The Complexity and Variability of the Female mTBI Patient: A Case Report

Background: Mild traumatic brain injuries (mTBIs) account for 70-90% of all brain traumas, with most of this population having full recovery of symptoms within 2 to 3 months. A small percentage experience their symptoms for months or years. The variety of symptoms that patients can have presents a challenge to clinicians. Females present an additional challenge, with reports of increased severity and longevity of symptoms when compared to males. The purpose of this case report is to describe some of the challenges associated with treating a female with persistent concussion symptoms due to the variability in symptom presentation and underlying pre-morbid factors. Case Description: The patient was a 26-year-old female who went through two episodes of care with the same clinic over a 4-year timeframe due to a concussion that was exacerbated by successive head impacts. Her symptom presentation was similar in both episodes, but the interventions varied between episodes of care and produced varying results. Interventions: The second episode introduced cervical kinesthetic exercises to prevent further head impacts, which seemed to have the most impact on her recovery. Other interventions were progression of activity tolerance, scapular strengthening, and manual therapy. Outcomes: The outcome measures used were the VAS pain scale, self-reported activity tolerance, Buffalo Concussion Test, and cervical joint position test. Others that could have been used are the Headache Impact Test and Major Depression Inventory. Discussion: This case study represents the complexity of a female with a concussion injury and the difficulty with determining the cause of long-term symptoms, making the treatment challenging as well. The patient demonstrated progress when her interventions were geared towards her most aggravating symptoms and measurable outcomes were used.