1. A Minimum Data Set for Benign Paroxysmal Positional Vertigo
Nicole Miranda, PT, MPT
Regis University
Advanced Clinical Decision Making
DPT 740
June 2008
Faculty Advisors:
Amy Stone Hammerich, PT, DPT
Julie Whitman, PT, DScPT

2. Objectives
Provide an overview regarding Benign Paroxysmal Positional Vertigo (BPPV).
Analyze current evidence and physical therapy practice patterns associated with BPPV.
Present a protocol and Minimum Data Set (MDS) for diagnosis, treatment and outcome measurement in BPPV.

3. Benign Paroxysmal Positional Vertigo (BPPV)
A syndrome characterized by brief vertiginous or spinning sensations elicited following head movement, typically in the vertical or horizontal planes.

4. BPPV Active Phase Inactive Phase
Brief vertigo attacks that recur with changes in head position
Nystagmus typically present
Duration of days to weeks
Can become chronic
Inactive Phase
No vertigo or nystagmus
Postural disturbance
Brief sensations of dizziness or vertigo may persist
Sense of insecurity
Can be life-long
Giannoni, 2005

5. Incidence/Prevalence
0.06% Incidence per year of newly diagnosed cases – Retrospective population-based study in Olmstead County, Minnesota
38% increase with each decade of life
(Froehling, 1991)
2.4% Lifetime Prevalence
Cumulative lifetime incidence nearly 10% by age 80.
(vonBrevern, 2007)
2:1 more prevalent in women than men
Female prevalence has possible link to migraine
(Neuhauser, 2007)

6. Etiology 50% Idiopathic Secondary Causes: Head Trauma
 Whiplash Injury
 Vestibular Neuritis
 Labyrinthitis
 Ménière’s Disease
 Migraine
 Endolymphatic Hydrops
 Auto-immune Ear Disease

7. Inner Ear Anatomy Three semi-circular canals
Anterior (Superior), Posterior (Inferior), Horizontal (Lateral)
Provide sensory input regarding head velocity
Spatial arrangement
Each plane is perpendicular to others (like two walls and a floor in a corner)
Co-planar pairs: left & right lateral, left anterior & right posterior, right anterior & left posterior

8. Semicircular Canal Orientation

9. Inner Ear Anatomy Hair Cells
Located in ampulla of each semi-circular canal and each otolith organ
Convert displacement caused by head movement into neural firing
Gelatinous membrane covers hair cells
Cupula in semi-circular canals
Macula in otolith organs
Contain calcium carbonate crystals (otoconia) which increase the mass of the macula – making them gravity sensitive

11. Mechanism of Action in BPPV

12. Cupulolithiasis Introduced by Schuknecht, 1969.
Displaced otoconia debris adheres to the cupula.
Ampulla becomes gravity sensitive.
When the affected ear is tipped below the horizon, the cupula is deflected.
Vertigo and nystagmus are immediate onset with change in position and persist as long as the head is tipped below the horizon.
Herdman, 2000

13. Cupulolithiasis

14. Canalithiasis Described by Hall, 1979.
Otolithic debris is free floating in the endolymph.
As the head is moved, the otoconia travel to the dependent part of the canal.
Movement of the endolymph pulls on the cupula and increases firing of the neurons.
Latency of symptoms due to the time for the cupula to be deflected. As the endolymph stops moving, symptoms subside.
Herdman, 2000

15. Canalithiasis

16. Ductolithiasis
Otoconia particles causing blockage of the endolymphatic duct.
Causes reduction in flow of endolymphatic fluid and increased aural pressure associated with hydrops.
Becvarovski, 2002

17. Impact of BPPV According to the ICF Model
Body Function
Sensory Function and Pain
Sensation of dizziness and vertigo
Dizziness
Vomiting due to dizziness and vertigo
Sensation of falling
Body Structure
Inner Ear
Semicircular canals
Brain

18. Impact of BPPV According to ICF Model
Activity Participation
General Tasks & Demands
Mobility
Self-Care
Domestic Life
Interpersonal Interactions & Relationships
Major Life Areas
Community, Social & Civic Life
Environmental Factors
Natural Environment & Human Made Changes to the Environment
Light
Climate
Support & Relationships
Attitudes

19. Purpose
Utilize a protocol for the evaluation and treatment of BPPV to ensure proper identification of canal involvement and intervention selection with outcome measurement.
Create a Minimum Data Set (MDS) to clinically analyze the effectiveness of physical therapy diagnosis, intervention and outcome measurement in individuals with BPPV.
More effectively manage patients with BPPV and identify those with chronic vertigo, persistent vertigo or resistance to conservative therapeutic intervention.

20. Protocol South Valley Physical Therapy, P.C. Centennial, CO and
Barbara Esses, M.D., Neurotology
Denver Ear Associates

21. Phase I PT Evaluation to determine canal involvement.
Up to 3 sessions of PT to perform repositioning maneuvers.
If unable to clear the vertigo/nystagmus after 3 visits, the physician is notified to allow the possibility of further medical work-up.

22. Phase II
Upon return from MD or after consultation between the PT and MD.
Resume treatment with presumed ductolithiasis or canalith jam.
Begin cranial oscillation one time per week for 4 weeks.
This can be done 2x/week if both ears are involved.

23. Diagnosis

24. Dix-Hallpike Test
Gold Standard for diagnosis of Anterior or Posterior Canal BPPV.
Starting seated with the neck rotated 45°,the person is brought into supine with 30° cervical extension.
Observe for torsional nystagmus and record the direction.

25. Dix-Hallpike Test Results
Diagnosis
Right Dix-Hallpike
Upbeat Torsional Nystagmus
Right Posterior Canal BPPV
Downbeat Torsional Nystagmus
Left Anterior Canal BPPV
Left Dix-Hallpike
Left Posterior Canal BPPV
Right Anterior Canal BPPV
Right or Left Dix-Hallpike
Lateral Nystagmus; Geotrophic or Ageotrophic
Perform Roll Test to check Horizontal Canal Involvement
Vertical Nystagmus
Central Vertigo:
Not BPPV

26. Posterior Canal BPPV 78-96% of cases
(Fife, 2008)
Posterior canal is a gravity dependent organ in both supine and upright positions.
Cupulolithiasis: Immediate onset of vertigo and nystagmus with head below the horizontal; persistent nystagmus.
Canalithiasis: Delayed onset of vertigo (15-30 second latency) and nystagmus with head movement; fatigue of nystagmus after sec.
Herdman, 2000

27. Anterior Canal BPPV Least often affected canal (1-3%).
(Fife, 2008) (Honrubia, 1999)
Often linked to structure changes in the canal detected on HR 3D-MRI:
Sticky endothelium
Filling defect with blockage of the canal
(Schratzenstaller, 2005)

28. Roll Test Most often utilized test for Horizontal canal BPPV.
Starting in a seated position, rotate the neck 60° toward the tested ear. The person is then assisted into supine, maintaining 20° of cervical flexion.
Observe for horizontal nystagmus and record geotrophic or ageotrophic direction.
Video Clip of Roll Test

29. Roll Test Results Test Result Diagnosis Right Roll Test
Geotrophic Nystagmus
Right Horizontal Canal BPPV; Canalithiasis
Ageotrophic Nystagmus
Right Horizontal Canal BPPV; Cupulolithiasis
Left Roll Test
Left Horizontal Canal BPPV; Canalithiasis
Ageotrophyic Nystagmus
Left Horizontal Canal BPPV; Cupulolithiasis
Right or Left Roll Test
Torsional Nystagmus
Perform Dix-Hallpike Test
Right of Left Roll Test
Vertical Nystagmus
Central Nystagmus; Not BPPV

30. Horizontal Canal BPPV Affects 2-15% of cases
Nausea and vomiting are commonly associated with episodes of the horizontal canal.
Cupulolithiasis: Ageotrophic nystagmus, beating away from the ground.
Canalithiasis: Geotrophic nystagmus, beating toward the ground.

31. BPPV without Nystagmus
“Subjective Vertigo” has been defined as symptomatic vertigo during either the Dix-Hallpike or Roll Test without visualization of nystagmus.
A diagnosis of “subjective vertigo” can be made during a right or left Dix-Hallpike or Roll Test, however the specific canal involved or type of BPPV may be vague.
Discuss need for Infra-red goggles to appreciate nystagmus more accurately
Haynes, 2002
Weidner, 1994
Tirelli, 2001

32. Bilateral BPPV More than one canal can be affected.
If more than on canal is affected, the intervention is directed toward the more symptomatic ear and all affected canals are documented.
Only one affected side can be treated in a session; however if 2 canals are involved on the same side (posterior and horizontal), both may be treated in one session.

33. Interventions

35. Interventions
Interventions are selected based on the canal affected and suspected cupulolithiasis vs. canalithiasis.
Repositioning maneuvers are used to return the otolithic debris to the utricle.
BPPV is resolved when observed nystagmus is extinguished during repeat Dix-Hallpike or Roll Test.

36. Epley Maneuver Used to treat posterior and anterior canal BPPV.
Typically used to treat canalithiasis.
The original Epley maneuver included use of mastoid oscillation on the affected side during the repositioning maneuver as well as use of vestibular suppressant medication.

37. Modified Epley Maneuver (CRP)
Positions (A) and (B) are repeated from the Dix-Hallpike exam.
The head is then rotated 45° past midline to the opposite side with cervical extension maintained (C).
The subject then rolls onto the side and the head is turned down to the floor (D) prior to sitting (E).

38. Semont ‘Liberatory’ Maneuver
Used to treat cupulolithiasis of the anterior/posterior canal.
A brisk movement from sitting to sidelying with the head turned 45° toward the affected side.
Subsequent movement to the opposite sidelying position with head maintained in 45° of rotation.

39. (Link to video on hard drive)
Lempert ‘BBQ’ 360° Roll
Used to treat horizontal canal BPPV.
Starting in sitting with the head turned 45° toward the affected ear. The person is moved into supine with maintained cervical rotation with the position held 1 min.
The head is then rotated 90° to the unaffected side with the position maintained for 1 min. or until symptoms subside.
The person then rolls through the unaffected side to prone on elbows, with the position maintained 1 min. or until symptoms subside.
The person rolls back to supine through the affected side, head maintained to the affected side for 1 min.
Finally the head is rotated to the unaffected side to rest.
(Link to video on hard drive)

40. (Link to video clip on hard drive)
Modified BBQ Roll
Slight modification to technique for use with cupulolithiasis of the horizontal canal.
Starting in sitting with the head turned to the affected side. The person is then brought swiftly into supine with the head turned toward the unaffected side and down into cervical extension.
The person is then assisted to roll into prone with the head forward off the mat table, followed by rolling back to supine as in the BBQ Roll.
(Link to video clip on hard drive)

41. Liberatory Maneuver for Horizontal Canal BPPV
Used to treat canalithiasis of the horizontal canal variant of BPPV.
Starting in sitting at the edge of the mat, the patient is taken into sidelying on the unaffected side for 1 min.
The head is moved briskly in a rotational movement to bring the face down to look downward at the floor.
(Link to video clip on hard drive)
Appiani, 2001

42. Post-Maneuver Precautions
Historically used in the Epley Maneuver
24-48 Hours after repositioning
Recommendations include:
Sleep with head slightly elevated
Don’t lie on the affected side
Limit head motion
Lack of evidence supporting use
Massoud, 1996

43. Brandt-Daroff Exercises
Home-based exercise to reduce canal sensitivity following vertigo episodes involving ant./post. canal.
Start sitting on the edge of the bed. Lie to one side with the head turned up to the ceiling and hold 30 sec.
Return to sit for 30 sec., then lie to the opposite side with head turned to face ceiling for 30 sec.

44. (Link to video clip on hard drive)
Cranial Oscillation
Used to treat suspected ductolithiasis.
Positioned in sidelying with the affected ear up, head tilted in a downward lateral tilt 20°.
Stabilize a vibrator against the mastoid of the upward ear for 30 minutes.
1 time per week for 4 weeks.
(Link to video clip on hard drive)

45. American Academy of Neurology
Quality Standards Subcommittee
Recommendations Released 5/28/08.

46. Recommendations
Level A recommendation for use of CRP in treatment of posterior canal BPPV
Level C recommendation for use of the Semont maneuver for treatment of posterior canal BPPV
Fife, 2008

47. Recommendations
Level C recommendations regarding the use of mastoid oscillation and Brandt-Daroff exercises in the treatment of posterior canal BPPV
Level U recommendations for repositioning maneuvers used to treat horizontal and anterior canal BPPV due to only class IV studies at present.
Fife, 2008

48. Recommendations
Insufficient evidence to support the use of post-treatment activity or positioning restrictions.
Insufficient evidence to support the use of vestibular suppressant medication in the treatment of BPPV.
Fife, 2008

49. Outcome Measures

50. Analogue Scales Dizziness Nausea 0 = No Dizziness 1 2 3 4 5 6 7 8 9
10 = Bed ridden due to dizziness
Nausea
0 = No Nausea 1 2 3 4 5 6 7 8 9
10 = Vomiting

51. Fall History
Self report of the number of falls in the 6 months prior to current episode of BPPV.
Report of number of falls since the last visit during current treatment.

52. Definition of a Fall
Definition of a fall: “a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force.”
(Tinetti, 1998)
Definition used by the Medicare Fall Prevention Act

53. Dizziness Handicap Inventory
Developed to assess perceived handicap in people with vestibular disorders.
25 items:
9 Functional
9 Emotional
7 Physical
100 points possible, high score indicates increased perceived handicap.
Jacobsen, 1990

54. Dizziness Handicap Inventory
5-Item Subscale
Looking up
Get in and out of bed
Quick head motion
Turn over in bed
Bending over
Whitney, 2005

55. Dizziness Handicap Inventory
Test-Retest Reliability r = 0.97
Minimum Detectable Change = 18 points
5-Item Subscale Score of 20 produces a likelihood ratio of 2.29.
Specificity of Subscore ≥ %
Sensitivity of Subscore = %
Whitney, 2005

56. Timed Up and Go
Gait assessment tool developed to identify fall risk in the elderly.
(Podsiadlo, 1991)
Rise from a chair, walk 3 meters, turn 180° and return to sit. Time is recorded in seconds.
Scores of ≥ 13.5 seconds indicate risk of falls.
(Shumway-Cook, 2000)

57. Timed Up and Go
Whitney et al. studied the TUG related to self-reported falls in persons with vestibular disorders.
Specificity of TUG at 11 seconds = 56%
PPV = 46%; NPV = 85%
Odds Ratio in favor of falling with a TUG of >11 seconds = 5.0 (95% CI )
Whitney, 2004

58. Dynamic Gait Index
Developed to assess gait stability in those over 60 at risk for falls.
8 Gait activities with a 4-scoring system
(Shumway-Cook, 1995)
Score of < 19 identifies risk of falling.
(Shumway-Cook, 1997)
Inter-rater reliability in persons with vestibular disorders = 0.64; ICC = 0.86
(Hall, Herdman, 2006)

59. Dynamic Gait Index
Whitney et al. (2000) studied relationship between the DGI and self reported falls.
Score <19 produced an OR of 2.58 in favor of falling (95% CI ) for those >65 with vestibular dysfunction and an OR of 3.55 (95% CI ) for those 65 or less.
Whitney et al. (2004)
Sensitivity of a score < %
Specificity of a score < %
PPV of a score < %
NPV of a score < %

60. Minimum Data Set
(In a formal presentation, the MDS form would be opened and presented or distributed as a handout)
Open MDS from link on computer
Then discuss operational definitions and use of Excel Spreadsheet for data collection

61. The Next Step
Implement the MDS to clinically analyze a protocol for diagnosing, providing intervention and tracking outcomes in BPPV.
Determine whether the MDS and protocol are able to guide successful resolution of BPPV with implementation of 2 intervention phases.
Utilize the MDS and protocol to determine appropriateness for referral back to MD.

62. The First Steps
Brief clinical analysis to determine adjustments needed to current MDS form and data collection forms.
Submission to IRB to allow movement toward clinical trial.
Application for research grant to obtain Infrared goggles for accurate visualization of nystagmus.

63. Clinical Trials are needed as current evidence supports use of repositioning maneuvers to cure BPPV.
The question is….
Single Blind… or
Double Blind???

64. Conclusion
Current evidence supports use of the Dix-Hallpike and Roll Test for diagnosis of BPPV.
Variable evidence is available to support the use of repositioning maneuvers for the treatment of BPPV.
Use of the proposed protocol and MDS could help identify resistance to physical therapy intervention with reduction in cost and prompt referral to MD.
Outcome measures used in BPPV indicate that resolution of vertigo will reduce fall risk, improve gait stability and allow return to life activities.

65. References
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66. References
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67. References
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68. Image References
Hain TC. Benign Paroxysmal Positional Vertigo Available at: Accessed on May 23, 2008.
Brandt-Daroff Exercises. American Hearing Research Foundation. Available at: Accessed June 15, 2008.
Canalithiasis. Available at: Accessed on June 15, 2008.
Cupulolithiasis. Available at: Accessed on June 15, 2008.
Illusion Spinning. Available at: Accessed June 15, 2008.
RealEyes goggles and camera Monocular Configuration. Avilable at: Accessed on June 15, 2008.
The International Classification of Function. The World Health Organization. Available at: Accessed on June 15, 2008.