Failure to Improve Post-Concussive “Brain Fog” and Other Associated Symptoms, Despite Improvements in Reaction Time, Neurocognitive, Visual Tracking, and Vestibular-Ocular Function Following a 5-Day Intensive Rehabilitation Program.

Presentation: A 23-year-old male, presented with a chief complaint of brain fog and bouts of dizziness after suffering three concussions in 5-month period. His symptoms remained persistent despite pharmacological management, rest, chiropractic care, and neurofeedback.

Assessment: Patient was alert and oriented to time, place, and person. He had a significant left ptosis and left hypertropia. Gait exam revealed decreased right arm swing. Dual task with gait revealed further decrease in right arm. Auscultation demonstrated abnormal Valsalva response with ten second delay in cardio-deceleration. Ophthalmic examination revealed a V:A ratio of 2:1 in left eye with left beating nystagmus. Oculomotor examination revealed a right-greater-than-left convergence myospasm. Video Nystagmography (VNG) testing was performed and confirmed left ptosis and exposed a mild left anisocoria. Smooth pursuit testing shows saccadic intrusions predominantly in leftward direction. Saccadometry testing revealed latencies between 120 and 220. Phase plot showed decreased leftward velocity-positions and heteroscedastic distribution of saccadic positioning between 16 and 22 degrees. Posturography testing revealed a stability score of 86.305% overall average with better scores on solid surface than on perturbed surface. Neurocognitive testing revealed a symptom severity score of 29/162. Trails A recorded a time of 19.6 and Trails B a time of 36. Simple reaction time was 267 msec and choice reaction time was 340 msec. There was a 2.0 line discrepancy between visual acuity with head still and visual acuity during head motion. Normal visual acuity should have no change between head stationary and head in motion.

Intervention: A 5-day intensive treatment plan consisting of nerve stimulation, vision therapy, vestibular rehabilitation, neuromuscular re-education exercises, chiropractic manipulation, and multi-axis rotational therapy was implemented.

Outcome: After 5 days of treatment, he exhibited a decreased left ptosis. Gait examination revealed increase in arm swing bilaterally with improved speed with and without dual-tasking. Ophthalmic examination showed 1:1 ratio bilaterally with no resting nystagmus. Right convergence myospasm was decreased but still present. Stethoscope examination revealed normal Valsalva response of three seconds. Maddox rod showed no skew deviation. Video Nystagmography (VNG) testing was performed and demonstrated an improvement in smooth pursuits with no saccadic intrusions in horizontal pursuits. Optokinetic response improved significantly with increased reflexive saccades and increased amplitude. Phase plot showed a balancing of rightward to leftward eye position/velocity. Neurocognitive testing revealed a 3.44% increased symptom severity (29/162 to 30/162). Trails A improved 17.86% (19.6 sec to 16.1 sec), and Trails B improved 23.89% (36 sec to 27.4 sec). Simple reaction time decreased 12.46% (267 msec to 234 msec) and choice reaction time decreased 7.65% (340 msec to 314 msec. There was a complete resolution of his vestibular-ocular mismatch (2.0 lines of visual loss to 0.0 line.

Conclusion: 5-day, multi-sensory, intensive rehabilitation programs may be able to improve cognitive processing, vestibular-ocular parity, ocular alignment, visual tracking, autonomic integrity, without improving the commonly reported symptom of “brain-fog”. The authors propose that in some instances, “brain fog” may be unrelated to visual, vestibular, or cognitive function.