Possible Anxiety-Induced Dizziness and Vestibular Physical Therapy: A Case Report

A case report submitted for the degree of

Doctor of Physical Therapy

at

Carroll University

Waukesha, WI

Megan McKinney, SPT

Spring 2009

 

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Possible Anxiety-Induced Dizziness and Vestibular Physical Therapy: A Case Report

Megan McKinney, SPT and

Elfrida Zakrzewski, PT Rebecca Blanchette, PT

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Abstract:

Background and Purpose: Traditionally, psychotherapy has primarily treated psychogenic dizziness

disorders. Few studies have been found attributing solely physical therapy on impacting this disorder. This case

report describes a patient with benign paroxysmal positional vertigo, chronic dizziness and self-diagnosed

claustrophobia. She was referred for physical therapy including vestibular rehabilitation. Case Description: The

patient was a 79-year-old female with symptoms such as fear, shortness of breath, gasping for air and feeling as if

the ceiling is falling down when in small spaces with all symptoms triggering a dizziness sensation. These

symptoms occurred with most mobilities. Intervention: The patient was seen for 16 physical therapy visits with a

focus on vestibular rehabilitation over a 12-week period. Due to the patient’s unexplained symptoms,

inconsistencies with diagnoses and symptoms consistent with claustrophobia, she was referred to a

psychotherapist after 12 visits. The patient denied this referral, and physical therapy was continued as the patient

was making functional gains. She was treated with manual therapy, ultrasound, neuromuscular re-education,

therapeutic exercise with a progressive home exercise program, and gait training. Outcomes: After 16 visits of

therapy the patient had an improved subjective functional ability, elimination of bilateral benign paroxysmal

positional vertigo, increased strength testing of neck musculature, increased Berg Balance Assessment score,

decrease in Neck Disability Index score and no remarkable change in Dizziness Handicap Inventory scores.

Discussion: It appears that vestibular rehabilitation might be a valuable treatment for an individual suffering from

possible psychologically-induced dizziness. One can speculate that the patient improved due to habituation and

transferring control of symptoms back to the patient.

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Introduction: Dizziness is a common symptom in the elderly, reported by up to one in three individuals over

the age of 65.1 Also, there is a higher prevalence of these problems among women.2 Furthermore, 40%

of persons with dizziness fail to discuss it with their doctor and only a few are referred for further testing

from a specialist.1 Multiple authors have stated possible diagnoses causing dizziness such as positional

vertigo, cerebrovascular disease, a variety of labyrinthine issues, neck problems, deconditioning,

medications, imbalance, lightheadedness, presyncope, disequilibrium, phobias, psychogenic issues, and

phobic postural vertigo.3

After a diagnosis of dizziness is made, according to Heinrichs et al., 30% of symptomatic

individuals are at risk for developing chronic dizziness.4 As stated by Sloane et al., vestibular issues and

psychiatric disorders are the most frequent causes of continued dizziness.5 Of the subjects in this study,

37.5% had a psychological diagnosis causing or contributing to their dizziness, with anxiety listed as

one of the most common.5 Many other studies have found a link between dizziness and psychological

issues. Authors have found that an abnormal change in the vestibular system could activate irregular

respiratory patterns which then trigger an avoidance response to motion due to fear of continued

symptoms. In addition, this distress may increase arousal and hyperventilation, which can lead to a

vicious cycle of impairment.6 This fear, according to Monzani et al., has been found to be the most

common complaint within individuals suffering from vestibular disorders due to its unpredictable

nature.7 Further studies have found increases in respiratory rate with head movements among subjects

found to have psychological symptoms.8 Yardley et el. found that maximum velocity of nystagmus

induced by head rotation was significantly increased while performing a stressful mental task than when

not.9

One question pondered is, “Do these individuals have a predisposition to anxiety or is the

development of a vestibular problem secondarily causing anxiety?”3 The research is controversial as to

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which event occurs first. A 1996 study found if an individual presents with a psychological disorder, the

presence of a vestibular issue may become a complicating factor.10 In opposition to this statement,

Holmberg et al. concluded that an onset of psychological issues often occurs after a period of emotional

stress, a serious illness or even a vestibular disorder.2 Although this controversy exists, the research does

state that psychological distress is greater in subjects with vestibular disorders and balance dysfunction

than in the general population. 11&12 A review of the literature found that when working with an

individual with a vestibular dysfunction, the rates of a panic disorder are 5 to 15 times greater than in the

general population.13 Asmundson et al. found that 75% of subjects with panic disorder and 60% of

subjects with panic attacks were found to have abnormal vestibular function.14

Although the research on the cause of dizziness isn’t concrete, the effects are more solid. The

presence of dizziness can present as a major handicap and disabling symptom for many individuals. This

disability proves to be more severe and prolonged when the individual suffers from psychologically-

induced dizziness.7&15 Monzani et al. stated that vestibular disability occurs more from psychological

distress rather than symptomology.13 Yardley et al. found that two thirds of the subjects with

handicapping dizziness complained of having panic attacks.16 Due to the life altering characteristic of

dizziness, appropriate and exceptional treatment is necessary. Traditionally, psychotherapy has been

used to treat the diagnosis of psychogenic dizziness.17- 20 Few studies have been found attributing

physical therapy treatments alone on impacting this disorder.

Physical therapists plan their interventions towards reducing disabilities and handicaps through

treating impairments. This case report describes a patient with a pre-existing diagnosis of benign

positional vertigo, chronic dizziness and self-diagnosed claustrophobia with spontaneous and situational

attacks of vertigo. She was referred for physical therapy (PT) including vestibular rehabilitation (VR), to

assist in improving her condition.

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Case Description:

The Patient: The patient gave informed consent and the initial evaluation was performed. The patient

was a 79-year-old female referred from her physician for treatment in an outpatient physical therapy

facility for posterior neck pain. The patient was a poor historian, determined through inconsistent

responses to questions. Past medical history included breast cancer with left mastectomy and removal of

16 lymph nodes (2000) details undisclosed, dizziness, gastro-esophageal reflux disease, diverticulitis,

arthritis, breathing problems requiring daily bronchodilator, hypertension, angina, and anxiety. The

patient also had self-diagnosed claustrophobia with symptoms such as fear, shortness of breath, gasping

for air and feeling as if the ceiling is falling down on her when in small, enclosed spaces. Previous

surgeries consisted of cardiac bypass with a stent placement. The patient’s medications are listed in

Table 1. The patient’s primary diagnosis of neck pain started three months prior with x-rays revealing no

bony deformities. The secondary diagnosis of dizziness started five years prior to therapy evaluation.

The patient stated falling twice that year when turning quickly to answer the door, and the patient did

not receive medical care at the time. The patient subjectively stated fearing and avoiding medical care

for over 20 years unless medical condition warranted. Within six months prior to evaluation, the patient

received home physical therapy for benign paroxysmal positional vertigo (BPPV). The patient stated she

had no success with this treatment in decreasing dizziness and it also induced posterior neck pain for

which she received this referral. The only activities that would relieve her dizziness were sleeping,

getting fresh air, or removing herself from a restrictive environment. She was a full-time homemaker,

widowed and had three children that lived in the area. Her functional level at initial evaluation consisted

of impairments in several activities of daily living (ADL) and sleep, which is drastically different than

her independent prior level of function. (See Table 2.) The patient’s goals were to decrease neck pain

and decrease dizziness.

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Clinical Impression: The patient proved to be a prime candidate for this study due to the uniqueness of

her case. Differential diagnosis was needed to determine the cause of the dizziness and neck pain.

Further examination followed in order to identify and measure her impairments and functional

limitations. The tests and measures were selected based on the subjective interview, past medical

history, and goals for returning to her prior level of function.

Examination: Subjective statements consisted of sharp and shooting pain from the neck up into the

temporal region of the head with cervical range of motion (ROM) with the pain description at initial

evaluation of 0/10 at rest, worst at 8/10. The patient had further complaints of dizziness with transfers

and rolling in bed. The initial examination consisted of a general posture assessment, cervical palpation,

cervical ROM, cervical manual muscle testing (MMT), and the modified Clinical Test of Sensory

Integration on Balance (CTSIB) on the facility owned Balance Master®*. The CTSIB has been found to

have >90% specificity and 61-89% sensitivity.21 The examination was also comprised of special tests

including the Berg Balance Assessment (BBA) with a score of 36/56, the Hallpike-Dix Test, found

positive for bilateral posterior canal BPPV, and vertebral-basilar insufficiency (VBI) test, found

negative. According to the research the Hallpike-Dix test has been found to have 88% sensitivity22 and

the VBI test has been found to have 0% sensitivity and positive predictive value as well as 63-97%

negative predictive value.23 The patient’s limitations consisted of impaired posture, impaired balance,

pain with palpation of posterior neck muscles due to guarding, and impaired cervical active range of

motion (AROM) due to increased dizziness with head movements. The patient was unable to tolerate

cervical MMT due to pain and dizziness exacerbation. See Tables 3, 4 and 5 for a detailed summary of

the patient’s initial results. Most examination procedures performed are supported within the literature.

Cervical ROM measured by goniometer has been found to have good interrater (.80) and intrarater

* NeuroCom International, Inc. 9570 SE Lawnfield Road Clackamas, OR 97015  

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reliability (greater than .80).24 According to a review of the literature, MMT has been found to have

good validity, including internal and external, and reliability in patients with neuro-musculo-skeletal

diagnoses.25 Per patient report, when slouching and performing cervical AROM, the patient complained

of dizziness, but when therapist instructed the patient to sit with upright posture, the dizziness subsided.

The patient did present with orthostatic changes in blood pressure which may have contributed to the

complaint of dizziness with changes in positioning, although does not explain dizziness during other

activities. (See Table 9.)

The patient had various definitions of dizziness depending on the activity performed. The patient

described symptoms as lightheadedness, spinning, room spinning, ceiling falling down on her (all

consistent per subjective self-diagnosis of claustrophobia), and unsteadiness. The therapist was unable to

distinguish between all definitions due to the variation of the patient’s subjective reports. From here on

in this report, the patient’s symptoms will be described as “dizziness”; the reader should be aware that

this definition could indicate one or all of the symptoms stated above. This symptom uncertainty adds to

the perplexity of this patient’s diagnosis, treatment plan and measurable recovery or outcomes.

Clinical Impression: Signs and symptoms are consistent with physical therapy diagnosis of bilateral

posterior canal BPPV causing dizziness due to a positive Hallpike Dix test of bilateral posterior canals.

The patient was also diagnosed with posterior cervical pain due to muscle guarding from anticipation of

dizziness with cervical motion, possibly indicating cervical vertigo due to symptoms mirroring those

stated in the research for this diagnosis.26 With this data in mind, the therapist proceeded to treatment as

well as further testing to rule out any other causes of dizziness such as cervical vertigo, hypotension, or

vertebral-basilar insufficiency (VBI). The patient was appropriate for the case study due to symptom

inconsistencies with diagnosis of BPPV such as blurred/grayed vision and exacerbation of dizziness

with transfers, balance challenges and poor posture. The aforementioned subjective and objective results

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were used when determining patient goals and interventions in order to produce a successful outcome of

attaining functional recovery. Goals, with a target date of 16 visits, consisted of the patient being able to:

be independent with progressive home exercise program, perform sit to and from stand transfers without

an increase in dizziness, reach overhead with cervical extension without increase in dizziness in order to

get objects in a cabinet, bend and kneel with correct form without loss of balance to get objects off the

floor, and demonstrate cervical ROM within functional limits (WFL) with 0/10 dizziness to perform

activities of daily living (ADL).

Intervention:

The patient was seen 16 visits for 45-60 minute sessions over a 12-week period, which was interrupted

by one hospital visit due to intestinal bleeding from a medication overdose. Subsequently, the patient

was then taken off all medications (see Table 1). She was seen for manual treatment and ultrasound in

early treatment sessions as well as neuromuscular re-education, therapeutic exercise with a progressive

home exercise program, and gait training throughout the episode of care. The selection of the specific

interventions was based on equipment availability, training of the therapists treating the patient, and the

physical therapy goals. The hypothesis was that these interventions would result in the patient achieving

the previously set goals and mobility demands for functional recovery.

Manual treatment:

The therapist performed manual treatment secondary to symptoms mirroring cervical vertigo. Treatment

consisted of clearing and direct pressure of bilateral upper trapezius, bilateral levator scapulae, and

cervical paraspinal musculature. The muscle clearing technique was performed through applying manual

pressure directly over the muscle from insertion to attachment or vice versa to decrease muscle tone.

The therapist also applied kinesiotape to bilateral upper trapezius to inhibit the muscle and decrease

muscle tension and pain. Cervical spinal mobility assessment revealed hypomobility at 50% of normal

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and pain into rotation between levels C4 and C5, therefore grade I and II mobilizations were performed

to facilitate rotation. The manual techniques, kinesio-taping, and mobilizations decreased the patient’s

subjective complaint of muscle tightness, but increased the patient’s dizziness per subjective report.

This increase in dizziness is inconsistent with research stating improved condition with these

treatments.26 The patient did not tolerate these interventions and therefore they were terminated.

Modalities:

Ultrasound was performed to right upper trapezius in one session for eight minutes, continuous at 0.8

w/cm2. Patient expressed increased muscular relaxation, but also increased dizziness post-ultrasound

treatment, therefore this modality was terminated.26

Neuromuscular re-education:

The patient performed multiple activities related to the balance deficits recorded from the CTSIB and

BBA. The balance treatment started with the patient on firm surfaces including: sitting with cane

reaching out of base of support (BOS) anteriorly and laterally (See Figures 1&2), toe taps for single limb

stance (SLS), side-stepping, and weight shifting to increase safety (See Figures 3-5.) Balance challenges

were progressed to compliant surfaces including: weight shifting on foam, tilt board and air-discs. To

increase the patient’s balance and confidence with gait, the patient was instructed in standing exercises

with progressive decrease in upper extremity support. Progression was monitored through subjective and

objective balance ability. (See Figures 9-14.) The patient was also instructed to perform gaze stability

exercises due to subjective report of motion sensitivity and dizziness when following cursor on Balance

Master®†. These exercises consisted of vestibular ocular reflex (VOR) 1 and 2 performed in the saggital

and frontal planes with repetitions to tolerance. By discharge, the patient reported increased balance

† NeuroCom International, Inc. 9570 SE Lawnfield Road Clackamas, OR 97015  

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abilities; see table 6 for objective results of increased balance and safety. No change in dizziness was

reported after balance treatments or VOR exercises.

Vestibular treatments:

The Canalith Repositioning Treatment (CRT)27 was performed, alternating each ear at every session due

to diagnosis of bilateral BPPV.27&28 This exercise was terminated when the CRT was performed and

resulted in a negative nystagmus and subjective denial of dizziness or vertigo. Throughout treatment,

therapist noted clearing of BPPV due to nystagmus severity lessened viewed through Frenzel Lenses®‡.

Even with this progression, however, the patient still had excessive complaints of dizziness with other

activities. The patient was then referred for an Electronystagmography (ENG) test to assist in ruling out

other possible diagnosis for these complaints. The results were negative for peripheral vestibular

problems and symptoms were not consistent with a central vestibular issue.

Therapeutic exercise:

The amount of therapeutic exercise, other than the vestibular treatments, was limited due to patient’s

subjective complaint of disabling dizziness upon arrival to many treatment sessions. The patient was

instructed on low amplitude cervical AROM to increase functional mobility and use of neck. ROM was

performed into flexion, extension, bilateral side-bending, and rotation. Initial introduction of these

exercises increased dizziness and subjective neck pain, therefore was deferred until a later session when

dizziness was less disabling per subjective report. See table 2 for results in subjective functional

measurements.

Home Exercise Program (HEP):

A home exercise program was initiated to maintain treatment benefits throughout episode of care. The

patient was instructed on the exercises and given pictures with written instructions for performing

bilateral CRT28; weight shifting with bilateral upper extremity supports for safety; cervical ROM into ‡ 1685 E. Park Place Blvd. Stone Mountain, GA 30087 

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flexion, extension, bilateral side bending, bilateral rotation; sitting cane weight shifts; and VOR 1 and 2.

The patient reported compliance with the HEP, shown through resultant improvements between

sessions.

Outcomes:

Subjective reports: Abruptly, and not prior to, the 16th physical therapy session, the patient reported an

overall improvement of function. She remarked that the only areas of deficits included walking safety

without an assistive device as well as maintaining her balance with a narrow base of support. The patient

stated she was “feeling great,” with no complaints of dizziness the last few sessions of treatment. She

reported that she was confident with all functional activities at home as well as completing the home

exercise program regularly without concern. Although this was the case, throughout this episode of care,

the patient was inconsistent visit to visit with symptoms and complaints of dizziness. Furthermore,

symptoms were inconsistent with vestibular (per ENG findings), central (per symptom descriptions) or

physical therapy diagnoses. Therefore the patient was referred to psychological services at the twelfth

visit for potential psychogenic dizziness. The patient declined the referral and continued physical

therapy services for the remaining four sessions to treat her impairments.

Outcome Measures: The specific functional measures used were cervical ROM, cervical MMT, the

Neck Disability Index, the BBA, and the Dizziness Handicap Inventory. (Refer to tables 2-9 for

outcomes). Cervical ROM within this study was measured with a standard goniometer. This has been

found to exhibit anywhere from poor to excellent reliability depending on the direction of ROM and in

comparison within or between testers.24 Cervical musculature strength was measured with manual

muscle testing secondary to lack of equipment, such as a dynamometer, to improve specificity of

measurement. Manual muscle testing was performed by the same therapist, and has been found in the

literature to have good reliability and validity (0.80-0.96) in multiple studies in individuals with neuro-

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musculoskeletal conditions.25 The Neck Disability Index (NDI) is a 10-item questionnaire to assess neck

pain.3 The NDI has been shown to have good reliability, validity and internal consistency in a sample of

patients with whiplash injuries.29 Although the patient in this study did not experience whiplash, the

results of the NDI study can still be utilized as the patient’s subjective neck pain complaints were similar

to those of whiplash injuries. The patient’s initial evaluation score on the NDI demonstrated moderate

disability (42%) and her discharge score showed less than mild disability (8%) (see table 8.) The BBA is

an easy and brief balance measure to assess safety of community-dwelling elderly individuals.30 This

test has been found to have low sensitivity and high specificity.30 The patient’s initial evaluation score

was 36/56 and final evaluation score was 43/56 (See table 6.) The literature states that persons who

score a 45 or greater on the BBA are at a low risk for falling without the use of an assistive device,

consistent with patient’s later use without a wheeled walker. The Dizziness Handicap Inventory is a 25-

question survey with three subscales to assess functional, emotional and physical disability correlated

with vestibular diagnoses.31 This scale has been shown to have high internal consistency and high test-

retest reliability in individuals with vestibular issues.32 Furthermore, this scale has been found to show a

relationship between impaired function and negative affect in a group of individuals with panic

disorder.31 The patient’s score did not change significantly from initial to discharge evaluation (See table

10.) No research has been found by this author documenting the specific relation of these tests to

individuals with the exact conditions and diagnosis of the subject in this study.

The patient’s overall change in condition following PT including VR can be summarized as

follows: increased subjective functional ability, elimination of bilateral BPPV per CRT, increased

tolerance to strength testing of neck musculature resulting in strength measures within functional limits,

increased BBA score and therefore improved safety, dramatic decrease in Neck Disability Index score

and no remarkable change in Dizziness Handicap Index scores. (See tables 2-8.)

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Discussion:

As Yardley et al. states, VR consists of a progression of exercises consisting of eye, head and

body movements intended to excite the vestibular system and allow central nervous system

compensation, therefore allowing patients to regain confidence and skill in balance.33 VR treatments

within individuals with anxiety disorders has been studied within the literature both on its own as well as

in combination with cognitive behavioral therapy (CBT). Both have been found to positively affect the

patient’s condition through exercises of habituation.34 The following two studies assessed the effect of

VR on the emotional aspects of suffering from a vestibular disorder. Meli et al. found that subjects who

underwent VR showed an improvement in balance, dizziness, quality of life ratings, handicap and

disabilities, as well as levels of anxiety and depression.34 Yardley et al. found that after VR subjects

significantly improved on postural control, symptom complaints and emotional status.33 In this case

report, physical therapy with VR was provided for a patient with a pre-existing diagnosis of benign

positional vertigo, chronic dizziness and self-diagnosed claustrophobia with spontaneous and situational

attacks of vertigo. These impairments lead to severe functional limitations of impaired balance, gait,

transfers, sleep and ADLs causing great disability in the patient’s daily environment. Due to the

patient’s unexplained symptoms, inconsistencies with any diagnoses of vestibular, central or

musculoskeletal origin, as well as symptom descriptions concurrent with complaints of claustrophobia

or anxiety attacks the patient was referred to a psychotherapist in order to develop a diagnosis for

treatment. These decisions are supported within the research.7&11 The patient denied this referral,

therefore PT was continued to address the underlying impairments with the undiagnosed disorder.

The interventions performed within this case report consisted of research-validated treatments

for this population. The treatments consisted of balance challenges, VOR 1and 2 exercises28&33, manual

therapy26, kinesio-taping, ultrasound, cervical mobilizations35, canalith repositioning treatments27,

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cervical AROM exercises and gait training.28&33 The effectiveness of kinesio-taping techniques within

this patient population is lacking within the research.

Although the patient refused psychotherapy, the literature has found significant changes with

psychologically-induced dizziness with the use of CBT.17&20 Furthermore, PT treatments in conjunction

with CBT has been found even more effective than solely one treatment.18&19 Jensen et al. stated that the

treatment of dizziness should be provided in a multidisciplinary approach, such as what has been done

with individuals suffering from chronic pain.36 Therefore, with any patient being treated for vestibular

deficits, as Heinrichs et al. states, it is important to identify those patients at risk for developing a

secondary psychological disorder or those who present with one, and refer them for psychological

intervention.4

Based on this patient’s reports, her function at home and within the community had improved

after a 16-visit course of PT with vestibular-focused rehabilitation. Since these results were based on a

case report, it is not possible to attribute cause and effect of the care of this patient to the improvements

she gained. A controlled trial would need to be completed to determine whether PT with VR without

psychotherapy assistance is useful in managing an individual suffering from an undiagnosed

psychological disorder. One can speculate that the patient improved without psychological help due to

the habituation effect of VR, which is consistent with CBT34, as well as transferring the control back to

the patient to manage their symptoms.4 It is also possible that through treating her vestibular issues, she

had less dizziness and therefore her anxiety improved. Although it appears that PT with VR might be a

valuable treatment for an individual suffering from possible psychologically-induced dizziness, things

could have been done differently. As stated in the literature, this subject would have had increased

benefits from both PT and psychotherapy.18,19,36 An assessment tool that is performed to assess anxiety-

induced dizziness, called the hyperventilation test, was not performed and should be tested in future

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studies for effectiveness. Nardi et al. found that this test is an easy and quick test to validate panic

disorder in a patient.37 Further studies should also assess how physical therapists and psychotherapists

can work together to share treatment strategies in order to coordinate and carryover care.

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Table 1: Patient’s Medication List

Regular Medications Dose Imdur 30 MG tablet ER 24HR 1 Tablet ER 24HR (Oral) Daily Theophylline CR 300MG Tablet ER 12HR 1 (Oral) Daily Lisinopril 40MG Tablet 1 (Oral) Daily Plavix 75MG Tablet 1 (Oral) Daily Aspirin 325MG Tablet 1 (Oral) Daily Amlodipine Besylate 5MG Tablet 1 (Oral) Daily Metoprolol Tartrate 50 MG Tablet ½ (Oral) Two times daily Nexium 1 (Oral) Daily Diclofenac 1 (Oral) Two times daily As Needed Medications Dose Proventil 90MCG/ACT Aerosol Soln 1 (Inhalation) DuoNeb 2.5-0.5MG/3ML Solution 1 (Inhalation) NitroQuick 0.3MG Tab Sublingual 1 (Sublingual)

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Table 2: Patient’s Level of Function Function Prior Level Initial Evaluation Discharge Evaluation Vigorous activities (heavy lifting, shoveling snow, mowing grass)

x x x

Household activities (meal preparation, vacuuming, laundry)

x

Sport/Recreation activities Community activities Job-specific activities Walking x (cane, 1 city block) x (4 w/w, inside

apartment distances) x SBQC for days when

dizzy Up/Down stairs x Bending, kneeling or squatting x (arthritis) x (due to dizziness) x (arthritis) Maintaining balance x (due to dizziness) Getting in and out of chairs x (due to dizziness) Getting in and out of bed x (due to dizziness) Prolonged sitting Prolonged standing x (15-20 minutes) x (15-20 minutes) x (15-20 minutes) Driving Sleeping x Opening and closing doors Bathing/Dressing self Reaching overhead in cabinet x (due to dizziness) Gripping or opening a can Handling small items Understanding Hearing x x x Vision x (blurry/grey when

dizzy)

Reading Writing Talking Remembering x x x Eating/Swallowing *Above boxes checked if unable to perform functional activity listed.

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Table 3: Evaluation: Posture Assessment, Palpation, Special Tests

Initial Discharge Assessment Comments Comments Posture Sitting/Standing forward/rounded shoulders,

forward head, needs B UE support to assist in sitting balance.

Appropriate posture with gait with cane. Forward head and shoulders noted.

Palpation Increased tone and tenderness in B upper trapezius, B rhomboids, splenius capitis. + for pain at a level 1 tissue depth. Increased muscle guarding due to subjective fear of dizziness.

Not Tested

Special Test + R sided posterior canal BPPV, (-) bilateral horizontal BPPV Unable to assess L side due to increased dizziness and L side neck pain, therefore assumption of (+) L sided posterior canal BPPV (-) VBI test & (-) modified VBI

(-) bilateral BPPV per CRT

Table 4: Upper Extremity and Cervical ROM

Motion Initial Evaluation Discharge Evaluation WFL Comments WFL Comments Cervical Flexion x c/o dizziness 35° no

dizziness Extension x c/o dizziness 25° no

dizziness L Rotation x c/o dizziness 51° no

dizziness R Rotation x c/o dizziness 55° no

dizziness L Side Bending 41° 29° no

dizziness R Side Bending 31° c/o

dizziness 34° no

dizziness Shoulder Flexion x x Table 5: Manual Muscle Testing Results Muscle Initial Evaluation Discharge

Evaluation L R L R Flexion NT due to pain 4/5 Extension NT due to pain 4/5 Rotation NT due to pain 4+/5 4+/5 Side Bending NT due to pain 4+/5 4+/5

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Table 6: Berg Balance Scale Scores Item Description Initial Evaluation Discharge Evaluation

Sitting to standing 3* 4 Standing unsupported 4* 4 Sitting unsupported 4 4 Standing to sitting 3 4 Transfers 4 3 Standing with eyes closed 3* 3 Standing with two feet together 2 4 Reaching forward with outstretched arm

4 4

Retrieving object from floor 3* 3 Turning to look behind 3 3 Turning 360 degrees NT per patient request 2 Placing alternate foot on stool 3 4 Standing with one foot in front 0 0 Standing on one foot 0 1

Total 36 43 *subjective c/o dizziness with test

Table 7: Clinical Test of Sensory Integration on Balance Results

Condition Initial Evaluation Discharge Evaluation Eyes open on firm surface WFL NT Eyes closed on firm surface Impaired NT Eyes open on foam Impaired NT Eyes closed on foam Impaired NT *Considered Impaired per “The Balance Master” computerized age group comparison for balance abilities.

Table 8: Neck Disability Index Results

Description Initial Evaluation Discharge Evaluation

VAS pain grade 8/10 0/10 Pain Intensity 0 0 Personal Care 0 0 Lifting 4 0 Reading 0 1 Headaches 1 0 Concentration 1 0 Work 3 1 Driving 5 N/A no longer drivesSleeping 4 2 Recreation 3 0

Total 21 4 Percentage 42% 8%

*Total score out of 50. A score of 10-28%=mild disability, 30-48%=moderate, 50-68%=severe, >72%=complete

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Table 9: Vitals at Midway point of episode of care Supine Sitting Standing Blood Pressure 160/90 140/80 130/90 Table 10: Dizziness Handicap Inventory Results

Question Initial Evaluation Discharge Evaluation

Y S N Y S N

1. Does looking up increase your problem? × ×

2. Because of your problem, do you feel frustrated? × ×

3. Because of your problem, do you restrict your travel for business or recreation? × ×

4. Does walking down the aisle of a supermarket increase your problem? × ×

5. Because of your problem, do you have difficulty getting into or out of bed? × ×

6. Does your problem significantly restrict your participation in social activities such as going out to dinner, going to movies, dancing, or to parties?

× ×

7. Because of your problem, do you have difficulty reading? × ×

8. Does performing more ambitious activities like sports, dancing, household chores such as sweeping or putting dishes away increase your problem?

× ×

9. Because of your problem, are you afraid to leave home without having someone with you? × ×

10. Because of your problem, have you been embarrassed in front of others? × ×

11. Do quick movements of your head increase your problem? × ×

12. Because of your problem, do you avoid heights? × ×

13. Does turning over in bed increase your problem? × ×

14. Because of your problem, is it difficult for you to do strenuous housework or yard work? × ×

15. Because of your problem, are you afraid people may think you are intoxicated? × ×

16. Because of your problem, is it difficult for you to go for a walk by yourself? × ×

17. Does walking down a sidewalk increase your problem? × ×

18. Because of your problem, is it difficult for you to concentrate? × ×

19. Because of your problem, is it difficult for you to go for a walk around your house in the dark?

× ×

20. Because of your problem, are you afraid to stay home alone? × ×

21. Because of your problem, do you feel handicapped? × ×

22. Has your problem placed stress on your relationship with members of your family or friends? × ×

23. Because of your problem, are you depressed? × ×

24. Does your problem interfere with your job or household responsibilities? × ×

25. Does bending over increase your problem? × ×

Total* 54 56

*Score of (0-100). Score of 0=No handicap, Score of 100=maximal handicap

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Figure 1: Sitting weight shift anteriorly Figure 2: Sitting weight shift laterally

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Figure 3: Standing weight shift to left Figure 4: Standing weight shift to right

 

 

 

 

 

 

 

 

 

 

Figure 5: Standing weight shift anterior and posterior

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Figure 6: Step ups Figure 7: Step downs

 

 

 

 

 

 

 

 

 

 

 

 

          Figure 8: Side step ups

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Figure 9: Standing hip flexion Figure 10: Standing hip extension Figure 11: Standing heel raises

 

 

 

 

 

 

 

 

 

Figure 12: Standing mini squats Figure 13: Standing hip Abduction Figure 14: Standing knee flexion

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