May 3, 2023 at 4:23 am #2362bkennedyParticipant
I am wondering your thoughts about BPPV being a structural problem of the crystals in the semicircular canals which is what I was taught in medical school. It makes sense in that there is a bit of a delay after the movement with the symptoms starting, as explained to me the crystals lagging behind the fluid in moving past the nerve. However I wonder how much is MBS. Even before I knew of this work I noticed for years that the patients with BPPV generally had stress, history of anxiety, depression… I have a patient who I helped get rid of debilitating dizziness after she fell alone at home and broke her leg which was very scary for her. She understands that it was MBS and her anxiety. However, she has seen a PT along the way that told her about the crystals and does the Epley maneuver on her to help. She really likes this PT and feels very supported by her. So i think it is a placebo effect. Which on one hand is fine. BUt her dizziness came back yesterday and she is very distressed by it and fearful of it. I tried to talk to her about looking into why this may have happened, or calming the fear because now she understands it, it’s not dangerous… But she was just fixated on that is due to the crystals and had to get in to see her PT so she could do the Epley maneuver on her and fix it. Curious about others thoughts on it.May 3, 2023 at 12:23 pm #2364dschwarzParticipant
Whenever I see someone with a BPPV diagnosis, I rarely see it as the only reason (if a reason at all) for the dizziness. When BPPV is clear and the only issue, it is pretty easy to treat nearly every time (1-2 sessions with near if not full resolution)
For example, I had a recent home care patient (female, late 70s) with lateral/horizontal BPPV (cupulolithiasis) but neck pain with relief of dizziness with cervical distraction. However, also had a history of eustachian tube dysfunction, cardiac problems, and deconditioning which could indicate potential orthostatic hypotension, chronic GI problems including frequent diarrhea (every 1-3 hours), and a few other things. However, there was also stress of a daughter with frontotemporal dementia, hoarding behaviors, limited social interactions, aberrant sensitivity to pressure, difficulty sleeping, fear of falling, etc. So I addressed what I could related to the structure (conversion of the crystal to a more advantageous spot and getting it out of the canal). However, we then addressed the fears and pain through recognition of the behaviors that were exacerbating her symptoms such as helping her find better balance and increasing her tolerance to movement (some simple exercise), helping her find good rest (positioning for comfort), calming her system (reducing fear response with movement through visualization and graded motor imagery), and giving her external cues based on the calming imagery (moving like a wave versus telling her how she must move).
Other vestibular diagnoses are limited in their use though I think they may be more common such as Persistent Postural Perceptual Disorder (PPPD) and Mal de Debarquement. Unfortunately, well-meaning PTs do not want to break from the BPPV model because they can explain it more easily. The problem is that a functional neurological condition such as PPPD does respond to an Epley maneuver, but it likely only harms the patient as it gives a false hope with the mechanistic/structural explanation. In that sense, I would say it may not truly be a placebo but rather digging the patient down into their condition…in other words iatrogenic harm. The problem that I have found is that no matter how much you try to show a patient or even tell them that their PT was not really helpful before, the amount of time, effort, and money they put into that person does not allow for them to change their mind. A way I have reframed the benefit of the movement is that it is an exposure to a movement that is novel and it gives the opportunity for their system to build confidence, which can be done with plenty of other movements too…and then we work towards breaking free from that model of BPPV and only return to it if the signs and symptoms are clear.
I could go on about this because I normally do, but I will summarize: Dizziness can always be a functional neurological symptom, and I believe the science supports that an element of it is nearly every time as distress is common.May 4, 2023 at 3:34 pm #2374khughesParticipant
super helpful! thank you!May 4, 2023 at 6:18 pm #2376hschubinerModerator
Thanks very much for this discussion! I really don’t know if there is a simple BPPV diagnosis, but I would guess that some people have just that: a simple vestibular issue due to a virus or some crystal problem. I’d love to know if the Epley manuveurs are more of a placebo or not. It shouldn’t be hard to study real versus placebo Epleys!!
Best, HowardMay 4, 2023 at 7:49 pm #2381abatsonModerator
Chang, A. K., et al. (2004). “A randomized clinical trial to assess the efficacy of the Epley maneuver in the treatment of acute benign positional vertigo.” Acad Emerg Med 11(9): 918-924.
OBJECTIVES: To compare the efficacy of the Epley maneuver with that of a placebo maneuver in patients presenting to the emergency department (ED) with benign positional vertigo (BPV). METHODS: This was a prospective, randomized, single-blind placebo-controlled trial. Consecutive adult ED patients presenting to a university teaching hospital with BPV were randomized to treatment with either the Epley or placebo maneuver. The severity of vertigo was evaluated on a 0 to 10-point scale before and after the maneuvers. RESULTS: Eleven patients were randomized to the Epley group and 11 to the placebo group before the trial was terminated, based on a planned interim analysis. The median decreases in vertigo severity were 6 (95% confidence interval [95% CI] = 4 to 9) for the Epley group and 1 (95% CI = 0 to 3) for the placebo group (p = 0.001). CONCLUSIONS: The Epley maneuver is a simple bedside maneuver that appears to be more efficacious than a placebo maneuver in the treatment of acute BPV among ED patients.May 4, 2023 at 7:55 pm #2382abatsonModerator
Celis-Aguilar, E., et al. (2022). “Effectiveness of Brandt Daroff, Semont and Epley maneuvers in the treatment of Benign Paroxysmal Positional Vertigo: A Randomized Controlled Clinical Trial.” Indian J Otolaryngol Head Neck Surg 74(3): 314-321.
The aim was to compare the effectiveness of Brandt-Daroff, Semont and Epley maneuver in BPPV resolution. A Single Blind RCT in a Secondary Care Center was performed. Inclusion criteria were: patients with unilateral rotatory nystagmus on Dix-Hallpike Maneuver (DHM). Exclusion criteria: other causes of peripheral or central vertigo. Patients were randomized into 4 groups: Brandt-Daroff, “sham”, Semont and Epley. Patients underwent allocation, 1st visit (at 1 week with reprise of original maneuver if persistent nystagmus) and 2nd visit (2 to 4 weeks) with repetitions of both DHM and DHI. Main Outcome Measures: Absence of nystagmus on DHM at 1st and 2nd visit evaluations and DHI score. Resolution was defined as the abscence of nystagmus. We included 34 patients (25 females, 9 males). Patients were randomized to Brandt-Daroff (n = 9), “sham” (n = 7), Semont (n = 9) and Epley (n = 9) group. Overall mean age was 59.85 years (SD +/- 13.10). A total of 47.06% patients (n = 16) had negative DHM at 1st visit. Resolution for Brandt-Daroff was 22.22%, “sham” 28.57%, Semont 44.44% and Epley 88.88% (p = 0.024); at 2nd visit follow up, Epley achieved 100% resolution (other maneuvers: 42.86%, 16.67%, 44.44%, respectively. P = 0.006). The DHI improvement at 2nd visit for Brandt-Daroff was 21.17 points, “sham” 8.05, Semont 14.67 and Epley 61.78 (p = 0.001). Epley maneuver was superior to Brandt Daroff, “sham” and Semont maneuvers on nystagmus resolution and DHI improvement in patients with BPPV.May 4, 2023 at 9:04 pm #2386bkennedyParticipant
All very helpful! Thank youMay 4, 2023 at 11:24 pm #2391dschwarzParticipant
The most basic or simple BPPV is when it is clear from history and it is recent. A young to middle aged adult with a clear posterior canalithiasis BPPV is normally 1 session, maybe 2. This is the most common condition. Lateral canal treatment is tough and an cupulolithiasis treatment becomes much more difficult.
However, I don’t think that is what we are referring to. As otoliths generally dissolve over a few weeks or months and can naturally migrate out of the canal, I believe that we are talking about a sustained central nervous system response…though by that time it is hard to know if an otolith is still present or if it even ever was.May 5, 2023 at 12:04 am #2393mwoodsParticipant
Good discussion. I have found that the structural plus MBS explanation for BPPV fits best. Like others who have posted, I have seen this problem typically in the context of a host of other complaints (back to the circumstantial assessment, ROS, pain chart, etc, where other MBS diagnoses are frequently present). With a history of repeat BPPV occurrences, the predictive coding error/rumination-fixation and buy in to the structural (and perceived as dangerous) explanation have typically gotten entrenched. Better long term results seem to occur (anecdotally) with a 1st time BPPV presentation and successful Epley procedure, where there is later opportunity to address the other complaints, especially where one’s credibility is established after resolving the problem early on, regardless of its cause. Ruminative sorts who comb the internet and fuel their fears,
are particularly vulnerable in these cases ie in search of (often another) diagnosis.
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