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.

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Clinical practice guideline: Benign paroxysmal positional vertigo

The 2008 AAN guideline “Practice Parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review)” has been retired by the Guideline Development, Dissemination, and Implementation Subcommittee …

https://n.neurology.org/content/neurology/70/22/2067.full.pdf

Practice Parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review) : Report of the Quality Standards Subcommittee of the American Academy of Neurology

Background Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo.

Purpose The purpose of this systematic review was to determine whether patients diagnosed with posterior canal (PC) BPPV, based on positional testing, and treated with a particle repositioning maneuver will show the resolution of benign paroxysmal positional nystagmus (BPPN) on the Dix-Hallpike Test performed 24 hours or more after treatment.

Data Sources Data were obtained from an electronic search of the MEDLINE, EMBASE, and CINAHL databases from 1966 through September 2009.

Study Selection The study topics were randomized controlled trials (RCTs), quasi-RCTs, the diagnosis of PC BPPV, treatment with the particle repositioning maneuver, and outcome measured with a positional test 24 hours or more after treatment.

Data Extraction Data extracted were study descriptors and the information used to code for effect size.

Data Synthesis In 2 double-blind RCTs, the odds in favor of the resolution of BPPN were 22 times (95% confidence interval=3.41–141.73) and 37 times (95% confidence interval=8.75–159.22) higher in people receiving the canalith repositioning procedure (CRP) than in people receiving a sham treatment. This finding was supported by the results reported in 8 nonmasked quasi-RCTs. Studies with limited methodological quality suggested that a liberatory maneuver (LM) was more effective than a control intervention; there was no significant difference in the effectiveness of the LM and the effectiveness of the CRP; the self-administered CRP was more effective than the self-administered LM; and the CRP administered together with the self-administered CRP was more effective than the CRP administered alone. The Brandt-Daroff exercises were the least effective self-administered treatments.

Limitations The limitations included the methodological quality of the studies, the lack of quality-of-life measures, and confounding factors in reporting vertigo.

Conclusions Randomized controlled trials provided strong evidence that the CRP resolves PC BPPN, and quasi-RCTs suggested that the CRP or the LM performed by a clinician or with proper instruction at home by the patient resolves PC BPPN. There were no data on the effects of the maneuvers on outcomes relevant to patients.

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Effectiveness of Particle Repositioning Maneuvers in the Treatment of Benign Paroxysmal Positional Vertigo: A Systematic Review

Objective: To investigate the effect of an additional vestibular stimulated exercise programme on balance for patients with benign paroxysmal positional vertigo.Design: Randomized controlled trial.Setting: Medical centre.Subjects: Twenty-six subjects with benign paroxysmal positional vertigo involving the unilateral posterior semicircular canal.Interventions: Subjects were randomized into experimental or control groups. Thirteen subjects in the experimental group received the canalith repositioning manoeuvre and vestibular stimulated exercise training three times a week for four weeks. Thirteen subjects in the control group received only the canalith repositioning manoeuvre.Main measures: Static balance tests, tandem walk test, Dynamic Gait Index and subjective rating of the intensity of vertigo were measured at baseline, two-week and four-week assessments.Results: Compared with the control group, subjects in the experimental group demonstrated a statistically significant improvement in single leg stance ...

Balance improvement in patients with benign paroxysmal positional vertigo

ObjectiveTo investigate the potential risk factors associated to the treatment failure and recurrence of benign paroxysmal positional vertigo (BPPV).Study DesignProspective cohort study.SettingTertiary referral center.PatientsFour hundred patients with benign paroxysmal positional vertigo, 119 men a

Why do treatment failure and recurrences of benign paroxysmal positional vertigo occur

Summary Benign Paroxysmal Positional Vertigo (BPPV) is one of the most frequent diseases of the vestibular system and it is characterized by episodes of recurrent vertigo triggered by head movements or position changes. There are several approaches for treatment, but efficacy is still being discussed. Aim To asses the effectiveness of the specific maneuvers available to the treatment of BPPV. Methodology An electronic search at the main databases, including MEDLINE, LILACS, PEDro, Cochrane Collaborations Database was performed, and we selected only randomized clinical trials studying adults with diagnosis of BPPV confirmed by the Dix-Hallpike test. The trials should have included physical maneuvers such as Epley and Semont. The main outcome was Dix-Hallpike negative test and the changes to subjective complaints. The trials were assessed using Jadad's scale and only studies with quality scores equal or above 3 were pooled on a meta-analyses to assess their effectiveness. Results We found five controlled clinical trials phase I comparing the Epley's maneuver with controls or placebo. The metaanalysis showed positive evidence of Epley's maneuver to the posterior semicircular canal (effect size = 0.11 [CI 95% 0.05, 0.26] of objective improvement [Dix-Halpike] within one week, 0.24 [CI 95% 0.13, 0.45] within one month and 0.16 [CI 95% 0.08, 0.33] of improvement reported by the patients within one week. There are no studies about the efficacy of Semont's maneuver. Conclusion There is scientific evidence showing good efficacy of Epley's maneuver in the treatment.

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Maneuvers for the treatment of benign positional paroxysmal vertigo: a systematic review.

A Vertigem Posicional Paroxistica Benigna (VPPB) e uma das mais frequentes patologias do sistema vestibular e e caracterizada por episodios de vertigens recorrentes desencadeados por movimentos da cabeca ou mudancas posturais. Ha varias opcoes para o seu tratamento, porem as efetividades terapeuticas das mesmas permanecem controversas. OBJETIVO: Avaliar a efetividade terapeutica das manobras especificas disponiveis para o tratamento da VPPB. METODOLOGIA: Realizou-se uma busca eletronica nas principais bases de dados, selecionando-se estudos clinicos randomizados envolvendo adultos com diagnostico de VPPB confirmado com o teste de Dix-Hallpike e tratamento com manobras especificas (Epley ou Semont, por exemplo). Considerou-se como desfecho clinico a negativacao do teste de Dix-Hallpike e a melhora das queixas subjetivas. Agruparam-se em metanalise os estudos com Escala de Jadad igual ou superior a tres. RESULTADOS: Cinco estudos clinicos preencheram os criterios de inclusao, ou seja, ensaios randomizados de fase I comparando a manobra de Epley com placebos e controles. A metanalise mostra evidencia dos efeitos beneficos da manobra de Epley para o tratamento do canal semicircular posterior (magnitude do efeito de 0,11 [IC 95% 0.05, 0.26] de melhora objetiva (Dix-Halpike) apos uma semana, 0.24 [IC 95% 0.13, 0.45] apos um mes e 0.16 [IC 95% 0.08, 0.33] de melhora referida pelos pacientes apos a primeira semana). CONCLUSAO: Evidencia-se boa eficacia clinica da manobra de Epley para o tratamento da VPPB do canal semicircular posterior. Contrariamente, trabalhos com a manobra de Semont e as propostas de manejo dos demais canais semicirculares nao obtiveram qualidade metodologica satisfatoria, nao sendo possivel demonstrar a efetividade dos mesmos.

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Lázaro Juliano Teixeira

Papers

Maneuvers for the treatment of benign positional paroxysmal vertigo: a systematic review.

Manobras para o tratamento da vertigem posicional paroxística benigna: revisão sistemática da literatura