2004/12/6 EBM The treatment of acute vertigo Cesarani A, Alpini D, Monti B, Raponi G Neurol Sci 2004;24:S26-30.

2004/12/6 EBM Introduction Vertigo and dizziness are very common symptoms in the general population Prevalence rate: 5~10% Particularly common in the individuals over 40 years of age The first reason for a medical visit in patients over 65 years

2004/12/6 EBM Two main group of acute vertigo –Spontaneous vertigo –Provoked vertigo ( paroxysmal positional vertigo, PPV, BPPV )

2004/12/6 EBM Acute spontaneous vertigo acute spontaneous unilateral vestibular failure, which means sudden asymmetrical vestibular functioning. 4 stages –Stage 1: irritation –Stage 2: sudden loss of paralysis of the system –Stage 3: central compensation –Stage 4: recovery

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Early phase –Nausea and vomiting –Rotatory vertigo is present in every position of the head and body, slightly less when lying on the SS. –The first mechanism of recovery is internuclear inhibition of the vestibular responses. –Pharmacotherapy vs physical therapy Stage1&2

2004/12/6 EBM Aims of therapy Decreasing the neurovegetative S/S Decreasing antigravitary failure of the affected side Decreasing oscillopsia due to nystagmus Decreasing internuclear inhibition that decreases progression of functional compensation Activating sensory substitution phenomena Re-activating coordination Decreasing spatial disorientation ( vertigo)

2004/12/6 EBM Pharmacotherapy

2004/12/6 EBM Physical therapy Vestibular electrical stimulation ( VES) Exercise

2004/12/6 EBM Vestibular Electrical Stimulation The first step of physical therapy Aimed to reduce antigravity failure and to increase proprioceptive cervical sensory substitution. TENS; on paravertebral muscle opposite to the affected side and on the trapezius of the affected side. At 1 hr per day at least The first half hour: p ’ t lye on the SS, in the light, and try to keep their eyes open The other half hour: practice activities in upright position and walking during VES

2004/12/6 EBM Exercise in bed Twice a day, mins per session

2004/12/6 EBM Exercise in sitting (1) Performed during VES and wearing visual prisms (saccade)

2004/12/6 EBM Exercise in sitting (2)

2004/12/6 EBM Paroxysmal Positional Vertigo (1) Sudden attacks of vertigo precipitated by certain head positions. Rolling over in the bed,reaching for an object from the top shelf, washing the hair … Vertigo is of short duration ( < 1min ) Etiology: –Litiasis theory, originally describe by Schucknecht in1974 Degeneration of the salt-like crystals (otoliths) in the utricle which break free and float into or attach to semicircular canals. –Proprioceptive mismatch btw the general proprioception (from muscles, ligament and joints) and special proprioception (from maculae and cristae); spino-cerebello-vestibular circuitry.

2004/12/6 EBM Paroxysmal Positional Vertigo (2) Two main types –Dix-Hallpike maneuver elicited Head hyperextension and rotation to AS Induced typical horizontal-rotatory geotropic (towards the ground) nystagmus Nystagmus appears some seconds delay Habituation phenomena –MacClure maneuver elicited P ’ t supine, rolling the head from side to side Pure horizontal geotropic and ageotropic nystagmus

2004/12/6 EBM Treatment for PPV Semont maneuver Epley maneuver Personal maneuver for PPV elicited by Dix- Hallpike positioning ( Epley modified) Lempert maneuver horizontal semicircular lithiasis post. Semicircular canal lithiasis 80~90%effective

2004/12/6 EBM Semont maneuver 1 & 4 2 眼睛朝上看 3 眼睛朝下看  Right ear lat canal PPV 1.Head turn towards left side(SS) 2.Lying on R side, head is rotated upward 105°, 3mins 3.Lying on L side, head is rotated downward 195°, 3 mins 4.Slowly sit-up 頭朝左轉 (video 1)

2004/12/6 EBM Epley maneuver  Left ear post. Canal PPV Head rotate to left 45° Each stage wait 30 s (video 2)

2004/12/6 EBM Modified Epley  Left ear BPPV 30 sec

2004/12/6 EBM Lempert maneuver 30~60 sec  Right ear PPV

2004/12/6 EBM Thank you for your attention