DIAGNOSIS AND TREATMENT OF BPPV FOR PHYSICAL THERAPY

Transcription

1 DIAGNOSIS AND TREATMENT OF BPPV FOR PHYSICAL THERAPY DISCLOSURES JAMES R. BARSKY PT, DPT CHESTNUT HILL HOSPITAL NEUROLOGY, PSYCHIATRY AND BALANCE THERAPY CENTER None Pennsylvania Physical Therapy Association Southeastern District Meeting March 9, 2016 Top of the Hill Physical Therapy Chestnut Hill Hospital 35 Bethlehem Pike Philadelphia, PA The BPPV videos on it along with many other excellent videos can be found on Dr. Timothy C. Hain s website OBJECTIVES OVERVIEW 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. 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 Spinning or whirling Tilting Tilting Rocking Rocking Shifting Shifting =VERTIGO Lightheaded Faint Woozy Disequilibrium= Feeling off balance Wobbly Woobly Dizziness Dizzy Giddy Spacey Foggy Off Not right Heavy headed Swimmy Whooshy Blackness behind my eyes 1

2 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 R42, ICD 9 Code 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 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 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), DIRECTION Up/Down Right/Left Right/Left Plane Vertical Horizontal 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 and balance.com, 1/26/14, and balance.com/sitedvd.htm Haines, DE. Fundamental Neuroscience. Churchill Livingston Inc Fig

3 CANAL ANGLES SEMICIRCULAR CANALS ARE CURVILINEAR 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, 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), doi: /s IPSILATERAL HEAD MOVEMENTS CAUSE EXCITATION VESTIBULAR OCULAR REFLEX AND EWALD S 1 ST LAW Vertical Canals: Excited by endolymph flow away from the utricle. Horizontal Canals: Excited by endolymph flow toward the utricle. Vestibular Ocular Reflex (VOR) For stable vision, eyes will move equal and opposite to head movements. Ewald s 1 st Law 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. Richard Rabbitt, PhD, Janet O. Helminski, PT, PhD, 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, Ocular_Reflex 02.jpg. 8/25/2015 POSTERIOR CANAL CANALITHIASIS: + DIX HALLPIKES BPPV EXAMPLES OF VOR AND EWALD S 1 ST LAW Leigh, RJ and Zee, DS. The Neurology of Eye Movements 4 th ed. Oxford, NY. Oxford University Press, Bhattacharyya N et al. Otolaryngology -- Head and Neck Surgery 2008;139:S47-S81 Copyright by American Academy of Otolaryngology- Head and Neck Surgery 3

4 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. HORIZONTAL SEMICIRCULAR CANAL BPPV HSC Canalithiasis HSC Cupulolithiasis Kevin A. Kerber, and Christoph Helmchen Neurology 2012;78: Copyright 2012 by AAN Enterprises, Inc. Kevin A. Kerber, and Christoph Helmchen Neurology 2012;78: Kevin A. Kerber, and Christoph Helmchen Neurology 2012;78: BOW AND LEAN TEST Bow Lean SIT TO SUPINE TEST BOW AND LEAN TEST Herdman J, Clendanial R. Vestibular Rehabilitation. Forth Ed. Pg 330. F.A. Davis 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, doi: /2011/

5 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/3PD). Balance training: if there is any residual imbalance. In my opinion this can also be helpful in preventing Chronic Subjective Dizziness (CSD/3PD). Figure 2 Canalith repositioning procedure for right-sided benign paroxysmal positional vertigo Steps 1 and 2 are identical to the Dix Hallpike maneuver. 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 SurgNovember 2008 vol. 139 no. 5 suppls47 S81 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, PhD, R. W. Baloh, MD, R. J. Tusa, MD, PhD, T. C. Hain, MD, S. Herdman, PT, PhD, 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. Neurology May 27, 2008 vol. 70 no by Lippincott Williams & Wilkins T. D. Fife et al. Neurology 2008;70: SELF ADMINISTERED MODIFIED EPLEY Semont or Liberatory maneuver for posterior canal BPPV NPBTC.COM Lorne S. Parnes, Sumit K. Agrawal, Jason Atlas. Diagnosis and management of benign paroxysmal positional vertigo (BPPV). CMAJ 2003;169(7): 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. 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 2008 by Lippincott Williams & Wilkins T. D. Fife et al. Neurology 2008;70: Ji Soo Kim et al. Neurology 2012;79: Appiani GC, Catania G, Gagliardi M. A liberatory maneuver for the treatment of horizontal canal paroxysmal positional vertigo. Otol Neurotol 2001; 22:

6 Casani maneuver, Gufoni maneuver for HSC cupulolithiasis, modified Semont maneuver: for HSC cupulolithiasis Gufoni maneuver or Gufoni maneuver for apogeotripic nystagmus: for canalithiasis of the anterior(short) arm of the HSC 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 AP1, Vannucci G, Fattori B, Berrettini S. The treatment of horizontal canal positional vertigo: our experience in 66 cases. Laryngoscope Jan;112(1):172 8 May need to be followed tx for canalithiasis of the posterior (long) arm of the HSSC J.-S. Kim et al. Neurology 2012;78: Repositioning maneuver for the treatment of the apogeotropic variant of horizontal canal benign paroxysmal positional vertigo. Ciniglio Appiani G et al. Otol Neurotol. (2005) ANTERIOR CANAL CANALITHIASIS 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 Apr;39(2): Maneuver reported by Faldon and Bronstein, 2008: for anterior canal cupulolithiasis Richard Rabbitt, PhD, University of Utah, Salt Lake City, UT Janet O. Helminski, PT, PhD, 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, CENTRAL POSITIONAL NYSTAGMUS VS BPPV NYSTAGMUS CENTRAL POSITIONAL NYSTAGMUS (CPN) Can take on any form depending on the cause. Does not have to follow Ewald s first law, but may look like it does. Patient may or may not have symptoms with it. 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. CANALITHIASIS Nystagmus can have a longer latency. Nystagmus typically will build, peak, and decay in under a minute. Follows Ewald s first law. Symptoms usually coincide with the nystagmus. Jeong Yoon Choi et al. Central paroxysmal positional nystagmus: Characteristics and possible mechanisms. Neurology 2015;84: 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, PhD, University of Utah, Salt Lake City, UT Janet O. Helminski, PT, PhD, 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,

7 CENTRAL POSITIONAL NYSTAGMUS CAUSES Figure 2 Origin of ocular motor abnormalities in the symptom-free interval at initial presentation (n = 60) and on follow-up (n = 61). Vestibular migraine Vertebrobasilar insufficiency Infarction, hemorrhage, tumor, MS, Chiari malformation, olivopontocerebellar atrophy, etc. Andrea Radtke et al. Neurology 2012;79: Herdman J, Clendanial R. Vestibular Rehabilitation. Forth Ed. Chapter 20. F.A. Davis Copyright 2012 by AAN Enterprises, Inc. Andrea Radtke et al. Neurology 2012;79: CASE OF CF QUESTIONS? 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. 7