By Louise M. Klebanoff, MD
Assistant Professor of Clinical Neurology, Weill Cornell Medical College
SYNOPSIS: Using a cell phone-based app, self-treatment of recurrent benign positional paroxysmal vertigo was feasible and effective in most patients.
SOURCE: Kim HJ, Kim JS, Choi KD, et al. Effect of self-treatment of recurrent benign paroxysmal positional vertigo: A randomized clinical trial. JAMA Neurol 2023; Jan 17. doi: 10.1001/jamaneurol.2022.4944. [Online ahead of print].
Dizziness and vertigo are common neurological complaints, accounting for 3.5% to 11% of all emergency department visits, with an annual cost estimated at $3.9 million in the United States in 2011. Benign paroxysmal positional vertigo (BPPV), thought to be the result of dislodged otoconia in the semicircular canals, is the most common form of vertigo, diagnosed in 17% to 42% of patients presenting with vertigo. BPPV has an annual recurrence rate of 15% to 18%.
The canalith repositioning maneuver (CRM) results in immediate improvement in BPPV, with 80% immediate resolution of vertigo in approximately 80% of patients. Repeat applications of the maneuver increase the success rate to 92%. The CRM is relatively easy to perform, and patients can perform CRM on their own. However, because CRM is canal-specific, to effectively treat BPPV with CRM, the correct canal must be identified. The authors previously developed a simple six-question questionnaire that diagnosed the involved canal with an accuracy of 71.2%. The current study examined the therapeutic efficacy of web-guided, self-administered CRM according to the questionnaire-driven diagnosis in the setting of recurrent BPPV.
The authors conducted a multicenter, randomized, parallel-group, double-blinded trial to assess the efficacy of diagnosis and treatment of recurrent BPPV using a web-based system. The diagnosis of BPPV was made by in-person assessment according to the Barany Society criteria, with subsequent successful treatment of symptoms with CRM. Patients were excluded if they were younger than 20 years of age, had multi-canal BPPV, were unable to access a smartphone or computer, or were unable to use the program.
Following initial diagnosis and successful treatment of BPPV with CRM, patients were enrolled in the study and randomly assigned to a treatment or control group. Patients were instructed to access the Stop!BPPV website when they experienced recurrent symptoms of BPPV. Patients in the treatment group were guided to complete a six-question questionnaire to determine the subtype of BPPV they were experiencing (see Table 1); they then received a video clip for self-administration of the CRM designed for their specific subtype of BPPV. Control patients were provided with the video clip for the subtype of BPPV diagnosed at initial presentation without completing the questionnaire to determine their current subtype of BPPV. Patients repeated the CRM after one hour.
Table 1. Questionnaire for Self-Diagnosis of Benign Paroxysmal Positional Vertigo |
1. Do you have spinning or whirling sensation of the surroundings or yourself?
2. Do you feel dizzy mostly when your head is moved?
3. Does the dizziness last less than three minutes?
4. Which position makes you feel more dizzy?
a. Lying down or getting out of bed?
b. Turning your head (or body) while lying down?
5. Which makes you more dizzy?
a. Turning your head to the right?
b. Turning you head to the left?
6. How long does the dizziness induced by head turning last?
a. Less than one minute?
b. More than one minute? |
Source: Kim HJ, Kim JS, Choi KD, et al. Effect of self-treatment of recurrent benign paroxysmal positional vertigo: A randomized clinical trial. JAMA Neurol 2023; Jan 17. doi: 10.1001/jamaneurol.2022.4944. [Online ahead of print]. |
The first three questions were designed to exclude patients with dizziness caused by a diagnosis other than BPPV. The second three questions were designed to determine the specific canal involved and make a recommendation for the specific CRM to be used. The questions also helped to identify patients who should not be treated with CRM and needed further neurological investigation.
The efficacy of the treatment was determined by a standardized telephone interview performed by independent investigators blinded to the patient’s information. Three standardized questions were used: 1) Did you have dizziness when you woke up this morning? 2) If you have dizziness, is it spinning? 3) If you have dizziness, was it related to any head position changes? BPPV was cured if the patients answered no to any of these questions. Patients with persistent symptoms were seen in the clinic for further evaluation and treatment.
A total of 728 patients with confirmed and treated BPPV were screened for participation; 143 were excluded, including those who could not use the internet, declined to participate in the study, could not perform the CRM by themselves because of spinal problems, showed multi-canal BPPV, or had cognitive dysfunction. Therefore, 585 patients were enrolled in the study, with 292 in the treatment group and 293 in the control group. The mean age of the patients was 60.3 years in the treatment group and 61.1 years in the control group; there was a preponderance of women in both groups. Clinical characteristics were similar between groups. Of the 585 enrolled patients, 128 (21%) experienced recurrent BPPV with a mean recurrence interval of 179.8 days. 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 resolution of BPPV after application of the web-based system. In the per-protocol analysis, 42 of 51 patients (82.4%) in the treatment group and 30 of 58 (51.7%) in the control group reported resolution of vertigo during the telephone interview. In the treatment group, posterior canal BPPV resolved in 27 of 28 patents (96.4%) and horizontal canal BPPV resolved in 13 of 18 patients (72.2%). Patients reported using the program without difficulty, with less than 20% of patients needing assistance from a family member or caregiver.
COMMENTARY
Dizziness is a common neurological symptom, with BPPV being a very common cause. Recurrent BPPV is seen in 15% to 27% of patients, with an overall recurrent rate of 50% over three years. Despite the benign nature of this condition and the high success rate of treatment with simple CRM, BPPV often results in hospital evaluation and a high burden of cost. The authors showed that a simple web-based questionnaire can help confirm the diagnosis of recurrent BPPV, identify the involved canal, and recommend specific CRM with positive results in most patients. This study was limited in that only patients with previously diagnosed and successfully treated BPPV were enrolled and patients needed to be able to access the internet through a smartphone or a computer, which can be challenging for older individuals or for those with cognitive impairment. Despite these limitations, the study demonstrated the ease and efficacy of using a web-based program to diagnose and treat recurrent BPPV. Further study, including the safety and efficacy of the system in patients with an initial presentation of vertigo, should be pursued.
