Key Takeaways
- Stroke (CVA): Middle cerebral artery (MCA) stroke causes contralateral hemiplegia (arm > leg), aphasia (if dominant hemisphere), and hemineglect (if non-dominant hemisphere)
- Spinal cord injury levels: C4 (ventilator dependent), C5 (deltoid/biceps), C6 (wrist extensors — tenodesis grasp), C7 (triceps — independent transfers), T1 (full UE), T6-T12 (increasing trunk control)
- Parkinson disease presents with the classic triad: resting tremor (pill-rolling), rigidity (cogwheel or lead-pipe), and bradykinesia; plus postural instability
- Multiple sclerosis (MS) is characterized by demyelination of CNS white matter, with relapsing-remitting pattern being most common; symptoms worsen with heat (Uhthoff phenomenon)
- Traumatic brain injury (TBI) recovery follows the Rancho Los Amigos Levels (I-VIII), progressing from no response to purposeful-appropriate behavior
- Guillain-Barre syndrome (GBS) is an acute inflammatory demyelinating polyneuropathy causing ascending LMN weakness; autonomic dysfunction is a life-threatening complication
- Vestibular disorders present with vertigo, nystagmus, and balance dysfunction; BPPV is the most common and is treated with canalith repositioning (Epley maneuver)
- ALS (amyotrophic lateral sclerosis) involves both UMN and LMN degeneration; it is progressive and fatal, with PT focused on maintaining function and quality of life
Neurological Conditions
The NPTE tests your knowledge of common neurological conditions, their clinical presentations, expected functional outcomes, and appropriate PT interventions. This section covers the highest-yield neurological conditions.
Stroke (Cerebrovascular Accident)
Stroke by Artery
| Artery | Region Affected | Clinical Presentation |
|---|---|---|
| Middle Cerebral Artery (MCA) | Lateral hemisphere | Contralateral hemiplegia (arm and face > leg), contralateral sensory loss, aphasia (dominant hemisphere), hemineglect (non-dominant), homonymous hemianopsia |
| Anterior Cerebral Artery (ACA) | Medial hemisphere | Contralateral hemiplegia (leg > arm), personality changes, urinary incontinence |
| Posterior Cerebral Artery (PCA) | Occipital lobe, medial temporal | Contralateral homonymous hemianopsia, memory deficits, visual agnosia |
| Vertebrobasilar | Brainstem, cerebellum | Ataxia, vertigo, cranial nerve deficits, dysphagia, "locked-in syndrome" (basilar artery) |
Aphasia Types (Left/Dominant Hemisphere)
| Type | Fluency | Comprehension | Repetition | Lesion Location |
|---|---|---|---|---|
| Broca (Expressive) | Non-fluent | Intact | Impaired | Frontal lobe (Broca area) |
| Wernicke (Receptive) | Fluent but nonsensical | Impaired | Impaired | Temporal lobe (Wernicke area) |
| Global | Non-fluent | Impaired | Impaired | Large MCA territory |
Brunnstrom Stages of Motor Recovery (Stroke)
| Stage | Description |
|---|---|
| Stage 1 | Flaccidity — no voluntary movement |
| Stage 2 | Spasticity begins, synergies emerge |
| Stage 3 | Spasticity peaks, voluntary synergy patterns |
| Stage 4 | Spasticity decreases, movement outside synergies begins |
| Stage 5 | Isolated joint movements, near-normal function |
| Stage 6 | Coordination and speed approach normal |
| Stage 7 | Normal motor function restored |
Spinal Cord Injury (SCI)
Functional Levels
| Level | Key Muscle | Functional Expectation |
|---|---|---|
| C1-C3 | None (diaphragm paralyzed) | Ventilator dependent, power wheelchair with head control |
| C4 | Diaphragm | May wean from ventilator, power wheelchair with chin/sip-and-puff |
| C5 | Deltoid, biceps | Independent feeding with setup, power or manual wheelchair |
| C6 | Wrist extensors | Tenodesis grasp, modified independent ADLs, manual wheelchair on flat surfaces |
| C7 | Triceps | Independent transfers, manual wheelchair, modified independent in most ADLs |
| C8-T1 | Hand intrinsics | Independent in ADLs, fine motor tasks, manual wheelchair |
| T6-T12 | Trunk muscles (progressive) | Increasing trunk control, independent wheelchair, standing frame |
| L2-L4 | Hip flexors, quadriceps | Household ambulation with orthoses and assistive device |
| L5-S1 | Ankle muscles | Community ambulation, may need AFO |
Incomplete SCI Syndromes
| Syndrome | Area Affected | Presentation |
|---|---|---|
| Central cord | Central gray matter | UE weakness > LE, "cape-like" sensory loss, hand dysfunction |
| Anterior cord | Anterior 2/3 of cord | Motor loss and pain/temp loss below lesion; proprioception preserved |
| Brown-Sequard | Lateral half of cord (hemisection) | Ipsilateral motor loss + proprioception loss; contralateral pain/temp loss |
| Posterior cord | Posterior columns | Loss of proprioception and vibration; motor and pain/temp preserved |
| Cauda equina | Nerve roots below conus | LMN signs, bowel/bladder dysfunction, saddle anesthesia |
Parkinson Disease
Parkinson disease results from degeneration of dopaminergic neurons in the substantia nigra of the basal ganglia.
Cardinal Signs (TRAP)
- Tremor: Resting tremor ("pill-rolling"), decreases with purposeful movement
- Rigidity: Cogwheel (ratchety) or lead-pipe (constant) resistance to passive movement
- Akinesia/Bradykinesia: Slowness and poverty of movement, difficulty initiating movement
- Postural instability: Impaired balance, retropulsive (backward falls), festinating gait
Parkinson Gait Characteristics
- Shuffling steps (short stride length)
- Festination (progressively faster, shorter steps)
- Reduced arm swing
- Forward trunk lean
- Difficulty with turns (multiple steps to turn)
- Freezing of gait (especially in doorways or when turning)
Multiple Sclerosis (MS)
MS is an autoimmune disease causing demyelination of CNS white matter:
MS Types
| Type | Description | Percentage |
|---|---|---|
| Relapsing-Remitting (RRMS) | Episodes of worsening followed by partial/complete recovery | ~85% at onset |
| Secondary Progressive (SPMS) | Begins as RRMS, then progresses continuously | ~50% of RRMS develop SPMS |
| Primary Progressive (PPMS) | Gradual progression from onset without relapses | ~10-15% |
| Progressive-Relapsing (PRMS) | Progressive from onset with acute relapses | Rare (~5%) |
Key MS Concepts for NPTE
- Uhthoff phenomenon: Symptoms worsen with increased body temperature (heat sensitivity)
- Lhermitte sign: Electric shock sensation down the spine with neck flexion
- Exercise precaution: Avoid overheating; aquatic therapy water temperature should be below 85 degrees F (29 degrees C)
- Fatigue management: Energy conservation techniques, scheduled rest periods
A patient presents with contralateral hemiplegia affecting the arm more than the leg, Broca aphasia, and right homonymous hemianopsia. The MOST likely location of the stroke is:
A patient with a C6 complete spinal cord injury would be expected to:
Which of the following is characteristic of Parkinson disease gait?
A patient with MS reports that their symptoms worsen when they take a hot bath. This is known as:
Brown-Sequard syndrome (hemisection of the spinal cord) results in:
In Parkinson disease, the cardinal signs are remembered by the mnemonic TRAP: Tremor, Rigidity, Akinesia/Bradykinesia, and Postural _____.
Type your answer below
Central cord syndrome typically presents with:
In Brunnstrom stages of motor recovery after stroke, spasticity is at its PEAK during which stage?
Guillain-Barre syndrome (GBS) is characterized by:
The most common type of multiple sclerosis at initial diagnosis is:
BPPV (Benign Paroxysmal Positional Vertigo) is MOST effectively treated with:
Match each incomplete spinal cord injury syndrome to its characteristic presentation.
Match each item on the left with the correct item on the right