A Minimum Data Set for Benign
Paroxysmal Positional Vertigo
Nicole Miranda, PT, MPT
Regis University
Advanced Clinical Decision Making
DPT 740
June 2008
Faculty Advisors:
Amy Stone Hammerich, PT, DPT
Julie Whitman, PT, DScPT
Objectives
• Provide an overview regarding Benign
Paroxysmal Positional Vertigo (BPPV).
• Analyze current evidence and physical therapy
practice patterns associated with BPPV.
• Present a protocol and Minimum Data Set (MDS)
for diagnosis, treatment and outcome
measurement in BPPV.
Benign Paroxysmal
Positional Vertigo
(BPPV)
A syndrome
characterized by brief
vertiginous or
spinning sensations
elicited following head
movement, typically in
the vertical or
horizontal planes.
www.mobile-pedia.com/.../illusion_Spinning.png
BPPV
• Active Phase
– Brief vertigo attacks
that recur with changes
in head position
– Nystagmus typically
present
– Duration of days to
weeks
– Can become chronic
• Inactive Phase
– No vertigo or
nystagmus
– Postural disturbance
– Brief sensations of
dizziness or vertigo
may persist
– Sense of insecurity
– Can be life-long
Giannoni, 2005
Incidence/Prevalence
• 0.06% Incidence per year of newly diagnosed cases –
Retrospective population-based study in Olmstead County,
Minnesota
• 38% increase with each decade of life
– (Froehling, 1991)
• 2.4% Lifetime Prevalence
• Cumulative lifetime incidence nearly 10% by age 80.
– (vonBrevern, 2007)
• 2:1 more prevalent in women than men
• Female prevalence has possible link to migraine
– (Neuhauser, 2007)
Etiology
• 50% Idiopathic
• Secondary Causes:
Head Trauma
 Whiplash Injury
 Vestibular Neuritis
 Labyrinthitis
 Ménière’s Disease
 Migraine
 Endolymphatic Hydrops
 Auto-immune Ear Disease
Inner Ear Anatomy
• Three semi-circular canals
• Anterior (Superior), Posterior (Inferior), Horizontal
(Lateral)
– Provide sensory input regarding head velocity
– Spatial arrangement
• Each plane is perpendicular to others (like two walls and a
floor in a corner)
• Co-planar pairs: left & right lateral, left anterior & right
posterior, right anterior & left posterior
Semicircular
Canal
Orientation
Inner Ear Anatomy
• Hair Cells
– Located in ampulla of each semi-circular canal and
each otolith organ
– Convert displacement caused by head movement into
neural firing
– Gelatinous membrane covers hair cells
• Cupula in semi-circular canals
• Macula in otolith organs
– Contain calcium carbonate crystals (otoconia) which increase the
mass of the macula – making them gravity sensitive
Mechanism of Action in BPPV
Cupulolithiasis
• Introduced by Schuknecht, 1969.
• Displaced otoconia debris adheres to the cupula.
• Ampulla becomes gravity sensitive.
• When the affected ear is tipped below the horizon,
the cupula is deflected.
• Vertigo and nystagmus are immediate onset with
change in position and persist as long as the head
is tipped below the horizon.
Herdman, 2000
Cupulolithiasis
www.micromedical.com
Canalithiasis
• Described by Hall, 1979.
• Otolithic debris is free floating in the endolymph.
• As the head is moved, the otoconia travel to the
dependent part of the canal.
• Movement of the endolymph pulls on the cupula
and increases firing of the neurons.
• Latency of symptoms due to the time for the
cupula to be deflected. As the endolymph stops
moving, symptoms subside.
Herdman, 2000
Canalithiasis
www.micromedical.com
Ductolithiasis
• Otoconia particles causing blockage of the
endolymphatic duct.
• Causes reduction in flow of endolymphatic
fluid and increased aural pressure associated
with hydrops.
Becvarovski, 2002
Impact of BPPV
According to the ICF Model
• Body Function
• Body Structure
– Sensory Function and
Pain
• Sensation of dizziness
and vertigo
• Dizziness
• Vomiting due to
dizziness and vertigo
• Sensation of falling
– Inner Ear
• Semicircular canals
• Brain
www.who.int/classification.icf
Impact of BPPV
According to ICF Model
• Activity Participation
–
–
–
–
–
General Tasks & Demands
Mobility
Self-Care
Domestic Life
Interpersonal Interactions &
Relationships
– Major Life Areas
– Community, Social & Civic
Life
• Environmental Factors
– Natural Environment &
Human Made Changes to
the Environment
• Light
• Climate
– Support & Relationships
– Attitudes
www.who.int/classification.icf
Protocol
South Valley Physical Therapy, P.C.
Centennial, CO
and
Barbara Esses, M.D., Neurotology
Denver Ear Associates
Phase I
• PT Evaluation to determine canal involvement.
• Up to 3 sessions of PT to perform repositioning
maneuvers.
• If unable to clear the vertigo/nystagmus after 3
visits, the physician is notified to allow the
possibility of further medical work-up.
Phase II
• Upon return from MD or after consultation
between the PT and MD.
• Resume treatment with presumed ductolithiasis or
canalith jam.
• Begin cranial oscillation one time per week for 4
weeks.
• This can be done 2x/week if both ears are
involved.
Diagnosis
Dix-Hallpike Test
• Gold Standard for
diagnosis of Anterior or
Posterior Canal BPPV.
• Starting seated with the
neck rotated 45°,the
person is brought into
supine with 30° cervical
extension.
• Observe for torsional
nystagmus and record the
direction.
www.dizziness-and-balance.com
Dix-Hallpike Test Results
Test
Result
Diagnosis
Right Dix-Hallpike
Upbeat Torsional Nystagmus
Right Posterior Canal BPPV
Right Dix-Hallpike
Downbeat Torsional
Nystagmus
Left Anterior Canal BPPV
Left Dix-Hallpike
Upbeat Torsional Nystagmus
Left Posterior Canal BPPV
Left Dix-Hallpike
Downbeat Torsional
Nystagmus
Right Anterior Canal BPPV
Right or Left Dix-Hallpike
Lateral Nystagmus;
Geotrophic or Ageotrophic
Perform Roll Test to check
Horizontal Canal
Involvement
Right or Left Dix-Hallpike
Vertical Nystagmus
Central Vertigo:
Not BPPV
Posterior Canal BPPV
• 78-96% of cases
– (Fife, 2008)
• Posterior canal is a gravity dependent organ in
both supine and upright positions.
• Cupulolithiasis: Immediate onset of vertigo and
nystagmus with head below the horizontal;
persistent nystagmus.
• Canalithiasis: Delayed onset of vertigo (15-30
second latency) and nystagmus with head
movement; fatigue of nystagmus after 30-60 sec.
Herdman, 2000
Anterior Canal BPPV
• Least often affected canal (1-3%).
– (Fife, 2008) (Honrubia, 1999)
• Often linked to structure changes in the canal
detected on HR 3D-MRI:
– Sticky endothelium
– Filling defect with blockage of the canal
– (Schratzenstaller, 2005)
Roll Test
• Most often utilized test for Horizontal canal
BPPV.
• Starting in a seated position, rotate the neck 60°
toward the tested ear. The person is then assisted
into supine, maintaining 20° of cervical flexion.
• Observe for horizontal nystagmus and record
geotrophic or ageotrophic direction.
Roll Test Results
Test
Result
Diagnosis
Right Roll Test
Geotrophic Nystagmus
Right Horizontal Canal
BPPV; Canalithiasis
Right Roll Test
Ageotrophic Nystagmus
Right Horizontal Canal
BPPV; Cupulolithiasis
Left Roll Test
Geotrophic Nystagmus
Left Horizontal Canal BPPV;
Canalithiasis
Left Roll Test
Ageotrophyic Nystagmus
Left Horizontal Canal BPPV;
Cupulolithiasis
Right or Left Roll Test
Torsional Nystagmus
Perform Dix-Hallpike Test
Right of Left Roll Test
Vertical Nystagmus
Central Nystagmus;
Not BPPV
Horizontal Canal BPPV
• Affects 2-15% of cases
• Nausea and vomiting are commonly associated
with episodes of the horizontal canal.
• Cupulolithiasis: Ageotrophic nystagmus, beating
away from the ground.
• Canalithiasis: Geotrophic nystagmus, beating
toward the ground.
BPPV without Nystagmus
• “Subjective Vertigo” has been defined as
symptomatic vertigo during either the DixHallpike or Roll Test without visualization of
nystagmus.
• A diagnosis of “subjective vertigo” can be made
during a right or left Dix-Hallpike or Roll Test,
however the specific canal involved or type of
BPPV may be vague.
Haynes, 2002
Weidner, 1994
Tirelli, 2001
Bilateral BPPV
• More than one canal can be affected.
• If more than on canal is affected, the intervention
is directed toward the more symptomatic ear and
all affected canals are documented.
• Only one affected side can be treated in a session;
however if 2 canals are involved on the same side
(posterior and horizontal), both may be treated in
one session.
Interventions
Interventions
• Interventions are selected based on the canal
affected and suspected cupulolithiasis vs.
canalithiasis.
• Repositioning maneuvers are used to return the
otolithic debris to the utricle.
• BPPV is resolved when observed nystagmus is
extinguished during repeat Dix-Hallpike or Roll
Test.
Epley Maneuver
• Used to treat posterior and anterior canal BPPV.
• Typically used to treat canalithiasis.
• The original Epley maneuver included use of
mastoid oscillation on the affected side during the
repositioning maneuver as well as use of
vestibular suppressant medication.
Modified Epley Maneuver (CRP)
• Positions (A) and (B) are
repeated from the DixHallpike exam.
• The head is then rotated
45° past midline to the
opposite side with cervical
extension maintained (C).
• The subject then rolls onto
the side and the head is
turned down to the floor
(D) prior to sitting (E).
www.dizziness-and-balance.com
Semont ‘Liberatory’ Maneuver
• Used to treat
cupulolithiasis of the
anterior/posterior canal.
• A brisk movement from
sitting to sidelying with
the head turned 45°
toward the affected side.
• Subsequent movement to
the opposite sidelying
position with head
maintained in 45° of
rotation.
www.thieme-connect.com
Lempert ‘BBQ’ 360° Roll
• Used to treat horizontal canal BPPV.
• Starting in sitting with the head turned 45° toward the
affected ear. The person is moved into supine with
maintained cervical rotation with the position held 1 min.
• The head is then rotated 90° to the unaffected side with the
position maintained for 1 min. or until symptoms subside.
• The person then rolls through the unaffected side to prone
on elbows, with the position maintained 1 min. or until
symptoms subside.
• The person rolls back to supine through the affected side,
head maintained to the affected side for 1 min.
• Finally the head is rotated to the unaffected side to rest.
(Link to video on hard drive)
Modified BBQ Roll
• Slight modification to technique for use with
cupulolithiasis of the horizontal canal.
• Starting in sitting with the head turned to the
affected side. The person is then brought swiftly
into supine with the head turned toward the
unaffected side and down into cervical extension.
• The person is then assisted to roll into prone with
the head forward off the mat table, followed by
rolling back to supine as in the BBQ Roll.
(Link to video clip on hard drive)
Liberatory Maneuver for
Horizontal Canal BPPV
• Used to treat canalithiasis of the horizontal canal
variant of BPPV.
• Starting in sitting at the edge of the mat, the
patient is taken into sidelying on the unaffected
side for 1 min.
• The head is moved briskly in a rotational
movement to bring the face down to look
downward at the floor.
(Link to video clip on hard drive)
Appiani, 2001
Post-Maneuver Precautions
• Historically used in the Epley Maneuver
• 24-48 Hours after repositioning
• Recommendations include:
– Sleep with head slightly elevated
– Don’t lie on the affected side
– Limit head motion
• Lack of evidence supporting use
Massoud, 1996
Brandt-Daroff Exercises
• Home-based exercise to
reduce canal sensitivity
following vertigo episodes
involving ant./post. canal.
• Start sitting on the edge of
the bed. Lie to one side with
the head turned up to the
ceiling and hold 30 sec.
• Return to sit for 30 sec., then
lie to the opposite side with
head turned to face ceiling
for 30 sec.
www.american-hearing.org
Cranial Oscillation
• Used to treat suspected
ductolithiasis.
• Positioned in sidelying
with the affected ear up,
head tilted in a downward
lateral tilt 20°.
• Stabilize a vibrator against
the mastoid of the upward
ear for 30 minutes.
• 1 time per week for 4
weeks.
(Link to video clip on hard drive)
American Academy of Neurology
Quality Standards Subcommittee
Recommendations Released 5/28/08.
Recommendations
• Level A recommendation for use of CRP in
treatment of posterior canal BPPV
• Level C recommendation for use of the Semont
maneuver for treatment of posterior canal BPPV
Fife, 2008
Recommendations
• Level C recommendations regarding the use of
mastoid oscillation and Brandt-Daroff exercises in
the treatment of posterior canal BPPV
• Level U recommendations for repositioning
maneuvers used to treat horizontal and anterior
canal BPPV due to only class IV studies at
present.
Fife, 2008
Recommendations
• Insufficient evidence to support the use of posttreatment activity or positioning restrictions.
• Insufficient evidence to support the use of
vestibular suppressant medication in the treatment
of BPPV.
Fife, 2008
Outcome Measures
Analogue Scales
• Dizziness
–
–
–
–
–
–
–
–
–
–
–
0 = No Dizziness
1
2
3
4
5
6
7
8
9
10 = Bed ridden due to
dizziness
• Nausea
–
–
–
–
–
–
–
–
–
–
–
0 = No Nausea
1
2
3
4
5
6
7
8
9
10 = Vomiting
Fall History
• Self report of the
number of falls in the
6 months prior to
current episode of
BPPV.
• Report of number of
falls since the last visit
during current
treatment.
Definition of a Fall
• Definition of a fall: “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.”
– (Tinetti, 1998)
• Definition used by the Medicare Fall Prevention
Act
Dizziness Handicap Inventory
• Developed to assess perceived handicap in people
with vestibular disorders.
• 25 items:
– 9 Functional
– 9 Emotional
– 7 Physical
• 100 points possible, high score indicates increased
perceived handicap.
Jacobsen, 1990
Dizziness Handicap Inventory
5-Item Subscale
• Looking up
• Get in and out of bed
• Quick head motion
• Turn over in bed
• Bending over
Whitney, 2005
Dizziness Handicap Inventory
• Test-Retest Reliability r = 0.97
• Minimum Detectable Change = 18 points
• 5-Item Subscale Score of 20 produces a likelihood
ratio of 2.29.
• Specificity of Subscore ≥ 18
93.8%
• Sensitivity of Subscore = 0
97.6%
Whitney, 2005
Timed Up and Go
• Gait assessment tool developed to identify fall risk
in the elderly.
– (Podsiadlo, 1991)
• Rise from a chair, walk 3 meters, turn 180° and
return to sit. Time is recorded in seconds.
• Scores of ≥ 13.5 seconds indicate risk of falls.
– (Shumway-Cook, 2000)
Timed Up and Go
• Whitney et al. studied the TUG related to selfreported falls in persons with vestibular disorders.
• Specificity of TUG at 11 seconds = 56%
• PPV = 46%; NPV = 85%
• Odds Ratio in favor of falling with a TUG of >11 seconds
= 5.0 (95% CI 1.80-13.91)
Whitney, 2004
Dynamic Gait Index
• Developed to assess gait stability in those over 60
at risk for falls.
• 8 Gait activities with a 4-scoring system
– (Shumway-Cook, 1995)
• Score of < 19 identifies risk of falling.
– (Shumway-Cook, 1997)
• Inter-rater reliability in persons with vestibular
disorders = 0.64; ICC = 0.86
– (Hall, Herdman, 2006)
Dynamic Gait Index
• Whitney et al. (2000) studied relationship between
the DGI and self reported falls.
• Score <19 produced an OR of 2.58 in favor of
falling (95% CI 1.47-4.53) for those >65 with
vestibular dysfunction and an OR of 3.55 (95% CI
1.53-5.26) for those 65 or less.
• Whitney et al. (2004)
–
–
–
–
Sensitivity of a score <19
Specificity of a score <19
PPV of a score <19
NPV of a score <19
71%
53%
39%
81%
Minimum Data Set
(In a formal presentation, the MDS
form would be opened and presented
or distributed as a handout)
The Next Step
• Implement the MDS to clinically analyze a
protocol for diagnosing, providing intervention
and tracking outcomes in BPPV.
• Determine whether the MDS and protocol are able
to guide successful resolution of BPPV with
implementation of 2 intervention phases.
• Utilize the MDS and protocol to determine
appropriateness for referral back to MD.
The First Steps
• Brief clinical analysis to determine adjustments
needed to current MDS form and data collection
forms.
• Submission to IRB to allow movement toward
clinical trial.
• Application for research grant to obtain Infrared
goggles for accurate visualization of nystagmus.
Clinical Trials are needed as
current evidence supports
use of repositioning
maneuvers to cure BPPV.
The question is….
Single Blind… or
Double Blind???
http://www.micromedical.com/goggles.htm
Conclusion
• Current evidence supports use of the Dix-Hallpike
and Roll Test for diagnosis of BPPV.
• Variable evidence is available to support the use of
repositioning maneuvers for the treatment of
BPPV.
• Use of the proposed protocol and MDS could help
identify resistance to physical therapy intervention
with reduction in cost and prompt referral to MD.
• Outcome measures used in BPPV indicate that
resolution of vertigo will reduce fall risk, improve
gait stability and allow return to life activities.
References
Becvarovski Z, Zappia J, The ZB mastoid oscillation protocol (ZBMOP) in meniere’s
disease and ductolithiasis. Otolaryngol Head Neck Surg. 2002;127:491-492.
Dix MR, Hallpike CS. The pathology, symptoms and diagnosis of certain common disorders
of the vestibular system. Ann Otol Rhinol Laryngol. 1952:61:987-1016.
Fife TD, Iverson DJ, Lempert T, Furman JM, Baloh RW, TUsa RJ, Hain TC, Herdman S,
Morrow JM, Gronseth GS. Practice parameters: Therapies for benign paroxysmal
positional vertigo (an evidence-based review). Neurol. 2008;70:2067-2074.
Froehling DA, Silverstein MD, Mohr DN, Beatty CW, Oxford KP, Ballard DJ. Benign
positional vertigo: incidence and prognosis in a population-based study in Olmsted
County, Minnesota, Mayo Clin Proc. 1991;66:596-601.
Giannoni G, Vannucchi P, Pagnini. Definition and classification of paroxysmal positional
vertigo. Audiological Medicine. 2005;3:4-6.
Hall CD, Herdman SJ, Reliability of clinical measures used to assess patients with
peripheral vestibular disorders. J of Neurol Phys Ther. 2006;30:74-81.
Hall SF, Ruby RRF, McClure JA. The mechanics of benign paroxysmal positional vertigo. J
Otolaryngol. 1979;8:151-158.
Haynes DS, Resser JR, Labadie FR et al. Treatment of benign positional vertigo using the
semont maneuver: efficacy in patients presenting without nystagmus. Laryngoscope.
2002;112:796-801.
References
Herdman SJ, Tusa RJ. Benign Paroxysmal Positional Vertigo. In: Herdman SJ, ed. Vestibular
Rehabilitation. Second Edition. Philadelphia, PA. FA Davis Co., 2000:451-470.
Honrubia V, Baloh RW, Harris MR, et al. Paroxysmal positional vertigo syndrome. Am J
Otol. 1999;20:465-470.
Jacobson GP and Newman DW. The development of the dizziness handicap inventory. Arch
Otolarygol Head Neck Surg. 1990;116:424-427.
Massoud EA, Ireland DJ. Posttreatment of benign paroxysmal positional vertigo: no need for
postmaneuver restrictions. J Otolaryngol. 1996;25:121-125.
Exhauster HK, Epidemioloty of vertigo. Curr Opinion Neurol. 2007;20:40-46.
Podsiadlo D, Richardson S. The timed up and go: a test of basic functional mobility for frail
elderly persons. J Am Geriatr Soc. 1991;671;387-389.
Schratzenstaller B, Wagner-Manslau C, Strasser G, Arnold W. Canalolithiasis of the superior
semicircular canal: an anomaly in benign paryoxysmal vertigo. Acta OtoLaryongologica. 2005;125:1055-1062.
Schuknecht HF. Cululolithiasis. Arch Otolaryngol. 1969;90:113-126.
Shumway-Cook A, Woollacott M. Motor Control Theory and Applications. Williams and
Wilkins Baltimore, 1995.
References
Shumway-Cook A, Bladwin M, POlissar NL, Bruber W, Predicting the probability for falls
in community-dwelling older adults. Phys Ther. 1997;77:812-819.
Shumwas-Cook A, Brauer S, Woollacott M. Predicting the probability of falls in the
community-dwelling older adults using the timed up & go test. Phys Ther. 2000;80: 7984.
Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in
the community. N Eng J Med. 1998;319:1701-1707.
Tirelli G, D’Orlandao E, Giacomarra V, Russolo M. Benign positional vertigo without
detectable nystagmus. Laryngoscope. 2001;111:1053-1056.
Weider DJ, Ryder DJ, Stram JR. Benign paroxysmal positional vertigo; analysis of 44 cases
treated by the canalith respositioning procedure of Epley. Am J Otol. 1994;15:321-326.
Whitney SL, Hudak MT, Marchetti GF. The dynamic gait index relates to self-reported fall
history in individuals with vestibular dysfunction. J Vest Research. 2000;10:99-105.
Whitney SL, Marchetti GF, Schade A, Wrisley DM. The sensitivity and specificity of the
timed “up & go” and the dynamic gait index for self-reported falls in persons with
vestibular disorders, J Vestib Research. 2004;14:397-409.
Whitney SL, Marchetti GF, Morris LO. Usefulness of the dizziness handicap inventory in
the screening for benign paroxysmal positional vertigo. Otology & Neurology.
2005;26:1027-1033.
Image References
Hain TC. Benign Paroxysmal Positional Vertigo Available at: http://www.dizziness-andbalance.com/disorders/bppv/bppv.html. Accessed on May 23, 2008.
Brandt-Daroff Exercises. American Hearing Research Foundation. Available at:
www.american-hearing.org. Accessed June 15, 2008.
Canalithiasis. Available at: www.micromedical.com. Accessed on June 15, 2008.
Cupulolithiasis. Available at: www.micromedical.com. Accessed on June 15, 2008.
Illusion Spinning. Available at: www.mobile-pedia.com/.../illusion_Spinning.png. Accessed
June 15, 2008.
RealEyes goggles and camera Monocular Configuration. Avilable at:
http://www.micromedical.com/goggles.htm. Accessed on June 15, 2008.
The International Classification of Function. The World Health Organization. Available at:
www.who.int/classification.icf. Accessed on June 15, 2008.