This document discusses vestibular disorders, specifically Benign Paroxysmal Positional Vertigo (BPPV). It defines BPPV as the most common cause of vertigo, triggered by certain head positions. Physical therapists are well-suited to diagnose and treat BPPV using positional tests to identify affected semicircular canals, followed by repositioning maneuvers like the Epley maneuver to guide loose crystals back to their proper position. Proper diagnosis and treatment of BPPV by a physical therapist can resolve symptoms and address related functional impairments.
2. Vestibular disorders
The vestibular system includes the parts of the inner
ear and brain that process the sensory information
involved with controlling balance and eye movements.
If disease or injury damages these these processing
areas , vestibular disorders can result.
4. BENIGN PAROXYSMAL POSITIONAL
VERTIGO
Benign Paroxysmal Positional Vertigo (or BPPV) is the
most common cause of vertigo, which is a false
sensation of spinning.1
Benign – it is not life-threatening
Paroxysmal – it comes in sudden, brief spells
Positional – it gets triggered by certain head positions
or movements
Vertigo – a false sense of rotational movement
5.
6. WHO IS AFFECTED
BPPV is fairly common, with an estimated incidence of 107
per 100,000 per year (Froehling DA, 1991) and a lifetime
prevalence of 2.4 percent (von Brevern M, 2007).
It is thought to be extremely rare in children but can affect
adults of any age, especially seniors. The vast majority of
cases occur for no apparent reason, with many people
describing that they simply went to get out of bed one
morning and the room started to spin.
However associations have been made with trauma,
migraine, inner ear infection or disease, diabetes,
osteoporosis, intubation (presumably due to prolonged
time lying in bed) and reduced blood flow. There may also
be a correlation with one’s preferred sleep side (Shigeno K,
et al.2012).
7. DIAGNOSIS
Normal medical imaging (e.g. an MRI) is not effective in
diagnosing BPPV, because it does not show the crystals that
have moved into the semi-circular canals.
However, when someone with BPPV has their head moved
into a position that makes the dislodged crystals move
within a canal, the error signals cause the eyes to move in a
very specific pattern, called “nystagmus”.
Tests like the Dix-Hallpike or Roll Tests involve moving the
head into specific orientations, which allow gravity to move
the dislodged crystals and trigger the vertigo while the
practitioner watches for the tell-tale eye movements, or
nystagmus.
8. TYPES OF BPVV
There are two types of BPPV: one where the loose crystals can
move freely in the fluid of the canal (canalithiasis), and, more
rarely, one where the crystals are thought to be ‘hung up’ on the
bundle of nerves that sense the fluid movement
(cupulolithiasis).
With canalithiasis, it takes less than a minute for the crystals to
stop moving after a particular change in head position has
triggered a spin. Once the crystals stop moving, the fluid
movement settles and the nystagmus and vertigo stop.
With cupulolithiasis, the crystals stuck on the bundle of sensory
nerves will make the nystagmus and vertigo last longer, until the
head is moved out of the offending position. It is important to
make this distinction, as the treatment is different for each
variant.
9. How to diagnose which canal is
involved
Differential Diagnosis of BPPV To formulate a physical therapy differential diagnosis, a
thorough history and neurologic examination is performed to identify BPPV from other
potential causes of positional vertigo such as orthostatic hypotension, low spinal fluid
pressure, and brainstem or cerebellar dysfunction. Cervical spine and vertebral artery
screening tests should be included prior to positional testing to identify limitations and
potential contraindications to performing the positional tests. Once the cervical spine
and vertebral artery are cleared, positional testing is performed.
The AAO-HNS describes the diagnosis of posterior semicircular when two conditions are
present:
(1) the patient reports a history of vertigo associated with changes in head position and
(2) the Dix-Hallpike test provokes the characteristic nystagmus described for this
condition. The nystagmus described for posterior canal BPPV is up-beating and
torsional with the fast phase beating toward the side being tested.The standard
recommendation to diagnosis HC BPPV for entrylevel physical therapists and specialists
in vestibular rehabilitation continues to be a single positional test, the Supine Roll Test
10. When a therapist cannot determine side of involvement they may take longer to apply
the most appropriate canalith repositioning maneuver (CRM) and patients will require
more physical therapy sessions and experiences longer durations of active BPPV before
symptoms are resolved.
In the Supine Roll Test (SRT) the patient lies in supine with neck flexed 30
degrees to align the horizontal canals into the gravitational field. The head is then
quickly rotated 90 degrees to the right and the eyes are observed for either geotropic
(towards the ground) or apogeotropic (away from the ground) nystagmus. The head is
then brought back to facing upward, and then quickly rotated to the left 90 degrees.
Because of the relationship of the two HCs to gravity in supine, when otoconia are
present,nystagmus will be provoked on both the right and left rotations and the
direction (geotropic or apogeotropic) will be the same in each head rotation. There
will be a greater response when otoconia move toward the ampulla (ampulopetal) and
the system is excited than when they are displaced away from the ampulla
(ampullofugal) and the system is inhibited.
Head Pitch Test (HPT) or Bow and Lean Test (BLT),may further differentiate
between sides of involvement. The upward pitch (or lean) creates a horizontal
nystagmus away from the side of involvement in the geotropic form and toward the
side of involvement in the apogeotropic form. The downward pitch (Bow) creates a
horizontal nystagmus towards the side of involvement in the geotropic and away from
the side of involvement in the apogeotropic form.
11. The right Dix-Hallpike position
used to elicit nystagmus for
diagnosis. The patient is moved
from a seated to a supine
position with her head turned 45
degrees to the right and held for
30 seconds.
12. Head Shaking Induced Nystagmus (HSIN) may be
an additional sign to localize side. The Head Shake
Test involves rotating the head in upright several times
at ~2Hz and then observing for nystagmus1
13. 10 reasons why a PT should treat
BPPVAnne K. Galgon, PT, PhD, NCS Vestibular SIG Vice Chair Here are my TOP TEN
REASONS
1) Physical therapists can evaluate and treat gait and balance deficits that are concurrent or
result from BPPV.
2) Physical Therapists will address functional changes in bed mobility, transfers and
ambulation that are concurrent or result from BPPV
3) Physical Therapists spend more time with each patient than most other health
professionals.
4) Physical Therapists will schedule a patient quickly and at a frequency which addresses an
individual's BPPV in a timely fashion.
5) Physical Therapists can address residual movement sensitivity that may present after
nystagmus is resolved.
6) Physical Therapists can provide the most appropriate education (knowledge of the disorder,
recognizing signs and symptoms, treatment options, self management). 7) The physical
therapists' optimal goal is self management of the condition.
8) Physical Therapists develop rapport with their patient that will help reduce anxiety and
intensity of symptoms associated with BPPV during examination and intervention.
9) Physical Therapists have the knowledge and skills to examine for BPPV, make appropriate
diagnosis and clinical decisions for intervention.
10) Physical Therapists have the knowledge and skill to consider other physical, emotional and
medical conditions when examining and treating individual patients with BPPV.
14. TREATMENT
Though many people are given medication for BPPV, there is no evidence to support
its use in treatment of this condition (Fife TD, et al., 2008). In extremely rare
circumstances, surgical options are considered. However, fortunately, in the vast
majority of cases, BPPV can be corrected mechanically.
Canalith Repositioning Maneuvers: The maneuvers make use of gravity to guide the
crystals back to the chamber where they are supposed to be via a very specific series
of head movements
Liberatory Maneuver: In the case of cupulolithiasis, they would utilize rapid head
movement in the plane of the affected canal to try to dislodge the ‘hung-up’ crystals
first. and then guide them out as described above.
Epley maneuver
Additionally, before testing or treating for BPPV, the healthcare provider should
perform a careful neurological scan, evaluation of the neck, and other safety-related
investigations to determine if certain elements of the procedure need to be
modified or avoided.
It is possible to have more than one canal involved, especially after trauma, in which
case your vestibular therapist would typically have to correct them one at a time.
