Post Concussion Syndrome Case Study: Following a Fall

Examination Findings

Subjective

History of Present Illness

Past Medical History

Symptoms

Medications

Health Habits

Social History

Current Level of Function

Objective

Blood Pressure - 108mmHg/66mmHg (within normal limits)

Heart Rate - 66bpm (within normal limits)

General Observation - no significant postural abnormalities

Gait - normal

Speech - normal speech comprehension and fluency

Upper Limb scan exam - normal

Upper Limb Neurological exam - dermatomes, myotomes & reflexes all normal

Cranial Nerve Testing - normal

Cervical Active ROM - all ranges within normal limits

Superficial and Deep Neck Flexors - activation and strength both normal

Palpation - increased tightness bilaterally in upper fibre trapezius and levator scapulae

Outcome Measures

Static Balance

Functional Gait Assessment

• Score: 24/30, moderate impairment
• Difficulty with gait with horizontal and vertical head turns category
• Experienced increased dizziness

The Headache Impact Test

• Score: 59, substantial impact on health related quality of life
• Score range: 36-78

Dizziness Handicap Inventory

• Score: 45/96, moderate handicap
• Physical, Emotional, Functional subscales

Vestibular-Ocular Screening (VOMS) Test

Clinical Impression

Diagnosis: 36 year-old female presenting with post concussion syndrome two weeks after diagnosis of concussion from fall while ice skating on Jan 2, 2020. Patient has bilateral tightness in upper trapezius and levator scapulae, impaired bilateral single leg stance with eyes closed, and gait impacted by vertical and horizontal head turns. Symptoms are interfering with return to work, driving at night, getting a restful sleep, and grocery shopping. Patient is an excellent candidate for physiotherapy.

Problem List

• Disturbance in quality of sleep (unable to sleep straight through the night)
• Inability to drive at night due to light sensitivity
• Experiencing dizziness with dual tasks when walking and impacting performance in ADLs
• Unable to return to work due to symptoms from post concussion syndrome
• Tightness bilaterally in upper fibre traps and levator scapula
• Impaired single leg stance with eyes closed
• Gait impacted with vertical and horizontal head turns
• Headaches impacting health related quality of life
• Headache with all tasks on the VOMS
• Vestibular ocular reflex horizontal and vertical elicits dizziness and nausea along with  headache
• Mild dizziness during visual motion sensitivity test
• Increase in pain when performing activities with head movements

Intervention

Exercise

Balance

• 

  When the head moves to the right, the right semicircular canals detect this movement, sending an excitatory signal to the ipsilateral vestibular nucleus, subsequently to the left abducens nucleus which causes excitation of left lateral rectus and right medial rectus - keeping eye gaze in the same direction as the head moves to the right.

Stretching

Vestibular-ocular Reflex Specific Exercise

Self Study Questions

The consequences of concussions can include which of the following?

1. Physical
2. Cognitive
3. Emotional
4. All of the above

Post concussion symptoms typically resolve in _________ days in adults.

1. 4-6
2. 7-10
3. 15-20
4. 10-12

The vestibular oculomotor screening test (VOMS) test the following?

1. Convergence
2. Smooth pursuits
3. Visual motion sensitivity
4. a and b
5. a and c
6. a, b, and c