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W/ Modifications, Canalith Positioning Maneuver Safe & Effective for Treating Benign Positional Paroxysmal Vertigo in Elderl

A first of its kind research study finds that accommodating for cardiovascular and spinal problems increases the cure rate for the most common cause of dizziness.

San Diego, CA -- Benign positional paroxysmal vertigo (BPPV) is a disorder of the inner ear that is most associated with dizziness in the elderly. The condition is caused by a dislodging of very small crystals of calcium carbonate located in the inner ear. The crystals float into one of the three inner ear canals, become trapped, and create a sensation of spinning (vertigo) when the head is moved a certain way. The incidence of BPPV is estimated to be 10.7 to 64 per 100 000 per year, and this incidence increases with age. In the elderly population, BPPV and dizziness are associated with falls, a significant risk of serious injury and mortality.

In most cases if a patient has BPPV, the most effective treatment, has proven to be the canalith repositioning maneuver (CRM) pioneered by Dr. John Epley. The canalith repositioning maneuver is a series of head positions that cause the loosened crystals to fall out of the posterior semicircular canal into a less sensitive part of the inner ear where they may be absorbed more rapidly. The procedure is painless, although the patient may need to endure some vertigo. It can be done in the office, by the audiologist, physical therapist, or physician in less than one hour.
However, treatment of the elderly can present special challenges and concerns. Certain age-related illnesses such as degenerative osteoarthritic disease, cerebrovascular disease, peripheral neuropathy, autonomic dysfunction, and cognitive dysfunction are more common in this age group. The performance of the diagnostic Dix-Hallpike test and the repositioning maneuvers for treatment of BPPV can be harmful or inappropriate for the aged.

A research team has completed the first randomized, controlled study that specifically evaluates CRM efficiency in treating BPPV in the very old. Because this procedure requires significant head and neck manipulation, the study incorporated modifications to make the procedure safe and effective.

The authors of "Systematic Approach to BPPV in the Elderly" are Simon I. Angeli, MD, and Orlando Gomez PhD, from the University of Miami, Miami, FL; and Rose Hawley PT (physical therapist) from Sunspectrum Outpatient Rehabilitation, Jupiter, FL. Their findings are to be presented at the American Academy of Otolaryngology--Head and Neck Surgery Foundation Annual Meeting and OTO EXPO, September 22-25, 2002, at the San Diego Convention Center, San Diego, CA.

Methodology: The study was conducted in a private neurotological practice. Patients aged 70 years or older were eligible if they had complaints of vertigo provoked by changes in head position, lasting less than one minute, and accompanied by unilateral posterior semicircular canal BPPV. Forty-seven patients were enrolled in a two-part study.

Patients were randomized in two groups: in the treatment group, the patients underwent canalith repositioning maneuver; the control group participants were instructed to use anti-vertigo medications and avoid the motion changes that provoked vertigo. The outcome measure was the response to the Dix-Hallpike test one month after treatment. In the CPM group, 18 of 28 (64 percent) were cured; in the control group, only one of 19 had a negative test. Patients from both groups still indicating BPPV after one month were then treated with a combination of CPM and vestibular exercises, depending on their previous experience with the treatments. They were then re-evaluated six weeks later.

Results: Of the 28 patients who had participated in the second phase of the study, an additional 17 patients were cured, six had vertigo, and five were lost to follow-up. Overall, 36 of 42 patients (excluding the five lost to follow-up) patients were cured of vertigo by the end of the study.

The researchers identified risk factors as cerebrovascular disease (e.g., older age, family history, diabetes mellitus, hypertension, tobacco use, elevated blood cholesterol) and cervical spine disease that would limit head and neck motion, and searched for bruits of the carotid arteries and for orthostatic hypotension.

The study results revealed that only minimal neck extension such as that obtained by having the patient's head rest flat on the table, is necessary to elicit nystagmus. Therefore, they were able to avoid the head hanging position during the Dix-Hallpike test. When performing the CRM, a nurse stood by the table's side to support the patient's body and limbs, while the practitioner held the head to avoid extreme lateral torsion of the neck.

Conclusions: This study validates current use of CPM for the elderly and reinforces the idea that a customized, individualized program is better suited for a group of patients with a higher prevalence of compounding medical conditions such as the elderly. The findings also support a collaborative effort between the medical specialist and physical therapist in treating balance disorders in the elderly.

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