A 68-year-old retired elementary school teacher reported dizziness and vertigo when rolling over in bed 2 days ago. Since then, she has fallen while in the shower. Although she did not report any injuries, she became increasingly concerned about her “unsteadiness.” On the third day, she called 911 because her symptoms had become severe. She was admitted through the emergency department for further medical work-up. Results from all neuroradiographic imaging were negative. Her symptoms persisted, particularly when she was rolling in the hospital bed. She lives alone and is recently widowed. She is concerned about her ability to be able to return home and care for herself. She enjoys gardening and playing bridge with residents that live in her retirement community. She is a breast cancer survivor (initial diagnosis made 8 years ago) and has mild complaints of osteoarthritis in both knees. She only takes over-the-counter medicine (acetaminophen) as needed for arthritis pain. Her medical history is otherwise unremarkable.
What are the most appropriate physical therapy interventions?
What are the most appropriate examination tests?
- APOGEOTROPIC NYSTAGMUS: Horizontal nystagmus beating away from the ground or uppermost ear that is indicative of lateral canal benign paroxysmal positional vertigo (thought to be caused by otoliths adhering to the cupula)
- CENTRAL VESTIBULE: Location where all three semicircular canals join within the membranous labyrinth
- FORCED PROLONGED POSITIONING: Clinical technique used in treating lateral semicircular canal benign paroxysmal positional vertigo (BPPV)
- GEOTROPIC NYSTAGMUS: Horizontal nystagmus beating toward the ground or undermost ear that is indicative of lateral canal BPPV (thought to be caused by free-floating otoliths in the posterior arm of the lateral semicircular canal)
- ROLL MANEUVER/LEMPERT MANEUVER/BARBECUE ROLL MANEUVER: Clinical technique used in treating lateral semicircular canal BPPV (canalithiasis form)
- SUPINE ROLL TEST: Clinical test for diagnosing BPPV in the lateral semicircular canals
Describe how to differentiate lateral canal BPPV from posterior or anterior canal BPPV.
Describe the most appropriate assessment and treatment for lateral canal BPPV (canalithiasis).
Identify appropriate standardized outcome measures for an individual with a diagnosis of BPPV that capture activity limitations and participation restrictions domains of the International Classification of Functioning, Disability and Health (ICF) model.
PT considerations during management of the individual with vertigo due to lateral canal BPPV that is causing activity and participation restrictions:
- General physical therapy plan of care/goals: Assess and treat BPPV symptoms; monitor secondary impairments of limited gait and postural control
- Physical therapy interventions: Roll maneuver/Lempert maneuver/barbecue roll maneuver; forced prolonged positioning
- Precautions during physical therapy: Close guarding and monitoring because the patient could have impaired postural control with nausea and vomiting; caution with patients who have hypomobility or hypermobility in the cervical spine
- Complications interfering with physical therapy: Use of vestibular suppressant medications; multiple semicircular canal involvement
See Case 9 for understanding basic vestibular anatomy and BPPV.