SAER 2009 Flashcards
stenosis. Calculating anteroposterior (AP) ratios to other anatomical structures, which ratio would enable you to assess for bony cervical spinal stenosis on lateral radiographs?
(a) AP diameter of the vertebral body to the height of vertebral body.
(b) AP diameter of the vertebral canal to the AP diameter of the vertebral body at the same level.
(c) Vertebral height to the AP of the vertebral canal at the same level.
(d) Distance from the anterior border of the vertebral body to the tip of the spinous process
Answer: B
Commentary: Assessment of cervical spinal stenosis on lateral radiograph can be made by calculating the ratio of the anteroposterior (AP) diameter of the vertebral canal to the AP diameter of the vertebral body at the same level. This ratio is called the Pavlov ratio. A normal ratio is 1.0 with less than 0.82 indicating stenosis. The Torg ratio is the same as Pavlov ratio.
A 47-year-old woman injures her back on the job. Her supervisor inquires about the injury and creates a document with the employee’s name, outlining how the injury occurred and where the employee is experiencing pain. The information in the document is protected by the
(a) Health Insurance Portability and Accountability Act (HIPAA).
(b) The Joint Commission (JC).
(c) Americans with Disabilities Act (ADA).
(d) United States Supreme Court.
Answer: A
Commentary: Once the document was created by the supervisor and it contained individually identifiable health information it became information that is protected by HIPAA. The term ‘individually identifiable health information’ means any information, including demographic information collected from an individual, that: (A) is created or received by a health care provider, health plan, employer, or health care clearinghouse; and (B) relates to the past, present, or future physical or mental health or condition of an individual, the provision of health care to an individual, or the past, present, or future payment for the provision of health care to an individual, and identifies the individual.
Your patient has a tremor of 5-8Hz, which is made worse with activity, and there is little or no tremor at rest. This finding best describes which type of tremor?
(a) Parkinsonian
(b) Essential
(c) Enhanced physiological
(d) Cerebellar
Commentary: An essential tremor is more prominent with activity (5-8Hz) and is diminished at rest. Stress exacerbates the tremor. The essential tremor can be confused with parkinsonian tremor. Essential tremor is more prominent with activity, while parkinsonian tremor is more prominent at rest, with a 4-5Hz frequency. There is also an absence of the other symptoms of parkinsonism such as loss of postural reflexes, rigidity and bradykinesia. Enhanced physiologic tremor is a high-frequency tremor that is most prominent with posture and action. It is exacerbated by anxiety, fatigue and many drugs. It can be seen with alcohol withdrawal. The cerebellar tremor has a frequency of about 3Hz and is mainly in a horizontal plane. It is most prominent with fine repetitive action of the extremities and is associated with other signs of cerebellar ataxia.
An individual with T4 ASIA C paraplegia must have
(a) normal sensory function below T4.
(b) sensation in the sacral segments S4–S5.
(c) a muscle grade of 3 or greater in at least half of the key muscles below T4.
(d) voluntary sphincter contraction.
Answer: B
Commentary: All ASIA levels except ASIA A must include sensation through the sacral segments S4–S5. The ASIA C classification can include voluntary sphincter contraction but it is not required. An injury classed as T4 ASIA C would include sensation below T4 but the sensation may be normal or impaired. A muscle grade of less than 3 in more than half of the key muscles below the neurologic level would be expected with ASIA C.
Which scale evaluates sensory perception, moisture, activity, mobility, nutrition, and friction/shear to determine risk of pressure ulcers?
(a) Norton
(b) Barthel
(c) Braden
(d) Beck
Answer: C
Commentary: Both the Braden scale and the Norton scale are used to assess pressure ulcer risk. The Braden scale consists of 6 factors: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The Norton scale assesses 5 factors: physical condition, mental condition, activity, mobility, and incontinence. The Barthel index measures activities of daily living and mobility and is not related to assessing pressure ulcer risk. The Beck Depression Inventory and Beck Anxiety Inventory are not related to pressure ulcers.
Two-thirds of infections that occur 1 to 6 months post-transplant are caused by
(a) methicillin-resistant staphylococcus aureus (MRSA).
(b) pneumocystis carinii (PCP).
(c) clostridium difficile (C. diff).
(d) cytomegalovirus (CMV).
Answer: D
Commentary: Transplant patients are at high risk for cytomegalovirus (CMV) infection and frequently receive prophylaxis with acyclovir or ganciclovir.
Repeatedly lifting the shoulder past which degree of flexion or abduction is associated with an increased prevalence of shoulder disorders?
(a) 10o
(b) 30o
(c) 45o
(d) 60o
Answer: D
Commentary: Repeatedly lifting the shoulder past 60 degrees of flexion or abduction is associated with an increased prevalence of shoulder disorders.
A weight-activated stance-control knee unit would be indicated in a transfemoral amputee who
(a) has cognitive deficits.
(b) has a contralateral weak limb.
(c) is an unlimited ambulator.
(d) is a new amputee.
Commentary: Weight-activated stance-controlled knees are often used for individuals with a transfemoral amputation. They are especially useful as a preparatory prosthesis in a new amputee, because their simplicity and safety help new amputees learn to walk with a prosthesis. To flex the knee, the amputee must shift weight onto the opposite leg, which requires the opposite limb to accept increased weight. Additionally, the amputee must have the cognitive ability to learn to weight shift. The requirement to shift weight off of the prosthesis to allow knee flexion presents few problems at slow cadences, but if the amputee attempts to walk at a more normal speed, the gait pattern is disrupted by the premature weight shift.
Which drug is NOT associated with increased seizure risk in patients with traumatic brain injury?
(a) methylphenidate (Ritalin)
(b) ciprofloxin (Cipro)
(c) amitriptyline (Elavil)
(d) bupropion (Wellbutrin)
Answer: A
Commentary: Methylphenidate and dextroamphetamine do not appear to be associated with increased seizure risk among patients with traumatic brain injury. However, amitriptyline, bupropion and quinolones decrease seizure threshold.
Which complaint is NOT an early sign of dysphagia in amyotrophic lateral sclerosis?
(a) Increasing hoarseness
(b) Persistent coughing after swallowing
(c) Painful swelling in the oropharynx
(d) Inability to manage thin liquids
Answer: C
Commentary: Dysphagia in amyotrophic lateral sclerosis is directly due to weakness and spasticity of the oropharyngeal musculature and does not involve pain or swelling. The presence of any of the other symptoms indicates dysphagia that can lead to aspiration. A speech therapist should be consulted for clinical swallowing evaluations and recommendations on dietary modification.
Following repair of a right distal biceps tendon rupture, a 31-year-old construction worker presents with problems extending his fingers. He had noticed swelling in the arm and forearm before his cast was removed about 4 weeks ago. He does not have any sensory complaints and the right superficial radial sensory nerve action potential is normal. Needle exam shows these data: Muscle Abnormal Spontaneous Activity Recruitment R Triceps 0 Normal R Biceps 0 Normal R Brachioradialis 0 Normal R Extensor digitorum communis 2+ Reduced R Extensor indicis proprius 2+ Reduced R Flexor carpi ulnaris 0 Normal R 1st dorsal interosseous 0 Normal R Extensor carpi radialis 0 Normal R Supraspinatus 0 Normal R Cervical paraspinals0 -- This patient most likely has a right (a) radial mononeuropathy at the elbow. (b) posterior interosseous neuropathy. (c) posterior cord plexopathy. (d) C7 and/or C8 radiculopathy.
Answer: B
Commentary: The electrophysiologic findings are consistent with involvement of the right posterior interosseous nerve (PIN). Typically in PIN injuries the triceps, brachioradialis, and extensor carpi radialis longus/brevis muscles are spared.
What is the primary disadvantage of moving the rear axle of a wheelchair forward?
(a) Ascending curbs becomes more difficult.
(b) It takes more muscle effort to propel the wheelchair.
(c) More strokes are required to push the wheelchair.
(d) Ascending a ramp becomes more difficult.
Answer: D
Commentary: Moving a wheelchair’s rear axle forward enables the user to propel the chair with less muscle effort and fewer strokes. Because the modification causes more weight to be centered over the rear wheels, it is easier to pop a wheelie, negotiate obstacles and ascend or descend curbs. However, moving the axle forward can also make the wheelchair more “tippy” (likely to tip backwards) and that tendency to tip backwards makes it more difficult to push the chair up a ramp.
Which abbreviation or symbol is acceptable to use when writing prescriptions, according to The Joint Commission (JC)?
(a) QD for once daily
(b) U for units
(c) ml for milliliters
(d) cc for milliliters
Commentary: Of the options given the Joint Commission has only approved the use of the abbreviation ml for milliliters. Using the abbreviation QD can be dangerous since it may be mistaken for QID, which stands for four times per day.
A 22-year-old woman with complaints of fluctuating weakness and abnormal fatigability that improves with rest is sent for electrophysiologic testing. Which electrophysiologic finding on routine testing would be most consistent with this clinical presentation?
(a) Small sensory nerve action potentials
(b) Slow motor nerve conduction velocities
(c) Variability in motor unit action potential amplitude
(d) Small compound muscle action potentials
Answer: C
Commentary: This patient’s presentation is most consistent with myasthenia gravis. The incidence of this condition is bimodal and affects women more than men in the younger age group. When one suspects myasthenia gravis the test of choice is repetitive stimulation. However, it is still important to assess for other possible problems and routine nerve conduction and needle electromyographic examination should be performed. The sensory component of the
peripheral nervous system lacks a neuromuscular junction and hence the sensory responses should be normal. Motor amplitudes can be small, but this is usually only in severe cases. Motor conduction velocities are normal, since this study assesses the conduction along the motor fibers. Motor unit action potential amplitude variability is a characteristic abnormality observed during routine electromyography in patients with neuromuscular junction disorders. This finding is due to the variability in the total number of single muscle fibers being activated at any single time.
Patients are NOT candidates for bariatric surgery if they are
(a) twice their ideal body weight.
(b) age 50 or younger.
(c) without a psychiatric contraindication.
(d) experiencing skin breakdown
Answer: D
Commentary: Surgical candidates include persons who are twice their ideal weight, demonstrate recurrent failure to lose weight through dieting, have no cardiopulmonary or psychiatric contraindications, and are usually50 years of age or younger in most cases, with minor exceptions. Some patients may ask about this procedure when it is recommended they lose weight in order to mitigate musculoskeletal pain.
In response to a request for information regarding ejaculation, you advise a 22-year-old man with T4 ASIA A paraplegia who is 1 year postinjury to
(a) avoid ejaculation, because of the risk of autonomic dysreflexia.
(b) use sildenafil (Viagra) 60 minutes before intercourse.
(c) use vibratory stimulation.
(d) see a urologist for direct sperm harvest.
Answer: C
Commentary: In men with spinal cord injury who have an ejaculation reflex (upper motor neuron lesion), there is a 30% to 96% ejaculation rate, depending on the amplitude and frequency of vibratory stimulation. Sildenafil is an option for erectile dysfunction, rather than for ejaculation-related problems. Autonomic dysreflexia can occur with ejaculation but is more commonly a transient phenomenon and does not lead to complications
As compared to children with severe traumatic brain injuries, children with severe anoxic encephalopathy are more likely to have
(a) rigidity and decreased rate of regaining consciousness.
(b) rigidity and increased rate of regaining consciousness.
(c) hypotonia and decreased rate of regaining consciousness.
(d) hypotonia and increased rate of regaining consciousness.
Answer: A
Commentary: Compared to children with severe traumatic brain injury, children with severe anoxic encephalopathy are less likely to regain consciousness; they also have shorter survival time, and often have profound rigidity.
Which condition is a progressive neuromuscular disease that destroys upper and lower motor neurons?
(a) Transverse myelitis
(b) Amyotrophic lateral sclerosis
(c) Kugelberg-Welander disease
(d) Multiple sclerosis
Commentary: Amyotrophic lateral sclerosis (ALS) is perhaps the most severe of all the major neuromuscular diseases. It is a rapidly progressive disease that destroys both upper and lower motor neurons. This destruction results in diffuse muscular weakness and atrophy. Unlike most primary nerve disorders, ALS also produces spasticity because of the loss of upper motor neurons. This loss creates unique clinical management issues. Kugelberg-Welander disease has a very slow progressive course with no upper motor neuron findings of spasticity. Multiple sclerosis and transverse myelitis are demyelinating diseases of the central nervous system with symptoms that mimic lower motor neuron findings, such as weakness.
A 42-year-old man with human immunodeficiency virus (HIV) presents with proximal muscle weakness, myalgia, and weight loss. His creatine phosphokinase (CPK) is elevated. What is the most likely cause?
(a) HIV myopathy
(b) Fibromyalgia
(c) Antiretroviral medications
(d) Vacuolar myelopathy
Commentary: HIV myopathy commonly presents with proximal muscle weakness, myalgia (in 25%-50% of cases), and weight loss. Vacuolar myelopathy causes spinal cord dysfunction, such as paraparesis, ataxia, posterior column sensory loss, spasticity, and neurogenic bowel and bladder. CPK would not be elevated in fibromyalgia or as a result of antiretroviral medications. Antiretroviral medications are associated with neuropathies, not myopathies.
A 45-year-old secretary comes in complaining of right hand numbness that began 6 weeks ago, and her symptoms are beginning to bother her at night. After performing a physical exam you diagnose her with carpal tunnel syndrome. Which treatment is shown to improve the symptoms of carpal tunnel syndrome for up to 1 year?
(a) Oral corticosteroids
(b) Therapeutic ultrasound
(c) Wrist/hand splint
(d) Tendon glide maneuvers
Answer: C
Commentary: Using a wrist/hand splint can improve the symptoms of carpal tunnel syndrome for up to 1 year. Therapeutic ultrasound and oral corticosteroids have been shown to provide only short-term relief. Tendon glide maneuvers have not been shown to affect the outcome of carpal tunnel syndrome.
jarum E1 di dalam, E2 diluar bawah E-1 active electrode E-2 reference electrode What kind of needle electrode is depicted above? (a) Monopolar (b) Standard concentric (c) Single fiber (d) Bipolar concentric
C
Commentary: The single fiber electrode has an active electrode as a side port pickup and the cannula serves as the reference. A separate ground electrode is also required
In prosthetics, K levels are used to describe or define
(a) activity levels.
(b) prosthetic feet.
(c) funding levels for prosthesis.
(d) etiology of amputation.
Answer: A
Commentary: K levels are used to describe activity levels These K0-K4 designations are guidelines for prosthetic components covered by Medicare.
Which electroencephalogram pattern is associated with a better prognosis after traumatic brain injury?
(a) Low amplitude delta activity
(b) Burst suppression
(c) Isoelectric activity
(d) Spindle pattern
Answer: D
Commentary: Favorable electroencephalogram (EEG) patterns after a traumatic brain injury are normal activity, rhythmic theta activity, frontal rhythmic delta activity, and spindle pattern. Poor prognosis is associated with epileptiform activity, nonreactive, low amplitude delta activity and burst suppression patterns with interruption of isoelectricity. Complete isoelectric EEG activity had the highest mortality.
A 35-year-old gentleman with a history of Lyme disease that was treated adequately with antibiotics 1 year ago complains of continued muscle aches, joint pain, fatigue, and difficulty concentrating. His repeat Lyme serologies have been negative, as have all other laboratory tests. He has had a full medical work-up from his internist that has been unremarkable. You recommend
(a)
intravenousceftriaxone for 28 days.
(b)
sulfasalazine for his muscle and joint pains.
(c)
intra-articular cortisone injections for joint pain.
(d)
emotional support and symptom management.
Answer: D
Commentary: The patient has postLyme disease syndrome, which occurs in a minority of patients who have had Lyme disease. There is no specific treatment. Physicians should provide support and management of patient complaints. Antibiotic treatment is contraindicated. Sulfasalazine is not a treatment for Lyme disease.
A 37-year-old man presents to your office with a Grade 2 sacral pressure sore which appears clean, with no necrotic tissue and only a slight amount of serosanguinous drainage. In order to optimize wound healing, you suggest
(a) allowing a protective eschar to form.
(b) wet to dry gauze dressings.
(c) vacuum-assisted closure.
(d) an occlusive dressing.
Answer: D
Commentary: An occlusive dressing will help to maintain a moist environment, which is ideal for wound healing. Allowing eschar to form will inhibit healing. Wet to dry dressing changes are used only when debridement is required. Vacuum-assisted closure is usually used on grade 3 and grade 4 wounds.
Which is the most common neuropsychological dysfunction after a liver transplant?
(a) Seizures
(b) Encephalopathy
(c) Stroke
(d) Depression
Answer: B
Commentary: In a study by Ghaus et al, 62% of liver transplant patients developed encephalopathy. Seizures occurred in 11% and stroke in 9%. In another study by Rothenhausler, 3% of transplant patients had depression.
Which factor is associated with increased risk for occupational injury in an older individual?
(a) White collar occupation
(b) Female gender
(c) Impaired hearing
(d) Self employment
Answer: C
Commentary: Predictors of increased injury risk in an older worker include male gender, less education, obesity, alcohol abuse, disability, self report of impaired hearing or sight, and several specific job requirements. Service workers, mechanics, machine operators, and laborers are at increased risk for occupational injury compared to people in white collar occupations. Individuals who are self-employed have a lower risk of injury.
Which maternal factor is associated with an increased risk of spina bifida?
(a) Anticonvulsant medications during pregnancy
(b) Upper socioeconomic class
(c) Alcohol ingestion during pregnancy
(d) Folic acid 4mg/day prior to and during pregnancy
Answer: A Commentary: The etiology of spina bifida is multifactorial. Both polygenic inheritance and environmental influences contribute. Several studies have shown that there the incidence of spina bifida is reduced if food is fortified with folic acid or if mothers take folic acid prior to conception and during pregnancy. Recommended doses of folic acid are 0.4 mg/day in women who are not at high risk and 4 mg /day in women at high risk (eg, those with a family history of spina bifida). Some studies have also implicated lower socioeconomic class and in utero exposure to anticonvulsant medications as being risk factors. Maternal alcohol ingestion is not related to an increased risk of spina bifida in a baby.
Which factor promotes knee stability during the gait cycle of a person with transfemoral amputation?
(a) Knee component placed anterior to the socket
(b) Hard heel in the prosthetic foot
(c) Polycentric 4-bar linkage prosthetic knee
(d) Anterior position of the shank on the prosthetic foot
Answer: C
Commentary: Flexion moment at the hip, a rigid heel in the solid ankle, cushion heel foot and the anterior position of the shank all shift the ground reaction force behind the knee joint to produce a knee flexion moment. The 4-bar linkage with instantaneous center of rotation and the posterior location of instant center in extension creates knee stability, especially at heel strike
In a patient with traumatic brain injury who has impaired speed of processing, inattention and decreased arousal, which medication is regarded as first-line therapy?
(a) modafinil (Provigil)
(b) methylphenidate (Ritalin)
(c) bromocriptine (Parodel)
(d) carbidopa/levodopa (Sinemet)
Answer: B Commentary: The present evidence suggests that methylphenidate should be regarded as first-line therapy when an agent from this medication class is used. If methylphenidate proves ineffective or produces intolerable side effects, dextroamphetamine, amantadine, or bromocriptine may be useful alternative stimulant medications. Amantadine’s side effect profile is worse than methylphenidate and there is some evidence of a lowering of the seizure threshold, but this is controversial. There is no support at this time in the literature for the use of modafinil over methylphenidate. Bromocriptine and carbidopa/levodopa both have worse side effects and are not as well studied as methylphenidate or amantadine.
A 75-year-old manwith a recent calcaneal stress fracture after starting a walking program presents to your clinic. Initially, you should
(a) order a bone mineral density test.
(b) prescribe a lower extremity strengthening program.
(c) obtain a nuclear bone scan.
(d) prescribe a swimming program
Answer: A
Commentary: The initial assessment should include checking his bone density to establish a diagnosis of osteopenia/osteoporosis and then identifying secondary risk factors (such as hypogonadism, corticosteroid use, excessive alcohol use). Once a diagnosis is established, prescribing weight-bearing and strengthening exercises are important. Obtaining a nuclear bone scan is not as helpful. Swimming is a non-weight bearing exercise.
Which of the following is a benefit of a phrenic pacemaker in an individual with tetraplegia
(a) elimination of ventilator support
(b) improved speech
(c) improved hearing acuity
(d) longer life expectancy
Answer: B
Commentary: Benefits of p hrenic pacemaking include improved speech, improved smell, ease of transfers and out of home mobility, reduced incidence of respiratory tract infections, and reduced volume of repiratory secretions.
Hydrocolloid dressings facilitate debridement through which mechanism?
(a) Enzymatic
(b) Autolytic
(c) Sharp
(d) Mechanical
Answer: B
Commentary: Hydrocolloid dressings maintain a moist wound environment. Subsequently, proteases and collagenase digest eschar that is in contact with the wound fluid. This process is called autolysis. In enzymatic debridement, chemical agents such as papain-urea break down necrotic tissue. Sharp debridement is performed using an instrument such as a scalpel. An example of mechanical debridement would be wet-to-dry dressing or whirlpool treatment.
Which electrodiagnostic criterion is included in the diagnosis of peripheral nerve demyelination?
(a) Conduction velocity reduced in at least 4 nerves
(b) Compound muscle action potential conduction block in at least 3 nerves
(c) Prolonged distal motor latencies in at least 4 nerves
(d) Prolonged F-wave latency or absent F wave
Answer: D
Commentary: The criteria require conduction velocity to be reduced in 2 or more nerves, compound muscle action potential conduction block or abnormal temporal dispersion in 1 or more nerves, prolonged distal motor latencies in 2 or more nerves, and prolonged F wave or absent F wave. Three of these four criteria must be present.
45-year-old concert violinist presents to your clinic for evaluation of left elbow pain. She has been diagnosed with “lateral epicondylitis” and has had pain and impaired function for 8 months. She has been treating her symptoms with relative rest, occupational therapy and alternative therapies, such as acupuncture and massage, without improvement in her symptoms. What other diagnoses should you consider in this patient?
(a) Intersection syndrome
(b) Musculocutaneous neuropathy
(c) Posterior interosseous neuropathy
(d) Rotator cuff tendinopathy
Answer: C
Commentary: Patients whose symptoms are consistent with lateral epicondylitis or “tennis elbow” but who do not respond to conservative treatments should be considered to have a posterior interosseous neuropathy. Mild neural compression of the posterior interosseous nerve may present with proximal and dorsal forearm pain without obvious muscle weakness, wasting, or sensory deficits.
The physical therapist calls you concerning the patient with traumatic brain injury you
admitted last week. She tells you that his bladder incontinence is disrupting therapy. You have checked his urinalysis and there is no evidence of a urinary tract infection. A postvoid residual bladder ultrasound shows that his bladder is emptying well. Your next step is to initiate
(a)
an anticholinergic medication.
(b)
in/out catheterization.
(c)
a condom catheter with a leg bag.
(d)
a behavioral modification program and timed voiding.
Answer: D
Commentary: This patient is exhibiting normal bladder emptying with no evidence of a bladder infection. An anticholinergic in a patient with a traumatic brain injury may exacerbate his confusion. A condom catheter in this population will probably not stay in place. It may increase agitation and will not help the patient. Intermittent catheterization and a Foley catheter will increase the patient’s infection risk. The best course at this time is frequent bladder emptying and retraining, with the entire rehabilitation team encouraging the new behavioral modification.
Children with L4-5 spina bifida are most likely to have
(a) equinus foot.
(b) cavus foot.
(c) knee flexion contractures.
(d) knee extension contractures.
Answer: D
Commentary: The knee extensors (quadriceps) are innervated at the L3-4 level, while the knee flexors (hamstrings) are innervated at the L5-S1 level. A child with L4-5 preserved level would have quadriceps muscles that work, while hamstrings will either be weak or absent. Foot muscles are innervated at the L5-S2 levels. Equinus and cavus feet result from asymmetric pull of foot muscles, which would be seen in sacral levels of spina bifida.
Which statement is TRUE for children with acute inflammatory demyelinating polyneuropathy compared to adults with that disease?
(a) Both recover at the same rate.
(b) Disease course is more benign.
(c) Residual weakness is more common.
(d) Respiratory failure rates are equal.
Answer: B
Commentary: The natural history of acute inflammatory demyelinating polyneuropathy (AIDP) in children is more benign than AIDP in adults. Children usually recover more quickly by 3 months
on some occasions. Residual weakness is not as common for adults. The best prognostic indicator is the degree of disability at the peak of illness.
What function would be expected in a 24-year-old healthy woman with C7 ASIA A tetraplegia?
(a) Requires minimal assistance for level transfers
(b) Requires minimal assistance for side-side weight shifts
(c) Independent manual wheelchair use on uneven terrain
(d) Independent dressing and bathing with adaptive equipment
Answer: D
Commentary: The C7 level is considered the key level for becoming independent in most activities at a wheelchair level. Persons with a C7 motor level who are in good health are usually independent for weight shifts, transfers between level surfaces, feeding, grooming, and upper body dressing. Some assistance may be required for wheelchair propulsion on uneven terrain. Bathing can be performed independently with the appropriate adaptive equipment.
A 6-month-old child with L4 spina bifida presents to your clinic. He also has shunted hydrocephalus. Other than repair of his back and shunt placement, his past medical history has been negative. On examination, you find that he has full hip flexion against gravity and knee extension strength is at least 4/5. The infant has no movement around the ankle. Feet are in neutral position. Hip examination is symmetric. Which prediction is most accurate in this patient?
(a) The child is likely to be a functional community ambulator by age 5 years.
(b) The child is likely to be only a household ambulator.
(c) The child is likely to learn to crutch walk by 18 months.
(d) The child is likely to be only a wheelchair user.
Answer: A
Commentary: This child has a strong quadriceps muscle and no deformities noted at 6 months of age. He is reported to be healthy. The best early predictor of ambulation in children with spina bifida is a strong quadriceps muscle. Negative predictors are spine and lower extremity deformities and obesity. Children do not typically learn to use crutches until 3 to 5 years of age or older.
