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Posterior canal benign paroxysmal positional vertigo pc-BPPV causes physical, functional, and emotional impairment. The treatment is the Epley manoeuvre EM. The purpose of the study was to compare the impact of the EM and a sham manoeuvre in primary care on self-perceived disability. Randomised, double-blind, sham-controlled clinical trial conducted in primary care with a follow-up of 1 year. Intervention EM group or a control sham manoeuvre group.

The main study covariates were age, sex, history of depression and anxiety, presence of nystagmus in the DHT, patient-perceived disability assessed with the Dizziness Handicap Inventory — screening version DHI-S. Data were analyzed using bivariate and multivariate mixed Tobit analyses. Overall, patients were studied: 66 in the intervention group and 68 in the control group. Median age was 52 years interquartile range [IQR], The DHT triggered nystagmus in Patients treated with the EM experienced a mean reduction of 2.

Pc-BPPV affects the quality of life of primary care patients. El tratamiento es la maniobra de Epley ME. Benign paroxysmal positional vertigo BPPVthe most frequent cause of vertigo, has an annual incidence ranging from Pc-BBPV can be diagnosed with relative ease in primary care, as a targeted history, a basic physical examination, and performance of the Dix—Hallpike test DHT are sufficient to establish a diagnosis. According to some authors, however, the DHT may also be considered positive if the patient experiences symptoms without nystagmus. Many patients with BPPV experience impaired physical and functional performance and the condition can also have an effect on family and social life.

Perceived disability among patients with BPPV is usually assessed using standardised questionnaires, the most common being the Dizziness Handicap Inventory DHI13 for which several abbreviated versions have been created. It is a self-administered questionnaire that can be completed in 4—5 min, making it suitable for use in centres that have to deal with large s of patients such as primary care practices.

It has been validated for use in Spain. The treatment of choice for BPPV is the Epley manoeuvre EMwhose effectiveness has been demonstrated in numerous studies and systematic reviews. Although performance of the EM is feasible in primary care, 23 most of the studies that have evaluated its impact on perceived disability among patients with pc-BPPV have been performed in specialised clinics. Studies thus are needed to evaluate its impact in patients diagnosed and treated in primary care. The aim of the study was to compare the effect of the EM and a sham manoeuvre on self-perceived disability assessed using the DHI-S at 1 week, 1 month, and 1 year in primary care patients with pc-BPPV.

Randomised, double-blind, sham-controlled clinical trial with an allocation ratio of conducted in two primary care practices. Patients who agreed to participate were referred for baseline evaluation by one of six GPs on the research team. The full list of exclusion criteria is available in the study protocol. Although vestibular migraine was not an exclusion criterion for the trial, 24 emerging evidence on the high prevalence of this condition 25 and its overlapping symptoms with pc-BPPV suggested that patients with vestibular migraine might have been recruited for the trial.

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It was therefore decided to re-assess all patients after completion of the follow-up phase and to remove those who met the criteria for probable vestibular migraine. At the baseline visit, the patients underwent a full physical examination and a complete medical history, including review of electronic medical records. Patients in the intervention group were treated with a single EM.

Patients in the control group were prescribed betahistine as the same dosage. The GPs who administered the EM took part in a 2-h practical training session on diagnosing vertigo and applying the manoeuvre under the supervision of an ENT specialist to ensure consistent execution across patients. The total possible score therefore ranges from 0 no self-perceived disability to 40 worst possible self-perceived disability. The sample size was calculated for outcomes not analysed in this study. Patients were ased to the intervention and control groups using a unique list of randomisation sequences prepared in advance by the study statistician.

Continuous variables e. For the between-group comparisons at each time point, the distribution of DHI-S answers was compared using the Chi-square test, while DHI-S scores were compared using the Wilcoxon test. These bivariate analyses were performed for the overall samples and stratified by sex and presence or absence of nystagmus at baseline. A longitudinal multivariate regression model was built using DHI-S scores.

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Given the considerable proportion of 0 scores, a full mixed-effects multivariate Tobit regression model was adjusted to explain DHI-S scores by intervention, baseline DHI-S score, sex, baseline diagnosis O-BPPV vs S-BPPVand three-way interactions between all these variables and the treatment group, with adjustment for correlated intraindividual observations. Stepwise backward variable selection using the Akaike information criterion AIC was applied to obtain the final model. This reduced Tobit model contained all relevant variables and interactions; are presented as marginal effects medians of individual effects 29,30 and statistical ificance P -value of the associated coefficients.

Of the patients with suspected pc-BPPV analysed, The reasons for exclusion are summarised in the study flowchart Fig. Nineteen patients were removed retrospectively because they had criteria compatible with vestibular migraine. Theirhowever, can be consulted in the supplementary material. The respective of patients lost to follow-up at the three time points week, month, and year was 7, 17, and The baseline characteristics for the overall sample and the intervention and control groups are shown in Table 1.

The median age was 52 years IQR, The proportion of patients with anxiety and depression was In total, No ificant differences were observed between the intervention and control group for any of the study variables. Flowchart of participants. Characteristics of the study participants overall and by intervention. A higher median score was observed in women compared with men 16 [IQR, Patient-perceived disability during the follow-up period week, month, year was not influenced by a history of anxiety or depression or treatment with anxiolytics.

The final multivariate model the model with the best performance according to the AIC showed that variations in DHI-S scores were explained by treatment group, baseline DHI-S score, follow-up time pointand interaction between DHI-S score and time all other interactions and effects did not provide enough likelihood to the model. The respective effects at 1 month and 1 year were 0. Multivariate mixed-effects regression.

Final model built following stepwise backward selection of variables using the Akaike Information Criterion from an initial model featuring treatment adjusted for follow-up, baseline DHI-S score, sex, nystagmus at baseline, and three-way interactions between these factors and treatment and follow-up. Expected values from Table 3 estimated by the Tobit model with the best predictive accuracy according to treatment received Epley manoeuvre [interv] vs sham manoeuvre [control].

We might also have observed greater differences if we had treated certain patients with more than one EM the recommended is up to four. The median age of the patients in our series is similar to that observed in other studies at specialised clinics 16,31 and primary care practices. Also supporting findings, 2,20,33,34 women outed men in our study, which is consistent with the higher prevalence of pc-BPPV in women.

Sex was not a ificant factor in the multivariate model. Pereira et al. One possible explanation for the better scores in our series is that the patients were diagnosed and treated in primary care, avoiding the delays associated with referral to a specialist.

Their younger age may also have played a part. A high proportion of patients in our series had anxiety or depression. It is not uncommon for patients with BPPV to experience psychiatric-psychosomatic disorders such as depression or anxiety.

The main strength of our study is that it was conducted under typical conditions encountered in primary care practices, which is where most patients with BPPV are seen. We acknowledge some limitations of this study. Patients seen in primary care often have early-stage nystagmus, which is more difficult to diagnosis, particularly if special tools such as Frenzel goggles or videonystagmography are not used. Testing primary care patients with S-BPPV in addition to those with O-BBPV greater diagnostic sensitivity at the expense of specificity in primary care may improve early diagnosis and treatment rates, and such an approach has been suggested by other authors.

Response to the EM in terms of perceived disability was not influenced by the presence or absence of nystagmus at baseline, supporting findings by Huebner et al. Another possible limitation of the present paper is that initial sample size was calculated for other analyses, and this sample size was later reduced due to non-planned exclusion criteria. Although this could have led to lack of statistical power, our found statistical ificance for the main effect of the manoeuvre; further research is needed to discard any other possible effects, such as a time variation of the effect of the manoeuvre.

The DHI-S is a simple tool that can be administered in a matter of minutes. It would therefore be interesting to determine cut-off points for different levels of perceived disability none, mild, moderate, and severe. It would also be interesting to calculate the minimal detectable change and minimal clinically important difference for the DHI-S in order to determine the relevance of changes over time. BPPV can cause considerable disability. Early treatment of pc-BPPV using repositioning manoeuvres can result in ificant improvements, highlighting the importance of prompt treatment in all patients, including those seen in primary care.

It would be very interesting to determine whether performance of more than one EM would improve the outcomes observed in this study. Nonetheless, although this difference is statistically ificant, it may have little clinical relevance. Keypoints Benign paroxysmal positional vertigo, primary health care, Epley manoeuvre, health-related quality of life, randomised controlled trial.

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Performance of the EM is feasible in primary care.

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Modifications of the Epley (canalith repositioning) manoeuvre for posterior canal benign paroxysmal positional vertigo (BPPV)