Continuing Education Bits for PTs & PTAs

Archive for October, 2012

My Own Approach To This Case

INTRODUCTION, by Marilyn Pink, PT, Ph.D. — And so, we arrive at the 4th and final post in this case study by Dr. Landel. We hope that you’ve acquired new insights, and we very much appreciate your comments. They provide additional dimensions to a discussion that is, by all measures, very rich. So, don’t be shy and participate once more, as Rob closes out with icing on the cake!

Rob Landel

Guest blogger Rob Landel, PT, DPT, OCS, CSCS, FAPTA

What would be your initial treatment intervention?

By guest blogger, Dr. Robert Landel

  • The cervical spine has some significant impairments, understandable given her recent MVA and complaints of neck pain.
  • All PE findings suggest a normal central nervous system.
  • Oculomotor exam suggests no central vestibular pathology.
  • Head thrust suggests no peripheral vestibular hypofunction.
  • Report of instability (without falls) suggests a balance issue. Balance testing reveals a normal Rhomberg, but this is not a sensitive test. Sharpened Rhomberg, mCTSIB and SLS testing suggest further that there are balance issues. Of interest is the difficulty with SLS while the head is rotated right.
  • Flexibility tests are non-contributory but you might consider addressing these.
  • Positional testing is positive and suggests a right posterior canal canalithiasis BPPV. Horizontal canals appear normal

Thus, my approach would be to address the BPPV first using a canalith repositioning maneuver, or CRM. This is highly likely to resolve the BPPV within one treatment. My preference is to do one CRM, and send the patient home without doing other treatments, with a return visit in a week or sooner. I do not give post-CRM precautions.

As to prognosis…

As I noted above, very good for the BPPV. (Helminski et al., 2010) However, patients can have continued complaints of dizziness despite resolution of their BPPV (as defined by no nystagmus or vertigo during the Dix-Hallpike maneuver). (Seok et al., 2008)

In this patient’s case she complained of continuing dizziness despite a successful CRM. Since there were no central vestibular signs, and once the BPPV was cleared there were no clinical signs of peripheral vestibular pathologies, the possibility of cervicogenic dizziness comes to the forefront. This is particularly true when the dizziness is accompanied by neck pain. (Wrisley et al., 2000). As noted above, the difficulty with SLS while the head is rotated right is significant; this suggests that the cervical spine is playing a role in her postural instability. Further testing is warranted at this point, and in particular, testing for cervical sensorimotor impairments. An excellent article to review this is by Kristjansson and Treleaven (Kristjansson & Treleaven, 2009) and I highly recommend you read it if you treat patients with neck pain. To summarize, sensorimotor impairments can cause a variety of symptoms, and clinical tests are available to help determine the problem and potential solutions. The table below is a summary:

Each component needs to be assessed and treated. Here are some suggestions:


  • Use a laser on the head to provide feedback while the patient practices returning the head to a starting position, eyes open (knowledge of performance) and eyes closed (knowledge of results).
  • neck flexor strengthening improves head JPE. (Jull et al., 2007)

Neck Movement Control:

  • Practice tracing patterns using the laser on the head.
  • Strengthen the deep neck flexors and the cervical and capital extensors.

Postural stability:

  • Neck extensor endurance is also very important for postural control; subjects whose neck extensor muscles fatigue have been shown to have increased postural sway. Just as importantly, the authors were able to improve postural sway by training the neck extensors. (Stapley et al., 2006)
  • This patient exhibits some LE impairments that will adversely affect balance, namely LE weakness, and these will need to be addressed.

Oculomotor control: practice smooth pursuit with the head in neutral and with the body turned underneath a stable head. Do the same with saccades.

Let’s not forget the other cervical spine impairments we found earlier, mainly, reduced ROM. For this, use your joint and soft tissue mobilization, whichever particular flavor works well for you, and follow your manual therapy with appropriate exercises.

I hope you found this patient case interesting, and I welcome comments and suggestions. Perhaps I’ll see you at a future course or conference!

Best regards,



Helminski JO, Zee DS, Janssen I, Hain TC. Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: A systematic review. Phys Ther 2010: 90(5): 663-678.
Jull G, Falla D, Treleaven J, Hodges P, Vicenzino B. Retraining cervical joint position sense: The effect of two exercise regimes. J Orthop Res 2007: 25(3): 404-412.
Kristjansson E, Treleaven J. Sensorimotor function and dizziness in neck pain: Implications for assessment and management. J Orthop Sports Phys Ther 2009: 39(5): 364-377.
Seok JI, Lee HM, Yoo JH, Lee DK. Residual dizziness after successful repositioning treatment in patients with benign paroxysmal positional vertigo. J Clin Neurol 2008: 4(3): 107-110.
Stapley PJ, Beretta MV, Dalla Toffola E, Schieppati M. Neck muscle fatigue and postural control in patients with whiplash injury. Clinical Neurophysiology 2006: 117(3): 610-622.
Wrisley DM, Sparto PJ, Whitney SL, Furman JM. Cervicogenic dizziness: A review of diagnosis and treatment. J Orthop Sports Phys Ther 2000: 30(12): 755-766.

What Is This Patient’s Prognosis?

INTRODUCTION, by Marilyn Pink, PT, Ph.D.: Dr. Landel ended  last week’s post with some thought-provoking questions. Here he provides instructive answers — in many cases matching some of the comments left by you. As we learn more, more is revealed. In this next post, Dr. Landel tells us what he found on his physical exam of our patient, and leaves us with new questions, including the one about her prognosis. Take a look and let us know what YOU think, and why!  Best,



Rob Landel

Guest blogger Rob Landel, PT, DPT, OCS, CSCS, FAPTA

Physical Exam Findings

But first, a recap of the questions posed at the end of last week’s article, with my stab at the answers:

1)     What are the most likely causes of the patient’s dizziness?  Support your choices with the known facts.

Given the paucity of information to rule many diagnoses out, I would argue that the list of possible diagnoses should be long. In addition they should cover many different systems (e.g. neurologic, vascular, vestibular) and processes (inflammation, infection, trauma, degeneration). Thus, we could consider:

  • traumatic causes, such as fractures of the spine or head, torn ligaments (e.g. alar, transverse), BPPV (since ~50% of reported cases have a history of trauma associated with onset), or cervical spine injury
  • inflammatory processes such as seen in RA or even OA of the spine
  • infectious causes (e.g. sinusitis, acoustic neuronitis, labyrynthitis, some type of brain infection)
  • metabolic issues (related to medications for example)
  • vascular pathologies (e.g. VBI, orthostatic hypotension)
  • degenerative, such as TMJD, BPPV (since the other ~50% of cases don’t have a history of traumatic onset, and it occurs frequently in the elderly, could we consider it a degenerative process?), OA of the C-spine
  • tumors, such as acoustic neuroma
  • neurogenic causes, such as MS or TIA’s
  • psychogenic issues such as anxiety

Just a brief list, of course there are others. Did I miss any that you thought of?

2)     Are there any pathologies that may be causing her symptoms that are concerning to you (even if they aren’t likely causes)? If so what are they, and how would they present?

We got a lot of great suggestions in the comments to the last post, including checking for VBI, upper cervical ligamentous stability (alar ligament and transverse ligament were mentioned, we could have added tectoral membrane), looking for central neurologic signs and in particular looking for evidence that the patient’s neurologic condition was changing unexpectedly. The presence of any of these conditions should be concerning, could cause the patient’s complaints, and would require referral for further workup before commencing any therapy that would involve head or neck movements. One might also consider a cranial bleed, but given the time since the MVA, the short duration and episodic nature of her symptoms this is less likely. We could and should consider systemic disorders, such as RA or infection, and of course the presence of tumors. Since she has a history of trauma, we should consider fractures, however unlikely (as suggested by the Canadian C-spine Rules (Stiell et al. 2001 JAMA). Finally, other cardiovascular pathologies besides VBI should be considered, particularly if the patient describes her dizziness has been similar to the pre-syncope symptoms one gets with orthostatic hypotension and arising from a supine or sitting position too quickly.

3)     What questions would you ask of your patient, and why?

There are a multitude of questions that could help clarify her condition, and that will a) help determine if this condition is benign or serious, and b) will not delay further treatment or provoke further complications. I think Jennifer’s comment to the last blog post was excellent, and is worth reading because it contains the answer to this question as well as the others. Rather than repeat her response here, I’ll direct you to it.

4)     What physical examination would you perform at the initial evaluation?  Prioritize your tests and measures, and justify your answers?

There are a many tests that can be performed that will a) help determine if this condition is benign or serious, and b) will not delay further treatment or provoke further complications (Froehling et al., 1994). Specifically, Froehling et al. suggest that if the patient is over 69 years of age and has a positive neurologic exam that there is a 40% chance that their vertigo is serious in nature, serious being defined as “due to conditions associated with increased mortality or long-term disability. Vertigo severe enough to impair daily functioning and lasting for more than a month would be included as a serious form of vertigo.” (Froehling et al., 1994)

One of the key points of this studywas that positive neurologic findings  were a key to determining if the cause was serious; therefore there is good evidence for doing a thorough neurologic examination that would include sensation, motor function, reflexes, cranial nerve exam, coordination, cerebellar tests, and abnormal reflexes. In considering the concern over the presence of VBI or upper cervical instability, it is clear that most of the neurologic examination can be performed without adversely affecting the vertebral arteries or the upper cervical ligaments.

Again, I would refer the reader to Jennifer’s comment, which is quite thorough. Once you’ve gone through that, read on for the physical examination findings.


Self-reported Outcome measures: DHI 45/100, NDI 30/100

Special Tests:

Upper cervical ligament and membrane stress tests are normal.

Sustained positioning of the head in her available range of motion while in sitting does not increase her dizziness.

 Cervical Active Range of Motion:

Flexion:                0°-50°

Extension:           0°-35°, complaints of pain

Right rotation:     0°- 55°, complaints of discomfort

Left rotation:        0°-70°

Neurologic exam

Reflexes: 2+ upper and lower extremities.

Sensation: Intact to vibration in upper and lower extremities.


Manual Muscle Tests:              Left                             Right

Hip flexors                                      4/5                               4/5

Quadriceps                                     5/5                               5/5

Anterior tibialis                               4/5                               4/5

Plantarflexors                                12 heel raises          15 heel raises

Gluteus medius                              3+/5                           3+/5

Neck flexion                   3/5, endurance <5 second hold

Neck extension             3+/5, endurance 30 second hold

Upper Extremity:          4+/5 throughout, bilaterally

Pathologic reflexes:    Babinski (-), Hoffman’s (-)

Cerebellar tests:          Intact finger to nose, heel-shin tap, rapid alternating movements.

No hypertonicity is noted with fast passive movement of the extremities.

Oculomotor Exam:

Ocular alignment and motility normal.

Absent spontaneous or gaze-evoked nystagmus in room light.

Saccade testing normal.

Smooth pursuit normal.

VOR cancellation normal.

VOR to slow and rapid head movement (head thrust, in pain-free ROM) normal.


She is able to walk without assistance but demonstrates decreased step length and velocity.  She avoids turning her head when walking; when asked why, she denies pain but reports instability, without falls.


Romberg with eyes closed 30 seconds.

Sharpened Romberg with eyes open 20 seconds, eyes closed 4 seconds.

mCTSIB: 30 seconds all conditions except eyes closed on foam, 25 seconds with increased sway.

SLS eyes open 30 seconds bilaterally, but eyes closed 15 seconds Left, 20 seconds right; both times decrease to 5 seconds if head held in right rotation.


Thomas test positive bilaterally.  Dorsiflexion 7° bilaterally.

Positional Testing:

Left Dix-Hallpike negative.

Right Dix-Hallpike reproduces vertigo and upbeating, right torsional nystagmus of short duration.

Roll Test (Horizontal canals) negative.


1) What is your diagnosis?

2) What would be your initial treatment intervention?

3) What is the patient’s prognosis?


Froehling DA, Silverstein MD, Mohr DN, Beatty CW. Does this dizzy patient have a serious form of vertigo? JAMA: Journal of the American Medical Association 1994: 271(5): 385-388.

May S, Withers S, Reeve S, Greasley A. Limited clinical reasoning skills used by novice physiotherapists when involved in the assessment and management of patients with shoulder problems: A qualitative study. J Man Manip Ther 2010: 18(2): 84-88.

Pelaccia T, Tardif J, Triby E, Charlin B. An analysis of clinical reasoning through a recent and comprehensive approach: The dual-process theory. Medical Education Online 2011: 16(5890).

Stiell IG, et al. The Canadian C-Spine Rule for Radiography in Alert and Stable Trauma Patients. JAMA 2001: 286(15): 1841-1848.

And the answer is…

INTRODUCTION: Well, we had great participation to the first post in this series! Now, are you ready to find out what the results of the poll were, and take the next step on the journey of treating this 67-year-old patient? We look forward to your comments on this follow-up post!

Note: You can be automatically notified of  new postings and comments by clicking the “Follow” button on the lower right end of your screen and/or checking “Notify me of comments” when you enter your comment.

Without further ado, I give you Dr. Landel!

Marilyn Pink, PT, Ph.D


Rob Landel

Guest blogger Rob Landel, PT, DPT, OCS, CSCS, FAPTA

Thank you all for your thoughtful answers!

Here’s how you voted:

And while an argument could be made for all of these possible answers being correct, the answer that places the PT in the most responsible role is #D (“Consider what diagnoses might be causing her symptoms”). Surprised? Here’s the rationale:

Answer A could be appropriate and naturally is the safe course of action. However, for the sake of argument (and this blog!), could a physical therapist proceed with further investigations to determine what the problem is? Could activating the ERS be an overreaction considering her response after the dizzy spell passes? (please feel free to submit your thoughts on this!)

While answer B is correct,it is likely the physician will ask for more information; having immediately made the call, you won’t have any answers to give. In addition, proceeding in this manner has the PT working in the role of a technician rather than as a contributing member of the healthcare team.

 Answer C will provide the PT with more information, so could also be considered correct. But what will guide the PT as to what questions should be asked? The most organized method of questioning will be be based on a differential diagnostic process, using a list of hypothetical diagnoses to guide which questions should be asked.

I would argue, supported in the medical education literature, e.g. (May et al., 2010; Pelaccia et al., 2011) that even a novice clinician would intuitively have a few possible diagnoses in mind, and that these would influence which questions he or she asks and follows up on. The more experienced or expert clinician will follow the intuitive thought process with a more analytical one, likely resulting in a greater number of possible diagnoses (Pelaccia et al., 2011). Therefore, Answer D is the best answer, and you are likely doing it already even if you aren’t aware of it!

Do you agree with this reasoning, or do you have some other take? I’d love to hear back on the above.

And now, onto the next chapter in our case:

Further Subjective Findings

You assure her that dizziness is a condition that many PT’s encounter in their patients and treat effectively. She reports an initial onset of dizziness 7 months ago while playing in the pool with her grandchildren.  She reports the acute symptoms lasted 2-3 minutes, and then gradually subsided although she felt nauseated for an hour or more afterwards. She denies trauma to her head or neck at that time, but she does report occasional neck pain. Since then she has had two more episodes of dizziness that she describes as spinning, both of short duration (a few minutes) and perhaps associated with looking up, bending down to a low cupboard, lying down, and turning over in bed. She also feels generally unsteady and off balance. Because of these problems she has difficulty caring for her grandchildren. Since the MVA 4 weeks ago she has had an increase in the severity and frequency of her spinning episodes.

She is retired and lives with her husband in a single story home. Past medical history is significant for hypertension, hearing loss in her left ear that she describes as “minimal,” and a 15 year history of intermittent neck pain. Medications include Lasix and a potassium supplement, and a multi-vitamin. She takes Advil for her headaches prn and that usually helps.

I’ll leave you with the following questions:

  1. What are the most likely causes of the patient’s dizziness?  Support your choices with the known facts.
  2. Are there any pathologies that may be causing her symptoms that are concerning to you (even if they aren’t likely causes)? If so what are they, and how would they present?
  3. What questions would you ask of your patient, and why?
  4. What physical examination would you perform at the initial evaluation?  Prioritize your tests and measures, and justify why you would choose to do each test.

And I look forward to your comments!

When Orthopedic and Vestibular Physical Therapy Meet Neck Pain, Headaches and Dizziness

INTRODUCTION, by Marilyn Pink, PT, Ph.D: I have known and admired Dr. Landel for many years as a top orthopedic clinician, researcher and educator, recognized with numerous awards. Just this year, Dr. Landel was named a Catherine Worthingham APTA Fellow, the highest honor among APTA membership categories. So, we are particularly pleased to bring you the first on a series of posts by Rob and encourage you to comment & pose questions. This is an opportunity to interact with a real luminary in PT!

An evolving patient presentation: what else is going on here?

Rob Landelby guest blogger, Rob Landel, PT, DPT, OCS, CSCS, FAPTA

You are a physical therapist treating a 67-year-old female accounts payable administrator for the past 2 weeks for neck pain and headaches (HA).

Her neck pain is bilateral, localized to the suboccipital region, without radiation into either upper or lower extremitiy. Her headaches are mainly in her bilateral forehead region. Both her neck pain and HA began after a motor vehicle accident (MVA) 4 weeks ago but both are improving since starting PT with you.

Radiographs taken the day of the MVA were negative and the MD referred her to PT for a diagnosis of “muscle strain.” Your plan of care has been to address the impairments associated with soft tissue damage in the cervical spine following her whiplash injury: early immobilization and inflammation-reducing modalities followed by progressive AROM as tolerated, gradually introducing gentle PROM including manual therapy, and postural re-education. You have just recently started working on improving her muscle function through exercise.

Today as you begin her treatment when she goes to lie down she grabs the plinth for several seconds, shutting her eyes and swaying slightly, before gradually relaxing and proceeding to assume a supine position. She opens her eyes, notes you looking at her, smiles grimly and sheepishly apologizes. When you question what just happened, she says she’s been getting dizzy spells for the past several days. She hadn’t mentioned it to you since you were treating her for her neck pain, not for dizziness.

How did you vote?  

In our next blog post I will provide our own input, but for now I invite you to not only vote, but type in your comments to expand on WHY you picked that particular answer.

I look forward to hearing from you!

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