BACKGROUND AND PURPOSE
Benign Paroxysmal Positional Vertigo
Dizziness accounts for the primary complaint that necessitates 5.6 million clinic visits in the United States per year. Of these patients with vertigo, between 17% and 42% received a diagnosis of benign paroxysmal positional vertigo (BPPV).1 This condition was first described in 1921 by Barany as an “attack” of violent vertigo and nausea occurring when side-lying and lasting approximately 30 seconds prior to abolishment of symptoms. BPPV occurs when free-floating otoconia migrate into 1 of 3 semicircular canals of the inner ear and either becomes trapped inside the canals (canalithiasis), or becomes adherent to the cupula of the semicircular canal (cupluolithiasis). Although symptoms only last up to 60 seconds at a time, 80% of patients experience rotary nystagmus and 47% complain of a floating sensation with such activities as rolling over in bed, extending the cervical spine, and trunk flexion. However, BPPV is thought to be self-limiting with abolishment of symptoms within 6 months.2
There are several different types of BPPV with posterior canal BPPV occurring most frequently at a rate of 85% to 95% of cases.1 Posterior canal BPPV canalithiasis is the most common form because this canal is in the most gravity-dependent position when a person is either standing or supine and in order for the otoconia to exit the canal spontaneously, it must move opposite the gravitational pull.2 Lateral or horizontal canal BPPV accounts for the majority of the remainder 5% to 15% of cases, with other variations including anterior canal BPPV, multiple canal BPPV, and bilateral multiple canal BPPV occurring rarely.1
BPPV can either be classified as primary or secondary. Primary BPPV occurs when found in isolation and accounts for 50% to 70% of cases whereas secondary BPPV is caused by another injury or disorder. The most common cause is head trauma, which can account for up to 17% of cases of BPPV; less common causes include viral labyrinthitis with 15% and Ménière disease at 5% of cases.2 The prevalence of BPPV ranges from 10.7 to 64 per 100 000 population with a lifetime prevalence of 2.4%. BPPV has been found to be the most common vestibular disorder across the lifespan with the most common age of onset between 50 and 70 years. The recurrence rate of BPPV has been estimated at 15% per year; however, this rate increases if BPPV is due to head trauma.1 The gold standard for BPPV diagnosis includes patient history and eye findings during positional testing, specifically Dix-Hallpike for posterior canal.2 A positive result for the Dix-Hallpike includes a brief latency of symptoms for 1 to 5 seconds, followed by nystagmus featuring an upbeating motion as well as rotation toward the dependent ear of up to 60 seconds. With repeated testing, the signs become less intense and fatigue entirely. The Dix-Hallpike test has a sensitivity of 79% and specificity of 75% with a positive likelihood ratio of 3.17, making it minimally useful for clinical decision making.3
The most significant consequence of untreated BPPV, especially in older adults, would be the resultant increased likelihood of falls due to a reduced sense of equilibrium. Falls with increasing age have negative consequences, including fractures, brain injury, and institutionalization, which can lead to significant costs for both the individual and society.1 Thus it is clear why prompt appropriate diagnosis and treatment of BPPV is crucial.
International Classification of Functioning, Disability, and Health
The World Health Organization's International Classification of Functioning, Disability and Health (ICF) is the culmination of efforts that began in 1993 by the active participation of 1800 experts from 65 countries, which was eventually accepted in 2001 as the international standard to describe and measure health and disability. The goal of the ICF was to develop a unified and standard language and framework for the analysis of all aspects of health as well as some health-related wellness aspects. The ICF is laid out in a manner where there are 2 subgroups for each of the 2 main divisions of the model. The first part of the ICF, functioning and disability, consists of body functions and structures and activities and participation.4 Body functions and structures are analyzed in terms of change in physiologic function and anatomic structure. Activities are considered the execution of tasks or actions; participation is defined as the involvement in life affairs.5 The second part of the ICF, contextual factors, consists of environmental and personal factors.4 In terms of the ICF, functioning is considered the positive aspect of each component and disability is deemed the negative aspect.5 Each of these domains are further broken down into categories, which are the units of the ICF classification. These categories and their respective codes are then selected to describe the individual's health-related states and are given numeric codes, which specify the magnitude of the functioning or disability of that category to the extent that an environmental factor is either a facilitator or barrier.4 Implementation of the ICF in a case study involving physical therapy for low back pain found that treatment was prioritized whereas another study on physical therapy for patellar dislocations found improved decision making as the patient's contextual factors were taken into account.6,7 By use of the ICF, care is ensured to be patient-centered, which improves outcomes and efficiency as well as allows comparison for international research. Minimal literature is available about implementing the ICF into physical therapy practice, which can make the process daunting to initiate. The purpose of this case report is to illustrate the use of the ICF model in the evidence-based management of posterior canal BPPV.
Patient History and Systems Review
The patient was a 74-year-old woman who presented with dizziness, which she stated had been present for 2 months in duration. She reported that the spinning sensation first occurred while watching her grandchild play a video game. She admitted the symptoms of spinning and nausea were worst when getting in and out of bed, but they also occurred while looking down to read or when she looked up to change a light bulb. Although she described the sensation as severe, she admitted the symptoms lasted less than 1 minute before abolishing. She stated that if she avoided head movements and changes in position, such as laying flat in bed, she could avoid her symptoms. She denied any hearing loss, tinnitus, headaches, or neck pain. She did not have a history of hypertension nor did she present with any orthostatic hypotension. Other medical conditions included a recent hernia repair and cardiac catheterization. She currently was taking the prescription Pravastatin for hypercholesterolemia. The patient was retired; however, she had guardianship of her 5-year-old granddaughter whom she was actively raising. The patient's stated goal was to abolish her dizziness to allow greater ease with getting in and out of bed and return to reading to her granddaughter.
As the patient did not meet the typical criteria for other otologic or neurologic disorders (Table 1), the differential diagnosis was reduced to posterior canal BPPV of the canalithiasis type. It was postulated that because of the improper location of the otoconia in the semicircular canals, the patient experienced dizziness, vertigo, nausea, decreased balance reactions, and increased risk of falling. Because of this, an examination plan was made, which included the Dizziness Handicap Inventory (DHI) and the Dix-Hallpike maneuver.
The patient was issued the DHI, which is a 25-item scale with scores that can range from 0 to 100; a score of 0 indicates no handicap. The self-report screen has been deemed reliable and validated in the measurement of self-perceived handicap associated with dizziness.8 The minimal clinically important difference for the DHI is 11 points.9 A study regarding BPPV and the use of the DHI found that dizziness negatively affected the quality of life of patients in all the aspects of daily life: functional, emotional, and physical.10 At the start of her physical therapy care, the patient's DHI score was 14/100 with points obtained due to positive responses to looking up, bending over, and quick head movements. She also had difficulty getting in and out of bed and expressed frustration with her symptoms.
The patient was screened for gaze instability, including smooth pursuit, saccades and vestibulo-ocular reflex, with no abnormalities found and tested negative bilaterally with the vertebral basilar insufficiency test. This test was performed in seated position to negate the potential false-positive that would be produced if the patient had BPPV due to the effects of gravity. The vertebral basilar insufficiency test has been found to have a positive likelihood ratio of 4.243 (95% confidence interval, 1.678–10.729) and a negative likelihood ratio of 0.928 (95% confidence interval, 0.851–1.011) making the test minimally useful in clinical decision making and therefore that vertebral basilar insufficiency could not be discounted. However, we thought that her symptoms were not likely vascular as they were not produced in this position.11 The Dix-Hallpike was then performed bilaterally by quickly lowering the patient from seated to supine with the head extended 20° and rotated 45° to each side, which resulted in a positive finding on the right posterior canal for canalithiasis.1 According to the BPPV clinical practice guideline (Table 2), clinicians should be cautious due to potential stroke or vascular injury despite no documented reports of vertebrobasilar insufficiency occurring with the Dix-Hallpike maneuver. The Dix-Hallpike has a positive likelihood ratio of 3.17 and negative likelihood ratio of 0.28, making the test minimally useful as a diagnostic tool, but is considered the gold standard test in diagnosis of posterior canal BPPV.3 The clinical practice guideline for BPPV recommended educating the patient regarding the maneuver as it would likely produce sudden and potentially severe vertigo and nausea that would subside within 60 seconds and also recommended to reassure the patient that the maneuver would be completed safely and securely.1 This patient was adequately educated per the guideline and consented to examination.
The differential diagnosis confirmed posterior canal BPPV of the canalithiasis type through the combination of patient history and eye findings with the Dix-Hallpike maneuver. The anticipated plan of care of repositioning maneuvers to treat BPPV provided this patient with an excellent prognosis of complete symptom abolishment. Using the examination data, the aspects influencing the patient's BPPV were categorized according to the ICF model (Figure). The ICF model delineated that impairments limited the patient's activities of daily life including caring for herself and her granddaughter and negatively impacted her active participation in play and education of her grandchild. Because of the symptoms of vertigo being provoked with any cervical spine extension or flexion and trunk flexion, she avoided cooking and cleaning tasks as well as recreation activities with her granddaughter. Her past experience with self-independence and resiliency as well as her role in caring for others led to feelings of frustration and further avoidance of activities to reduce the frequency of her symptoms.
When posterior canal canalithiasis is thought to be the cause of BPPV, the Epley canalith repositioning procedure is the recommended repositioning maneuver.3 The Epley maneuver has a reported odds ratio of 4.2 for subjective symptoms resolution in posterior canal BPPV and a reported odds ratio of 5.1 treatment for conversion of a positive to negative Dix-Hallpike.1 An intervention plan that included the Epley maneuver was made with a negative Dix-Hallpike and a lower DHI score as outcome goals.
The patient was informed of and consented to the physical therapist's diagnosis, prognosis, and plan of care. She was seen for 2 additional visits over the course of 3 weeks. She was treated with the Epley maneuver for right side posterior canal canalithiasis at the first and second visits; the Epley maneuver and postural restrictions were repeated at the second visit because she had a positive Dix-Hallpike at the second session. She was found to be negative for BPPV on the third session. The Epley maneuver began with the patient in long sitting with the head turned 45° toward the affected ear and was quickly brought to supine with the head hung off the edge of the surface. This position was maintained until the nystagmus subsided and then for an additional 30 seconds. Next, the head was turned 90° toward the unaffected side and held for the same time duration. After that position, the patient was rolled onto her unaffected side while her head remained in the same alignment and held for the same time duration as the previous positions. Finally, the maneuver was completed when the patient was returned to sitting.6,12 Prior to the maneuver, she was again given clear expectations of symptom production and duration per the clinical practice guideline.1 After the maneuver, the typical postural restrictions of avoidance of previously provoking activities including laying supine for 24 hours and recent studies indicating the lack of efficacy with these restrictions were discussed. The patient elected to follow the restrictions for a 24-hour period in the hopes of securing abolishment of her symptoms. Although the success rate of the repositioning maneuver with postmaneuver restrictions was greater than those individuals treated without postmaneuver restrictions, the difference was not statistically significant. However, the patients who were given the restrictions reported greater satisfaction in their care than those with immediate freedom of movement because 96.4% of those with restrictions reported “great” or “complete” improvement in symptoms compared with 59.2% of those without restrictions.12
At her third session in 4 weeks the patient was found to be negative of BPPV per the Dix-Hallpike and she reported abolishment of subjective complaints. She was provided with education of BPPV recurrence per the clinical practice guideline and she was then discharged. The benefits of this education has been found to allow earlier recognition of recurrent BPPV allowing expedited return for treatment, reduced potential anxiety with recurrence, and facilitated adjustments for increased risk for falls for greater safety until treatment is provided.1
At 4 weeks, the patient had resumed reading to her granddaughter, had changed light bulbs, and had increased ease with bed mobility and meal preparation as neck movement, trunk flexion and laying supine no longer produced vertigo or nausea. Her DHI score reduced to 0/100, which was within the minimal clinically important difference of 11 points, and she was negative for the Dix-Hallpike test.
The ICF model is unique in that there is not a hierarchical organization of its domains but rather a bidirectional flow of information. This type of flow helps to exemplify the idea that functioning and disability are achieved by the influence of multiple separate, but interrelated aspects. These domains are termed body structure and function, participation, activity, and environmental and personal contextual factors. This allows physical therapists to better understand the impact of a patient's impairments in relation to their daily life and facilitates prioritization of interventions to remedy these various domains. As this framework also aids in showcasing a patient's potential barriers, these too can be addressed to allow progression toward goals in a timely fashion.
Other diagnoses that have successfully utilized the ICF model include diagnoses of acute and chronic low back pain, spinal cord injury, and patellar dislocation. In terms of acute and chronic low back pain, it was found that the ICF model provided an effective framework that enhanced physical therapists' ability to better understand a patient's experience with her disablement and aided in the prioritization of the treatment plan.7 A case report exploring the use of the ICF model in the multidisciplinary approach to a patient with a spinal cord injury found that patient management was improved and even clinician roles were clarified.13 Another case report involving a patient with a patellar dislocation determined that through the use of the ICF model, a patient's problems were addressed at the level of the whole person and appropriate adjustments were made because of her contextual factors, thus improved clinical decision making.14 Clinical practice guidelines for neck and heel pain have also been developed incorporating the ICF model and its domains into the examination and diagnostic criteria indicating a shift in physical therapy care to the eventual use of the ICF model into daily practice.15,16
The ICF model ensured that when the patient with BPPV was being treated with evidence-based tests and procedures, the focus was on her perceived impact of disability and her goals for treatment and not simply the nystagmus. Much time was spent on education about the pathology and how the anatomic abnormalities were impacting her daily life, as well as how specifically the repositioning maneuvers aimed to correct this problem. She was also involved in her care by providing her with the choice of following postural restrictions. This may have helped to increase her satisfaction in her care.12
The patient in this case report benefited from the concurrent utilization of the ICF and evidence-based care in both expediting her recovery and ensuring that the care was individualized to fully meet her unique needs. A negative personal factor was demonstrated as the patient was avoiding participation in leisure activities with her granddaughter because of fear of provoking her severe vertigo and nausea. Repositioning techniques were used to remedy the body structure cause of the impairment and education was given regarding recurrence rates of BPPV to help reduce further anxiety and avoidance of activities.
The care provided in this case report was evidence-based by utilizing the recommended clinical practice guideline and a notable clinical reasoning model to help ensure proper sequencing of the various functions of the physical therapist.17 Following the clinical reasoning model, a hypothesis was proposed using information from the patient history and examination data as well as the therapist's knowledge and patient's experience. The best, evidence-based treatment was then selected taking into account patient preferences. Reassessment occurred by monitoring effectiveness of the treatment using special tests and outcome measures. The DHI was given as a precursor to therapy and at the conclusion of care to allow validated measurement of perceived handicap related to her dizziness and the change over the course of therapy.
The DHI was used in this case study despite minimal clinometric data supporting its utilization because it has been used widespread in the research literature when attempting to determine quality of life in patients with vertigo. This screen has been found to be more responsive to change than the Patient Specific Functional Scale–36 because the DHI is specific to vertigo; however, the use of multiple functional quality of life scales in future studies could lead to a more complete portrait of the patient's daily life.18 Although the ICF model provided an excellent method of organizing the multiple aspects related to a patient's functioning and disability, other clinical reasoning models such as the rehabilitation cycle17 and Sackett's principles of evidence-based practice19 will likely remain utilized as an adjunct to decision making to provide a more thorough patient care experience.
The health care costs associated with the diagnosis of BPPV is approaching $2 billion dollars per year.1 Falls, which are closely related to BPPV, are correlated with costs that exceed $20 billion annually in the United States.20 These falls due to BPPV can lead to secondary injuries in older adults such as fractures or brain injury and may even lead to institutionalization. As the United States population continues to grow older, the incidence and prevalence of BPPV will likely increase.1 As BPPV has such a significant potential impact on both the individual, in terms of quality of life, and the society, in respect to health care costs, it is vitally important that all steps be taken to improve the efficiency and quality of care for people with BPPV. The use of the ICF and evidence-based practice has this capability and is recommended for use in patients with BPPV.
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benign paroxysmal positional vertigo; International Classification of Functioning, Disability, and Health; physical therapy; repositioning maneuvers