Stroke
A 63 year-old male presents following a cerebrovascular insufficiency event. He exhibits right hemiparesis, and his left eye appears to be gazing down and out (inferiorly and laterally). His left eyelid droops. There is no aphasia or cognitive deficit. Which of the following is the most likely diagnosis?
A Locked-In syndrome
B Middle cerebral artery stroke
C Wallenberg syndrome (lateral medullary syndrome)
D Weber syndrome (medial midbrain lesion)
D Weber syndrome (medial midbrain lesion)
This patient suffers from classic Weber syndrome (medial midbrain stroke). This syndrome involves contralateral hemiparesis and ipsilateral cranial nerve 3 palsy (the affected eye shows ptosis and “down and out” gaze). Brain stem strokes such as Weber syndrome do not exhibit cognitive deficits or aphasia as a result of the stroke.
In the context of traumatic brain injury (TBI), diffuse axonal injury refers to which of the following processes?
A Chronically impaired cognitive processes following a TBI
B Secondary injury
C Toxic neurotransmitter surge following a TBI
D Intracranial axonal shear force injury secondary to a physical blow to the head
D Intracranial axonal shear force injury secondary to a physical blow to the head
Diffuse axonal injury (DAI) is defined as shear force injury to the white matter of the brain and brainstem (where axonal tracts are located) as a direct result of a traumatic physical force to the head/brain.
In SCI patients, the most common time to onset of heterotopic ossification following injury is:
A 24 hours
B 72 hours
C.1 to 4 months
D.6 months
C 1 to 4 months
The most common onset is 1-4 months, but can be present up to the first 6 months
Which of the following braces is most appropriate for a patient with severe plantarflexion spasticity? AFO: ankle-foot orthosis. KAFO: knee-ankle-foot orthosis.
A KAFO
B Rigid AFO
C Posterior leaf spring (PLS)
D Semirigid AFO
B Rigid AFO
A rigid AFO is also called a solid AFO, and prevents any motion at all of the ankle and foot; this is most useful in cases of severe spasticity that needs to be controlled more firmly with a rigid orthosis. PLS and semirigid AFOs are more useful if severe spasticity is not present, as the spasticity will inappropriately overpower these orthoses. A KAFO is useful in cases of impaired muscular control of the knee and ankle, not the ankle alone.
You are rounding at a skilled nursing facility when a 67 year-old male with a past medical history of acute ischemic right middle cerebral artery (MCA) stroke presents with medial left knee pain. He is currently undergoing rehabilitation at this facility following his stroke 2 weeks ago. On examination, he exhibits 3/5 strength throughout the left lower extremity with diminished sensation to light touch. His patellar and achilles reflexes are trace. The pain is aching, nonradiating, and is worsened during ambulation with a walker, and improved with rest, acetaminophen, and ibuprofen. His therapy progress has been limited by this pain.His left knee hurts when palpating its medial aspect. X-rays demonstrate moderate medial compartment narrowing in the left knee. Which of the following is the next best step in treatment?
A Intraarticular corticosteroid injection
B Gabapentin
C Duloxetine
D Physical therapy
A Intraarticular corticosteroid injection
This patient who is currently rehabilitating post-stroke is expected to have residual left-sided weakness and sensory dysfunction. Patients with stroke may also experience neuropathic pain, also known as central neuropathic pain. Neuropathic pain is classically described as burning or electric, but does not necessarily carry these features. An important point to remember is that patients with neurologic disease still develop “routine” musculoskeletal conditions just as the rest of the population does. In this case, the patient exhibits classic features of pain related to left knee medial compartment osteoarthritis. Treatments for osteoarthritis involve physical therapy (already underway in this case), oral pain medications (already being attempted), intraarticular steroid or viscosupplementation injection, or total knee replacement, in addition to more advanced nerve-based procedures. This patient is currently limited in therapy progress by his knee pain, for which oral pain medications have remained insufficient. Intraarticular left knee corticosteroid injection is indicated, assuming no contraindications. There is no evidence of central neuropathic pain taking place in this patient; thus, duloxetine and gabapentin are not as good of answer choices as joint injection.
You are asked to evaluate a patient in the ED with sudden-onset right hemiplegia and right facial droop. On examination you note intact fluency, impaired comprehension, and intact repetition. This patient’s language disorder can be classified as:
A Transcortical sensory aphasia
B Transcortical motor aphasia
C Wernicke (receptive) aphasia
D Conduction aphasia
A Transcortical sensory aphasia
In transcortical motor or transcortical sensory aphasia, the patient can repeat. In Broca and Wernicke aphasia, the patient cannot repeat. Once you’ve narrowed it down to transcortical motor or transcortical sensory aphasia, remember that transcortical motor is otherwise similar to Broca (expressive) aphasia, while transcortical sensory is otherwise similar to Wernicke (receptive) aphasia.
You are called to see a patient in the neurological ICU who suffered a traumatic brain injury. Their labs are remarkable for hypovolemia, hyponatremia, decreased serum osmolality, and elevated urine osmolality. What is the most likely diagnosis?
A SIADH
B Cerebral Salt Wasting
C Diabetes Insipidus
D Hypothyroidism
B Cerebral Salt Wasting
SIADH and CSW cause hyponatremia while DI and hypothyroidism do not. The hallmarks of substantial CSW are hyponatraemia, reduced volume status and inappropriately high renal sodium loss.
The most common location of pressure ulcers in individuals with spinal cord injury during the first month post-injury is:
A Trochanter
B Sacrum
C Heel
D Occiput
B Sacrum
Some degree of pressure ulcer development occurs in 30-50% of patients with new SCI during the first month post-injury. The sacrum is the most common location of these ulcers.
Which of the following will assist plantarflexion of an ankle-foot orthosis (AFO)?
A Spring placed in the posterior channel
B Pin placed in the posterior channel
C Spring placed in the anterior channel
D Pin placed in the anterior channel
C Spring placed in the anterior channel
In an AFO, a pin placed in the anterior channel will prevent dorsiflexion. A spring in the anterior channel will assist plantarflexion (will not prevent dorsiflexion, but will assist the opposite movement - plantarflexion). A pin in the posterior channel will prevent plantarflexion. A spring in the posterior channel will assist dorsiflexion.
A 77 year-old female presents to your office complaining of progressive weakness, rigidity, slowed mobility, and falls. On examination you note minimal facial movement when interacting with her, as well as a 5 Hz tremor in her right hand at rest. She follows with a neurologist who has gradually increased oral medications for this condition, but this has been of minimal benefit. What is the next best step?
A Deep brain stimulator
B Increase levodopa-carbidopa
C Start propranolol
D Start amantadine
A Deep brain stimulator
A patient with Parkinson Disease who fails oral medications should be considered for a deep brain stimulator to the subthalamic nucleus
A patient experiences a sudden-onset severe headache with nausea and vomiting while performing a heavy deadlift. He is rushed to the ED where the ED physician documents the patient with headache, neck stiffness, mild left hemiparesis, and confusion. What is the most appropriate Hunt and Hess score for this patient?
A 4
B 3
C 2
D 1
B 3
The Hunt and Hess scale for subarachnoid hemorrhages can be simplified as follows: Grade 1: roughly asymptomatic (potentially mild symptoms) with no neurologic deficits. Grade 2: Severe headache, neck stiffness are present with no major neurologic deficit or confusion. Grade 3: Headache, neck stiffness, confusion, with focal neurologic deficit. Grade 4: Extremely confused (think heavily inebriated), headache, neck stiffness, with severe focal neurologic deficit. Grade 5: coma.
A 50 year-old male is admitted following a motor vehicle accident (MVA). He is diagnosed with a traumatic brain injury (TBI). On MRI of his brain you note focal white matter changes involving the medulla. What grade of diffuse axonal injury (DAI) would you assign to this patient?
A 4
B 3
C 2
D 1
B 3
DAI is graded on MRI criteria. A simplified grading method is as follows: Grade 1 = lobar white matter changes on MRI. Grade 2 = central white matter (corpus callosum) changes on MRI. Grade 3 = brainstem involvement.
When considering menstrual function and pregnancy in women with SCI:
A After a period of amenorrhea, menstruation returns but long-term fertility is significantly reduced
B Amenorrhea is common in early stage of SCI; menstruation often returns within 6 months.
C Amenorrhea is uncommon; menstruation is rarely interrupted by a spinal cord injury
D Amenorrhea is common after SCI and in most women persists great than 1 year
B Amenorrhea is common in early stage of SCI; menstruation often returns within 6 months.
Amenorrhea is a common complication following spinal cord injury, affecting 41-85% of patients. Menstruation returns within 6 months after acute spinal cord injury in 50% of women, and about 90% of women with spinal cord injury recovered normal menstrual cycles within 12 months after injury. Once normal menstruation resumes, women can become pregnant with sexual intercourse with similar success rates as the general population.
Which of the following orthoses would be most appropriate for a patient with 27 degrees of thoracic scoliosis?
A Milwaukee brace
B Jewett brace
C Minerva jacket
D Knight-Taylor brace
A Milwaukee brace
The Milwaukee brace is essentially a cervicothoracolumbosacral orthosis (CTLSO) whose function is to correct a scoliotic curve by maintaining postural control of essentially the entire spine. It must be worn at all times, except for bathing, and is typically indicated for a scoliotic curve between 20-40 degrees. The Jewett and Knight-Taylor braces are TLSOs that are most useful in preventing thoracic hyperflexion, notably after suffering from a vertebral body compression fracture. The Minerva jacket is useful in cases of unstable cervical spine fractures, not scoliosis.
A collegiate runner presents to you with pain overlying the tuberosity of the 5th metatarsal. You are concerned for a possible Jones fracture, but X-ray and MRI are both negative for fracture. Tendonitis of which muscle is the likely culprit for pain overlying the tuberosity of the 5th metatarsal?
A Tibialis posterior
B Tibialis anterior
C Fibularis brevis
D Fibularis longus
C Fibularis brevis
Pain along the lateral aspect of the foot, specifically overlying the base or tuberosity of the 5th metatarsal, should prompt consideration of fibularis brevis tendinopathy. This tendon inserts onto the 5th metatarsal tuberosity. This is the same anatomic location that should alarm clinicians to the possibility of a Jones fracture. The fibularis longus tendon inserts onto the medial cuneiform and 1st metatarsal bone. The tibialis anterior tendon inserts onto the medial cuneiform bone and the base of the first metatarsal bone. The tibialis posterior tendon inserts primarily onto the navicular bone.
In the Brunnstrom stages of recovery from hemiparetic stroke, at what stage does the patient develop peak spasticity?
A 5
B 4
C 3
D 2
C 3
The Brunnstrom hemiparetic stroke recovery stages are as follows: ○1 = totally flaccid ○2 = spasticity, hyperreflexia, UE flexor synergy pattern, LE extensor synergy pattern ○3 = spasticity peaks; control over synergy patterns begins ○4 = spasticity decreases; control is maximized ○5 = complex voluntary movements ○6 = spasticity gone ○7 = normal
A 36 year-old male is involved in an MVA and sustains a TBI. He loses consciousness immediately following the accident. What do you expect to see on his brain MRI?
A Abnormal central white matter signal
B Abnormal motor cortex signal
C Abnormal occipital lobe signal
D Abnormal parietal lobe signal
A Abnormal central white matter signal
This patient with impaired consciousness and documented MVA with TBI is at highest risk of having sustained diffuse axonal injury (DAI), which classically causes central white matter abnormalities due to the traumatic forces causing sudden shearing forces upon the white matter axons of the brain, classically within the central white matter, such as the corpus callosum or the brain stem.
Which of the following is the most common cause of spinal cord injury in children?
A Falls
B Violence/child abuse
C Motor vehicle accident
D Sports
C Motor vehicle accident
Similar to adults, motor vehicle accidents are the most common cause of spinal cord injury in children, followed by violence/child abuse and sports. Violent etiology increases during adolescence, especially among Hispanic and African-American adolescence.
A patient with a traumatic bilateral transtibial amputation status post bilateral transtibial prostheses would be expected to ambulate with which of the following energy costs of ambulation above normal?
A 80% above normal
B 60% above normal
C 40% above normal
D 20% above normal
C 40% above normal
Energy costs of ambulation as a percentage above normal values for various traumatic amputation levels are as follows: Unilateral transtibial amputation: 20%. Bilateral transtibial: 40%. Unilateral transfemoral: 60%. Bilateral transfemoral: 200%. These values are approximations and will vary depending on the patient.
A 30 year-old female presents to your clinic with complaints of 1 month of right wrist pain. Her pain is constant, severe, and only mildly relieved with ibuprofen. She gave birth to her new baby daughter 6 weeks ago. She denies numbness or tingling. On exam, strength is intact. When tucking the thumb into the palm and making a fist, then ulnarly deviating the wrist, the patient experiences sudden-onset exquisite pain that reproduces her usual wrist pain. What is the most appropriate next step?
A Ultrasound-guided injection
B Continue ibuprofen, add acetaminophen and ice
C Reassurance
D Orthopedic surgery consult
A Ultrasound-guided injection
This patient with a positive Finkelstein test as noted in the question stem, has findings highly suspicious for 1st extensor compartment tenosynovitis, or De Quervain Tenosynovitis (inflammation of the abductor pollicis longus and/or extensor pollicis brevis tendon sheath). This commonly occurs in new mothers who are spending a lot of time straining their wrists, holding their new baby. If conservative measures have failed, such as oral over the counter medications, and/or the pain is constant and severe, then ultrasound-guided corticosteroid injection into the tendon sheath (not the tendon itself!) is indicated, and is highly effective for this disease.
The most common etiology for ischemic stroke in children is:
A Cardiac disease
B Vascular malformation
C Arteriopathy
D Factor V Leiden
C Arteriopathy
Arteriopathy is the most common cause of arterial ischemic stroke in children. Cardiac disease (congenital or acquired) and prothrombotic conditions (such as Factor V Leiden) are also causes of ischemic stroke in children. Arteriovenous malformations are a common cause of hemorrhagic (not ischemic) stroke in children
You are called to the bedside on PM&R consult service rounds to examine a brain injury patient. The patient exhibits open eyes. He follows no commands. He does appear to maintain sleep-wake cycles on EEG. When you pinch his arm, he flexes his elbow. How would you define this patient’s arousal status?
A Traumatic brain injury (TBI)
B Vegetative state
C Minimally conscious state
D Coma
B Vegetative state
In short, coma is defined as closed eyes, no sleep/wake cycles on EEG, and no purposeful behavior or comprehension. In vegetative state, the patient does have sleep/wake cycles on EEG, and eyes are open, but there is no purposeful activity, only reflexive actions. Minimally conscious state is defined as open eyes, presence of sleep-wake cycles on EEG, and inconsistent awareness of the environment with purposeful behaviors. When this becomes consistent, the patient is said to have “emerged” and is considered to exhibit “normal” arousal at that point, or to at least not possess a disorder of consciousness (DOC).
What is the recommended minimum duration for anticoagulation prophylaxis in a patient with a complicated complete spinal cord injury?
A 2 weeks
B 8 weeks
C 12 weeks
D 6 months
C 12 weeks
Anticoagulation should be continued for 8 weeks in a patient with uncomplicated complete motor injury (AIS A and B) and for 12 weeks for those with complete Motor injury and other risk factors (e.g. lower limb fractures, a history of thrombosis, cancer, heart failure, obesity or age over 70). Patients with AIS C SCI should receive chemoprohylaxis for up to 8 weeks, and those with ASI D injuries should receive chemoprohylaxis while remaining in the hospital.
Which of the following is the most common type of amputation?
A Transfemoral
B Transtibial
C Transradial
D Transmetatarsal
D Transmetatarsal
Of those listed, transmetatarsal amputations are the most common. Consider that in lower limb amputations, dysvascular disease (the most common cause of lower limb amputations) tends to affect the limb distally > proximally.
Which of the following describes the primary difference between massage and myofascial release?
A Massage generally does not improve myofascial pain, whereas myofascial release does
B Myofascial release emphasizes the use of sustained pressure and stretch on the target muscle
C Myofascial release is preferred over massage for muscle strains
D Massage generally feels good; myofascial release generally hurts
B Myofascial release emphasizes the use of sustained pressure and stretch on the target muscle
The correct answer is that myofascial release emphasizes the use of sustained pressure and stretch on the target muscle and its surrounding fascia in order to more permanently release a myofascial bundle from its contracted, painful state. If “muscle strain” is all the info we are given, and asked to select between using massage vs. myofascial release, massage may be the superior option, as it may speed healing of muscle strains, whereas sustained stretch of already-torn muscle may worsen an existing muscle tear. The remaining two answers are subject to personal opinion.