SAER 2011 Flashcards
A 22-year-old runner presents with acute onset of distal calf pain. She is diagnosed with Achilles
tendinitis and is referred to physical therapy. Which therapeutic modality is the LEAST
beneficial in treating an overuse injury of this sort?
(a) Therapeutic ultrasound
(b) Iontophoresis
(c) Ice massage
(d) Neuromuscular electrical stimulation
Answer :(d)
Commentary: With acute overuse injuries, modalities such as ultrasound, iontophoresis, and ice
massage may decrease pain and facilitate rehabilitation. Electrical stimulation with recruitment
of muscle fibers may be contraindicated in treating acute overuse injuries.
What is the most frequent presenting symptom of brain metastasis?
(a) Focal weakness
(b) Headache
(c) Seizure
(d) Visual disturbance
Answer: (b)
Commentary: Presenting symptoms at the time of diagnosis with brain metastasis, in order of
decreasing frequency, are as follows: (patients can have more than a single symptom): headache,
49%; mental disturbance, 32%; focal weakness, 30 %; gait ataxia, 21 %; seizures, 18%; speech
difficulty, 12%, visual disturbance, 6%; sensory disturbance, 6%; and limb ataxia, 6%.
Which disorder does NOT have pes cavus as a feature?
(a) Poliomyelitis
(b) Cerebral palsy
(c) Friedreich ataxia
(d) Peroneal spastic foot
Answer: (d)
Commentary: The etiology of pes cavus includes malunion of calcaneal or talar fractures, burns,
sequelae resulting from compartment syndrome, residual clubfoot, and neuromuscular disease.
The remaining cases are idiopathic and nonprogressive. Neuromuscular diseases, such as
muscular dystrophy, Charcot-Marie-Tooth (CMT) disease, spinal dysraphism, polyneuritis,
intraspinal tumors, poliomyelitis, syringomyelia, Friedreich ataxia, cerebral palsy and spinal cord
tumors can cause muscle imbalances that lead to elevated arches. Multiple theories have been
proposed for the pathogenesis of pes cavus. Duchenne described intrinsic muscle imbalances
Page 3 of 33
causing an elevated arch. Whereas, peroneal spastic foot is characterized by pain in the foot,
limited subtalar motion, pes planus deformity, and shortening with spasm of the peroneal muscles
often initiated by minor trauma or unusual activity.
Which cardiac response is increased as a result of aerobic training?
(a) Oxygen consumption (VO2)
(b) Maximal heart rate
(c) Anginal threshold
(d) Stroke volume at rest
Answer:(d)
Commentary: After an aerobic training program, the anginal threshold is unchanged. Oxygen
consumption (VO2) at rest, and during any given submaximal load remains unchanged, while
VO2 max is increased. The maximal heart rate also does not change, but the heart rate is lower
both at rest and during any submaximal load (bradycardia of training). The stroke volume at rest
is increased, reciprocal to the decrease in heart rate. Although angina threshold is unchanged,
myocardial oxygen demand decreases relative to oxygen consumption, which allows more intense
activity before the ischemic threshold is reached.
Injured workers with acute low back pain treated with high-dosage opioids compared to low-dose
or nonopioid medications demonstrated which outcome?
(a) Lower overall medical costs
(b) Same duration of disability
(c) Higher risk for surgery
(d) Shorter duration of opioid use
Answer: (c)
Commentary: Injured workers with acute low back pain who received higher dosages of opioids
in early treatment had adverse outcomes compared to patients given no or low-dose opioids. In
the high-dose opioid group, adverse outcomes included higher medical costs, prolonged
disability, higher risk for surgery, and continued use of opioids. The high-dose opioid group was
disabled 69 days longer than the non-opioid group, had a 3 times greater risk for surgery, and a 6-
times-greater risk of receiving long-term opioids. The severity of the low back injury was a strong
predictor of all outcomes.
A 40-year-old man presents with a gradual onset of painful distal paresthesias while playing
soccer. He feels clumsy and is falling more frequently. He has no known significant past medical
history. Physical exam demonstrates normal symmetric strength throughout his upper and lower
extremities, normal vibration sensation and normal Romberg testing. His electrodiagnostic exam
results are as follows:
MOTOR NERVE CONDUCTION STUDIES*
Nerve Stimulation Site Distal Latency
(ms)
Amplitude
(mV)
NCV (m/s)
R Fibular (Peroneal) Ankle 6.1 (≤ 6.5) 2.0 (≥2.0)
Below knee 1.9 41 (≥40)
Above knee 1.9 41
L Fibular (Peroneal) Ankle 6.0 (≤ 6.5) 2.1 (≥2.0)
Below knee 2.0 40 (≥40)
R Tibial Ankle 6.1 (≤ 6.1) 3.0 (≥3.0)
Knee 2.9 42 (≥40)
R Median Wrist 4.4 (≤ 4.4) 5.2 (≥4.0)
Elbow 5.2 49 (≥49)
R Ulnar Wrist 3.5 (≤ 3.5) 7.0 (≥6.0)
Below elbow 6.9 49 (≥49)
* Normal values are in parentheses
Abbreviation: NCV, nerve conduction velocity; R, right; L, left.
SENSORY NERVE CONDUCTION STUDIES*
Nerve Distal Latency (ms) Amplitude (μV)
R Sural NR NR
L Sural NR NR
R Median 3.9 (≤ 3.7) 12.0 (≥20.0)
R Ulnar 3.9 (≤ 3.5) 5.0 (≥15.0)
* Normal values are in parentheses
Abbreviations: NR, nonresponsive; R, right; L, left.
NEEDLE ELECTROMYOGRAPHY
Muscle Spontaneous
Activity
Recruitment
R Gluteus medius 0 Normal
RVastus medialis 0 Normal
R Tibialis anterior 0 Normal
R Medial gastrocnemius 0 Normal
R Extensor hallicus longus 1+ Normal
Page 5 of 33
R First dorsal interosseous (Pedis) 2+ Reduced
L First dorsal interosseous (Pedis) 2+ Reduced
R Pronator teres 0 Normal
R Abductor pollicus brevis 0 Normal
R First dorsal interosseous (Hand) 0 Normal
Abbreviations: R, right; L, left.
In addition, F waves were mildly prolonged in all motor nerves tested. His history and exam is
most consistent with a diagnosis of sensorimotor neuropathy due to
(a) diabetes or glucose intolerance.
(b) uremic disease.
(c) chronic inflammatory demyelinating polyradiculopathy.
(d) hereditary motor sensory neuropathy
Answer: (a)
Commentary: Diabetic neuropathy electrophysiological exam may demonstrate sensory nerve
conduction study abnormalities with normal motor nerve conduction studies but positive
fibrillation potentials distally on needle examination. In this case, motor nerve conduction studies
are borderline normal. It is likely that had F waves been obtained they would be mildly
prolonged. A neuropathy due to uremic disease would likely demonstrate pronounced conduction
slowing and low amplitude responses in sensory and motor nerves, and likely would not be
undiagnosed prior to the presentation described in the scenario. Chronic inflammatory
demyelinating polyradiculopathy (CIDP) and hereditary motor sensory neuropathy (HMSN-1)
represent demyelinating processes, and there is no evidence of this finding in the results.
A 14-year-old with severe traumatic brain injury admitted to your rehabilitation unit has no
spontaneous movement. What is the best prevention for heterotopic ossification?
(a) Passive range of motion
(b) Nonsteroidal anti-inflammatory medications
(c) Disodium etidronate (Didronel)
(d) Radiation
Answer: (a)
Commentary: Heterotopic ossification is found in a high percentage of children immobilized by
traumatic brain injury and spinal cord injury. The best prevention for the development of HO is
an aggressive program of passive range of motion. Nonsteroidal anti-inflammatory medications
and radiation are available as treatment options. Didronel is not used in pediatric patients due to
risk of rickets or rachitic syndrome.
Which muscle group displays the earliest pattern of weakness in Duchenne muscular dystrophy?
(a) Ankle dorsiflexors
(b) Neck flexors
(c) Shoulder flexors
(d) Knee extensors
Answer: (b)
Commentary: In Duchenne muscular dystrophy, weakness is first seen in the neck flexors during
preschool years. Pelvic girdle weakness precedes shoulder girdle weakness by several years.
Ankle dorsiflexors are weaker than plantarflexors; ankle everters are weaker than inverters; knee
extensors are weaker than flexors; hip extensors are weaker than flexors.
A 50-year-old man has obstructive sleep apnea (OSA). He is morbidly obese and has a body mass
index (BMI) of 39 kg/m². He is also complaining of chronic low back pain, which he claims
limits his mobility. Which approach would best benefit him?
(a) Prescribe a motorized wheelchair.
(b) Prescribe modafinil (Provigil) for daytime sleepiness.
(c) Schedule opioid analgesics for pain control.
(d) Order surgical referral for a tracheostomy
Answer: (b)
Commentary: Obstructive sleep apnea (OSA) is characterized by snoring, arousals, and daytime
sleepiness. Most patients with OSA are male, middle-aged, with an average BMI of 32.5 +/-
9.0kg/m2. Wheelchairs should be used only in cases of compromised mobility and powered
mobility used only when no other options exist. Modafinil can be used as adjunct therapy for
daytime sleepiness. Narcotic analgesics should be prescribed with caution because of depression
of central respiratory drive. Positive airway pressure (PAP) delivered with continuous (CPAP) or
bilevel (BiPAP) pressures can correct upper airway obstruction. If the noninvasive approach is
not effective, tracheostomy may be necessary.
A construction company manager is concerned about hiring employees over the age of 40, citing
lower productivity because of lower endurance compared to younger workers. You tell him that
the average decline in physical work capacity between the ages of 40 and 60 is
(a) 5%
Page 7 of 33
(b) 20%
(c) 35%
(d) 50%
Answer: (b)
Commentary: While variation exists, an average decline of 20% in physical work capacity has
been reported between the ages of 40 and 60 years, due to decreases in aerobic and
musculoskeletal capacity. However, differences in habitual physical activity will influence the
variability seen in individual physical work capacity and its components.
Of the following modalities, which is the most effective in treating phantom limb pain?
(a) Iontophoresis
(b) Transcutaneous electrical nerve stimulation
(c) Short wave diathermy
(d) Paraffin baths
Answer: (b)
Commentary: Of the options listed, transcutaneous electrical nerve stimulation (TENS) is the
modality that may be useful in treating phantom limb pain. Iontophoresis is generally used for
dispersion of medications. Short wave diathermy is a method of deep heat. Paraffin bath is a
superficial heat modality.
Hamstring injuries occur most commonly
a) at the proximal attachment of the lateral hamstrings to the pelvis.
b) during concentric contraction of the medial hamstrings.
c) at the distal attachment of the medial hamstrings to the tibia.
d) during eccentric contraction of the lateral hamstrings.
Answer: (d)
Commentary: The majority of hamstring injuries occur from indirect forces during running and
sprinting activities. Most injuries occur at the myotendinous junction, not at the osseous
attachments, during eccentric contraction of the hamstring. The lateral hamstrings (biceps
femoris) are affected more than the medial hamstrings (semitendinous and semimembranosus).
Which modifiable risk factor MOST increases the relative risk of stroke?
(a) Smoking
(b) Hypertension
(c) Hypercholesterolemia
(d) Diabetes mellitus
Answer: (b)
Commentary: Hypertension, defined as a systolic pressure greater than 165mmHg, or a diastolic
pressure greater than 95mmHg, increases the relative risk of stroke by a factor of 6. The
Framingham study has confirmed that smoking is independently associated with stroke. The
relative risk for heavy smokers (more than 40 cigarettes a day) is twice that of light smokers
(fewer than 10 cigarettes a day). Cessation of smoking reverses the risk to that of nonsmokers
within 5 years of quitting. Hypercholesterolemia has not been epidemiologically linked to
increased stroke incidence, but its strong influence on atherosclerosis makes it an indirect risk
factor. Diabetes mellitus increases the relative risk of stroke by 3 to 6 times the general
population.
Which muscle fiber types are recruited first in isometric contractions?
(a) Type 1
(b) Type 1b
(c) Type 2
(d) Type 2b
Answer: (a)
Commentary: Fatigue-resistant type 1 fibers are recruited initially followed by type 2b fibers.
There are no type 1b fibers.
Which symptom most frequently impacts quality of life in patients with incurable cancers?
(a) Fatigue
(b) Anorexia
(c) Weakness
(d) Depression
Answer: (a)
Commentary: Cancer patients experience a much broader range of symptoms that impact their
quality of life and their ability to address existential issues at the end of life than those listed here.
A systematic review of symptom prevalence studies in patients with incurable cancer identified
Page 9 of 33
fatigue (74%), pain (71%), lack of energy (69%), weakness (60%) and anorexia (53%) being the
most prevalent that impact quality of life. The prevalence of nausea is 40% in the last 6 weeks of
life. Fatigue is often the primary condition adversely affecting quality of life.
Which therapeutic application of functional electrical stimulation is NOT applicable in the
population with spinal cord injury?
(a) Lower limb exercise in cauda equina syndrome
(b) Ventilatory assistance in a C2 ASIA class A injury
(c) Achieving lateral or palmar prehension in a C6 ASIA class A injury
(d) Electroejaculation to harvest sperm for assisted reproduction techniques
Answer: (a)
Commentary: Functional electrical stimulation (FES) strategies use applied electrical current to
activate weak or denervated muscle. FES is most effective in upper motor neuron injuries with
preservation of the anterior horn cells and motor nerve roots. Because of the amount of charge
density required to directly depolarize muscle, FES is not effective if large quantities of
musculature are denervated. FES can be applied to the skin surface, or by means of implanted
electrodes. One application in the population with SCI is its use in conjunction with a bicycle
ergometer to improve cardiac capacity. Generally, individuals with cauda equina syndrome will
not be good candidates for FES-assisted cycling, due to the extent of denervation associated with
this injury level. Phrenic nerve and diaphragmatic pacing have been used to wean standard
ventilator dependence in individuals with high tetraplegia and preserved phrenic nerve function.
Implanted FES systems have been used to generate hand grasp and release, with or without
tendon transplantation. External hand/forearm orthoses have also been developed primarily for
therapeutic stimulation, with the hope of developing future neuroprostheses. Patients with intact
parasympathetic efferent innervation to the detrusor have improved control of micturition, albeit
with the need for sacral deafferentation, resulting in the loss of perineal sensation and reflex
erection. Electroejaculation using a rectal probe has been highly successful at producing seminal
emission for sperm harvesting for the purpose of assisted reproduction in individuals with SCI.
For injured workers with chronic low back pain, which outcome is associated with better
performance during a functional capacity evaluation (FCE)?
(a) Shorter usage of temporary disability benefits
(b) Lower subjective reports of perceived disability
(c) Higher likelihood of sustainable work tolerance
(d) Fewer recurrences of low back pain over the next 12 months
Answer: (a)
Page 10 of 33
Commentary: Functional capacity evaluations (FCEs) are commonly used to determine readiness
for return to work. These evaluations measure the injured worker’s functional abilities relative to
the physical demands required by the job. The clinical assumption is that workers who perform
better during FCEs will have a lower risk of reinjures and less pain exacerbation upon return to
work. One-year follow-up of patients with chronic low back pain whose FCE demonstrated
performance that met or exceeded physical job requirements did not demonstrate a reduction of
recurrent low back pain, improved occupational sustainability, or improved perception of
disability. Better FCE performance was mildly associated with faster return to work and shorter
duration of temporary disability benefits.
Which statement concerning management of seizures after a traumatic brain injury is TRUE?
(a) All patients with postresuscitation Glasgow Coma Scale score below 12 require 3 months
of an antiepileptic medication.
(b) Seizures occurring less than 24 hours postinjury require an antiepileptic medication for at
least 12 months.
(c) Seizures occurring 24 hours to 7 days postinjury should be treated with at least 12 months
of an antiepileptic medication.
(d) Seizures occurring more than 7 days postinjury should be treated with an antiepileptic
medication for at least 3 years.
Answer: (c)
Commentary: The American Academy of Physical Medicine and Rehabilitation and the
American Association of Neurological Surgeons recommend seizure prophylaxis after a traumatic
brain injury as standard treatment. All patients with postresuscitation Glasgow Coma Score
(GCS) below 12 require 7 days of therapeutic phenytoin sodium. Immediate posttraumatic
seizures (defined as those occurring within 24 hours postinjury) do not require any additional
prophylaxis after 7 days. Early (more than 24 hours but less than7 days) seizures should be
treated with at least 12 months of an antiepileptic medication, unless a time-limited intracranial
abnormality such as hydrocephalus, infection, or active hemorrhage, etc., was the cause. Late
seizures – those occurring more than 7 days postinjury – should be treated with an antiepileptic
medication for at least 12 months. Any seizure that lasts longer than 2 minutes is defined as
“status epilepticus” and warrants treatment with an antiepileptic medication for at least 12
months.
A 30-year-old man with a T12 fracture and a spinal cord injury has the following findings on neurologic exam: Motor Exam Sensory Exam* Page 11 of 33 Nerve R L R L C5 5/5 5/5 2 2 C6 5/5 5/5 2 2 C7 5/5 5/5 2 2 C8 5/5 5/5 2 2 T1 5/5 5/5 2 2 T2- T12 N/A N/A 2 2 L1 N/A N/A 2 2 L2 3/5 3/5 1 1 L3 3/5 3/5 1 1 L4 1/5 1/5 1 1 L5 1/5 1/5 1 1 S1 1/5 1/5 1 1 S2-5 - - 1 1 * Light touch and pin prick testing Abbreviations: L, left; R, right, N/A, not applicable. The patient’s ASIA classification would be a) T12 ASIA class D b) L1 ASIA class C c) L2 ASIA class B d) L3 ASIA class C
Answer: (b)
Commentary: The motor level is defined as the most distal motor level with functional strength
(at least 3/5), so long as the motor level immediately superior is 5/5 or normal; if there is no
defined myotome (ie, T2-T12) the last normal dermatome is used. In the example given, the
myotome is L2, because the L1 dermatome is normal and is used as the myotome. The sensory
level is defined as the most distal dermatome with normal sensation, and the neurologic
dermatome is L1. So the neurologic level is L1, since it is the most distal level with a normal
myotome and dermatome. The ASIA impairment classification is C because more than half (6 of
10) of the key muscles below the neurologic level have a muscle grade less than 3/5.
Which statement regarding an independent medical examination (IME) is TRUE?
(a) The traditional physician-patient relationship is not maintained, and confidentiality is not
guaranteed.
(b) The examiner is exempt from potential liability since the purpose of the evaluation is to
assess medical-legal issues, not clinical issues.
(c) Treating providers may conduct an IME as long as records from other providers are also
reviewed.
(d) Because of potential conflicts of interest, only providers no longer in clinical practice
should conduct IMEs.
Answer: (a)
Commentary: In the IME context, a traditional physician-patient relationship does not exist, since
the evaluation does not include “intent to treat.” Confidentiality is not guaranteed, since the
examiner is expected to share certain medical information and findings with the referring party.
Because a “limited doctor-patient relationship” exists during an IME, the physician is responsible
for disclosing in the IME any medical findings that could affect the patient’s health, and he or she
is potentially liable for any harm, direct or indirect, that may be sustained by the person
examined. Only a provider who is uninvolved with an examinee’s treatment may conduct an
IME, although a treating provider may be an “expert witness.” Legal requirements for
qualification as an expert witness vary from state to state. There is no restriction regarding a
provider’s clinical status and eligibility to conduct IMEs
A patient having difficulty late in the day getting up from a chair, going up or down stairs, and
reaching with his arms presents for electrodiagnostic studies. Physical exam demonstrates normal
deep tendon reflexes and normal findings on manual muscle testing. Standard sensory and motor
nerve conduction studies are normal. Repetitive axillary nerve stimulation (RNS) performed at
2Hz demonstrates 20% decremental response. Immediately after exercise, the RNS decrement is
no longer observed. Three minutes following exercise, however, the decrement is greater. Needle
electromyography results are normal.
Upon further investigation, you would most likely find what additional clinical finding?
(a) Asthma
(b) Dry mouth
(c) Ptosis
(d) Skin rash
Answer (c)
Commentary: The patient presents with myasthenia gravis (MG), a postsynaptic neuromuscular
junction disorder. Ptosis and extraocular weakness often occur in MG. Lambert-Eaton myasthenic
syndrome (LEMS), a presynaptic neuromuscular junction disorder, would demonstrate
postexercise facilitation (at least 100% increase in first response CMAP immediately following
exercise) and likely have low-amplitude baseline CMAP results. Autonomic symptoms such as
dry mouth often accompany LEMS. Long-term steroid treatment for asthma may cause myopathy
without significant needle EMG results, but RNS would be normal. Although dermatomyositis
typically presents with proximal weakness, no abnormalities characteristic of an inflammatory
myopathy were seen on needle electromyography.
Which sign is associated with central dysautonomia following severe traumatic brain injury? Page 13 of 33 (a) Flaccidity (b) Hyperthermia (c) Hypotension (d) Bradycardia
Answer (b)
Commentary: Central dysautonomia can occur acutely after severe traumatic brain injury. It has
also been called diencephalic seizures, autonomic or neuro storming or hypothalamic
dysregulation syndrome. Signs include elevated temperature with a normal fever work up,
tachycardia, elevated blood pressure, rapid respiratory rate and posturing. Facial flushing and
diaphoresis may also be seen.
A patient with a left transfemoral amputation demonstrates a lateral trunk lean towards his
prosthetic side. What is the most likely cause?
(a) Prosthesis too long
(b) Long residual limb
(c) Prosthesis aligned in adduction
(d) Hip abduction contracture
Commentary: Causes of lateral trunk lean towards the prosthetic side include: prosthesis too
short, hip abduction contracture, prosthesis lined in abduction, and short residual limb.
Which type of study best differentiates a severe polyradiculopathy from amyotrophic lateral
sclerosis (ALS)?
(a) Motor nerve conduction studies of upper and lower extremities
(b) Needle electromyography of thoracic paraspinals or bulbar muscles
(c) Sensory nerve conduction studies of upper and lower extremities
(d) Needle electromyography of multiple extremities
Answer (b)
Commentary: Sensory nerve conduction studies are normal in both radiculopathy and motor
neuron disease. Motor nerve conduction studies are also often normal in both diseases. Both
diseases may demonstrate abnormal needle examination in multiple extremities. Thoracic
paraspinals and bulbar muscle examinations are most helpful in differentiating severe
polyradiculopathy from amyotrophic lateral sclerosis (ALS), since one would expect these studies
to be normal in radiculopathy but may be abnormal in ALS.
Pathological drooling in children with spastic quadriparetic cerebral palsy is
(a) due to excessive saliva production.
(b) unsightly, but has no medical significance.
(c) associated with inefficient, uncoordinated swallowing.
(d) associated with increased dental caries.
Answer: (c)
Commentary: Pathological drooling is the unintentional loss of saliva either anteriorly over the
lips or posteriorly over the back of the tongue. It is associated with an inefficient, uncoordinated
swallow. Anterior drooling is normal in infants up to 18 months of age. Recent studies have
shown that salivary production is similar to that of typical children without cerebral palsy.
Medical complications of pathological drooling include chronic aspiration, pulmonary infections
and skin irritation. Saliva is protective of dentition.
Comparing the functional outcomes at 1-year post treatment of 2 groups of patients with
nonspecific low back pain greater than 12-months’ duration and no prior history of lumbar fusion,
which finding regarding structured rehabilitation with cognitive behavioral therapy (CBT) versus
lumbar fusion is TRUE?
(a) Better functional outcomes in the surgical group versus the CBT group
(b) Improvements in both groups with similar functional outcomes
(c) Better functional outcomes in the CBT group versus the surgical group
(d) Poor functional outcomes in the CBT group, but no consistent outcome in the surgical
group
Answer: (b)
Commentary: Randomized trials for surgery are difficult to conduct, particularly those that
compare surgical to nonsurgical treatment. While available studies do not allow a general
statement regarding the efficacy of fusion over nonsurgical care for discogenic back pain, 4 trials
suggest any advantage of surgery over nonsurgical care is modest, on average near or below the
minimally important change in the disability score. Both groups demonstrated improvement
compared to baseline. Highly structured rehabilitation with a cognitive-behavioral component
seems nearly equivalent to surgery in efficacy at 1 year, with fewer complications.
In a patient with a neuromuscular junction disorder, which electrodiagnostic results for compound
muscle action potential (CMAP), motor unit action potential (MUAP) or nerve action potential
(SNAP) may be misleading if the limb is cold?
(a) Diminished CMAP decrement on repetitive nerve stimulation
(b) Diminished polyphasia of the MUAP
(c) Shortened distal latency of the CMAP
(d) Decreased amplitude of the SNAP
Answer (a)
Commentary: In neuromuscular junction (NMJ) disorders, compound muscle action potential
(CMAP) decrement may be diminished if the limb is cold, likely due to decreased functioning of
acetylcholinesterase. Cool temperatures may alter results by slowing nerve conduction velocity,
prolonging distal latency, increasing amplitude and duration of sensory nerve action potential
(SNAP) and CMAP and motor unit action potential (MUAP), increasing phases of MUAP.
