Head and Neck Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C.
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Transcript of Head and Neck Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C.
Head and Head and NeckNeck
Orthopedic Assessment III Orthopedic Assessment III – Head, Spine, and Trunk – Head, Spine, and Trunk
with Labwith Lab
PET 5609CPET 5609C
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 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 Olfactory and
tastetaste
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 cerebral motor cortex (sends info to muscles) and spinocerebellar tract muscles) and spinocerebellar tract (proprioceptive feedback)(proprioceptive 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
Brain: Brain: DiencephalonDiencephalon Processing Processing
center for center for conscious and 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
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 (continuous with spinal cord)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 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 Circulates nutrients
and chemicals filtered and chemicals filtered from the blood and from the blood and removes waste removes waste products from the 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
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 Symptoms
BrainBrain AmnesiaAmnesia
Confusion and Confusion and DisorientationDisorientation
Irritability and Irritability and UncoordinationUncoordination
DizzinessDizziness
HeadacheHeadache
OcularOcular Blurred vision and Blurred vision and PhotophobiaPhotophobia
NystagmusNystagmus
EarsEars TinnitusTinnitus
DizzinessDizziness
StomachStomach NauseaNausea
VomitingVomiting
SystemicSystemic Unusually fatiguedUnusually fatigued
Clinical EvaluationClinical Evaluation
Mechanism of Injury: Mechanism of Injury: HeadHead Coup Injury:Coup Injury:
Stationary skull is hit by Stationary skull is hit by object traveling at high object traveling at high velocity (i.e. hit in head with velocity (i.e. hit in head with baseball)baseball)
Trauma → side of head where Trauma → side of head where contact occurredcontact occurred
Contrecoup Injury:Contrecoup Injury: Skull is moving at high Skull is moving at high
velocity and is suddenly velocity and is suddenly stopped (i.e. falling and stopped (i.e. falling and hitting head on the ground)hitting head on the ground)
Brain strikes the skull on side Brain strikes the skull on side opposite of the impactopposite of the impact
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 Axial load → through vertical axis of vertebral
columncolumn Catastrophic injuriesCatastrophic injuries
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 Trauma to brain, spinal cord, spinal nerve
rootsroots
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, seated
EXAMINER 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 injuryinjury
Each 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 Tandem Leg Stance – nondominant leg
placed behind the dominant leg and the placed behind the dominant leg and the patient stands in a heel-toe mannerpatient stands 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 If more than 1 error scores simultaneously, only 1 error is scoredis scored
Patients unable to hold the test position for 5 seconds Patients unable to hold the test position for 5 seconds are assigned the score of 10are assigned 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, – spatial scanning, speed,
cognitive flexibilitycognitive flexibility 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 – visual
scanning and processing speed; match scanning and processing speed; match numbers/symbols under pressurenumbers/symbols under pressure
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