1. Vestibular Case Study

2. Description 16 year old ice hockey player suffered a head injury during a game. History of concussions but never severe. January 3 rd 2012 patient was in hockey practice had a bad hit to the same area (back and right side of head) (+) LOC and disoriented, (+) amnesia just immediately after hit these symptoms recovered. January 8 2012 during a hockey game checked in the game, then had multiple impacts to back and right side of head (punched). Mom says he looked sluggish while playing, patient reports headache after game was over. Headache lasted and got progressively worse took the next day (Monday) off from school 2* to headache, went back to school Tuesday reported he felt even worse went to pediatrician who diagnosed with migraine and cleared for back to school. © Jennifer Fay, PT, DPT, NCS

3. Course of Treatment: March 2012 Patient was evaluated by NYULMC Sports Medicine Doctor prescribed physical and cognitive rest with gentle exercise. May 2012 patient experienced exacerbation of symptoms he was again prescribed rest, however was referred to neurologist for treatment of headaches. January 2013 evaluated by Vestibular Physical Therapy. © Jennifer Fay, PT, DPT, NCS

4. Symptoms: Current symptoms, feel dizzy with walking through crowds and busy environment. Off balance when standing with eyes closed. Feel off balance when in crowded stimulating environments, subway rides, reports he feels "clumsy" and has been walking into doorways or walls. Ambulation on TM caused patient to c/o increased headache and dizziness at HR 120bpm or 60% of age predicted max HR. Difficulty completing school work due to headaches and difficulty reading. Veering while walking on the treadmill and reports feeling dizzy. © Jennifer Fay, PT, DPT, NCS

5. Clinical Findings: No nystagmus with and without fixation Negative head thrust BESS score: 20 (mean score 10.97 points) Horizontal VOR (HVOR): Patient performed 44 Head turns/minute (HT/min); 66.67 % of expected norm Vertical VOR (VVOR): Patient performed 52 Head turns/minute (HT/min); 43.33% of expected norm Increased dizziness, reduced gait speed and veering with ambulation with head turns. Baseline dizziness 4/10 at rest. © Jennifer Fay, PT, DPT, NCS

6. Treatment Static and dynamic balance, gaze stabilization exercises (VOR x1 and VOR x2) to promote adaptation and reduce dizziness. Exertion testing on stationary bicycle (able to perform for 14 minutes prior to worsening of symptoms and HR 140 (70% of age predicted max HR). Aerobic exercise on stationary bicycle for 20-30 minutes 2-3 times per week while monitoring symptoms and heart rate at 112bpm gradually increasing as tolerated. © Jennifer Fay, PT, DPT, NCS

7. Outcomes Baseline dizziness decreased at rest from 4/10 to 1/10. At discharge he was able to exercise at 65% of age predicted max HR for 30 minutes without symptom complaint. He no longer demonstrated imbalance while walking with head turns. Improved speed on the VOR from 43.3% of expected norm to 100% of expected norm. He returned to school full time to finish his senior year. After 6 months reported running again for 8-10 miles with no HA or dizziness. © Jennifer Fay, PT, DPT, NCS