Benign Paroxysmal Positional Vertigo: A Case Study

Original Editor - Ben Chang as part of the Queen's University Neuromotor Function Project Top Contributors - Stephanie Pilon, Ben Chang, Cindy John-Chu, Adam Hanton-Fong, Rishika Babburu, Chris Sweeney, Connor DAngelo, Brooke Chamberland and Uchechukwu Chukwuemeka

Client Characteristics

The patient is a 55 year old male who lives a relatively sedentary lifestyle and works as an accountant. He has high blood pressure which has been controlled by 40mg of Diovan daily. The patient also has high cholesterol in which he takes 5mg of Crestor daily to help control. The patient enjoys gardening, driving with his wife and walking his dog. He complains of nausea, dizziness and the feeling of the room spinning. He is planning on retiring and is nervous about not being able to do what he wants and enjoy his retirement because of his symptoms. He first noticed symptoms 2 weeks ago while turning his head quickly while driving. Following the onset, medications did not help symptoms and therefore he has since been getting treatment for BPPV. Sleeping has become increasingly difficult as any time he lays down he begins to feel dizzy.

Examination Findings

Subjective

History of Present Illness

His symptoms first started on April 22nd, 2022, while he was shoulder checking to switch lanes while driving. He went to see his Family Physician on April 24th, 2022 who referred him to physical therapy. Currently, his chief complaints are dizziness, a feeling of his surroundings "spinning", and occasional nausea.

Past Medical History

This patient was diagnosed with hypertension and hypercholesterolemia in December 2015. He has also been experiencing headaches for the past three months (about one headache per week, lasting longer than 30 minutes)

Medications

Currently, this patient takes 40mg of Diovan daily to control his high blood pressure and 5mg of Crestor daily to control his high cholesterol. He also takes 1 Gravol liquid gel capsule (50mg) every 4 hours when he begins feeling symptomatic.

Functional History

The patient has mentioned that he is unable to perform activities that he usually enjoys such as gardening, driving, and walking his dog. Although he can perform basic activities of daily living independently such as getting dressed, eating, walking short distances, using the washroom, and bathing, he has more difficulty with instrumental activities of daily living such as shopping, housework, and cooking. Aggravating activities include rolling out of bed and bending over. Pain is alleviated when lying on his back with his head elevated using multiple pillows.

Social History

This patient works full-time as an accountant. He lives in a bungalow in a small neighbourhood with his wife and golden retriever. All of the rooms that he needs are on the main floor (i.e. bedroom, kitchen, bathroom), with the top floor mainly used for storage and guest bedrooms. His two adult children (aged 30 and 27) live within a 15 minute drive and visit often. In his free time, he enjoys gardening, walking his dog, and going on drives into the city with his wife. He has never been a smoker and does not use any recreational drugs, but will have the occasional beer or glass of wine on the weekend with his wife and kids. He reports feeling stressed about getting tasks done at work due to having to take frequent breaks.

Family History

When asked, the patient could not recall any family members having BPPV. However, he did report that his father also has hypertension and suffered a heart attack at the age of 65. His mother is also currently exhibiting signs of early dementia, although this has not been officially diagnosed yet. No other family history can be recalled by the patient.

Outcome Measures

The outcome measures chosen to assess this patient were the Dynamic Gait Index, Dizziness Handicap Inventory, and Activities-specific Balance Confidence Scale. He obtained a baseline score of 18 on the Dynamic Gait Index, a baseline score of 37 on the Dizziness Handicap Inventory, and a baseline score of 44% on the Activities-specific Balance Confidence Scale.

Clinical Hypothesis

Problem List

Goals:

Short-term Goals:

• The pt wants to go 48 hours without any provocation of symptoms by the second week of treatment (14 days post-treatment).
• The patient wants to improve his dynamic gait index score to 20 by the 10th-day post-treatment.

Long-term Goals:

• Pt wants to be able to drive to work without feeling dizzy checking his blindspots (30 min drive) in 6 weeks.
• Pt wants to be able to play fetch with his dog for 20 minutes without an onset of symptoms from picking up the ball in 8 weeks.

Intervention

Upon the next treatment visit, vestibular rehabilitation was performed. The patient was taught Cawthrone-Cooksey exercises with a focus of training the eyes to move independently of the head. This consisted of performing exercises by gradually building up from one exercise to the next. Having the patient rate the severity of symptoms during the exercise on a scale of 0-5 (where 0 = no symptoms and 5 = severe symptoms) to pace the progression of exercises. Exercises may include gaze training, balancing in day-to-day situations, improving coordination (catching and throwing a ball, walking on incline, stooping) (14).

Outcome

After six weeks of treatment, this patient experiences a great degree of improvement. First, his Dynamic Gait Index post-treatment score is now 22, compared to his baseline score of 18. This is considered a significant change as minimal detectable change is expected to be approximately 4 points. This also means that this patient is no longer considered to be a fall risk as their score is now higher than 19/24.

Additionally, his Dizziness Handicap Inventory post-treatment score improved to 14, compared to his baseline score of 37 which surpasses the estimated minimal clinically important difference of 4 points and the minimal detectable change of 17 points. This means that he is no longer considered to have a handicap associated with their dizziness.

Furthermore, his Activities-specific Balance Confidence Scale post-treatment score is now 86%, compared to his baseline score of 44%. This surpasses the estimated minimal detectable change of 15 points. This also means that he is now considered to have a high level of functioning.

In addition to outcome measures, the patient now only reports mild dizziness during specific tasks, but does not feel like the room is spinning around them and no longer feels nauseous. He is also now able to do all the tasks he was able to do prior to the onset of symptoms such as gardening and driving. He is very motivated and continues to work on his balance training at home.

Due to our patient's current functional status as well as their high motivation levels, we believe they are ready for discharge. In order to prepare them for discharge, we will have a meeting with out patient along with any family members they want to include in this process (ex. spouse) to make a plan together. We will have the patient continue their at-home balance management program and we will also provide him with resources to educate him on his condition as well as positions and movements that might alleviate or aggravate symptoms. We will explain to him that although his scores have improved tremendously since beginning treatment, there is always room for improvement. We will make a follow-up appointment for three months from the discharge date with a goal of near-perfect scores on the Dynamic Gait Index, Dizziness Handicap Inventory, and Activities-specific Balance Confidence Scale.

At this time, we do not believe that referral to other health care providers is necessary as our patient is highly functional with minimal symptoms. However, we will ensure to let the patient know that if symptoms become worse or they experience any other symptoms, they should seek help from their Family Physician, a neurologist or an otolaryngologist as soon as possible.