Stroke

Question 1

An infarct in the lower division of the left middle cerebral artery division would be associated
with which type of aphasia?

(a) Global
(b) Broca
(c) Transcortical sensory
(d) Wernicke

Answer 1

Answer: (d)
Commentary: An infarct in the area of the middle cerebral artery lower division is much less
common than an upper division stroke of the middle cerebral artery. It is usually caused by an
embolic event. If the stroke is in the dominant hemisphere it will demonstrate a Wernicke
aphasia; if it is in the nondominant hemisphere an affective agnosia is seen. A contralateral Page 11 of 23

homonymous hemianopsia is also caused by a stroke in this area. Classically, global aphasia is associated with an infarction of the middle cerebral artery main stem, and Broca’s aphasia with infarction of upper division of the middle cerebral artery. Transcortical sensory aphasia typically is associated with a posterior cerebral artery infarction.

Reference: (a) Harvey RL, Roth EJ, Yu D. Rehabilitation in stroke syndromes. In: Braddom RL, editor. Physical medicine and rehabilitation. 3rd ed. Philadelphia: Elsevier; 2007. p. 1181-1182. (b) Harvey RL, Roth EJ, Yu D. Stroke syndromes. In: Braddom RL, editor. Physical medicine and
rehabilitation. 4th ed. Philadelphia: Saunders; 2011. p 1185-1186

2013

Question 2

Which clinical examination finding increases the likelihood that a stroke patient has had an
ischemic stroke and NOT a hemorrhagic stroke?

(a) Neck stiffness
(b) Cervical bruit
(c) Diastolic blood pressure greater than 110 mm Hg
(d) Headache

Answer 2

Answer: (b)
Commentary: There are two fundamental types of stroke and differentiating the two types of
stroke has become more important as the use of thrombolytics in the acute management of stroke
has become more important. Runchey and McGee in a review of 19 prospective articles with data from 6438 patients found that the following clinical findings increased the probability of hemorrhagic stroke: coma, neck stiffness, seizures, diastolic blood pressure greater than 110 mm
Hg, vomiting and headache. While other findings (cervical bruit and prior transient ischemic attack) decreased the probability of hemorrhagic stroke and made ischemic stroke more probable.
However, no specific finding or combination of findings was definitively diagnostic.

Question 3

Which modifiable risk factor MOST increases the relative risk of stroke?

(a) Smoking
(b) Hypertension
(c) Hypercholesterolemia
(d) Diabetes mellitus

Answer 3

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.

2011

Question 4

An infarct in the lower division of the left middle cerebral artery division would be associated with which type of aphasia?

(a) Global
(b) Broca
(c) Transcortical sensory
(d) Wernicke

Answer 4

Answer: (d)
Commentary: An infarct in the area of the middle cerebral artery lower division is much less common than an upper division stroke of the middle cerebral artery. It is usually caused by an embolic event. If the stroke is in the dominant hemisphere it will demonstrate a Wernicke aphasia; if it is in the nondominant hemisphere an affective agnosia is seen. A contralateral
Page 11 of 23
homonymous hemianopsia is also caused by a stroke in this area. Classically, global aphasia is associated with an infarction of the middle cerebral artery main stem, and Broca’s aphasia with infarction of upper division of the middle cerebral artery. Transcortical sensory aphasia typically is associated with a posterior cerebral artery infarction

2013

Question 5

Which statement best describes the effects of repetitive task training after stroke?

(a) Lower limb functional recovery is greater than upper limb functional recovery.
(b) Improvement in activities of daily living is a major benefit of the training.
(c) Training effects are more significant in early stroke therapy.
(d) Improvement in functional benefit is sustained for more than a year.

Answer 5

Answer: (a)
Commentary: This review of 14 studies with 659 participants looked at whether repeated practice
of tasks similar to those commonly performed in daily life could improve functional abilities. In
comparison with usual care or placebo groups, people who practiced functional tasks showed
modest improvements in walking speed, walking distance and the ability to stand from sitting, but
improvements in leg function were not maintained 6 months later. Repetitive task practice had no
effect on arm or hand function. There was a small amount of improvement in ability to manage
activities of daily living. Training effects were no different for people whether the training was
given early or late after stroke

2010

Question 6

Which clinical examination finding increases the likelihood that a stroke patient has had an
ischemic stroke and NOT a hemorrhagic stroke?
(a) Neck stiffness
(b) Cervical bruit
(c) Diastolic blood pressure greater than 110 mm Hg
(d) Headache

Answer 6

Answer: (b)
Commentary: There are two fundamental types of stroke and differentiating the two types of
stroke has become more important as the use of thrombolytics in the acute management of stroke
has become more important. Runchey and McGee in a review of 19 prospective articles with
data from 6438 patients found that the following clinical findings increased the probability of
hemorrhagic stroke: coma, neck stiffness, seizures, diastolic blood pressure greater than 110 mm
Hg, vomiting and headache. While other findings (cervical bruit and prior transient ischemic
attack) decreased the probability of hemorrhagic stroke and made ischemic stroke more probable.
However, no specific finding or combination of findings was definitively diagnostic.

2012

Question 7

Which is the most significant risk factor for a stroke?

(a) Smoking
(b) Hypertension
(c) Age
(d) Diabetes

Answer 7

Answer: (c)
Commentary: Age is the single most important risk factor for stroke, worldwide. The incidence
of stroke for both males and females doubles for each decade after age 55. Stroke is more
prevalent in men than women, except for the age cohort of 35-44 (a finding considered to be due
to the use of oral contraceptives and pregnancy) and among persons over age 85. Hypertension is
the most important modifiable risk factor for both ischemic and hemorrhagic stroke regardless of
age. A family history of stroke increases the risk of stroke by about 30%. Cigarette smoking is
an important risk factor and doubles one’s risk of ischemic stroke and triples the risk of
subarachnoid hemorrhage. Other well-documented risk factors include diabetes, dyslipidemia,
and atrial fibrillation.

2012

Question 8

A 49-year-old man is seen in your outpatient clinic 2 years after a stroke. You notice a
Trendelenberg gait and suspect weakness of which muscle?
(a) Gluteus maximus
(b) Quadratus lumborum
(c) Quadriceps
(d) Gluteus medius

Answer 8

Answer: (d)
Commentary: Weakness of the gluteus medius muscle, or reluctance to use the gluteus medius
muscle because of hip pain, can cause this gait pattern. It is a pattern of either excessive pelvic
obliquity during the stance phase of the affected side (uncompensated) or excessive lateral truncal
lean during the stance phase on the affected side (compensated).

2012

Question 9

When compared to conventional stroke rehabilitation methods, mirror therapy has
been shown to

(a) improve Modified Ashworth Scale scores for spasticity.
(b) improve self-care Functional Independence Measure (FIM) score.
(c) not show any benefit for spasticity or self-care on FIM scores.
(d) improve motor FIM score only.

Answer 9

Answer: B
Commentary:When comparing a conventional stroke rehabilitation program with mirror therapy
for stroke patients, researchers found that mirror therapy resulted in impmrovement only in the selfcare FIM score; it did not improve scores on the Modified Ashworth Scale for spasticity.

2009

Question 10

As the medical director of an inpatient rehabilitation program, you become concerned because
you have recently noticed an increase in the number of urinary tract infections in the patients on
your service. Which action would NOT be considered a reasonable initial management strategy
in this scenario?

(a) Discuss the issue with the Rehabilitation Center Quality Improvement Committee and
examine the rate of urinary tract infections over the past year.
(b) Perform a literature review examining the incidence and prevalence of urinary tract
infections in an inpatient rehabilitation setting.
(c) Immediately order that a urine culture be obtained on every patient at the time of
admission to the rehabilitation service.
(d) Provide an educational inservice to the nursing staff regarding catheter and bladder
management.

Answer 10

Answer: C
Commentary:Continuous quality improvement should be a part of each physician’s clinical
practice. All of the options listed would be appropriate to consider, with the exception of
immediately ordering a urine culture on every patient at the time of admission to the
rehabilitation service. This option would not be appropriate without gathering more information
and understanding the implications of this intervention strategy.

2009

Question 11

182. What is the main principle underlying the Bobath neurofacilitation techniques for rehabilitation?

(a) Work from proximal to distal muscle groups.
(b) Promote diagonal movement patterns.
(c) Focus on multiple joint movements.
(d) Establish synergistic patterns.

Answer 11

Answer: A Commentary:The Bobath technique of therapy focuses on good posture and works on proximal
muscle groups first before proceeding to distal muscle groups. Brunnstrom method uses
synergistic patterns and focuses on general movement patterns before moving to more isolated
movements. Proprioceptive neuromuscular facilitation (PNF) focuses on multijoint movement
patterns in a “diagonal” pattern. The Rood approach focuses on specific muscles selected
according to the recovery stage of the stroke

2009

Question 12

You see a 50-year-old man in your clinic in follow-up for a stroke 6 months after he was discharged from your inpatient rehabilitation service. He made good functional gains during his initial rehabilitation, but recent functional gains are slower despite intense outpatient rehabilitation effort. Early functional gains are most likely due to

a. structural and functional brain reorganization of partially damaged pathways and expansion of the representational brain maps.
b. neuroplasticity and recruitment of neurons not normally involved in an activity.
c.early rehabilitation efforts emphasizing forced use of the hemiplegic arm and leg.
d the resolution of ischemia, metabolic injury, edema, hemorrhage, and pressure in the ischemic penumbra.

Answer 12

Option d is correct.

In the early phase of stroke recovery the resolution of the ischemic insult and sequelae of secondary injury explain the early and rapid recovery. The time frame of recovery in the area of reversibly injured neurons is relatively short and accounts for the improvement in the first several weeks.

2014

Question 13

A 65-year-old right handed man has a pure Wernicke aphasia without hemiplegia after a stroke. The location of his stroke is in which branch of the left middle cerebral artery?

a. Posterior branch of the lower division
b. Anterior branch of the lower division
c. Posterior branch of the upper division
d. Anterior branch of the upper division

Answer 13

Option a is correct.

Pure Wernicke aphasia without hemiplegia is seen with occlusion of the posterior branch of the lower division of the middle cerebral artery supplying the hemisphere dominant for speech. Broca aphasia is seen with occlusion of the anterior branch of the upper division. A literal paraphasia, featuring speech errors of mispronounced words, is limited to the posterior branch of the upper division of the middle cerebral artery.

2014

Question 14

The Western Aphasia Battery provides

(a) an aphasia quotient as a measure of the severity of aphasia.
(b) a classification of the aphasic features observed in a particular patient.
(c) a statistical summary of language impairments and an outcome prediction.
(d) an overall rating of functional communication.

Answer 14

Answer: A
Commentary:The Western Aphasia Battery measures various parameters of language and
provides the aphasia quotient as a measure of aphasic severity. The Boston Diagnostic Aphasia
examination produces a classification of the features of a particular patient and a score of severity
and is similar to the Western Aphasia battery, but not the aphasia quotient. The Porch Index of
Communication Ability (PICA) is different and evaluates verbal, gestural and graphic responses.
The Functional Communication profile provides an overall rating of functional communication.

2009

Question 15

Answer: A
Commentary:The motor unit size principle, which has been supported by many investigators,
states that during muscle activation, smaller motor units are activated first and the larger motor
units are recruited with more forceful contraction

Answer 15

Answer: A
Commentary:The motor unit size principle, which has been supported by many investigators,
states that during muscle activation, smaller motor units are activated first and the larger motor
units are recruited with more forceful contraction

2009

Question 16

What is the most common medical complication during postacute stroke rehabilitation?

(a) Venous thromboembolism
(b) Falls
(c) Depression
(d) Pulmonary aspiration, pneumonia

Answer 16

Answer: D
Commentary:Of the complications listed, aspiration/pneumonia is seen in about 40%, while
venous thromboembolism is seen in 6%; falls occur in 16%, musculoskeletal complications in
5%, and reflex sympathetic dystrophy (RSD) in 30 %. Depression affects 30%. Urinary tract
infection is just as frequent at 40%, but is not listed

2009

Question 17

Which Brunnstrom stage of motor recovery in a stroke patient with a hemiplegic arm is
characterized by activating muscles selectively outside the flexor and extensor synergies?
(a) Stage 2
(b) Stage 3
(c) Stage 4
(d) Stage 5

Answer 17

(c)
The Brunnstrom stages of motor recovery can be used to describe motor recovery following stroke. Brunnstrom classification stage 4 is when the patient begins to activate muscles selectively outside of flexor and extensor synergy.

2008

Question 18

A patient presents with right hemiparesis and dysarthria but language and sensation are intact. The
lesion is most likely in the

(a) posterior limb of the internal capsule.
(b) left frontoparietal lobe.
(c) lateral pons.
(d) thalamus.

Answer 18

(a) A pure motor stroke (hemiplegia and dysarthria without sensory deficits) is caused by a lesion in the
posterior limb of the internal capsule.

2008

Question 19

[ITEM WAS NOT SCORED ON 2007 SAE-R]
The largest change in bone mineral density in a hemiplegic patient 1 year after a stroke occurs in the
(a) humerus on the paretic side.
(b) proximal femur on the paretic side.
(c) distal radius on the paretic side.
(d) lumbar spine.

Answer 19

[ITEM WAS NOT SCORED ON 2007 SAE-R]
(a) In studies by Beaupre and Lew, and Ramnemark et al, the largest change in bone mineral density (BMD) is in the humerus on the paretic side (-17%), the next largest change was -12% in the proximal femur on the paretic side and -9% in the distal radius on the paretic side. No change in BMD was found in the lumbar spine.

2007

Question 20

You are seeing a 56-year-old male patient in consultation 3 days after a severe stroke. He is medically stable and has flaccid hemiplegia with poor sitting balance. He is sitting up in a chair for 2 hours twice daily and has just started bedside physical therapy (PT) and occupational therapy (OT). You recommend

(a) continued bedside therapy with OT and PT, focusing on sitting balance, followed by transfer to your inpatient rehabilitation unit when he can sit and stand with minimum assistance.
(b) transfer to your inpatient rehabilitation unit to start aggressive PT and OT.
(c) transfer to a subacute rehabilitation center to allow the patient time to improve with less intensive therapy.
(d) that his OT start functional electrical stimulation to the flaccid arm to enhance neurologic recovery

Answer 20

(b) Early and aggressive therapy addressing the higher level skills of gait, higher order functional skills, and problem solving were associated with better outcomes in a multi-center observational study.

2007

Question 21

It is recommended that a patient with a first ischemic stroke who is positive for an antiphospholipid antibody be treated with:

(a) aspirin, 325mg orally daily.
(b) warfarin, with an INR goal of 3.0–3.5.
(c) clopidogrel (Plavix), 75mg orally daily.
(d) ticlopidine (Ticlid), 250mg orally twice daily.

Answer 21

(a) Patients with a first ischemic stroke and a single positive antiphospholipid antibody test result who do not have another indication for anticoagulation may be treated with aspirin (325mg/day) or moderate-intensity warfarin (INR 1.4–2.8).

2007

Question 22

A patient with a recent stroke and hemiplegia presents to your clinic and is noted to have a genu recurvatum gait pattern. An aggressive stretching program has improved ankle range-of-motion, but not her spasticity and gait. The most appropriate treatment is

(a) an ankle foot orthosis with 5º of plantarflexion.
(b) Achilles tendon lengthening.
(c) phenol motor point injection to the hamstrings.
(d) botulinum toxin injection to the gastrocsoleus muscle group

Answer 22

(d) Genu recurvatum is a common atypical gait pattern in patients with upper motor neuron pathology. It may be caused by ankle plantarflexor spasticity, heel cord contracture, quadriceps weakness, or spasticity and a combination of the above impairments. In this case an ankle foot orthosis with 5º of plantarflexion would worsen the gait. A tendon lengthening would be aggressive and more conservative management should be attempted first. A phenol motor point injection to the hamstrings would make knee control more problematic. Botulinim toxin can be very helpful for focal spasticity and can decrease ankle plantarflexor spasticity and decrease the backward force at the knee

2007

Question 23

Electromyographic biofeedback for stroke patients is most beneficial when

(a) proprioception is preserved.
(b) used in the upper limb.
(c) the patient is young.
(d) the patient has flaccid paralysis.

Answer 23

(a) Hemiplegic stroke patients engaged in electromyography biofeedback training have a better functional outcome with lower extremity training than with upper extremity training. Further, their age and the duration of their hemiplegia have no effect on training outcome. Proprioceptive loss of the upper limb decreases the probability of making functional gains. Motivation by the patient is a necessity and is most beneficial when some voluntary activity is present.

2007

Question 24

After an acute stroke, a 60-year-old woman presents for stroke rehabilitation with an indwelling
catheter for bladder management. What action should you order regarding the catheter?
(a) Maintain it until the patient is able to transfer to the toilet with minimal assistance.
(b) Remove it because reflex voiding returns very quickly after a stroke and risk of urine retention
is minimal.
(c) Remove it and start intermittent catheterization because reflex voiding return is often delayed
and the risk of urine retention is high.
(d) Maintain it to decrease the risk of urinary incontinence and pressure sores.

Answer 24

(b) Impaired bladder control is frequent following stroke with initial hypotonic bladder, but voiding
returns very quickly and urine retention is rarely a problem. In the postacute phase of stroke
rehabilitation, the problem is not bladder overdistention, but uninhibited bladder with incontinence.

2006

Question 25

A 59 year old man had a stroke 6 months ago and has residual expressive aphasia and weakness of the right upper limb with only slight voluntary contractions at the shoulder and elbow. He would like to try constraint-induced movement therapy (CIMT). You inform him that you do not think CIMT will help him because:

a. CIMT is only effective if initiated within the first 3 months after a stroke
b. his aphasia prohibits him from effectively understanding the treatment protocol.
c. he does not have adequate motor control in the right upper limb to participate
d. the medical literature has shown poorer outcomes with CIMT than conventional treatment.

Answer 25

Constraint induced movement therapy is a relatively recently developed type of therapy based on the current concepts of neuroplasticity. Patients must have adequate proximal limb control and at least partial wrist and finger extension, as well as sufficient balance during limb restraint. There is emerging support for the effectiveness of CIMT in acute, subacute, and chronic phases of stroke recovery, and outcomes have compared favorably to conventional treatment. Expressive aphasia would not be prohibitive of participation in a CIMT protocol. Logistic and cost considerations have limited the availability of CIMT, as has the candidacy of patients with only mild to moderate unilateral limb paresis.

2015

Question 26

A patient presents to clinic for evaluation of her left sided post stroke spasticity. Passive movement of the left elbow flexor over a 1-second time frame reveals a catch at 100 degrees, followed by minimal resistance throughout the remainder of the range of motion. Using the modified ashworth scale, what is the correct grading of this patient’s elbow flexor tone?

a. 1
b. 1+
c. 2
d. 3

Answer 26

b

Modified ashworth scale is scored as follows:

0 - no increase in tone
1 is the slightest increase in muscle tone manifested by a catch and release at the end of range of motion
1+ is the slight increase in muscle tone manifested by a catch followed by minimal resistance throughout the remainder (less than half) of the range of motion
2 is more marked increase in tone, through most of the range of motion, but joint is easily moved
3 is considerable increase in muscle tone, passive movement is difficult
4 is affected part is rigid in flexion or extension

2015

Question 27

A 57 yo woman with a history of HTN complains of vertigo and poor balance when trying to sit up. Her voice is hoarse, and she has a nasogastric tube in place. On examination she is noted to have a constricted left pupil, left eye ptosis, weakness and poor motor control of the left arm and leg. Sensory exam reveals impaired pinprick sensation on the left face and right arm and leg. These signs and symptoms indicate she likely has a brain stem stroke with a:

a. lateral medullary infarction
b. medial medullary infarction
c. midbrain infarction
d. medial pontine infarction

Answer 27

A

These signs and symptoms describe a lateral medullary infarction, also known as the Wallenberg syndrome. It is caused by an infarction in the lateral wedge of the medulla and occurs with occlusion of the vertebral artery or the PICA.

2015

Question 28

The circle of willis is comprised of which complex of arteries?

a. anterior communicating, posterior communicating, middle cerebral, superior cerebellar
b. anterior communicating, posterior cerebral, anterior cerebral, vertebral
c. posterior communicating, posterior cerebral, superior cerebellar, basilar
d. anterior communicating, posterior communicating, posterior cerebral, anterior cerebral

Answer 28

d

ACA, anterior cerebral arteries and posterior communicating arteries as they come off the middle cerebral arteries, and the posterior cerebral arteries after they come off the basilar artery.

2015

Question 29

A patient with post stroke spasticity is noted on exam to have a hemiplegic gait pattern with typical synergy patterns of tone. What is the most common synergy pattern you expect to see in the upper limb and lower limb

a. Flexion synergy i the upper limb, flexion synergy in the lower.
b. flexion synergy in the upper limb, extension synergy i the lower.
c. extension synergy in the upper limb, flexion synergy in the lower.
d. extension synergy in the upper limb, extension synergy in the lower.

Answer 29

b

the typical spastic posture int he post stroke patient is a flexion synergy in the upper limb with a flexed, adducted, IR arm with pronated forearm and flexed wrist and fingers, and an extension synergy in the lower limb with leg extended, internally rotated and adducted, and the ankle plantar flexed and inverted.

2015

Question 30

What is the most likely cause of a hemorrhagic stroke in a 14 yr old child?

a. congenital heart disease
b. carotid dissection
c. hemophilia
d. sickle cell disease

Answer 30

c

hemorrhagic strokes in children can occur as a result of moyamoya disease and hemophilia. Causes of ischemic stroke in children include cerebrovascular anomalies, congenital heart disease, carotid dissection, sickle cell disease, inherited disorders of coagulation, and previous infection with varicella zoster. Children have an annual incidence of 2.7 strokes per 100,000.

2015

Question 31

You are working with a 65 year old man with dysphagia who has decreased oral bolus control, right-sided oral and pharyngeal weakness, and decreased airway protection. Which position should he avoid during swallowing?

a. head rotation to the right
b. head tilt to the left
c. neck extension
d. chin tuck

Answer 31

c

the goal of neck extension in swallowing compensation is to use gravity to increase the speed and efficiency of oral transit; this is contraindicated in patients such as this gentleman with decreased oral control of bolus for swallowing. Neck extension strategy is also contraindicated when the airway cannot be adequately protected. Head rotation to the weaker side or head tilt to the stronger side directs the food bolus to the stronger and more sensate side of the oral cavidty and pharynx allowing for better sensory input and motor control and more efficient propulsion of the bolus. Chin tuck shifts the anterior pharyngeal structures posterior; this is thought to decrease the vallecular space and vallecular residue but can increase residue in some patients and generally needs to be verified by swallow study.

2015.