Balance in posterior and horizontal canal type benign paroxysmal positional vertigo before and after canalith repositioning maneuvers

Benign paroxysmal positional vertigo without dizziness is common in people presenting to falls clinics

PURPOSE

To determine the prevalence of benign paroxysmal positional vertigo without dizziness, a treatable falls risk factor in people attending outpatient falls clinics.

METHODS

Over 6 years, 618 people at risk of falls attending 2 falls clinics were assessed for benign paroxysmal positional vertigo, whether dizzy or non dizzy. Data regarding demographics, canal location of positive tests and comorbidities were collected from medical records.

RESULTS

Thirty-nine percent (238) of people with falls risk tested positive for benign paroxysmal positional vertigo; 62 (26%) or 1 in 4 of those testing positive were not dizzy. Thirty-nine of 104 (38%) testing positive for single canal benign paroxysmal positional vertigo and twenty-four of 134 (18%) testing positive for multiple canal benign paroxysmal positional vertigo were not dizzy. Comorbidities were common for all with falls risk but did not differentiate for benign paroxysmal positional vertigo on testing.

CONCLUSIONS

Benign paroxysmal positional vertigo is common in people attending falls clinics and contributes to falls risk. Dizziness is common in BPPV though 26% or 1 in 4 people testing positive were not dizzy and would be missed without mandatory testing. Testing should also include all semicircular canals as multiple-canal involvement was high.

Gait and Falls in Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-analysis

BACKGROUND AND PURPOSE

Benign paroxysmal positional vertigo (BPPV) is one of the most common vestibular disorders, and is treated effectively with particle repositioning maneuvers (PRM). The aim of this study was to assess the influence of BPPV and treatment effects of PRM on gait, falls, and fear of falling.

METHODS

Three databases and the reference lists of included articles were systematically searched for studies comparing gait and/or falls between (1) people with BPPV (pwBPPV) and controls and (2) pre- and posttreatment with PRM. The Joanna Briggs Institute critical appraisal tools were used to assess risk of bias.

RESULTS

Twenty of the 25 included studies were suitable for meta-analysis. Quality assessment resulted in 2 studies with high risk of bias, 13 with moderate risk, and 10 with low risk. PwBPPV walked slower and demonstrated more sway during tandem walking compared with controls. PwBPPV also walked slower during head rotations. After PRM, gait velocity during level walking increased significantly, and gait became safer according to gait assessment scales. Impairments during tandem walking and walking with head rotations did not improve. The number of fallers was significantly higher for pwBPPV than for controls. After treatment, the number of falls, number of pwBPPV who fell, and fear of falling decreased.

DISCUSSION AND CONCLUSIONS

BPPV increases the odds of falls and negatively impacts spatiotemporal parameters of gait. PRM improves falls, fear of falling, and gait during level walking. Additional rehabilitation might be necessary to improve gait while walking with head movements or tandem walking.Video Abstract available for more insights from the authors (see the Supplemental Digital Content Video, available at: http://links.lww.com/JNPT/A421 ).

Comparison of the Efficacy of Vestibular Rehabilitation and Pharmacological Treatment in Benign Paroxysmal Positional Vertigo

Aim: The aim of the study is to compare the effects of vestibular rehabilitation and pharmacological treatment in benign paroxysmal positional vertigo (BPPV). Materials and methods: Thirty patients (40.93 ± 8.66 years old) diagnosed with BPPV were recruited. Patients were equally divided into pharmacological control group and vestibular rehabilitation group. The pharmacological control group was further divided into Group A (n = 8, 2 doses/day, 24 mg betahistine) and Group B (n = 7, 1 dose/day, 50 mg dimenhydrinate in addition to betahistine). Patients in the rehabilitation group underwent repeated head and eye movements, and Epley or Barbecue Roll Maneuvers were applied for 4 weeks. Subjective assessment of vertigo was measured with the visual analog scale. Static balance parameters were measured with the tandem, one-legged stance, and Romberg tests. Dynamic visual acuity was measured with a Snellen chart, and vestibular dysfunction was measured with the Unterberger (Fukuda stepping) test. All parameters were evaluated before and after treatment. Results: Vestibular rehabilitation resulted in greater improvement in severity of vertigo, balance parameters except Romberg test, and vestibular dysfunction than pharmacological therapy (p < 0,001). There was no significant difference in dynamic visual acuity between groups (p = 0,24). The effects of medication with the active ingredients betahistine and dimenhydrinate were similar (p > 0,05). Conclusion: The vestibular rehabilitation method can positively change the severity of vertigo, balance ability, and vestibular dysfunction compared to pharmacological therapy. Dimenhydrinate administered in combination with betahistine was not superior to betahistine alone but can be recommended for its antiemetic effect.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03598-4.

Immediate Improvement in Subjective Visual Vertical and Disequilibrium Predicts Resolution of Benign Paroxysmal Positional Vertigo Following Single Canalith Repositioning Maneuver

Objective

To evaluate whether immediate post-canalith repositioning maneuver (CRM) vestibular changes are predictive of benign paroxysmal positional vertigo (BPPV) resolution.

Study Design

Retrospective cohort study.

Setting

Tertiary referral center.

Patients

Adults (n = 27) with posterior canal BPPV.

Interventions

Single CRM with Frenzel goggles.

Main Outcome Measures

The Visual Analog Scale (VAS) for disequilibrium, the subjective visual vertical (SVV), the subjective visual horizontal (SVH), and the Modified Clinical Test of Sensory Interaction on Balance (mCTSIB) were administered pre- and immediately following single CRM. Dix-Hallpike was performed 1-3 weeks after CRM to assess for BPPV resolution. Pre- and post-treatment vestibular assessments were compared between groups to determine if post-CRM vestibular changes could predict BPPV resolution.

Results

The change in VAS score following CRM treatment was statistically different between patients who responded to CRM treatment (n = 15) and those who did not (n = 12), (-0.07 points versus -2.40 points, respectively; P = 0.03). Likewise, a significantly greater improvement in SVV score was observed for CRM responders compared with CRM nonresponders (0.92° versus -0.06°, respectively; P = 0.02). Change in SVH and mCTSIB scores did not differ significantly between groups. Additionally, patient age was found to predict outcome of CRM treatment, with older patients more likely to experience persistent BPPV (P ≤ 0.01).

Conclusions

Immediate improvement in VAS and SVV scores following CRM may be useful in predicting resolution of BPPV and may assist in directing the timing and need for future interventions. Younger age may have a favorable predictive value for improvement following single CRM.

Assessment of sensory organization testing in benign paroxysmal positional vertigo patients before and after repositioning manoeuvre

INTRODUCTION AND OBJECTIVE

Benign paroxysmal positioning vertigo is considered the most common disorder of the peripheral vestibular system. After successful physical manoeuvres for BPPV, a number of patients complain of non-positional sustained imbalance of variable duration called residual dizziness lasting for several days. The objective of this study was to compare the posturographic changes before and one week after successful repositioning manoeuvres in patients with idiopathic BPPV.

MATERIALS AND METHODS

This study was a case-control study, where the first group was composed of 20 patients with confirmed BPPV diagnosis regardless of the affected canal or pathology. Twenty age and gender matched normal subjects constituted the control group. The sensory organization test was performed before and one week after a repositioning manoeuvre in BPPV patients.

RESULTS

All 20 BPPV patients, except 6 who had no significant improvement of symptoms even after disappearance of classic vertigo and nystagmus, had substantial improvement in sensory scores after CRPs in the antero-posterior visual and vestibular scores and the medio-lateral visual and global scores. All antero-posterior and medio-lateral scores before and after CRPs, except for the AP preferential score, were considerably poorer in BPPV patients than healthy subjects. The 6 patients, who showed no improvement after CRPs, presented with a history of non-specific symptoms i.e., light-headedness or sense of floating.

CONCLUSIONS

Sensory organization test might have a role in the assessment of residual dizziness in patients with BPPV after CRPs.

Neuropsychiatric Treatment for Mild Traumatic Brain Injury: Nonpharmacological Approaches

Postconcussive symptoms following mild traumatic brain injury (mTBI)/concussion are common, disabling, and challenging to manage. Patients can experience a range of symptoms (e.g., mood disturbance, headaches, insomnia, vestibular symptoms, and cognitive dysfunction), and neuropsychiatric management relies heavily on nonpharmacological and multidisciplinary approaches. This article presents an overview of current nonpharmacological strategies for postconcussive symptoms including psychoeducation; psychotherapy; vestibular, visual, and physical therapies; cognitive rehabilitation; as well as more novel approaches, such as neuromodulation. Ultimately, treatment and management of mTBI should begin early with appropriate psychoeducation/counseling, and be tailored based on core symptoms and individual goals.

Effectiveness of the Epley maneuver versus Cawthorne-Cooksey vestibular exercises in the treatment of posterior semicircular canal benign paroxysmal positional vertigo (BPPV): A randomized controlled trial

OBJECTIVE

Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral vertigo that mainly affects the posterior semicircular canal. Studies suggest that Epley maneuver could improve balance of patients, but Cawthorne-Cooksey vestibular exercises are still scarce. This study aimed to observe the effects of Cawthorne-Cooksey vestibular exercises applied after the Epley maneuver on balance, vertigo symptoms, and quality of life in posterior semicircular canal BPPV.

METHODS

Thirty-six patients with posterior semicircular canal BPPV were randomly assigned into Epley maneuver (EpleyM) and Epley maneuver and exercise (EpleyM&Exe) groups. All patients were treated with the Epley maneuver, while Cawthorne-Cooksey vestibular exercises were given to the EpleyM&Exe group as home exercises for 6 weeks. Their static and dynamic balance, vertigo symptoms, and quality of life were assessed at pre-, post-intervention (1st, 3rd and 6th weeks).

RESULTS

Thirty-two patients completed the study (mean age: 46.91 ± 9.78 years). Epley maneuver applied alone and combined with Cawthorne-Cooksey vestibular exercises, was found to be effective in 25 patients (78.1%), 6 patients (18.8%) and 1 patient (3.1%) at the 1st, 3rd and 6th weeks, respectively. After 6 weeks, both groups had gained significant improvements in balance, vertigo symptoms, and quality of life (p < 0.001); however, there were no significant differences between the groups, except for the static dominant leg balance test (p = 0.022).

CONCLUSIONS

The Epley maneuver can be considered as the first option compared to Cawthorne-Cooksey vestibular exercises. Exercises do not appear to have any additional effects in improving posterior semicircular canal BPPV symptoms.

A Systematic Review on the Association Between Vestibular Dysfunction and Balance Performance in Children With Hearing Loss

OBJECTIVES

The objective of this study was to understand the functional impact of vestibular dysfunction on balance control in children with hearing loss. The vestibular system is an important contributor to maintaining balance. In adults, vestibular dysfunction is known to lead to unsteadiness and falls. Considerably less is known about the effects of vestibular dysfunction in children with hearing loss.

DESIGN

We conducted a systematic review in concordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We included articles on children with hearing loss who underwent vestibular and balance testing. The Downs and Black checklist was used to assess the risk of bias.

RESULTS

A total of 20 articles were included in this systematic review, of which, 17 reported an association between vestibular dysfunction and balance abnormalities in children with hearing loss. Bias (as measured by the Downs and Black Checklist) was a concern, as most studies were nonblinded cohort studies or case series selected through convenience sampling.

CONCLUSIONS

Research to date has predominantly found that children with concomitant hearing loss and vestibular impairment tend to perform more poorly on balance measures than either children with hearing loss and normal vestibular function or children with both normal-hearing and normal vestibular function. A standardized approach to assessing both vestibular function and balance would better characterize the impact of vestibular dysfunction in children with hearing loss at the population level.

Assessment of sensory organization testing in benign paroxysmal positional vertigo patients before and after repositioning manoeuvre

INTRODUCTION AND OBJECTIVE

Benign paroxysmal positioning vertigo is considered the most common disorder of the peripheral vestibular system. After successful physical manoeuvres for BPPV, a number of patients complain of non-positional sustained imbalance of variable duration called residual dizziness lasting for several days. The objective of this study was to compare the posturographic changes before and one week after successful repositioning manoeuvres in patients with idiopathic BPPV.

MATERIALS AND METHODS

This study was a case-control study, where the first group was composed of 20 patients with confirmed BPPV diagnosis regardless of the affected canal or pathology. Twenty age and gender matched normal subjects constituted the control group. The sensory organization test was performed before and one week after a repositioning manoeuvre in BPPV patients.

RESULTS

All 20 BPPV patients, except 6 who had no significant improvement of symptoms even after disappearance of classic vertigo and nystagmus, had substantial improvement in sensory scores after CRPs in the antero-posterior visual and vestibular scores and the medio-lateral visual and global scores. All antero-posterior and medio-lateral scores before and after CRPs, except for the AP preferential score, were considerably poorer in BPPV patients than healthy subjects. The 6 patients, who showed no improvement after CRPs, presented with a history of non-specific symptoms i.e., light-headedness or sense of floating.

CONCLUSIONS

Sensory organization test might have a role in the assessment of residual dizziness in patients with BPPV after CRPs.

Effects of customized vestibular rehabilitation plus canalith repositioning maneuver on gait and balance in adults with Benign Paroxysmal Positional Vertigo: A Randomized Controlled Trial

BACKGROUND

Adults with unilateral posterior canal benign paroxysmal positional vertigo (BPPV) may continue to present with residual dizziness and balance impairments after the canalith repositioning maneuver (CRM). Customized Vestibular rehabilitation (VR) in addition to the standard CRM may improve postural control in adults with BPPV. However, the effectiveness of this intervention for improving dyanmic gait measures in adults with BPPV is unknown.

OBJECTIVE

We aimed to determine the effectiveness of customized VR in addition to the standard CRM on dynamic gait measures among adults with unilateral posterior canal BPPV.

METHODS

In this double blind, randomized controlled trial, 28 adults with BPPV were randomized to either control (n = 14, age: 54.36±8.55) or experimental (n = 14, age: 50.71±9.88) groups. The experimental and control groups received customized VR plus standard CRM for six weeks and standard CRM for two weeks respectively. Dynamic gait measures (duration of a complete gait cycle, stride velocity, turning duration and number of steps while turning) were recorded using a portable mobility sensor (iTUG) at baseline, week 4 and 6. A mixed model ANOVA was used to estimate the main effects of the interventions.

RESULTS

During walking, a group effect was demonstrated on gait duration, stride velocity, turning duration and number of steps while turning (p <  0.05).

CONCLUSIONS

Six weeks of customized VR performed in addition to the standard CRM was more effective than the standard CRM alone in improving balance and gait in adults with posterior canal BPPV. (252 words).

Walking stability in patients with benign paroxysmal positional vertigo: an objective assessment using wearable accelerometers and machine learning

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is one of the most common peripheral vestibular disorders leading to balance difficulties and increased fall risks. This study aims to investigate the walking stability of BPPV patients in clinical settings and propose a machine-learning-based classification method for determining the severity of gait disturbances of BPPV.

METHODS

Twenty-seven BPPV outpatients and twenty-seven healthy subjects completed level walking trials at self-preferred speed in clinical settings while wearing two accelerometers on the head and lower trunk, respectively. Temporo-spatial variables and six walking stability related variables [root mean square (RMS), harmonic ratio (HR), gait variability, step/stride regularity, and gait symmetry] derived from the acceleration signals were analyzed. A support vector machine model (SVM) based on the gait variables of BPPV patients were developed to differentiate patients from healthy controls and classify the handicapping effects of dizziness imposed by BPPV.

RESULTS

The results showed that BPPV patients employed a conservative gait and significantly reduced walking stability compared to the healthy controls. Significant different mediolateral HR at the lower trunk and anteroposterior step regularity at the head were found in BPPV patients among mild, moderate, and severe DHI (dizziness handicap inventory) subgroups. SVM classification achieved promising accuracies with area under the curve (AUC) of 0.78, 0.83, 0.85 and 0.96 respectively for differentiating patients from healthy controls and classifying the three stages of DHI subgroups. Study results suggest that the proposed gait analysis that is based on the coupling of wearable accelerometers and machine learning provides an objective approach for assessing gait disturbances and handicapping effects of dizziness imposed by BPPV.

Gait in Benign Paroxysmal Positional Vertigo

Purpose: Patients with benign paroxysmal positional vertigo (BPPV) experience gait unsteadiness not only during the attacks but also between the spells. This study aimed to measure gait changes in BPPV and determine whether these changes are associated with the involved canal or lesion side.

Methods: We recruited 33 patients with a diagnosis of unilateral BPPV. Patients with other vestibular or central nervous system disorders were excluded. Gait was assessed using the GAITRite™ system before and after canalith repositioning treatment (CRT).

Results: After CRT, improvements were observed in various gait parameters including velocity (p < 0.001), cadence (p < 0.001), functional ambulation profile (p = 0.011), and the coefficient of variation of stride time (p = 0.004). Exploration of the center of pressure (COP) distribution also revealed improved stabilization during locomotion after CRT. The spatiotemporal gait variables did not differ between the patients with horizontal- and posterior-canal BPPV, or between the ipsilesional and contralesional sides before CRT.

Conclusions: The gait parameters reflecting velocity and rhythmicity along with stability of COP distribution improved after the resolution of BPPV. Episodic overexcitation of semicircular canal may impair the vestibular information that is integrated with the other reference afferent systems and lead to impaired gait performance.

Canalith repositioning procedure improves gait and static balance in people with posterior semicircular canal benign paroxysmal positional vertigo

BACKGROUND: Investigations measuring gait tests have rarely been studied in the benign paroxysmal positional vertigo (BPPV) population. OBJECTIVE: Examine instrumented mobility metrics in people with posterior semicircular canal BPPV. We examined the impact of a canalith repositioning procedure (CRP), prior to and after treatment on instrumented mobility measures, comparing the scores to those of healthy controls. METHODS: At baseline, the subject performed a series of instrumented gait and balance tests and then, the CRP was performed. At re-evaluation (1-week later), identical gait and balance tests were assessed. In addition, the Hallpike-Dix test identified patients who had improved or had not improved in their BPPV signs and symptoms. RESULTS: Thirty-two people with BPPV (25 women) and 15 healthy subjects participated in the study. At baseline (pre-CRP), people with BPPV demonstrated an increased vestibular ratio, and walked more slowly compared with the healthy controls. The CRP resolved the vertigo in 90.6% of the BPPV subjects. Compared with the pre-CRP scores, the BPPV subjects demonstrated a decreased vestibular ratio and faster walking at the post-CRP evaluation. Out of the five parameters that were significantly different from the healthy values pre-CRP, only one remained different post-CRP. CONCLUSIONS: Besides vertigo and balance difficulties, people with BPPV demonstrate walking modifications. Furthermore, the CRP has a high success rate in improving not only vertigo but also in restoring gait and balance in persons with BPPV.

A Benign Paroxysmal Positional Vertigo Triage Clinic

PURPOSE

The purpose of this study was to evaluate the effectiveness of triaging patients with motion-provoked dizziness into a benign paroxysmal positional vertigo (BPPV) clinic.

METHOD

A retrospective chart review was performed of veterans who were tested and treated for BPPV in a triaged BPPV clinic and veterans who were tested and treated for BPPV in a traditional vestibular clinic.

RESULTS

The BPPV triage clinic had a hit rate of 39%. On average, the triaged BPPV clinic reduced patient wait times by 23 days relative to the wait times for the traditional vestibular clinic while also reducing patient costs.

CONCLUSION

Triaging patients with BPPV is one method to improve access to evaluation and treatment and a mechanism for the effective use of clinic time and resources.

The impact of diabetes on mobility, balance, and recovery after repositioning maneuvers in individuals with benign paroxysmal positional vertigo

AIM

The prevalence of benign paroxysmal positional vertigo (BPPV) is higher in people with type 2 diabetes (DM). The impact of DM on mobility, balance, and management of BPPV is unknown. This prospective study compared symptom severity, mobility and balance before and after the canalith repositioning maneuver (CRM) in people with posterior canal BPPV canalithiasis, with and without DM.

METHODS

Fifty participants, BPPV (n=34) and BPPV+DM (n=16) were examined for symptom severity (dizziness handicap inventory, DHI), mobility (functional gait assessment, FGA), and postural sway (using an accelerometer in five conditions) before and after the CRM. The number of maneuvers required for symptom resolution was recorded.

RESULTS

At baseline, no differences in DHI or FGA scores were seen between groups, however, people with BPPV+DM had higher sway velocity in the medio-lateral direction in tandem stance (p<0.01). After treatment, both groups improved in DHI and FGA scores (p<0.01), with no differences between groups. Decrease in sway velocity in the mediolateral direction (p=0.003) were seen in tandem stance in persons with BPPV+DM. There were no differences between the groups in the number of CRMs provided.

CONCLUSIONS

This pilot study showed no differences in symptom severity, mobility deficits or efficacy of CRM treatments in people with posterior canal BPPV canalithiasis with and without DM. Future studies examining the impact of the severity and duration of diabetes, as well as the influence of diabetic peripheral neuropathy on functional performance are essential.

Postural sway in individuals with type 2 diabetes and concurrent benign paroxysmal positional vertigo

BACKGROUND AND PURPOSE

diabetes has been shown to affect the peripheral vestibular end organs and is associated with an increase in the frequency of benign paroxysmal positional vertigo (BPPV). People with diabetes have higher postural sway; however, the impact of symptomatic BPPV on postural sway in individuals with diabetes is unclear. The purpose of this cross-sectional study was to examine postural sway in people with type 2 diabetes who have symptomatic, untreated BPPV (BPPVDM).

METHODS

fifty-two participants (mean age 56.9 ± 5.6 years) were enrolled: controls (n = 14), diabetes (n = 14), BPPV only (n = 13) and BPPVDM (n = 11). An inertial motion sensor was used to detect pelvic acceleration across five standing conditions with eyes open/closed on firm/foam surfaces. Range of acceleration (cm/s²), peak velocity (cm/s) and variability of sway [root mean square (RMS)] in the anterior-posterior (AP) and medial-lateral (ML) directions were used to compare postural sway between groups across conditions.

RESULTS

participants with BPPVDM had higher ranges of acceleration in the AP (p = 0.02) and ML (p = 0.02) directions, as well as higher peak velocity (p < 0.001) and RMS values (p = 0.006) in the AP direction compared to the control and diabetes groups. Standing on foam with eyes closed and tandem stance were challenging conditions for people with BPPVDM.

CONCLUSION

clinicians may consider using standing on foam with eyes closed and tandem standing with eyes open to assess postural control in people with BPPVDM to identify postural instability.

Association of dementia in patients with benign paroxysmal positional vertigo

OBJECTIVE

We conducted a cohort study to investigate whether benign paroxysmal positional vertigo (BPPV) is correlated with an increased risk of dementia.

METHODS

We established a case cohort comprising 7818 patients aged over 20 years who were diagnosed with BPPV from 2000 to 2010. In addition, we formed a control cohort by randomly selecting 31,272 people without BPPV and matched them with the BPPV patients according to gender, age, and index year. Cox proportional hazard regressions were performed to compute the hazard ratio (HR) of dementia after we adjusted for demographic characteristics and comorbidity.

RESULTS

The prevalence of comorbidity was higher among patients with BPPV than among those without BPPV. In addition, patients with BPPV exhibited a 1.24-fold (95% confidence interval, CI 1.09-1.40; P < 0.001) higher risk of dementia than those without BPPV after we adjusted for age, gender, and comorbidity. An analysis stratified according to demographic factors revealed that women with BPPV exhibited a 1.36-fold (95% CI 1.16-1.59; P < 0.001) higher risk of dementia. Patients with BPPV aged over 65 years exhibited a significantly higher risk of dementia (adjusted HR: 1.26; 95% CI 1.10-1.43; P < 0.001) than those without BPPV.

CONCLUSIONS

Patients with BPPV exhibited a higher risk of dementia than those without BPPV.

Residual Dizziness after Successful Repositioning Maneuver for Idiopathic Benign Paroxysmal Positional Vertigo: A Review

The benign paroxysmal positional vertigo (BPPV) is a vestibular disorder cause of vertigo. The BPPV may be corrected mechanically by repositioning maneuvers but even after successful maneuvers, some patients report residual dizziness for a certain period afterward. Early recognition and treatment might decrease the incidence of residual dizziness in patients with BPPV, especially in those patients with psychiatric comorbidities and in the elderly, lowering the risk of falling. Many pathogenetic hypotheses for residual dizziness are under debate. The purpose of this review was to identify, evaluate and review recent researches about possible causal factors involved in residual dizziness and the implications on clinical practice. A literature search was performed using different databases such as Pubmed and Scopus. The following search terms were used: residual dizziness, otolithic membrane and BPPV. The search found a total of 1192 titles, which were reduced to 963 after a procedure of de-duplication of the found titles. The research was then restricted to an interval of time comprised between 2000 and 2016 for a total of 800 titles. Among these titles, only those including the terms benign paroxysmal positional vertigo were considered eligible for this review. Only publications in English language were taken into consideration and we excluded those with not available abstract. Finally, 90 abstracts were obtained and critically evaluated by two different Authors, and additional studies were identified by hand searching from the references of artiche of interest. Only 53 were included in this work.

Effectiveness of the Parnes particle repositioning manoeuvre for posterior canal benign paroxysmal positional vertigo

BACKGROUND

Benign paroxysmal positional vertigo is a common vestibular disorder that negatively affects an individual's health-related quality of life. This study aimed to examine the effectiveness of the Parnes particle repositioning manoeuvre as an intervention for individuals with posterior canal benign paroxysmal positional vertigo.

METHODS

The de-identified records of 155 individuals treated with the Parnes manoeuvre were examined. Descriptive statistics were calculated, including the frequency and valid per cent of participants whose nystagmus was resolved with the Parnes manoeuvre.

RESULTS

In all, nystagmus was resolved with the Parnes manoeuvre in 145 participants (93.5 per cent). The mean number of manoeuvres needed to resolve the nystagmus was 1.3.

CONCLUSION

The Parnes manoeuvre proved to be as effective as the Epley canalith repositioning manoeuvre, currently the most common intervention, in treating individuals with posterior canal benign paroxysmal positional vertigo.

Clinical efficacy of the Romberg test using a foam pad to identify balance problems: a comparative study with the sensory organization test

The modified Romberg test using a foam pad ("MRuFP") as a bedside examination has been used to assess the function of the complex sensory input needed for upright stance. The objective of this study was to assess its clinical value detecting vestibular falls in comparison with the sensory organization test (SOT), the gold standard. In total, 80 patients who had undergone the MRuFP, SOT, and bithermal caloric tests were included in this study. The MRuFPs were performed on two (height 12 cm, MRu2FP) or three (18 cm, MRu3FP) layers of foam pads. The odds ratios of falling on SOT were calculated. Iterative algorithms were used for linear curve fitting between the balance time on the MRuFP and SOT equilibrium score (ES). The diagnostic performance of MRuFP under different conditions was poor, with low sensitivity (0.07-0.63), when the results of SOT were used as the gold standard. However, the odds ratios of failing SOT condition 5 were 6.78 (95% CI = 1.26-36.50) for patients with abnormal findings on eyes closed (EC)-MRu2FP and 10.91 (95% CI = 2.58-46.11) for those on the EC-MRu3FP in patients without caloric weakness. In patients with caloric weakness, the odds ratio of failing SOT condition 5 for patients with abnormal findings on EC-MRu2FP was 7.0 (95% CI = 0.69-70.74, p > 0.05), and 32.0 for those on EC-MRu3FP (95% CI = 2.81-364.7). A linear equation was presented as the model fit (adjusted R(2) = 0.355) predicting the SOT condition 5 ES according to the balance time on EC-MRu3FP. In conclusion, the EC-MRu3FP, as a bedside examination, correlated well with SOT condition 5 as an objective measure.

Forward and backward locomotion in individuals with dizziness

The vestibular system plays an important role in locomotion. Individuals with vestibular pathology present with gait abnormalities, which may increase their fall frequency. Backward walking (BW) has been suggested as a predictor of falls in other patient populations; however it has not been studied in individuals with dizziness. Our aims were: (1) to investigate the differences in forward walking (FW) and BW both between and within 3 groups: Healthy controls, individuals with dizziness and vestibular pathology, and individuals with dizziness without vestibular pathology, (2) describe differences in FW and BW between individuals that have fallen and those that have not. We studied 28 healthy controls (mean 53.8 ± 17 years), 21 individuals with pathophysiology of the vestibular system (mean 68.5 ± 13 years), and 18 individuals without a vestibular cause for their dizziness (mean 67.4 ± 17 years). Subjects performed 2 FW and 2 BW trials over the GAITRite walkway. Data on history of falls in the preceding year were collected. We found BW was different to FW within each group. When comparing between groups and correcting for age and gender, only BW velocity (beta=-11.390, p=0.019), cadence (beta=-8.471, p=0.021), step time (beta=0.067, p=0.007) and stride time (beta=0.137, p=0.005) were significantly affected by having dizziness, with no differences in FW characteristics. There were no differences between FW and BW between fallers and non-fallers. BW appears to be a better biomarker than FW for identifying individuals with symptoms of dizziness; though it does not appear to characterize those who fall.

The Incidence of Benign Paroxysmal Positional Vertigo (BPPV) in Patients Admitted to an Acquired Brain Injury Unit

Objective: Brain injury is described as one potential cause of benign paroxysmal positional vertigo (BPPV); however, there is little information regarding the actual incidence in people who have suffered a brain injury. The objectives of this study were to determine the incidence of BPPV in a group of inpatients with a brain injury and to document the pattern of recovery.

Methods: A retrospective chart review was used to collate data associated with dizziness and BPPV for all inpatients admitted to an acquired brain injury (ABI) unit over 1 year.

Results: Data from 89 individuals were collated. Forty-three individuals reported dizziness and 13 of these were clinically diagnosed with BPPV. All cases of BPPV occurred in individuals with traumatic brain injury (TBI) with 17.6% of this diagnostic group affected. Over half the cases were diagnosed with bilateral BPPV. Seventy per cent of individuals with BPPV required multiple treatments to resolve all symptoms.

Conclusions: Forty-one per cent of the inpatients who reported dizziness, and were able to be assessed, received a clinical diagnosis of BPPV. The study highlights the high incidence of BPPV following TBI, the importance of specifically enquiring about vertigo symptoms and undertaking appropriate assessment, and the increased complexity of treating BPPV in this group.

Repositioning nystagmus: prognostic usefulness?

CONCLUSIONS

The presence of orthotropic nystagmus (ON), in multiple positions, appears to predict the success of canalith repositioning maneuvers (CRMs). In this sense CRMs under video-Frenzel are informative for the immediate follow-up, although not related to the degree of disability or emotional distress. Still, attention should be given to psychological assistance even in cases of clinically cured benign paroxysmal positional vertigo (BPPV).

OBJECTIVE

The aim of the study was to highlight the prognostic value of nystagmus in CRMs for BPPV and its relevance for emotional and patient-perceived disability.

METHODS

A group of 57 patients were selected from 3 balance disorders centers. CRMs were performed under video-Frenzel control. Assessment of patient disability and positional nystagmus was performed 2 months later. Emotional (Cuestionario de Impacto Emocional del Vértigo, CIEV) and quality of life (Dizziness Handicap Inventory, DHI) impact were evaluated.

RESULTS

The posterior semicircular canal (SCC) was affected in 84.2% of cases, the horizontal SCC in 10.5%, and the anterior SCC in 5.1%. Appropriate CRMs were performed. ON was present in 67% of cases. Overall resolution after the first treatment was achieved in 56% of cases. With ON present the success rate was 63% and when not observed the rate was 42%. DHI or CIEV scores were not significantly different when comparing the presence vs absence of ON. In nine patients (16%) an abnormal CIEV score was observed after treatment, even though a cured status was achieved in six of these nine patients.

Benign paroxysmal positional vertigo in the elderly

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is the most frequent peripheral vertigo in the elderly. It is a well-characterized entity and generally easy to treat.

OBJECTIVE

To evaluate the main symptoms, time to consult for the problem, vertigo characteristics, treatment and follow-up in patients over 70 with BPPV.

METHODS

This was a retrospective cohort study. Four hundred and four patients were diagnosed to have BPPV (between January 2006 and December 2012); 211 of them were ≥70 years old (mean 77.7 years) and 193 <70 years old (mean 53.82 years).

RESULTS

Patients over 70 with BPPV took longer to consult for the problem (Spearman rho, p = 0.01). The frequency of a clinical presentation consisting of unsteadiness or imbalance without vertigo sensation is higher among elderly patients (χ(2), p = 10(-6)). The effectiveness of the repositioning maneuver is lower than in patients under 70 (χ(2), p = 0.002), and the recurrences are more frequent (χ(2), p = 0.04).

CONCLUSION

BPPV is a frequent entity in the elderly, and it is necessary to take it into account when older patients complain about imbalance. An appropriate treatment with repositioning maneuvers and prolonged follow-up are required in order to detect recurrences.

Geriatric vestibulopathy assessment and management

PURPOSE OF REVIEW

This review discusses the demographics of dizziness in the older person, the evaluation of the older dizzy patient and how the treatment of dizziness in older patients differs from that in younger individuals.

RECENT FINDINGS

Seven percent of all visits to primary care physicians for patients older than 65 years of age are for dizziness, and dizziness is the most common complaint for patients older than 75 years. In a German study, the 12-month prevalence of vertigo in the general population was 5% with an incidence of 1.4% in adults overall. For individuals aged 60-69 the 12-month prevalence was found to be 7.2% and in individuals 70 years of age or older 8.9%. Data from the United States National Health and Nutrition Examination Surveys indicated that the prevalence of vestibular dysfunction for individuals in the seventh decade of life, eighth decade of life, and older was 49.4, 68.7, and 84.8 percent, respectively. Only subtle age effects are seen on caloric and rotational testing whereas vestibular evoked myogenic potentials (VEMPs) change somewhat with age. Particle repositioning for benign paroxysmal positional vertigo combined with vestibular rehabilitation is more effective than only performing the repositioning maneuver. Tai Chi appears to be an effective intervention for older adults at risk for falling.

SUMMARY

When caring for an older dizzy patient always assess medication use, perform a Dix-Hallpike maneuver, obtain orthostatic vital signs, discuss fall risk precautions, and consider referral for vestibular rehabilitation.