901 Living Room

Patient 1 Vestibular

Today was a short day. My CI let me treat two of her patients. One was a 87 year old lay who complained of spinning. The diagnosis is still unclear. Hallpike dix test was positive for both R and L, but there was no nystagmus seen on either side, which may be due to Meclizine she is taking. Patient reported that spinning was more severe with L Hallpike, so we decided to treat her L side first. 

We did Epley maneuver 5 times. Her spinning decreased with repetition. It was consistent that the last step of Epley reproduced her spinning more, and took longer to resolve. Reassessed her walking and no spinning. Patient did say that she rolls onto her L somtimes whe she sleeps. Education is super important here. Told her do not sleep on her L and do not lie dow with neck extended (eg. hair wash basin in hair salon). She doesn't speak English very well, so really have to make sure she understands all these.

She also has some emotional problems. She told me she lives alone, but my CI said actually she lives with her son. She has lots issues and wants her son to be with her all day and drive her to doctors, PT. She wants to be able to drive again. So hopefully she will get better with her spinning soon and go back to her doctor and get permission to drive again.

She told me her husband passed away four years ago. She almost cried when she said that. I think it is a psychological issue that has to be solved....not necessarily by us.

Patient 2 Cervical

An old man with neck stiffness. Conclusion: all he needs now is lots of repetition of active cervical retraction. 10 times a set for 5 sets. each time his symptoms improved. He had pain and stiffness with cervical L rotation initialy, and stiffness with R rotation. It was his chief complaint so we used that as our baseline reassessment. After 5 sets, he did not feel pain with L Rt anymore. Stiffness on both side decreased as well. 

If the active movement is still improving the symptoms, what you need to do is to add more repetitions. There's no reason to load it. You can also argue that It's not improving that much now so you want to add something to speed the recovery.

My CI challenged me by asking, "would you add overpressure to retraction, or would you add cervical extension?" My answer was cervical extension, but you can argue either way.

PT overpressure: if you think the patient is not getting end range retraction yet.

Cervical extension: if you think active movement may be better than passive OP -> we tried this one, but it made him worse (peripherilize, stiff), so we gave up this exercise

***The patient was quite satisfied with the treatment even though the only thing I did was telling him to do more cervical retractions. Why did he take it? My CI's education. She said id one exercise can make you better, that's great. We don't need to do two. We just need to do it more! It's even easier!

See marketing!!!!! It's true, but you have to make it sound reasonable to the patient.

***The patient said: do I have to do so many retractions my whole life?

CI: No! You have to do more now so that your tissue can heal. As you get better, you don't have to do as many and as frequent. You just need to do some to maintain it, and maintain good posture!