JOURNAL READING“ The Role of Postural Restrictions

after BPPV Treatment: RealEffect on Successful Treatment and

BPPV’s Recurrence Rates “

Edited by :

Satriya Tjahja H.

Veransa Arizona

Concelors :

dr. Agus Sudarwi, Sp.THT-KL

dr. Afif Zjauhari, Sp.THT-KL

The Role of Postural Restrictions after BPPV Treatment: Real

Effect on Successful Treatment and BPPV’s Recurrence Rates

• George X. Papacharalampous,• P. V. Vlastarakos,• G. P. Kotsis,• D. Davilis,• L.Manolopoulos

ABSTRACT

Canalith repositioning techniques (CRT) as the

treatment of choice BPPV.

A retrospective review of 82 patients was conducted to determine the e cacy of ffi

postural restrictions, when combined with the classic CRT, for successful treatment and recurrence rates. Follow-up period

until 12 months after the initial treatment.

In this study, postural restrictions did not

appear to significantly a ect theff

outcomes of repositioning

maneuvers and recurrence rate.

there is no significant e ect of postmaneuver postural ffrestrictions on both treatment and recurrence rates.

larger multicentric research projects, adopting improved methodology, are still necessary in order to determine the contribution of such restrictions to both

the therapeutic results and the prevention of recurrence. Adequate follow-up, focusing on the first six months after the initially successful repositioning

maneuver, is important.

INTRODUCTIONBPPV is a common

peripheral vestibular disorder encountered in primary care

and specialist otolaryngology and neurology clinics.

Typically, BPPV is associated with a characteristic paroxysmal positional

nystagmus elicited withspecific diagnostic positional maneuvers

The patient is usually advised to

avoid sleeping over the a ected ear for the ffnext five days following the repositioning maneuver.

avoid head and trunk movement

use a cervical collar

sleep in a semiseated position for two days

The aim of the present study is to assess the efficacy of such restrictions, when combined with the classic canalith repositioning techniques. A retrospective chart review of 82 patients, divided into two different groups and treated either with canalith repositioning techniques plus postural restrictions or with repositioning maneuvers alone, was conducted.

Group B(CRT only)

82 patients with BBPV

Group ACRT and postural

restriction

Dix Hallpike diagnostic manuver

Follow up period until 12 months

By phone

TreatmentRecurrence rate

Statistic analyze with X2 and Student’s t-test

MATERIALS AND METHODS

Each group

Dix Hallpike diagnostic manuver

Horizontal canal involve

Anterior or posterior canal involve

Treated with Epley modified canalith

reposition maneuver

Treated with Vannucchi Maneuver

Just once

Reexamined after 7 days

Semont maneuver

Failure or incomplete remission

retreated

Complete remission

Follow up period until 12 months

Epley Maneuver

Vannucchi Maneuver

Semont Maneuver

• INCLUTIONS

1. Patients who suffering from BPPV

2. Age : 18-84 years

• EXCLUTIONS

1. Patients with abnormalities of central nervous system

RESULTS

82 patients BPPV

( 34 ♂ and 48♀)

Group A

17 ♂ and 24 ♀

Mean Age : 58.9 ± 13.7

Group B

18 ♂ and 23 ♀

Mean Age : 60.5 ± 14.8

GROUP A GROUP B TOTAL

Posterior semicircular canal

involvement32 34 66

Horizontal canal involvement

5 3 8

Anterior canal involvement

2 - 2

Posterior Canal affected bilateral

2 2 4

Successfully treated BPPV

appeared to be the posteriorcanal variant

30 30 60

DISCUSSIONSThe “canalith repositioning procedure” (CRP), induced by Epley in 1992, founded a new era in the treatment of BPPV

Various modifications proposed by several researchers, since Epley’s original description, developed and improved repositioning procedure towards an essential and e cient ffitherapeutic tool because of its simplicity, noninvasive nature, and apparent e ectiveness in relieving vertigoff

Most authors divide treated patients into two di erent groups: one ffgroup of individuals instructed to restrict their movement after CRP and another group (control group) of patients who are usually advised to behave normally at least after 48 hours from the last repositioning maneuver. Follow-up period varies between 3 and 12 months in most studies.

In our patients postural restrictions had no statistically significant contribution to successful treatment, as treatment rates were almost similar in both groups.

In addition, most of our patients, who were instructed to restrict their movement right after CRP, expressed a serious sense of discomfort.

Cakir et al. reported that such postural restrictions enhanced the e ect of canalith ffrepositioning, when the posterior semicircular canal is involved, especially in resistant cases

About half of our patients, classified in group A, expressed sleep disorders of some extent, mainly for the next two days following CRP, probably because of the awkward sleeping position that they were advised to adopt.

In our study, patients included in group B were given no

posttreatment instructions at all. Normal activity was

encouraged, even from the first hours after treatment. However, this fact did not a ect the final ff

result in a statistically significant level

In a recent study by McGinnis

et al., the authors stated that therapists could reduce the length of

postural restrictions to 24 hours upright, withoutadversely a ecting the ffsuccessful result of the

repositioningmaneuver

The follow-up period is not clearly defined in all studies.

Therefore, a follow-up periodof 6–12 months is recommended to avoid underestimatingrecurrence rates.

The crucial methodological advantages of the present study are :

(a) the number of patients is adequate, compared with most studies conducted and published during the 10 last years

(b) group B patients were given no postural restrictions at all, so that any probable e ect gained even from restricting head movement for ff24–48 hours (which is still advocated by most authors) is totally eliminated, along with the possible placebo e ect of such ffinstructions

(c) follow-up period comprises with the gold standards, suggested by the majority of researchers. Therefore, the possibility of missing any expected recurrences is considered to be almost negligible

(d) In the present study, each semicircular canal is evaluated separately, allowing comparative assessment of CRP among the di erent canal variants.ff

CONCLUSIONSAlthough the e cacy of canalith repositioning ffimaneuvers in the therapeutic management of BPPV has been definitely established in the literature, the role of the posttreatment instructions is still not clearly defined.

Even though most recent control studies state that there is no significant e ect of postmaneuver postural ffrestrictions on both treatment and recurrence rates, larger multicentric studies, adopting improved methodology, are still necessary in order to determine the realistic contribution of such restrictions to the final outcomes of the canalith repositioning techniques.

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