Dr. David Topps (biography and disclosure)
What I did before
I used to dread the frail old lady with dizziness – the history and examination was time consuming with vague findings in both, leading to uncertainty about diagnosis and cause. Worse, the medications we used helped little and falls were common.
My fears were compounded by research findings about the rising mortality and morbidity from falls, (1) which gave rise to the establishment of falls clinics – a wonderful idea but with long wait lists. Polypharmacy was clearly adding to the risks. Vertigo was particularly frustrating – easy to suppress the symptoms, but did this really help?
What changed my practice
About ten years ago, the earliest recommendations about the use of therapeutic manipulation of the head and repositioning of otoliths started to appear. Apart from some of the traditional skepticism that meets many manipulation therapies, the paper descriptions of the necessary steps appeared perplexing, problematic and painful to perform. “Rotating the neck 270°… ” seemed guaranteed to break something, including my confidence.
YouTube brought a variety of short clinical videos, demonstrating in more cogent form how to perform the Dix-Hallpike and Epley’s maneuvers, but the success rate remained low. The minor obstacle of finding a good teaching source also contributed to the low attempt rate. Then I discovered the DizzyFix app for the iPhone. Designed in Ottawa, this makes great use of the motion sensing in these devices. Be warned that it also acts as part-infomercial for other products from that company but this does not detract from the app’s usefulness.
You place your phone on the patient’s forehead. DizzyFix’s diagrams (2) walk you through the steps needed for the Dix-Hallpike and Epley’s maneuvers, including a real-time display of exactly what path and angle to move the patient’s head through, and a timer to introduce appropriate pauses. Patience and predictable positioning pay off!
What I do now
Because of simplicity of use and ready availability, I now use this app and promote its use amongst my colleagues and learners at our teaching clinic. The simple, self-explanatory steps with embedded tutorials reduce the time required to learn and teach so my colleagues are more apt (apped?) to use the maneuvers.
Now I can hear you say that not all dizziness is Benign Positional Vertigo. (3) Indeed the Falls Clinics emphasize the multifactorial nature of dizziness and a careful assessment of all cases. There is some helpful information included with DizzyFix. To address this need, I created a virtual patient case (4) to assist colleagues and learners in thinking through such problems. The case provides more context and illustrates some of the common pitfalls in history, examination and management.
DizzyFix is available in the iPhone App Store but is not free. At present, there is no Android version available. In recommending this app, I have no conflict of interest.
References and further reading
1. Rogers C. Presbyastasis: A multifactorial cause of balance problems in the elderly. South African Family Practice 2010, May;52(5):431-4. (View)
2. DizzyFix iPhone Instruction Video. http://www.youtube.com/watch?v=Fk1hgJXzjQU
3. Labuguen RH. Initial evaluation of vertigo. Am Fam Physician. 2006;73:244-251 (View)
4. Topps. A dizzy blonde. Sharcfm virtual patient series: Available from: http://fmsharc.cfpc.ca/openlabyrinth/mstartnode.asp?mapid=82.