Abstract
This page is for educational purposes and outlines a fictional case study of a 19-year-old female athlete who experienced a concussion and subsequent post-concussion syndrome. The patient’s presentation was mixed because she had recently experienced several concussions before the problem arose. period If she had persistent symptoms and psychosocial comorbidities—as suggested in [1][2]—complicated diagnosis and treatment. The purpose of this case study is to provide an overview of the condition and its wide range of possible symptoms Describes the unique presentation of the condition Discusses the approach to assessment and presents relevant treatments used to achieve the patient’s return-to-school and athletic goals. Patient enrolls in physical therapy class to treat visual cognitive difficulties with balance Fainting pain intensity and cervical spine mobility.
Introduction
In recent years, post-concussion syndrome has become an increasingly researched and well-understood condition that all physical therapists should be familiar with and be prepared to treat. Post-concussion syndrome describes persistent cognitive and physical symptoms beyond typical symptoms Most concussions recover within 1-3 months [3]. As the literature develops, it is recognized that 10-30% of mild head traumas may result in symptoms that persist for months to years [1]. With this in mind, physical therapists must be vigilant in recognizing when patients may Go through this situation.
Client Characteristics
A 19-year-old woman who plays for the Ontario team Ringette was accidentally hit on the head during a scuffle during practice. The patient collided with another teammate and hit the ice headfirst. Initially she didn’t feel any different other than feeling a little dizzy, but she reported The next day she started experiencing extreme nausea, vomiting, headaches, dizziness and double vision. She was closely monitored by doctors for the next two weeks while trying to continue living at the university, but was sent home after her score increased by 10 points SCAT5 symptom scores from day 1 to day 14 after injury. After returning home, she stayed in a dark room for a long time and could not return to school until her condition stabilized. She experienced several relapses during her recovery, often blacking out for up to an hour from the constant studying and studying. Try physical activity.
She reported that she had suffered 3 minor concussions in the past 8 months. She noted that her recovery time increased from her first concussion (1 week) to her third (3 weeks), but each time she followed the return-to-play protocol established by her coach. since she Her sports medicine physician diagnosed her with post-concussion syndrome (PCS) after she had experienced concussion symptoms for more than 3 months prior to her initial evaluation with the author. She decided to try physical therapy at the doctor’s request to see if she can reduce her symptoms and improve her quality of life.
Examination Findings
During the examination, she subjectively described the pain she was going through. In the absence of light and movement, she explained, she had dull, aching headaches resulting in a NPRS score of 4/10. However, with increased light noise readings and increased neck pain, her headaches became sharp and severe From the base of her neck to her skull resulting in an NPRS rating of 8/10. Sleep was unaffected, and she often describes it as her only moment of relief. It’s clear she’s going through an identity crisis as her lifelong athletic career comes to an abrupt end Characterized by emotional responses [4], such as depression, loss of self-awareness, and anger. She often mentions that she doesn’t know who she is without her sport and is very angry at her situation and the girl who hurt her. Her family also noticed changes in her personality, including Introverted depression anxiety and emotional out of control.
She was a powerful young woman who was a former competitive boxer and practiced at least 5 times a week in addition to completing her kinesiology degree. Her main goal is to continue her degree while continuing to play top-level hockey with hope Medalized at the National Ringette Championships. Due to this latest injury, her main concern is being able to return to school with strategies to minimize aggravating factors/symptoms while attempting to complete her degree. She is able to study for a moderate amount of time (20-30 minutes with breaks) However, the prolonged study required for the exam resulted in major PCS symptoms such as dizziness, nausea, vomiting and fainting. She is still able to live independently at the residence and has only moderate trouble with transportation (car bus, etc.).
Objective Assessment
The Sports Concussion Assessment Tool Version 5 (SCAT-5)[5] was completed by the Ontario team trainer immediately after impact and a copy of the results was provided to the physical therapist for reference. SCAT-5 is the latest version of the SCAT assessment tool for screening Concussions exist in the sporting environment. SCAT-5 addresses the following subtopics [5]:
- Athlete Background
- Symptom Evaluation
- Cognitive Screening (Directed Immediate Memory Concentration)
- Neurological Screening and Balance Checks
- Delayed Recall
- Decision
The most notable issues in the assessment are as follows:
- Nystagmus – detected when testing bilateral visual tracking
- Positive Romberg test – 10 seconds with eyes closed, 30 seconds with both eyes open
- Tandem gait – up to 30 seconds with apparent difficulty/effort
- Short-term memory impairment
- Poor delayed recall
During the initial assessment, the physical therapist selected several other outcome measures as baselines to track progress over time:
Cervical range of motion at initial assessment
- The Community Balance and Mobility Scale (CBMS) was chosen as an appropriate outcome measure to track progression over time because the patient was a young high-functioning and outpatient individual with balance impairment due to her concussion [6]. Score: 42/96, where MCID = 8[6]
- The PHQ-9 is a screening questionnaire used to measure the severity of depression in relation to an individual’s status. The PHQ-9 was applied to this patient because she reported significant psychological distress and relative depression as a result of her injury [7]. Score: 11; moderate. This Physiotherapists should use their clinical judgment and be aware of the considerable psychological impact on treatment and recovery. [7] However, the diagnosis of mental illness does not belong to the scope of physical therapy and should be referred to family members for further investigation.
- Scan Exam: Cleared
- Cranial Nerve Test: All cranial nerves are within normal range
- Upper Motor Neuron Testing: Negative
- Palpation: suboccipital, sternocleidomastoid, and upper trapezius fibers tenderness on palpation
Clinical Hypothesis/Impression
A major problem faced by patients during recovery is the inability to gradually return to school due to the high demand of science courses. This affected her progress as she often had relapses when she was studying for exams or trying to study finish homework. In addition, the forward head posture that the student often exhibited while studying exacerbated already tensed neck muscles (whiplash from the injury), further causing her daily headaches. The combination of the school’s constant workload and her seriousness Symptoms due to repeated blows to her head (4 concussions in 8 months) negatively affected her psyche as she was struggling with an identity crisis which exacerbated her altered/accelerated psyche state. She will have pain, nausea, vomiting, dizziness, diplopia, and fainting. For a student living alone and away from home, the constant experience due to exertion was not only disabling but deeply disturbing.
Patient is a former high functioning athlete and 19 year old college student who had 4 concussions in 8 months presenting with pain, nausea, dizziness, fainting, nystagmus, poor balance, poor memory, neck movement reduction and personality change.
Due to the number of concussions in a short period of time and the severity of the patient’s ongoing symptoms, the focus will be on returning to school as a return to sport is neither foreseen nor recommended.
Excellent candidate for physical therapy activities aimed at increasing balance range VOR and proprioception; functional mobility and optimizing participation in activities suitable for patient’s return to school protocol.
Problem List
- Pain Nausea Vomiting Dizziness Fainting Double vision
- Balance and postural control problems
- Reduced range of motion of the neck muscles
- Decreased cognitive levels (memory and recall)
Intervention
The treatment regimen is designed based on the results of the patient’s assessment and will be completed following a protocol similar to the Fowler-Kennedy guidelines [3] to achieve the patient’s tolerance level. These should not exceed the patient’s limits, nor should they cause the patient’s reproductive Symptoms or fatigue develop during the first few sessions.
- Range of motion exercises – unidirectional and/or combination movements
- Cervical Spine AROM Flexion-Extension Rotation and Lateral Flexion Chin Tightening
- Progression of isometric strengthening exercises
- Cervical mobilization – based on evaluation
- Deep Neck Flexor (DNF) Workout [8] – can be performed in multiple positions
- Sitting (with/without head support)
- Supine
- 4-point kneeling.
- Can advance to involve DNE recruitment
- Deep neck extensor (DNE) training; can also be performed in multiple positions and combined with DNF recruitment
- Muscle Extensibility Exercises
- Stretching: deep neck flexor stretching
- Muscle energy techniques
- Postural correction
- Upper and lower cervical spine movements control strength and endurance
- Cervical and pectoral exercise control strength and endurance
- Cervical Proprioception[9]
- Joint position sense
- predecessor. Move head towards stimulus and reposition to neutral (eyes open and closed)
- Cervical movement sense
- predecessor. Tracking pattern mounted on wall with laser
- Gaze stability
- Saccades
- Smooth pursuit
- Head-eye coordination
- predecessor. Eyes follow stimulus Keep head in neutral position
- Balance
- Cervical Movement Control
These exercises can be done by varying the support base (width stable vs. unstable surface) and adding internal disturbances followed by external disturbances.
- Joint position sense
- Acupuncture
- Points in cervical and cranial regions
Therapy for balance and visual processing
An integral part of the treatment plan will include interventions to address limitations in balance postural control and dizziness/associated visual tracking limitations, following a protocol similar to the Fowler-Kennedy guidelines [3].
Balance Limits will first address basic balance exercises and then add progressions to these exercises as follows:
Basic balance exercises Progression of basic balance exercises 2-foot balance to single-leg balance Change surface (hard surface to foam surface) Eyes open and closed add a double Task component (adding cognitive tasks while maintaining balance)
Additionally, visual tracking/dizziness limitations [10] will be addressed with various vestibular vision and vestibulo-ocular reflex (VOR) exercises, which may include the following:
- Alternative exercise: move the eyes to the target first, then move the head
- VOR exercise: stay focused on the target while shaking your head back and forth – do this by moving your head up, down, side to side
Once balance and VOR factors are addressed, they can actually be combined to increase the difficulty within the patient’s tolerance [3]. For example, stand on a bosu ball (balance challenge) while keeping your eyes on the target while moving your head back and forth.
Return to School Protocol
Using the Ontario Concussion/Minor Traumatic Brain Injury and Persistent Symptoms Practice Guidelines [2] and SCAT 5 [5], we can work towards implementing a Graduation Back to School protocol for our patients. Currently she has determined that she can study for about 20-30 minutes before eliciting Symptoms, but long-term study will reproduce symptoms.
By grading the study and screening time within the patient’s tolerance (meaning no recurrence of symptoms), we can try to gradually increase the time she is able to study without developing symptoms [3]. For example, we will have patients Sit down and study how long it takes for her symptoms to appear, and use that as a frame. If symptoms develop after 20 minutes of studying at her desk, we will take 20% of that measure, so have the patient study for 15-17 minutes every hour until she can be symptom free for a week.
Outcome
After two months of treatment with her physiotherapist, the patient showed significant improvement since the initial visit.
Her SCAT5 scores were regularly reassessed weekly to monitor changes and there were significant improvements overall, including an increase from 10 seconds on the closed-eye Romberg test to 25 seconds. Dramatically improved convergent vestibulo-ocular reflex and overall reduction The severity and prevalence of symptoms (nystagmus, diplopia, dizziness, nausea, etc.) were also recorded.
The patient’s balance and proprioception were challenged by using many different techniques in her treatment plan. After two months of therapy and a prescription for home exercises, the patient was able to demonstrate that she was able to maintain balance with eyes open and closed and in various positions for 30 seconds surface and slope. Series balance has improved, but is still challenging.
The patient’s limited cervical range of motion and myofascial tone were addressed in therapy through the use of soft tissue release motor control exercises for postural correction and neck proprioception training. As a result, the range of motion of the patient’s neck in all directions is improved Within normal range since her initial assessment. The patient’s NPRS score at reassessment also dropped to 0/10 during rest and to 2/10 at worst.
Cervical range of motion after physical therapy intervention
Cognitive improvements were also noted subjectively. However, memory and cognition were not the immediate focus of physical therapy interventions, so improvements cannot be inferred to be a direct result of treatment.
CBMS Score: 60/96 where MCID = 8[6]
Based on her CBMS scores, the patient showed significant improvements in overall balance and mobility. According to MCID, changes in results from initial assessment to reassessment are clinically relevant.
PHQ-9 Score: 7 (Mild)[7]
The patient is now below the cutoff for clinically significant depression, but she still reports a depressive attitude toward her condition. As previously stated, diagnosing mental illness is outside the scope of PT practice, so changes in scores should be determined by Physician. Due to the level of psychological distress the patient was experiencing with her condition and her inability to return to sport, she was referred to a counselor for mental health counseling.
Patients have also struggled to comply with the back-to-school protocol [2], which requires a licensed healthcare professional (physiotherapist) to sign off at each stage of the grading plan. The patient no longer had difficulty managing her symptoms due to the school workload, so the patient deemed suitable to return to school full-time[2].
Discussion
Overall, this case study presents a complex case of post-concussion syndrome. Because of her recent history of multiple concussions, this patient experienced nearly all of the symptoms typically associated with PCS. Therefore, therapeutic interventions have a broad focus, including balancing Mobility Visual Exercises Postural Correction Intensive and Back-to-School Protocol. It is not uncommon for the patient to have severe psychosocial comorbidities that complicate her recovery [11]. Her depressive symptoms, anxiety and identity crisis went beyond comfort Treatment at the level of a physical therapist, so referral to a counselor for mental health counseling is indicated.
Comparing the outcome measures used before and after the intervention allowed the conclusion that patients benefited significantly from physical therapy. All outcomes improved to varying degrees after treatment, suggesting that physical therapists – and various other healthcare Professionals – should be included in personal care similar to the patient in this case study. Ultimately, it is important to individualize the care of a PCS patient based on the patient’s symptoms and this care should be modified accordingly based on the patient’s unique symptoms progression or prognosis [2].
As only one individual is depicted on this page, it should be noted that the selected outcome measures and interventions are some of the many valid and reliable tools available to treat PCS. If the patient presents similarly to the patient in this example, a physical therapist may be successful Use some or all of the protocols above.
References
- ↑ Jump up to:1.0 1.1 Hugentobler JA, Vegh M, Janiszewski B, Quatman‐Yates C. Physical therapy intervention strategies for patients with prolonged mild traumatic brain injury symptoms: a case series. International journal of sports physical therapy. 2015 Oct;10(5):676.
- ↑ Jump up to:2.0 2.1 2.2 2.3 2.4 Ontario Neurotrauma Foundation. Guideline For Concussion/Mild Traumatic Brain Injury & Persistent Symptoms, 3rd Edition, For Adults Over 18 Years Of Age. Available from: https://braininjuryguidelines.org/concussion/fileadmin/media/adult-concussion-guidelines-3rd-edition.pdf (Accessed 7 May 2019).
- ↑ Jump up to:3.0 3.1 3.2 3.3 3.4 Fowler Kennedy Sport Medicine. Post-Concussion Syndrome Management Guidelines. Available from: https://www.fowlerkennedy.com/wp-content/uploads/2017/02/Post-Concussion-Treatment-Guidelines.pdf (Accessed 7 May 2019)
- ↑ Green SL, Weinberg RS. Relationships among athletic identity, coping skills, social support and the psychological impact of injury in recreational participants. J Appl Psychol [Internet]. 2001 Fall [cited 2007 Oct 24];13(1):40-59. Available from:https://www.tandfonline.com/doi/abs/10.1080/10413200109339003#aHR0cHM6Ly93d3cudGFuZGZvbmxpbmUuY29tL2RvaS9wZGYvMTAuMTA4MC8xMDQxMzIwMDEwOTMzOTAwMz9uZWVkQWNjZXNzPXRydWVAQEAw
- ↑ Jump up to:5.0 5.1 5.2 British Journal of Sports Medicine. Sport concussion assessment tool. bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097506SCAT5.full.pdf
- ↑ Jump up to:6.0 6.1 6.2 Howe J, Inness E, Wright V. The Community Balance and Mobility Scale [Internet]. Tbims.org. 2011 [cited 5 May 2018]. Available from: http://www.tbims.org/cbm/index.html
- ↑ Jump up to:7.0 7.1 7.2 Kroenke K, Spitzer RL, Williams JB. The PHQ‐9: validity of a brief depression severity measure. Journal of general internal medicine. 2001 Sep;16(9):606-13.
- ↑ Lowe R, Ritchie L, Leddy A, Polishchuk K, Burns SA. Deep Neck Flexor Stabilisation Protocol [Internet]. Physiopedia. [cited 2019May6]. Available from: https://www.physio-pedia.com/Deep_Neck_Flexor_Stabilisation_Protocol
- ↑ Werner I. Training of cervical proprioception in addition to manual therapy [Internet]. International Maitland Teachers Association. 1970 [cited 2019May6]. Available from: https://www.imta.ch/en/blog/post/training-of-cervical-proprioception-in-addition-to-manual-therapy/
- ↑ PhysioTools. Dizziness and Imbalance: Choosing the best exercise [Internet]. Physiospot – Physiotherapy and Physical Therapy in the Spotlight. [cited 2019May9]. Available from: https://www.physiospot.com/sponsors/dizziness-and-imbalance-choosing-the-best-exercise/
- ↑ Ontario Neurotrauma Foundation. Guideline For Concussion/Mild Traumatic Brain Injury & Persistent Symptoms, 3rd Edition, For Adults Over 18 Years Of Age. Available from: https://braininjuryguidelines.org/concussion/fileadmin/media/adult-concussion-guidelines-3rd-edition.pdf (Accessed 7 May 2019).