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Year : 2018  |  Volume : 24  |  Issue : 1  |  Page : 13-15

Effect of postural restrictions on the outcome of benign paroxysmal positional vertigo, postcanalith repositioning maneuver

Department of ENT, SRM Medical College and Research Centre, Chennai, Tamil Nadu, India

Date of Web Publication24-May-2018

Correspondence Address:
Dr. P K Purushothaman
Department of ENT, SRM Medical College and Research Centre, Potheri, Chennai - 603 202, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/indianjotol.INDIANJOTOL_77_17

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Introduction: Postural Restrictions of Head are advised by some physicians after BPPV is treated by canalith repositioning maneuvers.
Aim: To find out if these postural restrictions are beneficial. Methodology: A total of 682 patients were studied over a period of 2 years. They were separated into 2 groups where one observed postural restrictions and the other didn't. Both the groups were compared. Results: The group which observed postural restrictions had better symptom relief after the first repositioning maneuver itself and recurrences were less. An odds ratio of 1.7862 was obtained upon statistical analysis. Conclusion: BPPV patients who observed postural restrictions after canalith repositioning maneuver had a better outcome than those who didn't.

Keywords: Benign paroxysmal positional vertigo, canalith repositioning maneuver, postural restrictions, vertigo

How to cite this article:
Karthikeyan D A, Purushothaman P K, Ramakrishnan R, Banumathi K. Effect of postural restrictions on the outcome of benign paroxysmal positional vertigo, postcanalith repositioning maneuver. Indian J Otol 2018;24:13-5

How to cite this URL:
Karthikeyan D A, Purushothaman P K, Ramakrishnan R, Banumathi K. Effect of postural restrictions on the outcome of benign paroxysmal positional vertigo, postcanalith repositioning maneuver. Indian J Otol [serial online] 2018 [cited 2019 Sep 19];24:13-5. Available from: http://www.indianjotol.org/text.asp?2018/24/1/13/233132

  Introduction Top

Benign paroxysmal positional vertigo is said to occur when otoconial debris freely floats in semicircular canals and stimulates the ampulla with its inertial forces upon head movement. Canalith repositioning maneuvers are the mainstay of treatment of BPPV. Patients may have recurrence or residual disease and may require repeated maneuvers. After repositioning maneuvers, postural restrictions were advised by many authors in the intent of preventing the otoconia entering the semicircular canals from the utricle into which it is deposited. Postural restrictions were a matter of debate, with some authors observing additional beneficial effect and some observing none. In this study, we intended to find out if there are any beneficial effects of advising the patients to observe postural restrictions after treating BPPV with maneuvers.

Aims and objectives

  1. To find if postural restrictions are beneficial after performing canalith repositioning maneuver (CRM) for benign paroxysmal positional vertigo (BPPV) patients
  2. To find the differences in recurrence rates post-CRM between patients observing postural restrictions and patients who do not
  3. To find patient's symptom relief post-CRM, who observe postural restrictions and patients who do not.

  Methodology Top

Patients presenting to the vertigo clinic in our medical college were studied from July 2014 to June 2016. BPPV patients were divided into two groups using simple randomization. BPPV patients with otitis media, neurologic, cardiac, and diabetic ailments were excluded from the study. After performing modified Epley maneuver for BPPV, Group A patients are asked to sit for 10 min before heading home and given a set of postural restrictions as follows:

  1. Sleep semi-recumbent for the first two nights
  2. Not to lie with the affected ear down
  3. Not to move the head suddenly or bend down or lift up to retrieve objects
  4. Avoid lifting heavy objects.

Group B patients underwent CRM but no postural restrictions were advised.

Vestibular suppressants were avoided in either group.

Both group patients were reviewed in the vertigo clinic after 1 week of initial canalith repositioning maneuver (CRM), and Dix Hallpike maneuver is repeated, and nystagmus checked. If patients had nystagmus or complained of spinning sensation, CRM was repeated and again observed after 1 week. Three CRMs were done before labeling the patients as recurrence. Patients were followed up for 6 months. Results were noted and statistically analyzed.

  Results Top


A total of 682 patients of BPPV were studied. Six hundred and sixty-nine (98%) patients had posterior semicircular canal BPPV. Eight had a bilateral posterior semicircular canal, two superior semicircular canal, and two had lateral semicircular canal involvement.

A total of 278 patients (84.23%) belonging to the Group A (n = 337) and 239 patients (74.91%) belonging to Group B (n = 332) responded to the first instance of CRM and were negative for nystagmus in repeat Dix–Hallpike test on follow-up the next week. Fifty-two (15.77%) of Group A and 80 (25.09%) of Group B had positive nystagmus and symptoms of vertigo during the first review week and required another instance of CRM [Table 2].
Table 1: Gender distribution of benign paroxysmal positional vertigo patients

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Table 2: Symptom relief after canalolith repositioning maneuver

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Seven patients (2.08%) of Group A and 13 patients (3.92%) of Group B had persistent nystagmus or spinning sensation even after three CRMs and were labeled as recurrences.

Results were analyzed statistically. The odds ratio was 1.7895 (confidence interval of 95%). Chi-square value was 8.6974 and P = 0.003187 (<0.005) and statistically significant.

  Discussion Top

BPPV is a common condition diagnosed in a dizziness clinic. About 85% of all the cases presenting to the vertigo clinic are peripheral vertigo, and 18.3% of them are BPPV.[1] Toupet, 1994, showed that 68% of all BPPV patients (n = 1467) were female and most were in the ages between 45 and 60. Moon et al.[2] also quoted a female-to-male ratio of 1.5:1. In our study, also, the female-to-male ratio was 1.36, males being 283 and females being 386 [Table 1].

BPPV is due to the stimulation of the semicircular canal sensory apparatus by otoconial debris. The otoconial debris is formed due to normal, natural degeneration of the cupula, or due to pathological reasons. There are two forms of BPPV. Cupulithiasis [3] and canalolithiasis [4] clinically both of these cannot be readily differentiated except for the fact that cupulolithiasis has no or little latency as compared to the latter.

CRMs form the main modality of treatment of BPPV. Semont liberatory maneuver and the Brandt–Daroff exercises are based on dispersing the debris attached to the cupula, the Schucknet theory. Epley maneuver is based on displacing the free floating otoconia into the utricle for adsorption, the canalolithiasis theory.

There were certain reasons behind the imposition of postural restrictions after performing a CRM. The floating otoconial debris, if they are small, do not exert ampullofugal pull, thereby have no or little effect on stimulating the cupula. However, if they clump together, they exert an ampullofugal force strong enough to cause activation. This formed the basis for liberatory maneuvers and mastoid vibrator use post maneuver by Epley. When postural restrictions are employed, the small debris clump together in the utricle and cannot reenter the posterior semicircular canal. Since the plane of the utricle is 30° above the naso-occipital plane, the patient is asked to lie semi-recumbent to keep the debris in utricle for a period until they clump together and cannot re-enter the posterior semicircular canal, thereby theoretically reducing recurrences.[5]

Recurrences are more in cupulolithiasis, and they are refractory to CRM. About 20% of patients recur after 2 weeks and 15% within 1 year. The recent prospective study by Cakir et al.[6] reported that postural restrictions enhanced the outcome of CRM, especially in resistant cases. The study also supports this conclusion.

  Conclusion Top

We conclude that patients who followed postural restrictions post maneuver had 1.7862 times better outcome than those who did not. Further, patients with BPPV, during their initial clinical visit give a history of vertigo in a particular head position which they tend not to do again fearing a repeat attack. Hence, they are already on postural restriction. Extension of that restriction period, in our context, had no additional discomfort to the patient. Hence, we conclude that post CRM restrictions are helpful in treating BPPV.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Brandt T, Dieterich M, Strupp M. Vertigo and Dizziness Common Complaints. USA: Springer; 2005. p. 4.  Back to cited text no. 1
Moon SJ, Bae SH, Kim HD, Kim JH, Cho YB. The effect of postural restrictions in the treatment of benign paroxysmal positional vertigo. Eur Arch Otorhinolaryngol 2005;262:408-11.  Back to cited text no. 2
Schucknet HF. Cupulolithiasis. Arch Otolaryngol 1969;90:765-78.  Back to cited text no. 3
Hall SF, Ruby RR, McClure JA. The mechanics of benign paroxysmal vertigo. J Otolaryngol 1979;8:151-8.  Back to cited text no. 4
Korres S, Balatsouras DG, Kaberos A, Economou C, Kandiloros D, Ferekidis E, et al. Occurrence of semicircular canal involvement in benign paroxysmal positional vertigo. Otol Neurotol 2002;23:926-32.  Back to cited text no. 5
Cakir BO, Ercan I, Cakir ZA, Turgut S. Efficacy of postural restriction in treating benign paroxysmal positional vertigo. Arch Otolaryngol Head Neck Surg 2006;132:501-5.  Back to cited text no. 6


  [Table 1], [Table 2]


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