Making Sense of the Cranial Nerves: 3 SHORT FILMS

Cranial nerve testing should be within the skill set of ALL clinicians who treat neck, head and orofacial presentations.

Most clinicians are well versed and confident with neurological testing of the upper and lower limbs as well as upper motor neuron tests. However, when it comes to what is arguably the riskiest of anatomical regions, the head and neck ... there appears to be a strong suggestion that history and education have not prepared physiotherapists well for this.

The harsh reality is that many #Physios report that:

1. They were not taught CN’s at University

2. If they were, they are a little rusty with application and interpretation

3. It’s not something they do very often, and the tests are really hard to recall

Indeed a recent Twitter poll revealed that 53% of respondents suggested that they had not been taught these skills at University. Of those that had, over 50% suggested that they were not comfortable with applying them and interpreting the tests in clinical practice.

This is perhaps a little alarming for a profession which is championing the concepts of FCP and ACP roles within healthcare. There is a mismatch here, and a clear need to improve understanding, education and competencies. But it is not just FCP’s & ACP’s who need these skills. They are easily attainable for any clinician, and can easily be understood and applied from UG level. BUT DON'T FEEL BAD ... I think perhaps the educational system in some places (not all), has let us all down, and I agree entirely, the CN's are a bit complex and do at first provide a challenge to learn.

The missing links are often context, understanding, working knowledge and the application of clinical reasoning.

That is why I've put together 3 short films in the 'Fireside CPD Sessions' series, to help make sense of the cranial nerves, their functions + when and how we might test them.

FILM 1. Cranial Nerves: A Clinical Reasoning Guide

An opportunity to get to know the cranial nerves and their functions from a clinical reasoning perspective.

FILM 2. Cranial Nerves: Subjective questioning - A SHORT FILM

This short film is designed to introduce the cranial nerves and consider the subjective questions (that we often don't ask) that might lead us to test them in the clinical situation.

FILM 3. How to remember the Cranial Nerves: A Function Based Approach - A SHORT FILM This short, tongue in cheek, ‘Fireside CPD’ film, draws upon story telling, and offers an inventive and fun method of recalling the FUNCTIONS of the cranial nerves. Pull up a chair, open a bottle, or make a nice cuppa and enjoy a fun and inventive way to remember the cranial nerves based on FUNCTION.

These films should provide a solid base for all clinicians who wish to familiarise themselves with the cranial nerves, gain a basic understanding of their function, AND develop an easy method for recalling the tests.

ENJOY! For more on the Cranial Nerves, go to: http://alteredhaemodynamics.blogspot.... For a 'Cranial Nerves Country Song' ... go to: https://www.youtube.com/watch?v=WgjyE... Look out for 'Cervical Spine: Risk & Rehabilitation for Clinicians' ONLINE COURSE (2021)

Andrew Marr's "exercise induced stroke" ...What have we to learn?

Andrew Marr; a case of exercise induced stroke?

Well-known political commentator Andrew Marr, recently told the story of his sudden stroke. It seems that Marr was of the belief that his stroke was ‘exercise induced’ … alarming news indeed, so alarming that the topic made the Jeremy Vine show on Radio 2! So how did he come to that conclusion I hear you ask? Marr explained that he had suffered two 'mini-strokes' – or transient ischaemic attacks – the year before, but that he "hadn't noticed" (presumably revealed by subsequent scans). He went on to make the suggestion that his stroke was triggered by a vigorous rowing machine exercise bout, that he was undergoing in response to newspaper reports relating to the benefit of high intensity training (HIT).........

Carotid artery dissection

So what happened? Well all we can say, is that Marr reported how he felt the symptoms of his stroke (“blinding head ache and flashes of light”) following the exercise where he said he "gave it everything I had" in the belief that this would benefit his health. He described how he had “torn the carotid artery, which takes the blood supply to the brain”. In other words he had suffered an arterial dissection with embolisation. He woke the next morning with what was essentially an ischaemic stroke........

NHS response

There has been much commentary since the interview and the NHS have been quick to respond and reassure patients in a factual way. Is-exercise-to-blame-for-Andrew-Marrs-stroke?

.......... Indeed, some ‘experts’ have made the suggestion that there may not have been a link between the two events. Marr had explained some of his life style risk factors such as his high-pressure job, previous smoking and a history of being overweight. So it is of course plausible that his carotid arteries were already showing signs of atherosclerotic pathology. Was there a link? Well it is impossible to say for sure, but stroke sufferers commonly report headache, neck pain and visual disturbances as their primary symptoms and this is well documented in the literature........

IFOMPT guidance on risk

The significance of this event to physiotherapists is multifactorial. As prescribers of exercise we have to have an understanding of what happened and be able to risk assess and advise patients accordingly. It illustrates also that we must consider the holistic health of patients too as part of a risk assessment strategy and this is supported by the recent IFOMPT cervical spine document. 

Cranial nerve examination?

Indeed it is feasible for such a patient (pre-ischaemia) to walk into a physiotherapy out patient department seeking treatment for their “head ache” (Marr had a window between the onset of his symptoms and his eventual stroke).  Only careful consideration of their symptoms and physical examination, to include blood pressure and cranial nerve testing, may reveal the true nature of the underlying pathology. 

Remember the acronym FAST (face, arms, speech, time – full details on the NHS website) and don’t forget to include the cranial nerves in your examination.

So, is HIT harmful?

Well the jury remains out on that one, though the balance of evidence suggests not. Whilst it would be bad science to use a single case study to promote a knee jerk reaction, Marr’s experience certainly raises the debate and once again raises the spectre of heterogeneity. 

The key message

If those commentators are right; and this was simply a stroke that was 'waiting to happen'. Then you truly never know, quite who or what might be lying on your treatment table ... Happy risk assessment! 

The author  

..... has written over 20 peer reviewed papers relating to blood flow issues related to manual therapy, his work has been cited in the IFOMPT International Framework for Examination of the Cervical Region for potential of Cervical Arterial Dysfunction prior to Orthopaedic Manual Therapy Intervention

Altered haemodynamics

Follow on twitter@TaylorAlanJ