Treating BPPV using telemedicine in the era of Covid-19
Timothy C. Hain,
MD •Page last modified:
November 7, 2020
|The head positions of the home Epley maneuver
The Epley and/or Semont maneuvers for BPPV can be done at home (Radke et al, 1999; Furman and Hain, 2004). We often recommend the home-Epley to
our patients who have a clear diagnosis. This procedure seems to be even more effective than the in-office procedure, perhaps because it is repeated every night for a week. Other variant maneuvers, such as the Foster maneuver (summersault) are basically the same in terms of success rate as the home Epley.
The method (for the left side) is performed as shown on the figure above. One stays in each of the supine (lying down) positions for 30 seconds, and in the sitting upright position (top) for 1 minute. Thus, once cycle takes 2 1/2 minutes. Typically 3 cycles are performed just prior to going to sleep. It is best to do them at night rather than in the morning or midday, as if one becomes dizzy following the exercises, then it can resolve while one is sleeping. The mirror image of this procedure is used for the right ear.
Adapting the home Epley to telemedicine
Surprisingly enough, one can do an Epley (CRP) maneuver through a telemedicine connection. Practically, this has to be done using a smartphone on both ends. This process is not nearly as good as the "real thing", but it may be better than no treatment. Here are the steps:
- Let the patient know that they will need a helper to be the "camera person". Ideally, another person can be the "home therapist".
- Establish an audiovisual connection using your telemed system -- we use "doximity dialer" right now. This is designed for a smart phone. It is not nearly as good as the "real goggles", but better than nothing.
- Make sure the patient has a copy of the home exercises (usually home Epley, but might be Logroll). In our practice (Chicago Dizziness and Hearing), we keep these exercises on our website for patients to download if needed.
- Have the person operating the "camera" hold the cell phone in front of the patient's eyes. It might help here to use the rear facing camera, as it is important that the eyes are "on screen", and also fairly clear. Examine the patient for spontaneous nystagmus and gaze nystagmus. This is to rule out disorders other than BPPV, that have spontaneous nystagmus.
- Make sure you know what you are treating - -if the diagnosis is not entirely certain, do a Dix-Hallpike first (use similar camera technique as described below).
- Next, have the patient positioned on the bed or couch.
- Tell the camera person that for each position of the maneuver, you want both a "close-up" for about 15 seconds, followed by a "long shot" to make sure the position is correct..
- Go through the 3 steps shown above lying on their back, getting both a close-up and a long shot. This can be done either with a pillow as shown, or if there is an assistant, with the head extended over the end of the bed (cautiously of course).
- Have the patient sit up with head tucked for 30 seconds to a minute.
- Instruct the patient/helper regarding frequency of exercises, when to stop (when not dizzy), and whether or not to take nausea medicine.
- Arrange for follow-up (possibly another televisit).
Advantages of doing the Home Epley or Logroll with telemed over unsupervised Home Epley
- One can also do a Dix-Hallpike maneuver with the technique described above, and may be able to diagnose the bad side and type of exercise needed.
- If there is a complication (such as a canal conversion), one knows immediately with telemed and can revise the exercise accordingly.
- This may be more practical than having the patient drive themself into the clinic, possibly get very dizzy, and not being able to get home without help.
Problems with the telemed version of the home Epley or Logroll
- From the perspective of 11/7/2020, remote treatment and diagnosis is much worse than in person, but the best we have right now in the midst of a global pandemic. Once things are safe, we will want to return to regular practice.
- It is frequent that telemed connections are not "optimal". One may lose the signal, it may be poor resolution, it may not be updated very often. If this happens, the telemed version becomes much less useful. The diagnosis part of the visit (Dix-Hallpike) is useless on a poor connection.
- If the diagnosis of BPPV is not definite, one
may be attempting to treat another condition (such as a brain tumor or stroke)
with positional exercises -- this is unlikely to be successful and may delay
proper treatment. This is rare but can happen. Although telemed makes this less likely than just having people do the exercises without any monitoring, the optics of the smartphone are not as good as the optics in the clinic using video Frenzel goggles, and there may be connection issues as noted above.
- Complications such as conversion to another canal can occur during the Epley maneuver,
which are much better handled in a provider's office than at home. Still, the telemed Epley is better than the unsupervised home Epley, or the Youtube home Epley, done without any supervision at all.
- There are many Youtube videos that document the home Epley, and these may also be helpful.
Published literature referred to above:
- Furman, J. M. and T. C. Hain (2004). ""Do try this at home": self-treatment of BPPV." Neurology63(1): 8-9.
- Radtke, A., M. von Brevern, et al. (2004). "Self-treatment of benign paroxysmal positional vertigo: Semont maneuver vs Epley procedure." Neurology 63(1): 150-152.