Clinical decision-making to address poor outcomes in persistent horizontal semicircular canal benign paroxysmal positional vertigo: A case study.

Background: Horizontal semicircular canal BPPV (HSC-BPPV) can occur in 10-30% of BPPV cases. Lower success rates are reported for HSC-BPPV. The apogeotropic form of HSC-BPPV is more difficult to treat, as 5-40% of cases are described to be refractory to repositioning maneuvers.

Purpose: To describe the assessment and treatment of a patient presenting with HSC-BPPV and to demonstrate the potential use of Forced-Prolonged Positioning (FPP) as a home exercise program (HEP) for persistent HSC-BPPV in an elderly patient.

Case Description: An 89-year-old female referred to physical therapy with a diagnosis of BPPV. She experienced dizziness with positional changes and was found to have apogeotropic form of HSC-BPPV.

Intervention: To supplement maneuvers performed in the clinic, the patient was provided instructions for the FPP as her HEP. With continued symptoms and positive positional tests by week four of treatment, the patient was instructed to switch the FPP with the opposing ear directed toward the floor.

Outcome: Following 2 weeks of performing FPP on the opposite side, the patient reported symptoms had resolved and positional testing confirmed resolution of HSC-BPPV.

Discussion: There is a potential benefit of using FPP as a HEP to supplement maneuvers used in the clinic to improve outcomes in patients with HSC-BPPV that are refractory to traditional repositioning maneuvers. Prescribing the FPP maneuver as a HEP is feasible, and clinicians should consider the FPP technique as a HEP to adjunct repositioning maneuvers performed in the clinic to address persistent HSC-BPPV.