Physiotherapy Vestibular Initial Assessment

S//

PC

Symptoms: "The room spins violently whenever I roll onto my right side in bed or look up at the top shelf."

• Dizziness: Intense rotational vertigo (horizontal spinning) triggered by positional changes; mild residual lightheadedness between episodes.
• Visual: Transient oscillopsia during acute spinning episodes; nil diplopia or photophobia.
• Balance: Unsteadiness and veering to the right immediately following positional triggers; nil falls.
• Ear: Nil.
• Neck pain: Mild bilateral suboccipital stiffness (2/10 VAS) secondary to guarding head movements; does not directly trigger vertigo.
• Headache: Nil.
• Nausea/vomiting: Moderate nausea with morning episodes; nil vomiting.
• **Drop attacks: **Nil.
• Other (red flags): Nil.

Consistency: Episodic

Episode frequency & Duration: 4–5 times daily, lasting 15–30 seconds per episode.

Agg

• Positions/ movements: Rolling to the right in bed, getting out of bed, looking up, bending forward to tie shoes, rapid head turns.
• Environments: Nil.
• Other: Worse first thing in the morning upon waking.

Ease

• Keeping head still, sleeping propped up on two pillows, prochlorperazine (Stemetil®) (minimal effect on rotational component).

HPC

• **DOI: **10/03/2026
• **Onset: **Woke at 06:30 and rolled onto right side to turn off alarm; experienced sudden, severe rotational vertigo and nausea lasting ~20 seconds.
• Precursor: nil virus/head/ barotrauma
• Progression: Unchanged; episodes remain consistent in intensity and duration over the past 10 days when provoked.
• **Prior Intervention: **Reviewed by GP on 14/03/2026; prescribed prochlorperazine 5 mg PO TID PRN and referred to vestibular physiotherapy for suspected BPPV.
• **Radiology: **Nil.

PMH

• **Medical conditions/medications: **Hypertension (perindopril (Coversyl®) 5 mg PO daily), Osteopenia (cholecalciferol 1,000 IU PO daily). NKDA.
  • Vestibulotoxic substance; Nil.
  • Vision Issues: Multifocal glasses worn for reading and distance.
  • Peripheral Neuropathy: Nil.
  • Mobility/falls: Independent, nil walking aids, nil history of falls.
  • Cervical Pain: Occasional mild age-related cervical spondylosis; nil acute issues.
  • Migraines: Nil.
• **Prior vestibular episodes: **Nil previous history of vertigo or balance disorders.

SHx

• Occ: Part-time librarian (20 hrs/wk); involves reaching high shelves, bending to low shelves, and screen use. Currently on sick leave since 12/03/2026.
• **Exercise: **Pilates 2x/wk (Tues/Thurs - currently paused due to mat work triggers) and daily 30-minute dog walking.
• Goals: Resolve positional spinning to return to work within 1 week and resume Pilates within 2 weeks.
• Other: Lives in a single-storey house with husband (supportive). Non-smoker, social alcohol (1–2 glasses wine/wk). Anxious about falling in the shower and fearful of provoking symptoms by moving head.

O//

• Observation: Cervical stiffness (en-bloc head and trunk rotation); facial symmetry NAD.
• Gait: Wide-based gait with reduced head turns and decreased gait velocity.
• Cervical AROM: Normal range, performed slowly to avoid symptom provocation.
• Sustained Cx Rot: Nil symptoms.

Oculomotor assessment/ CNS

• **Spontaneous Nystagmus **(with/without fixation): Absent. Fast phase: N/A.
• Gaze evoked nystagmus: Nil change.
• **Smooth Pursuits: **Normal.
• **Saccades: **Normal.
• VOR Suppression: Normal.
• **Skew test: **Normal (nil vertical ocular misalignment).
• Visual field: Normal.
• Cranial nerves: NAD.
• Cerebellar tests: Rapid finger nose, heel shin, and supinate/pronate NAD.

VOR Assessment

• HIT: Normal bilateral.
• **DVA: **Normal (1 line difference).
• Fukuda Step test: Normal (nil significant rotation or displacement).

Positional/BPPV Assessment

• **Dix-Hallpike Test: **
  • Right: Positive. 3-second latency, upbeat and rightward torsional nystagmus lasting 18 seconds, fatigable on repeat testing; reproduced severe rotational vertigo.
  • Left: Negative. Nil nystagmus, nil symptoms.
• Roll Test: Negative bilateral.
  • Right: Negative, nil latency, nil nystagmus, nil symptoms.
  • Left: Negative, nil latency, nil nystagmus, nil symptoms.

Balance & Postural Control

• SLS: >10sec bilateral Eyes Open (EO), impaired (4 sec R, 5 sec L) Eyes Closed (EC).
• Romberg: Feet together eyes open >10sec, FT eyes closed >10sec, tandem EO >10sec, and T EC abnormal (5 sec).
• CTSIB: Floor eyes open >30sec, floor eyes closed >30sec, foam EO >30sec, and foam EC abnormal (14 sec, increased sway).
• DGI: 20/24 (Level surface: 3, Change speed: 3, Horizontal head turns: 2, Vertical head turns: 1, Pivot turn: 2, Obstacles: 3, Around obstacles: 3, Stairs: 3).
• TUG: 9.5 sec, normal.

A//

PC: 10/7 history of unchanged, brief episodic positional vertigo and mild unsteadiness.

Dx: R) Posterior Canal BPPV (Canalithiasis) Dx: Secondary cervical muscle guarding

• Differential: Central positional vertigo (ruled out via CNS/oculomotor exam), Vestibular migraine.
• Key CF: Osteopenia (associated with otoconia detachment), fear-avoidance behaviour leading to en-bloc movement patterns.

B/G: Fear of symptom provocation limiting daily activities; requires rapid resolution to return to library duties (overhead reaching/bending) and mat Pilates. Multifocal glasses may impact visual reliance during balance tasks.

I//

Edu/Advice

• Explained pathology of BPPV (displaced otoconia in the right posterior semicircular canal) and high success rate of canalith repositioning manoeuvres.
• Advised to cease Stemetil® as it suppresses central compensation and is ineffective for mechanical BPPV.
• Provided post-Epley advice: avoid extreme head extension or lying flat for the remainder of the day; resume normal sleeping posture tomorrow night; expect possible mild residual "walking on clouds" sensation for 24–48 hours.
• Plan to review in 3 days to re-assess Dix-Hallpike and progress balance/VOR exercises if clear.

**Manual Tx: **

• CRM (Epley Manoeuvre) R) x2 // 1st pass reproduced vertigo in pos 2, 2nd pass nil nystagmus and nil vertigo across all positions.
• STM bilateral suboccipitals and upper trapezius 5 mins // improved ease of Cx AROM.

**HEP: **

• Seated Cervical AROM (Rotation & Flex/Ext within comfort): 10 reps, 3x/day to reduce en-bloc guarding.
• Static Balance: Tandem stance EO near kitchen bench, 3 x 30s, 2x/day.
• Walking with horizontal head turns (normalising gait): 2 mins daily in hallway.

Communication: Sent initial assessment summary letter to referring GP (Dr A. Sterling) outlining R) PC-BPPV diagnosis and treatment provided.

R//

3/7

Re-assess R) Dix-Hallpike to confirm resolution of BPPV, re-evaluate DGI (specifically horizontal/vertical head turns) and CTSIB Condition 4, and clear for return to work and Pilates if asymptomatic.