Effect of self-treatment of recurrent benign paroxysmal positional vertigo: a randomized clinical trial
Kim H-J, Kim J-S, Choi K-D, et al. JAMA Neurol. 2023;80(3):244-250.
SUMMARY:
Dizziness/vertigo is the third most common reason for an ED visit, and benign paroxysmal positional vertigo (BPPV) is the most common cause identified. BPPV is caused by a dislodged otolith in the semicircular canals, which leads to a false sense of rotation. Canalith repositioning maneuvers are highly effective and can be used to resolve symptoms in most cases. However, accurately identifying the affected canal is essential to ensure that the correct positions are used. Importantly, even after repositioning, approximately 1 in 5 patients have recurrence of symptoms.
In this study, the authors assessed the value of a website called “Stop! BPPV” to confirm the diagnosis, identify the canal involved, and suggest a repositing technique for patients with recurrent BPPV.
The authors previously tested a 6-item questionnaire to make the diagnosis of vertigo and identify the canal affected. The abbreviated items are: 1. Do you feel spinning? 2. Do you feel dizzy mostly when your head is moved? 3. Does the dizziness last <3 minutes? 4. Which position makes you feel more dizzy? 5. Is the dizziness worse when turning to the right or left? 6. How long does the dizziness last?
This was a multicenter, randomized, double-blind trial from 4 medical centers in South Korea enrolling patients older than 20 years with BPPV diagnosed via standardized criteria during an in-person visit, who experienced symptom resolution with repositioning. Patients with multicanal (bilateral) BPPV, those with physical limitations preventing repositioning techniques (eg, spinal issues), and those without access to a smartphone or computer were excluded. The intervention group was asked to visit the website and follow instructions if they had recurrence, and the control group was given access to a video clip describing how to perform the specific maneuver used in the index visit. The effectiveness of their self-repositioning efforts was assessed 1 to 3 days after the attempt via telephone by a blinded assessor.
Of 728 patients assessed for enrollment, 143 were excluded, primarily because of an inability to access the internet, thus leaving 585 for randomization. The median age was approximately 60 years, two-thirds were women, and more than two-thirds had the posterior canal affected. Of note, the Epley maneuver is used for repositioning when the posterior or anterior canal is affected; the maneuvers for horizontal canal otolith dislodgement are called the barbecue and Gufoni maneuvers.
Overall, 128 (21.9%) patients experienced recurrence (58 in the treatment group and 70 in the control group) within 6 months of the index visit. Of these, in the intention-to-treat analysis, 42 of 58 patients (72.4%) in the treatment group and 30 of 70 patients (42.9%) in the control group reported vertigo resolution after interaction with the web-based system.
In terms of technical feasibility, most patients rated the website as easy to use, and 80.7% were able to navigate it themselves, whereas 19.3% required assistance from a family member or caregiver. The patients who needed assistance were significantly older than those who did not.
Although the authors do not provide data on the percentage of patients in the intervention arm for whom the location of otolith dislodgement diagnosed by the website differed from the location identified in the index visit, they do cite other studies suggesting that the same canal is affected in only approximately one-quarter to one-third of cases of recurrence.
The main limitations of this study are that the findings are applicable only to patients who already have a confirmed diagnosis of BPPV, and who can access the internet via a smartphone or computer; all outcomes were self-reported, and the reporting might possibly have differed across groups; the frequency of repeat and return visits was not assessed; and whether the results might have been similar if all techniques had been taught, and patients had been told to run through all techniques until one is successful, is unknown.
EDITOR’S COMMENTARY: In this interesting randomized trial, the authors found that among patients with recurrence of confirmed BPPV, use of a website designed to locate the dislodged otolith and suggest the correct maneuver to move it back was much more effective in resolving symptoms than having patients repeat the same maneuver used to correct the problem in the index visit. There is a lot to learn from this article, including that repositioning in BPPV is highly effective, there are more techniques than just the Epley maneuver, recurrence of symptoms is common, recurrence is unlikely to affect the same canal that was previously affected, and clinicians and researchers are actively using technology-based solutions to solve common medical problems. If you don’t currently use repositioning when treating patients with BPPV, it’s time to start.
I Just tried looking for Stop!BPPV on the web and can't find it. I wonder if it is only available in South Korea. Also, as an aside, I learned next to nothing about BPPV in residency. Basically I'd convince myself that there was no central cause and give meclizine. Imagine my surprise when I came across the videos from a certain Canadian EP extolling the virtues of BPPV treatment in the ED. Once I could recognize it I began to find it everywhere (as you mentioned, it's the most common cause of dizziness that we see). It actually became kinda fun to perform the Epley's. It takes about 5 minutes total from Dix-Hallpike to completion of the maneuver. In a busy ED this may be too much time to take. Give it a try sometime and you may well become addicted as I have. I view it as the nursemaid's elbow of the nervous system. It's fun and satisfying to effect a cure using your own two hands (although I don't give popsicles to my BPPVV patients). People go from being miserable and probably a bit scared to upright and ready to go in minutes.
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John S., M.D. - May 4, 2023 12:34 PM
I Just tried looking for Stop!BPPV on the web and can't find it. I wonder if it is only available in South Korea. Also, as an aside, I learned next to nothing about BPPV in residency. Basically I'd convince myself that there was no central cause and give meclizine. Imagine my surprise when I came across the videos from a certain Canadian EP extolling the virtues of BPPV treatment in the ED. Once I could recognize it I began to find it everywhere (as you mentioned, it's the most common cause of dizziness that we see). It actually became kinda fun to perform the Epley's. It takes about 5 minutes total from Dix-Hallpike to completion of the maneuver. In a busy ED this may be too much time to take. Give it a try sometime and you may well become addicted as I have. I view it as the nursemaid's elbow of the nervous system. It's fun and satisfying to effect a cure using your own two hands (although I don't give popsicles to my BPPVV patients). People go from being miserable and probably a bit scared to upright and ready to go in minutes.