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Author: admin, 10.12.2013. Category: Treatment For Tinnitus

How to cite this article Bittar RSM, Mezzalira R, Furtado PL, Venosa AR, Sampaio ALL, Oliveira CACP. Benign Paroxysmal Positional Vertigo (BPPV) is one of the most prevalent clinical disorders in common Neurotology practice and accounts for approximately 17% of complaints of vertigo1. Given the noteworthy prevalence of BPPV, its health care and societal impacts are tremendous8. Positional vertigo is defined as a spinning sensation produced by changes in head position relative to gravity.
Significant improvements in the diagnosis and treatment of patients with BPPV may lead to significant health care quality improvements as well as medical and societal cost savings. The purpose of this paper is to review the available methods for diagnosis and treatment of BPPV intended for clinicians who are likely to diagnose and manage patients with BPPV, and applies to any setting in which BPPV would be identified, monitored, or managed. Of the two variants of BPPV, canalithiasis is the most common, and the posterior semicircular canal is the most affected because of its anatomical position (85-95% of cases of BPPV)8.
Recently, Gacek21 proposed a neural theory for BPPV, in which there was degeneration of the saccular ganglion secondary to a latent viral reactivation.
Identifying the affected canal includes observation of the position that triggers the dizziness and the resulting type of nystagmus.
When the patient gets in the position that triggers the dizziness, eye movement is observed resulting from the contraction of muscles related to the affected canal (slow component), followed by subsequent rapid correction in the opposite direction (fast component).
In the vertical canals, there are excitatory connections to the ipsilateral superior oblique and contralateral inferior rectus to the posterior canal; ipsilateral superior rectus and contralateral inferior oblique to the superior canal, so that the arising movements are always rotational, but the nystagmus is vertical upward in the posterior canal and vertically downward in the superior canal23. The characterization of the nystagmus, allows the identification of the canal involved as well as the mechanism involved, and it is essential to choose the repositioning procedure.
The Dix-Hallpike maneuver is considered the gold standard tool for the diagnosis of BPPV of posterior canal8. The Dix-Hallpike maneuver is performed by the clinician moving the patient through a set of specified head-positioning maneuvers to elicit the expected characteristic nystagmus of posterior canal BPPV (Figure 1).
The maneuver begins with the patient in the upright seated position with the examiner standing at the patient's side. After resolution of the subjective vertigo and the nystagmus, if present, the patient may be slowly returned to the upright position.
The particles present inside the semicircular canal undergo the effects of gravity and are shifted downward, and after a short latency, the liberating force created on the ampullar crista triggers the vertigo and nystagmus (Figure 2). In the case of the superior semicircular canal, a torsional downbeating nystagmus is exhibited. If the patient has a history compatible with BPPV and the Dix-Hallpike test is negative, the clinician should perform a supine roll test to assess for lateral semicircular canal BPPV8. Lateral canal BPPV (also called horizontal canal BPPV) is the second most common type of BPPV. In many instances, the presenting symptoms of lateral canal BPPV are indistinguishable from posterior canal BPPV. Due to an adaptation of the central nervous system8,26 or to the reversion of the direction of movement of the debris by the gravitational action26, it is not unusual that nystagmus spontaneously changes the direction without the head turning to the opposite side8,26. Additional exams are essential to clarify the trigger and associated features of BPPV1,15, 23,35. Imaging is not useful in the routine diagnosis of BPPV because there are no radiological findings characteristic of or diagnostic for BPPV8. Electronystmography has limited utility in the vertical canal BPPV diagnosis, since the torsional component of nystagmus cannot be registered by conventional techniques.
Audiometry is not required for diagnosing BPPV, however it may offer additional information in cases where the clinical diagnosis of vertigo is unclear8. The treatment of BPPV is based on the performance of liberatory maneuvers or canalith repositioning procedures, with the aim of returning the displaced particles to their original location: utricular macula. A standard protocol, that is described in Table 3, is used in our service, considering the better results for each maneuver indicated for each BPPV variant. Some patients manifest severe symptoms with dizziness, nausea, sweating and vomiting while undergoing diagnostic or therapeutic maneuvers.
The Epley maneuver39 is the most frequently performed repositioning maneuver of the vertical canal. According to the clinical practice guideline8, based on the review of the literature, it was not possible to determine the optimal number of cycles for the repositioning maneuvers.
The maneuver described by Semont41 is indicated for the treatment of posterior canal cupulolithiasis. Lempert42 described a maneuver (Barbecue Maneuver or Roll Maneuver) which is the most commonly employed maneuver for the treatment of lateral canal BPPV.
Forced prolonged position is another treatment maneuver, described by Vannuchi44, for the treatment of lateral canal BPPV.
The Brandt-Daroff exercises were developed for home self-administration, as an additional therapy for patients who have been symptomatic, even after Epley or Semont maneuver40. Many patients complain of imbalance during and between vertigo attacks, as observed by Celebisoy45. The otolithic dysfunction induced by unequal loads of the macular beds has been considered as the underlying mechanism46.
The repositioning maneuvers are associated to mild and self-limited adverse effects in about 12 percent of the treated patients8. During the course of repositioning maneuvers of vertical canals, the displaced particles could migrate into the lateral canal, in 6 to 7 % of the cases8. During the repositioning maneuvers, some patients develop severe, persistent vertigo, nausea, vomiting and nystagmus, which has the same features observed in the diagnostic maneuvers. The treatment consists of performance of the reverse maneuver, to aim to eliminate the blockade.
By virtue of possible complications during the repositioning procedures, it is not a proper conduct to guide the patient self-treatment at home, without a physician. After repositioning procedures, it is important to keep the patient in sitting position, for 10 minutes, to avoid falls51. Epley39, in his original paper, described the application of a bone conduction vibrator associated to repositioning maneuver, in order to release some adhered particles in the ampullar crista. The effectiveness of repositioning and liberatory maneuvers varies from 70% to 100%14,15,23,48. It is important to be careful when performing diagnostic, repositioning and liberatory maneuvers in obese patients, with limited cervical range of motion or with unstable heart failure or carotid stenois8,25,58. Some authors believe in natural course of BPPV toward spontaneous relief48,59,60,61,62, which is possible in up to 89% of the patients in the first month, with subsequent recurrence in up to 33%, in three years37,38. Thirty to 50 % of the patients have vestibular system dysfunction associated with initially treated BPPV, which can be demonstrated by caloric testing abnormalities.
Objective: The aim was to evaluate the oxidative stress and the angiitis in patients with BPPV. The pathogenesis of the benign paroxysmal positional vertigo (BPPV) is a vestibular lesion like canalolithiasis or cupulolithiasis. It is known that oxidative stress play some role in some of inner ear disease like sensorineural hearing loss due to aging. We postulated that ischemia of the vestibular organ followed by blood recirculation may provoke oxidative stress. As a treatment for BPPV, the patients were instructed to perform the Brandt - Daroff exercise11 at home by themselves three times a day. The prognosis of BPPV was evaluated as the time until the disappearance of positional nystagmus.
Patients who required longer time for the disappearance of positional nystagmus showed high VCAM level, whereas those who required shorter time for remission showed low VCAM1 level. Patients who required longer time for the disappearance of positional nystagmus showed high d-ROM level, whereas those who required shorter correlation between the value of d-ROM and time until remission (Figure 2). The ischemia of the vestibular organ followed by blood recirculation may provoke generation of cytotoxic radical and produce damage of phospholipids in cytomembrane and result in elevated oxidative stress. In the previous report, we presented that free oxygen radicals, as measured in peripheral blood samples by the d-ROM test, were relatively enhanced in BPPV patients13. Based on these results, it is reasonable to assume that the angiitis may contribute to the onset of benign paroxysmal positional vertigo (BPPV). In conclusion, the relation between both the values of d-ROMs and of VCAM-1 and the duration of BPPV was found in patients with BPPV.
In summary, it is reasonable to assume that the severe the angiitis, the longer the time required for the remission of vertigo of BPPV. Thyroid disease, Hypertension, Diabetes mellitus, anaemia, decreased supply of blood to brain from posture related low blood pressure (postural hypotension) or cardiac arrhythmias can lead to dizziness or vertigo. A myriad of medications including those used to treat high blood pressure, high blood sugar and cardiac arrhythmias can also predispose a person to vertigo. Electronystagmography – it records eye movements during various neck and eye movements. The purpose of this study was to investigate the effects of a vestibular rehabilitation program on patients with the diagnosis of migraine-associated dizziness. The occurrence of migraine headaches with secondary vestibulopathy and associated vestibular dysfunction is well documented [1-4].
However, research has shown that patients with episodic disorders, such as migraine-associated dizziness (MAD), have not responded consistently to vestibular physical therapy rehabilitation programs [13]. Thirty-four (25 male, 9 female) consecutive patients with migraine-related vestibular symptoms were treated with a customized vestibular rehabilitation program and a migraine preventive medication.
All the individuals underwent a workup that included a detailed otolaryngologic history and physical examination, standard neurological examination, and a magnetic resonance imaging scan to rule out a cerebellopontine angle lesion or other pathological findings.
The vestibular rehabilitation strategy employed specific exercises designed to decrease dizziness, increase balance function, and increase general activity levels.
Specifically, the vestibular exercise program included vestibuloocular reflex exercises, cervicoocular reflex exercises, depth perception training, somatosensory retraining, and varied ambulation skill exercises. Large-amplitude head and trunk movements were also employed to increase somatosensory input. Ambulation exercises were graded in difficulty by a change in direction, performance with eyes closed, increasing speed of ambulation, proprioceptive neuromuscular facilitation, resisted balance and resisted gait, walking on soft surfaces, and stair climbing.
Patients were also instructed in a progressive aerobic exercise program of increasing time and distance and were instructed to perform the exercises twice daily at home.
All patients were treated with low-dose Neurontin as a migraine preventive medicine (100 mg twice daily). Figure 1 demonstrates the results of the DHI, ABC, DGI, and CDP measurements before and after 6-8 weeks of treatment for all the patients studied.
The results of the time to return to work and time to remission of symptoms are presented in Figure 3. Our work demonstrates that vestibular physical therapy rehabilitation strategies produced improvement in DHI, ABC, DGI, and CDP measures for all groups studied. As we have indicated, this study had a greater population of male subjects and a greater population of younger subjects than did previous studies [6,15,16].
In this study, we have not compared these treated patient groups to control (nontreated) groups. This vestibular syndrome is characterized by transient attacks of vertigo, caused by change in head position, and associated with paroxysmal characteristic nystagmus. It represents the most important peripheral vestibular impairment along the lifespan1,2,3, although the age at onset is commonly between the fifth and seventh decades of life4. It is estimated that it costs approximately US$2000 to arrive at the diagnosis of BPPV, and that 86 percent of patients suffer some interrupted daily activities and lost days at work because of BPPV8. Benign paroxysmal positional vertigo is defined as a disorder in the inner ear, characterized by repeated episodes of positional vertigo8, with typical paroxysmal nystagmus. Despite its significant prevalence, and quality of-life and economic impacts, considerable practice variations exist in the management of BPPV across disciplines8.
Such improvements may be achievable with the reduction of the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of unnecessary tests such as radiographic imaging, and by increasing the use of appropriate cost effective therapeutic repositioning maneuvers. Displaced particles from utricule otoliths float around in the endolymph (canalithiasis)11 or adheren to the cupulae (cupulolithiasis)12 and may change the density relation of the cupulae-endolymph system.
The ampulla of the posterior semicircular canal is located in the lower region of the vestibule, both in the supine and standing position. Such reinfection could result in the loss of its antagonistic effect on the posterior semicircular canal.
The classic complaint is vertigo in episodes, triggered by changes in the body position or head movements, lasting seconds and ceasing spontaneously.
Each of the semicircular canals is directly connected to a pair of extrinsic muscles in the eye, having an excitatory and inhibitory influence, which determines the movement of the eyeball in the same plane as the canal24 (Table 1).
This biphasic movement, called nystagmus, is a standard direction that is known as being the same as the fast component. In Table 2, we can observe the main features of involvement of different semicircular canals.
Before beginning the maneuver, the clinician should counsel the patient regarding the upcoming movements and warn that they may provoke a sudden onset of intense subjective vertigo, possibly with nausea, which will subside within 60 seconds. During the return to the upright position, a reversal of the nystagmus may be observed and should be allowed to resolve8. Mechanism of displacement of the debris from the dome of the canal at rest and under the action of gravity (g), indicated by the arrow. The direction of the torsional component of the positioning nystagmus indicates which ear is the origin of nystagmus.
Because this type of BPPV has received considerably less attention in the literature, clinicians may be relatively unaware of its existence and the appropriate diagnostic maneuvers for lateral canal BPPV8. The supine roll test is performed by initially positioning the patient supine with the head in neutral position, followed by quickly rotating the head 90 degrees to one side with the clinician observing the patient's eyes for nystagmus. In canalithiasis, the movement of the head toward the affected ear promotes the displacement of free particles in the direction of the ampulla, triggering a horizontal nystagmus whose fast component will be toward the tested ear, so geotropic (towards the ground). The mechanisms that initiate geotropic and apogeotropic eye movements can be seen in Figure 3. We can observe the mechanism of displacement of the ampullar crista that is responsible for the origin of geotropic nystagmus in canalithiasis(a), or for apogeotropic nystagmus in cupulolithiasis (b).
De la Meilleure et al.26 reported the inversion of the horizontal nystagmus, in electronystagmography, in 75% of patients with BPPV of the lateral canal, always on the affected side. Further radiographic imaging may play a role in diagnosis if the clinical presentation is felt to be atypical, if the diagnostic maneuvers are unusual, or if additional symptoms aside from those attributable to BPPV are present, suggesting an accompanying modifying central nervous system or otological disorders8. On the other hand in horizontal semicircular canal BPPV diagnosis, the nystagmus is present in the positional testing23. These are non-invasive procedures that have been found to be long term effective for BPPV2,14. In these cases, vestibular suppressant medications are recommended as adjuncts not only to relieve the vertigo after maneuver but also to control the clinical symptoms until the procedure can be repeated4.


The patient is placed in the upright position with the head turned 45 degrees to left when the left ear is affected. If the posterior canal is affected, the patient is seated in the upright position; then the patient's head is turned 45 degrees toward the unaffected side, and then is rapidly moved to the side-lying position.
Demonstration of Lempert Maneuver sequence - treatment of lateral semicircular canal BPPV (right ear in black). This maneuver involves rolling the patient 360 degrees in a series of steps to effect particle repositioning8. The strategy consists of maintaining the forced lateral decubitus, with affected ear in the undermost position for 12 hours23,25.
Some authors indicate them one week before the therapeutic maneuver, aiming to improve the patient's tolerability14. This observation lead to the investigation of postural balance in patients with lateral and posterior semicircular canal BPPV.
Other possibilities are the persistency of small amounts of residual debris in the canal, paresis of the ampullar receptors or the vestibular re-adaptation after peripheral disorder45.
This phenomenon could result from a jamming of the otolithic debris (named jam) when migrating from a wider to narrower segment, such as from the ampulla to the canal or at the bifurcation of the commom crus50. The use of a cervical collar, positional avoidance, or other restrictions are not necessary52,53,54.
However, studies found no benefit in the BPPV treatment, since it does not modify the results of repositioning or liberatory maneuvers2,55,56,57. The successful treatment is based on the identification of the affected semicircular canal, the distinction between cupulolithiasis and canalithiasis, the right choice of the most indicated maneuver2. The spontaneous resolution is faster in the lateral semicircular canal BPPV than in posterior canal because the former spatial and anatomic orientation facilitates the return of the particles to their original place63,64. Therefore, even if symptoms are typical of BPPV, the diagnostic maneuver has been positive, the repositioning maneuver has been successful, it is important that complete neurotological evaluation is obtained to rule out other vestibular disorders. For the therapeutic maneuvers, correct diagnosis of the BPPV variant and affected semicircular canal is necessary. Central etiologies must be investigated when atypical nystagmus is found and therapeutic maneuvers are unsucessfully. Bhattacharayya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, Chalian AA, Desmond AL, Earll JM, Fife TD, Fuller DC, Judge JO, Mann NR, Rosenfeld RM, Schuring LT, Steiner RWP, Whitney SL, Haidari J.
The possible contribution of angiitis to the onset of benign paroxysmal positional vertigo (BPPV). Method: Patients with benign paroxysmal positional vertigo (BPPV) within 14 days of onset were analyzed. Physical examination was performed for the evaluation of vertigo including pure tone audiometry and vestibular examination including positional nystagmus. Patients are asked to visit each week for evaluation (positional nystagmus) by a physician to confirm the cure of BPPV. Patients who required longer time for the disappearance of positional nystagmus showed high d-ROM level, whereas those who required shorter time for remission showed low d-ROM level. Some interfering factors must be considered when the D-ROM test is used because several vascular diseases, the use of oral contraceptives, and a state of fatigue after physical exercises have been shown to increase U. It may be useful to control dizziness or vertigo by reducing free radicals as a product of oxidative stress. The diagnostic value could be such that enhanced values of oxidative stress would be a marker for BPPV and provide additional information for a diagnosis of BPPV. It is considered that the angiitis and following oxidative stress can be one of the causes of BPPV.
Morimoto K, Morikawa M, Kimura H, Ishii N, Takamata A, Hara Y, Uji M, Yoshida K, Ohta Y, Chiba S, Tada M, Imai Y, Kitagawa A. Cesarone MR, Belcaro G, Carratelli M, Cornelli U, De Sanctis MT, Incandela L, Barsotti A, Terranova R, Nicolaides A.
They may have associated symptoms like deafness, tinnitus (hearing sound in absence of external stimulus), nausea, vomiting, double vision, blurring of vision, numbness of face, headache, sudden falling and loss of consciousness. Inner ear diseases like benign paroxysmal positional Vertigo, Meniere`s disease and vestibular Neuronitis are some of the common causes of vertigo. Even psychogenic disorders like anxiety disorders, panic syndromes can lead to vertigo. Vestibular physical therapy rehabilitation has been established as a useful intervention in the management of patients with a wide range of vestibular disorders [5-7]. The purpose of this study was to investigate the effects of a vestibular physical therapy rehabilitation program used in conjunction with preventive migraine medications for patients presenting with MAD. We administered to each patient a functional test battery consisting of an impulse head-thrust test, a Fukuda step test, a Romberg test, a tandem Romberg test, and a dynamic gait index (DGI) [7].
Exercises to decrease dizziness focused on exposure to specific stimuli for habituation or attenuation of the dizziness response in the brain.
The vestibuloocular reflex exercises, cervicoocular reflex exercises, and depth perception training were graded in difficulty based on increases of head motion, object motion, and progression of body positioning from sit to stand to ambulation.
These exercises included the proprioceptive neuromuscular facilitation techniques of slow-reversal head and neck patterns, modified chopping and lifting for head and trunk in progression from supine to sitting and standing postures, and total body mass rolling activities.
During ambulation, patients were challenged with distracting stimuli, which included stationary obstacles, moving objects, and ball skills.
They were monitored by the physical therapist twice the first week and once weekly for the subsequent 7 weeks. Analysis of outcomes measures for patients who suffered mild head injury (posttraumatic closed-head-injury migraine-associated dizziness and posttraumatic closed-headinjury migraine-associated dizziness and benign positional vertigo groups). Time required for return to work and for symptoms resolution after initiation of treatment for each group and for the entire study.
We analyzed the time required to return to work and the time required for remission of symptoms.
Because the final outcome data of all groups were the same, we can now compare this entire group of patients to a control group of untreated patients. Click your specific condition to learn more about what Coal Creek Physical Therapy can do to get you back to feeling better and living a life you love. The symptoms result from movement of the free floating otoconia particles in the endolymph or their attachment to the cupulae of the semicircular canal.
These variations relate to both diagnostic strategies for BPPV and rates of utilization of various treatment options available for BPPV within and across the various medical specialties and disciplines involved in its management. In this context, BPPV should be mentioned not only because of the high prevalence, but also because of the relative simplicity of the diagnosis and cost effectiveness of the treatment9. The semicircular canals change their gravitational orientation plane while the patients move their head. The fragments in suspension inside the labirinth tend to be deposited in this region, by the action of gravity1,13,14,15.
Typically, the vertigo arises in the lateral position of one or both sides, in hyperextension of the head, when standing up or lying down. Because the patient is going to be placed in the supine position relatively quickly with the head position slightly below the body, the patient should be oriented so that, in the supine position, the head can "hang" with support off the posterior edge of the examination table by about 20 degrees.
The examiner rotates the patient's head 45 degrees to the left and, with manual support, maintains the 45-degree head turn to the left during the next part of the maneuver8.
The Dix-Hallpike maneuver should then be repeated for the right side, with the right ear arriving at the dependent position.
If the upper pole of the eye beats away from the ground toward the uppermost ear, then it originates from the anterior canal of the uppermost ear. Patients with a history compatible with BPPV (ie, repeated episodes of vertigo produced by changes in head position relative to gravity) who do not meet diagnostic criteria for posterior canal BPPV should be investigated for lateral canal BPPV.
After the nystagmus subsides (or if no nystagmus is elicited), the head is then returned to the straight face-up supine position.
When the head is rotated to the healthy side, the particles displace and lead to a current moving in the opposite direction from the ampulla (also generating geotropic nystagmus), and the stimulation is less intense than that observed on the affected side. Lee and colleagues27 described the spontaneous reversal of nystagmus bilaterally, and the primary phase of nystagmus was shorter and with greater velocity of the slow-phase. Other possible causes are ovarian hormonal dysfunction, hyperlipidemia, hypoglycemia or hyperglycemia, hyperinsulinemia, migraine, cervical trauma, otological surgery, sedentary and prolonged bed rest2,15,32,33,34. Successful treatment depends mainly on the choice of the most appropriate maneuver for the case.
The patient is rapidly laid back in a supine head-hanging position, which is maintained for a period of 1 to 2 minutes.
The patient is in supine position; the patient's head is turned 90 degrees slowly toward the unaffected side.
The Brandt-Daroff exercises (Figure 8) are positioning exercises that, theoretically, promote habituation4.
The treatment of each affected semicircular canal will be performed, in protocols according to the observed ocular movements and the correct identification of each affected semicircular canal. Patients with posterior BPPV had impaired static balance ability when visual and proprioceptive inputs were inadequate as described by Celebisoy45, Di Girolamo46. The conversion to lateral canal BPPV (so called canal switch) and Canalith Jam are unusual conditions, however when present must be promptly diagnosed and treated47. In the Epley Maneuver, it happens when the head of the patient is turned to facedown position (Figure 5 - position c and d). If the patient develops important symptoms, vestibular suppressant medications may be considered to help in a later repositioning.
Therefore, it is possible to propose to the patient to wait the spontaneous resolution, in cases where the maneuver can't be indicated.
Benign paroxysmal positional vertigo: 10 year experience in treating 592 patients with canalith repositioning procedure. Neuro-otological features of benign paroxysmal vertigo and benign paroxysmal positioning vertigo in children: a follow-up study. Free-floating endolymph particles: a new operative finding during posterior semicircular canal occlusion.
Effectiveness of treatment techniques in 923 cases of benign paroxysmal positional vertigo. Benign paroxysmal positional vertigo due to a simultaneous involvement of both horizontal and posterior semicircular canals. Monitoring of caloric response and outcome in patients with benign paroxysmal positional vertigo. Diagnostic, pathophysiologic, and therapeutic aspects of benign paroxysmal positional vertigo. Reversal of initial positioning nystagmus in benign paroxysmal positional vertigo involving the horizontal canal.
Eletronytagmographic (ENG) findings in paroxysmal positional vertigo (PPV) as a sign of vestibular dysfunction. Canalith repositioning for benign paroxysmal positional vertigo: a randomized controlled trial.
The canalith repositioning procedure for treatment of benign paroxysmal positional vertigo. A positional maneuver for treatment of horizontal-canal benign paroxysmal positional vertigo. Balance in posterior and horizontal canal type benign paroxysmal positional vertigo before and after repositioning maneuvers. Treatment efficacy of benign paroxysmal positional vertigo (BVVP) with canalith repositioning maneuver and Semont liberatory maneuver in 376 patients. Treatment of benign paroxysmal ositional vertigo: necessity of postmaneuver patient restrictions.
Vibration with the canalith repositioning maneuver: a prospective randomized study to determine efficacy. The canalith repositioning procedure with and without mastoid oscillation for the treatment of benign paroxysmal positional vertigo. Natural course of the remission of vertigo in patients with benign paroxysmal positional vertigo. Natural history of benign paroxysmal positional vertigo and efficacy of Epley and Lempert maneuvers. Treatment of anterior canal benign paroxysmal positional vertigo by a prolonged forced position procedure. Diagnostic criteria for central versus peripheral positioning nystagmus and vertigo: a review. The level of diacron reactive oxygen metabolites (d-ROM) and circulating soluble vascular cell adhesion molecule 1 (VCAM-1), were evaluated. The incidence of BPPV increases with each decade of life2, peaking at the sixth to seventh decade of life1. The diagnosis of BPPV was performed by the typical positional nystagmus evoked by Dix-Hallpike procedure for PC-BPPV.
ROMs were measured in blood samples by the Diacron reactive oxygen metabolite (D-ROM) test. The relation between these time periods and either initial VCAM-1 or d-ROM levels were evaluated. Patients who required longer time for the disappearance of positional nystagmus showed high VCAM level, whereas those who required shorter time for remission showed low VCAM-1 level.
Benign positional vertigo: incidence and prognosis in a population-based study in Olmsted County, Minnesota. Reactive oxygen metabolites (ROMs) as an index of oxidative stress in obstructive sleep apnea patients. The relevance of an elevation in the plasma vasopressin levels to the pathogenesis of Meniere's attack. Mental stress induces sustained elevation of blood pressure and lipid peroxidation in postmenopausal women. Development of oxidative stress and cell damage in the liver of rats with water-immersion restraint stress. Soluble intercellular adhesion molecule 1 and soluble vascular cell adhesion molecule 1 in sudden hearing loss.
Oxidative stress and Meniere's disease and benign paroxysmal positional vertigo (in Japanese).
Evaluation of an automated spectrophotometric assay for reactive oxygen metabolites in serum. The patient feels as if the motion is within his head or that the objects in the surroundings are moving or tilting.
However, historically, vestibular physical therapy rehabilitation has been reserved for patients with complaints of consistent dizziness, imbalance, or other vestibular dysfunctions that are reproduced with movement activities. These authors reported significant improvement in functional outcomes in their patient population after vestibular physical therapy rehabilitation.


All the patients had migraine headaches as classified by the international headache system [14].
Each patient also underwent a sensory organization test, a motor control test, and an adaptation test on computerized dynamic posturography (CDP). Group A consisted of six patients with idiopathic migraine-associated dizziness (IMAD); these patients had at least a 2-year history of migraines and at least 6 months of vestibular symptoms and had failed to respond to medical therapy. Balance retraining involved exercises designed to improve organization of sensory information for balance control and coordination of muscle responses. The somatosensory exercises were graded in difficulty by narrowing the base of support, making the surface uneven, changing the surface from firm to soft, or the wearing of distortion lenses to decrease visual preference. Patient compliance to the home exercise program was surveyed by the physical therapist during patient visits.
Comparisons using a one-way ANOVA were performed between pre- and posttreatment test results for all the patients, for each group of patients, and to compare groups. The posttraumatic groups' mean ages were younger than the mean ages for the nontraumatic groups. An improvement in the dizziness handicap index (DHI) is demonstrated by a reduced posttreatment score. These two groups were composed primarily of active-duty military personnel engaged in strenuous physical activity, and they were at a high risk for head trauma. This is advantageous because a comparison of all treated to all nontreated patients will allow for a more statistically powerful analysis.
Certainly a controlled study comparing medicated to nonmedicated individuals would be helpful. Physical therapy for migraine-related vestibulopathy and vestibular dysfunction with history of migraine. Vestibular rehabilitation after low-dose microcatheter gentamicin treatment for Meniere's disease. Randomized controlled trial of vestibular rehabilitation combined with cognitive-behavioral therapy for dizziness in older people.
Physical therapy for migraine-related vestibulopathy and vestibulardysfunction with history of imigraine.
The diagnosis is essentially clinical and should be confirmed by performing diagnostic maneuvers.
Delays in the diagnosis and treatment of BPPV have both cost and quality-of-life implications for both patients and their caregivers8.
The debris dislocates and promotes anomalous activation of the ampullar crista and may interfere with the neuronal output index that normally would be expected for that head and canal position. The lateral semicircular canal may be involved in 5 to 15% of patients8 and the anterior canal is rarely involved8; but there is still the possibility of simultaneous involvement of two canals18,19,20.
The examiner should ensure that he can support the patient's head and guide the patient through the maneuver safely and securely, without the examiner losing support or balance himself8. Next, the examiner fairly quickly moves the patient (who is instructed to keep the eyes open) from the seated to the supine left-ear down position and then extends the patient's neck slightly (approximately 20 degrees below the horizontal plane) so that the patient's chin is pointed slightly upward, with the head hanging off the edge of the examining table and supported by the examiner.
Again, the examiner should inquire about subjective vertigo and identify objective nystagmus, when present.
After any additional elicited nystagmus has subsided, the head is then quickly turned 90 degrees to the opposite side, and the eyes are once again observed for nystagmus.
Thus, the resulting eye movement is always stronger when the affected ear is placed downward23.
The arrows indicate the direction of displacement of the cupulae by gravity with the lateralization movement of the head. It has been proposed by Korres22 that the unilateral vestibular hypofunction is more common in cases secondary to head trauma or viral infection. Next, the head is turned 90 degrees, to the right (usually necessitating the patient's body to move from supine position to the lateral decubitus position). The jam generates a constant counter-attraction force in the cupulae, as result from negative pressure. Possible explanations include some comorbidities and patient limitations during the maneuvers (for example: limited cervical range of motion or vascular failure)14. As a treatment the patients were taught to perform the Brandt-Daroff exercise at home by themselves.
BPPV is a mechanical problem of the inner ear caused by abnormal stimulation of a semicircular canal.
Radical scavengers and antioxidants play a role protecting the inner ear from oxidative stress. The elevated oxidative stress can provoke damage in vestibular organ (especially otolith dysfunction). AS for HC-BPPV characteristic direction alternating horizontal nystagmus during right lateral and left lateral position in lying down were examined. This test is based on the ability of transition metals to catalyze in the presence of peroxides, the formation of free radicals, which are trapped by an alchilamine.
Inflammation is known to play an important role as cause of various angiitis such as atherosclerosis.
It is reported that the D-ROM test is a simple, reliable and inexpensive method for the measurement of endogenous hydroperoxides. Criterion measurements included the dizziness handicap inventory, activities-specific balance confidence scale, computerized dynamic posturography performance, and dynamic gait index.
Vestibular physical therapy rehabilitation has been used with successful outcomes after vestibular neurectomy, labyrinthectomy, and Meniere's disease [5-8]. In addition, all patients had vestibular symptoms of imbalance, true vertigo, dizziness, or unsteadiness.
In addition, we administered the dizziness handicap index (DHI) [9] and the activitiesspecific balance confidence (ABC) scale surveys [8]. Group B consisted of four patients with IMAD and benign positional vertigo (IMADBPV); they were identical to the group A patients but, in addition, had BPV as defined by a positive Dix-Hallpike test on their initial visit.
General activity exercise involved a daily aerobic exercise program of progressive walking, cycling, or swimming.
The other three measures-activities-specific balance confidence scale (ABC), dynamic gait index (DCI), and sensory organization test score on computerized dynamic posturography (CDP) are improved as indicated by an increase in the posttreatment score. Both posttraumatic groups showed more improvement than did the other groups after vestibular rehabilitation procedures. A factor that might have produced this longer return-towork time in the posttraumatic groups was a more physically demanding work environment. Treatment is based on the identification of the affected semicircular canal and performance of liberatory maneuvers or repositioning of free floating particles of otoliths. Some other symptoms could be associated and often persist after the interruption of the episode, such as nausea, imbalance, or postural instability1,15. The examiner observes the patient's eyes for the latency, duration, and direction of the nystagmus.
Two potential nystagmus findings may occur with this maneuver, reflecting two types of lateral canal8. In cupulolithiasis, the fragments are adhered to the cupulae of the affected semicircular canal, which make them heavier than the endolymph.
Some authors prefer to wait for the natural course towards a spontaneous relief, considering BPPV a self-limited condition.
The patient is rapidly moved to the opposite side-lying position without pausing in the sitting position and without changing the head position relative to the shoulder. Then, the head is turned to the facedown position and the body is moved to the ventral decubitus. The jam pressure induces cupulae displacement and consequent depolarization (vertical canals) or hyperpolarization (lateral canals). The prognosis of BPPV, which is measured as the time until the disappearance of positional nystagmus by a physician during the outpatient visit each week, the relation among the level of oxygen metabolites, vascular molecule and the duration until remission were analyzed. Most BPPVs are thought to be caused by otoconia detaching from the otolithic membrane and moving to the lowest point of the inner ear, usually the posterior canal (PC). There are some basic data to indicate the relationship between oxidative stress and endolymphatic hydrops. The elevated oxidative stress can cause canalolithiasis, which is one of pathogenesis of BPPV as a result of otolith aberration to the canal organ. We postulated that ischemia of the vestibular organ followed by blood recirculation may provoke generation of cytotoxic radicals and produce damage of phospholipids in cytomembrane and result in elevated oxidative stress (Figure 3).
Cesarone and colleagues have found that in normal subjects the mean (±SD) levels of free radicals were 312 (±49) U. There is evidence that the D-ROM assay has both an acceptable stability and an acceptable margin of error14. After vestibular physical therapy, all subjects showed significant improvement in the dizziness handicap, activities-specific balance confidence, dynamic gait, and computerized dynamic posturography measures. The vestibular symptoms were reported as an aura prior to the headache, during the headache, or completely independent of the headache.
The foregoing measurements were obtained before treatment, during treatment, and after treatment (6-8 weeks after treatment initiation).
Group C consisted of 17 patients with posttraumatic closed-headinjury migraine-associated dizziness (PTMAD); these patients had suffered a closed-head injury with a Glasgow comma scale rating of 13-15 and no loss of consciousness.
Our results are unique in that our population was predominantly male and composed of a high number of posttraumatic patients. The younger age of this group, their general high level of physical condition, and their level of motivation may have influenced this result. The posttraumatic groups were composed of individuals who sustained a head injury in sports, military training, military combat, or motor vehicle accidents.
Besides the clinical history, the diagnosis of BPPV takes into account the type, direction and duration of nystagmus provoked by maneuvers that provide clues for identifying the affected canal and the pathophysiological mechanism involved (whether canalithiasis or cupulolithiasis). Again, the provoked nystagmus in posterior canal BPPV is classically described as a mixed torsional and vertical movement with the upper pole of the eye beating toward the dependent ear. When the head is rotated to one side, the action of gravity on the ampullar crista moves the debris into the opposite direction and it is possible to observe the nystagmus that is in the opposite direction from the tested ear (apogeotropic type)24,25.
Gradually the patient resumes the upright sitting position8.If the superior semicircular canal is affected, the movement is performed in the direction opposite to the procedure for posterior semicircular canal4,15,23,40.
Later the patient's head is turned 90 degrees, and the body is placed on lateral decubitus. Results: The patients who required longer time for the disappearance of positional nystagmus showed high d-ROM and VCAM levels, whereas those who required shorter time for remission showed lower d-ROM and VCAM levels. Free oxygen radicals are highly reactive molecules playing pivotal roles in the pathophysiology of such different diseases as neurodegenerative disorders, chronic inflammatory disease, and sleep apnea syndrome4,5. The automatic assay may be regarded as a fast and reproducible method for the quantitative evaluation of oxidative stress. Patients with migraine-associated dizziness can benefit from physical therapy intervention.
We documented subjective patient reports of degree and length of imbalance perception throughout treatment. They were initially evaluated by our medical system within 2 weeks of the head injury and then were referred to our clinic. As the mechanism of injury did not affect outcome, our results have implications for treating head injuries received in high-risk, collision sports (such as football, ice hockey, boxing, and rugby). Then the patient is asked to rest the chin on the shoulder and sit up slowly, completing the maneuver8 (Figure 4). Figure 6 demonstrates the Semont Maneuver for treatment of right-sided posterior semicircular canal cupulolithiasis. Conclusion: There is an increased expression of VCAM-1 and d-ROM confirming the existence of an angiitis and supporting the vascular involvement in BPPV. The vestibule connects to the 3 semicircular canals (posterior canal [PC], horizontal canal [HC], and anterior canal). In the previous study diacron reactive oxygen metabolites (d-ROM) was measured by the Free Radical Analytical system 4(FRAS4) from the blood of subjects with BPPV.
It is reported that psychological stress is closely related to the onset and course of Meniere's disease6 and BPPV7 Oxidative stress and psychological stress are closely related8, 9. The increased expression of circulating adhesion molecules confirmed the existence of an endothelial dysfunction and supports the vascular involvement of the disease. Since it is easily performed, the method is suitable for routine use in clinical laboratories and may provide an estimation of oxidative stress in vivo.
The results of this study are important in considering the approach to vertiginous migraine patients with and without head injury. Finally, we recorded the length of time required for patients to return to work after the initiation of physical therapy. These patients had no prior pathological findings or history of headaches and reported an interval of approximately 2 weeks between head injury and headaches. The 33% rate that we report in this study does not differ from previous work in the literature.
The head must stay in that position for some moments, before it returns to the normal position1,4,23,40.
Each step is maintained for 15 seconds - for slow migration of the particles, in response to gravity. The identification of the high levels of d-ROM and VCAM-1 can open the way to selective pharmacological treatments able to correct the oxidative stress and activation of endothelial cells. Although there are no statistically significant differences among three groups, the d-ROM value of BPPV and Meniere's disease are higher with respect to control.
Based on these considerations, it is hypothesized that BPPV may be linked to increased oxidative stress. Group D consisted of seven patients with PTMAD and BPV (PTMADBPV); they were identical to the Group C patients but, in addition, had BPV as defined by a positive Dix-Hallpike test on their initial visit.
To complete the maneuver, the patient is brought into the upright sitting position with head bowed down at 30 degrees23,43,44. The diagnosis of BPPV is based on the patient's history and the findings on positional testing.
The purpose of this study was to evaluate free oxygen radicals by a method providing values of reactive oxygen metabolite (d-ROM) concentration and VCAM-1 in blood samples from patients with BPPV. Once the canal is identified, the patients is treated effectively with an appropriate particle repositioning procedure which is now widely accepted. We should understand the basic pathology why either canalolithiasis or cupulolithiasis occur to invent new pharmacological treatment.



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