Almost 1 year ago, October 31st, 2017, a really cool and interesting case of BPPV walker-ed into the clinic. I think this case study hits on a few good points of how BPPV isn't always straight forward, how debilitating it can be for a patient, and just how important thorough evaluation techniques are. Let's jump in...
Patient's Subjective History
- This patient is a 79 y/o female who presents to physical therapy with severe recurrent attacks of positional related vertigo.
- Significant history of right sided BPPV that would not resolve with Epley maneuvers despite multiple attempts with physical therapists and ENTs over the last year.
- This is her third prolonged encounter/episode with positional related vertigo.
- Initial episode: February 2015
- Recurrence episode: January 2016
- The patient states that any head movement or changes in position make her very dizzy, and she is very afraid to move. She reports issues with anxiety.
- She avoids moving her head as much as possible, and sleeps almost sitting upright.
- She requires max assist from her 80 year old husband for basic transfers and ADLs. She only ambulates short distances with a rolling walker, and requires her husband to carry 2 large foam pads where ever they go to raise the height of the chair so that she won't get stuck if her husband is unable to lift her.
- Patient has very high anxiety related to fear of vertigo and fear of falling
Significant Medical History
- Myositis with progressive muscular degeneration (Diagnosed 11 years ago)
- has gotten significantly worse in the last 6 months due to inactivity.
- She reports multiple falls in the past, including a fall one month prior to initial evaluation. She fell forward onto her knee while reaching forward for something. She presented with continued increased swelling and pain.
- She sustained another fall 2 months prior to the evaluation and reports hitting her head.
- Other relevant health information: Anxiety, Circulation Problems, High Blood Pressure and Cholesterol, Myositis, history of TIA
Initial Evaluation Form & Findings
Dix-Hallpike IVOG Test
- Geotropic Nystagmus noted with Dix-Hallpike bilaterally
- Ewald's first two laws should be noted here:
- First Law: The direction of the nystagmus is directly correlated to the canal that is being stimulated… not the position of the head.
- Second Law: Fluid flow (or otoconia) moving towards the cupula in the HORIZONTAL canal is an EXCITATORY stimulus.
- Ewald's first two laws should be noted here:
- The patient's nystagmus and associated complaint of dizziness was stronger with Right Dix-Hallpike in comparison to Left
- This indicates Right Ear Involvement (since nystagmus was geotropic)
- Nystagmus was non-persistent suggesting the otoconia are not adhered to the cupula: Canalithiasis-type
- Roll tests were also performed and yielded the same results: non-persistent geotropic nystagmus with associated complaints of dizziness.
- Patient continues to be very anxious, and refuses to move head/change positions
- Required 3-4 people to perform positional testing
- Gufoni Maneuvers were unsuccessful. Absolutely no nystagmus or dizziness was present with a modified Right Gufoni Maneuver...... Why?
Canalith Jam-Like Symptoms
After digging into some research, and sitting down with The Functional Inner Ear, I came to the conclusion that the patient had something similar to a Canalith Jam in her right horizontal semicircular canal. She was habitually a right sided sleeper (when she wasn't so symptomatic that she chose to sleep sitting up), and she has been symptomatic now for over a year. Multiple attempts of Epley maneuvers were performed, placing her in dependent positions for free floating otoconia/debris to drop into her canals. She also occasionally woke up lying on her right side at night. I think that all this time, while attempts were being made to treat the posterior canal, she kept building up debris in her horizontal canal.
Everyone's anatomy varies to some degree, and that includes the Vestibular Organ. Some people may have stenotic narrowing of their canals, or maybe the alignment of the canals are a little off from "normal". I came across the article "Persistent Direction-Fixed Nystagmus Following Canalith Repositioning Maneuver for Horizontal Canal BPPV: A Case of Canalith Jam" by Chang et al. They quoted John Epley's canalith jam definition: freely moving otoconial particles block the endolymphatic flow. They also noted two theories for the cause of a canalith jam:
- innate semicircular canal stenosis and/or a plug caused by otoconial debris
- or, a giant otoconial plug could occur in a normal canal.
So in this case, I hypothesized that the patient had enough debris in her canal to roll around triggering BPPV canalithiasis-type symptoms and related nystgamus. However, when I tried to move her into a Gufoni Repositioning maneuver, the debris sat at the posterior aspect of a narrowed horizontal canal, and blocked the flow of endolymph, thus preventing associated nystagmus and vertigo.
Here is a rough illustration of what I am trying to explain. In this diagram, the patient would be side-lying on her left, as if she were in the first position of a modified Right Gufoni Maneuver. The red dot represents where I think the bolus was resting in the canal in this position. The bolus was bottle-necked here, and also still able to roll around the canal enough to trigger symptoms and nystagmus with positional changes.
The previously mentioned study disclosed what methods they used to treat their case of a right horizontal canal, canalith jam. They had their patient perform frequent head shaking and maintained left prolonged side lying. In my patient's case, there was no way she was going to actively shake her head, or lie down flat on her side. This was going to be a little more complicated.
Manual Mastoid Vibration in Sitting
- Patient would not actively shake or move her head
- Mastoid Vibration is successfully used in combination with repositioning maneuvers in Kim et al as a way to treat Horizontal Canal BPPV Cupulolithiasis-type by loosing up otoconia adhered to the cupula. Why not try to use mastoid vibration to break up a large bolus of debris if that is what is going on?!
- Mastoid Vibration was performed to Right mastoid for 10 seconds for three consecutive visits
Forced Prolonged Side Lying
- Patient was instructed to lie on her left side every night. This would wedge the bolus at the opening of the canal against gravity. Ideally, overnight, the bolus may slowly break up due to gravity pulling on the bolus.
- This was a gradual process to get the patient to transition from sitting up while sleeping to lying completely on her left side for the entire night
- Patient agreed to 1 Gufoni maneuver at each visit: This served as both habituation exercises and canalith repositioning for any debris that detached from the forced prolonged side-lying
- Exercises performed included seated 7 head positions with eyes open/eyes closed, and seated Bow & Lean exercises with eyes open/eyes closed.
- Performed gait exercises in a Safety Overhead Support System (SOLO Step) with CGA: walking forward/backwards, side stepping, over thin compliant surfaces, step ups onto 3 inch step
LE Strength Training
- Seated exercises: marching, long arc quads, hip adduction/abduction, plantar flexion, dorsiflexion
- The patient’s doctor recommended that the patient take Xanax and meclizine 1 hour prior to appointments. Meclizine was stopped after the second follow up, Xanax continued due to increased anxiety
- This dramatically cut down the patient’s anxiety during treatment
- At the patient’s 10th visit (Reevaluation), 29 days later, all positional tests were negative for both nystagmus and associated complaints of dizziness bilaterally.
- The morning of the patient's 9th visit, she had a sudden burst in vertigo when she first woke up. I believe this was the bolus finally giving way. When a modified Right Gufoni maneuver was performed at the 9th visit, she finally presented with Geotropic nystagmus in the first position of the canalith repositioning maneuver! This time, the maneuver was a success. She re-tested as negative at her re-evaluation during the subsequent visit.
- The patient is now able/comfortable with lying flat and turning in bed.
- Habituation and balance exercises were progressed, and the patient is significantly less symptomatic.
- The patient's LE strength has improved significantly.
- She is now able to transfer independently and ambulates with only the use of a cane. She is able to walk shorter distances around her home without the use of a device.
Here are a few things I took away from this case:
- Never forget Ewald's 1st Law! Watch the patient's nystagmus during the test, and make sure it corresponds with what you think is going on.
- Patient's WILL sometimes be difficult to treat... be creative and come up with treatment techniques that will achieve results for the patient.
- Use your imagination and knowledge of Ewald's laws to imagine where the otoconia might be in your BPPV patient.
To Vibrate, or Not To Vibrate
The study “The Skull Vibration-Induced Nystagmus Test of Vestibular Function—A Review” by Dumas et al. gives a list of patients you should cautiously use vibration testing with:
- “recently operated otosclerosis
- retinal detachment
- history of recent cerebral hematoma
- and poorly controlled anticoagulant therapy”.
These conditions should be greatly taken into consideration while using vibration as a treatment as well if vibration will be applied for possible longer lengths of time.
Vibration for treatment should also be used cautiously with patients who are more likely to "shed otoconia". Do they have a history of vestibular neuritis/labyrinitis, Meniere's disease, osteoporosis, recurrent BPPV..? If so, the clinician should be aware that applying vibration may cause additional otoconia/otolithic membrane to fall off and wander into the semicircular canals. The patient may experience worsening symptoms during treatment and/or require additional maneuvers. They may also require additional considerations for post maneuver precautions.