Medical Flashcards
Which clinical tool BEST measures and predicts the safety of ambulation in older adults?
(a) Berg Balance Scale (BBS)
(b) Braden Scale
(c) Timed Up and Go (TUG) test
(d) Katz Index
Answer: (c)
Commentary: The Berg Balance Scale (BBS) is a 56-point scale to evaluate performance during 14 common activities, such as standing, turning and reaching for an object on the floor. It does not rate walking. The Braden Scale is for predicting pressure sore risk, and is used to help determine the risk of skin breakdown or decubitus ulcer. In the Timed Up and Go (TUG) test, a patient is asked to rise from an armchair, walk 3 meters (10 feet), turn around, walk back to the
chair, and sit down again (the score is the time in seconds it takes to complete these tasks). This test has high interrater and content reliability, and predicts whether a patient can safely walk outside alone. The Katz Index is widely used to measure independence in activities of daily living (ADLs), but does not include measures of mobility, such as walking or stair climbing.
Reference: Stewart DG, Phillips EM, Bodenheimer CF, Cifu DX. Geriatric rehabilitation. 2. Physiatric approach to the older adult. Arch Phys Med Rehabil 2004;85 (Suppl 3):S7.
Which barrier is perceived by older individuals to be the LEAST significant obstacle to physical
activity?
(a) Time, money, family commitments
(b) Illness and injury
(c) Fear of injury
(d) Availability of an exercise partner
Answer: (a)
Commentary: Perceived barriers are a powerful negative predictor of physical activity in the elderly. Although individual variation is the rule, overall obstacles to physical activity tend to change with age, and seem to increase for many aging individuals. Elderly patients report that time, money and family commitments are less significant barriers as they age. Availability of an exercise partner, illness, injury and fear of injury become more prominent concerns as they grow older.
Reference: Phillips EM, Schneider JC, Mercer GR. Motivating elders to initiate and maintain
exercise. Arch Phys Med Rehabil 2004;85(Suppl 3):S52.
A 67-year-old man with chronic obstructive lung disease (COPD) is about to start a pulmonary rehabilitation program. Which option is an appropriate breathing retraining technique for the patient to learn?
(a) Diaphragmatic breathing
(b) Localized expansion exercises
(c) Rapid, shallow breathing
(d) Head up and bending backward postures
Answer: (b)
Commentary: Breathing retraining techniques for COPD include pursed lips breathing, head down and bending forward postures, slow deep breathing, and localized expansion exercises (also known as segmental breathing, wherein the patient is asked to inspire while the clinician applies pressure to the thoracic cage to resist respiratory excursion in a segment of the lung). These techniques maintain positive airway pressure during exhalation and help reduce overinflation. Although diaphragmatic breathing (done by expanding one’s belly and thereby allowing the diaphragm to move down creating more room for the lungs to expand) is widely taught, it has been shown to increase the work of breathing and dyspnea compared with the natural pattern of breathing in the patient with COPD.
Reference: Alba A, Chan L. Pulmonary rehabilitation. In: Braddom RL, editor. Physical medicine and rehabilitation. 4th ed. New York: WB Saunders; 2011. p 742.
A 48-year-old woman had an acute myocardial infarction (MI) 2 weeks ago. The referring
cardiologist informed you that she had a small MI and an uncomplicated hospital course. In a
situation such as this, which statement is TRUE?
(a) Combined aerobic and resistance training, compared to aerobic training alone, has a higher risk of adverse outcomes.
(b) Beta blocker agents will attenuate the benefits of exercise training.
(c) A change in left ventricular (LV) dimensions (remodeling) is associated with improving LV function.
(d) Cardiac rehabilitation will improve both myocardial perfusion and LVelectrophysiologic parameters.
Answer: (d)
Commentary: After a myocardial infarction (MI), exercise training is initiated within 2-4 weeks.
Combined resistance and aerobic training improves aerobic fitness and muscle strength more than aerobic training alone, without adverse outcomes. Beta blockers, which are a standard of care to reduce mortality after an MI, do not attenuate the benefits of exercise training. Following an MI, a change in left ventricular (LV) dimensions (remodeling) is associated with deteriorating LV function, ventricular arrhythmias, aneurysm formation, and higher mortality. Cardiac rehabilitation improves both myocardial perfusion and LV electrophysiologic parameters, reducing the risk for malignant ventricular arrhythmias and sudden cardiac death after MI.
Reference:
Reference: Whiteson, JH. Cardiac rehabilitation. In: Braddom RL, editor. Physical medicine and rehabilitation. 4th ed. New York: WB Saunders; 2011. p 731.
Cooling can produce physiological changes in the body. One of these changes is an increase in
(a) nerve conduction rate.
(b) stretch receptor sensitivity.
(c) elasticity of connective tissue.
(d) general sympathetic activity.
Answer: (d)
Commentary: Nerve conduction rate is slowed by cooling. The stretch receptor sensitivity in muscles and tendons is reduced, and the elasticity of connective tissue diminishes with cooling. The general sympathetic activity is increased with cooling of the body, and this may affect the responses of the stretch receptors in a beneficial way.
Reference: Lemons DE, Riedel G, Downey JA. Thermoregulation and the effects of thermoregulation. In: Gonzalez EG, Myers SJ, Edelstein JE, Lieberman JS, Downey JA, editors. Downey and Darling’s physiological basis of rehabilitation medicine. 3rd ed. Boston: Butterworth Heinemann; 2001. p 518.
Which burn patient has the highest risk of developing hypertrophic scars?
(a) Newborn baby
(b) Morbidly obese individual
(c) Heavily pigmented individual
(d) Elderly individual
Answer: (c)
Commentary: A hypertrophic scar is usually defined as a scar that is present at 3 or more months after the burn injury and is greater than or equal to 2 mm in thickness. Heavily pigmented patients tend to scar more than persons with less pigment. Little scarring has been
reported in neonates, newborns, elderly and the morbidly obese. Patients with wounds that take longer than 2-3 weeks to heal, and persons requiring skin grafts, are also considered at risk for developing hypertrophic scars.
Reference: Esselman PC, Moore ML. Issues in burn rehabilitation. In: Braddom RL, editor.
Physical medicine and rehabilitation. 4th ed. New York: WB Saunders; 2011. p 1408-9.
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
Answer:(d)
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.
Reference: (a) Moldover JR, Stein J, Krug PG. Cardiopulmonary physiology. In: Gonzalez EG,
Myers SJ, Edelstein JE, Lieberman JS, Downey JA, editors. Downey and Darling’s Physiological
basis of rehabilitation medicine, 3rd ed. Boston: Butterworth Heinemann; 200.; p 176-7.
(b) Whiteson JH. Cardiac rehabilitation. In: Braddom RL, editor. Physical medicine and
rehabilitation. 3rd ed. Philadelphia: WB Saunders; 2007. p 716-28.
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.
Answer: (b)
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.
Reference: Alba AS, Kim H, Whiteson JH, Bartels MN. Cardiopulmonary rehabilitation and
cancer rehabilitation. 2. Pulmonary rehabilitation review. Arch Phys Med Rehabil
2006;87(Suppl 1):S58
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
Answer: (c)
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
acetabulum.
Reference: Cheville A. Cancer rehabilitation. In: Braddom RL, editor. Physical medicine and
rehabilitation, 3rd ed. New York: WB Saunders; 2007. p1376
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.
(d) myelopathy.
Answer: (a)
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.
Reference: (a) Esselman PC, Moore ML. Issues in burn rehabilitation. In: Braddom RL, editor.
Physical medicine and rehabilitation, 3rd ed. New York: WB Saunders; 2007. p 1409. (b)
Hussman J, Kucan JO, Russell RC, et al. Electrical injuries – morbidity, outcome, and treatment
rationale. Burns 1995;7:530-5.
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
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.
Reference: Young MA, Stiens SA. Organ transplantation and rehabilitation. In: Braddom RL, editor. Physical medicine and rehabilitation, 3rd ed. New York: WB Saunders; 2007. p 1438-41.
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.
Answer: (b)
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.
Reference: Young MA, Stiens SA. Organ transplantation and rehabilitation. In: Braddom RL,
editor. Physical medicine and rehabilitation, 3rd ed. New York: WB Saunders; 2007. p 1442-4.
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.
Answer: (d) 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.
Reference: Nicolle LE. Urinary tract infections: asymptomatic bacteriuria in the elderly. Infect Dis Clin North Am 1997;11:647-62.
Which technique best minimizes resistance to stretch attributed to spinal reflex pathways?
(a) Static stretching
(b) Proprioceptive neuromuscular facilitation
(c) Active isolated stretching
(d) Ballistic exercises
Answer: (b) Commentary: Proprioceptive neuromuscular facilitation (PNF) has the advantage of minimizing resistance to stretch attributed to spinal reflex pathways. Static stretching has low energy cost, low risk of injury, with less chance of producing residual muscle soreness. High energy cost to perform complicated techniques is a disadvantage of active isolated stretching. Ballistic stretching is effective for patients requiring high levels of dynamic flexibility.
Reference: Gailey RS, Raya MA. Manual Modalities. In: Gonzalez EG, Myers SJ, Edelstein JE, Lieberman JS, Downey JA, editors. Downey and Darling’s Physiological basis of rehabilitation medicine, 3rd ed. Boston: Butterworth Heinemann; 200.; p 767-9.
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 diagnosis is
(a) viral myelitis.
(b) multiple sclerosis.
(c) cytomegalovirus (CMV) polyradiculopathy.
(d) vacuolar myelopathy.
Answer: (d) 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.
Reference: Levinson SF, Fine SM. Rehabilitation of the individual with HIV. In: Delisa JA, Gans BM, Walsh NE, editors. Physical medicine and rehabilitation: principles and practice. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p 1804.
