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TRAUMATIC BRAIN INJURY (TBI)



Patient Presentation

A 28-year-old male, professional athlete, presented for assessment and non-invasive brain treatment. History of a traumatic brain injury and post-concussion syndrome. The primary complaint was diplopia, with secondary complaints of memory impairment and fatigue.

Previous Treatments:

Vaguely reported by the patient, including care from numerous healthcare practitioners without results.

Plasticity™ Diagnosis:

Traumatic brain injury with post-concussion. syndrome coinciding with a centrally maintained vestibulopathy.

Plasticity™ Examination and Diagnostics:

  • Patient was unable to hold his eyes still on a fixed target, exhibited square-wave jerks of the eyes.
  • These pathological eye movements superimposed all ability to track moving targets.
  • Optokinetic responses were severely compromised.
  • Had a decreased ability to generate fast eye movements.
  • Had central nystagmus that changed in frequency, direction, and intensity with different head positions, vestibular stimulation, and fixation on different targets.
  • Balance was also compromised.

Plasticity™ Prescription:

A Plasticity treatment plan including a 4-day (9-visit) intensive, outpatient, multi-modal, individualized treatment protocol consisting of nerve stimulation, eye exercises, vestibular exercises, SMART™ activities, and a self-administered at-home rehabilitation program.

Patient Outcome:

After four days of treatment, the patient demonstrated an 80% improvement in the severity and occurrence of the diplopia and stated that his fatigue and memory had improved.

 


 

Summary

A 28-year-old male professional athlete presented with a primary complaint of diplopia, memory impairment and fatigue after sustaining a brain injury four years prior.

Background

TBI or traumatic brain injury is the most common acquired brain injury, with an estimated 3.8 million documented cases in the US annually. A traumatic brain injury occurs when there is a rapid acceleration, deceleration, or twisting of the head, causing diffuse axonal shearing and injury to brain tissue. Most mild traumatic brain injuries are termed “concussions” and research suggests that the majority of them are self-resolving within 6 months. However, over 6 million individuals are currently living in the United States with persistent symptoms from a head injury.

Case Presentation

The patient was a 28-year-old male, professional athlete, that had sustained a traumatic brain injury four years prior. He experienced a loss of consciousness (LOC) for an unknown period of time, greater than 30 minutes. Post-injury he was in a comatose state for a period, and then developed partial seizures following the injury. His main complaint was diplopia when looking down, particularly down and left. He also was experiencing memory impairment and fatigue. He had sought the care of numerous healthcare practitioners without any significant change in his post-injury symptoms. Upon examination, the patient presented with a left hyperopia and a right head tilt while in the seated position. During the exam, the patient showed facial twitching on the right side and nystagmus when looking at a target in the upward vertical plane. During gait, the patient had a decreased left-arm swing and his body deviated to the left. During dual tasking, the right arm swing decreased and was maintained after the dual task was over. Low amplitude vestibular ocular reflex (VOR) stimulation caused a right beating nystagmus, whereas a high-velocity Halmaygi head thrust and a VOR stimulation in the roll plane attenuated the nystagmus. The patient had no nystagmus during accommodation. When patient covered his right eye, nystagmus occurred in his left eye during accommodation. Maddox Rod testing revealed the right eye to be deviated downward in the horizontal plane and deviated outward in the vertical plane.

Diagnostic Testing Yielded the Following:

  • Vorteq® HIT: head and the eyes moved in the same direction of left anterior stimulation, with a VOR gain of 0. They had a VOR gain of 1 for eyes and head with right anterior stimulation.
  • Video Nystagmography (VNG) and saccadometry testing: right square wave jerks (SWJ) in total darkness. They were more stable vertical gaze vs horizontal gaze holding. He exhibited horizontal SWJ activity throughout vertical pursuits, which attenuated at faster speeds of 0.2 and 0.4 Hz. He had velocity storage perseveration with right SWJ activity at the end of rightward OPK and large right SWJ activity during leftward OPK. His upwards optokinetic nystagmus was absent, with a right-beating nystagmus overlaying downward OPK. His rightward saccades more unstable in gaze holding than leftward saccades. He had decreased velocity of vertical saccades.
  • CAPS® Balance Testing: The patient deviated posterior and to the right when eyes were closed and on a stable and perturbed surface.

Treatments

Based upon the physical examination of the patient and his diagnostic findings, a 4-day, 9-visit, intensive, outpatient, multi-modal, the individualized treatment protocol was prescribed. Repetitive Peripheral Somatosensory Stimulation were applied at various landmarks on the patient’s body, one of which was a 6-step gait-retraining protocol. Vision training exercises were prescribed and performed consisting of four separate variations of head and eye movements including optokinetic environmental simulation. SMART™ activity was performed in a MARC™ device, consisting of right yaw and posterior pitch beginning at 60º/sec and accelerating to 90º/sec over 2 sessions. The remaining sessions were performed in combinations of right and left yaw.

Outcome & Follow Up

After four days of treatment, the patient had an 80% improvement in the severity and occurrence of the diplopia, and stated that he felt that his fatigue and memory had improved. An at-home care plan was prescribed and practiced with the patient which consisted of a five-part, self-administered protocol including head, eye, and body movements, specific to his neurological integrity.

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