Vertigo and Disequilibrium, Chapter 8

5/17/2018 Vertigo and Disequilibrium, Chapter 8

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78 Vertigo and DisequilibriumTable 8-1 Impairments and Functional Limitations Directly or Indirect ly Caused By Benign ParoxysmalPositional Vertigo

lmpalrments~eaf of fallingInilbHity to driveDecreased community ;PrnJru !a t ion~ocial isolafion " "Decreased reereatlonal a"ctMtie:s andjorexerciseInabilitytp perform normal \1VorkdutiesInability to perform h o u seh o ld ch o re s or ADL'sDecreased independenceNeed for assistive devices for ambulation

Blurred visionDecreased static and tlyni'!mic balanceDecreased postural stabilityDifficulty ambulatingGeneralized muscle weaknessDeconditioningAnxietyDepression

Abbreviation: ADL. activities of daily living.

Table 8-2 Direction of Nystagmus and Extraocular Muscles Involved in BPPVContr'alateralirection of

NystilgmusanalUpbeat torsionalDownbeatHorizontal

Inferior rec tus (depression. ouInferior oblique (elevation, outLateral f~(;tus (abduction)~-~,~--Posterior CanalAnterior CanalHorizontal canal

Table 8-3 Characteristics and Treatment Options for Different Variants ofBPPVTDirection ofNystagmusest

Dix-HallpiketestDix-Hallpiketest

Upbeat torsional-towardthe affected 5ideUpbeat torsional-toward. th@affected 5ide

Symptoms colnctde with. nystagmusSymptqmslpieally

subside whilenystag\i1ils p,HS'iS~'

Epleosteriorcanal l thlasisPosterior. cupulQlithiasis sernl t

vle

O t : : mDowabe a t torsional-.toward .theaffected sldeDownbeat torsional-toward theaffected side

Dix-Hallptketest

Anteriorcanalfth l as is

Symp toms typicallYsubside y,ihi~nystagmus persists

Dix-Hallpiketest Semt

vDe360, rpp

Anteriorcupuloltthlasls minute

Horizontal nystagmusb.eating towardthe ground;nystagmus is moresevere on the.affeded side

'HQfiZPTitill nystqgm\-ls. oeating away from thegroofld~ nystagmus ismore severe on th eopposite side

Horlzontal.canajithiasis(ileotrapk)

Roll test

14orl.iontalt eupu lo l i th ias isrageotropic)

Roll test Con


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8 Testing and Treatment of Benign ParoxysmalPositionalVertigo 79Table 8-4 Direction of Nystagmus During a Positive Dix-Hallpike Test

Direetlcn of Nys t


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80 Vertigo and Disequilibrium

Figure 8-2 Roll test for horizontal canal. (These pictures demostrate the patient rolling into a side lying position versus the patieturning the head only.) The test can be performed by rotating tpatient's head 90D laterally; however, ifthe patient lacks cervical molity, they will need to be rolled into a side lying position as demostrated above. (A) Patient begins in the supine head center positio(B) Patient is rolled onto the left side. (C) Patient is rolled onto tright side. (Courtesy of BalanceSolutions.com.)

Toperform the test:Step 1 Have the patient lie supine with the head placed

~20 of flexion (Fig. 8-2A).Step 2 The patient's head is then rotated laterally ~90(fig. 8 -28). The direction and degree of nystagmus is noteStep 3 The patient's head is then rotated to the opposite sidand again the direction and degree of nystagmus is not(Fig. 8-2C). If the patient's head is not rotated far enougthe otoconia may not migrate through the canal, resultinin a false negative test.I f the patient has limited cervical mobility, the patiewill need to be rolled into a side lying position to complethe test.Horizontal canal BPPV will often produce stronger mointense symptoms of dizziness, which may be associatwith nausea and sometimes emesis. If you roll the patieonto one side and the patient experiences severe dizzineimmediately roll them onto their opposite side. Perform3600 barbecue roll (pages 84-85) in the opposite directiof the more symptomatic ear.


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8 Testing and Treatment of Benign Paroxysmal Positional Vertigo 81

A

c

BFigure8-3 Epley canalith reposit ioning maneuver, demonstrated forthe treatment of right posterior canal BPPVor left anterior canal BPPV.This can be performed with or without vibration (modified Epley). (A)Starting position: note that this is the same position used in the Dix-Hallpike Test. (8) Patient is rapidly brought back while maintaining450 of cervical rotation toward the affected side. (C ) Patients head isturned ~90 to the opposite side. (Continued on page 82)

Treatment of Benign ParoxysmalPositional Vertigo

Epley Canalith Repositioning ProcedureThe canalith repositioning procedure (eRP ) was designed byEpley for the treatment of BP PV .8 The eR P consists of timedhead maneuvers as well as applied vibration to assist in themigration of free otoconia from the semicircular canal backinto the utricle": however, the procedure can be modified toexclude vibration?-ll To perform the eRP :Step 1 On the exam table have the patient long sitting(Fig. 8-3A). The head is rotated ~45 toward the side youare treating. The patient's head is maintained in ~45 ofrotation and the patient is rapidly brought back with theneck extended ~20 over the edge of the treatment table(Fig. 8-38). This position is held for ~30 seconds after thenystagmus or symptoms subside.


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Figure 8-3 (Continued). Epley canali th repositioning maneuver, demonstrated for the treatment of right poster ior canal BPPVor leftcanal BPPV.This can be performed with or without vibrat ion (modified Epley). (0) Patient isrol led onto their opposite side with the nose pdown. (E ) Patient returns to sitting while maintaining head pitched ~20 forward. (Courtesy of BalanceSolutions.com.)

Step 2 The patient's head is kept in ~20 of extension androtated 90 to the opposite side. The patient's head shouldnow be ~45 toward the unaffected ear (Fig. 8-3C). Thisposition is held for ~30 seconds.Step 3 The patient is then rolled into a side lying positionwith their head turned ~45 downward to the floor(Fig. 8-3D). This position is held for ~30 seconds.Step 4 Keeping the head rotated toward the unaffected ear,with the chin tucked in, the patient slowly returns to aseated position (Fig. 8-3E).When performing the Epley canalith repositioning pro-cedure for treatment of the anterior canal, the maneuver isperformed on the opposite side of the affected ear. For

example, if left anterior canal BPPY is suspected, the Epleyprocedure must be performed on the right side. It is also rec-ommended to perform a deep maneuver, meaning performthe maneuver with increased cervical extension or a deepDix-Hallpike.6.12,13The CRPshould be performed two times as this increasesthe probability of resolving BPPY from 78 to 90%.14 Duringthe second CRP,if the patient does not experience symptoms

of vertigo or nystagmus is not elicited, proceed wimaneuver holding each position for ~ 15 seconds. Thgood sign that the first CRPwas successful,If the patient continues to experience symptoms of vor nystagmus continues to be observed, then repeat theneeded. Be certain to maintain ~20 of cervical extduring step 2 of the CRP, as lifting the head may remigration of the otoconia back toward the cupula. Miof the otoconia back toward the cupula may alsoduring step 3 of the CRP if the patient lifts their headtable while rolling into a side lying position.

The Semont ManeuverThe Semont maneuver is an option for treatment of poand anterior canal BPPv.15,16 This maneuver involvesmovements, which may not be tolerated well bypersons or individuals with cervical conditions. This mver is known as the Iiberatory maneuver and can auseful in treating cupulolithiasis variant BPPY.


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B

D

E

Figure 8-4 Semont maneuver, demonstrated for the treatment ofright posterior canal BPPV. (A) Starting position: note the hand place-ment used to protect the patient's head. (B,C) Patient is taken rapidlyinto a side lying position on their affected side with their nose pointingup. (D.E) Patient is rapidly moved onto their opposite side with theirnose point ing down. (Courtesy of BalanceSolutions.com.)

For treatment of right posterior canal BPPV: Step 4 The patient is then slowly brought back to a sittingposition (Fig. 8-4A).Step 1 Start the patient sitting with their head rotated ~45toward the unaffected side (Fig. 8-4A).Step 2 The patient is then moved rapidly into a side lyingposition on their affected side; they should be face up(Figs. 8-48,C). This position is held for 1 to 2 minutes.Step 3 The patient is rapidly moved to the opposite sidemaintaining the head in 45 of rotation, they should nowbe face down (Figs. 8-40,). This position is maintainedfor 1 to 2 minutes.

For treatment of left anterior canal BPPV:Step 1 Start the patient sitting with their head rotated ~45toward the affected side (Fig. 8-SA).Step 2 The patient is then moved rapidly into a side lyingposition on their affected side; they should beface down (Figs. 8-S8,C). This position is held for 1 to 2minutes.


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The 3600 Barbecue Roll

Step 3 The patient is rapidly moved to the opposite sidemaintaining the head in 45 of rotation, they should nowbe face up (Figs. 8-5D,E). This position is maintained for1 to 2 minutes.

Step 4 The patient is then slowly brought back to a sittingposition (Fig. 8 - SA).

Figure 8-5 Semont maneuver, demonstrated for the treleft anterior canal BPPV. {AI Starting position: note the hment used to protect the patient's head. (B,C) Patientrapidly into a side lying position on their affected sidenose point ing down. (D,E) Patient israpidly moved onto theis ide with their nose point ing up. (Courtesy of BalanceSoluti

In geotropic horizontal canal BPPV(fast phase of nbeats toward the ground), nystagmus and symptomsworse on the affected side. A 3600 barbecue roll toopposite side is the treatment of choice. This procvery effective in the treatment of geotropic horizonBPPVand will often result in the immediate terminpositional vertigo and nystagmus7.17-19To perform the maneuver:

Step 1 Start with the patient in the supine positionhead flexed at ~O to 20 (Fig. 8-6A).Step 2 The patient is rolled toward their unaffec(Fig. 8-68). This position is held for ~30 to 60 se


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Figure 8-6 The 3600 barbecue rol l, demonstrated for the treatment of r ight horizontal canal BPPV.(A) Pat ient starts in the supine posit ion with0-200 of cervical flexion. (B) Pat ient is rolled onto their left side. (e) Pat ient is then rolled into the prone posit ion maintaining 0-20 of cervicalf lexion. (D) Pat ient is f inally rolled onto their r ight side. (Courtesy of BalanceSolut ions.com.)


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Figure 8-7 Guffoni maneuver, demonstrated for thof lef t horizontal canali thiasis (geotropic horizontal BPPeuver is demonstrated without the aide of a practitionedemonstrate the head position. (A) Starting position.rapidly moved into a left side lying position on their a(C ) Patient 's head is rapidly rotated ~45 downward.BalanceSol uti ons. com.)

Step 3 The patient is then rolled onto their stomach main-taining ~O to 200 of cervical flexion (Fig. 8-6C). This pos-ition is held for ~30 to 60 seconds,Step 4 Having the patient roll back onto their affected sidecompletes the procedure (Fig, 8-6D). This position is heldfor ~30 to 60 seconds.If BPPV is successfully treated, then the patient may not

experience symptoms on their affected side when theyfinish. In such a case, have the patient sit up and follow thepostprocedure protocol.If the patient continues to experience severe symptoms,repeat the maneuver. If you perform the maneuver twiceand the patient continues to experience severe symptoms orcontinues to present with Significant geotropic nystagmus,try performing the maneuver in the opposite direction asyou may have chosen the incorrect ear to treat.Ifyou are using VNGduring the treatment of geotropic hori-zontal BPPV,you can confirm that you are treating the properside if the nystagmus continues to beat in the same direction

throughout the maneuver. If the nystagmus chations when the patient rolls onto their stomachindicate that you have chosen the incorrect side tFor example, in right geotropic horizontal cnystagmus and symptoms will be more severepatient is lying on the right side. The fast phase owill be beating toward the right when the patieright-ear-down position. The treatment of choica 3600 barbecue roll toward the left, away fromside. When the patient is rolled onto their left sidcontinue to present with geotropic horizontalthe fast phase will now be beating toward thethe 360b barbecue roll, the nystagmus shoulbeating toward the left ear in each position.In ageotropic horizontal canal BPPV(fast phasemus beats away from the ground), nystagmus andwill be worse on the opposite side. This is much mging to treat. You must convert ageotropic horizBPPVto geotropic horizontal canal BPPVto succethis variant.


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8 Testing and Treatment of Benign Paroxysmal Positional Vertigo 87converting ageotropic to geotropic BPPVcan be attemptedby performing a series of quick head turns from the affectedside to the unaffected side. This is performed in an attemptto free or move the otoconia away from the cupula to thelong arm of the canal.The modified Guffoni maneuver is another option to convertageotropic to geotropic 8PPV.If you are successful at convert-ing ageotropic to geotropic. you will finish treating by per-

forming the 3600 barbecue roll toward the unaffected side.If you are unable to convert to geotropic horizontal BPPV,you may have the patient attempt forced prolonged position-ing or perform modified Brandt-Daroff exercises.

The Guffoni ManeuverThe Guffoni maneuver has been reported to be successfulfor the treatment of geotropic horizontal canal BPPV.and it has also been found to be effective in converting

ageotropic horizontal canal BPPVto geotropic horizontal canalBPPV_2-22For treatment of geotropic horizontal canal BPPV:

Step 1 Start with the patient in a sitting position with legsover the side of the table (Fig. 8-7A).Step 2 The patient is rapidly brought down into a side lyingposition toward the affected side (Fig. 8-78).Step 3 The patient's head is rapidly rotated ~45 downward(Fig. 8-7C). This position is maintained for 2 to 3 minutes.For treatment of ageotropic horizontal canal BPPV:

Step 1 Start with the patient in a sitting position with legsover the side of the table (Fig. 8-8A).Step 2 The patient is rapidly brought down into a side lyingposition toward the affected side (Fig. 8-88).Step 3 The patient's head is rapidly rotated ~45 upward(Fig. 8-8C). This position is maintained for 2 to 3 minutes,

Figure 8-8 Guffoni maneuver, demonstrated for the treatment ofleft horizontal cupulolithiasis (ageotropic horizontal BPPV). Thismaneuver is demonstrated without the aide of a practitioner tobetter demonstrate the head position, [A) Starting position,(8) Patient is rapidly moved into a left side lying position on theiraffected side, (C) Patient's head is rapidly rotated ~45 upward.(Courtesy of BalanceSolutions.com.)


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Brandt- Daroff ExercisesThese exercises are aimed at habituating a patient's symptomsof dizziness when other maneuvers are unsuccessful at resol-ving BPPV.These exercises are an option for treatment ofcupulolithiasis or persistent canalithiasis BPPV, and aregiven as a home exercise program. These exercises can bemodified for treatment of horizontal canal BPPV by simplykeeping the head in a neutral position throughout theprocedure (versus 45 of rotation)."To perform these exercises:Step 1 The patient begins by sitting in the center of the bedwith their feet on the floor (Fig.8-9A).Step 2 The patient turns the head ~45 toward either side.Step 3 The patient then moves quickly into a side lying pos-ition with the face up (Fig. 8-98). This position is held for30 seconds. If vertigo or dizziness is induced, the patientmust wait until the symptoms subside plus an additional30 seconds.Step 4 The patient then returns to a seated position for 30seconds.

Figure 8-9 Brandt-Daroff exercises .. (A) Starting posititurns head ~45 toward the side prior to moving intoand C. (B) Patient begins in the sitting position with the~45 to the left and rapidly moves into the right side lywith nose pointing up. (C ) After returning to the sittinpatient turns their head ~45 to the right, and rapidlythe left side lying position with nose pointing up. (BalanceSolutions.com.)

Step 5 Repeat this procedure to the oppo(Fig.8-9C).The patient is instructed to repeat this 10 timestimes per day. The patient is further instructedthis every day until they experience 2 consecuwithout symptoms, at which time they no longperform this exercise.

Forced Prolonged PositioningThe patient is instructed to remain in a side lyingtheir unaffected side for 12 hours. This positionotoconia to fall out of the horizontal canal.i"

Postprocedure Management of BParoxysmal Positional Vertigo

If treatment of BPPV is believed to be successfulpatient is instructed to keep his or her head in the uition for the next 24 to 48 hours and to avoid lyin


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Step 1 Turn your head 45 toward your affected ear and layback quickly. Hold ~ 1 minute. (If you do not know which isyour affected ear, perform the self-testing procedure on bothsides and treat your most symptomatic side.)Step 2 Keep your head against the bed and turn it 45 towardyour good ear. Hold Nl minute. (Be certain not to lift yourhead while you are turning it to the opposite side as thismay cause the crystals to roll in the wrong direction.)Step 3 Roll onto your side with your good ear down, Yournose should be turned toward the floor. Hold ~ 1 minute,(Be certain to roll completely onto your good side, if youdo not point your nose into your bed, crystals may not rollout of the canal.)Step 4 Sit up keeping your chin tucked in toward yourshoulder, your head should be turned 45 toward yourgood side. Hold ~ 1minute.


~ affected side for the next 3 to 5 days. Patients should beformed that BPPVmay not be fully resolved or may recur~ the future. Instructions for self canalith repositioning~euvers or Brandt-Daroff exercises may be provided inzase of recurrence. Patients should also be educated onsafety precautions and fall prevention as they may continuem experience symptoms of dizziness and imbalance for thenext several days.Treatment of BPPV results in improved postural stabilityfor many individuals; however, postural stability may not.. tum to normal for all individuals after BPPV has beenTe5olved.25,26 Proper balance assessment may be required toidentify factors contributing to an individual's continuedbalance deficits. Treatment of the identified balance deficitsmay be necessary to restore an individual's normal posturalstability. particularly in the elderly.Pre-existing neck and back conditions may be aggravatedby performing the different treatment protocols, so careshould be taken to avoid injury when performing any man-euver. Patients may also develop neck pain or stiffness as aresult of avoiding head movements. When appropriate, itmay be helpful for patients to apply moist heat orperform gentle range of motion exercises to decrease neckstiffness,

Self-Testinq and Self-Treatment forBenign Paroxysmal PositionalVertigo (BPPV)

T o testyo urseff, sit o n yo ur bed w ith y ou r leg s stra ig ht, P la ce apillow behind your back so that when you lie back your headwill rest on your bed in a slightly extended position. This mayalso be performed over the edge of your bed; however, youmust be careful not to cause or aggravate a neck problem byoverextending your neck, Once you are a proper position,turn your head toward your affected ear and lie back quickly.Ifyou experience symptoms of dizziness or vertigo, remainin this position and continue with step 2 of the Epley maneu-ver in the next section (step 1of the maneuver is the same asthe self-test). if you do not experience symptoms of dizzinessor vertigo. sit straight up and check your opposite side. If youexperience symptoms on both sides, treat the side that feelsthe most severe.

Epley ProcedureSit in your bed with your legs straight. Place a pillow behindyour back so that when you lie back your head will rest onyour bed in a slightly extended position. This may also be per-formed over the edge of your bed; however, you must becareful not to cause or aggravate a neck problem by over-extending your neck. If you experience severe symptoms, youmay require help to peJjonn this procedure.

Performing this procedure one time gives you a 75 % chance ofresolving your BPPV,Repeating this procedure 2 times willincrease your chance of resolving BPPVto 90%. If you performthis 2 times and do not experience symptoms on the secondrepetition, continue with the procedure, holding for only 10 to15 seconds versus 1 minute. In some cases, this may need tobe repeated more than 2 times for full resolution of symptoms.For 24 to 48 hours after you perform this procedure, You may not lie down flat. You may not bend over, \ook up, or \ook down. Y ou may experience a s e ns a ti on of dizziness lasting 1 to 2days, which may occur at rest or with head movement andwill gradually decrease .

Roll ManeuverTo resolve horizontal canal BPPV,you must roll in a 3600 circleaway from your affected ear. Rollslowly in three steps, holdingeach position for ~60 seconds.Step 1 Start by rolling onto your good side and hold.Step 2 Ron onto your stomach, try not to lift your head up asyou roll by keeping your chin tucked in toward your chest,and hold.Step 3 Roll onto your affected side and hold.Repeat this procedure if you continue to experience dizzi-

ness or vertigo on your affected side.

Brandt- Daroff ExercisesThis exercise has been designed to help decrease your symp-toms of dizziness by retraining your central nervous system.This exercise will reproduce your symptoms of dizziness,


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the affected side for the next 3 to 5 days. Patients should beinformed that BPPV may not be fully resolved or may recurin the future. Instructions for self canalirh repositioningmaneuvers or Brandt-Daroff exercises may be provided incase of recurrence. Patients should also be educated onsafety precautions and fall prevention as they may continueto experience symptoms of dizziness and imbalance for thenext several clays.Treatment of BPPV results in improved postural stabilityfor many individuals; however, postural stability may notreturn to normal for all individuals after BPPV has beenresolved.25.26 Proper balance assessment may be required toidentify factors contributing to an individual's continuedbalance deficits. Treatment of the identified balance deficitsmay be necessary to restore an individual's normal posturalstability, particularly in the elderly.Pre-existing neck and back conditions may be aggravated

by performing the different treatment protocols, so careshould be taken to avoid injury when performing any man-euver. Patients may also develop neck pain or stiffness as aresult of avoiding head movements. When appropriate, itmay be helpful for patients to apply moist heat orperform gentle range of motion exercises to decrease neckstiffness.

Self-Testing and Self-Treatment forBenign Paroxysmal PositionalVertigo (BPPV)

To test yourself, sit on your bed with your legs straight. Place apillow behind your back so that when you lie back your headwill rest on your bed in a slightly extended position. This mayalso be performed over the edge of your bed; however. youmust be careful not to cause or aggravate a neck problem byoverextending your neck. Once you are a proper position,turn your head toward your affected ear and lie back quickly.If you experience symptoms of dizziness or vertigo, remain

in this position and continue with step 2 of the Epley maneu-ver in the next section (step 1 of the maneuver is the same asthe self-test). If you do not experience symptoms of dizzinessor vertigo. sit straight up and check your opposite side. If youexperience symptoms on both sides, treat the side that feelsthe most severe.

Epley ProcedureSit in your bed with your legs straight. Place a pillow behindyour back so that when you lie back your head will rest onyour bed in a slightly extended position. This may also be per-formed over the edge of your bed: however, you must becareful not to cause or aggravate a neck problem by over-extending your neck. If you experience severe symptoms, youmay require help to peiiotm this procedure.

Step 1 Turn your head 45 toward your affected ear and layback quickly. Hold r--;1 minute. (If you do not know which isyour affected ear, perform the self-testing procedure on bothsides and treat your most symptomatic side.)

Step 2 Keep your head against the bed and turn it 45 towardyour good ear. Hold ~ 1 minute. (Be certain not to lift yourhead while you are turning it to the opposite side as thismay cause the crystals to roll in the wrong direction.)Step 3 Roll onto your side with your good ear down. Yournose should be turned toward the floor. Hold ~ 1 minute.(Be certain to roll completely onto your good side, if youdo not point your nose into your bed. crystals may not rollout of the canal.)

Step 4 Sit up keeping your chin tucked in toward yourshoulder, your head should be turned 45 toward yourgood side. Hold ~ 1 minute.Performing this procedure one time gives you a 75% chance of

resolving your BPPV. Repeating this procedure 2 times willincrease your chance of resolving BPPV to 90%. If YOLl performthis 2 times and do not experience symptoms on the secondrepetition, continue with the procedure, holding for only 10 to15 seconds versus 1 minute. In some cases, this may need tobe repeated more than 2 times for full resolution of symptoms.For 24 to 48 hours after you perform this procedure,

You may not lie down flat. You may not bend over, look up. or look down. Y ou may experience a sensation of dizziness lasting 1 to 2

days, which may occur at rest or with head movement andwill gradually decrease .

Roll ManeuverTo resolve horizontal canal BPPV. you must roll in a 3600 circleaway from your affected ear. Roll slowly in three steps, holdingeach position for ......0 seconds.Step 1 Start by rolling onto your good side and hold.Step 2 Roll onto your stomach, try not to lift your head up asyou roll by keeping your chin tucked in toward your chest.and hold.

Step 3 Roll onto your affected side and hold.Repeat this procedure if you continue to experience dizzi-

ness or vertigo on your affected side.

Brandt- Daroff ExercisesThis exercise has been designed to help decrease your symp-toms of dizziness by retraining your central nervous system.This exercise will reproduce your symptoms of dizziness.


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The Testing and Treatment of BenignParoxysmal Positional Vertigo

8Kelly S. Beaudoin

New developments in research have led to an increasedunderstanding of the pathophysiology of benign paroxysmalpositional vertigo (BPPV), thus guiding new treatment pro-tocols for the specific semicircular canals involved. BPPVcanresolve spontaneously; however, countless individuals mayexperience unremitting symptoms or recurrent BPPV.Inter-vention for BPPVcan rapidly alleviate an individual's symp-toms, enabling them to return to their normal activities. Theparticular protocol used for treatment of BPPV depends onseveral factors, including the semicircular canal involved,whether the individual has canalithiasis or cupulolithiasis,any underlying cornorbidities or mobility restrictions, aswell as the individual's willingness to perform a particularprotocol.An episode of BPPV,whether single or recurrent, may have asignificant impact on an individual, especially when the indi-vidual lacks an understanding as to the cause of the symp-toms. BPPV may contribute to secondary comorbidity suchas anxiety and depression and result in impairments andfunctional limitations (Table 8-1) due to decreased activitylevels, social isolation, and fear of falling. Decreased balanceand postural control is associated with BPPV and maypersist for hours to weeks once the BPPVresolves.l" " Posturalinstability can be devastating to the elderly population result-ing in increased risk for falls, particularly when combinedwith underlying comorbidities such as visual impairments,muscle weakness, or neuropathy ..Indirectly, BPPVmay be avery disabling condition if left untreated.The pathophysiology of BPPVis discussed in Chapter 7. Inthis chapter we demonstrate the methods utilized to returnan individual's vestibular system back to its normal state.

Testing of Benign ParoxysmalPositional VertigoThe Dix-Hallpike TestThe Dix-Hallpike test is the standard for diagnosis of anterioror posterior canal BPPV.5When performing the Dix-Hallpiketest, nystagmus should be observed with Frenzel lenses orrecorded with videonystagmography (VNG), and the patient'ssubjective complaint should be noted. The examiner must beable to identify which patterns of nystagmus indicate BPPV(Table 8-2) to determine the canal affected and the appropri-ate treatment (Table 8-3). If performing the test withoutFrenzel lenses or VNG,mild nystagmus may not be observable.The patient may fixate and suppress the nystagmus. In thiscase, if BPPV is suspected, perform the test on both sidesand treat the most symptomatic side.To perform the test, have the patient long sitting on theexam table (Fig. 8-1A) with the head rotated ~45 towardthe side you are testing. The patient's head is maintained in~45 of rotation and the patient is rapidly taken back withthe head extended ~20 over the edge of the treatmenttable (Figs. 8-1B,C). Nystagmus is noted as well as thepatient's subjective complaints. The patient is then takenback into the sitting position with the head maintained at~45 rotation. Reversal of nystagmus is noted (Table 8 -4).If the Dix-Hailpike test fails to reproduce the patient'ssymptoms or fails to elicit nystagmus, it should be repeated.Debris may accumulate in the head-hanging position andresult in a positive test on the second trial." If repeating thetest continues to fail at reproducing symptoms or eliciting

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Vertigo and Disequilibrium, Chapter 8