Literature Review Supporting a Minimum Data Set for the Diagnosis
and Treatment of Benign Paroxysmal Positional Vertigo
Nicole Miranda, PT, MPT
Faculty Advisors:
Amy Stone Hammerich, PT, DPT
Julie Whitman, PT, DScPT
Regis University
Advanced Clinical Decision Making
DPT 740
June 10, 2008
Background Information
Benign Paroxysmal Positional Vertigo (BPPV) is a syndrome characterized by brief
episodes of a spinning or vertiginous sensation which is often precipitated by head
motion in the vertical or horizontal planes. Each episode is described as an ‘attack’
where a combination of vertigo, dizziness, unsteadiness and/or nausea can last for days to
months with the possibility of recovering as spontaneously as it began. BPPV is
frequently seen in emergency departments, with high cost for unnecessary diagnostic
testing and interventions due to poor identification of signs and symptoms as the average
BPPV patient reportedly consults with four physicians and incurs costs of up to $2000
with no positive findings or resolution of symptoms.1,2
The prevalence of BPPV is relatively unknown due to the lack of recognition by primary
care providers and epidemiology studies which have been largely conducted in
specialized care settings.3 A population-based study performed at the Mayo Clinic in
Minnesota indicated a .06% incidence of BPPV, with a 38% increase incidence with each
decade of life.4 Other population-based questionnaires have found that 20-30% of adults
report a rotational dizziness as a primary medical complaint.5 The increased prevalence
of BPPV in women than men (2:1) may be associated with higher prevalence of migraine
in women.3 The syndrome is characterized by an ‘active phase’, during which
spontaneous vertigo attacks typically occur for days or weeks, or even months in chronic
conditions. The subsequent ‘inactive phase’ ranges from no symptoms to a persistent
sense of mild to moderate insecurity or abnormal sensations associated with instability.6
The mechanism of action in BPPV continues to be debated. Schuknecht7 initially
proposed the concept of cupulolithiasis, where otolithic particles are released from the
utricle and become lodged on the cupula of the posterior semicircular canal. The weight
of the otoconia causes deflection of the cupula in response to change in gravitational pull
with altered head position, which results in nystagmus. An alternative theory of
canalithiasis postulates that free-floating otolithic debris moves within the endolymphatic
fluid of the semicircular canals in response to changes in head position and the force of
gravity.8
2
BPPV is idiopathic in approximately 50% of cases, with secondary BPPV being
associated with head trauma, and inner ear disorders such as vestibular neuritis,
labyrinthitis, vestibular migraine and Meniere’s Disease.3 Recurrence of BPPV has been
found to be higher in cases associated with head trauma and in females.9,10 The highest
recurrence rate has been found in the first year, at 80%; while recurrence rates are less
than 5% after 5 years.10
Variant Forms of BPPV
The posterior/inferior semicircular canal is affected in approximately 96% of cases of
benign paroxysmal positional vertigo.11 The posterior canal is the most often affected
canal as it is the most dependent organ in both supine and upright positions, which allows
the otlithic debris to move through the canal with respect to gravity.12 Failure to resolve
BPPV with standard repositioning maneuvers has led to further studies investigating
variant forms of BPPV which occur in both the lateral/horizontal and anterior/superior
canals.
Pictorial diagram of otoconia displaced in the posterior semicircular canal.13
Horizontal canal variant of BPPV affects 2-15% of those with BPPV.14,15 Individuals
suffering from horizontal canal BPPV frequently complain of symptoms with rolling over
in bed and have increased reports of nausea and vomiting associated with vertigo. White,
3
et al.14 reported that Dix-Hallpike testing alone does not adequately identify BPPV of the
horizontal canal, clarifying the need for supine testing for assessment of persons with
BPPV.
The anterior canals are the least often affected canals due to their superior position and
the relative inability of the otolithic debris to travel against gravity. Schratzenstaller, et
al.12 reviewed 3 case studies using high resolution 3D MRI and concluded that
canalithiasis of the anterior canal can occur if structural changes have occurred in the
lumen of the anterior canal, creating an adhesive endothelium, and if there is a filling
defect visible on HR-3D-MRI due to a solid structure in the anterior canal.
Proper diagnosis and determination of which semicircular canal(s) are involved is
imperative for selection of intervention techniques. Failure to resolve BPPV with
customary repositioning maneuvers often indicates a chronic or persistent case of vertigo,
and may be an indication for further medical management.
Statement of Purpose
South Valley Physical Therapy, P.C. has implemented a protocol for treatment of persons
with BPPV in an effort to determine success and failure in the resolution of BPPV via
physical therapy intervention, and to facilitate a team approach with physicians who
manage complicating factors associated with vertigo. According to this protocol, failure
to clear the BPPV through the use of repositioning maneuvers after 3 physical therapy
visits results in notification of the referring physician of a case of ‘persistent BPPV’ and
to indicate the possible need for further medical work-up. Referral back to the MD may
lead to alterations in medications or diagnostic testing such as MRI to rule out a neuroma
or structural abnormality within the semicircular canals.
If a patient returns to physical therapy with no positive findings or changes in medication,
ductolithiasis may be suspected and the patient begins a 4-week program of cranial
oscillation. Ductolithiasis has been described by Zappia and Becvarovski16 as a build up
of particles causing blockage of the endolyphatic duct, which causes reduced flow of
4
endolymphatic fluid and hydrops. Following four weeks of cranial oscillation the BPPV
episode is either cleared by resumed flow of endolymphatic fluid and opening of the duct,
or further consultation with the MD is indicated. Cases involving failure to cure the
BPPV episode require further differential diagnosis, which makes a team approach and
effective communication imperative to allow one to return to previous life activities.
The purpose of this project is to create a Minimum Data Set (MDS) and data collection
form to clinically analyze whether the above described protocol provides effective
management and resolution of BPPV. The data will be collected and assessed according
to the canal(s) involved and whether intervention includes repositioning maneuvers,
habituation exercises, sleeping precautions, cranial oscillation and /or medical
intervention. The length of time to resolve BPPV and whether or not further vestibular
rehabilitation is indicated will also be recorded for assessment of clinical outcomes.
Diagnosis
The Dix-Hallpike Test is the ‘gold standard’ for diagnosis of BPPV.17,18 The test consists
of moving a person from long sitting to supine with the head turned 45 degrees to one
side and the neck extended 20-30 degrees. The supine position, with neck rotated and
extended, is maintained for 30-60 seconds to observe any nystagmus. A positive test
results when paroxysmal positional nystagmus is observed.
Right Dix-Hallpike Test13
5
The direction of the nystagmus and the side to which the head is rotated indicate the canal
involvement in BPPV. In posterior canal BPPV, during a right Hallpike test nystagmus
occurs in a clockwise direction; whereas during a left Hallpike test posterior canal
involvement is indicated when the nystagmus is appreciated in a counterclockwise
direction. Anterior canal BPPV can be detected on Dix-Hallpike testing with the
presence of counterclockwise nystagmus during right Hallpike testing or clockwise
nystagmus on left Hallpike testing.19
BPPV associated with cupulolithiasis reportedly causes symptoms when the head is
hanging below the horizon, which causes deflection of the cupula of the posterior canal.19
Vertigo symptoms and nystagmus should occur immediately upon placing a person in the
provocative position and should persist the entire time the position is maintained, as the
cupula remains deflected in the dependent position. Canalithiasis is suspected if there is
a latency period of 1-40 seconds after moving into the provoking position followed by an
increase and subsequent decrease in both nystagmus and vertigo sensation that
extinguishes within 60 seconds.19
A Roll Test is commonly used to diagnose horizontal canal involvement in BPPV.19
During the Roll Test the person is brought back in to a supine position with the head
flexed 20 degrees. Upon reaching the supine position, the head is rotated quickly toward
one side with observation for the presence or absence of nystagmus. The head is then
brought back to midline and quickly turned to the opposite side. A positive test results
with the presence of nystagmus in the geotropic (toward the ground) or ageotrophic
(away from the ground) direction. Geotrophic nystagmus will typically fatigue and
indicates canalithiasis, while ageotrophic nystagmus will be persistent due to suspected
cupulolithiasis.19
Treatment Interventions and Efficacy
Intervention for BPPV consists of habituation exercises and repositioning maneuvers that
were developed in an effort to return the otoconia to the utricle. The Semont, or
‘liberatory’ maneuver is characterized by a brisk movement from one sidelying position
6
to the opposing sidelying position, with the head turned 45 degrees out of the plane of the
body with either nose up or nose down depending on the canal involved. The brisk
motion is thought to dislodge the debris from the cupula in cases of cupulolithiasis for
either anterior or posterior canal BPPV.
The Epley20 maneuver, often referred to as the canalith repositioning procedure (CRP),
was designed to move particles from the semicircular canal back to the utricle by moving
a person through a series of positions to push the debris through the affected posterior or
anterior canal. The original Epley maneuver involved use of mastoid oscillation and premedication with vestibular suppressants. Modified versions of the Epley (CRP) are now
performed with exclusion of mastoid oscillation due to lack of evidence to support
vibration or medication usage assisting in resolution of BPPV.21,22,23 Many retrospective
and prospective RCTs as well as meta-analyses of these studies have been conducted to
investigate the efficacy of repositioning techniques.
The Epley Maneuver13
White et al.24 conducted a meta-analysis to asses the efficacy of repositioning maneuvers
in the treatment of posterior canal BPPV as compared to untreated controls. Nine RCTs
with a total of 505 patients were reviewed. The risk of persistent BPPV without
treatment reduced from 69% to 28% after a single canalith repositioning maneuver, with
an absolute risk reduction of 41%. The number needed to treat (NNT) was 2.38 to
achieve a favorable outcome using repositioning maneuvers to treat posterior canal
7
BPPV. Tusa and Herdman25 similarly reviewed RCTs and found a 67-89% response rate
to the Epley or liberatory maneuvers as compared to a 0-48% response rate with no
treatment or sham treatment. They also reported 8-14% of patients who had ongoing
imbalance after resolution of BPPV, requiring further intervention.
Complications associated with failure to resolve BPPV of the posterior canal include
conversion to the horizontal canal or anterior canal as described by Herdman and Tusa.26
Recommendations were published more recently to reduce conversion of posterior canal
BPPV to other semicircular canals.25 The recommendations include: 1) performing
repositioning maneuvers on a tilt table that ensure head tilt of at least 20 degrees into
extension, 2) instruction in horizontal head motion a few times every hour while awake to
avoid cervical stiffness, and 3) to sit still for at least 2 minutes after treatment and for 10
minutes prior to leaving the clinic to avoid nausea and emesis associated with severe
vertigo.
BPPV affecting the horizontal canal requires repositioning maneuvers in the plane of the
horizontal canal. The technique most often used is the Lempert or Barbecue rotation of
360 degrees. The patient begins in sitting with the head turned to the affected side. The
patient is moved to supine, maintaining the 90 degree head rotation. The person is then
slowly rolled in 90 degree segments until 360 degrees have been completed. Each
position is typically held 15-30 seconds, and then the person returns to sitting avoiding
any cervical extension. A recently published retrospective study determined the efficacy
of the Barbecue maneuver to cure horizontal canal 74% following one maneuver, and
85% after a maximum of 3 rotations.27
While an objective finding of nystagmus is the hallmark for a positive test, subjective
complaint of vertiginous symptoms or nausea during Dix-Hallpike testing without
visualization of nystagmus is not uncommon. This would be considered a positive test
with ‘non-classic’ presentation due to the lack of objective findings of nystagmus, and is
often termed ‘subjective vertigo’. Despite lack of objective test findings, Haynes et al.28
reported a response rate of 86% to an average 1.13 liberatory maneuvers to treat vertigo
8
without nystagmus. This is consistent with findings of Weider et al.29 and Tirellia et al.30,
who found 76% and 93% response to repositioning procedures respectively for subjective
vertigo.
Patients are typically advised to sleep with the head slightly elevated by using one 1-2
extra pillows, to avoid lying on the affected side and to limit head movement for 24-48
hours following repositioning maneuvers. These sleep and activity precautions are
recommended to allow the canalith debris to settle into the utricle and to keep the
particles out of the semicircular canals. However, activity restrictions and sleep
precautions have not been shown to alter the effectiveness of CRP maneuvers.31
Cranial oscillation is a newer intervention that is not well researched and has only been
introduced in the literature by Zappia and Becvarovsk.16 The technique was developed to
mimic the vibration induced during endolymphatic sac surgery based on a hypothesis that
otolithic particles were causing an obstruction of the endolymphatic duct, termed
ductolithiasis. The authors performed cranial oscillation on 10 patients and studied the
short-term effects on vertigo, imbalance, hearing, aural pressure and tinnitus. Vertigo
was resolved in all patients who had vertigo symptoms, and 80% remained clear at the 3
month follow-up.31 While no further clinical trials have been published to date, the
ZBMOP technique has been used successfully in the protocol presented in this paper.
The most recent review of practice parameters performed by the Quality Standards
Subcommittee of the American Academy of Neurology32 assigned Level A
recommendations for use of the CRP in treatment of posterior canal BPPV, based on two
Class I and three Class II studies that reported resolution of symptoms using the CRP
with NNT between 1.43 and 3.7. The Semont maneuver was given a Level C
recommendation based on only one Class II study. Only Class IV studies have been
conducted regarding treatment of horizontal canal and anterior canal BPPV, with a Level
U recommendation, or no specific recommendation, regarding specific selection of
repositioning techniques. Fife, et al.32 further determined:1) there was insufficient
evidence available to determine the efficacy of post-treatment restrictions with use of
9
CRP, 2) use of mastoid oscillation in the treatment of posterior canal BPPV was
determined not to influence response to CRP with Level C recommendations, 3) CRP
was more effective than use of Brandt-Daroff exercises for treatment of posterior canal
BPPV (Level C recommendation), and 4) there is no available evidence supporting the
use of medication to treat BPPV.
Outcome Measures
Multiple outcome measures have been studied in vestibular rehabilitation to determine
balance and fall risk as well as gait stability. The following section discusses the
rationale behind the selection of the 5-item subscale of the Dizziness Handicap Inventory,
the Timed Up & Go and the Dynamic Gait Index as outcome tools for the BPPV MDS.
These outcomes tools will be analyzed alongside the subjective report of perceived
dizziness and nausea via analog scales and the report of falls. Resolution of BPPV will
be determined with negative Dix-Hallpike and Roll Tests, while the below described
outcome measures should help identify those in need of further intervention to reduce
imbalance following BPPV.
Dizziness Handicap Inventory
The Dizziness Handicap Inventory (DHI) was developed by Jacobson and Newman in
order to quantify the perceived handicap in persons with vestibular disorders.33 The
questionnaire contains 25 items divided into nine functional, seven physical and nine
emotional categories, with possible responses of “yes” (4 points), “sometimes” (2 points)
and “no” (0 points). Higher scores reflect increased perceived dizziness, with a possible
total score of 100 points.
Test-retest reliability was found to be high, r=0.97, by Jacobson and Newman. They
determined an 18 point change would be significant to indicate an effect from
intervention with a 95% confidence interval that was not specifically revealed in their
publication. The DHI has been used to study the efficacy of vestibular rehabilitation and
the impact of dizziness on one’s quality of life.34,35,36 The DHI is frequently utilized in
the clinical setting to assess response to treatment in vestibular rehabilitation.37
10
A more recent study has identified specific items of the DHI which indicate an increased
likelihood of a diagnosis of BPPV.38 A 5-item BPPV subscale of the DHI was created as
a tool to assist physicians in the diagnosis of BPPV. The subscale items include looking
up, difficulty getting out of bed, quick head movements, rolling over in bed and bending.
A response of “yes” on all 5 items, with a total score of 20 points produced a likelihood
ratio of 2.29.38 The specificity of a subscore of ≥ 18 was 93.8% and the sensitivity of a
subscore of 0 was 97.6%.7 The estimated OR for the BPPV subscore was 1.07 (95% CI,
1.02-1.13; p<0.01), with odds in favor of BPPV of 0.13 with a subscore of 0, and an
increase in OR by approximately 15% with each two-point increase in the subscore.7
Further analysis by Whitney et al. revealed a two-item subscale, consisting of getting out
of bed and rolling over in bed, which produced a LR of 2.61 with a score of 8 on the two
items.38 Because the DHI has specific items correlated with the diagnosis of BPPV, the
DHI will be used to assess perceived handicap and reduced participation in life activities.
In an effort to reduce the length of time needed to complete the full DHI at each visit, the
5-item subscale will be used to specifically track items associated with BPPV.
Timed Up and Go
The Timed Up and Go (TUG) is a gait assessment tool developed to assess fall risk in the
elderly population with multiple co-morbidities.39 The test consists of rising from a
chair, walking forward 3 meters, turning 180 degrees and returning to sit in the chair at a
comfortable walking speed. Scores of ≥ 13.5 seconds have been related to risk of falls in
the elderly population.40 In studies using the TUG, the chair seat to floor height and
armrest height are standardized.
Whitney et al. looked at the sensitivity and specificity of the TUG and DGI for selfreported falls in 93 subjects with vestibular disorders.41 The specificity of the TUG at
11.1 seconds was 56%, with a PPV of 46% and NPV of 85%. The OR in favor of falling
with a TUG of >11.1 seconds was 5.0 (95%CI 1.80-13.91). The time of 11.1 seconds
was selected as the best cut-off to identify risk for falling in persons with vestibular
11
disorders due to the higher sensitivity that was found previously at a cut-off of 13.5
seconds.
The TUG is an ideal test in the clinic for assessing gait speed in conjunction with rising
from a chair, where the head may tip forward or backward, and incorporates a change in
direction via 180 degree turn. Persons with BPPV typically refrain from movements that
cause fluid to move within the semicircular canals, which would likely cause an increase
in TUG score. While there is ongoing research being done to assess the psychometric
properties of various measures for gait stability and fall risk, the Timed Up & Go appears
to have the best ability to identify risk of falls in persons with vestibular disorders, and is
a standard measure by which to compare outcome measures in current literature.
Dynamic Gait Index
The dynamic gait index (DGI) was originally developed by Shumway-Cook42 to assess
postural stability during gait in adults over 60 years of age at risk of falling. The DGI
consists of 8 gait activities, such as walking with head motion, which are rated on a 4point ordinal scale with a lower score indicating increased impairment. A score of <19
has been identified as the cut off for identifying risk of falls in older adults.43 In a study
looking at the reliability of clinical measures used in vestibular rehabilitation, Hall and
Herdman17 determined excellent inter-rater reliability of the DGI in persons with
peripheral vestibular disorders at k= 0.64 and ICC of 0.86.
Whitney et al.44 investigated the correlation between self-reported falls in 6 months and
the DGI with an odds ratio of 2.58 (95% CI 1.47-4.53) in favor of falls with a DGI score
of <19. Further analysis revealed an OR of 2.38 (95%CI 1.53-5.26) in favor of falls in
subjects with vestibular dysfunction who were >65 years of age, and an OR of 3.55 (95%
CI1.43-8.87) for those 65 or younger. In 2004 Whitney et al.41 related the TUG and DGI
to self-reported falls, as cited above. The sensitivity of the DGI score of <19 was 71%
and the specificity was 53%. The PPV was 39% and the NPV 81% for a score of <19.
The odds ratio in favor of falling with a DGI score of <19 was 2.66 (95% CI 1.08-6.57).
12
The DHI, TUG and DGI will be used in this clinical analysis alongside the patients’
perceived dizziness and nausea as rated on a visual analog scale. Additionally,
individuals will report the number of falls between visits and during the 6 months prior to
initial evaluation. The Tinetti definition for falls will be use for consistency with the
definition used by the Medicare Fall Prevention Act, which states that a fall is “a sudden,
unintentional change in position causing an individual to land at a lower level, on an
object, the floor, or the ground, other than as a consequence of sudden onset of paralysis,
epileptic seizure, or overwhelming external force.”45 The combination of self-report
scales and outcome measures should reflect the impact of BPPV on one’s ability to
function independently without loss of balance or instability of gait as well as measure
the ability to perform routine life activities.
Conclusion
Current literature supports the use of repositioning maneuvers to effectively treat benign
paroxysmal position vertigo, especially related to the more common posterior canal
involvement. Proper identification of the canal involved greatly affects selection of
repositioning maneuvers and ultimately success in clearing BPPV. Failure to respond to
repositioning within three physical therapy sessions has been hypothesized as an
indicator for an atypical case of BPPV that may require alternative intervention via either
cranial oscillation or medical work-up.
A Minimum Data Set for physical therapy intervention in cases of BPPV would both
guide practitioners in utilizing the current best evidence to treat BPPV and determine the
number of maneuvers and number of sessions needed to clear specific types of vertigo.
An MDS would also identify individuals with resistance to repositioning maneuvers and
cases of persistent vertigo that may require further medical diagnosis and/or intervention.
Utilization of the proposed MDS for BPPV in the clinical setting will allow analysis of
current clinical practice and modification of the proposed protocol for treatment of
BPPV.
13
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