Mr. H was playing ice hockey one night when he was hit from behind by another player. Though he was wearing his helmet, his head hit the glass and while falling backwards, his head hit the ice. Mr. H did not recall how he left the ice. He did remember being in the locker room, changing out of his hockey gear and experiencing a terrible headache. He recalled a loud ringing in his ear, seeing stars and feeling nauseas. Feeling unfit to drive, his teammates called his wife and his wife drove him home. The next morning, Mr. H was awakened at 5am with an intense dizziness which he described as “the whole room was spinning out of control.” His wife called 911 and the ambulance arrived to take him to the hospital. At the hospital, the emergency physicians diagnosed him with a concussion and discharged him on the same day. Mr. H saw his family doctor the next day who also diagnosed him with a concussion. He was told to remain off work until such time his dizziness resolved and since he was also experiencing neck pain, he was given a prescription for physiotherapy. Five days after the hockey injury, Mr. H saw me for physiotherapy. Mr. H felt very discouraged by the news from his doctor that the recovery from concussions is slow and could take several weeks if not months. He had just started a new job and was worried that he may lose his job should his recovery take more than a few days.
After my assessment of Mr. H, I felt that his symptoms of dizziness were separate from his concussion symptoms. In fact, Mr. H was describing a condition called Benign Paroxysmal Positional Vertigo or BPPV. This is a condition which affects the vestibular apparatus in the inner ears. It is Benign in that the condition itself is not life threatening. Paroxysmal means it is episodic and is provoked by certain head positions, hence it is Positional and Vertigo is a sensation of circular motion. Dizziness is a non-specific term with numerous subclassifications, vertigo being one of them.
Fortunately, BPPV is easily treatable. It is diagnosed with a careful history and then confirmed with a bedside test called the Dix Hallpike. If positive, it can be easily treated with the Epley’s Repositioning Maneuvre. In Mr. H’s case, I was able to reproduce his vertigo with the Dix Hallpike test. He tolerated 2 Epley’s Repositioning Maneuvres that day and afterwards, he felt immediately better. He was able to walk independently from the treatment cubicle to the waiting area. Since Mr. H was desperate to return to work, I saw him again 3 days later. He stated that his vertigo resolved completely after treatment that day and that he had slept through the night without waking. I re-tested his Dix Hallpike test and indeed, there was no vertigo. I subsequently tested Mr. H’s head movements in all planes including bending down and getting up and he was dizzy-free. Mr. H returned to work the next day with no issues. I followed up with Mr. H one week later and he remained dizzy-free.
In concussion patients, a thorough assessment is vital to differentiate the sources of a patient’s symptoms. In Mr. H’s case, resolution of his most debilitating symptom was straightforward in that the problem was not stemming from his brain but from the peripheral vestibular apparatus in the inner ear. Rather than taking weeks or months, Mr. H’s condition improved after 1 treatment session, thus allowing him to return to work, to sleep and to function.
The new and updated Clinical Practise Guidelines for the management of BPPV has just been released. The current best practise for the treatment of BPPV is not medications or “just waiting it out” but it is treatment with a Physiotherapist with special training in Vestibular Rehabilitation.
At Elevation Physiotherapy, we offer treatments for BPPV as well as the following:
– Post Concussion Syndrome
– Meniere’s disease
– Vestibular loss
– Balance Disturbances
– Vestibular Migraines
– Labyrinthitis
Submitted by Albert Chan
References:
Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngol Head Neck Surg. 2017 Mar;156(3_suppl):S1-S47.