Chapter 54. Principles and Practice of neurological Rehabilitation

Question 1

Question 54-1: 
Which of the following is the most common complication seen in stroke patients in tbe rehabilitation unit? 
A  Arrhytlunia 
B.  Pneumonia 
C.  Pulmonary embolism 
D.  Urinary tract infection

Answer 1

Answer 54-1: D.
UTI is the most common medical
complication seen in stroke patients in the
rehab unit at 40%. Depression is not far
behind at 30%. All of the others are potential
complications, but luckily they are much less
common, with pneumonia and arrhythmia
developing in 10% of patients and PE in less
than 5% of patients. (p1048)

Question 2

Question 54-2:
A 74-year-old man on the rehab unit for ischemic stroke is found to have urinary frequency and occasional episodes of urinary incontinence. Screen for UTI is negative. Which is the best next approach to management?
A Place indwelling (Foley) catheter
B. Place suprapubic catheter
C. Perform bladder scan for urinary retention to assess need for treatment
D. Place a condom catheter

Answer 2

Answer 54-2: C.
Indwelling bladder catheters carry a
significant risk of complications, including
UTI. Bladder scan can determine whether
there is urinary retention, and should be
considered prior to automatic placement of a
catheter in the rehab unit. (p1047)

Question 3

Question 54-3:
A patient admitted to the rehab unit taken in transfer from another hospital has profound unilateral facial weakness and dysarthria and may be having difficulty dealing with secretions. Which is the best approach to management?
A. Allow the patient to eat if there is no evident aspiration on observation of eating
B. Allow to eat with supervision until a swallowing study can be performed
C. Keep the patient without oral feedings until the swallowing study is performed

Answer 3

Answer 54-3: c.
Patients with facial weakness and dysarthria
are high potential risks for aspiration. The
aspiration may be silent, so bedside
observation is not reliable. The best approach
would be to hold the patient NPO until the
swallowing evaluation can be performed. If
the evaluation is not available, tube feedings
can be temporarily used. (p1049)

Question 4

Question 54-4:
Which of the following are appropriate DVT prophylaxis procedures for a patient who has a dense left hemiplegia and receives most of therapy in bed and wheelchair?
1. Heparin intravenous administration
2. Heparin subcutaneous administration
3. Antiembolism hose
4.Low-molecular weight heparanoid administration
Select: A = 1,2,3. B = 1,3. C = 2, 4. D = 4 only. E = All

Answer 4

Answer 54-4: C.
DVT with subsequent PE is an uncommon but
deadly complication of hospitalization,
especially on the rehab unit. After the acute
hospitalization, intravenous heparin is not
needed, and treatment with subcutaneous
heparin or LMW -heparinoids is most
appropriate. Antiembolism hose are
unfortunately not sufficient for patients who
are at or near total bed rest, since DVT can
form prox.imal to the level of the hose.
(p1050)

Question 5

Question 54-5:
Which is the best method for preventing skin ulcers in patients at bed rest after stroke?
A. Cushioning the sacrum and heels
B. Inclining the bed to take vertical pressure off the back
C. Frequent pressure relief from position change or automatic bed
D. Placing cream on the areas of erythema and induration

Answer 5

Answer 54-5: C.
Frequent pressure change is the best method
for limiting the risk of pressure sores. This can
be accomplished manually by the nursing staff
assisting with change in position or by the lise
of an automatic bed which has air-filled
chambers which alter pressure distribution.
Cushioning helps but does not prevent skin
break: dow11. T rea anent of the erythematous
areas v.ill not prevent breakdown. (p1050)

Question 6

Question 54-6:
A 24-year-old man sustains a severe closed head injury and is transferred to the rehab unit six days after the accident. Upon admission to the rehab unit, he is on phenytoin although he did not have a seizure during the hospital admission. Which is the best approach to management of tile phenytoin?
A. Continue the phenytoin until he returns to the neurosurgeon following discharge from the rehab unit
B. Discontinue the phenytoin
C. Check an EEG and if it is normal discontinue the phenytoin
D. Change to lamotrigine

Answer 6

Answer 54-6:B.
The risk of seizure is not changed by the
administration of anticonvulsants, so there is
no clear reason to continue phenytoin beyond
the first week. EEG can be abnormal
following head injury secondary to neuronal
damage, and is not particularly helpful in
determining whether the patient is at increased
risk of seizures. (p1051)

Question 7

Question 54-7: 
Which is the best approach to spasticity in patients with cerebral palsy? 
A.  Baclofen 
B.  Dantrolene 
C.  Clonazepam 
D.  Botulinum toxin injection 
E.  Physical therapy

Answer 7

Answer 54-7: E.
Physical therapy is commonly used for
patients with cerebral palsy, and is part of a
comprehensive care program including
stretching and range of motion. The other
treatments listed can be used for spasticity,
and baclofen is especially helpful. Botulinum
toxin injection can be helpful for isolated
muscle groups such as adductor spasticity, but
is not generally used for widespread
spasticity. (p 1055)

Question 8

Question 54-8:
Which of the following statements are true regarding management of memory difficulty folIowing head injury?
1. Cholinesterase inhibitors may be helpful
2. Cognitive retraining is important for improvement
3. Compensatory aids are important
4. Prognosis for further recovery is poor following the fIrst month
Select: A = 1,2,3 B = I, 3. C = 2, 4. D = 4 only. E = All

Answer 8

Answer 54-8: A.
Although most patients make improvements
within the first few weeks, there is time for
subsequent improvement following the first
month. Compensatory aids are important
because patients often reach a plateau with
continued cognitive and memory deficits.
Cholinesterase inhibitors have been approved
for use in Alzheimer’s disease, but are used in
other disorders including traumatic brain
injury. (p1062-1063)

Question 9

Question 54-9:
Which of the following statements are true regarding depression in patients with traumatic brain injury?
1.Premorbid psychiatric disorder predisposes to late depression
2. Depression is usually refractory to antidepressants
3. Left anterior cerebral inj uries predispose to early depression
4. Mood disorders are uncommon after head injury
Select : A = 1,2,3. B= 1,3. C = 2,4. D=4 only. E=AII

Answer 9

Answer 54-9: B.
Mood disturbance is common in patients with
traumatic brain injury. Depression develops in
somewhere between 25 and 60% of patients.
Left anterior cerebral injuries predispose to
early development of depression. Premorbid
psychiatric disturbance predisposes to late·
onset depression. The depression often
improves with pharmacologic treatment, and
SSRIs are most commonly used. (p 1065)

Question 10

Question 54-10:
What is the role of rehabilitation and physical activity for patients with Parkinson’sdisease?
A. No benefit has been demonstrated
B. Self-guided exercise is encouraged, but formal rehabilitative training is not of benefit
C. Rehab and exercise produces benefits which outlast the duration of the activity
D. Rehab and exercise produce benefits which are lost without continued activity

Answer 10

Answer 54-10: D.
Rehabilitation and exercise are important for
patients with Parkinson’s disease.
Improvement in United Parkinson’s Disease
Rating Scale and ADL subscales has been
demonstrated. Unfortunately, the benefit is
lost without continued activity (p 1068)