P&O SAEs

Question 1

Comparing lower limb amputations to upper limb amputations in the United States, lower limb

amputations are

(a) most often due to trauma.
(b) expected to significantly increase over the next 20 years due to increasing rates of

diabetes mellitus.

(c) less common than upper extremity amputations.
(d) expected to decrease over time due to improved prenatal care leading to less congenital

malformations.

Answer 1

Answer (b)

Commentary: The prevalence of diabetes mellitus continues to increase in the United States and

this trend is expected to cause increasing rates of lower extremity amputation. Lower extremity

amputations are more common than upper extremity amputations and are more likely to be

related to dysvascular causes. Despite improvements in prenatal care enabling more births, rates

of amputations due to congenital defects have not changed significantly. The most common cause

of upper extremity limb loss is trauma-related injury.

Question 2

What is the primary benefit of using a postoperative, rigid, non-removable dressing in a new

transtibial amputee?

(a) Improved monitoring of postoperative wounds
(b) Protection of the wound and edema control
(c) Prevention of hip flexion contractures
(d) Improved strength in the residual limb

Answer 2

Answer (b)

Commentary: The primary benefits of a rigid dressing include wound protection, edema control

and prevention of knee flexion contractures (not hip flexion contractures). Monitoring the wound

may be more difficult with a non-removable rigid dressing. The dressing should be removed for

wound check regularly and if there is a concern for infection. Type of postoperative dressing has

no effect on residual limb strength.

Question 3

A 45-year-old man with a history of transtibial amputation secondary to trauma presents to your

office 6 months following surgery. He is successfully ambulating independently with his

prosthesis. His chief complaint today is new mild phantom limb pain. Evaluation does not reveal

any significant problems with his prosthesis or gait. What treatment would you recommend to

decrease his phantom limb pain?

(a) Cryotherapy
(b) Ultrasound
(c) Desensitization
(d) Paraffin wax

Answer 3

Answer (c)

Commentary: First line treatment for phantom limb pain should include use of desensitization

techniques (massage, friction rubbing, wrapping, etc.) The other types of therapeutics listed

would not be effective in phantom limb pain management. Phantom limb pain is one of many

sources of pain in an amputee and is difficult to treat. It affects anywhere from 67% to 79% of

amputees. For patients whose pain interferes with function and quality of life, a biopsychosocial

approach to pain management is crucial.

Question 4

A 49-year-old man is seen in your outpatient clinic 2 years after a stroke. You notice a

Trendelenberg gait and suspect weakness of which muscle?

(a) Gluteus maximus
(b) Quadratus lumborum
(c) Quadriceps
(d) Gluteus medius

Answer 4

Answer: (d)

Commentary: Weakness of the gluteus medius muscle, or reluctance to use the gluteus medius

muscle because of hip pain, can cause this gait pattern. It is a pattern of either excessive pelvic

obliquity during the stance phase of the affected side (uncompensated) or excessive lateral truncal

lean during the stance phase on the affected side (compensated).

Question 5

In a transfemoral amputee, a circumducted gait pattern, on the prosthetic side, could be caused by

which factor?

(a) Insufficient prosthetic knee friction
(b) Long prosthetic limb
(c) Hip flexion contracture
(d) Poor balance

Answer 5

Answer (b)

Commentary: When observing gait deviations in an amputee, one should consider both the

prosthetic issues and amputee compensatory maneuvers as a potential cause for the deviation. A

circumducted gait pattern can have various causes, including a long prosthetic limb, excessive

prosthetic knee friction (making it difficult to bend the knee), and hip abduction contracture. Poor

balance is usually associated with excessive lateral trunk bending, uneven arm swing, and short

stance phase on the prosthetic side.

Question 6

A 65-year-old woman with diabetes mellitus has been sent to your clinic for evaluation of

appropriate footwear. She had a diabetic foot ulcer 2 months ago over her first metatarsal head,

which is now healed. Examination reveals distal sensory loss and a mild claw foot deformity.

Which footwear/orthotic recommendation is the most appropriate?

(a) Since the wound is healed, no specialized footwear is needed.
(b) Well-fitting regular tennis shoes or sneakers are the best option.
(c) Off-the-shelf diabetic shoe with a custom molded orthotic based on severity of claw foot

deformity is indicated.

(d) Patellar tendon-bearing ankle-foot orthoses to help unload the metatarsal head should be

used.

Answer 6

Answer (c)

Commentary: The patient is at high risk for future diabetic foot ulcers based on her history of

previous ulcers, claw foot deformity and peripheral neuropathy. Based on this risk profile,

specialized footwear is recommended. Patients with diabetes mellitus (DM) without risk factors

for ulcer could be counseled and educated regarding the use of well fitting tennis shoes and

sneakers. While a custom molded shoe could benefit this patient, they are very expensive and

usually needed for patients with severe foot deformity. At this point a prefabricated diabetic shoe

and custom orthotic would be clinically appropriate and more cost-effective. A patella tendon

bearing ankle-foot-orthosis is not indicated and would not effectively offload the metatarsal

heads. A metatarsal bar or pad placed proximal to the metatarsal head is an effective way to

offload the metatarsal head.

Question 7

20. Of the following modalities, which is the most effective in treating phantom limb pain?
    (a) Iontophoresis
    (b) Transcutaneous electrical nerve stimulation
    (c) Short wave diathermy
    (d) Paraffin baths

Answer 7

Answer: (b)

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.

Question 8

40. 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

Answer 8

Answer: (d)

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.

Question 9

80. 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.

Answer 9

Answer: (c)

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.

Question 10

66. Upper extremity exercise (eg, crutch walking) leads to a greater increase in heart rate and blood

pressure compared with lower extremity activity (eg, normal walking) due to the

(a) smaller upper extremity muscles, which contract at a higher maximal percentage.
(b) proximity of the upper extremities to the heart and major blood vessels.
(c) upper extremities having to overcome the effect of gravity.
(d) greater range of motion of the upper extremities compared to the lower ones.

Answer 10

Answer: (a)

Commentary: Upper extremity work leads to greater increases in heart rate and blood pressure.

When a muscle contracts with a given percentage of its maximum force, its effect on blood

pressure is about the same as during the same percentage of contraction of any other muscle. The

smaller muscles in the upper extremity contract more, and stimulate the cardiovascular system

more relative to the larger lower extremity muscles.

Question 11

80. Which cervical orthosis is the most restrictive?
    (a) Four-poster brace
    (b) Philadelphia collar
    (c) Sterno-occipital mandibular immobilizer (SOMI)
    (d) Halo

Answer 11

Answer: (d)

Commentary: The halo device provides the greatest restriction of cervical motion for

flexion/extension, lateral bending and rotation, as shown in the table below:

Table 1: Percentage of Cervical Motion Permitted by 4 Cervical Orthoses

Orthosis % Flexion/extension %Lateral Bending % Rotation

Philadelphia collar 28.9 66.4 43.7

SOMI brace 20.6 65.6 33.6

Four-poster brace 20.6 45.9 27.1

Halo device 4.0-11.7 4.0-8.4 1.0-2.4

Question 12

100. You are performing a consultation on a 58-year-old man with a history of diabetes and peripheral

vascular disease who presents with a non-healing foot ulcer. You are concerned that he is at risk

for amputation because his

(a) ankle brachial index (ABI) is 0.8.
(b) ABI is 0.4.
(c) transcutaneous oxygen pressure (TcPO2) is 80mmHg.
(d) TcPO2 is 40mmHg.

Answer 12

Answer: (b)

Commentary: ABI is a noninvasive technique that is used in the assessment of arterial occlusive

disease. The ABI is the ratio between the ankle and the brachial systolic pressure. Normal ABI is

defined as values greater than 0.9. An ABI below 0.4 tends to carry a poor prognosis. TcPO2 is

defined as transcutaneous oxygen, which is in essence a “blood gas” of the skin. Normal TcPO2 is

greater than 50mmHg. Values of more than 40mmHg are associated with healing. Ischemia is

defined as periwound TcPO2 < 20mmHg.

Question 13

140. Which phenomenon is an effect of functional electrical stimulation (FES) as it pertains to gait?
     (a) Decrease in muscle spasticity
     (b) Increase in physiologic cost of gait
     (c) Decrease in voluntary muscle strength
     (d) Decrease in stride length

Answer 13

Answer: (a)

Commentary: In addition to a decrease in muscle spasticity, FES decreases the physiologic cost

of gait, increases voluntary muscle strength, and increases stride length.

Question 14

70. In prosthetics, K levels are used to describe or define
    (a) activity levels.
    (b) prosthetic feet.
    (c) funding levels for prosthesis.
    (d) etiology of amputation.

Answer 14

Answer: A

Commentary: K levels are used to describe activity levels These K0-K4 designations are guidelines for prosthetic components covered by Medicare.

Question 15

80. Which factor promotes knee stability during the gait cycle of a person with transfemoral amputation?
    (a) Knee component placed anterior to the socket
    (b) Hard heel in the prosthetic foot
    (c) Polycentric 4-bar linkage prosthetic knee
    (d) Anterior position of the shank on the prosthetic foot

Answer 15

Answer: C

Commentary: Flexion moment at the hip, a rigid heel in the solid ankle, cushion heel foot and the anterior position of the shank all shift the ground reaction force behind the knee joint to produce a knee flexion moment. The 4-bar linkage with instantaneous center of rotation and the posterior location of instant center in extension creates knee stability, especially at heel strike.

Question 16

110. The primary advantage of a soft insert fitted into the socket of a transtibial prosthesis is that it is
     (a) perspiration resistant.
     (b) easy to keep clean.
     (c) easily modified.
     (d) very durable.

Answer 16

Answer: C

Commentary: Soft inserts are fabricated to fit inside the socket. They are recommended for patients with thin, sensitive, or scarred skin, or peripheral vascular disease (PVD). They are easily modified. Hard sockets also have their advantages. They are perspiration resistant, less bulky than sockets fitted with a soft insert, easy to keep clean, and durable. Further, reliefs or modifications can be located with precision in the hard socket.

Question 17

130. How are mobility devices paid for through Medicare?
     (a) The patient must make a 50% down payment, with the rest covered by Medicare upon delivery of the device.
     (b) Medicare part A pays 80% of the allowed purchase price and Medicare part B pays the remaining 20%.
     (c) Medicare will pay for purchase but not rental of mobility devices.
     (d) Medicare part B pays 80% of the allowed purchase price in one lump sum.

Answer 17

Answer: D

Commentary: Medicare Part B pays 80% of the allowed purchase price in one lump sum payment if the patient chooses to purchase the device. The patient is required to pay 20% of the allowed purchase price. If the patient chooses to rent a wheelchair, Medicare part B will pay 80% of the allowed rental price for months 1 through 10 and the patient will pay 20% of the allowed rental charge.

Question 18

140. At mid stance, where is the ground reaction force vector located?
     (a) Anterior to ankle, posterior to knee
     (b) Anterior to ankle, anterior to knee
     (c) Anterior to knee, anterior to hip
     (d) Posterior to knee, posterior to hip

Answer 18

Answer: B

Commentary: In mid stance, the ground reaction vector lies anterior to the ankle, anterior to or through the knee axis, and posterior to the hip center. The passive torques created by this vector alignment are ankle dorsiflexion, knee extension and hip extension.

Question 19

189. What is the primary advantage of a body powered upper limb prosthesis compared to a myoelectric prosthesis?
     (a) Greater sensory feedback
     (b) Moderate or no harnessing
     (c) Less body movement to operate
     (d) Enhanced cosmesis

Answer 19

Answer: A

Commentary: The advantages of body powered upper limb prostheses include the following factors: moderate cost, most durability, highest sensory feedback, and a variety of prehensors available for various activities. Their disadvantages are that they require the most body movement to operate, have the most harnessing and require increased energy expenditure to use. Myoelectric and/or switch controlled upper limb prostheses have the following advantages: they require moderate to no harnessing, require fewer body movements to operate, have moderate cosmesis, provide more function in proximal areas and, in some cases, provide a stronger grasp. Battery powered prostheses are the heaviest and most expensive prostheses. They also require the most maintenance, provide limited sensory feedback and require extended therapy time.

Question 20

190. What is the minimal number of points of contact that an orthosis must have in order to exert rotational control?
     (a) One
     (b) Two
     (c) Three
     (d) Four

Answer 20

Answer: C

Commentary: Rotational control forces or moments across a joint are not effective unless there are at least 3 points of contact between the device and the limb segment.

Question 21

200. The primary stabilizing effect of the flexible lumbosacral orthosis is its ability to
     (a) restrict spinal extension.
     (b) prevent atrophy of trunk muscles.
     (c) elevate intra-abdominal pressure.
     (d) enhance kinesthetic feedback.

Answer 21

Answer: C

Commentary: Although they do not effectively restrict motion to a significant degree, flexible lumbosacral orthoses elevate intra-abdominal pressure, thereby unloading the spine and supporting structures. This action also provides inhibitory kinesthetic feedback and warmth. Long-term use of binders and other flexible lumbosacral orthoses may, unfortunately, result in atrophy of trunk muscles.

Question 22

10. Individuals with diabetes are at high risk of amputation despite ankle pressures greater than 55 mmHg because
    (a) the ankle brachial pressure index must be greater than or equal to 0.3 to prevent limb threatening ischemia.
    (b) ankle pressures seldom correlate with severity of symptoms and are unreliable.
    (c) calcification of the arterial media results in a spuriously high pressure.
    (d) transcutaneous oxygen partial pressures and not ankle pressures correlate with ischemia.

Answer 22

(c)

In patients with diabetes, amputation is a strong possibility, even with ankle pressures higher than 55 mmHg because spuriously high pressures can be present in these patients as a result of calcification of the arterial media. The ankle brachial pressure index (ABPI) is the patient’s brachial pressure compared to the ankle pressure. A resting ABPI greater than 1.0 is considered normal. Patients with intermittent claudication have an ABPI in the range of 0.5 to 0.7, and patients with rest pain or other symptoms of severe ischemia have an ABPI of less than or equal to 0.3. A pressure less than 50 mmHg at the ankle is associated with limb threatening ischemia.

Question 23

40. The most common reason for prescribing a plastic leaf-spring ankle-foot orthosis is to
    (a) overcome ankle spasticity.
    (b) reduce lower-extremity edema.
    (c) prevent plantar flexion deformity.
    (d) support weak ankle dorsiflexors.

Answer 23

(d)

A plastic leaf-spring orthosis (PLSO) is probably the most commonly prescribed type of ankle-foot orthosis (AFO). It substitutes for weak ankle dorsiflexors and provides some medial lateral stability. Severe spasticity of the ankle may require prescription of a solid AFO. A plastic spiral AFO may be prescribed for concomitant weakness of both the ankle dorsiflexors and plantar flexors when spasticity is absent.

Question 24

90. The gluteus maximus is primarily active during which part of the gait cycle?
    (a) Pre swing
    (b) Loading response
    (c) Midstance
    (d) Terminal stance

Answer 24

(b)

The gluteus maximus is primarily active from terminal swing through initial contact and loading response. During midstance, terminal stance, and pre swing the gluteus maximus is actually silent.

Question 25

100. Your patient demonstrates ipsilateral pelvic drop during gait. What is the most likely cause?
     (a) Scoliosis
     (b) Short contralateral limb
     (c) Hip adductor weakness
     (d) Weak hip extensors

Answer 25

(a)

Deformity in the spine presents with malalignment of in the pelvis as either contralateral or ipsilateral drop. Two other causes of ipsilateral pelvic drop are contralateral hip abductor weakness and short ipsilateral limb. Weak hip extensors are a cause of backward lean. In stance, a backward lean of the trunk substitutes for weak hip extensors.

Question 26

102. For a patient with hemiplegia who prefers to use his legs and push his wheelchair backwards, the wheelchair should be configured with
     (a) the back edge of the seat lower than the front edge.
     (b) a single arm drive mechanism on the non-hemiplegic side.
     (c) the large wheel axle plate moved to a more anterior position.
     (d) large wheels in the front and casters in the back.

Answer 26

(d)

The casters should lead the rear wheels for the most common direction of travel. This will help reduce the possibility of the user flipping over when hitting an obstacle and will make the chair more directionally stable.

Question 27

130. A potential benefit of osseointegration (the direct skeletal attachment of the prosthesis to bone) is
     (a) elimination of poor prosthetic socket fit.
     (b) ability to return to running activities.
     (c) early prosthetic fitting.
     (d) ability to perform heavy manual work.

Answer 27

(a)

The primary benefits of attaching a prosthesis directly to the skeleton are comfort, elimination of poor prosthetic socket fit, and elimination of skin problems. Recipients report improved sensory feedback from the skeletally attached limb. Limitations include a 2-stage procedure, which results in an extended time of non-weight bearing, and extended rehabilitation (up to 2 years). The procedure poses a significant risk of infection, and the recipient must limit running, jumping, and heavy manual work in order to minimize loosening of the prosthesis.

Question 28

140. An advantage of a knee disarticulation compared to a transfemoral amputation is that the knee disarticulation offers
     (a) more options for a prosthetic knee.
     (b) enhanced ability to create power during ambulation or running.
     (c) better soft tissue coverage within the zone of injury.
     (d) better prosthetic cosmesis.

Answer 28

(b)

Disarticulation results in a bulbus distal residual limb, which may complicate prosthetic fitting. Choice of prosthetic knee options for a person with a knee disarticulation, therefore, is limited and potentially excludes the newer, more advanced knee-joint designs. Benefits of a knee disarticulation over a transfemoral approach include greater tolerance to distal limb weight bearing, a longer lever arm to create power during ambulation and running, and improved sitting balance. Of note, functional outcome studies of trauma-related lower extremity amputees concluded that persons with through knee amputations had significantly poorer outcomes. These poorer outcomes are attributed to complications arising from soft tissue failure within the zone of injury.

Question 29

150. In adults, the prevalence of phantom limb pain, phantom sensation or residual limb pain after amputation is
     (a) approximately 70% at 6 months postamputation.
     (b) dependent on age at the time of amputation.
     (c) directly related to surgical technique.
     (d) primarily dependent upon the level of amputation.

Answer 29

(a)

Phantom sensation, phantom pain, and residual limb pain have all been reported about equally in over 70% of amputees 6 months or more after lower limb amputation. This is typically not dependent upon the person’s age at the time of amputation, the level of amputation, or surgical technique.

Question 30

175. Your adult patient with a spinal cord injury needs to access his bathroom in his standard-width wheelchair. If no turn is required following entry into the bathroom, the minimal width of the doorway should be
     (a) 26 inches.
     (b) 32 inches.
     (c) 36 inches.
     (d) 40 inches.

Answer 30

(b)

The proper minimum width of a doorway for a wheelchair without a turn is 32 inches. If a turn is involved, then the doorway width should be at least 36 inches.

Question 31

190. Which K level best describes an individual who is able to ambulate within the household, but not out in the community?
     (a) K 1
     (b) K 2
     (c) K 3
     (d) K 4

Answer 31

(a)

The K level of 1 represents that of a household ambulator; K 2 limited community ambulator; K 3 unlimited community ambulator; K4 a very active community ambulator. The household exception FIM score of 5 indicates a “modified independent” ambulator who can handle household distances (i.e., less than 50 feet) inside or out.

Ref: Nelson VS, Flood KM, Bryant PR, Huang ME, Pasquina PF, Roberts TL. Limb deficiency and prosthetic management. 1. Decision making in prosthetic prescription and management. Arch Phys Med Rehabil 2006;87(3 Suppl 1):S3-9

Question 32

40. When should upper extremity prosthesis fitting be initiated in the adult?
    (a) Within the first month after amputation
    (b) When residual limb strength is full.
    (c) When the patient requests a prosthesis
    (d) When residual limb volume has stabilized

Answer 32

(a) The first month after upper limb amputation is the optimal period for prosthesis fitting. Fitting should be initiated during this time to maximize the level of acceptance and use of the prosthesis

Question 33

70. Double limb stance is what percent of the entire gait cycle?
    (a) 5%
    (b) 10%
    (c) 20%
    (d) 30%

Answer 33

(c) The average double limb support is 20% and single limb support is 40% of the entire gait cycle. Stance phase accounts for 60% of the gait cycle and swing phase accounts for 40%.

Question 34

80. What is a possible cause for circumduction during mid swing in the transfemoral amputee?
    (a) Insufficient knee friction
    (b) Prosthesis too short
    (c) Excessive medial brim pressures
    (d) Inadequate hip extension

Answer 34

(c) Possible causes for circumduction in the gait of a transfemoral amputee include excessive mechanical resistance to knee flexion, prosthesis aligned with too much stability, prosthesis too long, increased medial brim pressures, inadequate suspension, patient lacks confidence or has inadequate hip flexion.

Question 35

90. In a transtibial amputee, ambulation with a prosthesis, instead of unilateral non-weight bearing (with crutches) results in
    (a) higher rate of energy expenditure.
    (b) lower heart rate.
    (c) higher respiratory exchange rate.
    (d) equivalent amounts of energy to walk the same distance.

Answer 35

(b) Transtibial amputees have a lower rate of energy expenditure, heart rate and oxygen consumption when using a prosthesis (vs. non-weight bearing crutch gait). The cardiovascular demand of crutch walking is high, with increased rate of oxygen consumption, increased heart rate, increased energy costs, and respiratory exchange rate in the anaerobic range.

Question 36

110. The primary goal of a knee orthosis is to
     (a) prevent knee injury in athletes.
     (b) control knee instability in the anterior direction.
     (c) prevent recurvatum.
     (d) decrease the quadriceps force across the knee.

Answer 36

(c) Knee orthoses are prescribed to prevent genu recurvatum and provide mediolateral stability. They may be used during sports and other activities to provide functional support for an unstable knee or during the rehabilitation phase following injury or surgery on the knee. The use of knee orthoses for the prevention of knee injury in athletes is controversial. The Swedish knee cage prevents recurvatum but permits flexion. The three way knee stabilizer gives good control of structural knee instability in the lateral, medial, and posterior directions.

Question 37

140. The primary advantage of mag wheels over spoked wheels in the performance of a wheelchair is
     (a) lighter weight.
     (b) reduced maintenance.
     (c) more maneuverability.
     (d) general preference by active wheelchair users.

Answer 37

(b) Although MAG wheels require minimum maintenance and wear well, spoked wheels are substantially lighter, more responsive, and are generally preferred by active wheelchair users.

Question 38

For an individual who has C5 tetraplegia, orthotic splinting attempts to maintain the functional position of the hand. This usually includes

(a) closing the thumb web space.
(b) 30º to 40º of metacarpophalangeal flexion.
(c) promoting flattening of the palmar arch.
(d) supporting the wrist in 20º to 30º of extension.

Answer 38

(d) The functional position of the hand includes supporting the wrist in 20º to 30º of extension, supporting the palmar arch with the 4th and 5th metacarpals slightly anterior to the second and third digits. Metacarpophalangeal flexion of 30° to 40° would be excessive. The thumb web space should be preserved.

Question 39

19. A 10-year-old girl presents with scoliosis 5 years after sustaining a severe traumatic brain injury.

Radiographic studies reveal a 25° levoconvex curve from C8 to T12 with the apex at T4. After

consultation with the orthopedic surgeon, you prescribe a spinal orthosis. Which type of orthosis

should be used in this patient?

(a) Cervicothoracolumbosacral orthosis (CTLSO)
(b) Thoracolumbosacral orthosis (TLSO)
(c) Thermoplastic Minerva body jacket (TMBJ)
(d) Sterno-occipital mandibular orthosis (SOMI)

Answer 39

(a) A thoracolumbosacral orthosis is used for scoliosis having an apex at T9 or lower. A sternooccipital

mandibular orthosis immobilizes the neck. A thermoplastic Minerva body jacket is also

used for cervical immobilization. A cervicothoracolumbosacral orthosis such as the Milwaukee

brace extends from the pelvic section to the neck ring and has been shown to correct scoliotic

curves throughout that area.

Question 40

In a patient with a transfemoral amputation, what is the most likely cause of excessive knee flexion

during ambulation?

(a) Hip flexion contracture
(b) Prosthetic knee alignment in an excessively posterior position
(c) Excessive socket extension
(d) Too soft a plantar flexion bumper in the heel

Answer 40

(a) One of the most common gait deviations in patients with transfemoral amputations is abrupt or

excessive knee flexion during ambulation. The prosthetic knee joint should normally be stable in

extension in stance phase from heel contact to foot flat. This stability is accomplished by aligning

the prosthetic knee axis posterior to the trochanteric knee ankle line. Adequate strength and range

of motion in hip extension are critical to maintaining this alignment. Thus, weak hip extensors and

hip flexion contractures can cause knee instability. Two prosthetic causes of knee instability are (1)

knee malalignment in an excessively anterior position relative to the hip and ankle joints, and (2)

excessive socket flexion. A plantar flexion bumper that is too stiff, extensive foot dorsiflexion, or a

change in shoe heel height from low to high may all promote knee flexion.

Question 41

70. A circumducted gait in a man with an above knee amputation is most likely due to
    (a) a rigid heel in his solid ankle, cushioned heel (SACH) foot.
    (b) inadequate friction in his prosthetic knee unit.
    (c) his prosthetic foot being set in dorsiflexion.
    (d) inadequate socket suspension.

Answer 41

(d) Inadequate socket suspension causes the prosthesis to be functionally too long. A rigid heel and

foot set in dorsiflexion would increase knee flexion movement. Inadequate friction would cause the

leg to “snap” into terminal extension.

Question 42

100. Which modification will make a rocker bottom sole most effective?
     (a) Increase sole thickness with apex at the metatarsal heads.
     (b) Provide a rigid sole with no shock absorption.
     (c) Extend the length of the shoe to ½ inch beyond the longest toe.
     (d) Ensure that arch length is measured 2cm proximal to metatarsal heads

Answer 42

(c) The sole of a shoe for an individual with a neuropathic foot should be shock absorbing. The rocker

sole allows ambulation with reduced pressures on the forefoot. This requires an addition to the sole

thickness with an apex 1cm proximal to the metatarsal heads for the sole to roll over the forefoot.

The length of the shoe must be ½ to ¾ inches beyond the longest toe to accommodate the natural

elongation of the foot in ambulation. The arch length is measured at the metatarsal heads.

Ragnarsson KT. Lower extremity orthotics, shoes, and gait aids. In: DeLisa JA, Gans BM, Walsh NE,

editors. Physical medicine and rehabilitation: principles and practice. 4th ed. Philadelphia: Lippincott-

Raven; ,2005. p1380-3.

Question 43

A prescription for side joints and corset in a below knee prosthesis would be indicated in a patient

with

(a) a short residual limb.
(b) a slight degree of knee joint laxity.
(c) fluctuating limb volume.
(d) fragile skin.

Answer 43

(a) Side joints and corset are indicated for persons with short or damaged residual limbs, or those with

a high degree of limb laxity. Long-term users may also prefer to continue side joints and a corset

even without the aforementioned indications.

Question 44

140. The primary advantage of a sterno-occipital-mandibular immobilizer orthosis is its
     (a) excellent limitation of cervical extension.
     (b) ease of donning while the patient is supine.
     (c) high level of patient comfort.
     (d) excellent limitation of atlantoaxial motion.

Answer 44

(b) The sternal-occipital mandibular immobilizer (SOMI) is effective at limiting flexion, whereas the 4-

post orthosis restrains extension better. The SOMI can be applied to the supine patient without

having to rotate the individual. The SOMI is not comfortable. Overall, control of atlantoaxial

subluxation is difficult to achieve with orthoses.

Question 45

145. For a person who has C5 tetraplegia, orthotic splinting attempts to maintain the functional position

of the hand. This usually includes

(a) 1° to 20° of metacarpophalangeal flexion.
(b) supporting the wrist in 30° flexion.
(c) inhibiting metacarpophalangeal flexion.
(d) promoting flattening of the palmar arch.

Answer 45

(a) The functional position of the hand includes supporting the wrist in neutral to 30° extension,

supporting the palmar arch with the fourth and fifth metacarpals slightly anterior to the second and

third, 1° to 20° of metacarpophalangeal flexion, unimpeded, and preserving the thumb web space.

Question 46

195. The proper width of a doorway to allow transit of a power wheelchair without turning is at least
     (a) 26 inches.
     (b) 30 inches.
     (c) 36 inches.
     (d) 40 inches.

Answer 46

(c) The proper width of a doorway for a power wheelchair is at least 34 inches. Base would increase to

36 inches if a turn is involved. A manual wheelchair requires a 32-inch doorway. The minimum

turning space is a 5-foot radius for a manual wheelchair and a 6-foot radius for a power chair.

Question 47

45. In preparation for discharge from your rehabilitation unit, an individual with T12 ASIA A

paraplegia requests information regarding access to a home with 5 steps. You suggest a ramp that,

for every 1 inch in elevation, should have a length of

(a) 12 inches.
(b) 8 inches.
(c) 16 inches.
(d) 24 inches.

Answer 47

(a) Ramps must have a 12-inch length for every 1-inch rise in elevation. This ratio is a minimum
requirement. A ramp must often be longer for an individual with a higher level spinal cord injury to

be able to independently navigate it. When space allows, a longer, less steeply inclined ramp is

preferable.

Question 48

50. What does the acronym SACH stand for?
    (a) Simple amputation, cadence heel
    (b) Single axis, carbon heel
    (c) Standard adult, control heel
    (d) Solid ankle, cushion heel

Answer 48

(d) SACH is an acronym for solid ankle, cushion heel. The SACH foot has a cushioned heel that

compresses during heel strike, stimulating plantar flexion, and has a rigid anterior keel to roll over

during late stance. It is light, durable, and inexpensive, and is the orthosis most often prescribed for

juvenile and geriatric amputees.

Question 49

80. Which muscle is primarily responsible for clearance of the leg during swing phase?
    (a) Iliopsoas
    (b) Hamstrings
    (c) Quadriceps
    (d) Tibialis anterior

Answer 49

(d) Midswing is the continuation of the passive pendulum action of the leg. Foot clearance is

maintained by activity of the tibialis anterior.

Question 50

100. What is the arrow pointing to in this upper extremity prosthesis?

Picture:Passing down the anteromedial surface of the humeral section of the prosthesis, the proximal end in on the shoulder strap and the distal end of the cable engages in front of the elbow

(a) An excursion cable
(b) An anterior split cable
(c) The elbow-lock control cable
(d) The elbow flexion cable

Answer 50

(c) This is an elbow-lock control cable. Its proximal end originates at the anterior suspension strap and

its distal end engages the elbow-locking mechanism. The principal of the elbow-lock mechanism is

pull-and-release to lock, pull-and-release to unlock.

Question 51

110. The primary advantage of a 4-point crutch gait over a 2-point crutch gait is
     (a) stability.
     (b) speed.
     (c) weight-bearing relief.
     (d) efficiency of gait.

Answer 51

(a) The 4-point crutch gait has stability as its primary advantage. At least 3 points are always in

contact with the ground. It is more difficult to learn than the other gait patterns and is a relatively

slow form of ambulation. The 3-point crutch gait is used by patients with lower limb fractures,

amputations, or toe-touch weight-bearing. The 4-point gait pattern enables the crutch user to

eliminate all the weight-bearing on the affected lower limb. The 2-point crutch gait is much faster

than the 4-point gait and yet still provides some weight-bearing relief to both lower limbs

Question 52

150. One disadvantage to adding camber to a wheelchair is that it
     (a) decreases side to side stability.
     (b) exposes the hands to injury.
     (c) results in poor ergonomic positioning of push rims.
     (d) makes maneuvering in narrow spaces difficult.

Answer 52

(d) Camber has several advantages. The footprint of the chair is widened creating greater side to side

stability; camber allows quicker turning; camber helps to protect the hands by having the bottom of

the wheels scruff edges; and camber positions push rims more ergonomically for propulsion. A

disadvantage is that the increased width of the wheelchair may make it difficult to maneuver in an

environment made for walking (ie, narrow spaces).

Question 53

167. Abdominal belts worn by workers have been shown to restrict which motions in the lumbar spine?
     (a) Lateral bending and rotation
     (b) Lateral bending and flexion
     (c) Rotation and translation
     (d) Flexion and translation

Answer 53

(a) Research models have shown that abdominal support belts limit lateral bending and rotation. A

10cm leather belt increased stiffness at the torso during lateral bending, thereby reducing motion in

these planes. No changes in torso stiffness were noted, despite the belt being worn at full lumbar

flexion.

Question 54

10. Which knee component is preferred in the prosthetic prescription for an 80-year-old debilitated,

dysvascular, diabetic transfemoral amputee?

(a) Single axis
(b) Polycentric
(c) Pneumatic
(d) Manual locking

Answer 54

(d) A manual-locking knee is indicated for new unstable amputees and those who need utmost stability

because of muscular weakness or poor coordination. The other components are generally used in

persons with less risk of falling.

Question 55

70. When applying a static resting hand splint to a person who had a stroke with upper limb paralysis,

what is the appropriate joint position to maintain the hand in a functional position?

(a) 20° of wrist flexion
(b) 90° of metacarpophalangeal flexion
(c) Neutral position or slight flexion of the distal interphalangeal joints
(d) 30° of thumb opposition across the palm

Answer 55

(c) A resting hand splint is designed to maintain a position of function in a hand that is weak or
paralyzed. It is applied on the volar surface and extends from the fingertips to the proximal third of

the forearm. The wrist is typically placed in slight extension. The metacarpophalangeal joints are

placed in slight flexion and the interphalangeal joints are placed in a neutral position or in slight

flexion. The thumb is supported in a position between palmar and radial abduction.

Question 56

73. How does a weighted kypho-orthosis (Posture Training Support®) improve function in patients

with chronic thoracic kyphosis?

(a) Improves posture
(b) Strengthens spinal extensors
(c) Promotes bone formation
(d) Helps activate rectus abdominus

Answer 56

(a) A weighted kypho-orthosis improves posture without any effect on pain.

Question 57

80. A person with diabetes presents with an area of nonblanching erythema on the plantar surface of

the foot at the first metatarsal head. Recommendations for footwear would include

(a) custom-molded shoe insert.
(b) narrow toe box shoe.
(c) heel lift on the affected side.
(d) calcaneal bar added to the sole of the shoe.

Answer 57

(a) Footwear for the person with diabetes and grade 1 skin changes on the plantar aspect of the foot

should be designed to relieve pressure over the affected site while evenly distributing pressure over

the remaining foot surface to prevent other skin breakdown. A typical prescription would include an

extra-depth shoe with a wide toebox and a total-contact, custom-molded insert with pressure relief

at the area of skin irritation. Further shoe modifications with a metatarsal bar and rocker bottom

sole could also be considered, especially if the patient had grade 2 skin changes or more severe foot

deformities. A calcaneal bar or heel lift would not be appropriate considerations in this case.

Question 58

110. What type of prehension is provided by a wrist-driven tenodesis orthosis?
     (a) Lateral
     (b) 3-jaw chuck
     (c) Cylindrical
     (d) Tip-to-tip

Answer 58

(b) The wrist-driven tenodesis hinge orthosis creates a 3-jaw chuck prehension by stabilizing the

interphalangeal joints of digits 2 and 3 and the interphalangeal and metacarpophalangeal joints of

the thumb. The extensor carpi radialis muscle activates the wrist extension, which through tenodesis

action creates a 3-jaw chuck prehension.

Question 59

140. In adult patients, what advantage does a knee disarticulation amputation have over a transfemoral

amputation?

(a) Better cosmetic appearance with prosthetic fitting
(b) Reduced risk of phantom pain
(c) Increased ability to bear weight on the distal residual limb
(d) Improved surgical wound healing

Answer 59

(c) Compared with a transfemoral level amputation, a knee disarticulation provides increased ability to

bear weight on the distal residual limb. There is no evidence that knee disarticulation amputations

have a reduced risk of phantom pain or have improved surgical wound healing. Amputations at the

transfemoral level typically have a better cosmetic appearance with prosthetic fittings because the

distal prosthetic socket can be tapered to be more symmetric with the opposite side. Knee

disarticulation amputations also have a prosthetic knee axis of rotation that is distal compared to the

intact knee.

Question 60

150. The proper static alignment of the socket in a transtibial prosthesis will place the socket in slight
     (a) flexion.
     (b) extension.
     (c) external rotation.
     (d) abduction.

Answer 60

(a) The socket of a transtibial prosthesis is typically slightly flexed during the static prosthesis

alignment process. Proper flexion of the socket improves weight-bearing characteristics and also

reduces knee extension forces during mid-stance and the terminal stance phases of gait. The static

alignment also places the socket in 5° of adduction with the foot slightly inset relative to the socket.

Question 61

160. A 30-year-old man who is otherwise healthy presents following traumatic bilateral transfemoral
     amputations. Based on your understanding of the increased metabolic demands associated with

prosthetic ambulation, you conclude that

(a) he should not be considered a prosthetic candidate.
(b) he will have reduced ability to ambulate for long distances
(c) cardiac stress testing is recommended prior to consideration for prosthetic fitting.
(d) he will be able to use prosthetic devices for transfers and standing activities only.

Answer 61

(b) The metabolic cost of ambulation (mL oxygen consumed per body weight per meter) is a measure

of energy consumption per distance. The metabolic cost of ambulation increases following a lower

limb amputation and the amount of increase is related to the level of the amputation as well as the

amputation’s etiology. Because of this increased metabolic cost, persons will have reduced

endurance for ambulation following an amputation. This would be especially true for an individual

with bilateral transfemoral amputation(s). The person described, however, should be considered a

candidate for prosthetic ambulation and, since he has no prior cardiac history or significant risk

factors, cardiac stress testing would not be indicated.

Question 62

190. A 60-year-old woman is being discharged to home from your rehabilitation unit following a right

middle cerebral artery ischemic stroke with resultant left hemiparesis. She is ambulatory for short

household distances with the use of a hemiwalker on the right. Recommendations for a manual

wheelchair for this patient would include

(a) hemi-height, with removable swing-away leg rests.
(b) hemi-height, with nonremovable swing-away leg rests.
(c) standard-height, with removable swing-away leg rests.
(d) standard-height, with nonremovable swing-away leg rests.

Answer 62

(a) Wheelchair recommendations for a person with hemiparesis and limited ambulatory abilities would

include a hemi-height chair which is lower to the ground than to a standard height wheelchair. This

configuration provides the patient greater advantage to propel the wheelchair with the unaffected

lower extremity. It is also important for the leg rests to be removable so that they do not interfere

with the patient’s ability to propel the wheelchair.

Question 63

200. What is the average range of motion at the ankle during normal human ambulation over a level

surface?

(a) 0° dorsiflexion, 10° plantarflexion
(b) 30° dorsiflexion, 20° plantarflexion
(c) 5° dorsiflexion, 20° plantarflexion
(d) 10° dorsiflexion, 10° plantarflexion

Answer 63

(c) The average range of motion at the ankle during normal human ambulation over level surfaces is

from 5° of dorsiflexion to 20° of plantarflexion. This range of motion varies with ambulation over

uneven surfaces and with activities such as stair climbing.

Question 64

66. An elderly patient with breast cancer and widespread osseous metastases has developed acute onset,

severe low thoracic back pain while stooping forward to lift groceries. In addition to formulating a

pain management program and initiating bisphosphonate therapy, what brace do you prescribe for

this patient?

(a) Jewett
(b) Knight-Taylor
(c) Williams
(d) Chairback

Answer 64

(a) The patient has developed a vertebral compression fracture. An extension brace will minimize her

pain and possibly reduce further pathological compression fractures. The Knight-Taylor brace

provides thoracolumbar spine control in the saggital and coronal planes. The Williams brace is a

lumbosacral extension-lateral control orthotic. The chairback brace is an example of a lumbosacral

flexion-extension control orthosis.

Question 65

70. What is the best-established benefit of a microprocessor-controlled knee unit, compared to a

conventional pneumatic knee unit?

(a) It provides both swing and stance phase control.
(b) It allows greater knee flexion to perform bending and lifting activities.
(c) It allows running at faster speeds.
(d) It provides a more natural and symmetric gait pattern.

Answer 65

(d) Microprocessor controlled knee units use a computerized system to automatically adjust the knee

unit’s resistance over a wide range of gait speeds. With this automatic control, there is greater

consistency and reliability in the knee movement during the gait cycle. These benefits give the

amputee greater confidence and improve swing phase responsiveness and gait symmetry, as well.

Negative aspects of the microprocessor controlled knee units are heavier weight and greater

expense. These units have not been shown to improve running speed.

Question 66

80. Regarding energy expenditure during prosthetic ambulation,
    (a) at self selected walking speeds, someone ambulating with a transtibial prosthesis has a higher

rate of metabolic energy expenditure [mlO2/(kg•meter)] compared with normal human

locomotion.
(b) whether a person has a transtibial or transfemoral prosthesis, the metabolic cost

[mlO2/(kg•meter)] of ambulation is the same.

(c) at self selected walking speeds, cardiac work load during transtibial prosthetic ambulation is

comparable to that in normal human locomotion.

(d) gait velocity [meters/min] during transtibial prosthetic ambulation is comparable to that in

transfemoral prosthetic ambulation.

Answer 66

(c) The rate of metabolic energy expenditure–mlO2/(kg•minute)–represents energy expenditure per unitof time in comparison to metabolic cost–mlO2/(kg•minute)–which is a measure of energyexpenditure per unit distance, a meter. The metabolic cost of prosthetic ambulation is greater thanthat used in normal human locomotion and the metabolic cost of transfemoral prosthetic ambulationis greater than that in transtibial prosthetic ambulation. Because individuals who ambulate withaprosthesis slow their gait velocity, their rate of metabolic energy expenditure is relativelyunchanged compared to normal ambulation at self-selected walking speeds. Because the rate ofmetabolic energy expenditure is maintained at a level comparable to ambulation without aprosthesis, cardiac work load is also unchanged during ambulation with either a transtibial ortransfemoral prosthesis, if subjects are allowed to walk at their self-selected walking speed.

Question 67

87. What is the rationale for bracing for low back pain in the injured worker?
    (a) It has been shown to prevent further low back pain injury.
    (b) It prevents further injury and should be used in all injuries occurring at work.
    (c) It has been shown to improve lifting capabilities.
    (d) It can provide proprioceptive feedback to reinforce proper mechanics.

Answer 67

(d) Lumbar supports do not prophylactically prevent low back injuries or prevent recurrence of low

back pain. One study showed a decrease in lost time at work when lumbar supports were utilized

with a back injury educational program. No improvement in lifting capacity has been found with

the use of bracing. Workers who use lumbar supports use them as a proprioceptive reminder to use

proper mechanics with lifting and other work-related activities.

Question 68

90. Which circumstance is most likely to result in left knee hyperextension at initial contact (heel strike)

in a patient with spastic left hemiparesis?

(a) Solid ankle, double-metal, upright ankle-foot orthosis set in 5° of plantar flexion
(b) Addition of a solid one-quarter inch heel to the left shoe
(c) Addition of ankle dorsiflexion spring assistance to a dual-channel, double-metal, ankle-foot

orthosis

(d) Addition of a T-bar strap to a double-metal upright ankle-foot orthosis to reduce foot inversion

Answer 68

(a) Placing a solid ankle, double-metal, upright ankle-foot orthosis in 5° of plantarflexion will increase

the extension moment (forces) at the knee and this can result in knee hyperextension, especially at

the time of initial contact (heel strike). Addition of a T-bar strap should not effect the knee and the

addition of dorsiflexion spring assistance or a one-quarter inch heel will reduce the tendency to

have knee hyperextension.

Question 69

100. Which spinal orthosis is used to prevent thoracic spinal flexion by providing 3-point pressure over

the sternum and pubis anteriorly and the upper lumbar spine posteriorly?

(a) Custom molded, plastic thoracolumbosacral orthosis
(b) Lumbosacral corset with posterior metal stays
(c) Jewett orthosis
(d) Taylor orthosis

Answer 69

(c) Several different types of thoracolumbosacral (TLSO) orthoses are available to control segmental

spine motion in this region. A custom molded plastic TLSO provides almost total contact support

for uniform pressure distribution and control of motion in all plains. A lumbosacral corset with

metal stays provides support circumferentially and helps reduce spine motion primarily in the

lumbosacral region. A Taylor orthosis also provides circumferential support with the addition of

axillary straps. The Taylor orthosis is primarily designed to resist flexion and extension. A Jewett

brace is designed to limit thoracic spine flexion by providing 3-point pressure over the sterum and

pubis anteriorally and the upper lumbar spine posteriorally. This type of brace is used most

commonly for individuals with thoracic spine anterior compression fractures.

Question 70

At which location is a Syme amputation performed?

(a) through distal end of tibia and fibula
(b) coronally through the calcaneus
(c) just distal to talus and calcaneus
(d) tarsal metatarsal disarticulation (proximal to metatarsals)

Answer 70

(a) A Syme amputation (A) is ankle disarticulation with tapering of the medial and lateral malleoli and

preservation of the heel pad for soft tissue coverage and distal weight bearing. A Boyd hindfoot (B)

amputation is a talectomy and calcaneal-tibial arthrodesis after forward translation of the calcaneus.

A Chopart level (C) amputation is performed at the mid-tarsal level with sparing of the talus and

calcaneus. A tarsal-metatarsal disarticulation (D) is also referred to as a Lisfranc amputation.

Question 71

130. In an upper-extremity prosthesis, an advantage of a voluntary-closing hook terminal device that a

voluntary-opening device does not have is

(a) the ability to carry objects with less fatigue.
(b) improved ability to manipulate fragile objects.
(c) an adjustable pinch force effected by changing the number of elastic bands.
(d) a better ability to visualize the object being manipulated.

Answer 71

(b) One advantage of a voluntary-closing hook terminal device is the ability to adjust the amount of

pinch force by adjusting pressure on the cable control. This improves the ability to manipulate

fragile objects. A voluntary opening terminal device uses elastic bands to determine the pinch force

and the number of bands would have to be reduced to decrease the pinch force. When carrying

objects, voluntary-closing terminal devices require constant cable tension and this can result in

quicker fatigue. The ability to visualize the object being manipulated would not be dependent upon

whether the terminal device is voluntary closing or voluntary opening.

Question 72

140. What is the primary motion used to open a voluntary-opening terminal device in a body-powered

transradial prosthesis?

(a) Glenohumeral flexion
(b) Glenohumeral extension
(c) Biscapular elevation
(d) Biscapular adduction

Answer 72

(a) The control cable for opening the terminal device of a standard transradial prosthesis using a

voluntary-opening terminal device passes posterior to the elbow joint, along the posterior arm, and

attaches to the posterior support strap of a figure-of-8 harness. This arrangement allows

glenohumoral flexion to produce tension in the cable and open the terminal device. Glenohumoral

extension and biscapular adduction decrease tension on the control cable. Biscapular elevation

would not produce cable tension required for terminal device operation.

Question 73

150. Regarding acquired upper extremity amputation in adults,
     (a) the most common level is transhumeral.
     (b) they account for approximately 50% of all acquired major limb amputations.
     (c) they are most common in the 20- to 40-year-old age group.
     (d) their most common cause is malignancy.

Answer 73

(c) Trauma is the most common cause of upper extremity amputation in adults. Malignancy is a more

common cause of amputation in the pediatric population. Upper extremity amputations occur most

commonly in the 20- to 40-year-old age group, as a result of trauma and work related accidents.

The dominant extremity is affected more commonly and amputations at the transradial level are the

most common level of upper extremity amputation. Upper extremity amputations occur much less

frequently than lower extremity amputations. Upper extremity amputations account for

approximately 20% of all major limb amputations.

Question 74

154. A 37-year-old woman with polymyositis complains of difficulty walking and occasional falling. On

physical examination, she has muscle strength: iliopsoas 2/5, gluteus maximus 4/5, quadriceps 4+/5,

hamstrings 3+/5, anterior tibialis 4/5, gastrocnemius/soleus 4/5. Range of motion is normal. You

would prescribe

(a) bilateral forearm crutches.
(b) knee-ankle-foot orthoses.
(c) reciprocal gait orthosis.
(d) standard adult walker.

Answer 74

(a) The patient’s main weakness is proximal and she has sufficient ankle dorsiflexion and knee

extension strength. Hence she would not benefit just with knee-ankle-foot orthoses. Reciprocal

gait orthoses are designed to help children with active hip flexion but no hip extension.

Furthermore, both these options would be too bulky for such a patient to handle efficiently. A

standard walker would result in a bent forward posture and would limit the patient’s gait speed.

Forearm crutches would allow a more upright posture and an alternate 2-point gait or a 4-point gait.

Question 75

160. One advantage of a small diameter caster (front wheelchair wheel) is
     (a) greater ability to traverse rough terrain.
     (b) better stability on steep inclines.
     (c) less frequent maintenance.
     (d) greater maneuverability.

Answer 75

(d) Small diameter casters on a wheelchair reduce the chair’s turning radius, which gives it greater
maneuverability. These casters frequently are mounted on wheelchairs used for sports such as
basketball. Smaller diameter casters are less well suited for outdoor activities over rough terrain.

The size of the caster does not affect the maintenance required and does not improve wheelchair

stability on inclines. Hard, narrow casters are typically recommended for mobility over smooth,

level surfaces whereas wider, larger casters are better for mobility over uneven, rough surfaces.

Question 76

170. Which shoe modification would NOT be appropriate for an individual with loss of protective

sensation on the foot secondary to diabetes?

(a) Wide toe box
(b) Rocker bottom
(c) Soft inner shoe liner
(d) Solid steel shank

Answer 76

(d) All of the shoe modifications listed would be appropriate for an individual with loss of protective

sensation except for the use of a solid steel shank built into the sole of the shoe. This modification

would decrease the accommodative properties of the shoe and may increase the potential for skin

breakdown.

Question 77

180. In which case would a wrist-hand-finger orthosis utilizing dynamic metacarpophalangeal extension

assistance be most indicated?

(a) Complete radial nerve injury at the level of the mid-humerus
(b) Partial ulnar nerve injury at the level of the elbow
(c) Complete median nerve injury in the forearm
(d) C5 level ASIA class A spinal cord injury

Answer 77

(a) With a radial nerve injury at the level described, there is loss of wrist and metacarpal extension

because of denervation of the forearm extensor muscles. A dorsal wrist-hand-finger orthosis that

holds the wrist, fingers, and thumb in extension and permits flexion of the digits with a low-profile

outrigger is used to substitute for this loss of function. This type of orthosis would be inappropriate

for the other conditions described.

Question 78

40. A patient is referred to your office by his primary care physician for evaluation of an unusual gait

pattern caused by a remote case of polio. You note excessive lateral trunk flexion to the left during

stance phase between foot flat and heel off. Swing phase is normal. On exam there is normal hip

flexor strength bilaterally. The gluteus medius is 4-/5 on the left and 5/5 on the right. Knee strength

is normal. The tibialis anterior is 4-/5 on the right and 5-/5 on the left. Range of motion is normal at

all joints. Which gait abnormality is occurring?

(a) Waddling gait
(b) Steppage gait
(c) Trendelenberg gait
(d) Circumducted gait

Answer 78

(c) A waddling gait occurs when there is bilateral gluteus medius weakness. A steppage gait occurs as

an abnormality in swing phase due to severely weak dorsiflexors of the ankle. Foot slap is seen with

moderately weak dorsiflexors and occurs on the side of weakness. Trendelenberg gait is excessive

lateral flexion due to ipsilateral weakness. Circumduction is the swinging of the limb in a wide

lateral arc.

Question 79

44. A patient ambulates with a Trendelenburg gait. You suspect an injury to the
    (a) femoral nerve.
    (b) superior gluteal nerve.
    (c) obturator nerve.
    (d) sciatic nerve.

Answer 79

(b) Trendelenburg gait is characterized by excessive dropping of the pelvis contralateral to the stancephase
leg. It is caused by weakness of the hip abductors, which include the gluteus medius

innervated by the superior gluteal nerve.

Question 80

70. Which form of prosthetic suspension is NOT utilized with the transhumeral amputation?
    (a) Harness
    (b) Self-suspension
    (c) Suction
    (d) Joint and corset

Answer 80

(d) Traditional suspension systems include harness (figure-of-8 or -9, chest strap, and shoulder saddle),

self-suspension (condylar, Muenster, or Northwestern), semisuction (semisuction or hypobaric) and

suction (full suction or silicone sock).

Question 81

80. The best example of a dynamic orthosis is
    (a) dorsal wrist hand orthosis with extension force in radial nerve injury.
    (b) thermoplastic ankle foot orthosis in severe foot drop.
    (c) wrist hand orthosis in 15° of extension for carpal tunnel syndrome.
    (d) a C-bar in median nerve injury.

Answer 81

(a) Static means that the orthosis is rigid and gives support without allowing movement. These devices

are commonly used to rest a part after trauma or surgery, and for acutely inflamed joints and

tendons. Dynamic orthoses allow a certain degree of movement. They usually provide some

element of assisted motion to the joint, such as the elastic assist to wrist extension in the orthosis for

radial nerve palsy.

Question 82

85. On hospital rounds, you note that your patient, who has a T10ASIA B spinal cord injury is now

using a rigid frame wheelchair in the therapy gym. In his attempt to show off as he propels toward

you, he suddenly flips over backward. What is the most likely problem?

(a) The rear axles are located directly under his center of gravity.
(b) The rolling resistance is increased.
(c) There is too much caster flutter.
(d) There is asymmetry in the chair’s camber angle from side to side.

Answer 82

(a) The center of gravity for a hypothetical wheelchair rider is typically located slightly forward of the

rear axle. Moving the rear axle directly under the wheelchair user makes the person and the chair

more likely to flip backwards (wheelie). However, the advantages to having the center of gravity

near the rear axles include decreased tendency for caster flutter, decreased rolling resistance, since

most of the weight is borne by the larger rear wheels, and minimization of the turning torque.

Question 83

90. Which of the following is true regarding skeletal design of a lower extremity prosthesis?
    (a) Endoskeletal tends to weigh less.
    (b) Exoskeletal is less hardy.
    (c) Endoskeletal tends to demand less maintenance.
    (d) Exoskeletal is easily adjusted after fabrication.

Answer 83

(a) Exoskeletal designs tend to weigh more, are more rugged, demand less maintenance, and cannot be

adjusted after fabrication. Generally, the opposite is true of endoskeletal designs.

Question 84

110. A patient presents for evaluation of his new ankle-foot orthosis (AFO). During ambulation you

notice that he has reduced hip extension and stride length, and a slowed gait. At the initiation of

stance phase, heel strike is not consistently present. You conclude that the abnormal gait is due to

excessive

(a) knee extension at heel strike and recommend setting the AFO in greater dorsiflexion.
(b) hip flexion contracture and recommend setting the AFO in greater dorsiflexion.
(c) knee flexion at heel strike and recommend setting the AFO in greater plantar flexion.
(d) dorsiflexion of the ankle and recommend setting the AFO in plantar flexion.

Answer 84

(b) Excessive knee extension at heel strike is frequently seen with hamstring weakness or

gastrocnemius muscle spasticity. It causes the patient to walk on the heel, with external rotation of

the leg and no knee flexion at heel strike. Excessive knee flexion at heel strike is frequently seen

with an ankle-foot orthosis (AFO) that is set in too much dorsiflexion. This setting causes the midstance

period to be reduced and the push-off effect diminished, causing the knee to be excessively

flexed and thereby slowing the gait. If the tip of the shoe on the AFO side is raised too high at heel

strike, the AFO is set in too much dorsiflexion. Only answer b addresses all of the abnormalities

seen in this individual.

Question 85

120. In a person with complete paraplegia, which gait has the highest energy expenditure per meter?
     (a) Swing-through gait in standard knee-ankle-foot orthoses
     (b) Swing-through gait in Scott-Craig knee-ankle-foot orthoses
     (c) Reciprocating gait in a reciprocating gait orthosis
     (d) Swing-to gait using a standard walker

Answer 85

(c) Energy expenditure in paraplegia is as follows (in order of lowest to highest): normal walking,

swing-through gait in a Scott-Craig knee-ankle-foot orthosis (KAFO), swing-through gait in a

standard KAFO, reciprocating gait in a reciprocating gait orthosis. Swing-through gait in a

reciprocating gait orthosis requires approximately the same energy expenditure as the Scott-Craig

KAFO.

Question 86

130. In a metal ankle joint (double action joint or Klenzak ankle joint) used in ankle-foot orthoses, which

component assists dorsiflexion?

(a) Anterior spring
(b) Anterior rod
(c) Posterior spring
(d) Posterior rod

Answer 86

(c) An anterior spring assists plantar flexion and has no specific clinical indications. An anterior rod

limits dorsiflexion and is used for weak plantar flexors, weak knee extensors, and pain with ankle

motion. A posterior spring assists dorsiflexion and is used for flaccid footdrop and knee
hyperextension. A posterior rod limits plantar flexion and is used for plantar spasticity, toe drag,

and pain with ankle motion.

Question 87

150. A balanced forearm orthosis is indicated for patients with weakness in which muscle-group

combination?

(a) Deltoid and elbow flexors
(b) Deltoid and triceps
(c) Pectoralis group and pronators
(d) Pectoralis group and triceps

Answer 87

(a) A balanced forearm orthosis can be attached to a wheelchair. It consists of a forearm trough, which

is attached by a hinge joint to a ball-bearing swivel mechanism and a mount. It supports the weight

of the forearm and arm against gravity. With only minimal muscle force requirement at the

shoulder girdle and trunk, the patient can move the arm horizontally and flex the elbow to bring the

hand to the mouth. This orthosis is primarily used for patients with severe upper limb weakness

(especially the deltoid and elbow flexors), as in high quadriplegia or other severe neuromuscular

conditions. The patient must also have sufficient range of motion of the shoulder and elbow, as well

as adequate trunk stability (provided or innate) while sitting.

Question 88

20. Which of the following orthoses or shoe modifications is used in the conservative management of

plantar fasciitis?

(a) Heel lift
(b) Posterior night splint
(c) Lateral heel wedge
(d) Metatarsal bar

Answer 88

(b) A heel lift plantarflexes the foot and is used for Achilles tendinitis. A metatarsal bar is used for
metatarsalgia. A lateral heel wedge can be used for the conservative management of osteoarthritis

of the knee. A posterior night splint dorsiflexed to 5/ is the correct answer.

Question 89

30. During normal human locomotion, the center of gravity travels through a sinusoidal pathway that is

modified by 6 determinants of gait. Which of the following is not considered 1 of the 6

determinants?

(a) Pelvic extension
(b) Foot and ankle synchronization
(c) Knee flexion
(d) Lateral pelvic displacement

Answer 89

(a) The 6 determinants are as follows: lateral displacement that reduces horizontal excursion from 6”

down to 1.7”; knee flexion that reduces vertical excursion 7/16”; pelvic rotation that reduces

vertical excursion 3/8”; pelvic tilt that reduces vertical excursion 3/16”; and foot and ankle

synchronization as well as ankle and knee synchronization that both serve to smooth out the

sinusoidal curve but do not decrease excursion.

Question 90

40. A 79-year-old cachetic woman with coronary artery disease and unstable angina sustains a right hip

fracture after a fall. After an open-reduction internal fixation of the hip joint with the use of a

dynamic hip screw, the orthopedic surgeon determines that the patient is 25% partial weight

bearing to the right side. She has weak upper body strength and good balance. Which of the

following assistive devices is most appropriate?

(a) Standard walker
(b) Rolling walker
(c) Axillary crutches
(d) Quad cane

Answer 90

(b) Standard walkers require good standing balance and good upper body strength. Crutches require

good upper body strength and have an increased energy expenditure of 40%-60%, which would be

contraindicated in unstable angina. Quad canes are not appropriate when significant weight-bearing

relief is required. Rolling walkers are most appropriate for patients who lack upper body strength

and provide safer gait than crutches or canes.

Question 91

60. Which one of the following cervical orthoses is the most restrictive to range of motion in flexion,

extension, axial rotation, and lateral bending, both actively and passively?

(a) Soft collar
(b) Philadelphia collar
(c) Philadelphia collar with thoracic extension
(d) Sternal-occipital-mandibular immobilizer collar

Answer 91

(d) Measurements of the range of motion in flexion, extension, axial rotation, and lateral bending (both

actively and passively) using a computerized motion analyzer for four orthoses—soft collar,

Philadelphia collar, Philadelphia collar with thoracic extension, and a Sternal-occipital-mandibular

immobilizer (SOMI)—found that the SOMI was most restrictive.

Question 92

70. What level of amputation has the highest acceptance rate for an upper extremity prosthesis?
    (a) Wrist disarticulation
    (b) Transradial
    (c) Elbow disarticulation
    (d) Transhumeral

Answer 92

(b) Overall rejection of prosthetic usage occurs in 33%-38% of unilateral upper extremity amputees.

The highest acceptance rate is transradial at about 93%, and the lowest is wrist disarticulation at

about 6%.

Question 93

80. When considering realistic functional goals for the majority of transhumeral amputees, the

maximal weight (in pounds) that can be carried with the body-powered prosthesis is

(a) 7.
(b) 15.
(c) 30.
(d) 50.

Answer 93

(b) Handling of heavy objects is limited in upper extremity amputees. A transhumeral amputee is

expected to lift 10lb to 15lb, unless the residual limb is very short or sensitive. A transradial

amputee is expected to lift 20lb to 30lb unless the residual limb is very short or sensitive.

Question 94

100. When comparing quadrilateral sockets with ischial containment sockets, a successful fitting is

more likely in a quadrilateral socket when

(a) the adductor musculature is intact.
(b) the residual limb is fleshy.
(c) trunk stability demands are high at mid stance.
(d) the residual limb is shorter.

Answer 94

(a) Chances of a successful fitting of a quadrilateral socket are best when the residual limb is longer

with a firm residuum and intact adductor musculature. Ischial containment sockets are more

successful than quadrilateral sockets for persons with shorter, fleshy, unstable residual limbs.

Question 95

104. In a patient with bilateral hip flexion contractures, which of the following gait deviations would be

most likely?

(a) Bilateral Trendelenburg gait
(b) Early heel rise during stance
(c) Swing-phase circumduction
(d) Increased knee flexion in stance

Answer 95

(d) In normal gait, hip extension to neutral occurs during stance phase. When mild hip flexion

contractures are present, a compensatory increase in lumbar lordosis occurs to maintain upright

trunk posture. As the extent of the hip flexion contractures worsens, there is usually an additional

compensatory increase in knee flexion during stance phase.

Question 96

110. Which of the following knee types provides good stability in early stance phase and ease of flexion

while weight bearing during the pre-swing phase (terminal stance) of the gait cycle?

(a) Single axis
(b) Stance phase control
(c) Polycentric
(d) Manual locking

Answer 96

(c) Many polycentric knees are designed so that the center of rotation moves anteriorly very rapidly

during the first few degrees of knee flexion, quickly passing in front of the floor reaction line and

facilitating the swing phase. Because the polycentric knee can be flexed under weight bearing

during the terminal stance, when properly dynamically aligned it can offer both excellent stance

stability and ease of swing-phase flexion. Furthermore, all polycentric knees shorten mechanically

to a slight degree during flexion, adding additional toe clearance during midswing.

Question 97

120. An amputee presents for evaluation of distal blistering and evidence of vascular congestion. You

diagnose choke syndrome. Which of the following would NOT be an acceptable treatment for

choke syndrome?

(a) Expanding the proximal socket
(b) Increasing the auxiliary suspension to decrease vertical pull
(c) Relieving the distal socket where it interfaces with the choked surface
(d) Padding the distal socket where it corresponds to the choked surface

Answer 97

(c) The choke syndrome (proximal soft tissue constriction leading to vascular congestion) may occur

with suction sockets or self-suspending systems. Relieving the proximal socket to allow vascular

return, providing auxiliary suspension to decrease the vertical pull on the residual limb, and

improving the intimacy of the socket-limb interface correct this problem. Relieving the distal

socket where it interfaces with the choked surface would increase the vacuum effect in this area

and thereby increase the choke phenomenon.

Question 98

127. A wrist-hand orthosis used as symptomatic management for carpal tunnel syndrome should be
     (a) limited to patients with short-duration symptoms.
     (b) worn only during the day.
     (c) worn with the wrist in neutral position.
     (d) worn with the wrist in 30( of extension.

Answer 98

(c) A neutral position of a wrist-hand orthosis unloads the median nerve; wrist extension will

aggravate nerve compression.

Question 99

130. Which of the following shoe components distinguishes a blucher-style shoe from a bal-style shoe?
     (a) Throat
     (b) Toe box
     (c) Heel
     (d) Vamp

Answer 99

(a) There are two shoe types, the blucher and the bal. The components of a blucher shoe include the

tongue, lace stay, open throat, toe box, toe spring, vamp, ball, shank, breast, quarter, and heel. The

major difference with a bal style is that the throat is closed, limiting the ability of the shoe to open

and accommodate an orthosis. For this reason, a blucher is the style of dress shoe most often

recommended to patients who require an orthosis.

Question 100

140. A 35-year-old man experiences a severe S1 radiculopathy. As a result, he loses essentially all

strength within the posterior compartment of the leg. It is 6 months later, and you are consulted to

provide an orthosis to aid his ambulation. The best recommendation would be

(a) a posterior leaf spring ankle-foot orthosis (AFO).
(b) an articulating AFO with plantar flexion stop.
(c) an articulating AFO with dorsiflexion stop.
(d) an articulating AFO with dorsiflexion assist.

Answer 100

(c) In this condition, lack of active plantar flexion occurs, heel-rise is delayed, the mid-stance phase is

prolonged, and push-off force is reduced. A dorsiflexion stop can accommodate for this weakness.

Setting the stop at 5° of dorsiflexion substitutes best for gastrocnemius function.

Question 101

150. A 75-year-old woman falls and fractures her distal humerus. In the process, the ulnar nerve is
     damaged. She presents 6 months later with weakness in the fourth and fifth digits, claw deformity,

and loss of grip power. Which of the following orthotic components could benefit this patient and,

therefore, should be included in the orthotic prescription?

(a) Dorsal outrigger
(b) C bar
(c) Lumbrical bar
(d) Opponens bar

Answer 101

(c) A dorsal metacarpophalangeal extension stop (also called a lumbrical bar) to the fourth and fifth

digits is usually quite effective at preventing hyperextension of the fourth and fifth

metacarpophalangeal joints. This permits the proper wrapping of the fingers around an object and

thus allows a stronger grip.