A Minimum Data Set for Benign Paroxysmal Positional Vertigo

1
A Minimum Data Set for Benign Paroxysmal
Positional Vertigo

• Nicole Miranda, PT, MPT
• Regis University
• Advanced Clinical Decision Making
• DPT 740
• June 2008

Faculty Advisors Amy Stone Hammerich, PT,
DPT Julie Whitman, PT, DScPT
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Objectives

• Provide an overview regarding Benign Paroxysmal
  Positional Vertigo (BPPV).
• Analyze current evidence and physical therapy
  practice patterns associated with BPPV.
• Present a protocol and Minimum Data Set (MDS) for
  diagnosis, treatment and outcome measurement in
  BPPV.

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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.

www.mobile-pedia.com/.../illusion_Spinning.png
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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
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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)
• 21 more prevalent in women than men
• Female prevalence has possible link to migraine
• (Neuhauser, 2007)

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Etiology

• 50 Idiopathic
• Secondary Causes

?Head Trauma ? Whiplash Injury
? Vestibular Neuritis ? Labyrinthitis
? Ménières Disease ? Migraine
? Endolymphatic Hydrops ? Auto-immune Ear Disease
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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

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Semicircular Canal Orientation
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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

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Mechanism of Action in BPPV
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Cupulolithiasis

• Introduced by Schuknecht, 1969.
• 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
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Cupulolithiasis
www.micromedical.com
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Canalithiasis

• Described by Hall, 1979.
• 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
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Canalithiasis
www.micromedical.com
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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
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Impact of BPPVAccording 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

www.who.int/classification.icf
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Impact of BPPVAccording 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

www.who.int/classification.icf
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Purpose

• Utilize a protocol for the evaluation and
  treatment of BPPV to ensure proper identification
  of canal involvement and intervention selection
  with outcome measurement.
• Create a Minimum Data Set (MDS) to clinically
  analyze the effectiveness of physical therapy
  diagnosis, intervention and outcome measurement
  in individuals with BPPV.
• More effectively manage patients with BPPV and
  identify those with chronic vertigo, persistent
  vertigo or resistance to conservative therapeutic
  intervention.

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Protocol

• South Valley Physical Therapy, P.C.
• Centennial, CO
• and
• Barbara Esses, M.D., Neurotology
• Denver Ear Associates

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Phase I

• PT Evaluation to determine canal involvement.
• Up to 3 sessions of PT to perform repositioning
  maneuvers.
• If unable to clear the vertigo/nystagmus after 3
  visits, the physician is notified to allow the
  possibility of further medical work-up.

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Phase II

• Upon return from MD or after consultation between
  the PT and MD.
• Resume treatment with presumed ductolithiasis or
  canalith jam.
• Begin cranial oscillation one time per week for 4
  weeks.
• This can be done 2x/week if both ears are
  involved.

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Diagnosis
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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.

www.dizziness-and-balance.com
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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 Downbeat Torsional Nystagmus Right Anterior Canal BPPV
Right or Left Dix-Hallpike Lateral Nystagmus Geotrophic or Ageotrophic Perform Roll Test to check Horizontal Canal Involvement
Right or Left Dix-Hallpike Vertical Nystagmus Central Vertigo Not BPPV
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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 30-60 sec.

Herdman, 2000
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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)

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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.

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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
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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.

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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
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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.

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Interventions
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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.

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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.

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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).

www.dizziness-and-balance.com
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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.

www.thieme-connect.com
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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.

• (Link to video on hard drive)

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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.

(Link to video clip on hard drive)
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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.

• (Link to video clip on hard drive)

Appiani, 2001
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Post-Maneuver Precautions

• Historically used in the Epley Maneuver
• 24-48 Hours after repositioning
• Recommendations include
• Sleep with head slightly elevated
• Dont lie on the affected side
• Limit head motion
• Lack of evidence supporting use

Massoud, 1996
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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.

www.american-hearing.org
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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.

• (Link to video clip on hard drive)

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American Academy of Neurology

• Quality Standards Subcommittee
• Recommendations Released 5/28/08.

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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
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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
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Recommendations

• Insufficient evidence to support the use of
  post-treatment activity or positioning
  restrictions.
• Insufficient evidence to support the use of
  vestibular suppressant medication in the
  treatment of BPPV.

Fife, 2008
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Outcome Measures
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Analogue Scales

• Dizziness
• 0 No Dizziness
• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10 Bed ridden due to dizziness

• Nausea
• 0 No Nausea
• 1
• 2
• 3
• 4
• 5
• 6
• 7
• 8
• 9
• 10 Vomiting

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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.

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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

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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
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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
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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 2.29.
• Specificity of Subscore 18 93.8
• Sensitivity of Subscore 0 97.6

Whitney, 2005
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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)

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Timed Up and Go

• Whitney et al. studied the TUG related to
  self-reported 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 gt11
  seconds 5.0 (95 CI 1.80-13.91)

Whitney, 2004
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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 lt 19 identifies risk of falling.
• (Shumway-Cook, 1997)
• Inter-rater reliability in persons with
  vestibular disorders 0.64 ICC 0.86
• (Hall, Herdman, 2006)

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Dynamic Gait Index

• Whitney et al. (2000) studied relationship
  between the DGI and self reported falls.
• Score lt19 produced an OR of 2.58 in favor of
  falling (95 CI 1.47-4.53) for those gt65 with
  vestibular dysfunction and an OR of 3.55 (95 CI
  1.53-5.26) for those 65 or less.
• Whitney et al. (2004)
• Sensitivity of a score lt19 71
• Specificity of a score lt19 53
• PPV of a score lt19 39
• NPV of a score lt19 81

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Minimum Data Set

• (In a formal presentation, the MDS form would be
  opened and presented or distributed as a handout)

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The Next Step

• Implement the MDS to clinically analyze a
  protocol for diagnosing, providing intervention
  and tracking outcomes in BPPV.
• Determine whether the MDS and protocol are able
  to guide successful resolution of BPPV with
  implementation of 2 intervention phases.
• Utilize the MDS and protocol to determine
  appropriateness for referral back to MD.

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The First Steps

• Brief clinical analysis to determine adjustments
  needed to current MDS form and data collection
  forms.
• Submission to IRB to allow movement toward
  clinical trial.
• Application for research grant to obtain Infrared
  goggles for accurate visualization of nystagmus.

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• Clinical Trials are needed as current evidence
  supports use of repositioning maneuvers to cure
  BPPV.
• The question is.
• Single Blind or
• Double Blind???

http//www.micromedical.com/goggles.htm
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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.
• Use of the proposed protocol and MDS could help
  identify resistance to physical therapy
  intervention with reduction in cost and prompt
  referral to MD.
• Outcome measures used in BPPV indicate that
  resolution of vertigo will reduce fall risk,
  improve gait stability and allow return to life
  activities.

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