Head and Head and NeckNeck

Orthopedic Assessment III Orthopedic Assessment III – Head, Spine, and Trunk – Head, Spine, and Trunk

with Labwith LabPET 5609CPET 5609C

Clinical AnatomyClinical Anatomy

Clinical AnatomyClinical Anatomy

Clinical AnatomyClinical Anatomy Brain: CerebrumBrain: Cerebrum

Largest section of brain (most Largest section of brain (most anterior and superior region of CNS)anterior and superior region of CNS)

Formed by 2 hemispheres:Formed by 2 hemispheres: Longitudinal fissure – separates 2 sidesLongitudinal fissure – separates 2 sides Right and Left Hemisphere:Right and Left Hemisphere:

Frontal lobeFrontal lobe Parietal lobeParietal lobe Temporal lobeTemporal lobe Occipital lobeOccipital lobe

Clinical AnatomyClinical Anatomy

Clinical AnatomyClinical Anatomy Brain: CerebrumBrain: Cerebrum

Functions:Functions: Motor functionMotor function Sensory Sensory

information:information: Temperature Temperature TouchTouch PainPain PressurePressure ProprioceptionProprioception

Special senses:Special senses: VisualVisual AuditoryAuditory Olfactory and tasteOlfactory and taste

Functions (cont.)Functions (cont.) Cognition:Cognition:

Spatial Spatial relationshipsrelationships

BehaviorBehavior MemoryMemory AssociationAssociation

Communication:Communication: Right hemisphere Right hemisphere

→ controls left side → controls left side of bodyof body

Left hemisphere → Left hemisphere → controls right side controls right side of bodyof body

Clinical AnatomyClinical Anatomy Brain: CerebellumBrain: Cerebellum

Quick processor of incoming/outgoing Quick processor of incoming/outgoing information:information: Integrates sensory perception, coordination Integrates sensory perception, coordination

and motor control: Cerebellum → linked to and motor control: Cerebellum → linked to cerebral motor cortex (sends info to muscles) cerebral motor cortex (sends info to muscles) and spinocerebellar tract (proprioceptive and spinocerebellar tract (proprioceptive feedback)feedback)

Constant feedback on body position → fine Constant feedback on body position → fine tunes motor movementstunes motor movements

Key: Maintains BALANCE and Key: Maintains BALANCE and COORDINATIONCOORDINATION

Clinical AnatomyClinical Anatomy

Clinical AnatomyClinical Anatomy Brain: Brain:

DiencephalonDiencephalon Processing center Processing center

for conscious and for conscious and unconscious unconscious brain inputbrain input

Parts:Parts: ThalamusThalamus HypothalamusHypothalamus EpithalamusEpithalamus

Clinical AnatomyClinical Anatomy Brain: ThalamusBrain: Thalamus

Functions:Functions: Translates Translates

information information (inputs) for (inputs) for cerebral cortexcerebral cortex

Processes and Processes and relays sensory relays sensory information information

Helps regulate Helps regulate states/levels of states/levels of sleep and sleep and consciousnessconsciousness

Hypothalamic Hypothalamic RegulationRegulation

Posterior PituitaryPosterior Pituitary EffectEffect

Neurosecratory Neurosecratory NeuronNeuron

Vasopressin Vasopressin (ADH)(ADH)

Water RetentionWater Retention

Neurosecratory Neurosecratory NeuronNeuron

OxytocinOxytocin Milk ejection Milk ejection (mammary gland)(mammary gland)

Hypothalamic Hypothalamic RegulationRegulation

Anterior PituitaryAnterior Pituitary EffectEffect

Thyrotropin Releasing Thyrotropin Releasing HormoneHormone

ThyrotropinThyrotropin Involved Thyroxin Involved Thyroxin from Thyroid from Thyroid GlandGland

Corticotropin Corticotropin Releasing HormoneReleasing Hormone

AdrenocorticotropAdrenocorticotrophic Hormonehic Hormone

Cortisol Release Cortisol Release (adrenal gland)(adrenal gland)

Growth-Hormone Growth-Hormone Releasing HormoneReleasing Hormone

GHGH Whole body Whole body growthgrowth

Gonadotropin Gonadotropin Releasing HormoneReleasing Hormone

FSH, LHFSH, LH Reproductive Reproductive functionfunction

Prolactin Releasing Prolactin Releasing HormonesHormones

ProlactinProlactin Milk productionMilk production

MSH Releasing MSH Releasing FactorFactor

Melanocyte Melanocyte Stimulating Stimulating HormoneHormone

Skin pigmentsSkin pigments

Clinical AnatomyClinical Anatomy

Clinical AnatomyClinical Anatomy Brain: HypothalamusBrain: Hypothalamus

Control of Hydration: Supraoptic nuclei Control of Hydration: Supraoptic nuclei and Paraventricular nuclei (Hypothalamus)and Paraventricular nuclei (Hypothalamus)

What Happens?What Happens? Hydration Level too LOWHydration Level too LOW Osmoreceptors in blood detect increased Osmoreceptors in blood detect increased

concentration of salt in bloodconcentration of salt in blood Hypothalamus stimulated – neurosecratory Hypothalamus stimulated – neurosecratory

hormoneshormones Vasopressin released from Posterior PituitaryVasopressin released from Posterior Pituitary ADH causes kidneys to retain waterADH causes kidneys to retain water Level of water increases in the bodyLevel of water increases in the body

Clinical AnatomyClinical Anatomy Brain: Brain StemBrain: Brain Stem

Lower part of the brain Lower part of the brain (continuous with spinal cord)(continuous with spinal cord)

Medulla OblongataMedulla Oblongata PonsPons

Functions:Functions: Main motor and sensory Main motor and sensory

innervation to face and neckinnervation to face and neck Cranial nervesCranial nerves

Regulation of cardiac and Regulation of cardiac and respiratory function respiratory function (medulla)(medulla)

Relays information to and Relays information to and from the CNS from the CNS

Pons: Link between Pons: Link between cerebellum to brain stem cerebellum to brain stem and spinal cordand spinal cord

Clinical AnatomyClinical Anatomy Brain: MeningesBrain: Meninges

3 connective tissue layers which protect the 3 connective tissue layers which protect the CNSCNS

Supports blood vesselsSupports blood vessels Contains cerebrospinal fluidContains cerebrospinal fluid

Pia mater:Pia mater: Innermost layer (outer “skin” of brain)Innermost layer (outer “skin” of brain)

Dura Mater:Dura Mater: Outermost layerOutermost layer

Serves as periosteum for skull’s inner layerServes as periosteum for skull’s inner layer Arachnoid Mater:Arachnoid Mater:

Middle layerMiddle layer Subdural space – area between dura mater and Subdural space – area between dura mater and

arachnoid materarachnoid mater Subarachnoid space – beneath the arachnoidSubarachnoid space – beneath the arachnoid

Contains cerebrospinal fluidContains cerebrospinal fluid

Clinical AnatomyClinical Anatomy

Clinical AnatomyClinical Anatomy Cerebrospinal Fluid:Cerebrospinal Fluid:

Clear, colorless liquid Clear, colorless liquid that bathes the brain that bathes the brain and spinal cord and spinal cord (circulates within (circulates within subarachnoid space)subarachnoid space)

Functions:Functions: Cushions the brain Cushions the brain

within the skullwithin the skull Shock absorber for the Shock absorber for the

CNSCNS Circulates nutrients and Circulates nutrients and

chemicals filtered from chemicals filtered from the blood and removes the blood and removes waste products from the waste products from the brainbrain

Clinical AnatomyClinical Anatomy Brain blood Brain blood

demand:demand: 20% of body’s O2 20% of body’s O2

uptake at restuptake at rest ↑ ↑ 1100 Celsius, brains Celsius, brains

demand ↑ 7%demand ↑ 7% Supplying vessels:Supplying vessels:

Vertebral arteries Vertebral arteries Carotid arteries:Carotid arteries:

InternalInternal ExternalExternal

Circle of WillisCircle of Willis

Clinical EvaluationClinical Evaluation Key Points:Key Points:

All unconscious athletes must be All unconscious athletes must be managed as if a fracture or dislocation managed as if a fracture or dislocation of the cervical spine exists until the of the cervical spine exists until the presence of these injuries can be presence of these injuries can be definitively ruled outdefinitively ruled out

Ideally, 2 responders are available to Ideally, 2 responders are available to evaluate:evaluate: In-line stabilization and immobilization of In-line stabilization and immobilization of

athlete’s headathlete’s head Initial evaluation:Initial evaluation:

PalpationPalpation Sensory and motor testsSensory and motor tests

Clinical EvaluationClinical Evaluation

Clinical EvaluationClinical Evaluation Initial Evaluation:Initial Evaluation:

Assess ABC’s:Assess ABC’s: (airways, breathing, (airways, breathing, circulation)circulation)

Moving, speaking athlete → ABC’s presentMoving, speaking athlete → ABC’s present Still suspect cervical spine injury (until ruled Still suspect cervical spine injury (until ruled

out) out) Level of Consciousness:Level of Consciousness:

Communicate with athlete (verbal)Communicate with athlete (verbal) Unresponsive athlete:Unresponsive athlete:

Apply painful stimulus:Apply painful stimulus: Lunula of fingernailLunula of fingernail Pressure to sternumPressure to sternum

Clinical EvaluationClinical Evaluation Initial Evaluation:Initial Evaluation:

Primary Survey:Primary Survey: Look, listen, feel for Look, listen, feel for

breathingbreathing Absent breathing → Absent breathing →

modified jaw thrust to modified jaw thrust to open airwayopen airway

Absent pulse → CPRAbsent pulse → CPR Initiate EMS!Initiate EMS!

Secondary Survey:Secondary Survey: BleedingBleeding Possible fractures, Possible fractures,

dislocationsdislocations

Clinical EvaluationClinical Evaluation History:History:

Location of Location of symptoms:symptoms:

Cervical pain Cervical pain or muscle or muscle spasm:spasm:

PainPain NumbnessNumbness BurningBurning

Head pain:Head pain: Headaches Headaches

AreaArea Signs and SymptomsSigns and SymptomsBrainBrain AmnesiaAmnesia

Confusion and Confusion and DisorientationDisorientationIrritability and Irritability and UncoordinationUncoordinationDizzinessDizzinessHeadacheHeadache

OcularOcular Blurred vision and Blurred vision and PhotophobiaPhotophobiaNystagmusNystagmus

EarsEars TinnitusTinnitusDizzinessDizziness

StomachStomach NauseaNauseaVomitingVomiting

SystemicSystemic Unusually fatiguedUnusually fatigued

Clinical EvaluationClinical Evaluation Mechanism of Injury: Mechanism of Injury:

HeadHead Coup Injury:Coup Injury:

Stationary skull is hit by object Stationary skull is hit by object traveling at high velocity (i.e. traveling at high velocity (i.e. hit in head with baseball)hit in head with baseball)

Trauma → side of head where Trauma → side of head where contact occurredcontact occurred

Contrecoup Injury:Contrecoup Injury: Skull is moving at high velocity Skull is moving at high velocity

and is suddenly stopped (i.e. and is suddenly stopped (i.e. falling and hitting head on the falling and hitting head on the ground)ground)

Brain strikes the skull on side Brain strikes the skull on side opposite of the impactopposite of the impact

Clinical EvaluationClinical Evaluation

Clinical EvaluationClinical Evaluation

Clinical EvaluationClinical Evaluation Mechanism of Mechanism of

Injury: HeadInjury: Head Repeated Repeated

subconcussive subconcussive forces:forces:

Repeated trauma:Repeated trauma: BoxingBoxing Heading in soccerHeading in soccer

Rotational or Rotational or shear forces:shear forces:

TwistingTwisting Acceleration and Acceleration and

decelerationdeceleration

Clinical EvaluationClinical Evaluation Mechanism of Injury: Cervical spineMechanism of Injury: Cervical spine

Most forces → dissipated by cervical Most forces → dissipated by cervical musculature and intervertebral discsmusculature and intervertebral discs

Flexion, extension, lateral bending, Flexion, extension, lateral bending, rotationrotation

Flexion:Flexion: Removes natural lordotic curvature (30 Removes natural lordotic curvature (30

degrees)degrees) Forces directed to cervical vertebraeForces directed to cervical vertebrae Axial load → through vertical axis of vertebral columnAxial load → through vertical axis of vertebral column

Catastrophic injuriesCatastrophic injuries

Clinical EvaluationClinical Evaluation

Clinical EvaluationClinical Evaluation

Clinical EvaluationClinical Evaluation History:History:

Loss of consciousness:Loss of consciousness: Record athlete’s initial responses:Record athlete’s initial responses:

““Seeing stars”Seeing stars” ““Blacking out”Blacking out”

““Do you remember being hit?”Do you remember being hit?” History of concussion:History of concussion:

Recent concussions → increased riskRecent concussions → increased risk Second impact syndromeSecond impact syndrome

Complaints of weakness:Complaints of weakness: FatigueFatigue Muscular weakness:Muscular weakness:

More serious:More serious: Trauma to brain, spinal cord, spinal nerve rootsTrauma to brain, spinal cord, spinal nerve roots

Clinical EvaluationClinical Evaluation Inspection: Bony StructuresInspection: Bony Structures

Position of head:Position of head: Head should be upright in all planesHead should be upright in all planes Laterally flexed and rotated head → possible Laterally flexed and rotated head → possible

cervical vertebrae dislocationcervical vertebrae dislocation Cervical vertebrae:Cervical vertebrae:

View athlete from behind (positioning of spinous View athlete from behind (positioning of spinous processes)processes)

Mastoid process:Mastoid process: Battle’s sign → ecchymosis over mastoid processBattle’s sign → ecchymosis over mastoid process

Basilar skull fractureBasilar skull fracture Skull and scalp:Skull and scalp:

Bleeding, swelling, deformityBleeding, swelling, deformity

Clinical EvaluationClinical Evaluation Inspection: EyesInspection: Eyes

General:General: Dazed, distant stare may Dazed, distant stare may

indicate mental confusionindicate mental confusion Nystagmus:Nystagmus:

Involuntary cyclical movement Involuntary cyclical movement of the eyesof the eyes

Pupil size:Pupil size: Unilateral dilation (pressure Unilateral dilation (pressure

on cranial nerve III)on cranial nerve III) Note: Anisocoria (normal Note: Anisocoria (normal

unequal pupil size)unequal pupil size) Pupil reaction to lightPupil reaction to light

Clinical EvaluationClinical Evaluation Inspection: Inspection:

Nose and EarsNose and Ears Ears:Ears:

Bleeding and/or Bleeding and/or cerebrospinal cerebrospinal fluidfluid

Skull fractureSkull fracture Nose:Nose:

BleedingBleeding Nose fracture or Nose fracture or

skull fractureskull fracture Nose/eyes:Nose/eyes:

Raccoon eyes → Raccoon eyes → skull or nasal skull or nasal fracturefracture

Clinical EvaluationClinical Evaluation Palpation: Bony Palpation: Bony

StructuresStructures Spinous Processes:Spinous Processes:

Patient seated, leaning Patient seated, leaning slightly forwardslightly forward

C7 and C7 and ↑ ↑ Transverse ProcessesTransverse Processes Skull:Skull:

Occipital and temporalOccipital and temporal Sphenoid and Sphenoid and

zygomaticzygomatic Parietal and frontalParietal and frontal

Palpation: Soft Palpation: Soft TissueTissue Musculature:Musculature:

TrapeziusTrapezius SCMSCM

ThroatThroat

Clinical EvaluationClinical Evaluation Special Test: Halo TestSpecial Test: Halo Test

Patient position:Patient position: Lying or seatedLying or seated

Examiner position:Examiner position: At patient’s sideAt patient’s side

Procedure:Procedure: Fold a piece of sterile gauze into a triangleFold a piece of sterile gauze into a triangle Using the point of the gauze, collect a sample of Using the point of the gauze, collect a sample of

the fluid leaking from the ear or nose (allow it to the fluid leaking from the ear or nose (allow it to be absorbed)be absorbed)

Positive test:Positive test: Pale yellow “halo” will form on the gauzePale yellow “halo” will form on the gauze

Implications:Implications: Cerebrospinal fluid leakageCerebrospinal fluid leakage

Clinical EvaluationClinical Evaluation Functional Testing: MemoryFunctional Testing: Memory

Retrograde amnsesia:Retrograde amnsesia: Inability to recall events before injuryInability to recall events before injury

Anterograde amnesia:Anterograde amnesia: Inability to recall events after injury Inability to recall events after injury Fading memory → progressive Fading memory → progressive

deterioration of cerebral functiondeterioration of cerebral function

ATHLETE ATHLETE POSITION:POSITION:

On-field: athlete’s current positionOn-field: athlete’s current position

Sideline: standing, seatedSideline: standing, seatedEXAMINER EXAMINER POSITION:POSITION:

In a position able to hear athlete’s responsesIn a position able to hear athlete’s responses

PROCEDURE:PROCEDURE: Ask patient series of questions beginning with the time of the Ask patient series of questions beginning with the time of the injuryinjuryEach successive question progresses backward in timeEach successive question progresses backward in time What happened? What play were you What happened? What play were you running?running? Where are you? Who am I?Where are you? Who am I? Who are we playing? What quarter is it?Who are we playing? What quarter is it? What did you have for a pregame meal?What did you have for a pregame meal? Who did we play last week?Who did we play last week?

POSITIVE TEST:POSITIVE TEST: Athlete has difficulty remembering or cannot remember events Athlete has difficulty remembering or cannot remember events occurring before the injuryoccurring before the injury

IMPLICATIONS:IMPLICATIONS: Retrograde amnesia:Retrograde amnesia: Not remembering events from the day before is more Not remembering events from the day before is more significant that not significant that not remembering more recent eventsremembering more recent events The same set of questions should be repeated to determine The same set of questions should be repeated to determine whether memorywhether memory is returning, deteriorating, or staying the sameis returning, deteriorating, or staying the same Further deterioration of memory or acutely profound Further deterioration of memory or acutely profound memory loss warrantsmemory loss warrants immediate termination of evaluation and transportation to immediate termination of evaluation and transportation to emergency medicalemergency medical facilityfacility

COMMENTS:COMMENTS: Record patient’s responses and verify answers with Record patient’s responses and verify answers with coaches/teammatescoaches/teammates

PATIENT PATIENT POSITION:POSITION:

Sitting or standingSitting or standing

EXAMINER EXAMINER POSITION:POSITION:

Positioned to hear athlete’s responsePositioned to hear athlete’s response

EVALUATION:EVALUATION: Athlete is given a list of 4 unrelated items Athlete is given a list of 4 unrelated items (ask them to memorize the list)(ask them to memorize the list) HubcapHubcap

RabbitRabbit

Dog tagsDog tags

FilmFilm

IvyIvy

POSITIVE TEST:POSITIVE TEST: Inability to completely recite the listInability to completely recite the list

IMPLICATIONS:IMPLICATIONS: Anterograde amnesia, possibly the result Anterograde amnesia, possibly the result of intracranial bleedingof intracranial bleeding

COMMENT:COMMENT: Perform the test after test for retrograde Perform the test after test for retrograde amnesiaamnesia

Clinical Evaluation: Anterograde Amnesia

Clinical EvaluationClinical Evaluation Functional Testing: Cognitive Functional Testing: Cognitive

FunctionFunction Cerebral trauma → Unusual athlete Cerebral trauma → Unusual athlete

behaviorbehavior Behavior:Behavior:

Violent, irrational, inappropriate behaviorViolent, irrational, inappropriate behavior Analytical Skills:Analytical Skills:

Serial 7’s (count backwards from 100)Serial 7’s (count backwards from 100) Information Processing:Information Processing:

Provide command → can athlete follow?Provide command → can athlete follow?

Clinical EvaluationClinical Evaluation Balance and Coordination:Balance and Coordination:

Affected secondary to trauma Affected secondary to trauma involving cerebellum and inner earinvolving cerebellum and inner ear

Tests:Tests: Romberg TestRomberg Test Tandem WalkingTandem Walking Balance Error Scoring SystemBalance Error Scoring System

Clinical EvaluationClinical Evaluation Romberg Test:Romberg Test:

Patient Position:Patient Position: Standing, feet shoulder width Standing, feet shoulder width

apartapart ATC Position:ATC Position:

Ready to support patientReady to support patient Procedure:Procedure:

Patient shuts eyes and abducts Patient shuts eyes and abducts arms to 90arms to 9000

Patient tilts head backwards Patient tilts head backwards and lifts 1 foot off groundand lifts 1 foot off ground

Patient touches index finger to Patient touches index finger to nose (eyes closed)nose (eyes closed)

Positive Test:Positive Test: Patient unsteadinessPatient unsteadiness

Implications:Implications: Cerebellar dysfunctionCerebellar dysfunction

Clinical EvaluationClinical Evaluation Tandem Walking:Tandem Walking:

Patient Position:Patient Position: Athlete standing with feet straddling a straight lineAthlete standing with feet straddling a straight line

ATC Position:ATC Position: Beside patient to provide supportBeside patient to provide support

Evaluation:Evaluation: Athlete walks heel-to-toe along a straight line for Athlete walks heel-to-toe along a straight line for

approximately 10 yardsapproximately 10 yards Athlete returns to starting position by walking Athlete returns to starting position by walking

backwardsbackwards Positive Test:Positive Test:

Athlete unable to maintain a steady balanceAthlete unable to maintain a steady balance Implications:Implications:

Cerebral or inner ear dysfunction that inhibits Cerebral or inner ear dysfunction that inhibits balancebalance

Clinical EvaluationClinical Evaluation Balance Error Scoring System:Balance Error Scoring System:

Patient Position:Patient Position: Patient barefoot or wearing socks (no Patient barefoot or wearing socks (no

tape); hands on iliac crest; eyes closedtape); hands on iliac crest; eyes closed Phase 1:Phase 1:

Double Leg StanceDouble Leg Stance Phase 2:Phase 2:

Single Leg Stance – standing on the Single Leg Stance – standing on the nondominant leg; non-weight-bearing hip nondominant leg; non-weight-bearing hip flexed to 20flexed to 2000 and knee flexed to 40 and knee flexed to 4000-50-5000

Phase 3:Phase 3: Tandem Leg Stance – nondominant leg placed Tandem Leg Stance – nondominant leg placed

behind the dominant leg and the patient behind the dominant leg and the patient stands in a heel-toe mannerstands in a heel-toe manner

Clinical EvaluationClinical Evaluation Balance Error Scoring System:Balance Error Scoring System:

ATC Position:ATC Position: In front of the athlete; trials are timedIn front of the athlete; trials are timed

Procedure:Procedure: First battery performed with athlete First battery performed with athlete

standing on a firm surfacestanding on a firm surface DL stance, holds position for 20 secondsDL stance, holds position for 20 seconds SL stanceSL stance Tandem stanceTandem stance

Second battery performed with athlete Second battery performed with athlete standing on foamstanding on foam

Clinical EvaluationClinical Evaluation Balance Error Scoring System:Balance Error Scoring System:

Scoring:Scoring: One point is scored for each of the One point is scored for each of the following errorsfollowing errors

Hands lifted off iliac crestHands lifted off iliac crest Opening eyesOpening eyes Step, stumble or fallStep, stumble or fall Moving hip into > 30 degrees abductionMoving hip into > 30 degrees abduction Lifting forefoot or heelLifting forefoot or heel Remaining out of testing position > 5 sec.Remaining out of testing position > 5 sec. Note: Note:

If more than 1 error scores simultaneously, only 1 error is If more than 1 error scores simultaneously, only 1 error is scoredscored

Patients unable to hold the test position for 5 seconds are Patients unable to hold the test position for 5 seconds are assigned the score of 10assigned the score of 10

Positive Test:Positive Test: Scores that are 25% ABOVE patient’s baselineScores that are 25% ABOVE patient’s baseline Impaired cerebral functionImpaired cerebral function

Clinical EvaluationClinical Evaluation Standardized Assessment of Standardized Assessment of

Concussion (SAC)Concussion (SAC) Abbreviated neuropsychological testAbbreviated neuropsychological test Immediate objective dataImmediate objective data

Presence and severity of neurocognitive Presence and severity of neurocognitive impairmentimpairment

On or off field evaluationOn or off field evaluation Tests:Tests:

OrientationOrientation Immediate Memory RecallImmediate Memory Recall ConcentrationConcentration Delayed RecallDelayed Recall

Clinical EvaluationClinical Evaluation Neuropsychological Testing:Neuropsychological Testing:

Allow ATCs to objectively quantify athlete Allow ATCs to objectively quantify athlete cognitive dysfunctioncognitive dysfunction

Tests:Tests: Hopkins Verbal Learning Test (HVLT)Hopkins Verbal Learning Test (HVLT) – 12 word list; – 12 word list;

athlete recalls several timesathlete recalls several times Brief Visuospatial Memory Test (BVMT-R)Brief Visuospatial Memory Test (BVMT-R) – visual – visual

memorymemory Trail Making TestTrail Making Test – spatial scanning, speed, cognitive – spatial scanning, speed, cognitive

flexibilityflexibility Controlled Oral Word Association Test (COWAT)Controlled Oral Word Association Test (COWAT) – –

recall as many words as possible in 1 min. (starting recall as many words as possible in 1 min. (starting with a given letter)with a given letter)

Digit Span TestDigit Span Test – repeat strings of numbers – repeat strings of numbers Symbol Digit Modalities Test (SDMT)Symbol Digit Modalities Test (SDMT) – visual scanning – visual scanning

and processing speed; match numbers/symbols under and processing speed; match numbers/symbols under pressurepressure

Clinical EvaluationClinical Evaluation Vital Signs:Vital Signs:

Respirations:Respirations: Number of breaths per minute and quality of Number of breaths per minute and quality of

respirationsrespirations Pulse:Pulse:

Pulse rate and qualityPulse rate and quality Blood pressureBlood pressure Pulse pressure:Pulse pressure:

Systolic pressure – diastolic pressureSystolic pressure – diastolic pressure Normal: 40 mm HGNormal: 40 mm HG Pulse pressure > 50 mm HG → may indicate Pulse pressure > 50 mm HG → may indicate

increased intracranial bleedingincreased intracranial bleeding

Clinical EvaluationClinical Evaluation Cranial Nerve Cranial Nerve

Assessment:Assessment: 12 nerves that emerge 12 nerves that emerge

directly from the brain directly from the brain stemstem

spinal nerves which spinal nerves which emerge from segments of emerge from segments of the spinal cordthe spinal cord

Ganglia of sensory Ganglia of sensory component → outside component → outside CNSCNS

Ganglia of motor Ganglia of motor component → within component → within CNSCNS

↑ ↑ intracranial pressure intracranial pressure impairs motor componentimpairs motor component

Cranial Cranial NerveNerve

FunctionFunction TestTest

(I) Olfactory(I) Olfactory Transmits sense of Transmits sense of smellsmell

Check athlete’s Check athlete’s ability to smellability to smell

(II) Optic(II) Optic Transmits visual Transmits visual information to information to brainbrain

Check athlete’s Check athlete’s visionvision

(III) (III) OcculomotorOcculomotor

Innervates Innervates superior, medial, superior, medial, and inferior rectus and inferior rectus muscles and muscles and inferior obliqueinferior oblique

Ask athlete to Ask athlete to elevate the eyelid, elevate the eyelid, elevate, depress, elevate, depress, and adduct the eyeand adduct the eye

(IV) (IV) TrochlearTrochlear

Innervates Innervates superior oblique superior oblique musclemuscle

Ask athlete to Ask athlete to elevate the eyeselevate the eyes

(V) (V) TrigeminalTrigeminal

Receives sensation Receives sensation from the face, from the face, innervates innervates muscles of muscles of masticationmastication

Check sensation of Check sensation of face, ask athlete to face, ask athlete to elevate, depress, elevate, depress, protrude, retrude, protrude, retrude, laterally deviate jawlaterally deviate jaw

(VI) (VI) AbducensAbducens

Innervates lateral Innervates lateral rectus musclerectus muscle

Ask athlete to Ask athlete to abduct eyesabduct eyes

Cranial Cranial Nerve Nerve

FunctionFunction TestTest

(VII) Facial(VII) Facial Motor innervation Motor innervation to muscles of facial to muscles of facial expression, expression, receives special receives special sense of taste from sense of taste from anterior 2/3 of the anterior 2/3 of the tongue, provides tongue, provides secremotor secremotor innervation to innervation to salivary glands and salivary glands and lacrimal glandlacrimal gland

Check athlete’s Check athlete’s ability to taste along ability to taste along anterior portion of anterior portion of tongue; elevate, tongue; elevate, abduct, depress abduct, depress eyebrows, open/close eyebrows, open/close eyes, dilate and eyes, dilate and constrict nostrils, constrict nostrils, open and close open and close mouth, protrude lipsmouth, protrude lips

(VIII) (VIII) VestibulocochleVestibulocochlearar

Senses sound, Senses sound, rotation, and rotation, and gravity (essential gravity (essential for balance and for balance and movement)movement)

Romberg Test, Romberg Test, athlete’s ability to athlete’s ability to hearhear

(IX) (IX) GlossopharyngGlossopharyngealeal

Receives taste from Receives taste from posterior 1/3 of posterior 1/3 of tongue, provides tongue, provides secremotor secremotor innervation to innervation to parotid glandparotid gland

Check athlete’s Check athlete’s ability to taste on ability to taste on posterior tongue and posterior tongue and have athlete swallowhave athlete swallow

Cranial Cranial NerveNerve

FunctionFunction TestTest

(X) Vagus(X) Vagus Supplies innervation to Supplies innervation to most laryngeal and most laryngeal and pharyngeal muscles, pharyngeal muscles, provides parasympathetic provides parasympathetic fibers to thoracic and fibers to thoracic and abdominal viscera, abdominal viscera, receives special sense of receives special sense of taste from epiglottistaste from epiglottis

Assess Assess athletes athletes ability to ability to breathebreathe

(XI) (XI) AccessoryAccessory

Controls muscles of neck Controls muscles of neck and overlaps with and overlaps with functions of vagus nervefunctions of vagus nerve

Ask athlete to Ask athlete to shrug shrug shouldersshoulders

(XII) (XII) HypoglossalHypoglossal

Motor innervation to Motor innervation to intrinsic muscles of the intrinsic muscles of the tonguetongue

Ask athlete to Ask athlete to stick out stick out their tonguetheir tongue