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A 44 year old female presents to your clinic 6 days after a fall from a horse. She presents with dizziness, sensitivity to light, headaches, and neck pain. After the fall she went to the local emergency room and was screened with an x-ray. She was sent home to rest and referred for a physical therapy evaluation.
Based on the CPG and your own clinical experience with concussions, what would you want to look for in an examination.
What are you going to do on this visit today?
Each of you please select on direction that this could go and using the CPG, determine your plan of care and treatment.
Treat this like a “choose your own adventure” story where you play out the scenario and outcome.
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I’ll focus on the dizziness component of this case. I would want to ask for their reports of dizziness including frequency, severity, triggers, and type/experience. It seems as if the Dizziness handicap inventory would be a simple and effective tool to use to objectify the impact of this dizziness symptom on daily function. Further subjective questioning may help indicate what specific activities trigger the dizziness and guide objective measures. We would want to decipher if this was a cervicogenic dizziness, a vestibular symptom, an exertional tolerance impairment, or any combination of these. A cervical screen including upper cervical tests would be important to perform as well as a Dix-Hallpike and some sort of graded exercise testing. From there we should have a better idea of where to proceed.
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This CPG is super helpful in identifying different systems to assess and address post-concussion. Examination can be guided by questions and objective measures from each of these areas to determine the degree of involvement of each.
For the motor function component questions about balance, dual tasks, gait difficulty, coordination will help clue into impairments. Depending on the severity, you could expect that the patient report noticing balance and coordination difficulties during ADLs, gait, or other activities they may have tried. Based on the severity, PLOF, age some sort of standardized balance measure would be helpful to track progress (BBS, Tineti, DGI, HiMAT, walk while talk, etc.), but if these assessments aren’t rigorous enough being creative and using various functional assessments that you standardize to track progress as. Then functional assessment in general would be more geared towards challenging static, dynamic, double and single leg balance.
Treatment progression would likely start pretty basic (again depending on current level of function) with maybe just some static balance stuff then progress to dynamic and with dual task as able and ultimately mimicking activity/sport requirements.
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Taylor and Anna, I agree with you both.
Taylor, I like your thinking about dizziness. What do you think about the potential for an ocular trigger to her symptoms? I feel it would be interesting to investigate interventions such as tracking and convergence. I recently had a patient who was status post TBI. She had a reproduction of her headaches and symptoms of nausea with solely tracking exercises (seated without head movements).
Since this patient is having neck pain, I would want to get her back to tolerating cervical motions. Starting supine, we could work on STM and PROM into the cardinal planes. If tolerated, we could move onto AROM and performing joint position error testing.
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Adding to this a little late, sorry guys!
I like what everyone was saying about the dizziness but I would also want to make sure she’s cleared from a fracture standpoint. Given the mechanism, symptoms, and the emergency room x-ray (depending on the hospital), I don’t always trust the initial imaging findings. Depending on other risk factors she may have (ex: prolonged steroid use), I would be careful with my objective exam on day 1 and definitely perform both a subjective and objective screen for a cervical spine fracture prior to doing a lot of the dizziness testing – especially tests like Dix Hallpike that put the head into rather extreme positions.
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