Self-Treatment of Recurrent Benign Paroxysmal Positional Vertigo

This article by Hyo-Jung Kim reaches useful conclusions on the remote treatment of benign paroxysmal positional vertigo (BPPV). BPPV is the most common vestibular disorder, with patients presenting to different doctors and departments, including accident and emergency units. The treatment of BPPV with canal repositioning maneuvers, which remove the crystal particles from the affected semicircular canal, is a successful story in modern medicine. Common self-limiting conditions like the common cold or BPPV receive little publicity and research money from charitable and government bodies. However, the British Medical Research Council has been running a research unit for more than 40 years where a number of significant discoveries have been made, including the report of the first human coronavirus, which was published in the BMJ, but no treatment discovery has ever been made. The story of BPPV is just the opposite and a victory for plain clinical observation as a source of new treatments. An ENT surgeon in the US and a physiotherapist in France discovered almost simultaneously 35 years ago what we now call the Epley and Semont maneuvers, respectively. These procedures cure BPPV instantly in more than 90% of patients and can be carried out risk-free by doctors, nurses, physiotherapists, and audiologists.

The COVID pandemic raised this situation one step up. We all learned to examine patients on our screens (including video "selfies" of the patients’ nystagmus) and direct them to suitable videos on the Internet or plainly explain how to do the treatment maneuvers. We all knew, anecdotally, that this worked, but the paper by Hyo-Jung Kim takes us to another level. Not only do the authors demonstrate that remote treatments work for BPPV recurrences but also, importantly, that one should try to customize the treatment to the canal affected. On the basis of an online questionnaire, their “treatment” group received a canal-specific diagnosis, and the treatment was accordingly customized. Patients in the “control” group were just instructed to repeat the maneuver they had originally received in person at the hospital. The outcomes were superior in the customized “treatment” group, which the authors explain by the fact that only about a third of BPPV recurrences are in the canal originally affected. Hence, a canal-specific maneuver as done for the “treatment” group was proven superior. Clearly, there are direct benefits to patients from these findings, but the main beneficiaries of this trial should be the post-pandemic shaky health systems around the world struggling with long outpatient waiting lists. A shortcoming of this excellent article perhaps is the lack of models to show how much quicker patients with BPPV would be treated if a remote service were set up along the lines described in the article.

Web Based Treatment of Benign Positional Vertigo

Benign positional vertigo (BPV) is an uncomfortable condition that can be cured with specific exercises. About 50% of those effected by BPV have a recurrence and only one-third of them have it in the same location. This study stresses the importance of tailoring exercises to the canal effected when there is a recurrence.

In 585 patients with BPV, those who were directed via a web-based tool to an exercise specific to the canal that the recurring vertigo was related to reached a resolution of 72.4%, whereas those that did the same maneuver based on the canal location from the previous attack reached a resolution of 42.9%. These results stress the fact that recurrences often require different types of exercises.

One of the videos for right-sided BPV was published on the JAMA website. I will likely refer my patients to it and have them reverse the exercise if the BPV is worse with the head turning to the left.