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Metz D, Bryce K. The rationale and recommendations for inclusion of screening for benign paroxysmal positional vertigo in falls clinics. J Laryngol Otol 2024; 138:S32-S34. [PMID: 38291914 DOI: 10.1017/s0022215123002049] [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] [Indexed: 02/01/2024]
Abstract
BACKGROUND There have been many studies linking falls and benign paroxysmal positional vertigo. This article collates those studies, and demonstrates how a community falls service fast-tracked patients with benign paroxysmal positional vertigo by implementing validated screening tools and recognised guidance. OBJECTIVE This study aimed to explore whether routine screening of referrals to a community falls service can identify those with benign paroxysmal positional vertigo, for fast-tracked management. METHODS Patients referred to a community falls service were screened for possible benign paroxysmal positional vertigo using the Dizziness Handicap Inventory, and triaged to a physiotherapy-led falls and benign paroxysmal positional vertigo assessment service. RESULTS Twenty-five per cent of patients were fast-tracked to a falls and benign paroxysmal positional vertigo assessment service for management. The community falls service waiting list reduced by 25 per cent. CONCLUSION The data support incorporating assessment and treatment of benign paroxysmal positional vertigo into routine practice within all falls services.
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Affiliation(s)
- Dean Metz
- Community Falls, South Tyneside and Sunderland NHS Foundation Trust, South Shields, UK
- Gosforth Physio and Wellness Ltd, Gosforth, UK
| | - Kate Bryce
- Gosforth Physio and Wellness Ltd, Gosforth, UK
- Falls and Balance Physiotherapy Ltd, Newcastle upon Tyne, UK
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2
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Manford E, Garg A, Manford M. Drop attacks: a practical guide. Pract Neurol 2024; 24:106-113. [PMID: 37891001 DOI: 10.1136/pn-2023-003791] [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] [Accepted: 08/23/2023] [Indexed: 10/29/2023]
Abstract
'Drop attacks' encompass both falls and transient loss of consciousness, but the term is not clearly defined. We offer our definition and explore the differential diagnoses. The most common causes are cardiovascular. We discuss clinical and electrographic criteria that suggest underlying arrhythmia or other serious cardiac disorders that require further investigation, and the potential diagnoses that may underlie these 'worrying syncopes'. Vestibular dysfunction also commonly causes collapses, sometimes without typical vertigo. These two common conditions may coexist especially in the elderly. Falls in elderly people often require assessment through a lens of frailty and multifactorial risk factors, rather than seeking a unitary diagnosis. Some drop attacks may be due to longstanding epilepsy and we discuss how to approach these cases. Functional neurological disorder is a common cause in younger people, for which there may also be clinical clues. We review the rarer causes of collapse that may be described as drop attacks, including cataplexy and hydrocephalic attacks.
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Affiliation(s)
- Evelyn Manford
- Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Anupam Garg
- Cardiology, Royal United Hospital NHS Trust, Bath, UK
| | - Mark Manford
- Neurology, Royal United Hospital Bath NHS Trust, Bath, UK
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The Prevalence of Symptom Reporting for Benign Paroxysmal Positional Vertigo in a Traumatic Brain Injury Population. Otol Neurotol 2023; 44:172-176. [PMID: 36624599 DOI: 10.1097/mao.0000000000003770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To assess the prevalence of benign paroxysmal positional vertigo (BPPV) in traumatic brain injury population. STUDY DESIGN In this cross-sectional design, each subject completed screening for BPPV, which included subjective questioning and positional testing. Subjects were asked if they experienced dizziness with bed mobility. All were tested with the Dix-Hallpike and the roll test to determine if nystagmus consistent with BPPV was present. SETTING Brain injury inpatient rehabilitation unit. PARTICIPANTS Subjects admitted to the rehabilitation unit during a 6-month time frame who had a traumatic mechanism of brain injury or experienced a fall resulting from a neurologic event. INTERVENTIONS Diagnostic interventions included the Dix-Hallpike and roll tests. MAIN MEASURES The primary outcomes of this study were the prevalence of BPPV and symptom reports. RESULTS Seventy-six subjects met the inclusion criteria. Three subjects were transferred to acute care before screening for BPPV could be completed. Of the 73 subjects who completed the screening process, 42 (58%) tested positive for BPPV, of which only 7 (10%) reported subjective symptoms of dizziness and/or vertigo. χ2 Analysis of the two screening methods demonstrated a statistically significant difference in the positivity rate between tests (χ21 = 5.715, p = 0.017, Cohen's W = 0.279). If subjects responded yes to both screening questions, they were significantly more likely to test positive for BPPV with a moderate effect size of 0.279. CONCLUSION There was a high prevalence of BPPV within an inpatient rehabilitation facility in subjects with traumatic brain injury, with a small percentage of patients reporting dizziness with subjective questioning.
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Kim EK, Pasquesi L, Sharon JD. Examining Migraine as a Predictor of Benign Paroxysmal Positional Vertigo Onset, Severity, Recurrence, and Associated Falls. Cureus 2022; 14:e28278. [PMID: 36168362 PMCID: PMC9505626 DOI: 10.7759/cureus.28278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/22/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction: The comorbidity of migraine and benign paroxysmal positional vertigo (BPPV) is well-established, yet the impact of migraine on the BPPV phenotype remains understudied. Methods: A retrospective analysis of patients at a tertiary dizziness/vertigo clinic diagnosed with BPPV from 2015 and 2020 was conducted. The study's primary outcomes were the age of BPPV onset, Dizziness Handicap Index (DHI), BPPV recurrence, and dizziness-related falls. Results: In our cohort of 255 BPPV patients, 44.7% had a history of migraine. Those with migraine had an earlier age of BPPV onset than individuals without migraine (60.2 vs. 65.4, p = 0.0018). Migraineurs and non-migraineurs did not differ in their DHI (44.7 vs. 41.6, p= 0.44), recurrence rates (48.3% vs. 40.4%, p= 0.21), and falls (32.5% vs. 37.6%, p = 0.39). Among individuals with horizontal canal BPPV, a higher proportion of migraineurs experienced falls than non-migraineurs (50.0% vs. 6.3%, p = 0.02). Conclusions: Migraineurs experience BPPV at a younger age than those without migraine. This finding suggests that migraine, which has been shown to cause inner ear damage, predisposes individuals to developing BPPV earlier. Migraine was also associated with a higher rate of falls among patients with horizontal canal BPPV, indicating that a migraine history may impact the phenotype of BPPV.
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Edlow JA. Acute dizziness - a personal journey through a paradigm shift. Acad Emerg Med 2022; 30:598-602. [PMID: 35834498 DOI: 10.1111/acem.14559] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/20/2022] [Accepted: 07/08/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine,, Beth Israel Deaconess Medical Center.,Professor of Emergency Medicine, Harvard Medical School, Boston, MA
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Edlow JA, Kerber K. Benign Paroxysmal Positional Vertigo: A Practical Approach for Emergency Physicians. Acad Emerg Med 2022; 30:579-588. [PMID: 35833326 DOI: 10.1111/acem.14558] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 11/28/2022]
Abstract
Benign paroxysmal positional vertigo (BPPV) is a very common condition in the population and an important cause of acute vertigo or dizziness in patients presenting to an emergency department (ED). Despite this, abundant evidence shows that current ED management of patients with BPPV is suboptimal. Common ED management processes include brain imaging and treatment with vestibular suppressant medications such as meclizine, neither of which is recommended by current guidelines. The most efficient management of BPPV is to perform a bedside test (Dix-Hallpike test) and then to treat the patients with a bedside positional (the Epley) maneuver. In this practical review we emphasize the efficient management for the most common form of BPPV-posterior canal BPPV. Using this management will reduce resource utilization (laboratory testing, brain imaging, specialist consultation), reduce ED length of stay, and reduce use of ineffective mediations that have side effects but little therapeutic effect. Application of these practices would improve important patient-centered outcomes such as symptom reduction, radiation exposure, side effects from medications, and less need for urgent follow-up with another health care provider. The article also discusses the approach to patients in whom the Dix-Hallpike and/or Epley maneuvers do not seem to work. This includes a discussion the second most common variant of BPPV (horizontal canal BPPV) and criteria for safe discharge of patients. Another important advantage of learning BPPV best practices is that it is enormously satisfying for the clinician, not unlike treating a child with a nursemaid's elbow.
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Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center.,Professor of Emergency Medicine, Harvard Medical School
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Huang RJ, Smith SL, Brezina L, Riska KM. A Comparison of Falls and Dizziness Handicap by Vestibular Diagnosis. Am J Audiol 2021; 30:1048-1057. [PMID: 34662235 DOI: 10.1044/2021_aja-21-00086] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE There is a paucity of data that directly compares the falls rate and dizziness handicap of different vestibular diagnoses. The purpose of this study is to compare the falls rate and dizziness handicap of common vestibular diagnoses encountered among a cohort of vestibular patients at a single institution. METHOD We conducted a retrospective cross-sectional study of patients evaluated for dizziness at a tertiary care center vestibular clinic between August 1, 2017, and March 19, 2019. Vestibular diagnosis, demographic variables, comorbidities, falls status, and Dizziness Handicap Inventory (DHI) were extracted from the medical record for analysis. Associations between vestibular diagnosis and falls history or DHI were evaluated using multivariate logistic and linear regression, respectively. RESULTS A total of 283 patients met our inclusion criteria with the following diagnoses: benign paroxysmal positional vertigo (BPPV; n = 55), acoustic neuroma (n = 30), Ménière's disease (n = 28), multiple vestibular diagnoses (n = 15), vestibular migraine (n = 135), or vestibular neuritis (n = 20). After adjusting for age, sex, race, medications, and comorbidities, the odds of falling was 2.47 times greater (95% CI [1.08, 6.06], p = .039) and the DHI score was 11.66 points higher (95% CI [4.99, 18.33], p < .001) in those with vestibular migraine compared to those with BPPV. Other diagnoses were comparable to BPPV with respect to odds of falling and dizziness handicap. CONCLUSIONS Patients with vestibular migraine may suffer an increased risk of falls and dizziness handicap compared to patients with BPPV. Our findings highlight the need for timely evaluation and treatment of all patients with vestibular disease.
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Affiliation(s)
- Ryan J. Huang
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, NC
| | - Sherri L. Smith
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, NC
- Duke Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC
| | - Libor Brezina
- Medical School for International Health, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Kristal M. Riska
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, NC
- Duke Center for the Study of Aging and Human Development, Duke University School of Medicine, Durham, NC
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Hawke LJ, Barr CJ, McLoughlin JV. The frequency and impact of undiagnosed benign paroxysmal positional vertigo in outpatients with high falls risk. Age Ageing 2021; 50:2025-2030. [PMID: 34120167 DOI: 10.1093/ageing/afab122] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The frequency and impact of undiagnosed benign paroxysmal positional vertigo (BPPV) in people identified with high falls risk has not been investigated. OBJECTIVE To determine the frequency and impact on key psychosocial measures of undiagnosed BPPV in adult community rehabilitation outpatients identified with a high falls risk. DESIGN A frequency study with cross-sectional design. SETTING A Community Rehabilitation Program in Melbourne, Australia. SUBJECTS Adult community rehabilitation outpatients with a Falls Risk for Older People in the Community Screen score of four or higher. METHODS BPPV was assessed in 34 consecutive high falls risk rehabilitation outpatients using the Dix-Hallpike test and supine roll test. Participants were assessed for anxiety, depression, fear of falls, social isolation and loneliness using the Hospital Anxiety and Depression Scale, Falls Efficacy Scale-International and De Jong Gierveld 6-Item Loneliness Scale. RESULTS A total of 18 (53%; 95% confidence interval: 36, 70) participants tested positive for BPPV. There was no significant difference between those who tested positive for BPPV and those who did not for Falls Risk for Older People in the Community Screen scores (P = 0.555), Hospital Anxiety and Depression Scale (Anxiety) scores (P = 0.627), Hospital Anxiety and Depression Scale (Depression) scores (P = 0.368) or Falls Efficacy Scale-International scores (P = 0.481). Higher scores for the De Jong Gierveld 6-Item Loneliness Scale in participants with BPPV did not reach significance (P = 0.056). CONCLUSIONS Undiagnosed BPPV is very common and associated with a trend towards increased loneliness in adult rehabilitation outpatients identified as having a high falls risk.
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Affiliation(s)
- Lyndon J Hawke
- Allied Health Clinical Research Office, Eastern Health, Melbourne, Victoria, Australia
- School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, Victoria, Australia
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - Christopher J Barr
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
| | - James V McLoughlin
- College of Nursing and Health Sciences, Flinders University, Adelaide, South Australia, Australia
- Advanced Neuro Rehab, Adelaide, South Australia, Australia
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Lin Se To P, Ajit Singh DK, Whitney SL. Effects of customized vestibular rehabilitation plus canalith repositioning maneuver on gait and balance in adults with Benign Paroxysmal Positional Vertigo: A Randomized Controlled Trial. J Vestib Res 2021; 32:79-86. [PMID: 34151874 DOI: 10.3233/ves-190731] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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).
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Affiliation(s)
- Phui Lin Se To
- Physiotherapy Program & Centre for Healthy Ageing, Faculty of Health Sciences, Universiti Kebangsaan Malaysia.,Department of Physiotherapy, Serdang Hospital, Jalan Puchong, Kajang, Selangor Malaysia
| | - Devinder Kaur Ajit Singh
- Physiotherapy Program & Centre for Healthy Ageing, Faculty of Health Sciences, Universiti Kebangsaan Malaysia
| | - Susan L Whitney
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, University of Pittsburgh
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Chen J, Zhao W, Yue X, Zhang P. Risk Factors for the Occurrence of Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-Analysis. Front Neurol 2020; 11:506. [PMID: 32655479 PMCID: PMC7324663 DOI: 10.3389/fneur.2020.00506] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 05/07/2020] [Indexed: 01/05/2023] Open
Abstract
Background and Purpose: The lifetime prevalence of benign paroxysmal positional vertigo (BPPV) is high, especially in the elderly. Patients with BPPV are more susceptible to ischemic stroke, dementia, and fractures, severely reducing quality of life of patients. Many studies have analyzed risk factors for the occurrence of BPPV. However, the results of these studies are not identical. We performed this meta-analysis to determine potential risk factors associated with the occurrence of BPPV. Methods: PubMed, EMBASE, and the Cochrane Library (January 2000 through March 2020) were systematically searched for eligible studies analyzing risk factors for the occurrence of BPPV. Reference lists of eligible studies were also reviewed. We selected observational studies in English with a control group and sufficient data. Pooled odds ratios (ORs) or the mean differences (MDs) and 95% confidence intervals (CIs) were calculated to measure the impacts of all potential risk factors. Heterogeneity among studies was evaluated using the Q-test and I2 statistics. We used the random-effect model or the fixed-effect model according to the heterogeneity among the included studies. Results: We eventually included 19 studies published between 2006 and 2019, including 2,618 patients with BPPV and 11,668 participants without BPPV in total. In this meta-analysis, the occurrence of BPPV was significantly associated with female gender (OR = 1.18; 95% CI, 1.05–1.32; P = 0.004), serum vitamin D level (MD = −2.12; 95% CI, −3.85 to −0.38; P = 0.02), osteoporosis (OR = 2.49; 95% CI, 1.39–4.46; P = 0.002), migraine (OR = 4.40; 95% CI, 2.67–7.25; P < 0.00001), head trauma (OR = 3.42; 95% CI, 1.21–9.70; P = 0.02), and total cholesterol level (MD = 0.32; 95% CI, 0.02–0.62; P = 0.03). Conclusion: Female gender, vitamin D deficiency, osteoporosis, migraine, head trauma, and high TC level were risk factors for the occurrence of BPPV. However, the effects of other risk factors on BPPV occurrence need further investigations.
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Affiliation(s)
- Jinbao Chen
- Department of Pediatrics, The First Clinic College of Xinxiang Medical University, Xinxiang, China
| | - Weisong Zhao
- Department of Pediatrics, The First Clinic College of Xinxiang Medical University, Xinxiang, China
| | - Xuejing Yue
- School of Basic Medicine, Xinxiang Medical University, Xinxiang, China
| | - Ping Zhang
- Department of Neurology, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang, China
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Power L, Murray K, Szmulewicz DJ. Characteristics of assessment and treatment in Benign Paroxysmal Positional Vertigo (BPPV). J Vestib Res 2020; 30:55-62. [PMID: 31839619 PMCID: PMC9249279 DOI: 10.3233/ves-190687] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
QUESTION: Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause of dizziness presenting to specialist vestibular centres and accounts for approximately 20–30% of referrals to these clinics. In spite of the amount of clinical knowledge surrounding its diagnosis and management, the treatment of BPPV remains challenging for even the most experienced clinicians. This study outlines the incidence of BPPV in a specialised vestibular physiotherapy clinics and discusses the various nuances encountered during assessment and treatment of BPPV. DESIGN: Observational Study PARTICIPANTS: 314 patients with various forms of Benign Paroxysmal Positional Vertigo (BPPV) INTERVENTION: Canalith repositioning manoeuvres (CRP) for posterior canal (PC) or horizontal canal (HC) BPPV depending on the canal and variant of BPPV. OUTCOME MEASURES: Negative Dix-Hallpike (DHP) or Supine roll test (SRT) examination. RESULTS: In 91% of cases, PC BPPV was effectively treated in 2 manoeuvres or less. Similarly, 88% of HC BPPV presentations were effectively managed with 2 treatments. Bilateral PC, multiple canal or canal conversions required a greater number of treatments. There was no noticeable difference in treatment outcomes for patients who had nystagmus and symptoms during the Epley manoeuvre (EM) versus those who did not have nystagmus and symptoms throughout the EM. Nineteen percent of patients experienced post treatment down-beating nystagmus (DBN) and vertigo or “otolithic crisis” after the first or even the second consecutive EM. CONCLUSION: Based on the data collected, we make several clinical recommendations for assessment and treatment of BPPV. Firstly, repeated testing and treatment of BPPV within the same session is promoted as a safe and effective approach to the management of BPPV with a low risk of canal conversion. Secondly, vertigo and nystagmus throughout the EM is not indicative of treatment success. Thirdly, clinicians must remain vigilant and mindful of the possibility of post treatment otolithic crisis following the treatment of BPPV. This is to ensure patient safety and to prevent possible injurious falls. Our results challenge several clinical assumptions about the assessment and treatment of BPPV including the utility of certain markers of treatment success; hence influencing the current clinical guidelines and clinical practice and paving the way for future studies of the assessment and management of patients with BPPV.
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Affiliation(s)
- Laura Power
- Balance Disorders and Ataxia Service, Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, Australia
- Dizzy Day Clinics, Burnley, VIC, Australia
| | | | - David J. Szmulewicz
- Balance Disorders and Ataxia Service, Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, Australia
- Cerebellar Ataxia Clinic, Neuroscience Department, Alfred Health/Monash University, Melbourne, VIC, Australia
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Maas BDP.J, Bruintjes TD, van der Zaag-Loonen HJ, Winters SM, Masius-Olthof S, Colijn C, Benthem PPGV, van Leeuwen RB. Physical and Emotional Burden of the Epley Maneuver in the Elderly. Otol Neurotol 2019; 40:1082-1087. [DOI: 10.1097/mao.0000000000002326] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Eggers SD, Bisdorff A, von Brevern M, Zee DS, Kim JS, Perez-Fernandez N, Welgampola MS, Della Santina CC, Newman-Toker DE. Classification of vestibular signs and examination techniques: Nystagmus and nystagmus-like movements. J Vestib Res 2019; 29:57-87. [PMID: 31256095 PMCID: PMC9249296 DOI: 10.3233/ves-190658] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
This paper presents a classification and definitions for types of nystagmus and other oscillatory eye movements relevant to evaluation of patients with vestibular and neurological disorders, formulated by the Classification Committee of the Bárány Society, to facilitate identification and communication for research and clinical care. Terminology surrounding the numerous attributes and influencing factors necessary to characterize nystagmus are outlined and defined. The classification first organizes the complex nomenclature of nystagmus around phenomenology, while also considering knowledge of anatomy, pathophysiology, and etiology. Nystagmus is distinguished from various other nystagmus-like movements including saccadic intrusions and oscillations. View accompanying videos at http://www.jvr-web.org/ICVD.html
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Affiliation(s)
| | - Alexandre Bisdorff
- Department of Neurology, Centre Hospitalier Emile Mayrisch, Esch-sur-Alzette, Luxembourg
| | - Michael von Brevern
- Private Practice of Neurology and Department of Neurology, Charité, Berlin, Germany
| | - David S. Zee
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ji-Soo Kim
- Department of Neurology, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seoul, Korea
| | | | - Miriam S. Welgampola
- Institute of Clinical Neurosciences, Royal Prince Alfred Hospital, Central Clinical School, University of Sydney, Sydney, Australia
| | - Charles C. Della Santina
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David E. Newman-Toker
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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14
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Jumani K, Powell J. Benign Paroxysmal Positional Vertigo: Management and Its Impact on Falls. Ann Otol Rhinol Laryngol 2017; 126:602-605. [DOI: 10.1177/0003489417718847] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kiran Jumani
- Head and Neck Directorate, City Hospitals Sunderland NHS Trust, Sunderland, UK
| | - Jason Powell
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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15
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Macdonald NK, Kaski D, Saman Y, Al-Shaikh Sulaiman A, Anwer A, Bamiou DE. Central Positional Nystagmus: A Systematic Literature Review. Front Neurol 2017; 8:141. [PMID: 28473800 PMCID: PMC5397512 DOI: 10.3389/fneur.2017.00141] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 03/28/2017] [Indexed: 11/13/2022] Open
Abstract
Objective To provide a systematic review of the clinical and radiological features of lesion-induced central positional nystagmus (CPN) and identify salient characteristics that differentiate central from peripheral positional nystagmus (PN). Methods Systematic literature search according to the preferred reporting items for systematic reviews and meta-analysis. Results A total of 82 patients from 28 studies met the participants intervention, comparison, outcomes, and study designs criteria for inclusion. An atypical direction of nystagmus for the stimulated canal was reported in 97.5% patients during Dix–Hallpike (D–H) and 54.5% upon supine roll testing. Five types of CPNs were identified during positional testing: positional horizontal nystagmus (pHN) (36.8%), positional downbeating nystagmus (pDBN) (29.2%), positional torsional nystagmus (pTN) (2.1%), positional upbeating nystagmus (pUBN) (2.1%), and a combination of the four profiles (29.9%). CPN was paroxysmal (<60 s) in 85% patients on straight head hanging (SHH), 63.9% on D–H, and 37.5% on supine roll, and had a latency <3 s upon positioning in 94.7% patients in which it was reported. Concurrent vertigo was reportedly present in 63.4% patients and 48.8% demonstrated other neurological signs. Radiologically, in 74.4%, there was mention of cerebellar involvement, isolated brainstem involvement in 8.5%, and 14.6% involved the fourth ventricle. Conclusion Currently, there is a lack of robust data on the clinical and radiological characteristics of CPN highlighting the need for better phenotyping of CPN to help differentiate this entity from peripheral causes of PN. With increased awareness of CPN, particularly in the acute setting, we may see a change in the estimated prevalence of CPN and improved clinical markers to promptly identify the frequently sinister underlying causes.
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Affiliation(s)
- Nora K Macdonald
- Neuro-otology Department, National Hospital for Neurology and Neurosurgery, London, UK
| | | | - Yougan Saman
- Neuro-otology Department, National Hospital for Neurology and Neurosurgery, London, UK
| | - Amal Al-Shaikh Sulaiman
- UCL Ear Institute, London, UK.,Department of Otolaryngology and Head and Neck Surgery, King Fahd Hospital of University, University of Dammam, Al-Khobar, Saudi Arabia
| | | | - Doris-Eva Bamiou
- Neuro-otology Department, National Hospital for Neurology and Neurosurgery, London, UK.,UCL Ear Institute, London, UK
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Abstract
Dizziness is a common chief complaint in emergency medicine. The differential diagnosis is broad and includes serious conditions, such as stroke, cardiac arrhythmia, hypovolemic states, and acute toxic and metabolic disturbances. Emergency physicians must distinguish the majority of patients who suffer from benign self-limiting conditions from those with serious illnesses that require acute treatment. Misdiagnoses are frequent and diagnostic test costs high. The traditional approach does not distinguish benign from dangerous causes and is not consistent with best current evidence. This article presents a new approach to the diagnosis of acutely dizzy patients that highly leverages the history and the physical examination.
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Abbott J, Tomassen S, Lane L, Bishop K, Thomas N. Assessment for benign paroxysmal positional vertigo in medical patients admitted with falls in a district general hospital. Clin Med (Lond) 2016; 16:335-8. [PMID: 27481376 PMCID: PMC6280209 DOI: 10.7861/clinmedicine.16-4-335] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Having benign paroxysmal positional vertigo (BPPV) puts patients at a significantly higher risk of falling. It is poorly recognised and diagnosis is frequently delayed. BPPV has been studied in outpatient settings, but there have been no studies looking at the prevalence in patients admitted with falls. This study aims to establish how common BPPV is in these patients.For a 4-month period, patients admitted on an unselected medical take were screened for an admission precipitated by a fall. Patients who consented were assessed for BPPV using the Dix-Hallpike manoeuvre. Patients who tested positive were treated using the Epley manoeuvre. The assessments were carried out by specialist physiotherapists who were experienced at assessing and diagnosing patients with peripheral vestibular disorders. Out of the 111 patients initially identified, 37 (33%) were considered to be appropriate and consented to be part of the study. Of these, 20 patients (54%) had a positive Dix-Hallpike manoeuvre.Of the patients included in the study, over half tested positive for BPPV. This merits further study. Potentially, there is a proportion of patients admitted with falls who have an easily treatable contributing factor that is not being identified with standard practice.
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18
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Newman-Toker DE, Della Santina CC, Blitz AM. Vertigo and hearing loss. HANDBOOK OF CLINICAL NEUROLOGY 2016; 136:905-21. [PMID: 27430449 DOI: 10.1016/b978-0-444-53486-6.00046-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Symptoms referable to disorders affecting the inner ear and vestibulocochlear nerve (eighth cranial nerve) include dizziness, vertigo, tinnitus, and hearing loss, in various combinations. Similar symptoms may occur with involvement of the central nervous system, principally the brainstem and cerebellum, to which the vestibular and auditory systems are connected. Imaging choices should be tailored to patient symptoms and the clinical context. Computed tomography (CT) should be used primarily to assess bony structures. Magnetic resonance imaging (MRI) should be used primarily to assess soft-tissue structures. Vascular imaging by angiography or venography should be obtained when vascular lesions are suspected. No imaging should be obtained in patients with typical presentations of common peripheral vestibular or auditory disorders. In current clinical practice, neuroimaging is often overused, especially CT in the assessment of acute dizziness and vertigo in the emergency department. Despite low sensitivity for ischemic strokes, CT is often used to rule out neurologic causes. When ischemic stroke is the principal concern in acute vestibular presentations, imaging should almost always be by MRI with diffusion-weighted images, rather than CT. In this chapter, we describe recommended strategies for audiovestibular imaging based on patient symptoms and signs.
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Affiliation(s)
- David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA; Department of Otolaryngology, Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Charles C Della Santina
- Department of Otolaryngology, Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ari M Blitz
- Neuro-radiology Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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19
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Benign paroxysmal positional vertigo is associated with an increased risk of fracture: a population-based cohort study. J Orthop Sports Phys Ther 2015; 45:406-12. [PMID: 25808526 DOI: 10.2519/jospt.2015.5707] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
STUDY DESIGN A nationwide, population-based, retrospective cohort study. OBJECTIVES To investigate whether benign paroxysmal positional vertigo (BPPV) is associated with an increased risk of fracture. BACKGROUND Benign paroxysmal positional vertigo is a brief rotational vertigo induced by head position change that may increase the risk of falls and, therefore, fracture. METHODS Data from the Taiwan National Health Insurance Research Database were used for this study. We selected a case cohort comprising 3796 patients aged over 20 years who were newly diagnosed with BPPV between 2000 and 2006. In addition, we randomly selected a control cohort of 15 184 individuals without BPPV. Patients with BPPV were matched to individuals in the control group according to sex, age, and index year. A Cox proportional hazard regression was performed to compute the hazard ratio of fracture, after adjusting for demographic characteristics and comorbidities. RESULTS The prevalence of comorbidities was higher among patients with BPPV. After adjusting for age, sex, and comorbidities, patients with BPPV exhibited a 1.14-fold (95% confidence interval [CI]: 1.04, 1.25; P<.01) higher risk of fracture than those without BPPV. Trunk fracture (vertebra, rib, and pelvis) was the fracture type with the highest adjusted hazard ratio (1.24; 95% CI: 1.06, 1.45; P<.01) in patients with BPPV relative to those without BPPV. An analysis stratified according to demographic factors revealed that men with BPPV exhibited a 1.43-fold (95% CI: 1.22, 1.66; P<.001) higher risk of fracture. Patients with BPPV aged over 65 years exhibited a significantly higher risk of fracture (adjusted hazard ratio = 1.17; 95% CI: 1.03, 1.33; P<.05) than did those without BPPV. CONCLUSION Patients with BPPV exhibited a higher risk of fracture than did those without BPPV. LEVEL OF EVIDENCE Prognosis, level 2b.
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Abstract
PURPOSE OF REVIEW Symptoms and signs of neuro-otologic disorders are critical components in the diagnostic assessment of patients with vestibular symptoms such as vertigo, dizziness, unsteadiness, and oscillopsia. Most diagnoses can be accomplished at the bedside. An understanding of key diagnostic principles is essential for all practicing neurologists, who are often faced with determining whether such patients warrant urgent diagnostic testing or hospital admission. This article introduces readers to core concepts and recent advances in the understanding of directed history taking and physical examination in patients with vestibular symptoms or suspected neuro-otologic disorders. RECENT FINDINGS International consensus definitions for vestibular symptoms have recently been published. During the past 5 years, a growing body of scientific evidence has demonstrated that the traditional approach to bedside diagnosis of patients with vertigo and dizziness is inadequate. Former teaching that history taking should first rely on categorizing symptoms by type (eg, vertigo, presyncope, disequilibrium, nonspecific dizziness) has been replaced by an emphasis on categorizing timing and triggers for vestibular symptoms, which focuses the clinician's attention on four key syndromic patterns: (1) acute, spontaneous, prolonged vestibular symptoms; (2) episodic, positional vestibular symptoms; (3) episodic, spontaneous vestibular symptoms; and (4) chronic unsteadiness (with or without oscillopsia). Each of these categories delineates a relatively narrow differential diagnosis within which a focused examination distinguishes between benign common causes and dangerous uncommon ones. SUMMARY A focused approach to bedside assessment of patients with vestibular symptoms is essential for accurate and efficient diagnosis. All neurologists should be aware of major recent advances.
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Affiliation(s)
- David E Newman-Toker
- Johns Hopkins Hospital, Department of Neurology, 600 North Wolfe Street, Meyer 8-154, Baltimore, MD 21287, USA.
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Collerton J, Kingston A, Bond J, Davies K, Eccles MP, Jagger C, Kirkwood TBL, Newton JL. The personal and health service impact of falls in 85 year olds: cross-sectional findings from the Newcastle 85+ cohort study. PLoS One 2012; 7:e33078. [PMID: 22427954 PMCID: PMC3302867 DOI: 10.1371/journal.pone.0033078] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Accepted: 02/02/2012] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Falls are common in older people and increase in prevalence with advancing old age. There is limited knowledge about their impact in those aged 85 years and older, the fastest growing age group of the population. We investigated the prevalence and impact of falls, and the overlap between falls, dizziness and blackouts, in a population-based sample of 85 year olds. METHODS DESIGN Cross-sectional analysis of baseline data from Newcastle 85+ Cohort Study. SETTING Primary care, North-East England. PARTICIPANTS 816 men and women aged 85 years. MEASUREMENTS Structured interview with research nurse. Cost-consequence analysis of fall-related healthcare costs. RESULTS Over 38% (313/816) of participants had fallen at least once in the previous 12 months and of these: 10.6% (33/312) sustained a fracture, 30.1% (94/312) attended an emergency department, and 12.8% (40/312) were admitted to hospital. Only 37.2% (115/309) of fallers had specifically discussed their falls problem with their general practitioner and only 12.7% (39/308) had seen a falls specialist. The average annual healthcare cost per faller was estimated at £202 (inter-quartile range £174-£231) or US$329 ($284-$377). 'Worry about falling' was experienced by 42.0% (128/305) of fallers, 'loss of confidence' by 40.0% (122/305), and 'going out less often' by 25.9% (79/305); each was significantly more common in women, odds ratios (95% confidence interval) for women: men of 2.63 (1.45-4.55), 4.00 (2.27-7.14), and 2.86 (1.54-5.56) respectively. Dizziness and blackouts were reported by 40.0% (318/796) and 6.4% (52/808) of participants respectively. There was marked overlap in the report of falls, dizziness and blackouts. CONCLUSIONS Falls in 85 year olds are very common, associated with considerable psychological and physical morbidity, and have high impact on healthcare services. Wider use of fall prevention services is needed. Significant expansion in acute and preventative services is required in view of the rapid growth in this age group.
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Affiliation(s)
- Joanna Collerton
- Institute for Ageing and Health, Newcastle University, Newcastle upon Tyne, United Kingdom.
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22
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The Physiological Profile Assessment: Clinical validity of the postural sway measure and comparison of impairments by age. Eur Geriatr Med 2012. [DOI: 10.1016/j.eurger.2011.11.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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