CAGEN
Assessment Document Specifications
Written Blueprint
Case Topics
Tools and Modalities
Written Exam Case Template
References
Practical Blueprint
ACNB Practical Examination Case Template
Sample Case History Flow Chart
Practice Test
Practice Answers
- Adams, R.D. and Victor, M. (Latest edition) Principles of Neurology. New York:
McGraw-Hill Book Co.
- Annals of Neurology, (Journal). Little Brown & Company
- Barr, M.L. and Keirnan, J. A. The Human Nervous System: An Anatomical Viewpoint
(Latest edition). Philadelphia: Harper & Row, Publishers.
- Beatty, J. (1995) Principles of Behavioral Neuroscience. Time Mirror.
- Blume, Warren T. (1994) Atlas of Adult Electroencephalography. Raven Press
- Carpenter, M.B. Core Text of Neuroanatomy (Latest edition). Baltimore: Williams & Wilkins,
Co.
- Chiappa. Evoked Potentials in Clinical Medicine
- Conn, P. Michael (1994) Neuroscience in Medicine. J.B. Lippincott.
- Creutzfeldt, O. et.al. (1995) Cortex Cerebri: Performance, structural and functional
organization of the cortex.
- DeArmond, S.J., Fusco, M.M. and Dewey, M.M. Structure of the Human Brain. Structure
of the Human Brain: A Photographic Atlas. (Latest edition). New York: Oxford
University Press.
- Dejong, R.N. The Neurologic Examination (Latest edition). Hagerston (MD): Harper
and Row, Publishers.
- Dyck, Peripheral Neuropathy.
- Guyton. Textbook of Medical Physiology (Latest edition).
- Haines, D. Neuroanatomy: An Atlas of Structures, Sections and Systems. (Latest
edition). Baltimore: Urban & Schwarzenberg.
- Heimer, L. The Human Brain and Spinal Cord: Functional Neuroanatomy and Dissection
- Guide (Latest edition). New York: Springer-Verlag.
- Jennes, Lothar, et.al. (1994) Atlas of the Brain, with medical correlations.
Lippincott.
- Joynt. Clinical Neurology. Lippincott: updated yearly.
- Leigh, John R. & Zee, David S., 1999. Neurology of Eye Movements
(Contemporary). New York: Oxford University Press.
- Kandel, E.R., Schwartz, J.H. and Jessell, T.M. Principles of Neural Science
(Latest edition). New York: Elsevier Science Publishing Col, Inc.
- Kimura. Electrodiagnosis
- Langman, J. Medical Embryology. (Latest edition). Baltimore: Williams & Wilkins.
- Michaels (1994) The Cognitive Neurosciences. Gazzaniga (ed). MIT Press
- Mosenthal, W.T. (1994) A Textbook of Neuroanatomy with Atlas and discussion
guide. Parthenon.
- Pryce-Phillips, William (1995) A Companion to Clinical Neurology. Little, Brown & Co.
- Segev, Idan (ed), et.al. (1995) The theoretical foundation of Dendritic Function:
selected papers of Wilfrid Rall with commentaries. MIT Press.
- Theodore, William (ed) et.al. (1995) Epilepsy: 100 elementary principles. (3rd
Edition) W.B. Saunders.
- Yatsu, Frank M., et.al. (1994) Stroke (100 Maxims in Neurology Series). Hodder & Stoughton.
- Demonstrate the interview and psychomotor skills necessary in history taking and patient examination
- Identify normal and abnormal findings from a physical/neurological examination
- Demonstrate the capability of taking a patient history through the use of interview techniques
- Demonstrate the psychomotor skills of performing a physical/neurological examination on a patient
- Demonstrate the ability to accurately identify the findings of a physical/neurological examination through the use of video clips of examination results
- The applicant must hold the degree of Doctor of Chiropractic from a CCE accredited college (USA) or its equivalent.
- The applicant must show evidence of having successfully completed a post doctoral program in neurology of three hundred (300) credit hours from a chiropractic college, university, institution, foundation or agency whose program is approved by the continuing education committee of the Commission for the Accreditation of Graduate Education in Neurology (CAGEN). The Chiropractic College, university, organization, institution, foundation, or agency from which the applicant has completed his/her course of study must certify to the Board that the applicant has satisfactorily completed three hundred (300) credit hours of postdoctoral instruction in neurology.
- The applicant must possess a license or registration to practice chiropractic and be in good standing with the respective licensing/registration agency.
Written Blueprint
Introduction
This is an exam blueprint, also referred to as, exam specification for American Chiropractic Neurology Board’s certification exam in functional neurology. The skills and knowledge certified by this examination represent a postdoctoral chiropractic level of expertise where a certified individual can:
1. Examine individuals with a thorough functional neurological examination
2. Diagnose neurological and associated problems after examination
3. Treat through chiropractic methodologies neurological and associated problems
4. Treat through functional and environmental modalities neurological and associated
problems
5. Educate patients with respect to minimizing chronic neurologically related
problems
Exam Purpose
This examination is based upon the most critical job activities a Chiropractic
Neurologist performs. The skills and knowledge certified by this examination
represent entry level into the postdoctoral chiropractic neurological professional
level of expertise for a certified individual. The critical job activities
derived from the 2002 job analysis of Chiropractic Neurologists include the
following patient care areas:
1. Examination
2. Diagnosis
3. Treatment
4. Follow-up
Additionally, ethics and techniques were identified by our Subject Matter Expert (SME) Panel as important components not included on the 2002 job analysis. Questions asked of the Board by the public and Diplomates were also brought to the SME panel and this data supported the inclusion of ethics and techniques on the exam. The panel divided the neuraxis into the twelve domains sited below and identified as critical in the job analysis.
Background and Experience
The test is intended to address the knowledge and skill areas that demonstrate
proficiency as a Chiropractic Neurologist. Eligibility requirements are:
1. The applicant must hold the degree of Doctor of Chiropractic from a CCE accredited college (USA) or its equivalent.
2. The applicant must show evidence of having successfully completed a post doctoral program in neurology of three hundred (300) credit hours from a chiropractic college, university, institution, foundation or agency whose program is approved by the continuing education committee of the Commission for the Accreditation of Graduate Education in Neurology (CAGEN). The Chiropractic College, organization, institution, foundation, or agency from which the applicant has completed his/her course of study must certify to the Board that the applicant has satisfactorily completed three hundred (300) credit hours of postdoctoral instruction in neurology.
3. The applicant must possess a license or registration to practice chiropractic and be in good standing with the respective licensing/registration agency.
The skills and knowledge measured by this examination are derived from current course content and from an understanding of the jobs of current Chiropractic Neurologists. A team of highly qualified Chiropractic Neurologists defined the test content and determined the categories for case submission for the exam.
Exam Structure
The knowledge domains measured by this examination are shown in the table below along with the percentages of the exam that are applied to each domain. This is in accord with the job analysis update from the Subject Matter Experts performed in 2007.
Domains
|
Percentage of Exam
|
| Brain and Its Environment |
5.78% |
| Lobes of the Brain |
6.44% |
| Brain Stem & Cranial Nerves |
8.44% |
| Spinal Cord |
7.56% |
| Peripheral Nerves |
13.44% |
| Autonomic Nervous System |
5.11% |
| Cerebellum & Vestibular System |
14.44% |
| Basal Ganglia & Limbic System |
7.33% |
| Muscles / NMJ and Receptor Disease |
8.00% |
| Sensory |
7.78% |
| Neuro Endocrine |
7.33% |
| Neuro Anatomy & Physiology | 7.56% |
| Ethics |
1.11% |
Objectives:
The objectives for the examination as determined from the job analysis and
its update are as follows:
| Objectives |
Percentage of Exam |
| General Knowledge |
5.11% |
| Pathways |
12.00% |
| Diagnosis (Clinical, Level of Lesion & Functional) |
30.44 % |
| Differential Diagnosis |
15.11% |
| Treatment (Adjustment and other treatments) |
13.33% |
| Rehabilitation |
4.44% |
| Follow-up |
0.44% |
| Metabolic Rate |
1.78% |
| Risk Factors |
4.22% |
| Referral |
3.78% |
| Special Studies |
7.56% |
| Techniques |
0.67% |
| Ethics |
1.11% |
According to the job analysis update, diagnosis and differential diagnosis are the most significant portions of the job of the chiropractic neurologist. Treatment, of course, follows those. The reason that diagnosis is weighed so heavily is because each patient receives three types of diagnosis: clinical/medical, level of the lesion, and functional. In this way, the chiropractic neurologist differs from other diagnostic professions because the level of the lesion and the functional diagnoses are the ones that dictate the treatment and rehabilitation modalities and the mechanisms for measuring success of treatment.
All questions on the written examination are multiple-choice. Some are complex or multiple-multiple choice questions. A Scantron sheet is used for the recording of answers.
Tools used in Examination |
Special Test |
Risk Factors |
Treatment Tools |
Nutrition and |
Pen Light |
X-Ray |
Osteoporosis |
Hemi-field glasses |
Co-Q-10 |
HISTORY:
Chief Complaint/Present Illness:
Pain History:
Family History:
Social History:
Past Medical History/Review of Systems:
PHYSICAL EXAM:
General Appearance:
Vitals:
Height/WT; Temp; HR & Rhythm; Respiratory; B/P L and R. Ausculatory
Exam: (Bruits, Lung Sounds, Abdominal Sounds); Pulses: (Brachial,
radial, femoral, popliteal, dorsalis pedis); Rib Excursion:
Mental Status:
Cranial Nerves:
Sensation:
Motor:
Tone: Strength: Reflexes:
Coordination/Balance:
Imaging/Special Studies:
The following is a list of references used in preparation of the examination and to determine model answers.
Recent Additions:
Author Book/Article/Presentation ISBN/Journal
Blume, Warren T.
Atlas
of Adult Electroencephalography 3-936817-15-4
Brock, JB Board
Review Presentation (found
in Carrick Course Companion)
CarrickClinical
Neuroscience Course Companion
Guide I & II
DeMyerTechnique
of the Neurologic Examination, 5th Ed. 71405682
Kandel, Schwartz & Jessel.Principles
of Neural Science, 4th Ed 838577016
NolteThe
Human Brain 323013201
(An Introduction to It's Functional
Anatomy) 5th Ed.
Patten Neurological
Differential Diagnosis, 2nd Ed. 3540199373
Preston & Shapiro Electromyography & Neuromuscular 075067492X
Disorders, 2nd Ed.
Theodore, William Epilepsy:
100 elementary principles. (3rd Ed.) 702018139
(ed) et.al.
Yatsu, Frank M., Stroke
(100 Maxims in Neurology Series) BMJ
et. al. 1995;311:69
(1 July)
Introduction:
This is an exam specification for the Practical Exam in Chiropractic
Neurology. The
skills and knowledge and abilities certified by this examination represent
a professional level of expertise where the certified individual can:
Exam Purpose:
This examination is based upon the most crucial job analysis
activities a chiropractic neurologist performs. The psychomotor skills,
knowledge and abilities certified by this examination represent a professional
level of expertise for a certified individual. The critical job activities
of a chiropractic neurologist are:
Background and Experience:
The test is intended to address the knowledge and skill areas that demonstrate proficiency as a Chiropractic Neurologist. Eligibility requirements are:
The skills and knowledge measured by this examination are derived from current course content and from an understanding of the jobs of current Chiropractic Neurologists. A team of highly qualified Chiropractic Neurologists defined the test content and determined the categories and videoed examination findings for the video clips for the exam.
Exam Structure:
The knowledge domains measured by this examination are shown in the table below.
| Domains |
| History |
| Physical/Neurological Examination |
| Examination Finding |
Within the domains, the following table identifies the test objectives. Test items will relate to a specific objective within a domain.
| History | Percentage |
| Onset, Timing, Site Involved, Radiation, Quality/Characteristics, Palliative/Aggravating Factors (OPQRST) | 10% |
| Past HX; Trauma, Surgeries, etc. | 5% |
| Social HX | 5% |
| Family HX | 5% |
| Review of Systems | 5% |
| Examination | |
| Vital Signs: | 5% |
| Cranial Nerves | 6% |
| Sensory | 6% |
| Motor | 7% |
| Cerebellar/Balance | 6% |
| Cardiovascular/Provocative Maneuvers | 10% |
| Simulation Findings | |
| Reflexes | 2% |
| Gait | 2% |
| Eye Movements | 2% |
| Provocative Tests | 2% |
| Cerebellar tests- dysdiadochokinesis-dysmetria, etc. | 2% |
| Motor/Strength Tests | 2% |
| Tone (ptosis, facial paresis, etc) | 2% |
| Pupil responses | 2% |
| Palatal Paresis, Gag Reflex | 2% |
| Posture & angulation & tongue deviation | 2% |
| Spontaneity of movement | 2% |
| Observation (atrophy, sweating, edema, color, atrophic skin changes) | 2% |
| Recognition/sequencing tests | 2% |
| Parietal Drift | 2% |
| Percussion Myotonia, clonus | 2% |
The answers to the questions on the video simulations are oral. The candidate
will hear and read the questions, then respond orally. This section
is also videotaped.
The candidate must be able to conduct a thorough history:
OPQRST
Past History-thorough
Social History
Family History-1st and 2nd degree relatives
ROS-Every System
The candidate must be able to demonstrate the psychomotor skills and the knowledge to perform a complete head-to-toe Neurological Physical Examination:
Vital Signs: Ht/wt, Temperature, Pulse, Respirations, Blood Pressures
(Bilateral)
Cranial Nerves: ALL and all aspects of testing each one
Sensory: Pain & Temperature, Vibration and Light Touch, Joint Position Sense of ALL extremities
Motor: Reflexes, Tone, All extremities
Coordination/Balance: Romberg, Finger-Nose, Rapid alternating movements, pronation/supination, Gait & Tandem, Heel-Shin test. Be certain to perform all tests correctly and safely.
Heart/Lung: Auscultation of all heart sounds and areas, auscultation for bruits, auscultation of six (6) lung fields and apex, Palpation of pulses-upper and lower extremities
Abdomen: Auscultation of each quadrant and abdominal aorta; percussion of each quadrant, palpation of each quadrant (in this order)
Correctly perform special neurological and orthopedic tests such as: Optokinetics, Eply’s, Hall Pike, Homan, Lhermitte’s, Hoffman’s, Tromner’s, TOS, Mill’s, Cozen’s, S.I. Joint ortho tests, A.C. joint pathology, ACL, Hip capsule, Tinel’s, Kemp’s, O’Donohues, and others. This is NOT an exhaustive list.
Video Clips:
The candidate must be able to view a series of video clips of a neurological examination section (very short) and identify what he/she is seeing and what it means, including the nerves involved. The candidate will be asked two questions about each of the 15 clips. The questions are in an oral and written presentation format. Each clip may be viewed a maximum of two (2) times.
Patient Name:
_____________________________________________________
Home Address:
_____________________________________________________
Home Phone:
_____________________________________________________
Work Phone:
_____________________________________________________
Date of Birth:
_____________________________________________________
Age:
___________
Male: ___ Female: ___
Marital Status:
Single: ___ Married: ___ Separated: ___ Divorced: ___ Widowed:
___
Occupation:
_____________________________________________________
Referring Physician’s Name:
_____________________________________________________
Type of doctor who referred you:
_____________________________________________________
State your major problem/pain:
_____________________________________________________
Describe your symptoms in detail.
_____________________________________________________
How long have you had this condition?
_____________________________________________________
Have you had similar conditions in the past?
No: ___
Yes: ___ If Yes, please specify:
_____________________________________________________
What activities aggravate your condition?
_____________________________________________________
Is this condition interfering with:
Work: ___ Sleep: ___ Daily Routine: ___
Other: _____
Please specify:
_____________________________________________________
What other health care have you received for this problem, i.e. what other
doctors have treated this condition?
_____________________________________________________
Other complaints:
_____________________________________________________
Do you presently take any medication/over the counter/homeopathic or recreational
drugs?
No: ___ Yes: ___ If Yes, please specify:
_____________________________________________________
_____________________________________________________
List previous injuries/major illnesses/accidents
_____________________________________________________
_____________________________________________________
List fractures/dislocations/concussions past and present:
_____________________________________________________
_____________________________________________________
List previous surgeries/hospitalizations:
_____________________________________________________
_____________________________________________________
_____________________________________________________
Have you had changes in bowel/bladder/sexual function? If so, please specify.
_____________________________________________________
_____________________________________________________
Do you have any condition involving your heart/lungs/thyroid/or other internal
organs? If yes, please specify:
_____________________________________________________
_____________________________________________________
Are you a:
Non-smoker: ___
Smoker: ___ (# of Packs per day _____ for ____
years)
Ex-smoker: ___ (for how long ____).
Regarding alcohol use, are you a:
Never Drank: ___
Drinker: ___
Ex-drinker:
___
If you drink alcohol, enter the average number of drinks per weeks:
Bottles of beer: ____
Mixed drinks: ______
Glasses of wine: ____
Shots of liquor: _____
How would you rate the amount of physical activity you perform?
Very little: ___ Little: ___ Moderate: ___ Active: ___ Very Active: ___
List activities in which you participate on the average of two times per
week:
_____________________________________________________
Please specify any conditions or illnesses in your family medical history
(i.e. diabetes, cancer, etc.) (parents, grandparents, siblings, and children)
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
Females Only:
Date your last menstrual period began:
_____________________________________________________
Number and ages of your children:
_____________________________________________________
Are you pregnant now? No: ___ Yes: ___ Not sure: ___
Date of last pelvic/breast (PAP test) examination:
_____________________________________________________
_____________________________________________________
Doctor’s Comments from the interview:
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________
This Pretest is a sample of the format for testing that the ACNB Diplomate exam uses. The following case has been retired from the previous tests. The actual test is comprised of several cases in this format followed case related questions. A section at the end of each test, approximately the last 30 questions, will assess information from the Domains and Objectives in the blueprint but will not be case related. See “Pretest Answers” to check your knowledge on this particular Pretest case.
For questions 1-12 refer to the case below—
HISTORY:
Chief Complaint/Present Illness:
A 54-year-old Caucasian male presents with right arm weakness for the last
3 weeks.
Pain History:
Patient had onset of achiness and stiffness in his right neck and shoulder
and weakness of his right forearm, wrist, and fingers. He denied any
pain and stated the “problem was more achy than sharp pain”. He
stated the problem started after he feels asleep in his granddaughter’s
bed while holding her.
Family History: non-contributory.
Social History:
He reported he has 2-3 manhattan’s each evening, maybe an extra one
or two on the weekend. He stated he use to work out a lot, but has not been
very active for the last year or two. He is a retired Navy Chief.
Past Medical History/Review of Systems:
Non-contributory
PHYSICAL EXAM:
General Appearance:
Patient is a well groomed, healthy man.
Vitals:
B/P 128/80 bilaterally; 98.6 o F (37 o C) ear temperatures bilaterally; Ht.:
5’ 11” (180 cm); Wt.: 190 lbs. (83.4kg). Auscultation
Exam: Bruits are absent, heart sounds, lung sounds,
and abdominal sounds are all normal. Pulses:
Brachial, radial, femoral, popliteal, dorsalis pedis are normal.
Mental: Oriented x 3
Cranial Nerves: Normal.
Sensation: no change in sensations were found
on the skin of the right arm, forearm, or hand.
Motor: At
rest the patient’s right wrist and fingers are flexed slightly. He had
a slight weakness of elbow flexion, especially when tested in neutral pronated/supinated
position. No weakness was found when testing elbow flexion in the palm
up position. There was weakness of flexion of the proximal phalanges
on the metacarpals, and weakness of thumb abduction.
Left triceps 5/5 Right triceps 5/5
Left
pronation 5/5, right pronation 5/5
Left
wrist extension 5/5, right wrist extension 4/5
Left
finger flexors 5/5, right finger flexors 4/5
Left
finger extensors 5/5, right finger extensors 4/5
Reflexes: Left triceps 2/5. Right triceps
2/5
Left Brachioradialis 2/5. Right Brachioradialis
1/5
Left biceps 2/5. Right biceps 2/5
Lower extremity MSR’s 2/5
bilaterally.
Plantar responses were absent bilaterally
and he had no clonus.
Coordination/Balance:
Left Finger to Nose testing WNL
Right Finger to Nose testing was accurate and without tremor, but patient
was much slower doing the test on this side.
Labs: HgbA1C- 5, Fasting Blood glucose=98mg/dl.
Imaging/Special Studies:
Plain radiographs, moderate DJD at C5-6, and C6-7 with no mention of IVF
involvement.
QUESTIONS:
1. What peripheral nerve entrapment is the most likely cause
of this lesion?
Use the following as choices of answer(s) for #15.
1. anterior
interosseous
2. axillary
3. deep
radial
4. median
5. musculocutaneous
6. radial
7. superficial
radial
8. ulnar
a. 3
b. 6
c. 3, 6, & 7
d. 3 & 5
2. The
most likely diagnosis in this case is?
a. Cubital
tunnel syndrome
b.Klumpke
palsy
c. Anterior
Interosseous Syndrome
d. Saturday
Night Palsy
e. Erb’s
palsy
3. What
physiological process is responsible for this patient’s symptoms?
a. demyelination
secondary to compression
b. traction
axonopathy
c. Pancoast
tumor compressing the brachial plexus
d. ischemic
compression
4. The
most likely site of this nerve entrapment is?
a. supinator
muscle
b. axilla
c. spiral
groove of humerus
d. adhesions
from radial-humeral joint capsule
5. EMG
study with respect to this case should be ordered:
a. Immediately
b. 4-6
weeks post injury
c. 1 week
d. Contraindicated
in this case
6. Injury of the posterior cord would cause the most weakness in which
of the following muscles.
a. Brachioradialis
b. teres
minor
c. teres
major
d. supraspinatus
7. Which nerve injury is most likely in this case?
a. Grade
1 neuropraxia
b. Grade
2 neuropraxia
c. Grade
1 axonotmesis
d. Grade
1 neurotmesis
e. Grade
2 neurotmesis
8. Which of the following condition should be on your differential
in this case?
a. arsenic
intoxication
b. diabetes
c. lead
intoxication
d. polymyositis
9. With respect to this case, if an EMG study does not reveal any
abnormality in this muscle group, a root lesion can be ruled out as the cause
of this lesion.
a. paraspinal
b. flexor
digitorum profundus
c. pronator
teres
d. serratus
anterior
10. The main risk factor causing this patients dysfunction is?
a. diabetes
b. malnutrition
c. hereditary
d. alcoholism
11. After peripheral nerve injury, the nerve regenerates at a rate
of:
a. 1 cm/day
b. 1 inch/day
c. 1 millimeter/day
d. 1 meter/day
12. Utilizing
the concepts of Functional Neurology, what treatment is the most appropriate
for this patient?
a. Slow
stretch of the forearm and finger extensors on the right
b. Fast
stretch of the forearm flexors on the right
c. Slow
stretch of the shoulder protractors on the right
d. Fast
stretch of the elbow flexors on the right.