PHYSICAL THERAPY VESTIBULAR & BALANCE EVALUATION

INTAKE INFORMATION
Name: Allison Wierda Date: 12/4/19
Physician: Dr. Johnson Date of birth: 05/05/1943 Date of onset: 02/14/2018
Medical diagnosis: BPPV ICD-10 Code: H81.10
PT diagnosis: BPPV ICD-10 Code: H81.10
Referral notes: Referred for “PT treatment of BPPV”
Diagnostic tests: BPPV testing by neuro-otologist
Surgery / Other procedure: None reported Date: N/a
Medications: Covera and aspirin Medical F/U: N/a
Past medical history: HTN, hemorrhoidectomy, appendectomy, and hernia. Blast explosion while in the military
resulting in LOC for 3 days and deafness in R ear.
Social history: Married with 2 children (ages: 28 & 30). Retired school teacher, volunteers at the local grade school (story-
time and brings therapy dog to class. Enjoys making furniture and other woodshop items.
Home / Work / Other: Lives in a 2-story house, 2 steps to enter with no rail. Full flight of stairs to second floor with rails
on both sides.

HISTORY OF PRESENT ILLNESS/SUBJECTIVE

Chief complaint: New onset of off and on dizzy spells over the last few months that occur throughout the day.
Setting in which Symptoms first occurred: First episode occurred 1 year ago after getting off a ride at Disney World.
Description of Symptoms: vertigo (sense of spinning) -balance dedness
Symptoms are getting: c
Description of Spells:
Length of time spells occur: urs other: ______________
Aggravating factors: Changing head positions
Easing factors: Keeping head still
Hearing impairments: Due to injury while in the military
Changes in hearing since onset:
Visual changes since onset:
Recent falls:
History of migraines:
Previous treatments: Previous BPPV treatment (Feb, 2018) which relieved symptoms. PT treatment (December 2018)
consisting of horizontal head movement exercises which did not relieve symptoms.
Job requirements/work status: Volunteering at local grade school needing to get up and down from the floor for
story time and taking her dog to class. Pt also makes furniture in her garage which consists of manipulating
power tools and saws with UE’s.
Other: Vital signs: BP = 170/90 mmHg, HR = 80 bpm
 PHYSICAL THERAPY VESTIBULAR & BALANCE EVALUATION

MUSCULOSKELETAL SCREEN:
Cervical Spine complaints: None Cervical Pain: None
Cervical Spine ROM: WNL
Vertebral artery resting if indicated: Modified Vetebral Artery Test performed with pt in sitting. Test = negative.
ROM/Strength Screen: Gross bilateral UE and LE ROM and strength WNL.

POSTURE: In sitting and standing, pt presents with slightly rounded shoulders R>L and forward head posture.

SOMATOSENSORY:
Light touch: Intact

COORDINATION:
Coordination testing done with patient in sitting. All tests done bilaterally.
Rapid Alt Movements: dysdiadochokinesia / normal Finger to Nose: dysmetric / normal
Heel to Shin: ataxic / normal
Past Pointing: Normal

POSTURAL CONTROL TESTS:

GAIT: Pt ambulates on level surfaces with only minor deviations noted: decreased speed, head movements, arm swing, and trunk rotation.

OCULOMOTOR/VESTIBULAR TESTING:
Spontaneous Nystagmus: Absent VOR Head Thrust (horizontal canal function)
Left: Normal Right: Normal
Gaze-Evoked Nystagmus with fixation present: (1st, 2nd or 3rd degree)
Primary: Absent VOR Head Thrust (posterior canal function)
Right: Absent Left: Normal Right: Normal
Left: Absent
Post-Horizontal Head-Shaking Nystagmus + / -
Gaze-Evoked Nystagmus with fixation suppressed: (1st, 2nd or 3rd degree) Direction
Primary: Absent
Right: Absent
Left: Absent

Smooth Pursuit: Normal Saccades: Normal VOR Cancellation: Normal

Static Visual Acuity: Able to read 20/20 (Line 8) Dynamic Visual Acuity: Able to read 20/30 (Line 6)

POSITIONING TEST:
Left Hallpike: Negative with no nystagmus or increase in dizziness

Right Hallpike: Positive, minimal increase in dizziness (<5 seconds), no nystagmus noted.

Roll Test: Negative with no nystagmus or increase in dizziness

Comments: Pt had positive R Hallpike test with vertigo symptoms lasing <5 seconds. No nystagmus observed.

ASSESSMENT/IMPRESSION: Pt presents with recent episodes of dizziness throughout the day that worsen with
position changes. BPPV of right posterior canal is suspected due to subjective reports of dizziness and positive Right
Hallpike Dix maneuver. History of damage to the right ear making it more susceptible to otolith displacement and
previous successful BPPV treatment of right posterior canal are also indicative of right posterior canal BPPV diagnosis.
Rehab Potential: Pt has good rehab potential based on minor symptoms that have a short duration in addition to previous
successful treatment and high motivation as she is seeking out treatment to eliminate symptoms.
Problem list/functional limitations:
V
**No nystagmus observed during testing
 PHYSICAL THERAPY VESTIBULAR & BALANCE EVALUATION

Precautions: Pt has a history of HTN and is on medication, but presented today with uncontrolled high blood pressure.
Pt’s PCP should be notified of BP value and BP should be checked NV. Pt is at risk of falls due to episodes of dizziness.
GOALS (to be accomplished within 1 visit or after follow-up appointment)
-onset level: Report no episodes of dizziness after re-positioning maneuver by PT or self-maneuvers at
home in order to continue active lifestyle of volunteer work, walking dog, and woodwork.
t: Demonstrate understanding of Epley maneuvers by teach
back method to self-manage dizziness symptoms.
Demonstrate understanding of post-maneuver instructions, symptom identification, and administration of subsequent
self-repositioning maneuvers in order to manage or eliminate dizziness symptoms.
Demonstrate understanding of general treatment guidelines: compliance, initial symptom increases with exercises, head
and neck movement in daily tasks, and contacting PT if symptoms worsen or change in order to self-manage dizziness and
remain independent.

TREATMENT PLAN:
Today’s Treatment:  Codes: 97112 (Neuro-reeducation), 95992 (Canalith Repositioning)

ns provided and patient to follow precautions for next 24 hours in regards to BPPV management

: HEP given for self-Epley maneuver and sleeping precautions following treatment.

Plan: Pt will be seen for an additional visit with a follow up. Pt is instructed to call to report any dizziness or elimination
of symptoms after today’s treatment.
 Will keep patient’s chart active until 12/4/2020 in case patient has problems and/or symptoms reoccur.
 Canalith repositioning maneuvers  Gaze Stabilization exercises  Home exercise instruction
 Habituation exercises  Neuromuscular Re-Education  Clinic-based vestibular/balance therapy
 Patient education
 Patient agrees with plan of care.

Summer Demeuse, SPT/Summer Demeuse, SPT 12/4/19 ___________

Therapist’s Signature Date Physician’s Signature Date
 PHYSICAL THERAPY VESTIBULAR & BALANCE EVALUATION

Home Exercise Program

Allison Wierda

Self-Epley Maneuver

Perform this maneuver whenever dizziness symptoms increase. This may increase your symptoms for a short
period of time, but these symptoms are indicative that the crystal inside of your ear is moving (which is our goal to return
it back from where it was displaced.)

Sit quietly for 20 minutes after treatment maneuver. Complete the maneuver the following morning and continue to repeat
twice daily until symptoms are gone.

Modified Sleeping Position

Sleep in a recliner chair for 2 nights, then you may return to sleeping flat in the reclined position. This will allow the
crystal to return to its initial position and prevent re-displacement.
 PHYSICAL THERAPY VESTIBULAR & BALANCE EVALUATION

Physical Therapy Discharge

Name: Allison Wierda Age: 76 Gender identification: Female

Date of Service: 12/4/19

SUBJECTIVE:
Pt reports no episodes of dizziness over the last week and a half. She states that she has been able to
participate in story time, walk her dog, and work in her garage safely without any episodes of dizziness. Reports
HEP compliance as she performed self-Eply maneuver x1 and slept in the chair for 2 nights following. She
reports confidence and understanding of self-maneuvers for management of symptoms.

OBJECTIVE:
Negative Right Hallpike Dix testing as no nystagmus was observed and pt reported no symptoms of
dizziness. Pt was able to walk on even ground for 150 ft with horizontal and vertical head turns without
experiencing symptoms. BP was reassessed and in normal range: 120/78 mmHg.

ASSESMENT:
Pt responded well to BPPV treatment and met all goals: able to manage symptoms at home using HEP
and altered sleeping position. Based on negative Right Hallpike Dix testing and ability to walk with head turns
(normally provoked symptoms) the pt is able to continue working in garage with power tools safely. Negative
testing and symptoms indicate otolith repositioning was successful.

PLAN:
Pt to be discharged to home management of BPPV symptoms and will follow-up with PT if any
symptoms re-occur.

Summer Demeuse, SPT/Summer Demeuse, SPT 12/4/19 ___________

Therapist’s Signature Date Physician’s Signature Date
PHYSICAL THERAPY VESTIBULAR & BALANCE EVALUATION
PHYSICAL THERAPY VESTIBULAR & BALANCE EVALUATION