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2010 SAE-P: Pediatric Rehabilitation
Answer Key and Commentary
2010 SAE-P: Pediatric Rehabilitation Clinical Activity 1.1
Clinical Activity 1.3
Question: 1. Answer: (d)
Question: 4. Answer: (a)
Commentary: It is generally accepted that prophylactic treatment should be provided for the first 7 days after traumatic brain injury and that adverse effects should be monitored. Early seizures increase risk of late posttraumatic epilepsy. For those children who develop seizures after 7 days, ongoing treatment is required, but withdrawal of antiepileptic drugs can be considered if the patient has been seizure free on medication for at least 2 years.
Commentary: Many children with cerebral palsy treated with antiepileptic drugs have been shown to have increased risk of fracture. Antiepileptic drugs may cause rickets or osteoporosis. This may be caused by liver induction, with resultant increased breakdown of vitamin D, impaired calcium release from bone, or decreased intestinal absorption caused by vitamin D deficiency. Medications such as phenobarbital and carbamazepine may up-regulate liver enzymes, leading to vitamin D deficiency. Osteoporosis may be caused by a direct effect of phenytoin on osteoclasts and osteoblasts. The treatment for rickets is vitamin D supplementation. Also, a ketogenic diet, which may be used for children with refractory epilepsy, may also decrease bone mineral density by leaching calcium from bone.
Question: 2. Answer: (c) Commentary: Risk factors for pediatric deep-vein thrombosis includes use of endovascular cooling device, presence of central line, prolonged intensive care unit stay and an age of 9 years or older. High-risk patients might include those with spinal cord injury, history of previous deep-vein thrombosis, thrombophilia, initial Glasgow Coma Scale score at or less than 8, or lower extremity disease.
Clinical Activity 1.4 Question: 5. Answer: (b)
Clinical Activity 1.2 Question: 3. Answer: (d) Commentary: Targeting the appropriate salivary glands is essential. Because the submandibular glands are the major producers of saliva when the patient is not stimulated by food, and parotid glands produce mainly during feeding or other oral motor stimulation, these are the glands to target. Because the sublingual glands produce less than 5% of saliva, they typically are not injected. The parotid glands can be localized by surface anatomy, whereas the submandibular glands may require ultrasound guidance. Current studies show significantly decreased anterior drooling after botulinum toxin A injections to the submandibular and parotid glands.
PM&R
S42
1934-1482/10/$36.00 Printed in U.S.A.
Commentary: Scoliosis in neuromuscular disease is very common and can begin early and progress quickly. Neuromuscular curves are often long and sweeping and are fairly unresponsive to bracing. Orthoses may be beneficial because they can stabilize a weak trunk, improve sitting posture and improve respiratory clearance.
Clinical Activity 2.1 Question: 6. Answer: (d) Commentary: When the energy costs of daily activities for children with and without spina bifida are compared, ambulators with spina bifida consume more energy per task and tend toward early fatigue. Children with spina bifida who use wheelchairs consume less energy than those who walk. Fatigue with ambulation may induce teens who ambulated as children to cease walking as energy costs increase, speed becomes a greater priority, or upper limb stress from assistive devices begins to cause pain or discomfort. Upper limbs do not weaken; rather, stress from assistive devices may steer teenagers away from assistive devices. The metabolic syndrome is well described for children with spina bifida, but is not the reason children discontinue walking. Cessation of gait may contribute to the metabolic syndrome. Peer pressure would not influence an ambulatory child to discontinue ambulating.
© 2010 by the American Academy of Physical Medicine and Rehabilitation Suppl. 1, S42-S45, March 2010 DOI: 10.1016/j.pmrj.2010.03.005
PM&R
Question: 7. Answer: (a). Commentary: The presence of hydrocephalus correlates negatively with functional independence. When the functional skills of patients with and without hydrocephalus who have with spinal lesions at or above L2 are compared, those with hydrocephalus show greater impairments of mobility, self care, social skills, communication and cognition. Shunted hydrocephalus is also associated with neuropsychological differences in executive function such as disinhibition, attention, memory, problem solving and language and motivation. Teens with spina bifida and shunted hydrocephalus do not show the age-related improvements in behavior control of typically developing children.
Clinical Activity 2.2 Question: 8. Answer: (b) Commentary: Speech, occupational therapies, and physical therapies are provided to students in school because they are related to the student’s education, as mandated in Section 504 of the Rehabilitation Act of 1973. This law states that children with chronic conditions and disabilities are entitled to appropriate modifications within their educational program to accommodate their individual needs. The provision of special education and related services was further delineated in the Individuals with Disabilities Education Act in December of 2004. As defined by Part A of the Individuals with Disabilities Education Act, “related services” include speech-language pathology and audiology services, psychological services, physical and occupational therapy, recreation, social work services, rehabilitation counseling, and medical diagnostic services to assist a child to benefit from special education. Question: 9. Answer: (c) Commentary: It is important to distinguish educationally necessary related services from medically necessary interventions for children with disabilities. Medically necessary habilitation may include goal-directed interventions to increase range of motion, strength, self-care, and independence, with the prescription of appropriate adaptive devices. Educational needs may include adaptation of a desk and writing tools, access to medications, addressing architectural barriers, and the provision of an adapted program of physical education.
Clinical Activity 2.4 Question: 10. Answer: (c) Commentary: Children in foster care are automatically provided with state provided Medicaid coverage (regular or managed care); however, some hospitals or health-care providers may not accept this insurance.
Vol. 2, Iss. 3, Supplement 1, 2010
S43
Clinical Activity 3.1 Question: 11. Answer: (c) Commentary: Complex regional pain syndrome usually develops in teenage females after minor injuries. Symptoms can include continuous burning, pain disproportionate in intensity and allodynia, and signs can include swelling, hyperhydrosis, vasodilation/vasoconstriction, changes in skin temperature, and trophic skin changes. Management should include physical therapy to increase activity, psychological evaluation, and intervention. Desensitization, although uncomfortable for the patient, is an essential part of treatment. Sympathectomies in children are done very rarely, and the long-term effects are largely unknown. Question: 12. Answer: (b) Commentary: Unfavorable outcomes for children with complex regional pain syndrome are associated with pain that is of longer duration, more intense and generalized, and with lower parental education and more family difficulties. Therapeutic outcomes for children with complex regional pain syndrome are much more favorable than in adults, with approximately 80% to 90% of children reported to become pain free within 1 to 2 years.
Clinical Activity 3.2 Question: 13. Answer: (b) Commentary: In children with cerebral palsy any noxious stimuli, including pain from constipation, gastroesophageal reflux, musculoskeletal pain, infection, fatigue, or stress, can heighten spasticity. Autonomic dysreflexia occurs with noxious stimuli in patients with spinal cord injury above the sixth thoracic level and is not associated with cerebral palsy. Question: 14. Answer: (d) Commentary: Sleep disturbances in children with cerebral palsy have been associated with both medical factors (including pain, seizures, and gastroesophageal reflux) and environmental factors. Cautious use of medications to improve the sleep-wake cycle may improve spasticity while avoiding morning drowsiness and exacerbation of nocturnal breathing disorders. The short-term use of melatonin appears to be well tolerated and not associated with adverse side effects in children with neurodevelopmental disabilities.
S44
Clinical Activity 3.3
Educational Activity 4.3
Question: 15. Answer: (c)
Question: 18. Answer: (d)
Commentary: HBO treatment is shown to be effective in wound healing and decompression sickness. Inadequate evidence exists to support its use in the treatment of chronic brain injury (cerebral palsy, stroke, acquired brain injury). Patients undergoing HBO therapy have significant risk of Eustachian tube dysfunction, which otolaryngologists are frequently asked to manage with tympanostomy tube placement.
Commentary: Cerebral palsy is generally considered to be a static neurological condition; however, the gross motor skills of a person with cerebral palsy do evolve over time. Age, general health, and therapeutic or surgical interventions may all contribute to changes in functional abilities throughout childhood. The transition from a manual to a power wheelchair during adolescence may be motivated by increasing distances to travel, principles of energy conservation, musculoskeletal conditions and growing independence. It is important that these factors be discussed with the adolescent and his family in the clinic setting to clarify reasons for power mobility and dispel concerns about laziness or neurologic degeneration.
Educational Activity 4.1 Question: 16. Answer: (c) Commentary: Seizures are responsible for 1% of all motor vehicle collisions. Minimum requirements for length of seizure-free time before a person can drive vary from state to state. Risk factors for motor vehicle collisions in individuals with seizures include age, gender, generalized or complex seizures, partial complex seizures, history of multiple seizures, and noncompliance with antiepileptic medications. The probability of a seizure related collision is decreased by a long seizure-free period, reliable aura, and the use of the least sedating, but most effective, medication. Question: 17. Answer: (c) Commentary: Driving allows patients with cerebral palsy increased freedom in their surroundings. The clinician may be asked to assess whether a particular individual is medically fit to drive. Because driving requires multiple factors to work in tandem for success, a complete evaluation is needed. The individual requires adequate strength, speed and coordination of either the upper or lower extremities. Cognitive skills such as concentration, attention, visual perceptual skills, and memory will play a role. The ability to process multiple pieces of information simultaneously and make a quick, safe decision is required. It is helpful to have an adaptive vehicle, but it is not necessary to get a driver’s license. It is important for seizures to be well controlled and the requirements vary from state to state on when a person with seizures can drive, but being off all antiepileptic medication is not required in most states. There are no federal requirements, only state Motor Vehicle Administration requirements.
Question: 19. Answer: (d) Commentary: The goal of transition in health care is to maximize lifelong functioning and potential through the provision of high-quality, developmentally appropriate health care services that continue uninterrupted as the individual moves from adolescence to adulthood. The lack of preparation for health care transitions among youths and their families is an important factor in complicated transitions. Transition is patient centered, and based on flexibility, responsiveness, continuity, comprehensiveness and coordination. Youth, parents, and health-care providers all report that successful transition requires future planning, transfer of responsibility for activities of daily living and self-care from parents to youth, and the attainment of maturity and experience. Barriers to this process include aging out of treatment, availability and willingness of knowledgeable adult practitioners to assume care, insurance/funding, and practice differences.
Educational Activity 4.4 Question: 20. Answer: (a) Commentary: Successful outcome with AAC is noticed in cases of early trial, adequate training, and an age of 6 years or older at initial assessment. The focus of an AAC intervention is to facilitate meaningful participation in daily life activities and to identify strengths and abilities, not weaknesses and deficits. Technology alone does not make a competent communicator. Long-term overall compliance is reported to be less than 75% regardless of the model used. Because AAC users need the ongoing support of parents or communication partners to achieve success, instructions to both parties are necessary as early as possible when introducing AAC to the patient.
PM&R
Question: 21. Answer: (a) Commentary: The American with Disabilities Act of 1990 states that a covered entity shall not discriminate against a qualified individual with a disability. This applies to job application procedures, hiring, advancement and discharge of employees, worker’s compensation, job training and other terms, conditions and privileges of employment. This gives similar protections against discrimination to individuals with disability as those stipulated in the Civil Rights Act of 1964, which made discrimination based on race, religion, sex, national origin and other characteristics illegal.
Clinical Activity 5.1 Question: 22. Answer: (b) Commentary: The advantage of a cutaneous vesicostomy is that it is easily reversible and does not alter the person’s future continence mechanism. A catheterizable conduit by use of the appendix or a segment of small bowel connects the bladder to a stoma either through the umbilicus or lower abdominal wall. A continent stoma is small and inconspicuous and is easily covered with an adhesive bandage or small gauze pad. The catheterizable conduit allows individuals with spina bifida or a spinal cord injury to perform clean intermittent catheterization while sitting in a wheelchair. This surgical procedure is undertaken when repeated infections have occurred despite adequate antibiotics and a good bladder-emptying regimen. Question: 23. Answer: (b) Commentary: The anterograde continence enema procedure has been used for those patients with spina bifida or a spinal cord injury who have severe constipation and fecal incontinence. In this procedure the appendix is surgically connected to the abdominal wall, with a valve mechanism that allows anterograde flushing via the stoma with passage of the stool from the rectum. With anterograde continence enema, fecal continence can be significantly improved compared with conventional management.
Vol. 2, Iss. 3, Supplement 1, 2010
S45
Clinical Activity 5.2 Question: 24. Answer: (b) Commentary: Schools must meet with the parents within 30 days after a child is determined to be eligible for an Individual Educational Plan. The Individual Educational Plan will document the child’s mutually agreed upon needs, and the school services or accommodations to be provided to meet them. Independent evaluations, additional testing, mediation, or a due process hearing may occur if agreement is not met. Question: 25. Answer: (a) Commentary: If someone who is cognitively impaired cannot receive, evaluate, and communicate information related to managing finances, health care decisions, legal decisions or simply his or her own daily affairs, then a guardian should be considered. The laws regarding guardianship differ in all 50 states, so knowledgeable legal representation is needed. A guardian or co-guardians are court appointed upon appropriate medical or psychological documentation to the court.
Clinical Activity 5.3 Question: 26. Answer: (c) Commentary: Compared with a pregnant woman without a spinal cord injury, a woman with T6 paraplegia is more likely to deliver a small-for-dates infant. She is also likely to have premature cervical dilation and labor. Because of unrecognized contractions, pregnant women with SCI may be at risk for unattended delivery. Women with a level of injury above T10 could have painless labor because the uterine sensory afferent nerves enter the spinal cord at the T11 to L1 levels. Even at lower levels, women with complete SCI might not feel contractions.
2010 SAE-P: Pediatric Rehabilitation Clinical Activity 1.1
Clinical Activity 1.3
Question: 1. Answer: (d)
Question: 4. Answer: (a)
Commentary: It is generally accepted that prophylactic treatment should be provided for the first 7 days after traumatic brain injury and that adverse effects should be monitored. Early seizures increase risk of late posttraumatic epilepsy. For those children who develop seizures after 7 days, ongoing treatment is required, but withdrawal of antiepileptic drugs can be considered if the patient has been seizure free on medication for at least 2 years.
Commentary: Many children with cerebral palsy treated with antiepileptic drugs have been shown to have increased risk of fracture. Antiepileptic drugs may cause rickets or osteoporosis. This may be caused by liver induction, with resultant increased breakdown of vitamin D, impaired calcium release from bone, or decreased intestinal absorption caused by vitamin D deficiency. Medications such as phenobarbital and carbamazepine may up-regulate liver enzymes, leading to vitamin D deficiency. Osteoporosis may be caused by a direct effect of phenytoin on osteoclasts and osteoblasts. The treatment for rickets is vitamin D supplementation. Also, a ketogenic diet, which may be used for children with refractory epilepsy, may also decrease bone mineral density by leaching calcium from bone.
Question: 2. Answer: (c) Commentary: Risk factors for pediatric deep-vein thrombosis includes use of endovascular cooling device, presence of central line, prolonged intensive care unit stay and an age of 9 years or older. High-risk patients might include those with spinal cord injury, history of previous deep-vein thrombosis, thrombophilia, initial Glasgow Coma Scale score at or less than 8, or lower extremity disease.
Clinical Activity 1.4 Question: 5. Answer: (b)
Clinical Activity 1.2 Question: 3. Answer: (d) Commentary: Targeting the appropriate salivary glands is essential. Because the submandibular glands are the major producers of saliva when the patient is not stimulated by food, and parotid glands produce mainly during feeding or other oral motor stimulation, these are the glands to target. Because the sublingual glands produce less than 5% of saliva, they typically are not injected. The parotid glands can be localized by surface anatomy, whereas the submandibular glands may require ultrasound guidance. Current studies show significantly decreased anterior drooling after botulinum toxin A injections to the submandibular and parotid glands.
PM&R
S42
1934-1482/10/$36.00 Printed in U.S.A.
Commentary: Scoliosis in neuromuscular disease is very common and can begin early and progress quickly. Neuromuscular curves are often long and sweeping and are fairly unresponsive to bracing. Orthoses may be beneficial because they can stabilize a weak trunk, improve sitting posture and improve respiratory clearance.
Clinical Activity 2.1 Question: 6. Answer: (d) Commentary: When the energy costs of daily activities for children with and without spina bifida are compared, ambulators with spina bifida consume more energy per task and tend toward early fatigue. Children with spina bifida who use wheelchairs consume less energy than those who walk. Fatigue with ambulation may induce teens who ambulated as children to cease walking as energy costs increase, speed becomes a greater priority, or upper limb stress from assistive devices begins to cause pain or discomfort. Upper limbs do not weaken; rather, stress from assistive devices may steer teenagers away from assistive devices. The metabolic syndrome is well described for children with spina bifida, but is not the reason children discontinue walking. Cessation of gait may contribute to the metabolic syndrome. Peer pressure would not influence an ambulatory child to discontinue ambulating.
© 2010 by the American Academy of Physical Medicine and Rehabilitation Suppl. 1, S42-S45, March 2010 DOI: 10.1016/j.pmrj.2010.03.005
PM&R
Question: 7. Answer: (a). Commentary: The presence of hydrocephalus correlates negatively with functional independence. When the functional skills of patients with and without hydrocephalus who have with spinal lesions at or above L2 are compared, those with hydrocephalus show greater impairments of mobility, self care, social skills, communication and cognition. Shunted hydrocephalus is also associated with neuropsychological differences in executive function such as disinhibition, attention, memory, problem solving and language and motivation. Teens with spina bifida and shunted hydrocephalus do not show the age-related improvements in behavior control of typically developing children.
Clinical Activity 2.2 Question: 8. Answer: (b) Commentary: Speech, occupational therapies, and physical therapies are provided to students in school because they are related to the student’s education, as mandated in Section 504 of the Rehabilitation Act of 1973. This law states that children with chronic conditions and disabilities are entitled to appropriate modifications within their educational program to accommodate their individual needs. The provision of special education and related services was further delineated in the Individuals with Disabilities Education Act in December of 2004. As defined by Part A of the Individuals with Disabilities Education Act, “related services” include speech-language pathology and audiology services, psychological services, physical and occupational therapy, recreation, social work services, rehabilitation counseling, and medical diagnostic services to assist a child to benefit from special education. Question: 9. Answer: (c) Commentary: It is important to distinguish educationally necessary related services from medically necessary interventions for children with disabilities. Medically necessary habilitation may include goal-directed interventions to increase range of motion, strength, self-care, and independence, with the prescription of appropriate adaptive devices. Educational needs may include adaptation of a desk and writing tools, access to medications, addressing architectural barriers, and the provision of an adapted program of physical education.
Clinical Activity 2.4 Question: 10. Answer: (c) Commentary: Children in foster care are automatically provided with state provided Medicaid coverage (regular or managed care); however, some hospitals or health-care providers may not accept this insurance.
Vol. 2, Iss. 3, Supplement 1, 2010
S43
Clinical Activity 3.1 Question: 11. Answer: (c) Commentary: Complex regional pain syndrome usually develops in teenage females after minor injuries. Symptoms can include continuous burning, pain disproportionate in intensity and allodynia, and signs can include swelling, hyperhydrosis, vasodilation/vasoconstriction, changes in skin temperature, and trophic skin changes. Management should include physical therapy to increase activity, psychological evaluation, and intervention. Desensitization, although uncomfortable for the patient, is an essential part of treatment. Sympathectomies in children are done very rarely, and the long-term effects are largely unknown. Question: 12. Answer: (b) Commentary: Unfavorable outcomes for children with complex regional pain syndrome are associated with pain that is of longer duration, more intense and generalized, and with lower parental education and more family difficulties. Therapeutic outcomes for children with complex regional pain syndrome are much more favorable than in adults, with approximately 80% to 90% of children reported to become pain free within 1 to 2 years.
Clinical Activity 3.2 Question: 13. Answer: (b) Commentary: In children with cerebral palsy any noxious stimuli, including pain from constipation, gastroesophageal reflux, musculoskeletal pain, infection, fatigue, or stress, can heighten spasticity. Autonomic dysreflexia occurs with noxious stimuli in patients with spinal cord injury above the sixth thoracic level and is not associated with cerebral palsy. Question: 14. Answer: (d) Commentary: Sleep disturbances in children with cerebral palsy have been associated with both medical factors (including pain, seizures, and gastroesophageal reflux) and environmental factors. Cautious use of medications to improve the sleep-wake cycle may improve spasticity while avoiding morning drowsiness and exacerbation of nocturnal breathing disorders. The short-term use of melatonin appears to be well tolerated and not associated with adverse side effects in children with neurodevelopmental disabilities.
S44
Clinical Activity 3.3
Educational Activity 4.3
Question: 15. Answer: (c)
Question: 18. Answer: (d)
Commentary: HBO treatment is shown to be effective in wound healing and decompression sickness. Inadequate evidence exists to support its use in the treatment of chronic brain injury (cerebral palsy, stroke, acquired brain injury). Patients undergoing HBO therapy have significant risk of Eustachian tube dysfunction, which otolaryngologists are frequently asked to manage with tympanostomy tube placement.
Commentary: Cerebral palsy is generally considered to be a static neurological condition; however, the gross motor skills of a person with cerebral palsy do evolve over time. Age, general health, and therapeutic or surgical interventions may all contribute to changes in functional abilities throughout childhood. The transition from a manual to a power wheelchair during adolescence may be motivated by increasing distances to travel, principles of energy conservation, musculoskeletal conditions and growing independence. It is important that these factors be discussed with the adolescent and his family in the clinic setting to clarify reasons for power mobility and dispel concerns about laziness or neurologic degeneration.
Educational Activity 4.1 Question: 16. Answer: (c) Commentary: Seizures are responsible for 1% of all motor vehicle collisions. Minimum requirements for length of seizure-free time before a person can drive vary from state to state. Risk factors for motor vehicle collisions in individuals with seizures include age, gender, generalized or complex seizures, partial complex seizures, history of multiple seizures, and noncompliance with antiepileptic medications. The probability of a seizure related collision is decreased by a long seizure-free period, reliable aura, and the use of the least sedating, but most effective, medication. Question: 17. Answer: (c) Commentary: Driving allows patients with cerebral palsy increased freedom in their surroundings. The clinician may be asked to assess whether a particular individual is medically fit to drive. Because driving requires multiple factors to work in tandem for success, a complete evaluation is needed. The individual requires adequate strength, speed and coordination of either the upper or lower extremities. Cognitive skills such as concentration, attention, visual perceptual skills, and memory will play a role. The ability to process multiple pieces of information simultaneously and make a quick, safe decision is required. It is helpful to have an adaptive vehicle, but it is not necessary to get a driver’s license. It is important for seizures to be well controlled and the requirements vary from state to state on when a person with seizures can drive, but being off all antiepileptic medication is not required in most states. There are no federal requirements, only state Motor Vehicle Administration requirements.
Question: 19. Answer: (d) Commentary: The goal of transition in health care is to maximize lifelong functioning and potential through the provision of high-quality, developmentally appropriate health care services that continue uninterrupted as the individual moves from adolescence to adulthood. The lack of preparation for health care transitions among youths and their families is an important factor in complicated transitions. Transition is patient centered, and based on flexibility, responsiveness, continuity, comprehensiveness and coordination. Youth, parents, and health-care providers all report that successful transition requires future planning, transfer of responsibility for activities of daily living and self-care from parents to youth, and the attainment of maturity and experience. Barriers to this process include aging out of treatment, availability and willingness of knowledgeable adult practitioners to assume care, insurance/funding, and practice differences.
Educational Activity 4.4 Question: 20. Answer: (a) Commentary: Successful outcome with AAC is noticed in cases of early trial, adequate training, and an age of 6 years or older at initial assessment. The focus of an AAC intervention is to facilitate meaningful participation in daily life activities and to identify strengths and abilities, not weaknesses and deficits. Technology alone does not make a competent communicator. Long-term overall compliance is reported to be less than 75% regardless of the model used. Because AAC users need the ongoing support of parents or communication partners to achieve success, instructions to both parties are necessary as early as possible when introducing AAC to the patient.
PM&R
Question: 21. Answer: (a) Commentary: The American with Disabilities Act of 1990 states that a covered entity shall not discriminate against a qualified individual with a disability. This applies to job application procedures, hiring, advancement and discharge of employees, worker’s compensation, job training and other terms, conditions and privileges of employment. This gives similar protections against discrimination to individuals with disability as those stipulated in the Civil Rights Act of 1964, which made discrimination based on race, religion, sex, national origin and other characteristics illegal.
Clinical Activity 5.1 Question: 22. Answer: (b) Commentary: The advantage of a cutaneous vesicostomy is that it is easily reversible and does not alter the person’s future continence mechanism. A catheterizable conduit by use of the appendix or a segment of small bowel connects the bladder to a stoma either through the umbilicus or lower abdominal wall. A continent stoma is small and inconspicuous and is easily covered with an adhesive bandage or small gauze pad. The catheterizable conduit allows individuals with spina bifida or a spinal cord injury to perform clean intermittent catheterization while sitting in a wheelchair. This surgical procedure is undertaken when repeated infections have occurred despite adequate antibiotics and a good bladder-emptying regimen. Question: 23. Answer: (b) Commentary: The anterograde continence enema procedure has been used for those patients with spina bifida or a spinal cord injury who have severe constipation and fecal incontinence. In this procedure the appendix is surgically connected to the abdominal wall, with a valve mechanism that allows anterograde flushing via the stoma with passage of the stool from the rectum. With anterograde continence enema, fecal continence can be significantly improved compared with conventional management.
Vol. 2, Iss. 3, Supplement 1, 2010
S45
Clinical Activity 5.2 Question: 24. Answer: (b) Commentary: Schools must meet with the parents within 30 days after a child is determined to be eligible for an Individual Educational Plan. The Individual Educational Plan will document the child’s mutually agreed upon needs, and the school services or accommodations to be provided to meet them. Independent evaluations, additional testing, mediation, or a due process hearing may occur if agreement is not met. Question: 25. Answer: (a) Commentary: If someone who is cognitively impaired cannot receive, evaluate, and communicate information related to managing finances, health care decisions, legal decisions or simply his or her own daily affairs, then a guardian should be considered. The laws regarding guardianship differ in all 50 states, so knowledgeable legal representation is needed. A guardian or co-guardians are court appointed upon appropriate medical or psychological documentation to the court.
Clinical Activity 5.3 Question: 26. Answer: (c) Commentary: Compared with a pregnant woman without a spinal cord injury, a woman with T6 paraplegia is more likely to deliver a small-for-dates infant. She is also likely to have premature cervical dilation and labor. Because of unrecognized contractions, pregnant women with SCI may be at risk for unattended delivery. Women with a level of injury above T10 could have painless labor because the uterine sensory afferent nerves enter the spinal cord at the T11 to L1 levels. Even at lower levels, women with complete SCI might not feel contractions.