Case Study - Rehabilitation of Post Concussion Syndrome

Introduction

As a condition that has become increasingly researched and well-understood in recent years, post-concussion syndrome is something that all physiotherapists should be familiar with and prepared to treat. Post-concussion syndrome describes persistent cognitive and physical symptoms beyond the typical 1-3 month period during which most concussions recover. As the literature has developed, it has become recognized that 10-30% of mild head trauma may result in symptoms that last for months to years. With this in mind, physiotherapists must be vigilant in recognizing when a patient is likely experiencing the condition.


This page outlines a case study of a 19-year old female athlete experiencing concussion, and subsequently post-concussion syndrome. The patient presents in a complex manner as she has experienced several recent concussions prior to the one in question. During the case, she develops persistent symptoms and psychosocial comorbidities that – as suggested in the literature – make diagnosis and treatment more complicated. The purpose of this case study is to provide an overview of the condition and its broad range of possible symptoms, describe a unique presentation of the condition, discuss assessment methods, and present relevant treatment approaches used to achieve the patient’s goal of returning to school and sport.

Client Characteristics

A 19-year old female playing for Team Ontario ringette suffered a contre-coup blow to the head during a scrimmage in practice. The patient collided with another teammate, crashing head-first into the ice. Initially, she did not feel any different other than experiencing some dizziness, but reported that she began experiencing extreme nausea, vomiting, headache, dizziness and double vision the following day. Over the next two weeks, she was closely monitored by doctors while attempting to continue living in residence at university, however she was sent home following an increase of 10 points in her SCAT5 symptom score from day 1 post-injury to day 14. Once at home, she was dark roomed for long periods of time until deemed stable to return to school. She experienced several relapses in her recovery and often experienced fainting spells lasting as long as one hour from continuous studying and attempts at physical activity.

She reported that she had previously suffered three concussions in the last 8 months. She noted that her recovery time has increased from the first concussion (1 week) to the third concussion (1 month), however each time she followed a return to play protocol set out by her coaches. Since her concussion symptoms have been present and persisting for over 3 months prior to the initial assessment with the author, she was therefore diagnosed with Post-Concussion Syndrome (PCS) by her sports medicine doctor. She has decided to attempt physiotherapy upon request from her doctor to see if she can reduce her symptoms and increase her quality of life.

Intervention

The treatment program was designed based on the patients assessment findings and will be completed to the patients level of tolerance, following a similar protocol to Fowler-Kennedy Guidelines. These should not exceed patients limitations and should not cause the reproduction of the patients symptoms or fatigue in the first few sessions.

1) Range of Motion Exercises – unidirectional and/or combined movements

• AROM flexion, extension, rotation and side flexion, chin tucks
• Progress to isometric exercises

2) Mobilizations – as per assessment findings

3) Deep Neck Flexor (DNF) training  Can be performed in multiple positions

1) sitting (with/without head support)

2) supine

3) 4-point kneeling.

• Can be progressed to involve DNE recruitment

4) Deep Neck Extensor (DNE) training; can also be performed in multiple position and in combination with DNF recruitment

5) Muscle Extensibility Exercises

• Stretching: deep neck flexor stretching
• Muscle energy techniques

6) Postural correction

• Upper and lower cervical spine motor control, strength and endurance
• Cervicoscapulothoracic muscles motor control, strength and endurance

7) Cervical Proprioception

• Joint position sense
  • Ex. move head towards a stimulus and relocate back to neutral (eyes open, eyes closed)
• Cervical movement sense
  • Ex. trace patterns mounted on a wall with a laser
• Gaze stability
• Saccades
• Smooth pursuit
• Head-eye coordination
  • Ex. eyes follow a stimulus, head remains in neutral position
• Balance
• Cervical Movement Control

These exercises can be progressed by altering the base of support (width, stable vs unstable surface) and adding perturbations, internal to begin followed by external.

8) Acupuncture

• Points in cervical and cranial regions
• Found to have longer-lasting therapeutic effects for PCS symptoms such as headaches, neck pain and nausea.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4685187/

TREATMENT FOR BALANCE & VISUAL PROCESSING

A component of the treatment plan will include interventions to address the limitations in balance, postural control and dizziness/associated visual tracking limitations, following a similar protocol to the Fowler-Kennedy guidelines.

The balance limitations will be addressed first working on basic balance exercises as follows:

1)    2 feet to one foot,

2)    changing the surface (firm to foam surfaces),

3)    eyes opened and closed

These exercises will address the basic systems contributing to balance. We can progress these basic exercises as follows:

-       Inclination of the surface may be changed

-        Add internal perturbations such as moving other limbs, changing BOS – i.e tandem stance

-       Add a dual task component (adding cognitive tasks while maintaining balance)

The visual tracking/dizziness limitations will be addresses through vestibulo-ocular reflex (VOR) exercises which may include the following:

1)    Substitution exercises – move eyes to a target and then head

2)    VOR exercises: keep focused on target while shaking head back and forth - do it by moving head side to side, up and down.

Once balance and VOR factors have been addressed they can actually be combined in order to increase the level of difficulty within the tolerance of the patient. For example, standing on a bosu-ball (challenging balance) while keeping eyes focused on a target while moving head back and forth.