SAER 2005

Question 1

An overhead athlete with shoulder pain is found to have shoulder posterior capsule tightness. A
biomechanical consequence of this tightness is
(a) posterior displacement of the humeral head relative to the glenoid when the shoulder is
flexing.
(b) glenohumeral internal rotation deficit with range of motion less than 15° from neutral.
(c) impingement of the humeral head onto the superior glenoid labrum when the shoulder is
abducted less than 90°.
(d) posterior tilting of the scapula in the static position and with shoulder abduction.

Answer 1

(b) A tight posterior capsule is a common phenomenon in overhead athletes. Often rotator cuff
tendinopathy results from impingement and scapular dyskinesis. Glenohumeral internal rotation
deficit (GIRD) defined as internal rotation less than 15° or a greater than 25° side to side difference,
is due to tight posterior capsule, teres minor, and infraspinatus. Further, Matsen and Harriman
showed that a tight posterior capsule drives the humeral head anteriorly when flexing the shoulder,
thus predisposing to further impingement at the coracoacromial arch. Scapular dyskinesis, due to
weak scapular stabilizer muscle weakness, is typically in a position of anterior tilting rather than
posterior tilting.

Question 2

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

Answer 2

(b) Clinical practice guidelines for spinal cord injury (SCI) have been established for the prevention of
thromboembolism. Anticoagulant prophylaxis either with low-molecular-weight heparin or
adjusted-dose unfractionated heparin should be initiated within 72 hours after SCI. Inferior vena
cava filter placement is indicated in SCI patients who have failed to respond to or have
contraindications to anticoagulation. Filter placement is not considered a substitute for
thromboprophylaxis.

Question 3

A patient with multiple myeloma presents with a new pathologic fracture of the superior pubic
ramus. Computed tomography scans and plain radiographs fail to reveal additional myelomatous
involvement of the pelvic ring. When consulted regarding weight-bearing recommendations you
advise
(a) bed rest.
(b) non-weight bearing on ipsilateral lower extremity.
(c) weight bearing as tolerated.
(d) toe touch weight bearing until surgical stabilization.

Answer 3

(c) Pathologic fractures of the pelvis that do not involve the acetabulum are generally treated
nonsurgically. Patients may bear weight as tolerated. Aggressive analgesic management may be
required. Mechanical insufficiency of the acetabulum can only be managed surgically.

Question 4

The purpose of the Health Insurance Portability and Accountability Act (HIPAA) is to
(a) ensure that a patient’s medical record is available only to health care providers as directed by
the patient.
(b) make sure that only qualified physicians have access to a patient’s medical record.
(c) allow a lawyer access to a medical record only if litigation is pending.
(d) allow only the treating physician to know the patient’s diagnosis.

Answer 4

(a) The purpose of the Health Insurance Portability and Accountability Act (HIPAA) is to ensure that a
patient’s medical record remains private. A non-treating physician, lawyer, insurance company,
etc. can have access so long as the patient directs it, with written authorization. There are no
stipulations about a physician’s qualifications with regards to medical information access.

Question 5

Which statement is TRUE about volume conduction as it relates to electrophysiologic studies?
(a) Volume conduction is the transmission of an electrical potential through intracellular tissue.
(b) Volume conducted potentials produce a biphasic waveform as an advancing action potential
approaches and then passes beneath a recording electrode.
(c) The negative peak of a recorded waveform represents the time that the action potential is
beneath the active electrode.
(d) Volume conducted near field potential amplitudes does not characteristically depend on the
distance between the recording electrode and the source.

Answer 5

(c) The characteristics of volume conducted near field responses are dependent on the distance from
the recording electrode and the electrical source. The responses represent intracellular events
transmitted through extracellular fluid and tissue. They usually produce a triphasic waveform and
the negative phase is that time during which the advancing wave is directly underneath the
recording electrode.

Question 6

Which exercise creates the least stress of the rotator cuff musculature?

(a) Arms in the scapula plane in internal rotation with weights
(b) Arms in the scapula plane in external rotation with weights
(c) Prone horizontal shoulder abduction in external rotation
(d) Quadruped push-up

Answer 6

(d) The quadruped push-up is a closed kinetic chain (CKC) exercise. CKC exercises are the least
demanding of the rotator cuff exercises. The axial load with CKC exercises effectively reduces the
weight of the arm (ie, load). CKC promote muscle co-activation needed for functional tasks.

Question 7

Which diagnosis is associated with an increased risk of post-traumatic hydrocephalus?

(a) Diffuse axonal injury
(b) Subdural hematoma
(c) Epidural hematoma
(d) Subarachnoid hemorrhage

Answer 7

(d) Hydrocephalus is a well-recognized complication of subarachnoid hemorrhage. The fundamental
abnormality in post-traumatic hydrocephalus is an imbalance in the production and absorption of
cerebral spinal fluid (CSF). As the blood in the subarachnoid space obstructs the arachnoid villi it
impairs absorption of CSF, thus causing hydrocephalus

Question 8

Amputation rather than limb salvage is recommended for the surgical management of high-grade sarcomas involving the

(a) humerus.
(b) distal tibia.
(c) ilium.
(d) distal femur.

Answer 8

(b) Limb salvage is almost always preferred for the upper extremity because of the disability associated
with upper extremity amputation. Amputation is generally preferred for malignancies of the distal
leg and foot in order to ensure adequate tumor resection and because of the excellent functional
status of transtibial amputees. Limb salvage is also preferred for sarcomas of the pelvis and thigh.

Question 9

The Americans with Disabilities Act (ADA) was passed in order to

(a) require employers to hire individuals with disabilities.
(b) protect individuals with disabilities from having to work.
(c) ensure that the pay of workers with disabilities is equal to that of nondisabled workers.
(d) ensure that workers with disabilities have equal access in the work environment.

Answer 9

(d) The Americans with Disabilities Act (ADA) provides that workers with disabilities be offered equal
access in the work environment. The Act requires the employer to provide accessible environment
for the workers. Dimensions for doorways, hallways, ramps and elevator lifts are specified to allow
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wheelchair access. The ADA does not make stipulations with regards to pay, or that an employer is
forced to hire a disabled worker. The ADA does not make any determinations regarding a disabled
person’s ability to work.

Question 10

Which statement is TRUE about F-wave and H-reflex responses?

(a) They both are obtained with supramaximal stimulation.
(b) F waves can only be obtained from posterior tibial and median nerves.
(c) They both involve conduction along motor and sensory fibers.
(d) They both can be helpful in the diagnosis of S1 radiculopathy.

Answer 10

(d) The F-wave response is a pure motor response that is obtained with supramaximal stimulation and
can be obtained from any motor nerve in an adult. The H reflex is usually obtained with
submaximal stimulation and involves both sensory and motor fibers. Tibial and peroneal nerve F
waves can be abnormal in L5–S1 radiculopathies and tibial nerve H reflex can be abnormal in S1
radiculopathies.

Question 11

The Gross Motor Functional Measure (GMFM) is designed to measure

(a) motor changes over time.
(b) quality of motor performance.
(c) achievement of motor milestones.
(d) only walking, running, and jumping ability.

Answer 11

(a) The Gross Motor Functional Measure (GMFM) evaluates motor changes over time in children with
cerebral palsy. It includes activities in prone and supine positions, rolling, sitting, crawling,
kneeling, standing, walking, running, and jumping. It does not measure the quality of motor
performance.

Question 12

What is the major factor limiting ambulation in Duchenne muscular dystrophy?

(a) Joint contracture
(b) Weakness
(c) Scoliosis
(d) Restrictive lung disease

Answer 12

(b) Weakness, not contracture formation, is the major cause of loss of ambulation in Duchenne’s muscular
dystrophy. Contracture formation may actually assist with ambulation.

Question 13

A 25-year-old man with L5 complete paraplegia is admitted to your rehabilitation service 2 weeks
after his injury. On admission you note that he is tolerating an oral diet but has not produced a
bowel movement for 6 days. At this point, you recommend
(a) oxybutynin (Ditropan) 3 times a day.
(b) a contact irritant suppository with digital stimulation daily.
(c) manual removal of stool from the rectum 1–2 times daily.
(d) nasogastric decompression for a presumed ileus.

Answer 13

(c) Individuals with lower lumbar and sacral level injuries usually experience areflexic bowel function.
The use of suppositories are usually not useful in these individuals, because of the absence of spinal
reflex activity. Manual evacuation is often required for an effective bowel program in a lower
motor neuron injury. Anticholinergic medications may lead to constipation.

Question 14

A 35-year-old female tennis player and data entry clerk presents with a 6-week history of lateral
elbow pain. Which factor is promoting her injury?
(a) Her strong scapular stabilizer muscle strength
(b) Her leading with the shoulder when performing the backhand tennis stroke
(c) Her keyboard being placed at too high a level at work
(d) Her tennis racquet string tension being recently increased from a low to a moderate string
tension.

Answer 14

(c) This patient has lateral epicondylitis or so-called tennis elbow. Weak scapular stabilizer muscle
strength may cause decreased force production through the elbow, thus causing more force and load
through the elbow. Leading with the elbow during the backhand stroke can cause an increased load
on the wrist extensor muscles. Keyboards placed too high or too low may cause lateral
epicondylitis. Racquet string tension should be adjusted to mild to moderate tension (52 to 55
pounds if stringing machine is properly calibrated) in a normal (non-oversized) racquet. A racquet
strung to less than 30 pounds will require the tennis player to use more force. This may, in turn,
cause increased grip pressures and wrist extensor overuse

Question 15

What is the most common primary malignant tumor of the brain in adults?

(a) Medulloblastoma
(b) Meningioma
(c) Glioblastoma multiform
(d) Ependymoblastoma

Answer 15

(c) More than 90% of the primary malignant tumors of the brain in adults are high-grade astrocytomas
and, of these, the most common is glioblastoma multiform. Meningiomas are tumors that occur in
the membranes that cover and protect the brain and spinal cord (the meninges). Meningiomas
usually grow slowly. Medulloblastomas are almost always found in children or young adults.
Ependymoblastomas are rare cancers that usually occur in children.

Question 16

A 19-year-old man with Charcot-Marie-Tooth disease has begun falling frequently and you note 2/5
bilateral ankle dorsiflexion strength. He ambulates with a steppage gait pattern. You would recommend
which of the following?
(a) Knee-ankle-foot orthosis
(b) Ankle-foot orthosis
(c) High top shoes with rocker bottom
(d) Supramalleolar orthosis

Answer 16

(b) Persons with Charcot-Marie-Tooth (CMT) disease typically have dorsiflexion weakness and require
ankle-foot orthoses. Supramalleolar orthoses will not provide enough support to compensate for the
weakness in dorsiflexion. A rocker bottom shoe would not be an appropriate option. Patients with
CMT disease generally have functional (grade 4/5) strength in their quadriceps, thus a knee-ankle-foot
orthosis is not indicated

Question 17

An 8-year-old boy presents with an insidious onset of diffuse right elbow pain. Physical
examination reveals loss of full right-elbow extension. Radiographs reveal bone fragment
contiguous with the capitellum. Your advice to the patient and his parents is
(a) reassurance that this condition is self-limiting.
(b) referral to an orthopedic surgeon for surgery.
(c) start a weight-training program of his upper body.
(d) short-arm casting of the elbow for 4 to 6 weeks.

Answer 17

(a) This patient likely has Panner’s disease, or developmental osteochondrosis of the capitellum. This
is a self-limiting condition that does not need surgery or casting. Weight-training in children
should not be commenced until, at least, reaching puberty.

Question 18

What is the most likely diagnosis in a 45-year-old man with a rash over the upper and lower eyelids
who complains of insidious onset of difficulty getting out of a chair and ascending stairs?
(a) Inclusion body myositis
(b) Ankylosing spondylitis
(c) Dermatomyositis
(d) Guillain-Barré syndrome

Answer 18

(c) Individuals with dermatomyositis commonly present with slowly progressive proximal weakness. A
heliotrope rash affecting the eyelids occurs in 30% to 60 % of patients with dermatomyositis.
Inclusion body myositis primarily affects upper extremities distally and occurs in the older
population. Ankylosing spondylitis and Guillain-barré syndrome would not present in the fashion
described.

Question 19

A 68-year-old man with diabetes-related peripheral neuropathy presents with a painful forefoot.
Physical examination reveals a pes cavus foot with hammertoe deformity. Your initial recommendation
is
(a) surgical referral for correction of deformity.
(b) physical therapy focusing on plantar fascia lengthening and intrinsic foot muscle strengthening.
(c) custom-made, total-contact foot orthotic with a built-up arch and metatarsal bar.
(d) botulinum toxin injection of the foot intrinsic muscles.

Answer 19

(c) A well built, custom foot orthotic with a built-up arch and metatarsal bar will support and help correct
the foot deformity. Due to the patient’s insensate skin, the orthosis must be custom fit with even
pressure distribution. The skin should be checked daily for pressure areas. Although corrective foot
surgery may improve function, the initial treatment should be an orthosis. In addition to the built-up
arch, the metatarsal bar is needed to help relieve the hammertoe deformity.

Question 20

In preparation for discharge from your rehabilitation unit, an individual with T12 ASIA A
paraplegia requests information regarding access to a home with 5 steps. You suggest a ramp that,
for every 1 inch in elevation, should have a length of
(a) 12 inches.
(b) 8 inches.
(c) 16 inches.
(d) 24 inches.

Answer 20

(a) Ramps must have a 12-inch length for every 1-inch rise in elevation. This ratio is a minimum
requirement. A ramp must often be longer for an individual with a higher level spinal cord injury to
be able to independently navigate it. When space allows, a longer, less steeply inclined ramp is
preferable.

Question 21

Which adjuvant analgesic medication acts at ion channels to stabilize neuronal cell membranes?

(a) Gabapentin (Neurontin)
(b) Amitriptyline (Elavil)
(c) Clonidine (Catapres)
(d) Baclofen (Lioresal)

Answer 21

(a) Gabapentin’s therapeutic effects are mediated by binding to a calcium ion channel located on
neuronal cell membranes. It may also have GABA agonistic properties, but this remain equivocal

Question 22

What percentage of American children with myelomeningocele requires a shunt to manage
hydrocephalus?
(a) 10–20
(b) 25–50
(c) 60–70
(d) 80–90

Answer 22

(d) Seventy-five percent of lesions in spina bifida cystica (myelomeningocele) affect the lumbosacral
spine. Ninety percent of children with spina bifida have hydrocephalus that requires a shunt for
management.

Question 23

What does the acronym SACH stand for?

(a) Simple amputation, cadence heel
(b) Single axis, carbon heel
(c) Standard adult, control heel
(d) Solid ankle, cushion heel

Answer 23

(d) SACH is an acronym for solid ankle, cushion heel. The SACH foot has a cushioned heel that
compresses during heel strike, stimulating plantar flexion, and has a rigid anterior keel to roll over
during late stance. It is light, durable, and inexpensive, and is the orthosis most often prescribed for
juvenile and geriatric amputees.

Question 24

A 20-year-old female long-distance runner presents with a l-week history of worsening lateral hip
pain. Magnetic resonance imaging reveals bone edema at the lateral aspect of the femoral neck,
without evidence of a fracture line or cortical break. What is the next step in management?
(a) Relative rest for 4 weeks
(b) Refer to orthopedic surgeon for surgical evaluation
(c) Order a triple-phase bone scan to determine acuity of the injury
(d) Physical therapy with closed kinetic chain exercise emphasis

Answer 24

(b) Femoral neck stress fractures are serious injuries. Stress fractures may occur without a cortical
break. Stress fractures of the medial side of the femoral neck, the “compression” side, can be
treated with a weight-bearing restriction for 6 weeks or longer including no running or high impact
activities. Stress fractures on the lateral side of the femoral neck, the “tension” side, warrants
strong surgical consideration because of the poor healing capability at that location.

Question 25

A 45-year-old man complains of wrist, thumb, and elbow pain and swelling after being on a highprotein diet for 12 weeks. Aspiration of the elbow reveals negatively birefringent intracellular crystals on microscopic examination. What would you expect to see on radiographs of his hands and wrists? (a) Distal interphalangeal joint osteophytes (b) Pencil-in-cup deformity (c) Juxtarticular osteopenia (d) Joint erosion with sclerotic borders

Answer 25

(d) This patient has gout, and radiographs of the hands and wrists would likely demonstrate joint erosions with sclerotic borders. The finding in option (b) describes psoriatic arthritis. Juxtarticular osteopenia may be a finding on radiographic studies in patients with rheumatoid arthritis. Distal interphalangeal joint osteophytes are characteristic of osteoarthritis.

Question 26

``` What is the primary underlying cause of the restrictive lung disorders that are common in many neuromuscular disorders? (a) Recurrent pneumonia (b) Prolonged wheelchair use (c) Respiratory muscle weakness (d) Intrinsic lung damage ```

Answer 26

(c) Respiratory impairment in neuromuscular disease is due to weakness of the diaphragm, chest, and abdominal musculature. The other listed factors have not been shown to play a significant role.

Question 27

The term maximum medical improvement (MMI) indicates that (a) no deterioration of the condition is expected to occur. (b) no further treatment for the condition is required. (c) no further treatment is reasonably expected to improve the condition. (d) physician and patient agree that the condition has stabilized.

Answer 27

(c) Maximum medical improvement (MMI) is a term used by a physician to indicate that he/she has determined that no further significant recovery of a condition is anticipated to occur. Resolution of the condition may or may not occur. Determining MMI does not indicate that no treatment is indicated.

Question 28

A 60-year-old woman with diabetes and hypertension complains of right foot swelling and mild discomfort on ambulation. There is no history of trauma. Examination demonstrates decreased sensation in the foot and a plantar ulcer. There is no sinus tarsi tenderness and no ankle instability. What is the most likely diagnosis? (a) Charcot’s joint (b) Lateral ankle sprain (c) Tarsal tunnel syndrome (d) Plantar fasciitis

Answer 28

(a) Charcot’s joints often present as painless swelling in patients with diabetes. Other illnesses associated with Charcot’s joint include tabes dorsalis and syringomyelia.

Question 29

You are told by a physical therapist that your patient with acute C5 ASIA A tetraplegia is having difficulty breathing, but only when sitting upright. Appropriate lab tests and radiologic studies are unremarkable. To address the patient’s breathing difficulty, you suggest (a) bilateral above-knee compression stockings. (b) a tilt table program. (c) intermittent positive pressure breathing treatments. (d) the use of an abdominal binder.

Answer 29

(d) In the acute complete tetraplegic patient there is a lack of abdominal muscle tone. An abdominal binder can help because when the patient using it sits upright the abdominal contents are pulled caudally and also are pushed inward. This action pushes up on the diaphragm and allows it to start in a position of mechanical advantage when inhaling while upright. Compression stockings and tilt table programs can be useful for a decrease in blood pressure that accompanies upright posture. Orthostatic hypotension is associated with lightheadedness, dizziness, nausea, syncope. Intermittent positive pressure breathing can be useful to decrease atelectasis.

Question 30

The surgical transplant service requests physical therapy recommendations for a patient beginning to reject a single lung transplant. In addition to pursed lip and diaphragmatic breathing, recommendations should include (a) a focus on passive stretching and isometrics. (b) telemetry monitoring while out of bed. (c) an aerobic exercise program. (d) minimizing of supplemental oxygen.

Answer 30

(c) During rejection, lung transplant patients should perform basic breathing exercises. They can continue to perform aerobic exercise as tolerated with oxygen supplementation

Question 31

A 9-year-old girl with C5 ASIA A spinal cord injury sustained 2 years ago is evaluated for upper extremity splinting. Which statement regarding this scenario is TRUE? (a) A resting hand splint should be prescribed for daytime use to preserve function. (b) A wrist extension splint would be contraindicated for daytime use because it would interfere with function. (c) A mobile arm support or balanced forearm orthosis could be prescribed to make self-feeding possible. (d) A short hand splint should be prescribed to strengthen wrist extensor muscles.

Answer 31

``` (c) A mobile arm support or balanced forearm orthosis would enable the child with C5 ASIA A spinal cord injury (SCI) and weak arm muscles to move the arm through useful active range of motion and to position the hand for function. In patients with C5 SCI, these orthoses are typically combined with wrist extension splints or a universal or palmar cuff for feeding. A resting hand splint may be used at night to improve or maintain range of motion, but would interfere with daytime function. A short hand splint would not strengthen wrist extensor muscles, but may be useful to improve function. ```

Question 32

Which structure is NOT part of the pain pathway for rapid transmission of immediate pain? (a) Rexus lamina 2,3 (b) Lissauer’s tract (c) C fibers (d) Periaqueductal gray matter

Answer 32

(c) C fibers are unmyelinated fibers that modulate slow pain (“second pain”) rather than acute pain. “First pain” is mediated by A-delta nociceptors and is brief and localized.

Question 33

A 26-year-old woman is admitted to the inpatient rehabilitation unit following a traumatic brain injury. She is confused, inappropriate, agitated, and requires a padded floor bed. What is her Rancho Los Amigos level? (a) IV (b) V (c) VI (d) VII

Answer 33

(a) The Rancho Los Amigos level IV applies to persons who are confused and agitated. The need of a padded floor bed indicates that the patient is restless and agitated.

Question 34

with axial grinding of the first carpometacarpal joints as well as Heberden and Bouchard nodes in the hands. What is an appropriate initial treatment? (a) Resting wrist splints in neutral (b) Thumb spica splints (c) Compression gloves (d) Buddy taping the digits

Answer 34

(b) The carpometacarpal joint is a common location for osteoarthritis in the upper extremity. While cumbersome, a thumb spica splint will often alleviate the pain. The other options listed would not be considered appropriate initial treatment options

Question 35

Which statement about workers’ compensation cases is TRUE? (a) The most recent publication of the American Medical Association guidelines for disability are used uniformly in every state. (b) Parameters that guide entry to evaluation and treatment are unique to each state. (c) States require subspecialty board certification for physicians who practice industrial medicine. (d) Most states allow injured workers to choose the physician who manages their care.

Answer 35

(b) Guidelines for worker entry and treatment under workers’ compensation law are determined by each state. The published American Medical Association guidelines are useful tool in determining disability. Because each state determines which edition of the publication is used, its application is not uniform nationwide. Not all states require subspecialty certification required of a physician wishing to practice industrial medicine. In some states the employer chooses the physician to treat the injured worker.

Question 36

Which compound muscle action potential (CMAP) finding is the most compatible with myasthenia gravis? (a) A 15% decrement in the amplitude between the 1st and 4th responses with repetitive stimulation at 3 hertz (b) A low amplitude response with supramaximal stimulation of the ulnar nerve and pick-up over the hypothenar muscles (c) A 100% increase in the amplitude with stimulation of the spinal accessory nerve and pick-up over the trapezius muscle immediately post exercise (d) A 50% increment in the amplitude between the 1st and 4th responses with repetitive stimulation at 30 hertz

Answer 36

(a) In myasthenia gravis there is a decrement in the amplitude and area of the compound muscle action potential (CMAP) with stimulation at low frequencies (2–3Hz). Stimulation at high rates of 20– 50Hz can result in pseudofacilitation with correction of the amplitude decrement in normal subjects as well as patients with neuromuscular junction disorders. A 100% or greater increase in the amplitude of the post exercise CMAP is usually associated with a presynaptic neuromuscular junction disorder such as Lambert-Eaton myasthenic syndrome (LEMS). Small CMAPs on routine nerve conduction studies are more characteristic of LEMS than of myasthenia gravis

Question 37

Which muscle is primarily responsible for clearance of the leg during swing phase? (a) Iliopsoas (b) Hamstrings (c) Quadriceps (d) Tibialis anterior

Answer 37

(d) Midswing is the continuation of the passive pendulum action of the leg. Foot clearance is maintained by activity of the tibialis anterior

Question 38

A 70-year-old man with severe bilateral knee osteoarthritis states that over the counter nonsteroidal anti-inflammatory drugs and aceteminophen are not controlling his knee pain. He inquires about a more potent anti-inflammatory medication he saw on a television commercial. Once treatment has been initiated, which recommendation would be most appropriate? (a) Check kidney function and a hematocrit for anemia every 6 months. (b) Start concomitant anti-hypertensives if the patient develops high blood pressure. (c) Switch to a cyclooxygenase-2 inhibitor if the patient is on aspirin for cardioprotective effects. (d) Start concomitant proton pump inhibitor or histamine H2-receptor antagonists.

Answer 38

(a) Older patients on nonsteroidal anti-inflammatory drugs are at a high risk for medication-induced side effects. Kidney function and gastrointestinal (GI) bleeds (causing anemia) should be monitored every 6 months. The purported gastroproctective effects of cyclooxygenase-2 inhibitors may be lost with concomitant aspirin use. Gastritis side effects, especially in the elderly, should be worked up for a GI bleed prior to instituting histamine H2-receptor antagonists or a proton pump inhibitor.

Question 39

The mechanism of action of a phenol nerve block is (a) reduction of calcium release from the sarcoplasmic reticulum. (b) agonist action at alpha-adrenergic receptor sites. (c) denaturation of protein in myelin sheaths and axons. (d) inhibiton of presynaptic acetylcholine release.

Answer 39

(c) Phenol acts as a neurolytic agent that denatures protein in myelin sheaths and axons. Dantrolene sodium (Dantrium) reduces calcium release from the sarcoplasmic reticulum. Tizanidine (Zanaflex) is an alpha-2 agonist. Botulinum toxin (Botox) inhibits acetylcholine release.

Question 40

Which agent acts on osteoblasts to increase bone formation? (a) Calcium (b) Calcitonin (c) Vitamin D (d) Estrogen

Answer 40

(c) Bone remodeling has 5 phases; activation, resorption, reversal, formation, quiescence. Vitamin D will increase this process and acts on the osteoblasts, whereas the other choices act on the osteoclasts to stabilize bone.

Question 41

Based on the revised edition of the American Spinal Injury Association (ASIA) Impairment Scale, published in the year 2000, which condition would be sufficient to categorize a spinal cord injury as motor incomplete? (a) Some motor function more than 2 levels below the motor level (b) Voluntary anal sphincter contraction (c) A well-defined zone of partial preservation (d) An anterior spinal artery syndrome

Answer 41

(b) For an individual to receive an ASIA classification of motor incomplete injury (ASIA C or D), he/she must have either voluntary anal sphincter contraction or sensory sacral sparing with sparing of motor function more than 3 levels below the motor level. The zone of partial preservation is used 5 of 11 only in complete injuries. Individuals with anterior spinal artery syndrome are often motor complete.

Question 42

Which filter setting is usually considered appropriate for routine sensory nerve conduction studies? LOW-FREQUENCY FILTER HIGH-FREQUENCY FILTER (a) 2–10Hz 10,000Hz (b) 2–10Hz 2,000Hz (c) 20–30Hz 10,000Hz (d) 20–30Hz 2,000Hz

Answer 42

(b) 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 based on the optimum frequency content of the mean waveforms that are routinely observed. The recommended filter setting for routine sensory nerve conduction studies is 2–10Hz for the low-frequency filter and 2,000Hz for the high-frequency filter.

Question 43

In anoxic brain injury, which area of the brain is most susceptible to hypoxemia and hypotension? (a) Hippocampus (b) Pons (c) Basal ganglia (d) Cerebellum

Answer 43

(a) The mechanism of brain damage in anoxic brain injury is ischemia due to hypoxemia or decreased cerebral perfusion. Although anoxic brain injury typically causes diffuse neuronal death and injury, there is selective vulnerability of certain neurons. Neurons in parts of the hippocampus appear to be the most vulnerable, which correlates with the high frequency of amnesia following anoxic brain injury.

Question 44

A 16-year-old with Duchenne muscular dystrophy presents to your office with a 3-month history of worsening shortness of breath and pressure-like chest pain. His pulmonary function testing has not changed significantly. The most likely cause for his complaints is (a) decreased cardiac output. (b) bacterial pneumonia. (c) pulmonary embolus. (d) aspiration pneumonia.

Answer 44

(a) Given that his pulmonary function has not changed, the most likely cause for his shortness of breath is cardiac decompensation due to cardiomyopathy. Respiratory failure due to neuromuscular weakness would typically correspond to worsening of pulmonary function testing. Bacterial and aspiration pneumonia would both present with much more acute symptoms. Boys and men with Duchenne muscular dystrophy rarely get deep venous thromboses or pulmonary emboli. If left untreated, the patient will likely develop congestive heart failure from cardiomyopathy. The decreased cardiac output usually responds to treatment with digoxin and ACE-inhibitors.

Question 45

You elect to treat a patient with chronic pain and a seizure disorder with an opioid. Which medication should be avoided due to potential accumulation of a neurotoxic metabolite? (a) Meperidine (Demerol) (b) Hydromorphone (Dilaudid) (c) Methadone (Dolophine) (d) Fentanyl (Duragesic, Actiq)

Answer 45

(a) Meperidine (Demerol) is converted in the liver to normeperidine. Normeperidine accumulation may cause hyperexcitability of the central nervous system and lower the seizure threshold.

Question 46

The inferior gluteal nerve innervates which muscle? (a) Gluteus maximus (b) Gluteus medius (c) Gluteus minimus (d) Tensor fascia latae

Answer 46

(a) The inferior gluteal nerve innervates the gluteus maximus muscle. The other 3 muscles are all innervated by the superior gluteal nerve.

Question 47

A normal 6-month-old infant may demonstrate which reflex? (a) Rooting (b) Automatic walking (c) Plantar grasp (d) Posterior protective extension

Answer 47

(c) Rooting and automatic walking reflexes are present at birth, and are integrated by 4 months of age. Posterior protective extension does not appear until 7 to 8 months of age. Plantar grasp is present at birth and not integrated until after independent walking occurs at approximately 12 months of age. Reflex Age of Emergence Age of Suppression (or Integration) Moro Birth 4–6 months Rooting Birth 4 months Asymmetric tonic neck reflex (ATNR) 1–3 months 6–7 months Plantar grasp Birth 12–14 months–ie, when walking well Automatic walking Birth 3–4 months Posterior protective extension 7–8 months

Question 48

gambar prostesis above elbow, panah menunjuk pada tali dan kawat yg menempel pd strap axilla anterior dan bagian stump. What is the arrow pointing to in this upper extremity prosthesis? (a) An excursion cable (b) An anterior split cable (c) The elbow-lock control cable (d) The elbow flexion cable

Answer 48

(c) This is an elbow-lock control cable. Its proximal end originates at the anterior suspension strap and its distal end engages the elbow-locking mechanism. The principal of the elbow-lock mechanism is pull-and-release to lock, pull-and-release to unlock

Question 49

A 60-year-old woman presents with severe bulbar involvement at the time of initial diagnosis with amyotrophic lateral sclerosis. Regarding her prognosis, which statement is TRUE? (a) Riluzole (Rilutek) will improve life expectancy by 3 years. (b) Her prognosis is quite poor and her life expectancy is less than 5 years. (c) With aggressive speech therapy her prognosis will significantly improve. (d) Bulbar symptoms at the time of initial diagnosis have a positive influence on prognosis.

Answer 49

(b) Bulbar palsy associated with amyotrophic lateral sclerosis (ALS), particularly in women, is known to be prognostic of a poor outcome. While it may help palliate symptoms and improve ability to communicate, speech therapy has not been shown to modify disease progression in ALS. In clinical trials, riluzole improved the life expectancy of ALS patients by approximately 3 months over an 18- month period

Question 50

In regards to quality of life after spinal cord injury, which factor has the LEAST correlation with life satisfaction? (a) Level of injury (paraplegia versus tetraplegia) (b) Access to leisure activities (c) Marriage (d) Number of hospitalizations

Answer 50

(a) The highest levels of life satisfaction for individuals with spinal cord injuries have been correlated with employment, education, number of hospitalizations, marriage, time since injury, leisure activities, social support, and adequate finances. Little correlation has been found between level of injury and life satisfaction.

Question 51

A data entry operator presents to your office complaining of a 2-week history of bilateral elbow pain that increases in severity the longer she types. She denies sensory changes or weakness. She has not had treatment. The only significant exam finding is pain on palpation of the proximal extensor forearm muscles just distal to the lateral epicondyles. You recommend (a) ice, physical therapy, evaluation of keyboard placement. (b) heat, extensor strengthening exercises, raising of keyboard height. (c) ultrasound, elbow brace to limit flexion, raising of monitor height. (d) iontophoresis, wrist splint to limit extension, lowering of monitor height.

Answer 51

(a) The most likely diagnosis in this case is lateral epicondylitis. In acute overuse injuries ice should be used first to reduce inflammation. Physical therapy may be used to facilitate a home exercise program for flexibility and strengthening exercises and to ensure appropriate posture adaptations. The computer set-up—including chair height and positioning of the monitor, keyboard, and mouse—will help resolve current complaints and reduce risk of re-injury. This ergonomic evaluation is multifactorial.

Question 52

Which statement is TRUE about swallowing in infants? (a) Sucking and swallowing are well-coordinated for oral intake by 34 weeks of gestation. (b) The infant’s larynx is low, about the level of the sixth cervical vertebra. (c) The infant’s tongue fills less of the oral cavity than the adult’s tongue. (d) Oral breathing occurs at birth and may interfere with sucking.

Answer 52

(a) Sucking and swallowing are well-coordinated at 34 weeks’ gestation. Because the infant’s tongue is more anterior than the adult’s, the tongue fills more of the oral cavity than in the adult. The larynx in the infant is high, about at the C2–3 level. Newborn infants are obligate nose breathers and oral breathing is not observed until 3 to 4 months of age.

Question 53

The primary advantage of a 4-point crutch gait over a 2-point crutch gait is (a) stability. (b) speed. (c) weight-bearing relief. (d) efficiency of gait

Answer 53

(a) The 4-point crutch gait has stability as its primary advantage. At least 3 points are always in contact with the ground. It is more difficult to learn than the other gait patterns and is a relatively slow form of ambulation. The 3-point crutch gait is used by patients with lower limb fractures, amputations, or toe-touch weight-bearing. The 4-point gait pattern enables the crutch user to eliminate all the weight-bearing on the affected lower limb. The 2-point crutch gait is much faster than the 4-point gait and yet still provides some weight-bearing relief to both lower limbs.

Question 54

A 28-year-old non-pregnant woman presents with persistent lancinating pain along her right zygomatic arch. The pain is intermittent and often triggered by chewing. What is the initial management? (a) Transcutaneous electrical nerve stimulation (b) Carbamazepine (Tegretol) (c) Botulinum toxin (Botox) (d) Cervical epidural injection

Answer 54

(b) The patient suffers from trigeminal neuralgia (tic douloureux). This spasm is thought to be due to intracranial vascular compression of cranial nerve V. Often the pain is triggered by non-noxious stimuli and from an area separate from the area of pain. Trigeminal neuralgia is paroxysmal and often responsive to anticonvulsants. Carbamazepine appears to be particularly effective. Capsaicin and gabapentin have proven benefit for postherpetic neuralgia but not trigeminal neuralgia

Question 55

In multiple sclerosis, which factor is associated with poor prognosis? (a) Female sex (b) Onset before age 30 years (c) Positive Lhermitte sign (d) Cerebellar involvement at onset

Answer 55

(d) Factors associated with poor prognosis in multiple sclerosis are: progressive course at onset, male sex, age at onset >40 years, cerebellar involvement at onset, and multiple system involvement at onset. A positive Lhermitte sign (shocklike sensation down the spine, often into the limbs on neck flexion) is indicative of cervical myelopathy but has no prognostic significance.

Question 56

A 55-year-old man with limb girdle muscular dystrophy has severe lordosis and chronic low-back pain. What is your initial recommendation? (a) Thoracolumbosacral orthosis (b) Aquatic therapy program (c) Lumbar facet intra-articular steroid injections (d) Core strengthening exercises

Answer 56

(b) People with limb girdle muscular dystrophy have significant weakness in the abdominal muscles and the spinal extensors, leading to lordosis. Strengthening exercises will not likely help, nor will facet injections. Aquatic therapy will help unload his spine and will help maintain mobility. Putting the patient into a thoracolumbosacral orthosis will force his center of gravity too far forward, making him fall over

Question 57

Which statement is TRUE regarding treatment of spasticity in individuals with spinal cord injuries? (a) Over 75% of individuals require treatment for their spasticity at the time of discharge from rehabilitation. (b) The use of a muscle relaxant such as carisoprodol (Soma) is effective in spasticity of spinal origin. (c) Botulinum toxin injections are effective because of their long (6–12 month) duration of effect. (d) Intrathecal baclofen delivery often eliminates the need for oral antispasticity medication.

Answer 57

(d) Less than 40% of individuals with spinal cord injuries require treatment for their spinal cord injury at the time of discharge from acute rehabilitation. There is no evidence to support the use of carisoprodol in spasticity of spinal origin. The average duration of effect for botulinum toxin is 3 to 6 months.

Question 58

A factory owner consults you to make recommendations on how to reduce workers’ compensation claims. You recommend evaluation of workers’ ergonomics and equipment. Educating the employer regarding psychosocial factors is important because workers (a) who do not enjoy their job are more likely to report a back injury. (b) will claim low back injuries for attention. (c) employed in factories often have a psychiatric history. (d) claiming injuries after ergonomic evaluation are malingerers.

Answer 58

(a) Bigos's study of over 3,000 aircraft employees identified risk factors for low back injury that are outside of the physical factors. Workers who hardly ever enjoyed their job were 2.5 times more likely to report a back injury than those who “almost always” enjoyed their job. This study suggested that identifying factors outside of the physical and ergonomic model was important in determining risk of injury. No studies demonstrate that factory workers often have mental illness.

Question 59

``` A 55-year-old man has had worsening symptoms of right arm pain and numbness in the right index and long fingers. He does not have any bowel or bladder problems or symptoms in the other limbs. His electrodiagnostic studies on the right (R) side show the following: MOTOR NERVE CONDUCTION STUDIES Nerve Stimulation Site Distal Latency (ms) Amplitude (mV) NCV (m/s) R Median Wrist 3.6 8.4 Elbow 8.1 53 R Ulnar Wrist 3.5 8.9 Below elbow 8.5 57 Above elbow 8.1 55 SENSORY NERVE CONDUCTION STUDIES Nerve Stimulation Site Recording Site Distal Latency (ms) Amplitude (μV) R Median Wrist - 14 cm Digit II 3.2 55 R Ulnar Wrist - 14 cm Digit V 3.1 47 R Median- mixed Palm - 8 cm Wrist 1.9 76 R Ulnar - mixed Palm - 8 cm Wrist 1.8 45 NEEDLE ELECTROMYOGRAPHY Muscle Abnormal Spontaneous Activity Recruitment R Triceps 1+ Reduced R Biceps 0 Normal R Brachioradialis 1+ Reduced R Extensor Digitorum Communis 0 Normal R Pronator Teres 2+ Reduced R Flexor carpi ulnaris 0 Normal R 1st dorsal interosseous 0 Normal R Supraspinatus 0 Normal R Cervical-paraspinals upper 0 R Cervical-paraspinals middle 2+ R Cervical-paraspinals lower 0 These findings are most consistent with right (a) median neuropathy. (b) radial neuropathy at the spiral groove. (c) middle trunk plexopathy. (d) C6/C7 radiculopathy. ```

Answer 59

(d) The nerve conduction studies are normal. The needle electromyographic findings are limited to the muscles innervated by the C6 and C7 roots. Spontaneous activity in the cervical paraspinals makes a more distal lesion unlikely.

Question 60

``` During a physical examination, which structure CANNOT be effectively assessed by the modified Thomas test? (a) Iliotibial band (b) Hip flexors (c) Knee extensors (d) Hamstrings ```

Answer 60

(d) The modified Thomas test is performed with the patient supine; with the tested leg in maximal passive hip extension and knee flexion and the contralateral knee to the chest. The test position causes the pelvis to be placed in posterior pelvic tilt and reduces any lumbar lordosis. Tightness of hip flexors is measured by the degrees of hip flexion from neutral. Tightness of the knee extensors is measured by the degrees of knee flexion from neutral. Tightness of the iliotibial band is measured by the degrees of hip and knee external rotation.

Question 61

Which physical diagnosis finding is associated with poor functional outcome following stroke? (a) Loss of pinprick sensation (b) Prolonged flaccid period (c) Generalized increase in tone (d) Significant shoulder subluxation

Answer 61

(b) Factors associated with poor functional outcome following stroke include a prolonged flaccid period, severe proprioceptive deficits, late return of reflexes, and severe proximal spasticity.

Question 62

A 25-year-old nulliparous woman with a history of psoriasis complains of low-back pain and occasional groin discomfort. There is no history of recent trauma. Which finding would you expect on pelvic radiographs? (a) Avulsion fracture at the pubic tubercle (b) Osteitis condensans ilii (c) Traction apophysitis (d) Sacroiliitis

Answer 62

(d) Psoriatic arthritis is a seronegative spondyloarthropathy. Sacroilitis must be ruled out in these patients when they complain of back pain. Osteitis condensans ilii occurs in women with pelvic pain after pregnancy, avulsion fracture would typically be seen after a traumatic or high-impact event, and apophysitis is seen in the adolescent before full maturation of the end plates.

Question 63

The majority of new spinal cord injuries in the United States are a result of (a) violence. (b) falls. (c) motor vehicle accidents. (d) sports.

Answer 63

(c) Automobile accidents account for 34.5% of new spinal cord injuries, falls 22.0%, gunshot wounds 17. 2%, diving 4.5%, and motorcycle crashes 4.4%. These figures represent all races combined.

Question 64

During acute herpes zoster infection, empiric use of which medication was shown in a randomized, blinded trial to reduce the incidence of postherpetic neuralgia? (a) Gabapentin (Neurontin) (b) Amitriptyline (Elavil) (c) Clonidine (Catapres) (d) Lamotrigine (Lamictal)

Answer 64

(b) In a randomized trial using amitriptyline for preemptive treatment of postherpetic neuralgia, it was found that pain prevalence at 6 months was reduced by greater than 50%. The authors concluded that amitriptyline should be combined with antiviral therapy in the treatment of acute herpes zoster in elderly patients.

Question 65

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

Answer 65

(c) Case managers reduce workers’ compensation costs by 23% and reduce the overall number of lost-time cases. Overall case management can help improve the quality of care, reduce cost, and decrease time loss in the worker’s compensation system. Studies show that case managers doe not interfere with the physician-patient relationship or the physician’s recommendations, and do not make proposals that favor the insurer.

Question 66

You are performing a consult on an 8-year-old child who has sustained a traumatic brain injury. The child has hyperthermia, hypertension, tachycardia, and rigidity. The best management for this child would be (a) Propranolol (Inderal). (b) Baclofen (Lioresal). (c) Nonsteroidal anti-inflammatory drugs (NSAIDs). (d) Amantadine (Symmetrel).

Answer 66

(a) Fever in a child with a severe traumatic brain injury should be investigated and infections treated with appropriate antibiotics. In the absence of infection, the fever in central autonomic dysfunction is poorly responsive to nonsteroidal anti-inflammatory drugs. Baclofen may help to control the spasticity, but propranolol is more effective in controlling the hypertension, tachycardia, and hyperthermia.

Question 67

A 40-year-old woman with history of Hodgkin’s lymphoma was treated with radiation 20 years ago. She complains of left groin and thigh pain aggravated by weight-bearing. Symptoms have been insidious in onset and there is no evidence of recurrent cancer. She has limited active hip flexion, abduction, and external rotation. She has no back pain with passive hip extension and knee flexion in the prone position. What is the most likely diagnosis? (a) Avascular necrosis of the femoral head (b) Herniated nucleus pulposus at L3/L4 (c) Iliotibial band friction syndrome (d) Snapping hip syndrome

Answer 67

(a) The patient has avascular necrosis. Radiation, alcohol use, trauma, infections, and pancreatitis increase the risk of developing avascular necrosis. With a normal neurologic examination and a negative femoral stretch as described, a herniated disc is less likely.

Question 68

Which statement is TRUE regarding spasticity in the individual with spinal cord injury? (a) Most antispasticity medications can completely eliminate spasticity. (b) The incidence of spasticity is higher in individuals with lower thoracic spinal cord injury than in those with cervical spinal cord injuries. (c) Spasticity can offer a functional benefit to some individuals with spinal cord injuries. (d) Clonus is an example of a tonic stretch reflex.

Answer 68

(c) No single medication for spasticity is universally beneficial and reduction of spasticity, rather than elimination of it, is the more likely outcome. The incidence of spasticity is higher in individuals with cervical and upper thoracic injury than in those with lower thoracic injury. Lower extremity tone may be helpul for activities such as transfers, standing, and ambulation. Spasticity is often characterized as either phasic or tonic. Tonic spasticity is seen as increased tone. Phasic spasticity is usually seen in hyperactive tendon jerks.

Question 69

At the time of the initial evaluation of an injured worker, the physiatrist should (a) define the anticipated time frame that pain medications will be used. (b) ensure that the worker understands narcotic medications will be used if necessary up until time to return to work. (c) recommend that only non-narcotic pain medications will be used during rehabilitation. (d) recommend patient-directed use of pain medications during rehabilitation and return to work.

Answer 69

(a) Narcotics and non-narcotic medications often may be necessary to manage pain in the injured worker. It is important to set expectations of how these medications will be used. Expected length of time of narcotic usage is especially important. The goal should be to return the worker to his/her job without medication. Simply cutting off medications may be inappropriate. As pain improves, and strength and function improve, medications should be tapered.

Question 70

In order to obtain a semi-electric hospital bed for a patient who requires frequent changes in body position, which Medicare guideline must be met? (a) The patient requires a bed with side rails for positioning the body in ways not feasible with an ordinary bed. (b) The patient requires a heavy-duty bed due to morbid obesity, with body weight over 500 lbs. (c) The caregiver requires a bed to be raised up to 48 inches to facilitate wound care. (d) The patient requires traction equipment that can be attached only to a hospital bed.

Answer 70

(d) By Medicare guidelines, to obtain a semi-electric hospital bed for a patient the physician must complete a certificate of medical necessity. Although a full electric bed used in most hospitals may 8 of 11 be beneficial for many patients, Medicare guidelines consider the electric powered, variable height feature a convenience and, therefore, Medicare will not cover a full electric bed. A semi-electric hospital bed will be covered if the patient requires frequent changes in body position or has an immediate need for change in body position along with at least 1 of the following conditions: (1) The patient requires positioning of the body in ways not feasible with an ordinary bed. (2) For pain relief, the patient requires positioning of the body in ways not feasible in an ordinary bed. (3) Because of congestive heart failure, pulmonary disease, or aspiration, the patient requires the head of the bed to be elevated more than 30° most of the time. (4) The patient requires traction equipment that can only be attached to a hospital bed. The standard hospital bed has many disadvantages. The beds have a 10-inch excursion from a low of 24 inches to a high of 34 inches. Additionally, the standard hospital bed frame has a weight limitation of around 500 pounds.

Question 71

Which statement regarding the multifidi muscles of the back is TRUE? (a) Atrophy of the multifidi occurs in patients with low back pain. (b) Contraction of the multifidi causes gross trunk extension. (c) The multifidi muscles cross 4 or more spinal levels. (d) The multifidi have a low composition of muscle spindles.

Answer 71

(a) The multifidi are local postural muscles of the lumbar spine. They are length transducers or position sensors of a spinal segment, by way of their rich composition of muscle spindles. The multifidi pass along 2 or 3 spinal levels. They are theorized to work as segmental stabilizers rather than producing gross trunk motion, since they do not have a large moment arm. Researchers have found atrophy of the multifidi in people with low-back pain.

Question 72

Which finding supports a diagnosis of complex regional pain syndrome type I? (a) Sensory deficits in a dermatomal distribution (b) Cutaneous allodynia (c) Focal motor weakness (d) Side-to-side symmetry of dermal temperature

Answer 72

(b) The Task Force on Taxonomy convened by the International Association of Pain developed the descriptor “chronic regional pain syndrome, type I” (CRPS I) to refer to sympathetically maintained pain that is not associated with a nerve injury. The presence of motor or sensory deficits suggests the presence of complex regional pain syndrome, type II which requires the presence of nerve compromise. The four criteria for CRPS I are: (1) the presence of an intiating noxious event, or a cause of immobilization; (2) continuing pain, allodynia, or hyperalgesia with which the pain is disproportionate to any inciting event; (3) evidence at some time of edema, changes in skin blood flow, or abnormal sudomotor activity in the region of the pain; and 4) CRPS I is excluded by the existence of conditions that would otherwise account for the degree of pain and dysfunction

Question 73

A 49-year-old, right-handed man who works at an automobile plant painting cars presents with a 4- week history of right shoulder pain. His pain increases with overhead activities and with donning his coat. He is unable to sleep due to pain at night. With regards to work, you recommend physical therapy, ibuprofen and (a) modifying work activities to reduce overhead activities. (b) staying off work for 4 weeks. (c) no work restrictions or modifications. (d) staying off work until pain free with strengthening activities.

Answer 73

(a) Modifying the activity that is causing the repetitive overload is necessary if treatment is to succeed. Treatment success is measured by reduced pain and return to function, in this case to an occupation that requires repetitive overhead activities. The healthcare provider must communicate with the employer to best understand the specific musculoskeletal job requirements and modify these activities during the recovery phase of rehabilitation. Taking the worker off work entirely engages disability behavior and may not serve a specific recovery function. Not making a work modification is also a mistake, because the overload to the upper quadrant will continue and that will impair rehabilitation

Question 74

A 73-year-old hospitalized patient complains of pain in the inguinal area 6 hours after a cardiac angiogram. Examination reveals hip flexion and knee extension weakness. There is decreased sensation over the medial ankle. Which test would you order first? (a) Electrodiagnostic testing (b) Arteriogram of the legs (c) Venogram of the legs (d) Computerized tomography of the pelvis

Answer 74

(d) The nerve most likely affected in this type of situation is the femoral nerve, due to a retroperitoneal hematoma. The best way to assess for this acutely is by radiologic studies. Electrodiagnostic testing would be inappropriate in an acute setting, since needle examination findings usually take a few days to weeks to evolve, and the findings would not necessarily help in the acute management of this patient. Vascular studies may help identify the source of bleeding if the symptoms persist.

Question 75

The Education for All Handicapped Children Act (EHA, PL 94-142), passed in 1976, and the Individuals with Disabilities Education Act (IDEA, PL 105-17), passed in 1997, guarantee that children with disabilities have (a) education in special schools. (b) medical care at school. (c) education in the least restrictive environment. (d) education in regular classrooms

Answer 75

(c) The Education for All Handicapped Children Act and the Individuals with Disabilities Education Act guarantee children with disabilities education in the least restrictive environment. They also guarantee necessary health care be provided in the school environment (eg, intermittent catheterization) but do not require medical care be provided.

Question 76

One disadvantage to adding camber to a wheelchair is that it (a) decreases side to side stability. (b) exposes the hands to injury. (c) results in poor ergonomic positioning of push rims. (d) makes maneuvering in narrow spaces difficult.

Answer 76

(d) Camber has several advantages. The footprint of the chair is widened creating greater side to side stability; camber allows quicker turning; camber helps to protect the hands by having the bottom of the wheels scruff edges; and camber positions push rims more ergonomically for propulsion. A disadvantage is that the increased width of the wheelchair may make it difficult to maneuver in an environment made for walking (ie, narrow spaces).

Question 77

The medical literature supports the use of lumbar epidural steroid injections for which condition? (a) Sclerotomal pain from facet-mediated low back pain (b) Referred pain from a quadratus lumborum trigger point (c) Neurogenic claudication due to lumbar spinal stenosis (d) Radiculopathy caused by foraminal disc herniation

Answer 77

(d) Epidural steroid injections (ESIs) are indicated for radicular rather than referred pain. While anectodotal descriptions of ESIs used for neurogenic claudication may present them as helpful, the efficacy of ESIs have yet to be established for this condition.

Question 78

A 45-year-old man with left hemiparesis following a stroke complains of left shoulder pain with ambulation. Which of the following is the most probable cause? (a) Cervical radiculopathy (b) Impingement syndrome (c) Adhesive capsulitis (d) Shoulder subluxation

Answer 78

(d) Inferior subluxation of the glenohumeral joint occurs frequently following stroke. Pain in the shoulder is often felt in the upright position, since gravity further aggravates the subluxation

Question 79

A 29-year-old dancer presents with right groin pain. The musculoskeletal examination is significant for pain to palpation over the right psoas tendon and tightness in the right hip flexor. A muscle energy technique used to reduce pain and improve range of motion of the right hip would include (a) isometric contraction with the hip placed in flexion. (b) isotonic contraction with the hip placed in flexion. (c) isometric contraction with the hip placed in neutral position. (d) eccentric contraction with the hip placed in extension.

Answer 79

(c) Muscle energy is a therapeutic technique in which the patient produces an isometric muscle contraction, which is followed by passive lengthening of that muscle by the healthcare provider to allow the involved joint to move through a restrictive barrier. In the case described, to lengthen the iliopsoas the hip should be placed in a neutral position and stretched passively into extension as tolerated.

Question 80

Which fitness program has been shown to improve both balance and eccentric quadriceps strength? (a) Pilates (b) Tai Chi (c) Hatha Yoga (d) Jazzercise

Answer 80

(b) Tai Chi, an ancient Chinese form of the martial arts increases eccentric knee extensor muscle strength, with a consequent improvement in postural sway. However, studies have not found significant changes in concentric knee flexion strength among practitioners of Tai Chi.

Question 81

Which statement is NOT TRUE about the practice of evidence-based medicine? (a) It incorporates the conscientious and explicit use of the current best evidence in making treatment decisions. (b) It includes use of the medical literature to develop strict standards of care for clinical practice. (c) It integrates individual clinical expertise with the best available clinical evidence from systematic research. (d) It includes life-long, self-directed learning because caring for patients creates the need for clinically important information.

Answer 81

(b) Evidence-based medicine does not include the development of strict standards of care for clinical practice. Instead, evidence-based medicine emphasizes the conscientious and explicit use of the current best evidence in making decisions about the care of individual patients. Integrating individual clinical expertise with the best available clinical evidence from systematic research and life-long, self-directed learning in which caring for patients creates the need for clinically important information are also part of evidence-based medicine.

Question 82

Which condition is a contraindication to high velocity low amplitude manipulation of the cervical spine? (a) Facet arthropathy (b) Vertebral osteomyelitis (c) Discogenic pain (d) History of remote carotid endarterectomy

Answer 82

(b) When performing manual medicine, or when referring a patient to a physician for manual medicine, one must be acutely aware of what contraindications apply to the individual one is treating. The absolute contraindication to high velocity low amplitude among the options listed is osteomyelitis.

Question 83

The maximum safe exposure of the skin to heated water is 45° Celsius for 30 minutes. Paraffin dipwrap coats the skin with a mixture of mineral oil and paraffin at a temperature of 52° Celsius. Why does the skin not get burned? (a) Protective subcutaneous fat layer enhanced by mineral oil (b) More rapid cutaneous vasodilation with paraffin (c) Conversion of thermal energy to kinetic energy (d) Paraffin’s lower thermal conductivity

Answer 83

(d) Paraffin has a lower thermal conductivity than water, which allows it to be placed on the skin at a higher temperature without causing injury to the skin. The heat is more slowly transferred from the paraffin to the skin, which provides for heating over a longer period of time.

Question 84

Abdominal belts worn by workers have been shown to restrict which motions in the lumbar spine? (a) Lateral bending and rotation (b) Lateral bending and flexion (c) Rotation and translation (d) Flexion and translation

Answer 84

(a) Research models have shown that abdominal support belts limit lateral bending and rotation. A 10cm leather belt increased stiffness at the torso during lateral bending, thereby reducing motion in these planes. No changes in torso stiffness were noted, despite the belt being worn at full lumbar flexion.

Question 85

Federal research regulations stipulate that each institutional research review board (IRB) is responsible for approving all research studies at their particular institution. What condition is the IRB NOT specifically required to determine prior to approving a research protocol? (a) That risks related to the research are minimized (b) That selection of subjects is equitable (c) That protections for privacy and confidentiality are in place (d) That research does not involve vulnerable subjects such as prisoners

Answer 85

(d) Federal research regulations stipulate that each institutional research review board (IRB) is responsible for approving all research studies at their particular institution. Before approving a research protocol, the IRB must determine that risks are minimized, selection of subjects is equitable, protections for privacy and confidentiality are in place, informed consent is appropriate and will be documented in writing, and that the study has plans for data monitoring where appropriate. Research may involve subjects who are considered vulnerable, such as prisoners, but the research must add extra protections for these subjects.

Question 86

Once an individual becomes board-certified in the specialty of physical medicine and rehabilitation, he/she must continue to fulfill certain requirements in order to maintain certification status. Which action is NOT a requirement for maintenance of certification? (a) Continuing medical education credits (b) Maintenance of active medical licensure (c) Completion of a recertification examination every 10 years (d) Publication of at least 1 article in a scientific journal every 10 years

Answer 86

(d) Once an individual becomes board certified in the specialty of physical medicine and rehabilitation, he/she must continue to fulfill certain requirements in order to maintain their certification status. Publication of 1 article in a peer-reviewed journal every 10 years is not a requirement for maintenance of certification. All of the other options listed are required.

Question 87

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

Answer 87

(a) Experimental research designs allow researchers to determine a cause-and-effect relationship between 2 variables, whereas non-experimental research designs are only able to establish an association between 2 variables. In experimental research an intervention or experimental variable can be manipulated, and its effect on other variables can be measured. Experimental designs are 10 of 11 prospective in nature. Cohort studies that focus on observation of the natural history of a disease process are non-experimental.

Question 88

``` Which pharmacologic agent should be avoided because of its cognitive side-effects in individuals with brain injury? (a) Metoclopramide (Reglan) (b) Omeprazole (Prilosec) (c) Erythromycin (E-Mycin) (d) Sucralfate (Carafate) ```

Answer 88

(a) The use of metoclopramide (Reglan) should be avoided because it is known to cause sedation and significant cognitive difficulties for individuals with brain injuries, especially for those regaining consciousness. It also has potential side effects of extrapyramidal movements and tardive dyskinesia. The other agents do not have significant cognitive effects on brain-injured individuals.

Question 89

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

Answer 89

(a) Ultrasound should not be used near a pacemaker, near a spinal laminectomy site, near brain, eyes, or reproductive organs, near a malignancy, in areas of skeletal immaturity, or ear arthroplasties, especially in persons using methyl methacrylate

Question 90

One factor that is NOT pertinent to determining an individual’s decision-making capacity concerning informed consent and participation in treatment decisions is the ability to (a) express a choice, either verbally or nonverbally. (b) understand specific information related to treatment decisions. (c) seek advice from other health care providers. (d) appreciate the significance of information as it applies to one’s condition.

Answer 90

(c) Decision-making capacity is a requirement for providing informed consent and having a patient participates in treatment decisions. Central to determining an individual's capacity for making decisions is his/her ability to express a choice, ability to understand specific information related to treatment decisions, and ability to appreciate the significance of information as it applies to his/her condition and circumstances. The individual's ability to seek advice from other health care providers is not a central part of the individual's decision-making capacity.

Question 91

The Commission on Accreditation of Rehabilitation Facilities (CARF) defines program evaluation as a (a) systematic procedure for measuring the outcomes of care. (b) method of preventing medical complications. (c) routine means of building team relations. (d) procedure to develop new programs for rehabilitation.

Answer 91

(a) The Commission on Accreditation of Rehabilitation Facilities (CARF) defines program evaluation as a systematic procedure for measuring the outcomes of care. Program evaluation is 1 method to measure the effectiveness and efficiency of rehabilitation services. The other options listed are not the primary focus of program evaluation.

Question 92

In traumatic brain injury, magnetic resonance imaging (MRI) is preferred to computed tomography (CT) scan in the (a) evaluation of acute brain injury. (b) detection of subarachnoid hemorrhage. (c) detection of epidural hematomas. (d) evaluation of diffuse axonal injury.

Answer 92

(d) Magnetic resonance imaging (MRI) is considered better than computed tomography (CT) for evaluating diffuse axonal injury (DAI). A CT scan is superior to MRI for the detection of acute extra-axial hematomas, and in the evaluation of acute brain injury.

Question 93

Non-swimming aquatic therapy in late poliomyelitis patients provides which benefit? (a) Increased peak oxygen uptake (b) Reduction in knee joint effusion (c) Improved muscle strength in affected muscles (d) Reduction of heart rate with same work load

Answer 93

(d) After a 5-month non-swimming aquatic therapy program in late poliomyelitis patients, researchers found a reduction of pain, a subjective increase in self perceived fitness level, and a reduction of heart rate with same-work-load lifting. However, they found no changes in peak oxygen uptake or peak work load, and no increase in muscle function.

Question 94

``` A 25-year-old man is admitted to your rehabilitation facility 3 weeks after sustaining a spinal cord injury. His motor and sensory examination is as follows: Motor Examination __________________________________________________________________________ Muscle Tested Right Side Left Side Deltoids 5 5 Biceps 5 5 Wrist Extensor 5 5 Triceps 3 3 Finger Flexors 1 1 Intrinsics 0 0 Hip Flexors 0 0 Knee Extensors 0 0 Dorsiflexors 1 0 Plantarflexors 0 1 Sensory exam reveals intact pinprick and light touch sensation through C7. Sensation is absent below C7 except for intact perianal sensation. What is the patient’s ASIA score? (a) C7 ASIA C (b) C6 ASIA C (c) C6 ASIA B (d) C7 ASIA B ```

Answer 94

(a) Based on the American Spinal Injury Association (ASIA) classification system revised in 2000, the highest intact level would be C7 (a motor score greater than or equal to 3/5 with the level above being 5/5). ASIA B indicates sensation below the injury level that must include sacral sensory sparing. ASIA C indicates sacral sparing, as well, with more than half the muscle groups below the level of injury having a muscle grade of less than 3/5.

Question 95

You are asked to make specific exercise recommendations regarding how to reduce low back injuries in a factory’s workers. As part of your program, you recommend that workers (a) be fitted for a lumbar corsets. (b) with heavy lifting work requirements avoid participation in sports. (c) with a history of low back pain be moved to more sedentary, seated jobs. (d) be instructed to reduce the amount of early morning flexion.

Answer 95

(d) Patients instructed to limit early morning flexion have shown reduced pain intensity, compared to controls. This finding is related to disc hydration that occurs during sleep. No studies have shown that all workers wearing lumbar corsets have reduction in injuries. Athletic activities outside of the work environment often help improve endurance, which is protective for low back pain. Sedentary seated jobs over-promote disc loading, resulting in increased pain.

Question 96

You have just finished admitting a 60-year-old diabetic man who has recently undergone a right below-knee amputation. The patient's son stops you in the hallway and inquires about his father's health status and prognosis for walking again. You have never met the patient's son before, and before answering the questions, you would first (a) further review the patient's medical record and determine his cardiac status. (b) perform a literature review of outcomes research in individuals with below-knee amputations. (c) ask the patient for permission to discuss his health status with his son. (d) ask the son if the patient has a living will or a health care power-of-attorney.

Answer 96

(c) Maintaining confidentiality of patient information is important even when discussing health information with family members. Before discussing the patient's health status with his son, the appropriate first step would be to ask the patient for permission. The other options listed would not be appropriate initial management strategies.

Question 97

``` The association of apolipoprotein-E (APOE-4) allele and history of traumatic brain injury increases the risk of developing (a) hydrocephalus. (b) alzheimer’s disease. (c) post-traumatic epilepsy. (d) cerebral neoplasms. ```

Answer 97

(b) Individuals with a history of traumatic brain injury (TBI) and apolipoprotein-E (APOE-4) allele have 10 times the risk of developing Alzheimer’s disease compared with 2 times the risk for APOE-4 allele alone and no increased risk with TBI alone.

Question 98

A 65-year-old woman with shoulder osteoarthritis asks how to use ice for her shoulder pain. For how many minutes per session should she apply ice to her shoulder? (a) 5–10 (b) 10–15 (c) 20–30 (d) 30–40

Answer 98

(c) The most effective use of ice for pain control in osteoarthritis is application of ice for 20- to 30- minute periods. The ice should not touch the skin, but wrapped in a protective layer or towel to prevent damage to the skin. It should rest over the joint and not be moved around. Frequency should be on an as needed basis, but there should be at least a 30-minute break between sessions.

Question 99

Acupuncture is described as reducing pain through neuromodulation. Through what mechanism is neuromodulation theorized to reduce pain? (a) Stimulation of large sensory afferent fibers that suppress pain perception (b) Release of local cytotoxins that induce inflammation (c) Inhibition of sensory afferent fibers that transmit pain perceptions (d) Central nervous system reorganization of the somatosensory cortex

Answer 99

(a) Acupuncture is considered to help reduce pain through neuromodulation. The 2 theories of neuromodulation with acupuncture are (1) stimulation of large sensory afferent fibers suppress pain perception through gate control and (2) the needle insertion may act as a noxious stimulus and induce endogenous production of opiatelike substances.

Question 100

You have been asked to evaluate a 60-year-old man who suffered a left internal capsule ischemic stroke 3 days ago. He is currently hospitalized and he has been deemed by his primary care provider to be medically stable for transfer to an inpatient rehabilitation program. The patient has a right hemiparesis and dysarthria. On your assessment, cognition appears intact. You agree that the patient is an appropriate candidate for admission. You discuss the benefits of inpatient rehabilitation with the patient and his family, but the patient elects to go home with home health services instead of being admitted for inpatient rehabilitation. The ethical principle followed in abiding by the patient’s wishes is the principle of (a) beneficence. (b) autonomy. (c) paternalism. (d) social justice.

Answer 100

(b) The ethical principle demonstrated in this case in which the physician concedes to the patient’s desires and decisions is the principle of patient autonomy. The principle of beneficence refers to a moral obligation to help other people and to refrain from harming them. Inherent in the principle of autonomy is respect for the values and beliefs of other people. There is often tension between these 2 principles when patients refuse to accept information and advice from their health care providers. With a paternalistic approach, the physician or other health care provider is the decision maker and the patient takes on a more passive role of accepting his/her decisions. Social justice refers to the provision, rationing, and distribution of health care resources.