A canalith repositioning maneuver(CRM), such as the Epley or Semont maneuver, should be the first-line treatment for benign paroxysmal positional vertigo (BPPV) in the elderly (strength of recommendation [SOR]: A, several good-quality randomized controlled trials [RCTs])

Clinch, C. Randall

Kahill, Ailisa

Klatt, Laura A.

Stewart, David

University of Missouri: MOspace

Evidence-based answers from the  Family Physicians Inquiries Network295jFPoNlINE.com Vol 59, No 5  |  mAY 2010  |  ThE jourNAl oF FAmIlY PrAcTIcEA canalith repositioning maneuver (Epley or Semont maneuver) is the first-line treatment for benign paroxysmal positional vertigo in the elderly. C. Randall Clinch, DO, MS; Ailisa Kahill, MD; Laura A. Klatt, MDDepartment of Family and Community Medicine, Wake Forest University  School of Medicine,  Winston-Salem, NCDavid Stewart, MSLS Carpenter Library, Wake Forest University School of Medicine, Winston-Salem, NCa canalith repositioning ma-neuver (CRM), such as the Ep-ley or Semont maneuver, should be the first-line treatment for benign paroxysmal positional vertigo (BPPV) in the elderly (strength of recommendation [SOR]: A, several good-quality randomized con-trolled trials [RCTs]). Following the Epley maneuver with self-treatment at home using a modified Epley procedure improves outcomes (SOR: B, a single good-quality RCT). Postural re-strictions aren’t necessary after CRM treat-ment (SOR: A, several good-quality RCTs).Medications don’t work as well as a CRM, but studies comparing treatments are limited (SOR: B, a single good-quality RCT). EvidEncE-basEd answEr What is the best approach to benign paroxysmal positional vertigo in the elderly?AEvidence summaryNo epidemiologic data on BPPV in the Unit-ed States are available, but experts describe increasing incidence with advancing age. A recent German study found a lifetime preva-lence of 2.4%, with a cumulative incidence approaching 10% by age 80.1 Treatments in-clude repositioning maneuvers (regimens of positioning the patient’s head and body) and medication. Evidence about treat-ing BPPV in elderly patients specifically is limited.2-4These 2 maneuvers work bestBoth Epley’s CRM and Semont’s liberatory maneuver have been shown to treat BPPV effectively. (For descriptions of the maneu-vers and video links, see “How the Epley and Semont maneuvers work” on page 296.)An RCT with 124 participants (mean age 58.3 years) demonstrated that either Epley’s or Semont’s maneuver decreased the frequency of vertigo more than a sham maneuver (P=.021 and P=.010, respectively).5 Both maneuvers were more effective than the Brandt-Daroff home exercises (P=.033).5 Another high-quality, double-blind RCT with 67 participants (median age 59 years) re-ported an improvement in vertigo and nystag-mus at 24 hours among 80% of patients treated with Epley’s CRM, compared with 10% of those who received a sham maneuver (P<.001; number needed to treat [NNT]=1; 95% confi-dence interval [CI], 1-2).6 An RCT that enrolled 80 participants (me-dian age 64 years) found complete resolution of BPPV symptoms and a negative Dix-Hallpike test 1 week after treatment in 88% of patients who re-ceived Epley’s CRM plus self-treatment (a modi-fied Epley’s maneuver) compared with 69% who received Epley’s CRM alone (P=.048; NNT=5; 95% CI, 3-124).7 Posture restrictions are unnecessaryAn RCT involving 50 participants (mean age 60.9 years) demonstrated that postprocedure postural restrictions were unnecessary and didn’t improve BPPV remission rates among patients receiving CRM (P=.97). No differ-ences were noted by age or sex.8 Two prospec-tive nonrandomized studies found that the recurrence rate of BPPV symptoms was 15% to 296 ThE jourNAl oF FAmIlY PrAcTIcE  |   mAY 2010  |   Vol 59, No 5Postural restrictions aren’t necessary after a canalith repositioning maneuver. 18% at 12 months and 37% to 50% at 40 to 60 months.9,10 Drug studies are scarce, but CRM  appears to work betterStudies of drug treatment among patients with BPPV are extremely limited because BPPV as a cause of vertigo is often an exclusion criterion among medication trials. A small (N=20; age range 32-67 years) double-blinded RCT found no difference in dizziness symptom scores for participants with BPPV who took diazepam (5 mg, 3 times daily), lorazepam (1 mg, 3 times daily), or placebo (1 capsule, 3 times daily) over a period of 4 weeks.11 An RCT of 156 patients (mean age 74 years) with BPPV compared a calcium channel blocker (flunarizine, which isn’t available in the United States) with Semont’s liberatory maneuver or no therapy (observation only). Semont’s maneuver was more effective at the 6-month follow-up than either the calcium channel blocker or no therapy; the rates of asymptomatic patients with a nega-tive Dix-Hallpike test at follow-up were 94%, 58%, and 34%, respectively (P<.001).3 Although meclizine is often used in clini-cal practice, only 1 double-blind RCT from 1972 (N=31, age range 21-77 years) reported improvement in symptoms and physical find-ings for meclizine compared with placebo in patients with BPPV.12 Recommendations In a review article, Furman and Cass describe the diagnostic maneuver (Dix-Hallpike) and How the Epley and semont maneuvers workThE EPLEy MAnEuvERA patient with right-ear BPPV sits on the exam table with her head turned 45° to the right, then lies down quickly on the table on a pillow positioned under her shoulders. After maintaining this position for 30 seconds, the patient turns her head 90° to the left without raising it from the table and waits 30 more seconds. The patient then turns her head and body as a unit 90° to the left and waits an-other 30 seconds before sitting up on the left side of the table.A patient with left-ear BPPV would perform the maneuver in a similar fash-ion, but would begin with her head positioned to the left side, eventually rotat-ing her body to the right side, and end by sitting up on the right side of the exam table.The following link leads to a video showing the modified Epley’s crm for treating right-ear, posterior canal BPPV: http://www.neurology.org/content/vol63/issue1/images/data/150/Dc1/video2.mpgThE SEMOnT MAnEuvERA patient with right-ear BPPV sits on the exam table with her head turned 45° to the left, then drops rapidly to the right side so that her head contacts the table just behind the right ear. After waiting in this position for 30 seconds, the patient moves quickly and smoothly toward the left side (without stopping in the upright position) so that the left side of her forehead rests on the exam table. She holds this position for 30 seconds, then sits upright again. A patient with left-ear BPPV would perform the maneuver in a similar fash-ion, but begin with her head positioned to the right side.The following link leads to a video demonstrating Semont’s liberatory maneu-ver for treating right-ear BPPV: http://www.neurology.org/content/vol63/issue1/images/data/150/Dc1/video1.mpg297jFPoNlINE.com Vol 59, No 5  |  mAY 2010  |  ThE jourNAl oF FAmIlY PrAcTIcEBENIgN PAroxYSmAl PoSITIoNAl VErTIgoreferencestreatment maneuver (Epley) for BPPV.13 They recommend using either Epley’s or Semont’s maneuver for initial treatment. The authors noted that vestibular suppres-sant medications may decrease the intensity of symptoms but don’t reduce the frequency of recurrent vertigo attacks. Moreover, medications produce unwanted side effects (somnolence, lethargy, worsened balance) and may prove counterproductive by delaying the central nervous system’s adaptation to a peripheral vestibular abnormality.                 JFP 1.  von Brevern M, Radtke A, Lezius F, et al. Epidemiology of benign paroxysmal positional vertigo: a population based study. J Neurol Neurosurg Psychiatry. 2007;78:710-715. 2.  Lea P, Kushnir M, Shpirer Y, et al. Approach to benign par-oxysmal positional vertigo in old age. Isr Med Assoc J. 2005;7:447-450.  3.  Salvinelli F, Trivelli M, Casale M, et al. Treatment of benign po-sitional vertigo in the elderly: a randomized trial. Laryngoscope. 2004;114:827-831.  4.  Angeli SI, Hawley R, Gomez O. Systematic approach to benign paroxysmal positional vertigo in the elderly. Otolaryngol Head Neck Surg. 2003;128:719-725.  5.  Cohen HS, Kimball KT. Effectiveness of treatments for benign paroxysmal positional vertigo of the posterior canal. Otol Neu-rotol. 2005;26:1034-1040.  6.  von Brevern M, Seelig T, Radtke A, et al. Short-term efficacy of Epley’s manoeuvre: a double-blind randomised trial. J Neurol Neurosurg Psychiatry. 2006;77:980-982.  7.  Tanimoto H, Doi K, Katata K, et al. Self-treatment for benign par-oxysmal positional vertigo of the posterior semicircular canal. Neurology. 2005;65:1299-1300. 8.  Simoceli L, Bittar RS, Greters ME. Posture restrictions do not in-terfere in the results of canalith repositioning maneuver. Rev Bras Otorrinolaringol. 2005;71:55-59.  9.  Nunez RA, Cass SP, Furman JM. Short- and long-term outcomes of canalith repositioning for benign paroxysmal positional ver-tigo. Otolaryngol Head Neck Surg. 2000;122:647-652. 10.  Sakaida M, Takeuchi K, Ishinaga H, et al. Long-term outcome of benign paroxysmal positional vertigo. Neurology. 2003;60:1532-1534. 11.  McClure JA, Willett JM. Lorazepam and diazepam in the treat-ment of benign paroxysmal vertigo. J Otolaryngol. 1980;9:472-477.  12.  Cohen B, DeJong JM. Meclizine and placebo in treating vertigo of vestibular origin. Relative efficacy in a double-blind study. Arch Neurol. 1972;27:129-135. 13.  Furman JM, Cass SP. Benign paroxysmal positional vertigo. N Engl J Med. 1999;341:1590-1596.SPONSORED BY THE AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE. THIS ONLINE ACTIVITY IS SUPPORTED BY AN EDUCATIONAL GRANT FROM SOLVAY PHARMACEUTICALS, INC. Issues in postmenopausal hormone therapyDEPRESSION, ENDOMETRIAL HEALTH, AND DISCONTINUATIONFREE 0.5 CME CREDITBoth physicians and patients report being confused by con icting reports of the safety and e  cacy of hormone therapy (HT). In this supplement to Sexuality, Reproduction and Menopause, 3 experts use case-based evidence to o er suggestions for prescribing HT to postmenopausal women who experience depression or vasomotor symptoms, or who want to discontinue HT.Available online at http://www.srm-ejournal.com/srm.asp?id=8035CASE 1    HT and new-onset depression  Nanette F. Santoro, MDCASE 2    Estrogen and endometrial health  Veronica A. Ravnikar, MD, FACOGCASE 3    Discontinuing HT James H. Liu, MD

What is the best approach to benign paroxysmal positional vertigo in the elderly?

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