General Diagnosis
19%of exam
Physical ExamCardiopulmonary SignsGastrointestinal FindingsGenitourinary PathologyEndocrine Signs
Neuromusculoskeletal Diagnosis
20%of exam
Spine OrthopedicsExtremity TestsNeurologic ExaminationRadiculopathy SignsMyelopathy Signs
Diagnostic Imaging
17%of exam
Plain Film RulesSpinal InstabilityRadiographic LinesArthritidesBone Pathologies
Principles of Chiropractic
14%of exam
BiomechanicsChiropractic ModelsNeurophysiologyTissue MechanicsResearch Interpretation
Chiropractic Practice
17%of exam
Patient CareInformed ConsentDocumentationOutcome MeasuresCommunity Health
Associated Clinical Sciences
13%of exam
GeriatricsDermatologyToxicologyEmergency CarePediatricsPsychologyObstetrics and Gynecology
Quick Facts
- Item count
- 255 questions across six domains
- Session structure
- Two sessions; three domains each
- Testing time
- 206 minutes; 3 hours 26 minutes
- Appointment
- 4 hours including optional break
- Passing score
- 375 scaled; whole Part II
- Exam fee
- 710 US dollars
- Test locations
- Eligible colleges and Prometric centers
- Retakes
- Full examination; no domain retakes
Possible Posterior Circulation Warning Symptoms
Five Ds prompt assessment; absence never clears vascular risk
D = DizzinessD = Drop attacksD = DiplopiaD = DysarthriaD = Dysphagia
Neurogenic Versus Vascular Claudication
Neurogenic Claudication
- Often relieved by spinal flexion
- Standing walking may provoke symptoms
- Pulses may remain palpable
- Lumbar stenosis is one cause
Vascular Claudication
- Exertional symptoms improve with rest
- Posture alone less influential
- Pulses may be reduced
- Assess ankle-brachial index when indicated
Patterns overlap; bedside tests are adjuncts
Abdominal and Vascular Red Flags
- Murphy sign
- Supports gallbladder inflammationNot diagnostic alone
- Rovsing sign
- Right-sided pain from left palpationAppendicitis concern
- Blumberg sign
- Rebound suggests peritoneal irritationUrgent assessment
- Pulsatile mass
- Raises abdominal aneurysm concernUltrasound; emergency if symptomatic
- CVA tenderness
- Possible renal or nonrenal causeAssess urinary symptoms
- Grey Turner
- Flank ecchymosis may indicate bleedingNot pancreatitis-specific
- Cullen sign
- Periumbilical ecchymosis may indicate bleedingUrgent assessment
Cardiopulmonary and Neurologic Red Flags
- Horner syndrome
- Ptosis miosis; sometimes anhidrosisPainful onset: vascular emergency
- Abdominojugular reflux
- Sustained jugular rise supports congestionInterpret with other findings
- Kernig sign
- Pain resistance during knee extensionAbsence cannot exclude meningitis
- Brudzinski sign
- Hip flexion during neck flexionMeningeal irritation concern
- Saddle sensory change
- Perineal sensation reduced or alteredCauda equina concern
- New urinary retention
- Possible sacral nerve dysfunctionEmergency assessment and MRI
- Claudication bicycle test
- Postural relief supports neurogenic causeCannot exclude vascular disease
Upper Versus Lower Motor Neuron
Upper Motor Neuron
- Hyperreflexia below established lesion
- Extensor plantar response may occur
- Spasticity or clonus may develop
- Acute lesions may initially be flaccid
Lower Motor Neuron
- Reduced reflexes in affected distribution
- Weakness with reduced muscle tone
- Atrophy develops with denervation
- Fasciculations may occur; not mandatory
Patterns guide localization; exceptions occur
Spine Presentation Assessment and Referral
- New bladder dysfunction saddle sensory change→Immediate emergency assessment; urgent MRI(Possible cauda equina syndrome)
- New unusual headache focal neurologic signs→Emergency vascular and neurological assessment(Avoid manipulation and positional provocation)
- Back pain with possible infection malignancy→Prompt medical workup; appropriate MRI(Emergency if septic or neurologically compromised)
- Severe or progressive motor deficit→Urgent medical or spinal assessment(Do not prescribe automatic decompression)
- Exertional bilateral leg symptoms→Assess neurologic and vascular causes(Consider pulses and ankle-brachial index)
- Arm pain with positive Spurling→Correlate strength reflex sensation history(Test alone does not select treatment)
- Localized extension-related spinal pain→Assess differential and functional limitations(No automatic facet diagnosis or adjustment)
- Posterior pelvic provocation pain→Use cluster and assess hip alternatives(Exclude fracture infection inflammatory disease)
- Uncomplicated persistent mechanical back pain→Education activity and individualized exercise(Manual therapy only within assessed care)
Cervical Spine Orthopedic Tests
- Spurling test
- Reproduces familiar radiating arm symptomsSupports radiculopathy
- Cervical distraction
- May relieve familiar radicular symptomsSupportive finding only
- Bakody sign
- Arm elevation may relieve symptomsPossible cervical radiculopathy
- Lhermitte sign
- Electric shock with neck flexionCord disease assessment
- Hoffmann reflex
- Thumb index flexion after flickNot pathognomonic
- Jerk test
- Provokes posterior shoulder symptomsPosterior instability concern
- Adson test
- Pulse change has limited specificityCannot diagnose thoracic outlet syndrome
L5 Versus S1 Radiculopathy
L5 Nerve Root
- Great-toe extension often weak
- Dorsal foot sensory change possible
- No reliable routine tendon reflex
- Heel walking may be impaired
S1 Nerve Root
- Plantarflexion often weak
- Lateral foot sensory change possible
- Achilles reflex may decrease
- Toe walking may be impaired
Combine motor sensory and reflex patterns
Lumbar and Pelvic Orthopedic Tests
- Straight leg raise
- Reproduces familiar radicular leg painUsually L5 or S1
- Crossed straight-leg raise
- Opposite lift reproduces symptomatic painSupports disc-related radiculopathy
- Bragard maneuver
- Dorsiflexion modifies neural tension symptomsNot confirmatory alone
- Kemp test
- Extension rotation provokes spinal painLimited diagnostic specificity
- Patrick FABER
- Groin or posterior pain localizationInterpret within examination cluster
- Gaenslen test
- Stresses sacroiliac regionSingle test insufficient
- Yeoman test
- Hip extension provokes regional painNot ligament-specific
Shoulder and Knee Orthopedic Tests
- Neer test
- Elevation provokes shoulder painSubacromial pain concern
- Hawkins Kennedy
- Internal rotation provokes shoulder painNot lesion-specific
- Drop arm test
- Difficulty controlling arm loweringRaises rotator cuff concern
- Empty can test
- Pain weakness during resisted elevationCannot determine tear depth
- Lachman test
- Increased anterior translation soft endpointSupports ACL injury
- McMurray test
- Joint-line click pain during movementSupports meniscal pathology
- Apley grind test
- Compression rotation provokes joint painNot diagnostic alone
Inflammatory Versus Degenerative Arthritis
Inflammatory Arthropathy
- Often uniform joint-space loss
- Marginal erosions may occur
- Prolonged morning stiffness may occur
- Inflammatory markers may be normal
Degenerative Arthropathy
- Often asymmetric joint-space narrowing
- Osteophytes and subchondral sclerosis
- Morning stiffness usually briefer
- Laboratory markers often normal
Patterns support differential; neither is universal
Diagnostic Imaging Modality Selection
- Acute ankle knee injury meeting rules→Site-specific radiographs as indicated(Ottawa rules do not cover spine)
- Possible spinal cancer or infection→Appropriate MRI and medical workup(Contrast depends on clinical question)
- Uncomplicated acute radicular low-back pain→Usually no immediate imaging(Reassess persistence progression or red flags)
- Acute cord compression or myelopathy→Urgent MRI and specialist assessment(Protocol follows suspected cause)
- Persistent concern for pars stress injury→MRI or targeted CT when indicated(No mandatory oblique radiographs)
- Bone fragility risk assessment→DXA and clinical fracture assessment(Z-score interpretation for younger adults)
- Possible symptomatic abdominal aortic aneurysm→Emergency assessment; immediate aortic ultrasound(Vascular service directs further imaging)
- Adult cervical trauma requiring imaging→CT generally first-line(MRI for indicated neural ligament assessment)
- Hot swollen painful joint with fever→Urgent assessment; consider joint aspiration(Imaging cannot exclude septic arthritis)
Cervical Radiographic Lines and Signs
- Atlantodental interval
- Adult radiographic limit conventionally 3 mmPediatric and CT limits differ
- Posterior body line
- Step indicates altered vertebral alignmentNot proof of dynamic instability
- Spinolaminar line
- Posterior spinal canal alignment referenceInterpret with other lines
- Chamberlain line
- Posterior hard palate to opisthionCraniovertebral assessment
- McGregor line
- Posterior palate to lowest occiputTechnique-dependent interpretation
- C2 prevertebral tissue
- Adult radiograph conventionally ≤7 mmPosition and modality matter
- C6 prevertebral tissue
- Adult radiograph conventionally ≤22 mmNot pediatric CT thresholds
Lumbar and Bone Pathologies
- Scotty dog collar
- Lucency through pars interarticularisObliques not routinely required
- Meyerding grade
- Slip percentage relative to body belowInstability needs further assessment
- Winking owl sign
- Absent or poorly visualized pedicleCongenital or destructive causes
- Ivory vertebra
- Diffuse vertebral body sclerosisMetastasis lymphoma Paget differential
- Bamboo spine
- Bridging marginal syndesmophytesAnkylosed spine fracture risk
- Pencil in cup
- Erosion with adjacent bone remodelingPsoriatic arthritis pattern
- Spondylodiscitis pattern
- Endplate destruction with disc narrowingEarly films may be normal
Five Component Subluxation Conceptual Model
Motion Nerves Muscle Tissue Chemistry; theory requires evidence
N = Neuropathophysiology neural dysfunctionK = Kinesiopathology aberrant mechanicsM = Myopathology muscular imbalanceH = Histopathology inflammatory edemaB = Pathobiochemistry biochemical mediators
Conceptual Models Versus Clinical Evidence
Conceptual Model
- Organizes proposed mechanisms
- Can generate testable hypotheses
- May include subluxation terminology
- Does not establish systemic disease causation
Clinical Evidence
- Measures patient-important outcomes
- Compares benefits harms and alternatives
- Depends on population and condition
- Requires reassessment of actual response
Plausible mechanism does not prove efficacy
Biomechanics and Chiropractic Conceptual Models
- Cervical coupling
- Bending often accompanies ipsilateral rotationSubaxial tendency; not universal
- Lumbar coupling
- Varies with level posture taskAvoid universal directional rules
- Instantaneous axis
- Kinematic reference for instantaneous rotationNot a palpation diagnosis
- Kinesiopathology
- Abnormal motion within conceptual modelModel; not systemic disease proof
- Neuropathophysiology
- Proposed neural component of modelEvaluate neurologic findings clinically
- Tissue hysteresis
- Energy loss during loading cyclesViscoelastic property
- Tissue creep
- Deformation increases under constant loadContrast constant-deformation stress relaxation
Medicare Subluxation Documentation Criteria
Two PART findings; include A or R
P = Pain and tendernessA = Asymmetry misalignment landmarkR = Range motion abnormalityT = Tissue tone texture
Absolute Versus Relative Thrust Contraindications
Major Reasons to Defer Thrust
- Destructive spinal malignancy
- Acute fracture or instability
- Cauda equina or cord compression
- Suspected spinal infection or vascular emergency
Additional Risk Assessment
- Bone fragility or prior fracture
- Spondylolisthesis stability and symptoms
- Anticoagulation and bleeding risk
- Hypermobility and connective-tissue disease
Assess pathology region and proposed procedure
Practice Standards and Informed Consent
- Pain tenderness
- Document location and relevant findingsPART criterion P
- Asymmetry finding
- Segmental asymmetry or misalignmentA or R required
- Range abnormality
- Altered active passive accessory motionA or R required
- Tissue abnormality
- Tone texture temperature changesTwo PART findings required
- Informed consent
- Capacity voluntariness risks benefits alternativesJurisdictional requirements vary
- Oswestry index
- Patient-reported low-back functional disabilityHigher scores indicate greater disability
- Neck disability index
- Patient-reported neck-related functional disabilityThresholds depend on population
Malignant Melanoma Clinical Screening Criteria
Asymmetry Border Color Diameter Evolving Skin Spot
A = Asymmetry of lesionB = Border irregular scallopedC = Color variation variegationD = Often >6 mm; sometimes smallerE = Evolving changing size shape
Clinical Pharmacology and Emergency Signs
- NSAID toxicity
- Gastrointestinal renal cardiovascular harmsReview medicines and risk factors
- Systemic corticosteroids
- Fracture infection osteonecrosis risksAssess dose duration symptoms
- Herpes zoster
- Usually unilateral dermatomal vesicular rashPrompt antiviral assessment
- DXA osteoporosis
- Diagnostic T-score ≤−2.5Postmenopausal women; men ≥50
- Nursemaid elbow
- Radial head annular ligament displacementAtypical findings suggest fracture
- Melanoma ABCDE
- Asymmetry border color diameter evolutionSmall lesions may be malignant
- Cervical artery dissection
- New unusual pain or neurological signsEmergency assessment; no manipulation
Common Traps
Treating Claudication Patterns as Definitive
Neurogenic symptoms often improve with flexion ≠ Vascular symptoms often improve with rest
Ordering Routine Lumbar Oblique Views
Scotty dog is traditional radiographic anatomy ≠ Obliques add radiation; not universally required
Diagnosing From One Provocative Test
Local neck pain alone is nonspecific ≠ Radiculopathy may lack a textbook pattern
Assuming Low-force Treatment Is Automatically Safe
Osteoporosis includes T-score exactly −2.5 ≠ Assess age population and fracture history
Misreading Medicare PART Criteria
At least two findings are required ≠ Include either A or R
Using Five Ds as Vascular Clearance
Dissection may initially cause isolated pain ≠ Carotid disease may cause painful Horner
Converting Theory Into a Treatment Rule
Listings do not prove symptom causation ≠ Creep does not establish traction efficacy
Last Minute
- 1.Recall current 255-question 206-minute format
- 2.Recall the official domain weight distribution
- 3.Treat possible cauda equina as emergency
- 4.Combine signs with full clinical context
- 5.Apply Medicare PART and active-care requirements
- 6.Assess vascular and neurogenic claudication
- 7.Avoid routine imaging without appropriate indications
- 8.Document consent under applicable jurisdictional rules
- 9.Separate scoliometer screening from Cobb measurement
- 10.Use age-appropriate DXA classification and reference
- 11.Distinguish theoretical models from demonstrated benefit
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