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BRANDT DAROFF EXERCISES for BPPV Patient

1.1 BACKGROUND

BPPV (Benign Paroxysmal Positioning Vertigo) is the biggest caused of vertigo and dizziness. Data indicated 32 % patient’s dizziness was caused by BPPV(1) and other data stated that 50% all dizziness in older people is due to BPPV(2)

Budi Riyanto, 2004, stated that BPPV is the common cause of vertigo and will disappear by itself within 4 to 6 weeks. It is related to the unstable condition of otoliths or otoconia (calcium carbonate particle in semicircular canal). Physical therapy and Brandt Daroff Exercises were considered more effective than anti vertigo drugs.(3)

According to Andradi, 2002, vertigo symptom will arise suddenly when the position is changed, like tilted to one side when we lying down, get up from bed, bend or when enforcing agency, bow or look up. Onset lasted in a short time, usually less than 30 seconds. Vertigo patients with BPPV will perceive spins; can be accompanied by nausea, sometimes vomiting. When spinning sensation disappear patient will fill hovering. Usually BPPV will be disappeared by itself in few days to weeks and sometimes can be recurrent.(4)

Even though research cites BPPV is one type of peripheral vestibular vertigo most often found in daily practice, but many doctors cannot diagnose it as BPPV. Many of them refer patients directly to neurologist or ENT without knowing the cause. BPPV resulted great vertigo symptoms, it makes patients become anxious and concerned about the possibility of heavy disease such as stroke or brain tumor. The same thing with GPs, they may assume this is a heavy type of vertigo that should be addressed to specialists.

Ronald Labuguen, 2006 also concluded that many patients can not accurately describe their complaints.(5) Surely this is a challenge for the physician to determine the cause of vertigo.

PROBLEMS IN PATIENT AS A RESULT OF VERTIGO

Vertigo can be caused by many things. Determine the primary cause is a very important thing to prevent Vertigo recurrent. Why Vertigo and Dizziness should be resolved, partly because:

  • Patient stops their activity because of vertigo symptoms.
  • Productivity decreased and patient’s quality of life also decreased.
  • Patient must pay more money because their vertigo recurrent and they must find other doctors.

Hagemann, 2010 supported that statement, he said that:

  • The impact of dizziness on social and working life is considerable.(6)
  • 50% of the patients affected by dizziness feel that their efficiency at work has substantially dropped.(6)
  • 25% of patients even give up or change their work as a result of dizziness.(6)

CURRENT TREATMENT TREND IN VERTIGO

There are some references about vertigo treatment in Indonesia, among others;

1. 80% anti vertigo co prescribed (different mechanism of action).(7)

2. Internal survey :

  • Doctor used Betahistine co prescribed with Flunarizine or Cinnarizine, because they do not know the vertigo comes from central or peripheral.
  • Doctors use a high dose drug for all type of vertigo.
  • Medical doctors (GP) used anti vertigo drugs for 3-5 days to relieve the symptom. They did not find the cause. If vertigo still attack, they will refer the patient to specialist.

Discussion with the expert concluded the use of drugs is not always necessary in vertigo treatment. Determine the cause and treat the cause is the important thing. For example, in BPPV treatment, mostly anti vertigo drugs is often not needed because the vertigo attacked in a short time. Physical therapy is more effective than drugs. We want doctors to give the right treatment, find the cause and prescribe our product to relieve the symptoms. Not all type of vertigo need a combination of anti-vertigo drugs, not all type of vertigo need high dose anti vertigo drug. The most important thing is doctor must know the cause of vertigo and give the symptomatic drugs in effective dose.

1.2 SUMMARIZING THE PROBLEM

We can summarize the problem as follows:

    1. When doctors cannot diagnose vertigo, they cannot treat in the right way and vertigo will still be there.
    2. Patient suffering from Vertigo for a long time may decrease their quality of life.
    3. High cost and time, patient must stop their activity to find a good doctor or right treatment.
    4. High dose anti vertigo can cause side effect, whereas not all type of vertigo need high dose.
    5. The use of combination therapy may be needed, but if it is not needed, it will add cost, high risk of side effects.

SOLUTION FROM PT. EISAI INDONESIA TO ENHANCE PATIENT’S QUALITY OF LIFE

PT. Eisai Indonesia took part in order to enhance doctor knowledge about vertigo. Not only focus on how to increase sales of our product but how to give maximum benefit to the patients. We distributed Brandt Daroff Exercises as a follow up program from Workshop Vertigo. We hope patient can practice the Brandt Daroff Exercises in their home

2.1.1 BRANDT-DAROFF EXERCISES

After we did Vertigo Workshop to educate doctors about vertigo in 2012, we distributed 300 Detail Aid to targeted GP. We also distributed Brandt Daroff Exercises for BPPV treatment

The content of Detail Aid Flipchart is:

    1. Picture of Vestibular organ, with this picture, doctor can show to the patient which organ related to vertigo.
    2. Definition of Dizziness, Vertigo and lightheadedness.
    3. The differences type of sensation of vertigo, pre syncope, disequilibrium and other dizziness.
    4. Differential Diagnosis of Vertigo, so doctor can appropriately diagnose vertigo.
    5. Clues to determine whether vertigo comes from central or peripheral.

Brandt Daroff Exercises Booklet content of:

    1. Explanation that Brandt Daroff Exercises is treatment for BPPV.
    2. Step of Brandt Daroff Exercises.
    3. Duration and frequency of Brandt Daroff Exercises.

We hope doctor can distribute Brandt Daroff Exercises to the BPPV patient. Every times doctor prescribe our product to BPPV patient, doctor can suggest patient to take Brandt Daroff exercises to maximize the benefit of treatment.

2.1.2 GOAL OF THE ACTIVITY

Workshop vertigo, Detail Aid distribution and Brandt Daroff Exercises are purposed to educate doctors and help patients. Our goal to hold all the activities are:

    1. Doctor can diagnose the common cause of vertigo, especially BPPV.
    2. Doctors especially GP can diagnose peripheral vertigo and central vertigo, so if they meet central vertigo they can refer to the neurologist as soon as possible and they can treat by themselves for peripheral vertigo.
    3. Optimize treatment and improve patient’s quality of life.
    4. Doctor use the right drugs in the right way.

Our goal in distributing Brandt Daroff Exercises:

    1. Doctor understands betahistine mesylate with Brandt Daroff in BPPV treatment can faster the recovery and increase the recovery rate compare to Brandt Daroff Exercises without betahistine(8).
    2. Treat the cause of BPPV, patient can practice the Brandt Daroff exercises in their home.
    3. Patient can get maximum benefit of the treatment. They can continue their activities and increase their quality of life.

2.1.3 BENEFIT OF THE ACTIVITY.

Benefit for doctors and patients:

    1. Right diagnose can result right treatment. Doctor will get his goal in treatment, and patient will be free from vertigo faster and more efficient.
    2. Brandt Darofff exercises can accelerate the recovery and avoid BPPV recurrent.
    3. Increase Quality of Life and decreased cost therapy for patients and families. They don’t need to pay many doctors or drugs to cure their vertigo.

SUSTAINABILITY OF THE ACTIVITY

Key Opinion Leader of vertigo gave a good response for this activity. Many doctors ask Brandt Daroff exercises for more. They showed the exercises to their patients and patients repeated in their home. Now, doctor can demonstrate in their office and patient can use Brandt Daroff booklet as patron in their home. They can practice the same exercises in the right way. We will improve our activities not only for Brandt Daroff exercise but also for detail aid. We will put other rehabilitation therapy and some exercises to diagnose vertigo. We hope doctors can use the exercises to diagnose vertigo and to treat it.

CONCLUSION

Doctor needs to continuously update their knowledge. Vertigo Workshop and Detail Aid may help them increase their knowledge. We also distributed BRANDT DAROFF EXCERCISES for BPPV treatment, so doctor can use it to help their patients. When doctor’s knowledge is increased, it will also increase the success rate of therapy. Patient can continue their activities; without fear that vertigo will be back in the short time and it will increase patient’s quality of life. Patient will be happy and their family will be happy too.

Doctor will be happy because they can achieve their goal in vertigo and dizziness treatment. PT. Eisai Indonesia should also be happy because we can contribute and help vertigo patients; and our product will always become reliable partner for doctor in vertigo and dizziness treatment.

Notes:

Please consult with your doctor before proceeding with an exercise routine

References

    1. T Ronald J. Dizziness. Med Clin N Am 87 (2003) 609 – 641.
    2. Oghalai JS, et al., Unrecognized benign paroxysmal positional vertigo in elderly patients. Otolaryngol Head Neck Surg, 2000. 122(5): p. 630-4.
    3. Budi Riyanto, Cermin Dunia Kedokteran No. 144, 2004: 41-46.
    4. Andradi. Benign Paroxysmal Positional Vertigo in : H. Aboe Amar Joesoef (Editor) Neuro-Otologi klinis “Vertigo” 2002, 179-182.
    5. Labuguen RH. Initial Evaluation of Vertigo. J American Family Physician 2006; 73(2): pp. 244-251.
    6. Hagemann S,et al. New methods for diagnosis and treatment of vestibular diseases. Medicine Reports Ltd 2010; 2:10.
    7. Indonesian Medical Data Index 2010.
    8. Cavaliere M, et al. Benign Paroxysmal Positional Vertigo: a study of two maneuvers with and without betahistine. Acta Otorhinolaryngol Ital 25, 107-112, 2005.