left and down directions. Optokinetic gain was reduced in up and left direc-tions. Choice reaction time was slow. Left head impulse testing produced saccadic refixations. Antisaccade test-ing showed 20% error rate and pro-duced significant anxiety, testing also produced an increase in headache. mCTSIB balance testing produced significant sway which required assis-tance to prevent falls in head neutral, right, left and up conditions. Cervical spine joint position error was signficant in all directions. Other physical exam-ination procedures including: cranial nerve assessment, muscle tone, tandem stance, tandem gait, dual task gait, cervical orthopedic testing was unre-markable. A 34 year old family physician pre-sented with PPCS of 22 months dura-tion. She was injured when a contrac-tors ladder fell on her head as she was leaving her home. The ladder knocked her to the ground and she lost con-sciousness for approximately 3 min-utes. At the time of presentation previ-ous treatment included: vision therapy, cognitive behavioural therapy, psycho-therapy, cervical manual therapy, sub-occipital nerve blocks, neurofeedback, aerobic training, and clonazepam. Previous diagnostics included: MR imaging, CT scan, radiographs, ECG, and blood panel, all of which were unremarkable Her symptom burden on initial as-sessment included: significant brain fog and irritability, dizziness, neck pain, headaches, emotional liability, poor concentration, light-headedness with orthostatic change and depersonaliza-tion. She scored 58 on RPQ, 100 on PCSS and 16 on PHQ-9. Physical examination was completed and revealed: a pleasantly interactive woman, with good attention. Pulse 88, seated right sided BP 118/71, left sided BP 116/68. Oxygen saturation was 98%. Gait was grossly normal. Upper and lower extremity light and sharp touch, as well as, joint position sense was normal. Pathological reflexes were absent. Reflexes were 2+ bilaterally at all levels. No evidence of pyramidal paresis, atrophy, flaccidity, spasticity or motor spontaneity noted. Orthostatic www.Cndoctor.ca CASE 2 vital sign assessment was completed, findings were as follows: 5 minutes supine HR and BP: 62bpm and 118/70mmHg, 3 minutes standing HR and BP: 79bpm and 124/72mmHg, 7 minutes standing HR and BP: 107bpm and 121/74mmHg. During the 7 min-utes standing the patient expressed an increase in headache and excessive emotionality. These values met the clinical criteria for the diagnosis of postural orthostatic tachycardia syn-drome (POTS). Infrared VOG assess-ment revealed horizontal saccadic in-trusions and convergence spasms with vision occluded. Bedside near point convergence revealed divergence spasm at 8 and 11cm. Antisaccade error rate was 30% with long latencies. Optoki-netic gain was reduced in all directions, following the stimulus the patient felt significant dizziness. Luria’s three step test was abnormal on left. Rapid alter-nating movement testing revealed apraxia on the left. Vertical gaze hold-ing produces eye pain and patient was unable to maintain fixation. CTSIB balance testing revealed significant sway in the medial-lateral direction which was exacerbated in head up and left conditions. Other physical exami-nation procedures including: cranial nerve assessment, muscle tone, head impulse testing, vestibulo-ocular reflex exam, tandem stance, tandem gait, dual task gait, cervical orthopedic test-ing was unremarkable. treatment that matched their clinical dysfunctions. These strategies in-cluded: gaze stabilization training, oc-ular-movement exercises (smooth purstuts, saccades, OKN, conergence), spinal and extremity manupulation, motor coordination interventions, re-petitive peripheral nerve stimulation, somatic sensorimotor complex move-ments, isometric contractions, and di-aphragmatic breathing. Each case had a unique element of treatment: Case 1 performed whole body on axis rota-tions with simultaneous VOR cancella-tion. Case 2 began treatment supine and was gradually elevated until her HR increased 10bpm at which point she was lowered 10 degrees and the treatment previously mentioned was performed. OUTCOMES MULTISYSTEM MANAGEMENT APPROACH In Case 1 the author made a clinical diagnosis of persistent post-concussion symptoms with vestibulo-oculomotor dysfunction, motor coordination im-pairment and cervical spine musculo-skeletal impairments. Case 2 was diag-nosed with persistent post-concussion symptoms and a clinical diagnosis of POTS. Each patient was educated about PPCS and Case 2 was educated about the clinical POTS diagnosis and that this should ideally be made through passive tilt table testing and medical evaluation. Management strat-egies were offered by the author and both patients decided to participate in an individualized, targeted, multisys-tem neurorehab program. Both patients received targeted Both patients demonstrated significant improvements in their PPCS symp-toms as measured by the PCSS, RPQ and PHQ-9. Following 15 consulta-tions Case 1 reported a score of 2 on PCSS, 2 on RPQ and 0 on PHQ-9. She also reported complete resolution of all subjective complaints. Following 12 consultations Case 2 reported a score of 6 on PCSS, 4 on RPQ and 2 on PHQ-9. Upon standing during ortho-static vital sign assessment her HR in-creased 10bpm initally and returned to supine resting levels within 2 minutes. She also reported significant improve-ments in her brain fog, irritability, emontional liability, lightheadedness and depersonalization. This short case series demonstrates subjective and objective improvements in the symp-toms and fuction of two females with PPCS following a multisystem, individ-ualized, and targetted rehab program to address their specific dysfunctions. REFERENCES Polinder, S., Cnossen, M. C., Real, R. G., Covic, A., Gorbunova, A., Voormolen, D. C., ... & Von Steinbuechel, N. (2018). A multidimensional approach to post-concussion symptoms in mild traumatic brain injury. Frontiers in neurology, 9, 1113. McCrory, P., Meeuwisse, W., Dvorak, J., Aubry, M., Bailes, J., Broglio, S., ... & Vos, P. E. (2017). Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. British journal of sports medicine, 51(11), 838-847. Schneider, K. J., Iverson, G. L., Emery, C. A., McCrory, P., Herring, S. A., & Meeuwisse, W. H. (2013). The effects of rest and treatment following sport-related concussion: a systematic review of the literature. British journal of sports medicine, 47(5), 304-307. July/August 2022 Chiropractic and Naturopathic Doctor 17
Chiropractic + Naturopathic Doctor July/August 2022: Page 17
