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

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.

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. www.mobile-pedia.com/.../illusion_Spinning.png

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

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)

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

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

Semicircular Canal Orientation

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

Mechanism of Action in BPPV

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

Cupulolithiasis www.micromedical.com

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

Canalithiasis www.micromedical.com

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

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 www.who.int/classification.icf

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 www.who.int/classification.icf

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.

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

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.

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.

Diagnosis

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. www.dizziness-and-balance.com

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

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 30-60 sec. Herdman, 2000

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)

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

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

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.

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

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.

Interventions

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.

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.

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). www.dizziness-and-balance.com

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. www.thieme-connect.com

(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)

(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)

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

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

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. www.american-hearing.org

(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)

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

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

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

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

Outcome Measures

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

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.

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

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

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

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 ≥ 18 93.8% Sensitivity of Subscore = 0 97.6% Whitney, 2005

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)

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 1.80-13.91) Whitney, 2004

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)

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 1.47-4.53) for those >65 with vestibular dysfunction and an OR of 3.55 (95% CI 1.53-5.26) for those 65 or less. Whitney et al. (2004) Sensitivity of a score <19 71% Specificity of a score <19 53% PPV of a score <19 39% NPV of a score <19 81%

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

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.

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.

Clinical Trials are needed as current evidence supports use of repositioning maneuvers to cure BPPV. The question is…. Single Blind… or Double Blind??? http://www.micromedical.com/goggles.htm

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.

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Image References Hain TC. Benign Paroxysmal Positional Vertigo Available at: http://www.dizziness-and-balance.com/disorders/bppv/bppv.html. Accessed on May 23, 2008. Brandt-Daroff Exercises. American Hearing Research Foundation. Available at: www.american-hearing.org. Accessed June 15, 2008. Canalithiasis. Available at: www.micromedical.com. Accessed on June 15, 2008. Cupulolithiasis. Available at: www.micromedical.com. Accessed on June 15, 2008. Illusion Spinning. Available at: www.mobile-pedia.com/.../illusion_Spinning.png. Accessed June 15, 2008. RealEyes goggles and camera Monocular Configuration. Avilable at: http://www.micromedical.com/goggles.htm. Accessed on June 15, 2008. The International Classification of Function. The World Health Organization. Available at: www.who.int/classification.icf. Accessed on June 15, 2008.