BPPV

Question 1

BPPV - what does it stand for

Answer 1

Benign Paroxysmal Positional Vertigo

Question 2

What is BPPV

Answer 2

Recurrent positional vertigo and nystagmus occuring when the head is placed in certain positions

Question 3

BPPV - evoked by

Answer 3

Changes with respect to gravity (such as rolling over in bed or looking up to a shelf)

Question 4

BPPV - initial occurance usually experienced when

Answer 4

upon awakening in the morning and night rather than on first laying down

Question 5

What is vertigo

Answer 5

An illusion of movement, most commonly a sense of spinning

Question 6

Vertigo and Nystagmus - begin… and will last…

Answer 6

Begin after a latency of 3-4 seconds

Will last from 1-40 seconds

Question 7

Vertigo and Nystagmus - fatigue

Answer 7

Will fatigue with repetition

Question 8

BPPV - how long before it goes away

Answer 8

Usually spontaneously disappears after a few weeks

If no tx it may persist for months to eyars

Question 9

BPPV - reoccurence

Answer 9

in 18-50% of patients

Question 10

Characteristics of patients with BPPV

Answer 10

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

Question 11

Nystagmus

Answer 11

Eye jumping

Question 12

Otoconia

Answer 12

Small Ca carbonate crystals derived from utricle

ear debris

Question 13

Utricle

Answer 13

A small sac like structure of the inner ear

Primarily used for postural stability

Question 14

Cupula

Answer 14

Apex of cochlea

Question 15

Endolymph

Answer 15

Fluid in the semicircular canals
Moves freely in response to direction of angular movement
As it moves, it bends hair cells on cupula

Question 16

Semicircular canals

Answer 16

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

Question 17

Two theories of cause of BPPV

Answer 17

Cupulolithiasis theory

Canalithiasis theory

Question 18

Cupulolithiasis theory

Answer 18

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

Question 19

Problems with the cupulolithiasis theory

Answer 19

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

Question 20

Canalithiasis theory

Answer 20

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

Question 21

Canalithiasis theory continued - repeat positioning maneuvers does what

Answer 21

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

Question 22

Canalithiasis theory - accounts for what

Answer 22

the short duration of nystagmus upon position change

Question 23

Semicircular Canal involved with BPPV - most frequent cause of BPPV is what

Answer 23

a mechanical disorder in the posterior semicircular canal - upbeating and torsional nystagmus

Question 24

Semicircular canal involved with BPPV - what is rarer

Answer 24

Horizontal and anterior semicircular canal impairment are much rarer
Horizontal - horizontal nystagmus
Anterior - down beating and torsional nystagmus

Question 25

How is BPPV Diagnosed

Answer 25

A hx of vertigo and a physical exam showing nystagmus during these tests Hallpike Dix maneuver EMG

Question 26

Hallpike Dix

Answer 26

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

Question 27

Brandt Daroff Exercises

Answer 27

``` 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 ```

Question 28

Frenzel goggles

Answer 28

Magnify the patients eyes making nystagmus easier to observe Also prevent patient from fixating on an object to supress the nystagmus

Question 29

Prior to treating a patient with BPPV a PT should determine

Answer 29

What positional changes cause vertigo Any associated balance problems Any conditions like neck pain

Question 30

Documentation of vertigo

Answer 30

Latency, duration, and intensity should be documented for each position change Can scale 1 to 5 or 1 to 10

Question 31

Goals for patients with BPPV

Answer 31

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

Question 32

Medical tx of BPPV

Answer 32

No medication has been proven to to beffective to rid a person of BPPV

Question 33

Surgical tx of BPPV

Answer 33

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

Question 34

Commonly used interventions for BPPV

Answer 34

Epley maneuver/Canalith repositioning tx Semont/Liberatory maneuver Brandt Daroff exercises

Question 35

Epley Maneuver

Answer 35

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

Question 36

Epley Maneuver Restrictions

Answer 36

Remain upright for 1-2 nights | Avoid sleeping on involved side for 5 additional nights

Question 37

EM is based on what theory

Answer 37

Canalithiasis theory 93% effective Perform at weekly intervals until BPPV is gone

Question 38

Semot Maneuver

Answer 38

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

Question 39

Semont Maneuver restrictions

Answer 39

Recommend having the patient maintain an upright position for 48 hours after - found to be unnecessary Avoid provoking posiiton for 5 additional nights

Question 40

Semont maneuver - originally based on what theory

Answer 40

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

Question 41

SM - research

Answer 41

Efficacy dec each time it was repeated | Pts with long lasting or traumatic BPPV have lower recovery rates

Question 42

SM vs. EM

Answer 42

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

Question 43

Brandt-Daroff Exercises as treatment

Answer 43

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

Question 44

Brandt-Daroff Exercises as treatment - how many

Answer 44

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

Question 45

Considerations for tx of BPPV

Answer 45

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