Benign paroxysmal positional vertigo is a common disorder, characterized by a history of positional symptoms and positional nystagmus. The nystagmus is typically precipitated by a specific head-hanging maneuver, such as the Dix-Hallpike maneuver. The posterior semicircular canals of the vestibular labyrinth system have been recognized as the site of “injury” that produces the symptoms. Free-moving particles in the endolymph of the canals make the latter sensitive to position changes and produce the symptoms. At least one third of patients with benign paroxysmal positional vertigo have prolonged and disabling symptoms that do not respond to medical management (i.e., motion sickness medications). “Repositioning” therapies have been advocated for benign paroxysmal positional vertigo. These therapies involve positioning the head with standardized movements to displace any loose material in the canal. Previous studies of these therapies have been done in an uncontrolled manner, making determination of efficacy uncertain. Froehling and associates performed a randomized, controlled trial of the canalith repositioning procedure (CRP) for benign paroxysmal positional vertigo.
Patients who met specific criteria for benign paroxysmal positional vertigo were recruited. They were randomized to undergo CRP or a sham procedure. CRP was done in five steps. The five-position cycle was repeated until no positional nystagmus was elicited during any of the position changes or until a total of five cycles had been performed. In the sham procedure, patients were asked to lie on the examination table with the symptomatic side down for five minutes. Subsequent to the intervention, all patients were provided with a cervical collar and asked to sleep sitting up for the first two nights of the study. They were also asked not to sleep on the symptomatic side for an additional five days and to avoid excessive turning of the head for one week.
Fifty patients participated in the study (24 in the CRP maneuver, 26 in the sham maneuver). The average age of the participants was 64. Two thirds of the patients were women. The median duration of symptoms was 43 days in the CRP group, and there was similar use of meclizine in the two study groups. The authors found that 12 of the 24 patients (50 percent) who underwent CRP had resolution of vertigo compared with five of the 26 patients (19 percent) who underwent the sham maneuver.
The authors conclude that CRP is an effective intervention in patients with benign paroxysmal positional vertigo and can be performed in the outpatient setting.
editor's note: CRP is a straightforward maneuver that appears to be effective in treating this disabling condition. Family physicians should incorporate this procedure in the treatment of their patients with benign paroxysmal positional vertigo.—j.n.