Mod/Ex/Aging/Research SAEs

Question 1

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 1

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.

Question 2

7. A 67-year-old man who had a stroke is being discharged from the hospital. His 32-year-old

nephew plans to care for him at home, but is unfamiliar with the Family Medical Leave Act

(FMLA). How does FMLA apply to the nephew?

(a) He does not qualify since he is not the spouse or an immediate family member.
(b) FMLA only applies to the patient, not to the caregiver.
(c) He will be paid 66% of his usual salary while he is taking FMLA.
(d) If he takes FMLA, he may lose his employer-sponsored health insurance.

Answer 2

Answer: (a)

Commentary: The Family Medical Leave Act (FMLA) entitles eligible employees of covered

employers to take unpaid, job-protected leave for specified family and medical reasons with

continuation of group health insurance coverage. Eligible employees are entitled to 12 work

weeks of leave in a 12-month period for any of the following reasons:

1. the birth and care of the newborn child of an employee
2. the placement with the employee of a child for adoption or foster care
3. to care for an immediate family member (spouse, child, or parent) with a serious health

condition

4. to take medical leave when the employee is unable to work because of a serious health

condition

Employees are eligible for leave if they have worked for their employer at least 12 months, have

worked at least 1250 hours over the past 12 months, and work at a location where the company

employs 50 or more employees within 75 miles.

Question 3

11. When applying cryotherapy in the treatment of musculoskeletal disorders, which of the following

events is NOT a contraindication to its use?

(a) Paroxysmal cold hemoglobinuria
(b) Impaired sensation
(c) Arterial insufficiency
(d) Spasticity

Answer 3

Answer : (d)

Commentary: Contraindications for the use of cryotherapy include paroxysmal cold

hemoglobinuria, impaired sensation and arterial insufficiency. Other contraindications are cold

hypersensitivity, cryopathies, cold intolerance, cryotherapy-induced neurapraxia, and Raynaud

disease. Spasticity is one of the general uses of cryotherapy in addition to musculoskeletal

injuries and pain syndromes, postoperative conditions and emergency treatment of minor burns.

Question 4

16. 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 4

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.

Question 5

24. Which deep heat method recommends the use of protective eyewear to prevent the formation of

cataracts?

(a) Ultrasound
(b) Short wave diathermy
(c) Fluidotherapy
(d) Microwave diathermy

Answer 5

Answer:(d)

Commentary: Microwave diathermy is another form of electromagnetic energy that uses

conversion as its primary form of heat production. Temperature distribution in a particular tissue

is affected largely by its water content. In general, tissues with high water content absorb greater

amounts of energy and are selectively heated. General heat precautions should be observed with

microwave procedures. Metal implants, pacemakers, sites of skeletal immaturity, reproductive

organs and brain, and fluid-filled cavities (eye, bullae, effusions, etc.) should be avoided.

Microwaves can cause cataracts and protective eye wear should be worn by both patient and

therapist to reduce risk.

Question 6

37. Two medical experts (Drs. A and B) have differing opinions in a medical-legal case. Dr. A

accuses Dr. B of citing “junk science,” and states that Dr. B’s testimony fails to meet the Daubert

standard. Which statement supports the opinion that Dr. B has not met the Daubert standard?
(a) Dr. B’s research experience and publications are less than Dr. A’s.
(b) Dr. B’s peer-reviewed references are all more than 10 years old
(c) Dr. B’s cited references did not have a known error rate.
(d) Dr. B’s opinions are not fully accepted by the medical community.

Answer 6

Answer: (c)

Commentary: The Daubert standard refers to a federal Supreme Court decision to prevent “junk

science” from influencing juries. Information given by expert testimony must meet certain

criteria, and if these criteria are not met the expert can be barred from testifying. The information

provided by medical experts must meet the following four criteria:

1. Generally well accepted in the medical community
2. Published in peer-reviewed literature
3. Have a scientific basis
4. Have a known error rate

In the scenario presented, Dr. B satisfied the Daubert standard except for his failure to provide a

known error rate in his research.

Question 7

47. A 47-year-old woman with secondary progressive multiple sclerosis is applying for Social

Security Disability Insurance (SSDI). She asks her primary care physician for help. His correct

response to her is that

(a) SSDI benefits and policies vary from state to state.
(b) SSDI benefits include medical insurance.
(c) he will make the final determination of disability and employability.
(d) she must satisfy non-medical criteria before medical factors are considered.

Answer 7

Answer: (d)

Commentary: The Social Security Administration (SSA) provides both Social Security Disability

Insurance (SSDI) and Supplemental Security Income (SSI). SSDI and SSI are federal programs

with identical benefits and policies from state to state. SSDI and SSI provide financial assistance

to disabled individuals, but do not provide medical insurance. Final determination of SSDI or SSI

is made by the SSA, not the treating provider. However, medical information is usually requested

from treating providers in order to make a determination of disability. An applicant must first

meet certain non-medical (eg, economic) criteria before medical factors are considered.

Question 8

1. A 22-year-old runner presents with acute onset of distal calf pain. She is diagnosed with Achilles

tendinitis and is referred to physical therapy. Which therapeutic modality is the LEAST

beneficial in treating an overuse injury of this sort?

(a) Therapeutic ultrasound
(b) Iontophoresis
(c) Ice massage
(d) Neuromuscular electrical stimulation

Answer 8

Answer :(d)

Commentary: With acute overuse injuries, modalities such as ultrasound, iontophoresis, and ice

massage may decrease pain and facilitate rehabilitation. Electrical stimulation with recruitment

of muscle fibers may be contraindicated in treating acute overuse injuries.

Question 9

6. 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 9

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.

Question 10

20. Of the following modalities, which is the most effective in treating phantom limb pain?
    (a) Iontophoresis
    (b) Transcutaneous electrical nerve stimulation
    (c) Short wave diathermy
    (d) Paraffin baths

Answer 10

Answer: (b)

Commentary: Of the options listed, transcutaneous electrical nerve stimulation (TENS) is the

modality that may be useful in treating phantom limb pain. Iontophoresis is generally used for

dispersion of medications. Short wave diathermy is a method of deep heat. Paraffin bath is a

superficial heat modality.

Question 11

23. Which muscle fiber types are recruited first in isometric contractions?
    (a) Type 1
    (b) Type 1b
    (c) Type 2
    (d) Type 2b

Answer 11

Answer: (a)

Commentary: Fatigue-resistant type 1 fibers are recruited initially followed by type 2b fibers.

There are no type 1b fibers.

Question 12

25. Which therapeutic application of functional electrical stimulation is NOT applicable in the

population with spinal cord injury?

(a) Lower limb exercise in cauda equina syndrome
(b) Ventilatory assistance in a C2 ASIA class A injury
(c) Achieving lateral or palmar prehension in a C6 ASIA class A injury
(d) Electroejaculation to harvest sperm for assisted reproduction techniques

Answer 12

Answer: (a)

Commentary: Functional electrical stimulation (FES) strategies use applied electrical current to

activate weak or denervated muscle. FES is most effective in upper motor neuron injuries with

preservation of the anterior horn cells and motor nerve roots. Because of the amount of charge

density required to directly depolarize muscle, FES is not effective if large quantities of

musculature are denervated. FES can be applied to the skin surface, or by means of implanted

electrodes. One application in the population with SCI is its use in conjunction with a bicycle

ergometer to improve cardiac capacity. Generally, individuals with cauda equina syndrome will

not be good candidates for FES-assisted cycling, due to the extent of denervation associated with

this injury level. Phrenic nerve and diaphragmatic pacing have been used to wean standard

ventilator dependence in individuals with high tetraplegia and preserved phrenic nerve function.

Implanted FES systems have been used to generate hand grasp and release, with or without

tendon transplantation. External hand/forearm orthoses have also been developed primarily for

therapeutic stimulation, with the hope of developing future neuroprostheses. Patients with intact

parasympathetic efferent innervation to the detrusor have improved control of micturition, albeit

with the need for sacral deafferentation, resulting in the loss of perineal sensation and reflex

erection. Electroejaculation using a rectal probe has been highly successful at producing seminal

emission for sperm harvesting for the purpose of assisted reproduction in individuals with SCI.

Question 13

102. Neuromuscular electrical stimulation to treat shoulder subluxation after stroke should be applied

to which muscles?

(a) Deltoid and supraspinatus
(b) Supraspinatus and infraspinatus
(c) Deltoid and trapezius
(d) Subscapularis and infraspinatus

Answer 13

Answer: (a)

Commentary: Neuromuscular electrical stimulation (NMES) to the deltoid (mainly posterior) and

the supraspinatus can decrease subluxation and reduce shoulder pain. It is required for several

hours daily over several weeks to achieve clinical benefits.

Question 14

104. When using ultrasound, the production in a sound field of gas bubblesthat grow and collapse

producing high temperatures and tissue damage is called

(a) standing waves.
(b) oscillatory movement.
(c) acoustic streaming.
(d) unstable cavitation.

Answer 14

Answer: (d)

Commentary: Unstable cavitation refers to bubbles that continue to grow in size and then

collapse. The high temperatures and pressures generated by this can produce platelet

aggregation, localize tissue damage and cause cell death. The physiologic effects of ultrasound

can be divided into thermal and nonthermal effects. Nonthermal effects include cavitation, media

motion (acoustic streaming, microstreaming) and standing waves.

Question 15

Physical medicine and rehabilitation. 3rd ed. Philadelphia: Saunders-Elsevier; 2007. p 466.

136. The bulk of personal long-term care for most older individuals in the United States is provided by
     (a) paid home health aides.
     (b) extended care facilities.
     (c) government agencies.
     (d) family members.

Answer 15

Answer: (d)

Commentary: In the United States, immediate and extended families provide the bulk (up to 90%)

of personalized long-term care for their elderly disabled relatives. This includes personal care,

nursing care, meals, housekeeping, transportation and shopping. Outside or alternative support

systems (friends and neighbors, government and agencies) supplement this care, and can become

increasingly important with advancing age.

Question 16

6. 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 16

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.

Question 17

7. 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 17

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.

Question 18

37. Compared to a younger individual, an older worker who suffers a musculoskeletal injury is more

likely to

(a) return to work sooner.
(b) have a recurrent injury.
(c) have the injury treated nonsurgically.
(d) sustain a less serious injury.

Answer 18

Answer: (b)

Commentary: Compared to a younger individual who suffers a musculoskeletal injury, an older

individual is more likely to have a recurrent injury, a decreased likelihood of returning to work

after the injury, increased time lost from the job as a result of the injury and a more serious injury.

Also, an older individual with a spine injury is more likely to have surgery than is a younger

individual.

Question 19

47. Which treatment is shown consistently to improve pain in patients with acute low back pain?
    (a) Superficial heat
    (b) Traction
    (c) Transcutaneous electrical nerve stimulation (TENS)
    (d) Ultrasonography

Answer 19

Answer: (a)

Commentary: Superficial heat is the only modality listed that has consistently decreased pain in

acute low back pain, which is pain that has been present for less than 4 weeks.

Question 20

56. 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 20

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.

Question 21

131. Which therapeutic modality delivers medication to the site of pathology by promoting the

movement of charged particles through the skin under an imposed electrical field?

(a) Phonophoresis
(b) Low energy laser
(c) Ultraviolet radiation
(d) Iontophoresis

Answer 21

Answer: (d)

Commentary: Iontophoresis is a physical medicine modality that delivers topical medicine, such

as corticosteroids, through the skin and into soft tissues. A current is created to direct a particular

solution away from the electrode and into the surrounding tissue. Phonophoresis utilizes

ultrasound rather than current to deliver the topical medication. Low energy laser and ultraviolet

radiation are not used to deliver topical medications.

Question 22

140. Which phenomenon is an effect of functional electrical stimulation (FES) as it pertains to gait?
     (a) Decrease in muscle spasticity
     (b) Increase in physiologic cost of gait
     (c) Decrease in voluntary muscle strength
     (d) Decrease in stride length

Answer 22

Answer: (a)

Commentary: In addition to a decrease in muscle spasticity, FES decreases the physiologic cost

of gait, increases voluntary muscle strength, and increases stride length.

Question 23

148. Which muscle fiber is characterized by slow-twitch oxidative metabolic properties?
     (a) Type 2a
     (b) Type 1
     (c) Type 2b
     (d) Type 3

Answer 23

Answer: (b)

Commentary: There are 2 primary muscle fiber types in humans. They are categorized according

to many different characteristics, including speed of contraction and sources of fuel. Type 1

muscle fibers are slow-twitch with oxidative metabolic pathways. Type 2 muscle fibers are fasttwitch

fibers. The type 2 fibers can then be further divided into fast-twitch glyclolytic, and fasttwitch

oxidative glycolytic.

Question 24

47. Which abbreviation or symbol is acceptable to use when writing prescriptions, according to The Joint Commission (JC)?
    (a) QD for once daily
    (b) U for units
    (c) ml for milliliters
    (d) cc for milliliters

Answer 24

Answer: C

Commentary: Of the options given the Joint Commission has only approved the use of the abbreviation ml for milliliters. Using the abbreviation QD can be dangerous since it may be mistaken for QID, which stands for four times per day.

Question 25

77. Which factor is associated with increased risk for occupational injury in an older individual?
    (a) White collar occupation
    (b) Female gender
    (c) Impaired hearing
    (d) Self employment

Answer 25

Answer: C

Commentary: Predictors of increased injury risk in an older worker include male gender, less education, obesity, alcohol abuse, disability, self report of impaired hearing or sight, and several specific job requirements. Service workers, mechanics, machine operators, and laborers are at increased risk for occupational injury compared to people in white collar occupations. Individuals who are self-employed have a lower risk of injury.

Question 26

127. Which structure is required by the American with Disabilities Act (ADA) to have adequate accessibility for individuals with disabilities, so long as the modifications to it are readily achievable?
     (a) House of worship
     (b) Physician’s office within a private residence
     (c) Commercial airplane
     (d) Residential private apartments

Answer 26

Answer: B

Commentary: If a publicly accessible office is present within a single family home, it is required to be accessible under the ADA, so long as the necessary modifications are readily achievable. Accessibility of commercial airplanes is covered under the Air Carrier Access Act, not the ADA.

Access to houses of worship or strictly residential private apartments is not required under the ADA.

Question 27

143. Which type of muscle contraction produces the greatest amount of force generation (torque)?
     (a) Fast concentric
     (b) Slow concentric
     (c) Isometric
     (d) Fast eccentric

Answer 27

Answer: D

Commentary: Muscle force generation varies depending on the type of muscle contraction and the speed of the contraction. Eccentric contractions produce greater torque than isometric contractions and isometric contractions produce greater force than concentric muscle contractions. As the speed of contraction increases, eccentric contractions produce greater force. The opposite is true for concentric contractions, which generate greater forces at slower speeds.

Question 28

156. Which type of cryotherapy uses conduction for energy transfer?
     (a) Cold packs
     (b) Fluidotherapy
     (c) Vapocoolant spray
     (d) Whirlpool baths

Answer 28

Answer: A

Commentary: Conduction is a process of transferring thermal energy between 2 entities placed in direct contact with each other, for example cold packs on skin. Convection is a process of using a medium to transfer energy: Examples of convection include the use of husks with fluidotherapy, and the use of water with whirlpool therapy. Vapocoolant sprays are an example of evaporation, not conduction.

Question 29

157. Disability as defined by the Americans with Disabilities Act (ADA) is
     (a) a physical or mental impairment that substantially limits 1 or more major life activities.
     (b) abnormality of the physiologic or anatomic structure or function.
     (c) the barriers society places on the individual interacting in his/her community.
     (d) a rating based on an independent medical examination.

Answer 29

Answer: A

Commentary: The Americans with Disabilities Act defines disability as a physical or mental impairment that substantially limits 1 or more of a person’s major life activities. The person has a record of such impairment, or is regarded as having such impairment. Impairment is the actual physiologic, anatomic, or psychologic abnormality. Handicap refers to the barriers society places on an individual to perform function in the community. A permanent disability rating is used to determine financial compensation for an injury.

Question 30

158. Palliative care is characterized by
     (a) a holistic approach to comprehensive symptom management.
     (b) symptom only management in persons with terminal illnesses.
     (c) disease modifying therapies.
     (d) care provided in the home setting only.

Answer 30

Answer: A

Commentary: Palliative care involves a holistic approach to comprehensive symptom management. This care has a potential role in the management of all disease states that feature an intense and adverse symptom complex. Palliative care typically does not include disease modifying therapies, although it can be provided in conjunction with these treatments. Palliative care can be provided in a variety of health care settings and is not limited to persons with terminal illnesses.

Question 31

159. In terms of continuous quality improvement, a sentinel event is defined as
     (a) a benchmark event that sets the standard for patient care.
     (b) an occurrence that requires dismissal of personnel.
     (c) a single occurrence that is highly problematic or socially unacceptable.
     (d) an event that results in the opening of a new hospital program.

Answer 31

Answer: C

Commentary: In terms of continuous quality improvement, a sentinel event is defined as a single occurrence that is highly problematic or socially unacceptable. Sentinel events will typically trigger an in-depth root cause analysis to determine the cause of the event as well as potential solutions. The focus of these investigations is to evaluate the processes and systems that are in place rather than to focus blame on individual practitioners.

Question 32

160. The validity of a functional outcome measurement tool is defined as the ability
     (a) of two different raters to obtain the same conclusion.
     (b) of the tool to measure what it is designed to measure.
     (c) to minimize random error.
     (d) to measure several different outcomes simultaneously

Answer 32

Answer: B

Commentary: The validity of a functional outcome measurement tool is defined as the ability of the tool to measure what it is designed to measure. The ability to measure different outcomes simultaneously does not impact the validity of the instrument, but the validity of the tool would need to be established for each of the outcomes being measured. The ability of two different raters to obtain the same conclusion is referred to as inter-rater reliability. Freedom from random error is also related to the reliability of the instrument.

Question 33

164. Which muscle fiber type uses only glycolytic metabolism for energy?
     (a) Type 1
     (b) Type 2a
     (c) Type 2b
     (d) Type 3

Answer 33

Answer: C

Commentary: There are 2 primary muscle fiber types in humans. They are categorized according to speed of contraction and sources of fuel. Type 1 muscle fibers are slow-twitch with oxidative metabolic pathways. Type 2 muscle fibers are fast-twitch fibers. The type 2 fibers can then be further divided into fast-twitch with both oxidative and glycolytic metabolism (type 2a) and fast-twitch glycolytic (type 2b).

Question 34

166. What is the most beneficial combination of weight and plane of orientation when ordering cervical traction to treat an acute cervical radiculopathy?
     (a) 15–25 pounds applied with neck in extension
     (b) 75–100 pounds applied with neck in flexion
     (c) 55–75 pounds applied with neck in neutral
     (d) 25–35 pounds applied with neck in flexion

Answer 34

Answer: D

Commentary: The weight for cervical traction is most beneficial at 25 to 35 pounds of force. Positioning the neck at 20o to30o of flexion provides the maximal effect of distraction between the vertebrae.

Question 35

168. Which attribute is a characteristic of an experimental research design?
     (a) Results primarily provide information on associations between variables.
     (b) Manipulation of experimental variables is controlled.
     (c) It is retrospective in nature.
     (d) It is an observation of the natural history of a disease process.

Answer 35

Answer: B

Commentary: Experimental research designs enable investigators to determine a cause and effect relationship between 2 variables; whereas, non-experimental research designs can only establish an association between 2 variables. In an experimental research design an intervention or experimental variable is manipulated and its effect on other variables is measured. Experimental designs are prospective in nature. Cohort studies, in which researchers observe the natural history of a disease process, are non-experimental.

Question 36

169. A research study is performed to assess the degree of spasticity experienced by individuals after traumatic brain injury. Spasticity in the gastrocnemius muscle is evaluated in 10 patients using the Modified Ashworth Scale (0–5 scale). Which descriptive statistic is appropriate for summarizing the ordinal data measured with this scale?
     (a) Ratio
     (b) Median
     (c) Correlation
     (d) Mean

Answer 36

Answer: B

Commentary: The appropriate descriptive statistical method used to summarize ordinal data such as the values used in the Modified Ashworth Scale is the median. The median value is defined as the value that occurs in the middle of a set of values. The mean would be used to summarize ratio or interval type of data. The other options listed are not descriptive statistical measures.

Question 37

170. Informed consent documents for participation in research protocols must include language stating
     (a) that confidentiality cannot be assured.
     (b) that once the document is signed, participation will be required.
     (c) the procedures to be used in the study.
     (d) that the results of the study will be shared with the subject.

Answer 37

Answer: C

Commentary: Informed consent documents for participation in research protocols must include the procedures to be used in the study. Informed consent documents must also assure confidentiality of the subjects and outcomes of individuals participating in the research. Informed consent documents must also state that subjects have the right to terminate involvement in the study at any time, even after they have signed the consent document. It must also state that the decision to terminate involvement in the study will not affect the individual’s ongoing medical care. Informed consent documents do not provide information that research results will be shared with the individual subjects.

Question 38

173. Which massage technique has as it goal the breakup of tissue and muscle adhesions?
     (a) Acupressure
     (b) Petrissage
     (c) Friction Massage
     (d) Effleurage

Answer 38

Answer: B

Commentary: Petrissage is a method of compression massage that is used to break up tissue and muscle adhesions. In effleurage massage the practitioner uses a stroking motion that is beneficial for vascular and lymphatic drainage. Friction massage is a method of massage that uses circular motions to small areas of tissue to help with tendonitis and fasciitis. Acupressure is a massage method in which pressure is applied on specific body points to help reduce pain.

Question 39

174. In contrast to cryotherapy, heat may
     (a) be used safely over insensate areas.
     (b) increase edema in the treated area.
     (c) be used over areas with decreased vascular supply.
     (d) decrease pain while cold will not.

Answer 39

Answer: B

Commentary: Cryotherapy and heating modalities share several therapeutic benefits and therapeutic contraindications. Both heat and cold modalities have some analgesic properties and can be used as adjuvant treatments for pain management. Neither cold nor heat modalities should be used over insensate areas or over areas with decreased vascular supply. Heat modalities may increase edema in the area treated, whereas cold therapy will not lead to increased edema.

Question 40

176. Ultrasound utilizes the physiologic mechanism of
     (a) conduction.
     (b) evaporation.
     (c) convection.
     (d) conversion.

Answer 40

Answer: D

Commentary: Conversion is a process of transforming energy to heat; for example, sound transformation with ultrasound. Conduction is a transfer of thermal energy through direct contact; for example, hot packs. Convection is a process of using a medium to transfer energy; for example, fluidotherapy. Evaporation is a process of transforming a liquid to a gas; for example, vapocoolant sprays.

Question 41

178. According to the American Medical Association Code of Ethics Opinion, which statement is TRUE?
     (a) Individual gifts of minimal value from pharmaceutical representatives to physicians are permissible so long as the gifts are related to the physician’s work.
     (b) It is acceptable for physicians to request free pharmaceuticals for personal use or use by family members.
     (c) Subsidies to underwrite the costs of continuing medical education are permissible when provided directly from the pharmaceutical company to the physician.
     (d) Faculty present

Answer 41

Answer: A

Commentary: According to the AMA Code of Ethics Opinion, individual gifts of minimal value from pharmaceutical representatives to physicians are permissible, so long as the gifts are related to the physician’s work. It is not acceptable for physicians to request free pharmaceuticals for personal use or use by family members. Subsidies to underwrite the costs of continuing medical education are permissible when they are accepted by the conference’s sponsor and are not provided directly to the physician. It is acceptable for faculty at conferences to accept reasonable honoraria and reimbursement for travel, lodging, and meal expenses.

Question 42

179. A clinical trial can best be defined as a
     (a) retrospective study examining the natural history of a disease process.
     (b) prospective study that is randomized and double-blinded.
     (c) retrospective study with subjects selected on the basis of presence or absence of an illness.
     (d) prospective study comparing the effect of an intervention with a control.

Answer 42

Answer: D

Commentary: A clinical trial can best be defined as a prospective study comparing the effect and value of an intervention with a control. A study measuring the natural history of a disease process is more observational in nature and can be either prospective or retrospective. Clinical trials are not necessarily randomized or double-blinded. Clinical trials are prospective and not retrospective in nature.

Question 43

180. Your inpatient rehabilitation unit participates in the Uniform Data System for Functional Independence Measures (UDS-FIM) program by submitting information on the outcomes of all patients treated at your facility. Your unit subsequently receives information back from the UDS-FIM database about how outcomes from your center compare to centers in your geographic region and centers across the nation. This process is referred to as
     (a) root-cause analysis.
     (b) benchmarking.
     (c) performance indicator identification.
     (d) peer performance evaluation.

Answer 43

Answer: B

Commentary: A benchmark is a target value or standard for comparison for a performance indicator. Functional outcomes and efficiency of functional improvement during inpatient rehabilitation admission are examples of performance indicators. The UDS-FIM database provides a means by which individual rehabilitation units can compare their outcomes to other centers across the nation. This process of comparing outcomes to a standard is referred to as benchmarking.

Question 44

184. A patient has been receiving ultrasound treatments for contractures of the gastrocnemius and soleus muscle. You become concerned about the adequacy of the treatment technique when the patient states that
     (a) he has the sensation of a transient deep, dull ache in the calf area during treatment.
     (b) the ultrasound application only lasts for 8 to 10 minutes.
     (c) the ultrasound application is followed by 10 minutes of rest prior to the stretching.
     (d) he is standing during and after the treatment

Answer 44

Answer: C

Commentary: The physician should be concerned if there is a time gap between the ultrasound application and the stretching activity. In order to be effective, the deep heating that is accomplished with the ultrasound application should be combined with a period of prolonged passive stretching, both during and immediately after the ultrasound application. This can be achieved by having the patient stand during the ultrasound application and after it. An appropriate treatment time with ultrasound is 8 to 12 minutes and the patient may experience a transient deep ache in the treatment application area.

Question 45

188. As the medical director of an inpatient rehabilitation program, you become concerned because you have recently noticed an increase in the number of urinary tract infections in the patients on your service. Which action would NOT be considered a reasonable initial management strategy in this scenario?
     (a) Discuss the issue with the Rehabilitation Center Quality Improvement Committee and examine the rate of urinary tract infections over the past year.
     (b) Perform a literature review examining the incidence and prevalence of urinary tract infections in an inpatient rehabilitation setting.
     (c) Immediately order that a urine culture be obtained on every patient at the time of admission to the rehabilitation service.
     (d) Provide an educational inservice to the nursing staff regarding catheter and bladder management.

Answer 45

Answer: C

Commentary: Continuous quality improvement should be a part of each physician’s clinical practice. All of the options listed would be appropriate to consider, with the exception of immediately ordering a urine culture on every patient at the time of admission to the rehabilitation service. This option would not be appropriate without gathering more information and understanding the implications of this intervention strategy.

Question 46

197. Which statement about the Functional Independence Measure (FIM) is TRUE?
     (a) The instrument is limited by its lack of evaluation of cognitive skills.
     (b) It is used by inpatient rehabilitation programs to compare the outcomes of their patients with regional and national outcomes.
     (c) It uses a 5-point scale to rate the amount of assistance that an individual requires in various functional areas.
     (d) It is routinely applied only at discharge from an inpatient rehabilitation facility.

Answer 46

Answer: B

Commentary: The Functional Independence Measure (FIM) is an outcomes measurement tool used by inpatient rehabilitation facilities across the country. It enables inpatient rehabilitation programs to compare their patients’ outcomes with regional and national outcomes. The FIM measures an individual’s functional abilities and level of assistance required in 18 separate functional areas, including cognition and communication. The FIM instrument uses a 7-point scale to rate the amount of assistance that an individual requires in each of these functional areas. The FIM can be completed at any frequency, but is typically completed at least at the time of admission and at the time of discharge from an inpatient rehabilitation facility.

Question 47

127. According to the Joint Commission on Accreditation of Hospital Organizations (JCAHO), what is the minimum number of patient identifiers needed before medications, blood products, or other treatments or procedures may be administered?
     (a) 1
     (b) 2
     (c) 3

Answer 47

(b) While more than 2 patient identifiers may be used, a minimum of 2 is required: first, a marker to identify the individual as the person for whom the service or treatment is intended; second, an identifier to match the service or treatment to that individual.

Question 48

137. According to the Joint Commission on Accreditation of Hospital Organizations (JCAHO) which abbreviation may be used when writing a prescription?
     (a) U for units
     (b) QD for once daily
     (c) 2 mg for 2 milligrams
     (d) MSO4 for morphine sulfate

Answer 48

(c)The only listed expression that may be written on a prescription is 2 mg for 2 milligrams. JCAHO expects that the other abbreviations will not be used in writing drug prescriptions, since they can lead to errors. Davis’ Medical Abbreviations cites U as “the most dangerous abbreviation” and says spell out “unit.” The expression QD is too easily read as 4 times daily. Regarding MSO4, Davis also calls this as “a dangerous abbreviation.”

Question 49

154. Which diagnosis is NOT an indication for transcutaneous electrical neurostimulation (TENS) therapy?
     (a) Chronic low back pain
     (b) Acute surgical pain
     (c) Urinary urgency
     (d) Angina

Answer 49

(d) TENS therapy has not been shown to provide benefit for angina. It has been proven to have a beneficial effect in all the other diagnoses.

Question 50

156. Cervical traction is a useful modality for patients with
     (a) cervical strain.
     (b) diskitis.
     (c) acute radiculopathy.
     (d) vertebral compression fracture.

Answer 50

(c) Cervical traction is proven effective for illnesses that involve nerve root irritation or compression of nerve roots.

Question 51

157. You see the significant other of a close friend in your office for knee pain. As part of her past medical history you note that she has a congenital heart defect. She says she has not yet told your friend that she has this condition. You decide to tell your friend about her congenital heart defect even though the patient did not give you permission to do so. What penalty do you face for knowingly disclosing individually identifiable health information, which is in violation of HIPAA rules?
     (a) $50,000 and up to 1year of imprisonment
     (b) No penalty
     (c) $250,000 and up to 10 years imprisonment
     (d) $100,000 and up to 5 years imprisonment

Answer 51

(a) A person who knowingly discloses individually identifiable health information in violation of HIPAA faces a fine of $50,000 and up to a 1-year imprisonment. The criminal penalties increase to $100,000 and up to 5 years imprisonment if the wrongful conduct involves false pretenses, and to $250,000 and up to 10 years imprisonment if the wrongful conduct involves the intent to sell, transfer, or use individually identifiable health information for commercial advantage, personal gain, or malicious harm.

Question 52

160. Informed consent requires that risks associated with participation in a study be described in terms of
     (a) type, severity, and probability.
     (b) probability alone.
     (c) physical, but not psychological, risks.
     (d) major, but not minor, risks.

Answer 52

(a) Informed consent for participation in a research study requires that the risks be described in terms of type, severity, and probability. It is important to describe risks in each of these areas in order to fully inform the patient of the potential risks associated with study participation.

Question 53

167. Under the Health Insurance Portability and Accountability Act (HIPAA) Protected Health Information is data that
     (a) a physician can withhold from a patient.
     (b) a patient’s job supervisor can obtain from a physician.
     (c) can be used to identify a patient.
     (d) can be shared with family without permission.

Answer 53

(c) Protected Health Information includes individually identifiable health information. This is information, including demographic data, that relates to any of the following particulars: the individual’s past, present or future physical or mental health or condition; the provision of health care to the individual; or the past, present, or future payment for the provision of health care to the individual. It can also be information that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual. Individually identifiable health information includes many common identifiers (e.g., name, address, birth date, Social Security Number).

Question 54

169. Relevant to investigational studies, the principle of justice requires that
     (a) harm be minimized and benefits maximized.
     (b) informed consent includes full disclosure of risks and benefits.
     (c) research subjects be treated fairly and selected equitably.
     (d) investigators respect the privacy of research subjects.

Answer 54

(c) The principle of justice requires subjects to be treated fairly and selected equitably. The principle of beneficence ensures that researchers minimize harm and maximize benefits associated with research involvement. The principle of autonomy ensures that informed consent includes full disclosure of risks and benefits and that the privacy of subjects is respected.

Question 55

170. Type 1 (alpha) error is best described as occurring in research when
     (a) the study finds a positive benefit from the intervention, but no benefit really exists.
     (b) the study finds no benefit from the intervention, but a benefit really exists.
     (c) study results are biased by subject selection criteria.
     (d) study results are not generalizable outside the research setting.

Answer 55

(a) Type 1 (alpha) error is best described as occurring in research when the study finds a positive benefit from the intervention, but no benefit really exists. In this case, the study conclusions would be falsely positive.

Question 56

174. What adaptations to strength training are seen in elderly persons engaged in a consistent exercise program?
     (a) Hypertrophy of muscle only.
     (b) Revascularization of the exercised muscle
     (c) Strength gains from Neural and learning factors only
     (d) Gains from both neural factors and hypertrophy

Answer 56

(d) Significant evidence exists to show that elderly persons benefit from strength training. In the past it was believed that adaptations were due to only neural factors. Recent evidence has shown that strength gains in elderly persons are attributable to both neural factors and muscle hypertrophy.

Question 57

176. Cervical and lumbar traction applied over a 20–60 minute time period is defined as
     (a) continuous.
     (b) sustained.
     (c) intermittent.
     (d) pulsed.

Answer 57

(b) Sustained traction is the use of force greater than that applied in continuous traction, but less than that used in intermittent traction, and the application time is 20–60 minutes. This time frame makes sustained traction more practical in clinical use. Continuous traction is the use of low force of traction over long periods of time, 20–40 hours. Intermittent traction is the use of greater forces, but for shorter periods of time, 10–60 seconds. There is no pulsed traction.

Question 58

178. You are conducting a research study, and you want to use Functional Independence Measure (FIM) scores as 1 of your outcome measures. Because FIM information is scored on a 1 to 7 scale to describe the level of assistance an individual requires to perform a functional task, these scores represent which category of research data?
     (a) Nominal
     (b) Ordinal
     (c) Ratio
     (d) Interval

Answer 58

(b) FIM scores would be classified as ordinal data, because in an ordinal scale consecutive values are rank-ordered, but not equally spaced. For example, although there is an order to the ranking in the FIM scale, the difference between a 2 and a 3 may not be equal to the difference between a 6 and a 7. Nominal data refers to data with discrete values (yes/no; alive/dead). With interval data, there are equal intervals between consecutive values. An example of interval data is temperature in degrees Fahrenheit. Ratio data are interval data with equal intervals between consecutive values, but with an absolute zero point.

Question 59

179. The process of developing and adopting quality standards for clinical practice
     (a) is dependent on providers being mandated for reporting data.
     (b) is ineffective in changing physician practice patterns.
     (c) allows health insurance providers to deny reimbursement for care.
     (d) helps to form expectations for safety among both providers and consumers.

Answer 59

(d) The process of developing and adopting quality standards for clinical practice helps to form expectations for safety among both providers and consumers.

Question 60

183. Vapocoolant spray produces its cooling effects through
     (a) conduction.
     (b) convection.
     (c) conversion.
     (d) evaporation.

Answer 60

(d) Evaporation is a process of transforming a liquid into a gas and requires thermal energy, as in vapocoolant spray. Convection is a process of using a medium to transport energy, for example husks during fluidotherapy and water during whirlpool therapy. Conduction is a process of transferring thermal energy to bodies that are in direct contact, for instance cold packs applied to skin. Conversion is a process of transforming energy into heat, as occurs with an ultrasound device.

Question 61

184. High frequency electrical stimulation predominantly stimulates which type of muscle fiber?
     (a) Type 1
     (b) Type 2
     (c) Type 3a
     (d) Type 3b

Answer 61

(b) Low frequency electrical stimulation predominantly stimulates type 1 muscle fibers. High frequency electrical stimulation predominantly stimulates Type 2 muscle fibers. There are no type 3 muscle fibers.

Question 62

186. In which modality do charged particles migrate across biological membranes under an imposed electrical field?
     (a) Iontophoresis
     (b) Phonophoresis
     (c) Ultrasound
     (d) Laser therapy

Answer 62

(a) Iontophoresis is the migration of charged particles across biological membranes under an imposed electrical field. Phonophoresis is the use of ultrasound to facilitate transdermal migration of topically administered medications. Ultrasound is a type of heating that occurs as a result of acoustic vibration. Laser therapy is light amplification by stimulated emission of radiation. It consists of a coherent, collimated beam of photons of identical frequency.

Question 63

188. The benefits of quality outcomes management include
     (a) providing guidance for alignment of the program with the needs of the patient.
     (b) improved insurance reimbursement from third party payors.
     (c) improved retention of staff.
     (d) reduced expenses independent of outcomes.

Answer 63

(a) The primary benefit of quality outcomes management is that it provides guidance for aligning the program with the needs of the patient. None of the other options are benefits of quality outcomes management.

Question 64

27. Under the prospective payment system for inpatient rehabilitation facilities, which item is used in assigning a patient to a case-mix group?
    (a) Mini Mental Status Examination
    (b) Disability Rating Scale
    (c) Previous hospitalization
    (d) FIM instrument motor score

Answer 64

(d) The prospective payment system for inpatient rehabilitation facilities requires that all patients admitted for inpatient rehabilitation be assigned to an impairment group code category. Payment to the rehabilitation facility is further determined by the patient’s subclassification into a case-mix group. The FIM instrument motor score is used to help determine the case-mix group designation under the prospective payment system for inpatient rehabilitation facilities. None of the other options listed are used in this process.

Question 65

37. The interdisciplinary approach to patient care emphasizes
    (a) common patient and team goals.
    (b) discipline-specific goals.
    (c) concentration on specific clinical problems.
    (d) treatment by multiple team members.

Answer 65

(a) The interdisciplinary approach to patient care emphasizes common patient and team goals rather than discipline-specific goals. The patient and family members should be included in the goal setting process. All team members must work in a collaborative way to facilitate achievement of goals. Team members must have an appreciation for all the issues that affect the patient rather than focusing on an isolated problem. Team communication is essential at all points in the rehabilitation process, not just when problems occur. Stewart DG, Phillips EM, Bodenheimer CF, Cifu DX. Geriatric Rehabilitation. 2. Physiatric approach to the older adult. Arch Phys Med Rehabil 2004; 85(Suppl 3):S7-11.

Question 66

57. A case manager comes to your office accompanying the injured worker you are managing. The front desk person asks if you will see the case manager with the patient. You respond that
    (a) case managers inhibit patient care and you don’t wish to speak with them.
    (b) as requested by the patient you will see the case manager following the interview and examination.
    (c) you will speak with the case manager after the patient signs a release of information.
    (d) the case manager should always be present at the time of the patient’s interview and examination despite the patient’s request to avoid the case manager.

Answer 66

(b) Case managers are shown to be beneficial liaisons between the physician and workers compensation carrier and their presence facilitates patient care. To be treated as a workers compensation case, the patient must give the carrier full access to his/her medical record. The employee treated under workers compensation cannot restrict the access of the case manager to the physician; however, discussions with the case manger should be done in the environment that the patient requests. Nadler SF, Stitik T, Malanga GA. Optimizing outcome in the injured worker with low back pain. Crit Rev Phys Med Rehabil Med 1999;11:139-69.

Question 67

67. The purpose of the Health Insurance Portability and Accountability Act (HIPAA) is to
    (a) ensure that a patient’s medical record is available to health care providers as directed by the patient.
    (b) allow qualified physicians access to the patient’s medical record.
    (c) allow a lawyer access to a medical record only if litigation is pending.
    (d) prohibit the release of confidential health information to insurance carriers.

Answer 67

(a) The purpose of the Health Insurance Portability and Accountability Act (HIPAA) is to ensure that a patient’s medical record remains private, but is available to health care providers as directed by the patient. A non-treating physician, lawyer, or insurance company may have access to the record with written authorization by the patient or guardian. There are no stipulations about a physician’s qualifications with regards to medical information access

Question 68

147. In order to appropriately follow Medicare regulations for teaching physicians, when caring for a patient with a resident physician, the attending physician must
     (a) review the chart and personally document his/her level of involvement in patient care, separate from documentation performed by the resident.
     (b) examine the patient with the resident and co-sign the resident note.
     (c) examine the patient and review the resident’s medical record documentation.
     (d) examine the patient, review the resident’s documentation, and personally document involvement in the history, exam, and medical decision-making.

Answer 68

(d) In order to appropriately follow Medicare regulations for teaching physicians, when caring for a patient with a resident physician, the attending physician must see the patient, review the medical record documentation of the resident, and personally document involvement in key aspects of the history, exam, and medical decision-making. Documentation from the resident alone does not confirm the level of attending physician involvement. The attending physician documentation combined with the resident documentation can be used to determine the level of care provided and the appropriate level of billing.

Question 69

154. Which muscle fiber is characterized by fast-twitch oxidative metabolic properties?
     (a) Type 1
     (b) Type 2a
     (c) Type 2b
     (d) Type 3

Answer 69

(b) Humans have 2 primary types of muscle fiber. They are divided according to many different characteristics, including speed of contraction and sources of fuel. Type 1 muscle fibers are slow-twitch with oxidative metabolic pathways. Type 2 muscle fibers are fast-twitch fibers. The type 2 fibers can then be further divided into fast-twitch oxidative (type 2a) and fast-twitch glyclolytic (type 2b).

Question 70

170. Which statement describes an advantage of a single-subject research design (that is, A-B-A or multiple baseline design)?
     (a) It can account for variability between subjects.
     (b) It permits medication trials with no washout period.
     (c) It can establish cause and effect relationships.
     (d) It is useful for interventions with prolonged or extended effects.

Answer 70

(c) An advantage of a single-subject research design (A-B-A design) is that this design can establish cause and effect relationships similar to other true experimental designs. Single subject research designs involve systematic, repeated measurement of a dependent variable over time through 1 or more baseline and intervention phases. The primary limitation with a single-subject research design is that it only establishes the cause and effect relationship for the subject involved in the study. Therefore, these results cannot be assumed to occur in others, because of the variability between subjects. Typically, a single subject research design requires a washout period between medication trials to ensure that the effects of the medication are no longer active. Single subject research designs are especially useful for interventions that do not have extended or prolonged effects. If the intervention has only short-term effects, then a difference in the outcome measured can be clearly demonstrated by comparing results when the intervention is in use against results obtained when it has been removed.

Question 71

73. Effects of prolonged bed rest include
    (a) increased maximum oxygen consumption.
    (b) increase of plasma volume.
    (c) decreased resting heart rate.
    (d) decreased cardiac stroke volume.

Answer 71

(d) Prolonged bed rest has detrimental effects, which include an increased resting heart rate, loss of plasma volume, decreased cardiac stroke volume, and decreased maximum oxygen consumption. Buschbacher RM, Porter CD. Deconditioning, conditioning, and the benefits of exercise.

Question 72

176. Performing a leg press exercise is an example of an
     (a) open kinetic chain exercise.
     (b) closed kinetic chain exercise.
     (c) isokinetic exercise.
     (d) isometric exercise.

Answer 72

(b) Open kinetic chain exercise occurs when the most distal segment is not in contact with a surface (eg, leg extensions). Closed kinetic chain exercise occurs when the most distal segment is in contact with a surface (eg, a leg press). In isokinetic exercise a muscle contracts with a constant angular velocity and variable resistance. In isometric exercise a muscle contracts against an immovable object and there is no joint angular movement. Young J, Olsen N, Press J. Musculoskeletal disorders of the lower limbs.

Question 73

178. Professionalism is the basis of medicine’s contract with society. Which item is a fundamental principle of medical professionalism?
     (a) Social justice
     (b) Physician paternalism
     (c) Patient disclosure
     (d) Free enterprise

Answer 73

(a) According to the Charter on Medical Professionalism, there are 3 fundamental principles of medical professionalism. They are (1) the primacy of patient welfare, (2) patient autonomy, and (3) social justice.

Question 74

179. Preventable medical errors are
     (a) rarely associated with significant morbidity.
     (b) most commonly a result of individual human error.
     (c) associated with no impact on patient satisfaction.
     (d) associated with patients’ loss of trust in the health care system.

Answer 74

(d) Preventable medical errors can result in lower levels of patient satisfaction and loss of trust in the health care system. Preventable medical errors often result in significant morbidity and even mortality. Estimates are that 44,000 to 98,000 people die each year as a result of medical errors that could have been prevented. These errors are frequently the result of system type errors rather than individual human error.

Question 75

180. Your co-resident presents an article in journal club on a new medication and its impact on outcomes following traumatic brain injury. On which point would you NOT need assurance before you decide to use this medication in your clinical practice?
     (a) That the research study results are clinically significant
     (b) That bias was eliminated from the study
     (c) That the research study results are statistically significant
     (d) That research investigators used valid outcome measures

Answer 75

(b) When critically evaluating the medical literature, it is important to consider if the results of the study are both clinically and statistically significant. It is also important to consider whether the outcome assessment tools have been validated for both accuracy and reliability. While biases that may impact the outcome of the study also must be considered, it is often impossible to completely eliminate bias from the study.

Question 76

183. A 70-year-old woman presents with a cemented right total hip arthroplasty. She is partial weight bearing and struggling with physical therapy. The therapist asks to use ultrasound to the right hip to help with bone healing and ultimately progress the patient to weight bearing as tolerated. You advise
     (a) yes, because ultrasound helps with bone healing.
     (b) no, because ultrasound near arthroplasties is contraindicated.
     (c) yes, because the heat may help with pain management.
     (d) no, because ultrasound is expensive to use.

Answer 76

(b) Ultrasound is typically an inexpensive treatment that may help with pain and bone maturation, however, it is contraindicated near arthroplasties and therefore not a good treatment in this case. Further contraindications include use of ultrasound: near pacemaker, near spine or laminectomy site, near brain, eyes, or reproductive organs, is someone with malignancy or skeletal immaturity, or near sites where methyl methacrylate was applied

Question 77

186. Which method of paraffin bath heats the subcutaneous area to a greater degree?
     (a) Dipping method
     (b) Continuous method
     (c) Wrap method
     (d) Paint on method

Answer 77

(b) Paraffin bath use has many methods. The dipping method increases subcutaneous temperatures by 3o Celsius, and the intra-articular temperature by 1o Celsius. The continuous method increases the subcutaneous temperature by 5o Celsius and the intramuscular area by 3º Celsius. The paint on method heats the subcutaneous area less than the dipping method. There is no formal wrap method. Basford JR. Therapeutic physical agents.

Question 78

188. Which statement accurately characterizes a meta-analysis?
     (a) It summarizes the results of randomized controlled trials.
     (b) It summarizes the findings of an expert panel.
     (c) It groups research on a particular topic area into 3 tiers.
     (d) It summarizes findings of a single research protocol that is carried out a multiple centers.

Answer 78

(A) meta-analysis summarizes the results of randomized controlled trials on a particular topic or research question. A consensus statement summarizes the findings of an expert panel. In developing a consensus statement and reviewing the literature, research studies are typically divided into 3 tiers based on the type of research performed. A multi-center study implements a particular research protocol at multiple centers at different institutions.

Question 79

190. Practice-based learning and improvement is considered by the Accreditation Council of Graduate Medical Education (ACGME) to be an aspect of medical practice in which all physicians need to achieve and maintain competency. Which characteristic is NOT a key aspect of practice-based learning and improvement?
     (a) The ability to locate, appraise, and assimilate evidence from scientific studies related to their clinical practice
     (b) The ability to access and use information technology to support their own education
     (c) The ability to apply knowledge of study designs and statistical methods to the appraisal of medical literature
     (d) The ability to advocate for quality patient care and assist patients in dealing with system complexities

Answer 79

(d) All of the options listed are key aspects of practice-based learning and improvement, with the exception of the ability to advocate for quality patient care and assist patients in dealing with system complexities. This statement is a key aspect of systems-based practice as defined by the Accreditation Council of Graduate Medical Education

Question 80

197. The Commission on Accreditation of Rehabilitation Facilities (CARF)
     (a) requires mandatory surveys of all inpatient rehabilitation facilities.
     (b) provides accreditation status that confers a preferred status with payors.
     (c) provides accreditation status that signifies the rehabilitation facility holds itself to the highest standards in the field.
     (d) provides accreditation for comprehensive inpatient rehabilitation programs, but not specialty programs in areas such as spinal cord injury.

Answer 80

(c) The Commission on Accreditation of Rehabilitation Facilities (CARF) provides accreditation status that signifies the rehabilitation facility holds itself to the highest standards in the field. CARF accreditation is voluntary and not all inpatient rehabilitation facilities participate. Accreditation by CARF does not confer any preferred status with payors, and CARF provides accreditation in general comprehensive inpatient rehabilitation as well as specialty programs such as spinal cord injury and traumatic brain injury

Question 81

199. Investigators must address ethical considerations when designing and implementing research studies. One such consideration requires investigators to design protocols that will provide generalizable knowledge and ensure that the benefits of the research are proportionate to the risks assumed by the subjects. This ethical consideration is referred to as
     (a) respect.
     (b) beneficence.
     (c) justice.
     (d) autonomy.

Answer 81

(b) Beneficence requires investigators to design protocols that will provide generalizable knowledge and ensure that the benefits of the research are proportionate to the risks assumed by the subjects.

Question 82

200. In instances where a researcher has financial investments in a company and is researching the effectiveness of one of the company’s products, the researcher is obligated to
     (a) terminate the investigation if the investigational agent is found to be not effective.
     (b) disclose this involvement in writing to subjects that are being enrolled in the study.
     (c) end financial involvement in the company before the results of the research are revealed to the public.
     (d) disclose this involvement to the investigator’s medical center, to funding organizations, and to journals publishing the results.

Answer 82

(d) Conflicts of interest in biomedical research are becoming more apparent as private companies increasingly develop relationships with academic research scientists. Avoidance of real or perceived conflicts of interest in clinical research is necessary if the medical community is to ensure objectivity and maintain individual and institutional integrity. Financial investments should only transpire outside of the time that the investigator is involved in any research activity and the results of the research are known to the public. If conflicts of interest exist, the investigator is obligated to disclose this involvement in writing to the investigator’s medical center, organizations funding the research, and anytime that the research is presented or published.

Question 83

11. The American College of Obstetrics and Gynecologists (ACOG) recommendation regarding exercise

during pregnancy is that

(a) exercise should be 85%–95% of maximum predicted heart rate.
(b) pregnant women may exercise to exhaustion.
(c) exercise should be done 6 days a week for at least 60 minutes daily.
(d) pregnant women should avoid resistive exercises in the supine position.

Answer 83

(d) Exercise should be at 60% to 85% of predicted maximum heart rate. Pregnant women should not

exercise to exhaustion. Exercise should be done 3 to 4 days a week for 30 to 45 minutes at a time.

Pregnant women should avoid exercise in the supine position because such a position may decrease

cardiac output, resulting in blood diverting from the splanchnic beds (including the uterus).

Question 84

37. Which statement is TRUE regarding the way the Centers for Medicare and Medicaid Services

currently reimburses inpatient rehabilitation facilities (IRFs) based on a prospective payment system

(PPS)?

(a) Reimbursement is determined according to the patient’s severity of disability and his/her

required use of resources.

(b) Assignment of patients to a specific rehabilitation impairment category (RIC) is based

primarily on their medical co-morbidities.

(c) Early transfer of patients from an IRF to a skilled nursing facility does not affect

reimbursement to the IRF.

(d) Assignment of patients to specific case-mix groups (CMGs) is determined by the rehabilitation

diagnosis and the patient’s premorbid functional status

Answer 84

(a) The Center for Medicare and Medicaid Services currently reimburses inpatient rehabilitation

facilities (IRF) based on a prospective payment system (PPS) according to the patient’s severity of

disability and his/her required use of resources. The rehabilitation impairment category is based on

the primary rehabilitation diagnosis, and the case-mix group is determined in part by the patient’s

co-morbid medical conditions. (a) Johnston MV, Eastwood E, Wilkerson DL, Anderson L, Alves A. Systematically assessing and

improving the quality and outcomes of medical rehabilitation programs.

Question 85

67. Medical error reporting systems are designed to
    (a) ensure that patients and families are notified when a medical error has occurred.
    (b) assist patients and families in reporting activities that they perceive as an error.
    (c) discipline staff who report that an error has occurred.
    (d) encourage staff to report errors without fear of punishment.

Answer 85

(d) Medical error reporting systems are designed to encourage staff to report sentinel events, adverse

events, and close calls without fear of punishment. If these issues are recognized, then further

review and action can be initiated. Review may include a root cause analysis to determine the

exact cause of the problem and strategies for prevention. When a medical error has occurred, staff

are encouraged to recognize the issue and report the issue immediately. Johnston MV, Eastwood E, Wilkerson DL, Anderson L, Alves A. Systematically assessing and improving

the quality and outcomes of medical rehabilitation programs

Question 86

107. You are admitting a 48-year-old woman to your rehabilitation unit following a subarachnoid
     hemorrhage. She is married and has 2 teenage children. She has severe memory and cognitive
     impairments. She is unable to provide consent. To whom can you legally give information

regarding the patient’s medical condition?

(a) Anyone authorized by the attending physician
(b) Anyone who identifies themselves as direct family members
(c) Anyone authorized by the patient’s husband
(d) Anyone who is available for caregiver training

Answer 86

(c) The husband is the patient’s legal next-of-kin. Because the patient is unable to provide consent for

medical decision making, the husband is the primary contact person and has the medical power of

attorney for medical decision making. The husband would have to consent to allow other

individuals to receive medical information regarding the patient. United States Department of Health and Human Services.

Question 87

. Which behavior would most likely be a warning sign of substance abuse in a resident colleague?

(a) Deterioration in personal hygiene
(b) Infrequent tardiness to scheduled lectures
(c) Excessive concern regarding patient well-being
(d) Frustration over evening admissions to the rehabilitation unit

Answer 87

(a) Deterioration in personal hygiene is the most likely warning sign of substance abuse in a resident
colleague. Other warning signs of impairment secondary to substance abuse include increased rates

of absenteeism, inability to meet deadlines, loss of concern about patient welfare, and wide

fluctuations in mood and performance.

Question 88

164. Which type of cryotherapy uses convection for energy transfer?
     (a) Cold packs
     (b) Vapocoolant spray
     (c) Cold water immersion
     (d) Whirlpool baths

Answer 88

(d) Convection is a process of using a medium to transport energy: husks, for example, with

fluidotherapy, and water with whirlpool therapy. Conduction is a process of transferring thermal

energy between 2 entities placed in direct contact with each other: cold packs on skin or,

vapocoolant spray on skin or cold water immersion of a limb.

Question 89

168. Which responsibility is NOT within the purview of an institutional research review board (IRB) as

they evaluate a given research study at their institution?

(a) Ensure that risks are minimized.
(b) Ensure that selection of subjects is equitable.
(c) Ensure that protections for privacy and confidentiality are in place.
(d) Ensure that research does not involve vulnerable subjects such as prisoners.

Answer 89

(d) Federal research regulations stipulate that each institutional research review board (IRB) is

responsible for approving all research studies at their particular institution. Before approving a

research protocol, the IRB must determine that risks are minimized, selection of subjects is

equitable, protections for privacy and confidentiality are in place, informed consent is appropriate

and will be documented in writing, and that the study has plans for data monitoring where

appropriate. Research may involve subjects who are considered vulnerable, such as prisioners, but

the research must add extra protections for these subjects.

Question 90

169. Which action is NOT required of a certified physiatrist to maintain certification?
     (a) Obtain continuing medical education credits.
     (b) Maintain active medical license.
     (c) Complete a recertification examination every 10 years.
     (d) Publish at least 1 article in a scientific journal every 10 years.

Answer 90

(d) Once a physician is certified by the American Board of Physical Medicine and Rehabilitation, he or

she must continue to fulfill certain requirements in order to maintain certification status.

Publication of an article in a peer-reviewed journal every 10 years is not a requirement for

maintenance of certification. All the other options listed are required.

Question 91

178. Decision-making capacity is a requirement for providing informed consent and participating in

treatment decisions. Of the abilities listed, which one is NOT considered central to an individual’s

decision-making capacity?

(a) Ability to express a choice, either verbally or nonverbally
(b) Ability to understand specific information related to treatment decisions
(c) Ability to seek advice from other health care providers
(d) Ability to appreciate of the significance of information as it applies to their condition

Answer 91

(c) Central to determining an individual’s decision-making capacity are the individual’s ability to

express a choice, his/her ability to understand specific information related to treatment decisions,

and his/her ability to appreciate the significance of information as it applies to their condition and

circumstances. The individual’s ability to seek advice from other health care providers is not a

central part of the individual’s decision-making capacity.

Question 92

179. As the medical director of an inpatient rehabilitation program, you become concerned because you

have recently noticed an increased number of urinary tract infections in the patients on your service.

Which action would NOT be considered a reasonable initial management strategy?

(a) Discuss the issue with the rehabilitation center’s Quality Improvement Committee and

examine the rate of urinary tract infections over the past year.

(b) Perform a literature review examining the incidence and prevalence of urinary tract infections

in an inpatient rehabilitation setting.

(c) Immediately order that a urine culture be obtained on every patient at the time of admission to

the rehabilitation service.

(d) Provide an educational inservice to the nursing staff regarding catheter and bladder

management.

Answer 92

(c) Continuous quality improvement should be a part of each physician’s clinical practice. All the

options listed would be appropriate to consider with the exception of immediately ordering a urine

culture on every patient at the time of admission to the rehabilitation service. This would not be an

appropriate option without gathering more information and understanding the implications of this

intervention strategy.

Question 93

180. The Commission on Accreditation of Rehabilitation Facilities (CARF) defines program evaluation as

a

(a) systematic procedure for measuring the outcomes of care.
(b) method for preventing medical complications.
(c) routine means of building team relations.
(d) procedure to develop new programs for rehabilitation.

Answer 93

(a) The Commission on Accreditation of Rehabilitation Facilities (CARF) defines program evaluation

as a systematic procedure for measuring the outcomes of care. Program evaluation is a way to

measure the effectiveness and efficiency of rehabilitation services. The other options listed are not

the primary focus of program evaluation.

Question 94

183. What heating modality uses high frequency acoustic energy to produce thermal and non-thermal

effects in tissue?

(a) Fluidotherapy
(b) Microwave
(c) Ultrasound
(d) Shortwave diathermy

Answer 94

(c) Ultrasound uses high frequency acoustic energy to produce its effects. Fluidotherapy is superficial

dry heat using convection with forced hot air and a bed of finely divided particles. Microwave heat

occurs when thermal energy is produced by increasing the kinetic energy of molecules within the

microwave field, thus using the mechanism of conversion. Short wave diathermy is the conversion

of electromagnetic energy into thermal energy when the osscillation of high frequency electrical

and magnetic fields produces molecular movement and heat

Question 95

186. Which type of massage uses a stroking technique characterized by gliding, light strokes that cover a

large area and generally go from distal to proximal?

(a) Friction
(b) Petrissage
(c) Tapotement
(d) Effleurage

Answer 95

(d) The type of massage described in the question is effleurage. The other options are different forms

of massage therapy techniques: (1) friction, pressure is applied with the ball of the practitioner’s

thumb or fingers to the patient’s skin or muscle; (2) petrissage, compressing the skin and soft tissue

between the fingers and thumb of one hand; and (3) tapotement, striking the soft tissue with

repetitive blows using both hands in a rhythmic manner

Question 96

189. You have just finished admitting a 60-year-old man with diabetes who has recently undergone a

right below-knee amputation. The patient’s son stops you in the hallway and inquires about his

father’s health status and prognosis for walking again. You have never met the patient’s son before,

and before answering the questions, you would first

(a) further review the patient’s medical record and determine the patient’s cardiac status.
(b) perform a literature review of outcomes research in individuals with below-the-knee
amputations.
(c) ask the patient for permission to discuss his health status with his son.
(d) ask the son if the patient has a living will or a health care power-of-attorney.

Answer 96

(c) Maintaining confidentiality of patient information is important even when discussing health

information with family members. Before discussing the patient’s health status with his son, the

appropriate first step would be to ask the patient for permission. The other options listed would not

be appropriate initial management strategies. United States Department of Health and Human Services

Question 97

190. In terms of continuous quality improvement, a sentinel event is defined as
     (a) a benchmark event that sets the standard for patient care.
     (b) an occurrence that requires dismissal of personnel.
     (c) a single occurrence that is highly problematic or socially unacceptable.
     (d) an event that results in the opening of a new hospital program.

Answer 97

(c) In terms of continuous quality improvement, a sentinel event is defined as a single occurrence that

is highly problematic or socially unacceptable. Sentinel events will typically trigger an in-depth

root cause analysis to determine the cause of the event as well as potential solutions. The focus of

these investigations is to evaluate the processes and systems that are in place, rather than to focus

blame on individual practitioners. Johnston MV, Maney M, Wilkerson DL. Systematically assuring and improving the quality and outcomes

of medical rehabilitation programs.

Question 98

197. What effect did the Omnibus Budget Reconciliation Act of 1993 (Stark II legislation) have on

medical practice?

(a) It made referrals to medical specialists more profitable for primary care physicians.
(b) It legalized referrals to a physician-owned physical therapy practice, so long as the physician

owns less than 50% of the practice.

(c) It made illegal physician self-referral to physical therapy, durable medical equipment

suppliers, and certain other entities owned by the physician except for certain safe harbors.

(d) It made illegal physician referral to another physician for specialty care, if the physicians are in

the same practice.

Answer 98

(c) The Omnibus Budget Reconciliation Act of 1993 (Stark II legislation) made physician self-referral

to physical therapy, durable medical equipment suppliers, and certain other entities owned by the

physician illegal, except for certain safe harbors. Gnatz SM. Administration and management in Physical Medicine and Rehabilitation.

Question 99

199. A clinical trial can best be defined as a
     (a) retrospective study examining the natural history of a disease process.
     (b) prospective study that is randomized and double-blinded.
     (c) retrospective study with subjects selected on the basis of presence or absence of an illness.
     (d) prospective study comparing the effect of an intervention with a control.

Answer 99

(d) A clinical trial can best be defined as a prospective study that compares the effect and value of an

intervention with a control. A study measuring the natural history of a disease process is more

observational in nature and can be either prospective or retrospective. Clinical trials are not

necessarily randomized or double-blinded. Clinical trials are prospective and not retrospective in

nature.

Question 100

200. You have been asked to evaluate a 60-year-old man who sustained a left internal capsule ischemic

stroke 3 days ago. He is currently hospitalized, and he has been deemed by his primary care

provider to be medically stable for transfer to an inpatient rehabilitation program. The patient has a

right hemiparesis and dysarthria. On your assessment, cognition appears intact. You agree that the

patient is an appropriate candidate for admission. You discuss the benefits of inpatient rehabilitation

with the patient and his family, but the patient elects to go home with home health services instead of

being admitted for inpatient rehabilitation. The ethical principle followed in abiding by the patient’s

wishes is the principle of

(a) beneficence.
(b) autonomy.
(c) paternalism.
(d) social justice.

Answer 100

(b) The ethical principle in this case, where the physician concedes to the patient’s desires and

decisions, is the principle of patient autonomy. The principle of beneficence refers to a moral

obligation to help other people and refrain from harming them, while the principle of autonomy

involves respect for the values and beliefs of other people. There is often tension between these 2

principles when patients refuse to accept information and advice from their health care providers.

With a paternalistic approach, the physician or other health care provider is the decision maker and

the patient takes on a more passive role of accepting the decision of the health care provider. Social

justice involves the provision, rationing, and distribution of health care resources.

Question 101

7. The purpose of the Health Insurance Portability and Accountability Act (HIPAA) is to
   (a) ensure that a patient’s medical record is available only to health care providers as directed by

the patient.

(b) make sure that only qualified physicians have access to a patient’s medical record.
(c) allow a lawyer access to a medical record only if litigation is pending.
(d) allow only the treating physician to know the patient’s diagnosis.

Answer 101

(a) The purpose of the Health Insurance Portability and Accountability Act (HIPAA) is to ensure that a

patient’s medical record remains private. A non-treating physician, lawyer, insurance company,

etc. can have access so long as the patient directs it, with written authorization. There are no

stipulations about a physician’s qualifications with regards to medical information access. Office for Civil Rights–HIPAA Privacy: incidental uses and disclosures.

Question 102

17. The Americans with Disabilities Act (ADA) was passed in order to
    (a) require employers to hire individuals with disabilities.
    (b) protect individuals with disabilities from having to work.
    (c) ensure that the pay of workers with disabilities is equal to that of nondisabled workers.
    (d) ensure that workers with disabilities have equal access in the work environment.

Answer 102

(d) The Americans with Disabilities Act (ADA) provides that workers with disabilities be offered equal

access in the work environment. The Act requires the employer to provide accessible environment

for the workers. Dimensions for doorways, hallways, ramps and elevator lifts are specified to allow

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wheelchair access. The ADA does not make stipulations with regards to pay, or that an employer is

forced to hire a disabled worker. The ADA does not make any determinations regarding a disabled

person’s ability to work.

Question 103

127. Studies have shown that case managers working with injured workers have
     (a) interfered with the physician’s recommendations.
     (b) made recommendations that favor the insurer.
     (c) reduced workers’ compensation costs and lost-time cases.
     (d) interfered in the relationship between physician and patient.

Answer 103

(c) Case managers reduce workers’ compensation costs by 23% and reduce the overall number of

lost-time cases. Overall case management can help improve the quality of care, reduce cost, and

decrease time loss in the worker’s compensation system. Studies show that case managers doe not

interfere with the physician-patient relationship or the physician’s recommendations, and do not

make proposals that favor the insurer. (a) Bernacki EJ, Tsai SP. Managed care for workers’ compensation: three years of experience in an

“employee choice” state.

Question 104

137. At the time of the initial evaluation of an injured worker, the physiatrist should
     (a) define the anticipated time frame that pain medications will be used.
     (b) ensure that the worker understands narcotic medications will be used if necessary up until

time to return to work.

(c) recommend that only non-narcotic pain medications will be used during rehabilitation.
(d) recommend patient-directed use of pain medications during rehabilitation and return to work.

Answer 104

(a) Narcotics and non-narcotic medications often may be necessary to manage pain in the injured
worker. It is important to set expectations of how these medications will be used. Expected length

of time of narcotic usage is especially important. The goal should be to return the worker to his/her

job without medication. Simply cutting off medications may be inappropriate. As pain improves,

and strength and function improve, medications should be tapered. (a) Foye PM, Stitik TP, Marquardt CA, Cianca JC, Prather H. Industrial medicine and acute

musculoskeletal rehabilitation.

Question 105

140. In order to obtain a semi-electric hospital bed for a patient who requires frequent changes in body

position, which Medicare guideline must be met?

(a) The patient requires a bed with side rails for positioning the body in ways not feasible with an

ordinary bed.

(b) The patient requires a heavy-duty bed due to morbid obesity, with body weight over 500 lbs.
(c) The caregiver requires a bed to be raised up to 48 inches to facilitate wound care.
(d) The patient requires traction equipment that can be attached only to a hospital bed.

Answer 105

(d) By Medicare guidelines, to obtain a semi-electric hospital bed for a patient the physician must

complete a certificate of medical necessity. Although a full electric bed used in most hospitals may

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be beneficial for many patients, Medicare guidelines consider the electric powered, variable height

feature a convenience and, therefore, Medicare will not cover a full electric bed. A semi-electric

hospital bed will be covered if the patient requires frequent changes in body position or has an

immediate need for change in body position along with at least 1 of the following conditions: (1)

The patient requires positioning of the body in ways not feasible with an ordinary bed. (2) For pain

relief, the patient requires positioning of the body in ways not feasible in an ordinary bed. (3)

Because of congestive heart failure, pulmonary disease, or aspiration, the patient requires the head

of the bed to be elevated more than 30° most of the time. (4) The patient requires traction

equipment that can only be attached to a hospital bed.

The standard hospital bed has many disadvantages. The beds have a 10-inch excursion from a low

of 24 inches to a high of 34 inches. Additionally, the standard hospital bed frame has a weight

limitation of around 500 pounds.

Question 106

160. Which statement is NOT TRUE about the practice of evidence-based medicine?
     (a) It incorporates the conscientious and explicit use of the current best evidence in making

treatment decisions.

(b) It includes use of the medical literature to develop strict standards of care for clinical practice.
(c) It integrates individual clinical expertise with the best available clinical evidence from

systematic research.

(d) It includes life-long, self-directed learning because caring for patients creates the need for

clinically important information.

Answer 106

(b) Evidence-based medicine does not include the development of strict standards of care for clinical
practice. Instead, evidence-based medicine emphasizes the conscientious and explicit use of the

current best evidence in making decisions about the care of individual patients. Integrating

individual clinical expertise with the best available clinical evidence from systematic research and

life-long, self-directed learning in which caring for patients creates the need for clinically important

information are also part of evidence-based medicin

Question 107

163. Which condition is a contraindication to high velocity low amplitude manipulation of the cervical

spine?

(a) Facet arthropathy
(b) Vertebral osteomyelitis
(c) Discogenic pain
(d) History of remote carotid endarterectomy

Answer 107

(b) When performing manual medicine, or when referring a patient to a physician for manual medicine,

one must be acutely aware of what contraindications apply to the individual one is treating. The

absolute contraindication to high velocity low amplitude among the options listed is osteomyelitis

Question 108

164. The maximum safe exposure of the skin to heated water is 45° Celsius for 30 minutes. Paraffin dipwrap

coats the skin with a mixture of mineral oil and paraffin at a temperature of 52° Celsius. Why

does the skin not get burned?

(a) Protective subcutaneous fat layer enhanced by mineral oil
(b) More rapid cutaneous vasodilation with paraffin
(c) Conversion of thermal energy to kinetic energy
(d) Paraffin’s lower thermal conductivity

Answer 108

(d) Paraffin has a lower thermal conductivity than water, which allows it to be placed on the skin at a

higher temperature without causing injury to the skin. The heat is more slowly transferred from the

paraffin to the skin, which provides for heating over a longer period of time.

Question 109

168. Federal research regulations stipulate that each institutional research review board (IRB) is

responsible for approving all research studies at their particular institution. What condition is the

IRB NOT specifically required to determine prior to approving a research protocol?

(a) That risks related to the research are minimized
(b) That selection of subjects is equitable
(c) That protections for privacy and confidentiality are in place
(d) That research does not involve vulnerable subjects such as prisoners

Answer 109

(d) Federal research regulations stipulate that each institutional research review board (IRB) is

responsible for approving all research studies at their particular institution. Before approving a

research protocol, the IRB must determine that risks are minimized, selection of subjects is

equitable, protections for privacy and confidentiality are in place, informed consent is appropriate

and will be documented in writing, and that the study has plans for data monitoring where

appropriate. Research may involve subjects who are considered vulnerable, such as prisoners, but

the research must add extra protections for these subjects.

Question 110

169. Once an individual becomes board-certified in the specialty of physical medicine and rehabilitation,

he/she must continue to fulfill certain requirements in order to maintain certification status. Which

action is NOT a requirement for maintenance of certification?

(a) Continuing medical education credits
(b) Maintenance of active medical licensure
(c) Completion of a recertification examination every 10 years
(d) Publication of at least 1 article in a scientific journal every 10 years

Answer 110

(d) Once an individual becomes board certified in the specialty of physical medicine and rehabilitation,

he/she must continue to fulfill certain requirements in order to maintain their certification status.

Publication of 1 article in a peer-reviewed journal every 10 years is not a requirement for

maintenance of certification. All of the other options listed are required.

Question 111

170. Which attribute is a characteristic of an experimental research design?
     (a) It allows one to determine a cause-and-effect relationship.
     (b) It permits no manipulation of experimental variables.
     (c) It is retrospective in nature.
     (d) It is an observation of the natural history of a disease process.

Answer 111

(a) Experimental research designs allow researchers to determine a cause-and-effect relationship

between 2 variables, whereas non-experimental research designs are only able to establish an

association between 2 variables. In experimental research an intervention or experimental variable

can be manipulated, and its effect on other variables can be measured. Experimental designs are

prospective in nature. Cohort studies that focus on observation of the natural history of a disease

process are non-experimental.

Question 112

173. Which is a site where ultrasound should be used with caution?
     (a) Lumbar laminectomy
     (b) Osteoporotic hip fracture
     (c) Lateral epicondyle
     (d) Patellar bursa

Answer 112

(a) Ultrasound should not be used near a pacemaker, near a spinal laminectomy site, near brain, eyes,

or reproductive organs, near a malignancy, in areas of skeletal immaturity, or ear arthroplasties,

especially in persons using methyl methacrylate

Question 113

178. One factor that is NOT pertinent to determining an individual’s decision-making capacity

concerning informed consent and participation in treatment decisions is the ability to

(a) express a choice, either verbally or nonverbally.
(b) understand specific information related to treatment decisions.
(c) seek advice from other health care providers.
(d) appreciate the significance of information as it applies to one’s condition.

Answer 113

(c) Decision-making capacity is a requirement for providing informed consent and having a patient

participates in treatment decisions. Central to determining an individual’s capacity for making

decisions is his/her ability to express a choice, ability to understand specific information related to

treatment decisions, and ability to appreciate the significance of information as it applies to his/her

condition and circumstances. The individual’s ability to seek advice from other health care

providers is not a central part of the individual’s decision-making capacity.

Question 114

180. The Commission on Accreditation of Rehabilitation Facilities (CARF) defines program evaluation

as a

(a) systematic procedure for measuring the outcomes of care.
(b) method of preventing medical complications.
(c) routine means of building team relations.
(d) procedure to develop new programs for rehabilitation.

Answer 114

(a) The Commission on Accreditation of Rehabilitation Facilities (CARF) defines program evaluation

as a systematic procedure for measuring the outcomes of care. Program evaluation is 1 method to

measure the effectiveness and efficiency of rehabilitation services. The other options listed are not

the primary focus of program evaluation.

Question 115

189. You have just finished admitting a 60-year-old diabetic man who has recently undergone a right

below-knee amputation. The patient’s son stops you in the hallway and inquires about his father’s

health status and prognosis for walking again. You have never met the patient’s son before, and

before answering the questions, you would first

(a) further review the patient’s medical record and determine his cardiac status.
(b) perform a literature review of outcomes research in individuals with below-knee amputations.
(c) ask the patient for permission to discuss his health status with his son.
(d) ask the son if the patient has a living will or a health care power-of-attorney.

Answer 115

(c) Maintaining confidentiality of patient information is important even when discussing health

information with family members. Before discussing the patient’s health status with his son, the

appropriate first step would be to ask the patient for permission. The other options listed would not

be appropriate initial management strategies.

Question 116

193. A 65-year-old woman with shoulder osteoarthritis asks how to use ice for her shoulder pain. For

how many minutes per session should she apply ice to her shoulder?

(a) 5–10
(b) 10–15
(c) 20–30
(d) 30–40

Answer 116

(c) The most effective use of ice for pain control in osteoarthritis is application of ice for 20- to 30-

minute periods. The ice should not touch the skin, but wrapped in a protective layer or towel to

prevent damage to the skin. It should rest over the joint and not be moved around. Frequency

should be on an as needed basis, but there should be at least a 30-minute break between sessions.

Question 117

196. Acupuncture is described as reducing pain through neuromodulation. Through what mechanism is

neuromodulation theorized to reduce pain?

(a) Stimulation of large sensory afferent fibers that suppress pain perception
(b) Release of local cytotoxins that induce inflammation
(c) Inhibition of sensory afferent fibers that transmit pain perceptions
(d) Central nervous system reorganization of the somatosensory cortex

Answer 117

(a) Acupuncture is considered to help reduce pain through neuromodulation. The 2 theories of

neuromodulation with acupuncture are (1) stimulation of large sensory afferent fibers suppress pain

perception through gate control and (2) the needle insertion may act as a noxious stimulus and

induce endogenous production of opiatelike substances

Question 118

200. You have been asked to evaluate a 60-year-old man who suffered a left internal capsule ischemic

stroke 3 days ago. He is currently hospitalized and he has been deemed by his primary care

provider to be medically stable for transfer to an inpatient rehabilitation program. The patient has a

right hemiparesis and dysarthria. On your assessment, cognition appears intact. You agree that the

patient is an appropriate candidate for admission. You discuss the benefits of inpatient

rehabilitation with the patient and his family, but the patient elects to go home with home health

services instead of being admitted for inpatient rehabilitation. The ethical principle followed in

abiding by the patient’s wishes is the principle of

(a) beneficence.
(b) autonomy.
(c) paternalism.
(d) social justice.

Answer 118

(b) The ethical principle demonstrated in this case in which the physician concedes to the patient’s

desires and decisions is the principle of patient autonomy. The principle of beneficence refers to a

moral obligation to help other people and to refrain from harming them. Inherent in the principle of

autonomy is respect for the values and beliefs of other people. There is often tension between these

2 principles when patients refuse to accept information and advice from their health care providers.

With a paternalistic approach, the physician or other health care provider is the decision maker and

the patient takes on a more passive role of accepting his/her decisions. Social justice refers to the

provision, rationing, and distribution of health care resources.

Question 119

36. The circulatory system’s response to exercise is characterized by
    (a) parasympathetically mediated vasoconstriction of the skin.
    (b) vasodilatation in active muscle groups mediated by local factors.
    (c) sympathetically mediated vasodilatation of viscera.
    (d) an increase in total peripheral vascular resistance.

Answer 119

(b) During vigorous exercise, sympathetically mediated vasoconstriction occurs in the skin and viscera.

Vasodilatation in active muscle groups is mediated by local factors including potassium ion

concentrations, increases in osmolarity, changes in adenosine nucleotide concentrations, and

decreasing pH. Muscle blood flow may increase up to 15-20 times baseline. The vasodilatation in

muscle groups causes a reduction in total peripheral resistance by up to 50%.

Question 120

SAER-2003

31. Which statement regarding cervical traction is correct?
    (a) The best angle of pull is between 10° and 20° of cervical extension.
    (b) Its use in patients with rheumatoid arthritis is absolutely contraindicated.
    (c) At least 25 pounds of force is necessary to counter the effects of gravity on the head.
    (d) With an over-the-door traction unit, the patient should face away from the door to which the

pulley is attached.

Answer 120

(b) Patients with rheumatoid arthritis have ligamentous instability. This can lead to subluxation of

cervical vertebrae, especially at the atlantoaxial joint (C1-2). Because instability can lead to spinal

cord compression, cervical traction is, therefore, absolutely contraindicated in persons with

rheumatoid arthritis. The best angle of pull is between 20° and 30° of flexion. The most common

reason for cervical traction to fail or to exacerbate symptoms is applying the force in extension

rather than in flexion. The home traction unit should always be placed so the patient is facing

toward the door to which the pulley is attached. At least 10 pounds of force is needed to counter the

effects of gravity on the head. To straighten the cervical lordotic curve requires 25 pounds of force.

Question 121

67. How does work conditioning differ from work hardening? Work conditioning is
    (a) a maintenance exercise program.
    (b) activities simulating the worker’s tasks.
    (c) training the worker for a specific job.
    (d) aerobic training that may not be job specific.

Answer 121

(b) A functional capacity evaluation (FCE) is an assessment of a worker’s ability to perform workrelated
activities. A functional capacity examination can be used to determine if a worker might

benefit from work hardening or work conditioning, to determine whether a worker can return to

his/her job, to determine if work restrictions are recommended or if job modifications are needed,

and to document the worker’s activity capability. No absolute time line exists. An FCE can be used

in the subacute, or maintenance phase of treatment. An FCE does not determine validity of injury

but can reveal the effort a person expends to perform a task

Question 122

117. Disablement as defined by the World Health Organization is
     (a) all the effects of the injury or illness, impairments, activity limitations and barriers to
     participation.
     (b) inability to advance in the work place due to physical disability or need for workplace
     adaptations.
     (c) recognition that the work injury was the cause of the disability as determined by civil
     litigation.

restrictions in the work site that requires the worker to use special aids.

Answer 122

(a) Disablement as defined by the World Health Organization is the term that summarizes all the

effects of the injury or illness, impairments, activity limitations, and barriers to participation

experienced by the individual. Workers receiving disability compensation have a disincentive to

return to work. Reforms have been made to allow workers to investigate their ability to return to

the work force without losing benefits. Disablement does not relate to advancement in the

workplace.

Question 123

123. An elderly person’s risk factors for falling include
     (a) advanced age.
     (b) living alone.
     (c) osteoarthritis.
     (d) polypharmacy.

Answer 123

(d) Risk factors for falling in the elderly include polypharmacy, particularly sedative use, cognitive

impairment, lower extremity disability, palmomental reflex, foot problems, peripheral neuropathy

and poor balance. DeLisa JA, Gans BM, editors

Question 124

137. On the stand in a civil litigation case, a physiatrist asked about an event causing an injury should
     (a) decline to answer when the worker has had no objective testing that proves a diagnosis.
     (b) answer probable if he/she believes there is more than a 50% chance the event caused the
     injury.
     (c) answer probable if he/she believes there is less than a 50% chance the event caused the injury.
     (d) decline to answer if he/she is not the treating physician.

Answer 124

(b) During civil litigation, the physiatrist may be asked to comment on causality of an injury. The

determination that 1 condition caused another condition should be determined on a “reasonable

degree of medical certainty.” In this setting “probable” indicates that the physician believes there is

a greater than 50% chance that condition A caused condition B. The term “possible” indicates that

the physician believes there is a less than 50% chance that 1 event caused another condition.

Question 125

151. The DeLorme axiom states that
     (a) low-weight high-repetition exercises build strength, and high-weight low-repetition exercises

build endurance.

(b) high-weight low-repetition exercises build strength, and low-weight high-repetition exercises

build endurance.

(c) low-weight low-repetition exercises build endurance, and high-weight high-repetition

exercises build strength.

(d) high-weight high-repetition exercises build endurance, and low-weight low-repetition

exercises build strength.

Answer 125

(b) The DeLorme axiom states that high-weight, low-repetition exercises build strength and lowweight,

high-repetition exercises build endurance. DeLateur BJ. Therapeutic exercise. In: Braddom RL, editor. Physical medicine and rehabilitation.

Question 126

171. Muscle energy technique is a manual medicine treatment that is used to
     (a) stabilize unstable segments in the spine.
     (b) strengthen painful muscles by isotonic contraction.
     (c) increase functional range of motion.
     (d) improve efficiency of muscular oxygen extraction.

Answer 126

(c) Muscle energy technique is used to increase mobility of a hypomobile segment, increase functional

range of motion, allow the return of symmetrical motion to affected segments, strengthen weakened

muscles, and lengthen contracted or spastic muscles. It uses isometric contractions, not isotonic

ones. It is not used for unstable segments, and does not improve proprioception or focus on

facilitating volitional activity.

Question 127

57. A 32-year-old welder suffered a brachial plexus injury falling off a scaffold. He is unable to use his

right upper extremity because of severe weakness. According to the World Health Organization

classification system, the patient’s weakness describes his

(a) injury.
(b) impairment.
(c) disability.
(d) handicap.

Answer 127

(b) Impairment is defined as an alteration of a person’s health status, a deviation from normal in a body

part or any organ system (any loss or abnormality of psychologic, physiologic, or anatomic

structure or function).

Question 128

141. Which of the following is correctly associated with its kinetic chain?
     (a) The hand during a biceps curl represents an open kinetic chain.
     (b) The foot during heel strike represents an open kinetic chain.
     (c) The hand waving is an example of a closed kinetic chain.
     (d) The foot during a squat represents an example of an open kinetic chain.

Answer 128

(a) An open kinetic chain occurs when the terminal segment is free to move. A closed kinetic chain

occurs when the terminal segment is fixed. The hand during a biceps curl is free to move and

represents an open kinetic chain.