Clinical Problem Solving II

1. Clinical Problem Solving II A Look Into an Unconventional BPPV Patient Case Lealah Fremuth October 1, 2015

2. My Patient • 79 y/o female • Social Hx: retired, widowed, lives alone. Very active in church and independent w/ chores • PMH: migraines, neck pain (previously received PT for cervical radiculopathy) • Current diagnosis: posterior canal BPPV

3. Benign Paroxysmal Positional Vertigo • Most common form of recurrent vertigo: lifetime prevalence rate of 2.4% • Biomechanical problem: one or more semicircular canals are inappropriately excited by displaced otoconia • Characterized by short episodes of vertigo w/ changes in head position • Causes: idiopathic, head trauma, viral neurolabyrinthitis, Meniere’s, migraines

4. Vestibular Examination • Gait: WNL • Cervical AROM: WNL all planes, asymptomatic • Vertebral artery test: R and L both negative • Side-lying test for BPPV: upbeating rotary nystagmus lasting <45 secs on the R • R posterior canal canalithiasis

5. ICF Model

6. Evaluation • Prognosis: Good • Goals: • Patient will be independent with progressive HEP in the next 2 weeks • Patient will resume pre-illness level of function after 4 weeks • No episodes of vertigo over the span of 4 weeks • Plan of Care: perform canalith repositioning manuever for affected canal and monitor response

7. Intervention: Day 1 • Initial Evaluation • Manuever: Modified Epley for R PSC • Result: significant nausea and emesis, unable to recheck or perform second cycle • Sat for 20 mins w/ cold pack, instructed to come back for additional visit

8. Intervention: Day 2 • Subjective: Pt reports symptoms are the same, took Zophran prior to arrival • Manuevers: • Retest positive for R PSC BPPV • Modified Epley x1 for PSC BPPV • Result: Recheck positive, unable to continue tx due to nausea • MD called to suggest Meclizine to facilitate return to baseline

9. Intervention: Day 3 • Subjective: Pt feeling better w/ use of Meclizine, also took Zophran prior to arrival • Manuevers: • Retest indicated conversion to HSC BPPV • Casini x1 for HSC BPPV • Results: Recheck positive for HSC BPPV • Pt instructed to sleep on L side (~prolonged positioning technique)

10. Intervention: Day 4 • Subjective: Pt reports symptoms are different • “room slowly turning to one side” • Manuevers: • Supine head roll test positive for HSC BPPV • Casini x3 for HSC BPPV • Results: Recheck negative

11. Intervention: Day 5 • Pt reported via phone call that her symptoms no longer persisted.

12. For a 79 year old female patient, is the Epley manuever the treatment most likely to resolve symptoms of PSC BPPV without complications? Hilton MP, Pinder DK. “The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo” Cochrane Database of Systematic Reviews, 2014. Anagnostou E, Stamboulis E, Kararizou E. “Canal conversion after repositioning procedures: comparison of Semont and Epley maneuver.” Journal of Neurology, 2014

13. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Hilton MP, Pinder DK. Cochrane Database of Systematic Reviews, 2014.

14. What is the efficacy of the Epley manuever? • METHODS • Participants: 745 total patients, 18-90 years old, diagnosed w/ BPPV via Dix-Hallpike test • Design: 11 randomized control trials utilizing the Epley maneuver • Comparison interventions: placebo, untreated controls, other active treatment • Outcome measures: resolution of vertigo symptoms, negative Dix-Hallpike test

15. RESULTS • Statistically significant effect in favor of Epley maneuver over controls • Significantly higher resolution at 7 days when compared to Brandt-Daroff exercises, but no difference found after one month • No difference in comparison to the Semont maneuver or the Gans

16. DISCUSSION & CONSIDERATIONS • Active treatment is the best method of relieving symptoms of posterior canal BPPV • The Epley is comparable to the Semont and Gans, but has a more immediate effect than Brandt-Daroff • Must keep in mind that “the natural history of posterior canal BPPV is for spontaneous resolution over time” • Long-term follow-up was either lacking or inconclusive

17. Canal conversion after repositioning procedures: comparison of Semont and Epley maneuver. Anagnostou E, Stamboulis E, Kararizou E. Journal of Neurology, 2014

18. Canal Conversion

19. What is the likelihood of the Epley maneuver producing transitional BPPV? • METHODS • Participants: 102 patients, 36-72 years old, diagnosed w/ BPPV via Dix-Hallpike test • Design: comparative study • Every second patient was assigned to the Semont group while the others received the Epley • Every patient was only treated once • Outcome measure: Dix-Hallpike test performed 2-5 hours after treatment

20. RESULTS • The Semont maneuver resolved 67% of cases and the Epley 76% • The Epley maneuver led to 4 cases of canal conversion, the Semont produced none • All cases of conversion had switched to horizontal canal BPPV • Patient gender and affected canal side did not exhibit a statistical association with conversion rate

21. DISCUSSION & CONSIDERATIONS • The Epley consists of more steps than the Semont and maintains the patient in a dependent position for a longer period of time  greater odds of particle reentry? • Therapists preferentially using the Epley should be aware that uncleared cases may actually harbor a canal switch • The difference in likelihood for canal conversion is small between the Epley and Semont, but significant enough to remember as a clinical consideration

22. Summary • When treating a patient with PSC BPPV, an active maneuver is significantly the most effective way to resolve symptoms • In terms of initial efficacy, the Semont and Epley maneuvers have the highest success rate, and should be chosen over Brant-Daroff

23. Summary • To prevent transitional BPPV and fully clear the patient with initial treatment, the literature suggests that the Semont maneuver may be most effective • Clinicians should be familiar not only with the commonly used Epley maneuver, but should also pursue continuing education or further practice with the Semont

24. Questions?