VERTIGO & The Epley Manoeuvre Dr Colin Mitchell SpR Geriatrics / GIM MSc Geriatric Medicine  (Special Senses Module)
Objectives <ul><li>Differentiate the causes and clinical features of central and peripheral vertigo </li></ul><ul><li>Revi...
Vertigo <ul><li>Illusion of motion </li></ul><ul><li>Subjective / Objective </li></ul><ul><li>Caused by vestibular system ...
Vertigo <ul><li>Illusion of motion </li></ul><ul><li>Subjective / Objective </li></ul><ul><li>Caused by vestibular system ...
Peripheral vs Central <ul><li>Large crossover in  symptoms </li></ul>Peripheral Central Abrupt onset Intense Nausea / Vomi...
Peripheral vs Central <ul><li>Some crossover in  signs  too </li></ul>Peripheral Central Nystagmus - delayed, fatiguable (...
Causes of Vertigo <ul><li>Peripheral </li></ul><ul><ul><li>BPPV </li></ul></ul><ul><ul><li>Meniere’s disease (vertigo, tin...
Causes of Vertigo <ul><li>Peripheral (~90% of vertigo in over 65s) </li></ul><ul><ul><li>BPPV </li></ul></ul><ul><ul><li>M...
Causes of Vertigo <ul><li>Peripheral (~90% of vertigo in over 65s) </li></ul><ul><ul><li>BPPV (~20-50% of vertigo in over ...
“ Benign” Paroxysmal Positional Vertigo
BPPV <ul><li>Commonest cause of vertigo (20-50%) </li></ul><ul><li>Accounts for ~8-9% of  all  mod/sev dizziness </li></ul...
BPPV Pathophysiology <ul><li>Canalith theory </li></ul><ul><li>Usually PSC affected </li></ul><ul><li>RFs for otoconia: </...
Hallpike Test <ul><li>Hallpike’s test was developed in the 1950s </li></ul><ul><li>Lay patient down with head below bed le...
The Epley Manoeuvre <ul><li>Canalith repositioning (PSC) </li></ul><ul><li>Developed in 1992 by Dr John Epley </li></ul><u...
The Epley Manoeuvre <ul><li>Canalith repositioning (PSC) </li></ul><ul><li>Developed in 1992 by Dr John Epley </li></ul><u...
The Epley <ul><li>Patient starts sitting up, head forward </li></ul><ul><li>Turn head 45 °  to affected side (eg left) </l...
The Epley <ul><li>Patient starts sitting up, head forward </li></ul><ul><li>Turn head 45 °  to affected side (eg left) </l...
The Epley Video by Dr P Hain – see credits for attribution and web link
Evidence for Epley <ul><li>Cochrane review (2004) </li></ul><ul><ul><li>15 RCTs, only 3 well conducted (144 patients) </li...
Cochrane Review <ul><li>Epley versus placebo manoeuvre:  Conversion of +ve to -ve Hallpike test </li></ul>
Cochrane Review <ul><li>Epley versus placebo manoeuvre:  Subjective symptom resolution </li></ul>
Non-specialists <ul><li>Munoz et al, 2007 </li></ul><ul><li>Double blinded RCT by Canadian GPs </li></ul><ul><ul><li>81 pa...
Other Treatments <ul><li>Semont manoeuvre </li></ul><ul><li>Brandt-Daroff exercises </li></ul><ul><li>Dizzyfix </li></ul><...
Summary <ul><li>Clinical differentiation of central vs peripheral vertigo is important: </li></ul><ul><ul><li>Central vert...
Question Time
References <ul><li>Epidemiology of dizziness: </li></ul><ul><ul><li>Oghalai JS et al (2000), Unrecognized BPPV in elderly ...
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BPPV & The Epley Maneouvre / Maneuver

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A short presentation on BPPV and how to treat it with the Epley Manoeuvre / maneouvre / maneuver / manuva

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BPPV & The Epley Maneouvre / Maneuver

  1. 2. VERTIGO & The Epley Manoeuvre Dr Colin Mitchell SpR Geriatrics / GIM MSc Geriatric Medicine (Special Senses Module)
  2. 3. Objectives <ul><li>Differentiate the causes and clinical features of central and peripheral vertigo </li></ul><ul><li>Review the pathophysiology of BPPV </li></ul><ul><li>Explain the methods of the Hallpike and Epley Manoeuvres </li></ul><ul><li>Examine the evidence for the Epley manoeuvre </li></ul>
  3. 4. Vertigo <ul><li>Illusion of motion </li></ul><ul><li>Subjective / Objective </li></ul><ul><li>Caused by vestibular system failure: </li></ul><ul><ul><li>Inner ear </li></ul></ul><ul><ul><li>Vestibular nerve (CN8) </li></ul></ul><ul><ul><li>Brainstem </li></ul></ul><ul><ul><li>Cerebellum </li></ul></ul>
  4. 5. Vertigo <ul><li>Illusion of motion </li></ul><ul><li>Subjective / Objective </li></ul><ul><li>Caused by vestibular system failure: </li></ul><ul><ul><li>Inner ear </li></ul></ul><ul><ul><li>Vestibular nerve (CN8) </li></ul></ul><ul><ul><li>Brainstem </li></ul></ul><ul><ul><li>Cerebellum </li></ul></ul>Peripheral Central
  5. 6. Peripheral vs Central <ul><li>Large crossover in symptoms </li></ul>Peripheral Central Abrupt onset Intense Nausea / Vomiting Auditory complaints Associated with head position Usually more gradual onset Often less intense Less so Less often Constant / Non-positional
  6. 7. Peripheral vs Central <ul><li>Some crossover in signs too </li></ul>Peripheral Central Nystagmus - delayed, fatiguable (Torsional nystagmus) Auditory disturbance Nystagmus - immediate, non-fatiguable (Vertical nystagmus) Other CN2-12 signs Other PNS signs esp ataxia
  7. 8. Causes of Vertigo <ul><li>Peripheral </li></ul><ul><ul><li>BPPV </li></ul></ul><ul><ul><li>Meniere’s disease (vertigo, tinnitus, progressive hearing loss) </li></ul></ul><ul><ul><li>Ototoxicity (gentamicin, heavy metals, chemotherapy etc) </li></ul></ul><ul><ul><li>Vestibular neuritis </li></ul></ul><ul><ul><li>Alcohol </li></ul></ul><ul><li>Central </li></ul><ul><ul><li>Migraine </li></ul></ul><ul><ul><li>Stroke / TIA </li></ul></ul><ul><ul><li>Head trauma </li></ul></ul><ul><ul><li>MS </li></ul></ul><ul><ul><li>SOL (Acoustic neuroma, frequently CN7 involvement) </li></ul></ul>
  8. 9. Causes of Vertigo <ul><li>Peripheral (~90% of vertigo in over 65s) </li></ul><ul><ul><li>BPPV </li></ul></ul><ul><ul><li>Meniere’s disease (vertigo, tinnitus, progressive hearing loss) </li></ul></ul><ul><ul><li>Ototoxicity (gentamicin, heavy metals, chemotherapy etc) </li></ul></ul><ul><ul><li>Vestibular neuritis </li></ul></ul><ul><ul><li>Alcohol </li></ul></ul><ul><li>Central (~10%) </li></ul><ul><ul><li>Migraine </li></ul></ul><ul><ul><li>Stroke / TIA </li></ul></ul><ul><ul><li>Head trauma </li></ul></ul><ul><ul><li>MS </li></ul></ul><ul><ul><li>SOL (Acoustic neuroma, frequently CN7 involvement) </li></ul></ul>
  9. 10. Causes of Vertigo <ul><li>Peripheral (~90% of vertigo in over 65s) </li></ul><ul><ul><li>BPPV (~20-50% of vertigo in over 65s) </li></ul></ul><ul><ul><li>Meniere’s disease (vertigo, tinnitus, progressive hearing loss) </li></ul></ul><ul><ul><li>Ototoxicity (gentamicin, heavy metals, chemotherapy etc) </li></ul></ul><ul><ul><li>Vestibular neuritis </li></ul></ul><ul><ul><li>Alcohol </li></ul></ul><ul><li>Central (~10%) </li></ul><ul><ul><li>Migraine </li></ul></ul><ul><ul><li>Stroke / TIA </li></ul></ul><ul><ul><li>Head trauma </li></ul></ul><ul><ul><li>MS </li></ul></ul><ul><ul><li>SOL (Acoustic neuroma, frequently CN7 involvement) </li></ul></ul>
  10. 11. “ Benign” Paroxysmal Positional Vertigo
  11. 12. BPPV <ul><li>Commonest cause of vertigo (20-50%) </li></ul><ul><li>Accounts for ~8-9% of all mod/sev dizziness </li></ul><ul><li>History taking up to 90% predictive </li></ul><ul><ul><li>Episodic, self limiting, assoc with nausea </li></ul></ul><ul><ul><li>Occurs with head movement </li></ul></ul><ul><li>Hallpike test used to clinch diagnosis </li></ul><ul><ul><li>Neurological exam normal </li></ul></ul><ul><li>30-50% resolve spontaneously </li></ul><ul><li>50% recurrent (no predictive indicators) </li></ul>
  12. 13. BPPV Pathophysiology <ul><li>Canalith theory </li></ul><ul><li>Usually PSC affected </li></ul><ul><li>RFs for otoconia: </li></ul><ul><ul><li>Idiopathic (↑age) </li></ul></ul><ul><ul><li>Head trauma (younger pts) </li></ul></ul><ul><ul><li>Preceding viral infection </li></ul></ul><ul><ul><li>Surgical damage </li></ul></ul>
  13. 14. Hallpike Test <ul><li>Hallpike’s test was developed in the 1950s </li></ul><ul><li>Lay patient down with head below bed level </li></ul><ul><li>Turn head 45 ° to one side, observe for nystagmus </li></ul><ul><li>Repeat to other side, note affected side </li></ul><ul><li>In a positive test, nystagmus is </li></ul><ul><ul><li>delayed (usually 5-10s) </li></ul></ul><ul><ul><li>torsional </li></ul></ul><ul><ul><li>fatiguable </li></ul></ul>
  14. 15. The Epley Manoeuvre <ul><li>Canalith repositioning (PSC) </li></ul><ul><li>Developed in 1992 by Dr John Epley </li></ul><ul><li>40-80% improved after manoeuvre </li></ul><ul><ul><li>Better results with multiple treatments </li></ul></ul><ul><ul><li>Controversy over when to repeat </li></ul></ul><ul><li>Avoid if limited neck mobility </li></ul><ul><li>No significant adverse effects </li></ul><ul><li>? Mastoid Vibration </li></ul>
  15. 16. The Epley Manoeuvre <ul><li>Canalith repositioning (PSC) </li></ul><ul><li>Developed in 1992 by Dr John Epley </li></ul><ul><li>40-80% improved after manoeuvre </li></ul><ul><ul><li>Better results with multiple treatments </li></ul></ul><ul><ul><li>Controversy over when to repeat </li></ul></ul><ul><li>Avoid if limited neck mobility </li></ul><ul><li>No significant adverse effects </li></ul><ul><li>? Mastoid Vibration </li></ul>
  16. 17. The Epley <ul><li>Patient starts sitting up, head forward </li></ul><ul><li>Turn head 45 ° to affected side (eg left) </li></ul><ul><li>Lie flat, head below bed level </li></ul><ul><li>Turn head 90 °, now facing 45 ° to opposite side (right) </li></ul><ul><li>Roll patient onto right side (face to the floor) </li></ul><ul><li>Sit patient up (head still to the right) </li></ul><ul><li>Lean head forward, chin down </li></ul><ul><li>Advise patient to sleep upright for 2 days, and avoid provoking movements for 1 week </li></ul>
  17. 18. The Epley <ul><li>Patient starts sitting up, head forward </li></ul><ul><li>Turn head 45 ° to affected side (eg left) </li></ul><ul><li>Lie flat, head below bed level </li></ul><ul><li>Turn head 90 °, now facing 45 ° to opposite side (right) </li></ul><ul><li>Roll patient onto right side (face to the floor) </li></ul><ul><li>Sit patient up (head still to the right) </li></ul><ul><li>Lean head forward, chin down </li></ul><ul><li>Advise patient to sleep upright for 2 days, and avoid provoking movements for 1 week </li></ul>
  18. 19. The Epley Video by Dr P Hain – see credits for attribution and web link
  19. 20. Evidence for Epley <ul><li>Cochrane review (2004) </li></ul><ul><ul><li>15 RCTs, only 3 well conducted (144 patients) </li></ul></ul><ul><ul><li>All small. Many problems with blinding and randomisation </li></ul></ul><ul><li>Control groups: </li></ul><ul><ul><li>2 sham manoeuvres (Lynn, 1995 & Froehling, 2000) </li></ul></ul><ul><ul><li>1 normal care (Yimtae, 2003) </li></ul></ul><ul><li>Age range 18-90 </li></ul><ul><li>Manoeuvre globally well tolerated </li></ul><ul><li>No long-term follow-up </li></ul>
  20. 21. Cochrane Review <ul><li>Epley versus placebo manoeuvre: Conversion of +ve to -ve Hallpike test </li></ul>
  21. 22. Cochrane Review <ul><li>Epley versus placebo manoeuvre: Subjective symptom resolution </li></ul>
  22. 23. Non-specialists <ul><li>Munoz et al, 2007 </li></ul><ul><li>Double blinded RCT by Canadian GPs </li></ul><ul><ul><li>81 patients >18 yrs with positive Hallpike </li></ul></ul><ul><ul><li>Epley vs sham manoeuvre </li></ul></ul><ul><li>After one treatment, 34.2% of treatment group hallpike resolved vs 14.6% in control </li></ul><ul><ul><li>RR 2.3 (CI 1.03 – 5.2, P=.04) </li></ul></ul><ul><li>Non-significant trend in symptom resolution also favoured Epley </li></ul>
  23. 24. Other Treatments <ul><li>Semont manoeuvre </li></ul><ul><li>Brandt-Daroff exercises </li></ul><ul><li>Dizzyfix </li></ul><ul><li>Surgical </li></ul><ul><li>Little pharmacological role </li></ul>
  24. 25. Summary <ul><li>Clinical differentiation of central vs peripheral vertigo is important: </li></ul><ul><ul><li>Central vertigo requires investigation </li></ul></ul><ul><ul><li>Peripheral vertigo is often self limiting </li></ul></ul><ul><li>BPPV can be diagnosed and treated in the clinic by non-specialists </li></ul><ul><li>The Epley manoeuvre works for BPPV </li></ul><ul><li>But most need repeat treatment </li></ul>
  25. 26. Question Time
  26. 27. References <ul><li>Epidemiology of dizziness: </li></ul><ul><ul><li>Oghalai JS et al (2000), Unrecognized BPPV in elderly patients. Otolayngology and Head & Neck Surgery, 122(5): 630-634 </li></ul></ul><ul><ul><li>Uneri A, Polat S (2008), Vertigo, dizziness and imbalance in the elderly. Jounral of Laryngology and Otology, 122(5): 466-469 </li></ul></ul><ul><ul><li>Hansson EE et al (2005), BPPV among elderly patient in primary health care. Gerontology, 51(6): 386-389 </li></ul></ul><ul><ul><li>Von Brevern et al (2006), Epidemiology of BPPV: a population based study. Journal of Neurology, Neurosurgery and Psychiatry, 78: 710-715 </li></ul></ul><ul><li>Epley maneouvre evidence: </li></ul><ul><ul><li>Hilton M, Pinder D (2004). The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database of Systematic Reviews 2004, Issue 2. Art. No.: CD003162. DOI: 10.1002/14651858.CD003162.pub2 </li></ul></ul><ul><ul><li>Munoz et al (2007). Canalith repositioning maneuver for BPPV – RCT in family practice. Canadian Family Physician 53:1048-1053 </li></ul></ul><ul><li>Semicircular canal picture (Public domain) from NIH website </li></ul><ul><ul><li>http://www.nidcd.nih.gov/health/balance/balance_disorders.asp </li></ul></ul><ul><li>Epley manoeuvre video (C) Dr P Hain (30/4/08) </li></ul><ul><ul><li>http://www.dizziness-and-balance.com/sitedvd.htm </li></ul></ul><ul><li>Vertigo Optical Illusion from </li></ul><ul><ul><li>http://pos-psych.com/wp-content/uploads/2007/05/vertigo-new.jpg </li></ul></ul><ul><li>Screenshots from Vertigo are copyright Universal Pictures, reproduced under Fair Use as the film is a culturally significant demonstration of the effects of vertigo. </li></ul>

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