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DOI 10.1212/01.wnl.0000313378.77444.ac 2008;70;2067Neurology
T. D. Fife, D. J. Iverson, T. Lempert, et al.Standards
Subcommittee of the American Academy of Neurology
vertigo (an evidence-based review) : Report of the Quality
Practice Parameter: Therapies for benign paroxysmal positional
April 30, 2012This information is current as of
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article, along with updated information and services, is
rights reserved. Print ISSN: 0028-3878. Online ISSN:
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is the official journal of the American Academy of Neurology.
Published continuouslyNeurology
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Practice Parameter: Therapies for benignparoxysmal positional
vertigo(an evidence-based review)Report of the Quality Standards
Subcommittee of the AmericanAcademy of Neurology
T.D. Fife, MDD.J. Iverson, MDT. Lempert, MDJ.M. Furman,
MD,PhD
R.W. Baloh, MDR.J. Tusa, MD, PhDT.C. Hain, MDS. Herdman, PT,
PhD,FAPTA
M.J. Morrow, MDG.S. Gronseth, MD
INTRODUCTION Benign paroxysmal positionalvertigo (BPPV) is a
clinical syndrome character-ized by brief recurrent episodes of
vertigo trig-gered by changes in head position with respect
togravity. BPPV is the most common cause of recur-rent vertigo,
with a lifetime prevalence of 2.4%.1
The term BPPV excludes vertigo caused by le-sions of the CNS.
BPPV results from abnormalstimulation of the cupula within any of
the threesemicircular canals (figure e-1 on theNeurology
Web site at www.neurology.org); most cases ofBPPV affect the
posterior canal. The cupular exci-tatory response is usually
related to movement ofotoliths (calcium carbonate crystals) that
create acurrent of endolymph within the affected semicir-cular
canal. The most common form of BPPV oc-curswhen otoliths from
themacula of the utricle fallinto the lumen of the posterior
semicircular canalresponding to the effect of gravity. These
ectopicotoliths, which have been observed intraoperatively,are
referred to as canaliths. The canaliths are denseand move in the
semicircular canal when the headposition is changedwith respect to
gravity; the cana-lith movement ultimately deflects the cupula,
lead-ing to a burst of vertigo and nystagmus. In somecases,
canaliths adhere to the cupula, causing cupu-lolithiasis, which is
a form of BPPV less responsiveto treatment maneuvers.
Typical signs of BPPV are evoked when thehead is positioned so
that the plane of the affectedsemicircular canal is spatially
vertical and thus
aligned with gravity. This produces a paroxysmof vertigo and
nystagmus after a brief latency. Po-sitioning the head in the
opposite direction re-verses the direction of the nystagmus.
Theseresponses often fatigue upon repeat positioning.The duration,
frequency, and intensity of symptomsof BPPV vary, and spontaneous
recovery occurs fre-quently. Table e-1 outlines the characteristics
ofBPPV by canal type.
Repositioning maneuvers are believed to treatBPPV by moving the
canaliths from the semicir-cular canal to the vestibule from which
they areabsorbed. There are a number of repositioningmaneuvers in
use, but they lack standardization.The figures and Web-based video
clips do not in-clude all variations but represent those
maneuversand treatments used in the Class I and Class IIstudies
that are reviewed as well as several othersin common use.
This practice parameter seeks to answer the fol-lowing
questions: 1) What maneuvers effectivelytreat posterior canal BPPV?
2)Whichmaneuvers areeffective for anterior and horizontal canal
BPPV? 3)Are postmaneuver restrictions necessary? 4) Is con-current
mastoid vibration important for efficacy ofthe maneuvers? 5) What
is the efficacy of habitua-tion exercises, BrandtDaroff exercises,
or patientself-administered treatmentmaneuvers? 6) Aremed-ications
effective for BPPV? 7) Is surgical occlusionof the posterior canal
or singular neurectomy effec-tive for BPPV?
Supplemental data atwww.neurology.org
Address correspondence andreprint requests to theAmerican
Academy ofNeurology, 1080 MontrealAve., St. Paul, MN
[email protected]
GLOSSARYAAN American Academy of Neurology; BPPV benign
paroxysmal positional vertigo; CONSORT Consolidated Stan-dards of
Reporting Trials; CRP canalith repositioning procedure; NNT number
needed to treat.
From the Barrow Neurological Institute and University of Arizona
College of Medicine (T.D.F.), Phoenix, AZ; Humboldt
NeurologicalMedical Group, Inc. (D.J.I.), Eureka, CA; Department of
Neurology (T.L.), Schlosspark-Klinik, Berlin, Germany; Department
ofOtolaryngology (J.M.F.), University of Pittsburgh, PA; Department
of Neurology (R.W.B.), Reed Neurological Research Center,
Universityof California, Los Angeles, CA; Departments of Neurology
(R.J.T.) and Rehabilitation Medicine (S.H.), Emory University;
Atlanta, GA;Northwestern University (T.C.H.), Chicago, IL;
Providence Multiple Sclerosis Center (M.J.M.), Portland, OR; and
University of Kansas(G.S.G.), Kansas City, KS.
Approved by the Quality Standards Subcommittee on May 1, 2007;
by the Practice Committee on June 21, 2007; and by the
AmericanAcademy of Neurology Board of Directors in July 2007.
QSS Subcommittee members, AAN classification of evidence,
Classification of recommendations, Conflict of Interest Statement,
MissionStatement of the QSS, and references e1e32 are available as
supplemental data on theNeurology Web site at
www.neurology.org.
Disclosure: Author disclosures are provided at the end of the
article.
All figures in this manuscript and online were printed with
permission from Barrow Neurological Institute.
SPECIAL ARTICLE
Copyright 2008 by AAN Enterprises, Inc. 2067
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DESCRIPTION OF THE ANALYTIC PROCESSOtoneurologists with
expertise in BPPV and gen-eral neurologists with methodologic
expertisewere invited by the Quality Standards Subcom-mittee
(appendix e-1) to perform this review. Us-ing the four-tiered
classification scheme describedin appendix e-2, author panelists
rated all rele-vant articles between 1966 and June 2006.
Articles included in this analysis met all of thesecriteria: 1)
BPPV was diagnosed by both symptomsof positional vertigo lasting
less than 60 seconds,and paroxysmal positional nystagmus in
responseto the DixHallpike maneuver (figure 1) or otherappropriate
provocative maneuver; 2) for all formsof BPPV, the nystagmuswas
characterized by a brieflatency before the onset of nystagmus or a
reductionof nystagmus with repeat DixHallpike
maneuvers(fatigability); 3) for posterior canal BPPV, a
positiveDixHallpike maneuver was defined by the pres-ence of
upbeating and torsional nystagmus with thetop pole of rotation
beating toward the affected(downside) ear; and 4) for horizontal
canal BPPV,the DixHallpike or supine roll maneuver
producedhorizontal geotropic (toward the ground) or apo-geotropic
(away from the ground) direction-changing paroxysmal positional
nystagmus.Geotropic direction-changing positional nystag-mus refers
to paroxysmal right beating nystagmuswhen the supine head is turned
to the right andparoxysmal left beating nystagmus with the su-pine
head turned to the left. Conversely, apogeo-tropic indicates the
nystagmus is right beatingwith the head turned to the left and left
beatingwith head turned to the right.
ANALYSIS OF EVIDENCE Question 1: Whatmaneuvers effectively treat
posterior canal BPPV?Canalith repositioning procedure for BPPV.Of15
ran-domized controlled trials identified, there weretwo Class I
studies2,3 and three Class II studies.4-6
The first Class I study of 36 patients2 com-pared the canalith
repositioning procedure (CRP)(figure 2) with a sham maneuver where
the pa-tient was placed in a supine position with the af-fected ear
down for 5 minutes and then sat up. Allpatients were symptomatic
for at least 2 months;the median duration of symptoms was 17
months(range 2240 months) in the treatment group and4 months (range
2276 months) in the controlgroup, a difference that approached
significance.
At 4 weeks, 61% of the treated group reportedcomplete symptom
resolution, vs 20% of thesham-treated group (p 0.032). The
numberneeded to treat (NNT) was 2.44. The NNT is anepidemiologic
measure that indicates the numberof patients that had to have
treatment to elimi-nate symptoms in one patient. The
DixHallpikemaneuver was negative in 88.9% of treated pa-tients vs
26.7% in sham-treated patients (p 0.001; NNT 1.60), as measured by
an observerblinded to treatment.
The second Class I randomized controlled trialand crossover
study,3 of 66 patients with a diag-nosis of posterior BPPV based on
a positive DixHallpike maneuver, compared a CRP (figure 2)with a
sham procedure. The sham procedure con-sisted of a CRP performed on
the contralateral,asymptomatic ear.
After 24 hours, 80% of treated patients wereasymptomatic and had
no nystagmus with theDixHallpike maneuver compared with 10% ofsham
patients (p 0.001; NNT 1.43). At thispoint, all patients in both
the treatment and con-trol groups with a persistently positive
DixHallpike maneuver underwent a CRP. Ninety-three percent of
patients from the original controlgroup reported resolution of
symptoms 24 hoursafter undergoing the CRP. By 1 week, 94% of
pa-tients in the original treatment group and 82% ofpatients in the
original control group (all of whomunderwent a CRP at 24 hours)
were asymptomatic(p value not stated). At 4 weeks, 85% of patients
inboth groups were asymptomatic.
Three studies were rated as Class II becausethe method of
allocation concealment was notspecified. Allocation concealment is
a techniquefor preventing researchers from inadvertently
in-fluencing which patients are assigned to the treat-ment or
placebo group; inadequate allocationconcealment may cause selection
bias that overes-timates the treatment effect.7
The first Class II study of 50 patients4 com-pared a CRP with
the same sham maneuver per-formed by Lynn et al.,2 with blinded
outcomemeasurements of symptom resolution and absent
Figure 1 DixHallpike maneuver for diagnosis ofright posterior
canal benignparoxysmal positional vertigo(BPPV)
The patients head is turned 45 degrees toward the side tobe
tested and then laid back quickly. If BPPV is present, nys-tagmus
ensues usually within seconds.
2068 Neurology 70 May 27, 2008 (Part 1 of 2)
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nystagmus in response to the DixHallpike ma-neuver. One to 2
weeks after treatment, 50%of the treated group reported symptom
resolutionvs 19% in the sham group, an absolute differenceof 31%
(95% CI 0.06-0.56, p 0.02; NNT 3.22). Using the absence of
nystagmus after theDixHallpike maneuver as an outcome measure-ment,
an improvement was seen in 65% oftreated patients vs 38% of sham
patients, a27% absolute difference (95% CI 0.02 0.52,p 0.046; NNT
3.7).
Another Class II study5 randomized 29 pa-tients to a CRP and
another 29 patients to notreatment. The diagnosis of posterior BPPV
wasbased on observing nystagmus after the DixHallpike maneuver and
a complete neurotologi-cal examination. All patients were given
aprescription for cinnarizine to use for vertigo.Over the next
month, all patients were exam-
ined at weekly intervals by a blinded observer.Patients with a
positive DixHallpike maneu-ver who were assigned to the treatment
groupunderwent repeat CRP. A questionnaire wasadministered to
patients with a negative DixHallpike maneuver.
At 1 week, 41% of treated patients were symp-tom free, vs 3% of
untreated controls (p 0.005;NNT 2.63). The DixHallpike maneuver
wasnegative in 75.9% of treated patients vs 48.2% ofuntreated
controls, an absolute difference of27.7% (95% CI 0.2410.489, p
0.03; NNT 3.68). At 2 weeks, 65% were symptom free in thetreatment
group vs 3% of controls (p 0.005). At3 weeks, 65% were symptom free
vs 21% of thecontrols (p 0.014). There were no
significantdifferences at 4 weeks. The control group
usedcinnarizine more often (23 doses) than did thetreatment group
(5.8 doses, p 0.001).
The third study6 randomized 124 patients to aCRP, a Semont
liberatory maneuver (figure 3),BrandtDaroff exercises (figure e-2),
habituationexercises, or a sham maneuver of slow neck rota-tion and
flexion performed with the patient in asitting position. The
diagnosis for posterior canalBPPV was based on history and
paroxysmal posi-tional nystagmus in response to the
DixHallpikemaneuver (figure 1). The median duration ofsymptoms was
4 months (range 10 days to 30years). The outcome measure was an
arbitrarypatient-rated vertigo intensity and frequency scaleof 1 to
10 (10 being the most severe or frequent),recorded by a blinded
observer.
The treatment effect in this study is difficult toquantify
because the results are expressed in theform of regression curves,
rather than as discretevalues. At 90 days after treatment, vertigo
fre-quency was reportedly significantly reduced inboth CRP and
Semont maneuvertreated pa-tients. Both treatment maneuvers were
superiorto the sham maneuver (CRP, p 0.021; Semontmaneuver, p
0.010) for vertigo intensity. Thevertigo scores were not
significantly different be-tween the CRP and Semont maneuver. There
wassignificantly less frequent vertigo in those treatedby either
CRP or Semont maneuver comparedwith BrandtDaroff exercises (p
0.033).
The remaining randomized controlled trialswere graded as Class
IV because they did notclearly state whether the outcomes were
obtainedin a blinded and independent manner8-15 or be-cause of
important baseline differences betweenstudy and control
groups.16
The literature search also yielded four meta-analyses and one
systematic review. All four
Figure 2 Canalith repositioning procedure for right-sided benign
paroxysmalpositional vertigo
Steps 1 and 2 are identical to the DixHallpike maneuver. The
patient is held in the right headhanging position (Step 2) for 20
to 30 seconds, and then in Step 3 the head is turned 90degrees
toward the unaffected side. Step 3 is held for 20 to 30 seconds
before turning thehead another 90 degrees (Step 4) so the head is
nearly in the face-down position. Step 4 isheld for 20 to 30
seconds, and then the patient is brought to the sitting up
position. Themovement of the otolith material within the labyrinth
is depicted with each step, showing howotoliths are moved from the
semicircular canal to the vestibule. Although it is advisable
forthe examiner to guide the patient through these steps, it is the
patients head position that isthe key to a successful
treatment.
Neurology 70 May 27, 2008 (Part 1 of 2) 2069
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meta-analyses17-20 concluded that CRP and Se-mont maneuver have
significantly greater efficacythan no treatment in BPPV. All
references in-cluded in these four meta-analyses were
reviewedindividually for this practice parameter.
In all these studies, complications of nauseaand vomiting,
fainting, or conversion to horizon-tal canal BPPV occurred in 12%
of patients. In aretrospective study of 85 patients treated with
aCRP,21 6% developed a conversion to either hori-zontal canal BPPV
or anterior canal BPPV.
Semont maneuver for BPPV. One Class II study6
showed that patients treated with Semont maneu-ver were
significantly improved compared withthose treated with a sham
maneuver. A Class IIIstudy22 randomized 156 patients to Semont
ma-neuver, medical therapy (flunarizine 10 mg/dayfor 60 days), or
no treatment. At 6-month follow-up, 94.2% of patients treated with
Semont ma-neuver reported symptom resolution, vs 57.7% ofpatients
treated with flunarizine and 34.6% of pa-tients who received no
treatment.
A Class IV study23 comparing Semont maneu-ver and a CRP either
with or without post-treatment instructions found success rates for
allgroups ranging from 88% to 96%, with no differ-ences between
groups. Another Class IV study24
compared patients randomized to treatment withCRP, Semont
maneuver, or BrandtDaroff exer-cises. Symptom resolution among
those treatedwith either CRP or Semont maneuver at 1 weekwas the
same (74% vs 71%; 24% for BrandtDaroff exercises). At 3-month
follow-up, 93% ofpatients treated with CRP were asymptomatic vs
77% of those treated with Semont maneuver (p 0.027); 62% of
patients treated with BrandtDaroff exercises were asymptomatic at 3
months.
Conclusion. Two Class I studies and three ClassII studies have
demonstrated a short-term (1 dayto 4 weeks) resolution of symptoms
in patientstreated with the CRP, with NNT ranging from1.43 to 3.7.
The Semont maneuver is possiblymore effective than no treatment
(Class III), asham treatment (Class II), or BrandtDaroff exer-cises
(Class IV) as treatment for posterior canalBPPV. Two Class IV
studies comparing CRP withSemont maneuver have produced conflicting
re-sults; one showed no difference between groups,and the other
showed a lower recurrence rate inpatients undergoing CRP.
Recommendation (appendix e-3). Canalith reposi-tioning procedure
is established as an effectiveand safe therapy that should be
offered to patientsof all ages with posterior semicircular canal
BPPV(Level A recommendation). The Semont maneu-ver is possibly
effective for BPPV but receives onlya Level C recommendation based
on a singleClass II study. Although many experts believethat the
Semont maneuver is as effective as cana-lith repositioning
maneuver, based on currentlypublished articles the Semont maneuver
can onlybe classified as possibly effective. There is in-sufficient
evidence to establish the relative effi-cacy of the Semont maneuver
to CRP (Level U).
Question 2: Which maneuvers are the most effectivetreatments for
horizontal canal and anterior canalBPPV? Horizontal canal BPPV.
Horizontal canalBPPV accounts for 10% to 17% of BPPV,25-29
though some reports have been even higher.30,31
The nystagmus of horizontal canal BPPV is hori-zontal and
changes direction when the head isturned to the right or left while
supine (direction-changing paroxysmal positional nystagmus).
Thedirection-changing positional nystagmus may beeither geotropic
or apogeotropic.31 The geotropicform, which is thought to result
from free-movingotoconial debris in the long arm of the
semicircularduct, is generally more responsive to treatment.
Theapogeotropic form is likely due to otoconial mate-rial in the
short arm of the canal or attached to thecupula
(cupulolithiasis).24,32 Hence, one seeks toconvert the more
treatment-resistant apogeotropicto the more treatment-responsive
geotropic nystag-mus form of horizontal canal BPPV.32,33
The nystagmus and vertigo of horizontal canalBPPV may be
provoked by the DixHallpike ma-neuver but are more reliably induced
by the su-pine head roll test or so-called PagniniMcCluremaneuver
(figure 4).34-36 The methods used to de-
Figure 3 Semont maneuver for right-sided benign paroxysmal
positional vertigo
While sitting up in Step 1, the patients head is turned 45
degrees toward the left side, andthen the patient is rapidly moved
to the side-lying position as depicted in Step 2. This positionis
held for 30 seconds or so, and then the patient is rapidly taken to
the opposite side-lyingposition without pausing in the sitting
position or changing the head position relative to theshoulder.
This is in contrast to the BrandtDaroff exercises that entail
pausing in the sittingposition and turning the head with body
position changes.
2070 Neurology 70 May 27, 2008 (Part 1 of 2)
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termine the affected side in horizontal canal BPPVare described
elsewhere.30,37,38,e1 CRP or modifiedEpley maneuvers are usually
ineffective for hori-zontal canal BPPV,21,34 so a number of
alternativemaneuvers have been devised.
Variations of the roll maneuver (Lempert ma-neuver or barbecue
roll maneuver) (figure 5) are
the most widely published treatments for hori-zontal canal
BPPV.25,26,29,31,32,34,36,38,e1,e2 Success intreatment, based on
all Class IV studies, is proba-bly 75%32,e2 but ranges from
approximately50% to nearly 100%. However, the studies useddiffering
and sometimes unclear endpoints, andmany lacked control groups to
allow comparisonbetween the treatment and the natural rate of
res-olution of this condition.
The Gufoni maneuver is another techniquethat has been reported
as effective in treating hor-izontal canal BPPVe3 (figure e-3, A
and B). Severalstudies, all Class IV, have reported success
usingthis or a similar maneuver for horizontal canalBPPV for both
the geotropic and apogeotropicnystagmus forms.32,33,38,e4
Similarly, the Vannuc-chiAsprella liberatory maneuver may be
effec-tive, but there is only limited Class IV datasupporting its
use.38,e5,e6 Casani et al.32 and Appianiet al.33 review other
techniques used with success inthe treatment of both the geotropic
and apogeotro-pic forms of horizontal canal BPPV.
Another treatment reported as effective30,32,36,e2,e7
is referred to as forced prolonged positioning. Withthis method,
the patient lies down laterally to theaffected side, and the head
is then turned 45 degreestoward the ground and maintained in that
positionfor 12 hours before the patient is returned to thestarting
position. Some authors advocate this tech-nique for refractory
horizontal canal BPPV.32,e3 Us-ing this approach, one Class IV
study reportedremission rates of 75% to 90%.32
Anterior canal BPPV. Anterior canal BPPV is usu-ally transitory
and most often is the result of ca-nal switch that occurs in the
course of treatingother more common forms of BPPV.21
We identified only two studies specifically ad-dressing the
treatment of anterior canal BPPV;both were Class IV studies.e8,e9
Success rates werebetween 92% and 97%, though there were nocontrols
to determine whether this represents animprovement over the natural
history of this fre-quently self-resolving form of BPPV.
Conclusion. Based on Class IV studies, variationsof the Lempert
supine roll maneuver, the Gufonimethod, or forced prolonged
positioning seemmod-erately effective for horizontal canal
BPPV.Twoun-controlled Class IV studies report high responserates to
maneuvers for anterior canal BPPV.
Recommendation: None (Level U).
Question 3: Are postmaneuver activity restrictionsnecessary
after canalith repositioning procedure? Inone Class I study2 and
one Class II4 study demon-strating the benefit of CRP, patients
wore a cervi-cal collar for 48 hours and avoided sleeping on
the
Figure 4 Supine roll test (PagniniMcClure maneuver) to detect
horizontal canalbenign paroxysmal positional vertigo (BPPV)
The patient may be taken from sitting to straight supine
position (1). The head is turned to theright side (2) with
observation of nystagmus and then turned back to face up (1). Then
thehead is turned to the left side (3). The side with the most
prominent nystagmus is taken to bethe affected horizontal
semicircular canal. The direction of nystagmus in each position
deter-mines whether the horizontal canal BPPV is of the geotropic
or apogeotropic type.
Figure 5 Lempert roll maneuver for right-sided horizontal canal
benignparoxysmal positional vertigo (BPPV)
When it is determined to be horizontal canal BPPV affecting the
right side, the patient is takenthrough a series of step-wise
90-degree turns away from the affected side in Steps 1through 5,
holding each position for 10 to 30 seconds. From Step 5, the
patient positions hisor her body to the back (6) in preparation for
the rapid and simultaneous movement from thesupine face up to the
sitting position (7).
Neurology 70 May 27, 2008 (Part 1 of 2) 2071
-
affected side for 1 week. One Class I study3 andtwo Class II
studies5,6 that demonstrated the ben-efit of CRP used no
post-treatment restrictions orinstructions. These studies were not
designed todetermine whether such restrictions affect treat-ment
success; however, there seems to be little dif-ference in the rate
of treatment success whether ornot restrictions were included.
Six Class IV studies comparing CRP with andwithout
post-treatment activity restriction wereidentified.23,e10-e14 Five
studies23,e10-e13 showed noadded benefit from post-treatment
activity re-striction or positions. Only one study showed aminimal
benefit in patients with post-activity re-strictions, as measured
by the number of maneu-vers required to produce a negative
DixHallpikemaneuver.e14
Conclusion and recommendation. Five Class IVstudies support the
omission of post-treatmentactivity restrictions; one study supports
the use ofpost-treatment restrictions. There is
insufficientevidence to determine the efficacy of post-maneuver
restrictions in patients treated withCRP (Level U).
Question 4: Is it necessary to include mastoid vibrationwith
repositioning maneuvers? Mastoid vibrationwas included in the
original Epley repositioningmaneuver. One Class II study,e15
comparing pa-tients with posterior canal BPPV treated by
ap-propriate canalith repositioning maneuvers,performed with and
without vibration, showedno difference in immediate symptom
resolutionor relapse rate between groups.
A Class III studye16 compared patients treatedby CRP with and
without mastoid vibration.There was no difference in symptom relief
be-tween the groups at 4 to 6 weeks (p 0.68).
Two Class IV studiese17,e18 showed no differ-ence in the rate of
symptom resolution betweenpatients treated by a CRP with or without
mas-toid vibration. A third Class IV study9 reportedthat of
patients treated by a CRP with vibration,92% were improved, vs 60%
improvementwith CRP alone.
Conclusion and recommendation.OneClass II, oneClass III, and two
Class IV studies showed noadded benefit when mastoid vibration was
addedto a CRP as treatment for posterior canal BPPV.Mastoid
oscillation is probably of no added bene-fit to patients treated
with CRP for posterior ca-nal BPPV (Level C recommendation).
Question 5: What is the efficacy of BrandtDaroffexercises,
habituation exercises, or patient self-administered treatments for
BPPV? A Class II studythat randomized patients to a CRP, a
liberatory
maneuver, BrandtDaroff exercises, habituationexercises, or a
sham treatment found that patientstreatedwith habituation exercises
did no better thanthose treated with a sham procedure.6
Patientstreated with BrandtDaroff exercises did worsethan those
treated with CRP or liberatory maneu-vers but were not compared
with sham-treatedpatients.
A Class IV study24 compared BrandtDaroffexercises, performed
three times daily, with theSemont maneuver or CRP. Patients treated
withmaneuvers were pretreated with diazepam andgiven postmaneuver
activity restrictions; patientstreated with BrandtDaroff exercises
were not.Compliance with the exercises was not recorded.At 1-week
follow-up, 24% of patients treatedwith BrandtDaroff exercises were
symptom free,vs 74% of those treated with the Semont maneu-ver or
CRP. Given the limitations of the study, itsvalidity is
questionable.
Three Class IV studies investigated the effi-cacy of
patient-administered treatment forBPPV using various techniques.
One studyfound 88% improvement of BPPV when treatedwith CRP and
home CRP compared with 69%improvement in those only treated with
CRPonce.e19 Another study reported improved reso-lution of
nystagmus among patients that self-administered CRP (64% recovery)
vs self-administered BrandtDaroff exercises (23%).e20
The third study found that 95% had resolutionof positional
nystagmus 1 week after self-treatment with CRP vs 58% of
self-treatmentwith a modified Semont maneuver.e21
Conclusion and recommendation. One Class II andone Class IV
study suggest that BrandtDaroffexercises or habituation exercises
are less effectivethan CRP in the treatment of posterior canalBPPV.
Self-administered BrandtDaroff exercisesor habituation exercises
are less effective thanCRP in the treatment of posterior canal
BPPV(Level C). There is insufficient evidence to recom-mend or
refute self-treatment using Semont ma-neuver or CRP for BPPV (Level
U).
Question 6: What is the efficacy of medication treat-ments for
BPPV? One Class III studye22 found nodifference between lorazepam,
1 mg three timesdaily; diazepam, 5 mg three times daily; or
pla-cebo over the 4-week study period. Another ClassIII study21
found that flunarizine was more effec-tive than no treatment but
less effective than Se-mont maneuver in eliminating symptoms.
Thereare no randomized controlled trials of meclizine
2072 Neurology 70 May 27, 2008 (Part 1 of 2)
-
or other drugs used for motion sickness in thetreatment of
BPPV.
Conclusion and recommendation. A single Class IIIstudy did not
demonstrate that lorazepam or di-azepam hastened resolution of
symptoms inBPPV. A single Class III study demonstrated somebenefit
of flunarizine, a drug that is unavailable inthe United States, in
BPPV. There is no evidenceto support a recommendation of any
medicationin the routine treatment for BPPV (Level U).
Question 7: What are the safety and efficacy of sur-gical
treatments for posterior canal BPPV? All stud-ies of surgical
treatment for refractory BPPV areClass IV. The most common
procedure is fenes-tration and occlusion of the posterior
semicircu-lar canal. Five studies, e23-e27 with a total of
86patients undergoing canal occlusion, reportedcomplete relief of
BPPV symptoms in 85, as as-certained by the treating surgeon.
Reported com-plications included a mild conductive hearingloss for
4 weeks or less, mild and transientunsteadiness in most patients,
and a high fre-quency sensorineural hearing loss in 6 patients.
In a Class IV study of singular neurectomyas a treatment for
intractable BPPV,e28 96.8%were reported to have complete relief;
severesensorineural hearing loss occurred in 3.7% ofpatients.
Conclusion and recommendation. Six unblinded,retrospective Class
IV studies report relief fromsymptoms of BPPV in nearly every
patient under-going posterior semicircular canal occlusion
orsingular neurectomy. Because the studies areClass IV, they do not
provide sufficient evidenceto recommend or refute posterior
semicircular ca-nal occlusion or singular neurectomy as
treatmentfor BPPV (Level U).
RECOMMENDATIONS FOR FUTURE RE-SEARCH Class I studies are needed
to clarify thebest treatments for horizontal canal BPPV.
Futurestudies on these topics should adhere to theConsolidated
Standards of Reporting Trials(CONSORT) criteria using validated,
clinicallyrelevant outcomes.
PROGNOSIS AND RECURRENCE RATE The re-lapse rate and second
recurrence rate of BPPV arenot fully established. Short-term
relapse rates rangefrom 7% to nearly 23% within a year of
treatment,but long-term recurrences may approach 50%, de-pending on
the age of the patient. e29-e32
DISCLOSUREThe authors report the following disclosures: Dr. Fife
hasreceived research support from GlaxoSmithKline and esti-
mates that 6% of his time is spent on canalith
repositioningprocedures. Dr. Iverson has nothing to disclose. Dr.
Lempertestimates that 5% of his time is spent on videooculogra-phy.
Dr. Furman holds stock options in Neurokinetics, hasreceived
research support from Merck, has served as an ex-pert witness on
vestibular function, and estimates that 1% ofhis time is spent on
the Epley maneuver. Dr. Baloh estimates5% of his time is spent on
ENG. Dr. Tusa estimates that 5%of his time is spent on quantified
positional testing. Dr. Hainestimates that 5% of his time is spent
on ENG and 5% onVEMP. Dr. Herdman received research support
fromVAMC and served as an expert witness on the
Hallpike-Dixmaneuver. Dr. Morrow has received honoraria from
Bio-genIdec and has served as an expert witness and consultanton
medico-legal proceedings. Dr. Gronseth has receivedspeaker
honoraria from Pfizer, GlaxoSmithKline, andBoehringer Ingelheim and
served on the IDMC Committeeof Ortho-McNeil.
DISCLAIMERThis statement is provided as an educational service
of theAmerican Academy of Neurology. It is based on an assess-ment
of current scientific and clinical information. It isnot intended
to include all possible proper methods ofcare for a particular
neurologic problem or all legitimatecriteria for choosing to use a
specific procedure. Neither isit intended to exclude any reasonable
alternative method-ologies. The American Academy of Neurology
recognizesthat specific patient care decisions are the prerogative
ofthe patient and the physician caring for the patient, basedon all
of the circumstances involved.
Received August 1, 2007. Accepted in final form February23,
2008.
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DOI 10.1212/01.wnl.0000313378.77444.ac 2008;70;2067Neurology
T. D. Fife, D. J. Iverson, T. Lempert, et al.American Academy of
Neurology
evidence-based review) : Report of the Quality Standards
Subcommittee of the Practice Parameter: Therapies for benign
paroxysmal positional vertigo (an
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