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: The model provided by the World
Health Organization’s International Classification of Functioning,
Disability, and Health (ICF) was created to describe, clas-
sify, and measure function in both health care practice and
research. This model has not been applied to management
of many physical therapy cases, limiting its implementation
conceptually into practice as a whole. The purpose of this case
report is to illustrate the use of the ICF model in the evidence-
based management of posterior canal benign paroxysmal
positional vertigo.
Case Description: One patient with acute posterior canal
canalithiasis benign paroxysmal positional vertigo was treated
using the evidence-based clinical practice guideline for the
diagnosis as well as the ICF framework.
Interventions: Repositioning maneuvers and education were
provided to ameliorate the relevant body structure and func-
tion impairments, activity limitations, and contextual factors
related to the patient’s overall functioning and disability.
Outcomes: The patient demonstrated complete abolishment of
her symptoms, both objectively and subjectively after 3 ses-
sions over 4 weeks of care.
Discussion: The physical therapy community has adopted the
framework of the ICF because this model has been found to
be effective in illustrating the impact of a patient’s functional
impairments in terms of activity limitations as well as the role
that personal and environmental factors play in the patient’s
overall functioning and disability. When using the ICF in tan-
dem with evidence-based care, patient outcomes have the
capability to improve at an even greater rate; however, further
research should be completed to discover this potential effect
with appropriately designed clinical trials.
Key Words: benign paroxysmal positional vertigo, Interna-
tional Classification of Functioning, Disability, and Health,
physical therapy, repositioning maneuvers
(J Geriatr Phys Ther 2012;35:200-205.)
1StRita’s Medical Center, Lima, Ohio.
2Widener
University Institute for Physical Therapy
Education, Chester, Pennsylvania.
The authors declare no conflict of interest.
Address correspondence to: Amy Wahlgren, PT, DPT,
MSBS, St Rita’s Medical Center, 830 W High St, Suite 150,
Lima, OH 45801 (aewahlgren@health-partners.org).
DOI: 10.1519/JPT.0b013e318247a243
200
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JPT200141.indd 200
BACKGROUND AND PURPOSE
Benign Paroxysmal Positional Vertigo
Dizziness accounts for the primary complaint that neces-
sitates 5.6 million clinic visits in the United States per year.
Of these patients with vertigo, between 17% and 42%
received a diagnosis of benign paroxysmal positional ver-
tigo (BPPV).1 This condition was first described in 1921 by
Barany as an “attack” of violent vertigo and nausea occur-
ring when side-lying and lasting approximately 30 seconds
prior to abolishment of symptoms. BPPV occurs when free-
floating otoconia migrate into 1 of 3 semicircular canals of
the inner ear and either becomes trapped inside the canals
(canalithiasis), or becomes adherent to the cupula of the
semicircular canal (cupluolithiasis). Although symptoms
only last up to 60 seconds at a time, 80% of patients experi-
ence rotary nystagmus and 47% complain of a floating sen-
sation with such activities as rolling over in bed, extending
the cervical spine, and trunk flexion. However, BPPV is
thought to be self-limiting with abolishment of symptoms
within 6 months.2
There are several different types of BPPV with poste-
rior canal BPPV occurring most frequently at a rate of
85% to 95% of cases.1 Posterior canal BPPV canalithiasis
is the most common form because this canal is in the
most gravity-dependent position when a person is either
standing or supine and in order for the otoconia to exit
the canal spontaneously, it must move opposite the gravi-
tational pull.2 Lateral or horizontal canal BPPV accounts
for the majority of the remainder 5% to 15% of cases,
with other variations including anterior canal BPPV,
multiple canal BPPV, and bilateral multiple canal BPPV
occurring rarely.1
BPPV can either be classified as primary or secondary.
Primary BPPV occurs when found in isolation and accounts
for 50% to 70% of cases whereas secondary BPPV is caused
by another injury or disorder. The most common cause is
head trauma, which can account for up to 17% of cases of
BPPV; less common causes include viral labyrinthitis with
15% and Ménière disease at 5% of cases.2 The prevalence
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of BPPV ranges from 10.7 to 64 per 100 000 population
with a lifetime prevalence of 2.4%. BPPV has been found
to be the most common vestibular disorder across the lifes-
pan with the most common age of onset between 50 and
70 years. The recurrence rate of BPPV has been estimated
at 15% per year; however, this rate increases if BPPV is due
to head trauma.1 The gold standard for BPPV diagnosis
includes patient history and eye findings during positional
testing, specifically Dix-Hallpike for posterior canal.2 A
positive result for the Dix-Hallpike includes a brief latency
of symptoms for 1 to 5 seconds, followed by nystagmus
featuring an upbeating motion as well as rotation toward
the dependent ear of up to 60 seconds. With repeated test-
ing, the signs become less intense and fatigue entirely. The
Dix-Hallpike test has a sensitivity of 79% and specificity
of 75% with a positive likelihood ratio of 3.17, making it
minimally useful for clinical decision making.3
The most significant consequence of untreated BPPV,
especially in older adults, would be the resultant increased
likelihood of falls due to a reduced sense of equilibrium.
Falls with increasing age have negative consequences,
including fractures, brain injury, and institutionalization,
which can lead to significant costs for both the individual
and society.1 Thus it is clear why prompt appropriate diag-
nosis and treatment of BPPV is crucial.
International Classification of Functioning,
Disability, and Health
The World Health Organization’s International Classification
of Functioning, Disability and Health (ICF) is the culmi-
nation of efforts that began in 1993 by the active par-
ticipation of 1800 experts from 65 countries, which was
eventually accepted in 2001 as the international standard
to describe and measure health and disability. The goal of
the ICF was to develop a unified and standard language
and framework for the analysis of all aspects of health
as well as some health-related wellness aspects. The ICF
is laid out in a manner where there are 2 subgroups for
each of the 2 main divisions of the model. The first part
of the ICF, functioning and disability, consists of body
functions and structures and activities and participation.4
Body functions and structures are analyzed in terms of
change in physiologic function and anatomic structure.
Activities are considered the execution of tasks or actions;
participation is defined as the involvement in life affairs.5
The second part of the ICF, contextual factors, consists
of environmental and personal factors.4 In terms of the
ICF, functioning is considered the positive aspect of each
component and disability is deemed the negative aspect.5
Each of these domains are further broken down into cat-
egories, which are the units of the ICF classification. These
categories and their respective codes are then selected
to describe the individual’s health-related states and are
given numeric codes, which specify the magnitude of the
functioning or disability of that category to the extent that
Journal of GERIATRIC Physical Therapy
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JPT200141.indd 201
Case Report
an environmental factor is either a facilitator or barrier.4
Implementation of the ICF in a case study involving physi-
cal therapy for low back pain found that treatment was
prioritized whereas another study on physical therapy for
patellar dislocations found improved decision making as
the patient’s contextual factors were taken into account.6,7
By use of the ICF, care is ensured to be patient-centered,
which improves outcomes and efficiency as well as allows
comparison for international research. Minimal literature
is available about implementing the ICF into physical
therapy practice, which can make the process daunting to
initiate. The purpose of this case report is to illustrate the
use of the ICF model in the evidence-based management
of posterior canal BPPV.
CASE DESCRIPTION
Patient History and Systems Review
History
The patient was a 74-year-old woman who presented with
dizziness, which she stated had been present for 2 months
in duration. She reported that the spinning sensation first
occurred while watching her grandchild play a video
game. She admitted the symptoms of spinning and nausea
were worst when getting in and out of bed, but they also
occurred while looking down to read or when she looked
up to change a light bulb. Although she described the sensa-
tion as severe, she admitted the symptoms lasted less than
1 minute before abolishing. She stated that if she avoided
head movements and changes in position, such as laying
flat in bed, she could avoid her symptoms. She denied any
hearing loss, tinnitus, headaches, or neck pain. She did not
have a history of hypertension nor did she present with any
orthostatic hypotension. Other medical conditions included
a recent hernia repair and cardiac catheterization. She cur-
rently was taking the prescription Pravastatin for hyper-
cholesterolemia. The patient was retired; however, she had
guardianship of her 5-year-old granddaughter whom she
was actively raising. The patient’s stated goal was to abol-
ish her dizziness to allow greater ease with getting in and
out of bed and return to reading to her granddaughter.
Examination
As the patient did not meet the typical criteria for other
otologic or neurologic disorders (Table 1), the differen-
tial diagnosis was reduced to posterior canal BPPV of
the canalithiasis type. It was postulated that because of
the improper location of the otoconia in the semicircular
canals, the patient experienced dizziness, vertigo, nausea,
decreased balance reactions, and increased risk of falling.
Because of this, an examination plan was made, which
included the Dizziness Handicap Inventory (DHI) and the
Dix-Hallpike maneuver.
The patient was issued the DHI, which is a 25-item
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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JPT200141.indd 202 05/09/12 9:36 PM


then performed bilaterally by quickly lowering the patient
from seated to supine with the head extended 20° and
rotated 45° to each side, which resulted in a positive finding
on the right posterior canal for canalithiasis.1 According
to the BPPV clinical practice guideline (Table 2), clinicians
should be cautious due to potential stroke or vascular
injury despite no documented reports of vertebrobasilar
insufficiency occurring with the Dix-Hallpike maneuver.
The Dix-Hallpike has a positive likelihood ratio of 3.17
and negative likelihood ratio of 0.28, making the test
minimally useful as a diagnostic tool, but is considered the
gold standard test in diagnosis of posterior canal BPPV.3
The clinical practice guideline for BPPV recommended
educating the patient regarding the maneuver as it would
likely produce sudden and potentially severe vertigo and
nausea that would subside within 60 seconds and also
recommended to reassure the patient that the maneuver
would be completed safely and securely.1 This patient was
adequately educated per the guideline and consented to
examination.
The differential diagnosis confirmed posterior canal
BPPV of the canalithiasis type through the combination
of patient history and eye findings with the Dix-Hallpike
maneuver. The anticipated plan of care of repositioning
maneuvers to treat BPPV provided this patient with an
excellent prognosis of complete symptom abolishment.
Using the examination data, the aspects influencing the
patient’s BPPV were categorized according to the ICF
model (Figure). The ICF model delineated that impair-
ments limited the patient’s activities of daily life including
caring for herself and her granddaughter and negatively
impacted her active participation in play and education of
her grandchild. Because of the symptoms of vertigo being
provoked with any cervical spine extension or flexion and
trunk flexion, she avoided cooking and cleaning tasks as
well as recreation activities with her granddaughter. Her
past experience with self-independence and resiliency as
well as her role in caring for others led to feelings of frus-
tration and further avoidance of activities to reduce the
frequency of her symptoms.
INTERVENTIONS
When posterior canal canalithiasis is thought to be the
cause of BPPV, the Epley canalith repositioning procedure
is the recommended repositioning maneuver.3 The Epley
maneuver has a reported odds ratio of 4.2 for subjec-
tive symptoms resolution in posterior canal BPPV and a
reported odds ratio of 5.1 treatment for conversion of a
positive to negative Dix-Hallpike.1 An intervention plan
that included the Epley maneuver was made with a nega-
tive Dix-Hallpike and a lower DHI score as outcome goals.
The patient was informed of and consented to the physi-
cal therapist’s diagnosis, prognosis, and plan of care. She
was seen for 2 additional visits over the course of 3 weeks.
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Case Report
She was treated with the Epley maneuver for right side
posterior canal canalithiasis at the first and second visits;
the Epley maneuver and postural restrictions were repeated
at the second visit because she had a positive Dix-Hallpike
at the second session. She was found to be negative for
BPPV on the third session. The Epley maneuver began with
the patient in long sitting with the head turned 45° toward
the affected ear and was quickly brought to supine with
the head hung off the edge of the surface. This position
was maintained until the nystagmus subsided and then for
an additional 30 seconds. Next, the head was turned 90°
toward the unaffected side and held for the same time dura-
tion. After that position, the patient was rolled onto her
unaffected side while her head remained in the same align-
ment and held for the same time duration as the previous
positions. Finally, the maneuver was completed when the
patient was returned to sitting.6,12 Prior to the maneuver,
she was again given clear expectations of symptom produc-
tion and duration per the clinical practice guideline.1 After
the maneuver, the typical postural restrictions of avoidance
of previously provoking activities including laying supine
for 24 hours and recent studies indicating the lack of effi-
cacy with these restrictions were discussed. The patient
elected to follow the restrictions for a 24-hour period in the
hopes of securing abolishment of her symptoms. Although
the success rate of the repositioning maneuver with post-
maneuver restrictions was greater than those individuals
treated without postmaneuver restrictions, the difference
was not statistically significant. However, the patients who
were given the restrictions reported greater satisfaction in
their care than those with immediate freedom of movement
because 96.4% of those with restrictions reported “great”
or “complete” improvement in symptoms compared with
59.2% of those without restrictions.12
At her third session in 4 weeks the patient was found to
be negative of BPPV per the Dix-Hallpike and she reported
abolishment of subjective complaints. She was provided
with education of BPPV recurrence per the clinical practice
guideline and she was then discharged. The benefits of this
education has been found to allow earlier recognition of
recurrent BPPV allowing expedited return for treatment,
reduced potential anxiety with recurrence, and facilitated
adjustments for increased risk for falls for greater safety
until treatment is provided.1
OUTCOMES
At 4 weeks, the patient had resumed reading to her grand-
daughter, had changed light bulbs, and had increased
ease with bed mobility and meal preparation as neck
movement, trunk flexion and laying supine no longer
produced vertigo or nausea. Her DHI score reduced to
0/100, which was within the minimal clinically impor-
tant difference of 11 points, and she was negative for the
Dix-Hallpike test.
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 Case Report
DISCUSSION
The ICF model is unique in that there is not a hierarchi-
cal organization of its domains but rather a bidirectional
flow of information. This type of flow helps to exemplify
the idea that functioning and disability are achieved by
the influence of multiple separate, but interrelated aspects.
These domains are termed body structure and function,
participation, activity, and environmental and personal
contextual factors. This allows physical therapists to bet-
ter understand the impact of a patient’s impairments in
relation to their daily life and facilitates prioritization of
interventions to remedy these various domains. As this
framework also aids in showcasing a patient’s potential
barriers, these too can be addressed to allow progression
toward goals in a timely fashion.
Other diagnoses that have successfully utilized the ICF
model include diagnoses of acute and chronic low back
pain, spinal cord injury, and patellar dislocation. In terms
of acute and chronic low back pain, it was found that the
ICF model provided an effective framework that enhanced
physical therapists’ ability to better understand a patient’s
experience with her disablement and aided in the prioriti-
zation of the treatment plan.7 A case report exploring the
use of the ICF model in the multidisciplinary approach
to a patient with a spinal cord injury found that patient
management was improved and even clinician roles were
clarified.13 Another case report involving a patient with
a patellar dislocation determined that through the use
of the ICF model, a patient’s problems were addressed
at the level of the whole person and appropriate adjust-
ments were made because of her contextual factors, thus
improved clinical decision making.14 Clinical practice
guidelines for neck and heel pain have also been devel-
oped incorporating the ICF model and its domains into
the examination and diagnostic criteria indicating a shift
in physical therapy care to the eventual use of the ICF
model into daily practice.15,16
The ICF model ensured that when the patient with
BPPV was being treated with evidence-based tests and pro-
cedures, the focus was on her perceived impact of disability
and her goals for treatment and not simply the nystagmus.
Much time was spent on education about the pathology
and how the anatomic abnormalities were impacting her
daily life, as well as how specifically the repositioning
maneuvers aimed to correct this problem. She was also
involved in her care by providing her with the choice of
following postural restrictions. This may have helped to
increase her satisfaction in her care.12
The patient in this case report benefited from the con-
current utilization of the ICF and evidence-based care in
both expediting her recovery and ensuring that the care
was individualized to fully meet her unique needs. A
negative personal factor was demonstrated as the patient
was avoiding participation in leisure activities with her
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JPT200141.indd 204
granddaughter because of fear of provoking her severe
vertigo and nausea. Repositioning techniques were used
to remedy the body structure cause of the impairment and
education was given regarding recurrence rates of BPPV
to help reduce further anxiety and avoidance of activities.
The care provided in this case report was evidence-
based by utilizing the recommended clinical practice
guideline and a notable clinical reasoning model to help
ensure proper sequencing of the various functions of
the physical therapist.17 Following the clinical reasoning
model, a hypothesis was proposed using information from
the patient history and examination data as well as the
therapist’s knowledge and patient’s experience. The best,
evidence-based treatment was then selected taking into
account patient preferences. Reassessment occurred by
monitoring effectiveness of the treatment using special tests
and outcome measures. The DHI was given as a precursor
to therapy and at the conclusion of care to allow validated
measurement of perceived handicap related to her dizziness
and the change over the course of therapy.
The DHI was used in this case study despite minimal cli-
nometric data supporting its utilization because it has been
used widespread in the research literature when attempting
to determine quality of life in patients with vertigo. This
screen has been found to be more responsive to change
than the Patient Specific Functional Scale–36 because the
DHI is specific to vertigo; however, the use of multiple
functional quality of life scales in future studies could lead
to a more complete portrait of the patient’s daily life.18
Although the ICF model provided an excellent method
of organizing the multiple aspects related to a patient’s
functioning and disability, other clinical reasoning models
such as the rehabilitation cycle17 and Sackett’s principles
of evidence-based practice19 will likely remain utilized as
an adjunct to decision making to provide a more thorough
patient care experience.
The health care costs associated with the diagnosis of
BPPV is approaching $2 billion dollars per year.1 Falls,
which are closely related to BPPV, are correlated with costs
that exceed $20 billion annually in the United States.20
These falls due to BPPV can lead to secondary injuries in
older adults such as fractures or brain injury and may even
lead to institutionalization. As the United States population
continues to grow older, the incidence and prevalence of
BPPV will likely increase.1 As BPPV has such a significant
potential impact on both the individual, in terms of quality
of life, and the society, in respect to health care costs, it is
vitally important that all steps be taken to improve the effi-
ciency and quality of care for people with BPPV. The use of
the ICF and evidence-based practice has this capability and
is recommended for use in patients with BPPV.
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