Web-Based System Shows Benefits for Recurrent Benign Positional Vertigo

Web-guided diagnosis and treatment of recurrent benign paroxysmal positional vertigo (BPPV) proved efficacious in a randomized parallel-group study in South Korea.

In an intention-to-treat analysis of 128 patients, 72.4% of those who performed a self-administered canalith repositioning maneuver (CRM) according to the type of BPPV diagnosed when they experienced recurrent episodes reported resolution of their vertigo compared with 42.9% of those who performed a self-administered CRM according to the type of BPPV that had been diagnosed at enrollment (P<0.001), reported Ji-Soo Kim, MD, PhD, of Seoul National University Bundang Hospital, and colleagues.

Meanwhile, in a per-protocol analysis, 82.4% of the treatment group and 51.7% of the control group reported vertigo resolution (P<0.001), they noted in JAMA Neurology.

Nassim Zecavati, MD, of the Children’s Hospital of Richmond in Virginia, told MedPage Today that “benign positional vertigo is a common and truly disabling neurological condition. The first time I experienced it, I thought I had woken up to an earthquake.”

“As a neurologist and member of the telehealth subcommittee of the American Academy of Neurology, I am very encouraged by the results of this study, which suggest that self-administered maneuvers like this one are effective when guided by a web-based tutorial,” she added.

Of people with vertigo, 17% to 42% have BPPV, and one in five of those affected have multiple recurrences after treatment, with an overall incidence of approximately 50% by 3 years. “Indeed, 20% of the patients enrolled in this study experienced recurrence within a half year,” Kim and team said.

“CRM results in immediate resolution of BPPV in about 80% of patients after a single application, and the success rate increases to 92% with repetition,” they noted.

The team cited previous reports showing that the majority of recurrences of idiopathic BPPV were not of the same type, and that idiopathic BPPV of the posterior canal seldom recurred in the same canal. “These findings indicate a random chance of BPPV subtypes when it recurs and suggest a limited efficacy of administering the CRM according to the subtype from the previous attack.”

Thus, the resolution of BPPV — i.e., no dizziness on waking or with changes in head position, and no spinning dizziness — reported by 51.7% of controls in the per-protocol analysis “may be explained by possible recurrence of the same type or spontaneous reduction of the otolithic debris, which is an occasional finding in BPPV,” they suggested.

Given the growing importance of telemedicine during the COVID-19 pandemic, and “the effectiveness of the questionnaire-based diagnosis and self-administration of the CRM in BPPV, BPPV appears to be a vestibular disorder that is highly appropriate for telemedicine and digital therapeutics,” Kim and colleagues wrote. “Thus, the system adopted in this study may be used for primary care physicians, particularly when making a tentative diagnosis over the telephone or during an office visit when a provocative maneuver is equivocal or cannot be done.”

“The take-home point is that this maneuver should only be self-administered when there is recurrence of an established diagnosis of BPPV,” Zecavati said. “All patients should have a comprehensive neurological evaluation and if that evaluation results in a diagnosis of BPPV, self-treatment should absolutely be an option for patients who experience recurrent bouts of vertigo. As we emerge from the COVID-19 pandemic, there are a few silver linings and I believe the ability to access care and treatment from home is one of them — certainly this study provides data to support this.”

For this double-blind study, Kim and co-authors included 585 patients with diagnosed and treated BPPV from multiple referral-based university hospitals in South Korea from July 2017 to February 2020.

Of the total study population, 21.9% had recurrence (58 in the treatment group and 70 in the control group), and 85.2% successfully used the web-based system.

The treatment group included 292 patients (mean age 60.3, 64% women), and the control group included 293 patients (mean age 61.1, 71% women).

Patients in the treatment group completed a simple six-question web-based questionnaire, previously shown “to diagnose the involved canal and type of BPPV with an accuracy of 71.2%.” These patients then viewed a video clip for self-administration of the CRM for the the type of BPPV diagnosed when they experienced recurrent positional vertigo. Patients in the control group did not complete the questionnaire, but received a video clip for self-administration of CRM according to the type of BPPV that had been diagnosed at enrollment.

Self-reported resolution of positional vertigo was independently assessed using a standardized questionnaire in a phone interview within 3 days of CRM completion.

Kim and team noted that their study only included patients with confirmed and treated BPPV, which was a limitation. In addition, patients with traumatic BPPV, which tends to recur more frequently, may have been overrepresented.