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Flashcards in SAER 2008 Deck (100):

The most common clinical manifestation of Lyme disease is
a) monoarticular or oligoarticular arthritis.
b) facial-nerve palsy.
c) atrioventricular block.
d) erythema migrans


Erythema migrans (EM) is a skin lesion that is erythematous, and may be round or oval, flat or raised, and possibly have central clearing. Of persons with untreated EM, sixty percent will have monoarticular or oligoarticular arthritis. Ten percent will have a neurologic presentation, such as facial-nerve palsy. Approximately 5 percent will have a cardiac manifestation such as atrioventricular block.


You are consulting on a 28-year-old woman with metastatic cervical cancer. She is married with one young child. At this time, she requires minimum to moderate assistance with her mobility and activities of daily living. The oncology service is debating whether to discharge the patient to home with hospice care or to give her inpatient rehabilitation. You inform them that acute inpatient rehabilitation
a) improves function and quality of life despite the patient being at the end of her life.
b) is too much of a physical demand for her and agree with hospice care.
c) takes time away from the patient being with her family, so hospice is preferable.
d) will help the patient to some extent, but not as much as a patient without cancer.

A. improves function and quality of life despite the patient being at the end of her life.

When consulted on a patient with cancer, the physiatrist must balance the need to maximize the patient’s independence through rehabilitation with the desire to have the patient return home as soon as possible. Inpatient rehabilitation is useful to improve the patient's quality of life. Functional gains have been demonstrated to be significant and comparable to those gained by patients without cancer. The presence of metastatic disease does not influence functional outcome and should not preclude participation.


Cyclobenzaprine is a medication that is used to treat acute musculoskeletal pain. While the exact mechanism of action is unknown, its structure and side effects are similar to what class of drug?
a) Central alpha2-adrenergic agonist
b) Tricyclic antidepressant agent
c) Antihistamine
d) γ-aminobutyric acid agonist

B. Tricyclic antidepressant agent.

Cyclobenzaprine is structurally similar to tricyclic antidepressants and was first studied as an antidepressant. While its exact mechanism of action is unknown, it is presumed to work at the level of the brainstem or higher with a generalized sedative effect. Tizanidine is a central alpha2-adrenergic agonist. Orphenadrine is an antihistamine. Benzodiazepines, such as diazepam, and baclofen are γ-aminobutyric acid agonists.


You are asked to evaluate a 1-year-old patient who is not yet walking but is developmentally appropriate. Which reflex would you expect to find?
a) Asymmetric tonic neck
b) Symmetric tonic neck
c) Palmar grasp
d) Plantar grasp

D. plantar grasp

The asymmetric tonic neck reflex (ATNR) and symmetric tonic neck reflex (STNR) are usually integrated by 6 to 7 months. Palmar grasp disappears by 5 to 6 months. Plantar grasp is integrated when walking is achieved. The normal age of walking varies, but may be as late as 18 months.


Individuals with diabetes are at high risk of amputation despite ankle pressures greater than 55 mmHg because
a) the ankle brachial pressure index must be greater than or equal to 0.3 to prevent limb threatening ischemia.
b) ankle pressures seldom correlate with severity of symptoms and are unreliable.
c) calcification of the arterial media results in a spuriously high pressure.
d) transcutaneous oxygen partial pressures and not ankle pressures correlate with ischemia.

C. calcification of the arterial media results in a spuriously high pressure.

In patients with diabetes, amputation is a strong possibility, even with ankle pressures higher than 55 mmHg because spuriously high pressures can be present in these patients as a result of calcification of the arterial media. The ankle brachial pressure index (ABPI) is the patient’s brachial pressure compared to the ankle pressure. A resting ABPI greater than 1.0 is considered normal. Patients with intermittent claudication have an ABPI in the range of 0.5 to 0.7, and patients with rest pain or other symptoms of severe ischemia have an ABPI of less than or equal to 0.3. A pressure less than 50 mmHg at the ankle is associated with limb threatening ischemia.


An 11-year-old baseball player presents to your clinic complaining of elbow pain. X-rays of the affected side reveal an 8-mm separation of the medial epicondyle. What should be the next step in management?
a) Relative rest for at least 6 weeks
b) Long arm cast for at least 4 weeks
c) Refer to pediatric orthopedic surgeon
d) Physical therapy for strengthening

C. Refer to pediatric orthopedic surgeon.

"Little league elbow," seen in throwing athletes with immature skeletons, is a conglomeration of different diagnostic entities caused by valgus and extension-overload. Medial epicondylar avulsion can frequently occur. Separation from 3--5mm can be managed nonsurgically. However, separations greater 5mm usually require surgery.


Which of the brain tumors listed is a benign tumor?
a) Medulloblastoma
b) Astrocytoma
c) Glioblastoma
d) Craniopharyngioma

d) Craniopharyngioma

The only benign brain tumor listed is craniopharyngioma


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. muscle symptoms with creatine kinase elevation.

Myopathy refers to a disease or an 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.


Based on the revised edition of the American Spinal Injury Association (ASIA) Impairment Scale, published in 2000, which condition would be sufficient to categorize a spinal cord injury as motor incomplete?
a) Some motor function more than 1 level below the motor level
b) Voluntary anal sphincter contraction
c) A well-defined zone of partial preservation
d) An anterior spinal artery syndrome

B. Voluntary anal sphincter contraction.

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


Lambert-Eaton myasthenic syndrome is most commonly associated with cancer in the
a) prostate.
b) breast.
c) lung.
d) brain.

C. lung.

Lambert-Eaton myasthenic syndrome is most commonly associated with small-cell lung cancer, but it may also be seen in kidney and rectal cancer, malignant thymoma, basal cell carcinoma, and leukemia.


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) check 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. continue the medication with close monitoring of the creatine kinase levels.

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 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.


A 24-year-old man with T6 complete paraplegia whose injury occurred 16 weeks ago. He is concerned he can no longer reach down to put on and tie his right shoe. Upon evaluation, he has significant loss of range of motion in the right hip with mild warmth at the hip. There is no swelling at the knee, lower leg, ankle, or foot. The most likely diagnosis is
a) hip dislocation.
b) deep vein thrombosis.
c) heterotopic ossification.
d) iliopsoas abscess

C. heterotopic ossification.

Heterotopic ossification (HO) may develop as early as 17 days after a neurologic injury. However, it typically takes up to 6 weeks to begin to mineralize and decrease range of motion at the affected joint. Persons with spinal cord injury are prone to develop HO below their level of injury. This patient’s progressive loss of range of motion accompanied by a loss of function points toward HO. With no history of trauma, early fracture is unlikely, lack of systemic signs such as fever render an abscess unlikely, and with a deep vein thrombosis (DVT) one would expect edema distal to the clot. Persons with spinal cord injury are at highest risk for DVT within the first 6 to 8 weeks after injury.


A patient with a history of cancer treated with chemotherapy complains that her feet feel swollen, cold, and painful. The pain is described as shooting and is rated 10/10. On examination, there is no swelling and no temperature changes, but there is hypesthesia and dysesthesia. Of the following choices, which is the most appropriate pain management for this patient?
a) MS Contin (extended release morphine sulfate) 15 mg every 12 hours
b) Prednisone taper starting at 60 mg daily
c) Neurontin (gabapentin) 300 mg 3 times a day
d) Naprosyn (naproxen) 500 mg twice daily

C. Neurontin (gabapentin) 300 mg 3 times a day.

Many chemotherapeutic agents can cause a peripheral neuropathy. Treatment for neuropathic pain includes membrane-stabilizing medications such as Neurontin. Opiates like MS Contin and non-steroidal anti-inflammatory drugs (NSAIDs) like naproxen are not the first line treatment for neuropathic pain. Prednisone is appropriate for complex regional pain syndrome (CRPS), but CRPS is not common in cancer patients after chemotherapy. Further, this patient probably does not have CRPS, considering the absence of swelling, color changes, or temperature changes.


A 50-year-old construction worker has received a 30% whole person impairment rating because of his pericardial heart disease. According to the fifth edition of the American Medical Association Guides to the Evaluation of Permanent Impairment, this worker’s status indicates that
a) he is 100% disabled from performing his work activities.
b) his general functioning and ability to perform activities of daily living is reduced by 30%.
c) he has a 30% reduction in work capability.
d) he should receive 30% of his future wages and benefits in a disability payment.

B. his general functioning and ability to perform activities of daily living is reduced by 30%.

According to the AMA guides, a 30% whole person impairment rating indicates a 30% reduction in general functioning, excluding work. The whole person impairment rating does not directly correlate to the patient’s work abilities and it does not determine the disability compensation.


A 14-year-old girl is sent to you for electrodiagnostic evaluation of a left foot drop. The mother reports that the left foot drop has been present for about 2 months and that her daughter has lost about 40 pounds in the last 6 months. Nerve conduction studies and needle electromyography show the following data:

Motor NCS
L peroneal: Ankle amplitude of 1
NR on above knee

Sensory NCS
L superficial peroneal: NR

Needle Electromyography
L Tibial anterior: reduced recruitment (abN spontaneous activity at 3+)
L peroneus longus: reduced recruitment (abN spontaneous activity at 2+)

The patient’s symptoms are most likely due to left
a) peroneal nerve injury at the fibular head.
b) deep peroneal nerve injury.
c) sciatic nerve injury.
d) lumbosacral plexopathy.


The electrophysiologic findings are consistent with common peroneal nerve compression at the fibular head. The normal study of the short head of the biceps femoris points to a lesion distal to the innervation of this muscle, and hence a lesion at or below the level of the knee. Lack of involvement of muscles innervated by other nerves points away from a plexopathy or sciatic nerve injury. Excessive weight loss can often be a factor in patients with peroneal nerve compression lesions.


The most common reason for prescribing a plastic leaf-spring ankle-foot orthosis is to
a) overcome ankle spasticity.
b) reduce lower-extremity edema.
c) prevent plantar flexion deformity.
d) support weak ankle dorsiflexors

D. support weak ankle dorsiflexors.

A plastic leaf-spring orthosis (PLSO) is probably the most commonly prescribed type of ankle-foot orthosis (AFO). It substitutes for weak ankle dorsiflexors and provides some medial lateral stability. Severe spasticity of the ankle may require prescription of a solid AFO. A plastic spiral AFO may be prescribed for concomitant weakness of both the ankle dorsiflexors and plantar flexors when spasticity is absent.


A 67-year-old man with Parkinson disease is experiencing more falls. These falls usually occur shortly after getting up in the morning, or after a large meal. You suspect his falls are due to
a) vestibular dysfunction.
b) orthostatic hypotension.
c) increased lower extremity weakness.
d) increased rigidity

B. orthostatic hypotension.

The majority of patients with Parkinson disease experience orthostatic hypotension (OH) as the disease progresses. The patient’s history suggests falls related to postural changes and situations that lower blood pressure. Educating your patient to avoid or mitigate these situations (slow postural changes, small meals, and avoidance of high heat exposure and alcohol) is the best initial treatment.


The most significant risk factor for continued structural destruction of the knee in osteoarthritis is
a) joint malalignment.
b) obesity.
c) prior surgery.
d) occupational bending and lifting.


Joint malalignment is the most significant risk factor for further joint deterioration, since it creates uneven focal loading.


Cognitive deficits are common in
a) Duchenne muscular dystrophy.
b) inclusion body myositis.
c) fascioscapulohumeral dystrophy.
d) Becker muscular dystrophy.


A brain isoform of dystrophin exists and there are documented mildly decreased Intelligence Quotient scores in people with Duchenne muscular dystrophy. These lower scores may be specific to deficits with tasks requiring attention to complex verbal information.


Which statement is correct regarding the management of labor and delivery for women with cervical spinal cord injuries?
a) Pre-eclampsia is 3 times more likely to occur than in able-bodied women.
b) Vaginal delivery is contraindicated.
c) Autonomic dysreflexia occurs 60%--80% of the time.
d) Spinal and epidural anesthesia are contraindicated

C. Autonomic dysreflexia occurs 60%--80% of the time.

Women with paraplegia or tetraplegia can give birth vaginally and caesarean delivery is rarely necessary. Patients with neurologic levels above T6 are at risk for autonomic dysreflexia during pregnancy, labor, and delivery. Autonomic dysreflexia is reported to occur in 60% to 80% of women with SCI with lesions above T6. Preeclampsia occurs with the same frequency in able-bodied women and women with disabilities. Complications from autonomic dysreflexia may be severe and include encephalopathy, cerebrovascular accidents, death of the mother, and severe fetal asphyxia. Spinal or epidural anesthesia extending to the T10 level is the treatment of choice and the most reliable method of preventing and treating autonomic dysreflexia during labor and delivery.


In assisting patients returning to their previous level of work, work hardening programs can achieve return-to-work rates of
a) less than 25%.
b) 25%--49%.
c) 50%--75%.
d) more than 75%.

D. more than 75%.

Return-to-work rates of 77% can be achieved with work hardening programs. Poor outcome was associated with an increased number of treatments before the program, an increased length of time off from work; the patient's having lower satisfaction with the program, and a lawyer being involved in the case.


gambaran gelombang EMG, mulai defleksi sampai batas akhir hampir 2 kotak
@kotak = 10 ms

What is the total duration of the motor unit action potential shown above?
a) 8 ms
b) 12 ms
c) 18 ms
d) 22 ms

C. 18 ms.

The total duration of a motor unit is measured from the initial deflection from baseline to the final return to baseline.


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

B. Sacroiliitis.

Spondylonegative spondylarthropathies, such as psoriatic arthritis, are often associated with sacroiliitis. The Gelling phenomenon, characterized by stiffness after prolonged immobility, occurs with many inflammatory arthropathies.


During the initial, acute evaluation of a young spinal cord injury patient, which factor would make you suspicious of a concomitant brain injury?
a) Fall as the mechanism of injury
b) Female patient
c) Higher level spinal cord injury
d) African-American patient

C. Higher level spinal cord injury .

The following factors, evidenced at the time of a spinal cord injury, place an individual at higher risk for a concomitant traumatic brain injury: Male sex and a higher level of spinal cord injury. Up to the age of 74 years-old, a transportation accident is the major source of traumatic brain injury (TBI) and not falls. Studies have shown a potential relationship between race and the incidence of TBI, but there are too many confounding variables and no study has shown a clear evidence of a relationship.


A forty-year-old woman with rheumatoid arthritis (RA) complains of right wrist pain that limits her ability to use her computer and phone at work as a computer analyst. On exam, she has metacarpal phalangeal ulnar deviation, wrist radial deviation, and several boutonniere deformities in her fingers. There is no active synovitis. You suggest occupational therapy and
a) oral prednisone.
b) short forearm cast.
c) a resting wrist orthotic.
d) finger splints.

C. a resting wrist orthotic.

Resting wrist splints provide light support for a painful joint and are well tolerated. They are the most commonly prescribed orthotic in RA.


All hereditary sensory motor neuropathies are characterized by
a) decreased Intelligence Quotient scores.
b) absent spinal deformities.
c) muscle weakness.
d) joint contractures.

C. muscle weakness.

All types of hereditary sensory motor neuropathies (HSMN) are characterized by weakness. The residual muscle force in the later stages of disease is 20%--40% less than normal. Intelligence Quotient reduction, significant joint contractures, pulmonary/cardiac abnormalities and spinal deformities are not typical of these diseases.


If a man injures his low back while on the job and is off work for 6 months, then the chance that he will return to work is
a) 25%.
b) 35%.
c) 50%.
d) 75%.

C. 50%.

There is about a 50% chance of return to work when a worker who injures his low back on the job is off work for 6 months. The rate drops to 25% when the worker is off for 1 year, and is minimal is he is off for 2 years.


Acquired subluxation or dislocation of the hips in spastic cerebral palsy is usually due to muscular imbalance with excessive tone of which muscles?
a) Hip flexors and tensor fascia lata
b) Hip flexors and hip adductors
c) Rectus femoris and hip abductors
d) Tensor fascia lata and hip extensors

B. Hip flexors and hip adductors.

Progressive changes associated with hip subluxation in patients with cerebral palsy result from the effects of neuromuscular imbalance on the growth and development of the hip joint. The primary problem is spasticity and muscular imbalance, and the musculoskeletal manifestations are secondary. Soft tissue abnormalities include a muscular imbalance between the stronger flexors and adductors, and the weaker extensors and abductors. A flexion-adduction contracture also shifts the center of rotation of the hip from the femoral head to the lesser trochanter, and the proximal femur is gradually displaced upward and outward.


A 19 year-old male is seen after a traumatic brain injury. The patient’s mother is at the bedside and is asking you questions about the patient’s prognosis for recovery. As you consider your response, which statement is TRUE?
a) Severe disability is unlikely if the length of coma is less than 1 month.
b) Good recovery is unlikely if posttraumatic amnesia (PTA) lasts longer than 3 months.
c) An initial Glasgow Coma Scale score of less than 8 is associated with a poor outcome.
d) Neuroimaging studies are not helpful to determine a patient’s prognosis.

B. Good recovery is unlikely if posttraumatic amnesia (PTA) lasts longer than 3 months.

Multiple studies have shown that age, initial Glasgow Coma Scale (GCS) score, duration of coma, duration of posttraumatic amnesia (PTA), and neuroimaging findings are correlated with outcome. All provide valuable information that the clinician can use to mark milestones, and help with prognosis, but the most powerful of these is the duration of PTA. The longer the duration of the PTA, the worse the outcome. It is unlikely for a person with PTA lasting less than 2 months to have a serious disability; however, the likelihood of a good recovery is poor if the PTA extends beyond 3 months. Length of coma is determined by the time from coma onset to the time when the patient can follow commands. On average only 7%--8% will make a good recovery if the coma lasts longer than 4 weeks, and severe disability is unlikely if the coma lasts less than 2 weeks. Although the GCS score provides a general idea about the severity of the injury, it does not by itself yield a definitive prognosis.


The arthropathy in persons with systemic lupus erythematosus (SLE) generally is in the wrists, knees and small joints of the hands. It is also
a) symmetric and non-erosive.
b) symmetric and erosive.
c) asymmetric and non-erosive.
d) asymmetric and erosive.


The arthritis in SLE is symmetric and non-erosive. It is also generally non-deforming and reducible due to its involvement of the para-articular tissues.


A 52-year-old woman with a history of non-alcoholic steatohepatitis underwent a recent liver transplant. Her protein and albumin levels are very low and, on exam, she has anasarca. Your inpatient rehabilitation admission orders should include
a) referral for paracentesis.
b) nursing orders to avoid use of an abdominal binder.
c) high protein diet with high protein oral supplements.
d) oxandrolone and monitoring of liver enzymes.

C. high protein diet with high protein oral supplements.

Malnutrition is significant in patients with liver disease. Ascites can promote excessive protein loss. Patients should receive a high protein diet with high protein oral supplements when they are in rehabilitation. Paracentesis would be required only if the patient was having symptoms from the ascites and would probably not be appropriate in the admission orders. Oxandrolone carries a risk of liver damage and therefore should not be prescribed in this patient. Abdominal binders may be used to help with ascites, particularly if the patient has an umbilical hernia from it.


According to current guidelines, for the injured factory worker with acute low back pain, what is the recommendation?
a) >6
b) 4-5
c) 2-3
d) <1

D. <1.

In a systematic review of patients with acute low back pain, resting in bed was found to be less effective than staying active.


In children with spastic cerebral palsy, which approach strengthens weak muscles?
a) Ankle-foot orthotics
b) Tendon transfer surgery
c) Intrathecal baclofen
d) Functional training

D. Functional training.

Children with cerebral palsy often have weakness as part of their disorder. Treatments such as bracing, tendon lengthening or transfers, and medications such as botulinum toxin or intrathecal baclofen add to this weakness. Strengthening programs or functional training programs can help to strengthen weak muscles.


Which type of traumatic brain injury results in the most morbidity?
a) Focal cerebral contusion
b) Subarachnoid hemorrhage
c) Epidural hematoma
d) Diffuse axonal injury

D. Diffuse axonal injury.

After a traumatic brain injury, diffuse axonal injury (DAI) is the leading cause of morbidity, this morbidity includes impairments in cognition, behavior, and arousal.


In addition to routine weight-bearing exercises and calcium supplements, vitamin D is important in persons with osteoporosis because it
a) decreases the amount of calcium supplementation needed.
b) enhances muscle strength and reduces the risk of falling.
c) decreases bone turnover.
d) improves the mechanism of action of biphosphonates.

B. enhances muscle strength and reduces the risk of falling.

Vitamin D is essential for skeletal maintenance and has been shown to enhance muscle strength and reduce the risk of falling.


What percentage of patients with whiplash-associated disorders develop chronic symptoms?
a) less than 25%
b) 25%--49%
c) 50%--75%
d) more than 75%

B. 25%--49%. Up to 33% of individuals with symptoms from whiplash-associated disorders have chronic symptoms.

Symptoms associated with whiplash-associated disorders include neck pain, arm pain, paresthesias, temporomandibular joint dysfunction, headache, dizziness, visual disturbances, and difficulty with memory and concentration.


While recording an antidromic sensory nerve action potential, you increase the distance between the active and reference electrode from 1cm to 4cm by moving the reference electrode. What is the effect on the onset latency and peak latency?

a) No change | Increase
b) Increase | No change
c) Decrease | Decrease
d) Increase | Increase


Increasing the interelectrode distance from 1 cm to 4 cm does not alter the onset latency, but increases the peak latency and amplitude of the sensory response. The onset latency does not change because the active electrode position is not changed. The sensory nerve action potential amplitude increases because less of the information is eliminated by differential amplification. Similarly, the peak latency also is prolonged as less of the signal is eliminated.


The family of your 15-year-old patient who had a severe traumatic brain injury 6 weeks ago asks you if they may feed their son. You observe that the patient is agitated at times, has a hoarse voice, and drools. You try to feed him applesauce and notice that he seems to swallow part of it and does not cough. The most likely finding on the videofluoroscopic swallowing study will be
a) Silent aspiration
b) Reflux
c) Coughing and gagging
d) Normal swallow


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


A 24-year-old man with T4 paraplegia has a sacral pressure ulcer measuring 2 cm by 2 without depth. The ulcer base has pink granulation tissue. Which dressing is LEAST appropriate in this case?
a) Tegaderm (transparent adhesive dressing)
b) Duoderm (hydrocolloid wafer dressing)
c) Curasol (gel dressing)
d) Accuzyme (enzymatic debridement)

D. Accuzyme (enzymatic debridement).

This man has a stage II pressure ulcer. Debridement with an agent such as Accuzyme is indicated in wounds with necrotic tissue. Since no necrotic tissue is present in this patient's wound, Accuzyme is not appropriate. A transparent adhesive dressing such as Tegaderm, a hydrocolloid wafer dressing such as Duoderm, and a gel dressing such as Curasol are all appropriate for clean wounds such as the ulcer described


Which factor is most likely to be associated with the development of a work-related, repetitive-strain injury?
a) Normal body weight
b) Warm work environment
c) Younger age
d) Rheumatoid arthritis

D. Rheumatoid arthritis.

Risk factors associated with a repetitive strain injury include obesity, cold temperature, older age, diabetes, smoking, pregnancy, rheumatoid arthritis, and psychologic stress.


The gluteus maximus is primarily active during which part of the gait cycle?
a) Pre swing
b) Loading response
c) Midstance
d) Terminal stance

B. Loading response.

The gluteus maximus is primarily active from terminal swing through initial contact and loading response. During midstance, terminal stance, and pre swing the gluteus maximus is actually silent.


A 32-year-old male runner presents with left foot pain 3 days after completing a marathon. If the patient has exquisite tenderness to palpation at the location of the examiner’s right thumb, pictured above, what is your next step?

location: dorsal pedis, midfoot, align with digiti I

a) Order physical therapy for closed chain exercises.
b) Order a plantarflexion night splint.
c) Implement strict non-weight bearing.
d) Prescribe oral steroids.

C. Implement strict non-weight bearing. The patient has a navicular stress fracture until proven otherwise. It is among the most common stress fractures in athletes. Physical examination reveals tenderness over the so-called “N” spot between anterior tibialis and extensor hallicus longus tendons as well as pain with weight bearing and hopping. Strict non-weight bearing cast immobilization for 6 weeks should be implemented. Magnetic resonance imagining or bone scan can confirm the diagnosis.


Which Brunnstrom stage of motor recovery in a stroke patient with a hemiplegic arm is characterized by activating muscles selectively outside the flexor and extensor synergies?
a) Stage 2
b) Stage 3
c) Stage 4
d) Stage 5

C. Stage 4.

The Brunnstrom stages of motor recovery can be used to describe motor recovery following stroke. Brunnstrom classification stage 4 is when the patient begins to activate muscles selectively outside of flexor and extensor synergy.


A 24-year-old college student reports low back and lower limb joint pain for the past several months. His heels are especially painful, which makes it difficult for him to walk or stand for prolonged periods of time. He recalls an episode of gastroenteritis requiring hospitalization 6 months ago. Upon further questioning, he admits to some mild dysuria. His neurologic exam is normal. Radiographs of his ankles will most likely demonstrate
a) a normal joint.
b) osteophytes and subchondral cysts in the tibiotalar joint.
c) periosteal reaction and bony erosions of the calcaneus.
d) avascular necrosis of the talus.

c) periosteal reaction and bony erosions of the calcaneus.

The diagnosis is reactive arthritis / seronegative spondyloarthropathy that develops after certain genitourinary or gastrointestinal infections, most commonly in young men. Non-gonococcal urethritis and conjunctivitis is the remainder of the clinical triad. Heel pain is one of the most frequent and distinctive clinical features, along with low back pain radiating into the buttocks. Periostitis and erosions occur in the ankle joint in individuals with a several month history of heel pain. Osteophytes and subchondral cysts are typical of osteoarthritis. Avascular necrosis is not typical.


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) prior radiation therapy.

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 2.5 cm, proximal nerve injury and poor condition of nerve endings.


Vacuum-assisted closure marketed as "Wound VAC" works primarily by
a) increasing blood flow in the wound and adjacent tissue.
b) drawing the edges of the wound together.
c) sealing out potentially harmful bacteria from the wound.
d) maintaining a moist, anaerobic environment.


The Wound VAC device increases blood flow to the wound and adjacent tissue, resulting in increased oxygen delivery, increased clearance of bacteria from infected wounds, and wound healing.


A 65-year-old man is sent to you for electrodiagnostic assessment of his right facial droop. He presented to his internist 4 weeks ago with right facial pain and weakness, and decreased hearing. He was treated with high dose steroids without any improvement. His nerve conduction studies are as follows:

Nerve Distal Latency (ms) Amplitude
R Facial 3.5 0.8
L Facial 3.2 2.2

Blink reflex Recording R1 (ms) R2 (ms)
R Trigeminal Right absent absent
Left - 33
L trigeminal Right - absent
Left 11.5 35

R1 (early component)
R2 (late component)

These findings are most consistent with right
a) facial nerve lesion.
b) trigeminal nerve lesion.
c) pons lesion.
d) lateral medulla lesion.


The blink reflex study has two responses, an early component (R1) and a late component (R2). The absence of the right R1 and R2 responses, but normal left R2 responses suggests a lesion affecting the right facial nerve. Additionally, the small right facial nerve response with direct stimulation suggests distal facial nerve degeneration. In a lesion involving the trigeminal nerve both R2 responses would be abnormal. In a pons or lateral medulla lesion the direct facial nerve response would be normal.


Your patient demonstrates ipsilateral pelvic drop during gait. What is the most likely cause?
a) Scoliosis
b) Short contralateral limb
c) Hip adductor weakness
d) Weak hip extensors


Deformity in the spine presents with malalignment of in the pelvis as either contralateral or ipsilateral drop. Two other causes of ipsilateral pelvic drop are contralateral hip abductor weakness and short ipsilateral limb. Weak hip extensors are a cause of backward lean. In stance, a backward lean of the trunk substitutes for weak hip extensors.


A woman in her third trimester of pregnancy presents with severe burning pain in her right anterior thigh for the last 2 months. The pain is aggravated by prolonged standing. On examination of the right lower limb, there is no evidence of discoloration, edema, tenderness to palpation, or motor deficit. She has decreased sensation to pinprick over the lateral aspect of her distal thigh. What is the most likely diagnosis?
a) Trochanteric bursitis
b) Sacroiliitis
c) Femoral neuropathy
d) Meralgia paresthetica

D. Meralgia paresthetica.

This history and examination are consistent with a lateral femoral cutaneous neuropathy, known as “meralgia paresthetica.” It is seen with pregnancy, obesity, pressure from tight clothing, trauma and seatbelt use. The cause is usually idiopathic, and spontaneous recovery is usually the rule. This problem may be difficult to treat and may be recurrent for years. Anti-inflammatory medications and neuropathic pain medications may be tried, as well as attempting to remove the causative factors. This is a sensory nerve and should not result in motor deficit. Sacroiliac pain is associated with pregnancy but will not present with this pattern. A femoral neuropathy would likely have motor findings, and would have numbness in the anterior portion of the thigh. An L3 radiculopathy might mimic this condition. Trochanteric bursitis would cause this patient to be tender to palpation over the greater trochanter. Patients are usually unable to lie on the affected hip.


For a patient with hemiplegia who prefers to use his legs and push his wheelchair backwards, the wheelchair should be configured with
a) the back edge of the seat lower than the front edge.
b) a single arm drive mechanism on the non-hemiplegic side.
c) the large wheel axle plate moved to a more anterior position.
d) large wheels in the front and casters in the back.

D. large wheels in the front and casters in the back.

The casters should lead the rear wheels for the most common direction of travel. This will help reduce the possibility of the user flipping over when hitting an obstacle and will make the chair more directionally stable.


A 17 year old woman was involved in a motor vehicle crash 4 months ago. She suffered a shoulder dislocation. Electromyographic studies have confirmed a brachial plexus injury to her posterior cord and indicate nerve continuity (Sunderland 2 injury). 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 the patient to neurosurgery for exploratory surgery.

d) refer the patient to neurosurgery for exploratory surgery.

With closed nerve injury as described, early active and passive range of motion (ROM) therapy of the affected joints is begun. The value of electrical stimulation is uncertain. The purpose of surgical repair is to improve peripheral nerve recovery and eventual function. Therefore, surgery is done when the patient has an incomplete loss of function but shows no improvement over several weeks, or no return of function at 2 months for peripheral nerve and 4 months for a brachial plexus injury. 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--24 months, the denervated muscles usually are replaced by fatty connective tissue, making functional recovery impossible.


A 23-year-old man with C8 tetraplegia requests your opinion regarding routine urologic evaluations after spinal cord injury. You advise that
a) an intravenous pyelogram (IVP) should be performed every 1 to 2 years.
b) annual abdominal plain films are sufficient to detect early hydronephrosis.
c) renal ultrasound should be performed every 5 years.
d) it is reasonable to wait 10 years before getting his first cystoscopy.

d) it is reasonable to wait 10 years before getting his first cystoscopy.

Renal ultrasound should be included in the annual assessment of renal function and is more sensitive for detecting early hydronephrosis than are plain films. An IVP is not required on a regular basis unless a specific indication exists, such as localizing a renal stone. Patients with indwelling catheters should have a cystoscopy after the first 10 years postinjury.


A 47-year-old man with human immunodeficiency virus (HIV) presents with fever, headache, and memory loss. The most likely diagnosis is
a) progressive multifocal leukoencephalopathy (PML).
b) HIV encephalopathy.
c) cryptococcal meningitis.
d) central nervous system (CNS) lymphoma.

c) cryptococcal meningitis.

The patient most likely has cryptococcal meningitis. Fever would not be present in PML, HIV encephalopathy, or CNS lymphoma. In addition, headache is typically not a feature of PML or HIV encephalopathy.


What is the 5-year mortality rate for persons with diabetes after sustaining a major lower limb amputation?
a) 15%
b) 25%
c) 33%
d) 50%

d) 50%.

At least 50% of persons with diabetes and peripheral arterial disease who undergo major limb amputation will die within 5 years of sustaining major lower limb amputation.


Which nerve does NOT innervate the outer annulus of the lumbar intervertebral disc?
a) sinuvertebral nerve
b) lumbar medial branches of dorsal rami
c) grey rami communicantes
d) lumbar ventral rami

b) lumbar medial branches of dorsal rami.

The lumbar medial branches of the dorsal rami supply the facet joints as well as the deep paraspinals, such as the rotators and multifidi. The sinuvertebral nerve, also termed the recurrent meningeal nerve is the primary source of nerve supply to the lumbar intervertebral disc. It is derived from portions of the ventral rami and grey rami communicantes (sympathetic input). Accordingly, the referral pattern seen with intrinsic disc pain is vague and diffuse.


Which statement about primary cerebral lymphoma is TRUE?
a) It has an increased incidence in patients with (HIV) infection.
b) It usually presents as a solitary tumor.
c) It is treated surgically for improved outcome.
d) It has a median survival of approximately 2 years.


. Primary cerebral lymphoma presents as multiple tumor deposits in the brain and has an increased incidence in patients infected with human immunodeficiency virus (HIV). Surgical removal does not improve outcome.


A 50-year-old man complains of malaise, fatigue, and hand arthralgias for the past several months. He was recently diagnosed with diabetes mellitus. On exam, he has mild tenderness to palpation in his bilateral second and third metacarpophalangeal (MCP) joints with erosive lesions on radiographs. He also has a generalized bronzing of his skin. What is the most appropriate initial test to order?
a) Complete blood count (CBC)
b) Iron studies
c) Erythrocyte sedimentation rate (ESR)
d) Adrenocorticotropic hormone (ACTH) stimulation test

b) Iron studies.

Hemochromatosis is the diagnosis. It is a commonly inherited, autosomal recessive disorder (5 in 1000 persons) affecting Caucasians of European descent typically in the fourth and fifth decade of life. In hemochromatosis, arthralgias may be the first symptom and are classically in the second and third MCP and proximal interphalangeal (PIP) joints, resembling osteoarthritis (OA) on radiographs. However, OA typically affects the distal interphalangeal joints. The CBC, ESR, and ACTH tests are normal in hemochromatosis.


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) Gentamicin (Garamycin).

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. 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 acetylcholine quanta released. Use may lead to a myasthenic exacerbation.


Baclofen is thought to reduce spasticity by
a) preventing the release of calcium from the sarcoplasmic reticulum.
b) blocking sodium and potassium channels.
c) depressing of brainstem neuronal activity.
d) acting as a gamma-aminobutyric acid agonist.

d) acting as a gamma-aminobutyric acid agonist.

Baclofen is an analog of gamma-aminobutyric acid (GABA), a neurotransmitter that exerts inhibitory activity on monosynaptic and polysynaptic reflexes. Dantrolene prevents the release of calcium from the sarcoplasmic reticulum.


A 70-year-old man underwent a 2-vessel coronary artery bypass graft and mechanical mitral valve replacement five days ago. You note that he is presently taking Coumadin (warfarin). The primary reason to put this patient on Coumadin after this procedure is to prevent
a) deep vein thrombosis.
b) embolic stroke.
c) coronary artery occlusion.
d) valvular adhesion.

b) embolic stroke.

Patients are anticoagulated following mechanical valve replacements to prevent thromboembolic strokes. Anticoagulation will also prevent deep vein thromboses, but this is not the primary reason why it is prescribed.


According to the Joint Commission on Accreditation of Hospital Organizations (JCAHO), what is the minimum number of patient identifiers needed before medications, blood products, or other treatments or procedures may be administered?
a) 1
b) 2
c) 3
d) 4

b) 2.

While more than 2 patient identifiers may be used, a minimum of 2 is required: first, a marker to identify the individual as the person for whom the service or treatment is intended; second, an identifier to match the service or treatment to that individual.


A potential benefit of osseointegration (the direct skeletal attachment of the prosthesis to bone) is
a) elimination of poor prosthetic socket fit.
b) ability to return to running activities.
c) early prosthetic fitting.
d) ability to perform heavy manual work.


The primary benefits of attaching a prosthesis directly to the skeleton are comfort, elimination of poor prosthetic socket fit, and elimination of skin problems. Recipients report improved sensory feedback from the skeletally attached limb. Limitations include a 2-stage procedure, which results in an extended time of non-weight bearing, and extended rehabilitation (up to 2 years). The procedure poses a significant risk of infection, and the recipient must limit running, jumping, and heavy manual work in order to minimize loosening of the prosthesis.


A 22-year-old female gymnast with chronic low back pain is diagnosed with spondylolysis of the right L5 pars interarticularis. Spondylolisthesis is not identified on plain x-rays. What is the best test to determine fracture healing?
a) magnetic resonance imaging
b) single photon emission computed tomography
c) computed tomography scan
d) flexion and extension lateral x-rays

c) computed tomography scan.

Computed tomography (CT) scans with thin cuts through the area of the pars interarticularis can identify the healing pattern of a pars stress fracture.


According to the Joint Commission on Accreditation of Hospital Organizations (JCAHO) which abbreviation may be used when writing a prescription?
a) U for units
b) QD for once daily
c) 2 mg for 2 milligrams
d) MSO4 for morphine sulfate

c) 2 mg for 2 milligrams.

The only listed expression that may be written on a prescription is 2 mg for 2 milligrams. JCAHO expects that the other abbreviations will not be used in writing drug prescriptions, since they can lead to errors. Davis' Medical Abbreviations cites U as "the most dangerous abbreviation" and says spell out "unit." The expression QD is too easily read as 4 times daily. Regarding MSO4, Davis also calls this as "a dangerous abbreviation."


In patients with radiculopathy, how long does it take for morphologic changes of increased duration and amplitude to occur in the motor unit action potentials?
a) 1 day
b) 1 week
c) 3 weeks
d) 6 weeks

d) 6 weeks.

Reduced recruitment may be seen day 1. Positive waves may be seen in the paraspinals as early as 1 week, and positive waves and fibrillations may be seen in the extremities by 3–5 weeks, but, because of reinnervation by axon sprouting, it takes at least 6 weeks to see increased amplitude and duration of muscle activity.


A 3-year-old child has a high thoracic spinal cord injury. At age 10, which of the following is the most likely complication?
a) Severe lordosis without scoliosis
b) Scoliosis requiring surgical treatment
c) Deep venous thrombosis
d) Heterotopic ossification

b) Scoliosis requiring surgical treatment.

Children who sustain cervical or high thoracic spinal cord injuries at an early age are at high risk of developing progressive scoliosis that requires surgical management.


An advantage of a knee disarticulation compared to a transfemoral amputation is that the knee disarticulation offers
a) more options for a prosthetic knee.
b) enhanced ability to create power during ambulation or running.
c) better soft tissue coverage within the zone of injury.
d) better prosthetic cosmesis

b) enhanced ability to create power during ambulation or running.

Disarticulation results in a bulbus distal residual limb, which may complicate prosthetic fitting. Choice of prosthetic knee options for a person with a knee disarticulation, therefore, is limited and potentially excludes the newer, more advanced knee-joint designs. Benefits of a knee disarticulation over a transfemoral approach include greater tolerance to distal limb weight bearing, a longer lever arm to create power during ambulation and running, and improved sitting balance. Of note, functional outcome studies of trauma-related lower extremity amputees concluded that persons with through knee amputations had significantly poorer outcomes. These poorer outcomes are attributed to complications arising from soft tissue failure within the zone of injury.


Which factor increases the risk for long-term symptoms after a whiplash-type injury?
a) Male gender
b) Eastern European descent
c) Preexisting hyperlordosis of cervical spine
d) Presence of radiating pain into the limb

d) Presence of radiating pain into the limb.

Risk factors for chronic whiplash-associated pain include presence of preexisting degenerative disc disease, preexisting loss of cervical lordosis, female gender, awkward head position at time of impact, presence of radiating pain into upper limbs, and prior history of headache. A famous Lithuanian study showed no incidence of long-term whiplash pain in a country that had no compensation system for whiplash.


Compared to individuals without spinal cord injury, individuals with spinal cord injuries have a
a) lower risk of osteoporosis.
b) higher risk of diabetes.
c) lower rate of dyslipidemia.
d) higher rate of prostate cancer

b) higher risk of diabetes.

Individuals with spinal cord injury are at an increased risk for carbohydrate intolerance, cardiovascular disease, and dyslipidemia. There does not appear to be an added risk for prostate cancer in men with chronic SCI.


The most common congenital limb deficiency is
a) right transtibial limb deletion.
b) right transradial limb deletion.
c) left transtibial limb deletion.
d) left transradial limb deletion.

d) left transradial limb deletion.

The most common congenital limb deficiency is the left midlength transradial deficiency.


In adults, the prevalence of phantom limb pain, phantom sensation or residual limb pain after amputation is
a) approximately 70% at 6 months postamputation.
b) dependent on age at the time of amputation.
c) directly related to surgical technique.
d) primarily dependent upon the level of amputation.


Phantom sensation, phantom pain, and residual limb pain have all been reported about equally in over 70% of amputees 6 months or more after lower limb amputation. This is typically not dependent upon the person's age at the time of amputation, the level of amputation, or surgical technique.


As its mechanism of action, botulinum toxin
a) inactivates the calcium pump at the sarcoplasmic reticulum.
b) inhibits the troponin-tropomysin complex.
c) inhibits the production of acethylcholine.
d) inhibits the release of acethylcholine.

d) inhibits the release of acethylcholine.

Botulinum toxins act on the neuromuscular junction where they inhibit the release but not the production of acethylcholine (ACh). Botulinum toxin does not affect the sarcoplasmic reticulum, nor does it work at the troponin-tropomysin complex.


What articular abnormality is associated with systemic lupus erythematosus and its treatment?
a) Avascular necrosis
b) Erosions with subchondral sclerosis
c) Erosions with overhanging edges
d) Syndesmophytes


Avascular necrosis (or ostenecrosis) is the second form of joint disease that occurs in persons with SLE; it is associated with use of corticosteroids. Erosions are not seen with systemic lupus erythematosus. Erosions with subchondral sclerosis are seen in rheumatoid arthritis and overhanging edge in gout. Syndesmophytes occur in spondyloarthropathies at the anterior and posterior longitudinal ligaments of the spine.


Which diagnosis is NOT an indication for transcutaneous electrical neurostimulation (TENS) therapy?
a) Chronic low back pain
b) Acute surgical pain
c) Urinary urgency
d) Angina

d) Angina.

TENS therapy has not been shown to provide benefit for angina. It has been proven to have a beneficial effect in all the other diagnoses.


A 37-year-old woman with C5 ASIA A tetraplegia from trauma 1 month ago is admitted to your acute rehabilitation unit. She has a retrievable inferior vena cava (IVC) filter and no history of chemical prophylaxis for deep vein thrombosis (DVT). Her surgical team reports to you that they are no longer concerned with an acute bleeding potential related to her trauma and her hematocrit is stable. What should you do first?
a) Order a lower extremity doppler study to look for DVT
b) Start mechanical prophylaxis with sequential compression devices
c) Tell the patient she is completely protected from pulmonary emboli
d) Leave the IVC filter in place for a minimum of 4 months


. If anticoagulation is delayed for more than 72 hours after injury, a test to exclude the presence of clots in the legs should be performed. In complete injuries, low molecular weight heparin should be used when starting chemical prophylaxis. Pulmonary embolisms may occur as a result of upper extremity DVT and are not prevented by the IVC filter. In general, the longer you wait to remove the IVC filter, the more problems you may experience in the filter retrieval process.


Cervical traction is a useful modality for patients with
a) cervical strain.
b) diskitis.
c) acute radiculopathy.
d) vertebral compression fracture.

c) acute radiculopathy.

Cervical traction is proven effective for illnesses that involve nerve root irritation or compression of nerve roots.


You see the significant other of a close friend in your office for knee pain. As part of her past medical history you note that she has a congenital heart defect. She says she has not yet told your friend that she has this condition. You decide to tell your friend about her congenital heart defect even though the patient did not give you permission to do so. What penalty do you face for knowingly disclosing individually identifiable health information, which is in violation of HIPAA rules?
a) $50,000 and up to 1 year of imprisonment
b) No penalty
c) $250,000 and up to 10 years imprisonment
d) $100,000 and up to 5 years imprisonment


A person who knowingly discloses individually identifiable health information in violation of HIPAA faces a fine of $50,000 and up to a 1-year imprisonment. The criminal penalties increase to $100,000 and up to 5 years imprisonment if the wrongful conduct involves false pretenses, and to $250,000 and up to 10 years imprisonment if the wrongful conduct involves the intent to sell, transfer, or use individually identifiable health information for commercial advantage, personal gain, or malicious harm.


Informed consent requires that risks associated with participation in a study be described in terms of
a) type, severity, and probability.
b) probability alone.
c) physical, but not psychological, risks.
d) major, but not minor, risks.


Informed consent for participation in a research study requires that the risks be described in terms of type, severity, and probability. It is important to describe risks in each of these areas in order to fully inform the patient of the potential risks associated with study participation.


Which route of epidural steroid administration is most likely to deliver steroid to the junction of the posterior disc and anterior dura?
a) Transforaminal
b) Caudal with catheter
c) Interlaminar
d) Caudal


. The subpedicular transforaminal route of epidural steroid delivery places the needle at the anterior portion of the intervertebral foramen. The retroneural route of delivery purposefully terminates needle placement at the posterior edge of the intervertebral foramen to avoid injuring radicular vasculature. The caudal and interlaminar approaches are of limited utility in delivering steroid anteriorly due to raphe within the epidural space.


Which factor is a risk for heterotopic ossification in traumatic brain injury?
a) Late seizures
b) Prolonged coma
c) Male gender
d) Diabetes insipidus

b) Prolonged coma.

Significant risk factors for heterotopic ossification in traumatic brain injury include prolonged coma (>1 month), increased muscle tone, limited movement in the involved lower extremity, and associated fractures. Late seizures, gender, and diabetes insipidus are not associated with increased risk of heterotopic ossification.


A patient presents to your office with knee pain from a flare of rheumatoid arthritis. She has a mild effusion and warmth at her knee. The therapist wants to use ultrasound to her knee for treatment. You advise that ultrasound
a) accelerates healing.
b) helps with pain control.
c) is contraindicated.
d) will not help with the pain

c) is contraindicated.

Ultrasound use is contraindicated in acute rheumatoid arthritis. Ultrasound has been shown to help with pain, but not in the context of acute inflammation.


Under the Health Insurance Portability and Accountability Act (HIPAA) Protected Health Information is data that
a) a physician can withhold from a patient.
b) a patient’s job supervisor can obtain from a physician.
c) can be used to identify a patient.
d) can be shared with family without permission.

c) can be used to identify a patient.

Protected Health Information includes individually identifiable health information. This is information, including demographic data, that relates to any of the following particulars: the individual’s past, present or future physical or mental health or condition; the provision of health care to the individual; or the past, present, or future payment for the provision of health care to the individual. It can also be information that identifies the individual or for which there is a reasonable basis to believe it can be used to identify the individual. Individually identifiable health information includes many common identifiers (e.g., name, address, birth date, Social Security Number).


Relevant to investigational studies, the principle of justice requires that
a) harm be minimized and benefits maximized.
b) informed consent includes full disclosure of risks and benefits.
c) research subjects be treated fairly and selected equitably.
d) investigators respect the privacy of research subjects.

c) research subjects be treated fairly and selected equitably.

The principle of justice requires subjects to be treated fairly and selected equitably. The principle of beneficence ensures that researchers minimize harm and maximize benefits associated with research involvement. The principle of autonomy ensures that informed consent includes full disclosure of risks and benefits and that the privacy of subjects is respected.


Type 1 (alpha) error is best described as occurring in research when
a) the study finds a positive benefit from the intervention, but no benefit really exists.
b) the study finds no benefit from the intervention, but a benefit really exists.
c) study results are biased by subject selection criteria.
d) study results are not generalizable outside the research setting.


Type 1 (alpha) error is best described as occurring in research when the study finds a positive benefit from the intervention, but no benefit really exists. In this case, the study conclusions would be falsely positive.


A far lateral L4-5 disc herniation pictured above will impinge on which nerve root?
a) L3
b) L4
c) L5
d) S1


Since it occurs lateral to the intervertebral disc, a far lateral disc herniation is a relatively unusual location for disc herniation. A far lateral disc herniation can actually impinge the nerve root exiting above that intervertebral level.


What is the measure of the rate of oxygen utilization for the production of energy?
a) VO2min
b) Peak VO2
c) VO2max
d) VO2

d) VO2.

Oxygen uptake (VO2) is the measure used to describe the rate at which oxygen is used in the production of energy. Maximal oxygen uptake (VO2max) is the maximal rate at which an individual can use oxygen. Peak VO2 is the measure of oxygen uptake stated when the highest attainable VO2 may not have been reached due to external factors. There is no VO2min measure.


What adaptations to strength training are seen in elderly persons engaged in a consistent exercise program?
a) Hypertrophy of muscle only.
b) Revascularization of the exercised muscle
c) Strength gains from Neural and learning factors only
d) Gains from both neural factors and hypertrophy

d) Gains from both neural factors and hypertrophy.

Significant evidence exists to show that elderly persons benefit from strength training. In the past it was believed that adaptations were due to only neural factors. Recent evidence has shown that strength gains in elderly persons are attributable to both neural factors and muscle hypertrophy.


Your adult patient with a spinal cord injury needs to access his bathroom in his standard-width wheelchair. If no turn is required following entry into the bathroom, the minimal width of the doorway should be
a) 26 inches.
b) 32 inches.
c) 36 inches.
d) 40 inches.

b) 32 inches.

The proper minimum width of a doorway for a wheelchair without a turn is 32 inches. If a turn is involved, then the doorway width should be at least 36 inches.


Cervical and lumbar traction applied over a 20--60 minute time period is defined as
a) continuous.
b) sustained.
c) intermittent.
d) pulsed.

b) sustained.

Sustained traction is the use of force greater than that applied in continuous traction, but less than that used in intermittent traction, and the application time is 20--60 minutes. This time frame makes sustained traction more practical in clinical use. Continuous traction is the use of low force of traction over long periods of time, 20--40 hours. Intermittent traction is the use of greater forces, but for shorter periods of time, 10--60 seconds. There is no pulsed traction.


You are conducting a research study, and you want to use Functional Independence Measure (FIM) scores as 1 of your outcome measures. Because FIM information is scored on a 1 to 7 scale to describe the level of assistance an individual requires to perform a functional task, these scores represent which category of research data?
a) Nominal
b) Ordinal
c) Ratio
d) Interval

b) Ordinal.

FIM scores would be classified as ordinal data, because in an ordinal scale consecutive values are rank-ordered, but not equally spaced. For example, although there is an order to the ranking in the FIM scale, the difference between a 2 and a 3 may not be equal to the difference between a 6 and a 7. Nominal data refers to data with discrete values (yes/no; alive/dead). With interval data, there are equal intervals between consecutive values. An example of interval data is temperature in degrees Fahrenheit. Ratio data are interval data with equal intervals between consecutive values, but with an absolute zero point.


The process of developing and adopting quality standards for clinical practice
a) is dependent on providers being mandated for reporting data.
b) is ineffective in changing physician practice patterns.
c) allows health insurance providers to deny reimbursement for care.
d) helps to form expectations for safety among both providers and consumers.

d) helps to form expectations for safety among both providers and consumers.

The process of developing and adopting quality standards for clinical practice helps to form expectations for safety among both providers and consumers.


Which statement describes the natural history of lumbar spinal stenosis (LSS)?
a) The majority of individuals with LSS will develop focal weakness.
b) Of patients treated nonsurgically, 25%--50% have satisfactory outcomes.
c) Ambulation worsens in the majority of individuals with LSS.
d) Early surgery improves long-term outcome.

b) Of patients treated nonsurgically, 25%--50% have satisfactory outcomes.

The natural history of spinal stenosis is generally benign. While decompressive surgery achieves satisfactory results in the great majority of individuals, the difference in outcomes with their nonsurgical cohorts becomes narrower with time.


A patient presents with right hemiparesis and dysarthria but language and sensation are intact. The lesion is most likely in the
a) posterior limb of the internal capsule.
b) left frontoparietal lobe.
c) lateral pons.
d) thalamus.


A pure motor stroke (hemiplegia and dysarthria without sensory deficits) is caused by a lesion in the posterior limb of the internal capsule.


Vapocoolant spray produces its cooling effects through
a) conduction.
b) convection.
c) conversion.
d) evaporation.

d) evaporation.

Evaporation is a process of transforming a liquid into a gas and requires thermal energy, as in vapocoolant spray. Convection is a process of using a medium to transport energy, for example husks during fluidotherapy and water during whirlpool therapy. Conduction is a process of transferring thermal energy to bodies that are in direct contact, for instance cold packs applied to skin. Conversion is a process of transforming energy into heat, as occurs with an ultrasound device.


High frequency electrical stimulation predominantly stimulates which type of muscle fiber?
a) Type 1
b) Type 2
c) Type 3a
d) Type 3b

b) Type 2.

Low frequency electrical stimulation predominantly stimulates type 1 muscle fibers. High frequency electrical stimulation predominantly stimulates Type 2 muscle fibers. There are no type 3 muscle fibers.


In which modality do charged particles migrate across biological membranes under an imposed electrical field?
a) Iontophoresis
b) Phonophoresis
c) Ultrasound
d) Laser therapy


Iontophoresis is the migration of charged particles across biological membranes under an imposed electrical field. Phonophoresis is the use of ultrasound to facilitate transdermal migration of topically administered medications. Ultrasound is a type of heating that occurs as a result of acoustic vibration. Laser therapy is light amplification by stimulated emission of radiation. It consists of a coherent, collimated beam of photons of identical frequency.


The benefits of quality outcomes management include
a) providing guidance for alignment of the program with the needs of the patient.
b) improved insurance reimbursement from third party payors.
c) improved retention of staff.
d) reduced expenses independent of outcomes.


The primary benefit of quality outcomes management is that it provides guidance for aligning the program with the needs of the patient. None of the other options are benefits of quality outcomes management.


Which K level best describes an individual who is able to ambulate within the household, but not out in the community?
a) K 1
b) K 2
c) K 3
d) K 4


The K level of 1 represents that of a household ambulator; K 2 limited community ambulator; K 3 unlimited community ambulator; K4 a very active community ambulator. The household exception FIM score of 5 indicates a "modified independent" ambulator who can handle household distances (i.e., less than 50 feet) inside or out.


Trauma to the sacral roots would most likely result in
a) vesicoureteral reflux.
b) incontinence.
c) detrusor hyperreflexia.
d) small bladder capacity.

b) incontinence.

Damage to the sacral roots usually results in a flaccid bladder. Incontinence often occurs due to a weak sphincter mechanism, particularly if the patient has increased bladder volume or an increase in intra-abdominal pressure. However, the external sphincter may not always be affected to the same degree as the detrusor. This imbalance results in bladder overdistension and the possibility of upper tract deterioration.


In 2003, which diagnosis-related group (DRG) had the most admissions to inpatient rehabilitation facilities?
a) Stroke
b) Unilateral joint replacement in a lower extremity
c) Amputation for circulatory disorders except upper limb and toe
d) Hip or pelvis fracture

b) Unilateral joint replacement in a lower extremity.

In fiscal year 2003, the number of admissions to an inpatient rehabilitation facility with the diagnosis related group unilateral joint replacement in a lower extremity was 124,754, stroke was 54,433, amputation for circulatory disorders except upper limb and toe was 7,200, and hip or pelvis fracture was 5,863.