"Positive to Negative" Dix-Hallpike test and Benign Paroxysmal Positional Vertigo recurrence in elderly undergoing Canalith Repositioning Maneuver and Vestibular Rehabilitation

Current Therapies in Patients With Posterior Semicircular Canal BPPV, a Systematic Review and Network Meta-analysis

OBJECTIVE

To compare the efficacy of different treatments for posterior semicircular canal benign paroxysmal positional vertigo (PC-BPPV) by using direct and indirect evidence from existing randomized data.

METHODS

Randomized case-control studies that compared the efficacy of various nonsurgical treatments in PC-BPPV patients at 1 week and 1 month of follow-up were comprehensively screened. Bayesian network meta-analysis was performed to evaluate direct and indirect treatment comparisons. We further conducted subgroup pairwise meta-analysis to explore the inconsistency between comparisons of the Epley versus a sham maneuver and the Epley versus the Semont maneuver.

RESULTS

A total of 41 parallel, randomized controlled studies were included. The Epley with vestibular rehabilitation (EVR), Epley, Semont and Hybrid maneuvers were effective in eliminating nystagmus during a Dix-Hallpike test at 1 week of follow-up (odds ratios [ORs]: 11.41-23.8, 95% credible interval [CrI]: excluding null), among which EVR showed the best efficacy (the surface area under the cumulative ranking curves [SUCRA] = 77.5%). However, at 1 month of follow-up, only the Semont (rank first, SUCRA = 76.1%) and Epley maneuvers (rank second, SUCRA = 65.3%) were effective in eliminating nystagmus during a Dix-Hallpike test. In the pairwise subgroup meta-analysis, for patients younger than 55 years of age, the efficacy of the Epley maneuver was comparable to that of the Semont maneuver [rate ratio (RR): 0.99, 95% confidence interval (CI): 0.93-1.05]; for patients with a longer duration before treatment, the effect of the Epley maneuver was equivalent to that of a sham maneuver (RR: 1.07, 95% CI: 0.90-1.29).

CONCLUSION

Among the 12 types of PC-BPPV treatments, the Epley, Semont, EVR, and Hybrid maneuvers were effective in eliminating nystagmus during a Dix-Hallpike test for PC-BPPV at 1 week of follow-up, whereas only the Epley and Semont maneuvers were effective at 1 month of follow-up. The duration before treatments and the age of patients might contribute to the efficacy of treatments.

A single Epley manoeuvre can improve self-perceptions of disability (quality of life) in patients with pc-BPPV: A randomised controlled trial in primary care

Posterior canal benign paroxysmal positional vertigo (pc-BPPV) causes physical, functional, and emotional impairment. The treatment is the Epley manoeuvre (EM).

Objective

The purpose of the study was to compare the impact of the EM and a sham manoeuvre in primary care on self-perceived disability.

Design

Randomised, double-blind, sham-controlled clinical trial conducted in primary care with a follow-up of 1 year.

Participants

Patients aged ≥18 years old diagnosed with pc-BPPV according to the Dix–Hallpike test (DHT) were randomised to:

Interventions

Intervention (EM) group or a control (sham manoeuvre) group.

Main measurements

The main study covariates were age, sex, history of depression and anxiety, presence of nystagmus in the DHT, patient-perceived disability assessed with the Dizziness Handicap Inventory – screening version (DHI-S). Data were analyzed using bivariate and multivariate mixed Tobit analyses.

Results

Overall, 134 patients were studied: 66 in the intervention group and 68 in the control group. Median age was 52 years (interquartile range [IQR], 38.25–68.00 years. standard deviation, 16.98) and 76.12% of the patients were women. The DHT triggered nystagmus in 40.30% of patients. The median total DHI-S score for the overall sample at baseline was 16 (IQR, 8.00–22.00); 16 [IQR, 10.5–24.0] vs 10 [6.0–14.0] for women vs men (P < .001). Patients treated with the EM experienced a mean reduction of 2.03 points in DHI-S score over the follow-up period compared with patients in the sham group.

Conclusions

Pc-BPPV affects the quality of life of primary care patients. A single EM can improve self-perceptions of disability by around 2 points on the DHI-S scale.

Clinical effect of vestibular rehabilitation on benign paroxysmal positional vertigo: A protocol for systematic review

BACKGROUND

This study will evaluate the clinical effect of vestibular rehabilitation (VR) on benign paroxysmal positional vertigo (BPPV).

METHODS

In this study, we will identify relevant trials on the topic published in MEDLINE, EBASE, Web of Science, Cochrane Library, Scopus, CINAHL, CBM, and CNKI from inception to the present. We will also search conference proceedings, thesis/dissertation, ongoing trials in clinical trial registry, and reference lists of included studies. Two researchers will independently carry out record selection, data extraction, and study quality assessment, respectively. Any disagreement will be arbitrated and solved with the help of a third researcher. If necessary, we will conduct random-effects meta-analysis to pool the effect estimates of included trials determined to be acceptable heterogeneity.

RESULTS

We will summarize the latest evidence to assess the effect of VR for the treatment of patients with BPPV.

CONCLUSION

The findings of this study will help determine whether or not VR is effective in treating BPPV.

OSF REGISTRATION

osf.io/k83y5.

Poor Treatment Outcomes Following Repositioning Maneuvers in Younger and Older Adults With Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-analysis

OBJECTIVE

This systematic review aimed to methodically review the available evidence on poor treatment outcomes after repositioning maneuver treatments in adults with BPPV and whether there are differences in the outcomes for older and younger adults.

DATA SOURCES

Embase, CINAHL, Scopus, PsycINFO (Ovid), Central Register of Controlled Trials (CENTRAL), and PubMed.

REVIEW METHODS

Studies were included if they were prospective experimental or observational studies with a minimal follow-up of 1 month; the subjects were at least 18 years old, had BPPV, and were treated with repositioning maneuvers. Studies were excluded if they were not available in English full text and if the outcomes used were confined to positional tests and subjective vertigo rating. Methodological quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklists. Meta-analysis was performed to compare outcomes for younger and older (≥60 years) subjects where multiple studies utilized similar outcomes.

RESULTS

Thirty-five studies were selected. The methodological quality was poor in more than 60% of the studies. Treatment efficacy, based on positional test results and symptom resolution and recurrence were the most common outcomes. Balance and quality of life measures improved after treatment but were not always normalized. Residual symptoms and psychoemotional consequences persisted in some subjects, despite BPPV resolution. Meta-analyses indicated poorer dynamic balance recovery and increased self-perceived level of handicap in the older group relative to the younger group.

CONCLUSIONS AND IMPLICATIONS

Although repositioning maneuvers were effective in BPPV management, some patients experienced residual dizziness, postural instability, recurrences, and psychoemotional consequences at least 1 month after repositioning. Moreover, older adults experienced less improvements in dynamic balance and self-perceived handicap rating compared with younger people. These issues may further impact on older adults with BPPV physically and mentally and should be addressed by future better-quality research and interventions.

Efficacy of Epley Maneuver on Quality of Life of Elderly Patients with Subjective BPPV

OBJECTIVES

This study aimed to evaluate the efficacy of the repositioning maneuver on quality of life in elderly patients with dizziness and/or vertigo.

MATERIALS AND METHODS

This controlled, prospective randomized clinical trial was conducted in elderly patients aged 65 years and above with a positive history of benign paroxysmal positional vertigo (BPPV), presence of vertigo, and no observable nystagmus during the Dix-Hallpike test, so-called Subjective BPPV (S-BPPV). Individuals were evaluated by visual analog scale (VAS) and dizziness handicap inventory (DHI). Groups were defined as treatment (treated with Epley maneuver bilaterally) or no treatment control (no treatment modality or canalith repositioning maneuver). Ten days after the first assessment, all patients were reassessed using VAS and DHI.

RESULTS

A total of 50 patients were randomized into two groups: 25 to the treatment group, and 25 to the control group. No significant differences were observed for baseline VAS and total DHI scores between the groups (p=0.636, p=0.846, respectively). On the other hand, after the reassessment, VAS and total DHI scores were both significantly reduced in the treatment group (p<0.001, p<0.001, respectively), but no reduction in either score was found in the control group (p=0.216, p=0.731, respectively).

CONCLUSION

This study showed that elderly patients with S-BPPV benefit from the Epley maneuver, in particular global and disease-specific quality of life.

Disability perceived by primary care patients with posterior canal benign paroxysmal positional vertigo

Background

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo. Little is known on how posterior canal BPPV affects health-related quality of life in patients diagnosed and treated at primary care facilities or on whether patients with subjective and objective disease perceive the effects differently. This study was designed to describe how patients diagnosed with posterior canal BPPV in primary care perceive disability.

Methods

Cross-sectional descriptive study performed at two urban primary care centers. Participants were patients aged 18 years or older with suspected posterior canal BPPV recruited for baseline evaluation in a clinical trial on the effectiveness of the Epley maneuver in primary care. The recruitment period was from November 2012 to January 2015. Perceived disability was evaluated using the Dizziness Handicap Inventory – Screening version (DHI-S). Other variables collected were age and sex, a history or diagnosis of anxiety or depression, treatment with antidepressants and/or anxiolytics, and results of the Dix-Hallpike (DH) test, which was considered positive when it triggered vertigo with or without nystagmus and negative when it triggered neither.

Results

The DH test was positive in 134 patients, 40.30% of whom had objective BPPV (vertigo with nystagmus). The median age of the patients was 52 years (interquartile range [IQR], 39.00–68.50 years) and 76.1% were women. The median total score on the DHI-S was 16 out of 40 (IQR, 8.00–22.00). Scores were higher (greater perceived disability) in women (p < 0.001) and patients with subjective BPPV (vertigo without nystagmus) (p = 0.033). The items perceived as causing the greatest disability were feeling depressed (67.1%) and worsening of the condition on turning over in bed (88%).

Conclusions

Patients diagnosed with posterior canal BPPV in primary care perceive their condition as a disability according to DHI-S scores, with higher levels of disability reported by women and patients with subjective BPPV. Feelings of depression and turning over in bed were associated with the greatest perceived difficulties.

Trial registration

ClinicalTrials.gov Identifier: NCT01969513. Retrospectively registered. First Posted: October 25, 2013. https://clinicaltrials.gov/ct2/show/NCT01969513

Effectiveness of Otolith Repositioning Maneuvers and Vestibular Rehabilitation exercises in elderly people with Benign Paroxysmal Positional Vertigo: a systematic review

INTRODUCTION

Benign Paroxysmal Positional Vertigo is highly prevalent in elderly people. This condition is related to vertigo, hearing loss, tinnitus, poor balance, gait disturbance, and an increase in risk of falls, leading to postural changes and quality of life decreasing.

OBJECTIVE

To evaluate the outcomes obtained by clinical trials on the effectiveness of Otolith Repositioning Maneuver and Vestibular Rehabilitation exercises in the treatment of Benign Paroxysmal Positional Vertigo in elderly.

METHODS

The literature research was performed using PubMed, Scopus, Web of Science and PEDro databases, and included randomized controlled clinical trials in English, Spanish and Portuguese, published during January 2000 to August 2016. The methodological quality of the studies was assessed by PEDro score and the outcomes analysis was done by critical revision of content.

RESULTS

Six studies were fully reviewed. The average age of participants ranged between 67.2 and 74.5 years. The articles were classified from 2 to 7/10 through the PEDro score. The main outcome measures analyzed were vertigo, positional nystagmus and postural balance. Additionally, the number of maneuvers necessary for remission of the symptoms, the quality of life, and the functionality were also assessed. The majority of the clinical trials used Otolith Repositioning Maneuver (n=5) and 3 articles performed Vestibular Rehabilitation exercises in addition to Otolith Repositioning Maneuver or pharmacotherapy. One study showed that the addition of movement restrictions after maneuver did not influence the outcomes.

CONCLUSION

There was a trend of improvement in Benign Paroxysmal Positional Vertigo symptomatology in elderly patients who underwent Otolith Repositioning Maneuver. There is sparse evidence from methodologically robust clinical trials that examined the effects of Otolith Repositioning Maneuver and Vestibular Rehabilitation exercises for treating Benign Paroxysmal Positional Vertigo in the elderly. Randomized controlled clinical trials with comprehensive assessment of symptoms, quality of life, function and long-term follow up are warranted.