Incidence of Neck Pain in Benign Paroxysmal Positional Vertigo and Role of Muscle Relaxant as Adjuvant in Improving Outcome of Repositioning Manoeuvre

INTRODUCTION

Vertigo and dizziness cover several multisensory and sensorimotor syndromes of various aetiologies and pathogenesis.¹ It may be central or peripheral. Benign paroxysmal positional vertigo (BPPV) is the most common presenting cause of peripheral vertigo. It has an estimated lifetime prevalence of 2.4%.² Cases of BPPV seems to be explainable by the theory of canalolithiasis or cupulolithiasis.² BPPV patients can have other incapacitating symptoms, such as neck pain, musculoskeletal pain, headache, photophobia, visual disturbance and fatigue.³ The cervical spine has at least 20 pairs of muscles with numerous degrees of freedom of movement about each of its cervical joints, forming a complex biomechanical system.⁴ The major proprioceptors of the neck are the spindles of the cervical muscles.⁵ There are specific connections that exist between the cervical receptors and the visual, vestibular apparatus and sympathetic nervous system.⁶

The cervical afferents are also involved in three reflexes influencing head, eye and postural stability: the cervicocollic reflex(CCR), the cervicoocular reflex(COR), and the tonic neck reflex(TNR). All these reflexes work in conjunction with each other and are influenced by vestibular and visual input for coordinated stability of the head, eyes and posture.⁶ Postural mismatch occurs in all situations in BPPV.³ The purpose is to secure vertical balance. The most common way to compensate for a dynamic balance disturbance seems to be the static use of neck muscle. Static use of cervical muscle generates pain. This leads to sensorimotor control disturbance due to a lack of motor control. This will further create a vicious cycle of impaired postural control and pain.³

A positive positional test combined with an appropriate history is the key to making the diagnosis. BPPV can usually be adequately managed with canalith repositioning manoeuvre (CRM) without long-term medication or surgery.⁷ Proper execution of CRM involves extension, flexion and rotation of the patient’s neck. This is attributed to the cervical-range of motion (C-ROM).⁸ A reduced C-ROM could hinder the proper execution of the repositioning procedures or even cause their failure, the requirement of multiple CRMs and early recurrences.⁸

Any type of mechanical neck pain/stiffness limits the range of cervical motion. Analgesics, anti-inflammatories and muscle relaxants can be given orally and are commonly used in clinical practice to relieve neck pain/stiffness and muscle spasms.⁹ Muscle relaxants effectively reduce the neck pain^10, which indirectly increases the CRM’s efficacy.

Hence, muscle relaxants and anti-inflammatories could be of help in relieving cervical muscle pain and spasms, which increases the C-ROM. Our study aims to find the incidence of neck pain in BPPV patients and evaluate the role of muscle relaxants and anti-inflammatories as adjuvant in improving the outcome of repositioning manoeuvres.

MATERIAL AND METHODS

This was an observational and interventional study conducted in the department of otorhinolaryngology at our centre. After due approval from the Ethics Committee, the study was initiated.

Methodology

History was documented, and a detailed clinical evaluation was performed. Patients in whom history was suggestive of BPPV had clinical positional testing such as the Dix–Hallpike test for the posterior canal, the Barbeque test for the lateral canal and the supine straight head extension test for the anterior canal done to provoke canal-specific nystagmus. A pair of glasses with 20 diopter lenses was used to identify the character of nystagmus as torsional up-beating nystagmus for the posterior canal, horizontal nystagmus for the lateral canal and down-beating nystagmus for the anterior canal. Patients who didn’t show any nystagmus or there was suspicion of multiple canal involvement, they were further evaluated with video-oculography. Diagnosis of BPPV was confirmed. These patients were taken for study and informed written consent was taken. Pre-treatment DHI score was documented. Patients were asked about the associated neck pain/stiffness. The visual analogue scale (VAS) score was documented. This was the observational part of the study.

A neck examination was done. C-ROM was assessed clinically. An X-ray of the soft tissue neck (lateral view) was done to rule out any structural deformity. Other causes of neck pain/stiffness, like neurological causes/structural deformity, were ruled out.

All patients underwent CRM of the involved canal as Epley’s manoeuvre for the posterior canal, Barbeque roll for the horizontal canal and Yakovino manoeuvre for the anterior canal, which are the widely accepted manoeuvres for the treatment of BPPV. All patients were instructed on precautions to be taken at home.

Patients having neck pain/stiffness and a VAS score of 5 or more were further taken for the interventional part of the study. They were further divided into two groups (group A and group B) through convenience sampling. In group A, only CRM was performed, which is the standard treatment for BPPV. In group B, a fixed-dose combination of thiocolchicoside (4 mg) and aceclofenac (100 mg) was given orally, followed by CRM after 3 hours. These patients were further treated with the same medication in twice daily doses for 7 days. This was the interventional part of the study.

All patients were asked to come for follow-up on the 3rd day and 7th day. Patients were assessed for any change in vertiginous symptoms and/or relief of neck pain/stiffness. Patients were asked about any side effects of the drug or drug allergy. Any patient who developed dyspepsia was prescribed a proton pump inhibitor (PPI) for the duration of drug therapy. Repeat CRM was done only in cases where residual vertigo was persisting on the 3rd day and/or 7th day. Post-treatment DHI scores and VAS scores were documented in all patients on the 7th day. All patients of group B were able to complete the drug therapy [Figure 1].

Close

Figure 1:

Methodology flowchart. BPPV: Benign paroxysmal positional vertigo, VNG: Video nystagmography, DHI: Dizziness handicap inventory score, VAS: Visual analogue scale score, CRM: Canalith repositioning manoeuvre, FDCs: Fixed drug combinations.

Export to PPT

RESULTS

In the present study, 200 patients were included. The most commonly affected age group was 41–60 years (47.5%), with a female predominance of 59%. 189 subjects (94.5%) had single canal involvement. 9 (4.5%) of subjects had two-canal involvement. 2 (1%) of subjects had three-canal involvement. 77.5% of the patients had posterior canal involvement, 27% had anterior canal involvement, and 2% had lateral canal involvement. 53% of the subjects had associated neck pain. In group A, the median pre-treatment DHI was 44, which had reduced to 9 post-treatment. In group B, the median pre-treatment DHI was 50, which had reduced to 6 post-treatment. Change in DHI was 35 for group A and 44 for group B, which was statistically significant in comparison to group A. The change in VAS score was 0 for group A and 7 for group B, which was statistically significant in comparison to group A. The need for repeat CRM was significant in group A (45.2%) compared to group B (15.1%).

DISCUSSION

The commonest presenting cause of peripheral vertigo is BPPV.² Along with the classical symptoms, patients may have incapacitating symptoms such as neck pain, headache, musculoskeletal pain, photophobia, visual disturbance and fatigue.³ The most common way to compensate for a dynamic balance disturbance, as in BPPV, seems to be the static use of neck muscles to avoid vestibular symptoms. The vestibulospinal, vestibulocollic and vestibulo-ocular reflex that occurs with vestibular stimulation increases the tone of the neck muscle.¹¹ This is a protective response to limit further stimulation of the painful tissue. Such disturbances in the long run may cause tissue damage. This further aggravates the pain and promotes dysfunctional motion patterns. A vicious cycle is created, leading to more impaired postural control and pain.⁵ Associated neck pain/stiffness results in decreased cervical range of motion.¹² A reduced C-ROM could hinder the proper execution of the repositioning procedures or even cause their failure, the requirement of multiple CRMs and early recurrences.⁸ Muscle relaxants and anti-inflammatory are effective in reducing neck pain/stiffness, which indirectly increases the efficacy of CRM by reducing muscle tension, which is important to improve postural balance.⁵ This results in the normalisation of proprioceptive signals in the neck muscles,⁵ hence reducing sensory mismatch.⁵ Therefore, neck-directed therapy has a role in the management of BPPV patients with neck pain/stiffness.

Our study included 200 patients. The age range in our study was 18–81 years. Most of the patients were in the age group of 41–60 years (47.5%) with a mean age of 51.33 ± 14.65 years [Figure 2]. Studies by Swain et al.,¹³ von Breveren et al.,¹⁴ Khan et al.,¹⁵ Furman et al.,¹⁶ and Shim et al.¹⁷ found mean ages of 41.4 years,¹³ 49.4 (SD 13.8)¹⁴, 53.07,¹⁵ 54 years,¹⁶ and 54.4 ± 14.8,¹⁷ respectively. These findings were consistent with the findings of our study.

Close

Figure 2:

Distribution of study subjects based on age.

Export to PPT

There was a female preponderance of 59% in our study. 41% of the subjects were males [Figure 3a]. Other studies conducted by Khan et al.,¹⁵ von Breveren et al.,¹⁴ You et al.,¹⁸ Lee et al.,¹⁹ Swain et al.,¹³ Shim et al..,¹⁷ and Jeong et al.²⁰ showed similar results.

In our study, we found that the most commonly involved canal was the posterior semicircular canal—155 (77.5%) of the patients, followed by the anterior semicircular canal—54 (27%) of the patients; and the least common was the lateral semicircular canal—4 (2%) patients [Figure 3b]. Previous studies by Korres et al.²¹ and Balatsouras et al.²² had reported a lesser number of the anterior canal (1%–2%) involvement. Following the use of VNG in diagnosis and increasing availability, the involvement of the anterior canal has succeeded the lateral semicircular canal. Jackson et al.²³ had reported 21.2% of the anterior canal involvement. Other studies by Khan et al.,¹⁵ Lopez-Escamez et al.²⁴ reported 20.6% and 17.14% cases of anterior canal BPPV, respectively. Our study has documented 27% of anterior canal involvement, which is slightly higher to their finding.

Close

Figure 3:

(a) Distribution of study subjects based on gender, (b) Distribution of study subjects based on the number of canals involved.

Export to PPT

Among 200 of the subjects, 106 (53%) of the patients had neck pain [Figure 4]. Other studies by Wilhelmsen K et al.,²⁵ Kalland Knapstad M et al.,¹² Malmstrom et al.,²⁶ Wenche Iglebeek et al.,³ Wenche Iglebeek et al.²⁷ showed an association of BPPV with neck pain and having an association more than 50%, 59%, 85.3%, 87%, and 92%, respectively. Wilhelmsen K et al.^25, in their survey, found that head instability associated with vestibular disorders may result in dysfunctional head-on-trunk control strategies, putting excessive strain on the neck muscles over time. The combined effect of neck pain and dysfunctional control strategies may sustain balance problems and in part explain the association between neck pain and balance. In our study, more than 50% of associated neck pain with vertigo supports this evidence. Malmstrom et al.²⁶ in their study, found that initial neck shoulder back (NSB) pain might cause distorted cervical proprioceptive information and produce a sensory mismatch that induces or maintains conditions such as dizziness. Initial dizziness can result in cervical muscle tension which leads to NSB pain. Thus, a bi-directional relationship exists. Therefore their finding suggests that one should be aware of different additional symptoms in vertigo patients and treat them accordingly. Knapstad MK et al.¹² have found that neck pain may alter cervical proprioception and works as an exacerbator for dizziness even when the neck disorder is secondary to the dizziness. This may be due to increased avoidance behaviour and fear of head movements in patients of vertigo. Seemungal BM et al.²⁸ in their publication, mentioned that the increased neck muscle tension in vestibular patients may be linked to both cause and effect of reduced head movements.

Close

Figure 4:

Distribution of study subjects based on the presence of neck pain.

Export to PPT

The subjects with neck pain/stiffness were treated either with manoeuvre (group A) or with manoeuvre and adjuvant therapy of fixed drug combination (FDC) of thiocolchicoside (4 mg) and aceclofenac (100 mg) (group B). Before the treatment, the median DHI score of group A was 46 (41.5–52) and of group B was 47 (42.5–53.5) [Table 1]. DHI value at baseline was similar, and the difference was statistically non-significant (p-value = 0.054). Malmstrom et al.²⁶ in their study found that in patients with vertigo, those who have NSB pain have significantly higher DHI. In our study, the DHI value of the groups who have the associated neck pain/stiffness was slightly higher and supports the finding of Malmstrom et al.²⁶. In the study of Nishino et al.,²⁹ the total average scores of pre-treatment groups for BPPV were 47.93 ± 24.46. In the post-treatment group score, values diminished to 6.13 ± 7.22. This finding was also comparable with our findings. In both groups, there was a significant reduction in the DHI score after the intervention (p-value <0.05). This finding is again consistent with the fact that CRM is the standard treatment protocol of BPPV management. Emphasis was given primarily on the change of DHI in each group. The change in median DHI score of group A was 36 (32–39), and group B was 41 (39–44.5). This change was significantly greater in group B compared to group A (p-value <0.05) [Table 2] [Figure 5a]. As the change in median DHI value in group B was more, this correlates well with the fact that the more the change of DHI value, the better the functional outcomes in patients. Thus improving the quality of life of the patient.

Before the treatment, the median VAS score of group A was 7 (6–7) and of group B was 7 (6–8). VAS value at baseline was similar, and the difference was statistically non-significant (p-value = 0.412). After the treatment, the median VAS score of group A was 6 (5–7) and of group B was 0 (0–0). VAS was significantly greater in group A compared to group B, and the difference was statistically significant (p-value <0.05). The change in median VAS score of group A was 0 (0.0–2.0), and group B was 7 (6.0–7.0) [Table 3] [Figure 5b]. This change was significantly greater in group B compared to group A (p-value <0.05). Yahia A et al.³⁰ have documented the mean neck pain intensity of 6.65 on the VAS scale for patients with neck pain along with vertigo. This finding was also comparable with our finding, as in both the groups (group A and group B), the mean VAS score was 6.69 and 6.86, respectively.

Close

Figure 5:

(a) Change in DHI score in group A and group B, (b) Change in VAS score in group A and group B. DHI: Dizziness handicap inventory, VAS:Visual analogue scale.

Export to PPT

In group A, 29 (54.7%) of the patients didn’t require repeat repositioning manoeuvres. 20 (37.7%) of the patients required it once. 4 (7.5%) of the patients required it twice. In group B, 45 (84.9%) of the patients didn’t require repeat repositioning manoeuvres. 7 (13.2%) of the patients required it once. 1 (1.9%) of the patients required it twice [Figure 6]. Therefore, the need for repeat repositioning manoeuvres was greater among the subjects with neck pain/stiffness not receiving the muscle relaxant and anti-inflammatory (group A) compared to those receiving the muscle relaxant and anti-inflammatory (group B) (p-value <0.05) [Table 4]. Martelucci et al.⁸ in their prospective study have mentioned that a reduced C-ROM requires multiple CRMs to successfully treat BPPV and increase the risk of early recurrence. This is supported by our results, as in group A, 24 patients required CRM whereas in group B, only 8 patients required repeat CRM. Kültür Turgut et al.^31, in their study, have demonstrated that despite Epley being the most accepted treatment for posterior canal BPPV, relapses are frequent in BPPV patients with neck disorders. The addition of intervention (cervical manipulation in his case) reduces the relapse rate and is more effective. In our study, the addition of the combination drug (aceclofenac and thiocolchicoside) has improved the outcome of the CRM by reducing multiple sittings. Seemungal BM et al.^28, in their publication have mentioned that increased neck muscle tension in vestibular patients may be linked as both cause and effect to reduced head movements. Neck-directed therapy reduces neck pain, neck stiffness and dizziness. This is again supported by our study, as the addition of muscle relaxants significantly improves the DHI and VAS scores of the patients. Overall, the use of an FDC of a muscle relaxant and an anti-inflammatory relieved the muscle spasm and neck muscle stiffness and ameliorated pain. This actually helped by increasing the cervical range of motion, which improved the effectiveness of CRM and prevented multiple sittings. This ultimately resulted in a greater change in DHI value, proving the better functional outcome in patients.

Close

Figure 6:

Requirement of repeat manoeuvre.

Export to PPT

CONCLUSION

BPPV is the most common cause of peripheral vertigo. Patients can have additional musculoskeletal symptoms such as neck pain/stiffness. Our study concluded that BPPV and neck pain have a very strong correlation. Associated neck pain/stiffness adds to the existing picture of vertigo and increases the symptom severity. One should always address the neck symptoms while assessing and treating the vestibular symptoms of BPPV. Neck-directed therapies (muscle relaxant and anti-inflammatory) decrease pain/stiffness and inflammation and improve C-ROM, as suggested by significant changes in DHI and VAS scores in our study. Improved C-ROM leads to correct and proper execution of the particle repositioning manoeuvre, thereby reducing the need for repeated repositioning manoeuvre, and early reoccurrence.