Post Concussion Syndrome Case Study: Following a Fall

Abstract

The following is a fictional case study that is intended for educational purposes. The patient is a 36 year-old female experiencing post concussion syndrome following a fall while ice-skating. Four weeks after being diagnosed with a concussion the patient continued to experience prolonged symptoms including; persistent headaches, altered mood, impaired balance and decreased concentration, affecting her ability to work and quality of life. The purpose of this case study is to present to the readers, a typical patient with post-concussion syndrome, and the effects that post-concussion syndrome has on a patient's quality of life. Subsequently, this case study is intended to provide an example as to how post-concussion syndrome can be managed with physiotherapy.

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).[2]

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.[3] Following a concussion, patients are typically advised to rest and avoid any strenuous physical or cognitive activity until the patient’s symptoms have diminished. This has also been the traditional approach for post concussion syndrome combined with education, support/reassurance, antidepressants, and neuro-cognitive rehabilitation.[4] However, more recent research has recommended that there are several active therapies that may benefit recovery if intensity is kept below the symptom threshold.[3] Some of these 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.[5]

https://www.youtube.com/watch?v=TF_xyN_yg44&fbclid=IwAR1SN__FxhSENhvW5wVI-9msZtZizwrA1irCsVsmfT7fCnMHU4GIBhQDPO4 [6]

This video reviews the definition and differences between concussion and post-concussion syndrome. It is important to distinguish between the two conditions as management is different for both. Ability to make a correct diagnosis and provide appropriate treatment leads to improved outcomes and quicker recovery times.

Client Characteristics

A 36-year-old female with post-concussion syndrome; seeking help from physiotherapy due to persistent symptoms of headache and dizziness that are negatively affecting her quality of life. There are no other relevant comorbid conditions.

Examination Findings

Subjective

History of Present Illness - Initial injury was sustained when the 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 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. Her family physician referred her 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 8/10 with ~20 min of moderate activity, particularly when the activity involves head movements, which then reaches 8/10 more quickly
    • Cognitive activity: pain level increases to 5/10 with ~30 min of activities such as reading, planning, and learning.
    • Exposure to light sources: pain reaches 7/10 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 raise the pain level to 7/10
    • *pain-0 being no pain and 10 being in the worst pain imaginable
  • 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 - 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 her 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. She is able to drive during the 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. The patient is more likely to become emotional over relatively trivial issues (e.g., spilling milk). Tolerance for moderately challenging activities (such as work) has decreased drastically due to headaches, decreased cognitive capacity, moodiness. She also notes some tightness/discomfort around her shoulder and the back of her neck, which is similar to wearing a heavy backpack and is aggravated by stress. Furthermore, the patient also reports slight dizziness after certain activities, such as bending/squatting down to pick something up and quickly stand up, and frequent head turns during grocery shopping; but they usually resolve quickly with the cessation of the movements.

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, no pain noted, patient notes tightness bilaterally with flexion, side flexion, and rotation

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[7]

Outcome Measures

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

Condition Results (out of 30 sec)
Firm Surface, Eyes Open Trial 1: 30 sec
Firm Surface, Eyes Closed Trial 1: 30 sec
Foam Surface, Eyes Open Trial 1: 30 sec
Foam Surface, Eyes Closed Avg: 19.3 sec

(Trial 1: 18 sec; Trial 2: 21 sec; Trial 3: 19 sec)

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[8]

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: Avg: 15.3 sec

(Trial 1: 15 sec; Trial 2: 17 sec;Trial 3: 14 sec)

Right foot behind: Avg: 13.7

(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: Avg: 7 sec

(Trial 1: 5 sec;Trial 2: 9 sec;Trial 3: 7 sec)

Right foot: Avg: 8.3 sec

(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,[9] whereas for tandem stance, eyes closed, it is about 26 seconds.[10] 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;[11] study suggests that the cut-off score for increased fall risk is 22/30.[12] 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 (HIT-6)

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.[13] Using this categorization, the patient’s headache is having a severe impact on her life, which is consistent with her primary complaint, and will be a major focus of her 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

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, vestibular system, and motion sensitivity. She has a persistent headache, which can be exacerbated by motion, cognitive tasks, stress, and tightness in muscles such as upper fibre trapezius and levator scapulae. These symptoms are interfering with return to work, driving at night, getting a restful sleep, grocery shopping, spending time outside, and screen time. The patient is an excellent candidate for physiotherapy.

Problem List

  • Disturbance in quality of sleep
  • Inability to drive at night, reduced tolerance to sunlight, and reduction in screen time due to light sensitivity
  • Persistent headache (preventing return to work)
  • Decreased concentration
  • Motion sensitivity
  • Impaired balance, particularly when vestibular system is challenged
  • Tightness in upper fiber trapezius and levator scapulae
  • Vestibular ocular impairments

Intervention

For physiotherapy intervention, multiple types of treatment may be used independently or in combination depending on the type and extent of the injury/condition. For this patient, it was decided to use a combination of education, manual therapy supplemented with stretches, along with balance and gaze stabilizing exercises in order to form a well-rounded treatment plan to address multiple items outlined in the above sections of the case study.

Patient-focused Goals

Short-term goals:

  • Reduce headache severity at rest from a 2/10 to 0/10 by the end of the 4th week of treatment.
  • Maintain static single leg stance balance bilaterally with eyes closed for 20 seconds by the end of the 4th week of treatment.
  • Maintain tandem stance balance bilaterally with eyes closed for 30 seconds by the end of the 4th week of treatment.
  • Improve score on the FGA to 30/30 by the end of 2nd week of treatment.
  • Reducing the symptom severity by at least 2 units in each VOMS condition (e.g., scoring a maximum of 4/10 headache for VOR-horizontal) by the end of 4th week of treatment.
  • Begin gradual return to work during week 3 of treatment starting with 1-2 hours a day and gradually build up to full work days. Time limited and progressed based on the presence of symptoms. 

Long-term goals:

  • Maintain static single leg stance balance bilaterally with eyes closed for 30 seconds by the end of the 8th week of treatment.
  • Be able to complete the VOMS with a reduction in baseline symptoms to 0 by the end of 8th week of treatment.
  • Begin gradual return to yoga practice at pre-injury level intensity with little to no presence of symptoms by the end of 8th week of treatment.
  • Return to working full days by the end of the 8th week of treatment with little to no symptoms present.

Education

  • Provide the patient with reassurance about her condition
  • Provide coping strategies
  • Provide education pertaining to the risk of second impact syndrome
  • Discuss expected recovery time[3]
  • Educate the patient on appropriate performance, and structuring of return to activities[17]
  • Education regarding activity tolerance and progression (i.e., Increase activity tolerance without crossing the symptom threshold)[18], guiding recommendations for gradual return to yoga practice

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, 1-2 sets 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

  • Remarks: Manual therapy such as soft tissue release and trigger point release have been shown to decrease headache symptoms that originate from the soft tissues of the head and neck.[20] As well, it has been noted that various regions of myofascial trigger points found in the head and neck commonly produce pain features that are found among individuals suffering from headaches. Specifically, trigger points in the upper trapezius muscle and levator scapulae tend to refer pain ipsilaterally from the posterior-lateral region of the neck, behind the ear and to the temporal region of the head.[21]

Exercises (Balance, Stretches, Gaze Stability)

Balance

Warrior Pose - Patient stands with one foot in front, the other foot takes a big step behind. With both feet facing forward, patient can bring arms out to the side for increased stability (may use wall or counter for extra stability if needed). Once in position, patient closes eyes.

  • To address tandem stance balance

Parameters: Hold position for 30 seconds with 2 repetitions on each side; perform daily

Progression: Bring back foot closer to front foot (until in tandem stance), remove handheld support, bring arms down to side

Tree Pose - Patient stands on one foot with the other out in front resting on a plastic cup. Patient performs static stance without crushing the cup under their foot. Patient may use handheld support (i.e., counter, wall, etc.). Once in position, patient closes eyes.

  • To address single leg stance balance

Parameters: Hold position for 30 seconds with 2 repetitions on each side; perform daily

Progression: Remove handheld support, remove cup support, bring arms to centre, bring leg up to rest on weight bearing leg (to create yoga "tree pose")

Gait with Eyes Closed - Using a space with continuous support (i.e., area of wall available to walk beside), patient stands by hand support (wall, or parallel bars if in clinic) and attempts walking with eyes closed.

  • To address functional balance during gait

Parameters: Walk 5 steps one way, turn around and walk back to start, complete this 4 times (with proper guarding); perform daily

Progression: Remove handheld support (always with proper guarding)

Stretches

[22]Seated Levator Scapula stretch
[23]Seated Upper Trapezius Stretch
Upper Fibers Trapezius (UFT)

To stretch left upper fibres, patient moves right ear to right shoulder. The same is true for stretching right upper fibres, however, patient moves left ear to left shoulder. Can perform in seated or standing.

Levator Scapula (LS)

To stretch left side, patient moves left hand to apply downward pressure at the base of the neck (left side). Then patient rotates their head to the right and brings their chin to their armpit. Stretch for the right side is performed opposite to the left. Can be performed in seated or standing.

Parameters (for both UFT and LS): Static stretch, 30 second holds x 2 repetitions 2-3xa day; performed until gentle stretch is felt (each side)

Progression: Apply overpressure in direction of head movement to increase stretch

  • Performed to complement manual therapy in addressing headaches associated with tight neck muscles (UFT and LS)

Gaze Stability Exercise

VOR X1 - In seated position, the patient holds an object stationary in front of face while turning their head from side to side as fast as they can without blurred vision, while maintaining visual fixation on the object (Note - patient must adapt their head speed to be slower if object becomes blurry) VOR X2 - In seated position, the patient repeats VOR X1, but incorporates movement of the object in the opposite direction of the head movement

Parameters: 1-2 minutes, 5x per day (can also perform with vertical head movements, but main focus with this patient is on horizontal movements)

Progression: Perform in standing position - work up to walking to make it more functional

  • Remarks: The purpose of these exercises are to improve the vestibular-ocular reflex along with associated systems that are used to perform gaze stability with head motion.[18] Patients that experience dizziness and/or vertigo with associated impairments in eye-head coordination can benefit from exercises that target the VOR. Increasing the speed of these tasks, decreasing base of support, changing directions and increasing the complexity of the environment and lighting are important variations to progress and challenge the patient throughout treatment.[24]

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 compared to baseline, changing from a constant dull and aching pain to no pain. While completing her ADLs, the dizziness she previously experienced had become little to none and she began a gradual return to work at 3 weeks into treatment. Patient noticed that her moodiness was diminishing, and she no longer became annoyed by small inconveniences (such as spilling milk). She was able to get back into grocery shopping with her fiancé without any complaints of dizziness, and the sensitivity to light decreased. The tension in her shoulders and the back of the neck become unnoticeable. As well, the patient described her ability to sleep as one of the biggest improvements, leading to feeling more rested to take on the day.

Outcome Measures

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

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

Total Score: 120 sec / 120 sec

  • Patient improved on fourth condition, increasing the score from an average of 19.3 seconds to 30 seconds

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: 30 sec

Right foot behind: 30 sec

Single Leg Stance (eyes open) Left foot: 30 sec

Right foot: 30 sec

Single Leg Stance (eyes closed) Left foot: 30 sec

(Trial 1: 24 sec; Trial 2: 30 sec)

Right foot: 30 sec (Trial 1)

  • Patient was able to complete 30 sec in both tandem stance-eyes closed and single leg stance-eyes closed bilaterally.

Functional Gait Assessment

Score: 30/30

  • "Gait with eyes closed" condition improved from mild impairment to normal (score changed from a 2, to a 3)

The Headache Impact Test (HIT-6)

Score: 42

  • Score decreased from "severe impact" to "little to no impact" on daily activities,

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 0 0 0 0
Saccades - Horizontal 0 0 0 0
Saccades - Verticle 0 0 0 0
Convergence (Near Point) 0 0 0 0 No double vision noted
VOR - Horizontal 2 1 0 0 Symptoms returned to baseline within 15s
VOR - Vertical 1 0 0 0 Symptoms returned to baseline within 10s
Visual Motion Sensitivity Test 2 0 0 0 Symptoms returned to baseline within 10s

Patient reported little to no symptoms throughout the VOMS test; where she did experience slight symptoms, they were resolved within 10-15 seconds of rest, which is significantly shorter compared to the initial assessment.

Discharge Plan

Patient has demonstrated immense improvement in symptoms since the initiation of physiotherapy. Throughout the 8-weeks of treatment she has met most, if not all of her goals. Although the patient still notes very mild symptoms with the VOR along with the Visual Motion Sensitivity Test, she is able to recover with a brief resting period. Moreover, she was able to return to work for 3 days per week, and start practicing yoga. Overall, she is satisfied with her progress and has decided to conclude her visits.

It was recommended to the patient to continue the provided exercises to maintain her status and to further improve her symptoms. The home exercise program included static neck stretches, balance exercises (along with recommendation to incorporate yoga), and education on the use of heat to further relieve pain (after clearing contraindications and precautions). The patient was told to call or email if she had any further questions, or make a new appointment if her symptoms started to get worse.

Discussion

Overall, this is a relatively straightforward case of PCS. Several important factors played a key role in the patient’s recovery. Firstly, the patient did not sustain any additional injuries during her initial fall. Because the injury was predominantly neurological, we were able to create a more focused assessment and treatment design. Due to the lack of secondary injury, considerations pertaining to musculoskeletal injuries and their impact on neurological findings did not require an in-depth investigation. Secondly, because the patient was fairly young and healthy prior to injury, the rate of recovery was predicted to be shorter, compared to an elderly patient with comorbidities such as diabetes or osteoarthritis. The patient has a background in health and fitness and was motivated to get back to pre-injury functions. As well, due to the patient’s background knowledge in nursing, the process of education was greatly facilitated. In regards to the patient's history of yoga practice, it was highly encouraged to begin and continue gradual return to practice within our treatment. Furthermore, the patient’s motivation and dedication to exercising prior to injury enabled her to persevere with her prescribed exercises, which were paramount to making progress towards recovery.       

This case study is based on a real clinical case with modifications. The case does not capture all the common assessment and treatment techniques used, and serves as an introduction or overview of some of the positive impacts physiotherapy can bring to PCS patients. Other possible manifestations of post-concussion syndrome other than those represented in this case may include cervicogenic, autonomic, and visual presentations. Recommendations for assessment, education, and treatment regarding these symptoms can be found using the Fowler-Kennedy Guidelines.[17]

References

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