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Abstract

Background Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo.

Purpose The purpose of this systematic review was to determine whether patients diagnosed with posterior canal (PC) BPPV, based on positional testing, and treated with a particle repositioning maneuver will show the resolution of benign paroxysmal positional nystagmus (BPPN) on the Dix-Hallpike Test performed 24 hours or more after treatment.

Data Sources Data were obtained from an electronic search of the MEDLINE, EMBASE, and CINAHL databases from 1966 through September 2009.

Study Selection The study topics were randomized controlled trials (RCTs), quasi-RCTs, the diagnosis of PC BPPV, treatment with the particle repositioning maneuver, and outcome measured with a positional test 24 hours or more after treatment.

Data Extraction Data extracted were study descriptors and the information used to code for effect size.

Data Synthesis In 2 double-blind RCTs, the odds in favor of the resolution of BPPN were 22 times (95% confidence interval=3.41–141.73) and 37 times (95% confidence interval=8.75–159.22) higher in people receiving the canalith repositioning procedure (CRP) than in people receiving a sham treatment. This finding was supported by the results reported in 8 nonmasked quasi-RCTs. Studies with limited methodological quality suggested that a liberatory maneuver (LM) was more effective than a control intervention; there was no significant difference in the effectiveness of the LM and the effectiveness of the CRP; the self-administered CRP was more effective than the self-administered LM; and the CRP administered together with the self-administered CRP was more effective than the CRP administered alone. The Brandt-Daroff exercises were the least effective self-administered treatments.

Limitations The limitations included the methodological quality of the studies, the lack of quality-of-life measures, and confounding factors in reporting vertigo.

Conclusions Randomized controlled trials provided strong evidence that the CRP resolves PC BPPN, and quasi-RCTs suggested that the CRP or the LM performed by a clinician or with proper instruction at home by the patient resolves PC BPPN. There were no data on the effects of the maneuvers on outcomes relevant to patients.

Benign paroxysmal positional vertigo (BPPV) is characterized by brief periods of vertigo triggered by a change in the position of a person's head relative to gravity. In the general population, the lifetime prevalence of BPPV is 2.4%, and the 1-year incidence is 0.6%.1 It is the most common vestibular disorder, accounting for one third of vestibular diagnoses in the general population.1 Benign paroxysmal positional vertigo can affect the quality of life of elderly patients and is associated with reduced activities of daily living, falls, and depression.2 Patients with BPPV experience delays in diagnosis and treatment, the mean delay being 92 weeks, and they frequently are inappropriately treated with vestibular suppressant medications.3

Benign paroxysmal positional vertigo is caused by abnormal mechanical stimulation of 1 or more of the 3 semicircular canals within the inner ear (Fig. 1). The fluid-filled canals normally act to detect rotation of the head through the deflection of sensory hair cells embedded within a gelatinous membrane, the cupula. The weighted sensory membrane of the maculae normally acts to detect gravitational forces on the head. In BPPV, calcite particles (otoconia), which normally weight this membrane, become dislodged and sediment in the canals, changing the dynamics of the canals. There are 2 primary theories for the mechanism of BPPV. The first is cupulolithiasis,4 in which the dislodged otoconia directly attach to the cupula, weighting this membrane. Reorientation of the canal relative to gravity deflects the cupula, exciting or inhibiting the ampullary organ. The second is canalithiasis,5 in which the otoconia freely sediment in the canals. Reorientation of the canals causes the otoconia to move to the lowest part of the canals, creating a drag on the endolymph, resulting in fluid pressure on the cupula, and activating the ampullary organ.

Figure 1.

Mechanisms of benign paroxysmal positional vertigo. Reprinted with permission from American Dizziness and Balance. Copyright 2007.

The Dix-Hallpike maneuver,6 referred to as the Dix-Hallpike Test (DHT) in this article, is the standard from which the diagnosis of posterior canal (PC) BPPV is made and differentiated from other conditions.7,8 The diagnostic criteria for PC BPPV are vertigo associated with characteristic ocular nystagmus that is torsional (toward the dependent ear) and directed upward, consistent with the excitation of the ampullary organ of the PC9; a 1- to 40-second latency before the onset of vertigo and nystagmus1012; and vertigo and nystagmus with a duration of less than 60 seconds.13 With repeated positioning, PC BPPV temporarily becomes less intense and disappears.13 For the DHT, the estimated sensitivity and specificity are 79% (95% confidence interval [CI]=65–94) and 75% (CI=33–100), respectively.14 The interrater reliability for interpreting the direction of eye movement ranges from a mean percentage of agreement of 43% (fair) to a mean percentage of agreement of 81% (substantial), depending on the level of expertise.15

Treatment of BPPV

Once the involved canal is identified, BPPV often is treated with particle repositioning maneuvers. These maneuvers move otoconia out of the affected canal and back into the vestibule, where it is thought that the particles dissolve.16,17

Historically, the first maneuvers used for BPPV were the Brandt-Daroff exercises,10 which were designed to habituate symptoms. The patient repeatedly moved from sitting at the edge of the bed to lying on the side (side lying) with the head rotated 45 degrees toward the ceiling. The patient alternated between left side lying and right side lying.

The canalith repositioning procedure (CRP), developed by Epley18 (Fig. 2A), was designed to use gravity to treat canalithiasis of the PC. The clinician moves the patient through a series of 4 positions. With each position, the otoconia settle to the lowest part of the canal, move around the arc of the PC, and finally deposit in the vestibule. This procedure requires a 180-degree turn of the head1921 and a return to a sitting position from lying on the uninvolved side.21 To enable the otoconia to settle, each position is maintained for at least 30 seconds.20 Vibration applied to the mastoid process of the involved side does not affect the outcome of the procedure and is no longer considered necessary.2224

Figure 2.

Particle repositioning maneuvers. (A) Canalith repositioning procedure illustrated for treatment of the right posterior canal. The clinician moves the patient through a series of 4 positions, starting with the placement of the involved canal in the head-hanging position of the Dix-Hallpike Test. To begin, the patient is positioned in the long sitting position (sitting on the treatment table with the legs extended). The patient's head is rotated 45 degrees toward the right. The patient is then lowered into the supine position with the neck extended 20 degrees over the edge of the treatment table; this is the head-hanging position. The head is rotated through 90 degrees of motion, ending in 45 degrees of neck rotation toward the uninvolved side. This step is followed by rolling onto the uninvolved side while maintaining the head-on-trunk position and, finally, sitting up from lying on the uninvolved side. Each position is maintained for a minimum of 30 seconds or as long as the nystagmus lasts. The procedure is repeated 3 times. (B) Liberatory (Semont) maneuver illustrated for treatment of the right posterior canal. The patient sits on the edge of the treatment table. The clinician rapidly moves the patient to lying on the involved side with the head rotated 45 degrees toward the uninvolved side. While maintaining the head-on-trunk position, the clinician swings the patient from lying on the involved side to lying on the uninvolved side. The head then is gently tapped on the treatment table. Each position is maintained for 1.5 minutes. The procedure is repeated 3 times. Reprinted with permission from American Dizziness and Balance. Copyright 2007.

The liberatory maneuver, developed by Semont et al25 (Fig. 2B), was designed to use inertia and gravity to treat cupulolithiasis of the PC. To evacuate the particles, the patient is rapidly swung from lying on the involved side to lying on the uninvolved side through a 180-degree cartwheel motion with a duration of less than 1.3 seconds.19

Both the CRP and the liberatory maneuver have been modified to enable a patient to self-treat. With the self-administered CRP,26,27 the patient moves through the same positions as in the CRP, except that the head is extended over the edge of a pillow. With the self-administered liberatory maneuver,27 the patient performs the maneuver independently, with no other modifications. Both exercises are stopped when the patient has been vertigo free for at least 24 hours.26,27

The role of activity restrictions in the outcome of particle repositioning maneuvers remains uncertain. Postmaneuver activity restrictions did not improve the efficacy of treatment with the CRP28,29 or the liberatory maneuver,28 but patients with no activity restrictions required 1 or 2 more treatment sessions to achieve a successful outcome.30

The DHT is critical for determining the outcome of particle repositioning maneuvers.7,31 The absence of the characteristic nystagmus indicates the resolution of PC BPPV.32 The patient's report of vertigo is more variable than the observation of the characteristic nystagmus on positional testing. Patients showing the resolution of positional nystagmus on the DHT may report vertigo if concurrent vestibular deficits exist.33 Patients with positive findings on the DHT may report no vertigo at the time of follow-up if provoking positions are avoided or if they have unrecognized BPPV (imbalance with no vertigo).2 Because of these confounding factors, the patient's report of vertigo should not be the only outcome measure.

The time interval between treatment and outcome assessment is critical. To separate the effects of active treatment from a fatigue response, outcome should be assessed 24 hours or more after treatment.32 Repeated positioning may cause a fatigue response that can mimic successful treatment.32 Within 7 days of PC BPPV symptom onset, 30% of patients will experience spontaneous remission.34 To minimize the possibility of spontaneous remission causing a false-negative particle repositioning maneuver outcome and to avoid a fatigue response, outcome ideally should be assessed 24 hours after treatment.

Patients with BPPV experience a decrease in health-related quality of life, which is restored after successful remission of BPPV following treatment with a particle repositioning maneuver.35 However, health-related quality-of-life measures are not routinely used in treatment outcome studies.

A published overview of the Cochrane Collaboration (search dates: 1966–2004)36 and 2 meta-analyses37,38 evaluated the effectiveness of the CRP in the treatment of BPPV but did not evaluate other maneuvers. Two recently published practice guidelines7,8 evaluated the effectiveness of the CRP, the liberatory maneuver, and the self-administered variants. These publications included assessments of the methodological quality of the studies evaluated. A rigorous qualitative synthesis needs to include an evaluation not only of the methodological quality but also of the precise performance of the intervention and the validity, reliability, and responsiveness of the tests used in the studies.39

The purpose of this systematic review was to determine whether patients diagnosed with PC BPPV on positional testing and treated with a particle repositioning maneuver will show the resolution of benign paroxysmal positional nystagmus (BPPN) on the DHT performed 24 hours or more after treatment. A synthesis of methodological quality was performed. The standards of methodological quality for this systematic review were randomization,40 allocation concealment,41,42 masking,43 and sample size calculation.44 The CRP, the liberatory maneuver, and the self-administered variants were evaluated. The inclusion and exclusion criteria were based on the findings of the proposed mathematical models of the treatment of BPPV1921 with the particle repositioning maneuvers to take into account the quality of the performance of the intervention and were based on the performance of the DHT as an outcome measure to take into account the validity and reliability of the outcome. The responsiveness of the DHT has not been reported in the literature.

Method

Data Sources and Searches

An electronic literature search of the MEDLINE, EMBASE, and CINAHL databases for the period from 1966 through September 2009 was conducted with the medical subject heading term “vertigo.” In MEDLINE, to refine the search, the medical subject heading was combined with an “or” statement including “benign paroxysmal positional vertigo, BPPV, BPV, benign paroxysmal positional nystagmus, BPPN, or BPN.” The search was restricted to English (possibly introducing publication bias). In CINAHL, the search was replicated with the same terms. In EMBASE, because of more specific indexing, the search was performed with the medical subject heading “vertigo” and the subheadings “BPPV” and “therapy.” A published overview of the Cochrane Collaboration (search dates: 1966–2004),36 2 meta-analyses37,38 of the treatment of PC BPPV, and 2 practice guidelines7,8 were also reviewed. Bibliographies of the identified articles were manually searched for any additional relevant articles. The results of the searches were compared, and duplicates were removed (Fig. 3).

Figure 3.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement flow diagram of the literature search.

Study Selection

Published studies that reported on the effectiveness of particle repositioning maneuvers in the treatment of PC BPPV were eligible for inclusion. The inclusion criteria (Tab. 1) were as follows:

  1. The study design was a randomized controlled trial (RCT) or quasi-RCT.

  2. Participants had a clinical diagnosis of unilateral typical BPPV (PC involvement) on the basis of the findings on the DHT.7,8

  3. A manual particle repositioning maneuver was performed. If the CRP was used, it included all 4 positions described originally by Epley18 to optimize the removal of loose otoconia from the PC.1921 For the best outcome, simulated models of the CRP suggested from the initial head-hanging position a full 180-degree turn of the head toward the uninvolved side and a return to the upright position from the uninvolved side.1921 Acceptable modifications to the original CRP included self-administration,26,27,45 performance of the procedure without the use of vibration,2224 no activity restrictions after the procedure,2830 and no premedication to avoid nausea.

  4. The successful outcome of a particle repositioning maneuver was defined as the conversion of a positive DHT result to a negative DHT result or side-lying test result33 24 hours or more after the initial treatment procedure to avoid the fatiguing response32 but less than 1 month later to separate the effects of active treatment from natural history.34

  5. The proportion of participants who showed conversion from nystagmus to no nystagmus on the DHT at the time of follow-up was reported.

View this table:
Table 1.

Inclusion and Exclusion Criteriaa

The exclusion criteria (Tab. 1) were as follows:

  1. The study was a cohort study, a retrospective study, a case-control study, or a case study.

  2. No inclusion criteria were described.

  3. Participants had a clinical diagnosis of atypical BPPV (lateral canal or anterior canal involvement), bilateral PC BPPV due to confounding variables,46 or central vestibular deficit.

  4. The head positions of the CRP originally described by Epley18 were modified. The CRP was performed with less than 180 degrees of head rotation from the initial head-hanging position and a return to the upright position from the involved side.1921

  5. The successful outcome of a particle repositioning maneuver was defined only as the resolution of vertigo.

  6. A successful outcome was assessed less than 24 hours after treatment.

  7. The proportion of participants who showed successful conversion from nystagmus to no nystagmus on the DHT at the time of follow-up was not documented.

Data Extraction and Quality Assessment

Abstracts were screened. If the study was an RCT or a quasi-RCT and the study population was diagnosed with PC BPPV, then the article was obtained and reviewed by 2 reviewers (J.O.H. and D.S.Z.). When discrepancies occurred, the reasons were identified, and a final decision was made on the basis of the unanimous agreement of the authors (J.O.H., D.S.Z., and T.C.H.). The studies were stratified according to the particle repositioning maneuver.

The methodological quality standards for this systematic review were randomization,40 allocation concealment,41,42 masking,43 and sample size calculation.44 Lack of randomization, allocation concealment, or masking could change the treatment effects, resulting in study selection and confounding biases. Lack of calculation of the sample size could result in a greater risk of a type II error.44

Data were extracted, and a data form was completed to evaluate the methodological quality and quality of the interventions, tests, and outcomes of each study. The data collection form consisted of items compiled from a combination of instruments.39,47,48 Information was obtained on the setting, study design, patient selection process, masking, intervention, outcomes, and statistics to evaluate the components of internal validity (selection bias, performance bias, detection bias, and attrition bias) and external validity (patients, intervention, setting, and outcomes) for potential bias. In addition, we compiled the following variables: patient report and quantitative outcomes on positional testing at short-term follow-up (first follow-up session) and long-term follow-up (if multiple follow-up sessions, last session), complications, and postprocedure instructions. When studies used repeated follow-up periods, the shortest time between 1 and 30 days to follow-up was used to allow for the strongest association between treatment and outcome. Studies that met the inclusion criteria were stratified according to the study design and intervention.

Data Synthesis and Analysis

To assess the outcome of each study, the effect size was calculated. The successful outcome of a particle repositioning maneuver was defined as the conversion of a positive positional test to a negative positional test (no BPPN). The patient's report of vertigo was not qualitatively analyzed. Two-by-two contingency tables were used to organize the outcome data. The odds ratio (OR) and the 95% CI were calculated to determine the odds of a successful outcome or a negative positional test. The OR measures the association between treatment and outcome. For quasi-RCTs comparing active treatments, the OR was calculated with the standard treatment (control) as the CRP. The CRP was selected as the standard of treatment because the 2 RCTs supported its effectiveness.32,33 Only trials in which randomized treatment assignments and a clearly defined control group were used were considered for inclusion in a meta-analysis. Because only 2 such trials existed, a meta-analysis was not performed. We included quasi-RCTs and nonmasked trials in the systematic review. We acknowledge that these studies may be biased and may overestimate treatment efficacy.

Statistical analysis of the data was performed with SAS/STAT (version 9.1).* All tests of significance were performed at an α level of .05.

Results

Initially, 868 records were identified through an electronic database search (Fig. 3). From these records, 24 full-text articles were assessed for eligibility on the basis of their titles and abstracts. After complete articles were read, only 10 articles met the inclusion criteria,27,28,32,33,45,4953 and 14 met the exclusion criteria.26,5466 The main reasons for exclusion were study design, inclusion criteria (no inclusion criteria discussed or bilateral PC BPPV included), modifications to the head position used in the CRP, outcome not measured with a positional test, outcome assessed less than 24 hours or more than 1 month after treatment, and inadequate statistics (Tab. 1).

Of the 10 articles included in the qualitative synthesis, 2 studies used sealed envelopes with a computer-generated randomization code32 or a block randomization scheme (numbered, sealed envelopes containing treatment group assignments, prepared before the start of the study)33 to randomly allocate their participants to groups. Two studies quasi-randomly allocated their participants to groups on the basis of the date of their first visit.51,52 Six studies stated that participants were randomly allocated to groups but did not describe the method of randomization.27,28,45,49,50,53 Masking of participants and outcome occurred in 3 studies.32,33,49 None of the studies reported calculation of the sample size.27,28,32,33,45,4953 Attrition was described but was not included in statistical calculations in 8 studies (intention-to-treat analysis)27,28,32,33,45,49,52,53 and was not addressed in the remaining 2 articles.50,51 A summary of the items included to assess the methodological quality of the studies is provided in Table 2.

View this table:
Table 2.

Summary of Methodological Qualitya

Two RCTs32,33 and 2 quasi-RCTs49,52 compared the effectiveness of the CRP without vibration and the effectiveness of a sham treatment.32,33,49,52 At short-term follow-up, the success rates for patients treated with the CRP were 67% to 95%,32,33,49,52 those obtained with the sham treatment were 10% to 38%,32,33,49,52 and that obtained with the control was 60%.52 The magnitude of the effect of the CRP compared with that of the sham treatment was significant in all 4 studies.32,33,49,52 Because of the small sample sizes and the wide confidence intervals, homogeneity could not be determined. The odds in favor of symptom resolution in the RCTs were 22 to 37 times higher in people receiving the CRP32,33 and were more variable in the quasi-RCTs (3–25 times higher).49,52

Two quasi-RCTs compared the liberatory maneuver and no treatment (control).50,51 At short-term follow-up, the success rates for patients treated with the liberatory maneuver were 80% to 85%, whereas spontaneous resolution in the control group was 35% to 38%. The odds in favor of symptom resolution were 7 to 10 times higher in patients receiving the liberatory maneuver than in the control group (Tab. 3). There may have been overlap of participants in these 2 studies because the data were collected over the same time periods by the same authors.50,51

Table 3.

Information Used to Code for Effect Size

Two quasi-RCTs compared the CRP and the liberatory maneuver.28,53 At short-term follow-up, the success rates were 71% to 93% for the CRP and 74% to 92% for the liberatory maneuver. To calculate the OR, the CRP was selected as the standard of treatment. The odds in favor of symptom resolution were 0.80 and 1.16 higher in participants using the CRP, and the 95% CIs included 1, suggesting no significant difference in effectiveness between the liberatory maneuver and the CRP.

Three quasi-RCTs reported the results of self-administered maneuvers27,45,53 (Tab. 3). All of these studies compared 2 or more maneuvers. At 1 week, the success rates were 90% to 95% for the self-administered CRP or the CRP administered together with the self-administered CRP,27,45 58% for the self-administered liberatory maneuver,27 and 24% for the Brandt-Daroff exercises.53 The low success rate for the Brandt-Daroff exercises in those studies was contrary to the high success rate (98%) originally described in a 2-week, nonrandomized trial with longer treatment durations.10 To calculate the OR, the CRP was selected as the standard of treatment. If CRP was not performed, then the self-administered CRP was selected. The odds in favor of symptom resolution were only 0.13 times higher in participants using the Brandt-Daroff exercises (OR=0.13, 95% CI=0.04–0.38) and 0.08 times higher in participants using the self-administered liberatory maneuver (OR=0.08, 95% CI=0.02–0.38) (Tab. 3). The odds in favor of symptom resolution were 3.54 times higher (95% CI=1.02–12.30) with the CRP plus the self-administered CRP than with the CRP alone (Tab. 3), suggesting better outcomes with the performance of a combination of the CRP plus the self-administered CRP.

Two RCTs32,33 comparing the effectiveness of the CRP without vibration and the effectiveness of a sham treatment were eligible for quantitative synthesis. Because of the limited number of studies, a meta-analysis was not performed.

Discussion

This systematic review evaluated the effectiveness of several particle repositioning maneuvers, namely, the CRP, the liberatory maneuver, and the self-administered variants, in the treatment of PC BPPV. The present systematic review is a qualitative synthesis of methodological quality. Our inclusion and exclusion criteria took into account the quality of the performance of the intervention and the appropriateness of the tests and measures used.

Our inclusion and exclusion criteria were based on the findings of the proposed mathematical models for the treatment of BPPV1921 with the particle repositioning maneuvers. We excluded studies that included participants with bilateral BPPV to avoid confounding variables.56,64,65 We did not rate the methodological quality of the articles but provided a description of the quality because not all of the qualitative scales addressed the quality of the physical therapy interventions and the validity, reliability, and responsiveness of the outcomes used.39

Our results agree with those of earlier reviews7,8,3638—that the CRP is more effective than a control in the treatment of PC BPPV. On the basis of our inclusion and exclusion criteria, only 2 studies32,33 met the criteria for quantitative synthesis; therefore, a meta-analysis was not performed. The greater variability in the quasi-RCTs may have been due to the clinical expertise of the study personnel49 or to a difference in the patient populations. Professionals were trained to evaluate ocular nystagmus during positional testing.49 The interrater reliability for interpreting the direction of eye movement varied depending on the level of expertise.15 The low OR may reflect the lack of experience of the trained professionals in evaluating eye movements and may support the need for experienced professionals to treat BPPV to minimize delays in treatment and reduce health care costs.

The liberatory maneuver was effective in the treatment of PC BPPV, and the quasi-RCTs found that the liberatory maneuver was as effective as the CRP. However, RCTs need to be performed to determine whether the liberatory maneuver is more effective for PC BPPV than a sham treatment and whether there is a correlation between the speed at which the maneuver is performed and the success of the maneuver.19

The self-administered CRP was more effective than the self-administered liberatory maneuver in the treatment of PC BPPV. More patients performed the self-administered liberatory maneuver incorrectly than performed the self-administered CRP incorrectly. The Brandt-Daroff exercises had little or no effect on symptom resolution.53 Although this conclusion is based on a single randomized study, the low success rate of the Brandt-Daroff exercises was consistent with the findings of an earlier nonrandomized trial.26 Therefore, the self-administered CRP has the highest reported treatment efficacy, whereas the Brandt-Daroff exercises have the lowest reported efficacy. For this reason, the Brandt-Daroff exercises are not recommended as an initial treatment maneuver. Patients should be physically and mentally screened to determine whether they are good candidates for instruction in and correct performance of self-administered maneuvers. To optimize outcomes, all patients should receive illustrated instructions with specific exercises for the affected ear, perform the exercises under the supervision of an experienced clinician, and be asked to perform the maneuver at the time of follow-up to assess the accuracy of performance.27

Although these data demonstrate that the CRP, the liberatory maneuver, and the self-administered variant of the CRP are effective treatments for PC BPPV,27,28,32,33,45,4953,57 clinicians must recognize that with both of these maneuvers, there is a chance (2.5%–6%) of causing a transient worsening of the patient's condition through a “canal conversion” from the PC to the lateral canal.45,67 Because of this possibility, clinicians using these maneuvers should be able to recognize and treat lateral canal BPPV, although in most cases the complication resolves on its own. Patients performing self-administered treatments should be educated about the possibility of a canal conversion. Unfortunately, RCTs regarding the treatment of lateral canal BPPV are not available.

Limitations of Study/Further Investigation

Only 2 RCTs32,33 compared the effectiveness of the CRP and the effectiveness of a control in the treatment of PC BPPV. The limited number of studies prevented us from including the articles in a quantitative synthesis or meta-analysis. The methodological quality was low and the probability of bias was high in studies investigating the effectiveness of the liberatory maneuver and self-administered variants. Therefore, interpretation of the data should be limited. Randomized controlled trials investigating the effectiveness of the liberatory maneuver and self-administered variants need to be conducted.

The CRP was designed to use the forces associated with gravity to treat canalithiasis of the PC,18 and the liberatory maneuver was designed to use both inertia and gravity to treat cupulolithiasis of the PC.25 The mechanism of BPPV may be determined on the basis of the characteristic nystagmus parameters of latency to onset, duration, and amplitude. The nystagmus parameters were not reported for the particle repositioning maneuvers; therefore, correlations between the mechanism of BPPV and the outcome of the maneuvers could not be determined. Further research on this topic is needed.

Two studies reported by the same authors attempted to evaluate quality-of-life measures before and after the treatment of PC BPPV with the liberatory maneuver.50,51 Information was insufficient to draw any conclusions. Further studies assessing the quality of life before and after the successful treatment of PC BPPV with particle repositioning maneuvers are needed.

We did not qualitatively assess the outcome of the patient's report of vertigo. The patient's report of vertigo may be assessed during the DHT or with the patient's daily routine (1 week before the follow-up appointment). The scales vary in that they use the frequency of reports of vertigo, the intensity of vertigo on an analog scale of 1 to 10, and categorization of the resolution of BPPV on the basis of a combination of subjective symptoms and findings on the DHT. There was considerable variability in the collection of the reports of vertigo. The resolution of vertigo was reported at follow-up during positional testing,32,49 within 1 week of follow-up during daily activities,33 at follow-up with the completion of a questionnaire (Vestibular Disorders Activities of Daily Living Scale68),50,51 through categorization of the resolution of both symptoms and nystagmus45,53 as first described by Epley,18 or no mention of symptoms.27,28,52 The development of a means for assessing the patient's report of vertigo is indicated.

Conclusion

Randomized controlled trials suggested that the CRP was more effective than a control in the resolution of BPPN in patients with PC BPPV. The evidence for the use of other particle repositioning maneuvers in the treatment of PC BPPV was weak. There were limited numbers of studies and no RCTs. Individual results suggested that the liberatory maneuver was more effective than a control; there was no significant difference in the effectiveness of the liberatory maneuver and the effectiveness of the CRP; the self-administered CRP was more effective than the self-administered liberatory maneuver; and the CRP administered together with the self-administered CRP was more effective than the CRP administered alone. The Brandt-Daroff exercises were the least effective self-administered treatments. There were no data on the effects of the particle repositioning maneuvers on outcomes relevant to patients.

The Bottom Line

What do we already know about this topic?

Randomized controlled trials (RCTs) suggest that the canalith repositioning procedure (CRP) is more effective than a sham treatment in the resolution of posterior canal benign paroxysmal positional nystagmus (PC BPPN).

What new information does this study offer?

Evidence for the use of other particle repositioning maneuvers is weak due to the limited numbers of studies and no RCTs. There is no significant difference in the effectiveness of the CRP compared with the liberatory maneuver (LM). If properly instructed, self-administered CRP and LM are effective. The Brandt-Daroff habituation exercises are the least effective. The most effective treatment is a combination of the CRP and the self-administered CRP.

If you’re a patient, what might these findings mean for you?

The CRP and LM performed by a clinician or, with proper instruction, by the patient at home resolves PC BPPN.

Footnotes

  • Dr Helminski, Dr Zee, and Dr Hain provided concept/idea/research design and writing. Dr Helminski provided data collection and project management. Dr Helminski and Dr Janssen provided data analysis. Dr Hain provided consultation (including review of manuscript before submission). The authors acknowledge the assistance of Midwestern University's librarian, Rebecca Caton, MLIS, who assisted with the electronic literature search, and Sandra Levi, PT, PhD, for her guidance in writing this systematic review.

  • A poster presentation of data from this study was given at the Combined Sections Meeting of the American Physical Therapy Association; February 9–12, 2009; Las Vegas, Nevada.

  • * SAS Institute Inc, 100 SAS Campus Dr, Cary, NC 27513-2414.

  • Received March 10, 2009.
  • Accepted December 21, 2009.

References

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