The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo

Semont maneuver for posterior canal benign paroxysmal positional vertigo: a systematic review of randomized controlled trials

PURPOSE

This review aimed to examine the effects of the Semont maneuver on posterior canal benign paroxysmal positional vertigo (BPPV).

METHODS

PubMed, PEDro, SCOPUS, REHABDATA, EMBASE, and Web of Science were searched comprehensively from inception to January 2024. The Physiotherapy Evidence Database (PEDro) scale was employed to evaluate the quality of the selected studies.

RESULTS

In total, 18 randomized controlled trials met the eligibility criteria. A total of 2237 participants with BPPV (mean age = 58.10 years) were included in this review. Among them, 37.5% were males, and 58% presented with right-sided BPPV. The included studies ranked from 5 to 9 out of 10 (Median = 7), suggesting good to excellent quality on the PEDro scale. The available literature revealed that the Semont maneuver is effective in improving posterior canal BPPV symptoms.

CONCLUSION

The Semont maneuver is considered a standard option for treating posterior canal BPPV, with a high success rate of around 80%. It is suggested as the primary option for managing posterior canal BPPV in individuals who complain of cervical or lumbar problems, severe cardiac or respiratory conditions. Further studies are strongly needed to understand the long-term effects of the Semont maneuver and to identify the recurrence rate.

Effectiveness of brandt-daroff exercises in the treatment of benign paroxysmal positional vertigo: a systematic review of randomized controlled trials

PURPOSE

This review aims to examine the effects of Brandt-Daroff exercises (BDEs) on individuals with posterior canal Benign Paroxysmal Positional Vertigo (BPPV) and to provide recommendations for future research on this topic.

METHODS

PubMed, MEDLINE, PEDro, SCOPUS, REHABDATA, EMBASE, and Web of Science were searched from inception to November 2023. The Physiotherapy Evidence Database (PEDro) scale was used to assess the methodological quality of the included studies.

RESULTS

In total, ten randomized controlled trials met our eligibility criteria. A total of 880 individuals with BPPV (63.6% females) were included in this review. The included studies were ranked "good quality" on the PEDro scale. The available literature showed that BDEs do not significantly reduce symptoms or promote recovery in people with posterior canal BPPV compared to other interventions, such as Epley and Semont maneuvers.

CONCLUSIONS

The evidence for the effects of BDEs on patients with BPPV is limited. Further high-quality studies with long-term follow-ups are strongly required to investigate the long-term effects of BDEs in posterior canal BPPV, define the optimal application of BDEs, and identify the factors associated with treatment response and recovery.

A Comparison of the Efficacy of Four Repositioning Maneuvers in the Treatment of Posterior Benign Paroxysmal Positional Vertigo

PURPOSE

The purpose of the present review was to report the effectiveness of Epley maneuver compared to other manual repositioning maneuvers (RM) for treatment of posterior benign paroxysmal positional vertigo (P-BPPV). A systematic search of PubMed, Embase, and the Cochrane Library was conducted up until June 30, 2023.

RESULTS

Primary outcomes focused on complete resolution of vertiginous symptoms measured by either a Visual Analog Scale (VAS) or the Dix-Hallpike (DH) test. Secondary outcomes included conversion of a positive DH test to a negative DH test exclusively looking at positional nystagmus and assessment of side effects (cervical/back pain, posttreatment dizziness, and nausea). Both outcomes were assessed within a maximum of 4-week follow-up. Following systematic search and review, nine randomized controlled trials (RCTs; p = .413) were found. The studies reported on the effectiveness of the Epley maneuver compared to three other specific RM: Semont, Li, and Gans maneuvers. Results revealed a low to very low certainty of evidence. With the primary outcomes, Epley maneuver was superior to Gans maneuver 24-hr posttreatment but not after 1 week. No significant differences were found between the remaining maneuvers.

CONCLUSIONS

In summary, evidence of low to very low certainty indicates that Epley maneuver is comparable with Semont, Gans, and Li maneuvers for vertiginous symptoms in patients with P-BPPV. Further high-quality studies are needed.

Gufoni maneuver for treatment of horizontal canal benign paroxysmal positional vertigo: a systematic review of randomized controlled trials

PURPOSE

This review aims to investigate the effects of the Gufoni maneuver on horizontal semicircular canal benign paroxysmal positional vertigo (HC-BPPV).

METHODS

A comprehensive search, including PubMed, PEDro, REHABDATA, SCOPUS, EMBASE, and Web of Science, was conducted to determine randomized clinical trials (RCTs) studying the effects of the Gufoni maneuver for HC-BPPV from inception to March 1, 2024. The quality of the included studies was estimated using the Physiotherapy Evidence Database (PEDro) scale.

RESULTS

Ten randomized controlled trials (RCTs) were included in this review with a total of 1025 HC-BPPV patients (mean age = 58.58 years; 63% female; 55% right-side HC-HBPPV; 49% geotropic HC-BPPV). The included RCTs ranged from 4 to 9 out of 10 (median = 6.5) on the PEDro scale. The included studies showed that the Gufoni maneuver revealed efficacy when compared to the sham maneuver but not when compared to other maneuvers such as the Barbecue roll maneuver, the Appiani maneuver, the Mastoid oscillation, the head shaking, and the modified Gufoni maneuver.

CONCLUSIONS

The Gufoni maneuver is considered an option for treating patients with geotropic or apogeotropic HC-BPPV. Precise diagnosis of the BPPV, the subtype of HC-BPPV, symptom duration, history of previous BPPV attacks, the applied methods of maneuver and the proficiency of the clinician performing the maneuver, proper diagnosis, presence of any underlying health conditions are critical for successful treatment. Further studies are strongly warranted.

Associations between benign paroxysmal positional vertigo and seven mental disorders: a two-sample Mendelian randomization study

Background

The association between benign paroxysmal positional vertigo (BPPV) and various mental disorders is still controversial. This study used the Mendelian randomization (MR) method to clarify the correlation between BPPV and seven mental disorders (bipolar disorder, depression, anxiety disorder, schizophrenia, suicidality, neuroticism, and mood swings) to aid in the exploration of BPPV complications and prevention and early treatment of mental disorders.

Methods

The datasets for BPPV and seven mental disorders were obtained from genome-wide association studies (GWASs). Two-sample MR was used to analyze the correlation between exposure (BPPV) and various outcomes (bipolar disorder, depression, anxiety disorder, schizophrenia, suicidality, neuroticism, and mood swings). A reverse MR study was also performed. The inverse variance weighting (IVW) method, the MR-Egger method, the simple mode method, the weighted mode method, and the weighted median method were selected.

Results

The MR analysis and the reverse MR analysis results did not reveal significant associations between BPPV and bipolar disorder, depression, anxiety disorder, schizophrenia, suicidal tendencies, neuroticism, and mood swings. Interestingly, neuroticism (IVW: OR = 1.142, 95% CI: 1.059-1.231, P = 0.001; P-MR-PRESSO adjustment = 0.0002) and mood swings (IVW: OR = 3.119, 95% CI: 1.652-5.884, P = 0.0004) may have a significant association with BPPV. After MR-PRESSO adjustment, there was no horizontal pleiotropy or heterogeneity, and a significant association between neuroticism, mood swings, and BPPV has still been suggested.

Conclusion

We conducted MR analysis on genetic data from European populations and discovered a causal relationship between BPPV and the seven mental disorders. Our research findings suggest that BPPV may not have a significant causal relationship with bipolar disorder, depression, anxiety disorder, schizophrenia, or suicidal tendencies. However, neuroticism and mood swings may be risk factors for BPPV.

Clinical Evaluation of Curative Effect of SRM-IV Treatment System for Treating Refractory Benign Paroxysmal Positional Vertigo

Objective: This study aimed to explore the clinical characteristics of the automatic vestibular function therapy system (SRM-IV) fully automated benign paroxysmal positional vertigo (BPPV) diagnosis and treatment system in the treatment of refractory BPPV and evaluate the clinical effect of reduction therapy. Methods: The clinical data of 39 patients with refractory BPPV who were admitted to our hospital's department of neurology from January 2020 to May 2022 were analyzed retrospectively. Results: Eighteen, 14, and 5 patients were cured after 3, 4, and 5 reduction treatments, respectively, with the SRM-IV vertigo diagnosis and treatment system. Another 2 patients were unable to recover through canalith repositioning procedure, although they improved after alternating between manual repositioning and Brandt-Daroff habituation training. Conclusions: Most patients with refractory BPPV were cured after canalith repositioning procedure. The causes of intractability might involve many different aspects. Longer disease history and poor otolith mobility are also one of the reasons for this difficulty.

Increased functional connectivity between default mode network and visual network potentially correlates with duration of residual dizziness in patients with benign paroxysmal positional vertigo

Objective

To assess changes in static and dynamic functional network connectivity (sFNC and dFNC) and explore their correlations with clinical features in benign paroxysmal positional vertigo (BPPV) patients with residual dizziness (RD) after successful canalith repositioning maneuvers (CRM) using resting-state fMRI.

Methods

We studied resting-state fMRI data from 39 BPPV patients with RD compared to 38 BPPV patients without RD after successful CRM. Independent component analysis and methods of sliding window and k-means clustering were adopted to investigate the changes in dFNC and sFNC between the two groups. Additionally, temporal features and meta-states were compared between the two groups. Furthermore, the associations between fMRI results and clinical characteristics were analyzed using Pearson's partial correlation analysis.

Results

Compared with BPPV patients without RD, patients with RD had longer duration of BPPV and higher scores of dizziness handicap inventory (DHI) before successful CRM. BPPV patients with RD displayed no obvious abnormal sFNC compared to patients without RD. In the dFNC analysis, patients with RD showed increased FNC between default mode network (DMN) and visual network (VN) in state 4, the FNC between DMN and VN was positively correlated with the duration of RD. Furthermore, we found increased mean dwell time (MDT) and fractional windows (FW) in state 1 but decreased MDT and FW in state 3 in BPPV patients with RD. The FW of state 1 was positively correlated with DHI score before CRM, the MDT and FW of state 3 were negatively correlated with the duration of BPPV before CRM in patients with RD. Additionally, compared with patients without RD, patients with RD showed decreased number of states and state span.

Conclusion

The occurrence of RD might be associated with increased FNC between DMN and VN, and the increased FNC between DMN and VN might potentially correlate with the duration of RD symptoms. In addition, we found BPPV patients with RD showed altered global meta-states and temporal features. These findings are helpful for us to better understand the underlying neural mechanisms of RD and potentially contribute to intervention development for BPPV patients with RD.

[The six most frequent peripheral vestibular syndromes]

Three forms of peripheral vestibular disorders, each with its typical symptoms and clinical signs, can be differentiated functionally, anatomically and pathophysiologically: 1. inadequate unilateral paroxysmal stimulation or rarely inhibition of the peripheral vestibular system, e. g., BPPV, Menière's disease, vestibular paroxysmia or syndrome of the third mobile windows; 2. acute unilateral vestibulopathy leading to an acute vestibular tone imbalance manifesting as an acute peripheral vestibular syndrome; and 3. loss or impairment of function of the vestibular nerve and/or labyrinth: bilateral vestibulopathy. For all of these diseases, current diagnostic criteria by the Bárány-Society are available with a high clinical and scientific impact, also for clinical trials. The treatment depends on the underlying disease. It basically consists of 5 principles: 1. Explaining the symptoms and signs, pathophysiology, aetiology and treatment options to the patient; this is important for compliance, adherence and persistence. 2. Physical therapy: A) For BPPV specific liberatory maneuvers, depending on canal involved. Posterior canal: The new SémontPLUS maneuver is superior to the regular Sémont and Epley maneuvers; horizontal canal: the modified roll-maneuver; anterior canal the modified Yacovino-maneuver; 3. Symptomatic or causative drug therapy. There is still a deficit of placebo-controlled clinical trials so that the level of evidence for pharmacotherapy is most often low. 4. Surgery, mainly for the syndrome of the third mobile windows. 5. Psychotherapeutic measures for secondary functional dizziness.

Comparative Efficacy of Epley, Semont and Gans Maneuver in Treating Posterior Canal Benign Paroxysmal Positional Vertigo

Pharmacological therapies are used to control Benign paroxysmal positional vertigo (BPPV) symptoms for a brief period, discontinuing them usually results in recurrence. Canalolith repositioning maneuvers, including Epley, Semont, and Gans maneuvers, have been recommended for treating posterior canal BPPV with a high rate of success. A prospective, quasi-randomized study was carried out to compare the efficacy of Epley, Semont, and Gans maneuvers in the treatment of posterior canal BPPV and their durability. All patients over the age of 20 who met the BPPV diagnostic criteria, regardless of gender, were included in the study. Diagnosis of BPPV was done by Dix Hallpike maneuver. Typical posterior canal BPPV, the most frequent form of BPPV, is characterized by paroxysmal nystagmus evoked through the Dix-Hallpike test; the nystagmus is torsional clockwise for the left side, counter-clockwise for the right side, with a vertical up-beating component. The patients were uniformly quasi-randomized in a 1:1:1 ratio to be treated with Epley, Semont, and Gans maneuvers. After performing the maneuver, the patients were again subjected to the Dix-Hallpike test. Based on the result of the Dix-Hallpike test's positivity, the maneuvers were repeated up to three times. All the patients were called for a reassessment 30 days after the last intervention to assess the durability of the maneuver. In the study, 54.44% (49) of the 90 patients were female, whereas 45.56% (41) were male. Overall, 83.33% (75) of patients required only one attempt, 15.56% (14) required two attempts, and 1.11% (1) required three attempts to improve. In the Epley maneuvers group, 86.66% (26) required only one attempt, 10% (3) required two attempts, and 3.33% (1) required three attempts. Similarly, 83.33% (25) required only one attempt in the Gans maneuvers group, and 16.67% (5) required two attempts. In Semont maneuver groups, 80% (24) required only one attempt, and 20% (6) required two attempts. The recurrence of the symptoms was seen in a total of 11 patients: 27.27% (3 patients) of the Epley maneuvers group, 36.36% (4 patients) of the Gans maneuvers group, and 36.36% (4 patients) of the Semont maneuvers group. All three maneuvers show equal efficacy in reducing vertigo. The Epley maneuver may be more relevant in the treatment of BPPV compared to others, considering the slightly higher improvement rate and the requirement for fewer attempts for the treatment.

Hybrid maneuver for benign paroxysmal positional vertigo in individuals with limited neck mobility: Case series

INTRODUCTION

Mobility limitation of the cervical spine compromises the adequate execution of the canalith repositioning maneuver (CRM) in cases of posterior semicircular canal benign paroxysmal positional vertigo (PSC-BPPV-GEO). Thus, novel therapeutic options are required for such individuals.

OBJECTIVES

This study describes the effects of a change in the biomechanical position for the execution of the CRM on symptoms of dizziness and mobility limitation regarding flexion-extension of the cervical spine in older people with unilateral PSC-BPPV-GEO.

METHODS

A quasi-experimental viability study was conducted with 15 older adults (11 women; mean age: 72.2 ± 8.1 years). Treatment consisted of a hybrid CRM. The participants were evaluated before and after the intervention using the modified Dix & Hallpike test, Dizziness Handicap Inventory (DHI) and a visual analog scale (VAS) for vertigo.

RESULTS

The modified Dix & Hallpike test was negative in all cases after the execution of the hybrid CRM. A significant reduction was found for dizziness measured using the DHI (mean difference: -39.3 ± 9.4, p < 0.001) and VAS (mean difference: -2.9 ± 0.8, p = 0.04) after the intervention.

CONCLUSION

The hybrid CRM proved executable and satisfactory for resolving symptoms of dizziness in older adults with PSC-BPPV. The present findings are promising and randomized controlled clinical trials should be conducted to evaluate the effectiveness of the hybrid CRM in this population.

The use and effectiveness of the TRV Chair - a literature review

<b><br>Introduction:</b> Vertigo is a subjective sensation of swaying, tilting, spinning, instability, or being off-balance [1]. The concept of vertigo is not a precise term due to the possibility of its being related to numerous variable, frequently co-occurring sensations as experienced by the patient. For this reason, diagnosing the origin of vertigo quite frequently poses a serious dilemma for physicians. Dizziness can be of peripheral or central origin. Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral vertigo and is currently considered to account for about 14-42% of all cases of vertigo, depending on the authors [2-4]. However, this figure may be underestimated due to frequent misdiagnoses.</br> <b><br>Aim:</b> The aim of this paper is to review the currently available international literature on the use of the TRV chair so as to assess its usefulness and effectiveness in the diagnostics and possibly subsequent treatment of BPPV and its components.</br> <b><br>Materials and methods:</b> Included in this literature review are peer-reviewed papers authored by various research teams as available in PubMed, Google Scholar, and Scopus databases.</br> <b><br>Results:</b> The TRV chair is helpful in precise diagnosis and subsequent treatment of BPPV subtypes (canalithiasis and cupulolithiasis) as well as in the evaluation of the number of affected canals, as shown in the papers analyzed in this review.</br> <b><br>Conclusions:</b> The use of TRV in the context of diagnosis and therapy of benign paroxysmal positional vertigo presents with potential for the improvement of diagnostic results, management protocols, and patients' quality of lives.</br>.

The effectiveness of the modified Epley maneuver for the treatment of posterior semicircular canal benign paroxysmal positional vertigo

Objective

To compare the repositioning effect of the modified Epley maneuver and the traditional Epley maneuver for posterior semicircular canal benign paroxysmal positional vertigo (PC-BPPV).

Methods

Sixty-five patients with unilateral PC-BPPV were randomly divided into two groups. The control group received the traditional Epley maneuver, while the experimental group received the modified Epley maneuver, which prolonged the time in the healthy side lying position and the final bowing position. The number of successful repositions after one, two, and three attempts and the total number of successful repositions were recorded and compared between the two groups. A BPPV virtual simulation model was used to analyze the mechanism of the modified Epley maneuver.

Results

The first repositioning success rate of the experimental group was significantly higher than that of the control group (85% vs. 63%, p = 0.040). The experimental group achieved 100% repositioning success rate after two attempts, while the control group needed three attempts to reach 86% repositioning success rate. Four cases in the control group experienced canal switching during the repositioning process, while none in the experimental group did. The BPPV virtual simulation model showed that the modified Epley maneuver could facilitate the passage of otoliths through the posterior arm of the posterior semicircular canal, especially through the location of obstruction.

Conclusion

The modified Epley maneuver is more effective than the traditional Epley maneuver in improving the single repositioning success rate and reducing the canal switching rate for PC-BPPV. This study provides a new option for the treatment of BPPV.

Adoption of clinical practice guidelines in cases of benign paroxysmal positional vertigo

PURPOSE

Despite being one of the most common types of the peripheral vertigo encountered in clinical practice, benign paroxysmal positional vertigo (BPPV) remains underdiagnosed and undertreated, even in affluent health care systems. The publication of fully updated clinical practice guidelines significantly facilitated the diagnosis and treatment of BPPV. This study evaluates the adoption of the guidelines in our clinical setting and reviews further recommendations for quality-of-care improvement.

METHODS

This retrospective cross-sectional survey included a total of 1155 adult patients diagnosed with BPPV at the biggest tertiary care center in the country during a 5-year period (2017-2021). The data for the first three years (2017-2020) and 919 patients were collected in full, and for the remaining 236 patients (2020-2021) only partially due to the disturbance in referrals caused by COVID-19 pandemic.

RESULTS

The familiarity with and adherence to the published clinical guidelines by physicians judged by patients' charts and our health care database were overall unsatisfactory. The adherence varied from 0 to 40.5% in our sample. The recommendations for making the diagnosis and for repositioning procedure as first-line therapy were followed in only 20-30% of cases.

CONCLUSION

There are large opportunities for improvement in quality of care of BPPV patients. Apart from constant and systematic education at the primary health care level, the health care system may need to adopt more advanced measures of ensuring better adherence to guidelines and subsequent reduction in medical costs.

What is the current status of primary care in the diagnosis and treatment of patients with vertigo and dizziness in Switzerland? A national survey

Background

Vertigo and dizziness are among the most frequent presenting symptoms in the primary care physicians' (PCPs) office. With patients facing difficulties in describing their complaints and clinical findings often being subtle and transient, the diagnostic workup of the dizzy patient remains challenging. We aimed to gain more insights into the current state of practice in order to identify the limitations and needs of the PCPs and define strategies to continuously improve their knowledge in the care of the dizzy patient.

Materials and methods

Board-certified PCPs working in Switzerland were invited to participate in an online survey. A descriptive statistical analysis was performed, and prospectively defined hypotheses were assessed using regression analyses.

Results

A vast majority of participating PCPs (n = 152) were familiar with the key questions when taking the dizzy patient's history and with performing provocation/repositioning maneuvers when posterior-canal benign paroxysmal positional vertigo (BPPV) was suspected (91%). In contrast, strong agreement that performing the alternating cover test (21%), looking for a spontaneous nystagmus with fixation removed (42%), and performing the head-impulse test (47%) were important was considerably lower, and only 19% of PCPs were familiar with lateral-canal BPPV treatment. No specific diagnosis could be reached in substantial fractions of patients with acute (35% [25; 50%], median [inter-quartile range]) and episodic/chronic (50% [40; 65.8%]) dizziness/vertigo. Referral to specialists was higher in patients with episodic/chronic dizziness than in acutely dizzy patients (50% [20.3; 75] vs. 30% [20; 50]), with younger PCPs (aged 30-40 years) demonstrating significantly increased odds of referral to specialists (odds ratio = 2.20 [1.01-4.81], p = 0.048).

Conclusion

The assessment of dizzy patients takes longer than that of average patients in most primary care practices. Many dizzy patients remain undiagnosed even after a thorough examination, highlighting the challenges faced by PCPs and potentially leading to frequent referrals to specialists. To address this, it is crucial to promote state-of-the-art neuro-otological examination and treatment techniques that are currently neglected by most PCPs, such as "HINTS" and lateral-canal BPPV treatment. This can help reduce referral rates allowing more targeted treatment and referrals.

Role of Serum Markers in Benign Paroxysmal Positional Vertigo: Are They Useful?

Benign Paroxysmal Positional Vertigo is a peripheral labyrinthine disease and is one of the most common causes of dizziness in the general population. The proposed study was conducted in the Department of Otorhinolaryngology - Head and Neck Surgery at Indira Gandhi Medical College and Hospital, Shimla, Himachal Pradesh for a period of one year. About 44 patients aged between 14 and 60 years who came out positive on Dix Hallpike test and were willing for study were included in case group, whereas 44 patients aged 14-60 years who came out negative on Dix Hallpike test and with no complaint of vertiginous feeling were included in control group. Cases and controls were subjected to blood investigations like complete hemogram, calcium, vitamin D and uric acid. The mean Vitamin D was found to be significantly less in Case group (27.90 ± 15.89) compared to the Control group (39.05 ± 21.15) while no significant difference in mean Serum Calcium was observed between the Case group (8.48 ± 1.28) and Control group (8.88 ± 1.25). Serum uric acid levels were also compared and no significant difference was found between Case group (4.12 ± 1.15) and the Control group (4.06 ± 0.95). Our study found that there is relation between low vitamin D levels and occurrence of BPPV. Which supports the hypothesis that supplementation of Vitamin D might be helpful in preventing the occurrence and more frequent recurrence of BPPV. However in our study no association was found between serum calcium and uric acid levels with BPPV.

The role of electrocochleography and the caloric test in predicting short-term recurrence of benign paroxysmal positional vertigo

Objective

The study aimed to assess the value of physiological tests for evaluating inner ear function in predicting the short-term recurrence of benign paroxysmal positional vertigo (BPPV).

Materials and methods

The clinical information of all idiopathic BPPV patients who were treated in our clinic between February 2021 and December 2022 were reviewed. All patients included in the study had completed audiology examinations including pure tone audiometry, electrocochleography (EcochG), auditory brainstem response, and vestibular function examination such as the vestibular caloric test. The relationships between the results of the above tests and short-term recurrent BPPV were analyzed.

Results

A total of 96 patients with unilateral idiopathic BPPV were included for analysis. The numbers of non-recurrent patients and recurrent patients were 57 (59.4%) and 39 (40.6%), respectively. Only the results of EcochG and the caloric test showed significant differences between non-recurrent and recurrent patients (both P < 0.05). The results of these two tests were also found to be independently predictive of short-term recurrence (both P < 0.05). The non-recurrence rate for patients with normal results in both tests reached up to 78.3%, which was significantly higher than that for patients with abnormal results in both tests, 28.6% (P < 0.05).

Conclusion

Endolymphatic hydrops and canal paresis were independent risk factors for short-term recurrent BPPV. Additional treatments should be considered to reduce the recurrence rate, including dehydration treatment and vestibular rehabilitation.

The Semont-Plus Maneuver or the Epley Maneuver in Posterior Canal Benign Paroxysmal Positional Vertigo: A Randomized Clinical Study

Importance

Questions remain concerning treatment efficacy for the common condition of benign paroxysmal positional vertigo (BPPV).

Objective

To compare the effectiveness of the Semont-plus maneuver (SM-plus) and the Epley maneuver (EM) for treatment of posterior canal benign paroxysmal positional vertigo (pcBPPV) canalolithiasis.

Design, Setting, and Participants

This prospective randomized clinical trial was performed at 3 national referral centers (in Munich, Germany; Siena, Italy; and Bruges, Belgium) over 2 years, with a follow-up to 4 weeks after the initial examination. Recruitment took place from June 1, 2020, until March 10, 2022. Patients were selected randomly during routine outpatient care after being referred to 1 of the 3 centers. Two hundred fifty-three patients were assessed for eligibility. After consideration of the exclusion criteria as well as informed consent, 56 patients were excluded and 2 declined to participate, with 195 participants included in the final analysis. The analysis was prespecified and per-protocol.

Interventions

After being randomized to the SM-plus or the EM group, patients received 1 initial maneuver from a physician, then subsequently performed self-maneuvers at home 3 times in the morning, 3 times at noon, and 3 times in the evening.

Main Outcome and Measures

Patients had to document whether they could provoke positional vertigo every morning. The primary end point was the number of days until no positional vertigo could be induced on 3 consecutive mornings. The secondary end point was the effect of the single maneuver performed by the physician.

Results

Of the 195 participants included in the analysis, the mean (SD) age was 62.6 (13.9) years, and 125 (64.1%) were women. The mean (SD) time until no positional vertigo attacks could be induced in the SM-plus group was 2.0 (1.6) days (median, 1 [range, 1-8] day; 95% CI, 1.64-2.28 days); in the EM group, 3.3 (3.6) days (median, 2 [range, 1-20] days; 95% CI, 2.62-4.06 days) (P = .01; α = .05, 2-tailed Mann-Whitney test). For the secondary end point (effect of a single maneuver), no significant difference was detected (67 of 98 [68.4%] vs 61 of 97 [62.9%]; P = .42; α = .05). No serious adverse event was detected with both maneuvers. Nineteen patients (19.6%) in the EM group and 24 (24.5%) in the SM-plus group experienced relevant nausea.

Conclusions and Relevance

The SM-plus self-maneuver is superior to the EM self-maneuver in terms of the number of days until recovery in pcBPPV.

Trial Registration

ClinicalTrials.gov Identifier: NCT05853328.

Epley maneuver for benign paroxysmal positional vertigo: Evidence synthesis for guidelines for reasonable and appropriate care in the emergency department

BACKGROUND

Canalith repositioning maneuvers (such as the Epley maneuver) are recommended by specialty guidelines for management of benign paroxysmal positional vertigo (BPPV) yet are frequently underutilized in the emergency department (ED).

METHODS

We conducted a systematic review of systematic reviews to summarize the evidence of Epley maneuver for the treatment of posterior canal (pc) BPPV in any setting. We included systematic reviews of randomized controlled trials (RCTs) that compared Epley to control in adult patients with pc-BPPV. Titles, abstracts, and full texts were screened in duplicate. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) assessment was used to rate certainty of evidence. Odds ratios (OR) and 95% confidence intervals (CI) are reported. Meta-analysis of individual studies was conducted with random and fixed effects.

RESULTS

From 2,228 titles, 7 systematic reviews were selected for quality assessment. One review was of higher methodological quality, included only RCTs, and was the most current and comprehensive. Five of the 11 RCTs of the review, including 312 patients with pc-BPPV diagnosed by Dix-Hallpike, were relevant to our question. Meta-analysis of 4 RCTs (251 patients) showed the use of Epley (as compared to control) was associated with higher complete resolution of vertigo at 1 week (OR 7.19, CI 1.52 to 33.98, moderate certainty). Meta-analysis of 3 RCTs (195 patients) showed the use of Epley was associated with higher conversion to negative Dix-Hallpike at 1 week (OR 6.67, CI 1.52 to 33.98, moderate certainty). The number-needed-to-treat was 3. Meta-analysis of the outcomes at 1 month, and when observational studies were included, showed similar results. No serious adverse effects were reported.

CONCLUSIONS

Symptoms of pc-BPPV improve with the Epley maneuver. Emergency clinicians should become familiar with performing the Epley for BPPV. Further studies on ED implementation and clinician education of Epley are needed.

Epleys Versus Semonts Manoeuvre in Posterior Canal Benign Paroxysmal Positional Vertigo

Introduction: Benign paroxysmal positional vertigo (BPPV), the most common vestibular disorder is characterized by short-lived episodes of rotatory vertigo in association with rapid changes in head position. Diagnosis of BPPV is clinical. The principle of treatment of BPPV involves maneuvers comprising of head movements, in order to bring the free debris from the semicircular canal back to the utricle. In this study we tried to evaluate and compare Epleys and the Semonts manoeuvre in the treatment of Benign paroxysmal positional vertigo of the posterior semicircular canal in terms of subjective and objective improvement. Materials and methods: Study Design: This prospective randomized study included 200 vertigo patients attending ENT OPD of tertiary care centre with Dix Hallpike positive status. (September 2017 -August 2019). Objective improvement was compared in terms of Dix Hallpike positivity between both groups on weekly follow up for four weeks. Subjective improvement was compared in both the groups by dizziness Handicapp index ( DHI) on follow-ups. Results: Total 200 patients formed part of study, with 100 in each group. On comparing Dix Hallpike positivity between both groups on weekly follow ups there was no significant difference between both the groups. DHI, compared between both groups showed that Semonts Maneouver was significantly better. Conclusion: In patients of BPPV both Epleys and Semonts are equally effective objectively. However the subjective improvement was better in patients on whom Semonts manoeuvre was performed.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03624-5.

Impact of Age and Gender on Quality of Life Among General Otolaryngology Patients

OBJECTIVES

The combined effects of age and gender on health-related quality of life (HRQoL) in otolaryngology patients are unclear. This study tested the hypothesis that the effect of age on HRQoL differs by gender in otolaryngology patients.

METHODS

Patients seen in a general otolaryngology clinic were included in this retrospective chart review. HRQoL was measured by the SF-6D score. Patient characteristics, including demographics and category of chief otolaryngology complaint, were extracted from medical records. A multivariable linear regression analysis was used to analyze the combined effect of age and gender on HRQoL. The model was adjusted for race, ethnicity, number of complaint categories, and number of medications.

RESULTS

The study included 728 patients (age mean = 52, SD = 18; 48% male). Multivariable linear regression models found a significant interaction effect between age and gender (β = 0.213, p < 0.05). For younger patients, female gender was protective; however, at age greater than 35 years, female gender was a risk factor for decreased HRQoL. Compared to Black patients, Asian and other race patients reported significantly greater HRQoL (β = 0.207, p < 0.05 for Asian; β = 0.126, p < 0.05 for other races). Additionally, an antagonistic interaction effect was found between age and number of category of otolaryngology complaints in moderating HRQoL (β = 0.468, p < 0.001).

CONCLUSION

Age affects HRQoL differently in men than in women. Among otolaryngology patients, women experience a greater decrease in HRQoL as they age.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:801-806, 2023.

What is manipulation? A new definition

BACKGROUND

Definitions are important in healthcare. Unfortunately, problems can be found withall existing definitions of manipulation.

METHODS

This paper derives a set of eligibility criteria from prior definitions of manipulation to inform what should (and should not) be incorporated within a valid definition. These criteria were then used to select components from currently available empirical data to create a new definition.

RESULTS

The resulting definition of manipulation is: "Separation (gapping) of opposing articular surfaces of a synovial joint, caused by a force applied perpendicularly to those articular surfaces, that results in cavitation within the synovial fluid of that joint." The corresponding definition for the mechanical response of a manipulation is: "Separation (gapping) of opposing articular surfaces of a synovial joint that results in cavitation within the synovial fluid of that joint." In turn, the action of a manipulation can be defined as: "A force applied perpendicularly to the articular surfaces."

CONCLUSIONS

We believe these definitions to be valid (derived from and consistent with all available empirical data), complete (containing all necessary components), minimally sufficient (minimal redundancy, and sufficient to distinguish manipulation from other physical interventions), and robust (able to withstand important limitations embodied within sensible eligibility criteria). It is hoped that the simplicity and clarity of these definitions, and the transparency of their formation, will encourage their wide adoption in clinical, research, educational and professional settings.

Effect of Self-treatment of Recurrent Benign Paroxysmal Positional Vertigo: A Randomized Clinical Trial

Importance

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo with frequent recurrences.

Objective

To determine the efficacy of a web-based diagnosis and treatment of BPPV when it recurs in patients with confirmed and treated BPPV.

Design, Setting, and Participants

This randomized, controlled, parallel-group, double-blind trial took place in multiple referral-based university hospitals in South Korea between July 2017 and February 2020. Of 728 patients (age ≥20 years) with diagnosed and treated BPPV, 585 were enrolled after excluding 143 who declined participation, could not use the internet, or had spinal problems, multicanal BPPV, or cognitive dysfunction. Patients were followed up for recurrence at least for 2 years until February 2022.

Interventions

Patients were randomly assigned (1:1) to the treatment or control group. The patients in the treatment group completed a questionnaire for diagnosis and received a video clip for self-administration of canalith repositioning maneuver (CRM) according to the type of BPPV diagnosed when they experienced positional vertigo again. Patients in the control group received a video clip for self-administration of CRM according to the type of BPPV that had been diagnosed on enrollment.

Main Outcomes and Measures

The primary outcome was self-reported resolution of positional vertigo post-CRM. Secondary outcomes included difficulties and requirement for assistance when using the program and any falls or other adverse events related to CRM. The primary outcome was analyzed using both intention-to-treat and per-protocol methods.

Results

Of 585 patients enrolled, 292 were randomized to the treatment group (mean [SD] age, 60.3 [12.8] years, 37 [64%] women) and 293 were randomized to the control group (mean [SD] age, 61.1 [13.2] years; 50 [71%] women). Overall, 128 (21.9%) had recurrence (58 in the treatment group and 70 in the control group), and 109 (85.2%) successfully used the web-based system. In the intention-to-treat analysis, 42 of 58 individuals (72.4%) in the treatment group and 30 of 70 individuals (42.9%) in the control group reported vertigo resolution (χ2 test: 95% CI, 0.13-0.46; P < .001).

Conclusions and Relevance

This trial proved the efficacy of a web-based system for the diagnosis and treatment of recurrent BPPV. Use of this system may play an important role in telemedicine for vestibular disorders.

Trial Registration

Clinical Research Information Service Identifier: KCT0002364.

Characteristics of Benign Paroxysmal Positional Vertigo in Young Children

OBJECTIVES

This study aimed to determine the clinical characteristics of benign paroxysmal positional vertigo (BPPV) in young children.

STUDY DESIGN

Retrospective case review.

METHODS

All children <10 years old that have been diagnosed with BPPV at our pediatric vestibular program between December 2012-July 2021 were selected. Clinical features were identified by medical record review, including demographics, comorbidities, canal involvement, response to treatment, and incidence of recurrence.

RESULTS

A total of 34 children were diagnosed with BPPV with a mean age of 7.9 years old (SD ± 1/7; range 5-9) at the time of diagnosis and a male:female ratio of 1:1. Involved semicircular canals included posterior in 82% (n = 28), horizontal in 41% (n = 14), and superior in 24% (n = 8) of patients, respectively. Comorbid diagnoses included migraine (n = 14), concussion (n = 10), acute vestibular syndrome (n = 4), and persistent postural perceptual dizziness (n = 6). Recurrence with initially confirmed resolution occurred in 10 patients (29%) with a mean of 2.5 recurrences per patient (SD: 2.2; range 1-8). A family history of vertigo or migraine was identified in 11 and 17 patients, respectively.

CONCLUSIONS

BPPV is a cause of vertigo in children that may be overlooked. A relatively high proportion of patients demonstrated horizontal or superior canal involvement, recurrence, and additional comorbid causes of dizziness. Thus, providers evaluating young children with dizziness should perform diagnostic maneuvers to evaluate BPPV of all semicircular canals and continue to monitor children after successful treatment for recurrence.

LEVEL OF EVIDENCE

4, Case Series Laryngoscope, 133:694-699, 2023.

Comparison of the efficacy of the Epley maneuver and repeated Dix-Hallpike tests for eliminating positional nystagmus: A multicenter randomized study

Background and objectives

Patients with benign paroxysmal positional vertigo of the posterior canal (pc-BPPV) exhibit BPPV fatigue, where the positional nystagmus diminishes with the repeated performance of the Dix-Hallpike test (DHt). BPPV fatigue is thought to be caused by the disintegration of lumps of otoconial debris into smaller parts and can eliminate positional nystagmus within a few minutes [similar to the immediate effect of the Epley maneuver (EM)]. In this study, we aimed to show the non-inferiority of the repeated DHt to the EM for eliminating positional nystagmus after 1 week.

Methods

This multicenter, randomized controlled clinical trial was designed based on the CONSORT 2010 guidelines. Patients who had pc-BPPV were recruited and randomly allocated to Group A or Group B. Patients in Group A were treated using the EM, and patients in Group B were treated using repeated DHt. For both groups, head movements were repeated until the positional nystagmus had been eliminated (a maximum of three repetitions). After 1 week, the patients were examined to determine whether the positional nystagmus was still present. The groups were compared in terms of the percentage of patients whose positional nystagmus had been eliminated, with the non-inferiority margin set at 15%.

Results

Data for a total of 180 patients were analyzed (90 patients per group). Positional nystagmus had been eliminated in 50.0% of the patients in Group A compared with 47.8% in Group B. The upper limit of the 95% confidence interval for the difference was 14.5%, which was lower than the non-inferiority margin.

Discussion

This study showed the non-inferiority of repeated DHt to the EM for eliminating positional nystagmus after 1 week in patients with pc-BPPV and that even the disintegration of otoconial debris alone has a therapeutic effect for pc-BPPV. Disintegrated otoconial debris disappears from the posterior canal because it can be dissolved in the endolymph or returned to the vestibule via activities of daily living.

Classification of evidence

This study provides Class II evidence of the non-inferiority of repeated DHt to the EM for eliminating positional nystagmus after 1 week.

Registration number

UMIN000016421.

The Effect of Modified Epley Maneuver Implementation on the Anxiety and Comfort Levels of Patients with Posterior Canal Bening Paroxysmal Positional Vertigo: A Prospective Study

To evaluate the effects of the modified Epley maneuver during Posterior Canal Benign Paroxysmal Positional Vertigo (BPPV) on patients' anxiety and comfort levels. The study, organized as a prospective, worked with 72 patients who were diagnosed with Posterior Canal BPPV through Dix-Hallpike maneuver. The data for the study was collected through Descriptive Characteristics Form, General Comfort Questionnaire Short Form, and Beck Anxiety Inventory. It was found that that 63.9% of the patients experienced average-level anxiety before the implementation of the Epley maneuver and received a total of 3.07 ± .37 (1-6) from the General Comfort Questionnaire. Before applying the modified Epley maneuver and I and IV When the score changes after the week were examined, it was determined that there was a statistically significant difference in all scale scores, as comfort levels increased, anxiety levels decreased. Anxiety was identified as the most important predictor of patients' comfort level before and after the implementation of the modified Epley maneuver. In light of these findings, it can be said that modified Epley maneuver can safely be used to increase the comfort of patients with Posterior Canal BPPV. Considering that patients with BPPV can consult to emergency rooms, family clinics along with polyclinics, it is recommended to organize regular trainings on BPPV and the implementation of the Epley maneuver. It is believed that evaluation of BPPV patients for their anxiety and offer support when needed is important for the prognosis and patients' comfort.

Dynamic changes of otolith organ function before and after repositioning in patients with benign paroxysmal positional vertigo detected by virtual reality auxiliary technology: A cohort study

Objectives

To dynamically investigate otolith function in patients with benign paroxysmal positional vertigo (BPPV) before, after, and 1 month after repositioning, and explore the possible compensation mechanisms.

Methods

Thirty-six patients confirmed with BPPV (canal lithiasis) treated in our hospital between August 2020 and March 2021, as well as 36 health controls matched for age and gender (normal control group, NC group) were enrolled. For NC group, the virtual reality (VR) auxiliary static subjective visual vertical (SVV), subjective visual horizontal (SVH), and SVV of dynamic unilateral centrifugation (DUC), were measured at inclusion. For the BPPV group, visual analog scale (VAS) was used to assess the vertigo degree, while static SVV, SVH, and DUC were performed before, after, and 1 month after repositioning. First, we compare the deviations of SVV0/SVH0° when the subject's head is in the positive position, and SVV of DUC between BPPV and NC groups before repositioning, after which we compared the deviations in SVV45, SVV90, SVH45, SVH90°, and SVV of DUC between the affected and unaffected sides before repositioning. Finally, paired t-test was used to compare the VAS score, deviations in static SVV0, SVV45, SVV90, SVH0, SVH45, and SVH90°, and deviations in SVV of DUC before, after, and 1 month after repositioning. (Here, 0, 45, and 90° refer to the angle which the center axis of head deviates from the gravity line.)

Results

SVV0 SVH0°, and SVV of DUC at 120 and 180°/s 0 significantly differed between BPPV and NC group before repositioning. The deviations in SVV45, SVV90, SVH45, SVH90°, and SVV of DUC at 120°/s-2 and 180°/s-4.5 did not significantly differ between bilateral sides in BPPV patients before repositioning. The deviation in SVH90° was significantly lower after repositioning than before. The deviation in SVH45° was significantly higher 1 month after repositioning than before. The deviation angle of SVV of DUC at 180°/s-0 was significantly lower after repositioning than before. The vertigo VAS score of patient with BPPV continued to decrease after repositioning.

Conclusion

Before repositioning, the otolithic organ function of BPPV patients was obviously impaired, with no significant difference between the healthy and affected ear. After repositioning, there was a transient recovery of otolithic organ dysfunction followed by a sustained decline to similar levels to before repositioning.

Interdisciplinary Rehabilitation for Concussion Recovery (i-RECOveR): protocol of an investigator-blinded, randomised, case series with multiple baseline design to evaluate the feasibility and preliminary efficacy of a 12-week treatment for persistent post-concussion symptoms

BACKGROUND

Up to 25% of concussed individuals experience persistent post-concussion symptoms (PPCSs) which may interfere with the return to pre-injury activities and cause significant stress. Given that multiple etiological factors are thought to contribute to PPCSs, an interdisciplinary approach is recommended. This pilot study aims to primarily investigate the feasibility of a novel interdisciplinary treatment for PPCSs. Given this intervention is novel, uncertainty exists in terms of potential recruitment and retention rates, adverse events, and treatment adherence and fidelity. These factors will be explored to inform the feasibility of a phase-2 randomised controlled trial. Preliminary efficacy of this intervention will also be explored.

METHODS

Fifteen individuals with mild traumatic brain injury and PPCSs will receive up to 12 weeks of interdisciplinary treatments including psychology, physiotherapy, and medical interventions. Primary feasibility outcomes including data on recruitment and retention rates and treatment adherence will be explored descriptively. The cognitive therapy rating scale will be used to assess treatment fidelity. A single-case series with multiple baseline design will be used to explore preliminary efficacy. Participants will be randomly assigned to baseline phases of 2, 4, or 6 weeks. Regarding patient-centred secondary outcomes, the Rivermead Post-Concussion Symptoms Questionnaire will be assessed three times a week during baseline and treatment phases. Secondary outcomes also include measures of mood, sleep and fatigue, physical functioning, return to activity, and health-related quality of life. Patient-centred outcomes will be assessed at baseline, pretreatment, post-treatment, and one- and three-month follow-up. Thematic analysis of participant experiences will be explored through qualitative interviews.

DISCUSSION

Results from this trial will inform the feasibility and preliminary efficacy of this interdisciplinary concussion intervention and whether proceeding to a future definitive phase-2 randomised controlled trial is worthwhile. Understanding the end-user perspective of the treatment will also enable modifications to the treatment protocol for future trials to best suit the needs of individuals with PPCSs after mTBI. Outcomes from this trial can be directly translated into community rehabilitation programmes.

TRIAL REGISTRATION

ANZCTR, ACTRN12620001111965. Registered 27 October 2020, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=379118.

Effectiveness of Brandt Daroff, Semont and Epley maneuvers in the treatment of Benign Paroxysmal Positional Vertigo: A Randomized Controlled Clinical Trial

The aim was to compare the effectiveness of Brandt-Daroff, Semont and Epley maneuver in BPPV resolution. A Single Blind RCT in a Secondary Care Center was performed. Inclusion criteria were: patients with unilateral rotatory nystagmus on Dix-Hallpike Maneuver (DHM). Exclusion criteria: other causes of peripheral or central vertigo. Patients were randomized into 4 groups: Brandt-Daroff, "sham", Semont and Epley. Patients underwent allocation, 1st visit (at 1 week with reprise of original maneuver if persistent nystagmus) and 2nd visit (2 to 4 weeks) with repetitions of both DHM and DHI. Main Outcome Measures: Absence of nystagmus on DHM at 1st and 2nd visit evaluations and DHI score. Resolution was defined as the abscence of nystagmus. We included 34 patients (25 females, 9 males). Patients were randomized to Brandt-Daroff (n = 9), "sham" (n = 7), Semont (n = 9) and Epley (n = 9) group. Overall mean age was 59.85 years (SD ± 13.10). A total of 47.06% patients (n = 16) had negative DHM at 1st visit. Resolution for Brandt-Daroff was 22.22%, "sham" 28.57%, Semont 44.44% and Epley 88.88% (p = 0.024); at 2nd visit follow up, Epley achieved 100% resolution (other maneuvers: 42.86%, 16.67%, 44.44%, respectively. P = 0.006). The DHI improvement at 2nd visit for Brandt-Daroff was 21.17 points, "sham" 8.05, Semont 14.67 and Epley 61.78 (p = 0.001). Epley maneuver was superior to Brandt Daroff, "sham" and Semont maneuvers on nystagmus resolution and DHI improvement in patients with BPPV.

Seven years of experience with treatment of benign paroxysmal positional vertigo with a mechanical rotational chair

Background

Throughout the last decade, several mechanical rotational chairs have been developed for diagnostics and treatment of patients with a typical case history of benign paroxysmal positional vertigo. Sparse evidence, however, exists in terms of diagnostic accuracy and treatment efficiency with these mechanical rotational chairs. Also, recommendations for optimal use of these chairs are yet to be determined.

Objective

Primary objective was to evaluate overall treatment of benign paroxysmal positional vertigo with a mechanical rotational chair and secondary objectives included description of patient- and BPPV characteristics, determination of subjective and objective outcomes, as well as analyzation of recurrence- and recurrence-related risk factors following successful treatment.

Methods

Retrospective cohort study with 635 patients diagnosed with benign paroxysmal positional vertigo and treated by means of a mechanical rotational chair during a 7-year period from 2014 to 2021 at a tertiary University hospital. Patient- and disease-specific characteristics, treatment and recurrence data were collected through reviewing of patient records.

Results

The mean number of required treatments was 2.7 when accounting for a six percent treatment failure rate (defined as a need of more than 10 treatments), and 3.7 when not. Bilateral mono-canal affection required 3.8 treatments, unilateral multi-canal 3.5 treatments, and the combination of bilateral and multi-canal affection 5.2 treatments. All these scenarios were associated with significantly higher numbers of required treatments when compared to unilateral mono-canal affection, which required 1.9 treatments. The overall recurrence rate was 25.4 percent.

Conclusion

A mechanical rotational chair provides successful treatment of benign paroxysmal positional vertigo. Mechanical rotational chairs should primarily be reserved for the treatment of retractable and atypical benign paroxysmal positional vertigo patients. Many aspects of the optimal use of these chairs still require elaborative assessment.

Diagnostic Positional Tests and Therapeutic Maneuvers in the Management of Benign Paroxysmal Positional Vertigo

Benign Paroxysmal Positional Vertigo (BPPV), the most common vestibular disorder characterized by recurrent, brief episodes of vertigo, is attributed to the presence of otoconia in the semicircular canals. Two mechanisms contribute to its cause-canalolithiasis (otoconia freely mobile in the semicircular canal) and cupulolithiasis (otoconia adherent to the cupula). Posterior semicircular canal is the most common canal involved. Although the occurrence of BPPV in lateral and superior semicircular canal is rare, with the advancement in diagnostic techniques, their incidence is being reported in the past few years. Various diagnostic tests and therapeutic maneuvers have been described in the management of BPPV. The present report is a comprehensive review of the tests and maneuvers for BPPV written as a guide intended to help the clinicians in the accurate diagnosis and application of a canal-specific treatment maneuver for BPPV. A simplified algorithmic approach ("The Bangalore BPPV Algorithm") for the management of BPPV is described.

Effectiveness of a training intervention to improve the management of vertigo in primary care: a multicentre cluster-randomised trial, VERTAP

Background

Benign paroxysmal positional vertigo (BPPV) is the most common type of vertigo. While BPPV is best treated with canalicular repositioning manoeuvres, they are not routinely performed in primary care (PC).

Methods

To evaluate the effectiveness of blended training (online and face-to-face) on the diagnosis and management of vertigo to improve adherence of family doctors to clinical practice guidelines, we designed a community multicentre cluster-randomised open-label trial with an intervention (IG) and a control (GC) group of 10 primary care teams (PCT) each. Outcome variables will be ICD-10 diagnostic codes (proportion of nonspecific diagnoses such as dizziness and vertigo versus specific diagnoses such as BPPV, vestibular neuritis, and Menière’s disease); number of referrals to ENT or neurology specialists; prescription of antivertigo agents; and duration of sick leave due to vertigo. The baseline comparability of the two study groups will be analysed to ensure homogeneity. A description of all baseline variables will be performed. Student’s t-test will be used to evaluate the differences between the groups. Logistic regression multivariate analysis will be performed to study the relationship between baseline variables of professionals and centres with outcome variables.

Discussion

With the improvement of the diagnosis and management of vertigo by family doctors after this training, we expect an increase in the proportion of specific diagnoses, a decrease in the prescription of antivertigo agents, a decrease in referrals to ENT or neurology specialists and a reduction in the duration of sick leave due to temporary disability. The blended training will be easily expanded within primary care services, since it is mainly delivered online, with a single face-to-face session to ensure that the manoeuvres have been adequately learned.

Trial registration

ClinicalTrials.govNCT04929444. Registered June 18, 2021. This protocol has been approved by the Ethics Committee of the Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol) with the code 20/004-P. All patient data will be anonymised in agreement with the 2016/679 European Regulation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06548-7.

Efficacy of Benzodiazepines or Antihistamines for Patients With Acute Vertigo: A Systematic Review and Meta-analysis

Importance

Acute vertigo can be disabling. Antihistamines and benzodiazepines are frequently prescribed as "vestibular suppressants," but their efficacy is unclear.

Objective

To assess the efficacy of antihistamines and benzodiazepines in the treatment of acute vertigo from any underlying cause.

Data Sources

We searched the PubMed, CENTRAL, EMBASE, CINAHL, Scopus, and ClinicalTrials.gov databases from inception to January 14, 2019, without language restrictions. Bibliographies of the included studies and relevant reviews were also screened.

Study Selection

We included randomized clinical trials (RCTs) comparing antihistamine or benzodiazepine use with another comparator, placebo, or no intervention for patients with a duration of acute vertigo for 2 weeks or less. Studies of healthy volunteers, prophylactic treatment, or induced vertigo were excluded, as were studies that compared 2 medications from the same class.

Data Extraction and Synthesis

Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, data were extracted and risk of bias was assessed by 2 authors independently for each study. Data were pooled using a random-effects model.

Main Outcomes and Measures

The predefined primary outcome was change in 10- or 100-point vertigo or dizziness visual analog scale (VAS) scores at 2 hours after treatment. Secondary outcomes included change in nausea VAS scores at 2 hours, use of rescue medication at 2 hours, and improvement or resolution of vertigo at 1 week or 1 month.

Results

Of the 27 trials identified in the systematic review, 17 contributed to the quantitative meta-analysis and involved a total of 1586 participants. Seven trials with a total of 802 participants evaluated the primary outcome of interest: single-dose antihistamines resulted in significantly more improvement on 100-point VAS scores compared with benzodiazepines (difference, 16.1 [95% CI, 7.2 to 25.0]) but not compared with other active comparators (difference, 2.7 [95% CI, -6.1 to 11.5]). At 1 week and 1 month, neither daily benzodiazepines nor antihistamines were reported to be superior to placebo. RCTs comparing the immediate effects of medications (at 2 hours) after a single dose generally had a low risk of bias, but those evaluating 1-week and 1-month outcomes had a high risk of bias.

Conclusions and Relevance

Moderately strong evidence suggests that single-dose antihistamines provide greater vertigo relief at 2 hours than single-dose benzodiazepines. Furthermore, the available evidence did not support an association of benzodiazepine use with improvement in any outcomes for acute vertigo. Other evidence suggested that daily antihistamine use may not benefit patients with acute vertigo. Larger randomized trials comparing both antihistamines and benzodiazepines with placebo could better clarify the relative efficacy of these medications.

Clinical and cVEMP Evaluation Predict Short-Term Residual Dizziness After Successful Repositioning in Benign Paroxysmal Positional Vertigo

Objective

Residual dizziness (RD) is a frequent symptom with unknown pathogenesis, often complained about by the patients with benign paroxysmal positional vertigo (BPPV), even after a successful canalith repositioning procedure (CRP). This study aims to quantitatively evaluate the short-term RD severity and its risk factors in patients with BPPV after successful CRPs.

Methods

In total two hundred and twenty patients with BPPV after successful CRPs (W0) were prospectively followed up for 1 week (W1). Besides demographics and serial neuropsychological assessments (including dizziness handicap inventory-DHI, etc.), patients also received cervical/ocular vestibular evoked myogenic potential (c/oVEMP) evaluation. RD was defined as patients with dizziness or imbalance, dizziness visual analog scale (VAS) >1, and without positional vertigo or nystagmus at W1. Demographic, clinical, and VEMPs differences were compared among the three groups: patients with minor (dizziness VAS 1-3) and moderate-to-severe RD (dizziness VAS > 3) and without RD.

Results

The total frequency of RD at W1 was 49.1% (n = 108), with 32.3% (n = 71) minor, and 16.8% (n = 37) moderate-to-severe RD. Logistic regression analyses revealed that RD was closely associated with DHI status (OR = 2.101, P = 0.008) at W0, this effect was not present for minor RD. In addition to DHI score > 30 (OR = 4.898, P < 0.001) at W0, bilateral cVEMP absence (OR = 4.099, P = 0.005) was also an independent influential factor of moderate-to-severe RD.

Conclusion

Our study highlights the importance of RD quantified evaluation. DHI score >30 and bilateral cVEMP absence could increase the risk of short-term moderate-to-severe RD.

The Association Between Precuneus Function and Residual Dizziness in Patients With Benign Paroxysmal Positional Vertigo

Objectives

The purpose of this study was to apply the amplitude of the low-frequency fluctuation (ALFF) method to investigate the spontaneous brain activity alterations in patients with residual dizziness (RD) after successful canalith repositioning manoeuvre for benign paroxysmal positional vertigo (BPPV).

Methods

All BPPV patients underwent visual vertigo analog scale (VVAS) evaluations and functional magnetic resonance imaging (fMRI). The ALFF method was used to assess the spontaneous brain activity. Screening of brain regions with significant changes in ALFF values was based on analysis of the whole brain. We further analyze the relationship between ALFF values of the altered regions and VVAS scores in BPPV patients with RD.

Results

Fifteen BPPV patients with RD and fifteen without RD were recruited in this study. In contrast to without RD, RD patients exhibited increased scores in VVAS tests (p < 0.001) and RD patients also showed significant ALFF decrease in the bilateral precuneus (left: 251 voxels; x = −10, y = −69, z = 51; peak t-value = −3.25; right: 170 voxels; x = 4, y = −59, z = 42; peak t-value = −3.43). Correlation analysis revealed that the mean ALFF z-values in the left precuneus displayed significant negative correlations with the VVAS scores(r = −0.44, p = 0.01).

Conclusions

This study shows that RD is associated with left precuneus function as revealed by fMRI. It might provide useful information for explaining neural mechanisms in BPPV patients with RD.

Is a Mechanical Rotational Chair Superior to Manual Treatment Maneuvers on an Examination Bed in the Treatment of Benign Paroxysmal Positional Vertigo?

OBJECTIVE

To compare the efficacy of the TRV-chair, a mechanical rotational chair, against manual treatment maneuvers in the treatment of benign paroxysmal positional vertigo (BPPV).

STUDY DESIGN

Prospective open-label block-randomized controlled clinical trial.

SETTING

Tertiary referral center.

SUBJECTS

Seventy-four patients referred from primary care and subsequently diagnosed with BPPV.

INTERVENTIONS

Patients were randomized to diagnostics and treatment with either manual treatment maneuvers on an examination table or using the TRV-chair.

MAIN OUTCOMES

The primary outcome was treatment efficacy, defined as absence of positional nystagmus (with or without concomitant vertigo), following one treatment. Secondary outcomes were number of treatments necessary for treatment success and Dizziness Handicap Inventory (DHI) scores.

RESULTS

61.1% of the subjects in the TRV-group and 63.2% in the manual treatment group were treated successfully (p = 0.856). The differences in the number of treatments necessary to achieve treatment success as well as pre- and post-treatment DHI-scores between the TRV-group and the manual treatment group were nonsignificant.

CONCLUSIONS

Traditional manual treatment maneuvers and treatment maneuvers performed with the TRV-chair are equally good at treating BPPV in patients referred directly from primary care.

A comparative study of two methods for treatment of benign paroxysmal positional vertigo in the emergency department

Introduction

Posterior canal benign paroxysmal positional vertigo (PC-BPPV) is considered the most common cause of peripheral vertigo in the emergency department (ED). Although the canalith repositioning maneuver (CRM) is the standard of care, the most effective method to deliver it in the ED has been poorly studied.

Objective

To compare two protocols of the Epley maneuver for the treatment of PC-BPPV.

Patients and methods

We prospectively recruited 101 patients with unilateral PC-BPPV on physical examination, randomizing them to either a single Epley maneuver (EM) (n = 46) or multiple maneuvers (n = 55) on the same visit. Measured outcomes included presence/absence of positional nystagmus, resolution of vertigo, and score on the dizziness handicap inventory (DHI) at follow-up evaluations. The DHI was stratified into mild (≤30) and moderate-severe (>30).

Results

Normalization of the Dix-Hallpike maneuver at day 5 was observed in 38% of the single EM group and 44.4% in the multiple EM group (p = 0.62). The DHI showed reduction from 42.2 (SD 18.4) to 31.9 (SD 23.7) in the single EM group and from 43.7 (SD 22.9) to 33.5 (SD 21.5) in the multiple EM group (p = 0.06). A higher number of patients improved from moderate-severe to mild DHI (p = 0.03) in the single EM group compared to the multi-EM group (p = 0.23).

Conclusion

There was no statistically significant difference between performing a single EM versus multiple EMs for treatment of PC-BPPV in the emergency department. The single EM approach is associated with shorter physical contact between patients and examiner, which is logically safer in a pandemic context.

The resilience of the inner ear-vestibular and audiometric impact of transmastoid semicircular canal plugging

Background

Certain cases of superior semicircular canal dehiscence or benign paroxysmal positional vertigo can be treated by plugging of the affected semicircular canal. However, the extent of the impact on vestibular function and hearing during postoperative follow-up is not known.

Objective

To evaluate the evolution of vestibular function and hearing after plugging of a semicircular canal.

Methods

Six patients underwent testing before and 1 week, 2 months, and 6 months after plugging of the superior or posterior semicircular canal. Testing included caloric irrigation test, video Head Impulse Test (vHIT), cervical and ocular Vestibular Evoked Myogenic Potentials (VEMPs) and audiometry.

Results

Initially, ipsilateral caloric response decreased in all patients and vHIT vestibulo-ocular reflex (VOR) gain of each ipsilateral semicircular canal decreased in 4/6 patients. In 4/6 patients, postoperative caloric response recovered to > 60% of the preoperative value. In 5/6 patients, vHIT VOR gain was restored to > 85% of the preoperative value for both ipsilateral non-plugged semicircular canals. In the plugged semicircular canal, this gain decreased in 4/5 patients and recovered to > 50% of the preoperative value. Four patients preserved cervical and ocular VEMP responses. Bone conduction hearing deteriorated in 3/6 patients, but recovered within 6 months postoperatively, although one patient had a persistent loss of 15 dB at 8 kHz.

Conclusion

Plugging of a semicircular canal can affect both vestibular function and hearing. After initial deterioration, most patients show recovery during follow-up. However, a vestibular function loss or high-frequency hearing loss can persist. This stresses the importance of adequate counseling of patients considering plugging of a semicircular canal.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-021-10693-5.

Comparison of outcomes of the Epley and Semont maneuvers in posterior canal BPPV: A randomized controlled trial

OBJECTIVES

This study aims to compare the efficacy of the Epley and Semont maneuvers in relieving posterior canal benign paroxysmal positional vertigo (BPPV) arising in the in patients at the Outpatient Department of the Department of Otolaryngology, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand.

METHOD

In this prospective, randomized, comparative study, patients were assigned to receive one of the two treatment methods. First, BPPV was diagnosed with the Dix-Hallpike test. Then, each patient was treated by either the Epley or Semont maneuver. Immediately afterward, the efficacy of treatments was evaluated with the Dix-Hallpike test, and dizziness intensity was assessed with the visual analog scale (VAS).

RESULTS

This study enrolled 80 patients with posterior canal BPPV, 40 of which underwent the Epley maneuver and the other 40 underwent the Semont maneuver. In the first week, The Epley maneuver cured 37 (92.5%) of the 40 patients, and the Semont maneuver cured 36 (90%) of the 40 patients. Statistical analysis revealed no significant difference in the efficacy of these treatments (P = .251). Regarding dizziness intensity, VAS scores decreased from 6.48 to 1.65 after the Epley maneuver and from 6.53 to 2.18 after the Semont maneuver. Statistical analysis revealed that the Epley maneuver was superior to the Semont maneuver (P = .009) in reducing dizziness intensity.

CONCLUSIONS

The Epley and Semont maneuvers had similar efficacy in curing posterior canal BPPV. Regarding the severity of dizziness after treatment, the Epley maneuver produced significantly better results than did the Semont maneuver.Level of Evidence: II.

Benign paroxysmal positional vertigo and vestibular impairment among older adults with dizziness

OBJECTIVE

This article aimed to investigate older adults visiting a geriatric institution for a bone density measurement who reported dizziness on a daily or weekly basis (but who are not seeking care for dizziness), according to BPPV, vestibular function, walking abilities, and frequency of falls.

METHODS

Patients coming for a bone density measurement answered questions regarding occurrence of dizziness. Patients having dizziness on a daily or weekly basis were considered eligible for the study and invited for investigation at the Ear, Nose, and Throat clinic at Södra Älvsborg Hospital, Sweden. The patients answered questions about history of dizziness, medications, and comorbidities. They were also investigated for BPPV, vestibular deficits using the video head impulse test (vHIT), walking speed, Timed Up and Go test (TUG), and for perception of verticality and horizontality and Romberg test.

RESULTS

A total of 55 patients with dizziness were included. Fifteen (27%) were diagnosed with BPPV. Forty (73%) patients reported falling during the previous year, including 11 with BPPV. Dizziness when turning in bed was more common among patients with BPPV and increased the risk of BPPV 8-fold.

CONCLUSION

BPPV is common among older adults with dizziness, including among those not seeking medical care. It is important to identify older adults with BPPV and treat the condition since BPPV may contribute to falls. Asking about dizziness when turning in bed can help to distinguish patients with increased risk for BPPV and older adults with dizziness should be investigated for BPPV even when typical history is lacking. Level of evidence: 4.

Risk factors for residual dizziness in patients successfully treated for unilateral benign posterior semicircular canal paroxysmal positional vertigo

Objective

The risk factors for residual dizziness (RD) after successful treatment of benign paroxysmal positional vertigo (BPPV) are poorly characterized. We determined the risk factors for RD in patients with benign unilateral posterior semicircular canal paroxysmal positional vertigo (pc-BPPV) after successful treatment.

Methods

We conducted a prospective study of patients diagnosed with unilateral pc-BPPV between March 2015 and January 2017. Bone mineral density (BMD) was measured by dual-energy X-ray bone mineral densitometry. Participants underwent bithermal caloric testing (C-test) using videonystagmography and a canalith repositioning procedure (CRP). The occurrence of RD was the primary outcome. The participants underwent follow-up 1 week, 1 month, and 1 year after successful CRP, consisting of outpatient visits, questionnaires, and telephone interviews.

Results

We assessed 115 participants with unilateral pc-BPPV (31 men and 84 women) who were 53.2 ± 8.8 years old. RD occurred in 60 (52.2%) participants. The participants who experienced RD were older, had vertigo for longer before treatment, and were more likely to show a positive C-test and significant BMD loss.

Conclusions

We found that a significant reduction in BMD (T-score  < −1 standard deviation), a positive C-test, and older age are independently associated with RD in patients with pc-BPPV after successful CRP.

[Update on diagnosis and therapy in frequent vestibular and balance disorders]

The 8 most frequent vestibular disorders account for more than 70% of all presentations of vertigo, dizziness, and imbalance. In acute (and mostly non-repetitive) vestibular disorders acute unilateral vestibulopathy and vestibular stroke are most important, in episodic vestibulopathies benign paroxysmal positional vertigo (BPPV), Menière's disease and vestibular migraine, and in chronic vestibular disorders bilateral vestibulopathy/presbyvestibulopathy, functional dizziness and cerebellar dizziness. In the last decade, internationally consented diagnostic criteria and nomenclature were established for the most frequent vestibular disorders, which can be easily applied in clinical practice. The diagnostic guidelines are based on history taking (including onset, duration, course, triggers, accomanying symptoms), clinical examination, and only a few apparative tests (by videooculography and audiometry) for securing the diagnosis. Treatment of vestibular disorders includes physical training (repositioning maneuvers, multimodal balance training) and pharmacological approaches (e.g., corticosteroids, antiepileptics, antidepressants, potassium-canal-blockers, drugs enhancing neuroplasticity). For most drugs, high-level evidence from prospective controlled trials is lacking. In clinical practice, the most frequent vestibular disorders can be treated effectively, thus avoiding chronicity and secondary comorbidity (by immobility, falls or psychiatric disorders such as anxiety or depression).

BPPV: Comparison of the SémontPLUS With the Sémont Maneuver: A Prospective Randomized Trial

Objective: To compare the efficacy of the Sémont maneuver (SM) with the new “SémontPLUS maneuver” (SM+) in patients with posterior canal BPPV canalolithiasis (pcBPPVcan).

Methods and Patients: In a prospective trinational (Germany, Italy, and Belgium) randomized trial, patients with pcBPPVcan were randomly assigned to SM or SM+; SM+ means overextension of the head by 60+° below earth horizontal line during the movement of the patient toward the affected side. The first maneuver was done by the physician, and the subsequent maneuvers by the patients 9 times/day on their own. Each morning the patient documented whether vertigo could be induced. The primary endpoints were: “How long (in days) does it take until no attacks can be induced?” and “What is the efficacy of a single SM/SM+?”

Results: In the 194 patients analyzed (96 SM, 98 SM+), it took 2 days (median, range 1–21 days, mean 3.6 days) for recovery with SM and 1 day (median, range 1-8 days, mean 1.8 days) with SM+ (p = 0.001, Mann-Whitney U-test). There was no difference in the second primary endpoint (chi²-test, p = 0.39).

Interpretation: This prospective trial shows that SM+ is more effective than SM when repeated therapeutic maneuvers are performed but not when a single maneuver is performed. It also supports the hypothesis of the biophysical model: overextension of the head during step 2 brings the clot of otoconia beyond the vertex of the canal, which increases the effectivity.

Classification of Evidence: This study provides Class I evidence that SM+ is superior to SM for multiple treatment maneuvers of pcBPPVcan.

Epley manoeuvre for posterior semicircular canal benign paroxysmal positional vertigo in people with multiple sclerosis: protocol of a randomised controlled trial

INTRODUCTION

Vestibular disorders in multiple sclerosis (MS) could have central or peripheral origin. Although the central aetiology is the most expected in MS, peripheral damage is also significant in this disease. The most prevalent effect of vestibular peripheral damage is benign paroxysmal positional vertigo (BPPV). Impairments of the posterior semicircular canals represent 60%-90% of cases of BPPV. The standard gold treatment for this syndrome is the Epley manoeuvre (EM), the effectiveness of which has been poorly studied in patients with MS. Only one retrospective research study and a case study have reported encouraging results for EM with regard to resolution of posterior semicircular canal BPPV. The aim of this future randomised controlled trial (RCT) is to assess the effectiveness of EM for BPPV in participants with MS compared with a sham manoeuvre.

METHODS AND ANALYSIS

The current protocol describes an RCT with two-arm, parallel-group design. Randomisation, concealed allocation and double-blinding will be conducted to reduce possible bias. Participants and evaluators will be blinded to group allocation. At least 80 participants who meet all eligibility criteria will be recruited. Participants will have the EM or sham manoeuvre performed within the experimental or control group, respectively. The primary outcome of the study is changes in the Dix Hallpike test. The secondary outcome will be changes in self-perceived scales: Dizziness Handicap Inventory and Vestibular Disorders Activities of Daily Living Scale. The sample will be evaluated at baseline, immediately after the intervention and 48 hours postintervention.

ETHICS AND DISSEMINATION

The study was approved by the Andalusian Review Board and Ethics Committee of Virgen Macarena-Virgen del Rocio Hospitals (ID 0107-N-20, 23 July 2020). The results of the research will be disseminated by the investigators to peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04578262.

Curing Benign Paroxysmal Positional Vertigo in Patients With Brain Tumor: Case Series and Literature Review

Benign paroxysmal positional vertigo (BPPV) is a common vestibular disorder. It accounts for a third of all vestibular disorders diagnosed in the general population and is usually diagnosed and treated successfully. This article presents two cases of BPPV in a 52-year-old man and a 45-year-old patient, respectively. Both patients presented with recurrent episodes of vertigo associated with certain head movements. Medical history for the first patient included surgery for acoustic neuroma 12 months before developing the vertigo episodes. The second patient underwent a neurosurgical operation for glioblastoma multiforme (GBM) followed by radiotherapy three months before this presentation. Both patients were diagnosed with right-sided posterior canal BPPV after the Dix-Hallpike test. Their symptoms completely resolved within few minutes of the Epley maneuver. These cases highlight the importance of diagnosing and treating a potentially curable condition that can coexist in some patients with brain tumors.

An evaluation of serum Otolin-1 & Vitamin-D in benign paroxysmal positional vertigo

BACKGROUND

Serum otolin-1 is an inner ear protein exclusively expressed in otoconia and cells of vestibule and cochlea. Serum otolin-1 is found to be quantifiable in patients with BPPV. Low Vitamin-D is associated with pathogenesis of BPPV. Since otoconia degeneration contributes to BPPV, lack of Vitamin-D may impact otoconia structure and integrity.

OBJECTIVE

We aimed at studying the s.otolin-1 as biomarker and significance of vit-D in BPPV.

MATERIAL AND METHOD

23 patients in test and control groups respectively were chosen within the age of 20 to 65 years. All the patients were diagnosed using Dix Hallpike menouver and head roll test, patients were treated with appropriate Canal Reposition Menouver (CRM).

RESULTS

Serum Otolin-1 levels among the test ranged from 366 to 882 pg/mL with mean of 585.17 pg/mL whereas in control group ranged from 223 to 462 pg/mL with mean of 335.26 pg/mL. Mean Vitamin-D levels among the test group was 22.67 ng/mL (Range = 6.3-68.4) and that of control 15.43 pg/mL (Range = 5.4-27.7) respectively. The relationship between the serum Otolin-1 and Vitamin-D was not statistically significant.

CONCLUSION

Otolin-1 levels is increased in BPPV patients and is sensitive in BPPV, specificity needs to be validated. Role of vitamin-D with respect to inner ear proteins needs further investigation.

Vestibular rehabilitation in multiple sclerosis: study protocol for a randomised controlled trial and cost-effectiveness analysis comparing customised with booklet based vestibular rehabilitation for vestibulopathy and a 12 month observational cohort study of the symptom reduction and recurrence rate following treatment for benign paroxysmal positional vertigo

Background

Symptoms arising from vestibular system dysfunction are observed in 49–59% of people with Multiple Sclerosis (MS). Symptoms may include vertigo, dizziness and/or imbalance. These impact on functional ability, contribute to falls and significant health and social care costs. In people with MS, vestibular dysfunction can be due to peripheral pathology that may include Benign Paroxysmal Positional Vertigo (BPPV), as well as central or combined pathology. Vestibular symptoms may be treated with vestibular rehabilitation (VR), and with repositioning manoeuvres in the case of BPPV. However, there is a paucity of evidence about the rate and degree of symptom recovery with VR for people with MS and vestibulopathy. In addition, given the multiplicity of symptoms and underpinning vestibular pathologies often seen in people with MS, a customised VR approach may be more clinically appropriate and cost effective than generic booklet-based approaches. Likewise, BPPV should be identified and treated appropriately.

Methods/ design

People with MS and symptoms of vertigo, dizziness and/or imbalance will be screened for central and/or peripheral vestibulopathy and/or BPPV. Following consent, people with BPPV will be treated with re-positioning manoeuvres over 1–3 sessions and followed up at 6 and 12 months to assess for any re-occurrence of BPPV. People with central and/or peripheral vestibulopathy will be entered into a randomised controlled trial (RCT). Trial participants will be randomly allocated (1:1) to either a 12-week generic booklet-based home programme with telephone support or a 12-week VR programme consisting of customised treatment including 12 face-to-face sessions and a home exercise programme. Customised or booklet-based interventions will start 2 weeks after randomisation and all trial participants will be followed up 14 and 26 weeks from randomisation. The primary clinical outcome is the Dizziness Handicap Inventory at 26 weeks and the primary economic endpoint is quality-adjusted life-years. A range of secondary outcomes associated with vestibular function will be used.

Discussion

If customised VR is demonstrated to be clinically and cost-effective compared to generic booklet-based VR this will inform practice guidelines and the development of training packages for therapists in the diagnosis and treatment of vestibulopathy in people with MS.

Trial registration

ISRCTN Number: 27374299

Date of Registration 24/09/2018

Protocol Version 15 25/09/2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-020-01983-y.

The Clinical Response Time of Epley Maneuvers for Treatment of BPPV: A Hospital Based Study

The Epley maneuver is one of the most effective canalith repositioning procedures for treatment of posterior canal benign paroxysmal positional vertigo. It was found that response to BPPV varies with various factors such as types, single versus multiple canals BPPV, single or repeated cycles of head maneuvers in each session and duration of follow up of patient. Furthermore, less uniform result exists after treatment of BPPV among studies. Hence, the present study was taken with aim to investigate "The clinical response time of Epley maneuvers in treatment of BPPV: A Hospital Based Study. A total of 132 patients were included in study with age ranging from 30 to 50 years These patient visited department of ENT from 2019 to 2020 with complaint of vertigo. The subjective balancing assessments along with Dix-Hallpike maneuver were done and dizziness handicap inventory were administrated for screening of BPPV. The patients, who were diagnosed as posterior canal BPPV, were treated with Canal repositioning procedure i.e. Epley's Maneuvers during the initial visit. In addition, the same maneuvers were repeated after 1 week of sequential sessions if the patient reported no benefit or partial benefit from first session until the patient became asymptomatic and Dix-Hallpike maneuver were negative. The total number of sessions of Epley maneuver required by each patient was recorded. The findings of present study suggested that 37.69% of cases with posterior canal BPPV were asymptomatic after first CRP session of Epleys maneuver whereas repeated sessions were required in 61.52% of cases of BPPV and 0.76% of cases showed no response to repeated CRP up to 6 months. BPPV involving posterior canals may be easily detected by position test with good response to Epley maneuver. Short-term and long term control of symptoms of unilateral posterior SCC through this easy and simple procedure can be achieved. This cost effective approach requires proper trained and committed professionals. The repeated session may be required as complete recovery may not be immediate. Sometimes partial response can be due to canal switching during BPPV Hence, it is necessary to counsel the patient regarding the importance of follow-up.