Blog
The Self-Epley Repositioning Manuever for BPPV - July 12, 2020
BPPV is most commonly caused by loose particles of carbonate crystals called “otoconia” derived from the utricular macula that are free-floating in the long arm of the posterior semicircular canal.
The development of the home treatment is designed to reposition these displaced Otoconia back into the vestibule of the vestibular labyrinth.
Patients with a recurrence of BPPV should schedule an appointment for positional testing, but no harm is done when they start self-treatment in the meantime, which offers them a good chance to be relieved from positional dizziness within a few days.
Radtke et al. Has reported the self-treatment with a modified Epley procedure is one of the more reliable maneuvers to treat BPPV.
Self-treatment for BPPV should be considered as a complementary therapy, especially for patients who fail to respond to a single attempt at the particle repositioning performed by vestibular therapists.
Self-Epley maneuver may also be beneficial for patients with frequent recurrences of BPPV.
After 14 days of self-treatment the remission rates were 80 percent for the modified Epley maneuver (2004., Pereira et al).
Unsupervised home-repositioning maneuvers may be subject to uncontrolled errors due to either differences in accessory equipment (table, pillows) or the patient’s incorrect execution (being vertiginous at the time) due to lesser angles of head declination.
written by Peter Teloniatis RPT BScKin, MScPT, FCAMPT
Integrating Manual Therapy to Vestibular Rehab - June 25, 2020
When going through my manual therapy levels, one of my main goals was to view the program from more of a vestibular lens, and understand how the joints of the neck, low back and extremities may affect the vestibular system. I wanted to create an integrated assessment model that included both vestibular and orthopaedic testing, with the intention of helping my vestibular patients reach a more complete recovery. Early on in my vestibular physiotherapy career, I kept noticing that when I was strictly relying on my vestibular-related training, my patients were reaching a reasonably good level of recovery from their acute vestibular symptoms. However, asking further questions to see if they were ready for discharge, patients kept commenting that they didn’t feel like themselves, reporting symptoms of foggy- or fuzzy-headedness, headaches, and dizziness.
My manual therapy training has helped me recognize the added myofascial and joint-related changes that come with a patient who is suffering from a vestibular disorder. The motion of laying down horizontally and performing neck movements from side-to-side, can leave a patient feeling anxious and apprehensive about anyone touching their head and neck, with the worry of triggering positional vertigo. Tightness of the sternocleidomastoid muscle and scalenes muscles are common myofascial influencers. The presence of neck-related facet joint restrictions and degenerative changes may also contribute to symptom reproduction. Additional stress can be placed on the particular joints that help move our neck, causing their specialized joint receptors (used for proprioceptive feedback) to become over-stimulated. Thus, the lack of neck movement may result in abnormal levels of neck pain and dizziness-related symptoms, and is often associated with a specific condition called ‘cervicogenic dizziness’.
An area of the upper neck that is commonly affected during and after the presence of acute vertigo and dizziness attacks is joint pathology between the atlas and axis (1st and 2nd vertebrae). This region of our neck contributes to up to 50 percent of our neck rotation. Patients commonly report neck-related pain and clicking when vestibular exercises are introduced, such as head-eye coordination and neck turning. Patients may been avoiding the turning of their necks to avoid vertigo spells. Another area commonly affected is the lower neck joints and the cervical-thoracic junction (between C5-T1), due to the influences of the sternocleidomastoid, and the anterior and middle scalenes. Slouching habits, forward head postures and prolonged neck immobility can generate added stress to the lower cervical spine facet joints, generating further neck pain and stiffness, and even pathologies that cause nerve entrapment.
If evaluation of the cervical spine cannot be performed in a lying position, due to a patient’s neck discomfort or their reproduction of dizziness symptoms, the assessment of passive physiological intervertebral motions (PIVMS) of the neck can be performed with the patient in sitting. This is a nice alternative to traditional assessment methods, and once a myofascial or joint limitation is determined, its correction can be implemented into part of a patient’s manual therapy treatment program.
Integration of manual therapy into one’s vestibular practice can improve the speed and level of a patient’s overall recovery and satisfaction with physiotherapy treatment. The earlier a patient regains the confidence to start moving their neck and body normally, without hesitation of reproducing symptoms of pain or dizziness, the faster they will reach full recovery and reintegration back into their community. Joint mobilizations and manipulations can improve subjective reporting of neck pain and stiffness, helping a patient regain their normal levels of joint mobility and myofascial tone. More specific to vestibular disorders, manual therapy can alleviate signs and symptoms of cervicogenic (neck-related) headaches and dizziness by addressing the specific limitations present to myofascial and joint restrictions.
written by Peter Teloniatis RPT BScKin, MScPT, FCAMPT
The Sitting-Rising Test: Predicting Falls and Mortality. - April 4, 2020
Many of the conveniences of our western society have predisposed us to a great deal of sedentary behaviour, which consequently have led us to becoming predisposed to more muscle and joint disorders. Body composition, muscular strength and power, as well as balance, flexibility, coordination and postural stability have a large influence on our health, functional independence and overall quality of living. Vianna and colleagues (2007) showed that as early as 35 years of age, people begin to lose strength in their upper and lower extremities, as well as core strength. Furthermore, our behavioural tendencies as a society, to opt for the conveniences of drive-thrus over the simple act of walking into a store, or to use the elevator rather than the stairs, demonstrate how we are further feeding this muscle wasting process. The term “sarcopenia” describes this age-related degenerative process of musculoskeletal strength loss, which affects older adults. Sarcopenia causes a decrease in muscle mass, a reduction in the number and size of type II muscle fibres, our “powerhouse” muscles, and a decrease in motor units (Frontera, 2000).
This muscle wasting process is relevant with certain populations because it directly affects their ability to perform tasks of daily living at home and in the community, as well as influencing their risk of falling. The functional task of sitting and rising from the floor has been well researched in the literature, and has been closely linked to risk of falling, as well as the capacity to return to an upright position once having fallen (Alexander et al., 1997). The Sitting-Rising Test (SRT) is a simple screening tool to assess the strength and joint flexibility of an individual’s musculoskeletal fitness by evaluating their ability to sit and rise from the floor (Araujo, 1999). Brito and colleagues (2012) performed a retrospective cohort study, where 2002 subjects, ages 51 to 80, were followed for on average 6 years (range 0.1 - 13.9 years) to determine how musculoskeletal fitness influences the risk of all-cause mortality. The evaluators would instruct the subjects, “Without worrying about the speed of movement, try to sit and then rise from the floor, using the minimum support that you believe is needed.” The subject started with a total score of 10 points, five points were earned for their ability to transition smoothly from a standing to sitting position to the floor, and five more points to rise up smoothly to a standing position from sitting. One point was deducted for each limb support used (hand, forearm, knee and side of leg). The results of the research article demonstrated that there was a five times higher risk of all-cause mortality for subjects who had a lower score range on the SRT, suggesting a 3-year shorter life expectancy for this group of subjects. The authors of the study also noted that there was a 21 percent reduction in all-cause mortality for every one point the subject gained on the SRT score. On the other hand, a high SRT score indicated a reduced risk for falls. This is significant because a high SRT score may be used as a predictor to reflect an older adult’s capacity to safely and successfully bend forward to pick up a newspaper from the floor, or even to pick up one’s slippers from beneath a table.
The research on the Sitting-Rising Test can also be implemented as a useful screening tool for able bodied individuals suffering from dizziness. It could perhaps help predict a patient's risk of falling by functionally evaluating how strong and balanced they are, during a period of greater vulnerability, suffering from dizziness, vertigo or disequilibrium. It can also be used as an outcome measure upon preparation for a patient's discharge, examining a patient's capacity to perform various tasks of normal daily living, including transitioning in-out from the bath, gardening, or even looking after children or grandchildren.
written by Peter Teloniatis RPT BScKin, MScPT, FCAMPT
Making Sense of Dizziness. - February 24, 2020
When someone is suffering from dizziness, regardless of the cause, it is usually an unpleasant experience. Whether it is spinning of the room from rolling over in bed, or constant disequilibrium from a viral infection, dizziness usually catches us off guard due to its spontaneous and unfamiliar nature. However, because these dizziness symptoms are not what we normally experience on a regular basis, we sometimes do not know how to interpret and explain what we are feeling to others. Our body may cue us to thinking that these are unnatural and potentially life-threatening symptoms, and the brain goes on high alert, generating emotions of fear and anxiety as a protective strategy.
Understanding the subcategories of dizziness and how they differ from each other may help a patient gain perspective on the severity of their condition. A more extensive vocabulary on dizziness may also facilitate better communication about the topic when a patient is trying to verbalize what they are feeling to a family member or their health care providers. An analogy that most people may appreciate, can be drawn from making a comparison between how a casual coffee drinker would describe the aroma and taste of a fresh cup of coffee, compared to an experienced coffee barista. The casual coffee drinker would likely have a more limited vocabulary of descriptors to verbalize what they are experiencing, whereas the coffee barista would be using a more expansive selection of words to describe the coffee.
It is common amongst patients to use the word "dizziness" to describe the symptoms felt when they are feeling spinning or when they are not steady on their feet. When resorting to just this dizziness term, the patient may limit the conversation during the history taking, and may influence the order of physical tests performed by the health care practitioner. To be more specific, this umbrella term, can be broken down into descriptors of dizziness that would provide more information to a practitioner. The most commonly used dizziness term used is “vertigo” which by definition means the illusion of the room spinning or one’s body spinning. Secondly, there is the term “disequilibrium”, which is having a general sense of feeling imbalanced. Third, there is “light-headedness”, which is the sensation that you feel right before you faint. Fourth is “swaying”, as if you are rocking on a boat uncontrollably. Fifth is “oscillopsia” which is more of a visual disturbance in which objects in your visual field are jumping up and down (oscillating).
These subcategories of dizziness also vary in duration and intensity. Some dizziness disorders cause constant, unrelenting dizziness for hours to days, whereas other conditions cause momentary dizziness triggered only by a provoking position. To gain further insight of your dizziness symptoms, its often recommended to track your symptoms by journaling their frequency, as well as including your aggravating and alleviating factors.
A good health care practitioner will also inquire about a patient’s secondary signs and symptoms that will contribute to the overall picture of the case, and essentially help develop a hypothesis of the vestibular condition. These secondary signs and symptoms include but are not limited to tinnitus (defined as an ongoing high-pitch ringing in the ear), vomiting, nausea, headaches, neck pain, neck stiffness and a sense of imbalance.