Last week, I posed the question,” So, what do you do with a patient that presents with a history suggestive of BPPV, yet all vestibular exams, including the Dix-Hallpike, are negative?
We decided to do a little experiment. All patients fitting the above description were considered to possibly have “inactive BPPV.” There were 132 patients in this group. We broke these “inactive BPPV” patients down into two groups based on the length of time since their last episode of vertigo. One group was considered the remission group, and the other was labeled the fatigued group.
Patients were put in the Remission group if it had been more than 48/72 hours since their last episode. We put 72 patients in this group. We made the assumption that if they, in fact, were suffering from BPPV at the time the appointment was made, it had probably already resolved. In these cases, we explain the physiology and characteristics of BPPV, and instruct them to contact us when/if symptoms return.
The Fatigued group (n=60) included those patients that had had an episode of vertigo within 48 hours of their appointment. For these patients, we explain that “despite the negative exam, based on your description and lack of test findings for other explanations of your symptoms, we think there is a high probability you have BPPV but have fatigued out the response by doing the things people do as they prepare for their appointment” (drinking coffee, tying shoes, etc.) We explain that there is a 90% chance that the debri is located in the posterior canal. Unless they have identified a clear side (right or left) that triggers the episodes, we explain that it could be either ear, so we do exercises for both sides.
We put all patients in the fatigued group on one week of home exercises using a home version of the Epley Manuever, with instructions to do the exercises first thing in the morning and last thing at night. We feel that it is best to do the exercises when the particles have had a chance to settle, are more likely to trigger an episode, and are more likely to be moved out of canal during the exercise. We asked them to stop the exercises after seven days, then go one week without doing the exercises but resuming normal activities before seeing them at two week follow up.
Results
Remission group: We contacted each patient 30 days later. All these patients (100%) reported continued resolution of symptoms (no additional episodes of vertigo). We interpreted that as a high likelihood that our suspicion of resolved BPPV was probably correct, and that there was no other pathology causing their reported symptoms of positional vertigo.
Fatigued group: Some patients returned for follow up, some were followed up by phone. Here is what we found:
31 (of 60) returned for 2 week follow-up. All 31 (100%) resolved subjectively and by Dix-Hallpike exam.
21 better by phone report at 30 days
52 of 52 resolved at follow-up
8 no follow-up (call PRN)
Summary: All of the patients that returned for follow up Dix-Hallpike testing were better, both subjectively and objectively. Twenty one decided they didn’t need to make the drive to tell us they were better. We never heard from eight of them again. So, 52 of 52 were better after doing these exercises for one week.
What shall we conclude from these finding?
We know this is not a controlled study. This report is basically anecdotal, but it falls under the category of “Can’t hurt – -sure looks like it helps.”
So, are home exercises a reasonable alternative to in office Canalith Repositioning? Tune in next week.
Photo courtesy of https://www.med.unc.edu/ent/adunka/for-patients/symptoms-disorders/benign-paroxysmal-positional-vertigo-bppv
