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Tuesday, October 09, 2018

Essential Skills for Managing Benign Paroxysmal Positional Vertigo

By Tim Bertelsman, DC

Benign paroxysmal positional vertigo (BPPV) is the most common cause of dizziness and vertigo.1-4 The condition is characterized by brief episodes of dizziness, nausea, and/or nystagmus triggered by head movement.5 Over 7 percent of the population will experience BPPV at some point in their lifetime and 80 percent of those patients will require medical treatment. 6,7

Chiropractors are uniquely suited to differentiate BPPV from the similar-looking cervicogenic vertigo. Both conditions are very amenable to treatment; however, each is managed quite differently. Successful outcomes are predicated upon a solid understanding of both.

Watch this quick tutorial video to hone your skills for the current evidence-based assessment and management of Benign Paroxysmal Positional Vertigo (BPPV).

Presentation

The classic presentation for BPPV includes sudden (aka paroxysmal) episodes of rotary vertigo that last 10-20 seconds following head position changes.5,8 Typical provocative activities involve transitioning between upright and recumbent positions; rolling from side to side in bed; bending forward; and moving the head to look up, down, or side to side.9

Exam

The primary purpose of the clinical exam is twofold; first, to rule out more sinister causes of vertigo, and second, to identify the side (right, left, both) and site (posterior, anterior, horizontal) of the involved semicircular canal. Clinicians should keep in mind that multiple canals can be involved (4.6 percent of cases) and the condition can be bilateral.10-11

Most cases of BPPV affect the posterior semicircular canal.12-13 The Dix-Hallpike maneuver is the gold standard for diagnosing posterior semicircular canal involvement.14-17 The test has a specificity of 83 percent and sensitivity of 52 percent for BPPV arising from the posterior semicircular canal.18-19
 
BPPV symptoms are generally episodic, provoked by movement and eased by maintaining a stable position. Continuous symptoms or nystagmus that occurs without changing head position suggests central pathology.20,21 Clinicians should search for clues that suggest a non-BPPV origin, including a history of head trauma, loss of consciousness, frequent unexplained falls, hearing loss, tinnitus, ear “fullness”, earache, ptosis, facial or extremity paresthesia, visual disturbances, difficulty speaking, difficulty swallowing, ataxia, or a new medication, particularly anti-hypertensives or anti-depressants.

Diagnosis

Cervicogenic vertigo presents with symptoms similar to BPPV, i.e., episodic, provoked by movement, and eased by maintaining a stable position. Patients may complain of light-headedness, floating, unsteadiness, or general imbalance, but rarely true “spinning” vertigo22. Cervicogenic vertigo is often accompanied by loss of cervical range of motion, upper cervical tenderness, and upper cervical segmental joint restriction.23,24

One complicating factor for differentiating cervicogenic vertigo from BPPV is that most provocative movements concurrently stimulate both cervical spine proprioceptors and the vestibular apparatus. The Head-fixed/body-turn test (aka Neck torsion test) aims to isolate cervical mechanoreceptors without stimulating the vestibular apparatus.25,26 The neck torsion test is performed with the patient rotating their body on an exam stool while the clinician stabilizes their head, thereby minimizing vestibular input. Reproduction of dizziness or nystagmus when the head is stable suggests a cervical component. 27-29 

Treatment

Canalith repositioning maneuvers and home-based exercise are the current standard of care for BPPV.12,14,15,19,30 Management is predicated upon first identifying the involved semicircular canal(s), and then choosing the appropriate maneuver to reposition the wayward calcium carbonate sediment. 2,9 All repositioning maneuvers attempt to move the head into a position where debris can fall to the top of the problematic canal and then transition the head into a position where the debris moves around the canal back into the vestibule. 

When the posterior semicircular canal is involved, clinicians should choose the canalith repositioning procedure, aka, Epley maneuver.14-16 The effectiveness of the Epley maneuver ranges between 78-95 percent.31 A single intervention leads to remission in 44-89 percent of cases, and this rate improves with second, third, or fourth interventions.2 The addition of vibration does not enhance the effectiveness of this maneuver.32,33

 

SITE

EVALUATION

TREATMENT

Posterior Canal BPPV

Dix-Hallpike
(upbeat nystagmus)

Epley, Foster ½ Somersault, Sermont Liberatory

Anterior Canal BPPV

Dix-Hallpike   (downbeat nystagmus)

Reverse Epley

Horizontal Canal BPPV

Supine Roll Test

Lempert 360 Roll Maneuver

Cervicogenic

Head Fixed/ Body Turned Test

Manipulation



 
When performing repositioning maneuvers, movement should be quick in order to generate enough momentum to dislodge displaced canaliths. Clinicians should also recognize these crystals are moving through fluid, which requires a sufficient amount of time to settle into a new position. Clinicians should proactively inform patients that although they may become dizzy during testing or treatment, they should attempt to keep their eyes open and remember the intervention will ultimately help ease their symptoms.

Contraindications to performing repositioning maneuvers include acute cervical spine fracture or instability, recent cervical spine surgery, perilymph fistula, detached retina, unstable carotid artery disease/stenosis, vertebrobasilar insufficiency, stroke, TIA, unstable heart disease, and severe neck disease, such as cervical spondylosis with myelopathy or advanced rheumatoid arthritis.34,35

Dr. Tim Bertelsman is co-founder of the online clinical and business resource ChiroUp.com. Dr. Bertelsman graduated from Logan College of Chiropractic with honors and has been practicing in Belleville, Ill., since 1992. He is a post-graduate instructor for the University of Bridgeport Orthopedic Diplomate program. He has served in several leadership positions within the Illinois Chiropractic Society and currently serves as president of its executive board.

 

References

1. Teixido M et al., A 3D benign paroxysmal positional vertigo model for study of otolith disease. World Journal of Otorhinolaryngology-Head and Neck Surgery (2016) 2, 1-6
2. Fife TD, von Brevern M. Benign Paroxysmal Positional Vertigo in the Acute Care Setting. Neurol Clin 33 (2015) 601–617
3. Brandt T. Vertigo: its multisensory syndromes. London: Springer; 1999. 503p. 
4. Haybach PJ. BPPV: what you need to know. Portland: Vestibular Disorders Association; 2000. 207p. 
5. Mariana Azevedo Caldas et al. Clinical features of benign paroxysmal positional vertigo. Brazilian Journal of Otorhinolaryngology 75 (4) July/August 2009
6. Neuhauser HK. Epidemiology of vertigo. Curr Opin Neurol. 2007;20(1):40–46.
7. Neuhauser HK, von Brevern M, et al. Epidemiology of vestibular vertigo: A neurotologic survey of the general population. Neurology. 2005;65(6):898–904.
8. Terry D. Fife, Michael von Brevern. Benign Paroxysmal Positional Vertigo in the Acute Care Setting. Neurol Clin 33 (2015) 601–617
9. Haynes DS, Resser JR, Labadie RF, Girasole CR, Kovach BT, Scheker LE, et al. Treatment of benign positional vertigo using the Semont manouver: efficacy in patients presenting without nystagmus. Laryngoscope. 2002;112(5):796-801.
10. Lopez-Escamez JA, Molina MI, Gamiz MJ, Fernandez-Perez AJ, Gomes M, Palma MJ, Zapata PC. Multiple positional nystagmus suggests multiple canal involvement in benign paroxysmal positional vertigo. Acta Otolaryngol. 2005;125(9):954-61.
11. Shim DB, Benign Paroxysmal Positional Vertigo with Simultaneous Involvement of Multiple Semicircular Canals. Korean J Audiology 2014 Dec; 18(3): 126–130.
12. Korres SG, Balatsoura DG. Diagnostic, pathophysiologic, and therapeutic aspects of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2004;131:438-44.
13. Parnes LS, Agrawal SK, Atlas J. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). Can Med Assoc J. 2003;169(7):681-93.
14. Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017 Mar. 156 (3_suppl):S1-S47.
15. Garcia J. New guidelines for benign paroxysmal positional vertigo. Medscape Medical News. 2017 Mar 1.
16. Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2008 Nov. 139(5 Suppl 4):S47-81.
17. Herdman SJ, Tusa RJ. Avaliação e tratamento dos pacientes com vertigem posicional paroxística benigna. In: Herdman SJ, editor. Reabilitação Vestibular, 2ed, São Paulo: Manole; 2002. p. 447-71.
18. Gordon CR, Zur O, Furas R, Kott E, Gadoth N. Pitfalls in the diagnosis of benign paroxysmal positional vertigo. Harefuah. 2000;138(12):1024-7.
19. Labuguen RH. Initial evaluation of vertigo. Am Fam Physician. 2006;73(2):244-51.
20. Sakata E, Oihtsu K, Itoh Y. Positional nystagmus of benign paroxysmal type due to cerebellar vermis lesions. Acta Otolaryngol 1991;(Suppl 481):254e7.
21.  Dunniway HM, Weilling DB. Intracranial tumors mimicking benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1998;118:429e36.
22. Takasaki, H., V. Johnston, et al. (2011). "Driving with a chronic whiplash-associated disorder: a review of patients' perspectives." Archives of physical medicine and rehabilitation 92(1): 106-110.
23. Ojala M, Palo J. The aetiology of dizziness and how to examine a dizzy patient. Ann Med 1991;23:225-30.
24.  Stenger HH. Análisis del vertigo; exploración del nystagmo espontáneo y del provocado. In: Berendes J, Link R, Zöllner F, editors. Tratado de otorrinolaringologia. Barcelona: Editorial Cientifico Médica; 1969. p. 603-46.
25. Wrisley DM, Sparto PJ, Whitney SL, Furman JM. Cervicogenic dizziness: A review of diagnosis and treatment. J Orthop Sports Phys Ther 2000;30:755-766.
26. Phillipszoon AJ. Neck torsion nystagmus. Pract Oto-Rhi- no-Laryngologist. 1963;25:339-344.
27. Huijbregts P, Vidal P. Dizziness in orthopaedic physical therapy practice: Classification and pathophysiology. J Manual Manipulative Ther 2004;12:199-214.
28.  Norre ME, Stevens A. Cervical vertigo. Acta Oto-Rhino-Larynologica Belgica 1987; 41(3):436-52
29.  Fitz-Ritson D. Assessment of cervicogenic vertigo. J Manipulative Physiol Ther. 1991 Mar-Apr;14(3):193-8.
30. Dix R, Hallpike CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Ann Otol Rhinol Laryngol. 1952;6:987-1016.
31. Richard W, Bruintjes TD, Oostenbrink P, Van Leewen RB. Efficacy of the Epley maneuver for posterior canal BPPV: a long-term, controlled study of 81 patients. Ear Nose Throat J. 2005;84(1):22-5.
32. Macias JD, Ellensohn A, Massingale S, Gerkin R. Vibration with the canalith repositioning maneuver: a prospective randomized study to determine efficacy. Laryngoscope. 2004 Jun;114(6):1011-4.
33. Hain TzzC, Helminski JO, Reis IL, Uddin MK Vibration Does Not Improve Results of the Canalith Repositioning Procedure. Arch Otolaryngol Head Neck Surg. 2000; 126(5):617-622.
34. https://emedicine.medscape.com/article/82945-overview#a3
35. Humphriss RL, Baguley DM, Sparkes V, Peerman SE, Moffat DA. Contraindications to the Dix-Hallpike manoeuvre: a multidisciplinary review. Int J Audiol. 2003;42:166-73.

 

 

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