SAER 2003 Flashcards
A 61-year-old woman reports tingling in the posterior aspect of her upper arm, forearm and hand. She has no history of trauma and radiographs are negative. Her physician has ruled out a cervical
radiculopathy by electrodiagnostic studies, magnetic resonance imaging, and physical examination. The physician is suspicious that the cause of the patient’s paresthesias is myofascial in nature. Which finding would be consistent with myofascial pain?
(a) Positive sharp waves on electromyography at rest in trigger points
(b) Reproduction of symptoms with palpation over the trigger point
(c) Elevated serum creatine phosphokinase associated with prolonged muscle activity
(d) Resolution of symptoms with isokinetic exercise of the affected muscle
(b) Moderate, sustained pressure on an irritable trigger point causes symptoms in the reference zone for
that muscle. Myofascial trigger points are electrically silent and show no resting muscle activity on
EMG. No elevation in CPK is seen with this condition. Local injection and/or spray and stretch of
the muscle are the treatments of choice. Isokinetic exercise is not indicated as a treatment for this
condition.
A 24-year-old man was in a motor vehicle collision 36 hours ago. His initial Glasgow Coma Scale
score was 13 and his initial head computed tomography scan showed a small frontal contusion.
Initial blood alcohol level was .15g/dL. He is currently disoriented, combative, and tachycardic. He
reports visual hallucinations. Management of this case should include
(a) benzodiazepines for alcohol withdrawal.
(b) anticonvulsants for agitation.
(c) neuroleptics to treat hallucinations.
(d) beta-blockers to treat tachycardia.
(a) Premorbid alcohol abuse is commonly seen in people sustaining brain injury and alcohol
withdrawal causes agitation and hallucinations.
What bathroom modification should be made for nonambulatory individuals who have the ability to
transfer themselves in and out of a wheelchair?
(a) Toilet height of 15 inches
(b) Cabinet heights of 36 inches from the floor
(c) Three feet of clear turning space in the bathroom
(d) Separate hot and cold water handle controls
(b) When modifying a bathroom for a person who has the ability to transfer him/herself in and out of a
wheelchair, it is important to design bathroom space for the person’s efficiency, to allow him or her
to be as independent as possible. This includes providing a minimum of 5 feet of clear turning
space and toilets at least 20 inches high (it is reasonable to use a standard height toilet with a raised
toilet seat). Cabinets should be positioned for easy access. In most cases, the bottom of the cabinet
should be 36 inches from the floor. Mirrors also should be positioned so that their bottom edge is 36
inches from the floor. Single-lever type handles should be used for water control. The use of a
single handle control with a lever or blade shape that mixes the water to control and adjusts the
flow is recommended. Temperatures should be set between 110 and a 120 degrees Fahrenheit at the
point of supply so that the delivery temperature will be approximately 105 degrees Fahrenheit. All
hot water feed and drainage pipes should be insulated to prevent scalding.
A head and neck cancer patient completed external beam radiation therapy 1 week ago. You inform
the patient that prevention of cervical soft tissue contractures requires daily cervical range-of-motion
exercises for at least
(a) 1 month.
(b) 6 months.
(c) 1 year.
(d) 5 years.
(d) The late effects of external beam radiation therapy can continue for at least 5 years. Fibrosis of
fascia, skin, and muscles following radiation therapy is mediated by radiation-induced
microvascular injury. Daily cervical range-of -motion exercises should be performed for at least 5
years after completion of treatment to insure that progressive fibrosis does not occur.
Which finding on your history and physical examination of an injured worker with low back pain
would require immediate intervention?
(a) Pain radiating into the posterior thigh
(b) Pain that awakens the worker at night
(c) Paresthesias in the great toe
(d) Ankle weakness only with long-distance walking
(b) Pain that awakens the worker at night may indicate a serious etiology including tumor or infection.
Radicular pain, paresthesias, and weakness with fatigue may also present with serious as well as
common causes such as disc herniations and spinal stenosis. The latter may help direct the
diagnosis. However, pain worse at night should alert the treating physician to evaluate more serious
etiology without delay.
Which radial innervated muscle is innervated by the C5 root?
(a) Anconeus
(b) Extensor carpi radialis longus
(c) Brachioradialis
(d) Triceps
(c) None of the other muscles listed receives C5 innervation. The supinator is the only other radial
innervated muscle that has C5 innervation.
In children with spastic cerebral palsy, which intervention strengthens weak muscles?
(a) Ankle-foot orthotics
(b) Tendon transfer surgery
(c) Intrathecal baclofen
(d) Functional training program
(d) Children with cerebral palsy often have weakness as part of their disorder. Treatments such as
bracing, tendon lengthening or transfers, and medications such as botulinum toxin or intrathecal
baclofen add to this weakness. Strengthening programs or functional training programs can help to
strengthen weak muscles.
Shoulder pain in the hemiparetic shoulder due to cerebrovascular accident
(a) is commonly due to formation of heterotopic ossification in the glenohumeral joint.
(b) occurs more frequently in flaccid hemiplegia than in spastic hemiplegia.
(c) results in complex regional pain syndrome in up to 10%–15% of patients.
(d) is best treated with rest and immobilization in a sling while in bed.
(c) Complex regional pain syndrome is present in up to 10%–15% of patients with stroke and shoulder
pain. This condition has also been called shoulder-hand syndrome and reflex sympathetic
dystrophy. Heterotopic ossification may occur in the elbow or shoulder joint following CVA, but it
is uncommon. Shoulder pain associated with hemiparesis or hemiplegia due to stroke is more often
associated with spastic hemiparesis than with flaccid hemiparesis. Gentle, passive range of motion
exercises should be started early. Proper positioning should begin early as well. Abduction and
external rotation is the position of choice while the patient is in bed. A sling should not be used in
bed.
What is the most common form of arthritis in adults?
(a) Crystal arthritis
(b) Septic arthritis
(c) Osteoarthritis
(d) Rheumatoid arthritis
(c) Osteoarthritis is the most common form of arthritis.
A 59-year-old man admitted with atypical chest pain underwent an angiogram 2 days ago. He is now
having difficulty walking. Physical examination demonstrates 2/5 strength in right hip flexion and
knee extension. Muscle strength is otherwise 5/5. Sensation is decreased over the medial distal right
leg. What initial diagnostic test would be most appropriate?
(a) Electromyogram and nerve conduction velocities
(b) Magnetic resonance imaging of the lumbosacral spine
(c) Computed tomography scan of the pelvis
(d) Ultrasound of the abdomen
(c) The most likely pathology is the involvement of the femoral nerve secondary to hemorrhage. In
this situation imaging studies should be done promptly to assess for a hematoma or a mass.
Electrodiagnostic studies are useful to confirm the presence of femoral nerve involvement, but one
should wait 3–4 weeks postinjury.
What function is expected in an individual with a C7 ASIA class A spinal cord injury?
(a) Need assistance to perform level transfers
(b) Pressure reliefs primarily by side-to-side weight shift
(c) Independence in bowel and bladder management
(d) Independent dressing and bathing with adaptive equipment
(d) For persons with motor level C5, activities of daily living include drinking from a cup and feeding
with static spoons and set-up, some oral/facial hygiene, writing and typing with equipment, and
possibly some upper-body dressing. At the C6 injury level, individuals are able to feed and perform
upper body dressing with set-up and can perform level surface transfers with assistance. Persons
with motor level C7 ASIA class A should be able to independently feed, dress, and bathe
themselves, using adaptive equipment and built up utensils. They should be independent with bed
mobility, and level surface transfers and should be able to propel a wheelchair outdoors.
Independence in bowel and bladder function is generally seen with injury at level T1 and lower.
During discussion with the parents of a 2-year-old leukemic patient, you inform them that significant
brain irradiation almost uniformly produces
(a) attention deficits.
(b) focal motor weakness.
(c) ataxia.
(d) anosmia.
(a) An adverse sequela of intensive pediatric anticancer therapy is learning difficulty. Impaired
learning can exert a deleterious long-term impact. Whole brain irradiation for leukemic prophylaxis
results in enlarged cerebral sulci and ventriculomegaly on cranial imaging.Clinical
symptomatology roughly correlates with scan findings. Virtually all patients in whom a substantial
portion of the brain is radiated complain of memory loss and attentional deficits.
Why is it important to ask the injured worker if he/she is involved in litigation against the
workplace?
(a) It allows the physician to deny seeing the patient to avoid a deposition.
(b) It is not an appropriate question for the physician to ask.
(c) Workers with attorneys involved are less likely to return to work.
(d) The employer will be more cooperative in facilitating return to work.
(c) Several studies have found a strong relationship between attorney involvement and not returning to
work. In workman’s compensation cases involving lawyers, 73% of injured workers did not return
to work. In cases without lawyer involvement, 32% did not return to work. These factors are
important for the physician to know initially to best understand the psychosocial barriers involved
in treating the injured worker.
Which myopathy is most likely to demonstrate a “normal” EMG?
(a) Myotonic dystrophy
(b) Polymyositis
(c) Steroid myopathy
(d) Duchenne muscular dystrophy
(c) In steroid myopathy the only abnormalities are atrophy of the type II fibers. Since these fibers are
recruited last, when the screen is full of motor units, it is usually difficult to appreciate subtle
amplitude changes. The other myopathies noted typically may exhibit positive waves and
fibrillations with motor unit changes in the type I fibers.
One of your 4-year-old patients exhibits the following characteristics: distress over minor changes in
environment, echolalia, lack of awareness of the existence of feelings in others, nonparticipation in
simple games. The most likely diagnosis is
(a) autism.
(b) cerebral palsy.
(c) hearing impairment.
(d) mental retardation.
(a) Autism is characterized by echolalia, inability to play reciprocally, and abnormal relationships with
people. While children with mental retardation, cerebral palsy, and hearing impairment may have
some of these features, they do not have all of them in the absence of autism.
After aspirating 10cc of cloudy fluid from a patients knee, you find a white blood cell count of
20,000/cc, with intracellular, negatively birefringent rod-shaped structures under the polarized light
microscope. Your diagnosis is
(a) septic arthritis.
(b) gout.
(c) pseudo-gout.
(d) anterior cruciate ligament tear.
(b) A septic joint would reveal a white blood cell count greater than 50,000/cc, pseudogout has
positive-birefringent crystals, an anterior cruciate ligament tear would reveal a bloody aspirate.
Urate crystals from gout are negatively birefringent, needle- or rod-shaped crystals that can be
intracellular.
A 17-year-old boy from India presents with a longstanding history of areflexia and asymmetric
muscular atrophy after a febrile illness as a child. The likeliest site of neurologic pathology is
(a) myelin sheath of peripheral nerves.
(b) axons of peripheral nerves.
(c) anterior horn cells.
(d) muscle membrane.
(c) Poliomyelitis involves the anterior horn cells. During an acute infection, the virus is transported to
the anterior horn cells followed by inflammation and loss of spinal and bulbar motor neurons.
Regarding spinal shock in acute spinal cord injury,
(a) duration of spinal shock is correlated with long term outcome.
(b) reflex activity typically returns over the course of days.
(c) a reliable ASIA classification can be performed during spinal shock.
(d) it is more common in tetraplegia than in paraplegia.
(c) Spinal shock is a condition in which upper motor neuron sensory motor loss is associated with
areflexia below the level of injury. It is a poorly defined phenomenon. Reflex activity can often be
detected by electrophysiologic study when it is not clinically apparent. Reflex activity typically
returns over the course of weeks or months. The presence of spinal shock is of marginal prognostic
significance. A reliable ASIA classification can be carried out when spinal shock is present.
Which situation is associated with good treatment outcome in the injured worker?
(a) Poor evaluation by the employer within the past 6 months
(b) The employee works in middle management
(c) The employee received a recent increase in salary
(d) Communication between the worker and supervisor is empathetic
(d) Good treatment outcome is associated with a history of personal empathetic communication
between the supervisor and injured employee. No data show improved outcomes in injured workers
who have recently received a raise or have worked for the employer more than 5 years. Poor
outcomes have been found in injured workers who have received a poor evaluation within the 6
months preceding the injury. The level of position within the workplace is irrelevant in a worker’s
compensation outcome.
Which electrodiagnostic finding is more common in radiation plexopathy than in neoplastic
plexopathy?
(a) Myokymic discharges
(b) Fibrillations
(c) Decreased motor unit recruitment
(d) Decreased amplitude of the sensory nerve action potential
(a) Myokymia is present in 50% of patients who have radiation plexopathy, but is rarely seen in
neoplastic plexopathy. The other findings noted in both plexopathies, but predominate in neither.
Which finding is normal in newborn infants?
(a) Extensor tone predominates
(b) Hands are kept fisted
(c) Spine is straight when held in sitting position
(d) Unable to turn head to side in prone position
(b) In normal newborn infants flexor tone predominates and hands are kept fisted. In prone position a
normal newborn is able to turn the head to either side. The newborn has a rounded spine when
placed in supported sitting.
A 16-year-old male with a right above-knee amputation presents to your clinic to get your opinion on
operating a motor vehicle. You advise him that he would be required to
(a) strengthen his hip extensors.
(b) change the position of the car’s accelerator and brake.
(c) obtain a special driving prosthesis.
(d) install a handbrake on the vehicle’s left floor.
(b) The only situation that applies in this scenario is changing the position of the pedals in order to
operate the vehicle with the left lower limb. Installing a handbrake is reserved for persons with right
upper limb amputations. Other acceptable recommendations could include automatic transmission
and/or hand controls.
Which statement regarding cervical traction is correct?
(a) The best angle of pull is between 10° and 20° of cervical extension.
(b) Its use in patients with rheumatoid arthritis is absolutely contraindicated.
(c) At least 25 pounds of force is necessary to counter the effects of gravity on the head.
(d) With an over-the-door traction unit, the patient should face away from the door to which the
pulley is attached.
(b) Patients with rheumatoid arthritis have ligamentous instability. This can lead to subluxation of
cervical vertebrae, especially at the atlantoaxial joint (C1-2). Because instability can lead to spinal
cord compression, cervical traction is, therefore, absolutely contraindicated in persons with
rheumatoid arthritis. The best angle of pull is between 20° and 30° of flexion. The most common
reason for cervical traction to fail or to exacerbate symptoms is applying the force in extension
rather than in flexion. The home traction unit should always be placed so the patient is facing
toward the door to which the pulley is attached. At least 10 pounds of force is needed to counter the
effects of gravity on the head. To straighten the cervical lordotic curve requires 25 pounds of force.
According to the Hunt and Hess Scale, which grade of subarachnoid hemorrhage would apply to a
patient who presents with moderately severe headache, meningismus, and cranial nerve deficit?
(a) 0
(b) 1
(c) 2
(d) 3
(c) Grade 2 of the Hunt and Hess Scale is moderately severe headache/meningismus, no neurologic
deficit, except cranial nerve palsy.
Mr. Jones comes to your office complaining of a hot, painful, swollen left wrist. Additional findings
on physical examination include swan-neck and boutinierre deformities, subluxation of the
metacarpophalangeal joints with ulnar deviation of the digits. What will x-ray findings of his wrist
reveal?
(a) Chondrocalcinosis of articular cartilage
(b) Severe marginal erosions with juxta-articular osteopenia
(c) Bony erosion with an overhanging edge
(d) Pencil-in-cup deformity
(b) This patient has rheumatoid arthritis which shows juxta-articular osteopenia. Gout characteristically
reveals “overhanging edge” lytic lesions. Chondrocalcinosis is seen in pseudo-gout, and pencil-incup
deformity is seen with psoriatic arthritis.
What is the most common initial manifestation in Parkinson’s disease?
(a) Fatigue
(b) Gait difficulty
(c) Hypophonia
(d) Resting tremor
(d) Resting tremor and bradykinesia are the most common initial manifestations of Parkinson’s disease.
The other signs are less likely to be presenting complaints in parkinsonism.
Which chemotherapeutic agent can produce sensory polyneuropathy?
(a) Paclitaxel (Taxol)
(b) Doxorubicin (Adriamycin)
(c) Cyclophosphamide (Cytoxan)
(d) 5-fluorouracil (5-FU)
(a) The taxanes, docetaxel (Taxotere) and paclitaxel (Taxol), are being used increasingly as first line
chemotherapy for a variety of malignancies including ovarian, breast, and head and neck cancers.
They are associated with a high incidence of sensory polyneuropathy. Fortunately, this often
resolves or is significantly diminished following discontinuation of the agent. However, some
patients continue to experience severe, debilitating neuropathy.
What work-place situation is the most frequent cause of low back pain in workers?
(a) Jobs that result in falls at work
(b) Jobs that require standing for more than 4 hours
(c) Jobs that requires lifting and material handling
(d) Jobs that require sitting more than 2 hours
(c) Jobs that require lifting and material handling place the worker at increased risk for low back
injury. Lifting frequency, load movement, trunk twisting and trunk sagittal angle predict medium
and high-risk occupational low back pain. No risk correlation has been found for length of time
sitting or standing. Although falls in the work place put the worker at risk for low back injury, the
repetitive motion involved in lifting and material handling is thought to cause low back pain more
frequently.
Where do you place the cathode when performing a median motor nerve conduction study, stimulating at the elbow? (a) Lateral to the biceps tendon (b) Medial to the brachial artery (c) Lateral to brachioradialis (d) Medial to brachioradialis
(b) The median nerve is just medial to the brachial artery at the elbow.
The family of your 10-year-old patient who had a severe traumatic brain injury 6 weeks ago asks you
if they may feed their son. You observe that he is agitated at times, has a hoarse voice, and drools.
You try to feed him applesauce and notice that he seems to swallow part of it and does not cough.
The most likely finding on the videofluoroscopic feeding study will be
(a) Silent aspiration.
(b) Reflux.
(c) Coughing and gagging.
(d) Normal swallow.
(a) The lack of coughing in a patient with neurologic impairment when he/she is presented with food
may mean a normal swallow, but is more likely to mean silent aspiration. A normal
videofluoroscopic swallowing study is unlikely in a patient with a traumatic brain injury (TBI) who
is drooling and hoarse. Hoarseness may be a sign of reflux, but in a child with a TBI it is more
likely to mean vocal cord abnormality.
The criterion scale used to describe severity of brain injury is the
(a) Disability Rating Scale.
(b) Agitated Behavior Scale.
(c) FIM™ instrument.
(d) Glasgow Coma Scale.
(d) The criterion to describe the severity of a traumatic brain injury is the Glascow Coma Scale (GCS).
GCS score of 13-15 = mild
GCS score of 9-12 = moderate
GCS score of 3-8 = severe
A 40-year-old woman with a history of irritable bowel syndrome and tension headaches complains of
increasing fatigue and diffuse muscle soreness in her neck, shoulders, and low back. She has a
nonfocal neurologic examination. Initial recommendations should include
(a) craniosacral manipulation.
(b) closed kinetic chain exercises to strengthen the shoulder girdle.
(c) electrical stimulation to the upper and mid back.
(d) walking on a daily basis
(d) Promoting a restorative sleep and 20–30 minutes of aerobic activity daily is recommended to treat
fibromyalgia. Passive modalities are not the optimal therapeutic intervention.
Your patient has a C6 ASIA class A spinal cord injury which he sustained 8 weeks ago. He has been
noncompliant about attending therapy. Today he refuses to participate in therapy because he states
he has a headache. The nurses report poor urine output from the Foley catheter in the last 3 hours.
You order
(a) intravenous bolus of normal saline.
(b) push oral fluids and go to therapy.
(c) replacement of catheter.
(d) visit from peer mentor.
c) Autonomic dysreflexia must be ruled out. A Foley kink, or plugged catheter can distend the
bladder, causing autonomic dysreflexia with headache (and, ultimately, hypertension, piloerection
and flushing). The catheter should be checked for twists and kinks and be flushed. If urine/flush
return is poor, the catheter should be changed.
A patient with squamous cell carcinoma of the larynx elected to undergo organ preservation therapy
with intensive external beam radiation therapy to the anterior neck. He now presents with painless
bilateral lower extremity weakness. Which initial diagnostic test is most likely to be abnormal?
(a) Magnetic resonance imaging of the brain
(b) Nerve conduction studies of the lower extremities
(c) Thyroid stimulating hormone level test
(d) Computed tomography scan of the abdomen
(c) Patients who receive external beam radiation therapy to the anterior neck are at risk for developing
hypothyroidism. If their thyroid function tests are not monitored, they may initially present with
signs and symptoms of hypothyroidism. Myopathy is a common presenting complaint. This patient
is also at risk for radiation induced cervical myelopathy. However, since radiation
hypofractionation techniques have become the standard of care, the incidence of this dreaded
complication has significantly diminished.
Which measure is the first sign of respiratory muscle dysfunction in boys with Duchenne muscular dystrophy? (a) Vital capacity (b) Oxygen saturation (c) Maximal expiratory force (d) Negative inspiratory force
(c) Recent studies by McDonald and by Bach showed that reduction of maximal expiratory force
(MEF) to 40%–60% of normal in the 7- to 14-year-old age group was the first sign of respiratory
muscle dysfunction in boys with Duchenne muscular dystrophy (DMD). The earlier and more
severe decreases of MEF that are greater than the decreases in maximal inspiratory force,
correspond to the clinically observed weakness of abdominal muscles, which like coughing are
important in forced expiration. Vital capacity was not found to decrease until an average of 15–16
years. Low oxygen saturation is a late manifestation in DMD, developing after hypercapnia.
In which circumstance is supracondylar suspension on a transtibial prosthetic socket most indicated?
(a) A 4-centimeter residual limb length below the tibial tubercule
(b) A residual limb with mildly adherent distal scar tissue
(c) A cylindrical-shaped residual limb
(d) A residual limb with poor definition above the femoral condyles
(a) Supracondylar suspension would be most indicated for an individual with a short transtibial residual
limb to provide additional mediolateral support and to increase the weight-bearing surface area for
more even pressure distribution. A cylindrical-shaped transtibial limb is ideal for allowing total
contact between the residual limb and the socket and is not an indication for supracondylar
suspension. Supracondylar suspension is also not specifically indicated for mildly adherent scar
tissue. Supracondylar suspension would be difficult to utilize in a residual limb that has poor
definition above the femoral condyles
A 14-year-old soccer player seen on the day of injury is unable to bear weight on her right foot. On
examination, she has significant swelling and mild ecchymosis laterally. The patient is tender over
the lateral side of her ankle. X-rays are negative. Your initial plan of management should include
(a) a walking cast for 4–6 weeks.
(b) nonsteroidal anti-inflammatory drugs and contrast baths for 48 hours.
(c) an air stirrup for 2 weeks with weight bearing as tolerated.
(d) an ankle brace and non-weight bearing for 3–4 weeks.
(c) This patient has suffered a fairly significant ankle inversion sprain. The lateral collateral ligaments
are injured 85% of the time with this type of injury. This patient should be placed in an air stirrup
for 2 weeks, weight bearing as tolerated, using crutches as needed. A cast or cast boot is acceptable
for 2 weeks but usually is not required. Contrast baths are not indicated before 48 hours following
injury.
(This question has been eliminated from the exam, therefore, it was not scored.)
On a pharmacologic basis, which agent used to decrease gastric acid secretion is most appropriate
after brain injury?
(a) Ranitidine
(b) Famotidine
(c) Omeprazole
(d) Sucralfate
(c) (This question has been eliminated from the exam, therefore, it was not scored.)
Choices a and b are both histamine type-2 (H2) blockers that are cognitively impairing
Which of the following is NOT associated with a Charcot joint?
(a) Diabetes
(b) Syringomyelia
(c) Tabes dorsalis
(d) Rheumatoid arthritis
(d) Destruction of a joint due to loss of nociceptive input describes a Charcot joint.
A 17-year-old person presents with frequent falls and no other complaints. On physical examination
you note unusually high arches, distal lower limb strength of 4/5, and decreased reflexes. The most
appropriate next step in the diagnosis would be
(a) nerve conduction studies.
(b) muscle biopsy.
(c) magnetic resonance imaging of the lumbosacral spine.
(d) serum heavy metal levels.
(a) The clinical picture is suggestive of a polyneuropathy. Patients with hereditary polyneuropathies
may have feet with high arches. Electrodiagnostic studies including nerve conduction studies
remain the most important first tests in the evaluation of polyneuropathy
Regarding the American Spinal Injury Association (ASIA) classification in prognosticating recovery,
(a) ASIA class A has a reasonable probability of improvement if there is no concurrent brain
injury.
(b) preservation of pinprick in ASIA class B carries a better potential for ambulation than
preservation of light touch sensation.
(c) recovery statistics for ASIA class C do not include the central-cord syndrome.
(d) Brown-Séquard’s syndrome has the worst potential for ambulation in ASIA class D.
(b) The presence of sensation in the sacral (S3–S5) dermatomes in patients with motor complete injury
indicates a favorable prognosis in terms of motor recovery, with pinprick sparing having the closest
correlation for motor recovery. Motor segments in the zone of injury in patients with complete
injury and an initial strength of 0/5 were more likely to recovery strength of 3/5 or more at 1 year if
the sensation in the corresponding dermatomes was intact. Most patients originally categorized as
ASIA (or Frankel) class A who progressed to ASIA class D or E had sustained traumatic brain
injury with cognitive impairment and were incorrectly diagnosed initially as class A.
A patient with far advanced prostate cancer metastatic to liver and bone achieves pain control
through the use of a subcutaneous hydromorphone infusion. The therapy is complicated by
significant sedation. You therefore initiate therapy with
(a) Clonidine (Catapres).
(b) Pemoline (Cylert).
(c) Methylphenidate (Ritalin).
(d) Naloxone (Narcan).
(c) Opioid-based pharmacotherapy is the current standard of care for severe cancer-related pain. Side
effect management is an integral dimension of competent pain management. Opioid-induced
sedation can be managed through the use of psychostimulants such as methylphenidate (Ritalin).
Epidural and intrathecal drug delivery can also be used to minimize neuropsychological toxicity.
Pemoline (Cylert), a psychostimulant, is not widely used because of concern over hepatotoxocity,
particularly in patients with liver metastases.
A functional capacity evaluation is required when
(a) the injured worker is ready to return to his/her job.
(b) the worker’s ability to perform work-related activities must be assessed.
(c) an injured worker’s case remains open more than 7 weeks.
(d) the company physician must determine whether the worker is injured.
(b) A functional capacity evaluation (FCE) is an assessment of a worker’s ability to perform workrelated
activities. A functional capacity examination can be used to determine if a worker might
benefit from work hardening or work conditioning, to determine whether a worker can return to
his/her job, to determine if work restrictions are recommended or if job modifications are needed,
and to document the worker’s activity capability. No absolute time line exists. An FCE can be used
in the subacute, or maintenance phase of treatment. An FCE does not determine validity of injury
but can reveal the effort a person expends to perform a task.
A 10-year-old child with L4-5 myelodysplasia and shunted hydrocephalus develops spasticity in her
legs. The most likely cause of this spasticity is
(a) shunt malfunction.
(b) symptomatic Chiari malformation.
(c) growth.
(d) tethered cord.
(d) Tethered cord is the most common cause of new onset spasticity in patients with myelodysplasia.
Linear growth does not cause new spasticity. Symptoms of Chiari malformation include cranial
nerve disorders and respiratory problems. Shunt malfunction may be associated with headaches,
vomiting, eye muscle abnormalities, and sometimes abdominal symptoms.
What is the shortest functional level for a transtibial amputation?
(a) Just proximal to the tibial tuberosity
(b) Just distal to the tibial tuberosity
(c) Six centimeters distal to the tibial tuberosity
(d) Ten centimeters distal to the tibial tuberosity
(b) The shortest functional amputation level for a transtibial amputation is just distal to the tibial
tuberosity. Knee flexion and extension can occur with this level of amputation because the patella
tendon and hamstring tendon attachments are still present. Control of knee flexion and extension of
the knee is lost with amputations proximal to the tibial tuberosity.
Which muscle does NOT depress the scapula?
(a) Serratus anterior
(b) Rhomboid major
(c) Latissimus dorsi
(d) Pectoralis minor
(b) The rhomboid major elevates, retracts and causes medial (downward) rotation of the scapula, but it
does not depress the scapula. All the other muscles depress the scapula.
Six months after a moderate traumatic brain injury, a 32-year-old woman complains of daytime
somnolence. Her medical work-up is negative. She has normal sleep patterns. The medication you
would most likely consider in this case is
(a) donepezil.
(b) buspirone.
(c) tolcapone.
(d) modafinil.
(d) From the information given, it is clear that this patient is functioning well overall. She has some
difficulty staying awake. Of the answers given, modafinil is the medication most appropriate to
help with alertness during the day. Donepezil is an acetylcholinesterase inhibitor used most often to
improve memory. Buspirone is used to decrease anxiety. Tolcapone is a newer dopaminergic agent
that has not been studied in populations with brain injury.
Which of the following may be associated with a subacromial corticosteroid injection?
(a) Dermal keratinification
(b) Localized osteopenia
(c) Tendon rupture
(d) Dermal hyperpigmentation
(c) Intra-articular corticosteroid injections have enough systemic absorption that suppression of the
adrenal hypopituitary axis may be seen with repeated injections. More localized deleterious effects
include skin depigmentation, soft tissue atrophy, steroid arthropathy, postinjection flare, and tendon
rupture.
What advantage of a reciprocating gait orthosis applies for a person with T10 ASIA class A spinal
cord injury?
(a) The wearer ambulates with a relatively stable 4-point gait.
(b) It accommodates adductor spasticity through the cable mechanism.
(c) It allows longer steps than with traditional knee-ankle-foot orthoses.
(d) Gait is smooth because the pelvis is never stationary during the gait cycle.
(a) The advantages of the reciprocating gait orthosis (RGO) include enabling the wearer to ambulate
with a relatively stable 4-point or 2-point crutch gait. The cable mechanism prevents the patient
from taking an unduly long step that would make balance recovery difficult. The torso is stabilized
with an orthosis, which may also benefit patients who have thoracic spinal cord injury. Ambulation
with RGO is associated with a lower pulse rate and a lower heart rate than with other trunk-hipknee-
ankle-foot ortheses (THKAFOs). Velocity of the ambulation is somewhat faster and patients
appear to be able to manage longer distances than with other THKAFOs. The disadvantage of the
RGO is that donning is time consuming. The gait is slow and is not smooth because the pelvis is
stationary momentarily during each gait cycle. The orthosis is heavy. Marked spasticity of the
adductors disturbs the operation of the cable mechanism.
An elderly patient with breast cancer and widespread osseous metastases has developed acute onset,
severe low thoracic back pain while stooping forward to lift groceries. In addition to formulating a
pain management program and initiating bisphosphonate therapy, what brace do you prescribe for
this patient?
(a) Jewett
(b) Knight-Taylor
(c) Williams
(d) Chairback
(a) The patient has developed a vertebral compression fracture. An extension brace will minimize her
pain and possibly reduce further pathological compression fractures. The Knight-Taylor brace
provides thoracolumbar spine control in the saggital and coronal planes. The Williams brace is a
lumbosacral extension-lateral control orthotic. The chairback brace is an example of a lumbosacral
flexion-extension control orthosis.
How does work conditioning differ from work hardening? Work conditioning is
(a) a maintenance exercise program.
(b) activities simulating the worker’s tasks.
(c) training the worker for a specific job.
(d) aerobic training that may not be job specific.
(d) Work conditioning is the physical conditioning portion of work hardening. It has been referred to as
an aerobic training program for patients with less complex and more chronic conditions. Often
these patients are not being retrained to return to a specific job. In a work hardening program the
injured worker is gradually strengthened and reconditioned to the functional capacity level required
to perform a given job. Work hardening has also been referred to as work simulation, work
readiness training, and work rehabilitation
What is the earliest electrophysiologic abnormality seen in generalized myasthenia gravis?
(a) Increased jitter on single fiber electromyography of the extensor digitorum communis.
(b) Blocking on single fiber electromyography of the extensor digitorum communis.
(c) A 10% decrement of compound motor action potential (CMAP) amplitude with 2–3Hz
repetitive stimulation, recording from the abductor digiti minimi.
(d) A 10% decrement of CMAP amplitude with 2–3Hz repetitive stimulation, recording from the
frontalis.
(a) Increased jitter on single-fiber electromyography is the earliest abnormality seen in myasthenia
gravis. The other abnormalities noted are seen later in the disease process.
A 9-year-old girl with an L1 ASIA class A spinal cord injury that occurred at age 5 years presents in
your office with a 1-day history of a swollen left leg. History is that she woke up with the swollen
leg the day before. There is no history of trauma, fever, or shortness of breath. On examination, you
find a prepubertal girl in no distress with normal vital signs. Upper extremities are normal. Lower
extremities have moderate spasticity and no voluntary movement. Skin is normal. The left leg is
warm and swollen from the ankle to the knee. There is no sensation in the legs. Which test is most
likely to yield the correct diagnosis?
(a) Bone scan
(b) Plain radiograph
(c) Venous Doppler study
(d) White blood cell count with differential
(b) Deep venous thromboses (DVTs) which can be diagnosed by Doppler study usually occur in the
first 3 months after spinal cord injury (SCI) and are rare in prepubertal children. In lower leg DVTs
the foot and leg are usually swollen. Heterotopic ossification (HO), which can be detected by bone
scan, occurs in about 3% of children with SCI and has onset an average of 14 months after injury.
Heterotopic ossification most commonly involves the hip. Cellulitis is usually associated with skin
lesions and usually involves a discrete area. A fracture is the most likely cause of swelling in this
case and can be diagnosed by plain radiographs.
What is the best-established benefit of a microprocessor-controlled knee unit, compared to a
conventional pneumatic knee unit?
(a) It provides both swing and stance phase control.
(b) It allows greater knee flexion to perform bending and lifting activities.
(c) It allows running at faster speeds.
(d) It provides a more natural and symmetric gait pattern.
(d) Microprocessor controlled knee units use a computerized system to automatically adjust the knee
unit’s resistance over a wide range of gait speeds. With this automatic control, there is greater
consistency and reliability in the knee movement during the gait cycle. These benefits give the
amputee greater confidence and improve swing phase responsiveness and gait symmetry, as well.
Negative aspects of the microprocessor controlled knee units are heavier weight and greater
expense. These units have not been shown to improve running speed.
A 45-year-old man presents to his physician with complaints of posterior heel pain for several weeks.
The pain is worse when he first begins to ambulate after resting. He has a noticeable limp. He denies
any recent trauma. On examination, he is exquisitely tender along the medial and lateral aspects of
the calcaneus and along the Achilles tendon at its most distal portion. The area is mildly swollen and
warm to touch. What is the most likely diagnosis?
(a) Achilles tendon rupture
(b) Plantar fasciitis
(c) Posterior calcaneal nerve entrapment
(d) Retrocalcaneal bursitis
(d) This scenario is most likely retrocalcaneal bursitis. This condition is seen in middle aged to elderly
persons, and may occur with overuse. A limp is common and pain is usually worse with first
activity after rest. Swelling and local tenderness may be seen, and a “pump bump” may be present.
This bump is a prominence created by inflammation associated with shoe wear. The local swelling
is due to inflammation of the retrocalcaneal bursa. An acute Achilles tendon rupture is associated
with a positive Thompson test, which consists of compressing the calf and causing the foot to
plantarflex. If the tendon is ruptured, the foot will not plantarflex. The pain is not located in the
bottom of the foot as would be seen with plantar fasciitis. Posterior calcaneal nerve entrapment
would not cause swelling, nor would it be warm to touch.
Which is the best predictor of discharge from a rehabilitation center to home for a man who has had a stroke? (a) Lesion location (b) Shoulder pain (c) Ambulatory status (d) Bladder incontinence
(d) Of the choices presented above, the most consistent predictor of good outcome and discharge home
is bladder continence. Probably the strongest overall predictor of ability is admission functional
ability (which reflects severity of stroke).
A 23-year-old man complains of localized low back pain that is worse in the morning and improves
as the day progresses with activities. He has no radicular symptoms and a nonfocal neurologic
examination. Which finding unequivocally supports your diagnosis
(a) A positive human leukocyte antigen B27
(b) Bilateral sacroiliitis on a radiograph of the pelvis
(c) An elevated erythrocyte sedimentation rate
(d) Atlantoaxial subluxation on a radiograph of the cervical spine
(b) Bilateral spondylitis is diagnostic of ankylosing spondylitis. HLA-B27 is not helpful because a
percentage of the normal population is positive for HLA-B27 and not all patients with ankylosing
spondylitis are positive. Erythrocyte sedimentation rate is a general marker of inflammation.
Enthesopathies may occur in a wide variety of inflammatory disorders, including
spondyloarthropathies.
For a patient with myopathy, which type of exercise is most harmful?
(a) High intensity concentric
(b) High velocity isokinetic
(c) High intensity eccentric
(d) High intensity isotonic
(c) There is evidence of more muscle fiber damage with eccentric exercise. This appears to be true for
persons with myopathic disease as well as in control subjects. There is similar evidence in animal
studies. The type of exercise and its potential benefits versus detrimental effects continues to be a
controversial subject. However, more and more evidence suggests that exercise in persons with
myopathy may not be as detrimental as once thought.
A 52-year-old woman is seen for follow-up 1 year after right carpal tunnel release. She had good
initial relief of her symptoms following the release, but has had a 4-month history of recurrent symptoms in the right wrist and hand. Electromyography of the right upper extremity and cervical paraspinals is normal. Her nerve conduction studies (with normal values in parentheses) are as follows:
Motor Nerve Conduction
Nerve Segment Distal Latency (ms) Amplitude (mV) Velocity (m/s)
R. Median forearm 4.5 (5) 50 (>45)
R. Ulnar forearm 3.4 (5) 52 (>45)
R. Ulnar across elbow 9.5 55
L. Median forearm 3.5 10.0 (>5) 54 (>45)
Sensory
Nerve Segment Peak Latency (ms) Amplitude (uV)
R. Median 14cm antidromic-digit II 3.9 (10)
R. Median 7cm antidromic-digit II 1.9 15
R. Ulnar 14cm antidromic-digit V 3.2 (10)
You conclude that the patient has
(a) compression of the median nerve at Guyon’s canal.
(b) pronator syndrome.
(c) entrapment of the median nerve at the ligament of Struthers.
(d) normal postoperative findings.
(d) After a successful carpal tunnel release median distal latencies improve, but often do not return to
normal. Mild residual slowing is not unusual
Which positive effect of ankle-foot orthotics has been proven beneficial in the treatment of children
with cerebral palsy?
(a) Improved gait efficiency as measured by gait analysis
(b) Prevention of contractures
(c) Improved knee extensor strength
(d) Decreased plantar flexor posture
(a) There are no large, randomized, controlled studies that show the long-term effects of any type of
Ankle-Foot Orthosis (AFO) on function or contracture formation. Small studies have shown that
both rigid and hinged AFOs improve gait efficiency by preventing plantar flexion.
