Be Aware so you can Beware: Down Beating Nystagmus as a Red Flag in Vestibular Examination

Background: Vestibular dysfunction, manifested as dizziness, vertigo, and imbalance in patients, is a common cause for emergency department and outpatient medical facility visits. Physical therapists working with vestibular patients should screen patients for potential red flags to determine the appropriate treatment, whether that be vestibular rehabilitation or outside referral. The purpose of this case report is to highlight the importance of red flag screening during the vestibular examination to determine whether conservative treatment is the appropriate course of action. Case Description: A 73-year-old female presented with eight months of dizziness and buzzing in the ears. During vestibular examination, she demonstrated spontaneous down beating nystagmus but was lacking all other red flags for serious pathology. Intervention: The patient underwent vestibular rehabilitation with gaze stability training and balance exercises. Outcome Measures: The Dizziness Handicap Inventory (DHI) was utilized to assess dizziness-associated handicap. Gaze stability was assessed using dynamic visual acuity (DVA) testing. Static balance was measured using Modified Romberg using a foam pad (MRuFP). Discussion: The patient was continuously monitored for further red flag symptoms, but none presented during treatment. The patient reported improvements in DHI score from 64 to 24, indicating a change in disability level from severe to mild. Despite combination of central and peripheral signs and symptoms, the patient responded very well to vestibular rehabilitation, demonstrating that beginning treatment with close monitoring for further red flags may be an appropriate treatment choice for similar patient presentations.