1 Benign Paroxysmal Positional Vertigo Canalithiasis Tonya Fuller, PT, MSPT [email protected]Provider Disclaimer • Allied Health Education and the presenter of this webinar do not have any financial or other associations with the manufacturers of any products or suppliers of commercial services that may be discussed or displayed in this presentation. • There was no commercial support for this presentation. • The views expressed in this presentation are the views and opinions of the presenter. • Participants must use discretion when using the information contained in this presentation. Objectives • Understand the basic anatomy and physiology of the vestibular system • Understand the causes, signs, and symptoms of BPPV – canalithiasis • Perform a basic evaluation for BPPV • Determine affected canal and decide on treatment plan • Perform standard treatment for BPPV – canalithiasis • Establish goals and discharge criteria
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• Allied Health Education and the presenter of this
webinar do not have any financial or other
associations with the manufacturers of any products
or suppliers of commercial services that may be
discussed or displayed in this presentation.
• There was no commercial support for this
presentation.
• The views expressed in this presentation are the
views and opinions of the presenter.
• Participants must use discretion when using the
information contained in this presentation.
Objectives• Understand the basic anatomy and physiology of
the vestibular system
• Understand the causes, signs, and symptoms of
BPPV – canalithiasis
• Perform a basic evaluation for BPPV
• Determine affected canal and decide on
treatment plan
• Perform standard treatment for BPPV – canalithiasis
• Establish goals and discharge criteria
2
Benign Paroxysmal Positional
Vertigo (BPPV) Most common cause of vertigo in peripheral
vestibular disorders
Accounts for more than 50% of people over 65 with
dizziness
Most common complaint is dizziness with positional
changes
Imbalance
Lightheaded
Gait disturbance
Nausea
Increased risk for falls
Prevalence
10.7 - 64 / 100,000 population
2.4% lifetime
Estimated cost of $2000 to arrive at diagnosis
Total healthcare cost for BPPV / year: $2 billion
Estimated that 86% of patients suffer interruption of
ADL’s and lost work time due to BPPV
Falls
Falls are the leading
cause of fatal and
non-fatal injuries in
older adults
Between 30 – 40 % of
community dwelling
individuals age 65 and
over experience falls
every year
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Falls & Injury Of those who fall, 20-30% suffer
moderate to severe injuries such as lacerations, hip fractures, or head traumas
In 2010, there were 258,000 hip fractures and the rate for women was twice as much for men
95% of hip fractures are caused by falls
Falls are the most common cause of traumatic brain injury in older adults
In 2010, more than 2.3 million older
adults were treated in ER
departments for fall-related injuries
662,000 were hospitalized
21,700 died from fall-related injuries
Cost of Falls
The United States spends an estimated $30 billion annually for the treatment of fall-related injuries.
The average medical cost of an unintentional fall is $18,000 / individual
Common Causes of Falls
Muscle / Trunk Weakness
Decreased range of motion
Environmental hazards
Medications
History of falls
Deficits in one or more balance systems
Vision
Somatosensory
Vestibular
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What is Balance?
A complex process involving the reception and
organization of sensory inputs, and the planning
and execution of movement, to achieve a goal
requiring upright posture
Comprised of three balance systems
Visual
Somatosensory
Vestibular
Sensory Integration of the
Balance Systems
Vestibular system
Somatosensory System
Visual System
System Integration for
Balance
Stable Surface
70% SOM
20% VEST
10% VIS
Unstable Surface
60% VEST
30% VIS
10% SOM
Peterka, R. and P. Loughlin (2004). "Dynamic regulation of sensorimotor integration in human postural control." J Neurophysiol 91: 000-000; adopted from Horak 2003
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Anatomy and physiology of the Vestibular system
Vestibular System
Provides information about the movement of the head and its position with respect to gravity and other inertial forces
Contributes important information to the sensation and perception of the motion and position of the body as a whole
The vestibular system participates in the maintenance of stance and body posture; coordination of body, head, and eye movements; and visual fixation
Vestibular Anatomy
The bony labyrinth contains auditory and vestibular
organs
The membranous labyrinth is within the bony
labyrinth
CN VIII
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Vestibular Anatomy
Membranous Labyrinth
3 semicircular canals
anterior, posterior, and
horizontal
Primarily sense angular
acceleration
Aligned at right angles
to one another with
the horizontal canal
sloping down 30°
2 otolithic organs
Saccule = vertical
plane
Utricle = horizontal
plane
Primarily sense linear
acceleration and
head tilt
Semicircular Canals
Provides sensory input about head velocity,
enabling the VOR to generate an eye movement
equal in velocity to the head (stabilizing the eyes for
clear vision)
Contains endolymph
Coplanar pairing / sensory redundancy
Push-pull relationship
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Macula of the Otolithic Organ
Each macula contains a jelly-like bed of the
otolithic membrane
Otolithic membrane is embedded with calcium
carbonate crystals called otoconia
The otoconia increase the specific gravity causing
the otolithic organs to be responsive to the static
pull of gravity
Vestibular Anatomy
Central Connections
Primary vestibular afferents originate at the hair
cells, enter the brainstem between the pons and
medulla, and proceed to the cerebellum or
vestibular nuclei
There are four nuclei and each SCC and otolithic
organ has its own neural network
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Vestibular Nuclei
Superior: to eye muscles: VOR
Lateral: to Spinal Cord: VSR
Lateral Vestibulospinal Tract
Medial: to Spinal Cord and eye: VSR and VOR
Medial Vestibulospinal Tract
Inferior: Reticular Formation
Vestibulo-Ocular Reflex (VOR)
Vestibular input is used to hold images stable on the
retina during head rotations
The SCC’s signal how fast the head is rotating and
the oculomotor system responds by rotating the
eyes at an equal velocity in the opposite direction
Vestibulo-spinal Reflex (VSR)
The vestibular system provides the CNS with info
about the movement and position of the head with
respect to gravity and inertial forces
VSR = excitation of the extensor musculature to
help stabilize our body
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Reticular Formation
The reticular formation is not anatomically well defined because it includes neurons located in diverse parts of the brain
The neurons of the reticular formation are excited by a variety of sensory stimuli that are conducted from the somatosensory, auditory, visual, and visceral sensory systems
Responsible for general arousal / alertness, vital functions, attention, adjusts transmission of pain information, and consciousness levels
Vestibular System
Function
Posture and balance control
Vestibulospinal Reflex (VSR)
Knowledge of self movement
Saccule and utricle
Semicircular canals
Visual fixation during head movement
Vestibular Ocular Reflex (VOR)
BENIGN PAROXYSMAL
POSITIONAL VERTIGO (BPPV)
Canalithiasis
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Causes of BPPV
Under the age of 50
Head injury is most common cause
Over the age of 50
Idiopathic
Most common onset between 50 – 70 years
Other potential causes
Degeneration
Prolonged Positioning
Viral
Signs & Symptoms of BPPV
Dizziness with positional changes
rolling over in bed
quick head turns
bending over
Nausea due to excessive dizziness
Loss of balance with gait
Sense of “floating” or “swimming”
Forms of BPPV
Canalithiasis
Cupulolithiasis
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Canalithiasis
Most common
Onset of vertigo/nystagmus 1-40 seconds
Symptoms persist <60 seconds due to cessation of
endolymph movement
Canalithiasis
Mechanism
Otoconia from the utricle float freely in the
endolymph of the semicircular canal. When the
head is moved into a provoking position,
otoconia move to the most dependent position
of the canal. The movement of the otoconia
causes movement of the endolymph and pull on
the cupula. This increases the firing rate of the
neurons of that canal and sends an abnormal
signal resulting in dizziness.
Canalithiasis
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Canal Involvement
Posterior: > 80%
Horizontal: 3 – 12%
Multi – canal: 5%
Anterior: 2%
Diagnosis is made from direction and duration of
nystagmus
Evaluation
Subjective
Evaluation
• Subjective
o Chief Complaint / Hx of Illness
o Onset
o Conditions provoking symptoms
o Duration / Severity (of initial onset and of subsequent
episodes)
o Fall History
o Limitations in ADL’s
o Previous Medical History
o Previous Medical / Vestibular Testing
• Information that you get from your subjective evaluation