Presentation: A 22-year-old female was examined and treated for 4 days, by Dr. Antonucci and his team. She presented with the main complaint of severe exhaustion/fatigue, anxiety, fogginess, visual disturbances, sound sensitivity, dizziness, and headaches from a traumatic brain injury.
Assessment: The main physical exam findings were as follows: Her resting heart rate increased from 106bpm to 122bpm, in the supine and standing positions respectively, with an exacerbation of symptoms upon standing as well. Her right eye developed a down beating nystagmus during passive head rolls, and funduscopic exam revealed an ocular bobbing response (2 Hz) in the vertical plane in darkness. The patient had a right efferent pupillary defect, observed only during the indirect light response. A small-amplitude tremor was observed on her left arm when her arms were placed 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 her eyes, saccadic intrusions were present. Right finger-tap testing was given a UPDRS Grade III with numerous 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 upper extremity cantilever response that alternated 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.
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 orthoptic 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%.
Update 6/16/2017: I am so pleased to report that I received such a great email from this patient this past Monday. Nearly 2 years later, she is still feeling great. She was able to return back to college and enrolled in a pre-med program. She stated that recovering from this brain injury was a call that inspired and motivated her to pursue a career in health care. She aspires to complete her pre-med courses and wants to attend Canadian Memorial Chiropractic College, and continue her studies with the Carrick Institute, to become a chiropractic neurologist.
Antonucci MM, Sass CM, Sass BJ(2015). Brain-based Clinical Approach to a Patient with Post Concussive Syndrome and Dysautonmia. Front. Neurol. Conference Abstract: International Symposium on Clinical Neuroscience: TBI and Neurodegeneration. doi:10.3389/conf.fneur.2015.58.00085.