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Benign paroxysmal positional vertigo (BPPV) can be defined as transient, position-induced torsional, vertical, or horizontal nystagmus with vertigo.

What causes BPPV?

The pathology is based on displacement of the otoconia in the semicircular canal (canalolithiasis) or attachment of debris/otoliths to the cupula (cupulolithiasis). It can be a primary issue or secondary issue from other conditions.
Unfortunately, the underlying pathology is often obscure and the “main” reason is not always known – hence, what we call idiopathic. In this case, we call it idiopathic BPPV.

What factors lead up to having this diagnosis?

Considering most cases of BPPV are idiopathic, there are other factors associated with BPPV. Everyone wants to know “why” they have this diagnosis and as healthcare professionals, we can’t always pinpoint one specific reason. But, usually there are several reasons that then “overload” your system and cause a “spill-over” effect —- which means your body can’t compensate any further and you get symptoms.

Here is a list of 18, yes 18, factors associated with BPPV! 

  1. Aging
  2. Migraine
  3. Meniere’s Disease
  4. Trauma (such as car accident, concussion, whiplash)
  5. Infection
  6. Vestibular Neuronitis
  7. Idiopathic sudden sensorineural hearing loss
  8. Sleeping habits
  9. Osteoporosis and vitamin D insufficiency
  10. Hyperglycemia and diabetes mellitus
  11. Chronic head and neck pain
  12. Vestibule or semicircular canal pathology
  13. Pigmentation disorders
  14. Estrogen deficiency
  15. Neurological disorders
  16. Auto- immune, inflammatory, or rheumatologic disorders
  17. Familial or genetic predisposition
  18. Allergy
Wow, that’s a lot of factors that could lead to you having BPPV!

What does all of this mean for me if I treat BPPV and even other dizzy/vertigo patients?

Vestibular Therapy to Treat Cervicogenic Dizziness
Basically, this means that the well-rounded treatment is more than just “a manuever”. Yes, we can all knock this out and do a pretty solid job with it!  It is the more “complicated” cases that we aim for and can help the most.
Overall, we recommend getting trained in Vestibular Rehabilitation and Upper Quarter Manual Therapy to fully address these patients.  Also, take the time and training to examine their symptoms and discuss lifestyle factors and other strategies to not only prevent BPPV from having again but overall, address the entire body and give it all to your patients.

How does BPPV relate to Cervicogenic Dizziness?

For this article and our specialization under the realm of Cervicogenic Dizziness from Cervical Arthrogenic and Myofascial pain, I like to address 2 of the 18 points above — numbers 4 and 11.
#4 Trauma (such as car accident, concussion, whiplash)
We consider someone who has had trauma under the realm of “double entity”.  This means that there are at least 2 systems involved (i.e. inner ear and neck pain).  This is more common than generally Cervicogenic Dizziness is identified in the literature and quite frankly, we find some type of neck disturbance in pretty much every single one of these patients.
#11 Chronic head and neck pain
This coincides well with Trauma above but may need more explaining to the patient as there is not one single type of injury.  This is what you can consider to be more of a single entity instead of just BPPV, but coincides in at least 70% of our BPPV patients.  As we discuss in our clinic and courses, we recommend treating BPPV first via canalith repositioning manuevers, but adjunct it with manual therapies and exercises for the neck to fully treat the whole system.

You can learn more about the screening and treatment process of Cervicogenic Dizzinesss through Integrative Clinical Concepts, where the authors (husband–a manual therapist a wife—a vestibular specialist), teach a very unique course combining both the theory and practice of vestibular and manual principles in their 2-day course.  
Pertinent to this blog post, the 2nd day includes the “Physio Blend”, a multi-faceted physiotherapist approach to the management of Cervicogenic Dizziness, which includes addressing the articular and non-articular dysfunctions of the neck; as well as graded exercise, vestibular and sensorimotor approaches. 
If you would like to host a course for your staff (either a vestibular, neuro, sports or ortho clinic), please do not hesitate to contact me at harrisonvaughanpt@gmail.com for more information.

AUTHORS

Harrison N. Vaughan, PT, DPT, OCS, Dip. Osteopracic, FAAOMPT    
Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts
Danielle N. Vaughan, PT, DPT, Vestibular Specialist  
Instructor: Cervicogenic Dizziness for Integrative Clinical Concepts

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With many now working from home, how can we keep well?



Part 1 is available here.
Something deep in me (and many of you) has driven pursuit of knowledge, yet with every new thing I learn, there is this underlying feeling, urge, that recognizes the available pieces do not fit together in a meaningful way and that simply pursuing more knowledge mindlessly is, to some extent, a dead-end road. Given enough time, anyone who has extensively explored movement and pain science would also start to feel the urge to look for new knowledge to serve as another patch and to provide another fix toward our insatiable addiction to gain more and more knowledge that might once again temporarily satisfy us. Unfortunately, this process can lead to endlessly spinning of cognitive wheels in new territories with little reward of fulfillment after spending enough time there. Some just give up and call it “good enough,” make do with their knowledge base and do what they can with it and feel their clients will either get what they’re giving them or not. Many others, particularly those early in their careers will continue to be unsatisfied. 

While working through an ACT Intensive course led the creator of Acceptance and Commitment Therapy (ACT), Steven Hayes, we were introduced to several “core yearnings” which form some of the functional basis of ACT. One of these yearnings I believe best describes the urge for things to make sense, and that is the “yearning for coherence.” In the course, this yearning was an introduction to Relational Frame Theory (RFT), which is a working model of language and behavior (we will discuss this further and it’s valuable role for working with movement behavior in subsequent posts), but for the purpose of this first series, we are stepping back further and looking at  “yearning for coherence” as our entry point addressing a bigger picture of our desire for things to make sense. This recognition of my own yearning for coherence required me to follow Hayes's advice to look at Stephen Pepper’s work on “World Hypotheses,” or world viewpoints, as a place to begin to make steps toward a sense of coherence.  In this process, it is important to note that coherence in a literal sense is not achievable, but coherence in a functional sense is sustainable, workable, and “liveable.” To recognize, understand, and firmly place your feet in one world viewpoint is necessary to develop a sense of coherence, yet most of us have no idea where we stand. In observation of this in myself, past and current colleagues and clients, it has become very clear that most of us are not fully aware of our current world viewpoint, and if we believe we have one, it is likely an incomplete awareness at best. This makes our current working viewpoint unstable ground to begin with, and our efforts to create a new viewpoint out of two distinctly different world views, let alone inadequately developed viewpoints, is further broken when creating “something in the middle” of two perspectives. Creating yet another cobbled together viewpoint which will fail to withstand minimal scrutiny. We then keep throwing knowledge on top of this shaky ground hoping somehow things will fall into place and finally “make sense” , but instead we get further convolution, poor translation, and of course, arguments that are based more on the viewpoint, than on the content of the argument. Content-based on language, which as we will discuss later, lends to it’s own complications, but for now I best leave this post with the following:
“Hold language lightly even the things called facts because they are built only on one part of your interactions..” Stephen Hayes

How can we even define this for ourselves and our patients? Find out in Part 3 next week!
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The use of patient-rated outcome measures (PROM), often in the form of questionnaires, is a key part of our evaluation and re-evaluation. They play an important role in documenting activity limitations, levels of disability, quality of life, response to interventions and they help provide a quantifiable measure of subjective complaints.
As our knowledge of chronic pain broadens, we are beginning to appreciate that there are modifiable risk factors that contribute to the development of long term pain and disability. For example, fear avoidance beliefs and behaviours, fear of movement, high levels of anxiety and depression, low satisfaction with work and catastrophization beliefs. Several outcome measures are currently available to clinicians to help guide their clinical reasoning by identifying these risk factors and dig deeper into how they play a part in the patient’s pain presentation. The purpose of this blog is to look specifically at outcome measures and explore how they guide our patient management.

START BACK QUESTIONNAIRE

This is a tool used to match patients to treatment packages with the hope of reducing disability from back pain, reduced time off work and reduced medical usage costs. Originally designed in the UK for doctors to identify what treatment path patients may require. It has been adopted in Physiotherapy practice to identify risk factors for long term disability for low back pain and the need for additional input (pain psychology).
This questionnaire is easy to use, simple to complete and is a screening tool to identify risk factors associated with the development of long term disability due to back pain (biomedical, psychological, and social).
Each question assesses a different domain of pain:
  • Question 1 & 2 are exploring physical pain, radicular pain and the presence of widespread pain - which might lead you to administer the central sensitizing inventory
  • Question 3 & 4 look at level of disability in ADLs (activities of daily living)
  • Question 5 Fear Avoidance - which might lead you to administer the Fear Avoidance Beliefs Questionnaire or Tampa Kinesiophobia Scale
  • Question 6 Anxiety
  • Question 7 Catastrophizing - which might lead you to administer the Pain Satastrophizing scale
  • Question 8 Depression
  • Question 9 Overall bothersomeness
It is a 9-item tool with each answer agree/disagree
  • <3 low risk
  • >4 look at scores 5-9
    • If <3 medium risk
    • If >4 high risk and would benefit from 6 x 1:1 60 minute PT sessions with cognitive behavioural therapy and pain neuroscience education
One of the downfalls of this screening tool is that it is not used to re-evaluate patient risk. It does however, have an extended form that has been created to give a scale from 0-10 for each answer. This extended form can provide a number for each question and a total, that can be used in reassessment. I did not learn of a meaningful significant difference suggested for this extended scale, but it does allow for some measure of change. The cut off points for high risk on this extended questionnaire are listed for each question below:
  • Leg pain > moderate
  • Shoulder/neck pain >slightly
  • Dressing >5
  • Walking >5
  • Fear >7
  • Worry >3
  • Catastrophsing >6
  • Mood >7
  • Bothersomeness > Very
Prior to researching this questionnaire, I didn’t know that an extended form existed and always thought it was little silly to just administer the screening tool once so that a degree of risk could be associated with the case. I then learnt aside from selecting treatment packages, it was also intended to provide feedback to patients about their risk of long term disability (again something I had not done before and now do). For example, you might say to a patient “that even though they have pain, they are at low risk of developing long term disability”. Or, “based on the story you have told me and the score on this test, I might recommend a more comprehensive treatment approach”. After understanding the use and value of this questionnaire, I have been far more agreeable to use it to create helpful discussions with patients about the chronicity of their symptoms and the need for further assessment (fear avoidance, anxiety etc) or referral for additional help in treatment (pain psychology) and patients have been far more receptive to these ideas because it is not just “my impression” but what we can interpret from the information on a standardized measure.

NEUROPHYSIOLOGY OF PAIN QUESTIONNAIRE

This is a great questionnaire developed by Body in Mind to assess a patient’s current understanding about pain neurophysiology. It provides an overall score of true/false answers and can be approached to cover each question (relating to a key topic) as a starting point for educating patients about pain. Patients’ understanding of their pain will influence their experience of pain, especially in chronicity. The NPQ provides important information about patients’ understanding of their pain. You can choose to use this questionnaire to:
  • To measure patients’ knowledge of pain
  • To determine where patients require further pain education
  • To evaluate effectiveness of pain education sessions
  • To evaluate clinician understanding of current concepts in pain physiology
I was not able to find information about a cut-off score, significant change score, and believe that the goal is to educate your patient in all incorrect answers until they score 100%. Personally, I have always been daunted by the idea of educating patients about chronic pain. There are two fantastic resources that I commonly recommend to patients: Explain Pain and Why do I hurt, but when you look at these approaches, it often involves teaching someone all the content. So I ask myself, where should I start to really maximize patient engagement and learning? And this questionnaire is my answer. It tells me where to begin the conversation, where to direct the patient to further their understand and how to individualize a pain neuroscience education approach.

CENTRAL SENSITIZATION INVENTORY

The CSI is a self-reported outcome measure designed to identify patients with symptoms of central sensitization or central sensitisation syndromes (CSS). If you find it complicated in the clinical setting to differentiate pain symptoms and interpret the findings of your subjective and objective examination, perhaps consider using this questionnaire to confirm/refute your clinical impressions. Another way to approach this questionnaire is that if you suspect your patient has signs of central sensitisation and wish to communicate these findings with external providers, it helps to give a degree of severity that others can relate more easily to.
Part A: 25 Q’s – each question is scored 0-4 with a total score of 100
Part B: Diagnosis of CSS
  • 0-29 subclinical
  • 30-39 mild CS
  • 40-49 moderate CS - Score >40 indicates the presence of central sensitisation
  • 50-59 severe CS
  • 60-100 extreme CS

TAMPA SCALE FOR KINESIOPHOBIA

The Tampa Scale for Kinesiophobia (TSK) was designed by Miller and colleagues in 1991, in an attempt to quantify the extent of kinesiophobia in individuals.
  • The questionnaire has 17 questions, with a short form of 11 also available.
  • The therapist must then invert the scores of question 4, 8, 12 and 16, for example if the patient scores 1 on question 4, this must be counted as a score of 4.
  • Total score of 68
  • Most authors agree that a score greater than 37 shows high levels of kinesiophobia (Vlaeyen et al., 2016).

PAIN CATASTROPHIZING SCALE

Catastrophization is currently defined as “an exaggerated negative mental set brought to bear during actual or anticipated painful experience” (Sullivan et al, 2001). The PCS was developed in 1995. Attention to pain symptoms is one mechanism that leads to catastrophizing and the development of chronic hyperalgesic state. Catastrophizing directly impacts endogenous pain modulation mechanisms. The PCS was developed to identify patients with these beliefs in the hope of recognizing psychosocial contributors to chronic pain and delayed recovery.
  • Rumination – Q 8,9,10,11
  • Magnification – Q 6,7,13
  • Helplessness – Q 1,2,3,4,5,12
It takes 5 minutes to complete and score with a total of 13 items.
Internal consistency of 0.87.
Scores range from 0-52 with the cut off as 30 (representing the 75%).
If score >30
  • >70% remain unemployed >1 year
  • >70% described themselves as totally disabled for work duties
  • 66% also score with moderate depression.

FEAR AVOIDANCE BELIEFS QUESTIONNAIRE

There is little evidence to support that pain severity is related to level of disability. But, fear avoidance beliefs are correlated with levels of disability. Increased FAB = reduced RTW. Therefore FABQ measures how FAB contributes to LBP and resulting disability (identifying prolonged disability). I also find it very helpful to understand the breakdown between daily activities and work-related activities as it might help direct treatment approaches for functional re-training and activity modification.
There are two subsets
  • Fear avoidance beliefs about work Q 6,7,9,10,11,12,15
    • High score 42, cut of >34
  • Fear avoidance beliefs about physical activity Q 2,3,4,5
    • High score 24, cut off >15
  • Therefore you do not score question 1,8,13,14,16
  • Even though there are 16 questions, the total score is 66.

CONCLUSION

It is common for patients to develop survey-fatigue and frustration towards the continued implementation of questionnaires and as clinicians we might contribute to this by not taking the time really evaluate the outcome of the questionnaires. Beyond the cut off score for high risk, are you discussing the answers to the questions with patients, seeking clarification in our understanding of the answers, and providing further information about how these answers can help develop a more thorough and individualized treatment plan?
I would urge you to change your perspective, these are not a waste of time, they are valuable ways to measure different domains of the biopsychosocial contributions to pain. Ask yourselves, what does this questionnaire tell me about the patient that I didn’t previously know? In answering this question, you may discover a treatment pathway that is beyond your scope of practice or resources within your practice. Ultimately it will likely lead to improved patient outcomes and satisfaction with care.

Sian Smale is an Australian-trained Musculoskeletal Physiotherapist. Sian completed her Bachelor of Physiotherapy through La Trobe University in 2009 and in 2013 was awarded a Masters in Musculoskeletal Physiotherapy through Melbourne University. Since graduating from her Masters program, Sian has been working in a Private Practice setting and writing a Physiotherapy Blog "Rayner & Smale". Prior to moving to San Francisco, Sian worked at Physical Spinal and Physiotherapy Clinic and has a strong background in manual therapy and management of spinal spine, headaches and sports injuries. Since moving to the Bay area, Sian has become a Physiotherapist for the Olympic Winter Institute of Australia, traveling with their Para Alpine teams. Sian currently works full time at TherapydiaSF as a physical therapist and clinical pilates instructor. 


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Want an approach that enhances your existing evaluation and treatment? No commercial model gives you THE answer. You need an approach that blends the modern with the old school. 
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1️⃣. Reduced chance of dying from cardiovascular disease (Lee et al 2014)
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3️⃣. Decreased disability later in life (Chakravarty et al 2008)
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💻Ref: .
👉🏻Chakravarty EF, Hubert HB, Lingala VB, Fries JF. Reduced Disability and Mortality Among Ageing Runners: A 21-Year Longitudinal Study. Arch Intern Med. 2008;168(15):1638–1646
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👉🏻Lee DC, Pate RR, Lavie CJ, Sui X, Church TS, Blair SN. Leisure-time running reduces all-cause and cardiovascular mortality risk [published correction appears in J Am Coll Cardiol. 2014 Oct 7;64(14):1537]. J Am Coll Cardiol. 2014;64(5):472–481.
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✋🏻TAG a run bud you know this would interest or help ✅


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