J Manipulative Physiol Ther. 2013 (Feb); 36 (2): 119–126 ~ FULL TEXT
Sandy S. Sajko, MSc, Kent Stuber, MSc, DC, Tim N. Welsh, PhD
Maple Grove Chiropractic Clinic,
OBJECTIVE: The purpose of this case series is to describe the management of benign paroxysmal positional vertigo in a chiropractic clinical setting.
CLINICAL FEATURES: Eight patients (4 women, 4 men) with symptoms of persistent benign paroxysmal positional vertigo presented for chiropractic care. The outcome measures included self-reported resolution of vertigo, a Short Form 12 Health Survey, Measure Yourself Medical Outcome Profile, and the Dix-Hallpike maneuver. Outcome measures were assessed at initial assessment, 6 days, 30 days, and 3 months postintervention.
INTERVENTION AND OUTCOME: The patients underwent one or more canalith repositioning procedures (Epley maneuver). Scores in each of the categories decreased from the initial to 6-day assessment and then again at the 30-day assessment. The effects of the treatment on the Short Form 12 scores showed changes between the initial assessment and 30 days posttreatment.
CONCLUSION: The patients in this case series demonstrated reduction in symptoms with chiropractic management.
Key Indexing Terms: Vertigo, Chiropractic, Benign Paroxysmal Positional Vertigo, BPPV, Dizziness, Nystagmus, Labyrinth Diseases, Head Movement
Benign paroxysmal positional vertigo (BPPV) is characterized by a brief recurrent episode of vertigo and nystagmus brought on by changes in head position with associated symptoms, which may or may not include nausea, balance difficulties, and light-headedness. [1–3] This condition is the most common cause of recurrent vertigo,  as between 17% and 42% of patients with vertigo have BPPV.  It is more common in women than men. [4, 5] The lifetime prevalence of BPPV is 2.4% overall, 3.2% for women and 1.6% for men, whereas the 1–year prevalence has been reported as 1.6% or 131.6 per 100000 people. [3, 4] The incidence of BPPV has been reported at a rate of 95.8 per 100000 people annually or 0.6% annually. [3, 4] Benign paroxysmal positional vertigo is more common in older individuals; the peak decades of onset are between the fifth and seventh, with the sixth decade as the most common; the average age of onset has generally been reported to be between 49 and 57 years. [1, 3–6] The 1–year prevalence of BPPV in those older than 60 years is 7 times higher than in the 18– to 39–year age group.  To date, several factors have been associated with an increased risk for developing BPPV including being female, advanced age, osteoporosis, endolymphatic hydrops, and head trauma.  Benign paroxysmal positional vertigo is considered idiopathic in more than 80% of cases; however, approximately 10% to 17% of cases are posttraumatic. [5, 8]
The predominant theory for the pathophysiology of BPPV is canalithiasis, whereby otoliths (ie, canaliths, which are calcium carbonate crystals) enter one of the semicircular canals and become entrapped. The entrapped otoliths cause inertial changes via a current of endolymph and produce abnormal stimulation of the inner ear with head motion in the plane of the canal. The end result is subsequent vertigo and nystagmus. [1, 3] The literature suggests that approximately 85% to 95% of all BPPV cases are attributed to the posterior canal, as it is in the most gravity-dependent position, compared with the horizontal canal, which accounts for 5% to 17% of BPPV cases, and the anterior canal, which accounts for 1% to 2% of BPPV cases. [1, 3, 5] It is postulated that the higher incidence involving the posterior canal may be because it is in the most gravity-dependent orientation.  Cupulolithiasis is another major theory for the pathophysiology of BPPV and involves the canaliths adhering to the cupula. 
Although BPPV is a benign condition, it can be debilitating for those dealing with the symptoms. Specifically, it can have an important impact on health and quality of life among the elderly, with higher rates of falls, depression, and impairment experienced among the elderly with BPPV when compared with those without BPPV. [1, 2] Furthermore, approximately 85% of BPPV patients experience an interruption in their activities of daily living, lose time from work, or seek medical consultation. 
As primary health care practitioners with a focus on neuromusculoskeletal conditions, doctors of chiropractic see patients with vertigo regularly, as the most recent job analysis from the National Board of Chiropractic Examiners suggests.  Chiropractic physicians indicated seeing patients with vertigo/loss of equilibrium “sometimes” (equated with 1–3 times per month), which corresponded with an average of 1.6 on a 0–to–4 scale.  The literature regarding the treatment of BPPV by doctors of chiropractic is sparse with only a few case reports published in the chiropractic literature [11–13] and 1 larger study of 60 vertigo patients, 9 of whom had BPPV.  Two of the single case reports [12, 13] detail the use of a canalith repositioning procedure (CRP) on BPPV patients. The purpose of this study is to present a case series detailing the diagnosis and management of BPPV in a chiropractic clinical setting.
Participants and Settings
The patients for this retrospective case series were selected over a 30–month period (August 2008 to February 2011). The subjects presented with a complaint of dizziness or vertigo and were referred by their primary care physician to 1 of 2 clinics in Southern Ontario (Maple Grove Chiropractic Clinic and the Sports Clinic at the University of Toronto-Mississauga). Patients had a chief complaint of vertigo and a recent referral from their family physician or medical specialist (neurologist or otolaryngologists) with indication of normal standard laboratory analyses, neurological examination, and the absence of spontaneous nystagmus.
Patients were English-speaking adults with a positive Dix-Hallpike test confirming a diagnosis of BPPV. None of the patients had a history of head or neck surgery, metabolic diseases, diagnoses of an ongoing central nervous system disease, otitis media, refused to participate or tolerate the Dix-Hallpike maneuver, severe cardiovascular disease (ie, transient ischemic attack, angina or hypertension), osteosclerosis, and any other red flags noted in the patient's medical screening questionnaires. Patient demographics are reported in Table 1. All participants provided written informed consent to the treatment and consent to be included in this case series.
All of the participants were referred by their medical physician/specialists with the diagnosis of BPPV. Participants were given a diagnosis of posterior canal BPPV if they had a history of vertigo that was provoked by changes in head position relative to gravity with nystagmus upon performing the Dix-Hallpike maneuver.
The Dix-Hallpike maneuver includes the following 2 steps:
first, the patient is seated and their head is turned 45° to the side to be tested to align the ipsilateral posterior semicircular canal with the sagittal plane of the body (Figure 1A).
Next, the patient is quickly brought to a supine position with the neck slightly extended to approximately 20° (Figure 1B). [1, 3, 15]
A positive test reproduces the vertigo and brings on up-beating rotary nystagmus toward the downside ear after a brief latency period. [1, 3, 15] The vertigo and nystagmus will dissipate within 1 minute, and it is important to note that the nystagmus is fatigable, meaning that repeated attempts of the Dix-Hallpike test will produce a diminished response.  It is imperative to note the latency and direction of the nystagmus as well as the duration of both the nystagmus and vertigo. 
The starting position for the maneuver is shown in A,
and the testing or finishing position is shown in B.
The Epley maneuver was used for these patients. This procedure is one of the most commonly used CRP for BPPV and was first described by JM Epley in 1980.  The modified Epley maneuver used for this case series was performed by initially having the patient seated with their head turned 45° toward the side of the vertigo. They were then brought to a supine position with the head and neck extended approximately 20° for 20 to 30 seconds with the head still turned 45°. The head was turned 90° toward the unaffected side, and the patient's head was held in this position for 20 to 30 seconds before the patient's body was turned 90° (lateral decubitus or in a side-lying position) and held there for another 20 to 30 seconds before being brought to a sitting position (Figure 2). [1, 3] When the patient was brought up to a seated position, head flexion was maintained for approximately 20 to 30 seconds. Participants in this study were seen a total of 3 times over a 6–day period and underwent the Epley maneuver on each of those visits if symptoms continued to persist.
The initial position is shown in A.
The patient lying supine with head rotated towards the affected/vertigo side is shown in B.
In C, the patient turns the head toward the unaffected side while in the supine position.
D, Then, the patient's head is stabilized while she rotates her body toward the unaffected side.
The finishing position is shown in E.
The outcome measures included self-reported resolution of vertigo, a Short Form 12 (SF-12) Health Survey, a Measure Yourself Medical Outcome Profile (MYMOP2), and the results of the Dix-Hallpike maneuver. The self-reported resolution of vertigo provided by the participants pertained to the changes in the duration, frequency of episodes, and the severity of the vertigo or dizziness symptoms. The SF-12 was used to provide a Physical Component Summary and Mental Component Summary scores at baseline and at 1 month posttreatment. [17, 18] Similarly, the MYMOP2 was used to provide a questionnaire to measure the effects of the Epley maneuver on their vertigo-related symptoms. 
Participants completed the SF-12 at the initial examination and 30 days posttreatment, whereas the MYMOP2 was completed at the initial assessment and at re-evaluation on day 6, day 30, and 3 months posttreatment.
All participant scores for the SF-12 (Physical Component Summary and Mental Component Summary) at the initial examination and 30 days posttreatment as well as the 5 individual scores for the MYMOP2 (symptom 1, symptom 2, activity, well-being, and profile) were coded and entered into an Excel spreadsheet and imported into SPSS Statistics 18 to perform the statistical analyses.
Eight patients, composed of 4 men and 4 women, with ages ranging from 27 to 72 years (mean, 48 years; SD, 16.7) were included in this case series.
The patients reported full resolution of their vertigo symptoms at an average of 8.63 days (SD, 3.85) following the initial treatment. Post–Epley maneuver scores on the MYMOP2 and SF-12 for each the 8 patients are shown in Figure 3. No differences were found between the 30–day and 3-month assessments in any of the MYMOP2 categories. This pattern of changes was observed in each of the 5 categories. Short Form 12 scores increased from the initial assessment and 30 days posttreatment for both the physical and mental component summaries (Figure 4).
The MYMOP category scores for each patient at initial assessment, 6 days, 30 days, and 3 months posttreatment.
Short Form 12 category scores for each patient at initial assessment and 30 days posttreatment physical component summary and mental component summary.
This case series is the first to date of patients with BPPV being managed in a chiropractic setting using CRP maneuvers, as the previous reports had only been single case reports. [12, 13] Among the strengths of this study was the use of validated outcome measures such as the SF-12 and MYMOP2. The MYMOP2 is a potentially valuable outcome measure to health professionals, as it is easy to use and can be used with any number of conditions.  Recently, use of the MYMOP2 has grown, and it has been used in chiropractic care,  acupuncture, [30–32] massage therapy,  and on conditions ranging from chronic bronchitis  to various tendinopathies. [35, 36] The MYMOP allows the patient to indicate and rate the severity of symptoms that are most important to them, the impact of those symptoms on their ability to perform a chosen activity of daily living while also providing an indication of their well-being.  The MYMOP has been found to be more responsive to change than the Short Form 36.  This study was also unique in that all of the patients in this case series arrived for chiropractic care through medical referral.
The Dix-Hallpike test may be considered the diagnostic standard for posterior semicircular BPPV, and its use has been recommended in clinical guidelines for diagnosis of posterior semicircular canal BPPV. [1, 15] Its sensitivity has been reported to be 79%, with a specificity of 75%, positive likelihood ratio of 3.17, and negative likelihood ratio of 0.28.  Several contraindications to the use of the Dix-Hallpike maneuver have been proposed particularly for those with cervical pathology.  Other tests for neurotologic condition such as brain magnetic resonance imaging, audiogram, serologic tests, brain computed tomographic scan, caloric electronystmography, and magnetic resonance angiography  are of little to no diagnostic value for isolated BPPV. It has been indicated that the elimination of such tests from the evaluation of patients with likely BPPV could produce substantial health care savings. 
An evaluation consisting history and physical examination with specific testing for positional nystagmus is advocated to improve diagnostic yield, reduce costs, and lead to faster improvements in patient status.  Regardless, it is still important to differentiate BPPV from other differential diagnoses for vertigo such Ménière disease, vestibular neuritis, labyrinthitis, superior canal dehiscence syndrome, migraine-associated dizziness, vertebrobasilar insufficiency, demyelinating diseases, central nervous system lesions, anxiety or panic disorder, cervicogenic vertigo, medication side effects, and postural hypotension.  The supine roll test is advocated in cases where BPPV seems likely but the Dix-Hallpike test is negative as a positive supine roll test indicates lateral semicircular canal BPPV.  Clinical guidelines for the management of BPPV indicate that radiographic imaging and/or vestibular testing are not recommended for cases with BPPV unless there is diagnostic uncertainty or the presence of additional signs or symptoms unrelated to BPPV that require evaluation.  This study shows use of the Dix-Hallpike test in a chiropractic setting can be successful in diagnosing patient with BPPV as evidenced by the positive treatment results achieved.
Canalith repositioning procedures have been indicated as the treatment of choice for BPPV as several clinical guidelines and systematic reviews have determined that these maneuvers are a safe and effective treatment for BPPV. [1, 3, 22] However, even with the use of CRPs, there may be a high recurrence rate for BPPV. Long-term recurrence rates of up to 51% [1, 23, 24] have been reported regardless of whether CRPs were performed. Approximately 50% to 80% of recurrences take place within the first 2 years, and approximately 95% will occur within the first 5 years. [23, 25, 26] Those with a previous history of BPPV episodes have higher recurrence rates.  Relapse rates are highest among those in their sixth decades and higher for females at a ratio of 3:2.  Endolymphatic hydrops, Ménière disease, central nervous system–related dizziness as a cofactor (including conditions such as migraine, acoustic neuroma, cavernoma, or vascular loop), and head trauma etiology has been identified as possible risk factors for BPPV recurrence. [7, 25]
The natural history of BPPV without CRP treatment has an average resolution time of 39 days from onset for patients with posterior canal BPPV and 16 days for horizontal canal BPPV.  Approximately 30% of posterior canal BPPV patients and 53% of horizontal canal BPPV patients will have their symptoms disappear within 1 week.  However, 36% of posterior canal BPPV patients and 11% of horizontal canal BPPV patients will have symptoms last over 1 month.  As such, the use of CRPs has been advocated as it should safely and effectively reduce the natural history of the condition.
There are several CRPs including those described by Epley and Semont, which appear to be effective for BPPV, although the Epley maneuver is the more widely studied and recognized manoeuvre.  The long-term effects of the Epley maneuver are largely unknown.  The use of mastoid oscillation with CRPs, originally used by Epley is not currently supported in the literature.  One-month follow-up is advocated after successful application of CRPs that lead to symptom resolution.  It is important for clinicians to provide counseling regarding the impact of BPPV on patient safety, possible recurrence, and the importance of follow-up. 
The use of Brandt-Daroff or habituation exercises have been found to be less than CRPs for posterior canal BPPV but can still be offered as possible rehabilitative therapy for BPPV. [1, 3] The routine prescription of any medications including vestibular suppressants for the treatment of BPPV is not supported or currently recommended by clinical practice guidelines. [1, 3] A recent meta-analysis of 523 patients treated with CRPs for BPPV showed that postural restrictions do not appear to significantly improve the efficacy or clinical outcomes of BPPV maneuvers ; these findings were in agreement with current clinical guidelines. 
The American Academy of Otolaryngology—Head and Neck Surgery Foundation has proposed various clinical practice guidelines for health practitioners, potentially including doctors of chiropractic, who manage patients with BPPV.  This case series demonstrates that patients with BPPV can receive care from doctors of chiropractic as they would from other health care professionals such as family medical doctors, medical specialists such as neurologists and otolaryngologists, and other manual and physical therapists and expect similar outcomes. [1, 3, 28]
There are limitations to this case series. It is not possible to attribute the patients' improvement solely to the Epley maneuver as a control group was not used to compare the intervention with natural history. It is possible that the patients may have improved in spite of treatment. However, all 8 patients showed important changes 6 days postintervention, which is a considerably shorter period than the usual period for natural history resolution of BPPV and no other clinical interventions were used in this case series. Another limitation was the relatively short follow-up period with 3 months as the final follow-up point in all cases. Given the recurrent nature of BPPV, longer follow-up periods extending past 1 year would have been beneficial to determine the frequency of BPPV recurrence in the subjects involved.
Finally, this case series was small; however, it still represents the largest case series conducted solely on BPPV patients in a chiropractic setting, particularly using guideline-recommended diagnostic and treatment interventions such as the Dix-Hallpike maneuver and CRP, respectively. Future research in this area is necessary to bring insight onto the cause of BPPV and the high recurrence rates as well as future research on the treatment of BPPV by doctors of chiropractic.
Benign paroxysmal positional vertigo is a common pathology that may present for chiropractic care. Based on the findings of this case series, the patients reported a measurable decrease in symptoms under chiropractic management.
Funding Sources and Potential Conflicts of Interest
No funding sources or conflicts of interest were reported for this study.
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