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A 37-year-old female construction worker at a high-rise building had an acute onset of spontaneous ongoing vertigo accompanied by nausea, vomiting, and severely impaired balance. She was unable to walk and had to crawl on the floor. After having 34 hours of continuous symptoms, she was taken to the emergency department (ED) by her sister. Her sister had to provide maximum assistance due to her significantly impaired mobility. The ED physician observed nystagmus during an ocular examination. He ordered diagnostic imaging of the brain, which demonstrated no abnormalities. The patient mentioned recently recovering from a flu virus. The physician administered intramuscular promethazine for the management of vertigo and nausea. He prescribed an oral antivertiginous drug (meclizine [Antivert]) to be taken up to three times per day for the next 30 days. Since her vertigo was eliminated within an hour after the intramuscular injection, he discharged her home with a recommendation to follow-up with her primary care physician. The ED physician suggested “relative bed rest” for the next 2 to 3 days. The patient saw her primary care physician on the fifth day after the initial event. At this stage, she was experiencing vague dizziness and oscillopsia with quick motions but no further vertigo or nausea. She was avoiding moving her head because this exacerbated her dizziness and caused loss of balance. The primary care physician diagnosed the patient with a severe sinus infection for which he prescribed an antihistamine (loratadine [Claritin]). After 2 weeks, she had no change in her symptoms of dizziness, motion intolerance, and imbalance. The primary care physician referred her to an ear, nose, and throat (ENT) physician who requested the audiologist in his office to perform a hearing test (which was normal) and a videonystagmography test, which indicated a 42% left caloric weakness. Based on these tests, the ENT physician diagnosed the patient with vestibular neuritis. She has not been able to work at her construction job for a month and is concerned about her finances. She also does not feel confident in driving. She lives in a two-story home with her domestic partner who works full-time. The ENT physician instructed the patient to stop taking meclizine and referred her to an outpatient balance and vestibular physical therapy clinic due to her persistent symptoms.

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What is her rehabilitation prognosis?

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What are the most appropriate physical therapy interventions?

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What are the critical elements of the clinical examination of the patient?

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What are the most appropriate examination tests?

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  • ALEXANDER'S LAW: Looking in the direction of the fast component of the nystagmus increases its amplitude and frequency while looking in the reverse direction has the opposite effect
  • COMPUTERIZED DYNAMIC POSTUROGRAPHY (CDP): Laboratory tests that measure balance or center of gravity sway
  • DYNAMIC GAIT INDEX (DGI): Gait and fall risk assessment developed for patients with vestibular dysfunction
  • ...

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