Flashcards in SAER 2010 Deck (50):
20-year-old football player reports anterior shoulder pain during a game. He completes the game,
but radiographs after the game revealed a type 2 acromioclavicular (AC) joint sprain. How is a
type 2 acromioclavicular (AC) joint injury defined?
(a) Acromioclavicular and coracoclavicular ligaments are both disrupted.
(b) Acromioclavicular and coracoclavicular ligaments are both intact.
(c) Acromioclavicular ligament is disrupted, but the coracoclavicular ligament is intact.
(d) Acromioclavicular ligament is intact, and the coracoclavicular ligament is disrupted.
Commentary: Acromioclavicular joint injuries are classified into 6 types according Rockwood
classification. A type 1 injury describes a mild injury to the AC joint without disruption of either
the acromioclavicular or the coracoclavicular ligaments. A type 2 injury describes disruption of
the acromioclavicular ligament, but the coracoclavicular ligament remains intact. A type 3 injury
describes disruption of both ligaments whereas a type 4 injury entails complete disruption of both
ligaments with posterior displacement of the distal clavicle into the trapezius muscle.
You are consulted to see a young patient 3 days after the motor vehicle crash in which he
sustained a traumatic brain injury. You note that he is not receiving nutritional support. In starting
nutrition in this patient, which statement concerning enteral compared to parenteral nutrition is
(a) Enteral nutrition has a higher incidence of complications.
(b) Parenteral nutrition is more likely to cause pneumonia.
(c) Enteral access is easier to obtain at a higher cost.
(d) No significant difference exists in measured nutritional parameters.
Commentary: Early feeding of a person who has a traumatic brain injury is associated with fewer
infections and a trend towards better outcomes in terms of survival and disability. Two trials
reported the effect of route of feeding on the incidence of infection of any type, but both trials
showed a trend towards more infection with parenteral nutrition (PN) than with enteral nutrition
(EN). This difference might reflect catheter related infection with PN. In 3 trials reporting the
effect of route of feeding on the occurrence of pneumonia, a trend towards reduced incidence of
pneumonia was found in the PN group.
Although it is easier to provide PN than it is to obtain adequate EN access, EN has a decreased
incidence of complications and lower cost compared to PN, with no significant differences in
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measured nutritional parameters. Also, providing nutrition to the intestine can stimulate gut
immune function and limit deterioration of the intestinal mucosa characteristic of bacterial
translocation and its potential for contributing to sepsis.
Prolonged coma is a significant risk factor for the development of contractures in the traumatic
brain injury population. What is the most common site for a contracture to develop in this
Commentary: The overall 1-year incidence was 84% for contracture development in the
population of persons with brain injury. The hip was the most common joint affected (81%),
followed by the shoulder (76%), ankle (74%) and elbow (44%).
Which finding is a functional physiological change seen in the elderly?
(a) Increased drug-binding for highly-protein bound drugs
(b) Doubling of D-dimer levels
(c) Decreased erythrocyte sedimentation rate
(d) Macrocytic anemia
Commentary: D-dimer levels are shown to double with aging, especially among African
Americans and functionally impaired individuals. Increased erythrocyte sedimentation rate and
C-reactive protein have also been seen in the elderly. Although anemia occurs with increasing
prevalence with aging, there is convicncing evidence that it is not a normal consequence of aging.
Decreased drug-binding for highly protein-bound drugs in the elderly may lead to higher unbound
or free drug concentrations.
When considering risk of cumulative trauma in an older individual, it is important to know the
typical decreases in strength that occur with aging. Between ages 70 and 80 people typically lose
what percentage of their strength?
Commentary: Between the ages of 70 and 80 people typically lose 30 percent of their strength.
Muscular weakness occurs after age 30 in association with generalized muscle fiber atrophy,
decreased muscle density and increased intramuscular fat. Between the ages of 50 and 70 people
typically lose 15 percent of their strength.
Which safety practice is the most appropriate when performing an electrodiagnostic study on a
patient in a hospital bed?
(a) The device should be turned on after the placement of electrodes on the patient.
(b) An insulated extension cord should be used to connect the power line.
(c) More than 1 ground electrode should be attached to the patient.
(d) All electrical devices in contact with the patient should share a common ground.
Commentary: It is important to have all the electrical devices that are in contact with the patient
plugged into the same outlet to share a common ground. Similarly, only 1 ground electrode
should be used on the patient. To avoid power surges, the device should be turned on prior to the
application of any electrodes to the patient and turned off after the removal of electrodes.
Extension cords can increase leakage currents and should be avoided.
A 72-year-old woman is receiving warfarin (Coumadin) for deep venous thrombosis (DVT)
prophylaxis after repair of a hip fracture. She is on several other medications. The medication that
will significantly elevate her international normalized ratio (INR) is
(a) diphenhydramine (Benadryl).
(b) acetaminophen (Tylenol).
(c) carbamazepine (Tegretol).
(d) ranitidine (Zantac).
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Commentary: Warfarin (Coumadin) is used for anticoagulation in several different disease
conditions while patients are under the care of a physiatrist. One of the drug’s most common
applications is for DVT prophylaxis after repair of a hip fracture. Many medications can alter the
therapeutic efficacy of warfarin. Sulfonamides, acetaminophen, amiodarone, aspirin, and
nonsteroidal anti-inflammatory drugs (NSAIDs) may increase the prothrombin (PT)/INR.
Adrenocorticoids, antacids, antihistamines, carbamazepine, haloperidol, and vitamin C can
decrease the PT/INR.
A 23-year-old woman with a traumatic brain injury from a motor vehicle crash is seen in clinic 1
year after her injury. She is in a minimally conscious state and still requires total assistance with
all her activities of daily living. The family wants to pursue treatment with hyperbaric oxygen
therapy (HBOT). You advise them, that HBOT can
(a) reduce the size of the injury to the brain.
(b) cause short-term visual disturbances.
(c) increase the incidence of mortality.
(d) improve the functional outcome.
Commentary: Hyperbaric oxygen therapy (HBOT) delivers 100% oxygen under pressure, which
increases the amount of oxygen dissolved in the blood, thereby increasing the oxygen delivered to
the body tissues. HBOT may also enhance the formation of new blood vessels, decrease
inflammation, and increase the volume of blood flow. Treatment sessions occur inside a sealed,
pressurized space known as a hyperbaric chamber. The oxygen is delivered either by mask or
directly into the chamber. The pressures used are expressed in units of atmospheric pressure and
commonly range from 1.5 to 3 atmospheres. The sessions last from 30 to 90 minutes and many
practitioners recommend 100 sessions (range, 80-150 sessions). The cost ranges from $200 to
$400 per session.
HBOT is not FDA approved for treatment of traumatic brain injury. A number of more minor
complications may occur due to HBOT. Visual disturbance, usually a reduction in visual acuity
secondary to conformational changes in the lens, is common. While the great majority of patients
recover spontaneously over a period of days to weeks, a small proportion of patients continue to
require correction to restore sight to pretreatment levels. The second most common adverse effect
associated with HBOT is aural barotrauma. Barotrauma can affect any air-filled cavity in the
body (including the middle ear, lungs and respiratory sinuses) and occurs as a direct result of
compression. There is limited evidence that HBOT reduces the chance of dying following a
traumatic brain injury. There is little evidence that more survivors have a good outcome. Thus,
the routine adjunctive use of HBOT in these patients cannot be justified. Because evidence of
lesion resolution or change in size of persistent defect obtained by magnetic resonance imaging
(MRI) or computed tomography (CT) has not been studied, there is no evidence to suggest this
Which artery provides the arterial vascular supply to the ventral grey matter of the spinal cord?
(a) Anterior spinal
(b) Posterior spinal
Commentary: The single anterior spinal artery and its sulcal branches provide blood supply
directly to the anterior two-thirds of the spinal cord after arising from branches off the vertebral
arteries. The paired posterior spinal arteries similarly originate from the vertebral arteries, and
supply the posterior one-third of the cord. Radicular arteries are segmental branches from the
thoracic and abdominal aorta. These arteries provide vascular supply to the thoracic, lumbar,
sacral and coccygeal cord.
Which characteristic best describes fasciculation potentials?
(a) Semirhythmic in their firing pattern
(b) Morphologically the same as motor unit potentials
(c) Produced by ephaptic conduction between single muscle fibers
(d) Randomly firing single muscle fibers
Commentary: Fasciculation potentials are spontaneously firing motor unit potentials with the
same morphologic characteristics as that of a motor unit or polyphasic action potential. They
have an irregular firing pattern usually and the site of origin is unclear. Ephaptic conduction
between single muscle fibers is thought to be the mechanism for complex repetitive discharges.
Single muscle fiber potentials are much smaller and represent units such as a fibrillation potential.
Which statement is TRUE regarding the rehabilitation of anterior cruciate ligament (ACL)
(a) Immediate postoperative weight bearing adversely affects subsequent knee function.
(b) A self-directed program is not as effective as regular physical therapy visits.
(c) Use of a continuous passive motion machine improves outcome.
(d) Postoperative functional bracing does not improve outcome.
Commentary: The use of postoperative functional bracing does not improve outcome. Immediate
postoperative weight bearing does not adversely affect subsequent knee function. A self-directed
program is as effective as regular physical therapy visits in a motivated patient. The use of a
continuous passive motion machine does not improve outcome.
In patients with neuromuscular disease, which measurement is shown to be the most influential in
determining the intensity of their aerobic exercise?
(a) 70%-85% maximum heart rate
(b) 60%-80% of heart rate reserve
(c) Borg scale of perceived exertion
(d) Delayed-onset muscle soreness
Commentary: Thirty-three studies, to date, report absent or negligible adverse effects of exercise
in neuromuscular disease patients. Maximum heart rate and cardiac reserve are the same goals
for able bodied and neuromuscular patients. Delayed onset muscle soreness is shown to be the
most influential factor for patients to modify their own exercise program.
Compared to a younger individual, an older worker who suffers a musculoskeletal injury is more
(a) return to work sooner.
(b) have a recurrent injury.
(c) have the injury treated nonsurgically.
(d) sustain a less serious injury.
Commentary: Compared to a younger individual who suffers a musculoskeletal injury, an older
individual is more likely to have a recurrent injury, a decreased likelihood of returning to work
after the injury, increased time lost from the job as a result of the injury and a more serious injury.
Also, an older individual with a spine injury is more likely to have surgery than is a younger
Which modification can be used to increase the sensitivity of repetitive testing in neuromuscular
(a) Decrease the muscle temperature below 30°C.
(b) Allow the muscle to be rested for 6 minutes.
(c) Test the most distal muscles in the feet.
(d) Test the muscles after inducing ischemia.
Commentary: In postjunctional disorders, such as myasthenia gravis, the proximal muscles seem
to be more affected and it is thought that this difference is due to the increased temperature as one
gets closer to the core of the body. The higher temperatures potentiate a reduced safety factor.
Hence, the sensitivity of detecting a decrement response is higher with proximal muscle testing.
Maximal exercise can help in demonstrating postactivation exhaustion. When repetitive
stimulation is normal in both proximal and distal muscles, testing under ischemic conditions can
demonstrate a decrement in the responses.
A 6-year-old girl with Erb palsy since birth has an internal rotation deformity of her right
shoulder. Her shoulder external range of motion, whether passive or active, is zero degrees. Right
elbow, forearm, wrist, and hand function is good, latissimus dorsi strength is normal. Shoulder
MRI shows glenoid dysplasia, but no shoulder dislocation. She writes with her right hand but is
unable to reach the back of her head to fix her hair on the right. What is the most appropriate
management by the physiatrist at this time?
(a) Aggressive stretching of right shoulder internal rotators and strengthening of external
(b) Evaluation for compensatory strategies and assistive devices for independence in
activities of daily living
(c) Consultation with orthopedic surgeon
(d) Observation until adolescence for anticipated further improvement
Commentary: Shoulder surgery, most often internal rotation contracture release, often combined
with latissimus dorsi tendon transfer to provide active external rotation, is shown to improve
shoulder function in children with birth brachial plexus palsy. The majority (60%--70%) of
infants with birth brachial plexus palsy recover spontaneously, in the first months of life. Longterm
sequelae including fixed contractures warrant intervention. Physical or occupational therapy
will be appropriate for this child postoperatively, when greater progress can likely be made.
Which statement concerning the use of prophylactic antiepileptics in the management of patients
with traumatic brain injury is TRUE?
(a) They decrease the functional disability of the injury.
(b) They reduce the occurrence of late seizures.
(c) They reduce the incidence of death.
(d) They reduce the occurrence of early seizures
Commentary: There is no evidence that prophylactic antiepileptic medications, used at any time
after head injury, reduce death and disability. Evidence exists that prophylactic antiepileptics
reduce early seizures, but there is no clinical evidence that late seizures are reduced, or that
treatment has any effect on death or neurological disability.
A 40-year-old woman reports left-sided facial pain for the past month along with difficulty in
moving her jaw. She hears a clicking noise with chewing along with constant tinnitus. Upon
examination, she has tenderness to palpation along her muscles of mastication on the left with
deviation of the mandible upon jaw opening. She would like to have pain relief. You suggest
(a) referral to an oral surgeon.
(b) that she perform jaw isometric exercises in a closed position with massage.
(c) a 2-week trial of an oral nonsteroidal anti-inflammatory medication.
(d) an ultrasound-guided intra-articular injection with steroids
Commentary: This woman has a temporomandibular joint (TMJ) disorder most likely myofascial
in origin, which is the most common etiology. It is usually self-limited, and is managed
conservatively with relative rest (eg, avoiding jaw clenching, gum chewing), heat, and
nonsteroidal anti-inflammatory agents. Intra-articular steroid injections are not needed with a
myofascial origin of pain. She also does not need a referral to an oral surgeon at this time.
Which electrodiagnostic feature is more common in type 2 Charcot-Marie-Tooth (CMT) disease
than in CMT type1?
(a) It is primarly demyelinating.
(b) Lower limbs are more affected than upper.
(c) Conduction velocity slows.
(d) Secondary axonal changes occur over time.
Commentary: The type-2 form of Charcot-Marie-Tooth disease (CMT2) tends to affect the lower
extremities more than the upper extremities. In CMT type 1 (CMT1), which is primarily a
demyelinating neuropathy, anatomic changes directly affect the myelin sheath, with secondary
axonal changes. In areas of focal demyelination, impulse conduction from 1 node of Ranvier to
the next is slowed, because current leakage occurs and the time for impulses to reach threshold at
successive nodes of Ranvier is prolonged. The prolongation slows conduction velocity along the
nerve segment. CMT2 is often a clinically less severe disease than CMT1.
According to the most recent data from the National Spinal Cord Injury Statistical Center and
Model Spinal Cord Injury Systems, which source of trauma is the leading cause of traumatic
spinal cord injury among individuals between the ages of 46 and 60 years?
(a) Motor vehicle accidents
(b) Acts of violence
(c) Sports-related injuries
Commentary: Falls comprise the leading cause of traumatic spinal cord injury in the 46- to 60-
year-old age group, while motor vehicle crashes are the most common etiology for traumatic
spinal cord injury among people younger than age 46. Incidence rates for acts of violence and
sports-related injuries are lower in the 46-60 age group than in younger age groups.
Which treatment is shown consistently to improve pain in patients with acute low back pain?
(a) Superficial heat
(c) Transcutaneous electrical nerve stimulation (TENS)
Commentary: Superficial heat is the only modality listed that has consistently decreased pain in
acute low back pain, which is pain that has been present for less than 4 weeks.
A 60-year-old woman with right medial knee pain has a genu varum deformity that is observed
while she is standing and walking. What shoe modification can help her pain?
(a) Medial wedge
(b) Lateral wedge
(c) Rocker bottom
(d) Arch support
Commentary: Medial compartment osteoarthritis causes a genu varum deformity. Lateral heel
wedges can be used for conservative treatment of medial compartment osteoarthritis. A medial
wedge would exacerbate the genu varum. An arch support would help with pes planus (flatfoot)
which may be helpful for genu valgum deformity. Rocker bottoms may be used to offload
pressure from the metatarsal heads.
Which physiological change occurs in the cardiovascular system with aging?
(a) Increased resting heart rate
(b) Increased resting cardiac output
(c) Decreased ejection fraction
(d) Decreased orthostatic hypotension
Commentary: As a person ages, decreased inotropic responsiveness to adrenergic stimuli leads
to decreased myocardial contractility and, hence, to a decrease in ejection fraction. Resting heart
rate does not change with aging, but maximal heart rate with exercise does decrease
progressively. Cardiac output at rest and with modest exercise is maintained by early
involvement of the Frank-Starling mechanism. There is an increased incidence of orthostatic
hypotension in the elderly due to decreased baroreceptor sensitivity and diminished reflex
When should one be concerned when observing a child with an asymmetric tonic neck reflex
(ATNR,“fencer” position) with neck rotation, relative extension of the limbs on the chin side and
flexion of the limbs on the occiput side?
(a) In a 3-month-old infant who is able to move out of the “fencer” position
(b) In a 5-month-old infant who is unable to move out of the “fencer” position
(c) In a 6-month-old infant whose leg response to the stimulus is greater than the arm’s
(d) In an infant of any age, since the ATNR is a primitive pathological reflex.
Commentary: The ATNR is typically present at birth and integrates between 4 and 6 months of
age. An obligatory “fencer” position is abnormal at any age. A persistent or obligatory ATNR
may be an early clue that a child has a disorder of motor control, most often cerebral palsy.
A 65-year-old woman has right-sided hip pain secondary to osteoarthritis. She denies upper limb
arthritis symptoms. Which prescription is the most appropriate?
(a) Straight cane used in the left hand
(b) Four point cane used in the right hand
(c) Platform crutch used in the left arm
(d) Lofstrand crutch used in the right arm
Commentary: A straight cane should be used on the unaffected side to lessen the force exerted on
the hip with pathology. A Lofstrand crutch is also known as a Lofstrand forearm orthosis. It
includes a cuff placed along the lateral aspect of the forearm. Lofstrand crutches are often used
bilaterally. Because it does not require the use of the hand or wrist, and does not apply pressure
through them, a platform crutch is helpful for patients who need an assistive device and have
wrist/ hand pain or weakness.
a gap between the scaphoid and lunate seen on a anterior-posterior x-ray of the wrist
A patient presents with wrist and hand pain. The radiograph below demonstrates what finding?
(a) Osteoarthritis of the carpal bones
(b) Impaction syndrome
(c) Capitate fracture
(d) Scapholunate instability
Commentary: This radiograph demonstrates a gap between the scaphoid and lunate seen on a
anterior-posterior x-ray of the wrist. This finding is consistent with scapholunate dissociation. A
measured distance of 3mm between the scaphoid and lunate is diagnostic for dissociation and
In a patient with neuromuscular disease, which pulmonary function parameter best represents
abdominal and chest wall strength?
(a) Tidal volume
(b) Maximal inspiratory pressure
(c) Peak cough
(d) Maximal expiratory pressure
Commentary: The maximal inspiratory pressure reflects diaphragm strength and ventilatory
ability. Maximum expiratory pressure is indicative of abdominal and chest wall muscle strength
and the ability to cough and clear secretions. The tidal volume represents the normal volume of
air displaced between normal inhalation and exhalation when extra effort is not applied. Peak
cough flow is a measure of the amount of air flow that a patient can generate during a volitional
Upper extremity exercise (eg, crutch walking) leads to a greater increase in heart rate and blood
pressure compared with lower extremity activity (eg, normal walking) due to the
(a) smaller upper extremity muscles, which contract at a higher maximal percentage.
(b) proximity of the upper extremities to the heart and major blood vessels.
(c) upper extremities having to overcome the effect of gravity.
(d) greater range of motion of the upper extremities compared to the lower ones.
Commentary: Upper extremity work leads to greater increases in heart rate and blood pressure.
When a muscle contracts with a given percentage of its maximum force, its effect on blood
pressure is about the same as during the same percentage of contraction of any other muscle. The
smaller muscles in the upper extremity contract more, and stimulate the cardiovascular system
more relative to the larger lower extremity muscles.
A 1-year-old boy presents with marked weakness. Parents report a weak cry and cough since
birth, and the child cannot sit independently. Exam findings include a bell-shaped thorax,
hypotonia, some movement of the hands and feet but minimal movement at the hips and
shoulders, and there are tongue fasciculations. The diagnosis is best confirmed by
(a) genetic analysis.
(b) muscle biopsy.
(d) repetitive nerve stimulation.
Commentary: This child’s presentation is typical for spinal muscular atrophy (SMA) type I, also
known as Werdnig-Hoffmann disease. SMA is the second most common neuromuscular disease
of childhood, occurring with an incidence of 1:6,000. Deletion of the survival motor neuron gene
leads to degeneration of anterior horn cells and can be detected in over 90% of children with
SMA. Prior to availability of genetic diagnosis, EMG and muscle biopsies were utilized.
Repetitive nerve stimulation has been used in the investigation of botulism and congenital
myasthenia gravis but is not helpful in SMA.
Bone loss following spinal cord injury is characterized by
(a) greater loss of cortical rather than trabecular bone.
(b) low bone mineral density in the spine.
(c) predilection for regions below the level of injury.
(d) new bone homeostasis that ensues by 6 months after injury.
Commentary: Bone loss occurs inevitably following spinal cord injury, and is uniquely
characterized by a predilection for trabecular more than cortical bone in regions below the level
of injury. This is associated with relative sparing of spine bone mineral density, possibly due to
continued functional loading of the spine. A new homeostasis in bone resorption and formation is
achieved by about 16 months.
The current workers’ compensation system in the United States is a “no fault” system. This
means that the
(a) employee does not have to prove that the employer is at fault for the injury.
(b) employer does not have to prove they are at fault for the employee’s injury.
(c) employee and employer do not have to prove that the other is at fault for the injury.
(d) employer does not have to prove that the employee is at fault for the employee’s injury.
Commentary: In the United States workers’ compensation system the injured worker does not
have to prove that the employer is at fault for the employee’s injury. Similarly, the employer
does not have to prove that the injured worker is at fault for his/her injury. If the injury occurred
at work, the medical costs and partial payment of lost income are covered.
Which cervical orthosis is the most restrictive?
(a) Four-poster brace
(b) Philadelphia collar
(c) Sterno-occipital mandibular immobilizer (SOMI)
Commentary: The halo device provides the greatest restriction of cervical motion for
flexion/extension, lateral bending and rotation, as shown in the table below:
Table 1: Percentage of Cervical Motion Permitted by 4 Cervical Orthoses
Orthosis % Flexion/extension %Lateral Bending % Rotation
Philadelphia collar 28.9 66.4 43.7
SOMI brace 20.6 65.6 33.6
Four-poster brace 20.6 45.9 27.1
Halo device 4.0-11.7 4.0-8.4 1.0-2.4
Which statement best describes the effects of repetitive task training after stroke?
(a) Lower limb functional recovery is greater than upper limb functional recovery.
(b) Improvement in activities of daily living is a major benefit of the training.
(c) Training effects are more significant in early stroke therapy.
(d) Improvement in functional benefit is sustained for more than a year.
Commentary: This review of 14 studies with 659 participants looked at whether repeated practice
of tasks similar to those commonly performed in daily life could improve functional abilities. In
comparison with usual care or placebo groups, people who practiced functional tasks showed
modest improvements in walking speed, walking distance and the ability to stand from sitting, but
improvements in leg function were not maintained 6 months later. Repetitive task practice had no
effect on arm or hand function. There was a small amount of improvement in ability to manage
activities of daily living. Training effects were no different for people whether the training was
given early or late after stroke
An 87-year-old man on your inpatient rehabilitation unit was found on the therapy mat in much
pain after hearing a loud “cracking” noise when he transferred himself. What position of his right
lower limb would suggest hip fracture?
(a) Internal rotation and lengthened
(b) Internal rotation and shortened
(c) External rotation and lengthened
(d) External rotation and shortened
Commentary: In most cases, the lower limb of the fractured hip would be held in external rotation
(rotated outward) and would appear shortened relative to the unaffected lower limb.
A 24 year-old man sustains an acute, traumatic C5 American Spinal Injury Association
Impairment Scale (AIS) A tetraplegia and a proximal left femur fracture following a motor
vehicle crash. His hemoglobin has remained stable. Based on the Consortium for Spinal Cord
Medicine’s Clinical Practice Guidelines, venous thromboembolic prophylaxis should include
sequential compression devices for a minimum of 2 weeks and
(a) coumadin for 4 weeks.
(b) low molecular weight heparin for 8 weeks.
(c) low molecular weight heparin for 12 weeks.
(d) prophylactic inferior vena cava placement.
Commentary: According to the Clinical Practice Guidelines, venous thromboembolic
prophylaxis for uncomplicated motor-complete tetraplegia and AIS C injuries should be
comprised of low molecular weight heparin or adjusted dose unfractionated heparin for 8 weeks.
However, in the presence of complicating factors (eg, lower limb fractures, advanced age,
obesity, heart failure, cancer) prophylaxis with low molecular weight or unfractionated heparin
should continue for a total of 12 weeks or until discharge from Rehabilitation. Individuals with
AIS D paraplegia without other complications require chemoprophylaxis with unfractionated
heparin only until the rehabilitation discharge. Prophylactic intravenous chemotherapy filter
placement is recommended only if there are contraindications or high risk associated with
anticoagulation, and prophylaxis should be initiated as soon as hemostasis is achieved or
Which approach is shown to be efficacious in treating carpal tunnel syndrome?
(a) Oral corticosteroids
(b) Exercise therapy
(c) Vitamin B6
(d) Botulinum toxin injection
Commentary: Of the choices listed, only oral steroids have been shown to be efficacious in the
treatment of carpal tunnel syndrome. In addition to oral steroids, local injection of corticosteroids
and wrist splint are shown to be effective. Exercise therapy and botulinum toxin are ineffective
in the treatment of carpal tunnel syndrome.
You are consulted to see a 19-year-old woman with a traumatic brain injury after a motor vehicle
crash 2 days ago. She is unconscious even though the computed tomography scan of her brain is
normal. The most likely cause is
(a) diffuse axonal injury.
(b) cerebral contusion.
(c) arterial vasospasm.
(d) epidural hemorrhage.
Commentary: The initial computed tomography and magnetic resonance imaging scans taken
soon after injury are often normal. Only 10% of patients with diffuse axonal injury (DAI)
demonstrate the classic CT findings of DAI. These are hemorrhagic punctate lesions of (1) the
corpus callosum, (2) the gray-white matter junction of the cerebrum, and (3) the pontinemesencephalic
You are seeing a 79-year-old gentleman with chronic right shoulder pain. For the past several
years he has had limited shoulder movement and is diffusely tender around the shoulder.
Magnetic resonance imaging demonstrates a partial tear of the supraspinatus and infraspinatus
tendons with degenerative changes of the glenohumeral joint. You recommend
(a) rotator cuff repair.
(b) total shoulder arthroplasty.
(c) intra-articular viscosupplementation injection.
(d) flexibility and progressive strengthening exercises.
Commentary: The nonsurgical management of shoulder osteoarthritis (OA) with a chronic,
massive rotator cuff defect requires flexibility exercises and gentle progressive strengthening
exercises to increase shoulder function. Surgical repair involves humeral hemiarthroplasty.
Rotator cuff repair in partial thickness tears consists of surgical smoothing of the humeroscapular
motion interface with cuff curettage. Reverse total shoulder arthroplasty is used for
anterosuperior escape rotator cuff lesions. There is no role for shoulder viscosupplementation,
since it has not been shown to be beneficial.
You are performing a consultation on a 58-year-old man with a history of diabetes and peripheral
vascular disease who presents with a non-healing foot ulcer. You are concerned that he is at risk
for amputation because his
(a) ankle brachial index (ABI) is 0.8.
(b) ABI is 0.4.
(c) transcutaneous oxygen pressure (TcPO2) is 80mmHg.
(d) TcPO2 is 40mmHg.
Commentary: ABI is a noninvasive technique that is used in the assessment of arterial occlusive
disease. The ABI is the ratio between the ankle and the brachial systolic pressure. Normal ABI is
defined as values greater than 0.9. An ABI below 0.4 tends to carry a poor prognosis. TcPO2 is
defined as transcutaneous oxygen, which is in essence a "blood gas" of the skin. Normal TcPO2 is
greater than 50mmHg. Values of more than 40mmHg are associated with healing. Ischemia is
defined as periwound TcPO2
25-year-old man presents to clinic with an insidious onset of low back pain over the past 6
months. He denies any trauma, but is quite active running and biking. He does not report any leg
symptoms. His pain is worse in the morning, but improves with activity and with antiinflammatory
medication. What additional information would be most helpful in making the
(a) Blood work revealing elevated erythrocyte sedimentation rate (ESR)
(b) Magnetic resonance imaging revealing degenerative disc disease
(c) Plain radiograph revealing sacroiliitis
(d) Physical examination revealing an absent Achilles deep tendon reflex (DTR)
Commentary: This patient presents with a clinical history consistent with ankylosing spondylitis
(AS).This spondyloarthropathy is more common in men in their late teenage years to early
twenties. It generally presents with morning stiffness in the low back and/or buttocks. Criteria for
diagnosis (modified New York classification) include the presence of sacroiliitis on x-ray and 1
of the following: history of inflammatory back, decreased range of motion of spine, and limited
Supplemental oxygen therapy in patients with chronic obstructive pulmonary disease (COPD) has
been shown to
(a) improve walking endurance.
(b) increase blood pressures.
(c) maximize work rate.
(d) produce polycythemia.
Commentary: Supplemental oxygen therapy is indicated in patients with arterial partial pressure
of oxygen (PO2) continuously less than 55-60mmHg. Home oxygen therapy can decrease
pulmonary hypertension, polycythemia, blood pressure, and pulse. In patients with mild
hypoxemia and exercise desaturation, supplemental oxygen by nasal prongs did not influence
maximum work rate, but did increase mean walking endurance time and exercise tolerance.
A 14-year-old girl with spastic quadriplegic cerebral palsy (CP) has driven a power wheelchair as
her primary means of mobility since age 4 years. She recently sustained a fracture of her tibia
with no known significant trauma. You anticipate that the bone mineral density (BMD) z score
for her distal femur as measured on a dual-energy x-ray absorptiometry (DEXA) scan will be
(a) increased relative to peers without spasticity.
(b) increased relative to younger nonambulatory children with CP.
(c) similar to younger ambulatory children with CP.
(d) decreased relative to age-matched peers without CP.
Commentary: Children with severe CP develop clinically significant osteopenia. Lower BMD z
scores are associated with greater severity of CP as indicated by gross motor function, and these
scores decrease with age. Rather than occurring primarily from actual losses in bone mineral, as
in aging adults, the decreasing BMD z scores seen in older youths with CP occur because they
have a slower rate of growth in bone mineral, relative to their healthy peers.
A 37-year-old man is sent to you for electrodiagnostic assessment for right lumbosacral
radiculopathy. Nerve conduction studies of the right leg are normal. Needle exam shows the
Adductor longus 0 Normal
Vastus medialis 0 Normal
Tensor fascia lata 1+ Normal
Semimembranosus 1+ Normal
Biceps femoris (short head) 0 Normal
Tibialis anterior 2+ Reduced
Medial gastrocnemius 0 Normal
Lumbar paraspinals 1+
Which root is most likely injured?
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Commentary: The common root among the affected muscles is L5. It is often difficult to narrow
the involvement to a single root level.
You suspect that a 10-month-old boy’s subdural hematoma may be the result of child abuse.
Which action is LEAST likely to be helpful in further evaluation?
(a) Skeletal survey
(b) Physical examination for cutaneous injuries
(c) Hematology consultation
(d) Ophthalmology consultation
Commentary: The most common cause of serious brain injury in children younger than 1 year of
age is abuse. In very young children subdural hematoma, subarachnoid hemorrhage, retinal
hemorrhages and associated cutaneous, skeletal and visceral injuries are significantly more
common among those with inflicted brain injury than in children with unintentional injury.
Which clinical scenario is most consistent with a L4-5 foraminal disc herniation?
(a) Weakness of the extensor hallicus longus, decreased sensation of the web space between
the first and second toes, absent hamstring reflex
(b) Weakness of the gastrocnemius, decreased sensation of lateral foot, absent Achilles reflex
(c) Weakness of the anterior tibialis, decreased sensation of the web space between the first
and second toes, absent hamstring reflex
(d) Weakness of quadriceps and anterior tibialis, decreased sensation of medial lower leg,
absent patellar reflex
Commentary: A foraminal disc herniation at L4-5 level would most likely affect the exiting L4
nerve root. A nerve root lesion could result in muscle weakness in the affected myotomes,
sensation loss in the affected dermatomes, and deep tendon reflex changes. The physical
examination findings most consistent with a lesion to the L4 nerve root would be weakness of
the quadriceps (L2-4), decreased sensation in L4 dermatomes, and decreased or absent patellar
deep tendon reflex (L4).
A patient with neuromuscular disease complains of morning headache and excessive daytime
fatigue. What is your initial diagnostic evaluation?
(a) Order chest radiographs.
(b) Order pulmonary function tests.
(c) Monitor end-tidal carbon dioxide levels.
(d) Measure assisted-cough peak flows
Commentary: Patients with neuromuscular disease (NMD) are often sent for pulmonary function
tests designed for patients with lung disease. Patients with NMD often do not have a history of
asthma or cigarette smoking and most of these tests are unnecessary, except for spirometry.
Because underventilation often begins during sleep, spirometry or simple determination of vital
capacity is best done in the supine position. The patient’s carbon dioxide level will provide
insight into hypoventilation and should be monitored, especially when the patient complains of
excess fatigue and headaches.
An individual with T4 American Spinal Injury Association Impairment Scale (AIS) A paraplegia
is 2 months postinjury and acutely develops pounding headache, flushing of the face and upper
trunk, anxiety and piloerection of the lower body. Blood pressure is 120/80 with a usual blood
pressure of 100/60. After loosening all tight garments, what should be the next intervention?
(a) Assess bladder for distention.
(b) Check bowel for impaction.
(c) Apply topical nitroglycerin immediately.
(d) Lay the patient supine immediately
Commentary: The scenario depicts a typical presentation for autonomic dysreflexia (AD).
Treatment should consist of checking the blood pressure, elevating the head, loosening tight
clothing or garments, and proceeding with systematic investigation and elimination of causative
factors. Because bladder distension is the most common stimulus for AD, the algorithm proposed
in the clinical practice guideline begins with assessment for bladder-related causes and treatment
of any distension. Because bowel obstruction or distension is the second most common stimulus
and it, therefore, should be evaluated next if urinary evaluation fails to reveal the cause. The
guideline recommends consideration for antihypertensive pharmacotherapy if the individual’s
systolic blood pressure is above 150.
Which therapeutic modality delivers medication to the site of pathology by promoting the
movement of charged particles through the skin under an imposed electrical field?
(b) Low energy laser
(c) Ultraviolet radiation
Commentary: Iontophoresis is a physical medicine modality that delivers topical medicine, such
as corticosteroids, through the skin and into soft tissues. A current is created to direct a particular
solution away from the electrode and into the surrounding tissue. Phonophoresis utilizes
ultrasound rather than current to deliver the topical medication. Low energy laser and ultraviolet
radiation are not used to deliver topical medications.
Which phenomenon is an effect of functional electrical stimulation (FES) as it pertains to gait?
(a) Decrease in muscle spasticity
(b) Increase in physiologic cost of gait
(c) Decrease in voluntary muscle strength
(d) Decrease in stride length
Commentary: In addition to a decrease in muscle spasticity, FES decreases the physiologic cost
of gait, increases voluntary muscle strength, and increases stride length.
The use of a magnetic knee wraps in patients suffering with mild to moderate knee osteoarthritis
has been shown to
(a) decrease edema.
(b) increase walking distance.
(c) increase isokinetic strength.
(d) increase range of motion.
Commentary: The application of magnetic knee wraps has been shown to increase isokinetic
strength and improve pain scales. Edema, walking distance and range of motion were not