The Clinical Reasoning and Multi-Modal Rehabilitation Approach in a Patient with Post Concussive Syndrome Following a Moderate-TBI: A Case Study

Background: Prolonged and persistent symptoms following a concussion, also known as post concussion syndrome, are becoming more prevalent in recent literature. Multi-modal treatment is widely accepted in the treatment of patients with post concussive syndrome; however, the initiation and progression of specific interventions is still debated. Purpose: The purpose of this case report is to describe the clinical decision-making process associated with multi-modal rehabilitation options for a patient with post concussive syndrome following a moderate TBI. Case Description: A 57-year-old male referred to physical therapy 2 months following a moderate-TBI and diagnosed with post concussion syndrome. His symptoms consisted of dizziness, severe headache, cervical pain, photophobia, hyperacusis, and impaired balance. His past medical history is benign with no history of previous concussions. Intervention: The interventions utilized in this patient’s rehabilitation can be divided into four main categories: manual therapy, postural re-education, balance interventions, and vestibular inventions. His treatment consisted of 13 therapy sessions over an 8-week period. Outcome Measures: Two outcome measures were utilized in this patient’s plan of care, including the symptom evaluation section of the Sport Concussion Assessment Tool 5^th Edition (SCAT 5) and the Berg Balance Assessment. Other objective measures included pain rating, cervical range of motion, and vestibular-ocular assessments. Discussion: This case study outlines a multi-modal plan of care for a patient with post concussion syndrome. Furthermore, this case highlights the complexity and individuality associated with patients diagnosed with post concussion syndrome.