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BENIGN POSITIONAL PAROXYSMAL VERTIGO (BPPV)



Patient Presentation

20-year-old female soccer player with a history of multiple head injuries presented with complaints of vertigo, headaches, and nausea. Vertigo is worst when lying completely flat. Headaches were predominantly in the right sub-occipital region and were unremitting.

Previous Treatments:

The patient had been manipulated by a chiropractor 22 times over a period of 2 months, with only transient relief of headaches, and no relief of vertiginous episodes.

Plasticity Examination and Diagnostics:

The neurological examination was grossly normal neurological, with the exception of her ability to stand with her head neutral on a foam surface, the UPDRS grading of finger-to-thumb on her right hand, right arm swing with dual tasking and an aberrant eye movement without visual fixation and during tracking of moving targets.

Plasticity® Diagnosis:

BPPV with aberrant plastic changes in the autonomic projections of her vestibular system.

Plasticity® Prescription:

Beginning with a repositioning maneuver, a Plasticity 3×5 treatment plan was implemented, including a 5-day (14-visit) intensive, outpatient, multi-modal, individualized treatment protocol consisting of nerve stimulation, eye exercises, vestibular exercises, SMART™ activities, and a self-administered at-home rehabilitation program.

Patient Outcome:

Upon discharge, the patient had normal saccadic velocities, an absence of square wave jerks, and all other ocular motor aberrancies. One month after treatment, with continued at-home treatment, the patient was completely relieved of headaches. She was back in school full-time and playing soccer again.

 


 

Summary

20-year-old female soccer player with a history of multiple head injuries presented with complaints of vertigo, headaches, and nausea. Vertigo is worst when lying completely flat. Her headaches were predominantly in the right sub-occipital region and were non-remitting.

Background

BPPV or Benign Positional Paroxysmal Vertigo is one of the most common vestibular disorders in patients with dizziness (20% of all dizziness is caused by BPPV, and 50% of all dizziness in the elderly). It occurs when calcium crystals known as otoconia are dislodged from their normal position within a vestibular organ called the utricle. These crystals migrate into one of the semicircular vestibular canals and cause positional vertigo. In addition to vertigo, due to the central projections of the vestibular system, an individual may experience headaches, nausea, neck pain, faintness, or blurred vision.

Case Presentation

The patient was a 20-year-old female college soccer player who had sustained multiple head injuries throughout her life. Her most recent head injury was 1 year prior to the time of visit when she was struck in the head by a soccer ball in the right temporal region and lost consciousness for an unknown period of time. Subsequently, she has had complaints of vertigo, headaches, and nausea. Vertigo is worst when lying completely flat. Headaches were predominantly in the right sub-occipital region and were non-remitting. She had reported feeling more emotional with spontaneous crying. The symptoms impacted her daily activities to the degree she quit soccer, withdrew from college due to difficulty reading. She had received 22 cervical manipulations over the past 2 months, with no sustained improvement in her condition. Upon examination, the patient presented with facial and shoulder twitching; exhibited a Grade 2 (UPDRS) pincer test on the right; gait was absent of right arm swing with right arm swinging across the midline upon gait dual tasking. She had intorsion of her eyes at rest, during right gaze, pursuit activity in all directions, and left optokinetic stimulus.

Diagnostic Testing Yielded the Following:

  • Video Nystagmography: rightward square wave jerks at rest and during horizontal pursuits
  • Saccadometry Testing: the majority of saccades occurred at <200 ms (normal finding); rightward saccades had a slower average velocity vs leftward saccades
  • CAPS® Balance Testing: paradoxical response; the patient was more stable with head in flexion and less stable with head neutral while on a perturbed surface when compared to head in extension

Treatments

A 5-day intensive, outpatient, multi-modal, individualized treatment protocol was prescribed, based upon the physical examination of the patient and her diagnostic findings.

  • First, a repositioning maneuver was performed. Repetitive Peripheral Somatosensory Stimulations were applied at various landmarks on the patient’s body, including a 6-step gait-retraining protocol.
  • Specific eye exercises were prescribed, performed, and monitored that consisted of 1º saccades in an up-right direction followed by a pursuit down-left, on an iPad for 3 minutes. Vestibular rehabilitation exercises consisting of focusing on a target and the therapist passively moving her head were also performed.
  • For the first 3 sessions, SMART™ activity was performed in a MARC™ device, consisting of right yaw with acceleration and deceleration steps spanning 10 seconds each at a maximum rotational velocity of 30º/sec for 33 seconds total. After the third session, SMART™ activity was performed in a MARC™ device, consisting of right yaw and posterior pitch at 90º/sec. These therapies were performed using the Plasticity 3×5 Model, with 3 treatments each day, for 5 days.

Outcome & Follow Up

After five days of treatment, an at-home care plan was prescribed and practiced including iPad exercises administered in the facility, self-performed vestibular therapies, and customized soccer drills to promote vestibular integrity. Upon discharge, the patient had normal saccadic velocities, an absence of square wave jerks, and all other ocular motor aberrancies. One month after treatment, with continued at-home treatment, the patient was completely relieved of headaches. She was back in school full time and playing soccer again.

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