Abridged Version

2002 Self-Assessment Examination for Residents (SAE-R)

Answer Key and Commentary on Preferred Choice
QUESTION ANSWER COMMENTARY

1. (b) Plantar fasciitis is classically most painful upon arising first thing in the morning, and is aggravated
by overuse or change in footwear. An S1 radiculopathy often presents with numbness and tingling
and has associated reflex changes and possibly weakness in the plantar flexors. Tarsal tunnel
syndrome is caused by compression of the posterior tibial nerve inferior to the medial malleolus. A
Morton’s neuroma causes plantar pain in the forefoot and is aggravated by wearing tight, restrictive
shoes.

2. (a) Constraint-induced movement is effective in persons more than a year after stroke if they have
preserved wrist extension and finger movement along with good sensation. Proprioceptive
neuromuscular facilitation is typically used during the acute phase of stroke and is not more
effective than other traditional treatments. EMG biofeedback has a mixed record but is probably a
good adjunctive treatment. Functional electrical stimulation appears to be useful in muscle
retraining but would probably not be applied to the finger flexors in this patient. No randomized,
controlled studies have compared these therapies for efficacy.

3. (c) A meta-analysis of randomized controlled studies on the treatment of knee and hip osteoarthritis
with glucosamine and chondroitin found moderate effects on symptoms. These effects take a
minimum of 4 weeks. Glucosamine and chondroitin are capable of increasing proteoglycan
synthesis in articular cartilage.

5. (c) The 2000 revisions have clarified a few issues from the previous standards. For a person to receive
a classification of motor incomplete spinal cord injury (ASIA C or ASIA D) they must have either
1) voluntary anal sphincter contraction or 2) sacral sensory sparing with sparing of motor function
more than 3 levels below the motor level. Previously, the person needed only to have sparing more
than 2 levels below the motor level. The FIM was eliminated from the standards. The ZPP is to be
documented as the most caudal segment with some sensory and/or motor function. There has been
no change in the 3-point (0-2) scale for the sensory exam.

6. (b) Radiation reactions may occur at any time during or after radiation therapy. Acute reactions that
occur within hours after the first dose are caused by edema, and manifested by headache, nausea,
vomiting, somnolence and fever. Worsening neurological symptoms may occur with dose fractions
greater than 2 Gray. Symptoms are preventable through use of corticosteroids, eg, dexamethasone 2
mg daily or twice daily.

7. (b) Alhough, house painters may be at risk for injury, machine operators, truck drivers, and nurses have
the greatest incidence in compensated low back pain injuries.

8. (c) Pain medication has no effect on EMG findings. All the other choices can be an explanation for a
normal EMG in a patient who has a lumbar radiculopathy.

9. (c) These options all describe reflexes. (a) asymmetric tonic neck reflex, (b) palmar grasp, and (d)
Moroare seen until a baby is about 6 months old. Protective extension or parachute reaction (c)
does not appear until after 6 months.

11. (b) This patient has a grade 3 acromioclavicular separation. Grade 1 or 2 separations would not have a
visible deformity and would require weighted bilateral shoulder films. A grade 3 separation may
have good results with conservative care, but a young manual laborer should be referred for
surgical repair to ensure good results. Grade 4-6 separations should be surgically repaired. Patients
should only be placed in a sling for a few days until the pain subsides. This will decrease the
possibility of losing shoulder range of motion. The shoulder should be given a few days rest, and
 physical therapy referral is not appropriate at this time. A corticosteroid injection is not the
treatment of choice and will not repair the separation.

12. (b) There are several determinants to successful return to work for persons with traumatic brain
injuries. All studies have identified the severity of head injury as a primary factor in return to work;
the Glasgow Coma Scale is one of the robust measures of injury severity. Other factors include
preinjury work history, age, cognitive abilities, or motor limitations.

13. (d) The National Osteoporosis Foundation (NOF) established guidelines to reduce risk of osteoporotic
fractures. These recommendations include, participating in weight bearing exercise, ingesting
adequate calcium (1200mg/day) and vitamin D (400-800IU), and avoiding tobacco use.

14. (b) This patient is most likely to have acute inflammatory demyelinating polyneuropathy of Guillain-
Barré syndrome. This syndrome presents with ascending symmetrical weakness, generally has mild
sensory involvement although pain complaints are prominent, and commonly spares extraocular
movements despite involvement of other cranial nerves. Management would include careful
monitoring of vital capacity, since respiratory muscle weakness could result in the need for
ventilation. Steroids by any route of administration have not been shown to be effective.

15. (b) The leading cause of death for persons with spinal cord injury who survive more than 24 hours is
pulmonary dysfunction (pneumonia, adult respiratory distress syndrome) followed by nonischemic
heart disease, septicemia and pulmonary embolus.

17. (d) Workers who participated in a cardiovascular training program were compared to a control group.
Those in the training program reported 51% fewer sick days than controls despite no change in their
maximum oxygen consumption (VO2max).

23. (c) Spinal flexion will increase pain related to vertebral compression fractures. An extension brace will
promote a position of comfort during the healing process. These braces may include a Jewett brace,
cruciform anterior spinal hyperextension brace, and a chairback or warm and form brace.

24. (d) Patients with acute inflammatory demyelinating polyneuropathy (AIDP) commonly develop painful
tightness in the two-joint muscles, including the hamstrings, tensor fascia lata, and gastrocnemius.
Actual joint capsule contracture is much less common. The vast majority of persons with AIDP
significantly improve and are unlikely to develop scoliosis as a result of muscle weakness. Tendon
inflammation is not a feature of AIDP.

25. (c) Although the pattern of emotional reaction is unique to every person, coping with a spinal cord
injury normally involves sadness, yearning, and intense feelings of loss. While bereavement might
appear similar to depression, it does not ordinarily involve prolonged feelings of guilt,
worthlessness, self-reproach or thoughts of death as seen in depressive disorders. Because grieving
or bereavement is universal in the context of spinal cord injury, it is important to differentiate
bereavement from a depressive disorder.

26. (c) The external jugular vein, spinal accessory nerve, and sternocleidomastoid muscle are removed
during a radical neck dissection. Loss of the spinal accessory nerve leads to shoulder dysfunction
with long-term adverse functional sequelae.

27. (c) Nonsteroidal medications, education in lumbar positions of comfort, and physical therapy constitute
the standard of care in conservative management of lumbar radiculopathy. Ten days of bedrest is no
longer recommended, since the effects of immobilization can further impair recovery. Limited or
relative rest can help relieve repetitive trauma while acute pain management interventions are
underway. A lumbar corset may help with pain in the first few days but immediate return to work
while relying on a lumbar corset does aid in recovery. Jackhammer operators are exposed to a great
deal of vibration, which increases an individual’s risk of disc injury. When a disc injury is
suspected in this population, return to a modified work description avoiding lifting, bending,
 twisting, and vibration should be recommended. Lumbar discography should be reserved for
individuals who have exhausted conservative management and are contemplating a spine
procedure.

28. (c) This is a classic history for neuralgic amyotrophy or idiopathic brachial plexopathy involving the
long thoracic nerve. In 30% of patients with neuralgic amyotrophy, EMG abnormalities can be
found in the asymptomatic upper extremity; however, the absence of such findings does not
obviously exclude the diagnosis. The findings are inconsistent with the other diagnoses.

29. (c) Spinal cord injury without obvious radiologic abnormality (SCIWORA) usually occurs in young
children, is thought to be due to the relatively large head size and weak neck muscles, and motor
abnormalities may not be apparent for up to several days. SCIWORA most commonly occurs in
the cervical region.

31. (c) Spondylolisthesis in the lumbar spine is a common finding, occurring 70% of the time at L5-S1 and
25% at L4-5. It is caused by a defect or fracture in the pars interarticularis and is graded 0-4 on the
basis of the amount of slippage of one body on the other. It may indeed lead to spinal stenosis and
compromise of the cauda equina. A spinal orthosis will not be effective in stabilizing this defect but
can be useful in reducing lumbar lordosis, decreasing pain, and reducing gravitational forces on the
slippage.

32. (a) Fatigue is a common, limiting symptom in patients with multiple sclerosis. Behavioral techniques
such as energy conservation and well-planned rest periods are often required. Amantadine is
traditionally the first choice; however, pemoline may provide relief. Beta-interferon and ACTH are
more disease-modifying agents used during periods of acute exacerbation.

33. (b) Aseptic loosening is seen 10 years after implant of prosthesis, the other choices are common
etiologies for dislocations during the first few weeks after implant.

34. (a) Because of growth and increasing weakness, a common sequela of motor neuron disease is
scoliosis. It is important to provide adequate pelvic support with a firm seat to avoid hip
asymmetry. If wheelchairs are too big, asymmetric spinal posture is encouraged. Slanted seats with
pommels are useful to control extensor spasticity, which should not be an issue here. Seat backs
should be high to help control spinal posture.

35. (d) This individual is experiencing autonomic dysreflexia, seen typically in individuals with spinal cord
injury with lesions at or above T6. A treatment algorithm that outlines the timing of treatment
recommendations was established by the consortium for spinal cord medicine in 1997. When an
individual presents with autonomic dysreflexic symptoms including elevated blood pressure
(systolic blood pressure greater than 150mm Hg), the very first thing to do is to sit the patient up
with his/her clothing and constrictive devices loosened. If the blood pressure remains elevated and
the individual has an indwelling catheter, kinks and twists should be removed. If there is no urine
flow, the catheter then needs to be irrigated. If the individual does not have an indwelling catheter,
a Foley catheter must be inserted and again if there is no urine flow, it should be irrigated. If there
is good urine flow and/or the blood pressure drops down to normal, then the work-up as well as
other interventions would cease. If the blood pressure remains elevated after irrigation or initiation
of catheter, and the systolic blood pressure remains above 150mm Hg, a short-acting
antihypertensive medication such as topical nitropaste is initiated. After this, if the individual
continues to be hypertensive, he/she may have to be admitted to a hospital to control blood
pressure. If, after the short-acting antihypertensive, the blood pressure drops, evaluation of the
rectum for fecal impaction begins, including installation of lidocaine into the rectum and allowing it
to sit for approximately 5 minutes to decrease sensation before probing the rectum with a gloved
finger and subsequently attempting to disimpact.
36. (c) The generation of speech following trachealesophageal puncture requires that air flow be directed
from the trachea into the esophagus and through the oropharyngeal cavity. This can only be
achieved if the patient’s tracheostomy site is manually occluded, usually with a digit.

37. (a) A functional capacity evaluation (FCE) is a comprehensive test with some objective data that tests a
person’s ability to perform work-related tasks. An FCE helps determine what the worker can do at
work on a safe and dependable basis. Testing is usually performed work after the initial
rehabilitation program has been completed.

38. (d) There is conduction block across the mid-forearm consistent with a posterior interosseous
neuropathy with neurapraxia.

39. (b) Scoliosis requiring surgery is a common complication seen in children who have had an spinal cord
injury (SCI) at a young age. Increased lordosis in the absence of scoliosis is rarely seen. Deep
venous thrombosis rarely occurs in young children and when it does occur it usually occurs soon
after the SCI. Heterotopic ossification tends to occur soon after the SCI.

40. (c) A waddling gait occurs when there is bilateral gluteus medius weakness. A steppage gait occurs as
an abnormality in swing phase due to severely weak dorsiflexors of the ankle. Foot slap is seen with
moderately weak dorsiflexors and occurs on the side of weakness. Trendelenberg gait is excessive
lateral flexion due to ipsilateral weakness. Circumduction is the swinging of the limb in a wide
lateral arc.

41. (c) This patient has lateral epicondylitis or “tennis elbow,” a condition brought on by repetitive flexion-
extension or pronation-supination of the forearm. The pain will be increased by resisted wrist
extension with the elbow at 180°. The reflexes will not be affected, nor will atrophy be noted. This
is not a neurologic condition, but a myofascial one. No audible click will be heard. This might
occur if the radial head is subluxing, but not in lateral epicondylitis.

42. (c) Although the most common bladder among patients with stroke is normal or hyperreflexic, bladder
hyporeflexia is very common in diabetics (especially in this case with recorded gastroparesis).
These patients will have small frequent voids due to overflow from distended bladders with poor
detrusor contraction.

43. (a) Arthritis and other rheumatic conditions are the leading cause of disability in the United States,
imparting an aggregate cost of about 1.1% of the gross national product.

44. (b) Trendelenburg gait is characterized by excessive dropping of the pelvis contralateral to the stance-
phase leg. It is caused by weakness of the hip abductors, which include the gluteus medius
innervated by the superior gluteal nerve.

45. (d) Tetraplegic patients usually have a reduction in all measures of pulmonary function with the
exception of residual volume. Residual volume is increased due to lack of active expiratory effort.
Vital capacity will continue to improve. Tracheostomy is usually not necessary for pulmonary
hygiene, especially with adequate hydration and techniques for facilitating cough. Since the
diaphragm is supplied by cervical roots C3, C4, and C5, it is common for persons injured above the
C4 level to need ventilator support. In acute spinal cord injury, 67% experience significant
pulmonary complications, most commonly atelectasis. Ventilatory failure and aspiration occur the
earliest (mean, 4.5 days), followed by atelectasis (mean, 17 days) and pneumonia (mean, 24 days).
The late decline coincides with the onset of mucus hypersecretion and muscle fatigue. Ventilator
weaning has been demonstrated in 80% of C4 spinal cord injury patients and 57% of C3 patients.
Considerable patience is required and respiratory muscle fatigue must be closely monitored.

46. (c) Female gynecologic malignancies tend to recur locally within the pelvis. This patient likely has a
lumbosacral plexopathy due to compression by the tumor. An electromyogram could potentially
identify the portions of the plexus involved, however spontaneous activity would not yet have
 developed. Computed tomography of the abdomen and pelvis would determine whether and where
recurrent tumor was present. This would inform surgical or radiation oncologic treatment options.

47. (a) Appropriate management for acute knee injuries include, ice, elevation, non-steroidal anti-
inflammatory drugs, protection, weight bearing as tolerated and activity modification. X-rays
initially rule out bony injury. magnetic resonance imaging should be reserved for cases where the
diagnosis is in question or a surgical procedure is planned. A careful examination to fully exclude
ligament or cartilage injury cannot be completed until the effusion has resolved enough to allow for
an appropriate examination. Therefore, in the case of an acute knee injury with effusion, the patient
should be reexamined within a 1- to 2-week interval in order to narrow the diagnosis and progress
treatment.

48. (d) There is slowing of the median motor distal latency and the median sensory latency across the
wrist, findings consistent with carpal tunnel syndrome.

49. (b) Strong hip flexor and adductor muscles can overpower weak extensors and abductors. Acquired
hip dislocation can be prevented in some cases by release of spastic hip flexors and adductors.

50. (b) Sixty percent of the complete gait cycle is spent in stance phase while walking. Only 40% of the
time is spent in stance phase during running. By definition, running involves little to no heel strike
and has no double support. Stride length and step length are much greater in running than in
walking.

51. (b) Suspicion of a compartment syndrome should lead the physician to get pressure measurements
immediately, since delays may result in permanent muscle or nerve damage. Usual pressures are
less than 30mmHg. Pressures from 30 to 50mmHg are equivocal, but pressures greater than
50mmHg constitute a surgical emergency. The leg should NOT be elevated, because this will lower
arterial perfusion pressure and will further compromise vascular supply. An external
circumferential force will increase pressure. An x-ray and bone scan are not indicated in this
patient.

52. (c) Strokes on the nondominant hemisphere present with contralateral hemiplegia and hemianesthesia,
aprosody, visual-spatial deficit, and neglect syndrome.

53. (b) This patient has gout with characteristic “overhanging edge” lytic lesions. Chondrocalcinosis is
seen in pseudogout, juxta-articular osteopenia is seen in RA, and pencil in cup deformity is seen
with psoriatic arthritis.

54. (d) Because amyotrophic lateral sclerosis is a relentlessly progressive disease, only muscles with
unaffected strength should be exercised, to prevent disuse atrophy. In the postpolio patient, it is
acceptable to strengthen weak muscles with greater than fair (or 3/5) strength.

55. (c) Factors associated with a poor prognosis in multiple sclerosis include: 1) progressive course at
onset. 2) Male sex. 3) Age at onset greater than 40 years. 4) Cerebellar involvement at onset. 5)
Multiple system involvement at onset.

56. (d) In a retrospective chart review it was found that neither the presence of metastatic disease, nor the
need for ongoing anticancer therapy (eg, chemo- or radiation therapy delayed the achievement of
rehabilitation goals or extended rehabilitation hospital stay.

57. (b) Impairment is defined as an alteration of a person’s health status, a deviation from normal in a body
part or any organ system (any loss or abnormality of psychologic, physiologic, or anatomic
structure or function).

59. (b) Migraines do not typically occur only in the morning. Neck extensor tightness usually occurs
before the loss of ambulation in boys with Duchenne muscular dystrophy, which usually occurs
 before the age of 15 years. Vision changes usually do not cause morning headaches. Hypercarbia
results from hypoventilation during sleep and is an early sign of impending respiratory failure.

60. (c) Trauma is the leading cause (approximately 75%) of acquired amputation in the upper extremity,
occurring primarily in men between the ages of 15 and 45 years. Disease and tumors are
responsible for about equal numbers of the remaining acquired upper-extremity amputations. In the
lower extremity, disease states account for approximately 75% of all acquired amputations, with
complications of diabetes and peripheral vascular disease accounting for the great majority of these,
especially in persons age 60 years and over. Trauma is the next most common cause for lower
extremity amputation (20%), followed by tumors (5%). Among persons between the ages of 10 and
20 years, however, tumor is the most frequent cause of all amputations in both the upper and lower
extremities.

61. (d) Patients with diabetes mellitus are at risk for serious infection and for systemic effects of absorbed
corticosteroids. Injection into an infected joint, tendon or bursa is contraindicated. Multiple
injections should not be performed unless clear improvement has been demonstrated. More than 3
steroid injections are rarely indicated. There is a risk of tendon rupture in patients who return to
usual activity too rapidly. Plantar fasciitis and lateral epicondylitis respond well to steroid injection.

62. (d) Post traumatic headaches are a common symptom after cervicocranial trauma. The differential
diagnosis includes cervical disease, occipital neuralgia and migraines, and myofascial pain. In this
scenario, points that reproduce the headaches should be treated either with or without local
anesthesia. This helps to reduce pain, inhibit the muscle contracture band, and enhance local muscle
blood flow.

63. (d) Medications that promote sleep, such as low dose tricyclic antidepressant medications, have been
shown to be the most helpful pharmacologic approach to patients with fibromyalgia.

65. (d) (This question has been eliminated from the exam, therefore, it was not scored.)
Because electrical stimulation for bladder and bowel function depends on the ability to activate
intact motor neurons from the sacral segments of the cord, it is at this time limited to persons with
suprasacral lesions. Micturition is produced by stimulation of the anterior (motor) S2, S3, and S4
nerve roots. Continence has been greatly improved by concurrent posterior rhizotomy of the
(sensory) sacral nerve roots. The advantages of posterior rhizotomy include increasing bladder
capacity and abolishing reflex voiding, reducing dyssynergia and abolishing episodes of autonomic
dysreflexia. The primary disadvantage of posterior rhizotomy is the loss of reflex erection and
reflex ejaculation (if these are present). The hardware cost is approximately $40,000 with the
projection that after factoring in the cost of medications, supplies, medical procedures, durable
medical equipment, and attendant care, the device pays for itself in 5 to 7 years.

66. (d) The transplanted heart is denervated and therefore cardiac ischemia does not cause pain. Because
vagal tone is lost, the resting heart rate following transplant is close to 100 beats per minute.
Exercise induced increase in heart rate is blunted and peak heart rates are generally 20% to 25%
lower than age-matched controls. Swan Ganz monitoring is not required.

67. (d) The patient’s symptoms and the physical exam findings are consistent with an ulnar neuropathy at
the elbow.

68. (c) Rotating the anode around the cathode can decrease stimulus artifact. The other choices have no
effect, or increase it.

69. (c) Spastic diplegic cerebral palsy occurs most commonly in premature infants who have had an
intraventricular hemorrhage during the neonatal period. Intrauterine stroke causes hemiplegia.
Neonatal hyperbilirubinemia most commonly causes athetosis. Birth asphyxia is more commonly
associated with spastic quadriplegic cerebral palsy.
70. (d) Traditional suspension systems include harness (figure-of-8 or -9, chest strap, and shoulder saddle),
self-suspension (condylar, Muenster, or Northwestern), semisuction (semisuction or hypobaric) and
suction (full suction or silicone sock).

73. (d) Acute iritis is an extra-skeletal manifestation of ankylosing spondylitis (AS). HLA-B27 is not
necessary to make the diagnosis of AS. Involvement of peripheral joints is infrequent and, when
present, is asymmetric. The Schober test is typically positive.

74. (d) Thyroid disease is associated with several different aspects of the neuromuscular system. In both
hypothyroidism and hyperthyroidism, there can be neuromuscular junction disorders (increased
incidence of myasthenia gravis), and myopathy. Hypothyroidism is associated with sensorimotor
peripheral neuropathy and entrapment neuropathy, especially carpal tunnel syndrome. Thyroid
disease is not associated with radiculopathy.

78. (b) There is a single motor unit firing at approximately 20Hz without another motor unit coming in.
This is an example of decreased recruitment, which may be seen in neuropathy. In myopathy one
may see early recruitment of motor units. In patients who give submaximal effort there may be only
1 motor unit seen on the screen, but the firing rate is less than 20Hz.

79. (b) There are many studies about longterm outcomes of ambulation in children and adults with
myelomeningocele. While many factors influence outcome, including intelligence, medical
problems, and obesity, the best predictor of ambulation into adulthood is strong quadriceps
function. Bowel and bladder continence has no relationship to ambulation.

80. (a) Static means that the orthosis is rigid and gives support without allowing movement. These devices
are commonly used to rest a part after trauma or surgery, and for acutely inflamed joints and
tendons. Dynamic orthoses allow a certain degree of movement. They usually provide some
element of assisted motion to the joint, such as the elastic assist to wrist extension in the orthosis for
radial nerve palsy.

81. (b) Moderate, sustained pressure for approximately 10 seconds on an irritable trigger point causes
symptoms in the reference zone for that muscle. No specific amount of pressure is required for this
diagnosis. Trigger points should not be confused with fibromyalgia “tender points” which require
approximately 4 kg of pressure for diagnosis. Myofascial trigger points are electrically silent and
show no resting muscle activity on electromyogram. No elevation in muscle creatine phosphokinase
is seen with this condition. Isokinetic exercise is not indicated as a treatment for this condition.
Local injection with anesthetic and/or spray with a vaporcoolant spray and stretch of the muscle are
the treatments of choice.

82. (b) Risk factors for the development of heterotopic ossification include prolonged coma,
immobilization, and limb spasticity.

84. (a) Relapsing-remitting multiple sclerosis (MS) is the most common type of presentation—
approximately 80%.

85. (a) The center of gravity for a hypothetical wheelchair rider is typically located slightly forward of the
rear axle. Moving the rear axle directly under the wheelchair user makes the person and the chair
more likely to flip backwards (wheelie). However, the advantages to having the center of gravity
near the rear axles include decreased tendency for caster flutter, decreased rolling resistance, since
most of the weight is borne by the larger rear wheels, and minimization of the turning torque.

86. (c) Patients who have just undergone coronary artery bypass grafting have recently been revascularized
and are therefore excellent rehabilitation candidates. Typically, patients begin progressive
ambulation training on postoperative day 2, with independent ambulation usually being performed
on day 3.
87. (d) Postural changes can produce muscle imbalances that can cause pain syndromes. Changing posture
and re-education of muscles through appropriate strengthening programs is appropriate
management. The ergonomics at her work site have a lot to do with her pain complaints. Time away
from work may temporarily reduce symptoms but will likely have no long-term effect. The use of
pain management interventions such as ice and anti-inflammatory medications is appropriate but
should not be expected to correct the long term problem.

88. (b) A 2 to 3Hz stimulation is optimal for demonstrating a decremental response. At this rate there is no
build up of Ca++ concentration within the nerve terminal and the amount of acetylcholine in the
readily available stores diminishes, making failure of some of the neuromuscular junctions possible
in those patients with an already small safety factor. A decrement of up to 10% on 2 to 3Hz
repetitive stimulation is considered normal. Small CMAPs initially are more suggestive of
myasthenic (Lambert-Eaton) syndrome than of myasthenia gravis. Single fiber EMG reveals
increased jitter and may reveal blocking.

90. (a) Exoskeletal designs tend to weigh more, are more rugged, demand less maintenance, and cannot be
adjusted after fabrication. Generally, the opposite is true of endoskeletal designs.

91. (b) This patient most likely has suffered a grade I or II ulnar collateral ligament injury. This injury is
called a “gamekeeper’s or skier’s thumb.” A complete (grade III) tear is diagnosed by a difference
of 15° or more of lateral laxity compared to the uninjured side or an absolute laxity of 35°. This is
not a grade III injury, and will likely heal with nonsurgical treatment consisting of immobilization
in a thumb spica cast or splint for 2 to 4 weeks. This patient may be returned to ski with a thumb
spica or cast in place. A steroid injection is not indicated. Ice may help with the pain and swelling,
but immobilization is required for this patient. Nonsteroidal anti-inflammatory drugs may be given
for pain control.

92. (c) Based on the information presented in the question, the Glasgow Coma Scale score for this patient
is 11 (eyes open when spoken to 3, withdraws to pain 4, converses but is disoriented 4 = total score
11). Moderate injury is defined by GCS scores of 9 to 12.

94. (b) Facioscapulohumeral and myotonic dystrophy are usually autosomal recessive. Emery-Dreifuss
muscular dystrophy is X-linked recessive. Limb-girdle dystrophy is a group of disorders producing
weakness about the hips and shoulders. It can be either autosomal recessive or dominant.

97. (b) If job requirements cannot be modified, an injured worker may not be able to return to his/her job.
The employee’s age or the length of time that has elapsed since the injury does not by definition
exclude the worker from returning to work. Whether the worker was responsible for the injury does
not exclude him/her from returning to work.

98. (c) The duration of these potentials is approximately 5ms, too short for a motor unit. The initial
deflection is negative, distinguishing this potential as an end plate spike rather than a fibrillation.

99. (c) A child with C5 ASIA A spinal cord injury should eventually become independent in feeding, and
in upper extremity dressing with assistive devices, in driving a power wheelchair, and in propelling
a manual wheelchair short distances on level surfaces.

100. (d) During full weight bearing the ischial tuberosity sits on the ischial seat (the wide flat posterior
brim). Only with ischial containment sockets does it slide down into the socket when properly fit.
There should be room for the finger between the ischial tuberosity and the ischial seat during knee
flexion when weight bearing is decreased. The best position for determining the relationship of the
ischial tuberosity and the ischial seat is knee extension. If there is no room for the finger between
the ischial tuberosity and the ischial seat during full weight bearing, the socket fits correctly with
regard to the proximal landmarks.
102. (d) From the details given in the case, this resident appears to be having problems in mental flexibility
and paying attention to multiple stimuli. The Trails A and B test examines simple and alternating
attention. The Galveston Orientation and Amnesia Test, which is used to measure the presence of
post-traumatic amnesia, would not be helpful. The Wechsler Adult Intelligence Scale–Revised and
Wechsler Memory Scale, while necessary in a complete neuropsychological examination, do not
directly measure attentional abilities.

103. (a) Radiographs will show a mottled appearance. The skull, tibia, pelvis and vertebral bodies are most
commonly invloved. Syndesmophytes are seen with spondyloarthropathys. Blue sclera is seen in
osteogenesis imperfecta.

105. (d) In persons with spinal cord injury, there is an initial dramatic loss of muscle mass after the acute
paralysis. However, even decades after injury, there is continuous loss of lean body tissue
compared to that observed in an able-bodied person. It is of particular interest that the arms of
persons with paraplegia have significantly less percent lean tissue compared with controls. No
differences in the cross sectional rate of loss of lean body mass is noted between persons with
tetraplegia and paraplegia. Men with spinal cord injury can be expected to lose about 3.2% per
decade of the total lean body tissue vs. 1% per decade in able-bodied males. Individuals with spinal
cord injury have a pattern of metabolic alteration that is atherogenic with dyslipidemia, glucose
intolerance, insulin resistance, and reduction in metabolic rate. Although the literature in persons
with spinal cord injury is conflicting regarding anabolic hormonal changes in persons with spinal
cord injury, there are subsets of individuals with relative androgen deficiency states. The etiology
of a relative deficiency of testosterone in persons with spinal cord injury has not yet been
established. However, it is conceivable that prolonged sitting and euthermia of the scrotal sack and
testes may itself have a deleterious local effect on testosterone production.

106. (b) Duchenne muscular dystrophy, like all myopathies, causes a restrictive pattern of respiratory
compromise. Therefore, functional residual capacity, tidal volume, residual capacity, and vital
capacity are all reduced relative to age-matched normals.

107. (c) Repetitive injuries from keyboard occupations are well recognized and require active rehabilitation
for restorative function. Eccentric exercises will increase repetitive stress to the injured site and
should not be used in the initial treatment recommendations. The prescription of biweekly steroid
injections is excessive and may promote musculotendon atrophy and susceptibility to further injury.
Moving the mouse further away from the keyboard will likely increase symptoms and dysfunctions.
Wrist splints can be used during the initial treatment program to provide relative rest, reduce
inflammation, and to provide comfort.

109. (d) Spinal muscular atrophy (SMA)is a term used to describe a group of inherited disorders
characterized by weakness and muscle wasting due to degeneration of anterior horn cells of the
spinal cord and brainstem motor nuclei. Three subtypes of autosomal recessive predominantly
proximal SMA have been linked to chromosome 5q. The majority of cases of SMA type I present
within the first 2 months of life with generalized hypotonia and symmetric weakness. Children
typically sit only with support. Tongue fasciculations have been reported in 56%-61% of patients.
Proximal muscles are weaker than distal.

110. (b) Excessive knee extension at heel strike is frequently seen with hamstring weakness or
gastrocnemius muscle spasticity. It causes the patient to walk on the heel, with external rotation of
the leg and no knee flexion at heel strike. Excessive knee flexion at heel strike is frequently seen
with an ankle-foot orthosis (AFO) that is set in too much dorsiflexion. This setting causes the mid-
stance period to be reduced and the push-off effect diminished, causing the knee to be excessively
flexed and thereby slowing the gait. If the tip of the shoe on the AFO side is raised too high at heel
strike, the AFO is set in too much dorsiflexion. Only answer b addresses all of the abnormalities
seen in this individual.
111. (b) The Gaenslen sign is a test to determine sacroiliac pathology. This test is performed by having the
patient lie supine. One buttock is extended over the table’s edge while the other remains on the
table. The ipsilateral leg is allowed to drop below the edge of the table, with the other leg remaining
in a flexed position. Pain in the area of the sacroiliac joint on the side of the extended leg represents
a positive test. The Thomas test is a test to measure hip flexion contracture. The Ober test is used to
identify contracture of the iliotibial band or the tensor fascia lata. The Lasegue sign is the straight
leg test, a nerve root stretch test to identify radicular pain.

112. (d) For infants, more than two-thirds of all traumatic brain injuries result from falls; only 8% of these
result in moderate or severe injuries. For preschool children, falls account for 51% of TBI and
motor vehicle crashes for 22%. For children 8 to 9 years of age, etiology of TBI is evenly divided
between falls, sports, and recreational activities, and motor vehicle crashes.

113. (d) This patient describes classic neurogenic claudication due to spinal stenosis. He has a non-focal
examination and should be managed conservatively initially with flexion based exercises. Epidural
steroid injections may be warranted if the patient does not respond to initial therapeutic exercise.

114. (c) The ulnar nerve innervates all the dorsal interossei muscles and the third and fourth lumbricals. The
median nerve innervates the first dorsal interosseus muscle in about 1% of the individuals. Rarely,
the radial nerve innervates the first dorsal interosseus. The first and second lumbricals are
innervated by the median nerve.

115. (c) Based on the ASIA classification revised in 2000, the highest intact level would be C5 (normal
muscle strength or >3/5 with the next level being normal). ASIA classification is based on
completeness of injury. ASIA A indicates no motor or sensory preservation below the level of
injury. ASIA B indicates sacral sparing. ASIA C is motor incomplete with more than half of the
muscle groups below the level of injury with muscle grade less than 3/5. ASIA D is also motor
incomplete, with at least half of the muscle groups greater than 3/5. In this case, 11/18 muscle
groups are 3/5 or greater, making this person an ASIA D. The highest intact level is C5.

116. (a) Optimizing the nutritional status of patients undergoing pulmonary rehabilitation is critical for
treatment success. However, inappropriately increasing carbohydrate consumption can aggravate
hypercapnia.

117. (a) Electrodiagnostic testing supplies objective measurement of peripheral nerve compression. Though
x-rays are an objective test, a diagnosis of carpal tunnel syndrome cannot be made by x-rays. A
positive Tinel’s test and symptoms of paresthesias in the thumb and index finger are commonly
found in patients diagnosed with carpal tunnel syndrome but are not objective findings.

118. (d) The anterior part of adductor magnus is innervated by the obturator nerve. The piriformis receives
its own branch off the lumbosacral plexus. The semimembranosus is innervated by the tibial
division of the sciatic nerve. Only the short head of the biceps femoris is innervated by the peroneal
division of the sciatic nerve.

120. (c) Energy expenditure in paraplegia is as follows (in order of lowest to highest): normal walking,
swing-through gait in a Scott-Craig knee-ankle-foot orthosis (KAFO), swing-through gait in a
standard KAFO, reciprocating gait in a reciprocating gait orthosis. Swing-through gait in a
reciprocating gait orthosis requires approximately the same energy expenditure as the Scott-Craig
KAFO.

121. (a) The breaststroke has an associated “whip kick” which puts stress on the medial knee. For proper
propulsion, the knee must be in a significant valgus position during leg extension. This can lead to
overuse of the adductors and the quadriceps and a condition known as “breaststroker’s knee.”
Individuals who have patellar tracking problems or a high Q angle (greater than 18° in men) with
the knee extended will be prone to patellofemoral pain. You should prescribe that this young man
work on stretching and strengthening of his adductors and quadriceps. The quadriceps
 strengthening should focus on the last 30° of knee extension, which selectively strengthens the
vastus medialis. This patient has negative tests for internal derangement, such as anterior cruciate
ligament tear or meniscus tear. No laxity was noted, and referral for arthroscopy is not indicated.

122. (b) Pregnancy has little impact on the long-term course of multiple sclerosis. The disease tends to be
quiescent during pregnancy. Studies have shown an increased number of exacerbations in the
postpartum period. The use of interferon therapy during pregnancy is controversial. There have
been reports of successful use during pregnancy in other disease processes; however, laboratory
data indicate abortifacient properties at higher doses and some degree of organ abnormality in
laboratory animals.

123. (b) Anterior knee pain syndrome is associated with atrophy of the quadriceps, a large (more than 15°)
Q angle, tight lateral thigh structures, positive posterior drawer, and lateral patellar tilt.

124. (c) The pattern of weakness and numbness is consistent with a median neuropathy in the forearm.
Pronator syndrome is an entrapment of the median nerve as it passes through the pronator teres
muscle. Depending on severity, neurologic deficits may include weakness in wrist flexion (flexor
carpi radialis), finger flexion (flexor pollicis longus, flexor digitorum superficialis, flexor digitorum
profundus digit 2/3), intrinsic hand muscles (abductor pollicis brevis, opponens pollicis), and
sensory abnormalities in a median nerve distribution. Reflexes are normal.

125. (a) Initial acute care and rehabilitation costs average $223,261 per person. Acute care charges are
higher for persons with tetraplegia compared with persons who have paraplegia at the equivalent
severity of injury. Charges approach $157,000 for ASIA A, B, or C tetraplegia and vary from
$69,000 to $ 87,000 for other persons with spinal cord injury. Hospital costs for rehabilitation are
more than twice as high for persons with severe tetraplegia compared with severe paraplegia.
Average annual medical costs (excluding medications, supplies, and physician costs) are just over
$9,000 per year. Given a prevalence of 180,000 persons with spinal cord injury beyond their first
year of injury, this approaches $1.65 billion for the spinal cord injury population. Costs for supplies
and medications are 30% greater for tetraplegics than for paraplegics ($3,308 vs. $2,470). Home
modifications to the residence of a person with spinal cord injury is more than $15,000, and the cost
to modify other homes owned by the person, family, or friends is an additional $5,000.

126. (c) One limitation to the use of aquatic therapy in severe heart failure is its potential to produce rapid
hemodynamic changes. Isometric strengthening can result in increased afterload, with the
possibility of deleterious effects on ventricular function. In severe heart failure, it is generally
recommended that the exercise heart rate be kept at least 10 beats per minute below the
arrhythmia/severe dyspnea level. Telemetry is recommended in this population (at least at the
initiation of their exercise program), as they are usually at the highest level of risk stratification.

128. (b) The sural nerve travels posterior to the lateral malleolus and is best recorded over this area.

129. (a) Any disorder that interferes with cerebral perfusion or oxygenation can cause further damage
following traumatic brain injury. This includes hypotension, hypoxia, increased intracranial
pressure because of cerebral edema, acute hydrocephalus, or space-occupying lesions. Midline shift
or herniation may lead to infarction because of pressure or traction on cerebral vessels. Therefore,
efforts are made to control intracranial pressure through fluid and electrolyte management,
hyperventilation, and maintenance of normal blood pressure and oxygenation. Growing skull
fractures result from the arachnoid protruding through a dural tear, producing a cyst that can
contribute to a widening skull deficit, which usually requires operative repair. This is a
complication of traumatic brain injury but not a secondary injury. Coup and contrecoup cerebral
contusions and diffuse axonal injuries are examples of primary injury.

130. (c) An anterior spring assists plantar flexion and has no specific clinical indications. An anterior rod
limits dorsiflexion and is used for weak plantar flexors, weak knee extensors, and pain with ankle
motion. A posterior spring assists dorsiflexion and is used for flaccid footdrop and knee
 hyperextension. A posterior rod limits plantar flexion and is used for plantar spasticity, toe drag,
and pain with ankle motion.

131. (b) Anesthetics mixed with corticosteroid can mask the pain associated with needle placement into the
nerve and should not be used. The risk of intraneural injection is real, but in experienced hands this
injection is safe. Numbness is anticipated with this injection without use of anesthetics, and helps to
confirm proper placement. Local tenderness and hematomas are common with this injection and do
not represent a complication. Persistent or worsening pain, or swelling lasting more than 48 hours,
are signs of nerve injection or neurotoxic injury. Severe carpal tunnel syndrome with axonal loss is
not reversed with this procedure.

134. (b) The radial nerve is the most likely nerve to be affected at the level of the spiral groove of the
humerus. This can either be due to fractures or compressive lesions (Saturday night palsy). These
patients usually have involvement of the radial innervated muscles except the triceps and anconeus.
Abductor pollicis longus is innervated by the radial nerve.

135. (c) For persons with tetraplegia, proper hand position is maintained by resting hand splints that allow
tightening of the flexor tendons; this tightening promotes the use of tenodesis for hand function.
Functional activities improve significantly with the addition of wrist extensor muscles at the C6
level. Active wrist extensor result in tenodesis of the hand. With wrist control, patients can use a
short opponens orthosis or utensil cuff to feed themselves. While patients with tetraplegia usually
benefit from a lightweight, manual wheelchair, these patients are often appropriate for powered
mobility. The energy saved from pushing the wheelchair can be used for transfers, weight shifts,
and other activities, reducing the wear and tear on joints and soft tissues. Tendon transfers and
upper limb reconstructive surgery are considered 1 year postinjury, keeping in mind that upper limb
muscle recovery can occur over the course of up to 2 years.

136. (c) Scoliosis often becomes evident or exacerbated during this stage. Customized seating and
orthopedic interventions can minimize loss of vital capacity.

137. (a) The amount of lost time is a major determinant of return to the work place. Although more
extensive injuries may more easily deter the employee from returning to work, the extent or type of
injury has not been found to be the major determinant in all worker’s compensation cases. Neither
the type of job or the type of treatment required, such as surgery, are major determinants of
successful return to work. Several studies have shown that the longer the worker is out of work
related to the injury, the more unlikely it is that he/she will return to work successfully.

138. (c) The abnormalities noted are in a posterior cord distribution.

139. (b) Children with major burn injuries should be placed in positions that tend to prevent contractures.
These include neck extension (no pillows); shoulders at 90° abduction and neutral rotation with
elbows, wrists, hips, and knees extended; feet at neutral dorsiflexion, metacarpophalangeal joints at
70° to 90° flexion and finger interphalangeal joints in full extension.

140. (b) Unlike infantile idiopathic scoliosis, the juvenile type almost never spontaneously resolves, and
owing to the many years of growth during which progression can take place, extremely severe
curves can develop. Because of the very poor prognosis of this scoliosis, and the great desire to
avoid fusion at a young age, bracing becomes an extremely important method of management.
Therefore, the standard of care is to begin bracing when the curve reaches approximately 25°. It is
not necessary to brace curves less than 20°, and curves as high as 60° can still respond to a brace.
This is a much higher value than for successful bracing of adolescent idiopathic scoliosis where the
upper limit is 40° to 45°.
141. (a) An open kinetic chain occurs when the terminal segment is free to move. A closed kinetic chain
occurs when the terminal segment is fixed. The hand during a biceps curl is free to move and
represents an open kinetic chain.

142. (d) This is a classic description of the dysarthria-clumsy hand syndrome. The lesion is most commonly
located in the anterior limb of the internal capsule but may also be seen with certain pontine lesions.

143. (d) These are all characteristics of Scheuermann’s disease.

144. (c) In the treatment of inflammatory myopathies such as polymyositis and dermatomyositis,
glucocorticosteroids are considered the first drug of choice. Patients refractory to steroids or unable
to tolerate high doses because of complications require an immunosuppressive agent.
Immunoglobulins are effective and are also used in patients with recurrent relapses. Plasmapheresis
and leukapheresis are ineffective in these patients.

146. (d) Fatigue is the most common complaint of cancer patients, affecting up to 78% of patients, with
70% noting that fatigue affected their daily routine.

148. (c) An entrapment of the median nerve at the ligament of Struthers could involve all median innervated
muscles of the forearm, including the pronator teres. Pronator teres syndrome usually does not
involve the pronator teres since it is innervated from a branch of the median nerve that is more
proximal. The patient does not have slowing of the median distal latencies suggestive of carpal
tunnel syndrome, and the EMG abnormalities include abnormalities in more muscles than can be
explained by an anterior interosseous neuropathy.

149. (d) Most children with severe traumatic brain injury have dysphagia, incontinence, and agitation at
some time during the recovery period. Central autonomic dysfunction (hypertension, hyperpyrexia,
sweating, tachypnea, and rigidity) is associated with worse cognitive and motor outcomes a year or
more after injury.

150. (a) A balanced forearm orthosis can be attached to a wheelchair. It consists of a forearm trough, which
is attached by a hinge joint to a ball-bearing swivel mechanism and a mount. It supports the weight
of the forearm and arm against gravity. With only minimal muscle force requirement at the
shoulder girdle and trunk, the patient can move the arm horizontally and flex the elbow to bring the
hand to the mouth. This orthosis is primarily used for patients with severe upper limb weakness
(especially the deltoid and elbow flexors), as in high quadriplegia or other severe neuromuscular
conditions. The patient must also have sufficient range of motion of the shoulder and elbow, as well
as adequate trunk stability (provided or innate) while sitting.

Copyright © 2002
American Academy of Physical Medicine and Rehabilitation
Chicago, Illinois