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Flashcards in SAER 2009 Deck (100):
1

stenosis. Calculating anteroposterior (AP) ratios to other anatomical structures, which ratio would enable you to assess for bony cervical spinal stenosis on lateral radiographs?
(a) AP diameter of the vertebral body to the height of vertebral body.
(b) AP diameter of the vertebral canal to the AP diameter of the vertebral body at the same level.
(c) Vertebral height to the AP of the vertebral canal at the same level.
(d) Distance from the anterior border of the vertebral body to the tip of the spinous process

Answer: B
Commentary: Assessment of cervical spinal stenosis on lateral radiograph can be made by calculating the ratio of the anteroposterior (AP) diameter of the vertebral canal to the AP diameter of the vertebral body at the same level. This ratio is called the Pavlov ratio. A normal ratio is 1.0 with less than 0.82 indicating stenosis. The Torg ratio is the same as Pavlov ratio.

2

A 47-year-old woman injures her back on the job. Her supervisor inquires about the injury and creates a document with the employee’s name, outlining how the injury occurred and where the employee is experiencing pain. The information in the document is protected by the
(a) Health Insurance Portability and Accountability Act (HIPAA).
(b) The Joint Commission (JC).
(c) Americans with Disabilities Act (ADA).
(d) United States Supreme Court.

Answer: A
Commentary: Once the document was created by the supervisor and it contained individually identifiable health information it became information that is protected by HIPAA. The term 'individually identifiable health information' means any information, including demographic information collected from an individual, that: (A) is created or received by a health care provider, health plan, employer, or health care clearinghouse; and (B) relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual, and identifies the individual.

3

Your patient has a tremor of 5-8Hz, which is made worse with activity, and there is little or no tremor at rest. This finding best describes which type of tremor?
(a) Parkinsonian
(b) Essential
(c) Enhanced physiological
(d) Cerebellar

Commentary: An essential tremor is more prominent with activity (5-8Hz) and is diminished at rest. Stress exacerbates the tremor. The essential tremor can be confused with parkinsonian tremor. Essential tremor is more prominent with activity, while parkinsonian tremor is more prominent at rest, with a 4-5Hz frequency. There is also an absence of the other symptoms of parkinsonism such as loss of postural reflexes, rigidity and bradykinesia. Enhanced physiologic tremor is a high-frequency tremor that is most prominent with posture and action. It is exacerbated by anxiety, fatigue and many drugs. It can be seen with alcohol withdrawal. The cerebellar tremor has a frequency of about 3Hz and is mainly in a horizontal plane. It is most prominent with fine repetitive action of the extremities and is associated with other signs of cerebellar ataxia.

4

An individual with T4 ASIA C paraplegia must have
(a) normal sensory function below T4.
(b) sensation in the sacral segments S4–S5.
(c) a muscle grade of 3 or greater in at least half of the key muscles below T4.
(d) voluntary sphincter contraction.

Answer: B
Commentary: All ASIA levels except ASIA A must include sensation through the sacral segments S4–S5. The ASIA C classification can include voluntary sphincter contraction but it is not required. An injury classed as T4 ASIA C would include sensation below T4 but the sensation may be normal or impaired. A muscle grade of less than 3 in more than half of the key muscles below the neurologic level would be expected with ASIA C.

5

Which scale evaluates sensory perception, moisture, activity, mobility, nutrition, and friction/shear to determine risk of pressure ulcers?
(a) Norton
(b) Barthel
(c) Braden
(d) Beck

Answer: C
Commentary: Both the Braden scale and the Norton scale are used to assess pressure ulcer risk. The Braden scale consists of 6 factors: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The Norton scale assesses 5 factors: physical condition, mental condition, activity, mobility, and incontinence. The Barthel index measures activities of daily living and mobility and is not related to assessing pressure ulcer risk. The Beck Depression Inventory and Beck Anxiety Inventory are not related to pressure ulcers.

6

Two-thirds of infections that occur 1 to 6 months post-transplant are caused by
(a) methicillin-resistant staphylococcus aureus (MRSA).
(b) pneumocystis carinii (PCP).
(c) clostridium difficile (C. diff).
(d) cytomegalovirus (CMV).

Answer: D
Commentary: Transplant patients are at high risk for cytomegalovirus (CMV) infection and frequently receive prophylaxis with acyclovir or ganciclovir.

7

Repeatedly lifting the shoulder past which degree of flexion or abduction is associated with an increased prevalence of shoulder disorders?
(a) 10o
(b) 30o
(c) 45o
(d) 60o

Answer: D
Commentary: Repeatedly lifting the shoulder past 60 degrees of flexion or abduction is associated with an increased prevalence of shoulder disorders.

8

A weight-activated stance-control knee unit would be indicated in a transfemoral amputee who
(a) has cognitive deficits.
(b) has a contralateral weak limb.
(c) is an unlimited ambulator.
(d) is a new amputee.

Commentary: Weight-activated stance-controlled knees are often used for individuals with a transfemoral amputation. They are especially useful as a preparatory prosthesis in a new amputee, because their simplicity and safety help new amputees learn to walk with a prosthesis. To flex the knee, the amputee must shift weight onto the opposite leg, which requires the opposite limb to accept increased weight. Additionally, the amputee must have the cognitive ability to learn to weight shift. The requirement to shift weight off of the prosthesis to allow knee flexion presents few problems at slow cadences, but if the amputee attempts to walk at a more normal speed, the gait pattern is disrupted by the premature weight shift.

9

Which drug is NOT associated with increased seizure risk in patients with traumatic brain injury?
(a) methylphenidate (Ritalin)
(b) ciprofloxin (Cipro)
(c) amitriptyline (Elavil)
(d) bupropion (Wellbutrin)

Answer: A
Commentary: Methylphenidate and dextroamphetamine do not appear to be associated with increased seizure risk among patients with traumatic brain injury. However, amitriptyline, bupropion and quinolones decrease seizure threshold.

10

Which complaint is NOT an early sign of dysphagia in amyotrophic lateral sclerosis?
(a) Increasing hoarseness
(b) Persistent coughing after swallowing
(c) Painful swelling in the oropharynx
(d) Inability to manage thin liquids

Answer: C
Commentary: Dysphagia in amyotrophic lateral sclerosis is directly due to weakness and spasticity of the oropharyngeal musculature and does not involve pain or swelling. The presence of any of the other symptoms indicates dysphagia that can lead to aspiration. A speech therapist should be consulted for clinical swallowing evaluations and recommendations on dietary modification.

11

Following repair of a right distal biceps tendon rupture, a 31-year-old construction worker presents with problems extending his fingers. He had noticed swelling in the arm and forearm before his cast was removed about 4 weeks ago. He does not have any sensory complaints and the right superficial radial sensory nerve action potential is normal. Needle exam shows these data:
Muscle
Abnormal
Spontaneous
Activity
Recruitment
R Triceps
0
Normal
R Biceps
0
Normal
R Brachioradialis
0
Normal
R Extensor digitorum communis
2+
Reduced
R Extensor indicis proprius
2+
Reduced
R Flexor carpi ulnaris
0
Normal
R 1st dorsal interosseous
0
Normal
R Extensor carpi radialis
0
Normal
R Supraspinatus
0
Normal
R Cervical paraspinals0
--
This patient most likely has a right
(a) radial mononeuropathy at the elbow.
(b) posterior interosseous neuropathy.
(c) posterior cord plexopathy.
(d) C7 and/or C8 radiculopathy.

Answer: B
Commentary: The electrophysiologic findings are consistent with involvement of the right posterior interosseous nerve (PIN). Typically in PIN injuries the triceps, brachioradialis, and extensor carpi radialis longus/brevis muscles are spared.

12

What is the primary disadvantage of moving the rear axle of a wheelchair forward?
(a) Ascending curbs becomes more difficult.
(b) It takes more muscle effort to propel the wheelchair.
(c) More strokes are required to push the wheelchair.
(d) Ascending a ramp becomes more difficult.

Answer: D
Commentary: Moving a wheelchair’s rear axle forward enables the user to propel the chair with less muscle effort and fewer strokes. Because the modification causes more weight to be centered over the rear wheels, it is easier to pop a wheelie, negotiate obstacles and ascend or descend curbs. However, moving the axle forward can also make the wheelchair more “tippy” (likely to tip backwards) and that tendency to tip backwards makes it more difficult to push the chair up a ramp.

13

Which abbreviation or symbol is acceptable to use when writing prescriptions, according to The Joint Commission (JC)?
(a) QD for once daily
(b) U for units
(c) ml for milliliters
(d) cc for milliliters

Commentary: Of the options given the Joint Commission has only approved the use of the abbreviation ml for milliliters. Using the abbreviation QD can be dangerous since it may be mistaken for QID, which stands for four times per day.

14

A 22-year-old woman with complaints of fluctuating weakness and abnormal fatigability that improves with rest is sent for electrophysiologic testing. Which electrophysiologic finding on routine testing would be most consistent with this clinical presentation?
(a) Small sensory nerve action potentials
(b) Slow motor nerve conduction velocities
(c) Variability in motor unit action potential amplitude
(d) Small compound muscle action potentials

Answer: C
Commentary: This patient’s presentation is most consistent with myasthenia gravis. The incidence of this condition is bimodal and affects women more than men in the younger age group. When one suspects myasthenia gravis the test of choice is repetitive stimulation. However, it is still important to assess for other possible problems and routine nerve conduction and needle electromyographic examination should be performed. The sensory component of the
peripheral nervous system lacks a neuromuscular junction and hence the sensory responses should be normal. Motor amplitudes can be small, but this is usually only in severe cases. Motor conduction velocities are normal, since this study assesses the conduction along the motor fibers. Motor unit action potential amplitude variability is a characteristic abnormality observed during routine electromyography in patients with neuromuscular junction disorders. This finding is due to the variability in the total number of single muscle fibers being activated at any single time.

15

Patients are NOT candidates for bariatric surgery if they are
(a) twice their ideal body weight.
(b) age 50 or younger.
(c) without a psychiatric contraindication.
(d) experiencing skin breakdown

Answer: D
Commentary: Surgical candidates include persons who are twice their ideal weight, demonstrate recurrent failure to lose weight through dieting, have no cardiopulmonary or psychiatric contraindications, and are usually50 years of age or younger in most cases, with minor exceptions. Some patients may ask about this procedure when it is recommended they lose weight in order to mitigate musculoskeletal pain.

16

In response to a request for information regarding ejaculation, you advise a 22-year-old man with T4 ASIA A paraplegia who is 1 year postinjury to
(a) avoid ejaculation, because of the risk of autonomic dysreflexia.
(b) use sildenafil (Viagra) 60 minutes before intercourse.
(c) use vibratory stimulation.
(d) see a urologist for direct sperm harvest.

Answer: C
Commentary: In men with spinal cord injury who have an ejaculation reflex (upper motor neuron lesion), there is a 30% to 96% ejaculation rate, depending on the amplitude and frequency of vibratory stimulation. Sildenafil is an option for erectile dysfunction, rather than for ejaculation-related problems. Autonomic dysreflexia can occur with ejaculation but is more commonly a transient phenomenon and does not lead to complications

17

As compared to children with severe traumatic brain injuries, children with severe anoxic encephalopathy are more likely to have
(a) rigidity and decreased rate of regaining consciousness.
(b) rigidity and increased rate of regaining consciousness.
(c) hypotonia and decreased rate of regaining consciousness.
(d) hypotonia and increased rate of regaining consciousness.

Answer: A
Commentary: Compared to children with severe traumatic brain injury, children with severe anoxic encephalopathy are less likely to regain consciousness; they also have shorter survival time, and often have profound rigidity.

18

Which condition is a progressive neuromuscular disease that destroys upper and lower motor neurons?
(a) Transverse myelitis
(b) Amyotrophic lateral sclerosis
(c) Kugelberg-Welander disease
(d) Multiple sclerosis

Commentary: Amyotrophic lateral sclerosis (ALS) is perhaps the most severe of all the major neuromuscular diseases. It is a rapidly progressive disease that destroys both upper and lower motor neurons. This destruction results in diffuse muscular weakness and atrophy. Unlike most primary nerve disorders, ALS also produces spasticity because of the loss of upper motor neurons. This loss creates unique clinical management issues. Kugelberg-Welander disease has a very slow progressive course with no upper motor neuron findings of spasticity. Multiple sclerosis and transverse myelitis are demyelinating diseases of the central nervous system with symptoms that mimic lower motor neuron findings, such as weakness.

19

A 42-year-old man with human immunodeficiency virus (HIV) presents with proximal muscle weakness, myalgia, and weight loss. His creatine phosphokinase (CPK) is elevated. What is the most likely cause?
(a) HIV myopathy
(b) Fibromyalgia
(c) Antiretroviral medications
(d) Vacuolar myelopathy

Commentary: HIV myopathy commonly presents with proximal muscle weakness, myalgia (in 25%-50% of cases), and weight loss. Vacuolar myelopathy causes spinal cord dysfunction, such as paraparesis, ataxia, posterior column sensory loss, spasticity, and neurogenic bowel and bladder. CPK would not be elevated in fibromyalgia or as a result of antiretroviral medications. Antiretroviral medications are associated with neuropathies, not myopathies.

20

A 45-year-old secretary comes in complaining of right hand numbness that began 6 weeks ago, and her symptoms are beginning to bother her at night. After performing a physical exam you diagnose her with carpal tunnel syndrome. Which treatment is shown to improve the symptoms of carpal tunnel syndrome for up to 1 year?
(a) Oral corticosteroids
(b) Therapeutic ultrasound
(c) Wrist/hand splint
(d) Tendon glide maneuvers

Answer: C
Commentary: Using a wrist/hand splint can improve the symptoms of carpal tunnel syndrome for up to 1 year. Therapeutic ultrasound and oral corticosteroids have been shown to provide only short-term relief. Tendon glide maneuvers have not been shown to affect the outcome of carpal tunnel syndrome.

21

jarum E1 di dalam, E2 diluar bawah
E-1 active electrode
E-2 reference electrode
What kind of needle electrode is depicted above?
(a) Monopolar
(b) Standard concentric
(c) Single fiber
(d) Bipolar concentric

C
Commentary: The single fiber electrode has an active electrode as a side port pickup and the cannula serves as the reference. A separate ground electrode is also required

22

In prosthetics, K levels are used to describe or define
(a) activity levels.
(b) prosthetic feet.
(c) funding levels for prosthesis.
(d) etiology of amputation.

Answer: A
Commentary: K levels are used to describe activity levels These K0-K4 designations are guidelines for prosthetic components covered by Medicare.

23

Which electroencephalogram pattern is associated with a better prognosis after traumatic brain injury?
(a) Low amplitude delta activity
(b) Burst suppression
(c) Isoelectric activity
(d) Spindle pattern

Answer: D
Commentary: Favorable electroencephalogram (EEG) patterns after a traumatic brain injury are normal activity, rhythmic theta activity, frontal rhythmic delta activity, and spindle pattern. Poor prognosis is associated with epileptiform activity, nonreactive, low amplitude delta activity and burst suppression patterns with interruption of isoelectricity. Complete isoelectric EEG activity had the highest mortality.

24

A 35-year-old gentleman with a history of Lyme disease that was treated adequately with antibiotics 1 year ago complains of continued muscle aches, joint pain, fatigue, and difficulty concentrating. His repeat Lyme serologies have been negative, as have all other laboratory tests. He has had a full medical work-up from his internist that has been unremarkable. You recommend
(a)
intravenousceftriaxone for 28 days.
(b)
sulfasalazine for his muscle and joint pains.
(c)
intra-articular cortisone injections for joint pain.
(d)
emotional support and symptom management.

Answer: D
Commentary: The patient has postLyme disease syndrome, which occurs in a minority of patients who have had Lyme disease. There is no specific treatment. Physicians should provide support and management of patient complaints. Antibiotic treatment is contraindicated. Sulfasalazine is not a treatment for Lyme disease.

25

A 37-year-old man presents to your office with a Grade 2 sacral pressure sore which appears clean, with no necrotic tissue and only a slight amount of serosanguinous drainage. In order to optimize wound healing, you suggest
(a) allowing a protective eschar to form.
(b) wet to dry gauze dressings.
(c) vacuum-assisted closure.
(d) an occlusive dressing.

Answer: D
Commentary: An occlusive dressing will help to maintain a moist environment, which is ideal for wound healing. Allowing eschar to form will inhibit healing. Wet to dry dressing changes are used only when debridement is required. Vacuum-assisted closure is usually used on grade 3 and grade 4 wounds.

26

Which is the most common neuropsychological dysfunction after a liver transplant?
(a) Seizures
(b) Encephalopathy
(c) Stroke
(d) Depression

Answer: B
Commentary: In a study by Ghaus et al, 62% of liver transplant patients developed encephalopathy. Seizures occurred in 11% and stroke in 9%. In another study by Rothenhausler, 3% of transplant patients had depression.

27

Which factor is associated with increased risk for occupational injury in an older individual?
(a) White collar occupation
(b) Female gender
(c) Impaired hearing
(d) Self employment

Answer: C
Commentary: Predictors of increased injury risk in an older worker include male gender, less education, obesity, alcohol abuse, disability, self report of impaired hearing or sight, and several specific job requirements. Service workers, mechanics, machine operators, and laborers are at increased risk for occupational injury compared to people in white collar occupations. Individuals who are self-employed have a lower risk of injury.

28

Which maternal factor is associated with an increased risk of spina bifida?
(a) Anticonvulsant medications during pregnancy
(b) Upper socioeconomic class
(c) Alcohol ingestion during pregnancy
(d) Folic acid 4mg/day prior to and during pregnancy

Answer: A
Commentary: The etiology of spina bifida is multifactorial. Both polygenic inheritance and environmental influences contribute. Several studies have shown that there the incidence of spina bifida is reduced if food is fortified with folic acid or if mothers take folic acid prior to conception and during pregnancy. Recommended doses of folic acid are 0.4 mg/day in women who are not at high risk and 4 mg /day in women at high risk (eg, those with a family history of spina bifida). Some studies have also implicated lower socioeconomic class and in utero exposure to anticonvulsant medications as being risk factors. Maternal alcohol ingestion is not related to an increased risk of spina bifida in a baby.

29

Which factor promotes knee stability during the gait cycle of a person with transfemoral amputation?
(a) Knee component placed anterior to the socket
(b) Hard heel in the prosthetic foot
(c) Polycentric 4-bar linkage prosthetic knee
(d) Anterior position of the shank on the prosthetic foot

Answer: C
Commentary: Flexion moment at the hip, a rigid heel in the solid ankle, cushion heel foot and the anterior position of the shank all shift the ground reaction force behind the knee joint to produce a knee flexion moment. The 4-bar linkage with instantaneous center of rotation and the posterior location of instant center in extension creates knee stability, especially at heel strike

30

In a patient with traumatic brain injury who has impaired speed of processing, inattention and decreased arousal, which medication is regarded as first-line therapy?
(a) modafinil (Provigil)
(b) methylphenidate (Ritalin)
(c) bromocriptine (Parodel)
(d) carbidopa/levodopa (Sinemet)

Answer: B
Commentary: The present evidence suggests that methylphenidate should be regarded as first-line therapy when an agent from this medication class is used. If methylphenidate proves ineffective
or produces intolerable side effects, dextroamphetamine, amantadine, or bromocriptine may be useful alternative stimulant medications. Amantadine’s side effect profile is worse than methylphenidate and there is some evidence of a lowering of the seizure threshold, but this is controversial. There is no support at this time in the literature for the use of modafinil over methylphenidate. Bromocriptine and carbidopa/levodopa both have worse side effects and are not as well studied as methylphenidate or amantadine.

31

A 75-year-old manwith a recent calcaneal stress fracture after starting a walking program presents to your clinic. Initially, you should
(a) order a bone mineral density test.
(b) prescribe a lower extremity strengthening program.
(c) obtain a nuclear bone scan.
(d) prescribe a swimming program

Answer: A
Commentary: The initial assessment should include checking his bone density to establish a diagnosis of osteopenia/osteoporosis and then identifying secondary risk factors (such as hypogonadism, corticosteroid use, excessive alcohol use). Once a diagnosis is established, prescribing weight-bearing and strengthening exercises are important. Obtaining a nuclear bone scan is not as helpful. Swimming is a non-weight bearing exercise.

32

Which of the following is a benefit of a phrenic pacemaker in an individual with tetraplegia
(a) elimination of ventilator support
(b) improved speech
(c) improved hearing acuity
(d) longer life expectancy

Answer: B
Commentary: Benefits of p hrenic pacemaking include improved speech, improved smell, ease of transfers and out of home mobility, reduced incidence of respiratory tract infections, and reduced volume of repiratory secretions.

33

Hydrocolloid dressings facilitate debridement through which mechanism?
(a) Enzymatic
(b) Autolytic
(c) Sharp
(d) Mechanical

Answer: B
Commentary: Hydrocolloid dressings maintain a moist wound environment. Subsequently, proteases and collagenase digest eschar that is in contact with the wound fluid. This process is called autolysis. In enzymatic debridement, chemical agents such as papain-urea break down necrotic tissue. Sharp debridement is performed using an instrument such as a scalpel. An example of mechanical debridement would be wet-to-dry dressing or whirlpool treatment.

34

Which electrodiagnostic criterion is included in the diagnosis of peripheral nerve demyelination?
(a) Conduction velocity reduced in at least 4 nerves
(b) Compound muscle action potential conduction block in at least 3 nerves
(c) Prolonged distal motor latencies in at least 4 nerves
(d) Prolonged F-wave latency or absent F wave

Answer: D
Commentary: The criteria require conduction velocity to be reduced in 2 or more nerves, compound muscle action potential conduction block or abnormal temporal dispersion in 1 or more nerves, prolonged distal motor latencies in 2 or more nerves, and prolonged F wave or absent F wave. Three of these four criteria must be present.

35

45-year-old concert violinist presents to your clinic for evaluation of left elbow pain. She has been diagnosed with “lateral epicondylitis” and has had pain and impaired function for 8 months. She has been treating her symptoms with relative rest, occupational therapy and alternative therapies, such as acupuncture and massage, without improvement in her symptoms. What other diagnoses should you consider in this patient?
(a) Intersection syndrome
(b) Musculocutaneous neuropathy
(c) Posterior interosseous neuropathy
(d) Rotator cuff tendinopathy

Answer: C
Commentary: Patients whose symptoms are consistent with lateral epicondylitis or “tennis elbow” but who do not respond to conservative treatments should be considered to have a posterior interosseous neuropathy. Mild neural compression of the posterior interosseous nerve may present with proximal and dorsal forearm pain without obvious muscle weakness, wasting, or sensory deficits.

36

The physical therapist calls you concerning the patient with traumatic brain injury you
admitted last week. She tells you that his bladder incontinence is disrupting therapy. You have checked his urinalysis and there is no evidence of a urinary tract infection. A postvoid residual bladder ultrasound shows that his bladder is emptying well. Your next step is to initiate
(a)
an anticholinergic medication.
(b)
in/out catheterization.
(c)
a condom catheter with a leg bag.
(d)
a behavioral modification program and timed voiding.

Answer: D
Commentary: This patient is exhibiting normal bladder emptying with no evidence of a bladder infection. An anticholinergic in a patient with a traumatic brain injury may exacerbate his confusion. A condom catheter in this population will probably not stay in place. It may increase agitation and will not help the patient. Intermittent catheterization and a Foley catheter will increase the patient's infection risk. The best course at this time is frequent bladder emptying and retraining, with the entire rehabilitation team encouraging the new behavioral modification.

37

Children with L4-5 spina bifida are most likely to have
(a) equinus foot.
(b) cavus foot.
(c) knee flexion contractures.
(d) knee extension contractures.

Answer: D
Commentary: The knee extensors (quadriceps) are innervated at the L3-4 level, while the knee flexors (hamstrings) are innervated at the L5-S1 level. A child with L4-5 preserved level would have quadriceps muscles that work, while hamstrings will either be weak or absent. Foot muscles are innervated at the L5-S2 levels. Equinus and cavus feet result from asymmetric pull of foot muscles, which would be seen in sacral levels of spina bifida.

38

Which statement is TRUE for children with acute inflammatory demyelinating polyneuropathy compared to adults with that disease?
(a) Both recover at the same rate.
(b) Disease course is more benign.
(c) Residual weakness is more common.
(d) Respiratory failure rates are equal.

Answer: B
Commentary: The natural history of acute inflammatory demyelinating polyneuropathy (AIDP) in children is more benign than AIDP in adults. Children usually recover more quickly by 3 months
on some occasions. Residual weakness is not as common for adults. The best prognostic indicator is the degree of disability at the peak of illness.

39

What function would be expected in a 24-year-old healthy woman with C7 ASIA A tetraplegia?
(a) Requires minimal assistance for level transfers
(b) Requires minimal assistance for side-side weight shifts
(c) Independent manual wheelchair use on uneven terrain
(d) Independent dressing and bathing with adaptive equipment

Answer: D
Commentary: The C7 level is considered the key level for becoming independent in most activities at a wheelchair level. Persons with a C7 motor level who are in good health are usually independent for weight shifts, transfers between level surfaces, feeding, grooming, and upper body dressing. Some assistance may be required for wheelchair propulsion on uneven terrain. Bathing can be performed independently with the appropriate adaptive equipment.

40

A 6-month-old child with L4 spina bifida presents to your clinic. He also has shunted hydrocephalus. Other than repair of his back and shunt placement, his past medical history has been negative. On examination, you find that he has full hip flexion against gravity and knee extension strength is at least 4/5. The infant has no movement around the ankle. Feet are in neutral position. Hip examination is symmetric. Which prediction is most accurate in this patient?
(a) The child is likely to be a functional community ambulator by age 5 years.
(b) The child is likely to be only a household ambulator.
(c) The child is likely to learn to crutch walk by 18 months.
(d) The child is likely to be only a wheelchair user.

Answer: A
Commentary: This child has a strong quadriceps muscle and no deformities noted at 6 months of age. He is reported to be healthy. The best early predictor of ambulation in children with spina bifida is a strong quadriceps muscle. Negative predictors are spine and lower extremity deformities and obesity. Children do not typically learn to use crutches until 3 to 5 years of age or older.

41

The primary advantage of a soft insert fitted into the socket of a transtibial prosthesis is that it is
(a) perspiration resistant.
(b) easy to keep clean.
(c) easily modified.
(d) very durable.

Answer: C
Commentary: Soft inserts are fabricated to fit inside the socket. They are recommended for patients with thin, sensitive, or scarred skin, or peripheral vascular disease (PVD). They are easily modified. Hard sockets also have their advantages. They are perspiration resistant, less bulky than sockets fitted with a soft insert, easy to keep clean, and durable. Further, reliefs or modifications can be located with precision in the hard socket.

42

A 35-year-old man presents to your clinic with a 3-month history of groin pain exacerbated by activity. He is an avid skier and runner. He has been taking anti-inflammatories with minimal relief. Anteroposterior films of the hip were normal. The magnetic resonance imaging of the hip reported a bony prominence at the femoral head-neck junction. What clinical exam finding is most likely to correlate with these radiographic “abnormalities” ?
(a) Pain with resisted straight leg raise
(b) Pain with hip flexion, external rotation, and abduction
(c) Pain with sacral thrust
(d) Pain with hip flexion, internal rotation, and adduction

Answer:D
Commentary: This patient has radiographic evidence of femoroacetabular impingement. Two types have been described, cam impingement and pincer impingement. Cam impingement is described more commonly in active males and describes a non-spherical femoral head or osseous abnormalities of the femoral head-neck junction. These bony abnormalities have abnormal contact with the acetabulum in hip flexion, adduction, and internal rotation. Pincer impingement describes abnormal contact between the femur and the acetabulum due to overcoverage of the femoral head from an abnormally deep or retroverted acetabulum.

43

The usual time of onset of diabetes insipidus in patients with traumatic brain injury is
(a)
at time of injury.
(b)
10 days postinjury.
(c)
30 days postinjury.
(d)
3 months postinjury

Answer: B
Commentary: Diabetes insipidus after TBI usually has an onset 10 days after trauma when the antidiuretic hormone (ADH) stored in the posterior pituitary is depleted.

44

Which factor is a criterion for hip osteoarthritis?
(a)
Periarticularosteopenia
(b)
Femoral head erosions with sclerosis
(c)
Acetabular osteophytes
(d)
Erythrocyte sedimentation rate above20mm/hr

Answer: C
Commentary: The American College of Rheumatology states that the criteria for osteoarthritis of the hip are hip pain along with 2 of the three findings: erythrocyte sedimentation rate less than 20mm/hr, radiographic evidence of femoral/acetabular osteophytes, radiographic evidence joint-space narrowing.

45

A recent study of individuals undergoing a single knee or hip replacement surgery who were treated at an inpatient rehabilitation facility (IRF) compared to those treated at a skilled nursing facility (SNF) found that those treated in an IRF were more likely to
(a) need the use of a walker to ambulate.
(b) require home care services.
(c) be discharged home.
(d) ambulate a shorter distance

Answer: C
Commentary: Patients undergoing single knee or hip replacement surgery who were treated at an IRF were more likely to be discharged home, less likely to require home care services upon discharge, and were able to ambulate farther distances compared to those treated in an SNF.

46

Which statement is true about the asymmetric tonic neck reflex (ATNR) or the symmetric tonic neck reflex (STNR)?
(a) The STNR is present at birth and fades away by 1 year.
(b) The STNR provides postural stability as the child goes from crawling to standing.
(c) The ATNR appears about 6 months of age and fades away by 1 year.
(d) The ATNR is obligatory in all children at certain ages.

Answer: B
Commentary: The ATNR is also known as the fencer position and is a neonatal reflex that disappears by 6 months of age. It is never obligatory in normal children. The STNR appears about 6 months and disappears by 1 year. It provides postural stability as the child makes the transition from crawling to standing.

47

A 55-year-old woman presents to the clinic with a 6-week history of right wrist pain. She is an administrative assistant and has been working extra hours for the past 3 months. She has been taking anti-inflammatory medications without relief. You diagnose her with de Quervain tenosynovitis. What is the next most appropriate step in treatment?
(a) Trial of a higher dose of anti-inflammatory medication
(b) Surgical consultation
(c) Corticosteroid injection
(d) Splinting the wrist

Answer: C
Commentary: Corticosteroid injection for de Quervain tenosynovitis has been shown to be more effective treatment than splinting and anti-inflammatory medications

48

Which factor makes it most probable that a patient is at risk for nerve damage?
(a) Bone fracture without dislocation
(b) Hematoma
(c) Open fracture
(d) High velocity trauma

Answer: B
Commentary: A hematoma places the nerve at risk for injury by 400%, since the expanding fluid will lead to an acute compression neuropathy

49

A 48-year-old is admitted to your rehabilitation facility 3 weeks after sustaining a spinal cord injury. The motor and sensory examination is as follows:
R Motor L Motor
Deltoid 5 5
Biceps 5 5
Wrist extensor 5 5
Triceps 3 3
Finger flexors 1 1
Intrinsics 1 1
Hip flexors 0 0
Knee extensors 0 0
Dorsiflexors 0 0
Plantarflexors 0 0
Sensory exam revealed intact pinprick and light touch sensation through C7. Sensation is absent below C7 except for intact perianal sensation.
What is the patient's ASIA score?
(a) C7 ASIA B
(b) C6 ASIA B
(c) C6 ASIA C
(d) C7 ASIA C

Answer: A
Commentary: Based on the ASIA classification system this patient would be classified as C7, given the normal sensation in that myotome and a muscle grade of 3/5 at C7 with the level above being 5/5. The trace activity in finger flexors and intrinsics are within 3 segments of the level of injury and cannot be used to suggest the patient is motor incomplete (ASIA C). The patient is classified as ASIA B because of the retained sacral sensation

50

Which structure is required by the American with Disabilities Act (ADA) to have adequate accessibility for individuals with disabilities, so long as the modifications to it are readily achievable?
(a) House of worship
(b) Physician’s office within a private residence
(c) Commercial airplane
(d) Residential private apartments

Answer: B
Commentary: If a publicly accessible office is present within a single family home, it is required to be accessible under the ADA, so long as the necessary modifications are readily achievable. Accessibility of commercial airplanes is covered under the Air Carrier Access Act, not the ADA.
Access to houses of worship or strictly residential private apartments is not required under the ADA.

51

Which electrodiagnostic finding is most consistent with neurogenic thoracic outlet syndrome?
(a) Small median motor response from the thenar muscles
(b) Abnormal response of the lateral antebrachial cutaneous nerve
(c) Abnormal median sensory responses
(d) Abnormal spontaneous activity in the pronator teres muscle

Answer: B
Commentary: Neurogenic thoracic outlet syndrome involves the lower trunk of the brachial plexus; hence, sensory and motor loss develops in the C8–T1 distribution. Thumb abduction is often affected. Sensory changes are usually in the distribution of the ulnar and medial antebrachial cutaneous nerves.

52

Your 3-year-old patient with cerebral palsy has a Gross Motor Function Classification System (GMFCS) Level IV. Family is asking you what to expect she will be able to do when she is a teenager. Which activity is the highest level she is most likely to attain as a teenager?
(a) Independent ambulation in the household
(b) Independent ambulation in the community
(c) No independent mobility in the household
(d) Wheelchair use in the community

Answer: D
Commentary: The Gross Motor Function Classification System (GMFCS) classifies mobility of people with cerebral palsy from I to V. Level I is independent ambulation indoors and outdoors with no assistive device. Level IV requires wheelchair for household and community mobility.

53

How are mobility devices paid for through Medicare?
(a) The patient must make a 50% down payment, with the rest covered by Medicare upon delivery of the device.
(b) Medicare part A pays 80% of the allowed purchase price and Medicare part B pays the remaining 20%.
(c) Medicare will pay for purchase but not rental of mobility devices.
(d) Medicare part B pays 80% of the allowed purchase price in one lump sum.

Answer: D
Commentary: Medicare Part B pays 80% of the allowed purchase price in one lump sum payment if the patient chooses to purchase the device. The patient is required to pay 20% of the allowed purchase price. If the patient chooses to rent a wheelchair, Medicare part B will pay 80% of the allowed rental price for months 1 through 10 and the patient will pay 20% of the allowed rental charge.

54

22-year-old female volleyball player fell on an outstretched right hand 3 weeks ago and complains of continued wrist pain. On examination, she has minimal swelling of the distal limb and is tender to palpation distal to the ulnar styloid between the flexor carpi ulnaris and extensor carpi ulnaris tendons. A plain radiograph was normal except for an ulnar plus variant. She failed conservative treatment with splinting and activity modification. The most appropriate imaging study to obtain would be
(a) computed tomography scan of the wrist.
(b) repeat plain films in 10 days.
(c) triple phase bone scan.
(d) magnetic resonance imaging with arthrogram

Answer: D
Commentary: This patient sustained an injury to her triangular fibrocartilage complex. This structure is a stabilizer of the distal radioulnar joint and is composed of an avascular articular disc and radioulnar ligament complex. It is often injured with repetitive wrist activities or compressive loads. Tears to it are best imaged by MRI arthrogram. Injury to this complex would not be optimally evaluated on plain films, bone scan, or computed tomography scan.

55

A 45-year-old woman is currently hospitalized for an acute flare of her dermatomyositis. On consultation, you recommend
(a)
passive range-of-motion exercises.
(b)
isometric strengthening exercises at the bedside.
(c)
ambulation with a walker in the hallways.
(d)
aquatic therapy.

Answer: A
Commentary: Passive range of motion to maintain joint movement is recommended during periods of acute flares. With resolution of the flare, active-assisted exercises may be started, progressing to strengthening exercises.

56

Which clinical factor offers a favorable prognosis in multiple sclerosis?
(a) Male sex
(b) Older age at onset
(c) Normal MRI at presentation
(d) Early development of mild disability

Answer: C
Commentary: Favorable clinical factors with prognostic value in multiple sclerosis include younger age at onset, female, normal MRI at presentation, complete recovery from first relapse, low relapse rate, long interval to second relapse, and low disability at 2 and 4 years.

57

At mid stance, where is the ground reaction force vector located?
(a) Anterior to ankle, posterior to knee
(b) Anterior to ankle, anterior to knee
(c) Anterior to knee, anterior to hip
(d) Posterior to knee, posterior to hip

Answer: B
Commentary: In mid stance, the ground reaction vector lies anterior to the ankle, anterior to or through the knee axis, and posterior to the hip center. The passive torques created by this vector alignment are ankle dorsiflexion, knee extension and hip extension.

58

Which type of muscle contraction produces the greatest amount of force generation (torque)?
(a) Fast concentric
(b) Slow concentric
(c) Isometric
(d) Fast eccentric

Answer: D
Commentary: Muscle force generation varies depending on the type of muscle contraction and the speed of the contraction. Eccentric contractions produce greater torque than isometric contractions and isometric contractions produce greater force than concentric muscle contractions. As the speed of contraction increases, eccentric contractions produce greater force. The opposite is true for concentric contractions, which generate greater forces at slower speeds.

59

Which approach is an initial management strategy for sialorrhea that does not interfere with swallowing?
(a) Antihistamine medication
(b) Botulinum toxin injection
(c) Irradiation of salivary glands
(d) Salivary duct ligation

Answer: A
Commentary: Antihistamine and anticholinergics have both been used with varying success and are often first line management options. Botulinum toxin has been used in cases of axillary hyperhidrosis and case reports identify use in sialorrhea. This approach should be considered after less invasive measures fail. For very thick secretions, hydration will help make the discharge thinner and easier to manage. In some cases, irradiation or surgery may be needed to allow safe swallowing.

60

Autonomic dysreflexia is
(a) best treated by placing the patient supine.
(b) a common occurrence in patients with T8 spinal cord injuries.
(c) predominantly characterized by parasympathetic activity.
(d) rarely occurs earlier than 1 month after injury.

Answer: D
Commentary: Autonomic dysreflexia is most commonly found in patients with spinal cord injury at T6 and above. It is associated with a release of sympathetic activity, which results in regional vasoconstriction. It is usually present by 6 months to 1 year after injury. Initial treatment involves prompt removal of the noxious stimulus and sitting the patient up.

61

You recommend work hardening for a worker recovering from a shoulder injury. You explain to the worker to expect a therapy program that
(a) builds aerobic conditioning and will be performed 2 hours daily.
(b) simulates work duties and will be performed approximately 4 hours daily.
(c) simulates a heavy manual labor job and will be performed 6 hours daily.
(d) improves aerobic conditioning while simulating a light duty job and will be performed 8 hours daily.

Answer: B
Commentary: Work hardening is a rehabilitation program designed to simulate the individual worker’s job. It can be performed at a center or at the worker’s jobsite. These programs are often recommended to be done 5 days a week. The worker performs an individualized program based
on his/her specific job requirements. Physician follow-up is needed to determine if goals have been achieved. Work conditioning is a program used to enhance aerobic conditioning but does not attempt to replicate the tasks of a specific job.

62

What is the most common medical complication during postacute stroke rehabilitation?
(a) Venous thromboembolism
(b) Falls
(c) Depression
(d) Pulmonary aspiration, pneumonia

Answer: D
Commentary: Of the complications listed, aspiration/pneumonia is seen in about 40%, while venous thromboembolism is seen in 6%; falls occur in 16%, musculoskeletal complications in 5%, and reflex sympathetic dystrophy (RSD) in 30 %. Depression affects 30%. Urinary tract infection is just as frequent at 40%, but is not listed.

63

A 60-year-old man with left total knee arthroplasty 5 days prior continues to have difficulty with ambulation during rehabilitation. On exam, he has 70oof active knee flexion, a 20oextensor lag, and a distal lower limb normal to palpation. You then notice that he has trouble clearing his toes during swing phase. You suspect the major cause of his difficulty walking is due to
(a)
weak quadriceps strength.
(b)
inadequate knee flexion range.
(c)
commonperoneal nerve palsy.
(d)
tibialis anterior tendon tear.

Answer: C
Commentary: The patient has a common peroneal nerve palsy which can occur after total knee arthroplasty. Weak quadriceps strength and inadequate knee flexion may cause difficulty with ambulation, but not the loss of ankle dorsiflexion. Tibialis anterior tendon tear will cause difficulty with ankle dorsiflexion, but is not a common complication after knee arthroplasty. Also, acute tendon tears present with sudden pain and palpatory defect.

64

A 28-year-old man returns to clinic after failing conservative management for clinical medial epicondylitis. In order to determine the appropriateness of a surgical referral, what is the most cost effective diagnostic test to localize the site of pathology?
(a)
Plain radiographs of the elbow and forearm
(b)
Magnetic resonance imaging of upper extremity
(c)
Real time ultrasound
(d)
Electrodiagnostic studies

Answer: C
Commentary: Real time ultrasound is less costly than magnetic resonance imaging (MRI) and has similar sensitivity and specificity in diagnosing medial epicondylitis. Plain radiographs and electrodiagnostic studies will not help localize or confirm your diagnosis of medial epicondylitis, but may help with diagnosing a fracture or nerve injury, respectively.

65

Which statement is TRUE concerning traumatic spinal cord injury (SCI)?
(a) More than 80% of individuals identified as having motor incomplete SCI at 72 hours after their injury will walk.
(b) There is a plateau of functional recovery after incomplete SCI that occurs after the first 3 months.
(c) More than 80% of individuals with complete tetraplegia will regain 2 motor levels below their initial injury level.
(d) Approximately one-third of individuals with SCI have complete injuries and two-thirds have incomplete injuries.

Answer: A
Commentary: The majority of patients with complete tetraplegia regain 1 level below their original injury. Up to 87% of motor incomplete subjects (ASIA C) identified at 72 hours postinjury were ambulating at 1 year. The ratio of complete to incomplete SCI is close to 50:50. Recovery after incomplete SCI is often most rapid up to 6 months postinjury but can still occur at a slower rate after 2 years.

66

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

Answer: A
Commentary: Conduction is a process of transferring thermal energy between 2 entities placed in direct contact with each other, for example cold packs on skin. Convection is a process of using a medium to transfer energy: Examples of convection include the use of husks with fluidotherapy,
and the use of water with whirlpool therapy. Vapocoolant sprays are an example of evaporation, not conduction.

67

Disability as defined by the Americans with Disabilities Act (ADA) is
(a) a physical or mental impairment that substantially limits 1 or more major life activities.
(b) abnormality of the physiologic or anatomic structure or function.
(c) the barriers society places on the individual interacting in his/her community.
(d) a rating based on an independent medical examination.

Commentary: The Americans with Disabilities Act defines disability as a physical or mental impairment that substantially limits 1 or more of a person’s major life activities. The person has a record of such impairment, or is regarded as having such impairment. Impairment is the actual physiologic, anatomic, or psychologic abnormality. Handicap refers to the barriers society places on an individual to perform function in the community. A permanent disability rating is used to determine financial compensation for an injury.

68

Palliative care is characterized by
(a) a holistic approach to comprehensive symptom management.
(b) symptom only management in persons with terminal illnesses.
(c) disease modifying therapies.
(d) care provided in the home setting only.

Answer: A
Commentary: Palliative care involves a holistic approach to comprehensive symptom management. This care has a potential role in the management of all disease states that feature an intense and adverse symptom complex. Palliative care typically does not include disease modifying therapies, although it can be provided in conjunction with these treatments. Palliative care can be provided in a variety of health care settings and is not limited to persons with terminal illnesses.

69

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

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

70

The validity of a functional outcome measurement tool is defined as the ability
(a) of two different raters to obtain the same conclusion.
(b) of the tool to measure what it is designed to measure.
(c) to minimize random error.
(d) to measure several different outcomes simultaneously

Answer: B
Commentary: The validity of a functional outcome measurement tool is defined as the ability of the tool to measure what it is designed to measure. The ability to measure different outcomes simultaneously does not impact the validity of the instrument, but the validity of the tool would need to be established for each of the outcomes being measured. The ability of two different raters to obtain the same conclusion is referred to as inter-rater reliability. Freedom from random error is also related to the reliability of the instrument.

71

A 23-year-old postgraduate student presents to your office with bilateral knee pain. She just began training for a half marathon but has been limited by her knee pain. She reports pain in the anterior aspect of the knee and describes it as “beneath the knee cap.” The pain is worse when arising after sitting for a prolonged period of time. Which physical examination finding might you expect in this patient?
(a) Pes cavus
(b) Strong hip abductors
(c) Negative Ober test
(d) Tight quadriceps muscles

Answer: D
Commentary: Patellofemoral arthralgia is thought to result from tracking problems of the patella within the trochlear groove. Several biomechanical issues, such as tight and inflexible quadriceps, pes planus, tight iliotibial band, weak and ineffective vastalis medialis, and weak hip abductors, may contribute to incorrect tracking of the patella. The Ober test assesses the tensor fascia lata and iliotibial band for contracture and inflexibility.

72

A 60-year-old woman had a stroke 1 week ago. On examination you find loss of pain-and-temperature sensation on the right side of her face as well as on the left side of her body. You also note some nystagmus, with right eye ptosis and miosis. What is the most likely location of the lesion?
(a) Lateral pons
(b) Frontoparietal lobe
(c) Lateral medulla
(d) Medial basal midbrain

Answer: C
Commentary: A lesion in the lateral medulla causes Wallenberg syndrome and is associated with ipsilateral loss of facial pain- and temperature-sensation and contralateral loss of body pain-and-temperature sensation. Ipsilateral Horner syndrome (ptosis, miosis and anhidrosis) is found, as well as nystagmus, dysphagia and dysphonia

73

According to the motor unit size principle, which statement is TRUE about muscle activation?
(a)
Recruitment of smaller units is followed by recruitment of larger units.
(b)
Motor unit size gradually decreases with increased recruitment.
(c)
Motor unit size is independent of the force of muscle contraction.
(d)
Larger motor units are found in larger muscles.

Answer: A
Commentary: The motor unit size principle, which has been supported by many investigators, states that during muscle activation, smaller motor units are activated first and the larger motor units are recruited with more forceful contraction.

74

Which muscle fiber type uses only glycolytic metabolism for energy?
(a)
Type 1
(b)
Type 2a
(c)
Type 2b
(d)
Type 3

Answer: C
Commentary: There are 2 primary muscle fiber types in humans. They are categorized according to 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 with both oxidative and glycolytic metabolism (type 2a) and fast-twitch glycolytic (type 2b).

75

What is the most beneficial combination of weight and plane of orientation when ordering cervical traction to treat an acute cervical radiculopathy?
(a) 15--25 pounds applied with neck in extension
(b) 75--100 pounds applied with neck in flexion
(c) 55--75 pounds applied with neck in neutral
(d) 25--35 pounds applied with neck in flexion

Answer: D
Commentary: The weight for cervical traction is most beneficial at 25 to 35 pounds of force. Positioning the neck at 20o to30o of flexion provides the maximal effect of distraction between the vertebrae.

76

Which attribute is a characteristic of an experimental research design?
(a) Results primarily provide information on associations between variables.
(b) Manipulation of experimental variables is controlled.
(c) It is retrospective in nature.
(d) It is an observation of the natural history of a disease process

Answer: B
Commentary: Experimental research designs enable investigators to determine a cause and effect relationship between 2 variables; whereas, non-experimental research designs can only establish an association between 2 variables. In an experimental research design an intervention or experimental variable is manipulated and its effect on other variables is measured. Experimental designs are prospective in nature. Cohort studies, in which researchers observe the natural history of a disease process, are non-experimental.

77

A research study is performed to assess the degree of spasticity experienced by individuals after traumatic brain injury. Spasticity in the gastrocnemius muscle is evaluated in 10 patients using the Modified Ashworth Scale (0–5 scale). Which descriptive statistic is appropriate for summarizing the ordinal data measured with this scale?
(a) Ratio
(b) Median
(c) Correlation
(d) Mean

Answer: B
Commentary: The appropriate descriptive statistical method used to summarize ordinal data such as the values used in the Modified Ashworth Scale is the median. The median value is defined as
the value that occurs in the middle of a set of values. The mean would be used to summarize ratio or interval type of data. The other options listed are not descriptive statistical measures.

78

Informed consent documents for participation in research protocols must include language stating
(a) that confidentiality cannot be assured.
(b) that once the document is signed, participation will be required.
(c) the procedures to be used in the study.
(d) that the results of the study will be shared with the subject.

Answer: C
Commentary: Informed consent documents for participation in research protocols must include the procedures to be used in the study. Informed consent documents must also assure confidentiality of the subjects and outcomes of individuals participating in the research. Informed consent documents must also state that subjects have the right to terminate involvement in the study at any time, even after they have signed the consent document. It must also state that the decision to terminate involvement in the study will not affect the individual’s ongoing medical care. Informed consent documents do not provide information that research results will be shared with the individual subjects.

79

The Western Aphasia Battery provides
(a) an aphasia quotient as a measure of the severity of aphasia.
(b) a classification of the aphasic features observed in a particular patient.
(c) a statistical summary of language impairments and an outcome prediction.
(d) an overall rating of functional communication.

Answer: A
Commentary: The Western Aphasia Battery measures various parameters of language and provides the aphasia quotient as a measure of aphasic severity. The Boston Diagnostic Aphasia examination produces a classification of the features of a particular patient and a score of severity and is similar to the Western Aphasia battery, but not the aphasia quotient. The Porch Index of Communication Ability (PICA) is different and evaluates verbal, gestural and graphic responses. The Functional Communication profile provides an overall rating of functional communication.

80

Which massage technique has as it goal the breakup of tissue and muscle adhesions?
(a) Acupressure
(b) Petrissage
(c) Friction Massage
(d) Effleurage

Answer: B
Commentary: Petrissage is a method of compression massage that is used to break up tissue and muscle adhesions. In effleurage massage the practitioner uses a stroking motion that is beneficial for vascular and lymphatic drainage. Friction massage is a method of massage that uses circular motions to small areas of tissue to help with tendonitis and fasciitis. Acupressure is a massage method in which pressure is applied on specific body points to help reduce pain.

81

In contrast to cryotherapy, heat may
(a) be used safely over insensate areas.
(b) increase edema in the treated area.
(c) be used over areas with decreased vascular supply.
(d) decrease pain while cold will not.

Answer: B
Commentary: Cryotherapy and heating modalities share several therapeutic benefits and therapeutic contraindications. Both heat and cold modalities have some analgesic properties and can be used as adjuvant treatments for pain management. Neither cold nor heat modalities should be used over insensate areas or over areas with decreased vascular supply. Heat modalities may increase edema in the area treated, whereas cold therapy will not lead to increased edema.

82

Ultrasound utilizes the physiologic mechanism of
(a) conduction.
(b) evaporation.
(c) convection.
(d) conversion.

Answer: D
Commentary: Conversion is a process of transforming energy to heat; for example, sound transformation with ultrasound. Conduction is a transfer of thermal energy through direct contact; for example, hot packs. Convection is a process of using a medium to transfer energy; for example, fluidotherapy. Evaporation is a process of transforming a liquid to a gas; for example, vapocoolant sprays.

83

According to the American Medical Association Code of Ethics Opinion, which statement is TRUE?
(a) Individual gifts of minimal value from pharmaceutical representatives to physicians are permissible so long as the gifts are related to the physician's work.
(b) It is acceptable for physicians to request free pharmaceuticals for personal use or use by family members.
(c) Subsidies to underwrite the costs of continuing medical education are permissible when provided directly from the pharmaceutical company to the physician.
(d) Faculty presenting at conferences cannot accept honoraria and reimbursement for travel, lodging, and meal expenses.

Answer: A
Commentary: According to the AMA Code of Ethics Opinion, individual gifts of minimal value from pharmaceutical representatives to physicians are permissible, so long as the gifts are related to the physician's work. It is not acceptable for physicians to request free pharmaceuticals for personal use or use by family members. Subsidies to underwrite the costs of continuing medical education are permissible when they are accepted by the conference's sponsor and are not provided directly to the physician. It is acceptable for faculty at conferences to accept reasonable honoraria and reimbursement for travel, lodging, and meal expenses.

84

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

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

85

Your inpatient rehabilitation unit participates in the Uniform Data System for Functional Independence Measures (UDS-FIM) program by submitting information on the outcomes of all patients treated at your facility. Your unit subsequently receives information back from the UDS-FIM database about how outcomes from your center compare to centers in your geographic region and centers across the nation. This process is referred to as
(a) root-cause analysis.
(b) benchmarking.
(c) performance indicator identification.
(d) peer performance evaluation.

Answer: B
Commentary: A benchmark is a target value or standard for comparison for a performance indicator. Functional outcomes and efficiency of functional improvement during inpatient rehabilitation admission are examples of performance indicators. The UDS-FIM database provides a means by which individual rehabilitation units can compare their outcomes to other centers across the nation. This process of comparing outcomes to a standard is referred to as benchmarking.

86

A 50-year-old administrative assistant presents with low back pain. After taking her history, performing a physical examination, and reviewing her imaging studies, you determine that her pain is likely discogenic. She asks if there are any positions which would be better for her back while at work. Which position exerts the most pressure on the lumbar discs?
(a) Standing erect
(b) Standing erect and flexed forward
(c) Seated in a chair
(d) Seated in a chair and flexed forward

Commentary: Nachemson measured the relative pressure changes within the third lumbar disc with changes of position. Standing erect was the reference position and pressures decreased with lying supine and increased in the seated position. Seated and flexed forward further increased disc pressures. Several other positions were evaluated.

87

What is the main principle underlying the Bobath neurofacilitation techniques for rehabilitation?
(a) Work from proximal to distal muscle groups.
(b) Promote diagonal movement patterns.
(c) Focus on multiple joint movements.
(d) Establish synergistic patterns.

Answer: A
Commentary: The Bobath technique of therapy focuses on good posture and works on proximal muscle groups first before proceeding to distal muscle groups. Brunnstrom method uses synergistic patterns and focuses on general movement patterns before moving to more isolated movements. Proprioceptive neuromuscular facilitation (PNF) focuses on multijoint movement patterns in a “diagonal” pattern. The Rood approach focuses on specific muscles selected according to the recovery stage of the stroke.

88

Lying quietly is equivalent to how many metabolic equivalents (METs)?
(a) 0.5 to 1.0
(b) 1.5 to 2.5
(c) 3.0 to 3.5
(d) 4.0 to 4.5

Answer: A
Commentary: Lying quietly is 1.0 MET. Climbing stairs is equivalent to 3-4 METs, and heavy gardening is equivalent to 4-5 METs.

89

A patient has been receiving ultrasound treatments for contractures of the gastrocnemius and soleus muscle. You become concerned about the adequacy of the treatment technique when the patient states that
(a) he has the sensation of a transient deep, dull ache in the calf area during treatment.
(b) the ultrasound application only lasts for 8 to 10 minutes.
(c) the ultrasound application is followed by 10 minutes of rest prior to the stretching.
(d) he is standing during and after the treatment.

Answer: C
Commentary: The physician should be concerned if there is a time gap between the ultrasound application and the stretching activity. In order to be effective, the deep heating that is accomplished with the ultrasound application should be combined with a period of prolonged passive stretching, both during and immediately after the ultrasound application. This can be achieved by having the patient stand during the ultrasound application and after it. An appropriate treatment time with ultrasound is 8 to 12 minutes and the patient may experience a transient deep ache in the treatment application area.

90

Which statement is TRUE when comparing a functional restoration program to active individual therapy for chronic low back pain?
(a)
Flexibility is increased to a greater extent with active individual therapy program.
(b)
Pain intensity is reduced to a greater extent with active individual therapy.
(c)
Functional restoration programs have a greater effect on flexibility and pain than do active individual therapy programs.
(d)
Functional restoration programs produce greater improvements in endurance than do active individual therapy programs.

Answer: D
Commentary: Functional restoration programs produce a greater improvement in endurance, but no differences are noted between functional restoration programs and active individual therapy programs.

91

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

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

92

What is the primary advantage of a body powered upper limb prosthesis compared to a myoelectric prosthesis?
(a) Greater sensory feedback
(b) Moderate or no harnessing
(c) Less body movement to operate
(d) Enhanced cosmesis

Answer: A
Commentary: The advantages of body powered upper limb prostheses include the following factors: moderate cost, most durability, highest sensory feedback, and a variety of prehensors available for various activities. Their disadvantages are that they require the most body movement to operate, have the most harnessing and require increased energy expenditure to use. Myoelectric and/or switch controlled upper limb prostheses have the following advantages: they require moderate to no harnessing, require fewer body movements to operate, have moderate cosmesis, provide more function in proximal areas and, in some cases, provide a stronger grasp. Battery powered prostheses are the heaviest and most expensive prostheses. They also require the most maintenance, provide limited sensory feedback and require extended therapy time.

93

What is the minimal number of points of contact that an orthosis must have in order to exert rotational control?
(a) One
(b) Two
(c) Three
(d) Four

Answer: C
Commentary: Rotational control forces or moments across a joint are not effective unless there are at least 3 points of contact between the device and the limb segment.

94

20-year-old college basketball player was seen in the training room after practice. He reports “twisting” his ankle while attempting to rebound a missed shot. On further questioning, he describes an inversion-type injury. He has swelling along the lateral aspect of the ankle. He is tender to palpation over the anterior talofibular ligament and calcaneofibular ligament as well as the 5th metatarsal base. He has no pain over the lateral or medial malleolus or proximally over the fibular head. You obtain plain radiographs, which show a nondisplaced avulsion fracture of the 5th metatarsal base. What is the next step in treating this individual?
(a) Provide clearance for return to playing basketball without immobilization.
(b) Obtain a surgical consult for possible screw or pin fixation.
(c) Recommend immobilization with a postoperative shoe for 1-2 weeks.
(d) Prescribe non-weight bearing with crutches for 6-8 weeks or until radiographically verified healing occurs.

Answer: C
Commentary: Nondisplaced or minimally displaced avulsion fractures of the 5th metatarsal base can occur with inversion ankle sprains. These generally are treated nonsurgically with a short course of immobilization (1-2 weeks) with a postoperative shoe or a short walking boot. Displaced fractures may require screw or pin fixation. It is important to differentiate an avulsion fracture of the base from a fracture of the metaphyseal-diaphyseal junction (Jones fracture), since treatment is different.

95

You perform an extraocular muscle exam of a patient with multiple sclerosis. You note
that when looking to the right the left eye will not cross midline and she complains of diplopia when looking to the right but not straight ahead or to the left. You classify her findings as
(a) Parinaud syndrome .
(b) Horner syndrome.
(c) Internuclear ophthalmoplegia.
(d) Millard-Gubler syndrome

Answer: C
Commentary: Internuclear ophthalmoplegia (INO) is caused by a lesion in the medial longitudinal fasciculus (MLF) in the paramedian brainstem. It is characterized by impaired adduction of the contralateral eye with gaze toward the side of the lesion. In practice, an isolated case of INO is rare since the 2 sides of the MLF are very near the midline of the brain stem. The two most common causes of INO are multiple sclerosis and paramedian brain stem infarct. The Horner syndrome is due to a superior cervical sympathetic ganglion lesion and causes miosis, ptosis and anhydrosis. Parinaud syndrome causes impaired upward gaze with dilated and nonreactive pupils and is the result of a lesion in the midbrain, usually a pineal tumor. Millard-Gubler syndrome is due to an ipsilateral pons lesion causing ipsilateral palsy of cranial nerve (CN) 6 and CN 7 and a contralateral hemiparesis.

96

When compared to conventional stroke rehabilitation methods, mirror therapy has
been shown to
(a)
improve Modified Ashworth Scale scores for spasticity.
(b)
improve self-care Functional Independence Measure (FIM) score.
(c)
not show any benefit for spasticity or self-care on FIM scores.
(d)
improve motor FIM score only.

Answer: B
Commentary: When comparing a conventional stroke rehabilitation program with mirror therapy for stroke patients, researchers found that mirror therapy resulted in improvement only in the self-care FIM score; it did not improve scores on the Modified Ashworth Scale for spasticity.

97

Performing a seated leg extension exercise is an example of what type of kinetic chain exercise?
(a) Open
(b) Closed
(c) Static
(d) Mixed

Answer: A
Commentary: In open kinetic chain exercises the most distal segment moves around a fixed proximal segment. In closed kinetic chain exercises the proximal segment moves around a fixed distal segment. Static muscle contractions occur when the muscle is contracted but the proximal and distal segments do not move. There are no mixed kinetic chain exercises.

98

What is the effect of treadmill training in Parkinson patients?
(a)
It has no effect on fall risk.
(b)
It improves quality of life.
(c)
It produces no change in gait impairments.
(d)
It reduces tremor.

Answer: B
Commentary: A 6-week treadmill training program in patients with Parkinson disease showed that the program decreased fall risk, improved quality of life, and improved gait impairments. There was no indication of a reduction of tremors.

99

Which statement about the Functional Independence Measure (FIM) is TRUE?
(a) The instrument is limited by its lack of evaluation of cognitive skills.
(b) It is used by inpatient rehabilitation programs to compare the outcomes of their patients with regional and national outcomes.
(c) It uses a 5-point scale to rate the amount of assistance that an individual requires in various functional areas.
(d) It is routinely applied only at discharge from an inpatient rehabilitation facility

Answer: B
Commentary: The Functional Independence Measure (FIM) is an outcomes measurement tool used by inpatient rehabilitation facilities across the country. It enables inpatient rehabilitation programs to compare their patients’ outcomes with regional and national outcomes. The FIM measures an individual’s functional abilities and level of assistance required in 18 separate
functional areas, including cognition and communication. The FIM instrument uses a 7-point scale to rate the amount of assistance that an individual requires in each of these functional areas. The FIM can be completed at any frequency, but is typically completed at least at the time of admission and at the time of discharge from an inpatient rehabilitation facility.

100

The primary stabilizing effect of the flexible lumbosacral orthosis is its ability to
(a) restrict spinal extension.
(b) prevent atrophy of trunk muscles.
(c) elevate intra-abdominal pressure.
(d) enhance kinesthetic feedback

Answer: C
Commentary: Although they do not effectively restrict motion to a significant degree, flexible lumbosacral orthoses elevate intra-abdominal pressure, thereby unloading the spine and supporting structures. This action also provides inhibitory kinesthetic feedback and warmth. Long-term use of binders and other flexible lumbosacral orthoses may, unfortunately, result in atrophy of trunk muscles.