An Effective Home-Based Particle Repositioning Procedure for Posterior Canal Benign Paroxysmal Positional Vertigo (BPPV)

Abstract

Patients with benign paroxysmal positional vertigo (BPPV) find it difficult to visit the hospital many times for a standard Epley’s maneuver performed only by a specialist. The aim of this study was to compare the efficacy of a home-based particle repositioning procedure (HBPRP) with the standard Epley’s maneuver in treating patients with posterior canal BPPV. A prospective non-blinded randomized controlled study was conducted. Patients were randomized into two groups, where one group received the standard treatment and other received a new HBPRP. The vertigo scale, duration of nystagmus during Dix-Hallpike test and frequency of vertigo, were documented on first, second and third visits, with complications noted during the second and third visits. These parameters were compared between both the groups following the treatment, during all visits. The patients were randomized into 2 arms with 15 each. Those belonging to group 1 received Epley’s maneuver and group 2 received HBPRP. There was no significant difference in the baseline characteristics of patients in both groups. Both groups of patients had significant improvement of symptoms at the end of the study. A comparison of both groups at 2nd and 3rd visits showed no differences in frequency of vertigo, reduction in vertigo scale and duration of nystagmus following Dix-Hallpike test between both groups. HBPRP is a safe and effective procedure and can be taught as a home-based treatment for patients diagnosed with posterior canal BPPV.

Introduction

Benign paroxysmal positional vertigo (BPPV) is one of the most common vestibular disorders, accounting for about 1–20% of all patients presenting with vertigo [1–3]. These patients present with short episodes of vertigo lasting for a few seconds, usually precipitated by changing head positions with respect to gravity and associated with nausea, vomiting and nystagmus [3]. The prevalence of BPPV is 11–64/10,000 and its life time prevalence is 2.4% [4]. Though this disease is benign and usually self-limiting, it can be troublesome for the patient with spontaneous recovery at two weeks or by 3 months in 50% [5, 6]. The mean age of incidence is fourth and fifth decades, but it can also occur in childhood [7]. The most frequently affected canal is the posterior semicircular canal (60–90%), followed by the horizontal canal (5–30%); anterior canal BPPV is rare [3, 8, 9]. BPPV is most commonly found in the elderly and in women [4], though there are studies which report the contrary [10].

It was in 1921 that Barany described BPPV for the first time as an otolith disease [11]. In 1952, Dix and Hallpike described the classic positioning test which induces the characteristic nystagmus and it is now used as the diagnostic test for BPPV [12]. This enabled easier clinical diagnosis of the disease. Though commonly noted following head injury [13, 14], BPPV is also seen following an episode of vestibular neuronitis [15] and prolonged bed rest [16]. Repositioning maneuvers are the treatment of choice for BPPV and surgical treatment is rarely indicated. Mechanical assistance chairs namely Epley Omniax System developed by Dr. John M. Epley and TRV chairs developed by Thomas Richard-Vitton [17, 18] are recently described for the diagnosis and management of this condition.

It was Epley who first reported the canalolith repositioning procedure which is used as treatment for BPPV [2, 19]. There are other treatment maneuvers used for BPPV like Semont’s maneuver and Brandt-Daroff’s exercise [20, 21]. Both Epley’s manueuver and Semont’s maneuver have been shown to be superior to Brandt-Daroff’s exercise, but require to be performed by specialists, as there could be complications if performed by the patient or by relatives. The conventional Epley’s maneuver is difficult in patients with neck pain and cervical spine diseases. The patient may have to visit the hospital multiple times for repeating the maneuver as 10–30% of people might not get relief with a single Epley’s maneuver. After a single treatment session, the success rate varied from 60 to 90% in different studies [7, 22–24].

Home-based particle repositioning procedure is a potential alternative to the Epley's maneuver since it circumvents the inconveniences related to the latter. The patient can perform the exercise by themselves without the need of a physician or a health personnel. Hence we developed the home-based particle repositioning procedure (HBPRP) to treat patients with BPPV at home.

Materials and Methods

A pilot study was conducted by performing the home-based particle repositioning procedure on 5 patients with posterior canal BPPV, to look at its efficacy and side effects. Outcome measures such as vertigo scale and nystagmus duration during Dix Hallpike test were studied. HBPRP was found to be effective, as compared to Epley’s maneuver, with no adverse effects. Based on this, we planned to carry out the present study. This study was a prospective, non-blinded randomized control trial on the effect of HBPRP in the treatment of patients who were diagnosed with posterior canal BPPV, in the Otology and Audio-vestibular Clinic of the Ear, Nose & Throat (ENT) department of a tertiary care academic hospital. After obtaining clearance from the institutional ethical committee and institutional review board (IRB No: 9642), the patients visiting the outpatient department with posterior canal BPPV, who fulfilled the inclusion criteria and gave written consent for this study were recruited. The inclusion criteria included patients aged above 18 years, who had a typical history of BPPV with a positive Dix-Hallpike test for posterior canal BPPV and willingness to come for follow up at 2nd week and 4th week after canalolith repositioning maneuver. Patients who had cardiac diseases like aortic aneurysm or symptoms of the same, cervical spine abnormalities like fracture spine/unstable spine/cranio-cervical anomalies and clinical suspicion of other co-existent vestibular disorders like migrainous vertigo or Meniere’s disease were excluded from the study. The patients who were recruited were randomized into two treatment groups, group 1 and group 2 using permuted block randomization with various block sizes. SAS 9.3 was used for the randomization. The outline of the treatment given to the two groups is shown in Fig. 1.

Fig. 1.

Flowchart representing the clinical presentation, randomization, treatment given and follow-up of patients with posterior canal BPPV

A detailed history was taken and a proforma filled with information on baseline characteristics like age, gender, co-morbid illness (including hypertension, diabetes mellitus, hypothyroidism, dyslipidemia and vitamin D deficiency), affected side, duration of illness, frequency of vertigo per day, duration of each vertigo episode, change with physical activities, and any previous episodes. The main outcome measures taken were vertigo scale and nystagmus duration during Dix-Hallpike test.

Vertigo Scale

The patients were asked to score the vertigo on a scale of 0 to 5 where they gave a score of 0 (no vertigo) to 5 (severe vertigo) depending upon the perceived intensity during each visit. They were asked to compare the intensity of vertigo during the 2nd and 3rd visits, with that of the first visit.

Nystagmus duration

The severity of nystagmus was based on its duration, as noted by the examiner on Dix-Hallpike test during each visit.

Home-Based Particle Repositioning Procedure (HBPRP)

In group 2, patients were taught the HBPRP by demonstration in the presence of a relative by the principal investigator. The steps are as follows:

1. The patient was seated upright on an examination table, with their legs fully extended in front of them.

2. His/her head was turned by an angle of 45 degrees towards the side affected.

3. The patient then laid rapidly down on the bed with the head extended but not beyond the edge of the bed with the chin tilted 30 degrees above the head and kept this position with the nose pointing to an imaginary point at the outer edge of the ceiling. The patient was asked to maintain this position for a period of 30 s to 2 min, until his/her dizziness stopped (Fig. 2—position 1)

4. The patient rotated his/her head 90 degrees in the opposite direction, maintaining the 30 degree tilt angle of chin with the horizontal, looking at an imaginary point at the outer edge of the ceiling on that side. The patient was asked to maintain the position for a time of 30 s to 2 min, until his/her dizziness stopped (Fig. 2—position 2)

5. Next, the patient rolled 90 degrees in the same direction that they were facing, onto their side with the chin almost touching the bed. The patient was asked to maintain the position for a time of 30 s to 2 min, until his/her dizziness stopped (Fig. 2—position 3).

6. Finally, the patient sat up to a sitting position with the chin tucked to the chest (Fig. 2—position 4)

Fig. 2.

HBPRP positions 1, 2, 3 and 4

The post procedure instructions of avoiding strenuous activities, lifting heavy weights, excessive neck movements and the use of two soft pillows while lying on bed on the unaffected side or supine were followed as group 1.

Results

There were 15 patients each in groups 1 and 2. All patients were followed up for a period of 1 month after initial evaluation and therapy. There were no side effects in both groups and both groups tolerated the therapy well. There was no significant difference between the two groups with regards to the co-existence of co-morbidities like vitamin D deficiency, osteoporosis, diabetes mellitus, dyslipidemia, hypertension and hypothyroidism.

The main outcome measures were reduction in nystagmus duration and vertigo scale. The grade of symptoms between the two groups at the time of presentation, second visit and third visit were compared using Fisher’s exact test and p value was > 0.330, > 0.999 and > 0.999 respectively as shown in Table 1.

Table 1.

Grade of symptoms in patients in both groups at presentation, second and third visits

Group allotted	Grade of symptoms	At presentation (n*)	Fisher’s exact test	Second visit (n)	Fisher’s exact test	Third visit (n)	Fisher’s exact test
Epley’s (n = 15)	No symptoms	0	p > 0.330	0	p > 0.999	3	p > 0.999
	Mild symptoms	0		2		12
	Moderate symptoms	4		13		0
	Severe symptoms	11		0		0
HBPRP (n = 15)	No symptoms	0		0		3
	Mild symptoms	0		2		11
	Moderate symptoms	1		13		1
	Severe symptoms	14		0		0

*n—number of patients

One patient in group 2 had persistent symptoms at 1 week. On the second visit she was further counseled regarding regular performance of the HBPRP. On the third visit, since her symptoms persisted she was given the Epley’s maneuver, following which she improved.

Nystagmus Duration

The reduction in nystagmus duration during each visit in both the groups was compared, as depicted (Table 2). Both groups had reduced nystagmus between 1 and 4 weeks and there was no difference between the 2 groups during all 3 visits (p value-0.535, t test).

Table 2.

Duration of nystagmus during 1st, 2nd and 3rd visits in both groups

	1st visit	2nd visit (after 1 week)	3rd visit (after 4 weeks)
Group 1 (Epley’s)
Median	8 s#	0 s	0 s
Range	4–15 s	0–2 s	0–0 s
Group 2 (HBPRP)
Median	10 s	0 s	0 s
Range	6–15 s	0–6 s	0–0 s

^#s—seconds

Vertigo Scale

Vertigo scale was compared between the 2 groups, as depicted in Fig. 3. Both groups had reduction in vertigo scale and this was not statistically different between the groups. (Using Mann–Whitney test, p value = 0.512, reduction in 1st to 2nd visit and p value = 0.624, reduction in 2nd to 3rd visit).

Fig. 3.

Vertigo scale during the 1st, 2nd, and 3rd visits in both groups

Frequency of Vertigo

The percentage of reduction in the frequency of vertigo when compared between the 2 groups from 1st to 2nd and 2nd to 3rd visits was not significantly different (p value-0.847, repeated measures ANOVA) as is shown in Fig. 4.

Fig. 4.

Percentage of reduction in the frequency of vertigo during follow-up in both groups

Discussion

BPPV is one of the most common causes of vertigo in patients visiting an ENT outpatient clinic. The usage of appropriate diagnostic tests after taking history can avoid unnecessary expenses by the patient in the form of CT, MRI or other vestibular tests. The most accepted treatment of BPPV is inexpensive and comprises of exercises or repositioning maneuvers for the loose otoconia.

Epley’s maneuver is extremely successful in the treatment of posterior canal BPPV and is proved by a recent meta-analysis from Spain [22]. The authors reported that patients who underwent Epley’s maneuver were 6.5 times more likely to have resolution of their acute vertiginous symptoms as compared to controls. There are some studies comparing the Epley’s maneuver with others like Semont’s or Gan’s repositioning maneuvers and Brandt-Daroff exercises [21, 24].

In a retrospective review of 376 patients, it was concluded that both Epley’s and Semont’s maneuvers were equally efficacious in treating posterior canal BPPV, with the latter having a reduced recurrence rate (4%) compared to that of Epley’s (7%) [25]. Similar results were evident later in a systematic review by Helminski et al. [26].

The HBPRP was devised so that patients can practice it themselves at home without supervision from a medical professional. This can be performed safely by elderly, obese or those who had orthopedic injuries. The initial diagnosis is done in the clinic by the physician who determines the type of BPPV and the side involved. Subsequently HBPRP was carried out at home by the patient once a day till he/she became symptom free. Unlike Brandt-Daroff exercises, HBPRP requires diagnosis of the side and type of BPPV initially.

The main outcome measures in our study were reduction in nystagmus duration and vertigo scale. There was no significant difference noted for both these outcomes in the two groups. The other measures like reduction in frequency of vertigo and change in the grade of symptoms were also similar in both the groups after intervention.

A randomized controlled trial comparing Epley’s with Gan’s maneuvers, found higher success rates for those who underwent Epley’s on day 1 [86.7 and 60% rate of subjective improvement (p = 0.02); and 86.7 and 56.7% with objective improvement, respectively (p = 0.01)], with equal results after 1 week [70% versus 46.7% (p = 0.067)]. However cervical pain post repositioning, was higher in the Epley’s group (23% versus 0.0%, p = 0.005). The Gan’s maneuver was thus found appropriate for the elderly and those with cervical or lumbar problems, resulting in fewer complications [27].

On evaluation of the outcome and probability of recurrence of posterior canal BPPV, after performing Epley’s maneuver versus Brandt-Daroff exercises, Juan Carlos et al. found a statistically significant difference between both treatment groups at 1 month (negative Dix-Hallpike test in 92.7% and 42.5% respectively; p < 0.001). The authors concluded that the Epley’s maneuver was more effective and similar in safety as Brandt-Daroff exercises in the short term for unilateral, idiopathic posterior canal BPPV, and that it may delay a second recurrence in those patients who had experienced a single recurrence (p = 0.04) [21].

A home-based exercise for posterior canal BPPV, devised by Carol Foster is the half somersault exercise. A randomized controlled single blinded trial was conducted to compare this home based treatment with the Epley’s treatment [28]. The study reported that both exercises showed significant reduction in nystagmus, with Epley’s maneuver performing better. It was concluded that half somersault was better tolerated and had fewer side effects as a home-based exercise. However we noted that the half somersault cannot be done by patients who are elderly, obese or have spine/large joint dysfunction/arthritis.

Our study comparing HBPRP with the standard Epley’s maneuver shows that there was no statistically significant difference in outcomes between the two groups at 1 week and 4 weeks after the initial presentation. HBPRP as a home-based exercise is as effective as Epley’s maneuver in the treatment of posterior canal BPPV. HBPRP is safe and effective in reducing the signs and symptoms of posterior canal BPPV and there were no complications after the treatment in the form of severe nausea, neck pain or sprain, vomiting or worsening of vertigo in both the study arms.

Limitations

It was not feasible to monitor the way these home-based exercises were being done by patients at home. Compliance to HBPRP on a daily basis was also doubtful. However knowledge of the home-based procedure was re-checked by asking the patient to demonstrate the exercise during follow-up visits. Epley’s maneuver is a one-time, specific, targeted maneuver whereas HBPRP had to be done daily till asymptomatic. It was also not possible to blind our study. A long term follow up of the patients may shed light on long term effects and treatment failures and a larger sample size would have been better for comparison.

Conclusion

Both Epley’s maneuver and HBPRP were successful in treating the symptoms of posterior canal BPPV and both groups had similar outcomes in terms of reduction in vertigo and nystagmus at 1 week and 4 weeks without any side-effects. The Epley’s group had a higher reduction in frequency of vertigo but this was not statistically significant. HBPRP can be performed safely and effectively by patients who find it difficult to come to hospital multiple times and in cases of recurrent BPPV.

Author Contributions

Dr. AL conceptualised and designed the study. Material preparation, data collection and analysis were performed by Dr. RLR, Dr. AL, Dr. MDM and Mr. LV. The first draft of the manuscript was written by Dr. RLR and all authors commented on previous versions of the manuscript. The Title Page manuscript has been read and approved by all authors, and the requirements for authorship have been met. Each author believes that the manuscript represents honest work.

Funding

Limited funding was obtained from the institutional FLUID Research Grant.

Declarations

Conflict of interest

The authors have no conflict of interest to declare, that are relevant to the content of this article.

Ethical Approval

All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. This study was conducted after obtaining approval from the institutional ethical committee and institutional review board (IRB No: 9642).

Consent to Participate

Informed consent was obtained from all individual participants included in the study.