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.

/pdf/clinical-practice-guideline-benign-paroxysmal-positional-4c8374bric.pdf

Clinical practice guideline: Benign paroxysmal positional vertigo

Background Balance dysfunction can be debilitating and can lead to catastrophic outcomes such as falls. The inner ear vestibular system is an important contributor to balance control. However, to our knowledge, the prevalence of vestibular dysfunction in the United States and the magnitude of the increased risk of falling associated with vestibular dysfunction have never been estimated. The objective of this study was to determine the prevalence of vestibular dysfunction among US adults, evaluate differences by sociodemographic characteristics, and estimate the association between vestibular dysfunction and risk of falls. Methods We included data from the 2001-2004 National Health and Nutrition Examination Surveys, which were cross-sectional surveys of US adults aged 40 years and older (n = 5086). The main outcome measure was vestibular function as measured by the modified Romberg Test of Standing Balance on Firm and Compliant Support Surfaces. Results From 2001 through 2004, 35.4% of US adults aged 40 years and older (69 million Americans) had vestibular dysfunction. Odds of vestibular dysfunction increased significantly with age, were 40.3% lower in individuals with more than a high school education, and were 70.0% higher among people with diabetes mellitus. Participants with vestibular dysfunction who were clinically symptomatic (ie, reported dizziness) had a 12-fold increase in the odds of falling. Conclusions Vestibular dysfunction, as measured by a simple postural metric, is common among US adults. Vestibular dysfunction significantly increases the likelihood of falls, which are among the most morbid and costly health conditions affecting older individuals. These data suggest the importance of diagnosing, treating, and potentially screening for vestibular deficits to reduce the burden of fall-related injuries and deaths in the United States.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/773517/ioi90006_938_944.pdf

Disorders of Balance and Vestibular Function in US Adults: Data From the National Health and Nutrition Examination Survey, 2001-2004

Background: Balance dysfunction can be debilitating and can lead to catastrophic outcomes such as falls. The inner ear vestibular system is an important contributor to balance control. However, to our knowledge, the prevalence of vestibular dysfunction in the United States and the magnitude of the increased risk of falling associated with vestibular dysfunction have never been estimated. The objective of this study was to determine the prevalence of vestibular dysfunction among US adults, evaluate differences by sociodemographic characteristics, and estimate the association between vestibular dysfunction and risk of falls.

Disorders of Balance and Vestibular Function in US Adults

Background
This is an update of a Cochrane review first published in The Cochrane Library in Issue 4, 2007 and previously updated in 2011.

Unilateral peripheral vestibular dysfunction (UPVD) can occur as a result of disease, trauma or postoperatively. The dysfunction is characterised by complaints of dizziness, visual or gaze disturbances and balance impairment. Current management includes medication, physical manoeuvres and exercise regimes, the latter known collectively as vestibular rehabilitation.

Objectives
To assess the effectiveness of vestibular rehabilitation in the adult, community-dwelling population of people with symptomatic unilateral peripheral vestibular dysfunction.

Search methods
We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ISRCTN and additional sources for published and unpublished trials. The most recent search was 18 January 2014.

Selection criteria
Randomised controlled trials of adults living in the community, diagnosed with symptomatic unilateral peripheral vestibular dysfunction. We sought comparisons of vestibular rehabilitation versus control (e.g. placebo), other treatment (non-vestibular rehabilitation, e.g. pharmacological) or another form of vestibular rehabilitation. Our primary outcome measure was change in the specified symptomatology (for example, proportion with dizziness resolved, frequency or severity of dizziness). Secondary outcomes were measures of function, quality of life and/or measure(s) of physiological status, where reproducibility has been confirmed and shown to be relevant or related to health status (for example, posturography), and adverse effects

Data collection and analysis
We used the standard methodological procedures expected by The Cochrane Collaboration.

Main results
We included 39 studies involving 2441 participants with unilateral peripheral vestibular disorders in the review. Trials addressed the effectiveness of vestibular rehabilitation against control/sham interventions, medical interventions or other forms of vestibular rehabilitation. Non-blinding of outcome assessors and selective reporting were threats that may have biased the results in 25% of studies, but otherwise there was a low risk of selection or attrition bias.

Individual and pooled analyses of the primary outcome, frequency of dizziness, showed a statistically significant effect in favour of vestibular rehabilitation over control or no intervention (odds ratio (OR) 2.67, 95% confidence interval (CI) 1.85 to 3.86; four studies, 565 participants). Secondary outcomes measures related to levels of activity or participation measured, for example, with the Dizziness Handicap Inventory, which also showed a strong trend towards significant differences between the groups (standardised mean difference (SMD) -0.83, 95% CI -1.02 to -0.64). The exception to this was when movement-based vestibular rehabilitation was compared to physical manoeuvres for benign paroxysmal positional vertigo (BPPV), where the latter was shown to be superior in cure rate in the short term (OR 0.19, 95% CI 0.07 to 0.49). There were no reported adverse effects.

Authors' conclusions
There is moderate to strong evidence that vestibular rehabilitation is a safe, effective management for unilateral peripheral vestibular dysfunction, based on a number of high-quality randomised controlled trials. There is moderate evidence that vestibular rehabilitation resolves symptoms and improves functioning in the medium term. However, there is evidence that for the specific diagnostic group of BPPV, physical (repositioning) manoeuvres are more effective in the short term than exercise-based vestibular rehabilitation; although a combination of the two is effective for longer-term functional recovery. There is insufficient evidence to discriminate between differing forms of vestibular rehabilitation.

Vestibular rehabilitation for unilateral peripheral vestibular dysfunction

Background:
Uncompensated vestibular hypofunction results in postural instability, visual blurring with head movement, and subjective complaints of dizziness and/or imbalance. We sought to answer the question, “Is vestibular exercise effective at enhancing recovery of function in people with peripheral (unilateral or bilateral) vestibular hypofunction?”

/pdf/vestibular-rehabilitation-for-peripheral-vestibular-4ynttckx2b.pdf

Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice Guideline: FROM THE AMERICAN PHYSICAL THERAPY ASSOCIATION NEUROLOGY SECTION.

AIM: To investigate the circumstances and consequences of falls in the chronically dizzy elderly and to correlate them with the number of falls (one/two and more). METHOD: Transversal descriptive analytic study with 64 patients aged 65 or over, with history of falls and diagnostic of chronic vestibular dysfunction. We performed a descriptive analysis and Qui-Square test (<0.05). RESULTS: The sample was constituted by a female majority (76.6%) with a mean age of 73.62±5.69 years. The vestibular examination showed peripheral vestibulopathy in 81.5% of the cases and the most prevalent diagnostic hypothesis were benign paroxysmal positional vertigo (43.8%) and metabolic inner ear disease (42.2%). Recurrent falls were seen in 35 elderly (53.1%). In relation to the last fall, 39.1% of the patients had fallen in their homes, 51.6% of them occurred during the morning, 51.6% with some propulsion mechanism, 53.1% when walking, 25.0% caused by dizziness and 23.4% by stumbling. Activity restriction was significantly greater in patients that have already had two and more falls, when compared with those who had fallen only once (p=0.031). We found a significant association between the number of falls and their causes (p<0.001). Falls that have happened by slipping were more frequent in the elderly that reported one fall (p=0.0265) and falls that had happened because of dizziness were more frequent in the elderly that complained of two or more falls (p=0.0012). CONCLUSION: Fear and tendency to fall are referred by the majority of chronically dizzy elderly. Fall are more frequent in the morning, in the home and during walking. The propulsion direction is mentioned by half of the elderly and the most common cause for falls are dizziness and stumbling. The number of falls is significantly associated with activity restrictions after the last fall and with the causes for falling (slipping and dizziness).

/pdf/circunstancias-e-consequencias-de-quedas-em-idosos-com-3btbdr0zqp.pdf

Circunstâncias e consequências de quedas em idosos com vestibulopatia crônica

A tontura de origem vestibular e comum entre idosos. OBJETIVO: Caracterizar idosos com disfuncao vestibular cronica em relacao aos dados sociodemograficos, clinico-funcionais e otoneurologicos. MATERIAL E METODO: Estudo de casos que incluiu 120 idosos com disfuncao vestibular cronica. Foram realizadas analises descritivas simples. RESULTADOS: A 5,77±amostra apresentou maioria feminina (68,3%), com media etaria de 73,40 1,84±anos. O numero medio de doencas associadas ao quadro vestibular foi de 3,83 e o numero medio de medicamentos foi de 3,86±2,27. O exame vestibular evidenciou vestibulopatia periferica deficitaria unilateral (29,8%) e as hipoteses diagnosticas prevalentes foram labirintopatia metabolica (40,0%) e vertigem posicional paroxistica benigna (36,7%). Para 52 (43,3%) pacientes, a tontura comecou ha mais de 5 anos. Em relacao a queda, 64 idosos (53,3%) apresentaram pelo menos uma queda no ultimo ano e 35 (29,2%) referiram quedas recorrentes. CONCLUSOES: A amostra foi representada por maioria feminina e media etaria elevada, com doencas associadas ao quadro vestibular e polifarmacoterapia. As vestibulopatias e a topografia mais frequentes foram, respectivamente, labirintopatia metabolica e vascular e sindrome periferica deficitaria unilateral. A tontura e uma condicao cronica e a associacao de vestibulopatias e comum. A ocorrencia de quedas e prevalente na populacao de idosos com disfuncao vestibular cronica.

/pdf/caracterizacao-clinica-de-idosos-com-disfuncao-vestibular-45erb5uter.pdf

Caracterização clínica de idosos com disfunção vestibular crônica

Summary Aim To investigate the circumstances and consequences of falls in the chronically dizzy elderly and to correlate them with the number of falls (one/two and more). Method Transversal descriptive analytic study with 64 patients aged 65 or over, with history of falls and diagnostic of chronic vestibular dysfunction. We performed a descriptive analysis and Qui-Square test ( Results The sample was constituted by a female majority (76.6%) with a mean age of 73.62±5.69 years. The vestibular examination showed peripheral vestibulopathy in 81.5% of the cases and the most prevalent diagnostic hypothesis were benign paroxysmal positional vertigo (43.8%) and metabolic inner ear disease (42.2%). Recurrent falls were seen in 35 elderly (53.1%). In relation to the last fall, 39.1% of the patients had fallen in their homes, 51.6% of them occurred during the morning, 51.6% with some propulsion mechanism, 53.1% when walking, 25.0% caused by dizziness and 23.4% by stumbling. Activity restriction was significantly greater in patients that have already had two and more falls, when compared with those who had fallen only once (p=0.031). We found a significant association between the number of falls and their causes (p Conclusions Fear and tendency to fall are referred by the majority of chronically dizzy elderly. Fall are more frequent in the morning, in the home and during walking. The propulsion direction is mentioned by half of the elderly and the most common cause for falls are dizziness and stumbling. The number of falls is significantly associated with activity restrictions after the last fall and with the causes for falling (slipping and dizziness).

/pdf/circumstances-and-consequences-of-falls-in-elderly-people-ari0ireijz.pdf

Circumstances and consequences of falls in elderly people with vestibular disorder

OBJETIVO: Sistematizar os resultados de ensaios clinicos sobre reabilitacao vestibular (RV) em individuos de meia-idade e idosos com disturbios vestibulares. METODOS: A busca de publicacoes sobre a RV em individuos com disturbios vestibulares foi realizada nas bases de dados LILACS, EMBASE, MEDLINE, SciELO, Cochrane, ISI Web of Knowledge e bibliotecas virtuais de teses e dissertacoes. Foram selecionados ensaios clinicos aleatorios e controlados dos ultimos 10 anos em lingua inglesa, portuguesa e espanhola. A qualidade metodologica dos estudos foi avaliada pela escala PEDro. A analise dos resultados dos estudos foi feita por meio de revisao critica dos conteudos. RESULTADOS: Nove estudos foram revisados na integra, sendo a faixa etaria dos participantes acima de 40 anos (n=4) e composta exclusivamente por idosos (n=5). Os achados de disfuncao vestibular foram diversificados, sendo os mais comuns queixa de desequilibrio corporal ou instabilidade postural (n=3) e queixa de vertigem ou tontura (n=3). A Escala Visual Analogica (EVA) foi o instrumento mais utilizado para avaliar a percepcao subjetiva da sintomatologia da disfuncao vestibular (n=4). A escala PEDro revelou que quatro dos artigos apresentaram delineamento de boa qualidade para a conducao do estudo experimental. A proposta de intervencao mais utilizada foi o protocolo de Cawthorne & Cooksey (n=4). Os estudos que compararam a RV com outro tipo de intervencao nao apresentaram, na maioria dos desfechos analisados, diferenca entre os grupos apos a terapia. CONCLUSAO: Estudos aleatorizados controlados disponibilizaram evidencias de efeitos positivos da RV em idosos e adultos de meia-idade com disturbios vestibulares.

/pdf/revisao-sistematica-sobre-os-efeitos-da-reabilitacao-11yolbdsha.pdf

Revisão sistemática sobre os efeitos da reabilitação vestibular em adultos de meia-idade e idosos

Objective: To summarize the results of clinical trials on vestibular rehabilitation (VR) in middle-aged and elderly people with vestibular disorders. Methods: A search for relevant trials was performed in the databases LILACS, EMBASE, MEDLINE, SciELO, Cochrane, ISI Web of Knowledge and virtual libraries of theses and dissertations. Randomized controlled trials published in the last 10 years and written in English, Portuguese or Spanish were included. The methodological quality of the studies was assessed by the PEDro scale. Results from the included studies were analyzed through a critical review of content. Results: Nine studies were included in the review. Four studies reported on participants aged over 40 years (middle-aged and elderly) and five studies consisted exclusively of elderly subjects (over 60 years). Findings of vestibular dysfunction were diverse and the most common complaints were body imbalance or postural instability (3 studies), and vertigo or dizziness (3 studies). The Visual Analogue Scale (VAS) was the most commonly used instrument to assess subjective perception of symptoms of vestibular dysfunction (4 studies). According to the PEDro scale, four studies were considered to be of good quality. The most common experimental intervention was the Cawthorne & Cooksey protocol (4 studies). For most outcome measures, the studies comparing VR with another type of intervention showed no differences between the groups after the therapy. Conclusions: The studies included in this review provide evidence for the positive effects of VR in elderly and middle-aged adults with vestibular disturbances.

Revisão sistemática sobre os efeitos da reabilitação vestibular em adultos de meia-idade e idosos A systematic review about the effects of the vestibular rehabilitation in middle-age and older adults

Mayra Cristina Aratani

Papers

Circunstâncias e consequências de quedas em idosos com vestibulopatia crônica

Caracterização clínica de idosos com disfunção vestibular crônica

Circumstances and consequences of falls in elderly people with vestibular disorder

Revisão sistemática sobre os efeitos da reabilitação vestibular em adultos de meia-idade e idosos

Revisão sistemática sobre os efeitos da reabilitação vestibular em adultos de meia-idade e idosos A systematic review about the effects of the vestibular rehabilitation in middle-age and older adults