BPPV Flashcards
BPPV - what does it stand for
Benign Paroxysmal Positional Vertigo
What is BPPV
Recurrent positional vertigo and nystagmus occuring when the head is placed in certain positions
BPPV - evoked by
Changes with respect to gravity (such as rolling over in bed or looking up to a shelf)
BPPV - initial occurance usually experienced when
upon awakening in the morning and night rather than on first laying down
What is vertigo
An illusion of movement, most commonly a sense of spinning
Vertigo and Nystagmus - begin… and will last…
Begin after a latency of 3-4 seconds
Will last from 1-40 seconds
Vertigo and Nystagmus - fatigue
Will fatigue with repetition
BPPV - how long before it goes away
Usually spontaneously disappears after a few weeks
If no tx it may persist for months to eyars
BPPV - reoccurence
in 18-50% of patients
Characteristics of patients with BPPV
ADL scores are lower in those with BPPV Higher percentage of falls More incidence of depression May have abnormal postural reactions Usually learn to avoid whatever position causes their vertigo
Nystagmus
Eye jumping
Otoconia
Small Ca carbonate crystals derived from utricle
ear debris
Utricle
A small sac like structure of the inner ear
Primarily used for postural stability
Cupula
Apex of cochlea
Endolymph
Fluid in the semicircular canals
Moves freely in response to direction of angular movement
As it moves, it bends hair cells on cupula
Semicircular canals
Three canals of the bony labyrinth of the inner ear
Ant, Post, Horizontal
Each respond to movement in own plane
Filled with endolymph
Signals primarily used for gaze stability
Two theories of cause of BPPV
Cupulolithiasis theory
Canalithiasis theory
Cupulolithiasis theory
Fragments of otoconia break away from the utricle and adhere to the cupula of a semicircular canal
When head is moved into certain positions, the weighted cupula is deflected by the pull of gravity and this leads to vertigo and nystagmus
Problems with the cupulolithiasis theory
If it was the weighted down cupula that caused vertigo and nystagmus then it would persist as long as the person was in the provoking position
Canalithiasis theory
There are fragments of the otoconia freely floating around in one of the SC
When pt changes head position, the pull of gravity causes the otoconia to move within the canal
This mvmnt results in movement of endolymph, which deflects the cupula
Canalithiasis theory continued - repeat positioning maneuvers does what
would disperse the otoconia thorughout the canal where its movement would still shift the endolymph but be so far dispersed that it does not cause deflection of the cupula
Canalithiasis theory - accounts for what
the short duration of nystagmus upon position change
Semicircular Canal involved with BPPV - most frequent cause of BPPV is what
a mechanical disorder in the posterior semicircular canal - upbeating and torsional nystagmus
Semicircular canal involved with BPPV - what is rarer
Horizontal and anterior semicircular canal impairment are much rarer
Horizontal - horizontal nystagmus
Anterior - down beating and torsional nystagmus
How is BPPV Diagnosed
A hx of vertigo and a physical exam showing nystagmus during these tests
Hallpike Dix maneuver
EMG
Hallpike Dix
Pt is moved from sitting with their head rotated 45 degrees to one side, to a supine position of 30 degrees extension with 45 degrees rotation
Brandt Daroff Exercises
Also used as a diagnostic test Pt moves quickly from the seated position to the side lying position Pt returns to seated Pt repeats to opposite side Return to sitting Check nystagmus in all positions
Frenzel goggles
Magnify the patients eyes making nystagmus easier to observe
Also prevent patient from fixating on an object to supress the nystagmus
Prior to treating a patient with BPPV a PT should determine
What positional changes cause vertigo
Any associated balance problems
Any conditions like neck pain
Documentation of vertigo
Latency, duration, and intensity should be documented for each position change
Can scale 1 to 5 or 1 to 10
Goals for patients with BPPV
Replace the otoconia into the vestibule
Reduce the vertigo associated with head motion
Improve balance
Return to daily activities involving head motion
Educate the patient about self treatment strategies
Medical tx of BPPV
No medication has been proven to to beffective to rid a person of BPPV
Surgical tx of BPPV
Posterior canal plugging - blocks the post canal function without affecting the other canals
Poses small risk to hearing
Effective in 90%
Only 1% will eventually have this procedure
Commonly used interventions for BPPV
Epley maneuver/Canalith repositioning tx
Semont/Liberatory maneuver
Brandt Daroff exercises
Epley Maneuver
Start in sitting and quickly change to supine with head rotated 45 degrees toward symptomatic side with 30 degrees extension
Keep this position for 30-60 seconds based on duration of nystagmus
Quickly rotate head to opposite side and hold 30-60 seconds
Roll to same direction the head is rotated to so that the head is rotated 45 degrees with nose down
Return to sitting with head still tilted down for 1 minute
Epley Maneuver Restrictions
Remain upright for 1-2 nights
Avoid sleeping on involved side for 5 additional nights
EM is based on what theory
Canalithiasis theory
93% effective
Perform at weekly intervals until BPPV is gone
Semot Maneuver
Start in seated position with the head rotated 45 degrees toward the asymptomatic
Quickly lie down to opposite/lesion side shoulder
Remain in this position for 30 seconds/until vertigo stops
Rapidly move 180 degrees to opposite shoulder in ear down position
Remain until vertigo stops
Slowly return pt to seated
Semont Maneuver restrictions
Recommend having the patient maintain an upright position for 48 hours after - found to be unnecessary
Avoid provoking posiiton for 5 additional nights
Semont maneuver - originally based on what theory
Cupulolithiasis
90% pts cured after max of 4 sessions
Performed at weekly intervals until BPPV is gone
No more than 5 reps if given as HEP
SM - research
Efficacy dec each time it was repeated
Pts with long lasting or traumatic BPPV have lower recovery rates
SM vs. EM
No significant difference between the two maneuvers
Try one maneuver and if the patient still has nystagmus at the 2nd session , try the other maneuver
If both fail then prescribe the Brandt-Daroff exercises
Brandt-Daroff Exercises as treatment
The patient moves quickly from the seated position into side lying on the affected side
Remains in that position until the vertigo/nystagmus subsides
The patient then returns to the seated position
Wait until vertigo/nystagums subsides
The patient then repeats the maneuver on the opposite side
Return to sitting
Brandt-Daroff Exercises as treatment - how many
Performed 10 - 20 reps, 3 times a day
Until pt has no vertigo for 2 consecutive days
If pt has severe vertigo, can reduce number of daily reps
Considerations for tx of BPPV
Elderly may be less tolerant of SM
Pts with long hx of BPPV may have anxiety with provoking positions
Success of BD are dependent on pt compliance
Cervical or back pain might prohibit SM and/or might be aggravated by BD exercises
Epley might be better for patients who are obese
