Neurological Pathology

Anatomy - CNS
Anatomy - PNS
 Meninges
3 main layers
 Dura Mater – outer
 Arachnoid – middle
 CSF
 Pia Mater – inner
Signs & Symptoms of Neurological
Problems
1. Syncope or Coma

2. Paresthesia

3. Abnormal motor control, coordination

4. Seizure
 Petit-mal vs Grand-mal
 S/S cont.
5. HA

6. Change in vision, pupils, hearing,

senses

7. Changes in mental status

8. Bowel/bladder incontinence
 Neurological Conditions
Brain Trauma
Cardiovascular event – stroke, aneurysm
Subdural or Epidural Hematoma
Post-concussion syndrome
Seizure
Epilepsy
Cerebral palsy
Spina Bifida
Multiple Sclerosis - MS
Reflex Sympathetic Dystrophy
Amyotrophic Lateral Sclerosis - ALS
Peripheral Neuropathy
Encephalitis
Meningitis
Guillain-Barre Syndrome
Spinal Cord Trauma
 Brain Trauma
Football injuries associated with the brain occur at a rate of one in every
3.5 games
More than 60,000 HS athletes suffer concussions each year
Football is responsible for more than 250,000 mild brain injuries in the
US
In any given season, 10% of all college player and 20% of HS player
sustain brain injuries
Football players with brain injuries are 6x as likely to sustain new
injuries
About 5% of soccer players sustain brain injuries as a result of their
sport
The head is involved in more baseball injuries than any other body part.
The human brain isn’t fully developed until the third decade of life
More than 50% of concussions are grade I
Fewer than 10% of concussions result in LOC
Concussions are an EVOLVING process; either (+) or (-)
Affects ALL Sports
 Brain Trauma
AKA - Mild Traumatic Brain Injury (MTBI), Cerebral Contusion (brain
bruise), Concussion

Concussion: a transient disturbance of neurological function

caused by trauma with or without LOC

Second Impact Syndrome: when a player returns to activity

before symptoms of a first concussion have completely
resolved and sustains a second blow

Post Concussion Syndrome: The presents of lingering S/S

following a concussion
 Brain Trauma
MOI: Compressive Force, Tensile Force, Rotational Force (Shearing)
Early S/S: Confusion, HA, Blurred vision, Amnesia, Nausea, Ringing in the ears, Dizziness,
Light headedness, Pupil irregularity, Drowsiness, Balance problems, Change in behavior,
Motor skill deficit
Late S/S: Sleep disturbance, Fatigue, Memory deficit, Unable to concentrate, Decrease
cognitive speed, Irritable
TX: Monitoring is the best treatment for the athlete
Hopefully compare to BASELINE neuropsychological exam
Every 5 minutes- recheck for changes
GCS- see eval form
History – previous concussions
Neurological exam
Motor function
Memory
 Brain Trauma
TX: cont
 If any signs/symptoms increase…must send in to
ER
 While monitoring, hang on to necessary
item…helmet, shoe – Whatever it takes to protect
your athlete!
 THEY ARE NOT THINKING CLEARLY!
 Brain Trauma
Return to Play Decision:
 The final decision must be after an exertional test – 40 yard dash, sit-
ups, push-ups, jumping jacks
 All S/S must be clear at rest and during exertion
 If S/S subside within 15 mins, player may return to competition
 If not gone in 15 mins or returns with exertion, no return is
allowed…need MD clearance
 Usual protocol: Once S/S have ended, hours, days, weeks…. The athlete must
stay out at least one week
 The time held out is dependent in length of experienced S/S
 Final decision is up to the MD
 Brain Trauma – Termination of
Season
Grade 1 = 3
Grade 2 = 2
Grade 3 = 1 – Cantu

Estabilish with your MD what your grading criteria is!!!!!

Areas of Concern: # 1= Loss of Consciousness

# 2= Second Impact Syndrome

# 3= Accumulative effect
 Brain Trauma – Take Home
Messages
If you do not know athlete’s baseline
neuropsychological status, it is
difficult to judge normal!

Athletes can NOT return to any

activity until ALL symptoms are
gone
 Subdural Hematoma
Venous bleeding
Several hrs to days to develop
Lucid intervals
Can be deadlier because people assume they are fine
 Epidural Hematoma
Arterial bleeding
Side effects ~ 10 mins- hour after
Pupil/vision problems
Projectile vomit
 Cardiovascular Event
STROKE
AKA – Cerebral Vascular Accident (CVA)
Caused by lack of O2 to the brain leading to reversible or
irreversible paralysis and neurological damage – d/t bld
clot or aneurysm
RED FLAGS:
 1.
 2.
 3.
 4.
 5.
 6.
 STROKE
Special Tests:
 CN testing will help determine location of brain injury
 Frankenstein test
 CT scan / MRI
 Doppler Blood tests – dye given, look and vessels for
blockage

TX: 911
 Meds – ASA
 Post-stroke rehab immediately
 Epilepsy/Seizure
Chronic condition consisting of unprovoked, randomly
reoccurring seizures
1% - 2% of population; dx after 2 seizures Result of
electrical neuronal brain dysfunction
MOI (seizure): pre-existing epilepsy, old head
trauma, brain tumor, stroke, infection, high fever
(febrile), sleep deprivation, heat stroke, drugs,
alcohol, extreme stress, most are idiopathic
TX: Protect head, left side-lying, nothing in mouth,
airway protection, O2 post
Usually last less then 5 minutes
 Seizure
Referral needed if:
> 5 mins
First seizure
Pregnant
Head injury or get injured during convulsions
ABCs not stable after
Recurrent convulsions

Are allowed to participate in almost every sport

except for inherent risk involved (water, equipment)
Must be under control 1st, understand effects of
medications on performance
 Cerebral Palsy
An anoxic, metabolic or ischemic brain injury
during birth resulting in postural deficiencies and
voluntary movement issues
Most common type is spastic – hypertonicity –
dependant on brain region damaged
 Cerebral Palsy
Not progressive and can’t be transmitted
genetically
ATCs – may encounter mild CP athletes;
may have hx of corrective surgeries,
injuries, weakness, ↓ ROM
Spina Bifida

Congenitally incomplete formation of the neural tube

(vertebral arch & Meninges)
Varying degrees, most diagnosed at birth
Impairment distal to defect
ATCs – spina bifida occulta
 Incomplete formation of the posterior vertebral arch

without herniation of meninges or cord

 Discovered with X-ray after back pain c/c, faun’s

beard, skin discoloration

 Requires core strengthening or rarely surgery
Multiple Sclerosis

Forms regions of intermittent plaques

in the CNS causing demyelization of
surrounding neuron
Affects both sensory and motor functions in no pattern;
plaques lapse and recur affecting new regions of the
CNS. Eventually causing permanent nerve damage

Most commonly appearing in early adulthood (onset 20-

40), cause unknown; no cure; females more than males

2nd to trauma in western cultures as cause of

neurological disability
 MS; cont
S/S – vary; dependant on site
 1.
 2.
 3.
 4.
 5.
 6.
Tx: symptomatic, counseling, speech therapy
 Avoid heat – makes it worse
Lifespan isn’t affected except if severely progressive
forms. Impairment becomes the issue.
Reflex Sympathetic Dystrophy
RSD – over activity of the sympathetic nervous system
after minor injury or from unknown etiology
Classic Symptom – pain out of proportion to the degree
of injury
 Usually post ligament, bone or nerve injury
 In adults – common in shoulder
 In adolescent – common in lower extremity – ankle/foot sprains

S/S: hypersensitivity to touch, ↓ ROM, prolonged injury recovery,

anxiety, depression, poor peripheral vascular control

Tx: pain control, maintain ROM, desensitize extremity

RSD, cont.
Amyotrophic Lateral Sclerosis
ALS; Lou Gehrig’s Disease
Cause unknown
Occur in middle adulthood

S/S: gradual progressive muscle weakness (motor

neurons)
 Starts c hands/arms. As progresses may notice hypersensitive
reflexes, ↓speech, ↓ swallowing, then breathing

Tx: maintain function as long as possible

No cure and most die within 3 years d/t respiratory

failure
 Peripheral Neuropathy
Generic term for peripheral nerve damage

Only affects peripheral nerves

Causes: diabetes, trauma, toxicity,

infection

Tx: recovery depends on disorder

 Encephalitis
“Inflammation of the brain”
Cause – viral infection or by immunizations or vaccines
Primary vs Secondary

S/S: within 5-15 days after bite. Fever, HA, vomit,

photophobia, stiff neck/back, clumsiness, irritable, rash,
seizure, memory loss, coma
Tx: Viral? Antiviral meds – Acyclovir – early
Treat symptoms, recovery dependant on severity
 Meningitis
Inflammation of the meninges and CSF around
the brain & cord
Viral vs Bacterial

S/S: malaise, upper respiratory infection, sudden

high fever, HA, cervical rigidity (+) Kernigs &
Brudzinski’s sign (bacterial will also have
hypotension, tachycardia, tachypnea, myalgia)
Tx: Viral – supportive Bacterial - antibiotics
 Guillain-Barre´ Syndrome
Acquired demyelinating polyneuropathy
Affects the spinal roots and peripheral nerves
Acute, progressive & severe
Cause- some lymphocytes produce antibodies
against components of the myelin sheath
disrupting nerve conduction
S/S: sudden onset of disabling weakness in both
legs, progresses to arms, loss of deep tendon
reflexes, no fever, hx of recent viral URI, rapid
loss of respiratory function
Tx: no cure, rarely recover completely
 Spinal Cord Trauma
Complete vs incomplete

Complete - All voluntary and autonomic function distal to

the injury is immediately and permanently lost

Secondary: contusion, edema,

compression within the cord, may
Decrease rapidly c steroid admin.
After acute injury (spinal shock),
assessment of function loss
takes place
 Neurological Evaluation
Cranial Nerves
I – Olfactory
II – Optic
III – Oculomotor
IV – Trochlear
V – Trigeminal
VI – Abducens
VII – Facial
VII – Vestibulocochlear
IX – Glossopharyngeal
X – Vagas
XI – Accessory
XII - Hypoglossal
 Neurological Exam
Dermatomes
 Neurological Exam
Myotome
 C1—cervical flexion
 C2—cervical flexion & rotation
 C3—lateral flexion
 C4—shoulder shrug
 C5—abduction
 C6—Biceps-elbow flx
 C7—Triceps-elbow ext
 C8—Finger flx
 T1—Finger abduction
 T2 – T9: intercostals
 T10: Rectus abdominus
 T 11: Internal Obliques
 T12: External Obliques
 L1: Quadratus Lumborus & hip flx
 L2: Iliopsoas
 L3: knee ext & adductors
 L4: Tibialis Anterior
 L5: Ext hall longus & glut med
 S1: Gastroc/Soleus, peroneals & glut max
 S2: Flx hall longus
 Neurological Exam
Reflexes
 Neurological Exam
Inspection – Posturing
Evaluate – mood, coordination, mental
function, balance
Tinel’s
Beevor’s Sign - Abdonimal
Kernig’s Sign/Brudzinski’s Sign