The COVID 19 pandemic resulted in the extraordinary transition of many aspects of healthcare to “telemedicine” based platforms (1). While this has been a long-recognised possibility in a variety of medical specialties including stroke care (2), it was the rapidity of this transition which has been particularly striking. A close, arguably less discussed parallel to the delivery of clinical care using remote platforms, is the training of healthcare staff utilising similar technologies. Digital transformation of information and knowledge is the most recent paradigm shift (3) in our society, increasingly embraced by healthcare and academic institutions. Here we consider the possibility of leveraging such technologies to address a common, treatable clinical presentation.
Benign paroxysmal positional vertigo (BPPV) is the commonest cause of dizziness among the general population. Its incidence is conservatively estimated at 64 per 100 000 population per year (4) and is more common among the elderly population (its prevalence approaching 9% in those >65 years of age) (5). Diagnosing BPPV is important because the symptoms can be disabling and yet the disorder is easily treated. In most instances, it is thought to be caused by calcium carbonate crystals (from the otolith organs) that settle within the endolymphatic fluid of one or more semicircular canals, where they do not belong. A history of recurrent brief episodes of spinning vertigo triggered by head movement suggests BPPV, but a definitive diagnosis lies on a positional manoeuvre which will elicit positional nystagmus in patients with the disorder. Box 1 highlights the main indications for a positional manoeuvre.
Box 1
Indications for positional testing.
Any patient with brief episodic vertigo, especially positional vertigo, without spontaneous nystagmus.
Patients with otherwise unexplained unsteadiness, particularly in the elderly (where there may be a dissociation between vestibular activation and vestibular perception).
Individuals with attacks of non-positional vertigo are unlikely to have BPPV, but a positional manoeuvre can be worthwhile. If the positional manoeuvre elicits a typical BPPV-like nystagmus the patient should undergo repositioning, but if normal the patient should be referred onwards.
Given that BPPV may affect any one of the six semicircular canals in the head (three in each ear), one practical approach is to perform a Dix–Hallpike manoeuvre for right and left posterior semicircular canals as these are the most commonly involved (up to 95% of all BPPV cases (6). A manoeuvre such as the Dix-Hallpike should arguably be performed on every patient presenting with dizziness or imbalance because BPPV is common, carries an excellent treatment success rate, and dizzy symptoms are difficult for patients to describe (making history alone insufficient to make a confident diagnosis). Despite being an established procedure for the diagnosis and management of BPPV, positional manoeuvre are still substantially under-performed, mostly where it matters most: general practice and emergency settings, as this is where many patients with BPPV present (7). As such, there is an unmet need to improve training in positional manoeuvres across emergency, community, and primary care settings.
Assessment of the dizzy patient requires a comprehensive understanding of theory, examination and obtaining an appropriate patient history to exclude other causes of positional vertigo, nystagmus and more sinister pathologies. This degree of comprehensive assessment may be beyond the remit of non-specialists without more intensive training. Here, we focus specifically on positional manoeuvres for BPPV and explore aspects of a training program which may be amenable to the use of technologies or remote education. We argue that training therapists, not just physicians, is an important goal in ensuring BPPV is identified more promptly across emergency and primary care settings. In many services therapists already play a role in the assessment and treatment of BPPV, with development and access to telemedicine one possible avenue to increase the proportion of therapists who are competent and able to perform the associated manoeuvres. Communicating education through web-based technologies is commonplace–most notably, the use of video sharing platforms for interested individuals to self-direct their learning. While such platforms may contain excellent information, they potentially contain similar volumes of inaccurate and misleading content. We suggest the acceptance of web-based learning as convention provides the opportunity to develop comparative resources, scrutinised for rigour much the same way that a peer review process provides a degree of probity to the reader.
Constraints imposed during the COVID-19 pandemic saw clinical services pivot to digital technologies for a number of aspects of patient care. Here we consider if this accelerated implementation of telemedicine could meaningfully extend to training for BPPV, addressing a recognised shortfall of suitably trained healthcare staff. We describe some of the pitfalls to such telemedicine approaches, but also highlight practical factors that will increase the chances of a successful training programme and how existing technology may support this. We focus on the components which should comprise the training package for key positional manoeuvres for the diagnosis and treatment of common types of BPPV, namely Dix-Hallpike for the diagnosis of posterior semi-circular canal BPPV, and the Epley treatment manoeuvre.