Multi-Modal Neurorehabilitation Strategies Improve Temporal Dementia in a 58-Year-Old Male
Background: A 59-year-old caucasian, male attorney presented to a chiropractic neurology clinic having been previously diagnosed with fronto-temporal dementia and Lyme disease by his medical neurologist, but was not currently under treatment. He had difficulty remembering names and events, making him unable to have a normal conversation. He reported experiencing stress, anxiety and depression. He stated that the onset of these symptoms occurred gradually and were not triggered by trauma, injuries or drugs.
Methods: A neurological examination revealed memory and word recall difficulties. Biomechanical dysfunction in the cervical spine was noted. Patient perception of the color red had an increased saturation in his left eye. Maddox Rod testing exhibited a right exophoria and hypertropia with left esophoria. He had equal pupil size bilaterally with an increased time to fatigue of the left pupil in response to light. Upon assessment of his smooth pursuit eye movements, there where saccadic intrusions bilaterally. Optokinetics responses were more difficult to perform in the leftward direction. Vertical Optokinetics revealed decreased gain compared to horizontal. Saccadometry testing was performed assessing the latency, velocity, and accuracy of his fast eye movements. This assessment revealed bilateral increased latency to visual stimuli, with an average latency of 191ms and an average peak velocity of 558º/s. Left sided hearing loss was noted both on exam with a Weber/Rhinne test as well as the U-hear application. There were no signs of dysdiadochokinesia upon testing. Utilizing the Unified Parkinson’s Disease Rating Scale (UPDRS) to grade a finger tapping test and facial hypomimia, he scored a Grade 2 on both bilaterally, with mirroring noted on the right during the finger tapping test. Gait analysis revealed an upper extremity bilateral protraction of the shoulders. Dual tasking with gait caused him to develop a leftward directional drift of his gait with an increased latency of strides. A Comprehensive Assessment of Postural Systems (CAPS)® was performed assessing his balance and stability on both a solid and perturbed (standing on a foam cushion) surface, with his eyes open, eyes closed, and in multiple head positions. His overall average stability score on intake was 70.51%, with a center of pressure that was posterior measuring 0.46 inches. Neurocognitive assessment was performed using C3 Logix assessment suite. Significant findings of this assessment included a decreased ability of short-term recall, reverse digit sequencing and moderate cognitive impairment. The patient exhibited the signs and symptoms consistent with a diagnosis of temporal dementia, contrary to his prior diagnosis of fronto-temporal dementia. A five-day intensive neurological rehabilitation program consisting of somatosensory evoked potential noninvasive stimulation to the left median nerve, Erb’s point and the third branch of the trigeminal nerve bilaterally. Passive neuromuscular exercises of his left extremities were performed. Vestibular rehabilitation utilizing seated times one, sinusoidal and horizontal viewing to a single target therapies were also employed. Hand-eye and cognitive coordination exercises using a DynaVision D2, and Neurosensory Integrator Technologies were also utilized. Additional treatments included cognitive recall exercises with numbers, words, and mixed number-word; interactive metronome using a footpad, downward pursuits with a single dot over upward optokinetic strip. On-vertical axis rotation vestibular rehabilitation, consisting of rotations posterior and to the right at 90° per second for 6 rotations with a leftward fixated target, posterior and to the left at 90° per second for 3 rotations with a center fixated target.
Results: After 11 treatment sessions over five days the patient made some significant improvement in cognition, balance, and cerebellar function. The most dramatic change in his balance and simple choice reaction. Vertebral artery ratio changed from 2:1 on the right with square wave jerks, to 1:1 without aberrant eye movements. The patient’s eye pursuits were steady and no longer saccadic on the horizontal plane. His balance score increased by 17.41% overall. There was a marked shift in the center pressure posteriorly by 50% on average. Upon saccadometry testing his fast eye movements were less latent (191 ms to 184 ms) with more saccades overall under the 200ms target. Gait assessment with dual tasking demonstrated that he had no hesitations or freezing. The most notable neurocognitive variable that improved, was his processing speed with digit symbol matching (48 symbols to 63) and VOR. However, he still exhibits some cognitive impairment.
Conclusion: The results of this case demonstrated the importance of specific neurological stimulation creating improved clinical outcome in this case of temporal dementia. The results of this case warrant further study utilizing chiropractic neurological assessment strategies to improve cognitive function.