I have been having dizzy spells for years and was attributed to possible Meniere's disease. So, I had further testing at University of Wisconsin Health in Madison, Wisconsin. Most Neurologist look into your eyes and say I don't see anything moving in your eyes. Having video goggles on and recording your eye movements trump a neurologist looking into your eyes! I had two different therapists record my eye movements and both recorded nystagmus during Dix-Halipike in Neutra and the nystagmus reversed upon returning to neutral. Here is the treatment documents:
May 15, 2018
History of Present Condition and Description of Symptoms:
Terry is a is a 63 year old male who was seen in Neuro Outpatient Physical Therapy today for evaluation of the impact of dizziness and disequilibrium on his current functional capacity and to determine if ongoing physical therapy intervention is appropriate.
Bad vertigo a couple of years ago. Intense symptoms of external vertigo. Denies a specific trigger, but he notes he couldn’t stand being in a room with noise because sounds were like a distorted speaker. The vertigo was episodic and lasted for about 30 minutes, but the distortion persisted for close to a year. Denies photosensitivity. Endorses imbalance, but no falls. Denies any effective treatment. Needed to ride these episodes out. These vertigo spells were initially occurring about twice a week initially. The frequency gradually tapered.
Recently notes that he became nauseated when walking in a mall under a burning out, flickering light. His symptoms lasted 15 minutes.
Okay with phones, TV, and movies.
Unsure about being a passenger, usually the driver. He denies symptoms as the driver.
Also reports he became nauseous when his head went back below his chest after rolling back over a physioball. This lasted for 30 minutes.
Severe headache today. 8/10 at present. He took a half a Vicodin at 4am without benefit. Muscles at the base/back of skull are knotting up. He also feels exhausted. Eyes are very sore, but he denies photosensitivity. These headaches often take up to 1 .5 days to subside.
Most of the time he wakes or wakes at night with a headache. He has not tracked his headaches. He did meet
with two different neurologists in Green Bay. One gave him depakote. The other prescribed a different medication. These were not of benefit. Reports he had imaging that showed white matter changes and was placed on memantine to slow that process.
He did keep a headache log when he saw the first neurologist, but he doesn’t recall anything that stuck out. He takes valium when his headaches are associated with muscle tension.
Feels some ‘positional’ symptoms when coming up from being bent over. Describes this as being “room spinning” and “nausea.’ Also with bending forward. Denies these symptoms with looking up, laying down, or rolling over.
The following is an excerpt authored by Dr. Pyle, dated 1/1 9/1 8, from the UW Health medical record. ‘With regard to his vestibular complaints, the patient reports that overall he continues to have symptoms of dizziness, He describes this as a feeling of imbalance, disequilibrium, internal motion and lightheadedness. He had two 30-minute bouts of dizziness, 1 occurred when he was in a mall and another occurred when he was exercising and stretching back over an exercise ball. These episodes of dizziness were also associated with nausea, In addition to the chronic headaches, he will also have photosensitivity, he will have a trigger of nausea, headache and vestibular symptoms with flashing lights. He also has a significant history of motion intolerance. All of these are of course consistent with a working diagnosis of vestibular migraine.”
The following is an excerpt authored by Dr. Pyle, dated 4/6/18, from the UW Health medical record, “We did spend a good deal of time reviewing his vestibular testing. First of all, his rotary chair test showed normal function of the peripheral and central balance system. He had a normal gain, and he also had normal phase. He had good responses at all frequencies. There was abnormal symmetry, but in isolation, this is an essentially normal study. His electrocardiography was within normal limits.”
Test: Findings:
Left Dix-Hallpike: Nystagmus Direction: Pure, down beating nystagmus
Latency: < 5 seconds.
Duration: < 30 seconds.
Reversal: No nystagmus was present upon returning toneutral.
Symptom Description: vertigo.
Symptom Intensity: moderate.
Symptoms Provoked By: test position and returning to
upright.
Symptoms Strongest With: test position.
Effect of Repetition: The nystagmus fatigues and symptoms
fatigue.
Right Dix-Hallpike: Nystagmus: No nystagmus was present during the test.
Symptom Description: nausea.
Symptom Intensity: mild.
Symptoms Provoked By: test position and returning to
upright.
Symptoms Strongest With: test position.
Effect of Repetition: The test was not repeated.
Left Horizontal Canal: Nystagmus: No nystagmus was present during the test. Symptoms: No symptoms were present during testing. Effect of Repetition: The test was not repeated.
Right Horizontal Canal: Nystagmus: No nystagmus was present during the test. Symptoms: No symptoms were present during testing. Effect of Repetition: The test was not repeated.
Dix-Halipike in Neutral: Nystagmus Direction: Pure, down beating nystagmus
Latency: < 5 seconds.
Duration: c 30 seconds.
Reversal: The nystagmus reversed upon returning to neutral.
Symptom Description: vertigo and nausea.
Symptom Intensity: moderate.
Symptoms Provoked By: test position and returning to
upright.
Symptoms Strongest With: test position.
Effect of Repetition: The nystagmus fatigues and symptoms
fatigue.
Seated Supine Nystagmus Direction: Pure, down beating nystagmus
Positioning Test: Latency: <5 seconds.
Duration: c 30 seconds.
Symptom Description: nausea.
Symptom Intensity: mild.
Symptoms Provoked By: test position.
Effect of Repetition: The test was not repeated.
Horizontal Vestibulo-ocular Reflex (Slow Head Movement): Negative bilaterally.
Horizontal Vestibulo-ocular Reflex Suppression/Cancellation: Negative bilaterally.
Left Horizontal Head Impulse Test (Halmagyi Head Thrust Test): Negative.
Right Horizontal Head Impluse Test (Halmagyi Head Thrust Test): Negative.
Treatment for Positional Vertigo: The examination findings were discussed with the patient. The pathophysiology of positional vertigo was explained. Treatment presented included: 1) watch and wait, 2) home treatment with modified particle repositioning maneuvers for home use, 3) home treatment with habituation exercises, and/or 4) in-office treatment via the appropriate particle repositioning maneuver. Risks, benefits, advantages and disadvantages of each relevant option were discussed. He chose in-office treatment.
Treatment Diagnosis: anterior canal BPPV, canalithiasis. Treatment: Treatment was initiated with the Yacovino maneuver. Treatment Modifications: none.
Nystagmus Observation/Recording Technique: Digital video goggles. Response to Treatment: Response to treatment was as anticipated.
Repeated Testing: Repeat testing was positive for the same canal and the patient agreed to additional in-office treatment in order to increase the likelihood of treatment success.
Additional Treatment: He was taken through the same treatment x 1 cycles, with the expected response. We also did a left Epley maneuver today as well. He reported feeling nauseous after treatment, but was capable of ambulating throughout the clinic without imbalance.
Post-treatment Instructions:
No post-treatment instructions were given.
Issued information on anterior semi-circular canal benign paroxysmal positional vertigo and vestibular
migraine.
Encouraged to keep a headache diary and to look for patterns related to triggers.
Education Provided: Written descriptions of home recommendations and exercises were provided via handouts. Instructions provided that the “Patient Instructions” are part of the After Visit Summary report which is available from the clinic scheduling desk, as well as in MyChart.
Clinical Impression: Terry is a 63 year old male who presents to physical therapy with signs and symptoms consistent with vestibular migraine. Unfortunately, he was in the throes of a migraine headache when he arrived today. He agreed to complete as much of the examination and any treatment that he could tolerate. I explained to him that my diagnosis of anterior semi-circular canal benign paroxysmal positional vertigo is tentatively made today given the fact that he presented with a migraine headache and since there was not a strong torsional component to the nystagmus I observed. His positional symptoms and nystagmus could merely be an artifact of migraine.
Contextual Factors: The following are contextual (personal and environmental) factors that may influence Terry’s rehabilitation:
Positive Factors: patient is motivated to participate in therapy and goal-directed behavior.
Negative Factors: polypharmacy, use of centrally-active medications, participation in therapy requires a major lifestyle change due to a long history of being sedintary without regular exercise, considerable fear and avoidance behaviors are demonstrated, limited understanding of his symptoms and/or current situation, impaired insight and insurance constraints.
Number of Personal Factors, Environmental Factors, and Co-morbidities Impacting Physical Therapy>
3
Impairments in Body Function and Structure: Terry’s impairments in body function and/or structure as related to his physical therapy plan of care include: headache (migraine), decreased confidence in balance, a moderate perception of disability secondary to dizziness and positional dizziness due to BPPV
Activity Limitation and Participation Restrictions: Terry has difficulty with the following functional activities and areas of participation:
1. Basic Mobility: Lying down, Rolling over, Coming to sitting, Coming to standing and Bending
Number of Body Structures, Body Functions, Activity Limitations, and Participation Restrictions Impacting Physical Therapy: 10
Clinical Characteristics: Terry presents with a clinical presentation with unstable and unpredictable characteristics (high)
Determination of the Level of Complexity: Based on personal factors involved, systems assessed, characteristics of the clinical presentation, and level of clinical decision making required, the complexity of the evaluation performed today is determined to be: high complexity
Prognosis / Overall Rehabilitation Potential: Fair.
Rehabilitation potential is based on several indicators, including the diagnosis, readiness to learn, and contextual factors.
Rationale for Skilled Care: The patient requires physical therapy to design and develop a program to allow Terry to perform home exercises towards achieving goals set at evaluation, in order to problem solve with Terry functional difficulties through alternate movement strategies and to provide canalith repositioning maneuvers for benign paroxysmal positional vertigo.
I discussed the results of his evaluation and we developed the following treatment plan.
Terry and this therapist jointly agree to actively pursue the physical therapy goals as stated and/or this plan of treatment.
Goals / Therapeutic Outcomes for this Episode of Care:
No specialty comments available.
Terry’s physical therapy goals will be developed further and revised as needed following further evaluation and treatment as appropriate.
Treatment Planned: Therapeutic Exercise - 97110, Neuromuscular Re-education - 97112 and Canalith Repositioning Procedure(s) - 95992.
Frequency of Treatment: bi-weekly x 3 visits with tapered frequency based on patients response to skilled therapy.
Duration of Treatment: 2 months with modifications as indicated based on ongoing assessment and rate of progress towards attaining goals.
Anticipated discharge recommendations: To be determined
Additional Tests and Measures Planned: repeat testing related to BPPV.
Comprehensive Physical Performance Testing and Re-evaluation will be conducted as appropriate.
Recommended Referrals:
No additional referrals are recommended at this time.
Education was provided that physical therapy may include performance of a home exercise program; recommendations for behavioral modification, suggestions for lifestyle accommodation, recommendations for resuming life roles; and/or development of techniques for self-management where appropriate. Additional education related to the expectation and importance of active participation in order to obtain the most benefit from the services provided.
Terry did indicate a willingness to actively participate in rehabilitation and has expressed or demonstrated an understanding of his role. Mr. xxx was encouraged to contact me via MyChart or telephone with any questions or concerns that arise regarding the above assessment or plan of care.
I appreciate being involved in Terry’s care.
Cohn R. Grove, PT, DPT, MS NCS
UW Health Rehabilitation Clinic
6630 University Avenue
Middleton, WI 53562
07/31/20
Progress Notes - Clinical Notes
Progress Notes signed by G Mark Pyle, MD at 07/31/20 1005 PROGRESS NOTES
DATE: 07/27/2020
Mr. Nier is a 65-year-old patient with a complex otologic history. The patient has a known right tympanic membrane perforation. He also has a history of multifactorial vestibular symptoms including elements of vestibular migraine, as well as atypical lateral semicircular canal cupulolithiasis. The patient has had difficulty with conventional physical therapy and has not responded well to repositioning maneuvers. The patient also has a history of autoimmune disease and has been under excellent rheumatologic care. Finally, he has had elements of otitis externa and even fungal otitis externa on his right side.
The patient’s interval history is remarkable in that he has had 2 significant episodes of vestibular symptoms. In January, when in Arizona, he reported 3 days of intense imbalance, at which time he could not ambulate due to severe disequilibrium, which required him to be in a wheelchair for 3 days and be on a couch for almost a week. His vestibular symptoms then returned to baseline, but then following air travel back to Wisconsin in May, he developed a severe otalgia on the left, as well as occipital pain and had a lesser transient flare-up of his disequilibrium. He was managed symptomatically with lorazepam and Zofran with relief, which was much better than the Dramamine that he took. He had never had any drainage from the right and, interestingly, the posterior occipital pain was on his contralateral left side. He has had a very extensive workup that has shown no evidence of peripheral weakness but elements of atypical positional vertigo and probable central vestibulopathy.
PHYSICAL EXAM:
Binocular microscopy was carefully performed, and his right tympanic membrane perforation is stable. He had a separate perforation in the anterior superior quadrant, which has healed, and he now has only an inferior perforation. The edges are clean. The middle ear mucosa is normal. The contralateral ear is normal on examination, although he does have negative pressure on the left on his tympanogram. There is no spontaneous nystagmus present. His repeat audiogram shows stable thresholds with a mild high-frequency loss on the left and a mild-to-moderate conductive component in the low frequencies on the right, which is stable.
IMPRESSION AND RECOMMENDATIONS:
This patient’s tympanic membrane perforation is stable and he is not having any symptoms on that side. He continues to have significant elements of atypical positional vertigo and is requesting another physical therapy evaluation. He had previously seen Cohn Grove and would like to reestablish with another physical therapist at our balance center. We also discussed the option of local physical therapy in the Green Bay area, which he declined. He is not a candidate for tympanoplasty on the right side. Hopefully, he will have improvement with physical therapy, and we did review the possibility that his recent symptoms may have been viral neuritis. If his vestibular symptoms worsen or recur despite physical therapy, repeat VNG, VHIT and rotary chair could also be performed.
Counseling was 10 minutes of the 15-minute visit regarding this differential diagnosis and this was separate from the binocular microscopy.
G MARK PYLE, MD
Professor
07/30/2020
Return to treatment for possible BPPV. Ends up not BPPV.
Patient Instructions
- documented in this encounter
Patient Instructions
Bruria, Amy, PT - 07/30/2020 8:00 AM CDT
Deep Head Hanging treatment for Anterior Canal (both sides):
- Begin sitting on your bed with your legs stretched out in front of you.
- Lay back quickly, hanging your head off the end of the bed about 60 degrees. Stay here for 30 seconds.
- Then sit up quickly, tucking your chin to your chest as you go. Stay here for 30 seconds, then resume normal head position.
- Do 5 repetitions at a time, 1-2 times per day. Wait 1-2 minutes between repetitions.
- Try to keep track of whether symptoms reduce with repetition (both within the same set and across sets).
Electronically signed by Amy Bruria, PT at 07/30/2020 9:14 AM CDT
Progress Notes
- documented in this encounter
Bruno, Amy, PT - 07/30/2020 8:00 AM CDT
Formatting of this note might be different from the original.
Initial Evaluation
ONSET DATE: 7/27/2020 (the date of referral)
Start of care date: 7/30/2020
Referring Provider: Pyle, G Mark MD
Referral Diagnosis: dizziness and giddiness
Precautions: No documented or reported precautions
Time: 8:02am - 9:20am
Medicare Certification Date through 9/24/2020
SUBJECTIVE
HISTORY OF PRESENT CONDITION:
Date of onset: about 19 years ago
Terry is a is a 65 year old male referred to physical therapy for dizziness thought to be related to atypical BPPV.
Per chart review, Pt had worked with Cohn Grove, PT in 2018 for dizziness. Repositioning was attempted, but ceased due to atypical nature of symptoms and nystagmus, lack of improvement, and thought that symptoms may be migraine-related rather than BPPV.
Per patient, he has had this dizziness for about 19 years. He has been “beating on it” for years, seen many providers, and no one can figure out what the cause is. It is either BPPV or a central nervous system issue.
He reports that he had a failed tympanoplasty that failed in 1979 and initially after this he had little bouts of dizziness. Then he had the tympanoplasty revised in 2000 thinking that it would help with the dizziness, but it failed.
Reports that he can trigger dizziness with bending over, getting out of bed, tipping head back. Has also had 6-month bouts of ‘broken speaker” symptoms in his ears, and loud noises would trigger symptoms.
Also reports migraine headaches, but doesn’t necessarily correlate with the dizziness. Tried Depakote at one time, not really helpful.
Brings his rotary chair results from 2019 also, which showed “soft central signs” including square wavejerks. Unable to have calorics performed due to tympanoplasty.
CURRENT SYMPTOMS AND LEVEL OF FUNCTION:
Description of Symptoms: spinning sensation which lasts less than a minute. However, reports that over this winter he had
constant spinning for 3 days.
Spinning sensation: yes
Sudden hearing lass: no
Tinnitus: yes, has been chronic for many many years
Aural fullness: not lately
Headaches: does have history of migraines - tried Depakote for 6 months without benefit, hasn’t tried any other medications or
treatments
What brings symptoms on: bending over, tipping head back, getting out of bed, flashing lights can trigger it
What makes symptoms better Dramamine can be helpful. Also takes lorazepam for muscle spasms, but also helps with dizziness.
Pattern: Patient describes the nature of the symptoms since onset as fluctuating, but overall the same.
07/30/2020
ASSESSMENT — Initial Evaluation 7/30/2020
CLINICAL IMPRESSION:
Terry is a 65 year old male who presents to physical therapy without a clear medical diagnosis. He presents today with complaints of positional vertigo that have been present for the last 19 years. Pt’s history is also complicated by history of tympanoplasty and other bouts of dizziness that sound different than current positional dizziness. Exam today reveals normal oculomotor exam, no evidence of vestibular hypofunction, but Pt does have square-wavejerks throughout positional testing (central sign), with some mild downbeating nystagmus in various head hanging positions. However, this is inconsistently present. He does have reversal of this nystagmus with return to upright, though again this is somewhat inconsistent. It is possible that Pt does have anterior canal BPPV, though there are many factors that point away from BPPV and more toward a central cause, including that anterior canal BPPV is quite rare, ongoing BPPV for this length of time is quite rare, the nystagmus is inconsistently present, symptoms did not seem to fatigue with repetition today, square-wavejerks and downbeating can be central signs, and Pt has history of migraines that are not consistently treated. It would be worthwhile to trial a course of care for repositioning and habituation maneuvers to see if symptoms do respond. Would recommend trial of 4 sessions to assess for improvement and consistency, with performance of maneuvers at home between clinic sessions as well. Pt is agreeable with plan. The patient requires physical therapy to design and develop a program to allow Terry to perform home exercises towards achieving goals set at evaluation, to modify the current program based on his response to chosen components and to provide canalith repositioning maneuvers for benign paroxysmal positional vertigo. Therapist skill is required to select appropriate interventions for patient specific impairments and functional limitations, and to adjust interventions as needed based on patient response.
Current HEP:
Deep head hanging treatment for anterior canal (performing sit up quickly with chin tuck).
Overall Rehabilitation Potential and Prognosis: Fair.
Personal factors and environmental factors that may impact episode of care:
chronicity of symptoms
polypharmacy
limited understanding of symptoms and/or current situation previous history of failed conservative care with rehabilitation transportation arrangements
Rehabilitation potential is based on several indicators, including the diagnosis, readiness to learn, and contextual factors.
PRESENTATION: Characteristics of the clinical presentation are unstable and/or has unpredictable characteristics (high)
Rationale for Skilled Care:
Mr.xxxx presents with functional limitations and impairments that would benefit from skilled Physical Therapy services in an outpatient setting in order to improve functional abilities, maximize their level of independence and achieve the established goals for this episode of care. Education was provided that physical therapy may include performance of a home exercise program; recommendations for behavioral modification, suggestions for lifestyle accommodation, recommendations for resuming life roles; and/or development of techniques for self-management where appropriate. Education included the expectation and importance of active participation in order to obtain the most benefit from the services provided. Terry indicated a willingness to actively participate in rehabilitation and has expressed or demonstrated an understanding of his role. The patient requires physical therapy to design and develop a program to allow Terry to perform home exercises towards achieving goals set at evaluation, to modify the current program based on his response to chosen components and to provide canalith repositioning maneuvers for benign paroxysmal positional vertigo.
Amy Bruno, DPT
UW Health Rehabilitation Clinic
6630 University Avenue
Middleton, WI 53562
- 08/04/2020
SUBJECTIVE
Patient presents today unaccompanied. He reports that he had a headache and nausea the rest of the day after last appt. Did some of the exercises, with the same result. No improvement, kept developing headache and nausea each time.
Reports that he has a pineal gland cyst which sits right on the tactile plate right next to vestibular and auditory nerves. Is suspicious about this being the cause of his symptoms. Brought some articles today in support of this. He has an appt with neurology next week and plans to discuss this. Will also discuss with Mayo neurology. Isn’t sure that Dr. Pyle is aware that he has this pineal gland cyst. No one has an idea yet that I have an arachnoid web in my T spine.
Pain Score: Pain Score: 0 - No Pain
OBJECTIVE
Tests and Measures:
No formal testing today.
Interventions:
1. Briefly reviewed and discussed articles that patient brought regarding pineal glad cysts and central positional vertigo. Reinforced that current symptoms are more likely to be of central cause rather than BPPV given history, atypical features, lack of improvement with repositioning or habituation. Endorsed that Pt discuss this possibility with neurology and/or ENT with consideration for what the risks/benefits would be in terms of potential treatment of this. Pt agreeable.
ASSESSMENT
ASSESSMENT & Overall Response to Interventions:
He tolerated physical therapy well today. Session today focused on discussion regarding source of Pt’s symptoms, with special attention to articles that Pt had brought related to pineal gland cysts. Reiterated that pt’s symptoms seem more likely to be from a central cause rather than BPPV. Pt is planning to pursue with neurology whether a pineal gland cyst might be the cause of his symptoms, and see if there would be any available treatments for this. As such, he will be discharged from PT at this time. My T spine arachnoid web is not known yet!
Amy Bruno, DPT
UW Health Rehabilitation Clinic