Assessment and Treatment of the Dizzy/Balance Patient with BPPV Mary Horsch, Audiologist Barbara Newby, Physical Therapist Via Christi Rehabilitation Hospital

Benign Paroxysmal Positioning Vertigo Statistics/Facts of dizziness and imbalance Inner ear causes for dizziness and imbalance Testing available for dizziness/imbalance BPPV: Evaluation and Treatment

BPPV Case Studies Physical Therapist Role Management Outcomes

STATISTICS How many people are affected by vertigo/dizziness/imbalance? This is difficult to quantify in part because symptoms are difficult to describe and differences exist in the qualifying criteria within and across studies.

STATISTICS Broad based demographic studies consistently show that vestibular disorders are under diagnosed and under treated.

FACTS ABOUT BALANCE From 2001 through 2004, 35.4% of adults in the US age 40 years and older had vestibular dysfunction (69 million Americans).1 Dizziness is a common symptom affecting about 30% of people over the age of 65.2

FACTS ABOUT BALANCE Approximately 4% (almost 8 million) of American adults report a chronic problems (lasting 3 months or longer) with balance. U.S. physicians reported 5,417,000 patient visits in 1991 because of dizziness and vertigo.4

FACTS ABOUT BALANCE A majority of individuals over 70 report problems of dizziness and imbalance and balance related falls account for more than one-half of the accidental deaths in the elderly.1

Facts Continued Hip fractures are one of the most common orthopedic injuries for elderly Americans. Many of these hip fractures are related to balance disorders. According to the National Institutes of Health, 42 percent of people will visit their doctor because of dizziness at least once in their lifetime.

Facts Continued Each year, more than 450,000 people receive head injuries. Fifty-eight percent of people who have had a traumatic brain injury complain of dizziness one to three months after the injury.

CAUSES OF DIZZINESS

Some Causes of Dizziness Related to the Inner Ear Benign Paroxysmal Positioning Vertigo Vestibular Neuronitis Labyrinthitis Meniere’s disease Vestibular Migraine Labyrinthine ischemia Perilymphatic fistula Acoustic neuroma

Taking a Complete History The patient needs to describe their dizziness without using the word “dizzy.” Depending if the patient describes light headedness while walking vs. true vertigo with change in position can help determine where and what the issue may be.

Assessment by Audiologist Videonystagmography Electrocochleography Auditory Brainstem Response Rotary Chair Computerized Dynamic Posturography VEMP

VIDEONYSTAGMOGRAPHY A study of the digitally recorded changes in movements of the eye, used to assess nystagmus and to aid in separating vestibular and oculomotor deficits of the CNS, from deficits of the peripheral vestibular system.

ELECTROCOCHLEOGRAPHY A test that measures the electrical potentials generated in the inner ear in response to stimulation by sound. Electrocochleography may be done, for example, to confirm the diagnosis of Meniere’s disease.

AUDITORY BRAINSTEM RESPONSE Used in the evaluation of hearing integrity as well as defining normal neurologic synchrony along the VIII the nerve to brainstem.

ROTARY CHAIR

ROTARY CHAIR Evaluates the vestibulo-ocular reflex (VOR) which is a reflex eye movement that stabilizes images on the retina during head movement by producing an eye movement in the direction opposite to head movement, thus preserving the image on the center of the visual field.

COMPUTERIZED DYNAMIC POSTUROGRAPHY

COMPUTERIZED DYNAMIC POSTUROGRAPHY A non-invasive specialized clinical assessment technique used to quantify the central nervous system adaptive mechanisms (sensory, motor and central) involved in the control of posture and balance particularly in the diagnosis of balance disorders and postural re-education.

VEMP – VESTIBULAR MYOGENIC POTENTIAL

VEMP The purpose of the VEMP test is to determine if the saccule, one portion of the otoliths, as well the inferior vestibular nerve and central connections, are intact and working normally.

BPPV What is it?

BPPV Benign Paroxysmal Positional Vertigo is described as a brief, intense spinning sensation that occurs with a specific change in head position.

Benign Paroxysmal Positional Vertigo (BPPV) Benign: not a very serious or progressive condition Paroxysmal: sudden and unpredictable in onset Positional: comes with a change in head position Vertigo: causing a sense of dizziness.

BPPV Most common type of peripheral vertigo Patient will average 4.5 physician visits prior to obtaining the proper diagnosis Can be seen in patient’s following head injury, vestibular neuronitis, surgeries, Meniere’s or can be present alone Characterized by vertigo lasting for a few seconds following head movement

BPPV Movements that provoke symptoms Lying down or getting up Rolling over in bed Bending over Looking up Going to the dentist or beauty shop

Complaints of Patients with BPPV Vertigo of short duration Balance problems May last for hours or days following the episodic vertigo Swimming sensation Nausea Inability to concentrate, floating, blurred vision

BPPV Degeneration of calcium carbonate crystals (otoliths) in the utricle which break free and become lodged in the semi-circular canals Six canals – most commonly affecting the posterior Semi-circular canal, then horizontal canal(3-9%), least frequently the Anterior canal (less than 2%).

Canalolithiasis Theory The most widely accepted theory of the pathophysiology of BPPV Otoliths (calcium carbonate particles) are normally attached to a membrane inside the utricle and saccule The utricle is connected to the semicircular ducts These otoliths may become displaced from the utricle to enter the posterior semicircular duct since this is the most dependent of the 3 ducts Changing head position relative to gravity causes the free otoliths to gravitate longitudinally through the canal. The concurrent flow of endolymph stimulates the hair cells of the affected semicircular canal, causing vertigo.

The Inner Ear Semicircular Canals

BPPV - Length of time between onset of symptoms and evaluation Less than one month 1-3 months 4-12 months 13-36 months 37-60 months Over 60 months 8% 24% 26% 14% 7 % 13%

Treatment of BPPV The primary questions which should be asked are: Which is the involved ear or is it bilateral? Which canal is involved? Is it canalithiasis or cupulolithiasis?

Canalithiasis / Cupulolithiasis In Cupulolithiasis the debris is adhering to the cupula rather than free floating in the long process of the posterior canal. Often the debris must be dislodged from the cupula so that it can then be allowed to return to the utricle and dissolve.

BPPV Evaluating for BPPV Dix Hallpike Horizontal Head Roll

The Dix-Hallpike test – To Determine Posterior or Anterior Involvement

Canalith Repositioning Procedure ( CRP ) The treatment of choice for BPPV. Also known as the Epley maneuver, The patient is positioned in a series of steps so as to slowly move the otoconia particles from the posterior semicircular canal back into the utricle. Takes approximately 5 minutes. The patient is instructed to wear a neck brace for 24 hours and to not bend down or lay flat for 24 hours after the procedure. One week after the CRP, the Dix-Hallpike test is repeated. If the patient does experience vertigo and nystagmus, then the CRP is repeated with a vibrator placed on the skull in order to better dislodge the otoconia.

To Evaluate for Horizontal Canal BPPV

TREATMENT OF HORIZONAL CANAL BPPV The "log roll" exercises Liberatory Maneuver Appiani and associates (2001) Modified Brandt-Daroff

Clinical Trial Ruckenstein (2001) Therapeutic efficacy of the Epley canalith repositioning maneuver. Laryngoscope Eighty-six patients 74% of cases that were treated with one or two canalith repositioning maneuvers had a resolution of vertigo as a direct result of the maneuver. A resolution attributable to the first intervention was obtained in 70% of cases within 48 hours of the maneuver. An additional 14% of cases that were treated had a resolution of vertigo. Only 4% of cases (three patients) manifested BPV that persisted after four treatments.

Case study 1 82 year old female admitted through ER following a fall Patient reported episodes of dizziness beginning in 1988. The dizziness lasts for a few seconds and is associated with a change of position No ear symptoms

Diagnostics completed CT of head ECG 2 dimensional echo EKG Telemetry Portable chest Carotid duplex sonogram

Case study 1 cont. On third day following admission, Audiology consult initiated Audiology findings, Positive Dix Hallpike to right consistent with BPPV affecting the right posterior canal, treatment completed patient discharged Treatment repeated 2 weeks following hospital discharge Visit 3, patient no longer has any symptoms of dizziness

Case Study 2 48 year old female, ARNP for FP doc Extreme vertigo with movement, especially looking up to the right VNG negative for all but BPPV Treatment with Semont and Epley maneuver x 2 by audiologist Symptom free, return to all normal activities

Case Study 3 – PHYSICAL THERAPY Patient saw Audiology for sudden onset of vertigo. Positive for BPPV. Symptoms did not completely resolve after Epley. Patient is elderly with macular degeneration and has had several falls as a result of dysequilibrium. Patient was referred to PT to follow up on BPPV and fall risk.

Case Study 3 cont. Patient’s PT eval revealed continued vertigo and imbalance. Positive for BPPV as well as some gait unsteadiness with turns. Treated with Epley with resolution of symptoms. Follow up visit, still has positive Hallpike. Vibration prior to Epley.

Case Study 3 cont. Third visit: patient had no vertigo. Able to do quick turns without difficulty. Patient reports balance is back to prior level. Right Hallpike negative.

Physical Therapy Management for the Dizzy/Balance patient Goals of PT Decrease symptoms of dizziness and improve balance in order to return patient to the highest level of function possible

Physical Therapy evaluation Strength Range of Motion Sensation Static balance testing Dynamic balance testing including gait Sensory organization testing VOR testing Motion sensitivity testing BPPV screening if not seen by Audiology Computerized balance testing

Physical Therapy Treatment Balance exercises Gait training VOR exercises Habituation exercises Sensory substitution exercises Repositioning maneuvers for BPPV

Physical Therapy Treatment cont. Equipment recommendations Fall prevention General strengthening/flexibility

Patients who can benefit from VRT Inner ear disorders with Unilateral or bilateral involvement BPPV Central nervous system disorder with balance problems such as multiple sclerosis, stroke, brain injury Multideficit vertigo of the geriatric patient Other patients with balance problems or history of falls

Patient outcomes Group of 13 patients with history of balance problems VNG testing done on all patients PT Evaluations found specific problems with gaze stabilization, motion provoked dizziness, dizziness with head movement when walking, static and dynamic balance deficits

Patient outcomes cont. # of PT patient visits Goals Goals met 1-3 visits, only one with more 7 visits Goals Typically three – five goals including home program Goals met 75-100% of goals met at discharge

Implications Patients with dizziness, imbalance can return to normal function with proper diagnosis and vestibular rehabilitation with physical therapy directed treatment Other studies have shown VRT exercises highly facilitate recovery, improve postural stability and diminish perception of disequilibrium in patients

Outcomes Studies have shown that 85% of patient treated with VRT showed reduction of symptoms and reduction in disability score

Tools for screening Hearing handicap Inventory for the Elderly Balance function self test

Computerized Dynamic Posturography Battery of tests that helps assess the functional capacity of the balance disorder patient SOT – Sensory organization test Objectively identifies abnormalities in the patient’s use of the three sensory systems that contribute to postural control Motor control test Dynamic Visual Acuity test Assesses for loss of VOR vestibular ocular reflex

Dynamic Posturography Add to ability to identify specific problems which affect balance Used for assessment, treatment, and to measure progress as a result of treatment

CONCLUSION BPPV is the most common finding of those with a complaint of vertigo BPPV is easily identified with simple maneuvering techniques BPPV is easily treated in most cases with specific maneuvers in one visit