinician applies
pressure to the thoracic cage to resist respiratory excursion in a segment of the lung). These
techniques maintain positive airway pressure during exhalation and help reduce overinflation.
Although diaphragmatic breathing (done by expanding one's belly and thereby allowing the
diaphragm to move down creating more room for the lungs to expand) is widely taught, it has
been shown to increase the work of breathing and dyspnea compared with the natural pattern of
breathing in the patient with COPD.

2012

8

What is the most frequent presenting symptom of brain metastasis?

(a) Focal weakness
(b) Headache
(c) Seizure
(d) Visual disturbance


Answer: (b)
Commentary: Presenting symptoms at the time of diagnosis with brain metastasis, in order of
decreasing frequency, are as follows: (patients can have more than a single symptom): headache,
49%; mental disturbance, 32%; focal weakness, 30 %; gait ataxia, 21 %; seizures, 18%; speech
difficulty, 12%, visual disturbance, 6%; sensory disturbance, 6%; and limb ataxia, 6%.

2011

9

Which cardiac response is increased as a result of aerobic training?

(a) Oxygen consumption (VO2)
(b) Maximal heart rate
(c) Anginal threshold
(d) Stroke volume at rest


Answer:(d)
Commentary: After an aerobic training program, the anginal threshold is unchanged. Oxygen
consumption (VO2) at rest, and during any given submaximal load remains unchanged, while
VO2 max is increased. The maximal heart rate also does not change, but the heart rate is lower
both at rest and during any submaximal load (bradycardia of training). The stroke volume at rest
is increased, reciprocal to the decrease in heart rate. Although angina threshold is unchanged,
myocardial oxygen demand decreases relative to oxygen consumption, which allows more intense
activity before the ischemic threshold is reached.

2011

10

A 50-year-old man has obstructive sleep apnea (OSA). He is morbidly obese and has a body mass
index (BMI) of 39 kg/m². He is also complaining of chronic low back pain, which he claims
limits his mobility. Which approach would best benefit him?

(a) Prescribe a motorized wheelchair.
(b) Prescribe modafinil (Provigil) for daytime sleepiness.
(c) Schedule opioid analgesics for pain control.
(d) Order surgical referral for a tracheostomy.


Answer: (b)
Commentary: Obstructive sleep apnea (OSA) is characterized by snoring, arousals, and daytime
sleepiness. Most patients with OSA are male, middle-aged, with an average BMI of 32.5 +/-
9.0kg/m2
. Wheelchairs should be used only in cases of compromised mobility and powered
mobility used only when no other options exist. Modafinil can be used as adjunct therapy for
daytime sleepiness. Narcotic analgesics should be prescribed with caution because of depression
of central respiratory drive. Positive airway pressure (PAP) delivered with continuous (CPAP) or
bilevel (BiPAP) pressures can correct upper airway obstruction. If the noninvasive approach is
not effective, tracheostomy may be necessary.

2011

11

A construction company manager is concerned about hiring employees over the age of 40, citing
lower productivity because of lower endurance compared to younger workers. You tell him that the average decline in physical work capacity between the ages of 40 and 60 is

(a) 5% Page 7 of 33
(b) 20%
(c) 35%
(d) 50%


Answer: (b)
Commentary: While variation exists, an average decline of 20% in physical work capacity has
been reported between the ages of 40 and 60 years, due to decreases in aerobic and
musculoskeletal capacity. However, differences in habitual physical activity will influence the
variability seen in individual physical work capacity and its components.

2011

12

Which symptom most frequently impacts quality of life in patients with incurable cancers?

(a) Fatigue
(b) Anorexia
(c) Weakness
(d) Depression

Answer: (a)
Commentary: Cancer patients experience a much broader range of symptoms that impact their quality of life and their ability to address existential issues at the end of life than those listed here. A systematic review of symptom prevalence studies in patients with incurable cancer identified fatigue (74%), pain (71%), lack of energy (69%), weakness (60%) and anorexia (53%) being the most prevalent that impact quality of life. The prevalence of nausea is 40% in the last 6 weeks of life. Fatigue is often the primary condition adversely affecting quality of life.

2011

13

Which statement regarding an independent medical examination (IME) is TRUE?

(a) The traditional physician-patient relationship is not maintained, and confidentiality is not
guaranteed.
(b) The examiner is exempt from potential liability since the purpose of the evaluation is to
assess medical-legal issues, not clinical issues.
(c) Treating providers may conduct an IME as long as records from other providers are also
reviewed.
(d) Because of potential conflicts of interest, only providers no longer in clinical practice
should conduct IMEs.

 


Answer: (a)
Commentary: In the IME context, a traditional physician-patient relationship does not exist, since
the evaluation does not include “intent to treat.” Confidentiality is not guaranteed, since the
examiner is expected to share certain medical information and findings with the referring party. Because a “limited doctor-patient relationship” exists during an IME, the physician is responsible for disclosing in the IME any medical findings that could affect the patient’s health, and he or she is potentially liable for any harm, direct or indirect, that may be sustained by the person examined. Only a provider who is uninvolved with an examinee’s treatment may conduct an
IME, although a treating provider may be an “expert witness.” Legal requirements for qualification as an expert witness vary from state to state. There is no restriction regarding a provider’s clinical status and eligibility to conduct IMEs.

2011

14

A 59-year-old woman with metastatic breast cancer presents with painful swelling of her right arm over the last year. She underwent a radical mastectomy two years ago followed by radiation therapy. She describes an aching discomfort along with an ill-defined sensation of numbness and tingling. Effective decongestive therapy for the treatment of secondary lymphedema requires
(a) long-stretch bandaging of the affected limb.
(b) truncal clearance to facilitate drainage of the affected limb.
(c) intermittent pneumatic compression devices.
(d) low-level laser therapy.

Answer: (b)
Commentary: Truncal clearance is necessary to facilitate lymphatic drainage from affected limbs by promoting effective pressure gradients, reducing lymphatic network resistance, and stimulating lymphatic contractility. Short-stretch bandaging is recommended to create large functional dynamic pressures with low resting pressures helping to prevent circulatory compromise. Adjuvant intermittent pneumatic compression devices have been found to significantly reduce limb volume during both Phase 1 and Phase 2 of complete decongestive therapy. However, the older generation, non-programmable pumps may generate higher pressures than therapeutically necessary and risk the development of truncal or genital edema, as well as produce fibrotic cuffs. Low-level laser therapy is still being investigated for the management of secondary lymphedema, since the wavelength, pulse duration and frequency, dose and dose rate, duration of treatment, and repetition of treatment must be further defined

2013

15

When is the use of hyperbaric oxygen recommended for the treatment of diabetic foot ulcers?
(a) As first-line treatment
(b) If there are signs of infection
(c) If standard therapy is ineffective
(d) As prophylaxis after wound has healed

Answer: (c)
Commentary: Hyperbaric oxygen therapy is a treatment modality that can be considered for non-infected chronic diabetic foot ulcers that have not responded to other therapies. Systematic review did show improved wound healing at 6 weeks with use of hyperbaric oxygen but no differences were noted at 1 year.

2013

16

You see a patient in clinic with what appears to be a non-infected diabetic foot ulcer over the first metatarsal head and order an ankle-brachial index (ABI) study. The patient’s ABI is 1.4. What is your next step in treatment?
(a) Proceed with off loading the ulcer, since blood flow is normal.
(b) Order additional testing, such as an arterial duplex.
(c) Refer for to vascular surgery for urgent revascularization.
(d) Refer for consideration of a transmetatarsal amputation

Answer: (b)
Commentary: Evaluation of vascular status is critical in any patient presenting with diabetic ulcer. The ABI is considered a useful screening tool to look for peripheral arterial disease. Values under 0.91 are considered consistent with peripheral arterial disease. However, calcified vessels can lead to higher values and possibly false negative test results. If ABI is >1.3, this most likely due to calcified, non-compressible vessels; therefore, other means of testing vascular status should be used

2013

17

You are consulted to see a young patient 3 days after the motor vehicle crash in which he
sustained a traumatic brain injury. You note that he is not receiving nutritional support. In starting
nutrition in this patient, which statement concerning enteral compared to parenteral nutrition is
TRUE?

(a) Enteral nutrition has a higher incidence of complications.
(b) Parenteral nutrition is more likely to cause pneumonia.
(c) Enteral access is easier to obtain at a higher cost.
(d) No significant difference exists in measured nutritional parameters

You are consulted to see a young patient 3 days after the motor vehicle crash in which he
sustained a traumatic brain injury. You note that he is not receiving nutritional support. In starting
nutrition in this patient, which statement concerning enteral compared to parenteral nutrition is
TRUE?

(a) Enteral nutrition has a higher incidence of complications.
(b) Parenteral nutrition is more likely to cause pneumonia.
(c) Enteral access is easier to obtain at a higher cost.
(d) No significant difference exists in measured nutritional parameters.
 
Answer: (d)
Commentary: Early feeding of a person who has a traumatic brain injury is associated with fewer
infections and a trend towards better outcomes in terms of survival and disability. Two trials
reported the effect of route of feeding on the incidence of infection of any type, but both trials
showed a trend towards more infection with parenteral nutrition (PN) than with enteral nutrition
(EN). This difference might reflect catheter related infection with PN. In 3 trials reporting the
effect of route of feeding on the occurrence of pneumonia, a trend towards reduced incidence of
pneumonia was found in the PN group.

Although it is easier to provide PN than it is to obtain adequate EN access, EN has a decreased
incidence of complications and lower cost compared to PN, with no significant differences in measured nutritional parameters. Also, providing nutrition to the intestine can stimulate gut
immune function and limit deterioration of the intestinal mucosa characteristic of bacterial
translocation and its potential for contributing to sepsis.

2010

18

Which finding is a functional physiological change seen in the elderly?

(a) Increased drug-binding for highly-protein bound drugs
(b) Doubling of D-dimer levels
(c) Decreased erythrocyte sedimentation rate
(d) Macrocytic anemia

Answer: (b)
Commentary: D-dimer levels are shown to double with aging, especially among African
Americans and functionally impaired individuals. Increased erythrocyte sedimentation rate and
C-reactive protein have also been seen in the elderly. Although anemia occurs with increasing
prevalence with aging, there is convicncing evidence that it is not a normal consequence of aging.
Decreased drug-binding for highly protein-bound drugs in the elderly may lead to higher unbound
or free drug concentrations.


2010

19

When considering risk of cumulative trauma in an older individual, it is important to know the
typical decreases in strength that occur with aging. Between ages 70 and 80 people typically lose
what percentage of their strength?

(a) 5
(b) 15
(c) 30
(d) 50

Answer: (c)
Commentary: Between the ages of 70 and 80 people typically lose 30 percent of their strength.
Muscular weakness occurs after age 30 in association with generalized muscle fiber atrophy,
decreased muscle density and increased intramuscular fat. Between the ages of 50 and 70 people
typically lose 15 percent of their strength.

2010

20

A 72-year-old woman is receiving warfarin (Coumadin) for deep venous thrombosis (DVT)
prophylaxis after repair of a hip fracture. She is on several other medications. The medication that
will significantly elevate her international normalized ratio (INR) is

(a) diphenhydramine (Benadryl).
(b) acetaminophen (Tylenol).
(c) carbamazepine (Tegretol).
(d) ranitidine (Zantac).

Answer: (b)

Commentary: Warfarin (Coumadin) is used for anticoagulation in several different disease
conditions while patients are under the care of a physiatrist. One of the drug’s most common
applications is for DVT prophylaxis after repair of a hip fracture. Many medications can alter the
therapeutic efficacy of warfarin. Sulfonamides, acetaminophen, amiodarone, aspirin, and
nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the prothrombin (PT)/INR.
Adrenocorticoids, antacids, antihistamines, carbamazepine, haloperidol, and vitamin C can
decrease the PT/INR.

2010

21

Which physiological change occurs in the cardiovascular system with aging?

(a) Increased resting heart rate
(b) Increased resting cardiac output
(c) Decreased ejection fraction
(d) Decreased orthostatic hypotension

Answer: (c)
Commentary: As a person ages, decreased inotropic responsiveness to adrenergic stimuli leads
to decreased myocardial contractility and, hence, to a decrease in ejection fraction. Resting heart
rate does not change with aging, but maximal heart rate with exercise does decrease
progressively. Cardiac output at rest and with modest exercise is maintained by early
involvement of the Frank-Starling mechanism. There is an increased incidence of orthostatic
hypotension in the elderly due to decreased baroreceptor sensitivity and diminished reflex
tachycardia

2010

22

Upper extremity exercise (eg, crutch walking) leads to a greater increase in heart rate and blood
pressure compared with lower extremity activity (eg, normal walking) due to the

(a) smaller upper extremity muscles, which contract at a higher maximal percentage.
(b) proximity of the upper extremities to the heart and major blood vessels.
(c) upper extremities having to overcome the effect of gravity.
(d) greater range of motion of the upper extremities compared to the lower ones

Answer: (a)
Commentary: Upper extremity work leads to greater increases in heart rate and blood pressure.
When a muscle contracts with a given percentage of its maximum force, its effect on blood
pressure is about the same as during the same percentage of contraction of any other muscle. The
smaller muscles in the upper extremity contract more, and stimulate the cardiovascular system
more relative to the larger lower extremity muscles.

2010

23

You are performing a consultation on a 58-year-old man with a history of diabetes and peripheral
vascular disease who presents with a non-healing foot ulcer. You are concerned that he is at risk
for amputation because his

(a) ankle brachial index (ABI) is 0.8.
(b) ABI is 0.4.
(c) transcutaneous oxygen pressure (TcPO2) is 80mmHg.
(d) TcPO2 is 40mmHg.

Answer: (b)
Commentary: ABI is a noninvasive technique that is used in the assessment of arterial occlusive
disease. The ABI is the ratio between the ankle and the brachial systolic pressure. Normal ABI is
defined as values greater than 0.9. An ABI below 0.4 tends to carry a poor prognosis. TcPO2 is
defined as transcutaneous oxygen, which is in essence a "blood gas" of the skin. Normal TcPO2 is
greater than 50mmHg. Values of more than 40mmHg are associated with healing. Ischemia is
defined as periwound TcPO2

24

Supplemental oxygen therapy in patients with chronic obstructive pulmonary disease (COPD) has
been shown to

(a) improve walking endurance.
(b) increase blood pressures.
(c) maximize work rate.
(d) produce polycythemia.

Answer: (a)
Commentary: Supplemental oxygen therapy is indicated in patients with arterial partial pressure
of oxygen (PO2) continuously less than 55-60mmHg. Home oxygen therapy can decrease
pulmonary hypertension, polycythemia, blood pressure, and pulse. In patients with mild
hypoxemia and exercise desaturation, supplemental oxygen by nasal prongs did not influence
maximum work rate, but did increase mean walking endurance time and exercise tolerance.

2010

25

Which clinical tool BEST measures and predicts the safety of ambulation in older adults?
(a) Berg Balance Scale (BBS)
(b) Braden Scale
(c) Timed Up and Go (TUG) test
(d) Katz Index

Commentary: The Berg Balance Scale (BBS) is a 56-point scale to evaluate performance during
14 common activities, such as standing, turning and reaching for an object on the floor. It does
not rate walking. The Braden Scale is for predicting pressure sore risk, and is used to help
determine the risk of skin breakdown or decubitus ulcer. In the Timed Up and Go (TUG) test, a
patient is asked to rise from an armchair, walk 3 meters (10 feet), turn around, walk back to the
chair, and sit down again (the score is the time in seconds it takes to complete these tasks). This
test has high interrater and content reliability, and predicts whether a patient can safely walk
outside alone. The Katz Index is widely used to measure independence in activities of daily living
(ADLs), but does not include measures of mobility, such as walking or stair climbing.

2012

26

Which barrier is perceived by older individuals to be the LEAST significant obstacle to physical
activity?
(a) Time, money, family commitments
(b) Illness and injury
(c) Fear of injury
(d) Availability of an exercise partner

Answer: (a)
Commentary: Perceived barriers are a powerful negative predictor of physical activity in the
elderly. Although individual variation is the rule, overall obstacles to physical activity tend to
change with age, and seem to increase for many aging individuals. Elderly patients report that
time, money and family commitments are less significant barriers as they age. Availability of an
exercise partner, illness, injury and fear of injury become more prominent concerns as they grow
older.

2012

27

A 67-year-old man with chronic obstructive lung disease (COPD) is about to start a pulmonary
rehabilitation program. Which option is an appropriate breathing retraining technique for the
patient to learn?
(a) Diaphragmatic breathing
(b) Localized expansion exercises
(c) Rapid, shallow breathing
(d) Head up and bending backward postures

Answer: (b)
Commentary: Breathing retraining techniques for COPD include pursed lips breathing, head
down and bending forward postures, slow deep breathing, and localized expansion exercises (also
known as segmental breathing, wherein the patient is asked to inspire while the clinician applies
pressure to the thoracic cage to resist respiratory excursion in a segment of the lung). These
techniques maintain positive airway pressure during exhalation and help reduce overinflation.
Although diaphragmatic breathing (done by expanding one's belly and thereby allowing the
diaphragm to move down creating more room for the lungs to expand) is widely taught, it has
been shown to increase the work of breathing and dyspnea compared with the natural pattern of
breathing in the patient with COPD.

2012

28

Which pulmonary parameter is predictive of mortality in a child with Duchenne muscular
dystrophy?
(a) Maximal expiratory pressure
(b) Peak flow rate
(c) Cough peak flow
(d) Forced vital capacity

Answer:(d)
Commentary: One simple method of assessing the interplay between pump function and load is
the measurement of the forced vital capacity (FVC) and fractional lung volumes. In boys with
Duchenne muscular dystrophy (DMD), the relationship between the absolute value of FVC and
age can be divided into 3 epochs: one of gradual increase coincident with their ambulatory period,
followed by a plateau phase at 10 to 12 years when they become confined to wheelchairs, and
then a gradual but persistent decline thereafter. However, when the FVC is described as a percent
of the predicted value, it is lower than normal and diverges from the normal curve over time. The
decline in FVC to a value of less than 1 liter may also predict mortality in patients who do not
receive assisted ventilation.

2012

29

A 48-year-old woman had an acute myocardial infarction (MI) 2 weeks ago. The referring
cardiologist informed you that she had a small MI and an uncomplicated hospital course. In a
situation such as this, which statement is TRUE?
(a) Combined aerobic and resistance training, compared to aerobic training alone, has a
higher risk of adverse outcomes.
(b) Beta blocker agents will attenuate the benefits of exercise training.
(c) A change in left ventricular (LV) dimensions (remodeling) is associated with improving
LV function.
(d) Cardiac rehabilitation will improve both myocardial perfusion and LVelectrophysiologic
parameters.

Answer: (d)
Commentary: After a myocardial infarction (MI), exercise training is initiated within 2-4 weeks.
Combined resistance and aerobic training improves aerobic fitness and muscle strength more than
aerobic training alone, without adverse outcomes. Beta blockers, which are a standard of care to
reduce mortality after an MI, do not attenuate the benefits of exercise training. Following an MI,
a change in left ventricular (LV) dimensions (remodeling) is associated with deteriorating LV
function, ventricular arrhythmias, aneurysm formation, and higher mortality. Cardiac
rehabilitation improves both myocardial perfusion and LV electrophysiologic parameters,
reducing the risk for malignant ventricular arrhythmias and sudden cardiac death after MI.

2012

30

Which burn patient has the highest risk of developing hypertrophic scars?
(a) Newborn baby
(b) Morbidly obese individual
(c) Heavily pigmented individual
(d) Elderly individual

Answer: (c)
Commentary: A hypertrophic scar is usually defined as a scar that is present at 3 or more
months after the burn injury and is greater than or equal to 2 mm in thickness. Heavily
pigmented patients tend to scar more than persons with less pigment. Little scarring has been
reported in neonates, newborns, elderly and the morbidly obese. Patients with wounds that take
longer than 2-3 weeks to heal, and persons requiring skin grafts, are also considered at risk for
developing hypertrophic scars.

2012