History: B.W. is a 79 year old male referred to The Center for Balance with complaints of dizziness, balance problems, and 2 falls in the last 3-4 months. B.W. stated his symptoms began after having bypass surgery four months ago. Patient symptoms consist of a feeling of lightheadedness while moving his head, reading, walking with head movements, shopping in stores with bright lights, and walking on uneven surfaces. Patient describes his symptoms as, “a feeling of wooziness and light headedness, I cant control my balance, I think people think I am drunk, I could never pass a DUI test, I basically do nothing”. Patient complains of dizziness intensity of 7/10 (10 being severe, o being no dizziness). Patient further states his fear of falling during activities of daily living is 6/10 (10 high fear of falling, 0 no fear of falling). B.W. states he is afraid to go out by himself, feels he is a burden to his family, and not the person he used to be.
Examination: Patient demonstrated positive VOR testing (dizziness caused by head and eye movements). Patient static balance BERG testing 40/56 (36/56 severe deficits); dynamic balance testing/dynamic gait index 14/24 (13/24 severe deficit); timed up and go test 16 seconds (10 seconds or less is normal). Patient demonstrating severe gait disruptions amb. with head movements, walking on uneven surfaces, walking around and over obstacles.
Assessment: B.W. is demonstrating dizziness and a fear of falling limiting activities of daily living. Patient functional static and dynamic is poor putting patient t a high fall risk. Patient has significantly decreased his activity levels and is afraid to leave home alone.
Treatment: Patient treatment consisted of custom dizziness exercises, functional static and dynamic balance exercises, CORE strengthening exercises, gait balance exercises, and endurance training.
Results: At the time of discharge from physical therapy B.W. was able to perform ADL’s without dizziness or fear of falling during daily activities. Static balance BERG score 53/56 (goal 52/56), dynamic balance score dynamic gait index 22/24 (goal 22/24), timed up and go score 8 seconds (goal 10 seconds or less). B.W. states he is able to do things by himself, “I don’t have to bother my wife any more”.