Questions 1. What is your interpretation of these findings? 2. What is an appropriate plan of care for this patient? Responses 1. Interpretation : The patient’s initial history of vertigo is suspect for vestibular neuronitis. The positive HIT to right confirms right unilateral vestibular hypofunction. Given that vestibular neuritis can result in posterior canal BPPV due to otolith degeneration, the positive right Hallpike-Dix test is not a surprising finding. The persistent left lateral nystagmus may present as a confounding finding. However, recall that Case study 2 The patient is a 32-year-old female stockbroker who presents to physical therapy as referred by her primary care provider. She has had persistent vertigo and imbalance for the past few days and is finding it difficult to perform her job; she becomes severely dizzy and nauseated when trying to read the stock ticker boards on the floor of the stock exchange. She denies prior illness or injury. Her PMH is unremarkable. Examination : Normal sensorimotor examination noted. Oculomotor examination with Frenzel lenses reveals right- beating nystagmus with central gaze, which increases with gaze to the right. Vestibular testing reveals a positive HIT on the left. Gait assessment is normal, with mild loss of balance with head turns to the left. The mCTSIB reveals increased sway on conditions 3 and 4 without loss of balance. DVA testing reveals a 4-line degradation. DGI score is 23/24 with difficulty walking with head turns. Questions 1. What is your interpretation of these findings? 2. What is an appropriate plan of care for this patient? Case study 3 The patient is a 70-year-old community-dwelling male with a chief complaint of difficulties with balance and occasional dizziness on getting out of bed. His balance has been slowly worsening over the past 2 years, and he has started using a cane for his balance, especially when walking to the bathroom at night. PMH is remarkable for cervical spinal stenosis, changes in hearing with recent hearing aids, and hypertension for which he takes Lisinopril. The patient wears bifocal lenses. He denies a history of falls, aural fullness, and tinnitus. He has no recent medical events, swims regularly at the local YMCA, and lives in a private house with his wife. Examination : Sensorimotor and musculo-skeletal examination is unremarkable except for cervical extension limited to 15° by pain and stiffness. Position changes were without orthostatic hypotension (stable BP). Gait was normal on level surfaces. Oculomotor examination is within normal limits. Vestibular testing reveals a positive HIT bilaterally and a negative Head- Shaking Nystagmus test. Due to cervical ROM limitations, the Hallpike-Dix test position required modification, and the patient was tested on an exam table with the foot of the table elevated slightly so that the patient’s head was extended at 20° from the horizon. Hallpike-Dix was positive on the left with upward beating and left torsional nystagmus. The BBS score was 46/56, DGI was 21/24 with difficulty on walking with head turns and obstacle negotiation, and mCTSIB exhibited loss of balance on conditions 2 and 4. Questions 1. What is your interpretation of these findings? 2. What is an appropriate plan of care? Responses 1. The presentation of slow onset of loss of hearing and balance needs to be further investigated to rule out possible acoustic neuroma. The lack of classic symptoms associated with acoustic neuroma of aural fullness and tinnitus helps to
vestibular neuronitis typically affects the superior portion of the vestibular nerve, which can result in horizontal canal paresis. The Hallpike-Dix position can stimulate horizontal canals, generating directional nystagmus from asymmetry in horizontal canal inputs. 2. The BPPV should be treated first with an Epley maneuver because it is the source of the patient’s primary complaint, and easily treatable. If movement-provoked vertigo does not subside, reassess vestibular function by the HIT and initiate habituation activities as warranted. Responses 1. The HIT and DVA are the most revealing findings for this patient, indicating left unilateral vestibular hypofunction. Her oculomotor exam reveals second-degree nystagmus that follows Alexander’s law and is suppressed by visual fixation – all indicative of a peripheral vestibular deficit. Further, the finding of second-degree nystagmus is consistent with the timing of onset of her symptoms. The fact that her balance tests (DGI and mCTSIB) did not strongly identify balance deficits can be explained by the fact that her age and lack of sensory or motor deficits provide her with redundant resources to compensate adequately for her vestibular deficits to maintain postural control. Her deficit in gaze stabilization is her chief limitation at this point, making it difficult for her to perform her job. 2. Focus on adaptation exercises, starting with X1 viewing, and progressing to X2 viewing. Habituation exercises should also be prescribed, focusing on walking with head turns because this activity was found to be most challenging. The patient should perform these exercises daily and be followed once weekly for reassessment and progression. lessen the likelihood that that is the etiology of this patient’s symptoms. The finding of fatiguing nystagmus with Hallpike- Dix testing further confirms a peripheral versus central lesion. This is an important finding given that acoustic neuroma can present with a similar profile of symptoms as a peripheral lesion, but will present with nonfatiguing vertigo and nystagmus with positional testing. Positional testing was also indicated given the prevalence of BPPV in the older adult, along with the patient’s complaints of symptoms provoked with position changes. Modify the Hallpike-Dix position to ensure the posterior canal is in the proper plane relative to gravity to reduce the likelihood of a false negative test result. Coming back to the findings of slow progression of loss of hearing and balance, coupled with the finding of a positive HIT bilaterally, points to age-related degeneration of CN VIII. The mCTSIB findings reveal that the patient is reliant on vision, which is consistent with progressive bilateral vestibular hypofunction. 2. Treat the BPPV first with an Epley maneuver in a modified position so that the patient achieves head extension of 20° relative to the horizon in the absence of being able to achieve 20° of cervical extension. The treatment plan should also include habituation exercises to maximize any residual vestibular function and balance exercises to maximize postural control. The items that were most challenging on the BBS and DGI could guide balance training, and a program of balance exercises tailored to this patient’s needs should incorporate encountering obstacles, stairs, and uneven terrains to foster higher-level community-based mobility. Care should be taken when interpreting the mCTSIB to guide progression of exercises, avoiding training postural control with vision obliterated. With significant vestibular loss there may not be enough residual vestibular function for CNS compensation to occur and the patient will be reliant on vision as a compensation for loss of vestibular function.
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