Fiu head and neck

Head and NeckHead and Neck
Orthopedic Assessment III – Head,Orthopedic Assessment III – Head,
Spine, and Trunk with LabSpine, and Trunk with Lab
PET 5609CPET 5609C

Clinical AnatomyClinical Anatomy

 Brain: CerebrumBrain: Cerebrum
 Largest section of brain (most anterior andLargest section of brain (most anterior and
superior region of CNS)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

 Brain: CerebrumBrain: Cerebrum
 Functions:Functions:
 Motor functionMotor function
 Sensory information:Sensory information:
 TemperatureTemperature
 TouchTouch
 PainPain
 PressurePressure
 ProprioceptionProprioception
 Special senses:Special senses:
 VisualVisual
 AuditoryAuditory
 Olfactory and tasteOlfactory and taste
 Functions (cont.)Functions (cont.)
 Cognition:Cognition:
 Spatial relationshipsSpatial relationships
 BehaviorBehavior
 MemoryMemory
 AssociationAssociation
 Communication:Communication:
 Right hemisphere →Right hemisphere →
controls left side of bodycontrols left side of body
 Left hemisphere →Left hemisphere →
controls right side ofcontrols right side of
bodybody

 Brain: CerebellumBrain: Cerebellum
 Quick processor of incoming/outgoingQuick processor of incoming/outgoing
information:information:
 Integrates sensory perception, coordination andIntegrates sensory perception, coordination and
motor control: Cerebellum → linked to cerebralmotor control: Cerebellum → linked to cerebral
motor cortex (sends info to muscles) andmotor cortex (sends info to muscles) and
spinocerebellar tract (proprioceptive feedback)spinocerebellar tract (proprioceptive feedback)
 Constant feedback on body position → fine tunesConstant feedback on body position → fine tunes
motor movementsmotor movements
 Key: Maintains BALANCE and COORDINATIONKey: Maintains BALANCE and COORDINATION

 Brain: DiencephalonBrain: Diencephalon
 Processing center forProcessing center for
conscious andconscious and
unconscious brainunconscious brain
inputinput
 Parts:Parts:
 ThalamusThalamus
 HypothalamusHypothalamus
 EpithalamusEpithalamus

 Brain: ThalamusBrain: Thalamus
 TranslatesTranslates
information (inputs)information (inputs)
for cerebral cortexfor cerebral cortex
 Processes andProcesses and
relays sensoryrelays sensory
informationinformation
 Helps regulateHelps regulate
states/levels ofstates/levels of
sleep andsleep and
consciousnessconsciousness

Hypothalamic RegulationHypothalamic Regulation Posterior PituitaryPosterior Pituitary EffectEffect
Neurosecratory NeuronNeurosecratory Neuron Vasopressin (ADH)Vasopressin (ADH) Water RetentionWater Retention
Neurosecratory NeuronNeurosecratory Neuron OxytocinOxytocin Milk ejection (mammaryMilk ejection (mammary
gland)gland)
Hypothalamic RegulationHypothalamic Regulation Anterior PituitaryAnterior Pituitary EffectEffect
Thyrotropin ReleasingThyrotropin Releasing
HormoneHormone
ThyrotropinThyrotropin Involved Thyroxin fromInvolved Thyroxin from
Thyroid GlandThyroid Gland
Corticotropin ReleasingCorticotropin Releasing
HormoneHormone
AdrenocorticotrophicAdrenocorticotrophic
HormoneHormone
Cortisol Release (adrenalCortisol Release (adrenal
gland)gland)
Growth-Hormone ReleasingGrowth-Hormone Releasing
HormoneHormone
GHGH Whole body growthWhole body growth
Gonadotropin ReleasingGonadotropin Releasing
HormoneHormone
FSH, LHFSH, LH Reproductive functionReproductive function
Prolactin ReleasingProlactin Releasing
HormonesHormones
ProlactinProlactin Milk productionMilk production
MSH Releasing FactorMSH Releasing Factor Melanocyte StimulatingMelanocyte Stimulating
HormoneHormone
Skin pigmentsSkin pigments

 Brain: HypothalamusBrain: Hypothalamus
 Control of Hydration: Supraoptic nuclei andControl of Hydration: Supraoptic nuclei and
Paraventricular nuclei (Hypothalamus)Paraventricular nuclei (Hypothalamus)
 What Happens?What Happens?
 Hydration Level too LOWHydration Level too LOW
 Osmoreceptors in blood detect increased concentration of saltOsmoreceptors in blood detect increased concentration of salt
in bloodin blood
 Hypothalamus stimulated – neurosecratory hormonesHypothalamus stimulated – neurosecratory hormones
 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

 Brain: Brain StemBrain: Brain Stem
 Lower part of the brain (continuousLower part of the brain (continuous
with spinal cord)with spinal cord)
 Medulla OblongataMedulla Oblongata
 PonsPons
 Main motor and sensoryMain motor and sensory
innervation to face and neckinnervation to face and neck
 Cranial nervesCranial nerves
 Regulation of cardiac andRegulation of cardiac and
respiratory function (medulla)respiratory function (medulla)
 Relays information to and from theRelays information to and from the
CNSCNS
 Pons: Link between cerebellum toPons: Link between cerebellum to
brain stem and spinal cordbrain stem and spinal cord

 Brain: MeningesBrain: Meninges
 3 connective tissue layers which protect the CNS3 connective tissue layers which protect the CNS
 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 arachnoid materSubdural space – area between dura mater and arachnoid mater
 Subarachnoid space – beneath the arachnoidSubarachnoid space – beneath the arachnoid
 Contains cerebrospinal fluidContains cerebrospinal fluid

 Cerebrospinal Fluid:Cerebrospinal Fluid:
 Clear, colorless liquid thatClear, colorless liquid that
bathes the brain andbathes the brain and
spinal cord (circulatesspinal cord (circulates
within subarachnoidwithin subarachnoid
space)space)
 Cushions the brain withinCushions the brain within
the skullthe skull
 Shock absorber for the CNSShock absorber for the CNS
 Circulates nutrients andCirculates nutrients and
chemicals filtered from thechemicals filtered from the
blood and removes wasteblood and removes waste
products from the brainproducts from the brain

 Brain blood demand:Brain blood demand:
 20% of body’s O2 uptake20% of body’s O2 uptake
at restat rest
 ↑↑ 1100
Celsius, brainsCelsius, brains
demand ↑ 7%demand ↑ 7%
 Supplying vessels:Supplying vessels:
 Vertebral arteriesVertebral arteries
 Carotid arteries:Carotid arteries:
 InternalInternal
 ExternalExternal
 Circle of WillisCircle of Willis

Clinical EvaluationClinical Evaluation
 Key Points:Key Points:
 All unconscious athletes must be managed as ifAll unconscious athletes must be managed as if
a fracture or dislocation of the cervical spinea fracture or dislocation of the cervical spine
exists until the presence of these injuries can beexists until the presence of these injuries can be
definitively ruled outdefinitively ruled out
 Ideally, 2 responders are available to evaluate:Ideally, 2 responders are available to evaluate:
 In-line stabilization and immobilization of athlete’sIn-line stabilization and immobilization of athlete’s
headhead
 Initial evaluation:Initial evaluation:
 PalpationPalpation
 Sensory and motor testsSensory and motor tests

 Initial Evaluation:Initial Evaluation:
 Assess ABC’s:Assess ABC’s: (airways, breathing, circulation)(airways, breathing, circulation)
 Moving, speaking athlete → ABC’s presentMoving, speaking athlete → ABC’s present
 Still suspect cervical spine injury (until ruled out)Still suspect cervical spine injury (until ruled 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

 Initial Evaluation:Initial Evaluation:
 Primary Survey:Primary Survey:
 Look, listen, feel forLook, listen, feel for
breathingbreathing
 Absent breathing →Absent breathing →
modified jaw thrust to openmodified jaw thrust to open
airwayairway
 Absent pulse → CPRAbsent pulse → CPR
 Initiate EMS!Initiate EMS!
 Secondary Survey:Secondary Survey:
 BleedingBleeding
 Possible fractures, dislocationsPossible fractures, dislocations

 History:History:
 Location ofLocation of
symptoms:symptoms:
 Cervical pain orCervical pain or
muscle spasm:muscle spasm:
 PainPain
 NumbnessNumbness
 BurningBurning
 Head pain:Head pain:
 HeadachesHeadaches
AreaArea Signs and SymptomsSigns and Symptoms
BrainBrain AmnesiaAmnesia
Confusion and DisorientationConfusion and Disorientation
Irritability and UncoordinationIrritability and Uncoordination
DizzinessDizziness
HeadacheHeadache
OcularOcular Blurred vision and PhotophobiaBlurred vision and Photophobia
NystagmusNystagmus
EarsEars TinnitusTinnitus
DizzinessDizziness
StomachStomach NauseaNausea
VomitingVomiting
SystemicSystemic Unusually fatiguedUnusually fatigued

 Mechanism of Injury: HeadMechanism of Injury: Head
 Coup Injury:Coup Injury:
 Stationary skull is hit by objectStationary skull is hit by object
traveling at high velocity (i.e. hit intraveling at high velocity (i.e. hit in
head with baseball)head with baseball)
 Trauma → side of head whereTrauma → side of head where
contact occurredcontact occurred
 Contrecoup Injury:Contrecoup Injury:
 Skull is moving at high velocitySkull is moving at high velocity
and is suddenly stopped (i.e.and is suddenly stopped (i.e.
falling and hitting head on thefalling and hitting head on the
ground)ground)
 Brain strikes the skull on sideBrain strikes the skull on side
opposite of the impactopposite of the impact

 Mechanism of Injury:Mechanism of Injury:
HeadHead
 RepeatedRepeated
subconcussive forces:subconcussive forces:
 Repeated trauma:Repeated trauma:
 BoxingBoxing
 Heading in soccerHeading in soccer
 Rotational or shearRotational or shear
forces:forces:
 TwistingTwisting
 Acceleration andAcceleration and
decelerationdeceleration

 Mechanism of Injury: Cervical spineMechanism of Injury: Cervical spine
 Most forces → dissipated by cervicalMost forces → dissipated by cervical
musculature and intervertebral discsmusculature and intervertebral discs
 Flexion, extension, lateral bending, rotationFlexion, extension, lateral bending, rotation
 Flexion:Flexion:
 Removes natural lordotic curvature (30 degrees)Removes natural lordotic curvature (30 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

 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

 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 cervical vertebraeLaterally flexed and rotated head → possible cervical vertebrae
dislocationdislocation
 Cervical vertebrae:Cervical vertebrae:
 View athlete from behind (positioning of spinous processes)View athlete from behind (positioning of spinous 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

 Inspection: EyesInspection: Eyes
 General:General:
 Dazed, distant stare may indicateDazed, distant stare may indicate
mental confusionmental confusion
 Nystagmus:Nystagmus:
 Involuntary cyclical movement of theInvoluntary cyclical movement of the
eyeseyes
 Pupil size:Pupil size:
 Unilateral dilation (pressure on cranialUnilateral dilation (pressure on cranial
nerve III)nerve III)
 Note: Anisocoria (normal unequal pupilNote: Anisocoria (normal unequal pupil
size)size)
 Pupil reaction to lightPupil reaction to light

 Inspection: NoseInspection: Nose
and Earsand Ears
 Ears:Ears:
 Bleeding and/orBleeding and/or
cerebrospinal fluidcerebrospinal fluid
 Skull fractureSkull fracture
 Nose:Nose:
 BleedingBleeding
 Nose fracture or skullNose fracture or skull
fracturefracture
 Nose/eyes:Nose/eyes:
 Raccoon eyes → skullRaccoon eyes → skull
or nasal fractureor nasal fracture

 Palpation: BonyPalpation: Bony
StructuresStructures
 Spinous Processes:Spinous Processes:
 Patient seated, leaningPatient seated, leaning
slightly forwardslightly forward
 C7 andC7 and ↑↑
 Transverse ProcessesTransverse Processes
 Skull:Skull:
 Occipital and temporalOccipital and temporal
 Sphenoid and zygomaticSphenoid and zygomatic
 Parietal and frontalParietal and frontal
 Palpation: Soft TissuePalpation: Soft Tissue
 Musculature:Musculature:
 TrapeziusTrapezius
 SCMSCM
 ThroatThroat

 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 the fluidUsing the point of the gauze, collect a sample of the fluid
leaking from the ear or nose (allow it to be absorbed)leaking from the ear or nose (allow it to 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

 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 injuryInability to recall events after injury
 Fading memory → progressive deterioration ofFading memory → progressive deterioration of
cerebral functioncerebral function

ATHLETE POSITION:ATHLETE POSITION: On-field: athlete’s current positionOn-field: athlete’s current position
Sideline: standing, seatedSideline: standing, seated
EXAMINEREXAMINER
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 injuryAsk patient series of questions beginning with the time of the injury
Each successive question progresses backward in timeEach successive question progresses backward in time
What happened? What play were you running?What happened? What play were you 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 occurring before theAthlete has difficulty remembering or cannot remember events occurring before the
injuryinjury
IMPLICATIONS:IMPLICATIONS: Retrograde amnesia:Retrograde amnesia:
Not remembering events from the day before is more significant that notNot remembering events from the day before is more significant that not
remembering more recent eventsremembering more recent events
The same set of questions should be repeated to determine whether memoryThe same set of questions should be repeated to determine whether memory
is returning, deteriorating, or staying the sameis returning, deteriorating, or staying the same
Further deterioration of memory or acutely profound memory loss warrantsFurther deterioration of memory or acutely profound memory loss warrants
immediate termination of evaluation and transportation to emergency medicalimmediate termination of evaluation and transportation to emergency medical
facilityfacility
COMMENTS:COMMENTS: Record patient’s responses and verify answers with coaches/teammatesRecord patient’s responses and verify answers with coaches/teammates

PATIENT POSITION:PATIENT POSITION: Sitting or standingSitting or standing
EXAMINEREXAMINER
POSITION:POSITION:
Positioned to hear athlete’s responsePositioned to hear athlete’s response
EVALUATION:EVALUATION: Athlete is given a list of 4 unrelated items (ask them toAthlete is given a list of 4 unrelated items (ask them to
memorize the list)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 of intracranialAnterograde amnesia, possibly the result of intracranial
bleedingbleeding
COMMENT:COMMENT: Perform the test after test for retrograde amnesiaPerform the test after test for retrograde amnesia
Clinical Evaluation: Anterograde Amnesia

 Functional Testing: Cognitive FunctionFunctional Testing: Cognitive Function
 Cerebral trauma → Unusual athlete behaviorCerebral trauma → Unusual athlete behavior
 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?

 Balance and Coordination:Balance and Coordination:
 Affected secondary to trauma involvingAffected secondary to trauma involving
cerebellum and inner earcerebellum and inner ear
 Tests:Tests:
 Romberg TestRomberg Test
 Tandem WalkingTandem Walking
 Balance Error Scoring SystemBalance Error Scoring System

 Romberg Test:Romberg Test:
 Patient Position:Patient Position:
 Standing, feet shoulder width apartStanding, feet shoulder width apart
 ATC Position:ATC Position:
 Ready to support patientReady to support patient
 Patient shuts eyes and abducts arms toPatient shuts eyes and abducts arms to
909000
 Patient tilts head backwards and lifts 1Patient tilts head backwards and lifts 1
foot off groundfoot off ground
 Patient touches index finger to nosePatient touches index finger to nose
(eyes closed)(eyes closed)
 Positive Test:Positive Test:
 Patient unsteadinessPatient unsteadiness
 Cerebellar dysfunctionCerebellar dysfunction

 Tandem Walking:Tandem Walking:
 Athlete standing with feet straddling a straight lineAthlete standing with feet straddling a straight line
 Beside patient to provide supportBeside patient to provide support
 Evaluation:Evaluation:
 Athlete walks heel-to-toe along a straight line for approximatelyAthlete walks heel-to-toe along a straight line for approximately
10 yards10 yards
 Athlete returns to starting position by walking backwardsAthlete returns to starting position by walking backwards
 Athlete unable to maintain a steady balanceAthlete unable to maintain a steady balance
 Cerebral or inner ear dysfunction that inhibits balanceCerebral or inner ear dysfunction that inhibits balance

 Balance Error Scoring System:Balance Error Scoring System:
 Patient barefoot or wearing socks (no tape); handsPatient barefoot or wearing socks (no tape); hands
on iliac crest; eyes closedon iliac crest; eyes closed
 Phase 1:Phase 1:
 Double Leg StanceDouble Leg Stance
 Single Leg Stance – standing on the nondominant leg; non-Single Leg Stance – standing on the nondominant leg; non-
weight-bearing hip flexed to 20weight-bearing hip flexed to 2000
and knee flexed to 40and knee flexed to 4000
-50-5000
 Tandem Leg Stance – nondominant leg placed behind theTandem Leg Stance – nondominant leg placed behind the
dominant leg and the patient stands in a heel-toe mannerdominant leg and the patient stands in a heel-toe manner

 In front of the athlete; trials are timedIn front of the athlete; trials are timed
 First battery performed with athlete standing on aFirst battery performed with athlete standing on a
firm surfacefirm 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 standing onSecond battery performed with athlete standing on
foamfoam

 Scoring:Scoring: One point is scored for each of the following errorsOne point is scored for each of the following 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 scoredIf more than 1 error scores simultaneously, only 1 error is scored
 Patients unable to hold the test position for 5 seconds are assigned thePatients unable to hold the test position for 5 seconds are assigned the
score of 10score of 10
 Scores that are 25% ABOVE patient’s baselineScores that are 25% ABOVE patient’s baseline
 Impaired cerebral functionImpaired cerebral function

 Standardized Assessment of Concussion (SAC)Standardized Assessment of Concussion (SAC)
 Abbreviated neuropsychological testAbbreviated neuropsychological test
 Immediate objective dataImmediate objective data
 Presence and severity of neurocognitive impairmentPresence and severity of neurocognitive impairment
 On or off field evaluationOn or off field evaluation
 Tests:Tests:
 OrientationOrientation
 Immediate Memory RecallImmediate Memory Recall
 ConcentrationConcentration
 Delayed RecallDelayed Recall

 Neuropsychological Testing:Neuropsychological Testing:
 Allow ATCs to objectively quantify athlete cognitiveAllow ATCs to objectively quantify athlete cognitive
dysfunctiondysfunction
 Tests:Tests:
 Hopkins Verbal Learning Test (HVLT)Hopkins Verbal Learning Test (HVLT) – 12 word list; athlete– 12 word list; athlete
recalls several timesrecalls several times
 Brief Visuospatial Memory Test (BVMT-R)Brief Visuospatial Memory Test (BVMT-R) – visual memory– visual memory
 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– recall as
many words as possible in 1 min. (starting with a given letter)many words as possible in 1 min. (starting 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 and– visual scanning and
processing speed; match numbers/symbols under pressureprocessing speed; match numbers/symbols under pressure

 Vital Signs:Vital Signs:
 Respirations:Respirations:
 Number of breaths per minute and quality of respirationsNumber of breaths per minute and quality of respirations
 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 increasedPulse pressure > 50 mm HG → may indicate increased
intracranial bleedingintracranial bleeding

 Cranial Nerve Assessment:Cranial Nerve Assessment:
 12 nerves that emerge12 nerves that emerge
directly from the brain stemdirectly from the brain stem
 spinal nerves which emergespinal nerves which emerge
from segments of the spinalfrom segments of the spinal
cordcord
 Ganglia of sensoryGanglia of sensory
component → outside CNScomponent → outside CNS
 Ganglia of motorGanglia of motor
component → within CNScomponent → within CNS
 ↑↑ intracranial pressureintracranial pressure
impairs motor componentimpairs motor component

Cranial NerveCranial Nerve FunctionFunction TestTest
(I) Olfactory(I) Olfactory Transmits sense of smellTransmits sense of smell Check athlete’s ability toCheck athlete’s ability to
smellsmell
(II) Optic(II) Optic Transmits visualTransmits visual
information to braininformation to brain
Check athlete’s visionCheck athlete’s vision
(III) Occulomotor(III) Occulomotor Innervates superior,Innervates superior,
medial, and inferiormedial, and inferior
rectus muscles andrectus muscles and
inferior obliqueinferior oblique
Ask athlete to elevate theAsk athlete to elevate the
eyelid, elevate, depress,eyelid, elevate, depress,
and adduct the eyeand adduct the eye
(IV) Trochlear(IV) Trochlear Innervates superiorInnervates superior
oblique muscleoblique muscle
Ask athlete to elevate theAsk athlete to elevate the
eyeseyes
(V) Trigeminal(V) Trigeminal Receives sensation fromReceives sensation from
the face, innervatesthe face, innervates
muscles of masticationmuscles of mastication
Check sensation of face,Check sensation of face,
ask athlete to elevate,ask athlete to elevate,
depress, protrude, retrude,depress, protrude, retrude,
laterally deviate jawlaterally deviate jaw
(VI) Abducens(VI) Abducens Innervates lateral rectusInnervates lateral rectus
musclemuscle
Ask athlete to abduct eyesAsk athlete to abduct eyes

(VII) Facial(VII) Facial Motor innervation toMotor innervation to
muscles of facialmuscles of facial
expression, receivesexpression, receives
special sense of taste fromspecial sense of taste from
anterior 2/3 of the tongue,anterior 2/3 of the tongue,
provides secremotorprovides secremotor
innervation to salivaryinnervation to salivary
glands and lacrimal glandglands and lacrimal gland
Check athlete’s ability toCheck athlete’s ability to
taste along anterior portiontaste along anterior portion
of tongue; elevate, abduct,of tongue; elevate, abduct,
depress eyebrows,depress eyebrows,
open/close eyes, dilate andopen/close eyes, dilate and
constrict nostrils, open andconstrict nostrils, open and
close mouth, protrude lipsclose mouth, protrude lips
(VIII)(VIII)
VestibulocochlearVestibulocochlear
Senses sound, rotation,Senses sound, rotation,
and gravity (essential forand gravity (essential for
balance and movement)balance and movement)
Romberg Test, athlete’sRomberg Test, athlete’s
ability to hearability to hear
(IX)(IX)
GlossopharyngealGlossopharyngeal
Receives taste fromReceives taste from
posterior 1/3 of tongue,posterior 1/3 of tongue,
provides secremotorprovides secremotor
innervation to parotidinnervation to parotid
glandgland
Check athlete’s ability toCheck athlete’s ability to
taste on posterior tonguetaste on posterior tongue
and have athlete swallowand have athlete swallow

(X) Vagus(X) Vagus Supplies innervation to mostSupplies innervation to most
laryngeal and pharyngeal muscles,laryngeal and pharyngeal muscles,
provides parasympathetic fibers toprovides parasympathetic fibers to
thoracic and abdominal viscera,thoracic and abdominal viscera,
receives special sense of taste fromreceives special sense of taste from
epiglottisepiglottis
Assess athletesAssess athletes
ability to breatheability to breathe
(XI) Accessory(XI) Accessory Controls muscles of neck andControls muscles of neck and
overlaps with functions of vagusoverlaps with functions of vagus
nervenerve
Ask athlete toAsk athlete to
shrug shouldersshrug shoulders
(XII)(XII)
HypoglossalHypoglossal
Motor innervation to intrinsicMotor innervation to intrinsic
muscles of the tonguemuscles of the tongue
Ask athlete toAsk athlete to
stick out theirstick out their
tonguetongue

Fiu head and neck

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