Benign Paroxysmal Positional Vertigo (BPPV) Training for Sports Medicine Providers in a Pediatric Concussion Program
Condition: Benign Paroxysmal Positional Vertigo
MeSH terms: Vertigo; Benign Paroxysmal Positional Vertigo; Dizziness
Study type: Interventional

Summary: 
      The investigators are training a group of four pediatric Sports Medicine providers in BPPV
      maneuvers. All four providers will be trained in the diagnostic maneuvers, and two will be
      randomly selected to also be trained in the treatment maneuvers. The providers will be
      encouraged to use the diagnostic maneuvers on all new concussion patients whose initial visit
      is within 28 days of their injury. They will complete a survey at the start and end of the
      study to determine if they thought the training affected their understanding of BPPV and
      confidence in managing it, as well as determine any challenges they faced with
      learning/administering the maneuvers. Additionally, the investigators will determine if the
      additional training impacts time to recovery from concussion, as well as determine potential
      risk factors for BPPV in concussion.
    

Detailed description: 
      Benign paroxysmal positional vertigo (BPPV) is a common disorder of the inner ear that causes
      episodes of vertigo. BPPV occurs as a result of displacement of otoliths from their position
      on the utricle into one of the semicircular canals. Posterior canal BPPV is diagnosed by
      performing the Dix-Hallpike maneuver, and lateral canal BPPV is diagnosed by performing the
      supine head roll test (Pagnini-McClure maneuver). Most cases of BPPV will resolve
      spontaneously, but this can take weeks to months without intervention, and approximately a
      third of cases will not resolve without treatment. Repositioning maneuvers, such as the Epley
      maneuver and Barbecue maneuver, move the otolith crystals out of the affected semicircular
      canal and back to their position on the utricle organ. Such maneuvers have been shown to be
      highly effective at resolving BPPV, and typically only 1-2 treatments are required.

      BPPV most commonly occurs as an isolated spontaneous disorder, but it can also occur
      following a concussion. While the diagnosis and treatment of BPPV is a routine component of
      most Otolaryngology and Neurology training programs, it is not a component of most Sports
      Medicine training programs. It is also common that providers who are taught to diagnose BPPV
      do not know how to treat it. Furthermore, the role of BPPV in concussion recovery has not
      been well studied. Hoffer and colleagues found BPPV to be present in nearly a third of adult
      military patients with dizziness immediately following a concussion, and they found that
      these patients had rapid symptom resolution following repositioning maneuvers. The
      investigators recently found evidence of BPPV in 21% of patients referred to their pediatric
      vestibular program clinic for prolonged dizziness symptoms following a concussion. The
      majority of these patients were successfully treated with repositioning maneuvers following
      their first visit to the vestibular clinic, but that visit occurred at a mean of 4 months
      following their initial injury.

      In order to determine if early recognition and management of BPPV will expedite recovery from
      concussion in affected patients, the investigators will train a group of four pediatric
      Sports Medicine providers in BPPV maneuvers. All four providers will be trained by Dr. Jacob
      Brodsky in the Dix-Hallpike and head roll maneuvers (BPPV diagnosis; Both Groups A & B), and
      two will be randomly selected to also be trained by Dr. Brodsky in the Epley and Barbecue
      maneuvers (BPPV treatment; Group A only). The providers will be encouraged to use the
      Dix-Hallpike and head roll maneuvers on all new concussion patients whose initial visit is
      within 28 days of their injury to determine if the patients have BPPV. Providers who have
      been trained in treatment maneuvers (Group A, Early BPPV Management) will be encouraged to
      perform them accordingly on any patients with positive diagnostic maneuvers. Providers who
      have not been trained in treatment maneuvers (Group B, Late BPPV Management) will refer
      patients with suspected BPPV to Dr. Brodsky for treatment, as is currently the routine.
      Patients are not being directly randomized and do not need to do anything beyond attend their
      regularly scheduled appointments.

      The Sports Medicine providers will complete a source document after each visit to document
      which maneuvers were performed and if the patient has recovered from concussion. They will
      also complete a survey at the start and end of the study to determine if they thought the
      training affected their understanding of BPPV and confidence in managing it, as well as
      determine any challenges they faced with learning/administering the maneuvers. The patients
      managed by providers in Group A will then be compared to patients managed by providers in
      Group B by multiple variables, including their post concussion symptom scores (PCSS), time to
      clearance for return to play, and time to symptom resolution. The investigators will also
      compare patients who were diagnosed with BPPV to those who were not to evaluate for risk
      factors for post-concussion BPPV, including comparison of age, gender, migraine history,
      prior concussion history, and mode of injury.
    

Intervention name(s): Diagnostic training; Diagnostic and treatment training
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Training in the Dix-Hallpike maneuver and the supine head roll test to diagnose BPPV.; Training in the Dix-Hallpike maneuver and the supine head roll test to diagnose BPPV. Training in the Epley and Barbecue maneuvers to treat BPPV.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Other