Referring Physician: ______Date:
Systems Review
Other current medical issues:
Joint pain? Y/ N Neck pain? Y/ N Back pain? Y/ N Ability to lay supine for positioning maneuvers if needed? Y/ N
PMH: Heart conditions, High Blood Pressure, Hypotension, DM,High Cholesterol, HA’s or migraines,Hx of infection,Recent antibiotic use, Osteoporosis, CA, Falls, Head trauma, MS, Parkinson, CVA: any residual effects?
Red Flags:
- Have you currently been experiencing unexplained abnormal fatigue, SOB, slurred speech, difficulty swallowing
- blurred vision, double vision, numbness tingling, poor coordination, unexplained weight loss/gain, Visual field cut
- unexplained weakness/ loss of strength in arms/legs, tremors,
- Passed out recently or lost consciousness? Memory Loss?
Hearing Loss? Y/ N Side? Right/ None / Left ~ (labrynthitis, Menieres, Vestibular schwanomma, SCD)
Tinnitus: Right / Left
Has the loss been gradual or sudden?
Hearing test (Audiogram) done recently ? Y/ N
Medical Tests: MRI CT scan Smoke? Y/ N Drink Y/ N
History of current issue:
Date of Onset: What were you doing when it came on?
Vertigo (spinning) Imbalanced (unsteadiness) Faint (light head/pass out)
Spontaneous (nothing you think you can do to trigger it) or is it brought on by positional Changesor non-specific head movement?
Worse with? Laying down in bed, Sitting up in bed, Rolling over in bed R / L, Looking side to side? Standing up quickly, Bending forward, Pitching head back,
Symptom review:Floating, Swimming, Rocking/swaying, Spinning, tilting, light headedness, pass out, motion sickness, dyseuillibrium, vertigo
How long did your initial episode last?: sec min hours day(s) weeks
BPPV (canal) BPPV (cupulo) Meniere’s Neuritis CNS
SCD TIA Labyrinthitis Psychiatric
Vestibular ischemia
Are there any other symptoms that come along with the dizziness?
Nausea, Vomiting, Loss of Balance, Oscillopsia,popping of ears, Headache,Diplopia, Visual loss, Dysarthria, Sensory disturbances, Limb incoordination, Falls, Does sneezing, coughing,holding your breath or specific sounds exacerbate your dizziness? (S Canal Dehisence/Perilymphatic fistula), Associated sensitivity to lights, sounds or odors with your dizziness? Hormonally triggered? Headaches? ( Migraine related dizziness)
What relieves your symptoms?
Is your dizziness recurrent?
How often does an episode recur? Duration of recurrences?
Improving / Worse / Same? Prior treatment?
Oculomotor Tests:
1) Smooth Pursuits(central) H-test :WNL/ saccadic / Abno. ocular ROM 2) Saccades(central):WNL/Abnormal
3)VOR Cx(Central)Normal/Abnormal4)VOR slow (central):Nystagmus Rt/ Lt
5)OptokineticNystagmus(central)WNL/Abnormal
6)Dynamic Visual Acuity: (peripheral)WNL/ DegradedLines
7) Gaze Stability with fixation: WNL/Nystagmus: Rt/ Lt
8) Gaze Stability without fixation: negative or Nystagmus: Rt / Lt
9) Head Shake without fixation(10 sec):negative Nystagmus/ direction
10) Head Thrust(Peripheral):WNL Positive: Rt / Lt12) Heave Test(Peripheral) : WNL/Positive: Rt/ Lt /BL
Cervical Screen:
1) Vertebral Artery TestRt/Lt/BL+ve/-ve2)Sharp Purser Test+ve/-ve
CoordinationDysdiadochokinesiaWNL/Abnormal
Finger to nose/Heel to ShinWNL/Abnormal/Overshooting/Undershooting
Proprioception:Left LE : WNL/intactImpaired/Absent
Right LE : WNL/intactImpaired/Absent
Postural Control
1) Romberg:
Standing level/ firm surface Eyes Open WNL Sway: Mild/ Moderate/ Severe / LOB
Standing level/ firm surface Eyes Closed WNL Sway: Mild/ Moderate/ Severe / LOB
Sharpenedeyesopen/closeWNL/Abnormal
2) FUKUDA (arms @90, eyes closed 50 steps on one spot):Rt/Lt
3) CTSIB:
Standing on foam Eyes Open WNL Sway: Mild/ Moderate/ Severe / LOB
Standing on foam Eyes Closed WNL Sway: Mild/ Moderate/ Severe / LOB
Gait:StandardWNLUnsteady With head vertical movements:WNLUnsteady
Eyes closed:WNLUnsteady Tandem gait:WNLUnsteady
With head horizontal rotation:WNLUnsteady
Sensation:Left LE : WNL/intactDiminishedAbsent
Right LE : WNL/intactDiminishedAbsent
Identification of Anterior / Posterior Canalithiasis or Cupulolithiasis
16) Hallpike Dix: Left / Right WNL Nystagmus R / L / up / down torsion: R / L Duration: ______With fixation present: ________
17) Sit Patient up: Left / Right WNL Nystagmus R / L / up / down torsion: R / L Duration: ______With fixation present: ______
18) Hallpike Dix : Left / Right WNL Nystagmus R / L / up / down torsion: R / L Duration: ______
With fixation present: ______
19) Sit Patient up: Left / Right WNL Nystagmus R / L / up / down torsion: R / L Duration: ______
With fixation present: ______
•Posterior Canal BPPV Torsion ipsilateral to the ear down and upbeat Canalithiasis duration: < 60 sec
•Anterior Canal BPPV Torsion ipsilateral to the ear down and downbeat Cupulolitiasis duration: > 60 sec
Identification of Horizontal Canalithiasis
19) Roll Test Left WNL Nystagmus R / L / up / down torsion: R / L Duration: ______With fixation present: ______
Right WNL Nystagmus R / L / up / down torsion: R / L Duration: ______
With fixation present: ______
Horizontal Canal BPPV – Canalithiasis Horizontal Canal BPPV – Cupulolithiasis
-Horizontal geotropic (toward with ground) < 60 sec - Horizontal ageotropic(away from the ground) > 60 sec
OUTCOME MEASURES:
Dizziness handicap Inventory (DHI)Dynamic Gait Index (DGI)______Berg Balance Score______
Timed Get “Up and Go” ______Activities Specific Balance Confidence Scale (ABC) ______
Motion Sensitivity Quotient (MSQ) ______Other
Rehab Potential Excellent Good Fair
Problem list/functional limitations
BPPV
Right/Left/BL Posterior/Anterior/Horizontal Canal Canalithiasis Cupulolithiasis
Decreased Gaze Stabilization Increased Motion Sensitivity Vestibular Weakness
Gait Instability Decreased tolerance for ADLs Decreased Strength
Decreased Balance Decreased ROM
Other ______
Patient’s Goal:______
TREATMENT PLAN:
Home Exercise Program
Canalith repositioning maneuvers Gaze Stabilization exercises Home exercise instruction
Habituation exercises Neuromuscular Re-Education Clinic-based vestibular/balance therapy
Patient education Other______
Patient agrees with plan of care.
Therapist’s SignatureDate