soal sem 8 - 4

Question 1

1. 68 year old man who is not able to walk without assistance 123 months after his stroke. You advise him that ambulation does not improve after stroke beyond
   a. 5 weeks
   b. 11 weeks
   c. 7 months
   d. 12 months
   e. 18 months

Answer 1

B

Question 2

2. All of the following are gait characteristics of a person with RA, EXCEPT:
   a. slower speed
   b. decreased stride length
   c. prolonged single limb stance phase
   d. plantar flexion during swing phase
   e. delayed heel rise

Answer 2

C

Question 3

3. which one of the following is a gait characteristic of a person with RA
   a. slower speed
   b. increased stride length
   c. prolonged single limb stance phase
   d. increased knee flexion during swing phase
   e. increased heel rise

Answer 3

A

Question 4

A prerequisite to glossopharyngeal breathing is

a. some diaphragmatic activity to assist
b. patent tracheostomy
c. good tongue strength
d. some scalene activity
e. abdominal supp

Answer 4

(C ) GP breathing requires tongue and pharyngeal muscles to push bolus of air past the vocal cords

Question 5

Which of the following finding is INCONSISTENT with the diagnosis of amyotrophic lateral sclerosis

a. elevated CK
b. abnormal repetitive stimulation test
c. unilateral arm and leg weakness
d. profound atrophy of the intrinsic hand muscles
e. diplopia

Answer 5

Answer: (E)
Sparing of the extraocular eye muscles occurs in ALS. Mild elevation of CK is seen. Abnormalities in repetitive nerve stimulation reflects the effects of impaired neuromuscular junction function due to failing motor neurons or reparative attempts by collateral sprouting.

Question 6

5. A 35 year old female with spinal muscular atrophy with progressive weakness of the arm. Shoulder strength is 2+/5, elbow flexion 3/5, elbow extension 3/5, and fingers are 4/5. Which statement is true?
   a. This patient would not be able to effectively use a balanced forearm orthosis
   b. Proximal scapular fusion would allow her to effectively use her arm
   c. Electrical stimulation can improve function
   d. Rejection of the orthosis is high unless it enhances feeding or leisure time activities
   e. Arm activity should be reduced to prevent progressive weakness

Answer 6

Answer: D. One needs at least 2/5 in elbow flexion to use the balanced forearm orthosis. Limited upper extremity exercise does not adversely affect strength in slowly progressive neuromuscular disorders.

Question 7

6. A 32 year old with two week history of wrist extension weakness. EMG shows CMAP prolonged distal latency and decreased amplitude of the bilateral radial nerve (pick up at extensor indicus). Sensory study is normal. DX is
   a. CTS
   b. C5 radiculopathy
   c. Idiopathic neuralgic amyotrophy (brachial neuritis)
   d. toxic neuropathy due to lead poisoning
   e. malingerer.

Answer 7

D

Lead poisoning leads to a motor axonopathy particularly affecting the extensor muscles of the forearm

Question 8

7. A person with painless weakness of external rotation four weeks after receiving a flu shot. Dx is
   a. RTC tear
   b. Tendonitis
   c. labrum tear
   d. brachial neuritis involving the suprascapular nerve
   e. axillary nerve injury

Answer 8

D

Upper trunk of the brachial plexus, or C5, and C6 nerve roots can also be involved. Pancoast tumor usually involves C8 and T1

Question 9

8. Which of the following statements is TRUE regarding depression in poststroke patients?
   a. Depression following CVA is of short duration
   b. Family members of CVA patients have 2.5 – 3.5 times depression rate
   c. Outcome measures in stroke which emphasize physical status also predicts adjustment
   d. Family members of stroke patient have rates of depression similar to general population
   e. Patient impairment severity at discharge predicts family adjustment problems

Answer 9

B

Family members of CVA patients have 2.5-3.5 times depression rate. Other statements are false

Question 10

9. 6 year old boy with Down syndrome who develops torticollis, hyperreflexia, lower extremity hypertonicity after open heart surgery. You should
   a. EMG of the LE
   b. obtain cervical spine x-ray
   c. MRI of lumbar spine
   d. ophthalmologic evaluation
   e. angiogram of the aorta

Answer 10

B

Atlantoaxial instability is not uncommon in Down syndrome. It can result in spinal cord injury after minimal stress or trauma to the neck.

Question 11

10. The pretibial group is most active at what phase of the gait cycle?
    a. Immediately following heel strike
    b. at mid stance
    c. at toe off
    d. at mid swing
    e. at late swing

Answer 11

A

Don’t confuse that with answer D though I know you are tempted to choose that answer

Question 12

11. What exercises are recommended for persons with nonprogressive mild to moderate restrictive lung disease (VC of 60% predicted)?
    a. pursed lip breathing
    b. glossopharyngeal breathing
    c. valsalva
    d. rapid shallow breathing
    e. inspiratory resistive exercise

Answer 12

E

Inspiratory resistive exercise can improve respiratory muscle endurance but does not affect spirometry values or ventilatory pressures. In progressive conditions, the value of exercise is uncertain and it may lead to long term detriment in lung condition

Question 13

12. Which of the following is true regarding exercise and activity in the elderly?
    a. Reduction in maximal cardiac output is primarily due to reduced maximal heart rate
    b. Walking speed is unrelated to lower extremity muscle strength
    c. The decline in maximal VO2 uptake can be prevented by regular aerobic exercise
    d. The functional effects of bed rest are overstressed relative to their clinical importance.
    e. The incidence of falls is not related to hip muscular strength or balance

Answer 13

A

A reduction in heart rate during maximal exercise has consistently been identified as a cause of reduced cardiac output and maximal VO2 consumption. With aging there is an increase in stroke volume to compensate for the decrease in cardiac output. (Anyone has any comments about this? I thought with aging, your stroke volume would decrease)

Question 14

13. The most common cause of death 2-3 weeks after CVA is
    a. MI
    b. pneumonia
    c. another CVA
    d. arrythmia
    e. Pulmonary Emboli

Answer 14

E

MI is the most common cause of death after 3 months

Question 15

14. Patients with cervical radiculopathy should avoid
    a. cervical forward flexion
    b. cervical lateral bending
    c. NSAIDS
    d. heat modalities
    e. bed rest

Answer 15

B

they should avoid extension and lateral bending, Spurling’s maneuver

Question 16

15. A 16 year old boy with LBP for 6 months. Pain is worse with extension. Standing hyperextension test is positive. The diagnosis is
    a. lumbar radiculopathy
    b. lumbar spondylolysis
    c. lumbar spondylosis
    d. conversion reaction
    e. piriformis syndrome

Answer 16

B

History suggests lumbar spondylolysis which is a stress fracture to the pars interarticularis. The standing hyperextension test is done to stress the pars interarticularis on each side with ipsilateral one-legged standing with hyperextesion.

Question 17

16. 32 year old dock worker has lower back pain, severe at night, morning stiffness, ESR of 50 mm in 1 hour, negative RF, sclerosis of bilateral SI. Patient is concerned about vocational rehab. Your rec’d
    a. sedentary work to reduce the likelihood of long term disability
    b. prompt return to work to avoid deconditioning
    c. work hardening program to increase endurance
    d. 2 weeks of bed rest
    e. development of a thorough job description for a dock worker position

Answer 17

A

Above is classic description of AS which there is no Tx. Vocational rehab and sedentary work can reduce long term disability.

Question 18

17. In patients less than 45 years old, the most likely cause of stroke is
    a. hypertensive encephalopathy
    b. embolus following a MI
    c. migraine headache induced vasospasm
    d. cerebral arteriosclerosis
    e. embolus due to mitral valve disease

Answer 18

E

Cardiac embolus is the most common cause of stroke below the age of 45, most commonly a/w mitral valve prolapse or stenosis. Migrain rarely produces permanent neurologic sequelae

Question 19

18. 25 year old with proximal femoral nerve injury. HF and KE are 3/5. Which is the most appropriate initial management of the gait abnormalities
    a. a heel lift to place the foot in plantarflexion to stabilize the knee
    b. strengthening of the gluteus maximus and hamstring muscles
    c. KAFO with alocked knee and ankle joint
    d. dorsiflexion assist orthosis to improve foot clearance
    e. training in the use of bilateral forearm crutches

Answer 19

B

During ambulation, maximal quadriceps activity occurs in early stance during an eccentric contration which absorbs impact and controls knee flexion. With weakness, instability can occur. The hip extensor muscles can fx in a closed kinetic chain to exten the knee and thus help to substitute for the weak quads. A heel lift would increase the heel level arm, increasing knee flexion moment at heel strike. Orthoses and crutches would correct the problem, but would you put someone in it?.

Question 20

19. With an ischial containment socket design for an AKA prosthesis
    a. the medial lateral diameter is generally wider than the anterior posterior diameter, allowing containment of the ischium and ramus
    b. pressure over Scarpa’s triangle forces the ischium into a posterior ischial containment area
    c. containing the ischium, trochanter, and distal femur securely within the socket provides improved biomechanical fx of the hip abductors to help stabilize the pelvis during stance phase
    d. suction suspension is required for fitting of an ischial containment socket
    e. myodesis of the hip adductor group is required for consideration of ischial containment socket fitting

Answer 20

C

The resulting bony lock of the ischium, trochanter, and lateral distal aspect of the femur provides a biomechanical advantage to the hip abductors to help stabilize the pelvis during stance phase. Ans (a) describes a quadrilateral socket.

Question 21

20. 32 year old laborer presents with numbness and tingling in his right leg. SLR is positive. This means that
    a. tension is transmitted to the nerve root immediately upon raising the heel off the table
    b. irritation of an affected nerve root has occurred
    c. raising the leg causes transient weakness of the affected leg
    d. raising the leg more than 70 degrees causes increased tethering of the affected nerve root
    e. the patient is a malingerer

Answer 21

B

A symptomatic disc herniation tethers the affected nerve roots so that pain results from stretching the nerve by straight leg raising from the supine position. Tension is transmitted to the nerve roots once the leg is raised beyond 30 degrees, but after 70 degrees further movement of the nerve is negligible

Question 22

21. 4 year old girl with spastic quadriparetic CP is seeing you for wheelchair evaluation. She has normal cognitive and language development, able to sit erect, marked increase tone in bilateral lower extremities, truncal weakness but good head control, flexor posture of the right upper extremity (RUE), poor fine motor control of the left upper extremity (LUE) but with good proximal control and placement of the left hand is precise.
    a. hemi type wheelchair for self propulsion using the left UE
    b. standard wheelchair since powered is not safe
    c. intensive PT for gait training
    d. no wheelchair since this may reduce her motivation to walk
    e. powered wheelchair

Answer 22

E

A normal 3 year old can learn to operate a powered wheelchair safely. This girl is not going to walk, and a hemi chair is limiting

Question 23

22. In a patient with recent stroke, the most sensitive clinical indicator for early RSD of the upper limb is
    a. pain in the shoulder at rest
    b. tenderness in the MCP joints
    c. mottled skin changes with temperature change
    d. edema in the hand
    e. decreased IP join flexion

Answer 23

B

Stage I of RSD is characterized by pain, tenderness, vasomotor changes, and edema. The most sensitive is pain in flexion of the MCP joints

Question 24

23. 23 year old MVA with weakness in the right shoulder. EMG shows 4+ spont activities in the C5C6 muscles. No voluntary motor units in C5 C6. NCS of median and ulnar nerves is normal. Where is the injury?
    a. neuropraxic injury of C5 C6 with good prognosis
    b. root avulsion with a poor prognosis
    c. severe brachial injury involving the lateral cord
    d. severe brachial injury involving the upper trunk
    e. too early to know the prognosis

Answer 24

B

Lesion is proximal to the dorsal root ganglion which is probably a root avulsion.

Question 25

24. 60 year old golfer with shoulder pain and positive drop arm test. You tell him
    a. unlikely that he has RCT
    b. unlikely that he has RCT, MRI is very sensitive and specific
    c. likely to have RCT and his MRI will be abnormal
    d. likely to have RCT and MRI will be normal
    e. very few over 60 will have RCT

Answer 25

C

MRI will pick up RCT in asymptomatic patients (non specific). Overall prevalence of asymptomatic RCT in all groups was 34%.. Fifty four % of persons over 60 had RCT (28% full thickness, 26% partial). MRI is sensitive but not specific.

Question 26

25. A patient has arm weakness 3 weeks after removal of a cast for proximal radius fracture. Weakness is noted in pronation, WF, finer flexion, thumb abduction and opposition, and decrease in sensation in lateral palmar aspect. EMG showed normal median nerve response at the wrist but a 70% conduction block at the level of the mid humerus. Spontaneous activities are noted in the intrinsics.
    a. referral for nerve exploration and decompression
    b. MRI
    c. wrist splint and reassurance of a favorable prognosis
    d. electrical stim to ensure recovery
    e. r/o compartment syndrome by pressure meas’t

Answer 26

C

Although mid axon loss is present, the normal amplitude distally and a focal conduction block indicate that recovery is likely once the source of compression ( the cast) is removed. Spontaneous remyelination and recovery usually takes several weeks to months. The use of wrist splint to place the arm in functional position is reasonable. Electrical stim can retard atrophy but does not alter outcome

Question 27

26. Vascular supply of the spinal cord.
    a. the great spinal artery of Adamdiewicz supplies the lumbar and sacral cord
    b. the two anterior spinal arteries are branches of the vertebral artery
    c. the watershed zone is at C6-7, which causes most cervical lesions to be complete
    d. the spinal venous complex drains directly into the inferior vena cava
    e. the midthoracic region is most vulnerable to ischemia

Answer 27

E

The midthoracic region T4-6 is the watershed zone. The great artery of Adam, a large radicular artery arising from the posterior intercostal artery, enters between T9 and L1. There are one anterior and two posterior spinal arteries. The two posterior arteries arise from the vertebral arteries. The anterior artery receive contribution from the vertebral arteries, posterior intercostal, lumbar and sacral arteries.

Question 28

27. A 3 year old girl with a history of swelling of the knees bilaterally and left ankle with restricted rom. She has no fevers, no h/o trauma. The pupils show slight irregularity in shape when they constrict to light. The DX is
    a. pauciarticular juvenile RA
    b. polyarticular juvenile RA
    c. Still’s disease
    d. SLE
    e. leukemia

Answer 28

A

Pauciarticular JRA involves four or fewer joints (usually larger joints), more common in girls. Iridocyclitis, manifests as irregular pupils as a result of formation of synechia, occurs at lest 10% and leads to blindness. Opthal consult is needed in these children even when there are no symptoms. Polyarticular JRA involves 5 or more joints. Still’s or systemic JRA, sle, and leukemia would have systemic symptoms

Question 29

28. An infant is born at term with normal weight and Apgar. She has hypotonia and poor suck, tented mouth and unable to fully close her eyes. This is the first child of a 20 year old mom with uncomplicated pregnancy. FHx : 24 year old maternal uncle with cataracts, clumsiness of the hands, and recent onset of DM. It is expected that
    a. the baby’s symptoms will be rapidly progressive
    b. the baby’s symptoms will resolve with minimal sequelae
    c. the baby’s symptoms are consistent with congenital myotonic dystrophy
    d. the baby’s symptoms are consistent with Werdnig Hoffman disease
    e. there is essentially no risk with future pregnancies

Answer 29

C

Myotonic muscular dystrophy may present at birth in offspring of mothers who have not been dx as having myotonia because of insignificant symptoms. Ther is great variability in expression of the myotonia phenotype within families because sx depend on the number of GCT triplets replicated at the time of conception. Newborn with spinal muscular dystrophy (Werdnig Hoffman) do not have facial weakness

Question 30

29. Common musculoskeletal problems in pregnancy include all the following EXCEPT:
    a. low back pain
    b. leg cramps
    c. carpal tunnel syndrome
    d. shin splints
    e. DeQuervain tenosynovitis

Answer 30

D

Common problems include widening of the symphysis pubis, low back pain, carpal tunnel syndrome, Dequervain, leg cramps, and transient osteoporosis of the hip..

Question 31

30. The most common site of spine fracture in patients with AS
    a. C1-2
    b. C5-6
    c. T11-12
    d. L2-3
    e. L5-S1

Answer 31

C

Most common site

Question 32

31. Characteristics of central, poststroke pain include which of the following?
    a. Early onset after stroke
    b. Hyperpathia
    c. Sharpness in quality
    d. Association with hypothalamic lesions
    e. Association with psychomotor seizures

Answer 32

B

Hyperpathia is an excessive reaction to even mild tactile stimulation of the affected limb. Common characteristics of central poststroke pain include intractable dysesthetic qualities, which may be diffuse and deep or localized and syperficial, may be intense or severe, burning, stinging, shooting or aching. It occurs weeks to months after the onset of the stroke. It is very intense but not described as sharp. Lesions may be in the thalamic, cortical, or brainstem regions.

Question 33

32. Neuropathic foot ulcers
    a. are typically located over the medial malleolus
    b. rarely occur if the vascular supply is good
    c. are acutely painful
    d. often occur in feet with hammer toe deformities
    e. result from an excessive inflammotory response due to autonomic neuropathy

Answer 33

D

Neuropathic ulcers occur in patient with impaired or absent sensation and are often asymptomatic. Hammer toe defromities resulting from weak intrinsic foot muscles can lead to metatarsal phalangeal subluxation and distal migration of the plantar fat pad, exposing the metatarsal head to abnormal pressure during walking. Other common places include the calcaneous, dorsum of toe, lateral and medial border of the forefoot. Altered blood flow due to autonomic neuropathy is thought to play a role in neuropathic arthropathy (Charcot joints). Anhidrosis a/w autonomic neuropathy may contribute to drying and cracking of the skin which increases the risk of breakdown

Question 34

33. 2 year old with spastic diplegia with a scissoring stiff gait requiring a walker. She was 26 weeks gestational age, on mechanical ventilation for 1 month, and had a grade II intraventricular hemorrhage. The abnormal gait is due to
    a. a brain disorder caused by a stroke before birth
    b. motor disorder due to injury or a lesion in an immature brain
    c. common complication of prematurity a/w spasticity and mental retardation
    d. brain disorder caused by anoxia at birth
    e. spinal disorder

Answer 34

B

Anoxia at birth is responsible for less than 10% of cerebral palsy. Only a fracture of childer with CP is retarded. Prenatal stroke accounts for a small number of CP especially in term infants. Lower birth weight, lower gestation increase the risk of periventricular leukomalacia and CP in premature infants.

Question 35

34. In a hemiplegic, the function of a posterior stop in a double upright AFO with dual action adjustble ankle joint and extended steel shank is to
    a. cause the ground reaction force line to fall posterior to the knee joint in mid stance
    b. assist in control of moderate to severe plantar flexor spasticity
    c. assist weak plantar flexors
    d. improve knee stability at heel strike when the posterior stop is set in 5 degrees of dorsiflexor rather than plantar flexion
    e. improve medial and lateral stability at the ankle

Answer 35

B

Answer a) will cause increase in knee flexion moment. C) requires an anterior stop. AFO does not offer ankle stability. D) is correct, but B) is the best. A stop is requried to prevent equinus at the ankle in moderate-severe spasticity

Question 36

35. The most likely symptoms of surgically proven spinal stenosis is
    a. LBP
    b. neurogenic claudication
    c. lower extremity weakness
    d. tingling in toes with prolonged sitting
    e. B/B symptoms

Answer 36

B

pseudoclaudication is the most common symptoms which include pain, numbness, and weakness. Lower extremity weakness is not specific to back pain. B/B is rare.

Question 37

pseudoclaudication is the most common symptoms which include pain, numbness, and weakness. Lower extremity weakness is not specific to back pain. B/B is rare.

Answer 37

D

Reiter’s is seronegative spondyloarthropathy. 90% is HLA-B27 positive.

Question 38

37. 18 month old with hypotonia at birth, gross motor delays, able to sit at 1 year old, not crawling or pulling to stand proximal muscle weakness, hypotonia, fasiculation of the tongue and joint hyperextensibility. She is social and has no language delay. Dx is:
    a. myotonic muscular dystrophy
    b. spinal muscular dystrophy
    c. Becker
    d. CP
    e. Charcot Marie Tooth

Answer 38

B

Spinal muscular dystrophy type II presents with above. Congenital muscular dystrophy are siginficantly cognitively impaired. CP has hypertonia

Question 39

38. When considering EMG of HIV infection
    a. inflammatory neuropathies and myopathies occur early in the course
    b. medications are an unlikely cause of neuromuscular findings
    c. opportunistic infections present with characteristic findings
    d. neuromuscular abnormalities occur in 80-90% of patients
    e. neuromuscular abnormalities have not been reported to precede manifestations of HIV

Answer 39

A

Inflammaroy neuro and myopathies occur early in the course of the disease, but sensory neuropathy occurs late. Medications can be a significant cause of findings. Opportunistic infections presentation is variable. D) occur in 30-50% and can be presenting symptoms

Question 40

39. 19 year old dancer with posterior heel pain, swelling an thickening of archilles tendon. Most likely contributing factor is
    a. dancing on the soft floor
    b. pronation of ankle and feet
    c. flexible heel cords
    d. peripheral neuropathy
    e. hammer toes

Answer 40

B

Dancing on hard floor, pronation, congenital small or thin cord, cavus foot can contribute to archilles tendonitis

Question 41

40. 3 weeks after partial laceration of the raidal nerve at the level of the proximal humerus with strength of 3+/5.
    a. nerve conduction will be able to differentiate neurotmesis from axonotmesis
    b. improvement in strength is unlikely without surgery
    c. neuropraxia is likely the cause
    d. collateral sprouting will be an important mechanism in recovery
    e. Wallerian degeneration was complete by 48 hours post injury

Answer 41

D

Nerve injury can be classified as neurapraxia,axonotmesis, neurotmesis. Both axon and neurotmesis appear on EMG as axon loss with reduced motor and sensory amplitudes and denervation potentials. Recovery can be by collateral sprouting, axonal regrowth and hypertrophyof residual intact motor units. It is estimated that loss of up to 1/3 to 1/2 of axons can be compensated for by collateral sprouting. Wallerian degeneration occurs over 3 to 7 days as documented by axon conduction failure

Question 42

Nerve injury can be classified as neurapraxia,axonotmesis, neurotmesis. Both axon and neurotmesis appear on EMG as axon loss with reduced motor and sensory amplitudes and denervation potentials. Recovery can be by collateral sprouting, axonal regrowth and hypertrophyof residual intact motor units. It is estimated that loss of up to 1/3 to 1/2 of axons can be compensated for by collateral sprouting. Wallerian degeneration occurs over 3 to 7 days as documented by axon conduction failure

Answer 42

B

The wrist driven tenodesis flexor hinge orthosis creates a three jawed chuck prehension stabilizing the IP joints of digits two and three and both the IP and MCP joints of the thumb. The extensor carpi radialis muscle activates wrist extension, which through tenodesis creates a three jaw chuck prehension

Question 43

42. 7 year old boy with L4-5 spina bifida but no hydrocephalus or Arnold Ciari malformation has had worsening gait problems over past few months with no change in school performance but with increased tone and weakness in the lower extremities without sensory loss. You should
    a. observe
    b. plain films of the thoracic spine
    c. MRI of cervical spine
    d. brain CT
    e. lumbosacral MRI

Answer 43

E

Hydrocephalus presents with cognitive changes, lethargy, and irritability. Hydromyelia is accompanied with sensory loss. Progressive scoliosis which happens in spina bifida can result in a tethered cord causing lower extremity weakness. MRI or CT of spine is the procedure of choice

Question 44

43. EMG on a patient with weakness shows fibrillations, positive sharp waves, and brief short duration. Low amplitude polyphasic motor unit potentials in proximal muscles of arm arm and one leg. The impression reads “needle EMG shows denervation potentials in proximal muscles of the arm and the leg. Weakness most likely due to polymyositis”. You would conclude that
    a. the examiner has made the wrong Dx
    b. the abnormal potentials may not represent denervation
    c. the examiner should have tested for all 4 limbs
    d. the examiner should have consider spinal stenosis as the casue of the findings.
    e. no conclusion should be drawn without NCS

Answer 44

B

Fibs and sharps represent instability of the muscle membrane, not necessarily denervation. In the case of inflammatory myopathy such as polymyositis, it is not appropriate to refere to these abnormal potentials as “denervation potentials”. The examiner is correct not to test all four limbs just in case a biopsy is needed. NCS is not helpful

Question 45

44. Which of the following is true of sleep apnea after a stroke?
    a. seen almost exclusively with brainstem lesions
    b. slow wave sleep is longer comapred to controls
    c. REM sleep is longer compared to controls
    d. O2 desaturation in uncommon
    e. reduced cerebral blood flow occures during sleep

Answer 45

E

Reduced cerebral blood flow may persist into waking hours and reduce neurologic performance. REM and slow wave are shorter than in controls

Question 46

45. Post cardiac transplant exercise intensity is best gauged by
    a. target heart rate based on exercise stress testing
    b. Borg rating of perceived exertional scale
    c. target heart rate of 70-85% of age predicted maximal heart rate
    d. anginal threshold
    e. circulatory catecholamine measurement

Answer 46

B
Heart rate responses are not reliable in the denervated heart, as seen after cardiac transplant. Exired air meas’t, to gauge anaerobic threshold, may also be reduced..

Question 47

46. A 6 year old with progressive difficulty walking, mild scoliosis, a small hemangioma over the midline of the sacrum, and a slightly diminished left ankle reflex. DIAGNOSIS is
    a. spina bifida occulta
    b. muscular dystrophy
    c. tethered cord
    d. spinal muscular dystrophy
    e. invasive hemangioma involving the cauda equina

Answer 47

C

Spina bifida occulta is a normal x ray finding in many children and adults. The midline hemangioma is a clue spinal dysraphism. Findings and symptoms above are classic of tethered cord

Question 48

47. You are referred a 3 month old infant with severe torticollis who is otherwise well. You should:
    a. that it is self limiting and will resolve
    b. referral to a nsg urgently
    c. checking the infant’s hip carefully for dysplasia
    d. emg to r/o radiculopathy
    e. phenol block to the sternocleidomastoid muscle

Answer 48

C
Torticollis is not uncommon and can be present at birth. It can be associated with developmental dysplasia of the hips and long term problems with hemi neglect and craniofacial asymmetry. A referral to PT is appropriate.

Question 49

48. Which one is true
    a. the two spinal arteries are branches of the vertebral artery
    b. there are 35 pairs of spinal nerve roots
    c. the great spinal artery of Adamkiewicz supplies the cervical spinal cord
    d. the caudal spinal cord tapers to end opposite to L1 vertebra
    e. the posterior spinal arteries originate from the posterior cerebral arteries

Answer 49

D

There is only one anterior spinal artery. There are 31 spinal nerves. Adamkiewicz is a large radicular artery that enters between T9 and L1. Posterior arteries are from the posterior inferior cerebellar ateries ro the vertebral arteries themselves

Question 50

49. Kugelberg-Welander disease (SMA type 3) usually results in
    a. clinical signs by age 2
    b. early involvement of distal musculature
    c. death by age 40
    d. moderate cognitive dysfunction
    e. preserved ambulation until the fourth decade

Answer 50

E

SMA type 3 has a milder course with preserved ambulation

Question 51

50. AIDS associated reactive arthritis has clinical characteristics similar to those of
    a. RA
    b. Reiter’s
    c. DISH
    d. late onset juvenile arthritis
    e. AS

Answer 51

B

A classic Reiter of a reactive arthritis with similar features can develop in AIDS. 75% of AIDS with reactive arthritis are HLA-B27 positive. Conjunctivitis, urethritis, enthesitis, and fasciitis are often present. Reactive arthritis in AIDS tends to be rapidly progressive and poorly responsive to NSAID therapy

Question 52

51. Idiopathic facial paralysis
    a. is usually bilateral
    b. clears completely in at least one half of cases
    c. rarely affects taste sensation
    d. is associated with decreased ipsilateral facial sensation
    e. is recurrent in up to 70% of cases

Answer 52

B

70% recover facial function. Taste is often affected and side to side evoked amplitude comparison is the best method to evaluate the facial nerve

Question 53

52. 84 year old with 25% anterior T10 body fracture one week ago, who complains of pain with sitting and standing. The best orthotic for her is
    a. a lumbosacral corset
    b. a custom molded plastic thoracolumosacral orthosis
    c. CASH (cruciform anterior spinal hyperextension) orthosis
    d. a dorsolumbar corset
    e. none

Answer 53

C

the fracture is stable. Since she has pain, she needs a flexion control orthosis. Both CASH and Jewett are flexion control and hyperextension orthosis.

Question 54

53. Which of the following is true of sex after MI?
    a. there is little difference between marital and extramarital sex
    b. if you can climb 2 flights of steps, you can return to sex after an MI
    c. typical energy expenditure is 2-3 METs
    d. you should wait 2-3 months before resuming sex
    e. exercise training reduces the frequency of sexual activity

Answer 54

B is true. Typical expenditure is 3-5 METS

Question 55

54. A 6 month old with new onset spastic quadriparesis and vision impairment is referred for rehabiliation. She has resolving bilateral retinal hemorrhages. Dx is
    a. near miss sudden death syndrome
    b. an accidental fall off an elevated surface
    c. shaken impact syndrome
    d. Tay Sacks disease
    e. astrocytoma

Answer 55

C

Retinal hemorrhages are rarely ever caused by anything else other than shaken impact syndrome. Sudden increase in intracranial pressure can sometimes cause it.

Question 56

55. A 14 year old Hispanic immigrant presents with weakness in the left upper extremity and right lower extremity, with decreased reflexes and normal sensation. Nerve conduction velocities are normal. Dx is likely to be
    a. ALS
    b. poliomyelitis
    c. GB syndrome
    d. polymyalgia rheumatica
    e. cervical spondylosis

Answer 56

B

: asymmetric weakness with normal sensory indicates anterior horn cell disease.

Question 57

56. A 54 year old man complains of pain in the heel and radiates to foward into the feet, worse with planting the heel and prolonged walking and standing. No numbness or weakness. No trauma. This condition
    a. should response to the use of inverted heel “Earth” shoe
    b. is most likely Achilles tendinitis
    c. is more common in women
    d. occurs more commonly when the ffot is excessively supinated
    e. may or may not show a heel spur

Answer 57

E

Plantar fasciitis is best treated with a soft cushion rasing the heel. It affects men more than women and more often in those who pronate excessively.

Question 58

57. Among the following, the most likey cause of a child’s not starting to walk until 18 months of age is
    a. idiopathic late walking
    b. CP
    c. spinal muscular atrophy
    d. congenital hypotonia
    e. MD

Answer 58

A

there usually a family history in 50% of these children

Question 59

58. Muscle tension is monitored primarily by
    a. golgi tendon organs
    b. msucle spindles
    c. extrafusal muscle fibers
    d. panician corpuscles
    e. motor end plate

Answer 59

A

Golgi monitors tension, spindles monitor length changes

Question 60

59. In a child with muscular dystrophy with resultant respiratory dysfunction, a regular program of exercise to improve respiratory function will
    a. improve maximal inspiratory pressure
    b. have clinical effects measurable by spirometry
    c. require more time than is practical
    d. improve endurance of respiratory muscles
    e. substantially reduce the incidence of pneumonia

Answer 60

D

Respiratory muscle endurance can be increased by inspiratory resistive breathing.

Question 61

60. A negative prognostic sign of MS is
    a. young age of onset
    b. cerebellar sign
    c. optic neuritis
    d. monosymptomatic presentation
    e. long remissions

Answer 61

B

Favorable prognosis are all of the above except B

Question 62

61. A person with complete median nerve palsy due to laceration at the wrist. You recommend
    a. long opponens wrist hand orthosis with a C bar
    b. short opponens hand orthosis with a C bar and MP extension loop
    c. cock up wrist
    d. wrist driven tenodesis flexor hinge splint
    e. ratchet flexor hinge wrist hand orthosis

Answer 62

B

A hand only orthosis is needed since wrist flexion is unaffected. C bar maintains lost thumb abduction, and MP extension stop replaces lost lumbrical function and allows lost second and third digit extension

Question 63

62. 5 year old with lumbar spina bifida walks with AFO and Lofstrand.
    a. she should get wheelchair to avoid overusing the shoulders
    b. unlikely to continue to ambulate into adolescence
    c. limiting ambulation to household
    d. she will probably maintain her ambulatory skills into adulthood
    e. will never use a wheelchair

Answer 63

D

Most children with bifida who are able to walk outdoors independently maintain these skills through adolescence

Question 64

63. A patient with DM has painful, swollen ankle, worse with weight bear, xray reveals fragmentation of the articular surface. Synovial fluid is clear. The best orthosis is
    a. custom made shoe insert
    b. AFO
    c. patellar tendon bearing orthosis
    d. orthopedic shoe with rocker bottom sole
    e. varus prevention strap

Answer 64

C

Patient has Charcot arthropathy

Question 65

64. A patient with right C6 radiculopathy, the best traction is
    a. 10 lb with the neck in flexion
    b. 20 in flexion
    c. 30 in extension
    d. 20 in extension
    e. 30 in flexion

Answer 65

E

Question 66

65. 15 year old girl with proximal weakness, difficult arising from chairs and ambulating on stairs, has normal sensory exam, normal cranial nerves, MTP erythema, and dilated fingernail capillaries. Initial treatment is
    a. steroids
    b. MTX
    c. hydrotherapy
    d. plasmapheresis
    e. surgical decompression

Answer 66

A

Dx is dermatomyositis

Question 67

66. The best time to fit a child with below elbow prosthesis for congenital limb deficiency is
    a. 2-3 months so the child can incorporate into the body image
    b. 1 month
    c. when the child is old enough to follow simple commands
    d. when he can follow 2 step commands to allow operation of a child amputee prosthetic project (CAPP)
    e. when he can achieve sitting balance

Answer 67

E

Study by CAPP showed that there is no long term difference in outcome of wearing and acceptance of prosthesis when fitted 2-6 months or when independent sitting is achieved

Question 68

67. In Duchenne muscular dystrophy, scoliosis
    a. can be prevented with proper positioning
    b. occurs rarely before ambulation ceases
    c. is an age related phenomenon
    d. is a rare complication
    e. is the primary cause of death

Answer 68

C

Occurs in 90%. 25% have scoliosis before become wheelchair bound, and 64% after

Question 69

68. The autosomal dominant pattern, distal atrophy, weakness, early age of onset, and slow nerve conduction velocities are characteristics features of
    a. Friedreich’s ataxia
    b. ALS (Lou Gehrig’s)
    c. Charcot Marie Tooth
    d. Refsum disease
    e. Werdnig Hoffmann

Answer 69

C

Classic description

Question 70

69. After a complete transection of the ulnar nerve:
    a. conduction in axons fails within 6 hours
    b. distal myelin remains as intact tubules
    c. reparative sprouting begins after axonal degeneration is complete
    d. recognizable axonal contents are usually absent by 5 days
    e. axonal recovery will be complete in 2 years

Answer 70

D

Axonal contents degenerate quickly. Conduction persists for up to 48 hours, and myelin degeneration will occur

Question 71

70. Side joints and a thigh lacer on a total contact patellar tendon bearing below knee prosthesis are mainly used to
    a. completely unload the distal residual limb
    b. assist in prevention of a knee flexion contracture
    c. replace a waist belt and fork strap
    d. replace a prosthetic liner
    e. provide increased mediolateral stability of the knee

Answer 71

E

Also distributes weight bearing to the thigh and prevents recurvatum. Disadvantages are that they can lead to distal edema, cause atrophy of thigh musculature, and usually require additional suspension of a fork strap and waist belt

Question 72

71. The most common gait abnormality seen in patients with a painful, arthritic hip is
    a. lateral trunk shift over the affected joint during stance phase
    b. trunk extension at heel strike
    c. vaulting on the extended knee
    d. internal rotation of the limb at the hip
    e. circumduction of the affected limb

Answer 72

A

this is to avoid a painful contraction of the abductors

Question 73

72. The factor most predictive of the development of back pain in a newly hired employee is
    a. work requiring a static work posture
    b. repetitive work
    c. history of smoking
    d. older than 55
    e. history of LOW BACK PAIN

Answer 73

E

ABCD are probably true. E is the most correct

Question 74

73. The most common initial clinical symptom of spinal cord compression due to metastatic disease is
    a. incontinence
    b. weakness
    c. sensory loss
    d. paresthesias
    e. pain

Answer 74

E

Question 75

74. A 6 year old boy is evaluated because of frequent falls. He has difficulty with stair ambulation. An older brother has a similar problem, but sister is OK. He has calf hypertrophy and tendency to stand on his toes. It is likely that
    a. his father has the disease
    b. the patient will cease ambulating in 2 years
    c. hand contractures will shortly develop
    d. pain will be a persistent comorbidity
    e. scoliosis will exacerbate pulmonary compromise

Answer 75

E

In Duchene, X linked, progresses without pain, ambulation is retain into second decade, but pulmonary compromise exacerbated by kyphoscoliosis is the ultimate cause of death

Question 76

75. The most common feature of radiation induced brachial plexopathy is
    a. muscle atrophy
    b. pain
    c. numbness or paresthesias
    d. Horner’s syndrome
    e. lymphedema

Answer 76

C

Occurs in 71% of breast CA patients, 71% with weakness, and pain 43%.

Question 77

76. A 12 month old with mild spastic diplegia is likely to
    a. have gradually worsening symptoms with maturation
    b. have major leaning problems or mental retardation
    c. have a normal neuromotor exam at age 7
    d. require AFO for safe ambulation
    e. have neurogenic B/B

Answer 77

C

Most will outgrow their problems by age 7

Question 78

77. When playing sports, children with Down are at risk for
    a. hydrocephalus
    b. Legg Calve Perthes disease
    c. lumbar spondylolithesis
    d. scoliosis
    e. atlantoaxial instability

Answer 78

E

Question 79

78. The risk of depression in left CVA
    a. low than right CVA
    b. occurs within 6 months
    c. incidence is low if physical impairment is low
    d. major depression rarely occurs
    e. prolonged depression may still occur

Answer 79

E

Left CVA has higher risk particularly left frontal CVA

Question 80

79. A patient has arm weakness 3 weeks after removal of a cast for proximal radius fracture. Weakness is noted in pronation, WF, finger flexion, thumb abduction and opposition, and a decrease in sensation in lateral palmar aspect. EMG examination shows normal median nerve response at the wrist but a 70% conduction block at the level of the mid humerus. Spontaneous activities are noted in the intrinsics. What is the best approach for this patient?
    a. referral for nerve exploration and decompression
    b. MRI
    c. wrist splint and reassurance of a favorable prognosis
    d. electrical stimulation to ensure recovery
    e. r/o compartment syndrome by pressure mass

Answer 80

C

Question 81

80. the following are true about ACL :
81. prevents anterior displacement of the tibia with respect to the femur
82. provides stability for lateral movements
83. causes large effusion when torn
84. acts in concert with the quadriceps

Answer 81

A

It acts as an antagonist. It does provide stability for lateral movements by preventing anterior translation. It is not however a lateral stability ligament