The effect of postural restrictions in the treatment of benign paroxysmal positional vertigo

Treatment of benign paroxysmal positional vertigo. A clinical review

Benign paroxysmal positional vertigo (BPPV) is the most frequent episodic vestibular disorder. It is due to otolith rests that are free into the canals or attached to the cupulas. Well over 90% of patients can be successfully treated with manoeuvres that move the particles back to the utriculus. Among the great variety of procedures that have been described, the manoeuvres that are supported by evidenced-based studies or extensive series are commented in this review. Some topics regarding BPPV treatment, such as controlling the accuracy of the procedures or the utility of post-manoeuvre restrictions are also discussed.

Impact of postmaneuver sleep position on recurrence of benign paroxysmal positional vertigo

Background

The necessity of postural restriction to patients suffering from benign paroxysmal positional vertigo is controversial.

Objective

To investigate the impact of the sleep position after the repositioning maneuver on BPPV recurrence.

Methods

150 unilateral BPPV patients who were treated by repositioning maneuver were distributed into two groups. The patients in group A were instructed to sleep in a semi-sitting position at an angle of approximately 30 degrees and refrain from sleeping on their BPPV affected side for one week. The patients in group B were told to sleep in any preferred position. The comparison of recurrence rates according to different actual sleep positions in one week and one month was performed.

Results

There was a statistically significant correlation between the sleeping side and the side affected by BPPV. Without instructions on postural restriction, most patients (82.9%, 73/88) avoided sleeping on their affected side. The patients sleeping on their affected side had a higher recurrence rate (35.3%) than ones sleeping in other positions in the first week after the repositioning maneuver (p<0.05, Chi-square test and Fisher's exact test). The patients sleeping randomly in following 3 weeks had a lower recurrence rate than ones sleeping in other position (p<0.05, Fisher's exact test).

Conclusions

BPPV patients had a poor compliance to postural instructions. The habitual sleep side was associated with the side affected by BPPV. The patients sleeping on their affected side had a higher recurrence rate than those sleeping in other positions in first week after the repositioning maneuver.

Effect of repositioning maneuver type and postmaneuver restrictions on vertigo and dizziness in benign positional paroxysmal vertigo

Introduction. To compare the efficiency of Epley (Ep) and Sémont-Toupet (ST) repositioning maneuvers and to evaluate postmaneuver restriction effect on short-term vertigo and dizziness after repositioning maneuvers by an analog visual scale (VAS) in benign positional paroxysmal vertigo (BPPV). Material and Methods. 226 consecutive adult patients with posterior canal BPPV were included. Patients were randomized into 2 different maneuver sequence groups (n = 113): 2 ST then 1 Ep or 2 Ep then 1 ST. Each group of sequence was randomized into 2 subgroups: with or without postmaneuver restrictions. Vertigo and dizziness were assessed from days 0 to 5 by VAS. Results. There was no difference between vertigo scores between Ep and ST groups. Dizziness scores were higher in Ep group during the first 3 days but became similar to those of ST group at days 4 and 5. ST maneuvers induced liberatory signs more frequently than Ep (58% versus 42% resp., P < 0.01, Fisher's test). After repositioning maneuvers, VAS scores decreased similarly in patients with and without liberatory signs. Postmaneuver restrictions did not influence VAS scores. Conclusion. Even if ST showed a higher rate of liberatory signs than Ep in this series, VAS scores were not influenced by these signs.

The necessity of post-maneuver postural restriction in treating benign paroxysmal positional vertigo: a meta-analytic study

The objective of this article is to verify the role of postural restrictions after repositioning maneuvers in treating patients with benign paroxysmal positional vertigo (BPPV). The study included published articles yielded by a Pubmed search concerning post-maneuver postural restriction in treating BPPV. The search was limited to articles published in English language in the last three decades. The search was done on 1/11/2011. For the 18 relevant articles, we applied our inclusion and exclusion criteria and only 9 articles were included. The data collected from each article were statistically analyzed utilizing meta-analytic Review Manager (RevMan 5.1) software. (Version: 5.1.0.0). There were no significant differences between patients instructed with postural restriction after undergoing repositioning maneuver and patients left free to move after undergoing repositioning maneuver with regard to the presence or absence of post-maneuver symptoms. In conclusion, post-maneuver restrictions do not add to the success of the treatment of BPPV and there is no reason to submit patients to these impractical instructions.

Modifications of the Epley (canalith repositioning) manoeuvre for posterior canal benign paroxysmal positional vertigo (BPPV)

BACKGROUND

Benign paroxsymal positional vertigo (BPPV) is a syndrome characterised by short-lived episodes of vertigo associated with rapid changes in head position. It is a common cause of vertigo presenting to primary care and specialist otolaryngology (ENT) clinics. BPPV of the posterior canal is a specific type of BPPV for which the Epley (canalith repositioning) manoeuvre is a verified treatment. A range of modifications of the Epley manoeuvre are used in clinical practice, including post-Epley vestibular exercises and post-Epley postural restrictions.

OBJECTIVES

To assess whether the various modifications of the Epley manoeuvre for posterior canal BPPV enhance its efficacy in clinical practice.

SEARCH METHODS

We searched the Cochrane ENT Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 15 December 2011.

SELECTION CRITERIA

Randomised controlled trials of modifications of the Epley manoeuvre versus a standard Epley manoeuvre as a control in adults with posterior canal BPPV diagnosed with a positive Dix-Hallpike test. Specific modifications sought were: application of vibration/oscillation to the mastoid region, vestibular rehabilitation exercises, additional steps in the Epley manoeuvre and post-treatment instructions relating to movement restriction.

DATA COLLECTION AND ANALYSIS

Two authors independently selected studies from the search results and the third author reviewed and resolved any disagreement. Two authors independently extracted data from the studies using standardised data forms. All authors independently assessed the trials for risk of bias.

MAIN RESULTS

The review includes 11 trials involving 855 participants. A total of nine studies used post-Epley postural restrictions as their modification of the Epley manoeuvre. There was no evidence of a difference in the results for post-treatment vertigo intensity or subjective assessment of improvement in individual or pooled data. All nine trials included the conversion of a positive to a negative Dix-Hallpike test as an outcome measure. Pooled data identified a significant difference from the addition of postural restrictions in the frequency of Dix-Hallpike conversion when compared to the Epley manoeuvre alone. In the experimental group 88.7% (220 out of 248) patients versus 78.2% (219 out of 280) in the control group converted from a positive to negative Dix-Hallpike test (risk ratio (RR) 1.13, 95% confidence interval (CI) 1.05 to 1.22, P = 0.002). No serious adverse effects were reported, however three studies reported minor complications such as neck stiffness, horizontal BPPV, dizziness and disequilibrium in some patients.There was no evidence of benefit of mastoid oscillation applied during the Epley manoeuvre, or of additional steps in the Epley manoeuvre. No adverse effects were reported.

AUTHORS' CONCLUSIONS

There is evidence supporting a statistically significant effect of post-Epley postural restrictions in comparison to the Epley manoeuvre alone. However, it important to note that this statistically significant effect only highlights a small improvement in treatment efficacy. An Epley manoeuvre alone is effective in just under 80% of patients with typical BPPV. The additional intervention of postural restrictions has a number needed to treat (NNT) of 10. The addition of postural restrictions does not expose the majority of patients to risk of harm, does not pose a major inconvenience, and can be routinely discussed and advised. Specific patients who experience discomfort due to wearing a cervical collar and inconvenience in sleeping upright may be treated with the Epley manoeuvre alone and still expect to be cured in most instances.There is insufficient evidence to support the routine application of mastoid oscillation during the Epley manoeuvre, or additional steps in an 'augmented' Epley manoeuvre. Neither treatment is associated with adverse outcomes. Further studies should employ a rigorous randomisation technique, blinded outcome assessment, a post-treatment Dix-Hallpike test as an outcome measure and longer-term follow-up of patients.

The Role of Postural Restrictions after BPPV Treatment: Real Effect on Successful Treatment and BPPV's Recurrence Rates

Background. Canalith repositioning techniques are adequately established in the literature, as the treatment of choice for benign paroxysmal positional vertigo. However, the role of the posttreatment instructions is still not clearly defined. Patients and Methods. A retrospective chart review of 82 patients was conducted in order to determine the efficacy of postural restrictions, when combined with the classic canalith repositioning techniques, in terms of successful treatment and recurrence rates. Follow-up period reached at least 12 months after the initial treatment. Results. In this study, postural restrictions did not appear to significantly affect the outcomes of repositioning maneuvers, as well as the recurrence rate. Conclusions. Although this study, as well as most recent control studies, states that there is no significant effect of postmaneuver postural restrictions on both treatment and recurrence rates, larger multicentric research projects, adopting improved methodology, are still necessary in order to determine the contribution of such restrictions to both the therapeutic results and the prevention of recurrence. Adequate followup, focusing on the first six months after the initially successful repositioning maneuver, is also of paramount importance.

Are postural restrictions necessary for management of posterior canal benign paroxysmal positional vertigo?

OBJECTIVES

An important component of management of benign paroxysmal positional vertigo (BPPV) has been the application of postural restrictions after use of a canalith repositioning maneuver (CRM) to prevent the return of otolithic debris into the posterior semicircular canal (PSC). This study was designed to explore the effectiveness of postural restrictions in patients with BPPV caused by otolithic debris in the PSC.

METHODS

Seventy-four adult patients with unilateral PSC BPPV were enrolled into this study. All patients were managed with a CRM--either the modified Epley maneuver or the Semont maneuver. The patients were divided randomly into 2 groups: group A, with postural restrictions, and group B, without postural restrictions. The statistical analysis was performed with X2 tests and t-tests.

RESULTS

No patients in either group showed positional nystagmus in the posttreatment evaluation under infrared videonystagmoscopy. No patients had symptoms of vertigo after the therapy. The results of follow-up vestibular tests were normal in both groups.

CONCLUSIONS

In our experience, postural restrictions do not enhance the beneficial effect of the CRMs. They do not seem to have any protective role and therefore should not be recommended as an adjunct to the treatment of PSC BPPV.

Model experiments of otoconia stability after canalith repositioning procedure of BPPV

CONCLUSION

Postural restrictions are probably not necessary after the canalith repositioning procedure (CRP).

OBJECTIVES

Epley reported the effect of CRP for benign paroxysmal positional vertigo (BPPV). After CRP, patients are often requested to restrict postural change. However, some studies suggested that CRP may work without postural restrictions. The present study aimed to determine the necessity of post-maneuver postural restriction using the frog labyrinth model.

METHODS

The otoconial mass from the sacculus was placed on the utricular macular otoconia, mimicking a condition after CRP. The stability of the otoconial mass was observed by tilting the preparation, immediately, 3 min, and 5 min after it was placed on the macular otoconia. The utricular macula was maintained in the vertical plane for 10 s, during which period the behavior of the otoconial mass was observed. In experiment 1 the utricular macula was intact, in experiment 2 otoconia were partially removed, and in experiment 3 they were totally removed from the macula.

RESULTS

In experiments 1 and 2, in all preparations the otoconial mass became stabilized after 3 min. Even in experiment 3, in most preparations the otoconial mass became stabilized after 5 min.

Postmaneuver restrictions in benign paroxysmal positional vertigo: An individual patient data meta-analysis

Objective: Treatment of benign paroxysmal positional vertigo (BPPV) with the Epley and Semont maneuvers has been used with and without postmaneuver postural restrictions. Studies examining these restrictions have yielded differing results. This study sought to examine the studies for a more uniform conclusion.

Data Sources: Controlled studies with objective identification of unilateral posterior semicircular canal BPPV and symptom resolution were analyzed. A PubMed search identified six studies totaling 523 patients meeting all inclusion criteria.

Review Methods: Cohorts treated with and without restrictions were compared. Individual patient pooled analyses in a one-stage comparison were used for the meta-analysis.

Results: Pooled results of all restriction types showed no advantage over no restriction. Studies including each individual restriction were examined against the pooled population to look for technique differences. No restriction was found to be statistically significant.

Conclusions: The restrictions examined in controlled trials did not differ significantly in clinical outcomes, which suggests that restrictions do not appear to significantly affect the efficacy of BPPV maneuvers.

Retrospective comparison of outcomes for patients with benign paroxysmal positional vertigo based on length of postural restrictions

PURPOSE

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo in older adults. The effectiveness of the repositioning maneuver as an intervention has been established in the literature; however, the efficacy of the posttreatment instructions has not been established. The purpose of this retrospective study was compare treatment outcomes for patients receiving 24 hour postural restrictions posttreatment versus 48 hour restrictions.

METHODS

Medical records of 76 patients diagnosed with BPPV at an outpatient physical therapy practice were reviewed. The average age was 61.05 years (SD 16.16). A positive outcome was determined by partial or complete resolution of symptoms, defined as a reduction in the number of special tests or positions that provoked symptoms from initial examination to discharge, as well as a reduction in vertigo intensity ratings.

RESULTS

Patients in both groups experienced significant reductions in the number of symptom provoking positions, positive special tests, and ratings of vertigo intensity following treatment. Mean ratings of vertigo intensity on a 10 point scale were 5.71 pre and 1.83 post for the 24 hour group, and 6.75 pre and 3.00 post for the 48 hour group. Positive treatment outcomes were experienced by 95.4% of patients in the 24 hour group (n=63), with 53% (n=35) achieving complete resolution.

CONCLUSION

Patients experienced positive treatment outcomes regardless of the length of postural restrictions following repositioning maneuver for BPPV. Therapists can reduce the length of postural restrictions to 24 hours upright following a repositioning maneuver without adversely affecting patient outcomes.