Vestibular Rehab Blog Series: 5 of 12

Hello, everyone. This is the final video of lesson two. In this video, we're going to talk about clinical tests to treatment. Now, in previous videos we began with BPPV. So, let's start there.

Video Transcript:

Hello, everyone, and welcome back. This is the final video of lesson two. In this video, we're going to talk about clinical tests to treatment. Now, in previous videos we began with BPPV. So, let's start there. Let's talk about canal involvement. As you know, we have three different semicircular canals. Now the most common canal affected is the posterior canal. The interior canal is the least affected. For those of you that might have read the guidelines to best practices in BPPV [Benign Paroxysmal Positional Vertigo], will remember that anterior canal wasn't even mentioned in there. And then there's the horizontal or what we call a lateral canal.

And remember, there's two types of BPPV. There's canal or canalithiasis, that’s where the ear crystals of the otoconia are free floating in one or more of the canals. And then there's cupulolithaisis, where it's suspected that otoconia could be adhering to the hair cells. In our clinic, we have a rule of thumb related to three strikes and you're out where we recommend a VNG if we cannot resolve the BPPV within three visits. Now, by no means is that to suggest you have to have a VNG to successfully treat BPPV, even complicated BPPV. You may have Frenzel lenses or you may have infrared goggles. The beauty about the infrared goggles is that they can actually record the eye movement, particularly the intensity of the nystagmus, which can be very, very helpful. I consider this kind of bonus for us that we utilize when needed. And now the unicorn is showing up. So, what's that about?

Well, in the clinic we reference unicorn cases, which is classic post ear canal BPPV and nothing else. And we just rarely, rarely see that. Most of the patients that come to the clinic have been referred because of unresolved complicated BPPV and/or other vestibular related issues. Now the good news is part of that is because more and more providers are out there treating BPPV and also the internet has played a role in that where people are self-treating. However, in my experience, I'm seeing more anterior canal and horizontal canal today than I did 20 plus years ago. And it's not just me. We have a number of clinicians in the clinic and they say the same thing. I think self treatments have something to do with that. Particularly the horizontal canal where people are doing self epley [maneuvers] at home and then transitioning it into the horizontal canal. I also think there's some risk with the somersault maneuver and transitioning it into the anterior canal and stay tuned there will be more reference to the unicorn.

So, here's just a summary of various treatments. You may see the acronym CRM for Canalith Repositioning Maneuver, which could be the Epley Maneuver, the Semont, or the Role Test. The most commonly used is the Epley maneuver for canalithiasis. And I say most commonly, that's here in the states. In Europe, Semont is used more than the Epley, and Semont is typically the go to treatment for cupulolithaisis. For anterior canal you can also use the Epley. We use the Yacovino or what we call the “deep head hanging” maneuver for suspected anterior canalithiasis. And for the horizontal canal, the log roll or the Gufoni. There seems to be a little bit of movement away from the log roll but I've been doing it so long and it works so well. I think it's more of a habit just to kind of that's my go to for horizontal canal. But certainly we modify these maneuvers, we try combinations of these maneuvers, particularly in complicated BPPV. That's something we won't address in this mini series but we do go into detail in our more advanced vestibular rehab course.

Of course, there's the Brandt-Daroff for habituation. It can also be a home exercise program. It's not as effective as the Canalith Repositioning Maneuvers. It's really rare that I would use Brandt-Daroff. Now, some therapists give Brandt-Daroff as a home exercise program after the BPPV is resolved and the theory behind that is it will decrease the recurrence. I certainly haven't seen the Brandt-Daroff decrease the occurrence of BPPV and really wouldn't completely understand the rationale of that. We see such high recurrences of BPPV in our patients, but it's also patients who have endolymphatic hydrops, Meniere's disease, migraine associated vertigo. We will see an influx of patients during really high allergy seasons and with huge barometric pressure changes. So, I've been using the same EMR for about eleven years now and we can go back and even look at patients coming in at the same time of year. And if that's the case, we do see that pattern or they identify the pattern. We are talking with their physician, their ENT about addressing the management of allergies in an effort to decrease the recurrence of BPPV. There is a very, very large study that also shows that vitamin D can help decrease the high recurrences of BPPV. And then there's surgery. This isn't even 1 percent of the patients that I see. There have been patients I've known who did benefit from surgery due to the high recurrence of BPPV. And when I say high recurrence, I'm talking about every few days. And don't forget, the patient may need vestibular rehab after the BPPV is treated.

So one of the things that we do in the clinic is if someone comes in with classic symptoms of BPPV, you know what those are, we go ahead and do a comprehensive exam. We do a neuro screen. We check their static balance. Some of that's kind of time dependent. But certainly we try to fit as much in before we do a Dix-Hallpike or a role test and treatment if indicated. We're trying to identify if there might be other balance impairments that may need treated with vestibular rehab, but we also have an interest in retesting people's balance after we treat them for BPPV. It is not uncommon for someone to come in with BPPV, we correct it. They come back a week later. We retest their balance and it's better. Some people it's not. We see those folks for vestibular rehab. So, remember, it's not just about being BPPV. You want to see if there's other impairments that you can address in rehab.

Click here to progress to the next blog in this series: Clinical Tests to Treatment: Meniere’s Disease