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Practice Parameter: Therapies for benign paroxysmal positional vertigo (an evidence-based review)

Report of the Quality Standards Subcommittee of the American Academy of Neurology


T.D. Fife, MD; D.J. Iverson, MD; T. Lempert, MD; J.M. Furman, MD, PhD; R.W. Baloh, MD; R.J. Tusa, MD, PhD; T.C. Hain, MD; S. Herdman, PT, PhD, FAPTA; M.J. Morrow, MD; G.S. Gronseth, MD
2006 American Academy of Neurology

Presentation Objectives
To perform an evidence-based review of the treatment of benign paroxysmal positional vertigo To make evidence-based recommendations

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Overview
Background Gaps in care AAN guideline process Analysis of evidence, conclusions, recommendations Recommendations for future research

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Background
BPPV is a clinical syndrome characterized by brief recurrent episodes of vertigo triggered by changes in head position with respect to gravity. BPPV is the most common cause of recurrent vertigo, with a lifetime prevalence of 2.4%.1 The duration, frequency, and intensity of symptoms of BPPV vary, and spontaneous recovery occurs frequently.
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Inner ear

2008, Barrow

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BPPV by canal type


Posterior Horizontal Anterior

Estimated frequency2-6

81-89%

8-17%

1-3%

Provocative maneuver Nystagmus

Dix Hallpike* Upbeat, torsional

Supine Roll Test (Pagnini-McClure) Horizontal Direction Changing

Dix Hallpike* Downbeat**, torsional

* In posterior canal benign positional vertigo, nystagmus is provoked following Dix Hallpike positioning with the affected ear down. In anterior canal benign positional vertigo, nystagmus is provoked following Dix Hallpike positioning with the affected ear up. ** The observation of downbeating positional nystagmus requires careful assessment to rule out brainstem or cerebellar lesions.
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Gaps in Care
There are a number of repositioning maneuvers in use, but they lack standardization. Several video clips and figure drawings are available at www.aan.com but do not include all variations for treatment.

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AAN Guideline Process


Clinical Question
Evidence Conclusions Recommendations
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Clinical Questions
First step of developing guidelines is to clearly formulate questions to be answered. Questions address areas of controversy, confusion, or variation in practice. Questions must be answerable with data from the literature. Answering the question must have the potential to improve care/patient outcomes.

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Literature Search/Review:
Rigorous, Comprehensive, Transparent

Complete Search Review abstracts Review full text

Select articles
Relevant
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AAN Classification of Evidence


All studies rated Class I, II, III, or IV Five different classification systems:
Therapeutic
Randomization, control, blinding

Diagnostic
Comparison to gold standard

Prognostic Screening Causation


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A = Established as effective, ineffective, or harmful for the given condition in the specified population. B = Probably effective, ineffective, or harmful for the given condition in the specified population. C = Possibly effective, ineffective, or harmful for the given condition in the specified population. U = Data is inadequate or conflicting; given current knowledge, treatment is unproven.

AAN Level of Recommendations

Note that recommendations can be positive or negative.

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Translating Class to Recommendations


A = Requires two consistent Class I studies. B = Requires one Class I study or two consistent Class II studies. C = Requires one Class II study or two consistent Class III studies. U = Studies not meeting criteria for Class I through Class III.
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Applying This Process to the Issue

We will now turn our attention to the guidelines.

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Clinical Questions
1. 2. 3. 4. 5. What maneuvers effectively treat posterior canal BPPV? Which maneuvers are effective for anterior and horizontal canal BPPV? Are postmaneuver restrictions necessary? Is concurrent mastoid vibration important for efficacy of the maneuvers? What is the efficacy of habituation exercises, BrandtDaroff exercises, or patient self-administered treatment maneuvers? Are medications effective for BPPV? Is surgical occlusion of the posterior canal or singular neurectomy effective for BPPV?

6. 7.

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Methods
Medline, EMBASE and Current Contents:
1966 to June 2006 Relevant, fully published, peer-reviewed articles Supplemented through manual searches by panel members

Search terms:
Benign paroxysmal positional vertigo, Semont liberatory maneuver, canalith repositioning maneuver, particle repositioning maneuver, Epley maneuver, modified Epley maneuver

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Methods
Panel comprised of otoneurologists with expertise in BPPV and general neurologists with methodologic expertise. At least two panelists reviewed each article for inclusion. Risk of bias determined using the classification of evidence for each study (Class IIV). Strength of practice recommendations linked directly to level of evidence (Level AU). Conflicts of interests disclosed.
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Literature Review
399 abstracts
Inclusion criteria: - Relevant to the clinical questions - Limited to human subjects -RCT, case control, cohort studies, case series > 6, metaanalysis Exclusion criteria: -Abstracts, reviews, and undocumented or unstated mention of improvement

70 articles

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AAN Classification of Evidence for Therapeutic Intervention


Class I: Randomized, controlled clinical trial with masked or objective outcome assessment in a representative population. Relevant baseline characteristics are presented and substantially equivalent among treatment groups or there is appropriate statistical adjustment for differences. The following are required: a) concealed allocation b) primary outcome(s) clearly defined c) exclusion/inclusion criteria clearly defined, and d) adequate accounting for drop-outs (with at least 80% of enrolled subjects completing the study) and crossovers with numbers sufficiently low to have minimal potential for bias.
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AAN Classification of Evidence for Therapeutic Intervention


Class II: Prospective matched group cohort study in a representative population with masked outcome assessment that meets b-d above OR a randomized controlled trial in a representative population that lacks one criteria a-d.

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AAN Classification of Evidence for Therapeutic Intervention


Class III: All other controlled trials (including well-defined natural history controls or patients serving as own controls) in a representative population, where outcome is independently assessed, or independently derived by objective outcome measurement*. Class IV: Studies not meeting Class I, II, or III criteria including consensus, expert opinion, or a case report. *Objective outcome measurement: an outcome measure that is unlikely to be affected by an observers (patient, treating physician, investigator) expectation or bias (e.g., blood tests, administrative outcome data).
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Analysis of Evidence
Question 1: What maneuvers effectively treat posterior canal BPPV?
Canalith repositioning procedure (CRP) 15 RCTs identified (two Class I2,3 and three Class II4-6 studies). Semont maneuver 4 studies identified (one class II6, one Class III7 two Class IV8,9 studies).

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Analysis of Evidence (CRP)


36 patients2 compared CRP to sham in supine position with affected ear down for 5 minutes and then sat up. All patients symptomatic for at least 2 months/ median duration of symptoms was 17 months (range 2-240 months) in treatment group and 4 months (range 2276 months) in control group.

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Analysis of Evidence (CRP)


At 4 weeks, 61% of treated group reported complete resolution vs. 20% of shamtreated group (p=0.032). NNT = 2.44. Dix-Hallpike maneuver was negative in 88.9% of treated patients vs. 26.7% in sham-treated patients (p<0.001, NNT = 1.60) as measured by an observer blinded to treatment.

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Canalith Repositioning Procedure

2008, Barrow

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Analysis of Evidence (CRP)


Randomized controlled trial and crossover study3
66 patients with a diagnosis of posterior BPPV based on a positive Dix-Hallpike maneuver, compared a CRP with sham. After 24 hours, 80% of treated patients were asymptomatic and had no nystagmus compared with 10% of sham patients (p<0.001, NNT = 1.43). Ninety-three percent of patients from original control reported resolution of symptoms 24 hours after undergoing CRP. By 1 week, 94% of patients in the original treatment group and 92% of patients in original control were asymptomatic. At 4 weeks, 85% of patients in both groups were asymptomatic.

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Analysis of Evidence (CRP)


Three studies were rated as Class II4-6 because the method of allocation concealment* was not specified. Remaining RCTs were graded Class IV because they did not clearly state whether the outcomes were obtained in a blinded and independent manner10-17 or because of important baseline difference between study and control groups.18 Five additional studies were identified (four meta-analyses19-22 and one systematic review). All references in the meta-analyses were reviewed individually for this practice parameter.
*Technique for preventing researchers from inadvertently influencing which patients are assigned to the treatment or placebo group (may cause selection bias that overestimates the treatment effect).23

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Analysis of Evidence
One study6 showed patients treated with Semont maneuver were significantly improved compared to those treated with sham. One study randomized 156 patients to Semont maneuver, medical therapy and no treatment.
Six month follow-up, 94.2% of patients treated with Semont maneuver reported symptom resolution, vs. 57.7% of patients treated medically and 34.6% of patients who received no treatment.

Semont Maneuver

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Semont maneuver

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Analysis of Evidence
Semont Maneuver
One Class IV study8 comparing Semont and a CRP with or without post-treatment found success rates for all groups ranging from 88% to 96%, with no difference between groups.

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Analysis of Evidence
Another Class IV study9 compared patients randomized to treatment with CRP, Semont maneuver, or Brandt-Daroff exercises.
Symptom resolution among those treated with either CRP or Semont maneuver at 1 week was the same (74% vs 71%; 24% for Brandt-Daroff exercises). At 3-month follow-up, 93% of patients treated with CRP were asymptomatic vs. 77% of those treated with Semont maneuver (p=0.027); 62% of patients treated with Brandt-Daroff exercises were asymptomatic at 3 months.
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Semont Maneuver

Conclusions
Two Class I studies and three Class II studies have demonstrated a short-term (1 day to 4 weeks) resolution of symptoms in patients treated with the CRP (NNT ranging from 1.43 to 3.7). The Semont maneuver is possibly more effective than no treatment (Class III), a sham treatment (Class II), or Brandt-Daroff exercises (Class IV) as treatment for posterior canal BPPV. Two Class IV studies comparing CRP with Semont maneuver have produced conflicting results.
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Recommendations
CRP is established as an effective and safe therapy that should be offered to patients of all ages with posterior semicircular canal BPPV (Level A). The Semont maneuver is possibly effective for BPPV (Level C).* There is insufficient evidence to establish the relative efficacy of the Semont maneuver to CRP (Level U).
* Single Class II study.

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Analysis of Evidence
Question 2: Which maneuvers are the most effective treatments for horizontal canal and anterior canal BPPV?
Horizontal canal BPPV 21 studies identified24-44 (Class IV). Anterior canal BPPV 2 studies identified45,46 (Class IV).

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Analysis of Evidence
Horizontal Canal BPPV
Horizontal canal BPPV accounts for 1017% of BPPV,24-28 though some reports have been even higher.29,30 The nystagmus and vertigo of horizontal canal BPPV may be provoked by the DixHallpike maneuver but are more reliably induced by the supine head roll test (Pagnini-McClure maneuver).33-35
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Analysis of Evidence
Horizontal Canal BPPV
CRP or modified Epley maneuvers are usually ineffective for horizontal canal BPPV,7-9,24-33,47 so a number of alternative maneuvers have been devised.
Modified maneuvers include the Lempert maneuver (barbecue roll), the Gufoni maneuver, and the Vanucchi-Asprella liberatory maneuver. Success in treatment for each of these maneuvers is based on Class IV data.
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Supine roll test (Pagnini-McClure maneuver)

2008, Barrow

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Lempert roll maneuver

2008, Barrow

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Analysis of Evidence Anterior Canal BPPV


Anterior canal BPPV is usually transitory and most often the result of canal switch that occurs in the course of treatment more common forms of BPPV.47 Success rates were between 92-97%,45, 46 though there were no controls to determine whether this represents an improvement over the natural history of this frequently selfresolving form of BPPV.

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Conclusions/Recommendation

Based on Class IV studies, variations of the Lempert supine roll maneuver, the Gufoni method, or forced prolonged positioning seem moderately effective for horizontal canal BPPV. Two uncontrolled Class IV studies report high response rates to maneuvers for anterior canal BPPV. No recommendation can be made (Level U).

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Analysis of Evidence
Question 3: Are postmaneuver activity activity restrictions necessary after canalith repositioning treatment? One Class I2, one Class II4 and six Class IV studies.8,48-52

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Analysis of Evidence
One Class I study2 and one Class II study4 demonstrating the benefit of CRP, patients wore a cervical collar for 48 hours and avoided sleeping on the affected side for 1 week. Five Class IV studies8,48-52 comparing CRP with and without post-treatment activity restriction showed no added benefit from post-treatment activity restriction or positions. One Class IV study52 showed minimal benefit in patients with post-activity restrictions.

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Conclusion/Recommendation

Based on six Class IV studies, there is insufficient evidence to determine the efficacy of post-maneuver restrictions in patients treated with CRP. No recommendation can be made (Level U).

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Analysis of Evidence
Question 4: Is it necessary to include mastoid vibration with repositioning maneuvers? One Class II,53 one Class III54 and three Class IV studies.11,55,56

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Analysis of Evidence
One Class II study53 comparing patients with posterior canal BPPV treated by appropriate canalith repositioning maneuvers, performed with and without vibration, showed no difference in immediate symptom resolution or relapse rate between groups. One Class III study54 compared patients treated by CRP with and without mastoid vibration. There was no difference in symptom relief between the groups at 4 to 6 weeks (p=0.68).

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Analysis of Evidence
Two Class IV studies55,56 showed no difference in the rate of symptom resolution between patients treated by a CRP with or without mastoid vibration. A third Class IV study11 reported that of patients treated by a CRP with vibration, 92% were improved, vs. 60% improvement with CRP alone.
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Conclusion
One Class II, one Class III, and two Class IV studies showed no added benefit when mastoid vibration was added to a CRP as treatment for posterior canal BPPV.

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Recommendation
Mastoid oscillation is probably of no added benefit to patients treated with CRP for posterior canal BPPV (Level C).

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Analysis of Evidence
Question 5: What is the efficacy of Brandt-Daroff exercises, habituation exercises, or patient self-administered treatments for BPPV? One Class II6 and one Class IV study.9

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Analysis of Evidence
One Class II study6 randomized patients to a CRP, a liberatory maneuver, Brandt-Daroff exercises, habituation exercises, or sham treatment found that patients treated with habituation exercises did no better than those treated with sham. Patients treated with BrandtDaroff exercises did worse than those treated with CRP or liberatory maneuvers, but were not compared with sham treated patients.

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Analysis of Evidence
One Class IV study9 compared Brandt-Daroff exercises, performed three times daily, with the Semont maneuver or CRP.
Patients treated with maneuvers were pretreated with diazepam and given postmaneuver activity restrictions; patients treated with Brandt-Daroff exercises were not. Compliance was not recorded. At 1-week follow-up, 24% of patients treated with Brandt-Daroff exercises were symptom free, vs. 74% of those treated with the Semont maneuver or CRP.

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Conclusion
One Class II and one Class IV study suggest that BrandtDaroff exercises or habituation exercises are less effective than CRP in the treatment of posterior canal BPPV.

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Recommendations
Self-administered BrandtDaroff exercises or habituation exercises are less effective than CRP in the treatment of posterior canal BPPV (Level C). There is insufficient evidence to recommend or refute self-treatment using Semont maneuver or CRP for BPPV (Level U).
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Analysis of Evidence
Question 6: What is the efficacy of medication treatments for BPPV? Two Class III studies.47,57

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Analysis of Evidence
One Class III study57 found no difference between lorazepam, 1mg three times daily; diazepam, 5mg three times daily; or placebo over the 4-week study period. One Class III study47 found that flunarizine was more effective than no treatment but less effective than Semont maneuver in eliminating symptoms. There are no randomized controlled trials of meclizine or other drugs used for motion sickness in the treatment of BPPV.
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Conclusions/Recommendation
A single Class III study did not demonstrate that lorazepam or diazepam hastened resolution of symptoms in BPPV. Another Class III study demonstrated some benefit of flunarizine (unavailable in the US) in BPPV. There is no evidence to support or refute a recommendation of any medication in the routine treatment for BPPV (Level U).

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Analysis of Evidence
Question 7: What are the safety and efficacy of surgical treatments for posterior canal BPPV? Six Class IV studies.58-63

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Analysis of Evidence
Five Class IV studies58-62 with a total of 86 patients undergoing canal occlusion, reported complete relief of BPPV symptoms in 85, as ascertained by the treating surgeon.
Reported complications included a mild conductive hearing loss for 4 weeks or less, mild and transient unsteadiness in most patients, and a high frequency sensorineural hearing loss in 6 patients.

One Class IV study63 of singular neurectomy as a treatment for intractable BPPV, 96.8% were reported to have complete relief.
Severe sensorineural hearing loss occurred in 3.7% of patients.
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Conclusion/Recommendation

Six unblinded, retrospective Class IV studies report relief from symptoms of BPPV in nearly every patient undergoing posterior semicircular canal occlusion or singular neurectomy. The studies do not provide sufficient evidence to recommend or refute posterior semicircular canal occlusion or singular neurectomy as treatment for BPPV (Level U).

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Future Research
Class I studies are needed to clarify the best treatments for horizontal canal BPPV. Future studies on these topics should adhere to the Consolidated Standards of Reporting Trials (CONSORT) criteria using validated, clinically relevant outcomes.

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References
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McClure JA, Willett JM. Lorazepam and diazepam in the treatment of benign paroxysmal vertigo. J Otolaryngol 1980;9:472-7. Dingle AF, Hawthorne MR, Kumar BU. Fenestration and occlusion of the posterior semicircular canal for benign positional vertigo. Clinical Otolaryngology & Allied Sciences 1992;17:300-2. Zappia JJ. Posterior semicircular canal occlusion for benign paroxysmal positional vertigo. American Journal of Otology 1996;17:749-54. Pulec JL. Ablation of posterior semicircular canal for benign paroxysmal positional vertigo. Ear, Nose, & Throat Journal 1997;76:17-22, 24. Walsh RM, Bath AP, Cullen JR, Rutka JA. Long-term results of posterior semicircular canal occlusion for intractable benign paroxysmal positional vertigo. Clinical Otolaryngology & Allied Sciences 1999;24:316-23. Agrawal SK, Parnes LS. Human experience with canal plugging. Annals of the New York Academy of Sciences 2001; 942:300-5. Gacek RR, Gacek MR. Results of singular neurectomy in the posterior ampullary recess. Journal of Oto-Rhino-Laryngology & its Related Specialties 2002;64:397402.

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Questions/Comments

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Thank you for your participation!

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