Background and aim
A diagnosis of chronic benign paroxysmal positional vertigo (BPPV) is based on brief attacks of rotatory vertigo and concomitant nystagmus elicited by rapid changes in head position relative to gravity. However, the clinical course of BPPV may vary considerably from a self-limiting to a persisting and/or recurrent disabling problem. The authors’ experience is that the most common complaints of patients with chronic BPPV are nautical vertigo or dizziness with other symptoms including neck pain, headache, widespread musculoskeletal pain, fatigue, and visual disturbances. Trauma is believed to be the major cause of BPPV in individuals younger than fifty years. Chronic BPPV is associated with high morbidity. Since these patients often suffer from pain and do not have rotatory vertigo, their symptoms are often attributed to other conditions. The aim of this study was to investigate possible associations between these symptoms and chronic BPPV.
During 2010 a consecutive prospective cohort observational study was performed. Diagnostic criteria: (A) BPPV diagnosis confirmed by the following: (1) a specific history of vertigo/dizziness evoked by acceleration/deceleration, (2) nystagmus in the first position of otolith repositioning maneuvers, and (3) appearing and disappearing nystagmus during the repositioning maneuvers; (B) the disorder has persisted for at least six months. (C) Normal MRI of the cerebrum. Exclusion criteria: (A) Any disorder of the central nervous system (CNS), (B) migraine, (C) active Ménière’s disease, and (D) severe eye disorders. Symptom questionnaire (‘yes or no’ answers during a personal interview) and Dizziness Handicap Inventory (DHI) were used.
We included 69 patients (20 males and 49 females) with a median age of 45 years (range 21-68 years). The median duration of the disease was five years and three months. The video-oculography confirmed BPPV in more than one semicircular canal in all patients. In 15% there was a latency of more than 1 min before nystagmus occurred. The Dizziness Handicap Inventory (DHI) median score was 55.5 (score >60 indicates a risk of fall). Seventy-five percent were on 50-100% sick leave. Eighty-one percent had a history of head or neck trauma. Nineteen percent could not recall any history of trauma. In our cohort, nautical vertigo and dizziness (81%) was far more common than rotatory vertigo (20%). The majority of patients (87%) reported pain as a major symptom: neck pain (87%), headache (75%) and widespread pain (40%). Fatigue (85%), visual disturbances (84%), and decreased concentration ability (81%) were the most frequently reported symptoms. In addition, unexpected findings such as involuntary movements of the extremities, face, neck or torso were found during otolith repositioning maneuvers (12%). We describe one case, as an example, how treatment of his BPPV also resolved his chronic, severe pain condition.
This observational study demonstrates a likely connection between chronic BPPV and the following symptoms: nautical vertigo/dizziness, neck pain, headache, widespread pain, fatigue, visual disturbances, cognitive dysfunctions, nausea, and tinnitus.
Patients with complex pain conditions associated with nautical vertigo and dizziness should be evaluated with the Dizziness Handicap Inventory (DHI)-questionnaire which can identify treatable balance disorders in patients with chronic musculoskeletal pain.
DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2013.06.005.
Conflict of interest
The authors declare that they have no conflict of interest.
 Barány R. Diagnose von Krankheitserscheinungen im Bereiche des Otolithenapparates. Acta Otolaryngol (Stockh) 1921;2:334–7.Search in Google Scholar
 Dix R, Hallpike CS. The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Ann Otol Rhinol Laryngol 1952;8:151–8.Search in Google Scholar
 Norré ME. Reliability of examination data in the diagnosis of benign paroxysmal positional vertigo. AmJ Otol 1995;16:806–10.Search in Google Scholar
 Lopez-Escamez JA, Gamiz MJ, Fernandez-Perez A, Gomez-Fiñana M, Sanchez-Canet I. Impact of treatment on health-related quality of life in patients with posterior canal benign paroxysmal positional vertigo. Otol Neurotol 2003;24:637–41.10.1097/00129492-200307000-00018Search in Google Scholar PubMed
 Gordon CR, Levite R, Joffe V, Gadoth N. Is posttraumatic benign paroxysmal positional vertigo different from the idiopathic form? Arch Neurol 2004;61: 1590–3.10.1001/archneur.61.10.1590Search in Google Scholar PubMed
 Jackson LE, Morgan B, Fletcher Jr JC, Krueger WW. Anterior canal benign paroxysmal positional vertigo: an underappreciated entity. Otol Neurotol 2007;28:218–22.10.1097/01.mao.0000247825.90774.6bSearch in Google Scholar PubMed
 Kansu L, Avci S, Yilmaz I, Ozluoglu LN. Long-term follow-up of patients with posterior canal benign paroxysmal positional vertigo. Acta Otolaryngol 2010;130:1009–12.10.3109/00016481003629333Search in Google Scholar PubMed
 Ahn SK, Jeon SY, Kim JP, Hur DG, Kim DW, Woo SH, Kwon OJ, Kim JY. Clinical characteristics and treatment of benign paroxysmal positional vertigo after traumatic brain injury. J Trauma 2011;70:442–6.10.1097/TA.0b013e3181d0c3d9Search in Google Scholar PubMed
 Dlugaiczyk J, Siebert S, Hecker DJ, Brase C, Schick B. Involvement of the anterior semicircular canal in posttraumatic benign paroxysmal positioningvertigo. Otol Neurotol 2011;32:1285–90.10.1097/MAO.0b013e31822e94d9Search in Google Scholar PubMed
 Hornibrook J. Benign paroxysmal positional vertigo (BPPV). History, pathophysiology. Office treatment and future directions. Int J Otolaryngol 2011;2011:1–13.10.1155/2011/835671Search in Google Scholar PubMed PubMed Central
 Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, Chalian AA, Desmond AL, Earll JM, Fife TD, Fuller DC, Judge JO, Mann NR, Rosenfeld RM, Schuring LT, Steiner RW, Whitney SL, Haidari J. Clinical practice guideline: benign paroxysmal positional vertigo. American Academy of Otolaryngology-Head and Neck Surgery Foundation. Otolaryngol Head Neck Surg 2008;139:S47–81.10.1016/j.otohns.2008.08.022Search in Google Scholar PubMed
 Spitzer WO, Skovron ML, Salmi LR, Cassidy JD, Duranceau J, Suissa S, Zeiss E. Scientific monograph of the Quebec Task Force on Whiplash-Associated Disorders: redefining “whiplash”and its management. Spine 1995;20:1S-73S (Phila Pa 1976).Search in Google Scholar
 Whitney SL, Marchetti GF, Morris LO. Usefulness of the dizziness handicap inventory in the screening for benign paroxysmal positional vertigo. Otol Neurotol 2005;26:1027–33.10.1097/01.mao.0000185066.04834.4eSearch in Google Scholar
 Stedman’s Medical Dictionary. 26th ed. Baltimore: Williams & Wilkins; 1995.Search in Google Scholar
 Lopez-Escamez JA, Molina MI, Gamiz M, Fernandez-Perez AJ, Gomez M, Palma MJ, Zapata C. Multiple positional nystagmus suggests multiple canal involvement in benign paroxysmal vertigo. Acta Otolaryngol 2005;125:954–61.10.1080/00016480510040146Search in Google Scholar
 Polensek SH, Tusa R. Unnecessary diagnostic tests often obtained for benign paroxysmal positional vertigo. Med Sci Monit 2009;15:MT89–94.Search in Google Scholar
 Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107:399–404.10.1177/019459989210700310Search in Google Scholar
 von Brevern M, Radtke A, Clarke AH, Lempert T. Migrainous vertigo presenting as episodic positional vertigo. Neurology 2004;62:469–72.10.1212/01.WNL.0000106949.55346.CDSearch in Google Scholar PubMed
 Brandt T. Vertigo, its multisensory syndromes. London: Springer; 1999. p. 445.Search in Google Scholar
 Tjell C, Iglebekk W. Postural mismatch in musculoskeletal disorders. In: Alricsson M, editor. Musculoskeletal disorder. Rijeka: InTech; 2012., http://dx.doi.org/10.5772/38880.10.5772/38880Search in Google Scholar
 Baloh R, Halmagyi G. Disorders of the vestibular system. New York: Oxford University Press; 1996.Search in Google Scholar
 Hillier SL, McDonnell M. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev 2011;2. CD005397, doi:10.1002/14651858.CD005397.pub3.10.1002/14651858.CD005397.pub3Search in Google Scholar PubMed
 Peters BT, Mulavara AP, Cohen HS, Sangi-Haghpeykar H, Bloomberg JJ. Dynamic visual acuity testing for screening patients with vestibular impairments. J Vestib Res 2012;22:145–51.10.3233/VES-2012-0440Search in Google Scholar PubMed PubMed Central
 Fernández-de-Las-Peñas C, Cuadrado ML, Gerwin RD, Pareja JA. Referred pain elicited by manual exploration of the lateral rectus muscle in chronic tension-type headache. Pain Med 2009;10:43–8.10.1111/j.1526-4637.2008.00416.xSearch in Google Scholar
 Peterson BW, Goldberg J, Biolotto G, Fuller JH. Cervicocollic reflex: its dynamic properties and interaction with vestibular reflexes. J Neurophys 1985;54:90–109.10.1152/jn.19184.108.40.206Search in Google Scholar
 Peterson BW. Current approaches and future directions to understanding control of head movement. Brain mechanisms for the integration of posture and movement. Prog Brain Res 2004;143:369–81.Search in Google Scholar
 Tellegen AJ, Arends JJ, Dubbeldam JL. The vestibular nuclei and vestibuloreticular connections in the mallard (Anas platyrhynchos L.) An anterograde and retrograde tracing study. Brain Behav Evol 2001;58:205–17.10.1159/000057564Search in Google Scholar
 Larsson B, Søgaard K, Rosendal L. Work related neck-shoulder pain: a review on magnitude, risk factors, biochemical characteristics, clinical picture and preventive interventions. Best Pract Res Clin Rheumatol 2007;21: 447–63.10.1016/j.berh.2007.02.015Search in Google Scholar
 Jull G, Kristjansson E, Dall’Alba P. Impairment in the cervical flexors: a comparison of whiplash and insidious onset neck pain patients. Man Ther 2004;9:89–94.10.1016/S1356-689X(03)00086-9Search in Google Scholar
 Falla D, Jull G, Hodges PW. Patients with neck pain demonstrate reduced electromyographic activity of the deep cervical flexor muscles during performance of the craniocervical flexiontest. Spine 2004;29:2108–14.10.1097/01.brs.0000141170.89317.0eSearch in Google Scholar PubMed
 O’Sullivan PB, Burnett A, Floyd AN, Gadsdon K, Logiudice J, Miller D, Quirke H. Lumbar repositioning deficit in a specific low back pain population. Spine 2003;28:1074–9 (Phila Pa 1976).10.1097/01.BRS.0000061990.56113.6FSearch in Google Scholar PubMed
 Kulkarni V, Chandy MJ, Babu KS. Quantitative study of muscle spindles in suboccipital muscles of human foetuses. Neurol India 2001;49:355–9.Search in Google Scholar
 Boyd-Clarc LC, Briggs CA, Galea MP. Muscle spindle distribution, morphology, and density in longus colli and multifidus muscles of the cervical spine. Spine 2002;27:694–701.10.1097/00007632-200204010-00005Search in Google Scholar PubMed
 Liu J, Thornell L, Pedrosa-Domellof F. Muscle spindles in the deep muscles of the human neck: a morphological and immunocytochemical study. J Histochem Cytochem 2003;51:175–86.10.1177/002215540305100206Search in Google Scholar PubMed
 Messier J, Adamovich S, Berkinblit M, Tunik E, Poizner H. Influence of movement speed on accuracy and coordination of reaching movements to memorized targets in three-dimensional space in a deafferented subject. Exp Brain Res 2003;150:399–416.10.1007/s00221-003-1413-9Search in Google Scholar PubMed
 Delwaide PJ, Juprelle M. The effects of caloric stimulation of the labyrinth on the soleus motor pool in man. Acta Neurol Scand 1977;55:310–22.10.1111/j.1600-0404.1977.tb05650.xSearch in Google Scholar PubMed
 Fukushima K, Fukushima J, Ito N, Takei H, Ikeno K, Olley PM, Chiba S, Kobayashi N, Inoue K, Warabi T. Cerebellum and eye movement control -Neuronal mechanisms of memory-based smooth-pursuit and their early clinical application. Rinsho Shinkeigaku 2012;52:1001–5.10.5692/clinicalneurol.52.1001Search in Google Scholar PubMed
 Hillman D, Chen S, Aung TT, Cherksey B, Sugimori M, Llinas RR. Localization of P-type calciumchannels in the central nervous system. Proc Natl Acad Sci U S A 1991;88:7076–80.10.1073/pnas.88.16.7076Search in Google Scholar PubMed PubMed Central
 Shore SE, Koehler S, Oldakowski M, Hughes LF, Syed S. Dorsal cochlear nucleus responses to somatosensory stimulation are enhanced after noise-induced hearing loss. Eur J Neurosci 2008;27:155–68.10.1111/j.1460-9568.2007.05983.xSearch in Google Scholar PubMed PubMed Central
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