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Strupp M, Mandala M, Vinck AS, Van Breda L, Salerni L, Gerb J, Bayer O, Mavrodiev V, Goldschagg N. The Semont-Plus Maneuver or the Epley Maneuver in Posterior Canal Benign Paroxysmal Positional Vertigo: A Randomized Clinical Study. JAMA Neurol 2023; 80:798-804. [PMID: 37358870 PMCID: PMC10425825 DOI: 10.1001/jamaneurol.2023.1408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 03/18/2023] [Indexed: 06/27/2023]
Abstract
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.
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Affiliation(s)
- Michael Strupp
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
- German Center for Vertigo and Balance Disorders, Ludwig Maximilian University, Munich, Germany
| | - Marco Mandala
- Department of ENT (Ear, Nose, and Throat), University of Siena, Siena, Italy
| | | | - Laure Van Breda
- Department of ENT, AZ Sint-Jan Brugge-Oostende AV, Brugge, Belgium
| | - Lorenzo Salerni
- Department of ENT (Ear, Nose, and Throat), University of Siena, Siena, Italy
| | - Johannes Gerb
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
- German Center for Vertigo and Balance Disorders, Ludwig Maximilian University, Munich, Germany
| | - Otmar Bayer
- German Center for Vertigo and Balance Disorders, Ludwig Maximilian University, Munich, Germany
- ReliaTec GmbH, Garching, Germany
| | - Vergil Mavrodiev
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
- German Center for Vertigo and Balance Disorders, Ludwig Maximilian University, Munich, Germany
| | - Nicolina Goldschagg
- Department of Neurology, Ludwig Maximilian University, Munich, Germany
- German Center for Vertigo and Balance Disorders, Ludwig Maximilian University, Munich, Germany
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Fu W, He F, Bai Y, Wang Y, Wei D, Shi Y, An X, Han J, Wang X. Assessment of residual dizziness after successful canalith repositioning maneuvre in benign paroxysmal positional vertigo patients: a questionnaire-based study. Eur Arch Otorhinolaryngol 2023; 280:137-141. [PMID: 35727415 DOI: 10.1007/s00405-022-07474-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/27/2022] [Indexed: 01/07/2023]
Abstract
OBJECTIVE The purpose of this study was to assess residual dizziness (RD) after successful canalith repositioning maneuvre (CRM) treatment in patients with benign paroxysmal positional vertigo (BPPV) using Dizziness Handicap Inventory (DHI) questionnaire and Visual Analog Scale (VAS). METHODS One hundred sixty BPPV patients after successful CRM treatment were recruited. All patients were divided into the residual dizziness (RD) group and without RD group. The DHI questionnaire and VAS before CRM and follow-up were asked to complete. For analysis of the improvement in symptom, we defined ∆DHI and ∆VAS as the difference between the baseline score and the follow-up score. RESULTS High incidence of RD was observed in the older patients (p < 0.001). The incidence of hypertension in the RD group was also significantly higher than that of the without RD group (p = 0.022). The ∆DHI-P, ∆DHI-E, ∆DHI-F, ∆DHI-T, and ∆VAS scores in the without RD group were significantly higher than that of the RD group (p < 0.001). When the cutoff point of the ∆DHI total scores was 17, the sensitivity was 64.86% and the specificity was 73.26% for diagnosing RD. When the cutoff point of the ∆VAS scores was 2.5, the sensitivity was 77.03% and the specificity was 81.40% for diagnosing RD. CONCLUSIONS RD is prone to occur in the older patients and ∆VAS exhibits higher sensitivity and specificity in assessing RD.
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Affiliation(s)
- Wei Fu
- Department of Geriatrics, Xijing Hospital, Air Force Medical University, No. 127, Changle West Road, Xi'an, 710032, Shaanxi, China
| | - Feng He
- Department of Neurology, Xijing Hospital, Air Force Medical University, No. 127, Changle West Road, Xi'an, 710032, Shaanxi, China
| | - Ya Bai
- Department of Neurology, Xijing Hospital, Air Force Medical University, No. 127, Changle West Road, Xi'an, 710032, Shaanxi, China
| | - Yuanyuan Wang
- Department of Neurology, Xijing Hospital, Air Force Medical University, No. 127, Changle West Road, Xi'an, 710032, Shaanxi, China
| | - Dong Wei
- Department of Neurology, Xijing Hospital, Air Force Medical University, No. 127, Changle West Road, Xi'an, 710032, Shaanxi, China
| | - Ying Shi
- Department of Neurology, Xijing Hospital, Air Force Medical University, No. 127, Changle West Road, Xi'an, 710032, Shaanxi, China
| | - Xinyue An
- Department of Neurology, Xijing Hospital, Air Force Medical University, No. 127, Changle West Road, Xi'an, 710032, Shaanxi, China
| | - Junliang Han
- Department of Neurology, Xijing Hospital, Air Force Medical University, No. 127, Changle West Road, Xi'an, 710032, Shaanxi, China
| | - Xiaoming Wang
- Department of Geriatrics, Xijing Hospital, Air Force Medical University, No. 127, Changle West Road, Xi'an, 710032, Shaanxi, China.
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Fu W, He F, Bai Y, An X, Shi Y, Han J, Wang X. Risk Factors of Residual Dizziness After Successful Treatment for Benign Paroxysmal Positional Vertigo in Middle-Aged and Older Adults. Front Neurol 2022; 13:850088. [PMID: 36176560 PMCID: PMC9514231 DOI: 10.3389/fneur.2022.850088] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 05/30/2022] [Indexed: 11/17/2022] Open
Abstract
Objective The purpose of this study was to analyze risk factors of residual dizziness (RD) after successful treatment for benign paroxysmal positional vertigo (BPPV) in middle-aged and older adults. Methods 181 patients with BPPV, after successful canalith repositioning maneuver (CRM) treatment, were recruited. All patients were divided into the middle-aged group (aged 45–59 years, n = 101) and the older group (over 60 years, n = 80). The clinical characteristics were recorded, including age, gender, numbers of maneuvers, involved canal, affected side, RD, comorbidities, dizziness handicap inventory score, and generalized anxiety disorder's 7-item scale score. Results The incidence of RD in the older group was significantly higher than that of the middle-aged group (p = 0.033). Multivariate logistic regression analysis shows that age (odds ratio = 1.042, p = 0.006), moderate to severe dizziness (odds ratio = 2.017, p = 0.034), and moderate to severe anxiety (odds ratio = 2.228, p = 0.017) were independently associated with RD in middle-aged and older adults. Conclusion Older adults exhibited higher incidence of RD after successful treatment for BPPV. Age, moderate to severe dizziness, and moderate to severe anxiety were independent risk factors of RD in middle-aged and older adults.
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Affiliation(s)
- Wei Fu
- Department of Geriatrics, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Feng He
- Department of Neurology, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Ya Bai
- Department of Neurology, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Xinyue An
- Department of Neurology, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Ying Shi
- Department of Neurology, Xijing Hospital, Air Force Medical University, Xi'an, China
| | - Junliang Han
- Department of Neurology, Xijing Hospital, Air Force Medical University, Xi'an, China
- *Correspondence: Junliang Han
| | - Xiaoming Wang
- Department of Geriatrics, Xijing Hospital, Air Force Medical University, Xi'an, China
- Xiaoming Wang
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Hunter BR, Wang AZ, Bucca AW, Musey PI, Strachan CC, Roumpf SK, Propst SL, Croft A, Menard LM, Kirschner JM. Efficacy of Benzodiazepines or Antihistamines for Patients With Acute Vertigo: A Systematic Review and Meta-analysis. JAMA Neurol 2022; 79:846-855. [PMID: 35849408 DOI: 10.1001/jamaneurol.2022.1858] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- Benton R Hunter
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Alfred Z Wang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Antonino W Bucca
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis.,Department of Emergency Medicine, Parma Medical Center, University Hospitals, Parma, Ohio
| | - Paul I Musey
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Christian C Strachan
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Steven K Roumpf
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Steven L Propst
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis.,Department of Emergency Medicine, University of Missouri, Springfield
| | - Alexander Croft
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Laura M Menard
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis
| | - Jonathan M Kirschner
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
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Cohen-Shwartz Y, Nechemya Y, Kalron A. Canalith repositioning procedure improves gait and static balance in people with posterior semicircular canal benign paroxysmal positional vertigo. J Vestib Res 2020; 30:335-343. [DOI: 10.3233/ves-200713] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Yafit Cohen-Shwartz
- Maccabi Healthcare Services, Rishon LeZion, Israel
- Department of Physical Therapy, School of Health Professions, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | | | - Alon Kalron
- Department of Physical Therapy, School of Health Professions, Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
- Sagol School of Neuroscience, Tel-Aviv University, Tel Aviv, Israel
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Dunlap PM, Khoja SS, Whitney SL, Freburger JK. Predictors of Physical Therapy Referral Among Persons With Peripheral Vestibular Disorders in the United States. Arch Phys Med Rehabil 2020; 101:1747-1753. [PMID: 32445851 DOI: 10.1016/j.apmr.2020.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 04/15/2020] [Accepted: 04/19/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the rate of physical therapy (PT) referral and patient and physician characteristics associated with PT referral for benign paroxysmal positional vertigo (BPPV) and other peripheral vestibular disorders (PVD) in ambulatory care clinics in the United States. DESIGN Cross-sectional analysis of the National Ambulatory Medical Care Survey 2004-2015 SETTING: Ambulatory care clinics in the United States. PARTICIPANTS We identified 5.6 million weighted adult visits for BPPV (International Classification of Diseases-9th Revision-Clinical Modifications (ICD-9-CM): 386.11) and 6.6 million weighted visits for other PVDs (ICD-9-CM: 386.1-386.9, excluding 386.11 and 386.2) made by patients 18 years and older from 2004 through 2015. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Patient, clinical, and physician characteristics were extracted, and descriptive statistics were stratified by referral to PT. Two multivariable logistic regression models were estimated for each diagnostic group (BPPV and other PVDs) to identify predictors of PT referral. RESULTS PT referrals for BPPV increased from 6.2% in the period from 2004 to 2006 to 12.9% in the period from 2013 to 2015, whereas PT referrals for other PVDs decreased from 3.8% in the period from 2004 to 2006 to 0.5% in the period from 2013 to 2015. Other insurance coverage (versus private) and neurologists and other specialists (versus otolaryngologists) were associated with a greater odds of PT referral for BPPV. Visits made in the Midwest and West (versus the Northeast) and in rural versus metropolitan areas had greater odds of PT referral for BPPV. Relative to otolaryngologists, primary care physicians were less likely to refer to PT for other PVDs. Visits made in metropolitan versus rural areas and visits with 1 or more comorbidities (versus none) had greater odds of PT referral for other PVDs. CONCLUSIONS PT referrals remain low for ambulatory care visits for BPPV and other PVDs in the United States. Referral to PT for BPPV and other PVDs varied by insurance type, physician specialty, and office location.
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Affiliation(s)
- Pamela M Dunlap
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA.
| | - Samannaaz S Khoja
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA
| | - Susan L Whitney
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA; Department of Otolaryngology, University of Pittsburgh, Pittsburgh, PA
| | - Janet K Freburger
- Department of Physical Therapy, University of Pittsburgh, Pittsburgh, PA
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Strupp M, Dlugaiczyk J, Ertl-Wagner BB, Rujescu D, Westhofen M, Dieterich M. Vestibular Disorders. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:300-310. [PMID: 32530417 PMCID: PMC7297064 DOI: 10.3238/arztebl.2020.0300] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 05/11/2019] [Accepted: 10/16/2019] [Indexed: 12/18/2022]
Abstract
BACKGROUND Recent research findings have improved the understanding of the diagnosis, pathophysiology, genetics, etiology, and treatment of peripheral, central, and functional vestibular vertigo syndromes. METHOD A literature search, with special attention to the current classification, treatment trials, Cochrane analyses, and other meta-analyses. RESULTS There are internationally accepted diagnostic criteria for benign positional paroxysmal vertigo, Menière's disease, bilateral vestibulopathy, vestibular paroxysmia, and functional dizziness. Whether an acute vestibular syndrome is central or peripheral can usually be determined rapidly on the basis of the history and the clinical examination. "Cere - bellar vertigo" is a clinically important entity. For bilateral vestibulopathy, balance training is an effective treatment. For Menière's disease, preventive treatment with betahistine (48 mg and 144 mg per day) is not superior to placebo. For vestibular paroxysmia, oxcarbazepine has been shown to be effective. Treatments that are probably effective for functional dizziness include vestibular rehabilitation, cognitive behavioral therapy, and serotonin reuptake inhibitors. CONCLUSION The diagnostic assessment of vestibular syndromes is much easier for clinicians now that it has been internationally standardized. There is still a lack of randomized, controlled trials on the treatment of, for example, Menière's disease, vestibular migraine, and "cerebellar vertigo."
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Affiliation(s)
- Michael Strupp
- Department of Neurology, Ludwig Maximilians University, Munich (LMU); German Center for Dizziness and Balance Disorders, Ludwig Maximilians University, Munich (LMU); Medical Imaging, University of Toronto, Canada; University Clinic and Outpatient Department for Psychiatry, Psychotherapy and Psychosomatics, University of Halle-Wittenberg; Department of Otorhinolaryngology and Plastic Head and Neck Surgery, University Medical Center, RWTH Aachen; Munich Cluster for Systems Neurology (SyNergy), Munich
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Abstract
PURPOSE OF THE REVIEW To define the best up-to-date practical approach to treat benign paroxysmal positional vertigo (BPPV). RECENT FINDINGS Both posterior and horizontal canal BPPV canalith repositioning maneuvers (Semont, Epley, and Gufoni's maneuvers) are level 1 evidence treatment for evidence-based medicine. The choice of maneuver (since their efficacy is comparable) is up to the clinician's preferences, failure of the previous maneuver, or movement restrictions of the patient. Maneuvers for controversial variants, such as anterior canal and apogeotropic posterior canal BPPV, have weaker evidence of efficacy. Despite this, these variants are increasingly diagnosed and treated. Maneuvers also play a role in the differential diagnosis with central vestibular disorders. Chair-assisted treatment may be of help if available while surgical canal plugging should be indicated in selected same-canal, same-side intractable severe BPPV. The primary evidence-based treatment strategy for BPPV should be physical therapy through maneuvers. Despite the high success rate of liberatory maneuvers, there is a low percentage of subjects who have unsatisfactory outcomes. These patients need to be investigated to identify recurrences, multiple canal involvement, associated comorbidities (migraine, persistent postural perceptual dizziness), or risk factors for recurrences (low vitamin D serum level). Future research should also identify the optimum maneuvers for variants whose diagnosis and treatment are still a matter of some debate.
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