But two months ago, when the 50-year-old Phoenix man woke up one Saturday reeling from vertigo, he had no idea what to do.
“I felt like I was drunk,” he said. “I couldn’t stand up. I kept falling over.”
Fortunately for Janisch, he works at a hospital where a vestibular therapist, a specialist in inner ear disorders, is almost always available.
Within 10 minutes of walking into the lab at Banner Good Samaritan Medical Center, Janisch was better, thanks to a simple technique that neurology experts have verified as the best way to treat benign paroxysmal positional vertigo — BPPV — a common cause of severe dizziness.
A series of gentle head and neck movements known as the canalith repositioning procedure is the fastest, easiest way to cure BPPV, according to a new guideline developed by the American Academy of Neurology.
About 3 million new patients a year in the United States are diagnosed with the problem characterized by dizziness, lightheadedness, imbalance and nausea that can last for days — or even months. Traditional treatments have ranged widely, from drastic measures such as sedatives to nerve surgery to nothing at all.
“Instead of telling patients to ‘wait it out’ or having them take drugs, we can perform a safe and quick treatment that is immediate and effective,” said Dr. Terry D. Fife, an assistant professor of clinical neurology at the University of Arizona, who led the study presented in the latest issue of the academy’s journal.
“No special chair is needed, no goggles are needed, no special device is needed, just the hands — and the knowledge,” added Fife, who also directs the Balance Center at the Barrow Neurological Institute.
Tiny crystals lodge in sensing tubes
BPPV is caused when tiny calcium carbonate crystals in the inner ear dislodge and land in the sensing tubes that detect motion and gravity. When sufferers move their heads, those “ear rocks” cause severe sensations of spinning or whirling.
“It’s bad,” recalled Janisch, a physical therapist.
The condition is typically caused by head injury in people younger than 50. It’s far more common in older people, however, as aging causes degeneration in the structures of the inner ear.
The canalith repositioning procedure works by moving the calcium crystals out of the sensing tubes and into another chamber of the inner ear, where they’re safely reabsorbed.
Fife and his team reviewed 40 years of research on treatment of BPPV, including 925 articles published from 1966 to 2006, to provide the first evidence-based recommendation for treatment of BPPV.
Final analysis showed that the procedure, also known as the Epley maneuver, should be offered to BPPV patients of all ages, he said. A second, more vigorous, technique, known as the Semont maneuver, is also possibly effective, but there’s not enough evidence to say for sure, Fife said.
While the new guideline is gratifying, the Portland, Ore., otologist who came up with the Epley maneuver nearly 30 years ago wondered what took the AAN so long.
“I think it’s about time,” said Dr. John Epley, 78.
Epley’s technique involves positioning a patient on his back, with his head hanging slightly over the edge of a bed or table and tilted 45 degrees toward the affected ear. Then the patient’s head is moved into a series of four positions until it is rotated 90 degrees toward the other ear.
Technique cures vertigo in most patients
The maneuver, which resolves vertigo in about 80 percent to 90 percent of patients, is widely used, but only among doctors who know about it, Fife said. The technique is not taught in medical schools and most general practice doctors may have heard only rumors of a quick, easy way to treat vertigo.
“I think for physicians, the new thing is the evidence-based status,” said Fife, who hopes the guideline will encourage more doctors to use the method.
Besides, Epley’s technique has been controversial. In the early years, he was ridiculed by colleagues for suggesting that such a simple treatment could have profound effects on vertigo. “Everyone thought it was crazy,” Epley said.
More recently, there’s been debate over which of several repositioning techniques works best. European doctors, for instance, seem to favor the Semont maneuver, Fife said. Others prefer techniques such as the Brandt-Daroff maneuver, one of several alternatives aimed at shifting the calcium crystals.
Even Epley has tried to improve on the physical technique with a device called the Omniax chair, which holds patients in place while it rotates them 360 degrees. Epley received research funding from the National Institutes of Health to study the chair and he expects federal Food and Drug Administration approval of the device soon.
The chair is useful for the small percentage of patients who can’t be cured with the regular maneuver, as well as those too large, too old or too frail to be perched on a bed or table, Epley said.
For Michelle Soper, 37, an elementary school secretary in Banks, Ore., one treatment in the Omniax chair in March appears to have cured bouts of recurrent BPPV.
“I would go to roll over in bed and my whole room would spin. I’d look up, it would spin. I’d look down, it would spin,” she said. “After the chair, it was unbelievable.”
Home treatment a possibility
But Fife and Epley agree that most BPPV patients don’t need the chair. They only need a few minutes with a doctor or therapist trained in the maneuver. With practice, some patients can even learn to perform the Epley maneuver on themselves, Fife said.
Although BPPV will resolve on its own in up to half of patients, the new guideline could make the difference between enduring months of life-altering dizziness — or only a few days.
“We hope more people will see there is some value in treating symptoms sooner rather than later,” Fife said.