Pediatric Rehab 2001-2009

PEDIATRIC REHAB
SAE Questions 2001-2009
Sunday, January 17, 2010

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

9. The most useful clinical criterion to distinguish Becker
muscular dystrophy from Duchenne
muscular dystrophy is
(a) creatine kinase values at the time of diagnosis.

(b) walking ability during the teen-age years.
(c) Gowersʼ sign and calf enlargement.
(d) age at onset of diagnosis

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

19. The leading cause of childhood disability is
(a) traumatic brain injury.
(b) spinal muscular atrophy.
(c) spina bifida.
(d) cerebral palsy.

19. (d)
Cerebral palsy is the leading cause of childhood disability. The
reported incidence is approximately 2-3 per 1,000 live births.
The incidence of spina bifida is 0.5 per 1,000
spinal muscular atrophy 1 in 25,000.
The annual incidence for traumatic brain injury in children is 1-2

per 1,000. However,
the great majority of cases are minor and result in no long-term
disability. Approximately 15% of
brain-injured children have moderate and severe injuries resulting in
permanent impairment.

29. The earliest weakness seen in skeletal muscle in
Duchenne muscular dystrophy is located in
(a) knee extensors.

(b) hip flexors.
(c) neck flexors.
(d) ankle plantar flexors.

29. (c) Neck flexor weakness occurs during preschool
years. Weakness is generalized but is predominantly
proximal early in the disease course.
Pelvic girdle weakness precedes shoulder girdle weakness by

several years. Weakness progresses steadily. Quantitative
strength testing is more sensitive than
manual muscle testing.

39. The most common complication after amputation in the
immature child is
(a) phantom limb pain.

(b) diffuse edema.
(c) terminal overgrowth.
(d) painful neuroma.

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

49. In children hospitalized with acute burns, early
management should include
(a) avoidance of sedation.

(b) positioning for comfort to reduce severe pain.
(c) use of a pressure garment over areas of full-thickness
burns.
(d) administration of narcotics and anesthetic agents.

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

the position that promotes deformity and, therefore, should be
avoided.
Garments are fitted later in

the course of treatment.

59. In considering selection of a lower limb prosthesis for a
child with a congenital transfemoral amputation, a knee joint
should be included
(a) at initial fitting.
(b) between 3 to 5 years of age.
(c) when sports activities are anticipated.
(d) when the child pulls to stand.

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

69. The earliest marker of abnormal central nervous system
maturation is
(a) diffuse fasciculations.
(b) gross motor delay.
(c) delay of postural responses.
(d) persistence of primitive reflexes.

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

earliest markers of abnormal neurologic
maturation.

79. A parent of an 18-month-old child reports that the child
babbled as an infant but became much quieter after about 8
months of age. She has no true words, though she will wave
bye-bye. She follows no verbal commands but will follow
occasional pantomime commands. Her gross and fine motor
skills have been normal. The most likely diagnosis is
(a) autism.
(b) mental retardation.
(c) hearing impairment.
(d) oral motor apraxia.

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

99. The most severe form of mental retardation in cerebral
palsy occurs in association with
(a) spastic diplegia.
(b) ataxia.
(c) spastic quadriplegia.
(d) athetosis.

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

childhood disability

Also:
Spastic diplegic cerebral palsy occurs most commonly in premature

infants who have had an intraventricular hemorrhage during the neonatal
period.
Intrauterine stroke causes hemiplegia.
Neonatal hyperbilirubinemia most commonly causes athetosis.
Birth asphyxia is more commonly associated with spastic quadriplegic

cerebral palsy.

139. Following severe traumatic brain injury, neuroendocrine
dysfunction can result in diabetes insipidus, SIADH
(syndrome of inappropriate antidiuretic hormone), and
cerebral salt wasting.
Cerebral salt wasting is manifested by
(a) hypernatremia.
(b) low serum osmolality.
(c) high urine output.
(d) dehydration.

139. (d)
Diabetes insipidus is characterized by excessive FREE

water loss, and therefore affected patients experience
hypernatremia, dehydration, polyuria, and polydipsia.
SIADH is associated with decreased urine output,

hyponatremia (from dilution), and a decreased serum
osmolarity.
Cerebral salt wasting is a result of a neural effect on

the renal tubules, causing loss of sodium>water and resulting
in hyponatremia (not as much as SIADH) and dehydration.

149. In traumatic brain injury in children, outcome is
primarily related to
(a) severity of original injury.
(b) location of injury.
(c) age at time of injury.
(d) associated injuries.

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

END OF 2001
Copyright © 2001
Chicago, Illinois

2002
Copyright © 2002
Chicago, Illinois

9. Which reflex is typically NOT seen in a normal 4-month-old
infant?
(a) Extremities extend on the face side as the head is turned to the
side.
(b) Fingers flex when the palm is touched.
(c) Extremities extend to the direction of displacement when center
of gravity is displaced.
(d) Shoulder abduction, and shoulder, elbow, and finger extension
occur when the neck is
suddenly extended.

9. (c)
These options all describe reflexes.
(a) asymmetric tonic neck reflex
(b) palmar grasp
(d) Moro are seen until a baby is about 6 months old.
Protective extension or parachute reaction (c) does not appear until
after 6 months.

29. Which statement is true regarding spinal cord injury without
obvious radiologic abnormality in children?
(a) It most commonly occurs in lumbar rather than cervical injuries.

(b) There is a lower incidence in younger children.
(c) It is associated with larger head size and relatively weak neck
muscles.
(d) Neurologic impairment, if it occurs, is usually apparent within 2 to 4
hours post-injury.

29. (c) Spinal cord injury without obvious radiologic abnormality
(SCIWORA) usually occurs in young
children, is thought to be due to the relatively large head size and
weak neck muscles, and motor
abnormalities may not be apparent for up to several days. SCIWORA
most commonly occurs in
the cervical region.

39. A 3-year-old child has a high thoracic spinal cord injury. When he
reaches the age 10 years, which complication is the child most likely
to have?
(a) Isolated lumbar lordosis

(b) Thoracolumbar scoliosis
(c) Deep venous thrombosis
(d) Heterotopic ossification

39. (b)
Scoliosis requiring surgery is a common complication seen in children
who have had an spinal cord injury (SCI) at a young age. Increased
lordosis in the absence of scoliosis is rarely seen. Deep venous
thrombosis rarely occurs in young children and when it does occur it
usually occurs soon after the SCI.
Heterotopic ossification tends to occur soon after the SCI

49. Acquired subluxation or dislocation of the hips in spastic
cerebral palsy is usually due to muscular imbalance and pull of the
(a) hip flexors and tensor fascia lata.

(b) hip flexors and hip adductors.
(c) rectus femoris and hip abductors.
(d) tensor fascia lata and hip extensors.

49. (b) Strong hip flexor and adductor muscles can
overpower weak extensors and abductors.
Acquired hip dislocation can be prevented in some cases by
release of spastic hip flexors and adductors.

59. Your 15-year-old patient with Duchenne muscular
dystrophy complains of new onset morning
headaches. What is the most likely cause?
(a) Neck extensor tightness

(b) Hypercarbia
(c) Migraines
(d) Vision changes

59. (b) Migraines do not typically occur only in the morning. Neck
extensor tightness usually occurs
before the loss of ambulation in boys with Duchenne muscular
dystrophy, which usually occurs
before the age of 15 years. Vision changes usually do not cause
morning headaches.
Hypercarbia results from hypoventilation during sleep and is an early

sign of impending respiratory failure.
Note: You could treat the hypercarbia by getting patient a CPAP

69. Which insult is the most likely cause of spastic diplegic cerebral
palsy?
(a) Intrauterine stroke

(b) Hyperbilirubinemia in the neonatal period
(c) Postnatal intraventricular hemorrhage
(d) Perinatal asphyxia

69. (c)
Spastic diplegic cerebral palsy occurs most commonly in premature
infants who have had an intraventricular hemorrhage during the neonatal
period.
Intrauterine stroke causes hemiplegia.
Neonatal hyperbilirubinemia most commonly causes athetosis.
Birth asphyxia is more commonly associated with spastic quadriplegic

cerebral palsy.

79. The best predictor of community ambulation beyond
childhood in patients with myelomeningocele is
(a) body mass index.
(b) quadriceps strength.
(c) early surgical closure of the meningocele.
(d) bowel and bladder continence.

79. (b) There are many studies about longterm outcomes of
ambulation in children and adults with
myelomeningocele. While many factors influence
outcome, including intelligence, medical problems, and
obesity, the best predictor of ambulation into
adulthood is strong quadriceps function.
Bowel and bladder continence has no relationship to

ambulation.

99. A child with C5 ASIA A spinal cord injury should
eventually become independent in which activity?
(a) Intermittent catheterization
(b) Transfer to level surfaces
(c) Feeding
(d) Bathing

99. (c) A child with C5 ASIA A spinal cord injury should
eventually become independent in feeding, and in upper
extremity dressing with assistive devices, in driving a power
wheelchair, and in propelling a manual wheelchair short
distances on level surfaces

109. A 6-month-old child presents in your office for rehabilitation
assessment. She was born at full term. There was mild transient
respiratory distress at birth. The patient was noted to be diffusely
hypotonic at birth except for normal cranial nerves. There were no
feeding issues once the respiratory distress resolved within 24 hours.
The baby has remained relatively hypotonic since birth. However, she
has become very socially alert and aware and attempts to use her arms
to reach for toys and pick up lightweight objects. She doesnʼt roll. She
cannot sit except very briefly when propped and bearing weight through
both arms with elbows extended. On examination, head circumference
is normal, length is normal, as is weight. There is a pronounced head
lag. Arms, while in the supine position, maintain a “jug-handle” posture.
Reflexes are present but diminished. There is no spasticity. The cranial
nerves are normal except for fine fasciculations of the tongue.
The most likely diagnosis is

(a) myotonic muscular dystrophy.
(b) cerebral palsy.
(c) infantile botulism.
(d) spinal muscular atrophy.

109. (d)
Spinal muscular atrophy (SMA) is a term used to describe a group
of inherited disorders characterized by weakness and muscle wasting
due to degeneration of anterior horn cells of the spinal cord and
brainstem motor nuclei. Three subtypes of autosomal recessive
predominantly proximal SMA have been linked to chromosome 5q.
The majority of cases of SMA type I present within the first 2 months
of life with generalized hypotonia and symmetric weakness. Children
typically sit only with support. Tongue fasciculations have been
reported in 56%-61% of patients. Proximal muscles are weaker than
distal.
Type I SMA:
• aka Werdnig-Hoffman Disease and Infantile spinal muscular atrophy
• the most lethal form

129. Secondary injury in pediatric brain trauma is caused by
(a) hypotension, hypoxia, and hydrocephalus.
(b) growing skull fractures.
(c) coup and contrecoup cerebral contusions.
(d) diffuse axonal injuries and punctate hemorrhages.

129. (a) Any disorder that interferes with cerebral perfusion or oxygenation
can cause further damage following traumatic brain injury.
This includes
• Hypotension
• Hypoxia
• Increased intracranial pressure because of cerebral edema, acute
hydrocephalus, or space-occupying lesions.
Midline shift or herniation may lead to infarction because of pressure or traction

on cerebral vessels. Therefore, efforts are made to control intracranial pressure
through fluid and electrolyte management, hyperventilation, and maintenance of
normal blood pressure and oxygenation.
Growing skull fractures result from the arachnoid protruding through a dural tear,
producing a cyst that can contribute to a widening skull deficit, which usually
requires operative repair. This is a complication of traumatic brain injury but not a
secondary injury.
Coup and contrecoup cerebral contusions and diffuse axonal injuries are
examples of primary injury.

139. To prevent contractures, which position is the correct
placement for children with major burns?
(a) Shoulder in external rotation
(b) Wrist in extension
(c) Hip in flexion
(d) Metacarpophalangeal joints in hyperextension

139. (b)
Children with major burn injuries should be placed in

positions that tend to prevent contractures.
These include:
•neck extension (no pillows)
•shoulders at 90° abduction and neutral rotation with
•elbows, wrists, hips, and knees extended
•feet at neutral dorsiflexion,
•metacarpophalangeal joints at 70° to 90° flexion
•finger interphalangeal joints in full extension.

149. Which finding would indicate a poor long-term
outcome in a 9-year-old child with a severe traumatic brain
injury?
(a) Bladder and bowel incontinence
(b) Agitation
(c) Dysphagia
(d) Hypertension and hyperpyrexia

149. (d) Most children with severe traumatic brain injury
have dysphagia, incontinence, and agitation at some time
during the recovery period.
Central autonomic dysfunction (hypertension,

hyperpyrexia, sweating, tachypnea, and rigidity) is associated
with worse cognitive and motor outcomes a year or more
after injury

END OF 2002
Copyright © 2002
Chicago, Illinois

2003
Copyright © 2003
Chicago, Illinois

9. In children with spastic cerebral palsy, which intervention
strengthens weak muscles?
(a) Ankle-foot orthotics
(b) Tendon transfer surgery
(c) Intrathecal baclofen
(d) Functional training program

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

help to strengthen weak muscles
Note: tendon transfer surgery restores motion/function,

but does NOT “strengthen weak muscles”

19. One of your 4-year-old patients exhibits the following
characteristics: distress over minor changes in environment,
echolalia, lack of awareness of the existence of feelings in
others, nonparticipation in simple games. The most likely
diagnosis is
(a) autism.
(b) cerebral palsy.
(c) hearing impairment.
(d) mental retardation

19. (a) Autism is characterized by echolalia, inability to play
reciprocally, and abnormal relationships with people. While
children with mental retardation, cerebral palsy, and hearing
impairment may have some of these features, they do not
have all of them in the absence of autism.
Echolalia = automatic repetition of vocalizations made by

another person

29. Which finding is normal in newborn infants?
(a) Extensor tone predominates
(b) Hands are kept fisted
(c) Spine is straight when held in sitting position
(d) Unable to turn head to side in prone position

29. (b) In normal newborn infants flexor tone predominates
and hands are kept fisted. In prone position a normal
newborn is able to turn the head to either side. The
newborn has a rounded spine when placed in supported
sitting

39. The family of your 10-year-old patient who had a severe
traumatic brain injury 6 weeks ago asks you if they may feed
their son. You observe that he is agitated at times, has a
hoarse voice, and drools. You try to feed him applesauce
and notice that he seems to swallow part of it and does not
cough. The most likely finding on the videofluoroscopic
feeding study will be
(a) Silent aspiration.
(b) Reflux.
(c) Coughing and gagging.
(d) Normal swallow.

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

49. Which measure is the first sign of respiratory muscle
dysfunction in boys with Duchenne muscular dystrophy?
(a) Vital capacity
(b) Oxygen saturation
(c) Maximal expiratory force
(d) Negative inspiratory force

49. (c) Recent studies by McDonald and by Bach showed
that reduction of maximal expiratory force (MEF)
to 40%–60% of normal in the 7- to 14-year-old age group
was the first sign of respiratory muscle dysfunction in boys
with Duchenne muscular dystrophy (DMD). The earlier and
more severe decreases of MEF that are greater than the
decreases in maximal inspiratory force, correspond to the
clinically observed weakness of abdominal muscles, which like
coughing are important in forced expiration. Vital capacity
was not found to decrease until an average of 15–16 years.
Low oxygen saturation is a late manifestation in DMD,
developing after hypercapnia.

59. A 10-year-old child with L4-5 myelodysplasia and
shunted hydrocephalus develops spasticity in her legs. The
most likely cause of this spasticity is
(a) shunt malfunction.
(b) symptomatic Chiari malformation.
(c) growth.
(d) tethered cord.

59. (d)
Tethered cord is the most common cause of new onset

spasticity in patients with myelodysplasia. Linear growth
does not cause new spasticity.
Symptoms of Chiari malformation include cranial nerve

disorders and respiratory problems.
Shunt malfunction may be associated with headaches,

vomiting, eye muscle abnormalities, and sometimes
abdominal symptoms.

69. A 9-year-old girl with an L1 ASIA class A spinal cord injury that occurred at
age 5 years presents in
your office with a 1-day history of a swollen left leg. History is that she woke up
with the swollen
leg the day before. There is no history of trauma, fever, or shortness of breath.
On examination, you
find a prepubertal girl in no distress with normal vital signs. Upper extremities are
normal. Lower
extremities have moderate spasticity and no voluntary movement. Skin is normal.
The left leg is
warm and swollen from the ankle to the knee. There is no sensation in the legs.
Which test is most
likely to yield the correct diagnosis?
(a) Bone scan

(b) Plain radiograph
(c) Venous Doppler study
(d) White blood cell count with differential

69. (b)
Deep venous thromboses (DVTs) which can be diagnosed by Doppler
study usually occur in the first 3 months after spinal cord injury (SCI) and
are rare in prepubertal children. In lower leg DVTs the foot and leg are
usually swollen (NOT warm).
Heterotopic ossification (HO), which can be detected by bone

scan, occurs in about 3% of children with SCI and has onset an average of
14 months after injury. Heterotopic ossification most commonly involves the
hip.
Cellulitis is usually associated with skin lesions and usually involves a

discrete area.
A fracture is the most likely cause of swelling in this case and can be
diagnosed by plain radiographs.

79. Which positive effect of ankle-foot orthotics has been proven
beneficial in the treatment of children with cerebral palsy?
(a) Improved gait efficiency as measured by gait analysis

(b) Prevention of contractures
(c) Improved knee extensor strength
(d) Decreased plantar flexor posture

79. (a) There are no large, randomized, controlled studies that show
the long-term effects of any type of Ankle-Foot Orthosis (AFO) on
function or contracture formation. Small studies have shown that both
rigid and hinged AFOs improve gait efficiency by preventing plantar
flexion.

99. Juvenile rheumatoid arthritis (JRA) differs from adult
onset rheumatoid arthritis: in JRA
(a) joint destruction occurs earlier.

(b) large joint involvement is less frequent.
(c) the cervical spine is involved less frequently.
(d) systemic features are more common.

99. (d)
Children with juvenile rheumatoid arthritis are more likely to have:
• systemic features (fever, rash, swollen lymph nodes)
• large joints involved
• cervical spine involvement.
Adults with rheumatoid arthritis have joint destruction earlier.

109. Children with which physical disorder tend to have higher
verbal skills compared to overall cognitive ability?
(a) Muscular dystrophy

(b) Myelodysplasia
(c) Cerebral palsy
(d) Autism

109. (b) Children with myelodysplasia (spina bifida) have deceptively
good verbal facility that creates the impression of higher intellectual
functioning than is found on formal testing (“cocktail party syndrome”).
Children with cerebral palsy, autism, and muscular dystrophy do not

typically demonstrate this finding.

129. Your 10-year old patient with T6 ASIA class B paraplegia
complains of right knee pain. On
examination there is no swelling of the knee or leg. Knee examination
is normal. The right leg
appears shorter when the hips and knees are flexed. What is the most
likely cause of these findings?
(a) Knee sprain

(b) Right hip subluxation
(c) Hip adductor spasticity
(d) Dysesthetic pain

129. (b) Hip subluxation is the most likely cause of knee pain in
a child with T6 ASIA B SCI. Pain from hip pathology is often
referred to the knee in children.
While hip adductor spasticity contributes to subluxation or

dislocation (spastic hip adductors and hip flexors), the spasticity
itself is not painful.
Dysesthetic pain is usually generalized.
An abnormal knee examination is usually found in a knee injury that

causes pain.

149. A 16-year-old girl who had a severe traumatic brain injury 4
weeks ago with left frontal contusion and left basilar skull fracture
demonstrates worse auditory than visual attention. Which
diagnostic
test would be most likely to explain this finding?
(a) Magnetic resonance imaging

(b) Electroencephalogram
(c) Audiogram
(d) Visual evoked response

149. (c) A basilar skull fracture is often associated with a permanent
sensorineural hearing loss. Other
traumatic brain injuries may be associated with hearing loss, but this
is less common. All patients
with basilar skull fracture should be assumed to have a hearing loss
and have audiological
evaluation as soon as possible.

Basilar Skull Fractures
Note:
• includes fractures to the base of the skull, whether posterior AND
anterior (temporal bone, occipital bone, sphenoid bone, and/or
ethmoid bone)
• Can cause tearing of meninges --> drain of CSF into middle ear (and
out thru perforated drum), eustachian tube (salty taste) and out nose
Raccoon eyes
Battle sign
159. What condition causes the typical “myopathic gait” seen in
a young boy with Duchenne muscular
dystrophy with accentuated lumbar lordosis and toe walking?
(a) Hip and knee extensor weakness

(b) Hip flexion and ankle plantar flexion contractures
(c) Hip extensor weakness and plantar flexion contracture
(d) Hip flexion contracture and knee extensor weakness

159. (a) The typical “myopathic
gait” seen in early Duchenne
muscular dystrophy is caused by
weakness of
the gluteus maximus and
quadriceps muscles. In order to
maintain upright posture the child
assumes the hyperlordotic stance.
Contractures of the gastrocsoleus

and iliopsoas muscles occur
later in the disorder.

169. In which type of cerebral palsy is a seizure disorder
most commonly seen?
(a) Tetraplegia
(b) Diplegia
(c) Athetosis
(d) Hemiplegia

169. (d)
Approx. 70% of children with hemiplegia have seizures.
About 50% of children with tetraplegic cerebral palsy have
seizures.
Seizures are rare in children with diplegia or athetosis.
Remember:
Cerebral palsies
• Intrauterine stroke --> hemiplegic
• Intraventricular hemorrhage --> spastic diplegic
• Neonatal hyperbilirubinemia --> athetosis
• Birth asphyxia --> spastic quadriplegic

179. A 1-year-old child with a midlength transfemoral limb
deficiency presents for prosthetic
management. Which component should be in the prosthetic
prescription?
(a) Socket with a growth liner

(b) Single action knee joint
(c) Vertical shock pylon
(d) Dynamic foot

179. (a)
The 1-year-old child should be fit with a simple prosthesis which
suspends securely and allows for growth.
The knee joint should be added between 3 and 5 years.
The SACH foot is most commonly prescribed because of its simple

design and durability. SACH = solid ankle cushion heel
All prostheses for growing children should incorporate a removable

growth liner in the socket.

END OF 2003
Copyright © 2003
Chicago, Illinois

2004
Copyright © 2004
Chicago, Illinois

9. A 2-year-old patient with spinal muscular atrophy type 2 (intermediate
form) presents with a 25°,
C-shaped scoliosis. What is the best treatment option at this time?
(a) Muscle strengthening

(b) Electrical stimulation
(c) Spinal fusion
(d) Spinal orthosis

9. (d) Muscle strengthening will not reduce the curve or prevent it
from progressing and is not easily
accomplished in 2-year-old children. Posterior or anterior spinal
fusion is not indicated with a
curve of this size and is to be avoided in a young child if at all
possible. Spinal orthotics are used in
young children with spinal muscular atrophy to improve sitting
balance and to attempt to halt curve
progression.

19. The most common spinal problem seen with
achondroplasia during childhood is
(a) kyphosis.
(b) scoliosis.
(c) spinal stenosis.
(d) low back pain.

19. (a) While scoliosis may occur in children with achondroplasia, it is
less common than kyphosis, which begins in infancy.
Spinal stenosis occurs frequently in individuals with achondroplasia, with

38 years being the average age of symptom onset.
Low back pain is extremely frequent in adults with achondroplasia, but

rare in children.
Progressive kyphosis that occurs in infants and young children with

achondroplasia is treated with a spinal orthosis

39. In which activity should a 16-year-old girl with C5 ASIA
class A spinal cord injury be independent with the use of
assistive devices?
(a) Self catheterization

(b) Transfers to level surfaces
(c) Self feeding
(d) Bathing

39. (c) While boys with C5 spinal cord
injury (SCI) may learn to perform
bladder self-catheterization with
assistive devices, girls do not.
Level transfers require active elbow and

wrist extension, which
would not be present in a person with C5
SCI.
Self-feeding with assistive devices such

as a palmar band can usually be done by
persons with C5 tetraplegia.

49. Your 6-month-old patient had burns to his head and both
arms in a house fire. What approximate percent of his total
body surface area (TBSA) was burned?
(a) 37
(b) 18
(c) 27
(d) 49

49. (a) An infantʼs head
is approximately 19%
and each arm
constitutes 9% of the
total body surface area
(TBSA). In adults and
older children the head is
approximately 9% of the
TBSA.

59. Which joints are most commonly involved in juvenile
rheumatoid arthritis?
(a) Shoulder, hip, fingers

(b) Atlantoaxial, costomanubrum, hip
(c) Sternomanubrum, shoulder, sacroiliac
(d) Elbow, hip, temporomandibular

59. (d) The elbow is involved 90% of the time in juvenile
rheumatoid arthritis (JRA), the
temporomandibular and hip 50% each. The shoulder is involved
about 8% of the time in early JRA
and about 33% later.

69. Which of the following is part of neurodevelopmental
therapy (NDT)?
(a) Promotion of primitive reflexes

(b) Use of taping and icing
(c) Strengthening exercises
(d) Facilitating automatic reactions

69. (d) Neurodevelopmental therapy, developed by Bobath,
emphasizes inhibition of reflex patterns,
normalizing tone, and facilitating automatic reactions. The therapy
does not include strengthening exercises.

79. Your 14-year-old patient with spastic diplegic cerebral palsy has
increasing problems with
spasticity. He walks with ankle-foot orthoses (AFOs) and crutches and is
independent in his
activities of daily living. Which medication would reduce his spasticity while
minimizing
undesirable side effects?
(a) Diazepam (Valium)

(b) Baclofen (Lioresal)
(c) Dantrolene (Dantrium)
(d) Oxybutynin (Ditropan)

79. (b) Diazepam has lethargy and sleepiness as major side
effects. Dantrolene works at the level of the
muscle and often causes weakness, which can interfere with
function. Oxybutynin relaxes the
muscles of the bladder, not skeletal muscles.

109. You are asked to evaluate an 8-month-old child with
developmental delay. On exam you find low
tone, but brisk deep tendon reflexes at the knees and biceps, full
passive range of motion, and poor
head and trunk control. This childʼs diagnosis is likely
(a) myotonic dystrophy.

(b) cerebral palsy.
(c) spinal muscular atrophy.
(d) Hunterʼs syndrome.

109. (b) This patient presents with hypotonia, weakness, and
hyperreflexia, a combination most commonly
seen in central nervous system lesions such as cerebral palsy. A child
with a neuromuscular
disorder would not have hyperreflexia with the hypotonia and weakness.
In severe cerebral palsy it is common to see early hypotonia with brisk

reflexes that changes to hypertonia as the child gets older.

129. Which endocrine abnormality is most likely to occur 5 years after
severe traumatic brain injury in a 2-year-old girl?
(a) Diabetes insipidus

(b) Precocious puberty
(c) Hypothyroidism
(d) Hyperparathyroidism

129. (b) Precocious puberty occurs in up to 50% of girls who sustain a
severe traumatic brain injury (TBI) in
early childhood.
Diabetes insipidus is an early complication of TBI. While other endocrine

abnormalities may occur, they are less common.

169. On physical examination an 8-year-old patient stands on his
toes and has increased lumbar
lordosis. He has a Trendelenburg gait with circumduction. What else
would you expect to find on
his exam?
(a) Decreased sensation in his feet

(b) Anterior tibialis weakness
(c) Quadriceps weakness
(d) Hyperreflexia at the ankle

169. (c) The exam describes typical findings in a boy with myopathy
such as Duchenne muscular dystrophy
(DMD). The earliest weakness in DMD is proximally in the gluteus
maximus. The boy assumes a
posture of lumbar lordosis to place the center of gravity posterior to
the hip joint to prevent
hyperflexion of the hip and thus a fall.
Toe walking is a compensatory adaptation to knee extensor

weakness.

189. You are asked to evaluate a child who was born at 25 weeks
gestation and had a grade 4 intraventricular hemorrhage. What type of
cerebral palsy are you most likely to find?
(a) Athetoid
(b) Hemiplegic
(c) Diplegic
(d) Hypotonic

189. (c)Grade 4 intraventricular hemorrhages in premature
infants are most commonly associated with spastic
diplegia.
Remember:
Cerebral palsies
• Intrauterine stroke --> hemiplegic
• Intraventricular hemorrhage --> spastic diplegic
• Neonatal hyperbilirubinemia --> athetosis
• Birth asphyxia --> spastic quadriplegic

199. You are asked to evaluate a child with arthrogryposis and
equinovarus. Which treatment strategy would be the best to employ?
(a) Short leg braces attached to orthopedic shoes

(b) Botulinum toxin injections, stretching, and plastic ankle-foot orthoses
(c) Oral baclofen (Lioresal), range of motion, and extra depth shoes
(d) Casting followed by surgical releases

199. (d) Arthrogryposis multiplex congenita (AMC) may be caused by a
variety of conditions, but is usually not accompanied by spasticity. Thus
botulinum toxin and baclofen are not indicated. Most club
feet (equinovarus) in patients with AMC are resistant to conservative
methods and require surgical releases.
arthro = joints
gryposis = twisted
http://www.pediatric-orthopedics.com/Topics/
Muscle/Diseases/Arthrogryposis_Multiplex/
arthrogryposis_multiplex.html

END OF 2004
Copyright © 2004
Chicago, Illinois

2005
Copyright © 2005
Chicago, Illinois

19. The Gross Motor Functional Measure (GMFM) is designed to measure
(a) motor changes over time.

(b) quality of motor performance.
(c) achievement of motor milestones.
(d) only walking, running, and jumping ability.

19. (a) The Gross Motor Functional Measure (GMFM) evaluates motor
changes over time in children with cerebral palsy. It includes activities in
prone and supine positions, rolling, sitting, crawling, kneeling, standing,
walking, running, and jumping.
It does NOT measure the quality of motor performance.

49. What percentage of American children with myelomeningocele
requires a shunt to manage hydrocephalus?
(a) 10–20
(b) 25–50
(c) 60–70
(d) 80–90

49. (d) Seventy-five (75%) percent of lesions in spina bifida cystica
(myelomeningocele) affect the lumbosacral spine.
Ninety percent (90%)of children with spina bifida have hydrocephalus

that requires a shunt for management.

69. A 9-year-old girl with C5 ASIA A spinal cord injury sustained 2 years
ago is evaluated for upper extremity splinting. Which statement
regarding this scenario is TRUE?
(a) A resting hand splint should be prescribed for daytime use to preserve
function.
(b) A wrist extension splint would be contraindicated for daytime use
because it would interfere
with function.
(c) A mobile arm support or balanced forearm orthosis could be prescribed
to make self-feeding possible.
(d) A short hand splint should be prescribed to strengthen wrist extensor
muscles.

69. (c) A mobile arm support or balanced forearm orthosis
would enable the child with C5 ASIA A spinal cord injury (SCI)
and weak arm muscles to move the arm through useful active
range of motion and to position the hand for function. In patients
with C5 SCI, these orthoses are typically combined with wrist
extension splints or a universal or palmar cuff for feeding.
A resting hand splint may be used at night to improve or maintain

range of motion, but would interfere with daytime function.
A short hand splint would not strengthen wrist extensor muscles,

but may be useful to improve function.

99. A normal 6-month-old infant may demonstrate which reflex?
(a) Rooting
(b) Automatic walking
(c) Plantar grasp
(d) Posterior protective extension

99. (c) Rooting and automatic walking reflexes are present at birth, and are
integrated by 4 months of age.
Posterior protective extension does not appear until 7 to 8 months of age.
Plantar grasp is present at birth and not integrated until after independent walking
occurs at approximately 12 months of age.
Reflex Age of Emergence Age of Suppression (or Integration)

Moro Birth 4–6 months
Rooting Birth 4 months
Asymmetric tonic neck
reflex (ATNR) 1–3 months 6–7 months
Plantar grasp Birth 12–14 months–ie, when walking well
Automatic walking Birth 3–4 months
Posterior protective
Extension 7–8 months

109. Which statement is TRUE about swallowing in infants?
(a) Sucking and swallowing are well-coordinated for oral intake by 34

weeks of gestation.
(b) The infantʼs larynx is low, about the level of the sixth cervical vertebra.
(c) The infantʼs tongue fills less of the oral cavity than the adultʼs tongue.
(d) Oral breathing occurs at birth and may interfere with sucking.

109. (a) Sucking and swallowing are well-coordinated at 34 weeksʼ
gestation.
Because the infantʼs tongue is more anterior than the adultʼs, the tongue fills
more of the oral cavity than in the adult.
The larynx in the infant is high, about at the C2–3 level.
Newborn infants are obligate nose breathers and oral breathing is not
observed until 3 to 4 months of age.

129. You are performing a consult on an 8-year-old child who has
sustained a traumatic brain injury.
The child has hyperthermia, hypertension, tachycardia, and rigidity. The best
management for this
child would be
(a) Propranolol (Inderal).

(b) Baclofen (Lioresal).
(c) Nonsteroidal anti-inflammatory drugs (NSAIDs).
(d) Amantadine (Symmetrel).

129. (a) Fever in a child with a severe traumatic brain injury should be
investigated and infections treated with appropriate antibiotics. In the absence
of infection, the fever in central autonomic dysfunction is poorly responsive
to nonsteroidal anti-inflammatory drugs. Baclofen may help to control the
spasticity, but propranolol is more effective in controlling the hypertension,
tachycardia, and hyperthermia.
Remember:
Central autonomic dysfunction (hypertension, hyperpyrexia, sweating,
tachypnea, and rigidity) is associated with worse cognitive and motor outcomes a
year or more after injury

149. The Education for All Handicapped Children Act (EHA, PL 94-142),
passed in 1976, and the Individuals with Disabilities Education Act
(IDEA, PL 105-17), passed in 1997, guarantee that children with
disabilities have
(a) education in special schools.

(b) medical care at school.
(c) education in the least restrictive environment.
(d) education in regular classrooms.

149. (c) The Education for All Handicapped Children Act and the
Individuals with Disabilities Education
Act guarantee children with disabilities education in the least restrictive
environment. They also
guarantee necessary health care be provided in the school environment
(eg, intermittent
catheterization) but do NOT require medical care be provided.

169. Once an individual becomes board-certified in the specialty of
physical medicine and rehabilitation,
he/she must continue to fulfill certain requirements in order to maintain
certification status. Which
action is NOT a requirement for maintenance of certification?
(a) Continuing medical education credits

(b) Maintenance of active medical licensure
(c) Completion of a recertification examination every 10 years
(d) Publication of at least 1 article in a scientific journal every 10 years

169. (d) Once an individual becomes board certified in the specialty of
physical medicine and rehabilitation,
he/she must continue to fulfill certain requirements in order to maintain their
certification status.
Publication of 1 article in a peer-reviewed journal every 10 years is not a
requirement for
maintenance of certification. All of the other options listed are required.

189. You have just finished admitting a 60-year-old diabetic man
who has recently undergone a right below-knee amputation. The
patient's son stops you in the hallway and inquires about his
father's health status and prognosis for walking again. You have
never met the patient's son before, and before answering the
questions, you would first
(a) further review the patient's medical record and determine his
cardiac status.
(b) perform a literature review of outcomes research in individuals with
below-knee amputations.
(c) ask the patient for permission to discuss his health status with his
son.
(d) ask the son if the patient has a living will or a health care power-of-
attorney.

189. (c) Maintaining confidentiality of patient information is
important even when discussing health
information with family members. Before discussing the patient's
health status with his son, the
appropriate first step would be to ask the patient for permission.
The other options listed would not
be appropriate initial management strategies.

END OF 2005
Copyright © 2005
Chicago, Illinois

2006
Copyright © 2006
Chicago, Illinois

19. A 10-year-old girl presents with scoliosis 5 years after sustaining a
severe traumatic brain injury.
Radiographic studies reveal a 25° levoconvex curve from C8 to T12 with the
apex at T4. After
consultation with the orthopedic surgeon, you prescribe a spinal orthosis.
Which type of orthosis
should be used in this patient?
(a) Cervicothoracolumbosacral orthosis (CTLSO)

(b) Thoracolumbosacral orthosis (TLSO)
(c) Thermoplastic Minerva body jacket (TMBJ)
(d) Sterno-occipital mandibular orthosis (SOMI)

19. (a)
A thoracolumbosacral orthosis is used for scoliosis having an
apex at T9 or lower.
A sternooccipital mandibular orthosis immobilizes the neck.
A thermoplastic Minerva body jacket is also used for cervical
immobilization.
A cervicothoracolumbosacral orthosis such as the Milwaukee
brace extends from the pelvic section to the neck ring and has
been shown to correct scoliotic curves throughout that area.

Sterno-occipital mandibular
Minerva body jacket

59. Randomized controlled trials examining intrathecal baclofen (ITB)
use in children with cerebral palsy show that children who receive ITB
have
(a) improved upper extremity function.

(b) reduced spasticity in lower extremities.
(c) improved walking and transfers.
(d) improved knee range of motion.

59. (b) A comprehensive review of published English language studies
on intrathecal baclofen (ITB)
showed evidence of statistically significant improvement in upper AND
lower extremity tone with ITB use in children with cerebral palsy (CP).
Other reported improvements with ITB in children

with CP are either anecdotal or not substantiated by randomized controlled
trials.

69. You are called to see your 3-year-old inpatient with a C5 ASIA class A spinal cord
injury. She has a headache and complains of not feeling well. Vital signs are pulse 60,
respirations 20, blood pressure 120/80. Weight 33 lbs (15kg). Physical examination is
unchanged from previously. You order:
(a) Place the patient in the supine position.

(b) Administer acetaminophen (Tylenol) orally.
(c) Empty the bladder.
(d) Obtain computed tomography of the head.

69. (c) The child is experiencing autonomic dysreflexia. The 90th percentile
for blood pressure in an average sized 3-year-old girl is 103/62. A child with
C5 tetraplegia would be expected to have even lower average blood
pressure.
Initial treatment consists of positioning the patient in an

upright position and emptying the bladder. If this does not correct the problem,
medications should be considered. If medications are needed, either nitropaste
2% or nifedipine may be used. For a
child weighing 15kg the correct initial dose is 0.25 to 0.5 mg/kg/dose (3.75–7mg)
of nifedipine or
1/2 inch of nitropaste.

89. The most common congenital limb deficiency is a
(a) transverse tibial and fibular limb deficiency (below-knee limb

deletion).
(b) transverse transmetacarpal limb deficiency (partial hand deletion).
(c) longitudinal fibular deficiency (fibular hemimelia).
(d) transverse radial limb deficiency (below-elbow limb deletion).

89. (d) The left short transradial congenital limb
deficiency (below-elbow limb deletion) is the most
common congenital limb deficiency.
It is thought to be caused by a clot which occludes

the artery,
resulting in resorption of the distal limb, often leaving
nubbins of fingers at the end of the stump.

109. Disorders of executive functioning are common in children after severe
traumatic brain injury.
Which sign indicates problems of executive function?
(a) Low intelligence quotient

(b) Attention and memory problems
(c) Aphasia
(d) Agitation

109. (b) Problems of executive function include impairments in attention,
memory, and abstract reasoning.
While aphasia and low intelligence may be seen following traumatic brain injury
(TBI), they are not problems of executive function.
Agitation is usually seen early in recovery from TBI, at the Rancho Los Amigos stage
4. The full consequences of a TBI that occurs in a young child may not
be seen until much later, at an age when the child is expected to have that skill. For
example,
problems in abstract reasoning in a child who had a TBI at age 5 may not be seen
until the child
reaches 9 or 10 years of age.

129. What is a reasonable long-term rehabilitation goal for a 6-year-old
child with a C6 ASIA class A
spinal cord injury?
(a) Independent lower extremity dressing
(b) Bed mobility
(c) Independent bathing
(d) Independent feeding

129. (d) A child with C6 ASIA class A spinal cord injury would be
expected ultimately to independently
self-feed, but not bathe, do lower extremity dressing, or perform bed
mobility.
Note:
A C6 pt would have forearm extensors (C6) for tenodesis action to grasp
a utensil, and biceps/deltoid fxn to bring the food to the mouth.

149. A 6-month-old infant presents to you with hypotonia. You perform an
electrodiagnostic study which
shows normal motor conduction velocity, normal sensory conduction velocity and
amplitude, normal
motor units, and occasional fibrillations and positive waves. The most likely
cause of these findings
is
(a) congenital myotonic dystrophy.
(b) spinal muscular atrophy.
(c) metachromatic leukodystrophy.
(d) infantile botulism.

149. (a) Hypotonia in infants can be caused by many abnormalities,
including cerebral lesions, spinal cord
pathology, polyneuropathies, and myopathies. These electrodiagnostic
findings are most consistent
with congenital myotonic dystrophy.
Side note:
Operations and anaesthetics can be risky. It is very important that any
surgeon and anesthesiologist should know a child has congenital
myotonic dystrophy before surgery is planned.

169. Which action is NOT required of a certified physiatrist to maintain
certification?
(a) Obtain continuing medical education credits.

(b) Maintain active medical license.
(c) Complete a recertification examination every 10 years.
(d) Publish at least 1 article in a scientific journal every 10 years.

169. (d) Once a physician is certified by the American Board of Physical
Medicine and Rehabilitation, he or
she must continue to fulfill certain requirements in order to maintain certification
status.
Publication of an article in a peer-reviewed journal every 10 years is not a
requirement for
maintenance of certification. All the other options listed are required.

179. As the medical director of an inpatient rehabilitation program, you become
concerned because you
have recently noticed an increased number of urinary tract infections in the patients on
your service.
Which action would NOT be considered a reasonable initial management strategy?
(a) Discuss the issue with the rehabilitation centerʼs Quality Improvement Committee
and
examine the rate of urinary tract infections over the past year.
(b) Perform a literature review examining the incidence and prevalence of urinary tract
infections
in an inpatient rehabilitation setting.
(c) Immediately order that a urine culture be obtained on every patient at the time of
admission to
the rehabilitation service.
(d) Provide an educational inservice to the nursing staff regarding catheter and bladder
management.

179. (c) Continuous quality improvement should be a part of each
physician's clinical practice. All the
options listed would be appropriate to consider with the exception of
immediately ordering a urine
culture on every patient at the time of admission to the rehabilitation service.
This would not be an
appropriate option without gathering more information and understanding the
implications of this
intervention strategy.

189. You have just finished admitting a 60-year-old man with diabetes who has
recently undergone a
right below-knee amputation. The patient's son stops you in the hallway and inquires
about his
father's health status and prognosis for walking again. You have never met the patient's
son before,
and before answering the questions, you would first
(a) further review the patient's medical record and determine the patient's cardiac
status.
(b) perform a literature review of outcomes research in individuals with below-the-knee
amputations.
(c) ask the patient for permission to discuss his health status with his son.
(d) ask the son if the patient has a living will or a health care power-of-attorney.

189. (c) Maintaining confidentiality of patient information is important
even when discussing health
information with family members. Before discussing the patient's health
status with his son, the
appropriate first step would be to ask the patient for permission. The
other options listed would not
be appropriate initial management strategies.

199. A clinical trial can best be defined as a
(a) retrospective study examining the natural history of a disease process.
(b) prospective study that is randomized and double-blinded.
(c) retrospective study with subjects selected on the basis of presence or
absence of an illness.
(d) prospective study comparing the effect of an intervention with a control.

199. (d) A clinical trial can best be defined as a prospective study that compares
the effect and value of an
intervention with a control. A study measuring the natural history of a disease
process is more
observational in nature and can be either prospective or retrospective. Clinical trials
are not
necessarily randomized or double-blinded. Clinical trials are prospective and not
retrospective in
nature.

END OF 2006
Copyright © 2006
Chicago, Illinois

2007
Copyright © 2007
Chicago, Illinois

9. According to national databases of spinal cord injury (SCI), children under the age
of 6 years are more likely to have which epidemiologic pattern of spinal cord injury?
(a) high tetraplegia, motor incomplete, occurred in motor vehicle accident

(b) paraplegia, complete, occurred in motor vehicle accident
(c) high tetraplegia, complete, caused by medical/surgical complications
(d) paraplegia, motor incomplete, caused by medical/surgical complications

9. (b) According to databases of the Model SCI Systems and Shriner’s Hospital for
Children, children under age 6 years are more likely than teenagers to sustain SCI in a
motor vehicle accident. Their injuries are more likely to be T1 and lower, and they are
more likely to have complete injuries.

49. Your 5-year-old patient with spastic tetraplegic cerebral palsy needs a
wheelchair prescription. He is dependent for transfers, but cognitively normal.
He is able to feed himself and uses a communication device. His family
transports him in their car in an adapted car seat. On examination, he is unable
to sit unsupported, but sits well with minimal support; he has no scoliosis, and
his passive range of motion is full. Which elements would be best to include
in his wheelchair prescription?
(a) Folding frame, sling seating

(b) Adaptive stroller, linear seating
(c) Tilt in space frame, custom seating
(d) Rigid frame, contoured seating

49. (d) While this child is totally dependent for transfers, he only requires
minimal support to sit upright and has no fixed deformities.
Custom seating should be used for those with fixed deformities.
A tilt-in-space frame should be used when children need to have their

position in space changed frequently because of deformities or medical
problems.
While it is tempting to prescribe a wheelchair with a folding frame for a

family who transports a child in a car rather than a van, the child will be
better positioned using contoured seating and a rigid frame. At age 5 years,
the size of frame needed will be able to be transported in a car even without
folding.
Adaptive strollers usually position the child in a reclined position and

should be used as a backup to a wheelchair, which is not easily transported in
an automobile, or for a child who can walk but periodically needs dependent
mobility for fatigue or following seizures or for similar reasons.

99. On examination, a 3-month-old girl still has a Moro reflex,
asymmetric tonic neck reflex, and plantar grasp reflex. She does not
have any protective extension. You advise her parents that
(a) further diagnostic evaluation is indicated.

(b) she requires a physical therapy evaluation.
(c) she needs a neurology evaluation.
(d) these reflexes are normal reflexes.

99. (d) These are normal reflexes in a 3-month-old child. The Moro and
asymmetric tonic neck reflexes (ATNR) usually are integrated by
approximately 6 months. The plantar grasp reflex is integrated by 12 to 14
months after walking has begun. Protective extension in sitting is seen
anteriorly at 5 to 7 months, lateral at 6 to 8 months, and posterior at 7 to 8
months.

109. Which of the following is NOT a feature of central autonomic
dysfunction in traumatic brain injury in children?
(a) Hypertension
(b) Tachypnea
(c) Rigidity
(d) Hypothermia

109. (d) Central autonomic dysfunction occurs in some children following severe
brain injury. It is characterized by hypertension, hyperpyrexia, rigidity,
tachypnea, tachycardia, and diaphoresis. Various medications are used to
treat this dysfunction, but no studies prove the value of one medication
over another.
Remember:
Pts with this condition after TBI have worse cognitive and motor outcomes at 1 yr
after injury.

139. A 2-month-old infant presents to you for evaluation of delayed
development. He was the product of a normal term pregnancy,
labor, and delivery. Birth weight was 3500 grams. He has had
difficulty feeding since birth. Family history is negative for
developmental problems. On physical examination, he is awake, but
not alert. Weight is 3600 grams. Respiration is unlabored. He has
poor head control and decreased tone throughout. Deep tendon
reflexes are absent. What is the most likely diagnosis?
(a) Kugelberg Welander syndrome

(b) Duchenne muscular dystrophy
(c) Infantile botulism
(d) Tetraplegic cerebral palsy

139. (d) This patient illustrates the diagnostic dilemma of the floppy infant.
Causes of this problem include central nervous system lesions (both brain
and spinal cord), myopathies, neuropathies, and neuromuscular junction
problems.
This infant has had abnormalities since birth, which argues against infantile
botulism.
Kugelberg Welander syndrome (also known as spinal muscular atrophy

type 3) has onset during childhood, as does Duchenne muscular dystrophy.
Tetraplegic cerebral palsy often presents in infancy with floppiness and

hyporeflexia, which later change to spasticity and hyperreflexia.

149. The most common musculoskeletal abnormalities seen in a child with
L5 myelodysplasia with sparing of the L5 segment and above are
(a) cavus foot, early hip dislocation, hip and knee flexion contractures.
(b) calcaneus foot, late hip dislocation, hip and knee flexion contractures.
(c) cavus foot, late hip dislocation, hip adduction contractures.
(d) calcaneus foot, early hip dislocation, hip adduction contractures.

149. (b) The child with L5 myelodysplasia typically has late hip dislocation, calcaneus
foot, hip flexion contractures, and may have either knee extension or flexion
contractures, depending on whether quadriceps (L2-4) or hamstrings (L4-S1)
are stronger. Gluteus medius (hip abductor, L4-S1) and hip adductors (L1-3)
are innervated higher than L5 and are typically balanced in L5 myelodysplasia.
Late hip dislocation is due to either unbalanced hip musculature or spinal
deformities.

169. An unusually high incidence of pressure ulcers is noted on your
inpatient rehabilitation unit. As the medical director for the unit, you
decide to implement a quality improvement process. The next best step
in process would be to
(a) understand the cause of the skin breakdown.

(b) select a strategy to decrease the incidence of pressure ulcers.
(c) organize a team to investigate the problem.
(d) reprimand the nurse manager for the unit.

169. (c) Various strategies can be used when implementing a quality
improvement process. One widely accepted method is FOCUS PDCA.
The steps in the process include finding an opportunity, organizing the
team, clarifying the current process, understanding the causes of the
variation, and selecting a strategy to implement it (FOCUS). Once this
has been accomplished, then the strategy involves planning, doing,
checking, and acting (PDCA). According to this process, the next best
step in the scenario provided would be to organize a team to investigate
the problem.

179. Preventable medical errors are
(a) rarely associated with significant morbidity.

(b) most commonly a result of individual human error.
(c) associated with no impact on patient satisfaction.
(d) associated with patients’ loss of trust in the health care system.

179. (d) Preventable medical errors can result in lower levels of patient
satisfaction and loss of trust in the health care system. Preventable
medical errors often result in significant morbidity and even
mortality. Estimates are that 44,000 to 98,000 people die each year as
a result of medical errors that could have been prevented. These
errors are frequently the result of system type errors rather than
individual human error.

199. Investigators must address ethical considerations when
designing and implementing research studies. One such
consideration requires investigators to design protocols that
will provide generalizable knowledge and ensure that the
benefits of the research are proportionate to the risks assumed
by the subjects. This ethical consideration is referred to as
(a) respect.
(b) beneficence.
(c) justice.
(d) autonomy.

199. (b) Beneficence requires investigators to design protocols that will
provide generalizable knowledge and ensure that the benefits of
the research are proportionate to the risks assumed by the
subjects.

END OF 2007
Copyright © 2007
Chicago, Illinois

2008
Copyright © 2008
Chicago, Illinois

9. You are asked to evaluate a 1-year-old patient who is not yet walking
but is developmentally appropriate. Which reflex would you expect to
find?
(a) Asymmetric tonic neck

(b) Symmetric tonic neck
(c) Palmar grasp
(d) Plantar grasp

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

walking varies, but may be as late as 18 months.

59. Acquired subluxation or dislocation of the hips in spastic
cerebral palsy is usually due to muscular imbalance with
excessive tone of which muscles?
(a) Hip flexors and tensor fascia lata

(b) Hip flexors and hip adductors
(c) Rectus femoris and hip abductors
(d) Tensor fascia lata and hip extensors

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

69. In children with spastic cerebral palsy, which approach strengthens
weak muscles?
(a) Ankle-foot orthotics

(b) Tendon transfer surgery
(c) Intrathecal baclofen
(d) Functional training

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

79. The family of your 15-year-old patient who had a severe traumatic brain
injury 6 weeks ago asks you if they may feed their son. You observe that
the patient is agitated at times, has a hoarse voice, and drools. You try to
feed him applesauce and notice that he seems to swallow part of it and does
not cough. The most likely finding on the videofluoroscopic swallowing
study will be
(a) Silent aspiration

(b) Reflux
(c) Coughing and gagging
(d) Normal swallow

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

139. A 3-year-old child has a high thoracic spinal cord injury. At age 10,
which of the following is the most likely complication?
(a) Severe lordosis without scoliosis

(b) Scoliosis requiring surgical treatment
(c) Deep venous thrombosis
(d) Heterotopic ossification

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

149. The most common congenital limb deficiency is
(a) right transtibial limb deletion.

(b) right transradial limb deletion.
(c) left transtibial limb deletion.
(d) left transradial limb deletion.

149.
(d)
The most common congenital limb deficiency is
the left midlength transradial deficiency.
Remember:
It is thought to be caused by a clot which occludes
the artery, resulting in resorption of the distal limb,
often leaving nubbins of fingers at the end of the
stump.

169. Relevant to investigational studies, the principle of justice
requires that
(a) harm be minimized and benefits maximized.

(b) informed consent includes full disclosure of risks and benefits.
(c) research subjects be treated fairly and selected equitably.
(d) investigators respect the privacy of research subjects.

169.
(c)
The principle of justice requires subjects to be treated fairly and selected equitably.
The principle of beneficence ensures that researchers minimize harm and

maximize benefits associated with research involvement.
The principle of autonomy ensures that informed consent includes full disclosure
of risks and benefits and that the privacy of subjects is respected.
Remember:
Social justice was about being “fair” with the allocation of health care resources

179. The process of developing and adopting quality standards
for clinical practice
(a) is dependent on providers being mandated for reporting data.

(b) is ineffective in changing physician practice patterns.
(c) allows health insurance providers to deny reimbursement for
care.
(d) helps to form expectations for safety among both providers
and consumers.

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

END OF 2008
Copyright © 2008
Chicago, Illinois

2009
Copyright © 2009
Chicago, Illinois

59. As compared to children with severe traumatic brain injuries,
children with severe anoxic encephalopathy are more likely to have
(a) rigidity and decreased rate of regaining consciousness.

(b) rigidity and increased rate of regaining consciousness.
(c) hypotonia and decreased rate of regaining consciousness.
(d) hypotonia and increased rate of regaining consciousness.

Answer: A
Commentary: Compared to children with severe traumatic brain
injury, children with severe anoxic encephalopathy are less likely to
regain consciousness; they also have shorter survival time, and often
have profound rigidity.
Note:
Think about the spasticity from the anoxic injury that causes spastic
tetraplegic cerebral palsy

79. Which maternal factor is associated with an increased risk of spina
bifida?
(a) Anticonvulsant medications during pregnancy

(b) Upper socioeconomic class
(c) Alcohol ingestion during pregnancy
(d) Folic acid 4mg/day prior to and during pregnancy

Answer: A
Commentary: The etiology of spina bifida is multifactorial. Both polygenic
inheritance and environmental influences contribute. Several studies have
shown that the incidence of spina bifida is reduced if food is fortified with
folic acid or if mothers take folic acid prior to conception and during
pregnancy. Recommended doses of folic acid are 0.4 mg/day in women
who are not at high risk and 4 mg /day in women at high risk (eg, those
with a family history of spina bifida). Some studies have also implicated
lower socioeconomic class and in utero exposure to anticonvulsant
medications as being risk factors. Maternal alcohol ingestion is not related
to an increased risk of spina bifida in a baby.

99. Children with L4-5 spina bifida are most likely to have
(a) equinus foot.

(b) cavus foot.
(c) knee flexion contractures.
(d) knee extension contractures.

Answer: D
Commentary: The knee extensors (quadriceps) are innervated at the L3-4
level, while the knee flexors (hamstrings) are innervated at the L5-S1 level.
A child with L4-5 preserved level would have quadriceps muscles that
work, while hamstrings will either be weak or absent. Foot muscles are
innervated at the L5-S2 levels.
Equinus and cavus feet result from asymmetric pull of foot muscles, which
would be seen in sacral levels of spina bifida.
So:
Knee extensors = L3-4
Knee flexors = L5-S1

109. A 6-month-old child with L4 spina bifida presents to your clinic. He also has
shunted hydrocephalus. Other than repair of his back and shunt placement, his
past medical history has been negative. On examination, you find that he has
full hip flexion against gravity and knee extension strength is at least 4/5. The
infant has no movement around the ankle. Feet are in neutral position. Hip
examination is symmetric. Which prediction is most accurate in this patient?
(a) The child is likely to be a functional community ambulator by age 5 years.

(b) The child is likely to be only a household ambulator.
(c) The child is likely to learn to crutch walk by 18 months.
(d) The child is likely to be only a wheelchair user.

Answer: A
Commentary: This child has a strong quadriceps muscle and no deformities
noted at 6 months of age. He is reported to be healthy. The best early
predictor of ambulation in children with spina bifida is a strong quadriceps
muscle. Negative predictors are spine and lower extremity deformities and
obesity. Children do not typically learn to use crutches until 3 to 5 years of
age or older.

119. Which statement is true about the asymmetric tonic neck reflex (ATNR)
or the symmetric tonic neck reflex (STNR)?
(a) The STNR is present at birth and fades away by 1 year.

(b) The STNR provides postural stability as the child goes from crawling to
standing.
(c) The ATNR appears about 6 months of age and fades away by 1 year.
(d) The ATNR is obligatory in all children at certain ages.

Answer: B
Commentary: The ATNR is also known as the fencer position and is a
neonatal reflex that disappears by 6 months of age. It is never obligatory
in normal children. The STNR appears about 6 months and disappears
by 1 year. It provides postural stability as the child makes the transition
from crawling to standing.
Asymmetric tonic neck reflex

The transition up into a crawling position is assisted by the emergence of
the STNR which enables extension of the arms and flexion of the legs at
the same time. However, the STNR has to be 'switched off' before the
baby can crawl forward as this involves a combination of flexion and
extension - e.g. in a cross-pattern crawl the right arm and left leg flex
while the left arm and right leg extend.

129. Your 3-year-old patient with cerebral palsy has a Gross Motor Function
Classification System (GMFCS) Level IV. Family is asking you what to
expect she will be able to do when she is a teenager. Which activity is the
highest level she is most likely to attain as a teenager?
(a) Independent ambulation in the household

(b) Independent ambulation in the community
(c) No independent mobility in the household
(d) Wheelchair use in the community

Answer: D
Commentary: The Gross Motor Function Classification System
(GMFCS) classifies mobility of people with cerebral palsy from I to V.
Level I is independent ambulation indoors and outdoors with no
assistive device. Level IV requires wheelchair for household and
community mobility.
Remember:
The Gross Motor Functional Measure (GMFM) evaluates motor changes
over time in children with cerebral palsy. It includes activities in prone
and supine positions, rolling, sitting, crawling, kneeling, standing,
walking, running, and jumping.

159. In terms of continuous quality improvement, a sentinel
event is defined as
(a) a benchmark event that sets the standard for patient care.
(b) an occurrence that requires dismissal of personnel.
(c) a single occurrence that is highly problematic or socially
unacceptable.
(d) an event that results in the opening of a new hospital
program.

Answer: C
Commentary: In terms of continuous quality improvement, a sentinel
event is defined as a single occurrence that is highly problematic or
socially unacceptable. Sentinel events will typically trigger an in-
depth root cause analysis to determine the cause of the event as well
as potential solutions. The focus of these investigations is to evaluate
the processes and systems that are in place rather than to focus blame
on individual practitioners.

189. What is the primary advantage of a body powered upper limb
prosthesis compared to a myoelectric prosthesis?
(a) Greater sensory feedback

(b) Moderate or no harnessing
(c) Less body movement to operate
(d) Enhanced cosmesis

Answer: A
Commentary:
The advantages of body powered upper limb prostheses include the
following factors: moderate cost, most durability, highest sensory feedback,
and a variety of prehensors available for various activities.
Their disadvantages are that they require the most body movement to
operate, have the most harnessing and require increased energy expenditure
to use.
Myoelectric and/or switch controlled upper limb prostheses have the

following advantages: they require moderate to no harnessing, require
fewer body movements to operate, have moderate cosmesis, provide more
function in proximal areas and, in some cases, provide a stronger grasp.
Battery powered prostheses are the heaviest and most expensive

prostheses. They also require the most maintenance, provide limited
sensory feedback and require extended therapy time.

END OF 2009
Copyright © 2009
Chicago, Illinois

2010
Copyright © 2010
Chicago, Illinois


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PEDIATRIC REHAB

SAE Questions 2001-2009

Sunday, January 17, 2010

Sunday, January 17, 2010

(a) creatine kinase values at the time of diagnosis.

Sunday, January 17, 2010

Sunday, January 17, 2010

Sunday, January 17, 2010

The incidence of spina bifida is 0.5 per 1,000

spinal muscular atrophy 1 in 25,000.

The annual incidence for traumatic brain injury in children is 1-2

Sunday, January 17, 2010

(a) knee extensors.

Sunday, January 17, 2010

Pelvic girdle weakness precedes shoulder girdle weakness by

Sunday, January 17, 2010

(a) phantom limb pain.

Sunday, January 17, 2010

Sunday, January 17, 2010

(a) avoidance of sedation.

Sunday, January 17, 2010

Typically, the position of comfort for a burned child is

Garments are fitted later in

Sunday, January 17, 2010

(a) at initial fitting.

(b) between 3 to 5 years of age.

(c) when sports activities are anticipated.

(d) when the child pulls to stand.

Sunday, January 17, 2010

A knee joint is added between 3 and 5 years.

Sunday, January 17, 2010

(a) diffuse fasciculations.

(b) gross motor delay.

(c) delay of postural responses.

(d) persistence of primitive reflexes.

Sunday, January 17, 2010

Obligatory persistent primitive reflexes are the

Sunday, January 17, 2010

(b) mental retardation.

(c) hearing impairment.

(d) oral motor apraxia.

Sunday, January 17, 2010

Pantomime = conveying a story by bodily movements only

Sunday, January 17, 2010

(a) spastic diplegia.

(c) spastic quadriplegia.

Sunday, January 17, 2010

Remember: cerebral palsy is the number one cause of

Sunday, January 17, 2010

Spastic diplegic cerebral palsy occurs most commonly in premature

Intrauterine stroke causes hemiplegia.

Neonatal hyperbilirubinemia most commonly causes athetosis.

Birth asphyxia is more commonly associated with spastic quadriplegic

Sunday, January 17, 2010

Cerebral salt wasting is manifested by

(b) low serum osmolality.

(c) high urine output.

Sunday, January 17, 2010

Diabetes insipidus is characterized by excessive FREE

SIADH is associated with decreased urine output,

Cerebral salt wasting is a result of a neural effect on

Sunday, January 17, 2010