Epley maneuver Archives - Page 2 of 2

How Can I Prevent Recurrence of BPPV?

October 5, 2020 By Wendy Webb Schoenewald, PT, OCS 1 Comment

Do you have symptoms like dizziness, lightheadedness, nausea, or a feeling of being off-balance? These are all symptoms of a very common form of an inner ear disorder called Benign Paroxysmal Positional Vertigo, BPPV. It is the most common disorder of the inner ear affecting about 9% of the population over 60 years old. It is the most common diagnosis treated in my clinic, representing 30 to 40% of the dizzy patients we evaluate. Since it is associated with increased fall risk in adults, it is important to treat them promptly.

BPPV is a mechanical disorder of the inner ear that occurs when calcium carbonate crystals, called otoconia, which are normally embedded in the utricle of the inner ear, become dislodged. They migrate into one or more of the three semicircular canals, where they are not supposed to be. When this happens, the otoconia shift and create an abnormal movement of fluid in the canal, causing a false sense of rotational motion. Once the otoconia are loose, if we move our head or body, the fluid moves more quickly because of the weight of the otoconia. This causes the inner ear to send false signals to the brain that the room is spinning. This creates the illusion of motion the patient perceives as vertigo, though physiologically it causes abnormal eye movement called nystagmus, which therapists can observe to diagnose BPPV. How is it treated? Since #BPPV is a mechanical disorder of the inner ear, it can be treated quickly without medicine. A specially trained vestibular physical therapist can resolve vertigo by performing an #Epley maneuver, also called a canalith repositioning maneuver. The therapist uses a very specific series of head and body movements to guide the otoconia back to the utricle where they belong. Sometimes, the otoconia are found to be in a different canal or are adhered to the cupula. This will then require the use of a different maneuver for treatment, but your therapist will be able to determine this through observations during the exam.

Though patients can commonly be treated effectively with the Epley maneuver, the recurrence rate for BPPV is high. Since its symptoms are not very pleasant, patients who suffer from vertigo do not like to hear that there is a 10 to 18% chance of another attack within the next year. The recurrence can vary greatly; patients might have another attack within 6 months or 6 years.

Epley

How can I prevent recurrent attacks?

The etiology of BPPV is unclear, but a recent systematic review of research articles from 14 countries looks at risk factors affecting the recurrence of BPPV. The risk factors identified may help us identify fall risk patients and help clinicians educate patients about the importance of follow-up after BPPV diagnosis.

Women are more likely to relapse than men, which may be related to menopause causing changes in hormone levels. Patients older than 65 years are more likely than their younger peers to suffer from BPPV. Osteoporosis has been found to be common in patients with BPPV. Age-related decline in calcium metabolism may also affect the otoconia, weakening their structure, which causes them to break off and allows them to float freely. Treatment of osteoporosis may have a protective effect against BPPV. This study also suggests that systemic diseases, including hypertension, hyperlipidemia, and diabetes mellitus, could increase the incidence of relapse attacks. This may be related to the known effect of vascular disease on the inner ear. These diseases can affect microcirculation, causing ischemia or reduced blood flow to the inner ear. It is important to monitor your glucose, A1C readings, and blood pressure and follow your doctor’s recommendations for the management of these disorders.

History of migraines is a strong risk factor for relapse of BPPV which can have a vascular factor that can damage the inner ear making recurrent BPPV more prevalent. Common inner ear disorders, such as otitis media and Meniere’s disease, increase the incidence of BPPV by disrupting the normal function of the semicircular canals.

In head trauma, 13% of patients report positional vertigo and have bilateral disease at a higher rate than idiopathic attacks of BPPV. Another risk factor that is a common problem with aging adults is cervical spondylosis and limited mobility of the spine, which makes BPPV treatment maneuvers more difficult to perform.

These risk factors for the recurrence of BPPV help us measure fall risk in patients and help clinicians educate patients about the importance of follow-up after BPPV diagnosis. Regular aerobic exercise can be helpful in managing all these disorders and in keeping the vestibular system healthy. Medical management from your primary physician is important in managing the systemic conditions. A thorough discussion about your medical history with our clinicians helps us customize a treatment and education program specific to you. Although we love what we do in fixing dizzy patients, we want to teach our patients to have confidence in managing and preventing their own symptoms.

Wendy Webb Schoenewald, PT, OCS

WWS Physical Therapy & Vestibular Rehabilitation
Doylestown, PA
215-489-3234

Balance and Aging

September 19, 2020 By Wendy Webb Schoenewald, PT, OCS Leave a Comment

WHY ARE SENIORS AT HIGHER RISK FOR FALLS?

Dizziness can happen at any age, but if it results in falling it can be a serious health concern, particularly in older adults.

Studies show that you can take action to reduce dizziness and your risk of falling. Begin by talking with your health care providers to explore medical issues that may be contributing to your symptoms, and exercise to improve your balance and strength.

How Do We Maintain Balance?

Normal balance is dependent on many factors, including multiple systems of the body, as well as external and environmental factors.

The body has three primary sensory systems that work together to create postural stability. With normal brain function, the vestibular system of the inner ear coordinates with the visual system and proprioceptors that sense the position and movement of your body in space. These three systems work together while we perform simple tasks, such as standing and walking, or more complex and dynamic activities, such as yoga or hitting a golf ball accurately.

What Causes Dizziness & Imbalance As We Age?

Impaired Inner Ear Function
Cardiovascular Health
Neurological Disease
Arthritis
Mental Status
Nutrition
Impaired Vision
Lifestyle and Environmental Factors

How Does the Inner Ear Create Symptoms?

The inner ear is a complex structure of fluid-filled tubes and chambers. Specialized nerve endings inside these structures sense the position and movement of the head and detect the direction of gravity. Signals sent from the nerves of the vestibular system are critically important to the brain’s ability to control balance in standing and walking. They also control movements of the eyes that make it possible to see clearly while moving.

Anatomical studies have shown that the number of nerve cells in the vestibular system decreases after about age 55. Blood flow to the inner ear also decreases with age. When the vestibular system is damaged, an individual may experience dizziness and balance problems. However, the gradual, age-related loss of vestibular nerve endings can result in balance problems without any associated dizziness. This type of slow loss of vestibular function may be first noticed as difficulty walking or standing, especially in the dark while on soft or uneven surfaces (such as thick carpet or a forest path).

A decline in inner ear function may be caused by a number of conditions, including normal aging, benign paroxysmal positional vertigo (BPPV), infection, Meniere’s disease, or diminished blood flow to specialized nerve cells. Additionally, certain medications such as some antibiotics for severe infections and chemotherapy may damage the inner ear, resulting in temporary or permanent hearing loss, impaired balance, and trouble seeing clearly while in motion. Feelings of dizziness, vertigo, imbalance, and disequilibrium may indicate that the inner ear is not functioning correctly.

Benign Paroxysmal Positional Vertigo (BPPV) is the most common vestibular disorder in older adults and causes a sense of true spinning vertigo triggered by a change of position of the head or body. With this condition the spinning can be triggered by things like tipping your head up or down, quickly rotating your head, bending over, rolling over in bed, or getting in and out of bed. BPPV is a mechanical disorder that occurs when debris, called otoconia, loosen and tumble into the semicircular canals of the inner ear. This event causes false signals to the brain triggering a brief sense of vertigo. The spinning lasts less than a minute and can provoke nausea, vomiting, and imbalance. BPPV can be effectively treated by a Vestibular Physical Therapist with specialized training by using proven techniques, such as the Epley maneuver or canal repositioning techniques, which help return the otoconia to their correct position in the inner ear.

Labyrinthitis is an infection or inflammation of the inner ear that causes severe vertigo lasting 1-2 days, hearing loss, and severe imbalance that can affect walking. Neuronitis is a similar disorder causing vertigo, but it does not affect hearing. Both can be triggered by an upper respiratory infection, virus or flu, or can occur with no obvious cause.

Meniere’s disease causes similar symptoms, including periodic episodes of vertigo, dizziness, and hearing loss. It is thought to be a result of an excess amount of fluid, called endolymph, collecting in the inner ear.

Neurological Diseases – Healthy Brain

Normal orientation also relies on healthy brain function to process, adapt, and interpret changing sensory information from the vestibular system, vision, and body input. The brain must process this information to select appropriate balancing strategies and learn new strategies necessary for changing environments. There are many disorders, such as stroke, Alzheimer’s, Parkinson’s Disease, concussion, and dementia, that interfere with brain function resulting in slower and inaccurate balance reactions. Cognitive deficits are often associated with balance problems, demonstrating the complex nature of performing dynamic balance tasks.

As you can see, balance is very complex and there are a variety of conditions that can put a person at risk of falling. See VeDA’s article Balance and Falls in Older Adults for more information.

Some people may believe feeling off-balance or having dizziness is an unavoidable consequence of aging. Here’s the good news: with proper diagnosis, many of the causes that result in imbalance, dizziness, or falls can be treated or diminished with lifestyle changes.

Start by having a thorough assessment by your primary physician at least once a year. Tell them if you are experiencing dizziness, lightheadedness, vertigo, imbalance, or have suffered a fall. There may be multiple health issues and medication interactions contributing to symptoms of dizziness and imbalance. Making an accurate diagnosis to determine the source of the symptoms may be a complicated task for your physician, and they may refer you to a specialist.

The physician should include checking for specific muscle weakness in the legs and feet or a decline in sensation, which can indicate a need for strengthening or specific footwear.
If you are experiencing dizziness with specific head movements or sitting up in bed you should be screened for BPPV. If your physician concludes that your vestibular, visual, or sensory systems are creating a risk of falling, s/he will refer you to a certified vestibular therapist who specializes in Vestibular Rehabilitation Therapy (VRT). Studies have shown that VRT can help improve balance, decrease dizziness, and decrease fall risk. A vestibular therapist is a physical therapist with specific training in the assessment of balance deficits and inner ear disorders. Exercises provided by a vestibular therapist will be based on the functional impairments that are measured in the therapist’s evaluation of the vestibular and balance systems. The exercises are designed to reduce dizziness associated with movement and improve visual clarity, balance reactions, joint mobility, and strength to decrease fall risk. (See VeDA’s article about Vestibular Rehabilitation.)

It’s essential that you see your eye doctor and make sure your glasses are the correct prescription. If you have bifocal or progressive lenses, you may want to get a pair of glasses with only your distance prescription for outdoor activities, such as walking. Sometimes progressive lenses can make things seem closer or farther away than they really are, which is especially risky when walking down steps or slopes.

It is also important to be screened for diabetes, cataracts, macular degeneration, or neuropathy.

You can also make lifestyle choices that have been shown to improve balance and facilitate good health as we age.

First, it is important to have adequate nutrition, which includes a balanced diet of fruits, vegetables, protein, and low sugar foods. You should also include supplements of Vitamin D 880 IU with calcium to strengthen the bone and reduce the risk of fractures (CDC, Shahar 2009).

Second, it has been shown that staying active and exercising can reduce fall risk in the elderly (Shubert 2011). In community-dwelling adults, a progressive exercise program with a moderate to a high level of balance exercises and cardiovascular conditioning has been shown to be an effective way to reduce falls. Exercise programs may include standing squats, single-leg standing, toe, and heel raises, tandem stance or walking, hip and knee strengthening, walking tasks, and high-level balance tasks such as reaching, turning, and stair-stepping. Tai chi is a form of exercise involving low impact dynamic movements of the arms and legs with reaching and turning, and movement of the torso in repetitive patterns. It not only benefits the body but also is cognitively challenging.

Walking is a beneficial form of exercise, especially when the additional emphasis is placed on increasing stride and speed of steps, which studies have shown to reduce falls in older adults.

Another easy step in reducing falls is to make changes to your home creating a safer environment.

Authors: By Wendy Webb Schoenewald PT, OCS and Viviann C. Bailey MSPT

BPPV, Spinning, and Vertigo

February 22, 2018 By Wendy Webb Schoenewald, PT, OCS Leave a Comment

BPPV is A disorder of the inner ear that is the most common cause of episodic Vertigo, a false sensation of spinning. It is a mechanical disorder where calcium carbonate crystals (otoconia), that are normally embedded in gel substance in the utricle of the inner ear , become dislodged and migrate into one of the three fluid filled semicircular Canal’s. Since these fluid filled canals are designed to sense rotational movement ,the crystals which react to gravitational pull or pull of gravity , cause the nerve endings in the canal to be more excited than normal , resulting in a mismatch of information to the brain creating Nystagmus of the eyes, which create a false sense that the room is spinning.

The most common symptom is a spinning sensation of vertigo but often patients have complained of feeling like they’re falling even when they’re laying down or describe feeling of walking like they are drunk. Vertigo events frequently occur in the morning when you sit up or turn over in bed but often can also be associated with quick turns of the head or bending over to pick something up. These episodes can last seconds or minutes and are commonly associated with nausea vomiting and dizziness as well as imbalance.The level of symptoms can range from mild annoyance to a highly debilitating condition that can affect function and safety and fall risk.

There are several types of BPPV including canalithiasis and cupulolithiasis which need to be recognized because they are treated differently. BPPV can occur in each of the three canals in the right and left ear therefore a proper examination is necessary to allow correct treatment with the patient having minimal symptoms. Other disorders may be misdiagnosed as BPPV or patients are given incorrect diagnosis of a more serious condition instead of BPPV.

BPPV is a very common disorder with an incidence of 107 per 100,000/year . it is common in senior adults and appears to increase incidences with each decade of life. It can also be associated with trauma, concussion ,migraine inner ear infections or disorders,diabetes and osteoporosis.

Treatment
Treatment of BPPV follows a detailed physical exam by the vestibular rehabilitation specialist. Since it is a mechanical disorder ,there are treatment maneuvers which differ depending on which canal or type that is involved, these maneuvers assist the otoconia to float back to their origin in the utricle. The most well-known maneuver is called the Epley maneuver but there are many different maneuvers for specific variants of BPPV. The treatment procedure involves tilting the head at several different angles and rolling the body to dump the crystals back into the utricle.(see figure) A Skilled vestibular therapist can resolve BPPV with two to three maneuvers in the first session. Often abnormal balance reactions result from BPPV And they need to be assessed further once the vertigo is effectively treated. it is important to treat both BPPV and the imbalance to prevent future falls.
Examination.

Treating BPPV with Frenzel Lens

A proper examination involves an assessment of the eyes for normal movement patterns in room light and assessment of static balance examination then using Frenzel lenses ,special tests that involve positional changes are performed. The most common test is called the Dix-Hallpike test where the patient is laid down with her head turned 45° to one side allowing the head to hang off the edge of the table. Frenzel lenses ,which are infrared goggles that assist the vestibular therapist in observing nystagmus , are used during the exam to assist with accuracy of diagnosis.
it is common after treatment for the patient to feel mildly dizzy and sometimes nauseous but generally this improves in less than 24 hours. There are some cases that takes several treatments to resolve or patients need several further treatments to return their balance reactions to normal to prevent falls.

Unfortunately BPPV is a condition that commonly reoccurs periodically with rates as high as 50% within five years. We will educate you about how to perform a specific treatment maneuver on your self and if this does not appear to be effective then we you can follow up in the office for further assessment.

All of the therapists at Wendy Webb Schoenewald Physical Therapy and Vestibular Rehabilitation are advanced distributor therapists with extensive training in the proper treatment for BPPV and other vestibular and balance disorders. WWSPT has been involved in clinical research trials to teach other physical therapists which maneuvers are most effective in treating some unusual forms of BPPV.

Contact WWSTP for an appointment evaluation.

How Can I Prevent Recurrence of BPPV?

Balance and Aging