EVIDENCE-BASED REHABILITATION FOR PERSONS WITH PERIPHERAL VESTIBULAR DYSFUNCTION
Studies have identified the effectiveness of vestibular rehabilitation in reducing symptoms of dizziness, improving balance, and restoring quality of life in persons with peripheral vestibular disorders (Dunlap et al., 2019; Hall, et al., 2016; Sulway et al., 2019). The goals of treatment for the patient with peripheral vestibular dysfunction are to reduce dizziness, improve gait and balance, improve gaze stabilization, increase activity level, and reduce disability. Treatment should follow a problem-oriented approach so that the patient receives an individualized program of care, thereby optimizing his or her BPPV Treatment of BPPV will depend on whether the otoconia are free-floating in the semicircular canal (canalithiasis) or adhered to the cupula (cupulolithiasis), based on examination findings. Canalith repositioning maneuvers (CRM) have been shown to be effective treatments for canalithiasis and cupulolithiasis (Casani et al., 2002; Gans & Harrington-Gans, 2000; Hilton & Pinder, 2002; Nunez et al., 2000; Steenerson et al., 2005). Repositioning maneuvers aim to move the otoconia out of the affected canal and back to the utricle to eliminate their effect on endolymph flow and resulting provocation of vertigo with head movement. Repositioning maneuvers to treat posterior and anterior canal BPPV are the Epley maneuver for canalithiasis and the Semont (or Liberatory) maneuver for cupulolithiasis. For horizontal canal BPPV, the maneuvers are the Barbeque Roll and the Appiani maneuver for canalithiasis and the Casani (modified Semont) The Epley maneuver for posterior canalithiasis moves the patient through a series of positions while lying on the treatment table, to move the otoconia through the posterior semicircular canal. The position of the head and the direction of roll that are the main components of this CRM take into account the anatomical orientation of the posterior canal. The first position of the Epley maneuver begins in the Hallpike-Dix position, with the patient in supine, the head rotated 45° to the affected side (affected side down) and in 20° of cervical extension off the end of the examination table. The clinician must be certain to quickly guide the patient down into position from a long-sit position, avoiding a slow transition that may not effectively move the otoconia. The patient maintains that position, with the therapist supporting the patient’s head, for at least 30 seconds, or twice as long as the duration of the nystagmus and vertigo. The second position is simply guiding the patient’s head to roll to 45° of rotation to the other side, maintaining 20° of cervical extension. This position is also maintained for at least 30 seconds, or twice the duration of the nystagmus and vertigo. For the final position, the patient rolls to the side of cervical rotation while the therapist maintains the 45° of cervical rotation. This results in the patient in a sidelying position on the unaffected side, with the head turned with the nose to the floor, while the therapist is supporting the head. Again, this position is maintained for at least 30 seconds, or twice the duration of the nystagmus. Finally, the patient moves into a short-sit position over the edge of the mat, while keeping the chin tucked (see Figure 7). Treatment of anterior canalithiasis using the Epley maneuver is exactly the same as for the posterior canal, with the affected ear down as the first treatment position. At the completion of the Epley canalith repositioning maneuver, the Hallpike-Dix can be repeated to determine whether there are any remaining symptoms of BPPV, and thus residual otoconia in the posterior canal. In that case, the Epley maneuver can be performed another time, but should not be repeated more than three times in the same session. maneuver for cupulolithiasis. Posterior and anterior canal
recovery. Developing a problem-oriented approach to care takes into account the patient’s diagnosis and category of vestibular dysfunction (i.e., reduced function, distorted function), the problem areas identified during the examination, and the patient’s medical history. Thus, the patient with anxiety and resulting peripheral vestibular hypofunction due to repeated attacks of Ménière’s disease, the patient with BPPV, and the patient with unilateral vestibular hypofunction will each have a different approach to care.
Figure 7: Epley Maneuver
The Semont (or Liberatory) maneuver is used to treat posterior canal cupulolithiasis. In this treatment, the patient sits on the edge of a treatment table with the head rotated 45° toward the unaffected side (away from the affected side). From there, the patient is moved quickly into a sidelying position on the affected side in a nose-up position . The rapid movement into this position aims to dislodge the otoconia from the cupula. In this position, the patient will be lying with the affected side down, in a nose-up position, with 20° of cervical extension. The posterior canal will be positioned perpendicular to the horizon. The patient remains in this position for 1 to 2 minutes, allowing the otoconia to migrate to the lowest point in the canal with respect to gravity (the upper portion of the canal) and is then moved rapidly through the initial sitting position to the opposite side, without turning the head, coming to sidelying on the opposite side in a nose-down position. This brings the otoconia around and out of the posterior canal. The patient holds this position for 2 minutes and then slowly returns to a sitting position. There are no post-treatment restrictions or precautions for either of these maneuvers.
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