Case Studies

Below is a collection of abstracts published in the publication Frontiers: Neurology. Each case was attended by Dr. Keiser and presented in poster presentations at the International Symposium on Clinical Neuroscience.

Cyclical daily vomiting following a mild traumatic brain injury.

Abstract:

Objective: The purpose of this case study is to describe the symptomatology and neurological improvement in a patient suffering from an acute mild traumatic brain injury (mTBI) following an intensive multi-modal neuro-rehabilitative program.

 

Clinical Features: A 24 -year-old male presented with a history of multiple concussions and a current mild TBI after experiencing a loss of consciousness in the shower, striking his head 10 days prior. Noted symptomatology included the following: Cyclical daily vomiting, nausea, fatigue, dizziness, headaches, paresthesia, photophobia, hyperacusis, and poor balance. A functional neurological examination revealed optokinetic and vesitbulo-ocular abnormalities, hesitations in rapid alternating movements and mild dysmetria of the left upper and lower extremities.

 

Interventions and Outcomes: The patient was seen thirteen times over a 4-day period. A patient specific protocol was designed utilizing a combination of vestibular rehabilitation, optokinetic exercises, electrical stimulation protocols, and neuromuscular re-education. Post treatment exam findings showed significant subjective improvement, including cessation of rapid unexplained vomiting and feelings of dizziness, nausea and fatigue. Objective improvements included regulation of the vestibulo-ocular reflex, improved optokinetics, and rapid alternating movements of the upper extremity.

 

Conclusions: Utilizing findings from a functional neurologic examination, an intensive multi-modal neuro-rehabilitation program was developed and implemented to address functional deficits following a mTBI. In response to a 4-day treatment protocol, the subject demonstrated significant subjective and objective improvement. The results of the study are limited to a single patient and further research is encouraged to determine if results can be replicated in similar conditions.

Front. Neurol. Conference Abstract: International Symposium on Clinical Neuroscience: TBI and Neurodegeneration. doi: 10.3389/conf.fneur.2015.58.00039

Postural orthostatic tachycardia syndrome secondary to mild traumatic brain injury

Abstract:

Objective: Symptom resolution in an individual with postural orthostatic tachycardia syndrome (POTs) sustained from a mild traumatic brain injury.

 

Clinical Features: The patient is an 14-year-old Female Soccer player who presented with a 16 month history of post-concussive symptoms she sustained from hitting her head after tripping on a soccer ball. Positive symptoms included brain fog, fatigue, irritability, lethargy, neck discomfort, difficulty with reading, concentration, difficulty with falling asleep, poor appetite and headache. On examination the following were observed: Grade 3 hypomimia with a decrease in affect. Blood pressure(BP) seated 81/60 with a heart rate of 86 bpm to a standing BP of 80/63 with heart rate of 118 bpm. Dysmetria was observed with finger-nose-finger testing, rapid pronation and supination and heel to shin on the left side. Videonystagmography (VNG) testing revealed large amplitude left beating nystagmus and poor tracking with upward pursuits. Increased latencies were noted in vertical saccades. Optokinetic responses (OKR) in the horizontal plane were variable to the right and showed elongated slow phases to the downward stimulus. Computerized dynamic posturography (CDP) revealed a 77.5% stability score with eyes open on a perturbed surface and 65.7% stability score with eyes closed on a perturbed surface.

 

Interventions and Outcomes: A case specific intensive multi-modal neurorehabilitation protocol was designed including tilt table rehabilitation, oculomotor therapy, exertion training and vestibular therapy, over a five day period. Post-treatment findings were decreased headache intensity and frequency, normalization of affect and hypomimia, coordination of upper and lower extremities, and resolution of POTS phenomenology. VNG revealed normal vertical pursuits, saccades and OKR in horizontal and vertical planes. CDP stability scores increased to a 78.8% stability score with eyes closed on a perturbed surface.

 

Conclusions: Intensive rehabilitation addressed signs and symptoms in a patient with POTS secondary to post concussion syndrome. The subject demonstrated significant improvements subjectively and objectively after five days of therapy. Further investigation may establish a therapeutic approach for other individuals with POTS and/or Post Concussion Syndrome.

Front. Neurol. Conference Abstract: International Symposium on Clinical Neuroscience: Clinical Neuroscience for Optimization of Human Function. doi: 10.3389/conf.fneur.2016.59.00090

Focal myoclonus following vestibular concussion: A diagnostic and treatment perspective.

Interventions and Outcomes: A case specific intensive multi-modal neuro-rehabilitation protocol was designed including a modified anterior canal repositioning maneuver, vestibular rehabilitation, neuromuscular reeducation, electrical stimulation and spinal manipulative therapy over an initial 2 day period, with a 5 day follow-up after a period of two months. Post-treatment findings

Abstract:

Objective: Successful treatment of an individual with post-concussive vertigo with paroxysmal focal myoclonus is described.

 

Clinical Features: The subject is a 27-year-old male former collegiate football player with a history of “10 or more” concussions. The most recent of which occurred from a slip-and-fall on ice in which he struck his head. Symptoms evolved rapidly into “severe migraines”, right arm pain, vertigo and focal myoclonus exacerbated in a head down position. On examination the following were observed: Up and left beating nystagmus with vision occluded, abnormalities in right and down gaze, horizontal and vertical pursuits and optokinetic responses (OKR), clonus in the right ankle, dysrhythmia in the upper and lower extremities and gait abnormalities with loss of associated movements. 

 

revealed an attenuation of his myoclonus, dizziness, arm pain and vertigo. No nystagmus was observed in occluded vision, gaze, pursuits and OKR were normal. Improvements were also seen in gait and rapid alternating movements in the upper and lower extremities among other findings.

 

Conclusions: Utilizing findings from a functional neurological exam, an individual protocol of intensive multi-modal neuro-rehabilitation was devised and implemented. Following the execution of the protocol he had an improvement in symptomatology and neurological findings. With further investigation, it may provide a therapeutic approach for other individuals with focal myoclonus.

Front. Neurol. Conference Abstract: International Symposium on Clinical Neuroscience: TBI and Neurodegeneration. doi: 10.3389/conf.fneur.2015.58.00062

Intensive multi-modal neuro-rehabilitation program for a case of post-concussion syndrome in a professional hockey player.

Abstract:

Objective: Neurological improvements in a professional hockey player suffering with post-concussive syndrome (PCS) following an intensive multi-modal neuro-rehabilitation program is described.

Clinical Features: The subject is a 33-year-old male with a history of multiple concussions, the latest of which occurred one month prior and arrested his ability to play hockey. His symptoms included “blurry vision, dizziness and neck pain.” Examination revealed poor optokinetic responses (OKR), aberrancies in right-sided rapid-alternating movements (RAM) of the upper and lower extremities and loss of associated movements in gait, worsened by dual tasking.

 

Interventions and Outcomes: A patient specific protocol was designed utilizing a novel combination of electrical stimulation protocols, neuromuscular re-education, vestibular rehabilitation both in the lab and on the ice in 3 one-hour sessions daily for 5 days. Post-treatment exam findings include normalization of OKR, RAM and gait parameters, as well as subjective amelioration of dizziness, blurred vision and neck pain. Of significance, other neurological functions also improved, and he was able to return to competition.

Conclusions: Utilizing findings from a functional neurological exam, an intensive multi-modal neuro-rehabilitation program was developed and implemented to address functional deficits following PCS. In response to the 5-day treatment, the subject demonstrated significant subjective and objective improvement that allowed him to return to competition. With further investigation, this may provide a form of therapy for other individuals with PCS.​

Front. Neurol. Conference Abstract: International Symposium on Clinical Neuroscience: TBI and Neurodegeneration. doi: 10.3389/conf.fneur.2015.58.00053

Benign paroxysmal positional vertigo (BPPV) following a concussion.

Abstract:

Objective: Symptomatology and neurological improvements in a hockey player suffering from post-concussive syndrome (PCS) following an intensive multi-modal neuro-rehabilitation program is described.

 

Clinical Features: The subject is an 18-year-old male suffering from the symptoms of BPPV following a concussion sustained in a hockey game. Symptomatology included vertigo, nausea, dizziness, difficulty concentrating, and headaches. A neurological evaluation revealed a positive Dix-Hallpike test for the left posterior canal, global hyporeflexia, abnormal gait with dual tasking, aberrant optokinetic responses (OKR) on videonystagmography (VNG), and disturbances in balance with computerized dynamic posturography (CDP).

 

Interventions and Outcomes: A patient specific protocol was designed utilizing a combination of electrical stimulation protocols, neuromuscular re-education, vestibular rehabilitation and optokinetic exercises. The patient was treated seven times in five days. Pre and post CDP testing was performed standing with feet parallel to a line and perturbation of head in neutral, pitched forward, backward, right and left yaw. Pre and post findings were noted showing an upward trend in stability scores. VNG showed improved OKR. Gait abnormalities with dual tasking, and global hyporeflexia also showed improvement. Symptomatology associated with BPPV showed significant improvement.

 

Conclusion: Utilizing findings from a functional neurologic examination, an intensive multi-modal neuro-rehabilitation program was developed and implemented to address functional deficits following PCS. In response to the five-day treatment, the subject demonstrated significant subjective and objective improvement. The results of the study are limited to a single patient and further research is encouraged to determine if results can be replicated in similar conditions.

Front. Neurol. Conference Abstract: International Symposium on Clinical Neuroscience: TBI and Neurodegeneration.doi: 10.3389/conf.fneur.2015.58.00061

Headache and Cognitive dysfunction: A diagnostic and treatment perspective.

Abstract:

Objective: Successful treatment of an individual with headache and cognitive dysfunction is described.

 

Clinical Features: A 58-year-old female presented for consultations in a chiropractic neurology facility with a history of bilateral frontal headaches and cognitive dysfunction following a motor vehicle collision. Chief complaints included difficulty concentrating, amnesia, brain fog, fatigue, difficulty falling asleep. Videonystagmography (VNG) and physical exam reveal failure of left eye adduction with convergence, horizontal square-wave jerks in vertical gaze and optokinetic responses (OKR). In-phase hypermetric square wave intrusions were present in horizontal and vertical pursuits, fast phase re-correction were absent on leftward and upward optokinetic stimulation. Gait abnormalities were observed with loss of left arm swing and dual tasking decreasing arm swing bilaterally.

 

Interventions and Outcomes: An intensive multi-modal neurorehabilitation protocol was designed utilizing electrical stimulation, vestibular rehabilitation, neuromuscular re-education over a 5 day period. Post-treatment VNG findings revealed an attenuation of jerks in vertical gaze and OKR. Horizontal and vertical pursuits and OKR were normal. Improvement in arm swing was also observed in both casual and dual-tasking gait, and subjective complaints of headache, brain fog, poor concentration and fatigue showed subjective improvement.

 

Conclusions: Utilizing findings from a functional neurological exam, an individual protocol of intensive multi-modal neurorehabilitation was devised and implemented. Following the execution of the protocol the subject had an improvement in symptomatology and neurological findings.

Front. Neurol. Conference Abstract: International Symposium on Clinical Neuroscience: Clinical Neuroscience for Optimization of Human Function. doi: 10.3389/conf.fneur.2016.59.00074

Mixed clinical results following multimodal treatment of a hockey coach with chronic, progressive post-concussion syndrome

Abstract

Background: A 40-year-old male hockey coach presented to a chiropractic neurology clinic with right-sided headaches, mental fogginess, anxiety, slowness with thinking, and a general lack of motivation. He also complained of blurred vision and hyperacusis. He described tightness in his right leg and generalized pain on the right side of his body. The patient had a history of six concussions from playing hockey with symptoms progressing gradually over the past 12 years.

 

Methods: Postural findings utilizing Computerized Dynamic Posturography (CDP) revealed widespread instability with eyes open and closed in multiple head positions including right and left rotation, as well as flexion and extension. When placed on a perturbed surface with the eyes closed and the head in an extended position he had a low stability score of 54.7%. Videonystagmography (VNG) was employed to quantitatively measure eye movements. A finding of hippus was observed in all directions of fixed gaze as well as in horizontal pursuits and upward and downward saccades. Saccades were found to be hypometric. Optokinetic (OPK) testing revealed low amplitude movements with protracted slow phases with leftward, rightward and downward stimulation. Examination of the patient’s gait showed a decreased right arm swing with freezes on dual tasking. Sensory findings included pinwheel and light touch hypoesthesia at multiple dermatomes, and hyperesthesia to vibration at the patient’s left knee. The initial working diagnosis was post concussive syndrome (PCS). A five-day treatment plan was implemented which focused on neuromuscular re-education and vestibular rehabilitation, including gaze stabilization and cortical exercises targeted at stimulating deficient neural networks.

 

Results: Upon completion of five days of multiple rounds of treatment, his CDP improved overall and his most unstable position of eyes closed, perturbed surface, head extended improved to a stability score of 74.6%. Eye movements assessed by the VNG found that the patient’s gaze holding, pursuits, and saccades became normalized in all directions without hippus or hypometria. Also, the OPK reflex had improved amplitude in all directions of stimulation. His subjective findings, such as headaches, showed mild improvement in intensity and duration; however, there was no improvement in his mental fogginess or anxiety levels. The patient was discharged with a home therapy program targeting the same neural networks with recommendation of biweekly follow-up e-mails to track results.

 

Conclusion: Short-term clinical treatment resulted in positive objective outcomes with moderate subjective improvement. Further research into the long-term brain-based treatment of PCS is recommended to better understand the presence of a potential subjective and objective correlation for this case.

Front. Neurol. Conference Abstract: International Symposium on Clinical Neuroscience: Clinical Neuroscience for Optimization of Human Function. doi: 10.3389/conf.fneur.2016.59.00033

A novel treatment and diagnostic approach to myoclonus and restless leg syndrome.

Abstract

Objective: Discuss improvements in myoclonic jerks and restless leg syndrome (RLS) following intensive neuromuscular and vestibular rehabilitation.

 

Clinical Features: Male subject was 53 years old with a history of myoclonus in his legs, back, and shoulders that began 30-40 years ago with RLS. Upon examination the following was observed: eye-head strategy during pursuits vertically and leftward, irregular optokinetic responses (OKR), square wave jerks throughout videonystagmography (VNG) testing and bedside examination at the same frequency as myoclonic jerks, a fall on dynamic posturography with subject on a perturbed surface with eyes closed and head extended (PSECHE), and myoclonic jerks during muscle stretch reflex (MSR) of the bilateral patella, brachioradialis, and biceps.

 

Interventions and Outcomes: The subject was seen for a five day period including testing/examination day one, three daily treatment sessions the following four days, and post-treatment evaluation the final day. Vestibular rehabilitation and neuromuscular re-education was implemented in the clinic including gaze stabilization exercises, electrical stimulation procedures, and therapeutic application of light into the left eye from the lateral field. Marked improvement was observed on day five with resolution of eye-head strategy during pursuits, reduced amplitude of myoclonus during percussion of MSRs, improved stability score during dynamic posturography including a change from 0% to 63% with PSECHE, and the subject reported a reduction in restless leg activity. Square wave jerk activity persisted during VNG testing and during bedside examination

 

Conclusions: Intensive rehabilitation impacted long-standing RLS myoclonus in a male subject’s legs, back, and shoulders. While full resolution was not achieved, the subject demonstrated a significant reduction in frequency and amplitude of jerks after five days of therapy as well as a reduction in activity of restless legs. Further investigation may establish a therapeutic approach with expanding improvements for individuals with hyperkinetic movement disorders.

Front. Neurol. Conference Abstract: International Symposium on Clinical Neuroscience: Clinical Neuroscience for Optimization of Human Function. doi: 10.3389/conf.fneur.2016.59.00080

Post-concussive cervical dystonia and chronic frontal headache: A diagnostic and treatment perspective.

Abstract

Clinical Features: An 18-year-old male hockey player presented to a chiropractic neurology clinic with post-concussive symptoms following a fall backwards on the ice without striking his head. After resting for the better part of the season, he returned to play and was subsequently cross-checked from behind which re-aggravated his symptoms of stiff neck, supraorbital headache, fogginess, fatigue, dizziness, akathisia, and “drunk feeling” that had persisted for over 12 months.

 

Methods: Videonystagmography (VNG) was employed to quantitatively measure oculomotor strategies. Findings included mild upward drift with vision occluded. Upward vertical pursuits were contaminated with square wave jerks to the right. Increased latencies measured in horizontal and vertical saccades. Optokinetic responses (OKR) in the horizontal plane were variable in frequency and amplitude to the left. Vertical OPK were adequate, but with mild convergence in the upward direction. Mild bilateral postural tremor noted in the upper limbs. Mild hyperalgesia noted in the left trigeminal nerve distribution. Loss of associated arm swing in the right upper limb during casual and dual-tasking gait. A case specific intensive multi-modal neurorehabilitation protocol was designed including vestibular rehabilitation, oculomotor training and visual therapy, over a three-day period.

 

Results: Post-treatment findings revealed attenuation of tremor, equalization of sensation in the trigeminal distribution, decreased headache, increased cervical range of motion, and normalization of gait. VNG testing measured normalization of gaze, pursuits, saccades, and OKR in horizontal and vertical planes. Complaints of stiff neck, supraorbital headache, fogginess, fatigue, dizziness, akathisia, and disequilibrium showed improvement on subjective assessment.

 

Conclusions: Utilizing findings from a functional neurological exam, an individual protocol of intensive multi-modal neurorehabilitation was devised and implemented. Following the execution of the protocol the subject had an improvement in symptomatology and neurological findings. With further investigation, it may provide a therapeutic approach for other individuals with cervical dystonia and chronic frontal headache.

Front. Neurol. Conference Abstract: International Symposium on Clinical Neuroscience: Clinical Neuroscience for Optimization of Human Function. doi: 10.3389/conf.fneur.2016.59.00081

Focal dystonia and greater occipital neuralgia secondary to post concussion syndrome in a professional hockey player.

Abstract

Objective: Demonstrate resolution of focal dystonia, greater occipital neuralgia, and post concussive symptoms following neuromuscular re-education and vestibular rehabilitation program.

 

Clinical Features: Male subject was 25 years old with a history of four concussions since the age of 17. Most recent concussion occurred with a blind-sided hit to the right side of his head leading to his current symptomatology. Subject reported difficulties with headaches, fogginess, head pressure, fatigue, neck pain, and a long standing low back pain extending in to left buttock and the posterior compartment of the left lower extremity. He also reported a history of three surgeries for femoroacetabular impingement syndrome on his left and one on his right. Examination revealed irregular optokinetic responses (OKR), catch up saccades with rightward pursuits, abnormal eye-head saccades, a positive slump test, and decreased speed of finger-tapping test (FTT) on the right and Grade I on the left on the unified Parkinson’s disease rating scale (UPDRS).

 

Interventions and Outcomes: A five day treatment protocol was implemented incorporating vestibular rehabilitation neuromuscular re-education and sport-specific athletic drills. Marked improvement after the protocol was observed with: normalized OKR, negative slump test with mild right-sided tightness, and normalized pursuits, FTT, and eye-head saccades. The patient noted resolution of headaches, fogginess, head pressure, fatigue, neck pain, and low back pain.

 

Conclusions: Intensive rehabilitation addressed signs and symptoms in a patient with focal dystonia of the hip extensors, as well as occipital neuralgia secondary to post concussion syndrome. The subject demonstrated significant improvements subjectively and objectively after five days of therapy. Further investigation may establish a therapeutic approach for other individuals with greater occipital neuralgia, focal dystonia and/or post-concussion syndrome.

 

Key Words: Post concussion syndrome, PCS, vestibular rehabilitation, neuromuscular re-education, dystonia, greater occipital neuralgia, femoroacetabular impingement, hip impingement.

Front. Neurol. Conference Abstract: International Symposium on Clinical Neuroscience: Clinical Neuroscience for Optimization of Human Function. doi: 10.3389/conf.fneur.2016.59.00089

Pre-treatment Balance ellipse with eyes closed and head extended. 46.5%

Post-treatment Balance ellipse with eyes closed and head extended. 71.0%