Rajiv Gandhi University of Health Sciences, Karnataka,
Bangalore.
ANNEXURE- II
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / NAME OF THE CANDIDATEAND ADDRESS / SULE GAURAI SUHAS
A/103, ROYAL PARK, 66 KV ROAD, AMLI, SILVASSA, DADRA AND NAGAR HAVELI, PINCODE: 396230
2 /
NAME OF THE INSTITUTION
/ SHREE DEVI COLLEGE OF PHYSIOTHERAPY, MAINA TOWERS, BALLALBAGH, MANGALORE- 5750033 /
COURSE OF STUDY AND SUBJECT
/ MASTER OF PHYSIOTHERAPY( NEUROLOGICAL AND PSYCHOSOMATIC
DISORDERS )
4 /
DATE OF ADMISSION TO COURSE
/ 01st JUNE 20115 /
TITLE OF THE TOPIC:
“TO STUDY THE EFFECTIVENESS OF CANALITH REPOSITIONING MANEUVER IN BENIGN PAROXYSMAL POSITIONAL VERTIGO.”6 / BRIEF RESUME OF THE INTENDED WORK:
6.1 Need for the study:-
Vertigo occurs when an imbalance or disturbance in vestibular function is present anywhere in the peripheral or central vestibular system and it is associated with several different disorders. A common form of vertigo is benign paroxysmal positional vertigo (BPPV). BPPV can be defined as brief, episodic, and transient vertigo induced by a rapid change in head position, associated with a characteristic paroxysmal positional nystagmus.1 Benign paroxysmal positional vertigo (BPPV) is a relatively frequent entity in otolaryngology, and its impact increases as age progresses. Its rate of
occurrence ranges between 10.7 and 64 cases / 100,000 population per year, and increases by approximately 38% per decade of life.2 Women are more affected than men, 2:1 ratio.3
There are two classical theories about the pathophysiology of this disease. The first was cupulolithiasis (Schuknecht,1969), according to which fragments of otoliths, typically found in the utricle and saccule, moved into the posterior semicircular duct (PSD). Later, in the early nineties, it was postulated that at other times the otoliths could become “trapped” within the PSD and would be the source of symptoms (canalithiasis).2
The Dix-Hallpike test confirms the diagnosis. The test is performed by moving the patient rapidly from a sitting position to a position with the head hanging 45° below the horizontal , with each ear alternately undermost. A positive response is considered a burst of vertigo accompanied by a characteristic nystagmus. The nystagmus starts after a short latent period and typically beats towards the undermost and affected ear, with a torsional component clockwise when following a leftward movement or counterclockwise when following a rightward movement. Typically, an upbeating component is superimposed, resulting in a mixed torsional-vertical eye movement. Intense vertigo in coexistence with this pattern of nystagmus may easily establish the diagnosis.1
Treatment for BPPV includes expectant observation, medication, operative procedures and physical treatment. Numerous physical treatments for BPPV have evolved over the past two decades, inspired by the pathophysiological theories cupulolithiasis and canalithiasis. Brandt and Daroff, assuming that cupulolithiasis is the underlying cause of BPPV, used sequential repetitive positionings to mechanically dislodge and disperse cupular deposits. Norre and Beckers applied vestibular habituation training, a series of provocative manoeuvres developed by Cawthorne and Cooksey to stimulate central compensation for a vestibular deficit, specifically for BPPV. Semont and Toupet later attempted to simplify Brandt and Daroff s repetitive positionings into a single maneuvre called the Liberatory maneuvre or Semont manoeuvre. Epley endeavoured to develop a better tolerated physical treatment for benign paroxysmal positional vertigo. His canalith repositioning procedure marked the beginning of positioning maneuvres based on the premise that canalithiasis causes benign paxoysmal positioning vertigo.4 There is a sure need to assess the effectiveness of canalith repositioning maneuver and also to rule out whether canalith repositioning maneuver can be a choice of treatment for patients suffering from benign paroxysmal positional vertigo.
The Dizziness Handicap Inventory (DHI) is a validated, self-report questionnaire which is widely used as an outcome measure in those patients presenting dizziness.5 The DHI provides a useful, reliable and valid assessment of self-perceived handicap associated with acute dizziness. In addition to the results of the reliability and validity, the additional advantages of the DHI include its simplicity, the relevance of its items and its capacity to take into account all those health components described by the WHO’s International classification of Functioning, Disability and Health. The DHI is a reliable, valid and clinically useful tool to measure the self-perceived handicap associated with the dizziness symptoms triggered by a variety of causes. The DHI may be used by clinicians not only to evaluate the dizziness handicap, but also to demonstrate functional outcomes in those patients presenting dizziness following surgery.
6.2 Objective of the study:-
· To study the effectiveness of canalith repositioning maneuver in benign paroxysmal positional vertigo.
6.3 Hypothesis:-
Alternate hypothesis
Canalith repositioning maneuver is effective for treating patients suffering from benign paroxysmal positional vertigo.
Null hypothesis
Canalith repositioning maneuver is not effective for treating patients suffering from benign paroxysmal positional vertigo .
6.4 Review of literature:-
TP Chan conducted study in Hongkong on 88 newly admitted hospitalised patients who complained of having dizziness or having had dizziness two weeks before admission. In the study using outcome measure as presence of the pathognomonic nystagmus of benign paroxysmal positional vertigo. The study concluded that out of 88 patients, five had benign paroxysmal positional vertigo, all of the posterior type. None had the horizontal or anterior types. The frequency of BPPV was 6% (5/88) with 95% confidence interval of 1 to11%.6
M von Brevern et al conducted study on general adult generation of Germany. Screening of 4869 participants was done from the German National Telephone Health Interview Survey 2003 (response rate 52%) for moderate or severe dizziness or vertigo, followed by validated neurotological interviews (n = 1003; response rate 87% ). In the study it was found that BPPV accounted for 8% of individuals with moderate or severe dizziness/vertigo. The lifetime prevalence of benign paroxysmal positional vertigo was 2.4%, the 1 year prevalence was 1.6% and the 1 year incidence was 0.6% and thereby concluding that BPPV is a common vestibular disorder leading to significant morbidity, psychosocial impact and medical costs.7
Burak O. Cakir et al conducted study on patients having benign paroxysmal positional vertigo. The diagnosis was done on the basis of Dix-Hallpike test. The patients were divided into 2 groups and canalith repositioning maneuver was performed on them as treatment of choice. The study concluded that Dix-Hallpike test is one of the efficient mean to establish the diagnosis of BPPV and canalith repositioning maneuver effectively treat patients having BPPV.8
Suwicha Isaradisaikul et al conducted study on sixty patients with typical history of benign paroxysmal positional vertigo. In the study the diagnosis for BPPV patients was done on the basis of Dix-Hallpike maneuver and the brief head turn maneuver. The study concluded that patients with typical history of BPPV can be evaluated with Dix-Hallpike maneuver and the brief head turn maneuver .9
Sheikh Saadat Ullah Waleem et al conducted study on 44 patients having BPPV on the basis of their history and Dix-Hallpike test. In the study the patients were grouped as 22 each in A and B and were give placebo treatment and Epley maneuver respectively. After the end of 1st and 2nd week based on patient’s history and Dix-Hallpike test it was observed that those patients in group B had no symptoms after Epley maneuver on the contrary group A had no much improvement treated with placebo. Thus, the study concluded that Epley maneuver is a much better form of management for benign paroxysmal positional vertigo.10
David A. Froehling et al conducted study on the effectiveness of canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo. The study was done among 50 patients with history of positional vertigo and unilateral positional nystagmus based on Dix-Hallpike maneuver. Twenty-four and twenty-six patients were treated with canalith repositioning procedure and Sham maneuver respectively. The conclusion stated that canalith repositioning procedure is effective treatment of BPPV.11
Robert C. O’Reilly et al conducted study on the efficacy of canalith repositioning maneuver in patients presenting with idiopathic benign paroxysmal positional vertigo. The study was done among 41 patients with primary BPPV and 31 patients with secondary BPPV to evaluate their symptoms before and after CRM using retrospective administration of Dizziness Handicap Inventory ( DHI ).The conclusion stated that canalith repositioning maneuver is highly effective in all forms of BPPV.12
Whitney SL et al conducted study on 383 patients to determine whether Dizziness Handicap Inventory (DHI) could assist in the screening of benign paroxysmal positional vertigo. In the study it was found that individuals with BPPV had significantly higher mean scores on the DHI and concluded items on the DHI appear to be helpful in determining the likelihood of an individual having the diagnosis of benign paroxysmal positional vertigo.13
No Hee Lee et al conducted study on 135 patients having benign paroxysmal positional vertigo. In the study patients were treated with canalith repositioning maneuver using Dizziness Handicap Inventory (DHI) as outcome measure. The study concluded that DHI is efficient, valid and reliable scale can be used for patients suffering from BPPV for comparing pre as well as post maneuver improvement.14
7 / MATERIALS & METHOD:
7.1 Source of data:-
1. Government Wenlock District Hospital, Mangalore.
2. Shree Devi College of Physiotherapy Clinic, Mangalore.
7.2 Method of data collection:-
Patients complaining and with history of dizziness and nystagmus respectively fulfilling inclusion criteria will be asked to sign the consent form for voluntary participation in my study.
Study design : Quasi-experimental design
Sampling : Purposive sampling
Methodology :
Patients complaining of dizziness and nystagmus and diagnosed by physician as suffering from benign paroxysmal positional vertigo are included in the study. The diagnosis is confirmed by Dix-Hallpike test. Dix-Hallpike test procedure is as follows. The patient is positioned in long sitting (sitting on the treatment table with the legs extended). The patient’s head is rotated 45 degrees towards the right. The patient is then lowered into supine with the neck extended 20 degrees over the edge of the treatment table. The position is maintained for 45 seconds. The procedure is then repeated towards the left. If the patient has a positive Dix-Hallpike test, then the patient is guided through a series of movements before being brought back up to the sitting position. The patients diagnosed positive for Dix-Hallpike test are administered the canalith repositioning maneuver for 1 session.
Canalith repositioning procedure for right-sided benign paroxysmal positional vertigo:
· Steps 1 and 2 - are identical to the Dix–Hallpike maneuver.
· Step 2 - The patient is held in the right head hanging position for 20 to 30 seconds.
· Step 3 - The head is turned 90 degrees toward the unaffected side and is held for 20 to 30 seconds before turning the head another 90 degrees.
· Step 4 - The head is nearly in the face-down position and is held for 20 to 30 seconds, and then the patient is brought to the sitting up position.
The patients are asked to complete the Dizziness Handicap Inventory scale before, immediately after and 1 week after their treatment with canalith repositioning maneuver. Comparison is made between the pre and the post maneuver scores of Dizziness Handicap Inventory to elicit the degree of improvement in the patient and effectiveness of the treatment given to the patients. A week after the administration of canalith repositioning maneuver again Dix-Hallpike test is performed on the patients to rule out if any symptom persists or is there recurrence of BPPV.
Inclusion criteria
1. Patients diagnosed by physician as having BPPV.
2. Patients diagnosed having BPPV by Dix-Hallpike test.
3. Patients between age groups of 18-70 years.
4. Patients including both males and females
Exclusion criteria
Patients suffering from:
1. Stroke.
2. Meniere’s disease.
3. Acoustic neuroma / vestibular schwannoma.
4. Parkinson’s disease.
5. Vertebrobasilar insufficiency.
6. Vestibular neuritis (labyrinthitis).
7. Cervical spondylosis.
Statistical analysis
Collected data will be analysed by mean standard deviation paired ‘t’ test and chi square test.
Tools used:
1. Couch.
2. Dizziness Handicap Inventory scale.
Outcome measures:
1. Dizziness Handicap Inventory scale
2. Dix-Hallpike test
7.3 Does the study require any investigations or any interventions to be conducted on patients or other humans or animals? If so, please describe briefly.
Yes.
Patients will be diagnosed using Dix-Hallpike test and receive treatment in the form of canalith
repositioning maneuver.
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
Yes
As this study involves human subjects, the ethical clearance has been obtained from the ethical committee of Shree Devi Of Physiotherapy, Ballalbagh, Mangalore, as per the Ethical guidelines for Bio-medical research on human subjects, 2000, ICMR, New Delhi.
8 /
LIST OF REFERENCES:
1) Stavros G. Korres et al: Benign paroxysmal positional vertigo and its management. © Med Sci Monit 13(6): CR275-282, 2007.2) M.P. Prim-Espada et al: Meta-analysis on the efficacy of Epley’s manoeuvre in benign paroxysmal positional vertigo. Neurologia 25(5):295-299, 2010.
3) Abdul Aziz J Ashoor and Fach Arzt fuer Hals Nasen Ohren (HNO): The Efficacy of Repositioning Maneuver in the Management of Benign Paroxysmal Positional Vertigo. Bahrain Med Bull 32(3), 2010.
4) Gabrielle M van der Velde: Benign paroxysmal positional vertigo Part 11: A qualitative review of non-pharmacological, conservative treatments and a case report presenting Epley's "canalith repositioning procedure", a non-invasive bedside maneuvre for treating BPPV. J Can Chiropr Assoc 43(1),1999.
5) Kurre A et al: Exploratory factor analysis of the Dizziness Handicap Inventory (German version). BMC Ear Nose Throat disorders 10(3), 2010.
6) TP Chan: Is benign paroxysmal positional vertigo underdiagnosed in hospitalised patients. Hong Kong Med J 14:198-202, 2008.
7) M von Brevern et al: Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry 78:710–715, 2007.
8) Burak O . Cakir et al: Efficacy of postural restriction in treating benign paroxysmal positional vertigo. Arch Otolaryngol Head Neck Surg 132:501-505, 2006.
9) Suwicha Isaradisaikul et al: Outcome of the Dix-Hallpike maneuver and the brief head turn maneuver in benign paroxysmal positional vertigo patients. Chiang Mai Med Bull 44(3):101-106, 2005.
10) Sheikh Saadat Ullah Waleem et al: Office management of benign paroxysmal positional vertigo with Epley’s maneuver. J Ayub Med Coll Abnbottabad 20(1), 2008.
11) David A. Froehling et al: The Canalith Repositioning Procedure for the Treatment of Benign Paroxysmal Positional Vertigo: A Randomized Controlled Trial. Mayo Clin Proc 75:695-700, 2000.
12) Robert C. O’Reilly et al: Effectiveness of the Particle Repositioning Maneuver in Subtypes of Benign Paroxysmal Positional Vertigo. Laryngoscope110:1385–1388, 2000.
13) Whitney SL et al: Usefulness of the dizziness handicap inventory in the screening for benign paroxysmal positional vertigo. Otol Neurotol 26(5):1027-33, 2005.
14) No Hee Lee et al: Analysis of Residual Symptoms after Treatment in Benign Paroxysmal Positional Vertigo Using Questionnaire. Otolaryngol Head Neck Surg141(2)232-236, 2009.
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12 / SIGNATURE OF THE CANDIDATE :-
REMARKS OF THE GUIDE :-
NAME AND DESIGNATION OF
11.1 GUIDE :-HARIPRIYA S.
ASSISTANT PROFESSOR,
SHREE DEVI COLLEGE OF
PHYSIOTHERAPY, MAINA TOWERS,
BALLALBAGH, MANGALORE- 575003
11.2 SIGNATURE :-
11.3 CO-GUIDE :-SMITHA D.
ASSISTANT PROFESSOR,
SHREE DEVI COLLEGE OF
PHYSIOTHERAPY, MAINA TOWERS,
BALLALBAGH, MANGALORE- 575003
11.4 SIGNATURE :-
11.5 HEAD OF DEPARTMENT :-DR. VIJAY P.
PRINCIPAL,
SHREE DEVI COLLEG OF
PHYSIOTHERAPY, MAINA TOWERS,
BALLALBAGH, MANGALORE- 575003
11.6 SIGNATURE :-
12.1 REMARK OF THE :-
CHAIRMAN AND PRINCIPAL
12.2 SIGNATURE :-
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