SAER 2003 Flashcards

Question

Mr. Jones comes to your office complaining of a hot, painful, swollen left wrist. Additional findings on physical examination include swan-neck and boutinierre deformities, subluxation of the metacarpophalangeal joints with ulnar deviation of the digits. What will x-ray findings of his wrist reveal? (a) Chondrocalcinosis of articular cartilage (b) Severe marginal erosions with juxta-articular osteopenia (c) Bony erosion with an overhanging edge (d) Pencil-in-cup deformity

Answer 1

(b) This patient has rheumatoid arthritis which shows juxta-articular osteopenia. Gout characteristically reveals “overhanging edge” lytic lesions. Chondrocalcinosis is seen in pseudo-gout, and pencil-incup deformity is seen with psoriatic arthritis.

Answer 2

(d) Resting tremor and bradykinesia are the most common initial manifestations of Parkinson's disease. The other signs are less likely to be presenting complaints in parkinsonism.

Answer 3

(a) The taxanes, docetaxel (Taxotere) and paclitaxel (Taxol), are being used increasingly as first line chemotherapy for a variety of malignancies including ovarian, breast, and head and neck cancers. They are associated with a high incidence of sensory polyneuropathy. Fortunately, this often resolves or is significantly diminished following discontinuation of the agent. However, some patients continue to experience severe, debilitating neuropathy.

Answer 4

(c) Jobs that require lifting and material handling place the worker at increased risk for low back injury. Lifting frequency, load movement, trunk twisting and trunk sagittal angle predict medium and high-risk occupational low back pain. No risk correlation has been found for length of time sitting or standing. Although falls in the work place put the worker at risk for low back injury, the repetitive motion involved in lifting and material handling is thought to cause low back pain more frequently.

Answer 5

(b) The median nerve is just medial to the brachial artery at the elbow.

Answer 6

(a) The lack of coughing in a patient with neurologic impairment when he/she is presented with food may mean a normal swallow, but is more likely to mean silent aspiration. A normal videofluoroscopic swallowing study is unlikely in a patient with a traumatic brain injury (TBI) who is drooling and hoarse. Hoarseness may be a sign of reflux, but in a child with a TBI it is more likely to mean vocal cord abnormality.

Answer 7

(d) The criterion to describe the severity of a traumatic brain injury is the Glascow Coma Scale (GCS). GCS score of 13-15 = mild GCS score of 9-12 = moderate GCS score of 3-8 = severe

Answer 8

(d) Promoting a restorative sleep and 20–30 minutes of aerobic activity daily is recommended to treat fibromyalgia. Passive modalities are not the optimal therapeutic intervention.

Answer 9

c) Autonomic dysreflexia must be ruled out. A Foley kink, or plugged catheter can distend the bladder, causing autonomic dysreflexia with headache (and, ultimately, hypertension, piloerection and flushing). The catheter should be checked for twists and kinks and be flushed. If urine/flush return is poor, the catheter should be changed.

Answer 10

(c) Patients who receive external beam radiation therapy to the anterior neck are at risk for developing hypothyroidism. If their thyroid function tests are not monitored, they may initially present with signs and symptoms of hypothyroidism. Myopathy is a common presenting complaint. This patient is also at risk for radiation induced cervical myelopathy. However, since radiation hypofractionation techniques have become the standard of care, the incidence of this dreaded complication has significantly diminished.

Answer 11

(c) Recent studies by McDonald and by Bach showed that reduction of maximal expiratory force (MEF) to 40%–60% of normal in the 7- to 14-year-old age group was the first sign of respiratory muscle dysfunction in boys with Duchenne muscular dystrophy (DMD). The earlier and more severe decreases of MEF that are greater than the decreases in maximal inspiratory force, correspond to the clinically observed weakness of abdominal muscles, which like coughing are important in forced expiration. Vital capacity was not found to decrease until an average of 15–16 years. Low oxygen saturation is a late manifestation in DMD, developing after hypercapnia.

Answer 12

(a) Supracondylar suspension would be most indicated for an individual with a short transtibial residual limb to provide additional mediolateral support and to increase the weight-bearing surface area for more even pressure distribution. A cylindrical-shaped transtibial limb is ideal for allowing total contact between the residual limb and the socket and is not an indication for supracondylar suspension. Supracondylar suspension is also not specifically indicated for mildly adherent scar tissue. Supracondylar suspension would be difficult to utilize in a residual limb that has poor definition above the femoral condyles

Answer 13

(c) This patient has suffered a fairly significant ankle inversion sprain. The lateral collateral ligaments are injured 85% of the time with this type of injury. This patient should be placed in an air stirrup for 2 weeks, weight bearing as tolerated, using crutches as needed. A cast or cast boot is acceptable for 2 weeks but usually is not required. Contrast baths are not indicated before 48 hours following injury.

Answer 14

(c) (This question has been eliminated from the exam, therefore, it was not scored.) Choices a and b are both histamine type-2 (H2) blockers that are cognitively impairing

Answer 15

(d) Destruction of a joint due to loss of nociceptive input describes a Charcot joint.

Answer 16

(a) The clinical picture is suggestive of a polyneuropathy. Patients with hereditary polyneuropathies may have feet with high arches. Electrodiagnostic studies including nerve conduction studies remain the most important first tests in the evaluation of polyneuropathy

Answer 17

(b) The presence of sensation in the sacral (S3–S5) dermatomes in patients with motor complete injury indicates a favorable prognosis in terms of motor recovery, with pinprick sparing having the closest correlation for motor recovery. Motor segments in the zone of injury in patients with complete injury and an initial strength of 0/5 were more likely to recovery strength of 3/5 or more at 1 year if the sensation in the corresponding dermatomes was intact. Most patients originally categorized as ASIA (or Frankel) class A who progressed to ASIA class D or E had sustained traumatic brain injury with cognitive impairment and were incorrectly diagnosed initially as class A.

Answer 18

(c) Opioid-based pharmacotherapy is the current standard of care for severe cancer-related pain. Side effect management is an integral dimension of competent pain management. Opioid-induced sedation can be managed through the use of psychostimulants such as methylphenidate (Ritalin). Epidural and intrathecal drug delivery can also be used to minimize neuropsychological toxicity. Pemoline (Cylert), a psychostimulant, is not widely used because of concern over hepatotoxocity, particularly in patients with liver metastases.

Answer 19

(b) A functional capacity evaluation (FCE) is an assessment of a worker’s ability to perform workrelated activities. A functional capacity examination can be used to determine if a worker might benefit from work hardening or work conditioning, to determine whether a worker can return to his/her job, to determine if work restrictions are recommended or if job modifications are needed, and to document the worker’s activity capability. No absolute time line exists. An FCE can be used in the subacute, or maintenance phase of treatment. An FCE does not determine validity of injury but can reveal the effort a person expends to perform a task.

Answer 20

(d) Tethered cord is the most common cause of new onset spasticity in patients with myelodysplasia. Linear growth does not cause new spasticity. Symptoms of Chiari malformation include cranial nerve disorders and respiratory problems. Shunt malfunction may be associated with headaches, vomiting, eye muscle abnormalities, and sometimes abdominal symptoms.

Answer 21

(b) The shortest functional amputation level for a transtibial amputation is just distal to the tibial tuberosity. Knee flexion and extension can occur with this level of amputation because the patella tendon and hamstring tendon attachments are still present. Control of knee flexion and extension of the knee is lost with amputations proximal to the tibial tuberosity.

Answer 22

(b) The rhomboid major elevates, retracts and causes medial (downward) rotation of the scapula, but it does not depress the scapula. All the other muscles depress the scapula.

Answer 23

(d) From the information given, it is clear that this patient is functioning well overall. She has some difficulty staying awake. Of the answers given, modafinil is the medication most appropriate to help with alertness during the day. Donepezil is an acetylcholinesterase inhibitor used most often to improve memory. Buspirone is used to decrease anxiety. Tolcapone is a newer dopaminergic agent that has not been studied in populations with brain injury.

Answer 24

(c) Intra-articular corticosteroid injections have enough systemic absorption that suppression of the adrenal hypopituitary axis may be seen with repeated injections. More localized deleterious effects include skin depigmentation, soft tissue atrophy, steroid arthropathy, postinjection flare, and tendon rupture.

Answer 25

(a) The advantages of the reciprocating gait orthosis (RGO) include enabling the wearer to ambulate with a relatively stable 4-point or 2-point crutch gait. The cable mechanism prevents the patient from taking an unduly long step that would make balance recovery difficult. The torso is stabilized with an orthosis, which may also benefit patients who have thoracic spinal cord injury. Ambulation with RGO is associated with a lower pulse rate and a lower heart rate than with other trunk-hipknee- ankle-foot ortheses (THKAFOs). Velocity of the ambulation is somewhat faster and patients appear to be able to manage longer distances than with other THKAFOs. The disadvantage of the RGO is that donning is time consuming. The gait is slow and is not smooth because the pelvis is stationary momentarily during each gait cycle. The orthosis is heavy. Marked spasticity of the adductors disturbs the operation of the cable mechanism.

Answer 26

(a) The patient has developed a vertebral compression fracture. An extension brace will minimize her pain and possibly reduce further pathological compression fractures. The Knight-Taylor brace provides thoracolumbar spine control in the saggital and coronal planes. The Williams brace is a lumbosacral extension-lateral control orthotic. The chairback brace is an example of a lumbosacral flexion-extension control orthosis.

Answer 27

(d) Work conditioning is the physical conditioning portion of work hardening. It has been referred to as an aerobic training program for patients with less complex and more chronic conditions. Often these patients are not being retrained to return to a specific job. In a work hardening program the injured worker is gradually strengthened and reconditioned to the functional capacity level required to perform a given job. Work hardening has also been referred to as work simulation, work readiness training, and work rehabilitation

Answer 28

(a) Increased jitter on single-fiber electromyography is the earliest abnormality seen in myasthenia gravis. The other abnormalities noted are seen later in the disease process.

Answer 29

(b) Deep venous thromboses (DVTs) which can be diagnosed by Doppler study usually occur in the first 3 months after spinal cord injury (SCI) and are rare in prepubertal children. In lower leg DVTs the foot and leg are usually swollen. Heterotopic ossification (HO), which can be detected by bone scan, occurs in about 3% of children with SCI and has onset an average of 14 months after injury. Heterotopic ossification most commonly involves the hip. Cellulitis is usually associated with skin lesions and usually involves a discrete area. A fracture is the most likely cause of swelling in this case and can be diagnosed by plain radiographs.

Answer 30

(d) Microprocessor controlled knee units use a computerized system to automatically adjust the knee unit’s resistance over a wide range of gait speeds. With this automatic control, there is greater consistency and reliability in the knee movement during the gait cycle. These benefits give the amputee greater confidence and improve swing phase responsiveness and gait symmetry, as well. Negative aspects of the microprocessor controlled knee units are heavier weight and greater expense. These units have not been shown to improve running speed.

Answer 31

(d) This scenario is most likely retrocalcaneal bursitis. This condition is seen in middle aged to elderly persons, and may occur with overuse. A limp is common and pain is usually worse with first activity after rest. Swelling and local tenderness may be seen, and a “pump bump” may be present. This bump is a prominence created by inflammation associated with shoe wear. The local swelling is due to inflammation of the retrocalcaneal bursa. An acute Achilles tendon rupture is associated with a positive Thompson test, which consists of compressing the calf and causing the foot to plantarflex. If the tendon is ruptured, the foot will not plantarflex. The pain is not located in the bottom of the foot as would be seen with plantar fasciitis. Posterior calcaneal nerve entrapment would not cause swelling, nor would it be warm to touch.

Answer 32

(d) Of the choices presented above, the most consistent predictor of good outcome and discharge home is bladder continence. Probably the strongest overall predictor of ability is admission functional ability (which reflects severity of stroke).

Answer 33

(b) Bilateral spondylitis is diagnostic of ankylosing spondylitis. HLA-B27 is not helpful because a percentage of the normal population is positive for HLA-B27 and not all patients with ankylosing spondylitis are positive. Erythrocyte sedimentation rate is a general marker of inflammation. Enthesopathies may occur in a wide variety of inflammatory disorders, including spondyloarthropathies.

Answer 34

(c) There is evidence of more muscle fiber damage with eccentric exercise. This appears to be true for persons with myopathic disease as well as in control subjects. There is similar evidence in animal studies. The type of exercise and its potential benefits versus detrimental effects continues to be a controversial subject. However, more and more evidence suggests that exercise in persons with myopathy may not be as detrimental as once thought.

Answer 35

(d) After a successful carpal tunnel release median distal latencies improve, but often do not return to normal. Mild residual slowing is not unusual

Answer 36

(a) There are no large, randomized, controlled studies that show the long-term effects of any type of Ankle-Foot Orthosis (AFO) on function or contracture formation. Small studies have shown that both rigid and hinged AFOs improve gait efficiency by preventing plantar flexion.

Answer 37

(c) The rate of metabolic energy expenditure–mlO2/(kg•minute)–represents energy expenditure per unit of time in comparison to metabolic cost–mlO2/(kg•minute)–which is a measure of energy expenditure per unit distance, a meter. The metabolic cost of prosthetic ambulation is greater than that used in normal human locomotion and the metabolic cost of transfemoral prosthetic ambulation is greater than that in transtibial prosthetic ambulation. Because individuals who ambulate witha prosthesis slow their gait velocity, their rate of metabolic energy expenditure is relatively unchanged compared to normal ambulation at self-selected walking speeds. Because the rate of metabolic energy expenditure is maintained at a level comparable to ambulation without a prosthesis, cardiac work load is also unchanged during ambulation with either a transtibial or transfemoral prosthesis, if subjects are allowed to walk at their self-selected walking speed.

Answer 38

(b) The Waddell signs are nonorganic physical signs that are used for patients with low back pain. They are a simple screen that can be used to help identify patients who may require a more detailed psychological assessment. Three or more positive signs are a clinically significant finding. The signs include simulation, distraction, overreaction, regional disturbances and either superficial or nonanatomic tenderness.

Answer 39

(d) The guideline set by the American Association of Neurological Surgeons included avoidance of oxygen saturations of less than 90%. Cerebral perfusion pressure is a more important predictor of outcome than ICP since CPP is more directly related to metabolic delivery and ischemia. CPP is mean arterial pressure minus ICP and in this patient is 95. Pupillary response is a very important early predictor of eventual outcome.

Answer 40

(c) Nonsteroidal anti-inflammatory medications inhibit the cyclooxygenase enzyme (COX) which is necessary for prostaglandin and thromboxane synthesis. At least two isoforms of cyclooxygenase have been identified, named COX 1 and COX 2. COX 1 is in the gastric mucosa where the prostaglandin synthesis has a protective effect; COX 2 is primarily induced by inflammatory stimuli and is the target of the new COX 2 inhibitors, which have less gastric toxicity.

Answer 41

(b) The clinical presentation is that of a person with an acute cervical radiculopathy. In this setting the use of steroids is often indicated for a potent anti-inflammatory effect. The treatment is typically initiated when an inflammatory etiology is suspected and there are no contraindications such as an infection or history of peptic ulcer disease.

Answer 42

(a) Constriction rings (cock rings) to occlude venous outflow can be used if a person is having a poorly sustained erection. A vacuum pump and constriction rings can be used if a person is having no erections. To prevent skin breakdown from prolonged venous congestion within the penis, the ring should not be kept in place for more than 30 minutes. They should not be used in men with sickle cell disease. Anticoagulants are a relative contraindication to their use.

Answer 43

(d) Obesity and weight gain has consistently been shown to increase breast cancer survivors' risk of developing lymphedema.

Answer 44

(d) Lumbar supports do not prophylactically prevent low back injuries or prevent recurrence of low back pain. One study showed a decrease in lost time at work when lumbar supports were utilized with a back injury educational program. No improvement in lifting capacity has been found with the use of bracing. Workers who use lumbar supports use them as a proprioceptive reminder to use proper mechanics with lifting and other work-related activities.

Answer 45

(c) Complex repetitive discharges can only be detected with electromyography. The remainder of the discharges have manifestations that can be observed on physical examination.

Answer 46

(a) Placing a solid ankle, double-metal, upright ankle-foot orthosis in 5° of plantarflexion will increase the extension moment (forces) at the knee and this can result in knee hyperextension, especially at the time of initial contact (heel strike). Addition of a T-bar strap should not effect the knee and the addition of dorsiflexion spring assistance or a one-quarter inch heel will reduce the tendency to have knee hyperextension.

Answer 47

(d) Following anterior shoulder dislocation, the most common neural injury is damage to the axillary nerve. Gentle pendular exercises (Codman exercises) are not allowed until weeks 2–3 postinjury. Early postreduction rehabilitation should avoid active external rotation past 45° for at least 3 weeks and usually up to 6 weeks. External rotation with abduction is not allowed until 8 weeks postinjury. Return to contact sports is not allowed until isokinetic values reach 85% of normal.

Answer 48

(c) Diffusion characteristics do not change. Electromyographic guidance helps to ensure that the botulinum toxin is injected into the targeted muscle. Localization does not become more difficult with repeated injections when spasticity returns. Botulinum toxin is not metabolized by the liver. The development of neutralizing antibodies is the primary reason for loss of efficacy with repeated injections.

Answer 49

(c) (This question has been eliminated from the exam, therefore, it was not scored.) The Miller-Fisher variant of Guillain-Barré syndrome consists principally of a triad of ophthalmoplegia, ataxia, and areflexia. Altered sensation in the hands and around the mouth can also occur. Most patients first note the sudden onset of diplopia. This is generally a benign condition and does not require specific immune therapy. Pure sensory and pure motor are other forms of Guillain-Barré syndrome.

Answer 50

(a) The information provided by functional capacity evaluations (FCE) includes the worker’s capability to return to full or restricted duty, the need for work hardening, or the need for work conditioning. It can also define discrepancies between subjective complaints and objective findings. The FCE can also help determine if the worker has reached maximal medical improvement. Although general aerobic condition may be assessed, the FCE does not include formal aerobic capacity testing. The psychological assessment is important during the FCE but formal psychiatric diagnosis is not made during an FCE. Unfortunately, functional capacity evaluations are not standardized and cannot be compared. Such standardization has been proposed but currently does not exist.

Answer 51

(a) Myotonic discharges consist of repetitive waveforms of similar configuration which wax and wane in their frequency and amplitude.

Answer 52

(d) Children with juvenile rheumatoid arthritis are more likely to have systemic features, have large joints involved, and have cervical spine involvement. Adults with rheumatoid arthritis have joint destruction earlier.

Answer 53

(c) Several different types of thoracolumbosacral (TLSO) orthoses are available to control segmental spine motion in this region. A custom molded plastic TLSO provides almost total contact support for uniform pressure distribution and control of motion in all plains. A lumbosacral corset with metal stays provides support circumferentially and helps reduce spine motion primarily in the lumbosacral region. A Taylor orthosis also provides circumferential support with the addition of axillary straps. The Taylor orthosis is primarily designed to resist flexion and extension. A Jewett brace is designed to limit thoracic spine flexion by providing 3-point pressure over the sterum and pubis anteriorally and the upper lumbar spine posteriorally. This type of brace is used most commonly for individuals with thoracic spine anterior compression fractures.

Answer 54

(c) Tilting the head to the stronger side and turning the head to the weaker side (but not vice versa) are appropriate compensatory techniques. Glossopharyngeal breathing is used in pulmonary rehabilitation and has no value in dysphagia management.

Answer 55

(d) This patient has polymyalgia rheumatica. When you diagnose polymyalgia rheumatica the patient is placed on daily prednisone and should note dramatic improvement within a few days.

Answer 56

(c) Polio affects the anterior horn cells, resulting in motor axon dropout. Compensatory effects include individual muscle fiber hypertrophy of the surviving muscle fibers and increase in motor unit size due to sprouting and innervation of some of the surrounding denervated muscles. There is also an increase in fiber density as a result of re-innervation as well as atrophy and replacement of denervated muscles. This can be assessed by single fiber electromyography. Jitter also can be increased because of the re-innervated muscle fibers’ instability.

Answer 57

(a) Occult cervical fractures are most often seen at the C1 and C7 levels. By adding computed tomography (CT) scanning to the evaluation of trauma patients, a significant number of occult cervical fractures can be diagnosed. Of spinal fractures, 5%–30% are multiple and may appear at noncontiguous levels. Thus, radiographic evaluation of the entire spinal axis is necessary whenever injury at 1 region of the spine is detected.

Answer 58

(d) Peripheral training effects are largely responsible for the enhanced functional status of patients who undergo cardiac rehabilitation. Increased oxygen extraction and a wider arteriovenous oxygen difference have been described. Improved utilization of oxygen by active muscles, because of an increase in oxidative enzymes, is an important factor.

Answer 59

(d) Cumulative trauma disorders (CTDs) develop as a result of repetitive microtrauma to tissue in the setting of poor ergonomics. Any worker who performs a task requiring repetitive loading or motion is at risk. This includes keyboard operators but is not exclusive to them. The most common occupational hazard has not been determined. Often, implementing ergonomic recommendations can help reduce CTDs.

Answer 60

(b) Children with myelodysplasia have deceptively good verbal facility that creates the impression of higher intellectual functioning than is found on formal testing (“cocktail party syndrome”). Children with cerebral palsy, autism, and muscular dystrophy do not typically demonstrate this finding.

Answer 61

(c) High-profile, dynamic elastic response prosthetic feet and ankle components such as the Flex-Foot and Springlite are primarily indicated for individuals who are expected to be community ambulators and are able to ambulate at variable cadences. This class of prosthetic components is also used for individuals participating in running and sports activities. Therefore, this class of components would be most indicated for the individual with a transtibial amputation interested in returning to running. An individual who farms would likely benefit from a prosthetic foot and ankle system which is more accommodative over uneven surfaces.

Answer 62

(c) This child has Legg-Calvé-Perthes disease. This is avascular necrosis of the femoral head (also known as idiopathic osteonecrosis of the femoral head) and typically affects children between the ages of 4 and 8 years. Boys are affected 4 times more than girls are, and it is unilateral in 90% of children. It is uncommon in African American children. The bone dies and loses its structural integrity, leading to collapse of the femoral head with deformity and arthritis. An abduction brace is worn all day in an attempt to position the femoral head in the acetabulum. This will hopefully lead to a more spherical head of the femur. The femoral head can revascularize and remodel, but this occurs over several months. Osteotomy is usually reserved for older children.

Answer 63

(b) Hypoxia in the setting of brain injury is associated with poor outcome. Maintaining perfusion pressure and avoiding hypotension are important critical care measures to avoid secondary complications in brain injury. Inducing hypothermia has not been found to improve outcome in patients with brain injury.

Answer 64

(d) The Codman pendulum exercises are recommended to treat adhesive capsulitis (frozen shoulder).

Answer 65

(d) All the definitions are correct except for the definition of hypesthesia, which is not only diminution to painful stimuli but also diminished sensation to any sensory modality. Paresthesias can also be described as abnormal sensations in the absence of stimulation.

Answer 66

(a) Wrist extension via extensor carpi radialis results in passive shortening of the (finger) flexor tendons. This phenomenon is termed tenodesis.

Answer 67

(c) For both functional and diagnostic testing, patients must proceed to 85% of their age-adjusted maximal heart rate. Otherwise half of the abnormalities will be missed. Patients on beta blockers should be tested to a work load that would incur oxygen consumption of 80% of maximal oxygen consuption (V02.max).

Answer 68

(a) Disablement as defined by the World Health Organization is the term that summarizes all the effects of the injury or illness, impairments, activity limitations, and barriers to participation experienced by the individual. Workers receiving disability compensation have a disincentive to return to work. Reforms have been made to allow workers to investigate their ability to return to the work force without losing benefits. Disablement does not relate to advancement in the workplace.

Answer 69

(d) Typical settings are 20Hz for the low frequency filter and 10,000Hz for the high frequency filter. Allowing such a narrow bandwidth will cause distortion of the recorded potentials. It would have no effect on the input impedance or common mode rejection ratio.

Answer 70

(a) A Syme amputation (A) is ankle disarticulation with tapering of the medial and lateral malleoli and preservation of the heel pad for soft tissue coverage and distal weight bearing. A Boyd hindfoot (B) amputation is a talectomy and calcaneal-tibial arthrodesis after forward translation of the calcaneus. A Chopart level (C) amputation is performed at the mid-tarsal level with sparing of the talus and calcaneus. A tarsal-metatarsal disarticulation (D) is also referred to as a Lisfranc amputation.

Answer 71

(a) This patient has a seronegative spondyloarthropathy, ankylosing spondylitis. This usually begins in the patient’s twenties and presents with pain in the low back and sacroiliac area. An advanced case of this disease will show a patient with fused sacroiliac joints and ossification of the anterior longitudinal ligament and posterior facets. This does not spare the thoracic spine but ascends from the sacroiliac joints to the cervical spine, resulting in a C-curve of the spine. Ankylosing spondylitis has a positive human leukocyte antigen B27 in 90% of patients and a negative rheumatoid factor, negative antinuclear antibody and a normal erythrocyte sedimentation rate.

Answer 72

(b) Meningiomas are the second most common form of primary tumors. Gliomas are the most common. Glioblastoma multiforme has a median survival rate of less than 1 year. Treatment side effects do affect outcome. Metastatic disease comprises 50% of central nervous system tumors.

Answer 73

(d) Risk factors for falling in the elderly include polypharmacy, particularly sedative use, cognitive impairment, lower extremity disability, palmomental reflex, foot problems, peripheral neuropathy and poor balance.

Answer 74

(a) Electrodiagnostic testing at this point would be an appropriate test, given that the patient is 3 weeks postinjury. It could help differentiate a pre- versus postdorsal root ganglion lesion. Although radiologic studies can assess for possible root avulsion they do not assess the physiologic function of the peripheral neural elements.

Answer 75

(b) Bladder cancer is the fifth most common neoplasm and the twelfth leading cause of cancer mortality in the United States. Known risk factors for bladder cancer include male gender, smoking, occupational exposure to aromatic amines and schistosomiasis. In studies of spinal cord injury featuring age-matched and gender-adjusted standardized data, however, bladder cancer has generally been found to be far more prevalent. When looking at independent variables, which point to a higher risk of bladder cancer, only bladder management method and age at spinal cord injury significantly predicted bladder cancer. ASIA classification, level of spinal cord injury and a history of bladder calculi did not contribute significantly. Risk of bladder cancer is the highest in individuals who have used an indwelling catheters for longer than 10 years. The relative risk of bladder cancer from indwelling catheter use is relatively unchanged when adjusted for smoking status. Multiple urinary tract infections is not a risk factor.

Answer 76

(c) In a large series, cardiac patients with LVEFs less than 30% had normal hemodynamics and 28% attained a work capacity of 100 watts. Thirty-three percent of patients with LVEFs greater than 45% had abnormal hemodynamic responses and lower work capacities. These data indicate that perfomance capacity is largely dependent on peripheral adaptations and that LVEF has limited predictive capacity.

Answer 77

(c) This can be noted using a trigger and delay line and observing a single motor unit firing repetitively. The other abnormalities are not seen in myasthenia gravis.

Answer 78

(b) Hip subluxation is the most likely cause of knee pain in a child with T6 ASIA B SCI. Pain from hip pathology is often referred to the knee in children. While hip adductor spasticity contributes to subluxation or dislocation, the spasticity itself is not painful. Dysesthetic pain is usually generalized. An abnormal knee examination is usually found in a knee injury that causes pain

Answer 79

(b) One advantage of a voluntary-closing hook terminal device is the ability to adjust the amount of pinch force by adjusting pressure on the cable control. This improves the ability to manipulate fragile objects. A voluntary opening terminal device uses elastic bands to determine the pinch force and the number of bands would have to be reduced to decrease the pinch force. When carrying objects, voluntary-closing terminal devices require constant cable tension and this can result in quicker fatigue. The ability to visualize the object being manipulated would not be dependent upon whether the terminal device is voluntary closing or voluntary opening.

Answer 80

(c) The first step would be to make sure the patient is neurovascularly intact. The next step would be to obtain bilateral shoulder films with the patient holding and not holding 10-pound weights to accentuate any laxity present. Bilateral films are necessary as the patient may have lax ligaments in both shoulders. A scapular Y view is used for shoulder dislocations. An axillary radiograph is used for shoulder dislocations and will also evaluate the glenoid.

Answer 81

(a) Alcohol-induced neuropathy involves both motor and sensory fibers and is typically axonal in nature rather than demyelinating. Diabetic neuropathy is usually a mixed motor/sensory and mixed axonal/demyelinating process. Guillain-Barré syndrome is primarily demyelinating. Lead neuropathy affects primarily motor fibers and is axonal in nature.

Answer 82

(c) The prevalence of pain in spinal cord injury (SCI) has been reported to be as high as 94%. It is reported to interfere with activities of daily living in 5% to 45% of patients with spinal cord injury. The onset of SCI pain typically occurs within the first year of injury in the majority of patients. Pain is reported to decrease in intensity and frequency over time. Factors related to self-reported pain include patients with older age, incomplete spinal cord injury, cauda equina injuries, cervical spinal cord injury, central cord syndrome, gunshot wound injury, and syringomyelia.

Answer 83

(a) Supplemental feeding of malnourished patients leads to improved respiratory muscle endurance and increased respiratory muscle strength. These improvements occur without changes in skeletal muscle.

Answer 84

(b) During civil litigation, the physiatrist may be asked to comment on causality of an injury. The determination that 1 condition caused another condition should be determined on a “reasonable degree of medical certainty.” In this setting “probable” indicates that the physician believes there is a greater than 50% chance that condition A caused condition B. The term “possible” indicates that the physician believes there is a less than 50% chance that 1 event caused another condition.

Answer 85

(b) With all of the studies being normal a diagnosis of multiple sclerosis should be considered. Of those listed the only study that might provide any useful information would be the somatosensory evoked potentials.

Answer 86

(a) The control cable for opening the terminal device of a standard transradial prosthesis using a voluntary-opening terminal device passes posterior to the elbow joint, along the posterior arm, and attaches to the posterior support strap of a figure-of-8 harness. This arrangement allows glenohumoral flexion to produce tension in the cable and open the terminal device. Glenohumoral extension and biscapular adduction decrease tension on the control cable. Biscapular elevation would not produce cable tension required for terminal device operation.

Answer 87

(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.

Answer 88

(a) The apolipoprotein-Î4 has been linked both to Alzheimer disease and to chronic effects of traumatic brain injury.

Answer 89

(a) Extraskeletal manifestations of ankylosing spondylitis include uveitis/iritis, aortic regurgitation, and enthesopathy

Answer 90

(b) Most patients with Bell's palsy usually present with sudden unilateral facial weakness. Persons of any age can be affected. Men and women are affected equally and in about 2%–9% of patients the condition can be recurrent. Very rarely it affects both the facial nerves.

Answer 91

(d) Shoulder and neck pain are common following spinal cord injury (SCI). The pain may arise from the neck, shoulder, girdle, or the glenohumeral joint. Pain may be a symptom of post-traumatic syringomyelia or a manifestation of cervical disc degeneration. The prevalence of shoulder pain in persons with SCI is estimated to be 30% to 50%. Rotator cuff tear, bursitis, tendonitis and impingement have all been reported. While the diagnosis of these disorders is similar to that in the able-bodied population, the treatment is not. In a person with SCI and upper limb pain, rest is often not possible. Pain is often related to overall posture and poor biomechanics. Strengthening of scapular stabilizers can help to correct this imbalance. Immobilization should be avoided. Pain relief is the focus, and may include: relative rest (not to interfere with a person’s independence), medications, injections, icing, ultrasound, transcutaneous electrical nerve stimulation, and/or accupuncture.

Answer 92

(c) Patients with restrictive lung disease, contingent on the underlying etiology, will rely on purely diaphragmatic or paradoxical breathing. Sputum production, auxillary muscle use, and hyperresonant lung sounds are characteristic of patients with predominant oxygenation impairment. Pursed lip breathing is used to prevent end expiratory airway collapse

Answer 93

(c) Maximum medical improvement is defined as the time when no improvement is likely to further be achieved after a work-related injury. This definition is exclusive of the amount of time spent in physical therapy, the worker’s subjective complaints, or whether or not the worker is able to return to his/her previous job. A worker may reach maximum medical improvement and continue to have impairments that prevent return to his/her former job.

Answer 94

(a) The presence of an insensate thumb and index finger with a normal median sensory nerve action potential (SNAP) recorded from the index finger is indicative of a lesion proximal to the dorsal root ganglion, such as root avulsion. Positive waves in the paraspinals are usually seen 1 week post onset. While the full EMG findings may not be apparent for 3 to 4 weeks, the data presented are sufficient to draw conclusions.

Answer 95

(c) A basilar skull fracture is often associated with a permanent sensorineural hearing loss. Other traumatic brain injuries may be associated with hearing loss, but this is less common. All patients with basilar skull fracture should be assumed to have a hearing loss and have audiological evaluation as soon as possible.

Answer 96

(c) Trauma is the most common cause of upper extremity amputation in adults. Malignancy is a more common cause of amputation in the pediatric population. Upper extremity amputations occur most commonly in the 20- to 40-year-old age group, as a result of trauma and work related accidents. The dominant extremity is affected more commonly and amputations at the transradial level are the most common level of upper extremity amputation. Upper extremity amputations occur much less frequently than lower extremity amputations. Upper extremity amputations account for approximately 20% of all major limb amputations

Answer 97

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

Answer 98

(d) Clinical presentation is not nonspecific. Patients often complain of severe headaches (“worst of their lives”) and present with loss of consciousness. Atriovenous malformation present with hemorrhages earlier in life, in the second or third decade. Aneurysms are most commonly found in the anterior region of the circle of Willis, particularly near branches of the anterior communicating, internal carotid, and middle cerebral arteries.

Answer 99

(a) The World Health Organization defines osteoporosis as bone mass 2.5 standard deviations below normals. A history of fracture is not part of the definition.

Answer 100

(a) The patient's main weakness is proximal and she has sufficient ankle dorsiflexion and knee extension strength. Hence she would not benefit just with knee-ankle-foot orthoses. Reciprocal gait orthoses are designed to help children with active hip flexion but no hip extension. Furthermore, both these options would be too bulky for such a patient to handle efficiently. A standard walker would result in a bent forward posture and would limit the patient's gait speed. Forearm crutches would allow a more upright posture and an alternate 2-point gait or a 4-point gait.

Answer 101

(a) The role of surgery is controversial in fractures of the thoracic spine and thoracolumbar junction. Patients with complete injuries do not have significantly improved neurologic function after decompression. However, individuals with incomplete injuries may benefit from surgical intervention. Indications for emergent surgical treatment include progressive neurologic deterioration, and expanding epidural hematoma. Because it may destabilize the spine, laminectomy is infrequently indicated in acute spinal cord injury. Initial management of penetrating spinal injury differs from that of other traumatic spinal cord injury. Operative treatment is often not warranted since neither bullet removal nor spinal debridement has been associated with a lower risk of infection, diminished pain, or enhanced neurologic recovery. The risk of lead toxicity rarely necessitates bullet removal. Indications for surgery after penetrating injury include persistent cerebral spinal fluid leak, early progressive neurologic deterioration with bone, missile fragments, or hematoma in the spinal canal, and injuries involving the cauda equina.

Answer 102

(a) During otherwise benign upper respiratory tract infections, patients with predominantly ventilatory impairment generally develop acute respiratory failure due to ineffective coughing. When peak cough flows are less than 300L/min patients should be taught maximal insufflation techniques

Answer 103

(a) A worker may have 2 financial disincentives to return to work. First, employees usually receive a portion of their salary while unable to work, if the injury occurred while the worker was performing his/her job. Second, the worker may not want to return to work if monetary gain is being sought through pending litigation.

Answer 104

(d) Guillain-Barré syndrome (acute idiopathic demyelinating polyradiculoneuropathy) commonly affects the most proximal portion of the nerve while sparing the main nerve trunk in the early stages. While motor conduction velocities obtained with ordinary techniques may be normal, Fwave studies help detect proximal abnormalities.

Answer 105

(a) The typical “myopathic gait” seen in early Duchenne muscular dystrophy is caused by weakness of the gluteus maximus and quadriceps muscles. In order to maintain upright posture the child assumes the hyperlordotic stance. Contractures of the gastrocsoleus and iliopsoas muscles occur later in the disorder.

Answer 106

(d) Small diameter casters on a wheelchair reduce the chair’s turning radius, which gives it greater maneuverability. These casters frequently are mounted on wheelchairs used for sports such as basketball. Smaller diameter casters are less well suited for outdoor activities over rough terrain. The size of the caster does not affect the maintenance required and does not improve wheelchair stability on inclines. Hard, narrow casters are typically recommended for mobility over smooth, level surfaces whereas wider, larger casters are better for mobility over uneven, rough surfaces.

Answer 107

(a) A Grade 1 concussion has no loss of consciousness (LOC) and symptoms which resolve in less than 15 minutes. Participants may return to play only after being asymptomatic with normal neurologic examination at rest and with exercise after 15 minutes provided there has been only 1 insult. A Grade 2 concussion has no LOC, but symptoms last more than 15 minutes. These participants may return to play after 1 week after a single insult (after 2 weeks for multiple insults). A Grade 3 concussion is characterized by LOC of any duration, either for seconds (brief) or minutes (prolonged). This participant may return to play after 1 week following a brief LOC, 2 weeks after prolonged LOC, and 1 month or longer after multiple insults with LOC. There is no Grade 4 concussion in the American Academy of Neurology grading system.

Answer 108

(b) Early seizures occur within the first week. Late seizures are either simple partial or complex partial. Alcohol is not a risk factor for developing late post-traumatic seizures.

Answer 109

(a) There are many secondary causes of osteoporosis. Drug induced osteoporosis is seen with alcohol, heparin, steroids, phenytoin and tobacco. Other causes include immobilization, multiple myeloma, and endocrine related syndromes such as hyperthyroidism, hyperparathyroidism, and diabetes mellitus type II.

Answer 110

(d) Diabetes-related peripheral neuropathy involves both motor and sensory fibers and both the axon and myelin are affected. Sensory fibers are the earliest to be affected and autonomic involvement is common. Tight serum glucose control limits progression of the neuropathy, but does not help recovery.

Answer 111

(a) Amitriptyline, a tricyclic antidepressant is among the classic first line treatments in neuropathic pain. Most common side effects related to tricyclic antidepressants are related mainly to the anticholinergic effects and include dry mouth, urinary retention, and sedation. For this patient who has difficulty sleeping, as well as urinary leakage between catheterizations, the anticholinergic sideeffects may prove to be of benefit. Trazodone has not been demonstrated to reduce pain in for spinal cord injury. Paroxetine causes insomnia and sexual dysfunction and therefore would not be appropriate in this patient. Venlafaxine, sertraline, and fluoxetine have proven to be of limited benefit for neuropathic pain.

Answer 112

(d) Doxorubicin (Adriamycin) and herceptin (Trastizumab) are increasingly common antineoplastics used in primary breast cancer treatment. Both are associated with cardiac toxicity. Patients who receive either agent have a multigated angiogram (MUGA) scan prior to the initiation of chemotherapy to establish baseline cardiac function. Signs or symptoms suggestive of cardiac failure indicate the need for a repeat MUGA scan and referral to a cardiologist

Answer 113

(a) The worker at the computer keyboard may need several adjustments to avoid excessive wrist extension. Raising the chair height to allow the forearm to remain horizontal to the floor allows the wrist to remain in a neutral position. Increasing the height of the mouse, angling the forearms towards the keyboard, and lowering the chair will all increase wrist extension.

Answer 114

(b) For testing of ulnar conduction around the elbow, flexion of 45° or greater is preferred because conduction studies frequently show slowing in the elbow segment when the fully extended position is used. The discrepancy is thought to arise from the underestimation of the actual length of the nerve when using surface distance measurement.

Answer 115

(d) Approximately 70% of children with hemiplegia have seizures. About 50% of children with tetraplegic cerebral palsy have seizures. Seizures are rare in children with diplegia or athetosis.

Answer 116

(d) All of the shoe modifications listed would be appropriate for an individual with loss of protective sensation except for the use of a solid steel shank built into the sole of the shoe. This modification would decrease the accommodative properties of the shoe and may increase the potential for skin breakdown.

Answer 117

(c) Muscle energy technique is used to increase mobility of a hypomobile segment, increase functional range of motion, allow the return of symmetrical motion to affected segments, strengthen weakened muscles, and lengthen contracted or spastic muscles. It uses isometric contractions, not isotonic ones. It is not used for unstable segments, and does not improve proprioception or focus on facilitating volitional activity.

Answer 118

(c) Risk factors for HO include: long bone fractures, spasticity, prolonged immobilization, and prolonged coma

Answer 119

(a) Factors associated with permanent institutionalization after hip fractures are age greater than 80 years, lack of involvement by family members, insufficient physical therapy at a skilled nursing facility, and pre-existing dementia.

Answer 120

(d) The patient has symptoms suggestive of upper motor neuron involvement, given extensor plantar responses. This finding would point away from a neuromuscular junction disorder such as myasthenia gravis. These symptoms could indicate multiple sclerosis but the clinical picture described is more typical of amyotrophic lateral sclerosis. Needle exam of the muscles can help confirm lower motor neuron findings.

Answer 121

(c) The primary risk factor for serious urologic complications such as vesicoureteral reflux and deterioration of renal function in persons with detrusor external sphincter dyssynergia is that of elevated intravesical pressure. For this reason, it is essential to determine urinary storage and leak point pressures. In general, damage to the upper urinary tract can be avoided if voiding pressure is maintained less than 60cm of water while the maximum filling pressure or leak point pressure should be less than 40cm of water. For this patient who is having no episodes of leaking between his every 6-hour catheterizations, continuation of current program is reasonable. If on follow-up, his leak point pressure exceeds 40cm of water, conversion to a low pressure system via anticholinergics would be reasonable. The use of a cholinergic agonist (Urecholine) would be contraindicated, since this agent may increase the intravesical pressure.

Answer 122

(c) The patient’s presentation includes virtually all of the clinical characteristics of AIDS dementia complex (ADC). This is a relentlessly progressive encephalopathy whose presentation is typical of subcortical dementia. It is a late complication of AIDS, usually occurring when the antigenic marker on hilpir T cells (the CD4 count) falls below 250/ml. While each of the other choices can complicate AIDS, it would be unusual for them to present with the constellation of signs and symptoms seen in this patient.

Answer 123

(b) Compression of the ulnar nerve at the elbow is a common occurrence among computer users. Etiologies include compression of the nerve against the chair armrest or combined elbow flexion with pronation. Elbow extension and supination reduce tension on the ulnar nerve at the elbow.

Answer 124

(d) Vincristine can cause an axonal peripheral neuropathy. The others listed are demyelinating peripheral neuropathies.

Answer 125

(a) The 1-year-old child should be fit with a simple prosthesis which suspends securely and allows for growth. The knee joint should be added between 3 and 5 years. The SACH foot is most commonly prescribed because of its simple design and durability. All prostheses for growing children should incorporate a removable growth liner in the socket.

Answer 126

(a) With a radial nerve injury at the level described, there is loss of wrist and metacarpal extension because of denervation of the forearm extensor muscles. A dorsal wrist-hand-finger orthosis that holds the wrist, fingers, and thumb in extension and permits flexion of the digits with a low-profile outrigger is used to substitute for this loss of function. This type of orthosis would be inappropriate for the other conditions described.

SAER 2003 Flashcards

(150 cards)