Post Concussion Syndrome Case Study: Following a Fall

Introduction

Concussion is a mild brain injury that is commonly seen in events such as sports and motor vehicle accidents. After the initial injury, symptoms such as headache and dizziness tend to persist for weeks, months, or even years; this phenomenon is referred to as post-concussion syndrome (PCS).

The consequences of concussion can include physical, cognitive and/or emotional abnormalities. The duration of concussion symptoms can range depending on the nature of the injury and the individual affected. Sport-related concussion symptoms typically resolve in 7-10 days in adults, and up to 3-4 weeks in children and adolescence. However, in some cases, these symptoms persist for a longer period of time, this is referred to as post-concussion syndrome. Following a concussion, patients are typically advised to rest and avoid any strenuous physical or cognitive activity until the patient’s symptoms have resided. This has also been the traditional approach for post concussion syndrome combined with education, support/reassurance and antidepressants, and neuro-cognitive rehabilitation. However, more recent research has recommended that there are several active therapies that may benefit recovery if intensity is kept below the symptom threshold. Some of these more active approaches may include cognitive therapies, physical therapy, aerobic exercise, vestibular therapies and ocular therapies. Although rest may be important in the initial phases of recovery from concussion, there is evidence that low-level exercise and multimodal physical therapy is beneficial for patients who are recovering slowly following a sports related concussion.

The purpose of this case study is to expose the readers on a typical patient with post-concussion syndrome, how it affects the patient’s life, and how it can be managed with physiotherapy, to subsequently improve the patient’s quality of life.

Client Characteristics

36-year-old female with post-concussion syndrome; seeking help from physiotherapy due to persistent symptoms (e.g., headache, dizziness) that are affecting the quality of her life. There are no other relevant comorbid conditions.

Examination Findings

Subjective

History of Present Illness - Initial injury occurred on January 2^nd, 2020; patient fell and hit the back of her head while ice-skating and lost consciousness. She was sent to the hospital and diagnosed with a concussion. The patient was discharged from the hospital the following day and returned home. Patient returned to work on January 6^th, four days post injury, but was unable to continue after a few hours due to the presence of severe headache. She then remained off work for a few weeks with persistent symptoms, at which point the she made an appointment with her family physician, and she was then referred to see a physiotherapist for rehabilitation and management.

Past Medical History - Healthy prior to injury; no previous trauma, surgeries, or other serious health conditions/comorbidities noted

Major Symptoms

Headache - constant, dull, diffuse headache 2/10 at rest

• Aggravating factors
  • Physical activity: pain increases to 7 or 8/10 with ~20 min of moderate activity, particularly when the activity involves head movements, which then reaches 7 or 8/10 more quickly
  • Cognitive activity: pain level increases to 4 or 5/10 with ~30 min of activities such as reading, planning, and learning.
  • Exposure to light sources: pain reaches 7 or 8/10 in ~20 min when outside on a sunny day without sunglasses (able to tolerate over one hour with sunglasses); ~30 min of screen time can also raise the pain level to 7 or 8/10
• Easing factors:
  • Rest: pain usually returns to baseline (2/10) with ~10 minutes of rest and removal of aggravating factors;
    • The higher the pain level, the longer it usually takes to return to baseline
    • The longer the exposure to aggravating factors, the longer it takes to return to baseline

Medications - No medications; occasionally takes Tylenol 2-3 days per week if headaches become unbearable (i.e., 8/10 pain)

Health Habits - Non-smoker; consumption of wine (2-3 glasses/week) prior to the injury - has ceased drinking any alcohol post-injury

Social History - Registered Nurse (RN) for 11 years; practiced yoga for 10 years and has been teaching yoga for the past 5 years; currently living in a two-storey townhouse with fiancé.

Current Level of Function - Able to ambulate normally at home and perform simple chores independently, sleep quality has decreased markedly since the injury: has trouble falling asleep and wakes up 2-3 times on average at night; able to drive during day time, but has difficulty at night time due to light sensitivity (i.e., bright lights from car); decreased concentration and memory has been noted; more likely to become emotional over relatively trivial issues (i.e., spilling milk); tolerance for moderately challenging activities (such as work) has decreased drastically due to headaches, decreased cognitive capacity, moodiness, etc. Although the major complaint is of headache, the patient also reports slight dizziness when looking around frequently (i.e., such as looking for a product during grocery shopping).

Objective

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

Heart Rate - 66 bpm (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 - normal dermatomes, myotomes & reflexes

Cranial Nerve Testing - normal

Cervical Active ROM - all ranges within normal limits

Superficial and Deep Neck Flexors - normal activation and strength

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

• Remarks: neck muscles dysfunctions are often associated with people with PCS, and tightness in neck muscles may lead to increased headaches

Outcome Measures

Modified Clinical Test for Sensory Interaction on Balance (CTSIB-M)

Condition	Results (out of 30 sec)
Firm Surface, Eyes Open	Trial 1: 30sec
Firm Surface, Eyes Closed	Trial 1: 30sec
Foam Surface, Eyes Open	Trial 1: 30sec
Foam Surface, Eyes Closed	Trial 1: 18sec Trial 2: 21sec Trial 3: 19sec

Total Score: 111 sec/ 120 sec (sum of best results from each condition)

• Remarks: CTSIB-M is used to test the three sensory inputs (somatosensory, visual, and vestibular inputs) that are important for balance

Static Balance

Condition	Results (out of 30 sec)
Tandem stance (eyes open)	Left foot behind: 30 sec Right foot behind: 30 sec
Tandem Stance (eyes closed)	Left foot behind: Trial 1: 15 sec Trial 2: 17 sec Trial 3: 14 sec Right foot behind: Trial 1: 12 sec Trial 2: 15 sec Trial 3: 14 sec
Single Leg Stance (eyes open)	Left foot: 30 sec Right foot: 30 sec
Single Leg Stance (eyes closed)	Left foot: Trial 1: 5 sec Trial 2: 9 sec Trial 3: 7 sec Right foot: Trial 1: 8 sec Trial 2: 10 sec Trial 3: 7 sec

• Remarks: these items were included since the patient reported having no difficulty staying in tandem stance or single leg stance, eyes closed, for at least 30 seconds prior to the injury. Research suggests that the mean for single leg stance, eyes closed for the patient’s demographic (18-39 y.o. female) is about 13 seconds, whereas for tandem stance, eyes closed, it is about 26 seconds. The 30 second mark is set both as a convenient value for assessment and as a (short-term) goal for the patient to return to prior-to-injury function.

Functional Gait Assessment

Score: 29/30 - Mild difficulties for "Gait with Eyes Closed" condition (Score: 2/3)

• Remarks: the FGA is a 10-item assessment tool used to evaluate a patient's dynamic gait and vestibular impairments; study suggests that the cut-off score for increased fall risk is 22/30. Although the patient’s score is above the cut-off, it does give us some hints as to the exercises to prescribe (i.e., dynamic balance when eyes closed)

The Headache Impact Test

Score: 61 - Severe impact on quality of life

• Remarks: The Headache Impact Test is a 6-question questionnaire that assesses the severity of the impact a headache has on one’s life. The score ranges from 36 to 78: the impact is considered little to none for scores below 50, scores of 50-55 are interpreted as some impact is produced by the headache, 56-59 is substantial impact, and scores above 60 are severe impact. Using this categorization, the patient’s headache is having a severe impact on her life, which is consistent with her primary complaint, and it is certainly a major focus of the treatment.

Vestibular-Oculomotor Screening (VOMS) Test

Vestibular/Ocular Motor Test	Headaches (0-10)	Dizziness (0-10)	Nausea (0-10)	Fogginess (0-10)	Comments
Baseline Symptoms	2	0	0	0	Constant dull headache at rest
Smooth Pursuits	2	0	0	0
Saccades - Horizontal	4	1	0	0	Symptoms returned to baseline in less than 30s
Saccades - Verticle	3	0	0	0	Symptoms returned to baseline in less than 30s
Convergence (Near Point)	2	0	0	0	Able to bring the tip of pen to nose, no double vision noted
VOR - Horizontal	6	4	3	0	Symptoms returned to baseline after ~1 min
VOR - Vertical	5	2	2	0	Symptoms returned to baseline after ~30s
Visual Motion Sensitivity Test	5	4	2	0	Symptoms returned to baseline after ~30s

• Remarks: the VOMS is a tool used to test vestibular/oculomotor impairments and motion sensitivity for patients with PCS; results from VOMS can guide our treatment exercises.

Clinical Impression

Diagnosis

36 year-old female presenting with post concussion syndrome 4 weeks after diagnosis of concussion from fall while ice skating on Jan 2, 2020. Patient has impaired balance and vestibular system, and motion sensitivity. She has persistent headache, which is exacerbated by motion and cognitive tasks; the bilateral tightness in upper trapezius and levator scapulae might also contribute to her headache. These symptoms are interfering with return to work, driving at night, getting a restful sleep, grocery shopping, learning, etc. The patient is an excellent candidate for physiotherapy.

Problem List

• Disturbance in quality of sleep
• Inability to drive at night due to light sensitivity
• Persistent headache
• Decreased concentration and moodiness
• Motion sensitivity
• Impaired balance, particularly when vestibular system is challenged

Intervention

Patient-focused Goals

1. Reduce headache severity at rest from a 2/10 to 0/10 by the end of the 3rd week of treatment
2. Be able to maintain static single leg stance balance bilaterally with eyes closed for 30 seconds by the end of the 4th week of treatment
3. Be able to turn head while walking without causing nausea or dizziness by the end of the 6th week of treatment

Education

• Provide the patient with reassurance about her condition
• Provide coping strategies
• Discuss expected recovery time
• Educate the patient on appropriate performance, and structuring of return to activities and work

Manual Therapy

Soft Tissue Release Technique

• Upper fibers trapezius (bilateral)
• Levator Scapulae (bilateral)

Parameters: Passive approach with gliding pressure along muscle fibres in multiple planes, 10 reps total each side

Progression: Can progress to performing active-assisted and then active STR

Trigger Point Release Technique

• Upper fibers Trapezius (bilateral)
• Levator Scapulae (bilateral)

Parameters: Apply pressure on trigger points for 30 seconds, 2 reps, each side

*****need to include research on why STR is good at relieving post-concussion headache symptoms, same with trigger point release******

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.

Exercise

Balance

Stretching

Gaze Stability Exercise (VOR)

Outcome

Change in Status Post Intervention

After the patient completed physiotherapy treatment (duration: 8 weeks, 2 sessions per week), she noticed a marked change in the presence of her symptoms. The headaches completely disappeared from baseline, presenting as a constant dull and achey pain, to no pain at all. While completing her ADLs, ***

Outcome Measures

Modified Clinical Test for Sensory Interaction on Balance (CTSIB-M)

Condition	Results (out of a possible 30sec)
Firm Surface, Eyes Open	Trial 1: 30sec
Firm Surface, Eyes Closed	Trial 1: 30sec
Foam Surface, Eyes Open	Trial 1: 30sec
Foam Surface, Eyes Closed	Trial 1: 30sec

Total Score: 120sec/120sec

Static Balance

Condition	Results (out of a possible 30 sec)
Tandem Stance (eyes open)	Left foot behind: 30sec Right foot behind: 30 sec
Tandem Stance (eyes closed)	Left foot behind: 30sec Right foot behind: 30sec
Single Leg Stance (eyes open)	Left foot: 30sec Right foot: 30sec
Single Leg Stance (eyes closed)	Left foot: 30sec Right foot: 30sec

Functional Gait Assessment

The Headache Impact Test

Vestibular-Oculomotor Screening (VOMS) Test

Vestibular/Ocular Motor Test	Headaches (0-10)	Dizziness (0-10)	Nausea (0-10)	Fogginess (0-10)	Comments
Baseline Symptoms	0	0	0	0
Smooth Pursuits	2	0	0	0
Saccades - Horizontal	2	1	0	0	Symptoms returned to baseline after ~10s
Saccades - Verticle	1	0	0	0	Symptoms returned to baseline after ~10s
Convergence (Near Point)	0	0	0	0	No double vision noted
VOR - Horizontal	2	2	0	0	Symptoms returned to baseline after ~30s
VOR - Vertical	1	0	0	0	Symptoms returned to baseline after ~10s
Visual Motion Sensitivity Test	2	2	0	0	Symptoms returned to baseline after ~30s

Discharge Plan

Patient has met all goals laid out at the beginning of treatment.

Self Study Questions

The consequences of concussions can include which of the following?

a) Physical

b) Cognitive

c) Emotional

d) All of the above

Post concussion symptoms typically resolve in _________ days among adults.

a) 4-6

b) 7-10

c) 15-20

d) 10-12

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

a) Convergence

b) Smooth pursuits

c) Visual motion sensitivity

d) a and b

e) a and c

f) a, b, and c