Effectiveness of the Canalith Repositioning Procedure in the Treatment of Benign Paroxysmal Positional Vertigo Janet O. Helminski PHYS THER. Published online June 5, 2014 doi: 10.2522/ptj.20130239
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Running head: Case #24 Applying Evidence to a Patient With BPPV
Linking Evidence And Practice
Effectiveness of the Canalith Repositioning Procedure in the Treatment of Benign Paroxysmal Positional Vertigo
Janet O. Helminski
J.O. Helminski, Physical Therapy, Midwestern University, 555 31st St, Downers Grove, IL 60515 (USA). Address all correspondence to Dr Helminski at: [email protected].
[Helminski JO. Effectiveness of the canalith repositioning procedure in the treatment of benign paroxysmal positional vertigo. Phys Ther. 2014;94:xxx–xxx.]
© 2014 American Physical Therapy Association
Publish Ahead of Print: xxxx
Downloaded from http://ptjournal.apta.org/ by Sara Blaszczak on June 14, 2014
Accepted: May 26, 2014 Submitted: June 7, 2013
Downloaded from http://ptjournal.apta.org/ by Sara Blaszczak on June 14, 2014
highlights the findings and application of Cochrane reviews and other evidence pertinent to the practice of physical therapy. The Cochrane Library is a respected source of reliable evidence related to health care. Cochrane systematic reviews explore the evidence for and against the effectiveness and appropriateness of interventions—medications, surgery, education, nutrition, exercise—and the evidence for and against the use of diagnostic tests for specific conditions. Cochrane reviews are designed to facilitate the decisions of clinicians, patients, and others in health care by providing a careful review and interpretation of research studies published in the scientific literature.1 Each article in this PTJ series summarizes a Cochrane review or other scientific evidence on a single topic and presents clinical scenarios based on real patients or programs to illustrate how the results of the review can be used to directly inform clinical decisions. This article focuses on an adult patient with benign paroxysmal positional vertigo.
Downloaded from http://ptjournal.apta.org/ by Sara Blaszczak on June 14, 2014
Introduction Benign Paroxysmal Positional Vertigo (BPPV) presents with brief periods of vertigo experienced with a change in the position of the person’s head relative to gravity. BPPV is a mechanical disorder of the inner ear caused by abnormal stimulation of one or more of the three semicircular canals (Figure 1). The otoconia from the utricle dislodge and settle within one of the three semicircular canals changing the fluid filled canal dynamics from detecting rotation of the canals to detecting gravitation forces on the head. With BPPV, changing the plane of the involved canal relative to gravity causes debris to settle to the lowest part of the canal, changing the fluid pressure across the cupula, deflecting the hair cells, and generating the characteristic ocular nystagmus with associated vertigo. There are three mechanisms of BPPV, the most common being debris within the long arm of the canal called canalithiasis.1 Debris may also be found in the short arm of the canal2 or attached to the cupula weighting the membrane called cupulolithiasis.2 The most common canal involved is the posterior semicircular canal (PC).3 The diagnosis of BPPV is based on history and findings on positional testing.4,5 If patients complain of vertigo with rolling in bed or getting out of bed, patients are 4.3 times more likely to have BPPV.6 The Dix-Hallpike test7 and the Side-Lying test8 are the standard tests4,5 for evaluating posterior canal BPPV. A comparison of the Dix-Hallpike test and Side-Lying test found no significant difference between the two techniques.8 Frenzel lenses or video oculography should be used to prevent suppression of ocular nystagmus. The diagnostic criteria for posterior canal BPPV are vertigo associated with the characteristic nystagmus of torsional, superior pole towards the lowermost ear - the involved ear, and upbeating9 with a 1-45 s latency before the onset,10-12 duration of 24 hours after treatment to avoid the effects of fatigue.21 Successful outcome is defined as conversion from a positive to negative Dix-Hallpike test, no benign paroxysmal positional nystagmus and associated vertigo. A Cochrane systematic review by Hilton and Pinder22 examined the evidence to determine the effectiveness of the CRP compared to other treatments available or no treatment for individuals with posterior canal BPPV. This review is an update of a Cochrane Review first published in the Cochrane Library in Issue 1, 2002 and then updated in 2004 and 2007. Randomized controlled trials were included if participants were adults (> 16 years of age) with the clinical diagnosis of posterior canal BPPV based on positive findings during the Dix-Hallpike test (observation of the characteristic nystagmus and symptoms of associated vertigo). Trials compared the effectiveness of the modified CRP (without the use of vibration) with a sham maneuver or an untreated control. There was no evidence comparing the effectiveness of the CRP with other physical, medical or surgical therapy for posterior canal BPPV. Follow-up ranged from 16 years old) with a clinical diagnosis of posterior canal BPPV based on history and a positive Dix-Hallpike test. All studies included subjects with unilateral posterior canal BPPV. One study also included subjects with bilateral posterior canal BPPV and atypical BPPV. The duration of subjects’ symptoms varied. • Intervention was modified CRP (no mastoid vibration). Comparator was sham maneuver in 4 trials or control in 1 trial. • Follow-up ranged from immediately to 1 month post-treatment Interventions • Type of particle repositioning maneuver: CRP, sham maneuver (lying on affected side for 5 minutes, lying in the 1st lateral position of the liberatory maneuver for 5 minutes, and CRP performed as if opposite ear affected), and control (untreated). • Number of cycles per treatment session: Ranged from 1-5. • Post-intervention postural and activity restrictions: Two trials instructed subjects in postintervention restrictions. Three trials had no post-intervention restrictions. Outcomes • Proportion of subjects who had complete resolution of their symptoms and who converted from a positive to a negative Dix-Hallpike test. • Two studies asked participants to complete a diary of symptoms. Froehling et Lynn et al, Munoz et al, von Brevern Yimtae et al, al, 200024 199525 200723 et al, 200621 200326 Measure CRP Sham CRP Sham CRP Sham CRP Sham CRP Contro l No. of 24 26 18 15 38 41 35 31 29 27 participants/ group No. of 12(50 5(19) 11(61 3(20) 12(32 10(24 28(80 4(13) 12(41 1(4) participants/ ) ) ) ) ) ) group with complete resolution of symptoms (%) No. of 16(67 10(38 16(89 4(27) 13(34 6(15) 28(80 3(10) 22(76 13(48) participants/ ) ) ) ) ) ) group with negative DixHallpike test result (%)
Downloaded from http://ptjournal.apta.org/ by Sara Blaszczak on June 14, 2014
No. of participants/ group with complications nausea/ vomiting/ fainting Overall assessment of risk of bias Lost to followup Results Complete resolution of symptoms Negative DixHallpike test result Safety
1
0
Low
8
Low
Low
1
Low
2
0
Insufficient data to determine bias
Completed data available for 273/292 patients. Symptom outcome reported as dichotomous variable. Success defined as complete resolution of symptoms or not. In each trial, a statistically significant difference in symptom resolution in favor of the treatment group was observed. Pooled trail data yielded an odds ratio of 4.42 (95% CI 2.62 to 7.44) in favor of treatment. In all trials, there was a statistically significant difference in conversion from a positive to a negative Dix-Hallpike test in favor of the treatment group. Pooled trial data yielded an odds ratio of 6.40 (95% CI 3.63 to 11.28) in favor of treatment. No serious complications of treatment. Reported problems were inability to tolerate treatment due to cervical spine problems, emesis during treatment, nausea, and fainting.
Limitations • None of the trials assessed outcome after 1 month so long term efficacy is unknown. • At the time of the updated search there were no trials comparing CRP to other active treatments.
Downloaded from http://ptjournal.apta.org/ by Sara Blaszczak on June 14, 2014
Table 2. Pre-intervention and Post-intervention Outcome Measures Outcome Measure Activities-specific Balance Confidence (ABC) Scale28 Dizziness Handicap Inventory27 Dynamic Gait Index29
Timed “Up & Go” Test30
Properties of Measure Range: 0-100 points Higher score indicates greater balance confidence. Strong test-retest and high internal consistency in community-dwelling older adults28 and valid in individuals with complaints of dizziness37. Range: 0-100 points Higher score indicates greater self-perceived handicapping effects imposed by vestibular system disease. Range: 0-24 points
The online version of this article, along with updated information and services, can be found online at: http://ptjournal.apta.org/content/early/2014/06/04/ptj.20130239 E-mail alerts
Sign up here to receive free e-mail alerts
Online First articles are published online before they appear in a regular issue of Physical Therapy (PTJ). PTJ publishes 2 types of Online First articles: Author manuscripts: PDF versions of manuscripts that have been peer-reviewed and accepted for publication but have not yet been copyedited or typeset. This allows PTJ readers almost immediate access to accepted papers. Page proofs: edited and typeset versions of articles that incorporate any author corrections and replace the original author manuscript.
Downloaded from http://ptjournal.apta.org/ by Sara Blaszczak on June 14, 2014
Running head: Case #24 Applying Evidence to a Patient With BPPV
Linking Evidence And Practice
Effectiveness of the Canalith Repositioning Procedure in the Treatment of Benign Paroxysmal Positional Vertigo
Janet O. Helminski
J.O. Helminski, Physical Therapy, Midwestern University, 555 31st St, Downers Grove, IL 60515 (USA). Address all correspondence to Dr Helminski at: [email protected].
[Helminski JO. Effectiveness of the canalith repositioning procedure in the treatment of benign paroxysmal positional vertigo. Phys Ther. 2014;94:xxx–xxx.]
© 2014 American Physical Therapy Association
Publish Ahead of Print: xxxx
Downloaded from http://ptjournal.apta.org/ by Sara Blaszczak on June 14, 2014
Accepted: May 26, 2014 Submitted: June 7, 2013
Downloaded from http://ptjournal.apta.org/ by Sara Blaszczak on June 14, 2014
highlights the findings and application of Cochrane reviews and other evidence pertinent to the practice of physical therapy. The Cochrane Library is a respected source of reliable evidence related to health care. Cochrane systematic reviews explore the evidence for and against the effectiveness and appropriateness of interventions—medications, surgery, education, nutrition, exercise—and the evidence for and against the use of diagnostic tests for specific conditions. Cochrane reviews are designed to facilitate the decisions of clinicians, patients, and others in health care by providing a careful review and interpretation of research studies published in the scientific literature.1 Each article in this PTJ series summarizes a Cochrane review or other scientific evidence on a single topic and presents clinical scenarios based on real patients or programs to illustrate how the results of the review can be used to directly inform clinical decisions. This article focuses on an adult patient with benign paroxysmal positional vertigo.
Downloaded from http://ptjournal.apta.org/ by Sara Blaszczak on June 14, 2014
Introduction Benign Paroxysmal Positional Vertigo (BPPV) presents with brief periods of vertigo experienced with a change in the position of the person’s head relative to gravity. BPPV is a mechanical disorder of the inner ear caused by abnormal stimulation of one or more of the three semicircular canals (Figure 1). The otoconia from the utricle dislodge and settle within one of the three semicircular canals changing the fluid filled canal dynamics from detecting rotation of the canals to detecting gravitation forces on the head. With BPPV, changing the plane of the involved canal relative to gravity causes debris to settle to the lowest part of the canal, changing the fluid pressure across the cupula, deflecting the hair cells, and generating the characteristic ocular nystagmus with associated vertigo. There are three mechanisms of BPPV, the most common being debris within the long arm of the canal called canalithiasis.1 Debris may also be found in the short arm of the canal2 or attached to the cupula weighting the membrane called cupulolithiasis.2 The most common canal involved is the posterior semicircular canal (PC).3 The diagnosis of BPPV is based on history and findings on positional testing.4,5 If patients complain of vertigo with rolling in bed or getting out of bed, patients are 4.3 times more likely to have BPPV.6 The Dix-Hallpike test7 and the Side-Lying test8 are the standard tests4,5 for evaluating posterior canal BPPV. A comparison of the Dix-Hallpike test and Side-Lying test found no significant difference between the two techniques.8 Frenzel lenses or video oculography should be used to prevent suppression of ocular nystagmus. The diagnostic criteria for posterior canal BPPV are vertigo associated with the characteristic nystagmus of torsional, superior pole towards the lowermost ear - the involved ear, and upbeating9 with a 1-45 s latency before the onset,10-12 duration of 24 hours after treatment to avoid the effects of fatigue.21 Successful outcome is defined as conversion from a positive to negative Dix-Hallpike test, no benign paroxysmal positional nystagmus and associated vertigo. A Cochrane systematic review by Hilton and Pinder22 examined the evidence to determine the effectiveness of the CRP compared to other treatments available or no treatment for individuals with posterior canal BPPV. This review is an update of a Cochrane Review first published in the Cochrane Library in Issue 1, 2002 and then updated in 2004 and 2007. Randomized controlled trials were included if participants were adults (> 16 years of age) with the clinical diagnosis of posterior canal BPPV based on positive findings during the Dix-Hallpike test (observation of the characteristic nystagmus and symptoms of associated vertigo). Trials compared the effectiveness of the modified CRP (without the use of vibration) with a sham maneuver or an untreated control. There was no evidence comparing the effectiveness of the CRP with other physical, medical or surgical therapy for posterior canal BPPV. Follow-up ranged from 16 years old) with a clinical diagnosis of posterior canal BPPV based on history and a positive Dix-Hallpike test. All studies included subjects with unilateral posterior canal BPPV. One study also included subjects with bilateral posterior canal BPPV and atypical BPPV. The duration of subjects’ symptoms varied. • Intervention was modified CRP (no mastoid vibration). Comparator was sham maneuver in 4 trials or control in 1 trial. • Follow-up ranged from immediately to 1 month post-treatment Interventions • Type of particle repositioning maneuver: CRP, sham maneuver (lying on affected side for 5 minutes, lying in the 1st lateral position of the liberatory maneuver for 5 minutes, and CRP performed as if opposite ear affected), and control (untreated). • Number of cycles per treatment session: Ranged from 1-5. • Post-intervention postural and activity restrictions: Two trials instructed subjects in postintervention restrictions. Three trials had no post-intervention restrictions. Outcomes • Proportion of subjects who had complete resolution of their symptoms and who converted from a positive to a negative Dix-Hallpike test. • Two studies asked participants to complete a diary of symptoms. Froehling et Lynn et al, Munoz et al, von Brevern Yimtae et al, al, 200024 199525 200723 et al, 200621 200326 Measure CRP Sham CRP Sham CRP Sham CRP Sham CRP Contro l No. of 24 26 18 15 38 41 35 31 29 27 participants/ group No. of 12(50 5(19) 11(61 3(20) 12(32 10(24 28(80 4(13) 12(41 1(4) participants/ ) ) ) ) ) ) group with complete resolution of symptoms (%) No. of 16(67 10(38 16(89 4(27) 13(34 6(15) 28(80 3(10) 22(76 13(48) participants/ ) ) ) ) ) ) group with negative DixHallpike test result (%)
Downloaded from http://ptjournal.apta.org/ by Sara Blaszczak on June 14, 2014
No. of participants/ group with complications nausea/ vomiting/ fainting Overall assessment of risk of bias Lost to followup Results Complete resolution of symptoms Negative DixHallpike test result Safety
1
0
Low
8
Low
Low
1
Low
2
0
Insufficient data to determine bias
Completed data available for 273/292 patients. Symptom outcome reported as dichotomous variable. Success defined as complete resolution of symptoms or not. In each trial, a statistically significant difference in symptom resolution in favor of the treatment group was observed. Pooled trail data yielded an odds ratio of 4.42 (95% CI 2.62 to 7.44) in favor of treatment. In all trials, there was a statistically significant difference in conversion from a positive to a negative Dix-Hallpike test in favor of the treatment group. Pooled trial data yielded an odds ratio of 6.40 (95% CI 3.63 to 11.28) in favor of treatment. No serious complications of treatment. Reported problems were inability to tolerate treatment due to cervical spine problems, emesis during treatment, nausea, and fainting.
Limitations • None of the trials assessed outcome after 1 month so long term efficacy is unknown. • At the time of the updated search there were no trials comparing CRP to other active treatments.
Downloaded from http://ptjournal.apta.org/ by Sara Blaszczak on June 14, 2014
Table 2. Pre-intervention and Post-intervention Outcome Measures Outcome Measure Activities-specific Balance Confidence (ABC) Scale28 Dizziness Handicap Inventory27 Dynamic Gait Index29
Timed “Up & Go” Test30
Properties of Measure Range: 0-100 points Higher score indicates greater balance confidence. Strong test-retest and high internal consistency in community-dwelling older adults28 and valid in individuals with complaints of dizziness37. Range: 0-100 points Higher score indicates greater self-perceived handicapping effects imposed by vestibular system disease. Range: 0-24 points
