Test results indicate abnormal tracking and fixation suppression which
suggests a central lesion. Fixation suppression and tracking mechanisms share
central pathways. Additionally significant down beating vertical nystagmus
was noted in the head hanging position which is also indicative of a central
lesion

1. VNG Results-
-Failure of fixation suppression indicates a central finding, often involving
the cerebellar flocculus or the surrounding structures
-Essentially normal oculomotor findings.
2. vHIT- testing indicated essentially normal results. The reduced gain in the
LARP condition is likely a result of the limited range of motion and should be
interpreted carefully.
The Dizziness Handicap Inventory (DHI) was administered and indicated a severe
(54+) handicap due to Veteran's
dizziness.
Functional: 22 (out of 36)
Emotional: 14 (out of 36)
Physical: 20 (out of 28)
Total: 56 (out of 100)

Thank you for the video. I cannot identify the nature of the shaking which moves from one leg to the other. It is no consistent with restless leg syndrome or seizure activity as I kn andow them

11 May, 2015
Impression:
1. Multilevel cervical spondylosis. There may be a left foraminal
disc protrusion at C4/C5. Consider MRI or CT myelography for
further evaluation, as indicated.
2. Nonvisualization of the left lobe of the thyroid, possibly
absent. Tiny hypodensities in the right lobe could be further
evaluated by ultrasound. 
Primary Diagnostic Code: SIGNIFICANT ABNORMALITY, ATTN NEEDED

FINDINGS: The ventricles are normal in size, shape and position
without midline shift or mass effect. There is a small focus of
lucency in the periventricular white matter on the left adjacent
to the frontal horn of the lateral ventricle consistent with
chronic ischemic change. There are no areas of acute hemorrhage
and no mass lesions are identified. The visualized paranasal
sinuses are clear with exception of a small mucous retention cyst
in the sphenoid sinus on the right. The mild deformity of the
skull table with relative flattening in the right parietal region
is stable and probably developmental.

PT has been seen for total of 11 visits for vestibular training and CDP testing on Neurocom. (age 65, ht 5'11".)
Testing procedures reviewed pt and pt agreeable to testing. HArness
applied and pt secured in machine. UNderwent 4 tests with the following
results--
1) Limits of Stability: tests ability of pt to move safely/quickly/smoothly
through full limits of stability. abnormal findings--
(a) pt continues to demonstrates inability to reach set targets of this
test in single, linear movements as well as reduced endpoint
excursions (EPE) improvement-- pt's reaction time and movement velocity now within the norm for age
2) Adaptation test: objectively quantifies pt's ability to adapt or develop
a balance response to varying support surfaces.
abnormal findings--
(a) still has difficulty generating required force initially to overcome
the induced postural instability posteriorly thus subsequently lost his balance with first trial.
improvement-- in subsequent trials, pt was better able to consistently
demosntrate ability to adapt to surface change. SUbsequent trials show slight improvement from initial testing results of 6-30-14.
3) Rhythmic weight shift: quantifies pt's ability to vary movement speeds
while maintaining coordinated motor control.
abnormal findings--
(a) pt demonstrated lack of coordination and control of movement(DCL)
toward FORWARD position; but directional control(DCL) was within normal
limits for LEFT/RIGHT.
improvement-- demosntrated improvement in average speed of movement in BOTH directions to be within normal limits for age/ht.
4) Sensory organization test (SOT): isolates/quantifies abnormalities in
pt's ability to make effective use of (or suppress inapproriate) input from
three sensory systems that contribute to postural control as well as brain's central integration of these inputs-
somatosensory/proprioceptive(SOM), visual(VIS), vestibular(VEST).
abnormal findings--
(a) SOM score (condition 1&2) reflects NO CHANGE pt's inability
to use cues from the somatosensory system to maintain balance- this is likley
related to foot surgery pt underwent July 2013 from which he has continued to have numbness in (L)foot.
(b) VEST score(condition 1&5) reflects NO CHANGE pt's inability to use
cues from vestibular system to maintain balance. Pt again lost balance with every trial of condition #5.
(c) pts composite score of all 6 conditions is 13 points below normative
performance range (68). This is 4 points higher than previous test.
(d) pt lost balance on all but one trial of conditions 2, 5, and 6 which
are conditions dependent on somatosensory and vestibular systems.
THese results are UNCHANGED from previous test.
(e) COG position demostrates pt's tendency toward standing slightly
posterior and to right side to center of base of support(again likley
explained by issues with surgery/resultant numbness left foot) -
UNCHANGED from previous test.
(f) strategy analysis demonstrates ankle stretegy ONLY, hip strategy
ONLY used when starting to step to avoid fall - UNCHANGED from
previous test.
PROGRESS TOWARD GOALS OF PHYSICAL THERAPY--
(1) will demonstrate improved ability by 10-15% improvement in ability to reach targets in the LEFT/FRONT quadrant - not met
(2) independent with home program that encourages wieght shift/limits of
stability into LEFT/FRONT quadrant - MET
(3)demosntrate working knowledge of safety issues with gait on outside uneven surfaces/terrain - MET
Patient Plan/Comments: Essentially results of pre and post-CDP reveal NO CHANGE in pt's ability to maintain balance after 10 weeks of vestibular
retraining.
Will discontinue PT at this time however pt encouraged to continue use of cane when walking in community and to continue home program.

ASSESSMENT: Dysequilibrium problem is likely of central origin. I
strongly doubt an inner ear issue, with normal hearing and the
videonystagmography (VNG) pointing towards a central lesion. I really
have no further suggestions at the present time.

Be advised that damage to the organ of balance is the most common cause of imbalance. stroke MAY have such a symptom but is the rare, unusual, atypical cause for imbalance. but, as they say , it is possible it could relate to a stroke so small that it cannot be seen on CT scanning but this is unusual, and a stroke so small you cannot see it should have correspondingly minimal symptoms, which is not your case.