SCI

115. Etidronate disodium (Didronel) is used in the manag ement of hete rotopic ossification to (a) improve range of motion. (b) reverse immature ossification. (c) reverse mature ossification. (d) prevent ossification.

115 (d) Etidronate blocks the late phase of bone formation (mineralization), by preventing the conversion of amorphous calcium phosphate to hydroxyapatite. The drug has no effect on the early phase of ossification.

152. As its mechanism of action, botulinum tox in (a) inactivates the calcium pump at the sarcop las mi c reticulum. (b) inhibits the troponin-tropomysin complex. (c) inhibits the production of acethylcholine. (d) inhibits the release of acethylcholine.

152. (d) Botulinum toxins act on the neuromuscular junction where they inhibit the release but not the production of acethylcholine (ACh). Botulinum toxin does not affect the sarcoplasmic reticulum, nor does it work at the troponin-tropomysin complex. Ref: Elovic E, Bogey R. Spasticity and movement disorder. In: DeLisa JA, Gans BM, Walsh NE, editors. Physical medicine and rehabilitation: principles and practice. 4th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. p 1435.

155. Which antispasticity medication is relatively contraindicated in individu als who have mot or in com pl ete s pina l cor d injur y? (a) Baclofen (Lioresal) (b) Dantrolene (Dantrium) (c) Diazepam (Valium) (d) Tizanidine (Zanaflex)

155 (b) Dantrolene sodium depresses the release of calcium from the sarcoplasmic reticulum and is unique in having a direct effect on skeletal muscles. It acts on all sk eletal muscles and may weaken partially innervated muscles, causing muscle s which are funct ional t o be coming no nfuncti onal.

27. Repeatedly lifting the shoulder past which degree of flexion or abduction is associated with an increased prevalence of shoulder disorders? (a) 10o (b) 30o (c) 45o (d) 60o

27 Answer: D Commentary: Repeatedly lifting the shoulder past 60 degrees of flexion or abduction is associated with an increased prevalence of shoulder disorders. Ref:a) Bjelle A, Hagberg M, Michaelson G. Occupational and individual factors in acute shoulder-neck disorders among industrial workers. Br J Ind Med 1981;38:356-63.(b) Ohlsson K, Attewell R, Paisson B, Karlsson B, Balogh I, Johnsson B, et al. Repetitive industrial work and neck and upper limb disorders in females. Am J Ind Med 1995;27(5):731-47.

45. The most common cause of upper limb pain in long-standing tetraplegia is (a) shoulder pain of radicular origin. (b) shoulder pain of musculoskeletal origin. (c) elbow pain of radicular origin. (d) elbow pain of musculoskeletal origin.

45 (b) In patients with quadriplegia, 55% reported pain in at least one region of the upper extremity. The shoulder was reported as painful in 46% of subjects; the most frequent diagnoses for shoulder pain were orthopedically related—tendinitis, bursitis, and osteoarthritis. Referred pain of cervical origin accounted for 33% of shoulder pain. In patients with paraplegia, symptoms of carpal tunnel syndrome were the most common complaint (66%).

45. In preparation for discharge from your rehabilitation unit, an i ndividual with T12 ASIA A paraplegia requests information regarding access to a home with 5 steps. You suggest a ramp that, for every 1 inch in elevation, should have a length of (a) 12 inches. (b) 8 inches. (c) 16 inches. (d) 24 inches. 46. Which adjuvant analgesic medication acts at ion channels to stab ilize neu ronal cel l mem bra nes?

45. (a) Ramps must have a 12-inch length for every 1-inch rise in elevation. This ratio is a minimum requirement. A ramp must often be longer for an individual with a higher level spinal cord injury to be able to independently navigate it. When space allows, a longer, less steeply inclined ramp is preferable.

55. The occurrence of renal calculi during the first 3 months after spinal cor d injury is rela ted t o (a) level of injury. (b) immobilization hypercalciuria. (c) method of bladder management. (d) number of urinary tract infections.

55 (b) Renal calculi occur in approximately 8% of patients with spi nal cord injury. Approximately 98% of renal calculi in persons with spinal cord injury are composed e ither o f calcium phosphate or magnesium ammonium phosphate. These stones a re typic ally asso ciated with urina ry tract i nfections (UTIs) . E arl y sto ne form at io n is li kely sec on dar y to imm obi liz ati on hy po calc em ia , wh ere as later st on e f ormat ion is secon dary to repeated UTIs and long term use of an indwelling catheter.

"125. The majority of new spinal cord injuries in the United States a re a resu lt of (a) violence.

(b) falls. (c) motor vehicle accidents. (d) sports." 125. (c) Automobile accidents account for 34.5% of new spinal cord injuries, falls 22.0%, gunshot wounds 17.2%, diving 4.5%, and motorcycle crashes 4.4%. These figures represent all races combined.

"25. A 25-year-old man with L5 complete paraplegia is admitted to you r rehabil itation s ervic e 2 weeks after his injury. On admission you note that he is tolerating an oral diet but has not produced a bowel movement for 6 days. At this point, you recommend (a) oxybutynin (Ditropan) 3 times a day. (b) a contact irritant suppository with digital stimulation daily. (c) manual removal of stool from the rectum 1-2 times daily.

(d) nasogastr ic decomp ressi on for a presumed ileus." 25. (c) Individuals with lower lumbar and sacral level injuries usually experience areflexic bowel function. The use of suppositories are usually not useful in these individuals, because of the absence of spinal reflex activity. Manual evacuation is often required for an effective bowel program in a lower motor neuron injury. Anticholinergic medications may lead to constipation.

"102. For a patient with hemiplegia who prefers to u se his legs and push his wheelchair backwards, the wheelchair should be configured with (a) the back edge of the seat lower than the fro nt edge. (b) a single arm drive mechanism on the non-he mip le gic side. (c) the large wheel axle plate moved to a more an te rior position. (d)

large wheels in the front and casters in the back." 102. (d) The casters should lead the rear wheels for the most common direction of travel. This will help reduce the possibility of the user flipping over when hitting an obstacle and will make the chair more directionally stable. Ref: Cooper, RA. Wheelchair selection and configuration. New York: Demos; 1998. p 204.

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

182. (a) A pure motor stroke (hemiplegia and dysarthria without sensory deficits) is caused by a lesion in the posterior limb of the internal capsule. Ref: Roth E, Harvey R. Rehabilitation of stroke syndromes. In: Braddom RL, Buschbacher RM, editors. Physical medicine and rehabilitation. 2nd ed. Philadelphia: WB Saunders; 2000. p 1131.

185. Which statement is TRUE regarding the vascular supply to the spinal cord? (a) The paired anterior spinal arteries provide circulation to the anterior tw o-thirds of the spina l c or d. (b) The posterior spinal artery is a single vessel that provides circulation t o the po sterior oneth ird o f the spi nal c or d. (c) The watershed region is supplied only via the radicular arteries. (d) The artery of Adamkiewicz provides circulation to the lumbosacral region.

185 (c) There is a watershed zone from approximately T4 to T6 that i s highly vulnerable to ischemia. The zone has 1 anterior and 2 posterior spinal arteries. T he artery of Adam kiewicz enters between about T9 and T10.

"145. Compared to individuals without spinal co rd in jury, individuals with spinal cord injuries have a (a) lower risk of osteoporosis. (b) higher risk of diabetes. (c) lower rate of dyslipidemia. (d) higher rate of prostate cancer.

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

"82. The mechanism of action of a phenol nerve block is

(a) reduction of calcium release from the sarcoplasmic reticulum. (b) agonist action at alpha-adrenergic receptor sites. (c) denaturation of protein in myelin sheaths and axons. (d) inhibiton of presynaptic acetylcholine release." 82. (c) Phenol acts as a neurolytic agent that denatures protein in myelin sheaths and axons. Dantrolene sodium (Dantrium) reduces calcium release from the sarcoplasmic reticulum. Tizanidine (Zanaflex) is an alpha-2 agonist. Botulinum toxin (Botox) inhibits acetylcholine release.

"185. Five weeks after sustaining a T6 complete spinal co rd injury , yo ur patient is noted to have new urinary incontinence with intermittent catheterization volumes of less than 150cc. Work-up is negative for a urinary tract infection. You consider starting

(a) tamsulosin (Flomax). (b) tolterodine (Detrol). (c) terazosin (Hytrin). (d) bethanechol (Urecholine)." 185. (b) The patient is likely developing spontaneous detrusor contractions. You would consider using an anticholinergic agent to decrease detrusor (and hence bladder) pressures. Ideally, you would obtain urodynamic studies to ascertain bladder pressures and detrusor-sphincter coordination and would use these findings to guide treatment.

55. Regarding the American Spinal Injury Association (ASIA) classification in progn osti ca tin g r eco very, (a) ASIA class A has a reasonable probability of improvement if there is no concurr ent br ain in jur y. (b) preservation of pinprick in ASIA class B carries a better potential for ambulat ion th an pre ser vatio n of li ght t ouc h s ensation . (c) recovery statistics for ASIA class C do not include the central-cord syndrome. (d) Brown-Séquard's syndrome has the worst potential for ambulation in ASIA class D .

(b) The presence of sensation in the sacral (S3-S5) dermatomes in patients with motor complete injury indicates a favorable prognosis in terms of motor reco ver y, w ith p inp rick sparing hav in g the cl ose st corr elat ion for motor r ecovery. Moto r se gments in the zon e o f injury in pa tie nts w ith co mp lete injury and an initial stre ngth of 0/ 5 w ere more li kel y to rec ove ry strengt h of 3/5 or more at 1 year if the sensation in the corresponding dermatomes was intact. Most patients originally categorized as ASIA (or Frankel) class A who progressed to ASIA class D or E had sustained traumatic brain injury with cognitive impairment and were incorrectly diagno sed ini tiall y a s cla ss A.

"195. Trauma to the sacral roots would most lik ely r esult in (a) vesicoureteral reflux.

(b) incontinence. (c) detrusor hyperreflexia. (d) small bladder capacity. " 195 (b) Damage to the sacral roots usually results in a flaccid bladder. Incontinence often occurs due to a weak sphincter mechanism, particularly if the patient has increased bladder volume or an increase in intraabdominal pressure. However, the external sphincter may not always be affected to the same degree as the detrusor. This imbalance results in bladder overdistension and the possibility of upper tract deterioration. Ref: Linsenmeyer TA. Neurogenic bladder following spinal cord injury. In: Kirshblum S, Campagnola D, DeLisa J, editors. Spinal cord medicine. Philadelphia: Williams & Wilkins; 2002. p 198-200.

"85.

Based on the revised edition of the American Spinal Injury Asso ciation ( ASIA) Imp airme nt Scale, published in the year 2000, which condition would be sufficient to categorize a spinal cord injury as motor incomplete? (a) Some motor function more than 2 levels below the motor level (b) Voluntary anal sphincter contraction (c) A well-defined zone of partial preservation (d) An anterior spinal artery syndrome" 85 (b) For an individual to receive an ASIA classification of motor incomplete injury (ASIA C or D), he/she must have either voluntary anal sphincter contraction or sensory sacral sparing with sparing of motor function more than 3 levels below the motor level. The zone of partial preservation is used only in complete injuries. Individuals with anterior spinal artery syndrome are often motor complete.

85. Autonomic dysreflexia is most commonly precipitated by (a) bladder distension (b) bowel impaction (c) heterotopic ossification (d) atelectasis

85. (a) Autonomic dysreflexia occurs in individuals with spinal cord injuries at the level of T6 and above. It occurs because of sympathetic discharge resulting from a stimulus below the injury level. The most common cause is bladder distension, which can result from a clogged or kinked indwelling urinary catheter or from delayed intermittent catheterization. Bowel impaction is the second most common cause of autonomic dysreflexia.

"39.

In which activity should a 16-year-old girl with C5 ASIA class A spinal co rd injur y be ind epend ent w ith t he u se of a ssist iv e dev ices? (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 per form bladder self-catheterization with assistive devices, girls do not. Level transfers req uire activ e elbow and wrist extension, which would not be present in a person with C 5 SCI. S elf-feedi ng with ass istive de vices s uch as a palmar ban d c an us ual ly b e do ne by p erso ns w it h C 5 te trap leg ia.

"45. Your patient has a C6 ASIA class A spinal cord injury which he sustained 8 week s ag o. He ha s b een n onco mpl iant abo ut attendin g t he rapy . T od ay he refuses to participate in therapy because he states he has a headache. The nurses report poor urine output from the Foley catheter in the last 3 hours. You order (a) intravenous bolus of normal saline. (b) push oral fluids and go to therapy. (c) replacement of catheter. (d)

visit from peer mentor." 45 (c) Autonomic dysreflexia must be ruled out. A Foley kink, or plugged catheter can distend the bladder, causing autonomic dysreflexia with headache (and, ul tim atel y, hy per tensi on, piloere ct ion and flu shi ng). The ca theter shoul d be checked for twists an d kinks and be flush ed. I f u rine/ flush re turn is poo r, th e catheter shou ld be c han ged .

"85. On hospital rounds, you note that yo ur pat ient, who has a T10 ASIA B spinal cord injury is now using a rigid frame wheelchair in the therapy gym. In his attempt to show off as he propels toward you, he suddenly flips over backward. What is the most likely problem?(a) The rear axles are locat ed d irect ly under his center of gravity. (b) The rolling resistance i s in creas ed. (c) There is too much caster flu tter. (d) There is asymmetry in th e ch air's ca mber a ngle from side to side.

" 85. (a) The center of gravity for a hypothetical wheelchair rider is typically located slightly forward of the rear axle. Moving the rear axle directly under the wheelchair user makes the person and the chair more likely to flip backwards (wheelie). However, the advantages to having the center of gravity near the rear axles include decreased tendency for caster flutter, decreased rolling resistance, since most of the weight is borne by the larger rear wheels, and minimization of the turning torque.

"65. A 21-year-old man is evaluated in your spinal cord i njury cli nic 12 months after a C2 complete spinal cord injury requiring full-time mechanical ventilation. You recommend

(a) avoiding a breath control system for his power wheel chair. (b) aggressive diaphragmatic strengthening exercises. (c) initiating a weaning protocol by slowly decreasing t idal volu me. (d) an electrodiagnostic study to evaluate for a phrenic nerve pa cema ker." 65. (d) It is unlikely that an individual will be able to wean from a ventilator if he is still completely dependent on mechanical ventilation 12 months after a C2 complete injury, so a weaning protocol and diaphragmatic strengthening are not indicated. An individual who requires mechanical ventilation can use a breath control system effectively. If electrodiagnostic testing indicate that the phrenic nerves are intact, then a phrenic pacemaker could be implanted, which would significantly reduce the need for mechanical ventilation.

"65.

(This question has been eli minat ed from t he exam, therefore, it was not scored.) Which statement is TRUE re gard ing p ers ons wi th complete spinal cord injury with concurrent posterior rhizotomy who receive functional neuromuscular stimulation via an implanted device to restore bowel and bladder function?(a) Stimulation of the poste rior S2, S3, S4 ne rve roots will produce micturition. (b) Stimulation will enhance ref lex v oid ing. (c) Stimulation will improve ref lexog eni c erec tion. (d) Stimulation will increas e bl adder ca pacity ." 65. (d) Because electrical stimulation for bladder and bowel function depends on the ability to activate intact motor neurons from the sacral segments of the cord, it is at this time limited to persons with suprasacral lesions. Micturition is produced by stimulation of the anterior (motor) S2, S3, and S4 nerve roots. Continence has been greatly improved by concurrent posterior rhizotomy of the (sensory) sacral nerve roots. The advantages of posterior rhizotomy include increasing bladder capacity and abolishing reflex voiding, reducing dyssynergia and abolishing episodes of autonomic dysreflexia. The primary disadvantage of posterior rhizotomy is the loss of reflex erection and reflex ejaculation (if these are present). The hardware cost is approximately $40,000 with the projection that after factoring in the cost of medications, supplies, medical procedures, durable medical equipment, and attendant care, the device pays for itself in 5 to 7 years.

"45. Which statement is correct regarding the m ana ge ment of labor and delivery for women with cervical spinal cord injuries?

(a) Pre-eclampsia is 3 times more likely to oc cur t han in able-bodied women. (b) Vaginal delivery is contraindicated. (c) Autonomic dysreflexia occurs 60%--80% of t he ti me. (d) Spinal and epidural anesthesia are contrai ndi ca ted" 45. (c) Women with paraplegia or tetraplegia can give birth vaginally and caesarean delivery is rarely necessary. Patients with neurologic levels above T6 are at risk for autonomic dysreflexia during pregnancy, labor, and delivery. Autonomic dysreflexia is reported to occur in 60% to 80% of women with SCI with lesions above T6. Preeclampsia occurs with the same frequency in able-bodied women and women with disabilities. Complications from autonomic dysreflexia may be severe and include encephalopathy, cerebrovascular accidents, death of the mother, and severe fetal asphyxia. Spinal or epidural anesthesia extending to the T10 level is the treatment of choice and the most reliable method of preventing and treating autonomic dysreflexia during labor and delivery. Ref: Jackson A. Women's health challenges after spinal cord injury. In: Lin VW, editor. Spinal cord medicine principles and practice. New York: Demos; 2003. p 842-5.

"25. An individual with C7 ASIA D tetraplegia must have

(a) a bulbocavernosus reflex and voluntary sphincter con traction. (b) a muscle grade of 3 or greater in at least half of t he key mu scle s below C7. (c) normal pinprick and light touch sensation through th e sacral derm atomes. (d) normal strength (5/5) in the C7 myotome." 25. (b) A bulbocavernosus reflex does affect American Spinal Injury Association (ASIA) scoring, and voluntary sphincter contraction is not a mandatory component of ASIA C or D. Muscle grade of less than 3 in at least half of the key muscles below C7 would be characterized as ASIA C. Someone with ASIA B through E must have some retained sensation in the sacral segments S4-S5 but that sensation can be normal or impaired. To classify the injury as C7 ASIA D would require a motor score of at least 3 out of 5 in the C7 myotome with normal strength in C6.

"140. The primary advantage of mag wheels over spoked whe els in th e pe rformance of a wheelchair is

(a) lighter weight. (b) reduced maintenance. (c) more maneuverability. (d) general preference by active wheelchair users." 140. (b) Although MAG wheels require minimum maintenance and wear well, spoked wheels are substantially lighter, more responsive, and are generally preferred by active wheelchair users.

"135. Which statement is TRUE regarding spasticity in the individual with spin al cord i njury ? (a) Most antispasticity medications can completely eliminate spastic ity. (b) The incidence of spasticity is higher in individuals with lower thoracic spinal co rd in jur y than in those with cervical spinal cord injuries. (c) Spasticity can offer a functional benefit to some individuals wi th spinal cord inj uries .

(d) Clonus is an example of a tonic stretch reflex." 135 (c) No single medication for spasticity is universally beneficial and reduction of spasticity, rather than elimination of it, is the more likely outcome. The incidence of spasticity is higher in individuals with cervical and upper thoracic injury than in those with lower thoracic injury. Lower extremity tone may be helpul for activities such as transfers, standing, and ambulation. Spasticity is often characterized as either phasic or tonic. Tonic spasticity is seen as increased tone. Phasic spasticity is usually seen in hyperactive tendon jerks.

"115. In an individual with a C6 complete spinal cord injury, the ability to generat e a "p inc h" is produ ced by (a) wrist extension. (b) elbow supination (c) wrist flexion.:

(d) elbow pronation." 115 (a) Wrist extension via extensor carpi radialis results in passive shortening of the (finger) flexor tendons. This phenomenon is termed tenodesis.

"135. A 46-year-old man with a 1-year history of C8 ASIA A spinal cord injury presents to your clinic with a 1-month history of increasing bilateral upper extremity weakness and pain. There is no history of trauma. You would (a) observe for 2 to 4 weeks and repeat ASIA exam. (b) perform electrodiagnostic testing to rule out periph eral nerv e co mpression. (c) order a magnetic resonance imaging study to look for posttrau mati c syringomyelia.

(d) initiate a workup for pernicious anemia." 135. (c) Posttraumatic syrinx results in neurologic decline in 3% to 8% of patients with spinal cord injuries and can develop 2 months to 30 years after spinal cord injury. Prompt diagnosis is essential and magnetic resonance imaging is usually definitive for diagnosing posttraumatic syrinx. Surgical treatment is usually indicated when there is clear neurological decline.

100. Which spinal orthosis is used to prevent thoracic spinal flexion by providing 3-po in t p res sur e ove r th e s ternu m a nd pubis an ter io rly and t he upper lumbar spine posteriorly? (a) Custom molded, plastic thoracolumbosacral orthosis (b) Lumbosacral corset with posterior metal stays (c) Jewett orthosis (d) Taylor orthosis

100 (c) Several different types of thoracolumbosacral (TLSO) orthoses are available to control segmental spine motion in this region. A custom molded plastic TL SO prov ides alm ost t otal contac t support for un ifor m pr ess ure distribu tion and cont rol of mot ion in all pla ins. A lu mbo sa cra l cor set wi th metal stay s pro vi des supp ort c ircum fe ren tia lly and hel ps reduc e s pin e m otion p rimarily in the lumbosacral region. A Taylor orthosis also provides circumferential support with the addition of axillary straps. The Taylor orthosis is primarily designed to resist flexion and extension. A Jewett brace is designed to limit thoracic spine flexion by providing 3-point pressure over the sterum and pubis anteriorally and the upper lumbar spine posteriorally. This type of brace is used most commonly for individuals with thoracic spine anterior compression fractures.

105. What is the most common level of occult spine fracture after trauma that is mi ssed b y p lai n r adiog raph s? (a) C7/T1 (b) T5/T6 (c) T12/L1 (d) L4/L5

105 (a) Occult cervical fractures are most often seen at the C1 and C7 levels. By adding computed tomography (CT) scanning to the evaluation of trauma patients, a sign ifica nt numbe r of occult c ervical fra ctu res can be diagnosed. O f spinal frac ture s, 5%- 0.3 are mul tip le and ma y a pp ear at n oncont ig uous levels . Thu s, radiogr aphic eval ua tio n o f th e en tir e s pinal ax is is necessa ry whenever injury at 1 region of the spine is detected.

105. In regards to quality of life after spinal cord injury, which f actor has the LEAS T cor rel ation with life satisfaction? (a) Level of injury (paraplegia versus tetraplegia) (b) Access to leisure activities (c) Marriage (d) Number of hospitalizations

105. (a) The highest levels of life satisfaction for individuals with spinal cord injuries have been correlated with employment, education, number of hospitalizations, marriage, time since injury, leisure activities, social support, and adequate finances. Little correlation has been found between level of injury and life satisfaction.

175. Your adult patient with a spinal cord inj ury n eeds to access his bathroom in his standard-width wheelchair. If no turn is required following entry into the bathroom, the minimal width of the doorway should be (a) 26 inches. (b) 32 inches. (c) 36 inches. (d ) 40 inches.

175. (b) The proper minimum width of a doorway for a wheelchair without a turn is 32 inches. If a turn is involved, then the doorway width should be at least 36 inches. Ref: Hsiao I, Hodne T. Architectural considerations for improving access. In: Lin VW, editor. Spinal cord medicine principles and practice. New York: Demos; 2003. p 975-86.

105. Compared with able-bodi ed i ndivi dua ls, pe rsons with spinal cord injury are likely to have(a) equivalent percentage of reg ional an d tota l body lean tissue. (b) higher testosterone leve ls. (c) equivalent incidence of dysl ipide mia . (d) a lower resting metaboli c ra te.

105. (d) In persons with spinal cord injury, there is an initial dramatic loss of muscle mass after the acute paralysis. However, even decades after injury, there is continuous loss of lean body tissue compared to that observed in an able-bodied person. It is of particular interest that the arms of persons with paraplegia have significantly less percent lean tissue compared with controls. No differences in the cross sectional rate of loss of lean body mass is noted between persons with tetraplegia and paraplegia. Men with spinal cord injury can be expected to lose about 3.2% per decade of the total lean body tissue vs. 1% per decade in able-bodied males. Individuals with spinal cord injury have a pattern of metabolic alteration that is atherogenic with dyslipidemia, glucose intolerance, insulin resistance, and reduction in metabolic rate. Although the literature in persons with spinal cord injury is conflicting regarding anabolic hormonal changes in persons with spinal cord injury, there are subsets of individuals with relative androgen deficiency states. The etiology of a relative deficiency of testosterone in persons with spinal cord injury has not yet been established. However, it is conceivable that prolonged sitting and euthermia of the scrotal sack and testes may itself have a deleterious local effect on testosterone production.

115. The management of acute spinal cord compression due to tumor includes (a) nerve growth factor. (b) thoracolumbosacral orthosis (TLSO). (c) corticosteroids. (d) urecholine.

115 (c) Corticosteroids are indicated in acute spinal cord compressi on in an effort to reduce the tumorrelated inflammatory changes and prostaglandin productio n. The dos e, howe ver, is controversial. Radiation therapy is indicated for patients wi th spi nal cord compres sion due t o s oft tis sue encroachment . I t c an be em ploy ed a s monot hera py i n cas es o f sp ina l s tab ility , with o r with out ne urolo gic c han ges, or as an adj unctive therapy to surgery for patients with spinal instability. The major complications of radiation treatment include the development of radiation myelopathy, radiation plexopathy, and tumor recurrence. However, radiation therapy is indicated for these individuals to provide decompression of neural structures and cytoreduction of the tumor, prevention of neurologic progression and prevention of local recurrence, and for relief of pain. Most surgeons will not consider surgical intervention if the patient has a prognosis of less than 3 months' survival when faced with the question of surgical management of tumors. With either a primary or metastatic spine tumor, commonly a corpectomy will be performed. In this procedure most of the involved vertebral body and the intervertebral disk above and below the involved vertebra are excised. Since the majority of corpectomies for spine tumors involve metastatic disease, the goal of surgery is palliation rather than sur gical cure . Corticosteroids are indicated in acute spinal cord compressi on in an effort to reduce the tumorrelated inflammatory changes and prostaglandin productio n. The dos e, howe ver, is controversial. Radiation therapy is indicated for patients wi th spi nal cord compres sion due t o s oft tis sue encroachment . I t c an be em ploy ed a s monot hera py i n cas es o f sp ina l s tab ility , with o r with out ne urolo gic c han ges, or as an adj

115. Which statement is TRUE regarding treatment of spasticity in in dividuals with spi nal c ord injuries? (a) Over 75% of individuals require treatment for their spasticity a t the tim e of disc harge fr om rehabilitation. (b) The use of a muscle relaxant such as carisoprodol (Soma) is effe ctive in spasticit y of spi nal origin. (c) Botulinum toxin injections are effective because of their long ( 6-12 mont h) durati on of ef fect. (d) Intrathecal baclofen delivery often eliminates the need for oral antispas ticity me dicat ion .

115. (d) Less than 40% of individuals with spinal cord injuries require treatment for their spinal cord injury at the time of discharge from acute rehabilitation. There is no evidence to support the use of carisoprodol in spasticity of spinal origin. The average duration of effect for botulinum toxin is 3 to 6 months.

120. In a person with comple te p arapl egi a, whi ch gait has the highest energy expenditure per meter?(a) Swing-through gait in st anda rd kn ee- ankle- foot orthoses(b) Swing-through gait in Sc ott- Craig kn ee-ank le-foot orthoses(c) Reciprocating gait in a reci proca tin g gait orthosis(d) Swing-to gait using a st anda rd wa lke r

120. (c) Energy expenditure in paraplegia is as follows (in order of lowest to highest): normal walking, swing-through gait in a Scott-Craig knee-ankle-foot orthosis (KAFO), swing-through gait in a standard KAFO, reciprocating gait in a reciprocating gait orthosis. Swing-through gait in a reciprocating gait orthosis requires approximately the same energy expenditure as the Scott-Craig KAFO.

125. Baclofen is thought to reduce spasticity by (a) preventing the release of calcium from the sa rc oplasmic reticulum. (b) blocking sodium and potassium channels. (c) depressing of brainstem neuronal activity. (d) acting as a gamma-aminobutyric acid agonis t.

125. (d) Baclofen is an analog of gamma-aminobutyric acid (GABA), a neurotransmitter that exerts inhibitory activity on monosynaptic and polysynaptic reflexes. Dantrolene prevents the release of calcium from the sarcoplasmic reticulum. Ref: Priebe MM, Goetz LL, Wuermser LA. Spasticity following spinal cord injury. In: Kirshblum S, Campagnola D, DeLisa J, editors. Spinal cord medicine. Philadelphia: Lippincott-Williams & Wilkins; 2002. p 221-33.

129. Your 10-year old patient with T6 ASIA class B paraplegia complains of right kn ee p ai n. On exa minat ion the re is no sw elling o f t he kne e o r 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. Whi le h ip ad duc tor s pasticity c on tributes to su blux atio n o r dislocatio n, the spasti city itsel f i s not pa inf ul. Dyses the ti c p ain i s usua ll y generaliz ed. A n abnormal knee exam in ati on is u sual ly fou nd in a kne e i njury t hat causes pain.

135. Which factor is associated with successful phrenic nerve pacing for indep endent r espirati on in pa ti ents with tetr ap legia ? (a) Initiation of pacing shortly after injury (b) Location of injury at or above C2 (c) The presence of central sleep apnea (d) Ability to breathe on t-piece for 15 minutes

135 (b) Electrophrenic respiration or phrenic nerve pacing should no t be performed until at least several months after injury, since some patients recover diap hragmatic functio n over a period of several months. Criteria for use of phrenic nerv e pacing include an inju ry a t or a bov e C2, w ith intact phren ic ner ve s. Mos t pa ti en ts inju red at C 3, C4 , or C5 sho uld be able t o we an f rom the ve ntila tor . Som e ris k exists wit h phrenic pacing because the electric transmitter can fail. Additionally, patients may not be able to develop a deep enough breath with this technique to prevent atelectasis. Electrophrenic pacing is expensive and requires extensive training of personnel who will care for patients. There must be a backup ventilator in the event of electrophrenic failure.

135. In spinal cord injury, increased reports of pain are seen more commonly in pat ient s wit h (a) complete spinal cord injury. (b) hypercalcemia. (c) gunshot wound. (d) surgical stabilization.

135 (c) The prevalence of pain in spinal cord injury (SCI) has been reported to be as high as 94%. It is reported to interfere with activities of daily living i n 5 % to 0.45 of patie nts with sp in al cord inj ury . Th e on set of SCI pain typically oc curs withi n t he first ye ar of inj ury i n t he ma jority o f patients. Pain i s report ed to decr ea se in inte nsit y a nd frequ enc y o ver time. Factors related to self-reported pain include patients with older age, incomplete spinal cord injury, cauda equina injuries, cervical spinal cord injury, central cord syndrome, gunshot wound injury, and syringomyelia.

135. In a 22-year-old man wh o in curre d a n acut e C5-6 fracture-subluxation (complete C5 tetraplegia), from diving with an initial restoration of arm function includes(a) upper extremity tendon t rans fers as early as possible to enhance goals for acute rehabilitation. (b) splinting in a flat hand pos ition to avoid tightening of the flexor tendons. (c) a short opponens orthosi s or uten sil cuff to initiate self-care activities. (d) exclusive use of a manua l wh eelch air to en hance upper extremity muscle strength.

135. (c) For persons with tetraplegia, proper hand position is maintained by resting hand splints that allow tightening of the flexor tendons; this tightening promotes the use of tenodesis for hand function. Functional activities improve significantly with the addition of wrist extensor muscles at the C6 level. Active wrist extensor result in tenodesis of the hand. With wrist control, patients can use a short opponens orthosis or utensil cuff to feed themselves. While patients with tetraplegia usually benefit from a lightweight, manual wheelchair, these patients are often appropriate for powered mobility. The energy saved from pushing the wheelchair can be used for transfers, weight shifts, and other activities, reducing the wear and tear on joints and soft tissues. Tendon transfers and upper limb reconstructive surgery are considered 1 year postinjury, keeping in mind that upper limb muscle recovery can occur over the course of up to 2 years.

145. What is one reason for placing a suprapubic cathete r in a pe rson with a complete cervical spinal cord injury who currently uses intermittent catheterization? (a) Decreased rate of bladder/kidney infections (b) Decreased high bladder pressures (c) Decreased rate of bladder/kidney stone formation (d) Reduced risk of developing autonomic dysreflexia

145 (b) The rates of infections and stones are higher with suprapubic catheters. An indwelling catheter results in a slight increased risk of bladder cancer. High internal bladder pressures may occur as a result of detrusor sphincter-dyssynergia and avoiding reflux by allowing continuous drainage can be safer than intermittent catheterization for some individuals.

145. Women who have sustained a spinal cord injury and become pregnant after injury are noted to have pregnancy-related complications including (a) high-birth-weight babies. (b) late-onset labor. (c) pressure sores. (d) higher than average spontaneous abortions.

145 (c) Women who become pregnant after sustaining a spinal cord injury undergo spontaneous abortions in the first trimester at the same rate as uninjured women; however, the incidence of premature and small-for-date babies is higher than normal. In addition, the spinal-cord-injured woman is known to have pregnancy-related complications such as urinary tract infections and pressure sores.

149. The most common musculoskeletal abnormalities seen in a chil d wi th L5 myelodysplasia with sparing of the L5 segment and above are (a) cavus foot, early hip dislocation, hip and knee flex ion contr actu res. (b) calcaneus foot, late hip dislocation, hip and knee f lexion co ntra ctures. (c) cavus foot, late hip dislocation, hip adduction cont ractures. (d) calcaneus foot, early hip dislocation, hip adduction contract ures .

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.

15. Compared to persons with traumatic spinal cord injury, persons with non-tr aumatic spinal c ord i nju ry are more like ly to b e (a) under the age of 35 years. (b) female. (c) tetraplegic. (d) single.

15 (b) Persons with nontraumatic spinal cord injury (SCI) are older , more likely married, female, retired, and have significantly more paraplegia and incomple te injury than pe rsons with SCI of traumatic etiology, with neoplasm (53%) and cervi ca l spon dylosis ( 25%) as the leadi ng causes of nontraumatic inj ury .

15. The best possible expected functional outcome for a person with C7 ASIA A spinal cord injury is (a) dependent with bladder, independent with bed mobility, and some assist with all transfers. (b) dependent with bladder, independent with bed mobility, and independent with level transfers. (c) independent with bladder, some assist with bed mobility, and independent with some transfers (d) independent with bladder, independent with bed mobility, and independent with level

15 (d) Expected functional outcomes after traumatic spinal cord injury have been delineated in the clinical practice guidelines for health care professionals. A person who has sustained a C7-8-level spinal cord injury can best be expected to need assistance in clearing secretions, may need partial to total assistance with a bowel program, and may be independent with respect to bladder management, bed mobility, and transfers to level surfaces. Adaptive equipment is listed in these tables (FIM (functional independent measures) purists can argue that these persons really are only modified independent).

15. What function is expected in an individual with a C7 ASIA class A spinal cord i njur y? (a) Need assistance to perform level transfers (b) Pressure reliefs primarily by side-to-side weight shift (c) Independence in bowel and bladder management (d) Independent dressing and bathing with adaptive equipment

15 (d) For persons with motor level C5, activities of daily living include drinking from a cup and feeding with static spoons and set-up, some oral/facial hygi ene , wr iting an d typ ing with eq ui pment, a nd pos sibl y so me upper-body d ressing. At t he C 6 inju ry level, i ndi viduals a re ab le to fe ed and p erform uppe r bod y dressing with set- up an d c an p erfo rm lev el su rfa ce tra nsfers with assistance. Persons with motor level C7 ASIA class A should be able to independently feed, dress, and bathe themselves, using adaptive equipment and built up utensils. They should be independent with bed mobility, and level surface transfers and should be able to propel a wheelchair outdoors. Independence in bowel and bladder function is generally seen with injury at level T1 and lower.

15. An individual with T4 ASIA C paraplegia must have (a) normal sensory function below T4. (b) sensation in the sacral segments S4-S5. (c) a muscle grade of 3 or greater in at least half of the key muscles below T4. (d) voluntary sphincter contraction.

15 Answer: B Commentary: All ASIA levels except ASIA A must include sensation through the sacral segments S4-S5. The ASIA C classification can include voluntary sphincter contraction but it is not required. An injury classed as T4 ASIA C would include sensation below T4 but the sensation may be normal or impaired. A muscle grade of less than 3 in more than half of the key muscles below the neurologic level would be expected with ASIA C. Ref: American Spinal Cord Injury Association, International Medical Society of Paraplegia. International standards for neurological and functional classification of spinal cord injury. Chicago: American Spinal Cord Injury Association; 2006.

15. Based on the revised edition of the Americ an Sp inal Injury Association (ASIA) Impairment Scale, published in 2000, which condition would be sufficient to categorize a spinal cord injury as motor incomplete? (a) Some motor function more than 1 level belo w t he motor level (b) Voluntary anal sphincter contraction (c) A well-defined zone of partial preservatio n (d) An anterior spinal artery syndrome

15. (b) For an individual to receive an ASIA classification of motor incomplete (ASIA C or D), he/she must have either voluntary anal sphincter contraction or sensory sacral sparing with sparing of motor function more than 3 levels below the motor level. The zone of partial preservation is used only in complete injuries. Individuals with anterior spinal artery syndrome are often motor complete. Ref: American Spinal Injury Association/International Medical Society of Paraplegia. International standards for neurological and functional classification of spinal cord injury patients. Chicago:ASIA/IMSP; 2002.

15. For persons with spinal cord injury who survive the first 24 hours, what is the leading cause of death the first year post-injury?(a) Pulmonary embolism(b) Pneumonia(c) Renal insufficiency(d) Nonischemic heart diseas e

15. (b) The leading cause of death for persons with spinal cord injury who survive more than 24 hours is pulmonary dysfunction (pneumonia, adult respiratory distress syndrome) followed by nonischemic heart disease, septicemia and pulmonary embolus.

150. One disadvantage to adding camber to a wheelchair is that it (a) decreases side to side stability. (b) exposes the hands to injury. (c) results in poor ergonomic positioning of push rims. (d) makes maneuvering in narrow spaces difficult.

150. (d) Camber has several advantages. The footprint of the chair is widened creating greater side to side stability; camber allows quicker turning; camber helps to protect the hands by having the bottom of the wheels scruff edges; and camber positions push rims more ergonomically for propulsion. A disadvantage is that the increased width of the wheelchair may make it difficult to maneuver in an environment made for walking (ie, narrow spaces).

16. Which scale evaluates sensory perception, moisture, activity, mobility, nutrition, and friction/shear to determine risk of pressure ulcers? (a) Norton (b) Barthel (c) Braden (d) Beck

16 Answer: C Commentary: Both the Braden scale and the Norton scale are used to assess pressure ulcer risk. The Braden scale consists of 6 factors: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. The Norton scale assesses 5 factors: physical condition, mental condition, activity, mobility, and incontinence. The Barthel index measures activities of daily living and mobility and is not related to assessing pressure ulcer risk. The Beck Depression Inventory and Beck Anxiety Inventory are not related to pressure ulcers. Ref: (a) O'Connor K. Pressure ulcers. In: Physical medicine and rehabilitation: principles and practice. 4th ed. DeLisa JA, Gans BM, Walsh NE, editors. Philadelphia: Lippincott Williams and Wilkins; 2005. p 1609. (b)Cheville AL. Palliative care. In: Physical medicine and rehabilitation: principles and practice. 4th ed. DeLisa JA, Gans BM, Walsh NE, editors. Philadelphia: Lippincott Williams and Wilkins; 2005. p 533.(c) Christiansen CH. Functional evaluation and management of self-care and other activities of daily living. In: Physical medicine and rehabilitation: principles and practice. 4th ed. DeLisa JA, Gans BM, Walsh NE, editors. Philadelphia: Lippincott Williams and Wilkins; 2005. p 983.

165. You are caring for a patient with a T3 ASIA class A spinal cord injury who com plai ns of bu rni ng pa in i n h is le gs. Ad ditional re vi ew o f s ys tems includes urinary leakage between catheterizations, sexual dysfunction, and difficulty sleeping. The best pharmacologic intervention at this time would be (a) amitriptyline (Elavil). (b) paroxetine (Paxil). (c) trazodone (Desyrel). (d) fluoxetine (Prozac).

165 (a) Amitriptyline, a tricyclic antidepressant is among the classic first line treatments in neuropathic pain. Most common side effects related to tricyclic ant idep ressa nts are related mai nl y to the an tic holi nerg ic effects and include dry m outh , urin ary retenti on, and seda tio n. Fo r thi s pati en t who has d iffic ul ty sleep ing, as we ll as ur inar y le aka ge betwe en cat het erizati ons, the anticholinergic sideeffects may prove to be of benefit. Trazodone has not been demonstrated to reduce pain in for spinal cord injury. Paroxetine causes insomnia and sexual dysfunction and therefore would not be appropriate in this patient. Venlafaxine, sertraline, and fluoxetine have proven to be of limited benefit for neuropathic pain.

165. For an individual who has C5 tetraplegia, orthotic splinting att empts to maintain the functional position of the hand. This usually includes (a) closing the thumb web space. (b) 30º to 40º of metacarpophalangeal flexion. (c) promoting flattening of the palmar arch. (d) supporting the wrist in 20º to 30º of extension.

165. (d) The functional position of the hand includes supporting the wrist in 20º to 30º of extension, supporting the palmar arch with the 4th and 5th metacarpals slightly anterior to the second and third digits. Metacarpophalangeal flexion of 30° to 40° would be excessive. The thumb web space should be preserved.

25. Outcomes of inpatient rehabilitation for neoplastic versus traumatic spinal cord injury reveal that (a) indices for depression were significantly higher in patients with neoplastic injury. (b) patients with neoplastic spinal cord injury had significantly shorter lengths of stay. (c) rate of functional change was significantly better in the traumatic population. (d) neoplastic spinal cord injury was associated with a significantly higher rate of discharge to the community.

25 (b) Patients with neoplastic spinal cord compression tend to be older than their traumatic counterparts, with a peak incidence between 50 and 70 years. Significant differences exist with regard to the level of injury; tumors involving the spinal cord tend to involve the thoracic and lumbar regions more than the cervical region. There was a shorter rehabilitation length of stay in patients with neoplasms. (This may allow patients to have more time at home with their families. These patients had an increased percentage of paraplegia and incomplete injury.) Patients with tumors did demonstrate a trend toward lower rate of discharge to the community, but this was not significant.

25. What is the leading cause of traumatic spinal cord injury in the United St ates? (a) Falls (b) Sports related injury (c) Gunshot wound (d) Motor vehicle crash

25 (d) The leading cause of traumatic spinal cord injury in the Uni ted States is motor vehicle crash. The incidence of spinal cord injury from gunshot wounds is decreas ing nat ionally; falls are now the second most common cause nationwide, fol lo wed by sports r elated inju ries.

25. In the emotional stages of recovery from spinal cord injury, most individuals (a) have prolonged feelings of guilt or worthlessness. (b) undergo a true depressive episode. (c) experience bereavement. (d) feel diminished interest or pleasure in almost all activities.

25. (c) Although the pattern of emotional reaction is unique to every person, coping with a spinal cord injury normally involves sadness, yearning, and intense feelings of loss. While bereavement might appear similar to depression, it does not ordinarily involve prolonged feelings of guilt, worthlessness, self-reproach or thoughts of death as seen in depressive disorders. Because grieving or bereavement is universal in the context of spinal cord injury, it is important to differentiate bereavement from a depressive disorder.

29. Which statement is true rega rding sp inal c ord injury without obvious radiologic abnormality in children?(a) It most commonly occurs in l umbar ra ther t han cervical injuries. (b) There is a lower inciden ce i n you nge r chil dren. (c) It is associated with la rger head si ze and relatively weak neck muscles. (d) Neurologic impairmen, if it occur s, is usu ally 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.

35. Five weeks after sustaining a T6 spinal cord injury, your patient is noted to have urinary incontinence with intermittent catheterization volumes of less than 200mL. Urinalysis is unremarkable. You consider starting (a) sodium etidronate (Didronel). (b) oxybutynin (Ditropan). (c) urecholine (Bethanechol). (d) terazosin (Hytrin).

35 (b) This patient is probably developing spontaneous detrusor contractions but is emptying incompletely. You would consider using an anticholinergic agent to decrease detrusor (and hence intravesical) pressures. Ideally, you would obtain urodynamic studies to delineate detrusor-sphincter coordination. One should not initiate a cholinergic agonist without knowing of possible detrusor -sphincter dyssynergy.

35. You are called to the be dsid e of an indivi dual with a T3 spinal cord injury sustained 7 ½ weeks earlier. The person complains of pounding headache and appears to have piloerection on the upper extremities, neck, and face, as well as flushing. Blood pressure is 150/90. The first thing you do is(a) instill a topical anesth etic into th e rect um in order to decrease sensation for a rectal check. (b) apply 1 inch of topical nitr opast e a bove t he level of injury. (c) irrigate the indwelling urin ary c ath eter w ith a small amount of normal saline. (d) sit the person up and lo osen any clo thing.

35. (d) This individual is experiencing autonomic dysreflexia, seen typically in individuals with spinal cord injury with lesions at or above T6. A treatment algorithm that outlines the timing of treatment recommendations was established by the consortium for spinal cord medicine in 1997. When an individual presents with autonomic dysreflexic symptoms including elevated blood pressure (systolic blood pressure greater than 150mm Hg), the very first thing to do is to sit the patient up with his/her clothing and constrictive devices loosened. If the blood pressure remains elevated and the individual has an indwelling catheter, kinks and twists should be removed. If there is no urine flow, the catheter then needs to be irrigated. If the individual does not have an indwelling catheter, a Foley catheter must be inserted and again if there is no urine flow, it should be irrigated. If there is good urine flow and/or the blood pressure drops down to normal, then the work-up as well as other interventions would cease. If the blood pressure remains elevated after irrigation or initiation of catheter, and the systolic blood pressure remains above 150mm Hg, a short-acting antihypertensive medication such as topical nitropaste is initiated. After this, if the individual continues to be hypertensive, he/she may have to be admitted to a hospital to control blood pressure. If, after the short-acting antihypertensive, the blood pressure drops, evaluation of the rectum for fecal impaction begins, including installation of lidocaine into the rectum and allowing it to sit for approximately 5 minutes to decrease sensation before probing the rectum with a gloved finger and subsequently attempting to disimpact.

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.

55. Functional outcomes after the use of methylprednisolone in persons with penetrating spinal cord injury as compared with blunt injury are (a) markedly improved. (b) better. (c) unchanged. (d) worse.

55 (c) The administration of methylprednisolone did not significantly improve functional outcomes in patients with gunshot wounds to the spine or increase the number of complications experienced by patients during their hospitalization.

40 What is the primary disadvantage of moving the rear axle of a wheelchair forward? (a) Ascending curbs becomes more difficult. (b) It takes more muscle effort to propel the wheelchair. (c) More strokes are required to push the wheelchair. (d) Ascending a ramp becomes more difficult.

40 Answer: D Commentary: Moving a wheelchair's rear axle forward enables the user to propel the chair with less muscle effort and fewer strokes. Because the modification causes more weight to be centered over the rear wheels, it is easier to pop a wheelie, negotiate obstacles and ascend or descend curbs. However, moving the axle forward can also make the wheelchair more "tippy" (likely to tip backwards) and that tendency to tip backwards makes it more difficult to push the chair up a ramp. Ref:Koontz AM, Spaeth DM, Sichmeler MR, Cooper RA. Prescription of wheelchairs and seating systems. In: Braddom RL. Physical medicine and rehabilitation. Philidelphia: Elsevier; 2007. P 381-411.

45. You are called to the neurology intensive care unit to evaluate a patient with new spinal cord injury; you determine that the patient has sustained a C7 ASIA A spinal cord injury. Which change in the respiratory system would be expected?(a) Residual volume will dec line to 3 0 of pre dicted value. (b) Pulmonary function will not impro ve after the first 2 weeks postinjury. (c) Expiratory reserve volum e in creas es 40% 6 weeks postinjury. (d) Vital capacity of 60% p redi cted val ue may be obtained within the first 6 months post-injury.

45. (d) Tetraplegic patients usually have a reduction in all measures of pulmonary function with the exception of residual volume. Residual volume is increased due to lack of active expiratory effort. Vital capacity will continue to improve. Tracheostomy is usually not necessary for pulmonary hygiene, especially with adequate hydration and techniques for facilitating cough. Since the diaphragm is supplied by cervical roots C3, C4, and C5, it is common for persons injured above the C4 level to need ventilator support. In acute spinal cord injury, 67% experience significant pulmonary complications, most commonly atelectasis. Ventilatory failure and aspiration occur the earliest (mean, 4.5 days), followed by atelectasis (mean, 17 days) and pneumonia (mean, 24 days). The late decline coincides with the onset of mucus hypersecretion and muscle fatigue. Ventilator weaning has been demonstrated in 80% of C4 spinal cord injury patients and 57% of C3 patients. Considerable patience is required and respiratory muscle fatigue must be closely monitored.

5. What bathroom modification should be made for nonambulatory individuals who have the a bil ity to tran sfer th emsel ves in and out of a whe elc ha ir? (a) Toilet height of 15 inches (b) Cabinet heights of 36 inches from the floor (c) Three feet of clear turning space in the bathroom (d) Separate hot and cold water handle controls

5 (b) When modifying a bathroom for a person who has the ability to transfer him/herself in and out of a wheelchair, it is important to design bathroom space for the pers on' s eff iciency, to a llow him or he r to be as independent as possible. This inclu des providi ng a minimum of 5 fe et of clear t urning spac e and t oilets a t lea st 20 i nch es high (it is re asona ble to us e a sta ndard height toilet with a raised toilet seat). Cabinets should be positioned for easy access. In most cases, the bottom of the cabinet should be 36 inches from the floor. Mirrors also should be positioned so that their bottom edge is 36 inches from the floor. Single-lever type handles should be used for water control. The use of a single handle control with a lever or blade shape that mixes the water to control and adjusts the flow is recommended. Temperatures should be set between 110 and a 120 degrees Fahrenheit at the point of supply so that the delivery temperature will be approximately 105 degrees Fahrenheit. All hot water feed and drainage pipes should be insulated to prevent scalding.

5. According to the Consortium for Spinal Cord Medicine's Clinical Practice Gu idelines for the Prev ent io n of Thro mboem bo lism in Spin al Co rd In jur y, indiv idu als wi th motor incomplete (ASIA class C or D) spinal cord injury should receive (a) warfarin (Coumadin), international normalized ratio target: 2-3. (b) low molecular weight heparin. (c) inferior vena cava filter. (d) unfractionated heparin, 5000 units every 12 hours.

5 (d) According to the guidelines for the prevention of thromboem bolism in spinal cord injury, patients with low risk motor incomplete injuries require only compressi on hose and compression boots; those with intermediate risk require unfrac ti onated heparin, 5000 u nits every 12 hours. Patients with a mo tor c omp let e in ju ry should rec eive e ith er u nfra cti ona ted hepa ri n to a h igh nor mal acti vat ed pa rtial thromboplas tin time (aPTT) or low molecular weight heparin twice daily. Persons with a motor complete injury with other risk factors including lower limb fracture, risk of thrombosis, cancer, heart failure, or other compromising factors may require an inferior vena cava filter in addition to the prescribed drugs.

5. According to the Consortium for Spinal Cord Medicine's Clinical P ractice G uidelines for the Prevention of Thromboembolism in Spinal Cord Injury, individuals with motor complete (ASIA A or B) spinal cord injury should receive (a) warfarin (Coumadin), international normalized ratio target: 2-3. (b) low-molecular-weight heparin or adjusted-dose unfractionated hep arin. (c) inferior vena cava filter. (d) unfractionated heparin, 5000 units every 12 hours.

5. (b) Clinical practice guidelines for spinal cord injury (SCI) have been established for the prevention of thromboembolism. Anticoagulant prophylaxis either with low-molecular-weight heparin or adjusted-dose unfractionated heparin should be initiated within 72 hours after SCI. Inferior vena cava filter placement is indicated in SCI patients who have failed to respond to or have contraindications to anticoagulation. Filter placement is not considered a substitute for thromboprophylaxis.

5. Which change is included in the revised edition of the American Spinal Injury Association (ASIA) Impairment Scale, published in the year 2000? (a) The zone of partial pres erva tion (ZP P) is defined as the most rostral segment with sensory function. (b) The Functional Independe nce Measu re (FIM) has been added to the standards. (c) The definition of a moto r in compl ete injur y requires some motor function more than 3 levels below the motor level. (d) The sensory exam now inc lude s a 5 po int sc ale to include sharp and dull sensations, proprioception, and vibration.

5. (c) The 2000 revisions have clarified a few issues from the previous standards. For a person to receive a classification of motor incomplete spinal cord injury (ASIA C or ASIA D) they must have either 1) voluntary anal sphincter contraction or 2) sacral sensory sparing with sparing of motor function more than 3 levels below the motor level. Previously, the person needed only to have sparing more than 2 levels below the motor level. The FIM was eliminated from the standards. The ZPP is to be documented as the most caudal segment with some sensory and/or motor function. There has been no change in the 3-point (0-2) scale for the sensory exam.

60. Which one of the following cervical orthoses is the most restrictive to range of motion in flexion, extension, axial rotation, and lateral bending, both actively and passively? (a) Soft collar (b) Philadelphia collar (c) Philadelphia collar with thoracic extension (d) Sternal-occipital-mandibular immobilizer collar

60 (d) Measurements of the range of motion in flexion, extension, axial rotation, and lateral bending (both actively and passively) using a computerized motion analyzer for four orthoses—soft collar, Philadelphia collar, Philadelphia collar with thoracic extension, and a Sternal-occipital-mandibular immobilizer (SOMI)—found that the SOMI was most restrictive.

65. Persons with neurogenic bowel often use laxatives such as senna (Senokot), which acts by (a) decreasing intraluminal fluid. (b) lubricating the intestinal mucosa. (c) (c) stimulating the myenteric plexus. (d) increasing the time for electrolyte resorption.

65 (c) Stimulant laxatives act by enhancing intestinal motility and thereby decreasing time available for water and electrolyte resorption. Senna is a glycoside that is split by colonic bacteria into absorbable anthraquinones. It generates increased propulsive activity by altering electrolyte transport and increasing intraluminal fluid. It exerts a direct stimulant effect on the myenteric plexus which increases intestinal motility. Senna works best in persons with upper motor neuron level injuries, and it facilitates bowel movements in 6 to 12 hours.

65. You are told by a physical therapist that your patient with acut e C5 ASIA A tetrap legia is having difficulty breathing, but only when sitting upright. Appropriate lab tests and radiologic studies are unremarkable. To address the patient's breathing difficulty, you suggest (a) bilateral above-knee compression stockings. (b) a tilt table program. (c) intermittent positive pressure breathing treatments. (d) the use of an abdominal binder.

65. (d) In the acute complete tetraplegic patient there is a lack of abdominal muscle tone. An abdominal binder can help because when the patient using it sits upright the abdominal contents are pulled caudally and also are pushed inward. This action pushes up on the diaphragm and allows it to start in a position of mechanical advantage when inhaling while upright. Compression stockings and tilt table programs can be useful for a decrease in blood pressure that accompanies upright posture. Orthostatic hypotension is associated with lightheadedness, dizziness, nausea, syncope. Intermittent positive pressure breathing can be useful to decrease atelectasis.

69. A 9-year-old girl with an L1 ASIA class A spinal cord injury that occurred at a ge 5 y ear s p res ents in y our offi ce wit h a 1-da y h is tory 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 pr epub ertal ch ildre n. In lower l eg DVTs the fo ot a nd l eg are usually swollen. Hete roto pic os sif ication (HO ), which can b e d etect ed by bo ne scan, oc curs in about 3 % of child re n w ith SCI and ha s o nset an ave rag e 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.

75. A 60-year-old woman is seen in consultation by your rehabilit atio n team after elective surgery. She has a new finding of 1/5 strength in her lower extremities, but retained propioception and vibratory sense. You make the diagnosis of (a) posterior spinal cord syndrome. (b) central cord syndrome. (c) anterior spinal cord syndrome. (d) conversion disorder.

75. (c) In anterior spinal cord syndrome there is usually paralysis below the level of the lesion, along with bilateral loss of pain and temperature sensation. Proprioception and vibratory sense are partially preserved. This syndrome often occurs after significant intraoperative hypotensive events. Central cord syndrome refers to weakness that is greater in the upper extremities than the lower extremities. Posterior cord syndrome shows loss of proprioception and is the least common of the incomplete spinal cord injury syndromes.

85. A 28-year-old with T11 paraplegia for 6 months comes to your office to discuss trea tm ent op tio ns fo r er ect ile d ysf unc tion. A tri al of sil de nafil (Viagra) was unsuccessful. He asks about constriction rings. You tell him (a) they should not be used in men with sickle cell disease. (b) they can be kept in place for up to 2 hours. (c) they cannot be used without a vacuum pump. (d) they are not effective for erectile dysfunction in spinal cord injury.

85 (a) Constriction rings (cock rings) to occlude venous outflow can be used if a person is having a poorly sustained erection. A vacuum pump and constriction rin gs c an be us ed if a person i s having n o e rec tion s. T o p revent skin breakdown fro m pr olonge d v enous co nge stion wit hin t he penis , the ri ng should n ot be k ept in p lace for m or e t han 30 minu tes . T hey s hou ld not be use d in men with sickle cell disease. Anticoagulants are a relative contraindication to their use.

85. The primary advantages associated with standing frames and standing wheelchairs for persons with spinal cord injury include (a) reduction in lower extremity edema. (b) reduction in cost to make a workplace accessible. (c) ease in transportation for everyday use. (d) increased bone density in the hips.

85 (b) Standing wheelchairs are often used as second wheelchairs for a particular activity or vocation. Although their weight has been reduced over the years, they still weigh at least 50lb, which continues to be the main factor precluding their use in everyday mobility. Third-party payors and departments of rehabilitation services have funded standing wheelchairs for persons returning to careers; this can reduce the modifications and costs necessary to make a workplace accessible. Physiologic benefits include decreased spasticity, a reduction in urinary tract infections, and a reduction in pressure ulcers. One issue noted is that most standing wheelchairs do not come to a full 90° position because of instability, which may limit a person's reach. Problems reported by users include ankle instability and lower extremity edema.

86. A 24-year-old man with T4 paraplegia has a sa cr al pressure ulcer measuring 2 cm by 2 without depth. The ulcer base has pink granulation tissue. Which dressing is LEAST appropriate in this case? (a) Tegaderm (transparent adhesive dressing) (b) Duoderm (hydrocolloid wafer dressing) (c) Curasol (gel dressing) (d) Accuzyme (enzymatic debridement)

86. (d) This man has a stage II pressure ulcer. Debridement with an agent such as Accuzyme is indicated in wounds with necrotic tissue. Since no necrotic tissue is present in this patient's wound, Accuzyme is not appropriate. A transparent adhesive dressing such as Tegaderm, a hydrocolloid wafer dressing such as Duoderm, and a gel dressing such as Curasol are all appropriate for clean wounds such as the ulcer described. Ref: Salcido R, Goldman R. Prevention and management of pressure ulcers and other chronic wounds. In: Braddom RL, editor. Physical medicine and rehabilitation. 2nd ed. Philadelphia: WB Saunders; 2000. p 651-2.

9. Which statement regarding coronary artery disease in spinal cord injury (SC I) is TRUE? (a) Cardiovascular disease is the second-leading cause ofdeath for patients wi th SCI. (b) Aerobic capacity achieved with arm ergometry isequal to that achieved with leg exercise. (c) High-density lipoproteins are reduced in people withcomplete, high-level, and longer-dur ation SCI . (d) Dietary advice includes a goal of body mass index lessthan 15kg/m2. Ref: (a) Raymond J, Davis GM, Climstein M, Sutton JR. Cardiorespiratory resp onses to arm c ranking a nd electr ical stim ulation leg cycling in people with paraplegia. Med Sci Sports Exerc 1999;31:822-8. (b) Demirel S, Demirel G, Tukek T, Erk O, Yilmaz H. Risk factors for coronar y heart diseas e in pati ents with spin al c ord injury in Turkey. Spinal Cord 2001;39:134-8. Educational Activity 1.13

9 (c) High-density lipoproteins are reduced further in patients who have complete, hi gher-level, and lon ger-duratio n spina l cord injuries ( SCIs). Cardiovascular disease is the leading cause of de ath for pat ients with SCI. Aerobic capacity achieved with arm ergometry may be up to 40% lower than aerobic capacity with leg exercise. Dietary goals include a body mass index of less than 25kg/m2.

92. Characteristic x-ray findings of new bone formation in heterotopic ossification include densities that are (a) noncircumscribed, extra-articular, and extracapsular. (b) noncircumscribed, extra-articular, and intracapsular. (c) circumscribed, extra-articular, and extracapsular. (d) circumscribed, intra-articular, and intracapsular.

92 (a) Typically, heterotopic ossification occurs in the more proximal joints. X-ray findings are a "popcorn" appearance of fluffy (noncircumscribed), immature bone, extracapsular and extraarticular.

92. A patient with focal right upper extremity spasticity initially demonstrated a good r esp ons e t o ele ctro myo graph ica lly =-guided bot ul inum to xi n injections, as measured functionally and on the Modified Ashworth Scale. He received 2 sets of follow-up injections, each 6 months apart, when spasticity returned. He returns 4 weeks after his most recent injection, complaining that he has not seen any effect. Of the options given, what is the most likely explanation for this lack of effect? (a) Diffusion characteristics of botulinum toxin change with repeated administratio n. (b) It becomes very difficult to localize spastic muscles with repeated administrat ion. (c) Antibodies have developed to botulinum toxin, neutralizing it. (d) The hepatic enzymes that metabolize botulinum toxin have increased with repeate d ad mi nis tra tio n.

92 (c) Diffusion characteristics do not change. Electromyographic guidance helps to ensure that the botulinum toxin is injected into the targeted muscle. Local iza tion does no t bec ome more di ff icult wi th rep eate d in jec tions when s pasticity ret urns . Botu lin um toxin is not meta bol iz ed by th e live r. The develo pment o f neutra lizin g ant ib odi es is t he p rim ary reas on for lo ss of e fficacy with repeated injections.

95. You have been following a person with a T4 spinal cord injury for 20 years. He is now 38, and he presents with recent onset of frequent episodes of incontinence between catheterizations. His intermittent catheterization volumes have increased to 600mL every 4-6 hours (they had been 300mL). He acknowledges an increase in his fluid intake, which he feels accounts for the increased volumes. Your first priority is to order (a) a blood glucose level. (b) a urodynamic study. (c) a basic metabolic panel. (d) a prostate-specific antigen test.

95 (a) Polydipsia and polyuria are strong indicators of new-onset diabetes. Diabetes is more common in the spinal cord injured person than in the uninjured population. Although the differential diagnosis may include detrusor hyperreflexia or urinary tract infection, this would not provide a reason for the new high catheterization volumes in this person with chronic spinal cord injury. Evaluation for diabetes should be done immediately.

99. A child with C5 ASIA A s pina l cor d i njury should eventually become independent in which activity?(a) Intermittent catheteriza tion(b) Transfer to level surfac es(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.

"69.

A 9-year-old girl with C5 ASIA A spinal cord injury sustained 2 years ag o is eval uated fo r upper extremity splinting. Which statement regarding this scenario is TRUE? (a) A resting hand splint should be prescribed for daytime use to pr eserve fu nction. (b) A wrist extension splint would be contraindicated for daytime us e because it would inte rfe re with function. (c) A mobile arm support or balanced forearm orthosis could be presc ribed to make self feed ing possible. (d) A short hand splint should be prescribed to strengthen wrist ext ensor mus cles." 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.

"125. Individuals with spinal cord injury who are at the highest risk of developing blad de r c anc er have as a ri sk fa cto r (a) multiple urinary tract infections. (b) indwelling Foley catheter. (c) history of bladder calculi. (d)

ASIA class A." 125 (b) Bladder cancer is the fifth most common neoplasm and the twelfth leading cause of cancer mortality in the United States. Known risk factors for bladder can cer inclu de male gender, smo ki ng, occu pat ion al e xpos ure to aromatic amines and s chis tosomi asi s. In st udi es of spi nal c ord inju ry fea tu ring age-ma tched a nd gende r-adj usted s tan dar dize d da ta, ho wever , b lad der cancer has generally been found to be far more prevalent. When looking at independent variables, which point to a higher risk of bladder cancer, only bladder management method and age at spinal cord injury significantly predicted bladder cancer. ASIA classification, level of spinal cord injury and a history of bladder calculi did not contribute significant ly. Ris k of bla dder cancer is t he highest in in divi dual s w ho have used an indwellin g ca theter s f or longe r t han 10 ye ars . The rela tive r is k of bladde r can ce r from i ndwel ling ca the ter use is rel ati vely unc han ged when a djusted for smoking status. Multiple urinary tract infections is not a risk factor.

"45.

According to data from the Model Spinal Cord Injury Care Sys tem, the leading cause of traumatic spinal cord injury in the United States is (a) motor vehicle accidents. (b) violence. (c) falls. (d) diving accidents." 45 (a) The top three causes of traumatic spinal cord injury in the United States are motor vehicle accidents, falls, and violence.

"9.

According to national databases of spinal cord injur y (SCI), chil dren 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 moto r vehicle acc ident (b) paraplegia, complete, occurred in motor vehicle acci dent (c) high tetraplegia, complete, caused by medical/surgic al compli cati ons (d) paraplegia, motor incomplete, caused by medical/surg ical comp lica tions" 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.

"52.

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

"155.

Indications for bulle t re mo val af ter a gu nsho t w ound inj ury to the spi na l co rd in clude (a) cauda equina location. (b) the need to reduce the risk of lead toxicity. (c) pain reduction. (d) the need to reduce risk of infection." 154 (a) The patient's main weakness is proximal and she has sufficient ankle dorsiflexion and knee extension strength. Hence she would not benefit just with kne e-a nkle =-foot or those s. Reciproc al gait or tho ses are des ign ed to help c hildren with acti ve hip fl exion bu t n o hip ext ens io n. Furth ermore , both these optio ns would b e too bulk y for su ch a pat ien t t o han dle ef fic iently. A standard walker would result in a bent forward posture and would limit the patient's gait speed.

"155. A 37-year-old woman with C5 ASIA A tetrap leg ia from trauma 1 month ago is admitted to your acute rehabilitation unit. She has a retrievable inferior vena cava (IVC) filter and no history of chemical prophylaxis for deep vein thrombosis (DVT). Her surgical team reports to you that they are no longer concerned with an acute bleeding potential related to her trauma and her hematocrit is stable. What should you do first? (a) Order a lower extremity doppler study to l ook f or DVT (b) Start mechanical prophylaxis with sequenti al co mpression devices (c) Tell the patient she is completely protect ed fr om pulmonary emboli (d)

Leave the IVC filter in place for a minimum of 4 months" 155. (a) If anticoagulation is delayed for more than 72 hours after injury, a test to exclude the presence of clots in the legs should be performed. In complete injuries, low molecular weight heparin should be used when starting chemical prophylaxis. Pulmonary embolisms may occur as a result of upper extremity DVT and are not prevented by the IVC filter. In general, the longer you wait to remove the IVC filter, the more problems you may experience in the filter retrieval process. Ref: Campagnolo DI, Merli GJ. Autonomic and cardiovascular complications of spinal cord injury. In: Kirshblum S, Campagnola D, DeLisa J, editors. Spinal cord medicine. Philadelphia: Lippincott Williams & Wilkins; 2002. p 123-34.

25. A 24-year-old man with T6 complete paraple gia w hose injury occurred 16 weeks ago. He is concerned he can no longer reach down to put on and tie his right shoe. Upon evaluation, he has significant loss of range of motion in the right hip with mild warmth at the hip. There is no swelling at the knee, lower leg, ankle, or foot. The most likely diagnosis is (a) hip dislocation. (b) deep vein thrombosis. (c) heterotopic ossification. (d) iliopsoas abscess.

Ref: Banovac K, Banovac F. Heterotopic ossification. In: Kirshblum S, Campagnolo DI, DeLisa JA, editors. Spinal cord medicine. Philadelphia: Lippincott Williams & Wilkins; 2002. p 253-60. 26. (c) Many chemotherapeutic agents can cause a peripheral neuropathy. Treatment for neuropathic pain includes membrane-stabilizing medications such as Neurontin. Opiates like MS Contin and nonsteroidal anti-inflammatory drugs (NSAIDs) like naproxen are not the first line treatment for neuropathic pain. Prednisone is appropriate for complex regional pain syndrome (CRPS), but CRPS is not common in cancer patients after chemotherapy. Further, this patient probably does not have CRPS, considering the absence of swelling, color changes, or temperature changes.

"19.

The most common spinal problem seen with achondroplasia during childhood i s (a) kyphosis. (b) scoliosis. (c) spinal stenosis. (d) low back pain." 19 (a) While scoliosis may occur in children with achondroplasia, i t is less common than kyphosis, which begins in infancy. Spinal stenosis occurs frequently in individ uals wi th achondroplasia, with 38 years being the average age of symptom o ns et. Lo w back pa in is e xtre mely f req uent in adults with ach ond rop la sia , b ut r ar e in chil dren . Pr og res si ve kyp hos is tha t occ ur s in i nf ants an d y oung chi ld ren with achondropla sia is treated with a spinal orthosis.

"49.

Your 5-year-old patient with spastic tetraplegic ce rebral pa lsy 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.

"85. A 22-year-old woman with a C5 ASIA class A spinal cord injury sustained in a car c rash 2 w eeks ago c ompla ins of li gh thead ed ness, dizz in ess , a nd nause a d uri ng he r physical therapy session. In response to her therapist's call, you recommend (a) sitting the patient up and loosening tight garments. (b) placing the patient in Trendelenburg position. (c) using elastic abdominal binders and elastic stockings. . (d)

adjustment of HALO vest" 85 (c) Orthostatic hypotension (OH) is a decrease in blood pressure that results from a change in body position toward the upright posture. Symptoms include l ightheaded ness, d izziness, nausea. This form of hypotension is most likely to occur in perso ns with h igh lev els of inj ury . Treat ment involves da ily ti lt ing wi th g ra du al chan ge t o up ri ght p os ture . E las tic bind er s he lp c ompr ess th e abd ome n, th us li miting blood accumulation in the abdominal vasculature. Elastic stockings limit blood accumulation in lower extremities. Patients must be adequately hydrated. Salt tablets, 1 gram 4 times daily, ephedrine, 20-30mg up to 4 times daily, Florinef, and Midodrine may be used as pharmacologic adjuncts.

"105. A 23-year-old man with C8 tetraplegia req ues ts your opinion regarding routine urologic

evaluations after spinal cord injury. You advise that (a) an intravenous pyelogram (IVP) should be p erf or med every 1 to 2 years. (b) annual abdominal plain films are sufficien t t o detect early hydronephrosis. (c) renal ultrasound should be performed every 5 ye ars. (d) it is reasonable to wait 10 years before g ett in g his first cystoscopy." 105. (d) Renal ultrasound should be included in the annual assessment of renal function and is more sensitive for detecting early hydronephrosis than are plain films. An IVP is not required on a regular basis unless a specific indication exists, such as localizing a renal stone. Patients with indwelling catheters should have a cystoscopy after the first 10 years postinjury. Ref: Schmitt JK, James J, Midha M, Armstrong B, McGurl J. Primary care for persons with spinal cord injury. In: Lin VW, editor. Spinal cord medicine principles and practice. New York: Demos; 2003. p 237-45.

"160. One advantage of a small diameter caster (front wheelchair wheel) is (a) greater ability to traverse rough terrain. (b) better stability on steep inclines. (c) less frequent maintenance. (d)

greater maneuverability" 160 (d) Small diameter casters on a wheelchair reduce the chair's turning radius, which gives it greater maneuverability. These casters frequently are mounted o n w heel chair s u sed f or sports s uc h as bas ket bal l. S mall er diameter cas ters are less wel l suit ed for outd oor activiti es ov er rough terra in . The size of th e caster d oes n ot af fe ct the mai nten anc e r equir ed and do es not improve wheelchair stability on inclines. Hard, narrow casters are typically recommended for mobility over smooth, level surfaces whereas wider, larger casters are better for mobility over uneven, rough surfaces.

"25. Regarding spinal shock in acute spinal cord injury, (a) duration of spinal shock is correlated with long term outcome. (b) reflex activity typically returns over the course of days. (c) a reliable ASIA classification can be performed during spinal shock. (d)

it is more c omm on in tetra pleg ia than in par aplegia." 25 (c) Spinal shock is a condition in which upper motor neuron sensory motor loss is associated with areflexia below the level of injury. It is a poorly define d p heno menon . R eflex activity c an often b e d ete cted by ele ctrophysiolo gic study whe n it is no t c linicall y a pparent. Ref le x a ctivi ty typ ic ally return s ove r the cour se of week s or mon ths. The pr ese nce o f s pin al shock i s of marginal prognostic significance. A reliable ASIA classification can be carried out when spinal shock is present.

"145. A 27-year-old man with a T12 ASIA A spinal cord injury for 10 years presents w ith ri ght sh oul der p ain tha t is wor se with use , p ar ticu lar ly when reaching and doing transfers. He plays basketball twice weekly. Recommendations should include (a) no wheeling or transfers for 2 weeks. (b) immobilization of the elbow and shoulder. (c) electrodiagnostic study of the upper extremity. (d)

strengthening of the scapul ar s ta bil ize rs." 145 (d) Shoulder and neck pain are common following spinal cord injury (SCI). The pain may arise from the neck, shoulder, girdle, or the glenohumeral joint. Pai n m ay b e a s ymp tom o f post-trau ma tic syri ngo mye lia or a ma nifestation of cervical d isc degene rat ion. The pr evalence of sh oul der p ain in p ersons with SCI is estimat ed to be 3 0 to 50 %. R otat or cuf f tea r, bur sit is, ten donitis and impingement have all been reported. While the diagnosis of these disorders is similar to that in the able-bodied population, the treatment is not. In a person with SCI and upper limb pain, rest is often not possible. Pain is often related to overall posture and poor biomechanics. Strengthening of scapular stabilizers can help to correct this imbalance. Immobilization should be avoided. Pain relief is the focus, and may include: relative rest (not to interfere with a person's independence), medications, injections, icing, ultrasound, transcutaneous electrical nerve stimulation, and/or accupuncture.

"175. You are performing urodynamic studies on an individual with a T10 ASIA class A spi na l c ord in jury sust ain ed 2 yea rs previous ly. H e pe rfo rm s intermittent catheterization every 6 hours and reports no episodes of urinary incontinence between catheterizations. You find that the filling pressure or leak point pressure is 20cm of water. At this time, you recommend (a) oxybutinin (Ditropan). (b) initiation of Credé maneuver. (c) continuation of current bladder program. (d)

urecholine (Bethanechol)." 175 (c) The primary risk factor for serious urologic complications such as vesicoureteral reflux and deterioration of renal function in persons with detrusor ex ter nal sphin cte r dys synergia is t hat of e lev ate d in trav esi cal pressure . For this re ason , it i s e ssential to determin e u ri nar y sto rage a nd leak point pres su res. In gener al, d am age to the upp er uri nary tra ct can be avo ided if voiding pressure is maintained less than 60cm of water while the maximum filling pressure or leak point pressure should be less than 40cm of water. For this patient who is having no episodes of leaking between his every 6-hour catheterizations, continuation of current program is reasonable. If on follow-up, his leak point pressure exceeds 40cm of water, conversion to a low pressure system via anticholinergics would be reasonable. The use of a cholinergic agonist (Urecholine) would be contraindicated, since this agent may increase the intravesical pressure.

"125. Treatment is indicated in asymptomatic bacteriuria when an individual wit h a spin al cord injur y h as (a) chronic use of an indwelling Foley catheter. (b) bladder augmentation. (c) pyuria of 10-20 white blood cell count (WBC). (d)

ureteral reflux or hydro nephrosi s." "125 (d) Bacteruria is a common problem in patients with voiding dysf unction. At approximately 1 year postinjury, 66% to 100% of all individuals with spinal cor d injury h ave had at least 1 episode of bacteruria, depending upon their bladder man ag ement program. Asympto mati c bact eru ria has been found to b e p res en t i n 1 %--2 0.05 o f commu nity dwe ll ing p at ient s a nd 0.25 -40% of nur si ng hom e p ati ents old er th an 65 . There is g eneral agreement that asymptomatic bacteruria in a patient using a Foley catheter should not be treated. Attempts should be made to eradicate asymptomatic bacteruria and bacteruria associated with high grade reflux before urologic instrumentation and hydronephrosis, or in the presence of urea splitting agents."