Uitgangsvraag

Zijn repositiemanoeuvres geschikt als therapie om patiënten met BPPD te behandelen?

Aanbeveling

Bij een zekere en waarschijnlijke p-BPPD is behandeling met een Epley- of Semontmanoeuvre geïndiceerd.

 

Er zijn aanwijzingen dat bij een h-BPPD behandeling met de log-roll manoeuvre of Lempert manoeuvre effectief is.

 

Er is onvoldoende bekend over de effectiviteit van repositiemanoeuvres bij de behandeling van a-BPPD.

 

Behandeling van BPPD dient door een arts of specifiek daartoe geschoolde paramedicus te geschieden. 

Conclusies

 

Niveau 2

Bij zekere en atypische p-BPPD zijn de ‘canalith repositiemanoeuvre’ (CRM, ook wel Epley manoeuvre genoemd) en 2) de bevrijdingsmanoeuvre (ook wel Semontmanoeuvre genoemd) bewezen effectief. Voor andere behandelstrategieën is geen kwalitatief goed bewijs.

Er is onvoldoende bewijs dat mastoidvibraties de effectiviteit van een repositiemanoeuvre verhogen bij p-BPPD.

 

 

 

Niveau 3

Er zijn aanwijzingen dat de ‘log roll manoeuvre’ of Lempert manoeuvre effectief is bij de behandeling van h-BPPD.

Andere manoeuvres zijn mogelijk ook effectief.

Er is onvoldoende bewijs dat mastoidvibraties de effectiviteit van een repositiemanoeuvre verhogen bij h-BPPD.

 

 

Niveau 4

Er is onvoldoende bekend over de effectiviteit van repositie manoeuvres bij de behandeling van a-BPPD.

 

 

Niveau 4

Er is geen bewijs dat postmanoeuvre beperkingen de effectiviteit van een repositie manoeuvre bij p-BPPD beïnvloeden.

Bronnen: niveau D: (Massoud, et al., 1996) (Blakley, et al., 1994) (Lempert, et al., 1997) (Wolf, et al., 1999) (Asawavichianginda, et al., 2009) (Asawavichianginda, et al., 2009)

Samenvatting literatuur

Although it has been historically commonplace to reassure patients diagnosed with BPPV that their condition is benign and is likely to spontaneously remit in the subsequent months, recent relatively high-quality evidence supports active, expeditious treatment with a particle repositioning maneuver (PRM). Treatment with PRMs consistently eliminates the vertigo due to BPPV, improves quality of life, and reduces the risks of falling.

 

Posterior Canal BPPV Treatments

Two types of PRMs have been found effective for posterior canal BPPV: 1) the canalith repositioning procedure (CRP, also referred to as the Epley maneuver) and 2) the liberatory maneuver (also called the Semont maneuver). Other PRMs have been proposed for the treatment of posterior canal BPPV, but high-quality, reproducible data that demonstrate their clinical efficacies are lacking.

 

Treatment with canalith repositioning procedure. CRP was first described by Epley in 1992 (Epley, et al., 1992). Through a series of head position changes, the CRP moves the canaliths from the posterior semicircular canal to the vestibule, thereby relieving the stimulus from the semicircular canal that had been producing the vertigo in BPPV. CRP is most commonly performed in the outpatient setting by a clinician after confirmation of the diagnosis of posterior canal BPPV (Fife, et al., 2008). Patients should be informed that nausea, occasional vomiting, and/or a sense of falling may arise during the CRP (Uneri, et al., 2005). Patients who previously manifested severe nausea and/or vomiting with the Dix-Hallpike maneuver may be considered for antiemetic prophylaxis during the CRP. Figure 5.1 depicts the CRP for posterior canal BPPV. Several RCTs have been published evaluating the efficacy of the CRP in the treatment of posterior canal BPPV. A number of these are high-quality RCTs, several of which have been included in a relatively recent Cochrane collaborative review of the Epley maneuver for BPPV (Hilton, et al., 2004) (Froehling, et al., 2000) (Lynn, et al., 1995) (Yimtae, et al., 2003). The Cochrane review identified a statistically significant effect in favor of the CRP compared with controls. An odds ratio of 4.2 (95% confidence interval, 2.0-9.1) was found in favor of treatment for subjective symptom resolution in posterior canal BPPV; an odds ratio of 5.1 (95% confidence interval, 2.3-11.4) was found in favor of treatment for conversion of a positive to negative Dix-Hallpike test. Another systematic review of randomized controlled trials provides strong evidence that the CRP resolves PC BPPV, and quasi-RCTs suggested that the CRP or the LM performed by a clinician or with proper instruction at home by the patient resolves PC BPPV (Helminski, et al., 2010). This systematic review included no data on the effects of the maneuvers on outcomes relevant to patients (Helminski, et al., 2010). Waleem et. al. conducted an RCT that compared an Epley maneuver with placebo treatment and found that 82% of patients in the Epley group was cured after two weeks, significantly more (P=0.002) than the 32% placebo group (Waleem, et al., 2008). Therefore, Epley's maneuver is a much better form of management for benign paroxysmal positional vertigo than expectant treatment.

 

Subsequently, additional RCTs have been published regarding the CRP, reflecting similar results. Table 5.1 summarizes recent RCTs evaluating CRP for posterior canal BPPV. Of note, consistent with the expected spontaneous resolution of posterior canal BPPV over time, treatment effects between CRP and control patients tended to diminish over time. In the short term, typically at 1 week, the CRP is very effective at providing symptom resolution for posterior canal BPPV with small numbers needed to treat (NNT).

 

All but one of the RCTs for CRP has taken place in the specialized clinic setting, most commonly with a referred population, which may limit the generalizability of these results. In the only RCT conducted in the primary care setting, investigators were unable to demonstrate a significant benefit for the CRP based on symptomatic outcome (Munoz, et al., 2007). At 1 week follow-up, 31.6 percent (12/38) of CRP patients demonstrated symptom resolution versus 24.4 percent (10/ 41) of sham patients (P _ 0.48). Objectively, however, 34.2 percent of CRP-treated patients converted to a negative Dix-Hallpike at 1 week, versus 14.6 percent in the sham group (P _ 0.04). Although statistically significant, this objective conversion rate is still lower than those reported among RCTs in the specialty setting (typically ranging from 66%-89%) (Hilton, et al., 2004). Because both the symptomatic response rates and conversion rates to a negative Dix-Hallpike maneuver are lower than those reported in specialty setting RCTs, further investigation into the effectiveness of the CRP in the primary care setting is warranted. Reasons for discrepancy between primary care and specialty settings may include differences in performance of the CRP (ie, a single maneuver vs repeated maneuvers at the same visit), intrinsic patient variability with comorbid balance disorders, differences in symptom reporting, or combinations thereof. In a Randomized, controlled, prospective trial. A Dizzy Fix score was used for home treatment of BPPV. The Dizzy Fix assisted users in performing a PRM and Dizzy Fix users performed significantly better on their PRM (particle replacement Manoevre) performance compared with controls (p = .0001). Results are promising and now we are waiting for results of a clinical trial using the Dizzy Fix in a group of patients. This seems a significant improvement from written instructions or in-office training. (Bromwich, et al., 2008) The positive treatment results of the CRP have also been demonstrated in lesser quality nonrandomized trials and case series (Sherman, et al., 2001) (Li, et al., 1995) (Lempert, et al., 1997) (Wolf, et al., 1999) (Asawavichianginda, et al., 2000) (Angeli, et al., 2003) (Chang, et al., 2004). In addition to the Cochrane review, four meta-analyses have been reported (White, et al., 2005) (Lopez-Escamez, et al., 1999) (Woodworth, et al., 2004) (Teixeira, et al., 2006). Each analysis concluded that the CRP is significantly more effective than placebo in posterior canal BPPV. Among these trials, however, significant heterogeneity has also been demonstrated (Teixeira, et al., 2006).

 

Many trials also report a secondary outcome of conversion from a positive to negative Dix-Hallpike maneuver after CRP. The odds ratios for this more objective measure of resolution for posterior canal BPPV range from 3.2 to 22 across studies, similar to reported rates of symptom resolution (Hilton, et al., 2004). In most nonrandomized case series assessing treatment response, symptom resolution is the only commonly reported outcome measure for the CRP.

 

Considerable variability exists in terms of the number of times the CRP is applied for the initial treatment of BPPV, even across RCTs (Froehling, et al., 2000) (Lynn, et al., 1995) (Yimtae, et al., 2003). Some investigators perform only one CRP cycle at the initial treatment, whereas others repeat a fixed number of cycles or perform the CRP repeatedly until the vertiginous symptoms extinguish or the Dix- Hallpike converts to negative (Lynn, et al., 195). Even further variability exists among published case series for CRP (Ruckenstein, et al., 2001) (Sekine, et al., 2006) (Prokopakis, et al., 2005). On the basis of a review of the literature, it was not possible to determine the optimal number of cycles for the CRP or a protocol for repeated procedures. The repeated application of the CRP is likely to be determined by the severity of the symptoms, if they persist; clinician availability; and the clinician’s historical success with the CRP.

 

 

Figure 5.1 Performance of the therapeutic canalith repositioning procedure for right-sided posterior canal BPPV. (Adapted from reference (Fife, et al., 2008).) (1) The patient is placed in the upright position with the head turned 45 degrees toward the affected ear (the ear that was positive on the Dix-Hallpike testing). (2) The patient is rapidly laid back to the supine head-hanging position, which is then maintained for 20 to 30 seconds. (3) Next, the head is turned 90 degrees toward the other (unaffected) side and held for about 20 seconds. (4) Following this rotation, the head is turned a further 90 degrees (usually necessitating the patient’s body to also move from the supine position to the lateral decubitus position) such that the patient’ head is nearly in the facedown position. This position is also held for 20 to 30 seconds. (5) The patient is then brought into the upright sitting position, completing the maneuver.

 

With respect to complications of treatment, CRP is associated with mild and generally self-limiting adverse effects in about 12 percent of those treated (Fife, et al., 2008). Serious complications from the CRP have not been identified in multiple RCTs. The most commonly encountered complications include nausea, vomiting, fainting, and conversion to lateral canal BPPV during the course of treatment (so-called canal switch). Such a canal switch occurs in about 6 to 7 percent of those treated with CRP, (Yimtae, et al., 2003) (Herdman, et al., 1996) underscoring the importance of recognizing the lateral canal variant of BPPV. Anecdotally, several investigators have suggested that the CRP should be applied cautiously in patients with cervical spine disease, certain vascular conditions, retinal detachment, and other contraindications to its performance (Sridhar, et al., 2005).

 

Table 5.1

Randomized controlled trials evaluating the effectiveness of CRP for posterior canal BPPV

Reference

Improved in treatment group n/N (%)

Improved in control group n/N (%)

Endpoint

Time to assessment

P value

Odds ratio (95% CI)

NNT

Lynn, 1995

11/18 (61%)

3/20 (15%)

Vertigo resolution

2 weeks

0.033

6.3 (1.29-30.5)

2.2

Froehling, 2000

12/24 (50%)

5/26 (19%)

Vertigo resolution

1-2 weeks

0.020

4.2 (1.2–14.8)

3.3

Simhadri, 2003

19/20 (95%)

3/20 (15%)

Vertigo resolution

1 week

0.001

107.7 (10.2-1135.5)

1.3

 

19/20 (95%)

3/20 (15%)

 

4 weeks

0.001

107.7 (10.2-1135.5)

1.3

Waleem, 2008

16/22

(73%)

6/22

(27%)

Vertigo resolution

1 week

0.001

?

?

 

18/22

(82%)

7/22

(32%)

Vertigo resolution

2 weeks

0.002

?

?

Yimtae, 2003

12/29 (41%)

1/27 (4%)

Vertigo resolution

1 week

0.005

18.4 (2.2-154.4)

2.7

 

16/25 (64%)

7/20 (35%)

 

4 weeks

0.336

3.3 (1.0-11.3)

3.4

Cohen, 2005

*/24 (CRP)

*/25 (CRP)

Vertigo frequency scale (0-10)

4 weeks †

0.021

 

 

 

*/25 (LM)

*/25 (LM)

 

4 weeks †

0.010

 

 

Von Brevern, 2006

28/35 (80%)

4/31 (13%)

Vertigo resolution

24 hours

0.001

27.0 (7.1-109.9)

1.5

Sugita, 2009

ROM

4/10

(40%)

CRP

6/12

(50%)

Vertigo resolution

1 week

No significant differences

NA

NA

 

7/10 (70%)

9/12 (75%)

 

2 weeks

 

 

 

 

10/10 (100%)

9/12 (75%)

 

4 weeks

 

 

 

Chang, 2008

CRP including vestibular stimulated exercise

CRP

Balance tests,

Tandem walk test, Dynamic Gait index,

Subjective rating of the intensity of vertigo

2 weeks

 

 

 

 

 

4 weeks

P<0.05

 

 

 

 

 

P<0.05

NA

 

 

 

 

 

NA

NA

 

 

 

 

 

NA

 

CI, confidence interval; CRP, canalith repositioning procedure; LM, Semont’s liberatory maneuver; NNT, number needed to treat.

*Responses were analyzed with multilevel methods and expressed as fitted linear regression graphs, so no discrete numerical expression of the response rates could be determined.

†Time to evaluation was varied, so data presented are based on fitted linear regression curves at 4 weeks.

 

Mastoid vibration. Mastoid vibration was included in the original Epley repositioning maneuver. One study, (Sridhar, et al., 2005) comparing patients with posterior canal BPPV treated by “appropriate canalith repositioning maneuvers,” performed with and without vibration, showed no difference in immediate symptom resolution or relapse rate between groups.

Post-treatment activity restriction One study (Chang, et al., 2004) compared patients treated by CRP with and without mastoid vibration. There was no difference in symptom relief between the groups at 4 to 6 weeks (p  0.68). Two other studies (Lopez-Escamaez, et al., 1999) (Woodworth, et al., 2004) showed no difference in the rate of symptom resolution between patients treated by a CRP with or without mastoid vibration. Another study (Li, et al., 1995) reported that of patients treated by a CRP with vibration, 92% were “improved,” vs 60% improvement with CRP alone.

 

In two studies (Lynn, et al., 1995; Froehling, et al., 2000) demonstrating the benefit of CRP, patients wore a cervical collar for 48 hours and avoided sleeping on the affected side for 1 week. Three studies (von Brevern, et al., 2006; Yimtae, et al., 2003; Cohen, et al., 2005) demonstrated the benefit of CRP and used no post-treatment restrictions or instructions. These studies were not designed to determine whether such restrictions affect treatment success; however, there seems to be little difference in the rate of treatment success whether or not restrictions were included. Six studies comparing CRP with and without post-treatment activity restriction were identified (Massoud, et al., 1996) (Blakley, et al., 1994) (Lempert, et al., 1997) (Wolf, et al., 1999) (Asawavichianginda, et al., 2009) (Angeli, et al., 2003). Five studies (Massoud, et al., 1996) (Blakley, et al., 1994) (Lempert, et al., 1997) (Wolf, et al., 1999) (Asawavichianginda, et al., 2009) showed no added benefit from post-treatment activity restriction or positions. Only one study showed a minimal benefit in patients with post-activity restrictions, as measured by the number of maneuvers required to produce a negative Dix–Hallpike maneuver (Asawavichianginda, et al., 2009).

Comparison of studies, in particular the treatment arms for RCTs, reveals similar response rates whether or not posttreatment positional or activity restrictions (ie, cervical collar or positional avoidance) are observed (Cohen, et al., 2005) (Froehling, et al., 2000) (Lynn, et al., 1995) (Yimtae, et al., 2003) (von Brevern, et al., 2006). Two studies looking at posttreatment restrictions after CRP found no evident improvement in those given restrictions (Massoud, et al., 1996) (Roberts, et al., 2005). Another study found slight benefit in patients with post-activity restrictions, as measured by the number of maneuvers required to produce a negative Dix-Hallpike maneuver (Cakir, et al., 2006). Overall, there is insufficient evidence to recommend post-maneuver restrictions in patients treated with CRP.

 

Treatment with the liberatory (Semont’s) maneuver. Clinical trials concerning the treatment effectiveness of the liberatory maneuver (Fig 5.2) are limited. One study, (Cohen, et al., 2005) which included a treatment arm with the Semont maneuver, demonstrated that this maneuver improved vertigo intensity more than the sham treatment (P _ 0.009).

 

Figure 5.2 The Semont maneuver for right-sided BPPV. (1) Patient is seated in the upright position; then the patient’s head is turned 45 degrees toward the left side, and the patient is then rapidly moved to the side-lying position as depicted in position (2). This position is held for approximately 30 seconds, and then the patient is rapidly moved to the opposite side-lying position without pausing in the sitting position and without changing the head position relative to the shoulder, resulting in position (3). This position is maintained for 30 seconds and then the patient gradually resumes the upright sitting position. (Adapted from reference (Fife, et al., 2008).)

 

A study by Salvinelli et al (Salvinelli, et al., 2003) randomized 156 patients to the Semont maneuver, flunarizine (a calcium channel blocker), or no treatment. At 6-month follow-up, symptom resolution occurred in 94.2 percent of patients treated with the Semont maneuver, 57.7 percent of patients treated with flunarizine, and 34.6 percent of untreated patients. Soto Varela et al (Soto Varela, et al., 2001) randomized patients to treatment with CRP, Semont maneuver, or Brandt-Daroff exercises. Symptom resolution among those treated with either CRP or Semont maneuver at 1 week was the same (74% vs 71%) but only 24 percent for Brandt-Daroff exercises. At 3-month follow-up, however, patients treated with CRP demonstrated superior outcomes compared with those treated with Semont maneuver (P _ 0.027). In conclusion, the Semont maneuver is more effective than no treatment or Brandt-Daroff exercises in relieving symptoms of posterior canal BPPV, according to studies with small sample sizes and limitations. No adverse events have been reported in trials with the liberatory maneuver. Because of limited studies with direct comparisons between the liberatory maneuver and the CRP, no conclusions about differential effectiveness can be drawn.

Sugita proposed in a RCT that his rolling-over maneuver (ROM) is as effective as the canalith repositioning maneuver (CRP) for the treatment of posterior benign paroxysmal positional vertigo (BPPV). (Sugita, et al., 2009)

 

Lateral (Horizontal) Canal BPPV Treatments

Lateral canal BPPV is usually unresponsive to CRPs used for posterior canal BPPV but may respond to other maneuvers intended to move canaliths from the lateral canal into the vestibule (Herdman, et al., 1996) (Fife, et al., 2008) (Lempert, et al., 1996). The roll maneuver (Lempert maneuver or barbecue roll maneuver) or its variations are the most commonly employed maneuvers for the treatment of lateral canal BPPV (White, et al., 2005) (Prokopakis, et al., 2005). This maneuver involves rolling the patient 360 degrees in a series of steps to effect particle repositioning. It may be performed in the outpatient setting after a diagnosis of lateral canal BPPV has been made with the supine roll test.

 

Rather limited data exist with respect to the effectiveness of the roll maneuver in lateral canal BPPV treatment. Based primarily on cohort studies and case series, the effectiveness of the roll maneuver in treating lateral canal BPPV appears to be approximately 75 percent, although reported response rates vary widely from 50 percent to almost 100 percent (White, et al., 2005) (Fife, et al., 2008) (Nuti, et al., 1998) (Tirelli, et al., 2004) (Casani, et al., 2002) (Prokopakis, et al., 2005) (Fife, et al., 1998) (Lempert, et al., 1996) (Appiani, et al., 1997) (Sargent, et al., 2001) (Asprella Libonati, et al., 2005) (Chiou, et al., 2005). Because lateral canal BPPV may spontaneously remit more quickly than other forms of BPPV, a control group is especially important in assessing treatment efficacy (Moon, et al., 2006) (Sekine, et al., 2006).

 

Forced prolonged positioning is another treatment maneuver reported to be as effective in treatinglateral canal BPPV. It may be performed either alone or concurrently with other maneuvers with a reported effectiveness of 75-90 percent based on case series (Casani, et al., 2002) (Appiani, et al., 1997) (Chiou, et al., 2005) (Vannuchi, et al., 1997). Other lesser known maneuvers such as the Gufoni maneuver and the Vannucchi-Asprella liberatory maneuver (Asprella Libonati, et al., 2005) (Gufoni, et al., 1998) (Appiani, et al., 1997), have also been reported as effective in uncontrolled studies. In 2009 Francesco concluded that the Gufoni's manoeuvre is effective in treating patients suffering from BPPV of LSC; it is simple to perform; there are not many movements to execute, it needs low time of positioning, and positions are comfortable to the patient (Francesco, et al., 2009)

In conclusion, variations of the roll maneuver appear moderately effective and are the most widely used treatments for lateral canal BPPV. Other methods of treatment have also been advocated, but currently no RCTs provide reliable measures of effectiveness. At this time, there is insufficient evidence to recommend a preferred treatment maneuver for lateral canal BPPV treatment.

 

Anterior canal BPPV Treatment

The literature on the treatment of anterior canal BPPV is scarce. Two studies specifically looked into the treatment of anterior canal BPPV. One study showed that the canalith repositioning procedure is very effective in the treatment of anterior canal BPPV (CRP, also referred to as the Epley maneuver). One study treated 30 anterior canal BPPV patients with CRP. After on average 2 maneuvers 96.7% became symptom free (Kim et al., 2005). Another study suggests that the orientation of the ASC strongly facilitates the whole procedure in all cases. The repositioning manoeuvres seem to use respectively different routes in order to achieve the movement of otoconia toward the utricle (Korres, et al., 2010).

 

Self-Administration and Posttreatment Restrictions

Three studies have assessed patient self-treatment for BPPV. One study found slightly greater improvement in those patients given instructions for self-administered CRP at home after initial CRP in the office (Sargent, et al., 2001). Self-administered CRP appeared to be more effective (64% improvement) than self-treatment with Brandt-Daroff exercises (23% improvement) (Radtke, et al., 1999). Another study reported 95 percent resolution of positional nystagmus 1 week after self-treatment with CRP compared with 58 percent in patients who selftreated using a modified Semont maneuver (P _ 0.001) (Radtke, et al., 2004). No comparison studies have been published from which to make recommendations regarding self-treatment vs clinician- administered treatment of BPPV. In motivated individuals, self-treatment of BPPV may be an option.

 

Tabel 5.2: Treatment of the affected semicircular canal

Semicircular canal involvement

Type

Treatment

Right posterior canal

Canalolithiasis

Right CRM (modified Epley without vibration)

 

Cupulolithiasis

Right Epley versus right Semont followed by right CRM

Left posterior canal

Canalolithiasis

Left CRM (modified Epley without vibration)

 

Cupulolithiasis

Left Epley versus left Semont followed by left CRM

Right anterior canal

Canalolithiasis

Right CRM (modified Epley without vibration)

 

Cupulolithiasis

Right Epley versus right Semont followed by right CRM

Left anterior canal

Canalolithiasis

Left CRM (modified Epley without vibration)

 

Cupulolithiasis

Left Epley versus left Semont followed by left CRM

Right horizontal canal

Canalolithiasis

Right horizontal canal CRM (BBQ roll)

 

Cupulolithiasis

Right modified Brandt-Daroff for horizontal canal followed by right horizontal canal CRM

Left horizontal canal

Canalolithiasis

Left horizontal canal CRM (BBQ roll)

 

Cupulolithiasis

Left modified Brandt-Daroff for horizontal canal followed by left horizontal canal CRM

(Overgenomen uit: Anterior canal beniging paroxysmal positional vertigo, Jackson et al, 2007, die hebben het aangepast en overgenomen uit Herdman SJ Advances in the treatment of vastibular disorders. Phys Ther 1997; 77: 602-18)

Referenties

  1. Angeli, S.I., Hawley, R., Gomez, O. (2003). Systematic approach to benign paroxysmal positional vertigo in the elderly. Otolaryngol Head Neck Surg, 128, 719-25.
  2. Appiani, G.C., Catania, G., Gagliardi, M., et al. (2005). Repositioning maneuver for the treatment of the apogeotropic variant of horizontal canal benign paroxysmal positional vertigo. Otol Neurotol, 26, 257-60.
  3. Appiani, G.C., Gagliardi, G., Magliulo, G. (1997). Physical treatment of horizontal canal benign positional vertigo. Eur Arch Otorhinolaryngol, 254, 326-8.
  4. Asawavichianginda, S., Isipradit, P., Snidvongs, K., et al. (2000). Canalith repositioning for benign paroxysmal positional vertigo: a randomized, controlled trial. Ear Nose Throat J, 79, 732-37.
  5. Asprella Libonati, G. (2005). Diagnostic and treatment strategy of lateral semicircular canal canalolithiasis. Acta Otorhinolaryngol Ital, 25, 277-83.
  6. Blakley, B.W. (1994). A randomized, controlled assessment of the canalith repositioning maneuver. Otolaryngol Head Neck Surg, 110, 391-396.
  7. von Brevern, M., Seelig, T., Radtke, A., et al. (2006). Short-term efficacy of Epley’s manoeuvre: a double-blind randomised trial. J Neurol Neurosurg Psychiatry, 77, 980-2.
  8. Bromwich, M.A., Parnes, L.S. (2008). The DizzyFix: initial results of a new dynamic visual device for the home treatment of benign paroxysmal positional vertigo. Journal of otolaryngology - head & neck surgery = Le Journal d'oto-rhino-laryngologie et de chir, 37 (3), 380-7.
  9. Cakir, B.O., Ercan, I., Cakir, Z.A., et al. (2006). Efficacy of postural restriction in treating benign paroxysmal positional vertigo. Arch Otolaryngol Head Neck Surg, 132, 501-5.
  10. Casani, A.P., Vannucci, G., Fattori, B., et al. (2002). The treatment of horizontal canal positional vertigo: our experience in 66 cases. Laryngoscope, 112, 172-8.
  11. Chang, A.K., Schoeman, G., Hill, M. (2004). A randomized clinical trial to assess the efficacy of the Epley maneuver in the treatment of acute benign positional vertigo. Acad Emerg Med, 11, 918-24.
  12. Cohen, H.S., Kimball, K.T. (2005). Effectiveness of treatments for benign paroxysmal positional vertigo of the posterior canal. Otol Neurotol, 26, 1034-40.
  13. Chiou, W.Y., Lee, H.L., Tsai, S.C., et al. (2005). A single therapy for all subtypes of horizontal canal positional vertigo. Laryngoscope, 115, 1432-5.
  14. Epley, J.M. (1992). The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg, 107, 399-404.
  15. Fife, T.D., Iverson, D.J., Lempert, T., et al. (2008). Practice parameter: therapies for benign paroxysmal positional vertigo (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology, 70, 2067-74.
  16. Fife, T.D. (1998). Recognition and management of horizontal canal benign positional vertigo. Am J Otol, 19, 345-51.
  17. Froehling, D.A., Bowen, J.M., Mohr, D.N., et al. (2000). The canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo: a randomized controlled trial. Mayo Clin Proc, 75, 695-700.
  18. Gufoni, M., Mastrosimone, L., Di Nasso, F. (1998). [Repositioning maneuver in benign paroxysmal vertigo of horizontal semicircular canal]. Acta Otorhinolaryngol Ital, 18, 363-7.
  19. Helminski, J.O., Zee, D.S., Janssen, I., Hain, T.C. (2010). Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review. Physical Therapy, 90 (5), 663-78.
  20. Herdman, S.J., Tusa, R.J. (1996). Complications of the canalith repositioning procedure. Arch Otolaryngol Head Neck Surg, 122, 281-6.
  21. Hilton, M., Pinder, D. (2004). The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev, 0, CD003162-.
  22. Lempert, T., Wolsley, C., Davies, R., et al. (1997). Three hundred sixty-degree rotation of the posterior semicircular canal for treatment of benign positional vertigo: a placebo-controlled trial. Neurology, 49, 729-33.
  23. Lempert, T., Tiel-Wilck, K. (1996). A positional maneuver for treatment of horizontal-canal benign positional vertigo. Laryngoscope, 106, 476-8.
  24. Lempert, T., Wolsley, C., Davies, R., et al. (1997). Three hundred sixty-degree rotation of the posterior semicircular canal for treatment of benign positional vertigo: a placebo-controlled trial. Neurology, 49, 729-733.
  25. Li, J.C. (1995). Mastoid oscillation: a critical factor for success in canalith repositioning procedure. Otolaryngol Head Neck Surg, 112, 670-5.
  26. Lopez-Escamez J, Gonzalez-Sanchez M, Salinero J. (1999). Meta-analysis of the treatment of benign paroxysmal positional vertigo by Epley and Semont maneuvers. Acta Otorrinolaringol Esp, 50, 366-70.
  27. Lynn, S., Pool, A., Rose, D., et al. (1995). Randomized trial of the canalith repositioning procedure. Otolaryngol Head Neck Surg, 113, 712-20.
  28. Massoud, E.A., Ireland, D.J. (1996). Post-treatment instructions in the nonsurgical management of benign paroxysmal positional vertigo. J Otolaryngol, 25, 121-5.
  29. Munoz, J.E., Miklea, J.T., Howard, M., et al. (2007). Canalith repositioning maneuver for benign paroxysmal positional vertigo: randomized controlled trial in family practice. Can Fam Physician, 53, 1049-53.
  30. Nuti, D., Agus, G., Barbieri, M.T., et al. (1998). The management of horizontalcanal paroxysmal positional vertigo. Acta Otolaryngol, 118, 455-60.
  31. Prokopakis, E.P., Chimona, T., Tsagournisakis, M., et al. (2005). Benign paroxysmal positional vertigo: 10-year experience in treating 592 patients with canalith repositioning procedure. Laryngoscope, 115, 1667-71.
  32. Radtke, A., von Brevern, M., Tiel-Wilck, K., et al. (2004). Self-treatment of benign paroxysmal positional vertigo: Semont maneuver vs Epley procedure. Neurology, 63, 150-2.
  33. Radtke, A., Neuhauser, H., von Brevern, M., et al. (1999). A modified Epley’s procedure for self-treatment of benign paroxysmal positional vertigo. Neurology, 53, 1358-60.
  34. Riggio, F., Dispenza, F., Gallina, S., Kulamarva, G., Gargano, R., Speciale, R. (2009). Management of benign paroxysmal positional vertigo of lateral semicircular canal by Gufoni's manoeuvre. Erratum appears in Am J Otolaryngol., 30 (4), 294-.
  35. Rosalia, Gargano [corrected to Gargano, Rosalia, Rosalia, Gargano [corrected to Gargano, Rosalia], Riccardo, Speciale [corrected to Speciale, Riccardo] (2009). X. American Journal of Otolaryngology, 30 (2), 106-11.
  36. Roberts, R.A., Gans, R.E., DeBoodt, J.L., et al. (2005). Treatment of benign paroxysmal positional vertigo: necessity of postmaneuver patient restrictions. J Am Acad Audiol, 16, 357-66.
  37. Ruckenstein, M.J. (2001). Therapeutic efficacy of the Epley canalith repositioning maneuver. Laryngoscope, 111, 940-5.
  38. Sekine, K., Imai, T., Sato, G., et al. (2006). Natural history of benign paroxysmal positional vertigo and efficacy of Epley and Lempert maneuvers. Otolaryngol Head Neck Surg, 135, 529-33.
  39. Salvinelli, F., Casale, M., Trivelli, M., et al. (2003). Benign paroxysmal positional vertigo: a comparative prospective study on the efficacy of Semont’s maneuver and no treatment strategy. Clin Ter, 154, 7-11.
  40. Sargent, E.W., Bankaitis, A.E., Hollenbeak, C.S., et al. (2001). Mastoid oscillation in canalith repositioning for paroxysmal positional vertigo. Otol Neurotol, 22, X-.
  41. Sherman, D., Massoud, E.A. (2001). Treatment outcomes of benign paroxysmal positional vertigo. Journal of Otolaryngology, 30, 295-9.
  42. Soto Varela, A., Bartual Magro, J., Santos Perez, S., et al. (2001). Benign paroxysmal vertigo: a comparative prospective study of the efficacy of Brandt and Daroff exercises, Semont and Epley maneuver. Rev Laryngol Otol Rhinol (Bord), 122, 179-83.
  43. Sridhar, S., Panda, N. (2005). Particle repositioning manoeuvre in benign paroxysmal positional vertigo: is it really safe?. J Otolaryngol, 34, 41-5.
  44. Sugita, K.A., Sato, S., Mikami, K., Mukaide, M., and K, I. (2009). Does vertigo disappear only by rolling over? Rehabilitation for benign paroxysmal positional vertigo. Acta Otolaryngol, 0, 1-5.
  45. Teixeira, L.J., Machado, J.N. (2006). Maneuvers for the treatment of benign positional paroxysmal vertigo: a systematic review. Rev Bras Otorrinolaringol (Engl Ed), 72, 130-9.
  46. Tirelli, G., Russolo, M. (2004). 360-Degree canalith repositioning procedure for the horizontal canal. Otolaryngol Head Neck Surg, 131, 740-6.
  47. Uneri, A. (2005). Falling sensation in patients who undergo the Epley maneuver: a retrospective study. Ear Nose Throat J, 84, 82-5.
  48. Vannucchi, P., Giannoni, B., Pagnini, P. (1997). Treatment of horizontal semicircular canal benign paroxysmal positional vertigo. J Vestib Res, 7, 1-6.
  49. Waleem, S.S., Malik, S.M., Ullah, S., ul, H.Z. (2008). Office management of benign paroxysmal positional vertigo with Epley's maneuver. Journal of Ayub Medical College, 20 (1), 77-9.
  50. White, J., Savvides, P., Cherian, N., et al. (2005). Canalith repositioning for benign paroxysmal positional vertigo. Otol Neurotol, 26, 704-10.
  51. White, J.A., Coale, K.D., Catalano, P.J., et al. (2005). Diagnosis and management of lateral semicircular canal benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg, 133, 278-84.
  52. Wolf, M., Hertanu, T., Novikov, I., et al. (1999). Epley’s manoeuvre for benign paroxysmal positional vertigo: a prospective study. Clin Otolaryngol Allied Sci, 24, 43-6.
  53. Woodworth, B.A., Gillespie, M.B., Lambert, P.R. (2004). The canalith repositioning procedure for benign positional vertigo: a meta-analysis. Laryngoscope, 114, 1143-6.
  54. Yimtae, K., Srirompotong, S., Sae-Seaw, P. (2003). A randomized trial of the canalith repositioning procedure. Laryngoscope, 113, 828-32.

Overwegingen

  • Voordeel: Snel verdwijnen van de symptomen
  • Nadeel: opwekken van draaiduizeligheid door het uitvoeren van de repositiemanoeuvre,
  • Kosten: laag
  • Afweging: De voordelen wegen op tegen de nadelen. Er is echter ook een aanzienlijke kans op spontaan herstel.
  • Waarde oordeel: grote waarde doordat symptomen onmiddellijk verdwijnen en ook gezien het gemak waarmee de CRP kan worden uitgevoerd.
  • Rol van de voorkeur van de patiënt: matig

Autorisatiedatum en geldigheid

Laatst beoordeeld : 01-01-2011

Laatst geautoriseerd : 01-01-2011

De richtlijn zal na 3 jaar worden getoetst aan de wetenschappelijke ontwikkelingen door een (nog samen te stellen) multidisciplinaire commissie. De commissie draagt de verantwoordelijkheid om tussentijdse peilingen bij de beroepsgroepen te verrichten naar behoefte voor herziening(en) van de huidige richtlijn. Bij essentiële ontwikkelingen kan er besloten worden tussentijdse elektronische amendementen te maken en deze onder de verschillende beroepsgroepen te verspreiden. Zo nodig wordt een nieuwe werkgroep geïnstalleerd om (delen van) de richtlijn te herzien. Uiterlijk in 2014 zal een nieuwe multidisciplinaire werkgroep worden geïnstalleerd voor een volledig herziene versie van de richtlijn.

Initiatief en autorisatie

Initiatief : Nederlandse Vereniging voor Neurologie

Geautoriseerd door:
  • Nederlandse Vereniging voor Neurologie

Algemene gegevens

Met ondersteuning van de Orde van Medisch Specialisten. De richtlijnontwikkeling werd gefinancierd uit de Stichting Kwaliteitsgelden Medisch Specialisten (SKMS).

 

De richtlijn betreft een adaptatie van:

Clinical practice guideline: Benigne Paroxysmale Positionele Duizeligheid.

De Amerikaanse richtlijn van de Academy of Otolaryngology-Head and Neck surgery foundation ‘Clinical practice guideline: Benign paroxysmal positional vertigo’ (Bhattacharayya, et al., 2008) vormde het uitgangspunt van de onderhavige richtlijn. Daarnaast werd de Amerikaanse richtlijn van de Academy of neurology, gericht op de behandeling van BPPD, gebruikt ter aanvulling (Fife, et al., 2008), alsmede de discussies en richtlijnen van de Standaardisatie commissie van de Barany Society (Reykjavik, et al., 2010, www.baranysociety.nl).

Doel en doelgroep

De primaire doelstellingen van deze richtlijn zijn:

  • De kwaliteit van de zorg te verbeteren door middel van een accurate en snelle diagnose van BPPD.
  • Voorkomen van onnodig gebruik van medicijnen.
  • Doelgericht gebruik van aanvullend onderzoek.
  • Stimuleren van het gebruik van repositiemanoeuvres als therapie voor BPPD.

Secundaire doelstellingen zijn: beperking van de kosten van diagnose en behandeling van BPPD, vermindering van het aantal artsenbezoeken, en verbetering van de kwaliteit van leven. Het grote aantal patiënten met BPPD en de verscheidenheid aan diagnostische en therapeutische interventies voor BPPD maakt dit een geschikt onderwerp voor een evidence-based richtlijn.

De Amerikaanse richtlijn van de Academy of Otolaryngology-Head and Neck surgery foundation ‘Clinical practice guideline: Benign paroxysmal positional vertigo’ (Bhattacharayya, et al., 2008) vormde het uitgangspunt van de onderhavige richtlijn. Daarnaast werd de Amerikaanse richtlijn van de Academy of neurology, gericht op de behandeling van BPPD, gebruikt ter aanvulling (Fife, et al., 2008), alsmede de discussies en richtlijnen van de Standaardisatie commissie van de Barany Society (Reykjavik, et al., 2010, www.baranysociety.nl)). Onze doelstelling was om deze multidisciplinaire richtlijn te adapteren aan de Nederlandse situatie met behulp van Nederlandse input, waarbij de aanbevelingen rekening houden met wetenschappelijk bewijs en zich richten op harm-benefit balans, en expert consensus om de gaten in wetenschappelijk bewijs op te vullen. Deze specifieke aanbevelingen kunnen dan gebruikt worden om indicatoren te ontwikkelen en te gebruiken voor kwaliteitsverbetering.

 

Deze richtlijn is opgesteld voor KNO-artsen en neurologen die in hun klinische praktijk in aanraking komen met BPPD. De richtlijn is toepasbaar in iedere setting waar BPPD gediagnosticeerd en behandeld wordt.

Samenstelling werkgroep

Deze werkgroep bestaat uit twee KNO-artsen, een neuroloog en een klinisch fysicus-vestibuloloog. Bij het samenstellen van de werkgroep is zoveel mogelijk rekening gehouden met specifieke deskundigheid en de geografische spreiding van de werkgroepleden en een evenredige vertegenwoordiging vanuit perifere en academische ziekenhuizen.

 

Personele samenstelling werkgroep

  • dr. Tj.D. Bruintjes (voorzitter), KNO-arts, Gelre ziekenhuizen, Apeldoorn
  • prof. dr. H. Kingma, klinisch fysicus/vestibuloloog, Maastricht Universitair Medisch Centrum en Technische Universiteit Eindhoven
  • dr. D.J.M. Mateijsen, KNO-arts, Catharina ziekenhuis, Eindhoven
  • dr. R.B. van Leeuwen, neuroloog, Gelre ziekenhuizen, Apeldoorn
  • dr. ir. T van Barneveld klinisch epidemioloog, Orde van Medisch specialisten (adviseur)
  • dr. M.L. Molag, Orde van Medisch specialisten (adviseur)

Belangenverklaringen

De werkgroepleden hebben onafhankelijk gehandeld en waren vrij van financiële of zakelijke belangen betreffende het onderwerp van de richtlijn.

Methode ontwikkeling

Evidence based

Werkwijze

De Amerikaanse richtlijn van de Academy of Otolaryngology-Head and Neck surgery foundation ‘Clinical practice guideline: Benign paroxysmal positional vertigo’ (Bhattacharayya, et al., 2008) vormde het uitgangspunt van de onderhavige richtlijn. Daarnaast werd de Amerikaanse richtlijn van de Academy of neurology gebruikt (Fife, et al., 2008). Dit betekent dat de Nederlandse richtlijncommissie de studies, de beoordeling & gradering ervan en de begeleidende tekst heeft overgenomen. Studies, relevant voor dit onderwerp, die nadien werden gepubliceerd konden in de richtlijncommissie worden ingebracht. De literatuur werd bovendien geupdate door te zoeken in Medline naar nieuw verschenen systematische reviews en RCTs met als onderwerp BPPD in de periode van 2008 t/m 2010.

 

De richtlijncommissie is voor elke aanbeveling in de Amerikaanse richtlijn nagegaan welke overwegingen naast het wetenschappelijk bewijs zijn gebruikt en of de door de commissie aangedragen studies de aanbeveling zouden kunnen veranderen. Wanneer er consensus was over deze overwegingen en door de commissie aangedragen studies geen ander inzicht opleverden, zijn de aanbevelingen overgenomen. Indien de commissie andere overwegingen (ook) van belang achtte of meende dat de door haar aangedragen studies een (iets) ander licht wierpen op de in de Amerikaanse richtlijn vermelde aanbeveling, zijn de aanbevelingen gemodificeerd.

 

De gradering van de studies in de Amerikaanse richtlijn wijkt af van wat hier te lande gangbaar is. Vanuit het oogpunt van uniformiteit achtte de Nederlandse commissie het wenselijk de classificatie van bewijs c.q. gradering te converteren naar de Nederlandse classificatie. De Amerikaanse classificatie is hieronder afgebeeld in tabel. De corresponderende “Nederlandse” classificatie is in tabel 1.2 opgenomen.

Tabel 1.1: gradering van de studies in de Amerikaanse richtlijn

 

 

Tabel 1.2 Relatie tussen Evidence quality for grades of evidence en niveau van conclusie op basis van kwaliteit van bewijs conform Classificatieschema van CBO.

Evidence Quality - symbool

Evidence Quality – omschrijving

Niveau van conclusie – symbool

Niveau van conclusie omschrijving

A

 

Well-designed randomized controlled trials or diagnostic studies performed on a population similar to the guideline’s target population

1

Meerdere gerandomiseerde dubbelblinde ver­gelijkende klinisch onderzoeken van goede kwaliteit van voldoende omvang, of

 

Meerdere onderzoeken ten opzichte van een referentietest (een ‘gouden standaard’) met tevoren gedefinieerde afkapwaarden en onafhankelijke beoordeling van de resultaten van test en gouden standaard, betreffende een voldoende grote serie van opeenvolgende patiënten die allen de index- en referentietest hebben gehad

B

Randomized controlled trials or diagnostic studies with minor limitations; overwhelmingly consistent evidence from observational studies

2

Meerdere vergelijkende onderzoeken, maar niet met alle kenmerken als genoemd onder 1 (hieronder valt ook patiënt-controle onderzoek, cohort-onderzoek), of

 

Meerdere onderzoeken ten opzichte van een referentietest, maar niet met alle kenmerken die onder 1 zijn genoemd.

C

Observational studies (case-control and cohort design)

D

Expert opinion, case reports, reasoning from first principles (bench research or animal studies)

3 en 4

Niet vergelijkend onderzoek of mening van deskundigen

 

In de Amerikaanse richtlijn worden ook de aanbevelingen gegradeerd in termen van ‘strong recommendation’, ‘recommendation’, ‘option’. Hier te lande is graderen van aanbevelingen niet gebruikelijk. Om deze reden zijn in de Nederlandse richtlijn de aanbevelingen niet gegradeerd.

 

De literatuurzoekstrategie die de Amerikaanse richtlijncommissie heeft gevolgd, staat in bijlage 1 beschreven. Voor het opstellen van de aanbevelingen heeft de Amerikaanse richtlijncommissie gebruik gemaakt van de GuideLine Implementability Appraisal (GLIA) tool. Dit instrument dient om de helderheid van de aanbevelingen te verbeteren en potentiële belemmeringen voor de implementatie te voorspellen. In bijlage 3 wordt een aantal criteria beschreven. Ook de Nederlandse richtlijncommissie heeft deze criteria gehanteerd.