Flashcards in SAER 2013 Deck (47):
An individual with T3 ASIA A paraplegia complains of burning pain in his legs. Additional review of symptoms includes urinary leakage between catheterizations and difficulty sleeping. The best pharmacologic intervention at this time would be
(a) fluoxetine (Prozac).
(b) amitriptyline (Elavil).
(c) alprazolam (Xanax).
(d) trazodone (Desyrel).
Commentary: Amitriptyline, a tricyclic antidepressant, can be effective in the treatment of neuropathic pain but has a significant side effect profile that includes an anticholinergic and sedative effect. These side effects would be desirable in this patient with leaking and difficulty sleeping. Prozac may be helpful with pain but may actually cause insomnia and has little anticholinergic effects. Trazodone is a mild sedative with slight anticholinergic properties. Alprazolam is primarily a sedative and is not commonly used for neuropathic pain.
A 22-year-old female gymnast presents to your clinic after a patellar dislocation during practice. She was treated in the emergency room with reduction of the patella and immobilization. Radiographs and magnetic resonance imaging of the knee are negative for fracture or evidence of osteochondral lesions. You choose to treat her with immobilization for 2 weeks and then begin physical therapy. The most appropriate therapy recommendation is to focus on improving
(a) flexibility of gastrocnemius-soleus complex.
(b) strength of the iliopsoas.
(c) flexibility of the biceps femoris.
(d) strength of the vastus medialis.
Commentary: Physical therapy in this patient should focus on strengthening of her medial quadriceps muscles and restoration of normal patellar motion. Surgery in select instances addresses realignment of the patella by a lateral retinacular release and/or medial retinaculum repair when torn.
An 18-year-old female on your inpatient traumatic brain injury service is inconsistently oriented and does not recall your name on a day-to-day basis. She can follow single-step commands. She gets more confused when stressed but can be re-directed and can finish her therapy sessions with encouragement. She is more consistent with goal-directed behavior but needs cueing. Greater participation in activities of daily living is evident and she is developing a better awareness of self and others. On the Rancho Los Amigos scale, what is her level of cognitive function?
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Commentary: She is presently displaying characteristics consistent with the sixth stage of recovery in the Rancho Los Amigos scale of cognitive function. This patient is not out of posttraumatic amnesia and is still confused. However, she responds appropriately to feedback and is able to participate in therapies. She is improving in goal-directed behavior and is developing greater awareness of self and others. On the Rancho Los Amigo scale, the other options listed are described as follows: Level V - Confused and Inappropriate; Level VI - Confused and Appropriate; Level VII - Automatic and Appropriate. For level VII, you would anticipate that she would no longer need cuing for goal-directed behavior but will still have problems with new activities or with planning and following through with activities.
A 50-year-old man with metastatic renal cell carcinoma status post nephrectomy 1 year ago was found to have a T10 lesion on recent post-operative imaging done as part of a work-up for right-sided mid-back pain. The patient’s pain is not relieved with recumbency and is not affected by thoracic rotation. He has a normal thoracic kyphosis and is neurologically intact on physical examination. An MRI scan of the thoracic spine shows a T10 lytic lesion, normal alignment, no discernable vertebral body collapse, and unilateral involvement of the T10 posterior elements. You recommend
(a) neurosurgical consultation for decompression and segmental stabilization.
(b) radiation oncology consultation for palliative radiotherapy treatments.
(c) T10 kyphoplasty.
(d) custom molded thoracic lumbosacral orthosis (TLSO).
Commentary: Palliative radiotherapy treatments directed at the T10 vertebral body will provide symptomatic pain relief from metastatic tumor involvement. The patient has a Spinal Instability Neoplastic Score (SINS) of 6, out of 18. A T10 lesion in the semirigid portion of the thoracic spine scores 1, non-mechanical pain scores 1, lytic bone lesion scores 2, normal alignment scores 0, no collapse with > 50% vertebral body involvement scores 1, and unilateral involvement of the posterior spinal elements scores 1. Neurosurgical decompression and segmental stabilization is not required for a stable T10 lesion in a neurologically intact patient. Similarly, a T10 kyphoplasty is not indicated in the absence of significant vertebral body collapse. A custom-molded TLSO is unlikely to benefit this patient who has no mechanical back pain symptoms.
What is the overall leading cause of death for individuals with paraplegia?
(a) Pulmonary embolism
(d) Heart disease
Commentary: In paraplegia, the overall leading cause of death is heart disease, followed by septicemia and then suicide. In tetraplegia, pneumonia is the leading cause of death.
You are asked to consult on a 60-year-old cancer patient with an acute deep vein thrombosis (DVT) in the right upper limb, secondary to a long-standing central venous catheter. What therapy restrictions would you recommend for the patient?
(a) Bed rest for 10-12 days to allow for clot maturation.
(b) No activity restrictions, since upper limb DVTs have a low likelihood of causing a pulmonary embolus.
(c) Begin resistive exercises 12-24 hours after the patient is therapeutic on an anticoagulant.
(d) Limit therapy to ambulation, balance, and ADL training if anticoagulation is medically contraindicated.
Commentary: Because patients with acute upper limb DVT who cannot safely be anticoagulated are at high risk for pulmonary emboli and death, their physical, occupational, or lymphedema therapy should be functional in nature (ie, ambulation, balance, ADL training). Resistive exercises should be deferred until 48 – 72 hours after a patient is therapeutic on an anticoagulant (low molecular weight heparin, unfractionated heparin, or Coumadin). Prolonged bed rest for clot maturation is no longer supported within the medical literature for lower extremity DVTs, since the initial recommendation was based on a single limited study. Although the timing of mobilization following an acute upper limb DVT and institution of therapy has not yet been defined in the literature, bed rest for 10-12 days is overly restrictive. However, placing no activity restrictions on the patient is potentially dangerous, since an immature clot may break off and embolize to the lungs.
What secondary condition requires the most medical management in adults with cerebral palsy?
(c) Cardiovascular disease
Comments: In adults with cerebral palsy (CP) The incidence of pain is high (67%-82%) across all disability groups and appears to increase with age. It is multifactorial with musculoskeletal issues being of primary concern. Constipation issues persist into adulthood and adjustments to the bowel program may be needed. Adults with CP are not reported to have a higher risk of cardiovascular disease but are less likely to be screened than the general population. Osteoporosis is most common (up to 50% in some studies) in non-ambulatory persons, (Gross Motor Function Classification System, GMFCS levels 4, 5), and it increases with age.
The definitive diagnostic test for inclusion body myositis is
(a) muscle enzyme serum levels.
(b) cerebrospinal fluid.
(c) muscle biopsy.
Commentary: Inclusion body myositis (IBM) is a slowly progressive myopathy that tends to affect middle-aged and older individuals. Clinical manifestations can include distal as well as proximal weakness, which can be asymmetrical. Muscle enzyme levels may be slightly elevated or normal. Myopathic motor units can be seen, although this finding is nonspecific, since it exists in other inflammatory myopathies, as well. Acquisition of cerebrospinal fluid is not part of the work-up for myopathy. Muscle biopsy is diagnostic with rimmed cytoplasmic vacuoles and cytoplasmic and nuclear inclusions.
In the United States, upper extremity amputations are
(a) most often due to vascular disease.
(b) more common in males than females.
(c) rarely caused by workplace injuries.
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(d) increasing due to the relaxing of occupational safety standards.
Commentary: Of all upper extremity amputations, 90% are due to trauma. The majority of these are related to workplace injuries involving saws or blades. Males account for 75% of all upper extremity amputations. Trauma related amputations have decreased over the last 20 years and they are expected to remain flat or decrease, due to ongoing enforcement of safety standards.
Which score range on the Galveston Orientation and Amnesia Test (GOAT) indicates the end of posttraumatic amnesia (PTA)?
Commentary: A standard technique for assessing posttraumatic amnesia (PTA) in adults is the Galveston Orientation and Amnesia Test (GOAT), a brief structured interview that quantifies orientation and recall of recent events. The GOAT score can range from 0 to 100, with a score at or above 75 defined as normal. The end of PTA is defined as when the GOAT score is at or above 75 for 2 consecutive days.
Following a crush injury with axonotmesis, the approximate growth regeneration rate at the wrist is 1 centimeter per
Commentary: Regenerating axons grow approximately 1 millimeter a day, 1 centimeter a week, 1 inch a month, or 1 foot a year. The rate of axon regeneration depends chiefly on type of injury (crush or laceration) and whether the lesion is proximal or distal. Growth rate following a crush injury with axonotmesis in the upper arm is about 8 millimeters a day; in the upper forearm it is about 6 millimeters a day, at the wrist about 1-2 millimeters a day, and in the hand about 1.0-1.5 millimeters a day. Easier figures to remember, however, are 1mm/day, 1cm/week, or 1 inch/month.
A 62-year-old woman complains of right knee pain and stiffness. On physical examination, she has a genu varum deformity. A physical therapy prescription should include
(a) isokinetic hamstring strengthening.
(b) isometric hamstring strengthening.
(c) closed kinetic chain quadriceps strengthening.
(d) open kinetic chain quadriceps strengthening.
Commentary: For knee osteoarthritis, quadriceps strengthening has been well studied and is shown to be beneficial. In closed kinetic chain exercises, the distal aspect of the limb is fixed against a source of resistance, whereas in open kinetic chain exercises, the distal part of the limb is free in space. Closed chain exercises are preferred because they result in less shear force across the joints and are also more functional.
Which finding is a relative contraindication to cryotherapy?
(a) Acute inflammation
(c) Acute hematoma
(d) Impaired sensation
Commentary: Cryotherapy, that is, the therapeutic use of cold by means such as ice, cold packs, or cold water immersion is commonly used to decrease pain, muscle soreness, fatigue and acute inflammation. Relative contraindications include cold intolerance, cryoglobulinemia, impaired sensation or cognitive defects. Cold intolerance can lead to decreased compliance and increased muscle guarding. Cryoglobulinemia results in immune complex precipitation at lower temperatures. Impaired sensation or cognitive defects may lead to tissue injury. Cryotherapy can be effective in decreasing the swelling or bleeding that commonly accompany tissue injuries.
After completing inpatient rehabilitation, an 18-year-old male with complete tetraplegia is able to feed himself with adaptive equipment and requires some assistance with upper body dressing and grooming. He is able to assist with bed mobility, but is dependent for transfers. He is also able to use a manual wheelchair with rim projections indoors on flat surfaces, but when outdoors he prefers to use a power wheelchair with a joystick. His physical therapist reports that he has achieved his maximal expected outcome. What is his level of injury?
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Commentary: Although each person is different, individuals with C5 tetraplegia are in general able to feed themselves with adaptive equipment after set-up and are able to assist with some upper body dressing. Some are able to independently use a manual wheelchair, but most require some assistance, especially on carpets, non-level surfaces and outdoors. Many prefer to use a power wheelchair. People with complete C4 levels of injury are not able to feed themselves, assist with activities of daily living (ADLs), or propel a manual wheelchair, especially if they have no zone of partial preservation. People with C6 and C7 levels of injury are often capable of transferring (independently or with assistance) and of attaining more independence with ADLs.
What is the strongest single predictor of mortality in adults with pediatric onset disabilities?
(a) Feeding problems
(b) Presence of epilepsy
(c) Inability to walk
(d) Intellectual disability
Comment: Feeding problems, epilepsy and inability to walk are conditions associated with pediatric mortality, but intellectual disability is the strongest single predictor of mortality in adults with pediatric onset disabilities. Intellectual disability affects a person’s ability to manage health care monitoring, exercise programs, nutrition, housing, and sexuality. These items are likely to be more closely monitored by parents and pediatricians for a child than by community workers and adult physicians caring for adults with pediatric onset disabilities.
For a person with an upper extremity amputation, what is the advantage of choosing a body-powered device over a myoelectric device?
(a) Stronger grip force
(b) Better cosmesis
(c) Lighter weight
(d) Less dependence on motor strength
Commentary: Main advantages of body powered systems are lower initial costs, lighter weight, easier repairs, and better tension feedback to body. Advantages of myoelectric devices are cosmesis, less need for motor strength/coordination to operate limb, and stronger grip force.
A 23-year-old woman with C7 ASIA B tetraplegia resulting from an accident 8 months ago is complaining of nausea for several days and has vomited non-bloody, non-bilious food particles the last 3 evenings when placed back to bed after dinner. She also reports some abdominal tightness and bloating. Her symptoms are relieved when lying on the left side. Her bowel training program is going well, resulting in regular, effective bowel movements. She recently lost 25 pounds and appears quite thin on exam. Which study will confirm this patient’s most likely diagnosis?
(a) Abdominal x-ray
(b) Head computed tomography (CT) scan
(c) Serum calcium level
(d) Upper gastrointestinal (GI) series
Commentary: Superior mesenteric artery (SMA) syndrome is a condition in which the third segment of the duodenum is compressed between the SMA and the aorta. Although it occurs rarely, it is more common in people with tetraplegia, especially if the person lost weight and is immobilized in the supine position. An upper GI series confirms the diagnosis with an abrupt cessation of barium in the third part of the duodenum. In addition to lying on the left side, some individuals get relief with metoclopramide (Reglan). A serum calcium level could be used to diagnose immobilization hypercalcemia, which is a common cause of nausea and vomiting in patients with tetraplegia. Hypercalcemia is not, however, alleviated with positioning and it usually occurs within the first few months after injury. Abdominal x-ray could identify chronic constipation, but since her bowel program is going well, constipation is not likely to be the cause of her symptoms. Although hydrocephalus would be identified by means of a head CT scan, it is the least likely diagnosis in this case.
A 70-year-old man with COPD presents to your office for follow-up. His forced expiratory volume in 1 second (FEV1) is 55% of predicted normative values. What would you expect the patient’s functional limitations to be?
(a) No functional impairment; the patient is able to walk significant distances without difficulty.
(b) Mild functional impairment; the patient is able to walk significant distances at a slower speed.
(c) Moderate functional impairment; the patient requires intermittent rest when walking and climbing stairs.
(d) Severe functional impairment; the patient is only able to ambulate for very short distances.
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Commentary: The World Health Organization’s Global Initiative for Chronic Obstructive Lung Disease classifies patients who have an FEV1 between 50%-79% of predicted values as moderately impaired. This equates to the FEV1 dropping between 1-2 liters. Functional impairment develops when the FEV1 falls below 3 liters. Patients with an FEV1 between 30%-49% of predicted values are severely impaired while those with an FEV1 less than 30% are the most impaired.
According to the documentation requirements of the Center for Medicare and Medicaid Services (CMS), which factor is not considered part of a patient’s History?
(a) Chief complaint
(c) Review of systems
(d) Social history
Commentary: Evaluation and Management (E/M) coding is the process by which physician-patient encounters are translated into numeric codes to facilitate billing. Different E/M codes exist for different types of encounters, such as inpatient or outpatient encounters and new patient or established patient encounters. Documentation for E/M services is based on 3 key components, including (1) history, (2) physical exam and (3) medical decision-making. While a patient’s allergy history is an important part of the evaluation, E/M coding does not credit this documentation as part of a patient’s history. The history is comprised of the patient’s chief complaint, history of present illness, review of systems, and past medical, family, and social history.
An infarct in the lower division of the left middle cerebral artery division would be associated with which type of aphasia?
(c) Transcortical sensory
Commentary: An infarct in the area of the middle cerebral artery lower division is much less common than an upper division stroke of the middle cerebral artery. It is usually caused by an embolic event. If the stroke is in the dominant hemisphere it will demonstrate a Wernicke aphasia; if it is in the nondominant hemisphere an affective agnosia is seen. A contralateral
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homonymous hemianopsia is also caused by a stroke in this area. Classically, global aphasia is associated with an infarction of the middle cerebral artery main stem, and Broca’s aphasia with infarction of upper division of the middle cerebral artery. Transcortical sensory aphasia typically is associated with a posterior cerebral artery infarction.
Which finding is associated with a more favorable prognosis in amyotrophic lateral sclerosis (ALS)?
(a) Bulbar involvement presentation
(b) Predominance of lower motor neuron findings on electrodiagnostic studies
(c) Young age and male sex
(d) Short time period from symptoms to diagnosis
Commentary: Several prognostic predictors exist for determining the severity of a person's ALS course. Presentation with bulbar or pulmonary dysfunction (or both), short time period from symptom onset to diagnosis, electrodiagnostic findings indicating primarily lower motor neuron involvement and advanced age all potentially indicate a poor prognosis. Women present with bulbar symptoms more frequently than men do. Bulbar palsy, which indicates a poor prognosis, appears to progress more rapidly in women. Young males with ALS have the best prognosis and may have a longer life expectancy. Overall, the median 50% survival rate is 2.5 years after diagnosis. In patients who present with bulbar symptoms, the 50% survival rate drops to 1 year. Survival rates vary depending on the patient's decision to use a feeding tube and assisted ventilation. Nonetheless, by 5 years postdiagnosis, the overall survival rate is only 28%.
A 57-year-old man with chronic low back pain is referred to see you. He has commercial medical insurance. The patient leaves radiologic films and medical records for review and also asks you to complete disability paperwork. That evening you review the films and records, fill out the paperwork, and call the referring physician. In addition to the charges for a New Patient Consultation, what charges may you submit to the commercial medical insurance for these services?
(a) No additional charges, since all your services are covered by the New Patient Consultation charge
(b) No additional charges to the commercial insurance, although you may charge the disability insurance for completing the disability paperwork
(c) One additional charge for Prolonged Services, up to 60 minutes for the time needed to complete all the additional services
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(d) Two additional charges, one for radiology review and another for Prolonged Services, up to 60 minutes for the time needed to complete the other services
Commentary: For outpatient services, Evaluation and Management (E/M) coding allows providers to bill based on time spent, as long as that time is spent face-to-face, and at least 50% of that time is used for patient counseling and education. Provider services that occur outside of the actual face-to-face encounter are assumed as part of the work necessary to complete the evaluation and management of the patient and may not be billed separately as “Prolonged Services.” Commercial and disability insurance companies are not obligated to reimburse providers to complete paperwork, and providers may opt to charge patients directly for completion of disability paperwork. Had this patient presented through the Workers’ Compensation (WC) system, some of these additional services may have been reimbursable, depending on the specific WC laws that are stipulated by each state.
You see a patient in clinic with what appears to be a non-infected diabetic foot ulcer over the first metatarsal head and order an ankle-brachial index (ABI) study. The patient’s ABI is 1.4. What is your next step in treatment?
(a) Proceed with off loading the ulcer, since blood flow is normal.
(b) Order additional testing, such as an arterial duplex.
(c) Refer for to vascular surgery for urgent revascularization.
(d) Refer for consideration of a transmetatarsal amputation.
Commentary: Evaluation of vascular status is critical in any patient presenting with diabetic ulcer. The ABI is considered a useful screening tool to look for peripheral arterial disease. Values under 0.91 are considered consistent with peripheral arterial disease. However, calcified vessels can lead to higher values and possibly false negative test results. If ABI is >1.3, this most likely due to calcified, non-compressible vessels; therefore, other means of testing vascular status should be used.
A 28-year-old male firefighter sustained deep dermal burns across his lower face, neck, anterior chest, and shoulders. To help manage the formation of hypertrophic scars, you recommend
(a) corticosteroid injections directly into localized, early hypertrophic scars.
(b) compression garments to be worn 12 hours a day.
(c) topical silicone to large areas of hypertrophic scar.
(d) ultrasound treatments with passive stretching
Commentary: Corticosteroid injections directly into localized, early hypertrophic scars can be useful, especially in highly cosmetic locations (face or neck) or in scars that are very pruritic. Compression garments should be worn 23 hours a day until wound erythema begins to abate, usually about 12-18 months after injury. Topical silicone, applied as a sheet, is effective in the
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management of small areas of hypertrophic scar. In a prospective randomized double-blind study, the effectiveness of ultrasound with passive stretching versus placebo ultrasound with passive stretching showed no difference in joint range of motion or perceived pain between the 2 treatment groups. This finding suggests that, although widely used, ultrasound may not have a beneficial effect on contractures that form secondary to hypertrophic scarring.
What is the biggest barrier for participation in outdoor activities for children with physical disabilities?
(a) Lack of an adult assistant
(b) Rejection by physically able children
(c) Need for aids such as braces or wheelchairs
(d) Inaccessible playgrounds
Comment: The environment is a significant barrier to play for children with physical disabilities. Fencing, sand, and inaccessible playground equipment relegate children with disabilities to an observational role and indicates they are not valued/welcomed. Younger children may see an adult assistant as a playmate but older children see them as intrusive and a hindrance in social situations. Physically able children are willing to include children with disabilities in their games but readily acknowledge limitations of playgrounds in accommodating them. Children often view their braces, walkers and wheelchairs as extensions of themselves and helpful in play situations.
A 25-year-old man comes to your office for evaluation of low back pain. As part of the physical examination, you mark a point at the L5 vertebral body and another point midline 10 cm above. You ask him to flex forward maximally while keeping his knees extended and measure the distance between the two points. This distance is 13.5 cm. You suspect he may have what diagnosis?
(a) Lumbar spondylolisthesis
(b) Scheuermann disease
(c) Lumbar herniated disc
(d) Ankylosing spondylitis
Commentary: The Schober test is used to assess restricted range of motion seen in ankylosing spondylitis as the disease progresses. The distance between the 2 points with forward flexion
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exceeds 15 cm in normal individuals. This clinical test is not used for the assessment of lumbar spondylolisthesis, Scheuermann disease, or lumbar herniated discs.
What is the best predictor of fractures in a person with osteoporosis?
(a) Low body weight
(b) Recent falls
(c) Low physical activity
(d) Prior fractures
Commentary: The best predictor of future fractures is prior fractures. Low body weight is also a major risk factor. Recent falls and low physical activity are additional risk factors.
Myotonic discharges produce a distinctive sound on electromyography (EMG). This sound results from
(a) spontaneous firing of motor unit action potentials (MUAPs).
(b) intermittent blocking of muscle fibers during voluntary activity.
(c) firing of just a few muscle fibers per motor unit during voluntary activity.
(d) spontaneous firing of muscle fibers.
Commentary: The classic myotonic discharge of waxing and waning in frequency and amplitude is often described as either a dive-bomber or revving engine. The source generator of a myotonic potential is muscle fiber, and thus may take the form of either positive wave or a brief spike potential. Neuromyotonia and myokymia result in spontaneous firing of motor unit action potentials as opposed to muscle fiber action potentials. Intermittent blocking of some muscle fibers within a motor unit result in unstable MUAPs, which are characterized by changes in either amplitude or number of phases from potential to potential. Unstable MUAPs are seen in primary neuromuscular junction (NMJ) disorders or with new and immature NMJs, as can be seen in early reinnervation. Mypopathic MUAPs result from a decreased number of muscle fibers firing within a motor unit. These signals are seen as short-duration, small amplitude, and polyphasic potentials.
What prosthesis is most appropriate for a 6-month-old child who has a congenital transhumeral amputation?
(a) Curve shaped “banana” arm
(b) Myoelectric hand
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(c) Body powered hook
(d) Friction elbow arm
Comment: The banana arm is a passive prosthesis designed to help in reaching and bimanual midline activities in the very young child. A myoelectric hand is most appropriate to initiate about age 1 year; a body-powered hook is appropriate for children age 4-5 years; a friction-elbow arm is appropriate about when a child with a transhumeral amputation starts to walk.
When is the use of hyperbaric oxygen recommended for the treatment of diabetic foot ulcers?
(a) As first-line treatment
(b) If there are signs of infection
(c) If standard therapy is ineffective
(d) As prophylaxis after wound has healed
Commentary: Hyperbaric oxygen therapy is a treatment modality that can be considered for non-infected chronic diabetic foot ulcers that have not responded to other therapies. Systematic review did show improved wound healing at 6 weeks with use of hyperbaric oxygen but no differences were noted at 1 year.
A 27-year-old manual laborer presents with a 6-month history of right shoulder pain. He has a past medical history of a right shoulder dislocation after a water-skiing accident 3 years ago. On physical exam, he has normal strength and sensation with symmetric reflexes. The shoulder apprehension test is positive. Impingement tests and the O’Brien active compression test are negative. Which diagnosis is most consistent with this presentation?
(a) Rotator cuff tendinitis
(b) Anterior-inferior labrum tear
(c) Glenohumeral osteoarthritis
(d) Superior labral anterior to posterior (SLAP) lesion
Commentary: This patient presents with an anterior-inferior labrum tear related to chronic anterior shoulder instability following a prior traumatic event (dislocation). Unidirectional instability refers to instability in only 1 direction, anterior direction being the most common. This type of instability is common after a traumatic event. Multidirectional instability refers to laxity in more than 1 direction and is associated with congenital laxity or chronic repetitive microtrauma. Anatomically, there is disruption in the anterior-inferior glenohumeral joint capsule and anterior-inferior labrum. Superior labral anterior to posterior (SLAP) lesions may occur, but
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that possibility is less likely in this patient, because of his history and a negative O’Brien compression test.
A 60-year-old woman had a left total hip arthroplasty 4 weeks ago. During her gait evaluation, she is noted to have a left lateral trunk lean during left stance phase. This gait deviation is most likely a result of weakness in which left lower limb muscle?
(a) Gluteus medius
(b) Gluteus maximus
(c) Tensor fascia lata
(d) Vastus lateralis
Commentary: Gluteus medius weakness leads to a Trendelenburg gait. This woman's lateral trunk lean is a compensated Trendelenburg gait. Gluteus medius or hip abductor weakness is common following total hip arthroplasty. In one study, 36 of 76 (47%) patients with total hip arthroplasty had hip abductor weakness. Of those 36 patients, all 36 had weakness in the gluteus medius, 28 had weakness in the gluteus minimus, and 4 had weakness in the tensor fascia latae.
A physiatrist assesses each of the following patients during hospitalization and determines that each one is clinically appropriate for an admission to your acute inpatient rehabilitation unit. Which patient does NOT qualify for the Center for Medicare and Medicaid Services (CMS) 60% Rule (formerly known as the 75% Rule)?
(a) 28-year-old woman with multiple sclerosis exacerbation, status-post intravenous methylprednisolone (Solu-Medrol)
(b) 60-year-old woman with active polyarticular rheumatoid arthritis, status-post left total shoulder arthroplasty
(c) 63-year-old man with end-stage kidney disease, status-post kidney transplant, complicated by sepsis
(d) 87-year-old man with end-stage osteoarthritis, status-post elective left total knee replacement
Commentary: Inpatient Rehabilitation Facilities (IRFs) must follow the Center for Medicare and Medicaid Services (CMS) criterion regarding admissions in order to receive payment. Previously known as the “75% Rule,” CMS changed the percentage to 60% in 2007. Currently, 60% of all admissions to an IRF must have 1 or more of 13 selected conditions that include stroke, spinal cord injury, congenital deformity, amputation, major multiple trauma, fracture of femur (hip fracture), brain injury, neurological disorders (including multiple sclerosis, motor neuron disease, polyneuropathy, muscular dystrophy, Parkinson disease), and burns. Other conditions such as
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rheumatologic arthritides or osteoarthritis have additional stipulations. Patients undergoing elective hip and/or knee joint replacements must also meet 1 of 3 additional criteria, including (1) bilateral joint replacement surgeries, (2) body mass index greater than 50, or (3) age 85 or older. The CMS criterion does not prohibit admission to an IRF if a patient does not have 1 of these 13 conditions, though IRFs must continually monitor compliance to ensure reimbursement. While the patient who underwent a kidney transplant may be able to participate in and benefit from 3 hours of interdisciplinary therapy daily and requires ongoing inpatient nursing and physician management, his diagnosis is not included in the 13 medical conditions recognized by the CMS criterion.
Where is the lesion site in ataxic dysarthria, as found in Friedreich’s ataxia?
(a) Extrapyramidal system
(b) Bilateral upper motor neuron
(d) Multiple sites
Commentary: Types of dysarthria include spastic, most commonly found in cerebral palsy; hypokinetic, as in Parkinson’s disease; hyperkinetic, as in dystonia; ataxic, as in Friedrich’s ataxia; flaccid, as in bulbar palsy; and mixed, as in amyotrophic lateral sclerosis. The site of the causative lesion in spastic dysarthria is bilateral upper motor neuron; hypo- and hyperkinetic is extrapyramidal system; ataxic is cerebellum; flaccid is lower motor neuron; mixed is multiple sites.
Which statement is TRUE of the lower trapezius muscle?
(a) It is innervated by the thoracodorsal nerve.
(b) It is innervated by the long thoracic nerve.
(c) Contraction of this muscle results in upward rotation of the scapula.
(d) Contraction of this muscle results in abduction of the scapula.
Commentary: The lower trapezius, as well as the upper trapezius and the middle trapezius, is innervated by the spinal accessory nerve (11th cranial nerve) and possibly contributions from the ventral rami of C2, C3, and C4. Contraction of the lower trapezius results in scapular depression, adduction, and upward rotation.
A 45-year-old man with T4 paraplegia secondary to transverse myelitis is in acute inpatient rehabilitation. Your physical therapist reports to you that the patient is asking whether he will ever be able to have sexual intercourse with his wife again. The next day you decide to address sexuality with your patient on morning rounds. What is the best way to approach this patient?
(a) Explain that there are important medical needs that should be addressed first.
(b) Offer to answer any questions that he has about his injury and sexual function.
(c) Provide him with specific examples of how to treat erectile dysfunction.
(d) Refer him to a therapist for intensive counseling on sexual techniques.
Commentary: The PLISSIT model is a framework for educational interventions related to sexuality. It is an acronym for 4 levels of intervention: Permission, Limited Information, Specific Suggestions, and Intensive Therapy. “Permission” is the first level of intervention and refers to creating an atmosphere in which it is clear that discussion about sex will be well received. In this case, answer (b) is most consistent with this level of intervention.
Which ergonomic recommendation for computer stations is NOT appropriate for an injured worker with upper extremity cumulative trauma disorder?
(a) Neutral position of the wrists
(b) Forearm position horizontal to the floor
(c) Elevated positioning of the mouse
(d) Mid-line positioning of the keyboard
Commentary: Ergonomic evaluation of the computer workstation is important for both the prevention and the treatment of cumulative trauma disorders. All the listed ergonomic recommendations are appropriate, with the exception of elevated placement of the mouse. More midline and level mouse placement is recommended, especially in cases of de Quervain tenosynovitis.
What aspect of gait is improved when a manual locking knee design is chosen for an individual with a unilateral transfemoral dysvascular amputation?
(a) Overall gait mechanics with decreased energy consumption
(b) Foot clearance in swing phase
(c) Stability in stance phase
(d) Ability to vary the gait cadence
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Commentary: The only advantage of a manual locking knee is its inherent stability. It is typically used for patients with significant weakness or instability, such as very low level household ambulators or patients using prosthetic limb for transfers. Since the knee does not bend during swing phase it compromises gait mechanics. Toe clearance is more difficult and the prosthetic limb is typically designed to be shorter than the intact limb.
In a patient with inflammatory arthritis, which type of exercise is LEAST likely to raise the white blood cell count in the synovial fluid of the affected joint?
Commentary: Isometric exercise allows for tension to be generated in the muscle without any visible joint movement occurring. An example of an isometric exercise would be pushing against a wall. Isometric exercise does not alter synovial fluid composition, in contrast to other forms of exercise that can increase white blood cell count and synovial fluid volume in patients with a history of inflammatory arthritis.
Isotonic exercises use constant external resistance with variable speed of movement. An example of this would be performing a biceps curl with a dumbbell.
Isokinetic exercises are characterized by constant joint speed and variable external resistance. Special equipment is needed for this type of exercise. In both isotonic and isokinetic exercise, there is visible joint movement.
Plyometric exercise involves fast, powerful movements. An example of a plyometric exercise would be jumping from a squatting position.
What is the benefit of using ankle-foot orthoses (AFOs) for a patient with Duchenne muscular dystrophy?
(a) Improves the patient’s ambulation
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(b) Assists the patient with rising from the floor
(c) Prevents contractures when used at rest
(d) Improves wheelchair positioning
Commentary: Resting AFOs can help prevent ankle plantar flexion contractures, but are not required for proper wheelchair positioning. Duchenne muscular dystrophy is an x-linked disease with progressive muscle weakness/degeneration that is usually diagnosed in early childhood. Loss of independent ambulation generally occurs in early adolescence, necessitating the transition to a wheelchair. The progressive weakness leads to compensatory strategies for ambulation such that AFOs may further impede ambulation or transferring.
Repetitive transcranial magnetic stimulation (rTMS) of the motor cortex appears to have therapeutic value in the treatment of
Commentary: With demonstrated facilitation of motor recovery after stroke, rTMS has been used in 2 ways: (1) frequency stimulation less than 1 Hz to the unaffected hemisphere, reducing its inhibitory effects on the affected hemisphere and (2) frequency stimulation greater than 1Hz to the affected hemisphere, increasing its excitability. Studies suggest possible greater benefit when the lesion is subcortical rather than cortical. Frequencies greater than 20 Hz, especially when intensity is higher, theoretically may increase the risk of seizure. Benefits of rTMS have been shown in preliminary studies of those with both chronic and acute stroke.
Possible adverse or undesirable effects of rTMS include seizure (with treatment frequencies greater than 20 Hz) and increasing blood pressure (with higher treatment frequencies after chronic stroke.) Transcranial magnetic stimulation can be used to evaluate central fatigue, but has not been used for treatment of fatigue.
Which non-surgical treatment for carpal tunnel syndrome is shown to provide significant short-term benefit?
(a) Magnet therapy
(b) Laser therapy
(c) Therapeutic exercise
(d) Therapeutic ultrasound
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Commentary: Patients suffering from carpal tunnel syndrome are often offered nonsurgical treatments. Current evidence shows significant benefit from therapeutic ultrasound treatments, splinting, yoga, and carpal bone mobilization. However, trials involving the use of magnet therapy, laser therapy, therapeutic exercise, and chiropractics have not produced significant benefits compared to placebo or control treatments.
Which pharmacologic and non-pharmacologic treatment combination is the most appropriate initial program in a patient with fibromyalgia?
(a) Duloxetine (Cymbalta) plus aerobic exercise
(b) Amitriptyline (Elavil) plus high intensity strength training
(c) Diazepam (Valium) plus trigger point injections
(d) Fentanyl (Duragesic) plus cognitive behavioral therapy
Commentary: Pharmacologic treatments used for fibromyalgia include tricyclic antidepressants (e.g., amitriptyline), serotonin-norepinephrine reuptake inhibitors (SNRIs, e.g., duloxetine, venlafaxine), and some anticonvulsants such as pregabalin. Opiates (e.g., fentanyl) and benzodiazepines (e.g., diazepam) are generally not recommended.
Non-pharmacologic therapies include cognitive behavioral therapy, aerobic exercise (low impact), and complementary therapies. To reduce the pain associated with exercise, it is recommended to "start low, go slow," with gradual progression in exercise intensity. Patients with fibromyalgia would not likely comply with a high intensity strength training program.
A negative prognostic sign in early multiple sclerosis is
(a) young age at onset.
(b) cerebellar signs.
(c) optic neuritis.
(d) monosymptomatic presentation.
Commentary: Early multiple sclerosis shows a more favorable outcome if presentation is at age less than 35 years, monosymptomatic, with optic signs, and of sudden onset with long remission.
A 59-year-old woman with metastatic breast cancer presents with painful swelling of her right arm over the last year. She underwent a radical mastectomy two years ago followed by radiation therapy. She describes an aching discomfort along with an ill-defined sensation of numbness and tingling. Effective decongestive therapy for the treatment of secondary lymphedema requires
(a) long-stretch bandaging of the affected limb.
(b) truncal clearance to facilitate drainage of the affected limb.
(c) intermittent pneumatic compression devices.
(d) low-level laser therapy.
Commentary: Truncal clearance is necessary to facilitate lymphatic drainage from affected limbs by promoting effective pressure gradients, reducing lymphatic network resistance, and stimulating lymphatic contractility. Short-stretch bandaging is recommended to create large functional dynamic pressures with low resting pressures helping to prevent circulatory compromise. Adjuvant intermittent pneumatic compression devices have been found to significantly reduce limb volume during both Phase 1 and Phase 2 of complete decongestive therapy. However, the older generation, non-programmable pumps may generate higher pressures than therapeutically necessary and risk the development of truncal or genital edema, as well as produce fibrotic cuffs. Low-level laser therapy is still being investigated for the management of secondary lymphedema, since the wavelength, pulse duration and frequency, dose and dose rate, duration of treatment, and repetition of treatment must be further defined.
An injured worker with complex regional pain syndrome (CRPS), type 1, asks his physician to prescribe methadone instead of morphine because of ongoing pain. The physician orders blood work and an electrocardiogram (EKG) first. What finding would be a strong contraindication to prescribing methadone for this patient?
(c) QT interval prolongation
(d) Premature atrial complexes
Commentary: A prolonged QT interval and serious arrhythmia (torsades de pointes) have been reported during treatment with methadone. Patients with cardiac hypertrophy, concomitant diuretic use, hypokalemia or hypomagnesemia are at higher risk for development of prolonged QT interval because methadone inhibits cardiac potassium channels. Premature atrial complexes without other cardiac abnormalities that would predispose the patient to QT interval prolongation would not be considered an absolute contraindication