SAER 2001

Question 1

A 27-year-old female runner presents to your office with foot pain for the last 3 weeks. She reports
a severe pain on the bottom of her foot which is worse with the first few steps in the morning after
getting out of bed. She has no history of trauma and typically runs up to 5 miles per day. Her
running has been severely limited since this pain began. What is the best initial treatment option
for this patient’s pain?
(a) Walking cast for the affected foot
(b) Complete bed rest for several days
(c) Corticosteroid injection at the involved site monthly for 3 months
(d) Foot orthotic and stretching

Answer 1

(d)
This patient’s symptoms are most consistent with plantar fasciitis. Classically, this syndrome is most painful first thing in the morning upon arising and is aggravated by overuse or change in footwear. Stretching the plantar fascia, often before getting out of bed in the morning, and use of a heel cup or medial longitudinal arch orthotic are the initial treatments for this condition.
Corticosteroid injection may be indicated at the insertion of the fascia into the plantar aspect of the calcaneus; however, this is usually not required on a repeated basis. Relative rest from the aggravating activity may be useful, but bed rest is not indicated. A walking cast would not allow
stretch of the plantar fascia.

Question 2

What magnetic resonance imaging findings would help to distinguish an acute from a chronic
intracerebral hemorrhage?
(a) T1 decreased, T2 increased
(b) T1 decreased, T2 decreased
(c) T1 increased, T2 increased
(d) T1 increased, T2 decreased

Answer 2

(b) The T1 signal in an acute hemorrhagic event would be decreased. Magnetic resonance imaging can
be helpful in distinguishing acute from chronic hemorrhagic events. The pathology and subsequent
neuroimaging results are based on the stage of hemoglobin molecular breakdown. In acute
hemorrhagic states, deoxyhemoglobin predominates and T1/T2 images are both decreased. In
chronic hemorrhagic states (more than 2 weeks) methemoglobin

Question 3

Which of the following synovial fluid findings is most specific for infection?

(a) White blood cell count of 5,000/mm3
(b) Transparent, straw-colored fluid
(c) Ninety-eight percent neutrophils on a differential leukocyte count
(d) Negatively birefringent crystals under a polarizing microscope

Answer 3

(c) All synovial fluid removed for diagnostic purposes should be sent for gram stain and cell count.
Noninflammatory synovial fluid typically has white blood cell counts of less than 2000/mm3, is
transparent or yellow colored, and has less than 50% neutrophils. Inflammatory fluid usually is
translucent or opaque, can have very high cell counts (up to 100,000/mm3), and usually has less
than 90% neutrophils. Synovial fluid that has cell counts over 100,000/mm3, is purulent and has
more than 95% neutrophils should be considered infected.

Question 4

6. A withdrawal syndrome produced by abrupt medication dose reduction or the administration of an
antagonist drug is referred to as
(a) tolerance.
(b) pseudoaddiction.
(c) physical dependence.
(d) addiction.

Answer 4

(c) Physical dependence is a pharmacologic property of many drugs caused by the body’s physiologic
acclimation to their presence. In the case of opioids, withdrawal will develop in tolerant patients if
the drug is not tapered.

Question 5

A nurse working in a rehabilitation hospital is most likely to injure her back while

(a) assisting a patient to perform a sliding-board transfer.
(b) catheterizing a patient.
(c) performing a wheelchair-to-toilet patient transfer.
(d) helping a patient move up in bed.

Answer 5

(d) The difficulty in using proper posture and body mechanics and the forces required for pulling
patients up in bed are believed to be the reasons that this task most often causes back pain among
nurses.

Question 6

The most useful clinical criterion to distinguish Becker muscular dystrophy from Duchenne
muscular dystrophy is
(a) creatine kinase values at the time of diagnosis.
(b) walking ability during the teen-age years.
(c) Gowers’ sign and calf enlargement.
(d) age at onset of diagnosis.

Answer 6

(b) The most useful clinical criterion to distinguish Becker muscular dystrophy (BMD) from Duchenne
muscular dystrophy (DMD) is the continued ability of the patient to walk into late teen-age years.
Persons with BMD will typically remain ambulatory beyond 16 years. Outlier DMD cases
generally stop ambulating between 13 and 16 years of age. Creatine kinase values cannot be used
to differentiate DMD from BMD. Calf enlargement and the presence of Gowers’ sign are a
nonspecific findings. Studies have shown significant overlap in the observed age at onset between
DMD and BMD.

Question 7

Dysesthesias on the plantar aspect of the foot may be associated with peripheral neuropathy or
tarsal tunnel syndrome. Which of the following would be most useful to help in distinguishing
between these?
(a) Reproduction of symptoms with compression inferior to the medial malleolus
(b) Sensory testing using a Semmes-Weinstein monofilament on the plantar aspect of the foot
(c) Plain anteroposterior and lateral radiographs of the foot, including the calcaneus
(d) Slowing of the medial and lateral plantar nerves on nerve conduction studies

Answer 7

(a) Both peripheral neuropathy and tarsal tunnel syndrome can present with painful dysesthesias. Plain
radiographs will not be helpful, as they can be normal with either of these conditions. Nerve
conduction studies may demonstrate slowing of the medial and lateral nerves with either condition,
and sensation on the plantar aspect of the foot may be decreased with either condition.
Compression over the tarsal tunnel should cause increased symptoms of numbness, tingling, or
burning in the plantar aspect of the foot.

Question 8

A primary care physician started a relative of yours on donepezil (Aricept) for the treatment of
Alzheimer’s disease. This medication is used to modify
(a) expressive language skills.
(b) behavioral and cognitive symptoms.
(c) disease progression.
(d) restoring normalized sleep-wake cycles.

Answer 8

(b) Donepezil is a cholinesterase inhibitor (C1) with properties shown to address cognitive behaviors,
specifically behavioral disturbances. C1 has not been shown to slow or stop disease progression.

Question 9

A 26-year-old woman presents with the new onset of lower extremity weakness and bladder
incontinence. Past medical history is remarkable for an episode of diplopia and blurred vision
which resolved spontaneously. The most likely diagnosis is
(a) multiple sclerosis.
(b) myasthenia gravis.
(c) myasthenic syndrome.
(d) amyotrophic lateral sclerosis.

Answer 9

(a) Clinically, multiple sclerosis is characterized by multiple lesions separated in time and location
within the central nervous system. Common presenting symptoms include diplopia, optic neuritis,
weakness, sensory loss, and ataxia. Women between the ages of 20 and 40 are the most commonly
affected population. Diplopia, though commonly associated with myasthenia gravis, is not seen in
myasthenia syndrome or amyotrophic lateral sclerosis.

Question 10

The best possible expected functional outcome for a person with C7 ASIA A spinal cord injury is
(a) dependent with bladder, independent with bed mobility, and some assist with all transfers.
(b) dependent with bladder, independent with bed mobility, and independent with level transfers.
(c) independent with bladder, some assist with bed mobility, and independent with some
transfers.
(d) independent with bladder, independent with bed mobility, and independent with level
transfers.

Answer 10

(d) Expected functional outcomes after traumatic spinal cord injury have been delineated in the
clinical practice guidelines for health care professionals. A person who has sustained a C7-8-level
spinal cord injury can best be expected to need assistance in clearing secretions, may need partial
to total assistance with a bowel program, and may be independent with respect to bladder
management, bed mobility, and transfers to level surfaces. Adaptive equipment is listed in these
tables (FIM (functional independent measures) purists can argue that these persons really are only
modified independent).

Question 11

Which of the following conditions is least likely to exacerbate preexistent lymphedema?

(a) Scuba diving in cold water
(b) Airplane travel
(c) Phlebotomy
(d) Sun exposure

Answer 11

(a) Conditions associated with decreased atmospheric pressure will cause lymphedema to progress.
Activities or situations that lead to increased blood flow in the affected extremity (eg, burns, heat,
physical exertion, trauma) exacerbate lymphedema. Atmospheric pressure increases during scuba
diving, therefore, it has the capacity to ameliorate lymphedema.

Question 12

Functional recovery programs for the injured worker with chronic pain should

(a) be done on an inpatient basis to increase the likelihood of success.
(b) not be started until pain medications have been discontinued.
(c) focus on restoration of function.
(d) focus on reducing the patient’s pain symptoms.

Answer 12

(c) Functional recovery programs should focus on restoring functional ability, including return to
work.

Question 13

Of the following, somatosensory studies would be the most useful in the diagnosis of

(a) tarsal tunnel syndrome.
(b) motor neuron disease.
(c) myasthenia gravis.
(d) multiple sclerosis.

Answer 13

(d) Somatosensory studies can be helpful in the diagnosis of multiple sclerosis. Standard nerve
conduction studies and electromyography are far more useful in the diagnosis of the other
disorders.

Question 14

The leading cause of childhood disability is

(a) traumatic brain injury.
(b) spinal muscular atrophy.
(c) spina bifida.
(d) cerebral palsy.

Answer 14

(d) Cerebral palsy is the leading cause of childhood disability. The reported incidence is approximately
2-3 per 1,000 live births. The incidence of spina bifida is .5 per 1,000, of spinal muscular atrophy 1
in 25,000. The annual incidence for traumatic brain injury in children is 1-2 per 1,000. However,
the great majority of cases are minor and result in no long-term disability. Approximately 15% of
brain-injured children have moderate and severe injuries resulting in permanent impairment.

Question 15

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 15

(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 16

A 32-year-old woman with known multiple sclerosis has frequent bladder sensation and urgency
but very little urination amounts. Nursing informs you that her void amounts are low, her post-void
residual is high, and the combined voided plus catheter specimen amounts are on the low-normal
side. You order urodynamic testing to verify
(a) an areflexic bladder with sphincter dyssynergia (increased tone).
(b) an areflexic bladder with normal sphincter tone.
(c) a hyperreflexic bladder with sphincter dyssynergia.
(d) a hyperreflexic bladder with normal sphincter tone.

Answer 16

(c) Bladder dysfunction in patients with multiple sclerosis can be challenging from a diagnostic
perspective. The use of urodynamic testing provides useful information. Bladder function in this
scenario would be hyperreflexic, and with high residual volumes it would indicate that bladder
outlet pressure is high so as to block urine flow, as if squeezing on a water balloon and holding the
spout. This outlet pressure is called dyssynergia, and treatment is directed at bladder neck
relaxation.

Question 17

Which of the following glucocorticoid preparations has the longest therapeutic action?

(a) Triamcinolone diacetate (Aristocort)
(b) Methylprednisolone acetate (Depomedrol)
(c) Hydrocortisone phosphate (Hydrocortone)
(d) Dexamethasone sodium phosphate (Decadron)

Answer 17

(d) The onset and length of symptomatic relief after steroid injection are related to the preparation
used. Dexamethasone sodium phosphate has an intermediate solubility and a fairly long biologic
half-life (36-72 hours). Methylprednisolone and triamcinolone have biologic half-lives of 12-26
hours. Hydrocortisone phosphate is not recommended for intraarticular use.

Question 18

Outcomes of inpatient rehabilitation for neoplastic versus traumatic spinal cord injury reveal that
(a) indices for depression were significantly higher in patients with neoplastic injury.
(b) patients with neoplastic spinal cord injury had significantly shorter lengths of stay.
(c) rate of functional change was significantly better in the traumatic population.
(d) neoplastic spinal cord injury was associated with a significantly higher rate of discharge to
the community.

Answer 18

(b) Patients with neoplastic spinal cord compression tend to be older than their traumatic counterparts,
with a peak incidence between 50 and 70 years. Significant differences exist with regard to the
level of injury; tumors involving the spinal cord tend to involve the thoracic and lumbar regions
more than the cervical region. There was a shorter rehabilitation length of stay in patients with
3
neoplasms. (This may allow patients to have more time at home with their families. These patients
had an increased percentage of paraplegia and incomplete injury.) Patients with tumors did
demonstrate a trend toward lower rate of discharge to the community, but this was not significant

Question 19

During the initial reductive phase of decongestive physiotherapy for advanced lymphedema,
compressive bandaging should remain in place
(a) 1-2 hours per day.
(b) overnight.
(c) whenever patients are not bathing or being manually drained.
(d) only during exercise periods.

Answer 19

(c) During the initial phase of complete decongestive physiotherapy (CDP), compressive bandages
traditionally remain in place 20 - 21 hours per day. They are removed only to permit bathing and
manual lymphatic drainage. Once maximal volume reduction has been achieved, patients transfer
to phase II, or maintenance, CDP indefinitely. The purpose of phase II CDP is to prevent
reaccumulation of lymphedema. During phase II, patients apply compressive wrapping only at
night.

Question 20

A 35-year-old fireman with a 3-month history of shoulder bursitis is referred to you for treatment.
Among the following, your initial management would include
(a) ice massage to the involved area.
(b) ultrasound to the involved area.
(c) transcutaneous electrical nerve stimulation.
(d) placing the arm in a shoulder sling.

Answer 20

(b) Ice massage is more effective for acute bursitis. Subacute or chronic bursitis may respond to deep
heating modalities such as ultrasound.

Question 21

The earliest weakness seen in skeletal muscle in Duchenne muscular dystrophy is located in

(a) knee extensors.
(b) hip flexors.
(c) neck flexors.
(d) ankle plantar flexors.

Answer 21

(c) Neck flexor weakness occurs during preschool years. Weakness is generalized but is predominantly
proximal early in the disease course. Pelvic girdle weakness precedes shoulder girdle weakness by
several years. Weakness progresses steadily. Quantitative strength testing is more sensitive than
manual muscle testing.

Question 22

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 22

(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 23

Clinical features of Friedreich’s ataxia include

(a) sparing of sensory function.
(b) onset in the fourth decade of life.
(c) a high incidence of scoliosis.
(d) ambulation into late adulthood.

Answer 23

(c) Friedreich’s ataxia is a spinocerebellar degenerative syndrome with onset in the first 2 decades of
life. Weakness, proprioceptive sensory loss, and ataxia dominate the clinical picture. The incidence
of scoliosis approaches 100%; it is typically more severe when onset occurs at a young age.
Ambulation is lost by early adulthood.

Question 24

Five weeks after sustaining a T6 spinal cord injury, your patient is noted to have urinary
incontinence with intermittent catheterization volumes of less than 200mL. Urinalysis is
unremarkable. You consider starting
(a) sodium etidronate (Didronel).
(b) oxybutynin (Ditropan).
(c) urecholine (Bethanechol).
(d) terazosin (Hytrin).

Answer 24

(b) This patient is probably developing spontaneous detrusor contractions but is emptying
incompletely. You would consider using an anticholinergic agent to decrease detrusor (and hence
intravesical) pressures. Ideally, you would obtain urodynamic studies to delineate detrusorsphincter
coordination. One should not initiate a cholinergic agonist without knowing of possible
detrusor -sphincter dyssynergy.

Question 25

A human resource firm working with a manufacturing company inquires about personal factors and low back injuries. It is interested in matching individuals with work stations. Which of the following was found to be most important in predicting injuries? (a) Age greater than 40 (b) Obesity (c) Psychologic factors (d) Poor physical fitness

Answer 25

(c) Other than a history of previous back injury, psychologic factors were found to be more important than physical factors in predicting injuries.

Question 26

You are treating a 48-year-old man who has had two lumbar laminectomies for what you suspect is a recurrent right L5 radiculopathy. You perform an electromyogram to confirm the diagnosis, and it reveals 2+ positive waves and fibrillations with decreased recruitment in the right anterior tibialis. The patient informs you that he can only tolerate the examination of one more muscle. Of the following you would choose (a) extensor hallucis longus. (b) L5 paraspinals. (c) vastus medialis. (d) flexor digitorum longus.

Answer 26

(d) The history is suggestive of an L5 radiculopathy. Given the previous laminectomies, examining a single level of paraspinals would provide limited information. Although you cannot form any firm conclusions based on such a limited examination, study of the flexor digitorum longus will provide findings outside the peroneal distribution and could lend support to the clinical diagnosis

Question 27

The most common complication after amputation in the immature child is (a) phantom limb pain. (b) diffuse edema. (c) terminal overgrowth. (d) painful neuroma.

Answer 27

(c) Terminal overgrowth at the transected end of a long bone is the most common complication after amputation in the skeletally immature child. It occurs most frequently in the humerus, fibula, tibia, and femur, in that order. The oppositional growth may be so vigorous that the bone pierces the skin. The treatment of choice is surgical revision.

Question 28

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 28

(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 29

A 16-year-old boy presents 2 days after being injured during a weekend football game. He reports receiving a direct blow on the right side from the helmet of a player. He had immediate pain in the right lower part of the posterolateral trunk. On exam, you note ecchymosis and tenderness to palpation just superior to the right iliac crest. Which of the following signs would be expected on subsequent examination? (a) Severe pain with internal rotation of the right hip (b) Pain on the right side with left lateral bending of the trunk (c) Numbness in the right femoral nerve distribution (d) A positive Gillet test

Answer 29

(b) This scenario is classic for a contusion of the iliac crest or "hip pointer." It occurs as a result of a direct blow to an unprotected iliac crest. Tenderness with swelling and ecchymosis is common, as is pain on the affected side with lateral bending away from the side of contact. This is not a hip injury, and internal rotation of the hip should be normal. The Gillet test is used to evaluate sacroiliac mobility. Numbness can be seen on the ipsilateral side because the T12-L3 lateral cutaneous nerve branches are often injured.

Question 30

A 75-year-old man with a recent anterior communicating artery aneurysm, treated by neurosurgical clipping is admitted to the inpatient rehabilitation unit for poststroke care. Deep vein thrombosis prophylaxis should include (a) heparin 5,000 units BID. (b) warfarin doses based on INR values. (c) pneumatic compression stocking (ankle or calf). (d) continuous passive motion devices.

Answer 30

(c) Venous thromboembolic events can occur in as many as 75% of untreated patients with after stroke. Prophylaxis is typically pharmacologic or manual venous compression. In patients with documented intracerebral bleeding, anticoagulation is not recommended, and alternating pneumatic compression derives are best used.

Question 31

The most common cause of upper limb pain in long-standing tetraplegia is (a) shoulder pain of radicular origin. (b) shoulder pain of musculoskeletal origin. (c) elbow pain of radicular origin. (d) elbow pain of musculoskeletal origin.

Answer 31

(b) In patients with quadriplegia, 55% reported pain in at least one region of the upper extremity. The shoulder was reported as painful in 46% of subjects; the most frequent diagnoses for shoulder pain were orthopedically related—tendinitis, bursitis, and osteoarthritis. Referred pain of cervical origin accounted for 33% of shoulder pain. In patients with paraplegia, symptoms of carpal tunnel syndrome were the most common complaint (66%).

Question 32

A patient with metastatic lung cancer presents to the emergency department with new-onset back pain and lower extremity weakness suspected to be due to spinal metastases. Initial management should include (a) observation for 24 hours and careful reexamination for progressive neurologic deficits. (b) emergent irradiation prior to imaging. (c) empiric administration of high-dose dexamethasone in the absence of contraindications. (d) alteration of the patient's chemotherapy regimen.

Answer 32

(c) A randomized controlled trial of high-dose steroids (96mg dexamethasone) versus placebo concluded that steroid-treated patients with spinal cord compression from malignant epidural disease were more likely to retain or regain ambulation. Surgery and radiation may be indicated, contingent on tumor location and type and on prior radiation history. Dexamethasone should be administered to patients before imaging in order to alleviate pain and to optimize neurologic recovery.

Question 33

A 63-year-old man was in a car accident 3 days ago. Cervical radiographs performed in the emergency department demonstrate multilevel degenerative disc disease. He is currently asymptomatic but is concerned about the radiographic findings. You inform him that (a) this is diagnostic of central spinal stenosis. (b) further neuroimaging is required. (c) cervical spine immobilization with a soft collar is recommended. (d) no evaluation or treatment is necessary until symptoms occur.

Answer 33

(d) Cervical spine degenerative changes in males over 60 are commonly seen in asymptomatic patients.

Question 34

In children hospitalized with acute burns, early management should include (a) avoidance of sedation. (b) positioning for comfort to reduce severe pain. (c) use of a pressure garment over areas of full-thickness burns. (d) administration of narcotics and anesthetic agents.

Answer 34

(d) Although opiates should be considered the most important part of acute pain management nonopiates should be used when possible. As the needs become more chronic, other agents should be instituted to minimize the problems seen with opiates. Behavioral management and relaxation therapy should also be used when possible. Typically, the position of comfort for a burned child is the position that promotes deformity and, therefore, should be avoided. Garments are fitted later in the course of treatment.

Question 35

A 77-year-old woman is admitted to the rehab inpatient unit with a diagnosis of general debility after urosepsis and dehydration. Clinical exam reveals impaired memory, diminished abstract reasoning, gait ataxia, and peripheral distal extremity numbness. Past medical/surgical history is positive for coronary artery disease and poor nutrition. Lab data include Na 135, K 3.5, Cl 95, C02 24, WBC 7.4, Hgb 9.5, MCV 101, urinalysis negative, RPR negative, Cobalamin assay 200 pg/mL (normal 170-900). You believe her neurologic abnormalities are attributable to (a) normal-pressure hydrocephalus. (b) latent neurosyphyilis. (c) postdehydration cerebral infarction. (d) pernicious anemia.

Answer 35

(d) Pernicious anemia can account for significant cognitive and motor disturbances in patients typically more than 60 years old. The most frequent clinical findings are paresthesias, numbness, gait ataxia, focal incontinence, leg weakness, memory disturbance, and acute dementia. Workup for cobalamin levels, intrinsic factor antibodies, and Shilling’s test are useful in making a correct diagnosis. Treatment consists of cobalamin replacement.

Question 36

Use of continuous passive motion after total knee replacement surgery (a) is associated with increased knee flexion at 6 months. (b) decreases the risk of joint infection. (c) facilitates knee flexion within the hospital stay. (d) obviates deep vein thrombosis prophylaxis.

Answer 36

(c) Patients treated with continuous passive motion obtain greater early knee flexion (and thus experience fewer hospital days and manipulations). These devices might exacerbate flexion contractures and extension lags. Their use has no effect on rates of infection or deep vein thrombosis.

Question 37

A typical clinical finding in patients with alcoholic cerebellar disease is (a) gait ataxia out of proportion to extremity ataxia. (b) benign positional vertigo. (c) severe upper extremity dysdiadochokinesia. (d) vertical nystagmus.

Answer 37

(a) Alcoholic cerebellar disease preferentially affects the superior vermis of the cerebellum, resulting in gait instability, poor trunk control, and lower greater than upper extremity ataxia.

Question 38

``` Functional outcomes after the use of methylprednisolone in persons with penetrating spinal cord injury as compared with blunt injury are (a) markedly improved. (b) better. (c) unchanged. (d) worse. ```

Answer 38

(c) The administration of methylprednisolone did not significantly improve functional outcomes in patients with gunshot wounds to the spine or increase the number of complications experienced by patients during their hospitalization.

Question 39

A 45-year-old colon cancer patient presents with new urinary incontinence and dull pain radiating into the right buttock. Physical examination fails to reveal evidence of lower extremity motor or sensory deficits. Of the following, the MOST appropriate next step in the patient's evaluation would include (a) pelvic computed tomography with contrast. (b) lower extremity electromyogram. (c) positron-emission tomography scan. (d) urodynamics studies.

Answer 39

(a) The sacral plexus is usually involved by tumor from the colon, prostate, bladder, or uterus. Presenting symptoms usually begin as a dull, aching, midline pain, which may radiate into the 5 buttocks. The pain may be associated with numbness in the perianal region. Numbness and aresthesias may extend to involve the buttock and posterior aspect of the thigh. Bowel and bladder function are often compromised. Computed tomography and magnetic resonance imaging scans of the pelvis are excellent tools for detecting presacral masses and sacral destruction.

Question 40

In considering selection of a lower limb prosthesis for a child with a congenital transfemoral amputation, a knee joint should be included (a) at initial fitting. (b) between 3 to 5 years of age. (c) when sports activities are anticipated. (d) when the child pulls to stand.

Answer 40

(b) The lower limb deficient child should be fitted with a prosthesis when he or she is ready to pull up to a standing position, usually between 9 and 12 months. A knee joint is added between 3 and 5 years.

Question 41

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 41

(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 42

You are asked to see a 35-year-old woman with systemic lupus erythematosus who has severe left groin pain. She underwent a cadaveric renal transplant 4 years ago. She has a Trendelenburg gait and pain upon internal rotation of the hip. There is reproduction of the groin pain with hip flexion. Your diagnosis is (a) L5 radiculopathy. (b) trochanteric bursitis. (c) avascular necrosis. (d) femoral neuropathy.

Answer 42

(c) The patient has aseptic necrosis of the femoral head. Her symptoms will be resolved with a hip replacement. Before surgery, a program of isometric strengthening and endurance exercise is appropriate. Trochanteric bursitis presents as lateral hip pain extending down the leg, worse with walking or lying on that side. There is tenderness over the greater trochanter and pain with endrange adduction or resisted abduction. Femoral neuropathy presents with weakness of the knee extensors. An L5 radiculopathy typically presents with leg pain that extends to the dorsum of the foot and is not worsened with hip rotation.

Question 43

A middle-aged man is evaluated 1 week after the onset of painless foot drop. On exam, 1/5 strength of ankle dorsiflexion and eversion is present. Electrodiagnostic testing demonstrates a 90% loss in the compound muscle action potential amplitude of the anterior tibialis without conduction block across the fibular head. Markedly reduced motor unit recruitment is present in the anterior tibialis. Of the following, the most appropriate recommendation is (a) observation and a temporary ankle-foot orthosis, as the prognosis is excellent. (b) a custom-molded ankle-foot orthosis with dorsiflexion assist. (c) functional electrical simulation of the anterior tibialis to facilitate recovery. (d) magnetic resonance imaging of the brain to rule out a lacunar stroke.

Answer 43

(b) The clinical features and electrodiagnostic studies are consistent with a peroneal neuropathy. The reduction in compound muscle action potential amplitude is indicative of significant axonal loss. In this situation, recovery is likely to be delayed and incomplete. The use of an ankle-foot orthosis to supply medial lateral stability and ankle dorsiflexion is appropriate. Functional electrical stimulation has not been shown to alter outcome after nerve injury.

Question 44

Persons with neurogenic bowel often use laxatives such as senna (Senokot), which acts by (a) decreasing intraluminal fluid. (b) lubricating the intestinal mucosa. (c) stimulating the myenteric plexus. (d) increasing the time for electrolyte resorption.

Answer 44

(c) Stimulant laxatives act by enhancing intestinal motility and thereby decreasing time available for water and electrolyte resorption. Senna is a glycoside that is split by colonic bacteria into absorbable anthraquinones. It generates increased propulsive activity by altering electrolyte transport and increasing intraluminal fluid. It exerts a direct stimulant effect on the myenteric plexus which increases intestinal motility. Senna works best in persons with upper motor neuron level injuries, and it facilitates bowel movements in 6 to 12 hours.

Question 45

``` Electromyographic findings consistent with Lambert-Eaton myasthenic syndrome suggest the presence of (a) small cell lung cancer. (b) malignant melanoma. (c) inflammatory breast cancer. (d) renal cell carcinoma. ```

Answer 45

(a) About 60% of patients with Lambert-Eaton myasthenic syndrome have small cell lung cancer. A few others have small cell cancer elsewhere in the body, such as in the prostate or cervix. About 40%, usually women with other evidence of autoimmune dysfunction, do not have cancer.

Question 46

The number of phases of a motor unit is related to the (a) conduction time through collateral nerve sprouts. (b) sweep speed setting on the oscilloscope screen. (c) sensitivity (gain) setting on the oscilloscope screen. (d) central conduction time and the state of the upper motor neuron.

Answer 46

(a) The number of phases of the motor unit potential represents the synchronization of firing of the individual muscle fibers in a motor unit and is related to conduction time through collateral sprouts of the nerve. The number of phases is increased under conditions in which some sprouts are poorly myelinated and conduction is slow and less synchronous. The other factors do not affect the number of phases of a motor unit potential.

Question 47

The earliest marker of abnormal central nervous system maturation is (a) diffuse fasciculations. (b) gross motor delay. (c) delay of postural responses. (d) persistence of primitive reflexes.

Answer 47

(d) In neonates and young infants, motor behavior is influenced by primitive reflexes because of the immature central nervous system. These reflexes gradually become suppressed. Concurrently, more sophisticated postural responses emerge. Obligatory persistent primitive reflexes are the earliest markers of abnormal neurologic maturation.

Question 48

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 48

(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 49

Fibromyalgia is a systemic disorder that affects primarily the musculoskeletal system and results in pain and stiffness. Which of the following statements is true about the diagnosis and treatment of fibromyalgia? (a) It has an equal distribution in both men and women. (b) The “tender points” associated with this condition cause radicular pain. (c) Severe sleep disturbances and fatigue are common complaints. (d) Palpable taut bands, which exhibit local twitch responses, are characteristic.

Answer 49

(c) Fibromyalgia is found predominantly in women, and 16 paired tender points are identified by the 6 American Rheumatism Association. They do not show referred pain patterns. Palpable taut bands are seen with myofascial pain but are not specific for fibromyalgia. Sleep disturbances and depression are very common in patients with this diagnosis.

Question 50

A 29-year-old woman with a traumatic brain injury is seen by you for consultation. On chart review, it is noted that she has frequent episodes of emesis with percutaneous endoscopic gastrostomy tube bolus feeding. Your initial recommendation would be (a) placement of a jejunostomy tube. (b) surgical consult for pyloroplasty. (c) continuous tube feeding. (d) switch to elemental formula tube feeding.

Answer 50

(c) Feeding issues for patients with traumatic brain injury can become quite complex. It is important to use stepwise approaches when investigating emesis in this population. Quite frequently a percutaneous gastrostomy tube is placed in the neurointensive care unit. Intolerance to feeding can be related to increased gastric distention, and adjusting from bolus to continuous feeding may provide relief. Other steps might then include converting to a jejunostomy or using agents to facilitate gastric emptying.

Question 51

Which of the following symptoms is typically present in vascular claudication but not in neurogenic claudication? (a) Earlier onset of pain with uphill walking (b) Pain in the posterior calf (c) Leg paresthesias and numbness (d) Pain relief with sitting

Answer 51

(a) Calf pain that worsens with walking and is relieved with sitting occurs with both neurogenic and vascular claudication. The onset of vascular claudication occurs earlier with the increased muscular demands of uphill walking, whereas the symptoms of neurogenic claudication tend to be less severe in positions of spine flexion such as occurs during uphill walking or with the use of a shopping cart. Paresthesias and numbness are more typical of neurogenic claudication than vascular claudication.

Question 52

During the electromyographic evaluation of a patient, you note discharges consistent with myotonia and small motor units in the distal muscles of the upper and lower extremities. The most likely diagnosis is (a) paramyotonia congenita. (b) myotonic dystrophy. (c) myotonia congenita. (d) hyperkalemic periodic paralysis

Answer 52

(b) Although myotonic discharges may be seen in all of these disorders, myotonic dystrophy is the only one with low-amplitude motor units in the distal muscles.

Question 53

A parent of an 18-month-old child reports that the child babbled as an infant but became much quieter after about 8 months of age. She has no true words, though she will wave bye-bye. She follows no verbal commands but will follow occasional pantomime commands. Her gross and fine motor skills have been normal. The most likely diagnosis is (a) autism. (b) mental retardation. (c) hearing impairment. (d) oral motor apraxia.

Answer 53

(c) A history of delay in communication development raises several diagnostic possibilities, including true language dysfunction or a motor dysfunction or significant hearing loss. Infants with hearing loss start to fall behind after 6-8 months of age, when learning of auditory-dependent vocalization begins. Oral motor dysfunction is often associated with cerebral palsy, most often spastic quadriparesis. Difficulty with drinking from a cup and difficulty with the introduction of solid food are early symptoms of oral motor dysfunction. Autism is a spectrum disorder with qualitative abnormalities in communication and in social and behavioral realms.

Question 54

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 54

(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 55

What is your recommended treatment of a T11 compression fracture in a 72-year-old woman? (a) She should be referred to an orthopedic surgeon for immediate fusion because of the risk of neurologic compromise. (b) Neurologic compromise should be ruled out by physical examination, and the patient should be sent home with reassurance that “time will heal this.” (c) Neurologic compromise should be ruled out, and the patient should be given an appropriate pain medication to provide adequate relief. (d) To prevent neurologic compromise, the patient should be placed in a spinal orthosis.

Answer 55

(c) Fusion of the compression fracture is not indicated unless there is evidence of instability and neurologic compromise. A thorough neurologic examination should be performed, and the patient should be given appropriate pain medication, including opioids as indicated, for adequate relief. This compression fracture pain will resolve in 6-8 weeks as the fracture heals. If physical therapy is ordered, flexion exercises should be avoided because they can increase wedging of the fractured body. An extension brace, such as the Jewett brace, may be indicated to provide pain relief, but it will not prevent bony retropulsion and subsequent neurologic compromise.

Question 56

In the orthotic and prosthetic clinic, a patient with Parkinson’s disease presents for gait analysis. The primary gait disturbance found is an alternation in stride length and altered cadence. A gaittraining program for a person with Parkinson’s disease should include (a) visual cueing techniques. (b) bilateral ankle-foot orthoses. (c) patterning techniques. (d) vestibular stimulation exercises.

Answer 56

(a) Treatment options for gait disturbance in patients with Parkinson’s disease include visual and auditory cueing, in addition to traditional endurance and strengthening exercises

Question 57

Which of the following is associated with a good outcome following surgical decompression for spinal stenosis? (a) Leg more than back pain (b) Long duration (more than 4 years) of symptoms (c) Minimal constriction of the spinal canal (d) Multilevel spondylosis and degenerative joint disease

Answer 57

(a) Prognostic factors associated with good surgical outcome following surgical decompression include pronounced constriction of the spinal canal (

Question 58

The primary advantages associated with standing frames and standing wheelchairs for persons with spinal cord injury include (a) reduction in lower extremity edema. (b) reduction in cost to make a workplace accessible. (c) ease in transportation for everyday use. (d) increased bone density in the hips.

Answer 58

(b) Standing wheelchairs are often used as second wheelchairs for a particular activity or vocation. Although their weight has been reduced over the years, they still weigh at least 50lb, which continues to be the main factor precluding their use in everyday mobility. Third-party payors and departments of rehabilitation services have funded standing wheelchairs for persons returning to careers; this can reduce the modifications and costs necessary to make a workplace accessible. Physiologic benefits include decreased spasticity, a reduction in urinary tract infections, and a 7 reduction in pressure ulcers. One issue noted is that most standing wheelchairs do not come to a full 90° position because of instability, which may limit a person’s reach. Problems reported by users include ankle instability and lower extremity edema.

Question 59

Patients with head and neck malignancies who are receiving radiation therapy should be instructed that cervical range-of-motion activities should be (a) initiated only when radiation sessions have been completed. (b) performed throughout the course of radiation therapy to prevent contracture. (c) limited to movement planes contralateral to the involved side. (d) initiated no sooner than 1 month after radiation therapy.

Answer 59

(b) Radiation therapy causes rapid and potentially irreversible fibrosis of muscle and other soft tissue structures. In order to mitigate the inevitable fibrosis that attends high-dose external-beam radiation therapy delivered to patients with head and neck cancer, cervical range-of-motion exercises should begin at the outset of radiation and be continued through the entire course.

Question 60

The most significant factor contributing to upper limb cumulative trauma disorders is (a) size of the equipment used. (b) age of the person. (c) macrotrauma to the area. (d) repeated forceful exertions.

Answer 60

(d) Upper limb cumulative trauma disorders, especially those involving the hand and wrist, most often result from repetitive forceful exertions.

Question 61

Dorsal ulnar cutaneous nerve conduction studies are most useful in differentiating (a) ulnar neuropathy at the elbow from lower trunk plexopathy. (b) ulnar neuropathy at the elbow from ulnar neuropathy at the wrist. (c) lower trunk plexopathy from medial cord plexopathy. (d) ulnar neuropathy at the cubital tunnel from ulnar neuropathy at the ulnar groove.

Answer 61

(b) The fibers of the dorsal ulnar cutaneous nerve travel in the lower trunk and the medial cord of the brachial plexus. This nerve travels with the ulnar nerve to the forearm, where it branches off proximal to the wrist and supplies sensation to the ulnar aspect of the dorsum of the hand and wrist. The dorsal ulnar cutaneous sensory nerve action potential amplitude could be decreased with a lesion of the lower trunk, the medial cord, or the ulnar nerve at the elbow or proximal forearm, and would not be useful in differentiating among them. It should be normal in ulnar neuropathy at the wrist.

Question 62

A 33-year-old female homemaker presents with pain in the area of the left “anatomic snuff box” for the last 2 weeks. She has been knitting a blanket for her pregnant sister, and she reports that the pain has significantly increased since she began this project. On examination, she has exquisite tenderness to palpation at the site of the snuff box. There is no erythema, but mild swelling is noted in the painful area. Which of the following statements is true about the patient’s condition? (a) The inflamed tendon sheath should be injected with a corticosteroid and her hand placed in a resting splint. (b) The tendons most likely to be involved are the abductor pollicis brevis and the extensor pollicis brevis. (c) This condition is so severe that it warrants referral to a hand surgeon. (d) She will have a negative Finkelstein’s test.

Answer 62

(a) These symptoms are consistent with stenosing tenosynovitis, commonly referred to as de Quervain's tenosynovitis. The patient should have tenderness over the common tendon sheath for the abductor pollicis longus and the extensor pollicis brevis. Finkelstein's test is confirmative of this diagnosis. It consists of flexing the thumb under cupped fingers and flexing the wrist in an ulnar direction, stretching the thumb tendons. This condition usually responds to conservative management of steroid injection and placement in a splint. Severe refractory cases may require surgical release, but not until at least a month of conservative therapy has been tried.

Question 63

Characteristic x-ray findings of new bone formation in heterotopic ossification include densities that are (a) noncircumscribed, extra-articular, and extracapsular. (b) noncircumscribed, extra-articular, and intracapsular. (c) circumscribed, extra-articular, and extracapsular. (d) circumscribed, intra-articular, and intracapsular.

Answer 63

(a) Typically, heterotopic ossification occurs in the more proximal joints. X-ray findings are a “popcorn” appearance of fluffy (noncircumscribed), immature bone, extracapsular and extraarticular.

Question 64

``` The most successful treatment for adolescent idiopathic scoliosis with an upper thoracic spinal curve of 30( is (a) electrical stimulation. (b) physical therapy. (c) observation. (d) Milwaukee brace for 23 hours daily. ```

Answer 64

(d) A meta-analysis of 1910 patients with adolescent idiopathic scoliosis evaluated the effects of observation, electrical stimulation, and bracing. Of the six brace types used, the highest success was seen with the Milwaukee brace. Bracing for 23 hours was significantly more successful than any other treatment.

Question 65

A 70-year-old man with first-degree heart block presents with a painful distal sensory neuropathy. Of the following, the most appropriate initial treatment is (a) fluoxetine. (b) gabapentin. (c) oxycodone. (d) trazodone.

Answer 65

(b) Tricyclic antidepressants such as amitriptyline and nortriptyline have traditionally been the initial drug sof choice but can lead to cardiac conduction block. Newer anticonvulsants such as gabapentin are becoming the preferred treatment. Although selective serotonin reuptake inhibitors such as fluoxetine can improve depression associated with chronic pain, they have not been shown to have a direct effect on reducing neuropathic pain. Trazodone has not been shown efficacious in the treatment of painful neuropathies. Long-acting narcotics are increasingly being used when other agents fail to adequately control pain.

Question 66

You have been following a person with a T4 spinal cord injury for 20 years. He is now 38, and he presents with recent onset of frequent episodes of incontinence between catheterizations. His intermittent catheterization volumes have increased to 600mL every 4-6 hours (they had been 300mL). He acknowledges an increase in his fluid intake, which he feels accounts for the increased volumes. Your first priority is to order (a) a blood glucose level. (b) a urodynamic study. (c) a basic metabolic panel. (d) a prostate-specific antigen test.

Answer 66

(a) Polydipsia and polyuria are strong indicators of new-onset diabetes. Diabetes is more common in the spinal cord injured person than in the uninjured population. Although the differential diagnosis may include detrusor hyperreflexia or urinary tract infection, this would not provide a reason for the new high catheterization volumes in this person with chronic spinal cord injury. Evaluation for diabetes should be done immediately.

Question 67

In general, the risk of fracture is lower for blastic metastases than for lytic metastases. Which one of the following tumors tends to form blastic metastases? (a) Lung (b) Multiple myeloma (c) Prostate (d) Renal cel

Answer 67

(c) In general, lytic lesions are considered more prone to fracture, although blastic lesions are not immune to fracture. Lytic lesions typically occur with primary or metastatic lesions of the following malignancies: breast, lung, kidney, thyroid, gastrointestinal tumors, neuroblastoma, lymphoma, and melanoma. Prostate cancer tends to form blastic metastases.

Question 68

A 23-year-old painter is recovering from a rotator cuff injury after falling off a ladder. His impairment would be influenced by (a) the physical demands of his job. (b) how he injured the shoulder. (c) the treatment required. (d) the extent of limitation of shoulder range of motion.

Answer 68

(d) Impairment ratings are based on physical examination findings such as joint limitations and muscle atrophy and function loss.

Question 69

The most severe form of mental retardation in cerebral palsy occurs in association with (a) spastic diplegia. (b) ataxia. (c) spastic quadriplegia. (d) athetosis.

Answer 69

(c) Mental retardation is the most common serious associated disability in cerebral palsy. The overall incidence of mental retardation is approximately 30%-50%. Severe mental retardation is present in about one-half of the retarded group. Approximately one-third of cases have mild cognitive deficits. The greatest retardation is seen in rigid, atonic, and severe spastic quadriplegic cerebral palsy.

Question 70

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 70

(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 71

A 39-year-old mail sorter complains of severe right elbow pain for 6 months. He has tried antiinflammatory drugs without relief. He denies numbness, but does report weakness in his grip. On examination, the patient has severe pain with palpation just inferior to the lateral epicondyle. The best plan for treating the patient’s condition will include (a) medical retirement because this condition is resistant to all forms of therapy. (b) exercise consisting of wrist extensor strengthening and positioning the elbow at 90( flexion and also full extension. (c) corticosteroid injection into the elbow joint. (d) surgical release of the extensor carpi ulnaris tendon to allow the wrist unresisted radial deviation.

Answer 71

(b) This condition can be treated with the use of ice after activity and ultrasound to the inflamed area at the lateral epicondyle. Steroid and local anesthetic injection into the tendinous insertion can be useful for temporary relief. A lateral epicondyle counterforce brace ("tennis elbow" band) can provide relative rest for the inflamed extensor tendons. Exercise using light weights to strengthen the wrist extensors is useful. This should be done with the elbow flexed and in full extension. If surgical release is indicated, lateral extensor release is considered to be the procedure of choice.

Question 72

The most common neurologic disturbance associated with cranial irradiation is (a) short-term memory deficit. (b) anomia. (c) bradykinesia. (d) high-frequency hearing loss

Answer 72

(a) Cranial irradiation typically has more side effects in children than in adults. Common side effects include short-term memory loss, fatigue, and occasional gait apraxia.

Question 73

A 7-year-old boy is referred for evaluation and management of gradually progressive pain located in the right medial thigh and knee, a limp, and limited painful hip motion. There was a similar episode 3 months before which resolved spontaneously. Of the following conditions, the most likely diagnosis is (a) congenital hip dysplasia. (b) slipped capital femoral epiphysis. (c) Legg-Calvé-Perthes disease. (d) epiphyseal fracture.

Answer 73

(c) Legg-Calvé-Perthes disease, avascular necrosis of the femoral head, occurs most commonly in boys between the ages of 4 and 8 years. It is characterized by medial thigh, groin, and knee pain, is associated with a limp, and is often preceded by a transient episode of hip synovitis. Congenital hip displasia is usually apparent much earlier; slipped capital femoral epiphysis occurs during periods of rapid growth, typically in adolescent boys, and may be preceded by trauma.

Question 74

``` 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 74

(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 75

Abrupt withdrawal of which of the following medications is most likely to result in death? (a) tizanidine 8mg qid (b) diazepam 15mg qid (c) dantrolene 50mg qid (d) baclofen 40mg qid

Answer 75

(b) Symptoms of withdrawal from high-dose diazepam (>40mg/day) include anxiety and agitation, restlessness, tremor, muscle faspinal cord injuryculation, hypersensitivity to touch, taste, smell, light, and sound, hyperpyrexia, psychosis, and possibly death. The intensity of symptoms, and hence the risk of death, is related to the prewithdrawal dose.

Question 76

many METs? (a) 2 (b) 5 (c) 10 (d) 15

Answer 76

(b) In males, the energy cost of sexual activity with a married partner does not typically exceed 5 METs and is lowest in familiar positions.

Question 77

You are providing testimony in a worker’s compensation case. Of the following tests which, would provide the most objective evidence for a lumbar radiculopathy? (a) Straight leg raise (b) Pin prick sensory examination (c) Electromyogram (d) Magnetic resonance imaging of the lumbar spine

Answer 77

(c) Of the choices provided, electromyogram/nerve conduction velocity testing would provide the most objective documentation of radiculopathy. Magnetic resonance imaging is an anatomic test. Straight leg raising and findings of manual strength of 4/5 provide more subjective information.

Question 78

gelombang paku awalna berjarak 8 ms, lama2 merapat dan amplitudo memendek. total gelombang 120 ms. The potentials above are (a) complex repetitive discharges. (b) myotonic discharges. (c) neuromyotonia. (d) myokymia.

Answer 78

(b) The potentials noted are single-fiber discharges waxing and waning in frequency and amplitude. This is characteristic of myotonic discharges.

Question 79

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 79

(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 80

A 21-year-old US Army recruit reports to boot camp. After 5 days of marching, he reports to the base physiatrist with complaints of severe pain in his left shin. He states that the pain began after a 10-mile run in full gear that morning. The pain has gotten significantly worse over the last 2 hours. He is now unable to bear weight on his left leg. On examination, his left shin is shiny and edematous. He has severe pain with palpation, and the muscles seem tight. You are suspicious that this man has (a) a severe muscle strain in the tibialis anterior. (b) a muscle contusion due to a fall while running. (c) an anterior leg compartment syndrome. (d) a stress fracture in the left tibia

Answer 80

(c) This patient has been performing excessive, unaccustomed, intense exercise. He is at risk for a compartment syndrome, which occurs when perfusion of muscle and nerve tissues decreases to a level inadequate to sustain the viability of the tissues. The intracompartmental pressure increases and produces venous obstruction. This in turn increases the intracompartmental pressures even more, and necrosis of muscle and nerve tissue may ensue in as little as 4-8 hours.

Question 81

A 58-year-old man with Parkinson’s disease has been on stable levodopa therapy for 2 years. He is beginning to show signs of the “on-off” phenomenon. Your initial treatment considerations would be (a) referring him to neurosurgery for ablation. (b) reducing levodopa dosing intervals. (c) increasing dietary protein intake. (d) adding an anticholinergic agent.

Answer 81

(b) Motor fluctuations that occur in Parkinson’s disease can be related to levodopa therapy. A proposed mechanism is degeneration of presynaptic dopaminergic (DA) nerve terminals, altered DA receptor sensitivity, or associated fluctuations in non-DA neurotransmitter systems. Best initial approaches to treatment are to decrease dosing intervals, decrease protein load (give levodopa 1-2 hours before meals) to reduce amino acid binding competition, and/or adding a dopamine agonist. Using an anticholinergic agent will have little effect on completing this “on-off” problem.

Question 82

A 60-year-old man, on postoperative day 4 after total hip arthroplasty, experiences acute pain, redness, and swelling of the first metatarsophalangeal joint. He has had similar episodes in the past. You recommend (a) warfarin. (b) allopurinol. (c) colchicine. (d) dicloxacillin.

Answer 82

(c) Postoperative patients are at risk for acute exacerbations of gout. Oral colchicine is the standard therapy for acute gout. Allopurinol is indicated for the prevention of gout flares in patients with frequent (less than every 9 months) attacks and is contraindicated in the acute phase. Low-dose aspirin can precipitate an acute attack. The clinical vignette is not consistent with infection or deep vein thrombosis.

Question 83

``` Recommended therapeutic interventions in orthostatic hypotension due to autonomic neuropathy include (a) amitriptyline use at bed time. (b) sleeping in a head-down position. (c) use of oral corticosteroids. (d) avoidance of postprandial exercise ```

Answer 83

(d) Aerobic exercise programs carry the risk of exercise-induced vasodilation and worsening of the hypotension. This is more likely after meals, when hypotension is often exacerbated because of blood pooling in the gastrointestinal vasculature. Other interventions include constrictive garments, dietary modifications (high-salt diet or supplemental salt tablets), and sleeping with the head of the bed elevated to reduce early morning symptoms. Fludrocortisone (Florinef) is the most commonly used drug treatment; it works by sensitizing blood vessels to endogenous catecholamines and expanding the blood volume. Prostaglandin inhibitors such as indomethacin and ibuprofen are reported to be useful, especially for postprandial exacerbations of hypotension.

Question 84

``` Elevated plasma levels of this substance have been determined to be a risk factor for atherosclerosis. (a) High-density lipoprotein cholesterol (b) Vitamin E (c) Homocysteine (d) Vitamin C ```

Answer 84

(c) Elevated plasma level of homocysteine is a risk factor for atherosclerosis. Antioxidants such as vitamin E may potentially have a protective effect. Likewise, the benefits of high-densitylipoprotein cholesterol are well defined.

Question 85

A 62-year-old stevedore describes experiencing abrupt-onset shoulder pain after lifting a bale. He has a positive drop arm test and difficulty with overhead reaching activities. He requests magnetic resonance imaging (MRI) of his shoulder. You tell him that (a) a rotator cuff tear is unlikely and MRI is not indicated. (b) a rotator cuff tear is unlikely and MRI would be a very sensitive and specific test. (c) a rotator cuff tear is likely and MRI will probably be abnormal. (d) a rotator cuff tear is likely and MRI will probably be normal.

Answer 85

(c) Magnetic resonance imaging can identify a large percentage of tears on the rotator cuff of asymptomatic persons. These tears may be partial or complete. The overall prevalence of asymptomatic tears of the rotator cuff in all groups was 34%. Fifty-four percent of persons over age 60 had a tear of the rotator cuff (28% full thickness, 26% partial thickness).

Question 86

Comparing the results of electrodiagnostic studies on patients with clinical evidence of postpolio syndrome and the results of those obtained in persons with a history of polio of similar severity and duration since polio onset but no clinical evidence of postpolio syndrome, you find (a) smaller motor units in the symptomatic group. (b) more polyphasic motor units in the symptomatic group. (c) more fasciculations in the symptomatic group. (d) no significant differences between the groups.

Answer 86

(d) There are no significant differences between the groups. Electrodiagnostic studies are not performed to confirm the diagnosis of postpolio syndrome; this is a clinical diagnosis. They are performed to rule out other disorders in the differential diagnosis.

Question 87

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 87

(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 88

Which of the following statements about rupture of the bicipital tendon is true? (a) Significant deficit in supination strength is usually associated with this condition. (b) Rupture of this tendon requires surgical repair to maintain functional strength in the biceps. (c) The tear occurs most commonly in the short head of the biceps and results in only a cosmetic deformity. (d) Tears most often occur in persons with long-standing shoulder impingement pain.

Answer 88

(d) Rupture of the long head of the biceps most often occurs in persons over 40 years of age with longstanding shoulder pain due to rotator cuff pathology. It may result in approximately 10% loss of supination in turning the forearm. It does result in a cosmetic deformity with a bulge in the lower arm, but most patients regain full range of motion and normal elbow flexion strength with a conservative therapy program. Usually only heavy laborers under age 40 need surgical intervention to provide the extra strength for lifting.

Question 89

A 22-year-old man with a severe brain injury has repeated episodes of inappropriate sexual touching of female staff. An initial treatment option for decreasing this behavior would include (a) assigning only male staff. (b) precribing clomipramine (Anafranil) 25 mg BID. (c) using of soft hand restraints for 3 minutes. (d) offering firm verbal discouragement.

Answer 89

(d) Inappropriate sexual touching occurs more commonly in patients with a history of frontal lobe damage. Treatment is best directed at staff education to make certain all team members are consistent in responses. Behavior modification is directed at telling the patient his behavior is wrong and firmly taking his hand and putting it closer to his person. Restraints are only indicated as temporary solutions to prevent acute bodily injury.

Question 90

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 90

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

Question 91

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 91

(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 92

134. Foot ulcers in patients with diabetes (a) are frequently associated with plantar foot callus. (b) commonly occur even with clinically asymptomatic neuropathy. (c) are most frequently located over the malleolus. (d) are more common when subtalar hypermobility exists.

Answer 92

(a) Neuropathic ulcers typically occur in patients with impaired or absent sensation due to peripheral neuropathy. Plantar callus formation is indicative of excessive pressure and is a common site of ulcer formation. Ulcers most commonly occur under the metatarsal heads and toes and along the lateral borders of the forefoot. Rigidity of the subtalar and ankle joints adversely alters plantar pressures and increases the risk of ulceration. Changes in joint motion are the result of increased glycosylation of collagen and associated thickening and cross linking of collagen bundles seen in diabetes.

Question 93

During an independent medical examination, maximum medical improvement is defined by (a) the original symptoms having resolved. (b) expected improvement on functional gains having occurred. (c) the patient having returned to employment. (d) a period of 12 months having elapsed since the injury.

Answer 93

(b) When expected improvement on functional gains has occurred, a patient has reached maximum medical improvement.

Question 94

In testing a patient with suspected myasthenia gravis, needle electromyography (EMG) of the right upper extremity and orbicularis oculi is normal. Repetitive stimulation of the right ulnar nerve at a rate of 2/second shows no decrement before or immediately after 1 minute of exercise. A 4% decrement is noted 2 minutes after exercise. Your next electrodiagnostic step should be (a) EMG of the lower extremities. (b) EMG of the frontalis before and after edrophonium (Tensilon). (c) repetitive stimulation of recording from a proximal muscle. (d) ulnar somatosensory evoked potentials.

Answer 94

(c) In patients with myasthenia gravis, repetitive nerve studies recorded from proximal muscles are more sensitive, though technically more difficult.

Question 95

Following severe traumatic brain injury, neuroendocrine dysfunction can result in diabetes insipidus, SIADH (syndrome of inappropriate antidiuretic hormone), and cerebral salt wasting. Cerebral salt wasting is manifested by (a) hypernatremia. (b) low serum osmolality. (c) high urine output. (d) dehydration.

Answer 95

(d) Diabetes insipidus is characterized by excessive water loss, and therefore affected patients experience hypernatremia, dehydration, polyuria, and polydipsia. SIADH is associated with decreased urine output, hyponatremia, and a decreased serum osmolarity. Cerebral salt wasting is a result of a neural effect on the renal tubules, causing loss of sodium and water and resulting in hyponatremia and dehydration

Question 96

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 96

(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 97

Risk factors for the development of Alzheimer’s disease include advancing age, family history, presence of the gene APO E-4, and which of the following? (a) low intelligence. (b) large head circumference. (c) male gender. (d) co-morbidity with diabetes mellitus.

Answer 97

(a) It is important to recognize these historical and clinical characteristics acting as risk factors in the development of Alzheimer’s disease. It has been shown that lower intelligence, female gender, and smaller head size are all associated with increased risk. Diabetes mellitus affects cerebral vasculature and increases the risk of vascular dementia, not Alzheimer’s disease.

Question 98

The American College of Rheumatology (ACR) criteria for fibromyalgia include all of the following EXCEPT (a) widespread pain. (b) nonrestorative sleep. (c) at least 11 of 18 tender points. (d) symptom duration of at least 3 months

Answer 98

(b) The ACR criteria for fibromyalgia include the presence of widespread pain (both sides of the body, above and below the waist) for at least 3 months and tenderness at 11 of 18 points. Disturbed sleep, fatigue, various neurologic symptoms, and gastrointestinal complaints are common but not part of the criteria. A complete history and physical is usually adequate to make the diagnosis; screening laboratory testing should exclude hypothyroidism, connective tissue diseases (such as polymyalgia rheumatica or rheumatoid arthritis), and metabolic myopathies. Treatment involves restoration of sleep, reduction of psychologic variables (such as stress and depression), physical conditioning, stretching, and postural training. Nonsteroidal anti-inflammatory drugs, muscle relaxants, narcotics, and passive modalities are not useful and their use should be minimized.

Question 99

Following a head injury, a 35-year-old woman presents with vertigo. She reports a sensation of spinning beginning several seconds after standing up rapidly, bending over, or rolling in bed. Symptoms lasts for approximately 30 seconds. Exam is notable for nystagmus during episodes of vertigo, normal extremity coordination, and minimal increase in sway during Romberg testing. The most likely diagnosis is (a) benign positional vertigo. (b) cerebellar contusion. (c) unilateral vestibular paresis. (d) bilateral vestibular paresis.

Answer 99

(a) The symptoms are most consistent with benign positional vertigo, a disorder characterized by 11 transient episodes of vertigo precipitated by changes in the position of the head.The underlying etiology is thought to be related to movement of otoliths or otolithic debris within the semicircular canals. It commonly occurs following head injury or viral labyrinthitis. Treatment involves a specific otolith repositioning maneuver or a series of habituation exercises.

Question 100

Women who have sustained a spinal cord injury and become pregnant after injury are noted to have pregnancy-related complications including (a) high-birth-weight babies. (b) late-onset labor. (c) pressure sores. (d) higher than average spontaneous abortions.

Answer 100

(c) Women who become pregnant after sustaining a spinal cord injury undergo spontaneous abortions in the first trimester at the same rate as uninjured women; however, the incidence of premature and small-for-date babies is higher than normal. In addition, the spinal-cord-injured woman is known to have pregnancy-related complications such as urinary tract infections and pressure sores.

Question 101

``` Noninvasive nocturnal assisted ventilation in patients with neuromuscular disease has been associated with (a) increased polycythemia. (b) accelerated pulmonary hypertension. (c) decreased daytime PaCO2. (d) increased daytime fatigue. ```

Answer 101

(c) Assisted ventilation should be considered in pulmonary involvement from neuromuscular disease. Alternative measures such as low-flow oxygen may exacerbate hypercapnia.

Question 102

Lumbar intradiscal pressure is lowest when a person (a) stands erect. (b) sits. (c) stands with hips flexed. (d) lies prone.

Answer 102

(d) Intradiscal pressure is lowest when a person lies prone and is much higher when standing, running, sitting, or bending.

Question 103

In evaluating a hypotonic infant with electromyography you find low-amplitude, short-duration motor units with early recruitment. Based on these findings, the LEAST likely diagnosis would be (a) central core disease. (b) nemaline myopathy. (c) type II glycogenosis (acid maltase deficiency). (d) infantile spinal muscular atrophy.

Answer 103

(d) The motor unit changes noted are typically seen in myopathies. Spinal muscular atrophy is an anterior horn cell disease.

Question 104

In traumatic brain injury in children, outcome is primarily related to (a) severity of original injury. (b) location of injury. (c) age at time of injury. (d) associated injuries.

Answer 104

(a) Although there is considerable variability from case to case, outcome is primarily related to the severity of the injury.

Question 105

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 105

(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.