Special Thanks and congrats goes to Dr. Chris Capilli, one of my former OMPT Fellowship mentees! Luckily for his patient, he is a much better PT than tennis player!
I had a patient 34 yer old female come in with a referring diagnosis of unsteadiness/vertigo. Her history is as follows, in 1998 (20 years old), she "blacked out" while driving and was unable to stop or maneuver the car and ended up luckily go off the road into a field between two large trees. The air bag went off and her symptoms post MVA were a bitter taste in her mouth and felt like someone was choking her at times. All of her tests at the hospital there afterwards x-ray, EEG, etc...
She then went to Strong Memorial for further testing in 2002 and had an EKG and sleep study done all of which were negative. She said that from 2002-2012 she had the same taste in her mouth and felt like someone was choking her from time to time; she had two children within that time frame without any problems or acceleration of her symptoms.
In April of this year she told me that she flew to Florida for a few days, then flew back. When she got home, she started having an exacerbation of her symptoms. In addition to her previous complaints, she also had headaches, vertigo every 3-5 mins, left sided tinnitus, loss of hearing occasionally, some slurring of her speech, short/long-term memory loss, finds herself staring a lot of the time, feels "off," loss of balance, and had fallen 2-3 times in the past month.
The physicians do not have any idea what is going on and she is set up to see a neurologist at the end of July, which I believe is too long of a wait. Her clinical examination for vertigo was negative, she reported dizziness in various positions, movement examination was WNL, cranial nerve/ VBI testing was negative, reflexes/dermatomes in the upper/lower extremities were negative, segmental and soft tissue examinations were negative, as were her balance tests.
I left the examination room to think about this. At first, I thought maybe this was a concussion from a whiplash injury caused by the airbag that was not addressed. The plane ride caused increase in intracranial pressure and must have aggravated the symptoms. However, this was not adding up to the years of no change. Ironically I saw a show last week, one of those "believe or not" shows which featured a case about a guy who had a whiplash injury. Years later having he presented with these abnormal symptoms To make a long story short, this 2 cases correlated in terms of these symptoms.
I did some more research on the topic and decided to call the patient's referring PCP and talked to her about the possibility of a cerebral spinal fluid leak. This would explain her symptoms as well as her exacerbation due to the increase in intracranial pressure from the airplane. She dismissed the idea and wanted me to tell the patient to wait until she sees a neurologist at the end of July. I explained the situation to the patient and strongly advised her to go to the ER, where she saw the neurologist and they confirmed the findings.
It's a crazy scenario, but it explained her frequency of falling due to the change in CSF pressure, HA's, dizziness, etc... I thought this would be a great case to pass along to your students, it was definitely a first in terms of symptom presentation.
Chris Capilli PT, DPT, FAAOMPT, MS
Doctor of Physical Therapy
Fellow of the American Academy of Orthopedic Manual Physical Therapists
Department of Rehabilitation
Robert Packer Hospital