Multi-system management: Persistent post-concussion syndrome case series

The purpose of this case series is to present the clinical assessment and diagnosis of two patients with persistent post-concussion symptoms who remained refractory to typical interventions, and to discuss the outcomes of an individualized, targeted, multisystem management provided by a chiropractor. 

Concussions are among the most common neurological conditions, representing a substantial burden to adults and children(1). Persistent post-concussion symptoms (PPCS) are defined as symptoms that persist beyond the expected clinical recovery time frame, >10 – 14 days in adults and > 28 days in children (2). PPCS may include: nausea, dizziness, headaches, blurred vision, poor sleep, auditory disturbances, reduced executive function and emotional liability(1). Currently, research supports an active symptom-based return to activity for individuals recovering from concussion. The Berlin consensus statement recommends 24-48 hours of rest before gradual return to activities(2). Active treatments may include: sub-symptom threshold aerobic exercise, cervical, vestibulo-ocular, and cognitive therapies(3). 

Background
Two females age 24 and 34 were referred to the author from other health care providers for further assessment and management of their PPCS which remained refractory to previous intervention. Previous management included: vestibulo-ocular rehab, aerobic exercise, psychotherapy, vision therapy, manual therapy for the cervical spinal, acupuncture, medication and suboccipital nerve blocks. 

Case 1
A 24 year old female, enrolled in teachers college presented with PPCS of 14 month duration. She was injured after being elbowed in the head while falling out of a towable-water tube during summer vacation. At the time of presentation previous treatment included: vestibular rehabilitation, suboccipital nerve blocks, vision therapy, cervical manual therapy, and occupational therapy. Previous diagnostics included: MR imaging, CT scan, radiographs, and blood panel, all of which were interpreted as normal. 

Her symptom burden at initial assessment included: significant anxiety particularly with visual motion and egocentric motion, dizziness, social irritability, poor short term memory, left sided tinnitus, neck pain, frontal and suboccipital headaches, motion sickness, and sensitivity to light and sound. She scored 54 on RPQ, 90 on PCSS and 16 on PHQ-9. 

Physical examination was completed and revealed: a pleasantly interactive woman, with good attention and focus. Pulse 97, right sided BP 133/83, left sided BP 135/84. Oxygen saturation was 99%. Gait was grossly normal. Upper and lower extremity light and sharp touch, as well as, joint position sense was normal. Pathological reflexes were absent. Reflexes were 2+ bilaterally at all levels. No evidence of pyramidal paresis, atrophy, flaccidity, spasticity or motor spontaneity noted. Infrared video goggle (VOG) assessment revealed downbeat nystagmus with vision occluded. This was present in all seated head positions (ie: head right, left, up, down, and tilted). Downbeat nystagmus was also produced in all directions of gaze eccentricity (ie: right, left, up, down). Bedside assessment of smooth pursuits reveals saccadic intrusions in left and down directions. Optokinetic gain was reduced in up and left directions. Choice reaction time was slow. Left head impulse testing produced saccadic refixations. Antisaccade testing showed 20% error rate and produced significant anxiety, testing also produced an increase in headache. mCTSIB balance testing produced significant sway which required assistance to prevent falls in head neutral, right, left and up conditions. Cervical spine joint position error was signficant in all directions. Other physical examination procedures including: cranial nerve assessment, muscle tone, tandem stance, tandem gait, dual task gait, cervical orthopedic testing was unremarkable. 

Case 2
A 34 year old family physician presented with PPCS of 22 months duration. She was injured when a contractors ladder fell on her head as she was leaving her home. The ladder knocked her to the ground and she lost consciousness for approximately 3 minutes. At the time of presentation previous treatment included: vision therapy, cognitive behavioural therapy, psychotherapy, cervical manual therapy, suboccipital nerve blocks, neurofeedback, aerobic training, and clonazepam. Previous diagnostics included: MR imaging, CT scan, radiographs, ECG, and blood panel, all of which were unremarkable

Her symptom burden on initial assessment included: significant brain fog and irritability, dizziness, neck pain, headaches, emotional liability, poor concentration, light-headedness with orthostatic change and depersonalization. She scored 58 on RPQ, 100 on PCSS and 16 on PHQ-9. 

Physical examination was completed and revealed: a pleasantly interactive woman, with good attention. Pulse 88, seated right sided BP 118/71, left sided BP 116/68. Oxygen saturation was 98%. Gait was grossly normal. Upper and lower extremity light and sharp touch, as well as, joint position sense was normal. Pathological reflexes were absent. Reflexes were 2+ bilaterally at all levels. No evidence of pyramidal paresis, atrophy, flaccidity, spasticity or motor spontaneity noted. Orthostatic vital sign assessment was completed, findings were as follows: 5 minutes supine HR and BP: 62bpm and 118/70mmHg, 3 minutes standing HR and BP: 79bpm and 124/72mmHg, 7 minutes standing HR and BP: 107bpm and 121/74mmHg. During the 7 minutes standing the patient expressed an increase in headache and excessive emotionality. These values met the clinical criteria for the diagnosis of postural orthostatic tachycardia syndrome (POTS). Infrared VOG assessment revealed horizontal saccadic intrusions and convergence spasms with vision occluded. Bedside near point convergence revealed divergence spasm at 8 and 11cm. Antisaccade error rate was 30% with long latencies. Optokinetic gain was reduced in all directions, following the stimulus the patient felt significant dizziness. Luria’s three step test was abnormal on left. Rapid alternating movement testing revealed apraxia on the left. Vertical gaze holding produces eye pain and patient was unable to maintain fixation. CTSIB balance testing revealed significant sway in the medial-lateral direction which was exacerbated in head up and left conditions. Other physical examination procedures including: cranial nerve assessment, muscle tone, head impulse testing, vestibulo-ocular reflex exam, tandem stance, tandem gait, dual task gait, cervical orthopedic testing was unremarkable.

Multisystem management approach
In Case 1 the author made a clinical diagnosis of persistent post-concussion symptoms with vestibulo-oculomotor dysfunction, motor coordination impairment and cervical spine musculoskeletal impairments. Case 2 was diagnosed with persistent post-concussion symptoms and a clinical diagnosis of POTS. Each patient was educated about PPCS and Case 2 was educated about the clinical POTS diagnosis and that this should ideally be made through passive tilt table testing and medical evaluation. Management strategies were offered by the author and both patients decided to participate in an individualized, targeted, multisystem neurorehab program. 

Both patients received targeted treatment that matched their clinical dysfunctions. These strategies included: gaze stabilization training, ocular-movement exercises (smooth purstuts, saccades, OKN, conergence), spinal and extremity manupulation, motor coordination interventions, repetitive peripheral nerve stimulation, somatic sensorimotor complex movements, isometric contractions, and diaphragmatic breathing. Each case had a unique element of treatment: Case 1 performed whole body on axis rotations with simultaneous VOR cancellation. Case 2 began treatment supine and was gradually elevated until her HR increased 10bpm at which point she was lowered 10 degrees and the treatment previously mentioned was performed. 

Outcomes
Both patients demonstrated significant improvements in their PPCS symptoms as measured by the PCSS, RPQ and PHQ-9. Following 15 consultations Case 1 reported a score of 2 on PCSS, 2 on RPQ and 0 on PHQ-9. She also reported complete resolution of all subjective complaints. Following 12 consultations Case 2 reported a score of 6 on PCSS, 4 on RPQ and 2 on PHQ-9. Upon standing during orthostatic vital sign assessment her HR increased 10bpm initally and returned to supine resting levels within 2 minutes. She also reported significant improvements in her brain fog, irritability, emontional liability, lightheadedness and depersonalization. This short case series demonstrates subjective and objective improvements in the symptoms and fuction of two females with PPCS following a multisystem, individualized, and targetted rehab program to address their specific dysfunctions.

References

• Polinder, S., Cnossen, M. C., Real, R. G., Covic, A., Gorbunova, A., Voormolen, D. C., … & Von Steinbuechel, N. (2018). A multidimensional approach to post-concussion symptoms in mild traumatic brain injury. Frontiers in neurology, 9, 1113.
• McCrory, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., … & Vos, P. E. (2017). Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. British journal of sports medicine, 51(11), 838-847.
• Schneider, K. J., Iverson, G. L., Emery, C. A., McCrory, P., Herring, S. A., & Meeuwisse, W. H. (2013). The effects of rest and treatment following sport-related concussion: a systematic review of the literature. British journal of sports medicine, 47(5), 304-307.

Dr. Dylan Rodgers B.Sc. DC. graduated from Queen’s University in Kingston where he completed his Bachelor of Science (Hons.) with an emphasis in human physiology and neuroanatomy. He then completed his chiropractic training at Canadian Memorial Chiropractic College in Toronto Ontario. Dr. Rodgers furthered his education by completing a three-year fellowship in Clinical Neuroscience and Rehabilitation at the Carrick Institute for Graduate studies.