1
|
Tunnell NC, Corner SE, Roque AD, Kroll JL, Ritz T, Meuret AE. Biobehavioral approach to distinguishing panic symptoms from medical illness. Front Psychiatry 2024; 15:1296569. [PMID: 38779550 PMCID: PMC11109415 DOI: 10.3389/fpsyt.2024.1296569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 03/19/2024] [Indexed: 05/25/2024] Open
Abstract
Panic disorder is a common psychiatric diagnosis characterized by acute, distressing somatic symptoms that mimic medically-relevant symptoms. As a result, individuals with panic disorder overutilize personal and healthcare resources in an attempt to diagnose and treat physical symptoms that are often medically benign. A biobehavioral perspective on these symptoms is needed that integrates psychological and medical knowledge to avoid costly treatments and prolonged suffering. This narrative review examines six common somatic symptoms of panic attacks (non-cardiac chest pain, palpitations, dyspnea, dizziness, abdominal distress, and paresthesia), identified in the literature as the most severe, prevalent, or critical for differential diagnosis in somatic illness, including long COVID. We review somatic illnesses that are commonly comorbid or produce panic-like symptoms, their relevant risk factors, characteristics that assist in distinguishing them from panic, and treatment approaches that are typical for these conditions. Additionally, this review discusses key factors, including cultural considerations, to assist healthcare professionals in differentiating benign from medically relevant symptoms in panic sufferers.
Collapse
Affiliation(s)
- Natalie C. Tunnell
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
- Department of Psychiatry & Behavioral Sciences, The University of Kansas Medical Center, Kansas City, KS, United States
| | - Sarah E. Corner
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
| | - Andres D. Roque
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
- Primary Care Department, Miami VA Healthcare System, Miami, FL, United States
| | - Juliet L. Kroll
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Thomas Ritz
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
| | - Alicia E. Meuret
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
| |
Collapse
|
2
|
Wan Y, Li Y, Sun J. The reliability of a subtype-determining questionnaire in efficient benign paroxysmal positional vertigo diagnosis in geriatrics. Front Aging Neurosci 2023; 15:1209342. [PMID: 37409007 PMCID: PMC10318130 DOI: 10.3389/fnagi.2023.1209342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/05/2023] [Indexed: 07/07/2023] Open
Abstract
Introduction Benign paroxysmal positional vertigo (BPPV), the most common cause of dizziness, especially for older adults, exposes patients to the lethal risk of falling. However, the diagnosis of BPPV in this population can be more elusive as they present few characteristic symptoms. Therefore, we explored the application of a subtype-determining questionnaire in BPPV diagnosis among the geriatric population. Methods Patients were assigned to the aware and unaware groups. In the aware group, the technician would directly test the suspected canal indicated by the questionnaire, whereas, in the unaware group, the technician performed the regular positional test. The diagnostic parameters of the questionnaire were examined. Results The accuracy, sensitivity, and specificity of questions 1-3 for diagnosing BPPV were 75.8, 77.6, and 74.7%, respectively. Question 4 demonstrated an accuracy of 75.6% in ascertaining the BPPV subtype, question 5 showed an accuracy of 75.6% in determining the affected side, and question 6 yielded an accuracy of 87.5% in distinguishing canalithiasis or cupulolithiasis. Examination time was shorter in the aware group than that in the unaware group (P < 0.05). No difference was found between the two groups for treatment time (P = 0.153). Conclusion This subtype-determining questionnaire is practical in daily use and capable of providing instructive information for an efficient diagnosis in geriatric patients with BPPV.
Collapse
|
3
|
Edlow JA, Carpenter C, Akhter M, Khoujah D, Marcolini E, Meurer WJ, Morrill D, Naples JG, Ohle R, Omron R, Sharif S, Siket M, Upadhye S, E Silva LOJ, Sundberg E, Tartt K, Vanni S, Newman-Toker DE, Bellolio F. Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE-3): Acute dizziness and vertigo in the emergency department. Acad Emerg Med 2023; 30:442-486. [PMID: 37166022 DOI: 10.1111/acem.14728] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 03/14/2023] [Indexed: 05/12/2023]
Abstract
This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").
Collapse
Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Christopher Carpenter
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Emergency Medicine, Washington University, St. Louis, Missouri, USA
| | - Murtaza Akhter
- Department of Emergency Medicine, Penn State School of Medicine, State College, Pennsylvania, USA
- Hershey Medical Center, State College, Pennsylvania, USA
| | - Danya Khoujah
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, Adventhealth Tampa, Tampa, Florida, USA
| | - Evie Marcolini
- Department of Emergency Medicine, Geisel School of Medicine, Dartmouth, Hanover, New Hampshire, USA
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | | | - James G Naples
- Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Division of Otolaryngology-Head & Neck Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Robert Ohle
- Department of Emergency Medicine, Northern Ontario School of Medicine, Sudbury, Ontario, Canada
- Health Science North Research Institute, Sudbury, Ontario, Canada
- Department of Emergency Medicine, Health Sciences North, Sudbury, Ontario, Canada
| | - Rodney Omron
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Department of Emergency Medicine, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Sameer Sharif
- Division of Critical Care and Emergency Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Matt Siket
- Department of Emergency Medicine, Robert Larner College of Medicine at the University of Vermont, Burlington, Vermont, USA
- Department of Emergency Medicine, Larner College of Medicine, University of Vermont, Burlington, Vermont, USA
| | - Suneel Upadhye
- Emergency Medicine, Evidence and Impact (HEI), McMaster University, Burlington, Ontario, Canada
- Health Research Methods, Evidence and Impact (HEI), McMaster University, Burlington, Ontario, Canada
| | - Lucas Oliveira J E Silva
- Mayo Clinic, Rochester, Minnesota, USA
- Department of Emergency Medicine, Hospital de Clinicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Etta Sundberg
- COO Royal Oasis Pool and Spas, Las Vegas, Nevada, USA
| | - Karen Tartt
- Absinthe Brasserie & Bar, San Francisco, California, USA
- St. George Spirits, San Francisco, California, USA
| | - Simone Vanni
- Department of Emergency Medicine, University of Florence, Firenze, Italy
- Department of Emergency Medicine, University Hospital Careggi, Firenze, Italy
| | - David E Newman-Toker
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Fernanda Bellolio
- Mayo Clinic College of Medicine, Rochester, Minnesota, USA
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
4
|
Wan Y, Li Y, Zhou L, Ma R, Sun J. Significance of subtype-determining questionnaire in efficient diagnosis and treatment of BPPV. Acta Otolaryngol 2023; 143:106-112. [PMID: 36662151 DOI: 10.1080/00016489.2023.2166987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND Rapid recognition of benign paroxysmal positional vertigo (BPPV) matters in many ways, questionnaires evolve as a new alternative for diagnosis. A subtype-determining questionnaire is a more advanced but rarely studied type. OBJECTIVE To explore the practicability of a subtype-determining questionnaire in facilitating diagnosis and treatment of BPPV. METHODS A BPPV subtype-determining questionnaire was applied to vertiginous patients. All patients underwent the positional test, performed by one technician, who was either informed or uninformed about questionnaire results randomly. In the informed group, the technician checked the canal indicated by the questionnaire straightforwardly; in the uninformed group, she performed the conventional positional test. Diagnostic parameters of the questionnaire and disparities between the 2 groups were investigated. RESULTS The accuracy, sensitivity, specificity of question 1-3 for diagnosing BPPV is 74.4%, 90.9%, 66.6% respectively. Question 4 shows an accuracy of 80.7% in determining BPPV subtype, question 5 yields an accuracy of 78.7% in ascertaining the affected side, question 6 exhibits an accuracy of 87.2% in deciding canalithiasis or cupulolithiasis. Both examination and treatment time were shorter in the informed group (p < .05). CONCLUSION This subtype-determining questionnaire has appealing diagnostic ability. It provides valuable information that's conducive to fast diagnosis and efficient treatment of BPPV.
Collapse
Affiliation(s)
- Yichen Wan
- Department of Otolaryngology Head Neck Surgery, Peking University International Hospital, Beijing, China
| | - Yingxuan Li
- Department of Otolaryngology Head Neck Surgery, Peking University International Hospital, Beijing, China
| | - Lihong Zhou
- Department of Otolaryngology Head Neck Surgery, Peking University International Hospital, Beijing, China
| | - Rui Ma
- Department of Otolaryngology Head Neck Surgery, Peking University International Hospital, Beijing, China
| | - Jianjun Sun
- Department of Otolaryngology Head Neck Surgery, Peking University International Hospital, Beijing, China
| |
Collapse
|
5
|
Iglebekk W, Tjell C. High score of dizziness-handicap-inventory (DHI) in patients with chronic musculoskeletal pain makes a chronic vestibular disorder probable. Scand J Pain 2022; 22:561-568. [PMID: 35119799 DOI: 10.1515/sjpain-2021-0102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 01/25/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES In patients with a vestibular disorder a high score of dizziness-handicap-inventory (DHI) is common. Patients with chronic lithiasis of multiple canals benign paroxysmal positional vertigo (mc-BPPV) can have incapacitating symptoms, e.g. headache, neck pain, musculoskeletal pain, and cognitive dysfunction. Patients with chronic musculoskeletal pain with few objective findings at an ordinary examination of the musculoskeletal system together with unsuccessful interventions can either receive a diagnosis of a biopsychosocial disorder or a diagnosis connected to the dominant symptom. The aim of this investigation is to examine if the DHI- and the DHI subscale scores are abnormal in 49 patients with chronic musculoskeletal pain disorders. In addition, explore the possibility of a chronic mc-BPPV diagnosis. METHODS Consecutive prospective observational cohort study at five different physiotherapy clinics. A personal interview using a structured symptom questionnaire consisting of 15 items. Modified Dizziness Handicap Inventory (DHI) including the Physical-, Catastrophic- and Emotional impact DHI subscale scores suggested by the Mayo Clinic was applied. RESULTS Eighty-four percent of the 49 patients have a pathological DHI-score and a potential underlying undiagnosed vestibular disorder. Very few patients have scores at the catastrophic subscale. A correlation is found between the number of symptoms of the structured scheme and the DHI-score. Results from all five physiotherapy clinics were similar. CONCLUSIONS Patients with a high number of symptoms and a high DHI-score can have a potential underlying treatable balance disorder like mc-BPPV. Increased awareness and treatment of mc-BPPV may reduce suffering and continuous medication in patients with chronic musculoskeletal pain. Regional Ethical Committee (No IRB 00001870).
Collapse
Affiliation(s)
| | - Carsten Tjell
- Specialist in Otorhinolaryngology, Head- and Neck Surgery, Vatnestrom, Norway
| |
Collapse
|
6
|
Edlow JA, Kerber K. Benign Paroxysmal Positional Vertigo: A Practical Approach for Emergency Physicians. Acad Emerg Med 2022; 30:579-588. [PMID: 35833326 DOI: 10.1111/acem.14558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 11/28/2022]
Abstract
Benign paroxysmal positional vertigo (BPPV) is a very common condition in the population and an important cause of acute vertigo or dizziness in patients presenting to an emergency department (ED). Despite this, abundant evidence shows that current ED management of patients with BPPV is suboptimal. Common ED management processes include brain imaging and treatment with vestibular suppressant medications such as meclizine, neither of which is recommended by current guidelines. The most efficient management of BPPV is to perform a bedside test (Dix-Hallpike test) and then to treat the patients with a bedside positional (the Epley) maneuver. In this practical review we emphasize the efficient management for the most common form of BPPV-posterior canal BPPV. Using this management will reduce resource utilization (laboratory testing, brain imaging, specialist consultation), reduce ED length of stay, and reduce use of ineffective mediations that have side effects but little therapeutic effect. Application of these practices would improve important patient-centered outcomes such as symptom reduction, radiation exposure, side effects from medications, and less need for urgent follow-up with another health care provider. The article also discusses the approach to patients in whom the Dix-Hallpike and/or Epley maneuvers do not seem to work. This includes a discussion the second most common variant of BPPV (horizontal canal BPPV) and criteria for safe discharge of patients. Another important advantage of learning BPPV best practices is that it is enormously satisfying for the clinician, not unlike treating a child with a nursemaid's elbow.
Collapse
Affiliation(s)
- Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center.,Professor of Emergency Medicine, Harvard Medical School
| | | |
Collapse
|
7
|
Dizziness Symptoms, Balance Confidence, and Vestibular Function in Older Women Reporting Dizziness and Unsteadiness. Otol Neurotol 2022; 43:e482-e488. [DOI: 10.1097/mao.0000000000003472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
8
|
Newman JL, Phillips JS, Cox SJ. Detecting positional vertigo using an ensemble of 2D convolutional neural networks. Biomed Signal Process Control 2021; 68:102708. [PMID: 34276807 PMCID: PMC8261823 DOI: 10.1016/j.bspc.2021.102708] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/04/2021] [Accepted: 04/28/2021] [Indexed: 11/18/2022]
Abstract
We trained Deep Neural Networks to detect attacks of motion provoked dizziness. 2D Convolutional Deep Neural Networks outperform 1D network architectures. Best results were provided by input features combining eye- and head-movement. An ensemble of five networks outperformed each individual network alone.
The aim of the work presented here was to develop a system that can automatically identify attacks of dizziness occurring in patients suffering from positional vertigo, which occurs when sufferers move their head into certain positions. We used our novel medical device, CAVA, to record eye- and head-movement data continually for up to 30 days in patients diagnosed with a disorder called Benign Paroxysmal Positional Vertigo. Building upon our previous work, we describe a novel ensemble of five 2D Convolutional Neural Networks, using composite recognition features, including eye-movement data and three-channel accelerometer data. We achieve an F1 score of 0.63 across an 11-fold cross-fold validation experiment, demonstrating that the system can detect a few seconds of motion provoked dizziness from within over a 100 h of normal eye-movement data. We show that the system outperforms our previous 1D Neural Network approach, and that our ensemble classifier is superior to each of the individual networks it contains. We also demonstrate that our composite recognition features provide improved performance over results obtained using the individual data sources independently.
Collapse
Affiliation(s)
- Jacob L. Newman
- The School of Computing Sciences, University of East Anglia, Norwich NR4 7TJ, United Kingdom
- Corresponding author.
| | - John S. Phillips
- The Department of Ear, Nose, and Throat Surgery, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich NR4 7UY, United Kingdom
| | - Stephen J. Cox
- The School of Computing Sciences, University of East Anglia, Norwich NR4 7TJ, United Kingdom
| |
Collapse
|
9
|
Lindell E, Karlsson T, Kollén L, Johansson M, Finizia C. Benign paroxysmal positional vertigo and vestibular impairment among older adults with dizziness. Laryngoscope Investig Otolaryngol 2021; 6:488-495. [PMID: 34195370 PMCID: PMC8223472 DOI: 10.1002/lio2.566] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/25/2021] [Accepted: 03/31/2021] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE This article aimed to investigate older adults visiting a geriatric institution for a bone density measurement who reported dizziness on a daily or weekly basis (but who are not seeking care for dizziness), according to BPPV, vestibular function, walking abilities, and frequency of falls. METHODS Patients coming for a bone density measurement answered questions regarding occurrence of dizziness. Patients having dizziness on a daily or weekly basis were considered eligible for the study and invited for investigation at the Ear, Nose, and Throat clinic at Södra Älvsborg Hospital, Sweden. The patients answered questions about history of dizziness, medications, and comorbidities. They were also investigated for BPPV, vestibular deficits using the video head impulse test (vHIT), walking speed, Timed Up and Go test (TUG), and for perception of verticality and horizontality and Romberg test. RESULTS A total of 55 patients with dizziness were included. Fifteen (27%) were diagnosed with BPPV. Forty (73%) patients reported falling during the previous year, including 11 with BPPV. Dizziness when turning in bed was more common among patients with BPPV and increased the risk of BPPV 8-fold. CONCLUSION BPPV is common among older adults with dizziness, including among those not seeking medical care. It is important to identify older adults with BPPV and treat the condition since BPPV may contribute to falls. Asking about dizziness when turning in bed can help to distinguish patients with increased risk for BPPV and older adults with dizziness should be investigated for BPPV even when typical history is lacking. Level of evidence: 4.
Collapse
Affiliation(s)
- Ellen Lindell
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Department of Otorhinolaryngology, Region Västra GötalandSödra Älvsborg HospitalSweden
| | - Therese Karlsson
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Department of Otorhinolaryngology, Head and Neck Surgery, Region Västra GötalandSahlgrenska University HospitalGothenburgSweden
| | - Lena Kollén
- Department of Otorhinolaryngology, Head and Neck Surgery, Region Västra GötalandSahlgrenska University HospitalGothenburgSweden
- Department of Occupational Therapy and Physiotherapy, Institute of Neuroscience and Physiology, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Mia Johansson
- Department of Oncology, Region Västra GötalandSahlgrenska University Hospital/SahlgrenskaGothenburgSweden
- Department of Oncology, Institute of Clinical Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Caterina Finizia
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
- Department of Otorhinolaryngology, Head and Neck Surgery, Region Västra GötalandSahlgrenska University HospitalGothenburgSweden
| |
Collapse
|
10
|
Agreement Between Physical Therapists in Diagnosing Benign Paroxysmal Positional Vertigo. J Neurol Phys Ther 2021; 45:79-86. [PMID: 33675601 DOI: 10.1097/npt.0000000000000349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE Individuals with benign paroxysmal positional vertigo (BPPV) are frequently referred to physical therapy for management, but little is known on how reliable therapists are at diagnosing BPPV. The purpose of the study was to examine the agreement between physical therapists in identifying nystagmus and diagnosing BPPV. METHODS Thirty-eight individuals with complaints of positional vertigo, 19 from each of 2 clinics (clinics 1 and 2) that specialize in vestibular rehabilitation, had eye movements recorded using video goggles during positioning tests including supine-to-sit, supine roll, and Dix-Hallpike tests. Three therapists from each of the clinics independently observed videos, documented nystagmus characteristics of each testing position, and made a diagnosis for each case. Kappa (κ) statistics were calculated between therapists within each clinic for nystagmus identification and diagnosis. RESULTS Clinic 1 therapists demonstrated substantial to almost perfect agreement in identifying nystagmus during positional tests (κ = 0.68-1, P < 0.005). Clinic 2 therapists showed moderate to almost perfect agreement for presence of nystagmus (κ = 0.57-1, P < 0.005). Therapists at both sites had almost perfect agreement of diagnosis side, canal, and mechanism (κ = 0.81-1, P < 0.005). DISCUSSION AND CONCLUSION Therapists utilized observations from multiple positional tests to determine diagnoses. This was evident by occasional disagreement in nystagmus presence and characteristics, but agreement in diagnosis, including ruling out BPPV. The results may not be generalizable to all physical therapists or therapists' ability to diagnose central and atypical nystagmus presentations. Experienced physical therapists demonstrated strong agreement in diagnosing common forms of BPPV.Video Abstract available for more insight from the authors (see the Video Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A340).
Collapse
|
11
|
Barreto RG, Yacovino DA, Teixeira LJ, Freitas MM. Teleconsultation and Teletreatment Protocol to Diagnose and Manage Patients with Benign Paroxysmal Positional Vertigo (BPPV) during the COVID-19 Pandemic. Int Arch Otorhinolaryngol 2021; 25:e141-e149. [PMID: 33542764 PMCID: PMC7851369 DOI: 10.1055/s-0040-1722252] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 11/10/2020] [Indexed: 02/08/2023] Open
Abstract
Introduction
Telehealth consists in the application of technology to provide remote health service. This resource is considered safe and effective and has attracted an exponential interest in the context of the COVID pandemic. Expanded to dizzy patients, it would be able to provide diagnosis and treatment, minimizing the risk of disease transmission. Benign paroxysmal positional vertigo (BPPV) is the most common vestibular disorder. The diagnosis typically rests on the description of the symptoms along with the nystagmus observed at a well-established positional testing.
Objectives
The aim of the present study was to propose a teleconsultation and teletreatment protocol to manage patients with BPPV during the COVID-19 pandemic.
Methods
Specialists in the vestibular field met through remote access technologies to discuss the best strategy to manage BPPV patients by teleconsultation and teletreatment system. Additionally, several scientific sources were consulted. Technical issues, patient safety, and clinical assessment were independently analyzed. All relevant information was considered in order to design a clinical protocol to manage BPPV patients in the pandemic context.
Results
Teleconsultation for BPPV patients requires a double way (video and audio) digital system. An adapted informed consent to follow good clinical practice statements must be considered. The time, trigger and target eye bedside examination (TiTRaTe) protocol has proven to be a valuable first approach. The bow and lean test is the most rational screening maneuver for patients with suspected positional vertigo, followed by most specific maneuvers to diagnostic the sub-variants of BPPV.
Conclusion
Although with limited evidence, teleconsultation and teletreatment are both reasonable and feasible strategies for the management of patients with BPPV in adverse situations for face-to-face consultation.
Collapse
Affiliation(s)
- Renato Gonzaga Barreto
- Clínica Otorrino Premier, Ilhéus, Bahia, Brazil.,Faculdade Madre Thaís, Ilhéus, Bahia, Brazil
| | - Darío Andrés Yacovino
- Otovestibular Section, Neurology department, Dr. Cesar Milstein Hospital, Buenos Aires, Argentina.,Memory and Balance Clinic, Buenos Aires, Argentina
| | - Lázaro Juliano Teixeira
- Prefeitura Municipal, Balneário Camboriú, SC, Brazil.,Consultório Particular, Balneário Camboriú, SC, Brazil
| | | |
Collapse
|
12
|
van Dam VS, Maas BDPJ, Schermer TR, van Benthem PPG, Bruintjes TD. Two Symptoms Strongly Suggest Benign Paroxysmal Positional Vertigo in a Dizzy Patient. Front Neurol 2021; 11:625776. [PMID: 33584519 PMCID: PMC7873998 DOI: 10.3389/fneur.2020.625776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 12/15/2020] [Indexed: 01/10/2023] Open
Abstract
Introduction: This prospective cohort study determined which questions in patient history are most likely to identify symptoms that are independently associated with a diagnosis of benign paroxysmal positional dizziness (BPPV) in patients presenting with dizziness, and to evaluate whether the patient's age and type of BPPV are of influence. Methods: We included adult patients with dizziness referred to our dizziness center, Apeldoorn, the Netherlands, from December 2018 to November 2019. All patients completed a questionnaire, underwent vestibular testing and received a diagnosis. Symptoms strongly suggesting BPPV were tested with multivariable analysis to determine their independent associations with BPPV. Subgroup analysis was performed for patient age, and the type of BPPV. Results: We included a total of 885 patients, 113 of whom (13%) were diagnosed with BPPV. The duration of dizziness spells <1 min (Q2) and dizziness provoked by rolling over in bed (Q4) were independently associated with the diagnosis BPPV. Q2 showed a sensitivity of 43%, and a specificity of 75%; Q4 scored 81% and 68%, respectively. Overall, the way patients perceived their dizziness (vertigo, light-headedness or instability) was not independently associated with the diagnosis BPPV. In younger patients, light-headedness and instability decreased the likelihood of BPPV compared to vertigo. Conclusion: The most reliable predictors for BPPV in patient history are a short duration of the dizziness spell and provocation of dizziness by rolling over in bed. Unlike younger patients, elderly patients with BPPV do not only perceive the dizziness as vertigo, but also as a feeling of instability.
Collapse
Affiliation(s)
- Victor S. van Dam
- Apeldoorn Dizziness Centre, Gelre Hospital, Apeldoorn, Netherlands
- Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | | | | | - Peter-Paul G. van Benthem
- Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Tjasse D. Bruintjes
- Apeldoorn Dizziness Centre, Gelre Hospital, Apeldoorn, Netherlands
- Department of Otorhinolaryngology and Head and Neck Surgery, Leiden University Medical Centre, Leiden, Netherlands
| |
Collapse
|
13
|
Abstract
Using an algorithmic approach to acutely dizzy patients, physicians can often confidently make a specific diagnosis that leads to correct treatment and should reduce the misdiagnosis of cerebrovascular events. Emergency clinicians should try to become familiar with an approach that exploits timing and triggers as well as some basic "rules" of nystagmus. The gait should always be tested in all patients who might be discharged. Computed tomographic scans are unreliable to exclude posterior circulation stroke presenting as dizziness, and early MRI (within the first 72 hours) also misses 10% to 20% of these cases.
Collapse
Affiliation(s)
- Kiersten L Gurley
- Harvard Medical School, Boston, MA, USA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA; Anna Jaques Hospital, Newburyport, MA, USA.
| | - Jonathan A Edlow
- Harvard Medical School, Boston, MA, USA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| |
Collapse
|
14
|
Lindell E, Kollén L, Johansson M, Karlsson T, Rydén L, Falk Erhag H, Wetterberg H, Zettergren A, Skoog I, Finizia C. Benign paroxysmal positional vertigo, dizziness, and health-related quality of life among older adults in a population-based setting. Eur Arch Otorhinolaryngol 2020; 278:1637-1644. [PMID: 32948896 PMCID: PMC8058011 DOI: 10.1007/s00405-020-06357-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 09/05/2020] [Indexed: 01/14/2023]
Abstract
Purpose Dizziness may affect quality of life in a negative way and contribute to falls. The aim of this study was to investigate and compare 75 years old with dizziness caused by benign paroxysmal positional vertigo (BPPV) to those with general dizziness/impaired balance (non-BPPV related) and to those reporting no dizziness, regarding health-related quality of life (HRQL), falls, tiredness, and walking speed in a population-based setting. Method A cross-sectional population-based sample, including 671 75 years old (398 women, 273 men), was investigated for BPPV, dizziness symptoms, falls, and walking speed. HRQL was assessed using the 36-item Short Form-36 Health Survey (SF-36). Result A total of 67 persons (10%) had symptoms of BPPV with 11 (1.6%) having nystagmus when tested for BPPV. Having BPPV as well as general dizziness/impaired balance was associated with reduced HRQL, more tiredness, enhanced number of falls, and lower walking speed. Furthermore, the risk of having BPPV increased fourfold if symptoms of dizziness when turning in bed was reported. Conclusion Having problems with dizziness is common among senior citizens where BPPV can be an unrecognized cause of dizziness that may impact HRQL and overall well-being. As BPPV is common among older adults, and is potentially curable through reposition maneuvers, it is important to liberally test for, and treat the condition. Information about dizziness when turning in bed can help to pinpoint persons with enhanced risk for BPPV also on a population-based level.
Collapse
Affiliation(s)
- Ellen Lindell
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg University, 413 45, Göteborg, Sweden. .,Region Västra Götaland, Department of Otorhinolaryngology, Sahlgrenska University Hospital, 413 45, Göteborg, Sweden.
| | - Lena Kollén
- Region Västra Götaland, Department of Otorhinolaryngology, Sahlgrenska University Hospital, 413 45, Göteborg, Sweden.,Department of Occupational Therapy and PhysiotherapyInstitute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, 413 45, Göteborg, Sweden
| | - Mia Johansson
- Region Västra Götaland, Department of Otorhinolaryngology, Sahlgrenska University Hospital, 413 45, Göteborg, Sweden.,Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy, Gothenburg University, 413 45, Göteborg, Sweden
| | - Therese Karlsson
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg University, 413 45, Göteborg, Sweden.,Region Västra Götaland, Department of Otorhinolaryngology, Sahlgrenska University Hospital, 413 45, Göteborg, Sweden
| | - Lina Rydén
- Neuropsychiatric Epidemiology Unit, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Centre for Ageing and Health (AgeCap) at the University of Gothenburg, Göteborg, Sweden
| | - Hanna Falk Erhag
- Neuropsychiatric Epidemiology Unit, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Centre for Ageing and Health (AgeCap) at the University of Gothenburg, Göteborg, Sweden
| | - Hanna Wetterberg
- Neuropsychiatric Epidemiology Unit, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Centre for Ageing and Health (AgeCap) at the University of Gothenburg, Göteborg, Sweden
| | - Anna Zettergren
- Neuropsychiatric Epidemiology Unit, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Centre for Ageing and Health (AgeCap) at the University of Gothenburg, Göteborg, Sweden
| | - Ingmar Skoog
- Neuropsychiatric Epidemiology Unit, Institute of Neuroscience and Physiology, Sahlgrenska Academy, Centre for Ageing and Health (AgeCap) at the University of Gothenburg, Göteborg, Sweden
| | - Caterina Finizia
- Department of Otorhinolaryngology, Head and Neck Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg University, 413 45, Göteborg, Sweden.,Region Västra Götaland, Department of Otorhinolaryngology, Sahlgrenska University Hospital, 413 45, Göteborg, Sweden
| |
Collapse
|
15
|
Kim HJ, Song JM, Zhong L, Yang X, Kim JS. Questionnaire-based diagnosis of benign paroxysmal positional vertigo. Neurology 2019; 94:e942-e949. [PMID: 31888973 DOI: 10.1212/wnl.0000000000008876] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Accepted: 08/29/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To develop a simple questionnaire for self-diagnosis of benign paroxysmal positional vertigo (BPPV). METHODS We developed a questionnaire that consisted of 6 questions, the first 3 to diagnose BPPV and the next 3 to determine the involved canal and type of BPPV. From 2016 to 2017, 578 patients with dizziness completed the questionnaire before the positional tests, a gold standard for diagnosis of BPPV, at the Dizziness Clinic of Seoul National University Bundang Hospital. RESULTS Of the 578 patients, 200 were screened to have BPPV and 378 were screened to have dizziness/vertigo due to disorders other than BPPV. Of the 200 patients with a questionnaire-based diagnosis of BPPV, 160 (80%) were confirmed to have BPPV with positional tests. Of the 378 patients with a questionnaire-based diagnosis of non-BPPV, 24 (6.3%) were found to have BPPV with positional tests. Thus, the sensitivity, specificity, and precision of the questionnaires for the diagnosis of BPPV were 87.0%, 89.8%, and 80.0% (121 of 161, 95% confidence interval 74.5%-85.5%). Of the 200 patients with a questionnaire-based diagnosis of BPPV, 30 failed to respond to the questions 4 through 6 to determine the involved canal and type of BPPV. The questionnaire and positional tests showed the same results for the subtype and affected side of BPPV in 121 patients (121 of 170, 71.2%). CONCLUSION The accuracy of questionnaire-based diagnosis of BPPV is acceptable. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that, in patients with dizziness, a questionnaire can diagnose BPPV with a sensitivity of 87.0% and a specificity of 89.8%.
Collapse
Affiliation(s)
- Hyo-Jung Kim
- From the Research Administration Team (H.-J.K.) and Department of Neurology (J.-M.S., J.-S.K.), Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, Korea; Department of Neurology (L.Z.), Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine; Department of Neurology (X.Y.), Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China; and Department of Neurology (J.-S.K.), College of Medicine, Seoul National University, Korea
| | - Jeong-Mi Song
- From the Research Administration Team (H.-J.K.) and Department of Neurology (J.-M.S., J.-S.K.), Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, Korea; Department of Neurology (L.Z.), Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine; Department of Neurology (X.Y.), Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China; and Department of Neurology (J.-S.K.), College of Medicine, Seoul National University, Korea
| | - Liqun Zhong
- From the Research Administration Team (H.-J.K.) and Department of Neurology (J.-M.S., J.-S.K.), Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, Korea; Department of Neurology (L.Z.), Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine; Department of Neurology (X.Y.), Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China; and Department of Neurology (J.-S.K.), College of Medicine, Seoul National University, Korea
| | - Xu Yang
- From the Research Administration Team (H.-J.K.) and Department of Neurology (J.-M.S., J.-S.K.), Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, Korea; Department of Neurology (L.Z.), Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine; Department of Neurology (X.Y.), Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China; and Department of Neurology (J.-S.K.), College of Medicine, Seoul National University, Korea
| | - Ji-Soo Kim
- From the Research Administration Team (H.-J.K.) and Department of Neurology (J.-M.S., J.-S.K.), Dizziness Center, Clinical Neuroscience Center, Seoul National University Bundang Hospital, Seongnam, Korea; Department of Neurology (L.Z.), Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine; Department of Neurology (X.Y.), Aerospace Center Hospital, Peking University Aerospace School of Clinical Medicine, Beijing, China; and Department of Neurology (J.-S.K.), College of Medicine, Seoul National University, Korea.
| |
Collapse
|
16
|
Abstract
PURPOSE OF THE REVIEW To define the best up-to-date practical approach to treat benign paroxysmal positional vertigo (BPPV). RECENT FINDINGS Both posterior and horizontal canal BPPV canalith repositioning maneuvers (Semont, Epley, and Gufoni's maneuvers) are level 1 evidence treatment for evidence-based medicine. The choice of maneuver (since their efficacy is comparable) is up to the clinician's preferences, failure of the previous maneuver, or movement restrictions of the patient. Maneuvers for controversial variants, such as anterior canal and apogeotropic posterior canal BPPV, have weaker evidence of efficacy. Despite this, these variants are increasingly diagnosed and treated. Maneuvers also play a role in the differential diagnosis with central vestibular disorders. Chair-assisted treatment may be of help if available while surgical canal plugging should be indicated in selected same-canal, same-side intractable severe BPPV. The primary evidence-based treatment strategy for BPPV should be physical therapy through maneuvers. Despite the high success rate of liberatory maneuvers, there is a low percentage of subjects who have unsatisfactory outcomes. These patients need to be investigated to identify recurrences, multiple canal involvement, associated comorbidities (migraine, persistent postural perceptual dizziness), or risk factors for recurrences (low vitamin D serum level). Future research should also identify the optimum maneuvers for variants whose diagnosis and treatment are still a matter of some debate.
Collapse
|
17
|
|