Cross Country Education Leading the Way in Continuing Education and Professional Development.

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1 To comply with professional boards/associations standards: I declare that I or my family do not have any financial relationship in any amount, occurring in the last 12 months with a commercial interest whose products or services are discussed in my presentation. Additionally, all planners involved do not have any financial relationship. Requirements for successful completion are attendance for the full session along with a completed session evaluation form. Cross Country Education and all current accreditation statuses does not imply endorsement of any commercial products displayed in conjunction with this activity. Advances in the Treatment of Benign Paroxysmal Positional Vertigo Chris Carpino, MPT Cross Country Education Leading the Way in Continuing Education and Professional Development. 1 Advances in the Treatment of Benign Paroxysmal Positional Vertigo Christopher R. Carpino Benign Paroxysmal Positional Vertigo Most common peripheral vestibular disorder Common in patients over 40 y/o Affects 50% of patients 70 and over More common in females Can spontaneously recover in weeks to months 1

2 Review of the Anatomy & Physiology of the Vestibular System Vestibular Anatomy Vestibular Anatomy Otolith Organs Sensitive to linear movement Utricle-sensitive to horizontal movement Saccule- sensitive to vertical movement Semicircular Canals Sensitive to angular movement 2

3 Utricle & Saccule Hair cells are embedded within gelatinous mass Hair cells are mechanically sensitive nerve endings of vestibular nerve Otoliths (otoconia) add weight to gelatinous mass 3

4 Semicircular Canals Ampulla & Cupula 4

5 Ampulla & Cupula Ipsilateral Side Cupula & hair cells deflected opposite head movement and toward its utricle Excitation of vestibular nerve Contralateral Side Cupula & hair cells deflected opposite head movement and away its utricle Inhibition of vestibular nerve Anterior Semicircular Canal Posterior Semicircular Canal 5

6 Horizontal Semicircular Canal Semicircular Canals Horizontal SC 30 posterior tilt Anterior & Posterior SCs 90 from each other ipsilaterally In same plane contralaterally Benign Paroxysmal Positional Vertigo Most common peripheral vestibular disorder Common in patients over 40 y/o Affects 50% of patients 70 and over More common in females Can spontaneously recover in weeks to months 6

7 Benign Paroxysmal Positional Vertigo Canalithiasis Free floating otoliths second symptom onset Duration seconds Treat with Epley Maneuver Cupulolithiasis Ot lith tt h d t l Hallpike-Dix Maneuver Test used to diagnose BPPV A positive test is a reproduction of symptoms that subside within 30 seconds +/- Assess for a vertebral artery test (VAT) prior to testing if the patient is elderly Vertebral Artery Test 1. Lean forward with arms on lap 2. Rotate head maximally to one side 3. Chin up (maximal cervical extension Look for: Nystagmus/Vertigo Dysarthria Pupillary Dilation Diaphoresis Syncope 7

8 Hallpike-Dix Maneuver Begin with the patient in long sitting Rotate cervical spine 45 toward test side Extend cervical spine 30 Hallpike-Dix Manuever Bring the patient into supine Head must be off edge of surface Maintain cervical rotation and extension Fully Supported Hallpike-Dix Maneuver Used if VAT is positive or if excessive cervical extension is contraindicated Place pillow behind scapulae Have patient rotate cervical spine maximally toward test side 8

9 Fully Supported Hallpike-Dix Maneuver Take patient into supine Maintain cervical rotation Patient s head remains on table Roll Test Begin with the patient in supine and head flexed degrees Roll Test Roll the patient to one side Take note of time of onset and duration of nystagmus 9

10 Lateral Hallpike-Dix Maneuver Alternative to Roll Test Not velocity-dependent Also biases Horizontal SC Begin with patient seated No cervical rotation Lateral Hallpike-Dix Maneuver Take patient into sidelying (toward testing side) Maintain neutral cervical rotation Take note of symptom reproduction, nystagmus direction and duration Semicircular Canal Test Anterior/Posterior SC Hallpike-Dix Fully Supported Hallpike-Dix Horizontal SC Roll Test Lateral Hallpike-Dix 10

11 Canalith Repositioning Canalith Repositioning Epley Maneuver Fully Supported Epley Maneuver Semont-Liberatory Manuever Apiani Manuever Cassani Manuever Gufoni Manuever Epley Maneuver- Posterior Canal Begin with patient in long sitting 11

12 Epley Maneuver- Posterior Canal Move client to supine with head rotated toward involved side 45 and neck extended Epley Maneuver- Posterior Canal Slowly rotate head 45 toward uninvolved side, maintaining neck in extension Epley Maneuver- Posterior Canal Have client slowly roll to sidelying with uninvolved side down. Maintain head in 45 rotation toward uninvolved side with face dowm Head shaking or vibration applied to mastiod is optional 12

13 Epley Maneuver- Posterior Canal Gently return client to sitting Have client turn head forward and down (tip) Fully Supported Epley Maneuver Alternative to Epley for Posterior SC Used if VAT is positive Begin with client sitting and cervical rotation toward involved side Place pillow behind scapulae Fully Supported Epley Maneuver Bring client gently into supine Head remains on treatment surface Maintain cervical rotation toward involved side Hold one minute 13

14 Fully Supported Epley Maneuver Rotate client s cervical 45 degrees (or maximally) toward opposite side Hold one minute Fully Supported Epley Maneuver Bring client into sidelying Maintain cervical rotation toward uninvolved side with face down Shaking or mastoid vibration is optional Hold 1 minute Fully Supported Epley Maneuver Gently bring patient into sitting position Client looks forward and down (tip) 14

15 BBQ Roll- Epley Horizontal SC Begin with client in supine Cervical Spine flexed Rotate head 45 toward uninvolved side BBQ Roll- Epley Horizontal SC Slowly rotate head to neutral Maintain cervical spine flexed BBQ Roll- Epley Horizontal SC Gently rotate head toward involved side Maintain cervical spine flexed

16 BBQ Roll- Epley Horizontal SC Continue until client is prone with head is face down Maintain cervical spine flexed Appiani Maneuver Begin with client in sitting, neutral cervical rotation Appiani Maneuver Client is taken into sidelying, toward uninvolved side Maintain neutral cervical rotation Hold one minute 16

17 Appiani Maneuver Cervical spine is then rotated downward Hold one minute Patient then returns to sitting upon completion Casani Maneuver Begin with client in sitting, neutral cervical rotation Casani Maneuver Client is taken into sidelying, toward involved side Maintain neutral cervical rotation Hold one minute 17

18 Casani Maneuver Cervical spine is then rotated downward Hold one minute Patient then returns to sitting upon completion Liberatory Maneuver Utilized in cupulolithiasis of anterior or posterior SC Also appropriate substitute for Epley Maneuver Also referred to as Semont Maneuver Begin with client seated Head is rotated 45 toward uninvolved side Liberatory Maneuver Client then quickly lies to involved side Head is maintained at 45 rotation toward uninvolved side 18

19 Liberatory Maneuver Client then quickly moves to opposite side with face down Head remains 45 rotated toward uninvolved side Liberatory Maneuver Client slowly returns to seated position Hybrid Maneuver Similar to Semont- Liberatory Maneuver Adequate option for patients with lumbar spondylosis, degeneration Begin with client seated Head is rotated 45 toward uninvolved side 19

20 Hybrid Maneuver Client then quickly lies to involved side Head is maintained at 45 rotation toward uninvolved side Hybrid Maneuver Rapidly roll patient to opposite side Head remains 45 rotated toward uninvolved side, patient is face down Post Repositioning Instructions Patient should sleep upright (head over body) for 48 hours Avoid excessive head motion (bending, looking up) Avoid prolonged cervical flexion or extension 20

21 Quick Guide Nystagmus Location of Pathology Treatment Upbeating Left Left Posterior SCC Epley Downbeating Right Right Anterior SCC Left Posterior Upbeating Right Right Posterior SCC Epley Downbeating Left Left Anterior SCC Right Posterior Lateral Left Left Horizontal SCC BBQ Roll Lateral Right Right Horizontal SCC Appiani or Casani 62 21