Neurorehabilitation for Persisting Post-Concussion Symptoms

Publication Title: “Multi-Modal Neurorehabilitation for Persisting Post-Concussion Symptoms”

Authors: Edward A. Ross, MD; Robert B. Hines, PhD; Michael Hoffmann, MD, PhD; Kenneth Jay, PhD; Matthew M. Antonucci, DC, DACNB, FACFN, FABBIR

Published in: Neurotrauma Reports, 2023

As a researcher in the field of neurology, my fascination has always been drawn toward the intricate workings of the human brain, particularly how it responds to and recovers from injuries. This curiosity led me to spearhead a significant research study, the results of which I had the opportunity to publish in the esteemed "Neurotrauma Reports." The focus of this study was on an often overlooked yet crucial aspect of brain injury – persisting post-concussive symptoms (PPCS).

PPCS represents a constellation of symptoms, formerly labeled Post-Concussion Syndrome (PCS), that linger long after the initial traumatic brain injury, often disrupting the lives of those affected in profound ways. The complexity and variability of these symptoms make PPCS a challenging condition to treat. Inspired by this challenge, my team and I sought to explore the efficacy of a comprehensive, multi-modal neurorehabilitation program tailored to address the diverse needs of individuals suffering from PPCS.

Our Subjects

Our study was a retrospective analysis of 418 patients with a confirmed diagnosis of concussion, that were treated at our functional neurology facility. We excluded patients from the analysis if they met any of the following criteria: 1) patients under the age of 13; 2) involved in active litigation; 3) other primary established or comorbid diagnosis (e.g., attention-deficit/hyperactivity disorder, migraine, bipolar disorder, or conversion disorder); 4) failure to perform one or more components of an assessment; 5) break in continuity of treatment >2 days; and 6) incomplete data set.

After excluding patients based on our criteria, our final analysis involved 62 patients, each grappling with the effects of PPCS/concussion for an average of 2.2 years. These were individuals from various walks of life, each with their unique struggles, bound by the common thread of an injury that had left a lasting impact on their brain's functioning. Our approach was multi-faceted; we didn't just focus on one aspect of rehabilitation but integrated a range of therapeutic modalities. This included non-invasive neuromodulation, which uses electrical stimulation to promote nerve function, neuromuscular re-education exercises to improve coordination and strength, cognitive training to enhance memory and processing skills, and gaze stabilization exercises aimed at improving visual focus and balance.

The core of our treatment protocol was spread over five intensive days, during which we closely monitored both subjective and objective changes in our patients. The subjective outcomes were measured using the modified Graded Symptom Checklist (mGSC), a tool allowing patients to self-report their symptoms' severity. On the other hand, the objective measures provided us with quantifiable data on improvements in motor speed, reaction time, cognitive processing, and visual acuity. The interplay of these subjective and objective measures was crucial in providing a holistic view of the patient's progress.

Data Analysis and Interpretation

As we analyzed the data, the results were more promising than initially anticipated. There was a marked improvement in both the subjective and objective measures post-treatment. Patients with concussion symptoms reported a significant decrease in the severity of their symptoms, corroborated by tangible improvements in cognitive and motor functions. This wasn’t just a statistical victory; it was a real, palpable change in the quality of life for these individuals. For some, it meant being able to return to work or engage in social activities they had withdrawn from. For others, it was the relief from chronic headaches, dizziness, or cognitive fog that had been constant companions since their injury.

This figure, extracted from our publication, elegantly displays a scatter plot juxtaposing pre-treatment cumulative symptom scores on the x-axis with post-treatment cumulative symptom scores on the y-axis.

A pivotal feature of this plot is the dashed line, serving as a reference, marking the equilibrium where pre-treatment symptoms are equivalent to post-treatment symptoms. Points situated above this line signify an exacerbation of symptoms, whereas those below the line represent an amelioration.

Central to this graphic is the blue regression line, which, through its variance, encapsulates an "average" trajectory across all data points. This line's interpretation reveals a notable trend: patients with very low initial scores exhibited minimal improvement. This phenomenon aligns with the concept of a 'flooring effect', where individuals with lower aggregate symptom scores inherently possess limited scope for further improvement.

Our research team noted the most significant enhancements in patients with moderate to high initial severity. Our distribution of severity was not homogeneous, skewed towards mild to moderate severity. This may explain why there was a trend toward diminishing improvements as severity increased.

This illustration presents a sophisticated rank-biserial correlation statistical analysis, delineating the array of symptoms experienced by our study participants. The horizontal axis, or x-axis, examines the correlation of symptoms pre and post treatment. Here, a negative correlation means that symptoms were reduced, and the number represents how many units of post-treatment change were observed per pre-treatment unit of symptoms. You can think of this as “average symptom change”.

In this graphical representation, symptoms are arranged in ascending order of pre-post relationships, implying that those positioned higher on the chart exhibit lesser degrees of change. In contrast, those towards the bottom manifest greater alterations.

Interpreting this chart demands careful consideration. Within our study cohort, prevalent symptoms like numbness, tingling, neck pain, tinnitus, and difficulty achieving deep sleep were infrequent or mild. Conversely, it's logical that cumulative scores would exhibit more significant changes than individual scores, considering that the latter contribute to forming the former.

Nonetheless, this chart illustrates that the subjects generally experienced substantial and clinically relevant alleviation across most symptoms.

In addition to the symptoms discussed above, our team also found statistically significant (p=<0.001) improvements in: cognitive sequencing (Trail Making Test), processing speed (Digit-Symbol Coding), motor reaction time (Simple and Complex R/T), as well as visual acuity (static and dynamic). The improvement in vision translated to 1 line of visual acuity improvement, on an eye chart.

Limitations of Our Study

Despite these promising results, we were cognizant of the study's limitations. Being a retrospective study, it had inherent biases, and the absence of a control group meant we couldn't definitively attribute all improvements to our intervention alone. We also recognize that the majority of our patients were in the mild to moderate severity range.

Nonetheless, this study was a step forward in the realm of PPCS treatment. It provided valuable insights into the potential of intensive, multi-modal neurorehabilitation in providing relief even years after an injury.

My Take-Home

This research journey has been exciting, humbling, and enlightening for me. I enjoyed working with amazing clinicians and researchers from the Carrick Institute, the University of Central Florida College of Medicine, and the Veteran's Administration. It has reinforced our belief in the necessity of personalized, comprehensive approaches in neurorehabilitation. The human brain is remarkably resilient, and with the right interventions, there's a potential for recovery from concussion that we are only beginning to understand. As I continue in this field, I am driven by the possibilities that lie ahead – possibilities to further unravel the mysteries of the brain and, more importantly, to bring change to the lives of those affected by traumatic brain injuries.

Read and Download My Paper:

Dr. Antonucci
Dr. Matthew Antonucci
Doctor | Educator | Researcher
Dr. Antonucci is an experienced chiropractic neurologist, board certified in functional neurology and multiple sub-specialties, a researcher, and an international lecturer, currently seeing patients out of Minneapolis, MN. He trained extensively under Prof. Frederick R. Carrick, maintains an active private practice with licenses in multiple states, and has provided breakthrough neurorehabilitation and performance training to thousands of patients. He consults with several NFL and NHL franchises on performance training and concussion. His work has been featured on ESPN, Sports Illustrated, CBS, Fox News, and more. He has delivered more than 11,000 hours of presentations, both nationally and internationally, on behalf of the Carrick Institute. Most importantly, he is a loving husband and the father of five amazing boys, whom he hopes to inspire to follow in his footsteps.

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