Brain

Question 1

A 49-year-old man is seen in your outpatient clinic 2 years after a stroke. You notice a Trendelenberg gait and suspect weakness of which muscle?

(a) Gluteus maximus
(b) Quadratus lumborum
(c) Quadriceps
(d) Gluteus medius

Answer 1

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

Reference: (a)Kerrigan DC, Edelstein JE. Gait. In: Gonzalez EF, Myers SJ, editors. Downey and Darling’s physiological basis of rehabilitation medicine. 3rd ed. Woburn (MA): Butterworth-Heinemann; 2001. p 412.(b)Krabak BJ, Jarmain SJ, Prather H. Physical examination of the hip. In: Malanga GA and Nadler SF, eds. Musculoskeletal physical examination: An evidence-based approach. Philadelphia: Elsevier; 2006. p 252, 266-7.

Question 2

Personality changes and/or aphasia are typical of which dementia?

(a) Alzheimer
(b) Frontotemporal
(c) Parkinson’s disease with dementia
(d) Vascular

Answer 2

Answer: (b)
Commentary: Frontotemporal dementia is a neurodegenerative disease of unknown etiology with
atrophy and neuronal loss in the frontal and temporal lobes of the brain resulting in a gradual and
progressive decline in behavior and/or language. Overuse of stock phrases, lack of conversational initiation and echolalia are more common in frontotemporal dementia. Alzheimer disease is primarily associated with memory and visuospatial loss of function, and speech is more fluent than in persons with frontotemporal dementia. Parkinson disease with dementia is associated with symptoms of memory loss, fluctuating cognition, and visual hallucinations with spontaneous parkinsonism motor features. Persons with vascular dementia usually have a history of stroke or have focal neurologic deficits, early gait disturbance, changes in personality and mood and a history of frequent falls or unsteadiness.

Reference: (a) Cardarelli R, Kertesz A, Knebl JA. Frontal dementia: a review for primary care
physicians. Am Fam Physician. 2010;82(11):1372-1377.

(b) Miller RM, Groher ME, Yorkston KM, Rees TS, Palmer JB. Speech, language, swallowing and auditory rehabilitation. In: DeLisa JA, Gans BM, Walsh NE, editors. Physical medicine and rehabilitation: principles and practice. 4th ed. Philadelphia: Lippincott-Raven; 2005. p 1036.

Question 3

Which is the most significant risk factor for a stroke?

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

Answer 3

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

Reference: a)Goldstein LB, Bushnell CD, Adams RJ, Appel LJ, Braun LT, Chaturvedi S, et al. Guidelines for the primary prevention of stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011;42:517-584. b) Brandstater ME. Stroke rehabilitation. In: DeLisa JA, Gans BM, Walsh NE, editors. Physical medicine and rehabilitation: principles and practice. 4th ed. Philadelphia: Lippincott-Raven; 2005. p 1657-1659. c) Zorowitz R, Baerga E, Cuccurullo S. In: Cuccurullo S, editor. Physical Medicine and rehabilitation board review. New York: Demos Medical; 2004. p 1.

Question 4

A neurologist refers a patient to you with Parkinson disease and poor gait. What treatment strategy is recommended to prevent frequent falls?

(a) Methylphenidate medication trial to increase attention and concentration
(b) Physical therapy with balance training and cueing strategies
(c) Referral to a neurosurgeon for implantation of a deep brain stimulator
(d) Maximized levodopa medication to improve balance control

Answer 4

Answer: (b)
Commentary: Physical therapy with cueing strategies, such as rhythmic auditory stimulation with a metronome and balance and strength training are shown to be useful in improving gait and decreasing falls. Treadmill training is still in its infancy and its role in improving gait is unclear, although early studies are positive. The use of methylphenidate in initial trials was positive but a
recent randomized, double blinded study using methylphenidate showed no improvement in gait.
The use of deep brain stimulation is very inconsistent in its effect on balance and gait and further study is needed to optimize type of stimulation and to define new targets for stimulation. Levodopa can improve gait, but can also cause a worsening of gait and balance, possibly due to drug-induced dyskinesias.

Reference: (a) Boonstra TA, van der Kooij H, Munneke M, Bloem BR. Gait disorders and
balance disturbances in Parkinson’s disease: clinical update and pathophysiology. Curr Opin
Neurol . 2008;21:461-471.(b) Mehrholz J, Friis R, Kugler J, Twork S, Storch A, Pohl M.
Treadmill training for patients with Parkinson’s disease. Cochrane Database Syst Rev. 2010;(1):
CD007830. DOI:10.1002/14651858.CD007830.pub2.(c) Espay AJ, Dwivdei AK, Payne M, Gaines L, Vaughan JE, Maddux BN, et al. Methylphenidate for gait impairment in Parkinson disease: a randomized clinical trial. Neurology 2011;76:1256-1262.

Question 5

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

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

Answer 5

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

Reference: a) Runchey S, McGee S. Does this patient have a hemorrhagic stroke? Clinical findings distinguishing hemorrhagic stroke from ischemic stroke. JAMA 2010;303(22):2280-2286.b) Harvey Rl, Roth EJ, Yu DT, Celnik P. Stroke syndromes. In: Braddom RL, editor. Physical medicine and rehabilitation: principles and practice. 4th ed. Philadelphia: Elseivier Saunders; 2011. p 1180-1182.c) Brandstater ME. Stroke rehabilitation. In: DeLisa JA, Gans BM, Walsh NE, editors. Physical medicine and rehabilitation: principles and practice. 4th ed. Philadelphia: Lippincott-Raven; 2005. p 1657-1659.

Question 6

1. A 24-year-old man was in a motor vehicle collision 36 hours ago. His initial Glasgow Coma Scale score was 13 and his initial head computed tomography scan showed a small frontal contusion. Initial blood alcohol level was .15g/dL. He is currently disoriented, combative, and tachycardic. He reports visual hallucinations. Management of this case should include
2. (a) benzodiazepines for alcohol withdrawal.
3. (b) anticonvulsants for agitation.
4. (c) neuroleptics to treat hallucinations.
5. (d) beta-blockers to treat tachycardia.

Answer 6

1. (a)Premorbid alcohol abuse is commonly seen in people sustaining brain injury and alcohol withdrawal causes agitation and hallucinations

Question 7

2. According to the Hunt and Hess Scale, which grade of subarachnoid hemorrhage would apply to a patient who presents with moderately severe headache, meningismus, and cranial nerve deficit?
3. (a) 0
4. (b) 1
5. (c) 2
6. (d) 3

Answer 7

2. (c)Grade 2 of the Hunt and Hess Scale is moderately severe headache/meningismus, no neurologic deficit, except cranial nerve palsy.

Question 8

3. The criterion scale used to describe severity of brain injury is the
4. (a) Disability Rating Scale.
5. (b) Agitated Behavior Scale.
6. (c) FIMTM instrument.
7. (d) Glasgow Coma Scale.

Answer 8

3. (d)The criterion to describe the severity of a traumatic brain injury is the Glascow Coma Scale (GCS). GCS score of 13-15 = mild GCS score of 9-12 = moderate GCS score of 3-8 = severe

Question 9

4. (This question has been eliminated from the exam, therefore, it was not scored.) On a pharmacologic basis, which agent used to decrease gastric acid secretion is most appropriate after brain injury?
5. (a) Ranitidine
6. (b) Famotidine
7. (c) Omeprazole
8. (d) Sucralfate

Answer 9

4. (c) Choices a and b are both histamine type-2 (H2) blockers that are cognitively impairing.

Question 10

5. Six months after a moderate traumatic brain injury, a 32-year-old woman complains of daytime somnolence. Her medical work-up is negative. She has normal sleep patterns. The medication you would most likely consider in this case is
6. (a) donepezil.
7. (b) buspirone.
8. (c) tolcapone.
9. (d) modafinil.

Answer 10

5. (d)From the information given, it is clear that this patient is functioning well overall. She has some difficulty staying awake. Of the answers given, modafinil is the medication most appropriate to help with alertness during the day. Donepezil is an acetylcholinesterase inhibitor used most often to improve memory. Buspirone is used to decrease anxiety. Tolcapone is a newer dopaminergic agent that has not been studied in populations with brain injury.

Question 11

6. Which is the best predictor of discharge from a rehabilitation center to home for a man who has had a stroke?
7. (a) Lesion location
8. (b) Shoulder pain
9. (c) Ambulatory status
10. (d) Bladder incontinence

Answer 11

6. (d)Of the choices presented above, the most consistent predictor of good outcome and discharge home is bladder continence. Probably the strongest overall predictor of ability is admission functional ability (which reflects severity of stroke).

Question 12

7. A 26-year-old man was in a motor vehicle crash last night. Oxygen saturation was consistently around 93%. Intracranial pressure was 15mmHg, with a mean arterial blood pressure of 110mmHg. Pupils were equally reactive. This patient’s prognosis is
8. (a) poor because oxygen saturation was consistently below 95%.
9. (b) poor because of the high intracranial pressure.
10. (c) not affected by pupillary response in the first 24 hours.
11. (d) good because his cerebral perfusion pressure was greater than 70mmHg.

Answer 12

7. (d)The guideline set by the American Association of Neurological Surgeons included avoidance of oxygen saturations of less than 90%. Cerebral perfusion pressure is a more important predictor of outcome than ICP since CPP is more directly related to metabolic delivery and ischemia. CPP is mean arterial pressure minus ICP and in this patient is 95. Pupillary response is a very important early predictor of eventual outcome.

Question 13

8. A patient with focal right upper extremity spasticity initially demonstrated a good response to electromyographically-guided botulinum toxin injections, as measured functionally and on the Modified Ashworth Scale. He received 2 sets of follow-up injections, each 6 months apart, when spasticity returned. He returns 4 weeks after his most recent injection, complaining that he has not seen any effect. Of the options given, what is the most likely explanation for this lack of effect?
9. (a) Diffusion characteristics of botulinum toxin change with repeated administration.
10. (b) It becomes very difficult to localize spastic muscles with repeated administration.
11. (c) Antibodies have developed to botulinum toxin, neutralizing it.
12. (d) The hepatic enzymes that metabolize botulinum toxin have increased with repeated administration.

Answer 13

8. (c)Diffusion characteristics do not change. Electromyographic guidance helps to ensure that the botulinum toxin is injected into the targeted muscle. Localization does not become more difficult with repeated injections when spasticity returns. Botulinum toxin is not metabolized by the liver. The development of neutralizing antibodies is the primary reason for loss of efficacy with repeated injections.

Question 14

9. Which of the following is an appropriate compensatory technique for managing dysphagia?
10. (a) Tilting the head to the weaker side
11. (b) Glossopharyngeal breathing
12. (c) Chin tuck
13. (d) Turning the head to the stronger side

Answer 14

9. (c)Tilting the head to the stronger side and turning the head to the weaker side (but not vice versa) are appropriate compensatory techniques. Glossopharyngeal breathing is used in pulmonary rehabilitation and has no value in dysphagia management.

Question 15

10. Which measure will ensure the best outcome for a 68-year-old man who is in the critical care unit with severe traumatic brain injury?
11. (a) Minimizing cerebral perfusion pressure
12. (b) Minimizing early hypoxia
13. (c) A voiding hypertension
14. (d) Inducing hypothermia

Answer 15

10. (b)Hypoxia in the setting of brain injury is associated with poor outcome. Maintaining perfusion pressure and avoiding hypotension are important critical care measures to avoid secondary complications in brain injury. Inducing hypothermia has not been found to improve outcome in patients with brain injury.

Question 16

11. Regarding central nervous system tumors in adults,
12. (a) meningiomas are the most common form of primary tumors.
13. (b) approximately 50% of these tumors are metastatic.
14. (c) glioblastoma multiforme has a median survival rate of 5 years.
15. (d) brain tumor treatment side effects do not affect outcome.

Answer 16

11. (b)Meningiomas are the second most common form of primary tumors. Gliomas are the most common. Glioblastoma multiforme has a median survival rate of less than 1 year. Treatment side effects do affect outcome. Metastatic disease comprises 50% of central nervous system tumors.

Question 17

12. Which genetic factor may link Alzheimer disease and chronic residual deficits in traumatic brain injury?
13. (a) €Apolipoprotein-∈4
14. (b) Human leukocyte antigen B27
15. (c) Mitochondrial protein C450
16. (d) Platelet aggregation factor

Answer 17

12. (a)The apolipoprotein-∈4 has been linked both to Alzheimer disease and to chronic effects of traumatic brain injury.

Question 18

13. Regarding subarachnoid hemorrhages,
14. (a) arteriovenous malformations present with hemorrhage after age 40.
15. (b) the risk of rebleeding after an unoperated aneurysm is low.
16. (c) their clinical presentation is nonspecific.
17. (d) aneurysms usually occur in the anterior region of the circle of Willis.

Answer 18

13. (d)Clinical presentation is not nonspecific. Patients often complain of severe headaches (“worst of their lives”) and present with loss of consciousness. Atriovenous malformation present with hemorrhages earlier in life, in the second or third decade. Aneurysms are most commonly found in the anterior region of the circle of Willis, particularly near branches of the anterior communicating, internal carotid, and middle cerebral arteries.

Question 19

14. Regarding post-traumatic seizures following brain injury,
15. (a) by definition, early seizures occur in the first 24 hours after an injury.
16. (b) prophylaxis beyond the first week postinjury does not prevent late seizures.
17. (c) an association exists between late post-traumatic seizures and alcohol use.
18. (d) most seizures are of the generalized tonicoclonic type.

Answer 19

14. (b)Early seizures occur within the first week. Late seizures are either simple partial or complex partial. Alcohol is not a risk factor for developing late post-traumatic seizures.

Question 20

15. Which characteristic is a risk factor for heterotopic ossification in traumatic brain injury?
    (a) Male gender (b) Flaccid tone (c) Long bone fractures (d) Older age

Answer 20

15. (c)Risk factors for HO include: long bone fractures, spasticity, prolonged immobilization, and prolonged coma.

Question 21

16. An 18-year-old man was in a high-speed motor vehicle collision 24 hours ago. He required a prolonged extrication from his vehicle and lost consciousness at the scene of the accident. Head computed tomography (CT) scan was notable for a small subarachnoid hemorrhage. He has had several episodes of hypotension and hypoxemia since admission. What information in this clinical case makes diffuse axonal injury highly likely?
    (a) High-speed motor vehicle collision
    (b) Subarachnoid hemorrhage on head CT scan
    (c) Episodes of hypoxia and hypotension
    (d) Prolonged extrication from vehicle

Answer 21

16. (a)Diffuse axonal injury is most commonly seen after high-speed motor vehicle collisions, particularly when immediate loss of consciousness occur.

Question 22

2. A 30-year-old man with a recent traumatic brain injury has frequent episodes of emesis with gastrostomy tube bolus feedings despite receiving agents to facilitate gastric emptying. The most appropriate next course of action is to
3. (a) switch the tube feeding formula.
4. (b) switch to continuous tube feedings.
5. (c) order a gastric endoscopy.
6. (d) place a jejunostomy tube.

Answer 22

17. (b)Intolerance to feeding can be related to increased gastric distention, and adjusting from bolus to a slower rate with longer feeding time may provide relief. Converting to a jejunostomy is appropriate if simpler measures fail.

Question 23

3. Which type of stroke typically results in the best overall outcome?
4. (a) Pontine hemorrhage
5. (b) Embolic cortical infarction
6. (c) Anterior cerebral artery aneurysm rupture
7. (d) Internal capsule lacune18. (d) Lacunar strokes are

Answer 23

18. (d) Lacunar strokes are typically small and very localized and, in general, have the best prognosis.

Question 24

4. Early post-traumatic seizures are defined as seizures within the first
5. (a) day.
6. (b) month.
7. (c) week.
8. (d) 3 months.

Answer 24

19. (c)Early post-traumatic seizures occur from the first day to 1 week postinjury. Immediate seizures occur within the first 24 hours. Late seizures occur after the first 7 days.

Question 25

5. In a patient with traumatic brain injury and vertigo, which physical examination finding from a Dix-Hallpike test would encourage you to perform an Epley maneuver? 1. (a) Persistence of responses to repeated provocation 2. (b) Fixed direction of nystagmus with rotary component 3. (c) Nonconcordant or divergent gaze 4. (d) Persistence of nystagmus, 30 seconds for each provocation

Answer 25

20. (b)A positive Dix-Hallpike test definitively establishes the diagnosis of benign paroxysmal positional vertigo (BPPV). The Dix-Hallpike maneuver is performed by quickly dropping a patient backwards from a sitting position so that the head is rotated 45 degrees and hangs over the edge of a mat. Characteristics of BPPV are mixed torsional and vertical nystagmus, which lasts for 10–20 seconds, associated with a sensation of rotational vertigo. Repetition of the test results in a reduction in the intensity of vertigo and nystagmus. The Epley maneuver, which is performed at the bedside, relocates debris from the posterior semicircular canal into the vestibule of the vestibular labyrinth.

Question 26

6. Which factor does NOT increase a person’s risk for hydrocephalus following traumatic brain injury? (a) subarachnoid hemorrhage (b) post traumatic seizures (c) intracranial infections (d) penetrating injury

Answer 26

21. (b)In communicating post-traumatic hydrocephalus, cerebral spinal fluid (CSF) absorption by the villi is impaired. This occurs with inflammation or subarachnoid hemorrhage.

Question 27

501. A 67-year-old patient with coronary artery disease suffered a stroke 1 week ago. His resting vital signs are: blood pressure 140/86, pulse 87 beats per minute, respiration 18 breaths per minute and oxygen saturation 97%. Which change in vital signs would warrant stopping a therapy session? 1. (a) Oxygen saturation 92% 2. (b) Diastolic blood pressure 110mmHg 3. (c) Systolic blood pressure 130mmHg 4. (d) Heart rate 105 beats per minute

Answer 27

22. (b)An increase in the diastolic blood pressure is indicative of an unstable cardiac condition. The other choices are normal responses to exercise.

Question 28

502. Which statement is TRUE regarding central nervous system (CNS) tumors? 1. (a) Meningiomas are the most common form of primary tumor 2. (b) Metastatic disease makes up approximately 50% of CNS tumors 3. (c) Glioblastoma multiforme has a median survival rate of 5 years 4. (d) Brain tumor treatment side effects do not affect outcome

Answer 28

23. (b)Meningiomas are the second most common form of primary tumors. Gliomas are the most common. Glioblastoma multiforme has a median survival rate of less than 1 year. Treatment side effects do affect outcome. Fifty percent of CNS tumors are metastatic.

Question 29

503. What isthe single largest indirect cause of traumatic brain injury? Falls Alcohol Motor vehicle accidents Polypharmacy

Answer 29

24. (b)Alcohol is believed to be involved in 60% of traumatic brain injury (TBI) cases. Polymedication is not a common indirect cause of traumatic brain injury. Motor vehicle accidents and falls are direct causes of TBI and not indirect.

Question 30

504. A 46-year-old woman was involved in a rear-end type motor vehicle accident in which she hit her head against the steering wheel and briefly lost consciousness. Her initial cognitive complaints have improved. She experiences 3 throbbing, unilateral headaches a week associated with nausea. These are graded 8/10 and last for 4 to 8 hours. Which medication would be most appropriate to prescribe? a. Intranasal butorphanol (Stadol) 1 spray 6 times daily b. Ibuprofen (Motrin) 600mg 4 times daily c. Sertraline (Zoloft) 100mg daily d. Valproic acid (Depakote) ER 500mg twice daily

Answer 30

25. (d)Divalproex sodium reduces the number and severity of migraine headaches. With 3 migraine-like headaches a week, prophylactic treatment for migraine is indicated. There is concern for developing dependence and abuse potential for butorphanol. Daily use of ibuprofen is more likely to result in rebound headaches when discontinued. There is no evidence that the selective serotonin release inhibitors are effective in the treatment of headache.

Question 31

505. Which diagnosis is associated with an increased risk of post-traumatic hydrocephalus? (a) Diffuse axonal injury (b) Subdural hematoma (c) Epidural hematoma (d) Subarachnoid hemorrhage

Answer 31

26. (d)Hydrocephalus is a well-recognized complication of subarachnoid hemorrhage. The fundamental abnormality in post-traumatic hydrocephalus is an imbalance in the production and absorption of cerebral spinal fluid (CSF). As the blood in the subarachnoid space obstructs the arachnoid villi it impairs absorption of CSF, thus causing hydrocephalus.

Question 32

506. What is the most common primary malignant tumor of the brain in adults? (a) Medulloblastoma (b) Meningioma (c) Glioblastoma multiform (d) Ependymoblastoma

Answer 32

27. (c)More than 90% of the primary malignant tumors of the brain in adults are **high-grade astrocytomas and, of these, the most common is glioblastoma multiform.** Meningiomas are tumors that occur in the membranes that cover and protect the brain and spinal cord (the meninges). Meningiomas usually grow slowly. Medulloblastomas are almost always found in children or young adults. Ependymoblastomas are rare cancers that usually occur in children.

Question 33

501. 26-year-old woman is admitted to the inpatient rehabilitation unit following a traumatic brain injury. She is confused, inappropriate, agitated, and requires a padded floor bed. What is her Rancho Los Amigos level? 1. (a) IV 2. (b) V 3. (c) VI 4. (d) VII

Answer 33

28. (a)The Rancho Los Amigos level IV applies to persons who are confused and agitated. The need of a padded floor bed indicates that the patient is restless and agitated.

Question 34

502. The mechanism of action of a phenol nerve block is 1. (a) reduction of calcium release from the sarcoplasmic reticulum. 2. (b) agonist action at alpha-adrenergic receptor sites. 3. (c) denaturation of protein in myelin sheaths and axons. 4. (d) inhibiton of presynaptic acetylcholine release.

Answer 34

c)Phenol acts as a neurolytic agent that denatures protein in myelin sheaths and axons. Dantrolene sodium (Dantrium) reduces calcium release from the sarcoplasmic reticulum. Tizanidine (Zanaflex) is an alpha-2 agonist. Botulinum toxin (Botox) inhibits acetylcholine release.

Question 35

503. In anoxic brain injury, which area of the brain is most susceptible to hypoxemia and hypotension? (a) Hippocampus (b) Pons (c) Basal ganglia (d) Cerebellum

Answer 35

30. (a)The mechanism of brain damage in anoxic brain injury is ischemia due to hypoxemia or decreased cerebral perfusion. Although anoxic brain injury typically causes diffuse neuronal death and injury, there is selective vulnerability of certain neurons. Neurons in parts of the hippocampus appear to be the most vulnerable, **which correlates with the high frequency of amnesia following anoxic brain injury.**

Question 36

501. In multiple sclerosis, which factor is associated with poor prognosis? 1. (a) Female sex 2. (b) Onset before age 30 years 3. (c) Positive Lhermitte sign 4. (d) Cerebellar involvement at onset

Answer 36

31. (d)Factors associated with poor prognosis in multiple sclerosis are: progressive course at onset, male sex, age at onset \>40 years, cerebellar involvement at onset, and multiple system involvement at onset. A positive Lhermitte sign (shocklike sensation down the spine, often into the limbs on neck flexion) is indicative of cervical myelopathy but has no prognostic significance.

Question 37

502. Which physical diagnosis finding is associated with poor functional outcome following stroke? (a) Loss of pinprick sensation (b) Prolonged flaccid period (c) Generalized increase in tone (d) Significant shoulder subluxation

Answer 37

32. (b)Factors associated with poor functional outcome following stroke include a prolonged flaccid period, severe proprioceptive deficits, late return of reflexes, and severe proximal spasticity.

Question 38

2. A 45-year-old man with left hemiparesis following a stroke complains of left shoulder pain with ambulation. Which of the following is the most probable cause? (a) Cervical radiculopathy (b) Impingement syndrome (c) Adhesive capsulitis (d) Shoulder subluxation

Answer 38

d)Inferior subluxation of the glenohumeral joint occurs frequently following stroke. Pain in the shoulder is often felt in the upright position, since gravity further aggravates the subluxation.

Question 39

34.Which pharmacologic agent should be avoided because of its cognitive side-effects in individuals with brain injury? (a) Metoclopramide (Reglan) (b) Omeprazole (Prilosec) (c) Erythromycin (E-Mycin) (d) Sucralfate (Carafate)

Answer 39

34. (a)The use of metoclopramide (Reglan) should be avoided because it is known to cause sedation and significant cognitive difficulties for individuals with brain injuries, especially for those regaining consciousness. It also has potential side effects of extrapyramidal movements and tardive dyskinesia. The other agents do not have significant cognitive effects on brain-injured individuals.

Question 40

2. In traumatic brain injury, magnetic resonance imaging (MRI) is preferred to computed tomography (CT) scan in the 1. (a) evaluation of acute brain injury. 2. (b) detection of subarachnoid hemorrhage. 3. (c) detection of epidural hematomas. 4. (d) evaluation of diffuse axonal injury.

Answer 40

35. (d)Magnetic resonance imaging (MRI) is considered better than computed tomography (CT) for evaluating diffuse axonal injury (DAI). A CT scan is superior to MRI for the detection of acute extra-axial hematomas, and in the evaluation of acute brain injury.

Question 41

3. The association of apolipoprotein-E (APOE-4) allele and history of traumatic brain injury increases the risk of developing (a) hydrocephalus. (b) alzheimer’s disease. (c) post-traumatic epilepsy. (d) cerebral neoplasms.

Answer 41

36. (b)Individuals with a history of traumatic brain injury (TBI) and apolipoprotein-E (APOE-4) allele have 10 times the risk of developing Alzheimer’s disease compared with 2 times the risk for APOE-4 allele alone and no increased risk with TBI alone.

Question 42

2. A 25-year-old man with a history of a traumatic brain injury is noted to have a marked functional decline from his normal level of functioning. You order a computed tomography (CT) scan, which reveals large ventricles with flattening of the sulci and periventricular lucency. You tell the family that a ventriculoperitoneal shunt (a) is emergently needed, and immediate referral to neurosurgery is indicated. (b) will not be helpful, because the findings on the CT scan are due to irreversible atrophy of brain tissue (hydrocephalus ex vacuo). (c) is not indicated, because he does not have the triad of incontinence, gait disorder, and dementia. (d) may be helpful, because about 50% of patients with post-traumatic brain injury hydrocephalus experience significant improvement.

Answer 42

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

Question 43

3. The largest change in bone mineral density in a hemiplegic patient 1 year after a stroke occurs in the (a) humerus on the paretic side. (b) proximal femur on the paretic side. (c) distal radius on the paretic side. (d) lumbar spine.

Answer 43

39. (a)In studies by Beaupre and Lew, and Ramnemark et al, the largest change in bone mineral density(BMD) is in the humerus on the paretic side (-17%), the next largest change was -12% in the proximal femur on the paretic side and -9% in the distal radius on the paretic side. No change in BMD was found in the lumbar spine

Question 44

4. A 23-year-old woman who is unresponsive after an acute traumatic brain injury can visually track. She periodically pushes the nurse’s hand away when the nurse administers a subcutaneous heparin injection. The patient is exhibiting (a) a coma state. (b) a minimally conscious state. (c) a vegetative state. (d) a sleep/wake cycle.

Answer 44

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

Question 45

2. You are seeing a 56-year-old male patient in consultation 3 days after a severe stroke. He is medically stable and has flaccid hemiplegia with poor sitting balance. He is sitting up in a chair for 2 hours twice daily and has just started bedside physical therapy (PT) and occupational therapy (OT). You recommend (a) continued bedside therapy with OT and PT, focusing on sitting balance, followed by transfer to your inpatient rehabilitation unit when he can sit and stand with minimum assistance. (b) transfer to your inpatient rehabilitation unit to start aggressive PT and OT. (c) transfer to a subacute rehabilitation center to allow the patient time to improve with less intensive therapy. (d) that his OT start functional electrical stimulation to the flaccid arm to enhance neurologic recovery.

Answer 45

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

Question 46

2. It is recommended that a patient with a first ischemic stroke who is positive for an antiphospholipid antibody be treated with: (a) aspirin, 325mg orally daily. (b) warfarin, with an INR goal of 3.0–3.5. (c) clopidogrel (Plavix), 75mg orally daily. (d) ticlopidine (Ticlid), 250mg orally twice daily.

Answer 46

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

Question 47

3. The most common benign brain tumor in adults is (a) astrocytoma. (b) oligoblastoma. (c) medulloblastoma. (d) meningioma.

Answer 47

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

Question 48

4. In patients with a traumatic brain injury, which factor suggests a poor prognosis for emergence from unresponsiveness? (a) Decorticate posturing (b) Flaccid muscle tone (c) Conjugate eye movement (d) Reactive pupils

Answer 48

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

Question 49

Which statement is TRUE regarding post-stroke central pain? (a) Damage to the thalamus plays a central role in the pathogenesis of central pain. (b) Amitriptyline is the drug of first choice to treat central pain. (c) 80% of stroke patients with central pain develop the pain within a month of their stroke. (d) The pain usually resolves spontaneously and does not require medication.

Answer 49

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

Question 50

2. A patient with a recent stroke and hemiplegia presents to your clinic and is noted to have a genu recurvatum gait pattern. An aggressive stretching program has improved ankle range-of-motion, but not her spasticity and gait. The most appropriate treatment is (a) an ankle foot orthosis with 5o of plantarflexion. (b) Achilles tendon lengthening. (c) phenol motor point injection to the hamstrings. (d) botulinum toxin injection to the gastrocsoleus muscle group.

Answer 50

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

Question 51

3. Which statement is TRUE about the relative responses of the brain and the spinal cord after concussive trauma? (a) The brain is more sensitive to trauma than the spinal cord. (b) The spinal cord is more sensitive to trauma than the brain. (c) The brain and the spinal cord are equally sensitive to trauma. (d) The brain’s neurologic recovery is less predictable than the spinal cord’s in its response to a given amount of trauma.

Answer 51

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

Question 52

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

Answer 52

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

Question 53

2. Rehabilitation strategies for addressing rigidity associated with Parkinson’s disease include (a) relaxation techniques with gentle stretching. (b) a strengthening program. (c) botulinium toxin injections. (d) oral baclofen.

Answer 53

49. (a) Relaxation techniques with slow, rhythmic rotational movements starting with passive range of motion distally and progressing proximally and then adding active range of motion is effective in decreasing rigidity.

Question 54

2. Y our patient with Parkinson’ s disease has sialorrhea. Initial treatment recommendations would include (a) a behavior modification program with speech therapy. (b) Robinul (glycopyrrolate) with meals. (c) Botox (botulinum toxin type A) to the salivary glands. (d) low dose Elavil (amitriptyline) at bedtime.

Answer 54

50. (a) A defective swallowing mechanism rather than excessive saliva production is the primary cause of drooling and the complaints of excessive drooling in Parkinson’s disease. A behavior modification program with frequent reinforcement may be effective in reducing drooling in Parkinson’s disease and should be used prior to medication or botulinum toxin therapy.

Question 55

3. Falls are common and often disabling in individuals with Parkinson’s disease. The risk of falls is increased in patients who (a) are taking nonsteroidal anti-inflammatory medication for pain. (b) are using a walker for ambulation. (c) have erratic arm swing with gait. (d) are taking benzodiazepines.

Answer 55

51. (d) Recurrent falls are more common in individuals with Parkinson’s disease who are taking benzodiazepines. Other risk factors are: history of falls, severe disease, poor balance, depression, and loss of arm swing with gait.

Question 56

A 59-year-old man with Parkinson’s disease is evaluated in your clinic. He complains of problems with rigidity, bradykinesia, tremor, and a functional decline in his activities of daily living. You order 1. (a) Mysoline (primidone) orally to decrease tremor and rigidity. 2. (b) botulinum toxin injections to decrease rigidity followed by occupational therapy with stretching program. 3. (c) occupational therapy with fluidotherapy to improve hand function and a stretching program. 4. (d) physical therapy with repetitive exercise and a home exercise program.

Answer 56

52. (d) A systematic program of physical therapy for Parkinson’s disease with repetitive exercise for 1 hour daily, 3 times a week for 4 weeks can significantly improve rigidity, bradykinesia, and activities of daily living, but not tremor. The improvements were not sustained if a regular home program of exercise was not continued.

Question 57

3. A 56-year-old man with cerebral palsy is evaluated in your clinic. He is noted to have a slow, writhing, worm-like movement in his arms. Which term correctly describes this movement? (a) Dystonia (b) Chorea (c) Myoclonus (d) Athetosis

Answer 57

53. (d) Athetosis is a continuous, slow writhing movement of the limbs or other body parts. It is important to differentiate athetosis from spasticity, because athetosis does not respond to antispasticity treatment. Chorea is characterized by brief, irregular contractions, which affect individual muscles as random events that seem to flow from one muscle to the other. Myoclonus manifests as rapid, shock-like or lightning-like jerks. Dystonia is a syndrome of sustained muscle contraction that frequently causes twisting and repetitive movements or abnormal postures.

Question 58

2. A 21-year-old woman presents for evaluation of hand tremors. They began when she was in mid adolescence but seem to be getting worse in college. She states that her writing is becoming less clear, and she reports difficulty in manipulating fine objects. She is studying to become an architect. In the review of systems, she mentions that wine lessens her tremors. Clinical examination is negative except for postural flexion/extension upper extremity tremors. Initial treatment would be 1. (a) botulinum toxin injections. 2. (b) observation with recheck in 6 months. 3. (c) a beta-noradrenergic blocker. 4. (d) high-frequency thalamic stimulation.

Answer 58

54. (c) Essential tremors, as described in this scenario, can develop in adolescence or in the fourth to fifth decades. Essential tremors are distiguished from parkinsonian tremors in that they are faster (7-10 Hertz, versus 4-7 Hertz) have more flexion/extension and less supination/pronation, and are not associated with bradykinesia, cogwheeling, or masked facies. Nonpharmacologic treatment consists of rest, decreasing central nervous system stimulants, and occasional use of situational alcohols. Medication would be started when activity of daily living skills are impaired, as in this case, with beta-noradrenergic blockers such as propranolol. Botulinum toxin would not be the initial treatment.

Question 59

3. You are on call and receive a page from the mother of a 23-year-old patient with a traumatic brain injury whose severe spasticity is managed by intrathecal baclofen (Lioresal). She reports that her son’s spasticity is getting worse over the last 24 hours, and he is complaining of whole body itching and a feeling like bugs crawling on his skin. He has developed nausea and just vomited. He had been doing well up until a day ago, and mom reports no rash on his skin. You tell her to (a) give him oral diphenhydramine (Benadryl) tablet for the itching and promethazine (Phenergan) for the nausea. You schedule him for the next available clinic to adjust his baclofen pump. (b) give him oral baclofen and bring him to the clinic the next day for further evaluation. (c) give him a diazepam (Valium) tablet and schedule him for clinic the next day for further evaluation. (d) give him oral baclofen and bring him to the emergency room for your further evaluation.

Answer 59

55. (d) Intrathecal baclofen withdrawal can be very serious and warrants immediate evaluation and management. The signs of baclofen withdrawal can be subtle with an intrathecal baclofen pump, but a sudden increase in spasticity and feeling ill wit**h whole body itching are seen with baclofen withdrawal.** Nausea and emesis is a warning of impending severe withdraw. **Prevention of severe spasticity and the sequelae of rhabdomyolysis** is critical to the health and welfare of the patient. The treatment is to restore intrathecal baclofen.

Question 60

56. A 19-year-old man with a traumatic brain injury 1 year ago and spastic hemiplegia is seen in your clinic. He has completed his outpatient rehabilitation program and is treated with antispasticity medication. He ambulates with a cane with minimal lower extremity tone, but his main problem is upper extremity spasticity. The best management option is 1. (a) occupational therapy with an aggressive stretching program. 2. (b) adjustment of his oral antispasticity medication. 3. (c) botulinum toxin injections of the upper extremity. 4. (d) placement of an intrathecal baclofen pump.

Answer 60

56. (c) A year out from his injury an aggressive stretching program and occupational therapy (OT) should have already been tried and oral antispasticity medication is managing his lower extremity tone well. Further OT and adjustment of medications are not likely to help. Intrathecal baclofen is more effective for lower extremity spasticity than for upper extremity spasticity. Botulinum toxin intramuscular injections can be quite effective when combined with a therapy program for upper extremity tone and spasticity.

Question 61

57. A 65-year-old woman has day-to-day memory problems and is concerned about possible Alzheimer’s disease. You explain that there are many causes of dementia and that some are reversible. The first step in evaluation of her declining mental function is a 1. (a) computed tomography scan of her brain. 2. (b) history and physical exam with cognitive screening. 3. (c) complete blood count and blood chemistry profile. 4. (d) trial of an antidepressant to treat an occult depression.57.

Answer 61

(b) As with all health problems, a workup for dementia must start with a history and physical exam. These findings will direct the rest of your dementia workup and treatment. Erythrocyte sedimentation rate and thyroid function studies should be added to her laboratory workup.

Question 62

A 65-year-old woman has Alzheimer’s disease and vascular dementia. What is the most effective way to protect her brain function? 1. (a) Cholinesterase inhibitor therapy 2. (b) N-methyl-D-aspartate (NMDA) antagonist Namenda (memantine) therapy 3. (c) Cholinesterase inhibitor and Namenda (memantine) therapy 4. (d) Treatment of cardiovascular risk factors

Answer 62

58. (d) Reducing cardiovascular risk factors, especially hypertension and hyperlipidemia, can decrease the risk of recurrent stroke and are important strategies in preventing or slowing the progression of mixed dementia.

Question 63

59. Which of the brain tumors listed is a benign tumor? 1. (a) Medulloblastoma 2. (b) Astrocytoma 3. (c) Glioblastoma 4. (d) Craniopharyngioma

Answer 63

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

Question 64

60. A 67-year-old man with Parkinson disease is experiencing more falls. These falls usually occur shortly after getting up in the morning, or after a large meal. You suspect his falls are due to 1. (a) vestibular dysfunction. 2. (b) orthostatic hypotension. 3. (c) increased lower extremity weakness. 4. (d) increased rigidity.

Answer 64

60. (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.

Question 65

62. A 19 year-old male is seen after a traumatic brain injury. The patient’s mother is at the bedside and is asking you questions about the patient’s prognosis for recovery. As you consider your response, which statement is TRUE? 1. (a) Severe disability is unlikely if the length of coma is less than 1 month. 2. (b) Good recovery is unlikely if posttraumatic amnesia (PTA) lasts longer than 3 months. 3. (c) An initial Glasgow Coma Scale score of less than 8 is associated with a poor outcome. 4. (d) Neuroimaging studies are not helpful to determine a patient’s prognosis.

Answer 65

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.

Question 66

63. Which type of traumatic brain injury results in the most morbidity? 1. (a) Focal cerebral contusion 2. (b) Subarachnoid hemorrhage 3. (c) Epidural hematoma 4. (d) Diffuse axonal injury

Answer 66

63. (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

Question 67

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

Answer 67

64. (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. Stage Description 1 Immediately following a stroke there is a period of flaccidity whereby no movement of the limbs on the affected side occurs. 2 Recovery begins with developing spasticity, increased reflexes and synergic movement patterns termed obligatory synergies. These obligatory synergies may manifest with the inclusion of all or only part of the synergic movement pattern and they occur as a result of reactions to stimuli or minimal movement responses. 3 Spasticity becomes more pronounced and obligatory synergies become strong. The patient gains voluntary control through the synergy pattern, but may have a limited range within it. 4 Spasticity and the influence of synergy begins to decline and the patient is able to move with less restrictions. The ease of these movements progresses from difficult to easy within this stage. 5 Spasticity continues to decline, and there is a greater ability for the patient to move freely from the synergy pattern. Here the patient is also able to demonstrate isolated joint movements, and more complex movement combinations. 6 Spasticity is no longer apparent, allowing near-normal to normal movement and coordination.

Question 68

65. For a patient with hemiplegia who prefers to use his legs and push his wheelchair backwards, the wheelchair should be configured with 1. (a) the back edge of the seat lower than the front edge. 2. (b) a single arm drive mechanism on the non-hemiplegic side. 3. (c) the large wheel axle plate moved to a more anterior position. 4. (d) large wheels in the front and casters in the back.

Answer 68

(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.

Question 69

66. Which statement about primary cerebral lymphoma is TRUE? 1. (a) It has an increased incidence in patients with (HIV) infection. 2. (b) It usually presents as a solitary tumor. 3. (c) It is treated surgically for improved outcome. 4. (d) It has a median survival of approximately 2 years.

Answer 69

66. (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.

Question 70

67. As its mechanism of action, botulinum toxin Ainactivates the calcium pump at the sarcoplasmic reticulum. B inhibits the troponin-tropomysin complex. Cinhibits the production of acethylcholine. D inhibits the release of acethylcholine.

Answer 70

67. (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.

Question 71

68. Which factor is a risk for heterotopic ossification in traumatic brain injury? (a) Late seizures (b) Prolonged coma (c) Male gender (d) Diabetes insipidus

Answer 71

68. (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.

Question 72

69. A patient presents with right hemiparesis and dysarthria but language and sensation are intact. The lesion is most likely in the (a) posterior limb of the internal capsule. (b) left frontoparietal lobe. (c) lateral pons. (d) thalamus.

Answer 72

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

Question 73

70. Your patient has a tremor of 5-8Hz, which is made worse with activity, and there is little or no tremor at rest. This finding best describes which type of tremor? (a) Parkinsonian (b) Essential (c) Enhanced physiological (d) Cerebellar

Answer 73

Commentary: An essential tremor is more prominent with activity (5-8Hz) and is diminished at rest. Stress exacerbates the tremor. The essential tremor can be confused with parkinsonian tremor. Essential tremor is more prominent with activity, while parkinsonian tremor is more prominent at rest, with a 4-5Hz frequency. There is also an absence of the other symptoms of parkinsonism such as loss of postural reflexes, rigidity and bradykinesia. Enhanced physiologic tremor is a high-frequency tremor that is most prominent with posture and action. It is exacerbated by anxiety, fatigue and many drugs. It can be seen with alcohol withdrawal. The cerebellar tremor has a frequency of about 3Hz and is mainly in a horizontal plane. It is most prominent with fine repetitive action of the extremities and is associated with other signs of cerebellar ataxia.

Question 74

Which drug is NOT associated with increased seizure risk in patients with traumatic brain injury? (a) methylphenidate (Ritalin) (b) ciprofloxin (Cipro) (c) amitriptyline (Elavil) (d) bupropion (Wellbutrin)

Answer 74

71. Answer: A Commentary: Methylphenidate and dextroamphetamine do not appear to be associated with increased seizure risk among patients with traumatic brain injury. However, **amitriptyline, bupropion and quinolones decrease seizure threshold.**

Question 75

2. Which electroencephalogram pattern is associated with a better prognosis after traumatic brain injury? 1. (a) Low amplitude delta activity 2. (b) Burst suppression 3. (c) Isoelectricactivity 4. (d) Spindle pattern

Answer 75

72. Answer: D Commentary: Favorable electroencephalogram (EEG) patterns after a traumatic brain injury are normal activity, rhythmic theta activity, frontal rhythmic delta activity, and spindle pattern. Poor prognosis is associated with epileptiform activity, nonreactive, low amplitude delta activity and burst suppression patterns with interruption of isoelectricity. Complete isoelectric EEG activity had the highest mortality.

Question 76

3. In a patient with traumatic brain injury who has impaired speed of processing, inattention and decreased arousal, which medication is regarded as first-line therapy? (a) modafinil (Provigil) (b) methylphenidate (Ritalin) (c) bromocriptine (Parodel) (d) carbidopa/levodopa (Sinemet)

Answer 76

Answer: B Commentary: The present evidence suggests that methylphenidate should be regarded as first-line therapy when an agent from this medication class is used. If methylphenidate proves ineffective Commentary: The present evidence suggests that methylphenidate should be regarded as first-line therapy when an agent from this medication class is used. If methylphenidate proves ineffective or produces intolerable side effects, dextroamphetamine, amantadine, or bromocriptine may be useful alternative stimulant medications. Amantadine’s side effect profile is worse than methylphenidate and there is some evidence of a lowering of the seizure threshold, but this is controversial. There is no support at this time in the literature for the use of modafinil over methylphenidate. Bromocriptine and carbidopa/levodopa both have worse side effects and are not as well studied as methylphenidate or amantadine.

Question 77

2. The physical therapist calls you concerning the patient with traumatic brain injury you admitted last week. She tells you that his bladder incontinence is disrupting therapy. You have checked his urinalysis and there is no evidence of a urinary tract infection. A postvoid residual bladder ultrasound shows that his bladder is emptying well. Your next step is to initiate (a) an anticholinergic medication. (b) in/out catheterization. (c) a condom catheter with a leg bag. (d) a behavioral modification program and timed voiding.

Answer 77

74. Answer: D Commentary: This patient is exhibiting normal bladder emptying with no evidence of a bladder infection. An anticholinergic in a patient with a traumatic brain injury may exacerbate his confusion. A condom catheter in this population will probably not stay in place. It may increase agitation and will not help the patient. Intermittent catheterization and a Foley catheter will increase the patient's infection risk. The best course at this time is frequent bladder emptying and retraining, with the entire rehabilitation team encouraging the new behavioral modification.

Question 78

2. The usual time of onset of diabetes insipidus in patients with traumatic brain injury is 1. (a) at time of injury. 2. (b) 10 days postinjury. 3. (c) 30 days postinjury. 4. (d) 3 months postinjury

Answer 78

75. Answer: B Commentary: Diabetes insipidus after TBI usually has an onset 10 days after trauma when the antidiuretic hormone (ADH) stored in the posterior pituitary is depleted.

Question 79

3. What is the most common medical complication during postacute stroke rehabilitation? 1. (a) V enous thromboembolism 2. (b) Falls 3. (c) Depression 4. (d) Pulmonary aspiration, pneumonia

Answer 79

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

Question 80

4. A 60-year-old woman had a stroke 1 week ago. On examination you find loss of pain-and- temperature sensation on the right side of her face as well as on the left side of her body. You also note some nystagmus, with right eye ptosis and miosis. What is the most likely location of the lesion? 1. (a) Lateral pons 2. (b) Frontoparietal lobe 3. (c) Lateral medulla 4. (d) Medial basal midbrain

Answer 80

Answer: C Commentary: A lesion in the lateral medulla causes Wallenberg syndrome and is associated with ipsilateral loss of facial pain- and temperature-sensation and contralateral loss of body pain-and- temperature sensation. Ipsilateral Horner syndrome (ptosis, miosis and anhidrosis) is found, as well as nystagmus, dysphagia and dysphonia

Question 81

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

Answer 81

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

Question 82

2. What is the main principle underlying the Bobath neurofacilitation techniques for rehabilitation? (a) Work from proximal to distal muscle groups. (b) Promote diagonal movement patterns. (c) Focus on multiple joint movements. Establish synergistic patterns.

Answer 82

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

Question 83

501. You perform an extraocular muscle exam of a patient with multiple sclerosis. You note that when looking to the right the left eye will not cross midline and she complains of diplopia when looking to the right but not straight ahead or to the left. You classify her findings as 1. (a) Parinaud syndrome . 2. (b) Horner syndrome. 3. (c) Internuclear ophthalmoplegia. 4. (d) Millard-Gubler syndrome.

Answer 83

80. Answer: C Commentary: Internuclear ophthalmoplegia (INO) is caused by a lesion in the medial longitudinal fasciculus (MLF) in the paramedian brainstem. It is characterized by impaired adduction of the contralateral eye with gaze toward the side of the lesion. In practice, an isolated case of INO is rare since the 2 sides of the MLF are very near the midline of the brain stem. The two most common causes of INO are multiple sclerosis and paramedian brain stem infarct. The Horner syndrome is due to a superior cervical sympathetic ganglion lesion and causes miosis, ptosis and anhydrosis. Parinaud syndrome causes impaired upward gaze with dilated and nonreactive pupils and is the result of a lesion in the midbrain, usually a pineal tumor. Millard-Gubler syndrome is due to an ipsilateral pons lesion causing ipsilateral palsy of cranial nerve (CN) 6 and CN 7 and a contralateral hemiparesis.

Question 84

502. You are consulted to see a young patient 3 days after the motor vehicle crash in which he sustained a traumatic brain injury. You note that he is not receiving nutritional support. In starting nutrition in this patient, which statement concerning enteral compared to parenteral nutrition is TRUE? (a) Enteral nutrition has a higher incidence of complications. (b) Parenteral nutrition is more likely to cause pneumonia. (c) Enteral access is easier to obtain at a higher cost. (d) No significant difference exists in measured nutritional parameters.

Answer 84

Answer: (d) Commentary: Early feeding of a person who has a traumatic brain injury is associated with fewer infections and a trend towards better outcomes in terms of survival and disability. Two trials reported the effect of route of feeding on the incidence of infection of any type, but both trials showed a trend towards more infection with parenteral nutrition (PN) than with enteral nutrition (EN). This difference might reflect catheter related infection with PN. In 3 trials reporting the effect of route of feeding on the occurrence of pneumonia, a trend towards reduced incidence of pneumonia was found in the PN group. Although it is easier to provide PN than it is to obtain adequate EN access, EN has a decreased incidence of complications and lower cost compared to PN, with no significant differences in measured nutritional parameters. Also, providing nutrition to the intestine can stimulate gut immune function and limit deterioration of the intestinal mucosa characteristic of bacterial translocation and its potential for contributing to sepsis.

Question 85

503. A 23-year-old woman with a traumatic brain injury from a motor vehicle crash is seen in clinic 1 year after her injury. She is in a minimally conscious state and still requires total assistance with all her activities of daily living. The family wants to pursue treatment with hyperbaric oxygen therapy (HBOT). You advise them, that HBOT can (a) reduce the size of the injury to the brain. (b) cause short-term visual disturbances. (c) increase the incidence of mortality. (d) improve the functional outcome.

Answer 85

Answer: (b) Commentary: Hyperbaric oxygen therapy (HBOT) delivers 100% oxygen under pressure, which increases the amount of oxygen dissolved in the blood, thereby increasing the oxygen delivered to the body tissues. HBOT may also enhance the formation of new blood vessels, decrease inflammation, and increase the volume of blood flow. Treatment sessions occur inside a sealed, pressurized space known as a hyperbaric chamber. The oxygen is delivered either by mask or directly into the chamber. The pressures used are expressed in units of atmospheric pressure and commonly range from 1.5 to 3 atmospheres. The sessions last from 30 to 90 minutes and many practitioners recommend 100 sessions (range, 80-150 sessions). The cost ranges from $200 to $400 per session. HBOT is not FDA approved for treatment of traumatic brain injury. A number of more minor complications may occur due to HBOT. V**isual disturbance, usually a reduction in visual acuity secondary to conformational changes in the lens, is common.** While the great majority of patients recover spontaneously over a period of days to weeks, a small proportion of patients continue to require correction to restore sight to pretreatment levels. **The second most common adverse effect associated with HBOT is aural barotrauma.** Barotrauma can affect any air-filled cavity in the body (including the middle ear, lungs and respiratory sinuses) and occurs as a direct result of compression. There is limited evidence that HBOT reduces the chance of dying following a traumatic brain injury. There is little evidence that more survivors have a good outcome. Thus, the routine adjunctive use of HBOT in these patients cannot be justified. Because evidence of lesion resolution or change in size of persistent defect obtained by magnetic resonance imaging (MRI) or computed tomography (CT) has not been studied, there is no evidence to suggest this occurs.

Question 86

2. Which statement concerning the use of prophylactic antiepileptics in the management of patients with traumatic brain injury is TRUE? (a) They decrease the functional disability of the injury. (b) They reduce the occurrence of late seizures. (c) They reduce the incidence of death. (d) They reduce the occurrence of early seizures.

Answer 86

83. Answer: (d) Commentary: There is no evidence that prophylactic antiepileptic medications, used at any time after head injury, reduce death and disability. Evidence exists that prophylactic antiepileptics reduce early seizures, but there is no clinical evidence that late seizures are reduced, or that treatment has any effect on death or neurological disability.

Question 87

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

Answer 87

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

Question 88

2. You are consulted to see a 19-year-old woman with a traumatic brain injury after a motor vehicle crash 2 days ago. She is unconscious even though the computed tomography scan of her brain is normal. The most likely cause is (a) diffuse axonal injury. (b) cerebral contusion. (c) arterial vasospasm. (d) epidural hemorrhage.

Answer 88

85. Answer: (a) Commentary: The initial computed tomography and magnetic resonance imaging scans taken soon after injury are often normal. Only 10% of patients with diffuse axonal injury (DAI) demonstrate the classic CT findings of DAI. These are hemorrhagic punctate lesions of (1) the corpus callosum, (2) the gray-white matter junction of the cerebrum, and (3) the pontine- mesencephalic junction.

Question 89

What is the most frequent presenting symptom of brain metastasis? 1. (a) Focal weakness 2. (b) Headache 3. (c) Seizure 4. (d) Visual disturbance

Answer 89

86. Answer: (b) Commentary: Presenting symptoms at the time of diagnosis with brain metastasis, in order of decreasing frequency, are as follows: (patients can have more than a single symptom): headache, 49%; mental disturbance, 32%; focal weakness, 30 %; gait ataxia, 21 %; seizures, 18%; speech difficulty, 12%, visual disturbance, 6%; sensory disturbance, 6%; and limb ataxia, 6%.

Question 90

Which modifiable risk factor MOST increases the relative risk of stroke? 1. (a) Smoking 2. (b) Hypertension 3. (c) Hypercholesterolemia 4. (d) Diabetes mellitus

Answer 90

87. Answer: (b) Commentary: Hypertension, defined as a systolic pressure greater than 165mmHg, or a diastolic pressure greater than 95mmHg, increases the relative risk of stroke by a factor of 6. The Framingham study has confirmed that smoking is independently associated with stroke. The relative risk for heavy smokers (more than 40 cigarettes a day) is twice that of light smokers (fewer than 10 cigarettes a day). Cessation of smoking reverses the risk to that of nonsmokers within 5 years of quitting. Hypercholesterolemia has not been epidemiologically linked to increased stroke incidence, but its strong influence on atherosclerosis makes it an indirect risk factor. Diabetes mellitus increases the relative risk of stroke by 3 to 6 times the general population.

Question 91

Which statement concerning management of seizures after a traumatic brain injury is TRUE? (a) All patients with postresuscitation Glasgow Coma Scale score below 12 require 3 months of an antiepileptic medication. (b) Seizures occurring less than 24 hours postinjury require an antiepileptic medication for at least 12 months. (c) Seizures occurring 24 hours to 7 days postinjury should be treated with at least 12 months of an antiepileptic medication. (d) Seizures occurring more than 7 days postinjury should be treated with an antiepileptic medication for at least 3 years.

Answer 91

88. Answer: (c) Commentary: The American Academy of Physical Medicine and Rehabilitation and the American Association of Neurological Surgeons recommend seizure prophylaxis after a traumatic brain injury as standard treatment. All patients with postresuscitation Glasgow Coma Score (GCS) below 12 require 7 days of therapeutic phenytoin sodium. Immediate posttraumatic seizures (defined as those occurring within 24 hours postinjury) do not require any additional prophylaxis after 7 days. Early (more than 24 hours but less than7 days) seizures should be treated with at least 12 months of an antiepileptic medication, unless a time-limited intracranial abnormality such as hydrocephalus, infection, or active hemorrhage, etc., was the cause. Late seizures -- those occurring more than 7 days postinjury -- should be treated with an antiepileptic medication for at least 12 months. Any seizure that lasts longer than 2 minutes is defined as “status epilepticus” and warrants treatment with an antiepileptic medication for at least 12 months.

Question 92

Which statement is TRUE of pseudodementia? 1. (a) Usually a history of previous psychiatric problems exists. 2. (b) Onset is indistinct with a long history of problems before consultation. 3. (c) Memory loss of recent items is worse than for remote items. 4. (d) Nocturnal accentuation of dysfunction is common.

Answer 92

89. Answer: (a) Commentary: Distinguishing dementia from pseudodementia (which is really depression) is important, in order to provide appropriate treatment to your patient with memory problems. Pseudodementia’s onset is fairly well demarcated with a short history and is rapidly progressive in nature. These patients usually have a history of a previous psychiatric difficulty or a recent life crisis. Their complaints of cognitive dysfunction are detailed and elaborate with an affective change and the patients expend little effort on examination items. Nocturnal exacerbations are rare and memory loss is inconsistent in recall of recent and remote items. Dementia’s onset, in contrast, is indistinct with a history of problems long before they seek clinical help and early deficits often go unnoticed. A history of previous psychiatric problems or emotional crisis is uncommon. These patients struggle with cognitive tasks but usually put forth good effort. Nocturnal dysfunction is common. The memory loss on recent items is worse than for remote items and there is a consistent impairment of performance.

Question 93

3. A 20-year-old man sustained a severe traumatic brain injury and a femur fracture 1 week ago. Magnetic resonance imaging reveals a diffuse axonal injury with no evidence of hemorrhage or a hematoma. His condition is stable 1 day after open reduction, internal fixation of the femur fracture and he is nonweight bearing on that leg. What is the appropriate recommendation for deep venous thrombosis prophylaxis in this patient? (a) Placement of a vena cava filter (b) Sequential compression devices (c) Graded compression stockings (d) Low molecular weight heparin sodium

Answer 93

90. Answer: (d) Commentary: Prophylaxis for deep vein thrombosis (DVT) should be considered in all patients with a traumatic brain injury after acute admission to the hospital. Graded compression stockings are of little benefit. Thigh high intermittent compression devices help reduce DVT risk but are not an appropriate primary prophylaxis. A vena cava filter is not appropriate prophylaxis and chemical prophylaxis is needed as soon as feasible. In patients who are not fully ambulatory in 24 hours unfractionated heparin sodium is adequate and can be used 12 hours after surgery. However, in all patients who have long-bone fractures, prior DVT, or more than 4 total risk factors, low molecular weight heparin sodium should be used until the patient is fully mobilized.

Question 94

2. Neuromuscular electrical stimulation to treat shoulder subluxation after stroke should be applied to which muscles? 1. (a) Deltoid and supraspinatus 2. (b) Supraspinatus and infraspinatus 3. (c) Deltoid and trapezius 4. (d) Subscapularis and infraspinatus

Answer 94

91. Answer: (a) Commentary: Neuromuscular electrical stimulation (NMES) to the deltoid (mainly posterior) and the supraspinatus can decrease subluxation and reduce shoulder pain. It is required for several hours daily over several weeks to achieve clinical benefits.

Question 95

3. Of the following modalities, which is the most effective in treating phantom limb pain? ## Footnote (a) Iontophoresis (b) Transcutaneous electrical nerve stimulation (c) Short wave diathermy (d) Paraffin baths

Answer 95

Answer: (b) Commentary: Of the options listed, transcutaneous electrical nerve stimulation (TENS) is the modality that may be useful in treating phantom limb pain. Iontophoresis is generally used for dispersion of medications. Short wave diathermy is a method of deep heat. Paraffin bath is a superficial heat modality.

Question 96

Basal skull fracture with involvement of the sella turcica. What is the complication? A) diabetes insipidus B) diplopia C) homonomous hemianopsia D) central fever

Answer 96

Answer: A The pituitary gland rests in the sella turcica. With involvement of the sella, diabetes insipidus can occur from damage to the posterior pituitary with interruption of ADH secretion. Other complications from damage to the pituitary gland include impotentence, reduced libido, and amenorrhea.

Question 97

1. What aphasia is characterized by impaired comprehension, intact fluency, and inability to repeat? A) Broca’s B) Wernicke’s C) transcortical motor D) transcortical sensory

Answer 97

b

Question 98

2. Which of the following is a lacunar syndrome? A) dysarthria-clumsy hand syndrome B) Wallenberg’s syndrome C) locked-in syndrome D) Anton’s syndrome

Answer 98

Answer: A Lacunar infarcts are small subcortical infarcts caused by the occlusion of a single deep penetrating artery. Lacunes make up 15-25% of all ischemic strokes in the U.S. Incidence increased with age with the mean age of 65 years. Risk factors include hypertension and diabetes mellitus. Lacunes have a more favorable prognosis than nonlacunar strokes. There are 5 lacunar syndromes. Pure Motor Stroke • most common lacunar syndrome (33-50%) • located in the posterior limb of internal capsule, basis pontis, pyramyids • usually affects face, arm, and leg equally • transient sensory symptoms (but not signs) may be present • may have dysarthria and/or dysphagia Pure Sensory Stroke • located in thalamus • persistent or transient numbness and/or tingling on one side of body • occasional complain of burning or pain Ataxic Hemiparesis • second most common lacunar syndrome • located in the posterior limb of internal capsule, basis pontis, corona radiata, cerebellum • weakness and clumsiness on one side of body • affects leg \> arm Dysarthria-Clumsy Hand • located in anterior limb of internal capsule, pons • dysarthria and clumsiness and/or weakness of the hand Mixed Sensorimotor Stroke • located in thalamaus, posterior limb internal capsule • hemiparesis with ipsilateral sensory involvement Ref: www.emedicine.com: Lacunar Stroke; PM&R Secrets: p 168; Braddom 2nd Edition: p 1131

Question 99

3. TBI patient on Restoril for sleep and Paxil for depression. Restoril was discontinued and Elavil started. Patient developed myoclonus, hyperreflexia, and agitation. What is the cause? A) benzodiazepine withdrawal B) serotonin syndrome C) NMS

Answer 99

Answer: B Serotonin syndrome typically develops within hours or days of the addition of a new serotonergic agent (i.e. TCA) to a medication regimen that already includes serotonin-enhancing drugs (i.e. SSRI). It may also develop when a new serotonergic agent is started following the recent discontinuation of another serotonergic drug without allowing an adequate washout period. Isolated overdoses of SSRIs can also cause the syndrome. Symptoms attributed to serotonin excess may include restlessness, hallucinations, shivering, diaphoresis, shivering, nausea, diarrhea, HA. Signs of serotonin excess are variable and can be subdivided into the following 3 categories: o Mental status changes - Confusion, agitation, coma o Neuromuscular findings - Myoclonus, rigidity, tremors, hyperreflexia (tends to be more prominent in the lower than the upper extremities), clonus, ataxia o Autonomic instability - Hyperthermia (excessive heat generation may develop secondary to prolonged seizure activity, rigidity, or muscular hyperactivity), mydriasis, tachycardia, blood pressure alterations (hypertension, hypotension) SS produces a clinical picture that is very similar to neuroleptic malignant syndrome (NMS). Both syndromes are associated with autonomic dysfunction, alteration of mental status, rigidity, and hyperthermia. Clinical differentiation between these syndromes is very important because management may differ. For example, chlorpromazine may be of some benefit in SS, whereas it may cause further deterioration in NMS. Distinctions between the two syndromes include the following: o NMS develops in association with neuroleptics, whereas SS develops in association with serotonergic agents. o NMS has a slow onset (days to weeks) and a slow progression of 24-72 hours, whereas SS has a more rapid onset and progression. o NMS is associated with bradykinesia and lead pipe rigidity, whereas SS is associated with hyperkinesia and less rigidity. o NMS is an idiosyncratic reaction to therapeutic doses, whereas SS is a manifestation of toxicity, frequently generated from the combination of two drugs with serotonergic activity Ref: www.emedicine.com: Serotonin Syndrome

Question 100

. Which is a measure of disability (question says impairment) in stroke? A) Barthels Index B) FIM C) Rapport Scale D) Glasgow Outcome Scale

Answer 100

Answer: B FIM is a functional assessment tool used to evaluate both physical (ADL, transfers, mobility) and cognitive (communication, social cognition) disabilities which are often present in stroke patients. The Barthel Index only examines physical components and is not as sensitive as the FIM to minor changes at higher levels of functioning (i.e. cooking, housekeeping, socialization). The Glasgow Outcome Scale is the most commonly used measure of outcome in brain injury research. (sorry, I couldn’t figure out what the Rappaport is) ## Footnote Ref: Braddom 2nd Edition: p 155-158, 1081; Practical Manual of PM&R (Tan): p 95

Question 101

24. Which cranial nerve is most commonly involved in a posterior cerebral artery (PCA) aneurysm? A) CN III B) CN VI C) CN VII D) CN XII

Answer 101

Answer: A Third nerve palsy (ptsosis, diplopia, dilatation of pupil, and divergent strabismus) usually indicates an aneurysm at the junction of the posterior communicating artery (PComA)-ICA junction and less often an aneursym at the PComA-posterior cerebral artery junction. CN III passes immediately lateral to the PComA-ICA junction (see Netter plate 132) Ref: Adams Principles of Neurology 7th Edition: p 890-891; Netter p 132

Question 102

25. What is the most common cause of unconsciousness after (during?) the first 24 hours of injury? A) diffuse axonal injury B) depressed skull fracture C) intracranial hemorrhage D) vasospasm

Answer 102

Answer: A Coma and unconsciousness are caused by the disruption of input to surface brain structures from deeper structures that subserve arousal and wakefulness. Diffuse axonal injury (DAI) is the hallmark lesion of TBI and typically a result of acceleration-deceleration and rotational forces. DAI is primarily responsible for initial LOC and preferentially disrupts fiber at the junction of the gray and white matter in the cortex, and in the corpus callosum, corona radiata, and cerebral and cerebellar peduncles. Epidural hematoma occurs secondary to a temporal or parietal skull fracture with laceration of the middle meningeal artery or vein. The injury may not produce coma initially but a few hours to a day later (longer if venous bleeding), severe headaches, vomiting, confusion, neurology deficits, and eventually coma ensues. The time between the initial injury and delayed coma is called the “lucid interval”. Ref: Pocketpaedia: p 54; Braddom 2nd Edition: p 1085; Adams Principles of Neurology 7th Edition: p 937

Question 103

26. What is the most common site for a cerebral contusion? A) orbital frontal lobe B) temporal lobe C) occipital lobe D) parietal lobe

Answer 103

Answer: A Contusions typically occur in the inferior frontal and anterior temporal lobes where the adjacent skull surfaces are irregular. (I chose answer A because it gives a specific location in the frontal lobe whereas answer B does not specify where (i.e. anterior) in the temporal lobe). Ref: PM&R Secrets: p 195; Pocketpaedia: p 54; Braddom 2nd Edition: p 1074

Question 104

27. An athlete gets hit in the head and sees “stars” for 5 minutes. 15 minutes later, he is asymptomatic. When can he return to play? A) now B) 30 minutes C) next game D) next week

Answer 104

Answer: A There was no LOC and symptoms lasted for less than 15 minutes so the athlete has suffered a grade I concussion. According to the American Academy of Neurology (AAN) guidelines, after a single grade I concussion, the athlete may return to play after being asymptomatic with normal neurologic exam at rest and with exercise after 15 minutes (i.e. now). AAN Return to Play Guidelines Grade Criteria Return to Play \*\* I No LOC Transient confusion Symptoms \< 15 minutes 15 minutes (single) 1 week (multiple) II No LOC Transient confusion Symptoms ≥ 15 minutes 1 week (single) 2 weeks (multiple) III Any LOC, either brief (seconds) or prolonged (minutes) 1 week (brief LOC) 2 weeks (prolonged LOC) ≥ 1 month (multiple) \*\* after being asymptomatic with normal neurologic exam at rest and with exercise Ref: Braddom 2nd Edition: p 1107

Question 105

41. What should be included in a dementia workup? A) TSH B) magnesium C) cholesterol D) homosysteine

Answer 105

Answer: A Baseline evaluation for dementia should include a CBC, standard chemistries, VDRL, TSH, and vitamin B12 level. Syphilis, vitamin B12 deficiency, and thyroid disease are potentially treatable causes of dementia. ## Footnote Ref: Cecils Essentials of Medicine 4th Edition: p 800

Question 106

43. Long term use of Didronel can cause which of the following? A) pathologic fracture B) decrease mineralization following surgery C) osteopenia D) dissolve bone formed by HO

Answer 106

``` Answer: B Etidronate disodium (Didronel) is a bisphosphonate which inhibits growth of hydroxyapatite crystals by preventing the precipitation of calcium phosphate. It also slows the rate of osteoclastic and osteoblastic activity. It cannot dissolve any bone already formed by HO; however, may prevent recurrence of HO after resection (no good studies; radiation and NSAIDs more effective?). Didronel carries a potential risk of bone fracture secondary to osteomalacia when used for prolonged periods. It can also inhibit mineralization of bone after surgery. ``` ## Footnote Ref: PDR 2002: p 2888; Essentials of PM&R: p 574; PM&R Clinics of North America 1992: 3(2) p 411-413; Pocketpaedia: p 88

Question 107

59. What drug should be avoided in the TBI population? A) Reglan B) Ritalin C) Amantadine D) Lovenox

Answer 107

Answer: A Reglan should be avoided in the TBI population because it can impair cognition. Other classes of medications to be avoided include benzodiazepines, phenothiazines / neuroleptics (i.e. Haldol), central sympathetic inhibitors / centrally acting antihypertensives (i.e. clonidine), and anticonvulsants (i.e. Dilantin) as they may limit the recovery of the brain-injured patient or induce mental status changes. ## Footnote Ref: PM&R Secrets: p 434, 502

Question 108

63. What is a Ranchos Los Amigos score of 3? A) confused-agitated B) localized response C) generalized response D) confused-inappropriate

Answer 108

Answer: B A patient with a Ranchos score of 3 has exhibits localized responses. The patient has spontaneous, purposeful movements but follows commands only inconsistently. Ranchos Los Amigos Medical Center Level of Cognitive Functioning Level Name Description I No response Deep sleep; no response to any stimulation II Generalized response Gross movements in response to noxious stimulation III Localized response Spontaneous, purposeful movements; follows commands inconsistently IV Confused-agitated Confused, amnestic, inattentive; may be aggressive V Confused-inappropriate Confused and amnestic but not agitated VI Confused-appropriate ↓ initiative and problem solving; functions with structure and supervision VII Automatic-appropriate Follows daily routines; need supervision for home and community skills VIII Purposeful-appropriate Independent with home/community skills; may have cognitive deficits Ref: Braddom 2nd Edition: p 1086

Question 109

64. What is a Ranchos Los Amigos score of 5? A) confused and appropriate B) confused and inappropriate C) confused and agitated D) localized response

Answer 109

Answer: B A patient with a Ranchos score of 5 is confused and inappropriate. The patient is amnestic but not agitated. See answer to Question 63.

Question 110

76. Which of the following stroke modalities utilizes cutaneous tapping to facilitate movement? (NYU 2003 Part II #6) A) Rood B) Bobath C) Knott & Voss D) PNF

Answer 110

Answer: A The Rood method (sensorimotor approach) relies on peripheral input of cutaneous sensory stimulation in the form of superficial brushing and tendon tapping, to facilitate or inhibit motor activity. The Bobath method (neurodevelopemental technique (NDT)) emphasizes inhibition of abnormal tone, postures, and reflex patterns while facilitating automatic motor responses that will eventually allow the performance of skilled voluntary movements. Patients are taught “reflex inhibiting patterns” and are guided by therapists from “key points of control” (proximal areas such as shoulder, pelvic girdles) to inhibit abnormal motor activity. Kabat and Voss method (proprioceptive neuromuscular facilitation(PNF)) uses spiral and diagonal movement patterns (as opposed to traditional movement in the cardinal planes) with the goal of facilitating movements that have more functional relevance than those achieved through traditional techniques of strengthening individual muscle groups. The movement patterns do not inhibit abnormal reflex activities. Brunnstrom method utilizes limb synergy patterns and primitive reflexes that are present during the recovery process after a CNS insult. Patients are taught to voluntarily control the motor patterns available to them and these are incorporated into simple to complex movements with functional relevance. Ref: PM&R Secrets: 171-172; Tan: p 172-173

Question 111

87. Which Bladder condition is most commonly associated with TBI?

Answer 111

Answer- Detrusor Hypereflexia ## Footnote Lesions above the pontine micturition center (head injury, MS, CVA, brain tumor) would lead to detrusor hyperreflexia because of the lack inhibitory effect of the cerebral cortex on the sacral (parasympathetic) micturition center. There would be no sphincter dyssynergic because of the intact pontine micturition center. Reference: Kessler Notes 2003, Lecture 43, Neuroanatomy, Physiology, Treatment of the Bladder