Vestibular Rehabilitation: Examination and Treatment of BPPV

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Vestibular RehabilitationExamination and
Treatment of BPPV
Kathy Joy, PT, MBA Braintree Rehabilitation
Hospital
[phone], ext. 312802
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Program Overview

• Anatomy and Physiology
• Roles of the vestibular system
• Categories of vestibular disorders
• -BPPV, spontaneous, chronic
• ? Treatment options for BPPV
• Vestibular injury s/p traumatic head and neck
  injuries
• (Treatment considerations)

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Incidence of Dizziness (VEDA)www.vestibular.org

• 8 million PCP visits annually (2.5)
• 2nd leading cause for PCP visit in adults
• 1 for people over age of 65
• 40-50 caused by vestibular system disorder
• Etiology for 80 of above is inner ear pathology
• 42 of the population (90 million) will complain
  of dizziness at least once in their lifetime (NIH)

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Causes of Vertigo

• Vestibular
• Neurological
• Orthostatic Hypotension
• Migraine / Vascular Disease
• Cervicogenic
• Anxiety / Phobic Disorders
• Other

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Vestibular injury following post-traumatic head
and neck injuries

• Incidence of vertigo sx 50-78
• Difficult to treat due to combination of deficits
• Lack of clear guidelines for return to work

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Roles of the VestibularSystem

• Inertial guidance system detecting gravity
• Detects head position in space
• Promotes gaze stability through VOR
• Resolution of sensory conflict
• Influences muscle tone for postural control

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Review of Vestibular System

• Peripheral Vestibular System
• semicircular canals, otoliths and the eighth
  cranial nerve

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Membranous Labyrinth
Herdman Vestibular Rehabilitation, 2007
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Labyrinth
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Physiology of the Labyrinth

• Push - Pull arrangement
• Resting vestibular tone (resting discharge
  frequency) is modulated, up or down, according to
  the direction of head rotation.

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Semicircular CanalsSpecific gravity relationship
Herdman Vestibular Rehabilitation, 2007
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Otolithic Macula
Herdman Vestibular Rehabilitation, 2007
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Sensory End Organs

• OTOLITHS
• Low frequency receptors
• Directionally specific
• Responds to linear accelerations/ GRAVITY
• Does not respond to constant velocity motion
• Otoconia in macula serve as inertial mass
• Pathology static postural problems difficulty
  detecting vertical

• SEMICIRCULAR CANALS
• Medium-high frequency receptors
• 3 of rotational freedom
• Responds to angular head motions, not to gravity
• Responds to movement along a curve
• Pathology results in a sense of spinning head
  movement-related symptoms

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Review of Vestibular System

• Central Vestibular System
• Vestibular nuclei and their projections into the
  brainstem, pons, midbrain, cerebellum, cortex and
  spinal cord

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Vestibulo-Ocular Reflex (VOR)
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Categories of Vestibular Disorders

• Paroxysmal Positional Disorders
• Acute Paroxysmal Spontaneous Disorders
• Acute Onset-Gradual Resolution/Chronic Disorders

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Symptom Presentation

• Positional Vertigo BPPV
• Movement-provoked spatial disorientation
• Visual flow deficits
• Distorted vision
• Dysequilibrium/Ataxia
• Neck restriction
• Headache
• Nausea
• Anxiety

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Clinical Examination of the Vertiginous Patient

• Thorough History
• PMH/DHI
• Nature of initial episode/ duration
• Activities being performed
• Functional limitations
• Provocation/reduction factors

• Describe symptoms
• Vertigo versus spatial disorientation
• Intermittent versus continuous
• associated symptoms of nausea, vomiting
• Changes during the day

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Benign Paroxysmal Positional Vertigo

• Brief Paroxysms of positional vertigo
• Duration less than one minute
• Initial imbalance following an episode
• ?Spatial disorientation
• Autonomic symptoms nausea, diaphoresis

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Neuro-Otologic ExaminationNystagmus

• Non-voluntary rhythmic oscillations of the eyes
• described by the direction of the fast phase
• describe latency, intensity, direction, duration

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Neuro-Otologic ExaminationNystagmus

• Physiologic versus Pathologic
• Physiologic nystagmus induced with natural or
  external stimuli.

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Rotational Chair
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Nystagmus

• Physiologic versus Pathologic
• Pathological nystagmus can be spontaneous,
  gaze-evoked, positional

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Positional Nystagmus

• Positional nystagmus
• Traditional classifications lesions of the
  otoliths, vestibular nuclei and cerebellum.
• More recent concept alteration in the specific
  gravity of the semicircular canal endolymph or
  cupula

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Positional Nystagmus

• Paroxysmal positional nystagmus
• provocative movement is in the plane of the
  canal
• benign paroxysmal positional nystagmus
• central positional nystagmus

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BPPV

• Distorted Function
• Benign Paroxysmal Positional Vertigo
• Cupulolithiasis
• Canalithiasis

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Cupulolithiasis
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Canalithiasis
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Otoconia
Furman JNEJM,341(21)1999
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Paroxysmal Positional Vestibular Disorders

• ETIOLOGIES
• Idiopathic
• Degenerative
• Post-traumatic
• TBI, mild head injury, whiplash
• Post-acute vestibulopathy (viral)
• Prolonged bedrest or post-surgical

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Clinical Examination

• History
• Vestibulo-ocular exam
• Vestibulospinal exam
• Postural control
• Other systems
• musculoskeletal, cognitive, behavior

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Clinical Examination

• Vestibulo-ocular function
• Ocular alignment
• Smooth pursuit
• Saccades
• VOR/Gaze stability

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Clinical Examination

• Vestibulo-ocular reflex
• VOR Head thrust, Head shaking nystagmus
• VOR x1 viewing
• VOR Dynamic visual acuity (Snellen Chart,
  LogMar)
• VOR cancellation

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Clinical ExaminationBPPV

• Positional provocation testing
• Dix-Hallpike Gold Standard
• Sidelying test
• Roll test/ lateral canal test
• Cohen, HS, Otology Neurology 25a 130-134, 2004

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Positional Provocation Testing

• Purpose
• Identify the involved canal(s)
• Lateralize
• Identify type (cupulo/canal)

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Comparison of BPPV by canal
type(neurology,May 2008Fife etal)
Posterior Horizontal Anterior
Estimated frequency 81-89 8-17 1-3
Provocative maneuver Dix-Hallpike Supine Roll Test (Pagnini-McClure) Dix-Hallpike
Nystagmus Upbeat, torsional Horizontal Direction Changing Downbeat, torsional
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Clinical Examination

• Positional Testing
• Dix-Hallpike Test
• Seated VA test

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Sidelying Test
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Describing Nystagmus

• Latency
• Direction
• Duration
• Reversal
• (Fatigability)

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Positional Nystagmus

• Peripheral
• 1-40 second latency
• Torsional component
• Crescendo / decrescendo
• Fatigues with repetition
• Vertigo symptoms
• Geotropic vs. Ageotropic (horizontal canal)

• Central
• No latency
• Varied nystagmus
• Lasts as long as positioned
• Does not fatigue with repetition
• No symptoms

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Duration of Nystagmus

• lt60 seconds canalithiasis
• Crescendo / decrescendo
• gt60 seconds/persistent cupulolithiasis or
  central
• No change in intensity with central

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Direction of Nystagmus

• Torsional
• Posterior or anterior canal
• No torsional component horizontal canal
• Upbeating / Downbeating
• Torsional upbeating posterior
• Torsional downbeating anterior
• Right-beating / Left-beating
• (Counterclockwise versus clockwise)

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Right posterior canalithiasis
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Left posterior canalithiasis
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Left posterior canalithiasis
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Reversal of Nystagmus

• Nystagmus often reverses direction with return to
  sitting (BPPV)

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Fatigability

• Fatigues with repetition canalithiasis
• Decrease in intensity but persistent cupulo
• Does not fatigue central

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Intervention

• Canal Involvement
• Repositioning Maneuvers
• Canalith Repositioning Maneuvers
• CRT, CRM, PRM, Epley use of vibration
• Liberatory/Semont
• Horizontal canal maneuvers
• Brandt-Daroff

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Repositioning Maneuvers Canalith-Repositioning
/Epley
Furman J NEJM, 341(21), 1999
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Repositioning Maneuvers - Liberatory
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Considerations for Anterior Canal BPPV

• Difficulty lies in determining which side to
  treat
• Right Dix Hallpike test
• downbeat and torsional to left Left anterior
• downbeat and torsional to right Right anterior

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Canal Involvement based on Direction of
Nystagmus ( R) Dix-Hallpike (Herdman,
Vestibular Rehabiitation, 2007)
CANAL Right Dix-Hallpike Reversal Phase Return to Sitting
Right posterior Upbeat, torsional right Downbeat, torsional left Downbeat, torsional left
Right anterior Downbeat, torsional right Upbeat, torsional left Upbeat, torsional left
Left anterior Downbeat, torsional left Upbeat, torsional right Upbeat, torsional right
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Roll Test
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Horizontal Canal BPPV

• Brief nystagmus that fatigues and is geotrophic
  canalithiasis
• Prolonged nystagmus and is ageotrophic
  cupulolithiasis

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Horizontal canal nystagmus
Geotropic Ageotropic
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Left horizontal canalithiasis
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Right horizontal canalithiasis
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Determining the Side with Horizontal Canal BPPV

• ?Bow and Lean Test
• Choung YH et al, Laryngoscope 116, 2006

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Repositioning Maneuvers Horizontal Canal
Involvement
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Repositioning Maneuvers Horizontal Canal
Involvement
360 degree barrel roll 270 degree roll
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Repositioning Maneuvers Horizontal Canal
Involvement

• Cassani et al in Laryngoscope 2002
• Appiani et al in Otology and Neurol 2001
• Vannuchi et al in Jvest Res 1997
• (Forced Proglonged Position FPP)

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Subjective BPPV
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How much time in each position?

• Varies in the literature
• Clinically have seen no difference between 2
  minutes and 30 seconds
• Epleys rule onset duration length of time
  in each position
• Clendaniel double length of nystagmus

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Home Guidelines

• Remain upright for 24-48 hours
• Do not lie on affected side
• Avoid extreme flexion and extension of the head
  and trunk.
• Avoid lateral tilt for horizontal canal
• Soft collar, towel
• Start head movement exercises after 48 hours

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• Resistance to Treatment??

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Brandt-Daroff
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Prognosis

• 85 -95 remission of symptoms
• Course of Treatment 2-6 visits
• Recurrence rate 20-30
• Co-morbidity considerations
• Head/Neck pain
• Fatigue

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Complications

• Conversion to a different canal
• Nausea and vomiting during or after treatment

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Epley Omniax

• http//www.arrigg.com/epley-omniax

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Anxiety
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Alternative Treatments

• Canal Plugging
• Singular nerve section