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Can GPs diagnose benign paroxysmal positional vertigo and does the Epley manoeuvre work in primary care?

Can GPs diagnose benign paroxysmal positional vertigo and does the Epley manoeuvre work in primary care?
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  698  British Journal of General Practice,  September 2010 moved quickly ‘from a sitting position tolying with the head tipped 45˚ below thehorizontal, 45˚ to the side, and with theside of the affected ear (and semicircularcanal) downwards.’ 2 The Dix-Hallpike testis positive when torsional (rotatory)nystagmus occurs when the head isturned to the affected ear. 4 In aprospective study of diagnosis of vertigoin general practice, a positive Dix-Hallpiketest had a positive predictive value of83.3% and a negative predictive value of52% in diagnosing BPPV. 3 Having doneso, GPs can then usually resolve thecondition through a manipulation calledthe Epley manoeuvre.Benign paroxysmal positional vertigo(BPPV) in adults is a common cause ofdizziness seen in general practice with a 1-year prevalence of 1.6%. 1 It is characterisedby brief episodes of dizziness or vertigotypically triggered by rapid changes in theposition of the head and can be associatedwith nausea which may persist. 2 BPPV canresolve spontaneously within weeks ormonths. 2 It can present in clusters and canrecur after remission. 2 This short paper isbased on a critical literature review. DIAGNOSING BPPV  GPs can confirm a diagnosis of BPPVusing the Dix-Hallpike test. 2,3 The patient is EPLEY MANOEUVRE The Epley (canalith repositioning)manoeuvre is a ‘safe and effectivetreatment’ for BPPV. 2 It consists of ‘a seriesof four quick movements of the head andbody from sitting to lying, rolling over, andback to sitting (Figure 1). Each position ismaintained until positional nystagmus hasdisappeared, indicating cessation ofendolymph flow’. 4 The Epley manoeuvrehas been shown to be beneficial after onesession when 77% of patients reportedeffective relief and an additional 20% ofpatients reported the same the followingweek after the second session. 4 Patientsare advised to perform self-treatment athome after receiving the Epley manoeuvre. 4 IS IT FEASIBLE TO IMPLEMENTTHE EPLEY MANOEUVRE INGENERAL PRACTICE? The Epley manoeuvre in general practiceproduces similar results whenimplemented in secondary or tertiarycentres. 5  A randomised, prospective,double-blind, sham-controlled studydetermined whether the Epley manoeuvreis effective for treating BPPV in primarycare. 5  At baseline the intervention groupreceived the Epley manoeuvre and thecontrol group received a sham manoeuvrewhich consisted of the Epley manoeuvreperformed on the unaffected side. 5  At1 week and 2 weeks both groups receivedthe Epley manoeuvre. 6 Initial improvementwas statistically significant, as after the firsttreatment 34.2% of patients in theintervention group had a negative Dix-Hallpike test, compared with 14.6% in thecontrol group (  P  value = 0.04; 95% CI =1.03 to 5.33). 5 This study concluded thatthe number of patients who weresuccessfully treated with the first Epleymanoeuvre was statistically significantcompared to the control group, and thatGPs could use the Epley manoeuvre totreat BPPV. 5 Can GPs diagnose benign paroxysmalpositional vertigo and does the Epley manoeuvre work in primary care?  Figure 1. The Epley manoeuvre for treating benign paroxysmal positional vertigo.This article was published in Otolaryngology — Head and Neck Surgery, 107(3), Epley JM, Thecanalith repositioning procedure: for treatment of benign paroxysmal positional vertigo, 399–404,Copyright Elsevier 1992. Figure 1.  Positions for canalith repositioning procedure targeting left posterior semicircular canal (PSC). Solid figures =side view. Boxes = operators exposed view of the labyrinth, showing gravitating canaliths. Semicirvular canals are labeled.S(start) Patient is seated, operator behind, oscillator is applied. (1) Head is placed over end of table, 45° to the left(canaliths gravitate to centre of PSC). (2) While head is kept tilted downward, it is rotated 45° right (canaliths reachcommon crus). (3) Head and body are rotated until facing down 135° from supine position (canaliths traverse commoncrus). (4) While head is kept turned right, patient is brought to sitting (canaliths enter utricle). (5) Head is turned forward,chin is tilted down 20°. Generally, pause at each position until vertigo and nystagmus stop. Make sure the nystagmusbeats in the same direction during each step as this conforms movement of the debris in the desired direction. Keeprepeating entire sequence (1 to 5) until no nystagmus in any position.  British Journal of General Practice,  September 2010  699 Glasziou suggested that the Epleymanoeuvre has been slow to beimplemented into primary care because ofthe level of skill involved and a lack ofconfidence with the Dix-Hallpike test andthe Epley manoeuvre. 1 This can beaddressed with training; for example, usinga video showing the Dix-Hallpike test andEpley manoeuvre. 1 It is useful to haveanother member of staff to assist whencarrying out the test and the manoeuvre.The staffing implications need to beconsidered.In a 10-minute consultation, a GP couldtake a history and perform Rinne’s andWeber’s tests followed by the Dix-Hallpiketest and the Epley manoeuvre. CONCLUSION The evidence suggests that BPPV can bediagnosed and subsequently treated withthe Epley manoeuvre in general practicewith great effect, thus reducing referrals tospecialist centres. If the patientsubsequently presents with unresolvedsymptoms they should then be referred.Further research needs to be undertakento measure the effectiveness of the Epleymanoeuvre in general practice throughfurther randomised controlled trials. Avoiding long-term medication, and theconsequent side effects, is another aspectof the cost-effectiveness of themanoeuvre.The research evidence suggests thisdiagnostic manoeuvre and manipulationcan be readily and successfully adopted inprimary care. Sarah Cranfield, Ian Mackenzie, andMark Gabbay REFERENCES 1. Glasziou P,Heneghan C.Epley and the slow boat fromresearch to practice. Evid Based Med   2008;  13: 34–35.2. Hilton M,Pinder D.The Epley (canalith repositioning)manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev   2004;  2:  CD003162.3. Hanley K,O’Dowd T.Symptoms of vertigo in generalpractice: a prospective study of diagnosis. Br J Gen Pract  2002;  52: 809–812.4. Lempert T,Gresty MA,Bronstein AM.Fortnightly Review: Benign positional vertigo: recognition andtreatment. BMJ   1995;  311: 489–491.5. Munoz JE,Miklea JT,Howard M, et al  .Canalithrepositioning maneuver for benign paroxysmalpositional vertigo Randomized controlled trial in family practice. Can Fam Physician  2007;  53: 1048–1053.DOI: 10.3399/bjgp10X515557 Essay   Mike Fitzpatrick  The new health White Paper proclaims, inits subtitle, the goal of ‘liberating theNHS’, but the ascendancy of the conceptof ‘wellbeing’ threatens to consolidatethe tyranny of health over patients andprofessionals alike. 1,2 Having suggested before the electionthat the abolition of PCTs would be a‘promising way of saving money andimproving primary care at a stroke’, 3 I findmyself in an unfamiliar position ofalignment with one of the morecontroversial proposals of the coalitiongovernment’s White Paper. On firstreading this hastily produced blueprintfor drastic restructuring of the healthservice, I was struck by the claim that theproposed replacement for PCTs — localGP consortia — would ‘increaseefficiency by enabling GPs to strip outactivities that do not have appreciablebenefits for patients’ health orhealthcare’. But my excitement at theprospect of ‘stripping out’ all the sort of‘health promotion’ and ‘diseaseprevention’ activities that have such abaneful effect on the health of ourpatients — starting with the NHS HealthCheck — was short-lived. These areexactly the sorts of activities that the Equity and Excellence  White Paper,whose very title and every page indicatea spirit of continuity with the buzzwordsand rhetoric of New Labour(‘transparency’, ‘world-class’, even‘information revolution’), is determined topursue, indeed, to enforce on generalpractice.The familiar weasel words of ‘choice’,‘competition’, and ‘empowerment’ thinlydisguise compulsion and coercion. Theproposed consortia will be assembled bya process of forced collectivisation: GPswill have no choice about the terms onwhich we compete in the new primarycare market. We will also have a ‘duty toparticipate’ with local governmentauthorities, who will be given major newpowers, including taking over many ofthe functions of the old PCTs. Inparticular, we will be obliged to surrenderto the ‘strategic role’ of the proposedlocal authority ‘health and wellbeingboards’. (To adapt an old adage, ‘Those Liberating the NHS who can do, those who can’t, take on astrategic role’.) These boards willprovide a new base from which thezealots of public health can promotetheir moral crusades (from ‘safe sex’ to‘five a day’) and hype up publicanxieties with their imaginaryepidemics and pandemics.The expansion of health reflected inthe relatively new, but now universallypromoted, coupling of ‘health andwellbeing’, has major consequencesfor society. Instead of being regardedas the absence of disease, the defaultstate of robust citizens in a maturedemocracy, health has become thetranscendent goal of the fragile andvulnerable individuals of the risksociety. Wellbeing — like its closerelation, ‘happiness’, another policy‘outcome’ for both Tony’s ‘Third Way’and Dave’s ‘Big Society’ —can only beattained through the pursuit of anascetic lifestyle and regular submissionto medical surveillance. The problemfor the NHS is that the burden ofdemand resulting from the health-related anxieties and expectations thatare unleashed by this process areunsustainable. The reforms proposedin the new White Paper, like itspredecessors, will merely ensure thatmore and more people, falling short inachieving the desired and promisedoutcomes of health and wellbeing, willfeel ill, fostering spiralling costs in bothprimary and secondary health care. REFERENCES 1. Department of Health.  Equity and excellence:Liberating the NHS .White Paper. July 2010. (accessed 6 Aug 2010).2. Fitzpatrick, M.  The tyranny of health: doctors and the regulation of lifestyle . London: Routledge,2000.3. Fitzpatrick, M. How to cut NHS spending andimprove the health of the nation.  Br J Gen Pract  2010;  60 :(572): 223.DOI: 10.3399/bjgp10X515566
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