Case Study: Balance Problems & Dizziness

Case Summary

A patient presented to Bangalow Headache Neck & Jaw Clinic with balance difficulties and unusual sensory symptoms following a fall. Routine safety screening identified a vascular red flag, and the patient was referred for further medical investigation rather than proceeding with treatment.

Presenting Concern

The patient reported having difficulties with balance and right-side lying since a fall of around one metre off a ladder 18 months earlier. The symptoms had persisted without improvement over this period.

The patient described that every time they lay on the right side, it felt like there were ants crawling inside their right ear and head. Family members who also attended the appointment reported that it appeared as though “he was not there” when this occurred – suggesting possible episodes of altered consciousness or neurological involvement. These symptoms are consistent with conditions that can present as dizziness or vertigo, but in this case warranted further investigation.

Assessment & Findings

As part of our comprehensive assessment approach, routine safety screening for the vertebral artery and upper cervical spine ligaments was conducted. This screening is performed with every patient who presents with balance, dizziness, or neck-related symptoms. Cranial nerve testing was also completed as part of the neurological examination.

Following the detailed history and physical examination, vertebral artery testing was performed and produced a strong positive indicator of a problem with the right vertebral artery. This is considered a significant clinical finding that requires immediate medical attention.

Key Findings Summary

Clinical Decision

Due to the findings and the potential risk associated with any manual treatment in the presence of vertebral artery compromise, the patient’s doctor was contacted immediately. The doctor referred the patient for an MRI of the vertebral arteries for further investigation.

This was a case where proceeding with any form of treatment was considered potentially dangerous. The priority was patient safety, and the appropriate course of action was to refer the patient for further medical examination rather than to treat.

Why This Matters

Not all dizziness and balance problems are benign. While many patients presenting with these symptoms respond well to physiotherapy and vestibular rehabilitation, a small number may have underlying vascular or neurological conditions that require medical investigation first. Without thorough safety screening, these cases can be missed – and treatment could potentially cause serious harm. This is why every patient at Bangalow Headache Neck & Jaw Clinic undergoes comprehensive vascular and neurological screening before any treatment begins.

Clinical Takeaway

This case highlights the importance of thorough neurological and vascular screening in patients presenting with balance or dizziness symptoms, and the need to prioritise patient safety above all else. A comprehensive initial assessment – including vertebral artery screening and cranial nerve testing – is not optional; it is essential for identifying red flags that may contraindicate treatment.

For patients experiencing vertigo, balance difficulties, or unexplained dizziness – particularly following trauma such as a fall – a thorough clinical assessment is the critical first step toward safe and effective care.

About the Practitioner

Michael Hayward is a qualified physiotherapist with over 28 years of experience treating patients across the North Coast. Trained in the Watson Headache® Approach and drawing from extensive research and training in Europe and Australia, [he/she] specialises in the assessment and treatment of headaches, migraines, jaw dysfunction, and vestibular disorders. Learn more about Michael.

Experiencing Balance Problems or Dizziness?

If you’re dealing with dizziness, vertigo, balance difficulties, or unexplained symptoms following a fall or injury, a thorough assessment is the first step. Book an appointment or call us on 0475 75 75 10 to discuss your situation. Your safety is always our first priority.