See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/326492465
The Effects of the Vestibular Rehabilitation on the Benign Paroxysmal
Positional Vertigo Recurrence Rate in Patients with Otolith Dysfunction
Article · July 2018
DOI: 10.7874/jao.2018.00087
CITATIONS
READS
0
46
7 authors, including:
Reza Hoseinabadi
Akram Pourbakht
19 PUBLICATIONS 17 CITATIONS
60 PUBLICATIONS 307 CITATIONS
Tehran University of Medical Sciences
SEE PROFILE
Iran University of Medical Sciences
SEE PROFILE
Nasrin Yazdani
Ali Kouhi
41 PUBLICATIONS 210 CITATIONS
50 PUBLICATIONS 550 CITATIONS
Tehran University of Medical Sciences
SEE PROFILE
Tehran University of Medical Sciences
SEE PROFILE
Some of the authors of this publication are also working on these related projects:
Effect of sound lateralization rehabilitation on behavioral performance and auditory middle-latency evoked responses of 8 to 12 year-old
children with suspected auditory processing disorders View project
auditory brainstem response View project
All content following this page was uploaded by Farzaneh Zamiri on 23 July 2018.
The user has requested enhancement of the downloaded file.
ORIGINAL ARTICLE
J Audiol Otol 2018 July 19 [Epub ahead of print]
pISSN 2384-1621 / eISSN 2384-1710
https://doi.org/10.7874/jao.2018.00087
The Effects of the Vestibular Rehabilitation
on the Benign Paroxysmal Positional Vertigo
Recurrence Rate in Patients with Otolith Dysfunction
Reza Hoseinabadi1, Akram Pourbakht2, Nasrin Yazdani3, Ali Kouhi3, Mohammad Kamali4,
Farzaneh Zamiri Abdollahi1, and Sadegh Jafarzade5
1
Department of Audiology, School of Rehabilitation, Tehran University of Medical Sciences, Tehran,
Department of Audiology, Rehabilitation Research Centre, School of Rehabilitation Sciences, Iran University of Medical Sciences,
Tehran,
3
Otorhinolaryngology Research Center, Amir-Alam Hospital, Tehran University of Medical Sciences, Tehran,
4
Department of Rehabilitation Management, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran,
5
Department of Audiology, School of Rehabilitation, Mashhad University of Medical Sciences, Mashhad, Iran
2
Received
Revised
Accepted
February 16, 2018
April 17, 2018
April 27, 2018
Address for correspondence
Nasrin Yazdani, MD
Otorhinolaryngology Research
Centre, Amir-Alam Hospital,
Saadi Avenue, Enghelab Street,
Tehran 11489-65111, Iran
Tel +98-91-2454-6457
Fax +98-21-2285-0149
E-mail Nasrinyazdani96@gmail.
com
Background and Objectives: Although repositioning maneuvers have shown remarkable
success rate in treatments of benign paroxysmal positional vertigo (BPPV), the high recurrence
rate of BPPV has been an important issue. The aims of present study were to examine the effects of otolith dysfunction on BPPV recurrence rate and to describe the effect of vestibular rehabilitation exercises on BPPV recurrence in BPPV patients with concomitant otolith dysfunction. Subjects and Methods: Forty-five BPPV patients included in this study (three groups).
Patients in group 1 had no otolith dysfunction and patients in groups 2 and 3 had concomitant otolith dysfunction. Otolith dysfunction was determined with ocular/cervical vestibular
evoked myogenic potential (oVEMP and cVEMP) abnormalities. Epley’s maneuver was performed for the patients in all groups but patients in group 3 also received a 2-month vestibular rehabilitation program (habituation and otolith exercises). Results: This study showed
that BPPV recurrent rate was significantly higher in patients with otolith dysfunction in comparison to the group 1 (p<0.05). Vestibular rehabilitation resulted in BPPV recurrence rate reduction. Utricular dysfunction showed significant correlation with BPPV recurrence rate. Conclusions: Otolith dysfunction can increase BPPV recurrence rate. Utricular dysfunction in
comparison to saccular dysfunction leads to more BPPV recurrence rate. Vestibular rehabilitation program including habituation and otolith exercises may reduce the chance of
BPPV recurrence.
J Audiol Otol
KEY WORDS:0Otolith dysfunction · Vestibular rehabilitation ·
Benign paroxysmal positional vertigo.
Introduction
Benign paroxysmal positional vertigo (BPPV) is the most
common vestibular disorder that causes true vertigo [1]. It
occurs spontaneously in many patients, so identification of
the underlying cause may always not be possible [2]. The
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the
original work is properly cited.
most common causes of BPPV include head trauma, labyrinthitis, and anterior vestibular artery ischemia, prolonged bed
rest [3] and vestibular neuritis [4]. It is characterized by brief
episodes of true vertigo induced by changing the head position in the plane of the involved semicircular canals. The diagnosis is confirmed by a positioning test called Dix-Hallpike
maneuver which reveals vertigo and/or nystagmus. There are
two forms of BPPV including canalithiasis and cupulolithiasis
[2]. BPPV most commonly affects the posterior canal. However, it may affect any of the semicircular canals and any
Copyright © 2018 The Korean Audiological Society and Korean Otological Society
1
BPPV Recurrence Rate in Otolith Dysfunction
combinations of the multiple canals simultaneously [5].
The displacement of the otoconia particles from utricle to
the semicircular canal is the most convincing theory to explain BPPV symptoms [6]. This theory is a basic concept for
BPPV treatment approaches [7]. Canalith repositioning maneuver (CRM) or Epley’s maneuver is the most commonly
used approach and in 70-100% of instances is successful [8].
The effectiveness of Epley’s maneuver as the most successfully used maneuver in the treatment of posterior canal BPPV
(PC-BPPV) has been shown in the previous studies [8].
Although CRM has a high success rate in BPPV treatment,
sometimes BPPV show recurrence [9]. The recurrence of
BPPV is an important issue. It leads to common symptoms of
BPPV, lack of patients’ trust in the medical team and unnecessary evaluations. It has been reported that recurrent BPPV
is not rare [10]. Studies have shown that most of the recurrences occur in the 6 to 12 months after the first attack [11]. Different studies have reported variety of recurrence rate for BPPV
from 13.5% [12,13] to 20-30% and 50% [14].
Otolithic signals play an important role in the perception of
gravity, uprightness, postural control and linear acceleration.
In BPPV, otoconia are detached from the utricle and this may
affect otolith function as well [15]. This detachment may be
due to a degenerative process in otolith organs [6] that may
lead to the high possibility of BPPV, its resistance to treatment and recurrence.
Recently, through relatively new tests of otolith function
including cervical vestibular evoked myogenic potential
(cVEMP) and ocular vestibular evoked myogenic potential
(oVEMP), we are able to detect otolith dysfunctions. The
cVEMP evaluates saccule and inferior vestibular nerve. The
oVEMP is presumably originated from the utricle and superior vestibular nerve. It has been shown that utricular dysfunction and oVEMP abnormalities are highly correlated [16].
We assumed that otolith dysfunction might be a risk factor
for BPPV recurrence. It is assumed that habituation rehabilitation might be beneficial in patients with BPPV who suffer
from otolith dysfunction and might reduce BPPV recurrence
rate. Therefore, the aims of the present study were: 1) to examine the effects of otolith dysfunction on recurrence of
BPPV and 2) to describe the effect of a habituation rehabilitation program on BPPV recurrence in BPPV patients with
otolith dysfunction.
Subjects and Methods
This clinical trial study was conducted on 45 age-matched
patients aged 20-60 years-old, with PC-BPPV in the DixHallpike test (upbeating and torsional nystagmus). Patients
2
J Audiol Otol 2018 July 19 [Epub ahead of print]
with BPPV were then divided into three groups: 1) The first
group included subjects with normal cVEMP and oVEMP in
both ears and they received a CRM maneuver. 2) The second
group included subjects with abnormal cVEMP and/or oVEMP
in the PC-BPPV side and they received a CRM maneuver.
3) The third group had abnormal cVEMP and/or oVEMP in
the PC-BPPV side and they received CRM maneuver and
two months of habituation and otolith rehabilitation. The time
interval between the onset of BPPV and the treatment were
less than two weeks.
Meniere’s disease, endolymphatic hydrops, labyrinthitis,
vestibular neuritis, cervical problems, trauma history, migraine,
otologic or non-otologic surgery including maxillofacial and
dental surgery, sudden sensory neural hearing loss, conductive
hearing loss, prolonged bed rest and patient refusal to participate in the study were exclusion criteria. Patients underwent
following tests to check exclusion criteria: neurologic examination, history taking, immittance acoustic (Zodiac 901, Madsen, GN Otometrics, Denmark), audiometry (AC40, Interacoustic, Assens, Denmark), EcochG with TipTrode (ICS Chartr
EP, GN Otometrics, Taastrup, Denmark), Bithermal Caloric test
(VNG Eye Dynamics Inc., Micromedical, Chatham, IL, USA).
The cVEMP recordings were performed using ICS Chartr
EP manufactured by BioLogic (GN Otometrics) with 500 Hz
tone burst at 95 dB normalized hearing level (nHL), with alternating polarity, band pass filter 10-1,500 Hz, 5.1/s rate
with 50 ms time window. Sweep number was 150. Stimuli
were delivered through TDH39 headphones (Telephonics,
Farmingdale, NY, USA). The electrode array was as follows:
the reference electrode on a middle part of the sternocleidomastoid muscle, the active electrode on an upper part of the
sternum, the ground electrode on the forehead. Subjects turned
their head to the contralateral side while sitting in the chair.
The device showed and monitored muscle contraction (RMS)
automatically. The amplitude of biphasic p13-n23 wave was
measured from the most positive peak of the wave (p13) to the
most negative peak (n23) in microvolts.
The oVEMP recordings were conducted in the sitting position while the patient was looking upward at a small target that
was within 100 cm. The visual angle was about 30 degree as
this angle has been shown to produce the best response in
comparison to other eye positions [17]. The electrode array
was as follows: the active electrode on the face approximately
1 cm below the contralateral lower eyelid, the reference electrode on the chin 1 cm below the active electrode, and the
ground electrode on the forehead. Using ICS Chartr EP manufactured by BioLogic (GN Otometrics), oVEMP was recorded by 500 Hz tone bursts at 95 dB nHL with alternating
polarity, the bandpass filter of 10-1,500 Hz and 5.1/s rate.
Hoseinabadi R, et al.
The analysis window was 75 ms and responses to 200 stimuli
were averaged. The initial negative-positive biphasic waveform comprised peaks N1 and P1. We analyzed the peak-topeak amplitude of N1 and P1. Otolith dysfunction was defined
as the lack of unilateral responses in cVEMP and oVEMP.
Epley’s maneuver was performed on all subjects with
BPPV. One week after treatment they were assessed with
Dix-Hallpike test and if there was no nystagmus and/or vertigo, treatment was considered successful. If symptoms were
persistent, Epley’s maneuver was repeated for the second
time. For subjects in group 3, a rehabilitation program including habituation and otolith exercises were utilized. Exercises
included: jumping on the trampoline-like surface with eyes
open and closed, walking on the inflated surface with eyes
open and closed (head straight and head tilted in different directions), reading a text with linear head movement, standing
on the tilt board and using an exercise ball. The duration of
the rehabilitation program was two months and subjects were
evaluated weekly to modify the exercises based on their performance. Follow-up care included communication by phone
and in case of symptoms recurrence, repetition of the Epley’s
maneuver was done.
The study was approved by ethical committee of Tehran University of Medical Sciences with number 260-316. Informed
consent was obtained from all participants.
For statistical analysis, SPSS 19.0 software (IBM Corp.,
Armonk, NY, USA) was used. The significance level was
considered 0.05. Data were analyzed using Pearson correlation and chi-square test.
Results
45 patients from 22 to 60 years old were included. The
BPPV with recurrence
Table 1. Number and percent of benign paroxysmal positional
vertigo recurrence in each group
Recurrent
Not recurrent
Total
(percent)
(percent)
(percent)
Group 1
1 (6.7)
14 (93.3)
15 (100)
Group 2
6 (40)
9 (60)
15 (100)
Group 3
2 (13.3)
13 (86.7)
15 (100)
Total
9 (20)
36 (80)
45 (100)
BPPV without recurrence
Table 2. Comparison of benign paroxysmal positional vertigo recurrence among groups
45
40
BPPV recurrence rate (%)
mean age of patients in the group without otolith dysfunction
was 45.46±7.39, in the group 2 was 44.80±9.70 and in the
group 3 was 42.40±10.04. There were 6 males and 9 females
in group 1, 8 males and 7 females in group 2, and 5 males
and 10 females in groups 3. The rate of BPPV recurrence before rehabilitation was 6.7%, 40%, and 33.3% in group 1, 2,
and 3, respectively. After rehabilitation, the rate of BPPV recurrence was 5.2%, 41.5%, and 2.7% in group 1, 2, and 3 respectively. Fig. 1 shows BPPV recurrence rate in 3 groups
before and after rehabilitation.
In Table 1, the number and percent of BPPV recurrence in
each group are shown. BPPV recurrence is more prevalent in
groups 2 and 3. Comparison of BPPV recurrence among
groups with chi-square test is shown in Table 2. The difference between groups 1 and 2 was statistically significant. The
BPPV recurrence in groups 2 and 3 in patients with cVEMP
and/or oVEMP abnormalities is shown in Table 3 and 4. Comparison of otolith abnormalities and BPPV recurrence in groups
2 and 3 with chi-square test is shown in Table 5. It shows that
in both groups BPPV recurrence was significantly correlated
with otolith dysfunction.
Comparison of BPPV recurrence among groups was performed by chi-square (χ2) test. The difference between groups
1 and 2 and also between group 1 and 3 were statistically significant (p<0.05). In general, 5% of patients with a cVEMP
abnormality, 12% of patients with oVEMP abnormality, and
35
30
25
Value
df
p value
Groups 1 and 2
4.658
1
0.031
Groups 1 and 3
0.370
1
0.543
Groups 2 and 3
2.727
1
0.099
20
15
Table 3. Recurrence of benign paroxysmal positional vertigo in
group 2 in patients with cVEMP and/or oVEMP abnormalities
10
5
0
Group 1
Group 2
Group 3
Recurrent
Not recurrent
Total
cVEMP abnormality
2
8
10
oVEMP abnormality
4
1
5
6
9
15
Total
Fig. 1. BPPV recurrence rate in three groups before and after rehabilitation. BPPV: benign paroxysmal positional vertigo.
cVEMP: cervical vestibular evoked myogenic potential, oVEMP:
ocular vestibular evoked myogenic potential
www.ejao.org
3
BPPV Recurrence Rate in Otolith Dysfunction
Table 4. Recurrence of benign paroxysmal positional vertigo in
group 3 in patients with cVEMP and/or oVEMP abnormalities
Recurrent
Not
recurrent
Total
cVEMP abnormality
0
10
10
oVEMP abnormality
2
2
4
cVEMP and oVEMP abnormality
0
1
1
Total
2
13
15
cVEMP: cervical vestibular evoked myogenic potential, oVEMP:
ocular vestibular evoked myogenic potential
Table 5. Correlation of otolith abnormalities with benign paroxysmal positional vertigo recurrence
Value
df
Group 2
5.00
1
p value
0.025
Group 3
6.34
2
0.042
5% of patients with both cVEMP and oVEMP abnormalities
showed recurrent BPPV (group 2 and 3). Therefore 73.3% of
patients with cVEMP and/or oVEMP abnormalities in group
2 and 3 showed recurrent BPPV. Spearman correlation analysis showed a significant correlation between recurrent
BPPV and otolithic abnormalities (r=0.81; p<0.05).
Chi-square (χ2) test showed a significant decrease in BPPV
recurrence rate in group 3 after repositioning rehabilitation
and otolithic exercise (p<0.05). On the other hand, chi-square
(χ2) test showed no significant decrease in BPPV recurrence
rate in group 2 following only repositioning maneuver (p>
0.05).
Discussion
This study was conducted on 45 subjects with BPPV. In
groups 1, 2, and 3, recurrence rate were 6.7%, 40%, and 13.3%,
respectively. Other studies have reported the BPPV recurrence rate from 13.5% to 50% [12,13,18]. Variability in reported BPPV recurrence may be related to patient variables
such as age, sample size, and treatment maneuver. This study
showed that patients without dysfunction of otolith organs
had less BPPV recurrence. In group 2, we found more BPPV
recurrence in comparison to groups 1 and 3 and there was a
significant correlation between BPPV recurrence and otolith
dysfunction (oVEMP abnormality). This shows the possible
effects of otolith dysfunction on BPPV recurrence. Degenerated saccular or utricular structures might lead to more BPPV
recurrence. A consistent detachment of otoconia particles that
move to posterior semicircular canal might cause BPPV [6,19].
Evaluating otolith function may have a potential use for determining patients’ prognosis about BPPV treatments and
probable BPPV recurrence. This may help clinician counsel
the patient regarding follow-up evaluations and treatments. It
4
J Audiol Otol 2018 July 19 [Epub ahead of print]
has been shown that endolymphatic hydrops is a risk factor
for BPPV recurrence [20] and the present study showed that
otolith dysfunction may be another important risk factor.
The BPPV recurrence was seen more prevalent in patients
with oVEMP abnormalities which represents utricle involvements. Patients with cVEMP abnormalities showed no significant difference regarding BPPV recurrence rate in comparison with group 1. cVEMP can evaluate saccular function.
It is supposed that otoconia particles inducing BPPV are generally detached from utricle which is in close anatomic proximity to the semicircular canal [1,21].
Despite the fact that Epley’s maneuver is an effective, safe
and the simple treatment for BPPV, to date, treatment of
BPPV patients has been limited to this maneuver and other
similar CRM maneuvers. The present study showed that a
proportion of patients with BPPV suffer from otolith dysfunction. In this population, adding habituation and otolith rehabilitation exercises to Epley’s maneuver can significantly decrease BPPV recurrence rate. The rate of BPPV recurrence
was 13.3% and 40% in group 2 and 3, respectively. Other
studies have shown that habituation exercises are beneficial
for BPPV patients. These daily exercises may prevent the accumulation of otoconia in the posterior canal by dispersing
otoconia particles in patients with recurrent BPPV, so BPPV
recurrence will be decreased in extended time.
In conclusion, this study showed that the BPPV recurrence
rate was higher in patients with otolith dysfunction, especially
utricular dysfunction, and habituation and otolith exercises in
addition to traditional CRM maneuvers can decrease BPPV
recurrence rate significantly. Otolith dysfunction may be a
good predictor of BPPV recurrence and may help with consulting the patient and arranging the follow-up sessions and planning the rehabilitation program.
Acknowledgments
We thank from Dr. Pedram Borghei who provided insight and
expertise that greatly assisted the research. This study was a part of
the first author Ph.D. thesis entitled “The effect of vestibular rehabilitation on BPPV recurrence and degeneration of otolithic organs
in idiopathic BPPV patients” sponsored by Tehran University of
medical sciences, school of rehabilitation, audiology department, at
2013.
Conflicts of interest
The authors have no financial conflicts of interest.
REFERENCES
1) Hornibrook J. Benign paroxysmal positional vertigo (BPPV): his-
tory, pathophysiology, office treatment and future directions. Int J
Otolaryngol 2011;2011:835671.
2) Pollak L, Kushnir M, Goldberg HS. Physical inactivity as a contributing factor for onset of idiopathic benign paroxysmal position-
Hoseinabadi R, et al.
al vertigo. Acta Otolaryngol 2011;131:624-7.
3) Korres S, Gkoritsa E, Giannakakou-Razelou D, Yiotakis I, Riga M,
4)
5)
6)
7)
8)
9)
10)
11)
12)
Nikolpoulos TP. Vestibular evoked myogenic potentials in patients
with BPPV. Med Sci Monit 2011;17:CR42-7.
Mandalà M, Santoro GP, Awrey J, Nuti D. Vestibular neuritis: recurrence and incidence of secondary benign paroxysmal positional
vertigo. Acta Otolaryngol 2010;130:565-7.
Dundar MA, Derin S, Aricigil M, Eryilmaz MA, Arbag H. Posttraumatic refractory multiple canal benign paroxysmal positional
vertigo: a case report. North Clin Istanb 2016;3:229-32.
von Brevern M, Bertholon P, Brandt T, Fife T, Imai T, Nuti D, et al.
Benign paroxysmal positional vertigo: diagnostic criteria. J Vestib
Res 2015;25:105-17.
Do YK, Kim J, Park CY, Chung MH, Moon IS, Yang HS. The effect of early canalith repositioning on benign paroxysmal positional vertigo on recurrence. Clin Exp Otorhinolaryngol 2011;4:113-7.
Pereira AB, Santos JN, Volpe FM. Effect of Epley’s maneuver on
the quality of life of paroxismal positional benign vertigo patients.
Braz J Otorhinolaryngol 2010;76:704-8.
Korres S, Balatsouras DG, Kaberos A, Economou C, Kandiloros D,
Ferekidis E. Occurrence of semicircular canal involvement in benign paroxysmal positional vertigo. Otol Neurotol 2002;23:926-32.
Choi SJ, Lee JB, Lim HJ, Park HY, Park K, In SM, et al. Clinical
features of recurrent or persistent benign paroxysmal positional
vertigo. Otolaryngol Head Neck Surg 2012;147:919-24.
Steenerson RL, Cronin GW, Marbach PM. Effectiveness of treatment techniques in 923 cases of benign paroxysmal positional vertigo. Laryngoscope 2005;115:226-31.
Macias JD, Lambert KM, Massingale S, Ellensohn A, Fritz JA.
Variables affecting treatment in benign paroxysmal positional ver-
tigo. Laryngoscope 2000;110:1921-4.
13) Sridhar S, Panda N. Particle repositioning manoeuvre in benign par-
oxysmal positional vertigo: is it really safe? J Otolaryngol 2005;34:
41-5.
14) Pérez P, Franco V, Cuesta P, Aldama P, Alvarez MJ, Méndez JC.
Recurrence of benign paroxysmal positional vertigo. Otol Neurotol
2012;33:437-43.
15) Ernst A, Basta D, Seidl RO, Todt I, Scherer H, Clarke A. Management of posttraumatic vertigo. Otolaryngol Head Neck Surg 2005;
132:554-8.
16) Jacobson GP, McCaslin DL, Piker EG, Gruenwald J, Grantham SL,
Tegel L. Patterns of abnormality in cVEMP, oVEMP, and caloric
tests may provide topological information about vestibular impairment. J Am Acad Audiol 2011;22:601-11.
17) Chihara Y, Iwasaki S, Ushio M, Murofushi T. Vestibular-evoked
extraocular potentials by air-conducted sound: another clinical test
for vestibular function. Clin Neurophysiol 2007;118:2745-51.
18) Brandt T, Huppert D, Hecht J, Karch C, Strupp M. Benign paroxysmal positioning vertigo: a long-term follow-up (6-17 years) of
125 patients. Acta Otolaryngol 2006;126:160-3.
19) von Brevern M, Schmidt T, Schönfeld U, Lempert T, Clarke AH.
Utricular dysfunction in patients with benign paroxysmal positional
vertigo. Otol Neurotol 2006;27:92-6.
20) Tanimoto H, Doi K, Nishikawa T, Nibu K. Risk factors for recurrence of benign paroxysmal positional vertigo. J Otolaryngol Head
Neck Surg 2008;37:832-5.
21) Inagaki T, Suzuki M, Otsuka K, Kitajima N, Furuya M, Ogawa Y,
et al. Model experiments of BPPV using isolated utricle and posterior semicircular canal. Auris Nasus Larynx 2006;33:129-34.
www.ejao.org
View publication stats
5