Continuing Education Bits for PTs & PTAs

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!

Comments on: "When Orthopedic and Vestibular Physical Therapy Meet Neck Pain, Headaches and Dizziness" (32)

  1. Isn’t CHT a consideration? In cases of whiplash, contracoup is a potential issue. Further questions would clarify the onset and behavior of the dizziness…did the airbag deploy during the accident? A valsalva would clear a traumatic fistula….

  2. Definitely asking more questions and calling the referring physician while pt is still in my office.

  3. sharmila shrestha said:

    i would refer to her physician

  4. Chas Barker said:

    I chose the following option: “Investigate her new symptoms by asking her some specific questions.” I think it’s important to utilize an appropriate algorithm for the dizzy patient. Based on subjective and objective data, I would do one of three things: 1. treat what is amenable to physical therapy, 2. refer to the appropriate specialist when indicated, or 2. combination of 1. and 2.

  5. Susan Stoffko said:

    As a PT who suffers from Vertigo and dizziness from multiple causes (Cervicogenic,Basialar Artery Migraine, BPPV, and re-current begnign brainstem cyst causing lateral shift of Medula and Pons. Note: H/O (L) occipital craniotomy with mesh hardware cranioplasty and C 1 Laminectomy to evacuate brainstem Arachnoid Cyst 14 yrs ago, with re-ocurance noted by MRI 1 yr ago) I would like to stress the complexity of dizziness, especially if multi-factoral causes have not been ruled out. I have seen clients s/p MVA, with Dx of “whiplash” as in this case senerio, go on to have W/U revealing much more ominous causes for dizziness-with the MVA mearly being the “straw that broke the camel’s back”. Unfortunately, clients are often sent to PT without a clear D/X or W/U to clear differencial diagnoses. HA and neck pain are not diagnoses-they are symptoms. What appears at first blush to be MVA whiplash, could be whiplash plus manifestations of co-morbidities. Bottom line: further questioning to gain information to assist with PT asssesment and communication with MD is indicated. With this dizziness being a new onset, I would have contacted the MD while client was in the office. If unable to talk with MD directly, I would have sought out MD/hospital advise nurse to provide immediate consult. Taking the time to call MD,provide MD with documentaion , and educating client on taking active role in managing condition(s)— (consider need to educate on fall risk reduction strategies) and informing MD ( as well as Pt/ PTA ) of any new symptoms would be prudent in this senerio. — Susan PT

  6. We’re getting some great responses here. It seems like most of you are interested in asking more questions and perhaps doing a few tests in order to get more information. Most of you stated you’d consult with a physician (some of you didn’t say either way, so I’ll go with the majority here). Before I reveal the results of the poll, and my comments/answer, I’d like you to consider Jennifer’s post and her question:

    ” Unless you have some kind of differential list, how to do know what your questions might be and what to include and not include?”

    As you are considering which questions to ask and what tests to do, what is your thought process in picking them? That is, what is driving your choice of questions, tests and measures? Any comments?

    Also, be sure to click on the notification buttons below your comments if you want to stay up to date on this discussion!

  7. I will check positional vertigo test , head trust test and gaze test

  8. victoria musyoka said:

    Investigate her new symptoms by asking her some specific questions this will help me in making differential diagnosis like vertigo and high BP

  9. claudia anglade said:

    claudia anglade:elegi la opcion de interrogar sobre nuevos sintomas; como es comun tener mareos despues de un latigazo, preguntaria si es al acostarse o agachar la cabeza,evaluar cuan rigidos estan los musculos del cuello, si tiene nistagmus lo que me indicaria vppb,que medicacion toma ,o si es hipertenso,si los mareos comenzaron despues del latigazo. si hay dolor de cabeza , en todo caso enviaria al paciente a ver un otoneurologo.

  10. I chose the option to consider what diagnoses might be causing her problem before I did anything else. Unless you have some kind of differential list, how to do know what your questions might be and what to include and not include? Given the history of whiplash we could have injuries in the CNS, otolith, and structures of the neck singularly or all in conjunction. This dizziness could just be coincidentally related to other pre-existing co-morbidities such as migraines, BP issues or she has simply started taking a new medication. So in this pts case we could be dealing with a brain issue, cervicogenic dizziness, VBI, fistula, med side effects, injury to the labyrinth, BPPV, migraines, and that’s just the short list. If you don’t consider all the many things dizziness could be in this or any situation, you could start heading down a wrong road either with your questions or exams and end up missing something that could be a big deal. Even if you think it’s a horse initially, you should always keep the possibility of zebras in mind. Once you have your list of possibilities, you can then ask questions to identify red flags and determine whether there is any kind of emergent situation and if not, use your questions to rule in/rule out possible diagnoses prior to calling the MD.

    • Lisa Beitman said:

      well said

      • Peg Olson, PT, MEd, NCS said:

        Ditto!! Conversation can be the key to what is the cause and significantly enhances the differential diagnosis process!!

    • Ann Worley Linnell said:

      I like the way you distilled that thought process into words! Often it is the horse … But one time I caught a Dens fracture missed on 2 previous radiological studies! Zebras are out there !

    • Lynda Dundas said:

      Excellent response. I would agree with all you have laid out here.

  11. I agree with Gina Miller’s response. I am thinking she may be having BPPV due to the recent MVA but need to rule out other systems.

  12. I practise in Kenya and physiotherapists are defined as clinical support staff responsible to doctors, dentists, nurses and clinical officers. Legally, I am duty bound to inform the physician before proceeding.

  13. Larry, PT said:

    I fully agree with Gina Miller and Susan Grieve.

  14. Gina Miller said:

    I would start by asking more questions. Because of the patient’s recent MVA and the high incidence of BPPV with trauma, I would direct my questions 1st at ruling in/out BPPV. A few specific questions are usually pretty good at assessing this and you don’t even need to put hands on them, yet. If after questioning, I felt BPPV was likely the root of the dizziness, I would contact their Dr., discuss the sx’s, and then request a script to eval. and Rx for possible peripheral vestibular issues incl. BPPV. If my questioning does not steer me toward a vestibular issue, I would ask questions to rule out head trauma/ concussion re. issues, cervicogenic origin, cardiovascular issues etc. and then proceed from there.

    • I agree with you Gina. The scenario leads me to believe that BPPV could be the cause of the dizziness but would want to also ask the appropriate questions to eliminate any neuro complications. Many times, the patient hasn’t even shared this info with her physician!

  15. I would understand why she have dizziness. The cause of dizziness are in the cervical region or depend from something in the head? why she don’t tell me nothing about it?

  16. Based on the referral diagnosis, the physician probably wasn’t told of any dizziness by the patient. Being a symptom of head trauma, the physician need to be made aware and determine the disposition of the patient from this point.

  17. I strongly believe that the patient needs further investigation,it would be essential to clearly understand if this patient has some underlying musculoskeletal and or vestibular problem(s). One of the likely reasons why a patient of the stated age range can present with this type of complain is when there is vertebro-basilar artery insufficiency. It would be a good idea to let this patient have a re-evaluation by her GP.

  18. I would ask specific symptoms. BPPV is a common result of head-changings injuries (whiplash). If the symptoms are specifically aggravated by position changes such as lying down or rolling over in bed (rather than C/S ROM) then BPPV can be suspected. Additionally, a C2 posterior displacement can cause this as well, but there will be no nystagmus, and vascular impingement, although extremely rare, should also be considered.

  19. Jordana Barmish PT DPT said:

    I selected “Investigate her new symptoms by asking her some specific questions” as a few pointed questions can provide a wealth of information regarding potential contributions to the dizziness (vestibular, cardiovascular, musculoskeletal) . The patient responses will help the PT to determine if further medical follow up is needed and if such follow up should occur prior to or in conjunction with continuation of PT services. Whenever there is a significant change in status or clinical presentation, the referring MD should be contacted. By asking the patient some questions regarding their dizziness, It can also allow the PT to relay a more thorough clinical picture to the physician.

  20. Gabriella M. Ferreira said:

    I chose “ask more questions, etc…” because as a PT Assistant with an indirect supervision license, I would have to obtain as much info as I could to relay to my supervising PT such as pt’s vitals, when the sx’s come/go, what makes them worse/better, how long has she been experiencing the sx’s, did she make mention of these sx’s to her MD, is she currently being treated elsewhere for those sx’s, is she taking any meds with known side effects, has she been eating/drinking enough, etc…

  21. I wil check the vital signs or or any pertinent factors such as if the pt is diabetic or if the pt has any metabolic condition. It is a responsible thing to refer it to the physician before treating this pt. remember the code do no harm.

  22. I whole heartedly agree with Susan Grieve. There is further investigation to be done and being able to rule out or rule in certain diagnoses will be of help to her physician as well. I also agree that calling her physician after further investigation is a must to keep the physician informed of all symptoms and progression of this patient’s response to PT treatment.

  23. Lisa Beitman said:

    I would like to know if her “dizziness” is consistent with her position changes such as lying down as she just performed or if she feels it coinciding with her neck pain. This would give me more info on BPPV or cervicogenic BPPV. Because I have been primarily treating vestibular patients I may have watched for flickering under her eyelids or asked her to repeat her sitting to supine to rule in BPPV.

  24. Susan Grieve said:

    Dizziness can be a symptom of a number of things some serious others not regardless it’s not considered a “normal” symptom. Further questioning is important here to better understand if additional medical care is needed. Important is asking to patient to describing the type of dizziness. Vertigo, lightheadedness, imbalance etc. When does it come on when does it go away? Is it associated with an increase in neck symptoms or particular head/body movements? Has she ever had it before? Any new medications? All this information tells us whether it’s safe for us as PT’s to proceed with interventions. In this case it does sound like possible BPPV but without questioning and testing to weigh up this possibility and weigh down others it’s wrong to proceed based just on patient report of symptoms. If an additional body system dysfunction is suspected, in this case possible vestibular dysfunction, then the referring physician should be notified and depending upon the etiology and skills of the providing PT intervention can begin.

  25. Deb Kegelmeyer said:

    I’m going to call the physician but voted for asking her more questions so that I can give the physician more information related to what is going on with this patient and her dizziness.

  26. I answered, “Investigate her new symptoms by asking her some specific questions”. Information given is that this occurred in the past few days. Client information along with observation may indicate reasons for the dizziness such as orthostatic hypotention, compression on the basilar vertebral artery, or vestibular problems. Information may indicate appropriate PT treatment, and will be helpful to her physician.

  27. Mesay Mohammed said:

    I prefer to do more investigation on VBI, so that i need to consider my passive modalities applying on her neck that may exacerbate the underlying condition.

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