SAE-R 2016 Flashcards
An important early diagnostic feature of Parkinson disease is
a. asymmetric symptoms of tremor, rigidity, and stiffness
b. a shuffling gait with balance problems and a history of falls
c. autonomic dysfunction, especially with orthostatic blood pressure symptoms
d. sialorrhea with poor ability to handle oral secretions
A. The early symptoms in Parkinson disease are asymmetric and progress to affect both sides of the body, but the stiffness and slowness remain more severe on 1 side throughout the course of the disease. The shuffling, festinating gait pattern, autonomic dysfunction and qsialorrhea are all seen later in the disease process
Which of the following modifiable risk factors is the leading cause of stroke?
a. HTN
b. DM
c. obesity
d. HLD
A. Hypertension is the most important modifiable risk factor in stroke prevention. HTN raises the risk of stroke by 6 fold. DM increases the relative risk of ischemic stroke to 3 to 6 times that of the general population. The risk from DM may be partly attributed to the higher prevalence of HTN and heart disease among persons with dM, but even after controlling for these factors, DM independently doubles stroke risk. Obesity and HLD per se have not been directly linked to increased risk of stroke, but are likely indirect factors
A 21-yo patient with T4 AIS A paraplegia presents with acute worsening of bilateral lower limb spasticity. The patient has been on a stable dose of oral baclofen (Lioresal) 3 times a day. Which of the following is the most appropriate recommendation?
a. increase the oral baclofen dose to 4 times a day
b. add a new oral anti spasticity agent
c. evaluate patient for underlying pathology
d. order physical therapy for stretching
C. It is imperative to first look for a remediable cause for spasticity when a patient has an acute change in spasticity. Noxious stimulation caused by a urinary tract infection, wound, bowel impaction, etc. can be the cause of increased spasticity and appropriate treatment of these medical problems will resolve the problem.
Which of the following is included in the black box FDA warning for botulinum toxins?
a. breathing difficulties
b. urinary retention
c. migraine headaches
d. antibody formation
A. Botulinum toxin is generally well tolerate in therapeutic doses, but does carry an FDA-mandated black box warning of a rare, but potentially life-threatening complication, when the effects of the toxin spread far beyond the injection site. These effects cause systemic weakness, vision changes, dysarthria, dysphonia, dysphagia, and respiratory insufficiency. These adverse reactions can be avoided by careful selection of muscles, proper method of injection guidance (e.g., electromyography, ultrasound, or motor-point electrical stimulation), appropriate dilution of toxin, and restricting dosage to the minimal needed to get therapeutic effect.
Which of the following should eb included in patient counseling about the management of intrathecal baclofen (ITB)?
a. the pump is MRI compatible
b. batteries will need to be replaced annually
c. overdose symptoms include itching
d. routine pump refill intervals are up to 1 year
A. in a prospective, observational study,… ITB therapy, there was an adverse event rate of 0.023 per month of ITB treatment. Similar to other published studies, most adverse events were related to the surgical procedure and, therefore, 58% of the adverse events were in the first month after surgery. Device-related adverse events were most commonly due to catheter complications. Baclofen pumps are MRI compatible, but must be interrogated after MR imaging since there is risk of the pump not restarting.
intrathecal baclofen (Lioresal) decreases spasticity by what mechanism?
a. it blocks 1a afferent signals through the dorsal root ganglia.
b. it inhibits gamma motor neuron activity and decrease muscle spindle sensitivity to spinal reflexes
c. it blocks acetylcholine release from neurons at the peripheral neuromuscular junction.
d. it inhibits calcium release from the sarcoplasmic reticulum during muscle contraction.
B. intrathecal baclofen acts as a GABA-agonist inhibiting the spinal reflex arc stimulated by intrafusal muscle fiber stretch. Selective dorsal rhizotomy seeks to diminish spasticity by decreasing the afferent signal by cutting rootlets in the dorsal root ganglia. Botulinum toxin blocks acetylcholine release at the neuromuscular junction. Dantrolene sodium decreases muscle contraction by inhibiting calcium release from the sarcoplasmic reticulum. All these therapeutics can be useful in the treatment of spasticity.
Abnormalities found in which of the following types of examinations best differentiates as polyradiculopathy from amyotrophic lateral sclerosis (ALS)?
a. motor nerve conduction studies of upper and lower extremities
b. needle electromyography of thoracic paraspinals or bulbar muscles
c. sensory nerve conduction studies of upper and lower extremities
d. needle electromyography of multiple extremities
B.
Thoracic paraspinals and bulbar muscle examinations are most helpful in differentiating a polyradiculopathy from ALS, since one would expect these studies to be normal in a radiculopathy but abnormal in ALS. Sensory nerve conduction studies are normal in both radiculopathy and motor neuron disease. Motor nerve conduction studies are also often normal in both diseases. Both diseases may demonstrate abnormal needle examination in multiple limbs.
A 35 yo patient with chronic, axial low back pain indicates that the back pain has worsened significantly in the last few weeks. The pain is no longer being managed by physical therapy exercises and main medications. The patient acknowledges increased irritability and poor sleep. The physical exam is stable. Which of the following actions is the most appropriate next step in managing the patient’s care?
a. obtaining lumbar MRI
b. evaluate for presence of depression
c. ordering additional physical therapy
d. starting a long acting opioid medication
B. chronic pain management requires multidisciplinary approach. A patient may have a structural injury that acts as a nidus for development of chronic pain syndrome but psychological issues such as anxiety and/or depression can compound the presentation. the resulting pain syndrome may fail to respond to standard medical treatment unless all the contributors are addressed. when secondary psychological or social issues become the predominant factors, management must shift to include these factors
A warehouse worker routinely lifts a heavy object from the floor. the techniques that causes the most stress on the lumbar spine is lifting with:
a. back straight and knees bent
b. back forward flexed and the knee straight
c. object too close to the body
d. object far away from the body
B.
the activity of the lumbar muscles correlates well with intradiskal pressures (ie, when back muscles contract, an associated increase in disk pressure occurs). These pressures change depending on spine posture and the activity undertaken. Adding rotation to the already flexed posture increases the disk pressure substantially. Comparing lifting maneuvers, researchers showed a significant difference in disk pressure when lifting with the legs (ie, back straight, knees bent) versus lifting with the back (ie, forward-flex back, straight legs). What decreases the forces on the lumbar spine is lifting the load close to the body because the farther the load is from the chest, the greater the stress on the lumbar spine
Which of the following therapeutic treatments is the most beneficial for a 25 yo patient who has complex regional pain syndrome in one hand? a. splinting b traction c. contrast baths d. laser therapy
C
Contrast baths consist of immersing the distal limb in warm/hot water, alternating with cold water. A person with complex regional pain syndrome (CRPS) may have vasomotor abnormalities. Contrast baths may be helpful by causing cyclic vasoconstriction and vasodilation
A 59 yo patient who had a stroke with dysphagia is undergoing a video fluoroscopic swallow study. The patient aspirates thin liquids and solids with a mechanical soft solid diet. Using a chin tuck, he has penetration but no aspiration with nectar-thick liquids and pureed solids. Which of the following diet orders is most appropriate?
a. tube feeds via gastrostomy tube and nothing by mouth
b. honey-thick liquids with a chin tuck and no solids
c. nectar-thick liquids and pureed solids with a chin tuck
d. thin liquids and mechanical soft solids with a chin tuck
C
Aspiration is defined as passage of material through the vocal folds; it is associated with an increased risk for PNA or airway obstruction. Penetration is passage of material into the larynx but not through the vocal folds. Normal individuals may have penetration. The rehabilitation goal is to allow the patient to have the safest but least restrictive method of nutrition. Because the patient was observed to aspirate thin liquids and mechanical soft solids, that diet is not appropriate for him. Nectar thick liquids and pureed solids with chin tuck is safe, because the patient was only noted to have penetration. Honey thick liquids with no solids is overly restrictive, since it does not allow the patient to have anything by mouth. Chin tuck is a postural compensatory strategy that can reduce aspiration in some patients.
Which of the following heating modalities uses convection with forced hot air and a bed of finely divided particles?
a. fluidotherapy
b. ultrasound
c. microwave
d. shortwave diathermy
A
Fluidotherapy is superficial dry heat using convection with forced hot air and a bed of finely divided particles. Ultrasound uses high frequency acoustic energy to produce its effects. Microwave heat occurs when thermal energy is produced by increasing the kinetic energy of molecules within the microwave field, thus using the mechanism of conversion. Short wave diathermy is the conversion of electromagnetic energy into thermal energy when the oscillation of high frequency electrical and magnetic fields produces molecular movement and heat.
A patient presents following a fall onto his outstretched arm with shoulder pain and a “clicking sensation”. The O’brien test produces deep shoulder pain. Discomfort is elicits pressure is applied to his proximal humerus from the posterior, while his arm is abducted and slightly externally rotated. His discomfort improves when pressure is removed or applied from the anterior. This man most likely has:
a. an acromioclavicular joint sprain
b. a labral injury
c. biceps tendonitis
d. rotator cuff impingement
B
The mechanism of injury and presenting signs indicate likely injury to the superior labrum and biceps tendon complex, or superior labral anterior to posterior (SLAP) injury, or SLAP lesion. The test shown is called a crank test, or a modification of the anterior apprehension test, which is typically performed from the supine position. With AC Joint pathology, the O’Brien test elicits anterior pain over the AC joint, while deeper pain is elicited with labral pathology. There is no mention of tests performed for biceps tendonitis (Speed’s, Yergason test) or rotator cuff impingement (Neer, Hawkins, or drop arm tests)
A 68 yo woman asks what kind of exercise would be beneficial for her osteopenia. A physician replies that at least 3 days of the week, she should:
a. do stationary bicycling for 30 min
b. swim for 30 min in a warm pool
c. walk for 45 min
d. perform sit ups for 10 min
C
Weight bearing exercise, such as walking, is osteogenic. Persons with osteopenia should limit the load lifting to less than 20 pounds. Walking 45 minutes, 3 days per week, or 30 minutes daily is recommended. Swimming and bicycling can fulfill cardiovascular benefits, but are not helpful in stimulating bone remodeling. Spinal flexion exercises should be avoided due to the risk of compression fractures.
Which of the following sensory nerves has fibers that come from the tibial nerve?
a. calcaneal
b. lateral sural cutaneous
c. superficial peroneal (fibular
d. saphenous
A
The calcaneal nerve has a medial and lateral branch. The medial branch comes off the tibial nerve and the lateral off the sural nerve. The saphenous is a branch off the femoral nerve. The lateral sural cutaneous and the superficial fibular nerves come off the common fibular nerve.
A prominent feature of the most common form of Charcot-Marie-Tooth disease is
a. truncal ataxia
b. sensory impariment
c. severe proximal weakness
d. mild mental retardation
B
CMT disease, otherwise known as hereditary motor and sensory neuropathy (HMSN), is a family of inherited neuropathies. Markedly reduced conduction velocities in peripheral motor and sensory nerves characterize the most common form. The reduced velocities create significant clinical sensory impairment, distal weakness, and atrophy. Cognition is intact. Mild proximal weakness may be present. Truncal ataxia is not characteristic of the disease.
Preterm infants who develop cerebral palsy as the result of an intraventricular hemorrhage (IVH) most commonly have which of the following types of cerebral palsy?
a. choreoathetoid
b. spastic quadriplegic
c. spastic diplegic
d. hemiplegic
C
Approx 80% of infants with severe IVH and periventricular leukomalacia have spastic diplegia cerebral palsy. Athetoid CP is associated with hyperbilirubinemia and kericterus with changes noted in the basal ganglia on MRI. Spastic tetraplegia is most commonly seen with severe hypoxic ischemic encephalopathy (HIE).
A 7 yo patient with Duchenne muscular dystrophy demonstrates a Gower sign. What is the cause of a Gower sign?
a. quadriceps weakness
b. gluteus maximus weakness
c. gastrocnemius weakness
d. paraspinal weakness
B
The Gower sign is the motion used to rise from seated on the floor to standing by placing the hands on the floor then “climbing up” the legs. This maneuver is used when hip extensor weakness prevents rising from the floor normally.
Which of the following gait abnormalities can occur in an individual with chronic unilateral hip osteoarthritis?
a. prolonged stance phase of the affected limb
b. lateral trunk shift over the affected joint during stance
c. longer step length of the unaffected limb
d. circumduction of the affected limb
B
A Trendelenburg gait can be seen as a result of weakness of hip muscles (gluteus medius) secondary to pain and/or disuse. Additionally, a painful hip would cause decreased weight bearing on the affected side, therefore shortening of the steep length of the unaffected limb. Circumduction is gait pathology seen during th swing phase resulting from a long limb, abductor muscle shortening, or a stiff knee.
Which of the following problems is UNLIKELY to lead to tissue breakdown of the distal tibia in a transtibial residual limb?
a. the socket is too large
b. the supracondylar wedge is too tight
c. the foot is aligned with excessive dorsiflexion
d. the socket has excessive anterior tilt upon the pylon
B
There are four common socket-related problems that expose the distal tibia to elevated forces that may lead to breakdown: 1. a socket that is too large, 2. a socket that is too broad in the anteroposterior plane (“bell clapper” effect), 3. excessive dorsiflexion of the prosthetic foot, and 4. excessive anterior tilt of the socket on the pylon. A supracondylar wedge would cause proximal breakdown, not distal breakdown.
When comparing patients with cancer to other non-cancer diagnoses in comprehensive inpatient rehabilitation, patients with cancer demonstrate which of the following Functional Independence Measure (FIM) changes:
a. equivalent FIM efficiencies
b. more gains in motor FIM
c. fewer gains in cognitive FIM
d. less FIM efficiency
A
In various studies, patients with cancer at an inpatient rehabilitation facility (IRF) has similar FIM efficiencies and rates of discharge home as non-cancer patients. There is no evidence that certain portions of the FIM are better improved in cancer patients than in the general IRF population.
The earliest that treadmill training can begin in a patient after a left ventricular assist device (LVAD) has been implanted is
a. 1 week
b. 3 weeks
c. 6 weeks
d. 12 weeks
C
On average, after an LVAD is placed, patients can begin ambulation within 1 week and treadmill training within 3 weeks. Progressing to activities that require up to 5 METs can occur within 6 weeks after the procedures.
Following lung transplantation, which of the following medications causes delirium, including visual hallucinations?
a. tobramycin (Tobi)
b. tacrolimus (Prograf)
c. sulfamethoxazole/trimethoprim (Bactrim)
d. metrolol (Lopressor)
B
Out of the above medications, tacrolimus and other calcineurin inhibitors have been noted to cause altered mental status including hallucinations, especially if levels of the drug are supra-therapeutic. If the cause of delirium is supra-therapeutic levels, often the delirium improves as the tacrolimus level falls into the therapeutic range. However, if there is still difficulty with delirium, and all other causes have been ruled out, a patient may need to be switched to an alternative immunosuppressant therapy by his/her transplant physical. This was first noted in the literature in liver transplant patients. The other listed options are not known for causing delirium.
An 80 yo patient recently sustained a fracture from a fall. Which of the following should a rehabilitation physical do next to reduce the risk of the future falls?
a. order a wheelchair
b. evaluate for polypharmacy
c. recommend carrying a cell phone
d. prescribe a bisphosphonate
B
The CDC reported that between 2012-2013, 55% of unintentional injury in persons 65 and older were due to falls. And one of the leading causes of falls in the elderly is poly pharmacy. The patient mentions that she has to take various medications and given her past medical history, she has several diagnoses that would require medications that can increase her risk of falls. Out of the given options, prescribing a wheelchair will not necessarily decrease falls as she still will also have to transfer in and out of the wheelchair, bed, commode, etc. Additionally, while it is important to have a system to call for help after a fall, this does not help prevent falls. Lastly, bisphosphonates create osteoporosis, but again, do not prevent falls.
A patient with medical history of osteoporosis and a new vertebral compression fracture has a serum 25(OH)D concentration of 15ng/mL. What of the following is the most appropriate treatment recommendation?
a. diet modification without vitamin supplementation
b. calcium carbonate 500 mg twice a day for 6 weeks
c. daily multivitamin with 400 IU of vitamin D3 for 6 weeks
d. 50,000 IU of vitamin D2 weekly for 6 weeks
D
The patient is considered a high-risk individual given her age, gender, and diagnosis of osteoporosis. A normal serum 25(OH)D serum concentration is 30ng/mL or above. For patients whose 25(OH)D concentration is between 20-30 ng/mL, supplementation of 600-800 IU of vitamin D3 is appropriate. The recommendation for relation in a high-risk individual with serum 25(OH)D concentration of less than 20 is for weekly ergocalciferol or cholecalciferol at 50,000 unites for 6-8 weeks.
A patient with traumatic brain injury has a post-resuscition Glasgow Coma Scale score of 10. The classification of severity for this patient is:
a. mild
b. mild-complicated
c. moderate
d. severe
C
The GCS is commonly used to classify the severity of TBI. The scale ranges from 3-15, utilizing best responses on exam for eye opening, motor, and verbal responses. The score is divided into severity categories of mild (GCS 13-15), moderate (GCS 9-12), and severe (3-8). the category of mild-complicated TBI is frequently used to describe TBI severe with GCS 13-15 and brain imaging fingers reflecting the TBI pathology on conventional imaging (i.e. head CT or brain MRI).
According to the CDC, the overall leading cause of traumatic brain injury is
a. sport injury
b. assault
c. fall
d. traffic crash
C.
Overall, the most common cause of TBI-related emergency department visits, hospitalizations, and deaths in the US is falls (35.2-43.5%). This highlights the importance and value of fall-prevention activities. Other common causes include traffic-related crashes and struck by/against events (sports). In 2006-2020 assaults accounted for 11.6% of tBI and other/unclassified injuries account for 12-21%. Causes of TBI are tracked from emergency department and hospitalization data by the CDC in the US, and categories that are especially useful for pubic health are utilized (e.g. traffic related, violence).
Patients who remain in a coma at 4 weeks after a traumatic brain injury are UNLIKELY to experience a
a. vegetative state
b. severe disability
c. moderate disability
d. good recovery
D
Using threshold values to combine findings from available studies, good recovery is unlikely when coma lasts for 4 weeks. Good recovery is defined using the Glasgow Outcome Scale (GOS) as mild deficits to no residual deficits and able to return to activities such as independent living, taking public transportation, work, and school
Which of the following is a mechanism of action of amantadine (Symmetrel)
a. GABA-receptor antagonist
b. serotonin-reuptake inhibitor
c. NMDA-receptor antagonist
d. norepinephrine-reuptake inhibitor
C
Amantadine is thought to act as an NMDA-receptor antagonist and direct dopamine agonist
Primary injury after traumatic brain injury is characterized by
a. disrupted ion homeostasis
b. elevated intracranial pressure
c. microscopic disruption of axons
d. elevated excitatory amino acids
C
Microscopic disruption of axonal structure is one of the key components of diffuse axonal injury (DAI). DAI is common as a primary injury factor in TBI especially when rotational/angular forces are involved. The other features listed here (elevated intracranial pressure disrupted ion homeostasis, and elevated elevated excitatory amino acids) are examples of secondary injury after TBI, and develop hours to days after injury
Which of the following factors is the strongest predictor for the development of chronic disability low back pain?
a. severity of pain
b. physical examination findings
c. psychosocial factors
d. duration of pain
C
Psychosocial factors and emotional distress are stronger predictors of low back pain than physical examination findings, severity of pain, or duration of pain. Specific psychosocial factors that may predict poorer outcomes in cases of low back pain included presence of depression, massive coping strategies, job dissatisfaction, higher disability levels, disputed compensation claims, and somatization.
