Physio vestibular initial template

Physiotherapist Aim: To assess and initiate vestibular rehabilitation for persistent dizziness and imbalance following a concussion. Consent was obtained for the session and for the use of Heidi Ai Health Scribe. Patient's husband, Dr. Anya Sharma (Physiotherapist student) Subjective Hx of Presenting Complaint: Patient reports primary vestibular symptoms of constant dizziness described as a 'swaying' sensation, occasional brief episodes of true vertigo lasting seconds when turning head quickly, and significant imbalance, particularly in low light conditions or on uneven surfaces. Nausea is present intermittently, especially with head movements, but no vomiting. Symptoms are rated 6/10 at their worst, 3/10 at best. Date of onset was 10 August 2024, following a fall during a hiking trip where she sustained a concussion. There was no direct head impact, but a whiplash type injury occurred when she stumbled and hit her shoulder, causing her head to snap back. The symptoms began approximately 24 hours after the fall, starting with mild dizziness which progressively worsened over the subsequent week. She initially attributed it to the concussion, but the dizziness and imbalance have persisted beyond typical concussion recovery timeframes. Symptom pattern includes daily dizziness, worse with fatigue and busy environments. Vertigo episodes are infrequent, maybe 2-3 times per week, lasting less than 30 seconds. Aggravating factors include quick head movements, visually stimulating environments (supermarkets), standing for prolonged periods, and looking up. Easing factors include lying still in a dark room and rest. She has not engaged in prior vestibular therapy but saw an ENT specialist who ruled out central causes and Meniere's disease. She also had a neurological assessment which was unremarkable. Secondary diagnoses or comorbidities relevant to presentation: Post-concussion syndrome, diagnosed 1 September 2024, by her GP. She also has a history of mild anxiety. Past Medical History: Osteoarthritis (knees), controlled hypertension, mild anxiety. Details of previous vestibular or neurological treatments or surgeries: None. Allergies: NKDA Current medications including vestibular suppressants, antidepressants and antihypertensives: - Ramipril 5mg OD - Sertraline 50mg OD - Occasional over-the-counter paracetamol for headaches. Family medical history of conditions that may impact vestibular function: Mother had benign paroxysmal positional vertigo (BPPV) in her 70s. Imaging: - CT brain on 12 August 2024: No acute intracranial pathology, consistent with post-concussion symptoms. Social History: Lives with husband in a two-storey house. History of one fall in the last month (tripped on a rug due to imbalance, no injury). Non-smoker, occasional social alcohol use. Enjoys gardening and walking. Formerly worked as an accountant, now retired. Husband provides significant support, particularly with household tasks and transportation. Reports feeling isolated due to inability to participate in previous hobbies safely. Mobility: Current mobility status includes independent ambulation indoors with a wide-based gait, uses a walking stick for outdoor ambulation due to perceived instability. Reports occasional veering to the left. Walks slowly. Transfers including bed and chair transfers: Independent, but reports feeling unsteady when standing up quickly. Stair ability and management: Negotiates stairs independently, holding onto the handrail, one step at a time. Reports increased dizziness on descent. Functional endurance: Can walk for approximately 15-20 minutes before fatigue and increased dizziness necessitates rest. Falls: - Falls history including mechanism, frequency and circumstances: One fall in the last month. Tripped on a rug in the living room. Resulted in a minor bruise to the hip. Occurred when she turned quickly to answer the phone. Prior to concussion, no falls history for the past 5 years. IADLs: - Medication management: Independent - Finances: Managed by husband with patient input - Meal preparation: Limited, primarily light snacks; husband cooks most meals - Housework: Minimal, husband manages most tasks - Gardening: Unable to perform due to balance issues - Phone and technology use: Independent - Shopping: Requires husband's assistance, finds supermarkets overwhelming Participation: - Driving: Ceased driving due to dizziness and concern for safety - Transport: Relies on husband or public transport - Work: Retired - Hobbies: Unable to participate in walking groups or gardening due to balance - Social interactions: Limited, often avoids crowded places Support: - Carer and family support including formal versus informal support, tasks supported, level of assistance required and availability of family support: Husband provides informal support for household tasks, transportation, and emotional support. Highly available and engaged. Patient Goals: Short-term physiotherapy goals and timeframe: - Reduce dizziness severity to 3/10 or less by 1 December 2024. - Improve balance to walk 30 minutes outdoors independently by 15 December 2024. Long-term physiotherapy goals and timeframe: - Return to driving independently by 1 February 2025. - Resume gardening activities by 1 March 2025. Objective - Vestibular assessment findings including oculomotor examination, positional testing, balance and gait testing, motion sensitivity, symptom reproduction and neck assessment: Smooth pursuits full range but saccades mildly dysmetric. VOR cancellation slightly impaired. Head Impulse Test (HIT) negative bilaterally. Dynamic Visual Acuity (DVA) reduced by 4 lines at 120 bpm. Dix-Hallpike negative for BPPV. Balance: Romberg positive with eyes closed (sway significantly increased). Modified Clinical Test of Sensory Interaction on Balance (mCTSIB) showed significant sway on foam with eyes open and closed. Gait: Wide-based gait, reduced arm swing, increased postural sway on tandem stance. Motion sensitivity: Mild dizziness with head turns, severe dizziness with quick head movements (e.g., looking up/down). Neck assessment: Mild upper cervical stiffness, no reproduction of primary dizziness with neck movements. - Outcome measures administered and results including rating scales such as DHI or ABC scale: Dizziness Handicap Inventory (DHI) score: 68/100 (severe handicap). Activities-specific Balance Confidence (ABC) Scale: 45% (low confidence). Treatment Education: Patient was educated on the concept of vestibular adaptation and habituation, explaining how the brain can learn to compensate for vestibular deficits. Discussed the common persistence of symptoms post-concussion and the role of targeted exercises. Reassured patient that symptoms are manageable with consistent therapy and not indicative of a worsening condition. Emphasised the importance of adherence to the home exercise program. Hands-On Treatment: None performed during this session, focus on assessment and exercise prescription. Active Therapy and Exercises: - Gaze Stability Exercises (VOR x1): Focus on keeping eyes fixed on a target while moving head horizontally and vertically, 3 sets of 10 repetitions each direction, 2 times per day. - Habituation Exercises: Repeated vertical and horizontal head movements to provoke mild dizziness, 3 sets of 10 repetitions, 2 times per day, aiming for symptom reduction over time. - Balance Exercises: Standing with feet together, progressing to semi-tandem and tandem stance, 30 seconds each, 3 times per day. Started on firm surface with eyes open. Analysis Clinical impression of the patient's presentation: The patient presents with persistent post-concussion vestibular dysfunction characterised by chronic dizziness, imbalance, and motion sensitivity. Objective findings align with a mixed vestibular deficit primarily impacting gaze stability and static/dynamic balance, with psychological overlay (anxiety, reduced confidence) contributing to functional limitations. There are no red flags suggesting a central lesion or other serious pathology. Prioritised clinical problems: - Chronic dizziness and imbalance post-concussion - Reduced gaze stability and postural control - Low confidence in balance (ABC score 45%) - Restricted participation in social and leisure activities Progress toward patient goals: Initial session, baseline established for future progress tracking. Barriers to progress or rehabilitation: Patient's anxiety regarding falls, visual dependence, and reduced confidence may hinder exercise adherence and progression. Plan Ongoing vestibular rehabilitation focus areas including habituation, adaptation and balance retraining: Therapy will focus on improving gaze stability through VOR exercises, reducing motion sensitivity via habituation, and enhancing static and dynamic balance through progressive challenges. Confidence building strategies will be integrated. Recommended frequency and duration of therapy: Weekly sessions for 6-8 weeks, followed by review and potential reduction in frequency. Home exercise program details including exercises, dosage and frequency: - VOR x1 exercises (horizontal/vertical): 3 sets of 10 reps each, 2x/day. - Habituation exercises (head turns): 3 sets of 10 reps, 2x/day, aiming for mild symptom provocation. - Static balance (feet together, semi-tandem, tandem): 30 seconds each, 3x/day. Safety strategies recommended for home environment: Advised to remove tripping hazards (rugs), use good lighting, and continue using walking stick outdoors until balance improves. Encourage walking with a confident gait and looking straight ahead rather than down. Referral recommendations based on red flags or poor response to treatment: None at this time, will consider referral to ophthalmology for visual assessment if DVA does not improve, or to psychology for anxiety management if significant psychological barriers persist. Timeline of next review: Next session scheduled for 1 November 2024. Planned therapy focus for the next appointment: Review home exercise program adherence and technique, progress balance exercises to dynamic tasks, and introduce visual motion desensitisation. Letters, phone calls or communications the treating therapist will complete before the next session: - Send initial assessment report to referring GP. - Email patient HEP instructions and educational materials.