Stroke
1. A 79-year-old female presents to outpatient rehabilitation services 6 weeks following a CVA with right hemiplegia. She complains of right shoulder pain with most upper extremity movements and has severe shoulder pain when practicing bed mobility activities such as rolling and scooting. On examination, it is observed that the humeral head is inferiorly displaced. Which of the following would be the MOST appropriate for her condition?
A. Transcutaneous electrical nerve stimulation (TENS)
B. Functional electrical stimulation (FES)
C. Short wave diathermy (SWD)
D. Interferential current (IFC) stimulation
A. TENS is a powerful modality that will treat pain in many individuals. This woman does complain of pain, but the impairment of an inferiorly displaced humeral head is also mentioned. TENS will have little effect on this displacement.
B. This is the correct answer. Using FES to help elevate her shoulder will treat the displacement and ideally eliminate the source of pain.
C. SWD is a pain relief modality that is not used often.
D. IFC is another form of TENS, and will not help much with the displaced humeral head.
A physical therapist evaluating a 66 year old female who has a history of severe head trauma following a motor vehicle accident. The patient has difficulty with rapid alternating movements while performing neurologic testing. What is the BEST term to describe this specific impairment?
A. Ataxia
B. Dysmetria
C. Dysarthria
D. Dysdiadochokinesia
A. Ataxia is a global term comprising inaccuracy and decomposition of movement. Although this encompases many forms of movement impairments, it is too general to describe difficulty with rapid alternating movement.
B. Dysmetria is defined as a decreased ability to judge distance and range.
C. Dysarthria is defined as a motor impairment involving the muscles used in speech and breathing.
D. This is the correct answer. By definition, dysdiadochokinesia is an impairment specifically involving rapid alternating movements, such as pronating and supinating one’s hands quickly.
A physical therapist is conducting an initial examination with a patient who has an incomplete spinal cord injury. The physical therapist assesses proprioception of the right ankle during their sensory testing and finds it to be absent. WHICH spinal tract is affected?
A. Dorsal column medial lemniscus
B. Lateral corticospinal
C. Medial corticospinal
D. Spinothalamic
A. This is the correct answer. The dorsal column medial lemniscus relays light touch and conscious proprioception in the spinal cord.
B. The lateral corticospinal tract relays motor information from the motor cortex through the spinal cord to the distal extremities.
C. The medial corticospinal tract relays motor information from the motor cortex through the spinal cord to the proximal muscles of the trunk and extremities.
A. The spinothalamic tract relays pain and temperature information in the spinal cord.
Your patient is a 60 y/o male with Parkinson's Disease. You are unsure of what Hoehn-Yahr stage he is. In order to assess his function and help determine what stage he might be in, what outcome measure would be BEST?
A. Mini BESTEST
B. Timed Up-and-Go
C. 2-minute Walk Test
D. FGA
A. This is the correct answer. This is the most recommended outcome measure for patients with PD as it assesses anticipatory and reactive balance, sensory orientation, and dynamic gait.
B. Although this is a great test for patient's with PD, it is not likely to pick up deficits unless the patient is a stage III or later. Furthermore, the mini BESTEST includes the TUG in its assessment.
C. This test is suitable for assessing a patient's endurance; however, it is not helpful for getting an idea of a patient's Hoehn-Yahr stage.
D. This test is helpful for assessing a patient's dynamic gait; however, it is not helpful for getting an idea of a patient's Hoehn-Yahr stage. Furthermore, the mini BESTEST includes a section for dynamic gait in its assessment.
You are completing an evaluation on a 34 y/o patient with primary complaints of dizziness. She states that gets dizzy any time she is getting out of bed and bending down. When performing the Dix-Hallpike test to the right, you note right torsional, up-beating nystagmus that lasts about 75 seconds. What is the proper diagnosis?
A. Canalithiasis of right anterior canal
B. Canalithiasis of right posterior canal
C. Cupulolithiasis of right anterior canal
D. Cupulolithiasis of right posterior canal
A. Anterior canal canalithiasis would cause down-beating nystagmus and would last less than 60 seconds.
B. Posterior canalithiasis would cause up-beating nystagmus, however, it would last less than 60 seconds.
C. Nystagmus lasting longer than 60 seconds does indicate cupulolithiasis, however, cupulolithiasis of the anterior canal would cause down-beating nystagmus.
D. This is the correct answer. It would most likely be cupulolithiasis due to the extended period of nystagmus (more than 60 seconds) and up-beating nystagmus is indicative of the posterior canal being affected.
A patient presents to the inpatient rehabilitation unit who has suffered a vertebro-basilar CVA and has difficulty adducting and depressing his eyes. Which cranial nerve (CN) is the MOST likely cause of this impairment?
A. CN I
B. CN II
C. CN III
D. CN IV
A. CN I is the olfactory nerve. It is a sensory nerve that controls the sense of smell.
B. CN II is the optic nerve, which is a sensory nerve that controls the sense of vision. It does not control the motor movements of the eye.
C. CN III is the oculomotor nerve. It innervates the Medial, superior, and inferior rectus muscles as well as the inferior oblique. These muscles will turn the eye up, down
D. This is the correct answer. CN IV is the trochlear nerve. It innervates the superior oblique. Difficulty adducting and depressing the eye is indicative of Trochlear nerve involvement.
Your patient is a 22 y/o male who you are evaluating for a concussion after a football injury occurred the previous day. Which of the following would be considered a red flag that would warrant further imaging?
A. An episode of vomiting on the field after the injury
B. Dizziness
C. A consistent headache since the injury
D. Loss of consciousness that lasted one hour after injury
A. Vomiting is only considered a red flag if it is repeated vomiting.
B. Dizziness is a common symptom of concussion and it not considered a red flag.
C. Headache is a common symptom following a concussion and is only considered a red flag if it is increasing in intensity.
D. This is the correct answer. LOC is considered a red flag, and a LOC more than 30 minutes may indicate a moderate severity TBI.
A 35 year old patient with a complete T5 spinal cord injury is working on supine to sit transfers on the mat table when he suddenly appears flushed and complains of his heart pounding. Upon examination, his blood pressure is 180/100 mmHg and he has a pounding headache. What is the most appropriate INITIAL course of action?
A. Lay the patient supine and notify the patient’s physician.
B. Sit the patient up and notify the patient’s physician.
C. Allow the patient to rest longer between sets of activity.
D. Initiate core strengthening exercises to maintain intraabdominal pressure.
A. This is not correct because putting the patient in supine will exacerbate the autonomic dysreflexia.
B. This is the correct answer. By sitting the patient up, you decrease the blood pressure in the head and mitigate the effects of the dysreflexia.
C. This is incorrect considering that autonomic dysreflexia is a life-threatening condition.
D. This is incorrect considering that autonomic dysreflexia is a life-threatening condition and intra-abdominal pressure drop is not going to address this condition
You are completing an evaluation on a patient who you suspect might have Parkinson's Disease. Which of the following would be a considered a red flag indicative of Parkinsonism rather than true Parkinson's?
A. Freezing of gait
B. Early cognitive deficits
C. Urinary incontinence
D. History of one fall
A. Freezing of gait is characteristic of PD and is not considered a red flag unless combined with frequent falls early in the disease OR urinary incontinence and cognitive impairment (normal pressure hydrocephalus)
B. This is the correct answer. PD can cause cognitive impairments, but it typically occurs later in the disease process. This could be a sign of Alzheimer's or Lewy-Body Dementia.
C. Urinary incontinence is a common symptom with PD. It is only considered a red flag when combined with freezing of gait and cognitive impairments.
D. Falls are common in PD. It would be considered a red flag if the falls were frequent early on in the disease course.
You are treating a 49 y/o male who has been hospitalized secondary to an upper respiratory infection. He has been treated with streptomycin. Although his infection appears to have been cleared, he has recently began complaining of dizziness. He denies any changes in hearing. What is the likely cause of his dizziness?
A. Meniere's Disease
B. Acoustic Neuroma
C. Ototoxicity
D. Labyrinthitis
A. Meniere's disease is caused by endolymph build up in the inner ear. Patients will also often complain of tinnitus or "fullness" in the ear.
B. Acoustic neuroma is a tumor on the vestibulocochlear nerve. patients will often complain of tinnitus or hearing loss.
C. Ototoxicity is caused by medications, which is likely the cause of the patient's dizziness in this case. It is also the most likely as he is not experiencing changes in hearing.
D. Labyrinthitis is spontaneous, but made worse by head movements. Patients will often complain of hearing loss and tinnitus.
A patient with a stroke affecting the right middle cerebral artery has difficulty walking, especially over uneven surfaces. Which of the following describes the MOST appropriate initial treatment to improve the patient’s ability to walk over uneven surfaces?
A. Place a single point cane in the patient’s left hand and train him to use a step-to gait pattern.
B. Place a single point cane in the patient’s right hand and train him to use a step-to gait pattern.
C. Fit the patient with a 4-wheeled walker and instruct him to use a 4-point gait pattern.
D. Fit the patient with axillary crutches and instruct him to use a 4-point gait pattern.
A. This answer is correct except for the hand placement. With a stroke in the right MCA, the patient’s left side will be affected, requiring the cane to be in the right hand.
B. This is the correct answer. The question indicates that the patient has difficulty with uneven surfaces, implying that even surfaces are not as difficult. Thus using a SPC with a swing-to gait pattern would be the most correct initial treatment.
C. This answer is a distractor. You cannot use a 4-wheeled walker to create a 4-point gait pattern.
D. Axillary crutches would be a possibility; however, the 4-point gait pattern is typically used for individuals with a very low tolerance of ambulation and would not be ideal for traversing uneven terrain. Also, it is not specified, but stroke patients often have both the lower extremity and upper extremity affected, making it difficult to negotiate axillary crutches.
You are treating a patient with a TBI who is classified as Ranchos Los Amigos Level VI. Which of the following motor learning strategies is appropriate for this patient?
A. Distributed practice
B. Open environment
C. Intrinsic feedback
D. Random practice
A. This is the correct answer. Distributed practice is ideal in this stage because these patients are more susceptible to mental and physical fatigue.
B. Open environment would be considered a progression; initially, it is important to start a patient with a TBI in a closed environment to limit distractions.
C. Extrinsic feedback is more beneficial than intrinsic feedback early on due to cognitive impairments.
D. Random practice is not ideal with these patients as they are able to relearn tasks, but not learn new tasks.
A patient who has suffered a cutting injury to the entire left half of the spinal cord at the T8 level is being examined by a physical therapist. Which of the following impairments would be MOST apparent on the ipsilateral lower extremity?
A. Loss of pain and temperature sensation
B. Loss of movement and light touch sensation
C. Loss of peripheral smooth muscle control
D. Loss of coordination and accuracy.
A. This would be lost on the contralateral lower extremity due to the decussation of these sensory afferent fibers.
B. This is the correct answer. These pathways decussate in the brain stem.
C. This is not correct at all since arterial smooth muscle relies wholly on adrenergic receptors.
D. This would be caused by an injury at the cerebellar level.
You are working on gait training with a patient diagnosed with Parkinson's Disease. Which of the following motor learning strategies would be most appropriate for this patient?
A. Random practice
B. Distributed practice
C. Part practice
D. Blocked practice
A. Random practice could be a progression, but is not recommended when beginning gait practice.
B. High repetition is recommended rather than distributed practice for patients with PD.
C. Part practice, or breaking a task down into parts, is not feasible with gait training.
D. This is the correct answer. Patients with PD benefit from blocked practice and high repetition.
You are performing an evaluation on a patient with complaints of dizziness. In your evaluation, you perform the head impulse test and notice a corrective saccade when thrusting the patient's head to the left. No saccade is noted when thrusting the patient's head to the right Which of the following is the patient's most likely diagnosis?
A. Right unilateral hypofunction
B. Left unilateral hypofunction
C. Bilateral hypofunction
D. Vestibular disease of central origin
A. The patient most likely has a unilateral hypofunction; however, a right hypofunction would cause a corrective saccade when the head is turned to the right.
B. This is the correct answer. The side in which the head is turned when the corrective saccade is made is the side of the hypofunction.
C. Bilateral hypofunction would cause a corrective saccade with the head impulse test in both directions.
D. A negative head impulse test could potentially indicate a vestibular disease of central origin rather than a positive test.
A patient presents with complaints of blurry vision and double vision. Cranial nerve examination revealed the inability of the right eye to move upward, medially, inferiorly, or downward when adducted. The right eye was able to move laterally and inferiorly when it’s adducted. Where is the possible lesion location?
A. Occipital lobe
B. Midbrain
C. Pons
D. Medulla
A. The patient's symptoms are caused by a lesion to CN III and IV, which is not located in the occipital lobe.
B. This is the correct answer because CNs III and IV are the nerves affected and they both exit through the midbrain.
C. CN VI is located in the pons, but testing to this nerve (lateral movement) revealed no abnormalities.
D. Only CNs IX, X, and XII exit the medulla, which are not affected in this patient.
You are treating a patient with a severe TBI in the hospital setting. You notice in his chart that his most recent ICP level was 17 mmHg. What should your next action be?
A. Perform only PROM as his ICP is high and mobility is contraindicated.
B. Notify the doctor immediately as his ICP level is considered a medical emergency.
C. Hold off on therapy for the day and wait to see if his ICP level decreases.
D. Continue with therapy as planned, this is a normal ICP level.
A. Any therapy at this time is contraindicated as the ICP level is above 15 mmHg.
B. It is not necessary to notify the doctor as ICP level is not considered a medical emergency unless > 20 mmHg.
C. This is the correct answer. Therapy is contraindicated as the ICP level is above 15 mmHg.
D. Therapy at this time is contraindicated as the ICP level is above 15 mmHg.
You are treating a 73 y/o female with a complete SCI. In right side lying, which of the following areas is MOST susceptible to skin breakdown?
A. Left fibular head
B. Left lateral malleolus
C. Right patella
D. Right medial malleolus
A. The left fibular head would only be susceptible to skin breakdown in left side lying.
B. The left lateral malleolus would only be susceptible to skin breakdown in left side lying.
C. The right patella would be most susceptible to skin breakdown in prone.
D. This is the correct answer. The right medial malleolus is at risk for skin breakdown due to its contact with the left medial malleolus.
You are treating a patient with Parkinson's Disease who is classified as Hoehn-Yahr stage V. Which of the following would be considered an appropriate intervention?
A. PROM to all extremities
B. Functional transfer training
C. Gait training
D. Sitting balance on edge of bed
A. This is the correct answer. PROM is necessary for preventing contractures as patients in this stage are bed and wheelchair-bound.
B. Functional transfer training is appropriate for stages II-IV rather than V.
C. Gait training is not feasible as these patients are bed and wheelchair-bound.
D. Balance training is appropriate for stages II-IV rather than V.
You are treating a patient with complaints of dizziness. After performing the Dix-Hallpike, you note that the patient has left posterior canalithiasis. Before proceeding with treatment, you assess their cervical ROM and determine they have 90 degrees of rotation to each side. Which of the following treatments is most appropriate for this patient?
A. Semont maneuver
B. Bar-B-Que treatment
C. Canalith repositioning maneuver
D. Gufoni maneuver
A. Semont maneuver can treat canalithiasis, however, it is primarily used for patients with limited cervical rotation.
B. Bar-B-Que is used to treat canalithiasis of the horizontal canal rather than the posterior canal.
C. This is the correct answer. Also known as the Epley, this is used to treat canalithiasis of either the anterior or posterior canals for patients who have normal cervical ROM.
D. Gufoni maneuver is used to treat canalithiasis or cupulolithiasis of the horizontal canal rather than the posterior canal.
Your patient is a 72 y/o female who presents to you post-stroke. Your examination findings reveal she has vertigo, nausea, vomiting, dysphagia, and dysarthria. Sensory examination reveals loss of pain and temperature sensation of the left side of her face and the right side of her body. Where is the likely location of her stroke?
A. Right pons
B. Right medulla
C. Left pons
D. Left medulla
A. A pontine stroke does not cause dysphagia or dysarthria; other expected findings with a right pontine stroke include right facial paralysis, decreased salivation, decreased tears, and right-sided deafness.
B. A right medullary stroke would cause loss of pain and temperature sensation over the right side of the face and the left side of the body
C. A pontine stroke does not cause dysphagia or dysarthria; other expected findings with a left pontine stroke include left facial paralysis, decreased salivation, decreased tears, and left-sided deafness.
D. This is the correct answer. A left medullary stroke would cause loss of pain and temperature sensation over the left side of the face and right side of the body as well as the other listed symptoms.
You are treating a patient with a TBI in the ICU. You notice that his BP has increased to 180/98, his HR is 158 bpm, and he is profusely sweating at rest. He is also lying in supine with all of his extremities in extension. You decide to alert the nurse because you recognize that this patient is most likely experiencing which of the following?
A. Dysautonomia
B. Autonomic dysreflexia
C. DVT
D. Seizure
A. This is the correct answer. Dysautonomia, also known as sympathetic storming or neurostorming, occurs in 8-33% of those with a TBI in the ICU and can cause hypertension, tachycardia, and diaphoresis as well as hyperthermia, decerebrate/decorticate posturing, hypertonia, and teeth grinding.
B. Autonomic dysreflexia can cause HTN and diaphoresis, but it occurs in SCI patients and causes bradycardia rather than tachycardia.
C. DVT is a common complication following TBI due to immobility, but S/S would not cause decerebrate posturing.
D. Seizures are common post-TBI, but would not cause the S/S noticed in this patient.
You are prescribing an assistive device and orthotics for a 26 y/o patient with an ASIA A SCI at the level of T12. You plan to prescribe them bilateral forearm crutches for household ambulation. Which of the following orthotics and gait pattern would the highest level the patient could achieve?
A. KAFOs with a swing-through gait pattern
B. AFOs with a swing-through gait pattern
C. KAFOs with a swing-to gait pattern
D. AFOs with a swing-to gait pattern
A. This is the correct answer. A patient with an ASIA A SCI at the level of T12 has innervation to abdominal muscles, so they would be able to utilize a swing-through gait pattern as opposed to a swing-to. KAFOs would be more appropriate as they do not have innervation to LE muscles.
B. AFOs would not be appropriate as the patient does not have innervation to knee flexors/extensors.
C. Although the patient could utilize a swing-to gait pattern, they would be able to achieve a swing-through gait pattern due to abdominal innervation and would allow for faster ambulation.
D. See B and C for real
You are treating a 80 y/o patient with Parkinson's Disease in an outpatient clinic. The patient is performing aerobic exercise on a stationary bike while you monitor his HRmax. Which of the following is an appropriate target HR for this patient?
A. 70 bpm
B. 98 bpm
C. 112 bpm
D. 126 bpm
A. 70 bpm is 50% of this patient's HRmax. The target HRmax for a patient with PD is moderate intensity, or 60-75% HRmax.
B. This is the correct answer. 98 bpm is 70% of this patient's HRmax, which is within the target range for moderate intensity.
C. 112 bpm is 80% of this patient's HRmax, which is outside of the target range and is considered high intensity.
D. 126 bpm is 90% of this patient's HRmax,which is outside of the target range and is considered high intensity.
You are treating a patient with a unilateral hypofunction using gaze stabilization. You have been performing VORx1 in sitting and with the letter on a blank wall. Which of the following would be considered the next appropriate progression?
A. Perform the same exercise while walking toward the target on an uneven surface
B. Perform the same exercise in standing
C. Perform the same exercise with the target on a window overlooking a busy street
D. Perform the same exercise with the patient standing closer to the target
A. This is considered a progression, however, it is too advanced to go from sitting to walking on an uneven surface.
B. This is the correct answer. Transitioning from sitting to standing is an appropriate progression as it makes the exercise slightly more difficult by challenging the patient's balance.
C. This is considered a progression, however, it is too advanced to go from a blank background to a background as busy as this.
D. This would be considered a regression as it is easier to perform the exercise closer to the target.