Medical Rehab Flashcards
Frailty can be described as:
Frailty can be defined as age- and disease-related loss of adaptation, such that events of previously minor stress result in disproportionately biomedical and social consequences. Frailty is difficult to quantify. There is a generalized decline in multiple systems with a loss of functional reserve.
What percentage of fractures in people older than 45 are related to osteoporosis?
70% of fractures in people over 45 years of age are related to osteoporosis. 1/3 of females greater than 65 years of age will have vertebral fractures. Hip fractures are the greatest cause of morbidity and mortality as related to osteoporosis.
Which of the following is related to increased risk of developing hypertrophic scars after burn injury?
The risk of developing hypertrophic scars is related to the SIZE OF BURN, depth and location of burn, time to healing, and patient race and age. Hypertrophic scars are more prevalent in children, and with people of darker skin. Hypertrophic scars also develop in area of motions, such as joints. Time to healing is a factor: wound that heal within 21 days have a 33% incidence of scarring, and wounds longer than 21 days have a 78% incidence.
Which of the following mediators is released from macrophages and neutrophils that act as vasodilators and increase microvascular permeability after burn injury?
Prostaglandins are released from macrophages and neutrophils and act vasodilators increase microvascular permeability. There are a few inflammatory mediators released during thermal injury. Histamine causes an increase in arteriolar dilatation and tissue pressure, leading to increased microvascular permeability. Thromboxane is produced by platelets. There is minimal effect on vascular permeability. Catecholamines cause arteriolar vasoconstriction.
Total lung capacity can be defined as amount of
The tidal volume is the amount of gas moved in resting inspiratory effort. Total lung capacity is the amount of gas within the lungs at the end of maximal inspiration. Residual volume is the amount of gas within the lungs at the end of maximal expiration. Forced expiratory volume in one second is the amount of air expelled in the first second of forced vital capacity.
Which of the following is an example of intrinsic restrictive lung disease?
Restrictive lung disease is impaired lung ventilation due to loss of normal elastic recoil of the lungs or chest wall. Intrinsic lung disease is increased stiffness of lung tissue. Extrinsic lung disease is increased stiffness of chest wall or weakness of the musculature. Examples of intrinsic lung disease are ASBESTOSIS, sarcoidosis, silicosis, and idiopathic pulmonary fibrosis. Examples of extrinsic lung disease are Duchenne muscular dystrophy, amyotrophic lateral sclerosis, spinal deformity and ankylosing spondylitis.
Which of the following is an example of chronic obstructive pulmonary disease (COPD)?
COPD is the fifth leading cause of death worldwide, and the third leading cause of death in the United States. Many patients with COPD have asthma or reactive airway disease. Diseases that fall within the umbrella of COPD include chronic bronchitis and emphysema.
Which of the following would be a relative contraindication for a pulmonary rehab program?
The inclusion criteria for exercise in pulmonary rehabilitation are straightforward. A candidate must show a decrease in functional exercise capacity due to pulmonary disease. The disease can be progressive (such as Interstitial lung disease) or stable. The patient may have oxygen therapy at any level of supplementation. There must be cardiac stability similar to what is recommended for cardiac rehabilitation. However, the patient cannot have an acute medical, orthopedic or neurologic condition that impedes exercise.
Which is NOT a proven direct benefit of pulmonary rehabilitation in a patient with COPD?
The evidence for the effectiveness of pulmonary rehabilitation as a treatment for patients with COPD is unequivocal. It can lead to:
* Statistically significant and clinically meaningful improvements in health-related quality of life
* Improved functional exercise capacity
* Increased maximum walking distance
* Reduced breathlessness.
Which of the following is a cardiovascular adaptation of aerobic training?
The following are cardiovascular and pulmonary adaptations noted with aerobic training:
* increased stroke volume and peak cardiac output
* increased respiratory muscle strength, maximal voluntary ventilation
* reduced dyspnea
The physiological effect of warfarin is to inhibit
Warfarin’s physiologic effect is the inhibition of Vitamin K carboxylation and the inhibition of clotting factors II, VII, IX and X. Aspirin inhibits thromboxane A formation to inhibit platelet aggregation. Clopidogel inhibits ADP-induced platelet aggregation
he following activities should be initiated in the acute period post-myocardial infarction in the critical care unit:
Mobilization after cardiac event must occur as rapidly as possible to prevent decubitus, pneumonia, and thromboembolism. Activities of low intensity are allowed (1 to 2 METs):
* passive ROM (1.5 METs)
* lower extremity ROM (2.0 METs)
* avoid isometrics and raising legs above heart
Which of the following provides a reliable and reproducible measure of dynamic work capacity and cardiovascular fitness in the cardiac rehab patient?
VO2max is the aerobic capacity, and measures the maximum oxygen consumption that an individual can achieve during exercise.VO2max provides a reliable and reproducible measure of dynamic work capacity as well as cardiovascular fitness. It provides information regarding prognosis in patients with heart disease and can assist in evaluating work resumption after recovery.
The decrease in cardiac mortality from participation in a program of cardiac rehabilitation is:
Comprehensive cardiac rehabilitation programs that address reducing risk factors and lifestyle changes such as nutrition, weight loss and smoking cessation have an impact on cardiac mortality by reducing risk by 25%.
Which is the best single predictor of falling in the elderly based on gait characteristics?***This question has been disabled. You will receive full credit for this question.
A.
Reduced gait speed
B.
Stride-to-stride variability
C.
Slowed postural reflexes
D.
Increased double limb support
***This question has been disabled. You will receive full credit for this question
An 80-year-old woman with a history of dementia diagnosed three years ago is brought to your clinic by her family. The patient had been gradually deteriorating but has been coping at home with family support. She is confused at baseline. Two days ago, she became incontinent of urine (unusual for her), more confused with occasional return to baseline cognition, disorganized and inattentive in her conversation with family. The family has noted increased lethargy. Balance has remained unchanged from baseline. Her change in symptoms is most consistent with:
As this patient has dementia, she is likely to be at a particularly high risk of delirium. Worsening dementia is likely, due to the long history and gradual deterioration, but not due to the increased confusion over the last two days. Increased sleepiness over two days (recent) is not conclusive of depression.
The recent onset of urinary incontinence suggests that the delirium precipitant may be a urinary tract infection. Acute onset of increased confusion and fluctuating course, with disorganized thinking, inattention and altered level of consciousness are features of delirium, superimposed on the gradual deterioration due to dementia. The prevalence of delirium superimposed on dementia ranged from 22% to 89% of hospitalized and community populations aged 65 and older with dementia. Adverse events are associated with delirium in persons with dementia, including accelerated and long-term cognitive and functional decline, need for institutionalization, re-hospitalization, and increased mortality.
The hallmark signs of normal pressure hydrocephalus (NPH) are dementia, gait disturbance, and urinary incontinence. Normal pressure hydrocephalus can be idiopathic or related to prior meningitis or subarachnoid hemorrhage. Ataxia is an important clinical sign of NPH
A 75-year-old man is found confused and wandering in the street at night wearing his night clothes. In the emergency room (ER) he appears disorderly and disheveled. He is alert, but disoriented in time and place and cannot recall his home address. He engages well with questions, but tends to shift the conversation to stories about his wife and children. He is admitted to the hospital from the ER and wanders around the ward appearing lost. When asked where he is going, he tells nursing personnel that he is looking for a bus stop to go home. The patient has:
In Alzheimer’s Dementia (AD), memory impairment occurs first, followed by decline in language and visuospatial skills relatively early. In Amnestic MCI, an early stage of AD, there is limited anterograde long-term memory impairment, with preserved function, but this patient’s disheveled appearance suggests functional decline. AD is characterized by:
(i) Memory impairment noted in learning or recall
(ii) Aphasia, Apraxia, Agnosia or Dysexecutive function (planning, organizing, sequencing, abstracting)
(iii) Cognitive deficits of sufficient severity to affect social or occupational functioning, representing a change from previous level
The clinical course of AD is gradual onset and progression, with no delirium precipitants contributing to the clinical picture and no alternative central nervous system explanation (e.g., stroke, Parkinson’s disease). There is no history such as a fall to suggest brain injury.
Criteria to define frailty include slowness on the 15-foot walk test, unintentional weight loss ≥ 5% over the past year and
Three or more of the following five criteria must be met for the diagnosis of frailty:
1. Weight loss of ≥5% in last year or Body mass index (BMI) less than 18.5 or unintentional weight loss of more than 10 pounds in the past year.
2. Exhaustion. The Center for Epidemiologic Studies Depression Scale is used.
3. Weakness (decreased grip strength measured by a dynamometer)
4. Slow walking speed of greater than6 to 7 seconds for 15 feet, or scoring less than the 20th percentile, stratified for sex and height
5. Decreased physical activity (males <383 kilocalories, kcals); females <270 kcals) or complete inactivity.
The stages of frailty are:
0 criteria are present: Non-frail stage
1– 2 criteria present: Prefrail stage
3– 5 criteria present: Frail stage
Chronic fatigue syndrome (CFS), is an entirely different disease entity with criteria that do not define frailty. It is a debilitating and complex disorder characterized by profound fatigue that is not improved by bed rest and that may be worsened by physical or mental activity. Symptoms affect several body systems and may include weakness, muscle pain, impaired memory and/or mental concentration, and insomnia, which can result in reduced participation in daily activities.
A 71-year-old man with metastatic prostate cancer to bone on androgen deprivation therapy presents to your office. He has clinically stable disease confirmed by recent computed tomography of the chest, abdomen, and pelvis. Magnetic resonance imaging of the spine demonstrates mild, diffuse degenerative disease. He has developed bilateral upper and lower extremity paresthesias and progressive gait dysfunction over the past several months. Which of the following is the most likely cause of his symptoms?
Cervical spinal stenosis is unlikely to cause upper and lower extremity paresthesias. Progressive metastases in the pelvis with subsequent lumbosacral plexopathy could explain lower extremity paresthesias and weakness, but unlikely in the setting of a negative CT imaging the pelvis and stable disease. Additionally, lumbosacral plexopathy does not explain the patient’s upper extremity symptoms. There is no indication that the patient received neurotoxic chemotherapy. Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP) has an incidence of 1.6/100,000 a year and a prevalence of 8.9/100,000. Elderly men are most commonly affected. Patients with cancer, even advanced cancer, are at risk for other disorders and they should be considered when evaluating the cause of new signs and symptoms.
Which of the following antineoplastic agents is LEAST neurotoxic?
Cyclophosphamide is NOT generally neurotoxic. Bortezomib, paclitaxel, and lenolidomide are all neurotoxic.
Which of the following may develop from exposure to cisplatin?
Cisplatin is a neurotoxic chemotherapeutic agent used in a variety of cancer types. Its putative mechanism of action with respect to neuropathy is disruption of cellular functions at the dorsal root ganglion and subsequent death or dysfunction of the sensory nerves. Since platinum analogues do not usually cross the blood-brain barrier at contemporary doses, the anterior horn motor cells are unaffected. Abnormal sensations (paresthesias), painful sensations (dysesthesias), loss of sensation (anesthesia) and other neuropathic sensory disorders are common but weakness is not generally seen. Gait dysfunction and ataxia is from sensory dysfunction and not muscle weakness.
You are asked to perform electrophysiologic studies on a 21-year-old man recently treated for testicular cancer with cisplatin who developed bilateral upper and lower extremity pain and paresthesias. Nerve conduction studies demonstrate low sensory nerve action potential (SNAP) amplitudes in the median, ulnar, and radial nerves bilaterally but normal SNAP amplitudes in the lower extremities. Compound muscle action potential (CMAP) amplitudes are normal in both the upper and lower extremities. Needle electromyography (EMG) is normal. What is the most likely cause of the patient’s symptoms?
This patient most likely has a sensory ganglionopathy from exposure to platinum-based chemotherapy (cisplatin) used to treat his testicular cancer. As opposed to neurotoxic chemotherapeutics such as the
VINCA ALKALOIDS (VINBLASTINE, VINCRISTINE, VINDESINE, VINORELBINE; also VINCOMINOLM VINERDIDINE, an VINBURNINE; VINPOCETINE is a smei-synthetic derivative of vincAMINE; MINOR VINCA ALKALOIDS include minovincine, methoxyminovincine, minovincinine, vincadifformine, desoxyvincaminol, and vincamajine ; VINKA ALKALOIDES=class of cell cycle–specific cytotoxic drugs that work by inhibiting the ability of cancer cells to divide: Acting upon tubulin, they prevent it from forming into microtubules, a necessary component for cellular division.The vinca alkaloids thus prevent microtubule polymerization, as opposed to the mechanism of action of taxanes)
and
TAXANES ( Paclitaxel (Taxol) and docetaxel (Taxotere) are widely used as chemotherapy agents.[2][3] Cabazitaxel was FDA approved to treat hormone-refractory prostate cancer; he principal mechanism of action of the taxane class of drugs is the disruption of microtubule function. Microtubules are essential to cell division, and taxanes stabilize GDP-bound tubulin in the microtubule, thereby inhibiting the process of cell division as depolymerization is prevented. Thus, in essence, taxanes are mitotic inhibitors. In contrast to the taxanes, the vinca alkaloids prevent mitotic spindle formation through inhibition of tubulin polymerization. Both taxanes and vinca alkaloids are, therefore, named spindle poisons or mitosis poisons, but they act in different ways. Taxanes are also thought to be radiosensitizing. OTHERS ABEOTAXANE, DOCETAXEL, TAXIN, TAXUYUNNANINE).)which cause a length-dependent axonopathy, platinum analogues exert their putative neurotoxic effect by intercalating in the DNA of the dorsal root ganglion thereby killing or disrupting function of affected sensory nerves. Sensory neuropathy caused by platinum analogues is not length dependent, so it is not unusual to see the sensory amplitudes in the upper extremities more affected than those in the lower extremities. Because platinum analogues do not cross the blood brain barrier to affect the anterior horn cells at contemporary doses, the CMAP amplitudes and needle EMG should be normal.
Brachial plexopathy tends to be unilateral although there are causes of bilateral brachial plexopathy such as exposure to mantle radiation. Polyradiculopathy would demonstrate a pattern of low CMAP amplitudes and preserved SNAP amplitudes. AIDP would demonstrate some demyelinating changes, likely affect the lower extremities, and generally affect CMAP as well as SNAP amplitudes.
A 21-year-old man is treated for testicular cancer with a protocol that includes radical orchiectomy, retroperitoneal lymph node dissection and cisplatin. Three months following completion of therapy he develops progressive lower extremity pain and gait dysfunction. What is the most likely cause of his symptoms?
Lumbosacral plexopathy, though a possibility is unlikely and should have occurred near the time of RPLND ( retroperitoneal lymph node dissection ). Guillain-Barré syndrome is also a possibility but relatively rare. Dermatomyositis is a paraneoplastic disorder with muscle inflammation and characteristic skin findings. Dermatomyositis can present in the setting of occult malignancy but is unlikely to occur immediately following cancer treatment. The coasting effect is a phenomenon often seen following exposure to platinum-based chemotherapeutics such as cisplatin commonly used to treat testicular cancer. Damage to the dorsal root ganglion by platinum-based chemotherapeutics causes progressive dysfunction of the dorsal root ganglion as cellular activities are disrupted. This leads to the progressive development of sensory neuropathy that can start weeks to months after the discontinuation of chemotherapy and continue for as long as a year. When patients develop signs and symptoms of neuropathy more than a year following exposure to chemotherapy other potential causes should be vigorously sought.
A 53-year-old woman was treated for Hodgkin lymphoma with 3600 cGy of mantle field radiation when she was 23 years old. She now presents to your clinic with progressive difficulty holding her head erect and upper extremity weakness. Which of the following is LEAST likely to be contributing to her symptoms?
POLYNEUROPATHY
Mantle field radiation includes all the lymph nodes in the neck, chest, and axilla. All structures in the radiation field are subject to damage, which can become clinically evident years later and can progress indefinitely. In addition to viscera such as the heart and lungs, mantle field radiation can damage all neuromuscular structures in the field including the spinal cord, nerve roots, plexus, local nerves, and muscles. This has been termed a “myelo-radiculo-plexo-neuro-myopathy.” The term “polyneuropathy” describes a diffuse neuropathic process affecting peripheral nerves. The damage to named and unnamed peripheral nerves from focus radiation is confined to the radiation field (i.e., multiple mononeuropathies) and therefore this term is not appropriate.
Which of the following is NOT a known risk factor for radiation-induced peripheral nervous system injury?
Risk factors for radiation-induced peripheral nerve system (PNS) injury include total dose of radiation, dose per fraction, volume of radiation, tissue type, prior radiation, local surgery, concomitant neurotoxic chemotherapy, and patient-related factors such as their physiological status, comorbidities, pre-existing PNS injury, and genetic susceptibility. Ethnicity is not a known risk factor for radiation-induced PNS injury.
A 48-year-old lawyer is unable to return to work 1 year following treatment of stage III breast cancer due to severe fatigue. Which of the following is the LEAST effective treatment strategy?
Cancer-related fatigue is extremely common with a prevalence ranging from 59% to nearly 100% depending on the clinical status of cancer. The mechanism is not clearly elucidated but involves both somatic and psychosocial factors. Treatment strategies include information and counseling, enhancement of activities, progressive aerobic and resistive exercise, psychosocial intervention, and pharmacologic treatments. Bed rest is not an appropriate or effective treatment strategy.
