Neurological rehabilitation of a patient with unrelenting head pain associated with post-concussive syndrome.
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1
Georgia Chiropractic Neurology Center, United States
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2
Carrick Institute, Neurology, United States
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3
Life University, United States
Background:
A twelve Year old male patient presented to the Georgia Chiropractic Neurology center following his third traumatic head injury. He presented with unrelenting dull, aching, and sharp pain located in the head, the dull aching pain was “all over”. This pain was constant and rated as a 7 out of 10. Intermittent sharp pain was on both sides of his head and was rated as a 10/10. Sneezing, loud noises, and looking at screens such as a television or a computer caused the pain to go from a 7/10 to above a 10/10. The patient was light sensitive, sound sensitive, had stomach pains, vertigo, and blurry vision making reading impossible. Bright lights would induce diplopia (the patient described this as seeing many lights appear around one light source). The first head injury occurred when the patient fainted, hit his head on a desk and fell out of the chair hitting his head on the floor rendering him unconscious. The second head injury happened when the patient fell on the playground hitting his head, knocking himself out. The third incident, which brought him into the office, occurred when he fell and hit the anterior right portion of his head on concrete.
Methods:
The patient became nauseous during VNG (Videonystagmography) testing; this is a method of graphing out the speed and accuracy of a multitude of eye movements. He reported the world going right and thought he was falling to the right. During spontaneous nystagmus the patient had upward and rightward drifting of the eyes as well as convergence. During leftward gaze the patient had vertical oscillations, right gaze exposed torsion and horizontal oscillations. Pursuits, saccades, and optokinetics induced convergence and increased all of his symptoms. Patient had an aversion response to the light during a pupillary light response test. When the patient was stuck by a reflex hammer with force and speed on the thenar region his thumb would go into persistent spasm, percussive myotonia. Piano test where the patient wiggled his fingers as if playing a piano was slower on the left. Pincer test was slower with decreased amplitude and freezes on the left. Dysdiadochokinesia on the left with alternating elbow supination and pronation was present. The patient laterally flexes bilaterally during gait which is improved by dual tasking (having the patient repeat every other month of the year), however with dual tasking the patient developed a shuffling gait and experienced freezes. With cervical compression the patient developed pain over his entire head which was described as a higher than 10/10 pain. Trigger points were apparent in the left sub-occipital muscles and left scalene muscles. Under CAPS analysis the patient scored a 75 when standing on a perturbed surface with his eyes open, mid 60’s with eyes closed and head in rotation or flexion down to a 45 with his eyes closed and head in extension on a perturbed surface. Before treatment began the patient was sneezing every 10 seconds causing debilitating pain. Initial treatments were performed in a dim room with the patient wearing sunglasses. Complex movements of the limbs (figure eights) were attempted but they caused the patient to go into convergence and increased all of his symptoms. Passive Yes-Yes and No-No gaze stabilization exercises were attempted but they caused the patient to go into convergence and increased all of his symptoms. Due to the increase of pain and convergence, treatment was modified to consist of a single pass of a horizontal pursuit followed by a one minute rest before repeating. More than one pursuit at a time would cause a convergence and an increase in symptoms. During visit’s 6-7 the patient would only sneeze once every 15 minutes and was able to remove his sunglasses without an increase in symptoms. At this point 3 consecutive pursuits were possible without an increase in symptoms. 14 visits into care tonotopic mapping was added to the treatment plan. When initially attempting to locate an auditory stimulus the patient was grossly inaccurate. With eyes closed when asked to point at a noise coming from his waist he would point directly above himself, when noise came from the right he would point to the left. Sound localization therapy was continued over several visits until he became accurate with a randomized stimulus in all quadrants. The patient was given saccade and anti-saccade exercises as well. 27 visits into care Interactive metronome exercises with the feet were started. Myofascial work was able to be tolerated below T6 at this point, however fascial treatments applied above T6 would cause convergence and head pain. Additional eye therapy’s were added including, simultaneous eye nose saccades, and eye saccades with a simultaneous nose anti saccade. At visit 50 the patient was able to tolerate myofascial work on the neck and was given home therapy consisting of all eye exercises performed in the office.
Results:
After approximately seven months of treatment consisting of 68 visits, the patient reported a 0/10 head pain with no exacerbations of pain or convergence by any stimulus that had previously increased symptoms. Cervical compression does not cause pain in the patient, and the patient was able to return to school with no restrictions. Post CAPS testing did not show an improvement. Post testing through the VNG revealed normal ocular motility and did not induce nausea or vertigo.
Conclusion:
In conclusion, several conservative methods for rehabilitation with post concussive syndrome have shown to be effective in this patient. Further research is warranted to explore efficacy and reliability of the therapies provided to help other patients who display similar pathology.
Keywords:
post concussive syndrome,
light sensitivity,
Noise sensitivity,
concussion rehabilitation,
EYE MOVEMENT
Conference:
International Symposium on Clinical Neuroscience: Clinical Neuroscience for Optimization of Human Function, Orlando, United States, 7 Oct - 9 Oct, 2016.
Presentation Type:
Poster Presentation
Topic:
Abstracts ISCN 2016
Citation:
Ellis
M,
Arkin
JE and
Esposito
S
(2016). Neurological rehabilitation of a patient with unrelenting head pain associated with post-concussive syndrome..
Front. Neurol.
Conference Abstract:
International Symposium on Clinical Neuroscience: Clinical Neuroscience for Optimization of Human Function.
doi: 10.3389/conf.fneur.2016.59.00046
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Received:
30 Aug 2016;
Published Online:
07 Sep 2016.
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Correspondence:
Dr. Marc Ellis, Georgia Chiropractic Neurology Center, Roswell, Georgia (GA), 30076, United States, healthybrainnow@gmail.com