|Year : 2013 | Volume
| Issue : 2 | Page : 72-74
Physical therapy rehabilitation of benign paroxysmal positional vertigo: Evidence based case report
Selvam Ramachandran, Manish Goon, Priyanka Singh
Department of Physiotherapy, Sikkim Manipal Institute of Medical Sciences, Tadong, Gangtok, East Sikkim, India
|Date of Web Publication||15-Jun-2013|
, Associate Professor, Department of Physiotherapy, Sikkim Manipal Institute of Medical Sciences, 5th Mile, Tadong, Gangtok 737 102, East Sikkim
Source of Support: None, Conflict of Interest: None
The benign paroxysmal positional vertigo results in dizziness and imbalance leading to risk of fall thus, imposing functional limitations. The repositioning-liberatory maneuvers, habituation and balance exercises are widely used as the treatment strategies of the rehabilitation program. This case report discusses the success of such rehabilitation program on two subjects based on the updated clinical evidence.
Keywords: Benign paroxysmal positional vertigo, Exercises, Physical therapy, Rehabilitation
|How to cite this article:|
Ramachandran S, Goon M, Singh P. Physical therapy rehabilitation of benign paroxysmal positional vertigo: Evidence based case report. Indian J Otol 2013;19:72-4
|How to cite this URL:|
Ramachandran S, Goon M, Singh P. Physical therapy rehabilitation of benign paroxysmal positional vertigo: Evidence based case report. Indian J Otol [serial online] 2013 [cited 2020 Apr 8];19:72-4. Available from: http://www.indianjotol.org/text.asp?2013/19/2/72/113503
| Introduction|| |
The various components of vestibular sensory system plays a primary role in the maintenance of posture and movement. The benign paroxysmal positional vertigo (BPPV) is a condition, in which the dislodged otoconia from the utricle freely floats into one or more semicircular canals, resulting in brief episodes of vertigo provoked with changes in head position causing postural instability and risk of fall. History of mild to severe head injury may or may not precede the onset of the condition. BPPV is a self-limiting disorder and resolves spontaneously. The physical therapy rehabilitation of BPPV often includes, repositioning and liberatory maneuvers; habituation, and balance exercises.  In this case report, we discuss the success of physical therapy rehabilitation of two subjects diagnosed with BPPV. A note on clinical evidence of such rehabilitation measures is also discussed.
| Case Report|| |
A 61-year-old male patient, a diagnosed case of BPPV, complained of sudden onset severe vertigo and nausea on right sided head movement with reportedly brief loss of consciousness. He had experienced similar episode of same intensity 20 years back. Since, then he reported to have mild vertigo occasionally and would resolve spontaneously in few seconds. There was no history of head trauma preceding the first episode. The subject also reported limitations in participation of social and professional activities since then. The medical history includes Ischemic heart disease and Cervical Spondylosis (with reduced intervertebral disc space at C4-C5, C5-C6 and C6-C7). The surgical history includes single vessel coronary angioplasty, ophthalmic surgery for temporal central retinal detachment and orthopedic surgery involving endo-prosthesis for ruptured right tibiofibular syndesmosis. On the day of referral, the Dix-Hallpike test was positive with increased sensation of vertigo, severe nausea and vertical torsional nystagmus toward the right side and the symptoms subsided spontaneously in the provocative position within 30 s. The direction of nystagmus reversed while positioning the subject back to a sitting position.
A 58-year-old male patient (super-specialty surgeon by profession) with a history of head trauma following road traffic accident 3 years back, again a diagnosed case of BPPV, complained of sudden onset vertigo on specific head movement to the left side. Similar episode was reported during his hospitalization following head trauma. Being health professional he referred himself to the Physical Therapy Department for rehabilitation measures. The subject reported himself that he was actively involved in academic, professional and sport activities preceding the head injury. The symptom of vertigo has, to a larger extent, limited his participation specifically in sport activities fearing risk of fall. The medical history includes hypertension and ischemic heart disease with elevated blood lipid levels. The surgical history includes multiple vessel coronary angioplasties. On the day of referral, the Dix-Hallpike test could not be completed as the subject experienced severe nausea (but not vertigo) on test positioning. The subject was advised bed rest with supported head positioning in mild neck extension with a pillow on upper-back. Next day the test was repeated with positive symptoms of vertigo and upbeating torsional nystagmus to the left side, but the symptoms were less severe and resolved spontaneously in few seconds.
Physical therapy rehabilitation of BPPV
The physical therapy rehabilitation program for both the cases involved canalith repositioning/liberatory maneuvers and habituation exercises. The subjects were followed-up for 5 days in a week for 2 weeks incorporated with home program. Home program involved repetition of liberatory and habituation exercises twice daily. A prospective clinical study on chronic unilateral PC Posterior Canal BPPV subjects ( n = 112) involved two stages of rehabilitation viz. supervised clinic based program for 2 weeks followed by the unsupervised home based program for 6 weeks. The study reported statistically significant improvements in resolution of symptoms following 2 weeks of supervised rehabilitation program than with unsupervised home based program. The corollary of this observation is that the ten supervised session (5 days in a week for 2 weeks) is sufficient for significant improvement in resolution of BPPV symptoms.  Our rehabilitation program included both supervised and unsupervised home based program for 2 weeks. At the end of 2 weeks rehabilitation program, both subjects reported complete resolution of BPPV symptoms indicated by negative Dix-Hallpike Maneuver. The summary of outcome measures of the rehabilitation program is presented in [Table 1].
Epley canalith repositioning maneuver
In this procedure, the subject in long sitting position on a couch, head was rotated to 45° towards the affected side. Then the subject was quickly taken to supine lying position with head out of the couch and maintained in neck extension (below horizontal). Now, while maintaining head extension, the head was rotated to the opposite side by 45°. Then the subject was asked to roll to side-lying with head maintained in the rotation and extension so that head now faces the floor. Following this position the subject was brought upright in a sitting position. Each position was maintained for 30-60 s, until the nystagmus and/or vertigo to resolve, before the transition to the next position sequence. The systematic review on this maneuver, which included five randomized controlled trials with 292 participants, reported statistically significant effects in resolution of BPPV symptoms with no serious adverse effects for short term period.  One other systematic review reported almost 80% of patient had resolution of BPPV symptoms when Epley' maneuver is used alone. It also reported a marginal increase in the treatment effect when Epley is combined with post-maneuver restriction, and insufficient evidence on the use of mastoid oscillation or on other modified strategies. 
Semont's liberatory maneuver
In this maneuver, the subject in a sitting position over the edge of the couch, head was rotated to 45° opposite to the affected side. Then the subject quickly goes to side lying on the affected side maintaining head rotation to the unaffected side, so that head faces upwards. From this position a quick transition is done to sitting and then to side-lying to the unaffected side so that now the head faces downwards. Each position is maintained for 30-60 s until the nystagmus and/or vertigo to resolve, before the transition to the next position sequence. A prospective randomized trial reported 94.2% resolution of symptoms following Semont maneuver and relapse rate at 3.8% at 6 months follow-up, which were statistically significant compared with medication or no treatment.  A double blind randomized trial on 174 unilateral PC BPPV patients reported 79.3 and 86.8% resolution of symptoms following Semont maneuver at 1 h and 24 h respectively against none in the sham ( n = 168) treatment group. 
This exercise involves the subject to be seated over the edge of the couch. Then the head is rotated to 45° to the affected side and quickly goes to side-lying on the affected side, so that head faces downwards. Then the subject comes back to a sitting position maintaining head rotation to the affected side. Now, the head is turned to the opposite side by 45° from the neutral position and assumes a side-lying position on the opposite side and again rises up to a sitting position maintaining head rotation to the opposite side. Each position is maintained for 30-60 s, until the nystagmus and/or vertigo to resolve, before the transition to the next position sequence. A randomized prospective clinical trial in which 40 subjects of unilateral BPPV treated with Brandt-Daroff exercises reported 25%, and 42.5% resolution of symptoms, indicated by negative Dix-Hallpike Maneuver, at day 7 and day 30 whereas the subjects on repositioning maneuver ( n = 41) reported 80.5 and 92.7% resolution of symptoms matched for follow-up.  Several studies have indicated insufficient evidence for Brandt-Daroff exercise but with n o adverse effects.
Cawthorne - cooksey habituation exercise
These exercises involve coordinated movements of head with eye movements; with trunk and extremities; and balance tasks. In general these habituation exercises involve activities in which the subject base of support is gradually decreased from lying to standing to walking; the activities to be carried out first with eyes open and then closed; from silent to distracting environment and the speed of movements in activities to be increased with progression of the exercises. A prospective clinical trial on 15 subjects on Cawthorne Cooksey exercises reported to have statistically significant improvement in balance promotion and reduced risk of fall. 
| Conclusion|| |
The physical therapy rehabilitation program involving repositioning/liberatory maneuvers, habituation and balance exercises on unilateral PC BPPV for 2 weeks has proven to be successful in complete resolution of symptoms.
| References|| |
|1.||Herdman SJ, Tusa RJ. Physical therapy management of benign positional vertigo. In Herdman SJ, editor. Vestibular Rehabilitation. Ch. 17. 3 rd ed. Philadelphia: FA Davis Company; 2007. |
|2.||Topuz O, Topuz B, Ardiç FN, Sarhuº M, Ogmen G, Ardiç F. Efficacy of vestibular rehabilitation on chronic unilateral vestibular dysfunction. Clin Rehabil 2004;18:76-83. |
|3.||Hilton MP, Pinder DK. The epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev 2004;Iss 2 CD003162. |
|4.||Hunt WT, Zimmermann EF, Hilton MP. Modifications of the epley (canalith repositioning) manoeuvre for posterior canal benign paroxysmal positional vertigo (BPPV). Cochrane Database Syst Rev 2012;4:CD008675. |
|5.||Salvinelli F, Trivelli M, Casale M, Firrisi L, Di Peco V, D'Ascanio L, et al. Treatment of benign positional vertigo in the elderly: A randomized trial. Laryngoscope 2004;114:827-31. |
|6.||Mandalà M, Santoro GP, Asprella Libonati G, Casani AP, Faralli M, Giannoni B, et al. Double-blind randomized trial on short-term efficacy of the semont maneuver for the treatment of posterior canal benign paroxysmal positional vertigo. J Neurol 2012;259:882-5. |
|7.||Amor-Dorado JC, Barreira-Fernández MP, Aran-Gonzalez I, Casariego-Vales E, Llorca J, González-Gay MA. Particle repositioning maneuver versus Brandt-Daroff exercise for treatment of unilateral idiopathic BPPV of the posterior semicircular canal: A randomized prospective clinical trial with short- and long-term outcome. Otol Neurotol 2012;33:1401-7. |
|8.||Ribeiro Ados S, Pereira JS. Balance improvement and reduction of likelihood of falls in older women after cawthorne and cooksey exercises. Braz J Otorhinolaryngol 2005;71:38-46. |