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!
DizzyFix App screen shots
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.
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It seems the use of this app may be a good starting point for a study on benign positional vertigo, it’s diagnosis, it’s mimics, it’s treatment. Or perhaps a comparison of teaching methods. Just a thought….
Good TCMP. IF not too pricey will try the app, and also the virtual patient.
I have recently been sending patients with BPV to a physio specially trained in treating this condition; rather than prescribing medication. I shall also look into this app.
We have actually just submitted for publication a prospective randomized study of medical students learning the Epley maneuver with and without using the DizzyFIX application. It does seem to have a very significant positive impact on maneuver performance. It would be great to get other studies done looking at residents or family practice. The physical device “DizzyFIX” can also be used for the same purpose but obviously it not downloadable.
Love the app! So much easier
I really feel that the type of patient yu see with dizzyness will NOT be helped by this app.
This is a good idea. There is also a unit that can be bought and lent to patients to help them do the manouvre at home. Having said this the key is in the diagnosis. That takes a careful history and exam. There are many shades of dizziness and also of bppv.
Too bad the app is not free. We live in a world where it is pay pay pay round every corner – enough to make me dizzy.
sounds like a great idea, I have just changed to blackberry but thinking of changing back to the iphone!
Please note that the DizzyFix will only work for the posterior canal canalithiasis variant of BPPV and you still have to determine the side. It is unlikely to work for horizontal canal or anterior canal issues and definitely won’t work for the cupulolithiasis variant in any of the canals. If not readily responding (1-3 tries) I recommend you find a physical or occupational therapist with training in vestibular rehabilitation. While you don’t need goggles for assessing and treating BPPV, therapists using infrared goggles would be a better choice, as they are more likely to be significantly trained in the area vs. ‘dabblers’ who have just taken a weekend intro course, and the goggles make it much easier to evaluate the nystagmus and thus accurately determine if it is truly consistent with BPPV, which canal is involved, and if it is canalithiasis or cupulolithiasis..
I can see the value of Physicians using this if attempting an Epley maneuver with their patients, however as a recommendations for patient purchase, this is often scary for patients so they do much better with a therapist helping them through the maneuver than having to try it themselves with this tool, and with treatment efficacy so good (1-3 treatments), there isn’t much reason for a patient to invest in one. Also, you don’t want a person trying this themselves if this is actually central positional vertigo so you would want to be very sure of your diagnosis.
i found the app on my iphone it was free, but with little or no instructions………..thanks
Is this app available for Android? I can’t find it!