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A Minimum Data Set for Benign Paroxysmal Positional Vertigo


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Title: A Minimum Data Set for Benign Paroxysmal Positional Vertigo

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
  • 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

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

  • 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
  • Sense of insecurity
  • Can be life-long

Giannoni, 2005
  • 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
  • (vonBrevern, 2007)
  • 21 more prevalent in women than men
  • Female prevalence has possible link to migraine
  • (Neuhauser, 2007)

  • 50 Idiopathic
  • Secondary Causes

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

Semicircular Canal Orientation
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
  • 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
  • Described by Hall, 1979.
  • Otolithic debris is free floating in the
  • 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
  • Otoconia particles causing blockage of the
    endolymphatic duct.
  • Causes reduction in flow of endolymphatic fluid
    and increased aural pressure associated with

Becvarovski, 2002
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

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
  • Light
  • Climate
  • Support Relationships
  • Attitudes

  • 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

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

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

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
  • This can be done 2x/week if both ears are

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
  • Observe for torsional nystagmus and record the

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
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
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)

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

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
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.

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
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
  • 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 are selected based on the canal
    affected and suspected cupulolithiasis vs.
  • 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

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.

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
  • The subject then rolls onto the side and the head
    is turned down to the floor (D) prior to sitting

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.

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)

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
  • 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)
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
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
Brandt-Daroff Exercises
  • Home-based exercise to reduce canal sensitivity
    following vertigo episodes involving ant./post.
  • 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.

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)

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

  • 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
  • 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

Fife, 2008
  • Insufficient evidence to support the use of
    post-treatment activity or positioning
  • Insufficient evidence to support the use of
    vestibular suppressant medication in the
    treatment of BPPV.

Fife, 2008
Outcome Measures
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

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.

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

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
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
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
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)

Timed Up and Go
  • Whitney et al. studied the TUG related to
    self-reported falls in persons with vestibular
  • 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
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)

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

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

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.

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

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

  • 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
  • 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

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Image References
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