Diagnosis and Treatment of BPPV for physical - PowerPoint Presentation

Slide1

Diagnosis and Treatment of BPPV for physical therapy

James R. Barsky PT, DPTChestnut Hill HospitalNeurology, Psychiatry and Balance Therapy Center

Pennsylvania Physical Therapy Association Southeastern District Meeting

March 9, 2016

Top

of the Hill Physical Therapy

Chestnut Hill Hospital

35 Bethlehem Pike

Philadelphia, PA 19115Slide2

disclosures

NoneSlide3

Objectives

Describe the anatomy and physiology of the vestibular system as it relates to BPPV.Identify the typical presentation of patients with BPPV.Describe how to diagnose BPPV type based on positional testing results.Know how to perform the modified Epley maneuver (

canalith

repositioning maneuver) for the treatment of posterior canal BPPV.

Be aware of the variety positional maneuvers for the treatment different forms of BPPV.

Identify central nervous system conditions that can be confused with BPPV for the purpose of differential diagnosis.

Be able to differently diagnose when central positional nystagmus can’t be due to BPPV.Slide4

Overview

Introduction and definitionsClinically relevant anatomy and physiology of the vestibular systemDiagnosis of the Types of BPPVTreatment of BPPVDifferential diagnosis of central positional nystagmus and nystagmus from BPPV.Slide5

Definitions

DizzinessVertigoNystagmusSlide6

Spinning or whirling

Tilting

Rocking

Shifting

Lightheaded

Faint

Woozy

Disequilibrium=

Feeling off balance

Wobbly

Woobly

Dizzy

GiddySpaceyFoggyOffNot rightHeavy headedSwimmyWhooshy“Blackness behind my eyes” “ “

Spinning or whirling

Tilting

Rocking

Shifting

=

VERTIGO

DizzinessSlide7

Beware of How Health Care Workers use the Words Dizziness and Vertigo

Barany SocietyVertigo- the sensation of motion when no motion is occurring or a distorted sensation of motion

Dizziness- the sensation of disturbed or impaired

spacial

orientation without a false sense or distorted sense of motion

1

Insurance companies:

Dizziness, Giddiness and

Vertigo=

ICD-10 code R42, ICD-9

Code 780.4

Some physicians and others healthcare providers: Vertigo=general vestibular pathology i.e. not something they treatDizzy Terms- Spinning or whirling, Rocking, Tilting, Lightheaded, Woozy, Dizzy, Faint, Giddy, Spacey, Not right, Off, Unsteady, Feeling off balance, Wobbly, Woobly, Head heaviness, Foggy, Swimmy, Whooshie, Blurry, Blackness behind my eyes1A. Bisdorff et al. Classification of vestibular symptoms: Towards an international classification of vestibular disorders. First consensus document of the Committee for the Classification of Vestibular Disorders of the Barany Society. Journal of Vestibular research. (2009), 19. 1-13Slide8

Documentation of Nystagmus

Patient positionDirection of the fast phase relative to the patientPlane

Rhythmic oscillations of the eyes initiated by a slow phase.Slide9

Direction

Plane

Up/Down

Vertical

Right/Left

Horizontal

Right/Left

TorsionalSlide10

Typical history for the most common presentation of bppv

Symptoms: vertigo, may have other dizziness and/or nausea as well.Duration: less than a minute.Circumstances: large position changes.

Lying down

Rolling over

Sitting up

Bending forward/coming upright

Extending head backSlide11

BPPV Anatomy and Physiology

Hain,

TC

http://

www.dizziness-and-balance.com

, 1/26/14,

http

://

www.dizziness-and-balance.com/sitedvd.htmSlide12

Haines, DE. Fundamental Neuroscience. Churchill Livingston Inc. 1997. Fig 21-3-4.Slide13

Canal angles

A new coordinates system for cranial organs using magnetic resonance

imaging.

Kazufumi

Suzuki , Ai

Masukawa

, Sachiko Aoki , Yasuko Arai ,

Eiko

Ueno.

Acta Oto-Laryngologica Vol. 130, Iss. 5, 2010.Slide14

Semicircular canals are curvilinear

Bradshaw, A. P.,

Curthoys

, I. S., Todd, M. J., Magnussen, J. S.,

Taubman

, D. S., Aw, S. T., &

Halmagyi

, G. M. (2010).

A

Mathematical Model of Human Semicircular Canal Geometry: A New Basis for Interpreting Vestibular Physiology. 

JARO: Journal of the Association for Research in Otolaryngology

,11(2), 145–159. doi:10.1007/s10162-009-0195-6Slide15

Ipsilateral Head movements cause excitation

Vertical Canals:

Excited by endolymph flow

away

from the utricle.

Horizontal Canals:

Excited by endolymph flow

toward

the utricle.

Richard

Rabbitt

, PhD, Janet O. Helminski, PT, PhD, Janene Holmberg, PT, DPT, NCS. Translating the Biomechanics of Benign Paroxysmal Positional Vertigo to the Differential Diagnosis and Treatment Combined Sections Meeting Las Vegas, NV – February 3-6, 2014Slide16

Vestibular Ocular reflex and ewald’s 1st

lawVestibular Ocular Reflex (VOR)For stable vision, eyes will move equal and opposite to head movements.

Ewald’s 1

st

Law

Eyes will move in the plane of the canal stimulated.

Horizontal canals will produce horizontal movements.

Vertical canals (anterior and posterior) will produce vertical and torsional movements

.

https://

commons.wikimedia.org/wiki/File:1608_Vestibulo-Ocular_Reflex-02.jpg

. 8/25/2015Slide17

Posterior canal canalithiasis: + Dix-hallpikes

Leigh, RJ and Zee, DS. The Neurology of Eye Movements 4

th

ed. Oxford, NY. Oxford University Press, 2006.Slide18

BPPV examples of VOR and Ewald’s 1st law

Bhattacharyya N et al. Otolaryngology -- Head and Neck Surgery 2008;139:S47-S81

Copyright © by American Academy of Otolaryngology- Head and Neck SurgerySlide19

Figure Head and horizontal canal position in the geotropic and apogeotropic variants of horizontal canal benign paroxysmal positional vertigo (HC-BPPV) affecting the right side The curved arrows along the canal show the direction of otolithic debris movement after head turn.

Kevin A.

Kerber

, and Christoph

Helmchen

Neurology 2012;78:154-156

Copyright © 2012 by AAN Enterprises, Inc

.Slide20

Horizontal semicircular canal bppv

HSC CanalithiasisHSC CupulolithiasisSlide21

Kevin A.

Kerber

, and Christoph

Helmchen

Neurology 2012;78:154-156Slide22

Kevin A.

Kerber

, and Christoph

Helmchen

Neurology 2012;78:154-156Slide23

Bow and lean test

Herdman J, Clendanial R. Vestibular Rehabilitation. Forth Ed. Pg

330. F.A. Davis. 2014.

Bow

LeanSlide24

Bow and lean test

SIT TO SUPINE TEST

Balatsouras

, D. G.,

Koukoutsis

, G.,

Ganelis

, P.,

Korres

, G. S., &

Kaberos

, A. (2011). Diagnosis of Single- or Multiple-Canal Benign Paroxysmal Positional Vertigo according to the Type of Nystagmus. International Journal of Otolaryngology, 2011, 483965. doi:10.1155/2011/483965Slide25

Treatment

Positional maneuvers: which maneuver depends on the type and location of the BPPV.Education: along with appropriate treatment can help prevent Chronic Subjective Dizziness (CSD/3PD)

.

Balance training:

if there is any residual imbalance. In my opinion this can also be helpful in preventing

Chronic Subjective Dizziness (

CSD/3PD).

“

Clinicians should not routinely treat BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines

.

Recommendation against based on observational studies and a preponderance of benefit over harm.” Bhattacharyya et al. Clinical practice guideline: Benign paroxysmal positional vertigo. Otolaryngol Head Neck SurgNovember 2008 vol. 139 no. 5 supplS47-S81 “There is no evidence to support a recommendation of any medication in the routine treatment for BPPV” T. D. Fife, MD, D. J. Iverson, MD, T. Lempert, MD, J. M. Furman, MD, PhD, R. W. Baloh, MD, R. J. Tusa, MD, PhD, T. C. Hain, MD, S. Herdman, PT, PhD, FAPTA, M. J. Morrow, MD and G. S. Gronseth, MD. Practice Parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review)Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology May 27, 2008 vol. 70 no. 22 2067-2074.Slide26

Figure 2

Canalith

repositioning procedure for right-sided benign paroxysmal positional vertigo Steps 1 and 2 are identical to the Dix–

Hallpike

maneuver

.

T. D. Fife et al. Neurology 2008;70:2067-2074

©2008 by Lippincott Williams & WilkinsSlide27

Self administered modified eplEy

NPBTC.COM

http://npbtc.com/specialties

/#

bppvSlide28

Lorne S.

Parnes, Sumit K. Agrawal, Jason Atlas. Diagnosis and management of benign paroxysmal positional vertigo (BPPV

). CMAJ

2003;169(7):681-93

Semont

or

Liberatory

maneuver for posterior canal BPPVSlide29

Figure 5

Lempert

roll

maneuver

for right-sided horizontal canal benign paroxysmal positional vertigo (BPPV) When it is determined to be horizontal canal BPPV affecting the right side, the patient is taken through a series of step-wise 90-degree turns away from the affected side in Steps 1 through 5, holding each position for 10 to 30 seconds.

T. D. Fife et al. Neurology 2008;70:2067-2074

©2008 by Lippincott Williams & WilkinsSlide30

Ji Soo Kim et al. Neurology 2012;79:700-707

Appiani

maneuver,

Gufoni

maneuver for HSC

canalithiasis

, or the

liberatory

maneuver proposed by

Asprella

et al in

1999: for canalithiasis of the posterior (long) arm of the HSCAppiani GC, Catania G, Gagliardi M. A liberatory maneuver for the treatment of horizontal canal paroxysmal positional vertigo. Otol Neurotol 2001; 22: 66– 69Slide31

From the seated position, the patient quickly lies down on the affected side.

The head is quickly rotated downward 45 degrees (nose to floor).This position is maintained for 2-3 minutes and then the patient sits up.

Casani

maneuver,

Gufoni

maneuver for HSC

cupulolithiasis

, modified

Semont

maneuver:

for HSC

cupulolithiasisCasani AP1, Vannucci G, Fattori B, Berrettini S. The treatment of horizontal canal positional vertigo: our experience in 66 cases. Laryngoscope. 2002 Jan;112(1):172-8Slide32

J.-S. Kim et al. Neurology 2012;78:159-166

Gufoni

maneuver

or

Gufoni

maneuver for

apogeotripic

nystagmus:

for

canalithiasis

of the anterior(short) arm of the HSCMay need to be followed tx for canalithiasis of the posterior (long) arm of the HSSCRepositioning maneuver for the treatment of the apogeotropic variant of horizontal canal benign paroxysmal positional vertigo. Ciniglio Appiani G et al. Otol Neurotol. (2005)Slide33

A

cupulolith repositioning maneuver in the treatment of horizontal canal cupulolithiasisKim, Sung Huhn

et al

.

Auris

Nasus

Larynx. 2012 Apr;39(2):163-8.

“Kim maneuver”:

for HSC

cupulolithiasis

on the

amplular and/or utricular side of the cupulaSlide34

Anterior canal canalithiasisSlide35

Richard

Rabbitt, PhD, University of Utah, Salt Lake City, UT Janet O. Helminski, PT, PhD, Midwestern University, Downers Grove, IL Janene

Holmberg, PT, DPT, NCS, Intermountain Hearing and Balance, Salt Lake City,

UT. Translating

the Biomechanics

of Benign

Paroxysmal Positional

Vertigo to

the Differential Diagnosis and

Treatment. Combined

Sections

Meeting. Las Vegas, NV – February 3-6, 2014.Maneuver reported by Faldon and Bronstein, 2008: for anterior canal cupulolithiasisSlide36

Central positional nystagmus VS BPPV

nystagmus

CENTRAL POSITIONAL NYSTAGMUS (CPN)

Can take on any form depending on the cause.

Does not have to follow Ewald’s first law, but may look like it does.

Patient may or may not have symptoms with it.

May often have associated central signs, but not necessarily.

CPN from lesions in the

nodulus

and uvula does not have any latency and is at its peak initially and decay’s over time.

CUPULOLITHIASIS

Latancy

for nystagmus is brief.Nystagmus is persistent, but will gradually start to decay after about a minute.Follows Ewald’s first law.Symptoms usually coincide with the nystagmus.

CANALITHIASIS

Nystagmus can have a longer latency.

Nystagmus typically will build, peak, and decay in under a minute.

Follows Ewald’s first law.

Symptoms usually coincide with the nystagmus.

Richard

Rabbitt

, PhD, University of Utah, Salt Lake City, UT Janet O.

Helminski

, PT, PhD, Midwestern University, Downers Grove, IL Janene Holmberg, PT, DPT, NCS, Intermountain Hearing and Balance, Salt Lake City, UT. Translating the Biomechanics of Benign Paroxysmal Positional Vertigo to the Differential Diagnosis and Treatment. Combined Sections Meeting. Las Vegas, NV – February 3-6, 2014.Jeong-Yoon Choi et al. Central paroxysmal positional nystagmus: Characteristics and possible mechanisms. Neurology 2015;84:2238-2246Slide37

Central positional nystagmus Causes

Vestibular migraineVertebrobasilar insufficiencyInfarction, hemorrhage, tumor, MS, Chiari malformation, olivopontocerebellar

atrophy, etc.

Herdman

J,

Clendanial

R. Vestibular Rehabilitation. Forth Ed. Chapter 20. F.A. Davis. 2014.Slide38

Figure 2 Origin of ocular motor abnormalities in the symptom-free interval at initial presentation (n = 60) and on follow-up (n = 61).

Andrea Radtke et al. Neurology 2012;79:1607-1614

Copyright © 2012 by AAN Enterprises, Inc

.

Andrea

Radtke

et al. Neurology 2012;79:1607-1614Slide39

Case of Cf

Bow Test: persistent right horizontal nystagmus without symptoms. Lean Test: persistent right horizontal nystagmus with symptoms. Right Dix-Hallpike Test: persistent second degree right horizontal nystagmus with symptoms.

Left Dix-

Hallpike

Test: questionable down beat nystagmus and questionable left and down beat nystagmus with left gaze. Increased dizziness with left gaze.

Sit to Supine Test: right horizontal nystagmus.

Right Supine Roll Test: persistent second degree right horizontal nystagmus with symptoms.

Left Supine Roll Test: persistent down beat nystagmus with symptoms.Slide40

Questions?