The Utility of Neuromotor Retraining to Augment Manual Therapy and Vestibular Rehabilitation in a Patient with Post-Concussion Syndrome: A Case Report

Abstract

Background and Purpose Less than half of patients discharged from the emergency department post-concussion receive patient education or follow-up care, and 10-20% of individuals will develop symptoms that last longer than six months. Current research on interventions for post-concussion syndrome (PCS) shows inconsistent results, and recommendations for effective physical therapy treatment for patients with chronic PCS are lacking. The purpose of this case report is to highlight a successful, multi-system approach to physical therapy examination and treatment of a patient with chronic PCS. Case Description This case describes a 21-year-old male who sustained a concussion 356 days prior to evaluation. He received no follow-up treatment and reported periods of worsening symptoms since the injury. Impairments in cervical range of motion and accessory mobility, vestibular and vestibulo-ocular function, and postural stability were identified. Both cognitive and emotional symptoms were also present. The patient attended eight, sixty-minute sessions over a five-week period in an outpatient setting. Comprehensive physical therapy interventions included manual therapy, vestibular rehabilitation, and neuromotor retraining aimed at restoring proper sensory integration and midline postural orientation. Outcomes Outcomes included cervical spine goniometric measurements and accessory mobility assessments. Objective measures of postural stability included the Modified Clinical Test of Sensory Interaction in Balance (m-CTSIB) and the Fukuda Step Test. The Rivermead Post-Concussion Symptoms Questionnaire (RPQ) was used to subjectively assess symptom severity. At discharge, goniometric measurements returned to within normal limits except left cervical rotation active range of motion (ROM), and both the m-CTSIB and Fukuda Step Test were within normal ranges. The RPQ score reduced from 20 to 2 demonstrating symptom resolution in all items but “headache.” Discussion PCS can affect multiple systems, necessitating a comprehensive approach to examination and intervention. Manual therapy was used to restore cervical spine ROM, vestibular rehabilitation was utilized to improve gaze stability and visual motion sensitivity, and neuromotor retraining was implemented to improve postural stability and sensory integration. Physical therapists have the ability to treat multiple systems impacted with PCS, with the potential to reduce the longevity and severity of impairments for patients. Level of Evidence Level V

Sensory sensitivity after acquired brain injury: A systematic review

“…Similarly, self‐reported discomfort when exposed to a computer screen decreased when using a non‐liquid crystal display (non‐LCD) screen (Mansur et al, 2018) that refreshed at a lower rate than a standard LCD screen. Lastly, Gunter et al (2018) and Teare‐Ketter et al (2021) described cases with light hypersensitivity after a mTBI. The cases were both symptom free after several weeks of physical therapy (no specific treatment for the hypersensitivity symptoms was mentioned).…”

Effectiveness of non-pharmacological treatments for vestibular and oculomotor dysfunction in patients with persistent post-concussive symptoms: protocol for a systematic review and meta-analysis

“… 19 Case studies have shown VOR disruption in those with PPCS. 20 21 Common complaints of vestibular dysfunction include dizziness, vertigo, nausea, fogginess, unsteady gait and postural instability. 15 22 The most common oculomotor disorders following a concussion are convergence insufficiency (affecting the ability of eyes to work together to clearly see nearby objects) and accommodative insufficiency (difficulty when focussing on a nearby object).…”

“…The vestibulo-ocular reflex (VOR) is a complex reflex that serves to maintain balance and spatial orientation by stabilising the gaze during head movement 19. Case studies have shown VOR disruption in those with PPCS 20 21. Common complaints of vestibular dysfunction include dizziness, vertigo, nausea, fogginess, unsteady gait and postural instability 15 22.…”

The Effectiveness of Non-pharmacological Treatments for Vestibular and Oculomotor Deficits in Post-concussive Syndrome: a Protocol for a Systematic Review and Meta-analysis

“…The vestibulo-ocular re ex (VOR) is a complex re ex that involves the vestibular and visual systems which functions to maintain balance and spatial orientation by stabilizing gaze during head movement (24). Case studies have shown VOR disruption in those with PCS (25,26). Common complaints of vestibular dysfunction include dizziness, vertigo, nausea, fogginess, unsteady gait, and postural instability (20,27).…”