Brain-Based Clinical Approach to a Patient with Post Concussive Syndrome and Dysautonmia
Presentation: A 22 year old female visited our clinic in Atlanta, GA from 8/22/2015 to 8/25/2015. She presented with the main complaint of severe exhaustion/fatigue, anxiety, fogginess, visual disturbances, sound sensitivity, dizziness, and headaches.
Assessment: The main physical exam findings were as follows: Her blood pressure increased from 106bpm to 122bpm from supine to standing, with an exacerbation of symptoms upon standing as well. The right eye developed a down beating nystagmus during passive head rolls, and fundiscopical exam revealed an ocular bobbing response (2 Hz) in the vertical plane in darkenss. The patient had a right efferent pupillary defect, observed only during the indirect light response. A small amplitude tremor was observed on the left side with the arms in a wing beating position. Pinwheel responses were increased on the right face and left body distributions. Sound lateralized to the right ear during Weber’s test. During vertical pursuit activity with the eyes, saccadic intrusions were present. Right finger tap testing was given a grade III with hesitations. The patient elicited exaggerated plantar responses with a withdrawal response on the right. Otoscope exam revealed vegetation on both tympanic membranes. During gait, the patient had a decreased right arm swing with left UE cantilever response that switched to the right side during dual tasking. CAPS balance scores with eyes closed and on a perturbed surface had a stability score of 48%. She fell with her eyes closed and head extended.
Impression: She exhibited the signs and symptoms associated with a post concussive syndrome complicated with a centrally maintained vestibulopathy and dysautonomia.
Intervention: Based on the above findings, we started a course of treatment including tilt table therapy, vestibular rehabilitation, eye exercises, and repetitive peripheral somatosensory stimulation. The treatment comprised of chair rotations, gaze stability with head movements, and iPad exercises.
Outcome: At the end of our 4 day treatment, she had complete resolution of her dysautonomia symptomatology, normal finger tapping bilaterally, improved gait, as well as improvements energy, balance, independent activities. She did not fall during CAPS testing and her stability score with eyes closed on a perturbed surface improved to 72%.
Acknowledgments: The authors would like to thank Dr. Frederick Carrick and the Carrick Institute of Graduate Studies for the training and clinical neuroscience.
The authors would like to also thank Dr. Marc Ellis for the temporary utilization of his facilities for which this patient was seen and treated.
The authors would also like to thank Dr. Kelsey Brenner, Dr. Stuart Rutledge, Dr. Lon Kalapp, Dr. Eduardo Fontana, Dr. Ben Berendt for their assistance in patient treatment