| Background Benign paroxysmal positional vertigo(BPPV)is the most common peripheral vertigo disease.The misdiagnosis and mistreatment rates are high,seriously affecting the lives of many patients.At present,it is believed that the otolith membrane of the utricle falls off into the semicircular canal due to various reasons.It then moves repeatedly along the semicircular canal as a consequence of the change of gravity.This change causes the static cilia of the ampulla of the semicircular canal to swing and move back and forth to the moving cilia.As a result,the patient experiences repeated and transient vertigo,vomiting and imbalance in a specific position.Subsequently serious anxiety may be experienced by the patient.It is considered that its proportion is the first in neurology and emergency department,but the risk factors for its occurrence and recurrence are not clear.Unhealthy lifestyle,such as poor physical activities and prolonged recumbent position time,may be associated with the occurrence and recurrence of BPPV,but it has not been included in the risk factor analysis of BPPV.Therefore,the purpose of this study is to explore the effects of poor physical activities and prolonged recumbent position time on the occurrence of BPPV.The risk factors of BPPV occurrence and recurrence in recent years will be reviewed in order to help formulate clinical prevention strategies.At present,the posterior semicircular canal is the most common type of BPPV.CRM is the standard treatment for BPPV,and Epley maneuver is the most commonly used and easy to master.Although the effective rate can reach more than 70%-80%,there are still a number of patients with recurrent symptoms,many of which have been long term.Some patients have obvious residual dizziness after CRM,such as dizziness and discomfort,and transient dizziness and imbalance when they look up and down,get up,turn around and walk.Improving the maneuver technique,in order to increase the success rate of CRM and reduce the incidence of residual symptoms is the primary aim of this paper.Persistent postural perceptual dizziness(PPPD)is the most common clinical chronic functional vestibular disorder syndrome.This can cause negative life changes such as the ability to work and enjoy leisure activities.Recently,research data has shown that PPPD is closely related to BPPV.Furthermore,BPPV is the first trigger factor of PPPD.In China,the disease also has a very high rate of misdiagnosis and mistreatment.Consequently leading to excessive examination and treatment based on incorrect evaluations.This wastes huge medical resources and brings unnecessary financial costs to patients and their families which many cannot afford.PPPD patients also suffer from persistent dizziness and imbalance symptoms,resulting in decreased exercise and increased bed rest.PPPD is problematic to medical practitioners.As it is not only difficult to make a clear diagnosis,but it is also difficult to control after medication and undertaking current rehabilitation training programs.Problematically,there is a lack of epidemiological investigation on PPPD in China within a clinical setting,whilst the distribution of trigger factors in domestic PPPD population is not clear,compounded by the fact there is no targeted and individualized treatment available.BPPV and PPPD have become the focus of research and dispute in the field of vertigo.In this study,(1)the first objective is to review the progress of risk factors of BPPV in recent years,and on this basis,analyze the risk factors of unhealthy lifestyles.Especially decreased physical activity and prolonged recumbent position time in BPPV cases.(2)The modified epley maneuver method was used to treat the posterior semicircular canal otolith,that is,to increase the head concussion movement.(3)The paper reviews the research progress of PPPD in recent years,especially in the field of treatment.(4)Objective to analyze the misdiagnosis,causes of mistreatment,spectrum of misdiagnosed diseases and over examination methods of PPPD in China,so as to enhance the vigilance of clinical workers.(5)Objective to analyze the distribution of trigger factors in different age groups of domestic PPPD patients,and to guide clinical intervention.(6)Based on sertraline and flunarizine,the patients with PPPD were treated with rapid exposure vestibular rehabilitation training,and compared with conventional vestibular rehabilitation treatment,to explore a new treatment strategy.Part 1:The relationship between BPPV and exerciseChapter 1: The risk factors of benign paroxysmal positional vertigo: A critical reviewBackground Benign paroxysmal positional vertigo(BPPV)is the most common peripheral vertigo vestibular disorder in adults,with different hypothesis used for risk factors.Although in most studies there is a consensus about risk factors,there seems to be some further verification about distinctions between risk factors.Methods A comprehensive search for articles included in the abstract information on onset and recurrence of BPPV was conducted within the Pub Med library.Results We can roughly divide these factors into two categories,one is uncontrollable factors,such as age,gender and season.The other is controllable factors,such as osteoporosis,inner ear disease,risk factors of cardio-cerebrovascular disease,migraine,hyperuricemia,Parkinson’s disease,sleep habits,serum vitamin D level,trauma,mental state,poor physical activities,and prolonged recumbent position time.Conclusion So this article discusses the potential risk factors associated with the onset and recurrence of benign paroxysmal positional vertigo.It references relevant papers published in recent years,aiming to guide clinical prevention strategies and reduce this incidence.Chapter 2:Unhealthy lifestyle is an important risk factor of idiopathic BPPVBackground Benign paroxysmal positional vertigo(BPPV)is self-limiting and recurrent disease but the cost is considerable.The number of patients of BPPV increased significantly under the quarantine policy in Hangzhou.The unhealthy lifestyle risk factors of BPPV have not yet been investigated.Thus,the objective is to analyze whether the unhealthy lifestyle is a risk factor of BPPV.Methods 163 patients with idiopathic BPPV aged 22–87 years(BPPV group),and 89 aged 23–92 years sex-matched control subjects(Non-BPPV group)were enrolled in this study.All BPPV patients received the definitive diagnosis and excluded secondary BPPV.Non-BPPV cases excluded BPPV,sudden deafness,Meniere’s disease,ear or craniofacial surgery,vestibular neuritis and head trauma history.We obtained blood lipids profile,serum uric acid,total bilirubin and related diagnostic information through electronic medical record system.To get the time of physical activities and recumbent position,we asked the patient or their family from February 2020 to June 2020,and the rest of patient’s information was acquired by phone or We Chat.Data Analyses The t-test or chi-squared test,univariate and multiple logistic regression analyses were performed for two groups.For each factor,odds ratios were calculated with 95% confidence intervals(CIs).Moreover,test equality of two or more receiver operating characteristic(ROC)analyses were applied to the physical activities,and recumbent position time;area under curve(AUC)measures were calculated with 95% CIs and compared with each other.Results The BPPV group had unhealthy lifestyles such as poor physical activities,prolonged recumbent position time,and low rate of calcium or VD supplementation in univariate logistic regression analyses(P <0.05).Poor physical activities and prolonged recumbent position time were independently associated with BPPV in multiple logistic regression models(OR=18.92,95%CI:6.34-56.43,p=0.00 and OR=1.15,95%CI: 1.01-1.33,p < 0.04).Comparison of ROC curves of recumbent position time and physical activities in identifying BPPV.AUCs were 0.68(0.61-0.74),and 0.68(0.63-0.73)respectively.Conclusion We conclude that poor physical activities and prolonged recumbent position time may be independent risk factors of BPPV patients,but hypertension,hyperuricemia,hyperlipidemia,hemoglobin,diabetes,serum bilirubin,CHD,CI,may not be.Chapter 3:Clinical observation of modified Epley maneuver of posterior semicircular canal otolithObjective To investigate the efficacy of modified Epley maneuver(first,second and fourth step vibration)in the treatment of posterior semicircular canal otolith.Methods Patients with posterior semicircular canal benign paroxysmal positional vertigo(BPPV)were included in the study.They were randomly divided into control group(80 cases)and observation group(52 cases).The difference of curative effect between the two groups on the first day,7 days,and 14 days after CRM was compared.The evaluation index was whether the patient’s positional vertigo and positional nystagmus disappeared,alleviated or unchanged.Results The success rate of CRM in the observation group was significantly higher than that in the control group(P < 0.05)on the first day.On the 7th and 14 th day of follow-up,those who failed to reset were treated with corresponding CRM again,and there was no significant difference between the two groups(P > 0.05).Overall success rate,there was a significant difference between the two groups,with statistical significance(P < 0.05).In terms of residual dizziness after successful CRM,there was a significant difference between the two groups(P < 0.05).Conclusion The success rate of Epley maneuver is 85%,and the modified Epley maneuver can significantly improve the clinical efficacy(98.08%),promote the recovery of patients rapidly.On the other hand,the modified Epley maneuver can significantly reduce the rate of residual dizziness.Part 2:The intervention study of Persistent postural-perceptual dizzinessChapter 4: Progress in diagnosis and treatment of persistent posturalperceptual dizzinessPersistent postural-perceptual dizziness(PPPD)is one of the most common chronic vestibular diseases.At present,it is considered as functional dizziness.The above symptoms are aggravated by persistent non rotational dizziness,instability,abnormal posture control,movement intolerance,and with or without visual induced dizziness.Its clinical characteristics are that it lasts for at least three months.A variety of pathophysiological hypotheses provide theoretical support for the application of various treatments,but the diagnosis of PPPD is still based on symptomatic,lack of targeted examination.In terms of treatment,this article will summarize the clinical research progress of medicine,vestibular rehabilitation,vagus nerve stimulation,cognitive behavior therapy in recent years,so as to provide the best individual and comprehensive treatment options for PPPD patients.Chapter 5: Analysis of misdiagnosis and over check of PPPDBackground The diagnosis of PPPD mainly depends on the symptoms,medical history and nervous system examination of the patients,and lacks a clear auxiliary examination method,it often leads to misdiagnosis and mistreatment in clinic.Therefore,patients usually visit several departments,who undertake non targeted checks,leading to excessive examination.Objective Analyze the risk factors of misdiagnosis of PPPD in Neurology department,to improve the accuracy of diagnosis.Analyze the causes of over examination items in order to reduce medical expenses.Methods 112 patients with PPPD were evaluated with general information,medical history and related scales.They were divided into misdiagnosis group(n = 98)and a non misdiagnosis group(n = 14).t-test was used for statistical data between groups,and χ2 was used for counting data.In order to avoid the occurrence of inaccurate diagnosis name and unclear examination items,the misdiagnosed diseases will be based on the diagnosis in the patient’s previous outpatient or discharge records.The examination items shall be subject to the report on the patient’s mobile phone or the examination ticket brought by the patient,otherwise they will not be included in the registration.Results There was no significant difference in gender,duration of disease,PPPD type,gad7,phq9 and DHI between misdiagnosed group(98 cases)and non misdiagnosed group(14 cases)(P > 0.05).But there were significant differences between the two groups in vertigo clinic,overall age and > 60(P < 0.05).According to the spectrum of misdiagnosis,mental dizziness(74.49%),cervical vertigo(54.08%)and cerebral insufficiency(53.06%)were the top three.Meniere’s disease,cerebral infarction,BPPV and hypertension accounted for 21.43%,20.41%,12.24% and 3.06% respectively.In the analysis of inappropriate examination methods,CT scan,cervical MRI,transcranial Doppler ultrasound(TCD)and cranial MRI were the most common.Conclusion The risk factors of misdiagnosis PPPD may be related to the patients’ older age and have more concomitant diseases.The vertigo clinic can reduce misdiagnosis and should to popularize the update of relevant knowledge.Negative relevant check often lead to the increase of misdiagnosis as psychogenic dizziness.However,the results such as cervical disc herniation and lacunar infarction cannot explain the characteristics of PPPD.Excessive check is a blind medical behavior that lacking diagnosis direction,needs to be paid attention to and vigilant by relevant disciplines.Chapter 6: Analysis of PPPD trigger factors in different age groupsBackground The treatment of PPPD including anti-anxiety,vestibular function rehabilitation,cognitive behavior therapy,but lack of treatment for etiology.On the one hand,etiology as a trigger factor has disappeared in some patients with PPPD.On the other hand,it is difficult to define the trigger factors.There is a lack of analysis on trigger factors of PPPD in Chinese population,especially in different age groups.If we can evaluate the trigger factors,especially the different trigger factors of different ages,it will provide targeted intervention measures for clinical and reduce its role in the continuous evolution of PPPD.Objective To analyze the differences of trigger factors in different age groups in China,and the distribution characteristics and constituent ratio of trigger factors,so as to provide clinical prevention and treatment strategies.Method The clinical data of PPPD patients from May 2020 to June 2021 were retrospectively analyzed.The diagnosis criteria were based on Barany Society(2017).According to the age,116 patients were divided into three groups: ≤ 40 years old,41-60 years old and > 60 years old.The general information,detailed medical history and neuro-otology physical examination characteristics of all patients were registered,and the characteristics of trigger events before onset were inquired,combined with relevant auxiliary examinations.All patients were screened with Dizziness handicap inventory(DHI),Generalized Anxiety Disorder(GAD7)and Patient Health Questionnaire-9(PHQ9).Result There were 47 males(40.52%)and 69 females(59.48%).Among them,vestibular migraine(VM)was found in 27(23.28%),anxiety or panic attack in 14(12.09%),benign paroxysmal positional vertigo(BPPV)in 12(10.34%),syncope in 5(4.31%),sudden deafness in 4(3.5%)and Meniere’s disease in 3(2.59%).There were 21 patients under 40 years-old,including 6 males(28.57%)and 15 females(71.43%).Among them,10(47.62%)were VM,4(19.05%)were anxiety or panic attack,2(9.52%)were syncope,2(9.52%)were sudden deafness,2(9.52%)were unexplained,and 1(4.76%)were after operation.There were 47 patients aged 41-60,including 19 males(40.43%)and 28 females(59.57%).Among them,VM 10(21.28%),anxiety or panic attack 4(8.51%),BPPV 3(6.38%),syncope 2(4.26%),motion sickness 2(4.26%),trauma 2(4.26%),sudden deafness 1(2.13%),Meniere’s disease 1(2.13%),vestibular neuritis 1(2.13%),other rare and unknown causes 21(44.68%).There were 48 patients over 60 years old,including 22 males(45.83%)and 26 females(54.17%);Among them,BPPV 9(18.75%),VM 7(14.58%),anxiety or panic attack 6(12.5%),cerebral infarction 2(4.17%),Meniere’s disease 2(4.17%),multiple system atrophy 1(2.08%),syncope 1(2.08%),sudden deafness 1(2.08%),other rare and unknown causes 19(39.58%).Conclusion In all cases,females accounted for more,but with the onset of age,the proportion of males increased gradually.In terms of trigger factors,VM is the most common trigger factor in Chinese people,especially in young and middle-aged people,but not BPPV.It is considered to be related to the promotion of BPPV diagnosis and treatment technology and the popularization of CRM.However,it was also found that the proportion of PPPD patients triggered by BPPV increased with age.It should be noted that anxiety or panic attack is the second trigger factor of PPPD in Chinese population,and attention should be paid to identification and intervention.Chapter 7: Effect of rapid exposure training on patients with PPPDBackground The treatment of PPPD including anti-anxiety,vestibular function rehabilitation training,cognitive behavior therapy,but it is still difficult to control the disease quickly and definitely.It is difficult to evaluate the complexity and individualized treatment of conventional training methods in accordance with the current international expert consensus,and to effectively implement in the current domestic medical situation.If implement some simple and easy to master rehabilitation technique and medicine,it will be convenient for clinical promotion and intervention.Objective To compare the efficacy of rapid exposure training(RET)with conventional vestibular rehabilitation training in patients with PPPD.Methods The patients diagnosed as PPPD in the outpatient and inpatient department of vertigo clinic were enrolled.They were evaluated by general information registration,GAD7,PHQ9 and DHI before followed up.Finally,25 patients in the conventional therapy group and 46 patients in the RET group.The conventional group was given basic medicine and Cawthorne-Cooksey rehabilitation training,while the RET group was given the same medicine and rapid exposure training.Follow up The follow-up was through wechat,we compared the curative effect of the two groups at 4 and 8 weeks of rehabilitation treatment,and the evaluation indexes were GAD7,PHQ9 and DHI.Result Before treatment,there was no significant difference in age,gender,GAD7,PHQ9,DHI and basic medication between the two groups(P>0.05).In the conventional group,there was no significant difference in GAD7 and PHQ9 after 4 weeks of treatment,but there was significant difference in DHI(P<0.05).There were significant differences in the scores of GAD7,PHQ9 and DHI between 8 weeks and before treatment(P<0.05).In the RET group,the GAD7,PHQ9 and DHI after 4 and 8 weeks of treatment were significantly different from those before treatment(P < 0.05).There was no significant difference in GAD7 and PHQ9 between the two groups after 4 weeks of treatment(P > 0.05).However,there was significant difference in DHI between these two groups(P < 0.05).After 8 weeks of treatment,there were significant differences in GAD7,PHQ9 and DHI between the two groups(P < 0.05).Conclusion Cawthorne-Cooksey based rehabilitation training for PPPD patients cannot produce a significant effect on anxiety and depression in a short time,but can reduce the level of DHI.Through a longer period of comprehensive intervention,the level of anxiety,depression and the DHI can be significantly reduced.Rapid exposure training can reduce the level of PPPD,and decrease emotional problems(depression and anxiety).In conclusion,compared with conventional training,rapid exposure training can significantly reduce the level of anxiety,depression and DHI. |
