from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm, mm
from reportlab.platypus import (
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    HRFlowable, PageBreak, KeepTogether
)
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_JUSTIFY
from reportlab.pdfbase import pdfmetrics

# ── Output path ──────────────────────────────────────────────────────────────
OUTPUT = "/home/daytona/workspace/relaxation-mcq/Kinesiology_Relaxation_MCQ_Quiz.pdf"

# ── Colour palette ────────────────────────────────────────────────────────────
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GREY_TEXT = colors.HexColor("#555555")
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# ── MCQ Data ──────────────────────────────────────────────────────────────────
sections = [
    {
        "title": "SECTION A: MUSCLE TONE & MECHANISMS",
        "questions": [
            {
                "n": 1,
                "stem": "A PT is examining a patient at complete rest. She palpates the biceps brachii and finds a slight firmness even though the patient is not voluntarily contracting the muscle. The patient asks, \"Is something wrong — why is my muscle not completely soft?\" What is the BEST explanation?",
                "opts": [
                    ("A", "The patient is involuntarily contracting the muscle due to anxiety"),
                    ("B", "There is mild inflammation causing the firmness"),
                    ("C", "Under ordinary circumstances, living muscles are never completely free from tension — they retain a quality of firmness known as muscle tone even when as relaxed as possible"),
                    ("D", "The muscle has developed fibrosis from previous injury"),
                    ("E", "Postural tone is abnormally elevated due to spinal cord hyperreflexia"),
                ],
                "answer": "C",
                "explanation": "The text states: \"Under ordinary circumstances living muscles are never completely free from tension, as they retain a quality of firmness known as muscle tone even when they are as relaxed as possible.\" This baseline firmness is normal physiology — not pathology — representing the resting state of all living muscle."
            },
            {
                "n": 2,
                "stem": "A physiology student asks: \"What is the neural mechanism that maintains muscle tone in a resting muscle?\" A PT educator gives the correct explanation. Which answer is MOST accurate?",
                "opts": [
                    ("A", "Muscle tone is maintained by continuous voluntary motor cortex firing"),
                    ("B", "Muscle tone is maintained through the activity of the muscle spindle circuit via efferent fibres of a small fibre nervous reflex pathway"),
                    ("C", "Muscle tone is maintained by the Golgi tendon organ reflexes"),
                    ("D", "Muscle tone is generated by the large extrafusal muscle fibres during rest"),
                    ("E", "Muscle tone depends entirely on passive connective tissue tension"),
                ],
                "answer": "B",
                "explanation": "The text explains: \"Muscle tone is maintained through the activity of the muscle spindle circuit. The efferent fibres of this small fibre nervous reflex pathway transmit impulses which produce a sustained contraction of the small intrafusal muscle fibres of the muscle spindles.\" It is the intrafusal fibres — not the large extrafusal fibres used for voluntary movement — that sustain resting muscle tone."
            },
            {
                "n": 3,
                "stem": "During a neurophysiology lecture, a student asks: \"When muscle tone is being maintained at rest, what happens to the large extrafusal muscle fibres?\" The correct response is:",
                "opts": [
                    ("A", "They contract tonically to stabilize the joints"),
                    ("B", "They fire at low frequency to provide background postural support"),
                    ("C", "They remain relaxed while only the small intrafusal fibres of the spindles are active"),
                    ("D", "They alternate contraction with the intrafusal fibres in a reciprocal pattern"),
                    ("E", "They contract maximally during the stretch reflex to counteract gravity"),
                ],
                "answer": "C",
                "explanation": "The text is explicit: the efferent fibres produce sustained contraction \"of the small intrafusal muscle fibres of the muscle spindles, while the large extrafusal fibres concerned in the production of voluntary movement remain relaxed.\" Intrafusal fibres maintain tone; extrafusal fibres produce voluntary movement — a fundamental physiological distinction."
            },
            {
                "n": 4,
                "stem": "A patient with cervical spondylosis undergoes physiotherapy in the supine position. The PT observes significant reduction in neck muscle tension compared to the sitting position. What is the PRIMARY physiological reason for this difference?",
                "opts": [
                    ("A", "Supine position reduces blood flow to the muscles, decreasing metabolic activity"),
                    ("B", "Supine position eliminates the vestibular inputs that maintain tone"),
                    ("C", "In upright positions, gravity stretches the anti-gravity muscles more, increasing postural tone; recumbent positions counterbalance gravity, reducing postural tone"),
                    ("D", "The cervical spine joints decompress in supine, removing pain inhibition"),
                    ("E", "Supine position activates the parasympathetic nervous system globally"),
                ],
                "answer": "C",
                "explanation": "The text states postural tone \"is greater in the upright position in which the force of gravity tends to stretch the muscles more\" and that recumbent positions \"in which the effects of the force of gravity upon them is adequately counterbalanced by full support of the body\" are most suitable for general relaxation."
            },
            {
                "n": 5,
                "stem": "A patient with chronic neck tension is transitioned from sitting to fully supported lying. The patient reports immediate muscle relaxation. Which principle BEST explains why full body support in recumbent positions is optimal for general relaxation?",
                "opts": [
                    ("A", "Horizontal position activates the parasympathetic nervous system directly"),
                    ("B", "Recumbent positions providing full support for ALL body segments are most suitable for obtaining general relaxation"),
                    ("C", "Lying reduces venous return, lowering blood pressure and muscle tension"),
                    ("D", "The prone position deactivates the muscle spindle circuit completely"),
                    ("E", "Any change in position reflexively reduces postural tone regardless of support"),
                ],
                "answer": "B",
                "explanation": "The text specifically states: \"Those recumbent positions which provide full support for all segments of the body are therefore most suitable for obtaining general relaxation.\" Partial support is insufficient — ALL segments must be supported to fully counterbalance gravity's stretching effect on anti-gravity muscles."
            },
            {
                "n": 6,
                "stem": "A PT treats a patient with increased postural tone in the back extensors by placing them in fully supported supine. Which mechanism is DIRECTLY responsible for the reduction in postural tone?",
                "opts": [
                    ("A", "Supine position activates Golgi tendon organs, causing autogenic inhibition"),
                    ("B", "The force of gravity is counterbalanced by full body support, reducing the stretch stimulus on sensory receptors in the anti-gravity muscles"),
                    ("C", "Supine position increases cerebellar inhibition of the motor cortex"),
                    ("D", "The stretch reflex is abolished in the horizontal position"),
                    ("E", "Muscle spindles are deactivated by joint compression in supine"),
                ],
                "answer": "B",
                "explanation": "Postural tone works via the myotatic reflex: gravity stretches muscles → stimulates sensory receptors → motor impulses → contraction to counterbalance stretch. When full body support eliminates gravity's effect, the stretch stimulus is removed, the reflex is not triggered, and postural tone is reduced — the direct mechanical mechanism described in the text."
            },
        ]
    },
    {
        "title": "SECTION B: POSTURAL TONE & THE STRETCH REFLEX",
        "questions": [
            {
                "n": 7,
                "stem": "A patient with poor posture starts to fall forward while standing. The back extensors contract immediately without conscious effort. Which reflex mechanism is DIRECTLY responsible?",
                "opts": [
                    ("A", "The voluntary motor pathway from the cerebral cortex"),
                    ("B", "The myotatic (stretch) reflex — gravity stretches the back extensors, stimulating sensory receptors which generate motor impulses to contract the same muscles"),
                    ("C", "The Golgi tendon organ reflex causing inhibition of the flexors"),
                    ("D", "The vestibulo-ocular reflex triggering spinal stabilization"),
                    ("E", "Reciprocal inhibition of the abdominal muscles allowing extension"),
                ],
                "answer": "B",
                "explanation": "The text describes: \"Any stretching of the muscles by an external force, such as the force of gravity, stimulates sensory receptors situated within the muscles themselves and so gives rise to a discharge of motor impulses to the same muscles. These motor impulses bring about a contraction of a sufficient number of the muscles' motor units to increase the tension sufficiently to enable the effects of the force which produced the stretching to be counterbalanced.\" This is the myotatic/stretch reflex mechanism."
            },
            {
                "n": 8,
                "stem": "A neurophysiology student asks: \"Is the stretch reflex the only mechanism controlling postural tone?\" Which answer BEST reflects the text?",
                "opts": [
                    ("A", "Yes — the stretch reflex is the sole and complete mechanism for postural tone"),
                    ("B", "No — the myotatic/stretch reflex is the FUNDAMENTAL basis, but higher centres also exert a controlling influence"),
                    ("C", "No — postural tone is controlled exclusively by the cerebellum"),
                    ("D", "Yes — the spinal cord alone maintains all postural tone without higher centre input"),
                    ("E", "No — the Golgi tendon organ is the primary mechanism, not the stretch reflex"),
                ],
                "answer": "B",
                "explanation": "The text states: \"Postural tone is maintained and regulated by a reflex mechanism, the fundamental basis of which is the myotatic or stretch reflex, although the higher centres also exert a controlling influence.\" The spinal stretch reflex is the foundation, but supraspinal centres modulate it — a hierarchical control model."
            },
            {
                "n": 9,
                "stem": "A patient reports that their calf muscle \"tightens up\" in response to passive stretching by the PT. What principle BEST explains this response?",
                "opts": [
                    ("A", "Voluntary protective guarding by the patient due to pain anticipation"),
                    ("B", "Tension in the muscles increases in response to stretching of their constituent fibres by an external force, in proportion to the degree of stretching"),
                    ("C", "The Golgi tendon organ is triggered, causing reflex muscle contraction"),
                    ("D", "Reciprocal inhibition causes the antagonist to contract during stretch"),
                    ("E", "The muscle enters active insufficiency range, increasing passive tension"),
                ],
                "answer": "B",
                "explanation": "The text states: \"As tension in these muscles is increased in response to stretching of their constituent fibres by an external force, and in proportion to the degree of stretching to which they are subjected...\" This proportional relationship between stretch magnitude and tension increase is the myotatic reflex basis — more stretch = more tension response."
            },
            {
                "n": 10,
                "stem": "A PT wants to reduce muscle tension in a tight calf to facilitate passive stretching. Which approach is MOST logical based on the stretch reflex mechanism in the text?",
                "opts": [
                    ("A", "Apply maximum passive stretch quickly to fatigue the stretch reflex"),
                    ("B", "Use measures that reduce or eliminate the effect of the stretching force on the muscle, as this assists in promoting relaxation"),
                    ("C", "Apply electrical stimulation to the antagonist to reciprocally inhibit the calf"),
                    ("D", "Place the patient in standing to maximize proprioceptive input"),
                    ("E", "Apply ice to the muscle to reduce spindle sensitivity"),
                ],
                "answer": "B",
                "explanation": "The text explicitly states: \"The use of measures tending to reduce or eliminate the effect of this force assists in promoting their relaxation.\" To relax a tense muscle, reduce the stretch force acting upon it (by positioning, gravity elimination, or support) — rather than fighting the reflex with more force."
            },
        ]
    },
    {
        "title": "SECTION C: VOLUNTARY MOVEMENT & RECIPROCAL RELAXATION",
        "questions": [
            {
                "n": 11,
                "stem": "A patient performs active elbow flexion. As the biceps concentrically contracts, the triceps relaxes simultaneously. At movement completion, the biceps also relaxes. Which biological principle BEST explains this full sequence?",
                "opts": [
                    ("A", "The Golgi tendon organ inhibits both muscles simultaneously at end range"),
                    ("B", "Activity of living cells tends to be followed by inhibition; contraction in one muscle group is accompanied by reciprocal relaxation of the antagonistic group"),
                    ("C", "Fatigue causes both muscles to relax simultaneously after contraction"),
                    ("D", "The cerebellum terminates motor activity after movement completion"),
                    ("E", "Autogenic inhibition from Ib fibres relaxes the biceps at completion"),
                ],
                "answer": "B",
                "explanation": "The text states: \"There is a recognised biological principle that activity of living cells tends to be followed by inhibition of that activity. Contraction in any one group of muscles is accompanied by a reciprocal relaxation of the antagonistic group to allow movement to take place smoothly.\" Both post-activity inhibition AND reciprocal inhibition apply here."
            },
            {
                "n": 12,
                "stem": "A PT wants to relax tight hip flexors (iliopsoas) using active exercise. Based on the principle of reciprocal relaxation, which movement would MOST effectively achieve this?",
                "opts": [
                    ("A", "Active hip flexion exercises to fatigue the hip flexors"),
                    ("B", "Active hip extension — contracting the hip extensors causes reciprocal relaxation of the antagonistic hip flexors"),
                    ("C", "Passive hip extension applied by the PT"),
                    ("D", "Active knee flexion to relax the iliopsoas via irradiation"),
                    ("E", "Isometric contraction of the hip flexors in the shortened position"),
                ],
                "answer": "B",
                "explanation": "The text states that \"contraction in any one group of muscles is accompanied by a reciprocal relaxation of the antagonistic group.\" The hip flexors are antagonists to hip extensors. By actively contracting the hip extensors (gluteus maximus), the hip flexors are reciprocally inhibited and relax. The text notes this is \"of importance during consideration of methods designed to obtain relaxation of a particular group of muscles.\""
            },
            {
                "n": 13,
                "stem": "At the END of active shoulder flexion, the anterior deltoid relaxes. What physiological principle MOST directly explains why specific muscles relax at the completion of voluntary movement?",
                "opts": [
                    ("A", "The muscle enters passive insufficiency at end range"),
                    ("B", "The recognised biological principle that activity of living cells tends to be followed by inhibition of that activity"),
                    ("C", "The Golgi tendon organ triggers autogenic inhibition at end range"),
                    ("D", "Central fatigue at the motor cortex reduces efferent drive"),
                    ("E", "The agonist relaxes because the antagonist now contracts to return the limb"),
                ],
                "answer": "B",
                "explanation": "The text states: \"Specific muscles contract as they work to initiate or control movement, but at the completion of the movement in question they relax and come to rest. There is a recognised biological principle that activity of living cells tends to be followed by inhibition of that activity.\" Post-activity inhibition is a fundamental property of biological cells."
            },
            {
                "n": 14,
                "stem": "A PT uses rhythmical active exercises to relax hypertonic biceps. Which TWO principles make active exercise an effective relaxation strategy?",
                "opts": [
                    ("A", "Active exercise fatigues the muscle, causing permanent tone reduction"),
                    ("B", "Post-activity inhibition (activity followed by inhibition) AND reciprocal relaxation of the antagonistic group during movement"),
                    ("C", "Active exercise increases blood flow, washing out tension-producing metabolites"),
                    ("D", "Voluntary movement activates the cerebellum, overriding the stretch reflex"),
                    ("E", "Active exercise stimulates Golgi tendon organs to inhibit the hypertonic muscle"),
                ],
                "answer": "B",
                "explanation": "Two text principles apply simultaneously: (1) \"Activity of living cells tends to be followed by inhibition\" — after active contraction, the muscle enters an inhibitory/relaxed state; (2) \"Contraction in any one group of muscles is accompanied by a reciprocal relaxation of the antagonistic group.\" The text notes these \"facts are of importance during consideration of methods designed to obtain relaxation of a particular group of muscles.\""
            },
        ]
    },
    {
        "title": "SECTION D: MENTAL ATTITUDES & TENSION",
        "questions": [
            {
                "n": 15,
                "stem": "A student athlete presents for pre-competition sports massage. She is visibly anxious about an upcoming national championship. The PT palpates significantly elevated muscle tension throughout the body. What is the PRIMARY mechanism?",
                "opts": [
                    ("A", "Dehydration before the competition causing muscle cramping"),
                    ("B", "Mental attitudes such as fear and excitement give rise to a general increase in muscular tension preparing muscles for rapid or forceful action"),
                    ("C", "The athlete has been overtraining, causing chronic muscle fatigue and spasm"),
                    ("D", "Cold environmental temperature is increasing baseline muscle tone"),
                    ("E", "Poor posture during travel to the venue has increased postural tone"),
                ],
                "answer": "B",
                "explanation": "The text states: \"Mental attitudes such as fear, anger and excitement give rise to a general increase in muscular tension which serves a useful purpose by preparing the muscles for rapid or forceful action.\" Pre-competition anxiety triggers this physiological preparation response — the emotional state increases muscular tension throughout the body."
            },
            {
                "n": 16,
                "stem": "An office worker presents with chronic neck and shoulder pain and elevated muscle tension despite no structural pathology. On history, they describe persistent work-related stress and anxiety. The PT explains the psychological mechanism. Which explanation is MOST accurate?",
                "opts": [
                    ("A", "Anxiety causes sympathetic vasoconstriction, reducing muscle oxygenation and causing tension"),
                    ("B", "Normally tension from fear/anxiety serves a useful purpose and is relaxed when no longer needed, but in some cases it persists and becomes habitual, leading to alterations in normal posture"),
                    ("C", "Work stress causes direct cortisol-mediated muscle fibre hypertrophy"),
                    ("D", "Anxiety increases pain sensitivity, which causes perceived muscle tension"),
                    ("E", "Chronic stress causes depletion of acetylcholine at the neuromuscular junction"),
                ],
                "answer": "B",
                "explanation": "The text explains: \"Normally this tension, developed to serve a useful purpose, is relaxed when the need for it no longer exists, but in some cases it persists and becomes habitual which may lead to alterations in normal posture.\" The office worker's anxiety tension has failed to resolve, becoming a chronic state altering posture — a direct clinical application of this principle."
            },
            {
                "n": 17,
                "stem": "A patient with tension headaches and forward head posture secondary to chronic anxiety is referred. What are the TWO MOST directly relevant consequences of persistent emotional tension described in the text?",
                "opts": [
                    ("A", "Muscle atrophy and joint contracture from disuse"),
                    ("B", "Altered normal posture AND reduction in normal range of movement in a joint"),
                    ("C", "Cardiovascular changes and metabolic dysregulation"),
                    ("D", "Peripheral neuropathy and sensory loss"),
                    ("E", "Muscle fibrosis and permanent structural shortening"),
                ],
                "answer": "B",
                "explanation": "The text identifies two consequences: (1) Tension \"persists and becomes habitual which may lead to alterations in normal posture\"; (2) \"In cases where the tension has resulted in the reduction of the normal range of movement in a joint, an increase in mobility can be achieved\" through voluntary relaxation. Both apply — forward head posture (altered posture) and potentially reduced cervical ROM."
            },
            {
                "n": 18,
                "stem": "A PT teaches voluntary relaxation to an anxious patient with persistent cervical tension reducing ROM. What is the CLINICAL BENEFIT of achieving voluntary relaxation in this scenario?",
                "opts": [
                    ("A", "Voluntary relaxation permanently eliminates the patient's anxiety"),
                    ("B", "Recognition of tension followed by voluntary relaxation helps the patient economise in nervous energy and increases mobility in joints where tension has reduced ROM"),
                    ("C", "Voluntary relaxation prevents the stretch reflex from activating during exercise"),
                    ("D", "Voluntary relaxation resets the muscle spindle sensitivity to normal levels"),
                    ("E", "Voluntary relaxation prevents postural tone from developing in anti-gravity muscles"),
                ],
                "answer": "B",
                "explanation": "The text states: \"Recognition of a state of tension followed by voluntary relaxation of the muscles in which it is present provide a means of helping the patient to economise in nervous energy, and in cases where the tension has resulted in the reduction of the normal range of movement in a joint, an increase in mobility can be achieved.\" Two direct benefits: nervous energy conservation AND restored joint mobility."
            },
            {
                "n": 19,
                "stem": "Before starting physical relaxation techniques with a highly stressed patient, the PT spends time building rapport and creating a calm restful environment. What rationale from the text BEST justifies this?",
                "opts": [
                    ("A", "Patient rapport improves compliance with the exercise program"),
                    ("B", "Fear is the most usual cause of persistent tension; gaining patient confidence and co-operation, and creating an atmosphere conducive to rest contributes much to success in helping the patient acquire voluntary relaxation"),
                    ("C", "A calm environment reduces sympathetic tone and lowers resting heart rate"),
                    ("D", "Reassurance prevents the Golgi tendon organ from activating during treatment"),
                    ("E", "Patient education about relaxation is required before any hands-on treatment"),
                ],
                "answer": "B",
                "explanation": "The text directly states: \"As fear in one form or another is the most usual cause of persistent tension, the physiotherapist must do her best to reassure the patient and to gain his confidence and co-operation. An atmosphere conducive to rest, both mental and physical, contributes much to success in helping the patient to acquire the art of voluntary relaxation.\""
            },
            {
                "n": 20,
                "stem": "A patient asks: \"Is the muscle tension I feel during exam stress ever actually useful?\" What is the CORRECT answer based on the text?",
                "opts": [
                    ("A", "No — emotional tension is always pathological and serves no useful purpose"),
                    ("B", "Yes — mental attitudes like fear and excitement increase muscular tension which serves a useful purpose by preparing muscles for rapid or forceful action"),
                    ("C", "Yes — tension improves joint stability and prevents injury during stress"),
                    ("D", "No — emotional tension only affects smooth muscle, not skeletal muscle"),
                    ("E", "Yes — tension during exams improves cognitive performance through arousal"),
                ],
                "answer": "B",
                "explanation": "The text explicitly states: \"Mental attitudes such as fear, anger and excitement give rise to a general increase in muscular tension which serves a useful purpose by preparing the muscles for rapid or forceful action.\" The tension is physiologically appropriate and beneficial in the short term. The problem only arises when it \"persists and becomes habitual.\""
            },
        ]
    },
    {
        "title": "SECTION E: DEGREES OF RELAXATION",
        "questions": [
            {
                "n": 21,
                "stem": "A PT explains to a student that the goal of a relaxation session is NOT to achieve complete absence of tension but rather a reduction in tension. Which statement from the text BEST supports this clinical approach?",
                "opts": [
                    ("A", "Complete relaxation is achievable but requires advanced biofeedback techniques"),
                    ("B", "The degree to which muscular tension can be reduced is very variable; 'Relaxation' should be regarded merely as an indication that some reduction in tension has taken place"),
                    ("C", "Complete relaxation occurs only during deep sleep and cannot be achieved in therapy"),
                    ("D", "Full relaxation requires Grade 0 muscle activity on EMG assessment"),
                    ("E", "Relaxation goals should always target 80-90% reduction from baseline tension"),
                ],
                "answer": "B",
                "explanation": "The text states: \"The degree to which muscular tension can be reduced is very variable and it is better to regard the term 'Relaxation' merely as an indication that some reduction in tension has taken place.\" This sets realistic clinical expectations — any reduction is meaningful. This prevents pursuing an unachievable standard of \"complete\" relaxation."
            },
            {
                "n": 22,
                "stem": "A PT is trying to assess how well a patient has relaxed during treatment. Which TWO clinical methods described in the text can be used to estimate the degree of relaxation achieved?",
                "opts": [
                    ("A", "EMG biofeedback and dynamometry"),
                    ("B", "Gentle passive movement of limbs AND palpation of the muscles (as during massage)"),
                    ("C", "Patient self-report on a visual analogue scale only"),
                    ("D", "Observation of respiratory rate and blood pressure monitoring"),
                    ("E", "Active ROM testing before and after the session"),
                ],
                "answer": "B",
                "explanation": "The text states: \"It is often possible to estimate the degree of relaxation achieved by gentle passive movement or by palpating the muscles, as for instance during massage.\" These are the two specifically named clinical assessment methods. A limb that moves freely with passive motion and muscles that feel soft on palpation indicate successful relaxation."
            },
            {
                "n": 23,
                "stem": "During a massage relaxation session, the PT notices the patient's back muscles have become significantly softer. Additionally, the patient has fallen asleep. How should the PT interpret these findings?",
                "opts": [
                    ("A", "The patient is uncooperative and the session should be ended"),
                    ("B", "Both findings — soft muscles on palpation AND the patient falling asleep — are positive indicators; sleep is ample proof of successful general relaxation"),
                    ("C", "Sleep indicates the technique was too sedating and should be modified"),
                    ("D", "Soft muscles indicate muscle weakness rather than relaxation"),
                    ("E", "Falling asleep prevents active participation and invalidates the session"),
                ],
                "answer": "B",
                "explanation": "The text states that relaxation can be estimated by palpating the muscles during massage \"and the fact that a patient falls asleep during treatment is ample proof that the method of obtaining general relaxation has been successful.\" Both the palpatory finding and sleep are positive indicators confirming successful general relaxation."
            },
        ]
    },
    {
        "title": "SECTION F: PATHOLOGICAL TENSION IN MUSCLES",
        "questions": [
            {
                "n": 24,
                "stem": "A patient diagnosed with multiple sclerosis presents with markedly increased muscle tone (spasticity) in the lower limbs. A student PT asks why this occurs. Which explanation BEST reflects the text?",
                "opts": [
                    ("A", "MS causes muscle fibrosis that stiffens the tissue directly"),
                    ("B", "Lesions of the higher motor centres interfere with the normal function of the nervous pathways connecting them with the spinal reflex arc, resulting in an abnormal state of muscular tension varying from hypertonicity to spasticity or rigidity"),
                    ("C", "MS causes excessive acetylcholine release at the neuromuscular junction"),
                    ("D", "MS damages the peripheral nerves, causing denervation hypersensitivity"),
                    ("E", "MS causes the muscle spindles to become hyperactive due to ischemia"),
                ],
                "answer": "B",
                "explanation": "The text states: \"Lesions of the higher motor centres, and those which interfere with the normal function of the nervous pathways which connect them with the spinal reflex arc, commonly result in an abnormal state of muscular tension which varies from hypertonicity to spasticity or rigidity.\" MS lesions in the higher motor centres or their descending pathways directly cause this spectrum of pathological tone increase."
            },
            {
                "n": 25,
                "stem": "A patient who had a stroke (UMN lesion) three weeks ago displays significant spasticity in the affected arm. Which clinical category does this represent, and what is the RANGE of abnormal tone states described in the text?",
                "opts": [
                    ("A", "Lower motor neuron pathology causing flaccidity"),
                    ("B", "Pathological tension — a marked persistent increase in muscular tension from a CNS lesion, varying from hypertonicity to spasticity to rigidity"),
                    ("C", "Postural tone abnormality due to positioning"),
                    ("D", "Habitual tension from emotional factors related to stroke-induced anxiety"),
                    ("E", "Normal response to pain and fear following the stroke event"),
                ],
                "answer": "B",
                "explanation": "The text describes pathological tension in muscles as \"a marked, persistent increase in muscular tension or tone is a feature of many pathological conditions which affect the nervous system.\" The range is explicitly stated: \"from hypertonicity to spasticity or rigidity.\" Post-stroke spasticity is a classic example of this upper motor neuron pattern."
            },
            {
                "n": 26,
                "stem": "A PT treats a patient with rigidity due to Parkinson's disease. The treatment goal is to temporarily reduce the abnormal tension to enable functional re-education. What does the text suggest is ACHIEVABLE?",
                "opts": [
                    ("A", "Permanent elimination of rigidity through exercise therapy"),
                    ("B", "A temporary reduction in tension can be achieved in some cases by suitable means, allowing re-education of any functional activity which remains"),
                    ("C", "Rigidity cannot be reduced by physiotherapy and requires only pharmacological management"),
                    ("D", "Active resistance exercises will permanently reduce the rigidity"),
                    ("E", "Relaxation techniques are contraindicated in neurological pathological tension"),
                ],
                "answer": "B",
                "explanation": "The text states: \"A temporary reduction in this tension in the affected area can be achieved in some cases by suitable means which promote relaxation, and this allows re-education of any functional activity which remains to take place.\" This is a realistic, clinically appropriate goal — temporary tension reduction creating a therapeutic window for functional re-education."
            },
            {
                "n": 27,
                "stem": "A neurological PT outlines treatment rationale for a patient with hypertonicity from a spinal cord lesion. Which approach MOST accurately reflects the text's recommended strategy for pathological tension?",
                "opts": [
                    ("A", "Stretch the spastic muscles maximally and hold for prolonged periods"),
                    ("B", "Use suitable means to promote relaxation and temporarily reduce the pathological tension, then use this window to re-educate remaining functional activities"),
                    ("C", "Apply electrical stimulation to the spastic muscles to fatigue them"),
                    ("D", "Strengthen the antagonist muscles before addressing the spastic muscle"),
                    ("E", "Apply joint mobilization to override the spinal reflex arc hyperactivity"),
                ],
                "answer": "B",
                "explanation": "The text outlines the logical sequence: achieve temporary reduction in pathological tension using suitable relaxation-promoting means → use this window to allow \"re-education of any functional activity which remains to take place.\" Relaxation is the prerequisite that enables functional re-education — a fundamental principle of neurological physiotherapy."
            },
        ]
    },
    {
        "title": "SECTION G: INTEGRATED CLINICAL SCENARIOS",
        "questions": [
            {
                "n": 28,
                "stem": "A PT treats three patients: (i) an office worker with chronic anxiety-related neck tension, (ii) a patient with post-stroke spasticity, and (iii) a healthy person assessed during rest. What is the PRIMARY type of tension each demonstrates respectively?",
                "opts": [
                    ("A", "Pathological, Habitual, Normal muscle tone"),
                    ("B", "Habitual tension from mental attitudes, Pathological tension from CNS lesion, Normal muscle tone (intrafusal fibre activity)"),
                    ("C", "Postural tone, Pathological tone, Voluntary tension"),
                    ("D", "Habitual tension, Normal muscle tone, Pathological tension"),
                    ("E", "All three demonstrate pathological tension requiring treatment"),
                ],
                "answer": "B",
                "explanation": "The text describes three distinct states: (i) Office worker = habitual tension from mental attitudes (fear/anxiety) that \"persists and becomes habitual\"; (ii) Post-stroke = pathological tension from \"lesions of the higher motor centres interfering with the spinal reflex arc\"; (iii) Healthy person = normal muscle tone maintained by \"the muscle spindle circuit\" through intrafusal fibre activity."
            },
            {
                "n": 29,
                "stem": "A PT plans a comprehensive relaxation program for a highly anxious patient with chronic musculoskeletal tension and limited cervical ROM. Based on ALL principles from the text, which COMBINATION of strategies is MOST complete?",
                "opts": [
                    ("A", "Electrical stimulation and ultrasound to the tense muscles"),
                    ("B", "Reassure and gain patient confidence (address fear), use fully supported recumbent positions (counterbalance gravity), apply massage/passive movement, and teach voluntary relaxation techniques (reciprocal inhibition)"),
                    ("C", "Prescribe progressive resistance exercises to fatigue the tense muscles"),
                    ("D", "Teach breathing exercises only to reduce sympathetic arousal"),
                    ("E", "Apply joint manipulation to restore cervical ROM without addressing muscle tension"),
                ],
                "answer": "B",
                "explanation": "This combines all relevant text principles: (1) Address fear — \"most usual cause of persistent tension\"; (2) Fully supported recumbent positions — \"most suitable for obtaining general relaxation\"; (3) Massage/passive movement — stated methods of estimating and promoting relaxation; (4) Measures reducing the stretching force — \"assists in promoting relaxation\"; (5) Voluntary relaxation after recognition of tension — restores ROM and conserves nervous energy."
            },
            {
                "n": 30,
                "stem": "A PT student asks: \"Why do we need to understand both the physiology of muscle tone AND the psychology of mental attitudes to be effective at treating patients with excessive tension?\" Which answer BEST explains this integration?",
                "opts": [
                    ("A", "Psychology is irrelevant — only the spinal reflex mechanisms matter in physiotherapy"),
                    ("B", "Muscle tone has purely physical mechanisms that are unaffected by mental states"),
                    ("C", "Muscle tone is maintained by spinal reflex mechanisms (intrafusal fibres, stretch reflex), but mental attitudes (fear, anger, excitement) generate a separate pathway for increasing general muscular tension; effective treatment must address BOTH the reflex physiology AND the psychological contributing factors simultaneously"),
                    ("D", "Mental attitudes only affect smooth muscle, not skeletal muscle relevant to physiotherapy"),
                    ("E", "Understanding psychology only helps with patient communication, not clinical outcomes"),
                ],
                "answer": "C",
                "explanation": "The text establishes two distinct pathways: (1) Physiological — the muscle spindle/stretch reflex arc maintaining tone through intrafusal fibre activity; and (2) Psychological — mental attitudes of fear, anger, excitement causing \"general increase in muscular tension.\" Since fear is \"the most usual cause of persistent tension,\" ignoring the psychological dimension means failing to address the PRIMARY cause. Complete treatment requires both physiological interventions AND addressing psychological contributing factors."
            },
        ]
    },
]

# ── Build elements ────────────────────────────────────────────────────────────
def build_pdf():
    doc = SimpleDocTemplate(
        OUTPUT,
        pagesize=A4,
        leftMargin=2*cm, rightMargin=2*cm,
        topMargin=2.2*cm, bottomMargin=2.2*cm,
        title="Kinesiology – Relaxation MCQ Quiz",
        author="Dr Ayyaz PT"
    )

    story = []

    # ── COVER PAGE ────────────────────────────────────────────────────────────
    story.append(Spacer(1, 1.2*cm))

    # Big teal header box
    cover_data = [[Paragraph(
        "KINESIOLOGY<br/>RELAXATION<br/><font size='15'>Chapter 6 — The Principles of Exercise Therapy</font>",
        cover_title)]]
    cover_table = Table(cover_data, colWidths=[16.5*cm])
    cover_table.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), NAVY),
        ("ROUNDEDCORNERS", [8]),
        ("TOPPADDING", (0,0), (-1,-1), 28),
        ("BOTTOMPADDING", (0,0), (-1,-1), 28),
        ("LEFTPADDING", (0,0), (-1,-1), 20),
        ("RIGHTPADDING", (0,0), (-1,-1), 20),
    ]))
    story.append(cover_table)
    story.append(Spacer(1, 0.6*cm))

    subtitle_data = [[Paragraph(
        "30 Scenario-Based MCQs  •  C3 Level (Application)",
        cover_sub)]]
    st = Table(subtitle_data, colWidths=[16.5*cm])
    st.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), TEAL),
        ("TOPPADDING", (0,0), (-1,-1), 14),
        ("BOTTOMPADDING", (0,0), (-1,-1), 14),
        ("LEFTPADDING", (0,0), (-1,-1), 16),
        ("RIGHTPADDING", (0,0), (-1,-1), 16),
    ]))
    story.append(st)
    story.append(Spacer(1, 1*cm))

    # Info grid
    info = [
        ["📖 Source", "The Principles of Exercise Therapy, Chapter 6 (pp. 62–64)"],
        ["📝 Format", "5 options (A–E) per question | Answer + Explanation included"],
        ["🎯 Bloom's Level", "C3 — Application (Scenario-Based)"],
        ["📊 Sections", "7 Sections covering all chapter concepts"],
        ["⏱ Suggested Time", "60–75 minutes (2–2.5 min per question)"],
    ]
    info_table = Table(info, colWidths=[5*cm, 11.5*cm])
    info_table.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (0,-1), LIGHT_BG),
        ("BACKGROUND", (1,0), (1,-1), WHITE),
        ("FONTNAME", (0,0), (0,-1), "Helvetica-Bold"),
        ("FONTNAME", (1,0), (1,-1), "Helvetica"),
        ("FONTSIZE", (0,0), (-1,-1), 10),
        ("ROWBACKGROUNDS", (0,0), (-1,-1), [LIGHT_BG, WHITE]),
        ("GRID", (0,0), (-1,-1), 0.5, RULE_CLR),
        ("TOPPADDING", (0,0), (-1,-1), 8),
        ("BOTTOMPADDING", (0,0), (-1,-1), 8),
        ("LEFTPADDING", (0,0), (-1,-1), 10),
        ("RIGHTPADDING", (0,0), (-1,-1), 10),
        ("VALIGN", (0,0), (-1,-1), "MIDDLE"),
    ]))
    story.append(info_table)
    story.append(Spacer(1, 1.2*cm))

    # Section overview box
    story.append(Paragraph("SECTION OVERVIEW", ParagraphStyle("sh", fontName="Helvetica-Bold",
        fontSize=11, textColor=NAVY, spaceAfter=6)))
    toc_rows = [["Section", "Topic", "Questions"]]
    for i, sec in enumerate(sections):
        title = sec["title"].replace("SECTION "+["A","B","C","D","E","F","G"][i]+": ", "")
        q_range = f"Q{sec['questions'][0]['n']}–Q{sec['questions'][-1]['n']}"
        toc_rows.append([["A","B","C","D","E","F","G"][i], title, q_range])
    toc_table = Table(toc_rows, colWidths=[1.2*cm, 12.5*cm, 2.8*cm])
    toc_table.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,0), NAVY),
        ("TEXTCOLOR", (0,0), (-1,0), WHITE),
        ("FONTNAME", (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTSIZE", (0,0), (-1,-1), 9.5),
        ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_BG, WHITE]),
        ("GRID", (0,0), (-1,-1), 0.5, RULE_CLR),
        ("TOPPADDING", (0,0), (-1,-1), 7),
        ("BOTTOMPADDING", (0,0), (-1,-1), 7),
        ("LEFTPADDING", (0,0), (-1,-1), 8),
        ("RIGHTPADDING", (0,0), (-1,-1), 8),
        ("ALIGN", (0,0), (0,-1), "CENTER"),
        ("ALIGN", (2,0), (2,-1), "CENTER"),
        ("FONTNAME", (0,1), (0,-1), "Helvetica-Bold"),
    ]))
    story.append(toc_table)
    story.append(PageBreak())

    # ── QUESTION PAGES ────────────────────────────────────────────────────────
    total_q = 0
    for sec in sections:
        # Section header
        sec_data = [[Paragraph(sec["title"], section_hdr)]]
        sec_table = Table(sec_data, colWidths=[16.5*cm])
        sec_table.setStyle(TableStyle([
            ("BACKGROUND", (0,0), (-1,-1), SECTION_BG),
            ("TOPPADDING", (0,0), (-1,-1), 9),
            ("BOTTOMPADDING", (0,0), (-1,-1), 9),
            ("LEFTPADDING", (0,0), (-1,-1), 12),
            ("RIGHTPADDING", (0,0), (-1,-1), 12),
        ]))
        story.append(sec_table)
        story.append(Spacer(1, 0.3*cm))

        for q in sec["questions"]:
            total_q += 1
            block = []

            # Question number + stem
            block.append(Paragraph(f"Q{q['n']}.", q_number))
            block.append(Paragraph(q["stem"], q_stem))

            # Options
            opt_rows = []
            for letter, text in q["opts"]:
                opt_rows.append([
                    Paragraph(f"<b>{letter}</b>", opt_style),
                    Paragraph(text, opt_style)
                ])
            opt_table = Table(opt_rows, colWidths=[0.7*cm, 15.3*cm])
            opt_table.setStyle(TableStyle([
                ("BACKGROUND", (0,0), (-1,-1), OPT_BG),
                ("TOPPADDING", (0,0), (-1,-1), 5),
                ("BOTTOMPADDING", (0,0), (-1,-1), 5),
                ("LEFTPADDING", (0,0), (-1,-1), 6),
                ("RIGHTPADDING", (0,0), (-1,-1), 6),
                ("LINEBELOW", (0,0), (-1,-2), 0.3, RULE_CLR),
                ("VALIGN", (0,0), (-1,-1), "TOP"),
            ]))
            block.append(opt_table)
            block.append(Spacer(1, 0.2*cm))

            # Answer + Explanation box
            ans_content = [
                [Paragraph(f"✅  Answer: {q['answer']}", answer_label)],
                [Paragraph(f"<b>Explanation:</b> {q['explanation']}", explanation_style)],
            ]
            ans_table = Table(ans_content, colWidths=[16*cm])
            ans_table.setStyle(TableStyle([
                ("BACKGROUND", (0,0), (-1,-1), ANSWER_BG),
                ("TOPPADDING", (0,0), (-1,-1), 7),
                ("BOTTOMPADDING", (0,0), (-1,-1), 7),
                ("LEFTPADDING", (0,0), (-1,-1), 10),
                ("RIGHTPADDING", (0,0), (-1,-1), 10),
                ("BOX", (0,0), (-1,-1), 1, ANSWER_BD),
                ("LINEBELOW", (0,0), (-1,0), 0.5, colors.HexColor("#a5d6a7")),
            ]))
            block.append(ans_table)
            block.append(Spacer(1, 0.5*cm))
            block.append(HRFlowable(width="100%", thickness=0.5, color=RULE_CLR))
            block.append(Spacer(1, 0.4*cm))

            story.append(KeepTogether(block))

        story.append(PageBreak())

    # ── ANSWER KEY PAGE ───────────────────────────────────────────────────────
    story.append(Paragraph("QUICK ANSWER KEY", page_title_style))
    story.append(HRFlowable(width="100%", thickness=1.5, color=TEAL))
    story.append(Spacer(1, 0.4*cm))

    # Collect all answers
    all_answers = []
    for sec in sections:
        for q in sec["questions"]:
            all_answers.append((q["n"], q["answer"]))

    # 3-column layout
    key_rows = [["Q", "Ans", "Q", "Ans", "Q", "Ans"]]
    rows_per_col = 10
    col1 = all_answers[0:10]
    col2 = all_answers[10:20]
    col3 = all_answers[20:30]
    for i in range(rows_per_col):
        row = []
        for col in [col1, col2, col3]:
            if i < len(col):
                row += [str(col[i][0]), col[i][1]]
            else:
                row += ["", ""]
        key_rows.append(row)

    key_table = Table(key_rows, colWidths=[1.5*cm, 1.5*cm, 1.5*cm, 1.5*cm, 1.5*cm, 1.5*cm])
    key_table.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,0), NAVY),
        ("TEXTCOLOR", (0,0), (-1,0), WHITE),
        ("FONTNAME", (0,0), (-1,0), "Helvetica-Bold"),
        ("FONTNAME", (0,1), (-1,-1), "Helvetica"),
        ("FONTSIZE", (0,0), (-1,-1), 11),
        ("ALIGN", (0,0), (-1,-1), "CENTER"),
        ("VALIGN", (0,0), (-1,-1), "MIDDLE"),
        ("ROWBACKGROUNDS", (0,1), (-1,-1), [LIGHT_BG, WHITE]),
        ("GRID", (0,0), (-1,-1), 0.5, RULE_CLR),
        ("TOPPADDING", (0,0), (-1,-1), 8),
        ("BOTTOMPADDING", (0,0), (-1,-1), 8),
        ("FONTNAME", (1,1), (1,-1), "Helvetica-Bold"),
        ("FONTNAME", (3,1), (3,-1), "Helvetica-Bold"),
        ("FONTNAME", (5,1), (5,-1), "Helvetica-Bold"),
        ("TEXTCOLOR", (1,1), (1,-1), TEAL),
        ("TEXTCOLOR", (3,1), (3,-1), TEAL),
        ("TEXTCOLOR", (5,1), (5,-1), TEAL),
    ]))
    story.append(key_table)

    story.append(Spacer(1, 1*cm))
    story.append(HRFlowable(width="100%", thickness=1, color=TEAL))
    story.append(Spacer(1, 0.3*cm))
    story.append(Paragraph(
        "Source: The Principles of Exercise Therapy, Chapter 6 — Relaxation (pp. 62–64)  |  "
        "Bloom's Taxonomy Level C3 (Application)  |  30 Questions  |  Dr Ayyaz PT",
        footer_style))

    doc.build(story)
    print(f"PDF created: {OUTPUT}")

build_pdf()