Research Stream Advances in the treatment of Vertigo Anne Burston
Advances in The Treatment of Vestibular Conditions Using Physical Interventions. NATIONAL RURAL HEALTH CONFERENCE 2015 A N N E B U R S T O N M H E A L S C ( R E H A B ), P H Y S I O T H E R A P I S T
Introduction Dizziness is the number 1 reason for people >75 yrs to visit their GPs (USA) As many as half of these may be due to vestibular problems Treatment outcomes in the elderly are just as good as in younger patients Don t underdiagnose. Significant changes can be made with treatment Vestibular pathologies are a major risk factor for falls
Causes of Dizziness BPPV Vestibular Neuritis/labyrinthitis Meniere s Disease Vestibular Migraine Cervicogenic Phobic Postural Vertigo Stroke PD/ MS Traumatic brain injury/concussion Anxiety/Hyperventilation Acoustic Neuroma Orthostatic Hypotension Medication Cardiac Psychiatric conditions Tumours Vascular Dementia
BPPV Diagnosis Timeline: 1952 Dix-Hallpike Test- posterior & anterior canals 1962/1969 Cupulolithiasis- Schuknecht 1979 Canalithiasis- Hall et al 1985 Roll test- Horizontal canals canalithiasis- McClure 1995 HC cupulolithaisis-baloh et al
The Dix-Hallpike manoeuvre showing deflection of the cupula by gravitational movement of the crystals away from the cupula within the posterior canal.
Roll Test for Horizontal Canals
BPPV Treatment 1980 Brandt-Daroff 5-10 reps/3x/day for up to 2 weeks- dispersing crystals within canal Posterior canal repositioning manoeuvres 1988 Semont - 84 % success rate with 1 manoeuvre/93% with 2 1992 Epley - 80% success with 1 manoeuvre/95% with 2 (Cochrane review 2009-some evidence that it is a safe and effective treatment for PC BPPV)
Modified Epley repositioning Manoeuvre for BPPV affecting the right PC
Horizontal & Anterior canal repositioning manoeuvres Horizontal Canal 1996 Barbeque Roll (Lempert)- Canalithiasis 90% success with 1 manoeuvre 2001 Gufoni Canalithiasis, 93-100% success 2005 Gufoni - Cupulolithiasis 77% success Anterior Canal 2009 Straight-Back Manoeuvre (Yacovino)- 85% success with 1 manoeuvre/100 % with 2 (13 patients)
Post Treatment Regimes Initially patients were instructed to sleep upright for 2 weeks post manoeuvre and wear a soft collar Research has shown this has no effect Now we instruct patients to sit quietly for 30 minutes post manoeuvre and then carry on as normal
Medication for BPPV-Not Effective! Prochlorperazine is most commonly prescribed vestibular suppressant Symptom suppression only should only be used for very short periods (2-3 days) when symptoms are severe (eg vomiting) Long term side affects such as Parkinsonism & dystonias Doesn t treat the BPPV or stop recurrences Repositioning manoeuvres are cheap and extremely effective with high success rates
Vestibular Function Tests Caloric tests- tests the horizontal canal function since late 1800s, with ENG (?70s) with electrooculography (EOG) (?1980s/90s) and infra-red video-oculography (since?2000) HIT- VOR-1988 (Halmagyi & Curthoys) Subjective visual horizontal or verticalutricle-1989 (Halmagyi & Curthoys) VEMPS- saccule- 1994 (Colebatch et al) vhit- 2009
Vestibular Rehabilitation Since the 1940s, Physiotherapy interventions for peripheral and central causes of dizziness have been used for symptom reduction. Cooksey and Cawthorne were the first to develop exercises to use provoking head movements as treatment. In the 1990s, Susan Herdman started using more specific vestibular adaptation, substitution and habituation exercises in more structured, individualized treatment programmes to promote functional recovery.
Evidence Cochrane database of Systemic Reviews (2007) There is moderate to strong evidence that vestibular rehabilitation is a safe, effective management for unilateral peripheral vestibular dysfunction, based on a number of high quality randomized controlled trials Cochrane Database of Systemic Reviews (2011)- Confirm these conclusions
Adaptation exercises Gaze stability exercises for unilateral and partial bilateral vestibular loss Increase the gain of the VOR Encourage central compensation Balance exercises as required
Substitution exercises Substitution exercises for partial and total bilateral vestibular loss Encourages use of other systems to maintain gaze stability and reduce oscillopsia (COR, saccadic system) Balance programme
Habituation exercises Habituation exercises to desensitise patients to movement Used in central conditions- stroke, MS, PD, vestibular migraine, PPPD
All patients need education and encouragement as anxiety is a big component for a lot of them
Outcomes Audit VR Patients All patients had been seen by either 1 of 2 Physiotherapists working in the ORA Kapiti Community service (CCDHB) between 2011 & 2013 2 groups were audited: 1. BPPV- sample size 100 2. Other vestibular pathologies- sample size 60
BPPV Audit Outcomes Age: range 30-92 years, mean 72 years Referral Source: GPs-46 Self-35 19 from inpatient PTs, Neurologists, Nurses, Geriatrician, Stroke Team, ED, SW, family
Falls Risks 48 had pre-existing conditions that affected their sensory inputs for balance other than vestibular. 42 were on >4 medications 21 fell due to BPPV & 8 had near falls 5 had increased unsteadiness & 1 FOF
Symptom Duration 48 had symptoms of 3 weeks or less 44 had symptoms from 1 to 10 months 4 had symptoms of 1 year or more 4 weren t recorded
Results Patients with single canal involvement: 65 in total 59 (91%) were objectively or subjectively clear after treatment with repositioning manoeuvres 5 (8%) were significantly improved 1 patient was referred back to GP
Patients with Multiple Canal Involvement: 13 patients 11 (85%) were objectively or subjectively clear after treatment, 1 was 80% improved and 1 admitted to hospital for dizziness Number of treatment manoeuvres ranged from 2 to 15 15/29 (52%) canals were cleared with 1 manoeuvre
Other Vestibular Pathologies Age: range 18-87 years, mean 64 years Referral Source: GP- 27 Self- 10 Neurologist- 7 16 from inpatient PTs, ENT, Geriatrician, Stroke team, family, ORA team members, calorics clinic, concussion clinic.
Conditions included Phobic postural vertigo (PPPD) Vestibular neuritis causing unilateral vestibular loss Traumatic brain Injury Stroke Vestibular migraine Meniere s Disease
Multiple Sclerosis Parkinson s Disease Mal de debarquement Medication Cervicogenic dizziness Fear of falling Cerebellar degeneration Ongoing symptoms following BPPV
Symptom Duration 17(28%) had symptoms for <2 months 16(27%) had symptoms lasting 2 to 8 months 21(35%) had symptoms lasting 1 year or longer (longest was 20 years) 6(10%) was not clear from history
Falls Risks 43% had pre-existing conditions that affected their sensory inputs for balance other than vestibular 19 (32%) were on >4 medications 16(27%) had falls due to dizziness 1 had a sense of falling
Treatment 35/60 received Physiotherapy treatment 4/60 received education only 7/60 received no treatment (5 were asymptomatic at time of assessment, 1 was too unwell and 1 declined input) 14/60 were referred for specialist input (Neurology, ENT or Geriatrician) after assessment.
Summary of Results 35 /60 patients received treatment 17/35 were already under a medical specialist (13- Neurologist, 3-Geriatrician, 1-concussion clinic) 25/35 (71%) of those treated had significant improvement on outcome measures &/or with functional activities Avg number of face-to-face contacts was 6. This shows significant improvements can be achieved with this patient group with a moderate amount of input.
Discussion Dizziness is the number 1 reason for people >75 yrs to visit their GPs (USA) Treatment outcomes in the elderly are just as good as in younger patients Don t underdiagnose. Significant changes can be made with treatment Vestibular pathologies are a major risk factor for falls
Physiotherapists can successfully diagnose and treat BPPV. Physiotherapists can help patients with other peripheral vestibular pathologies and central causes of dizziness to significantly decrease their symptoms and improve their functional abilities. Many of these patients are complex and it is necessary to work closely with Neurologists, ENT specialists, Geriatricians, Concussion Clinic, Psychologists and other team members to achieve optimum results.
However!!! Not all Physiotherapists are equal. This is a specialised area of Physiotherapy Don t just refer to any Physio- you need to find someone who has been trained in this area NZSBDV will have a website of Physios who are members
References 1. Dix R, Hallpike CS: The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Ann Otol Rhinol Laryngol 1952;6:987. 2. Lempert T, Tiel-Wilck K. A positional manoeuver for treatment of horizontal-canal benign positional vertigo. Laryngoscope 1996;106:476 3. Appiani GC, Catania G, Gagliardi M. A liberatory maneuver for the treatment of horizontal canal paroxysmal positional vertigo. Otol & Neurol 2001;22:66-69 4. Casani AP, Vannucci G, Fattori B, Berrettini S. The treatment of horizontal canal positional vertigo: our experience in 66 cases. Laryngoscope 2002;112:172-178 5. Yacovino DA, Hain T, Gualtieri F. New therapeutic manuever for anterior canal paroxysmal positional vertigo. J Neurol 2009. 6. Baloh RW, Yue Q, Jacobson KM, Honrubia V. Persistent direction-changing positional nystagmus: another variant of benign positional nystagmus? Neurology 1995; 45: 1297-30. 7. Brandt T, Daroff RB. Physical therapy for the benign paroxysmal positional vertigo. Arch Otolaryngol 1980; 106: 484-485. 8. Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992; 107: 399-404. 9. Hall SF, Ruby RR, McClure JA. The mechanics of benign paroxysmal vertigo. J Otolaryngol 1979; 8: 151-158. 10. McClure JA. Horizontal canal BPV. J Otolaryngol 1985; 14: 30-35. 11. Schuknecht HF. Cupulolithiasis. Arch Otolaryngol 1969; 90: 765-78. 12. Schuknecht HF. Positional vertigo: clinical and experimental observations. Trans Am Acad Opthalmol Otolaryngol 1962; 66: 319-332. 13. Semont A, Freyss G, Vitte E. Curing the BPPV with a liberatory maneuver. Adv Otorhinolaryngol 1988; 42: 290-293. 14. Halmagyi GM, Curthoys IS. A clinical sign of canal paresis. Arch Neurol 1988;45:737-739. 15. MacDougall HG, Weber KP, McGarvie LA, Curthoys IS, Halmagyi GM. The video impulse test. Diagnostic accuracy in peripheral vestibulopathy. Neurol 2009;73:1134-1141 16. Colebatch JG, Halmagyi GM, Skuse NF. Myogenic potentials generated by a click-evoked vestibulocollic reflex.j Neurol Neurosug Psychiatry 1994;57:190-7