Abridged Version

2008 Self-Assessment Examination for Residents (SAE-R)

Multiple-Choice Questions
Answer Key, Commentary, and References on Preferred Choice
QUESTION ANSWER COMMENTARY & REFERENCES

3. (d) Erythema migrans (EM) is a skin lesion that is erythematous, and may be round or oval, flat or raised,
and possibly have central clearing. Of persons with untreated EM, sixty percent will have monoarticular
or oligoarticular arthritis. Ten percent will have a neurologic presentation, such as facial-nerve palsy.
Approximately 5 percent will have a cardiac manifestation such as atrioventricular block.

Ref: Wormser GP. Early Lyme disease. N Engl J Med 2006;354:2794-801.

6. (a) When consulted on a patient with cancer, the physiatrist must balance the need to maximize the
patient’s independence through rehabilitation with the desire to have the patient return home as soon as
possible. Inpatient rehabilitation is useful to improve the patient's quality of life. Functional gains have
been demonstrated to be significant and comparable to those gained by patients without cancer. The
presence of metastatic disease does not influence functional outcome and should not preclude
participation.

Ref: (a) Marciniak CM, Sliwa JA, Spill G, Heinemann AW, Semik PE. Functional outcome following
rehabilitation of the cancer patient. Arch Phys Med Rehabil 1996; 77(1):54-7.(b) Vargo M, Gerber LH.
Rehabilitation for patients with cancer diagnoses. In: DeLisa JA, Gans BM, Walsh NE, editors.
Physical medicine and rehabilitation: principles and practice. 4th ed. Philadelphia: Lippincott
Williams & Wilkins; 2005. p 1771-3.

7. (b) Cyclobenzaprine is structurally similar to tricyclic antidepressants and was first studied as an
antidepressant. While its exact mechanism of action is unknown, it is presumed to work at the level of
the brainstem or higher with a generalized sedative effect. Tizanidine is a central alpha2-adrenergic
agonist. Orphenadrine is an antihistamine. Benzodiazepines, such as diazepam, and baclofen are γ-
aminobutyric acid agonists.

Ref: Sullivan WJ, Panagos A, Foye PM, Sable AW, Irwin RW, and Zuhosky [A1] JP. Industrial
medicine and acute musculoskeletal rehabilitation. 2. Medications for the treatment of acute
musculoskeletal pain. Arch Phys Med Rehabil 2007;88(3 Suppl):S10.

9. (d) The asymmetric tonic neck reflex (ATNR) and symmetric tonic neck reflex (STNR) are usually
integrated by 6 to 7 months. Palmar grasp disappears by 5 to 6 months. Plantar grasp is integrated when
walking is achieved. The normal age of walking varies, but may be as late as 18 months.

Ref: Molnar GE, Sobus KM. Growth and development. In: Molnar GE, Alexander MA, editors.
Pediatric rehabilitation. 3rd ed. Philadelphia: Hanley & Belfus; 1999. p 20.

10. (c) In patients with diabetes, amputation is a strong possibility, even with ankle pressures higher than 55
mmHg because spuriously high pressures can be present in these patients as a result of calcification of
the arterial media. The ankle brachial pressure index (ABPI) is the patient’s brachial pressure compared
to the ankle pressure. A resting ABPI greater than 1.0 is considered normal. Patients with intermittent
claudication have an ABPI in the range of 0.5 to 0.7, and patients with rest pain or other symptoms of
severe ischemia have an ABPI of less than or equal to 0.3. A pressure less than 50 mmHg at the ankle
is associated with limb threatening ischemia.

Ref: McCollum PT, Raza Z. Vascular disease: Limb salvage vs. amputation. In: Smith DG, Michael
JW, Bowker JH, editors. Atlas of amputations and limb deficiencies. 3rd ed. Rosemont (IL): American
Academy of Orthopedic Surgeons; 2004. p 38-9.

   

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11. (c) "Little league elbow," seen in throwing athletes with immature skeletons, is a conglomeration of
different diagnostic entities caused by valgus and extension-overload. Medial epicondylar avulsion can
frequently occur. Separation from 3--5mm can be managed nonsurgically. However, separations greater
5mm usually require surgery.

Ref: Rudzki JR, Paletta GA. Clin Sports Med 2004;23:581-608.

12. (d) The only benign brain tumor listed is craniopharyngioma

Ref: Gerber LH, Vargo M. Rehabilitation for patients with cancer diagnoses. In: DeLisa JA, Gans BM,
Walsh NE, editors. Physical medicine and rehabilitation principles and practice, 4th ed. Philadelphia:
Lippincott Williams & Wilkins; 2005. p 1789.

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

Ref: Strommen JA, Johns JS, Kim C-T, Williams FH, Weiss LD, Weiss JM, Rashbaum IG.
Neuromuscular rehabilitation and electrodiagnosis. 3. Diseases of muscles and neuromuscular
junction. Arch Phys Med Rehabil 2005;86(3 Suppl 1):S18-27.

15. (b) For an individual to receive an ASIA classification of motor incomplete (ASIA C or D), he/she must
have either voluntary anal sphincter contraction or sensory sacral sparing with sparing of motor
function more than 3 levels below the motor level. The zone of partial preservation is used only in
complete injuries. Individuals with anterior spinal artery syndrome are often motor complete.

Ref: American Spinal Injury Association/International Medical Society of Paraplegia. International

standards for neurological and functional classification of spinal cord injury patients.
Chicago:ASIA/IMSP; 2002.

16. (c) Lambert-Eaton myasthenic syndrome is most commonly associated with small-cell lung cancer, but it
may also be seen in kidney and rectal cancer, malignant thymoma, basal cell carcinoma, and leukemia.

Ref: Tunkel RS, Lachman E, Ho ML. Cancer. In: Grabois M, Garrison SJ, Hart KA, Lehmkuhl LD,
editors. Physical medicine and rehabilitation: the complete approach. Malden (MA): Blackwell Sci;
2000. p 1699.

24. (d) If a patient on a statin presents with muscle complaints, with or without creatine kinase (CK) elevations,
other causes, including strenuous exercise or hypothyroidism, must be considered. If a patient initially
has normal or only moderately elevated CK levels, the statin may be continued with close monitoring of
symptoms and CK levels; however, if symptoms become intolerable or if the CK level is 10 times the
upper limits of normal (ULN) or greater, the statin must be discontinued. If myositis is present or
strongly suspected, the statin should be discontinued immediately. Early diagnosis and treatment of
symptomatic CK elevations, including cessation of drug therapies potentially related to myopathy, can
prevent progression to rhabdomyolysis. Symptoms and CK levels should resolve completely before
reinitiating therapy, at a lower dose if possible. Asymptomatic elevation of CK at 10 times the ULN or
greater should also prompt discontinuation of the statin. Consideration should also be given to
discontinuation of statins before events that may exacerbate muscle injury, such as surgical procedures
or extreme physical exertion.Needle electromyography abnormalities are uncommon in statin-induced
myopathy. An EMG does not exclude statin-induced myopathy, because it primarily affects type 2
muscle fibers. Electromyography is not routinely performed or recommended unless the clinical
presentation does not improve with statin discontinuation or if concern exists about other diagnoses.

Ref: Strommen JA, Johns JS, Kim C-T, Williams FH, Weiss LD, Weiss JM, Rashbaum IG.
Neuromuscular rehabilitation and electrodiagnosis. 3. Diseases of muscles and neuromuscular
junction. Arch Phys Med Rehabil 2005;86(3 Suppl 1):S18-27.
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25. (c) Heterotopic ossification (HO) may develop as early as 17 days after a neurologic injury. However, it
typically takes up to 6 weeks to begin to mineralize and decrease range of motion at the affected joint.
Persons with spinal cord injury are prone to develop HO below their level of injury. This patient’s
progressive loss of range of motion accompanied by a loss of function points toward HO. With no
history of trauma, early fracture is unlikely, lack of systemic signs such as fever render an abscess
unlikely, and with a deep vein thrombosis (DVT) one would expect edema distal to the clot. Persons
with spinal cord injury are at highest risk for DVT within the first 6 to 8 weeks after injury.

Ref: Banovac K, Banovac F. Heterotopic ossification. In: Kirshblum S, Campagnolo DI, DeLisa JA,
editors. Spinal cord medicine. Philadelphia: Lippincott Williams & Wilkins; 2002. p 253-60.

26. (c) Many chemotherapeutic agents can cause a peripheral neuropathy. Treatment for neuropathic pain
includes membrane-stabilizing medications such as Neurontin. Opiates like MS Contin and non-
steroidal anti-inflammatory drugs (NSAIDs) like naproxen are not the first line treatment for
neuropathic pain. Prednisone is appropriate for complex regional pain syndrome (CRPS), but CRPS is
not common in cancer patients after chemotherapy. Further, this patient probably does not have CRPS,
considering the absence of swelling, color changes, or temperature changes.

Ref: (a) Gillis TA, Garden FH. Principles of cancer rehabilitation. In: Braddom RL, editor. Physical
medicine and rehabilitation. 2nd ed. Philadelphia: WB Saunders; 2000. p 1311. (b) Vargo M, Gerber
LH. Rehabilitation for patients with cancer diagnoses. In: DeLisa JA, Gans BM, Walsh NE, editors.
Physical medicine and rehabilitation: principles and practice. 4th ed. Philadelphia: Lippincott
Williams &Wilkins; 2005. p 1774-6. (c) Dworkin RH, Backonja M, Rowbotham MC, Allen RR, Argoff
CR, Bennett GJ, et al. Advances in neuropathic pain: diagnosis, mechanisms, and treatment
recommendations. Arch Neurol. 2003;60(11):1524-34.

27. (b) According to the AMA guides, a 30% whole person impairment rating indicates a 30% reduction in
general functioning, excluding work. The whole person impairment rating does not directly correlate to
the patient’s work abilities and it does not determine the disability compensation.

Ref: Cocchiarella L, Andersson G, eds. Guides to the evaluation of permanent impairment. 5th ed.
American Medical Association. Chicago (IL): AMA; 2001. p 4-5.

28. (a) The electrophysiologic findings are consistent with common peroneal nerve compression at the fibular
head. The normal study of the short head of the biceps femoris points to a lesion distal to the
innervation of this muscle, and hence a lesion at or below the level of the knee. Lack of involvement of
muscles innervated by other nerves points away from a plexopathy or sciatic nerve injury. Excessive
weight loss can often be a factor in patients with peroneal nerve compression lesions.

Ref: Dumitru D, Zwarts MJ. Focal peripheral neuropathies. In: Dumitru D, Amato AA, Zwarts MJ,
editors. Electrodiagnostic medicine. 2nd ed. Philadelphia: Hanley & Belfus; 2002. p 1094-9.

40. (d) A plastic leaf-spring orthosis (PLSO) is probably the most commonly prescribed type of ankle-foot
orthosis (AFO). It substitutes for weak ankle dorsiflexors and provides some medial lateral stability.
Severe spasticity of the ankle may require prescription of a solid AFO. A plastic spiral AFO may be
prescribed for concomitant weakness of both the ankle dorsiflexors and plantar flexors when spasticity
is absent.

Ref: Ragnarsson KT. Low extremity orthotic shoes and gait aids. In: DeLisa JA, Gans BM, Walsh NE,
editors. Physical medicine and rehabilitation: principles and practice. 4th ed. Lippincott Williams &
Wilkins. 2005. p 1383-5.

   

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42. (b) The majority of patients with Parkinson disease experience orthostatic hypotension (OH) as the disease
progresses. The patient’s history suggests falls related to postural changes and situations that lower
blood pressure. Educating your patient to avoid or mitigate these situations (slow postural changes,
small meals, and avoidance of high heat exposure and alcohol) is the best initial treatment.

Ref: Senard JM et al. Orthostatic hypotension in patients with Parkinson’s disease: pathophysiology
and management. Drugs Aging 2001;18:495-505.

43. (a) Joint malalignment is the most significant risk factor for further joint deterioration, since it creates
uneven focal loading.

Ref: Felson DT. Osteoarthritis of the knee. N Engl J Med 2006;354:841-8.

44. (a) A brain isoform of dystrophin exists and there are documented mildly decreased Intelligence Quotient
scores in people with Duchenne muscular dystrophy. These lower scores may be specific to deficits
with tasks requiring attention to complex verbal information.

Ref: Kilmer DD. Myopathy. In: DeLisa JA, Gans BM, Walsh, NE, editors. Physical medicine and
rehabilitation: principles and practice. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p
916-21

45. (c) Women with paraplegia or tetraplegia can give birth vaginally and caesarean delivery is rarely
necessary. Patients with neurologic levels above T6 are at risk for autonomic dysreflexia during
pregnancy, labor, and delivery. Autonomic dysreflexia is reported to occur in 60% to 80% of women
with SCI with lesions above T6. Preeclampsia occurs with the same frequency in able-bodied women
and women with disabilities. Complications from autonomic dysreflexia may be severe and include
encephalopathy, cerebrovascular accidents, death of the mother, and severe fetal asphyxia. Spinal or
epidural anesthesia extending to the T10 level is the treatment of choice and the most reliable method
of preventing and treating autonomic dysreflexia during labor and delivery.

Ref: Jackson A. Women’s health challenges after spinal cord injury. In: Lin VW, editor. Spinal cord
medicine principles and practice. New York: Demos; 2003. p 842-5.

47. (d) Return-to-work rates of 77% can be achieved with work hardening programs. Poor outcome was
associated with an increased number of treatments before the program, an increased length of time off
from work; the patient's having lower satisfaction with the program, and a lawyer being involved in the
case.

Ref: Foye PM, Stitik TP, Marquardt CA, Cianca JC, Prather H. Industrial medicine and acute
musculoskeletal rehabilitation. 5. Effective medical management of industrial injuries: from causality to
case closure. Arch Phys Med Rehabil 2002;83(Suppl 1):S20.

48. (c) The total duration of a motor unit is measured from the initial deflection from baseline to the final
return to baseline.

Ref: Wiechers DO. Normal and abnormal motor unit potentials. In: Johnson EW, editor. Practical
electromyography. 2nd ed. Baltimore: Lippincott Williams & Wilkins; 1988. p 28-9.

51. (b) Spondylonegative spondylarthropathies, such as psoriatic arthritis, are often associated with sacroiliitis.
The Gelling phenomenon, characterized by stiffness after prolonged immobility, occurs with many
inflammatory arthropathies.

Ref: Atkinson K. Psoriatic arthritis. In: Frontera W, Silver J, editors. Essentials of physical medicine
and rehabilitation. Philadelphia: Hanley & Belfus; 2002. p 694-8.

52. (c) The following factors, evidenced at the time of a spinal cord injury, place an individual at higher risk
for a concomitant traumatic brain injury: Male sex and a higher level of spinal cord injury. Up to the
age of 74 years-old, a transportation accident is the major source of traumatic brain injury (TBI) and not
falls. Studies have shown a potential relationship between race and the incidence of TBI, but there are
too many confounding variables and no study has shown a clear evidence of a relationship.
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 Ref: a) Kirschblum S. Rehabilitation of Spinal Cord Injury. In: DeLisa JA, Gans BM, Walsh NE,
editors. Physical medicine and rehabilitation: principles and practice. 4th ed. Philadelphia:
Lippincott-Williams & Wilkins; 2005. p 1742-3. b) Zafonte RD, Elovic E. Dual Diagnosis: Traumatic
Brain Injury in a person with Spinal Cord Injury. In: Kirschblum S. Campagnolo DI. DeLisa JA.
Editors. Spinal Cord Medicine. Philadelphia: Lippincott Williams & Wilkins; 2002. p 261-71.

53. (c) Resting wrist splints provide light support for a painful joint and are well tolerated. They are the most
commonly prescribed orthotic in RA.

Ref: Biundo JJ, Rush PJ. Rehabilitation of patients with rheumatic disease. In: Ruddy S, Harris ED,
Sledge CB, editors. Kelley’s textbook of rheumatology. 6th ed. Philadelphia: W.B. Saunders Company;
2001. p 769.

54. (c) All types of hereditary sensory motor neuropathies (HSMN) are characterized by weakness. The
residual muscle force in the later stages of disease is 20%--40% less than normal. Intelligence Quotient
reduction, significant joint contractures, pulmonary/cardiac abnormalities and spinal deformities are not
typical of these diseases.

Ref: Thomas MA, Felsenthal G, Fast A, Young M. Peripheral neuropathy. In: DeLisa JA, Gans BM,
Walsh, NE, editors. Physical medicine and rehabilitation: principles and practice. 4th ed.
Philadelphia: Lippincott Williams & Wilkins; 2005. p 898.

57. (c) There is about a 50% chance of return to work when a worker who injures his low back on the job is off
work for 6 months. The rate drops to 25% when the worker is off for 1 year, and is minimal is he is off
for 2 years.

Ref: Schuchmann JA. Occupational Rehabilitation. In: Braddom RL, editor. Physical medicine and
rehabilitation. 2nd ed. Philadelphia : WB Saunders; 2000. p 994.

59. (b) Progressive changes associated with hip subluxation in patients with cerebral palsy result from the
effects of neuromuscular imbalance on the growth and development of the hip joint. The primary
problem is spasticity and muscular imbalance, and the musculoskeletal manifestations are secondary.
Soft tissue abnormalities include a muscular imbalance between the stronger flexors and adductors, and
the weaker extensors and abductors. A flexion-adduction contracture also shifts the center of rotation of
the hip from the femoral head to the lesser trochanter, and the proximal femur is gradually displaced
upward and outward.

Ref: Spiegel DA, Flynn JM. Evaluation and treatment of hip dysplasia in cerebral palsy. Orthopedic
Clinics of North America 2006;37(2):185-96.

62. (b) Multiple studies have shown that age, initial Glasgow Coma Scale (GCS) score, duration of coma,
duration of posttraumatic amnesia (PTA), and neuroimaging findings are correlated with outcome. All
provide valuable information that the clinician can use to mark milestones, and help with prognosis, but
the most powerful of these is the duration of PTA. The longer the duration of the PTA, the worse the
outcome. It is unlikely for a person with PTA lasting less than 2 months to have a serious disability;
however, the likelihood of a good recovery is poor if the PTA extends beyond 3 months. Length of
coma is determined by the time from coma onset to the time when the patient can follow commands. On
average only 7%--8% will make a good recovery if the coma lasts longer than 4 weeks, and severe
disability is unlikely if the coma lasts less than 2 weeks. Although the GCS score provides a general
idea about the severity of the injury, it does not by itself yield a definitive prognosis.

Ref: Kothari S. Prognosis after severe TBI: a practical, evidence-based approach. In: Zasler ND, Katz
DI, Zafonte RD, editors. Brain injury medicine: principals and practice. New York: Demos; 2007. p
169-99.

   

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63. (a) The arthritis in SLE is symmetric and non-erosive. It is also generally non-deforming and reducible due
to its involvement of the para-articular tissues.

Ref: Buyon JP. Systemic lupus erythematosus. Epidemiology, pathology, and pathogenesis. In: Klippel
JH, editor. Primer on rheumatic disease. 12th ed. Atlanta (GA): Arthritis Foundation; 2001. p 337-8

66. (c) Malnutrition is significant in patients with liver disease. Ascites can promote excessive protein loss.
Patients should receive a high protein diet with high protein oral supplements when they are in
rehabilitation. Paracentesis would be required only if the patient was having symptoms from the ascites
and would probably not be appropriate in the admission orders. Oxandrolone carries a risk of liver
damage and therefore should not be prescribed in this patient. Abdominal binders may be used to help
with ascites, particularly if the patient has an umbilical hernia from it.

Ref: (a) Young MA, Stiens SA. Rehabilitation aspects of organ transplantation. In: Braddom RL,
editor. Physical medicine and rehabilitation. 2nd ed. Philadelphia: WB Saunders; 2000. p 1397. (b)
Zafonte RD, Pippin B, Munin M, Thai N. Transplantation medicine: a rehabilitation perspective. In:
DeLisa JA, Gans BM, Walsh NE, editors. Physical medicine and rehabilitation: principles and practice.
4th ed. Philadelphia: Lippincott-Williams & Wilkins; 2005. p 1921-2.(c) Cortazzo MH, Helkowski W,
Pippin B, Boninger ML, Zafonte R. Acute inpatient rehabilitation of 55 patients after liver
transplantation. Am J Phys Med Rehabil 2005; Nov 84(11):880-4. (d) Available at:
http://www.merck.com/mmpe/lexicomp/oxandrolone.html. Accessed 10/18/07(e) Available at:
http://www.emedicine.com/med/topic3183.htm. Accessed 10/18/07Wolf DC. Cirrhosis

67. (d) In a systematic review of patients with acute low back pain, resting in bed was found to be less effective
than staying active.

Ref: Hagen KB, Jarntvedt G, Hilde G, Winnem M. The updated Cochrane Review of bed rest, low back
pain and sciatica. Spine 2005;30:542-6.

69. (d) Children with cerebral palsy often have weakness as part of their disorder. Treatments such as bracing,
tendon lengthening or transfers, and medications such as botulinum toxin or intrathecal baclofen add to
this weakness. Strengthening programs or functional training programs can help to strengthen weak
muscles.

Ref: Damiano DL, Dodd K, Taylor FT. Should we be testing and training muscle strength in cerebral
palsy? Dev Med Ch Neurol 2002;44:68-72.

72. (d) After a traumatic brain injury, diffuse axonal injury (DAI) is the leading cause of morbidity, this
morbidity includes impairments in cognition, behavior, and arousal.

Ref: Gennarelli TA. The spectrum of traumatic axonal injury. Neuropathol Appl Neurobiol
1996;22:509-13.

73. (b) Vitamin D is essential for skeletal maintenance and has been shown to enhance muscle strength and
reduce the risk of falling.

Ref: Rosen CJ. Postmenopausal osteoporosis. N Engl J Med 2005;353:595-603.

77. (b) Up to 33% of individuals with symptoms from whiplash-associated disorders have chronic symptoms.
Symptoms associated with whiplash-associated disorders include neck pain, arm pain, paresthesias,
temporomandibular joint dysfunction, headache, dizziness, visual disturbances, and difficulty with
memory and concentration.

Ref: Panagos A, Sable AW, Zuhosky JP, Irwin RW, Sullivan WJ, and Foye PM. Industrial medicine and
acute musculoskeletal rehabilitation. 1. Diagnostic testing in industrial and acute musculoskeletal
injuries. Arch Phys Med Rehabil 2007;88(3 Suppl):S5.

   

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78. (a) Increasing the interelectrode distance from 1 cm to 4 cm does not alter the onset latency, but increases
the peak latency and amplitude of the sensory response. The onset latency does not change because the
active electrode position is not changed. The sensory nerve action potential amplitude increases because
less of the information is eliminated by differential amplification. Similarly, the peak latency also is
prolonged as less of the signal is eliminated.

Ref: Dumitru D, Zwarts MJ. Instrumentation. In: Dumitru D, Amato AA, Zwarts MJ, editors.
Electrodiagnostic medicine. 2nd ed. Philadelphia: Hanley & Belfus; 2002. p 73.

79. (a) The lack of coughing in a patient with neurologic impairment when presented with food may mean a
normal swallow, but is more likely to mean silent aspiration. A normal videofluoroscopic swallowing
study is unlikely in a patient with a TBI who is drooling and hoarse. Hoarseness may be a sign of
reflux, but in a child with a TBI is more likely to mean vocal cord abnormality.

Ref: Smith C, Hill J. Language development and disorders of communication and oral motor function.
In: Molnar GE, Alexander MA, editors. Pediatric rehabilitation. 3rd ed. Philadelphia: Hanley &
Belfus; 1999.p 72-8.

86. (d) This man has a stage II pressure ulcer. Debridement with an agent such as Accuzyme is indicated in
wounds with necrotic tissue. Since no necrotic tissue is present in this patient's wound, Accuzyme is not
appropriate. A transparent adhesive dressing such as Tegaderm, a hydrocolloid wafer dressing such as
Duoderm, and a gel dressing such as Curasol are all appropriate for clean wounds such as the ulcer
described.

Ref: Salcido R, Goldman R. Prevention and management of pressure ulcers and other chronic wounds.
In: Braddom RL, editor. Physical medicine and rehabilitation. 2nd ed. Philadelphia: WB Saunders;
2000. p 651-2.

87. (d) Risk factors associated with a repetitive strain injury include obesity, cold temperature, older age,
diabetes, smoking, pregnancy, rheumatoid arthritis, and psychologic stress.

Ref: Panagos A, Sable AW, Zuhosky JP, Irwin RW, Sullivan WJ, Foye PM. Industrial medicine and
acute musculoskeletal rehabilitation. 1. Diagnostic testing in industrial and acute musculoskeletal
injuries. Arch Phys Med Rehabil 2007;88(3 Suppl):S5.

90. (b) The gluteus maximus is primarily active from terminal swing through initial contact and loading
response. During midstance, terminal stance, and pre swing the gluteus maximus is actually silent.

Ref: Perry J. Gait analysis, normal and pathologic function. Soack;1992. p 111-8.

91. (c) The patient has a navicular stress fracture until proven otherwise. It is among the most common stress
fractures in athletes. Physical examination reveals tenderness over the so-called “N” spot between
anterior tibialis and extensor hallicus longus tendons as well as pain with weight bearing and hopping.
Strict non-weight bearing cast immobilization for 6 weeks should be implemented. Magnetic resonance
imagining or bone scan can confirm the diagnosis.

Ref: Brukner P, Khan K. Clinical sports medicine. 2nd ed. Roseville, NSW, Australia. New
York:McGraw-Hill; 2002. p 588.

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

Ref: Whyte J, Hart T, Laborde A, Rosenthal M. Rehabilitation of the patient with traumatic brain
injury. In: DeLisa JA, Gans BM, Walsh NE, editors. Physical medicine and rehabilitation: principles
and practice, 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p 1667

   

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93. (c) The diagnosis is reactive arthritis / seronegative spondyloarthropathy that develops after certain
genitourinary or gastrointestinal infections, most commonly in young men. Non-gonococcal urethritis
and conjunctivitis is the remainder of the clinical triad. Heel pain is one of the most frequent and
distinctive clinical features, along with low back pain radiating into the buttocks. Periostitis and
erosions occur in the ankle joint in individuals with a several month history of heel pain. Osteophytes
and subchondral cysts are typical of osteoarthritis. Avascular necrosis is not typical.

Ref: Arnett FC. Seronegative spondyloarthropathies: reactive arthritis and enteropathic arthritis. In:
Klippel JH, editor. Primer on rheumatic disease. 12th ed. Atlanta (GA): Arthritis Foundation; 2001. p
245-9.

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

Ref: Thomas MA, Felsenthal G, Fast A, Young M. Peripheral neuropathy. In: DeLisa JA, Gans BM,
Walsh, NE, editors. Physical medicine and rehabilitation: principles and practice. 4th ed.
Philadelphia: Lippincott Williams &Wilkins; 2005. p 908-9.

96. (a) The Wound VAC device increases blood flow to the wound and adjacent tissue, resulting in increased
oxygen delivery, increased clearance of bacteria from infected wounds, and wound healing.

Ref: O'Connor K. Pressure ulcers. In: DeLisa JA, Gans BM, Walsh NE, editors. Physical medicine and
rehabilitation: principles and practice, 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p
1614.

98. (a) The blink reflex study has two responses, an early component (R1) and a late component (R2). The
absence of the right R1 and R2 responses, but normal left R2 responses suggests a lesion affecting the
right facial nerve. Additionally, the small right facial nerve response with direct stimulation suggests
distal facial nerve degeneration. In a lesion involving the trigeminal nerve both R2 responses would be
abnormal. In a pons or lateral medulla lesion the direct facial nerve response would be normal.

Ref: (a) Dumitru D, Zwarts MJ. Special nerve conduction techniques. In: Dumitru D, Amato AA,
Zwarts MJ, editors. Electrodiagnostic medicine. 2nd ed. Philadelphia: Hanley & Belfus; 2002. p 232-
4. (b) Dumitru D, Zwarts MJ. Focal cranial neuropathies. In: Dumitru D, Amato AA, Zwarts MJ,
editors. Electrodiagnostic medicine. 2nd ed. Philadelphia: Hanley & Belfus; 2002. p 654, 677.

100. (a) Deformity in the spine presents with malalignment of in the pelvis as either contralateral or ipsilateral
drop. Two other causes of ipsilateral pelvic drop are contralateral hip abductor weakness and short
ipsilateral limb. Weak hip extensors are a cause of backward lean. In stance, a backward lean of the
trunk substitutes for weak hip extensors.

Ref: Perry J. Gait analysis, normal and pathologic function. Soack; 1992. p 269-73.

101. (d) This history and examination are consistent with a lateral femoral cutaneous neuropathy, known as
“meralgia paresthetica.” It is seen with pregnancy, obesity, pressure from tight clothing, trauma and
seatbelt use. The cause is usually idiopathic, and spontaneous recovery is usually the rule. This problem
may be difficult to treat and may be recurrent for years. Anti-inflammatory medications and neuropathic
pain medications may be tried, as well as attempting to remove the causative factors. This is a sensory
nerve and should not result in motor deficit. Sacroiliac pain is associated with pregnancy but will not
present with this pattern. A femoral neuropathy would likely have motor findings, and would have
numbness in the anterior portion of the thigh. An L3 radiculopathy might mimic this condition.
Trochanteric bursitis would cause this patient to be tender to palpation over the greater trochanter.
Patients are usually unable to lie on the affected hip.

Ref: Dumitru D. Electrodiagnostic medicine. Philadelphia: Hanley & Belfus; 1995. p 671-3

   

8 
 
102. (d) The casters should lead the rear wheels for the most common direction of travel. This will help reduce
the possibility of the user flipping over when hitting an obstacle and will make the chair more
directionally stable.

Ref: Cooper, RA. Wheelchair selection and configuration. New York: Demos; 1998. p 204.

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

Ref: Thomas MA, Felsenthal G, Fast A, Young M. Peripheral neuropathy. In: DeLisa JA, Gans BM,
Walsh, NE, editors. Physical medicine and rehabilitation: principles and practice. 4th ed.
Philadelphia: Lippincott Williams & Wilkins; 2005. p 908-9.

105. (d) Renal ultrasound should be included in the annual assessment of renal function and is more sensitive for
detecting early hydronephrosis than are plain films. An IVP is not required on a regular basis unless a
specific indication exists, such as localizing a renal stone. Patients with indwelling catheters should
have a cystoscopy after the first 10 years postinjury.

Ref: Schmitt JK, James J, Midha M, Armstrong B, McGurl J. Primary care for persons with spinal cord
injury. In: Lin VW, editor. Spinal cord medicine principles and practice. New York: Demos; 2003. p
237-45.

106. (c) The patient most likely has cryptococcal meningitis. Fever would not be present in PML, HIV
encephalopathy, or CNS lymphoma. In addition, headache is typically not a feature of PML or HIV
encephalopathy.

Ref: Levinson SF, Fine SM. Rehabilitation of the individual with HIV. In: DeLisa JA, Gans BM, Walsh
NE, editors. Physical medicine and rehabilitation: principles and practice. 4th ed. Philadelphia:
Lippincott Williams & Wilkins; 2005. p 1803.

110. (d) At least 50% of persons with diabetes and peripheral arterial disease who undergo major limb
amputation will die within 5 years of sustaining major lower limb amputation.

Ref: (a) Pandian G, Hameed F, Hammond M. Rehabilitation of the patient with peripheral vascular
disease anddiabetic foot problems. In: DeLisa J, Gans B, editors. Physical medicine: principles and
practice. 3rd ed. Philadelphia: Lippincott Raven; 1998. p1517-44.(b) Moolik P, Gill G. Mortality in
diabetic patients with foot ulcers. Diabetic Foot 2002: Spring.

111. (b) The lumbar medial branches of the dorsal rami supply the facet joints as well as the deep paraspinals,
such as the rotators and multifidi. The sinuvertebral nerve, also termed the recurrent meningeal nerve is
the primary source of nerve supply to the lumbar intervertebral disc. It is derived from portions of the
ventral rami and grey rami communicantes (sympathetic input). Accordingly, the referral pattern seen
with intrinsic disc pain is vague and diffuse.

Ref: ISIS Practice Guidelines for Spinal Diagnostics and Treatment Procedures, 2005; p 22.

112. (a) Primary cerebral lymphoma presents as multiple tumor deposits in the brain and has an increased
incidence in patients infected with human immunodeficiency virus (HIV). Surgical removal does not
improve outcome.

Ref: Gerber LH, Vargo M. Rehabilitation for patients with cancer diagnoses. In: DeLisa JA, Gans BM,
Walsh NE, editors. Physical medicine and rehabilitation: principles and practice. 4th ed. Philadelphia:
Lippincott Williams & Wilkins; 2005. p 1789.

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113. (b) Hemochromatosis is the diagnosis. It is a commonly inherited, autosomal recessive disorder (5 in 1000
persons) affecting Caucasians of European descent typically in the fourth and fifth decade of life. In
hemochromatosis, arthralgias may be the first symptom and are classically in the second and third MCP
and proximal interphalangeal (PIP) joints, resembling osteoarthritis (OA) on radiographs. However, OA
typically affects the distal interphalangeal joints. The CBC, ESR, and ACTH tests are normal in
hemochromatosis.

Ref: (a) Pietrangelo A. Hereditary hemochromatosis – A new look at an old disease. N Engl J Med
2004;350:2383-97.(b) Gordon DA. Storage and deposition disease. In: Klippel JH, editor. Primer on
rheumatic disease. 12th ed. Atlanta (GA): Arthritis Foundation; 2001. p 459-60.

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

Ref: (a) Middleton LT. Disorders of the neuromuscular junction. In: Schapira AH, Griggs RC. Blue
books of neurology: muscle diseases. Boston: Butterworth-Heinemann; 1999. p 277-8 (b) Gonzalez G.
Proteus infections. eMedicine [on line].2006 March; Available at:
http://www.emedicine.com/MED/topic1929.htm. Accessed May 6, 2007.

125. (d) Baclofen is an analog of gamma-aminobutyric acid (GABA), a neurotransmitter that exerts inhibitory
activity on monosynaptic and polysynaptic reflexes. Dantrolene prevents the release of calcium from
the sarcoplasmic reticulum.

Ref: Priebe MM, Goetz LL, Wuermser LA. Spasticity following spinal cord injury. In: Kirshblum S,
Campagnola D, DeLisa J, editors. Spinal cord medicine. Philadelphia: Lippincott-Williams & Wilkins;
2002. p 221-33.

126. (b) Patients are anticoagulated following mechanical valve replacements to prevent thromboembolic
strokes. Anticoagulation will also prevent deep vein thromboses, but this is not the primary reason why
it is prescribed.

Ref: (a) Ezekowitz MD. Anticoagulation management of valve replacement patients. J Heart Valve Dis
2002;11(Suppl 1):S56-60. (b) Stein PD, Alpert JS, Bussey HI, Dalen JE, Turpie AG. Antithrombotic
therapy in patients with mechanical and biological prosthetic heart valves. Chest 2001;119(1
Suppl):220S-7.

127. (b) While more than 2 patient identifiers may be used, a minimum of 2 is required: first, a marker to
identify the individual as the person for whom the service or treatment is intended; second, an identifier
to match the service or treatment to that individual.

Ref: Joint Commission on Accreditation of Hospital Organizations. JCAHO 2007 National Patient
Safety Goals. JCAHO Web site. Available at: http://www.jointcommission.org/NR/rdonlyres/98572685-
815E-4AF3-B1C4-C31B6ED22E8E/0/07_hap_npsgs.pdf. Date accessed July 4, 2007.

130. (a) The primary benefits of attaching a prosthesis directly to the skeleton are comfort, elimination of poor
prosthetic socket fit, and elimination of skin problems. Recipients report improved sensory feedback
from the skeletally attached limb. Limitations include a 2-stage procedure, which results in an extended
time of non-weight bearing, and extended rehabilitation (up to 2 years). The procedure poses a
significant risk of infection, and the recipient must limit running, jumping, and heavy manual work in
order to minimize loosening of the prosthesis.

Ref: Pasquini PS, Bryant PR, Huang NE, Robert TL, Nelson VS, Flood KM. Advances in amputee care.
Arch Phys Med Rehabil 2006:87(3 Suppl1);S34-43

   

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131. (c) Computed tomography (CT) scans with thin cuts through the area of the pars interarticularis can
identify the healing pattern of a pars stress fracture.

Ref: Standaert CJ, Herring SA. Expert opinion and controversies in sports and musculoskeletal
medicine: the diagnosis and treatment of spondylolysis in adolescent athletes. Arch Phys Med Rehabil.
2007. Apr;88(4):537-40.

137. (c) The only listed expression that may be written on a prescription is 2 mg for 2 milligrams. JCAHO
expects that the other abbreviations will not be used in writing drug prescriptions, since they can lead to
errors. Davis' Medical Abbreviations cites U as "the most dangerous abbreviation" and says spell out
"unit." The expression QD is too easily read as 4 times daily. Regarding MSO4, Davis also calls this as
"a dangerous abbreviation."

Ref: 2007 National Patient Safety Goals. Joint Commissions Resources Web site. Available at:
http://www.jcrinc.com/13469. Accessed July 4, 2007.

138. (d) Reduced recruitment may be seen day 1. Positive waves may be seen in the paraspinals as early as 1
week, and positive waves and fibrillations may be seen in the extremities by 3–5 weeks, but, because of
reinnervation by axon sprouting, it takes at least 6 weeks to see increased amplitude and duration of
muscle activity.

Ref: Dumitru, D, Zwarts, MJ. Radiculopathies. In Dumitru D, Amato AA, Zwarts, MJ, editors.
Electrodiagnostic medicine. 2nd ed. Philadelphia: Hanley & Belfus; 2002. p 732.

139. (b) Children who sustain cervical or high thoracic spinal cord injuries at an early age are at high risk of
developing progressive scoliosis that requires surgical management.

Ref: Lubicky JP, Betz RR. Spinal deformity in children and adolescents after spinal cord injury. In:
Betz RR, Mulcahey MJ, editors. The child with a spinal cord injury. Rosemont (IL): American
Academy of Orthopedic Surgeons; 1996. p 363-70.

140. (b) Disarticulation results in a bulbus distal residual limb, which may complicate prosthetic fitting. Choice
of prosthetic knee options for a person with a knee disarticulation, therefore, is limited and potentially
excludes the newer, more advanced knee-joint designs. Benefits of a knee disarticulation over a
transfemoral approach include greater tolerance to distal limb weight bearing, a longer lever arm to
create power during ambulation and running, and improved sitting balance. Of note, functional outcome
studies of trauma-related lower extremity amputees concluded that persons with through knee
amputations had significantly poorer outcomes. These poorer outcomes are attributed to complications
arising from soft tissue failure within the zone of injury.

Ref: Pasquini PS, Bryant PR, Huang ME, Roberts TL, Nelson VS, Flood KM. Advances in amputee
care. Arch Phys Med Rehabil 2006:87(3 Suppl1);S34-43.

141. (d) Risk factors for chronic whiplash-associated pain include presence of preexisting degenerative disc
disease, preexisting loss of cervical lordosis, female gender, awkward head position at time of impact,
presence of radiating pain into upper limbs, and prior history of headache. A famous Lithuanian study
showed no incidence of long-term whiplash pain in a country that had no compensation system for
whiplash.

Ref: Seroussi RE, Ferrari R. Curve/countercurve: Whiplash. SpineLine 2001:12-9.

145. (b) Individuals with spinal cord injury are at an increased risk for carbohydrate intolerance, cardiovascular
disease, and dyslipidemia. There does not appear to be an added risk for prostate cancer in men with
chronic SCI.

Ref: Schmitt JK, James J, Midha M, Armstrong B, McGurl J. Primary care for persons with spinal cord
injury. In: Lin VW, editor. Spinal cord medicine principles and practice. New York: Demos; 2003. p
237-45.

   
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149. (d) The most common congenital limb deficiency is the left midlength transradial deficiency.

Ref: Gaebler-Spira D, Uellendahl J. Pediatric limb deficiencies. In: Molnar GE, Alexander MA,
editors. Pediatric rehabilitation. 3rd ed. Philadelphia: Hanley & Belfus; 1999. p 334.

150. (a) Phantom sensation, phantom pain, and residual limb pain have all been reported about equally in over
70% of amputees 6 months or more after lower limb amputation. This is typically not dependent upon
the person's age at the time of amputation, the level of amputation, or surgical technique.

Ref: Ehde DN, Czerniecki JM, Smith DG. Chronic phantom sensation, phantom pain, and residual limb
pain and other regional pain after lower limb amputations. Arch Phys Med Rehabil 2000;81:1039-44.

152. (d) Botulinum toxins act on the neuromuscular junction where they inhibit the release but not the
production of acethylcholine (ACh). Botulinum toxin does not affect the sarcoplasmic reticulum, nor
does it work at the troponin-tropomysin complex.

Ref: Elovic E, Bogey R. Spasticity and movement disorder. In: DeLisa JA, Gans BM, Walsh NE, editors.
Physical medicine and rehabilitation: principles and practice. 4th ed. Philadelphia: Lippincott
Williams & Wilkins; 2005. p 1435.

153. (a) Avascular necrosis (or ostenecrosis) is the second form of joint disease that occurs in persons with SLE;
it is associated with use of corticosteroids. Erosions are not seen with systemic lupus erythematosus.
Erosions with subchondral sclerosis are seen in rheumatoid arthritis and overhanging edge in gout.
Syndesmophytes occur in spondyloarthropathies at the anterior and posterior longitudinal ligaments of
the spine.

Ref: Klippel JH, editor. Primer on rheumatic disease. 12th ed. Atlanta (GA): Arthritis Foundation;
2001. p 337-8.

154. (d) TENS therapy has not been shown to provide benefit for angina. It has been proven to have a beneficial
effect in all the other diagnoses.

Ref: Basford JR. Therapeutic physical agents. In: DeLisa JA, Gans BM, Walsh NE, editors. Physical
medicine and rehabilitation: principles and practice. 4th ed. Philadelphia: Lippincott; 2005. p 263-4.

155. (a) If anticoagulation is delayed for more than 72 hours after injury, a test to exclude the presence of clots
in the legs should be performed. In complete injuries, low molecular weight heparin should be used
when starting chemical prophylaxis. Pulmonary embolisms may occur as a result of upper extremity
DVT and are not prevented by the IVC filter. In general, the longer you wait to remove the IVC filter,
the more problems you may experience in the filter retrieval process.

Ref: Campagnolo DI, Merli GJ. Autonomic and cardiovascular complications of spinal cord injury. In:
Kirshblum S, Campagnola D, DeLisa J, editors. Spinal cord medicine. Philadelphia: Lippincott
Williams & Wilkins; 2002. p 123-34.

156. (c) Cervical traction is proven effective for illnesses that involve nerve root irritation or compression of
nerve roots.

Ref: Atchison JW, Stoll ST, Cotter AC. Manipulation, traction, and massage. In: Braddom RL, editor.
Physical medicine and rehabilitation. 2nd ed. Philadelphia: WB Saunders; 2000. p 427.

   

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157. (a) A person who knowingly discloses individually identifiable health information in violation of HIPAA
faces a fine of $50,000 and up to a 1-year imprisonment. The criminal penalties increase to $100,000
and up to 5 years imprisonment if the wrongful conduct involves false pretenses, and to $250,000 and
up to 10 years imprisonment if the wrongful conduct involves the intent to sell, transfer, or use
individually identifiable health information for commercial advantage, personal gain, or malicious
harm.

Ref: US Department of Health and Human Services. Summary of the HIPAA Privacy Rule, May 2003.
US Dept Health and Human Service Web site. Available at:
http://www.hhs.gov/ocr/privacysummary.pdf. Accessed July 4, 2007.

160. (a) Informed consent for participation in a research study requires that the risks be described in terms of
type, severity, and probability. It is important to describe risks in each of these areas in order to fully
inform the patient of the potential risks associated with study participation.

Ref: Lo B, Feigal D, Cummins S, and Hulley SB. Addressing ethical issues. In:Hulley SB, Cummings
SR, editors. Designing clinical research. Baltimore: Williams & Wilkins; 1988. p 153.

161. (a) The subpedicular transforaminal route of epidural steroid delivery places the needle at the anterior
portion of the intervertebral foramen. The retroneural route of delivery purposefully terminates needle
placement at the posterior edge of the intervertebral foramen to avoid injuring radicular vasculature.
The caudal and interlaminar approaches are of limited utility in delivering steroid anteriorly due to
raphe within the epidural space.

Ref: Irwin RW, Zuhosky JP, Sullivan WJ, et al. Interventional procedures for work-related lumbar
spine conditions. Arch Phys Med Rehabil 2007;88(Suppl):S22-3.

162. (b) Significant risk factors for heterotopic ossification in traumatic brain injury include prolonged coma (>1
month), increased muscle tone, limited movement in the involved lower extremity, and associated
fractures. Late seizures, gender, and diabetes insipidus are not associated with increased risk of
heterotopic ossification.

Ref: Whyte J, Hart T, Laborde A, Rosenthal M. Rehabilitation issues in traumatic brain injury. In:
DeLisa JA, Gans BM, Walsh NE, editors. Physical medicine and rehabilitation: principles and practice.
4th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p 1691.

163. (c) Ultrasound use is contraindicated in acute rheumatoid arthritis. Ultrasound has been shown to help with
pain, but not in the context of acute inflammation.

Ref: Basford JR. Therapeutic physical agents. In: DeLisa JA, Gans BM, Walsh NE, editors. Physical
medicine and rehabilitation: principles and practice. 4th ed. Philadelphia: Lippincott Williams &
Wilkins; 2005. p 258.

167. (c) Protected Health Information includes individually identifiable health information. This is information,
including demographic data, that relates to any of the following particulars: the individual’s past,
present or future physical or mental health or condition; the provision of health care to the individual; or
the past, present, or future payment for the provision of health care to the individual. It can also be
information that identifies the individual or for which there is a reasonable basis to believe it can be
used to identify the individual. Individually identifiable health information includes many common
identifiers (e.g., name, address, birth date, Social Security Number).

Ref: US Department of Health and Human Services. Summary of the HIPAA Privacy Rule. US Dept
Health and Human Service Web site. Available at: http://www.hhs.gov/ocr/privacysummary.pdf.
Accessed July 4, 2007.

   

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169. (c) The principle of justice requires subjects to be treated fairly and selected equitably. The principle of
beneficence ensures that researchers minimize harm and maximize benefits associated with research
involvement. The principle of autonomy ensures that informed consent includes full disclosure of risks
and benefits and that the privacy of subjects is respected.

Ref: (a) Haas JF. Ethical issues in rehabilitation medicine. In: DeLisa JA, Gans BM, editors.
Rehabilitation medicine: principles and practice. 3rd ed. Philadelphia: Lippincott-Raven; 1998. p 34-
5.(b) Lo B, Feigal D, Cummins S, Hulley SB. Addressing ethical issues. In:Hulley SB, Cummings SR,
editors. Designing clinical research. Baltimore: Williams & Wilkins; 1988. p 151.

170. (a) Type 1 (alpha) error is best described as occurring in research when the study finds a positive benefit
from the intervention, but no benefit really exists. In this case, the study conclusions would be falsely
positive.

Ref: Fletcher RH, Fletcher SW, Wagner EH. Clinical epidemiology: the essentials. 3rd ed. Williams &
Wilkins; 1996. p 186-8.

171. (a) Since it occurs lateral to the intervertebral disc, a far lateral disc herniation is a relatively unusual
location for disc herniation. A far lateral disc herniation can actually impinge the nerve root exiting
above that intervertebral level.

Ref: In Interventional Spine: An Algorithmic Approach. Ed: Slipman CW, Derby R, Simeone FA, Mayer
T. Philadelphia: Elsevier. 2008

173. (d) Oxygen uptake (VO2) is the measure used to describe the rate at which oxygen is used in the
production of energy. Maximal oxygen uptake (VO2max) is the maximal rate at which an individual
can use oxygen. Peak VO2 is the measure of oxygen uptake stated when the highest attainable VO2
may not have been reached due to external factors. There is no VO2min measure.

Ref: Hoffman MD, Sheldahl LM, Kraemer WJ. Therapeutic exercise. In: DeLisa JA, Gans BM, Walsh
NE, editors. Physical medicine and rehabilitation: principles and practice. 4th ed. Philadelphia:
Lippincott Williams & Wilkins; 2005. p 391

174. (d) Significant evidence exists to show that elderly persons benefit from strength training. In the past it was
believed that adaptations were due to only neural factors. Recent evidence has shown that strength gains
in elderly persons are attributable to both neural factors and muscle hypertrophy.

Ref: (a) Hoffman MD, Sheldahl LM, Kraemer WJ. Therapeutic exercise. In: DeLisa JA, Gans BM,
Walsh NE, editors. Physical medicine and rehabilitation: principles and practice. 4th ed. Philadelphia:
Lippincott Williams & Wilkins; 2005. p 409.(b) De Lateur BJ. Therapeutic exercise. In: Braddom R,
editor. Physical medicine and rehabilitation. 2nd ed. Philadelphia: WB Saunders; 2000. p 407.

175. (b) The proper minimum width of a doorway for a wheelchair without a turn is 32 inches. If a turn is
involved, then the doorway width should be at least 36 inches.

Ref: Hsiao I, Hodne T. Architectural considerations for improving access. In: Lin VW, editor. Spinal
cord medicine principles and practice. New York: Demos; 2003. p 975-86.

176. (b) Sustained traction is the use of force greater than that applied in continuous traction, but less than that
used in intermittent traction, and the application time is 20--60 minutes. This time frame makes
sustained traction more practical in clinical use. Continuous traction is the use of low force of traction
over long periods of time, 20--40 hours. Intermittent traction is the use of greater forces, but for shorter
periods of time, 10--60 seconds. There is no pulsed traction.

Ref: Atchison JW, Stoll ST, Cotter A. Manipulation, traction and massage. In: Braddom R, editor.
Physical medicine and rehabilitation. 2nd ed. Philadelphia: WB Saunders; 2000. p 428.

   

14 
 
178. (b) FIM scores would be classified as ordinal data, because in an ordinal scale consecutive values are rank-
ordered, but not equally spaced. For example, although there is an order to the ranking in the FIM scale,
the difference between a 2 and a 3 may not be equal to the difference between a 6 and a 7. Nominal data
refers to data with discrete values (yes/no; alive/dead). With interval data, there are equal intervals
between consecutive values. An example of interval data is temperature in degrees Fahrenheit. Ratio
data are interval data with equal intervals between consecutive values, but with an absolute zero point.

Ref: Katz RT, Priebe MM, Campagnolo DI. Research in physical medicine and rehabilitation. In:
Braddom RL, editor. Physical medicine and rehabilitation. 2nd ed. Philadelphia: WB Saunders; 2000.
p 170.

179. (d) The process of developing and adopting quality standards for clinical practice helps to form
expectations for safety among both providers and consumers.

Ref: National Institutes of medicine report. To err is human: building a safer health system. November
1999

181. (b) The natural history of spinal stenosis is generally benign. While decompressive surgery achieves
satisfactory results in the great majority of individuals, the difference in outcomes with their
nonsurgical cohorts becomes narrower with time.

Ref: Vo AN, Kamen LB, Shih VC, et al. Rehabilitation of orthopedic and rheumatologic disorders:
Spinal stenosis. Arch Phys Med Rehabil 2005;88 (Suppl): S74.

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

Ref: Roth E, Harvey R. Rehabilitation of stroke syndromes. In: Braddom RL, Buschbacher RM, editors.
Physical medicine and rehabilitation. 2nd ed. Philadelphia: WB Saunders; 2000. p 1131.

183. (d) Evaporation is a process of transforming a liquid into a gas and requires thermal energy, as in
vapocoolant spray. Convection is a process of using a medium to transport energy, for example husks
during fluidotherapy and water during whirlpool therapy. Conduction is a process of transferring
thermal energy to bodies that are in direct contact, for instance cold packs applied to skin. Conversion is
a process of transforming energy into heat, as occurs with an ultrasound device.

Ref: Weber DC, Brown AW. Physical agent modalities. In: Braddom R, editor. Physical medicine and
rehabilitation. 2nd ed. Philadelphia: WB Saunders; 2000. p 442-3, 451.

184. (b) Low frequency electrical stimulation predominantly stimulates type 1 muscle fibers. High frequency
electrical stimulation predominantly stimulates Type 2 muscle fibers. There are no type 3 muscle fibers.

Ref: Pape K, Chipman M. Electrotherapy in rehabilitation. In: DeLisa J, Gans BM, Walsh NE, editors.
Physical medicine and rehabilitation: principles and practice. 4thh ed. Philadelphia: Lippincott
Williams & Wilkins; 2005. p 437.

186. (a) Iontophoresis is the migration of charged particles across biological membranes under an imposed
electrical field. Phonophoresis is the use of ultrasound to facilitate transdermal migration of topically
administered medications. Ultrasound is a type of heating that occurs as a result of acoustic vibration.
Laser therapy is light amplification by stimulated emission of radiation. It consists of a coherent,
collimated beam of photons of identical frequency.

Ref: (a) Weber DC, Brown AW. Physical agent modalities.In: Braddom R, editor. Physical medicine
and rehabilitation. 2nd ed. Philadelphia: WB Saunders; 2000. p 449-53. (b) Basford JR. Therapeutic
physical agents. In: DeLisa JA, Gans BM, Walsh NE, editors. Physical medicine and rehabilitation:
principles and practice. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p 264.

   

15 
 
188. (a) The primary benefit of quality outcomes management is that it provides guidance for aligning the
program with the needs of the patient. None of the other options are benefits of quality outcomes
management.

Ref: Granger CV, Black T, Braun SL. Quality and outcome measures for medical rehabilitation. In:
Braddom RL, editor. Physical medicine and rehabilitation. 3rd ed. Philadelphia: Elsevier; 2007. p 157-
8.

190. (a) The K level of 1 represents that of a household ambulator; K 2 limited community ambulator; K 3
unlimited community ambulator; K4 a very active community ambulator. The household exception FIM
score of 5 indicates a "modified independent" ambulator who can handle household distances (i.e., less
than 50 feet) inside or out.

Ref: Nelson VS, Flood KM, Bryant PR, Huang ME, Pasquina PF, Roberts TL. Limb deficiency and
prosthetic management. 1. Decision making in prosthetic prescription and management. Arch Phys
Med Rehabil 2006;87(3 Suppl 1):S3-9

195. (b) Damage to the sacral roots usually results in a flaccid bladder. Incontinence often occurs due to a weak
sphincter mechanism, particularly if the patient has increased bladder volume or an increase in intra-
abdominal pressure. However, the external sphincter may not always be affected to the same degree as
the detrusor. This imbalance results in bladder overdistension and the possibility of upper tract
deterioration.

Ref: Linsenmeyer TA. Neurogenic bladder following spinal cord injury. In: Kirshblum S, Campagnola
D, DeLisa J, editors. Spinal cord medicine. Philadelphia: Williams & Wilkins; 2002. p 198-200.

197. (b) In fiscal year 2003, the number of admissions to an inpatient rehabilitation facility with the diagnosis
related group unilateral joint replacement in a lower extremity was 124,754, stroke was 54,433,
amputation for circulatory disorders except upper limb and toe was 7,200, and hip or pelvis fracture was
5,863.

Ref: US Government Accountability Office. Medicare: more specific diagnoses needed to classify
inpatient rehabilitation facilities. April 2005. Report GAO-05-366. Available at:
http://www.gao.gov/new.items/d05366.pdf. Accessed July 4, 2007.

200. (c) Body-powered, voluntary-opening terminal devices are available in the form of either a hand or a hook.
Both terminal devices have the same harnessing requirements and the pinch strength is controlled either
by the number of rubber bands placed on the terminal device or by a spring mechanism. Hooks do not
necessarily provide greater ability to grasp small objects. Hook terminal devices provide a lateral pinch
or tip-to-tip type of pinch compared to hands, which provide a 3-jaw chuck type of pinch. Hook devices
provide greater visibility of the object being grasped or manipulated than do hand terminal devices.

Ref: Esquenazi A. Upper limb amputee rehabilitation and prosthetic restoration. In: Braddom RL,
editor. Physical medicine and rehabilitation. 2nd ed. Philadelphia: WB Saunders; 2000. p 268-9.
 

Copyright © 2008
American Academy of Physical Medicine and Rehabilitation
Chicago, Illinois 

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