Brain-based Clinical Approach Improves Patient with BPPV after TBI

Case Presentation

  • History of concussions, with the most recent occurring one year prior to visit
  • Vertigo, headache, nausea
  • Increased frequency of sporadic crying
  • Decreased ability to perform daily activities
  • Difficulty reading; medical withdrawal from school; unable to play soccer

A Complex Case to Diagnosis:

  • Impaired balance and coordination stemming from vestibular consequences have been reported in over 30% of TBI cases1

A Complex Case to Treat:

  • Benign paroxysmal positional vertigo (BPPV) after TBI is more difficult to treat than idiopathic BPPV1

Accurate Diagnosis

Physical exam and evidenced-based diagnostics including Video Nystagmography, saccadometric testing, and CAPS Balance Testing

Individualized Protocols

5-day Clinic Treatment, followed by At-home Therapy; 3-4 sessions per day using the patented Off-Vertical Axis Rotational Device (OVARD), Repetitive Peripheral Somatosensory Stimulation (RPSS), balance training program, and a customized home protocol

Outcomes and Impact on Daily Life

After 1 month, the patient reported: resolution of headaches and returned to full daily activities

 

 

Case Presentation

The patient was a 20 year old female soccer player whose chief complaints were vertigo, headaches, and nausea. She had a history of multiple head injuries with the last one occurring during soccer, one year prior to the time of visit; she was hit on the head with the ball in the right temporal region and lost consciousness. Since her head injuries, she reported being more emotional and has cried sporadically for no distinct reason. The patient’s symptoms have impacted her daily activities whereby she received a medical withdrawal from college due to difficulty reading and is also unable to play soccer.

Symptoms

  • Vertigo: when lying completely flat
  • Headaches:  predominantly in the right suboccipital region and constant
  • Nausea and dizziness:  when standing up too quickly

Accurate Diagnosis

Physical Examination

  • Abnormal results: Facial and shoulder twitching; grade 2 pincer on right; gait was absent of right arm swing with right arm moving across the midline upon gait dual tasking; intorsion of eyes at rest, during right gaze, pursuit activity in all directions, and left optokinetic stimulus
  • Normal limits: Pull test; auscultation and percussion of the abdominal region; and sensory discrimination

Evidence-based Diagnostic Tools

  • Video Nystagmography: rightward square wave jerks at rest and during horizontal pursuits
  • Saccadometric testing: the majority of saccades occurred at <200 ms; rightward saccades had slower velocity vs leftward
  • 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

Individualized Protocols

  • “3X5 Model”: 3 times a day for 5 days in-clinic treatment

Head Repositioning Maneuversa

  • Gaze stability exercises employed specified eye movements while performing head maneuvers

Specific Eye Movement Exercises

  • The patient performed left brain eye movement exercises on an iPad for 3 minutes, or until the point of fatigue

OVAR

  • First 3 sessions: Right yaw with acceleration and deceleration components Remaining sessions: Right yaw and posterior pitch rotations

Gait Protocol

  • The protocol was a series of 4 steps, which included the use of Repetitive Peripheral Somatosensory Stimulation (RPSS) during varied types of motions

aIn patients with BPPV, a repositioning maneuver has been shown to be very effective in short and long-term resolution of symptoms 2-5

Home Protocol

An at-home care plan was explained and practiced with the patient before leaving the clinic.

The protocol included gaze stability exercises, left brain-computer exercises, and soccer practice activities.

Outcomes and Impact on Patient’s Daily Life

One month after treatment and performance of a home protocol, the patient was relieved of headaches and back to full activity.

References:
1. Basford JR, Chou LS, Kaufman KR, et al. An assessment of gait and balance deficits after traumatic brain injury. Arch Phys Med Rehabil. 2003;84(3):343-349. 2. Simhadri S, Panda N, Raghunathan M. Efficacy of particle repositioning maneuver in BPPV: a prospective study. Am J Otolaryngol. 2003;24(6):355-360. 3. Gans RE, Harrington-Gans PA.Treatment efficacy of benign paroxysmal positional vertigo (bppv) with canalith repositioning maneuver and Semont liberatory maneuver in 376 patients. Seminars in Hearing. 2002;23(2):129-142. 4. Nakayama M, Epley JM. BPPV and variants: improved treatment results with automated, nystagmus-based repositioning. Otolaryngol Head Neck Surg. 2005;133(1):107-112. 5. Hunt, WT, Zimmermann EF, Hilton MP. Modifications of the Epley (canalith repositioning) manoeuvre for posterior canal benign paroxysmal positional vertigo (BPPV). Cochrane Database Syst Rev. 2012;4.
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