Effectiveness of Treatments for Benign Paroxysmal Positional Vertigo of the Posterior Canal

The Effect of Different Sensory Perturbations on Postural Control and Fall Risk in Benign Paroxysmal Positional Vertigo Patients

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) patients may experience balance problems in various environmental conditions other than positional dizziness. Therefore, there is a need to investigate the postural control abilities and the ability to use sensory inputs in BPPV patients in different conditions.

OBJECTIVE

The aim of this study was to examine the postural control performance of middle-aged adult BPPV patients in easy and difficult balance tasks, the effect of vestibular stimulation on the maintenance of balance, and the risk of falling, by posturographic evaluation in various conditions.

METHOD

A total of 26 patients diagnosed with posterior canal BPPV and 26 controls were included in the study. Sensory Organization Test (SOT), Vestibular Stimulation Test (VST), and fall risk assessment (FRA) were applied to the participants, respectively.

RESULTS

Significant difference was observed in SOT medio-lateral (ML) plane in Conditions 2 and 5 (p < .05). A significant difference was observed in the vestibular score in the SOT ML plane. No significant difference was observed in VST test scores (p > .05). In the FRA test, a significant difference was observed in the energy and gain parameters in the anterio-posterior plane (p < .05).

CONCLUSIONS

The current study examined postural control abilities of patients with BPPV in extensive external conditions and in both planes, using various sensory perturbations and stimulation. It was thought that while BPPV patients were in the active phase of the disease, their postural control skills in the ML plane decreased and they might be at risk of falling.

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

PURPOSE

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Epley manoeuvre's efficacy for benign paroxysmal positional vertigo (BPPV) in primary-care and subspecialty settings: a systematic review and meta-analysis

BACKGROUND

Although previous studies have reported general inexperience with the Epley manoeuvre (EM) among general physicians, no report has evaluated the effect of EM on benign paroxysmal positional vertigo (BPPV) in primary care by using point estimates or certainty of evidence. We conducted this systematic review and meta-analysis and clarified the efficacy of EM for BPPV, regardless of primary-care and subspecialty settings.

METHODS

Systematic review and meta-analysis of randomised sham-controlled trials of EM for the treatment of posterior canal BPPV in primary-care and subspecialty settings. A primary-care setting was defined as a practice setting by general practitioners, primary-care doctors, or family doctors. A systematic search was conducted in January 2022 across databases, including Cochrane Central Resister of Controlled Trial, MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. Primary outcomes were the disappearance of subjective symptoms (vertigo), negative findings (Dix-Hallpike test), and all adverse events. We evaluated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

Twenty-seven randomised controlled trials were identified. In primary-care settings, EM reduced the subjective symptoms [risk ratio (RR), 3.14; 95% confidence interval (CI), 1.96-5.02]; however, there was no applicable article for all adverse events. In the subspeciality setting, EM reduced the subjective symptoms (RR, 2.42; 95% CI, 1.64-3.56), resulting in an increase in negative findings (RR, 1.81; 95% CI, 1.40-2.34). The evidence exhibited uncertainty about the effect of EM on negative findings in primary-care settings and all adverse events in subspecialty settings.

CONCLUSIONS

Regardless of primary-care and subspecialty settings, EM for BPPV was effective. This study has shown the significance of performing EM for BPPV in primary-care settings. EM for BPPV in a primary-care setting may aid in preventing referrals to higher tertiary care facilities and hospitalisation for follow-up.

TRIAL REGISTRATION

The study was registered in protocols.io (PROTOCOL INTEGER ID: 51,464) on July 11, 2021.

When Particle Repositioning Maneuvers Just Will Not Stick: Clinical Considerations for Persistent Benign Paroxysmal Positional Vertigo

PURPOSE

Although benign paroxysmal positional vertigo (BPPV) is often considered benign and easily treatable, aberrant cases of persistent BPPV can be challenging to manage. Detailed differential diagnosis is essential as central-, vascular-, and cervical-related etiologies may mirror the presentation of persistent BPPV. In addition, an understanding of alternative noninvasive treatment options is important as persistent BPPV is often refractory to traditional particle repositioning maneuvers (PRMs). This article reviews clinical considerations for persistent BPPV.

METHOD

A case of a 68-year-old male diagnosed with posterior semicircular canal BPPV (PC-BPPV) and received various unsuccessful PRMs treatments is described. His clinical presentation is referenced alongside various possible etiologies to discern the most likely diagnosis. Nonsurgical treatment options for intractable PC-BPPV will also be reviewed.

CONCLUSIONS

BPPV recalcitrant to PRM treatment warrants investigation of other etiologies; however, key elements of the case history and objective examination are helpful for differential diagnosis. Brandt-Daroff exercises may facilitate habituation of symptoms secondary to persistent BPPV. More research is needed to understand the use of multiaxial repositioning chairs for the treatment of intractable BPPV.

Physical Therapy for Benign Positional Vertigo of Posterior Canal: The Role of Alternated Epley and Semont Maneuvers

OBJECTIVE

To investigate if alternated Epley (EP) and Semont (ST) maneuvers could be more effective than repetition of the same in benign paroxysmal positional vertigo of posterior semicircular canal (pBPPV).

DESIGN

We retrospectively reviewed the outcome of pBPPV patients treated with a second maneuver for the persistence of positional nystagmus.

STUDY SAMPLE

Forty-seven patients underwent 2 STs, 64 with 2 EPs, and 71 EPs followed by ST. Videonystagmography and Dizziness Handicap Inventory (DHI) questionnaire were performed.

RESULTS

Absence of positional nystagmus was achieved after 2 maneuvers in 136 patients with pBPPV: 65.9% in the ST group, 70.3% in the EP group, and 84.5% in the EP-ST group. Alternated EP and ST were significantly more effective than repeated ST (P = .03), while we found no significant difference when compared with repeated EP (P = .07). At 1-month follow-up, 12 patients showed persistent positional nystagmus without difference between groups. After 1 month, the 46 patients with negative outcome had significantly higher DHI values (P = .01) than other 136 patients with pBPPV.

CONCLUSIONS

Alternated EP and ST seemed more effective than repeating the same maneuver in treating pBPPV, and this should be confirmed in prospective clinical studies. Resolution of nystagmus after maneuvers was fundamental to reduce handicap deriving from dizziness as reported in DHI.

Effect of age on treatment outcomes in benign paroxysmal positional vertigo: A systematic review

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) can lead to an increased fall risk in older adults. Therefore, we examined the influence of age on the effectiveness of canalith-repositioning procedures (CRPs) for the treatment of BPPV.

METHODS

Pubmed, Web of Science, and the bibliographies of selected articles were searched for studies conducted before September 2020 that examined the effectiveness of treatments for BPPV in various age groups. Meta-analyses were performed to compare treatment effectiveness and recurrence rates for younger and older adults. Odds ratios were calculated in a random-effects model. Mean differences were calculated using a fixed-effects model. A significance level of p < 0.05 (95% confidence interval) was set. The risk of bias and the methodological quality of all included articles were examined.

RESULTS

Forty-five studies were retrieved after full-text screening, of which 29 studies were included for a qualitative review. The remaining 16 studies were eligible for inclusion in the meta-analysis (3267 participants with BPPV). The success rate of a single CRP was higher in the younger group (72.5% vs. 67%, p < 0.001). An average of 1.4 and 1.5 CRPs was needed for complete recovery in the younger and older groups, respectively (p = 0.02). However, global treatment success did not differ between these groups (97.5% vs. 94.6%, p = 0.41). The recurrence rate was higher in the older population (23.2% vs. 18.6%, p = 0.007).

CONCLUSIONS

Although more CRPs are needed, the rate of complete recovery in older adults is similar to that observed in younger adults.

Relations between gait characteristics and subjective visual vertical results in young adults

OBJECTIVE

Subjective visual vertical (SVV) deviation can indicate impairments of motion perception and spatial orientation in individuals with vestibular disorders. This study investigated the influence of SVV on tandem gait ability by assessing differences between temporal, spatial, and kinematic characteristics in young adults.

METHODS

We recruited sixteen young adults with increased SVV and 17 age-matched control subjects. All subjects recruited for this study were with no history of neurological or musculoskeletal diseases. Knee and hip-joint kinematic data, spatio-temporal parameters, and gait variability were measured during tandem gait.

RESULTS

Stride time variability and stride velocity variability were significantly greater in the experimental group than the control group (p < 0.05). In addition, a significant correlation was observed between stride time variability and SVV results (r = 0.345, p < 0.05). However, hip and knee joint angles were non-significantly different in the experimental and control groups (p > 0.05) and spatio-temporal parameters were similar between the two groups (p > 0.05).

CONCLUSION

Stride time variability and stride velocity variability during tandem gait were significantly different in the experimental and control groups. We presume that increased SVV deviation is related to greater gait variability during tandem gait.

Sémont Maneuver for Benign Paroxysmal Positional Vertigo Treatment: Moving in the Correct Plane Matters

HYPOTHESIS

We aimed to investigate the effect of the head excursion angle on the success of the Sémont Maneuver (SM).

BACKGROUND

SM is performed with the head turned by 45 degrees toward the unaffected ear. In clinical routine, it is unlikely that physicians can turn the head to a position of exactly 45 degrees. Moreover, it is unclear how possible deviations from 45 degrees would affect the outcome with SM.

METHODS

We used an in vitro model (upscaled by ×5) of a posterior semicircular canal with canalithiasis to study head excursion angles (0-75 degrees) and minimum waiting times in SM. Additionally, we measured actual head excursion angles performed by trained physicians during SM on a healthy subject.

RESULTS

Successful canalith repositioning to the utricle was possible at head excursion angles between 21 and 67 degrees. Waiting time increased from 16 to 30 seconds with increasing deviation from 45 degrees. Angles larger than 67 degrees or smaller than 21 degrees did not lead to successful repositioning even after a waiting period of 5 minutes. Physicians set head excursion angles of 50 degrees ±SD 4.8 degrees while performing the SM.

CONCLUSION

Angular deviations up to ±20 degrees from the ideal SCC plane (45 degrees) still allows for successful SM. Although the tested physicians tended to underestimate the actual head excursion angle by 5 degrees (and more), the success of SM will not be affected provided that the waiting time is sufficiently long. Further, the results suggest that the Brandt-Daroff maneuver is a form of habituation training rather than a liberatory maneuver.

Lateral Modified Brandt-Daroff Exercises: A Novel Home Treatment Technique for Horizontal Canal BPPV

OBJECTIVES

Brandt-Daroff exercises (BDEs) are commonly used as an at-home treatment for posterior canalithiasis, but their efficacy in the treatment of benign paroxysmal positional vertigo (BPPV) of the horizontal canal (HC-BPPV) has not been previously studied. Using biomechanical model simulation, we investigated modifications that may optimize BDE use for HC-BPPV treatment.

MATERIALS AND METHODS

The BPPV Viewer, a three-dimensional model of the human labyrinth, was used to analyze BDE for HC-BPPV treatment. While moving the model through sequential BDE positions, the expected position of otoliths was demonstrated. Treatment steps were adjusted to maximize otolith movement around the canal circumference without compromising otolith repositioning into the semicircular duct's anterior arm. All adjustments were integrated into lateral modified BDEs (LMBDEs) presented here.

RESULTS

By implementing several modifications, BDE can effectively treat HC-BPPV. Model simulation indicates tilting the head 20° upward in the lateral position, instead of 45° specified by the original technique, which significantly increases displacement of otoliths originating from the horizontal duct's anterior and intermediate segments. LMBDE can be performed as a direct two-step sequence without pausing in the upright position before switching sides. If the affected ear is known, positioning the head 45° below horizontal on the unaffected side as a third treatment step can promote actual canal evacuation. These treatment enhancements increase circumferential otolith movement around the canal and may promote horizontal canal evacuation.

CONCLUSION

LMBDEs are a modification of BDE that may increase their effectiveness for use in patients with HC-BPPV. This safe treatment adjunct between office visits may promote long-term symptom reduction.

Congruous Torsional Down Beating Nystagmus in the Third Position of the Semont's Maneuver in Patients Treated for Canalithiasis of Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo: Its Significance and Prognostic Value

Due to its mechanical pathogenesis, benign paroxysmal positional vertigo treatment is mainly physical: when posterior semicircular canal is involved, Semont's maneuver is reported as one of the most effective liberating procedures. In the case of a canalolithiasis, the efficacy of the maneuver is corroborated by the appearance of some nystagmus findings during its performance. Liberating nystagmus, that can occur in the second position of Semont's maneuver and whose direction is congruous with the excitation of the affected posterior semicircular canal has proven to be a favorable prognostic sign. On the other hand, in clinical experience, we've frequently verified the appearance of another nystagmus during the execution of the maneuver: upon reaching the third position, when replacing the patient seated, a torsional down beating nystagmus, with the torsional component “congruous” with the stimulation of the vertical semicircular canals of the affected side, can often be appreciated. Such a sign can occur with or without having had the previous liberating nystagmus in the second position and is almost always associated with an intense vertigo and/or body pulsion. In this study, we describe the incidence and characteristics of the congruous torsional down beating nystagmus that can arise by assuming the third position of Semont's maneuver in a cohort of patients treated for posterior semicircular canal benign paroxysmal positional vertigo due to canalolithiasis. In the best of our knowledge, such a sign has never been described and explained before. On the basis of the pathophysiology and of the possible canal receptors stimulation during the different phases of Semont's maneuver, we formulated different hypothesis on how such a nystagmus can be generated. We observed that such a sign, when elicited, has a very good prognostic meaning for healing purposes, even better than that of liberating nystagmus. Therefore, congruous torsional down beating nystagmus should always be checked when performing Semont's maneuver because it could help in predicting success of physical treatment and in managing patients.

Balance performance when responding to visual stimuli in patients with Benign Paroxysmal Positional Vertigo (BPPV)

BACKGROUND

Patients with Benign Paroxysmal Positional Vertigo (BPPV) often report a sensation of disequilibrium before treatment with the canalith repositioning maneuvers. Apart from vestibular information, visual input also contributes to balance control. How visual stimuli influence balance control in BPPV patients is unclear.

OBJECTIVE

To investigate the influence of visual stimuli on balance performance in BPPV patients.

METHODS

Three groups of participants, patients with BPPV, and healthy young and older adults, were instructed to stand under three conditions: 1) eyes open (EO); 2) while watching a static picture via a video display; and 3) while watching a rotating visual scene. Antero-posterior (AP), lateral (ML), and total sway path during standing were analyzed.

RESULTS

In all conditions, patients with BPPV showed significantly larger AP, ML and total sway path than young, whereas older adults only showed significantly larger AP and total sway path than young adults. During the visual stimuli, all participants exhibited significantly increased AP and total sway while watching a static image and a moving scene as compared with the EO condition.

CONCLUSIONS

Patients with BPPV have similar balance control to older adults, but poorer balance control than young adults. The reduced lack of standing balance control in the coronal plane of patients with BPPV, might affect balance strategy after external perturbations.

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.

Screening for Vestibular Disorders Using the Modified Clinical Test of Sensory Interaction and Balance and Tandem Walking With Eyes Closed

OBJECTIVES

Determine accurate cut-points and optimal combinations of screening tests of balance to detect patients with vestibular disorders.

STUDY DESIGN

Case-control study.

SETTING

Out-patient tertiary care.

SUBJECTS AND METHODS

Community-dwelling adults, without known neurological deficits or significant musculoskeletal disorders, including patients with vestibular disorders and healthy controls without vestibular disorders were tested while standing on medium density compliant foam with feet together and eyes closed under three head movement conditions, head stationary, and head moving in yaw and pitch at 0.33 Hz, for up to 30 seconds per trial. Dependent measures were trial duration, number of head movements during head movement trials, trunk kinematic measures, and number of correct tandem steps during tandem walking trials.

RESULTS

Receiver operator characteristics (ROC), sensitivity and specificity, and specific cut-points were calculated. Individual tests had moderate ROC values, from 0.67 to 0.84. ROC values were higher in the head moving trials than the head stationary trial and best for subjects aged 40 to 79. Using combined analyses of two or more tests, including published data on tandem walking, ROC values were higher, 0.80 to 0.90. Age- and sex-related performance differences were found.

CONCLUSION

Balance skills in standing and walking differ, so testing both skills is optimal and increases the likelihood of finding a deficit. Patients should be compared to age-appropriate norms. Kinematics and number of head movements were not very useful. This combined set of rapid, low-tech balance tests is useful in an initial approach to screening patients who may have vestibular disorders.

Optimal reassessment time for treatment response in posterior canal benign paroxysmal positional vertigo

OBJECTIVES/HYPOTHESIS

The present study aimed to evaluate the optimal reassessment time for treatment response in posterior canal benign paroxysmal positional vertigo (PC-BPPV) following the initial Epley maneuver.

STUDY DESIGN

Prospective, single-blinded, randomized study.

METHODS

One hundred eight patients with PC-BPPV agreed to participate. These patients received a single modified Epley maneuver (recommended by the 2008 American Academy of Otolaryngology-Head and Neck Surgery guidelines) daily until positional nystagmus disappeared during the Dix-Hallpike maneuver 24 hours after the treatment. Repeated Dix-Hallpike testing to reassess the treatment response was performed at 1 hour (post-1 hour), every 24 hours (post-24 hours) until the positional nystagmus resolved, 1 week (post-1 week), and 1 month (post-1 month) following the therapeutic maneuver. The difference in the resolution rates at post-1 hour and post-24 hours reassessment was analyzed, and the recurrence rates at post-1 week and post-1 month were evaluated.

RESULTS

The resolution rate was 67.6% at post-1 hour, which increased to 79.6% at post-24 hours reassessment. There was a statistically significant difference in the results of the Dix-Hallpike test between post-1 hour and post-24 hours follow-up. After complete resolution, nine out of 108 patients (8.3%) demonstrated recurrence within 1 month.

CONCLUSIONS

Reassessment after 24 hours following the initial Epley maneuver is more advantageous than a 1-hour follow-up in patients with PC-BPPV. This information may be helpful for clinicians in deciding the appropriate follow-up period after treatment for PC-BPPV.

LEVEL OF EVIDENCE

1b Laryngoscope, 130:496-499, 2020.

Assessing misperception of rotation in benign paroxysmal positional vertigo with static and dynamic visual images

BACKGROUND

Perception of self-motion is difficult for patients to describe. In addition, the relationship between perceived rotation and eye movements is poorly understood, because most studies of patients have investigated only static orientation.

OBJECTIVE

First, to determine whether patients with benign paroxysmal positional vertigo (BPPV) can use visual images to report perceived rotation elicited by the Dix-Hallpike maneuver. Second, to determine if the direction of patients' perceptions align with data on classical nystagmus direction.

METHODS

After the Dix-Hallpike maneuver, BPPV patients viewed images - sketches or video animations - representing possible perceived motions. They selected one or more images representing perception.

RESULTS

All subjects could select images. The directions of the videos were most often backward pitch and/ or ipsilateral roll and yaw relative to body orientation in the supine Dix-Hallpike position, generally consistent with the canal stimulus. Perceived direction of rotation was statistically significantly different from the direction of eye movements as published previously, suggesting a difference in mechanisms for perception and eye movements.

CONCLUSION

Patients can easily learn to use a video language to describe their experiences. Perception is generally aligned with canal stimulus and nystagmus, but not exactly.

Implementation of evidence-based practice for benign paroxysmal positional vertigo: DIZZTINCT- A study protocol for an exploratory stepped-wedge randomized trial

Background

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder, and accounts for 8% of individuals with moderate or severe dizziness. BPPV patients experience substantial inconveniences and disabilities during symptomatic periods. BPPV therapeutic processes – the Dix-Hallpike Test (DHT) and the Canalith Repositioning Maneuver (CRM) – have an evidence base that is at the clinical practice guideline level. The most commonly used CRM is the modified Epley maneuver. The DHT is the gold standard test for BPPV and the CRM is supported by numerous randomized controlled trials and systematic reviews. Despite this, BPPV care processes are underutilized.

Methods/design

This is a stepped-wedge, randomized clinical trial of a multi-faceted educational and care-process-based intervention designed to improve the guideline-concordant care of patients with BPPV presenting to the emergency department (ED) with dizziness. The unit of randomization and target of intervention is the hospital. After an initial observation period, the six hospitals will undergo the intervention in five waves (two closely integrated hospitals will be paired). The order will be randomized. The primary endpoint is measured at the individual patient level, and is the presence of documentation of either the Dix-Hallpike Test or CRM. The secondary endpoints are referral to a health care provider qualified to treat dizziness for CRM and 90-day stroke rates following an ED dizziness visit. Formative evaluations are also performed to monitor and identify potential and actual influences on the progress and effectiveness of the implementation efforts.

Discussion

If this study safely increases documentation of the DHT/CRM, this will be an important step in implementing the use of these evidenced-based processes of care. Positive results will support conducting larger-scale follow-up studies that assess patient outcomes. The data collection also enables evaluation of potential and actual influences on the progress and effectiveness of the implementation efforts.

Trial registration

ClinicalTrials.gov, ID: NCT02809599. The record was first available to the public on 22 June 2016 prior to the enrollment of the first patients in October 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-3099-0) contains supplementary material, which is available to authorized users.

Visual dependence and spatial orientation in benign paroxysmal positional vertigo

People with benign paroxysmal positional vertigo (BPPV) probably have otoconial particles displaced from the utricle into the posterior semicircular canal. This unilateral change in the inertial load distributions of the labyrinth may result in visual dependence and may affect balance control. The goal of this study was to explore the interaction between visual dependence and balance control. We compared 23 healthy controls to 17 people with unilateral BPPV on the Clinical Test of Sensory Interaction and Balance on compliant foam with feet together, the Rod-and-Frame Test and a Mental Rotation Test. In controls, but not BPPV subjects, subjects with poor balance scores had significantly greater visual dependence, indicating that reliance on visual cues can affect balance control. BPPV and control subjects did not differ on the mental rotation task overall but BPPV reaction time was greater at greater orietantions, suggesting that this cognitive function was affected by BPPV. The side of impairment was strongly related to the side of perceived bias in the Earth vertical determined by BPPV subjects, indicating the relationship between the effect of asymmetric otolith unloading with simultaneous canal loading on spatial orientation perception.

Comparison of the effectiveness of Brandt-Daroff Vestibular training and Epley Canalith repositioning maneuver in benign Paroxysmal positional vertigo long term result: A randomized prospective clinical trial

Objective:

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral cause of vertigo. It can be defined as transient vertigo induced by rapid change in head position, associated with a characteristic paroxysmal positional nystagmus. Posterior canal benign paroxysmal positional vertigo is the most frequent form of BPPV. The aim of our study was to investigate and compare the effectiveness of Epley maneuver and Brand-Daroff home exercises for the treatment of posterior canal BPPV.

Methods:

A total of 50 patients between 27 and 76 years of age who were diagnosed with unilateral posterior canal into BPPV were randomized prospectively into two groups. In Group-1, modified particle repositioning maneuver and in Group-2 Brandt-Daroff exercises were utilized as treatment. Patients were followed weekly. Cure weeks were recorded. The patients were followed for 12 to 24 months for recurrence.

Results:

The recovery rates at the first, second and third week controls were 76%, 96% and 100% for Group-1 (modified Epley maneuver) and 64%, 88% and 100% for Group-2 (Brandt-Daroff exercises) respectively. The recovery rates were similar for both groups. The average follow-up duration was 18 months. In Group 1, 7 patients (28%) and in Group 2, 5 patients (20%) had recurrence, which was also similar with no statistical difference.

Conclusion:

It was concluded that both Brandt-Daroff Exercises and Modified Epley maneuvers were almost equally effective in the treatment of BPPV.

Effect of Epley, Semont Maneuvers and Brandt-Daroff Exercise on Quality of Life in Patients with Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo (PSCBPPV)

Benign Paroxysmal Positional Vertigo (BPPV) is the most common cause in patients with vertigo (Pereira et al. in Braz J Otorhinolaryngol (Impr) 76(6):704-708, 2010; Dix and Hallpike in Ann Otol Rhinol Laryngol 6:987-1016, 1952). Posterior Semicircular Canal BPPV (PSCBPPV) has more incidence and prevalence then Lateral, and Anterior Semicircular Canal BPPV (Alghwiri et al. in Arch Phys Med Rehabil 93:1822-1831, 2012). Quality of life (QoL) is significantly impaired by vertigo (Sargent et al. in Otol Neurotol 22:205-209, 2001; World Health Organization in International classification of functioning, disability and health, World Health Organization, Geneva, 2001). To study the effect and compare Epley, Semont maneuvers and Brandt-Daroff Exercise on QoL in patients with PSCBPPV. 90 individuals with unilateral PSCBPPV were selected based on positive Dix-Hallpike test. 3 groups Epley, Semont, and Brandt-Daroff were formed and 30 individuals were selected in each group randomly. Dix-Hallpike test and Vestibular Activities and Participation (VAP) Scale based on International Classification of Functioning were administered before and after Epley, Semont maneuvers, and Brandt-Daroff Exercise to fulfill the aim. VAP Scale results revealed significant difference between pre and post treatment score in all 3 groups, suggestive of positive effect on QoL in patients with PSCBPPV. Improvements in VAP Score between 3 groups were compared and significant difference was observed. Dix-Hallpike test results revealed that 90, 73.33, and 50% patients improved in Epely, Semont, and Brandt-Daroff group respectively. Epely maneuver found to be the best choice and then Semont and Brandt-Daroff should be least preferred in treatment of patients with PSCBPPV.

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.

Tandem walking as a quick screening test for vestibular disorders

OBJECTIVES/HYPOTHESIS

Although many screening tests of balance are available, few of them have been well validated for clinical or research uses. The goal of this study was to test an updated version of an old test, Tandem Walking, to determine how useful it is for screening patients with vestibular disorders.

STUDY DESIGN

Case-control study.

METHODS

Subjects were 90 adult patients with vestibular disorders and 292 healthy adult controls. They were tested on the number of correct tandem steps they could perform with arms crossed and eyes closed in a series of 10 steps. Correct steps could be nonconsecutive. Subjects were given one practice trial with eyes open and three experimental trials with eyes closed.

RESULTS

Receiver operating characteristic (ROC), and sensitivity and specificity were calculated. ROC values, sensitivity, and specificity were, at best, only moderate, no matter how the age range was cut. Even for subjects in the age group with the highest ROC value (i.e., age less than 50 years), ROC = 0.8, sensitivity = 0.77, and specificity = 0.72.

CONCLUSIONS

These results indicate that 23% of patients will not be identified. Therefore, we recommend that if this test is used for screening patients in the clinic or healthy volunteers, the result should be interpreted with care.

LEVEL OF EVIDENCE

3b. Laryngoscope, 128:1687-1691, 2018.

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.

Diagnostic value of repeated Dix-Hallpike and roll maneuvers in benign paroxysmal positional vertigo

Introduction

Benign Paroxysmal Positional Vertigo (BPPV) is the most common peripheral vestibular disorder. The Dix-Hallpike and Roll maneuvers are used to diagnose BPPV.

Objective

This study aims to investigate the diagnostic value of repeated Dix-Hallpike and Roll maneuvers in BPPV.

Methods

We performed Dix-Hallpike and roll maneuvers in patients who admitted with peripheral vertigo anamnesis and met our criteria. The present study consists of 207 patients ranging in age from 16 to 70 (52.67 ± 10.67). We conducted the same maneuvers sequentially one more time in patients with negative results. We detected patients who had negative results in first maneuver and later developed symptom and nystagmus. We evaluated post-treatment success and patient satisfaction by performing Dizziness Handicap Inventory (DHI) at first admittance and two weeks after treatment in all patients with BPPV.

Results

Of a total of 207 patients, we diagnosed 139 in first maneuver. We diagnosed 28 more patients in sequentially performed maneuvers. The remaining 40 patients were referred to imaging. There was a significant difference between pre- and post-treatment DHI scores in patients with BPPV (p < 0.001).

Conclusion

Performing the diagnostic maneuvers only one more time in vertigo patients in the first clinical evaluation increases the diagnosis success in BPPV. Canalith repositioning maneuvers are effective and satisfactory treatment methods in BPPV.

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)

Objective

This update of a 2008 guideline from the American Academy of Otolaryngology—Head and Neck Surgery Foundation provides evidence-based recommendations to benign paroxysmal positional vertigo (BPPV), defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo. Changes from the prior guideline include a consumer advocate added to the update group; new evidence from 2 clinical practice guidelines, 20 systematic reviews, and 27 randomized controlled trials; enhanced emphasis on patient education and shared decision making; a new algorithm to clarify action statement relationships; and new and expanded recommendations for the diagnosis and management of BPPV.

Purpose

The primary purposes of this guideline are to improve the quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing such as radiographic imaging, and increasing the use of appropriate therapeutic repositioning maneuvers. The guideline is intended for all clinicians who are likely to diagnose and manage patients with BPPV, and it applies to any setting in which BPPV would be identified, monitored, or managed. The target patient for the guideline is aged ≥18 years with a suspected or potential diagnosis of BPPV. The primary outcome considered in this guideline is the resolution of the symptoms associated with BPPV. Secondary outcomes considered include an increased rate of accurate diagnoses of BPPV, a more efficient return to regular activities and work, decreased use of inappropriate medications and unnecessary diagnostic tests, reduction in recurrence of BPPV, and reduction in adverse events associated with undiagnosed or untreated BPPV. Other outcomes considered include minimizing costs in the diagnosis and treatment of BPPV, minimizing potentially unnecessary return physician visits, and maximizing the health-related quality of life of individuals afflicted with BPPV.

Action Statements

The update group made strong recommendations that clinicians should (1) diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down, and (2) treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure. The update group made a strong recommendation against postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV. The update group made recommendations that the clinician should (1) perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV if the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus; (2) differentiate, or refer to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo; (3) assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling; (4) reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms; (5) evaluate, or refer to a clinician who can evaluate, patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders; and (6) educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The update group made recommendations against (1) radiographic imaging for a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging, (2) vestibular testing for a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing, and (3) routinely treating BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines. The guideline update group provided the options that clinicians may offer (1) observation with follow-up as initial management for patients with BPPV and (2) vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV.

Risk factors for the recurrence of post-semicircular canal benign paroxysmal positional vertigo after canalith repositioning

This retrospective study was conducted to determine the relationship between variable factors and the recurrence rate of post-semicircular canal benign paroxysmal positional vertigo (PSC-BPPV) after canalith repositioning procedure (CRP). Patients with PSC-BPPV were diagnosed by history and the presence of a positive Dix-Hallpike maneuver between 2008 and 2010. In total, 243 patients (47 males and 196 females, average age = 57.5 -years) treated with Epley's maneuver or canalith repositioning procedure (CRP) were included in the study. The demographic factors studied were age, sex, sleep disorders, inner ear diseases, head trauma history, and cardiovascular diseases. Multivariate statistics using SPSS version 15, Pearson's Chi-squared test (χ2), Kaplan-Meier analysis, log-rank test, and Cox proportional hazards regression model were used for the analysis. The success rate of vertigo control after the initial CRP was 83.1 %. Pearson's χ2 test results showed that females and participants with sleep disorders exhibited a significant difference in the recurrence of vertigo after the initial CRP. In addition, the Kaplan-Meier analysis and log-rank test survival analysis revealed that the recurrence was associated with females and participants with sleep disorders and inner ear diseases.However, Cox proportional hazards regression showed no differences in recurrences associated with old age, sex, sleep disorders, inner ear diseases, head trauma, and cardiovascular diseases. Epley's maneuver or CRP is an effective, safe, and simple treatment for BPPV. Females and participants with sleep disorders and inner ear diseases are likely associated with the recurrence of BPPV after CRP.

Classification, diagnostic criteria and management of benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vertigo and the posterior and/or lateral semicircular canals are usually affected. BPPV is characterized by brief attacks of rotatory vertigo associated with positional and/or positioning nystagmus, which are elicited by specific head positions or changes in head position relative to gravity. In patients with the posterior-canal-type of BPPV, torsional nystagmus is induced by the Dix-Hallpike maneuver. In patients with the lateral-canal-type of BPPV, horizontal geotropic or apogeotropic nystagmus is induced by the supine roll test. The pathophysiology of BPPV is canalolithiasis comprising free-floating otoconial debris within the endolymph of a semicircular canal, or cupulolithiasis comprising otoconial debris adherent to the cupula. The observation of positional and/or positioning nystagmus is essential for the diagnosis of BPPV. BPPV is treated with the canalith repositioning procedure (CRP). Through a series of head position changes, the CRP moves otoconial debris from the affected semicircular canal to the utricle. In this review, we provide the classification, diagnostic criteria, and examinations for the diagnosis, and specific and non-specific treatments of BPPV in accordance with the Japanese practical guidelines on BPPV published by the Japan Society for Equilibrium Research.

A Career in Inquiry

This article, based on the 52nd Eleanor Clarke Slagle lecture given at the 95th American Occupational Therapy Association Annual Conference & Expo, explores the concept of inquiry as the basis for a career and as an activity of daily living. Using the heliocentric theory and the space program at NASA as examples, the broad concept of inquiry is discussed, because it has led to important changes in society over the course of history. The article describes how a career as a clinician-scientist can be grounded in the concept of inquiry and explains how all occupational therapists and occupational therapy assistants can base their own careers in inquiry, using examples from the early history of the profession of occupational therapy and from work by current investigators. Practical suggestions applicable to every clinician are provided.

Benign paroxysmal positional vertigo: opportunities squandered

Benign paroxysmal positional vertigo (BPPV) presentations are unique opportunities to simultaneously improve the effectiveness and efficiency of care. The test and treatment for BPPV--the Dix-Hallpike test (DHT) and the canalith repositioning maneuver (CRM), respectively--are supported by two evidence-based guidelines (American Academy of Otolaryngology--Head and Neck Surgery and American Academy of Neurology). With these processes, patients can be readily identified and treated at the bedside, quickly and without expensive tests. Patients randomized to the CRM have a cure rate of 80% at 24 h, compared to only 10% of controls. Despite this large effect size, less than 10% of affected patients receive the treatment, which shows that the management of BPPV in routine care is suboptimal. Future research is necessary to disseminate and implement the DHT and the CRM into routine practice.

Vestibular rehabilitation for unilateral peripheral vestibular dysfunction

BACKGROUND

This is an update of a Cochrane review first published in The Cochrane Library in Issue 4, 2007 and previously updated in 2011.Unilateral peripheral vestibular dysfunction (UPVD) can occur as a result of disease, trauma or postoperatively. The dysfunction is characterised by complaints of dizziness, visual or gaze disturbances and balance impairment. Current management includes medication, physical manoeuvres and exercise regimes, the latter known collectively as vestibular rehabilitation.

OBJECTIVES

To assess the effectiveness of vestibular rehabilitation in the adult, community-dwelling population of people with symptomatic unilateral peripheral vestibular dysfunction.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The most recent search was 18 January 2014.

SELECTION CRITERIA

Randomised controlled trials of adults living in the community, diagnosed with symptomatic unilateral peripheral vestibular dysfunction. We sought comparisons of vestibular rehabilitation versus control (e.g. placebo), other treatment (non-vestibular rehabilitation, e.g. pharmacological) or another form of vestibular rehabilitation. Our primary outcome measure was change in the specified symptomatology (for example, proportion with dizziness resolved, frequency or severity of dizziness). Secondary outcomes were measures of function, quality of life and/or measure(s) of physiological status, where reproducibility has been confirmed and shown to be relevant or related to health status (for example, posturography), and adverse effects

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included 39 studies involving 2441 participants with unilateral peripheral vestibular disorders in the review. Trials addressed the effectiveness of vestibular rehabilitation against control/sham interventions, medical interventions or other forms of vestibular rehabilitation. Non-blinding of outcome assessors and selective reporting were threats that may have biased the results in 25% of studies, but otherwise there was a low risk of selection or attrition bias.Individual and pooled analyses of the primary outcome, frequency of dizziness, showed a statistically significant effect in favour of vestibular rehabilitation over control or no intervention (odds ratio (OR) 2.67, 95% confidence interval (CI) 1.85 to 3.86; four studies, 565 participants). Secondary outcomes measures related to levels of activity or participation measured, for example, with the Dizziness Handicap Inventory, which also showed a strong trend towards significant differences between the groups (standardised mean difference (SMD) -0.83, 95% CI -1.02 to -0.64). The exception to this was when movement-based vestibular rehabilitation was compared to physical manoeuvres for benign paroxysmal positional vertigo (BPPV), where the latter was shown to be superior in cure rate in the short term (OR 0.19, 95% CI 0.07 to 0.49). There were no reported adverse effects.

AUTHORS' CONCLUSIONS

There is moderate to strong evidence that vestibular rehabilitation is a safe, effective management for unilateral peripheral vestibular dysfunction, based on a number of high-quality randomised controlled trials. There is moderate evidence that vestibular rehabilitation resolves symptoms and improves functioning in the medium term. However, there is evidence that for the specific diagnostic group of BPPV, physical (repositioning) manoeuvres are more effective in the short term than exercise-based vestibular rehabilitation; although a combination of the two is effective for longer-term functional recovery. There is insufficient evidence to discriminate between differing forms of vestibular rehabilitation.

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

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 1, 2002 and previously updated in 2004 and 2007.Benign paroxysmal positional vertigo (BPPV) is a syndrome characterised by short-lived episodes of vertigo in association with rapid changes in head position. It is a common cause of vertigo presenting to primary care and specialist otolaryngology clinics. Current treatment approaches include rehabilitative exercises and physical manoeuvres, including the Epley manoeuvre.

OBJECTIVES

To assess the effectiveness of the Epley manoeuvre for posterior canal BPPV.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 23 January 2014.

SELECTION CRITERIA

Randomised controlled trials of the Epley manoeuvre versus placebo, no treatment or other active treatment for adults diagnosed with posterior canal BPPV (including a positive Dix-Hallpike test). The primary outcome of interest was complete resolution of vertigo symptoms. Secondary outcomes were conversion of a 'positive' Dix-Hallpike test to a 'negative' Dix-Hallpike test and adverse effects of treatment.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included 11 trials in the review with a total of 745 patients.Five studies compared the efficacy of the Epley manoeuvre against a sham manoeuvre, three against other particle repositioning manoeuvres (Semont, Brandt-Daroff and Gans) and three against a control (no treatment, medication only, postural restriction). Patients were treated in hospital otolaryngology departments in eight studies and family practices in two studies. All patients were adults aged 18 to 90 years old, with a sex ratio of 1:1.5 male to female.There was a low risk of overall bias in the studies included. All studies were randomised with six applying sealed envelope or external allocation techniques. Eight of the trials blinded the assessors to the participants' treatment group and data on all outcomes for all participants were reported in eight of the 11 studies. Complete resolution of vertigo Complete resolution of vertigo occurred significantly more often in the Epley treatment group when compared to a sham manoeuvre or control (odds ratio (OR) 4.42, 95% confidence interval (CI) 2.62 to 7.44; five studies, 273 participants); the proportion of patients resolving increased from 21% to 56%. None of the trials comparing Epley versus other particle repositioning manoeuvres reported vertigo resolution as an outcome. Conversion of Dix-Hallpike positional test result from positive to negative Conversion from a positive to a negative Dix-Hallpike test significantly favoured the Epley treatment group when compared to a sham manoeuvre or control (OR 9.62, 95% CI 6.0 to 15.42; eight studies, 507 participants). There was no difference when comparing the Epley with the Semont manoeuvre (two studies, 117 participants) or the Epley with the Gans manoeuvre (one study, 58 participants). In one study a single Epley treatment was more effective than a week of three times daily Brandt-Daroff exercises (OR 12.38, 95% CI 4.32 to 35.47; 81 participants). Adverse effects Adverse effects were infrequently reported. There were no serious adverse effects of treatment. Rates of nausea during the repositioning manoeuvre varied from 16.7% to 32%. Some patients were unable to tolerate the manoeuvres because of cervical spine problems.

AUTHORS' CONCLUSIONS

There is evidence that the Epley manoeuvre is a safe, effective treatment for posterior canal BPPV, based on the results of 11, mostly small, randomised controlled trials with relatively short follow-up. There is a high recurrence rate of BPPV after treatment (36%). Outcomes for Epley manoeuvre treatment are comparable to treatment with Semont and Gans manoeuvres, but superior to Brandt-Daroff exercises.

A multicenter randomized double-blind study: comparison of the Epley, Semont, and sham maneuvers for the treatment of posterior canal benign paroxysmal positional vertigo

We evaluated the short-term efficacy of Epley, Semont, and sham maneuvers for resolving posterior canal benign paroxysmal positional vertigo (BPPV) in a prospective multicenter randomized double-blind controlled study. Subjects were randomly divided into three groups: Epley (36 patients), Semont (32 patients), and sham (Epley maneuver for the unaffected side, 31 patients). Out of 14 institutes which participated in this study, 5 institutes had previous experience of the Epley but not the Semont maneuver and the other 9 had previous experience of both maneuvers. Each maneuver was repeated twice if there was still positional vertigo or nystagmus on day 0, and the presence of nystagmus and vertigo on positional testing were evaluated immediately, 1 day, and 1 week after treatment. After the first maneuver, the Epley group showed a significantly higher resolution rate of positional nystagmus than the Semont or sham groups (63.9, 37.5, and 38.7%, respectively). After the second maneuver, the resolution rate (83.3%) of the Epley group was significantly higher than that (51.6%) of the sham group. At 1 day and 1 week after treatment, the resolution rate of the Epley group was significantly higher than those of the other groups. Similar results were seen for the resolution of positional vertigo. The Epley maneuver showed persistent resolution rates of positional vertigo and nystagmus without a fatigue phenomenon. The Epley maneuver was significantly more effective per maneuver than Semont or sham maneuvers for the short-term treatment of posterior canal BPPV. The Semont maneuver showed a higher success rate than the sham maneuver, but it was not significantly different.

Efficacy of computer-controlled repositioning procedure for benign paroxysmal positional vertigo

OBJECTIVES/HYPOTHESIS

To evaluate the short-term efficacy of the computer-controlled canalith repositioning procedure (CRP) for treatment of posterior canal benign paroxysmal positional vertigo (BPPV) compared with the current standard CRP.

STUDY DESIGN

Prospective case series.

METHODS

One hundred thirty-two patients diagnosed as having idiopathic posterior canal BPPV, with an age range of 28 to 86 years (mean 56 years), 47 men and 85 women, were treated with computer-controlled CRP mimicking the Epley maneuver. Resolution of vertigo and nystagmus on the Dix-Hallpike test at 1-week follow-up after treatment was the main outcome measure to assess the efficacy of treatment.

RESULTS

At 1-week follow-up after treatment with computer-controlled CRP, 108 (81.8%) of 132 patients had complete resolution of vertigo and nystagmus, nine (6.8%) had resolution of vertigo but presence of nystagmus, and 15 (11.4%) had provoked vertigo and nystagmus on the Dix-Hallpike test. The 81.8% success rate was comparable to those who received current standard CRP treatment in randomized controlled trials at about 80%. No significant adverse effects or complications occurred in the patients treated with computer-controlled CRP, aside from two patients (1.5%) with conversion into lateral canal BPPV.

CONCLUSIONS

Computer-controlled CRP is effective for the treatment of posterior canal BPPV, with a success rate similar to those treated with the Epley maneuver, and is safe and easy to perform on patients.

The Efficacy of Vestibular Rehabilitation in Patients with Benign Paroxysmal Positional Vertigo

Objective

To systematically review the evidence on the effectiveness of vestibular rehabilitation in addition to a canalith repositioning maneuver in patients with benign paroxysmal positional vertigo.

Data Sources

A literature search was performed in the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, and EMBASE databases.

Review Methods

A comprehensive search was performed up to July 2013. Two authors independently scanned the search results to identify randomized controlled trials of vestibular rehabilitation in addition to a canalith repositioning maneuver in patients with benign paroxysmal positional vertigo. We included trials that were available in the English language and did not apply publication year or publication status restrictions. Studies were methodologically assessed using the Cochrane risk of bias tool. Primary outcome was the effect on vertigo attacks and balance.

Results

Of 76 identified trials, only 2 trials fulfilled our inclusion criteria and were included in this review, involving 106 patients. One study was methodologically weak, the other strong. The studies differed in type of intervention, type of outcome, and follow-up time. Both studies reported no significant difference in the vertigo intensity between groups. A small effect was found on balance.

Conclusion

Two level II studies in benign paroxysmal positional vertigo showed no effect of vestibular rehabilitation in addition to a canalith repositioning maneuver on vertigo intensity and a small, beneficial effect on balance. We therefore conclude that there is no evidence for an effect of vestibular rehabilitation in addition to a canalith repositioning maneuver in patients with benign paroxysmal positional vertigo.

Vestibular suppressants after canalith repositioning in benign paroxysmal positional vertigo

OBJECTIVES/HYPOTHESIS

To investigate the characteristics of residual symptoms and to evaluate the effects of adjuvant vestibular suppressants on residual symptoms after successful canalith repositioning procedures (CRPs).

STUDY DESIGN

Individual randomized controlled trial.

METHODS

One hundred fifty patients with idiopathic benign paroxysmal positional vertigo who achieved successful CRPs on initial visit participated in this study. Dizziness Handicap Inventory (DHI) questionnaires were completed before CRPs. All study populations were divided into three groups after successful CRPs on the initial visit day: the medication (V) group (treated with a vestibular suppressant [dimenhydrinate 50 mg per day]), the placebo (P) group, and the no medication (N) group. One week after successful CRPs, residual symptoms were checked and repeated DHI questionnaires were completed to compare residual symptoms.

RESULTS

Among the 138 patients who did not show positional nystagmus at follow-up, 67 (48.5%) complained of residual symptoms. The presence of residual symptoms was more prevalent in the P and N group compared with the V group (P = .035, P = .017, respectively). The most frequent residual symptom was lightheadedness (n = 42). Moreover, in the V group, lightheadedness was significantly reduced compared with the P group (P = .029). However, in the analysis of DHI, total and subscale scores did not differ across the three groups before or after successful CRP.

CONCLUSIONS

Vestibular suppressants significantly reduced residual symptoms compared to both placebo and no medication after CRP. However, there was no significant reduction in DHI score compared with the control group, suggesting that the residual symptoms could not be evaluated by DHI score alone.

Rapid Systematic Review of the Epley Maneuver versus Vestibular Rehabilitation for Benign Paroxysmal Positional Vertigo

OBJECTIVE

To evaluate the effectiveness of the Epley maneuver compared with vestibular rehabilitation on patient-reported symptom relief and conversion of the Dix-Hallpike from positive to negative in patients with posterior benign paroxysmal positional vertigo (p-BPPV).

DATA SOURCES

PubMed, Embase, and the Cochrane Library.

REVIEW METHODS

A systematic search was conducted. Studies reporting original study data were included. Relevance and risk of bias (RoB) of the selected articles were assessed. Studies with low relevance, high RoB, or both were excluded. For outcomes of interest, absolute risk differences and their 95% confidence intervals (CIs) were extracted.

RESULTS

A total of 373 unique studies were retrieved. Five of these satisfied the eligibility criteria. One study with low RoB and 3 studies with moderate RoB showed that the Epley maneuver is more effective than vestibular rehabilitation at 1-week follow-up with regard to patient-reported symptom relief and conversion of the Dix-Hallpike maneuver from positive to negative (risk differences range from 10% [95% CI, 30-47] to 55% [95% CI, 35-71]). There is inconsistent evidence for the effectiveness of the Epley maneuver compared with vestibular rehabilitation at 1-month follow-up. Most studies suggest that the Epley maneuver and vestibular rehabilitation are equally effective at 1-month follow-up.

CONCLUSION

The Epley maneuver is more effective in treating p-BPPV than vestibular rehabilitation at 1-week follow-up. There is inconsistent evidence for the effectiveness of the Epley maneuver compared with vestibular rehabilitation at 1-month follow-up.

New analyses of the sensory organization test compared to the clinical test of sensory integration and balance in patients with benign paroxysmal positional vertigo

OBJECTIVES/HYPOTHESIS

To determine whether the Sensory Organization Test (SOT) of the computerized dynamic posturography battery or the Clinical Test of Sensory Integration and Balance (CTSIB) is more likely to indicate balance disorders in people with benign paroxysmal positional vertigo (BPPV).

STUDY DESIGN

Normal controls were compared to patients with unilateral BPPV of the posterior semicircular canal.

METHODS

Subjects performed tests with eyes open or closed on stable and unstable surfaces, with head still or with head moving at 0.33 Hz in pitch or yaw. Dependent variables were the percent time of the standard duration each subject could perform the task, the number of head motions made, and kinematic variables measured with head- and torso-mounted inertial motion units.

RESULTS

Because equilibrium scores of control subjects improved significantly over repeated trials on SOT, patients were given only one trial per condition. For percent time between-group differences were found on CTSIB with eyes closed, on foam, head moving in yaw showing significantly reduced performance by BPPV subjects compared to controls. Compared to controls, patients made significantly fewer head movements on CTSIB, eyes closed, on foam, head still, in pitch and yaw. Kinematic data also differed between the groups on tests with eyes closed and unstable surfaces with different head movement combinations, indicating increased instability in BPPV patients.

CONCLUSIONS

For screening, CTSIB with head movements is more likely than SOT to indicate balance deficits, especially when dependent measures include percent time as well as head movement counts and kinematic measures.

Evidence-based practice: management of vertigo

The article focuses on the evidence basis for the management of benign paroxysmal positional vertigo, the most common diagnosis of vertigo in both primary care and subspecialty settings. An overview is presented, along with evidence-based clinical assessment, diagnosis, and management. Summaries of differential diagnosis of vertigo and outcomes are presented.

Tests of walking balance for screening vestibular disorders

Few reliable tests are available for screening people rapidly for vestibular disorders although such tests would be useful for a variety of testing situations. Balance testing is widely performed but of unknown value for screening. The goal of this study was to determine the value of tests of walking balance for screening people with vestibular impairments. We tested three groups of patients with known vestibular impairments: benign paroxysmal positional vertigo, unilateral vestibular weakness, and post-acoustic neuroma resection. We compared them to normal subjects. All subjects were independently ambulatory without gait aids. Subjects were tested on tandem walking (TW) with eyes open and eyes closed for 10 steps, walking with no additional head motions and with augmented head rotations in yaw for 7 m (WwHT), and an obstacle avoidance task, the Functional Mobility Test (FMT). Subjects wore a 3-D motion sensor centered at mid-torso to capture kinematic measures. Patients and normals differed significantly on some behavioral measures, such as the number of steps to perform TW, and on some but not all kinematic measures. ROC analyses, however, were at best only moderate, and failed to find strong differences and cut-points that would differentiate the groups. These findings suggest that although patients and normals differ in performance of these tests in some interesting ways the groups are not sufficiently different on these tests for easy use as screening tests to differentiate the populations.

Effect of repositioning maneuver type and postmaneuver restrictions on vertigo and dizziness in benign positional paroxysmal vertigo

Introduction. To compare the efficiency of Epley (Ep) and Sémont-Toupet (ST) repositioning maneuvers and to evaluate postmaneuver restriction effect on short-term vertigo and dizziness after repositioning maneuvers by an analog visual scale (VAS) in benign positional paroxysmal vertigo (BPPV). Material and Methods. 226 consecutive adult patients with posterior canal BPPV were included. Patients were randomized into 2 different maneuver sequence groups (n = 113): 2 ST then 1 Ep or 2 Ep then 1 ST. Each group of sequence was randomized into 2 subgroups: with or without postmaneuver restrictions. Vertigo and dizziness were assessed from days 0 to 5 by VAS. Results. There was no difference between vertigo scores between Ep and ST groups. Dizziness scores were higher in Ep group during the first 3 days but became similar to those of ST group at days 4 and 5. ST maneuvers induced liberatory signs more frequently than Ep (58% versus 42% resp., P < 0.01, Fisher's test). After repositioning maneuvers, VAS scores decreased similarly in patients with and without liberatory signs. Postmaneuver restrictions did not influence VAS scores. Conclusion. Even if ST showed a higher rate of liberatory signs than Ep in this series, VAS scores were not influenced by these signs.

Vestibular rehabilitation strategies and factors that affect the outcome

Ever since the introduction of Cawthorne-Cooksey exercises, vestibular rehabilitation (VR) has been gaining popularity in the treatment of the dizzy patient. Numerous studies support the effectiveness of VR in improving balance/walking skills, eye-head coordination and the quality of life of the patient. Different rehabilitation protocols have been used to treat patients with peripheral and central vestibular disorders. Assessment of the patients' progress is based on the patients' selfperception of dizziness and their functional skills. Factors such as age, medication, time of onset of vertigo and home based VR have been evaluated on their effect on the rehabilitation's outcome. The aim of this review is to evaluate rehabilitation strategies and discuss the factors that affect the outcome.

Vestibular disorders and dual task performance: impairment when walking a straight path

Locomotion is impaired in some people with vestibular disorders. Performance on cognitive tasks is also impaired in many people with vestibular disorders. The goal of this study was to determine if patients with vestibular disorders have decreased ability to complete a dual task performance involving a cognitive task, an additional motor task or both tasks, combined along a linear path. Subjects were normal, had benign paroxysmal positional vertigo, or had various vestibular disorders that caused unilateral weakness. They were asked to walk 7.62 m in a straight line with eyes open or closed, without extra tasks, and while nodding the head, naming things, and both nodding and naming. The patients walked significantly slower than controls, especially when performing the cognitive task. Patients had greater ataxia and began veering sooner than normals. The subjects' veering increased significantly with the addition of cognitive tasks. The patient groups did not differ significantly from each other. The changes in velocity did not affect the veering. These data suggest that patients with vestibular disorders are impaired in their ability to complete a linear path when cognitive tasks are added.