Clinical Trials Logo

Clinical Trial Summary

Acute vertigo accounts for around 4% of emergency room visits. Triggered episodic vestibular syndrome is the most commonly encountered symptomatic context. BPPV (Benign Paroxysmal Positional Vertigo) is the main cause, representing 40-50% of the vertigo cases assessed in emergency departments. It results from the migration of calcium carbonate particles (otoliths), from the sticky membrane of the utricle and saccule of the inner ear, to one of the 3 semicircular canals (SCC), posterior, horizontal or lateral, and anterior. It occurs idiopathically with head movement, through degeneration, or following head trauma. The otolith impulse causes the endolymph to move, temporarily and aberrantly displacing the cup of the affected canal, resulting in the transmission of erroneous information to the vestibular nuclei. This leads to the sudden onset of vertigo and eye deviation, resulting in transient nystagmus. The location of the displaced otoliths determines the variant of BPPV: BPPV of the posterior semicircular canal is the most common (around 65% of BPPVs), followed by BPPV of the horizontal canal, while BPPV of the anterior canal is rare, as it resolves spontaneously and rapidly. Although a benign condition, BPPV leads 9 times out of 10 to a medical consultation, interruption of daily activities, or sick leave. Untreated, it will usually recur, and can impact on patients' quality of life.


Clinical Trial Description

Recommendations for the appropriate management of vertigo in emergency departments published in 2023 reaffirmed that the management of BPPV is based solely on the clinic. There is no imaging test that can confirm the presence of otoliths migrating to a semicircular canal during head movement. BPPV should be suspected in the presence of an episodic vestibular syndrome triggered by head movements, and more broadly, in the presence of brief vertigo without a clear cause and without spontaneous or lateral facing nystagmus. The diagnosis of posterior BPPV is made when vertigo is accompanied by transient vertical torsional nystagmus on the Dix-Hallpike test. In some cases of BPPV, the Dix-Hallpike test produces vertigo, but not transient nystagmus. This phenomenon is known as "subjective BPPV", and may affect up to a quarter of patients suspected of having BPPV. It can be explained by a low otolith load in the affected canal, by spontaneous healing by otolith egress from the canal , but also by poor technique on the part of the clinician (slow maneuver or faulty final position). In patients with a typically positive Dix-Hallpike result or subjective BPPV, 1st-line treatment is based on a canalith repositioning maneuver. The modified Epley maneuver is the recommended one, and its efficacy is supported by numerous meta-analyses. It is significantly associated with complete resolution of symptoms after 7 days. Horizontal BPPV should be suspected by the presence of transient horizontal nystagmus in the Dix-Hallpike test. The Supine Head Roll test then confirms the diagnosis, with the appearance of vertigo and transient horizontal geo- or ageo-tropic nystagmus. The preferred treatment maneuver is Lempert's "Barbecue" maneuver. This management strategy can be summarized in a decision tree. As posterior BPPV is the most common, the appropriate use of the Dix-Hallpike and Epley maneuvers has a positive effect on a large majority of BPPV patients in emergency departments In terms of clinical decision rules, the management of vertigo has been mentioned as the 1st priority of emergency physicians . However, numerous studies have highlighted the fact that their clinical approach is often inappropriate and leads to underdiagnosis of BPPV. Under-diagnosis is generally due to failure to verify the existence of spontaneous nystagmus, under-use of the Dix-Hallpike test, or its misuse. While BPPV is a common and easily treatable condition, its diagnosis and treatment are largely delayed by a lack of theoretical knowledge and clinical skills among physicians. Understanding the orientation of the vestibular apparatus and how it is stimulated is difficult learning. Traditional lecture-based learning appears to have little gain in terms of skill acquisition. This approach is tedious and offers little opportunity to acquire clinical skills. Theoretical resources do exist; in particular, the BPPV Viewer software, which offers 3D modeling of the vestibular apparatus, and the demonstration videos by Prof. Peter Johns available on Youtube® could provide a fairly clear theoretical basis. Proposing new teaching methods could be one way of solving the problem of sub-optimal management of BPPV and the resulting under-diagnosis. Two original teaching methods have been published, one using demonstrations involving students to teach vestibular physiology, the other based on Gagne's 9 event. The retention and transfer of knowledge to the bedside needs to be investigated. ;


Study Design


Related Conditions & MeSH terms


NCT number NCT06314581
Study type Observational
Source Fondation Hôpital Saint-Joseph
Contact
Status Active, not recruiting
Phase
Start date May 1, 2023
Completion date December 1, 2024

See also
  Status Clinical Trial Phase
Completed NCT03425786 - Benign Paroxysmal Positional Vertigo (BPPV) Training for Sports Medicine Providers in a Pediatric Concussion Program N/A
Completed NCT02046980 - Treatment of Apogeotropic Horizontal Canal Benign Paroxysmal Positional Vertigo Phase 2
Withdrawn NCT00978809 - Effects of Physical Treatment on Postural Stability in Benign Paroxysmal Positional Vertigo (BPPV) Patients N/A
Completed NCT02029508 - The Treatment of Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo Phase 3
Completed NCT02809599 - Evidence Based Best Care Practice for Benign Paroxysmal Positional Vertigo N/A
Completed NCT03230513 - Comparison of Home-Based Exercise on the Posterior Canal Benign Paroxysmal Positional Vertigo Symptoms N/A
Completed NCT03643354 - Evaluation of the Prevalence of BPPV and Longterm Effects of Its Therapy Using the Rotundum Device in Retirement Homes N/A
Completed NCT00641797 - Treating Benign Paroxysmal Positional Vertigo (BPPV) in ED Patients N/A
Recruiting NCT06001047 - Head Acupuncture Treat Residual Symptoms After Canalith Repositioning Procedure for BPPV N/A
Not yet recruiting NCT04578470 - Benign Paroxysmal Positional Vertigo (BPPV) in Older Patients Phase 2
Not yet recruiting NCT04578262 - Epley Manoeuvre in Participants With Multiple Sclerosis Diagnosed From Benign Paroxysmal Positional Vertigo N/A
Completed NCT05748249 - Evaluation of the Efficacy of Vertistop® D and Vertistop® L in the Prevention of BPPV Recurrence Phase 1
Completed NCT04715282 - The Epley Maneuver Versus Cawthorne-Cooksey Exercises in the Treatment of Benign Paroxysmal Positional Vertigo (BPPV) N/A
Terminated NCT03161470 - Efficacy of a Mechanical Chair for Treatment of Benign Paroxysmal Positional Vertigo (BPPV) N/A
Completed NCT05425199 - Habituation Exercises Versus Proprioceptive Training in Benign Paroxysmal Positional Vertigo N/A
Recruiting NCT05922774 - Cervical Vestibular Evoked Myogenic Potentials in Recurrent and Persistant Benign Paroxysmal Positional Vertigo
Recruiting NCT05013684 - Benign Paroxysmal Positional Vertigo in Older Adults N/A
Not yet recruiting NCT05863949 - Clinical Trial of Vit D and Calcium for Recurrent BPPV N/A
Completed NCT05127694 - Treatment In Acute Benign Paroxysmal Positional Vertigo N/A
Suspended NCT04026516 - CAVA: Dizziness Trial N/A