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

Regional differences in patient-reported outcomes as a proxy of healthcare practices for Americans living with vestibular symptoms

BACKGROUND

Geographical location is known to affect health outcomes; however, evidence regarding whether location affects healthcare for persons suspected to have vestibular dysfunction is lacking.

OBJECTIVE

To investigate whether location affects healthcare seeking and outcomes for adults with symptoms of vestibular pathology.

METHODS

We assessed for regional disparities associated with demographics, diagnosis, chronological factors, and financial expenditures from Americans who participated in the Vestibular Disorders Association registry (N = 905, 57.4±12.5 years, 82.7% female, 94.8% White, and 8.1% Hispanic or Latino). Respondents were grouped per geographical regions defined by the United States Census Bureau.

RESULTS

There were no significant between-region differences for age (p = 0.10), sex (p = 0.78), or ethnicity (p = 0.24). There were more Asian respondents in the West versus the Midwest (p = 0.05) and more Black respondents in the South versus the West (p = 0.05). The time to first seek care was shorter in the Northeast (17.3 [SD = 49.5] weeks) versus the South (42.4 [SD = 83.7] weeks), p = 0.015. The time from the first healthcare visit to receiving a final diagnosis was shorter in the Northeast (46.5 [SD = 75.4] weeks) versus the South (68.9 [SD = 89.7] weeks), p = 0.015. Compared to the Midwest, fewer respondents in the Northeast reported "no" out-of-pocket financial impact, p = 0.039.

CONCLUSIONS

Geographical location affects healthcare seeking and outcomes for persons suspected to have vestibular dysfunction.

Comparison of outcomes of the Epley and Semont maneuvers in posterior canal BPPV: A randomized controlled trial

OBJECTIVES

This study aims to compare the efficacy of the Epley and Semont maneuvers in relieving posterior canal benign paroxysmal positional vertigo (BPPV) arising in the in patients at the Outpatient Department of the Department of Otolaryngology, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand.

METHOD

In this prospective, randomized, comparative study, patients were assigned to receive one of the two treatment methods. First, BPPV was diagnosed with the Dix-Hallpike test. Then, each patient was treated by either the Epley or Semont maneuver. Immediately afterward, the efficacy of treatments was evaluated with the Dix-Hallpike test, and dizziness intensity was assessed with the visual analog scale (VAS).

RESULTS

This study enrolled 80 patients with posterior canal BPPV, 40 of which underwent the Epley maneuver and the other 40 underwent the Semont maneuver. In the first week, The Epley maneuver cured 37 (92.5%) of the 40 patients, and the Semont maneuver cured 36 (90%) of the 40 patients. Statistical analysis revealed no significant difference in the efficacy of these treatments (P = .251). Regarding dizziness intensity, VAS scores decreased from 6.48 to 1.65 after the Epley maneuver and from 6.53 to 2.18 after the Semont maneuver. Statistical analysis revealed that the Epley maneuver was superior to the Semont maneuver (P = .009) in reducing dizziness intensity.

CONCLUSIONS

The Epley and Semont maneuvers had similar efficacy in curing posterior canal BPPV. Regarding the severity of dizziness after treatment, the Epley maneuver produced significantly better results than did the Semont maneuver.Level of Evidence: II.

Vertigo returning to the sitting position after the Semont manoeuvre. Is it a prognostic symptom?

SUMMARY

Benign paroxysmal positional vertigo (BPPV) is a frequent benign vestibular condition usually managed with particle repositioning manoeuvres, such as Semont manoeuvre (SM). Since few authors have described prognostic aspects of liberatory manoeuvres, the purpose of the present study was to investigate the possibility of considering vertigo in the final sitting position of the SM as a prognostic symptom in the outcome of posterior BPPV. One hundred and thirteen patients with diagnosis of unilateral posterior BPPV were taking into account in our retrospective cohort study: 41 men and 72 women, aged 22 to 85 years. All were submitted to one repositioning SM and afterwards controlled 3 to 5 days later by means of an additional Dix-Hallpike manoeuvre. The main outcomes investigated were the occurrence of Ny and vertigo in the different phases of the SM, as well as their characteristics in relation to outcome of the disease. Among all patients, 75 (66%) presented both orthotropic Ny and vertigo in the second SM position and 72% obtained a complete resolution of the disease after the liberatory manoeuvre. Contrarily, 17 subjects (15%) manifested vertigo in the final sitting position of the SM and among these, only 7 (41%) completely recovered from BPPV. According to our data, in case of sudden vertigo returning to the final sitting position of the SM, the failure rate of the liberatory manoeuvre was higher, even though not statistically significant: therefore, it can be considered as a negative prognostic factor of posterior BPPV after SM.

Physical Therapy for Posterior and Horizontal Canal Benign Paroxysmal Positional Vertigo: Long-term Effect and Recurrence: A Systematic Review

Introduction  Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo, and it is characterized by episodes of vertigo roundabout when the head is moved. A systematic review was performed using the most important scientific databases. This review included studies published in English in the last ten years, performed in adults, with emphasis on the diagnosis and treatment of BPPV. Objective  To investigate the long-term effectiveness of vestibular rehabilitation (VR) in patients with BPPV and the rate of recurrence of symptoms. Data Synthesis  A total of 38 studies were identified, of which only 12 met the inclusion criteria. The majority of the studies stated that VR is effective in decreasing the symptoms, with a short-term efficacy of 84.7%, and 89.2% in the long term in the reviewed studies. Conclusion  Valuable studies show the beneficial effects of the maneuvers for the treatment of BPPV and their long-term effectiveness. This strengthens the conclusion that this treatment is effective in resolving symptoms and decreasing recurrences.

Healing criteria: How should an episode of benign paroxistic positional vertigo of posterior semicircular canal's resolution be defined? Prospective observational study

OBJECTIVES

To compare the outcome of the Epley maneuver (EM) in benign paroxysmal positional vertigo of the posterior canal (CSP-BPPV) depending on the definition used for recovery.

DESIGN

Multicenter observational prospective study.

SETTING

Otoneurology Units of 5 tertiary reference hospitals.

PARTICIPANTS

All patients presenting with unilateral CSP-BPPV assisted for 1-year period.

EXCLUSION CRITERIA

Spontaneous nystagmus, positive McClure-Pagnini maneuver, positive bilateral Dix-Hallpike maneuver (DHM), positive DHM for vertigo but negative for nystagmus and atypical nystagmus.

MAIN OUTCOME MEASURES

Response to EM was measured after 7 days in 3 different outcomes: disappearance of nystagmus during the DHM in the follow-up visit, disappearance of vertigo during the DHM and general status (GS) during daily life activities.

RESULTS

264 patients were recruited (68 male/166 female, mean age 62 years). After the EM, nystagmus disappeared in 67% of them, vertigo in 54% and 36% were asymptomatic in their daily life. These outcomes were strongly correlated, but they were not concordant in a clinically significant group of cases; only the 26% of patients met all of them. The healing process follows the next sequence: negativization of positional nystagmus, then disappearance of positional vertigo and, finally, the improvement of GS during daily life activities.

CONCLUSION

Nowadays, healing criteria for the resolution of an PSC-BPPV episode have not been specifically defined yet. Provided that other otoneurological disorders have been ruled out, the next resolution criterion is proposed: absence of nystagmus and specifically during control DHM and disappearance of symptoms during daily life activities.

The Necessity for Post-Maneuver Restrictions in the Treatment of Benign Paroxysmal Positional Vertigo: An Updated Meta-Analysis of the Literature

OBJECTIVE

Many studies have published conflicting results regarding the necessity of post-maneuver postural restrictions following treatment of benign paroxysmal positional vertigo (BPPV). The purpose of this meta-analysis is to complete an updated, comprehensive review to determine best practice following a repositioning maneuver (RM).

DATA SOURCES

PubMed, CINAHL, and Embase were searched through July 2016. The reference lists of the selected studies were searched for studies that were not identified in the electronic database searches.

STUDY SELECTION

Studies investigating the effect of post-maneuver postural restrictions on RM treatment efficacy were included.

DATA EXTRACTION

The methodology, number of participants, type of RM administered, post-maneuver restrictions implemented, outcome measures, and results for each study were recorded.

DATA SYNTHESIS

Following data extraction, heterogeneity and homogeneity values of included studies were determined. Risk ratios and random effects values were obtained to determine effect size.

RESULTS

Eleven studies were included in the meta-analysis. The results of 739 total subjects were analyzed, 362 of which received post-maneuver postural restrictions and 377 of which did not. Meta-analysis revealed that there was not a statistically significant difference in treatment success rates between patients who received post-maneuver postural restrictions (90.3%) and those who did not (81.7%) (p = 0.095).

CONCLUSIONS

There was no statistically significant difference found in treatment efficacy between subjects who received post-maneuver postural restrictions and those who did not. Based on the results of this meta-analysis, if there is any benefit from prescribing the postural restrictions, it is likely to be a small marginal improvement in outcomes.

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.

Repeated canalith repositioning procedure in BPPV: Effects on recurrence and dizziness prevention

PURPOSE

To evaluate whether a repeated canalith repositioning procedure (CRP) influences the residual symptoms and the rate of recurrence of benign paroxysmal positional vertigo (BPPV) in patients with post-CRP dizziness.

MATERIALS AND METHODS

In this retrospective study, we analyzed 292 patients at the referral center for ENT diseases with a first episode of BPPV treated with a single CRP following clinical practice guidelines. In 178 patients (67.9%) who presented dizziness after BPPV recovery at the follow-up visit, 94 patients underwent CRP (treated group) and 84 did not (non-treated group). A subjective evaluation of vertigo was made by way of a questionnaire. The rates of recurrence of BPPV and residual dizziness were statistically compared between the treated and the non-treated groups; survival analysis was carried out as well.

RESULTS

In an observational period ranging from 1 to 6years, BPPV recurred in 122 subjects (46.6%) of the investigated population. Among the patients with residual dizziness, the difference in rate of recurrence of BPPV between the treated group and the non-treated group was not statistically significant (p=0.84). The treated group presented a significantly higher rate of recovery from dizziness compared to the non-treated group (p<0.001).

CONCLUSIONS

A repeated CRP in patients with post-CRP dizziness increased the rate of recovery from dizziness but had no influence on BBPV recurrence.

Vertiginous Symptoms and Objective Measures of Postural Balance in Elderly People with Benign Paroxysmal Positional Vertigo Submitted to the Epley Maneuver

Introduction Benign Paroxysmal Positional Vertigo (BPPV) is one of the most common and treatable causes of peripheral vestibular vertigo in adults. Its incidence increases with age, eventually leading to disability and a decreased quality of life. Objective The research aims to assess short-term effects of Otolith Repositioning Maneuver (ORM) on dizziness symptoms, quality of life, and postural balance in elderly people with Benign Paroxysmal Positional Vertigo. Methods A quasi-experimental study, which evaluated 14 elderly people that underwent the Otolith Repositioning Maneuver and reevaluation after one week. The authors performed statistical analysis by descriptive analysis of central tendency and dispersion; for pre- and post-treatment conditions, the authors used the Wilcoxon test. Results All aspects of the Dizziness Handicap Inventory (physical, functional, emotional, and total scores) as well as the Visual Analogue Scale (VAS) decreased after therapy (p < 0.05 and p = 0.001, respectively). However, more than half of the elderly participants did not achieve negative Dix-Hallpike. Regarding static and dynamic balance, there were significant differences in some parameters of the modified Clinical Test of Sensory Interaction and Balance, Limits of Stability and gait assessment measured by the Dizziness Gait Index (p < 0.05). Conclusion Results reveal clinical and functional benefits in elderly people with Benign Paroxysmal Positional Vertigo submitted to Otolith Repositioning Maneuver. However, most of the participants did not overcome Benign Paroxysmal Positional Vertigo and not all aspects of postural balance improved. Therefore, a longer follow-up period and a multidisciplinary team are required to establish comprehensive care for elderly patients with dizziness complaints.

Benign paroxysmal positional vertigo--a review of 101 cases

INTRODUCTION AND OBJECTIVE

Benign paroxysmal positional vertigo is one of the most common vestibular disorders, with a lifetime prevalence of 2.4%. This study aimed to assess age, gender, lesion type and site, association with other vestibular diseases, progression and recurrence in a Portuguese population.

METHODS

This was a retrospective observational study of 101 patients diagnosed with benign paroxysmal positional vertigo by the same senior doctor, in a tertiary academic hospital, between January 2009 and May 2011.

RESULTS

A total of 101 cases were pooled, with a mean age of 56.57±15.33 years (15-90 years). From these, 72.3% were women. The posterior canal was affected in 72.3%, the lateral in 24.7%, the anterior in 2% and multiple canals in 1%. Unilateral canal and left labyrinth involvement were more frequent. The therapeutic maneuver used most was Epley's. Recurrence was observed in 10.9% of the cases. It was idiopathic in 83.2% of cases. No association was found between the number of maneuvers necessary to treat benign paroxysmal positional vertigo and etiology.

CONCLUSION

Benign paroxysmal positional vertigo is more frequent in female subjects, in the 6th decade and involves preferably the posterior semicircular canal of the right labyrinth. In most cases it is idiopathic and treatment with repositioning maneuvers has a mean success of 90%. Our results were in accordance with the literature; nevertheless, in this study the left labyrinth was most affected and the follow-up period was variable.

Canal conversion after repositioning procedures: comparison of Semont and Epley maneuver

Although the efficacy of Semont (SM) and Epley maneuvers (EM) for treatment of posterior canal benign paroxysmal positional vertigo (BPPV) is well established, data comparing SM and EM regarding maneuver-induced canal switch are lacking. We prospectively investigated 102 posterior canal BPPV patients after application of the Semont or the Epley maneuver and looked for the appearance of ipsilateral horizontal canal BPPV symptoms. Although treatment success was similar for SM and EM (67 and 76 %, respectively), there was a significant difference in posterior-to-horizontal canal switch rates. In particular, 4 of 51 patients (7.8 %) of the EM group converted to the geotropic type of horizontal canal BPPV, whereas none of the 51 SM patients exhibited a canal switch. All four patients were cleared with a single barbecue maneuver. Our data suggest a small but significant difference in canal switch rate between EM and SM, which could be partly explained by the higher number of maneuver steps during which the head is in the dependent position throughout the EM.