1. Clinical Problem Solving II
A Look Into an Unconventional BPPV Patient Case
Lealah Fremuth
October 1, 2015

2. My Patient
79 y/o female
Social Hx: retired, widowed, lives alone. Very active in church and independent w/ chores
PMH: migraines, neck pain (previously received PT for cervical radiculopathy)
Current diagnosis: posterior canal BPPV

3. Benign Paroxysmal Positional Vertigo
Most common form of recurrent vertigo: lifetime prevalence rate of 2.4%
Biomechanical problem: one
or more semicircular canals
are inappropriately excited
by displaced otoconia
Characterized by short
episodes of vertigo w/
changes in head position
Causes: idiopathic, head trauma, viral neurolabyrinthitis, Meniere’s, migraines

4. Vestibular Examination
Gait: WNL
Cervical AROM: WNL all planes, asymptomatic
Vertebral artery test: R and L both negative
Side-lying test for BPPV: upbeating rotary nystagmus lasting <45 secs on the R
R posterior canal canalithiasis

5. ICF Model

6. Evaluation Prognosis: Good Goals:
Patient will be independent with progressive HEP in the next 2 weeks
Patient will resume pre-illness level of function after 4 weeks
No episodes of vertigo over the span of 4 weeks
Plan of Care: perform canalith repositioning manuever for affected canal and monitor response

7. Intervention: Day 1 Initial Evaluation
Manuever: Modified Epley for R PSC
Result: significant nausea and emesis, unable to recheck or perform second cycle
Sat for 20 mins w/ cold pack, instructed to come back for additional visit

8. Intervention: Day 2
Subjective: Pt reports symptoms are the same, took Zophran prior to arrival
Manuevers:
Retest positive for R PSC BPPV
Modified Epley x1 for PSC BPPV
Result: Recheck positive, unable to continue tx due to nausea
MD called to suggest Meclizine to facilitate return to baseline

9. Intervention: Day 3
Subjective: Pt feeling better w/ use of Meclizine, also took Zophran prior to arrival
Manuevers:
Retest indicated conversion to HSC BPPV
Casini x1 for HSC BPPV
Results: Recheck positive for HSC BPPV
Pt instructed to sleep on L side (~prolonged positioning technique)

10. Intervention: Day 4 Subjective: Pt reports symptoms are different
“room slowly turning to one side”
Manuevers:
Supine head roll test positive for
HSC BPPV
Casini x3 for HSC BPPV
Results: Recheck negative

11. Intervention: Day 5
Pt reported via phone call that her symptoms no longer persisted.

12. For a 79 year old female patient, is the Epley manuever the treatment most likely to resolve symptoms of PSC BPPV without complications?
Hilton MP, Pinder DK. “The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo” Cochrane Database of Systematic Reviews, 2014.
Anagnostou E, Stamboulis E, Kararizou E.
“Canal conversion after repositioning procedures: comparison of Semont and Epley maneuver.” Journal of Neurology, 2014

13. Cochrane Database of Systematic Reviews, 2014.
The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo.
Hilton MP, Pinder DK.
Cochrane Database of Systematic Reviews, 2014.

14. What is the efficacy of the Epley manuever?
METHODS
Participants: 745 total patients, years old, diagnosed w/ BPPV via Dix-Hallpike test
Design: 11 randomized control trials utilizing the Epley maneuver
Comparison interventions: placebo, untreated controls, other active treatment
Outcome measures: resolution of vertigo symptoms, negative Dix-Hallpike test

15. RESULTS
Statistically significant effect in favor of Epley maneuver over controls
Significantly higher resolution at 7 days when compared to Brandt-Daroff exercises, but no difference found after one month
No difference in comparison to the Semont maneuver or the Gans

16. DISCUSSION & CONSIDERATIONS
Active treatment is the best method of relieving symptoms of posterior canal BPPV
The Epley is comparable to the Semont and Gans, but has a more immediate effect than Brandt-Daroff
Must keep in mind that “the natural history of posterior canal BPPV is for spontaneous resolution over time”
Long-term follow-up was either lacking or inconclusive

17. Anagnostou E, Stamboulis E, Kararizou E.
Canal conversion after repositioning procedures: comparison of Semont and Epley maneuver.
Anagnostou E, Stamboulis E, Kararizou E.
Journal of Neurology, 2014

18. Canal Conversion

19. What is the likelihood of the Epley maneuver producing transitional BPPV?
METHODS
Participants: 102 patients, years old, diagnosed w/ BPPV via Dix-Hallpike test
Design: comparative study
Every second patient was assigned to the Semont group while the others received the Epley
Every patient was only treated once
Outcome measure: Dix-Hallpike test performed 2- 5 hours after treatment

20. RESULTS The Semont maneuver resolved 67% of cases and the Epley 76%
The Epley maneuver led to 4 cases of canal conversion, the Semont produced none
All cases of conversion had switched to horizontal canal BPPV
Patient gender and affected canal side did not exhibit a statistical association with conversion rate

21. DISCUSSION & CONSIDERATIONS
The Epley consists of more steps than the Semont and maintains the patient in a dependent position for a longer period of time  greater odds of particle reentry?
Therapists preferentially using the Epley should be aware that uncleared cases may actually harbor a canal switch
The difference in likelihood for canal conversion is small between the Epley and Semont, but significant enough to remember as a clinical consideration
Uncleared cases/switch  this complication should be explicitly looked for since it implies the need for a different liberation procedure

22. Summary
When treating a patient with PSC BPPV, an active maneuver is significantly the most effective way to resolve symptoms
In terms of initial efficacy, the Semont and Epley maneuvers have the highest success rate, and should be chosen over Brant-Daroff

23. Summary
To prevent transitional BPPV and fully clear the patient with initial treatment, the literature suggests that the Semont maneuver may be most effective
Clinicians should be familiar not only with the commonly used Epley maneuver, but should also pursue continuing education or further practice with the Semont

24. Questions?