NCS Clinical Decision-Making 3 — Questions and Answers
Question 1: A patient with cervical myelopathy reports progressive gait instability and hand clumsiness but no radicular pain. Which examination finding would most strongly support a surgical referral decision?
- Positive spurling's test with dermatomal paresthesia
- Hyperreflexia, Hoffman's sign, and gait ataxia (Correct answer)
- Cervical range of motion less than 50% of normal
- Positive Phalen's test bilaterally
Correct answer: Hyperreflexia, Hoffman's sign, and gait ataxia
Upper motor neuron signs (hyperreflexia, Hoffman's sign) combined with gait ataxia indicate cord compression requiring urgent surgical evaluation.
Question 2: When using the ICF model to guide clinical decision-making for a patient with ALS, which framework element best addresses the patient's inability to return to work as a teacher?
- Body structure and function
- Activity limitation
- Participation restriction (Correct answer)
- Environmental barrier
Correct answer: Participation restriction
Inability to fulfill societal roles such as employment is classified under participation restriction in the ICF framework.
Question 3: A 72-year-old patient with diabetic peripheral neuropathy and a Berg Balance Scale score of 42 is being evaluated. The most appropriate clinical decision is to:
- Discharge as BBS indicates minimal fall risk
- Recommend no exercise due to neuropathic sensory loss
- Implement a progressive balance and strengthening program with fall prevention education (Correct answer)
- Refer directly to orthotics for custom AFOs before initiating therapy
Correct answer: Implement a progressive balance and strengthening program with fall prevention education
A BBS score of 42 indicates moderate fall risk (cut-off ~45), warranting a targeted balance and strengthening program with fall prevention strategies.
Question 4: A neurologic PT is treating a patient with progressive MS. Despite consistent therapy, function continues to decline. The most appropriate clinical decision is to:
- Discontinue therapy as the patient is not improving
- Shift goals toward maintenance, adaptive strategies, and quality of life (Correct answer)
- Increase session frequency to counteract the decline
- Refer only to palliative care and end therapy
Correct answer: Shift goals toward maintenance, adaptive strategies, and quality of life
When disease progression overrides functional gains, evidence supports shifting to maintenance and compensatory strategy goals to preserve function and quality of life.
Question 5: A patient 6 months post-right MCA stroke shows left UE spasticity (MAS 2) limiting hand opening for grasp. Which intervention decision is most evidence-based?
- Provide static resting splint only and monitor
- Refer for botulinum toxin injection and combine with task-specific training (Correct answer)
- Avoid all passive stretching due to spasticity concerns
- Apply high-intensity NMES to the flexors to reduce tone
Correct answer: Refer for botulinum toxin injection and combine with task-specific training
Botulinum toxin combined with task-specific upper extremity training has the strongest evidence for reducing spasticity and improving function post-stroke.
Question 6: During a neurological exam, a therapist finds that a patient has intact light touch but absent proprioception and vibration sense in the lower extremities. This pattern most suggests pathology in which tract?
- Anterior spinothalamic tract
- Lateral spinothalamic tract
- Dorsal columns (posterior funiculus) (Correct answer)
- Corticospinal tract
Correct answer: Dorsal columns (posterior funiculus)
Proprioception and vibration are carried in the dorsal columns; loss of these with intact pain/temperature indicates a dorsal column lesion.
Question 7: A patient with vestibular neuritis presents with spontaneous nystagmus beating right and falls toward the left. The most appropriate initial clinical decision is:
- Immediately perform canalith repositioning maneuver
- Begin gaze stabilization exercises and adaptation training (Correct answer)
- Prescribe vestibular suppressants as the primary intervention
- Refer for audiological evaluation before initiating any therapy
Correct answer: Begin gaze stabilization exercises and adaptation training
Vestibular neuritis involves a unilateral peripheral hypofunction best treated with gaze stabilization and habituation exercises to promote central compensation.
NCS Clinical Decision-Making 3
A patient with cervical myelopathy reports progressive gait instability and hand clumsiness but no radicular pain.
Which examination finding would most strongly support a surgical referral decision?