International Journal of Clinical Medicine, 2011, 2, 171-177
doi:10.4236/ijcm.2011.22029 Published Online May 2011 (http://www.SciRP.org/journal/ijcm)
Copyright © 2011 SciRes. IJCM
Long-Term Efficacy of Repositioning Maneuvers
in Benign Paroxysmal Positional Vertigo
Erika Barioni Mantello1,2, Ana Paula do Rego André1,2, Nathali Singaretti Moreno1,
Miguel Ângelo Hyppolito1, Julio Cesar Moriguti3
1Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, Faculty of Medicine of Ribeirão Preto, Univer-
sity of São Paulo, Ribeirão Preto, Brazil (HCFMRP-USP); 2University of Franca, São Paulo, Brazil; 3Department of Internal Medi-
cine, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil (HCFMRP-USP).
Email: mahyppo@fmrp.usp.br
Received September 3rd 2010; revised January 17th 2011; accepted January 18th 2011.
ABSTRACT
To determine the characteristics of 12 patients with a diagnosis of benign p aroxysmal positional vertigo (BPPV) treated
by the repositioning maneuver during a 24-month follow-up period after the initial discharge a longitudinal clinical
study was performed in which a questionnaire for the assessment of discomfort caused by dizziness was applied at the
first visit, at the last visit after treatment and 2 years after the initial disch arge. Repositioning treatment was again of-
fered to patients who suffered relapses. In 10 cases (83.34%) there was no recurrence of symptoms and 2 patients
(16.66%) presented symptoms exactly 2 years after the original discharge showing that treatment of BPPV by reposi-
tioning manuevers is effective in the long term, but new studies in larger populations are needed to determine the pat-
tern of the rates of recurrence of BPPV.
Keywords: Positional Vertigo, Dizziness, Recurrence Omponen
1. Introduction
Benign paroxysmal positional vertigo (BPPV) is a fre-
quent peripheral dysfunction of the vestibular system
characterized by brief episodes of vertigo when the head
is moved in certain positions. In addition to rotary dizzi-
ness, this causes positional nausea, vomiting, sudoresis,
disequilibrium, tinnitus and sometimes hearing loss [1].
BPPV occurs when degenerated calcium carbonate parti-
cles of the utricular otoconia are dislodged by the action
of gravity and by movement of the head, remaining sus-
pended in the semicircular canals (ductolithiasis) or ad-
hering to their cupula (cupulolithiasis) [2]. The causes of
this conditions are varied, one of them being traumatic
injury to the skull; howev er, most cases are of idiopathic
origin.
Recent knowledge about the physiopathology of BPPV
has led to different treatment approaches, with reposi-
tioning maneuvers gaining more space due to the high
cure rate and the short treatment time. These maneuvers
can reposition the otoliths back into the utricle, whereas
medications have no effect on repositioning, simply treat-
ing the neurovegetative symptoms inherent to the periph-
eral vestibular signs and symptoms. In some cases the
patients are discharged within one week, after a single
repositi oning mane uver [3].
Repositioning maneuvers are an alternative type of
treatment for individuals with positional dizziness (the
type most frequently detected) or chronic or central diz-
ziness or dizziness occurring in bouts. Until recently, re-
positioning maneuvers were strictly associated with ves-
tibular rehabilitation (VR), a program of physical exer-
cises associated with a set of measures and changes in
habits aiming at the acceleration of vestibular compensa-
tion. VR is an important and effective strategy for the
treatment of indiv iduals with disorders of bodily equilib -
rium, providing a marked improvement of quality of life
[3]. Studies of VR in general, and specifically of BPPV,
conducted in recent years in Brazil as well as in other
countries are limited to the description of patient fol-
low-up after discharge and do not provide information
about recurrence [4-8].
Bittar et al. have described risk factors for patients in
whom repositioning treatment fails or who experience
recurrences [2]. Some of these factors are: inappropriate
indication, vasomotor instability, physical limitations,
psychiatric problems, and traumatic skull-brain injuries
[2]. Epley reported a 30% to 45% recurrence rate among
Long-Term Efficacy of Repositioning Maneuvers in Benign Paroxysmal Positional Vertigo
172
patients [9]. There is great interest in this topic, as dem-
onstrated by the large number of published papers and
investigations conducted both in Brazil and at university
centers all over the world regarding the maneuvers of
BPPV treatment. However, few studies have reported on
patient follow-up over a long period of time after dis-
charge in order to determine possible recurrences of the
disease, which would permit a longitudinal view of the
real therapeutic efficacy of this approach to BPPV reha-
bilitation.
Cohen and Jerabeck detected an almost null rate of
recurrence of symptoms in a population of 87 patients
after a 6 month follow-up regarding the frequency and
intensity of vertigo [10]. Hain et al. detected a 17% rate
of recurrence during the first four to six months after
treatment, increasing to 47% among patients treated with
VR after 5 years of follow-up [11]. Sidhar and Panda
detected recurrences in 5% of their patients six months
after treatment, with an increase to 10% one year after
treatment [5].
Although there is consensus in the literature that the
Epley maneuver is an excellent method for the treatment
of BPPV for the vertical canal, new studies are needed to
investigate vestibular suppressors and surgical treatment,
as well as an extended patient follow-up since the ma-
neuver does not guarantee complete long-term resolution
of symptoms [11]. Although many studies have con-
firmed the therapeutic efficacy of this method, especially
in BPPV, few authors have commented about the possi-
bility of recurrence [2-8,10-17]. Thus, it is important to
follow up patients submitted to this modality of treatment
in order to determine whether the repositioning maneu-
vers used for BPPV were actually effective on a long-
term basis. This is also important in order to define a new
conduct in cases of relapse and to determine whether VR
contributed to a second etiologic diagnosis leading to a
new treatment of vertigo.
The general objective of the present study was to fol-
low up 12 patients diagnosed with BPPV and treated
with the repositioning maneuver during the first 24
months after discharge, and the specific objectives were
to determine the occurrence of relapses and to characte-
rize relapsing patients with labyrinth symptoms.
2. Material and Methods
The study was conducted on 12 patients, 2 males and 10
females, ranging in age from 22 to 75 years, with a di-
agnosis of BPPV confirmed by an otorhinolaryngologist
and treated for more than 24 months by a speech thera-
pist with repositioning maneuvers. The repositioning
maneuvers used for treatment were the Epley maneuver
for otolith repositioning an d the Brandt-Daroff maneuver
for therapeutic complementation in partially asympto-
matic cases. The Dix-Hallpike test was used for treat-
ment monitoring and for the detection of recurrences [8,9,
13]. After the first repositioning maneuver, the protocol
described in Enclosure I was followed. Vestibulo-visual
and proprioceptive exercises were performed. For the
phonoaudiologic treatment of VR, exercises were indi-
cated in order to accelerate vestibular compensation.
These exercises were performed slowly and gradually at
the patient’s home, with the patient initially sitting down,
in order to stimulate the vestibulo-ocular reflexes (Fig-
ure 1), followed by stimulation of the vestibulospinal
reflex (Figure 2) [15]. The exercises were performed 3
times a day, with 20 repetitions during each period.
The study was approved by the Research Ethics Com-
mittee of the University of Franca (UNIFRAN - protocol
no. 162/03) and all pa tients gave written informed consent
sent to participate. Data were obtained from the medical
records of the 12 patients with a diagnosis of BPPV
treated with repositioning maneuvers from May to July
2002. The patients were called on the telephone and in-
vited to participate in a late follow-up study two years
after being submitted to treatment for BPPV. After the
patients accepted to participate, they were briefly inter-
viewed about their curr ent symptoms and responded to a
questionnaire for the assessment of discomfort concern-
ing the severity of the symptoms on initial visit to mild,
moderate, moderately severe, severe, serious or incapa-
citating and about therapeutic success on final visit to
asymptomatic, partial success, relative success, un-
changed and Failure (Enclosure II), the same applied
immediately after their initial discharge [18].
3. Results
Of the 12 patients who participated in the study, 83.34%
(n = 10) had no recurrence of the symptoms related to
BPPV over the last two years, whereas 16.66% (n = 2)
experienced recurrence of symptoms by 18 months after
discharge from the first treatment of BPPV. All the 10
patients with no recurrence of symptoms reported that
they had continued to follow dietary guidelines and
changes in life habits and to engage in sports activities on
a daily basis throughout the period after discharg e. Of the
two patients who suffered recurrence of symptoms, only
one (50%) continued to follow the suggested guidelines.
During the evaluation conducted before treatment,
when the etiologic diagnosis of BPPV was confirmed,
33.33% (n = 4) of the subjects stated that vertigo caused
them severe discomfort, 33.33% (n = 4) reported moder-
ately severe discomfort, 25% (n = 3) reported moderate
discomfort, and 8.33% (n = 1) reporte d serious discom fort.
During the ev aluation performed one da y after the end
of treatment, 83.33% (n = 10) of the patients presented
treatment success, remaining asymptomatic. One patient
Copyright © 2011 SciRes. IJCM
Long-Term Efficacy of Repositioning Maneuvers in Benign Paroxysmal Positional Vertigo 173
Enclosure I. Flow diagram for the treatment of BPPV.
(8.33%) reported partial success and important im-
provement, and the last patient (8.33%) was unable to
return to finalize treatment.
During the evaluation performed two years after dis-
charge, of the 10 patients who reported treatment suc-
cess (83.33%) and were asymptomatic, 75% (n = 9)
maintained treatment success, a fact demonstrating the
efficacy of the repositioning maneuver up to two years
after treatment in these cases of BPPV. Only two patients
(16.66%) reported current recurrence of vertigo, charac-
terizing partial treatment success.
The data obtained were analyzed statistically by the
Copyright © 2011 SciRes. IJCM
Long-Term Efficacy of Repositioning Maneuvers in Benign Paroxysmal Positional Vertigo
174
Figure 1. Demonstration of the exercises for the stimulation
of the vestíbulo-ocular reflex.15
Figure 2. Demonstration of the exercises for the stimulation
of the vestibulo-ocular and vestibulospinal reflexes.
chi-square test for categorical data, which revealed sig-
nificant differences (p < 0.001) (Figure 3).
Paired pre- and post-treatment statistical analysis
(Figure 4) revealed a statistically significant difference
(p < 0.01), demonstrating treatment success after the re-
positioning maneuver. When the results obtained after
the first treatment were compared to those obtained 24
months after treatment (Figure 5), no significant diffe-
rence was observed (p = 0.99). Figure 6 shows a signifi-
cant difference of results between the first treatment and
the period of 2 years after it (p < 0.05), suggesting the
therapeutic success of the repositioning maneuver.
The two patients who suffered relapses were women
respectively aged 53 and 63 years who reported dizziness
of the rotary type (vertigo) in sporadic crises of mild to
Initial visit – Please indicate below the sentence that best descri-
bes what you feel (Shepa rd et al.
18
):
1 ( ) (mild) No n si g n ificant symptoms.
2 ( ) (moderate) Unpleasant symptoms.
3 ( ) (moderately severe) Being able to carry out the habitual
tasks, but the symptoms interfere with external activities.
4 ( ) (severe) The symptoms interrupt the execution of
habitual and external activities.
5 ( ) (serious) Currently on medical leave or had to quit
his job due to the symptoms.
6 ( ) (incapacitating) Unable to work for more than one
year or permanent disability.
Final visit - Please indicate below the sentence that best descri-
bes what you feel (adapted from Shepard et al.
18
):
1 ( ) (Therapeutic success) Asymptomatic.
2 ( ) (Partial success) Important improvement during the
rest of the day after treatment.
3 ( ) (Relative success) Discrete improvement, symptoms
defined and present.
4 ( ) (Unchanged) No improvement or worsening of sym-
ptoms.
5 ( ) (Failure) Worsening of symptoms after treatment.
Enclosure II. Assessment of discomfort.
Figure 3. Assessment of patient discomfort in the pretreat-
ment situation (1, mild; 2, moderate; 3, moderately severe;
4, severe; 5, serious; 6, incapacitating) and after treatment,
2 years after the initial discharge or currently (1, treatment
success; 2, partial success; 3, relative success; 4, unchanged;
5, failure).
Figure 4. Assessment of patient discomfort in the pretreat-
ment situation (1, mild; 2, moderate; 3, moderately severe;
4, severe; 5, serious; 6, incapacitating) and after treatment,
(1, treatment success; 2, partial success; 3, relative success;
4, unchanged; 5, failure).
Copyright © 2011 SciRes. IJCM
Long-Term Efficacy of Repositioning Maneuvers in Benign Paroxysmal Positional Vertigo175
Figure 5. Assessment of patient discomfort in the post-
treatment situation (1, treatment success; 2, partial success;
3, relative success; 4, unchanged; 5, failure) and 2 years
after the initial discharge or currently (1, treatment success;
2, partial success; 3, relative success; 4, unchanged; 5, fail-
ure).
Figure 6. Assessment of patient discomfort in the pretreat-
ment situation (1, mild; 2, moderate; 3, moderately severe;
4, severe; 5, serious; 6, incapacitating) and 2 years after the
initial discharge or currently (1, treatment success; 2, par-
tial success; 3, relative success; 4, unchanged; 5, failure).
moderate intensity, with worsening of symptoms in the
presence of abrupt head movements, a fact possibly char-
acterizing a recurrence of BPPV.
Both patients also reported postural instability. In pa-
tient 1, the recurrence of symptoms coincided with crises
of arterial hypertension. The patient had excess body
weight and presented cervicospin al alteration, which con-
traindicated the execution of physical activity. She was
taking medications for obesity, depression and arterial
hypertension. Because of the impossibility to perform
physical exercises, the maneuvers for the treatment of
BPPV were contraindicated. The cited exercises of ve-
stibular compensation were indicated for VR and the
patient presented improvement of symptoms two months
after treatment. Patient 2 continued to follow the guide-
lines suggested after discharge, daily walks in particular.
After recovering from an episode of the flu, she gradu-
ally returned to her physical activities and to the Brandt-
Daroff exercises. She was instructed to perform these
exercises twice a day for three months, showing no
symptoms after this period.
4. Discussion
In a study of a population of 87 patients, Cohen and
Jarabeck detected a significant rate of recurrence of fre-
quency and intensity of vertigo after six months. Few of
these patients reported residual vertigo, which did not
require a new evaluation or treatment since these residual
symptoms did not interfere with their daily routine [10].
Hain et al. detected a 17% rate of recurrence during
the first four to six months after treatment, increasing to
47% of patients treated by the repositioning maneuver
after five years of follow-up [11]. These results suggest
that there is a cumulative increase of BPPV recurrence
over time [11]. In the present study, although two pa-
tients suffered relapses, we may state that, for this spe-
cific study, the repositioning maneuver presented thera-
peutic success even two years after discharge, suggesting
in a statistically significant manner that the sample of
two years ago and the present sample remained un-
changed, with the absence of BPPV symptoms.
Sidhar and Panda detected recurrence in 5% of a group
of 40 patients after six months of treatment, a rate that
increased to 10% one year after discharge from treatment
[17]. Maia et al. detected a 12.5% rate of recurrence one
year after discharge in a group of eight patients [14]. The
cases in question were treated again by repositioning
maneuvers with therapeutic success, in agreement with
the proposals of Epley, who stated that, even among pa-
tients correctly treated for BPPV, there may be a rate of
recurrence of symptoms of 30 to 45% [9].
In the present study, 83.34% of the patients presented
no recurrence of symptoms related to vertigo after dis-
charge from treatment, whereas 16.66% of the patients
did present recurrence, a fact that was not statistically
significant for the sample studied. We observed rates
similar to those reported by Maia et al. and Sidhar and
Panda, who detected rates of 10 and 12.5%, respectively,
after one year of follow-up [14,17]. We did not find
studies with a follow-up of two years; however, it should
be pointed out that relapsing patients experienced symp-
toms starting one year and four months after discharge.
Comparison of patient symptoms before and after
treatment and comparison of symptoms before treatment
and current symptoms revealed statistically significant
differences for both situations (p < 0.01 and p < 0.05,
respectively). There results were quantitated and ana-
lyzed statistically by qualitati ve assessment of symptoms
before and after treatment, emphasizing the importance
of this type of evaluation for the monitoring of treatment
and the definition of discharge, since objective otoneu-
rologic evaluation contributes little to the quantitation of
symptoms before and after treatment of BPPV by pro-
viding normal resu lts without specific findings fo r BPPV
in caloric tests, thus being of little diagnostic help [14 ].
The patients with recurrent vertigo were older than 50
years, in agreement with other studies that attributed the
Copyright © 2011 SciRes. IJCM
Long-Term Efficacy of Repositioning Maneuvers in Benign Paroxysmal Positional Vertigo
176
greater involvement of older patients to a decline in the
function of vestibular nuclei and of central vestibular
pathways [2,18,21]. However, the age of the patients is
not a factor that influences the rate of recurrence of
symptoms [20]. The groups with recurrence presented
the first symptoms starting one year and four months
after discharge, as also observed by Hain et al. who re-
ported that recurrence of symptoms in BPPV were
mainly observed during the first two years after dis-
charge [20]. The characteristics of the recurring symp-
toms in both patients clearly demonstrate, based on
clinical history, recurrence of BPPV, which is the most
common type of dysfunction of the vestibular system,
characterized by sporadic crises of vertigo of short dura-
tion and variable intensity occurring when the head is
moved in certain positions [1,21].
The first patient suffered recurrence of symptoms as-
sociated with crises of arterial hypertension, with hyper-
tension being diagnosed after labyrinth crises treated in
the hospital setting. The various vestibulopathies may be
secondary to vascular disorders such as arterial hypoten-
sion or hypertension and arteriosclerosis [22]. Other fac-
tors contributing to vestibular disorders were the appar-
ent excess weight and cervicospinal alteration that led to
the contraindication of physical activities, with the pa-
tient requiring medications for obesity, depression and
arterial hypertension. Cervicospinal alterations are an
important contraindication of the repositioning maneuver,
as well as a limitation of body movements, impairing
vestibular compensation. Thus, the patients presented
variables that impaired the maintenance of the bodily
equilibrium obtained after the initial treatment, which
probably induced recurrences.
The second patient had a milder complaint compared
to the first and she continued to follow the guidelines
received after discharge from the first treatment, espe-
cially daily walks. After suffering a cold, she presented
recurrence of the characteristic symptoms of BPPV, al-
though of mild intensity. The flu, colds, migraine and
other factors affecting the health and general well-being
of an individual impair the progression of treatment.
Thus, the patient should first treat these disorders and
then restart the program of vestibular treatment by means
of repositioning maneuvers only after their cure. At the
end of treatment with cold medications, the patient gra-
dually resumed her physical activities and the Brandt-
Daroff exercises, as previously recommended. Although
it can be effectively treated, BPPV is a disease that tends
to recur and, most of th e times the treatment ind icated for
the recurring symptoms is based on Brandt-Daroff exer-
cises [11].
Questionnaires containing qualitative measures are of
help for the assessment and monitoring of treatment for
BPPV and can be of help for the determination of the
time of discharge after the initial treatment.
To this sample of patients results to a long-term fol-
low-up were obtained for the treatment of the posterior
canal BPPV based on repositioning maneuvers with
highly effective. However, studies on larger populations
of patients with BPPV are needed to characterize the real
long-term efficacy of maneuvers in BPPV, contributing
to a standardization of the rates of recurrence of symp-
toms.
5. Conclusions
Vestibular treatment of BPPV based on repositioning
maneuvers is highly effective, with long-term results
over a two year period of follow-up.
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