BPPV Flashcards
Subjective Exam
-Quality of s/s
-Frequency
-Duration
-Agg/Eas
-Other s/s
Quality: Vertigo
-Illusion of movement
-spinning, rocking, swaying, falling
Frequency and Duration: BPPV
Short Spells: Canal
Long Spells: Cup
-recurring
Aggs and Eases: BPPV
Ag: changing positions or lying or rolling
Eas: holding still for time
Cervical Screen
- Contraindications
- Cervical AROM
- Seated Ext/ROT Test
- Alar, Transverse leg and VBAI Test
Cervical Screen: Contraindications
Ask about Hx of
-neck surgery
-recent trauma
-severe RA, AA or OA instability
-Cervical meylopathy/Radiculopathy
-Carotid sinus syncope
-Chiari malformation
-Vascular dissection
Cervical Screen: Cervical AROM
-flx/ext/SB/ROT (Ds and Ns)
-Rot head and ext head and count back from 10
no overpressure
Cervical Lig and ABI Testing
-verbalize
“I have checked the transverse and alar ligaments as well as the vertebral basilar artery for insufficiency”
BPPV Exam Order
- Subjective
- Clear C-Spine
- Perform Dix-Hallpike (only if cleared)
- Roll Test (if -)
- Side-Lying Test (if -)
- Determine side and canal/cup
Benign Paroxysmal Positional Vertigo: Canalithiasis
Canalithiasis (MC):
-otoconia fall off and free float in PSCC
-latent onset of vertico and nystagmus after provoking
-disappears in 1 min
s/s:
-short spells, recurring
-holding still makes it better
Benign Paroxysmal Positional Vertigo: BPPV
-BPPV
-most common; age, trauma
-crystals from utricle or saccule (MC) fall from utricle into SCC (PSCC MC)
-heavy crystals cause change in endolymph viscosity and fire nerve signals
-top shelf vertigo
-brief vertigo and nystagmus
s/s:
-short spells, recurring
-holding still makes it better
Benign Paroxysmal Positional Vertigo: Cupulolithiasis
Cupulolithiasis:
-otoconia fall off and adhere to cupula of PSCC making cupula denser around endolymph
-immediate vertigo is persistent until head moved
-nystagmus
s/s:
-short spells, recurring
-holding still makes it better
Nystagmus
-non voluntary rhythmic oscillation of eyes
-named by fast phase
-can be suppressed by fixation
-viewed with frenzel or infared goggles
-increases toward fast phase (Alexander’s law)
Physiologic: normal stimuli
Pathologic: abnormal; 4 types
Caused by vestib:
-slow phase caused by VOR
-fast corrective by cerebellum
Caused by CNS:
-smooth pursuit and saccades
Nystagmus: BPPV
BPPV:
-named by torsion (canal) and rotary component toward the lesion
-Upbeat and rotary for PSCC
-direction fixed
Cause:
-canal stimulation and mixed matched
Vertigo
-sensation of the room spinning
BPPV or non-BPPV (anything not canal related)
Determine Canal Involvement
-nystagmus present in provoking positions and gone when return to sitting
Canalithiasis
-free floating debris
-latent onset of s/s
-short term (<1 min)
-Geotropic
Tx: done slowly
Cupulolithiasis
-debris stuck on cupula and constantly firing
-immediate onset and long-lasting s/s in position
-Ageotropic
Tx: done quickly
Dix-Hallpike Test
-for PSSC
-test less affected side first
-Clears VBA first
- Use Frenzels
- Turn head to ipsi 45 deg
- Quickly bring their head down into ext
- Hold for 1 min or until dizziness subsides and look at nystagmus
(+) PSC: upbeat
(+) ASC: downbeat
Ewald’s 1st Law
-for vertical canal BPPV
-eye movements are in the plane of canal stimulated
-opp reaction shown in reversal phase
Posterior Canal: Upbeat
Anterior Canal: Downbeat
Left: Left torsional
Right: Right torsional
Ewald’s 3rd Law
-for vertical canal BPPV
-deflection of the cupula towards the canal affected creates a stronger excitatory response than away
-positional tests move cupula toward canal
Ewald’s 2nd Law
-horizonal canal BPPV and VOR
-excitation creates a greater response than inhibition
-flow towards ampulla creates a stronger response than away
Free floating (canal): turning head towards affected side brings cupula away from canal (stronger)
Stuck (cup): turning head towards non-affecred brigns cupula toward canal (strogner)
Horizontal Canal
-oriented 30 deg upwards and horizontal
-matched with opp HC
-pitch head down 30 to make it parallel to ground
Roll Test
-for HSC
-if DHP is (-), do it immediately after
- Use Frenzels
- Pt slides head down until it’s supported
- Flex head 30deg and support with pillow
- Quickly rotate head to unaffected side first and observe
(+): Geotropic/Canal: ground beating, stronger/faster to affected ear
(+): Ageotropic/Cup: sky beating; stronger/faster to affected ear
Sidelying Test
-for PSC/ASC as alternative to DHP or if DHP and RT are negative
- Pt sitting at edge
- Rotate head to less affected side
- Quickly bring pt’s head down on affected side with nose up
(+) PSC: upbeat, same side of testing side
(+) ASC: Downbeat, opp side of testing side
Precautions to Treatment of Vestibular Disorders
-sudden loss of hearing
-increase in pressure to the point of discomfort
-discharge or fluid from the ear
-severe ringing in ear
Posterior Canal BPPV Treatments
-Canalith Repositioning Maneuver (CRM) (Canal)
-Semont Maneuver (cup)
HEP: Epley
Anterior Canal BPPV Treatments
-Reverse Semont Maneuver (Canal AND Cup)
-Yacovino
Horizontal Canal BPPV Treatments
-BBQ Roll (Canal)
-Gufoni (Cup)
HEP:
-Forced Prolonged Positioning + BBQ roll
-Self-Casani
Brandt-Daroff Habituation
-non specific when maneuvers ineffective BPV
-given as an HEP
not on practical
Canalith Repositioning Maneuver (CRM)
-PSC canalithiasis
- Stay in DHP position until the nausea goes away +30s
- Rotate head slowly to opp side and wait 30s
- Have Pt move to sidelying and pitch head down in dump position while maintaining rotation, wait 30s
- Pt slowly sits up maintaining head position, wait 30s
- Bring head up to neutral, wait 30s
Epley Maneuver (Self-CRM)
-HEP for PSC Canal or Cup
- Pt in long sitting
- Rotate head slowly to same side of impairment, wait 30s
- Lay back maintaining rotation and have head off side of pillow, wait 30s
- Slowly turn head to opposite side, wait 30s
- Slowly turn body in direction and tuck head inttot dump position, wait 30s
- Return to sitting, wait 30s
3x/day until s/s stop for 3 days straight
Semont Maneuver
-PSC Cupulolithiasis
-2 reps in one session
- Pt at edge of table, turn head 45 deg in opp direction of affected side, wait 1 min
- Quickly bring Pt down on affected side with head rotation maintained, wait 1 min
- Quickly move onto opposite side maintaining rotation and flexing head into dump position, wait 1 min
-shake head if no s/s appears and wait 1 min - Slowly come up while maintaining head, wait 1 min
- Head to neutral slowly, wait 1 min
Reverse Semont Maneuver
-ASC Canalithiasis OR Cupulolithiasis
-2 reps in one session
- Pt at edge of table, turn head 45 deg in SAME direction of affected side, wait 1 min
- Quickly bring Pt down on affected side with head rotation maintained and head down into dump position, wait 1 min
- Quickly move onto opposite side maintaining rotation and tilting head up, wait 1 min
-shake head if no s/s appears and wait 1 min - Slowly come up while maintaining head turn to affected side, wait 1 min
- Head to neutral slowly, wait 1 min
HEP for ASC and PSC Cupulolithiasis
-Semont or Reverse Semont
-3-5 reps until 3 days s/s free
BBQ Roll
-HSC Canalithiasis or Geotropic
-wait for s/s to dec + 30s
- Begin in roll test position w/ head turned towards affected and flexed 30 deg, hold for 30s
- Slowly roll head in opposite direction maintaining flexion, wait 30s
- Slowly roll body in direction of head into dump position, wait 30s
- Slowly roll onto Pt stomach while maintaining head position, provide pillow under chest, wait 30s
- Slowly roll patient onto other side maintaining head position, wait 30s
- Slowly sit up maintaining position, wait 30s
- Return to neutral, wait 30s
Casani Maneuver
-HSC Cupulolithiasis or Ageotropic
-2 reps
- Pt sitting at mat in neutral
- Quickly bring patient down onto affected side (opp side of positive testing side), hold for 2 min
- Quickly rotate head upward away from affected side, hold for 2 min
- Slowly return to sitting w/ head position maintained, wait 2 min
- Head to neutral, wait 2 min
HEP for HSC Canalithiasis
-Forced Prolonged Positioning for that night followed by BBQ roll in the morning
-1x/night and bbq roll in morning, 3 days in a row w/o s/s
HEP for HSC Cupulolithias
-Self-Casani
-3-5 reps weeks x3 days
Forced Prolonged Position
-HEP for HSC Canalithiasis
-3 days in a roll
- Laying on affected ear for 1 min
- Lie on back for 1 min
- Quickly roll lying on unaffected ear and sleep in this position (explain way to prop up)
- In the morning finish BBQ roll
