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TREATING POSITIONAL VERTIGO
New Multi-Specialty Guidelines for Positional Vertigo (BPPV) Released (2008)
Benign Paroxysmal Positional Vertigo (BPPV) is by far the most common cause of episodic vertigo, and accounts for 20 to 25% of all patients seen in a vestibular specialty clinic. Patients typically report brief episodes (less than one minute) of intense vertigo, usually brought on by lying down, rolling over in bed, or tilting the head back. BPPV is a mechanical dysfunction of the inner ear, and does usually represent an ongoing disease process. It is believed to be the result of a plug of calcium carbonate and protein crystals (otoconia) that have become dislodged from the utricle, settling most frequently in the posterior semi-circular canal. The dislodged otoconia cause no problem until the patient moves in a manner that stimulates the offending semi-circular canal. The otoconia then begin moving, causing abnormal stimulation of the motion sensor in the affected ear. While the otoconia are in motion, the patient experiences conflicting signals from the two inner ears, resulting in transient vertigo. "Approximately 5.6 million medical appointments per year in the United States can be attributed to complaints of dizziness," said Neil Bhattacharyya, MD, chair of the multidisciplinary BPPV Guideline Panel. "We know now that anywhere from 17 to 42 percent of these patients will ultimately receive a diagnosis of BPPV. Unfortunately, proper diagnosis and treatment for those suffering is often delayed due to a lack of standardized diagnostic steps and relative unawareness of effective treatment options." The American Academy of Otolaryngology (AAO-HNS) sponsored a multi-specialty panel to develop evidence based guidelines for the most effective management of this common disorder. The guideline was created by a multidisciplinary panel of clinicians representing the fields of otolaryngology, audiology, emergency medicine, physical medicine and rehabilitation, geriatrics, physical therapy, family physicians, neurology, and chiropractics. According to Alan Desmond, Au.D., who represented Audiology on the panel, “One recent study performed in a general medical practice found that the incidence of BPPV in a geriatric population was actually 9 percent. The bottom line is that BPPV is very common, very distressing for the patient, and generally pretty easy to treat; however, the vast majority of cases are not correctly diagnosed or effectively treated. It’s estimated that less than 10 percent of BPPV patients are offered repositioning treatment.” The primary purposes of the new AAO-HNSF guideline are to “improve quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of the condition, reducing the inappropriate use of suppressant medications, decreasing the inappropriate use of ancillary tests such as radiographic imaging and vestibular testing, and to promote the use of effective repositioning maneuvers for treatment.” 1. BPPV should be diagnosed by performing the Dix-Hallpike test (detailed
2. BPPV should be treated with Canalith Repositioning Procedures (CRP),
3. Meclizine (Antivert) is not an appropriate, evidence based treatment for
4. Radiographic imaging and advanced vestibular function testing are not
needed in a patient diagnosed with BPPV. These tests are indicated if the diagnosis is unclear. "Clinical Practice Guideline on Benign Paroxysmal Positional Vertigo" appeared as a supplement to the November 2008 issue of Otolaryngology – Head and Neck Surgery, the peer-reviewed scientific journal of the American Academy of Otolaryngology – Head and Neck Surgery Foundation (AAO-HNSF) and the American Academy of Otolaryngologic Allergy. Full text of the guideline is available on the AAO-HNS website at http://www.entnet.org and at the journal site, http://www.otojournal.org. ANTIVERT AND DIZZINESS
Commonly prescribed, commonly ineffective
Considering how frequently Antivert (Meclizine) is prescribed for dizziness, its effectiveness has been measured in remarkably few studies. While there is general agreement among specialists that vestibular compensation is inhibited by the use of vestibular or central nervous system sedative medications, the literature suggests that these types of medications are used the majority of the time when a patient presents in the primary care setting with the complaint of dizziness, vertigo or imbalance. Well over half of these patients - 61 percent to 89 percent - receive some type of medication following their initial visit, Antivert being the most common. Dizziness is a vague term that can mean different things to different people. A recent study reports that of elderly patients complaining of dizziness, only 25 percent were describing rotary vertigo. On further questioning, approximately 75 percent described their dizziness as unsteadiness, dysequilibrium, loss of balance, or pre-syncopal lightheadedness. Although etiology of these complaints was not obtained, we know that BPPV is the most common cause of vertigo, and dysequilibrium and unsteadiness can be the result of vestibular and/or non-vestibular pathology. The intensity of vertigo associated with BPPV may be lessened when using Antivert. However, this is a less than ideal treatment for two reasons: a therapeutic dosage of Antivert creates a lasting sedating effect only to marginally reduce the intensity of symptoms, which last only a few seconds, and canalith repositioning procedures are extremely effective in relieving the symptoms of positional vertigo. In one study, approximately 90 percent of patients subsequently diagnosed with benign paroxysmal positional vertigo (BPPV) were given Antivert prior to receiving a correct diagnosis. Antivert (meclizine hydrochloride) is an antihistamine. According to the
Physicians Desk Reference, it is effective for “management of nausea and
vomiting and dizziness associated with motion sickness” and possibly effective
for “management of vertigo associated with diseases affecting the vestibular
system.” Antivert is not recommended for complaints of unsteadiness,
dysequilibrium, loss of balance, or pre-syncopal lightheadedness.
Medication taken to suppress vestibular symptoms ideally should be used only during the acute stage following vestibular insult. During the acute phase of vestibular dysfunction, typically lasting three to five days, vestibular suppressants are helpful in reducing the activity in the vestibular nuclei and cerebellum. Tonic asymmetry in activity in these areas creates the acute symptoms of vestibular-induced vertigo. In order for natural or therapeutically enhanced compensation to take place, the brain eventually must be made aware that an asymmetry exists. Appropriate treatment following the acute phase encourages activity to promote central compensation rather than suppression of stimulation needed for compensation. Many patients describing dizziness do not experience vertigo and may have perfectly normal vestibular function. However, since suppressant medications may hinder the function of the vestibular apparatus at a time when the patient is most dependent upon it, these patients actually may experience greater symptoms. Antivert is helpful for vertigo associated with sudden acute vestibular asymmetry due to Meniere’s disease or vestibular neuronitis, but should be withdrawn once the acute symptoms have diminished. It is not recommended for complaints of unsteadiness, loss of balance, and dysequilibrium, whether of vestibular origin or not. Vertigo related to BPPV is better treated through canalith repositioning techniques. Long-term use of Antivert is inappropriate, and the drug may be overprescribed in the primary care setting. This is a condensed version of an article by Desmond A, and Collie RB that first appeared (with references) in Advance for Audiologists, May/June 2001 Preventing Falls in the Elderly:
Can It Be Done?
Alan Desmond, Au.D.
Falls are the leading cause of injuries and injury deaths in the elderly population.
Falls leading to hip fracture often result in premature institutionalization and
death, as well as enormous health care costs. Approximately 40% of elderly
American patients with hip fractures die within one year or are placed in long
term care. Clearly, this is a staggering health care problem, which will increase
dramatically as the elderly population increases. No one argues that we, as
health care and medical professionals, should intervene. The questions are
rather, “What to do?” and “Will it actually make a difference?”
Much attention has been paid to this subject in
recent years, and systematic evaluation and
intervention is on the rise in the United States. In
fact, there is currently a bill before the US
Congress titled the “Elder Fall Prevention Act of
2002” with the stated goal “to expand and intensify
programs with respect to research and related
activities concerning elder falls.”
Poor balance and instability in the elderly has been
described as a “geriatric syndrome”, because the
specific cause of these complaints is often not
obvious to the examiner. This is primarily because
poor balance in the elderly is most often multi-
factorial, with no single clinical abnormality
responsible. The risk factors for increased likelihood of falling have been
identified, and intervention for these risk factors has been shown to significantly
reduce the risk of falling. Obviously, intervention can not eliminate the possibility
of an injurious fall, but research indicates that systematic evaluation and
intervention can dramatically reduce the likelihood of a fall.
Tinnetti et al (1994) studied a group of elderly (at least 70 years old) subjects
with known risk factors for falling. By applying interventions aimed at specific risk
factors, the intervention group had significantly fewer falls than the untreated
control group. Specifically, subjects identified with “balance impairment” had the
greatest reduction in falls (over 50% fewer). Close et al (1999) followed a group
of elderly (65 plus) patients that had presented to an emergency room after a fall
injury. After medical and occupational therapy assessment, the intervention
group received care for identified risk factors for falling. At one year follow-up,
the control group had more than twice as many falls than the intervention group.
Jacobson (2002) expanded on these findings by developing an assessment
protocol to identify risk factors in patients that had fallen or had fear of falling.
RISK FACTORS

The following is a list of known factors for increased risk of falling:
1. Vestibular Pathology – an impairment of the vestibular system can cause the
patient to become dizzy or off balance associated with certain movements and
certain visual environments.
2. Polypharmacy –The use of four or more prescription medications or the
initiation of a new medication or dosage have been associated with an increased
risk of falling.
3. Use of tricyclic anti-depressants or benzodiazepines are associated with
increased risk of falls. SSRI anti-depressants may have fewer side effects, but it
is not clear that they result in a reduced risk of falling compared to tricyclics and
benzodiazepines
4. Orthostatic (Postural) Hypotension – Postural pre-syncope associated with
orthostatic hypotension may result in an increased risk for falling when assuming
the upright position
5. Impaired Proprioception (Somatosensation) – The sense of touch is an
important contributor to balance and orientation. The stretch receptors in the
legs, the finger tips, and the soles of the feet, all provide feedback for balance.
6. Cerebellar Dysfunction – The integration of vestibular, visual and
proprioceptive information takes place in the cerebellum. Cerebellar dysfunction
can result in slow or inappropriate reaction to self movement or external visual
stimuli.
7. Hearing Loss -Hearing loss reduces ones orientation and awareness of ones
surroundings. A person with hearing loss is more likely to be startled by
movement in the visual field as they have fewer auditory warning signals.
8. Impaired Vision- Vision plays an important role in balance, and patients with
visual deficits have greater risk for falls. Visual problems associated with
decreased postural stability include: visual acuity less than 20/50, asymmetric
vision impairing binocular vision and depth perception, slow pupillary reaction
causing increased adaptation time when going from a lighted to a dark room and
vice versa, impaired peripheral vision.
9. Depression – Depressed patients may be more internally (therefore less
externally) aware. The use of antidepressants and anxiolytics increase the risk
of falling.
10. Impaired Cognition – Patients with impaired cognition may be less aware of
their surroundings or more likely to engage is risky activities.
11. Impaired Reaction Time – Many fall avoidance strategies are dependent on
reaction time when postural stability is challenged. Slower reaction time may
increase the risk of falls when the patient’s limits of stability are exceeded.

ASSESSMENT

Our program is modeled after that used at Vanderbilt University Medical Center.
We work with Physical Therapists in the region to provide a comprehensive
assessment of known risk factors. A report is then forwarded to the referring
physician with recommendations for intervention. Following a thorough history
interview, the patient undergoes a series of tests of hearing and vestibular
function (Audiogram, ENG, Rotary chair test and Posturography). Evaluation for
orthostatic hypotension and a review of medications is performed. Examination
for strength, sensation and range of motion of the lower extremities is performed.
Screening tests for depression and cognition are completed. The patient’s
lifestyle, goals, and concerns are reviewed.
INTERVENTION

Typically, there is no magic bullet, or single intervention that will make a
significant impact. Treating each identified risk factor has been shown (as noted
above) to reduce the risk of falling. Treating a vestibular disorder may eliminate
episodes of dizziness. Review of medications and possible side effects may
minimize some risk factors. Ongoing physical therapy and balance retraining can
increase mobility and independence. Modifications to the home may reduce the
number of fall hazards.

Source: http://joecannella.homeip.net:8888/x/BPPV/newsletter%20articles.pdf