Evidence-Based Practice for the Diagnosis and Treatment of Benign Paroxysmal Positional Vertigo

Transcription

1 Evidence-Based Practice for the Diagnosis and Treatment of Benign Paroxysmal Positional Vertigo Nicole Miranda, PT, DPT Regis University Grand Rounds September 19, 2008

2 Objectives Provide an overview regarding Benign Paroxysmal Positional Vertigo (BPPV). Analyze current evidence and physical therapy practice patterns associated with the diagnosis and treatment of BPPV. Present a rehabilitation plan for diagnosis, treatment and outcome measurement in BPPV.

3 Benign Paroxysmal Positional Vertigo (BPPV) A syndrome characterized by brief vertiginous or spinning sensations elicited following head movement, typically in the vertical or horizontal planes.

4 BPPV Active Phase Brief vertigo attacks that recur with changes in head position Nystagmus typically present Duration of days to weeks Can become chronic Inactive Phase No vertigo or nystagmus Postural disturbance Brief sensations of dizziness or vertigo may persist Sense of insecurity Can be life-long Giannoni, 2005

5 Incidence/Prevalence 0.06% Incidence per year of newly diagnosed cases Retrospective population-based study in Olmstead County, Minnesota 38% increase with each decade of life (Froehling, 1991) 2.4% Lifetime Prevalence Cumulative lifetime incidence nearly 10% by age 80. (vonbrevern, 2007) 2:1 more prevalent in women than men Female prevalence has possible link to migraine (Neuhauser, 2007)

6 Etiology 50% Idiopathic Secondary Causes: Head Trauma Vestibular Neuritis Ménière s Disease Endolymphatic Hydrops Whiplash Injury Labyrinthitis Migraine Auto-immune Ear Disease

7 Inner Ear Anatomy Three semi-circular canals Anterior (Superior), Posterior (Inferior), Horizontal (Lateral) Provide sensory input regarding head velocity Spatial arrangement Each plane is perpendicular to others (like two walls and a floor in a corner) Co-planar pairs: left & right lateral, left anterior & right posterior, right anterior & left posterior

8 Semicircular Canal Orientation

9 Inner Ear Anatomy Hair Cells Located in ampulla of each semi-circular canal and each otolith organ Convert displacement caused by head movement into neural firing Gelatinous membrane covers hair cells Cupula in semi-circular canals Macula in otolith organs Contain calcium carbonate crystals (otoconia) which increase the mass of the macula making them gravity sensitive

10

11 Mechanism of Action in BPPV

12 Cupulolithiasis Introduced by Schuknecht, Displaced otoconia debris adheres to the cupula. Ampulla becomes gravity sensitive. When the affected ear is tipped below the horizon, the cupula is deflected. Vertigo and nystagmus are immediate onset with change in position and persist as long as the head is tipped below the horizon. Herdman, 2000

13 Cupulolithiasis

14 Canalithiasis Described by Hall, Otolithic debris is free floating in the endolymph. As the head is moved, the otoconia travel to the dependent part of the canal. Movement of the endolymph pulls on the cupula and increases firing of the neurons. Latency of symptoms due to the time for the cupula to be deflected. As the endolymph stops moving, symptoms subside. Herdman, 2000

15 Canalithiasis

16 Ductolithiasis Otoconia particles causing blockage of the endolymphatic duct. Causes reduction in flow of endolymphatic fluid and increased aural pressure associated with hydrops. Becvarovski, 2002

17 Impact of BPPV According to the ICF Model Body Function Sensory Function and Pain Sensation of dizziness and vertigo Dizziness Vomiting due to dizziness and vertigo Sensation of falling Body Structure Inner Ear Semicircular canals Brain

18 Impact of BPPV According to ICF Model Activity Participation General Tasks & Demands Mobility Self-Care Domestic Life Interpersonal Interactions & Relationships Major Life Areas Community, Social & Civic Life Environmental Factors Natural Environment & Human Made Changes to the Environment Light Climate Support & Relationships Attitudes

19 Diagnosis

20 Dix-Hallpike Test Gold Standard for diagnosis of Anterior or Posterior Canal BPPV. Starting seated with the neck rotated 45,the person is brought into supine with 30 cervical extension. Observe for torsional nystagmus and record the direction.

21 Dix-Hallpike Test Results Test Result Diagnosis Right Dix-Hallpike Upbeat Torsional Nystagmus Right Posterior Canal BPPV Right Dix-Hallpike Downbeat Torsional Nystagmus Left Anterior Canal BPPV Left Dix-Hallpike Upbeat Torsional Nystagmus Left Posterior Canal BPPV Left Dix-Hallpike Right or Left Dix-Hallpike Downbeat Torsional Nystagmus Lateral Nystagmus; Geotrophic or Ageotrophic Right Anterior Canal BPPV Perform Roll Test to check Horizontal Canal Involvement Right or Left Dix-Hallpike Vertical Nystagmus Central Vertigo: Not BPPV

22 Posterior Canal BPPV 78-96% of cases (Fife, 2008) Posterior canal is a gravity dependent organ in both supine and upright positions. Cupulolithiasis: Immediate onset of vertigo and nystagmus with head below the horizontal; persistent nystagmus. Canalithiasis: Delayed onset of vertigo (15-30 second latency) and nystagmus with head movement; fatigue of nystagmus after sec. Herdman, 2000

23 Anterior Canal BPPV Least often affected canal (1-3%). (Fife, 2008) (Honrubia, 1999) Often linked to structure changes in the canal detected on HR 3D-MRI: Sticky endothelium Filling defect with blockage of the canal (Schratzenstaller, 2005)

24 Roll Test Most often utilized test for Horizontal canal BPPV. Starting in a seated position, rotate the neck 60 toward the tested ear. The person is then assisted into supine, maintaining 20 of cervical flexion. Observe for horizontal nystagmus and record geotrophic or ageotrophic direction.

25 Roll Test Results Test Result Diagnosis Right Roll Test Geotrophic Nystagmus Right Horizontal Canal BPPV; Canalithiasis Right Roll Test Ageotrophic Nystagmus Right Horizontal Canal BPPV; Cupulolithiasis Left Roll Test Geotrophic Nystagmus Left Horizontal Canal BPPV; Canalithiasis Left Roll Test Ageotrophyic Nystagmus Left Horizontal Canal BPPV; Cupulolithiasis Right or Left Roll Test Torsional Nystagmus Perform Dix-Hallpike Test Right of Left Roll Test Vertical Nystagmus Central Nystagmus; Not BPPV

26 Horizontal Canal BPPV Affects 2-15% of cases Nausea and vomiting are commonly associated with episodes of the horizontal canal. Cupulolithiasis: Ageotrophic nystagmus, beating away from the ground. Canalithiasis: Geotrophic nystagmus, beating toward the ground.

27 BPPV without Nystagmus Subjective Vertigo has been defined as symptomatic vertigo during either the Dix- Hallpike or Roll Test without visualization of nystagmus. A diagnosis of subjective vertigo can be made during a right or left Dix-Hallpike or Roll Test, however the specific canal involved or type of BPPV may be vague. Haynes, 2002 Weidner, 1994 Tirelli, 2001

28 Bilateral BPPV More than one canal can be affected. If more than on canal is affected, the intervention is directed toward the more symptomatic ear and all affected canals are documented. Only one affected side can be treated in a session; however if 2 canals are involved on the same side (posterior and horizontal), both may be treated in one session.

29 Interventions

30

31 Interventions Interventions are selected based on the canal affected and suspected cupulolithiasis vs. canalithiasis. Repositioning maneuvers are used to return the otolithic debris to the utricle. BPPV is resolved when observed nystagmus is extinguished during repeat Dix-Hallpike or Roll Test.

32 Epley Maneuver Used to treat posterior and anterior canal BPPV. Typically used to treat canalithiasis. The original Epley maneuver included use of mastoid oscillation on the affected side during the repositioning maneuver as well as use of vestibular suppressant medication.

33 Modified Epley Maneuver (CRP) Positions (A) and (B) are repeated from the Dix- Hallpike exam. The head is then rotated 45 past midline to the opposite side with cervical extension maintained (C). The subject then rolls onto the side and the head is turned down to the floor (D) prior to sitting (E).

34 Post-Maneuver Precautions Historically used in the Epley Maneuver Hours after repositioning Recommendations include: Sleep with head slightly elevated Don t lie on the affected side Limit head motion Lack of evidence supporting use Massoud, 1996

35 Semont Liberatory Maneuver Used to treat cupulolithiasis of the anterior/posterior canal. A brisk movement from sitting to sidelying with the head turned 45 toward the affected side. Subsequent movement to the opposite sidelying position with head maintained in 45 of rotation.

36 Lempert BBQ 360 Roll Used to treat horizontal canal BPPV. Starting in sitting with the head turned 45 toward the affected ear. The person is moved into supine with maintained cervical rotation with the position held 1 min. The head is then rotated 90 to the unaffected side with the position maintained for 1 min. or until symptoms subside. The person then rolls through the unaffected side to prone on elbows, with the position maintained 1 min. or until symptoms subside. The person rolls back to supine through the affected side, head maintained to the affected side for 1 min. Finally the head is rotated to the unaffected side to rest.

37 Modified BBQ Roll Slight modification to technique for use with cupulolithiasis of the horizontal canal. Starting in sitting with the head turned to the affected side. The person is then brought swiftly into supine with the head turned toward the unaffected side and down into cervical extension. The person is then assisted to roll into prone with the head forward off the mat table, followed by rolling back to supine as in the BBQ Roll.

38 Liberatory Maneuver for Horizontal Canal BPPV Used to treat canalithiasis of the horizontal canal variant of BPPV. Starting in sitting at the edge of the mat, the patient is taken into sidelying on the unaffected side for 1 min. The head is moved briskly in a rotational movement to bring the face down to look downward at the floor. Appiani, 2001

39 Brandt-Daroff Exercises Home-based exercise to reduce canal sensitivity following vertigo episodes involving ant./post. canal. Start sitting on the edge of the bed. Lie to one side with the head turned up to the ceiling and hold 30 sec. Return to sit for 30 sec., then lie to the opposite side with head turned to face ceiling for 30 sec.

40 Cranial Oscillation Used to treat suspected ductolithiasis. Positioned in sidelying with the affected ear up, head tilted in a downward lateral tilt 20. Stabilize a vibrator against the mastoid of the upward ear for 30 minutes. 1 time per week for 4 weeks.

41 American Academy of Neurology Quality Standards Subcommittee Recommendations Released 5/28/08.

42 Recommendations Level A recommendation for use of CRP in treatment of posterior canal BPPV Level C recommendation for use of the Semont maneuver for treatment of posterior canal BPPV Fife, 2008

43 Recommendations Level C recommendations regarding the use of mastoid oscillation and Brandt-Daroff exercises in the treatment of posterior canal BPPV Level U recommendations for repositioning maneuvers used to treat horizontal and anterior canal BPPV due to only class IV studies at present. Fife, 2008

44 Recommendations Insufficient evidence to support the use of posttreatment activity or positioning restrictions. Insufficient evidence to support the use of vestibular suppressant medication in the treatment of BPPV. Fife, 2008

45 Outcome Measures

46 Analogue Scales Dizziness 0 = No Dizziness = Bed ridden due to dizziness Nausea 0 = No Nausea = Vomiting

47 Fall History Self report of the number of falls in the 6 months prior to current episode of BPPV. Report of number of falls since the last visit during current treatment.

48 Definition of a Fall Definition of a fall: a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force. (Tinetti, 1998) Definition used by the Medicare Fall Prevention Act

49 Dizziness Handicap Inventory Developed to assess perceived handicap in people with vestibular disorders. 25 items: 9 Functional 9 Emotional 7 Physical 100 points possible, high score indicates increased perceived handicap. Jacobsen, 1990

50 Dizziness Handicap Inventory 5-Item Subscale Looking up Get in and out of bed Quick head motion Turn over in bed Bending over Whitney, 2005

51 Dizziness Handicap Inventory Test-Retest Reliability r = 0.97 Minimum Detectable Change = 18 points 5-Item Subscale Score of 20 produces a likelihood ratio of Specificity of Subscore % Sensitivity of Subscore = % Whitney, 2005

52 Timed Up and Go Gait assessment tool developed to identify fall risk in the elderly. (Podsiadlo, 1991) Rise from a chair, walk 3 meters, turn 180 and return to sit. Time is recorded in seconds. Scores of 13.5 seconds indicate risk of falls. (Shumway-Cook, 2000)

53 Timed Up and Go Whitney et al. studied the TUG related to selfreported falls in persons with vestibular disorders. Specificity of TUG at 11 seconds = 56% PPV = 46%; NPV = 85% Odds Ratio in favor of falling with a TUG of >11 seconds = 5.0 (95% CI ) Whitney, 2004

54 Dynamic Gait Index Developed to assess gait stability in those over 60 at risk for falls. 8 Gait activities with a 4-scoring system (Shumway-Cook, 1995) Score of < 19 identifies risk of falling. (Shumway-Cook, 1997) Inter-rater reliability in persons with vestibular disorders = 0.64; ICC = 0.86 (Hall, Herdman, 2006)

55 Dynamic Gait Index Whitney et al. (2000) studied relationship between the DGI and self reported falls. Score <19 produced an OR of 2.58 in favor of falling (95% CI ) for those >65 with vestibular dysfunction and an OR of 3.55 (95% CI ) for those 65 or less. Whitney et al. (2004) Sensitivity of a score <19 71% Specificity of a score <19 53% PPV of a score <19 39% NPV of a score <19 81%

56 Conclusion Current evidence supports use of the Dix-Hallpike and Roll Test for diagnosis of BPPV. Variable evidence is available to support the use of repositioning maneuvers for the treatment of BPPV. Outcome measures used in BPPV indicate that resolution of vertigo will reduce fall risk, improve gait stability and allow return to previous life activities.

57 References Becvarovski Z, Zappia J, The ZB mastoid oscillation protocol (ZBMOP) in meniere s disease and ductolithiasis. Otolaryngol Head Neck Surg. 2002;127: Dix MR, Hallpike CS. The pathology, symptoms and diagnosis of certain common disorders of the vestibular system. Ann Otol Rhinol Laryngol. 1952:61: Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, TUsa RJ, Hain TC, Herdman S, Morrow JM, Gronseth GS. Practice parameters: Therapies for benign paroxysmal positional vertigo (an evidence-based review). Neurol. 2008;70: Froehling DA, Silverstein MD, Mohr DN, Beatty CW, Oxford KP, Ballard DJ. Benign positional vertigo: incidence and prognosis in a population-based study in Olmsted County, Minnesota, Mayo Clin Proc. 1991;66: Giannoni G, Vannucchi P, Pagnini. Definition and classification of paroxysmal positional vertigo. Audiological Medicine. 2005;3:4-6. Hall CD, Herdman SJ, Reliability of clinical measures used to assess patients with peripheral vestibular disorders. J of Neurol Phys Ther. 2006;30: Hall SF, Ruby RRF, McClure JA. The mechanics of benign paroxysmal positional vertigo. J Otolaryngol. 1979;8: Haynes DS, Resser JR, Labadie FR et al. Treatment of benign positional vertigo using the semont maneuver: efficacy in patients presenting without nystagmus. Laryngoscope. 2002;112:

58 References Herdman SJ, Tusa RJ. Benign Paroxysmal Positional Vertigo. In: Herdman SJ, ed. Vestibular Rehabilitation. Second Edition. Philadelphia, PA. FA Davis Co., 2000: Honrubia V, Baloh RW, Harris MR, et al. Paroxysmal positional vertigo syndrome. Am J Otol. 1999;20: Jacobson GP and Newman DW. The development of the dizziness handicap inventory. Arch Otolarygol Head Neck Surg. 1990;116: Massoud EA, Ireland DJ. Posttreatment of benign paroxysmal positional vertigo: no need for postmaneuver restrictions. J Otolaryngol. 1996;25: Exhauster HK, Epidemioloty of vertigo. Curr Opinion Neurol. 2007;20: Podsiadlo D, Richardson S. The timed up and go: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;671; Schratzenstaller B, Wagner-Manslau C, Strasser G, Arnold W. Canalolithiasis of the superior semicircular canal: an anomaly in benign paryoxysmal vertigo. Acta Oto- Laryongologica. 2005;125: Schuknecht HF. Cululolithiasis. Arch Otolaryngol. 1969;90: Shumway-Cook A, Woollacott M. Motor Control Theory and Applications. Williams and Wilkins Baltimore, 1995.

59 References Shumway-Cook A, Bladwin M, POlissar NL, Bruber W, Predicting the probability for falls in community-dwelling older adults. Phys Ther. 1997;77: Shumwas-Cook A, Brauer S, Woollacott M. Predicting the probability of falls in the community-dwelling older adults using the timed up & go test. Phys Ther. 2000;80: Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Eng J Med. 1998;319: Tirelli G, D Orlandao E, Giacomarra V, Russolo M. Benign positional vertigo without detectable nystagmus. Laryngoscope. 2001;111: Weider DJ, Ryder DJ, Stram JR. Benign paroxysmal positional vertigo; analysis of 44 cases treated by the canalith respositioning procedure of Epley. Am J Otol. 1994;15: Whitney SL, Hudak MT, Marchetti GF. The dynamic gait index relates to self-reported fall history in individuals with vestibular dysfunction. J Vest Research. 2000;10: Whitney SL, Marchetti GF, Schade A, Wrisley DM. The sensitivity and specificity of the timed up & go and the dynamic gait index for self-reported falls in persons with vestibular disorders, J Vestib Research. 2004;14: Whitney SL, Marchetti GF, Morris LO. Usefulness of the dizziness handicap inventory in the screening for benign paroxysmal positional vertigo. Otology & Neurology. 2005;26:

60 Image References Hain TC. Benign Paroxysmal Positional Vertigo Available at: Accessed on May 23, Brandt-Daroff Exercises. American Hearing Research Foundation. Available at: Accessed June 15, Canalithiasis. Available at: Accessed on June 15, Cupulolithiasis. Available at: Accessed on June 15, Illusion Spinning. Available at: Accessed June 15, RealEyes goggles and camera Monocular Configuration. Avilable at: Accessed on June 15, The International Classification of Function. The World Health Organization. Available at: Accessed on June 15, 2008.

61