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 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 Conclusion The adoption of direct access legislation across the nation and the transition to a doctoring profession places greater responsibility on the physical therapist toward autonomy in practice. Physical therapists must be able to utilize an in-depth knowledge of human systems anatomy and physiology along with scientific evidence to be able to make decisions effectively about when to treat and when to refer. Most importantly, physical therapists need to be able to determine when physical therapy care is the most efficacious management approach. For patients with vestibular disorders, physical therapy care is central to the practice of vestibular rehabilitation. This course provided a foundation for the practicing physical therapist to better understand effective management of common peripheral vestibular disorders. Effective management of vestibular disease starts with a solid understanding of the functional anatomy of the vestibular system as a basis of determining the source of the vestibular dysfunction. Use of the evidence to foster accurate interpretation of examination findings further facilitates differential diagnosis. Physical therapists must also provide evidence that the patient is improving to
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. Taking away vision as a strategy to challenge the patient will leave him with inadequate sensory inputs to maintain balance. Encouraging the patient to continue to use the cane will help provide additional somatosensory inputs through the upper extremity, contributing to enhanced postural control. support our recommendations and to establish medical necessity for skilled care. Much of what was presented in this course emphasized these main areas to guide the clinician’s diagnostic process and use of outcome measures. Treatment of vestibular dysfunction is a targeted approach, based on the specific vestibular pathology and the patient’s individual limitations and functional needs. Exercises specific to vestibular system rehabilitation to promote vestibular adaptation and habituation were presented, with a review of the principles of gait and balance retraining as a basis to facilitate immediate application to clinical practice. Patients with dizziness seek care across multiple disciplines and across the continuum of care settings. The source of their symptoms of dizziness and difficulties with ambulation and balance can be due to peripheral vestibular dysfunction, CNS lesions, or other nonvestibular etiologies. As movement specialists, physical therapists play a pivotal role in the rehabilitation of all of these conditions. The focus of this course was to provide physical therapists with advanced knowledge of this highly specialized system, to expand their practice and to further augment their management of patients with balance dysfunction.
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