Case Report

Evidence-Based Physical Therapy for BPPV

Using the International Classification of
Functioning, Disability and Health Model:
A Case Report
Amy Wahlgren, PT, DPT, MSBS1; Kerstin Palombaro, PT, PhD, CAPS2
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ABSTRACT BACKGROUND AND PURPOSE

Background and Purpose: The model provided by the World
Health Organization’s International Classification of Functioning, Benign Paroxysmal Positional Vertigo
Disability, and Health (ICF) was created to describe, clas- Dizziness accounts for the primary complaint that neces-
sify, and measure function in both health care practice and sitates 5.6 million clinic visits in the United States per year.
research. This model has not been applied to management
of many physical therapy cases, limiting its implementation Of these patients with vertigo, between 17% and 42%
conceptually into practice as a whole. The purpose of this case received a diagnosis of benign paroxysmal positional ver-
report is to illustrate the use of the ICF model in the evidence- tigo (BPPV).1 This condition was first described in 1921 by
based management of posterior canal benign paroxysmal Barany as an “attack” of violent vertigo and nausea occur-
positional vertigo. ring when side-lying and lasting approximately 30 seconds
Case Description: One patient with acute posterior canal
canalithiasis benign paroxysmal positional vertigo was treated prior to abolishment of symptoms. BPPV occurs when free-
using the evidence-based clinical practice guideline for the floating otoconia migrate into 1 of 3 semicircular canals of
diagnosis as well as the ICF framework. the inner ear and either becomes trapped inside the canals
Interventions: Repositioning maneuvers and education were (canalithiasis), or becomes adherent to the cupula of the
provided to ameliorate the relevant body structure and func- semicircular canal (cupluolithiasis). Although symptoms
tion impairments, activity limitations, and contextual factors
related to the patient’s overall functioning and disability. only last up to 60 seconds at a time, 80% of patients experi-
Outcomes: The patient demonstrated complete abolishment of ence rotary nystagmus and 47% complain of a floating sen-
her symptoms, both objectively and subjectively after 3 ses- sation with such activities as rolling over in bed, extending
sions over 4 weeks of care. the cervical spine, and trunk flexion. However, BPPV is
Discussion: The physical therapy community has adopted the thought to be self-limiting with abolishment of symptoms
framework of the ICF because this model has been found to
be effective in illustrating the impact of a patient’s functional within 6 months.2
impairments in terms of activity limitations as well as the role There are several different types of BPPV with poste-
that personal and environmental factors play in the patient’s rior canal BPPV occurring most frequently at a rate of
overall functioning and disability. When using the ICF in tan- 85% to 95% of cases.1 Posterior canal BPPV canalithiasis
dem with evidence-based care, patient outcomes have the is the most common form because this canal is in the
capability to improve at an even greater rate; however, further
research should be completed to discover this potential effect most gravity-dependent position when a person is either
with appropriately designed clinical trials. standing or supine and in order for the otoconia to exit
Key Words: benign paroxysmal positional vertigo, Interna- the canal spontaneously, it must move opposite the gravi-
tional Classification of Functioning, Disability, and Health, tational pull.2 Lateral or horizontal canal BPPV accounts
physical therapy, repositioning maneuvers for the majority of the remainder 5% to 15% of cases,
(J Geriatr Phys Ther 2012;35:200-205.) with other variations including anterior canal BPPV,
multiple canal BPPV, and bilateral multiple canal BPPV
1StRita’s Medical Center, Lima, Ohio. occurring rarely.1
2Widener BPPV can either be classified as primary or secondary.
University Institute for Physical Therapy
Education, Chester, Pennsylvania. Primary BPPV occurs when found in isolation and accounts
The authors declare no conflict of interest. for 50% to 70% of cases whereas secondary BPPV is caused
by another injury or disorder. The most common cause is
Address correspondence to: Amy Wahlgren, PT, DPT,
MSBS, St Rita’s Medical Center, 830 W High St, Suite 150, head trauma, which can account for up to 17% of cases of
Lima, OH 45801 ([email protected]). BPPV; less common causes include viral labyrinthitis with
DOI: 10.1519/JPT.0b013e318247a243 15% and Ménière disease at 5% of cases.2 The prevalence

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 Case Report

of BPPV ranges from 10.7 to 64 per 100 000 population an environmental factor is either a facilitator or barrier.4
with a lifetime prevalence of 2.4%. BPPV has been found Implementation of the ICF in a case study involving physi-
to be the most common vestibular disorder across the lifes- cal therapy for low back pain found that treatment was
pan with the most common age of onset between 50 and prioritized whereas another study on physical therapy for
70 years. The recurrence rate of BPPV has been estimated patellar dislocations found improved decision making as
at 15% per year; however, this rate increases if BPPV is due the patient’s contextual factors were taken into account.6,7
to head trauma.1 The gold standard for BPPV diagnosis By use of the ICF, care is ensured to be patient-centered,
includes patient history and eye findings during positional which improves outcomes and efficiency as well as allows
testing, specifically Dix-Hallpike for posterior canal.2 A comparison for international research. Minimal literature
positive result for the Dix-Hallpike includes a brief latency is available about implementing the ICF into physical
of symptoms for 1 to 5 seconds, followed by nystagmus therapy practice, which can make the process daunting to
featuring an upbeating motion as well as rotation toward initiate. The purpose of this case report is to illustrate the
the dependent ear of up to 60 seconds. With repeated test- use of the ICF model in the evidence-based management
ing, the signs become less intense and fatigue entirely. The of posterior canal BPPV.
Dix-Hallpike test has a sensitivity of 79% and specificity
of 75% with a positive likelihood ratio of 3.17, making it CASE DESCRIPTION
minimally useful for clinical decision making.3
Patient History and Systems Review
The most significant consequence of untreated BPPV,
especially in older adults, would be the resultant increased History
likelihood of falls due to a reduced sense of equilibrium. The patient was a 74-year-old woman who presented with
Falls with increasing age have negative consequences, dizziness, which she stated had been present for 2 months
including fractures, brain injury, and institutionalization, in duration. She reported that the spinning sensation first
which can lead to significant costs for both the individual occurred while watching her grandchild play a video
and society.1 Thus it is clear why prompt appropriate diag- game. She admitted the symptoms of spinning and nausea
nosis and treatment of BPPV is crucial. were worst when getting in and out of bed, but they also
occurred while looking down to read or when she looked
International Classification of Functioning, up to change a light bulb. Although she described the sensa-
Disability, and Health tion as severe, she admitted the symptoms lasted less than
The World Health Organization’s International Classification 1 minute before abolishing. She stated that if she avoided
of Functioning, Disability and Health (ICF) is the culmi- head movements and changes in position, such as laying
nation of efforts that began in 1993 by the active par- flat in bed, she could avoid her symptoms. She denied any
ticipation of 1800 experts from 65 countries, which was hearing loss, tinnitus, headaches, or neck pain. She did not
eventually accepted in 2001 as the international standard have a history of hypertension nor did she present with any
to describe and measure health and disability. The goal of orthostatic hypotension. Other medical conditions included
the ICF was to develop a unified and standard language a recent hernia repair and cardiac catheterization. She cur-
and framework for the analysis of all aspects of health rently was taking the prescription Pravastatin for hyper-
as well as some health-related wellness aspects. The ICF cholesterolemia. The patient was retired; however, she had
is laid out in a manner where there are 2 subgroups for guardianship of her 5-year-old granddaughter whom she
each of the 2 main divisions of the model. The first part was actively raising. The patient’s stated goal was to abol-
of the ICF, functioning and disability, consists of body ish her dizziness to allow greater ease with getting in and
functions and structures and activities and participation.4 out of bed and return to reading to her granddaughter.
Body functions and structures are analyzed in terms of
change in physiologic function and anatomic structure. Examination
Activities are considered the execution of tasks or actions; As the patient did not meet the typical criteria for other
participation is defined as the involvement in life affairs.5 otologic or neurologic disorders (Table 1), the differen-
The second part of the ICF, contextual factors, consists tial diagnosis was reduced to posterior canal BPPV of
of environmental and personal factors.4 In terms of the the canalithiasis type. It was postulated that because of
ICF, functioning is considered the positive aspect of each the improper location of the otoconia in the semicircular
component and disability is deemed the negative aspect.5 canals, the patient experienced dizziness, vertigo, nausea,
Each of these domains are further broken down into cat- decreased balance reactions, and increased risk of falling.
egories, which are the units of the ICF classification. These Because of this, an examination plan was made, which
categories and their respective codes are then selected included the Dizziness Handicap Inventory (DHI) and the
to describe the individual’s health-related states and are Dix-Hallpike maneuver.
given numeric codes, which specify the magnitude of the The patient was issued the DHI, which is a 25-item
functioning or disability of that category to the extent that scale with scores that can range from 0 to 100; a score of 0
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Table 1. Differential Diagnosis of Benign Paroxysmal Positional Table 2. Clinical Practice Guideline for Benign Paroxysmal
Vertigo (BPPV) Positional Vertigo (BPPV)—As Utilized for This Patient Case1
Disorder Symptoms 1. Diagnosis of posterior canal BPPV via Dix-Hallpike maneuver
Otologic disorders 2. Differential diagnosis
Ménière disease Vertigo lasting hours, decline in 3. Treatment of posterior canal BPPV via Epley maneuver
sensorineural hearing, tinnitus
4. Reassess for effectiveness of treatment within 1 month
Vestibular neuritis or labyrinthitis Gradual onset of vertigo lasting
5. Education of patient regarding potential safety concerns,
days to weeks, present at rest
recurrence, and importance of follow-up
Neurologic disorders
Migraine-associated dizziness Migrainous headache,
photophobia, phonophobia
patient’s DHI score was 14/100 with points obtained due
Vertebrobasilar insufficiency Vertigo lasting ⬍30 s,
to positive responses to looking up, bending over, and quick
nystagmus does not fatigue
head movements. She also had difficulty getting in and out
Other of bed and expressed frustration with her symptoms.
Cervicogenic vertigo Vertigo with head movement The patient was screened for gaze instability, including
relative to body rather than smooth pursuit, saccades and vestibulo-ocular reflex, with
gravity
no abnormalities found and tested negative bilaterally
Postural hypotension Vertigo with transitioning from with the vertebral basilar insufficiency test. This test was
supine to sit or sit to stand
performed in seated position to negate the potential false-
positive that would be produced if the patient had BPPV
due to the effects of gravity. The vertebral basilar insuf-
indicates no handicap. The self-report screen has been ficiency test has been found to have a positive likelihood
deemed reliable and validated in the measurement of self- ratio of 4.243 (95% confidence interval, 1.678-10.729)
perceived handicap associated with dizziness.8 The minimal and a negative likelihood ratio of 0.928 (95% confidence
clinically important difference for the DHI is 11 points.9 A interval, 0.851-1.011) making the test minimally useful
study regarding BPPV and the use of the DHI found that in clinical decision making and therefore that vertebral
dizziness negatively affected the quality of life of patients basilar insufficiency could not be discounted. However, we
in all the aspects of daily life: functional, emotional, and thought that her symptoms were not likely vascular as they
physical.10 At the start of her physical therapy care, the were not produced in this position.11 The Dix-Hallpike was

Figure. International Classification of Functioning, Disability, and Health model

applied to patient with posterior canal benign paroxysmal positional vertigo (BPPV).
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 Case Report

then performed bilaterally by quickly lowering the patient She was treated with the Epley maneuver for right side
from seated to supine with the head extended 20° and posterior canal canalithiasis at the first and second visits;
rotated 45° to each side, which resulted in a positive finding the Epley maneuver and postural restrictions were repeated
on the right posterior canal for canalithiasis.1 According at the second visit because she had a positive Dix-Hallpike
to the BPPV clinical practice guideline (Table 2), clinicians at the second session. She was found to be negative for
should be cautious due to potential stroke or vascular BPPV on the third session. The Epley maneuver began with
injury despite no documented reports of vertebrobasilar the patient in long sitting with the head turned 45° toward
insufficiency occurring with the Dix-Hallpike maneuver. the affected ear and was quickly brought to supine with
The Dix-Hallpike has a positive likelihood ratio of 3.17 the head hung off the edge of the surface. This position
and negative likelihood ratio of 0.28, making the test was maintained until the nystagmus subsided and then for
minimally useful as a diagnostic tool, but is considered the an additional 30 seconds. Next, the head was turned 90°
gold standard test in diagnosis of posterior canal BPPV.3 toward the unaffected side and held for the same time dura-
The clinical practice guideline for BPPV recommended tion. After that position, the patient was rolled onto her
educating the patient regarding the maneuver as it would unaffected side while her head remained in the same align-
likely produce sudden and potentially severe vertigo and ment and held for the same time duration as the previous
nausea that would subside within 60 seconds and also positions. Finally, the maneuver was completed when the
recommended to reassure the patient that the maneuver patient was returned to sitting.6,12 Prior to the maneuver,
would be completed safely and securely.1 This patient was she was again given clear expectations of symptom produc-
adequately educated per the guideline and consented to tion and duration per the clinical practice guideline.1 After
examination. the maneuver, the typical postural restrictions of avoidance
The differential diagnosis confirmed posterior canal of previously provoking activities including laying supine
BPPV of the canalithiasis type through the combination for 24 hours and recent studies indicating the lack of effi-
of patient history and eye findings with the Dix-Hallpike cacy with these restrictions were discussed. The patient
maneuver. The anticipated plan of care of repositioning elected to follow the restrictions for a 24-hour period in the
maneuvers to treat BPPV provided this patient with an hopes of securing abolishment of her symptoms. Although
excellent prognosis of complete symptom abolishment. the success rate of the repositioning maneuver with post-
Using the examination data, the aspects influencing the maneuver restrictions was greater than those individuals
patient’s BPPV were categorized according to the ICF treated without postmaneuver restrictions, the difference
model (Figure). The ICF model delineated that impair- was not statistically significant. However, the patients who
ments limited the patient’s activities of daily life including were given the restrictions reported greater satisfaction in
caring for herself and her granddaughter and negatively their care than those with immediate freedom of movement
impacted her active participation in play and education of because 96.4% of those with restrictions reported “great”
her grandchild. Because of the symptoms of vertigo being or “complete” improvement in symptoms compared with
provoked with any cervical spine extension or flexion and 59.2% of those without restrictions.12
trunk flexion, she avoided cooking and cleaning tasks as At her third session in 4 weeks the patient was found to
well as recreation activities with her granddaughter. Her be negative of BPPV per the Dix-Hallpike and she reported
past experience with self-independence and resiliency as abolishment of subjective complaints. She was provided
well as her role in caring for others led to feelings of frus- with education of BPPV recurrence per the clinical practice
tration and further avoidance of activities to reduce the guideline and she was then discharged. The benefits of this
frequency of her symptoms. education has been found to allow earlier recognition of
recurrent BPPV allowing expedited return for treatment,
INTERVENTIONS reduced potential anxiety with recurrence, and facilitated
adjustments for increased risk for falls for greater safety
When posterior canal canalithiasis is thought to be the until treatment is provided.1
cause of BPPV, the Epley canalith repositioning procedure
is the recommended repositioning maneuver.3 The Epley OUTCOMES
maneuver has a reported odds ratio of 4.2 for subjec-
tive symptoms resolution in posterior canal BPPV and a At 4 weeks, the patient had resumed reading to her grand-
reported odds ratio of 5.1 treatment for conversion of a daughter, had changed light bulbs, and had increased
positive to negative Dix-Hallpike.1 An intervention plan ease with bed mobility and meal preparation as neck
that included the Epley maneuver was made with a nega- movement, trunk flexion and laying supine no longer
tive Dix-Hallpike and a lower DHI score as outcome goals. produced vertigo or nausea. Her DHI score reduced to
The patient was informed of and consented to the physi- 0/100, which was within the minimal clinically impor-
cal therapist’s diagnosis, prognosis, and plan of care. She tant difference of 11 points, and she was negative for the
was seen for 2 additional visits over the course of 3 weeks. Dix-Hallpike test.
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 Case Report

DISCUSSION granddaughter because of fear of provoking her severe

vertigo and nausea. Repositioning techniques were used
The ICF model is unique in that there is not a hierarchi- to remedy the body structure cause of the impairment and
cal organization of its domains but rather a bidirectional education was given regarding recurrence rates of BPPV
flow of information. This type of flow helps to exemplify to help reduce further anxiety and avoidance of activities.
the idea that functioning and disability are achieved by The care provided in this case report was evidence-
the influence of multiple separate, but interrelated aspects. based by utilizing the recommended clinical practice
These domains are termed body structure and function, guideline and a notable clinical reasoning model to help
participation, activity, and environmental and personal ensure proper sequencing of the various functions of
contextual factors. This allows physical therapists to bet- the physical therapist.17 Following the clinical reasoning
ter understand the impact of a patient’s impairments in model, a hypothesis was proposed using information from
relation to their daily life and facilitates prioritization of the patient history and examination data as well as the
interventions to remedy these various domains. As this therapist’s knowledge and patient’s experience. The best,
framework also aids in showcasing a patient’s potential evidence-based treatment was then selected taking into
barriers, these too can be addressed to allow progression account patient preferences. Reassessment occurred by
toward goals in a timely fashion. monitoring effectiveness of the treatment using special tests
Other diagnoses that have successfully utilized the ICF and outcome measures. The DHI was given as a precursor
model include diagnoses of acute and chronic low back to therapy and at the conclusion of care to allow validated
pain, spinal cord injury, and patellar dislocation. In terms measurement of perceived handicap related to her dizziness
of acute and chronic low back pain, it was found that the and the change over the course of therapy.
ICF model provided an effective framework that enhanced The DHI was used in this case study despite minimal cli-
physical therapists’ ability to better understand a patient’s nometric data supporting its utilization because it has been
experience with her disablement and aided in the prioriti- used widespread in the research literature when attempting
zation of the treatment plan.7 A case report exploring the to determine quality of life in patients with vertigo. This
use of the ICF model in the multidisciplinary approach screen has been found to be more responsive to change
to a patient with a spinal cord injury found that patient than the Patient Specific Functional Scale–36 because the
management was improved and even clinician roles were DHI is specific to vertigo; however, the use of multiple
clarified.13 Another case report involving a patient with functional quality of life scales in future studies could lead
a patellar dislocation determined that through the use to a more complete portrait of the patient’s daily life.18
of the ICF model, a patient’s problems were addressed Although the ICF model provided an excellent method
at the level of the whole person and appropriate adjust- of organizing the multiple aspects related to a patient’s
ments were made because of her contextual factors, thus functioning and disability, other clinical reasoning models
improved clinical decision making.14 Clinical practice such as the rehabilitation cycle17 and Sackett’s principles
guidelines for neck and heel pain have also been devel- of evidence-based practice19 will likely remain utilized as
oped incorporating the ICF model and its domains into an adjunct to decision making to provide a more thorough
the examination and diagnostic criteria indicating a shift patient care experience.
in physical therapy care to the eventual use of the ICF The health care costs associated with the diagnosis of
model into daily practice.15,16 BPPV is approaching $2 billion dollars per year.1 Falls,
The ICF model ensured that when the patient with which are closely related to BPPV, are correlated with costs
BPPV was being treated with evidence-based tests and pro- that exceed $20 billion annually in the United States.20
cedures, the focus was on her perceived impact of disability These falls due to BPPV can lead to secondary injuries in
and her goals for treatment and not simply the nystagmus. older adults such as fractures or brain injury and may even
Much time was spent on education about the pathology lead to institutionalization. As the United States population
and how the anatomic abnormalities were impacting her continues to grow older, the incidence and prevalence of
daily life, as well as how specifically the repositioning BPPV will likely increase.1 As BPPV has such a significant
maneuvers aimed to correct this problem. She was also potential impact on both the individual, in terms of quality
involved in her care by providing her with the choice of of life, and the society, in respect to health care costs, it is
following postural restrictions. This may have helped to vitally important that all steps be taken to improve the effi-
increase her satisfaction in her care.12 ciency and quality of care for people with BPPV. The use of
The patient in this case report benefited from the con- the ICF and evidence-based practice has this capability and
current utilization of the ICF and evidence-based care in is recommended for use in patients with BPPV.
both expediting her recovery and ensuring that the care
was individualized to fully meet her unique needs. A REFERENCES
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