neuro quiz 1

Question 30

A patient reports progressively worsening vertigo over the past week, accompanied by a severe headache for the past 48 hours. The patient is unable to ambulate more than a few feet without assistance. Examination reveals persistent, sustained downbeating nystagmus during right and left gaze, the head thrust test, and Dix-Hallpike testing. The patient is also unable to maintain visual fixation during VOR cancellation. Based on these findings, what is the MOST appropriate action for the physical therapist?

A	Continue physical therapy and reassess after one week
B	Immediately refer the patient for urgent medical evaluation
C	Treat for benign paroxysmal positional vertigo using canalith repositioning
D	Initiate vestibular rehabilitation focused on gaze stabilization

B Immediately refer the patient for urgent medical evaluation

Rationale: This patient presents with multiple red flags indicating a central vestibular pathology (failure of VOR cancellation, severe headache and progressive symptom worsening, severe gait instability and nystagmus present during multiple tests which is not position-specific or fatigable).

QUESTION 28

An individual is diagnosed with a unilateral peripheral vestibular hypofunction. Based on this presentation, which of the following movement system diagnoses would the individual be MOST appropriately classified as having?

A Force production deficit

B Sensory selection and weighting deficit

C Sensory detection deficit

D Fractionated movement deficit

B Sensory selection and weighting deficit

Correct answer: Sensory selection and weighting deficit. Unilateral peripheral vestibular hypofunction results in asymmetric or unreliable vestibular input. While the sensory receptors themselves may still detect motion, the central nervous system struggles to appropriately integrate, reweight, and prioritize vestibular input relative to visual and somatosensory cues. As a result, the movement problem is best classified as a sensory selection and weighting deficit, characterized by over reliance on visual or somatosensory input, difficulty maintaining balance when sensory conditions change.

A patient returned to full contact sporting activity the day after a severe concussive episode and sustained another concussion. You are monitoring for what cluster of signs and symptoms?

A - Increased agitation, restlessness, and increased blood pressure

B - Confusion, blurred vision, diaphoresis, and decreased blood pressure

C - Loss of consciousness, altered mental status, and increased intracranial pressure

D - Cluster headaches, decreased heart rate, and decreased blood pressure

C - Loss of consciousness, altered mental status, and increased intracranial pressure

C is the correct answer. The scenario describes the exact clinical mechanism for Second Impact Syndrome (SIS): a patient sustains a second head injury while still symptomatic from an initial, unhealed concussion. The patient typically transitions within seconds to minutes from a brief period of altered mental status (looking stunned or dazed) to a total loss of consciousness, coma, respiratory failure, and potential brain herniation.

A patient arrives for their regularly scheduled appointment for physical therapy. The therapist has been working on interventions to combat generalized balance difficulty due to decreased strength associated with aging. The patient reports experiencing another fall this morning in the bedroom in which they believe they hit their head on the nightstand table.

However, they were able to get up and take a cab to their appointment. Which of the following signs or symptoms warrant immediate referral for emergency care?

A - The patient doesn't remember the exact details of how they got back up off the floor.

B - The patient has a bruise and bump on their head and reports a low grade (mild) headache.

C - The patient is reporting nausea and one pupil is larger than the other.

D - The patient demonstrates impaired ankle, hip, and stepping balance strategies.

C - The patient is reporting nausea and one pupil is larger than the other.

Rationale: The correct answer is C: The combination of a known head strike followed by anisocoria (unequal pupil size) and nausea is a classic

"red flag" indicating a life-threatening neurological emergency.

Which vestibular structure is primarily responsible for detecting angular acceleration of the head?

A	Utricle
B	Otolith membrane
C	Semicircular canals
D	Saccule

Correct Answer: C. Semicircular canals

Rationale: The semicircular canals detect angular (rotational) acceleration, while the otolith organs detect linear acceleration and head position relative to gravity.

Which assessment is commonly used immediately following a suspected concussive episode?

A High-level Mobility Assessment (HiMat)

B Immediate Post-Concussion Assessment and Cognitive Test (ImPACT)

C Disability Rating Scale (DRS)

D Balance Evaluation Systems Test (BESTest)

B Immediate Post-Concussion Assessment and Cognitive Test (ImPACT)

B is the correct answer. The ImPACT tool is a widely accepted, computerized neurocognitive assessment specifically designed to help healthcare professionals evaluate and manage suspected concussions.

A high school student was diagnosed with a concussion by medical personnel during competition four days ago. Which of the following interventions is most appropriate following the Return to Sport or Return to Learn guidelines?

A Symptom limited light contact sport activities

B Light aerobic conditioning with no physical contact

C Relative rest with limited screen time

D Going on short walks outside with the family dog

D Going on short walks outside with the family dog

The correct answer is: Going on short walks with the family dog. At four days post-injury, assuming the student has completed a brief initial period of relative rest (24 to 48 hours) and their acute symptoms are beginning to stabilize, the goal is to introduce light, symptom-limited physical activity.

According to the APTA Clinical Practice Guideline titled "Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury" published in 2020, which of the following statements is most true regarding the evaluation and treatment of concussion?

A When benign paroxysmal positional vertigo (BPPV) is suspected, physical therapists should refer to a neurologist.

B Cervical musculoskeletal dysfunction is uncommon following a concussive event.

C Physical therapists should implement symptom-guided, progressive aerobic training programs

D Patients should be discouraged from participating in activity for 72 hours after screening for cervicogenic headache.

C Physical therapists should implement symptom-guided, progressive aerobic training programs

The correct answer is C) Physical Therapists should implement symptom-guided, progressive aerobic training programs. This is directly from the clinical practice guidelines.

A patient presents with dizziness when rolling in bed and imbalance during ambulation.

Examination reveals a positive right Dix-Hallpike test with upbeating torsional nystagmus and a positive Head Impulse Test. Which intervention should the physical therapist perform first?

A VOR x1 gaze stabilization exercises

B Static standing balance training on foam

C Habituation exercises for motion sensitivity

D Right Epley canalith repositioning maneuver

D Right Epley canalith repositioning maneuver

Correct Answer: Right Epley canalith repositioning maneuver When BPPV and vestibular hypofunction coexist, the Clinical Practice Guideline recommends addressing BPPV first using canalith repositioning maneuvers. Treating BPPV reduces positional vertigo and allows the patient to better tolerate gaze stabilization and balance exercises needed for hypofunction.

During near point of convergence testing, an individual reports the onset of diplopia at 10.1 cm from the tip of the nose. Based on this finding, which of the following interventions is MOST appropriate?

A Brock strings

B VOR ×1

C None, this is a normal value

D Blaze pod activities

A Brock strings

Correct Answer Brock string exercises.

Diplopia occurring at 10.1 cm indicates convergence insufficiency, meaning the eyes are unable to maintain adequate binocular convergence as a target moves closer. Brock string exercises are specifically designed to train vergence control, improve binocular coordination and reduce symptoms such as diplopia and visual strain during near tasks.

Because this intervention directly targets the underlying oculomotor deficit, Brock string exercises are the most appropriate choice.

Which of the following tests gaze stability?

Currently Selected: C

A	A Vestibulospinal reflex with the metronome set at 180-240 bpm
B	B Vestibulospinal reflex with the metronome at 50 bpm
C	C VOR with the metronome at 50 bpm
D	D VOR with the metronome at 240 bpm

VOR with the metronome at 240 bpm

Correct answer: VOR with the metronome at 240 bpm Gaze stability refers to the ability to maintain clear visual fixation on a target during head movement. This function is primarily mediated by the vestibulo-ocular reflex (VOR), which generates compensatory eye movements equal in speed and opposite in direction to head motion. High-speed VOR testing (e.g., metronome at 180-240 bpm)

challenges the vestibular system at physiologically relevant head velocities and is therefore an appropriate measure of gaze stability.

An individual is diagnosed with horizontal semicircular canal canalithiasis based on positional testing findings. Which of the following interventions is MOST appropriate?

A Semont maneuvre

B Casani maneuvre

C Li (Quick) maneuvre

D Epley maneuvre

C Li (Quick) maneuvre

The Li (Quick Roll) maneuver is specifically designed to treat this horizontal canal canalithiasis by rapidly rotating the patient through positions that use inertial and gravitational forces to move otoconia out of the horizontal canal and back into the utricle. Thus, the Li (Quick) maneuver is the most appropriate intervention for horizontal canal canalithiasis from the choices given.

A patient reports the onset of dizziness following a viral illness two weeks ago. Examination findings include a positive head thrust test, positive head shaking test, and a four-line difference between static and dynamic visual acuity. There is no associated hearing loss.

The patient MOST likely has which of the following conditions?

Currently Selected: B

A	Benign paroxysmal positional vertigo
B	Vestibular neuritis
C	Ménière disease
D	Vestibular labyrinthitis

B	Vestibular neuritis

Correct answer: C. Vestibular neuritis

Rationale: This presentation (positive head thrust test, positive head shaking test, four-line loss on dynamic visual acuity and no hearing loss) is most consistent with unilateral vestibular hypofunction secondary to vestibular neuritis, which commonly occurs after a viral illness. Vestibular neuritis affects the vestibular portion of cranial nerve VIII, and not the cochlea.

An individual is evaluated at the first physical therapy visit and diagnosed with unilateral peripheral vestibular hypofunction. Which of the following interventions is MOST appropriate to initiate at the initial visit?

A	VOR x 1 exercises
B	VOR x 2 exercises
C	Substitution exercises
D	Canalith repositioning maneuvre

A VOR x 1 exercises

Correct answer rationale: VOR x1 exercises are the cornerstone initial intervention for individuals with unilateral vestibular hypofunction. These exercises involve maintaining visual fixation on a stationary target while the head moves, directly targeting the impaired vestibulo ocular reflex (VOR). They are well tolerated early in rehabilitation.

A patient with unilateral peripheral vestibular hypofunction reports baseline dizziness of 4/10, which increases to 8/10 during VOR x1 gaze stabilization exercises. Which modification is MOST appropriate to optimize outcomes?

A Reduce the speed or duration of the VOR exercise

B Continue the exercise at the same intensity to habituate symptoms

C Progress to VOR x2 exercises

D Stop all vestibular exercises until symptoms fully resolve

A Reduce the speed or duration of the VOR exercise

Correct Answer: Reduce the speed or duration of the VOR exercise VOR exercises should provoke mild to moderate symptoms that return to baseline within a short period. An increase from 4/10 to 8/10 indicates the exercise intensity is too high and may impair adherence or recovery. Reducing speed, range, or duration maintains an appropriate stimulus while avoiding symptom exacerbation.

Progression or discontinuation is not indicated.

The Clinical Practice Guideline (CPG) for vestibular rehabilitation recommends minimizing or discontinuing the use of vestibular suppressants whenever possible. What is the primary reason for this recommendation?

A - Vestibular suppressants reduce sensory input needed for neural adaptation

B - Vestibular suppressants interfere with central vestibular compensation

C - Vestibular suppressants permanently damage vestibular hair cells

D - Vestibular suppressants are ineffective in treating vertigo symptoms

B	Vestibular suppressants interfere with central vestibular compensation

An individual reports dizziness and vestibular symptoms that are triggered by loud sounds or changes in pressure (e.g., coughing, sneezing, straining). Which condition is the most likely cause of these symptoms?

A Benign paroxysmal positional vertigo (BPPV)

B Superior semicircular canal dehiscence

C Menière's disease

D Unilateral peripheral hypofunction

B Superior semicircular canal dehiscence

Superior semicircular canal dehiscence

(SSCD) is characterized by a defect or thinning in the bony covering of the superior semicircular canal. This creates an abnormal "third window" in the inner ear, allowing sound and pressure changes to inappropriately stimulate the vestibular system. Key features supporting this diagnosis include vertigo or dizziness induced by loud sounds, symptoms triggered by changes in intracranial or middle-ear pressure (e.g., coughing, sneezing, Valsalva) and possible auditory symptoms such as sound-induced vertigo.

An individual reports vertigo when rolling over in bed. Dix-Hallpike testing is negative.

During the supine roll test, geotropic nystagmus is observed. With the Bow test, nystagmus beats toward the right and fatigues; with the Lean test, nystagmus beats toward the left and also fatigues. What is the most likely diagnosis?

A Right horizontal canal canalithiasis

B Right horizontal canal cupulolithiasis

C Left horizontal canal cupulolithiasis

D Left horizontal canal canalithiasis

A Right horizontal canal canalithiasis

Correct Answer Right horizontal canal canalithiasis A negative Dix-Hallpike test makes posterior canal BPPV unlikely. Geotropic nystagmus during the supine roll test is characteristic of horizontal canal canalithiasis (free floating otoconia), rather than cupulolithiasis, which typically produces ageotropic nystagmus. In horizontal canal canalithiasis, the Bow and Lean test helps lateralize the involved side. The nystagmus beats toward the affected ear during the Bow test which in this case is the right. Nystagmus beats away from the affected ear during the Lean test which in this case is the left.

A physical therapist assesses a patient's postural control using the modified Clinical Test for Sensory Integration in Balance (m-CTSIB). During testing, the patient loses balance when standing on foam with eyes closed. Which of the following BEST identifies the primary source of the patient's balance impairment?

A Somatosensory system impairment

B Inability to appropriately reweight sensory inputs

C Vestibular system dysfunction

D impaired visual input for postural control

C Vestibular system dysfunction

Rationale: In condition 4 of the m-CTSIB (eyes closed on a foam surface), visual and somatosensory inputs are minimized, requiring the patient to rely primarily on the vestibular system to maintain balance.

Excessive sway or loss of balance under this condition indicates vestibular impairment, as the patient cannot effectively use vestibular input to maintain postural stability.

An individual has a 6-month history of dizziness secondary to unilateral peripheral restibular hypofunction. According to the clinical practice guidelines, which of the following s the MOST appropriate prescription for gaze stability (VOR) exercises?

A 20 minutes/day for 4-6 weeks

B 12 minutes/day

C 20-40 minutes/day for 5-7 weeks

D 20 minutes/day for 6-9 weeks

A 20 minutes/day for 4-6 weeks

Correct Answer: 20 minutes/day for 4-6 weeks. A 6 month symptom duration classifies this individual as having chronic unilateral vestibular hypofunction. The APTA Clinical Practice Guidelines (CPG) recommend that individuals with chronic unilateral peripheral vestibular hypofunction perform gaze stability exercises totaling ~20 minutes per day, continued for at least 4-6 weeks and progressed based on symptom tolerance and performance.

An individual is diagnosed with posterior semicircular canal canalithiasis based on positional testing. Which of the following interventions is MOST appropriate?

A Liberatory maneuvre

B Canalith repositioning maneuvre

C Casani maneuvre

D VOR x 1 exercises

B Canalith repositioning maneuvre

The most appropriate and evidence based intervention for posterior canal canalithiasis is a canalith repositioning maneuver (CRM), such as the Epley maneuver, which is specifically designed to use gravity to move otoconia out of the canal and back into the utricle.

A patient undergoing a bedside vestibular examination demonstrates a positive Head Impulse Test and a negative Test of Skew. Based on these findings, what is the most appropriate next action for the physical therapist?

A Refer the patient to a physician due to concern for a central vestibular pathology

B Perform the Epley maneuver

C Initiate gaze stabilization (VOR ×1) and symptom-guided habituation exercises

D Perform the barbecue roll maneuver

C Initiate gaze stabilization (VOR ×1) and symptom-guided habituation exercises

Correct answer: Gaze stabilization and habituation exercises. A positive Head Impulse Test (HIT) indicates an impaired vestibulo ocular reflex (VOR), which is most consistent with a peripheral vestibular hypofunction. A negative Test of Skew reduces concern for a central vestibular pathology, as vertical ocular misalignment is more suggestive of brainstem or cerebellar involvement. This combination aligns with the HINTS exam pattern for peripheral vestibular dysfunction, making vestibular rehabilitation an appropriate next step within the physical therapist's scope of practice.

See attached document for a copy of the MSQ

A physical therapist is developing a home exercise program for a patient diagnosed with unilateral peripheral vestibular hypofunction, based on the patient's Motion Sensitivity Quotient (MSQ) results.

Which of the following exercises is most appropriate to include in the home program?

A Repeatedly bringing the head toward the left knee while sitting

B Repeated rolling toward the left while lying in bed

C VOR x1 gaze stabilization exercises

D VOR X2 gaze stabilization exercises

All answers except rolling in bed result in excessive symptoms.

A patient reports intense vertigo that does not fatigue when rolling in bed. Examination reveals persistent apogeotropic horizontal nystagmus during the supine roll test, with stronger symptoms when the head is turned to the right. Which intervention is MOST appropriate to address this condition?

A Epley maneuver

B Barbecue roll maneuver

C Semont maneuver

D Casani maneuver

D Casani maneuver

Horizontal canal cupulolithiasis is characterized by persistent (non-fatiguing) apogeotropic horizontal nystagmus during the roll test. The Casani maneuver is specifically indicated for horizontal canal cupulolithiasis, particularly in apogeotropic variants. The maneuver aims to dislodge otoconia adhered to the cupula, allowing them to either enter the canal lumen or the utricle. The Epley and Semont maneuvers are used for posterior canal BPPV, while the barbecue roll is more appropriate for horizontal canal canalithiasis.

An individual presents with clinical signs consistent with a left unilateral peripheral vestibular hypofunction. During the Head Impulse Test, which of the following findings would be MOST expected?

A	A Deviation of the eyes off the target when the head is quickly turned to the left
B	Deviation of the eyes off the target when the head is quickly turned to the right
C	Nystagmus beating toward the side of the lesion
D	The eyes stay on the target when the head is quickly turned to both sides

A	Deviation of the eyes off the target when the head is quickly turned to the left

Correct Answer Deviation of the eyes off the target when the head is quickly to the left. The Head Impulse Test (HIT) assesses the integrity of the vestibulo ocular reflex (VOR).

When the head is rapidly turned toward a hypofunctioning side, the impaired vestibular system is unable to generate an adequate compensatory eye movement. In left peripheral vestibular hypofunction, rapid head thrust to the left results in insufficient VOR activation. The eyes will move off the visual target and a corrective (catch up) saccade is then required to refixate.

Watch the video and identify the type of nystagmus.

A Right horizontal nystagmus

B Upbeating nystagmus

C Downbeating nystagmus

D Left horizontal nystagmus

Left horizontal nystagmus

The fast phase was toward the left.

Patient History: A 17-year-old high school football player presents to an outpatient physical therapy clinic 5 days following a concussion sustained during a game. The patient was struck on the side of his helmet during a tackle, experienced transient dizziness, and was immediately removed from play. He was evaluated by the team physician and instructed to undergo relative rest.

Current Complaints: The patient reports a constant, dull headache localized to the base of the skull and suboccipital region (rated 4/10 at rest), which increases to a 6/10 during visual tasks such as reading or using his smartphone. He also complains of intermittent dizziness when turning his head quickly while walking and a general feeling of "fogginess."

Physical Therapy Objective Examination:

• Cervical Spine Screen: Cervical active range of motion is limited in rotation bilaterally to 60 degrees with discomfort at end-range. Palpation reveals severe tenderness and muscle guarding in the bilatery suboccipital muscles and upper trapezius. The Cervical Flexion-Rotation Test (FRT) is positive bilaterally, reproducing his familiar occipital headache. Cranial cervical flexion test demonstrates poor deep neck flexor endurance.

• Oculomotor/Vestibular Screen: Smooth pursuits and saccades are within normal limits but prompt a mild increase in headache. The Vestibular-Ocular Reflex (VOR) horizontal test is positive for symptom reproduction (increased dizziness and fogginess). Dynamic Visual Acuitv (DVA) testina reveals a 3-line dearadation from static acuitv.

• Balance Evaluation: The Balance Error Scoring System (BESS) score is 14 errors (baseline pre-season score was 4 errors), with most errors occurring during the single-leg stance and tandem stance on foam.

• Vitals: Resting heart rate is 68 bpm; resting blood pressure is 118/76 mmHg

A Cognitive/fatigue and peripheral vestibular (BPPV)

B Anxiety/mood and aculomotor motor impairment

C Physiological (autonomic) and central vestibular

D Cervical musculoskeletal and vestibulocular

Cervical musculoskeletal and vestibulocular

Correct Answer: "Cervical musculoskeletal and vestibulocular'". The patient demonstrates clear objective signs of cervical

musculoskeletal dysfunction, highlighted by restricted cervical rotation, suboccipital tenderness, and a positive Cervical Flexion-Rotation Test (which isolates a restriction at C1-C2 driving cervicogenic headaches).

Concurrently, he demonstrates a vestibulocular profile, evidenced by the reproduction of dizziness during horizontal VOR testing and a 3-line drop during Dynamic Visual Acuity (DVA) testing (which indicates an inability to stabilize gaze during head

Patient History: A 17-year-old high school football player presents to an outpatient physical therapy clinic 5 days following a concussion sustained during a game. The patient was struck on the side of his helmet during a tackle, experienced transient dizziness, and was immediately removed from play. He was evaluated by the team physician and instructed to undergo relative rest.

Current Complaints: The patient reports a constant, dull headache localized to the base of the skull and suboccipital region (rated 4/10 at rest), which increases to a 6/10 during visual tasks such as reading or using his smartphone. He also complains of intermittent dizziness when turning his head quickly while walking and a general feeling of "fogginess."

Physical Therapy Objective Examination:

• Cervical Spine Screen: Cervical active range of motion is limited in rotation bilaterally to 60 degrees with discomfort at end-range. Palpation reveals severe tenderness and muscle guarding in the bilatery suboccipital muscles and upper trapezius. The Cervical Flexion-Rotation Test (FRT) is positive bilaterally, reproducing his familiar occipital headache. Cranial cervical flexion test demonstrates poor deep neck flexor endurance.

• Oculomotor/Vestibular Screen: Smooth pursuits and saccades are within normal limits but prompt a mild increase in headache. The Vestibular-Ocular Reflex (VOR) horizontal test is positive for symptom reproduction (increased dizziness and fogginess). Dynamic Visual Acuitv (DVA) testina reveals a 3-line dearadation from static acuitv.

• Balance Evaluation: The Balance Error Scoring System (BESS) score is 14 errors (baseline pre-season score was 4 errors), with most errors occurring during the single-leg stance and tandem stance on foam.

• Vitals: Resting heart rate is 68 bpm; resting blood pressure is 118/76 mmHg

SHIULD THE BCTT BE PREFORMED?

A The BCTT should be performed immediately to differentiate between a cervical and a vestibulocular driver of dizziness.

B The BCTT is contraindicated because the patient is only 5 days post-injury and still experiences a resting headache.

C The BCTT should be deferred because the patient's resting blood pressure and heart rate indicate orthostatic instability

D BCTT should be preformed because early introduction of sub-symptom threshold aerobic exercise is highly beneficial.

D BCTT should be preformed because early introduction of sub-symptom threshold aerobic exercise is highly beneficial.

According to the 2020 APTA Concussion

Clinical Practice Guideline (CPG), early introduction of sub-symptom threshold aerobic exercise is highly beneficial. Typically, safe and appropriate to perform in the acute/subacute phase (typically after the first 24-48 hours of relative rest) to determine the exact heart rate at which symptoms begin to exacerbate, allowing the therapist to prescribe controlled aerobic exercise. A mild resting symptom (like a 4/10 headache) is not a contraindication, provided it is not rapidly worsening or accompanied by neurological red flags.

Patient History: A 17-year-old high school football player presents to an outpatient physical therapy clinic 5 days following a concussion sustained during a game. The patient was struck on the side of his helmet during a tackle, experienced transient dizziness, and was immediately removed from play. He was evaluated by the team physician and instructed to undergo relative rest.

Current Complaints: The patient reports a constant, dull headache localized to the base of the skull and suboccipital region (rated 4/10 at rest), which increases to a 6/10 during visual tasks such as reading or using his smartphone. He also complains of intermittent dizziness when turning his head quickly while walking and a general feeling of "fogginess."

Physical Therapy Objective Examination:

• Cervical Spine Screen: Cervical active range of motion is limited in rotation bilaterally to 60 degrees with discomfort at end-range. Palpation reveals severe tenderness and muscle guarding in the bilatery suboccipital muscles and upper trapezius. The Cervical Flexion-Rotation Test (FRT) is positive bilaterally, reproducing his familiar occipital headache. Cranial cervical flexion test demonstrates poor deep neck flexor endurance.

• Oculomotor/Vestibular Screen: Smooth pursuits and saccades are within normal limits but prompt a mild increase in headache. The Vestibular-Ocular Reflex (VOR) horizontal test is positive for symptom reproduction (increased dizziness and fogginess). Dynamic Visual Acuitv (DVA) testina reveals a 3-line dearadation from static acuitv.

• Balance Evaluation: The Balance Error Scoring System (BESS) score is 14 errors (baseline pre-season score was 4 errors), with most errors occurring during the single-leg stance and tandem stance on foam.

• Vitals: Resting heart rate is 68 bpm; resting blood pressure is 118/76 mmHg

Best INITIAL TX:

A Prescribing strict cervical collar immobilization for the next 48 hours to minimize cervicogenic headache triggers.

B Continuous ultrasound to the suboccipital muscles for 8 minutes followed by aggressive mechanical cervical traction

C Grade Il passive joint mobilizations to the upper cervical spine, gentle suboccipital stretching and deep neck flexor coordination training

C Grade Il passive joint mobilizations to the upper cervical spine, gentle suboccipital stretching and deep neck flexor coordination training

The 2020 APTA Concussion CPG provides a Grade A recommendation for utilizing cervical manual therapy (passive joint mobilization), stretching, and strengthening for patients presenting with cervical dysfunction following a concussion. Gentle Grade Il mobilizations safely modulate pain and address upper cervical restriction (C1-C2) without introducing excessive force, while deep neck flexor retraining directly targets the motor control deficits found during the cranial cervical flexion test.

Patient History: A 17-year-old high school football player presents to an outpatient physical therapy clinic 5 days following a concussion sustained during a game. The patient was struck on the side of his helmet during a tackle, experienced transient dizziness, and was immediately removed from play. He was evaluated by the team physician and instructed to undergo relative rest.

Current Complaints: The patient reports a constant, dull headache localized to the base of the skull and suboccipital region (rated 4/10 at rest), which increases to a 6/10 during visual tasks such as reading or using his smartphone. He also complains of intermittent dizziness when turning his head quickly while walking and a general feeling of "fogginess."

Physical Therapy Objective Examination:

• Cervical Spine Screen: Cervical active range of motion is limited in rotation bilaterally to 60 degrees with discomfort at end-range. Palpation reveals severe tenderness and muscle guarding in the bilatery suboccipital muscles and upper trapezius. The Cervical Flexion-Rotation Test (FRT) is positive bilaterally, reproducing his familiar occipital headache. Cranial cervical flexion test demonstrates poor deep neck flexor endurance.

• Oculomotor/Vestibular Screen: Smooth pursuits and saccades are within normal limits but prompt a mild increase in headache. The Vestibular-Ocular Reflex (VOR) horizontal test is positive for symptom reproduction (increased dizziness and fogginess). Dynamic Visual Acuitv (DVA) testina reveals a 3-line dearadation from static acuitv.

• Balance Evaluation: The Balance Error Scoring System (BESS) score is 14 errors (baseline pre-season score was 4 errors), with most errors occurring during the single-leg stance and tandem stance on foam.

• Vitals: Resting heart rate is 68 bpm; resting blood pressure is 118/76 mmHg

The patient has successfully initiated a Return to Learn (RTL) protocol and itis tolerated well. He is now symptom-free at rest and has completed light aerobic exercise and sport-specific drills without sympto recurrence. He wants to progress to Step 5: Full-contact practice. What is the MOST critical requirement before the physical therapist can allow the patient to participate in this step?

A The patient must repeat a standard head CT scan to confirm complete structural healing of

B The patient must demonstrate a BESS score of 0 errors on both firm and foam surfaces.

C The patient must obtain formal medical clearance from a legally authorized healthcare professional in accordance with state law

C The patient must obtain formal medical clearance from a legally authorized healthcare professional in accordance with state law

Progressing to full-contact practice (Step 5) exposes the athlete to live collision risks and the potential for Second Impact Syndrome.

International consensus statements (Amsterdam 2023) and youth concussion legislation (Lystedt Laws) strictly mandate that an athlete must receive formal medical clearance from a licensed, authorized healthcare professional before returning to any contact or collision activities. The physical therapist must check their specific State Practice Act and local regulations to determine who holds this legal authority in their iurisdiction.