1. Assessment and Treatment of the Dizzy/Balance Patient with BPPV
Mary Horsch, Audiologist
Barbara Newby, Physical Therapist
Via Christi Rehabilitation Hospital

2. Benign Paroxysmal Positioning Vertigo
Statistics/Facts of dizziness and imbalance
Inner ear causes for dizziness and imbalance
Testing available for dizziness/imbalance
BPPV: Evaluation and Treatment

3. BPPV
Case Studies
Physical Therapist Role
Management
Outcomes

4. STATISTICS
How many people are affected by vertigo/dizziness/imbalance?
This is difficult to quantify in part because symptoms are difficult to describe and differences exist in the qualifying criteria within and across studies.

5. STATISTICS
Broad based demographic studies consistently show that vestibular disorders are under diagnosed and under treated.

6. FACTS ABOUT BALANCE
From 2001 through 2004, 35.4% of adults in the US age 40 years and older had vestibular dysfunction (69 million Americans).1
Dizziness is a common symptom affecting about 30% of people over the age of 65.2

7. FACTS ABOUT BALANCE
Approximately 4% (almost 8 million) of American adults report a chronic problems (lasting 3 months or longer) with balance.
U.S. physicians reported 5,417,000 patient visits in 1991 because of dizziness and vertigo.4

8. FACTS ABOUT BALANCE
A majority of individuals over 70 report problems of dizziness and imbalance and balance related falls account for more than one-half of the accidental deaths in the elderly.1

9. Facts Continued
Hip fractures are one of the most common orthopedic injuries for elderly Americans. Many of these hip fractures are related to balance disorders.
According to the National Institutes of Health, 42 percent of people will visit their doctor because of dizziness at least once in their lifetime.

10. Facts Continued
Each year, more than 450,000 people receive head injuries. Fifty-eight percent of people who have had a traumatic brain injury complain of dizziness one to three months after the injury.

11. CAUSES OF DIZZINESS

12. Some Causes of Dizziness Related to the Inner Ear
Benign Paroxysmal Positioning Vertigo
Vestibular Neuronitis
Labyrinthitis
Meniere’s disease
Vestibular Migraine
Labyrinthine ischemia
Perilymphatic fistula
Acoustic neuroma

13. Taking a Complete History
The patient needs to describe their dizziness without using the word “dizzy.” Depending if the patient describes light headedness while walking vs. true vertigo with change in position can help determine where and what the issue may be.

14. Assessment by Audiologist
Videonystagmography
Electrocochleography
Auditory Brainstem Response
Rotary Chair
Computerized Dynamic Posturography
VEMP

15. VIDEONYSTAGMOGRAPHY
A study of the digitally recorded changes in movements of the eye, used to assess nystagmus and to aid in separating vestibular and oculomotor deficits of the CNS, from deficits of the peripheral vestibular system.

16. ELECTROCOCHLEOGRAPHY A test that measures the electrical potentials generated in the inner ear in response to stimulation by sound. Electrocochleography may be done, for example, to confirm the diagnosis of Meniere’s disease.

17. AUDITORY BRAINSTEM RESPONSE
Used in the evaluation of hearing integrity as well as defining normal neurologic synchrony along the VIII the nerve to brainstem.

18. ROTARY CHAIR

19. ROTARY CHAIR
Evaluates the vestibulo-ocular reflex (VOR) which is a reflex eye movement that stabilizes images on the retina during head movement by producing an eye movement in the direction opposite to head movement, thus preserving the image on the center of the visual field.

20. COMPUTERIZED DYNAMIC POSTUROGRAPHY

21. COMPUTERIZED DYNAMIC POSTUROGRAPHY
A non-invasive specialized clinical assessment technique used to quantify the central nervous system adaptive mechanisms (sensory, motor and central) involved in the control of posture and balance particularly in the diagnosis of balance disorders and postural re-education.

22. VEMP – VESTIBULAR MYOGENIC POTENTIAL

23. VEMP
The purpose of the VEMP test is to determine if the saccule, one portion of the otoliths, as well the inferior vestibular nerve and central connections, are intact and working normally.

24. BPPV
What is it?

25. BPPV
Benign Paroxysmal Positional Vertigo is described as a brief, intense spinning sensation that occurs with a specific change in head position.

26. Benign Paroxysmal Positional Vertigo (BPPV)
Benign: not a very serious or progressive condition
Paroxysmal: sudden and unpredictable in onset
Positional: comes with a change in head position
Vertigo: causing a sense of dizziness.

27. BPPV Most common type of peripheral vertigo
Patient will average 4.5 physician visits prior to obtaining the proper diagnosis
Can be seen in patient’s following head injury, vestibular neuronitis, surgeries, Meniere’s or can be present alone
Characterized by vertigo lasting for a few seconds following head movement

28. BPPV Movements that provoke symptoms Lying down or getting up
Rolling over in bed
Bending over
Looking up
Going to the dentist or beauty shop

29. Complaints of Patients with BPPV
Vertigo of short duration
Balance problems
May last for hours or days following the episodic vertigo
Swimming sensation
Nausea
Inability to concentrate, floating, blurred vision

30. BPPV
Degeneration of calcium carbonate crystals (otoliths) in the utricle which break free and become lodged in the semi-circular canals
Six canals – most commonly affecting the posterior Semi-circular canal, then horizontal canal(3-9%), least frequently the Anterior canal (less than 2%).

31. Canalolithiasis Theory
The most widely accepted theory of the pathophysiology of BPPV
Otoliths (calcium carbonate particles) are normally attached to a membrane inside the utricle and saccule
The utricle is connected to the semicircular ducts
These otoliths may become displaced from the utricle to enter the posterior semicircular duct since this is the most dependent of the 3 ducts
Changing head position relative to gravity causes the free otoliths to gravitate longitudinally through the canal.
The concurrent flow of endolymph stimulates the hair cells of the affected semicircular canal, causing vertigo.

32. The Inner Ear Semicircular Canals

33. BPPV - Length of time between onset of symptoms and evaluation
Less than one month
1-3 months
4-12 months
13-36 months
37-60 months
Over 60 months 8%
24%
26%
14%
7 %
13%

34. Treatment of BPPV The primary questions which should be asked are:
Which is the involved ear or is it bilateral?
Which canal is involved?
Is it canalithiasis or cupulolithiasis?

35. Canalithiasis / Cupulolithiasis
In Cupulolithiasis the debris is adhering to the cupula rather than free floating in the long process of the posterior canal. Often the debris must be dislodged from the cupula so that it can then be allowed to return to the utricle and dissolve.

36. BPPV
Evaluating for BPPV
Dix Hallpike
Horizontal Head Roll

37. The Dix-Hallpike test – To Determine Posterior or Anterior Involvement

38. Canalith Repositioning Procedure ( CRP )
The treatment of choice for BPPV.
Also known as the Epley maneuver,
The patient is positioned in a series of steps so as to slowly move the otoconia particles from the posterior semicircular canal back into the utricle.
Takes approximately 5 minutes.
The patient is instructed to wear a neck brace for 24 hours and to not bend down or lay flat for 24 hours after the procedure.
One week after the CRP, the Dix-Hallpike test is repeated.
If the patient does experience vertigo and nystagmus, then the CRP is repeated with a vibrator placed on the skull in order to better dislodge the otoconia.

39. To Evaluate for Horizontal Canal BPPV

40. TREATMENT OF HORIZONAL CANAL BPPV
The "log roll" exercises
Liberatory Maneuver Appiani and associates (2001)
Modified Brandt-Daroff

41. Clinical Trial
Ruckenstein (2001) Therapeutic efficacy of the Epley canalith repositioning maneuver. Laryngoscope
Eighty-six patients
74% of cases that were treated with one or two canalith repositioning maneuvers had a resolution of vertigo as a direct result of the maneuver.
A resolution attributable to the first intervention was obtained in 70% of cases within 48 hours of the maneuver.
An additional 14% of cases that were treated had a resolution of vertigo.
Only 4% of cases (three patients) manifested BPV that persisted after four treatments.

42. Case study 1 82 year old female admitted through ER following a fall
Patient reported episodes of dizziness beginning in The dizziness lasts for a few seconds and is associated with a change of position
No ear symptoms

43. Diagnostics completed
CT of head
ECG
2 dimensional echo
EKG
Telemetry
Portable chest
Carotid duplex sonogram

44. Case study 1 cont.
On third day following admission, Audiology consult initiated
Audiology findings, Positive Dix Hallpike to right consistent with BPPV affecting the right posterior canal, treatment completed patient discharged
Treatment repeated 2 weeks following hospital discharge
Visit 3, patient no longer has any symptoms of dizziness

45. Case Study 2 48 year old female, ARNP for FP doc
Extreme vertigo with movement, especially looking up to the right
VNG negative for all but BPPV
Treatment with Semont and Epley maneuver x 2 by audiologist
Symptom free, return to all normal activities

46. Case Study 3 – PHYSICAL THERAPY
Patient saw Audiology for sudden onset of vertigo. Positive for BPPV. Symptoms did not completely resolve after Epley.
Patient is elderly with macular degeneration and has had several falls as a result of dysequilibrium.
Patient was referred to PT to follow up on BPPV and fall risk.

47. Case Study 3 cont.
Patient’s PT eval revealed continued vertigo and imbalance. Positive for BPPV as well as some gait unsteadiness with turns. Treated with Epley with resolution of symptoms.
Follow up visit, still has positive Hallpike. Vibration prior to Epley.

48. Case Study 3 cont.
Third visit: patient had no vertigo. Able to do quick turns without difficulty. Patient reports balance is back to prior level. Right Hallpike negative.

49. Physical Therapy Management for the Dizzy/Balance patient
Goals of PT
Decrease symptoms of dizziness and improve balance in order to return patient to the highest level of function possible

50. Physical Therapy evaluation
Strength
Range of Motion
Sensation
Static balance testing
Dynamic balance testing including gait
Sensory organization testing
VOR testing
Motion sensitivity testing
BPPV screening if not seen by Audiology
Computerized balance testing

51. Physical Therapy Treatment
Balance exercises
Gait training
VOR exercises
Habituation exercises
Sensory substitution exercises
Repositioning maneuvers for BPPV

52. Physical Therapy Treatment cont.
Equipment recommendations
Fall prevention
General strengthening/flexibility

53. Patients who can benefit from VRT
Inner ear disorders with Unilateral or bilateral involvement
BPPV
Central nervous system disorder with balance problems such as multiple sclerosis, stroke, brain injury
Multideficit vertigo of the geriatric patient
Other patients with balance problems or history of falls

54. Patient outcomes Group of 13 patients with history of balance problems
VNG testing done on all patients
PT Evaluations found specific problems with gaze stabilization, motion provoked dizziness, dizziness with head movement when walking, static and dynamic balance deficits

55. Patient outcomes cont. # of PT patient visits Goals Goals met
1-3 visits, only one with more 7 visits
Goals
Typically three – five goals including home program
Goals met
75-100% of goals met at discharge

56. Implications
Patients with dizziness, imbalance can return to normal function with proper diagnosis and vestibular rehabilitation with physical therapy directed treatment
Other studies have shown VRT exercises highly facilitate recovery, improve postural stability and diminish perception of disequilibrium in patients

57. Outcomes
Studies have shown that 85% of patient treated with VRT showed reduction of symptoms and reduction in disability score

58. Tools for screening Hearing handicap Inventory for the Elderly
Balance function self test

59. Computerized Dynamic Posturography
Battery of tests that helps assess the functional capacity of the balance disorder patient
SOT – Sensory organization test
Objectively identifies abnormalities in the patient’s use of the three sensory systems that contribute to postural control
Motor control test
Dynamic Visual Acuity test
Assesses for loss of VOR vestibular ocular reflex

60. Dynamic Posturography
Add to ability to identify specific problems which affect balance
Used for assessment, treatment, and to measure progress as a result of treatment

61. CONCLUSION
BPPV is the most common finding of those with a complaint of vertigo
BPPV is easily identified with simple maneuvering techniques
BPPV is easily treated in most cases with specific maneuvers in one visit