DIAGNOSIS AND TREATMENT OF BPPV FOR PHYSICAL THERAPY

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 Rocking 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 motion 1 • Insurance companies: Dizziness, Giddiness and Vertigo= ICD 10 code R 42, 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 1 A. 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/s 10162 -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, Ph. D, Janet O. Helminski, PT, Ph. D, 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 1 ST LAW Vestibular Ocular Reflex (VOR) Ewald’s 1 st 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 CANALITHIASIS: + DIX-HALLPIKES Leigh, RJ and Zee, DS. The Neurology of Eye Movements 4 th ed. Oxford, NY. Oxford University Press, 2006.

BPPV EXAMPLES OF VOR AND EWALD’S 1 ST LAW Bhattacharyya N et al. Otolaryngology

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

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/3 PD). • Balance training: if there is any residual imbalance. In my opinion this can also be helpful in preventing Chronic Subjective Dizziness (CSD/3 PD). “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 Surg. November 2008 vol. 139 no. 5 suppl. S 47 -S 81 “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, Ph. D, R. W. Baloh, MD, R. J. Tusa, MD, Ph. D, T. C. Hain, MD, S. Herdman, PT, Ph. D, 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 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 AP 1, 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 May need to be followed tx for canalithiasis of the posterior (long) arm of the HSSC J. -S. Kim et al. Neurology 2012; 78: 159 -166 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 CANALITHIASIS

Maneuver reported by Faldon and Bronstein, 2008: for anterior canal cupulolithiasis Richard Rabbitt, Ph. D, University of Utah, Salt Lake City, UT Janet O. Helminski, PT, Ph. D, 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. CANALITHIASIS • Nystagmus can have a longer latency. • Does not have to follow Ewald’s first law, but may look like it does. • Nystagmus typically will build, peak, and decay in under a minute. • Patient may or may not have symptoms with it. • Follows Ewald’s first law. • 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. • 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, Ph. D, University of Utah, Salt Lake City, UT Janet O. Helminski, PT, Ph. D, 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?