SAER 2004

Question 1

According to the Consortium for Spinal Cord Medicine’s Clinical Practice Guidelines for the
Prevention of Thromboembolism in Spinal Cord Injury, individuals with motor incomplete (ASIA
class C or D) spinal cord injury should receive
(a) warfarin (Coumadin), international normalized ratio target: 2–3.
(b) low molecular weight heparin.
(c) inferior vena cava filter.
(d) unfractionated heparin, 5000 units every 12 hours.

Answer 1

(d) According to the guidelines for the prevention of thromboembolism in spinal cord injury, patients
with low risk motor incomplete injuries require only compression hose and compression boots;
those with intermediate risk require unfractionated heparin, 5000 units every 12 hours. Patients
with a motor complete injury should receive either unfractionated heparin to a high normal
activated partial thromboplastin time (aPTT) or low molecular weight heparin twice daily. Persons
with a motor complete injury with other risk factors including lower limb fracture, risk of
thrombosis, cancer, heart failure, or other compromising factors may require an inferior vena cava
filter in addition to the prescribed drugs.

Question 2

In order to minimize myocardial oxygen requirements in a patient with known coronary artery
disease during low intensity resistive exercise it is best to prescribe
(a) isometric supine exercises.
(b) isometric standing exercises.
(c) isotonic supine exercises.
(d) isotonic standing exercises.

Answer 2

(d) With low intensity exercise the rate pressure product (RPP), a valid surrogate measure for
myocardial oxygen consumption, is higher for supine than standing activities. At higher exercise
intensities the situation is reversed and the RPP is higher for standing activities. Isometric
contractions greater than 15% of maximum cause continued increase in the RPP until fatigue limits
the duration of contraction. For patients at risk for cardiac ischemia, low intensity, isotonic,
standing exercises should be prescribed to avoid elevation of the RPP.

Question 3

A 45-year-old auto mechanic with a history of low back pain and a herniated disc presents to you
with 2-day history of leg pain, numbness in the lower extremity, stumbling, and 2 episodes of
urinary incontinence. Your recommendation includes
(a) Ibuprofen, ice, relative rest, pelvic tilts, and repeat magnetic resonance imaging this week.
(b) Lumbar epidural steroid injection and physical therapy.
(c) Immediate magnetic resonance imaging and referral to a spine surgeon.
(d) Acetaminophen, ultrasound, light duty for 5 days, and physical therapy.

Answer 3

(c) In this patient with known herniated disc now with urinary incontinence the primary concern should
be to evaluate for cauda equina syndrome. The MRI is necessary to determine if an extruded disc is
causing the current symptoms. Surgery in the acute setting is essential to achieve neurologic
recovery.

Question 4

A 2-year-old patient with spinal muscular atrophy type 2 (intermediate form) presents with a 25°,
C-shaped scoliosis. What is the best treatment option at this time?
(a) Muscle strengthening
(b) Electrical stimulation
(c) Spinal fusion
(d) Spinal orthosis

Answer 4

(d) Muscle strengthening will not reduce the curve or prevent it from progressing and is not easily
accomplished in 2-year-old children. Posterior or anterior spinal fusion is not indicated with a
curve of this size and is to be avoided in a young child if at all possible. Spinal orthotics are used in
young children with spinal muscular atrophy to improve sitting balance and to attempt to halt curve
progression.

Question 5

Which knee component is preferred in the prosthetic prescription for an 80-year-old debilitated,
dysvascular, diabetic transfemoral amputee?
(a) Single axis
(b) Polycentric
(c) Pneumatic
(d) Manual locking

Answer 5

(d) A manual-locking knee is indicated for new unstable amputees and those who need utmost stability
because of muscular weakness or poor coordination. The other components are generally used in
persons with less risk of falling.

Question 6

prolonged extrication from his vehicle and lost consciousness at the scene of the accident. Head
computed tomography (CT) scan was notable for a small subarachnoid hemorrhage. He has had
several episodes of hypotension and hypoxemia since admission. What information in this clinical
case makes diffuse axonal injury highly likely?
(a) High-speed motor vehicle collision
(b) Subarachnoid hemorrhage on head CT scan
(c) Episodes of hypoxia and hypotension
(d) Prolonged extrication from vehicle

Answer 6

(a) Diffuse axonal injury is most commonly seen after high-speed motor vehicle collisions, particularly
when immediate loss of consciousness occur

Question 7

A 13-year-old boy presents with waddling gait and difficulty in climbing stairs. On examination, he
demonstrates significant weakness in his proximal lower extremity muscles, especially the
quadriceps, and some calf hypertrophy. What is the genetic inheritance of this disorder?
(a) Autosomal dominant
(b) X-linked recessive
(c) Autosomal recessive
(d) No genetic linkage

Answer 7

(b) The abnormal gene for Duchenne and Becker muscular dystrophy (DMD, BMD, respectively) is on the
short arm of the X chromosome at position Xp21Reference. Both DMD and BMD are inherited Xlinked
recessive diseases affecting primarily skeletal and myocardial muscles. Dystrophin is a large
cytoskeletal protein in the subsarcolemmal lattice, the protein that stabilizes the plasma membrane
during muscle contractions.Mutations in the dystrophin gene that result in a complete loss of
dystrophin lead to the DMD phenotype. Mutations that cause a reduced, truncated, or dysfunctional
form of dystrophin to be produced lead to the BMD phenotype. Both DMD and BMD are progressive
myopathies, although DMD is much more severe and is universally fatal. BMD shows a similar pattern
of muscle weakness to DMD but with later onset and much slower rate of progression.

Question 8

Compared to persons with traumatic spinal cord injury, persons with non-traumatic spinal cord
injury are more likely to be
(a) under the age of 35 years.
(b) female.
(c) tetraplegic.
(d) single.

Answer 8

(b) Persons with nontraumatic spinal cord injury (SCI) are older, more likely married, female, retired,
and have significantly more paraplegia and incomplete injury than persons with SCI of traumatic
etiology, with neoplasm (53%) and cervical spondylosis (25%) as the leading causes of
nontraumatic injury.

Question 9

A pulmonary rehabilitation patient has a temperature of 101.5° and is breathing at a rate of 10
breaths per minute. In order to optimize his percent hemoglobin saturation at a given O2 partial
pressure, it would be best to
(a) administer an antipyretic and encourage him to breathe more rapidly.
(b) not treat his fever, but encourage him to breathe more rapidly.
(c) administer an antipyretic and encourage him to maintain his current respiratory rate.
(d) not treat his fever and encourage him to maintain his current respiratory rate.

Answer 9

(a) A number of different factors have the capacity to shift the hemoglobin-oxygen dissociation curve.
Acidosis, elevated temperature, and increased PCO2 all cause the curve to shift to the right. Thus,
controlling this patients fever and encouraging him to expire more rapidly thereby reducing PCO2
and acidosis and would increase the degree of hemoglobin saturation at a given O2 partial pressure.

Question 10

The owner of a landscape business is interested in implementing a program to reduce low back
injuries in his workers. Which therapeutic exercise program has been shown to reduce the risk of
low back injuries?
(a) Lumbar extension exercises
(b) Lumbar flexion exercises
(c) Lumbar spine stabilization exercises
(d) No specific group of exercises reduces risk

Answer 10

(d) No specific lumbar spine strengthening program has been shown to prevent low back pain in the
work place. Spine strength is not a predictor of reduced risk for onset of low back pain.

Question 11

The most common spinal problem seen with achondroplasia during childhood is

(a) kyphosis.
(b) scoliosis.
(c) spinal stenosis.
(d) low back pain.

Answer 11

(a) While scoliosis may occur in children with achondroplasia, it is less common than kyphosis, which
begins in infancy. Spinal stenosis occurs frequently in individuals with achondroplasia, with 38
years being the average age of symptom onset. Low back pain is extremely frequent in adults with
achondroplasia, but rare in children. Progressive kyphosis that occurs in infants and young children
with achondroplasia is treated with a spinal orthosis.

Question 12

How much knee flexion is required to descend stairs step over step after a total knee replacement?

(a) 45°
(b) 70°
(c) 90°
(d) 110°

Answer 12

(d) Descending stairs requires 110° knee flexion.

Question 13

What is the pathophysiology of Duchenne muscular dystrophy?

(a) merosin deficiency
(b) abnormally low levels of dysferlin
(c) absence of dystrophin
(d) mutations of alpha-sarcoglycan

Answer 13

(c) The absence of dystrophin is the basis of the pathophysiology of Duchenne muscular dystrophy
(DMD). Most genes in the affected area of the X chromosome encode for components of the
dystrophin-glycoprotein complex (DGC), an assembly of transmembrane and membrane-associated
proteins that form a structural linkage between the F-actin cytoskeleton and the extracellular matrix in
muscle. The proteins that comprise the DGC are organized into 3 subcomponents, the cytoskeletal
proteins, the sarcoglycans and the sarcospan. Many of the different types of muscular dystrophies arise
from primary mutations in genes encoding components of this complex. However, the other choices
noted above are not involved in DMD or Becker MD. Deficiencies in those proteins are associated
with forms of limb girdle muscular dystrophy

Question 14

What is the leading cause of traumatic spinal cord injury in the United States?

(a) Falls
(b) Sports related injury
(c) Gunshot wound
(d) Motor vehicle crash

Answer 14

(d) The leading cause of traumatic spinal cord injury in the United States is motor vehicle crash. The
incidence of spinal cord injury from gunshot wounds is decreasing nationally; falls are now the
second most common cause nationwide, followed by sports related injuries.

Question 15

Electrophysiologic findings of compound muscle action potential conduction block and temporal
dispersion, prolonged minimum F-wave latency, and reduced conduction velocity would most
likely be seen in
(a) Charcot-Marie-Tooth disease.
(b) myasthenic syndrome.
(c) Guillain-Barré syndrome.
(d) amyloidosis.

Answer 15

(c) All the findings mentioned are features associated with an acquired demyelinating condition such as
Guillain-Barré syndrome or acute inflammatory demyelinating polyradiculoneuropathy (AIDP).
Hereditary motor sensory neuropathies do not usually have temporal dispersion of compound
muscle action potentials. Myasthenic syndrome is a neuromuscular junction disorder and
amyloidosis is associated with a form of axonal peripheral neuropathy.

Question 16

What acquired upper extremity amputation is most common in adults?

(a) Dominant extremity at the transradial level
(b) Dominant extremity at the transhumeral level
(c) Non-dominant extremity at the transradial level
(d) Non-dominant extremity at the transhumeral level

Answer 16

(a) Acquired upper limb amputations in adults occur most commonly in males between the ages of 21
and 64 years. These amputations result frequently from work-related accidents or trauma and are
most common in the dominant limb at the transradial level. In contrast, congenital upper limb
deficiencies occur most commonly on the left side at the transradial level.

Question 17

A 30-year-old man with a recent traumatic brain injury has frequent episodes of emesis with
gastrostomy tube bolus feedings despite receiving agents to facilitate gastric emptying. The most
appropriate next course of action is to
(a) switch the tube feeding formula.
(b) switch to continuous tube feedings.
(c) order a gastric endoscopy.
(d) place a jejunostomy tube.

Answer 17

(b) Intolerance to feeding can be related to increased gastric distention, and adjusting from bolus to a
slower rate with longer feeding time may provide relief. Converting to a jejunostomy is appropriate
if simpler measures fail

Question 18

A 35-year-old man with history of psoriatic arthritis complains of localized low back pain
insidious in onset. The pain is worse in the morning and improves as the day progresses. What is
the most likely cause of his back pain?
(a) Piriformis strain
(b) Sacroiliitis
(c) Quadratus lumborum strain
(d) Discitis

Answer 18

(b) Sacroiliitis occurs in patients with spondyloarthropathies such as psoriatic arthritis, reactive
arthritis, enteropathic arthritis, and ankylosing spondylitis

Question 19

The circulatory system’s response to exercise is characterized by

(a) parasympathetically mediated vasoconstriction of the skin.
(b) vasodilatation in active muscle groups mediated by local factors.
(c) sympathetically mediated vasodilatation of viscera.
(d) an increase in total peripheral vascular resistance.

Answer 19

(b) During vigorous exercise, sympathetically mediated vasoconstriction occurs in the skin and viscera.
Vasodilatation in active muscle groups is mediated by local factors including potassium ion
concentrations, increases in osmolarity, changes in adenosine nucleotide concentrations, and
decreasing pH. Muscle blood flow may increase up to 15-20 times baseline. The vasodilatation in
muscle groups causes a reduction in total peripheral resistance by up to 50%.

Question 20

In which activity should a 16-year-old girl with C5 ASIA class A spinal cord injury be
independent with the use of assistive devices?
(a) Self catheterization
(b) Transfers to level surfaces
(c) Self feeding
(d) Bathing

Answer 20

(c) While boys with C5 spinal cord injury (SCI) may learn to perform bladder self-catheterization with
assistive devices, girls do not. Level transfers require active elbow and wrist extension, which
would not be present in a person with C5 SCI. Self-feeding with assistive devices such as a palmar
band can usually be done by persons with C5 tetraplegia.

Question 21

A 26-year-old mail handler is sent to you for management of her severe sensorimotor carpal tunnel
syndrome confirmed by electrodiagnostic evaluation. She was given a splint for her presumed
carpal tunnel syndrome 3 months ago, which she has worn 24 hours a day since that time without
relief. She notes severe tingling in her fingers that is worse at night, and she also notes difficulty
with gripping the mail, because of subjective weakness. She is now having severe pain, which
radiates up her hand into her forearm. You consider that a corticosteroid injection might benefit
this patient. Which statement is most correct regarding this injection?
(a) The risk of intraneural injection is too high, and the patient should not be injected.
(b) So that intraneural injection can clearly be recognized, do not dilute the corticosteroid with
anesthetics.
(c) Persisting or worsening pain and numbness or swelling normally last for more than 48
hours postinjection.
(d) Local tenderness and superficial hematomas are rare after this injection

Answer 21

(b) The risk of intraneural injection is real, but in experienced hands this injection is safe. Anesthetics
mixed with the corticosteroid can mask the pain associated with needle placement into the nerve
and should not be used. 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.

Question 22

A 28-year-old woman, who is 35 weeks pregnant, complains of right thigh and groin pain with
weight bearing. You diagnose her with idiopathic transient osteoporosis of the femoral neck.
What is the course of treatment?
(a) Recommend labor induction
(b) Prescribe protected weight bearing
(c) Recommend bedrest until delivery
(d) Prescribe alendronate (Fosamax)

Answer 22

(b) Patients with idiopathic transient osteoporosis of the femoral neck may ambulate as tolerated but
may need protective weight bearing for pain relief. Symptoms and pathology resolve within 6
months

Question 23

Regarding the epidemiology of neurogenic thoracic outlet syndrome,

(a) it is a commonly occurring syndrome.
(b) it occurs equally in men and women.
(c) it occurs more frequently in the young and middle-aged.
(d) it is highly associated with repetitive motion.

Answer 23

(c) Neurogenic thoracic outlet syndrome is rare, occurs most frequently in young to middle-aged
women, and involves the lower trunk of the brachial plexus. Pain is the most common sensory
symptom, and is usually in the medial forearm and ulnar aspect of the hand.

Question 24

A patient with advanced ankylosing spondylitis complains of increasing dyspnea. You order
pulmonary function tests. Which parameter do you anticipate will deviate the most from normal,
age-adjusted values?
(a) Functional residual capacity
(b) Expiratory reserve volume
(c) Vital capacity
(d) Tidal volume

Answer 24

(c) Spinal flexion and extension are necessary for full thoracic expansion. Limited spinal mobility, as
occurs in diffuse skeletal hyperostosis and ankylosing spondylitis, will directly affect full
respiratory capability. Functional residual capacity, residual volume, and tidal volume may be
decreased. However, vital capacity is related to inspiratory capacity and will therefore be more
significantly affected by reduced spinal mobility.

Question 25

Your 6-month-old patient had burns to his head and both arms in a house fire. What approximate percent of his total body surface area (TBSA) was burned? (a) 37 (b) 18 (c) 27 (d) 49

Answer 25

(a) An infant’s head is approximately 19% and each arm constitutes 9% of the total body surface area (TBSA). In adults and older children the head is approximately 9% of the TBSA.

Question 26

``` In patients with osteoporosis, which treatment reduces incidence of vertebral compression fracture? (a) Weight reduction (b) Cash brace (c) Strengthening of spinal extensors (d) Strengthening quadriceps ```

Answer 26

(c) Weak extensor muscles increase risk of compression fracture. Risk increases with immobilization longer than 2 days. There is no association between osteoporotic compression fractures and weight or family history

Question 27

The occurrence of renal calculi during the first 3 months after spinal cord injury is related to (a) level of injury. (b) immobilization hypercalciuria. (c) method of bladder management. (d) number of urinary tract infections.

Answer 27

(b) Renal calculi occur in approximately 8% of patients with spinal cord injury. Approximately 98% of renal calculi in persons with spinal cord injury are composed either of calcium phosphate or magnesium ammonium phosphate. These stones are typically associated with urinary tract infections (UTIs). Early stone formation is likely secondary to immobilization hypocalcemia, whereas later stone formation is secondary to repeated UTIs and long term use of an indwelling catheter.

Question 28

Which of the following medications exerts its analgesic effect by increasing the influence of the descending spinal tracts on nociceptive processing in the dorsal horn? (a) Valproic acid (Depakote) (b) Mexiletine (Mexitil) (c) Amitriptyline (Elavil) (d) Baclofen (Lioresal)

Answer 28

(c) Tricyclic antidepressants are believed to exert their analgesic effects through modulation of the descending inhibitory pathways the arise in various brain stem centers and synapse within the dorsal horn of the spinal cord. Neurons within these tracts are principally serotonergic and noradrenergic. By influencing the reuptake of these monoamines, amitriptiyline and other tricyclic antidepressants, enhance the inhibitory influence exerted by the descending tracts.

Question 29

The presence of nonorganic physical signs in low-back pain patients as described by Gordon Waddell is intended to (a) alert the examiner that psychological issues may be contributing to pain. (b) identify patients and workers that are malingerers. (c) determine which workers would benefit from low back and abdominal exercises. (d) indicate which patients require examination by a psychiatrist.

Answer 29

(a) Nonorganic physical signs in patients with low back pain was described by Gordon Waddell. His original paper describes the physical signs that correlated with psychological data and were distinguishable from standard clinical signs of physical pathology. Waddell’s signs should be used to determine if nonorganic issues may be contributing to the patient’s complaints. Not all patients with nonorganic physical signs are malingerers or require psychiatric evaluation. The signs are not indicators for therapeutic modalities.

Question 30

Which joints are most commonly involved in juvenile rheumatoid arthritis? (a) Shoulder, hip, fingers (b) Atlantoaxial, costomanubrum, hip (c) Sternomanubrum, shoulder, sacroiliac (d) Elbow, hip, temporomandibular

Answer 30

(d) The elbow is involved 90% of the time in juvenile rheumatoid arthritis (JRA), the temporomandibular and hip 50% each. The shoulder is involved about 8% of the time in early JRA and about 33% later.

Question 31

Which type of stroke typically results in the best overall outcome? (a) Pontine hemorrhage (b) Embolic cortical infarction (c) Anterior cerebral artery aneurysm rupture (d) Internal capsule lacune

Answer 31

(d) Lacunar strokes are typically small and very localized and, in general, have the best prognosis

Question 32

40-year-old woman with 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. She does not feel rested in the morning. The most appropriate initial recommendation is (a) lorazapam (Ativan) at bedtime. (b) amitriptyline (Elavil) at bedtime. (c) zolpidem (Ambien) at bedtime. (d) acetaminophen with codeine (Tylenol #3 ) at bedtime.

Answer 32

(b) This patient has fibromyalgia. Neuropathic medications such as trycyclic antidepressant medications are recommended.

Question 33

A 75-year-old patient with metastatic breast cancer, hypertension, and diabetes is admitted to the hospital for radiation of a pathological femoral fracture. Her severe osseous pain was controlled during the initial 72 hours of admission with intravenous morphine, 5 mg/hour. Eager to facilitate discharge, a well-meaning house officer converts her to oral sustained-release morphine sulfate, 120 mg tid. Twenty-four hours after receiving the first dose of oral morphine, the patient becomes increasingly confused and somnolent. The most likely explanation for this change in mental status is (a) the dose of oral morphine is excessive (not an accurate IV to PO conversion). (b) radiation-induced hypersomnolence. (c) accumulation of morphine metabolites. (d) hypercalcemia.

Answer 33

(c) Morphine sulfate is glucoronidated in the liver to produce two metabolites; morphine-6-glucoronide and morphine-3-glucoronide. Both of these compounds are renally excreted and can accumulate in elderly patients with compromised renal function. Morphine-6-glucoronide is a m-receptor agonist and is believed to contribute to morphine-induced analgesia. Morphine-3-glucoronide has been implicated in the undesirable neuropsychological side effects of morphine therapy and does not provide significant analgesia. Due to first-pass effect, the serum concentration of morphine metabolites is much higher when morphine is administered orally.

Question 34

Which of the following is part of neurodevelopmental therapy (NDT)? (a) Promotion of primitive reflexes (b) Use of taping and icing (c) Strengthening exercises (d) Facilitating automatic reactions

Answer 34

(d) Neurodevelopmental therapy, developed by Bobath, emphasizes inhibition of reflex patterns, normalizing tone, and facilitating automatic reactions. The therapy does not include strengthening exercises.

Question 35

When applying a static resting hand splint to a person who had a stroke with upper limb paralysis, what is the appropriate joint position to maintain the hand in a functional position? (a) 20° of wrist flexion (b) 90° of metacarpophalangeal flexion (c) Neutral position or slight flexion of the distal interphalangeal joints (d) 30° of thumb opposition across the palm

Answer 35

(c) A resting hand splint is designed to maintain a position of function in a hand that is weak or paralyzed. It is applied on the volar surface and extends from the fingertips to the proximal third of the forearm. The wrist is typically placed in slight extension. The metacarpophalangeal joints are placed in slight flexion and the interphalangeal joints are placed in a neutral position or in slight flexion. The thumb is supported in a position between palmar and radial abduction

Question 36

``` How does a weighted kypho-orthosis (Posture Training Support®) improve function in patients with chronic thoracic kyphosis? (a) Improves posture (b) Strengthens spinal extensors (c) Promotes bone formation (d) Helps activate rectus abdominus ```

Answer 36

(a) A weighted kypho-orthosis improves posture without any effect on pain.

Question 37

You prescribe a work-hardening program for a 36-year-old assembly-line worker. Work-hardening programs are most effective when (a) focused on upper limb function. (b) the patient’s job functions are simulated. (c) combined with a physical therapy program. (d) prescribed by a physiatrist

Answer 37

(b) Work-hardening programs are most effective when essential job duties are simulated.

Question 38

Your 14-year-old patient with spastic diplegic cerebral palsy has increasing problems with spasticity. He walks with ankle-foot orthoses (AFOs) and crutches and is independent in his activities of daily living. Which medication would reduce his spasticity while minimizing undesirable side effects? (a) Diazepam (Valium) (b) Baclofen (Lioresal) (c) Dantrolene (Dantrium) (d) Oxybutynin (Ditropan)

Answer 38

(b) Diazepam has lethargy and sleepiness as major side effects. Dantrolene works at the level of the muscle and often causes weakness, which can interfere with function. Oxybutynin relaxes the muscles of the bladder, not skeletal muscles.

Question 39

A person with diabetes presents with an area of nonblanching erythema on the plantar surface of the foot at the first metatarsal head. Recommendations for footwear would include (a) custom-molded shoe insert. (b) narrow toe box shoe. (c) heel lift on the affected side. (d) calcaneal bar added to the sole of the shoe.

Answer 39

(a) Footwear for the person with diabetes and grade 1 skin changes on the plantar aspect of the foot should be designed to relieve pressure over the affected site while evenly distributing pressure over the remaining foot surface to prevent other skin breakdown. A typical prescription would include an extra-depth shoe with a wide toebox and a total-contact, custom-molded insert with pressure relief at the area of skin irritation. Further shoe modifications with a metatarsal bar and rocker bottom sole could also be considered, especially if the patient had grade 2 skin changes or more severe foot deformities. A calcaneal bar or heel lift would not be appropriate considerations in this case.

Question 40

Which steroid compound has the longest half-life? (a) Dexamethasone (b) Prednisone (c) Triamcinolone (d) Hydrocortisone

Answer 40

(a) The least water-soluble compound will have the longest half-life.

Question 41

A 22-year-old woman with a C5 ASIA class A spinal cord injury sustained in a car crash 2 weeks ago complains of lightheadedness, dizziness, and nausea during her physical therapy session. In response to her therapist’s call, you recommend (a) sitting the patient up and loosening tight garments. (b) placing the patient in Trendelenburg position. (c) using elastic abdominal binders and elastic stockings. (d) adjustment of HALO vest.

Answer 41

(c) Orthostatic hypotension (OH) is a decrease in blood pressure that results from a change in body position toward the upright posture. Symptoms include lightheadedness, dizziness, nausea. This form of hypotension is most likely to occur in persons with high levels of injury. Treatment involves daily tilting with gradual change to upright posture. Elastic binders help compress the abdomen, thus limiting blood accumulation in the abdominal vasculature. Elastic stockings limit blood accumulation in lower extremities. Patients must be adequately hydrated. Salt tablets, 1 gram 4 times daily, ephedrine, 20–30mg up to 4 times daily, Florinef, and Midodrine may be used as pharmacologic adjuncts.

Question 42

A thrombocytopenic cancer patient has severe pain related to osseous metastases. Recognizing that pain from osteolytic metastases is prostaglandin mediated, you choose to initiate therapy with (a) Naproxen (Naprosyn, Aleve). (b) Celecoxib (Celebrex). (c) Valproic acid (Depakote). (d) Acetaminophen (Tylenol).

Answer 42

(b) Nonsteroidal anti-inflammatory drugs reversibly inhibit cyclooxygenase, the enzyme responsible for the conversion of arachadonic acid to prostaglandins. Given the importance of prostaglandins in mediating metastatic bone pain, use of an NSAID represents appropriate first-line therapy for this patient. For thrombocytopenic patients, use of a cyclooxygenase-2 specific inhibitor such as celecoxib or refocoxib will place the patient at a much lower risk of hemorrhage.

Question 43

A 32-year-old female cashier presents to you with a 2-week history of low back pain. She denies specific trauma or activity with onset. She has no lower extremity pain, numbness, or tingling. She denies night time pain, recent illness, or previous history of low back pain. Which radiological diagnostic test would you recommend? (a) Computed tomography scan (b) Radiographic imaging (c) No imaging (d) Magnetic resonance imaging

Answer 43

(c) No imaging is necessary in this patient with no known medical risk factors. The low back pain can be managed initially without the expense of CT or MRI. Recommendations for obtaining x-rays for the patient with a first episode of low back pain for less than 7 weeks include: over age 65, history of osteoporosis, history of urinary tract dysfunction, persistent sensory loss, progressive pain despite treatment, night or rest pain, fever, chills, unexplained weight loss, history of trauma or repetitive overuse, recurrent pain with no x-rays in 2 years, previous surgery, or fracture.

Question 44

``` Which filter setting is usually considered to be appropriate for routine needle electromyography? Low frequency High frequency (a) 2–10Hz 10,000Hz (b) 2–10Hz 2,000Hz (c) 20–30Hz 10,000Hz (d) 20–30Hz 2,000Hz ```

Answer 44

(c) There is no universally accepted guideline for filter settings. However, based on clinical experience certain ranges have been determined and are recommended. Each procedure has particular filter settings, which are based on optimum frequency content of mean waveforms routinely observed. The recommended filter setting for routine needle electromyography is 20–30 hertz for the low filter and 10kilo hertz for the high filter.

Question 45

Early post-traumatic seizures are defined as seizures within the first (a) day. (b) month. (c) week. (d) 3 months.

Answer 45

(c) Early post-traumatic seizures occur from the first day to 1 week postinjury. Immediate seizures occur within the first 24 hours. Late seizures occur after the first 7 days.

Question 46

A 40-year-old woman who runs 30 miles per week wants to prevent symptoms of hip and knee osteoarthritis. Proven methods include (a) avoidance of estrogen replacement. (b) maintaining optimal flexibility. (c) use of medial wedge orthotics. (d) nonsteroidal anti-inflammatory medications.

Answer 46

(b) Major risks for knee and hip osteoarthritis include major injury, obesity, and occupations that require repetitive motion of the joint. Proper training techniques for building strength and flexibility can reduce risk of major injury and thus prevent osteoarthritis. Estrogen may have a protective effect

Question 47

Which finding is most common in spinal muscular atrophy? (a) Brisk reflexes (b) Weakness and atrophy (c) Sensory loss (d) Urinary retention

Answer 47

(b) Although the various forms of spinal muscular atrophy (SMA) are clinically dissimilar, they all involve loss of the lower motor neurons, causing loss of reflexes, rather than hyperreflexia, along with weakness and atrophy. Sensation remains intact. Urinary retention is not part of the disease and the sensory nerves remain completely intact. The childhood forms of SMA may be quite severe, although the late-onset forms may be mild.

Question 48

In conducting an exercise tolerance test on a patient with a history of exertional angina, a fall in systolic blood pressure at Bruce Protocol Stage II should trigger (a) stabilization at the current exercise level. (b) an increase in exercise intensity. (c) discontinuation of the test. (d) a reduction in exercise intensity

Answer 48

(c) If systolic blood pressure fails to rise during exercise testing with increasing workload, ischemia should be suspected. A fall in systolic blood pressure may reflect significant ischemia and is an indication for aborting the exercise tolerance test.

Question 49

In an otherwise healthy worker with complaints of low back pain and no neurologic deficit on physical exam, magnetic resonance imaging of the lumbar spine is indicated when low back pain (a) persists for 8 weeks. (b) first occurs, so that work restrictions can be made. (c) persists after 2 weeks of bed rest. (d) continues for 4 weeks after the worker is placed on light duty.

Answer 49

(a) A magnetic resonance imaging (MRI) provides the most accurate and complete information during the initial assessment for lumbar disc pathology, stenosis, infection, tumor, or trauma. Because many patients who present with low back pain and lumbar radicular pain may have spontaneous improvement of symptoms, it is recommended to wait for approximately 7 weeks without improvement and with proper care before performing an MRI.

Question 50

What scapular motions should a patient avoid after a shoulder replacement? (a) Internal rotation and adduction (b) Internal rotation and abduction (c) External rotation and adduction (d) External rotation and abduction

Answer 50

(d) External rotation and abduction increase risk of dislocation because of anterior instability.

Question 51

Which statement is correct regarding amyotrophic lateral sclerosis (ALS)? (a) Bowel and bladder dysfunction are common in ALS. (b) ALS is most commonly inherited in an autosomal dominant pattern. (c) Both spasticity and diffuse muscular atrophy and weakness are common in ALS. (d) ALS may cause severe cardiac conduction abnormalities.

Answer 51

(c) The vast majority of ALS cases occur sporadically. However, approximately 10% of all ALS cases are familial (FALS), usually inherited as an autosomal dominant trait. The disease is typified by both upper and lowermotor neuron loss, causing spasticity and atrophy.

Question 52

What is the most appropriate treatment of an acute multiple sclerosis relapse? (a) Glucocorticosteroids (b) Mitoxantrone (c) Interferon (d) Methotrexate

Answer 52

(a) Most significant multiple sclerosis (MS) relapses should be acutely treated with Gluco corticosteroids. A significant relapse in MS is defined by visual or motor changes, pain, or incoordination. Such a relapse requires acute glucocorticosteroid therapy. Although there is no evidence that steroid therapy alters the long-term course of MS, clinical experience shows that most relapses resolve more quickly and possibly more completely with adequate glucocorticosteroids. Immunomodulating agents are used to reduce relapse frequency. These agents include Glatiramer 6 acetate (Copaxone), which when used long term and continuously, reduces the occurrence of relapses and lowers or delays the risk of fixed disability. Interferons are presumed to act by way of antiproliferating and immunomodulating effects. Interferons should be used in MS patients in hopes of reducing their relapse rate and their risk of increasing disability. Adverse affects of interferons include persistent flu-like symptoms. Methotrexate was originally considered a potential treatment for MS because of some similarities between rheumatoid arthritis and MS patients’ immune alterations and relapsing clinical courses. Methotrexate may offer a relatively well-tolerated treatment option for patients with chronic, progressive MS. Mitoxantrone, an antineoplastic agent, exerts a potent immunomodulating effect that suppresses immunity and enhances suppressor function. Further study of this therapy for patients with the progressive forms of MS is needed, particularly in light of its cardiotoxic effects.

Question 53

A leukemic patient undergoing allogeniec bone marrow transplant has recovered from a painful varicella zoster outbreak. He continues to complain of dysesthetic pain in the affected dermatome. Hoping to reduce to patient’s risk of developing chronic post-herpetic neuralgia, you initiate therapy with (a) oxycodone (Roxicodone). (b) ibuprofen (Motrin). (c) carbamazepine (Tegretol). (d) amitriptyline (Elavil).

Answer 53

(d) Of the medications listed, only amitriptyline has been demonstrated to reduce the incidence and severity of post-herpetic neuralgia. While carbamazepine has well demonstrated analgesic effects, it would be a poor choice in a bone marrow transplant patient given the risk of aggravating leukopenia. Similarly, the anti-platelet effects of ibuprofen are undesirable in this clinical context. While opioids have been shown to be effective in controlling neuropathic pain, adjuvant analgesics generally remain first-line therapy. Opioids have not been shown to influence the incidence of post-herpetic neuralgia.

Question 54

A 52-year-old house painter has completed physical therapy for shoulder pain due to rotator cuff tendonopathy. He is independent with his home exercise program and pain free with his usual activities. He has been off work for 10 weeks. You next recommend (a) return to work without restrictions. (b) a functional capacity evaluation. (c) physical therapy for a total of 14 weeks. (d) an aerobic conditioning program.

Answer 54

(b) A functional capacity evaluation will determine if the worker can return to his work duties on a safe and dependable basis. A painter’s work responsibilities require significant repetitive upper extremity activities not necessarily challenged with therapeutic exercise. Although aerobic conditioning is important, simulation of work duties should be done before this patient returns to work.

Question 55

You are asked to evaluate an 8-month-old child with developmental delay. On exam you find low tone, but brisk deep tendon reflexes at the knees and biceps, full passive range of motion, and poor head and trunk control. This child’s diagnosis is likely (a) myotonic dystrophy. (b) cerebral palsy. (c) spinal muscular atrophy. (d) Hunter’s syndrome.

Answer 55

(b) This patient presents with hypotonia, weakness, and hyperreflexia, a combination most commonly seen in central nervous system lesions such as cerebral palsy. A child with a neuromuscular disorder would not have hyperreflexia with the hypotonia and weakness. In severe cerebral palsy it is common to see early hypotonia with brisk reflexes that changes to hypertonia as the child gets older.

Question 56

What type of prehension is provided by a wrist-driven tenodesis orthosis? (a) Lateral (b) 3-jaw chuck (c) Cylindrical (d) Tip-to-tip

Answer 56

(b) The wrist-driven tenodesis hinge orthosis creates a 3-jaw chuck prehension by stabilizing the interphalangeal joints of digits 2 and 3 and the interphalangeal and metacarpophalangeal joints of the thumb. The extensor carpi radialis muscle activates the wrist extension, which through tenodesis action creates a 3-jaw chuck prehension.

Question 57

Which factor is associated with the highest risk for postoperative dislocation after a total hip arthroplasty? (a) Femoral anteversion (b) Anterior approach for hip replacement (c) Long femoral component (d) Previous hip replacement

Answer 57

(d) Patients with history of previous hip replacement and posterior approach are at greater risk for postoperative dislocation. Posterior surgical approach has a higher risk of dislocation than anterior approach

Question 58

The management of acute spinal cord compression due to tumor includes (a) nerve growth factor. (b) thoracolumbosacral orthosis (TLSO). (c) corticosteroids. (d) urecholine

Answer 58

(c) Corticosteroids are indicated in acute spinal cord compression in an effort to reduce the tumorrelated inflammatory changes and prostaglandin production. The dose, however, is controversial. Radiation therapy is indicated for patients with spinal cord compression due to soft tissue encroachment. It can be employed as monotherapy in cases of spinal stability, with or without neurologic changes, or as an adjunctive therapy to surgery for patients with spinal instability. The major complications of radiation treatment include the development of radiation myelopathy, radiation plexopathy, and tumor recurrence. However, radiation therapy is indicated for these individuals to provide decompression of neural structures and cytoreduction of the tumor, prevention of neurologic progression and prevention of local recurrence, and for relief of pain. Most surgeons will not consider surgical intervention if the patient has a prognosis of less than 3 months’ survival when faced with the question of surgical management of tumors. With either a primary or metastatic spine tumor, commonly a corpectomy will be performed. In this procedure most of the involved vertebral body and the intervertebral disk above and below the involved 7 vertebra are excised. Since the majority of corpectomies for spine tumors involve metastatic disease, the goal of surgery is palliation rather than surgical cure.

Question 59

At the time of seroconversion, an HIV-infected patient treated prophylactically with azathioprine (AZT) for 4 months develops rapidly progressive weakness of all extremities over several days with sensory sparing. Distal and proximal weakness are comparable. The most likely cause of weakness is (a) Chronic demyelinating polyneuropathy. (b) Acute demyelinating polyneuropathy. (c) HIV myopathy. (d) AZT myopathy.

Answer 59

(b) AIDP generally develops over days in HIV patients early in the course of disease. Often AIDP presents at the time of seroconversion. While CIDP may also develop early in the disease course, it usually develops gradually, over weeks. Myopathy does not occur at a particular stage in the disease. Similar to most myopathic processes, HIV myopathy affects proximal muscles to a greater extent. AZT myopathy presents after 9 or more months of drug use.

Question 60

A 43-year-old alcoholic man complains of left hip pain that is increased with weight bearing. He has had progressive symptoms for about 3 months. Additional medical history reveals no trauma, but the patient has oxygen dependent chronic obstructive pulmonary disease (COPD). On examination, internal and external rotation of both hips is painful. The patient ambulates with a lateral lean to the left. He uses a walking stick, which helps his pain. What radiologic evaluation would be most useful in diagnosing this patient’s problem? (a) Ultrasound of the left hip (b) Magnetic resonance imaging of both hips (c) Arthrography of the left hip (d) Tagged white blood cell scan of the hip

Answer 60

(b) This patient has multiple risk factors for osteonecrosis of the hip (avascular necrosis). Risk factors for this condition include steroid use, alcohol use, trauma, rheumatoid arthritis, sickle cell disease, radiation, chronic pancreatitis, systemic lupus erythematosus, Gaucher disease, and Crohn’s disease. It typically occurs in the third to fifth decades and affects 10,000 to 20,000 new patients per year in the US. This condition is often bilateral. Radiologic evaluation should include plain anterior-posterior pelvis and frog lateral views of the hip. If collapse of the femoral head is seen, no additional radiographic evaluation is necessary. If these are negative, magnetic resonance imaging of the hip may be more sensitive and should be performed on both hips. Ultrasound and arthrography are not indicated for this condition. Tagged white blood cell scan would evaluate for infection of the hip.

Question 61

In a patient with traumatic brain injury and vertigo, which physical examination finding from a Dix-Hallpike test would encourage you to perform an Epley maneuver? (a) Persistence of responses to repeated provocation (b) Fixed direction of nystagmus with rotary component (c) Nonconcordant or divergent gaze (d) Persistence of nystagmus, 30 seconds for each provocation

Answer 61

(b) A positive Dix-Hallpike test definitively establishes the diagnosis of benign paroxysmal positional vertigo (BPPV). The Dix-Hallpike maneuver is performed by quickly dropping a patient backwards from a sitting position so that the head is rotated 45 degrees and hangs over the edge of a mat. Characteristics of BPPV are mixed torsional and vertical nystagmus, which lasts for 10–20 seconds, associated with a sensation of rotational vertigo. Repetition of the test results in a reduction in the intensity of vertigo and nystagmus. The Epley maneuver, which is performed at the bedside, relocates debris from the posterior semicircular canal into the vestibule of the vestibular labyrinth

Question 62

What is the median post-diagnosis survival in amyotrophic lateral sclerosis? (a) 1 year (b) 2.5 years (c) 5 years (d) Too variable too predict

Answer 62

(b) Survival rates vary depending on the patient's decision to use mechanical ventilation and a feeding tube. Nonetheless, the median 50% survival rate is 2.5 years and by 5 years postdiagnosis the overall survival rate is only 28%.

Question 63

Treatment is indicated in asymptomatic bacteriuria when an individual with a spinal cord injury has (a) chronic use of an indwelling Foley catheter. (b) bladder augmentation. (c) pyuria of 10–20 white blood cell count (WBC). (d) ureteral reflux or hydronephrosis.

Answer 63

(d) Bacteruria is a common problem in patients with voiding dysfunction. At approximately 1 year postinjury, 66% to 100% of all individuals with spinal cord injury have had at least 1 episode of bacteruria, depending upon their bladder management program. Asymptomatic bacteruria has been found to be present in 1%–-25% of community dwelling patients and 25%–40% of nursing home patients older than 65. There is general agreement that asymptomatic bacteruria in a patient using a Foley catheter should not be treated. Attempts should be made to eradicate asymptomatic bacteruria and bacteruria associated with high grade reflux before urologic instrumentation and hydronephrosis, or in the presence of urea splitting agents

Question 64

When referring to the neurological manifestations of HIV, time locking describes (a) the simultaneous occurrence of central and peripheral nervous systems processes. (b) the occurrence of multiple pathological processes within one part of the neuraxis. (c) the tendency for particular neurological processes to occur during certain disease stages. (d) the capacity of a neurological or medical process to exacerbate a subclinical neurological process.

Answer 64

(c) Time locking refers to the predictability with which certain neurological manifestations of HIV develop during particular disease stages. For example, AIDS dementia complex is a late complication of AIDS which generally occurs when the CD4 count falls below 250/ml.

Question 65

``` Which endocrine abnormality is most likely to occur 5 years after severe traumatic brain injury in a 2-year-old girl? (a) Diabetes insipidus (b) Precocious puberty (c) Hypothyroidism (d) Hyperparathyroidism ```

Answer 65

(b) Precocious puberty occurs in up to 50% of girls who sustain a severe traumatic brain injury (TBI) in early childhood. Diabetes insipidus is an early complication of TBI. While other endocrine abnormalities may occur, they are less common

Question 66

Painful, arthritic hip disease is associated with the following gait abnormality. (a) Prolonged stance phase of the affected limb (b) Limb circumduction during swing (c) Lateral trunk shift over the affected joint during stance (d) Shortest step length of the affected limb

Answer 66

(c) The patient will lean over the affected hip (compensated Trendelenburg gait) in an attempt to minimize painful contractions of the hip abductors. In addition, the characteristics of an antalgic gait include shorter stance phase on the affected leg (as the patient attempts to remove weight quickly from the affected leg), decreased swing phase of the uninvolved leg, and a shorter step length on the uninvolved side. Limb circumduction is characteristic of increased limb length or abductor muscle shortening

Question 67

A 12-year-old girl with limb girdle muscular dystrophy has trouble keeping up in school because of slow gait and writing speed. What is the probable cause of her clinical problems? (a) Skeletal muscle weakness (b) Spasticity (c) Cardiomyopathy (d) Joint contracture

Answer 67

(a) The majority of clinical problems encountered in neuromuscular disease can be directly linked to skeletal muscle weakness. Studies indicate that what causes most of the functional problems and impairs quality of life for people with neuromuscular disease is muscle weakness

Question 68

Which factor is associated with successful phrenic nerve pacing for independent respiration in patients with tetraplegia? (a) Initiation of pacing shortly after injury (b) Location of injury at or above C2 (c) The presence of central sleep apnea (d) Ability to breathe on t-piece for 15 minutes

Answer 68

(b) Electrophrenic respiration or phrenic nerve pacing should not be performed until at least several months after injury, since some patients recover diaphragmatic function over a period of several months. Criteria for use of phrenic nerve pacing include an injury at or above C2, with intact phrenic nerves. Most patients injured at C3, C4, or C5 should be able to wean from the ventilator. Some risk exists with phrenic pacing because the electric transmitter can fail. Additionally, patients may not be able to develop a deep enough breath with this technique to prevent atelectasis. Electrophrenic pacing is expensive and requires extensive training of personnel who will care for patients. There must be a backup ventilator in the event of electrophrenic failure.

Question 69

In adult patients, what advantage does a knee disarticulation amputation have over a transfemoral amputation? (a) Better cosmetic appearance with prosthetic fitting (b) Reduced risk of phantom pain (c) Increased ability to bear weight on the distal residual limb (d) Improved surgical wound healing

Answer 69

(c) Compared with a transfemoral level amputation, a knee disarticulation provides increased ability to bear weight on the distal residual limb. There is no evidence that knee disarticulation amputations have a reduced risk of phantom pain or have improved surgical wound healing. Amputations at the transfemoral level typically have a better cosmetic appearance with prosthetic fittings because the distal prosthetic socket can be tapered to be more symmetric with the opposite side. Knee disarticulation amputations also have a prosthetic knee axis of rotation that is distal compared to the intact knee.

Question 70

``` Which factor does NOT increase a person’s risk for hydrocephalus following traumatic brain injury? (a) subarachnoid hemorrhage (b) post traumatic seizures (c) intracranial infections (d) penetrating injury ```

Answer 70

(b) In communicating post-traumatic hydrocephalus, cerebral spinal fluid (CSF) absorption by the villi is impaired. This occurs with inflammation or subarachnoid hemorrhage.

Question 71

A 25-year-old man with localized low back pain and knee pain that are worse with rest and improve with activities is noted to have recent history of salmonella gastroenteritis. The most likely diagnosis is (a) enteropathic arthritis. (b) ankylosing spondylitis. (c) reactive arthritis. (d) septic arthritis.

Answer 71

(c) Reactive arthritis is a form of peripheral arthritis that has 1 or more extra-articular manifestations and appears 2 to 4 weeks after gastrointestinal or genitourinary infections including salmonella, shigella, and campylobacter in young males. It is a type of spondyloarthropathy, which also includes enteropathic arthropathy, anklosing spondylitis, and psoriatic arthritis.

Question 72

A 29-year-old man with slowly progressive neuromuscular disease is eager to maintain overall function and preserve mobility. What type of exercise program would you prescribe? (a) Moderate resistance, low repetition (b) High resistance, low repetition (c) Isokinetic resistance (d) Isometric resistance

Answer 72

(a) There have been several well-controlled studies looking at the effect of exercise as a means to gain strength in neuromuscular diseases (NMDs). In slowly progressive NMDs a 12-week, moderate resistance (30% of maximum isometric force) exercise program resulted in strength gains ranging from 4% to 20% without any notable deleterious effects. However, in the same population, a 12-week, high resistance (training at the maximum weight a subject could lift 12 times) exercise program showed no further added beneficial effect compared to the moderate resistance program and there was evidence of overwork weakness in some of the subjects.

Question 73

A patient with stable angina develops chest pain and EKG changes during stage V of the Bruce protocol. You inform him that his risk of suffering a myocardial infarction during moderate exertion is (a) none. (b) low. (c) moderate. (d) high.

Answer 73

(b) Patients who are able to complete Stage IV of the Bruce protocol without anginal symptoms have a low risk of myocardial infarction.

Question 74

A 62-year-old ice cream truck driver fell getting out of his truck and suffered a medial meniscal tear. After 4 weeks of physical therapy, he has 95° of knee flexion, and the knee effusion has resolved. He is able to perform his activities of daily living with minimal pain. A functional capacity evaluation determines that he is able to perform duties at a medium level category. His job requires him to lift 75 pounds at each delivery site. You recommend (a) return to work with a lifting restriction of 20 pounds. (b) continue in physical therapy to increase knee flexion to 115°. (c) undergo a work hardening program with re-evaluation in 3 weeks. (d) return to work with a derotation knee brace

Answer 74

(c) The functional capacity evaluation indicated he can lift up to 50 pounds safely but his job requires that he lift 75 pounds so further intervention before return to work is indicated. A work hardening program is an interdisciplinary program that will incorporate work-specific activities and conditioning to transition the worker from acute care to a safe return to work. Although gaining knee flexion may be beneficial, it is not the major focus for return to work.

Question 75

The proper static alignment of the socket in a transtibial prosthesis will place the socket in slight (a) flexion. (b) extension. (c) external rotation. (d) abduction.

Answer 75

(a) The socket of a transtibial prosthesis is typically slightly flexed during the static prosthesis alignment process. Proper flexion of the socket improves weight-bearing characteristics and also reduces knee extension forces during mid-stance and the terminal stance phases of gait. The static alignment also places the socket in 5° of adduction with the foot slightly inset relative to the socket.

Question 76

A 37-year-old woman presents with complaints of paresthesias in the fourth and fifth digits of her dominant hand for the last 3 years. She has vague complaints of aching in and around her shoulder and neck. She reports great difficulty with overhead activities. She reports intermittent swelling and discoloration of her hand with these activities. She has no wasting of her muscles on exam, and Tinel’s maneuver at the elbow is negative. You suspect (a) thoracic outlet syndrome (b) myofascial pain syndrome (c) rotator cuff tendonopathy (d) Raynaud’s syndrome

Answer 76

(a) For a provocative test to be positive for thoracic outlet syndrome (TOS), the patient must volunteer that the maneuver exactly reproduces the symptoms. Adson’s test is performed by palpating the radial pulse while turning the patient’s head toward the affected side, extending his/her neck, and 9 holding the affected arm at the side. This will result in loss of the radial pulse. The costoclavicular maneuver is performed by having the patient move the shoulders back and down, resulting in a loss of the radial pulse. The elevated arm stress test (a/k/a Roos' test) is performed by having the patient hold his/her arms overhead while opening and closing the hands. A person with TOS will report pain and will fatigue within 30 seconds. A person without TOS will not report pain and will be able to perform the test for up to 3 minutes. Compression of the ulnar nerve is not a maneuver for the diagnosis of TOS.

Question 77

A 67-year-old patient with coronary artery disease suffered a stroke 1 week ago. His resting vital signs are: blood pressure 140/86, pulse 87 beats per minute, respiration 18 breaths per minute and oxygen saturation 97%. Which change in vital signs would warrant stopping a therapy session? (a) Oxygen saturation 92% (b) Diastolic blood pressure 110mmHg (c) Systolic blood pressure 130mmHg (d) Heart rate 105 beats per minute

Answer 77

(b) An increase in the diastolic blood pressure is indicative of an unstable cardiac condition. The other choices are normal responses to exercise.

Question 78

``` Which antispasticity medication is relatively contraindicated in individuals who have motor incomplete spinal cord injury? (a) Baclofen (Lioresal) (b) Dantrolene (Dantrium) (c) Diazepam (Valium) (d) Tizanidine (Zanaflex ```

Answer 78

(b) Dantrolene sodium depresses the release of calcium from the sarcoplasmic reticulum and is unique in having a direct effect on skeletal muscles. It acts on all skeletal muscles and may weaken partially innervated muscles, causing muscles which are functional to becoming nonfunctional

Question 79

A patient presents with Stage I upper extremity lymphedema related to primary breast cancer therapy. She is interested in pharmaceutical and dietary treatment options. Which of the following would be appropriate in the management of this patient? (a) Reduced protein consumption (b) Treatment with a diuretic (c) Reduced salt consumption (d) Treatment with a benzopyrone.

Answer 79

(c) Moderation in salt consumption will avoid increased intravascular volume and capillary ultrafiltration thereby reducing the likelihood of lymphedema progession. Diuretics should not be used in the management of uncomplicated lymphedema. Reduced protein consumption will potentially lead to hypoalbuminemia and reduced colloid osmotic pressure of the plasma. This will increase ultrafiltration, worsening lymphedema. Benzopyrone therapy has not been shown to benefit lymphedema related to breast cancer, and is associated with hepatotoxicity

Question 80

Which factor contributes most to poor worker motivation during rehabilitation? (a) Loss of worker identity (b) Boredom while away from work (c) Good evaluations by a supervisor prior to injury (d) Worker’s perception of severity of pain

Answer 80

(a) Loss of worker identity caused by depression and anxiety is associated with poor motivation during the rehabilitation process. Other associated factors include deteriorating financial status, change in family roles, loss of control regarding the future, and deteriorating employer relationships.

Question 81

A 35-year-old woman is sent to you for electrodiagnostic evaluation. Her symptoms include numbness in the right 4th and 5th digits and in the medial hand distal to the wrist. Your primary diagnosis is MOST likely to be (a) ulnar neuropathy. (b) C8/T1 radiculopathy. (c) lower trunk plexopathy. (d) medial cord plexopathy.

Answer 81

(a) The distribution described is most consistent with involvement of the ulnar nerve proximal to the dorsal cutaneous branch. Involvement of the C8/T1 roots, lower trunk of the brachial plexus, or medial cord of the brachial plexus would usually result in some additional sensory deficits over the medial forearm proximal to the wrist.

Question 82

A 30-year-old man who is otherwise healthy presents following traumatic bilateral transfemoral amputations. Based on your understanding of the increased metabolic demands associated with prosthetic ambulation, you conclude that (a) he should not be considered a prosthetic candidate. (b) he will have reduced ability to ambulate for long distances (c) cardiac stress testing is recommended prior to consideration for prosthetic fitting. (d) he will be able to use prosthetic devices for transfers and standing activities onl

Answer 82

(b) The metabolic cost of ambulation (mL oxygen consumed per body weight per meter) is a measure of energy consumption per distance. The metabolic cost of ambulation increases following a lower limb amputation and the amount of increase is related to the level of the amputation as well as the amputation’s etiology. Because of this increased metabolic cost, persons will have reduced endurance for ambulation following an amputation. This would be especially true for an individual with bilateral transfemoral amputation(s). The person described, however, should be considered a candidate for prosthetic ambulation and, since he has no prior cardiac history or significant risk factors, cardiac stress testing would not be indicated.

Question 83

An 18-year-old girl presents with a 2 week history of fever, chills, and right knee pain. On examination you note her right knee is hot and swollen. She has a painless, red maculopapular rash on her trunk. She denies trauma, but has an antalgic gait. What is the most likely cause of her symptoms? (a) Staphylococcus epidermidis (b) Neisseria gonorrhoeae (c) Monosodium urate monohydrate crystals (d) Haemophilus influenzae

Answer 83

(b) This patient has fever, chills, and rash. She likely has an infectious cause for her monoarthropathy. She denies traumatic etiology of knee swelling. She may be sexually active, and she should be questioned about this. Her symptoms most closely match the diagnosis of gonoccocal arthritis. This condition occurs following infection with gonorrhea, which presents as monoarthropathy in 25% of patients. The Neisseria gonorrhoeae organism can be recovered in less than 50% of purulent effusions. It affects women as often as men (1:1), and its highest incidence is among sexually active adolescents and young adults. It is the most common cause of septic arthritis in patients younger than 30 years. If the strain of bacteria is not antibiotic-resistant, recovery is expected. Single joint arthritis follows generalized spread (dissemination) of the gonococcal infection. Dissemination is associated with symptoms of fever, chills, asymmetric polyarthralgias (which may be migratory), and rashes (1-mm to 2-cm red macules). The most commonly involved joints are the large joints such as the knee, wrist, and ankle. Tenosynovitis may also be seen with disseminated disease. Gouty arthritis does not present with rash, fever and chills. In neonates, the most common cause of joint infection is Haemophilus influenzae.

Question 84

Which recommendation promotes correct posture in patients with ankylosing spondylitis? (a) Daily corner wall stretches (b) Soft mattress (c) Sidelying (d) Full sit ups

Answer 84

(a) Spinal extension should be promoted so that patients fuse in the most functional position. This also includes lying prone on a firm mattress.

Question 85

Parents of children with Duchenne muscular dystrophy who want them to participate in an exercise program should be advised to (a) encourage them to exercise to the point of fatigue. (b) initiate a graduated, submaximal exercise program. (c) have them participate in a competitive sports program. (d) preclude exercise because it could make the disease progress faster.

Answer 85

(b) Intervention with submaximal exercise training in neuromuscular disease improves physical performance and increases muscle efficiency, and thus helps fight fatigue and improve quality of life. However, in children, the exercise program must be conducted in an enjoyable setting. Supervision is necessary to make sure the children do not play to exhaustion, which could produce muscle damage and overwork weakness.

Question 86

Delerium commonly complicates the rehabilitation of patients with advanced cancer. The most common cause of delerium in this patient population is (a) organ failure. (b) drugs. (c) hypoxia. (d) brain lesions.

Answer 86

(b) In a series of 140 cancer patients with delerium, 59% were found to have some degree of phyarmacological contribution. Organ failure, fluid/electrolyte imbalance, and infection were also important contributing factors

Question 87

On physical examination an 8-year-old patient stands on his toes and has increased lumbar lordosis. He has a Trendelenburg gait with circumduction. What else would you expect to find on his exam? (a) Decreased sensation in his feet (b) Anterior tibialis weakness (c) Quadriceps weakness (d) Hyperreflexia at the ankle

Answer 87

(c) The exam describes typical findings in a boy with myopathy such as Duchenne muscular dystrophy (DMD). The earliest weakness in DMD is proximally in the gluteus maximus. The boy assumes a posture of lumbar lordosis to place the center of gravity posterior to the hip joint to prevent hyperflexion of the hip and thus a fall. Toe walking is a compensatory adaptation to knee extensor weakness.

Question 88

Which statement is TRUE regarding central nervous system (CNS) tumors? (a) Meningiomas are the most common form of primary tumor (b) Metastatic disease makes up approximately 50% of CNS tumors (c) Glioblastoma multiforme has a median survival rate of 5 years (d) Brain tumor treatment side effects do not affect outcome

Answer 88

(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. Fifty percent of CNS tumors are metastatic.

Question 89

What is the mechanism of action of alendronate (Fosamax) in treating osteoporosis? (a) Inhibits osteoclasts (b) Binds to estrogen receptors (c) Increases calcium absorption (d) Promotes osteoblasts

Answer 89

(d) (a) Fosamax inhibits osteoclasts at doses used for osteoporosis.

Question 90

Which symptom of excessive exertion is NOT typical in a person with neuromuscular disease? (a) Paresthesias (b) Hyperthermia (c) Severe muscle cramping (d) Excessive urine output (diuresis)

Answer 90

(d) Anuria or decreased urine output, rather than diuresis, is common following excessive exercise. The other statements are typical of overexertion and overwork weakness

Question 91

Which of the listed vaccinations should be given as part of appropriate medical management for patients participating in a comprehensive pulmonary rehabilitation program? (a) Legionella and mycoplasma avium intracellulare (b) Influenza and mycoplasma avium intracellulare (c) Pneumococcus and legionella (d) Influenza and pneumococcus

Answer 91

(d) Medical management including appropriate use of inhalers, early antibiotic therapy for respiratory infections, pneumococcal vaccine, and annual influenza vaccine.

Question 92

A 25-year-old construction worker fell from a ladder this morning. He presents with knee pain, immediate swelling, and inability to bear weight on the injured leg. The best initial recommendations would be (a) hydrocodone, a knee brace, and return to work with light duty restrictions. (b) nonsteroidal anti-inflammatory medication, x-ray, and return to work with a climbing restriction (c) ice, crutches, x-ray, and sedentary work restriction. (d) tramadol, ace wrap, and off work for 1 week.

Answer 92

(c) This worker has sustained a significant injury and may likely have torn his anterior cruciate ligament. The most appropriate recommendations in the acute setting include ice, compression, elevation, and x-ray to rule out fracture. Work restrictions should allow the worker to remain with restricted weight bearing until improvement is noted or further testing is completed.

Question 93

gelombang datar dg paku2 sangat kecil, gain 200 mikronV/div, Sweep 50 ms/div, ditengah2 ada gelombang paku tinggi 1,25 kotak The potential above is (a) a fibrillation. (b) an end plate spike. (c) a voluntary motor unit. (d) a fasciculation.

Answer 93

(d) The potential is of a duration consistent with a motor unit and fires only once over a 500-ms period. The firing rate would be inconsistent with a voluntary motor unit but is typical of a fasciculation. The amplitude and duration of the potential would also preclude an end plate spike or fibrillation potential. Furthermore, a fibrillation potential would have an initial positive deflection.

Question 94

A 31-year-old female office worker complains of a “lump” on the volar aspect of her left wrist. The lump on her wrist is painful especially late in the day and has been present for 2 weeks. There is no discoloration, and the lump is soft and tender to palpation. It is located between the flexor carpi radialis tendon and the radial styloid. Sensory and motor testing are normal, as are reflexes. How would this lump be treated initially? (a) Iontophoresis (b) Needle aspiration (c) Wrist splint (d) Surgical excision

Answer 94

(c) This patient likely has a benign volar ganglion cyst. These cysts are often located between the flexor carpi radialis tendon and the radial styloid. They can in unusual cases place pressure on the median nerve and result in sensory and motor symptoms. This patient does not complain of either of these. The cyst can be painful, especially with extreme flexion or extension. For acute, painful cysts placement in a wrist splint can decrease pain and can decrease the size of the cyst. A ganglion cyst will transilluminate with a pen light placed beside the cyst. A plain radiograph should be obtained to rule out bony pathology, such as an intraosseous ganglion, benign or malignant bone tumor, or collapse of the lunate (Kienbock’s disease). A magnetic resonance image is not necessary for this patient. Needle aspiration is not necessary. Fluid removed is consistent with synovial fluid in the joint, and does not need to be sent for pathological evaluation. Surgical excision may be indicated for cosmetic purposes, but is not required early.

Question 95

What is the single largest indirect cause of traumatic brain injury? (a) Falls (b) Alcohol (c) Motor vehicle accidents (d) Polypharmacy

Answer 95

(b) Alcohol is believed to be involved in 60% of traumatic brain injury (TBI) cases. Polymedication is not a common indirect cause of traumatic brain injury. Motor vehicle accidents and falls are direct 11 causes of TBI and not indirect.

Question 96

A recovering alcoholic complains of a painful swollen right knee. She has no history of trauma but tells you she has recently lost 10 pounds on the Atkins diet. You aspirate her knee and expect to find a 20,000 white blood cell count with (a) gram-negative rods. (b) positive birefringent rods. (c) 100,000 red blood cells. (d) negative birefringent rods.

Answer 96

(d) This patient has gout. These crystals are intracellular, rod-shaped, with negative birefringence when parallel in a light microscope. There is no history of trauma, therefore, excessive red blood cells would not be expected.

Question 97

A 42-year-old man with multiple sclerosis has disturbed sleep because of painful calf spasms. Your initial choice for pharmacological treatment of this is (a) baclofen (Lioresal). (b) clonidine (Catapres). (c) hydromorphone (Dilaudid). (d) gabapentin (Neurontin).

Answer 97

(a) Baclofen is the agent of choice in this setting. Dantrolene, although effective in reducing muscle tone, causes too much weakness to be an effective agent in amyotrophic lateral sclerosis. Diazepam may produce too much sedation and respiratory impairment. Gabapentin, although effective for neuropathic pain, has only a mild effect on muscle spasticity.

Question 98

Which statement is TRUE regarding the vascular supply to the spinal cord? (a) The paired anterior spinal arteries provide circulation to the anterior two-thirds of the spinal cord. (b) The posterior spinal artery is a single vessel that provides circulation to the posterior onethird of the spinal cord. (c) The watershed region is supplied only via the radicular arteries. (d) The artery of Adamkiewicz provides circulation to the lumbosacral region.

Answer 98

(c) There is a watershed zone from approximately T4 to T6 that is highly vulnerable to ischemia. The zone has 1 anterior and 2 posterior spinal arteries. The artery of Adamkiewicz enters between about T9 and T10

Question 99

A 10-year-old patient presents with spastic hemiparesis and diminished cognitive function several years following treatment for acute leukemia. His CT scan reveals enhancing bilateral white matter hypodensities. The patient received high-dose systemic chemotherapy with vincristine, prednisone/dexamethasone, and L-asparaginase in conjunction with intrathecal methotrexate. The most effective initial management approach to this patient would be (a) high dose parenteral dexamethasone. (b) resumption of intrathecal methtrexate. (c) hospitalization for broad spectrum antibiotic therapy. (d) rehabilitation for compensatory strategies.

Answer 99

(d) This patient’s presentation is typical of diffuse chronic leukoencephalopathy associated with methotrexate neurotoxicity. Leukoencephalopathy may appear years after completion of therapy. Often it is first detected as a learning disability. Pediatric leukemics treated with intrathecal methotrexate and cranial irradiation may demonstrate a reduction in IQ by more than 15 points.

Question 100

What is a barrier for return to work for the injured worker? (a) Receiving a portion of salary while recovering (b) Having a good relationship with supervisor (c) All lost salary being recoverable upon return to work (d) Being married to a spouse who is employed

Answer 100

(a) Financial barriers that are disincentives for return to work include that the worker receives a portion of his/her salary while not working and that the worker has potential for monetary gain through legal settlement.

Question 101

You are asked to evaluate a child who was born at 25 weeks gestation and had a grade 4 intraventricular hemorrhage. What type of cerebral palsy are you most likely to find? (a) Athetoid (b) Hemiplegic (c) Diplegic (d) Hypotonic

Answer 101

(c) Grade 4 intraventricular hemorrhages in premature infants are most commonly associated with spastic diplegia.

Question 102

A 60-year-old woman is being discharged to home from your rehabilitation unit following a right middle cerebral artery ischemic stroke with resultant left hemiparesis. She is ambulatory for short household distances with the use of a hemiwalker on the right. Recommendations for a manual wheelchair for this patient would include (a) hemi-height, with removable swing-away leg rests. (b) hemi-height, with nonremovable swing-away leg rests. (c) standard-height, with removable swing-away leg rests. (d) standard-height, with nonremovable swing-away leg rests.

Answer 102

(a) Wheelchair recommendations for a person with hemiparesis and limited ambulatory abilities would include a hemi-height chair which is lower to the ground than to a standard height wheelchair. This configuration provides the patient greater advantage to propel the wheelchair with the unaffected lower extremity. It is also important for the leg rests to be removable so that they do not interfere with the patient’s ability to propel the wheelchair.

Question 103

Which biomechanical factor is NOT implicated in persons at risk for recurrent stress fractures? (a) Excessive supination of the foot (b) Forefoot valgus (c) Leg length discrepancy (d) Hip joint hypermobility

Answer 103

(d) Reduced (not excessive) hip rotation, along with excessive supination or pronation of the foot, forefoot varus or valgus, and leg length inequality have all been implicated in those at risk for recurrent stress fractures.

Question 104

A 46-year-old woman was involved in a rear-end type motor vehicle accident in which she hit her head against the steering wheel and briefly lost consciousness. Her initial cognitive complaints have improved. She experiences 3 throbbing, unilateral headaches a week associated with nausea. These are graded 8/10 and last for 4 to 8 hours. Which medication would be most appropriate to prescribe? (a) Intranasal butorphanol (Stadol) 1 spray 6 times daily (b) Ibuprofen (Motrin) 600mg 4 times daily (c) Sertraline (Zoloft) 100mg daily (d) Valproic acid (Depakote) ER 500mg twice daily

Answer 104

(d) Divalproex sodium reduces the number and severity of migraine headaches. With 3 migraine-like headaches a week, prophylactic treatment for migraine is indicated. There is concern for developing dependence and abuse potential for butorphanol. Daily use of ibuprofen is more likely to result in rebound headaches when discontinued. There is no evidence that the selective serotonin release inhibitors are effective in the treatment of headache.

Question 105

What is the most common reason for revision of a total hip arthroplasty? (a) Recurrent dislocation (b) Peri-prosthetic fracture (c) Aseptic loosening from polyethylene wear (d) Infection

Answer 105

(c) Aseptic loosening caused by polyethylene wear is is the most common reason for hip arthroplasty revision surgery

Question 106

``` What is the most reproducible method for muscle strength testing in patients with neuromuscular disorders? (a) Manual muscle testing (b) Hand-held dynamometer (c) Isokinetic measurements (d) Single-repetition maximum ```

Answer 106

(b) Manual muscle testing is not reliable in this setting. The hand-held myometer is much more reproducible. Quantitative strength testing methods are highly accurate but require sophisticated equipment.

Question 107

During aerobic exercise, patients with cystic fibrosis should (a) avoid use of supplemental oxygen. (b) receive balanced fluid supplementation. (c) receive hypotonic fluid supplementation. (d) utilize supplementation oxygen for oxygen saturation

Answer 107

(b) Patients with cystic fibrosis are at risk for excessive sodium and chloride loss during exercise. They should therefore receive balanced fluid supplementation. Oxygen is indicated if patients’ oxygen saturation drops below 88%.

Question 108

A 39-year-old factory line worker admits to not wanting to return to work. Which job characteristic is associated with a delayed return to work? (a) Evening shift (b) Job monotony (c) Autonomy (d) Flexible hours

Answer 108

(b) Several job characteristics are associated with delayed return to work. These characteristics include: low pay, low challenge, low control, monotony, low task enjoyment, and conflicts with a supervisor

Question 109

You are asked to evaluate a child with arthrogryposis and equinovarus. Which treatment strategy would be the best to employ? (a) Short leg braces attached to orthopedic shoes (b) Botulinum toxin injections, stretching, and plastic ankle-foot orthoses (c) Oral baclofen (Lioresal), range of motion, and extra depth shoes (d) Casting followed by surgical releases

Answer 109

(d) Arthrogryposis multiplex congenita (AMC) may be caused by a variety of conditions, but is usually not accompanied by spasticity. Thus botulinum toxin and baclofen are not indicated. Most club feet (equinovarus) in patients with AMC are resistant to conservative methods and require surgical releases

Question 110

``` What is the average range of motion at the ankle during normal human ambulation over a level surface? (a) 0° dorsiflexion, 10° plantarflexion (b) 30° dorsiflexion, 20° plantarflexion (c) 5° dorsiflexion, 20° plantarflexion (d) 10° dorsiflexion, 10° plantarflexion ```

Answer 110

(c) The average range of motion at the ankle during normal human ambulation over level surfaces is from 5° of dorsiflexion to 20° of plantarflexion. This range of motion varies with ambulation over uneven surfaces and with activities such as stair climbing.