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Efficacy of canalith repositioning maneuvers for benign paroxysmal positional vertigo
Clinical Chiropractic (2009) 12, 95—100
www.elsevier.com/locate/clch
ORIGINAL ARTICLE
Efficacy of canalith repositioning maneuvers for benign paroxysmal positional vertigo ˘lu a ˘lu b, Duygu Kurtulus Cengiz Bahadır a,*, Demirhan Dırac¸og ¸ a, ˙Ilker Garipog a
Haydarpas¸a Numune Training and Research Hospital, Physical Medicine and Rehabilitation Clinic, Istanbul, Turkey b Istanbul University, Istanbul Faculty of Medicine, Physical Medicine and Rehabilitation Department, Istanbul, Turkey Received 18 December 2008; received in revised form 10 September 2009; accepted 1 October 2009
KEYWORDS Vertigo; Benign paroxysmal positional vertigo; Epley maneuver; Liberatory maneuver; Canalith repositioning maneuver; Falls
Summary Objective: Vertigo is a common clinical problem, particularly in older people. Benign paroxysmal positional vertigo (BPPV) is one of the most frequent causes of vertigo. It may be dangerous, especially in older individuals, because unsteadiness associated with BPPV can lead to falls. We aimed to investigate therapeutic effects of canalith repositioning maneuvers in patient with BPPV. Design: Prospective study. Setting: Patients complaining of vertigo referred to our Physical Medicine Outpatient Clinic for vestibular rehabilitation. Subjects: 26 patients (14 male, 12 female) were studied; mean age was 52.5 6.5 year (range 35—65), and mean symptom duration was 9.5 20 months (range 0.25— 96). Methods: Detailed clinical examination, tests, and imaging studies were performed to exclude other possible diseases that may cause vertigo. Previous falls from the onset of symptoms were recorded. The Dix—Hallpike test for posterior and anterior semicircular canals (SCC) BPPV, and the supine roll test for horizontal SCC BPPV were performed. In all patients, the Epley maneuver (canalith repositioning maneuver, CRM) was performed initially. The Semont (liberatory) maneuver was performed in those patients who showed no signs of improvement with the Epley maneuver. Patients were followed up during 3 months. Results: All patients were diagnosed as having posterior SCC BPPV. Eight patients described immediate relief of their vertigo following the first maneuver. Ten days later 16 patients (61.5%) showed complete relief from vertigo. The Epley maneuver
* Corresponding author at: Poyraz S. Erdemler Is Mrk. A-Blok No: 9, K: 2 Hasanpasa/Kadikoy, 34722 Istanbul, Turkey. Tel.: +90 216 4490941; fax: +90 216 4490859. E-mail address: [email protected] (C. Bahadır). 1479-2354/$36.00 # 2009 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clch.2009.10.001
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C. Bahadır et al. was repeated in five patients who showed moderate improvement with the first maneuver. Five patients with little or no improvement following the Epley maneuver undertook the Semont maneuver (liberatory maneuver): complete relief from vertigo was found in two. Patients were followed up during 3 months. No recurrence was observed in any patients during the study period. After 3 months, six patients still had the symptoms of BPPV but to a lesser degree. Conclusion: Our results indicate that BPPV can be diagnosed easily and treated using a simple maneuver. On the basis of patient history and the Dix—Hallpike test it seems to be unnecessary to perform other diagnostic examinations routinely before trying CRM. Diagnosis and appropriate therapy is important for the prevention of further complications. # 2009 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved.
Introduction Vertigo is a subtype of dizziness, which results from an imbalance within the vestibular system. Vertigo can result from lesions in such diverse locations as the inner ear, the visual/vestibular interaction centers in the brainstem and cerebellum, and in the subjective sensation pathways of the thalamus or cortex. In 80% of cases the condition is severe enough to require medical intervention.1 Vertigo can have many causes, and differential diagnosis can be difficult due to accompanying diseases, particularly in elderly patients. Vertigo is often associated with other vestibulo-ocular symptoms such as nystagmus, nausea, sweating and oscilopsia, and most commonly in cases with acute onset. Vertigo is also one of the most common causes of falls in old age.2,3 In patients with intermittent vertigo, the condition may be associated with vertebrobasilar insufficiency syndrome (VBIS) due to cervical spondylosis.4—6 Overall, however, VBIS only accounts for a small proportion of vertigo cases. Transient ischaemic attacks from vertebrobasilar ischaemia and cerebrovascular accidents were found in only 3% of vertigo patients aged 60 years or over.1 The most common cause of vertigo is benign paroxysmal positional vertigo (BPPV).7 BPPV is characterized by brief episodes of mild to intense dizziness associated with specific changes in head position. It is a common clinical condition. Von Brevern et al. reported that the lifetime prevalence of BPPV is 2.4%, the 1-year prevalence is 1.6% and the 1-year incidence is 0.6% in Germany.8 The incidence of BPPV is estimated at 10.7 per 100 000 population in Japan.9 The condition is thought to be caused by freefloating calcium carbonate crystals (otoconia) in the semicircular canals (SCC) (canalitiasis) or by otoconia attached to the cupula (cupulolitiasis) which have become displaced from the utricle. When the patient moves or inclines their head, movement of otoconia stimulates the cupula (displacement of
the cupula away from the ampulla) to generate the sensation of vertigo. BPPV can also cause loss of balance. If left untreated, fear of falling and disuse disequilibrium associated with falls may develop progressively, especially in older patients.1 Although the etiology of BPPV remains uncertain, the condition is sometimes associated with head trauma or vestibular neuritis.1,7 Diagnosis of BPPV is frequently missed in patients with mild symptomatology. Canalith reposioning maneuvers (CRM) are the most effective and the only treatment option for BPPV. Epley, Semont (liberatory), and Brandt—Daroff maneuvers are most frequently used for the treatment of BPPV. Higher success rates have been commonly reported with different CRMs.1 The present study aimed to investigate the efficacy of CRM in patients with BPPV.
Materials and methods All cases who met the following criteria were selected among patients who were referred to our clinic for vestibular rehabilitation: The sensation of vertigo caused by head and body movements. Positional vertigo and nystagmus elicited by Dix— Hallpike or supine roll tests. Elimination of possible diseases of different origin that may cause vertigo through a patient history, clinical examination and imaging studies. The Dix—Hallpike test for posterior and anterior SCC BPPV and the supine roll test for horizontal SCC BPPV were performed to establish the diagnosis. Dix—Hallpike test protocol was as follows: at the start, the patient sits on the examination table with the head turned horizontally at 458; the head and trunk are then brought back so that the patient is now in the supine position with the head inclined backwards at an angle of approximately
Efficacy of canalith repositioning maneuvers for benign paroxysmal positional vertigo 208 (Dix—Hallpike position). The eyes are observed for up to 1 min for signs of nystagmus; the patient is asked if they sense vertigo. The quick phase direction of nystagmus is noted. Ipsilateral torsion and upbeat, ipsilateral torsion and downbeat, horizontal nystagmus indicate posterior SCC, anterior SCC and horizontal SCC involvement respectively. The patient is then slowly returned to the sitting position with the head constantly inclined and nystagmus again recorded. The same procedure is then repeated with the head turned on the other side. Roll test protocol was as follows: at the start, the patient is laid supine; the head is quickly rolled to one side, signs of nystagmus are noted and the patient is asked if they sense any vertigo. The head is slowly rolled back to start position and the same movement and procedure are performed for the other side. Patients with positive Dix—Hallpike or supine roll tests were diagnosed with BPPV. The Dix—Hallpike test and all other clinical tests and examinations were done by the same investigator. Age of patients, symptom duration, previous and associated diseases, and vertigo medication were recorded. The frequency and duration of spells of vertigo, the specific movements inducing vertigo, and other associated symptoms (including nausea, blurred vision, tinnitus, hearing loss, and oscillopsia) were also noted. To exclude possible disease processes that may cause vertigo, clinical examination and imaging studies were performed. Neurological examinations included sensory tests, muscle strength and deep tendon reflexes. Myofascial trigger points were investigated for sternocleidomastoid trapezius and cervical extensor muscles. Supine and vertical blood pressure measurements were also made; the difference in values was used to detect orthostatic hypotension. The head-thrust test (HTT) was used to evaluate vestibular hypofunction (the vestibularocular reflex, VOR). During the HTT, the patient is asked to focus his or her eyes on a target. Next, the patient’s head is gently grasped, and a small-amplitude (5—108) but high-acceleration thrust is applied by the examiner. Once the head stops moving, the eyes are observed for a corrective saccade. The corrective saccade is a rapid eye motion that returns the eyes toward the target and indicates a decreased gain of the VOR. Caloric tests were also used to assess vestibular function in both ears; 5 ml of ice water were inserted into each ear and nystagmus in the ipsilateral eye was monitored. Imaging studies (if not performed previously) were performed in all patients to exclude central nervous system disorders. Cervical antero-posterior and lateral radiography was performed in the neutral position; brain magnetic resonance imaging (MRI), carotid
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and vertebral artery doppler ultrasonography (USG) were also performed. Participants were required to discontinue the use of any current vestibular acting medications throughout the study period. In 26 patients diagnosed with BPPV, the Epley maneuver (canalith repositioning maneuver, CRM) and Semont (liberatory) maneuver were performed. All maneuvers were performed by an another investigator.
Maneuvers protocol The patients sits on the examination table with the head rotated horizontally at 458 towards the affected side. The patient is then moved into the Dix—Hallpike position. After 20 s, the patient’s head is turned to the opposite side and held in that position for 20 s. After 20 s, the patient is rolled onto their shoulder on the same side and with the same head rotation. After 20 s in that position, the patient is allowed to sit up. Patients were fitted with a soft collar. For 48 h following the maneuver, patients were asked to use the soft collar and not to bend over, lie back, move the head up or down and sleep on the affected ear. Patients were re-examined after 10 days. If symptoms persisted, but with less intensity, the Epley maneuver was re-performed. If there was no improvement, the Semont (liberatory) maneuver was performed. In this maneuver, patient sits a on a examination table side-ways and head is rotated 458 toward the affected side. The patient is then moved quickly onto the affected side. After 20 s, the patient is rapidly moved through the initial sitting position to the opposite side while the head is still positioned 458 toward the unaffected side. The patient holds this position for 20 s and then moves slowly to a sitting position. The same post-maneuver procedure was done in these patients. Patients were re-examined after 10 days and the maneuver was repeated in patients with unresolved symptoms. All patients were asked to come back to our outpatient clinic if their symptoms recurred during follow-up period. After 3 months patients were re-examined for symptoms of BPPV. SPSS 11.0 software was used for statistical analysis. The efficacy of CRM was evaluated by using Mc Nemar test. This study was approved by the institutional ethics committee and all subjects gave written informed consent before any study procedure.
Results Between April 2008 and June 2009, 56 patients were referred to our clinic for vestibular rehabilitation.
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Table 1 Movements causing vertigo. Head movement
Turning in bed
Sitting up from the bed
Bending forward
26
22
18
14
Twenty-six (14 male, 12 female) were included in the study. The mean age of the patients was 52.5 6.5 year (range 35—65), mean symptom duration was 9.5 20 months (range 0.25—96). One patient had previous head trauma. Brain MRI was normal in all cases. Doppler USG found slightly reduced blood flow (below 200 ml/min) in 3 patients. At the time of admission, 22 patients (84%) were using symptomatic medications for their vertigo. The Dix—Hallpike test was positive for all cases, whereas supine roll test was negative. According to nystagmus direction during the Dix—Hallpike test, all patients had posterior SCC involvement. All patients described that their vertigo was initiated or aggravated by head and body movements. In the majority of patients, more than one type of movement was associated with episodes of vertigo (Table 1). Most of patients described their episodes of vertigo as lasting for only a few seconds. 5 patients (19%) had experienced 1 or more falls during their illness.
Results of the canalith repositioning maneuver (CRM) The canalith repositioning (Epley) maneuver was performed on the 26 patients who had a positive Dix—Hallpike test. Eight patients (30.7%) described vertigo improvement immediately following the first maneuver. Ten days later, 16 patients (61.5%) showed complete relief from vertigo (P < 0.001). The Epley maneuver was re-performed in five patients who showed moderate improvement with first maneuver (Table 2). Five patients with little or no improvement following the Epley maneuver undertook the Semont maneuver (liberatory maneuver): complete relief from vertigo was found in two. Five BPPV patients
who had experienced falls before the study reported no further falls during the study period. The only complications associated with performing the maneuvers were in two patients who vomited after the Epley maneuver. Patients were followed up during 3 months. No recurrence was observed in patients who achieved complete relief after maneuvers. Three patients with failed improvement at the beginning showed mild improvement after 3 months. After 3 months, six patients still had the symptoms of BPPV but to a lesser degree.
Discussion Although vertigo is common, the condition is often not explicitly recognized, particularly in older patients and when the symptoms are mild. Studies show that unrecognized BPPV is especially common in the elderly population.10,11 The most distinctive clinical feature between benign paroxysmal positional vertigo and other causes of vertigo is the duration of the spells of dizziness. In BPPV patients, each vertigo episode typically lasts only seconds.1,7 In our study, almost all BPPV patients had vertigo spells lasting in a few seconds. We believe that diagnosis of BPPV is often missed, and symptoms have often been attributed wrongly to VBIS. There are as yet no agreed criteria for the diagnosis of VBIS. Doppler USG is a well-proven method for revealing the decreased vertebral artery blood flow that can be responsible for vestibulo-ocular symptoms4,12,13; however, Seo et al showed vertebrobasilar artery abnormalities, such as bending, narrowing or obstruction, in 8 out of 14 BPPV patients by using MRI.14 Moreover, their study also suggested that the positional nystagmus might result from vertebrobasilar ischaemia, even if there were no other neurological signs. Although some studies reported that the vertebral artery blood flow is related to cervical rotation movements, in the majority no correlations were found between rotation, blood flow and vertebrobasilar insufficiency (VBI)15; however both diseases have similar symptomatology and can be
Table 2 Results of the maneuvers.
10 days 20 days 3 months a b
Complete recovery; negative Dix—Hallpike test
Moderate improvement; slightly positive Dix—Hallpike test
No improvement; positive Dix—Hallpike test
Total
16 (P < 0.001) 20 (P < 0.001) 20 (P < 0.001)
5a 3 3
5b 3 3
26
The Epley maneuver was re-performed. The liberatory maneuver was performed.
26
Efficacy of canalith repositioning maneuvers for benign paroxysmal positional vertigo misdiagnosed easily if clinical examination is performed without caution. In fact, three patients with BPPV (as revealed by the Dix—Hallpike test) in our study, whose vertigo was improved by the Epley maneuver (two of them gaining complete relief, one of them moderate improvement), were also found to have slightly reduced vertebral artery flow rate (below 200 ml/min). There are no data regarding manipulation of cervical spine reducing symptoms of VBIS in the literature. Our findings suggest that, in these patients, vertigo is unlikely to be due to decreased vertebral artery blood flow but to BPPV. It is frequently implied that head trauma and vestibular neuritis may be an etiologic agent for BPPV1,7; however, only one of our patients (3%) described previous head trauma. This patient responded well to the Epley maneuver. In our study 20 of 26 patients (77%) showed complete healing after one or two session of maneuvers. Recovery rates after CRM have previously been reported as 78—98%.16—20 Our cure rates (61.5% at 10 days and 79% at the end of study) are correlated with the majority of the literature data; however, Beynon et al. reported a short-term success rate of 98%.20 Our immediate cure rate (30.7%) after the first maneuver was lower compared with other studies. Only six patients still had symptoms after 3 months, but their symptoms were of a lesser degree. There are no similarities between these patients (four female, two male). Only two of them described previous major depression. Symtomatic medications were given to these patients with persistent BPPV after the study period. High spontaneous recovery rate is reported in BPPV patients. In a study from Richard et al., the efficacy of the Epley maneuver was compared with a control group and 60% spontaneous recovery was found at the end of 6th month.17 Sherman and Massoud reported that 60% of patients with BPPV showed spontaneous recovery after 2 weeks.21 In our study, we observed immediate recovery after the first maneuver in eight patients and short-term recovery in 16 patients. At the end of study period, six patients still had BPPV symptoms which were of a lesser degree. Some of these recoveries are likely to have been spontaneous. It is reported that about 10—20% of patients have a recurrence of vertigo 1—2 weeks after the maneuver, and around half will eventually have a recurrence.22 However, recurrence of BPPV symptoms was not observed in any patient during the study period. When left untreated, BBPV causes problems with balance. This is extremely important in older patients because of the increased risk of falling,10,23 and the significant disease burden resulting from osteoporotic fractures.24 Frequent falls in older
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patients can be complicated by fear of falling and disuse disequilibrium which cannot be treated easily. Prior to admission to the study, five of the 26 patients had experienced falls. Although a small number of our patients with BPPV had experienced falls, the maneuvers prevented further recurrence. In this study almost all patients were receiving vestibular acting medications before the study. Vestibular suppressants may contribute to chronic dizziness because they can impair vestibular adaptation. These drugs should, therefore, only be used during the acute stages of vertigo, and only for a short time,1 and our patients were asked to discontinue their medication. BPPV is unique among the different types of vertigo because it differs in etiology, diagnosis and therapy. A simple test is sufficient for accurate diagnosis, and an easily performed maneuver can provide rapid symptom relief. The majority of patients with BPPV have posterior SCC pathology.1,7 In our study, the majority of our patients were diagnosed as posterior SCC BPPV. The Epley and other maneuvers (liberatory, Brandt—Daroff) are well-proven treatment modalities for BPPV.1,7 The maneuvers are simple procedures and can be adapted even for home-based patient use. The Epley maneuver was chosen as the first line of treatment. The liberatory maneuver was performed in only five patients who showed no improvement with the Epley maneuver, possibly due to cupulolithiais. In our study, 16 out of 26 patients with BPPV, one of whom had suffered from vertigo for 8 years, quickly recovered from vertigo after the Epley maneuver.
Conclusion Vertigo is commonly seen in clinical practice and can sometimes be of complex etiology. Differentiating BPPV from other causes of vertigo is of great importance. Treatment of BPPV is particularly important for older patients as poor balance can lead to falling, with increased risk of fracture. Repositioning maneuvers are simple to perform, and safe and effective in the treatment of BPPV.
Conflict of interest There are no conflicts of interest.
References 1. Tusa RG. Vertigo. Neurol Clin 2001;19(1):23—55.
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2. Hansson EE, Ma ˚nsson NO, Ringsberg KA, Ha ˚kansson A. Falls among dizzy patients in primary healthcare: an intervention study with control group. Int J Rehabil Res 2008;31(1):51—7. 3. Lawson J, Johnson I, Bamiou DE, Newton JL. Benign paroxysmal positional vertigo: clinical characteristics of dizzy patients referred to a Falls and Syncope Unit. QJM 2005; 98(5):357—64. 4. Jargiello T, Pietura R, Rakowski P, Szczerbo-Trojanowska M, Szajner M, Janczarek M. Power Doppler imaging in the evaluation of extracranial vertebral artery compression in patients with vertebrobasilar insufficiency. Eur J Ultrasound 1998;8(3):149—56. 5. Bulsara KR, Velez DA, Villavicencio A. Rotational vertebral artery insufficiency resulting from cervical spondylosis: case report and review of the literature. Surg Neurol 2006; 65(6):625—7. 6. Ogino M, Kawamoto T, Asakuno K, Maeda Y, Kim P. Proper management of the rotational vertebral artery occlusion secondary to spondylosis. Clin Neurol Neurosurg 2001; 103(4):250—3. 7. Tusa RJ. Benign paroxysmal positional vertigo. Curr Neurol Neurosci Rep 2001;1(5):478—85. 8. Von Brevern M, Radtke A, Lezius F, Feldmann M, Ziese T, Lempert T, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry 2007;78(7):710—5. 9. Mizukoshi K, Watanabe Y, Shojaku H, Okubo J, Watanabe I. Epidemiological studies on benign paroxysmal positional vertigo in Japan. Acta Otolaryngol Suppl 1988;447:67—72. 10. Oghalai JS, Manolidis S, Barth JL, Stewart MG, Jenkins HA. Unrecognized benign paroxysmal positional vertigo in elderly patients. Otolaryngol Head Neck Surg 2000;122(5):630—4. 11. Pollak L. Awareness of benign paroxysmal positional vertigo in central Israel. BMC Neurol 2009;22(9):17. 12. Kalaria VG, Jacob S, Irwin W, Schainfeld RM. Duplex ultrasonography of vertebral and subclavian arteries. J Am Soc Echocardiogr 2005;18(10):1107—11. 13. von Bu ¨dingen HC, Staudacher T, von Bu ¨dingen HJ. Ultrasound diagnostics of the vertebrobasilar system. Front Neurol Neurosci 2006;21:57—69.
14. Seo T, Tominaga S, Sakagami M. Relationship between neurological asymptomatic vertigo and the vertebrobasilar system as revealed by magnetic resonance angiography. J Otorhinolaryngol Relat Spec 2000;62(2):63—7. 15. Mitchell J. Doppler insonation of vertebral artery blood flow changes associated with cervical spine rotation: implications for manual therapists. Physiother Theory Pract 2007;23(6): 303—13. 16. Prokopakis EP, Chimona T, Tsagournisakis M, Christodoulou P, Hirsch BE, Lachanas VA, et al. Benign paroxysmal positional vertigo: 10-year experience in treating 592 patients with canalith repositioning procedure. Laryngoscope 2005; 115(9):1667—71. 17. Richard W, Bruintjes TD, Oostenbrink P, van Leeuwen RB. Efficacy of the Epley maneuver for posterior canal BPPV: a long-term, controlled study of 81 patients. Ear Nose Throat J 2005;84(1):22—5. 18. Soto Varela A, Bartual Magro J, Santos Pe ´rez S, Ve ´lez Regueiro M, Lechuga Garcı´a R, Pe ´rez-Carro Rı´os A, et al. Benign paroxysmal vertigo: a comparative prospective study of the efficacy of Brandt and Daroff exercises, Semont and Epley maneuver. Rev Laryngol Otol Rhinol (Bord) 2001; 122(3):179—83. ˘lu LN, Ergin NT. The canalith repositioning 19. Dal T, Ozlu ¨og maneuver in patients with benign positional vertigo. Eur Arch Otorhinolaryngol 2000;257(3):133—6. 20. Beynon GJ, Baguley DM, da Cruz MJ. Recurrence of symptoms following treatment of posterior semicircular canal benign positional paroxysmal vertigo with a particle repositioning maneuver. J Otolaryngol 2000;29(1):2—6. 21. Sherman D, Massoud EA. Treatment outcomes of benign paroxysmal positional vertigo. J Otolaryngol 2001;30(5):295—9. 22. Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107:399—404. 23. Brandt T, Dieterich M. Vestibular falls. J Vestib Res 1993; 3(1):3—14. 24. Moayyeri A. The association between physical activity and osteoporotic fractures: a review of the evidence and implications for future research. Ann Epidemiol 2008;18(11):827—35.
Available online at www.sciencedirect.com
www.elsevier.com/locate/clch
ORIGINAL ARTICLE
Efficacy of canalith repositioning maneuvers for benign paroxysmal positional vertigo ˘lu a ˘lu b, Duygu Kurtulus Cengiz Bahadır a,*, Demirhan Dırac¸og ¸ a, ˙Ilker Garipog a
Haydarpas¸a Numune Training and Research Hospital, Physical Medicine and Rehabilitation Clinic, Istanbul, Turkey b Istanbul University, Istanbul Faculty of Medicine, Physical Medicine and Rehabilitation Department, Istanbul, Turkey Received 18 December 2008; received in revised form 10 September 2009; accepted 1 October 2009
KEYWORDS Vertigo; Benign paroxysmal positional vertigo; Epley maneuver; Liberatory maneuver; Canalith repositioning maneuver; Falls
Summary Objective: Vertigo is a common clinical problem, particularly in older people. Benign paroxysmal positional vertigo (BPPV) is one of the most frequent causes of vertigo. It may be dangerous, especially in older individuals, because unsteadiness associated with BPPV can lead to falls. We aimed to investigate therapeutic effects of canalith repositioning maneuvers in patient with BPPV. Design: Prospective study. Setting: Patients complaining of vertigo referred to our Physical Medicine Outpatient Clinic for vestibular rehabilitation. Subjects: 26 patients (14 male, 12 female) were studied; mean age was 52.5 6.5 year (range 35—65), and mean symptom duration was 9.5 20 months (range 0.25— 96). Methods: Detailed clinical examination, tests, and imaging studies were performed to exclude other possible diseases that may cause vertigo. Previous falls from the onset of symptoms were recorded. The Dix—Hallpike test for posterior and anterior semicircular canals (SCC) BPPV, and the supine roll test for horizontal SCC BPPV were performed. In all patients, the Epley maneuver (canalith repositioning maneuver, CRM) was performed initially. The Semont (liberatory) maneuver was performed in those patients who showed no signs of improvement with the Epley maneuver. Patients were followed up during 3 months. Results: All patients were diagnosed as having posterior SCC BPPV. Eight patients described immediate relief of their vertigo following the first maneuver. Ten days later 16 patients (61.5%) showed complete relief from vertigo. The Epley maneuver
* Corresponding author at: Poyraz S. Erdemler Is Mrk. A-Blok No: 9, K: 2 Hasanpasa/Kadikoy, 34722 Istanbul, Turkey. Tel.: +90 216 4490941; fax: +90 216 4490859. E-mail address: [email protected] (C. Bahadır). 1479-2354/$36.00 # 2009 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.clch.2009.10.001
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C. Bahadır et al. was repeated in five patients who showed moderate improvement with the first maneuver. Five patients with little or no improvement following the Epley maneuver undertook the Semont maneuver (liberatory maneuver): complete relief from vertigo was found in two. Patients were followed up during 3 months. No recurrence was observed in any patients during the study period. After 3 months, six patients still had the symptoms of BPPV but to a lesser degree. Conclusion: Our results indicate that BPPV can be diagnosed easily and treated using a simple maneuver. On the basis of patient history and the Dix—Hallpike test it seems to be unnecessary to perform other diagnostic examinations routinely before trying CRM. Diagnosis and appropriate therapy is important for the prevention of further complications. # 2009 The College of Chiropractors. Published by Elsevier Ltd. All rights reserved.
Introduction Vertigo is a subtype of dizziness, which results from an imbalance within the vestibular system. Vertigo can result from lesions in such diverse locations as the inner ear, the visual/vestibular interaction centers in the brainstem and cerebellum, and in the subjective sensation pathways of the thalamus or cortex. In 80% of cases the condition is severe enough to require medical intervention.1 Vertigo can have many causes, and differential diagnosis can be difficult due to accompanying diseases, particularly in elderly patients. Vertigo is often associated with other vestibulo-ocular symptoms such as nystagmus, nausea, sweating and oscilopsia, and most commonly in cases with acute onset. Vertigo is also one of the most common causes of falls in old age.2,3 In patients with intermittent vertigo, the condition may be associated with vertebrobasilar insufficiency syndrome (VBIS) due to cervical spondylosis.4—6 Overall, however, VBIS only accounts for a small proportion of vertigo cases. Transient ischaemic attacks from vertebrobasilar ischaemia and cerebrovascular accidents were found in only 3% of vertigo patients aged 60 years or over.1 The most common cause of vertigo is benign paroxysmal positional vertigo (BPPV).7 BPPV is characterized by brief episodes of mild to intense dizziness associated with specific changes in head position. It is a common clinical condition. Von Brevern et al. reported that the lifetime prevalence of BPPV is 2.4%, the 1-year prevalence is 1.6% and the 1-year incidence is 0.6% in Germany.8 The incidence of BPPV is estimated at 10.7 per 100 000 population in Japan.9 The condition is thought to be caused by freefloating calcium carbonate crystals (otoconia) in the semicircular canals (SCC) (canalitiasis) or by otoconia attached to the cupula (cupulolitiasis) which have become displaced from the utricle. When the patient moves or inclines their head, movement of otoconia stimulates the cupula (displacement of
the cupula away from the ampulla) to generate the sensation of vertigo. BPPV can also cause loss of balance. If left untreated, fear of falling and disuse disequilibrium associated with falls may develop progressively, especially in older patients.1 Although the etiology of BPPV remains uncertain, the condition is sometimes associated with head trauma or vestibular neuritis.1,7 Diagnosis of BPPV is frequently missed in patients with mild symptomatology. Canalith reposioning maneuvers (CRM) are the most effective and the only treatment option for BPPV. Epley, Semont (liberatory), and Brandt—Daroff maneuvers are most frequently used for the treatment of BPPV. Higher success rates have been commonly reported with different CRMs.1 The present study aimed to investigate the efficacy of CRM in patients with BPPV.
Materials and methods All cases who met the following criteria were selected among patients who were referred to our clinic for vestibular rehabilitation: The sensation of vertigo caused by head and body movements. Positional vertigo and nystagmus elicited by Dix— Hallpike or supine roll tests. Elimination of possible diseases of different origin that may cause vertigo through a patient history, clinical examination and imaging studies. The Dix—Hallpike test for posterior and anterior SCC BPPV and the supine roll test for horizontal SCC BPPV were performed to establish the diagnosis. Dix—Hallpike test protocol was as follows: at the start, the patient sits on the examination table with the head turned horizontally at 458; the head and trunk are then brought back so that the patient is now in the supine position with the head inclined backwards at an angle of approximately
Efficacy of canalith repositioning maneuvers for benign paroxysmal positional vertigo 208 (Dix—Hallpike position). The eyes are observed for up to 1 min for signs of nystagmus; the patient is asked if they sense vertigo. The quick phase direction of nystagmus is noted. Ipsilateral torsion and upbeat, ipsilateral torsion and downbeat, horizontal nystagmus indicate posterior SCC, anterior SCC and horizontal SCC involvement respectively. The patient is then slowly returned to the sitting position with the head constantly inclined and nystagmus again recorded. The same procedure is then repeated with the head turned on the other side. Roll test protocol was as follows: at the start, the patient is laid supine; the head is quickly rolled to one side, signs of nystagmus are noted and the patient is asked if they sense any vertigo. The head is slowly rolled back to start position and the same movement and procedure are performed for the other side. Patients with positive Dix—Hallpike or supine roll tests were diagnosed with BPPV. The Dix—Hallpike test and all other clinical tests and examinations were done by the same investigator. Age of patients, symptom duration, previous and associated diseases, and vertigo medication were recorded. The frequency and duration of spells of vertigo, the specific movements inducing vertigo, and other associated symptoms (including nausea, blurred vision, tinnitus, hearing loss, and oscillopsia) were also noted. To exclude possible disease processes that may cause vertigo, clinical examination and imaging studies were performed. Neurological examinations included sensory tests, muscle strength and deep tendon reflexes. Myofascial trigger points were investigated for sternocleidomastoid trapezius and cervical extensor muscles. Supine and vertical blood pressure measurements were also made; the difference in values was used to detect orthostatic hypotension. The head-thrust test (HTT) was used to evaluate vestibular hypofunction (the vestibularocular reflex, VOR). During the HTT, the patient is asked to focus his or her eyes on a target. Next, the patient’s head is gently grasped, and a small-amplitude (5—108) but high-acceleration thrust is applied by the examiner. Once the head stops moving, the eyes are observed for a corrective saccade. The corrective saccade is a rapid eye motion that returns the eyes toward the target and indicates a decreased gain of the VOR. Caloric tests were also used to assess vestibular function in both ears; 5 ml of ice water were inserted into each ear and nystagmus in the ipsilateral eye was monitored. Imaging studies (if not performed previously) were performed in all patients to exclude central nervous system disorders. Cervical antero-posterior and lateral radiography was performed in the neutral position; brain magnetic resonance imaging (MRI), carotid
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and vertebral artery doppler ultrasonography (USG) were also performed. Participants were required to discontinue the use of any current vestibular acting medications throughout the study period. In 26 patients diagnosed with BPPV, the Epley maneuver (canalith repositioning maneuver, CRM) and Semont (liberatory) maneuver were performed. All maneuvers were performed by an another investigator.
Maneuvers protocol The patients sits on the examination table with the head rotated horizontally at 458 towards the affected side. The patient is then moved into the Dix—Hallpike position. After 20 s, the patient’s head is turned to the opposite side and held in that position for 20 s. After 20 s, the patient is rolled onto their shoulder on the same side and with the same head rotation. After 20 s in that position, the patient is allowed to sit up. Patients were fitted with a soft collar. For 48 h following the maneuver, patients were asked to use the soft collar and not to bend over, lie back, move the head up or down and sleep on the affected ear. Patients were re-examined after 10 days. If symptoms persisted, but with less intensity, the Epley maneuver was re-performed. If there was no improvement, the Semont (liberatory) maneuver was performed. In this maneuver, patient sits a on a examination table side-ways and head is rotated 458 toward the affected side. The patient is then moved quickly onto the affected side. After 20 s, the patient is rapidly moved through the initial sitting position to the opposite side while the head is still positioned 458 toward the unaffected side. The patient holds this position for 20 s and then moves slowly to a sitting position. The same post-maneuver procedure was done in these patients. Patients were re-examined after 10 days and the maneuver was repeated in patients with unresolved symptoms. All patients were asked to come back to our outpatient clinic if their symptoms recurred during follow-up period. After 3 months patients were re-examined for symptoms of BPPV. SPSS 11.0 software was used for statistical analysis. The efficacy of CRM was evaluated by using Mc Nemar test. This study was approved by the institutional ethics committee and all subjects gave written informed consent before any study procedure.
Results Between April 2008 and June 2009, 56 patients were referred to our clinic for vestibular rehabilitation.
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Table 1 Movements causing vertigo. Head movement
Turning in bed
Sitting up from the bed
Bending forward
26
22
18
14
Twenty-six (14 male, 12 female) were included in the study. The mean age of the patients was 52.5 6.5 year (range 35—65), mean symptom duration was 9.5 20 months (range 0.25—96). One patient had previous head trauma. Brain MRI was normal in all cases. Doppler USG found slightly reduced blood flow (below 200 ml/min) in 3 patients. At the time of admission, 22 patients (84%) were using symptomatic medications for their vertigo. The Dix—Hallpike test was positive for all cases, whereas supine roll test was negative. According to nystagmus direction during the Dix—Hallpike test, all patients had posterior SCC involvement. All patients described that their vertigo was initiated or aggravated by head and body movements. In the majority of patients, more than one type of movement was associated with episodes of vertigo (Table 1). Most of patients described their episodes of vertigo as lasting for only a few seconds. 5 patients (19%) had experienced 1 or more falls during their illness.
Results of the canalith repositioning maneuver (CRM) The canalith repositioning (Epley) maneuver was performed on the 26 patients who had a positive Dix—Hallpike test. Eight patients (30.7%) described vertigo improvement immediately following the first maneuver. Ten days later, 16 patients (61.5%) showed complete relief from vertigo (P < 0.001). The Epley maneuver was re-performed in five patients who showed moderate improvement with first maneuver (Table 2). Five patients with little or no improvement following the Epley maneuver undertook the Semont maneuver (liberatory maneuver): complete relief from vertigo was found in two. Five BPPV patients
who had experienced falls before the study reported no further falls during the study period. The only complications associated with performing the maneuvers were in two patients who vomited after the Epley maneuver. Patients were followed up during 3 months. No recurrence was observed in patients who achieved complete relief after maneuvers. Three patients with failed improvement at the beginning showed mild improvement after 3 months. After 3 months, six patients still had the symptoms of BPPV but to a lesser degree.
Discussion Although vertigo is common, the condition is often not explicitly recognized, particularly in older patients and when the symptoms are mild. Studies show that unrecognized BPPV is especially common in the elderly population.10,11 The most distinctive clinical feature between benign paroxysmal positional vertigo and other causes of vertigo is the duration of the spells of dizziness. In BPPV patients, each vertigo episode typically lasts only seconds.1,7 In our study, almost all BPPV patients had vertigo spells lasting in a few seconds. We believe that diagnosis of BPPV is often missed, and symptoms have often been attributed wrongly to VBIS. There are as yet no agreed criteria for the diagnosis of VBIS. Doppler USG is a well-proven method for revealing the decreased vertebral artery blood flow that can be responsible for vestibulo-ocular symptoms4,12,13; however, Seo et al showed vertebrobasilar artery abnormalities, such as bending, narrowing or obstruction, in 8 out of 14 BPPV patients by using MRI.14 Moreover, their study also suggested that the positional nystagmus might result from vertebrobasilar ischaemia, even if there were no other neurological signs. Although some studies reported that the vertebral artery blood flow is related to cervical rotation movements, in the majority no correlations were found between rotation, blood flow and vertebrobasilar insufficiency (VBI)15; however both diseases have similar symptomatology and can be
Table 2 Results of the maneuvers.
10 days 20 days 3 months a b
Complete recovery; negative Dix—Hallpike test
Moderate improvement; slightly positive Dix—Hallpike test
No improvement; positive Dix—Hallpike test
Total
16 (P < 0.001) 20 (P < 0.001) 20 (P < 0.001)
5a 3 3
5b 3 3
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The Epley maneuver was re-performed. The liberatory maneuver was performed.
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Efficacy of canalith repositioning maneuvers for benign paroxysmal positional vertigo misdiagnosed easily if clinical examination is performed without caution. In fact, three patients with BPPV (as revealed by the Dix—Hallpike test) in our study, whose vertigo was improved by the Epley maneuver (two of them gaining complete relief, one of them moderate improvement), were also found to have slightly reduced vertebral artery flow rate (below 200 ml/min). There are no data regarding manipulation of cervical spine reducing symptoms of VBIS in the literature. Our findings suggest that, in these patients, vertigo is unlikely to be due to decreased vertebral artery blood flow but to BPPV. It is frequently implied that head trauma and vestibular neuritis may be an etiologic agent for BPPV1,7; however, only one of our patients (3%) described previous head trauma. This patient responded well to the Epley maneuver. In our study 20 of 26 patients (77%) showed complete healing after one or two session of maneuvers. Recovery rates after CRM have previously been reported as 78—98%.16—20 Our cure rates (61.5% at 10 days and 79% at the end of study) are correlated with the majority of the literature data; however, Beynon et al. reported a short-term success rate of 98%.20 Our immediate cure rate (30.7%) after the first maneuver was lower compared with other studies. Only six patients still had symptoms after 3 months, but their symptoms were of a lesser degree. There are no similarities between these patients (four female, two male). Only two of them described previous major depression. Symtomatic medications were given to these patients with persistent BPPV after the study period. High spontaneous recovery rate is reported in BPPV patients. In a study from Richard et al., the efficacy of the Epley maneuver was compared with a control group and 60% spontaneous recovery was found at the end of 6th month.17 Sherman and Massoud reported that 60% of patients with BPPV showed spontaneous recovery after 2 weeks.21 In our study, we observed immediate recovery after the first maneuver in eight patients and short-term recovery in 16 patients. At the end of study period, six patients still had BPPV symptoms which were of a lesser degree. Some of these recoveries are likely to have been spontaneous. It is reported that about 10—20% of patients have a recurrence of vertigo 1—2 weeks after the maneuver, and around half will eventually have a recurrence.22 However, recurrence of BPPV symptoms was not observed in any patient during the study period. When left untreated, BBPV causes problems with balance. This is extremely important in older patients because of the increased risk of falling,10,23 and the significant disease burden resulting from osteoporotic fractures.24 Frequent falls in older
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patients can be complicated by fear of falling and disuse disequilibrium which cannot be treated easily. Prior to admission to the study, five of the 26 patients had experienced falls. Although a small number of our patients with BPPV had experienced falls, the maneuvers prevented further recurrence. In this study almost all patients were receiving vestibular acting medications before the study. Vestibular suppressants may contribute to chronic dizziness because they can impair vestibular adaptation. These drugs should, therefore, only be used during the acute stages of vertigo, and only for a short time,1 and our patients were asked to discontinue their medication. BPPV is unique among the different types of vertigo because it differs in etiology, diagnosis and therapy. A simple test is sufficient for accurate diagnosis, and an easily performed maneuver can provide rapid symptom relief. The majority of patients with BPPV have posterior SCC pathology.1,7 In our study, the majority of our patients were diagnosed as posterior SCC BPPV. The Epley and other maneuvers (liberatory, Brandt—Daroff) are well-proven treatment modalities for BPPV.1,7 The maneuvers are simple procedures and can be adapted even for home-based patient use. The Epley maneuver was chosen as the first line of treatment. The liberatory maneuver was performed in only five patients who showed no improvement with the Epley maneuver, possibly due to cupulolithiais. In our study, 16 out of 26 patients with BPPV, one of whom had suffered from vertigo for 8 years, quickly recovered from vertigo after the Epley maneuver.
Conclusion Vertigo is commonly seen in clinical practice and can sometimes be of complex etiology. Differentiating BPPV from other causes of vertigo is of great importance. Treatment of BPPV is particularly important for older patients as poor balance can lead to falling, with increased risk of fracture. Repositioning maneuvers are simple to perform, and safe and effective in the treatment of BPPV.
Conflict of interest There are no conflicts of interest.
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