The Gufoni maneuver and head shaking are both effective techniques for relieving apogeotropic horizontal canal benign paroxysmal positional vertigo (HC-BPPV), according a randomized controlled study by Korean researchers.
The researchers noted that two types of HC-BPPV are recognized. “Geotropic HC-BPPV is characterized by positioning nystagmus beating toward the undermost ear when the head is turned to the side while supine. …In contrast, the induced nystagmus beats toward the uppermost ear in apogeotropic type of HC-BPPV.”
With the Gufoni maneuver, patients lie on their side for two minutes, turn their heads 45 degrees up or down, remaining in this position for two minutes, and then return to the upright position.
While some practitioners already use the head-repositioning Gufoni maneuver to treat patients with vertigo, the study provides a strong evidence-based rationale for doing the technique. Patients who underwent the Gufoni maneuver or back-and-forth head-shaking fared better initially and longer term than those who did a sham maneuver.
“This study provides Class II evidence that Gufoni and head-shaking maneuvers are effective in treating apogeotropic HC-BPPV up to one month after initial treatment,” concluded the researchers, who published their findings in the Dec. 14 online edition of Neurology.
One of the study's investigators, Sun-Young Oh, MD — of the department of neurology at Chonbuk National University in South Korea — noted that HC-BPPV “accounts for 10 percent to 42.7 percent of BPPV, and appears to be more prevalent than previously believed.” The symptoms of HC-BPPV — dizziness, nystagmus, and nausea — can be debilitating, sending some people to the emergency room. It may be mistaken for a stroke or a serious viral infection.
To treat vertigo, clinicians use different maneuvers — often named after their inventors (such as Epley, Semont, Gufoni) — that involve moving the head through a series of positions. The maneuvers are designed to move teeny bits of debris — called otoconia — that can cause problems if they migrate from the utricle into the semicircular ear canals. The AAN 2008 practice parameter for treating BPPV says there is not enough evidence to make recommendations on maneuvers for the horizontal canal or anterior canal forms of the condition. But the Gufoni maneuver has been nonetheless favored by some practitioners for treating HC-BPPV.
“We knew this was a rational thing to do because we understand the biomechanics of the ear,” said Timothy Hain, MD, a neurologist and professor of otolaryngology and physical therapy at Northwestern University, who was not involved with the current study. Dr. Hain, who helped write the AAN guideline, added: ”This (latest) paper involves a randomized clinical trial with controls, which makes the level of evidence to support this technique much higher.”
TESTING REPOSITIONING MOVES
The investigators enrolled 157 patients, ranging in age from 18-89, who sought treatment at 10 dizziness clinics in Korea for apogeotropic HC-BPPV. In nearly all cases, their BPPV was idiopathic. In 10 cases, patients had a predisposing illness, such as head trauma, vestibular neuritis, otitis media, or Meniere disease. The patients were randomized to the Gufoni method, head-shaking or a sham maneuver, which were performed by a trained physiotherapist or neurologist in each clinic.
For the Gufoni maneuver, the patient was quickly brought down from a sitting position to the side-lying position. After one minute, the head of the patient was quickly turned upward 45 degrees so that the nose was pointed up. After about two minutes, the patient was returned to the upright position. For the head shaking maneuver, the patient was placed in a sitting position. After the head was pitched forward by about 30 degrees, it was moved sideways in a sinusoidal fashion for about 15 seconds. In the sham maneuver, the subjects lay quickly onto the unaffected side and then returned to the sitting position after one minute.
After undergoing a repositioning maneuver, the patients were then evaluated by a neurologist (who was blinded to what treatment had been used) to determine if vertigo and nystagmus had resolved. If symptoms remained, the patient underwent the same maneuver again. After re-examination 30 minutes to an hour later, patients were scheduled for a follow-up visit the next day and were also scheduled for weekly follow-ups for one month, according to the paper. Patients were told to come back to the clinic if they had more symptoms, but otherwise researchers determined the final resolution of symptoms using a telephone interview.
Follow-up information was collected on 154 patients, and the absence of both vertigo and nystagmus was considered a resolution. After a maximum of two maneuvers on the initial visit day, 38 of 52 patients (73.1 percent) who got the Gufoni maneuver had a resolution of symptoms. In the case of head-shaking, 33 of 53 patients (62.3 percent), improved. Only 17 of 49 patients, (34.7 percent) who got the sham maneuver had a resolution. The researchers noted that sham result was still better than what would have happened if the condition was left to resolve itself.
Among the reported findings, “the cumulative therapeutic effects were also better with Gufoni (p=0.001) and head-shaking (p=0.026) maneuvers compared with the sham maneuver. However, therapeutic efficacies did not differ between the Gufoni and head-shaking groups in terms of both immediate (p=0.129) and long-term (p=0.239) outcomes.”
A RATIONAL APPROACH
Using a no-tech body maneuver to relieve dizziness may seem simple to the layperson, but clinicians say there needs to be a rationale for whatever approached is used. The first challenge is to figure out what type of BPPV the patent is experiencing and which ear is affected.
Nicole Steinberg, DPT, a physical therapist at Chicago Dizziness and Hearing, a practice affiliated with Northwestern University, uses the Gufoni maneuver. She said diagnosis can be tricky when it involves the lateral canal because it's sometimes difficult to determine which side is affected.
“We can make the patients sick during the repositioning maneuvers and you want to be sure to pick the one that will be the most effective,” Dr. Steinberg told Neurology Today.
Carol Foster, MD, an associate professor of otolaryngology at the University of Colorado Denver, has been using the Gufoni maneuver for about 10 years in her practice treating patients with vertigo. “It's highly effective,” said Dr. Foster, who does research on a wide variety of vertigo and balance disorders. “It works beautifully and I've abandoned all other treatments for HC-BPPV because it is such a superior treatment.”
Thanks to the availability of how-to instructions on the Internet — you can even see maneuvers on YouTube — more patients may be trying to do maneuvers on themselves, Dr. Foster said. It can work, but in some cases patients end up transferring particles from the posterior canal to the horizontal canal and in the process make things worse for themselves, she said. She said she is seeing more patients with HC-BPPV than she used to, perhaps because more patients are treating themselves.
Dr. Foster said it makes sense for clinicians who treat vertigo to be trained in maneuvers that are proven to work. She said studies such as this latest one from Korea are important “because without this kind of evidence, you never know what the optimal treatment is.”