Case - Passing out and falling head first

Pt is a 42 year old female presenting to PT with c/o dizziness and neck pain after suffering a head injury during a fall 4 months ago.  She reports being asleep on the couch and then "passing out" after getting up to go to her bed. She endorses a loss of consciousness, but is unsure of how long. She lives alone with her two dogs and was unable to drive. She was taken to the ER by emergency medical services and subsequently required 12 stitches for a forehead laceration. Imaging included a CT scan of the head/face which was negative. She has a past medical history of syncope as a teenager in which she had 2 separate episodes while getting out of the bed, but none up until now. She describes her previous episodes of syncope being lesser in intensity and without head injury

Current Medications: Cyclobenzaprine (Flexeril)and women's multivitamins

1. Based on the information provided. Is this patient an appropriate physical therapy candidate? If not, what would make you feel more comfortable proceeding with your examination?
2. Are there any red flags? yellow flags? Is there any sinister pathology you would like to rule out?
3. Based on the information provided, what additional subjective information would you like to know and why?
4. Could you come up with at least 2 preliminary diagnoses?
5. What subjective outcome measures would you select that may provide useful information from this patient?

Part 2

After further examination, you discover the patient has been seen by cardiology and had an electrocardiogram performed that was unremarkable. You question the patient further about her dizziness and determine that it is not likely true vertigo. You begin to consider orthostatic hypotension as a potential diagnosis. After additional questioning, the patient tells you the cardiologist tested for and ruled out orthostatic hypotension. She denies a history of anemia. She does mention that it has been suggested by a physician in the past that she may have hypovolemia. She was given suggestions of dietary changes she could make.  When she does feel dizzy, it lasts anywhere from a few minutes to hours at a time. She describes it as occurring every day with the sensation of being on a boat.  She does get headaches occasionally in her sub-occipital region that typically are associated with neck pain. She denies blurred or double vision, heart palpitations, photophobia, memory loss, difficulty concentrating or feelings of dehydration.

f/u questions

1. Is there anything else we need to know before proceeding with our objective examination?
2. What screening tools or assessments do you plan to include in your objective examination?
3. What outcome measures do you think will prove most useful in this particular case?

Part 3

You question the patient further about her neck pain before beginning your objective examination. You discover she did not receive imaging for her neck. Mentally, you automatically go to the Canadian C-spine rules for determining the use of imaging and feels she fit the profile for radiography of her cervical spine. Based on her acuity, you become less concerned of significant injury and move on. She describes her neck pain as unilateral, on the right side primarily. Her pain is in the right suboccipital region and presents as referred pain in the form of soreness in her upper trapezius/scapular region. She denies radiating/radicular pain, paresthesia or feelings of weakness. Her neck pain is reproduced with sustained right cervical rotation and left side-bending.  She has been sleeping on stomach and says she wakes up with pain/stiffness in neck.  Motrin and massage help.  She denies other falls/clumsiness or changes in bowel/bladder habits.

Objective Exam

BP: 110/70 mmHg
Pulse: 87
Height: 5'8'' Weight: 135 lbs

Observation: flat back posture with limited thoracic kyphosis and increased cervical lordosis
Gait: unremarkable
Dermatomal testing: unremarkable
Key muscle testing of cervical nerve roots: unremarkable

Oculomotor exam: unremarkable
Vestibular Ocular Reflex Testing:
 - Head thrust (horizontal): negative bilaterally
 - Head thrust (vertical): negative bilaterally
 - Visual acuity difference: 0

Cervical AROM
- flexion: 40 deg
- extension: 30 deg with reported generalized posterior neck pain
- sidebending: 35 deg (right), 30 deg (left) with reported right side neck pain
- rotation right: 48 deg with reported right sided neck pain
- rotation left: 50 deg

Positional Testing
- Dix Hallpike: negative bilaterally
- Modified Sidelying test: negative bilaterally
- Head roll test: negative bilaterally
- Cervical torsion test: negative bilaterally

Sensory organization testing: unremarkable

Part 4

You feel you have more than enough information to move forward. You decide to assess for potential cervical impairments and in your scan of the cervical spine you find areas needing a more detailed bio-mechanical exam. It is here you discover an region of hypo-mobility with PAIVMs of the right C2/C3 facet joint and an area of  hyper-mobility at the right C5/C6 facet joint. To be thorough, you examine the thoracic spine for physiological movements and determine limited extension in the upper thoracic region.

You decide to pursue ruling out autonomic dysfunction and exercise intolerance by administering the Buffalo Concussion Treadmill test. The results are significant for exercise intolerance with a reproduction of dizziness (greater than 3 point difference on Likert scale) that stopped the test at 6 minutes.

What do you do with this information? Are her symptoms of dizziness and neck pain related?

Considering the multitude of trajectories in the management of post concussion syndrome, you have several avenues to consider in the treatment of this patient. Implementing sound clinical reasoning, you must prioritize your findings in a manner that optimizes this patient's care.