Dizziness is one of the most common medical complaints affecting older adults, with10-20 percent of such complaints resulting from Benign Paroxysmal Positional Vertigo (BPPV). Many research studies have stated that without medical treatment, some 30 percent of BPPV patients will recover on their own. Now, a new evidence-based review has found that a single ten minute in-office treatment, based on a series of head and body turns, is highly effective in resolving this disorder, with an overall effectiveness of 70-80 percent.
Benign Paroxysmal Positional Vertigo is thought to develop when crystalline particles of calcium carbonate and a protein in the inner ear break off and float into the delicate nerves that sense position. Approximately 94 percent of BPPV cases involve particles in the posterior semicircular canal. This causes a sensation of spinning (vertigo) during certain changes in head and body position such as lying back, bending over, arising quickly or turning in bed. The vertigo usually lasts about a minute. This disorder affects the ability to control our balance and is a risk factor for falls, the leading cause of morbidity and mortality in older adults. The cause of BPPV is usually unknown but the condition can occur after head trauma or in association with other ear disorders such as vestibular neuritis or labyrinthitis.
Initially, BPPV treatments were exercise-based and emphasized compensation and habituation. In the last 15 years, specific body repositioning maneuvers have evolved and are now the standard of treatment for this disorder. These include the Semont, Epley, and the particle repositioning maneuvers, the latter of which is a modified Epley maneuver without mastoid vibration. A commonly used term for the modified Epley maneuver is “Canalith Repositioning Maneuver.”
All of the maneuvers can be performed in the office within approximately ten minutes. At the start of a typical treatment session, a patient is placed in a side lying position. The physician then guides them through a series of specific head and body maneuvers designed to affect flow of inner ear fluid in the posterior canal. During these maneuvers, the patient is moved from the affected side to the unaffected side and is then returned to a sitting position.
The effectiveness of the “Canalith Repositioning Maneuver” has been addressed in some research studies but the findings were often based on anecdotal information. A new evidenced-based research effort set out to evaluate the efficacy of Canalith Repositioning Maneuvers (Semont, Epley and modified maneuvers) in the treatment of posterior canal benign paroxysmal positional vertigo (BPPV) and compared the resolution rate in an untreated control cohort.
The authors of “Canalith Repositioning for Benign Paroxysmal Positional Vertigo: An Evidence- Based Review,” are Judith White MD PhD, Neil Cherian MD, and John Oas MD, all from the Cleveland Clinic, Cleveland, OH; and Panos Savvides MD PhD MPH, at University Hospital, Case Western Reserve School of Medicine, Cleveland, OH. Their findings are being presented at the annual meeting of the American Neurotology Society http://www.otology-neurotology.org/ANS/ans-main.html being held May 1, 2004, at the JW Marriott Desert Ridge Resort & Spa, Phoenix, AZ.
Methodology Evidence-based research encompasses a variety of data sources and methods.
The researchers reviewed 84 published studies, conducted an electronic Medline search, perused references from identified primary review articles, controlled trials and case reports, interviewed colleagues, and examined selected meeting abstract reviews.
The Medline search strategy examined randomized control trials for all body maneuver treatments for vertigo and BPPV. Cases were selected for inclusion in the meta-analysis if they met the following criteria: Dix-Hallpike testing (body positioned on the side) was used for both diagnosis and outcome assessment; inclusion of an untreated control group that was randomly assigned; Canalith repositioning maneuvers were performed (Epley, Semont, or modified maneuvers); patients were diagnosed with posterior canal benign paroxysmal positional vertigo; a study design either blinded or unblinded outcome assessment (a separate analysis was performed for blinded studies); and three independent reviewers agreed on study inclusion and evaluated potential for bias.
Results: Nine controlled randomized trials were identified and included in the analysis, of which three had blinded follow-up (the assessment at follow-up was blind to treatment group). A separate analysis of these three blinded randomized controlled trials was performed.
The nine trials consisted of 505 patients. Key findings included:
- The mean follow-up was 16 days. The risk of persistent BPPV without treatment was 69 percent. The risk of persistent BPPV after a single canalith repositioning treatment was 28 percent. The relative risk (risk of BPPV in the treatment group compared to the control group) was 39 percent. This represented a relative risk reduction of 61 percent.
- The risk of persistent BPPV without treatment was 67 percent whereas the risk of persistent BPPV after a single canalith repositioning treatment was 31 percent. The effect of treatment was significant. [
- Results were reported if possible after a single treatment session. The mean treatment efficacy reported was 78 percent, similar to the 72 percent efficacy seen in the nine controlled clinical trials included in the meta-analysis.
Conclusions: The results of this meta-analysis of nine controlled studies consisting of 505 patients suggest that canalith repositioning is a safe and effective treatment for BPPV. A single treatment session successfully resolves positional nystagmus 72 percent of the time; symptoms spontaneously resolve at three weeks in one third of patients.
As the U.S. population ages, falls are becoming an increasing public health concern. An estimated nine percent of older adults attending geriatric clinics are estimated to be living with BPPV. BPPV may be a considerable risk factor in older adults, and population estimates may have underestimated its true prevalence.
This study reveals that Canalith Repositioning Maneuver is safe, effective, and may also be learned and successfully performed in the primary care setting, where the majority of patients receive their medical care for the complaint of dizziness.