RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE

PERFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1. / NAME OF THE CANDIDATE AND ADDRESS / CHELUVI VIRA.C
FLORENCE GIRLS HOSTEL,
#507 & 509, 1ST ‘D’ MAIN ROAD,
H.R.B.R LAYOUT,4TH BLOCK,
KALYAN NAGAR,
BANGALORE-43
2. / NAME OF THE INSTITUTION / FLORENCE COLLEGE OF PHYSIOTHERAPY
3. / COURSE OF STUDY AND SUBJECT / MASTERS OF PHYSIOTHERAPY
(Neurology And Psychosomatic Disorders )
4. / DATE OF ADMISSION TO COURSE / 21-06-2011
5. / TITLE OF THE TOPIC /

Comparative Study To Assess The Efficacy Of Additional Vestibular Stimulated Exercises Incorporated With Canalith Repositioning Exercises Vs Isolated Use Of Canalith Repositioning To Improve Balance In Benign Paroxysmal Positional Vertigo.

6. BRIEF RESUME OF THE INTENDED WORKS:

6.1 NEED OF THE STUDY:

Benign paroxysmal positional vertigo (BPPV) is a common cause of self limited vertigo. Most patients with benign paroxysmal positional vertigo (90%) have involvement of semicircular canal. Positional pathologic vertigo is precipitated by a change in head position, usually recumbent with the head turned to either the right or the left. BPPV is characterised by positional vertigo and positional nystagmus, which occur when the head moves in certain directions or positions (2). Patients report the sudden onset of vertigo associated with specific movements involving the head, such as rolling over in bed, bending over, or looking upward.

BPPV is a common cause of dizziness, about 20% of all dizziness is due to BPPV. While BPPV can occur about 2 % in children. The older you are, the more likely it is that your dizziness is due BPPV about 50% (19).

The most common cause of BPPV in people under age 50 is head injury. There is also a strong association with migraine. In older people, the most common cause is degeneration of the vestibular system if the inner ear. BPPV becomes much more common with advancing age. Viruses affecting the ear such as those causing vestibular neuritis and Meniere’s disease are significant causes. Occasionally BPPV follows surgery, including dental work, where the cause is felt to be a combination of a prolonged period of supine positioning, or ear trauma when surgery is to the inner ear. BPPV is common in persons who have been treated with ototoxic medications such as gentamicin(1) In half of all cases, BPPV is called idiopathic.

The pathophysiology of BPPV is the mechanism of canalathiasis, a condition that involves the presence of free-floating particulate matter within the posterior semicircular canal of the vestibular labyrinth, causing vertigo. The free floating debris is thought to originate within the vestibular labyrinth. It is thought that BPPV results when the free- floating debris causes deflection of the cupula after provocative head movements (2).

Patients with benign paroxysmal positional vertigo (BPPV) often experience instability. Decreased dynamic postural control contributes to functional limitation in people with vestibular disorders (9). Impaired balance is also related to the increase in falls, fractures and other fall-related injuries. It is therefore clear that the balance impairment in patients with BPPV needs to be considered and managed. The other features also include lightheadedness and nausea (20).

The commonly used treatment for BPPV is Semont manuever, Gufoni maneuver, Brandt-Daroff maneuver. The two approaches used in this study for patients with BPPV are particle repositioning maneuver and vestibular rehabilitation (also referred to as vestibular exercise therapy or balance retraining). The primary aim of particle repositioning manuevers, such as epley canalith procedure, is to treat the underlying pathology causing the symptoms. Vestibular rehabilitation program follow the compensatory and adaptive models, rather than the restorative approach, teaching and training patients to adapt to their vestibular dysfunction and increasing the tolerance level to the vertigo and also improve balance through a series of exercises. The only way that the balance system can overcome dizziness and imbalance is by practicing the movements and situations that cause dizziness (16).

The need of the study is to improve the balance in patients suffering from vertigo facing balance disorders. Due to balance dysfunction individuals with BPPV tend to have dizziness which would lead to falls. This study may help us improve the balance in subjects with BPPV and thereby preventing the threat of fall related injuries. The combined effect of canalith repositioning exercises along with vestibular stimulated exercises may have faster and safer improvement in patients with BPPV and thereby, promoting the physiotherapists to achieve their goal easier and earlier.

6.2  REVIEW OF LITERATURE:

BREVERN et al (2006): Conducted, a randomised trial to determine the short-term efficacy of the Epley maneuver for the treatment of posterior canal (pc) BPPV. Sixty-seven patients with acute unilateral PC-BPPV were included and randomly assigned to treatment with the Epley maneuver or to a sham procedure (which consisted of the Epley manuever but performed on the unaffected side). After 24 hours, 28 (80%) of the 35 patients in the treatment group were free of positional vertigo and nystagmus compared to three (10%) of the 31 patients in the sham group. The patients in the sham group then received the Epley maneuver to the affected side and 24 hours after treatment,26(93%) of the 28 patients were symptom-free, At four weeks, 85% of all patients were free of positional vertigo. No serious side effects were reported. The authors concluded that treatment of PC- BPPV using the Epley manuever is more effective than sham in the short-term (18).

WOLLAN et al (1992): Conducted a study to compare the effectiveness of canalith repositioning procedure (CRP) with sham maneuver for the treatment of benign paroxysmal positional vertigo. He recruited 50 patients with a history of positional vertigo and unilateral positional nystagmus on physical examination. Patients were randomized to either the CPR or a sham maneuver. The result concluded that after a mean duration of follow-up of 10days for both groups, resolution of symptoms was reported by 12 (50%) of the 24 patients in the CRP group and by 5(19%) of the 26 patients in the sham group (5).

TUSA et al (2000): Conducted a study on patients with benign paroxysmal positional vertigo (BPPV) often experience postural instability as well as brief episodes of vertigo his study was to determine whether successful resolution of the episodic vertigo through use of the canalith repositioning treatment, would be accompanied by improvement in postural stability. He took 23 patients and treated them with canalith repositioning maneuver. Postural stability was assessed by computerized dynamic posturography before and 1 to 2 weeks of the treatment. The result shows that treatment of BPPV using the canalith repositioning treatment in improved postural stability in patients with BPPV (1).

S. KORRES et al (1994): Evaluated the prognostic factors in benign paroxysmal positional vertigo (BPPV) treated with canalith repositioning procedures (CPR). 155 patients were studied out of which 66 men and 89 women with mean ages of 58.7 and 60.4 years. He concluded that CPR procedures provide fast and long-lasting treatment of BPPV in most patients (5)

RICHARD et al (2005): Assessed the efficacy of the epley maneuver in a study of 81 patients with posterior semicircular canal benign paroxysmal positional vertigo. Out of that 61 patients underwent the maneuver, while a control group of 20 patients received no therapy. All patients were evaluated at 1 and 6 months. They concluded that Epley maneuver provides effective and long-term control of symptoms in patients with BPPV (13).

TEE et al (2005): Conducted a study on vestibular rehabilitation therapy for the dizzy patient. Subjects were assigned into 2 groups. 43 subjects were assigned into experimental group and 43 subjects into control group. The experimental group was given only vestibular stimulated exercise and the control group was given both vestibular stimulated exercises along with isometric strengthening exercises. The study concluded that vestibular rehabilitation therapy along with strengthening exercises improves the vestibular function for dizzy patients (17).

WHITNEY et al (2000): Conducted a study on Efficacy of vestibular rehabilitation on BPPV. In her study she included 24 subjects with BPPV. The patients were then treated with custom designed vestibular physical therapy exercise program. She concluded through her study that vestibular therapy was found to be effective for subjects with BPPV (18).

SUSAN et al (1993): Conducted a study on Single treatment approaches to benign paroxysmal positional vertigo. In this study 60 subjects with BPPV were included. Patients received either a single treatment like semont maneuver based on the hypothesis that the vertigo and nystagmus of BPPV are due to debris adhering to the cupula of the posterior semicircular canal (cupulolithiasis) or epley’s manuever based on the hypothesis that the debris is free floating in the long arm of the posterior canal (canalithiasis). The study concluded that both the treatment is equally effective for the treatment of BPPV (17).

6.3  OBJECTIVES OF THE STUDY.

o  To evaluate the effectiveness of canalith repositioning maneuver on balance for patients with BPPV.

o  To evaluate the combined effect of vestibular stimulated exercise and canalith repositioning maneuver on balance for patients with BPPV.

o  To compare the combined effect of vestibular stimulated exercise and canalith repositioning maneuver vs canalith repositioning exercise alone on balance for patients with BPPV.

6.4 HYPOTHESIS

NULL HYPOTHESIS

There may not be significant difference between canalith repositioning exercises with vestibular stimulated exercise Vs canalith repositioning exercise alone on balance in patients with BPPV.

ALTERNATE HYPOTHESIS

There may be significant difference between canalith repositioning exercise with vestibular stimulated exercise Vs canalith repositioning exercise alone on balance in patients with BPPV.

7. MATERIALS AND METHOD:

7.1  SOURCE OF DATA

o  Florence Rehabilitation Centre, Kalayan Nagar, Bangalore-43,

o  Old Age Homes (Bangalore).

7.2. METHOD OF COLLECTING DATA

7.2.1  STUDY DESIGN:

Comparative Study design with pre and post test.

7.2.2 POPULATION:

Subjects diagnosed with BPPV

7.2.3  STUDY SAMPLE DESIGN

Simple random sampling

7.2.4 SAMPLE SIZE

Sample size is 30.

7.2.5  DURATION OF STUDY

4months.

7.2.4 SELECTION CRITERIA

INCLUSION CRITERIA

o  Age between 45-60 years

o  Only male patients.

o  Unilateral posterior semicircular canal involvement.

o  Functional to normal ROM of neck and back.

o  Individuals diagnosed with involvement of unilateral posterior semicircular canal in BPPV

EXCLUSION CRITERIA

o  History of prior ear surgery (or) prior treatment for benign paroxysmal positional vertigo.

o  Orthopaedic disorder that impairs functional neck and trunk range of motion.

o  On vestibular suppressant medication.

o  Alcohol intoxication.

o  Meniere’s disease

o  Perilymphatic fistula.

o  Vestibular neuritis

o  Bilateral vestibular disorder.

o  Central vestibular disorder.

o  Head trauma.

7.2.5 OUTCOME MEASURES:

Balance.

7.2.6 MEASUREMENT TOOLS

Berg – balance scale.

7.2.7 MATERIAL USE

o  Couch

o  Pillows

o  Marking tools

o  Stopwatch

7.3 INTERVENTION TO BE CONDUCTED

7.3.1 METHODOLOGY:

The subjects who are satisfying the inclusion criteria will be taken for the study and informed consent will be taken from them before starting the study. 30 subjects will be included for the study and they will be randomly selected using Simple Random Sampling Method. They will be randomly assigned into Group A and Group B by allotting 15 subjects per group. All the subjects selected for the study of both groups will undergo pre-treatment assessment using Berg Balance Scale.

In Group A the subjects will be treated with Canalith repositioning maneuver for 30 minutes and vestibular stimulated exercise for 30minutes for 2 weeks, once in a day and 3 days per week. In Group B the subjects will be treated with Canalith repositioning manuever for 30 minutes and sham vestibular therapy for 30 minutes for 2 weeks, once in a day and 3 days per week.

PROCEDURE:

CANALITH REPOSITIONING EXERCISES:

Canalith repositioning maneuver, involves a five-position cycle in which the patient undergoes a series of timed head maneuvers. The cycle is repeated until a total of five cycles has been completed.

Step 1: The patient’s head is first rotated 45 degree towards the involved side.

Step 2: The patient is then moved into the Hallpike-Dix position with the affected side towards the ground.

Step 3: Next the head is rotated 90 degree to the opposite side it is important to maintain the 30 degree neck extension during the step. The head should now be positioned 45 degree to the opposite side.

Step 4: The patient is rolled on to the opposite shoulder.

Step 5: Slowly the patient is brought up to sitting position, head still rotated 45 degree to the opposite side.

VESTIBULAR REHABILITATION EXERCISES:

o  Sit upright with the patients legs out in front of him. Ask the patient to quickly lie straight down on his back. Wait for the symptoms to calm down, and then sit back again.

o  Sitting in chair, ask the patient to bend forward and to bring his head down halfway toward knees. Wait for the symptoms to calm down, and then ask him to sit back up again.

o  Sitting in a chair, quickly ask patient to turn his head and eyes from left to right, 5 times in each directions, as if watching a tennis match. Try to focus on an object in each direction. Stop; wait for the symptoms to go away.

o  Repeat the previous exercise but ask the patient to look up and down instead of right and left.

o  Repeat exercise 3 with eyes closed.

o  Do exercise 4 with eyes closed.

o  Sit in a chair with one arm outstretched in front of the patient with his first finger pointing up. Ask him to Stare at his finger and turn his head to the left and right 10times. Start slowly and gradually speed up.

o  Repeat exercise 7, but hold the finger sideways and move the head up and down.

SHAM VESTIBULAR THERAPY:

Patients are instructed to lie on the examination table with the affected side down for 30minutes, and then they are asked to sit up.

7.2  ETHICAL CLEARANCE

Ethical clearance has been obtained from the institution.

8.  LIST OF REFERECE

  1. Blatt PJ, Geogakakis GA, Herdman SJ, Clindaiel RA, Tusa RJ. The effects of the canalith repositioning manuever on resolving postural instability in patients’ witih benign paroxysmal vertigo. Am J Otol 2000; 21: 356-363.
  2. Chang WC, Hsu LC, Yang, YR Wang RY. Balance ability in patients with benign paroxysmal positional vertigo. Otolaryng Head neck 2006; 135: 534-540
  3. Darcy A Umphred, Neurological Rehabilitation, 4th Edition, Mosby pp 751-781.
  4. Dannenbaum E, Rappaport JM, Paquet N, Visintin M, Fung J, Watt D. A 2-Year review of a novel vestibular rehabilitation program in Montreal and Laval, Qubec, J Otolaryngol 2004; 33:5-9.
  5. Epley JM, Peter C Wollan et al. The canalith repositioning manuever for treatment of benign paroxysmal positional vertigo. Otolaryngol Head neck surg 1992; 107:399-404.
  6. Edwin R Bickerstaff and John A Spillane, Neurological Examination Clinical Practice, Reprinted 1992, Oxford University Press, pp: 153-204.
  7. Geraint Fuller, Neurological Examination made easy, Reprinted 2000, Churchill Livingstone, pp 9-10.
  8. Giacomini PG, Alessandrini M, Magrini A. Long – term postural abnormalities in benign paroxysmal positional vertigo. J Otorhinolaryngol Relat spec 2002: 64: 237-241.
  9. Horak FB, Jones- Rycewicz C, Black FO, Shumway-Cook A. Effects of vestibular rehabilitation on dizziness and imbalance. Otolaryngol Head Neck Surg 1992; 106: 175-180.
  10. J.M Todd and P.M Davies, Cash’s text book of neurology for physiotherapists, 5th edition, 1993, Jaypee brothers, pp 267-295.
  11. Katsarkas A, Kearney R. Postural disturbance in paroxysmal positional vertigo. Am J Otol 1990; 11:444- 446.
  12. Keshner EA. Postural abnormalities in vestibular disorders. Vestibular rehabilitation, 2nd edition. FA. Davis, 2000: 52-76.
  13. Nunez canalith RA, Cass SP, Furman JM. Short and long term outcomes of repositioning for benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2000; 122:647-652.
  14. Patricia M Davies, Steps to follow, 10th printing, 1994, Springerverlag, Berlin Heidelberg, pp 120-145.
  15. Raymond D Adams and Maurice Victor, principles of Neurology, 8th Edition, McGraw-Hill, 1993, pp 669-674, 681-682.
  16. Shepard NT, Tellian SA. Practical management of the balance disorder patient. San Diego: Singular publishing group, 1996; 180 D2
  17. Susan J.Herdman, MD; Doughlas E. Mattox,MD. Single treatment approached to BPPV, Arch otolaryngol head neck surg. 1993; 119: 450-454.
  18. Tee LH, Chee NWC. Vestibular rehabilitation therapy for dizzy patient. Ann Acad Med Singapore 2005 May ; 34(4): 289-94.
  19. Von Brevern M, Radtke A, Lezius et al; Efficacy of the epley maneuver for the treatment of posterior canal BPPV. J Neuronal Neurosurg Psychiatry 2006; 78:710-715
  20. Whitney SL, Rossi MM. Efficacy of vestibular rehabilitation. Otolaryngol Clin North Am. 2000 june, 33 (3): 659-72.
  21. Whitney SL, Wrisley DM, Marchetti GF, Furman JM. The effect of age on vestibular rehabilitation outcomes. Laryngoscope. 2002 Oct ; 112(10): 1785-90.
  22. Yardley L, Beech S, Zander L, Evans T, Weinman J. A randomized controlled trial of exercise therapy for dizziness and vertigo in primary care. Br J Gen Pract 1998 April; 48 (429):1136-40.

9. / SIGNATURE OF THE CANDIDATE
10. / REMARKS OF GUIDE / This study can prove the Efficacy of an additional vestibular stimulated exercise Programme on balance with Benign paroxysmal positional vertigo.
11. / 11.1 GUIDE
11.2 SIGNATURE
11.3 CO-GUIDE
11.4 SIGNATURE
11.5 HEAD OF THE
DEPARTMENT
11.6 SIGNATURE / Dr .DARIS FRANCIS (M.P.T)
Dr. MEGHANA PALKHADE (M.P.T)
12. / 12.1 REMARKS OF THE
CHAIRMAN AND
PRINCIPAL
12.2 SIGNATURE

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