??? Treating BPPV - which maneuver?

[MaxG]

A question to those who regularly treat patients with BPPV:

Have you noticed differences between maneuvers in patient outcome?

I occassionally treat BPPV patients and am generally successfull with the standard Epley Maneuver.
My question: Is there a place for other maneuvers (ie. sidelying Epley, Semont, Gufoni)?

I've read that Semont and Epley have similar outcomes, but Epley seems to be more effective as a home assignment.

Also, I sometimes prescribe the Brandt-Daroff for home use, but usually just stick to the Epley when possible. AM I missing out on something?

Lastly, I find vestibular rehab very interesting, but sadly, coursework for it is scarce around here.
Are there any good books for a general overview of the topic?

[tonyf315]

Hi Max!

here's a link to what is considered THE textbook on Vestibular rehab:

http://www.amazon.com/Vestibular-Reh...4872276&sr=8-1

This latest edition comes with a CD-ROM with videos that demonstrate many of the tests and exercises/maneuvers.

For something that is a little more current on BPPV, try Dr Hain's website. ( http://www.dizziness-and-balance.com...bppv/bppv.html ) This site talks about the statistics of the different maneuvers with references. What you will see is that Epley and Semont are about equal in effectiveness. However the Semont, recent studies showed, needs to be done EXTREMELY quickly (move from 1 side to the other in 1.5 seconds) to work. Therefore I use it VERY infrequently.

Gufoni is a Horizontal Canal maneuver, and I'm not a fan. I've only had success with horizontal canal BPPV using a full 360 degree log roll maneuver.

RE: Brandt-Daroff-these are good for motion tolerance habituation and little else. Janet Helminski (Dr Hain's PT) believes they carry a high risk of canal conversion when done for BPPV.

Hope some of that helps!

Tony

[MaxG]

Thanks for the timely reply, Tony!

Do you know of any studies done on the reliability of the testing maneuvers for locating the site of canalithiasis?
In the clinic where I currently practice, we have no testing goggles, so I rely solely on visual observation of nystagmus, which can be challenging, especially with semi-compliant patients (rapid blinking) and rotational nystagmus.
Thus, I can never be quite sure with how much certainty I could pin-point the site of canalithiasis (ie. positive left Dix-Hallpike - posterior or anterior canalithiasis?)


Side question: Does the CD-Rom of the vestibular rehab book contain examples of various nystagmi?

[tonyf315]

Oh you're welcome-I love vestibular threads as they are something I feel at least remotely qualified to contribute to.

Anyway: if I were to dig I could find something for you on the localization. I went to a course in 2010 where Dr Helminski presented on variants of BPPV and she quoted a study that challenges the traditional notion of BPPV being almost always posterior canal. This study was done using video goggles and showed that while PC is still most common, it's probably closer to 60% of occurrences, with horizontal and anterior canal being more often that thought, as well as multicanal. She highly advocated video goggles for this purpose.

What I've picked up the last couple years about nystagmus & BPPV is that if you see torsion think Posterior canal. This may help you if you don't have goggles as people aren't able to fixate to suppress torsional nystagmus while they can voluntarily suppress the vertical component. Apparently AC is more primarily downbeat and only has torsion <50% of the time. The Herdman book does have video examples of nystagmus that are helpful and I'm sure there are videos on the web also.

Edit: here's one of the sources that talks about the distribution of canal involvement when assessed with IR goggles;
Lopez-Escamez JA et al Acta Otolaryngol 2005;125(9):954-961


and the canal distribution per Dr Helminski

41-65% PC
20% multi canal
21-33% HC
17% AC


Hope that helps!

Tony

[CDano]

http://www.sciencedaily.com/releases...0423131846.htm

Does anyone know how the Half Somersault is performed?

[tonyf315]

http://content.karger.com/ProdukteDB...oduktNr=255124

looks promising!

[CDano]

Thanks Tony! That does look promising indeed.

[tonyf315]

Diane gets credit for posting on Facebook-that's where I first saw it literally minutes ago!

[advantage1]

When performing the Epley maneuver is is important to wait 1-2 mintues in each position for the vertigo to pass? Also, after perfroming the Epley should I retest the Dix-Hallpike each time?

[tonyf315]

sorry advantage1, I just now saw this today

Anyway, for your question: with the repositioning maneuvers there are differing recommendations as to how long to hold each position. I think it's safe to say at a minimum hold each position as long as it took for the vertigo and nystagmus to pass in the initial Dix-Hallpike position.

One course I was at cited a study (or was it a lit review?) showing no significant difference in outcome whether positions were held 30 sec or 2 min.

At the Neuro section's advanced vestibular course in 2010 Dr Helminski showed research showing it takes the particles at least 25 seconds to make it 90 degrees around the canal, and recommended sustaining each position for 45 sec to allow a margin of error for "silent debris" that clings closely to the canal wall and moves more slowly.

Jeff Walter and others advise holding each position til provoked symptoms stop plus 30 seconds, which is what I have been tending to do as well.

For the other ? on retesting after each, that too is variable by practitioner. One guideline I like is from Dr Janene Holmberg; her recommendation at her course ("Spinning Beyond Basics" put on by North American Seminars) is that if, on your first cycle of an Epley, you get a clear 2nd burst of dizziness and nystagmus beating in the desired direction (same as in the initial Dix-Hallpike) that you likely did an adequate job and could stop there. If not, or if in doubt, do again. For those that recommend re-testing, most also advise doing another cycle of the maneuver while you are at it even if the f/u test is (-). I usually try to do a 2nd test & maneuver whenever possible so the person can (usually) leave their session seeing a change has occured. Of course, if they have an upset stomach from the 1st one, I will let them make the choice.



Hope that helps and sorry for the slow reply!

Tony

[Elanchaim]

Not sure if this is of any help....