Knowing is half the battle
A 24-year-old professional sustained a concussion in May of this year. She initially went to the ER who reassured her there was nothing ominous going on. She followed her GP’s advice with benefit and then her GP referred her to our program. She was found to have the following challenges preventing her successful reintegration to work:
1. Headache: This was assessed with a thorough history, physical exam, laboratory investigations and a headache journal. She was diagnosed with asthenopic headaches (tension-type headaches stemming from visual abnormalities) and cervicogenic headaches (headaches coming from affected structures in the neck).
2. Neck: She had right-sided occipital neuralgia (an inflammation of the occipital nerve) and leftward neck restriction related to tense muscles secondary to biomechanical abnormalities. The same biomechanical abnormalities were evident in her scapular dyskinesia (abnormal shoulder blade movement pattern) and her less-than-ideal posture. Her tight neck muscles also caused her to have positive signs and symptoms of Thoracic Outlet Syndrome caused by increased tone of the anterior and posterior scalenes and the pectoralis minor muscle. Finally, it was felt she had a condition called cervicogenic dizziness, which basically means that her neck problems are contributing to her dizziness. It is a controversial diagnosis but everyone agrees, both proponents and adversaries of the entity, that this controversy does not affect management: if someone has dizziness and neck problems, you treat both and the treatment of each condition overlaps.
3. Vestibular: She had right posterior canal Benign Paroxysmal Positional Vertigo (BPPV) and this was treated with a canalith repositioning maneuver (CRM). The vertigo symptoms abated with CRM but she had symptoms of Visual Vestibular Mismatch (VVM) that persisted. She received Vestibular therapy for this.
4. Visual: A binocular vision exam looking at visual efficiency revealed that she had accommodative excess and vergence dysfunction. Thus, vision therapy was carefully integrated into the existing treatment plan without tipping over her sensory weighting problem back to one of visual dominance (See article on VVM for more information). She continued to progress and improve.
5. Biofeedback: Also, visual tasks seemed to aggravate her headaches and neck pain so she did her vision therapy while doing biofeedback, using surface EMG electrodes. The software would then give her positive feedback when she was not over-recruiting the problematic muscles with visual tasks and this positive feedback was taken away when she recruited her trapezius and scalene muscles past the threshold that we had set for her. This allowed her to become very mindful of her muscle tension during the day and she would consciously check that several times a day until it became a habit and her pain scores improved.
6. Fatigue: She was found to have vitamin B12 deficiency and was started on vitamin B12 intramuscular shots and given dietary advice. Her energy improved with enrollment in an energy management program with our team.
7. Autonomic Nervous System: She was diagnosed with autonomic dysfunction. This was managed with a graded exercise program and with HRV training using biofeedback technology. She was then reintegrated in to more dynamic and cognitively challenging exercises. We then took her to the large testing facility where our team put her through challenges and gave her neuromuscular control exercises to strengthen the identified weaknesses.
8. Stress and Relaxation techniques: Throughout the program, in all the contexts above, she was shown how to implement mindfulness. Like this, she had first hand practical experience of how to implement the same. Using biofeedback technology, we could identify the relaxation strategies that were most relaxing for her – passive muscle relaxation, autogenic training and guided imagery – which she utilized often in her meditation or when she felt stress welling up. By then end of her time with us, a notable difference could be seen in her poise and positivity.
9. Return-to-work: She was slowly transitioned to work by gradually increasing her hours and slowly relaxing her accommodations as appropriate. She even was presented with a great opportunity to help with her return-to-work, a position she would have liked to have even if it weren’t for the concussion, so it all worked well on that front.