Occupational Therapy Quick Sheets Compass.Rehab

Occupational Therapy Quick Sheets compass.rehab

Benign Paroxysmal Positional Vertigo (BPPV) Benign Paroxysmal Positional Vertigo (BPPV) is the number one cause of vertigo. Below you will find information regarding BPPV which can be helpful for patients in their understanding of this condition. It includes background on BPPV, some causes of the condition and treatments available. FACTS: • Benign Paroxysmal Positional Vertigo (BPPV) is the number one cause of vertigo. It occurs with change in head or body position, lasting no longer than a minute.

• This condition occurs because of changes in the balance portion of the inner ear. Calcium carbonate crystals, which the ear uses as gravity sensors, break away and can travel into the balance canals located in the inner ear.

• Although it may occur at any age, by age 70, fifty-percent of all individuals will experience BPPV.

• The most common ear conditions that cause BPPV are concussions, vestibular neuritis/labyrinthitis, or may occur spontaneously. There is no pain, such as with an earache, but you may have initially experienced sudden vertigo and nausea lasting hours.

• Common medical conditions such as cardiovascular disease, diabetes, migraine, and TIA’s (small vessel ischemia in the brain) may increase the incidence of BPPV. Mild head trauma may also cause BPPV.

• The most popular treatment of BPPV, is a simple and painless repositioning maneuver. The treatment returns the crystals to their originating larger space within the ear (utricle). Now, the body can absorb the loose crystals within a few days.

• The repositioning procedure is not a permanent cure, but a treatment. The condition may reoccur, and oftentimes does, or you may never experience BPPV again. Other medical conditions or prescription medications may promote the recurrence, if they affect the body’s absorption of calcium.

• There are several different repositioning treatment protocols. We will select one that will be best for your specific condition, and any physical limitations. If you have a history of acute nausea, or motion sickness your physician may recommend medication during treatment for your comfort.

If you are interested an in-service on BPPV and how to test for BPPV, please call Compass Health Rehabilitation at 517-337-3080 to set up a time that is convenient for your office. Occupational Therapy Quick Sheets compass.rehab

Superior Canal Dehiscence Syndrome (SCDS) • SCDS is caused by an opening or thinning of the bone overlying one of the inner ear semicircular canals. This is usually due to a congenital defect, trauma, or infection. It most often affects the anterior semicircular canal. Vestibular rehabilitation usually occurs after surgical intervention has been performed. The patient may still be uncompensated, with continued symptoms of imbalance, disequilibrium, and vertigo. Patients will benefit from skilled therapy to habituate these symptoms. Adaption and substitution approaches may also increase independence and safety with daily activities. The symptoms of SCDS are:

• SCDS related autophony in which the patient may report hearing their own voice as a disturbingly loud and distorted “kazoo-like” sound deep inside the head. They may hear the creaking and cracking of joints, the sound of their footsteps when walking or running, their heartbeat and the sound of chewing and other digestive noises. Some suffers may experience such a high level of conductive hyperacusis that a tuning fork placed on the ankle will be heard in the affected ear. Another feature is being able to hear the sound of the eyeballs moving in their sockets (when in a quiet room) “like sandpaper on wood”,

• Tullio phenomenon: This is sound-induced loss of balance. Patients showing this symptom may experience a loss of equilibrium, a feeling of motion sickness or even actual nausea, triggered by normal everyday sounds. Volume is not necessarily a factor, however, this is often a wide range of sounds that affect balance. For example: the rattle of a plastic bag, a cashier tossing coins into a register, a telephone ringing, a knock at the door, music, busy environments like a restaurant, children playing, sometimes even their own voice can cause a loss of balance. Patients may report that the world is being tilted sometimes up to 15 degrees, or report feeling like they are in an earthquake. A change in pressure such as when flying or blowing your noise may also result in loss of balance or nystagmus.

• Low frequency conductive hearing loss is present in many patients with SCDS and is explained by the dehiscence acting like a “third window.” Vibrations entering the ear canal and middle ear are then abnormally diverted through the superior semicircular canal and up into the intracranial space where they become absorbed instead of being registered as sound in the hearing center, the cochlea. Due to the difference in resistance between the normal round window and the pathological dehiscence window this hearing loss is more serious in the lower frequencies and may initially be mistaken for otosclerosis. A clinical sign of this phenomenon is the ability of the patient to hear (not feel) a tuning fork placed upon the ankle bone.

• Pulsatile tinnitus: This occurs when the dehiscent bone allows the normal pulse-related pressure changes within the cranial cavity to enter the inner ear abnormally. This affects the sound of the tinnitus which will be perceived as containing a pulse-synchronized “wave” or “blip” which patients describe as a “swooshing” sound or as being like to chirrup of a cricket or grasshopper.

• Brain fog and fatigue: By keeping the body in a state of equilibrium when it is constantly receiving confusing signals from the dysfunctional semicircular canal.

• Headache and migraine are also common complaints of patients showing other symptoms of SCDS. Occupational Therapy Quick Sheets compass.rehab

Hours: WELCOME TO OUR QUICK SHEETS ON OCCUPATIONAL THERAPY. Many of you have been asking for more information on Monday - Thursday: some of the most commonly treated conditions here at Compass Rehabilitation’s occupational therapy department. 7am-6pm As always, we welcome your suggestions for future additions of our quick sheets. Friday: 7am-5pm In addition to our traditional therapies, we also provide back-to-work programming. Please feel free to contact me regarding any of our treatments. My goal is to be here for you as an extension of care for your patients. Address: 250 East Saginaw Sincerely, East Lansing, MI 48823 Nicole Thelen, OT (517) 337-3080 Vestibular Rehabilitation Vestibular rehabilitation is the treatment of the inner ear and central nervous system disorders which cause chronic non-resolved vertigo, motion intolerance, and disequilibrium. The management of patients with chronic equilibrium disorders can be challenging, and yet also be among the most rewarding experiences for patient, physician, and clinician. Vestibular Rehabilitation programs provide patients with a successful alternative management strategy, allowing them to return to normal lives.

HISTORY... Although Vestibular Rehabilitation has only recently gained wide attention, the concept of head, body, and coordinated eye exercises as a treatment for vestibular disorders is actually over 60 years old. As far back as the mid 1940’s, an English otolaryngologist, Cawthorne, observed that some dizzy patients did better or recovered sooner when performing rapid head movements. In cooperation with a physiotherapist, Cooksey, they developed a regimen of exercise, which is still used today, with some modification. Since the resurgence of interest and research in vestibular rehabilitation in the mid 1980’s, hundreds of articles have been published in otolaryngology, neurology, and physical therapy journals. The overwhelming conclusion of these research studies has documented the benefits of this management strategy for vestibular dysfunction patients.

HOW… In order to understand how Vestibular Rehabilitation works and the underlying corrective mechanisms, it is important to remember that the primary role of the vestibular system is to tell the brain where the head is. Quite simply, the vestibular system is our internal reference telling the brain how our head is orientated in space. The visual, auditory and somatosensory systems, on the other hand, are external references, providing our brain with information about the movement and stability of the world around us. Working together in agreement, it is the harmonious integration of theses sensory modalities that provides us with equilibrium. When there is conflict between the internal and external references, the result is the brain’s inaccurate perception or hallucination of motion. Vestibular testing, early diagnosis, and vestibular rehabilitation therapy may reduce the incidence of falls, accidental deaths, increase independence in ADL’s and IADL’s, and empower the patient with knowledge to improve quality of life.

WHY… There are three generally accepted models to explain why therapy works: 1. Adaptation: The central vestibular system and brain learns to adapt to the imbalanced signal coming from the impaired peripheral vestibular sensory receptors. The role of the vestibule-ocular reflex is to keep the eyes focused on a target during head movement. If the incoming signal from the two internal head movement sensors is not in synchrony, the result is a sense of “after-motion” with head movement. A primary component of the equilibrium system adversely affected by the imbalance from the two peripheral vestibular mechanisms in the vestibule- ocular reflex. Gaze stabilization exercises work to “return” the vestibule-ocular reflex to eliminate the retinal slippage and the patient’s perception of this “after-motion”. 2. Substitution: The role of compensatory shift when one or more sensory system is lost or damaged is well known. The visually impaired individual does not develop better hearing acuity, nor does the deafened individual develop better vision. They simply utilize their remaining senses more efficiently. The redundancy of multiple sensory inputs allows the fully intact individual who has lost vestibular function, dependency on the remaining equilibrium sensory components, e.g. vestibule-spinal, cervico-spinal and visual input, must be made trustworthy. 3. Liberatory/Repositioning/Desensitization: There are several different approaches in the management of otolith dysfunction, commonly referred to as Benign Positional Vertigo. They include procedures in which the otoliths, which have escaped from the utricle and are now floating in the semicircular canals, are loosened, dislodged, or removed through a single or repetitive positioning maneuver(s). Occupational Therapy Quick Sheets compass.rehab

Migrainous Positional Vertigo (MPV) Ear vs. Brain This information was provided by The American Institute of Balance. Roberts, Gans and Kastner (2006), von Breveren (2004) and Neuhauser (2001) have all published articles about MPV. The condition is seen almost exclusively in post-menopausal females with history of migraine. At AIB we have seen dozens of patients ranging from 39 to 74 years of age. All had a history of migraine (IHC, 2004) since puberty with a range of manifestations (with and without aura, headache, motion intolerance etc.) typically associated with monthly menses. The majority no longer had the monthly migraine headache since menopause. All however, did report a migraine around the time of the onset of the acute positional vertigo.

Based on the patient’s gender, age and symptoms of acute positional vertigo, they are often initially diagnosed with Benign Paroxysmal Positioning Vertigo (BPPV). The provoked nystagmus direction, however, is typically horizontal (ageotropic) and occurs in lateral body positions. It appears to look more like an HC than PC involvement. Repositioning maneuvers for any canal variant do not extinguish the nystagmus or vertigo. vonBrevern, has speculated the genesis is in the brain, not the ear, likely resulting from dysfunction of inhibitory fibers from the vestibulocerebellar nodulus and uvula to the vestibular nuclei.

CASE STUDY: 66 year-old female. Acute onset of positional vertigo (initial episode with migraine headache), bilateral symptoms, but much more intense lying on her left side. Vertigo is rated at 10 with nausea and emesis is position is maintained. • When patient lays on her right side, there is a non-fatiguing, ageotropic, left beat nystagmus (LBN). Mild vertigo. • On left side, there is a 58 deg/sec non-fatiguing, ageotropic nystagmus, right beat nystagmus (RBN). Intense accompanying vertigo. • Multiple and varied treatments for HC-BPPV (Appiani, Cassani, barbecue roll) are ineffective. • Patient is prescribed Topamax and is asymptomatic within 36 hours, with complete resolution of symptoms.

Take Home Message: There are numerous underlying conditions that may cause positional nystagmus and vertigo other than BPPV, i.e. MPV, multiple sclerosis, Arnold Chiari, brainstem and cerebellar infarcts, alcohol and pharmacological influences. Therefore, the explanation by clinicians of a “non-classic” BPPV patient should be cautiously accepted in view of the clear mechanical aspects of BPPV versus neurological patterns, especially when symptoms cannot be managed by well-proven repositioning maneuvers.

References: 1. Neuhauser, H., Leopold, M., von Brevern, M., Arnold, G. & Lempert, T. 2001. The interrelations of migraine, vertigo, and migrainous vertigo. Neurology, 56, 436/441. 2. von Brevern, M., Radtke, A., Clarke, A. & Lempert, T. 2004. Migrainous vertigo presenting as episodic positional vertigo. Neurology, 62,469/472. 3. Roberts, R., Gans, R., Kastner, A. 2006. Differentiation of migrainous positional vertigo (MPV) from horizontal canal BPPV (HC-BPPV). International Journal of Audiology, 45:224/226 4. Roberts, R. and Gans, R., 2008. Nonmedical Management of Positional Vertigo, in Jacobson G., and Shepard, N. (Eds.) Balance Function Assessment and Management, Plural Publishing, San Diego.