Introduction

Benign paroxysmal positional vertigo (BPPV) is a prevalent vestibular disorder, diagnosed in approximately 17–42% of patients presenting with vertigo [1]. Characterized by recurrent episodes of positional vertigo, BPPV is attributed to disturbances in the inner ear, with varying involvement of the semicircular canals. The most affected is the posterior semicircular canal (PSC), followed by the horizontal semicircular canal (HSC) and, less frequently, the anterior semicircular canal (ASC). The impact of BPPV on patients' daily activities is significant, often leading to a substantial decrease in their quality of life (QoL).

Effective management of BPPV, particularly through repositioning manoeuvres, has been recognized as a critical intervention for improving patient outcomes. These manoeuvres are considered safe and have been widely accepted as an effective treatment for BPPV, particularly for symptoms originating from the PSC [2].

This study is designed to specifically assess the QoL in patients with PSC–BPPV and to evaluate the improvement in their QoL following treatment. The study's prospective and analytical nature will provide valuable insights into the effectiveness of repositioning manoeuvres in the management of PSC–BPPV and its impact on enhancing patients' QoL.

Methodology

Study Design and Setting

This was a prospective analytical study conducted in the Department of ENT at a tertiary care centre from January 2021 to December 2022.

Participants and Eligibility Criteria

  • Inclusion criteria were adult patients aged 18–60 years presenting with symptoms of vertigo and a positive Dix–Hallpike test. The diagnosis of PSC–BPPV was based on the observation of characteristic nystagmus (upward, geotropic nystagmus).

  • Exclusion criteria included patients with non-typical symptoms of PSC–BPPV, negative Dix–Hallpike test, coexistent cochlear symptoms or CNS disease, usage of ant vertiginous/ototoxic/psychiatric drugs, other ear pathologies, and uncontrolled systemic diseases or metabolic disorders.

The flow process of the patients was as per Fig. 1.

Fig. 1
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Flow process of the patients

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Variables, Data Sources, and Measurement

In this study, the primary variables for assessing quality of life (QoL) were the dizziness handicap inventory (DHI) and the visual vertigo analogue score (VAS), chosen for their reliability and validity in measuring the impact of vertigo.

  • The DHI is a 25-item self-reported questionnaire that evaluates the impact of dizziness across functional, emotional, and physical dimensions. Scoring ranges from 0 (no disability) to 100 (severe disability), allowing patients to express the extent to which dizziness affects their daily activities. Higher the score, greater the perceived handicap due to dizziness [3] (Fig. 2).

  • The VAS, a 9-item self-report scale, focuses specifically on the severity of visual vertigo symptoms, with scores ranging from 0 (no symptoms) to 10 (maximum severity), providing a quantitative measure of the patient's perceived intensity of visual vertigo. VAS is positive if > 2 questions are rated > 0 score. VAS = 0 means no visual vertigo and > 90 means severe visual vertigo [4] (Fig. 3)

Fig. 2
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DHI

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Fig. 3
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VAS

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Patients were administered these questionnaires at baseline and at follow-up visits on day 03, 10 and 30 of post Epley’s manoeuvre, ensuring a consistent and reliable measurement of changes in symptoms and QoL over time. This approach enables a comprehensive understanding of the impact of PSC–BPPV on patients' lives, capturing both general and specific aspects of their experience with vertigo.

Bias

The study design considered potential biases in patient self-reporting and the subjective nature of the DHI and VAS scales. Efforts were made to minimize bias through consistent administration of questionnaires and standardized interpretation of the Dix–Hallpike test.

Study Size

A total of 93 patients meeting the inclusion and exclusion criteria were enrolled in the study. The sample size was determined based on a power calculation to ensure sufficient statistical power to detect a meaningful change in the primary outcome measures (DHI and VAS scores) post-treatment with Epley’s Manoeuvre. This number also considered the anticipated rate of loss to follow-up, ensuring robustness in the study's findings. Additionally, practical considerations such as the expected number of eligible patients presenting with PSC–BPPV at the study site within the study timeframe were considered. This sample size balances the need for statistical validity with the practicalities of patient availability and study duration.

Quantitative Variables and Statistical Methods

The primary quantitative variables in this study were the scores from the dizziness handicap inventory (DHI) to the visual vertigo analogue score (VAS). These variables were chosen to quantitatively assess the impact of Epley’s Manoeuvre on the quality of life in patients with PSC–BPPV.

Statistical Analysis

  • Data analysis The collected data were analyzed using SPSS Statistics software, version 27.0. This software was chosen for its robust statistical capabilities and flexibility in handling various types of data.

  • Pre- and post-treatment comparison The primary focus of the statistical analysis was to compare DHI and VAS scores before and after the application of Epley’s Manoeuvre. This involved using paired statistical tests to determine whether there was a significant change in these scores following the treatment.

  • Interpretation of results The conclusions were drawn based on the observed changes in DHI and VAS scores, aiming to understand the extent to which Epley’s Manoeuvre affected the patients' quality of life.

By analysing these quantitative variables using appropriate statistical methods, the study aims to provide a clear and objective assessment of the effectiveness of Epley’s manoeuvre in improving the quality of life for patients suffering from PSC–BPPV.

Ethical Considerations

Informed consent was obtained from all participants. The study adhered to ethical guidelines for research involving human subjects. Approval for study was obtained from IRB of hospital.

Results

In present study total of 93 patients included after obtaining the consent from all. The study shown distribution of 58.1% male patients and 41.9% were female patients with male preponderance. (Table 1 and Fig. 4).

Table 1 Showing the distribution of gender among participants
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Fig. 4
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Pie chart showing the distribution of gender among participants

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Age Distribution

This study included total of 93 patients aged between 18 and 60 years as per inclusion and exclusion criteria. Age of 50 patients (46.5%) was more than 50 years. 30 patients (27.9%) with an age between 41 and 50 years, 10 patients (9.3%) with an age between 31 and 40 years and 03 patients (2.8%) with an age up to 30 years (Table 2).

Table 2 Age distribution among study population
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Follow-up and Recovery

Out of the 93 patients, 83 patients (90%) reported benefit on first follow-up (03 days). 07 patients showed improvement on second follow up (day 10) and 02 patients showed improvement on third follow up (day 30). 01 patient (0.1%) did not showed improvement on day 30 and referred to neurophysician to rule out central cause and further management of any coexistent cause (Table 3). This patient was later diagnosed as a case of psychogenic dizziness.

Table 3 Recovery of patients on different follow up
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Dizziness Handicap Inventory (DHI) Scores

In present study, with the follow-up period the DHI score was lower. The mean level of the DHI was significantly higher on day 0 compared to DHI 30. (p < 0.05) (Table 4 and Fig. 5).

Table 4 Showing the change in mean score of DHI
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Fig. 5
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Line graph showing the change in mean score of DHI

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Subcomponent Analysis of DHI

The changes in physical, functional and emotional aspect of DHI are shown in Table 5. The physical scores were the most compromised aspect, followed by the functional and the emotional aspect.

Table 5 Showing the change in physical, functional and emotional aspect of DHI
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Visual Vertigo Analogue Score (VAS) Changes

In present study, with the follow-up period the VAS score was lower. The mean level of the VAS was significantly higher on day 0 compared to VAS 30. (p < 0.05). (Table 6 and Fig. 6).

Table 6 Showing the change in mean score of VAS
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Fig. 6
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Line graph showing the change in mean score of VAS

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Correlation analysis

Correlation analysis provided following interpretation: (Table 7).

  • Age and DHI/VAS A positive correlation between age and DHI/VAS scores, especially on Day 0 and Day 3, suggests that older patients tended to report higher levels of dizziness and visual vertigo initially. However, the correlation decreases over time, indicating that the age-related impact lessens after treatment.

  • Gender and DHI/VAS The negative correlation values between gender and DHI/VAS scores, though small, indicate that male patients might have reported slightly lower levels of dizziness and visual vertigo compared to female patients. This difference diminishes significantly over time, suggesting that the treatment's effectiveness is similar across genders.

  • Over time The decreasing trend in correlation coefficients over time for both age and gender with DHI and VAS scores indicates that the impact of these demographic factors on the symptoms of vertigo diminishes following the treatment.

Table 7 Correlation analysis
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Discussion

Summary of Key Findings

Our study revealed significant improvements in quality of life (QoL) following treatment with Epley’s manoeuvre. These findings are consistent with the results of Lapenna et al. [5] and Keerthana et al. [6], who also reported the effectiveness of Epley’s manoeuvre in treating PSC–BPPV. Our study contributes to the growing body of evidence supporting the use of this manoeuvre as a standard treatment in clinical practice for PSC–BPPV, emphasizing its role in enhancing patient outcomes and improving QoL.

The observed improvements in dizziness handicap inventory (DHI) and visual vertigo analogue score (VAS) scores post-treatment highlight the clinical efficacy of Epley’s manoeuvre, reinforcing its value as a non-invasive, cost-effective, and easily administrable treatment option for PSC–BPPV patients. This aligns with the broader trends in the current research and clinical practice, advocating for Epley’s manoeuvre as a primary treatment modality for PSC–BPPV.

Interpretation

The male preponderance observed in our study presents a contrast to the typical demographic distribution of benign paroxysmal positional vertigo (BPPV), where a female dominance is usually reported, as highlighted in studies by von Brevern et al. [7] and Kim et al. [8]. This deviation in our findings could be attributed to specific demographic characteristics of the population studied or the relatively small sample size, which might not fully represent the broader BPPV patient population.

This variation highlights the need for a deeper understanding of the epidemiological factors that influence the prevalence and presentation of BPPV. It also suggests that factors beyond gender, such as lifestyle, occupational exposure, or genetic predispositions, could play a significant role in the occurrence and manifestation of BPPV.

Further, the discrepancy requires additional research to explore whether such demographic variations are observed in other populations or if they are unique to the specific cohort studied. This could lead to more personalized approaches in the diagnosis and treatment of BPPV, considering not only the symptoms and clinical presentations but also the demographic characteristics of the patients.

Strengths and Limitations

A key strength of this study is its prospective design, allowing for sequential observation of treatment effectiveness. However, limitations include the small sample size and the study's confinement to a single centre, as noted by De Stefano et al. [9] and Epley [10], potentially affecting the generalizability of results.

Generalizability

The findings from our study on the effectiveness of Epley’s manoeuvre in treating Posterior Semicircular Canal Benign Paroxysmal Positional Vertigo (PSC–BPPV) offer valuable insights but should be generalized with caution. The demographic specificity of our cohort and the limited sample size of 93 patients may not fully represent the broader BPPV patient population. Consequently, extrapolating these results to a more diverse or larger population requires further validation through larger-scale, multi-centre studies that encompass a wider range of demographic groups.

Implications for Clinical Practice

The results of our study strongly support the integration of Epley’s manoeuvre as a standard treatment approach in managing posterior semicircular canal benign paroxysmal positional vertigo (PSC–BPPV). This recommendation is in line with findings from You et al. [11] and Su et al. [12], who also highlighted the effectiveness of this manoeuvre in resolving vertigo symptoms associated with PSC–BPPV. The clear improvement observed in the Quality of Life (QoL) measures post-treatment in our study provides compelling evidence for the clinical utility of Epley’s manoeuvre.

Additionally, our study highlights the importance of individualized patient assessments in the management of PSC–BPPV. The observed demographic variations, particularly the unexpected male preponderance in our study cohort, emphasize the need for clinicians to consider demographic factors in their diagnostic and treatment strategies. Tailoring the management of PSC–BPPV to individual patient profiles, considering factors such as age, gender, and possibly other demographic or lifestyle attributes, could enhance treatment efficacy and patient outcomes.

Recommendations for Future Research

Future research in the field of posterior semicircular canal benign paroxysmal positional vertigo (PSC–BPPV) should focus on larger and more diverse population studies to validate and expand upon our findings. Comparative studies exploring different treatment modalities would be particularly valuable, providing a broader understanding of the most effective approaches for managing PSC–BPPV. Such research could offer more comprehensive insights into the condition, leading to optimized treatment strategies tailored to diverse patient needs and circumstances.

Conclusion

This study reaffirms the significant role of Epley’s manoeuvre in improving the quality of life (QoL) for patients with posterior semicircular canal benign paroxysmal positional vertigo (PSC–BPPV), contributing to the broader understanding of the condition's epidemiology and treatment efficacy. The findings highlight the effectiveness of this non-invasive treatment in managing the symptoms of PSC–BPPV and highlights its importance as a key therapeutic option in clinical practice. This study thus enhances our knowledge of PSC–BPPV treatment, forwarding the way for continued advancements in patient care and management strategies for this condition.