Characteristics and Treatment Outcomes of Benign Paroxysmal Positional Vertigo in a Cohort of Veterans Background The Mountain Home Veterans Affairs (VA) Medical Center has been diagnosing and treating veterans with benign paroxysmal positional vertigo (BPPV) for almost 2 decades. The clinic protocol includes a 2-week follow-up visit to determine the treatment outcome of the canalith repositioning treatment (CRT). To date, the characteristics of BPPV ... Clinical Focus
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Clinical Focus  |   September 18, 2017
Characteristics and Treatment Outcomes of Benign Paroxysmal Positional Vertigo in a Cohort of Veterans
 
Author Affiliations & Notes
  • Faith W. Akin
    Vestibular Balance Laboratory and Auditory Vestibular Research Enhancement Award Program, James H. Quillen VA Veterans Affairs Medical Center, Mountain Home, TN
    Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City
  • Kristal M. Riska
    Vestibular Balance Laboratory and Auditory Vestibular Research Enhancement Award Program, James H. Quillen VA Veterans Affairs Medical Center, Mountain Home, TN
    Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City
  • Laura Williams
    Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City
    Audiology and Speech Pathology Service, San Diego VA Medical Center, La Jolla, CA
  • Stephanie B. Rouse
    Vestibular Balance Laboratory and Auditory Vestibular Research Enhancement Award Program, James H. Quillen VA Veterans Affairs Medical Center, Mountain Home, TN
  • Owen D. Murnane
    Vestibular Balance Laboratory and Auditory Vestibular Research Enhancement Award Program, James H. Quillen VA Veterans Affairs Medical Center, Mountain Home, TN
    Department of Audiology and Speech-Language Pathology, East Tennessee State University, Johnson City
  • Disclosure: The authors have declared that no competing interests existed at the time of publication.
    Disclosure: The authors have declared that no competing interests existed at the time of publication. ×
  • Correspondence to Faith Akin: Faith.akin@va.gov
  • Editor: Sumitrajit Dhar
    Editor: Sumitrajit Dhar×
  • Associate Editor: Ann Eddins
    Associate Editor: Ann Eddins×
Article Information
Balance & Balance Disorders / Newly Published / Clinical Focus
Clinical Focus   |   September 18, 2017
Characteristics and Treatment Outcomes of Benign Paroxysmal Positional Vertigo in a Cohort of Veterans
American Journal of Audiology, Newly Published. doi:10.1044/2017_AJA-16-0118
History: Received December 8, 2016 , Revised March 30, 2017 , Accepted April 24, 2017
 
American Journal of Audiology, Newly Published. doi:10.1044/2017_AJA-16-0118
History: Received December 8, 2016; Revised March 30, 2017; Accepted April 24, 2017

Background The Mountain Home Veterans Affairs (VA) Medical Center has been diagnosing and treating veterans with benign paroxysmal positional vertigo (BPPV) for almost 2 decades. The clinic protocol includes a 2-week follow-up visit to determine the treatment outcome of the canalith repositioning treatment (CRT). To date, the characteristics of BPPV and treatment efficacy have not been reported in a cohort of veterans with BPPV.

Purpose To determine the prevalence and characteristics of veterans diagnosed with BPPV in a Veterans Affairs Medical Center Audiology Clinic and to examine treatment outcomes.

Research Design Retrospective chart review.

Study Sample A total of 102 veterans who tested positive for BPPV in the Vestibular Clinic at the Mountain Home VA Medical Center from March 2010 to August 2011.

Results In 102 veterans who were diagnosed with BPPV, the posterior semicircular canal was most often involved (75%), motion-provoked vertigo was the most common symptom (84%), and the majority (43%) were diagnosed with BPPV in their sixth decade. The prevalence of BPPV in the Audiology Vestibular Clinic was 15.6%. Forty-one percent of veterans reported a symptom onset within 12 months of treatment for BPPV; however, 36% reported their symptoms began > 36 months prior to treatment. CRT was effective (negative Dix–Hallpike/roll test) in most veterans (86%) following 1 treatment appointment (M = 1.6), but more than half reported incomplete symptom resolution (residual dizziness) at the follow-up appointment. Eighteen percent of veterans experienced a recurrence (M = 1.8 years; SD = 1.7 years).

Conclusions The characteristics and treatment outcomes of BPPV in our veteran cohort was similar to what has been reported in the general population. Future work should focus on improving the timeliness of evaluation and treatment of BPPV and examining the time course and management of residual dizziness.

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder, accounting for approximately 20% to 30% of diagnoses in specialty care clinics (Neuhauser et al., 2005). In the general population, the prevalence of BPPV is 11 to 64 per 100,000 people, and the lifetime prevalence of BPPV is 2.4% (von Brevern et al., 2007). The prevalence of BPPV increases in populations relevant to Veterans Affairs (VA) health care: individuals of older age and individuals with traumatic brain injury (Baloh, Honrubia, & Jacobson, 1987; Davies & Luxon, 1995; Katsarkas, 1999). In the recent wars in Iraq and Afghanistan, traumatic brain injury has been considered a signature injury (Warden, 2006). To date, the prevalence and characteristics of BPPV have not been reported in a veteran cohort.
BPPV is characterized by recurrent brief episodes of vertigo associated with changes in head position (e.g., looking up or rolling over in bed). Hall, Ruby, and McClure (1979)  described canalithiasis or free-floating otoconial debris in the endolymph of the posterior semicircular canal as the mechanism for BPPV. BPPV is diagnosed using the Dix–Hallpike test, which is performed by placing the patient in a supine position with the head rotated 45° to the left or to the right and hanging so that the neck is extended 20° off a bed or table (Dix & Hallpike, 1952). In individuals with BPPV, the change in position induces endolymph flow and activates vestibular sensory cells in the semicircular canals, producing characteristic nystagmus and brief vertigo. Activation of the vestibular sensory cells in the semicircular canals generates eye movement via the vestibulo-ocular reflex, and stimulation of each of the three semicircular canals produces characteristic nystagmus (vestibular-initiated eye movement). During the Dix–Hallpike maneuver, the head is rotated in the plane of the posterior and anterior semicircular canals, and the characteristic of the nystagmus indicates which semicircular canal is involved. That is, posterior canal BPPV is indicated by upbeating and torsional nystagmus beating toward the downward ear, whereas anterior canal BPPV is indicated by downbeating nystagmus that may have a torsional component. Horizontal canal BPPV is diagnosed using the roll test, or a supine head turn maneuver, and is characterized as brief horizontal nystagmus.
Modern treatments for BPPV are based on the canalithiasis theory as the mechanism for BPPV and performed by placing the patient in a series of positions with the goal of moving the otoconial debris out of the semicircular canal and into the vestibule (Epley, 1992; Semont, Freyss, & Vitte, 1988). Canalith repositioning treatment (CRT) is quick, well-tolerated by patients, and the standard of care for BPPV as its efficacy is well established (e.g., Bhattacharyya et al., 2008; T. D. Fife et al., 2008; Hilton & Pender, 2014).
The Mountain Home VA Medical Center has been diagnosing and treating veterans with BPPV for almost 2 decades. The clinic protocol includes a 2-week follow-up visit to determine the treatment outcome of the CRT. The aims of this study were to determine the prevalence and characteristics of veterans diagnosed with BPPV in a VA Medical Center audiology clinic and to examine treatment outcomes in veterans with BPPV.
Method
This study was approved by the East Tennessee State University/VA Institutional Review Board. From March 2010 to August 2011, 674 veterans were evaluated for dizziness in the Vestibular Clinic at the Mountain Home VA Medical Center, and a retrospective chart review was performed on a cohort of 102 veterans who were positive for BPPV. The primary methods used to test for BPPV were the Dix–Hallpike maneuver to diagnose posterior or anterior canal BPPV and the supine roll test to diagnose horizontal canal BPPV (Bhattacharyya et al., 2008). Video goggles (RealEyes xDVR Monocular Video Goggles, Micromedical Technologies, Chatham, IL) were used to visualize and record nystagmus during the Dix–Hallpike and roll tests. Patients were diagnosed with BPPV only if brief nystagmus and vertigo were observed during the diagnostic maneuvers.
The chart review included demographics, active problems, and progress and consult notes describing clinical appointments in the Vestibular Clinic. The following data were recorded from the VA computerized patient record system: (a) patient age and gender, (b) Dizziness Handicap Inventory (DHI) score, (c) presence or absence of a history of head trauma, (d) BPPV diagnosis (i.e., canal and side involved), (e) description of the patient’s symptoms and symptom duration, (f) time between the onset of symptoms and the diagnosis and treatment of BPPV, and (g) referral source.
Data were entered into Microsoft Access, and queries were used to address the aims of the project. Descriptive statistics were used to interpret the data and describe the characteristics of veterans with BPPV. The prevalence of BPPV in veterans evaluated for dizziness in the Vestibular Clinic was calculated using the following formula: Display Formula
Prevalence Rate = No. of cases of BPPV between March 2010 and August 2011 No. of patients seeking services from audiology for dizziness from March 2010 to August 2011 × 100
(1)
The treatment efficacy and BPPV recurrence rate were determined from a review of the computerized patient record system progress notes of veterans who were diagnosed and treated for BPPV in the Vestibular Clinic at Mountain Home from March 2010 to August 2011. The primary methods for CRT were a modified Epley maneuver (no mastoid vibration) for patients with posterior canal BPPV, a reverse Epley maneuver for anterior canal BPPV, and the Lempert supine roll for horizontal BPPV (T. D. Fife et al., 2008). At each treatment appointment, CRT was performed twice or until no nystagmus was observed during the procedure. Veterans who were treated for BPPV were scheduled routinely for a BPPV follow-up appointment at 1 to 2 weeks posttreatment. The Dix–Hallpike test was used to confirm resolution of posterior and anterior BPPV, and the roll test was used to confirm resolution of horizontal BPPV. To determine the treatment outcome for BPPV, the following data were recorded from the progress notes in the computerized patient record system: (a) the Dix–Hallpike or roll test results at the follow-up appointment, (b) whether or not a follow-up appointment occurred, (c) the number of treatment appointments prior to resolution of BPPV (i.e., negative Dix–Hallpike or Roll test), (d) the patient report of symptom resolution at follow-up appointment, and (e) the DHI score at the follow-up appointment. To determine the BPPV recurrence rate, the following data were recorded from the chart review: (a) whether or not recurrence occurred, (b) the canal and side of the recurrence, and (c) the number of recurrences from the initial diagnosis to August 2011.
Results
Prevalence and Characteristics of Veterans With BPPV
The overall prevalence of BPPV for all veterans evaluated for dizziness in the Vestibular Clinic from March 2010 to August 2011 was 15.1% (102/674). Table 1 provides a summary of the demographics of the 102 veterans diagnosed with BPPV. Veterans with BPPV ranged in age from 33 to 90+ years (M = 67; SD = 11), and a majority of patients in this sample were male (93%). The DHI score at the evaluation appointment ranged from 8 to 94 (M = 46; SD = 21), and 33% of veterans diagnosed with BPPV reported a positive history of head trauma. Figure 1 shows an age distribution across decades for veterans with a positive history of BPPV. The majority of veterans (43%) were diagnosed with BPPV in their sixth decade, and only nine veterans (9%) were diagnosed with BPPV before the age of 50 years.
Table 1. Demographics of 102 veterans with benign paroxysmal positional vertigo.
Demographics of 102 veterans with benign paroxysmal positional vertigo.×
Age (years)
Gender (%), n = 95
DHI
Head trauma (%), n = 34
Range M (SD) Male Female Range M (SD)
33–90+ 67 (11) 93 7 8–94 46 (21) 33
Table 1. Demographics of 102 veterans with benign paroxysmal positional vertigo.
Demographics of 102 veterans with benign paroxysmal positional vertigo.×
Age (years)
Gender (%), n = 95
DHI
Head trauma (%), n = 34
Range M (SD) Male Female Range M (SD)
33–90+ 67 (11) 93 7 8–94 46 (21) 33
×
Figure 1.

The age distribution across decades for 102 veterans diagnosed with benign paroxysmal positional vertigo.

 The age distribution across decades for 102 veterans diagnosed with benign paroxysmal positional vertigo.
Figure 1.

The age distribution across decades for 102 veterans diagnosed with benign paroxysmal positional vertigo.

×
BPPV most often occurred in the posterior semicircular canal (75%) and was less common in the anterior and horizontal semicircular canals (13% and 12%, respectively). The majority of BPPV cases occurred unilaterally (89%) rather than bilaterally (11%) and slightly more often in the right ear (50%) than in the left ear (39%).
Motion-provoked vertigo was the most common quality of symptom (84%; n = 86) reported by veterans with BPPV, and imbalance/unsteadiness was the second most common symptom (44%; n = 45). Fewer individuals reported lightheadedness (12%; n = 12) and non–motion-provoked vertigo (8%; n = 8). Approximately half (49%) of the veterans reported their symptom lasted seconds, 24% reported the symptoms lasted minutes, and the duration could not be determined from the chart review for 20% of veterans.
Figure 2 summarizes the frequency of the time between the onset of BPPV symptoms and the diagnosis of BPPV in our veteran cohort and ranged from 3 weeks to 30 years. Although a total of 41% of veterans (n = 39) reported a symptom onset within 12 months of evaluation and treatment for BPPV, more than a third (36%; n = 34) reported their symptoms began greater than 36 months prior to evaluation and treatment. The time of onset was unreported for eight veterans. Veterans with BPPV were most commonly referred to the Vestibular Clinic from the Primary Care Clinic (52%) and the Audiology Clinic (41%), and few patients were referred from the emergency department (2%).
Figure 2.

The onset of symptoms relative to the time of the benign paroxysmal positional vertigo diagnosis and treatment reported by 94 veterans.

 The onset of symptoms relative to the time of the benign paroxysmal positional vertigo diagnosis and treatment reported by 94 veterans.
Figure 2.

The onset of symptoms relative to the time of the benign paroxysmal positional vertigo diagnosis and treatment reported by 94 veterans.

×
BPPV Treatment Outcomes
All veterans treated for BPPV were scheduled for a follow-up appointment in the Vestibular Clinic, and 93% (n = 95) returned for the appointment. Most follow-up appointments (84%) occurred 1 to 2 weeks following CRT, with 66% at 1 week and 18% at 2 weeks. Ten percent of follow-up visits occurred beyond 2 weeks post-CRT, with 4% at 3 weeks, 2% at 4 weeks, 1% at 5 weeks, and 3% > 5 weeks post-CRT.
The resolution rate of BPPV, defined as a negative Dix–Hallpike or roll test at a follow-up appointment, was 83% (79/95). For the 79 veterans with resolution of BPPV, the number of CRT appointments needed to resolve BPPV (negative Dix–Hallpike/roll test) ranged from 1 to 11 (M = 1.6; SD = 1.3). BPPV was resolved after one CRT appointment in 63% (n = 50) of veterans and after two CRT appointments in 28%. Five percent of veterans (n = 7) required three or more CRT appointments for resolution of BPPV (negative Dix–Hallpike/roll test). Intractable BPPV was observed in one veteran who underwent 11 CRT appointments. Symptom resolution was also examined in the 95 veterans who returned for a BPPV follow-up appointment, and 39% (n = 37) of veterans reported complete symptom resolution, 56% (n = 53) reported incomplete or no resolution, and symptom resolution was not reported in the progress note for 5% (n = 10) of veterans.
The DHI ranged from 8 to 94 (M = 46; SD = 21) in 102 veterans prior to treatment for BPPV, and 0 to 94 (M = 33; SD = 23) in 78 veterans posttreatment (posttreatment DHI scores were not available for 24 veterans). Both pre- and post-CRT DHI scores were available for 64 veterans who had a resolution of BPPV (negative Dix–Hallpike and roll tests) following CRT (Figure 3). The mean baseline DHI score was 46.5 (SD = 21.2), and the mean post-CRT DHI was 33.4 (SD = 24). A Wilcoxon signed-rank test revealed a significant difference between the median pre- and post-DHI scores (median = 50 and 34 for pre- and postDHI, respectively; z = −3.463, p < .001). Individual data revealed that the majority of these 64 veterans (76%) demonstrated no significant change (±18 points) between pre- and posttreatment DHI scores, whereas 24% showed a significant decrease (improvement) in the DHI score following resolution of BPPV (negative Dix–Hallpike; Figure 3). No veterans demonstrated a significantly higher (poorer) DHI score following BPPV resolution.
Figure 3.

A scatterplot showing pre– and post–canalith repositioning treatment (CRT) scores for the Dizziness Handicap Inventory (DHI). The solid diagonal line indicates the line of equality, and the dashed diagonal lines indicate the 18-point cutoff for a significant change in the DHI. Data points within the dashed lines indicate no significant change in pre- and post-CRT DHI scores. Data points below the two parallel dashed lines indicate veterans with a decrease (improvement) in the DHI following successful CRT. No data points above the dashed lines indicate that no veterans had a significant increase (worsening) in the DHI following successful CRT.

 A scatterplot showing pre– and post–canalith repositioning treatment (CRT) scores for the Dizziness Handicap Inventory (DHI). The solid diagonal line indicates the line of equality, and the dashed diagonal lines indicate the 18-point cutoff for a significant change in the DHI. Data points within the dashed lines indicate no significant change in pre- and post-CRT DHI scores. Data points below the two parallel dashed lines indicate veterans with a decrease (improvement) in the DHI following successful CRT. No data points above the dashed lines indicate that no veterans had a significant increase (worsening) in the DHI following successful CRT.
Figure 3.

A scatterplot showing pre– and post–canalith repositioning treatment (CRT) scores for the Dizziness Handicap Inventory (DHI). The solid diagonal line indicates the line of equality, and the dashed diagonal lines indicate the 18-point cutoff for a significant change in the DHI. Data points within the dashed lines indicate no significant change in pre- and post-CRT DHI scores. Data points below the two parallel dashed lines indicate veterans with a decrease (improvement) in the DHI following successful CRT. No data points above the dashed lines indicate that no veterans had a significant increase (worsening) in the DHI following successful CRT.

×
The BPPV recurrence rate was examined for the 102 veterans who were treated for BPPV, and 18.6% (n = 19) experienced a recurrence of BPPV, whereas the majority of veterans (81%) had no recurrence. A single recurrence occurred in 12% of the veterans, 5% had two recurrences, and 2% had three recurrences. The time between BPPV resolution and recurrence ranged from 6.3 weeks to 6.4 years (M = 1.8 years; SD = 1.7 years). BPPV recurrences most often occurred in the same canal (90%) and on the same side (76%) as the initial occurrence.
Discussion
Prevalence and Characteristics of Veterans With BPPV
BPPV is considered the most common cause of vertigo and peripheral vestibular dysfunction. Our study suggests that the prevalence of BPPV in veterans is similar to previous epidemiological reports of BPPV in the private sector. In the present study, approximately 15% of veterans (or one in six) evaluated for dizziness or vertigo in the Vestibular Clinic tested positive for BPPV. Similar studies in nonveterans have demonstrated a 16% to 18% prevalence of BPPV in patients referred to specialty clinics for the evaluation of dizziness (e.g., Katsarkas, 1999; Ogita, Taura, Funabiki, Miura, & Ito, 2010).
Characteristics of BPPV in veterans were similar to reports of BPPV in the private sector. The majority of our veteran cohort was diagnosed with BPPV in their sixth decade (mean age = 67 years), and this finding was similar to studies in nonveterans who have shown the peak incidence of onset of BPPV in the sixth decade of life, particularly for idiopathic BPPV (e.g., Luscher, Theilgaard, & Edholm, 2014; Nunez, Cass, & Furman, 2000). Studies in mammals suggest that BPPV in older individuals may be due to age-related fragmentation and degeneration of the otoconia (e.g., Jang, Hwang, Shin, Bae, & Kim, 2006).
In our cohort, 33% of veterans with BPPV had a history of head trauma, which was not necessarily linked to the onset of the BPPV symptoms in the veteran cohort but rather indicated any history of head trauma or mild traumatic brain injury found in the medical record. Although posttraumatic BPPV could not be determined in our study because of limitations of the retrospective design, previous reports have indicated that BPPV can account for approximately 25% of postconcussion dizziness (Barber, 1964; Davies & Luxon, 1995; Hoffer, Gottshall, Moore, Balough, & Wester, 2004). Specifically, a head injury can cause the otoconia to become detached from the utricle (one of the otolith organs) and migrate into a semicircular canal causing BPPV (Barber, 1964; Proctor, Gurdjinan, & Webster, 1956). Several studies have demonstrated that patients with posttraumatic BPPV are younger than patients with idiopathic BPPV (Baloh et al., 1987; Katsarkas, 1999; Suarez, Alonso, Arocena, Suarez, & Geisinger, 2011). In our cohort, there was no statistical difference between the mean age of veterans with and without a history of head trauma (p > .05), and the mean ages were 68 and 65 years for veterans with and without a history of head trauma, respectively. The lack of an age difference between groups may reflect our inability to link the history of head trauma to the onset of symptoms using a retrospective study; thus, there is likely overlap in the veterans with idiopathic BPPV and those with posttraumatic BPPV.
The posterior semicircular canal was the most common site for BPPV in veterans, and BPPV occurred slightly more often in the right posterior semicircular canals than in the left. These characteristics are consistent with reports in the private sector that show the posterior semicircular canal is most at risk for BPPV and it is less common in the anterior or horizontal semicircular canals (Parnes, Agrawal, & Atlas, 2003). The predominance of right-sided BPPV has been reported previously and linked to sleep position (Korres, Riga, Balatsouras, & Sandris, 2008; Lopez-Escamez, Gamiz, Finana, Perez, & Canet, 2002; von Brevern, Seelig, Neuhauser, & Lempert, 2004).
Motion-provoked vertigo was the most common symptom in veterans with BPPV (84%) followed by imbalance/unsteadiness (44%). Few veterans reported lightheadedness (12%) or nonspecific vertigo or dizziness (8% and 4%, respectively). These findings are similar to other studies in which patients reported rotary vertigo (86%) caused by a precipitating head movement such as turning over in bed or lying down (e.g., von Brevern et al., 2007).
Although a majority (41%) reported their symptoms began within a year of evaluation and treatment for BPPV, more than a third of veterans reported the onset of their symptoms longer than 3 years prior to diagnosis and treatment for BPPV. This delay in acquiring a BPPV diagnosis and treatment has been reported previously in veteran and nonveteran populations. D. Fife and Fitzgerald (2005)  followed the clinical management of 20 patients in the United Kingdom and determined they waited an average of 93 weeks from the initial primary care referral to treatment for BPPV. A German epidemiological study suggested that less than 10% of individuals with BPPV are treated with canalith repositioning (von Brevern et al., 2007).
Patients who seek care for symptoms of BPPV frequently undergo unnecessary and costly diagnostic tests such as a head computed tomography scan (Newman-Toker, Camargo, Hsieh, Pelletier, & Edlow, 2009; Polensek & Tusa, 2009). In U.S. emergency departments, the diagnostic bedside test (the Dix–Hallpike test) is used infrequently (Kerber et al., 2012), and most patients who are diagnosed with BPPV are prescribed meclizine, which is not effective for BPPV (Newman-Toker et al., 2009). Few veterans (2%) in our cohort were referred from the emergency department, and most were referred from primary care physicians or audiologists. In a survey of VA clinicians, Polensek and Tusa (2009)  found that perceived barriers to managing vestibular disorders included insufficient training and expertise in the vestibular area and the lack of clinic time to evaluate the dizzy patient. Unrecognized BPPV has been associated with morbidities such as a higher prevalence of falls and depression (Oghalai, Manolidis, Barth, Stewart, & Jenkins, 2000); therefore, future work should focus on limiting the delay in the diagnosis and treatment of BPPV.
BPPV Treatment Outcomes
In clinical trials, successful CRT is defined traditionally as a negative Dix–Hallpike (or roll test) at a follow-up appointment (e.g., Bhattacharyya et al., 2008; T. D. Fife et al., 2008). A negative Dix–Hallpike or roll test was obtained in 83% veterans at the post-CRT follow-up appointment. In randomized controlled trials, conversion of a positive Dix–Hallpike to a negative Dix–Hallpike has ranged from 80% to 89% (e.g., Amor-Dorado et al., 2012; Lynn, Pool, Rose, Brey, & Suman, 1995). In our cohort, the rate of conversion to a negative Dix–Hallpike (83%) may have been slightly underestimated because 7% of veterans did not return for a follow-up appointment post-CRT.
Most veterans (63%) required one treatment appointment for resolution of BPPV (negative Dix–Hallpike/roll test), whereas 28% required two treatments and 9% required three or more treatment appointments. These findings are consistent with other studies that have demonstrated the number of treatments needed for resolution range from one to three, with most individuals resolving after one treatment (Bhattacharyya et al., 2008). In our cohort, one veteran had intractable BPPV and underwent numerous CRT appointments. Fortunately, intractable BPPV occurs infrequently, and surgical intervention is a more effective treatment than CRT (e.g., Ahmed, Pohl, MacDougall, Makeham, & Halmagyi, 2012; Beyea, Agrawal, & Parnes, 2012).
It is well established that residual dizziness is common following successful CRT (i.e., conversion to negative Dix–Hallpike; e.g., Lee, Kwon, & Ban, 2009; Lynn et al., 1995; Magliulo, Bertin, Ruggieri, & Gagliardi, 2005; Seok, Lee, Yoo, & Lee, 2008; Teggi, Giordano, Bondi, Fabiano, & Bussi, 2011). Residual dizziness is a nonspecific sensation of unsteadiness or lightheadedness without motion-provoked vertigo. More than half of the veterans (56%) reported some residual dizziness at the CRT follow-up appointment, which is similar to previous studies that have described residual dizziness in 27% to 61% of patients (e.g., Magliulo et al., 2005; Seok et al., 2008).
The cause of residual dizziness following successful CRT is unclear. Several studies have examined underlying otolith function using otolith tests such as subjective visual vertical and vestibular evoked myogenic potentials; however, the findings have been inconclusive (Faralli, Lapenna, Giommetti, Pellegrino, & Ricci, 2016; Gall, Ireland, & Robertson, 1999; Hoseinabadi, Pourbakht, Yazdani, Kouhi, & Kamali, 2016; von Brevern, Schmidt, Schonfeld, Lempert, & Andrew, 2006). Jung, Koo, Kim, Kim, and Song (2012)  reported that anxiolytics reduce residual dizziness following successful CRT, suggesting the possibility of an anxiety component to the symptoms. Teggi et al. (2011)  demonstrated that anxiety is associated with increased risk of residual dizziness after successful CRT. Other possible causes of residual dizziness include incomplete clearing of debris in the semicircular canal, underlying vestibulopathy such as vestibular neuritis, or lack of central adaptation (Pollak, Davies, & Luxon, 2002; Seok et al., 2008). The central adaption theory is supported by reports that residual dizziness resolves over time without intervention. For example, Seok et al. (2008)  reported all BPPV patients with residual dizziness (n = 49) resolved within 3 months. In our clinic, the follow-up appointment is scheduled within 1 to 2 weeks following treatment, and most veterans in our cohort (66%) were followed 1 week after CRT. This brief time period may not be long enough for central adaption or other natural recovery mechanism to occur.
The DHI is used in our clinic as a measure of self-perceived balance handicap in veterans undergoing vestibular assessment (Jacobson & Newman, 1990). In veterans who converted from a positive to a negative Dix–Hallpike following CRT, total DHI scores decreased significantly from 46.5 ± 21.2 at baseline to 33.4 ± 24 at 1 to 4 weeks after treatment. Previous studies have determined that an 18-point difference (95% confidence interval) in pre- and posttreatment DHI scores indicates a significant change in a self-perceived handicap (Jacobson & Newman, 1990). Using the 18-point cutoff, individual data revealed that only 24% of veterans demonstrated a significant improvement in the DHI score following successful CRT, and most veterans (76%) showed no change in self-perceived balance handicap. Similarly, Lee et al. (2009)  reported a significant decrease in the mean total DHI following CRT; however, improvement was incomplete for DHI items in the emotional domain. The DHI emotional domain score may predict residual dizziness following CRT (Martelucci et al., 2016).
Although effective treatment is available for most patients with BPPV, it is not uncommon for some individuals to experience a recurrence following resolution of BPPV (e.g., Nunez et al., 2000). The recurrence rate was 18.6% for the 102 veterans who were treated for BPPV, occurring, on average, 1.8 years following the initial episode. Previous studies have shown BPPV recurrence rates range from 10% to 50%, with higher recurrence rates in studies that examined long-term follow-up (Amor-Dorado et al., 2012; Beynon, Baguley, & da Cruz, 2000; Brandt, Huppert, Hecht, Karch, & Michael, 2006; Choi et al., 2012; Nunez et al., 2000). In our study, BPPV recurrences occurred from 6.3 weeks to 6.4 years following the initial BPPV episode. The length of time for recurrence following relief is limited by the time interval for this study. There is some evidence that recurrences are less likely the longer an individual with BPPV is symptom-free (Brandt et al., 2006). In our clinic, veterans who undergo successful CRT are counseled that BPPV can recur and are encouraged to return to the clinic for CRT. It is possible, however, that veterans experienced recurrences and did not return to the clinic, and these recurrences would have been missed in the chart review.
Conclusion
The characteristics and treatment outcomes of BPPV in our veteran cohort were similar to what has been reported in the general population. The prevalence of BPPV in veterans was 15.6%, and most often involved the posterior semicircular canal. CRT was effective in most veterans following one treatment appointment. Similar to previous studies, residual dizziness was reported by more than half of the veterans at the follow-up appointment, and BPPV recurred in 18%. Future work should focus on improving the timeliness of evaluation and treatment of BPPV and examining the time course and management of residual dizziness.
Acknowledgments
This work was presented at the Joint Defense Veterans Audiology Conference, Nashville, Tennessee, in February 2013 and at the American Balance Society Annual Meeting in Scottsdale, Arizona, in March 2012. Support for this study was provided by the Auditory Vestibular Research Enhancement Award Program sponsored by the Rehabilitation Research and Development Service, Department of Veterans Affairs, Washington, D.C. (awarded to Faith W. Akin and Owen D. Murnane). The authors would like to acknowledge Ginny Alexander and Dr. Courtney Hall for their help with the database and research design, respectively.
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Figure 1.

The age distribution across decades for 102 veterans diagnosed with benign paroxysmal positional vertigo.

 The age distribution across decades for 102 veterans diagnosed with benign paroxysmal positional vertigo.
Figure 1.

The age distribution across decades for 102 veterans diagnosed with benign paroxysmal positional vertigo.

×
Figure 2.

The onset of symptoms relative to the time of the benign paroxysmal positional vertigo diagnosis and treatment reported by 94 veterans.

 The onset of symptoms relative to the time of the benign paroxysmal positional vertigo diagnosis and treatment reported by 94 veterans.
Figure 2.

The onset of symptoms relative to the time of the benign paroxysmal positional vertigo diagnosis and treatment reported by 94 veterans.

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Figure 3.

A scatterplot showing pre– and post–canalith repositioning treatment (CRT) scores for the Dizziness Handicap Inventory (DHI). The solid diagonal line indicates the line of equality, and the dashed diagonal lines indicate the 18-point cutoff for a significant change in the DHI. Data points within the dashed lines indicate no significant change in pre- and post-CRT DHI scores. Data points below the two parallel dashed lines indicate veterans with a decrease (improvement) in the DHI following successful CRT. No data points above the dashed lines indicate that no veterans had a significant increase (worsening) in the DHI following successful CRT.

 A scatterplot showing pre– and post–canalith repositioning treatment (CRT) scores for the Dizziness Handicap Inventory (DHI). The solid diagonal line indicates the line of equality, and the dashed diagonal lines indicate the 18-point cutoff for a significant change in the DHI. Data points within the dashed lines indicate no significant change in pre- and post-CRT DHI scores. Data points below the two parallel dashed lines indicate veterans with a decrease (improvement) in the DHI following successful CRT. No data points above the dashed lines indicate that no veterans had a significant increase (worsening) in the DHI following successful CRT.
Figure 3.

A scatterplot showing pre– and post–canalith repositioning treatment (CRT) scores for the Dizziness Handicap Inventory (DHI). The solid diagonal line indicates the line of equality, and the dashed diagonal lines indicate the 18-point cutoff for a significant change in the DHI. Data points within the dashed lines indicate no significant change in pre- and post-CRT DHI scores. Data points below the two parallel dashed lines indicate veterans with a decrease (improvement) in the DHI following successful CRT. No data points above the dashed lines indicate that no veterans had a significant increase (worsening) in the DHI following successful CRT.

×
Table 1. Demographics of 102 veterans with benign paroxysmal positional vertigo.
Demographics of 102 veterans with benign paroxysmal positional vertigo.×
Age (years)
Gender (%), n = 95
DHI
Head trauma (%), n = 34
Range M (SD) Male Female Range M (SD)
33–90+ 67 (11) 93 7 8–94 46 (21) 33
Table 1. Demographics of 102 veterans with benign paroxysmal positional vertigo.
Demographics of 102 veterans with benign paroxysmal positional vertigo.×
Age (years)
Gender (%), n = 95
DHI
Head trauma (%), n = 34
Range M (SD) Male Female Range M (SD)
33–90+ 67 (11) 93 7 8–94 46 (21) 33
×