PATIENT <B>CASE REPORT: </B> COMBINED NEURO-MUSCULOSKELETAL TREATMENT APPROACH FOR POST-CONCUSSION SYMPTOMOLOGY

Buchner S.¹, Kerby J.¹, Gobert D.¹

¹Texas State University, Physical Therapy, San Marcos, United States

Background: Patient: Female, 23 year-old college student, four previous mild traumatic brain injuries (mTBI). Presented with chronic post-concussion syndrome previous to November 2015 when she suffered a fifth mTBI.

Purpose: To provide patient case report of benefit of a combined neurologic and musculoskeletal approach to decrease associated layered symptomology in a patient presenting with chronic post-concussion syndrome (CPCS) complicated by an additional acute concussive event.

Methods: Initial evaluation, December, 2015, assessed muscular and neurologic impairments. Provided subject with home exercise program (HEP) to address deficits while on holiday. 7 weeks of treatment to address neurologic and musculoskeletal deficits began January 2016 to March 2016. Immediate Post Concussion and Cognitive Test (ImPACT) assessment was completed at initial evaluation, 1week, and 4 weeks. Patient was provided HEP to address deficits remaining post-treatment. Follow-up May, 2016 determined efficacy of treatment and HEP and included ImPACT final eval. Subject received treatment once per week. During treatment, posture and cervical hypomobility were addressed to decrease headache, neck pain and increase range of motion (ROM). Sessions began with measuring cervical spine restrictions followed by mobilizations to increase ROM. Neuromuscular reeducation activities using biofeedback techniques strengthened deep neck musculature and reduced compensatory muscle activation, improving posture. Subsequent neurological deficits were addressed with patient centered functional training, including but not limited to vestibulo-ocular reflex, convergence, and balance training. After each intervention respective outcomes were reassessed. Data analysis: Outcome measures included: ImPACT, Patient Specific Functional Scale (PSFS), Dizziness Handicap Index (DHI), Motion Sensitivity Score, Neck Disability Index (NDI) Balance Error Scoring System (BESS) test. Minimal detectable change normative values for each test was compared to patient change in response over time.

Results: ImPACT scores characterized initial CPCS deficit in reaction time (RT) (45%). Other items tested: memory composite score verbal (MCSVe), memory composite score visual (MSCVi), and visual motor speed (VMS) were 80% or higher. At the end of treatment, RT improved to 93%, MCSVi to 91% and VMS decreased to 75%. Total symptom score decreased from 20 at initial evaluation to 0 at follow-up. Cervical ROM improved significantly at the alpha 0.05 level post treatment.

Conclusion(s): From results gathered, a neuro-musculoskeletal based treatment approach addressed and improved patient impairments resulting in return to student ADLs at an asymptomatic state. This case report establishes the benefits of a multi-modal approach to acute and chronic concussion treatment.

Implications: Clinical relevance: mTBI patient require a relevant test cluster of neurologic and orthopedic assessments to provide a comprehensive portrayal of symptoms, optimizing treatment and subsequent outcomes.

Funding acknowledgements: Funding was provided through Texas State University, Department of Physical Therapy.

Topic: Neurology

Ethics approval: This project was approved by the Texas State IRB.

All authors, affiliations and abstracts have been published as submitted.