NBCE Part IV cheat sheet

Red flags mandating referral: bowel/bladder dysfunction, saddle anesthesia, progressive motor deficit, unexplained weight loss, fever or night pain, cancer history, significant trauma.

OPQRST characterizes pain: Onset, Provocation/Palliation, Quality, Region/Radiation, Severity, Timing.

SAMPLE screens the history: Signs/symptoms, Allergies, Medications, Past medical history, Last oral intake, Events prior to presentation.

Ask specifically about anticoagulants, corticosteroids, bisphosphonates, bleeding disorders, and recent surgery before any manual therapy.

Open-ended questions first to capture narrative and unexpected detail; closed or direct questions later to quantify and verify.

Record onset, mechanism of injury, prior episodes, response to previous care, and patient-defined functional goals.

Comorbidities that alter healing or technique selection: diabetes, smoking, osteoporosis, inflammatory arthritis, known malignancy.

Document who accompanied the patient and whether history was obtained directly or through a third party or interpreter.

Standard sequence: observation and posture, vital signs, active range of motion, passive range of motion, palpation, orthopedic tests, neurologic and vascular screening.

Approximate cervical AROM norms: flexion 45–50°, extension 60–70°, rotation 70–80°, lateral flexion 40°.

Approximate lumbar AROM norms: flexion 60°, extension 25°, lateral flexion 25°, rotation 5–15°.

Manual muscle test scale 0–5: 0 no contraction, 1 trace, 2 movement without gravity, 3 against gravity, 4 against gravity with some resistance, 5 normal.

Straight leg raise is significant when pain is reproduced between 30° and 70°; Braggard's adds ankle dorsiflexion to increase tension.

True leg length is ASIS to medial malleolus; apparent leg length is umbilicus to medial malleolus and reflects pelvic obliquity.

FABER (Patrick) test stresses the hip and sacroiliac joint; groin pain implicates the hip, posterior pain the sacroiliac region.

Kemp's test applies extension with rotation and compression to provoke foraminal or nerve root pain.

Beighton score (9 points) quantifies generalized joint hypermobility; a score of 4 or more in adults is commonly used as a threshold.

Reflex root levels: biceps and brachioradialis C5–C6, triceps C7, patellar L3–L4, Achilles S1.

Key dermatomes: C5 lateral arm, C6 thumb, C7 middle finger, C8 little finger, T4 nipple line, T10 umbilicus, L4 medial leg, L5 dorsum of foot and great toe, S1 lateral foot.

Upper motor neuron signs: hyperreflexia, Babinski, Hoffman, clonus, spasticity; lower motor neuron signs: hyporeflexia, atrophy, fasciculations.

Light touch and pinprick assess the spinothalamic pathway; vibration and proprioception assess the dorsal columns.

Cranial nerves I olfactory, II optic, III/IV/VI ocular movement, V trigeminal, VII facial, VIII vestibulocochlear, IX–XII bulbar and tongue.

Romberg test is positive when sway markedly increases with eyes closed, indicating proprioceptive or vestibular loss.

Babinski sign is abnormal after roughly 1–2 years of age and indicates corticospinal tract dysfunction.

Compare strength and sensation side to side and note whether effort is pain-limited, since pain inhibition can mimic weakness.

HVLA adjustment is a high-velocity, low-amplitude thrust delivered at or near end range with a specific contact and line of drive.

Diversified listings denote segment plus direction of misalignment or restriction (for example PRS, PLS, rotation).

Absolute contraindications to thrust manipulation: acute fracture or dislocation, unstable ligamentous injury, destructive bone lesion, infection at the target segment, spinal cord compression.

Relative cautions: anticoagulation, severe osteoporosis, inflammatory arthritis with instability, vertebrobasilar disease, and positioning limits in pregnancy.

Gonstead technique uses full-spine segmental listings with knee-chest and cervical chair positioning and minimal force.

Flexion-distraction is a low-velocity, non-thrust, table-assisted technique applying cyclic traction and flexion, often for discogenic pain.

Instrument-assisted adjusting (Activator) delivers a low-amplitude impulse and is chosen for fragility, osteoporosis, or patient preference.

Cavitation reflects gas and pressure release within the synovial capsule and is not a measure of adjustment success.

Document the segment, technique, patient response, and any adverse reaction after each intervention.

Cervical series: AP open mouth for C1–C2, lateral for alignment and lordosis, obliques for foramina, flexion–extension for instability.

On oblique lumbar films the Scottie dog is composed of the ear (superior articular process), nose (transverse process), eye (pedicle), and neck (pars interarticularis).

Spondylolisthesis is graded I–IV by the Meyerding method in 25% increments of the superior endplate width; grade V is spondyloptosis.

A Cobb angle greater than 10° defines scoliosis; larger curves raise consideration of bracing or surgical referral.

Plain-film signs of malignancy include absence of a pedicle (winking owl), destructive lytic change, and a soft tissue mass.

Ankylosing spondylitis shows sacroiliitis, syndesmophytes, squared vertebral bodies, and eventually a bamboo spine.

DISH shows flowing ossification over at least four contiguous vertebral bodies with relative preservation of disc height.

ALARA governs technique: collimate, shield, use the lowest adequate exposure, and screen for pregnancy before imaging.

Typical staging: acute under 6 weeks, subacute 6–12 weeks, chronic beyond 12 weeks; staging drives technique intensity and prognosis.

Reassess at defined intervals (for example every 2 weeks or 6–8 visits) using repeatable objective measures.

Common outcome instruments: numeric pain rating scale, Oswestry Disability Index for lumbar, Neck Disability Index for cervical.

Refer when red flags are present, when there is no meaningful change after a reasonable trial of care, or when needs exceed scope.

Cryotherapy is applied for roughly 15–20 minutes with periodic skin checks; superficial heat suits chronic muscle guarding.

Documentation should include diagnosis, informed consent, treatment rendered, objective response, and the plan for the next interval.

Home exercise adherence and load management are addressed explicitly at each visit rather than assumed.

Coordinate with the primary care provider, imaging services, or specialists, and send reports that state findings and requests.

Differential order: serious pathology first, then common conditions, then treatable conditions.

Likelihood ratio formulas: LR+ = sensitivity ÷ (1 − specificity); LR− = (1 − sensitivity) ÷ specificity.

An LR+ above 10 or an LR− below 0.1 materially changes post-test probability; values near 1 are uninformative.

No single orthopedic or neurologic test rules a condition in or out; concordant clusters carry more weight than isolated findings.

Common reasoning errors: anchoring, confirmation bias, availability bias, and premature closure.

VINDICATE prompts a systematic differential: Vascular, Infectious, Neoplastic, Degenerative, Iatrogenic, Congenital, Autoimmune, Traumatic, Endocrine.

A patient who deviates from the expected recovery trajectory is a trigger to re-examine the working diagnosis.

Distinguish nociceptive, neuropathic, and nociplastic contributors, since each implies a different management emphasis.

Informed consent elements: diagnosis, nature of the procedure, material risks, expected benefits, reasonable alternatives, consequences of declining, and voluntary agreement.

Teach-back, in which the patient restates the plan in their own words, verifies comprehension better than asking whether they understand.

HIPAA minimum necessary standard limits protected health information disclosure to what the purpose requires; patients retain access rights.

SBAR (Situation, Background, Assessment, Recommendation) structures handoffs and referral communications.

Adverse events and errors are disclosed promptly, factually, and with a documented plan for follow-up.

Mandated reporting obligations include suspected abuse or neglect and specified communicable diseases, per jurisdiction.

Use plain language, qualified interpreters, and health-literacy-appropriate materials for all patient education.

Maintain professional boundaries, avoid dual relationships, and disclose any financial or personal conflict of interest.