Diagnosis and Treatment of BPPV for PT 3/9/2016 James R. Barsky, PT, DPT www.npbtc.com 1 DIAGNOSIS AND TREATMENT OF BPPV FOR PHYSICAL THERAPY JAMES R. BARSKY PT, DPT CHESTNUT HILL HOSPITAL NEUROLOGY, PSYCHIATRY AND BALANCE THERAPY CENTER Pennsylvania Physical Therapy Association Southeastern District Meeting March 9, 2016 Top of the Hill Physical Therapy Chestnut Hill Hospital 35 Bethlehem Pike Philadelphia, PA 19115 DISCLOSURES • None OBJECTIVES • Describe the anatomy and physiology of the vestibular system as it relates to BPPV. • Identify the typical presentation of patients with BPPV. • Describe how to diagnose BPPV type based on positional testing results. • Know how to perform the modified Epley maneuver (canalith repositioning maneuver) for the treatment of posterior canal BPPV. • Be aware of the variety positional maneuvers for the treatment different forms of BPPV. • Identify central nervous system conditions that can be confused with BPPV for the purpose of differential diagnosis. • Be able to differently diagnose when central positional nystagmus can’t be due to BPPV. OVERVIEW • Introduction and definitions • Clinically relevant anatomy and physiology of the vestibular system • Diagnosis of the Types of BPPV • Treatment of BPPV • Differential diagnosis of central positional nystagmus and nystagmus from BPPV. DEFINITIONS • Dizziness • Vertigo • Nystagmus Lightheaded Faint Woozy Disequilibrium= Feeling off balance Wobbly Woobly Dizzy Giddy Spacey Foggy Off Not right Heavy headed Swimmy Whooshy “Blackness behind my eyes” “ “ Spinning or whirling Tilting Rocking Shifting =VERTIGO Dizziness The BPPV videos on it along with many other excellent videos can be found on Dr. Timothy C. Hain’s website http://www.dizziness-and-balance.com/sitedvd.htm
Transcript
Diagnosis and Treatment of BPPV for PT 3/9/2016
James R. Barsky, PT, DPTwww.npbtc.com 1
DIAGNOSIS AND TREATMENT OF BPPV FOR
PHYSICAL THERAPY
JAMES R. BARSKY PT, DPT
CHESTNUT HILL HOSPITAL
NEUROLOGY, PSYCHIATRY AND BALANCE THERAPY CENTER
Pennsylvania Physical Therapy Association Southeastern District MeetingMarch 9, 2016
Top of the Hill Physical TherapyChestnut Hill Hospital35 Bethlehem Pike
Philadelphia, PA 19115
DISCLOSURES
• None
OBJECTIVES
• Describe the anatomy and physiology of the vestibular system as it relates to BPPV.
• Identify the typical presentation of patients with BPPV.
• Describe how to diagnose BPPV type based on positional testing results.
• Know how to perform the modified Epley maneuver (canalith repositioning maneuver) for the treatment of posterior canal BPPV.
• Be aware of the variety positional maneuvers for the treatment different forms of BPPV.
• Identify central nervous system conditions that can be confused with BPPV for the purpose ofdifferential diagnosis.
• Be able to differently diagnose when central positional nystagmus can’t be due to BPPV.
OVERVIEW
• Introduction and definitions
• Clinically relevant anatomy and physiology of the vestibular system
• Diagnosis of the Types of BPPV
• Treatment of BPPV
• Differential diagnosis of central positional nystagmus and nystagmus from BPPV.
DEFINITIONS
• Dizziness
• Vertigo
• Nystagmus
Spinning or whirlingTiltingRockingShiftingLightheadedFaintWoozyDisequilibrium=
Feeling off balanceWobblyWoobly
DizzyGiddySpaceyFoggyOffNot rightHeavy headedSwimmyWhooshy“Blackness behind my eyes”
“ “
Spinning or whirlingTiltingRockingShifting
=VERTIGO
Dizziness
The BPPV videos on it along with many other excellent videos can be found on Dr. Timothy C. Hain’s website http://www.dizziness-and-balance.com/sitedvd.htm
Diagnosis and Treatment of BPPV for PT 3/9/2016
James R. Barsky, PT, DPTwww.npbtc.com 2
BEWARE OF HOW HEALTH CARE WORKERS USE THE WORDS DIZZINESS AND VERTIGO
• Barany Society• Vertigo‐ the sensation of motion when no motion is occurring or a distorted sensation of motion• Dizziness‐ the sensation of disturbed or impaired spacial orientation without a false sense or distorted sense of motion1
• Some physicians and others healthcare providers: Vertigo=general vestibular pathology i.e. not something they treat
• Dizzy Terms‐ Spinning or whirling, Rocking, Tilting, Lightheaded, Woozy, Dizzy, Faint, Giddy, Spacey, Not right, Off, Unsteady, Feeling off balance, Wobbly, Woobly, Head heaviness, Foggy, Swimmy, Whooshie, Blurry, Blackness behind my eyes
1A. Bisdorff et al. Classification of vestibular symptoms: Towards an international classification of vestibular disorders. First consensus document of the Committee for the Classification of Vestibular Disorders of the Barany Society. Journal of Vestibular research. (2009), 19. 1‐13
DOCUMENTATION OF NYSTAGMUS
• Patient position
• Direction of the fast phase relative to the patient
• Plane
Rhythmic oscillations of the eyes initiated by a slow phase.
DIRECTION Plane
Up/Down Vertical
Right/Left Horizontal
Right/Left Torsional
TYPICAL HISTORY FOR THE MOST COMMON PRESENTATION OF BPPV
• Symptoms: vertigo, may have other dizziness and/or nausea as well.
Haines, DE. Fundamental Neuroscience. Churchill Livingston Inc. 1997. Fig 21-3-4.
Diagnosis and Treatment of BPPV for PT 3/9/2016
James R. Barsky, PT, DPTwww.npbtc.com 3
CANAL ANGLES
A new coordinates system for cranial organs using magnetic resonance imaging. Kazufumi Suzuki , Ai Masukawa , Sachiko Aoki , Yasuko Arai , Eiko Ueno. Acta Oto‐LaryngologicaVol. 130, Iss. 5, 2010.
SEMICIRCULAR CANALS ARE CURVILINEAR
Bradshaw, A. P., Curthoys, I. S., Todd, M. J., Magnussen, J. S., Taubman, D. S., Aw, S. T., & Halmagyi, G. M. (2010). A Mathematical Model of Human Semicircular Canal Geometry: A New Basis for Interpreting Vestibular Physiology. JARO: Journal of the Association for Research in Otolaryngology,11(2), 145–159. doi:10.1007/s10162‐009‐0195‐6
IPSILATERAL HEAD MOVEMENTS CAUSE EXCITATION
Vertical Canals: Excited by endolymph flow away from the utricle.
Horizontal Canals: Excited by endolymph flow towardthe utricle.
Richard Rabbitt, PhD, Janet O. Helminski, PT, PhD, Janene Holmberg, PT, DPT, NCS. Translating the Biomechanics of Benign Paroxysmal Positional Vertigo to the Differential Diagnosis and Treatment Combined Sections Meeting Las Vegas, NV – February 3‐6, 2014
VESTIBULAR OCULAR REFLEX AND EWALD’S 1ST LAW
Vestibular Ocular Reflex (VOR)
• For stable vision, eyes will move equal and opposite to head movements.
Ewald’s 1st Law
• Eyes will move in the plane of the canal stimulated.
• Horizontal canals will produce horizontal movements.
• Vertical canals (anterior and posterior) will produce vertical and torsional movements.
Figure Head and horizontal canal position in the geotropic and apogeotropic variants of horizontal canal benign paroxysmal positional vertigo (HC-BPPV) affecting the right side The
curved arrows along the canal show the direction of otolithic debris movement after head turn.
Kevin A. Kerber, and Christoph Helmchen Neurology 2012;78:154-156
Balatsouras, D. G., Koukoutsis, G., Ganelis, P., Korres, G. S., & Kaberos, A. (2011). Diagnosis of Single‐ or Multiple‐Canal Benign Paroxysmal Positional Vertigo according to the Type of Nystagmus. International Journal of Otolaryngology, 2011, 483965. doi:10.1155/2011/483965
Diagnosis and Treatment of BPPV for PT 3/9/2016
James R. Barsky, PT, DPTwww.npbtc.com 5
TREATMENT
• Positional maneuvers: which maneuver depends on the type and location of the BPPV.
• Education: along with appropriate treatment can help prevent Chronic Subjective Dizziness (CSD/3PD).
• Balance training: if there is any residual imbalance. In my opinion this can also be helpful in preventing Chronic Subjective Dizziness (CSD/3PD).
“Clinicians should not routinely treat BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines. Recommendation against based on observational studies and a preponderance of benefit over harm.” Bhattacharyya et al. Clinical practice guideline: Benign paroxysmal positional vertigo. Otolaryngol Head Neck SurgNovember 2008 vol. 139 no. 5 supplS47‐S81
“There is no evidence to support a recommendation of any medication in the routine treatment for BPPV” T. D. Fife, MD, D. J. Iverson, MD, T. Lempert, MD, J. M. Furman, MD, PhD, R. W. Baloh, MD, R. J. Tusa, MD, PhD, T. C. Hain, MD, S. Herdman, PT,
PhD, FAPTA, M. J. Morrow, MD and G. S. Gronseth, MD. Practice Parameter: Therapies for benign paroxysmal positional vertigo (an evidence‐based review)Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology May 27, 2008 vol. 70 no. 22 2067‐2074.
Figure 2 Canalith repositioning procedure for right-sided benign paroxysmal
positional vertigo Steps 1 and 2 are identical to the Dix–Hallpike maneuver.
Lorne S. Parnes, Sumit K. Agrawal, Jason Atlas. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 2003;169(7):681‐93
Semont or Liberatorymaneuver for posterior canal BPPV
Figure 5 Lempert roll maneuver for right-sided horizontal canal benign paroxysmal positional vertigo (BPPV) When it is determined to be horizontal canal BPPV affecting the right side, the patient is taken through a series of step-wise 90-degree turns away from the affected side in
Steps 1 through 5, holding each position for 10 to 30 seconds.
Appiani maneuver, Gufoni maneuver for HSC canalithiasis, or the liberatory maneuver proposed by Asprella et al in 1999: for canalithiasis of the posterior (long) arm of the HSC
Appiani GC, Catania G, Gagliardi M. A liberatory maneuver for the treatment of horizontal canal paroxysmal positional vertigo. Otol Neurotol2001; 22: 66– 69
Diagnosis and Treatment of BPPV for PT 3/9/2016
James R. Barsky, PT, DPTwww.npbtc.com 6
1. From the seated position, the patient quickly lies down on the affected side.
2. The head is quickly rotated downward 45 degrees (nose to floor).
3. This position is maintained for 2‐3 minutes and then the patient sits up.
Casani maneuver, Gufoni maneuver for HSC cupulolithiasis, modified Semont maneuver: for HSC cupulolithiasis
Casani AP1, Vannucci G, Fattori B, Berrettini S. The treatment of horizontal canal positional vertigo: our experience in 66 cases. Laryngoscope. 2002 Jan;112(1):172‐8
J.-S. Kim et al. Neurology 2012;78:159-166
Gufoni maneuver or Gufoni maneuver for apogeotripic nystagmus: for canalithiasis of the anterior(short) arm of the HSC
May need to be followed tx for canalithiasis of the posterior (long) arm of the HSSC Repositioning maneuver for the treatment of the apogeotropicvariant of horizontal canal benign paroxysmal positional vertigo. Ciniglio Appiani G et al. Otol Neurotol. (2005)
A cupulolith repositioning maneuver in the treatment of horizontal canal cupulolithiasisKim, Sung Huhn et al. Auris Nasus Larynx. 2012 Apr;39(2):163‐8.
“Kim maneuver”: for HSC cupulolithiasis on the amplular and/or utricularside of the cupula
ANTERIOR CANAL CANALITHIASIS
Richard Rabbitt, PhD, University of Utah, Salt Lake City, UT Janet O. Helminski, PT, PhD, Midwestern University, Downers Grove, IL Janene Holmberg, PT, DPT, NCS, Intermountain Hearing and Balance, Salt Lake City, UT. Translating the Biomechanics of Benign Paroxysmal Positional Vertigo to the Differential Diagnosis and Treatment. Combined Sections Meeting. Las Vegas, NV – February 3‐6, 2014.
Maneuver reported by Faldon and Bronstein, 2008: for anterior canal cupulolithiasis
CENTRAL POSITIONAL NYSTAGMUS VS BPPV NYSTAGMUSCENTRAL POSITIONAL NYSTAGMUS (CPN)
• Can take on any form depending on the cause.
• Does not have to follow Ewald’s first law, but may look like it does.
• Patient may or may not have symptoms with it.
• May often have associated central signs, but not necessarily.
• CPN from lesions in the nodulusand uvula does not have any latency and is at its peak initially and decay’s over time.
CUPULOLITHIASIS
• Latancy for nystagmus is brief.
• Nystagmus is persistent, but will gradually start to decay after about a minute.
• Follows Ewald’s first law.
• Symptoms usually coincide with the nystagmus.
CANALITHIASIS
• Nystagmus can have a longer latency.
• Nystagmus typically will build, peak, and decay in under a minute.
• Follows Ewald’s first law.
• Symptoms usually coincide with the nystagmus.
Richard Rabbitt, PhD, University of Utah, Salt Lake City, UT Janet O. Helminski, PT, PhD, Midwestern University, Downers Grove, IL Janene Holmberg, PT, DPT, NCS, Intermountain Hearing and Balance, Salt Lake City, UT. Translating the Biomechanics of Benign Paroxysmal Positional Vertigo to the Differential Diagnosis and Treatment. Combined Sections Meeting. Las Vegas, NV – February 3‐6, 2014.
Jeong‐Yoon Choi et al. Central paroxysmal positional nystagmus: Characteristics and possible mechanisms. Neurology 2015;84:2238‐2246
Diagnosis and Treatment of BPPV for PT 3/9/2016
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CENTRAL POSITIONAL NYSTAGMUS CAUSES
• Vestibular migraine
• Vertebrobasilar insufficiency
• Infarction, hemorrhage, tumor, MS, Chiari malformation, olivopontocerebellar atrophy, etc.
• Bow Test: persistent right horizontal nystagmus without symptoms.
• Lean Test: persistent right horizontal nystagmus with symptoms.
• Right Dix‐Hallpike Test: persistent second degree right horizontal nystagmus with symptoms.
• Left Dix‐Hallpike Test: questionable down beat nystagmus and questionable left and down beat nystagmus with left gaze. Increased dizziness with left gaze.
• Sit to Supine Test: right horizontal nystagmus.
• Right Supine Roll Test: persistent second degree right horizontal nystagmus with symptoms.
• Left Supine Roll Test: persistent down beat nystagmus with symptoms.
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