Objective: The purpose of this case study is to address the role of physical therapy (PT) in a case of complex dizziness, progressive symptoms, and evolving diagnoses.
Background: Patients often present to PT with multifactorial “dizziness” and other symptoms that vary session to session making diagnosis and treatment difficult.
Method: The patient had complaints of imbalance, recurrent bouts of “spinning,” tinnitus, and decreased hearing without traumatic onset. Initial presentation of symptoms was consistent with benign paroxysmal positional vertigo (BPPV). The vertigo resolved after treatment but new complaints of lightheadedness and a “different” feeling of dizziness emerged. The patient developed symptoms of unilateral vestibular hypofunction with good initial response to vestibular rehabilitation (VRT). However, the symptoms of lightheadedness and dizziness worsened despite VRT, diet modifications, medication treatment, and surgical intervention for a dural arteriovenous fistula. Due to symptom progression, referrals were made for further work up with audiology, neurology, otolaryngology, cardiology, and neurosurgery.
Results: The patient’s initial differential diagnoses of BPPV, Meniere’s, and vestibular migraines did not respond as expected to VRT. Final diagnoses included dural arteriovenous fistula, labyrinthitis ossificans, and Multiple System Atrophy (MSA). Diagnoses with limited treatment options and poor prognosis changed the PT goals from return to work, to providing tools to manage symptoms to maintain the patient’s redefined quality of life.
Conclusion: Physical Therapists have the knowledge and skill set to assess, reassess, and provide treatment to patients with complex symptoms. In this case, these skills were critical for encouraging the patient’s medical team to perform additional workup and to assist with the differential diagnosis, including diagnosis of MSA. The focus of PT intervention changed as the concern changed from BPPV, which is common and easily treated, to MSA, a rare neurodegenerative condition. In conclusion, Physical Therapists can be an important part of diagnosis and treatment in complex medical cases such as this case of MSA.
References: Clendaniel, RA. The Effects of Habituation and Gaze Stability Exercises in the Treatment of Unilateral Vestibular Hypofunction: A Preliminary Results. J Neurol Phys Ther. 2010; 34(2):111-116. Hall, CD, Herdman SJ, Whitney, SL, et al. Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice Guideline From the American Physical Therapy Association Neurology Section. J Neurol Phys Ther. 2014; 40(2):124-155. Herdman SJ, Hoder JM. Physical Therapy Management of Benign Paroxysmal Positional Vertigo. In: Vestibular Rehabilitation, 4th ed. Philadelphia, PA: F.A. Davis Company; 2014:324-354. Herdman SJ, Whitney SL. Physical therapy Treatment of Vestibular Hypofunction. In: Vestibular Rehabilitation, 4th ed. Philadelphia, PA: F.A. Davis Company; 2014: 394-431. The Multiple System Atrophy Coalition. About MSA. https://www.multiplesystematrophy.org/about-msa. Accessed August 26, 2018.
To cite this abstract in AMA style:
J. Liu. Physical Therapy Role with Differential Diagonosis and Treatment with Dizziness and Multiple System Atrophy: A Case Study [abstract]. Mov Disord. 2020; 35 (suppl 1). https://www.mdsabstracts.org/abstract/physical-therapy-role-with-differential-diagonosis-and-treatment-with-dizziness-and-multiple-system-atrophy-a-case-study/. Accessed June 15, 2025.« Back to MDS Virtual Congress 2020
MDS Abstracts - https://www.mdsabstracts.org/abstract/physical-therapy-role-with-differential-diagonosis-and-treatment-with-dizziness-and-multiple-system-atrophy-a-case-study/