AAPM&R

Abridged Version
2007 Self-Assessment Examination for Residents (SAE-R)
Multiple-Choice Questions
Answer Key and Commentary on Preferred Choice

QUESTION ANSWER COMMENTARY

1. (a) A telltale sign of cervical cord involvement is bilateral symptoms. In this case, the athlete should
be treated as having a potential spinal cord injury and should have his cervical spine immobilized.
The football helmet should not be removed, since the cervical spine may fall into extension in the
act of removing the helmet. If the airway needs to be accessed, then the face guards should be
removed using special equipment. If the athlete suffered and recovered from a temporary “stinger,”
involving 1 limb, he may return to play as long as his neurologic examination is normal.

3. (c) General treatment principles of osteoarthritis include medications and/or therapy to relieve joint
symptoms, along with maintaining or improving function and minimizing drug toxicity. To date,
no medications can reverse or repair damaged articular cartilage. Exercises, such as range of
motion and strengthening, are part of nonpharmacologic therapy of osteoarthritis. Surgical
correction is not an initial treatment strategy.

7. (a) Returning the employee to modified duty that fits the impairment and avoids provocative activities
is important from several aspects. One, behavioral management with the employee allows early
goals to be set, so that the employee can work with restrictions. It also establishes that simply
being off work until pain free is not always a logical goal. Second, the employer can fully
understand the employee’s capabilities during recovery. This management approach hones in on the
employer to comply with the restrictions. Third, starting with reasonable restrictions allows the
physician to guide the employee back to the work place by making adjustments as the worker’s
rehabilitation progresses.

9. (b) According to databases of the Model SCI Systems and Shriner’s Hospital for Children, children
under age 6 years are more likely than teenagers to sustain SCI in a motor vehicle accident. Their
injuries are more likely to be T1 and lower, and they are more likely to have complete injuries.

12. (d) In a 4-site Model System Center observational study, the highest risk factors for late post-traumatic
seizures were found to be bilateral parietal contusion (66%), penetration of the dura (62.5%), and
multiple intracranial operations (36.5%), multiple subcortical contusions (33.4%), subdural
hematoma with evacuation (27.8%), and midline shift greater than 5mm (25.8%).

14. (c) Myopathy refers to a disease or abnormal condition of striated muscle; whereas, myalgia is defined
as muscle aching or weakness without serum creatine kinase (CK) elevations. Myositis implies
muscle symptoms accompanied by CK elevations. Rhabdomyolysis signifies muscle complaints
with CK elevations 10 times the upper limits of normal (ULN) with creatinine elevation. Clinically
important myopathy with CK elevations greater than 10 times ULN is estimated to occur in
approximately 0.1% of patients who receive statin monotherapy. Clinically important myopathy
and rhabdomyolysis have been reported with all statins with an overall death rate of .15 per 1
million prescriptions.

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17. (d) The paramedic has a high demand job. A functional capacity evaluation would best determine the
employee’s ability to return to her job. If deficits are noted, work hardening over a period of weeks
will best ensure return to work. Work hardening for 1 week may not be sufficient. Work
conditioning enhances aerobic fitness and conditioning but is not job specific. The paramedic is at
high risk for recurrent injury. Returning the employee to work without testing the her ability to
perform her job duties may precipitate premature return and reinjury.

21. (b) Recurrent dislocations should be treated with surgery at some point if the athlete would like to
return to contact sports. Various anterior shoulder dislocation techniques that can be applied to
reduce the shoulder, most by external rotation of the shoulder or by using gravity.

24. [ITEM WAS NOT SCORED ON 2007 SAE-R]

(d) If a patient on a statin presents with muscle complaints, with or without creatine kinase (CK)
elevations, other causes, including strenuous exercise or hypothyroidism, must be considered. If a
patient initially has normal or only moderately elevated CK levels, the statin may be continued with
close monitoring of symptoms and CK levels; however, if symptoms become intolerable or if the
CK level is 10 times the upper limits of normal (ULN) or greater, the statin must be discontinued.
If myositis is present or strongly suspected, the statin should be discontinued immediately. Early
diagnosis and treatment of symptomatic CK elevations, including cessation of drug therapies
potentially related to myopathy, can prevent progression to rhabdomyolysis. Symptoms and CK
levels should resolve completely before reinitiating therapy, at a lower dose if possible.
Asymptomatic elevation of CK at 10 times the ULN or greater should also prompt discontinuation
of the statin. Consideration should also be given to discontinuation of statins before events that
may exacerbate muscle injury, such as surgical procedures or extreme physical exertion.

Needle electromyography (EMG) abnormalities are uncommon in statin-induced myopathy. An

EMG does not exclude statin-induced myopathy, because it primarily affects type 2 muscle fibers.
Electromyography is not routinely performed or recommended unless the clinical presentation does
not improve with statin discontinuation or if concern exists about other diagnoses.

25. (b) A bulbocavernosus reflex does affect American Spinal Injury Association (ASIA) scoring, and
voluntary sphincter contraction is not a mandatory component of ASIA C or D. Muscle grade of
less than 3 in at least half of the key muscles below C7 would be characterized as ASIA C.
Someone with ASIA B through E must have some retained sensation in the sacral segments S4-S5
but that sensation can be normal or impaired. To classify the injury as C7 ASIA D would require a
motor score of at least 3 out of 5 in the C7 myotome with normal strength in C6.

26. (a) Bony metastases from prostate cancer usually are blastic, whereas those from breast, lung, and
kidney are typically lytic. Knowing whether a metastatic bone lesion is blastic or lytic is important,
because lytic lesions have a higher risk of pathologic fracture.

27. (d) The prospective payment system for inpatient rehabilitation facilities requires that all patients
admitted for inpatient rehabilitation be assigned to an impairment group code category. Payment to
the rehabilitation facility is further determined by the patient’s subclassification into a case-mix
group. The FIM instrument motor score is used to help determine the case-mix group designation
under the prospective payment system for inpatient rehabilitation facilities. None of the other
options listed are used in this process.

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28. (d) Based on the clinical presentation, radial nerve injury is the most likely cause of the patient’s
symptoms. Considering the location of the trauma the other possibilities seem less likely. In a
posterior interosseous nerve injury one would not expect any sensory problems.

32. (d) A series reported by Tribl and Oder found that of 48 patients who underwent ventriculoperitoneal
shunting for post-traumatic hydrocephalus slightly more than half experienced significant benefit.

37. (a) The interdisciplinary approach to patient care emphasizes common patient and team goals rather
than discipline-specific goals. The patient and family members should be included in the goal
setting process. All team members must work in a collaborative way to facilitate achievement of
goals. Team members must have an appreciation for all the issues that affect the patient rather than
focusing on an isolated problem. Team communication is essential at all points in the rehabilitation
process, not just when problems occur.

38. (c) Answer (a) describes the location of the extensor digitorum communis muscle; answer (b) describes
the location of the extensor pollicis brevis muscle; and answer (d) describes the location of the
extensor pollicis longus.

40. (a) The first month after upper limb amputation is the optimal period for prosthesis fitting. Fitting
should be initiated during this time to maximize the level of acceptance and use of the prosthesis.

41. (b) The most common location for vertebral compression fractures due to osteoporosis is the
midthoracic spine, followed by the thoracolumbar junction. If fractures are seen at other levels, a
higher degree of suspicion for a pathologic (due to cancer) fracture should be raised.

45. (a) The top three causes of traumatic spinal cord injury in the United States are motor vehicle
accidents, falls, and violence.

49. (d) While this child is totally dependent for transfers, he only requires minimal support to sit upright
and has no fixed deformities. Custom seating should be used for those with fixed deformities. A
tilt-in-space frame should be used when children need to have their position in space changed
frequently because of deformities or medical problems. While it is tempting to prescribe a
wheelchair with a folding frame for a family who transports a child in a car rather than a van, the
child will be better positioned using contoured seating and a rigid frame. At age 5 years, the size of
frame needed will be able to be transported in a car even without folding. Adaptive strollers
usually position the child in a reclined position and should be used as a backup to a wheelchair,
which is not easily transported in an automobile, or for a child who can walk but periodically needs
dependent mobility for fatigue or following seizures or for similar reasons.

57. (b) Case managers are shown to be beneficial liaisons between the physician and workers
compensation carrier and their presence facilitates patient care. To be treated as a workers
compensation case, the patient must give the carrier full access to his/her medical record. The
employee treated under workers compensation cannot restrict the access of the case manager to the
physician; however, discussions with the case manger should be done in the environment that the
patient requests.

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58. (d) Blink reflex studies can help assess facial and trigeminal nerve lesions, as well as central lesions in
the brain stem. Neuromuscular junction disorders are better assessed by repetitive studies. Axonal
neuropathies rarely affect the blink reflex, but demyelinating peripheral neuropathy can affect all
potentials of the blink reflex study. Motor neuron disorders such as amyotrophic lateral sclerosis
do not typically affect the blink reflex.

62. [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.

63. (d) Rituximab works by binding to B-lymphocyte CD20 surface antigens (monoclonal antibody) and
thereby depleting the B cell population. Its previous indication was for treatment of non-Hodgkin’s
lymphoma. Etanercept is a TNF alpha antagonist. Abatacept blocks co-stimulatory molecules and
T-cell activation. Anakinra inhibits interleukin-1 type receptors.

65. (d) It is unlikely that an individual will be able to wean from a ventilator if he is still completely
dependent on mechanical ventilation 12 months after a C2 complete injury, so a weaning protocol
and diaphragmatic strengthening are not indicated. An individual who requires mechanical
ventilation can use a breath control system effectively. If electrodiagnostic testing indicate that the
phrenic nerves are intact, then a phrenic pacemaker could be implanted, which would significantly
reduce the need for mechanical ventilation.

66. (d) Vital capacity should be monitored in patients with neuromuscular disease such as ALS. The
forced vital capacity is convenient to follow disease progression, and it correlates with disability.
FEV1 is normal. Blood gases remain normal until the patient is in near respiratory arrest.
Hypercapnia precedes hypoxia, so monitoring oxygen saturation is not helpful.

67. (a) The purpose of the Health Insurance Portability and Accountability Act (HIPAA) is to ensure that a
patient’s medical record remains private, but is available to health care providers as directed by the
patient. A non-treating physician, lawyer, or insurance company may have access to the record
with written authorization by the patient or guardian. There are no stipulations about a physician’s
qualifications with regards to medical information access.

70. (c) The average double limb support is 20% and single limb support is 40% of the entire gait cycle.
Stance phase accounts for 60% of the gait cycle and swing phase accounts for 40%.

72. (b) A minimally conscious state is a condition of severely altered consciousness in which minimal but
definite behavioral evidence of self, or environmental awareness, is demonstrated by any or all
these actions: simple gestures, purposeful behavior, appropriate smile/cry or vocalization to
stimulation, reach for object, purposeful visual tracking. The vegetative state is associated with
preserved hypothalamic and brainstem autonomic function and the patient exhibits a sleep/wake
cycle, but there is an absence of cortical activity, judged behaviorally. The patient may exhibit
visual pursuit but not in relation to meaningful behavior. The term persistent vegetative state is
confusing and it is suggested that the term be abandoned, since it combines diagnosis (vegetative)
with prognosis (persistent). Coma is a transient state after a traumatic brain injury (TBI) of being
not awake and not aware of surroundings, and is seen in patients with a severe TBI and a Glasgow
coma scale (GCS) of 8 or lower.

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74. (b) Charcot Marie Tooth (CMT) disease type 2 has greater variability and produces more disability
than type 1. The disability can range from very mild to severe in CMT type 2. In addition to the
weakness typical of the hereditary sensory motor neuropathy diseases, paresis of diaphragm, vocal
cord, and intercostal muscle has been reported. CMT type 2 disease is characterized by less
hypertrophic change in myelin, with more neuronal or axonal involvement. Sensory deficits are
common to both forms. Both have autosomal dominant inheritance.

Motor nerve conduction velocities are reduced markedly in CMT type 1: values are less than 70%
of the lower limits of normal. Type 2 will have decreased amplitudes, due to its axonal nature. If
slowing of conduction velocities occurs in type 2, it does not reach the values seen in CMT type 1.

75. (c) In anterior spinal cord syndrome there is usually paralysis below the level of the lesion, along with
bilateral loss of pain and temperature sensation. Proprioception and vibratory sense are partially
preserved. This syndrome often occurs after significant intraoperative hypotensive events. Central
cord syndrome refers to weakness that is greater in the upper extremities than the lower extremities.
Posterior cord syndrome shows loss of proprioception and is the least common of the incomplete
spinal cord injury syndromes.

77. (b) Whole body-vibration is associated with increased frequency of low back pain. Some studies have
found a correlation between increased frequency of disc protrusion and occupational driving. The
exposure to vibration will likely facilitate continued symptoms in this worker, and relative rest is
indicated during the initial stages of recovery. There is no predetermined length of physical therapy
that is associated with recovery. Workers with low back pain and leg pain must learn to sit without
increasing symptoms. Complete avoidance will not necessarily improve recovery and is not
practical. The driver can likely perform some duties with restrictions. The employer has the
responsibility to provide a job that meets the restrictions set by the physician. If the employer is
unable to provide a job with these restrictions then the employee must remain off work.

78. (b) The clinical presentation is most consistent with a myopathic picture. In myopathies the
recruitment ratio is usually lower (<5). An increased recruitment ratio and large motor unit
amplitude potentials are associated with a neurogenic process. The number of phases of the motor
units is usually increased in myopathy and in different forms and stages of neuropathies. F waves
are typically prolonged or absent in neuropathies, but not in myopathies.

80. (c) Possible causes for circumduction in the gait of a transfemoral amputee include excessive
mechanical resistance to knee flexion, prosthesis aligned with too much stability, prosthesis too
long, increased medial brim pressures, inadequate suspension, patient lacks confidence or has
inadequate hip flexion.

81. (d) The transverse tarsal joint, namely the talonavicular and calcaneocuboid joints, must have their
joint axes in parallel to allow for a flexible midfoot and pronation. If the axes intersect, the midfoot
becomes rigid, which enables proper supination.

82. (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.

83. (a) Factors that impact bone mineral density negatively are smoking and high intake of caffeine,
protein, and phosphorus. An active lifestyle with regular weight-bearing exercise is advised.
Eliminating fall hazards such as throw rugs throughout the home is also essential.

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85. (a) Autonomic dysreflexia occurs in individuals with spinal cord injuries at the level of T6 and above.
It occurs because of sympathetic discharge resulting from a stimulus below the injury level. The
most common cause is bladder distension, which can result from a clogged or kinked indwelling
urinary catheter or from delayed intermittent catheterization. Bowel impaction is the second most
common cause of autonomic dysreflexia.

86. (c) Stage 1: Nonblanchable erythema of intact skin not resolved within 30 minutes; epidermis intact.
Stage 2: Partial-thickness skin loss involving the epidermis, possibly into dermis. Stage 3: Full-
thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to,
but not through, underlying fascia. Stage 4: Full-thickness skin loss with extensive destruction,
tissue necrosis, or damage to muscle, bone, or supporting structures (eg, tendon or joint capsule).

90. (b) Transtibial amputees have a lower rate of energy expenditure, heart rate and oxygen consumption
when using a prosthesis (vs. non-weight bearing crutch gait). The cardiovascular demand of crutch
walking is high, with increased rate of oxygen consumption, increased heart rate, increased energy
costs, and respiratory exchange rate in the anaerobic range.

94. (c) Negative prognosticators for successful nerve repair include advanced age, nerve injury resulting
from dislocation (stretch), delay of repair beyond 5 months, prior radiation therapy, nerve
discontinuity (gap) exceeding 2.5cm, proximal nerve injury and poor condition of nerve endings.

99. (d) These are normal reflexes in a 3-month-old child. The Moro and asymmetric tonic neck reflexes
(ATNR) usually are integrated by approximately 6 months. The plantar grasp reflex is integrated
by 12 to 14 months after walking has begun. Protective extension in sitting is seen anteriorly at 5 to
7 months, lateral at 6 to 8 months, and posterior at 7 to 8 months.

102. (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).

103. (a) Arthritis mutilans is osteolysis of the phalanges and metacarpals, which results in telescoping, or
shortening, of the involved digit. It is a highly characteristic feature of psoriatic arthritis. Auspitz’s
sign is pinpoint bleeding after scraping a psoriatic plaque. Dactylitis, or “sausage digits,” is a
combination of tenosynovitis and arthritis of the distal or proximal interphalangeal joint. Jaccoud’s
arthritis is a non-erosive deforming arthritis in systemic lupus erythematosus.

104. (d) With closed nerve injury as described, early active and passive range of motion exercise of affected
joints is begun. The value of electrical stimulation is uncertain. Surgery is done when there is an
incomplete loss of function but no improvement over several weeks or no return of function at 2
months for peripheral nerve and 4 months for a brachial plexus injury. The purpose of surgical
repair is to improve peripheral nerve recovery and eventual function. Findings at the time of
surgery help establish a prognosis. However, the chances of successful surgical repair begin to
decline by 6 months after the injury. By 18 to 24 months, the denervated muscles usually are
replaced by fatty connective tissue, making functional recovery impossible.

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105. (b) Based on the ASIA classification system revised in 2000, the lowest intact level on the left would
be C7 (a motor score ≥ 3/5 with the level above being 5/5). On the right, the ASIA score is
determined by the last intact sensory level, which is C4. When motor/sensory scoring differences
exist between the 2 sides, then each side should be reported separately. This example indicates that
there is no sacral sparing, so it can only be ASIA A.

106. (b) The target for this individual is 70% to 80% of maximum heart rate. One may use either this value
or the Borg scale. The Borg scale ranges from 6 to 20. This person’s goal is Borg 13 (somewhat
hard), in the range of 11 to 15 (fairly light to hard).

109. (d) Central autonomic dysfunction occurs in some children following severe brain injury. It is
characterized by hypertension, hyperpyrexia, rigidity, tachypnea, tachycardia, and diaphoresis.
Various medications are used to treat this dysfunction, but no studies prove the value of one
medication over another.

110. (c) Knee orthoses are prescribed to prevent genu recurvatum and provide mediolateral stability. They
may be used during sports and other activities to provide functional support for an unstable knee or
during the rehabilitation phase following injury or surgery on the knee. The use of knee orthoses
for the prevention of knee injury in athletes is controversial. The Swedish knee cage prevents
recurvatum but permits flexion. The three way knee stabilizer gives good control of structural knee
instability in the lateral, medial, and posterior directions.

111. (c) Central sensitization is a complex set of activation dependent post-translational changes occurring
at the dorsal horn, brainstem, and higher cerebral sites that sensitizes the central nervous system to
further perception of pain. Wind-up is an amplified evoked response to repeated afferent inputs at
the level of the dorsal horn.

112. (d) Meningiomas are the most common benign brain tumor, comprising about 15% of all primary brain
tumors.

113. (d) Temporary weaknesses of peri-articular muscles typically occurs after knee arthroplasty along with
loss of full flexion and extension due to pain, edema, and the procedure itself. Ankle dorsiflexion
is not typically weak following TKA and therefore peroneal nerve injury due to a hematoma would
be suspected, especially since the patient is on warfarin. This injury requires surgical exploration
and decompression. Sciatic nerve stretch injury, posterior tibialis tendon rupture, and inadequate
pain control would not present as ankle dorsiflexion weakness.

115. (d) Etidronate blocks the late phase of bone formation (mineralization), by preventing the conversion
of amorphous calcium phosphate to hydroxyapatite. The drug has no effect on the early phase of
ossification.

118. (b) The clinical and electrophysiologic presentation is consistent with a sensory neuronopathy. With
no evidence to suggest motor involvement, the numbness is likely a disorder of the dorsal root
ganglion. There are only a few distinct disorders associated with acute or subacute cases described
by the history and physical in this clinical vignette. They may be part of a paraneoplastic syndrome,
connective tissue disorder such as Sjogren’s, a postinfectious condition, pyridoxine intoxication, or
as an isolated autoimmune process. In this patient with a history of smoking, a cancer work up
would include obtaining anatomic studies of the chest. Biopsies of the nerve, muscle, or skin would
not add much to the case. Repetitive nerve conduction studies would be considered if a
neuromuscular junction disorder was suspected.

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121. (b) By successfully avoiding pain (ie, “punishment”), the individual achieves a reduction in pain, thus
rewarding the avoidance behavior. The acquisition of pain behaviors may be determined initially by
the history of learned avoidance behaviors, called operant learning. Respondent learning is when
an aversive stimulus is paired with a neutral stimulus and with repeated exposures over time the
neutral stimulus will come to elicit an aversive response (ie, fear).

122. (b) After a traumatic brain injury, the following factors are associated with a better prognosis: younger
age, reactive pupils, conjugate eye movement, decorticate posturing, early spontaneous eye
opening, absence of ventilatory support, and higher Disability Rating Score on admission. Factors
associated with poor prognosis include decerebrate posturing and flaccid muscle tone.

123. (c) It is advisable to select the finest needle that will reach the area. The injection should be
peritendinous with avoidance of the tendon to prevent rupture. The minimum interval between
injections should be at least 6 weeks. Early postinjection local anesthesia is not a complication of
steroids, but it will occur if local anesthetic is mixed with the steroid.

124. (b) The aminoglycoside class of antibiotics is contraindicated in patients with myasthenia and other
neuromuscular junction disorders. Most aminoglycosides exert their effect through reducing the
number of acetacholine quanta released. Use may lead to a myasthenic exacerbation. Acute
uncomplicated pyelonephritis in women can be treated with oral quinolones for 7 to 14 days,
single-dose ceftriaxone or gentamicin followed by trimethoprim-sulfamethoxazole, or an oral
cephalosporin or quinolone for 14 days as outpatient therapy. For hospitalized patients, therapy
consists of parenteral (or oral once the oral route is available) ceftriaxone, quinolone, gentamicin
(plus ampicillin), or aztreonam until defervescence. Then, an oral quinolone, cephalosporin, or
trimethoprim-sulfamethoxazole for 14 days may be added to complete treatment.

126. (c) Also known as AIDS-dementia complex, human immunodeficiency virus (HIV) encephalopathy is
usually seen late in the disease course. HIV encephalopathy develops in weeks to months, whereas
symptoms of toxoplasmosis and central nervous system (CNS) lymphoma are seen in days to
weeks. Fever and headache, along with mental status changes, would be seen in cryptococcal
meningitis. Headaches, seizures, and fatigue are commonly seen in toxoplasmosis, along with focal
or non-focal neurologic signs. In CNS lymphoma, headache, confusion, memory loss, or focal
neurologic signs are typically present.

127. (a) The work by Marras and colleagues showed that increasing the horizontal distance from the trunk
of an object being carried increased the risk of developing a low back disorder. This increase in
distance increased the forces consistently on the anterior column of the spine. Although the other
options can all place the worker at risk for a low back injury, only the increased carrying distance
from the trunk has been shown to be the most predictive of a low back injury.

131. (a) Dependence is a maladaptive pattern of drug use marked by tolerance and a drug-class-specific
withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing
blood levels of drug, or administration of an antagonist. Tolerance is a state of adaptation in which
exposure to a drug induces changes that result in diminution of 1 or more of the drug’s effects over
time. Addiction is a chronic biopsychosocial disease characterized by impaired control over drug
use, compulsive use, continued use despite harm, and craving.

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132. (b) The onset of central pain following a stroke occurs more than 1 month after the stroke in 40% to
60% of all patients. The pathogenesis of central pain is still largely a matter of conjecture and
hypothesis. It is generally believed that damage to the spinothalamicocortical sensory pathways
plays a significant role in the pathogenesis, but central pain can occur with lesions in any part of the
brain. Treatment options are limited and at present amitriptyline is the drug of first choice, other
drugs, including antidepressants, anticonvulsants, antiarrhythmics, and opioids may provide relief
for some patients who do not respond to amitriptyline.

135. (c) Posttraumatic syrinx results in neurologic decline in 3% to 8% of patients with spinal cord injuries
and can develop 2 months to 30 years after spinal cord injury. Prompt diagnosis is essential and
magnetic resonance imaging is usually definitive for diagnosing posttraumatic syrinx. Surgical
treatment is usually indicated when there is clear neurological decline.

136. (c) After a myocardial infarction, exercise intensity should start at 2 metabolic equivalents (METs) and
gradually progress to a maximum of 5 METs. Patients should await myocardial infarct healing
before vigorous exercise greater than 5 METs is performed, usually within 4 to 6 weeks post
infarctioin.

138. (a) The amplitude is primarily influenced by the distance between the electrode’s recording surface and
the electrical generator. The duration is a highly stable and reliable parameter of the motor unit.
The other parameters are not affected by the distance.

139. (d) This patient illustrates the diagnostic dilemma of the floppy infant. Causes of this problem include
central nervous system lesions (both brain and spinal cord), myopathies, neuropathies, and
neuromuscular junction problems. This infant has had abnormalities since birth, which argues
against infantile botulism. Kugelberg Welander syndrome (also known as spinal muscular atrophy
type 3) has onset during childhood, as does Duchenne muscular dystrophy. Tetraplegic cerebral
palsy often presents in infancy with floppiness and hyporeflexia, which later change to spasticity
and hyperreflexia.

140. (b) Although MAG wheels require minimum maintenance and wear well, spoked wheels are
substantially lighter, more responsive, and are generally preferred by active wheelchair users.

141. (b) The medial branches of the dorsal rami supply innervation to the facet joints and the deep
paraspinals, namely the segmental multifidi and rotators. The sacral multifidi are innervated by the
sacral (rather than the lumbar) dorsal rami. Each lumbar medial branch innervates the facet joint at
and below its derivation. The L4-5 facet joint is innervated by the L3 and L4 medial branches,
derived from the L3 and L4 nerve roots.

145. (b) The rates of infections and stones are higher with suprapubic catheters. An indwelling catheter
results in a slight increased risk of bladder cancer. High internal bladder pressures may occur as a
result of detrusor sphincter-dyssynergia and avoiding reflux by allowing continuous drainage can
be safer than intermittent catheterization for some individuals.

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147. (d) In order to appropriately follow Medicare regulations for teaching physicians, when caring for a
patient with a resident physician, the attending physician must see the patient, review the medical
record documentation of the resident, and personally document involvement in key aspects of the
history, exam, and medical decision-making. Documentation from the resident alone does not
confirm the level of attending physician involvement. The attending physician documentation
combined with the resident documentation can be used to determine the level of care provided and
the appropriate level of billing.

149. (b) The child with L5 myelodysplasia typically has late hip dislocation, calcaneus foot, hip flexion
contractures, and may have either knee extension or flexion contractures, depending on whether
quadriceps (L2-4) or hamstrings (L4-S1) are stronger. Gluteus medius (hip abductor, L4-S1) and
hip adductors (L1-3) are innervated higher than L5 and are typically balanced in L5
myelodysplasia. Late hip dislocation is due to either unbalanced hip musculature or spinal
deformities.

151. (d) The C6-7 and C7-T1 epidural levels have the greatest amount of space. Interlaminar epidural
injections should be performed with caution in the spaces that have a smaller diameter, such as
those at stenotic levels or high cervical levels. Practitioners should also be aware that the
ligamentum flavum may have defects in a high percentage of individuals.

154. (b) Humans have 2 primary types of muscle fiber. They are divided according to many different
characteristics, including speed of contraction and sources of fuel. Type 1 muscle fibers are slow-
twitch with oxidative metabolic pathways. Type 2 muscle fibers are fast-twitch fibers. The type 2
fibers can then be further divided into fast-twitch oxidative (type 2a) and fast-twitch glyclolytic
(type 2b). There are no muscle fibers designated as type 3.

161. (b) Patients with trouble initiating sleep may require shorter acting medications, while those with
fragmented sleep and frequent awakenings may more ideally benefit from medications with an
intermediate to long half-life. A third nonbenzodiazepine hypnotic, eszopiclone, is FDA approved
for long-term management of insomnia and retains a greater half life (5h–5.8 hours) with evidence
of greater sleep maintenance efficacy as compared to the current relatively shorter half-life Z-drugs.

162. (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.

165. (d) The functional position of the hand includes supporting the wrist in 20º to 30º of extension,
supporting the palmar arch with the 4th and 5th metacarpals slightly anterior to the second and third
digits. Metacarpophalangeal flexion of 30° to 40° would be excessive. The thumb web space
should be preserved.

166. (a) Lying quietly is 1.0 MET. Light housework is 1.2-3.0 METs. Standing at ease is 1.4-2.0 METs.
Walking at 3 miles per hour is equivalent to 4.3 METs.

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167. (d) The United States Department of Labor has determined that computer work is associated with a
significant number of musculoskeletal disorders, many of which are considered cumulative trauma
disorders. Examples include cervical and thoracic myofascial pain, rotator cuff tendonitis, medial
and lateral epicondylitis, de Quervain tenosynovitis, and carpal tunnel syndrome.

169. (c) Various strategies can be used when implementing a quality improvement process. One widely
accepted method is FOCUS PDCA. The steps in the process include finding an opportunity,
organizing the team, clarifying the current process, understanding the causes of the variation, and
selecting a strategy to implement it (FOCUS). Once this has been accomplished, then the strategy
involves planning, doing, checking, and acting (PDCA). According to this process, the next best
step in the scenario provided would be to organize a team to investigate the problem.

170. (c) An advantage of a single-subject research design (A-B-A design) is that this design can establish
cause and effect relationships similar to other true experimental designs. Single subject research
designs involve systematic, repeated measurement of a dependent variable over time through 1 or
more baseline and intervention phases. The primary limitation with a single-subject research
design is that it only establishes the cause and effect relationship for the subject involved in the
study. Therefore, these results cannot be assumed to occur in others, because of the variability
between subjects. Typically, a single subject research design requires a washout period between
medication trials to ensure that the effects of the medication are no longer active. Single subject
research designs are especially useful for interventions that do not have extended or prolonged
effects. If the intervention has only short-term effects, then a difference in the outcome measured
can be clearly demonstrated by comparing results when the intervention is in use against results
obtained when it has been removed.

171. (a) Complex regional pain syndrome (CRPS), previously known as reflex sympathetic dystrophy, as
well as by other names, is characterized by a preceding noxious event; allodynia is an exaggerated
pain response (ie, hyperesthesia) in response to a non-noxious stimulus or to vascular changes such
as those indicated by paleness and coolness or by edema. Sudeck’s atrophy is a name previously
given to late stage CRPS when osteopenia is present. Osteopenia is a rare and late occurrence with
CRPS. CRPS type 2 is also referred to as causalgia and is instigated from an initial nerve injury.
Children with CRPS have a better prognosis than adults.

173. (d) Prolonged bed rest has detrimental effects, which include an increased resting heart rate, loss of
plasma volume, decreased cardiac stroke volume, and decreased maximum oxygen consumption.

176. (b) Open kinetic chain exercise occurs when the most distal segment is not in contact with a surface
(eg, leg extensions). Closed kinetic chain exercise occurs when the most distal segment is in
contact with a surface (eg, a leg press). In isokinetic exercise a muscle contracts with a constant
angular velocity and variable resistance. In isometric exercise a muscle contracts against an
immovable object and there is no joint angular movement.

178. (a) According to the Charter on Medical Professionalism, there are 3 fundamental principles of medical
professionalism. They are (1) the primacy of patient welfare, (2) patient autonomy, and (3) social
justice.

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179. (d) Preventable medical errors can result in lower levels of patient satisfaction and loss of trust in the
health care system. Preventable medical errors often result in significant morbidity and even
mortality. Estimates are that 44,000 to 98,000 people die each year as a result of medical errors that
could have been prevented. These errors are frequently the result of system type errors rather than
individual human error.

180. (b) When critically evaluating the medical literature, it is important to consider if the results of the
study are both clinically and statistically significant. It is also important to consider whether the
outcome assessment tools have been validated for both accuracy and reliability. While biases that
may impact the outcome of the study also must be considered, it is often impossible to completely
eliminate bias from the study.

182. (b) Concussive injuries of the spinal cord are more varied in gradation than injuries to the brain.
Seemingly mild spinal concussions, seen most frequently in cervical hyperextension, may lead to
complete tetraplegia, even in the absence of penetration of the spinal canal or even vertebral
fracture. Mild concussive trauma to the brain results in a more mild brain injury and a more severe
concussive trauma to the brain results in a more severe neurologic dysfunction.

183. (b) Ultrasound is typically an inexpensive treatment that may help with pain and bone maturation,
however, it is contraindicated near arthroplasties and therefore not a good treatment in this case.
Further contraindications include use of ultrasound: near pacemaker, near spine or laminectomy
site, near brain, eyes, or reproductive organs, is someone with malignancy or skeletal immaturity, or
near sites where methyl methacrylate was applied.

184. (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.

185. (b) The patient is likely developing spontaneous detrusor contractions. You would consider using an
anticholinergic agent to decrease detrusor (and hence bladder) pressures. Ideally, you would obtain
urodynamic studies to ascertain bladder pressures and detrusor-sphincter coordination and would
use these findings to guide treatment.

186. (b) Paraffin bath use has many methods. The dipping method increases subcutaneous temperatures by
3o Celsius, and the intra-articular temperature by 1o Celsius. The continuous method increases the
subcutaneous temperature by 5o Celsius and the intramuscular area by 3º Celsius. The paint on
method heats the subcutaneous area less than the dipping method. There is no formal wrap method.

188. (a) A meta-analysis summarizes the results of randomized controlled trials on a particular topic or
research question. A consensus statement summarizes the findings of an expert panel. In
developing a consensus statement and reviewing the literature, research studies are typically
divided into 3 tiers based on the type of research performed. A multi-center study implements a
particular research protocol at multiple centers at different institutions.

190. (d) All of the options listed are key aspects of practice-based learning and improvement, with the
exception of the ability to advocate for quality patient care and assist patients in dealing with
system complexities. This statement is a key aspect of systems-based practice as defined by the
Accreditation Council of Graduate Medical Education.

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194. (d) Exclusion criteria for resistance training in stable cardiac patients include congestive heart failure,
severe valvular disease, poor left ventricular function, uncontrolled dysrhythmias, and peak
exercise capacity under 5 METs.

196. (a) Wrist strengthening, acupuncture, and shock wave therapy all help in the treatment of epicondylitis.
However, low intensity laser treatment is not proven beneficial.

197. (c) The Commission on Accreditation of Rehabilitation Facilities (CARF) provides accreditation status
that signifies the rehabilitation facility holds itself to the highest standards in the field. CARF
accreditation is voluntary and not all inpatient rehabilitation facilities participate. Accreditation by
CARF does not confer any preferred status with payors, and CARF provides accreditation in
general comprehensive inpatient rehabilitation as well as specialty programs such as spinal cord
injury and traumatic brain injury.

199. (b) Beneficence requires investigators to design protocols that will provide generalizable knowledge
and ensure that the benefits of the research are proportionate to the risks assumed by the subjects.

200. (d) Conflicts of interest in biomedical research are becoming more apparent as private companies
increasingly develop relationships with academic research scientists. Avoidance of real or
perceived conflicts of interest in clinical research is necessary if the medical community is to ensure
objectivity and maintain individual and institutional integrity. Financial investments should only
transpire outside of the time that the investigator is involved in any research activity and the results
of the research are known to the public. If conflicts of interest exist, the investigator is obligated to
disclose this involvement in writing to the investigator's medical center, organizations funding the
research, and anytime that the research is presented or published.

Copyright © 2007
American Academy of Physical Medicine and Rehabilitation
Chicago, Illinois

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