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Presentation Objectives
To perform an evidence-based review of the treatment of benign paroxysmal positional vertigo To make evidence-based recommendations
Overview
Background Gaps in care AAN guideline process Analysis of evidence, conclusions, recommendations Recommendations for future research
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.
2006 American Academy of Neurology
Inner ear
2008, Barrow
Estimated frequency2-6
81-89%
8-17%
1-3%
* 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.
2006 American Academy of Neurology
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.
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.
Literature Search/Review:
Rigorous, Comprehensive, Transparent
Select articles
Relevant
2006 American Academy of Neurology
Diagnostic
Comparison to gold standard
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.
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.
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
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.
2006 American Academy of Neurology
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
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
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
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.
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.
2006 American Academy of Neurology
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.
2006 American Academy of Neurology
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.
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).
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
2006 American Academy of Neurology
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.
2006 American Academy of Neurology
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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).
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
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.
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).
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
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).
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.
2006 American Academy of Neurology
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.
Recommendation
Mastoid oscillation is probably of no added benefit to patients treated with CRP for posterior canal BPPV (Level C).
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
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.
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.
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.
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).
2006 American Academy of Neurology
Analysis of Evidence
Question 6: What is the efficacy of medication treatments for BPPV? Two Class III studies.47,57
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).
Analysis of Evidence
Question 7: What are the safety and efficacy of surgical treatments for posterior canal BPPV? Six Class IV studies.58-63
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).
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.
References
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