Case of the Week 8-13-12: The Return of the Dizzy Busdriver!
The dizzy bus driver returns! It has been a little over 1 year since I saw her and her complaints have returned, albeit not as strong prior to PT last year.
The original case from last year is here.
Subjective: Pt reports lack of compliance with previously prescribed ther ex. She noticed onset of HA, cervical pain and dizziness three weeks ago and has been worsening since. Sx worse with sitting, head on neck movement. Sx rated 5-7/10 on average
Objective: fair sitting posture, moderate forward head
Key: F = functional (WNL), D=Dysfunctional, N = non-painful, P=Painful
extension DN, mod loss
Rot Left DN, mod loss Right DN, mod loss
Upper cerv FB DN, mod loss
Rotation Left DN Right DN
Myofascia: moderate restrictions in occiput bilaterally lateral to medial, B cervical paraspinals
Assessment: Signs and Sx consistent with cervicogenic dizziness and cervical dysfunction
Day 1: IASTM to the occiput, upper cervical spine proximal to distal bilaterally, subcranial shear distractions, and 1st rib mobilizations. We reviewed cervical retraction and use of a lumbar roll. She felt immediate improvement in her dizziness and HA.
Day 2: She reported at least 70% improvement, but also forgot to mention on last visit that she has difficulty going into stores with aisles having to look left and right; this increases her dizziness. Cervical rotation was now DN, mild loss, extension mild loss. Tx as on Day 1, for HEP I instructed her on supine lying reaching with UEs by her side, reaching to the ground and pushing UEs into the table lightly to stabilize her scapula. She then rotated her head back and forth lightly to improve cervical dissociation. Prior to this, after improving from cervical rotation L and R to min loss, her contralateral scapula still came along for the ride. I instructed this 3-4 minutes, 2-3 times/day.
Day 3: The patient reported 90% improvement, with no HA or cervical pain. She she still had difficulty going into stores and the cervical dissociation exercises also increased her dizziness. Cervical rotation was FN but extension was still DN with mild loss. Treatment as on the first two days, except the cervical dissociation exercise was now performed with the eyes tracking on one spot on the ceiling to train her VOR. She was able to do this and it did not produce her dizziness.
Day 4: Shopping and crowded places no longer produced dizziness and she was headache and cervical pain free. All cervical ROM was FN. I reviewed the HEP and told her she could continue to perform the VOR exercises with cervical dissociation in WB, and try to increase the speed of her rotation slowly. She was discharged happily, in time for the school season to start without fear of having to drive her bus dizzy!
Discussion: I am no vestibular expert but what I picked up from Mike Voight at the SFMA plus doing one clinical 15 years ago in outpatient ortho/vestibular helped this patient well enough. If she had required additional treatment or a more complex HEP to help resolve inner ear dysfunction, I would have referred her to our vestibular PT in the clinic. Hope you guys picked up something as well!