Flashcards in SAER 2011 Deck (69):
A 22-year-old runner presents with acute onset of distal calf pain. She is diagnosed with Achilles
tendinitis and is referred to physical therapy. Which therapeutic modality is the LEAST
beneficial in treating an overuse injury of this sort?
(a) Therapeutic ultrasound
(c) Ice massage
(d) Neuromuscular electrical stimulation
Commentary: With acute overuse injuries, modalities such as ultrasound, iontophoresis, and ice
massage may decrease pain and facilitate rehabilitation. Electrical stimulation with recruitment
of muscle fibers may be contraindicated in treating acute overuse injuries.
What is the most frequent presenting symptom of brain metastasis?
(a) Focal weakness
(d) Visual disturbance
Commentary: Presenting symptoms at the time of diagnosis with brain metastasis, in order of
decreasing frequency, are as follows: (patients can have more than a single symptom): headache,
49%; mental disturbance, 32%; focal weakness, 30 %; gait ataxia, 21 %; seizures, 18%; speech
difficulty, 12%, visual disturbance, 6%; sensory disturbance, 6%; and limb ataxia, 6%.
Which disorder does NOT have pes cavus as a feature?
(b) Cerebral palsy
(c) Friedreich ataxia
(d) Peroneal spastic foot
Commentary: The etiology of pes cavus includes malunion of calcaneal or talar fractures, burns,
sequelae resulting from compartment syndrome, residual clubfoot, and neuromuscular disease.
The remaining cases are idiopathic and nonprogressive. Neuromuscular diseases, such as
muscular dystrophy, Charcot-Marie-Tooth (CMT) disease, spinal dysraphism, polyneuritis,
intraspinal tumors, poliomyelitis, syringomyelia, Friedreich ataxia, cerebral palsy and spinal cord
tumors can cause muscle imbalances that lead to elevated arches. Multiple theories have been
proposed for the pathogenesis of pes cavus. Duchenne described intrinsic muscle imbalances
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causing an elevated arch. Whereas, peroneal spastic foot is characterized by pain in the foot,
limited subtalar motion, pes planus deformity, and shortening with spasm of the peroneal muscles
often initiated by minor trauma or unusual activity.
Which cardiac response is increased as a result of aerobic training?
(a) Oxygen consumption (VO2)
(b) Maximal heart rate
(c) Anginal threshold
(d) Stroke volume at rest
Commentary: After an aerobic training program, the anginal threshold is unchanged. Oxygen
consumption (VO2) at rest, and during any given submaximal load remains unchanged, while
VO2 max is increased. The maximal heart rate also does not change, but the heart rate is lower
both at rest and during any submaximal load (bradycardia of training). The stroke volume at rest
is increased, reciprocal to the decrease in heart rate. Although angina threshold is unchanged,
myocardial oxygen demand decreases relative to oxygen consumption, which allows more intense
activity before the ischemic threshold is reached.
Injured workers with acute low back pain treated with high-dosage opioids compared to low-dose
or nonopioid medications demonstrated which outcome?
(a) Lower overall medical costs
(b) Same duration of disability
(c) Higher risk for surgery
(d) Shorter duration of opioid use
Commentary: Injured workers with acute low back pain who received higher dosages of opioids
in early treatment had adverse outcomes compared to patients given no or low-dose opioids. In
the high-dose opioid group, adverse outcomes included higher medical costs, prolonged
disability, higher risk for surgery, and continued use of opioids. The high-dose opioid group was
disabled 69 days longer than the non-opioid group, had a 3 times greater risk for surgery, and a 6-
times-greater risk of receiving long-term opioids. The severity of the low back injury was a strong
predictor of all outcomes.
A 40-year-old man presents with a gradual onset of painful distal paresthesias while playing
soccer. He feels clumsy and is falling more frequently. He has no known significant past medical
history. Physical exam demonstrates normal symmetric strength throughout his upper and lower
extremities, normal vibration sensation and normal Romberg testing. His electrodiagnostic exam
results are as follows:
MOTOR NERVE CONDUCTION STUDIES*
Nerve Stimulation Site Distal Latency
R Fibular (Peroneal) Ankle 6.1 (≤ 6.5) 2.0 (≥2.0)
Below knee 1.9 41 (≥40)
Above knee 1.9 41
L Fibular (Peroneal) Ankle 6.0 (≤ 6.5) 2.1 (≥2.0)
Below knee 2.0 40 (≥40)
R Tibial Ankle 6.1 (≤ 6.1) 3.0 (≥3.0)
Knee 2.9 42 (≥40)
R Median Wrist 4.4 (≤ 4.4) 5.2 (≥4.0)
Elbow 5.2 49 (≥49)
R Ulnar Wrist 3.5 (≤ 3.5) 7.0 (≥6.0)
Below elbow 6.9 49 (≥49)
* Normal values are in parentheses
Abbreviation: NCV, nerve conduction velocity; R, right; L, left.
SENSORY NERVE CONDUCTION STUDIES*
Nerve Distal Latency (ms) Amplitude (μV)
R Sural NR NR
L Sural NR NR
R Median 3.9 (≤ 3.7) 12.0 (≥20.0)
R Ulnar 3.9 (≤ 3.5) 5.0 (≥15.0)
* Normal values are in parentheses
Abbreviations: NR, nonresponsive; R, right; L, left.
R Gluteus medius 0 Normal
RVastus medialis 0 Normal
R Tibialis anterior 0 Normal
R Medial gastrocnemius 0 Normal
R Extensor hallicus longus 1+ Normal
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R First dorsal interosseous (Pedis) 2+ Reduced
L First dorsal interosseous (Pedis) 2+ Reduced
R Pronator teres 0 Normal
R Abductor pollicus brevis 0 Normal
R First dorsal interosseous (Hand) 0 Normal
Abbreviations: R, right; L, left.
In addition, F waves were mildly prolonged in all motor nerves tested. His history and exam is
most consistent with a diagnosis of sensorimotor neuropathy due to
(a) diabetes or glucose intolerance.
(b) uremic disease.
(c) chronic inflammatory demyelinating polyradiculopathy.
(d) hereditary motor sensory neuropathy
Commentary: Diabetic neuropathy electrophysiological exam may demonstrate sensory nerve
conduction study abnormalities with normal motor nerve conduction studies but positive
fibrillation potentials distally on needle examination. In this case, motor nerve conduction studies
are borderline normal. It is likely that had F waves been obtained they would be mildly
prolonged. A neuropathy due to uremic disease would likely demonstrate pronounced conduction
slowing and low amplitude responses in sensory and motor nerves, and likely would not be
undiagnosed prior to the presentation described in the scenario. Chronic inflammatory
demyelinating polyradiculopathy (CIDP) and hereditary motor sensory neuropathy (HMSN-1)
represent demyelinating processes, and there is no evidence of this finding in the results.
A 14-year-old with severe traumatic brain injury admitted to your rehabilitation unit has no
spontaneous movement. What is the best prevention for heterotopic ossification?
(a) Passive range of motion
(b) Nonsteroidal anti-inflammatory medications
(c) Disodium etidronate (Didronel)
Commentary: Heterotopic ossification is found in a high percentage of children immobilized by
traumatic brain injury and spinal cord injury. The best prevention for the development of HO is
an aggressive program of passive range of motion. Nonsteroidal anti-inflammatory medications
and radiation are available as treatment options. Didronel is not used in pediatric patients due to
risk of rickets or rachitic syndrome.
Which muscle group displays the earliest pattern of weakness in Duchenne muscular dystrophy?
(a) Ankle dorsiflexors
(b) Neck flexors
(c) Shoulder flexors
(d) Knee extensors
Commentary: In Duchenne muscular dystrophy, weakness is first seen in the neck flexors during
preschool years. Pelvic girdle weakness precedes shoulder girdle weakness by several years.
Ankle dorsiflexors are weaker than plantarflexors; ankle everters are weaker than inverters; knee
extensors are weaker than flexors; hip extensors are weaker than flexors.
A 50-year-old man has obstructive sleep apnea (OSA). He is morbidly obese and has a body mass
index (BMI) of 39 kg/m². He is also complaining of chronic low back pain, which he claims
limits his mobility. Which approach would best benefit him?
(a) Prescribe a motorized wheelchair.
(b) Prescribe modafinil (Provigil) for daytime sleepiness.
(c) Schedule opioid analgesics for pain control.
(d) Order surgical referral for a tracheostomy
Commentary: Obstructive sleep apnea (OSA) is characterized by snoring, arousals, and daytime
sleepiness. Most patients with OSA are male, middle-aged, with an average BMI of 32.5 +/-
9.0kg/m2. Wheelchairs should be used only in cases of compromised mobility and powered
mobility used only when no other options exist. Modafinil can be used as adjunct therapy for
daytime sleepiness. Narcotic analgesics should be prescribed with caution because of depression
of central respiratory drive. Positive airway pressure (PAP) delivered with continuous (CPAP) or
bilevel (BiPAP) pressures can correct upper airway obstruction. If the noninvasive approach is
not effective, tracheostomy may be necessary.
A construction company manager is concerned about hiring employees over the age of 40, citing
lower productivity because of lower endurance compared to younger workers. You tell him that
the average decline in physical work capacity between the ages of 40 and 60 is
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Commentary: While variation exists, an average decline of 20% in physical work capacity has
been reported between the ages of 40 and 60 years, due to decreases in aerobic and
musculoskeletal capacity. However, differences in habitual physical activity will influence the
variability seen in individual physical work capacity and its components.
Of the following modalities, which is the most effective in treating phantom limb pain?
(b) Transcutaneous electrical nerve stimulation
(c) Short wave diathermy
(d) Paraffin baths
Commentary: Of the options listed, transcutaneous electrical nerve stimulation (TENS) is the
modality that may be useful in treating phantom limb pain. Iontophoresis is generally used for
dispersion of medications. Short wave diathermy is a method of deep heat. Paraffin bath is a
superficial heat modality.
Hamstring injuries occur most commonly
a) at the proximal attachment of the lateral hamstrings to the pelvis.
b) during concentric contraction of the medial hamstrings.
c) at the distal attachment of the medial hamstrings to the tibia.
d) during eccentric contraction of the lateral hamstrings.
Commentary: The majority of hamstring injuries occur from indirect forces during running and
sprinting activities. Most injuries occur at the myotendinous junction, not at the osseous
attachments, during eccentric contraction of the hamstring. The lateral hamstrings (biceps
femoris) are affected more than the medial hamstrings (semitendinous and semimembranosus).
Which modifiable risk factor MOST increases the relative risk of stroke?
(d) Diabetes mellitus
Commentary: Hypertension, defined as a systolic pressure greater than 165mmHg, or a diastolic
pressure greater than 95mmHg, increases the relative risk of stroke by a factor of 6. The
Framingham study has confirmed that smoking is independently associated with stroke. The
relative risk for heavy smokers (more than 40 cigarettes a day) is twice that of light smokers
(fewer than 10 cigarettes a day). Cessation of smoking reverses the risk to that of nonsmokers
within 5 years of quitting. Hypercholesterolemia has not been epidemiologically linked to
increased stroke incidence, but its strong influence on atherosclerosis makes it an indirect risk
factor. Diabetes mellitus increases the relative risk of stroke by 3 to 6 times the general
Which muscle fiber types are recruited first in isometric contractions?
(a) Type 1
(b) Type 1b
(c) Type 2
(d) Type 2b
Commentary: Fatigue-resistant type 1 fibers are recruited initially followed by type 2b fibers.
There are no type 1b fibers.
Which symptom most frequently impacts quality of life in patients with incurable cancers?
Commentary: Cancer patients experience a much broader range of symptoms that impact their
quality of life and their ability to address existential issues at the end of life than those listed here.
A systematic review of symptom prevalence studies in patients with incurable cancer identified
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fatigue (74%), pain (71%), lack of energy (69%), weakness (60%) and anorexia (53%) being the
most prevalent that impact quality of life. The prevalence of nausea is 40% in the last 6 weeks of
life. Fatigue is often the primary condition adversely affecting quality of life.
Which therapeutic application of functional electrical stimulation is NOT applicable in the
population with spinal cord injury?
(a) Lower limb exercise in cauda equina syndrome
(b) Ventilatory assistance in a C2 ASIA class A injury
(c) Achieving lateral or palmar prehension in a C6 ASIA class A injury
(d) Electroejaculation to harvest sperm for assisted reproduction techniques
Commentary: Functional electrical stimulation (FES) strategies use applied electrical current to
activate weak or denervated muscle. FES is most effective in upper motor neuron injuries with
preservation of the anterior horn cells and motor nerve roots. Because of the amount of charge
density required to directly depolarize muscle, FES is not effective if large quantities of
musculature are denervated. FES can be applied to the skin surface, or by means of implanted
electrodes. One application in the population with SCI is its use in conjunction with a bicycle
ergometer to improve cardiac capacity. Generally, individuals with cauda equina syndrome will
not be good candidates for FES-assisted cycling, due to the extent of denervation associated with
this injury level. Phrenic nerve and diaphragmatic pacing have been used to wean standard
ventilator dependence in individuals with high tetraplegia and preserved phrenic nerve function.
Implanted FES systems have been used to generate hand grasp and release, with or without
tendon transplantation. External hand/forearm orthoses have also been developed primarily for
therapeutic stimulation, with the hope of developing future neuroprostheses. Patients with intact
parasympathetic efferent innervation to the detrusor have improved control of micturition, albeit
with the need for sacral deafferentation, resulting in the loss of perineal sensation and reflex
erection. Electroejaculation using a rectal probe has been highly successful at producing seminal
emission for sperm harvesting for the purpose of assisted reproduction in individuals with SCI.
For injured workers with chronic low back pain, which outcome is associated with better
performance during a functional capacity evaluation (FCE)?
(a) Shorter usage of temporary disability benefits
(b) Lower subjective reports of perceived disability
(c) Higher likelihood of sustainable work tolerance
(d) Fewer recurrences of low back pain over the next 12 months
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Commentary: Functional capacity evaluations (FCEs) are commonly used to determine readiness
for return to work. These evaluations measure the injured worker’s functional abilities relative to
the physical demands required by the job. The clinical assumption is that workers who perform
better during FCEs will have a lower risk of reinjures and less pain exacerbation upon return to
work. One-year follow-up of patients with chronic low back pain whose FCE demonstrated
performance that met or exceeded physical job requirements did not demonstrate a reduction of
recurrent low back pain, improved occupational sustainability, or improved perception of
disability. Better FCE performance was mildly associated with faster return to work and shorter
duration of temporary disability benefits.
Which statement concerning management of seizures after a traumatic brain injury is TRUE?
(a) All patients with postresuscitation Glasgow Coma Scale score below 12 require 3 months
of an antiepileptic medication.
(b) Seizures occurring less than 24 hours postinjury require an antiepileptic medication for at
least 12 months.
(c) Seizures occurring 24 hours to 7 days postinjury should be treated with at least 12 months
of an antiepileptic medication.
(d) Seizures occurring more than 7 days postinjury should be treated with an antiepileptic
medication for at least 3 years.
Commentary: The American Academy of Physical Medicine and Rehabilitation and the
American Association of Neurological Surgeons recommend seizure prophylaxis after a traumatic
brain injury as standard treatment. All patients with postresuscitation Glasgow Coma Score
(GCS) below 12 require 7 days of therapeutic phenytoin sodium. Immediate posttraumatic
seizures (defined as those occurring within 24 hours postinjury) do not require any additional
prophylaxis after 7 days. Early (more than 24 hours but less than7 days) seizures should be
treated with at least 12 months of an antiepileptic medication, unless a time-limited intracranial
abnormality such as hydrocephalus, infection, or active hemorrhage, etc., was the cause. Late
seizures -- those occurring more than 7 days postinjury -- should be treated with an antiepileptic
medication for at least 12 months. Any seizure that lasts longer than 2 minutes is defined as
“status epilepticus” and warrants treatment with an antiepileptic medication for at least 12
A 30-year-old man with a T12 fracture and a spinal cord injury has the following findings on
Motor Exam Sensory Exam*
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R L R L
C5 5/5 5/5 2 2
C6 5/5 5/5 2 2
C7 5/5 5/5 2 2
C8 5/5 5/5 2 2
T1 5/5 5/5 2 2
N/A N/A 2 2
L1 N/A N/A 2 2
L2 3/5 3/5 1 1
L3 3/5 3/5 1 1
L4 1/5 1/5 1 1
L5 1/5 1/5 1 1
S1 1/5 1/5 1 1
S2-5 - - 1 1
* Light touch and pin prick testing
Abbreviations: L, left; R, right, N/A, not applicable.
The patient’s ASIA classification would be
a) T12 ASIA class D
b) L1 ASIA class C
c) L2 ASIA class B
d) L3 ASIA class C
Commentary: The motor level is defined as the most distal motor level with functional strength
(at least 3/5), so long as the motor level immediately superior is 5/5 or normal; if there is no
defined myotome (ie, T2-T12) the last normal dermatome is used. In the example given, the
myotome is L2, because the L1 dermatome is normal and is used as the myotome. The sensory
level is defined as the most distal dermatome with normal sensation, and the neurologic
dermatome is L1. So the neurologic level is L1, since it is the most distal level with a normal
myotome and dermatome. The ASIA impairment classification is C because more than half (6 of
10) of the key muscles below the neurologic level have a muscle grade less than 3/5.
Which statement regarding an independent medical examination (IME) is TRUE?
(a) The traditional physician-patient relationship is not maintained, and confidentiality is not
(b) The examiner is exempt from potential liability since the purpose of the evaluation is to
assess medical-legal issues, not clinical issues.
(c) Treating providers may conduct an IME as long as records from other providers are also
(d) Because of potential conflicts of interest, only providers no longer in clinical practice
should conduct IMEs.
Commentary: In the IME context, a traditional physician-patient relationship does not exist, since
the evaluation does not include “intent to treat.” Confidentiality is not guaranteed, since the
examiner is expected to share certain medical information and findings with the referring party.
Because a “limited doctor-patient relationship” exists during an IME, the physician is responsible
for disclosing in the IME any medical findings that could affect the patient’s health, and he or she
is potentially liable for any harm, direct or indirect, that may be sustained by the person
examined. Only a provider who is uninvolved with an examinee’s treatment may conduct an
IME, although a treating provider may be an “expert witness.” Legal requirements for
qualification as an expert witness vary from state to state. There is no restriction regarding a
provider’s clinical status and eligibility to conduct IMEs
A patient having difficulty late in the day getting up from a chair, going up or down stairs, and
reaching with his arms presents for electrodiagnostic studies. Physical exam demonstrates normal
deep tendon reflexes and normal findings on manual muscle testing. Standard sensory and motor
nerve conduction studies are normal. Repetitive axillary nerve stimulation (RNS) performed at
2Hz demonstrates 20% decremental response. Immediately after exercise, the RNS decrement is
no longer observed. Three minutes following exercise, however, the decrement is greater. Needle
electromyography results are normal.
Upon further investigation, you would most likely find what additional clinical finding?
(b) Dry mouth
(d) Skin rash
Commentary: The patient presents with myasthenia gravis (MG), a postsynaptic neuromuscular
junction disorder. Ptosis and extraocular weakness often occur in MG. Lambert-Eaton myasthenic
syndrome (LEMS), a presynaptic neuromuscular junction disorder, would demonstrate
postexercise facilitation (at least 100% increase in first response CMAP immediately following
exercise) and likely have low-amplitude baseline CMAP results. Autonomic symptoms such as
dry mouth often accompany LEMS. Long-term steroid treatment for asthma may cause myopathy
without significant needle EMG results, but RNS would be normal. Although dermatomyositis
typically presents with proximal weakness, no abnormalities characteristic of an inflammatory
myopathy were seen on needle electromyography.
Which sign is associated with central dysautonomia following severe traumatic brain injury?
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Commentary: Central dysautonomia can occur acutely after severe traumatic brain injury. It has
also been called diencephalic seizures, autonomic or neuro storming or hypothalamic
dysregulation syndrome. Signs include elevated temperature with a normal fever work up,
tachycardia, elevated blood pressure, rapid respiratory rate and posturing. Facial flushing and
diaphoresis may also be seen.
A patient with a left transfemoral amputation demonstrates a lateral trunk lean towards his
prosthetic side. What is the most likely cause?
(a) Prosthesis too long
(b) Long residual limb
(c) Prosthesis aligned in adduction
(d) Hip abduction contracture
Commentary: Causes of lateral trunk lean towards the prosthetic side include: prosthesis too
short, hip abduction contracture, prosthesis lined in abduction, and short residual limb.
Which type of study best differentiates a severe polyradiculopathy from amyotrophic lateral
(a) Motor nerve conduction studies of upper and lower extremities
(b) Needle electromyography of thoracic paraspinals or bulbar muscles
(c) Sensory nerve conduction studies of upper and lower extremities
(d) Needle electromyography of multiple extremities
Commentary: Sensory nerve conduction studies are normal in both radiculopathy and motor
neuron disease. Motor nerve conduction studies are also often normal in both diseases. Both
diseases may demonstrate abnormal needle examination in multiple extremities. Thoracic
paraspinals and bulbar muscle examinations are most helpful in differentiating severe
polyradiculopathy from amyotrophic lateral sclerosis (ALS), since one would expect these studies
to be normal in radiculopathy but may be abnormal in ALS.
Pathological drooling in children with spastic quadriparetic cerebral palsy is
(a) due to excessive saliva production.
(b) unsightly, but has no medical significance.
(c) associated with inefficient, uncoordinated swallowing.
(d) associated with increased dental caries.
Commentary: Pathological drooling is the unintentional loss of saliva either anteriorly over the
lips or posteriorly over the back of the tongue. It is associated with an inefficient, uncoordinated
swallow. Anterior drooling is normal in infants up to 18 months of age. Recent studies have
shown that salivary production is similar to that of typical children without cerebral palsy.
Medical complications of pathological drooling include chronic aspiration, pulmonary infections
and skin irritation. Saliva is protective of dentition.
Comparing the functional outcomes at 1-year post treatment of 2 groups of patients with
nonspecific low back pain greater than 12-months’ duration and no prior history of lumbar fusion,
which finding regarding structured rehabilitation with cognitive behavioral therapy (CBT) versus
lumbar fusion is TRUE?
(a) Better functional outcomes in the surgical group versus the CBT group
(b) Improvements in both groups with similar functional outcomes
(c) Better functional outcomes in the CBT group versus the surgical group
(d) Poor functional outcomes in the CBT group, but no consistent outcome in the surgical
Commentary: Randomized trials for surgery are difficult to conduct, particularly those that
compare surgical to nonsurgical treatment. While available studies do not allow a general
statement regarding the efficacy of fusion over nonsurgical care for discogenic back pain, 4 trials
suggest any advantage of surgery over nonsurgical care is modest, on average near or below the
minimally important change in the disability score. Both groups demonstrated improvement
compared to baseline. Highly structured rehabilitation with a cognitive-behavioral component
seems nearly equivalent to surgery in efficacy at 1 year, with fewer complications.
In a patient with a neuromuscular junction disorder, which electrodiagnostic results for compound
muscle action potential (CMAP), motor unit action potential (MUAP) or nerve action potential
(SNAP) may be misleading if the limb is cold?
(a) Diminished CMAP decrement on repetitive nerve stimulation
(b) Diminished polyphasia of the MUAP
(c) Shortened distal latency of the CMAP
(d) Decreased amplitude of the SNAP
Commentary: In neuromuscular junction (NMJ) disorders, compound muscle action potential
(CMAP) decrement may be diminished if the limb is cold, likely due to decreased functioning of
acetylcholinesterase. Cool temperatures may alter results by slowing nerve conduction velocity,
prolonging distal latency, increasing amplitude and duration of sensory nerve action potential
(SNAP) and CMAP and motor unit action potential (MUAP), increasing phases of MUAP.
What shoe modification can be used to treat medial compartment knee osteoarthritis?
(a) Rocker bottom sole
(b) Solid ankle cushioned heel
(c) Medial wedge
(d) Lateral wedge
Commentary: Medial compartment osteoarthritis results in genu varum. A lateral wedge can help
relieve pain by placing a valgus force at the knee. A medial wedge would exacerbate the problem.
Solid ankle cushioned heel is a type of prosthetic foot. A rocker bottom sole is helpful for other
conditions such as forefoot fractures, hallux rigidus, foot arthritis, and insensitive feet.
A 55-year-old overweight man presents to clinic with complaints of numbness in his left leg. He
reports that he does not exercise and has an office job. He is diagnosed with meralgia
paresthetica. Which of the following is consistent with this diagnosis?
a) Peroneal motor F-wave study is abnormal.
b) Sensory nerve conduction studies reveal decreased amplitude on the affected side.
c) Electromyography findings show denervation in the vastus lateralis.
d) Exam reveals decreased sensation in the medial thigh.
Meralgia paresthetica presents with paresthesias in the lateral thigh. Sensory nerve conduction
studies of the lateral femoral cutaneous nerve may show a drop in the sensory nerve action
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potential (SNAP) amplitude on the affected side compared to the asymptomatic, contralateral
study. Symptoms are confined to below the inguinal ligament and above the knee. Peroneal motor
nerve conduction studies and F waves should be normal and needle electromyography should not
show acute or chronic axonal motor loss, because the lateral femoral cutaneous nerve is purely
Which statement is TRUE of pseudodementia?
(a) Usually a history of previous psychiatric problems exists.
(b) Onset is indistinct with a long history of problems before consultation.
(c) Memory loss of recent items is worse than for remote items.
(d) Nocturnal accentuation of dysfunction is common.
Commentary: Distinguishing dementia from pseudodementia (which is really depression) is
important, in order to provide appropriate treatment to your patient with memory problems.
Pseudodementia’s onset is fairly well demarcated with a short history and is rapidly progressive
in nature. These patients usually have a history of a previous psychiatric difficulty or a recent life
crisis. Their complaints of cognitive dysfunction are detailed and elaborate with an affective
change and the patients expend little effort on examination items. Nocturnal exacerbations are
rare and memory loss is inconsistent in recall of recent and remote items.
Dementia’s onset, in contrast, is indistinct with a history of problems long before they seek
clinical help and early deficits often go unnoticed. A history of previous psychiatric problems or
emotional crisis is uncommon. These patients struggle with cognitive tasks but usually put forth
good effort. Nocturnal dysfunction is common. The memory loss on recent items is worse than
for remote items and there is a consistent impairment of performance.
A 60-year-old woman with rheumatoid arthritis is concerned about her fingers being crooked.
The ulnar deviation of her fingers at the metacarpal phalangeal joints is due to the rupture of the
(a) lateral retinaculum of the extensor tendon sheath.
(b) central slip of the extensor tendon.
(c) radial retinaculum.
(d) ulnar collateral ligament.
Commentary: Rupture of the radial retinaculum produces ulnar subluxation of the metacarpal
phalangeal (MCP) joints. Rupture of the lateral retinaculum of the extensor tendon sheath at the
proximal interphalangeal joints produces swan-neck deformities. Rupture of the central slip of
the extensor tendon produces boutonniere deformities. Rupture of the ulnar collateral ligament
would result in radial deviation of the fingers.
Which symptom is the most predictive of cardiac disease in Duchenne muscular dystrophy?
Commentary: The most frequent predictive symptom is dyspnea. Absence of exertion dyspnea
from lack of physical activity allows myocardial impairments to remain clinically silent and
difficult to detect. A high index of suspicion is required. Electrocdardiogram abnormalities in
both Duchenne and Becker muscular dystrophy patients are attributed to progressive fibrosis of
the cardiac conduction system and impairment in the cardiac autonomous nervous system.
Palpitations and syncope will be related to the conduction abnormalities and occurs late in the
disease process. Cachexia is a late finding that occurs when feeding becomes difficult as a result
of heart failure and dyspnea.
Which cancer related pathological fractures require surgical management?
(a) Humeral, if life expectancy is less than 3 months
(b) Radial, if pain resolves following radiation
(c) Femoral, if life expectancy is greater than 1 month
(d) Pelvic without acetabular involvement
Commentary: The indications for surgery for pathological fractures from cancer are life
expectancy of greater than 1 month with a fracture of a weight-bearing bone, and greater than 3
months for fracture of a non-weight-bearing bone. If pain persists following radiation, fractures
should be managed surgically. Healing rates are low following pathologic fractures, with 1
review of 123 patients reporting a 35% incidence of fracture healing. Fractures of the pelvis are
generally treated conservatively, unless pain persists after radiation or unless they involve the
A 33-year-old woman who is 6 months pregnant complains of right-sided, stabbing, low back
pain that is worse with movement. Which orthosis is most appropriate for her?
(a) Sacroiliac belt
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(b) Cruciform anterior spinal hyperextension orthosis
(c) Silesian belt
(d) Minerva brace
Commentary: Pregnant women frequently develop low back pain, and a sacroiliac belt can be
helpful. A cruciform anterior spinal hyperextension (CASH) brace is generally used for
osteoporotic compression fractures. A silesian belt is a type of suspension for transfemoral
prostheses. The Minerva brace is a cervicothoracic orthosis.
What is your next course of action in a 7-year-old boy newly diagnosed with Duchenne muscular
(a) Evaluate for a wheelchair
(b) Recommend spinal orthosis to correct scoliosis
(c) Order an echocardiogram
(d) Order physical therapy for contracture reduction
Commentary: Duchenne muscular dystrophy is an X-linked recessive disorder caused by the
absence of dystrophin. Prognosis is poor because of cardiac involvement leading to severe heart
failure. Baseline echocardiograms and electrocardiograms should be obtained after establishment
of the diagnosis. Contractures are common in DMD, but typically are seen after 13 years of age.
Scoliosis incidence is between 33% to 100% and presents between ages 12 and 15 years
corresponding to the adolescent growth spurt. Orthotics and a wheelchair will be necessary in the
course of the disease, but not at age 7.
What is the most common cause of autonomic dysreflexia?
a) Rectal distention
b) Pressure ulcers
c) Bladder distention
Commentary: In a spinal cord injury, the most common cause of autonomic dysreflexia is bladder
distention. The other answers can also cause autonomic dysreflexia but due to the frequency of
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bladder distention and potential problems of catheter blockage or bladder distention it is more
frequent than the other sources of painful stimulation listed.
A 39-year-old male factory worker suffers from a low voltage-induced electrical injury. The most
serious acute medical complication that can occur is
(a) cardiac arrhythmia.
(b) peripheral neuropathy.
(c) distal extremity amputation.
Commentary: Electrical injuries are usually caused by alternating current of 60Hz. They are
classified as high voltage injuries when the person comes in contact with 1000V or more, or low
voltage when the voltage is below 1000V. A large number of electrical injuries are work related.
Hussman found cardiac arrhythmias to be the most serious medical problem in patients admitted
with low voltage injuries (41% of patients). Other complications are soft tissue burns (especially
tissues with high water content, such as nerve, muscle and blood vessels), amputations (especially
of the fingers and toes), and neurological injuries (to the central or peripheral nervous system).
Peripheral neuropathy is reported in up to 34% of high voltage injuries and a lower incidence is
found in low voltage injuries.
A 32-year-old maintenance worker with full-thickness burns involving the right hand and forearm
is now ready for compressive garments. Which statement regarding his case is correct?
(a) In order to maximize blood flow to grafted sites, compressive garments should not
(b) Compressive garments should be worn a maximum of 18 hours a day to avoid graft site
(c) In 4 to 6 months full scar maturation will be achieved and compression garments may be
(d) To maintain adequate pressure, compression garments should be replaced every 2 to 3
Commentary: Compressive garments should provide capillary level pressures of at least
25mmHg. Wearing time should be increased gradually to 23 hours per day. Most active scarring
occurs between 4 to 6 months after injury, but full scar maturation may take 12 to 18 months. To
maintain adequate pressure, compression garments should be replaced every 2 to 3 months.
Proper positioning for a transtibial amputee should include use of a
(a) pillow underneath thigh.
(b) pommel between legs.
(c) limb board underneath knee.
(d) wedge cushion underneath buttocks.
Commentary: A limb board placed underneath the knee will help to prevent knee flexion
contractures. Placing a pillow underneath the thigh would encourage the development of a hip
flexion and possibly a knee flexion contracture. A pommel between the legs may encourage a hip
abduction contracture. A wedge cushion would promote hip flexion contractures.
A 20-year-old man sustained a severe traumatic brain injury and a femur fracture 1 week ago.
Magnetic resonance imaging reveals a diffuse axonal injury with no evidence of hemorrhage or a
hematoma. His condition is stable 1 day after open reduction, internal fixation of the femur
fracture and he is nonweight bearing on that leg. What is the appropriate recommendation for
deep venous thrombosis prophylaxis in this patient?
(a) Placement of a vena cava filter
(b) Sequential compression devices
(c) Graded compression stockings
(d) Low molecular weight heparin sodium
Commentary: Prophylaxis for deep vein thrombosis (DVT) should be considered in all patients
with a traumatic brain injury after acute admission to the hospital. Graded compression stockings
are of little benefit. Thigh high intermittent compression devices help reduce DVT risk but are not
an appropriate primary prophylaxis. A vena cava filter is not appropriate prophylaxis and
chemical prophylaxis is needed as soon as feasible. In patients who are not fully ambulatory in 24
hours unfractionated heparin sodium is adequate and can be used 12 hours after surgery.
However, in all patients who have long-bone fractures, prior DVT, or more than 4 total risk
factors, low molecular weight heparin sodium should be used until the patient is fully mobilized.
A 70-year-old obese gentleman presents to your office for follow-up with a several month history
of increasing left hip and groin pain that occurs with walking. His history is significant for prior
alcoholism, hypothyroidism, gout, and right knee osteoarthritis. He completed a physical therapy
course that did not help much. He now has difficulty even standing or walking for a few minutes
and complains of pain with moving his leg. Radiographs taken today demonstrate sclerosis and
slight collapse of the femoral head. What is his main risk factor for developing the condition
found on his radiographs?
(d) Older age
Commentary: The radiographic findings are typical for avascular necrosis which can be due to
trauma, high doses and/or prolonged use of steroids, heavy alcohol use, and certain systemic
diseases (diabetes, systemic lupus erythematosus). Obesity and older age are risk factors for
developing osteoarthritis. Typical radiographic findings of osteoarthritis include joint space
narrowing, osteophytes, subchondral cysts and sclerosis; collapse of bone is not seen.
Hypothyroidism is not a risk factor for avascular necrosis
The risk of an exacerbation of multiple sclerosis is reduced
a) during pregnancy.
b) in the first 3 months after delivery of a baby.
c) in the postoperative period after a surgery.
d) during a respiratory infection.
Commentary: During pregnancy multiple sclerosis (MS) exacerbations decrease to about half of
what they would be otherwise. During the first 3 months postpartum, the relapse rate is higher
than normal. The net effect of pregnancy on the course of MS is neutral, and women need not
make decisions about pregnancy based on fear that it will worsen their disease. There is no
documented effect on MS due to surgery or with a respiratory infection.
A 41- year-old African-American man had an orthotopic heart transplant 2 months ago. He has
started outpatient cardiac rehabilitation, 3 times a week. Compared to an age-matched individual
with a normal heart, which finding do you expect in this patient when he exercises?
(a) Lower resting heart rate
(b) Higher oxygen consumption
(c) Slower ability to reach maximal heart rate
(d) Higher peak heart rate during maximal exercise
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Commentary: A transplanted heart is denervated, and has a higher than normal resting heart rate
due to loss of vagal tone. It also has lower oxygen consumption during submaximal exercise than
that of the normal heart. It achieves a maximal heart rate more slowly than a normal heart, and the
peak heart rate achieved during maximal exercise is considerably lower in cardiac transplant
recipients than in age-matched controls.
In athletes, the etiology of thoracic outlet syndrome is most likely due to
a) clavicle fractures.
b) anatomic variations.
c) repetitive overhead activity.
d) hyperextension injuries of the neck.
Commentary: The most common etiology of thoracic outlet syndrome(TOS) in sports is likely
related to repetitive overhead motion. Hypertrophy of sport-specific musculature may predispose
to TOS. The role of anatomic variations is uncertain in TOS and may be common in patients with
and without this disorder. Fractures of the clavicle and hyperextension injuries of the neck may be
causes of TOS in the setting of trauma.
A 38-year-old woman with cystic fibrosis is scheduled to receive a lung transplant for end-stage
pulmonary disease. She has several questions about her pre- and posttransplant rehabilitation
program. You advise her that
(a) performing upper limb exercises is contraindicated.
(b) interval exercise training is better than continuous training.
(c) she should wait 5 days, postoperatively, before starting any out of bed activity.
(d) stair-climbing activity should not start until 6 weeks after surgery
Commentary: Preoperative rehabilitation for lung transplant patients is essential to physically
prepare them for the surgery itself, and to manage their failing strength, decreased thoracic
mobility and altered posture. Before surgery, interval exercise training is better than continuous
training. Upper limb exercise has been safely used in rehabilitation programs, although it can
contribute to dyspnea. Lung transplant patients with end-stage pulmonary disease often do better
with interval exercise training than with continuous training because less ventilatory demand is
required. Progressive activity should be initiated on the first postoperative day, beginning with
range of motion exercises. Before discharge from the hospital, the patient should progress to stairclimbing,
which is the hallmark of recovery.
Risk factors for osteoporotic long bone fractures in children with cerebral palsy include
(a) spastic hemiplegia.
(b) adequate oral nutrition.
(c) vitamin D supplementation.
(d) decreased mobility.
Commentary: Fracture risk is shown to increase with decreased mobility, nutrition via
gastrostomy tube and tetraplegia. Nutritional status is also linked to low bone mineral density
(BMD). Deficiencies in vitamin D, calcium, folate, iron and magnesium have been found in
children with cerebral palsy. Vitamin D and calcium are especially important in maintaining bone
mineral density (BMD).
Neuromuscular electrical stimulation to treat shoulder subluxation after stroke should be applied
to which muscles?
(a) Deltoid and supraspinatus
(b) Supraspinatus and infraspinatus
(c) Deltoid and trapezius
(d) Subscapularis and infraspinatus
Commentary: Neuromuscular electrical stimulation (NMES) to the deltoid (mainly posterior) and
the supraspinatus can decrease subluxation and reduce shoulder pain. It is required for several
hours daily over several weeks to achieve clinical benefits.
In Lyme disease, beyond the initial erythema migrans lesion from infection with the spirochete
Borrelia burgdorfer what other findings may be seen later on?
(a) Facial nerve palsy
(b) Renal insufficiency
(c) Pleural effusion
Commentary: Lyme disease is the result of a bite from a tick infected with Borrelia burgdorferi.
Erythema migrans lesion is typically the initial skin lesion seen. Other findings from systemic
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infection include mono-/polyarticular arthritis, facial nerve palsy, aseptic meningitis,
radiculopathy, or heart block. Renal insufficiency and pleural effusion are not seen.
When using ultrasound, the production in a sound field of gas bubblesthat grow and collapse
producing high temperatures and tissue damage is called
(a) standing waves.
(b) oscillatory movement.
(c) acoustic streaming.
(d) unstable cavitation.
Commentary: Unstable cavitation refers to bubbles that continue to grow in size and then
collapse. The high temperatures and pressures generated by this can produce platelet
aggregation, localize tissue damage and cause cell death. The physiologic effects of ultrasound
can be divided into thermal and nonthermal effects. Nonthermal effects include cavitation, media
motion (acoustic streaming, microstreaming) and standing waves.
Which respiratory measure declines when a patient with tetraplegia moves from a supine to
a) Total lung capacity
b) Functional residual capacity
c) Vital capacity
d) Residual volume
Commentary: With the exception of vital capacity (VC), the direction of change in total lung
capacity and functional residual capacity decrease in the supine position and increase in the
seated position, similar to an individual without a spinal cord injury. In contrast, patients with
tetraplegia or high paraplegia have a decrease in the VC in the seated position, which is the result
of an increase in the residual volume (RV) caused by the effect of gravity on the abdominal
contents, causing the diaphragm to move down into a less efficient position and increasing the
A 36-year-old man has a known history of human immunodeficiency virus (HIV). His family has
observed worsening confusion and memory loss. He later develops progressive paraparesis,
ataxia, posterior column sensory loss, and neurogenic bowel and bladder. The most likely
(a) viral myelitis.
(b) multiple sclerosis.
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(c) cytomegalovirus (CMV) polyradiculopathy.
(d) vacuolar myelopathy.
Commentary: Vacuolar myelopathy is the most common cause of spinal cord dysfunction in
human immunodeficiency virus (HIV) patients, being found in 11% to 22% of acquired
immunodeficiency disease (AIDS) cases, and demonstrable in as many as 40% of cases at
autopsy. It is strongly associated with HIV dementia, and shares a virtually identical
histopathology. The other diagnoses are less common, and can be ruled out or in with imaging,
laboratory and electrodiagnostic studies.
A firefighter who is now 5 days postsurgery for a rotator cuff and labral tear is in significant pain,
but is concerned about opioid use for pain control. He is concerned about becoming “addicted to
the pain killers.” In educating the patient about opioids and the issues of addiction, dependence
and tolerance, which statement is correct?
(a) While all 3 terms have subtle differences, they are essentially identical in meaning and
can be used interchangeably.
(b) Since he is a firefighter, he should avoid use of any opioids at all times since he is subject
to toxicology screening.
(c) Addiction is predictable and avoidable, and since he already concerned about it, he is
unlikely to have problems with addiction.
(d) Addiction is characterized by behavioral issues, whereas dependence and tolerance are
characterized by physiologic adaptation.
Commentary: Physical dependence, tolerance, and addiction are discrete and different phenomena
that are often confused. Addiction is characterized by behaviors that include one or more of the
following: impaired control over drug use, compulsive use, continued use despite harm, and
craving. Addiction is not a predictable drug effect, but represents an idiosyncratic adverse
reaction in biologically and psychosocially vulnerable individuals. Physical dependence is a state
of adaptation characterized by specific withdrawal symptoms that can be produced by abrupt
cessation, rapid dose reduction, and/or administration of an antagonist. Tolerance is a state of
adaptation that results in a decreased effect of a drug over time.
The most common movement disorder associated with cerebral palsy is
Commentary: While all of the listed movement disorders can be seen in cerebral palsy, spasticity
-- defined as velocity-dependent resistance to passive movement -- is the most common. Dystonia
is described as involuntary sustained muscle contractions that result in twisting and abnormal
posturing of the extremities. Athetosis is a slow, nearly continuous writhing movement, once a
common result of kernicterus, coupled with chorea. Rigidity is resistance to movement of a joint
because agonist and antagonist muscles are both contracting. It is not velocity dependent and is
rarely found in cerebral palsy.
Which wheelchair component is appropriate for a patient with T10 spinal cord injury?
(a) Quick release axle
(b) Projection rims
(c) Arm trough
(d) Tilt-in-space system
Commentary: Quick release axles allow persons with spinal cord injury who drive to load their
wheelchairs into the car more easily. Projection rims assist with wheelchair propulsion in patients
who have insufficient hand function. The tilt-in-space recline system offers independent pressure
relief in patients with tetraparesis. Arm troughs support the arms and forearms of persons with
limited upper limb strength. A patient with T10 spinal cord injury has sufficient upper limb and
trunk control so that projection rims, arm trough, and tilt-in-space features are not necessary.
A pharmacologic treatment for orthostatic hypotension that involves fluid retention is
b) ephedrine sulfate.
c) midodrine hydrochloride.
d) recombinant human erythropoietin.
Commentary: Fludrocortisones (0.05 mg once daily to 0.1 mg twice daily) is a potent
mineralocorticoid with little glucocorticoid activity. It has been used to manage orthostatic
hypotension (OH) related to autonomic dysfunction for more than 40 years. The pressor action of
fludrocortisones is a result of sodium retention, which occurs over several days. This delayed
action needs to be understood by the clinician as well as the patient to manage expectations and
time frame of benefit. Ephedrine (20mg to 30mg up to 4 times daily) acts primarily through the
release of stored catecholamines and has additional direct action on adrenoreceptors. It is a
nonselective and mimics epinephrine in its effects. Midodrine (2.5mg to 10mg 2 to 3 times daily)
is an alpha 1-adrenorecptor agonist and directly increases blood pressure by arteriolar and venous
constriction. Recombinant human erythropoietin has been shown in pilot studies to increase blood
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pressure by about 10mmHg to 20mmHg in patients with OH. In addition to the increase in red
blood cell count and blood viscosity that occurs with epoeitien α, it may have a yet unrecognized
effect on the vasculature.
You are asked to provide a brief synopsis of workers’ compensation benefits to the hospital’s
case management department. Which statement about the benefits and services provided in the
workers’ compensation system is correct?
(a) The employer has to be at fault in order for the injured employee to seek medical care.
(b) Injured workers continue to receive their full wages as long as they are unable to work.
(c) Workers’ compensation programs are designed and administered by each individual state.
(d) Workers’ compensation is primarily financed by federal and state funds.
Commentary: Workers’ compensation provides benefits to workers who are injured on the job or
have a work-related illness, regardless of who is at fault for the injury or illness. Benefits include
medical treatment for work-related conditions and cash payments that partially replace lost
wages. In the event that symptoms do not completely resolve, financial compensation is also
provided. In exchange, an injured worker gives up the right to sue the employer because of a
work-related injury or illness. Workers’ compensation programs are designed and administered
by each state, and programs and policies vary from state to state. Workers’ compensation is
financed almost exclusively by employers, not federal or state funds.
When performing needle electromyography in someone therapeutically anticoagulated with
warfarin, which muscle would be the safest to examine?
(a) Tibialis posterior
(b) Paraspinal muscles
(d) Flexor pollicis longus
Commentary: Although needle EMG is generally safe in patients taking warfarin, whenever
bleeding risk is increased it is best to limit the needle examination to a few superficial muscles,
where prolonged compression can be performed if necessary. The pronator teres and tibialis
posterior are deep muscles in which, theoretically, a hematoma could develop. It is also best to
avoid needle insertion into areas where possible hematoma could compress a nerve or artery, such
as exiting spinal nerves near paraspinals or the radial artery near the flexor pollicis longus.
Intrathecal baclofen decreases spasticity by what mechanism?
(a) It blocks Ia afferent signals through the dorsal root ganglia.
(b) It acts as a GABA agonist to inhibit gamma motor neuron activity and decrease muscle
spindle sensitivity to spinal reflexes.
(c) It blocks acetylcholine release from neurons at the peripheral neuromuscular junction.
(d) It inhibits calcium release from the sarcoplasmic reticulum during muscle contraction
Commentary: Intrathecal baclofen acts as a GABA agonist inhibiting the spinal reflex arc
stimulated by intrafusal muscle fiber stretch. Selective dorsal rhizotomy seeks to diminish
spasticity by decreasing the afferent signal by cutting rootlets in the dorsal root ganglia.
Botulinum toxin blocks acetylcholine release at the neuromuscular junction. Dantrolene sodium
decreases muscle contraction by inhibiting calcium release from the sarcoplasmic reticulum. All
these therapeutics can be useful in the treatment of spasticity.
A 22-year-old man who is right hand-dominant presents to your office with acute onset of right
shoulder pain. He is a former college tennis player without a previous history of shoulder
pathology. Which test would you perform to evaluate for pathology involving the labrum of the
a) Hawkin test
b) Bowstring sign
c) O’Brien active compression test
d) Apley scratch test
Commentary: The O’Brien active compression test is used to evaluate and differentiate labral
tears (superior labrum anterior posterior -- SLAP tears) from acromioclavicular joint pathology
and pain. The Hawkin test is an impingement test of the shoulder and is not intended to evaluate
tears of glenoid labrum. The bowstring sign is used to identify lumbar nerve root compression.
The Apley scratch test is used to assess the range of motion of the shoulder.
A 40-year-old woman is currently hospitalized for a severe flare of her polymyositis. On
consultation, you recommend that while in the hospital she begin
(a) passive range-of-motion exercises to prevent contractures.
(b) isometric strengthening exercises at the bedside to maintain her strength.
(c) ambulation with a walker in the hallways supervised by her therapist.
(d) strengthening exercises with light hand and ankle weights.
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 and ambulation.
Because urinary tract infections (UTIs) are the most widespread bacterial infection and the most
common source of bacteremia in older adults, treatment for bacteriuria greater than 10,000
CFU/ml in this population is indicated for an older patient with
(a) vaginal atrophy.
(b) a chronic indwelling Foley catheter.
(c) a neurogenic bladder.
(d) increased incontinence.
Commentary: Bacteriuria is defined as a quantitative count of 10,000 CFU/ml or more of 1 or
more organisms found in a patient’s urine culture, in the absence of clinical signs or symptoms of
UTI in the host. Vaginal atrophy, neurogenic bladder, and chronic use of urethral or condom
catheters are risk factors for UTIs. However, treatment in the elderly is indicated only if systemic
signs and symptoms -- such as low-grade fever, increased confusion, incontinence, anorexia and
functional decline -- are present.
A warehouse manager asks you about prescribing lumbar supports to help his workers prevent
and treat lumbar strains. You inform him that evidence-based medicine shows that lumbar
(a) prevent excessive spinal motion by providing sensory feedback.
(b) demonstrate low compliance by workers for both treatment and prevention of lumbar
(c) increase intra-abdominal pressure without increasing abdominal muscle activity.
(d) are superior to other available treatments in providing lumbar pain relief..
Commentary: While theories have been proposed regarding how lumbar supports may treat and
prevent lumbar strains, evidence-based medicine does not demonstrate consistent findings to
support their use. Studies have shown that there is very low compliance with consistent use of
lumbar supports. There have been no consistent findings showing that lumbar supports prevent
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excessive spinal motion or increase intra-abdominal pressure without increasing abdominal
muscle activity. Outcomes studies do not demonstrate superior outcomes with use of lumbar
supports compared to other available treatments.
A 30-year-old woman began running 2 weeks ago. She runs 4 miles a day, twice a week. She
began experiencing bilateral lower leg pain. On physical examination, she reports diffuse pain
along the medial tibia at the start of her run with improvement during the run. The most likely
a) stress fracture.
b) medial tibial stress syndrome.
c) anterior tibialis tendinitis.
d) tarsal tunnel syndrome.
Commentary: This woman presents with symptoms most consistent with medial tibial stress
syndrome (MTSS) or what has been termed “shin splints.”Pain from MTSS occurs along the
lower third of the posteromedial border of the tibia. A stress fracture is unlikely in this low
mileage runner who has had only 2 weeks of running activity. Stress fractures generally have a
focal area of pain and are not relieved with further running. Anterior tibialis tendinitis presents
with anterolateral pain along the dorsal aspect of the ankle. Tarsal tunnel syndrome is associated
with numbness and tingling in the foot.
The bulk of personal long-term care for most older individuals in the United States is provided by
(a) paid home health aides.
(b) extended care facilities.
(c) government agencies.
(d) family members.
Commentary: In the United States, immediate and extended families provide the bulk (up to 90%)
of personalized long-term care for their elderly disabled relatives. This includes personal care,
nursing care, meals, housekeeping, transportation and shopping. Outside or alternative support
systems (friends and neighbors, government and agencies) supplement this care, and can become
increasingly important with advancing age.
A 47-year-old woman develops complex regional pain syndrome (CRPS) type I following a fall
at work which resulted in a distal radius fracture. Although no established gold-standard
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treatment for CRPS currently exists, which option has been studied in multiple, large-scale
(c) Stellate/lumbar sympathetic blocks
Commentary: While all of the listed options have been used for the treatment of CRPS, only
bisphosphonates have been investigated in multiple, large-scale randomized trials. Clear benefits
have not been reported with gabapentin or stellate/lumbar sympathetic blocks. Available evidence
does not support the use of calcitonin.
A man presents to your clinic complaining of buttock pain that radiates posteriorly down the
thigh. On exam you note that he has a leg length discrepancy, symptoms are provoked by placing
the affected limb in the FAIR position (hip in flexion, adduction and internal rotation), and he has
a positive straight leg raise test. He has normal nerve conduction studies and a normal needle
electromyography test. Treatments that may be beneficial include
(a) stretching exercises of the iliotibial band and corticosteroid injection of the greater
(b) a lumbar stabilization exercise program and coricosteroid lumbar epidural spinal
(c) a lumbar stabilization exercise program and botulinum toxin injection of the lumbar
(d) stretching exercises in the FAIR position and botulinum toxin injection to the piriformis.
Commentary: This is a description of piriformis syndrome. Although some positive findings on
needle examination may be seen with piriformis syndrome, electrodiagnostic studies are often
normal. On the other hand, positive findings are expected in cases of lumbar radiculopathy.
Conservative treatment of piriformis syndrome begins with piriformis stretching (FAIR position
is a good position for this) and nonsteroidal anti-inflammatory drugs (NSAIDs), followed by
lumbosacral stabilization, hip strengthening, and myofascial release. Botulinum toxin relieves
pain via multiple mechanisms and is increasingly used in the treatment of myofascial dysfunction.
A lumbar stabilization exercise program and botulinum toxin injection of the lumbar paraspinals
may help relieve some of this patient’s pain if he also has low back pain, but would not address
the main issue, piriformis syndrome. Stretching exercises of the iliotibial band and corticosteroid
injection of the greater trochanteric bursae would be the treatment for greater trochanteric
bursitis. A lumbar stabilization exercise program and corticosteroid lumbar epidural spinal
injection would treat a lumbar radiculopathy.
The most common etiology of cerebral palsy is
(a) premature birth.
(b) birth asphyxia.
(c) intrauterine stroke.
(d) prenatal infection.
Commentary: There is a common misperception that cerebral palsy is caused by injury at birth;
however, the greatest risk factor for cerebral palsy is prematurity, accounting for nearly half of
the cases. Low birth weight, infection and stroke are also risk factors. Birth asphyxia accounts for
You receive a call from your 70-year-old patient with osteoporosis. She has been taking
alendronate (Fosamax) for 3 years. The news reports and her friends are all talking about hip
fractures in patients taking biphosphonates. You state that based upon scientific evidence there is
(a) increased risk of femoral fractures.
(b) increased risk with the initiation of bisphosphonates at a younger age.
(c) no increased risk in patients with prior fractures.
(d) no increased risk of femoral fractures
Commentary: Recent secondary analysis of 3 large, randomized biphosphonate studies did not
find increased risk of subtrochanteric or femoral fractures. Proposed risk factors such as younger
age upon initiation of biphosphonate treatment has not been confirmed or studied. A risk factor
for future fractures is a history of prior fractures