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DACNB practice questions

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Question 1Functional neuroanatomy and neurological reasoning

A patient demonstrates dysmetria of the right upper extremity on finger-to-nose testing, with intention tremor that worsens as the target is approached. Truncal stability is preserved. Which cerebellar region is most likely involved?

  1. Right cerebellar hemisphere Correct answer.
  2. Left cerebellar hemisphere
  3. Vermis
  4. Flocculonodular lobe

Explanation

The cerebrocerebellum (lateral hemispheres) controls coordination of distal limb movements ipsilateral to the side of the lesion. Right-sided ipsilateral limb dysmetria with intention tremor localizes to the right cerebellar hemisphere. Truncal preservation argues against vermis (spinocerebellum) and the absence of nystagmus/imbalance argues against flocculonodular involvement. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 2Functional neuroanatomy and neurological reasoning

A 50-year-old presents with resting tremor of the right hand (pill-rolling), bradykinesia, and cogwheel rigidity. Which structure is primarily implicated?

  1. Caudate nucleus
  2. Substantia nigra pars compacta (loss of dopaminergic neurons) Correct answer.
  3. Subthalamic nucleus
  4. Cerebellar dentate nucleus

Explanation

Idiopathic Parkinson disease results from progressive loss of dopaminergic neurons in the substantia nigra pars compacta, reducing dopaminergic input to the striatum and altering basal ganglia output. The classic triad is resting tremor, bradykinesia, and rigidity, often with asymmetric onset. Postural instability appears later in disease. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 3Functional neuroanatomy and neurological reasoning

A patient demonstrates left adduction weakness on right gaze with abducting nystagmus of the right eye. Convergence is intact. The most likely localization is:

  1. Left medial longitudinal fasciculus (left INO) Correct answer.
  2. Right oculomotor nerve
  3. Left abducens nerve
  4. Left lateral rectus

Explanation

Internuclear ophthalmoplegia (INO) is caused by a lesion of the medial longitudinal fasciculus (MLF) on the side of the impaired adduction. Preserved convergence helps localize to the MLF (rather than to a CN III nuclear/fascicular lesion). Bilateral INO in a young adult should raise concern for multiple sclerosis. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 4Vestibular, ocular motor and balance assessment

During the Dix-Hallpike maneuver toward the right, the patient develops upbeating-torsional nystagmus (top poles beating toward the right ear) with a 5-second latency, lasting 25 seconds, and fatigues with repetition. The most likely diagnosis is:

  1. Posterior canal BPPV on the right Correct answer.
  2. Posterior canal BPPV on the left
  3. Vestibular neuritis on the right
  4. Central positional vertigo

Explanation

Right posterior canal BPPV produces upbeating-torsional nystagmus (top pole beating toward the dependent ear) with classic latency, duration <60 seconds, and fatigability on a right Dix-Hallpike. The Epley canalith repositioning maneuver is the treatment of choice. Central positional nystagmus typically lacks latency, does not fatigue, and may be persistent or change direction. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 5Vestibular, ocular motor and balance assessment

The vestibulo-ocular reflex (VOR) gain is best assessed clinically with:

  1. Tandem Romberg
  2. Head impulse test (HIT) Correct answer.
  3. Vibration test of mastoid
  4. Babinski

Explanation

The head impulse test (Halmagyi-Curthoys) is the bedside test of VOR gain. A corrective catch-up saccade indicates reduced VOR gain on the tested side, suggesting peripheral vestibulopathy (vestibular neuritis, hypofunction). HIT is a key component of the HINTS exam for differentiating peripheral from central acute vestibular syndrome. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 6Vestibular, ocular motor and balance assessment

In an adult with an appropriate acute vestibular syndrome with nystagmus, a clinician trained in HINTS finds direction-changing nystagmus and a normal head impulse. Which listed interpretation requires urgent further assessment?

  1. Peripheral vestibulopathy (vestibular neuritis)
  2. Central (likely posterior circulation stroke) Correct answer.
  3. BPPV
  4. Migraine-associated vertigo

Explanation

In the appropriate acute vestibular syndrome population, trained HINTS assessment can help distinguish central from peripheral findings. Direction-changing nystagmus and a normal impulse in the stated pattern raise central concern. HINTS is not a general test for all dizziness, and central or equivocal findings need the appropriate urgent assessment.

Question 7Concussion, headache and functional recovery

Per ICHD-3, the minimum criteria for migraine without aura include all of the following EXCEPT:

  1. At least 5 attacks fulfilling criteria
  2. Duration 4-72 hours untreated or unsuccessfully treated
  3. At least 2 of: unilateral, pulsating, moderate-severe intensity, aggravated by physical activity
  4. Onset before age 10 Correct answer.

Explanation

ICHD-3 migraine without aura requires >=5 attacks, duration 4-72 hours, at least 2 of (unilateral, pulsating, moderate-severe, aggravation by routine activity), and at least 1 of (nausea/vomiting or photophobia and phonophobia). Onset before age 10 is not a criterion - migraine commonly begins in adolescence or young adulthood.

Question 8Concussion, headache and functional recovery

The SCAT6 (Sport Concussion Assessment Tool 6) acute evaluation tool is designed for athletes aged:

  1. <5 years
  2. 5-12 years (Child SCAT6)
  3. 13 years and older Correct answer.
  4. Adults only (>=18 years)

Explanation

SCAT6 is intended for athletes 13 years and older; Child SCAT6 is intended for ages 5-12. SCAT6 (released 2023 with the 2022 Amsterdam consensus) replaces SCAT5 and adds dual-task gait and improved cognitive subscales. Acute evaluation includes Maddocks questions, Glasgow Coma Scale, and on-field cognitive screen.

Question 9Concussion, headache and functional recovery

Per the 2022 Amsterdam concussion consensus, return-to-learn and return-to-play should:

  1. Begin only after 30 days of complete rest
  2. Begin with relative (not strict) rest in the first 24-48 hours and progress through stepwise, symptom-limited activity Correct answer.
  3. Be initiated immediately at full intensity
  4. Use a fixed timeline regardless of symptoms

Explanation

The 2022 Amsterdam consensus emphasizes early active rehabilitation: relative rest in the first 24-48 hours (avoid screens and strenuous activity but not strict bed rest), then graded symptom-limited reintroduction of cognitive and physical activity. Stepwise RTL/RTP advances by 24-hour increments if symptom-free.

Question 10Neuromusculoskeletal assessment and differential diagnosis

A patient has burning, allodynia, and color changes in the right foot 6 weeks after an ankle sprain, without nerve injury on exam. The most likely diagnosis is:

  1. Complex regional pain syndrome type I (CRPS-I, formerly RSD) Correct answer.
  2. Diabetic neuropathy
  3. Peripheral arterial disease
  4. Raynaud syndrome

Explanation

CRPS-I (formerly reflex sympathetic dystrophy) develops after an inciting injury without identifiable nerve injury and includes sensory (allodynia, hyperalgesia), vasomotor (color/temperature change), sudomotor (sweating, edema), and motor/trophic changes. The Budapest criteria are used for diagnosis. Early multimodal therapy (PT, desensitization, neuromodulation) improves outcomes. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 11Neuromusculoskeletal assessment and differential diagnosis

A C6 radiculopathy classically presents with weakness of:

  1. Wrist extension, elbow flexion (biceps), and diminished biceps reflex Correct answer.
  2. Triceps and wrist flexion with diminished triceps reflex
  3. Hand intrinsics with diminished finger flexor reflex
  4. Shoulder abduction with diminished deltoid reflex

Explanation

C6 radiculopathy classically presents with weakness in wrist extension and elbow flexion (biceps, brachioradialis), diminished biceps or brachioradialis reflex, and sensory changes along the radial forearm to the thumb and index finger. C7 affects triceps and wrist flexion; C8/T1 affects intrinsics. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 12Neuromusculoskeletal assessment and differential diagnosis

A diabetic patient develops sudden left foot drop with sensory loss in the lateral leg and dorsum of the foot. The lesion is most likely:

  1. L5 nerve root or common peroneal (fibular) nerve at the fibular head Correct answer.
  2. Tibial nerve
  3. S1 nerve root
  4. Femoral nerve

Explanation

Foot drop with sensory loss in the lateral leg and dorsum of the foot localizes to the L5 root (radiculopathy) or the common peroneal nerve at the fibular head (mononeuropathy). Distinction: peroneal mononeuropathy preserves inversion (tibialis posterior, tibial nerve), while L5 radiculopathy affects inversion. EMG can confirm. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 13Neurological and musculoskeletal danger signs

A patient has progressive gait imbalance, dysarthria, intention tremor, and visual field defect (homonymous hemianopia). MRI shows cerebellar mass and occipital cortex involvement. The most appropriate management is:

  1. Symptomatic management at home
  2. Urgent neurologic/neurosurgical referral for likely posterior fossa or occipital pathology (consider stroke, tumor, demyelination) Correct answer.
  3. Begin TMS therapy
  4. Repeat MRI in 6 months

Explanation

Progressive cerebellar signs plus homonymous hemianopia with imaging confirming cerebellar mass and occipital cortex involvement require urgent neurological/neurosurgical referral. The differential includes posterior circulation stroke, brain tumor (primary or metastatic), or demyelination. Delay risks brainstem compression or progression. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 14Neurological and musculoskeletal danger signs

Which finding most strongly suggests REFERRAL TO EMERGENCY for suspected stroke per current AHA guidelines?

  1. Mild tension headache
  2. Sudden onset focal weakness, facial droop, or speech disturbance (BE-FAST positive) Correct answer.
  3. Chronic neck pain
  4. Persistent low back pain

Explanation

BE-FAST (Balance, Eyes, Face, Arms, Speech, Time) is the AHA-endorsed screen for stroke. Any positive sign mandates immediate EMS activation. Time is brain - tPA window is up to 4.5 hours; mechanical thrombectomy up to 24 hours for select patients. Chiropractic neurologists must recognize and refer immediately. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 15Neurological and musculoskeletal danger signs

What is the typical cervical artery dissection presentation that mandates emergency referral?

  1. Painless chronic neck stiffness
  2. Acute severe neck or head pain (often unilateral) with focal neurologic deficits or Horner syndrome Correct answer.
  3. Bilateral arm tingling alone
  4. Knee pain

Explanation

Cervical artery dissection (carotid or vertebral) classically presents with acute severe ipsilateral neck or head pain plus focal neurologic deficits (e.g., stroke, TIA) and may include Horner syndrome (with internal carotid dissection). Mechanical manipulation of the cervical spine in this context is contraindicated. CTA or MRA is the diagnostic study of choice. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 16Neurorehabilitation, evidence and professional limits

Constraint-induced movement therapy (CIMT) restrains the less-affected upper extremity to force intensive use of the more-affected arm after stroke. Which prerequisite is generally required for a patient to be an appropriate CIMT candidate?

  1. Some active wrist and finger extension in the more-affected hand Correct answer.
  2. Complete absence of any active movement in the more-affected hand
  3. Full, symmetric strength already present in the more-affected arm
  4. A diagnosis of peripheral neuropathy rather than stroke

Explanation

CIMT candidacy typically requires some active wrist and finger extension in the more-affected hand, since the protocol depends on the patient's ability to use that limb for structured, intensive practice. The stated pattern or method supports the particular clinical comparison; it is not a universal diagnosis, treatment prescription or guarantee of outcome. Actual safety, patient selection and implementation require the qualified care plan.

Question 17Neurorehabilitation, evidence and professional limits

Motor learning research supports which practice structure for improving long-term retention of a functional motor skill after neurologic injury, compared with purely blocked, repetitive practice of one task?

  1. Variable, task-specific practice with meaningful feedback on knowledge of results/performance Correct answer.
  2. Passive range of motion exercises only, with no active practice
  3. A single, unchanging repetition performed exactly the same way every session
  4. Practice performed only in a completely unnatural, non-functional context

Explanation

Motor learning principles support variable, task-specific practice with appropriate feedback (knowledge of results/performance) to enhance retention and transfer of motor skills, compared with rigid, unvarying repetition alone. The stated pattern or method supports the particular clinical comparison; it is not a universal diagnosis, treatment prescription or guarantee of outcome. Actual safety, patient selection and implementation require the qualified care plan.

Question 18Neurorehabilitation, evidence and professional limits

Body-weight-supported treadmill training is a gait-rehabilitation intervention most associated with which patient populations?

  1. Patients with stroke or incomplete spinal cord injury working to regain functional ambulation Correct answer.
  2. Patients with isolated ankle sprains only
  3. Patients recovering from routine outpatient orthopedic knee surgery only
  4. Patients with intact, unimpaired gait needing no rehabilitation

Explanation

Body-weight-supported treadmill training unloads a portion of body weight to allow early, repetitive, task-specific stepping practice, and is well studied in stroke and incomplete spinal cord injury populations. The stated pattern or method supports the particular clinical comparison; it is not a universal diagnosis, treatment prescription or guarantee of outcome. Actual safety, patient selection and implementation require the qualified care plan.

Question 19Functional neuroanatomy and neurological reasoning

A patient has loss of position sense in the lower extremities with a wide-based stomping gait. Romberg sign is positive. The most likely affected pathway is:

  1. Dorsal columns (medial lemniscus pathway) Correct answer.
  2. Spinothalamic tract
  3. Corticospinal tract
  4. Cerebellar pathway

Explanation

Loss of proprioception and vibratory sense with positive Romberg and a sensory ataxic gait localizes to the dorsal columns (gracilis for lower extremities, cuneatus for upper). Tabes dorsalis (neurosyphilis), B12 deficiency (subacute combined degeneration), and dorsal column compression are classic etiologies. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 20Functional neuroanatomy and neurological reasoning

A patient has a compatible clinical neurological history and MRI lesions in characteristic periventricular locations. Which listed disorder is suggested in the differential, without claiming that a few hours of visual symptoms alone establish the current diagnostic criteria?

  1. Multiple sclerosis Correct answer.
  2. Migraine with aura
  3. Optic neuritis only
  4. Stroke

Explanation

Characteristic periventricular lesions and a compatible clinical pattern can support a multiple-sclerosis differential. Brief visual symptoms alone do not establish a typical demyelinating episode or the complete current criteria. Qualified neurological assessment must consider dissemination, appropriate biomarkers or imaging and alternative explanations.

Question 21Functional neuroanatomy and neurological reasoning

Which tract carries discriminative touch, vibration, and proprioception from the lower extremity?

  1. Fasciculus gracilis (medial dorsal column) Correct answer.
  2. Fasciculus cuneatus (lateral dorsal column)
  3. Lateral spinothalamic tract
  4. Spinocerebellar tract

Explanation

Fasciculus gracilis carries discriminative touch, vibration, and proprioception from the lower extremity to the nucleus gracilis in the medulla. Fasciculus cuneatus performs the same role for the upper extremity. The dorsal columns then decussate as the medial lemniscus and project to VPL of the thalamus.

Question 22Functional neuroanatomy and neurological reasoning

Functional MRI (fMRI) primarily measures:

  1. Direct neuronal action potential currents
  2. Blood-oxygen-level-dependent (BOLD) signal as a proxy for neural activity Correct answer.
  3. Cerebrospinal fluid pressure
  4. Cortical thickness

Explanation

fMRI measures BOLD signal - the ratio of oxygenated to deoxygenated hemoglobin - as a proxy for regional neural activity. Increases in neural activity cause vascular changes that alter the BOLD signal. fMRI does not directly measure action potentials and has limited temporal resolution. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 23Functional neuroanatomy and neurological reasoning

Which finding is most specific for a UPPER motor neuron lesion?

  1. Fasciculations and atrophy
  2. Spasticity, hyperreflexia, and a positive Babinski sign Correct answer.
  3. Areflexia with flaccid weakness
  4. Sensory level with bowel/bladder dysfunction

Explanation

UMN signs include spasticity (velocity-dependent increased tone), hyperreflexia, clonus, and pathologic reflexes (Babinski, Hoffmann). LMN signs include fasciculations, atrophy, hyporeflexia, and flaccid weakness. ALS classically presents with both UMN and LMN signs together. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 24Functional neuroanatomy and neurological reasoning

Which cranial nerve is involved in the corneal reflex's afferent limb?

  1. CN V (trigeminal, ophthalmic division) Correct answer.
  2. CN VII
  3. CN II
  4. CN III

Explanation

The corneal reflex afferent is CN V (ophthalmic division V1) and the efferent is CN VII (orbicularis oculi). Loss of the reflex with intact CN VII (the patient blinks with stimulation of the contralateral eye) suggests V1 lesion. Loss with intact V1 suggests CN VII lesion.

Question 25Functional neuroanatomy and neurological reasoning

A 65-year-old with Parkinson disease shows a sudden inability to initiate walking despite intent ('start hesitation'). This phenomenon is called:

  1. Freezing of gait (FOG) Correct answer.
  2. Festination
  3. Bradykinesia
  4. Akathisia

Explanation

Freezing of gait (FOG) is episodic motor block in Parkinson disease, manifesting as start hesitation, turning hesitation, or freezing in narrow spaces. Sensory cuing (visual lines, auditory metronome) can help break episodes. Festination is involuntary shuffling acceleration; akathisia is motor restlessness associated with dopamine antagonists. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 26Functional neuroanatomy and neurological reasoning

A 30-year-old presents with hemifacial spasm. The most common etiology is:

  1. Microvascular compression of CN VII at the cerebellopontine angle (root entry zone) Correct answer.
  2. Bell palsy
  3. Trigeminal neuralgia
  4. Multiple sclerosis plaque in the medulla

Explanation

Hemifacial spasm is most often caused by microvascular compression of CN VII at its root entry zone in the cerebellopontine angle, classically by the anterior inferior cerebellar artery (AICA). MRI with high-resolution sequences can demonstrate the offending vessel. Microvascular decompression (Jannetta procedure) is effective in refractory cases. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 27Functional neuroanatomy and neurological reasoning

A 60-year-old with cognitive decline has predominantly memory loss, normal motor exam, and MRI showing medial temporal lobe atrophy. The most likely diagnosis is:

  1. Alzheimer disease Correct answer.
  2. Frontotemporal dementia
  3. Lewy body dementia
  4. Vascular dementia

Explanation

Alzheimer disease classically presents with progressive episodic memory loss with medial temporal lobe (hippocampal) atrophy on MRI. FTD presents with personality/behavioral or language predominance and frontotemporal atrophy. Lewy body dementia features visual hallucinations, parkinsonism, and fluctuating cognition. Vascular dementia shows stepwise decline with vascular lesions. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 28Functional neuroanatomy and neurological reasoning

An EEG showing 3-Hz generalized spike-and-wave discharges in a child during hyperventilation is classic for:

  1. Childhood absence epilepsy Correct answer.
  2. Temporal lobe epilepsy
  3. Juvenile myoclonic epilepsy
  4. Lennox-Gastaut syndrome

Explanation

Childhood absence epilepsy (CAE) classically shows 3-Hz generalized spike-and-wave discharges, often provoked by hyperventilation. Clinical episodes are brief (5-20 s) staring spells with behavior arrest. Ethosuximide and valproate are first-line. Referral to neurology is appropriate. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 29Functional neuroanatomy and neurological reasoning

Which nutrient deficiency is associated with subacute combined degeneration of the spinal cord (dorsal columns and corticospinal tracts)?

  1. Vitamin B12 Correct answer.
  2. Vitamin C
  3. Iron
  4. Sodium

Explanation

Vitamin B12 deficiency causes subacute combined degeneration: demyelination of the dorsal columns (proprioception loss, positive Romberg) and corticospinal tracts (UMN signs). Causes include pernicious anemia, vegan diet without supplementation, ileal disease, and long-term metformin. Serum B12 plus methylmalonic acid and homocysteine confirm diagnosis. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 30Functional neuroanatomy and neurological reasoning

Which receptor type is the primary muscle spindle sensor for changes in muscle length (dynamic)?

  1. Group Ib (Golgi tendon organ)
  2. Group Ia (primary spindle afferent) Correct answer.
  3. Group II
  4. C fiber

Explanation

Group Ia afferents (annulospiral endings) wrap around muscle spindle intrafusal fibers and respond to dynamic changes in muscle length. They are the rapid sensors triggering the monosynaptic stretch reflex. Golgi tendon organs (Ib) sense tension; group II senses static stretch. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 31Functional neuroanatomy and neurological reasoning

Which thalamic nucleus relays motor information from cerebellum and basal ganglia to motor cortex?

  1. VPL (ventral posterolateral)
  2. VL/VA (ventrolateral / ventral anterior) Correct answer.
  3. MGN (medial geniculate)
  4. LGN (lateral geniculate)

Explanation

VL relays cerebellar output and VA relays basal ganglia output to motor and pre-motor cortex. VPL relays somatosensory information from the body, VPM from the face. MGN handles audition; LGN handles vision. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 32Functional neuroanatomy and neurological reasoning

A 45-year-old has progressive memory loss, visual hallucinations, and parkinsonism with fluctuations. Most likely diagnosis is:

  1. Lewy body dementia (LBD) Correct answer.
  2. Alzheimer disease
  3. Vascular dementia
  4. Multiple sclerosis

Explanation

Lewy body dementia features visual hallucinations, parkinsonism, fluctuating cognition, and REM sleep behavior disorder. Antipsychotic sensitivity (especially typical antipsychotics) is a major safety concern. Diagnosis is clinical with DaT scan as supportive imaging. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 33Functional neuroanatomy and neurological reasoning

Long-term potentiation (LTP) is a cellular substrate for learning involving:

  1. Pre-synaptic acetylcholine release alone
  2. NMDA receptor-dependent strengthening of synaptic transmission at glutamatergic synapses Correct answer.
  3. Inhibition of action potentials
  4. Reduced calcium signaling

Explanation

LTP is the persistent strengthening of synaptic transmission, most classically at hippocampal CA1 glutamatergic synapses. It depends on NMDA receptor activation (requiring both presynaptic glutamate release and postsynaptic depolarization) with subsequent calcium influx triggering downstream signaling cascades. LTP is considered a cellular correlate of learning and memory. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 34Functional neuroanatomy and neurological reasoning

Which listed ipsilateral coordination and possible associated brainstem pattern can occur with a PICA-territory infarction, recognizing that the actual vascular anatomy and lesion extent vary?

  1. Bilateral facial weakness
  2. Ipsilateral ataxia plus possible lateral medullary syndrome features (Wallenberg) Correct answer.
  3. Pure motor hemiparesis
  4. Wernicke aphasia

Explanation

PICA (posterior inferior cerebellar artery) strokes produce ipsilateral cerebellar ataxia and may include the Wallenberg (lateral medullary) syndrome: ipsilateral Horner, ipsilateral facial pain/temperature loss, contralateral body pain/temperature loss, dysphagia (CN IX/X), and vertigo with nystagmus. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 35Functional neuroanatomy and neurological reasoning

Which neurotransmitter is the primary excitatory transmitter at the neuromuscular junction?

  1. Acetylcholine (binding nicotinic receptors) Correct answer.
  2. GABA
  3. Glutamate
  4. Serotonin

Explanation

Acetylcholine released from motor neuron terminals binds nicotinic receptors on the muscle endplate, triggering depolarization and muscle contraction. Myasthenia gravis is an autoimmune disease against nicotinic ACh receptors, producing fatigable weakness. Lambert-Eaton syndrome affects presynaptic voltage-gated calcium channels. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 36Functional neuroanatomy and neurological reasoning

Which is the most likely brain region involved in producing a Wernicke (receptive) aphasia?

  1. Right frontal lobe
  2. Left posterior superior temporal gyrus (Wernicke area, typically left hemisphere) Correct answer.
  3. Right cerebellum
  4. Brainstem

Explanation

Wernicke (receptive, fluent) aphasia results from a lesion of the left posterior superior temporal gyrus (Brodmann area 22) in most right-handed individuals. Patients speak fluently but with paraphasic errors and lack comprehension. Broca (expressive, non-fluent) aphasia results from left frontal lobe (Brodmann area 44/45) lesions. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 37Functional neuroanatomy and neurological reasoning

Which structure is the principal site of the central pattern generator (CPG) for locomotion?

  1. Lumbar spinal cord (and supraspinal locomotor regions including the midbrain locomotor region) Correct answer.
  2. Frontal lobe only
  3. Cerebellum only
  4. Peripheral nerves only

Explanation

Central pattern generators for locomotion are located in the lumbar spinal cord and modulated by supraspinal regions including the midbrain locomotor region (MLR) and brainstem reticular formation. CPGs produce rhythmic alternating flexor/extensor activity even with descending input removed. Locomotor rehabilitation (e.g., body weight-supported treadmill training) leverages CPG plasticity post-SCI/stroke. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 38Vestibular, ocular motor and balance assessment

Vestibular rehabilitation for unilateral peripheral vestibular hypofunction should emphasize:

  1. Strict bed rest until symptoms resolve
  2. Gaze stabilization exercises (VOR x1, x2), habituation, and balance training Correct answer.
  3. Avoidance of all head movement
  4. Vestibular suppressant medication indefinitely

Explanation

Per APTA and Cochrane evidence, vestibular rehabilitation for unilateral peripheral hypofunction uses gaze stabilization (VOR x1 and x2 viewing), habituation, substitution, and balance training. Vestibular suppressants (e.g., meclizine) impair central compensation and should be tapered after the acute phase. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 39Vestibular, ocular motor and balance assessment

The flocculonodular lobe of the cerebellum primarily integrates inputs from:

  1. Visual and vestibular systems for postural and gaze control Correct answer.
  2. Spinal proprioceptive afferents
  3. Cortico-pontine projections
  4. Olivary nucleus only

Explanation

The vestibulocerebellum (flocculonodular lobe) integrates visual and vestibular afferents to control posture, balance, and the VOR. Spinocerebellum (vermis and paravermis) receives proprioceptive afferents from the spinal cord. Cerebrocerebellum (lateral hemispheres) receives cortico-pontine projections. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 40Vestibular, ocular motor and balance assessment

A patient demonstrates square-wave jerks on fixation testing. These are most commonly seen in:

  1. Normal aging or cerebellar/parkinsonian disease Correct answer.
  2. Optic neuritis
  3. Peripheral vestibulopathy
  4. Lower motor neuron disease

Explanation

Square-wave jerks are involuntary saccades away from fixation followed by a corrective saccade back, occurring during attempted steady fixation. Up to 10/min can be normal in elderly. Increased frequency is seen in cerebellar disease, parkinsonian syndromes, progressive supranuclear palsy, and multiple system atrophy. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 41Vestibular, ocular motor and balance assessment

A patient with a positive head impulse test on the right (corrective saccade after rightward head thrust), spontaneous left-beating horizontal nystagmus, and normal skew testing has:

  1. Right peripheral vestibular hypofunction (e.g., right vestibular neuritis) Correct answer.
  2. Left peripheral vestibular hypofunction
  3. Central vestibular lesion
  4. BPPV

Explanation

Right peripheral vestibular hypofunction produces an abnormal HIT to the right (corrective saccade after rightward thrust) and unopposed leftward tonic drive causing spontaneous left-beating nystagmus (Alexander law: stronger looking left, away from the affected ear). Normal skew test points to peripheral rather than central pathology. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 42Vestibular, ocular motor and balance assessment

Bell palsy is an acute idiopathic peripheral facial nerve palsy. Distinguishing it from a central (UMN) facial palsy is best done by:

  1. Hearing test
  2. Forehead sparing in central palsy due to bilateral cortical innervation of the upper face Correct answer.
  3. Pupillary response
  4. Optic disc examination

Explanation

Central (UMN) facial palsy spares the forehead because the upper face has bilateral cortical innervation. Peripheral (LMN) facial palsy (Bell palsy) affects the entire half of the face including the forehead. Bell palsy is treated with prednisone within 72 hours; antiviral therapy may be added. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 43Vestibular, ocular motor and balance assessment

A near-point-of-convergence measurement is receded during a post-concussion assessment. Which listed interpretation is supported as a concern for further assessment rather than a complete diagnosis from one distance?

  1. Normal NPC
  2. Receded NPC consistent with convergence insufficiency Correct answer.
  3. Excessive convergence
  4. Pseudostrabismus

Explanation

A receded near point of convergence can indicate a convergence-related concern in this setting. It must be interpreted with symptoms, test method, age, repeated findings and the broader binocular-vision assessment. One measurement does not independently establish the entire diagnosis or prove that concussion is the sole cause.

Question 44Vestibular, ocular motor and balance assessment

For an appropriately selected adult with acute vestibular syndrome and nystagmus, which listed examination is used by clinicians trained in its performance and interpretation to help distinguish central from peripheral patterns?

  1. MRI within 1 hour
  2. HINTS exam (head impulse, nystagmus pattern, test of skew) Correct answer.
  3. Otoscopy
  4. ECG

Explanation

In the appropriate acute vestibular syndrome population, trained HINTS assessment can help distinguish central from peripheral findings. Direction-changing nystagmus and a normal impulse in the stated pattern raise central concern. HINTS is not a general test for all dizziness, and central or equivocal findings need the appropriate urgent assessment.

Question 45Vestibular, ocular motor and balance assessment

Optokinetic nystagmus (OKN) abnormalities suggest dysfunction of:

  1. Peripheral nerves only
  2. Parieto-occipital cortex, brainstem, or cerebellar pathways involved in pursuit/saccadic integration Correct answer.
  3. Spinal cord only
  4. Lower motor neuron

Explanation

OKN tests pursuit and saccadic integration of the parieto-occipital cortex (especially V5/MT), brainstem, and cerebellar pathways. Asymmetric OKN can suggest parieto-occipital lesion (e.g., stroke). Absent OKN to one direction with intact pursuit warrants further evaluation. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 46Vestibular, ocular motor and balance assessment

Which structure is the primary integrator of multisensory cues for spatial orientation?

  1. Parieto-insular vestibular cortex (PIVC) Correct answer.
  2. Primary visual cortex (V1) only
  3. Cerebellum only
  4. Spinal cord

Explanation

The parieto-insular vestibular cortex (PIVC, sometimes considered analogous to area OP2) integrates vestibular, visual, and proprioceptive inputs for spatial orientation. PIVC dysfunction contributes to persistent postural-perceptual dizziness (PPPD), motion sensitivity, and spatial disorientation. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 47Vestibular, ocular motor and balance assessment

Persistent postural-perceptual dizziness (PPPD) is most consistent with which clinical picture?

  1. Acute peripheral vestibular hypofunction
  2. Chronic non-vertiginous dizziness with motion sensitivity, worsened by upright posture and visual motion, after an initial vestibular/medical event Correct answer.
  3. Sudden hearing loss
  4. Acute migraine attack

Explanation

PPPD (Barany Society 2017 criteria) is a chronic functional vestibular disorder presenting >=3 months after an inciting event with persistent non-vertiginous dizziness or unsteadiness exacerbated by upright posture, active or passive motion, and complex visual environments. Treatment includes vestibular rehabilitation, CBT, and SSRIs. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 48Vestibular, ocular motor and balance assessment

The bedside Romberg test is positive when:

  1. The patient sways with eyes open
  2. The patient sways significantly more with eyes closed than open Correct answer.
  3. The patient cannot stand at all
  4. The patient walks heel-to-toe poorly

Explanation

A positive Romberg requires that the patient stand stably with eyes open but sway significantly (or fall) with eyes closed. It indicates a sensory ataxia (dorsal columns or peripheral nerves) where visual compensation is required. Cerebellar ataxia produces wide-based instability with eyes open and only modest worsening with eyes closed (Romberg-negative). This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 49Vestibular, ocular motor and balance assessment

Which clinical finding suggests CENTRAL rather than peripheral facial weakness?

  1. Inability to wrinkle the affected forehead
  2. Forehead sparing on the affected side Correct answer.
  3. Hyperacusis
  4. Decreased taste sensation

Explanation

Central (UMN) facial weakness spares the forehead because of bilateral cortical innervation of the upper face. Peripheral (Bell palsy, CN VII) affects the entire half of the face including the forehead. Forehead sparing helps rapidly distinguish stroke from Bell palsy. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.

Question 50Vestibular, ocular motor and balance assessment

Which vestibular rehabilitation exercise targets gaze stability during head motion at a fixed visual target?

  1. Bridge
  2. VOR x1 (head moves, eyes fixed on stationary target) Correct answer.
  3. Treadmill running
  4. Plank

Explanation

VOR x1 exercises (head moves, eyes maintain fixation on a stationary target) are the foundation of vestibular gaze-stabilization rehab. VOR x2 progresses by moving target and head in opposite directions. Both exercises drive VOR adaptation, supporting central compensation after vestibular injury. This is a bounded clinical pattern or concept, not a unique diagnosis from one test, a guarantee of benefit or physician prescribing authority. Actual examination, safety and referral remain necessary.