The Mysteries of BPPV: A Case Study in Perseverance
As physical therapists specializing in vestibular and balance disorders, we've all been there: a case that doesn't quite fit the textbook. The patient who seems to have a simple, straightforward presentation suddenly develops an unexpected and dramatic response. It's in these moments that we truly test our clinical skills and, perhaps more importantly, our resilience. A recent conversation with a fellow physical therapist highlights just this kind of scenario, offering a valuable lesson in trusting our instincts and following the nystagmus. This shared experience reinforces the strength of our professional community and the support we can provide each other in challenging cases.
The Patient Presentation
A patient returned to the clinic a year after a successful treatment for what was believed to be anterior semicircular canal (ASC) BPPV. Her initial presentation was classic, with a Dix-Hallpike Test or Deep Head Hang revealing a downbeating nystagmus. She responded very well to a Yacovino maneuver, though it required a couple of visits.
A year later, her symptoms returned. All bedside tests were negative, but a deep head hang under video goggles once again provoked a low-amplitude, downbeating nystagmus. This initial finding seemed to confirm the recurrence of ASC BPPV. The physical therapist, following this lead, attempted a modified CRM for the right ASC.
A Nystagmus with a Twist
However, as the patient moved into the second position of the maneuver, an unexpected upbeating nystagmus appeared on the left side. This surprising finding, suggesting that the debris wasn't in the anterior canal after all, but was moving in the posterior semicircular canal (PSC), underscores the need for flexibility in our treatment plans. Specifically, this nystagmus pattern suggests debris moving ampullopetally first in the PSC (downbeating and torsion to the right) and then transitioning to moving ampullofugally (upbeating and torsion to the left) as the patient's head position changed.
The therapist, demonstrating excellent clinical acumen, followed the new finding and opted to treat the left PSC, which proved successful. This decision underscores the importance of adaptability in our clinical practice.
When Chaos Erupts
The real challenge came at the end of the maneuver. Upon returning to a seated position, the patient experienced a sudden and robust bout of vertigo and nystagmus, almost falling from the table. This kind of delayed reaction can be terrifying for both the patient and the clinician.
This event could be due to one of two things:
A 'pseudo-Tumarkin' phenomenon: Debris may have moved into the common crus and then into the utricle. This can cause a sudden, intense sensation of being pulled or pushed, similar to a Tumarkin-Like Phenomenon, which is a symptom of Meniere's disease.
Debris moving backward in the PSC: The debris may have settled in the endolymph but then moved again, causing a second, albeit brief, episode of vertigo.
The therapist, concerned about a possible canal conversion, wisely performed a Bow Maneuver to rule out not only horizontal canal BPPV but also assess the posterior canals. If the debris were still in the right posterior canal, the Bow Maneuver would have produced a downbeat nystagmus with left torsion. If it were in the left posterior canal, it would have made a downbeat nystagmus with right torsion. While the maneuver was negative, the event left the clinician a bit 'shaken up.' Welcome to BPPV!
Words of Wisdom
This case offers several key takeaways. First, always follow the nystagmus. It is our most important objective sign. If the nystagmus changes direction, so should our treatment plan. Second, be prepared for anything. Traumatically-induced BPPV, like the patient's from a fall in the '90s, can present with more severe and unpredictable symptoms.
Finally, remember to educate your patients about potential post-treatment sensations. We can tell them they will either feel better, feel no change, or feel worse. This simple communication can significantly reduce anxiety and build trust, enhancing the patient's understanding of the process.
This patient's story is a powerful reminder that vestibular rehabilitation is not always a linear process. Sometimes, the most challenging cases are the ones that teach us the most.
Brian Werner, PT, MPT, is the National Director of Vestibular Education & Training at FYZICAL and has been a physical therapist specializing in vestibular and balance disorders for over a quarter of a century.