SAER 2006 Flashcards
An athlete is found to have a high-arched (pes cavus) foot in supinated weight bearing. Which motion is associated with this finding? (a) Tibial external rotation (b) Forefoot abduction (c) Ankle dorsiflexion (d) Talus internal rotation
(a) Supination in weight bearing is a triplanar motion involving multiple joints of the foot and ankle.
Supination incorporates ankle plantar flexion, talus external rotation, and forefoot adduction.
Obligate tibial and femoral external rotation occurs with supination.
A 65-year-old woman describes a 6-year history of progressive pain and stiffness in her left knee,
right hip, and distal fingers. Plain radiographs of her left knee and right hip demonstrate
osteophytes and asymmetric joint space narrowing with subchondral bony sclerosis. The most
likely diagnosis is
(a) systemic lupus erythematosus.
(b) rheumatoid arthritis.
(c) gouty arthropathy.
(d) osteoarthritis.
(d) Arthritis in systemic lupus erythematosus is non-erosive and does not have articular cartilage
involvement. In rheumatoid arthritis, periarticular bony erosions and osteopenia are seen on
radiographs. Radiographic changes in gouty erosions are usually slightly removed from the joint
space and have atrophic and hypertrophic features (an overhanging edge and soft-tissue tophus).
Characteristic radiographic findings of osteoarthritis include bony proliferation at the joint margin,
asymmetric joint-space narrowing, and subchondral bone sclerosis.
What is the most common level of occult spine fracture after trauma that is missed by plain radiographs? (a) C7/T1 (b) T5/T6 (c) T12/L1 (d) L4/L5
(a) Occult cervical fractures are most often seen at the C1 and C7 levels. By adding computed
tomography (CT) scanning to the evaluation of trauma patients, a significant number of occult
cervical fractures can be diagnosed. Of spinal fractures, 5% to 30% are multiple and may appear at
noncontiguous levels. Thus, radiographic evaluation of the entire spinal axis is necessary whenever
injury at 1 region of the spine is detected.
A 67-year-old woman was just admitted to the general rehabilitation unit after a complicated 2-
month course at the acute care hospital. When the physical therapist gets her out of bed on the first
day, what is the most likely finding?
(a) Blood pressure goes from 120/80 to 150/100.
(b) Blood pressure goes from 120/80 to 90/50.
(c) Heart rate goes from 80 to 60.
(d) Heart rate remains at 60.
(b) Orthostatic hypotension is a common cardiovascular complication of immobility. Lying in bed for
a prolonged time causes a central fluid shift that results in an increased intravascular volume. There
is a resultant diuresis and decrease in plasma volume. When a person stands after bed rest, venous
pooling occurs in the lower extremities due to increased venous compliance (orthostatic
intolerance). Person also has blunted cardiac response to rapid changes in posture. With
immobility and deconditioning, the resting heart rate increases, and the heart rate response to
exercise also increases.
An injured worker with low back pain will return to full work duties faster if treatment includes
(a) back school and lumbar corset.
(b) aerobic conditioning and weight lifting.
(c) work conditioning and “off-duty” or no-work status.
(d) functional rehabilitation and ergonomic intervention.
(d) Loisel, in1997, performed a randomized controlled trial that showed that the injured worker with
low back pain returned to regular work activities 2.41 times faster if the worker received
therapeutic functional rehabilitation and ergonomic intervention when compared to usual care.
The American College of Obstetrics and Gynecologists (ACOG) recommendation regarding exercise
during pregnancy is that
(a) exercise should be 85%–95% of maximum predicted heart rate.
(b) pregnant women may exercise to exhaustion.
(c) exercise should be done 6 days a week for at least 60 minutes daily.
(d) pregnant women should avoid resistive exercises in the supine position.
(d) Exercise should be at 60% to 85% of predicted maximum heart rate. Pregnant women should not
exercise to exhaustion. Exercise should be done 3 to 4 days a week for 30 to 45 minutes at a time.
Pregnant women should avoid exercise in the supine position because such a position may decrease
cardiac output, resulting in blood diverting from the splanchnic beds (including the uterus).
A 10-year-old girl presents with scoliosis 5 years after sustaining a severe traumatic brain injury.
Radiographic studies reveal a 25° levoconvex curve from C8 to T12 with the apex at T4. After
consultation with the orthopedic surgeon, you prescribe a spinal orthosis. Which type of orthosis
should be used in this patient?
(a) Cervicothoracolumbosacral orthosis (CTLSO)
(b) Thoracolumbosacral orthosis (TLSO)
(c) Thermoplastic Minerva body jacket (TMBJ)
(d) Sterno-occipital mandibular orthosis (SOMI)
(a) A thoracolumbosacral orthosis is used for scoliosis having an apex at T9 or lower. A sternooccipital
mandibular orthosis immobilizes the neck. A thermoplastic Minerva body jacket is also
used for cervical immobilization. A cervicothoracolumbosacral orthosis such as the Milwaukee
brace extends from the pelvic section to the neck ring and has been shown to correct scoliotic
curves throughout that area.
A 42-year-old woman presents with a 3-month history of difficulty walking up stairs and rising from
chairs. She has no headaches or scalp pain and is currently on no medications. Physical
examination reveals bilateral weakness of her proximal legs and arms. Laboratory studies reveal a
markedly elevated creatine phosphokinase (CPK) level and a normal erythrocyte sedimentation rate
(ESR). The most likely diagnosis is
(a) myasthenia gravis.
(b) polymyalgia rheumatica.
(c) polymyositis.
(d) rhabdomyolysis
(c) The hallmark features of polymyositis, or idiopathic inflammatory myopathy, are symmetric muscle
weakness of the shoulder and pelvic girdles, occasionally accompanied by mild pain and
tenderness. Eventually, weakness of the proximal leg and arm muscles follows. The symptoms
usually appear insidiously, with no identifiable precipitating event. Laboratory examination shows
AAPM&R
an elevation in skeletal muscle enzymes, especially creatine phosphokinase. Electromyographic
changes are consistent with inflammatory myopathy: short small, polyphasic motor units;
filbrillations; positive waves; and high frequency, repetitive discharges. The absence of headaches
and scalp pain makes polymyalgia rheumatica less likely. Rhabdomyolysis is typically more acute
in onset and is associated with trauma or use of certain medications such as the statins.
A 27-year-old man with a T12 ASIA class A spinal cord injury for 10 years presents with right
shoulder pain that is worse with use, particularly when reaching and doing transfers. He plays
basketball twice weekly. Recommendations should include
(a) no wheeling or transfers for 2 weeks.
(b) immobilization of the elbow and shoulder.
(c) electrodiagnostic study of the upper extremity.
(d) strengthening of the scapular stabilizers.
(d) Shoulder and neck pain are common following spinal cord injury (SCI). The pain may arise from
the neck, shoulder girdle, or the glenohumeral joint. Pain may be a symptom of post-traumatic
syringomyelia or a manifestation of cervical disc degeneration. The prevalence of shoulder pain in
persons with SCI is estimated to be 30% to 50%. Rotator cuff tear, bursitis, tendonitis and
impingement have all been reported. While the diagnosis of these disorders is similar to that in the
able-bodied population, the treatment is not. In a person with SCI and upper limb pain, rest is often
not possible. Pain is often related to overall posture and poor biomechanics. Strengthening of
scapular stabilizers can help to correct this imbalance. Immobilization should be avoided. Pain
relief is the focus, and may include: relative rest (not to interfere with a person’s independence),
medications, injections, icing, ultrasound, transcutaneous electrical nerve stimulation, and/or
acupuncture.
A 36-year-old breast cancer patient presents with myofascial pain involving the upper and middle
trapezius and levator scapulae muscles. She underwent modified radical mastectomy and chest wall
irradiation 1 year ago. The breast has been reconstructed with a rather large implant. You note that
her acromial process on the affected side is depressed and protracted. Lasting relief will most likely
be achieved through a physical therapy program emphasizing
(a) ultrasound followed by shoulder mobilization.
(b) stretching of the pectoralis major and minor muscles.
(c) electrical stimulation of the painful muscles.
(d) isometric resistive exercise of the rhomboid muscles
(b) Muscles within any radiation field are at risk for fibrosis and contracture. The pectoralis major and
minor muscles are commonly shortened following radiation to the chest wall, an integral
component of breast conservation therapy. Radiation-induced shortening of the pectoralis muscles
pulls the scapula into a protracted and depressed position which places tension on the medial and
superior scapular stabilizers. To achieve long-term relief, this patient will require stretching of the
pectoralis muscles.
Which one of the following is associated with an axonal loss sensory polyneuropathy?
(a) Lead poisoning
(b) Cisplatin chemotherapy
(c) Polyarteritis nodosa
(d) Charcot-Marie-Tooth disease (type 1)
(b) Cisplatin is associated with an axonal loss sensory neuropathy. Lead usually causes upper limb
weakness and patients usually have few or no sensory complaints. Polyarteritis nodosa is the most
common of the necrotizing vasculitides and the most common pattern of nerve involvement is that
of mononeuropathy multiplex. In Charcot-Marie-Tooth disease type 1 the primary pathology
involves uniform demyelination of the peripheral nerves.
In a patient with a transfemoral amputation, what is the most likely cause of excessive knee flexion
during ambulation?
(a) Hip flexion contracture
(b) Prosthetic knee alignment in an excessively posterior position
(c) Excessive socket extension
(d) Too soft a plantar flexion bumper in the heel
(a) One of the most common gait deviations in patients with transfemoral amputations is abrupt or
excessive knee flexion during ambulation. The prosthetic knee joint should normally be stable in
extension in stance phase from heel contact to foot flat. This stability is accomplished by aligning
the prosthetic knee axis posterior to the trochanteric knee ankle line. Adequate strength and range
of motion in hip extension are critical to maintaining this alignment. Thus, weak hip extensors and
hip flexion contractures can cause knee instability. Two prosthetic causes of knee instability are (1)
knee malalignment in an excessively anterior position relative to the hip and ankle joints, and (2)
excessive socket flexion. A plantar flexion bumper that is too stiff, extensive foot dorsiflexion, or a
change in shoe heel height from low to high may all promote knee flexion.
Which surgical option would be most appropriate for a patient with rheumatoid arthritis who has
severe uncontrollable knee pain and loss of function?
(a) Synovectomy
(b) Hemiarthroplasty
(c) Total knee arthroplasty
(d) Arthrodesis
(c) Total knee arthroplasty is the surgery of choice in persons with severe pain and loss of function. A
synovectomy provides temporary pain relief and decreased swelling. Hemiarthroplasty is
contraindicated in rheumatoid arthritis due to total joint involvement. Arthrodesis would not
provide the range of motion needed for stairs, ambulation, and dressing.
A 20-year-old man develops weakness accompanied by difficulty in relaxation of the hand and foot
muscles. The muscle biopsy demonstrates prominent ring fibers, centrally located nuclei, and
disorganized sarcoplasmic masses. This condition has been associated with mutation on which
chromosomes?
(a) X
(b) Y
(c) 5
(d) 19
(d) The disease is myotonic dystrophy, which is an autosomal dominant disease. The affected gene has
been localized to chromosome 19. Myotonic dystrophy is relatively common and is best thought of
as a systemic disease since it causes cataracts, testicular atrophy, heart disease, dementia, and
baldness in addition to muscular dystrophy
A 50-year-old man is transferred to your rehabilitation unit after a cardiac transplant. Because of the
transplant, you anticipate that he will have a
(a) lower than normal resting heart rate.
(b) decreased time to achieve maximal heart rate during exercise.
(c) lower than normal peak heart rate achieved during maximal exercise.
(d) lower than normal systolic and diastolic blood pressure.
(c) A transplanted heart is denervated, so it achieves maximal heart rate more slowly because it relies
on circulating catecholamines to achieve a response. The resting heart rate is higher than normal,
most likely because of the loss in vagal input. Peak heart rate achieved during maximal exercise is
considerably lower in transplant patients compared with age-matched controls. Systolic and
diastolic blood pressures are higher than normal.
Which statement is TRUE regarding the way the Centers for Medicare and Medicaid Services
currently reimburses inpatient rehabilitation facilities (IRFs) based on a prospective payment system
(PPS)?
(a) Reimbursement is determined according to the patient’s severity of disability and his/her
required use of resources.
(b) Assignment of patients to a specific rehabilitation impairment category (RIC) is based
primarily on their medical co-morbidities.
(c) Early transfer of patients from an IRF to a skilled nursing facility does not affect
reimbursement to the IRF.
(d) Assignment of patients to specific case-mix groups (CMGs) is determined by the rehabilitation
diagnosis and the patient’s premorbid functional status.
(a) The Center for Medicare and Medicaid Services currently reimburses inpatient rehabilitation
facilities (IRF) based on a prospective payment system (PPS) according to the patient’s severity of
disability and his/her required use of resources. The rehabilitation impairment category is based on
the primary rehabilitation diagnosis, and the case-mix group is determined in part by the patient’s
co-morbid medical conditions.
What test is most sensitive for diagnosing myasthenia gravis?
(a) Facial nerve repetitive studies at 30 hertz
(b) Ulnar nerve repetitive studies at 3 hertz
(c) Single fiber electromyography
(d) Acetylcholine receptor antibodies
(c) With a sensitivity of 92% to 100%, single fiber electromyography, which includes measurement of
jitter, is the most sensitive test in assessing for myasthenia gravis. The sensitivity of repetitive
stimulation of distal and proximal nerves is 77% to 100%, and acetylcholine receptor antibody
sensitivity is 73% to 90%.
During which phase of the gait cycle are the ankle plantarflexor muscles (gastrocnemius and soleus) most active? (a) Initial contact (b) Loading response (c) Midstance (d) Terminal stance
(d) During the gait cycle, the ankle plantarflexors become active during the midstance phase when they
contract eccentrically to control forward progression of the tibia and ankle dorsiflexion. These
muscles become most active during the terminal stance phase when they contract concentrically to
produce ankle plantarflexion and accelerate the trunk forward. The ankle plantarflexors are
minimally active during the initial contact and loading response phases of the gait cycle.
A 30-year-old runner training for a marathon presents to your clinic with progressive pain in his right
medial tibia over the past 2 weeks. Which history and examination feature is more consistent with a
stress fracture rather than medial tibial stress syndrome?
(a) Diffuse rather than focal tenderness
(b) Pain with percussion around the site of pain
(c) Pain that diminishes as the run goes on
(d) No reproduction of pain with single leg hop test
(b) This is a common clinical conundrum. Medial tibial stress syndrome (frequently and improperly
referred to as shin splints) represents a range of pathology from posterior tibialis tendonitis to
periostitis. Fredericson et al determined that stress fractures, which will require more aggressive
treatment, have more focal pain and pain with percussion testing. Pain from a stress fracture
worsens as run goes on and often hurts after a run. A magnetic resonance image or bone scan can
make a definitive diagnosis.
After an acute stroke, a 60-year-old woman presents for stroke rehabilitation with an indwelling
catheter for bladder management. What action should you order regarding the catheter?
(a) Maintain it until the patient is able to transfer to the toilet with minimal assistance.
(b) Remove it because reflex voiding returns very quickly after a stroke and risk of urine retention
is minimal.
(c) Remove it and start intermittent catheterization because reflex voiding return is often delayed
and the risk of urine retention is high.
(d) Maintain it to decrease the risk of urinary incontinence and pressure sores
(b) Impaired bladder control is frequent following stroke with initial hypotonic bladder, but voiding
returns very quickly and urine retention is rarely a problem. In the postacute phase of stroke
rehabilitation, the problem is not bladder overdistention, but uninhibited bladder with incontinence.
Which of the following is a rare extra-articular manifestation of rheumatoid arthritis?
(a) Rheumatoid nodules
(b) Keratoconjunctivitis sicca
(c) Glomerular disease
(d) Microcytic anemia
(c) Rheumatoid nodules are present in up to 50% of persons with rheumatoid arthritis (RA).
Keratoconjunctivitis sicca and microcytic anemia are also very common. Glomerular disease is
very rare in RA, but requires management when found.
Spinal instrumentation in neuromuscular scoliosis is indicated when
(a) onset of scoliosis is before skeletal maturity.
(b) primary curve exceeds 25° and forced vital capacity (FVC) is greater than 35% of normal.
(c) ambulation abilities are lost due to severe back pain.
(d) primary curve exceeds 50° and FVC is less than 25% of normal.
(b) The indication for spinal instrumentation in neuromuscular scoliosis is that the primary curve
exceeds 25° and forced vital capacity has not dropped below 35% of normal.
You are caring for a patient with a T3ASIA class A spinal cord injury who complains of burning
pain in his legs. Additional review of systems includes urinary leakage between catheterizations, and
difficulty sleeping. The best pharmacologic intervention at this time would be
(a) amitriptyline (Elavil).
(b) paroxetine (Paxil).
(c) trazodone (Desyrel).
(d) fluoxetine (Prozac).
(a) Amitriptyline, a tricyclic antidepressant is among the classic first line treatments in neuropathic
pain. Most common side effects related to tricyclic antidepressants are related mainly to the
anticholinergic effects and include dry mouth, urinary retention, and sedation. For this patient who
has difficulty sleeping, as well as urinary leakage between catheterizations, the anticholinergic sideeffects
may prove to be of benefit. Trazodone has not been demonstrated to reduce pain in for
spinal cord injury. Paroxetine causes insomnia and sexual dysfunction and therefore would not be
appropriate in this patient. Venlafaxine, sertraline, and fluoxetine have proven to be of limited
benefit for neuropathic pain.
A 60-year-old woman with rheumatoid arthritis, hypertension, and hypothyroidism has undergone
bilateral total knee arthroplasty and is currently being admitted to a rehabilitation unit. Which
medication should be discontinued in this postoperative period?
(a) Warfarin (Coumadin)
(b) Etanercept (Enbrel)
(c) Furosemide (Lasix)
(d) Levothyroxine (Synthroid)
(b) Etanercept is typically recommended to be discontinued during the postoperative period in order to
allow adequate tissue healing and prevention of complications. Other immunosuppressive therapies
and disease modifying anti-rheumatic agents should also be discontinued. The remaining
medications do not need to be discontinued in the postoperative period.
For persons with spinal cord injury who survive the first 24 hours, what is the leading cause of death the first year postinjury? (a) Pulmonary embolism (b) Pneumonia (c) Renal insufficiency (d) Nonischemic heart disease
(b) The leading cause of death for persons with spinal cord injury who survive more than 24 hours is
pulmonary dysfunction (pneumonia, adult respiratory distress syndrome) followed by nonischemic
heart disease, septicemia and pulmonary embolus.
You are managing the care of a 63-year-old pipe fitter with shoulder pain in his dominant arm. He
has no history of trauma. An incomplete supraspinatus tear is found on imaging studies. He has
completed 8 sessions of physical therapy with improvement. He has pain at 140° of shoulder
abduction. Strength, range of motion, and neurological exam are normal. The case manager asks for
your next recommendation towards determining his work status. You recommend
(a) functional capacity evaluation exam.
(b) work conditioning.
(c) aquatic physical therapy.
(d) surgical referral.
(a) A functional capacity evaluation (FCE) is the next best choice for this worker. An FCE will
determine functional deficits the worker has by assessing work simulated activities. Work
conditioning may be helpful because it includes aerobic conditioning but does not provide
information and training regarding specific work tasks. His physical findings are minimal so
additional physical therapy may not be recommended. These minimal physical exam findings in a
63-year-old man may indicate a nontraumatic incomplete cuff tear that may be a part of normal
aging. In this setting, conservative management remains appropriate. Incomplete rotator cuff tears
can be found in the asymptomatic population, especially over the age of 50.
Randomized controlled trials examining intrathecal baclofen (ITB) use in children with cerebral
palsy show that children who receive ITB have
(a) improved upper extremity function.
(b) reduced spasticity in lower extremities.
(c) improved walking and transfers.
(d) improved knee range of motion
(b) A comprehensive review of published English language studies on intrathecal baclofen (ITB)
showed evidence of statistically significant improvement in upper and lower extremity tone with
ITB use in children with cerebral palsy (CP). Other reported improvements with ITB in children
with CP are either anecdotal or not substantiated by randomized controlled trials.
62. (a) Relaxation techniques with slow, rhythmic rotational movements starting with passiv
Rehabilitation strategies for addressing rigidity associated with Parkinson’s disease include
(a) relaxation techniques with gentle stretching.
(b) a strengthening program.
(c) botulinium toxin injections.
(d) oral baclofen.
(a) Relaxation techniques with slow, rhythmic rotational movements starting with passive range of
motion distally and progressing proximally and then adding active range of motion is effective in
decreasing rigidity.
You are taking care of a 72-year-old man who fell at home and remained on the ground for several
hours. He subsequently developed a sacral pressure ulcer that now has large areas of necrotic tissue
without fluctuance. Which intervention is most appropriate?
(a) Proteolytic enzymes
(b) Triple antibiotic ointment
(c) Incision and drainage
(d) Oral antibiotics
(a) The necrotic tissue in this wound needs debridement. This may be accomplished with surgical
sharp debridement, mechanical nonselective debridement, such as with a wet-to-dry dressing, or
enzymatic debridement with a chemical agent that uses proteolytic enzymes. Topical and oral
antibiotics are not necessary in this patient, as necrotic tissue does not signify an infection. An
incision and drainage would not be appropriate, since no abscess is present.
Medical error reporting systems are designed to
(a) ensure that patients and families are notified when a medical error has occurred.
(b) assist patients and families in reporting activities that they perceive as an error.
(c) discipline staff who report that an error has occurred.
(d) encourage staff to report errors without fear of punishment.
(d) Medical error reporting systems are designed to encourage staff to report sentinel events, adverse
events, and close calls without fear of punishment. If these issues are recognized, then further
review and action can be initiated. Review may include a root cause analysis to determine the
exact cause of the problem and strategies for prevention. When a medical error has occurred, staff
are encouraged to recognize the issue and report the issue immediately.
You are called to see your 3-year-old inpatient with a C5 ASIA class A spinal cord injury. She has a
headache and complains of not feeling well. Vital signs are pulse 60, respirations 20, blood pressure
120/80. Weight 33 lbs (15kg). Physical examination is unchanged from previously. You order:
(a) Place the patient in the supine position.
(b) Administer acetaminophen (Tylenol) orally.
(c) Empty the bladder.
(d) Obtain computed tomography of the head.
(c) The child is experiencing autonomic dysreflexia. The 90th percentile for blood pressure in an
average sized 3-year-old girl is 103/62. A child with C5 tetraplegia would be expected to have
even lower average blood pressure. Initial treatment consists of positioning the patient in an
upright position and emptying the bladder. If this does not correct the problem, medications should
be considered. If medications are needed, either nitropaste 2% or nifedipine may be used. For a
child weighing 15kg the correct initial dose is 0.25 to 0.5 mg/kg/dose (3.75–7mg) of nifedipine or
½ inch of nitropaste.
A circumducted gait in a man with an above knee amputation is most likely due to
(a) a rigid heel in his solid ankle, cushioned heel (SACH) foot.
(b) inadequate friction in his prosthetic knee unit.
(c) his prosthetic foot being set in dorsiflexion.
(d) inadequate socket suspension
(d) Inadequate socket suspension causes the prosthesis to be functionally too long. A rigid heel and
foot set in dorsiflexion would increase knee flexion movement. Inadequate friction would cause the
leg to “snap” into terminal extension.
Which finding is more characteristic of atypical facial pain than of trigeminal neuralgia?
(a) Lancinating pain
(b) Burning pain
(c) Paroxsymal pain
(d) Stabbing pain
(b) Trigeminal neuralgia has a lancinating and paroxsymal quality. Atypical facial pain is most often
described as burning pain, usually in areas not encompassing the trigeminal region. Atypical facial
pain is continuous rather than paroxysmal. Atypical facial pain occurs in young females whereas
trigeminal neuralgia occurs in the elderly. Atypical facial pain is initially treated with amitriptyline
while, trigeminal neuralgia is initially treated with anticonvulsants, particularly carbamazepine.
Your patient with Parkinson’s disease has sialorrhea. Initial treatment recommendations would
include
(a) a behavior modification program with speech therapy.
(b) Robinul (glycopyrrolate) with meals.
(c) Botox (botulinum toxin type A) to the salivary glands.
(d) low dose Elavil (amitriptyline) at bedtime.
(a) A defective swallowing mechanism rather than excessive saliva production is the primary cause of
drooling and the complaints of excessive drooling in Parkinson’s disease. A behavior modification
program with frequent reinforcement may be effective in reducing drooling in Parkinson’s disease
and should be used prior to medication or botulinum toxin therapy.
A 42-year-old administrative assistant presents with a 2-month history of bilateral forearm pain and
numbness in the index finger and thumb. Her symptoms worsen with increased use of bilateral upper
extremities and are interfering with work. Physical examination is significant for a positive Tinel’s
sign at the wrist and normal strength. Nerve conduction studies and electromyography confirm
compression of the median nerve at the wrist. You recommend
(a) lowering the keyboard height to facilitate wrist flexion.
(b) being off work for 8 weeks while in physical therapy.
(c) urgent surgical referral to minimize time off work.
(d) setting keyboard height to maintain a neutral wrist position.
(d) Trial of conservative management is warranted, since her symptoms are recurrent and there is no
evidence of motor weakness. There are no indications for urgent surgical release. Ergonomics
should be reviewed; an adjustable seat can improve keyboard height to maintain a neutral wrist
position. Wrist extension and flexion can further increase symptoms. Although rest can certainly
help improve her symptoms, changing ergonomics is essential in order to resolve symptoms.
Falls are common and often disabling in individuals with Parkinson’s disease. The risk of falls is
increased in patients who
(a) are taking nonsteroidal anti-inflammatory medication for pain.
(b) are using a walker for ambulation.
(c) have erratic arm swing with gait.
(d) are taking benzodiazepines.
(d) Recurrent falls are more common in individuals with Parkinson’s disease who are taking
benzodiazepines. Other risk factors are: history of falls, severe disease, poor balance, depression,
and loss of arm swing with gait.
Compared with able-bodied individuals, persons with spinal cord injury are likely to have
(a) equivalent percentage of regional and total body lean tissue.
(b) higher testosterone levels.
(c) equivalent incidence of dyslipidemia.
(d) a lower resting metabolic rate.
(d) In persons with spinal cord injury, there is an initial dramatic loss of muscle mass after the acute
paralysis. However, even decades after injury, there is continuous loss of lean body tissue
compared to that observed in an able-bodied person. It is of particular interest that the arms of
persons with paraplegia have significantly less percent lean tissue compared with controls. No
differences in the cross sectional rate of loss of lean body mass is noted between persons with
tetraplegia and paraplegia. Men with spinal cord injury can be expected to lose about 3.2% per
decade of the total lean body tissue vs. 1% per decade in able-bodied males. Individuals with spinal
cord injury have a pattern of metabolic alteration that is atherogenic with dyslipidemia, glucose
intolerance, insulin resistance, and reduction in metabolic rate. Although the literature in persons
with spinal cord injury is conflicting regarding anabolic hormonal changes in persons with spinal
cord injury, there are subsets of individuals with relative androgen deficiency states. The etiology
of a relative deficiency of testosterone in persons with spinal cord injury has not yet been
established. However, it is conceivable that prolonged sitting and euthermia of the scrotal sack and
testes may itself have a deleterious local effect on testosterone production.
You are managing the care of an injured worker with a working diagnosis of C6 radiculopathy. Your
assistant informs you that the case manager is in the room with the patient. You next ask the
(a) case manager to leave, because case managers represent only the interest of the company.
(b) worker if he prefers to have the case manager present throughout the exam.
(c) worker if he prefers you recommend to the case manager that he be placed in a new job.
(d) case manager to show evidence that the worker is malingering.
(b) Case managers work as medical liaisons between the company and medical care team to facilitate
communication of and approval for diagnostic tests and treatment. They have been shown to
improve timeliness of care. It is important to ask the patient’s preference regarding the case
manager’s presence and to ensure patient confidentiality. The physician is to determine if the
patient can return to work based on objective and subjective evidence. It is not the case manager’s
job to provide the treating physician with evidence regarding validity of the worker’s condition.
A 23-year-old man is sent to the electrophysiology laboratory for evaluation of bilateral foot drop.
His history is significant for recent treatment of Hodgkin’s lymphoma with surgery and
chemotherapy. Which electrophysiologic finding is most consistent with a polyneuropathy
secondary to vincristine use?
(a) Reduced conduction velocity of the motor nerves
(b) Absent sensory responses with preserved motor responses
(c) Small amplitude motor and sensory responses
(d) Motor and sensory conduction block
(c) Vincristine causes an axonal polyneuropathy that primarily affects the most distal aspects of the
nerve and produces a sensorimotor polyneuropathy. Nerve conduction studies reveal small
amplitude or absent motor and sensory responses.
The most common congenital limb deficiency is a
(a) transverse tibial and fibular limb deficiency (below-knee limb deletion).
(b) transverse transmetacarpal limb deficiency (partial hand deletion).
(c) longitudinal fibular deficiency (fibular hemimelia).
(d) transverse radial limb deficiency (below-elbow limb deletion).
(d) The left short transradial congenital limb deficiency (below-elbow limb deletion) is the most
common congenital limb deficiency. It is thought to be caused by a clot which occludes the artery,
resulting in resorption of the distal limb, often leaving nubbins of fingers at the end of the stump.
