Physical Therapy for Benign Paroxysmal Positional Vertigo

Questions: 1. List two impairments that may be found during a vestibular assessment that would indicate a central versus a peripheral vestibular pathology. Indicate during which test or observation in which these impairments may be noted. 2. Identify and describe the treatment strategies that are the most beneficial for the posterior and horizontal canal based upon the Practice Parameter: Therapies for Benign Paroxysmal Positional Vertigo (An Evidence-Based Review): Report of the Quality Standards Subcommittee of American Academy of Neurology. 3. Based upon the Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo, describe whether you would provide post-treatment precautions to a patient you treated for BPPV. If you recommend restrictions, describe your restriction, rationale as to why, and your restriction duration. 4. Perform the Dix Hallpike and the Canalith Repositioning Maneuver for the posterior canal on any willing person. Describe your experience. Do you feel you are ready to perform this on a patient? Answers: 1. It has been observed that the reduction in an appropriate neural output can happen due to the dual effect of Peripheral Vestibular Disorders (PVD) and Central Vestibular Disorders (CVD). This effect and reduction in neural output hamper the eye movement and spatial orientation. Individuals facing this impairment have found to face various problems that include dizziness, falls, imbalance, bilateral vestibulopathy, vertigo associated with dysfunction of the auditory system, benign paroxysmal positional vertigo (BPPV), vertigo associated with brainstem and oscillopsia (visual blurring) (Bhattacharyya et al., 2008). Assessment and inspection of the tympanic membrane and external ear are one of the tests and observations that can find out the impairment. Other tests and observation include Cranial nerve examination that can identify the potential cause of hearing loss and palsies. Apart from this, Dix-Hallpike test can clinically confirm the diagnosis of the posterior canal for benign paroxysmal positional vertigo (BPPV). However, various other tests are also important in finding out the impairments (Kutz 2010). These tests are vestibular testing, radiographic imaging, audiometric testing, computerized posturography, balance and gait testing, electronystagmography, orthostatic balance testing, audiometry testing, bedside testing, etc. 2. Many scientists and researchers have claimed that Dix-Hallpike maneuver therapy is the best-known diagnosis for posterior canal based BPPV. The treatment includes a top pole of rotational beating with the presence of torsion and up beating nystagmus. The whole set up is focused on the downside (affected) ear of the patient. The therapy follows a technique where the patients head is turned 45 degrees towards the position where it needs to be tested, and then the head is laid back (Fife et al., 2008). During this process, if the patient is suffering from BPVV then the nystagmus would ensure it within a second. Hence, nystagmus along with Dix-Hallpix maneuver technique is considered the ideal therapy for posterior canal BPPV. The horizontal canal based BPPV is diagnosed with Dix-Hallpike or supine maneuver process. They produce two types of geotropic positions. In the first prototype, the geotropic position is presented towards the ground that is known as the horizontal geotropic. The second prototype produces the geotropic position facing away from the ground that is known as apo-geotropic. Both of these geotropic possess a direction changing paroxysmal positional nystagmus. The patient is tested while he/she is seated in a straight supine position (Post Dickerson 2010). The patient is examined with the help of nystagmus. The observation of nystagmus is recorded by turning the head of the patient each in left and right side once. The readings and direction of nystagmus finally verify the type of horizontal canal BPPV and identifies the nature (geotropic or apogeotropic). Moreover, certain other techniques have been identified for the treatment of horizontal canal BPPV that are barbecue roll maneuver, Gu foni maneuver and VannucchiAsprella liberatory maneuver techniques (Troxel, Drobatz Vite 2015). 3. I would suggest the patients of post-treatment precautions who have been treated for BPPV under my guidance. Firstly, I would advise the patient to perform Brandt-Daroff exercises. This particular exercise would help him/her get accustomed to the abnormal balance signal that is triggered from the particles of the inner ear. Moreover, it would also assist the brain of the patient to get used to his/her conditions and it would provide immense help for setting him/her up for the further therapy and treatment. Moreover, I would like to suggest the patient that he/she should perform the exercise in three sets in a single day and should continue doing it for at least two weeks. Apart from this exercise, I would also suggest him/her to maintain a proper balance exercise for vertigo like standing up with the feet resting together, moving the head from side to side (Zaidi Sinha 2013). These small activities are believed to help the patient to get the cure and overcome the benign paroxysma l positional vertigo (BPPV) related problems. Moreover, the following exercises need to be performed by the patient on a regular basis (at least five times a day for the two weeks and so on). On the other hand, individual studies and research works have revealed that self-administered Canalith repositioning procedure (CRP) if assisted with Semont maneuver and Brandt-Daroff techniques result in good post-treatment precautions for the patients. And hence, I would also like to suggest the patient perform CRP's to provide them with better precautions. Apart from this, certain restrictions should be followed by the patients at every time as post-treatment restrictions are as follows - Getting up slowly from the bed and sitting on the edge of the bed before standing Try to avoid leaning to pick up anything from the ground Avoid sleeping sideways with the year as that may cause fatal and severe consequences Need to be extra careful while reclining Physical sports like football, rugby or anything that requires a vigorous jerk to the body should be avoided Avoid to move the head up and down . Avoid tilting the head frequently 4. The experience that I gained is that the Dix-Hallpike test requires "head hanging" for the patient maintaining a 10-degree rise in head position. Now, if the movement fails, then tests for horizontal semicircular canals are conducted. Again, if no nystagmus result is obtained in this position, then posterior semi-circular canals are tested. Moreover, I have also observed that the head hanging position followed by right and left movement of the head results in the collection of canaliths that ultimately provides a positive outcome. However, I have also observed that failure in conducting the posterior semi-circular canal testing will eventually provide us with false negative results. I have also experienced that horizontal canal trial and repetition of Dix-Hallpike test will ultimately decrease the chances for the patient undergoing extra tests. Moreover, these additional tests often lead to misdiagnosis. Furthermore, I also understood that if vertigo or nystagmuses elicit a moveme nt then a proper and appropriate CRM is carried out. Yes, as a doctor I am very much confident and ready on the fact that I can perform these methods on the patients. Reference Bhattacharyya, N., Baugh, R. 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