Transcript Assessment and Treatment of the Dizzy/Balance Patient

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
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Statistics/Facts of dizziness and
imbalance
Inner ear causes for dizziness and
imbalance
Testing available for
dizziness/imbalance
BPPV: Evaluation and Treatment
BPPV
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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
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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
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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
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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
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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
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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
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Benign Paroxysmal Positioning Vertigo
Vestibular Neuronitis
Labyrinthitis
Meniere’s disease
Vestibular Migraine
Labyrinthine ischemia
Perilymphatic fistula
Acoustic neuroma
Taking a Complete History
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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
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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
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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 reeducation.
VEMP – VESTIBULAR MYOGENIC
POTENTIAL
VEMP
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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
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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)
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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
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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
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Vertigo of short duration
Balance problems
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May last for hours or days following the
episodic vertigo
Swimming sensation
Nausea
Inability to concentrate, floating,
blurred vision
BPPV
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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
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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
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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 )
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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
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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
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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
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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
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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
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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.
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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.
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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
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Goals of PT
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Decrease symptoms of dizziness and
improve balance in order to return
patient to the highest level of function
possible
Physical Therapy evaluation
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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
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Balance exercises
Gait training
VOR exercises
Habituation exercises
Sensory substitution exercises
Repositioning maneuvers for BPPV
Physical Therapy Treatment cont.
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Equipment recommendations
Fall prevention
General strengthening/flexibility
Patients who can benefit from VRT
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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
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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.
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# of PT patient visits
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Goals
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1-3 visits, only one with more 7 visits
Typically three – five goals including
home program
Goals met
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75-100% of goals met at discharge
Implications
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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
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Studies have shown that 85% of
patient treated with VRT showed
reduction of symptoms and
reduction in disability score
Tools for screening
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Hearing handicap Inventory for the
Elderly
Balance function self test
Computerized Dynamic
Posturography
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Battery of tests that helps assess the
functional capacity of the balance disorder
patient
SOT – Sensory organization test
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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
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Assesses for loss of VOR vestibular ocular
reflex
Dynamic Posturography
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Add to ability to identify specific
problems which affect balance
Used for assessment, treatment,
and to measure progress as a result
of treatment
CONCLUSION
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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