Mr. H was playing ice hockey one night when he was hit from behind by another player. Though he was wearing his helmet, his head hit the glass, and while falling backwards, his head hit the ice. Mr. H did not recall how he left the rink.
Initial Symptoms and Diagnosis
Mr. H DID remember being in the locker room, changing out of his hockey gear and experiencing a terrible headache, a loud ringing in his ear, seeing stars and feeling nauseous. Feeling unfit to drive, his teammates called his wife, and his wife drove him home. The following day, Mr. H was awakened at 5am with an intense dizziness which he described as “the whole room was spinning out of control.” His wife called 911, and the ambulance arrived to take him to the hospital.
At the hospital, the emergency physicians diagnosed him with a concussion and discharged him on the same day. Mr. H saw his family doctor the following day, where he was again diagnosed with a concussion and told to remain off work until such time his dizziness resolved. Since Mr. H was also experiencing neck pain, he was given a prescription for physiotherapy.
Post Concussion Vertigo Assessment at Elevation Physiotherapy
Five days after the hockey injury, Mr. H visited our clinic for physiotherapy. At the time, he felt very discouraged by the news from his doctor that the recovery from concussions is slow and could take several weeks if not months. He had just started a new job and was worried that he might lose his job should his recovery take more than a few days.
After our post concussion vertigo assessment of Mr. H, it was concluded that his symptoms of dizziness were separate from his concussion symptoms. In fact, Mr. H was describing a condition called Benign Paroxysmal Positional Vertigo or BPPV, a condition which affects the vestibular apparatus in the inner ears. It is “Benign” in that the condition itself is not life-threatening. Paroxysmal means it is episodic and is provoked by certain head positions (hence, it is positional), and vertigo is a sensation of circular motion. Dizziness is a non-specific term with numerous subclassifications, vertigo being one of them.
Vestibular Rehabilitation and Positive Outcomes
Fortunately, BPPV is easily treatable, and is diagnosed with a careful history and confirmed with a bedside test called the Dix Hallpike. If positive, it can be easily treated with Epley’s Repositioning Maneuver. In Mr. H’s case, we could reproduce his vertigo with the Dix Hallpike test. He tolerated two Epley’s Repositioning Maneuvres that day and felt immediately better afterwards, even walking independently from the treatment cubicle to the waiting area.
Since Mr. H was desperate to return to work, we saw him again three days later. He stated that his vertigo resolved completely after treatment the previous day and that he had slept through the night without waking. We re-tested his Dix Hallpike test and indeed, there was no vertigo. We subsequently tested Mr. H’s head movements in all planes, including bending down and getting up, and he was dizzy-free. Mr. H returned to work the next day with no issues, and when we followed up one week later, he had remained dizzy-free.
The Importance of Comprehensive Vertigo Assessments
In concussion patients especially, a thorough assessment is vital to differentiate the sources of a patient’s symptoms. In Mr. H’s case, resolution of his most debilitating symptom was straightforward in that the problem was not stemming from his brain but from the peripheral vestibular apparatus in the inner ear. Rather than taking weeks or months, Mr. H’s condition improved after one treatment session, thus allowing him to return to work, sleep, and function.
The new and updated Clinical Practice Guidelines for managing BPPV state that the current best practice for treating BPPV is not medications or “just waiting it out,” but treatment with a physiotherapist with special training in Vestibular Rehabilitation.
Elevation Physiotherapy is Here for You!
At Elevation Physiotherapy, we offer effective treatments for BPPV as well as a comprehensive range of services for issues such as post-concussion syndrome, Meniere’s disease, vestibular loss, balance disturbances, vestibular migraines, and labyrinthitis.
If you or someone you know is experiencing dizziness or concussion symptoms, don’t hesitate to reach out! Book an appointment with us today and take the first step toward recovery.
References:
Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017 Mar;156(3_suppl):S1-S47.
Submitted by Albert Chan