Continuing Education Bits for PTs & PTAs

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,

Marilyn

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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.

PHYSICAL EXAM 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.

Motor:

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.

Gait:

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.

Balance:

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.

Flexibility:

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.

QUESTIONS:

1) What is your diagnosis?

2) What would be your initial treatment intervention?

3) What is the patient’s prognosis?

References

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.

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Comments on: "What Is This Patient’s Prognosis?" (6)

  1. I personally believe this amazing blog , “What Is This Patients Prognosis?
    | Continuing Education Tips for the Savvy PT” lordmichaelhunt , fairly interesting and also it was indeed a
    remarkable read. Many thanks-Maddison

  2. “What Is This Patients Prognosis? Continuing Education Tips for the Savvy
    PT” truly causes myself think a somewhat more.

    I cherished every individual section of it. Thanks for your effort ,Jeff

  3. The patient is exhibiting signs of BPPV, specifically Right posterior canalithiasis. I would initially treat her with the R modified Epley, or canalith repositioning manuever. This manuever is very successful up to 90% on the first manuever. I would not advise that she follow post manuever activity precautions. The literature hasn’t shown this to be effective and our pt is already starting to move carefully, slowing down her gait and nervous about moving her head. Her DHI score is already in the moderate perception of handicap range so we really don’t want to further perception of movement as a bad thing. I tend to treat most people once since I think most people have a tolerance for how much vertigo they can tolerate and we’ve already moved her up and down once before this treatment. Since she’s not flying out of town the next day, I’d prefer to see how she does once things get a chance to settle.

    I give this pt a good prognosis. While there is a excellent chance of resolution of her BPPV with the CRM or Epley, her odds of recurring with BPPV are 30-50% depending on what study you read. Either way, that can again be treated with CRM. What I think is important to note in this pt is that BPPV isn’t likely the only thing we need to be addressing here. She has continued neck ROM/pain issues which we need to help resolve. Her neck strength is also not great and we are going to need to retrain her brain about where her head is on her neck since her neck proprioceptors were injured. She doesn’t exhibit as much fall risk as a lot of my pts, but I’d like to address her hip weakness as strong gluts are important for a good hip strategy to maintain balance. Her hip flexors/ankle df could also use some stretching exercises and I’d later combine my head and neck exercises with standing balance and gait. In general, the main thing we want to emphasize to the patient that these things are definitely treatable issues. Movement avoidance and fear of falling can really cause pts to start declining so if we treat her other issues as successfully as her BPPV, she should do well. If we don’t, she could have continued dizziness and imbalance issues that cause her to start limiting herself and further the sequelae of disability.

  4. Nancy and Larry nailed the impression and intervention aspects. Regarding balance assessments, recent studies (Pardasaney et al 2012 PTJ, Pai 2010 JGPT) conclude many balance assessments are unresponsive and lack sensitivity to change particularly at upper ranges of performance. Muir et al cautions against the use of tandem stance and observational gait analysis for determining fall risk. Single limb stance has been examined extensively with inconclusive recommendations regarding predictive usefullness for fall risk. Perhaps in this case study some type of dizzy inventory assessment scale and use of a modified gait efficacy scale would make sense. Gait speed should be documented as a 6th vital sign with MICD improvements noted. An alternative to the mCTSIB could be the DBA described by Desai et al which inludes only foam standing : eyes open, closed, arm lifts, head rotations, trunk rotations, trunk bends. Great blog.

  5. Nancy Brue PT said:

    Diagnosis would be acute trauma relate right canalithiasis BPPV, short duration rotational nystagmus different from a cupulolithiasis which would not stop after 60 sec.
    Treatment that I typically perform is the CanalithRepositioning 2-3cycles that I monitor with Frenzel Lenses for effectiveness of the repositioning cycle. I have the patient observe a 24 hour activity restriction, especially for avoiding a static position on the involved side. Activity is advised to be low until I assess them again with the Frenzel Lenses. Nystagmus must be completely gone before I give them any habituation exercises for residual motion sensitivity. This patient also had decreased cervical flexibility and therefore would need continued manual tissue work, then incorporate dynamic walking and visual scanning training. The Dynamic Gait Index is a good testing tool for safety.
    Prognosis is very good if you can get complete resolution. The vertigo often returns due to incomplete treatment or poor compliance to activity precautions on post treatment,poor compliance with habituation exercises, or cervical flexibility and pain with head motions.

  6. Larry, PT said:

    1) What is your diagnosis?
    Based on the findings, I would say the patient is suffering from BPPV.

    2) What would be your initial treatment intervention?
    I would use the Epley maneuver, beginning in the R Dix-Hallpike position. I would assist the patient with 3 complete Epley sequences and assess her response to it. She would be instructed in either the Brandt-Darroff exercise or the home Epley maneuver and cautioned not to continue the home exercise if symptoms worsen.

    3) What is the patient’s prognosis?
    About 1/3 of patients have a recurrence in the first year after treatment, and by five years, about half of all patients have a recurrence (Hain et al, 2000; Nunez et al; 2000; Sakaida et al, 2003)

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