BPPV best practice: Understanding, applying and advancing the 2017 Revised OHNS BPPV Clinical Practice Guideline - Academy of ...
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2/18/18
BPPV best
practice:
Understanding, Janene M. Holmberg, PT, DPT,
NCS
applying and Intermountain Hearing & Balance
Center, SLC, UT
advancing the 2017
Susan L. Whitney, PT, DPT, FAPTA
Revised OHNS BPPV Professor in Physical Therapy and
Otolaryngology
Clinical Practice University of Pittsburgh, PA
Guideline
1
2/18/18 CPG Implementation Survey We invite you to take part in a implementation Survey to better understand how Clinical Practice Guidelines (CPGs) are used and how we can improve implementation. Use the QR code to access the survey Answer at most 14 questions (
2/18/18
Objectives:
Upon completion of this presentation, the
learner will be able to:
ü Understand key differences in the
new AAO-HNS 2017 CPG for BPPV
ü Understand key action statements
and implications for clinical practice
ü Understand the mandate for
timely referral for BPPV treatment
ü Understand resources available in
connection with the new CPG
Objectives:
ü Discuss the art of BPPV practice
beyond the narrow definitions of the
CPG
ü What “we wished we could have
said”
ü Discuss clinical applications of the
CPG
ü Discuss needs for future research
ü Important role of PT as a key
professional in shaping the art and
science of optimal BPPV
management
3
2/18/18
Benign Paroxysmal Positional Vertigo
(BPPV)
} Dizziness accounts for 5.6
million clinic visits a year in the
US with 17-42% BPPV
} Bhattacharyya N, 2008,
Hanley, 2001
} BPPV is the most common
vestibular disorder across the
life span and most common
cause of recurrent vertigo
Benign Paroxysmal Positional
Vertigo (BPPV)
◦ Lifetime prevalence 2.4 %
◦ >60 years old, 7times greater incidence of
BPPV
◦ 86% experience interrupted activities of
daily living or lost work
◦ Only 10% seen by an MD will receive a
repositioning maneuver
Van Beuren, 2007
4
2/18/18
CPG Multi-Disciplinary
Panel (2017 revision)
Jonathan Edlow, MD Emergency MD American Academy of Emergency Medicine (AAEM)
Hussam El-Kashlan, MD Otolaryngologist American Otological Society (AOS)
Terry Fife, MD Neurologist American Academy of Neurology (AAN)
Janene M. Holmberg,
Physical Therapist American Physical Therapy Association (APTA)
PT, DPT, NCS
Kathryn Mahoney Consumer Advocate Vestibular Disorders Association (Consumer Organization)
Deena B. Hollingsworth,
MSN, FNP-BC, CORLN Nurse Society of Otorhinolaryngology Head-Neck Nurses (SOHN)
Richard Roberts, PhD
Audiologist American Academy of Audiology (AAA)
Michael D. Seidman,
MD, FACS Otolaryngologist AAO-HNSF Board of Governors (BOG)
Robert Wm. Prasaad
Steiner, MD, PhD Family Practice MD American Academy of Family Physicians (AAFP)
Betty Tsai Do, MD
Otolaryngologist AAO-HNSF Otology and Neurotology Education Committee
Courtney C. J. Voelker, AAO-HNSF Section for Residents and Fellows/AAO-HNSF
MD, PhD Otolaryngologist Equilibrium Committee
Richard W.
Otolaryngologist AAO-HNSF Physician Payment Policy (3P) Committee
Waguespack, MD
2017 OHNS BPPV Summary of key changes
(entnet.org website)
• Evidence from 2 clinical practice guidelines,
20 systematic reviews, and 27 randomized
controlled trials
• Enhanced review process to include public comment &
journal peer review
• Increased patient education resources
• Plain language edition available
• Frequently asked question handout (can be co-branded)
• Increased emphasis on patient education/
shared decision making
5
2/18/18
BPPV pamphlet –
some of the
questions
How common
What caused
my BPPV
Can BPPV be
treated
Can BPPV go
away on its
own?
2017 OHNS BPPV Summary of key changes
• Stronger action statements
• Use and diagnostic criteria for Dix Hallpike and roll testing
(history alone is NOT sufficient)
• Identify specific quality of nystagmus
• Inclusion of lateral canal BPPV differential diagnosis table
and description of the maneuvers
• Continued emphasis of strong recommendation AGAINST…
• Medications
• Need/recommendation for further vestibular testing and
imaging
• Postmaneuver precautions
6
2/18/18
CRP as initial therapy
Thereis high-quality evidence
that patients diagnosed with
BPPV should be offered
expeditious treatment with the
canalith repositioning
maneuver” (pg. S20)
BPPVshould be diagnosed with
Dix-Hallpike/roll testing
CRP as initial therapy
There is NO evidence.. to suggest
that any.. medications are effective
as a primary treatment or as a
substitute for a repositioning
maneuver
Repositioning maneuvers are different
from Cawthorne-Cooksey or Brandt-
Daroff exercises
7
2/18/18
CPG Algorithm
Target Population: >18 years old
Purpose: improve quality of care/outcomes for
BPPV
accurate and efficient diagnosis of BPPV
Reduceinappropriate use of vestibular suppressant
medications,
decrease the inappropriate use of ancillary testing i.e.
imaging
Increase use of therapeutic repositioning maneuvers.
CPG Algorithm
Target audience:
All clinicians who are likely to diagnose
and manage patients with BPPV
Any setting in which BPPV would be
identified, monitored, or managed
NEW diagnostic and treatment visual
ALGORITHM
8
2/18/18
CPG Algorithm
CPG Algorithm
9
2/18/18
Open Access resources:
(www.entnet.org/BPPVCPG)
Fullguideline
Executive summary
Podcasts both for otolaryngologists and
non-otolaryngologists
Customizable versions of patient handouts
Plain language summary
Press release and links to media articles
Strength of Action Terms
Defined
Strong Recommendation
Quality of supporting evidence high (grade A/B or
level 1-2)
Clinicians should follow unless clear and
compelling rationale for alternative
Recommendation
Quality of evidence not as high (grade B/C or
level 3-4)
Clinicians should generally follow but remain alert
to new information
Option
Quality of evidence is suspect (grade D or level 5
or not well done studies) to show clear advantage
to one approach versus another
102/18/18
CPG Summary
Statement Action Strength
1a.Diagnsosis of Diagnose posterior semicircular canal BPPV when Strong
posterior canal vertigo associated with torsional, up-beating nystagmus recommendation
BPPV is provoked by the Dix-Hallpike maneuver
1b. Diagnosis of Diagnose lateral canal BPPV when history compatible Recommendation
lateral (horizontal) with BPPV and diagnostic testing (Dix Hallpike or
canal BPPV Supine Roll Test) provokes horizontal nystagmus
2a. Differential Differentiate BPPV from other causes of imbalance, Recommendation
diagnosis dizziness and vertigo.
2b. Modifying Assess for factors that modify management Recommendation
factors
3a. Radiographic RADIOGRAPHIC testing should not be obtain in the Recommendation
testing absence of additional signs and/or symptoms
inconsistent with BPPV
CPG Summary
3b. Vestibular Vestibular testing should not be obtained Recommendation
testing
4a. Clinicians should treat, or refer to a clinician Strong
Repositioning who can treat, patients with posterior canal recommendation
procedures as BPPV with a canalith repositioning
initial therapy procedure.
4b. Post Strong
Clinicians should not recommend
procedural recommendation
post-procedural postural restrictions
restrictions (against)
4c. Observation Clinicians may offer observation with follow Option
as initial up as initial management for patients with
therapy BPPV.
112/18/18
5. Vestibular The clinician may offer vestibular rehabilitation, Option
rehabilitation either self-administered or with a clinician, in the
therapy treatment of BPPV.
6. Medical Clinicians should not routinely treat BPPV with Recommendation
therapy vestibular suppressant medications (against)
7a. Outcome Clinicians should reassess patients within 1 Recommendation
Assessment month.
7b. Evaluation Clinicians should evaluate or refer to a clinician Recommendation
of treatment who can evaluate, patients with persistent
failure
8. Education Clinicians should educate regarding the impact of Recommendation
BPPV on safety, disease recurrence and the
importance of follow-up.
DIAGNOSIS OF POSTERIOR
SEMICIRCULAR CANAL BPPV
Criteria:
• Vertigo associated with torsional, up-beating
nystagmus is provoked by the Dix‑‑Hallpike
maneuver
• Performed by bringing patient to supine position
with the head turned 45 degrees and neck
extended 20 degrees with the affected ear down
Strong recommendation based on diagnostic studies with minor limitations
and a preponderance of benefit over harm.
122/18/18
Supporting Text
Historyalone not adequate to make diagnosis
of BPPV
Most commonly due to canalithiasis but can be
cupulolithiasis (>1min duration)
Supporting Text
Negative DH does not rule out a diagnosis
of BPPV
Care with certain conditions:
cervical stenosis, limited cervical ROM,
Down’s syndrome, severe rheumatoid
arthritis, cervical radiculopathies, Paget’s
disease, Ankylosing Spondylitis, low back
dysfunction, spinal cord injury, morbid
obesity
132/18/18
DIAGNOSIS OF LATERAL
(HORIZONTAL) SEMICIRCULAR
CANAL BPPV
If the patient has a history compatible with BPPV
and the Dix‑‑Hallpike test exhibits horizontal or
no nystagmus, the clinician should perform, or
refer to a clinician who can perform a supine
roll test to assess for lateral semicircular canal
BPPV
Recommendation based on diagnostic studies with
limitations and a preponderance of benefit over harm
Supporting Text
Second most common form of BPPV
Can be seen with canal conversion
during a posterior canal repositioning
Description of 2 forms of lateral canal
BPPV (geotropic vs apogeotropic)
Valuable chart is included on selected
methods for identifying the affected ear
142/18/18
Determining Affected Side
DIFFERENTIAL DIAGNOSIS
Clinicians should differentiate, or refer to a
clinician who can differentiate, BPPV from
other causes of imbalance, dizziness and
vertigo
Recommendation
Benefits: Prevent false positive diagnosis of
BPPV when another condition actually exists
152/18/18
Supporting Text
BPPV is often under or misdiagnosed
Nice section in the guidelines for
differential diagnosis of dizziness
Supporting Text
Centralvs peripheral section about
differential diagnosis
The CPG also suggests that you consider:
Panic/anxiety
Cervical
Orthostatic hypotension
medications
162/18/18
MODIFYING FACTORS
Clinicians should assess patients with BPPV for factors that
modify management including:
• impaired mobility or balance
• central nervous system disorders
• a lack of home support
• increased risk for falling
Recommendation based on observational and cross-
sectional studies and a preponderance of benefit over
harm.
Supporting Text
High incidence of medical comorbidities
Diabetes, anxiety, head trauma, migraine,
peripheral neuropathy, CNS disorder
Need for falls screening and/or assessment
Have you had 2 or more falls in past year
Do you feel unsteady when standing/walking
Do you worry about falling
Cautionto not miss BPPV when other co-
morbidity is prominent, e.g. Multiple sclerosis,
Parkinson's disease, concussion, migraine
172/18/18
RADIOGRAPHIC TESTING
Clinicians should not obtain radiographic
imaging in a patient who meets
diagnostic criteria for BPPV in the absence
of additional signs and/or symptoms
inconsistent with BPPV that warrant
imaging.
Recommendation against radiographic
imaging
Supporting Text
Retrospective review of 2,374 elderly
patients with MRI failed to detect any
significant differences between persons
with and without dizziness
Grill E et al, 2014
Radiographic imaging is indicated in
patients with additional neurologic
symptoms atypical for BPPV
182/18/18
Opinion Only
I have seen patients in the hospital for BPPV in the
morning. They had fully cleared (no symptoms and
a negative Dix Hallpike and roll test) after the
repositioning
The resident wants them scanned prior to leaving
Their BPPV can return from lying flat in the scanner
VESTIBULAR TESTING
Clinicians should NOT order vestibular testing
in a patient who meets diagnostic criteria for
BPPV in the absence of additional vestibular
signs and/or symptoms inconsistent with BPPV
that warrant testing
Recommendation against vestibular testing
based on diagnostic studies with limitations
and a preponderance of benefit over harm.
192/18/18
Supporting Text
Defined vestibular function tests
Comprehensive video
electronystagmography, rotary chair test,
vestibular evoked myogenic potenials,
computerized Posturography,
computerized Head Impulse Testing
Indications for testing
Suspect comorbid vestibular hypofunction
Atypical nystagmus
Failed response to repositioning
Frequent reoccurrences
Supporting Text
Diagnosiscan be made without
specialized equipment
“This does not imply that use of video-
oculographic technology.. Should not be
used when available”
The goggles help in BPPV identification and
differentiation
Unclear or atypical nystagmus may be
seen in up to 13% of persons seen
Bath AP et al, 2000
202/18/18
REPOSITIONING PROCEDURES AS INITIAL
THERAPYINITIAL THERAPY
Clinicians should treat, or refer to a
clinician who can treat, patients with
posterior canal BPPV with a canalith
repositioning procedure.
Strong recommendation based on
systematic reviews of randomized
controlled trials and a preponderance of
benefit over harm
Supporting Text
Single canalith repositioning
maneuver is >10 times more effective
than 3 times a week Brandt Daroff
exercises (Hilton MP et al, 2014)
Success at 80.5% with the canalith
repositioning maneuver vs 25%
success with the Brandt Daroff
exercise (Amor-Dorado JC 2012)
212/18/18
Supporting Text
High variability in the number of times the
canalith repositioning maneuver is applied
for the initial intervention
Benefit of multiple repositioning maneuvers in
persons who are not fully cleared (Gordon
and Gadoth, 2004; Reinink H et al 2014)
Supporting Text
2 major treatments for the posterior canal
are the modified Epley and the Semont
(Liberatory maneuver)
Lateral canal BPPV
Evidence is mounting for the repositioning
maneuvers
Determining the side of the horizontal canal
BPPV and confusion in names of the
maneuvers in literature is a problem
222/18/18
Biomechanical
physics of BPPV
(Rabbitt)
232/18/18
DIX-HALLPIKE TESTING
BPPV is caused by
displaced otoconia from the Only one way
utricle most commonly into the
posterior canal OUT
Hillman & McLaren, 1979
Canalith Repositioning Treatments or Epley
Maneuvers
242/18/18
Biomechanics
of canalith
repositioning
maneuver
R. Rabbitt
Canalith Repositioning
Treatment or Epley Maneuver
252/18/18
Changing Maneuver Based on
Quality of Eye movement
Supporting Text.
Horizontalcanal BPPV: geotropic/apogeotropic
Increased spontaneous recovery rates
Maneuvers discussed in the CPG
Lempert 360 roll
Gufoni for geotropic lateral canal BPPV
Success ranges 50-100% (Cassani 2011; Kim et al 2012)
262/18/18
Supporting Text.
Gufoni for apogeotropic lateral canal BPPV
Success rates are 62-73% (Kim JS 2012),
Forced Prolonged Positioning
Success ranges 75-90% (Casani 2002; Chiou W-Y 2005;
Appiani GC 2005)
Self Administered modified Epley and Semont
Success 64% vs 23% for Brandt Daroff (Radtke et al
1999)
Lempert Maneuver
272/18/18
Gufoni for geotropic type of benign paroxysmal positional vertigo involving
the horizontal canal (HC) (left affected ear)
Randomized clinical trial for geotropic horizontal canal benign paroxysmal positional vertigo.
Kim, Ji; Oh, Sun-Young; Lee, Seung-Han; Kang, Ji; Kim, Dong; Jeong, Seong-Hae; Choi, Kwang-Dong; Moon, In; Kim,
Byung; Kim, Hyo
Neurology. 79(7):700-707, August 14, 2012.
DOI: 10.1212/WNL.0b013e3182648b8b
2
Geotropic Right Lateral
Canal
• Forced Prolonged Positioning
(Vannuchhi et al, 1997) –
• Shown for geotropic right LC-BPPV.
• Geotropic –Lie down on back. Roll
towards involved side. Sleep on
uninvolved side.
282/18/18
Apogeotropic Right Lateral
Canal
• Forced Prolonged Positioning
(Vannuchhi et al, 1997)
Apogeotropic – Lie down on
back. Roll towards uninvolved
side. Sleep on involved side.
POST-PROCEDURAL RESTRICTIONS
Clinicians should not recommend post‑‑
procedural postural restrictions after canalith
repositioning procedure for posterior canal
BPPV.
Strong recommendation against restrictions
based on randomized controlled trials with
minor limitations and a preponderance of
benefit over harm.
292/18/18
OBSERVATION AS INITIAL THERAPY
Clinicians may offer observation with follow up as
initial management for patients with BPPV.
Option based on data from cohort and observational
studies with heterogeneity and a relative balance of
benefits and harms.
Supporting Text
We don’t like this statement
Frustrating given the level of success with the
repositionings and the potential RISK
Medical option when disease is self
limiting and/or when likely benign
Spontaneous rates 27-38% (Hilton, 2014)
Usually no serious adverse effects
Nausea, cervical spine pain, headache
Listed contra indications
302/18/18
Supporting Text
No consensus on length of “observation”
Panel favored CRP in subsets of patients
High risk for falls
More disabling symptoms
More distraught/anxious (PPPD not named
yet)
Observation may be more of option in
Primary care settings
Supporting Text
Risksof observing, patients should be
informed..
Possibility of longer duration of symptoms
WANTED TO ALSO SAY:
Fall risk
Death
Disability
Poorerquality of life
Triggering
event for persistent postural and
perceptual dizziness (PPPD)
312/18/18
VESTIBULAR REHABILITATION
The clinician may offer vestibular rehabilitation
in the treatment of BPPV.
Option based on controlled observational studies
and a balance of benefit and harm.
Supporting Text
There are physicians using Cawthorne
Cooksey/Brandt Daroff (BD) for BPPV
Vestibular rehab is significantly less
effective as first-line treatment
Indicated for patients
Persistent disability following
repositioning (refractory and/or high
recurrence)
Refuse the repositioning
Not candidate for the repositioning or it
is too difficult to perform the maneuvers
Comorbid modifying factors
322/18/18
Supporting Text
Insome cases, vestibular rehab is necessary
optimize resolution of disability
Clear residual complaints (dizziness/
balance)
Improved gait stability
Decrease fall risk
Secondary assessment to further
differential diagnosis
Comorbid hypofunction, modifying
factors for recovery
Supporting Text
Clarification on Customized vestibular
rehabilitation vs generic
Potential to improve outcomes
Role of better education and more tailored
exercise (Hall et al, 2016)
332/18/18
MEDICAL THERAPY
Clinicians should not routinely treat BPPV with
vestibular suppressant medications such as
antihistamines and/or benzodiazepines.
Recommendation against routine medication
based on observational studies and a
preponderance of benefit over harm.
Supporting Text
Review of pharmacologic
management with vestibular
suppressant medications
Benefit
Reduce spinning
Reduce accompanying motion
sickness
342/18/18
Supporting Text: Harm
Drowsiness, cognitive deficits, GI motility,
vision
Especially polypharmacy effects in elderly
Independent risk factor for falls
Interference with central compensation for
vestibular insult
Obscure diagnostic findings
Evidencethat BPPV, especially torsional,
nystagmus is not suppressed well with
common vestibular suppressants
Supporting Text
Data continues to strongly reinforce superiority
of active treatment (repositioning) for BPPV
rather then medication
Some benefit as adjunctive in select patients
Minimizing discomfort during CRP
Prophylaxis for severe nausea and/or
vomiting
Treating psychological anxiety secondary to
BPPV
352/18/18
Supporting Text
Power statement
“There is no evidence in the literature to
suggest that any of these vestibular
suppressant medication are effective as
a definitive, primary treatment for BPPV
or effective as a substitute for
repositioning maneuvers.”
p.30 of the CPG
OUTCOME ASSESSMENT
Clinicians should reassess patients within 1
month after an initial period of observation or
treatment to document resolution or
persistence of symptoms.
Recommendation based on observational
outcomes studies and expert opinion and a
preponderance of benefit over harm.
362/18/18
Supporting Text
Stressed variable responses to
CRP
Accuracy of initial diagnosis
Comorbidities/modifying
factors
Supporting Text
Treatment failures defined as >2-5 canalith
repositioning sessions
Definition of treatment success
Subjective symptom resolution and/or
conversion to a negative Dix Hallpike
If symptom-based assessment used
Detailed
to differentiate decreased/minimized
symptoms due to AVOIDANCE from true
symptom resolution
372/18/18
Supporting statement
Responseto treatment, optimal recovery
and any residual symptoms need to be
assessed
Ifurgent care initial treatment, the primary
care physician is suitable to reassess
Time frame within 1 month
Rationale
Safety with initial diagnosis
Reduce quality of life impact of unresolved BPPV
Especially as care shifts from the emergency
department/primary care physician rather than
subspecialty
EVALUATION OF TREATMENT FAILURE
Clinicians should evaluate, or refer to a
clinician who can evaluate, patients with
persistent symptoms for unresolved BPPV
and/or underlying peripheral vestibular or
central nervous system disorders.
Recommendation based on observational
studies of diagnostic outcomes in patients
with BPPV and a preponderance of benefit
over harm.
382/18/18
Supporting Text
Need to expeditiously identify treatment
failures
Failure rates of single-session repositioning
8-50%
Rationale
Persistent BPPV may be responsive to further
repositionings and/or vestibular
rehabilitation
Success up to 90-98% with additional
repositionings
Canalith respositionings are the initial
treatment of choice for initial failures
Supporting Text
Coexisting vestibular condition may be
present
Serious central nervous system disorder may
simulate BPPV and need to be identified
Case of paroxysmal positional nystagmus as first
sign of paraneoplastic syndrome
Atypical refractory to care cases need to be
questioned for central nervous system disease
Apogeotropic may be more refractory
Cupulolithiasis in general takes longer to get
better
392/18/18
Supporting Text
Factors associated with treatment failure
Secondary BPPV, e.g. head trauma, neuritis, &
Menieres
Migraine
Complicating comorbiities e.g. Peripheral
Neuropathy
Biomechanical limitations to optimal positioning
e.g severe kyphoscoliosis
BPPV associated with subclinical, underlying
impaired vestibular function
Pollak L et al (2002)
Supporting Text
Transient vestibular dysfunction (“vestibular
hangover”) can occur (1-3 months) with BPPV even
following successful repositionings especially in elderly
Need to identify these people and start vestibular
rehabilitation
Improve balance, minimize fall risk, and decrease
fear of falling (impaired balance confidence)
Black FO (1984), Blatt P (2000),
Giacomini PG (2002), Chang W-C (2006)
402/18/18
EDUCATION
Clinicians should educate patients regarding
the impact of BPPV on their safety, the
potential for disease recurrence and the
importance of follow‑‑up.
Recommendation based on observational
studies of diagnostic outcomes and
recurrence in patients with BPPV and a
preponderance of benefit over harm.
Supporting Text
Expanded and more detailed with hand out
Embracing advancing evidence of our treatment
efficacy
Education, reducing threat, and giving locus of
control
What we as PT can do SO well
Goals of any Education
Reassurance
Not serious
Clinicians experience with disorder and treating
Normalize experience (understandable frightening
and not so BENIGN)
412/18/18
Supporting Text
Remove threat
Great potential to heal
High success rates
Patient empowerment
Understanding BPPV pathophysiology and rationale
for success
Capacity and role of remaining active/moving again
Optimize Patient Acute and Long term management
Recurrence rates 36% (Hilton, 2014)
Need for early recognition
Greater risk for falls especially with the elderly
Importance of follow-up
What We wish
we could
say….
Implications from
biomechanical modeling,
clinical practice, and non-
randomized studies
422/18/18
What do we wish we could
have said….
Observation is NOT an option
Harm outweighing Benefit
Stronger lateral canal treatment statements
Possibility some patients may need post maneuver
precautions/long term restrictions
Art of maneuvers
Number of repetitions
Statements about cupulolithiasis vs canalithiasis
ID critical components of maneuvers
Rationale and success rates of various maneuvers
Uniqueness of individual/customization
Skilled vs “Youtube-Rx” maneuver
Applying
Mathematical models
Posterior canal “Epley”
Matches ideally with
biomechanical model
Lateral canal
Modeling supports 270 degree
roll (involved side to nose down)
Can we get rid of any need to
think we need to roll prone??
Anecdotal conversions
Epley, avoid initial position
Research Support
Gufoni maneuver success
Forced Prolonged Positioning
Kim Cupulolith Maneuver
2008
432/18/18
Cupulolith
Repositioning
Maneuver: Apogeotropic,
Right LC-BPPV.
Goal: Kim, Jo, Chung, Byeon, and
Lee, 2011-
Moves debris
long arm(1st)
off utricular (4th)
Each position 3
min
Vibration 1wth
and 4th
Sleep
uninvolved
97% success
after 2
maneuvers
1 2 3
5
4 6
442/18/18
Analyzing Gans Maneuver?
Hybrid liberatory/canalith
Number of articles
noted success
increased conversion
rates to Lateral canal
IF in Initial position the
debris is far enough
into the canal
Models stress initial
position as critical
Rolling could
successfully reposition
GANs Maneuver
“Liberatory” maneuver does not
hold up to anatomic scrutiny
Liberation could happen from the
utricular side but would not cause
“Nystagmus burst”
Manuever could force a
“secondary burst”
452/18/18
Predicting a successful treatment
in posterior BPPV
Oh HJ et al Neurology 2007 10; 68(15): 1219-22
Important to monitor the nystagmus
during CRT
78% have a secondary Burst (SB)
12% reversal SB, 10% no SB
80% of BPPV w/reversal and 67% of no
SB failed to resolve
100% of BPPV with orthotropic SB
resolved 1-2 trials
predictive of success
Initial Head Position IMPORTANCE
Use of sloping or Trendelenberg bed
462/18/18
Clinical Practice: Qualtifying
disability beyond “otoliths”
Refractory BPPV associated with
Meniere’s
Balatsouras DG et al 2012
Central and psychogenic/
functional contributors
Faralli M et al 2014
Triggering
of Persistent Postural and
Perceptual Dizziness (PPPD)
Clinical Practice: Post
maneuver Precautions
Devaiah, 2010 Meta analysis
Do the studies answer??
Frog otoconia stick in 5 min (Otsuka K
et al 2010) & randomized controlled
studies show no difference
But do BPPV need to be “taught”
to avoid has the study been done
that asks the right question? (This
does not make sense to me
472/18/18
BPPV Recurrences and
Education…
With Initial presentation is it correct…
“BPPV is highly recurrent, and likely you are going to
have this for the rest of your life”
Clinical belief that not everyone has the same
BPPV recurrence odds
Overall 36% recurrence with up to 47% (Hain TC
2000)
Schruknecht original theory BPPV is in thirds…
1/3: Benign self limiting, highly responsive (isolated
across lifetime)???
2/3: Increased vulnerability (happens increased
risk)???
3/3: Refractory/difficult cases
BPPV: Clinical and Oculographic features in 240 cases; Baloh,
1987
Could we research and further define…
Anterior Canal BPPV???
Initial findings… Discharge…
482/18/18
What about Anterior canal….
Edited out in review process
Although there is growing evidence of the
existence, definability and treatment
effectiveness of anterior canal BPPV
Controversy
Complexity of the diagnosis
Differentiate from central nervous system
involvement
Anagnostou 2015 Systematic Review concluded:
Anterior canal BPPV can be treated safely
Epley or other maneuvers
Symptom resolution rates comparable
More multicenter controlled trials are needed to
make evidence-based recommendations.
Advance Practice with Anterior
Canal BPPV …
Need highly skilled clinicians
Vestibular specialization
Well controlled research
CNS disease
False positives from
opposite side PC BPPV
Inferior Neuritis
generatetorsional down
beating nystagmus
Benign Downbeat
Nystagmus of Aging
Spontaneous
Inversion/Reversal
Neurologicdischarge
from severe PC Rx
492/18/18
Repetitions of Maneuvers???
Perform until evidence of clearing, no standard in research
Epley used multiple repositioning's until
nystagmus cleared
Superior results with repeated repositionings in
one session
Gordon and Gadoth 2004; Korn et al 2007
Variation in clinic
1-3 repositionings/session
Ideal setting: repeat test in 30 minutes and
finish with CRT
usually 2 per session, at most 3 per session
Case Study: How Many
Repetitions should you do??
Initial sidelying testing Initial Treatment
502/18/18
Retest/2nd CRP
Retesting/Teaching home
augmentative self CRT
Final treatment
512/18/18
Key points on
differential
diagnosis
Benign vestibulopathy
Migraine
Differentiating other benign
vestibulopathy…
72y.o with history of recurrent Right Posterior
Canal BPPV
Return symptoms last 2 weeks
Onset associated with tripping and falling
Unsuccessful self Canalith Repositioning attempts
Central screens/testing NORMAL
Computerized Head Impulse testing NORMAL
3 beats Left Beating after head shake Nystagmus
Right Dix Hallpike atypical persistent Right Beating
nystagmus
522/18/18
Initial Exam: Left sidelying and
right roll
Benign Vestibulopathy NOT
BPPV
Proposed etiology: “Light Cupula”
Kim, 2014 Med Hypothesis; T. Imai, 2014 BMJ
Change in density of the endolymph due to inner ear
hypoperfusion
Trauma from microcirculation/compromise
Infection disrupts blood-labyrinth barrier increased
proteins in inner ear
Seen with sudden sensory neural hearing loss
Incidence
4.9% patient’s diagnosed with BPPV
14% patient’s with geotropic direction changing
positional nystagmus
Kim CH et al, Laryngoscope, 2014
CONSIDERED: “Self-limiting benign condition”
532/18/18
Light Cupula Criteria
Kim CH 2014
Persistent Geotropic horizontal DCPN
No latency (no paroxysmal quality) on Roll testing
Presence of Null plane: 15-40 degrees affected side
Lean (supine): Horizontal nystagmus beating away
from affected side
Bow (prone): Horizontal Nystagmus reverses beating
toward the affected side
Spontaneous nystagmus: beating away
Other causes ruled out: Central, Unilateral
peripheral hypofunction
Clinical characteristics of light cupula vs
Lateral Canal Geotropic BPPV
(Schubert MC et al 2017, Adapted from Kim CH et al, 2014)
Light Cupula BPPV: Canalithiasis
Geotropic Nystagmus (GN) YES YES
Persistent YES NO
Prone reversal of GN YES Transient/NO
Fatigability NO YES/NO
Null plane YES YES/NO
Latency NO YES
542/18/18
Management & Outcome
Suspect for benign, self
limiting acute vestibular
crisis
Fit criteria for Right
“Light Cupula”
DOESN’T fit criteria for
lateral canal BPPV
Educated
Taught VORx1
adaptation
Returned in a week
Nystagmus resolved and
symptom free
Migraine and Positional
Nystagmus/Dizziness
Common
3.2 vs 2.4 lifetime
prevalence
Lempert (2009)
Atypical
BPPV or Acute
Unilateral loss
Migraine
Hx
Features
Light, sound
Nausea
Triggers
?headache
552/18/18
Potential for self limiting
resolve
Comorbidity with definable
BPPV
562/18/18
Future
Research
Needs
Research needs
Diagnosticand cost effective studies to ID
subset of patients
Require additional vestibular testing and/or
radiographic testing
Skilled intervention vs self CRT
Determine if CPG changes physician/clinician
behaviors
Perform studies on accuracy of diagnosis and
treatment of BPPV in non-specialty settings
572/18/18
Research Needs
Cost effectiveness for potential advantages for
earlier intervention
Can we take out “observation” as KAS option
Define the subset where observation is HARMFUL
Further epidemiologic studies
Rates of falls with BPPV as underlying cause/
diagnosis
Risk factors associated with development of BPPV
Extended cohort studies on measures associated
with decreased recurrence
Research needs
More Studies concerning confirming presence
and treatment efficacy for Anterior Canal
BPPV
More studies on treatment clarification and
success rates for Lateral canal BPPV
Clarify and standardize the terms use to describe
repositioning maneuvers of lateral canal
Studieson functional impact of BPPV on home
safety, work safety, absences, and driving risks
Develop/validate disease-specific QOL measure
for BPPV
582/18/18
Research Needs
Refine the “Art of BPPV” treatment
Determine optimal # of CRPs, time interval
When might multiple repetitions of maneuver
contraindicated
ID patient and treatment specific risk factors for
recalcitrant BPPV
Investigate role/need of addition VR beyond
isolated CRP
Better Differentiate positional nystagmus/
vertigo that is NOT BPPV
When is post maneuver precautions and long
term restrictions indicated
Summary
BPPV
2017 Revised CPG is a powerful
document
Advocates for treatment
Advances differential diagnosis across multiple
disciplines and treatment settings
Grounds us in state of scientific evidence
Calls for us to further advance practice
PT
has great potential to advance
particularly the “Art of BPPV” practice
592/18/18
Questions??
60BPPV best practice: understanding, applying, and advancing the
2017 Revised Clinical Practice guideline
References
Janene Holmberg, PT, DPT, NCS (Intermountain Hearing & Balance Center, Salt Lake City, UT)
Susan L. Whitney, PT, DPT, PhD, NCS, ATC, FAPTA (University of Pittsburg, PA)
Akin FW, et al (2017). Characteristics and Treatment Outcomes of Benign Paroxysmal
Positional Vertigo in a Cohort of Veterans. Am J Audiol. 2017;26(4):473-480.
Amor-Dorado JD et al. (2012) Particle repositioning maneuver versus Brandt-Daroff Exercise for
the treatment of unilateral idiopathic BPPV of the posterior semicircular canal: a randomized
prospective clinical trail with short- and long-term outcome. Otol Neurotol. 2012 Oct;
33(8):1401-7.
Appiani GC et al (2005) Repositioning maneuver for the treatment of the Apogeotropic variant
of horizontal canal BPPV. Otol Neurotol 2005; 26:257-260.
Agrawal Y et al (2009) Disorders of balance and vestibular function in US adults: data from the
National Health and Nutrition Examination Survey (NHNES), 2001-2004. Arch Intern Med. 2009;
169:938-944.
Baloh RW et al. (1987) BPPV: Clinical and oculographic features in 240 cases. Neurology 1987;
37: 371-378.
Bergenius J, (2006) Tomanovic T. Persistent geotropic nystagmus – a different kind of cupular
pathology and its localizing signs. Acta Otolaryngol 2006; 126:698-704.
Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, Holmberg JM, et al.
(2017) Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). OHNS 2017,
Vol 156 (3S) S1-S 47.
Bhattacharyya N, (2017) Gubbels SP, Schwartz SR, et al. Clinical Practice Guideline: Benign
Paroxysmal Positional Vertigo (Update) Executive Summary. Otolaryngol Head Neck Surg. 2017;
156: 403-16.
Bhattacharyya N, (2017) Hollingsworth DB, Mahoney K and O'Connor S. Plain Language
Summary: Benign Paroxysmal Positional Vertigo. Otolaryngol Head Neck Surg. 2017; 156: 417-
25.
Bhattacharyya N, Whitney SL et al (2008) Clinical Practice guideline: benign paroxysmal
positional vertigo, OHNS. 2008; 129:S47-S81.Balatsouras DB et al (2011) Diagnosis of single or multiple canal BPPV according to type of nystagmus. Intern Journal of Otolayngology 2011. Balatsouras DB et al (2012) BPPV associated with Meniere’s Disease: Epidemiological, Pathophysiologic, Clinical, and Therapeutic Aspects. Annals of Otology, Rhinology & Laryngology. 121(10: 682-688. Balatsouras DG et al (2013) BPPV secondary to Vestibular Neuritis. Eur Arch Otorhinolaryngol 2013 in press DOI 10.1007/s00405-013-2484-2. Baloh RW, (1993) Jacobson K, Honrubia V. Horizontal semicircular canal variant of benign positional vertigo. Neurology. 1993 Dec;43(12):2542-9. Baloh RW (1995), Yue Q, Jacobson KM, Honrubia V. Persistent direction-changing positional nystagmus: another variant of benign positional nystagmus? Neurology 1995;45: 1297–1301. Bath AP et al (2000) Experience from a multidisciplinary “dizzy” clinic. Am J Otol. 2000; 21: 92- 97. Beynon GJ et al (2000) Recurrence of symptoms following treatment of posterior semicircular canal BPPV with a particle repositioning manoeuvere. J Otolaryngol. 2000; 29: 2-6 Black FO et al. (1984) Postural disturbance in patients with BPPV. Ann Otol Rhinol Laryngol. 1984; 93: 595-599. Blatt PJ et al (2000) The effect of the canalith repositioning maneuver on resolving postural instability in patients with BPPV. Am J Otol 2000;21:356-363. Bradshaw AP et al (2010) A Mathematical Model of Human Semicircular Canal Geometry: A New Basis for Interpreting Vestibular Physiology. Journal of the Association for Research in Otolaryngology JARO. 2010; 11: 145-159. Brandt T Daroff RB (1980) Physical Therapy for BPPV. Arch Otolaryngol; 106 (8) 1980: 484-485. Brocchetti F et al (2003) Effect of repetition of Semont’s manoeuvere on BPPV of posterior semicircular canal. Acta Otorhinolaryngo Ital 2003; 23: 428-435. Buki B, (2014) Mandala M and Nuti D. Typical and atypical benign paroxysmal positional vertigo: literature review and new theoretical considerations. J Vestib Res. 2014; 24: 415-23. Burton MJ et al (2012) Extracts from the Cochrane library: modification of the Epley (canalith repositioning) maneuver for posterior canal BPPV. OHNS. 202; 147:407-411.
Chang W-C, et al. (2006) Balance ability in patients with BPPV. Otolaryngol Head Neck Surg. 2006; 135:534-540. Chang YS, (2014) Choi J and Chung WH. Persistent Direction-Fixed Nystagmus Following Canalith Repositioning Maneuver for Horizontal Canal BPPV: A Case of Canalith Jam. Clin Exp Otorhinolaryngol. 2014; 7: 138-41. Casani A, (1997) Giovanni V, Bruno F, Luigi GP. Positional vertigo and ageotropic bidirectional nystagmus. Laryngoscope 1997; 107:807– 813. Casani AP et al (2001) The treatment of horizontal canal BPPV: our experience in 66 cases. Laryngoscope. 2002; 112:172-178. Casani AP et al (2011) Anterior Canal lithiasis treatments. OHNS 2011; 144: 412-418. Casani AP et al (2011) Horizontal semicircular canal BPPV: effectiveness of two different methods of treatment. Audiol Neurootol. 2011; 16:175-184. Chen FY ( 2013), Chen TS, Wen C, et al. [Objective characteristics of nystagmus in horizontal semicircular canal benign paroxysmal positional vertigo]. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2013; 48: 622-7. Chiou W-Y et al (2005) A single therapy for all subtypes of horizontal canal positional vertigo. Laryngoscope. 2005; 115:1432-1435. Crevits L (2004) Treatment of anterior canal benign paroxysmal positional vertigo by a prolonged forced position procedure. J Neurol Neurosurg Psychiatry. 2004; 75:779-781. Colledge NR et al (1996) Evaluation of investigations to diagnose the cause of dizziness in elderly: a community based controlled study BMJ. 1996; 313:788-792. D'Silva LJ, (2017) Whitney SL, Santos M, Dai H, Kluding PM. The impact of diabetes on mobility, balance, and recovery after repositioning maneuvers in individuals with benign paroxysmal positional vertigo. J Diabetes Complications. 2017;31(6):976-982. De la Meilleure G (1996), Dehaene I, Depondt M, et al. Benign paroxysmal positional vertigo of the horizontal canal. J Neurol Neurosurg Psychiatry 1996; 60:68 –71. Devaiah AK (2010) Postmaneuver Restrictions in BPPV. OHNS 2010; 142:155-159. Dominguez-Duran E, (2017) Domenech-Vadillo E, Alvarez-Morujo de Sande MG, et al. Analysis of risk factors influencing the outcome of the Epley maneuver. Eur Arch Otorhinolaryngol. 2017;274(10):3567-3576
Faldon ME Bronstein (2008) Head Accelerations during Particle Repositioning with BPPV. Audiol Neurotol 2008;13:345-356. Faralli M et al (2012) Dizziness in Patients with Recent Episodes of BPPV: Real Otolithic Dysfunction or Mental Stress? J Otolaryng Head Neck Surgery 2009; 38 (3): 375-380. DOI 10.2310/7070.2009.080073 Fife TD. (1998) Recognition and management of horizontal canal benign positional vertigo. Am J Otol 1998;19:345–351. Fife TD et al (2008) Practice parameter: therapies for BPPV (an evidence-based review). Report of the Quality Standards Subcommiette of the American Academy of Neurology. Neurology. 2008; 70:2067-2074. Fife TD. (2009) Benign paroxysmal positional vertigo. Semin Neurol. 2009; 29: 500-8. Giacomini PG. et al (2002) Long-term postural abnormalities in BPPV. ORL J Otorhinolaryngol Relat Spec. 2002; 64: 237-241. Gordon CR & Gadoth N. (2004) Repeated vs single physical maneuver in BPPV. Acta Neurol Scand. 2004 Sept; 110(3):166-9. Grill E et al. (2014) Health services utilization of patients with vertigo in primary care: a retrospective cohort study. J Neurol. 2014; 261: 1492-1498. Hanley K et al. (2001) A systematic Review of vertigo in primary care. Br J Gen Pract. 2001; 51:666-671. Hain TC et al. (2002) Vibration does not improve results of the canalith repositioning procedure. Arch Otolaryngol Head Neck Surg. 2000; 126: 617-622. Hain TC (2005) Clinical Implications of Mathematical Model of BPPV Ann NY Acad Sci 2005; 1039:384-394. Haynes DS et al (2002) Treatment of BPPV using Semont Maneuver: Efficacy in Patients Presenting Without Nystagmus. Laryngoscope 2002; 112: 796-801. Heidenreich KD et al (2011) Persistent positional nystagmus: a case of superior semicircular canal BPPV? Laryngoscope. 2011; 121:1818-1820. Helminski JO (2010) Effectiveness of CRT in BPPV: A Systematic Review. PTJ 2010;90:663-678. Hilton MP, Pinder DK. The Epley (canalith repositioning) maneveure for BPPV. Cochrane database of systematic reviews 2014, Issue 12. Art. No: CD003162.
Horii A, (2003) Imai T, Mishiro Y, et al. Horizontal canal type BPPV: bilaterally affected case treated with canal plugging and Lempert's maneuver. ORL J Otorhinolaryngol Relat Spec. 2003; 65: 366-9. Hunt WT et al (2012) Modifications of the Epely (canalith repositioning) manoeuvre for posterior canal BPPV. Cochrane Database Sys Rev. 2012; (4): CD008675. Ichijo H. (2012) Persistent direction-changing geotropic positional nystagmus. Eur Arch Otorhinolaryngol 2012; 269:747-751. Imai T, (2017) Takeda N, Ikezono T, et al. Classification, diagnostic criteria and management of benign paroxysmal positional vertigo. Auris Nasus Larynx. 2017;44(1):1-6. Jung HJ et al (2012) Anxiolytics reduce residual dizziness after successful canalith repositioning maneuvers in BPPV. Acta Otolaryngol. 2012; 132: 277-284. Kerber KA, (2017) Forman J, Damschroder L, et al. Barriers and facilitators to ED physician use of the test and treatment for BPPV. Neurol Clin Pract. 2017; 7: 214-24. Kim CH, (2014) Kim MB, Ban JH. Persistent geotropic direction-changing positional nystagmus with a null plane: the light cupula. Laryngoscope 2014; 124:E15-19. Kim CH, (2016) Kim YG, Shin JE, Yang YS and Im D. Lateralization of horizontal semicircular canal canalolithiasis and cupulopathy using bow and lean test and head-roll test. Eur Arch Otorhinolaryngol. 2016; 273: 3003-9. Kim HA, (2012) Yi HA and Lee H. Apogeotropic central positional nystagmus as a sole sign of nodular infarction. Neurol Sci. 2012; 33: 1189-91. Kim HA, (2017) Park SW, Kim J, et al. Efficacy of mastoid oscillation and the Gufoni maneuver for treating apogeotropic horizontal benign positional vertigo: a randomized controlled study. J Neurol. 2017; 264: 848-55. Kim JS, (2012) Oh SY, Lee SH, et al. Randomized clinical trial for geotropic horizontal canal benign paroxysmal positional vertigo. Neurology. 2012; 79: 700-7 Kim JS et al (2012) Randomized clinical trial for Apogeotropic horizontal canal BPPV. Neurology 2012; 28: 159-166. Kao WT, (1994) Parnes LS, Chole RA. Otoconia and otolithic membrane fragments within the posterior semicircular canal in benign paroxysmal positional vertigo. Laryngoscope. 2017;127(3):709-714.
Korn GP et al (2007) Repeated Epley’s maneuver in the same session in BPPV. Rev Bras Otorrinolaringol 2007; 73(4): 533-9. Lee JD et al. (2014) A multicenter Randomized double-blind study: comparison of the Epley, Semont, and sham maneuvers for the treatment of posterior canal BPPV. Audiol Neurotol. 2014; 19(5): 336-41. Lechner C et al (2014) Causes and characteristics of horizontal positional nystagmus. J Neurol (2014) 261:1009-1017. Lempert T. (1994) Horizontal benign positional vertigo. Neurology 1994; 44:2213–2214. Lempert T et al (2009) Epidemiology of vertigo, migraine, and vestibular migraine. J Neurol. 2009; 256:333-338. Li JC et al 2000. Cost effective management of BPPV using canalith repositioning. OHNS. 2000; 122:334-339. Lopez-Escamez JA. (2009) Role of vestibular testing in diagnosis of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2009; 141: 7-9; author reply 10-1 McClure JA. (1985) Horizontal canal BPPV. J Otolaryngol 1985; 14:30 –35. McDonnell MN, Hillier LS. (2015) Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev. 2015;(1): CD005397. Moon SY, (2006) Kim JS, Kim BK, et al. Clinical characteristics of benign paroxysmal positional vertigo in Korea: a multicenter study. J Korean Med Sci 2006; 21:539 –543. Newman-Toker, DE et al (2015) TiTrATE: a novel, evidence-based approach to diagnosing acute dizziness and vertigo. Neurol CLin. 2015; 33:577-599. Obrist D, (2016) Nienhaus A, Zamaro E, Kalla R, Mantokoudis G and Strupp M. Determinants for a Successful Semont Maneuver: An In vitro Study with a Semicircular Canal Model. Front Neurol. 2016; 7: 150. Oghalai JS et al. (2000) Unrecognized BPPV in elderly patients. Otolarygol HNS. 2000; 122:630- 634. Oh HJ Kim JS et al (2007) Predicting a successful treatment in posterior canal benign paroxysmal positional vertigo. Neurology 2007; 68(15): 1219-22. Otsuka K (2010) Model experiments of otoconia stability after canalith repositioning procedure of BPPV. Acta Oto-Laryngologica 2010; 1-6 DOI: 10.3109/00016480903456318.
Perez-Vazquez P, (2017) Franco-Gutierrez V, Soto-Varela A, et al. Practice Guidelines for the Diagnosis and Management of Benign Paroxysmal Positional Vertigo Otoneurology Committee of Spanish Otorhinolaryngology and Head and Neck Surgery Consensus Document. Acta Otorrinolaringol Esp. 2017. Pollak L et al. (2002) Effectiveness of the particle repositioning maneuver in BPPV with and without vestibular pathology. Otol Neurotol 2002;23:79-83. Prokopakis EP, (2005) Chimona T, Tsagournisakis M, et al. Benign paroxysmal positional vertigo: 10-year experience in treating 592 patients with canalith repositioning procedure. Laryngoscope. 2005 Sep; 115(9):1667-71. Rabbitt RD et al (2001) How endolymph pressure modulates Semicircular canal primary afferent discharge. Annals New York Academy of Science 2001; 313-320. Radtke A et al (1999) A modified Epley’s procedure for self-treatment of BPPV. Neurology.1999; 53: 1358-1360. Radtke A et al (2004) Self treatment of BPPV: Semont maneuver vs Epley procedure. Neurology. 2004; 63: 150-152. Rajguru SM Rabbit RD (2004) 3D Biomechanical Model of BPPV. Annals of Biomedical Engin. 2004;32(6):831-846. Rajguru SM Rabbit RD (2005) Biomechanics of HC BPPV. Journal of Vestibular Research 2005;15:203-214. Rajguru SM Rabbit RD (2007) Afferent Responses During Experimentally-induced Semicircular Canalithiasis. J Neurophysiol 2007;97:2355-2367. Reinink H et al. (2014) Rapid systematic review of repeated application of the Epley maneuver for treating posterior BPPV. Otolaryngol Head Neck Surg. 2014; 151: 399-406. Roberts RA, (2006) Gans RE and Kastner AH. Differentiation of migrainous positional vertigo (MPV) from horizontal canal benign paroxysmal positional vertigo (HC-BPPV). Int J Audiol. 2006; 45: 224-6. Ruckenstein MJ. (2001)Therapeutic efficacy of the Epley canalith repositioning maneuver. Laryngoscope. 2001; 111:940-945.
Sacco RR, et al. (2014) Management of BPPV: a randomized controlled trial. J Emerg Med. 2014 Apr; 46(4):575-81. Sekine K et al (2006) Natural history of BPPV and efficacy of Epley and Lemper tmaneuvers. Otolaryngol Head Neck Surg. 2006; 135:529-533. Schubert MC, (2017) Dunlap PM and Whitney SL. A Case Study of High-Velocity, Persistent Geotropic Nystagmus: Is This BPPV? J Neurol Phys Ther. 2017; 41: 182-6. Soto Varela, A et al (2001) BPPV: a comparative prospective study of the efficacy of the Brandt and Daroff exercises, Semont and Epley maneuver. Rev Laryngol Otol Rehinol (Bord). 2001; 179-183. Steddin S, (1996) Ing D and Brandt T. Horizontal canal benign paroxysmal positioning vertigo (h- BPPV): transition of canalolithiasis to cupulolithiasis. Ann Neurol. 1996; 40: 918-22. Squires TM et al (2004) A Mathematical Model for top shelf vertigo: the role of sedimenting otoconia in BPPV. J of Biomechanics 37: (2004): 1137-1146. Takaya S (2002) and Yamamoto T. [Horizontal canal benign paroxysmal positional vertigo (HC- BPPV) with direction-changing apogeotropic nystagmus: a case with the more-triggering side altering over a short-term]. No To Shinkei. 2002; 54: 321-5. Tomanovic T (2011) and Bergenius J. Can the nystagmus pattern in patients with a ‘light cupula’ be reproduced in hemi-labyrinthectomized subjects during positional alcohol nystagmus 1? Acta Oto-Laryngologica, 2011; 131: 929–936 Tan F, (2017) Bartels C, Walsh RM. Our experience with 500 patients with benign paroxysmal positional vertigo: Reexploring aetiology and reevaluating MRI investigation. Auris Nasus Larynx. 2017. Tang H, (2017) Li W. Advances in the diagnosis and treatment of benign paroxysmal positional vertigo. Exp Ther Med. 2017;14(3):2424-2430. Toupet M et al (2012) Effect of repositioning maneuver type and postmaneuver restrictions on vertigo and dizziness in BPPV. Scientific-WorldJournal. 2012; 2012: 162123. Van den Broek EM et al. (2014) Systematic review: efficacy of Gufoni maneuver for treatment of lateral canal BPPV with geotopic nystagmus. Otolaryngol Head Neck Surg. 2014; 150: 933- 938. Vannucchi P. et al (1997) Treatment of horizontal semicircular canal BPPV. J Vest Res. 1997; 7: 1-6.
Von Brevern M et al. (2007) Epidemiology of BPPV: a population based study. J Neurol Neurosurg Psychiatry 2007; 78: 710-715. von Brevern M. (2013) Benign paroxysmal positional vertigo. Semin Neurol. 2013; 33: 204-11. Wahlgren A and Palombaro K. Evidence-based physical therapy for BPPV using the International Classification of Functioning, Disability and Health model: a case report. J Geriatr Phys Ther. 2012; 35: 200-5. Von Brevern M et al. (2015) BPPV: diagnostic criteria. J Vestib Res. 2014; 25:104-117. Wang H, et al. (2014) Delayed diagnosis and treatment of BPPV associated with current practice. Eur Arch Otorhino. 2014; 271:261-264. Yacovino (2009) New rx of AC BPPV. J Neurol 2009;256:1851-1855. Yahav O, (2015) Cohen-Atsmoni S, Len A and Roth Y. Treatment of horizontal canal BPPV: pathophysiology, available maneuvers, and recommended treatment. Laryngoscope. 2015; 125: 1959-64. Yetiser S. (2016) Should the clinician do the tests for benign paroxysmal positional vertigo even in the presence of spontaneous nystagmus at primary gaze? Clin Case Rep. 2016;4(7):708-709 Zuma e (2016) Maia FC, Albernaz PL, Cal RV. Behavior of the Posterior Semicircular Canal After Dix-Hallpike Maneuver. Audiol Res. 2016;6(1):140.
PATIENT INFORMATION
Frequently Asked Questions:
Benign Paroxysmal Positional Vertigo (BPPV)
QUESTION ANSWER
What is BPPV? Benign Paroxysmal Positional Vertigo (BPPV) is the most common inner ear
problem and cause of vertigo, or false sense of spinning.
BPPV is a specific diagnosis and each word describes the condition:
Benign: it is not life-threatening, even though the symptoms can be very intense
and upsetting
Paroxysmal (par-ek-siz-muhl): it comes in sudden, short spells
Positional: certain head positions or movements can trigger a spell
Vertigo: feeling like you are spinning or the world around you is spinning1
What causes BPPV? There are crystals of calcium carbonate that are a normal part of our inner ear
and help us with our balance and body motion. These tiny rocklike crystals or
“otoconia” (oh-toe-cone-ee-uh) are settled in the center “pouch” of the inner
ear. BPPV is caused by the crystals becoming “unglued” from their normal
place. They begin to float around and/or get stuck on sensors in the wrong part
or wrong canal of the inner ear. The most intense part of your BPPV symptoms
have to do with how long it takes the crystals or sensor to settle after you move
or change your head or body position. As the crystals move and settle, your
brain is getting powerful (false) messages telling you that you are violently
spinning when all you may have done is laid down or rolled over in bed.
What are the common symptoms Everyone will experience BPPV differently, but there are common symptoms.
and how can BPPV affect me? The most common symptoms are distinct triggered spells of vertigo or spinning
sensations. You may experience nausea (sometimes vomiting) and/or a severe
sense of disorientation in space. You may also feel unstable or like you are
losing your balance. These symptoms will be intense for seconds to minutes.
You can have lasting feelings of dizziness and instability, but at a lesser level,
once the episode has passed. In some people, especially seniors, BPPV can
appear as an isolated sense of instability brought on by position change
like sitting up, looking up, bending over and reaching. BPPV does not cause
constant severe dizziness and is usually triggered by movement. BPPV does
not affect your hearing or cause you to faint. The natural course of BPPV is to
become less severe over time. People will often report that their very first BPPV
spinning episode was the worst and the following episodes were not as bad.
1
Adapted from Woodhouse, S. “Benign Paroxysmal Positional Vertigo (BPPV)”. (n.d., para. 1). Retrieved from
https://vestibular.org/understanding-vestibular-disorders/types-vestibular-disorders/benign-paroxysmal-positional-vertigo
SOURCE: Bhattacharyya N, Gubbels SP, Schwartz SR, et al; Clinical Practice Guideline: Benign
Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017; 156(3_suppl):s1-s47.
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