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Flashcards in SAER 2007 Deck (98):
1

You are called onto a football field immediately after a defensive player involved in a spearheading tackle complains of neck pain and right greater than left arm tingling. What should be the next step?
(a) Call for an ambulance and stabilize the neck.
(b) Remove the athlete’s football helmet and palpate for any neck tenderness.
(c) Return the athlete to the game if his strength exam is normal.
(d) Walk the athlete to the locker room and perform a thorough neurologic examination.

A
A telltale sign of cervical cord involvement is bilateral symptoms. In this case, the athlete should be treated as having a potential spinal cord injury and should have his cervical spine immobilized. The football helmet should not be removed, since the cervical spine may fall into extension in the act of removing the helmet. If the airway needs to be accessed, then the face guards should be removed using special equipment. If the athlete suffered and recovered from a temporary “stinger,” involving 1 limb, he may return to play as long as his neurologic examination is normal.

2

The initial treatment for osteoarthritis is
(a) medication to reverse articular cartilage damage.
(b) surgical correction of joint deformities.
(c) therapy to relieve joint symptoms.
(d) immobilization of the joint to prevent deformity.

C

General treatment principles of osteoarthritis include medications and/or therapy to relieve joint symptoms, along with maintaining or improving function and minimizing drug toxicity. To date, no medications can reverse or repair damaged articular cartilage. Exercises, such as range of motion and strengthening, are part of nonpharmacologic therapy of osteoarthritis. Surgical correction is not an initial treatment strategy.

3

A 42-year-old car mechanic with a 3-week history of low back pain and lower limb pain after lifting equipment at work is referred to you for management. He has been taking ibuprofen 800mg 4 times daily without improvement. He is unable to flex through the lumbar spine or sit without pain. Your recommendations to his employer regarding work include
(a) modified duty to allow no repetitive twisting or bending and no push/pull heavier than 20 lbs.
(b) return to sedentary work 8 hours daily for 1 week, and no push/pull heavier than 10 lbs.
(c) light duty to include no pushing/pulling, or lifting more than 25 lbs for 1 month.
(d) remain off work until lumbar flexion, sitting, and lifting are no longer painful.

A

Returning the employee to modified duty that fits the impairment and avoids provocative activities is important from several aspects. One, behavioral management with the employee allows early goals to be set, so that the employee can work with restrictions. It also establishes that simply being off work until pain free is not always a logical goal. Second, the employer can fully understand the employee’s capabilities during recovery. This management approach hones in on the employer to comply with the restrictions. Third, starting with reasonable restrictions allows the physician to guide the employee back to the work place by making adjustments as the worker’s rehabilitation progresses.

4

According to national databases of spinal cord injury (SCI), children under the age of 6 years are more likely to have which epidemiologic pattern of spinal cord injury?
(a) high tetraplegia, motor incomplete, occurred in motor vehicle accident
(b) paraplegia, complete, occurred in motor vehicle accident
(c) high tetraplegia, complete, caused by medical/surgical complications
(d) paraplegia, motor incomplete, caused by medical/surgical complications

not yet answered

5

What is the greatest risk factor for late post-traumatic seizures in patients with a traumatic brain injury?
(a) Multiple subcortical contusions
(b) Subdural hematoma with evacuation
(c) Midline shift greater than 5mm
(d) Bilateral parietal contusions

D

The correct answer was (d) Bilateral parietal contusions In a 4-site Model System Center observational study, the highest risk factors for late post-traumatic seizures were found to be bilateral parietal contusion (66%), penetration of the dura (62.5%), and multiple intracranial operations (36.5%), multiple subcortical contusions (33.4%), subdural hematoma with evacuation (27.8%), and midline shift greater than 5mm (25.8%).

6

Myositis is defined as
(a) muscle aching.
(b) muscle aching with weakness.
(c) muscle symptoms with creatine kinase elevation.
(d) muscle symptoms with creatine kinase and creatinine elevations.

C

The correct answer was (c) muscle symptoms with creatine kinase elevation. Myopathy refers to a disease or abnormal condition of striated muscle; whereas, myalgia is defined as muscle aching or weakness without serum creatine kinase (CK) elevations. Myositis implies muscle symptoms accompanied by CK elevations. Rhabdomyolysis signifies muscle complaints with CK elevations 10 times the upper limits of normal (ULN) with creatinine elevation. Clinically important myopathy with CK elevations greater than 10 times ULN is estimated to occur in approximately 0.1% of patients who receive statin monotherapy. Clinically important myopathy and rhabdomyolysis have been reported with all statins with an overall death rate of .15 per 1 million prescriptions.

7

A 55-year-old paramedic is under your care for a work-related shoulder injury. She has completed physical therapy, no longer requires pain medications, and wants to return to work. She does not have full shoulder abduction and has some pain with overhead activities. Ideally, you recommend
(a) return to work without restrictions.
(b) work conditioning for 4 weeks.
(c) a week of work hardening.
(d) functional capacity evaluation.

D

The paramedic has a high demand job. A functional capacity evaluation would best determine the employee’s ability to return to her job. If deficits are noted, work hardening over a period of weeks will best ensure return to work. Work hardening for 1 week may not be sufficient. Work conditioning enhances aerobic fitness and conditioning but is not job specific. The paramedic is at high risk for recurrent injury. Returning the employee to work without testing the her ability to perform her job duties may precipitate premature return and reinjury.

8

An 18-year-old, right-handed hockey player presents to you after experiencing 3 right shoulder anterior dislocations in the prior season after falls on ice. Magnetic resonance imaging shows supraspinatus tendonitis but no other lesions or tears. After 6 sessions of physical therapy, he is pain free. He has been invited to play professionally in 6 months. What is your next recommendation?
(a) Tell him that he will likely dislocate again and that he should relocate the shoulder by forcefully pushing the anterior shoulder against a wall.
(b) Refer him to a surgeon to consider shoulder stabilization surgery.
(c) Tell him he should not return to any sports because of his increased chance of dislocating again.
(d) Stress the importance of compliance with his home exercise program.

B

Recurrent dislocations should be treated with surgery at some point if the athlete would like to return to contact sports. Various anterior shoulder dislocation techniques that can be applied to reduce the shoulder, most by external rotation of the shoulder or by using gravity.

9

You have evaluated a 50-year-old man for lower extremity muscle pain and discomfort. The pain increases with jogging. You have reviewed his medications, which include simvastatin (Zocor). Baseline laboratory studies were normal 6 months ago. The creatine kinase level is mildly elevated at 185 units/L. The next most appropriate step is to
(a) discontinue the medication and check creatinine and thyroid stimulating hormone levels.
(b) order electrodiagnostic study.
(c) switch to a different class of lipid lowering medications.
(d) continue the medication with close monitoring of the creatine kinase levels.

D

If a patient on a statin presents with muscle complaints, with or without creatine kinase (CK) elevations, other causes, including strenuous exercise or hypothyroidism, must be considered. If a patient initially has normal or only moderately elevated CK levels, the statin may be continued with close monitoring of symptoms and CK levels; however, if symptoms become intolerable or if the CK level is 10 times the upper limits of normal (ULN) or greater, the statin must be discontinued. If myositis is present or strongly suspected, the statin should be discontinued immediately. Early diagnosis and treatment of symptomatic CK elevations, including cessation of drug therapies potentially related to myopathy, can prevent progression to rhabdomyolysis. Symptoms and CK levels should resolve completely before reinitiating therapy, at a lower dose if possible. Asymptomatic elevation of CK at 10 times the ULN or greater should also prompt discontinuation of the statin. Consideration should also be given to discontinuation of statins before events that may exacerbate muscle injury, such as surgical procedures or extreme physical exertion. Needle electromyography (EMG) abnormalities are uncommon in statin-induced myopathy. An EMG does not exclude statin-induced myopathy, because it primarily affects type 2 muscle fibers. Electromyography is not routinely performed or recommended unless the clinical presentation does not improve with statin discontinuation or if concern exists about other diagnoses.

10

An individual with C7 ASIA D tetraplegia must have
(a) a bulbocavernosus reflex and voluntary sphincter contraction.
(b) a muscle grade of 3 or greater in at least half of the key muscles below C7.
(c) normal pinprick and light touch sensation through the sacral dermatomes.
(d) normal strength (5/5) in the C7 myotome.

A

A bulbocavernosus reflex does affect American Spinal Injury Association (ASIA) scoring, and voluntary sphincter contraction is not a mandatory component of ASIA C or D. Muscle grade of less than 3 in at least half of the key muscles below C7 would be characterized as ASIA C. Someone with ASIA B through E must have some retained sensation in the sacral segments S4-S5 but that sensation can be normal or impaired. To classify the injury as C7 ASIA D would require a motor score of at least 3 out of 5 in the C7 myotome with normal strength in C6.

11

Osteoblastic lesions are seen in which type of cancer?
(a) Prostate
(b) Lung
(c) Breast
(d) Renal

A

Bony metastases from prostate cancer usually are blastic, whereas those from breast, lung, and kidney are typically lytic. Knowing whether a metastatic bone lesion is blastic or lytic is important, because lytic lesions have a higher risk of pathologic fracture.

12

Under the prospective payment system for inpatient rehabilitation facilities, which item is used in assigning a patient to a case-mix group?
(a) Mini Mental Status Examination
(b) Disability Rating Scale
(c) Previous hospitalization
(d) FIM instrument motor score

D

FIM instrument motor score The prospective payment system for inpatient rehabilitation facilities requires that all patients admitted for inpatient rehabilitation be assigned to an impairment group code category. Payment to the rehabilitation facility is further determined by the patient’s subclassification into a case-mix group. The FIM instrument motor score is used to help determine the case-mix group designation under the prospective payment system for inpatient rehabilitation facilities. None of the other options listed are used in this process.

13

A 40-year-old man sustained an injury to his left arm, 3 weeks ago, when he lost his balance and crashed into a bookshelf. His complaints include left arm pain, weakness with extension of his wrist and fingers, and decreased hand grip. He denies any numbness but has odd sensations over the dorsum of the left hand. Prior to any testing, which problem would you consider as the most likely?
(a) Posterior interosseous neuropathy
(b) C7 radiculopathy
(c) Posterior cord brachial plexopathy
(d) Radial neuropathy

D

Based on the clinical presentation, radial nerve injury is the most likely cause of the patient’s symptoms. Considering the location of the trauma the other possibilities seem less likely. In a posterior interosseous nerve injury one would not expect any sensory problems.

14

A 25-year-old man with a history of a traumatic brain injury is noted to have a marked functional decline from his normal level of functioning. You order a computed tomography (CT) scan, which reveals large ventricles with flattening of the sulci and periventricular lucency. You tell the family that a ventriculoperitoneal shunt
(a) is emergently needed, and immediate referral to neurosurgery is indicated.
(b) will not be helpful, because the findings on the CT scan are due to irreversible atrophy of brain tissue (hydrocephalus ex vacuo).
(c) is not indicated, because he does not have the triad of incontinence, gait disorder, and dementia.
(d) may be helpful, because about 50% of patients with post-traumatic brain injury hydrocephalus experience significant improvement.

D

A series reported by Tribl and Oder found that of 48 patients who underwent ventriculoperitoneal shunting for post-traumatic hydrocephalus slightly more than half experienced significant benefit.

15

The interdisciplinary approach to patient care emphasizes
(a) common patient and team goals.
(b) discipline-specific goals.
(c) concentration on specific clinical problems.
(d) treatment by multiple team members.

B

The interdisciplinary approach to patient care emphasizes common patient and team goals rather than discipline-specific goals. The patient and family members should be included in the goal setting process. All team members must work in a collaborative way to facilitate achievement of goals. Team members must have an appreciation for all the issues that affect the patient rather than focusing on an isolated problem. Team communication is essential at all points in the rehabilitation process, not just when problems occur.

16

Which description best localizes the extensor indicis proprius muscle (with the forearm fully pronated) for needle electrode examination?
(a) Junction of the upper and middle third of the forearm between the radius and ulna
(b) Four fingerbreadths proximal to the wrist and directly over the ulnar side of the radius
(c) Two fingerbreadths proximal to the ulnar styloid and just radial to the ulna
(d) Mid-forearm along the radial border of the ulna

C

Answer (a) describes the location of the extensor digitorum communis muscle; answer (b) describes the location of the extensor pollicis brevis muscle; and answer (d) describes the location of the extensor pollicis longus.

17

When should upper extremity prosthesis fitting be initiated in the adult?
(a) Within the first month after amputation
(b) When residual limb strength is full.
(c) When the patient requests a prosthesis
(d) When residual limb volume has stabilized

A

The first month after upper limb amputation is the optimal period for prosthesis fitting. Fitting should be initiated during this time to maximize the level of acceptance and use of the prosthesis.

18

Which injury level is the most common location for an osteoporotic vertebral compression fracture?
(a) Upper thoracic spine
(b) Middle thoracic spine
(c) Thoracolumbar junction
(d) Middle lumbar spine

B

The most common location for vertebral compression fractures due to osteoporosis is the midthoracic spine, followed by the thoracolumbar junction. If fractures are seen at other levels, a higher degree of suspicion for a pathologic (due to cancer) fracture should be raised

19

According to data from the Model Spinal Cord Injury Care System, the leading cause of traumatic spinal cord injury in the United States is
(a) motor vehicle accidents.
(b) violence.
(c) falls.
(d) diving accidents

A

top three causes of traumatic spinal cord injury in the United States are motor vehicle accidents, falls, and violence.

20

Your 5-year-old patient with spastic tetraplegic cerebral palsy needs a wheelchair prescription. He is dependent for transfers, but cognitively normal. He is able to feed himself and uses a communication device. His family transports him in their car in an adapted car seat. On examination, he is unable to sit unsupported, but sits well with minimal support; he has no scoliosis, and his passive range of motion is full. Which elements would be best to include in his wheelchair prescription?
(a) Folding frame, sling seating
(b) Adaptive stroller, linear seating
(c) Tilt in space frame, custom seating
(d) Rigid frame, contoured seating

D

While this child is totally dependent for transfers, he only requires minimal support to sit upright and has no fixed deformities. Custom seating should be used for those with fixed deformities. A tilt-in-space frame should be used when children need to have their position in space changed frequently because of deformities or medical problems. While it is tempting to prescribe a wheelchair with a folding frame for a family who transports a child in a car rather than a van, the child will be better positioned using contoured seating and a rigid frame. At age 5 years, the size of frame needed will be able to be transported in a car even without folding. Adaptive strollers usually position the child in a reclined position and should be used as a backup to a wheelchair, which is not easily transported in an automobile, or for a child who can walk but periodically needs dependent mobility for fatigue or following seizures or for similar reasons

21

A case manager comes to your office accompanying the injured worker you are managing. The front desk person asks if you will see the case manager with the patient. You respond that
(a) case managers inhibit patient care and you don’t wish to speak with them.
(b) as requested by the patient you will see the case manager following the interview and examination.
(c) you will speak with the case manager after the patient signs a release of information.
(d) the case manager should always be present at the time of the patient’s interview and examination despite the patient’s request to avoid the case manager.

B

Case managers are shown to be beneficial liaisons between the physician and workers compensation carrier and their presence facilitates patient care. To be treated as a workers compensation case, the patient must give the carrier full access to his/her medical record. The employee treated under workers compensation cannot restrict the access of the case manager to the physician; however, discussions with the case manger should be done in the environment that the patient requests.

22

Blink reflex studies can be useful in diagnosing which condition?
(a) Neuromuscular junction disorder
(b) Axonal neuropathy
(c) Motor neuron disease
(d) Midpontine lesion

D

Blink reflex studies can help assess facial and trigeminal nerve lesions, as well as central lesions in the brain stem. Neuromuscular junction disorders are better assessed by repetitive studies. Axonal neuropathies rarely affect the blink reflex, but demyelinating peripheral neuropathy can affect all potentials of the blink reflex study. Motor neuron disorders such as amyotrophic lateral sclerosis do not typically affect the blink reflex.

23

The largest change in bone mineral density in a hemiplegic patient 1 year after a stroke occurs in the
(a) humerus on the paretic side.
(b) proximal femur on the paretic side.
(c) distal radius on the paretic side.
(d) lumbar spine.

A

In studies by Beaupre and Lew, and Ramnemark et al, the largest change in bone mineral density (BMD) is in the humerus on the paretic side (-17%), the next largest change was -12% in the proximal femur on the paretic side and -9% in the distal radius on the paretic side. No change in BMD was found in the lumbar spine.

24

Which medication that binds to B-lymphocyte CD20 surface antigens (monoclonal antibody) has recently received a new indication for treatment of rheumatoid arthritis in patients who have failed tumor necrosis factor (TNF) alpha antagonists and who are receiving concomitant methotrexate (Trexall)?
(a) Etanercept (Enbrel)
(b) Abatacept (Orencia)
(c) Anakinra (Kineret)
(d) Rituximab (Rituxan)

D

Rituximab works by binding to B-lymphocyte CD20 surface antigens (monoclonal antibody) and thereby depleting the B cell population. Its previous indication was for treatment of non-Hodgkin’s lymphoma. Etanercept is a TNF alpha antagonist. Abatacept blocks co-stimulatory molecules and T-cell activation. Anakinra inhibits interleukin-1 type receptors.

25

A 21-year-old man is evaluated in your spinal cord injury clinic 12 months after a C2 complete spinal cord injury requiring full-time mechanical ventilation. You recommend
(a) avoiding a breath control system for his power wheelchair.
(b) aggressive diaphragmatic strengthening exercises.
(c) initiating a weaning protocol by slowly decreasing tidal volume.
(d) an electrodiagnostic study to evaluate for a phrenic nerve pacemaker.

D

It is unlikely that an individual will be able to wean from a ventilator if he is still completely dependent on mechanical ventilation 12 months after a C2 complete injury, so a weaning protocol and diaphragmatic strengthening are not indicated. An individual who requires mechanical ventilation can use a breath control system effectively. If electrodiagnostic testing indicate that the phrenic nerves are intact, then a phrenic pacemaker could be implanted, which would significantly reduce the need for mechanical ventilation.

26

Which pulmonary parameter is most commonly followed in a patient with amyotrophic lateral sclerosis (ALS)?
(a) Arterial blood gas (ABG)
(b) Oxygen saturation (O2 sat)
(c) Forced expiratory volume in 1 second (FEV1)
(d) Vital capacity (VC)

D

Vital capacity should be monitored in patients with neuromuscular disease such as ALS. The forced vital capacity is convenient to follow disease progression, and it correlates with disability. FEV1 is normal. Blood gases remain normal until the patient is in near respiratory arrest. Hypercapnia precedes hypoxia, so monitoring oxygen saturation is not helpful.

27

The purpose of the Health Insurance Portability and Accountability Act (HIPAA) is to
(a) ensure that a patient’s medical record is available to health care providers as directed by the patient.
(b) allow qualified physicians access to the patient’s medical record.
(c) allow a lawyer access to a medical record only if litigation is pending.
(d) prohibit the release of confidential health information to insurance carriers.

A

The purpose of the Health Insurance Portability and Accountability Act (HIPAA) is to ensure that a patient’s medical record remains private, but is available to health care providers as directed by the patient. A non-treating physician, lawyer, or insurance company may have access to the record with written authorization by the patient or guardian. There are no stipulations about a physician’s qualifications with regards to medical information access.

28

Double limb stance is what percent of the entire gait cycle?
(a) 5%
(b) 10%
(c) 20%
(d) 30%

C

The average double limb support is 20% and single limb support is 40% of the entire gait cycle. Stance phase accounts for 60% of the gait cycle and swing phase accounts for 40%.

29

A 23-year-old woman who is unresponsive after an acute traumatic brain injury can visually track. She periodically pushes the nurse’s hand away when the nurse administers a subcutaneous heparin injection. The patient is exhibiting
(a) a coma state.
(b) a minimally conscious state.
(c) a vegetative state.
(d) a sleep/wake cycle

B

A minimally conscious state is a condition of severely altered consciousness in which minimal but definite behavioral evidence of self, or environmental awareness, is demonstrated by any or all these actions: simple gestures, purposeful behavior, appropriate smile/cry or vocalization to stimulation, reach for object, purposeful visual tracking. The vegetative state is associated with preserved hypothalamic and brainstem autonomic function and the patient exhibits a sleep/wake cycle, but there is an absence of cortical activity, judged behaviorally. The patient may exhibit visual pursuit but not in relation to meaningful behavior. The term persistent vegetative state is confusing and it is suggested that the term be abandoned, since it combines diagnosis (vegetative) with prognosis (persistent). Coma is a transient state after a traumatic brain injury (TBI) of being not awake and not aware of surroundings, and is seen in patients with a severe TBI and a Glasgow coma scale (GCS) of 8 or lower.

30

Which one of the following characteristics is typically associated with Charcot Marie Tooth (CMT) disease type 2?
(a) minimal level of disability.
(b) minimal decrease in nerve conduction velocity.
(c) autosomal recessive inheritance.
(d) absence of sensory deficits.

B

Charcot Marie Tooth (CMT) disease type 2 has greater variability and produces more disability than type 1. The disability can range from very mild to severe in CMT type 2. In addition to the weakness typical of the hereditary sensory motor neuropathy diseases, paresis of diaphragm, vocal cord, and intercostal muscle has been reported. CMT type 2 disease is characterized by less hypertrophic change in myelin, with more neuronal or axonal involvement. Sensory deficits are common to both forms. Both have autosomal dominant inheritance. Motor nerve conduction velocities are reduced markedly in CMT type 1: values are less than 70% of the lower limits of normal. Type 2 will have decreased amplitudes, due to its axonal nature. If slowing of conduction velocities occurs in type 2, it does not reach the values seen in CMT type 1.

31

A 60-year-old woman is seen in consultation by your rehabilitation team after elective surgery. She has a new finding of 1/5 strength in her lower extremities, but retained propioception and vibratory sense. You make the diagnosis of
(a) posterior spinal cord syndrome.
(b) central cord syndrome.
(c) anterior spinal cord syndrome.
(d) conversion disorder.

C

In anterior spinal cord syndrome there is usually paralysis below the level of the lesion, along with bilateral loss of pain and temperature sensation. Proprioception and vibratory sense are partially preserved. This syndrome often occurs after significant intraoperative hypotensive events. Central cord syndrome refers to weakness that is greater in the upper extremities than the lower extremities. Posterior cord syndrome shows loss of proprioception and is the least common of the incomplete spinal cord injury syndromes.

32

A 55-year-old long-distance truck driver is recovering from a work related low back injury that occurred during lifting. The worker has completed 2 weeks of physical therapy and continues to have low back pain, lower extremity pain, and paresthesias. The employer calls you and is upset that you have restricted the worker from truck driving during the treatment phase, citing that “driving is sedentary work.” You recommend that the driver refrain from truck driving because
(a) a minimum of 4 weeks of physical therapy will be necessary to facilitate recovery.
(b) low back pain has been found to be more frequent in people exposed to whole body vibration.
(c) workers with low back pain should not sit while symptoms of radiculopathy are present.
(d) the employer is unlikely to follow the restrictions you recommend.

B

was (b) low back pain has been found to be more frequent in people exposed to whole body vibration. Whole body-vibration is associated with increased frequency of low back pain. Some studies have found a correlation between increased frequency of disc protrusion and occupational driving. The exposure to vibration will likely facilitate continued symptoms in this worker, and relative rest is indicated during the initial stages of recovery. There is no predetermined length of physical therapy that is associated with recovery. Workers with low back pain and leg pain must learn to sit without increasing symptoms. Complete avoidance will not necessarily improve recovery and is not practical. The driver can likely perform some duties with restrictions. The employer has the responsibility to provide a job that meets the restrictions set by the physician. If the employer is unable to provide a job with these restrictions then the employee must remain off work.

33

A 55-year-old man presents with a 2-month history of progressive weakness. On examination he has mild proximal weakness in the upper and lower limbs. His muscle tone and bulk are normal and he has no facial weakness. Sensation is normal and deep tendon reflexes are 1+ and symmetrical. Which finding on electrodiagnostic testing is most consistent with this patient’s presentation?
(a) Prolonged or absent F waves
(b) Decreased recruitment ratio
(c) Motor unit potentials with amplitudes of 10 millivolts
(d) Normal number of phases of the motor unit potentials

B

ratio The clinical presentation is most consistent with a myopathic picture. In myopathies the recruitment ratio is usually lower (

34

What is a possible cause for circumduction during mid swing in the transfemoral amputee?
(a) Insufficient knee friction
(b) Prosthesis too short
(c) Excessive medial brim pressures
(d) Inadequate hip extension

C

Possible causes for circumduction in the gait of a transfemoral amputee include excessive mechanical resistance to knee flexion, prosthesis aligned with too much stability, prosthesis too long, increased medial brim pressures, inadequate suspension, patient lacks confidence or has inadequate hip flexion.

35

To allow pronation of the foot, which 2 joints must have their axis of rotation in parallel?
(a) Lisfranc and talonavicular
(b) Subtalar and calcanocuboid
(c) Talocrural and subtalar
(d) Talonavicular and calcaneocuboid

D

The transverse tarsal joint, namely the talonavicular and calcaneocuboid joints, must have their joint axes in parallel to allow for a flexible midfoot and pronation. If the axes intersect, the midfoot becomes rigid, which enables proper supination.

36

You are seeing a 56-year-old male patient in consultation 3 days after a severe stroke. He is medically stable and has flaccid hemiplegia with poor sitting balance. He is sitting up in a chair for 2 hours twice daily and has just started bedside physical therapy (PT) and occupational therapy (OT). You recommend
(a) continued bedside therapy with OT and PT, focusing on sitting balance, followed by transfer to your inpatient rehabilitation unit when he can sit and stand with minimum assistance.
(b) transfer to your inpatient rehabilitation unit to start aggressive PT and OT.
(c) transfer to a subacute rehabilitation center to allow the patient time to improve with less intensive therapy.
(d) that his OT start functional electrical stimulation to the flaccid arm to enhance neurologic recovery.

B

. Early and aggressive therapy addressing the higher level skills of gait, higher order functional skills, and problem solving were associated with better outcomes in a multi-center observational study

37

Which of the following is the most important lifestyle modification for prevention of osteoporosis?
(a) Avoiding cigarette smoking and high intake of caffeine
(b) Decreasing the intake of alcohol
(c) Minimizing the use of nonsteroidal anti-inflammatory medications
(d) Eating a diet high in protein and phosphorus

A

Factors that impact bone mineral density negatively are smoking and high intake of caffeine, protein, and phosphorus. An active lifestyle with regular weight-bearing exercise is advised. Eliminating fall hazards such as throw rugs throughout the home is also essential.

38

Autonomic dysreflexia is most commonly precipitated by
(a) bladder distension
(b) bowel impaction
(c) heterotopic ossification
(d) atelectasis

A

. Autonomic dysreflexia occurs in individuals with spinal cord injuries at the level of T6 and above. It occurs because of sympathetic discharge resulting from a stimulus below the injury level. The most common cause is bladder distension, which can result from a clogged or kinked indwelling urinary catheter or from delayed intermittent catheterization. Bowel impaction is the second most common cause of autonomic dysreflexia.

39

An 80-year-old man with peripheral neuropathy and multiple medical conditions fell at home and was found several hours later. He was admitted to the hospital for a sacral insufficiency fracture and failure to thrive. During your initial consultation, you notice a skin ulcer in which the entire thickness of the skin is involved without involvement of the underlying fascia. According to the National Pressure Ulcer Advisory Panel, the patient's ulcer is classified as stage
(a) 1
(b) 2
(c) 3
(d) 4

C

Stage 1: Nonblanchable erythema of intact skin not resolved within 30 minutes; epidermis intact. Stage 2: Partial-thickness skin loss involving the epidermis, possibly into dermis. Stage 3: Full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia. Stage 4: Full-thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures (eg, tendon or joint capsule).

40

In a transtibial amputee, ambulation with a prosthesis, instead of unilateral non-weight bearing (with crutches) results in
(a) higher rate of energy expenditure.
(b) lower heart rate.
(c) higher respiratory exchange rate.
(d) equivalent amounts of energy to walk the same distance.

B

Transtibial amputees have a lower rate of energy expenditure, heart rate and oxygen consumption when using a prosthesis (vs. non-weight bearing crutch gait). The cardiovascular demand of crutch walking is high, with increased rate of oxygen consumption, increased heart rate, increased energy costs, and respiratory exchange rate in the anaerobic range.

41

A negative prognosticator for successful surgical nerve repair after trauma is
(a) partial transection of the nerve.
(b) distal nerve injury.
(c) prior radiation therapy.
(d) nerve repair within 4 months of injury.

C

Negative prognosticators for successful nerve repair include advanced age, nerve injury resulting from dislocation (stretch), delay of repair beyond 5 months, prior radiation therapy, nerve discontinuity (gap) exceeding 2.5cm, proximal nerve injury and poor condition of nerve endings.

42

On examination, a 3-month-old girl still has a Moro reflex, asymmetric tonic neck reflex, and plantar grasp reflex. She does not have any protective extension. You advise her parents that
(a) further diagnostic evaluation is indicated.
(b) she requires a physical therapy evaluation.
(c) she needs a neurology evaluation.
(d) these reflexes are normal reflexes

D

These are normal reflexes in a 3-month-old child. The Moro and asymmetric tonic neck reflexes (ATNR) usually are integrated by approximately 6 months. The plantar grasp reflex is integrated by 12 to 14 months after walking has begun. Protective extension in sitting is seen anteriorly at 5 to 7 months, lateral at 6 to 8 months, and posterior at 7 to 8 months.

43

It is recommended that a patient with a first ischemic stroke who is positive for an antiphospholipid antibody be treated with:
(a) aspirin, 325mg orally daily.
(b) warfarin, with an INR goal of 3.0–3.5.
(c) clopidogrel (Plavix), 75mg orally daily.
(d) ticlopidine (Ticlid), 250mg orally twice daily

A

Patients with a first ischemic stroke and a single positive antiphospholipid antibody test result who do not have another indication for anticoagulation may be treated with aspirin (325mg/day) or moderate-intensity warfarin (INR 1.4–2.8).

44

A 40-year-old man with psoriatic arthritis consults you regarding his hand pain. On examination, you notice that his left index finger is noticeably shorter than all of his other fingers and has extra folds of skin. The most likely diagnosis is
(a) arthritis mutilans.
(b) Auspitz’s sign.
(c) dactylitis.
(d) Jaccoud’s arthritis.

A

Arthritis mutilans is osteolysis of the phalanges and metacarpals, which results in telescoping, or shortening, of the involved digit. It is a highly characteristic feature of psoriatic arthritis. Auspitz’s sign is pinpoint bleeding after scraping a psoriatic plaque. Dactylitis, or “sausage digits,” is a combination of tenosynovitis and arthritis of the distal or proximal interphalangeal joint. Jaccoud’s arthritis is a non-erosive deforming arthritis in systemic lupus erythematosus.

45

A 17-year-old female was involved in a motor vehicle crash 4 months ago. She sustained a shoulder dislocation. Electromyographic studies have confirmed a brachial plexus injury to her posterior cord and indicate nerve continuity. Although she has completed 4 weeks of occupational therapy, she has had no improvement in her strength from baseline. Your next step would be to
(a) reassure the patient and continue to monitor for improvement.
(b) continue occupational therapy for 4 additional weeks.
(c) initiate neuromuscular electrical stimulation to the affected muscles.
(d) refer her to neurosurgery for exploratory surgery.

D

With closed nerve injury as described, early active and passive range of motion exercise of affected joints is begun. The value of electrical stimulation is uncertain. Surgery is done when there is an incomplete loss of function but no improvement over several weeks or no return of function at 2 months for peripheral nerve and 4 months for a brachial plexus injury. The purpose of surgical repair is to improve peripheral nerve recovery and eventual function. Findings at the time of surgery help establish a prognosis. However, the chances of successful surgical repair begin to decline by 6 months after the injury. By 18 to 24 months, the denervated muscles usually are replaced by fatty connective tissue, making functional recovery impossible.

46

A 32-year-old man is admitted to your rehabilitation facility 3 weeks after sustaining a spinal cord injury. The motor (right/left) examination reveals
R Motor L Motor
Deltoids 2 5
Biceps 2 5
Wrist extensor 2 5
Triceps 2 3
Finger flexors 1 1
Intrinsics 1 1
Hip flexors 0 0
Knee extensors 0 0
Dorsiflexors 0 0
Plantarflexors 0 0
Sensory exam reveals intact pinprick and light touch sensation through C4 on the right and C7 on the left. Sensation is absent below C5 on the right and C7 on the left. What is this patient’s ASIA score?
(a) C4 ASIA A
(b) Right C4/ Left C7 ASIA A
(c) C6 ASIA A
(d) Right C4/ Left C7 ASIA B

B

Based on the ASIA classification system revised in 2000, the lowest intact level on the left would be C7 (a motor score ≥ 3/5 with the level above being 5/5). On the right, the ASIA score is determined by the last intact sensory level, which is C4. When motor/sensory scoring differences exist between the 2 sides, then each side should be reported separately. This example indicates that there is no sacral sparing, so it can only be ASIA A

47

What is the target exercise intensity for optimal aerobic training in a healthy, young individual?
(a) Borg rating of perceived exertion 6.
(b) 70%–80% of maximum heart rate.
(c) Borg rating of perceived exertion 20.
(d) 50%–60% of maximum heart rate

B

The target for this individual is 70% to 80% of maximum heart rate. One may use either this value or the Borg scale. The Borg scale ranges from 6 to 20. This person’s goal is Borg 13 (somewhat hard), in the range of 11 to 15 (fairly light to hard).

48

Which of the following is NOT a feature of central autonomic dysfunction in traumatic brain injury in children?
(a) Hypertension
(b) Tachypnea
(c) Rigidity
(d) Hypothermia

D

Central autonomic dysfunction occurs in some children following severe brain injury. It is characterized by hypertension, hyperpyrexia, rigidity, tachypnea, tachycardia, and diaphoresis. Various medications are used to treat this dysfunction, but no studies prove the value of one medication over another.

49

The primary goal of a knee orthosis is to
(a) prevent knee injury in athletes.
(b) control knee instability in the anterior direction.
(c) prevent recurvatum.
(d) decrease the quadriceps force across the knee

C

Knee orthoses are prescribed to prevent genu recurvatum and provide mediolateral stability. They may be used during sports and other activities to provide functional support for an unstable knee or during the rehabilitation phase following injury or surgery on the knee. The use of knee orthoses for the prevention of knee injury in athletes is controversial. The Swedish knee cage prevents recurvatum but permits flexion. The three way knee stabilizer gives good control of structural knee instability in the lateral, medial, and posterior directions.

50

Which statement describes the chronic-pain concept of “central sensitization”?
(a) The evoked response of A-delta fibers to subsequent input is amplified.
(b) The influx of sodium is fundamental to electrical signaling and subsequent generation of action potentials and excitatory postsynaptic potentials.
(c) A complex set of activation-dependent post-translational changes occurs at the dorsal horn, brainstem, and higher cerebral sites.
(d) The so-called “inflammatory soup,” rich in algesic substances, causes a lowering of threshold for activation and subsequent evoked pain.

C

A complex set of activation-dependent post-translational changes occurs at the dorsal horn, brainstem, and higher cerebral sites. Central sensitization is a complex set of activation dependent post-translational changes occurring at the dorsal horn, brainstem, and higher cerebral sites that sensitizes the central nervous system to further perception of pain. Wind-up is an amplified evoked response to repeated afferent inputs at the level of the dorsal horn

51

The most common benign brain tumor in adults is
(a) astrocytoma.
(b) oligoblastoma.
(c) medulloblastoma.
(d) meningioma

D

Meningiomas are the most common benign brain tumor, comprising about 15% of all primary brain tumors.

52

A 66-year-old woman with rheumatoid arthritis is admitted to inpatient rehabilitation following a right total knee arthroplasty (TKA). On her initial day of therapy, she had difficulty walking with her physical therapist. Her medications included methotrexate (Trexall), etanercept (Enbrel), ezetimibe (Zetia), multi-vitamin, calcium with vitamin D, alendronate (Fosamax), acetaminophen/hydrocodone (Norco), and warfarin (Coumadin). Re-examination shows hip flexion 5/5, knee extension 4/5, knee flexion 4/4, ankle dorsiflexion 1–2/5, ankle plantar flexion 5/5. You suspect
(a) sciatic nerve stretch injury.
(b) posterior tibialis tendon rupture.
(c) inadequate pain control.
(d) peroneal nerve injury.

D

Temporary weaknesses of peri-articular muscles typically occurs after knee arthroplasty along with loss of full flexion and extension due to pain, edema, and the procedure itself. Ankle dorsiflexion is not typically weak following TKA and therefore peroneal nerve injury due to a hematoma would be suspected, especially since the patient is on warfarin. This injury requires surgical exploration and decompression. Sciatic nerve stretch injury, posterior tibialis tendon rupture, and inadequate pain control would not present as ankle dorsiflexion weakness.

53

Etidronate disodium (Didronel) is used in the management of heterotopic ossification to
(a) improve range of motion.
(b) reverse immature ossification.
(c) reverse mature ossification.
(d) prevent ossification.

D

Etidronate blocks the late phase of bone formation (mineralization), by preventing the conversion of amorphous calcium phosphate to hydroxyapatite. The drug has no effect on the early phase of ossification

54

A 70-year-old man presents with a 3-month history of numbness in patchy areas over the limbs and torso. His numbness began in the left foot, then the right hand, followed by numbness over the back and all the limbs. He has no complaints of bowel or bladder problems. He has a long history of smoking. His examination reveals normal strength, normal cranial nerve function, but sensation is decreased to pin prick, vibration, and position in the limbs. Deep tendon reflexes are absent. Electrophysiologic studies show normal motor nerve conduction and needle examination of the upper and lower limb muscles. The sensory nerve conduction studies show small or absent responses. Based on this information what test would you order next?
(a) Nerve and muscle biopsies
(b) Radiologic studies to assess for a tumor
(c) Skin biopsy to assess small nerve fibers
(d) Repetitive nerve conduction studies

B

The clinical and electrophysiologic presentation is consistent with a sensory neuronopathy. With no evidence to suggest motor involvement, the numbness is likely a disorder of the dorsal root ganglion. There are only a few distinct disorders associated with acute or subacute cases described by the history and physical in this clinical vignette. They may be part of a paraneoplastic syndrome, connective tissue disorder such as Sjogren’s, a postinfectious condition, pyridoxine intoxication, or as an isolated autoimmune process. In this patient with a history of smoking, a cancer work up would include obtaining anatomic studies of the chest. Biopsies of the nerve, muscle, or skin would not add much to the case. Repetitive nerve conduction studies would be considered if a neuromuscular junction disorder was suspected

55

When an individual is exposed to a stimulus that causes tissue damage, an immediate response occurs that involves withdrawal and/or attempts to escape the stimulus. This reaction is an example of
(a) respondent learning.
(b) operant learning.
(c) cognitive behavioral theory.
(d) trial and error.

B

By successfully avoiding pain (ie, “punishment”), the individual achieves a reduction in pain, thus rewarding the avoidance behavior. The acquisition of pain behaviors may be determined initially by the history of learned avoidance behaviors, called operant learning. Respondent learning is when an aversive stimulus is paired with a neutral stimulus and with repeated exposures over time the neutral stimulus will come to elicit an aversive response (ie, fear)

56

In patients with a traumatic brain injury, which factor suggests a poor prognosis for emergence from unresponsiveness?
(a) Decorticate posturing
(b) Flaccid muscle tone
(c) Conjugate eye movement
(d) Reactive pupils

B

After a traumatic brain injury, the following factors are associated with a better prognosis: younger age, reactive pupils, conjugate eye movement, decorticate posturing, early spontaneous eye opening, absence of ventilatory support, and higher Disability Rating Score on admission. Factors associated with poor prognosis include decerebrate posturing and flaccid muscle tone

57

When using local steroid injections in patients with tendinopathies
(a) injection into the tendon substance is optimal.
(b) minimum interval between injections is 2 weeks.
(c) select the finest needle that will reach the area.
(d) early postinjection local anesthesia is a complication.

C

It is advisable to select the finest needle that will reach the area. The injection should be peritendinous with avoidance of the tendon to prevent rupture. The minimum interval between injections should be at least 6 weeks. Early postinjection local anesthesia is not a complication of steroids, but it will occur if local anesthetic is mixed with the steroid.

58

A 56-year-old woman with myasthenia gravis is in the intensive care unit with urosepsis. Which antibiotic should be avoided in this patient?
(a) Aztreonam (Azactam)
(b) Gentamicin (Garamycin)
(c) Ceftriaxone (Rocephin)
(d) Ciprofloxacin (Cipro

B

The aminoglycoside class of antibiotics is contraindicated in patients with myasthenia and other neuromuscular junction disorders. Most aminoglycosides exert their effect through reducing the number of acetacholine quanta released. Use may lead to a myasthenic exacerbation. Acute uncomplicated pyelonephritis in women can be treated with oral quinolones for 7 to 14 days, single-dose ceftriaxone or gentamicin followed by trimethoprim-sulfamethoxazole, or an oral cephalosporin or quinolone for 14 days as outpatient therapy. For hospitalized patients, therapy consists of parenteral (or oral once the oral route is available) ceftriaxone, quinolone, gentamicin (plus ampicillin), or aztreonam until defervescence. Then, an oral quinolone, cephalosporin, or trimethoprim-sulfamethoxazole for 14 days may be added to complete treatment

59

A 45-year-old woman with advanced acquired immunodeficiency syndrome (AIDS) presents with a gradual onset of forgetfulness and inattention without other focal neurologic deficits. Review of systems is negative for headache and fever. The most likely diagnosis is
(a) toxoplasmosis.
(b) cryptococcal meningitis.
(c) human immunodeficiency virus (HIV) encephalopathy.
(d) central nervous system (CNS) lymphoma.

C

Also known as AIDS-dementia complex, human immunodeficiency virus (HIV) encephalopathy is usually seen late in the disease course. HIV encephalopathy develops in weeks to months, whereas symptoms of toxoplasmosis and central nervous system (CNS) lymphoma are seen in days to weeks. Fever and headache, along with mental status changes, would be seen in cryptococcal meningitis. Headaches, seizures, and fatigue are commonly seen in toxoplasmosis, along with focal or non-focal neurologic signs. In CNS lymphoma, headache, confusion, memory loss, or focal neurologic signs are typically present.

60

The activity established as most predictive of developing a low back disorder is
(a) carrying an object at an increased horizontal distance from the body.
(b) lifting an object repeatedly at 20% less than the individual’s maximum lift capacity.
(c) repetitive sit-to-stand transitions with a weighted back pack.
(d) bending at knees rather than at the waist to lift an object.

A

The work by Marras and colleagues showed that increasing the horizontal distance from the trunk of an object being carried increased the risk of developing a low back disorder. This increase in distance increased the forces consistently on the anterior column of the spine. Although the other options can all place the worker at risk for a low back injury, only the increased carrying distance from the trunk has been shown to be the most predictive of a low back injury.

61

Which term describes a maladaptive pattern of drug use marked by increasing doses to achieve a similar pain relieving effect and a withdrawal syndrome?
(a) Dependence
(b) Addiction
(c) Craving
(d) Tolerance

A

Dependence Dependence is a maladaptive pattern of drug use marked by tolerance and a drug-class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood levels of drug, or administration of an antagonist. Tolerance is a state of adaptation in which exposure to a drug induces changes that result in diminution of 1 or more of the drug’s effects over time. Addiction is a chronic biopsychosocial disease characterized by impaired control over drug use, compulsive use, continued use despite harm, and craving.

62

Which statement is TRUE regarding post-stroke central pain?
(a) Damage to the thalamus plays a central role in the pathogenesis of central pain.
(b) Amitriptyline is the drug of first choice to treat central pain.
(c) 80% of stroke patients with central pain develop the pain within a month of their stroke.
(d) The pain usually resolves spontaneously and does not require medication.

B

The onset of central pain following a stroke occurs more than 1 month after the stroke in 40% to 60% of all patients. The pathogenesis of central pain is still largely a matter of conjecture and hypothesis. It is generally believed that damage to the spinothalamicocortical sensory pathways plays a significant role in the pathogenesis, but central pain can occur with lesions in any part of the brain. Treatment options are limited and at present amitriptyline is the drug of first choice, other drugs, including antidepressants, anticonvulsants, antiarrhythmics, and opioids may provide relief for some patients who do not respond to amitriptyline.

63

A 46-year-old man with a 1-year history of C8 ASIA A spinal cord injury presents to your clinic with a 1-month history of increasing bilateral upper extremity weakness and pain. There is no history of trauma. You would
(a) observe for 2 to 4 weeks and repeat ASIA exam.
(b) perform electrodiagnostic testing to rule out peripheral nerve compression.
(c) order a magnetic resonance imaging study to look for posttraumatic syringomyelia.
(d) initiate a workup for pernicious anemia.

D

Posttraumatic syrinx results in neurologic decline in 3% to 8% of patients with spinal cord injuries and can develop 2 months to 30 years after spinal cord injury. Prompt diagnosis is essential and magnetic resonance imaging is usually definitive for diagnosing posttraumatic syrinx. Surgical treatment is usually indicated when there is clear neurological decline

64

A 58-year-old man sustained a myocardial infarction 1 week ago. He is undergoing phase 1 of cardiac rehabilitation. His activity level should be limited to how many metabolic equivalents (METs)?
(a) 1
(b) 3
(c) 5
(d) 7

C

After a myocardial infarction, exercise intensity should start at 2 metabolic equivalents (METs) and gradually progress to a maximum of 5 METs. Patients should await myocardial infarct healing before vigorous exercise greater than 5 METs is performed, usually within 4 to 6 weeks post infarctioin.

65

What parameter of the motor unit action potential (MUAP) is the most sensitive to the distance between the generator source and recording electrode?
(a) Amplitude
(b) Phases
(c) Firing rate
(d) Duration

A

The amplitude is primarily influenced by the distance between the electrode’s recording surface and the electrical generator. The duration is a highly stable and reliable parameter of the motor unit. The other parameters are not affected by the distance

66

A 2-month-old infant presents to you for evaluation of delayed development. He was the product of a normal term pregnancy, labor, and delivery. Birth weight was 3500 grams. He has had difficulty feeding since birth. Family history is negative for developmental problems. On physical examination, he is awake, but not alert. Weight is 3600 grams. Respiration is unlabored. He has poor head control and decreased tone throughout. Deep tendon reflexes are absent. What is the most likely diagnosis?
(a) Kugelberg Welander syndrome
(b) Duchenne muscular dystrophy
(c) Infantile botulism
(d) Tetraplegic cerebral palsy

D

. This patient illustrates the diagnostic dilemma of the floppy infant. Causes of this problem include central nervous system lesions (both brain and spinal cord), myopathies, neuropathies, and neuromuscular junction problems. This infant has had abnormalities since birth, which argues against infantile botulism. Kugelberg Welander syndrome (also known as spinal muscular atrophy type 3) has onset during childhood, as does Duchenne muscular dystrophy. Tetraplegic cerebral palsy often presents in infancy with floppiness and hyporeflexia, which later change to spasticity and hyperreflexia

67

The primary advantage of mag wheels over spoked wheels in the performance of a wheelchair is
(a) lighter weight.
(b) reduced maintenance.
(c) more maneuverability.
(d) general preference by active wheelchair users.

B

. Although MAG wheels require minimum maintenance and wear well, spoked wheels are substantially lighter, more responsive, and are generally preferred by active wheelchair users.

68

If the L3 and L4 medial branches of the dorsal rami are ablated, the patient will experience blocked afferents from the
(a) L5-S1 facet joint.
(b) L4-5 facet joint.
(c) L3-4 facet joint.
(d) L2-3 facet joint.

B L4-5 facet joint.

The medial branches of the dorsal rami supply innervation to the facet joints and the deep paraspinals, namely the segmental multifidi and rotators. The sacral multifidi are innervated by the sacral (rather than the lumbar) dorsal rami. Each lumbar medial branch innervates the facet joint at and below its derivation. The L4-5 facet joint is innervated by the L3 and L4 medial branches, derived from the L3 and L4 nerve roots.

69

What is one reason for placing a suprapubic catheter in a person with a complete cervical spinal cord injury who currently uses intermittent catheterization?
(a) Decreased rate of bladder/kidney infections
(b) Decreased high bladder pressures
(c) Decreased rate of bladder/kidney stone formation
(d) Reduced risk of developing autonomic dysreflexia

B. Decreased high bladder pressures

The rates of infections and stones are higher with suprapubic catheters. An indwelling catheter results in a slight increased risk of bladder cancer. High internal bladder pressures may occur as a result of detrusor sphincter-dyssynergia and avoiding reflux by allowing continuous drainage can be safer than intermittent catheterization for some individuals.

70

In order to appropriately follow Medicare regulations for teaching physicians, when caring for a patient with a resident physician, the attending physician must
(a) review the chart and personally document his/her level of involvement in patient care, separate from documentation performed by the resident.
(b) examine the patient with the resident and co-sign the resident note.
(c) examine the patient and review the resident’s medical record documentation.
(d) examine the patient, review the resident’s documentation, and personally document involvement in the history, exam, and medical decision-making.

D

. In order to appropriately follow Medicare regulations for teaching physicians, when caring for a patient with a resident physician, the attending physician must see the patient, review the medical record documentation of the resident, and personally document involvement in key aspects of the history, exam, and medical decision-making. Documentation from the resident alone does not confirm the level of attending physician involvement. The attending physician documentation combined with the resident documentation can be used to determine the level of care provided and the appropriate level of billing.

71

The most common musculoskeletal abnormalities seen in a child with L5 myelodysplasia with sparing of the L5 segment and above are
(a) cavus foot, early hip dislocation, hip and knee flexion contractures.
(b) calcaneus foot, late hip dislocation, hip and knee flexion contractures.
(c) cavus foot, late hip dislocation, hip adduction contractures.
(d) calcaneus foot, early hip dislocation, hip adduction contractures.

B. calcaneus foot, late hip dislocation, hip and knee flexion contractures.

The child with L5 myelodysplasia typically has late hip dislocation, calcaneus foot, hip flexion contractures, and may have either knee extension or flexion contractures, depending on whether quadriceps (L2-4) or hamstrings (L4-S1) are stronger. Gluteus medius (hip abductor, L4-S1) and hip adductors (L1-3) are innervated higher than L5 and are typically balanced in L5 myelodysplasia. Late hip dislocation is due to either unbalanced hip musculature or spinal deformities.

72

Which spinal level has the greatest depth of posterior epidural space?
(a) C3-4
(b) C4-5
(c) C5-6
(d) C6-7

D

The C6-7 and C7-T1 epidural levels have the greatest amount of space. Interlaminar epidural injections should be performed with caution in the spaces that have a smaller diameter, such as those at stenotic levels or high cervical levels. Practitioners should also be aware that the ligamentum flavum may have defects in a high percentage of individuals.

73

Which muscle fiber is characterized by fast-twitch oxidative metabolic properties?
(a) Type 1
(b) Type 2a
(c) Type 2b
(d) Type 3

B. Type 2a Humans have 2 primary types of muscle fiber.

They are divided according to many different characteristics, including speed of contraction and sources of fuel. Type 1 muscle fibers are slow-twitch with oxidative metabolic pathways. Type 2 muscle fibers are fast-twitch fibers. The type 2 fibers can then be further divided into fast-twitch oxidative (type 2a) and fast-twitch glyclolytic (type 2b). There are no muscle fibers designated as type 3.

74

A 45-year-old woman with fibromyalgia presents to you with complaints of poor sleep. She notes that she has no trouble falling asleep but has a difficult time staying asleep. She has improved her sleep hygiene and eliminated caffeine from her diet. Which medication would you recommend?
(a) Diazepam (Valium)
(b) Eszopiclone (Lunesta)
(c) Chloral hydrate
(d) Fluoxetine (Prozac)

B. Eszopiclone (Lunesta)

Patients with trouble initiating sleep may require shorter acting medications, while those with fragmented sleep and frequent awakenings may more ideally benefit from medications with an intermediate to long half-life. A third nonbenzodiazepine hypnotic, eszopiclone, is FDA approved for long-term management of insomnia and retains a greater half life (5h–5.8 hours) with evidence of greater sleep maintenance efficacy as compared to the current relatively shorter half-life Z-drugs.

75

A patient with a recent stroke and hemiplegia presents to your clinic and is noted to have a genu recurvatum gait pattern. An aggressive stretching program has improved ankle range-of-motion, but not her spasticity and gait. The most appropriate treatment is
(a) an ankle foot orthosis with 5º of plantarflexion.
(b) Achilles tendon lengthening.
(c) phenol motor point injection to the hamstrings.
(d) botulinum toxin injection to the gastrocsoleus muscle group.

D. botulinum toxin injection to the gastrocsoleus muscle group.

Genu recurvatum is a common atypical gait pattern in patients with upper motor neuron pathology. It may be caused by ankle plantarflexor spasticity, heel cord contracture, quadriceps weakness, or spasticity and a combination of the above impairments. In this case an ankle foot orthosis with 5º of plantarflexion would worsen the gait. A tendon lengthening would be aggressive and more conservative management should be attempted first. A phenol motor point injection to the hamstrings would make knee control more problematic. Botulinim toxin can be very helpful for focal spasticity and can decrease ankle plantarflexor spasticity and decrease the backward force at the knee.

76

For an individual who has C5 tetraplegia, orthotic splinting attempts to maintain the functional position of the hand. This usually includes
(a) closing the thumb web space.
(b) 30º to 40º of metacarpophalangeal flexion.
(c) promoting flattening of the palmar arch.
(d) supporting the wrist in 20º to 30º of extension.

D. supporting the wrist in 20º to 30º of extension.

The functional position of the hand includes supporting the wrist in 20º to 30º of extension, supporting the palmar arch with the 4th and 5th metacarpals slightly anterior to the second and third digits. Metacarpophalangeal flexion of 30° to 40° would be excessive. The thumb web space should be preserved

77

Standing at ease is equivalent to how many metabolic equivalents (METs)?
(a) 1.5 to 2.0
(b) 2.5 to 3.0
(c) 4.0 to 4.5
(d) 5.0 to 5.5

A

. Lying quietly is 1.0 MET. Light housework is 1.2-3.0 METs. Standing at ease is 1.4-2.0 METs. Walking at 3 miles per hour is equivalent to 4.3 METs

78

Which condition is a cumulative trauma disorder that has been associated with intensive computer use?
(a) Herniated thoracic disc
(b) Shoulder adhesive capsulitis
(c) Post-traumatic stress syndrome
(d) Cervical myofascial pain

D. Cervical myofascial pain

The United States Department of Labor has determined that computer work is associated with a significant number of musculoskeletal disorders, many of which are considered cumulative trauma disorders. Examples include cervical and thoracic myofascial pain, rotator cuff tendonitis, medial and lateral epicondylitis, de Quervain tenosynovitis, and carpal tunnel syndrome

79

An unusually high incidence of pressure ulcers is noted on your inpatient rehabilitation unit. As the medical director for the unit, you decide to implement a quality improvement process. The next best step in process would be to
(a) understand the cause of the skin breakdown.
(b) select a strategy to decrease the incidence of pressure ulcers.
(c) organize a team to investigate the problem.(
d) reprimand the nurse manager for the unit.

C. organize a team to investigate the problem.

Various strategies can be used when implementing a quality improvement process. One widely accepted method is FOCUS PDCA. The steps in the process include finding an opportunity, organizing the team, clarifying the current process, understanding the causes of the variation, and selecting a strategy to implement it (FOCUS). Once this has been accomplished, then the strategy involves planning, doing, checking, and acting (PDCA). According to this process, the next best step in the scenario provided would be to organize a team to investigate the problem

80

Which statement describes an advantage of a single-subject research design (that is, A-B-A or multiple baseline design)?
(a) It can account for variability between subjects.
(b) It permits medication trials with no washout period.
(c) It can establish cause and effect relationships.
(d) It is useful for interventions with prolonged or extended effects.

C. It can establish cause and effect relationships.

An advantage of a single-subject research design (A-B-A design) is that this design can establish cause and effect relationships similar to other true experimental designs. Single subject research designs involve systematic, repeated measurement of a dependent variable over time through 1 or more baseline and intervention phases. The primary limitation with a single-subject research design is that it only establishes the cause and effect relationship for the subject involved in the study. Therefore, these results cannot be assumed to occur in others, because of the variability between subjects. Typically, a single subject research design requires a washout period between medication trials to ensure that the effects of the medication are no longer active. Single subject research designs are especially useful for interventions that do not have extended or prolonged effects. If the intervention has only short-term effects, then a difference in the outcome measured can be clearly demonstrated by comparing results when the intervention is in use against results obtained when it has been removed.

81

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

A. Pain is characterized by allodynia.

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 is an exaggerated pain response (ie, hyperesthesia) in response to a non-noxious stimulus or to vascular changes such as those indicated by paleness and coolness or by 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 with CRPS have a better prognosis than adults.

82

Effects of prolonged bed rest include
(a) increased maximum oxygen consumption.
(b) increase of plasma volume.
(c) decreased resting heart rate.
(d) decreased cardiac stroke volume.

D. decreased cardiac stroke volume.

Prolonged bed rest has detrimental effects, which include an increased resting heart rate, loss of plasma volume, decreased cardiac stroke volume, and decreased maximum oxygen consumption.

83

Performing a leg press exercise is an example of an
(a) open kinetic chain exercise.
(b) closed kinetic chain exercise.
(c) isokinetic exercise.
(d) isometric exercise.

B. closed kinetic chain exercise.

Open kinetic chain exercise occurs when the most distal segment is not in contact with a surface (eg, leg extensions). Closed kinetic chain exercise occurs when the most distal segment is in contact with a surface (eg, a leg press). In isokinetic exercise a muscle contracts with a constant angular velocity and variable resistance. In isometric exercise a muscle contracts against an immovable object and there is no joint angular movement.

84

Professionalism is the basis of medicine’s contract with society. Which item is a fundamental principle of medical professionalism?
(a) Social justice
(b) Physician paternalism
(c) Patient disclosure
(d) Free enterprise

A. Social justice

According to the Charter on Medical Professionalism, there are 3 fundamental principles of medical professionalism. They are (1) the primacy of patient welfare, (2) patient autonomy, and (3) social justice.

85

Preventable medical errors are
(a) rarely associated with significant morbidity.
(b) most commonly a result of individual human error.
(c) associated with no impact on patient satisfaction..
(d) associated with patients’ loss of trust in the health care system.

D. associated with patients’ loss of trust in the health care system.

Preventable medical errors can result in lower levels of patient satisfaction and loss of trust in the health care system. Preventable medical errors often result in significant morbidity and even mortality. Estimates are that 44,000 to 98,000 people die each year as a result of medical errors that could have been prevented. These errors are frequently the result of system type errors rather than individual human error.

86

Your co-resident presents an article in journal club on a new medication and its impact on outcomes following traumatic brain injury. On which point would you NOT need assurance before you decide to use this medication in your clinical practice?
(a) That the research study results are clinically significant
(b) That bias was eliminated from the study
(c) That the research study results are statistically significant
(d) That research investigators used valid outcome measures

B. That bias was eliminated from the study

When critically evaluating the medical literature, it is important to consider if the results of the study are both clinically and statistically significant. It is also important to consider whether the outcome assessment tools have been validated for both accuracy and reliability. While biases that may impact the outcome of the study also must be considered, it is often impossible to completely eliminate bias from the study

87

Which statement is TRUE about the relative responses of the brain and the spinal cord after concussive trauma?
(a) The brain is more sensitive to trauma than the spinal cord.
(b) The spinal cord is more sensitive to trauma than the brain.
(c) The brain and the spinal cord are equally sensitive to trauma.
(d) The brain’s neurologic recovery is less predictable than the spinal cord’s in its response to a given amount of trauma.

B. The spinal cord is more sensitive to trauma than the brain.

Concussive injuries of the spinal cord are more varied in gradation than injuries to the brain. Seemingly mild spinal concussions, seen most frequently in cervical hyperextension, may lead to complete tetraplegia, even in the absence of penetration of the spinal canal or even vertebral fracture. Mild concussive trauma to the brain results in a more mild brain injury and a more severe concussive trauma to the brain results in a more severe neurologic dysfunction.

88

A 70-year-old woman presents with a cemented right total hip arthroplasty. She is partial weight bearing and struggling with physical therapy. The therapist asks to use ultrasound to the right hip to help with bone healing and ultimately progress the patient to weight bearing as tolerated. You advise
(a) yes, because ultrasound helps with bone healing.
(b) no, because ultrasound near arthroplasties is contraindicated.
(c) yes, because the heat may help with pain management.
(d) no, because ultrasound is expensive to use.

B. no, because ultrasound near arthroplasties is contraindicated.

Ultrasound is typically an inexpensive treatment that may help with pain and bone maturation, however, it is contraindicated near arthroplasties and therefore not a good treatment in this case. Further contraindications include use of ultrasound: near pacemaker, near spine or laminectomy site, near brain, eyes, or reproductive organs, is someone with malignancy or skeletal immaturity, or near sites where methyl methacrylate was applied.

89

Electromyographic biofeedback for stroke patients is most beneficial when
(a) proprioception is preserved.
(b) used in the upper limb.
(c) the patient is young.
(d) the patient has flaccid paralysis

A. proprioception is preserved.

Hemiplegic stroke patients engaged in electromyography biofeedback training have a better functional outcome with lower extremity training than with upper extremity training. Further, their age and the duration of their hemiplegia have no effect on training outcome. Proprioceptive loss of the upper limb decreases the probability of making functional gains. Motivation by the patient is a necessity and is most beneficial when some voluntary activity is present.

90

Five weeks after sustaining a T6 complete spinal cord injury, your patient is noted to have new urinary incontinence with intermittent catheterization volumes of less than 150cc. Work-up is negative for a urinary tract infection. You consider starting
(a) tamsulosin (Flomax).
(b) tolterodine (Detrol).
(c) terazosin (Hytrin).
(d) bethanechol (Urecholine).

B. tolterodine (Detrol).

The patient is likely developing spontaneous detrusor contractions. You would consider using an anticholinergic agent to decrease detrusor (and hence bladder) pressures. Ideally, you would obtain urodynamic studies to ascertain bladder pressures and detrusor-sphincter coordination and would use these findings to guide treatment.

91

Which method of paraffin bath heats the subcutaneous area to a greater degree?
(a) Dipping method
(b) Continuous method
(c) Wrap method
(d) Paint on method

B. Continuous method Paraffin bath use has many methods.

The dipping method increases subcutaneous temperatures by 3o Celsius, and the intra-articular temperature by 1o Celsius. The continuous method increases the subcutaneous temperature by 5o Celsius and the intramuscular area by 3º Celsius. The paint on method heats the subcutaneous area less than the dipping method. There is no formal wrap method

92

Which statement accurately characterizes a meta-analysis?
(a) It summarizes the results of randomized controlled trials.
(b) It summarizes the findings of an expert panel.
(c) It groups research on a particular topic area into 3 tiers.
(d) It summarizes findings of a single research protocol that is carried out a multiple centers.

A

A meta-analysis summarizes the results of randomized controlled trials on a particular topic or research question. A consensus statement summarizes the findings of an expert panel. In developing a consensus statement and reviewing the literature, research studies are typically divided into 3 tiers based on the type of research performed. A multi-center study implements a particular research protocol at multiple centers at different institutions.

93

Practice-based learning and improvement is considered by the Accreditation Council of Graduate Medical Education (ACGME) to be an aspect of medical practice in which all physicians need to achieve and maintain competency. Which characteristic is NOT a key aspect of practice-based learning and improvement?
(a) The ability to locate, appraise, and assimilate evidence from scientific studies related to their clinical practice
(b) The ability to access and use information technology to support their own education
(c) The ability to apply knowledge of study designs and statistical methods to the appraisal of medical literature
(d) The ability to advocate for quality patient care and assist patients in dealing with system complexities

D. The ability to advocate for quality patient care and assist patients in dealing with system complexities

All of the options listed are key aspects of practice-based learning and improvement, with the exception of the ability to advocate for quality patient care and assist patients in dealing with system complexities. This statement is a key aspect of systems-based practice as defined by the Accreditation Council of Graduate Medical Education.

94

An exclusion criterion for resistance training in patients with stable cardiac disease is
(a) peak exercise capacity at 7 metabolic equivalents (METs).
(b) prior history of a stroke.
(c) controlled hypertension.
(d) severe valvular disease.

D. severe valvular disease.

Exclusion criteria for resistance training in stable cardiac patients include congestive heart failure, severe valvular disease, poor left ventricular function, uncontrolled dysrhythmias, and peak exercise capacity under 5 METs

95

Which treatment has NOT been shown to improve epicondylitis?
(a) Low intensity laser irradiation
(b) Wrist extension strengthening exercises
(c) Acupuncture
(d) Extracorporeal shock-wave therapy

A

Wrist strengthening, acupuncture, and shock wave therapy all help in the treatment of epicondylitis. However, low intensity laser treatment is not proven beneficial

96

The Commission on Accreditation of Rehabilitation Facilities (CARF)
(a) requires mandatory surveys of all inpatient rehabilitation facilities.
(b) provides accreditation status that confers a preferred status with payors.
(c) provides accreditation status that signifies the rehabilitation facility holds itself to the highest standards in the field.
(d) provides accreditation for comprehensive inpatient rehabilitation programs, but not specialty programs in areas such as spinal cord injury.

C. provides accreditation status that signifies the rehabilitation facility holds itself to the highest standards in the field.

The Commission on Accreditation of Rehabilitation Facilities (CARF) provides accreditation status that signifies the rehabilitation facility holds itself to the highest standards in the field. CARF accreditation is voluntary and not all inpatient rehabilitation facilities participate. Accreditation by CARF does not confer any preferred status with payors, and CARF provides accreditation in general comprehensive inpatient rehabilitation as well as specialty programs such as spinal cord injury and traumatic brain injury.

97

Investigators must address ethical considerations when designing and implementing research studies. One such consideration requires investigators to design protocols that will provide generalizable knowledge and ensure that the benefits of the research are proportionate to the risks assumed by the subjects. This ethical consideration is referred to as
(a) respect.
(b) beneficence.
(c) justice.
(d) autonomy.

B. beneficence.

Beneficence requires investigators to design protocols that will provide generalizable knowledge and ensure that the benefits of the research are proportionate to the risks assumed by the subjects

98

In instances where a researcher has financial investments in a company and is researching the effectiveness of one of the company’s products, the researcher is obligated to
(a) terminate the investigation if the investigational agent is found to be not effective.
(b) disclose this involvement in writing to subjects that are being enrolled in the study.
(c) end financial involvement in the company before the results of the research are revealed to the public.
(d) disclose this involvement to the investigator's medical center, to funding organizations, and to journals publishing the results

D. disclose this involvement to the investigator's medical center, to funding organizations, and to journals publishing the results.

Conflicts of interest in biomedical research are becoming more apparent as private companies increasingly develop relationships with academic research scientists. Avoidance of real or perceived conflicts of interest in clinical research is necessary if the medical community is to ensure objectivity and maintain individual and institutional integrity. Financial investments should only transpire outside of the time that the investigator is involved in any research activity and the results of the research are known to the public. If conflicts of interest exist, the investigator is obligated to disclose this involvement in writing to the investigator's medical center, organizations funding the research, and anytime that the research is presented or published.