Yasmeen A. Khan, DC, MS
Vertigo is a common source of dizziness in the adult population, and many present to chiropractic clinics seeking care. The risk of vertigo increases with age, and with a rapidly aging population it is prudent for doctors of chiropractic (DCs) to refine their diagnostic skills in differentiating between common sources of vertigo among adults and older adults.
The most common causes of vertigo include inner ear infections, benign paroxysmal positional vertigo (BPPV), vestibular neuritis and Meniere’s disease. BPPV is the most common cause of vertigo in the adult population, and occurs when calcium particles (canaliths) deposit within the inner ear canals. It presents as sudden, short bouts of dizziness (or a feeling that the environment is spinning) and is triggered by certain head movements or positions. While many patients will experience dizziness or vertigo throughout their lives, the risk of BPPV increases as one ages.
The following abstracts and commentaries describe three recent studies investigating BPPV in the adult population. The article by Michael et al. describes a new alternative to a traditional diagnostic test for BPPV (the Dix-Hallpike maneuver), which may be easier for patients to execute. The articles by Bhattacharya et al. and Fife and von Brevern describe the current state of evidence for the diagnosis and treatment of BPPV and its variants.
An Abbreviated Diagnostic Maneuver for Posterior Benign Positional Paroxysmal Vertigo
Michael P, Oliva CE, Nuñez M, Barraza C, Faúndez JP and Breinbauer HA. Front Neurol. 2016 Jul 18;7:115.
Introduction—Benign paroxysmal positional vertigo (BPPV) secondary to canalolithiasis of the posterior semicircular canal is perhaps the most frequent cause of vertigo and dizziness. One of its properties is a high response rate to canalith repositioning maneuvers. However, delays in the diagnosis and treatment of this entity can range from days to years, depending on the setting. Here, we present an abbreviated variation of the Dix-Hallpike maneuver, which can be used to diagnose this disease. It is similar to the standard maneuver, but can be performed without an examination bed or table and requires only a backed chair (a difference that is very important in settings where a clinical bed or table is not readily available).
Methods—A diagnostic assessment study was conducted on 163 patients who presented with vertigo or dizziness.
Results—The abbreviated test had fairly good sensitivity (80%) and high specificity (95%) for diagnosing posterior BPPV.
Discussion—This new diagnostic maneuver may serve as a screening procedure for quickly identifying this pathology. This will allow patients to be more directly treated, without requiring unnecessary referrals or full vestibular testing, and will be especially useful in primary care settings or heavily overloaded otolaryngology or neurology departments.
Efficient and effective screening and diagnostic procedures are fundamental in providing optimal healthcare. This study conducted in Chile describes an abbreviated version of the Dix-Hallpike maneuver that has utility for clinicians in diagnosing posterior canal BPPV. The traditional Dix-Hallpike maneuver involves the following steps: 1) a patient sits on an examination table, 2) turns the head 45 degrees to the suspected involved side, and 3) lies back (with the support of the doctor) until the body is resting supine on the table with the turned head extending 20 degrees off the edge of the table. This maneuver involves complex coordination from a potentially dizzy patient, help from the doctor to support the patient’s body weight on the decline, and potential discomfort to the patient.
The modified maneuver described by Michael and colleagues provides a useful alternative to the traditional Dix-Hallpike, with less burden to both the doctor and patient. The abbreviated version involves the patient turning the head to the affected side and then simply lying back in a chair, thus markedly decreasing risk to the patient, requiring less coordinated movement from the patient and promoting efficiency. Aside from replacing the supine position with neck extension over the back of the chair, the remaining movements and procedures remain unchanged (turning the head to one side, extending the head at the neck and leaning backward as the doctor observes for nystagmus). Because the abbreviated Dix-Hallpike maneuver does not require the patient to lie on an examination table, it increases office efficiency and decreases patient burden.
The abbreviated screening procedure displayed fair sensitivity and high specificity in the 163 participants studied. DCs receive training on the diagnosis and treatment of benign paroxysmal positional vertigo (BPPV) while attending chiropractic college, and the increased efficiency offered by this abbreviated Dix-Hallpike maneuver may be appealing to practicing chiropractic clinicians.
This article includes tables and figures illustrating the involved anatomy, the use of the modified maneuver in schematic form, and a step-by-step description of the maneuver in the methods section of text. Ultimately, this study illustrated a diagnostic test that may prevent unnecessary referrals to vestibular specialists and aid in speed and accuracy in diagnosing posterior canal BPPV.
Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)
Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, Holmberg JM, Mahoney K, Hollingsworth DB, Roberts R, Seidman MD, Steiner RW, Do BT, Voelker CC, Waguespack RW and Corrigan MD. Otolaryngol Head Neck Surg. 2017 Mar;156(3_suppl):S1-S47.
Objective—This update of a 2008 guideline from the American Academy of Otolaryngology Head and Neck Surgery Foundation provides evidence-based recommendations for benign paroxysmal positional vertigo (BPPV), defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo. Changes from the prior guideline include: a consumer advocate added to the update group, new evidence from two clinical practice guidelines, 20 systematic reviews and 27 randomized controlled trials, enhanced emphasis on patient education and shared decision-making, a new algorithm to clarify action statement relationships, and new and expanded recommendations for the diagnosis and management of BPPV.
Purpose—The primary purposes of this guideline are to improve the quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing such as radiographic imaging, and increasing the use of appropriate therapeutic repositioning maneuvers. The guideline is intended for all clinicians who are likely to diagnose and manage patients with BPPV, and it applies to any setting in which BPPV would be identified, monitored, or managed.
The target patient for the guideline is aged 18 years or older, with a suspected or potential diagnosis of BPPV. The primary outcome considered in this guideline is the resolution of the symptoms associated with BPPV. Secondary outcomes considered include an increased rate of accurate diagnoses of BPPV, a more efficient return to regular activities and work, decreased use of inappropriate medications and unnecessary diagnostic tests, reduction in recurrence of BPPV, and reduction in adverse events associated with undiagnosed or untreated BPPV. Other outcomes considered include minimizing costs in the diagnosis and treatment of BPPV, minimizing potentially unnecessary return physician visits, and maximizing the health-related quality of life of individuals afflicted with BPPV.
Action Statements—The update group made strong recommendations that clinicians should: (1) diagnose posterior semicircular canal BPPV when vertigo associated with torsional, up-beating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45 degrees to one side and neck extended 20 degrees with the affected ear down, and (2) treat (or refer to a clinician who can) patients with posterior canal BPPV with a canalith repositioning procedure.
The update group made a strong recommendation against post-procedural postural restrictions after a canalith repositioning procedure for posterior canal BPPV. The update group recommended that the clinician should: (1) perform (or refer to a clinician who can) a supine roll test to assess for lateral semicircular canal BPPV if the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus, (2) differentiate (or refer to a clinician who can) BPPV from other causes of imbalance, dizziness and vertigo, (3) assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support and/or increased risk for falling, (4) re-assess patients within one month after an initial period of observation or treatment to document resolution or persistence of symptoms, (5) evaluate (or refer to a clinician who can) patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders, and (6) educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence and the importance of follow-up.
The update group made recommendations against: (1) radiographic imaging for a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging, (2) vestibular testing for a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing, and (3) routinely treating BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines.
The guideline update group provided the options that clinicians may offer: (1) observation with follow-up as initial management for patients with BPPV, and (2) vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV.
Clinical practice guidelines are beneficial for clinicians because they provide evidence-based directives with regard to specific diseases, conditions or procedures. In other words, guidelines serve as a comprehensive appraisal of the best evidence, providing clinicians with scientific rationale for clinical decisions. These guidelines, written by a committee of clinicians, scientists and a patient advocate, are quite comprehensive and contain a breadth of useful clinical information. The authors also compiled two supplemental documents that summarize its findings (an “Executive Summary” and a “Plain Language” summary), both available online at PubMed.gov and may be preferred by many readers in lieu of the 47-page full document.
These guidelines are an update to a 2008 version, and are meant to be generalized for persons 18 years and older with suspected or diagnosed BPPV. Updates include adding a patient advocate to the guideline development group and substantial additional evidence in the form of systematic reviews and randomized controlled trials.
This article includes many clinically relevant facts and figures. For example, the introduction section includes useful epidemiological data on subjects such as the prevalence of BPPV in the United States (5.6 million clinical visits per year due to dizziness; ten to 42 cases per 100,000 in the US population) and the proportion of vertigo cases which receive a BPPV diagnosis (ranging from 17% to 42%).
The text also includes statistics regarding the prevalence of spontaneous recovery (20% of patients within one month, 50% within three months), and that reoccurrence is more common within the first year after an initial episode. DCs can use this information to inform patient education efforts and provide patients with appropriate expectations for prognosis and recovery. Other highlights of this document include Table 1, which provides a useful glossary of relevant medical terms, and Table 2, which provides a comprehensive list of current evidence- based diagnostic procedures and treatment options.
Diagnostic and treatment guidelines are divided into “strong recommendations” (which clinicians should follow unless there is a clear and compelling rationale for an alternate approach), “recommendations” (which clinicians should follow while remaining alert to new and emerging information as well as patient preference), and “options” (which clinicians can be flexible with in decision-making and for which patient preference may have a substantial influencing role). These guidelines can be found in Table 5.
Strong recommendations include:
- Diagnostic testing: Clinicians should use specific diagnostic tests (including the Dix-Hallpike maneuver) when vertigo is accompanied by torsional, up-beating nystagmus.
- Repositioning procedures as initial therapy: Clinicians should treat (or refer to a clinician who can) patients with posterior BPPV using a canalith repositioning procedure.
- Post-procedural postural restrictions: Clinicians should not recommend post-procedural postural restrictions after a canalith repositioning procedure for poster canal BPPV.
- Diagnosing lateral/horizontal BPPV (or referring to a clinician who can) using the supine roll test when horizontal or when no nystagmus occurs after performing a Dix-Hallpike test.
- Differentiating (or referring to a clinician who can) for other causes of imbalance, dizziness or vertigo.
- Assessing for factors that would modify management such as home supports and environments that increase the risk for falling.
- Clinicians should not obtain radiographic imaging in a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging.
- Clinicians should not order vestibular testing in a patient who meets the diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant testing.
- Clinicians should not routinely treat BPPV with other vestibular suppressant medications such as antihistamines and/or benzodiazepines.
- Clinicians should reassess patients within one month after an initial period of observation or treatment to document resolution or persistence of symptoms.
- Clinicians should evaluate (or refer for evaluation) underlying peripheral vestibular or central nervous system disorders in patients with unresolved or persistent BPPV.
- Clinicians should educate patients regarding the impact of BPPV on their safety, the potential for recurrence, and the importance of follow-up.
Optional recommendations can be located in the abstract and in Table 5 of the guidelines manuscript. This manuscript is filled with clinically useful information, evidence-based rationale for recommendations, figures, diagrams and diagnostic criteria for BPPV. It is a useful read for clinicians wishing to augment their understanding of BPPV and remain aware of the current best evidence in caring for patients experiencing it.
- Bhattacharyya N, Gubbels SP, Schwartz SR, et al. Clinical practice guideline: benign paroxysmal positional vertigo (update) executive summary. Otolaryngol Head Neck Surg. 2017 Mar;156(3):403-416.
- Bhattacharyya N, Hollingsworth DB, Mahoney K, O’Connor S. Plain language summary: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg. 2017 Mar;156(3):417-425.
Benign Paroxysmal Positional Vertigo in the Acute Care Setting
Fife TD and von Brevern M. Neurol Clin. 2015 Aug;33(3):601-617, viii-ix.
Benign paroxysmal positional vertigo (BPPV) is a common cause of vertigo characterized by brief episodes provoked by head movements. The first attack of BPPV usually occurs in bed or upon getting up. Because it often begins abruptly, it can be alarming and can lead to emergency department evaluation. The episodes of spinning often last ten to 20 seconds, but may occasionally last as long as a minute. There are several forms of BPPV. In nearly all cases, highly effective treatment can be offered to patients. This article reviews the current state of our understanding of this condition and its management.
This article was created to be a comprehensive guide for clinicians working in acute care settings. It has some similarities to the Bhattacharyya report above, but is shorter and may therefore present as more user-friendly to some readers. The article begins with a description of BPPV, and later discusses its etiology, pathophysiology and diagnostic instructions. Well-organized text boxes describing diagnostic procedures are accompanied by schematic illustrations to assist in conceptualizing the procedures.
The article was written for doctors who do not specialize in vestibular disorders. Therefore, it caters to an audience that may benefit from a comprehensive guide to the subtypes of BPPV and includes a listing of the evidence-based diagnostic and treatment options for each subtype (posterior canal BPPV, horizontal BPPV and anterior BPPV). It is well-organized and provides clinicians with a well-rounded understanding of BPPV and step-by-step instructions for differentiating and treating its subtypes. The lists below summarize the diagnostic and treatment procedures for each BPPV variant described in this report.
- Diagnostic test: Dix-Hallpike maneuver
- Treatment procedures:
- Canalith repositioning procedure (Epley maneuver; see Figure 3 in report)
- Liberator maneuver (Semont maneuver; see Figure 4 in report)
- Prognosis: A 90% rate of improvement can be expected from the treatments listed above, although recurrence rates range from 30% to 50%.
- Diagnostic test: supine roll test, looking for horizontal direction-changing positional nystagmus (the Dix-Hallpike maneuver can also provoke nystagmus in some cases of horizontal BPPV)
- This test can produce geotropic (toward the earth) nystagmus (indicating presumed canalolithiasis) or apogeotropic (away from the earth) nystagmus (indicating presumed cupulolithiasis).
- Lempert 360-degree roll maneuver (see Figure 6 in report)
- Forced prolonged positioning
- Gufoni maneuver (see Figure 7 in report)
- Miscellaneous additional/other maneuvers
Anterior canal BPPV:
- Diagnostic test: Dix-Hallpike maneuver
- This is rare and resolves quickly, so no established treatment maneuvers were indicated.
- In some cases, maneuvers that treat poster BPPV may be used.