SAER 2013 Flashcards
An individual with T3 ASIA A paraplegia complains of burning pain in his legs. Additional review of symptoms includes urinary leakage between catheterizations and difficulty sleeping. The best pharmacologic intervention at this time would be
(a) fluoxetine (Prozac).
(b) amitriptyline (Elavil).
(c) alprazolam (Xanax).
(d) trazodone (Desyrel).
Answer: (b)
Commentary: Amitriptyline, a tricyclic antidepressant, can be effective in the treatment of neuropathic pain but has a significant side effect profile that includes an anticholinergic and sedative effect. These side effects would be desirable in this patient with leaking and difficulty sleeping. Prozac may be helpful with pain but may actually cause insomnia and has little anticholinergic effects. Trazodone is a mild sedative with slight anticholinergic properties. Alprazolam is primarily a sedative and is not commonly used for neuropathic pain.
A 22-year-old female gymnast presents to your clinic after a patellar dislocation during practice. She was treated in the emergency room with reduction of the patella and immobilization. Radiographs and magnetic resonance imaging of the knee are negative for fracture or evidence of osteochondral lesions. You choose to treat her with immobilization for 2 weeks and then begin physical therapy. The most appropriate therapy recommendation is to focus on improving
(a) flexibility of gastrocnemius-soleus complex.
(b) strength of the iliopsoas.
(c) flexibility of the biceps femoris.
(d) strength of the vastus medialis.
Answer: (d)
Commentary: Physical therapy in this patient should focus on strengthening of her medial quadriceps muscles and restoration of normal patellar motion. Surgery in select instances addresses realignment of the patella by a lateral retinacular release and/or medial retinaculum repair when torn.
An 18-year-old female on your inpatient traumatic brain injury service is inconsistently oriented and does not recall your name on a day-to-day basis. She can follow single-step commands. She gets more confused when stressed but can be re-directed and can finish her therapy sessions with encouragement. She is more consistent with goal-directed behavior but needs cueing. Greater participation in activities of daily living is evident and she is developing a better awareness of self and others. On the Rancho Los Amigos scale, what is her level of cognitive function? Page 3 of 23 (a) IV (b) V (c) VI (d) VII
Answer: (c)
Commentary: She is presently displaying characteristics consistent with the sixth stage of recovery in the Rancho Los Amigos scale of cognitive function. This patient is not out of posttraumatic amnesia and is still confused. However, she responds appropriately to feedback and is able to participate in therapies. She is improving in goal-directed behavior and is developing greater awareness of self and others. On the Rancho Los Amigo scale, the other options listed are described as follows: Level V - Confused and Inappropriate; Level VI - Confused and Appropriate; Level VII - Automatic and Appropriate. For level VII, you would anticipate that she would no longer need cuing for goal-directed behavior but will still have problems with new activities or with planning and following through with activities.
A 50-year-old man with metastatic renal cell carcinoma status post nephrectomy 1 year ago was found to have a T10 lesion on recent post-operative imaging done as part of a work-up for right-sided mid-back pain. The patient’s pain is not relieved with recumbency and is not affected by thoracic rotation. He has a normal thoracic kyphosis and is neurologically intact on physical examination. An MRI scan of the thoracic spine shows a T10 lytic lesion, normal alignment, no discernable vertebral body collapse, and unilateral involvement of the T10 posterior elements. You recommend
(a) neurosurgical consultation for decompression and segmental stabilization.
(b) radiation oncology consultation for palliative radiotherapy treatments.
(c) T10 kyphoplasty.
(d) custom molded thoracic lumbosacral orthosis (TLSO).
Answer: (b)
Commentary: Palliative radiotherapy treatments directed at the T10 vertebral body will provide symptomatic pain relief from metastatic tumor involvement. The patient has a Spinal Instability Neoplastic Score (SINS) of 6, out of 18. A T10 lesion in the semirigid portion of the thoracic spine scores 1, non-mechanical pain scores 1, lytic bone lesion scores 2, normal alignment scores 0, no collapse with > 50% vertebral body involvement scores 1, and unilateral involvement of the posterior spinal elements scores 1. Neurosurgical decompression and segmental stabilization is not required for a stable T10 lesion in a neurologically intact patient. Similarly, a T10 kyphoplasty is not indicated in the absence of significant vertebral body collapse. A custom-molded TLSO is unlikely to benefit this patient who has no mechanical back pain symptoms.
What is the overall leading cause of death for individuals with paraplegia?
(a) Pulmonary embolism
(b) Suicide
(c) Septicemia
(d) Heart disease
Answer: (d)
Commentary: In paraplegia, the overall leading cause of death is heart disease, followed by septicemia and then suicide. In tetraplegia, pneumonia is the leading cause of death.
You are asked to consult on a 60-year-old cancer patient with an acute deep vein thrombosis (DVT) in the right upper limb, secondary to a long-standing central venous catheter. What therapy restrictions would you recommend for the patient?
(a) Bed rest for 10-12 days to allow for clot maturation.
(b) No activity restrictions, since upper limb DVTs have a low likelihood of causing a pulmonary embolus.
(c) Begin resistive exercises 12-24 hours after the patient is therapeutic on an anticoagulant.
(d) Limit therapy to ambulation, balance, and ADL training if anticoagulation is medically contraindicated.
Answer: (d)
Commentary: Because patients with acute upper limb DVT who cannot safely be anticoagulated are at high risk for pulmonary emboli and death, their physical, occupational, or lymphedema therapy should be functional in nature (ie, ambulation, balance, ADL training). Resistive exercises should be deferred until 48 – 72 hours after a patient is therapeutic on an anticoagulant (low molecular weight heparin, unfractionated heparin, or Coumadin). Prolonged bed rest for clot maturation is no longer supported within the medical literature for lower extremity DVTs, since the initial recommendation was based on a single limited study. Although the timing of mobilization following an acute upper limb DVT and institution of therapy has not yet been defined in the literature, bed rest for 10-12 days is overly restrictive. However, placing no activity restrictions on the patient is potentially dangerous, since an immature clot may break off and embolize to the lungs.
What secondary condition requires the most medical management in adults with cerebral palsy?
(a) Constipation
(b) Pain
(c) Cardiovascular disease
(d) Osteoporosis
Answer: (b)
Comments: In adults with cerebral palsy (CP) The incidence of pain is high (67%-82%) across all disability groups and appears to increase with age. It is multifactorial with musculoskeletal issues being of primary concern. Constipation issues persist into adulthood and adjustments to the bowel program may be needed. Adults with CP are not reported to have a higher risk of cardiovascular disease but are less likely to be screened than the general population. Osteoporosis is most common (up to 50% in some studies) in non-ambulatory persons, (Gross Motor Function Classification System, GMFCS levels 4, 5), and it increases with age.
The definitive diagnostic test for inclusion body myositis is
(a) muscle enzyme serum levels.
(b) cerebrospinal fluid.
(c) muscle biopsy.
(d) electromyography
Answer: (c)
Commentary: Inclusion body myositis (IBM) is a slowly progressive myopathy that tends to affect middle-aged and older individuals. Clinical manifestations can include distal as well as proximal weakness, which can be asymmetrical. Muscle enzyme levels may be slightly elevated or normal. Myopathic motor units can be seen, although this finding is nonspecific, since it exists in other inflammatory myopathies, as well. Acquisition of cerebrospinal fluid is not part of the work-up for myopathy. Muscle biopsy is diagnostic with rimmed cytoplasmic vacuoles and cytoplasmic and nuclear inclusions.
In the United States, upper extremity amputations are
(a) most often due to vascular disease.
(b) more common in males than females.
(c) rarely caused by workplace injuries.
Page 6 of 23
(d) increasing due to the relaxing of occupational safety standards.
Answer: (b)
Commentary: Of all upper extremity amputations, 90% are due to trauma. The majority of these are related to workplace injuries involving saws or blades. Males account for 75% of all upper extremity amputations. Trauma related amputations have decreased over the last 20 years and they are expected to remain flat or decrease, due to ongoing enforcement of safety standards.
Which score range on the Galveston Orientation and Amnesia Test (GOAT) indicates the end of posttraumatic amnesia (PTA)?
(a) 75–85
(b) 55–65
(c) 35–45
(d) 15-25
Answer: (a)
Commentary: A standard technique for assessing posttraumatic amnesia (PTA) in adults is the Galveston Orientation and Amnesia Test (GOAT), a brief structured interview that quantifies orientation and recall of recent events. The GOAT score can range from 0 to 100, with a score at or above 75 defined as normal. The end of PTA is defined as when the GOAT score is at or above 75 for 2 consecutive days.
Following a crush injury with axonotmesis, the approximate growth regeneration rate at the wrist is 1 centimeter per
(a) day.
(b) week.
(c) month.
(d) year.
Answer: (b)
Commentary: Regenerating axons grow approximately 1 millimeter a day, 1 centimeter a week, 1 inch a month, or 1 foot a year. The rate of axon regeneration depends chiefly on type of injury (crush or laceration) and whether the lesion is proximal or distal. Growth rate following a crush injury with axonotmesis in the upper arm is about 8 millimeters a day; in the upper forearm it is about 6 millimeters a day, at the wrist about 1-2 millimeters a day, and in the hand about 1.0-1.5 millimeters a day. Easier figures to remember, however, are 1mm/day, 1cm/week, or 1 inch/month.
A 62-year-old woman complains of right knee pain and stiffness. On physical examination, she has a genu varum deformity. A physical therapy prescription should include
(a) isokinetic hamstring strengthening.
(b) isometric hamstring strengthening.
(c) closed kinetic chain quadriceps strengthening.
(d) open kinetic chain quadriceps strengthening.
Answer: (c)
Commentary: For knee osteoarthritis, quadriceps strengthening has been well studied and is shown to be beneficial. In closed kinetic chain exercises, the distal aspect of the limb is fixed against a source of resistance, whereas in open kinetic chain exercises, the distal part of the limb is free in space. Closed chain exercises are preferred because they result in less shear force across the joints and are also more functional.
Which finding is a relative contraindication to cryotherapy?
(a) Acute inflammation
(b) Pain
(c) Acute hematoma
(d) Impaired sensation
Answer: (d)
Commentary: Cryotherapy, that is, the therapeutic use of cold by means such as ice, cold packs, or cold water immersion is commonly used to decrease pain, muscle soreness, fatigue and acute inflammation. Relative contraindications include cold intolerance, cryoglobulinemia, impaired sensation or cognitive defects. Cold intolerance can lead to decreased compliance and increased muscle guarding. Cryoglobulinemia results in immune complex precipitation at lower temperatures. Impaired sensation or cognitive defects may lead to tissue injury. Cryotherapy can be effective in decreasing the swelling or bleeding that commonly accompany tissue injuries.
After completing inpatient rehabilitation, an 18-year-old male with complete tetraplegia is able to feed himself with adaptive equipment and requires some assistance with upper body dressing and grooming. He is able to assist with bed mobility, but is dependent for transfers. He is also able to use a manual wheelchair with rim projections indoors on flat surfaces, but when outdoors he prefers to use a power wheelchair with a joystick. His physical therapist reports that he has achieved his maximal expected outcome. What is his level of injury? (a) C4 (b) C5 Page 8 of 23 (c) C6 (d) C7
Answer: (b)
Commentary: Although each person is different, individuals with C5 tetraplegia are in general able to feed themselves with adaptive equipment after set-up and are able to assist with some upper body dressing. Some are able to independently use a manual wheelchair, but most require some assistance, especially on carpets, non-level surfaces and outdoors. Many prefer to use a power wheelchair. People with complete C4 levels of injury are not able to feed themselves, assist with activities of daily living (ADLs), or propel a manual wheelchair, especially if they have no zone of partial preservation. People with C6 and C7 levels of injury are often capable of transferring (independently or with assistance) and of attaining more independence with ADLs.
What is the strongest single predictor of mortality in adults with pediatric onset disabilities?
(a) Feeding problems
(b) Presence of epilepsy
(c) Inability to walk
(d) Intellectual disability
Answer: (d)
Comment: Feeding problems, epilepsy and inability to walk are conditions associated with pediatric mortality, but intellectual disability is the strongest single predictor of mortality in adults with pediatric onset disabilities. Intellectual disability affects a person’s ability to manage health care monitoring, exercise programs, nutrition, housing, and sexuality. These items are likely to be more closely monitored by parents and pediatricians for a child than by community workers and adult physicians caring for adults with pediatric onset disabilities.
For a person with an upper extremity amputation, what is the advantage of choosing a body-powered device over a myoelectric device?
(a) Stronger grip force
(b) Better cosmesis
(c) Lighter weight
(d) Less dependence on motor strength
Answer: (c)
Commentary: Main advantages of body powered systems are lower initial costs, lighter weight, easier repairs, and better tension feedback to body. Advantages of myoelectric devices are cosmesis, less need for motor strength/coordination to operate limb, and stronger grip force.
A 23-year-old woman with C7 ASIA B tetraplegia resulting from an accident 8 months ago is complaining of nausea for several days and has vomited non-bloody, non-bilious food particles the last 3 evenings when placed back to bed after dinner. She also reports some abdominal tightness and bloating. Her symptoms are relieved when lying on the left side. Her bowel training program is going well, resulting in regular, effective bowel movements. She recently lost 25 pounds and appears quite thin on exam. Which study will confirm this patient’s most likely diagnosis?
(a) Abdominal x-ray
(b) Head computed tomography (CT) scan
(c) Serum calcium level
(d) Upper gastrointestinal (GI) series
Answer: (d)
Commentary: Superior mesenteric artery (SMA) syndrome is a condition in which the third segment of the duodenum is compressed between the SMA and the aorta. Although it occurs rarely, it is more common in people with tetraplegia, especially if the person lost weight and is immobilized in the supine position. An upper GI series confirms the diagnosis with an abrupt cessation of barium in the third part of the duodenum. In addition to lying on the left side, some individuals get relief with metoclopramide (Reglan). A serum calcium level could be used to diagnose immobilization hypercalcemia, which is a common cause of nausea and vomiting in patients with tetraplegia. Hypercalcemia is not, however, alleviated with positioning and it usually occurs within the first few months after injury. Abdominal x-ray could identify chronic constipation, but since her bowel program is going well, constipation is not likely to be the cause of her symptoms. Although hydrocephalus would be identified by means of a head CT scan, it is the least likely diagnosis in this case.
A 70-year-old man with COPD presents to your office for follow-up. His forced expiratory volume in 1 second (FEV1) is 55% of predicted normative values. What would you expect the patient’s functional limitations to be?
(a) No functional impairment; the patient is able to walk significant distances without difficulty.
(b) Mild functional impairment; the patient is able to walk significant distances at a slower speed.
(c) Moderate functional impairment; the patient requires intermittent rest when walking and climbing stairs.
(d) Severe functional impairment; the patient is only able to ambulate for very short distances.
Answer: (c)
Page 10 of 23
Commentary: The World Health Organization’s Global Initiative for Chronic Obstructive Lung Disease classifies patients who have an FEV1 between 50%-79% of predicted values as moderately impaired. This equates to the FEV1 dropping between 1-2 liters. Functional impairment develops when the FEV1 falls below 3 liters. Patients with an FEV1 between 30%-49% of predicted values are severely impaired while those with an FEV1 less than 30% are the most impaired.
