Benign paroxysmal positioning vertigo in multiple sclerosis: diagnosis, pathophysiology and therapeutic techniques

Clinical aspects of vertigo and dizziness: what should the radiologist know?

Dizziness and vertigo are common complaints in both emergency and outpatient settings, requiring careful evaluation to determine appropriate diagnosis and treatment. Differentiating between peripheral and central causes of dizziness is crucial for effective management. Peripheral causes, such as vestibular neuritis, benign paroxysmal positional vertigo (BPPV), and Ménière's disease, are contrasted with central causes like stroke, demyelinating diseases, and posterior fossa tumors. Diagnostic approaches include assessing nystagmus patterns, the vestibulo-ocular reflex (VOR), and the HINTS Plus test. Vestibular disorders are classified as acute, episodic, or chronic based on duration and symptom presentation. Imaging plays a significant role in identifying central causes when clinical findings are inconclusive. This paper provides a comprehensive overview of the clinical evaluation and diagnostic methods for dizziness and vertigo, with emphasis on distinguishing peripheral from central etiologies.

Posterior semicircular canal cupulolithiasis during acute pontomedullary demyelination

Positional vertigo poses a diagnostic challenge in people with multiple sclerosis (MS). The characteristics of positional nystagmus and its response to repositioning manoeuvres are usually sufficient to diagnose benign paroxysmal positional vertigo (BPPV). However, certain BPPV variants respond poorly to repositioning manoeuvres and their nystagmus pattern can resemble that of central positional vertigo caused by infratentorial demyelination. This diagnostic difficulty is particularly challenging if positional vertigo occurs during an MS relapse. We describe a woman with MS who developed a sixth nerve palsy and gaze-evoked nystagmus, caused by demyelination near or within areas classically involved in central positional vertigo. However, she also had positional vertigo from coincident BPPV (and not central positional vertigo). This was initially a treatment resistant-posterior semicircular canal cupulolithiasis but it later progressed to a posterior semicircular canal canalolithiasis, with symptoms promptly resolving after a repositioning manoeuvre.

Cervical vestibular evoked myogenic potentials and video head impulse test studies: alternative methods for detecting brainstem involvement in multiple sclerosis

BACKGROUND

Brainstem involvement (BSI) has been reported as a major predictive factor for future disability in Multiple Sclerosis (MS).

AIMS/OBJECTIVES

To evaluate whether Cervical Vestibular Evoked Myogenic Potentials (cVEMPs) and Video Head Impulse Test (vHIT) can be used to detect demyelinating lesions in vestibular pathways in MS.

MATERIAL AND METHODS

Fifty three people with MS and 40 controls were evaluated with Dizziness Handicap Inventory (DHI), vHIT and cVEMP.

RESULTS

The median value of DHI in MS group was significantly higher than controls (p<.001). According to vHIT results, while the results of horizontal canal vestibulo-ocular reflex gain in group with brain stem involvement (gBSI (+)) were significantly different from both controls and group without brain stem involvement (gBSI (-)) (p= .036 and .024, respectively), results of gBSI (-) were similar with controls (p= .858). When cVEMP results were examined, mean P1 wave latency in gBSI (+) was significantly longer than controls (p= .002), but difference between gBSI (-) and controls and gBSI (+) was not statistically significant (p= .104 and .279, respectively).

CONCLUSIONS AND SIGNIFICANCE

vHIT and cVEMP can be used in diagnosis and follow-up of people with MS without demyelinating brainstem lesions on MRI.

Feasibility and safety of an immersive virtual reality-based vestibular rehabilitation programme in people with multiple sclerosis experiencing vestibular impairment: a protocol for a pilot randomised controlled trial

INTRODUCTION

Vestibular system damage in patients with multiple sclerosis (MS) may have a central and/or peripheral origin. Subsequent vestibular impairments may contribute to dizziness, balance disorders and fatigue in this population. Vestibular rehabilitation targeting vestibular impairments may improve these symptoms. Furthermore, as a successful tool in neurological rehabilitation, immersive virtual reality (VRi) could also be implemented within a vestibular rehabilitation intervention.

METHODS AND ANALYSIS

This protocol describes a parallel-arm, pilot randomised controlled trial, with blinded assessments, in 30 patients with MS with vestibular impairment (Dizziness Handicap Inventory ≥16). The experimental group will receive a VRi vestibular rehabilitation intervention based on the conventional Cawthorne-Cooksey protocol; the control group will perform the conventional protocol. The duration of the intervention in both groups will be 7 weeks (20 sessions, 3 sessions/week). The primary outcomes are the feasibility and safety of the vestibular VRi intervention in patients with MS. Secondary outcome measures are dizziness symptoms, balance performance, fatigue and quality of life. Quantitative assessment will be carried out at baseline (T0), immediately after intervention (T1), and after a follow-up period of 3 and 6 months (T2 and T3). Additionally, in order to further examine the feasibility of the intervention, a qualitative assessment will be performed at T1.

ETHICS AND DISSEMINATION

The study was approved by the Andalusian Review Board and Ethics Committee, Virgen Macarena-Virgen del Rocio Hospitals (ID 2148-N-19, 25 March 2020). Informed consent will be collected from participants who wish to participate in the research. The results of this research will be disseminated by publication in peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT04497025.

Immersive Virtual Reality and Vestibular Rehabilitation in Multiple Sclerosis: Case Report

Background

Dizziness and imbalance are common and disabling symptoms in patients with multiple sclerosis (MS) and are caused by a central, peripheral, or mixed vestibulopathy. Central vestibular disorder is the most frequently reported vestibular problem in the MS population due to demyelination. Vestibular rehabilitation ameliorates these symptoms and their repercussions and improves quality of life. Immersive virtual reality (VRi) is an emerging tool in this field; however, no previous research has been performed studying its effects in MS.

Objective

The aim of this study was to apply a VRi vestibular training protocol to a patient with MS and assess the effects induced by the experimental intervention.

Methods

This case study included a 54-year-old woman with relapsing-remitting MS. We developed a standardized VRi exercise protocol for vestibular rehabilitation based on the gold-standard Cawthorne-Cooksey vestibular training protocol. The 20-session intervention was made up of 10 initial sessions and 10 advanced sessions. Each 50-minute session was performed two to three times per week for 7 weeks. Four evaluations were carried out over the study period: at baseline (T0), between initial and advances phases (T1), postintervention (T2), and 1 month after the experimental procedure (T3). The research outcomes were dizziness, balance, gait, impact of fatigue, quality of life, repercussions in muscular tone, and usability of the head-mounted display device.

Results

After implementing the VRi vestibular protocol, improvements were seen in the following patient parameters: Dizziness Handicap Inventory score (62 points at T0; 4 points at T2); Berg Balance Scale score (47 points at T0; 54 points at T2); instrumented Timed Up and Go time (8.35 seconds at T0; 5.57 seconds at T2); muscular tone of the erector spinae, rectus femoris, and soleus; Modified Fatigue Impact Scale score (61 points at T0; 37 points at T2); and Multiple Sclerosis Quality of Life-54 values (67.16% in the physical health area at T2; 33.56% in the mental health area at T2). The patient rated the usability of the system as 90%, based on the System Usability Scale, and gave the system a grade of A.

Conclusions

Although further research is needed, this study provided initial evidence that the first VRi vestibular protocol for the MS population can improve dizziness, balance, gait, impact of fatigue, quality of life, and muscular tone through an exergame intervention. This study may help establish a standardized VRi protocol for vestibular rehabilitation.

Vertigo Related to Central Nervous System Disorders

PURPOSE OF REVIEW

This article provides an overview of the numerous causes of vertigo and dizziness that are due to central nervous system (CNS) pathology and guides clinicians in formulating a differential diagnosis and treating patients with CNS causes of vertigo.

RECENT FINDINGS

Specific autoimmune vestibulocerebellar syndromes may now be tested for, and this article discusses the antibodies known to cause such syndromes. Superficial siderosis can be more accurately diagnosed with imaging studies, and treatment using iron chelation has recently been studied but has not yet been established as an effective treatment. Central autonomic network damage in the brain can cause central orthostatic hypotension in some neurodegenerative diseases, and medication has been approved for treatment.

SUMMARY

CNS causes of vertigo are numerous and important for clinicians to recognize. Examination findings are still an extremely valuable way to diagnose central vertigo; therefore, learning how to differentiate central from peripheral vertigo based on examination is an important skill. CNS causes of vertigo often have available treatments.

Epley manoeuvre for posterior semicircular canal benign paroxysmal positional vertigo in people with multiple sclerosis: protocol of a randomised controlled trial

INTRODUCTION

Vestibular disorders in multiple sclerosis (MS) could have central or peripheral origin. Although the central aetiology is the most expected in MS, peripheral damage is also significant in this disease. The most prevalent effect of vestibular peripheral damage is benign paroxysmal positional vertigo (BPPV). Impairments of the posterior semicircular canals represent 60%-90% of cases of BPPV. The standard gold treatment for this syndrome is the Epley manoeuvre (EM), the effectiveness of which has been poorly studied in patients with MS. Only one retrospective research study and a case study have reported encouraging results for EM with regard to resolution of posterior semicircular canal BPPV. The aim of this future randomised controlled trial (RCT) is to assess the effectiveness of EM for BPPV in participants with MS compared with a sham manoeuvre.

METHODS AND ANALYSIS

The current protocol describes an RCT with two-arm, parallel-group design. Randomisation, concealed allocation and double-blinding will be conducted to reduce possible bias. Participants and evaluators will be blinded to group allocation. At least 80 participants who meet all eligibility criteria will be recruited. Participants will have the EM or sham manoeuvre performed within the experimental or control group, respectively. The primary outcome of the study is changes in the Dix Hallpike test. The secondary outcome will be changes in self-perceived scales: Dizziness Handicap Inventory and Vestibular Disorders Activities of Daily Living Scale. The sample will be evaluated at baseline, immediately after the intervention and 48 hours postintervention.

ETHICS AND DISSEMINATION

The study was approved by the Andalusian Review Board and Ethics Committee of Virgen Macarena-Virgen del Rocio Hospitals (ID 0107-N-20, 23 July 2020). The results of the research will be disseminated by the investigators to peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04578262.

Vestibular rehabilitation in multiple sclerosis: study protocol for a randomised controlled trial and cost-effectiveness analysis comparing customised with booklet based vestibular rehabilitation for vestibulopathy and a 12 month observational cohort study of the symptom reduction and recurrence rate following treatment for benign paroxysmal positional vertigo

Background

Symptoms arising from vestibular system dysfunction are observed in 49–59% of people with Multiple Sclerosis (MS). Symptoms may include vertigo, dizziness and/or imbalance. These impact on functional ability, contribute to falls and significant health and social care costs. In people with MS, vestibular dysfunction can be due to peripheral pathology that may include Benign Paroxysmal Positional Vertigo (BPPV), as well as central or combined pathology. Vestibular symptoms may be treated with vestibular rehabilitation (VR), and with repositioning manoeuvres in the case of BPPV. However, there is a paucity of evidence about the rate and degree of symptom recovery with VR for people with MS and vestibulopathy. In addition, given the multiplicity of symptoms and underpinning vestibular pathologies often seen in people with MS, a customised VR approach may be more clinically appropriate and cost effective than generic booklet-based approaches. Likewise, BPPV should be identified and treated appropriately.

Methods/ design

People with MS and symptoms of vertigo, dizziness and/or imbalance will be screened for central and/or peripheral vestibulopathy and/or BPPV. Following consent, people with BPPV will be treated with re-positioning manoeuvres over 1–3 sessions and followed up at 6 and 12 months to assess for any re-occurrence of BPPV. People with central and/or peripheral vestibulopathy will be entered into a randomised controlled trial (RCT). Trial participants will be randomly allocated (1:1) to either a 12-week generic booklet-based home programme with telephone support or a 12-week VR programme consisting of customised treatment including 12 face-to-face sessions and a home exercise programme. Customised or booklet-based interventions will start 2 weeks after randomisation and all trial participants will be followed up 14 and 26 weeks from randomisation. The primary clinical outcome is the Dizziness Handicap Inventory at 26 weeks and the primary economic endpoint is quality-adjusted life-years. A range of secondary outcomes associated with vestibular function will be used.

Discussion

If customised VR is demonstrated to be clinically and cost-effective compared to generic booklet-based VR this will inform practice guidelines and the development of training packages for therapists in the diagnosis and treatment of vestibulopathy in people with MS.

Trial registration

ISRCTN Number: 27374299

Date of Registration 24/09/2018

Protocol Version 15 25/09/2019

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-020-01983-y.

Acute vestibular syndrome and hearing loss mimicking labyrinthitis as initial presentation of multiple sclerosis

Acute vestibular syndrome is most often caused by vestibular neuritis or stroke, although demyelinating diseases may be responsible for 4% of all AVS episodes. The authors present the case of a previously healthy 17-year-old female patient complaining of spontaneous vertigo and right-sided hearing loss. Otoneurological examination suggested a peripheral vestibular cause and video head impulse test revealed a reduced vestibulo-ocular reflex gain. The presence of sensorineural hearing loss raised the suspicion of a central cause and prompted imaging evaluation. A brain MRI evidenced demyelinating lesions in the right middle cerebellar peduncle and the patient was ultimately diagnosed with Multiple Sclerosis.

Update on HINTS Plus, With Discussion of Pitfalls and Pearls

BACKGROUND AND PURPOSE

The team that manages acute vertigo in patients requires multispecialty skills. This special interest article offers a simplified list of common pitfalls to be avoided when applying the HINTS (Head-Impulse, Nystagmus, Test-of-Skew) Plus examination protocol in patients with acute vertigo. Benign paroxysmal positional vertigo is the most frequent cause of positional vertigo. The lack of systematic evaluation of symptom duration and triggers, and/or incomplete target examination, leads to improper diagnosis and management. Pitfalls to avoid and pearls to apply are offered to avoid misclassification of acute vertigo.

SUMMARY OF KEY POINTS

Appropriate, expeditious treatment implemented upon diagnostic certainty by the first health professional evaluating the patient is key to a good outcome. The absence of a typical positional nystagmus is particularly concerning for an alternative diagnosis. Misclassification of the type of vertigo leads to potential diagnostic error. The HINTS Plus examination is useful when applied to the correct clinical scenario. The most common misclassification of vertigo relates to an inability to detect spontaneous nystagmus suppressed by visual fixation and subsequent classification and treatment for positional vertigo. The second most common classification relates to inadequate evaluation of the HINTS Plus examination.

RECOMMENDATIONS FOR CLINICAL PRACTICE

Through an organized evaluation of the acutely vertiginous patient, common pitfalls in the classification of vertigo can be avoided. Such an evaluation leads to identification of those patients who require canal repositioning maneuvers and those who need referral for evaluation of other causes.

Non-inflammatory causes of emergency consultation in patients with multiple sclerosis

OBJECTIVES

To describe non-relapse-related emergency consultations of patients with multiple sclerosis (MS): causes, difficulties in the diagnosis, clinical characteristics, and treatments administered.

METHODS

We performed a retrospective study of patients who attended a multiple sclerosis day hospital due to suspected relapse and received an alternative diagnosis, over a 2-year period. Demographic data, clinical characteristics, final diagnosis, and treatments administered were evaluated. Patients who were initially diagnosed with pseudo-relapse and ultimately diagnosed with true relapse were evaluated specifically. As an exploratory analysis, patients who consulted with non-inflammatory causes were compared with a randomly selected cohort of patients with true relapses who attended the centre in the same period.

RESULTS

The study included 50 patients (33 were women; mean age 41.4 ± 11.7 years). Four patients (8%) were initially diagnosed with pseudo-relapse and later diagnosed as having a true relapse. Fever and vertigo were the main confounding factors. The non-inflammatory causes of emergency consultation were: neurological, 43.5% (20 patients); infectious, 15.2% (7); psychiatric, 10.9% (5); vertigo, 8.6% (4); trauma, 10.9% (5); and miscellaneous, 10.9% (5).

CONCLUSIONS

MS-related symptoms constituted the most frequent cause of non-inflammatory emergency consultations. Close follow-up of relapse and pseudo-relapse is necessary to detect incorrect initial diagnoses, avoid unnecessary treatments, and relieve patients' symptoms.

Effectiveness of Vestibular Training for Balance and Dizziness Rehabilitation in People with Multiple Sclerosis: A Systematic Review and Meta-Analysis

Postural instability and dizziness are commonly observed in people with multiple sclerosis (PwMS). The aim of this systematic review was to evaluate the evidence for the use of vestibular rehabilitation, in comparison with other exercise interventions or no intervention, to treat balance impairments and dizziness in PwMS. An electronic search was conducted by two independent reviewers in the following databases: MEDLINE (Pubmed), Scopus, the Physiotherapy Evidence Database (PEDro), Web of Science (WOS), Lilacs, CINHAL and the Cochrane Database of Systematic Reviews (CDSR). A quality assessment was performed using the PEDro scale and the Cochrane Risk of Bias Tool. When possible, the data were pooled in a meta-analysis (95%CI). This systematic review followed the PRISMA guideline statement and was registered in the PROSPERO database (CRD42019134230). Seven studies were included, with a total of 321 participants analysed. Compared with no intervention, vestibular rehabilitation was more effective for balance development (SMD = 2.12; 95% CI = 0.49, 3.75; p = 0.01; I² = 89%) and dizziness symptoms improvement (SMD = −17.43; 95% CI = −29.99, −4.87; p= 0.007; I²= 66%). Compared with other exercise interventions, improvements in favour of the experimental group were observed, but statistical significance for the differences between groups was not reached.

Multiple Sclerosis Presenting as an Anterior Semicircular Canal Benign Paroxysmal Positional Vertigo: Case Report

We present the case of a 31-year-old woman with isolated symptomatology accusing positional vertigo. The videonystagmography (VNG) including Dix-Hallpike testing we have performed, highlighted atypical eye movements. We have observed a positional downbeating nystagmus with characteristics that could be accounted for anterior semicircular canal benign paroxysmal positional vertigo. Furthermore, examining the atypical nystagmus at the measurements performed during VNG recordings, we suspicioned a central positional vertigo. The abnormalities observed at the positional nystagmus were the lack of latency period, the downbeating component not limited in time, and the atypical torsional component. The magnetic resonance imaging examination recommended showed multiple white matter lesions characteristic for multiple sclerosis. The patient was referred to the neurology department for further evaluation and treatment. The diagnosis was unexpected because the patient did not have any other symptom that could have been linked to multiple sclerosis.

Review of the pathology underlying benign paroxysmal positional vertigo

The pathophysiological mechanism underlying benign paroxysmal positional vertigo (BPPV) is related to free-floating debris/otoliths in the semicircular canal (canalolithiasis) or debris/otoliths attached to the cupula (cupulolithiasis). These debris/otoliths are considered to originally accumulate after detachment from the neuroepithelium of the utricular macula secondary to a type of degeneration. An idiopathic form, which is assumed to occur spontaneously, is diagnosed when the causative pathology is obscure. However, an association between various other systemic or inner ear conditions and BPPV has been reported, indicating the existence of secondary BPPV. This study was performed to present the first review of the pathology underlying BPPV following a complete PubMed/Medline search. In total, 1932 articles published from 1975 to 2018 were reviewed. The articles were classified according to 17 potentially causative factors (aging; migraine; Meniere's disease; infection; trauma; idiopathic sudden sensorineural hearing loss; sleeping habits; osteoporosis and vitamin D insufficiency; hyperglycemia and diabetes mellitus; chronic head and neck pain; vestibule or semicircular canal pathology; pigmentation disorders; estrogen deficiency; neurological disorders; autoimmune, inflammatory, or rheumatologic disorders; familial or genetic predisposition; and allergy). A discussion of the underlying cause of BPPV for each factor is presented.

Risk of benign paroxysmal positional vertigo in patients with depressive disorders: a nationwide population-based cohort study

OBJECTIVE

The association between depression and benign paroxysmal positional vertigo (BPPV) remains debated. This study aimed to investigate the risk of BPPV in patients with depressive disorders.

DESIGN

Longitudinal nationwide cohort study.

SETTING

National health insurance research database in Taiwan.

PARTICIPANTS

We enrolled 10 297 patients diagnosed with depressive disorders between 2000 and 2009 and compared them to 41 188 selected control patients who had never been diagnosed with depressive disorders (at a 1:4 ratio matched by age, sex and index date) in relation to the risk of developing BPPV.

METHODS

The follow-up period was defined as the time from the initial diagnosis of depressive disorders to the date of BPPV, censoring or 31 December 2009. Cox proportional hazard regression analysis was used to investigate the risk of BPPV by sex, age and comorbidities, with HRs and 95% CIs.

RESULTS

During the 9-year follow-up period, 44 (0.59 per 1000 person-years) patients with depressive disorders and 99 (0.33 per 1000 person-years) control patients were diagnosed with BPPV. The incidence rate ratio of BPPV among both cohorts calculating from events of BPPV per 1000 person-years of observation time was 1.79 (95% CI 1.23 to 2.58, p=0.002). Following adjustments for age, sex and comorbidities, patients with depressive disorders were 1.55 times more likely to develop BPPV (95% CI 1.08 to 2.23, p=0.019) as compared with control patients. In addition, hyperthyroidism (HR=3.75, 95% CI 1.67-8.42, p=0.001) and systemic lupus erythematosus (SLE) (HR=3.47, 95% CI 1.07 to 11.22, p=0.038) were potential risk factors for developing BPPV in patients with depressive disorders.

CONCLUSIONS

Patients with depressive disorders may have an increased risk of developing BPPV, especially those who have hyperthyroidism and SLE.

Mining healthcare data for markers of the multiple sclerosis prodrome

BACKGROUND

Previous studies suggest the existence of a prodromal period in multiple sclerosis, but little is known about the phenotypic characteristics. This study aims to characterize the multiple sclerosis (MS) prodrome using data mining analytics in the healthcare setting.

METHODS

We identified people with MS and matched general population controls using health administrative data in two Canadian provinces (British Columbia and Saskatchewan). Using a training dataset (66.6% of British Columbia's cohort), L1 penalized logistic regression models were fitted to predict MS from physician and hospital encounters (via International Classification of Diseases [ICD] codes) and prescriptions filled (as drug classes) during the five years before the MS case's first demyelinating event. Internal and external validation of identified predictors was performed using logistic regression on the remaining British Columbia (33.4%) and Saskatchewan data. Adjusted odds ratios (aORs) and Area under the Curve (AUC) metrics for the models' predictive performance were reported.

RESULTS

We identified 8,669 MS cases and 40,867 controls. Good predictive performance was observed for physician data (internal/external validation AUC = 0.81/0.79). Physician-generated ICD codes that were associated with MS and validated in both provinces included disorders of the central and peripheral nervous system, disorders of the eye, and cerebrovascular disease (aOR = 1.3-7.0). Overall, hospital and prescription data showed very poor and poor predictive performance (internal/external validation AUCs = 0.54/0.55 and 0.66/0.61, respectively). However, hospitalizations related to the urinary system or spinal cord diseases, or prescriptions for urinary antispasmodics or anti-vertigo preparations, were associated with 2 to 3-fold higher odds of MS (aOR = 2.3-3.3).

CONCLUSIONS

Findings provide insight into the clinical characteristics of the MS prodrome. Diagnostic codes from physician encounters were capable of differentiating between MS cases and controls.

Non-inflammatory causes of emergency consultation in patients with multiple sclerosis

OBJECTIVES

To describe non-relapse-related emergency consultations of patients with multiple sclerosis (MS): causes, difficulties in the diagnosis, clinical characteristics, and treatments administered.

METHODS

We performed a retrospective study of patients who attended a multiple sclerosis day hospital due to suspected relapse and received an alternative diagnosis, over a 2-year period. Demographic data, clinical characteristics, final diagnosis, and treatments administered were evaluated. Patients who were initially diagnosed with pseudo-relapse and ultimately diagnosed with true relapse were evaluated specifically. As an exploratory analysis, patients who consulted with non-inflammatory causes were compared with a randomly selected cohort of patients with true relapses who attended the centre in the same period.

RESULTS

The study included 50 patients (33 were women; mean age 41.4±11.7years). Four patients (8%) were initially diagnosed with pseudo-relapse and later diagnosed as having a true relapse. Fever and vertigo were the main confounding factors. The non-inflammatory causes of emergency consultation were: neurological, 43.5% (20 patients); infectious, 15.2% (7); psychiatric, 10.9% (5); vertigo, 8.6% (4); trauma, 10.9% (5); and miscellaneous, 10.9% (5).

CONCLUSIONS

MS-related symptoms constituted the most frequent cause of non-inflammatory emergency consultations. Close follow-up of relapse and pseudo-relapse is necessary to detect incorrect initial diagnoses, avoid unnecessary treatments, and relieve patients' symptoms.

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.

Increased risk of benign paroxysmal positional vertigo in patients with anxiety disorders: a nationwide population-based retrospective cohort study

BACKGROUND

The objective of this study was to evaluate the risk of benign peripheral persistent vertigo (BPPV) among patients with anxiety disorders by using the Taiwan National Health Insurance Research Database (NHIRD).

METHODS

We conducted a retrospective study of 15,470 participants (7735 anxiety disorder patients and 7735 control patients) selected from the NHIRD. Patients were observed for a maximum of 9 years to determine the rates of newly diagnosed BPPV. A Cox regression model was used to evaluate the risk of BPPV among the patients with anxiety disorders.

RESULTS

During the 9-year follow-up period, 178 (2.05 per 1000 person-years) anxiety disorder patients and 71 (0.81 per 1000 person-years) control patients were diagnosed with BPPV. The incidence risk ratio of BPPV between anxiety disorder patients and control patients was 2.52 (95 % confidence interval [CI], 1.90-3.37, P < .001). After adjustment for age, sex, and comorbidities, patients with anxiety disorders were found to be 2.17 times more likely to develop BPPV (95 % CI, 1.63-2.90, P < .001) than the control patients. Furthermore, female sex (HR = 1.81, 95 % CI, 1.31-2.50, P < .001) and cerebrovascular disease (HR = 1.53, 95 % CI, 1.00-2.34, P = .050) were independent risk factors for developing new-onset BPPV in patients with anxiety disorders.

CONCLUSIONS

Anxiety disorder patients may have an increased risk of developing BPPV, especially those who are female or have cerebrovascular disease.

Symptomatic management in multiple sclerosis

Multiple sclerosis (MS) is the commonest cause of disability in young adults. While there is increasing choice and better treatments available for delaying disease progression, there are still, very few, effective symptomatic treatments. For many patients such as those with primary progressive MS (PPMS) and those that inevitably become secondary progressive, symptom management is the only treatment available. MS related symptoms are complex, interrelated, and can be interdependent. It requires good understanding of the condition, a holistic multidisciplinary approach, and above all, patient education and empowerment.

Management of benign paroxysmal positional vertigo (BPPV) in the emergency department

Benign paroxysmal positional vertigo (BPPV) is a common medical condition that can be managed by emergency physicians. Vertigo sufferers usually complain of the room spinning associated with certain head movements such as getting out of bed, looking up and bending down. BPPV can be diagnosed clinically from history and examination and does not require any investigations. BPPV can be effectively treated at the bedside by using one of the Canalith repositioning maneuvers (particle repositioning maneuvers). This treatment has been proven to be effective in randomised controlled trials and carries minimal risks. The common complications during the procedure include nausea, vomiting and vertigo. There are no absolute contraindications. BPPV can resolve spontaneously but symptoms may last for weeks in most patients, to years in others. Failure to respond to physical maneuvers and an unusual pattern of nystagmus may suggest a central pathology. Diagnostic strategies and physical manoeuvres are described in this narrative review. Future directions and recommendations also discussed.

Multiple sclerosis symptom management

Multiple sclerosis (MS) is the most common cause of nontraumatic disability in young adults. The increasing emphasis on early treatment with disease-modifying therapies has the goal of preventing long-term disability. However, current disease treatments are only partially effective, and most patients experience a variety of neurologic symptoms at various times during their disease course. Because these symptoms often have a profound impact on social, occupational and physical performance, effective symptom management is an important component of therapy to maintain quality of life. Effective symptom management often requires a multidisciplinary team approach. This review outlines general principles of the management of MS symptoms.

Symptomatic treatment and management of multiple sclerosis

The range of symptoms which occur in multiple sclerosis (MS) can have disabling functional consequences for patients and lead to significant reductions in their quality of life. MS symptoms can also interact with each other, making their management challenging. Clinical trials aimed at identifying symptomatic therapies have generally been poorly designed and have tended to be underpowered. Therefore, the evidence base for the management of MS symptoms with pharmacologic therapies is not strong and tends to rely upon open-label studies, case reports, and clinical trials with small numbers of patients and poorly validated clinical outcome measures. Recently, there has been a growing interest in the management of MS symptoms with pharmacologic treatments, and better-designed, randomized, double-blind, controlled trials have been reported. This chapter will describe the evidence base predominantly behind the various pharmacologic approaches to the management of MS symptoms, which in most, if not all, cases, requires multidisciplinary input. Drugs routinely recommended for individual symptoms and new therapies, which are currently in the development pipeline, will be reviewed. More interventional therapies related to symptoms that are refractory to pharmacotherapy will also be discussed, where relevant.

Revised criteria for suspicion of non-benign positional vertigo

Benign paroxysmal positional vertigo (BPPV) is the most commonly diagnosed vestibular vertigo. BPPV can be diagnosed by clinical examination and its treatment is based on particle repositioning manoeuvres, and specialized equipment is not required. Therefore, most patients could be diagnosed and treated by their general practitioner. Unfortunately, not all positional vertigos are benign. Symptoms similar to those of BPPV can be caused by diseases that affect the central nervous system. It must be possible to define criteria that allow us to suspect, in a patient with symptoms of positional vertigo, the possibility of a cerebral origin ('non-benign PV'). Requests for magnetic resonance imaging must be justified by the fulfillment of these criteria. That is especially relevant in primary care, because these criteria should make possible to distinguish between patients with positional vertigo that could be treated by general practitioner and patients that need to be directed to especialized units. We propose the following revised criteria for suspected non-benign PV: (i) association with signs or symptoms of neurological disorder, (ii) nystagmus without dizziness in positional diagnostic tests, (iii) atypical nystagmus direction, (iv) poor response to therapeutic manoeuvres and (v) recurrence (confirmed by positional tests) on at least three occasions.

Symptomatic therapy in multiple sclerosis

Multiple sclerosis is the most common disabling neurological disease of young adults. The ability to impact the quality of life of patients with multiple sclerosis should not only incorporate therapies that are disease modifying, but should also include a course of action for the global multidisciplinary management focused on quality of life and functional capabilities.

Symptomatic therapy in multiple sclerosis: a review for a multimodal approach in clinical practice

As more investigations into factors affecting the quality of life of patients with multiple sclerosis (MS) are undertaken, it is becoming increasingly apparent that certain comorbidities and associated symptoms commonly found in these patients differ in incidence, pathophysiology and other factors compared with the general population. Many of these MS-related symptoms are frequently ignored in assessments of disease status and are often not considered to be associated with the disease. Research into how such comorbidities and symptoms can be diagnosed and treated within the MS population is lacking. This information gap adds further complexity to disease management and represents an unmet need in MS, particularly as early recognition and treatment of these conditions can improve patient outcomes. In this manuscript, we sought to review the literature on the comorbidities and symptoms of MS and to summarize the evidence for treatments that have been or may be used to alleviate them.

Reliability of a rating scale used to distinguish direction of eye movement using infrared/video ENG recordings during repositioning maneuvers

The purpose of this study was to determine the validity of the nystagmus rating scale (NRS) and to assess inter- and intra-rater reliability of audiologists and experts using the scale. Face and content validity was established by eliciting feedback from two neurotologists and one neurologist. A training tape was developed to describe the rating scale and provide practice with patterns of nystagmus in benign paroxysmal positional vertigo (BPPV). Eye movements of 34 patients, ages 33 to 82 years, were videotaped using infrared/video ENG during repositioning maneuvers. Six randomly paired audiologists and six experts viewed the videotape recordings and completed the NRS for each pattern. Cohen's kappa coefficients were calculated to determine inter-rater reliability. The kappa values were 0.31 with 41% agreement for audiologists, and 0.48 with 59% agreement for experts. Intra-rater reliability for a subgroup of audiologists was 0.55 with 64% agreement, and for experts was 0.75 with 81% agreement. In summary, even in this experienced population, additional training in viewing nystagmus patterns is needed to improve reliability among clinicians during diagnosis and treatment.

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo

Objectives:

This guideline provides evidence-based recommendations on managing benign paroxysmal positional vertigo (BPPV), which is the most common vestibular disorder in adults, with a lifetime prevalence of 2.4 percent. The guideline targets patients aged 18 years or older with a potential diagnosis of BPPV, evaluated in any setting in which an adult with BPPV would be identified, monitored, or managed. This guideline is intended for all clinicians who are likely to diagnose and manage adults with BPPV.

Purpose:

The primary purposes of this guideline are to improve 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 tests such as radiographic imaging and vestibular testing, and to promote the use of effective repositioning maneuvers for treatment. In creating this guideline, the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of audiology, chiropractic medicine, emergency medicine, family medicine, geriatric medicine, internal medicine, neurology, nursing, otolaryngology–head and neck surgery, physical therapy, and physical medicine and rehabilitation.

Results

The panel made strong recommendations that 1) clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with nystagmus is provoked by the Dix-Hallpike maneuver. The panel made recommendations against 1) radiographic imaging, vestibular testing, or both in patients diagnosed with BPPV, unless the diagnosis is uncertain or there are additional symptoms or signs unrelated to BPPV that warrant testing; and 2) routinely treating BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines. The panel made recommendations that 1) if the patient has a history compatible with BPPV and the Dix-Hallpike test is negative, clinicians should perform a supine roll test to assess for lateral semicircular canal BPPV; 2) clinicians should differentiate BPPV from other causes of imbalance, dizziness, and vertigo; 3) clinicians should question patients with BPPV for factors that modify management including impaired mobility or balance, CNS disorders, lack of home support, and increased risk for falling; 4) clinicians should treat patients with posterior canal BPPV with a particle repositioning maneuver (PRM); 5) clinicians should reassess patients within 1 month after an initial period of observation or treatment to confirm symptom resolution; 6) clinicians should evaluate patients with BPPV who are initial treatment failures for persistent BPPV or underlying peripheral vestibular or CNS disorders; and 7) clinicians should counsel patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The panel offered as options that 1) clinicians may offer vestibular rehabilitation, either self-administered or with a clinician, for the initial treatment of BPPV and 2) clinicians may offer observation as initial management for patients with BPPV and with assurance of follow-up. The panel made no recommendation concerning audiometric testing in patients diagnosed with BPPV.

Disclaimer:

This clinical practice guideline is not intended as a sole source of guidance in managing benign paroxysmal positional vertigo. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgement or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem. ® 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.

Some aspects of balance disorder in patients with multiple sclerosis

The aim of this study was to analyze: frequency of balance disorder (vertigo and disequilibrium), frequency of abnormalities in auditory evoked potentials (AEP) and magnetic resonance imaging (MRI) changes of the brain in multiple sclerosis (MS) patients with balance disorder, relation of patient's disability status to balance disorder and relation of the changes in MRI of the brainstem to AEP abnormalities. It was analyzed 60 patients with relapsing-remitting form of MS. Two groups of patients were made consecutively under Expanded Disability Status Scale score (EDSS): A (EDSS < or =4,5) and B (EDSS > or =5,0). The study was retrospective-prospective. After the neurological exam AEP and MRI of the brain have been done. Balance disorder has been verified as initial symptom in 29 (48,4%) and out of them disequilibrium experienced 24 (83,4%) patients. During the relapses balance disorder experienced 48 (80%) patients and in 37 (77,1%) it was disequilibrium. Among them 33 (68,7%) were with lower EDSS (< or =4,5) and 15 (31,3%) with higher EDSS score (> or =5). There is no correlation between disability status and vertigo which means that vertigo is not more frequent in more disabled patients and vice-versa. The AEP were pathological in 57 (95%) patients. Of all 29 patients with vertigo AEP were pathological in 28 (96,5%) while in 31 patients without vertigo pathological AEP were in 29 (93,5%) but it is not statistical significant. The most frequent characteristic of AEP changes were prolonged inter-peak latency III-V waves (48 patients or 80%). The plaque in brainstem visualized by MRI was found in 41 (71,8%) of patients (38 or 92,6% of them had pathological AEP and in three patients AEP were normal). In group of patients with pathological AEP, 38 (66,6%) of them had plaque in brainstem. In other three patients with normal AEP it was visualized plaque in brainstem. In the group of 29 patients with balance disorder, 20 (68,9%) had plaque in brainstem as well as 21 (67,7%) out of 31 patients without balance disorder had plaque in the brainstem. This difference is not statistical significant. It is concluded that the vertigo (including disequilibrium) is relatively often (48,4%) initial symptom of MS. Vertigo is not more frequent in patients with higher EDSS score and vice-versa. Pathological AEP are frequent neurophysiologic finding in both (95%) patients with (96,5%) and without (93,5%) vertigo. The most often pathological characteristic of AEP are prolonged interpeak latency of III-V waves (78,5%), as well as abnormalities of V and than IV wave. MS plaques in brainstem visualized by MRI technique are frequent in both groups of patients with and without pathological finding of the AEP.

A minute demyelinating lesion causing acute positional vertigo

Clinico-anatomical correlations in multiple sclerosis patients presenting with central positional vertigo are lacking. We report on a patient with acute onset positional vertigo mimicking benign paroxysmal positional vertigo with a single enhancing lesion in the inner part of the superior cerebellar peduncle, disclosed only after thin slice MR-imaging. This location appears to be a common cause of central positional vertigo and should be regarded as characteristic for demyelinating rather than vascular pathology. In cases presenting with positional nystagmus and vertigo without other cerebellar deficits one should look explicitly for signal abnormalities in the inner part of the superior cerebellar peduncle. High spatial resolution-MRI seems to be mandatory for lesion detection.

Reabilitação vestibular em pacientes com esclerose múltipla remitente-recorrente

A esclerose múltipla (EM) é doença desmielinizante, inflamatória, que acomete a substância branca do sistema nervoso central, e sensações vestibulares anormais (vertigem, desequilíbrio) são freqüentes. A reabilitação vestibular (RV) é determinada por mecanismos de adaptações, substituições e compensações neurais. Este estudo avaliou a melhora da vertigem central ou periférica em pacientes com EM remitente-recorrente submetidos à RV (exercícios de Cawthorne-Cooksey), através da escala de Berg e Dizziness Handicap Inventory (DHI). Nesta amostra de 4 casos a RV, realizada em um período de 2 meses, demonstrou a melhora em 3 pacientes avaliados pela escala de Berg e em 2 pacientes quando avaliados pela DHI.

The association between apolipoprotein E and multiple sclerosis

The article is a complete literature study that investigates the association between apolipoprotein E (Apo E) and multiple sclerosis (MS). Apo E is an important factor in transport, uptake, and redistribution of cholesterol, which is significant to remodelling and repair of nerve tissue. Apo E is involved in neurodegenerative diseases and the most well known association is between Apo epsilon4 and Alzheimer's disease. Only one study found that homozygosity for Apo epsilon4 does cause an increased risk of developing MS. No results indicate that heterozygosity for Apo epsilon4 causes a greater risk of developing MS. No association between the Apo epsilon4 allele and MS subgroups, age of onset, and gender has been found. The association between Apo epsilon4 and relapse rate is contradictory. Most results confirm the hypothesis about an association between the Apo epsilon4 allele and increased disease progression. Two longitudinal studies found an association between Apo epsilon4 and increased disease progression. Half of the cross-sectional studies found the same association. Four of seven published studies examining the association between Apo epsilon4 and increased disease progression using magnetic resonance imaging (MRI) found a significant association. Apo epsilon4 appears to be a predisposing factor to a faster disease progression in MS.

Sinais e sintomas associados a alterações otoneurológicas diagnoticadas ao exame vestibular computadorizado em pacientes com esclerose múltipla

OBJETIVO: Descrever os principais sintomas e sinais ao exame vestibular computadorizado em pacientes com diagnóstico de esclerose múltipla. MÉTODO:Foram examinados 30 pacientes com diagnóstico de esclerose múltipla. Analisaram-se os dados relativos à sintomatologia e achados ao exame vestibular computadorizado realizado no ambulatório de otoneurologia da Irmandade Santa Casa de Misericórdia de São Paulo, em 2003. RESULTADOS: Em relação aos sintomas relatados, observamos desequilíbrio (60%), formigamento de extremidades (43,3%), vertigem (40%), cefaléia e ansiedade (36,7%), zumbido (30%), depressão (26,7%). Ao exame vestibular encontramos alterações do nistagmo de posicionamento (6,7%), nistagmo espontâneo de olhos fechados (30%), nistagmo semi-espontâneo (13,3%), rastreio pendular (3,3%) e prova calórica (63,3%). Na conclusão do exame tivemos prevalência de síndrome vestibular periférica irritativa (60%) e síndrome central (13,4%). CONCLUÇÃO: Concluimos que a realização do exame otoneurológico torna-se imprescindível nos pacientes com esclerose múltipla devido a elevada prevalência de alterações à vectonistagmografia computadorizada e elevada prevalência de sintomas otoneurológicos.