MedBridge Course Review: Vestibular Rehabilitation: Identification and Management of BPPV | Modern Manual Therapy Blog

MedBridge Course Review: Vestibular Rehabilitation: Identification and Management of BPPV

I recently became a MedBridge Affiliate to take advantage of their course offerings that I could study online when I am at work during cancellations or on the road.

MedBridge in general
  • very easy to navigate
  • videos are professional looking 
  • come with course notes that can be downloaded/printed or viewed simultaneously - they change automagically as the instructor is speaking
  • can forward with typically video slider or forward and back arrows per slide, which also automatically restarts video - very convenient for review!
  • small quizzes are given after some chapters for learning purposes only, which is great because I bombed the first 5 question one based on anatomy!
One of the areas I am lacking in treating is Vestibular Rehab. I did some when I was a student and found it interesting, but most of the cervical and TMD courses

Course notes
  • of 253 pts with positive positional tests
    • posterior cancel involvement 4/5
    • 1/5 multicanal involvement or horizontal
    • anterior canal not common
      • rare
      • non-existent
      • "debris" easier falling into the horizontal and posterior canal rather than anteriorly due to the anterior canal not normally being gravity dependent functionally and in lying
  • you learn the reason why you get the bed spins after drinking
  • as a techy, I like the updated metaphors of the canals as accelerometers for your head (the devices that sense acceleration/position in our smartphones)
  • gravity sensation is from the otolithic organs - also linear acceleration, not the hair cells in the canals
  • VOR counter rolls your eyes during head movements, short latency 7-15 ms
  • right roll test
    • + with right beating nystagmus without torsion is horizontal canal
    • + with right beating nystagmus with torsion is posterior canal
  • test patients based on their history based on aggravating factors (ear dependent positions) versus subjective complaints
  • pt's with history of motion sickness more likely to have nausea with BPPV

Mechanisms of BPPV

  • The above mathematical model for BPPV explains why certain conditions may show nystagmus or patients may have complaints immediately, within seconds, or after 30 seconds or longer
    • depending on where the particles fall, they may fall directly into the canal, or hit a wall and then migrate, or hit the initial wall, then fall a bit, then hit another wall, before migrating with movements/head positions

  • cupulolithiasis (1969)- not as common
    • CA particles breaking free from utricle, and getting caught on cupula
    • cupula made heavier by the particles, then in dependent positions, cupula affected
  • canulolithiasis (1992) - debris migrating through semicircular canal
    • charateristics
      • laterncy range: 1-40 sec, typically 3-5 sec
      • nystagmus following the latency
      • reversal of nystagmus
      • temporariliy fatigues with repetition
  • mathematical model (Squires 2004)
    • latency explained b/c particles migrating between the y portion of the canal
    • if the particles hug the wall when falling, then eventually fall into the canal - may need to hold provocative position longer 
    • if the particles fall directly into the canal, immediate Sx reproduction
    • cannot trust 1 negative test - if the history is right repeat the test
  • canulolithiasis creates more pressure because debris is migrating in pieces throughout the canal versus cupulolithiasis - nystagmus is less
  • the tests are position dependent, not acceleration - also for the vast majority of treatments
  • head trauma - displaces particles
  • inner ear disease - secondary BPPV
  • genetic
  • osteoporosis/penia - more likely to have BPPV if lower bone density female > male
  • if you habitually lie with one ear down, more humans tend to sleep on right side, 1.5/1, involved side down more at risk
Tests that are reviewed
  • Hallpike
  • right sidelying test 
  • roll Test - for horizontal canal BPPV
The tests and treatments are reviewed very well. I am a visual learner and Jeff reviews the tests slowly and clearly with a live model; as a great bonus, he also instructs with a 3d model of the canals, showing clearly what happens to the particles as they travel through the canals.
Both the tests and the treatments are done on live patients, and one of them he leaves the audio in of the patient vomiting after testing. This is a purposeful inclusion to remind you to have an emesis container handy while testing these patients.

Overall, I highly recommend taking this course and MedBridge in general as their yearly rate for approved CEUs is very competitive. Since I am also taking the Better Physiology Capnotrainer webinars, I could start this course two weeks ago, and resume exactly where I left off any time, on any device.  

Keeping it Eclectic...


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