This case study outlines challenges facing clinicians when treating vestibular neuritis in patients who continue to work full-time in highly stimulating vestibular environments.
Jen Beasley, a 37-year old first grade teacher, was referred to me by her ENT in December, 2014. She had awakened a month earlier with severe dizziness and nausea. After attempting to push through, holding on to the walls at school as she went through her day, she was diagnosed with vertigo by her family doctor and sent home with anti-nausea medication. Two weeks later, Jen saw an Urgent Care doctor who saw fluid in her ears and attributed it to allergies. Jen eventually ended up in bed as the dizziness and nausea exhausted her. Her ENT referred her to me with a diagnosis of BPPV.
During our first meeting, we spent time talking about her symptoms and situation. I suspected Jen was not dealing with “simple” BPPV and was likely suffering with either vestibular neuritis or labyrinthitis.
The most important component of any patient evaluation is getting a good history.
- Onset – 2 to 4 days extreme nausea, vertigo, and imbalance. By the time they see the physical therapist they should be SLOWLY improving. Episodes usually follow a cold/flu or sinus infection.
- Hearing loss distinguishes labyrinthitis from vestibular neuritis. Treatment plans from a PT perspective are the same. An ENT/ audiologist should be consulted about the hearing loss.
- Increased symptoms with movement in visual fields, such as computer use, crowded places, TV.
- Balance – impaired stability with gait especially with un-level or darkened environments.
- Motion sensitivity – increased symptoms with position changes, quick turns. THIS IS USUALLY THE ONLY SYMPTOM WITH A BPPV PATIENT.
- Dizziness Handicap Inventory (DHI) – usually in the moderate disability range.
Key objective elements include:
- Most important tests are Head Thrust and Dynamic Visual Acuity (DVA). If these 2 tests are positive and you have normal oculomotor & neurological exams; this is usually a peripheral vestibular insult verses a central insult such as stroke.
- Frenzel goggles to rule out BPPV with Hallpike maneuver, performing the test at slow to medium speed. Hallpike test is negative if there is no sign of a torsional nystagmus.
- Dynamic Gait Index (DGI) After a comprehensive work up we concluded that
Jen’s diagnosis was vestibular neuritis.
As we put together the plan for her vestibular rehabilitation, the biggest challenge was limiting stimulation in her work environment. Jen’s job responsibilities involve constant head movement, frequent turning and excessive visual & auditory stimulation.
Early on, she had to modify her work duties as much as possible. One of her “extra” responsibilities was supervising children during bus duty. A medical excuse note eliminated this from her daily schedule. Because her work environment was heavily loaded with vestibular stimulation, it was difficult to progressively load her vestibular system during therapy as I would normally recommend. I had to be careful with her home program. Visual retraining is essential to recovery of normal function but it has to be progressed more slowly for active patients like Jen than for patients who are retired or in less stimulating work environments. I taught Jen strategies such as limiting head movement and focusing her eyes when she felt “overloaded.”
It is essential to teach patients that vestibular exercises should increase dizziness for 5-10 minutes but if the symptom increase lasts, they are overloading an impaired system.
Jen needed to accept that this would not be a smooth recovery because of her work environment. She hit her first setback at week 4, which is common. Many patients are driven to see steady weekly progress. At about week 4, they increase their home exercise program and try to do more at work because they are feeling better. Consequently, they will have a 2+ day spike in symptoms from doing too much. This is when we have “emotional chat” days for encouragement and counseling to accept that the road to recovery isn’t always easy and modifications need to be made along the way.
Jen has learned to modify her activities while continuing her VRT exercises in my office and at home. She has seen overall improvements and is feeling hopeful. Although it may take longer than she would like, I expect Jen to make a full recovery of normal vestibular function.
I want to emphasize that patient education is essential for ALL vestibular patients. They need to know the reasoning behind what they are doing, be warned about pitfalls that may happen along the way, and most importantly, that compliance is key to vestibular success!
Editor’s Note: Jennifer Liss is certified in vestibular rehabilitation by Susan Herdman’s VRT certification course at Emory University. TheraSport Physical Therapy offices are located in New Jersey, where Jennifer has practiced for 16 years. Jennifer can be reached at JLiss@Therasport.org