A patient stands with feet together and maintains balance with eyes open but loses balance when eyes are closed. This is a positive:

Romberg test. A positive Romberg test occurs when the patient loses balance with eyes closed but can maintain balance with eyes open. This indicates impaired proprioception (dorsal column dysfunction) — the patient relies on visual compensation to maintain balance. When vision is removed, the proprioceptive deficit becomes apparent.

A patient with a GCS Motor score of 3 is exhibiting:

Decorticate posturing (flexion). GCS Motor score 3 represents decorticate posturing (abnormal flexion response to pain). The patient flexes the upper extremities and extends the lower extremities. This indicates damage above the red nucleus in the midbrain. Decerebrate posturing (extension of all extremities) is a Motor score of 2, indicating brainstem-level damage.

On the Berg Balance Scale, a total score of 38 out of 56 indicates:

Medium fall risk — requires assistance. On the Berg Balance Scale, a score of 38 falls in the medium fall risk category (21-40), indicating the patient likely requires some assistance. Scores of 41-56 indicate low fall risk, and scores of 0-20 indicate high fall risk. A score below 45 is generally considered to indicate increased fall risk.

Which nerve root level corresponds to the patellar (knee jerk) reflex?

L3-L4. The patellar (knee jerk) reflex tests the L3-L4 nerve root level. Other key reflex levels: biceps (C5-C6), triceps (C7), and Achilles/ankle jerk (S1-S2). These reflex levels are frequently tested on the NPTE for localizing nerve root pathology.

2.2 Neurological Examination | NPTE Physical Therapy Exam | Free Exam Prep

Key Takeaways

Deep tendon reflexes are graded 0-4: 0=absent, 1+=diminished, 2+=normal, 3+=brisk, 4+=clonus; asymmetry is more significant than absolute grade
Key reflex levels: C5-C6 (biceps), C5-C6 (brachioradialis), C7 (triceps), L3-L4 (patellar/knee jerk), S1-S2 (Achilles/ankle jerk)
The Glasgow Coma Scale (GCS) assesses Eye opening (1-4), Verbal response (1-5), and Motor response (1-6), range 3-15; score of 8 or below indicates severe TBI
The Berg Balance Scale (BBS) is a 14-item test scored 0-56; scores below 45 indicate increased fall risk
The Romberg test assesses proprioceptive function: positive if patient loses balance with eyes closed (removing visual compensation for impaired proprioception)
Cranial nerve assessment is essential for identifying brainstem lesions: CN V (trigeminal — facial sensation), CN VII (facial — facial expression), CN VIII (vestibulocochlear — hearing/balance)
Coordination tests include finger-to-nose, heel-to-shin, and rapid alternating movements (dysdiadochokinesia indicates cerebellar dysfunction)
The Modified Ashworth Scale (MAS) grades spasticity from 0 (no increase in tone) to 4 (rigid in flexion or extension)

Neurological Examination

A systematic neurological examination allows physical therapists to localize lesions, establish baselines, and monitor progress. The NPTE heavily tests the selection, administration, and interpretation of neurological assessment tools.

Deep Tendon Reflexes (DTR)

Reflex Grading Scale

Grade	Description	Interpretation
0	Absent	Abnormal — LMN lesion
1+	Diminished	May be normal or indicate LMN pathology
2+	Normal	Expected response
3+	Brisk (hyperactive)	May indicate UMN pathology
4+	Clonus (sustained rhythmic oscillation)	Abnormal — UMN lesion

Clinical Note: Asymmetry between sides is often more clinically significant than the absolute grade. Always compare reflexes bilaterally.

Key Reflex Levels

Reflex	Nerve Root Level	Muscle/Tendon
Biceps reflex	C5, C6	Biceps tendon at antecubital fossa
Brachioradialis	C5, C6	Brachioradialis tendon at wrist
Triceps reflex	C7	Triceps tendon at olecranon
Patellar (knee jerk)	L3, L4	Quadriceps tendon below patella
Achilles (ankle jerk)	S1, S2	Achilles tendon

Glasgow Coma Scale (GCS)

The GCS is used to assess consciousness, particularly after traumatic brain injury:

Response	Score Range	Best Response
Eye Opening	1-4	4 = Spontaneous, 3 = To voice, 2 = To pain, 1 = None
Verbal Response	1-5	5 = Oriented, 4 = Confused, 3 = Inappropriate words, 2 = Incomprehensible sounds, 1 = None
Motor Response	1-6	6 = Obeys commands, 5 = Localizes pain, 4 = Withdrawal, 3 = Flexion (decorticate), 2 = Extension (decerebrate), 1 = None

Score Interpretation:

Total range: 3-15
13-15: Mild TBI
9-12: Moderate TBI
3-8: Severe TBI (intubation typically required at GCS ≤8)

Key Clinical Point: Decorticate posturing (GCS Motor 3) involves flexion of the upper extremities, indicating damage above the red nucleus (midbrain). Decerebrate posturing (GCS Motor 2) involves extension of all extremities, indicating damage below the red nucleus (pons/brainstem), which carries a worse prognosis.

Balance Assessment

Berg Balance Scale (BBS)

The BBS is a 14-item performance-based scale commonly used in PT:

Each item scored 0-4 (0 = unable, 4 = independent)
Maximum score: 56
Score interpretation:
- 41-56: Low fall risk (independent)
- 21-40: Medium fall risk (requires assistance)
- 0-20: High fall risk (wheelchair level)
A score below 45 indicates increased fall risk
Minimal detectable change (MDC): ~5 points

Romberg Test

The Romberg test specifically assesses proprioceptive function:

Patient stands with feet together, eyes open, then eyes closed
Positive Romberg: Patient loses balance when eyes are closed
Interpretation: The patient can compensate with vision but cannot maintain balance without visual input, indicating impaired proprioception (dorsal column dysfunction)
Note: If the patient cannot maintain balance with eyes open, the problem is not proprioceptive — it may be cerebellar, vestibular, or motor

Timed Up and Go (TUG)

Patient rises from a chair, walks 3 meters, turns, walks back, and sits down
Normal: <10 seconds
Increased fall risk: >12-14 seconds
Indicates need for assistance: >20 seconds

Coordination Testing

Cerebellar dysfunction produces characteristic movement errors:

Test	Assessment	Positive Finding
Finger-to-nose	Upper extremity coordination	Dysmetria (overshoot or undershoot), intention tremor
Heel-to-shin	Lower extremity coordination	Inability to smoothly trace the shin
Rapid alternating movements	Diadochokinesia	Dysdiadochokinesia (irregular rhythm, speed)
Tandem walking	Dynamic balance, coordination	Wide-based gait, deviation from line

Cerebellar vs. Basal Ganglia Dysfunction

Feature	Cerebellar Dysfunction	Basal Ganglia Dysfunction
Tremor	Intention tremor (worse with movement)	Resting tremor (worse at rest, better with movement)
Movements	Dysmetria, ataxia	Bradykinesia, rigidity, chorea
Gait	Wide-based, ataxic	Shuffling, festinating
Example	Cerebellar stroke, MS	Parkinson disease, Huntington disease

Spasticity Assessment

Modified Ashworth Scale (MAS)

Grade	Description
0	No increase in muscle tone
1	Slight increase; catch and release or minimal resistance at end range
1+	Slight increase; catch followed by minimal resistance through less than half the range
2	More marked increase through most of the range; limb easily moved
3	Considerable increase; passive movement difficult
4	Rigid in flexion or extension

NPTE Physical Therapy Exam

1Introduction: NPTE Exam Overview

2Chapter 1: Musculoskeletal System

3Chapter 2: Neuromuscular & Nervous Systems

4Chapter 3: Cardiovascular & Pulmonary Systems

5Chapter 4: Integumentary & Other Body Systems

6Chapter 5: Non-Systems (Equipment, Safety & Professional Practice)