Category: Vestibular/Concussion

Case: The 26-year-old weekend warrior

7/2/2021

The patient is a 26-year-old male presenting to PT with complaints of neck pain of traumatic onset three weeks ago. He reports falling on his head while attempting to do a handstand push-up after finishing a CrossFit workout. He describes feeling a jolt through his head and neck followed by a period of neck stiffness. He rates his initial neck pain as 4/10 that increased to 6/10 the next day on the numeric pain rating scale. He denies any use of medications for pain and has refrained from working out at CrossFit since. He is having difficulty sleeping and has begun to experience headaches. He works full time as a clinical assistant at a physician’s office where he receives phone calls and helps with intake information for patient visits. He has difficulty driving, reading, and concentrating for extended periods of time.

Imaging was performed after visiting his primary care physician and x-rays were unremarkable

f/u Questions for you

1. Do you have enough information to determine if this patient appropriate for physical therapy?
2. Based on the information listed above, are we able to establish any hypotheses?
3. If so, what are some competing diagnoses for this patient?
4. What additional subjective information would you like to know for this case to assist you in establishing a physical therapy diagnosis?

Part 1 summary

After further investigation, the patient reveals a sense of being lightheaded and having blurred vision immediately after landing on his head. He denied any loss of consciousness, dizziness or double vision. He has returned to exercising, but has limited himself to walking on the treadmill for up to 15 minutes and only use of light free weights at the gym. He feels more tired at work and averages about 4 to 5 hours of sleep a night. His neck pain has limited his ability to drive due to turning his head so he has limited driving outside of work and getting food. He tells you he feels like his neck just needs to be manipulated. He continues to experience blurred vision and attributes these symptoms to his lack of sleep and feeling tired. He denies any history of head/neck trauma.

f/u questions for you based on summary

1. Based on this information, what subjective outcome measures would be appropriate for this patient?
2. Are referrals to a specialist needed?
3. Based on the patient’s age and mechanism of injury or would you like any additional imaging for this patient? If so what type?
4. Considering moving forward with an objective exam, what red flag information would you want to rule out and where would you start with your exam?

Objective Exam

The patient's history does not suggest any signs of an upper motor neuron lesion or a multi-level nerve root pathology. He does not have a history of hypertension, smoking, cancer, connective tissue or autoimmune disorders, or recent infections. He has self manipulated his neck in the past after falling asleep on the couch while watching television and experiencing similar symptoms.

You decide to start with a screen of his cervical spine for potential cervical artery dysfunction and upper cervical instability that could compromise vascular and neurological structures. You determine increased laxity in the left alar ligament, with other ligamentous testing being unremarkable in regards to symptom provocation or abnormal end-feel. You examine his willingness to move and discover he has limited cervical rotation active range of motion bilaterally. He also lacks the ability to perform proper cranio-vertebral flexion. You find this information to be clinically relevant, but you are pushed for time and want to make sure you screen other systems.

You finish your physical examination with vestibular ocular motor screening and conclude that he has visual motion sensitivity with reported symptoms of headache and fogginess, scores of 4/10 and 5/10, respectively.

Being constrained due to time, you make the decision to incorporate additional objective outcome measures in the patient's second visit to be thorough. Take some time to consider what measures you feel are clinically relevant for this patient.

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Case - Passing out and falling head first

7/2/2021

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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.

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Case Studies: Is Your Clinical Reasoning Within Reason?

Case: The 26-year-old weekend warrior

Case - Passing out and falling head first

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