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Scandinavian Journal of Pain

Official Journal of the Scandinavian Association for the Study of Pain

Editor-in-Chief: Breivik, Harald

4 Issues per year


CiteScore 2017: 0.84

SCImago Journal Rank (SJR) 2017: 0.401
Source Normalized Impact per Paper (SNIP) 2017: 0.452

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1877-8879
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Volume 4, Issue 4

Pain and other symptoms in patients with chronic benign paroxysmal positional vertigo (BPPV)

Wenche Iglebekk / Carsten Tjell / Peter Borenstein
Published Online: 2013-10-01 | DOI: https://doi.org/10.1016/j.sjpain.2013.06.004

Abstract

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.

Methods

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.

Results

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.

Conclusion

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.

Implications

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.

Keywords: Vertigo; Paroxysmal positional; Dizziness; Pain; Fatigue

References

  • [1]

    Barány R. Diagnose von Krankheitserscheinungen im Bereiche des Otolithenapparates. Acta Otolaryngol (Stockh) 1921;2:334–7.Google Scholar

  • [2]

    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.Google Scholar

  • [3]

    Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional vertigo. Arch Otolaryngol 1980;106:484–5.CrossrefPubMedGoogle Scholar

  • [4]

    Norré ME. Reliability of examination data in the diagnosis of benign paroxysmal positional vertigo. AmJ Otol 1995;16:806–10.Google Scholar

  • [5]

    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.PubMedCrossrefGoogle Scholar

  • [6]

    Korres S, Luxon L, Vannucchi P, Gibson B. Benign paroxysmal positional vertigo. Int J Otolaryngol 2011:353865.PubMedGoogle Scholar

  • [7]

    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.CrossrefPubMedGoogle Scholar

  • [8]

    Jackson LE, Morgan B, Fletcher Jr JC, Krueger WW. Anterior canal benign paroxysmal positional vertigo: an underappreciated entity. Otol Neurotol 2007;28:218–22.PubMedCrossrefGoogle Scholar

  • [9]

    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.PubMedCrossrefGoogle Scholar

  • [10]

    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.CrossrefPubMedGoogle Scholar

  • [11]

    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.PubMedCrossrefGoogle Scholar

  • [12]

    Hornibrook J. Benign paroxysmal positional vertigo (BPPV). History, pathophysiology. Office treatment and future directions. Int J Otolaryngol 2011;2011:1–13.Google Scholar

  • [13]

    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.PubMedCrossrefGoogle Scholar

  • [14]

    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).Google Scholar

  • [15]

    Jacobson GP, Newman CW. The development of the dizziness handicap inventory. Arch Otolaryngol Head Neck Surg 1990;116:424–7.CrossrefPubMedGoogle Scholar

  • [16]

    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.CrossrefPubMedGoogle Scholar

  • [17]

    Stedman’s Medical Dictionary. 26th ed. Baltimore: Williams & Wilkins; 1995.Google Scholar

  • [18]

    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.CrossrefPubMedGoogle Scholar

  • [19]

    Polensek SH, Tusa R. Unnecessary diagnostic tests often obtained for benign paroxysmal positional vertigo. Med Sci Monit 2009;15:MT89–94.PubMedGoogle Scholar

  • [20]

    Epley JM. The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 1992;107:399–404.CrossrefPubMedGoogle Scholar

  • [21]

    Epley JM. Positional vertigo related to semicircular canalithiasis. Otolaryngol Head NeckSurg 1995;112:154–61.CrossrefGoogle Scholar

  • [22]

    von Brevern M, Radtke A, Clarke AH, Lempert T. Migrainous vertigo presenting as episodic positional vertigo. Neurology 2004;62:469–72.CrossrefPubMedGoogle Scholar

  • [23]

    Brandt T. Vertigo, its multisensory syndromes. London: Springer; 1999. p. 445.Google Scholar

  • [24]

    Staab JP. Chronic subjective dizziness. Continuum (Minneap Minn) Neurootology 2012;18:1118–41.Google Scholar

  • [25]

    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.

  • [26]

    Baloh R, Halmagyi G. Disorders of the vestibular system. New York: Oxford University Press; 1996.Google Scholar

  • [27]

    Hillier SL, McDonnell M. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database Syst Rev 2011;2. CD005397, doi:10.1002/14651858.CD005397.pub3.Google Scholar

  • [28]

    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.PubMedGoogle Scholar

  • [29]

    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.CrossrefPubMedGoogle Scholar

  • [30]

    Peterson BW, Goldberg J, Biolotto G, Fuller JH. Cervicocollic reflex: its dynamic properties and interaction with vestibular reflexes. J Neurophys 1985;54:90–109.CrossrefGoogle Scholar

  • [31]

    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.Google Scholar

  • [32]

    Bacsi AM, Colebatch JG. Evidence for reflex and perceptual vestibular contributions to postural control. Exp Brain Res 2005;160:22–8.CrossrefPubMedGoogle Scholar

  • [33]

    Goldberg JM, Cullen KE. Vestibular control of the head: possible functions of the vestibulocollic reflex. Exp Brain Res 2011;210:331–45.CrossrefPubMedGoogle Scholar

  • [34]

    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.CrossrefPubMedGoogle Scholar

  • [35]

    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.CrossrefGoogle Scholar

  • [36]

    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.CrossrefPubMedGoogle Scholar

  • [37]

    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.CrossrefPubMedGoogle Scholar

  • [38]

    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).CrossrefGoogle Scholar

  • [39]

    Kulkarni V, Chandy MJ, Babu KS. Quantitative study of muscle spindles in suboccipital muscles of human foetuses. Neurol India 2001;49:355–9.PubMedGoogle Scholar

  • [40]

    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.CrossrefPubMedGoogle Scholar

  • [41]

    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.CrossrefGoogle Scholar

  • [42]

    Ghez C, Sainburg R. Proprioceptive control of interjoint coordination. Can J Physiol Pharmacol 1995;73:273–84.PubMedCrossrefGoogle Scholar

  • [43]

    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.CrossrefGoogle Scholar

  • [44]

    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.PubMedCrossrefGoogle Scholar

  • [45]

    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.CrossrefPubMedGoogle Scholar

  • [46]

    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.CrossrefGoogle Scholar

  • [47]

    Yarom Y, Cohen D. The olivocerebellar system as a generator of temporal patterns. Ann N Y Acad Sci 2002;978:122–34.CrossrefPubMedGoogle Scholar

  • [48]

    Smith PF, Zheng Y, Horii A, Darlington CL. Does vestibular damage cause cognitive dysfunction in humans? J Vestib Res 2005;15:1–9.PubMedGoogle Scholar

  • [49]

    McKinney M, Jacksonville MC. Brain cholinergic vulnerability: relevance to behavior and disease. Biochem Pharmacol 2005;70:1115–24.CrossrefPubMedGoogle Scholar

  • [50]

    Tjell C, Tenenbaum A, Rosenhall U. Auditory function in whiplash associated disorders. Scand Audiology 1999;28:203–9.CrossrefGoogle Scholar

  • [51]

    Lew HL, Jerger JF, Guillory SB, Henry JA. Auditory dysfunction in traumatic brain injury. J Rehabil Res Dev 2007;44:921–8.PubMedCrossrefGoogle Scholar

  • [52]

    Shore SE, Zhou J. Somatosensory influence on the cochlear nucleus and beyond. Hear Res 2006;216–217:90–9.PubMedGoogle Scholar

  • [53]

    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.PubMedGoogle Scholar

About the article

Otoneurology Centre, Post Box 130, N-4702 Vennesla, Norway. Tel.: +47 97 04 22 31 E-mail: igysiot@gmail.com


Received: 2013-02-15

Revised: 2013-06-07

Accepted: 2013-06-11

Published Online: 2013-10-01

Published in Print: 2013-10-01


Conflict of interestThe authors declare that they have no conflict of interest.


Citation Information: Scandinavian Journal of Pain, Volume 4, Issue 4, Pages 233–240, ISSN (Online) 1877-8879, ISSN (Print) 1877-8860, DOI: https://doi.org/10.1016/j.sjpain.2013.06.004.

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