SAER 2002 Flashcards
(120 cards)
1
Q
A 32-year-old male runner presents to your office with foot pain for the last 3 weeks. He reports
severe pain on the bottom of his foot, which is worse with the first few steps in the morning after
getting out of bed. He has no history of trauma and previously ran up to 12 miles daily. His running
has been severely limited since this pain began. What is the most likely diagnosis?
(a) Morton’s neuroma
(b) Plantar fasciitis
(c) Tarsal tunnel syndrome
(d) Stress fracture
A
(b) Plantar fasciitis is classically most painful upon arising first thing in the morning, and is aggravated
by overuse or change in footwear. An S1 radiculopathy often presents with numbness and tingling
and has associated reflex changes and possibly weakness in the plantar flexors. Tarsal tunnel
syndrome is caused by compression of the posterior tibial nerve inferior to the medial malleolus. A
Morton’s neuroma causes plantar pain in the forefoot and is aggravated by wearing tight, restrictive
shoes.
2
Q
A 67-year-old woman who had a left cortical stroke 12 months ago wishes to improve her arm and
hand function. She has good cognition. Sensation is only mildly decreased to light touch. Muscle
strength is shoulder flexion 4-/5, elbow flexion 3/5, elbow extension 3-/5, wrist extension 3-/5,
finger flexion 2/5, and finger extension 2-/5. Which technique is most likely to result in functional
improvement in this patient?
(a) Constraint-induced movement
(b) Proprioceptive neuromuscular facilitation
(c) Electromyographic biofeedback to wrist and arm extensors
(d) Electrical stimulation to finger flexors
A
(a) Constraint-induced movement is effective in persons more than a year after stroke if they have
preserved wrist extension and finger movement along with good sensation. Proprioceptive
neuromuscular facilitation is typically used during the acute phase of stroke and is not more
effective than other traditional treatments. EMG biofeedback has a mixed record but is probably a
good adjunctive treatment. Functional electrical stimulation appears to be useful in muscle
retraining but would probably not be applied to the finger flexors in this patient. No randomized,
controlled studies have compared these therapies for efficacy.
3
Q
Trials on the use of glucosamine and chondroitin for knee and hip osteoarthritis have shown that
these compounds
(a) reduced subchondral sclerosis, as evidenced by x-ray.
(b) decreased proteoglycan synthesis in articular cartilage.
(c) had a moderate effect on pain symptoms.
(d) had an immediate effect on symptom severity
A
(c) A meta-analysis of randomized controlled studies on the treatment of knee and hip osteoarthritis
with glucosamine and chondroitin found moderate effects on symptoms. These effects take a
minimum of 4 weeks. Glucosamine and chondroitin are capable of increasing proteoglycan
synthesis in articular cartilage.
4
Q
Which change is included in the revised edition of the American Spinal Injury Association (ASIA)
Impairment Scale, published in the year 2000?
(a) The zone of partial preservation (ZPP) is defined as the most rostral segment with sensory
function.
(b) The Functional Independence Measure (FIM) has been added to the standards.
(c) The definition of a motor incomplete injury requires some motor function more than 3 levels
below the motor level.
(d) The sensory exam now includes a 5-point scale to include sharp and dull sensations,
proprioception, and vibration.
A
(c) The 2000 revisions have clarified a few issues from the previous standards. For a person to receive
a classification of motor incomplete spinal cord injury (ASIA C or ASIA D) they must have either
1) voluntary anal sphincter contraction or 2) sacral sensory sparing with sparing of motor function
more than 3 levels below the motor level. Previously, the person needed only to have sparing more
than 2 levels below the motor level. The FIM was eliminated from the standards. The ZPP is to be
documented as the most caudal segment with some sensory and/or motor function. There has been
no change in the 3-point (0-2) scale for the sensory exam.
5
Q
A 65-year-old brain tumor patient receiving inpatient rehabilitation develops nausea, fever, and
headache several hours after radiation therapy. You prescribe
(a) ceftriaxone.
(b) dexamethasone.
(c) nimodipine.
(d) sumatriptan.
A
(b) Radiation reactions may occur at any time during or after radiation therapy. Acute reactions that
occur within hours after the first dose are caused by edema, and manifested by headache, nausea,
vomiting, somnolence and fever. Worsening neurological symptoms may occur with dose fractions
greater than 2 Gray. Symptoms are preventable through use of corticosteroids, eg, dexamethasone 2
mg daily or twice daily.
6
Q
Which group would NOT be included on a list of occupations with the largest incidences of low
back injuries that receive workman’s compensation?
(a) Truck drivers
(b) House painters
(c) Machine operators
(d) Nurses
A
(b) Alhough, house painters may be at risk for injury, machine operators, truck drivers, and nurses have
the greatest incidence in compensated low back pain injuries.
7
Q
Which hypothesis does NOT explain a normal electromyograph (EMG) in a patient who has a lumbar radiculopathy? (a) Involvement of only the sensory root (b) Limited sampling of muscles (c) Oxycodone taken prior to the study (d) Timing of the study
A
(c) Pain medication has no effect on EMG findings. All the other choices can be an explanation for a
normal EMG in a patient who has a lumbar radiculopathy.
8
Q
Which reflex is typically NOT seen in a normal 4-month-old infant?
(a) Extremities extend on the face side as the head is turned to the side.
(b) Fingers flex when the palm is touched.
(c) Extremities extend to the direction of displacement when center of gravity is displaced.
(d) Shoulder abduction, and shoulder, elbow, and finger extension occur when the neck is
suddenly extended.
A
(c) These options all describe reflexes. (a) asymmetric tonic neck reflex, (b) palmar grasp, and (d)
Moroare seen until a baby is about 6 months old. Protective extension or parachute reaction (c)
does not appear until after 6 months.
9
Q
A 38-year-old drywall hanger presents with shoulder pain after falling onto the tip of his shoulder.
He felt immediate pain in the upper part of his shoulder, but no numbness or tingling in his arm. On
examination, he has a visible deformity on the superior aspect of his shoulder. He has pain with
horizontal adduction of his left arm across his chest and is having difficulty lifting his arm. His
passive range of motion is good. The best treatment for this patient would involve
(a) use of an arm sling for at least 4 weeks.
(b) referral to an orthopedic surgeon for surgical repair.
(c) physical therapy for Codman exercises.
(d) corticosteroid injection after 10 days.
A
(b) This patient has a grade 3 acromioclavicular separation. Grade 1 or 2 separations would not have a
visible deformity and would require weighted bilateral shoulder films. A grade 3 separation may
have good results with conservative care, but a young manual laborer should be referred for
surgical repair to ensure good results. Grade 4-6 separations should be surgically repaired. Patients
should only be placed in a sling for a few days until the pain subsides. This will decrease the
possibility of losing shoulder range of motion. The shoulder should be given a few days rest, and
physical therapy referral is not appropriate at this time. A corticosteroid injection is not the
treatment of choice and will not repair the separation.
10
Q
Which factor is a prime determinant of successful return to work after traumatic brain injury?
(a) Presence of associated musculoskeletal injuries
(b) Glasgow Coma Scale score at 48 hours post injury
(c) Presence of post-injury depression
(d) Pre-injury occupation type
A
(b) There are several determinants to successful return to work for persons with traumatic brain
injuries. All studies have identified the severity of head injury as a primary factor in return to work;
the Glasgow Coma Scale is one of the robust measures of injury severity. Other factors include
preinjury work history, age, cognitive abilities, or motor limitations.
11
Q
A 70-year-old woman complains of acute localized mid back pain. She has a non-focal neurologic
examination. An anteroposterior and lateral thoracic spine x-ray confirms your clinical suspicion of
an acute T8 compression fracture. Which recommendation would best help her to reduce her risk of
future fractures?
(a) Swimming laps 20-30 minutes daily
(b) Isotonic abdominal strengthening program
(c) A weight reduction diet
(d) Avoidance of tobacco use
A
(d) The National Osteoporosis Foundation (NOF) established guidelines to reduce risk of osteoporotic
fractures. These recommendations include, participating in weight bearing exercise, ingesting
adequate calcium (1200mg/day) and vitamin D (400-800IU), and avoiding tobacco use.
12
Q
A 57-year-old woman complains of the onset of tingling in her feet about 2 weeks ago. She now has
muscle weakness of both legs and weakness in her handgrip. She is complaining of pain in the back
of both thighs. On examination, she is noted to have mild weakness of the orbicularis oculi
bilaterally, intact extraocular muscle movements, intact peripheral sensation, decreased grip strength
and lower limb strength measured at 3-/5. Biceps reflexes are present at 1+ and other reflexes are
absent. Immediate management measures would include
(a) oral multivitamins and folate.
(b) twice daily vital capacity testing.
(c) intrathecal steroid injection.
(d) serial erythrocyte sedimentation rates.
A
(b) This patient is most likely to have acute inflammatory demyelinating polyneuropathy of Guillain-
Barré syndrome. This syndrome presents with ascending symmetrical weakness, generally has mild
sensory involvement although pain complaints are prominent, and commonly spares extraocular
movements despite involvement of other cranial nerves. Management would include careful
monitoring of vital capacity, since respiratory muscle weakness could result in the need for
ventilation. Steroids by any route of administration have not been shown to be effective.
13
Q
For persons with spinal cord injury who survive the first 24 hours, what is the leading cause of death the first year post-injury? (a) Pulmonary embolism (b) Pneumonia (c) Renal insufficiency (d) Nonischemic heart disease
A
(b) The leading cause of death for persons with spinal cord injury who survive more than 24 hours is
pulmonary dysfunction (pneumonia, adult respiratory distress syndrome) followed by nonischemic
heart disease, septicemia and pulmonary embolus.
14
Q
Workers who participate in a cardiovascular training program have been found to
(a) communicate with their supervisors better.
(b) be more efficient.
(c) have better job performance evaluations.
(d) report fewer sick days.
A
(d) Workers who participated in a cardiovascular training program were compared to a control group.
Those in the training program reported 51% fewer sick days than controls despite no change in their
maximum oxygen consumption (VO2max).
15
Q
An otherwise healthy elderly woman with history of osteoporosis presents with the acute onset of
focal thoracic spine pain. Your management program should include
(a) William’s flexion exercises.
(b) epidural steroid injections.
(c) spinal extension brace.
(d) steroid iontophoresis.
A
(c) Spinal flexion will increase pain related to vertebral compression fractures. An extension brace will
promote a position of comfort during the healing process. These braces may include a Jewett brace,
cruciform anterior spinal hyperextension brace, and a chairback or warm and form brace.
16
Q
What is a common musculoskeletal complication of acute inflammatory demyelinating polyneuropathy? (a) Joint capsule contractures (b) Lumbar scoliosis (c) Achilles tendinitis (d) Two-joint muscle contractures
A
(d) Patients with acute inflammatory demyelinating polyneuropathy (AIDP) commonly develop painful
tightness in the two-joint muscles, including the hamstrings, tensor fascia lata, and gastrocnemius.
Actual joint capsule contracture is much less common. The vast majority of persons with AIDP
significantly improve and are unlikely to develop scoliosis as a result of muscle weakness. Tendon
inflammation is not a feature of AIDP.
17
Q
In the emotional stages of recovery from spinal cord injury, most individuals
(a) have prolonged feelings of guilt or worthlessness.
(b) undergo a true depressive episode.
(c) experience bereavement.
(d) feel diminished interest or pleasure in almost all activities.
A
(c) Although the pattern of emotional reaction is unique to every person, coping with a spinal cord
injury normally involves sadness, yearning, and intense feelings of loss. While bereavement might
appear similar to depression, it does not ordinarily involve prolonged feelings of guilt,
worthlessness, self-reproach or thoughts of death as seen in depressive disorders. Because grieving
or bereavement is universal in the context of spinal cord injury, it is important to differentiate
bereavement from a depressive disorder.
18
Q
A radical neck dissection for head and neck cancer, by definition, involves sacrifice of which nerve?
(a) Glossopharyngeal
(b) Hypoglossal
(c) Spinal accessory
(d) Auriculotemporal
A
(c) The external jugular vein, spinal accessory nerve, and sternocleidomastoid muscle are removed
during a radical neck dissection. Loss of the spinal accessory nerve leads to shoulder dysfunction
with long-term adverse functional sequelae.
19
Q
A 42-year-old jackhammer operator presents with low back and left posterior-lateral thigh pain and
numbness that began at the end of his shift 1 week ago. He has been unable to return to his job since
the onset of pain. His physical examination reveals normal reflexes, strength, and sensory function
upon examination of both lower extremities. His pain is reproduced with forward flexion of the
lumbar spine and left straight leg raise. Your recommendations include
(a) ice, muscle relaxants, x-rays, 10 days of bedrest.
(b) nonsteroidal anti-inflammatory drugs, muscle relaxants, lumbar corset, return to work.
(c) nonsteroidal anti-inflammatory drugs, education in positions of comfort, physical therapy.
(d) narcotic pain medications, lumbar corset, lumbar discography.
A
(c) Nonsteroidal medications, education in lumbar positions of comfort, and physical therapy constitute
the standard of care in conservative management of lumbar radiculopathy. Ten days of bedrest is no
longer recommended, since the effects of immobilization can further impair recovery. Limited or
relative rest can help relieve repetitive trauma while acute pain management interventions are
underway. A lumbar corset may help with pain in the first few days but immediate return to work
while relying on a lumbar corset does aid in recovery. Jackhammer operators are exposed to a great
deal of vibration, which increases an individual’s risk of disc injury. When a disc injury is
suspected in this population, return to a modified work description avoiding lifting, bending,
twisting, and vibration should be recommended. Lumbar discography should be reserved for
individuals who have exhausted conservative management and are contemplating a spine
procedure.
20
Q
A 27-year-old previously healthy woman awoke with severe right scapular and shoulder pain 4
weeks ago. There is no history of trauma. She has no constitutional symptoms. Three weeks ago,
her pain began resolving and scapular winging developed. Electromyography (EMG) reveals 3+
positive waves and fibrillations with markedly decreased recruitment in the right serratus anterior.
EMG of the right deltoid, biceps, pronator teres, abductor pollicis brevis, first dorsal interosseous,
and cervical paraspinals is normal, as is EMG of the left serratus anterior. The most likely
diagnosis is
(a) systemic lupus erythematosus.
(b) compression neuropathy of the dorsal scapular nerve.
(c) idiopathic brachial neuropathy (neuralgic amyotrophy).
(d) C5 radiculopathy due to cervical disc herniation.
A
(c) This is a classic history for neuralgic amyotrophy or idiopathic brachial plexopathy involving the
long thoracic nerve. In 30% of patients with neuralgic amyotrophy, EMG abnormalities can be
found in the asymptomatic upper extremity; however, the absence of such findings does not
obviously exclude the diagnosis. The findings are inconsistent with the other diagnoses.
21
Q
Which statement is true regarding spinal cord injury without obvious radiologic abnormality in
children?
(a) It most commonly occurs in lumbar rather than cervical injuries.
(b) There is a lower incidence in younger children.
(c) It is associated with larger head size and relatively weak neck muscles.
(d) Neurologic impairmen, if it occurs, is usually apparent within 2 to 4 hours post-injury.
A
(c) Spinal cord injury without obvious radiologic abnormality (SCIWORA) usually occurs in young
children, is thought to be due to the relatively large head size and weak neck muscles, and motor
abnormalities may not be apparent for up to several days. SCIWORA most commonly occurs in
the cervical region.
22
Q
Lumbar spondylolisthesis is the term for slippage of one vertebral body on the adjacent body
below. All of the following statements are true EXCEPT
(a) It is graded 0-4, by the percentage of slippage of the superior body on the inferior one.
(b) It is caused by a fracture or defect in the pars interarticularis.
(c) A TLSO brace is the best method to stabilize an unstable spondylolisthesis.
(d) A spondylolisthesis may cause neurologic compromise of the cauda equina.
A
(c) Spondylolisthesis in the lumbar spine is a common finding, occurring 70% of the time at L5-S1 and
25% at L4-5. It is caused by a defect or fracture in the pars interarticularis and is graded 0-4 on the
basis of the amount of slippage of one body on the other. It may indeed lead to spinal stenosis and
compromise of the cauda equina. A spinal orthosis will not be effective in stabilizing this defect but
can be useful in reducing lumbar lordosis, decreasing pain, and reducing gravitational forces on the
slippage.
23
Q
A 45-year-old woman with multiple sclerosis reports that her fatigue is interfering with the
activities of daily living. You prescribe an energy conservation program and
(a) amantadine (Symmetrel).
(b) valproic acid (Depakote).
(c) beta-interferon (Avonex).
(d) adrenocorticotropic hormone (ACTH).
A
(a) Fatigue is a common, limiting symptom in patients with multiple sclerosis. Behavioral techniques
such as energy conservation and well-planned rest periods are often required. Amantadine is
traditionally the first choice; however, pemoline may provide relief. Beta-interferon and ACTH are
more disease-modifying agents used during periods of acute exacerbation.
24
Q
On the 4th day after revision of his left total hip arthroplasty with an anterior approach, your patient
complains of pain in the left thigh after bridging in bed for the bedpan. You notice that his left leg is
externally rotated and appears shorter than his right. The LEAST likely factor contributing to your
patient’s predicament is
(a) a surgically malpositioned implant.
(b) aseptic loosening of the implant.
(c) inadherence to precautions.
(d) profound soft tissue weakness.
A
(b) Aseptic loosening is seen 10 years after implant of prosthesis, the other choices are common
etiologies for dislocations during the first few weeks after implant.
25
A nonambulatory 15-year-old boy with spinal muscular atrophy is requesting a new power
wheelchair after a growth spurt. An important feature of the wheelchair prescription will be
(a) a solid seat with foam padding.
(b) extra room at each side to allow for growth.
(c) seat back below the scapular ridge.
(d) back-slanted seat with pommel.
(a) Because of growth and increasing weakness, a common sequela of motor neuron disease is
scoliosis. It is important to provide adequate pelvic support with a firm seat to avoid hip
asymmetry. If wheelchairs are too big, asymmetric spinal posture is encouraged. Slanted seats with
pommels are useful to control extensor spasticity, which should not be an issue here. Seat backs
should be high to help control spinal posture.
26
You are called to the bedside of an individual with a T3 spinal cord injury sustained 7 ½ weeks
earlier. The person complains of pounding headache and appears to have piloerection on the upper
extremities, neck, and face, as well as flushing. Blood pressure is 150/90. The first thing you do is
(a) instill a topical anesthetic into the rectum in order to decrease sensation for a rectal check.
(b) apply 1 inch of topical nitropaste above the level of injury.
(c) irrigate the indwelling urinary catheter with a small amount of normal saline.
(d) sit the person up and loosen any clothing.
(d) This individual is experiencing autonomic dysreflexia, seen typically in individuals with spinal cord
injury with lesions at or above T6. A treatment algorithm that outlines the timing of treatment
recommendations was established by the consortium for spinal cord medicine in 1997. When an
individual presents with autonomic dysreflexic symptoms including elevated blood pressure
(systolic blood pressure greater than 150mm Hg), the very first thing to do is to sit the patient up
with his/her clothing and constrictive devices loosened. If the blood pressure remains elevated and
the individual has an indwelling catheter, kinks and twists should be removed. If there is no urine
flow, the catheter then needs to be irrigated. If the individual does not have an indwelling catheter,
a Foley catheter must be inserted and again if there is no urine flow, it should be irrigated. If there
is good urine flow and/or the blood pressure drops down to normal, then the work-up as well as
other interventions would cease. If the blood pressure remains elevated after irrigation or initiation
of catheter, and the systolic blood pressure remains above 150mm Hg, a short-acting
antihypertensive medication such as topical nitropaste is initiated. After this, if the individual
continues to be hypertensive, he/she may have to be admitted to a hospital to control blood
pressure. If, after the short-acting antihypertensive, the blood pressure drops, evaluation of the
rectum for fecal impaction begins, including installation of lidocaine into the rectum and allowing it
to sit for approximately 5 minutes to decrease sensation before probing the rectum with a gloved
finger and subsequently attempting to disimpact.
27
The generation of speech following a tracheoesophageal puncture procedure requires
(a) use of an electrolarynx.
(b) swallow prior to vocalization.
(c) manual tracheostomy occlusion.
(d) insertion of a one way valve
(c) The generation of speech following trachealesophageal puncture requires that air flow be directed
from the trachea into the esophagus and through the oropharyngeal cavity. This can only be
achieved if the patient’s tracheostomy site is manually occluded, usually with a digit.
28
A 37-year-old male pipefitter has completed physical therapy you prescribed for a C6 radiculopathy.
He no longer requires pain medication and is independent in his home exercise program. He
complains of some pain and fatigue during physical therapy. His neurologic and strength
examination is normal. Your next recommendation is
(a) a functional capacity evaluation.
(b) return to work without restrictions.
(c) vocational rehabilitation.
(d) exercise program with weights at home.
(a) A functional capacity evaluation (FCE) is a comprehensive test with some objective data that tests a
person’s ability to perform work-related tasks. An FCE helps determine what the worker can do at
work on a safe and dependable basis. Testing is usually performed work after the initial
rehabilitation program has been completed.
29
A 47-year-old soldier presents with left finger extensor weakness after repetitive wrist extension
exercises at the gym. Motor nerve conduction studies were as follows:
Extensor Indicis
Nerve Stimulation Site Amplitude(mV) Conduction Velocity (m/s)
L. Radial mid-forearm 6.0
L. Radial elbow 2.0 60
L. Radial spiral groove 2.0 65
R. Radial elbow 5.8
This patient has
(a) radial neuropathy just distal to the spiral groove with axonotmesis.
(b) radial neuropathy just distal to the spiral groove with neurapraxia.
(c) posterior interosseous neuropathy with axonotmesis.
(d) posterior interosseous neuropathy with neurapraxia
(d) There is conduction block across the mid-forearm consistent with a posterior interosseous
neuropathy with neurapraxia
30
A 3-year-old child has a high thoracic spinal cord injury. When he reaches the age 10 years, which
complication is the child most likely to have?
(a) Isolated lumbar lordosis
(b) Thoracolumbar scoliosis
(c) Deep venous thrombosis
(d) Heterotopic ossification
(b) Scoliosis requiring surgery is a common complication seen in children who have had an spinal cord
injury (SCI) at a young age. Increased lordosis in the absence of scoliosis is rarely seen. Deep
venous thrombosis rarely occurs in young children and when it does occur it usually occurs soon
after the SCI. Heterotopic ossification tends to occur soon after the SCI.
31
A patient is referred to your office by his primary care physician for evaluation of an unusual gait
pattern caused by a remote case of polio. You note excessive lateral trunk flexion to the left during
stance phase between foot flat and heel off. Swing phase is normal. On exam there is normal hip
flexor strength bilaterally. The gluteus medius is 4-/5 on the left and 5/5 on the right. Knee strength
is normal. The tibialis anterior is 4-/5 on the right and 5-/5 on the left. Range of motion is normal at
all joints. Which gait abnormality is occurring?
(a) Waddling gait
(b) Steppage gait
(c) Trendelenberg gait
(d) Circumducted gait
(c) A waddling gait occurs when there is bilateral gluteus medius weakness. A steppage gait occurs as
an abnormality in swing phase due to severely weak dorsiflexors of the ankle. Foot slap is seen with
moderately weak dorsiflexors and occurs on the side of weakness. Trendelenberg gait is excessive
lateral flexion due to ipsilateral weakness. Circumduction is the swinging of the limb in a wide
lateral arc.
32
A 42-year-old amateur tennis player complains of severe right elbow pain for 6 months. He has tried
heat, ice, and compression wrap without relief. He denies numbness, but does report weakness in his
grip, especially with his backhand. On examination, the patient has severe pain with palpation just
inferior to the lateral epicondyle. Which finding will most likely be present on further examination?
(a) Pain will be increased with ulnar deviation of the wrist with resisted flexion.
(b) The patient’s brachioradialis reflex will be significantly diminished or absent.
(c) Resisted wrist extension with a straightened elbow will reproduce the patient’s pain.
(d) An audible click will be heard with active supination of the forearm.
(c) This patient has lateral epicondylitis or “tennis elbow,” a condition brought on by repetitive flexionextension
or pronation-supination of the forearm. The pain will be increased by resisted wrist
extension with the elbow at 180°. The reflexes will not be affected, nor will atrophy be noted. This
is not a neurologic condition, but a myofascial one. No audible click will be heard. This might
occur if the radial head is subluxing, but not in lateral epicondylitis.
33
A 43-year-old man with a history of insulin dependent diabetes mellitus, gastroparesis, hypertension,
and obesity had a right cortical ischemic infarct 7 days ago. The nurses note that he is having
frequent small urinary voids with a weak voiding stream. What bladder mechanism is most
characteristic for this presentation?
(a) Small volume bladder with sphincter flaccidity
(b) Spastic detrusor activity with normal sphincter
(c) Flaccid detrusor with large volume bladder
(d) Hyperactive detrusor with large volume bladder
(c) Although the most common bladder among patients with stroke is normal or hyperreflexic, bladder
hyporeflexia is very common in diabetics (especially in this case with recorded gastroparesis).
These patients will have small frequent voids due to overflow from distended bladders with poor
detrusor contraction.
34
The most common cause of disability in the United States is
(a) arthritis.
(b) carpal tunnel syndrome.
(c) coronary artery disease.
(d) stroke
(a) Arthritis and other rheumatic conditions are the leading cause of disability in the United States,
imparting an aggregate cost of about 1.1% of the gross national product.
35
A patient ambulates with a Trendelenburg gait. You suspect an injury to the
(a) femoral nerve.
(b) superior gluteal nerve.
(c) obturator nerve.
(d) sciatic nerve.
(b) Trendelenburg gait is characterized by excessive dropping of the pelvis contralateral to the stancephase
leg. It is caused by weakness of the hip abductors, which include the gluteus medius
innervated by the superior gluteal nerve.
36
You are called to the neurology intensive care unit to evaluate a patient with new spinal cord injury;
you determine that the patient has sustained a C7 ASIA A spinal cord injury. Which change in the
respiratory system would be expected?
(a) Residual volume will decline to 30% of predicted value.
(b) Pulmonary function will not improve after the first 2 weeks postinjury.
(c) Expiratory reserve volume increases 40% 6 weeks postinjury.
(d) Vital capacity of 60% predicted value may be obtained within the first 6 months post-injury.
(d) Tetraplegic patients usually have a reduction in all measures of pulmonary function with the
exception of residual volume. Residual volume is increased due to lack of active expiratory effort.
Vital capacity will continue to improve. Tracheostomy is usually not necessary for pulmonary
hygiene, especially with adequate hydration and techniques for facilitating cough. Since the
diaphragm is supplied by cervical roots C3, C4, and C5, it is common for persons injured above the
C4 level to need ventilator support. In acute spinal cord injury, 67% experience significant
pulmonary complications, most commonly atelectasis. Ventilatory failure and aspiration occur the
earliest (mean, 4.5 days), followed by atelectasis (mean, 17 days) and pneumonia (mean, 24 days).
The late decline coincides with the onset of mucus hypersecretion and muscle fatigue. Ventilator
weaning has been demonstrated in 80% of C4 spinal cord injury patients and 57% of C3 patients.
Considerable patience is required and respiratory muscle fatigue must be closely monitored.
37
One year has elapsed since a 56-year-old patient received aggressive treatment for high grade ovarian
cancer. She now presents with a 2-week history of progressive unilateral lower extremity swelling and
weakness, as well as urinary incontinence. The most appropriate initial diagnostic test would be
(a) electromyogram.
(b) urodynamic studies.
(c) pelvic CAT scan.
(d) venogram.
(c) Female gynecologic malignancies tend to recur locally within the pelvis. This patient likely has a
lumbosacral plexopathy due to compression by the tumor. An electromyogram could potentially
identify the portions of the plexus involved, however spontaneous activity would not yet have
developed. Computed tomography of the abdomen and pelvis would determine whether and where
recurrent tumor was present. This would inform surgical or radiation oncologic treatment options.
38
A 29-year-old painter presents to you with 2 days of knee pain and swelling after falling off a ladder
at work. The swelling began immediately after the fall. His neurologic examination is normal, and
peripheral pulses are normal at the knee and ankle. He is unable to fully extend or flex the knee
because of pain and swelling. He is ambulating with an antalgic gait limp. Your recommendations
include ice and
(a) knee immobilizer, crutches, x-rays, return to sedentary work, recheck in 5 days.
(b) crutches, magnetic resonance imaging, referral to an orthopaedic surgeon.
(c) narcotics, physical therapy, recheck in 3 weeks.
(d) nonsteroidal anti-inflammatory drugs, x-rays, return to work.
(a) Appropriate management for acute knee injuries include, ice, elevation, non-steroidal antiinflammatory
drugs, protection, weight bearing as tolerated and activity modification. X-rays
initially rule out bony injury. magnetic resonance imaging should be reserved for cases where the
diagnosis is in question or a surgical procedure is planned. A careful examination to fully exclude
ligament or cartilage injury cannot be completed until the effusion has resolved enough to allow for
an appropriate examination. Therefore, in the case of an acute knee injury with effusion, the patient
should be reexamined within a 1- to 2-week interval in order to narrow the diagnosis and progress
treatment.
39
A 50-year-old man complains of paresthesias of the right lateral 3 ½ digits and wrist pain. Nerve
conduction studies for the right arm (norm in parentheses) are as follows:
Motor
Nerve Distal Latency (ms) Amplitude (mV) Conduction Velocity (m/s)
R. Median 5.3 (5) 48 (>45)
R. Ulnar 3.7 (5) 52 (>45) forearm
8.5 50 across the elbow
Sensory
Nerve Stimulation Site Peak Latency(ms) Amplitude ()V)
Median (digit II) wrist 14cm 5.2 (10)
mid palm 7cm 2.0 20
Ulnar (digit V) wrist 14cm 3.4 (10)
The most likely diagnosis is
(a) cubital tunnel syndrome.
(b) ulnar entrapment at Guyon’s canal.
(c) peripheral neuropathy.
(d) carpal tunnel syndrome.
(d) There is slowing of the median motor distal latency and the median sensory latency across the
wrist, findings consistent with carpal tunnel syndrome.
40
Acquired subluxation or dislocation of the hips in spastic cerebral palsy is usually due to muscular
imbalance and pull of the
(a) hip flexors and tensor fascia lata.
(b) hip flexors and hip adductors.
(c) rectus femoris and hip abductors.
(d) tensor fascia lata and hip extensors.
(b) Strong hip flexor and adductor muscles can overpower weak extensors and abductors. Acquired
hip dislocation can be prevented in some cases by release of spastic hip flexors and adductors.
41
Which of the following distinguishes running from walking?
(a) Shorter stance phase in walking
(b) No double support in running
(c) Longer step length in walking
(d) Shorter stride length in running
(b) Sixty percent of the complete gait cycle is spent in stance phase while walking. Only 40% of the
time is spent in stance phase during running. By definition, running involves little to no heel strike
and has no double support. Stride length and step length are much greater in running than in
walking.
42
A 21-year-old US Army recruit reports to boot camp. After 5 days of marching, he reports to the
base physiatrist with complaints of severe pain in his left shin. He states his pain began after a 10-
mile run in full gear this morning. The pain has gotten significantly worse over the last 2 hours. He
is now unable to bear weight on his left leg. On examination, his left shin is shiny and edematous.
He has severe pain with palpation and the muscles seem tight. The most appropriate treatment plan
for this patient would be to
(a) obtain an x-ray and a triple phase bone scan.
(b) measure the pressure in his tibialis anterior muscle immediately.
(c) wrap the foreleg with an Ace bandage, applying pressure from distal to proximal.
(d) apply ice and have the patient elevate his leg when he gets back to his barracks.
(b) Suspicion of a compartment syndrome should lead the physician to get pressure measurements
immediately, since delays may result in permanent muscle or nerve damage. Usual pressures are
less than 30mmHg. Pressures from 30 to 50mmHg are equivocal, but pressures greater than
50mmHg constitute a surgical emergency. The leg should NOT be elevated, because this will lower
arterial perfusion pressure and will further compromise vascular supply. An external
circumferential force will increase pressure. An x-ray and bone scan are not indicated in this
patient.
43
Findings commonly seen after a right hemispheric stroke include
(a) right hemiplegia.
(b) aphasia.
(c) visual-perceptual deficits.
(d) agraphia.
(c) Strokes on the nondominant hemisphere present with contralateral hemiplegia and hemianesthesia,
aprosody, visual-spatial deficit, and neglect syndrome.
44
Mr. Smith comes to your office complaining of a hot, painful, swollen left foot. He denies any
history of trauma and states that he forgot to take his allopurinol the past several days. X-rays of his
foot may reveal
(a) chondrocalcinosis of articular cartilage.
(b) bony erosion with an overhanging edge.
(c) severe juxta-articular osteopenia.
(d) pencil in cup deformity.
(b) This patient has gout with characteristic “overhanging edge” lytic lesions. Chondrocalcinosis is
seen in pseudogout, juxta-articular osteopenia is seen in RA, and pencil in cup deformity is seen
with psoriatic arthritis.
45
For patients with amyotrophic lateral sclerosis, exercise should be prescribed for muscles with
(a) weakness and less than 2/5 strength.
(b) muscles with visible fasciculations.
(c) weakness and better than 3/5 strength.
(d) unaffected muscles
(d) Because amyotrophic lateral sclerosis is a relentlessly progressive disease, only muscles with
unaffected strength should be exercised, to prevent disuse atrophy. In the postpolio patient, it is
acceptable to strengthen weak muscles with greater than fair (or 3/5) strength.
46
Factors associated with poor prognosis in multiple sclerosis include
(a) female gender.
(b) age at onset less than 20 years.
(c) cerebellar involvement at onset.
(d) relapsing remitting course at onset.
(c) Factors associated with a poor prognosis in multiple sclerosis include: 1) progressive course at
onset. 2) Male sex. 3) Age at onset greater than 40 years. 4) Cerebellar involvement at onset. 5)
Multiple system involvement at onset.
47
An HMO case manager questions the potential benefits of inpatient rehabilitation for a patient with
metastatic cancer. You explain that the presence of metastases
(a) extends inpatient rehabilitation stays.
(b) decreases durable medical equipment costs.
(c) precludes autonomous mobility and self-care.
(d) does not impact achievement of rehabilitation goals.
(d) In a retrospective chart review it was found that neither the presence of metastatic disease, nor the
need for ongoing anticancer therapy (eg, chemo- or radiation therapy delayed the achievement of
rehabilitation goals or extended rehabilitation hospital stay
48
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.
(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).
49
Your 15-year-old patient with Duchenne muscular dystrophy complains of new onset morning
headaches. What is the most likely cause?
(a) Neck extensor tightness
(b) Hypercarbia
(c) Migraines
(d) Vision changes
(b) Migraines do not typically occur only in the morning. Neck extensor tightness usually occurs
before the loss of ambulation in boys with Duchenne muscular dystrophy, which usually occurs
before the age of 15 years. Vision changes usually do not cause morning headaches. Hypercarbia
results from hypoventilation during sleep and is an early sign of impending respiratory failure.
50
What is the leading cause of amputation in the upper extremity for men between the ages of 15 and
45 years?
(a) Diabetes mellitus and/or peripheral vascular disease
(b) Other disease states (excluding diabetes, peripheral vascular disease)
(c) Trauma
(d) Tumor
(c) Trauma is the leading cause (approximately 75%) of acquired amputation in the upper extremity,
occurring primarily in men between the ages of 15 and 45 years. Disease and tumors are
responsible for about equal numbers of the remaining acquired upper-extremity amputations. In the
lower extremity, disease states account for approximately 75% of all acquired amputations, with
complications of diabetes and peripheral vascular disease accounting for the great majority of these,
especially in persons age 60 years and over. Trauma is the next most common cause for lower
extremity amputation (20%), followed by tumors (5%). Among persons between the ages of 10 and
20 years, however, tumor is the most frequent cause of all amputations in both the upper and lower
extremities.
51
In which case is a corticosteroid injection contraindicated?
(a) A police officer with plantar fasciitis who will return to his usual street duties 2 days after
treatment
(b) A professional tennis player with acute elbow pain associated with her backhand 1 week
before a tournament
(c) A drywall hanger with chronic shoulder pain who has had 1 prior injection 6 months ago with
good results
(d) A diabetic weightlifter with subacute medial knee pain that is warm to touch compared to the
other leg
(d) Patients with diabetes mellitus are at risk for serious infection and for systemic effects of absorbed
corticosteroids. Injection into an infected joint, tendon or bursa is contraindicated. Multiple
injections should not be performed unless clear improvement has been demonstrated. More than 3
steroid injections are rarely indicated. There is a risk of tendon rupture in patients who return to
usual activity too rapidly. Plantar fasciitis and lateral epicondylitis respond well to steroid injection.
52
An 18-year-old man incurs a mild traumatic brain injury in a bar dispute. He presents 2 months
later complaining of persistent headaches originating in the back of the neck and radiating
circumferentially forward. After a thorough history and physical examination, you feel his
principal problem is myofascial in origin; specifically, two offending trigger points are found. Your
first approach to treatment would be
(a) amitriptyline 100mg at bed time.
(b) injection with botulinum toxin.
(c) establishing an outpatient cognitive behavioral program through psychology to address a
subacute pain syndrome.
(d) injection with 1% lidocaine.
(d) Post traumatic headaches are a common symptom after cervicocranial trauma. The differential
diagnosis includes cervical disease, occipital neuralgia and migraines, and myofascial pain. In this
scenario, points that reproduce the headaches should be treated either with or without local
anesthesia. This helps to reduce pain, inhibit the muscle contracture band, and enhance local muscle
blood flow.
53
A 40-year-old woman with a history of irritable bowel syndrome and tension headaches complains of
increasing fatigue and diffuse muscle soreness in her neck, shoulders, and low back. She has a nonfocal
neurologic examination. Initial treatment should include
(a) 30mg twice daily of sustained release morphine.
(b) 60mg prednisone with rapid taper.
(c) 1mg lorazepam twice daily.
(d) 25mg nortriptyline each night.
(d) Medications that promote sleep, such as low dose tricyclic antidepressant medications, have been
shown to be the most helpful pharmacologic approach to patients with fibromyalgia.
54
(This question has been eliminated from the exam, therefore, it was not scored.)
Which statement is TRUE regarding persons with complete spinal cord injury with concurrent
posterior rhizotomy who receive functional neuromuscular stimulation via an implanted device to
restore bowel and bladder function?
(a) Stimulation of the posterior S2, S3, S4 nerve roots will produce micturition.
(b) Stimulation will enhance reflex voiding.
(c) Stimulation will improve reflexogenic erection.
(d) Stimulation will increase bladder capacity.
(d) (This question has been eliminated from the exam, therefore, it was not scored.)
Because electrical stimulation for bladder and bowel function depends on the ability to activate
intact motor neurons from the sacral segments of the cord, it is at this time limited to persons with
suprasacral lesions. Micturition is produced by stimulation of the anterior (motor) S2, S3, and S4
nerve roots. Continence has been greatly improved by concurrent posterior rhizotomy of the
(sensory) sacral nerve roots. The advantages of posterior rhizotomy include increasing bladder
capacity and abolishing reflex voiding, reducing dyssynergia and abolishing episodes of autonomic
dysreflexia. The primary disadvantage of posterior rhizotomy is the loss of reflex erection and
reflex ejaculation (if these are present). The hardware cost is approximately $40,000 with the
projection that after factoring in the cost of medications, supplies, medical procedures, durable
medical equipment, and attendant care, the device pays for itself in 5 to 7 years.
55
You are conducting an exercise tolerance test on a patient 2 months after successful heart transplant.
Relative to a patient with similar clinical characteristics following coronary artery bypass grafting,
you would rely more heavily on monitoring which parameter?
(a) Heart rate
(b) Perception of pain
(c) Intracardiac pressure via Swan Ganz
(d) Electrocardiogram changes
(d) The transplanted heart is denervated and therefore cardiac ischemia does not cause pain. Because
vagal tone is lost, the resting heart rate following transplant is close to 100 beats per minute.
Exercise induced increase in heart rate is blunted and peak heart rates are generally 20% to 25%
lower than age-matched controls. Swan Ganz monitoring is not required.
56
A 50-year-old insulin-dependent diabetic truck driver with a long-standing history of smoking is
sent to you after experiencing left hand weakness following a long haul across the country. Signs
and symptoms include weakness in hand intrinsics and wrist, with numbness in the ring and little
fingers. Exam demonstrates normal upper extremity reflexes. Motor strength is normal for deltoid,
biceps, triceps, pronator teres, and opponens pollicus. There is moderate weakness of the abductor
digiti minimi. Your diagnosis is
(a) C7 radiculopathy.
(b) carpal tunnel syndrome.
(c) ulnar compression at Guyon’s canal.
(d) ulnar neuropathy at the elbow.
(d) The patient’s symptoms and the physical exam findings are consistent with an ulnar neuropathy at
the elbow.
57
Which technique may reduce stimulus artifact when performing sensory nerve conduction studies?
(a) Increasing the impedance of the recording electrodes
(b) Increasing the stimulus duration
(c) Rotating the anode around the cathode
(d) Decreasing the low frequency filter
(c) Rotating the anode around the cathode can decrease stimulus artifact. The other choices have no
effect, or increase it.
58
Which insult is the most likely cause of spastic diplegic cerebral palsy?
(a) Intrauterine stroke
(b) Hyperbilirubinemia in the neonatal period
(c) Postnatal intraventricular hemorrhage
(d) Perinatal asphyxi
(c) Spastic diplegic cerebral palsy occurs most commonly in premature infants who have had an
intraventricular hemorrhage during the neonatal period. Intrauterine stroke causes hemiplegia.
Neonatal hyperbilirubinemia most commonly causes athetosis. Birth asphyxia is more commonly
associated with spastic quadriplegic cerebral palsy.
59
Which form of prosthetic suspension is NOT utilized with the transhumeral amputation?
(a) Harness
(b) Self-suspension
(c) Suction
(d) Joint and corset
(d) Traditional suspension systems include harness (figure-of-8 or -9, chest strap, and shoulder saddle),
self-suspension (condylar, Muenster, or Northwestern), semisuction (semisuction or hypobaric) and
suction (full suction or silicone sock).
60
A 20-year-old man complains of 4-month history of low back pain that radiates into the buttocks. The
pain began insidiously, is worse in the morning, and eases up after a hot shower. The neurologic
exam is normal. Which finding will help support your likeliest diagnosis?
(a) A negative HLA-B27
(b) Symmetric wrist swelling
(c) A negative Schober test
(d) Acute iritis
(d) Acute iritis is an extra-skeletal manifestation of ankylosing spondylitis (AS). HLA-B27 is not
necessary to make the diagnosis of AS. Involvement of peripheral joints is infrequent and, when
present, is asymmetric. The Schober test is typically positive
61
Which neuromuscular disorder is NOT usually associated with thyroid disease?
(a) Peripheral neuropathy
(b) Neuromuscular junction disorder
(c) Myopathy
(d) Radiculopathy
(d) Thyroid disease is associated with several different aspects of the neuromuscular system. In both
hypothyroidism and hyperthyroidism, there can be neuromuscular junction disorders (increased
incidence of myasthenia gravis), and myopathy. Hypothyroidism is associated with sensorimotor
peripheral neuropathy and entrapment neuropathy, especially carpal tunnel syndrome. Thyroid
disease is not associated with radiculopathy.
62
The type of recruitment in this graph (gain: 500 )V/div, Sweep: 10 ms/div ) is most often seen in
(gamb 2 gelombang mulai amplitudo positif plg tinggi mengecil hingga negatif, jarak antar gelombang 4 kotak)
(a) normals.
(b) neuropathy.
(c) myopathy.
(d) poor patient effort.
(b) There is a single motor unit firing at approximately 20Hz without another motor unit coming in.
This is an example of decreased recruitment, which may be seen in neuropathy. In myopathy one
may see early recruitment of motor units. In patients who give submaximal effort there may be only
1 motor unit seen on the screen, but the firing rate is less than 20Hz.
63
The best predictor of community ambulation beyond childhood in patients with myelomeningocele is
(a) body mass index.
(b) quadriceps strength.
(c) early surgical closure of the meningocele.
(d) bowel and bladder continence.
(b) There are many studies about longterm outcomes of ambulation in children and adults with
myelomeningocele. While many factors influence outcome, including intelligence, medical
problems, and obesity, the best predictor of ambulation into adulthood is strong quadriceps
function. Bowel and bladder continence has no relationship to ambulation
64
The best example of a dynamic orthosis is
(a) dorsal wrist hand orthosis with extension force in radial nerve injury.
(b) thermoplastic ankle foot orthosis in severe foot drop.
(c) wrist hand orthosis in 15° of extension for carpal tunnel syndrome.
(d) a C-bar in median nerve injury.
(a) Static means that the orthosis is rigid and gives support without allowing movement. These devices
are commonly used to rest a part after trauma or surgery, and for acutely inflamed joints and
tendons. Dynamic orthoses allow a certain degree of movement. They usually provide some
element of assisted motion to the joint, such as the elastic assist to wrist extension in the orthosis for
radial nerve palsy.
65
Which statement is TRUE regarding myofascial trigger points?
(a) They exhibit electrodiagnostic abnormalities on needle examination.
(b) Their symptoms can be reproduced with palpation over the trigger point.
(c) Their identification requires at least 8 kilograms of pressure.
(d) They resolve with isokinetic exercise of the affected muscle.
(b) Moderate, sustained pressure for approximately 10 seconds on an irritable trigger point causes
symptoms in the reference zone for that muscle. No specific amount of pressure is required for this
diagnosis. Trigger points should not be confused with fibromyalgia “tender points” which require
approximately 4 kg of pressure for diagnosis. Myofascial trigger points are electrically silent and
show no resting muscle activity on electromyogram. No elevation in muscle creatine phosphokinase
is seen with this condition. Isokinetic exercise is not indicated as a treatment for this condition.
Local injection with anesthetic and/or spray with a vaporcoolant spray and stretch of the muscle are
the treatments of choice.
66
```
Risk factors for heterotopic ossification in a 27-year-old man with severe traumatic brain injury
include
(a) total parenteral nutrition.
(b) prolonged coma.
(c) seizure disorder.
(d) hypotonicity.
```
(b) Risk factors for the development of heterotopic ossification include prolonged coma,
immobilization, and limb spasticity.
67
Which presentation of multiple sclerosis is most common?
(a) Relapsing-remitting
(b) Primary progressive
(c) Secondary progressive
(d) Relapsing-progressive
(a) Relapsing-remitting multiple sclerosis (MS) is the most common type of presentation—
approximately 80%.
68
On hospital rounds, you note that your patient, who has a T10ASIA B spinal cord injury is now
using a rigid frame wheelchair in the therapy gym. In his attempt to show off as he propels toward
you, he suddenly flips over backward. What is the most likely problem?
(a) The rear axles are located directly under his center of gravity.
(b) The rolling resistance is increased.
(c) There is too much caster flutter.
(d) There is asymmetry in the chair’s camber angle from side to side.
(a) The center of gravity for a hypothetical wheelchair rider is typically located slightly forward of the
rear axle. Moving the rear axle directly under the wheelchair user makes the person and the chair
more likely to flip backwards (wheelie). However, the advantages to having the center of gravity
near the rear axles include decreased tendency for caster flutter, decreased rolling resistance, since
most of the weight is borne by the larger rear wheels, and minimization of the turning torque.
69
An inpatient consultation is requested on a 56-year-old patient 3 days after uncomplicated coronary
artery bypass grafting. The cardiothoracic surgical resident maintains that the patient must remain
either in his bed or chair during exercise. In formulating a rehabilitation program you
(a) agree with the resident, adding that only isometric exercise be performed.
(b) agree with the resident, adding that no upper extremity strengthening be performed.
(c) maintain that progressive ambulation can be safely initiated after postoperative day 2.
(d) maintain that upper extremity ergometry should be used for aerobic conditioning.
(c) Patients who have just undergone coronary artery bypass grafting have recently been revascularized
and are therefore excellent rehabilitation candidates. Typically, patients begin progressive
ambulation training on postoperative day 2, with independent ambulation usually being performed
on day 3.
70
A 55-year-old secretary presents to you with neck, shoulder, and arm pain. Her pain is worse on
Friday than Monday. She denies any trauma or history of previous similar complaints. Her work
station changed a week before the onset of her symptoms. You advise her that
(a) her job has nothing to do with the pain she is experiencing.
(b) taking a week off will reduce symptoms and allow her to return to work without problems.
(c) nonsteroidal anti-inflammatory medications and ice will resolve her problem.
(d) her work station should be evaluated.
(d) Postural changes can produce muscle imbalances that can cause pain syndromes. Changing posture
and re-education of muscles through appropriate strengthening programs is appropriate
management. The ergonomics at her work site have a lot to do with her pain complaints. Time away
from work may temporarily reduce symptoms but will likely have no long-term effect. The use of
pain management interventions such as ice and anti-inflammatory medications is appropriate but
should not be expected to correct the long term problem.
71
Regarding the electrodiagnostic testing of a patient with definite myasthenia gravis, which statement
is TRUE?
(a) An increment on repetitive stimulation at 1Hz of up to 25% is expected.
(b) A stimulation rate of 2-3Hz is most useful in demonstrating a decrement.
(c) An initial low amplitude compound motor action potential after a supramaximal stimulus is
expected.
(d) Motor unit variability is reflected by decreased jitter during single fiber EMG.
(b) A 2 to 3Hz stimulation is optimal for demonstrating a decremental response. At this rate there is no
build up of Ca++ concentration within the nerve terminal and the amount of acetylcholine in the
readily available stores diminishes, making failure of some of the neuromuscular junctions possible
in those patients with an already small safety factor. A decrement of up to 10% on 2 to 3Hz
repetitive stimulation is considered normal. Small CMAPs initially are more suggestive of
myasthenic (Lambert-Eaton) syndrome than of myasthenia gravis. Single fiber EMG reveals
increased jitter and may reveal blocking.
72
Which of the following is true regarding skeletal design of a lower extremity prosthesis?
(a) Endoskeletal tends to weigh less.
(b) Exoskeletal is less hardy.
(c) Endoskeletal tends to demand less maintenance.
(d) Exoskeletal is easily adjusted after fabrication.
(a) Exoskeletal designs tend to weigh more, are more rugged, demand less maintenance, and cannot be
adjusted after fabrication. Generally, the opposite is true of endoskeletal designs.
73
A 22-year-old skier reports to your mountain ski clinic the day after falling over her ski pole. She
complains of severe pain in her left thumb along the medial aspect of the metacarpophalangeal joint.
She has minimal swelling and no ecchymosis, but is exquisitely tender along the ulnar collateral
ligament. No mediolateral laxity is found on exam. Optimal treatment for this patient should include
(a) immediate referral to a hand surgeon for a grade III ulnar collateral ligament tear.
(b) immobilization in a thumb spica splint for a period of 2 to 4 weeks.
(c) a corticosteroid injection at the site of pain to relieve the inflammation.
(d) no intervention indicated; she should be allowed to return to ski.
(b) This patient most likely has suffered a grade I or II ulnar collateral ligament injury. This injury is
called a “gamekeeper’s or skier’s thumb.” A complete (grade III) tear is diagnosed by a difference
of 15° or more of lateral laxity compared to the uninjured side or an absolute laxity of 35°. This is
not a grade III injury, and will likely heal with nonsurgical treatment consisting of immobilization
in a thumb spica cast or splint for 2 to 4 weeks. This patient may be returned to ski with a thumb
spica or cast in place. A steroid injection is not indicated. Ice may help with the pain and swelling,
but immobilization is required for this patient. Nonsteroidal anti-inflammatory drugs may be given
for pain control.
74
You are asked to evaluate a 25-year-old man who sustained a traumatic brain injury (TBI) in a car
crash. In the emergency department, he was unable to follow commands but withdrew to pain,
opened his eyes when spoken to, and was disoriented. Head computed tomography revealed a frontal
contusion. According to the Glasgow Coma scale, his injury can be classified as
(a) uncomplicated mild TBI.
(b) complicated mild TBI.
(c) moderate TBI.
(d) severe TBI.
```
(c) Based on the information presented in the question, the Glasgow Coma Scale score for this patient
is 11 (eyes open when spoken to 3, withdraws to pain 4, converses but is disoriented 4 = total score
11). Moderate injury is defined by GCS scores of 9 to 12.
```
75
Which myopathy can be either autosomal dominant or autosomal recessive?
(a) Facioscapulohumeral dystrophy
(b) Limb-girdle dystrophy
(c) Myotonic dystrophy
(d) Emery-Dreifuss muscular dystrophy
(b) Facioscapulohumeral and myotonic dystrophy are usually autosomal recessive. Emery-Dreifuss
muscular dystrophy is X-linked recessive. Limb-girdle dystrophy is a group of disorders producing
weakness about the hips and shoulders. It can be either autosomal recessive or dominant.
76
Workers who sustain an injury causing continued impairment cannot return to work if
(a) they are at or over the age of 55 years.
(b) their job cannot be modified to accommodate their impairments.
(c) more than 3 months have elapsed since the injury.
(d) the worker was responsible for the injury.
(b) If job requirements cannot be modified, an injured worker may not be able to return to his/her job.
The employee’s age or the length of time that has elapsed since the injury does not by definition
exclude the worker from returning to work. Whether the worker was responsible for the injury does
not exclude him/her from returning to work.
77
The potentials shown in this graph are
(gamb. 2,5 gelombang, mulai dr negatif -datar - hingga tiba2 positif sgt tinggi, jarak antar gelombang 30 ms, tinggi gelombang 250 micronVolt)
(a) fibrillations.
(b) myopathic motor units.
(c) end plate spikes.
(d) complex repetitive discharges.
(c) The duration of these potentials is approximately 5ms, too short for a motor unit. The initial
deflection is negative, distinguishing this potential as an end plate spike rather than a fibrillation
78
```
A child with C5 ASIA A spinal cord injury should eventually become independent in which
activity?
(a) Intermittent catheterization
(b) Transfer to level surfaces
(c) Feeding
(d) Bathing
```
(c) A child with C5 ASIA A spinal cord injury should eventually become independent in feeding, and
in upper extremity dressing with assistive devices, in driving a power wheelchair, and in propelling
a manual wheelchair short distances on level surfaces
79
A medical student asks you to show her how to assess the fit of a traditional quadrilateral socket.
You explain that the best evaluation is carried out by placing the examiner’s finger between the
ischial tuberosity (IT) and the ischial seat (IS). You then tell that during full weight bearing
(a) the IT slides down into the socket when properly fit.
(b) there should be 1 fingerbreath between the IT and the IS during knee extension.
(c) the best position for determining the relationship of the IT and the IS is knee flexion.
(d) there is no room to place a finger between the IT and the IS.
(d) During full weight bearing the ischial tuberosity sits on the ischial seat (the wide flat posterior
brim). Only with ischial containment sockets does it slide down into the socket when properly fit.
There should be room for the finger between the ischial tuberosity and the ischial seat during knee
flexion when weight bearing is decreased. The best position for determining the relationship of the
ischial tuberosity and the ischial seat is knee extension. If there is no room for the finger between
the ischial tuberosity and the ischial seat during full weight bearing, the socket fits correctly with
regard to the proximal landmarks.
80
A 28-year-old PM&R resident had a mild traumatic brain injury. He is now having problems
organizing and leading team meeting, although his ability to perform other aspects of his job as an
individual are unimpaired. Of the following, the most useful neuropsychologic test for assessing his
deficits is the
(a) Galveston Orientation and Amnesia Test.
(b) Wechsler Adult Intelligence Scale–Revised.
(c) Wechsler Memory Scale.
(d) Trails A and B test.
(d) From the details given in the case, this resident appears to be having problems in mental flexibility
and paying attention to multiple stimuli. The Trails A and B test examines simple and alternating
attention. The Galveston Orientation and Amnesia Test, which is used to measure the presence of
post-traumatic amnesia, would not be helpful. The Wechsler Adult Intelligence Scale–Revised and
Wechsler Memory Scale, while necessary in a complete neuropsychological examination, do not
directly measure attentional abilities.
81
person with Paget’s disease typically has
(a) alternating osteoblastic and osteoclastic phases.
(b) equivocal radiographs.
(c) evidence of syndesmophytes.
(d) blue sclera.
(a) Radiographs will show a mottled appearance. The skull, tibia, pelvis and vertebral bodies are most
commonly invloved. Syndesmophytes are seen with spondyloarthropathys. Blue sclera is seen in
osteogenesis imperfecta.
82
Compared with able-bodied individuals, persons with spinal cord injury are likely to have
(a) equivalent percentage of regional and total body lean tissue.
(b) higher testosterone levels.
(c) equivalent incidence of dyslipidemia.
(d) a lower resting metabolic rate
(d) In persons with spinal cord injury, there is an initial dramatic loss of muscle mass after the acute
paralysis. However, even decades after injury, there is continuous loss of lean body tissue
compared to that observed in an able-bodied person. It is of particular interest that the arms of
persons with paraplegia have significantly less percent lean tissue compared with controls. No
differences in the cross sectional rate of loss of lean body mass is noted between persons with
tetraplegia and paraplegia. Men with spinal cord injury can be expected to lose about 3.2% per
decade of the total lean body tissue vs. 1% per decade in able-bodied males. Individuals with spinal
cord injury have a pattern of metabolic alteration that is atherogenic with dyslipidemia, glucose
intolerance, insulin resistance, and reduction in metabolic rate. Although the literature in persons
with spinal cord injury is conflicting regarding anabolic hormonal changes in persons with spinal
cord injury, there are subsets of individuals with relative androgen deficiency states. The etiology
of a relative deficiency of testosterone in persons with spinal cord injury has not yet been
established. However, it is conceivable that prolonged sitting and euthermia of the scrotal sack and
testes may itself have a deleterious local effect on testosterone production.
83
In reviewing the pulmonary function tests of a patient with Duchenne muscular dystrophy before
prescribing an exercise program, relative to a healthy normal person, you would expect the patient to
have
(a) increased tidal volume and increased functional residual capacity.
(b) decreased tidal volume and decreased functional residual capacity.
(c) increased tidal volume and unchanged vital capacity.
(d) unchanged tidal volume and decreased vital capacity.
(b) Duchenne muscular dystrophy, like all myopathies, causes a restrictive pattern of respiratory
compromise. Therefore, functional residual capacity, tidal volume, residual capacity, and vital
capacity are all reduced relative to age-matched normals.
84
A data entry clerk presents with complaints of right wrist and hand pain. She attributes the problem
to prolonged use of the computer mouse. Which intervention should be included in the initial
treatment plan?
(a) Eccentric strengthening of the wrist extensors with hand weights
(b) Biweekly steroid injections to minimize symptoms
(c) Wrist splint to minimize symptoms
(d) Moving the mouse away from the keyboard
(c) Repetitive injuries from keyboard occupations are well recognized and require active rehabilitation
for restorative function. Eccentric exercises will increase repetitive stress to the injured site and
should not be used in the initial treatment recommendations. The prescription of biweekly steroid
injections is excessive and may promote musculotendon atrophy and susceptibility to further injury.
Moving the mouse further away from the keyboard will likely increase symptoms and dysfunctions.
Wrist splints can be used during the initial treatment program to provide relative rest, reduce
inflammation, and to provide comfort.
85
A 6-month-old child presents in your office for rehabilitation assessment. She was born at full
term. There was mild transient respiratory distress at birth. The patient was noted to be diffusely
hypotonic at birth except for normal cranial nerves. There were no feeding issues once the
respiratory distress resolved within 24 hours. The baby has remained relatively hypotonic since
birth. However, she has become very socially alert and aware and attempts to use her arms to reach
for toys and pick up lightweight objects. She doesn’t roll. She cannot sit except very briefly when
propped and bearing weight through both arms with elbows extended. On examination, head
circumference is normal, length is normal, as is weight. There is a pronounced head lag. Arms,
while in the supine position, maintain a “jug-handle” posture. Reflexes are present but diminished.
There is no spasticity. The cranial nerves are normal except for fine fasciculations of the tongue.
The most likely diagnosis is
(a) myotonic muscular dystrophy.
(b) cerebral palsy.
(c) infantile botulism.
(d) spinal muscular atrophy.
(d) Spinal muscular atrophy (SMA)is a term used to describe a group of inherited disorders
characterized by weakness and muscle wasting due to degeneration of anterior horn cells of the
spinal cord and brainstem motor nuclei. Three subtypes of autosomal recessive predominantly
proximal SMA have been linked to chromosome 5q. The majority of cases of SMA type I present
within the first 2 months of life with generalized hypotonia and symmetric weakness. Children
typically sit only with support. Tongue fasciculations have been reported in 56%-61% of patients.
Proximal muscles are weaker than distal.
86
patient presents for evaluation of his new ankle-foot orthosis (AFO). During ambulation you
notice that he has reduced hip extension and stride length, and a slowed gait. At the initiation of
stance phase, heel strike is not consistently present. You conclude that the abnormal gait is due to
excessive
(a) knee extension at heel strike and recommend setting the AFO in greater dorsiflexion.
(b) hip flexion contracture and recommend setting the AFO in greater dorsiflexion.
(c) knee flexion at heel strike and recommend setting the AFO in greater plantar flexion.
(d) dorsiflexion of the ankle and recommend setting the AFO in plantar flexion.
(b) Excessive knee extension at heel strike is frequently seen with hamstring weakness or
gastrocnemius muscle spasticity. It causes the patient to walk on the heel, with external rotation of
the leg and no knee flexion at heel strike. Excessive knee flexion at heel strike is frequently seen
with an ankle-foot orthosis (AFO) that is set in too much dorsiflexion. This setting causes the midstance
period to be reduced and the push-off effect diminished, causing the knee to be excessively
flexed and thereby slowing the gait. If the tip of the shoe on the AFO side is raised too high at heel
strike, the AFO is set in too much dorsiflexion. Only answer b addresses all of the abnormalities
seen in this individual.
87
Which maneuver is used to identify sacroiliac joint pathology?
(a) Lasegue
(b) Gaenslen
(c) Ober
(d) Thomas
(b) The Gaenslen sign is a test to determine sacroiliac pathology. This test is performed by having the
patient lie supine. One buttock is extended over the table’s edge while the other remains on the
table. The ipsilateral leg is allowed to drop below the edge of the table, with the other leg remaining
in a flexed position. Pain in the area of the sacroiliac joint on the side of the extended leg represents
a positive test. The Thomas test is a test to measure hip flexion contracture. The Ober test is used to
identify contracture of the iliotibial band or the tensor fascia lata. The Lasegue sign is the straight
leg test, a nerve root stretch test to identify radicular pain.
88
What is the most common cause of traumatic brain injury in a child under the age of 1 year?
(a) Motor vehicle crash
(b) Near drowning in bath
(c) Inflicted injuries
(d) Fall from changing table
(d) For infants, more than two-thirds of all traumatic brain injuries result from falls; only 8% of these
result in moderate or severe injuries. For preschool children, falls account for 51% of TBI and
motor vehicle crashes for 22%. For children 8 to 9 years of age, etiology of TBI is evenly divided
between falls, sports, and recreational activities, and motor vehicle crashes.
89
For the past 2 months, a 75-year-old man has had low back pain that radiates in a posterolateral
distribution down his right leg when he stands or ambulates. The pain is relieved by pushing a cart in
the store. He has a non-focal neurologic examination and an x-ray rules out metastatic disease. Your
initial management plan should include
(a) neurosurgical evaluation.
(b) lumbosacral corset.
(c) epidural steroid injection.
(d) flexion based exercises
(d) This patient describes classic neurogenic claudication due to spinal stenosis. He has a non-focal
examination and should be managed conservatively initially with flexion based exercises. Epidural
steroid injections may be warranted if the patient does not respond to initial therapeutic exercise
90
Which muscles are usually innervated by the median nerve?
(a) Third and fourth lumbricals
(b) Third and fourth dorsal interossei
(c) First and second lumbricals
(d) First and second dorsal interossei
(c) The ulnar nerve innervates all the dorsal interossei muscles and the third and fourth lumbricals. The
median nerve innervates the first dorsal interosseus muscle in about 1% of the individuals. Rarely,
the radial nerve innervates the first dorsal interosseus. The first and second lumbricals are
innervated by the median nerve.
91
```
A 15-year-old presents to the trauma unit at your hospital after a gunshot wound to the right upper
back, with an exit wound at the posterior left neck. Physical exam is as follows
R L
biceps 5/5 5/5
wrist extensors 2/5 2/5
triceps 3/5 2/5
finger flexors 2/5 2/5
intrinsics 2/5 2/5
hip flexors 4/5 4/5
knee extensors 4/5 4/5
dorsiflexors 4/5 4/5
extensor hallicus 4/5 4/5
plantarflexors 4/5 4/5
Rectal exam reveals volitional sphincter control.
```
You determine that his ASIA level and class are
(a) C5 ASIA C
(b) C6 ASIA C
(c) C5 ASIA D
(d) C6 ASIA D
116. A patient with advanced
c) Based on the ASIA classification revised in 2000, the highest intact level would be C5 (normal
muscle strength or >3/5 with the next level being normal). ASIA classification is based on
completeness of injury. ASIA A indicates no motor or sensory preservation below the level of
injury. ASIA B indicates sacral sparing. ASIA C is motor incomplete with more than half of the
muscle groups below the level of injury with muscle grade less than 3/5. ASIA D is also motor
incomplete, with at least half of the muscle groups greater than 3/5. In this case, 11/18 muscle
groups are 3/5 or greater, making this person an ASIA D. The highest intact level is C5.
92
A patient with advanced chronic obstructive pulmonary disease (COPD), coronary artery disease,
and copious airway secretions has begun a pulmonary rehabilitation program. The program
involves progressive aerobic conditioning on a treadmill. In order to enhance the efficacy of the
program, you recommend all the following EXCEPT
(a) nutritional counseling and increased carbohydrate intake.
(b) application of positive airway pressure breathing.
(c) low flow supplemental intranasal oxygen.
(d) inspiratory resistive loading.
(a) Optimizing the nutritional status of patients undergoing pulmonary rehabilitation is critical for
treatment success. However, inappropriately increasing carbohydrate consumption can aggravate
hypercapnia
93
You are being deposed regarding a 42-year-old factory worker you have diagnosed and treated with
carpal tunnel syndrome. Objective testing that confirms your diagnosis includes
(a) nerve conduction studies and electromyography.
(b) x-rays of the wrist.
(c) positive Tinel’s test at the wrist.
(d) paresthesias in the thumb and index finger.
(a) Electrodiagnostic testing supplies objective measurement of peripheral nerve compression. Though
x-rays are an objective test, a diagnosis of carpal tunnel syndrome cannot be made by x-rays. A
positive Tinel’s test and symptoms of paresthesias in the thumb and index finger are commonly
found in patients diagnosed with carpal tunnel syndrome but are not objective findings.
94
Which muscle is innervated by the peroneal division of the sciatic nerve?
(a) Adductor magnus–anterior part
(b) Piriformis
(c) Semimembranosus
(d) Biceps femoris- short head
(d) The anterior part of adductor magnus is innervated by the obturator nerve. The piriformis receives
its own branch off the lumbosacral plexus. The semimembranosus is innervated by the tibial
division of the sciatic nerve. Only the short head of the biceps femoris is innervated by the peroneal
division of the sciatic nerve.
95
In a person with complete paraplegia, which gait has the highest energy expenditure per meter?
(a) Swing-through gait in standard knee-ankle-foot orthoses
(b) Swing-through gait in Scott-Craig knee-ankle-foot orthoses
(c) Reciprocating gait in a reciprocating gait orthosis
(d) Swing-to gait using a standard walker
(c) Energy expenditure in paraplegia is as follows (in order of lowest to highest): normal walking,
swing-through gait in a Scott-Craig knee-ankle-foot orthosis (KAFO), swing-through gait in a
standard KAFO, reciprocating gait in a reciprocating gait orthosis. Swing-through gait in a
reciprocating gait orthosis requires approximately the same energy expenditure as the Scott-Craig
KAFO.
96
A 19-year-old male competitive swimmer complains of medial knee pain for the last 6 weeks. He
specializes in the breaststroke, and his current practice regimen consists of sprinting 1 hour per day 4
days per week. On exam, he has no effusion or crepitus. His Lachman, McMurray and pivot shift
tests are all negative, and there is no significant laxity. His Q angle is 24° with his knee extended.
His strength is normal. Which action should be recommended?
(a) Strengthen his quadriceps, concentrating on the last 30° of extension.
(b) Modify his swimming program to 3 hours per day of endurance training 6 days per week.
(c) Quit swimming, as he does not have the knee joint architecture for the sport.
(d) Refer for arthroscopic evaluation for internal derangement.
(a) The breaststroke has an associated “whip kick” which puts stress on the medial knee. For proper
propulsion, the knee must be in a significant valgus position during leg extension. This can lead to
overuse of the adductors and the quadriceps and a condition known as “breaststroker’s knee.”
Individuals who have patellar tracking problems or a high Q angle (greater than 18° in men) with
the knee extended will be prone to patellofemoral pain. You should prescribe that this young man
work on stretching and strengthening of his adductors and quadriceps. The quadriceps
strengthening should focus on the last 30° of knee extension, which selectively strengthens the
vastus medialis. This patient has negative tests for internal derangement, such as anterior cruciate
ligament tear or meniscus tear. No laxity was noted, and referral for arthroscopy is not indicated.
97
A 25-year-old woman with multiple sclerosis is considering having a baby, and she wants your
advice. You tell her that
(a) multiple sclerosis is not compatible with pregnancy.
(b) pregnancy does not influence the long-term disease course.
(c) multiple sclerosis exacerbations are increased during pregnancy.
(d) interferon therapy poses no risks during pregnancy
(b) Pregnancy has little impact on the long-term course of multiple sclerosis. The disease tends to be
quiescent during pregnancy. Studies have shown an increased number of exacerbations in the
postpartum period. The use of interferon therapy during pregnancy is controversial. There have
been reports of successful use during pregnancy in other disease processes; however, laboratory
data indicate abortifacient properties at higher doses and some degree of organ abnormality in
laboratory animals.
98
A 45-year-old woman presents with patellofemoral pain syndrome. Which physical finding is
likely?
(a) Positive anterior drawer
(b) Tight lateral thigh structures that cross the joint
(c) Q angle less than 15°
(d) Medial patellar tilt
(b) Anterior knee pain syndrome is associated with atrophy of the quadriceps, a large (more than 15°)
Q angle, tight lateral thigh structures, positive posterior drawer, and lateral patellar tilt.
99
A 40-year-old construction worker presents with the gradual onset of aching pain in the forearm
and hand. He reports numbness of the thumb and index fingers and drops objects at work. On
exam, weakness is present in thumb opposition, wrist flexion, and finger flexion. Reflexes at the
biceps and triceps are intact. The most likely diagnosis is
(a) C7 radiculopathy.
(b) upper trunk plexopathy (Erb's palsy).
(c) median neuropathy at the elbow (pronator syndrome).
(d) carpal tunnel syndrome.
(c) The pattern of weakness and numbness is consistent with a median neuropathy in the forearm.
Pronator syndrome is an entrapment of the median nerve as it passes through the pronator teres
muscle. Depending on severity, neurologic deficits may include weakness in wrist flexion (flexor
carpi radialis), finger flexion (flexor pollicis longus, flexor digitorum superficialis, flexor digitorum
profundus digit 2/3), intrinsic hand muscles (abductor pollicis brevis, opponens pollicis), and
sensory abnormalities in a median nerve distribution. Reflexes are normal.
100
Which of the following is true regarding first-year costs for persons with complete spinal cord
injury?
(a) Average hospital charges for tetraplegia are almost double those for paraplegia.
(b) Average costs for medications and supplies are equivalent to those for paraplegics and
tetraplegics.
(c) Average costs for home modifications equal those for the acute rehabilitation hospitalization.
(d) Annual recurring costs for medical care and treatment of secondary complications approach
those for that of initial injury costs.
(a) Initial acute care and rehabilitation costs average $223,261 per person. Acute care charges are
higher for persons with tetraplegia compared with persons who have paraplegia at the equivalent
severity of injury. Charges approach $157,000 for ASIA A, B, or C tetraplegia and vary from
$69,000 to $ 87,000 for other persons with spinal cord injury. Hospital costs for rehabilitation are
more than twice as high for persons with severe tetraplegia compared with severe paraplegia.
Average annual medical costs (excluding medications, supplies, and physician costs) are just over
$9,000 per year. Given a prevalence of 180,000 persons with spinal cord injury beyond their first
year of injury, this approaches $1.65 billion for the spinal cord injury population. Costs for supplies
and medications are 30% greater for tetraplegics than for paraplegics ($3,308 vs. $2,470). Home
modifications to the residence of a person with spinal cord injury is more than $15,000, and the cost
to modify other homes owned by the person, family, or friends is an additional $5,000.
101
Regarding exercise in severe heart failure, which of the following is true?
(a) Strengthening should be done isometrically.
(b) Exercise heart rate should be at 80%-90% of estimated maximum heart rate.
(c) Rapid hemodynamic changes may occur during warm-water aquatic therapy.
(d) Telemetry is never necessary.
(c) One limitation to the use of aquatic therapy in severe heart failure is its potential to produce rapid
hemodynamic changes. Isometric strengthening can result in increased afterload, with the
possibility of deleterious effects on ventricular function. In severe heart failure, it is generally
recommended that the exercise heart rate be kept at least 10 beats per minute below the
arrhythmia/severe dyspnea level. Telemetry is recommended in this population (at least at the
initiation of their exercise program), as they are usually at the highest level of risk stratification
102
Surface electrodes for recording antidromic sural nerve conduction studies are best placed
(a) posterior to the medial malleolus.
(b) posterior to the lateral malleolus.
(c) anterior to the medial malleolus.
(d) anterior to the lateral malleolus.
(b) The sural nerve travels posterior to the lateral malleolus and is best recorded over this area.
103
Secondary injury in pediatric brain trauma is caused by
(a) hypotension, hypoxia, and hydrocephalus.
(b) growing skull fractures.
(c) coup and contrecoup cerebral contusions.
(d) diffuse axonal injuries and punctate hemorrhages.
(a) Any disorder that interferes with cerebral perfusion or oxygenation can cause further damage
following traumatic brain injury. This includes hypotension, hypoxia, increased intracranial
pressure because of cerebral edema, acute hydrocephalus, or space-occupying lesions. Midline shift
or herniation may lead to infarction because of pressure or traction on cerebral vessels. Therefore,
efforts are made to control intracranial pressure through fluid and electrolyte management,
hyperventilation, and maintenance of normal blood pressure and oxygenation. Growing skull
fractures result from the arachnoid protruding through a dural tear, producing a cyst that can
contribute to a widening skull deficit, which usually requires operative repair. This is a
complication of traumatic brain injury but not a secondary injury. Coup and contrecoup cerebral
contusions and diffuse axonal injuries are examples of primary injury
104
```
In a metal ankle joint (double action joint or Klenzak ankle joint) used in ankle-foot orthoses, which
component assists dorsiflexion?
(a) Anterior spring
(b) Anterior rod
(c) Posterior spring
(d) Posterior rod
```
(c) An anterior spring assists plantar flexion and has no specific clinical indications. An anterior rod
limits dorsiflexion and is used for weak plantar flexors, weak knee extensors, and pain with ankle
motion. A posterior spring assists dorsiflexion and is used for flaccid footdrop and knee hyperextension. A posterior rod limits plantar flexion and is used for plantar spasticity, toe drag,
and pain with ankle motion.
105
Which statement is TRUE regarding corticosteroid injection for severe carpal tunnel syndrome?
(a) Axonal injury can be successfully reversed with this procedure.
(b) To recognize nerve injection, do not dilute the corticosteroid with anesthetics.
(c) New pain and numbness lasting for more than 48 hours are normal.
(d) Local tenderness and superficial hematomas are rare and indicate a complication.
(b) Anesthetics mixed with corticosteroid can mask the pain associated with needle placement into the
nerve and should not be used. The risk of intraneural injection is real, but in experienced hands this
injection is safe. Numbness is anticipated with this injection without use of anesthetics, and helps to
confirm proper placement. Local tenderness and hematomas are common with this injection and do
not represent a complication. Persistent or worsening pain, or swelling lasting more than 48 hours,
are signs of nerve injection or neurotoxic injury. Severe carpal tunnel syndrome with axonal loss is
not reversed with this procedure.
106
A 29-year-old man returned from his Hawaiian honeymoon complaining of hand weakness. On
examination, you find the following on muscle testing: shoulder abduction 5/5, elbow flexion 5/5,
elbow extension 5/5, wrist flexion 4+/5, wrist extension 3-/5, finger flexion 4+/5, finger extension
3/5, thumb adduction 5/5, thumb opposition 5/5. What nerve is most likely affected?
(a) Axillary nerve at the humeral head
(b) Radial nerve at the spiral groove
(c) Ulnar nerve at the cubital tunnel
(d) Posterior interosseous nerve
(b) The radial nerve is the most likely nerve to be affected at the level of the spiral groove of the
humerus. This can either be due to fractures or compressive lesions (Saturday night palsy). These
patients usually have involvement of the radial innervated muscles except the triceps and anconeus.
Abductor pollicis longus is innervated by the radial nerve.
107
In a 22-year-old man who incurred an acute C5-6 fracture-subluxation (complete C5 tetraplegia),
from diving with an initial restoration of arm function includes
(a) upper extremity tendon transfers as early as possible to enhance goals for acute rehabilitation.
(b) splinting in a flat hand position to avoid tightening of the flexor tendons.
(c) a short opponens orthosis or utensil cuff to initiate self-care activities.
(d) exclusive use of a manual wheelchair to enhance upper extremity muscle strength.
(c) For persons with tetraplegia, proper hand position is maintained by resting hand splints that allow
tightening of the flexor tendons; this tightening promotes the use of tenodesis for hand function.
Functional activities improve significantly with the addition of wrist extensor muscles at the C6
level. Active wrist extensor result in tenodesis of the hand. With wrist control, patients can use a
short opponens orthosis or utensil cuff to feed themselves. While patients with tetraplegia usually
benefit from a lightweight, manual wheelchair, these patients are often appropriate for powered
mobility. The energy saved from pushing the wheelchair can be used for transfers, weight shifts,
and other activities, reducing the wear and tear on joints and soft tissues. Tendon transfers and
upper limb reconstructive surgery are considered 1 year postinjury, keeping in mind that upper limb
muscle recovery can occur over the course of up to 2 years.
108
In patients with Duchenne muscular dystrophy, decline in vital capacity tends to coincide with the
onset of
(a) limb contractures.
(b) use of orthotic/assistive devices for ambulation.
(c) wheelchair dependence.
(d) dysphagia.
(c) Scoliosis often becomes evident or exacerbated during this stage. Customized seating and
orthopedic interventions can minimize loss of vital capacity.
109
What is the major determinant of successful return to work after a work related injury?
(a) Amount of lost time
(b) Type of injury sustained
(c) Type of job
(d) Surgical intervention was required
(a) The amount of lost time is a major determinant of return to the work place. Although more
extensive injuries may more easily deter the employee from returning to work, the extent or type of
injury has not been found to be the major determinant in all worker’s compensation cases. Neither
the type of job or the type of treatment required, such as surgery, are major determinants of
successful return to work. Several studies have shown that the longer the worker is out of work
related to the injury, the more unlikely it is that he/she will return to work successfully.
110
A 40-year-old patient presents with weakness and sensory loss in the left arm after a motor vehicle
accident. An EMG study 4 weeks after the injury shows the following results:
Muscle Positive Waves Fibrillations Fasciculations Recruitment
L. Deltoid 2+ 2+ 1+ mod decreased
L. Biceps 0 0 0 normal
L. Latissimus dorsi 2+ 1+ 1+ mild decreased
L. Triceps 2+ 2+ 1+ mod decreased
L. Pronator teres 0 0 0 normal
L. Abd pollicis brevis 0 0 0 normal
L. 1st dorsal interosseous 0 0 0 normal
L. Paraspinals 0 0 0
Based on these findings what is the cause of the patient’s weakness?
(a) C6 radiculopathy
(b) Upper trunk plexopathy
(c) Posterior cord plexopathy
(d) Lateral cord plexopathy
(c) The abnormalities noted are in a posterior cord distribution.
111
To prevent contractures, which position is the correct placement for children with major burns?
(a) Shoulder in external rotation
(b) Wrist in extension
(c) Hip in flexion
(d) Metacarpophalangeal joints in hyperextension
(b) Children with major burn injuries should be placed in positions that tend to prevent contractures.
These include neck extension (no pillows); shoulders at 90° abduction and neutral rotation with
elbows, wrists, hips, and knees extended; feet at neutral dorsiflexion, metacarpophalangeal joints at
70° to 90° flexion and finger interphalangeal joints in full extension
112
Bracing for curves developing after age 3, but before puberty onset (juvenile idiopathic scoliosis)
should commence when the curve reaches approximately how many degrees?
(a) 15°
(b) 25°
(c) 40°
(d) 60°
(b) Unlike infantile idiopathic scoliosis, the juvenile type almost never spontaneously resolves, and
owing to the many years of growth during which progression can take place, extremely severe
curves can develop. Because of the very poor prognosis of this scoliosis, and the great desire to
avoid fusion at a young age, bracing becomes an extremely important method of management.
Therefore, the standard of care is to begin bracing when the curve reaches approximately 25°. It is
not necessary to brace curves less than 20°, and curves as high as 60° can still respond to a brace.
This is a much higher value than for successful bracing of adolescent idiopathic scoliosis where the
upper limit is 40° to 45°.
113
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
(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.
114
A 60-year-old woman with dysarthria and right arm weakness is admitted to your stroke unit. Her
lower extremity strength is intact. You would expect the infarct to be located in the
(a) posterior frontal lobe.
(b) ventromedial thalamus.
(c) lateral medulla.
(d) anterior limb of the internal capsule.
(d) This is a classic description of the dysarthria-clumsy hand syndrome. The lesion is most commonly
located in the anterior limb of the internal capsule but may also be seen with certain pontine lesions.
115
A 12-year-old girl complains of localized mid back pain for 3 months, with no history of trauma. She
has a non-focal examination with a prominent thoracic kyphosis and compensatory cervical and
lumbar lordosis. She also has compensatory hamstring tightness. The most likely diagnosis is
(a) idiopathic juvenile scoliosis.
(b) juvenile ankylosing spondylitis.
(c) Pagets disease.
(d) Scheuermann’s disease.
(d) These are all characteristics of Scheuermann’s disease.
116
A 52-year-old African American woman presents with a 3-month history of fatigue, weight loss,
proximal weakness, and muscle pain. Laboratory studies reveal an elevated creatine kinase level.
Which treatment would NOT be considered appropriate?
(a) Glucocorticoids
(b) Methotrexate
(c) Plasmapheresis
(d) Intravenous gamma globulin
(c) In the treatment of inflammatory myopathies such as polymyositis and dermatomyositis,
glucocorticosteroids are considered the first drug of choice. Patients refractory to steroids or unable
to tolerate high doses because of complications require an immunosuppressive agent.
Immunoglobulins are effective and are also used in patients with recurrent relapses. Plasmapheresis
and leukapheresis are ineffective in these patients.
117
The most common symptom associated with cancer and its treatment is
(a) pain.
(b) weakness.
(c) anorexia.
(d) fatigue.
(d) Fatigue is the most common complaint of cancer patients, affecting up to 78% of patients, with
70% noting that fatigue affected their daily routine.
118
A 34-year-old pregnant woman with nocturnal paresthesias of the right lateral 3 digits and pain in
the wrist and forearm is seen for electrodiagnostic studies. The studies (norms in parentheses) reveal
the following results:
Nerve Latency (ms) Amplitude (mV) Conduction Velocity (m/s)
Motor studies
R. Median – Wrist 4.2 (5)
R. Median – Elbow 4(>5) 45 (>45)
R. Ulnar – Wrist 3.4 (5)
R. Ulnar – Elbow 6 (>5) 55 (>45)
L. Median – Wrist 3.9 (5)
L. Median – Elbow 7 (>5) 52 (>45)
L. Ulnar – Wrist 3.3 (5)
L. Ulnar – Elbow 7 (>5) 56 (>45)
Muscle Positive Waves Fibrillations Recruitment
R. Deltoid 0 0 normal
R. Biceps 0 0 normal
R. Triceps 0 0 normal
R. Pronator teres 2+ 2+ decreased
R. Flex carpi radialis 2+ 2+ decreased
R. Flex carpi ulnaris 0 0 normal
R. Flex pollicis longus 2+ 2+ decreased
R. Abd pollicis brevis 2+ 2+ decreased
R. 1st Dorsal interosseous 0 0 normal
R. Cervical paraspinals 0 0
The patient’s symptoms are most likely due to an entrapment of the
(a) median nerve at the wrist (carpal tunnel syndrome).
(b) median nerve at the pronator teres muscle.
(c) median nerve at the ligament of Struthers.
(d) anterior interosseous nerve of the forearm.
(c) An entrapment of the median nerve at the ligament of Struthers could involve all median innervated
muscles of the forearm, including the pronator teres. Pronator teres syndrome usually does not
involve the pronator teres since it is innervated from a branch of the median nerve that is more
proximal. The patient does not have slowing of the median distal latencies suggestive of carpal
tunnel syndrome, and the EMG abnormalities include abnormalities in more muscles than can be
explained by an anterior interosseous neuropathy.
119
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Which finding would indicate a poor long-term outcome in a 9-year-old child with a severe traumatic
brain injury?
(a) Bladder and bowel incontinence
(b) Agitation
(c) Dysphagia
(d) Hypertension and hyperpyrexia
```
(d) Most children with severe traumatic brain injury have dysphagia, incontinence, and agitation at
some time during the recovery period. Central autonomic dysfunction (hypertension, hyperpyrexia,
sweating, tachypnea, and rigidity) is associated with worse cognitive and motor outcomes a year or
more after injury.
120
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A balanced forearm orthosis is indicated for patients with weakness in which muscle-group
combination?
(a) Deltoid and elbow flexors
(b) Deltoid and triceps
(c) Pectoralis group and pronators
(d) Pectoralis group and triceps
```
(a) A balanced forearm orthosis can be attached to a wheelchair. It consists of a forearm trough, which
is attached by a hinge joint to a ball-bearing swivel mechanism and a mount. It supports the weight
of the forearm and arm against gravity. With only minimal muscle force requirement at the
shoulder girdle and trunk, the patient can move the arm horizontally and flex the elbow to bring the
hand to the mouth. This orthosis is primarily used for patients with severe upper limb weakness
(especially the deltoid and elbow flexors), as in high quadriplegia or other severe neuromuscular
conditions. The patient must also have sufficient range of motion of the shoulder and elbow, as well
as adequate trunk stability (provided or innate) while sitting.
