Two Symptoms Strongly Suggest Benign Paroxysmal Positional Vertigo in a Dizzy Patient

Dam, Victor S. van; Maas, Britta D. P. J.; Schermer, Tjard; Benthem, Peter-Paul G. van; Bruintjes, T.

doi:10.3389/fneur.2020.625776

Cited by 11 publications

(10 citation statements)

References 28 publications

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“…30 Older pwBPPV often present with more vague symptoms of general dizziness and instability rather than classic symptoms of vertigo, which are often considered a normal part of aging. 59,60 The cost to arrive at a diagnosis of BPPV is estimated at $2000, 61 and is associated with multiple consultations and unnecessary laboratory testing. This budget might even be an underestimation since it does not account for the consequences of the increased odds of falling in pwBPPV.…”

Section: Discussionmentioning

confidence: 99%

Gait and Falls in Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-analysis

Pauwels

Casters

Lemkens

et al. 2023

Journal of Neurologic Physical Therapy

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Background and Purpose: Benign paroxysmal positional vertigo (BPPV) is one of the most common vestibular disorders, and is treated effectively with particle repositioning maneuvers (PRM). The aim of this study was to assess the influence of BPPV and treatment effects of PRM on gait, falls, and fear of falling. Methods: Three databases and the reference lists of included articles were systematically searched for studies comparing gait and/or falls between (1) people with BPPV (pwBPPV) and controls and (2) pre- and posttreatment with PRM. The Joanna Briggs Institute critical appraisal tools were used to assess risk of bias. Results: Twenty of the 25 included studies were suitable for meta-analysis. Quality assessment resulted in 2 studies with high risk of bias, 13 with moderate risk, and 10 with low risk. PwBPPV walked slower and demonstrated more sway during tandem walking compared with controls. PwBPPV also walked slower during head rotations. After PRM, gait velocity during level walking increased significantly, and gait became safer according to gait assessment scales. Impairments during tandem walking and walking with head rotations did not improve. The number of fallers was significantly higher for pwBPPV than for controls. After treatment, the number of falls, number of pwBPPV who fell, and fear of falling decreased. Discussion and Conclusions: BPPV increases the odds of falls and negatively impacts spatiotemporal parameters of gait. PRM improves falls, fear of falling, and gait during level walking. Additional rehabilitation might be necessary to improve gait while walking with head movements or tandem walking. Video Abstract available for more insights from the authors (see the Supplemental Digital Content Video, available at: http://links.lww.com/JNPT/A421).

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Section: Discussionmentioning

confidence: 99%

Gait and Falls in Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-analysis

Pauwels

Casters

Lemkens

et al. 2023

Journal of Neurologic Physical Therapy

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“…However, careful history‐taking readily separates those with BPPV, since symptoms in BPPV usually also occur on reclining or when rolling over in bed 220 . Similarly, episodes that occur during sleep strongly suggest the diagnosis of BPPV 220,221 . Furthermore, patients with orthostatic hypotension rarely have nystagmus on positional testing unless the hypotension is profound 222 …”

Section: Methodsmentioning

confidence: 99%

“…220 Similarly, episodes that occur during sleep strongly suggest the diagnosis of BPPV. 220,221 Furthermore, patients with orthostatic hypotension rarely have nystagmus on positional testing unless the hypotension is profound. 222…”

Section: Summary Of Evidencementioning

confidence: 99%

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department

Edlow,

Carpenter,

Akhter

et al. 2023

Academic Emergency Medicine

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This third Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-3) from the Society for Academic Emergency Medicine is on the topic adult patients with acute dizziness and vertigo in the emergency department (ED). A multidisciplinary guideline panel applied the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding five questions for adult ED patients with acute dizziness of less than 2 weeks' duration. The intended population is adults presenting to the ED with acute dizziness or vertigo. The panel derived 15 evidence-based recommendations based on the timing and triggers of the dizziness but recognizes that alternative diagnostic approaches exist, such as the STANDING protocol and nystagmus examination in combination with gait unsteadiness or the presence of vascular risk factors. As an overarching recommendation, (1) emergency clinicians should receive training in bedside physical examination techniques for patients with the acute vestibular syndrome (AVS; HINTS) and the diagnostic and therapeutic maneuvers for benign paroxysmal positional vertigo (BPPV; Dix-Hallpike test and Epley maneuver). To help distinguish central from peripheral causes in patients with the AVS, we recommend: (2) use HINTS (for clinicians trained in its use) in patients with nystagmus, (3) use finger rub to further aid in excluding stroke in patients with nystagmus, (4) use severity of gait unsteadiness in patients without nystagmus, (5) do not use brain computed tomography (CT), (6) do not use routine magnetic resonance imaging (MRI) as a first-line test if a clinician trained in HINTS is available, and (7) use MRI as a confirmatory test in patients with central or equivocal HINTS examinations. In patients with the spontaneous episodic vestibular syndrome: (8) search for symptoms or signs of cerebral ischemia, (9) do not use CT, and (10) use CT angiography or MRI angiography if there is concern for transient ischemic attack. In patients with the triggered (positional) episodic vestibular syndrome, (11) use the Dix-Hallpike test to diagnose posterior canal BPPV (pc-BPPV), (12) do not use CT, and (13) do not use MRI routinely, unless atypical clinical features are present. In patients diagnosed with vestibular neuritis, (14) consider short-term steroids as a treatment option. In patients diagnosed with pc-BPPV, (15) treat with the Epley maneuver. It is clear that as of 2023, when applied in routine practice by emergency clinicians without special training, HINTS testing is inaccurate, partly due to use in the wrong patients and partly due to issues with its interpretation. Most emergency physicians have not received training in use of HINTS. As such, it is not standard of care, either in the legal sense of that term ("what the average physician would do in similar circumstances") or in the common parlance sense ("the standard action typically used by physicians in routine practice").

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“…One important clue to BPPV is the nighttime occurrence of episodes while in bed. 23,28,29 This finding in a dizzy patient had a positive likelihood ratio for BPPV of 60 (95% confidence interval 7 to 481). 23 Dizzy episodes while supine (at night or otherwise) would not occur in orthostatic hypotension, another common cause of a t-EVS.…”

Section: His Tory: When To Sus Pec T B Ppv and Perform The Dhtmentioning

confidence: 82%

“…One important clue to BPPV is the nighttime occurrence of episodes while in bed 23,28,29 . This finding in a dizzy patient had a positive likelihood ratio for BPPV of 60 (95% confidence interval 7 to 481) 23 .…”

Section: History: When To Suspect Bppv and Perform The Dhtmentioning

confidence: 94%

Benign paroxysmal positional vertigo: A practical approach for emergency physicians

Edlow

Kerber

2022

Academic Emergency Medicine

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Benign paroxysmal positional vertigo (BPPV) is a very common condition in the population and an important cause of acute vertigo or dizziness in patients presenting to an emergency department (ED). Despite this, abundant evidence shows that current ED management of patients with BPPV is suboptimal. Common ED management processes include brain imaging and treatment with vestibular suppressant medications such as meclizine, neither of which is recommended by current guidelines. The most efficient management of BPPV is to perform a bedside test (Dix‐Hallpike test) and then to treat the patients with a bedside positional (the Epley) maneuver. In this practical review we emphasize the efficient management for the most common form of BPPV—posterior canal BPPV. Using this management will reduce resource utilization (laboratory testing, brain imaging, specialist consultation), reduce ED length of stay, and reduce use of ineffective mediations that have side effects but little therapeutic effect. Application of these practices would improve important patient‐centered outcomes such as symptom reduction, radiation exposure, side effects from medications, and less need for urgent follow‐up with another health care provider. The article also discusses the approach to patients in whom the Dix‐Hallpike and/or Epley maneuvers do not seem to work. This includes a discussion the second most common variant of BPPV (horizontal canal BPPV) and criteria for safe discharge of patients. Another important advantage of learning BPPV best practices is that it is enormously satisfying for the clinician, not unlike treating a child with a nursemaid's elbow.

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Two Symptoms Strongly Suggest Benign Paroxysmal Positional Vertigo in a Dizzy Patient

Cited by 11 publications

References 28 publications

Gait and Falls in Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-analysis

Gait and Falls in Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-analysis

Guidelines for reasonable and appropriate care in the emergency department 3 (GRACE‐3): Acute dizziness and vertigo in the emergency department

Benign paroxysmal positional vertigo: A practical approach for emergency physicians

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