Neuromuscular Practice
Neuromuscular items test whether you can localise a lesion and then translate that localisation into a safe, evidence-informed plan. Start with the upper versus lower motor neuron distinction: UMN signs include hyperreflexia, spasticity, clonus, a positive Babinski and loss of dexterity; LMN signs include flaccidity, hyporeflexia, fasciculations, atrophy and marked weakness. Conditions such as Guillain-Barré are LMN, while stroke and most MS presentations are UMN.
Concepts to own
- Neuroanatomy screening: dermatomes, myotomes, reflexes, cranial nerves, and the ASIA impairment scale for spinal cord injury (including sacral sparing for completeness).
- Tone measurement (Modified Ashworth, Tardieu) and spasticity management: positioning, stretch, botulinum toxin adjuncts, and the risk of over-lengthening already-shortened tissue.
- Motor learning and neuroplasticity principles: task specificity, high repetition, salience, progression, and functional relevance.
- Condition-specific priorities: fatigue and heat sensitivity in MS, amplitude and cueing strategies with freezing in Parkinson disease, autonomic dysreflexia in higher-level cord injury, vestibular adaptation and habituation.
- Standardised outcome measures (Berg Balance Scale, Timed Up and Go, functional gait and reach tests) with known cut-scores and psychometrics.
Traps
Questions often describe a deteriorating patient and expect you to recognise when to stop and escalate rather than continue therapy. Another frequent error is applying UMN-style strengthening to a fatigable LMN patient, or interpreting a score without its meaning - for example, a Berg score below roughly 45 is associated with increased fall risk. Do not confuse a compensatory gait deviation with the primary impairment.
Rule of thumb
Localise first, treat second: decide UMN versus LMN, level, and symmetry before choosing an intervention. If the presentation mixes both, suspect a process affecting both - for example, cervical spondylotic myelopathy or amyotrophic lateral sclerosis - and refer.