Transcript BPPV for physical therapy - The Neurology, Psychiatry and Balance

DIAGNOSIS AND
TREATMENT OF BPPV FOR
PHYSICAL THERAPY
JAMES R. BARSKY PT, DPT
CHESTNUT HILL HOSPITAL
NEUROLOGY, PSYCHIATRY AND BALANCE THERAPY CENTER
Pennsylvania Physical Therapy Association Southeastern District Meeting
March 9, 2016
Top of the Hill Physical Therapy
Chestnut Hill Hospital
35 Bethlehem Pike
Philadelphia, PA 19115
DISCLOSURES
• None
OBJECTIVES
• Describe the anatomy and physiology of the vestibular system as it relates to BPPV.
• Identify the typical presentation of patients with BPPV.
• Describe how to diagnose BPPV type based on positional testing results.
• Know how to perform the modified Epley maneuver (canalith repositioning maneuver) for the
treatment of posterior canal BPPV.
• Be aware of the variety positional maneuvers for the treatment different forms of BPPV.
• Identify central nervous system conditions that can be confused with BPPV for the purpose of
differential diagnosis.
• Be able to differently diagnose when central positional nystagmus can’t be due to BPPV.
OVERVIEW
• Introduction and definitions
• Clinically relevant anatomy and physiology of the vestibular system
• Diagnosis of the Types of BPPV
• Treatment of BPPV
• Differential diagnosis of central positional nystagmus and nystagmus from BPPV.
DEFINITIONS
• Dizziness
• Vertigo
• Nystagmus
Dizziness
Spinning or
or whirling
Spinning
whirling
Tilting
Tilting
Rocking
Rocking
Shifting
Shifting
=VERTIGO
Lightheaded
Faint
Woozy
Disequilibrium=
Feeling off balance
Wobbly
Woobly
Dizzy
Giddy
Spacey
Foggy
Off
Not right
Heavy headed
Swimmy
Whooshy
“Blackness behind my
eyes”
“
“
BEWARE OF HOW HEALTH CARE WORKERS USE THE
WORDS DIZZINESS AND VERTIGO
•
Barany Society
•
•
Vertigo- the sensation of motion when no motion is occurring or a distorted sensation of motion
Dizziness- the sensation of disturbed or impaired spacial orientation without a false sense or distorted sense of motion1
• Insurance companies: Dizziness, Giddiness and Vertigo= ICD10 code R42, ICD-9 Code 780.4
• Some physicians and others healthcare providers:
Vertigo=general vestibular pathology i.e. not something
they treat
•
Dizzy Terms- Spinning or
whirling, Rocking, Tilting, Lightheaded, Woozy, Dizzy, Faint, Giddy,
Spacey, Not right, Off, Unsteady, Feeling off balance, Wobbly, Woobly, Head heaviness, Foggy,
Swimmy, Whooshie, Blurry, Blackness behind my eyes
1A.
Bisdorff et al. Classification of vestibular symptoms: Towards an international classification of vestibular disorders. First consensus document of
the Committee for the Classification of Vestibular Disorders of the Barany Society. Journal of Vestibular research. (2009), 19. 1-13
DOCUMENTATION OF NYSTAGMUS
Rhythmic oscillations of the eyes initiated by a slow phase.
• Patient position
• Direction of the fast phase relative to the patient
• Plane
DIRECTION
Plane
Up/Down
Vertical
Right/Left
Horizontal
Right/Left
Torsional
TYPICAL HISTORY FOR THE MOST COMMON
PRESENTATION OF BPPV
• Symptoms: vertigo, may have other dizziness and/or nausea as well.
• Duration: less than a minute.
• Circumstances: large position changes.
•
Lying down
•
Rolling over
•
Sitting up
•
Bending forward/coming upright
•
Extending head back
BPPV ANATOMY AND PHYSIOLOGY
Hain, TC http://www.dizziness-and-balance.com, 1/26/14, http://www.dizziness-and-balance.com/sitedvd.htm
Haines, DE. Fundamental Neuroscience. Churchill Livingston Inc. 1997. Fig 21-3-4.
CANAL ANGLES
A new coordinates system for cranial organs using magnetic resonance imaging. Kazufumi Suzuki , Ai Masukawa , Sachiko Aoki , Yasuko Arai , Eiko Ueno. Acta Oto-Laryngologica Vol. 130, Iss. 5, 2010.
SEMICIRCULAR CANALS ARE CURVILINEAR
Bradshaw, A. P., Curthoys, I. S., Todd, M. J., Magnussen, J. S., Taubman, D. S., Aw, S. T., & Halmagyi, G. M. (2010).
A Mathematical Model of Human Semicircular Canal Geometry: A New Basis for Interpreting Vestibular Physiology. JARO: Journal of the Association for Research in Otolaryngology,11(2), 145–159. doi:10.1007/s10162-009-0195-6
IPSILATERAL HEAD
MOVEMENTS CAUSE
EXCITATION
Vertical Canals: Excited by
endolymph flow away from
the utricle.
Horizontal Canals: Excited
by endolymph flow toward
the utricle.
Richard Rabbitt, PhD, Janet O. Helminski, PT, PhD, Janene Holmberg, PT, DPT, NCS. Translating the Biomechanics of Benign Paroxysmal Positional Vertigo to the Differential Diagnosis and Treatment Combined
Sections Meeting Las Vegas, NV – February 3-6, 2014
VESTIBULAR OCULAR REFLEX AND EWALD’S 1ST LAW
Vestibular Ocular Reflex (VOR)
Ewald’s 1st Law
• For stable vision, eyes will move
equal and opposite to head
movements.
• Eyes will move in the plane of the
canal stimulated.
• Horizontal canals will produce
horizontal movements.
• Vertical canals (anterior and posterior)
will produce vertical and torsional
movements.
https://commons.wikimedia.org/wiki/File:1608_Vestibulo-Ocular_Reflex-02.jpg. 8/25/2015
POSTERIOR CANAL CANALITHIASIS: + DIX-HALLPIKES
Leigh, RJ and Zee, DS. The Neurology of Eye Movements 4th ed. Oxford, NY. Oxford
University Press, 2006.
BPPV EXAMPLES OF
VOR AND EWALD’S 1ST LAW
Bhattacharyya N et al. Otolaryngology -- Head and Neck
Surgery 2008;139:S47-S81
Copyright © by American Academy of Otolaryngology- Head and Neck Surgery
Figure Head and horizontal canal position in the geotropic and apogeotropic variants of
horizontal canal benign paroxysmal positional vertigo (HC-BPPV) affecting the right side The
curved arrows along the canal show the direction of otolithic debris movement after head turn.
Kevin A. Kerber, and Christoph Helmchen Neurology
2012;78:154-156
Copyright © 2012 by AAN Enterprises, Inc.
HORIZONTAL SEMICIRCULAR CANAL BPPV
HSC Canalithiasis
HSC Cupulolithiasis
Kevin A. Kerber, and Christoph Helmchen Neurology
2012;78:154-156
Kevin A. Kerber, and Christoph Helmchen Neurology
2012;78:154-156
BOW AND LEAN TEST
Bow
Lean
Herdman J, Clendanial R. Vestibular Rehabilitation. Forth Ed. Pg 330. F.A. Davis. 2014.
SIT TO SUPINE TEST
BOW AND LEAN
TEST
Balatsouras, D. G., Koukoutsis, G., Ganelis, P., Korres, G. S., & Kaberos, A. (2011). Diagnosis of Single- or Multiple-Canal Benign Paroxysmal Positional Vertigo according to the Type of Nystagmus. International Journal of
Otolaryngology, 2011, 483965. doi:10.1155/2011/483965
TREATMENT
• Positional maneuvers: which maneuver depends on the type and location of the BPPV.
• Education: along with appropriate treatment can help prevent Chronic Subjective Dizziness (CSD/3PD).
• Balance training: if there is any residual imbalance. In my opinion this can also be helpful in preventing
Chronic Subjective Dizziness (CSD/3PD).
“Clinicians should not routinely treat BPPV with vestibular suppressant
medications such as antihistamines or benzodiazepines. Recommendation against
based on observational studies and a preponderance of benefit over harm.” Bhattacharyya et al.
Clinical practice guideline: Benign paroxysmal positional vertigo. Otolaryngol Head Neck SurgNovember 2008 vol. 139 no. 5 supplS47-S81
“There is no evidence to support a recommendation of any medication in the routine
treatment for BPPV” T. D. Fife, MD, D. J. Iverson, MD, T. Lempert, MD, J. M. Furman, MD, PhD, R. W. Baloh, MD, R. J. Tusa, MD, PhD, T. C. Hain, MD, S. Herdman, PT,
PhD, FAPTA, M. J. Morrow, MD and G. S. Gronseth, MD. Practice Parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review)
Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology May 27, 2008 vol. 70 no. 22 2067-2074.
Figure 2 Canalith repositioning procedure
for right-sided benign paroxysmal
positional vertigo Steps 1 and 2 are
identical to the Dix–Hallpike maneuver.
©2008 by Lippincott Williams & Wilkins
T. D. Fife et al. Neurology 2008;70:2067-2074
SELF ADMINISTERED MODIFIED EPLEY
http://npbtc.com/specialties/#bppv
NPBTC.COM
Semont or
Liberatory
maneuver
for posterior
canal BPPV
Lorne S. Parnes, Sumit K. Agrawal, Jason Atlas. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 2003;169(7):681-93
Figure 5 Lempert roll maneuver for right-sided horizontal canal benign paroxysmal positional
vertigo (BPPV) When it is determined to be horizontal canal BPPV affecting the right side, the
patient is taken through a series of step-wise 90-degree turns away from the affected side in
Steps 1 through 5, holding each position for 10 to 30 seconds.
T. D. Fife et al. Neurology 2008;70:2067-2074
©2008 by Lippincott Williams & Wilkins
Appiani maneuver, Gufoni maneuver for HSC canalithiasis, or the liberatory maneuver proposed by Asprella et al in 1999:
for canalithiasis of the posterior (long) arm of the HSC
Ji Soo Kim et al. Neurology 2012;79:700-707
Appiani GC, Catania G, Gagliardi M. A liberatory maneuver for the
treatment of horizontal canal paroxysmal positional vertigo. Otol Neurotol
2001; 22: 66– 69
Casani maneuver, Gufoni maneuver for HSC cupulolithiasis,
modified Semont maneuver: for HSC cupulolithiasis
1. From the seated position, the patient quickly lies down on the
affected side.
2. The head is quickly rotated downward 45 degrees (nose to floor).
3. This position is maintained for 2-3 minutes and then the patient
sits up.
Casani AP1, Vannucci G, Fattori B, Berrettini S. The treatment of horizontal canal positional vertigo: our experience in 66 cases. Laryngoscope. 2002 Jan;112(1):172-8
Gufoni maneuver or Gufoni maneuver for apogeotripic nystagmus: for canalithiasis of the anterior(short) arm of the HSC
J.-S. Kim et al. Neurology 2012;78:159-166
May need to be followed tx for canalithiasis of the posterior (long) arm of the HSSC
Repositioning maneuver for the treatment of the apogeotropic
variant of horizontal canal benign paroxysmal positional vertigo.
Ciniglio Appiani G et al. Otol Neurotol. (2005)
“Kim maneuver”: for HSC
cupulolithiasis on the
amplular and/or utricular
side of the cupula
A cupulolith repositioning maneuver in the treatment of horizontal canal cupulolithiasis
Kim, Sung Huhn et al. Auris Nasus Larynx. 2012 Apr;39(2):163-8.
ANTERIOR CANAL CANALITHIASIS
Maneuver reported by Faldon and Bronstein, 2008: for anterior canal cupulolithiasis
Richard Rabbitt, PhD, University of Utah, Salt Lake City, UT Janet O. Helminski, PT, PhD, Midwestern University, Downers Grove, IL Janene Holmberg, PT, DPT, NCS, Intermountain Hearing and Balance, Salt
Lake City, UT. Translating the Biomechanics of Benign Paroxysmal Positional Vertigo to the Differential Diagnosis and Treatment. Combined Sections Meeting. Las Vegas, NV – February 3-6, 2014.
CENTRAL POSITIONAL NYSTAGMUS VS BPPV
NYSTAGMUS
CENTRAL POSITIONAL
NYSTAGMUS (CPN)
•
Can take on any form depending
on the cause.
•
Does not have to follow Ewald’s
first law, but may look like it does.
•
Patient may or may not have
symptoms with it.
•
May often have associated central
signs, but not necessarily.
•
CPN from lesions in the nodulus
and uvula does not have any
latency and is at its peak initially
and decay’s over time.
CANALITHIASIS
• Nystagmus can have a longer
latency.
• Nystagmus typically will build,
peak, and decay in under a
minute.
• Follows Ewald’s first law.
• Symptoms usually coincide
with the nystagmus.
Jeong-Yoon Choi et al. Central paroxysmal positional
nystagmus: Characteristics and possible mechanisms.
Neurology 2015;84:2238-2246
CUPULOLITHIASIS
• Latancy for nystagmus is brief.
• Nystagmus is persistent, but will
gradually start to decay after
about a minute.
• Follows Ewald’s first law.
• Symptoms usually coincide with
the nystagmus.
Richard Rabbitt, PhD, University of Utah, Salt Lake City, UT Janet O. Helminski, PT,
PhD, Midwestern University, Downers Grove, IL Janene Holmberg, PT, DPT, NCS,
Intermountain Hearing and Balance, Salt Lake City, UT. Translating the
Biomechanics of Benign Paroxysmal Positional Vertigo to the Differential Diagnosis
and Treatment. Combined Sections Meeting. Las Vegas, NV – February 3-6, 2014.
CENTRAL POSITIONAL NYSTAGMUS CAUSES
• Vestibular migraine
• Vertebrobasilar insufficiency
• Infarction, hemorrhage, tumor, MS, Chiari malformation,
olivopontocerebellar atrophy, etc.
Herdman J, Clendanial R. Vestibular Rehabilitation. Forth Ed. Chapter 20. F.A. Davis. 2014.
Figure 2 Origin of ocular motor abnormalities in the symptom-free interval
at initial presentation (n = 60) and on follow-up (n = 61).
Andrea Radtke et al. Neurology 2012;79:1607-1614
Copyright © 2012 by AAN Enterprises, Inc.
Andrea Radtke et al. Neurology 2012;79:1607-1614
CASE OF CF
•
Bow Test: persistent right horizontal nystagmus without
symptoms.
•
Lean Test: persistent right horizontal nystagmus with
symptoms.
•
Right Dix-Hallpike Test: persistent second degree right
horizontal nystagmus with symptoms.
•
Left Dix-Hallpike Test: questionable down beat nystagmus
and questionable left and down beat nystagmus with left
gaze. Increased dizziness with left gaze.
•
Sit to Supine Test: right horizontal nystagmus.
•
Right Supine Roll Test: persistent second degree right
horizontal nystagmus with symptoms.
•
Left Supine Roll Test: persistent down beat nystagmus with
symptoms.
QUESTIONS?