Abridged Version

2001 Self-Assessment Examination for Residents (SAE-R)

1. (d) This patient's symptoms are most consistent with plantar fasciitis. Classically, this syndrome is
most painful first thing in the morning upon arising and is aggravated by overuse or change in
footwear. Stretching the plantar fascia, often before getting out of bed in the morning, and use of a
heel cup or medial longitudinal arch orthotic are the initial treatments for this condition.
Corticosteroid injection may be indicated at the insertion of the fascia into the plantar aspect of the
calcaneus; however, this is usually not required on a repeated basis. Relative rest from the
aggravating activity may be useful, but bed rest is not indicated. A walking cast would not allow
stretch of the plantar fascia.

(This question has been eliminated from the exam, therefore, it was not scored.)
2. (b) The T1 signal in an acute hemorrhagic event would be decreased. Magnetic resonance imaging can
be helpful in distinguishing acute from chronic hemorrhagic events. The pathology and subsequent
neuroimaging results are based on the stage of hemoglobin molecular breakdown. In acute
hemorrhagic states, deoxyhemoglobin predominates and T1/T2 images are both decreased. In
chronic hemorrhagic states (more than 2 weeks) methemoglobin predominates (mainly
extracellular) and T1/T2 signals are decreased.

3. (c) All synovial fluid removed for diagnostic purposes should be sent for gram stain and cell count.
Noninflammatory synovial fluid typically has white blood cell counts of less than 2000/mm3 , is
transparent or yellow colored, and has less than 50% neutrophils. Inflammatory fluid usually is
translucent or opaque, can have very high cell counts (up to 100,000/mm3 ), and usually has less
than 90% neutrophils. Synovial fluid that has cell counts over 100,000/mm3 , is purulent and has
more than 95% neutrophils should be considered infected.

6. (c) Physical dependence is a pharmacologic property of many drugs caused by the body's physiologic
acclimation to their presence. In the case of opioids, withdrawal will develop in tolerant patients if
the drug is not tapered.

7. (d) The difficulty in using proper posture and body mechanics and the forces required for pulling
patients up in bed are believed to be the reasons that this task most often causes back pain among
nurses.

9. (b) The most useful clinical criterion to distinguish Becker muscular dystrophy (BMD) from Duchenne
muscular dystrophy (DMD) is the continued ability of the patient to walk into late teen-age years.
Persons with BMD will typically remain ambulatory beyond 16 years. Outlier DMD cases
generally stop ambulating between 13 and 16 years of age. Creatine kinase values cannot be used
to differentiate DMD from BMD. Calf enlargement and the presence of Gowers’ sign are a
nonspecific findings. Studies have shown significant overlap in the observed age at onset between
DMD and BMD.

11. (a) Both peripheral neuropathy and tarsal tunnel syndrome can present with painful dysesthesias. Plain
radiographs will not be helpful, as they can be normal with either of these conditions. Nerve
conduction studies may demonstrate slowing of the medial and lateral nerves with either condition,
and sensation on the plantar aspect of the foot may be decreased with either condition.
Compression over the tarsal tunnel should cause increased symptoms of numbness, tingling, or
burning in the plantar aspect of the foot.

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12. (b) Donepezil is a cholinesterase inhibitor (C1) with properties shown to address cognitive behaviors,
specifically behavioral disturbances. C1 has not been shown to slow or stop disease progression.

14. (a) Clinically, multiple sclerosis is characterized by multiple lesions separated in time and location
within the central nervous system. Common presenting symptoms include diplopia, optic neuritis,
weakness, sensory loss, and ataxia. Women between the ages of 20 and 40 are the most commonly
affected population. Diplopia, though commonly associated with myasthenia gravis, is not seen in
myasthenia syndrome or amyotrophic lateral sclerosis.

15. (d) Expected functional outcomes after traumatic spinal cord injury have been delineated in the
clinical practice guidelines for health care professionals. A person who has sustained a C7-8-level
spinal cord injury can best be expected to need assistance in clearing secretions, may need partial
to total assistance with a bowel program, and may be independent with respect to bladder
management, bed mobility, and transfers to level surfaces. Adaptive equipment is listed in these
tables (FIM (functional independent measures) purists can argue that these persons really are only
modified independent).

16. (a) Conditions associated with decreased atmospheric pressure will cause lymphedema to progress.
Activities or situations that lead to increased blood flow in the affected extremity (eg, burns, heat,
physical exertion, trauma) exacerbate lymphedema. Atmospheric pressure increases during scuba
diving, therefore, it has the capacity to ameliorate lymphedema.

17. (c) Functional recovery programs should focus on restoring functional ability, including return to
work.

18. (d) Somatosensory studies can be helpful in the diagnosis of multiple sclerosis. Standard nerve
conduction studies and electromyography are far more useful in the diagnosis of the other
disorders.

19. (d) Cerebral palsy is the leading cause of childhood disability. The reported incidence is approximately
2-3 per 1,000 live births. The incidence of spina bifida is .5 per 1,000, of spinal muscular atrophy 1
in 25,000. The annual incidence for traumatic brain injury in children is 1-2 per 1,000. However,
the great majority of cases are minor and result in no long-term disability. Approximately 15% of
brain-injured children have moderate and severe injuries resulting in permanent impairment.

20. (b) A heel lift plantarflexes the foot and is used for Achilles tendinitis. A metatarsal bar is used for
metatarsalgia. A lateral heel wedge can be used for the conservative management of osteoarthritis
of the knee. A posterior night splint dorsiflexed to 5/ is the correct answer.

22. (c) Bladder dysfunction in patients with multiple sclerosis can be challenging from a diagnostic
perspective. The use of urodynamic testing provides useful information. Bladder function in this
scenario would be hyperreflexic, and with high residual volumes it would indicate that bladder
outlet pressure is high so as to block urine flow, as if squeezing on a water balloon and holding the
spout. This outlet pressure is called dyssynergia, and treatment is directed at bladder neck
relaxation.

23. (d) The onset and length of symptomatic relief after steroid injection are related to the preparation
used. Dexamethasone sodium phosphate has an intermediate solubility and a fairly long biologic
half-life (36-72 hours). Methylprednisolone and triamcinolone have biologic half-lives of 12-26
hours. Hydrocortisone phosphate is not recommended for intraarticular use.

25. (b) Patients with neoplastic spinal cord compression tend to be older than their traumatic counterparts,
with a peak incidence between 50 and 70 years. Significant differences exist with regard to the
level of injury; tumors involving the spinal cord tend to involve the thoracic and lumbar regions
more than the cervical region. There was a shorter rehabilitation length of stay in patients with

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 neoplasms. (This may allow patients to have more time at home with their families. These patients
had an increased percentage of paraplegia and incomplete injury.) Patients with tumors did
demonstrate a trend toward lower rate of discharge to the community, but this was not significant.

26. (c) During the initial phase of complete decongestive physiotherapy (CDP), compressive bandages
traditionally remain in place 20 - 21 hours per day. They are removed only to permit bathing and
manual lymphatic drainage. Once maximal volume reduction has been achieved, patients transfer
to phase II, or maintenance, CDP indefinitely. The purpose of phase II CDP is to prevent
reaccumulation of lymphedema. During phase II, patients apply compressive wrapping only at
night.

27. (b) Ice massage is more effective for acute bursitis. Subacute or chronic bursitis may respond to deep
heating modalities such as ultrasound.

29. (c) Neck flexor weakness occurs during preschool years. Weakness is generalized but is predominantly
proximal early in the disease course. Pelvic girdle weakness precedes shoulder girdle weakness by
several years. Weakness progresses steadily. Quantitative strength testing is more sensitive than
manual muscle testing.

30. (a) The 6 determinants are as follows: lateral displacement that reduces horizontal excursion from 6"
down to 1.7"; knee flexion that reduces vertical excursion 7/16"; pelvic rotation that reduces
vertical excursion 3/8"; pelvic tilt that reduces vertical excursion 3/16"; and foot and ankle
synchronization as well as ankle and knee synchronization that both serve to smooth out the
sinusoidal curve but do not decrease excursion.

34. (c) Friedreich's ataxia is a spinocerebellar degenerative syndrome with onset in the first 2 decades of
life. Weakness, proprioceptive sensory loss, and ataxia dominate the clinical picture. The incidence
of scoliosis approaches 100%; it is typically more severe when onset occurs at a young age.
Ambulation is lost by early adulthood.

35. (b) This patient is probably developing spontaneous detrusor contractions but is emptying
incompletely. You would consider using an anticholinergic agent to decrease detrusor (and hence
intravesical) pressures. Ideally, you would obtain urodynamic studies to delineate detrusor-
sphincter coordination. One should not initiate a cholinergic agonist without knowing of possible
detrusor -sphincter dyssynergy.

37. (c) Other than a history of previous back injury, psychologic factors were found to be more important
than physical factors in predicting injuries.

38. (d) The history is suggestive of an L5 radiculopathy. Given the previous laminectomies, examining a
single level of paraspinals would provide limited information. Although you cannot form any firm
conclusions based on such a limited examination, study of the flexor digitorum longus will provide
findings outside the peroneal distribution and could lend support to the clinical diagnosis.

39. (c) Terminal overgrowth at the transected end of a long bone is the most common complication after
amputation in the skeletally immature child. It occurs most frequently in the humerus, fibula, tibia,
and femur, in that order. The oppositional growth may be so vigorous that the bone pierces the
skin. The treatment of choice is surgical revision.

40. (b) Standard walkers require good standing balance and good upper body strength. Crutches require
good upper body strength and have an increased energy expenditure of 40%-60%, which would be
contraindicated in unstable angina. Quad canes are not appropriate when significant weight-bearing
relief is required. Rolling walkers are most appropriate for patients who lack upper body strength
and provide safer gait than crutches or canes.

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41. (b) This scenario is classic for a contusion of the iliac crest or "hip pointer." It occurs as a result of a
direct blow to an unprotected iliac crest. Tenderness with swelling and ecchymosis is common, as
is pain on the affected side with lateral bending away from the side of contact. This is not a hip
injury, and internal rotation of the hip should be normal. The Gillet test is used to evaluate
sacroiliac mobility. Numbness can be seen on the ipsilateral side because the T12-L3 lateral
cutaneous nerve branches are often injured.

42. (c) Venous thromboembolic events can occur in as many as 75% of untreated patients with after
stroke. Prophylaxis is typically pharmacologic or manual venous compression. In patients with
documented intracerebral bleeding, anticoagulation is not recommended, and alternating pneumatic
compression derives are best used.

45. (b) In patients with quadriplegia, 55% reported pain in at least one region of the upper extremity. The
shoulder was reported as painful in 46% of subjects; the most frequent diagnoses for shoulder pain
were orthopedically related—tendinitis, bursitis, and osteoarthritis. Referred pain of cervical origin
accounted for 33% of shoulder pain. In patients with paraplegia, symptoms of carpal tunnel
syndrome were the most common complaint (66%).

46. (c) A randomized controlled trial of high-dose steroids (96mg dexamethasone) versus placebo
concluded that steroid-treated patients with spinal cord compression from malignant epidural
disease were more likely to retain or regain ambulation. Surgery and radiation may be indicated,
contingent on tumor location and type and on prior radiation history. Dexamethasone should be
administered to patients before imaging in order to alleviate pain and to optimize neurologic
recovery.

47. (d) Cervical spine degenerative changes in males over 60 are commonly seen in asymptomatic
patients.

49. (d) Although opiates should be considered the most important part of acute pain management
nonopiates should be used when possible. As the needs become more chronic, other agents should
be instituted to minimize the problems seen with opiates. Behavioral management and relaxation
therapy should also be used when possible. Typically, the position of comfort for a burned child is
the position that promotes deformity and, therefore, should be avoided. Garments are fitted later in
the course of treatment.

52. (d) Pernicious anemia can account for significant cognitive and motor disturbances in patients
typically more than 60 years old. The most frequent clinical findings are paresthesias, numbness,
gait ataxia, focal incontinence, leg weakness, memory disturbance, and acute dementia. Workup for
cobalamin levels, intrinsic factor antibodies, and Shilling’s test are useful in making a correct
diagnosis. Treatment consists of cobalamin replacement.

53. (c) Patients treated with continuous passive motion obtain greater early knee flexion (and thus
experience fewer hospital days and manipulations). These devices might exacerbate flexion
contractures and extension lags. Their use has no effect on rates of infection or deep vein
thrombosis.

54. (a) Alcoholic cerebellar disease preferentially affects the superior vermis of the cerebellum, resulting
in gait instability, poor trunk control, and lower greater than upper extremity ataxia.

55. (c) The administration of methylprednisolone did not significantly improve functional outcomes in
patients with gunshot wounds to the spine or increase the number of complications experienced by
patients during their hospitalization.

56. (a) The sacral plexus is usually involved by tumor from the colon, prostate, bladder, or uterus.
Presenting symptoms usually begin as a dull, aching, midline pain, which may radiate into the

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 buttocks. The pain may be associated with numbness in the perianal region. Numbness and
aresthesias may extend to involve the buttock and posterior aspect of the thigh. Bowel and bladder
function are often compromised. Computed tomography and magnetic resonance imaging scans of
the pelvis are excellent tools for detecting presacral masses and sacral destruction.

59. (b) The lower limb deficient child should be fitted with a prosthesis when he or she is ready to pull up
to a standing position, usually between 9 and 12 months. A knee joint is added between 3 and 5
years.

60. (d) Measurements of the range of motion in flexion, extension, axial rotation, and lateral bending (both
actively and passively) using a computerized motion analyzer for four orthoses—soft collar,
Philadelphia collar, Philadelphia collar with thoracic extension, and a Sternal-occipital-mandibular
immobilizer (SOMI)—found that the SOMI was most restrictive.

63. (c) The patient has aseptic necrosis of the femoral head. Her symptoms will be resolved with a hip
replacement. Before surgery, a program of isometric strengthening and endurance exercise is
appropriate. Trochanteric bursitis presents as lateral hip pain extending down the leg, worse with
walking or lying on that side. There is tenderness over the greater trochanter and pain with end-
range adduction or resisted abduction. Femoral neuropathy presents with weakness of the knee
extensors. An L5 radiculopathy typically presents with leg pain that extends to the dorsum of the
foot and is not worsened with hip rotation.

64. (b) The clinical features and electrodiagnostic studies are consistent with a peroneal neuropathy. The
reduction in compound muscle action potential amplitude is indicative of significant axonal loss. In
this situation, recovery is likely to be delayed and incomplete. The use of an ankle-foot orthosis to
supply medial lateral stability and ankle dorsiflexion is appropriate. Functional electrical
stimulation has not been shown to alter outcome after nerve injury.

65. (c) Stimulant laxatives act by enhancing intestinal motility and thereby decreasing time available for
water and electrolyte resorption. Senna is a glycoside that is split by colonic bacteria into
absorbable anthraquinones. It generates increased propulsive activity by altering electrolyte
transport and increasing intraluminal fluid. It exerts a direct stimulant effect on the myenteric
plexus which increases intestinal motility. Senna works best in persons with upper motor neuron
level injuries, and it facilitates bowel movements in 6 to 12 hours.

66. (a) About 60% of patients with Lambert-Eaton myasthenic syndrome have small cell lung cancer. A
few others have small cell cancer elsewhere in the body, such as in the prostate or cervix. About
40%, usually women with other evidence of autoimmune dysfunction, do not have cancer.

68. (a) The number of phases of the motor unit potential represents the synchronization of firing of the
individual muscle fibers in a motor unit and is related to conduction time through collateral sprouts
of the nerve. The number of phases is increased under conditions in which some sprouts are poorly
myelinated and conduction is slow and less synchronous. The other factors do not affect the
number of phases of a motor unit potential.

69. (d) In neonates and young infants, motor behavior is influenced by primitive reflexes because of the
immature central nervous system. These reflexes gradually become suppressed. Concurrently, more
sophisticated postural responses emerge. Obligatory persistent primitive reflexes are the earliest
markers of abnormal neurologic maturation.

70. (b) Overall rejection of prosthetic usage occurs in 33%-38% of unilateral upper extremity amputees.
The highest acceptance rate is transradial at about 93%, and the lowest is wrist disarticulation at
about 6%.

71. (c) Fibromyalgia is found predominantly in women, and 16 paired tender points are identified by the

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 American Rheumatism Association. They do not show referred pain patterns. Palpable taut bands
are seen with myofascial pain but are not specific for fibromyalgia. Sleep disturbances and
depression are very common in patients with this diagnosis.

72. (c) Feeding issues for patients with traumatic brain injury can become quite complex. It is important to
use stepwise approaches when investigating emesis in this population. Quite frequently a
percutaneous gastrostomy tube is placed in the neurointensive care unit. Intolerance to feeding can
be related to increased gastric distention, and adjusting from bolus to continuous feeding may
provide relief. Other steps might then include converting to a jejunostomy or using agents to
facilitate gastric emptying.

74. (a) Calf pain that worsens with walking and is relieved with sitting occurs with both neurogenic and
vascular claudication. The onset of vascular claudication occurs earlier with the increased muscular
demands of uphill walking, whereas the symptoms of neurogenic claudication tend to be less
severe in positions of spine flexion such as occurs during uphill walking or with the use of a
shopping cart. Paresthesias and numbness are more typical of neurogenic claudication than
vascular claudication.

78. (b) Although myotonic discharges may be seen in all of these disorders, myotonic dystrophy is the
only one with low-amplitude motor units in the distal muscles.

79. (c) A history of delay in communication development raises several diagnostic possibilities, including
true language dysfunction or a motor dysfunction or significant hearing loss. Infants with hearing
loss start to fall behind after 6-8 months of age, when learning of auditory-dependent vocalization
begins. Oral motor dysfunction is often associated with cerebral palsy, most often spastic
quadriparesis. Difficulty with drinking from a cup and difficulty with the introduction of solid food
are early symptoms of oral motor dysfunction. Autism is a spectrum disorder with qualitative
abnormalities in communication and in social and behavioral realms.

80. (b) Handling of heavy objects is limited in upper extremity amputees. A transhumeral amputee is
expected to lift 10lb to 15lb, unless the residual limb is very short or sensitive. A transradial
amputee is expected to lift 20lb to 30lb unless the residual limb is very short or sensitive.

81. (c) Fusion of the compression fracture is not indicated unless there is evidence of instability and
neurologic compromise. A thorough neurologic examination should be performed, and the patient
should be given appropriate pain medication, including opioids as indicated, for adequate relief.
This compression fracture pain will resolve in 6-8 weeks as the fracture heals. If physical therapy is
ordered, flexion exercises should be avoided because they can increase wedging of the fractured
body. An extension brace, such as the Jewett brace, may be indicated to provide pain relief, but it
will not prevent bony retropulsion and subsequent neurologic compromise.

82. (a) Treatment options for gait disturbance in patients with Parkinson’s disease include visual and
auditory cueing, in addition to traditional endurance and strengthening exercises.

83. (a) Prognostic factors associated with good surgical outcome following surgical decompression
include pronounced constriction of the spinal canal (<6mm anteroposterior diameter), prominent
leg rather than back symptoms, symptom duration of less than 4 years, and absence of concomitant
disease affecting walking ability.

85. (b) Standing wheelchairs are often used as second wheelchairs for a particular activity or vocation.
Although their weight has been reduced over the years, they still weigh at least 50lb, which
continues to be the main factor precluding their use in everyday mobility. Third-party payors and
departments of rehabilitation services have funded standing wheelchairs for persons returning to
careers; this can reduce the modifications and costs necessary to make a workplace accessible.
Physiologic benefits include decreased spasticity, a reduction in urinary tract infections, and a

6
 reduction in pressure ulcers. One issue noted is that most standing wheelchairs do not come to a
full 90° position because of instability, which may limit a person’s reach. Problems reported by
users include ankle instability and lower extremity edema.

86. (b) Radiation therapy causes rapid and potentially irreversible fibrosis of muscle and other soft tissue
structures. In order to mitigate the inevitable fibrosis that attends high-dose external-beam radiation
therapy delivered to patients with head and neck cancer, cervical range-of-motion exercises should
begin at the outset of radiation and be continued through the entire course.

87. (d) Upper limb cumulative trauma disorders, especially those involving the hand and wrist, most often
result from repetitive forceful exertions.

88. (b) The fibers of the dorsal ulnar cutaneous nerve travel in the lower trunk and the medial cord of the
brachial plexus. This nerve travels with the ulnar nerve to the forearm, where it branches off
proximal to the wrist and supplies sensation to the ulnar aspect of the dorsum of the hand and
wrist. The dorsal ulnar cutaneous sensory nerve action potential amplitude could be decreased with
a lesion of the lower trunk, the medial cord, or the ulnar nerve at the elbow or proximal forearm,
and would not be useful in differentiating among them. It should be normal in ulnar neuropathy at
the wrist.

91. (a) These symptoms are consistent with stenosing tenosynovitis, commonly referred to as de
Quervain's tenosynovitis. The patient should have tenderness over the common tendon sheath for
the abductor pollicis longus and the extensor pollicis brevis. Finkelstein's test is confirmative of
this diagnosis. It consists of flexing the thumb under cupped fingers and flexing the wrist in an
ulnar direction, stretching the thumb tendons. This condition usually responds to conservative
management of steroid injection and placement in a splint. Severe refractory cases may require
surgical release, but not until at least a month of conservative therapy has been tried.

92. (a) Typically, heterotopic ossification occurs in the more proximal joints. X-ray findings are a
“popcorn” appearance of fluffy (noncircumscribed), immature bone, extracapsular and extra-
articular.

93. (d) A meta-analysis of 1910 patients with adolescent idiopathic scoliosis evaluated the effects of
observation, electrical stimulation, and bracing. Of the six brace types used, the highest success
was seen with the Milwaukee brace. Bracing for 23 hours was significantly more successful than
any other treatment.

94. (b) Tricyclic antidepressants such as amitriptyline and nortriptyline have traditionally been the initial
drug sof choice but can lead to cardiac conduction block. Newer anticonvulsants such as
gabapentin are becoming the preferred treatment. Although selective serotonin reuptake inhibitors
such as fluoxetine can improve depression associated with chronic pain, they have not been shown
to have a direct effect on reducing neuropathic pain. Trazodone has not been shown efficacious in
the treatment of painful neuropathies. Long-acting narcotics are increasingly being used when
other agents fail to adequately control pain.

95. (a) Polydipsia and polyuria are strong indicators of new-onset diabetes. Diabetes is more common in
the spinal cord injured person than in the uninjured population. Although the differential diagnosis
may include detrusor hyperreflexia or urinary tract infection, this would not provide a reason for
the new high catheterization volumes in this person with chronic spinal cord injury. Evaluation for
diabetes should be done immediately.

96. (c) In general, lytic lesions are considered more prone to fracture, although blastic lesions are not
immune to fracture. Lytic lesions typically occur with primary or metastatic lesions of the
following malignancies: breast, lung, kidney, thyroid, gastrointestinal tumors, neuroblastoma,
lymphoma, and melanoma. Prostate cancer tends to form blastic metastases.

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97. (d) Impairment ratings are based on physical examination findings such as joint limitations and muscle
atrophy and function loss.

99. (c) Mental retardation is the most common serious associated disability in cerebral palsy. The overall
incidence of mental retardation is approximately 30%-50%. Severe mental retardation is present in
about one-half of the retarded group. Approximately one-third of cases have mild cognitive
deficits. The greatest retardation is seen in rigid, atonic, and severe spastic quadriplegic cerebral
palsy.

100. (a) Chances of a successful fitting of a quadrilateral socket are best when the residual limb is longer
with a firm residuum and intact adductor musculature. Ischial containment sockets are more
successful than quadrilateral sockets for persons with shorter, fleshy, unstable residual limbs.

101. (b) This condition can be treated with the use of ice after activity and ultrasound to the inflamed area
at the lateral epicondyle. Steroid and local anesthetic injection into the tendinous insertion can be
useful for temporary relief. A lateral epicondyle counterforce brace ("tennis elbow" band) can
provide relative rest for the inflamed extensor tendons. Exercise using light weights to strengthen
the wrist extensors is useful. This should be done with the elbow flexed and in full extension. If
surgical release is indicated, lateral extensor release is considered to be the procedure of choice.

102. (a) Cranial irradiation typically has more side effects in children than in adults. Common side effects
include short-term memory loss, fatigue, and occasional gait apraxia.

103. (c) Legg-Calvé-Perthes disease, avascular necrosis of the femoral head, occurs most commonly in boys
between the ages of 4 and 8 years. It is characterized by medial thigh, groin, and knee pain, is
associated with a limp, and is often preceded by a transient episode of hip synovitis. Congenital hip
displasia is usually apparent much earlier; slipped capital femoral epiphysis occurs during periods
of rapid growth, typically in adolescent boys, and may be preceded by trauma.

104. (d) In normal gait, hip extension to neutral occurs during stance phase. When mild hip flexion
contractures are present, a compensatory increase in lumbar lordosis occurs to maintain upright
trunk posture. As the extent of the hip flexion contractures worsens, there is usually an additional
compensatory increase in knee flexion during stance phase.

105. (b) Symptoms of withdrawal from high-dose diazepam (>40mg/day) include anxiety and agitation,
restlessness, tremor, muscle faspinal cord injuryculation, hypersensitivity to touch, taste, smell,
light, and sound, hyperpyrexia, psychosis, and possibly death. The intensity of symptoms, and
hence the risk of death, is related to the prewithdrawal dose.

106. (b) In males, the energy cost of sexual activity with a married partner does not typically exceed 5
METs and is lowest in familiar positions.

107. (c) Of the choices provided, electromyogram/nerve conduction velocity testing would provide the most
objective documentation of radiculopathy. Magnetic resonance imaging is an anatomic test.
Straight leg raising and findings of manual strength of 4/5 provide more subjective information.

108. (b) The potentials noted are single-fiber discharges waxing and waning in frequency and amplitude.
This is characteristic of myotonic discharges.

110. (c) Many polycentric knees are designed so that the center of rotation moves anteriorly very rapidly
during the first few degrees of knee flexion, quickly passing in front of the floor reaction line and
facilitating the swing phase. Because the polycentric knee can be flexed under weight bearing
during the terminal stance, when properly dynamically aligned it can offer both excellent stance
stability and ease of swing-phase flexion. Furthermore, all polycentric knees shorten mechanically
to a slight degree during flexion, adding additional toe clearance during midswing.

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111. (c) This patient has been performing excessive, unaccustomed, intense exercise. He is at risk for a
compartment syndrome, which occurs when perfusion of muscle and nerve tissues decreases to a
level inadequate to sustain the viability of the tissues. The intracompartmental pressure increases
and produces venous obstruction. This in turn increases the intracompartmental pressures even
more, and necrosis of muscle and nerve tissue may ensue in as little as 4-8 hours.

112. (b) Motor fluctuations that occur in Parkinson’s disease can be related to levodopa therapy. A
proposed mechanism is degeneration of presynaptic dopaminergic (DA) nerve terminals, altered
DA receptor sensitivity, or associated fluctuations in non-DA neurotransmitter systems. Best initial
approaches to treatment are to decrease dosing intervals, decrease protein load (give levodopa 1-2
hours before meals) to reduce amino acid binding competition, and/or adding a dopamine agonist.
Using an anticholinergic agent will have little effect on completing this “on-off” problem.

113. (c) Postoperative patients are at risk for acute exacerbations of gout. Oral colchicine is the standard
therapy for acute gout. Allopurinol is indicated for the prevention of gout flares in patients with
frequent (less than every 9 months) attacks and is contraindicated in the acute phase. Low-dose
aspirin can precipitate an acute attack. The clinical vignette is not consistent with infection or deep
vein thrombosis.

114. (d) Aerobic exercise programs carry the risk of exercise-induced vasodilation and worsening of the
hypotension. This is more likely after meals, when hypotension is often exacerbated because of
blood pooling in the gastrointestinal vasculature. Other interventions include constrictive garments,
dietary modifications (high-salt diet or supplemental salt tablets), and sleeping with the head of the
bed elevated to reduce early morning symptoms. Fludrocortisone (Florinef) is the most commonly
used drug treatment; it works by sensitizing blood vessels to endogenous catecholamines and
expanding the blood volume. Prostaglandin inhibitors such as indomethacin and ibuprofen are
reported to be useful, especially for postprandial exacerbations of hypotension.

116. (c) Elevated plasma level of homocysteine is a risk factor for atherosclerosis. Antioxidants such as
vitamin E may potentially have a protective effect. Likewise, the benefits of high-density-
lipoprotein cholesterol are well defined.

117. (c) Magnetic resonance imaging can identify a large percentage of tears on the rotator cuff of
asymptomatic persons. These tears may be partial or complete. The overall prevalence of
asymptomatic tears of the rotator cuff in all groups was 34%. Fifty-four percent of persons over
age 60 had a tear of the rotator cuff (28% full thickness, 26% partial thickness).

118. (d) There are no significant differences between the groups. Electrodiagnostic studies are not
performed to confirm the diagnosis of postpolio syndrome; this is a clinical diagnosis. They are
performed to rule out other disorders in the differential diagnosis.

120. (c) The choke syndrome (proximal soft tissue constriction leading to vascular congestion) may occur
with suction sockets or self-suspending systems. Relieving the proximal socket to allow vascular
return, providing auxiliary suspension to decrease the vertical pull on the residual limb, and
improving the intimacy of the socket-limb interface correct this problem. Relieving the distal
socket where it interfaces with the choked surface would increase the vacuum effect in this area
and thereby increase the choke phenomenon.

121. (d) Rupture of the long head of the biceps most often occurs in persons over 40 years of age with long-
standing shoulder pain due to rotator cuff pathology. It may result in approximately 10% loss of
supination in turning the forearm. It does result in a cosmetic deformity with a bulge in the lower
arm, but most patients regain full range of motion and normal elbow flexion strength with a
conservative therapy program. Usually only heavy laborers under age 40 need surgical intervention
to provide the extra strength for lifting.

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122. (d) Inappropriate sexual touching occurs more commonly in patients with a history of frontal lobe
damage. Treatment is best directed at staff education to make certain all team members are
consistent in responses. Behavior modification is directed at telling the patient his behavior is
wrong and firmly taking his hand and putting it closer to his person. Restraints are only indicated
as temporary solutions to prevent acute bodily injury.

127. (c) A neutral position of a wrist-hand orthosis unloads the median nerve; wrist extension will
aggravate nerve compression.

130. (a) There are two shoe types, the blucher and the bal. The components of a blucher shoe include the
tongue, lace stay, open throat, toe box, toe spring, vamp, ball, shank, breast, quarter, and heel. The
major difference with a bal style is that the throat is closed, limiting the ability of the shoe to open
and accommodate an orthosis. For this reason, a blucher is the style of dress shoe most often
recommended to patients who require an orthosis.

134. (a) Neuropathic ulcers typically occur in patients with impaired or absent sensation due to peripheral
neuropathy. Plantar callus formation is indicative of excessive pressure and is a common site of
ulcer formation. Ulcers most commonly occur under the metatarsal heads and toes and along the
lateral borders of the forefoot. Rigidity of the subtalar and ankle joints adversely alters plantar
pressures and increases the risk of ulceration. Changes in joint motion are the result of increased
glycosylation of collagen and associated thickening and cross linking of collagen bundles seen in
diabetes.

137. (b) When expected improvement on functional gains has occurred, a patient has reached maximum
medical improvement.

138. (c) In patients with myasthenia gravis, repetitive nerve studies recorded from proximal muscles are
more sensitive, though technically more difficult.

139. (d) Diabetes insipidus is characterized by excessive water loss, and therefore affected patients
experience hypernatremia, dehydration, polyuria, and polydipsia. SIADH is associated with
decreased urine output, hyponatremia, and a decreased serum osmolarity. Cerebral salt wasting is a
result of a neural effect on the renal tubules, causing loss of sodium and water and resulting in
hyponatremia and dehydration.

140. (c) In this condition, lack of active plantar flexion occurs, heel-rise is delayed, the mid-stance phase is
prolonged, and push-off force is reduced. A dorsiflexion stop can accommodate for this weakness.
Setting the stop at 5° of dorsiflexion substitutes best for gastrocnemius function.

142. (a) It is important to recognize these historical and clinical characteristics acting as risk factors in the
development of Alzheimer’s disease. It has been shown that lower intelligence, female gender, and
smaller head size are all associated with increased risk. Diabetes mellitus affects cerebral
vasculature and increases the risk of vascular dementia, not Alzheimer’s disease.

143. (b) The ACR criteria for fibromyalgia include the presence of widespread pain (both sides of the body,
above and below the waist) for at least 3 months and tenderness at 11 of 18 points. Disturbed sleep,
fatigue, various neurologic symptoms, and gastrointestinal complaints are common but not part of
the criteria. A complete history and physical is usually adequate to make the diagnosis; screening
laboratory testing should exclude hypothyroidism, connective tissue diseases (such as polymyalgia
rheumatica or rheumatoid arthritis), and metabolic myopathies. Treatment involves restoration of
sleep, reduction of psychologic variables (such as stress and depression), physical conditioning,
stretching, and postural training. Nonsteroidal anti-inflammatory drugs, muscle relaxants,
narcotics, and passive modalities are not useful and their use should be minimized.

144. (a) The symptoms are most consistent with benign positional vertigo, a disorder characterized by

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 transient episodes of vertigo precipitated by changes in the position of the head.The underlying
etiology is thought to be related to movement of otoliths or otolithic debris within the semicircular
canals. It commonly occurs following head injury or viral labyrinthitis. Treatment involves a
specific otolith repositioning maneuver or a series of habituation exercises.

145. (c) Women who become pregnant after sustaining a spinal cord injury undergo spontaneous abortions
in the first trimester at the same rate as uninjured women; however, the incidence of premature and
small-for-date babies is higher than normal. In addition, the spinal-cord-injured woman is known to
have pregnancy-related complications such as urinary tract infections and pressure sores.

146. (c) Assisted ventilation should be considered in pulmonary involvement from neuromuscular disease.
Alternative measures such as low-flow oxygen may exacerbate hypercapnia.

147. (d) Intradiscal pressure is lowest when a person lies prone and is much higher when standing, running,
sitting, or bending.

148. (d) The motor unit changes noted are typically seen in myopathies. Spinal muscular atrophy is an
anterior horn cell disease.

149. (a) Although there is considerable variability from case to case, outcome is primarily related to the
severity of the injury.

150. (c) A dorsal metacarpophalangeal extension stop (also called a lumbrical bar) to the fourth and fifth
digits is usually quite effective at preventing hyperextension of the fourth and fifth
metacarpophalangeal joints. This permits the proper wrapping of the fingers around an object and
thus allows a stronger grip.

Copyright © 2001
American Academy of Physical Medicine and Rehabilitation
Chicago, Illinois

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