By Dr. Jeff Cullers, DC, CMMP, Daytona Beach, FL
Recently I had the opportunity to witness firsthand the shortcomings of allopathic medicine in rehabilitation of patient with Post-Concussion Syndrome (PCS) and high clinical effectiveness of Medical Massage therapy. I am forever grateful for the guidance provided by Science Of Massage Institute. It is great when there is reliable clinical source is always available when therapist encounters new pathology, he or she is not fully familiar with.
In issue #2 and #3 of JMS, 2016 I read excellent article by Boris Prilutsky LMT MA on the pathophysiology of PCS and Medical Massage Therapy for the patients who suffer from it. Here are links to the original publication ‘Management Of Post-Concussion Symptoms And Post-Traumatic Encephalopathy With Medical Massage’:
PART I: https://www.scienceofmassage.com/2016/06/management-post-concussion-symptoms-post-traumatic-encephalopathy-medical-massage-part/
PART II: https://www.scienceofmassage.com/2016/09/management-post-concussion-symptoms-post-traumatic-encephalopathy-medical-massage-part-ii/
On November 12th, 2019 I encountered my first patient with severe PCS and immediately re-read Prilutsky’s article which gave me enough clinical guidance to start working on this patient.
A 28 y/o male presents to my office for a New Patient Examination/Clinical Interview seeking relief from symptoms related to multiple injuries sustained as result of a motor vehicle accident (see images below) 3 weeks prior.
Immediately after the accident he was seen in the ER, evaluated by the on-call MD and a series of CT scans were performed. The diagnosis given was a Mild Concussion, with associated sprain/strain of the spinal musculature. He was prescribed Naproxen, advised to follow up with his primary care doctor and was released.
Upon evaluation in our clinic, the patient leaning severely to the left and was complaining about severe spasm and pain in the left lower back. Upon standing up, he was antalgic, unable to ambulate without assistance from his girlfriend, suffered from staccato speech and his eyes frequently closed and rolled back. To the average person, the patient may look that that he was under the strong influence of drugs and/or alcohol.
Due to the severity of the patient’s symptoms and prior to any care rendered, the Rivermead PCS Questionnaire was conducted and filled out by the patients’ girlfriend. The RPQ is used to determine the presence and severity of somatic, cognitive, and emotional symptoms of PCS after traumatic brain injury. This form can be easily found and downloaded from Google.
The patient was mentally unable to complete the questionnaire himself, so his girlfriend had to complete it for him. Upon completion of the form his girlfriend said that the patient had been unusually verbally and physically aggressive since the accident. She made the comment:
“This is NOT my boyfriend – he never acts like this and I am very concerned”
The patient presented the same clinical symptoms as B. Prilutsky mentioned in his article and I was 100% certain the patient suffers from the set of combined psycho-somatic abnormalities that had developed as a result of a concussion and he is right now in Hypermetabolic Stage of Post-Concussion Syndrome.
I followed the steps from Part II of B. Prilutsky’s article and performed entire protocol for the PCS protocol and scheduled the patient for the PCS protocol daily for the next 5 days.
For the first 3 days, the patient was showing some progress. To tune up our therapy I reached out to Dr. Ross Turchaninov and consulted him for advice. He suggested that the patient needed to be taking a prescription strength water pill (diuretics) to reduce the immediate symptoms associated with the increase of intracranial pressure. The combination of initial intake of diuretics with continuous application of PCS protocol is going to speed up his recovery.
I immediately advised the patient to return to the ER or to a Walk-In clinic and to request a water pill prescription. The patient chose to go to a Walk-In clinic was evaluated and denied diuretics! Frustrated and angry, the patient’s girlfriend promptly drove 3 hours roundtrip to get a diuretics prescription she had.
On the 4th day, I witnessed a dramatic change. As I greeted the patient he was standing upright without assistance, smiling, speaking clearly, eyes focused and apologizing that he did not remember anything. While MM for PCS was continuously performed for PCS the speed of patient’s recovery was amazing.
At the next appointment, the Rivermead PCS Questionnaire was again given to the patient and this time he was able to complete the questionnaire on his own. The comparative results of the questionnaire were staggering. It was recommended that another series of 3 back to back MM treatments be scheduled.
On the 8th visit I was able to further and evaluate the secondary pathologies in the soft tissues that had developed as a result of the initial trauma. Examination revealed presence of the CTZs in the 1st and 2nd levels in the lower back, and Reflex Zones in the Left Quadratus Lumborum Muscle.
As of this writing, MM for PCS continues every other day and we now alternating it with MM protocols to address post-traumatic changes in his Lumbar area.
This case is excellent example of how Medical Massage when performed correctly and on time can literally change patients’ lives!
LESSONS:
1. Head and neck trauma besides causing various somatic pains and dysfunctions may trigger personality changes and the therapist must be patient and ready to deal with sometimes nasty behavior exhibited by the patient.
2. In complex clinical cases the therapist’s ability to identify the treatment’s priorities is the key for the final success. Notice that the patient came to the office with main complain about severe pain and dysfunction in the lower back, but Dr. Cullers noticed and correctly identified that despite lower back pain and dysfunction indeed were present the treatment priority is PCS.
3. Each therapist must be open minded to use whatever is available to help patient as much as and as soon as possible. Don’t get stuck with only what you were trained and currently use. Establish co-referral relations with other medical professionals and therapists. The decisive help to patients with complex clinical picture comes from comprehensive approach to their therapy when abnormalities are attacked from different directions at the same time. There is always room for adding medications, acupuncture, strengthening exercise etc., if needed. In this particular case the initial usage of diuretics additionally sped up the patient’s recovery.
4. Please use search window and Forum in our main educational website: www.scienceofmassage.com If you encounter a complex clinical case and don’t know how to proceed forward. The solution may be already there, since it was shared earlier by your colleague and published in the JMS.
Category: Blog