Neurorehabilitation, neuropsychology and palliative care
This domain tests rehabilitation principles and outcome-relevant interventions, the interpretation of neuropsychological profiles, and the practical delivery of palliative care in progressive neurological disease.
Rehabilitation principles
Neuroplasticity is driven by task-specific, repetitive, salient practice; "use it or lose it" and intensity matter. Organised stroke unit care reduces death and disability. Motor approaches include task-specific training, constraint-induced movement therapy, robotic gait training and functional electrical stimulation. Spasticity is graded with the Ashworth or modified Ashworth scale and treated with physiotherapy, botulinum toxin for focal problems, intrathecal baclofen for generalised severe spasticity, and phenol nerve blocks. Aphasia therapy should be intensive and impairment-focused; dysphagia requires screening and instrumental assessment (FEES or videofluoroscopy).
Neuropsychology
Screen with MMSE or MoCA; both are brief and the MMSE is insensitive to executive and mild cognitive impairment. Formal assessment covers attention and processing speed (Trail Making Test A), memory (Auditory Verbal Learning Test, Rey–Osterrieth Complex Figure), executive function (Trail Making Test B, Stroop, verbal fluency), language (Boston Naming Test), and visuospatial and praxis skills. Typical patterns: Alzheimer disease - amnesic onset with medial temporal atrophy; vascular cognitive impairment - stepwise course with frontal-executive deficits; behavioural variant frontotemporal dementia - personality change with relative memory preservation; dementia with Lewy bodies - visuospatial deficits and fluctuation. Distinguish delirium (acute, fluctuating, inattention) from dementia, and depression with cognitive complaints from dementia.
Palliative care
In amyotrophic lateral sclerosis, non-invasive ventilation for orthopnoea and a feeding tube for weight loss improve quality of life; discuss advance directives early. Symptom control includes opioids for pain and dyspnoea, glycopyrrolate or botulinum toxin for sialorrhoea, and benzodiazepines for anxiety and terminal agitation. Use the SPIKES framework for breaking bad news; document DNAR decisions and preferred place of care.
Worked example
A stroke patient has a flexed, painful arm 3 months after onset with modified Ashworth 3 in the elbow flexors. Focal spasticity is best treated with botulinum toxin injected into the elbow flexors combined with stretching and task practice, not with systemic antispastics alone, because the problem is focal.
Traps
Relying on the MMSE alone to exclude cognitive impairment; labelling depression as dementia; withholding adequate analgesia in dying patients for fear of respiratory depression; treating generalised spasticity with repeated focal injections only.