2.3 Neurological Conditions

The NPTE tests recognition, expected function, and PT management of major neurological conditions. This section covers the highest-yield ones.

Stroke (Cerebrovascular Accident)

By artery

Aphasia (dominant/left hemisphere)

Brunnstrom recovery progresses through 7 stages: flaccidity (1), emerging spasticity/synergies (2), peak spasticity (3), spasticity declining with movement out of synergy (4), more isolated movement (5), near-normal coordination (6), and normal (7).

Spinal Cord Injury (SCI)

Functional levels (complete injury)

Incomplete syndromes

Watch for autonomic dysreflexia in injuries at or above T6: a noxious stimulus below the lesion (often a blocked catheter) triggers a hypertensive emergency. The PT immediately sits the patient upright and removes the trigger.

Parkinson Disease, MS, and TBI

Parkinson disease results from loss of dopaminergic neurons in the substantia nigra. The cardinal TRAP signs are resting (pill-rolling) Tremor, cogwheel/lead-pipe Rigidity, Akinesia/bradykinesia, and Postural instability. The gait is shuffling and festinating (short, accelerating steps) with reduced arm swing, forward lean, and freezing, especially at doorways and turns.

Multiple sclerosis is autoimmune demyelination of CNS white matter. Relapsing-remitting MS (~85% at onset) is most common; many later convert to secondary-progressive. Key NPTE pearls: Uhthoff phenomenon (symptoms worsen with heat), Lhermitte sign (electric shock down the spine with neck flexion), and the avoid-overheating precaution—keep aquatic-therapy water cool (around or below ~29 C / 85 F) and use energy conservation for fatigue.

Traumatic brain injury recovery is staged with the Rancho Los Amigos Levels of Cognitive Functioning (I-VIII), from Level I (no response) through Level IV (confused-agitated) to Level VIII (purposeful-appropriate). PT structures the environment for low-level/agitated patients and progressively challenges cognition and mobility as the patient advances.

Guillain-Barre, Vestibular Disorders, and ALS

Guillain-Barre syndrome (GBS) is an acute inflammatory demyelinating polyneuropathy producing ascending, symmetric LMN weakness (flaccidity, areflexia), often after an infection. The danger is respiratory failure (monitor vital capacity) and autonomic instability. PT emphasizes positioning, gentle non-fatiguing exercise during recovery, and respiratory care; overexertion early can worsen outcomes.

Vestibular disorders cause vertigo, nystagmus, and imbalance. Benign paroxysmal positional vertigo (BPPV)—otoconia displaced into a semicircular canal—is the most common and is treated with canalith repositioning (the Epley maneuver), not with prolonged rest. Unilateral vestibular hypofunction is treated with vestibular rehabilitation (gaze-stabilization and habituation exercises).

Amyotrophic lateral sclerosis (ALS) degenerates both UMN and LMN, producing a mixed picture (spasticity plus atrophy/fasciculations) that progresses to respiratory failure and is ultimately fatal. PT is not curative: it focuses on preserving function and safety, energy conservation, equipment and assistive devices, and avoiding overwork weakness while supporting quality of life.

Tying Presentation to PT Priorities

For each condition, the exam wants the priority that flows from the pathology. After stroke, prevent learned non-use and train tasks. In SCI, predict function by level and guard against complications such as autonomic dysreflexia (T6 and above), pressure injuries, and orthostatic hypotension. In Parkinson disease, use external cueing and large-amplitude movement to counter bradykinesia and freezing. In MS, conserve energy and avoid overheating. In GBS, monitor respiration and avoid overexertion during recovery. In ALS, preserve function and prevent overwork fatigue rather than chase strength gains.

Pairing each diagnosis with its single highest PT priority converts a long list of diseases into a small set of decision rules the exam rewards.

Recovery Expectations and Prognosis

The exam also probes realistic prognosis. After stroke, the fastest motor recovery occurs in the first weeks to months, though gains continue longer with training. Complete (ASIA A) SCI carries a guarded prognosis for motor return below the level, whereas incomplete injuries have more potential. Progressive diseases (MS, Parkinson, ALS) require goals framed around maintaining function and safety and adapting as the disease evolves, not curing.

Matching your goal-setting and family education to each condition's expected trajectory is itself a tested competency, and it guides whether the plan emphasizes restoration, compensation, or maintenance.