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

Dizziness Spinning or whirling Tilting Rocking Shifting Lightheaded =VERTIGO Spinning or whirling Tilting Rocking Shifting Lightheaded Faint Woozy Disequilibrium= Feeling off balance Wobbly Woobly Dizzy Giddy Spacey Foggy Off Not right Heavy headed Swimmy Whooshy “Blackness behind my eyes” “ “

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 Insurance companies: Dizziness, Giddiness and Vertigo= ICD-10 code R42, ICD-9 Code 780.4 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 Rhythmic oscillations of the eyes initiated by a slow phase. Patient position Direction of the fast phase relative to the patient Plane

Plane Direction 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. Duration: less than a minute. Circumstances: large position changes. Lying down Rolling over Sitting up Bending forward/coming upright Extending head back

BPPV Anatomy and Physiology Hain, TC http://www.dizziness-and-balance.com, 1/26/14, http://www.dizziness-and-balance.com/sitedvd.htm

Haines, DE. Fundamental Neuroscience. Churchill Livingston Inc. 1997 Haines, DE. Fundamental Neuroscience. Churchill Livingston Inc. 1997. Fig 21-3-4.

Canal angles Range (min/max) 27.7/43.9 39.7/58.5 79.5/107.4for AC&SP PC&SP HC&SP respectively A new coordinates system for cranial organs using magnetic resonance imaging. Kazufumi Suzuki , Ai Masukawa , Sachiko Aoki , Yasuko Arai , Eiko Ueno. Acta Oto-Laryngologica Vol. 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 toward the utricle. The ampulla contains the cupula with the hair cells projecting into it and each ampulla is set anteriorly in the head to relative to the rest of the canal. These structures are organized in such a way that ipsilateral head movements cause excitation, e.g. … That structure results in the vertical canals being exited by movement of endolymph and the cupula away utricle and the horizontal canals being excited by movement of endolymph and the cupula toward the 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. https://commons.wikimedia.org/wiki/File:1608_Vestibulo-Ocular_Reflex-02.jpg. 8/25/2015

Posterior canal canalithiasis: + Dix-hallpikes Leigh, RJ and Zee, DS. The Neurology of Eye Movements 4th ed. Oxford, NY. Oxford University Press, 2006.

BPPV examples of VOR and Ewald’s 1st law Bhattacharyya N et al. Otolaryngology -- Head and Neck Surgery 2008;139:S47-S81 Copyright © by American Academy of Otolaryngology- Head and Neck Surgery

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. 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. A.a and B.a demonstrate debris position within the canal when a patient with right HC-BPPV is lying supine. A.b and B.b demonstrate debris movement, the different effects on the cupula, and the direction of the fast phase of horizontal nystagmus when the patient turns to the right side. The size of the arrow in front of the subject's nose also indicates nystagmus intensity (amplitude). The density of lines in the afferent vestibular nerve indicates the firing rate which accounts for the stronger nystagmus when debris moves toward the cupula (ampullopetal) as opposed to away from it (ampullofugal). A.c and B.c demonstrate debris movement, the effect on the cupula, and the direction of the fast phase of horizontal nystagmus when the patient turns the head to the left side. (From: Nuti D, Mandala M, Salerni L. Lateral canal paroxysmal positional vertigo revisited. Ann NY Acad Sci 2009;1163:316–323.)‏ Kevin A. Kerber, and Christoph Helmchen Neurology 2012;78:154-156 Copyright © 2012 by AAN Enterprises, Inc.

Horizontal semicircular canal bppv HSC Canalithiasis HSC Cupulolithiasis

Kevin A. Kerber, and Christoph Helmchen Neurology 2012;78:154-156

Kevin A. Kerber, and Christoph Helmchen Neurology 2012;78:154-156

Bow and lean test Lean Bow If you saw geotropic nystagmus in supine roll test, then the nystagmus from the bow test will beat toward the affected side. If you apogeotropic nystagmus in the supine roll test, then the nystagmus from the lean test will beat toward the affected side. Herdman J, Clendanial R. Vestibular Rehabilitation. Forth Ed. Pg 330. F.A. Davis. 2014.

Bow and lean test SIT TO SUPINE TEST 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

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. Figure 2 Canalith repositioning procedure for right-sided benign paroxysmal positional vertigo Steps 1 and 2 are identical to the Dix–Hallpike maneuver. The patient is held in the right head hanging position (Step 2) for 20 to 30 seconds, and then in Step 3 the head is turned 90 degrees toward the unaffected side. Step 3 is held for 20 to 30 seconds before turning the head another 90 degrees (Step 4) so the head is nearly in the face-down position. Step 4 is held for 20 to 30 seconds, and then the patient is brought to the sitting up position. The movement of the otolith material within the labyrinth is depicted with each step, showing how otoliths are moved from the semicircular canal to the vestibule. Although it is advisable for the examiner to guide the patient through these steps, it is the patient’s head position that is the key to a successful treatment. ©2008 by Lippincott Williams & Wilkins T. D. Fife et al. Neurology 2008;70:2067-2074

Self administered modified eplEy http://npbtc.com/specialties/#bppv NPBTC.COM

Semont or Liberatory maneuver for posterior canal BPPV Semont maneuver for right-sided benign paroxysmal positional vertigo While sitting up in Step 1, the patient’s head is turned 45 degrees toward the left side, and then the patient is rapidly moved to the side-lying position as depicted in Step 2. This position is held for 30 seconds or so, and then the patient is rapidly taken to the opposite side-lying position without pausing in the sitting position or changing the head position relative to the shoulder. This is in contrast to the Brandt–Daroff exercises that entail pausing in the sitting position and turning the head with body position changes Lorne S. Parnes, Sumit K. Agrawal, Jason Atlas. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 2003;169(7):681-93

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. 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. From Step 5, the patient positions his or her body to the back (6) in preparation for the rapid and simultaneous movement from the supine face up to the sitting position (7). T. D. Fife et al. Neurology 2008;70:2067-2074 ©2008 by Lippincott Williams & Wilkins

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 For the Gufoni maneuver,14,22 the patient is quickly brought down on the healthy side from the sitting position and remained in this position until the geotropic nystagmus stops plus another 1 minute. Then the head is turned about 45° down, so that the nose is on the bed. After 2 minutes in this position, the patient is returned to the upright position. Appiani GC, Catania G, Gagliardi M. A liberatory maneuver for the treatment of horizontal canal paroxysmal positional vertigo. Otol Neurotol 2001; 22: 66– 69 Ji Soo Kim et al. Neurology 2012;79:700-707

Casani maneuver, Gufoni maneuver for HSC cupulolithiasis, modified Semont maneuver: for HSC cupulolithiasis From the seated position, the patient quickly lies down on the affected side. The head is quickly rotated downward 45 degrees (nose to floor). This position is maintained for 2-3 minutes and then the patient sits up. 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

Gufoni maneuver or Gufoni maneuver for apogeotripic nystagmus: for canalithiasis of the anterior(short) arm of the HSC The patient is quickly brought down to the side-lying position on the affected ear from the sitting position. Wait there until 1 minute after the apogeotropic nystagmus has ended. The head of the patient is then quickly turned 45° upward, so that the nose directed upward. Approximately 2 minutes, the patient is returned to the upright position. J.-S. Kim et al. Neurology 2012;78:159-166 May need to be followed tx for canalithiasis of the posterior (long) arm of the HSSC Repositioning maneuver for the treatment of the apogeotropic variant of horizontal canal benign paroxysmal positional vertigo. Ciniglio Appiani G et al. Otol Neurotol. (2005)

“Kim maneuver”: for HSC cupulolithiasis on the amplular and/or utricular side of the cupula A cupulolith repositioning maneuver in the treatment of horizontal canal cupulolithiasis Kim, Sung Huhn et al. Auris Nasus Larynx. 2012 Apr;39(2):163-8.

Anterior canal canalithiasis

Maneuver reported by Faldon and Bronstein, 2008: for anterior canal cupulolithiasis 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.

Central positional nystagmus VS BPPV nystagmus CUPULOLITHIASIS CENTRAL POSITIONAL NYSTAGMUS (CPN) 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. 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. 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 nodulus and uvula does not have any latency and is at its peak initially and decay’s over time. Jeong-Yoon Choi et al. Central paroxysmal positional nystagmus: Characteristics and possible mechanisms. Neurology 2015;84:2238-2246 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.

Central positional nystagmus Causes Vestibular migraine Vertebrobasilar insufficiency Infarction, hemorrhage, tumor, MS, Chiari malformation, olivopontocerebellar atrophy, etc. Herdman J, Clendanial R. Vestibular Rehabilitation. Forth Ed. Chapter 20. F.A. Davis. 2014.

Figure 2 Origin of ocular motor abnormalities in the symptom-free interval at initial presentation (n = 60) and on follow-up (n = 61). Origin of ocular motor abnormalities in the symptom-free interval at initial presentation (n = 60) and on follow-up (n = 61)‏ Andrea Radtke et al. Neurology 2012;79:1607-1614 Andrea Radtke et al. Neurology 2012;79:1607-1614 Copyright © 2012 by AAN Enterprises, Inc.

Case of Cf 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.

Questions?