January 19, 2018 at 7:10 am #73693
Why did you choose this article or document?
This is the first CPG (clinical practice guideline) for BPPV (same chief author) since 2008, given the amount of exposure that Physiotherapists now have to potential vestibular clientele (many courses, certifications, concussion practices etc.) it is imperative that physiotherapists are comfortable and confident in providing the most evidence based care to their patients presenting with BPPV. There is also a lot of misinformation and information overload out there (on the internet) for patients to navigate and make sense of; as well as physiotherapists and referral sources (GP’s etc.) who may not necessarily be totally comfortable managing patients with more complex or confusing signs of BPPV. Therefore, having this internationally recognized CPG for best practice in managing BPPV patients is a particularly useful tool for clinicians.
What is the question being asked?
The authors delineate a few main questions or concerns that they are seeking to address. Primarily, to increase the quality of care and outcomes for BPPV via:
1) Improved accuracy and efficiency of diagnosis
2) Reduced inappropriate use of vestibular suppressant medications
3) Decreased use of unnecessary imaging/radiography
4) Increase use of appropriate repositioning maneuvers
Beyond the above points, the authors also sought to examine secondary outcomes such as return to regular activity/work, reduction in recurrence and adverse effects, minimizing healthcare costs and return physician visits, and improving overall health related quality of life in BPPV patients.
Study design therefore was structured as most CPG’s via combination of:
• The old CPG (2008): by the American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF)
• Plus, new evidence from 2 clinical practice guidelines, 20 systematic reviews, and 27 randomized controlled trials (RCTs)
• Plus, the addition of a patient advocate, and an enhanced external review process, with an emphasis on patient education and shared decision making
Can you comment on the number and quality of the studies used to develop this CPG?
The studies involved with creating this updated CPG were quite robust. The objective of the authors was to revise the prior guidelines (2008) with a “priori determined transparent process, reconsidering a more current evidence base while taking into account advances in knowledge with respect to BPPV.” To achieve this goal, their strategy was as follows:
1) Revising the previous guideline: An executive summary of the original BPPV guideline from 2008 was sent to a panel of expert reviewers from the fields of general otolaryngology, otology, neurotology, neurology, family practice, nursing, physical therapy, emergency medicine, radiology, audiology, and complementary medicine who assessed the key action statements to decide if they should be kept in their current form, revised, or removed and to identify new research that might affect the guideline recommendations. The reviewers concluded that the original guideline action statements remained valid but should be updated with minor modifications. Suggestions were also made for new key action statements that are outlined in the new guidelines.
2) Search for other clinical practice guidelines (since 2008) using the quality criteria of:
a. An explicit scope and purpose
b. Multidisciplinary stakeholder involvement
c. Systematic literature review
d. Explicit system for ranking evidence
e. Explicit system for linking evidence to recommendations
The final data set retained 2 other guidelines that met the above inclusion criteria.
3) Search for other systematic reviews (since 2008): Identified 44 systematic reviews or meta-analyses that were distributed to the panel members. Quality criteria for including reviews were:
a. Relevance to the guideline topic
b. Clear objective and methodology
c. Explicit search strategy
d. Valid data extraction methods
The final data set retained was 20 systematic reviews or meta-analyses that met the above inclusion criteria.
4) Search for other RCTs (since 2008): Identified 38 RCTs that were distributed to panel members for review. Quality criteria for including RCTs were:
a. Relevance to the guideline topic
b. Publication in a peer-reviewed journal
c. Clear methodology with randomized allocation to treatment groups
The total final data set retained 27 RCTs that met the above inclusion criteria.
The total new studies that contributed, therefore, totalled 2 other CPG’s, 20 systematic reviews, and 27 RCTs. As there were built-in inclusion criteria to ensure the quality of the research included, the authors were able to put forward specific quality/strength recommendations to support each of the Action Statements proposed. Quality “Strong Recommendation” (Grade A or B evidence); “Recommendation” (Grade B or C evidence); or “Option” (Grade D – suspect evidence; or that grades A, B, C show little clear advantage to one approach versus another).
Can you comment on the validity of the study?
All Action Statements of the CPG met the above noted validity guidelines as set out by the research panel (validity in a non-experimental design). As far as ongoing questions that may expand on the validity of some action statements, the authors did put forward a variety of points that are described as evidence gaps/further research needs:
1. Conduct diagnostic and cost-effectiveness studies to identify which subsets of patients, based on specific history or physical examination findings, should be submitted for additional vestibular testing and/or radiographic imaging in the setting of presumed BPPV.
2. Diagnostic and cost-effectiveness studies evaluating the utility and costs of audiometry in the diagnostic evaluation of BPPV are needed.
3. Determine whether education and application of clinical diagnostic criteria for BPPV will change physician behavior in terms of anticipated decreases in ordering of diagnostic tests.
4. Determine the optimal number of CRPs and the time interval between performance of CRPs for patients with posterior canal BPPV.
5. Cost-effectiveness studies for the potential advantages of earlier intervention based on earlier diagnosis and earlier symptom resolution with expedient CRPs for BPPV are needed. Both direct health care and global economic costs require assessment.
6. Extended cohort studies with longer follow-up to determine if measures such as self-performance of CRP or longitudinal VR decrease recurrence rates for BPPV or complications from BPPV such as falls.
7. Determine whether vestibular therapy after the CRP offers additional benefits over CRP alone in select patient populations.
8. Studies on the functional impact of BPPV as they relate to home safety, work safety and absences, and driving risks.
9. Epidemiologic studies on the rates of falls with BPPV as an underlying cause/diagnosis.
10. Assess the impact of BPPV on quality of life for those affected with general quality-of-life and/or dizziness-specific quality-of-life metrics.
11. Develop and validate a disease-specific quality of-life measure for BPPV to assess treatment outcomes.
12. Perform studies to evaluate the effect of structured versus “as needed” follow-up regimens on the outcomes of patients with BPPV.
13. Clarify and standardize the terms used to describe repositioning maneuvers for BPPV of the lateral canal to enable meaningful comparison of their efficacy.
14. Perform studies to evaluate the effectiveness of mastoid vibration in the treatment of BPPV. 15. Epidemiologic studies to characterize the relative risk of factors associated with the development of BPPV, such as osteoporosis, dental procedures, and other devices that deliver cranial vibrations (massage devices, motorized toothbrushes, etc.).
16. Identify patient- and treatment-related risk factors for the development of recalcitrant BPPV.
17. Perform studies to evaluate the sensitivity, specificity, and predictive values of the available examination maneuvers to determine the presence and laterality of BPPV affecting the anterior semicircular canal.
18. Perform studies to characterize the accuracy of diagnostic maneuvers for posterior and lateral canal BPPV and to evaluate the treatment outcomes for patients with BPPV seen in non-specialty settings.
How do the results relate to current practice or influence future practice?
I will specifically comment on this question as it relates to our profession of physiotherapy (so the aspects of the study that discuss reducing imaging and medication prescription etc. are not as relevant to us as PTs). As with all areas of practice, there remains some disparity amongst physiotherapists (even those trained through continuing education) in the consistency of assessment and treatment approaches for certain conditions. This recent CPG on BPPV does provide a clinician with an evidence based reasoning process to provide the best practice care of a BPPV patient. The guideline also puts forth a patient education package that supports patient knowledge and management of their condition (see Algorithm and FAQs Pgs S36/37 in the CPG). These are useful tools that clinicians can refer to in management of BPPV patients. Also, the published “Patient Information FAQ’s” (Pg. S35) provides a useful tool for clinicians to further educate and empower their patients in managing symptoms and expectations following treatment for BPPV.
There is further benefit in disseminating this information out to all potential referral sources – GP’s, ENT, Neurology, Otology etc. From a Physiotherapy perspective, we are uniquely positioned to provide value in management from a perspective of: evidenced based interventions, cost effectiveness/savings to the healthcare system in general, ability to provide adequate time in educating and treating patients. By disseminating the information in this CPG to potential referral sources we are positioning ourselves as ideally suited to effectively manage this patient population.
Action Statements that are directly relevant to how we should practice as PT’s seeing BPPV patients (and also support decision making in how to best manage these patients):
1a, b; 2a, b; 4a, b, c; 5; 7a, b; 8
Thank you so much, Sandeep!