SAER 2006

Question 1

An athlete is found to have a high-arched (pes cavus) foot in supinated weight bearing. Which
motion is associated with this finding?
(a) Tibial external rotation
(b) Forefoot abduction
(c) Ankle dorsiflexion
(d) Talus internal rotation

Answer 1

(a) Supination in weight bearing is a triplanar motion involving multiple joints of the foot and ankle.
Supination incorporates ankle plantar flexion, talus external rotation, and forefoot adduction.
Obligate tibial and femoral external rotation occurs with supination.

Question 2

A 65-year-old woman describes a 6-year history of progressive pain and stiffness in her left knee,
right hip, and distal fingers. Plain radiographs of her left knee and right hip demonstrate
osteophytes and asymmetric joint space narrowing with subchondral bony sclerosis. The most
likely diagnosis is
(a) systemic lupus erythematosus.
(b) rheumatoid arthritis.
(c) gouty arthropathy.
(d) osteoarthritis.

Answer 2

(d) Arthritis in systemic lupus erythematosus is non-erosive and does not have articular cartilage
involvement. In rheumatoid arthritis, periarticular bony erosions and osteopenia are seen on
radiographs. Radiographic changes in gouty erosions are usually slightly removed from the joint
space and have atrophic and hypertrophic features (an overhanging edge and soft-tissue tophus).
Characteristic radiographic findings of osteoarthritis include bony proliferation at the joint margin,
asymmetric joint-space narrowing, and subchondral bone sclerosis.

Question 3

What is the most common level of occult spine fracture after trauma that is missed by plain
radiographs?
(a) C7/T1
(b) T5/T6
(c) T12/L1
(d) L4/L5

Answer 3

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

Question 4

A 67-year-old woman was just admitted to the general rehabilitation unit after a complicated 2-
month course at the acute care hospital. When the physical therapist gets her out of bed on the first
day, what is the most likely finding?
(a) Blood pressure goes from 120/80 to 150/100.
(b) Blood pressure goes from 120/80 to 90/50.
(c) Heart rate goes from 80 to 60.
(d) Heart rate remains at 60.

Answer 4

(b) Orthostatic hypotension is a common cardiovascular complication of immobility. Lying in bed for
a prolonged time causes a central fluid shift that results in an increased intravascular volume. There
is a resultant diuresis and decrease in plasma volume. When a person stands after bed rest, venous
pooling occurs in the lower extremities due to increased venous compliance (orthostatic
intolerance). Person also has blunted cardiac response to rapid changes in posture. With
immobility and deconditioning, the resting heart rate increases, and the heart rate response to
exercise also increases.

Question 5

An injured worker with low back pain will return to full work duties faster if treatment includes

(a) back school and lumbar corset.
(b) aerobic conditioning and weight lifting.
(c) work conditioning and “off-duty” or no-work status.
(d) functional rehabilitation and ergonomic intervention.

Answer 5

(d) Loisel, in1997, performed a randomized controlled trial that showed that the injured worker with
low back pain returned to regular work activities 2.41 times faster if the worker received
therapeutic functional rehabilitation and ergonomic intervention when compared to usual care.

Question 6

The American College of Obstetrics and Gynecologists (ACOG) recommendation regarding exercise
during pregnancy is that
(a) exercise should be 85%–95% of maximum predicted heart rate.
(b) pregnant women may exercise to exhaustion.
(c) exercise should be done 6 days a week for at least 60 minutes daily.
(d) pregnant women should avoid resistive exercises in the supine position.

Answer 6

(d) Exercise should be at 60% to 85% of predicted maximum heart rate. Pregnant women should not
exercise to exhaustion. Exercise should be done 3 to 4 days a week for 30 to 45 minutes at a time.
Pregnant women should avoid exercise in the supine position because such a position may decrease
cardiac output, resulting in blood diverting from the splanchnic beds (including the uterus).

Question 7

A 10-year-old girl presents with scoliosis 5 years after sustaining a severe traumatic brain injury.
Radiographic studies reveal a 25° levoconvex curve from C8 to T12 with the apex at T4. After
consultation with the orthopedic surgeon, you prescribe a spinal orthosis. Which type of orthosis
should be used in this patient?
(a) Cervicothoracolumbosacral orthosis (CTLSO)
(b) Thoracolumbosacral orthosis (TLSO)
(c) Thermoplastic Minerva body jacket (TMBJ)
(d) Sterno-occipital mandibular orthosis (SOMI)

Answer 7

(a) A thoracolumbosacral orthosis is used for scoliosis having an apex at T9 or lower. A sternooccipital
mandibular orthosis immobilizes the neck. A thermoplastic Minerva body jacket is also
used for cervical immobilization. A cervicothoracolumbosacral orthosis such as the Milwaukee
brace extends from the pelvic section to the neck ring and has been shown to correct scoliotic
curves throughout that area.

Question 8

A 42-year-old woman presents with a 3-month history of difficulty walking up stairs and rising from
chairs. She has no headaches or scalp pain and is currently on no medications. Physical
examination reveals bilateral weakness of her proximal legs and arms. Laboratory studies reveal a
markedly elevated creatine phosphokinase (CPK) level and a normal erythrocyte sedimentation rate
(ESR). The most likely diagnosis is
(a) myasthenia gravis.
(b) polymyalgia rheumatica.
(c) polymyositis.
(d) rhabdomyolysis

Answer 8

(c) The hallmark features of polymyositis, or idiopathic inflammatory myopathy, are symmetric muscle
weakness of the shoulder and pelvic girdles, occasionally accompanied by mild pain and
tenderness. Eventually, weakness of the proximal leg and arm muscles follows. The symptoms
usually appear insidiously, with no identifiable precipitating event. Laboratory examination shows
AAPM&R
an elevation in skeletal muscle enzymes, especially creatine phosphokinase. Electromyographic
changes are consistent with inflammatory myopathy: short small, polyphasic motor units;
filbrillations; positive waves; and high frequency, repetitive discharges. The absence of headaches
and scalp pain makes polymyalgia rheumatica less likely. Rhabdomyolysis is typically more acute
in onset and is associated with trauma or use of certain medications such as the statins.

Question 9

A 27-year-old man with a T12 ASIA class A spinal cord injury for 10 years presents with right
shoulder pain that is worse with use, particularly when reaching and doing transfers. He plays
basketball twice weekly. Recommendations should include
(a) no wheeling or transfers for 2 weeks.
(b) immobilization of the elbow and shoulder.
(c) electrodiagnostic study of the upper extremity.
(d) strengthening of the scapular stabilizers.

Answer 9

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

Question 10

A 36-year-old breast cancer patient presents with myofascial pain involving the upper and middle
trapezius and levator scapulae muscles. She underwent modified radical mastectomy and chest wall
irradiation 1 year ago. The breast has been reconstructed with a rather large implant. You note that
her acromial process on the affected side is depressed and protracted. Lasting relief will most likely
be achieved through a physical therapy program emphasizing
(a) ultrasound followed by shoulder mobilization.
(b) stretching of the pectoralis major and minor muscles.
(c) electrical stimulation of the painful muscles.
(d) isometric resistive exercise of the rhomboid muscles

Answer 10

(b) Muscles within any radiation field are at risk for fibrosis and contracture. The pectoralis major and
minor muscles are commonly shortened following radiation to the chest wall, an integral
component of breast conservation therapy. Radiation-induced shortening of the pectoralis muscles
pulls the scapula into a protracted and depressed position which places tension on the medial and
superior scapular stabilizers. To achieve long-term relief, this patient will require stretching of the
pectoralis muscles.

Question 11

Which one of the following is associated with an axonal loss sensory polyneuropathy?

(a) Lead poisoning
(b) Cisplatin chemotherapy
(c) Polyarteritis nodosa
(d) Charcot-Marie-Tooth disease (type 1)

Answer 11

(b) Cisplatin is associated with an axonal loss sensory neuropathy. Lead usually causes upper limb
weakness and patients usually have few or no sensory complaints. Polyarteritis nodosa is the most
common of the necrotizing vasculitides and the most common pattern of nerve involvement is that
of mononeuropathy multiplex. In Charcot-Marie-Tooth disease type 1 the primary pathology
involves uniform demyelination of the peripheral nerves.

Question 12

In a patient with a transfemoral amputation, what is the most likely cause of excessive knee flexion
during ambulation?
(a) Hip flexion contracture
(b) Prosthetic knee alignment in an excessively posterior position
(c) Excessive socket extension
(d) Too soft a plantar flexion bumper in the heel

Answer 12

(a) One of the most common gait deviations in patients with transfemoral amputations is abrupt or
excessive knee flexion during ambulation. The prosthetic knee joint should normally be stable in
extension in stance phase from heel contact to foot flat. This stability is accomplished by aligning
the prosthetic knee axis posterior to the trochanteric knee ankle line. Adequate strength and range
of motion in hip extension are critical to maintaining this alignment. Thus, weak hip extensors and
hip flexion contractures can cause knee instability. Two prosthetic causes of knee instability are (1)
knee malalignment in an excessively anterior position relative to the hip and ankle joints, and (2)
excessive socket flexion. A plantar flexion bumper that is too stiff, extensive foot dorsiflexion, or a
change in shoe heel height from low to high may all promote knee flexion.

Question 13

Which surgical option would be most appropriate for a patient with rheumatoid arthritis who has
severe uncontrollable knee pain and loss of function?
(a) Synovectomy
(b) Hemiarthroplasty
(c) Total knee arthroplasty
(d) Arthrodesis

Answer 13

(c) Total knee arthroplasty is the surgery of choice in persons with severe pain and loss of function. A
synovectomy provides temporary pain relief and decreased swelling. Hemiarthroplasty is
contraindicated in rheumatoid arthritis due to total joint involvement. Arthrodesis would not
provide the range of motion needed for stairs, ambulation, and dressing.

Question 14

A 20-year-old man develops weakness accompanied by difficulty in relaxation of the hand and foot
muscles. The muscle biopsy demonstrates prominent ring fibers, centrally located nuclei, and
disorganized sarcoplasmic masses. This condition has been associated with mutation on which
chromosomes?
(a) X
(b) Y
(c) 5
(d) 19

Answer 14

(d) The disease is myotonic dystrophy, which is an autosomal dominant disease. The affected gene has
been localized to chromosome 19. Myotonic dystrophy is relatively common and is best thought of
as a systemic disease since it causes cataracts, testicular atrophy, heart disease, dementia, and
baldness in addition to muscular dystrophy

Question 15

A 50-year-old man is transferred to your rehabilitation unit after a cardiac transplant. Because of the
transplant, you anticipate that he will have a
(a) lower than normal resting heart rate.
(b) decreased time to achieve maximal heart rate during exercise.
(c) lower than normal peak heart rate achieved during maximal exercise.
(d) lower than normal systolic and diastolic blood pressure.

Answer 15

(c) A transplanted heart is denervated, so it achieves maximal heart rate more slowly because it relies
on circulating catecholamines to achieve a response. The resting heart rate is higher than normal,
most likely because of the loss in vagal input. Peak heart rate achieved during maximal exercise is
considerably lower in transplant patients compared with age-matched controls. Systolic and
diastolic blood pressures are higher than normal.

Question 16

Which statement is TRUE regarding the way the Centers for Medicare and Medicaid Services
currently reimburses inpatient rehabilitation facilities (IRFs) based on a prospective payment system
(PPS)?
(a) Reimbursement is determined according to the patient’s severity of disability and his/her
required use of resources.
(b) Assignment of patients to a specific rehabilitation impairment category (RIC) is based
primarily on their medical co-morbidities.
(c) Early transfer of patients from an IRF to a skilled nursing facility does not affect
reimbursement to the IRF.
(d) Assignment of patients to specific case-mix groups (CMGs) is determined by the rehabilitation
diagnosis and the patient’s premorbid functional status.

Answer 16

(a) The Center for Medicare and Medicaid Services currently reimburses inpatient rehabilitation
facilities (IRF) based on a prospective payment system (PPS) according to the patient’s severity of
disability and his/her required use of resources. The rehabilitation impairment category is based on
the primary rehabilitation diagnosis, and the case-mix group is determined in part by the patient’s
co-morbid medical conditions.

Question 17

What test is most sensitive for diagnosing myasthenia gravis?

(a) Facial nerve repetitive studies at 30 hertz
(b) Ulnar nerve repetitive studies at 3 hertz
(c) Single fiber electromyography
(d) Acetylcholine receptor antibodies

Answer 17

(c) With a sensitivity of 92% to 100%, single fiber electromyography, which includes measurement of
jitter, is the most sensitive test in assessing for myasthenia gravis. The sensitivity of repetitive
stimulation of distal and proximal nerves is 77% to 100%, and acetylcholine receptor antibody
sensitivity is 73% to 90%.

Question 18

During which phase of the gait cycle are the ankle plantarflexor muscles (gastrocnemius and soleus)
most active?
(a) Initial contact
(b) Loading response
(c) Midstance
(d) Terminal stance

Answer 18

(d) During the gait cycle, the ankle plantarflexors become active during the midstance phase when they
contract eccentrically to control forward progression of the tibia and ankle dorsiflexion. These
muscles become most active during the terminal stance phase when they contract concentrically to
produce ankle plantarflexion and accelerate the trunk forward. The ankle plantarflexors are
minimally active during the initial contact and loading response phases of the gait cycle.

Question 19

A 30-year-old runner training for a marathon presents to your clinic with progressive pain in his right
medial tibia over the past 2 weeks. Which history and examination feature is more consistent with a
stress fracture rather than medial tibial stress syndrome?
(a) Diffuse rather than focal tenderness
(b) Pain with percussion around the site of pain
(c) Pain that diminishes as the run goes on
(d) No reproduction of pain with single leg hop test

Answer 19

(b) This is a common clinical conundrum. Medial tibial stress syndrome (frequently and improperly
referred to as shin splints) represents a range of pathology from posterior tibialis tendonitis to
periostitis. Fredericson et al determined that stress fractures, which will require more aggressive
treatment, have more focal pain and pain with percussion testing. Pain from a stress fracture
worsens as run goes on and often hurts after a run. A magnetic resonance image or bone scan can
make a definitive diagnosis.

Question 20

After an acute stroke, a 60-year-old woman presents for stroke rehabilitation with an indwelling
catheter for bladder management. What action should you order regarding the catheter?
(a) Maintain it until the patient is able to transfer to the toilet with minimal assistance.
(b) Remove it because reflex voiding returns very quickly after a stroke and risk of urine retention
is minimal.
(c) Remove it and start intermittent catheterization because reflex voiding return is often delayed
and the risk of urine retention is high.
(d) Maintain it to decrease the risk of urinary incontinence and pressure sores

Answer 20

(b) Impaired bladder control is frequent following stroke with initial hypotonic bladder, but voiding
returns very quickly and urine retention is rarely a problem. In the postacute phase of stroke
rehabilitation, the problem is not bladder overdistention, but uninhibited bladder with incontinence.

Question 21

Which of the following is a rare extra-articular manifestation of rheumatoid arthritis?

(a) Rheumatoid nodules
(b) Keratoconjunctivitis sicca
(c) Glomerular disease
(d) Microcytic anemia

Answer 21

(c) Rheumatoid nodules are present in up to 50% of persons with rheumatoid arthritis (RA).
Keratoconjunctivitis sicca and microcytic anemia are also very common. Glomerular disease is
very rare in RA, but requires management when found.

Question 22

Spinal instrumentation in neuromuscular scoliosis is indicated when

(a) onset of scoliosis is before skeletal maturity.
(b) primary curve exceeds 25° and forced vital capacity (FVC) is greater than 35% of normal.
(c) ambulation abilities are lost due to severe back pain.
(d) primary curve exceeds 50° and FVC is less than 25% of normal.

Answer 22

(b) The indication for spinal instrumentation in neuromuscular scoliosis is that the primary curve
exceeds 25° and forced vital capacity has not dropped below 35% of normal.

Question 23

You are caring for a patient with a T3ASIA class A spinal cord injury who complains of burning
pain in his legs. Additional review of systems includes urinary leakage between catheterizations, and
difficulty sleeping. The best pharmacologic intervention at this time would be
(a) amitriptyline (Elavil).
(b) paroxetine (Paxil).
(c) trazodone (Desyrel).
(d) fluoxetine (Prozac).

Answer 23

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

Question 24

A 60-year-old woman with rheumatoid arthritis, hypertension, and hypothyroidism has undergone
bilateral total knee arthroplasty and is currently being admitted to a rehabilitation unit. Which
medication should be discontinued in this postoperative period?
(a) Warfarin (Coumadin)
(b) Etanercept (Enbrel)
(c) Furosemide (Lasix)
(d) Levothyroxine (Synthroid)

Answer 24

(b) Etanercept is typically recommended to be discontinued during the postoperative period in order to
allow adequate tissue healing and prevention of complications. Other immunosuppressive therapies
and disease modifying anti-rheumatic agents should also be discontinued. The remaining
medications do not need to be discontinued in the postoperative period.

Question 25

``` For persons with spinal cord injury who survive the first 24 hours, what is the leading cause of death the first year postinjury? (a) Pulmonary embolism (b) Pneumonia (c) Renal insufficiency (d) Nonischemic heart disease ```

Answer 25

(b) The leading cause of death for persons with spinal cord injury who survive more than 24 hours is pulmonary dysfunction (pneumonia, adult respiratory distress syndrome) followed by nonischemic heart disease, septicemia and pulmonary embolus.

Question 26

You are managing the care of a 63-year-old pipe fitter with shoulder pain in his dominant arm. He has no history of trauma. An incomplete supraspinatus tear is found on imaging studies. He has completed 8 sessions of physical therapy with improvement. He has pain at 140° of shoulder abduction. Strength, range of motion, and neurological exam are normal. The case manager asks for your next recommendation towards determining his work status. You recommend (a) functional capacity evaluation exam. (b) work conditioning. (c) aquatic physical therapy. (d) surgical referral.

Answer 26

(a) A functional capacity evaluation (FCE) is the next best choice for this worker. An FCE will determine functional deficits the worker has by assessing work simulated activities. Work conditioning may be helpful because it includes aerobic conditioning but does not provide information and training regarding specific work tasks. His physical findings are minimal so additional physical therapy may not be recommended. These minimal physical exam findings in a 63-year-old man may indicate a nontraumatic incomplete cuff tear that may be a part of normal aging. In this setting, conservative management remains appropriate. Incomplete rotator cuff tears can be found in the asymptomatic population, especially over the age of 50.

Question 27

Randomized controlled trials examining intrathecal baclofen (ITB) use in children with cerebral palsy show that children who receive ITB have (a) improved upper extremity function. (b) reduced spasticity in lower extremities. (c) improved walking and transfers. (d) improved knee range of motion

Answer 27

(b) A comprehensive review of published English language studies on intrathecal baclofen (ITB) showed evidence of statistically significant improvement in upper and lower extremity tone with ITB use in children with cerebral palsy (CP). Other reported improvements with ITB in children with CP are either anecdotal or not substantiated by randomized controlled trials. 62. (a) Relaxation techniques with slow, rhythmic rotational movements starting with passiv

Question 28

Rehabilitation strategies for addressing rigidity associated with Parkinson’s disease include (a) relaxation techniques with gentle stretching. (b) a strengthening program. (c) botulinium toxin injections. (d) oral baclofen.

Answer 28

(a) Relaxation techniques with slow, rhythmic rotational movements starting with passive range of motion distally and progressing proximally and then adding active range of motion is effective in decreasing rigidity.

Question 29

You are taking care of a 72-year-old man who fell at home and remained on the ground for several hours. He subsequently developed a sacral pressure ulcer that now has large areas of necrotic tissue without fluctuance. Which intervention is most appropriate? (a) Proteolytic enzymes (b) Triple antibiotic ointment (c) Incision and drainage (d) Oral antibiotics

Answer 29

(a) The necrotic tissue in this wound needs debridement. This may be accomplished with surgical sharp debridement, mechanical nonselective debridement, such as with a wet-to-dry dressing, or enzymatic debridement with a chemical agent that uses proteolytic enzymes. Topical and oral antibiotics are not necessary in this patient, as necrotic tissue does not signify an infection. An incision and drainage would not be appropriate, since no abscess is present.

Question 30

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

Answer 30

(d) Medical error reporting systems are designed to encourage staff to report sentinel events, adverse events, and close calls without fear of punishment. If these issues are recognized, then further review and action can be initiated. Review may include a root cause analysis to determine the exact cause of the problem and strategies for prevention. When a medical error has occurred, staff are encouraged to recognize the issue and report the issue immediately.

Question 31

You are called to see your 3-year-old inpatient with a C5 ASIA class A spinal cord injury. She has a headache and complains of not feeling well. Vital signs are pulse 60, respirations 20, blood pressure 120/80. Weight 33 lbs (15kg). Physical examination is unchanged from previously. You order: (a) Place the patient in the supine position. (b) Administer acetaminophen (Tylenol) orally. (c) Empty the bladder. (d) Obtain computed tomography of the head.

Answer 31

(c) The child is experiencing autonomic dysreflexia. The 90th percentile for blood pressure in an average sized 3-year-old girl is 103/62. A child with C5 tetraplegia would be expected to have even lower average blood pressure. Initial treatment consists of positioning the patient in an upright position and emptying the bladder. If this does not correct the problem, medications should be considered. If medications are needed, either nitropaste 2% or nifedipine may be used. For a child weighing 15kg the correct initial dose is 0.25 to 0.5 mg/kg/dose (3.75–7mg) of nifedipine or ½ inch of nitropaste.

Question 32

A circumducted gait in a man with an above knee amputation is most likely due to (a) a rigid heel in his solid ankle, cushioned heel (SACH) foot. (b) inadequate friction in his prosthetic knee unit. (c) his prosthetic foot being set in dorsiflexion. (d) inadequate socket suspension

Answer 32

(d) Inadequate socket suspension causes the prosthesis to be functionally too long. A rigid heel and foot set in dorsiflexion would increase knee flexion movement. Inadequate friction would cause the leg to “snap” into terminal extension.

Question 33

Which finding is more characteristic of atypical facial pain than of trigeminal neuralgia? (a) Lancinating pain (b) Burning pain (c) Paroxsymal pain (d) Stabbing pain

Answer 33

(b) Trigeminal neuralgia has a lancinating and paroxsymal quality. Atypical facial pain is most often described as burning pain, usually in areas not encompassing the trigeminal region. Atypical facial pain is continuous rather than paroxysmal. Atypical facial pain occurs in young females whereas trigeminal neuralgia occurs in the elderly. Atypical facial pain is initially treated with amitriptyline while, trigeminal neuralgia is initially treated with anticonvulsants, particularly carbamazepine.

Question 34

Your patient with Parkinson’s disease has sialorrhea. Initial treatment recommendations would include (a) a behavior modification program with speech therapy. (b) Robinul (glycopyrrolate) with meals. (c) Botox (botulinum toxin type A) to the salivary glands. (d) low dose Elavil (amitriptyline) at bedtime.

Answer 34

(a) A defective swallowing mechanism rather than excessive saliva production is the primary cause of drooling and the complaints of excessive drooling in Parkinson’s disease. A behavior modification program with frequent reinforcement may be effective in reducing drooling in Parkinson’s disease and should be used prior to medication or botulinum toxin therapy.

Question 35

A 42-year-old administrative assistant presents with a 2-month history of bilateral forearm pain and numbness in the index finger and thumb. Her symptoms worsen with increased use of bilateral upper extremities and are interfering with work. Physical examination is significant for a positive Tinel’s sign at the wrist and normal strength. Nerve conduction studies and electromyography confirm compression of the median nerve at the wrist. You recommend (a) lowering the keyboard height to facilitate wrist flexion. (b) being off work for 8 weeks while in physical therapy. (c) urgent surgical referral to minimize time off work. (d) setting keyboard height to maintain a neutral wrist position.

Answer 35

(d) Trial of conservative management is warranted, since her symptoms are recurrent and there is no evidence of motor weakness. There are no indications for urgent surgical release. Ergonomics should be reviewed; an adjustable seat can improve keyboard height to maintain a neutral wrist position. Wrist extension and flexion can further increase symptoms. Although rest can certainly help improve her symptoms, changing ergonomics is essential in order to resolve symptoms.

Question 36

Falls are common and often disabling in individuals with Parkinson’s disease. The risk of falls is increased in patients who (a) are taking nonsteroidal anti-inflammatory medication for pain. (b) are using a walker for ambulation. (c) have erratic arm swing with gait. (d) are taking benzodiazepines.

Answer 36

(d) Recurrent falls are more common in individuals with Parkinson’s disease who are taking benzodiazepines. Other risk factors are: history of falls, severe disease, poor balance, depression, and loss of arm swing with gait.

Question 37

Compared with able-bodied individuals, persons with spinal cord injury are likely to have (a) equivalent percentage of regional and total body lean tissue. (b) higher testosterone levels. (c) equivalent incidence of dyslipidemia. (d) a lower resting metabolic rate.

Answer 37

(d) In persons with spinal cord injury, there is an initial dramatic loss of muscle mass after the acute paralysis. However, even decades after injury, there is continuous loss of lean body tissue compared to that observed in an able-bodied person. It is of particular interest that the arms of persons with paraplegia have significantly less percent lean tissue compared with controls. No differences in the cross sectional rate of loss of lean body mass is noted between persons with tetraplegia and paraplegia. Men with spinal cord injury can be expected to lose about 3.2% per decade of the total lean body tissue vs. 1% per decade in able-bodied males. Individuals with spinal cord injury have a pattern of metabolic alteration that is atherogenic with dyslipidemia, glucose intolerance, insulin resistance, and reduction in metabolic rate. Although the literature in persons with spinal cord injury is conflicting regarding anabolic hormonal changes in persons with spinal cord injury, there are subsets of individuals with relative androgen deficiency states. The etiology of a relative deficiency of testosterone in persons with spinal cord injury has not yet been established. However, it is conceivable that prolonged sitting and euthermia of the scrotal sack and testes may itself have a deleterious local effect on testosterone production.

Question 38

You are managing the care of an injured worker with a working diagnosis of C6 radiculopathy. Your assistant informs you that the case manager is in the room with the patient. You next ask the (a) case manager to leave, because case managers represent only the interest of the company. (b) worker if he prefers to have the case manager present throughout the exam. (c) worker if he prefers you recommend to the case manager that he be placed in a new job. (d) case manager to show evidence that the worker is malingering.

Answer 38

(b) Case managers work as medical liaisons between the company and medical care team to facilitate communication of and approval for diagnostic tests and treatment. They have been shown to improve timeliness of care. It is important to ask the patient’s preference regarding the case manager’s presence and to ensure patient confidentiality. The physician is to determine if the patient can return to work based on objective and subjective evidence. It is not the case manager’s job to provide the treating physician with evidence regarding validity of the worker’s condition.

Question 39

A 23-year-old man is sent to the electrophysiology laboratory for evaluation of bilateral foot drop. His history is significant for recent treatment of Hodgkin’s lymphoma with surgery and chemotherapy. Which electrophysiologic finding is most consistent with a polyneuropathy secondary to vincristine use? (a) Reduced conduction velocity of the motor nerves (b) Absent sensory responses with preserved motor responses (c) Small amplitude motor and sensory responses (d) Motor and sensory conduction block

Answer 39

(c) Vincristine causes an axonal polyneuropathy that primarily affects the most distal aspects of the nerve and produces a sensorimotor polyneuropathy. Nerve conduction studies reveal small amplitude or absent motor and sensory responses.

Question 40

The most common congenital limb deficiency is a (a) transverse tibial and fibular limb deficiency (below-knee limb deletion). (b) transverse transmetacarpal limb deficiency (partial hand deletion). (c) longitudinal fibular deficiency (fibular hemimelia). (d) transverse radial limb deficiency (below-elbow limb deletion).

Answer 40

(d) The left short transradial congenital limb deficiency (below-elbow limb deletion) is the most common congenital limb deficiency. It is thought to be caused by a clot which occludes the artery, resulting in resorption of the distal limb, often leaving nubbins of fingers at the end of the stump.

Question 41

A 35 year-old man with ankylosing spondylitis develops a painful left red eye with photophobia and blurred vision. What is the most likely reason for urgently referring this man to an ophthalmologist in an effort to prevent vision loss or impairment? (a) Viral conjunctivitis (b) Blepharitis (c) Subconjunctival hemorrhage (d) Acute anterior uveitis

Answer 41

(d) An ophthalmologist is needed to evaluate for acute anterior uveitis. Acute anterior uveitis is usually unilateral, and occurs at some time in one-third of patients with ankylosing spondylitis (AS). It may also be recurrent. If untreated, it may lead to scarring, pupil irregularity, and vision loss. The other options are also reasons for visiting an ophthalmologist but are not associated with vision loss in patients with AS.

Question 42

You are covering for your partner who is a pediatric physiatrist. Today, you are admitting a 2-yearold girl who sustained a burn. You suspect that this girl is a victim of a non-accidental injury (ie, child abuse) because you see (a) non-symmetrical burns. (b) splash marks in a scald-type injury. (c) injuries in various stages of healing. (d) non-uniform burn depth.

Answer 42

(c) Non-accidental injuries account for approximately 10% to 28% of pediatric burns. Of all nonaccidental injuries experienced by children, 10% are due to burns. Among abused children 30% to 70% suffer a repeat injury. Signs of abuse include injury that does not correlate with the type and location of injury observed on examination; uniform burn depth; sharp lines of demarcation between burned and non-burned areas; symmetrical wounds (eg, in a stocking or glove pattern); an absence of splash marks in scald injuries; the presence of other injuries in various stages of healing.

Question 43

Which modification will make a rocker bottom sole most effective? (a) Increase sole thickness with apex at the metatarsal heads. (b) Provide a rigid sole with no shock absorption. (c) Extend the length of the shoe to ½ inch beyond the longest toe. (d) Ensure that arch length is measured 2cm proximal to metatarsal heads

Answer 43

(c) The sole of a shoe for an individual with a neuropathic foot should be shock absorbing. The rocker sole allows ambulation with reduced pressures on the forefoot. This requires an addition to the sole thickness with an apex 1cm proximal to the metatarsal heads for the sole to roll over the forefoot. The length of the shoe must be ½ to ¾ inches beyond the longest toe to accommodate the natural elongation of the foot in ambulation. The arch length is measured at the metatarsal heads.

Question 44

A 59-year-old man with Parkinson’s disease is evaluated in your clinic. He complains of problems with rigidity, bradykinesia, tremor, and a functional decline in his activities of daily living. You order (a) Mysoline (primidone) orally to decrease tremor and rigidity. (b) botulinum toxin injections to decrease rigidity followed by occupational therapy with stretching program. (c) occupational therapy with fluidotherapy to improve hand function and a stretching program. (d) physical therapy with repetitive exercise and a home exercise program.

Answer 44

(d) A systematic program of physical therapy for Parkinson’s disease with repetitive exercise for 1 hour daily, 3 times a week for 4 weeks can significantly improve rigidity, bradykinesia, and activities of daily living, but not tremor. The improvements were not sustained if a regular home program of exercise was not continued.

Question 45

Which seronegative spondylarthropathy frequently follows enteric or urogenital infections? (a) Ankylosing spondylitis (b) Reiter’s syndrome (c) Psoriatic arthritis (d) Juvenile spondyloarthropathy

Answer 45

(b) Reiter’s syndrome or reactive arthritis most frequently follows certain urogenital infections with Chlamydia trachomatis or enteric infections such as Shigella, Salmonella, and Campylobacter organisms. The other choices are not associated with such infections.

Question 46

``` A benefit of marijuana (cannabis) when used in the management of motor neuron disorders such as amyotrophic lateral sclerosis is (a) decreased daytime sleepiness. (b) appetite reduction. (c) saliva production stimulation. (d) bronchodilation. ```

Answer 46

(d) The benefits of using cannabinoid medications in patients with motor neuron disorders include analgesia, muscle relaxation, bronchodilation, saliva reduction, appetite stimulation, and sleep induction.

Question 47

You are admitting a 48-year-old woman to your rehabilitation unit following a subarachnoid hemorrhage. She is married and has 2 teenage children. She has severe memory and cognitive impairments. She is unable to provide consent. To whom can you legally give information regarding the patient’s medical condition? (a) Anyone authorized by the attending physician (b) Anyone who identifies themselves as direct family members (c) Anyone authorized by the patient’s husband (d) Anyone who is available for caregiver training

Answer 47

(c) The husband is the patient’s legal next-of-kin. Because the patient is unable to provide consent for medical decision making, the husband is the primary contact person and has the medical power of attorney for medical decision making. The husband would have to consent to allow other individuals to receive medical information regarding the patient.

Question 48

Disorders of executive functioning are common in children after severe traumatic brain injury. Which sign indicates problems of executive function? (a) Low intelligence quotient (b) Attention and memory problems (c) Aphasia (d) Agitation

Answer 48

(b) Problems of executive function include impairments in attention, memory, and abstract reasoning. While aphasia and low intelligence may be seen following traumatic brain injury (TBI), they are not problems of executive function. Agitation is usually seen early in recovery from TBI, at the Rancho Los Amigos stage 4. The full consequences of a TBI that occurs in a young child may not be seen until much later, at an age when the child is expected to have that skill. For example, problems in abstract reasoning in a child who had a TBI at age 5 may not be seen until the child reaches 9 or 10 years of age.

Question 49

A 56-year-old man with cerebral palsy is evaluated in your clinic. He is noted to have a slow, writhing, worm-like movement in his arms. Which term correctly describes this movement? (a) Dystonia (b) Chorea (c) Myoclonus (d) Athetosis

Answer 49

(d) Athetosis is a continuous, slow writhing movement of the limbs or other body parts. It is important to differentiate athetosis from spasticity, because athetosis does not respond to antispasticity treatment. Chorea is characterized by brief, irregular contractions, which affect individual muscles as random events that seem to flow from one muscle to the other. Myoclonus manifests as rapid, shock-like or lightning-like jerks. Dystonia is a syndrome of sustained muscle contraction that frequently causes twisting and repetitive movements or abnormal postures.

Question 50

A 10-year-old boy suffered a blunt injury to his arm with resultant wrist drop. Electrophysiologic studies done on the day of injury show normal nerve conduction studies in the nerves in the affected limb except for the radial nerve. The radial nerve responses are normal distally but with stimulation proximal to the site of injury responses are absent. Which finding is most consistent with a good prognosis for recovery? (a) Normal radial motor response with stimulation distal to the injury on day 5 (b) Normal radial sensory response with stimulation distal to the injury on day 5 (c) Absence of fibrillation potentials in the radial innervated muscles on day 5 (d) Presence of fibrillation potential in the radial innervated muscles on day 15

Answer 50

(a) It is difficult to differentiate between neurapraxia (good prognosis for recovery) and axonotemesis (poorer prognosis for complete recovery) immediately postinjury using electrophysiologic testing. The compound muscle action potentials (CMAPs) are normal with stimulation distal to the lesion initially for the first 2 to 3 days. In lesions involving the axons, the CMAPs drop significantly, reaching a nadir at about day 7. In contrast, the CMAPs remain the same size with distal stimulation in lesions that only produce conduction block. Similar changes are noted in the amplitudes of the sensory nerve action potentials (SNAPs); however, the amplitudes are unaffected for the first 5 days, and then progressively fall over the next 4 to 5 days. If axonal damage exists, the needle electrode examination usually does not show fibrillation potentials until 2 to 3 weeks after the injury.

Question 51

Which action is a sacroiliac joint provocation test? (a) Thomas test (b) Gillet test (c) Thigh thrust maneuver (d) Flexion, adduction, internal rotation (FADIR) maneuver

Answer 51

(c) While data on sacroiliac joint provocative tests have been equivocal in the literature, recent evidence has shown thigh thrust and pelvic distraction maneuvers to be helpful. The Thomas test is used to assess hip flexor contracture. The Gillet test is a sacroiliac joint motion test and not a provocation test. The FADIR maneuver is used to assess piriformis tightness and provocation.

Question 52

``` Which medication has demonstrated positive effects in treating fatigue in patients with amyotrophic lateral sclerosis? (a) Modafinil (Provigil) (b) Baclofen (Lioresal) (c) Bromocriptine (Parlodel) (d) Gabapentin (Neurontin) ```

Answer 52

(a) Modafinil (Provigil) is well tolerated and may reduce the symptoms of fatigue in amyotrophic lateral sclerosis

Question 53

The best expected functional outcome for a person with C7 ASIA class A spinal cord injury is (a) dependent with bladder management, independent with bed mobility, and some assist with all transfers. (b) dependent with bladder management, independent with bed mobility, and independent with level transfers. (c) independent with bladder management, some assist with bed mobility, and independent with some transfers. (d) independent with bladder management, independent with bed mobility, and independent with level transfers.

Answer 53

(d) Expected functional outcomes after traumatic spinal cord injury have been delineated in the clinical practice guidelines for health care professionals. A person who has sustained a spinal cord injury at the C7-8 level can best be expected to need assistance in clearing secretions, may need partial to total assistance with a bowel program, and may be independent with respect to bladder management, bed mobility, and transfers to level surfaces.

Question 54

Which statement about carpal tunnel syndrome is TRUE? (a) A prolonged median motor distal latency is mandatory for diagnosis. (b) Symptoms improve after splinting the wrist in flexion for 2 weeks. (c) X-ray and magnetic resonance imaging studies have been standardized for diagnosis. (d) The syndrome is a complex of numbness and pain in a median nerve distribution.

Answer 54

(d) Carpal tunnel syndrome is a symptom complex that includes numbness, tingling, and pain in a median nerve distribution. Although objective testing such as nerve conduction studies can help confirm the diagnosis, evaluation must include the patients’ symptoms. Magnetic resonance imaging and ultrasound measurements will likely add objective evidence to help confirm the diagnosis, although standards are not in place at this time. Symptom reduction may occur after splinting in neutral, but is not diagnostic.

Question 55

``` What is a reasonable long-term rehabilitation goal for a 6-year-old child with a C6 ASIA class A spinal cord injury? (a) Independent lower extremity dressing (b) Bed mobility (c) Independent bathing (d) Independent feeding ```

Answer 55

``` (d) A child with C6 ASIA class A spinal cord injury would be expected ultimately to independently self-feed, but not bathe, do lower extremity dressing, or perform bed mobility. ```

Question 56

A prescription for side joints and corset in a below knee prosthesis would be indicated in a patient with (a) a short residual limb. (b) a slight degree of knee joint laxity. (c) fluctuating limb volume. (d) fragile skin

Answer 56

(a) Side joints and corset are indicated for persons with short or damaged residual limbs, or those with a high degree of limb laxity. Long-term users may also prefer to continue side joints and a corset even without the aforementioned indications.

Question 57

Which statement regarding complex regional pain syndrome (CRPS) is TRUE? (a) Pain is characterized by allodynia. (b) Local osteopenia is a common early occurrence. (c) Causalgia is also known as CRPS type 1. (d) Adults have a better prognosis than do children with CRPS

Answer 57

(a) Complex regional pain syndrome (CRPS), previously known as reflex sympathetic dystrophy as well as by other names, is characterized by a preceding noxious event; allodynia (exaggerated pain, ie, hyperesthesia) in response to a non-noxious stimuli; vascular changes such paleness and coolness; and edema. Sudeck’s atrophy is a name previously given to late stage CRPS when osteopenia is present. Osteopenia is a rare and late occurrence with CRPS. CRPS type 2 is also referred to as causalgia and is instigated from an initial nerve injury. Children have a better prognosis than adults.

Question 58

A 21-year-old woman presents for evaluation of hand tremors. They began when she was in mid adolescence but seem to be getting worse in college. She states that her writing is becoming less clear, and she reports difficulty in manipulating fine objects. She is studying to become an architect. In the review of systems, she mentions that wine lessens her tremors. Clinical examination is negative except for postural flexion/extension upper extremity tremors. Initial treatment would be (a) botulinum toxin injections. (b) observation with recheck in 6 months. (c) a beta-noradrenergic blocker. (d) high-frequency thalamic stimulation.

Answer 58

(c) Essential tremors, as described in this scenario, can develop in adolescence or in the fourth to fifth decades. Essential tremors are distiguished from parkinsonian tremors in that they are faster (7-10 Hertz, versus 4-7 Hertz) have more flexion/extension and less supination/pronation, and are not AAPM&R associated with bradykinesia, cogwheeling, or masked facies. Nonpharmacologic treatment consists of rest, decreasing central nervous system stimulants, and occasional use of situational alcohols. Medication would be started when activity of daily living skills are impaired, as in this case, with beta-noradrenergic blockers such as propranolol. Botulinum toxin would not be the initial treatment.

Question 59

Which treatment or medication is effective in treating both the skin and joint disease in persons with psoriatic arthritis? (a) Photochemotherapy (b) Nonsteroidal anti-inflammatory drugs (c) Intra-articular injections of corticosteroids (d) Methotrexate (Rheumatrex, Trexall)

Answer 59

(d) Methotrexate is effective for both skin disease and peripheral arthritis treatment. Photochemotherapy is for the treatment of skin disease, or psoriasis, only. Nonsteroidal antiinflammatory drugs are effective as the initial treatment option for persons with mild joint disease. For persons with limited joint involvement (1 or 2 joints), intra-articular steroids are a treatment choice for joint disease only.

Question 60

A 30-year-old woman with a slowly progressive neuromuscular disease desires an exercise program to maintain her mobility and function. Manual muscle strength testing shows greater than 3/5 strength in all muscle groups. You recommend a program with (a) emphasis on eccentric muscle contractions. (b) high resistance exercise with 10 to 12 repetitions. (c) low resistance exercise with 3 to 5 repetitions. (d) moderate resistance with 8 to 10 repetitions.

Answer 60

(d) Several well-controlled studies have looked at the effect of exercise as a means to gain strength with neuromuscular diseases. In slowly progressive neuromuscular disorders a 12-week moderate resistance exercise program resulted in strength gain ranging from 4% to 20% without notable deleterious effects. However, in the same population, a 12-week high resistance exercise program showed no further added beneficial effect compared to the moderate resistance program. Eccentric exercises are not recommended because they can produce to increased muscle trauma and soreness.

Question 61

Which condition is a proven barrier for the injured worker to return to a modified work position? (a) The employee has no incentive to return to modified work. (b) Employee and employer cannot agree on the job assigned. (c) The employee’s education does not match work requirements. (d) The employer must pay a fee to the carrier to implement modified work.

Answer 61

(c) Return-to-work barriers proven to date include the following: lack of knowledge regarding modified work, negative attitudes of employees, difficulty changing the work tasks and organization of the work, and a mismatch between the employee’s education level and the requirements of the modified job.

Question 62

A patient with a history of cervical cancer treated with pelvic radiation is sent to the electrodiagnostic laboratory for assessment of a suspected lumbosacral plexopathy (LSP). Which feature would more likely be seen in recurrent neoplasm than radiation plexopathy as the cause of the LSP? (a) Membrane instability shown by needle electrode examination (b) Weakness in the distal muscles of the affected limb (c) Decreased amplitude of the sensory nerve action potentials (d) Deep aching pain locally presenting within 3 months of treatment

Answer 62

(d) Neoplasm is a common cause of lumbosacral plexopathy (LSP). Usually it is from direct extension of tumor from nearby regions. Patients with tumor extension usually present initially with pain, both locally and in a radicular pattern. Radiation induced LSP usually results in proximal weakness without any pain or with little pain and most commonly present years after treatment is completed. Membrane instability, distal weakness, and decreased motor and sensory responses can be seen both in tumor recurrence and in radiation induced LSP.

Question 63

The primary advantage of a sterno-occipital-mandibular immobilizer orthosis is its (a) excellent limitation of cervical extension. (b) ease of donning while the patient is supine. (c) high level of patient comfort. (d) excellent limitation of atlantoaxial motion.

Answer 63

(b) The sternal-occipital mandibular immobilizer (SOMI) is effective at limiting flexion, whereas the 4- post orthosis restrains extension better. The SOMI can be applied to the supine patient without having to rotate the individual. The SOMI is not comfortable. Overall, control of atlantoaxial subluxation is difficult to achieve with orthoses.

Question 64

When performing an intra-articular facet joint injection on a patient with no previous history of surgery, you note extravasation of dye, which is flowing anteriorly into the epidural space. A defect in what structure will cause this scenario? (a) Posterior facet capsule (b) Ligamentum flavum (c) Interspinous ligament (d) Dural sac

Answer 64

(b) The ligamentum flavum forms the anterior border of the facet joint. Rents in the facet capsule allow contrast material to leak and therefore medication will also leak out of the intended area. Intra-articular injections into the facet joint performed for diagnostic purposes may lose specificity when this extravasation into the epidural space occurs, because other pain generating structures may also be blocked from receiving the medication.

Question 65

A 47-year-old man complains of generalized weakness and dysarthria that worsens throughout the day. He has dysphagia primarily with dinner and his wife reports that “he looks sleepy.” On examination, ptosis is prominent along with proximal muscle weakness. The most likely diagnosis is (a) myotonic dystrophy. (b) amyotrophic lateral sclerosis. (c) myasthenia gravis. (d) hyperkalemic periodic paralysis.

Answer 65

(c) Myasthenia gravis is not infrequent in men, and progression with activity is common. Ptosis is a common finding.

Question 66

For a person who has C5 tetraplegia, orthotic splinting attempts to maintain the functional position of the hand. This usually includes (a) 1° to 20° of metacarpophalangeal flexion. (b) supporting the wrist in 30° flexion. (c) inhibiting metacarpophalangeal flexion. (d) promoting flattening of the palmar arch.

Answer 66

(a) The functional position of the hand includes supporting the wrist in neutral to 30° extension, supporting the palmar arch with the fourth and fifth metacarpals slightly anterior to the second and third, 1° to 20° of metacarpophalangeal flexion, unimpeded, and preserving the thumb web space.

Question 67

You have just performed electrodiagnostic testing on a patient with human immunodeficiency virus (HIV). He has been complaining of burning in his feet for several months. The study reveals a symmetric sensory peripheral neuropathy. Which medication is the most likely cause? (a) Zidovudine (AZT) (b) Indinavir (Crixivan) (c) Saquinavir (Fortovase, Invirase) (d) Didanosine (ddI, Videx)

Answer 67

(d) Several of the antiretrovirals, specifically the nucleoside analog reverse transcriptase inhibitors didanosine (ddI), zalcitabine (ddC, Hivid), stavudine (d4T, Zerit), and lamivudine (3TC, Epivir), AAPM&R can cause a painful neuropathy. The drug AZT is also a reverse transcriptase inhibitor, but generally does not cause a neuropathy. Instead, it may lead to a myopathy. Saquinavir is a protease inhibitor that may cause gastrointestinal distress and elevated liver function test results. Indinavir is another protease inhibitor that may cause hepatotoxicity and nephrolithiasis.

Question 68

Which behavior would most likely be a warning sign of substance abuse in a resident colleague? (a) Deterioration in personal hygiene (b) Infrequent tardiness to scheduled lectures (c) Excessive concern regarding patient well-being (d) Frustration over evening admissions to the rehabilitation unit

Answer 68

(a) Deterioration in personal hygiene is the most likely warning sign of substance abuse in a resident colleague. Other warning signs of impairment secondary to substance abuse include increased rates of absenteeism, inability to meet deadlines, loss of concern about patient welfare, and wide fluctuations in mood and performance.

Question 69

``` A 45-year-old woman presents with a 2-week history of left leg weakness and paresthesias in the left leg for about 1 month. Examination reveals 4/5 strength with left foot dorsiflexion and plantar flexion, and 4+/5 strength with left knee flexion. Strength otherwise is 5/5 in the left lower extremity. Her nerve conduction and needle examination findings are as follows. MOTOR NERVE CONDUCTION STUDIES Nerve Stimulation Site Distal Latency (ms) Amplitude (mV) NCV (m/s) L Peroneal Ankle 4.5 4.4 Below knee 4.1 48 Above knee 3.8 51 R Peroneal Ankle 4.2 5.9 Below knee 5.5 52 Above knee 5.1 55 L Tibial Ankle 4.4 7.0 Knee 6.5 53 R Tibial Ankle 4.6 8.6 Knee 8.1 55 SENSORY NERVE CONDUCTION STUDIES Nerve Stimulation Site Distal Latency (ms) Amplitude (μV) L Sural Ankle - 14 cm 3.6 8 R Sural Ankle - 14 cm 3.7 17 L Superficial peroneal Ankle - 12 cm 3.2 6 R Superficial peroneal Ankle - 12 cm 3.1 15 NEEDLE ELECTROMYOGRAPHY Muscle Abnormal Spontaneous Activity Recruitment Adductor longus 0 Normal Quadriceps femoris 0 Normal Iliopsoas 0 Normal Semimembranosus 1+ Reduced Biceps femoris (shorthead) 1+ Reduced Tibialis anterior 2+ Reduced Extensor hallucis longus 2+ Reduced Medial gastrocnemius 2+ Reduced Tibialis posterior 2+ Reduced bTensor fascia latae 0 Normal Gluteus maximus 0 Normal Lumbar paraspinals 0 These findings are most consistent with a lesion located (a) in the spine. (b) between the spine and hip. (c) between the hip and distal thigh. (d) between the distal thigh and ankle. ```

Answer 69

(c) The lesion is in the sciatic nerve affecting both the tibial and peroneal nerves. The lesion is distal to the origin of the gluteal nerves. The femoral nerve is not involved. The left lower extremity motor and sensory studies are normal but compared to the right side reveal small amplitude responses.

Question 70

A 6-month-old infant presents to you with hypotonia. You perform an electrodiagnostic study which shows normal motor conduction velocity, normal sensory conduction velocity and amplitude, normal motor units, and occasional fibrillations and positive waves. The most likely cause of these findings is (a) congenital myotonic dystrophy. (b) spinal muscular atrophy. (c) metachromatic leukodystrophy. (d) infantile botulism.

Answer 70

(a) Hypotonia in infants can be caused by many abnormalities, including cerebral lesions, spinal cord pathology, polyneuropathies, and myopathies. These electrodiagnostic findings are most consistent with congenital myotonic dystrophy.

Question 71

A 29-year-old man with paraplegia who plays sledge hockey presents after a concussion with a loss of consciousness of less than 30 seconds. When would you suggest that he return to hockey? (a) If he has a headache that resolves after 48 hours, he may return to play 1 week from the provoking incident. (b) If he does not have postconcussion symptoms, he may return to play 1 week from the provoking incident. (c) If he does not have postconcussion symptoms, he may return to play the same day. (d) If he has dizziness, he may return to play as soon as the dizziness resolves

Answer 71

(b) The International Congress of the Concussion in Sports Group (CISG) convened in 2001 to provide recommendations on the care of concussions. According to the Vienna Group guidelines, when a player shows any symptoms or signs of concussion, they should not be returned to play in the current game or practice. They should be monitored and follow a stepwise process to return to play. Like anyone else, paraplegics who have suffered a concussion should be asymptomatic for 1 week prior to returning to play.

Question 72

You are on call and receive a page from the mother of a 23-year-old patient with a traumatic brain injury whose severe spasticity is managed by intrathecal baclofen (Lioresal). She reports that her son’s spasticity is getting worse over the last 24 hours, and he is complaining of whole body itching and a feeling like bugs crawling on his skin. He has developed nausea and just vomited. He had been doing well up until a day ago, and mom reports no rash on his skin. You tell her to (a) give him oral diphenhydramine (Benadryl) tablet for the itching and promethazine (Phenergan) for the nausea. You schedule him for the next available clinic to adjust his baclofen pump. (b) give him oral baclofen and bring him to the clinic the next day for further evaluation. (c) give him a diazepam (Valium) tablet and schedule him for clinic the next day for further evaluation. (d) give him oral baclofen and bring him to the emergency room for your further evaluation.

Answer 72

(d) Intrathecal baclofen withdrawal can be very serious and warrants immediate evaluation and management. The signs of baclofen withdrawal can be subtle with an intrathecal baclofen pump, but a sudden increase in spasticity and feeling ill with whole body itching are seen with baclofen withdrawal. Nausea and emesis is a warning of impending severe withdraw. Prevention of severe spasticity and the sequelae of rhabdomyolysis is critical to the health and welfare of the patient. The treatment is to restore intrathecal baclofen.

Question 73

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

Answer 73

(d) Convection is a process of using a medium to transport energy: husks, for example, with fluidotherapy, and water with whirlpool therapy. Conduction is a process of transferring thermal energy between 2 entities placed in direct contact with each other: cold packs on skin or, vapocoolant spray on skin or cold water immersion of a limb.

Question 74

A 25-year-old man with C6 tetraplegia, in a rehabilitation facility 6 weeks after injury, is having difficulties with orthostatic hypotension. General measures including compression stockings, abdominal binder, tilt table treatment, and daily salt tablets have been unsuccessful. Your next step may be to prescribe (a) bethanechol (Urecholine). (b) baclofen (Lioresal). (c) etidronate disodium (Didronel). (d) fludrocortisone (Florinef).

Answer 74

(d) Fludrocortisone is a steroid with potent mineralocorticoid activity which acts on the renal distal tubule, enhancing reabsorption of sodium and increasing fluid retention. Its property of increasing the circulating plasma volume makes it an appropriate choice for reducing blood pressure drops in patients with orthostatic hypotension.

Question 75

A 35-year-old receptionist presents with right lateral epicondylitis and periscapular myofascial pain. What change should be made to her desk? (a) Adjust chair height to allow 120° of knee flexion (b) Move computer disk drive to the floor to facilitate seated flexion. (c) Move mouse to allow 40° to 90° of elbow flexion. (d) Change height of computer screen to allow neck extension.

Answer 75

(c) The mouse should be placed at a distance that is easy to reach and allows comfortable flexion of the elbow approximately 40° to 90°. Chair height is not a preset determined height but is individualized so that the hips are at a 90° angle to the knees. The computer disk drive should be easily reached if used repetitively. Avoiding seated flexion would be a better recommendation. The computer screen height should allow a neutral neck position and minimize static flexion or extension.

Question 76

Which responsibility is NOT within the purview of an institutional research review board (IRB) as they evaluate a given research study at their institution? (a) Ensure that risks are minimized. (b) Ensure that selection of subjects is equitable. (c) Ensure that protections for privacy and confidentiality are in place. (d) Ensure that research does not involve vulnerable subjects such as prisoners.

Answer 76

(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 AAPM&R research protocol, the IRB must determine that risks are minimized, selection of subjects is equitable, protections for privacy and confidentiality are in place, informed consent is appropriate and will be documented in writing, and that the study has plans for data monitoring where appropriate. Research may involve subjects who are considered vulnerable, such as prisioners, but the research must add extra protections for these subjects.

Question 77

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

Answer 77

(d) Once a physician is certified by the American Board of Physical Medicine and Rehabilitation, he or she must continue to fulfill certain requirements in order to maintain certification status. Publication of an article in a peer-reviewed journal every 10 years is not a requirement for maintenance of certification. All the other options listed are required.

Question 78

What is the most effective type of medication for treating pain in patients with fibromyalgia? (a) Tricyclic antidepressants (b) Serotonin reuptake inhibitors (c) Narcotics (d) Anticonvulsants

Answer 78

(a) Tricylic antidepressants are more effective than serotonin reuptake inhibitors in the treatment of chronic pain syndromes. There is no definitive evidence that narcotics or anticonvulsants are effective in fibromyalgia.

Question 79

A 19-year-old man with a traumatic brain injury 1 year ago and spastic hemiplegia is seen in your clinic. He has completed his outpatient rehabilitation program and is treated with antispasticity medication. He ambulates with a cane with minimal lower extremity tone, but his main problem is upper extremity spasticity. The best management option is (a) occupational therapy with an aggressive stretching program. (b) adjustment of his oral antispasticity medication. (c) botulinum toxin injections of the upper extremity. (d) placement of an intrathecal baclofen pump.

Answer 79

(c) A year out from his injury an aggressive stretching program and occupational therapy (OT) should have already been tried and oral antispasticity medication is managing his lower extremity tone well. Further OT and adjustment of medications are not likely to help. Intrathecal baclofen is more effective for lower extremity spasticity than for upper extremity spasticity. Botulinum toxin intramuscular injections can be quite effective when combined with a therapy program for upper extremity tone and spasticity

Question 80

Walking at 3 miles per hour is equivalent to how many metabolic equivalents (METs)? (a) 1.0 to 1.5 (b) 2.0 to 2.5 (c) 4.0 to 4.5 (d) 5.0 to 5.5

Answer 80

(c) Lying quietly is 1.0 metabolic equivalents (METs). Light housework is 1.2 to 3.0 METs. Standing at ease is 1.4 to 2.0 METs. Walking at 3 miles per hour is equivalent to 4.3 METs.

Question 81

In the management of the neurogenic bowel, bisacodyl (Dulcolax) tablets and suppositories are (a) colonic stimulants that stimulate and enhance the gastrocolic reflex and thereby induce peristalsis in the colon. (b) stool softeners that aid in softening the stool by emulsifying fats in the gastrointestinal tract. (c) colonic stimulants that are primarily effective by being directly absorbed through the mucosa of the small intestine or colon. (d) contact irritants that act directly on the colonic mucosa to produce peristalsis throughout the colon.

Answer 81

(d) Bisacodyl (Dulcolax) tablets and suppositories are contact irritants that act directly on the colonic mucosa, and produce peristalsis throughout the colon. Administered orally, the drug exerts its effect through direct contact on the colon, not through absorption in the small intestine.

Question 82

A 58-year-old African-American man comes into your clinic for an exercise prescription and to have questions answered. He has hypertension and hyperlipidemia and asks about the difference between land based and aquatic exercises to help with his hyperlipidemia. You advise him that (a) aquatic therapy has a higher likelihood of on increasing his high-density lipoprotein (HDL) compared to land based exercises. (b) aquatic therapy has no added benefit than land based exercises in lowering total cholesterol, low-density lipoprotein (LDL), or triglycerides. (c) land based exercises decrease HDL to a greater extent than do aquatic based exercises. (d) land based exercises lower LDL, total cholesterol, and triglycerides more effectively than aquatic exercises.

Answer 82

(b) When compared to land based exercises, aquatic exercises have no added benefit in lowering total cholesterol, low-density lipoprotein or triglycerides. In regards to high-density lipoproteins (HDL), land based exercises increase HDL to a greater extent than aquatic exercises.

Question 83

Decision-making capacity is a requirement for providing informed consent and participating in treatment decisions. Of the abilities listed, which one is NOT considered central to an individual’s decision-making capacity? (a) Ability to express a choice, either verbally or nonverbally (b) Ability to understand specific information related to treatment decisions (c) Ability to seek advice from other health care providers (d) Ability to appreciate of the significance of information as it applies to their condition

Answer 83

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

Question 84

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

Answer 84

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

Question 85

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

Answer 85

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

Question 86

A 65-year-old woman has day-to-day memory problems and is concerned about possible Alzheimer’s disease. You explain that there are many causes of dementia and that some are reversible. The first step in evaluation of her declining mental function is a (a) computed tomography scan of her brain. (b) history and physical exam with cognitive screening. (c) complete blood count and blood chemistry profile. (d) trial of an antidepressant to treat an occult depression.

Answer 86

(b) As with all health problems, a workup for dementia must start with a history and physical exam. These findings will direct the rest of your dementia workup and treatment. Erythrocyte sedimentation rate and thyroid function studies should be added to her laboratory workup.

Question 87

``` What heating modality uses high frequency acoustic energy to produce thermal and non-thermal effects in tissue? (a) Fluidotherapy (b) Microwave (c) Ultrasound (d) Shortwave diathermy ```

Answer 87

(c) Ultrasound uses high frequency acoustic energy to produce its effects. Fluidotherapy is superficial dry heat using convection with forced hot air and a bed of finely divided particles. Microwave heat occurs when thermal energy is produced by increasing the kinetic energy of molecules within the microwave field, thus using the mechanism of conversion. Short wave diathermy is the conversion of electromagnetic energy into thermal energy when the osscillation of high frequency electrical and magnetic fields produces molecular movement and heat.

Question 88

The best test to diagnose a suspected post-traumatic syrinx in the cervical cord is (a) cervical spine x-ray. (b) spiral computerized tomography. (c) magnetic resonance imaging. (d) contrast myelogram.

Answer 88

(c) Magnetic resonance imaging (MRI) is considered the best imaging study available for diagnosing posttraumatic syringomyelia. MRI findings often associated with clinical neurological decline include a spinal cord syrinx that is longer and wider, a syrinx with poorly demarcated T2-weighted signal hyperintensity at the rostral extent, syrinxes associated with spinal stenosis, or a flow void sign on T2-weighted images suggesting high pressure. A large syrinx however may be seen without any symptoms noted.

Question 89

Which type of massage uses a stroking technique characterized by gliding, light strokes that cover a large area and generally go from distal to proximal? (a) Friction (b) Petrissage (c) Tapotement (d) Effleurage

Answer 89

(d) The type of massage described in the question is effleurage. The other options are different forms of massage therapy techniques: (1) friction, pressure is applied with the ball of the practitioner’s thumb or fingers to the patient’s skin or muscle; (2) petrissage, compressing the skin and soft tissue between the fingers and thumb of one hand; and (3) tapotement, striking the soft tissue with repetitive blows using both hands in a rhythmic manner.

Question 90

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

Answer 90

(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 91

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

Answer 91

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

Question 92

``` Which anatomical configuration is associated with an anterior pelvic tilt when the patient is standing? (a) Short abdominal muscles (b) Increased lumbar lordosis (c) Elongated hip flexors (d) Short and strong gluteal muscles ```

Answer 92

(b) An anterior pelvic tilt is caused by one of several anatomic factors. These include tight hip flexors, weak lower abdominals, and weak gluteal muscles. Compensatory lumbar extension through lumbar lordosis results in individuals with excessive anterior pelvic tilt.

Question 93

A 65-year-old woman has Alzheimer’s disease and vascular dementia. What is the most effective way to protect her brain function? (a) Cholinesterase inhibitor therapy (b) N-methyl-D-aspartate (NMDA) antagonist Namenda (memantine) therapy (c) Cholinesterase inhibitor and Namenda (memantine) therapy (d) Treatment of cardiovascular risk factors

Answer 93

(d) Reducing cardiovascular risk factors, especially hypertension and hyperlipidemia, can decrease the risk of recurrent stroke and are important strategies in preventing or slowing the progression of mixed dementia.

Question 94

You are giving a lecture to a group of physical therapists on the use of transcutaneous electrical stimulation and shoulder subluxation after a stroke. During the lecture, you explain that (a) the stimulation electrodes are placed on the posterior deltoid and supraspinatus muscles to help prevent shoulder subluxation. (b) electrical stimulation only helps with shoulder pain and does not help prevent shoulder subluxation. (c) the stimulation electrodes are placed on the infraspinatus and anterior deltoid. (d) electrical stimulation is less effective at preventing shoulder subluxation than are wheelchair arm supports and upper extremity slings.

Answer 94

(a) Electrical stimulation is a superior treatment to arm trays and slings to help prevent and treat shoulder subluxation after a stroke. The electrode placement is on the posterior deltoid and supraspinatus muscles.

Question 95

A 45-year-old woman who is actively involved in an exercise program asks your opinion on the use of magnets to help relieve post-exercise muscle soreness and increase muscle force production. Your advice to her is based on the knowledge that magnets (a) are more effective than placebo in helping with pain reduction. (b) are no more effective than placebo in helping with pain reduction. (c) are more effective than placebo in helping with pain reduction or with increasing muscle force production. (d) are more effective than placebo in helping with muscle force production.

Answer 95

(b) Magnets are no more effective than placebo in helping with pain reduction or muscle force production.

Question 96

The proper width of a doorway to allow transit of a power wheelchair without turning is at least (a) 26 inches. (b) 30 inches. (c) 36 inches. (d) 40 inches.

Answer 96

(c) The proper width of a doorway for a power wheelchair is at least 34 inches. Base would increase to 36 inches if a turn is involved. A manual wheelchair requires a 32-inch doorway. The minimum turning space is a 5-foot radius for a manual wheelchair and a 6-foot radius for a power chair.

Question 97

Which statement regarding the proven effects of Tai Chi in persons with osteoporosis is TRUE? (a) It helps retard bone loss in both trabecular and cortical weight bearing bones. (b) It helps with muscle strength but has no effect on retarding bone loss. (c) It helps retard bone loss only in trabecular bone. (d) It helps retard bone loss only in cortical bone.

Answer 97

(a) A Tai Chi program over the course of 12 months has been shown to be beneficial in retarding bone loss in both trabecular and cortical bone when compared to a sedentary lifestyle.

Question 98

What effect did the Omnibus Budget Reconciliation Act of 1993 (Stark II legislation) have on medical practice? (a) It made referrals to medical specialists more profitable for primary care physicians. (b) It legalized referrals to a physician-owned physical therapy practice, so long as the physician owns less than 50% of the practice. (c) It made illegal physician self-referral to physical therapy, durable medical equipment suppliers, and certain other entities owned by the physician except for certain safe harbors. (d) It made illegal physician referral to another physician for specialty care, if the physicians are in the same practice.

Answer 98

(c) The Omnibus Budget Reconciliation Act of 1993 (Stark II legislation) made physician self-referral to physical therapy, durable medical equipment suppliers, and certain other entities owned by the physician illegal, except for certain safe harbors.

Question 99

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

Answer 99

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

Question 100

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

Answer 100

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