Abstract
Although the Epley maneuver is considered the primary treatment in BPPV, anti-vertigo medications are effective in residual symptoms. This study was designed to compare betahistine and dimenhydrinate plus the Epley maneuver and the Epley maneuver alone. This prospective cohort study was performed in Mashhad, Iran, from 2013 to 2015. 90 adult patients diagnosed with BPPV in hospitals and ENT clinics were selected through convenience sampling. Patients received betahistine 8 mg TDS or dimenhydrinate 50 mg once daily plus Epley or the Epley alone for four weeks. SF-36 and the DHI were used before and after the treatment. 49 were females (54.4%). The mean (SD) age was 47.9 (8.7) years. There was no significant difference between the groups in age (P = 0.753) and gender (P = 0.050).There were significant differences in all areas of SF-36 except for social activities in the dimenhydrinate group. There was a marginally significant difference between the betahistine and dimenhydrinate groups in role limitation due to physical health problems (P = 0.046). There were significant differences between the females and males in emotional well-being before and after treatment in the dimenhydrinate group (P = 0.014) and in terms of role limitation due to physical health problems in the Epley maneuver group (P = 0.022). Older patients in the betahistine group had better social activities after treatment (P = 0.048). In severe forms of BPPV, betahistine or dimenhydrinate might effectively reduce the symptoms.
Keywords: BPPV, Benign paroxysmal positional vertigo, Dimenhydrinate
Introduction
Benign paroxysmal positional vertigo (BPPV) is a common disorder due to the particles in the endolymphatic canal. Although the disorder is benign and peripheral, it can cause lots of problems for the patients and decrease the quality of life significantly. Epley maneuver, a canalith repositioning maneuver, is shown to be efficient in reducing the symptoms and vertigo [1].
Such as any chronic neurological disorder [2, 3], BPPV affects the patient's quality of life. Semicircular canal stimulation by the canaliths is the cause assumed for the fake sensation of moving and rotation hallucination in BPPV [4]. The life-long prevalence of the disorder is reported to be 2.4%. Drugs such as anti-anxieties, dexamethasone, and some others have been evaluated. Betahistine is an antagonist of H3 receptors and an agonist of H1 receptors with promising results in the case of Meniere disease and some other causes of vertigo. One previous study showed that betahistine may act on the ERK1/2-AKT/PPARy pathway, and positive effects on BPPV symptoms are expected [5]. Dimenhydrinate, a first-generation antihistamine, is shown to be effective in patients who still have symptoms despite the Epley maneuver [6]. However, repositioning maneuvers are considered the mainstay treatment for BPPV [7].
Although acute vertigo is treated by repositioning maneuvers, some patients develop recurrence. In addition, some patients suffer residual symptoms of dizziness and unsteadiness. Medications show little efficacy in the treatment of BPPV [8]. However, studies comparing medications and the maneuver alone are few, and in addition, after repositioning, although the rotational vertigo resolves, residual unsteadiness is shown to remain [9]. One previous study showed the efficacy of dimenhydrinate for residual symptoms after repositioning [10]. Therefore, medications deserve to be further studied in BPPV patients.
According to the importance of dizziness and vertigo in the quality of life of the patients, it is essential to design studies that compare treatment modalities together to know which one is the most effective. In the current study, we investigated the effects of the Epley maneuver alone with dimenhydrinate or betahistine plus therapeutic maneuvers. The results of the current study will help to know which treatment shows better efficacy.
Methods
This was a prospective cohort study. Inclusion criteria were as follows: having BPPV based on the history and the Dix-Hallpike maneuver. Illiterate people and people with a lack of cooperation in addition to patients with another diagnosis rather than BPPV such as Meniere disease were excluded. Patients aged between 18 to 60 years referred to hospitals and ENT clinics in Mashhad, Iran from 2013 to 2015 were included using the convenience sampling method.
Groups and Treatments
Patients who received the following treatments were followed for four weeks (30 patients in each group):
Dimenhydrinate (TRAVELIN®, Tehrandarou) 50 mg, once daily plus therapeutic maneuver
Betahistine (BETAHISTINE Shahrdarou) 8 mg, TDS plus therapeutic maneuver
Epley maneuver alone (performed by trained personnel at the audiometry clinic)
Quality of Life Assessment
The 36-item Short Form Survey (SF-36) questionnaire was used. This questionnaire assesses the quality of life in 8 dimensions: general health status, vitality and energy, physical function, physical function limitation, physical pain, mental health, mental function limitation, and social activities. Each area is given a score between 0 and 100. Higher scores describe a better quality of life [11]. The validity of the questionnaire is shown in Iranian people [12, 13].
DHI Questionnaire
The dizziness handicap inventory (DHI) is used to evaluate the impact of balance problems on quality of life [14]. This questionnaire has 25 questions graded in three levels mild, moderate, and severe. The range of scores is (0–30), (31–60), and (more than 60). Lower scores are interpreted in favor of better quality of life.
The questionnaires were answered by the patients before and four weeks after the initiation of the interventions.
Statistical Analysis
Using IBM SPSS statistics (version 24), the data were analyzed. Data normality was assessed using the Kolmogorov–Smirnov statistic, and in the case of normality, the t-test was used. For non-parametric variables, the Mann–Whitney U test was used. Variables are reported as mean (SD) and number (%). The Analysis of Covariance (ANCOVA) test was used to compare the SF-36 scores. The paired t-test or Wilcoxon was used to compare the scores before and after the treatment in each group. In all the tests, a P-value of less than 0.05 was considered significant.
Ethical Issues
This study was done according to the statements of the Declaration of Helsinki. Patients entered the study after a written informed consent.
Results
In this study, 90 adult patients with BPPV, 49 females (54.4%) and 41 males (45.6%) were included. The mean (SD) age of the patients was 47.9 (8.7) years; 47.7 (8.7) in the dimenhydrinate group, 47.1 (8.5) in the betahistine group, and 48.8 (8.9) in the Epley maneuver group (P = 0.753). In terms of gender, there were 20 females and 10 males in the dimenhydrinate group, 18 females and 12 males in the betahistine group, and 11 females and 19 males in the Epley maneuver group (P = 0.050, X2 = 6.003; Chi-squared test).
Mean (SD) scores of SF-36 were recorded before and after treatment in each group, and assumptions required for the ANCOVA test were assured. There was no significant difference before and after treatment and in different groups (Table 1). The results of every category of mental and physical health perception before and after treatment are provided in Tables 2, 3, 4. There were significant differences in SF-36 and DHI scores before and after treatment in the dimenhydrinate group except for social activities (Table 2). There were significant differences in SF-36 and DHI scores before and after treatment in the betahistine group in all categories (Table 3). There were significant differences in SF-36 and DHI scores before and after treatment in the Epley maneuver group in all categories (Table 4). The scores at each category were compared in every two groups using ANCOVA. There was a marginally significant difference between the betahistine and dimenhydrinate groups in role limitation due to physical health problems scores before and after treatment (P = 0.046). Scores in the other categories of the SF-36 scale didn’t differ significantly between these two groups before and after treatment. Comparing the betahistine and the Epley maneuver groups, there were significant differences in the role limitation due to physical health problems, bodily pain, and emotional well-being scores (P = 0.037, 0.027, 0.016, respectively). Again, there were no significant differences in the other categories when comparing these two groups (P > 0.05). When all three groups were compared, the only significant difference was in emotional well-being, with a P-value of 0.043 for ANCOVA, which was marginally significant. There were significant differences between the females and males in emotional well-being before and after treatment in the dimenhydrinate group (P = 0.014) and in role limitation due to physical health problems in the Epley maneuver group (P = 0.022). Patients in each group were divided into two groups of 20 to 40 years and above 40 to 60 years and were compared. There was a marginally significant difference in the betahistine group before and after treatment between the two age groups, and older patients had better social activities after treatment with betahistine plus the therapeutic maneuvers (P = 0.048). Scores in each category and treatment plan by gender and age groups are provided in Appendix 1. Imbalance severity based on the DHI values is listed in Table 5.
Table 1.
Mean (SD) scores of SF-36 before and after treatment in the three groups
| Groups | Number of the patients | Mean (SD) SF-36 scores | P-value* | |
|---|---|---|---|---|
| Before treatment | After treatment | |||
| Dimenhydrinate | 30 | 39.3 (7) | 67.5 (10.3) | 0.496 |
| Betahistine | 30 | 40.5 (9) | 67.6 (9.6) | |
| Epley maneuver | 30 | 38.4 (8.2) | 67.4 (7) | |
*ANCOVA test
Table 2.
SF-36 categories and DHI scores in patient who received dimenhydrinate before and after treatment
| Variables | Mean (SD) | Test statistics* | P-value | |
|---|---|---|---|---|
| Before treatment | After treatment | |||
| Categories in SF-36 | ||||
| General health perceptions | 45.5 (17.8) | 75.2 (18.1) | − 7.403 | 0.0001 |
| Vitality | 46.2 (14.6) | 74.5 (14.9) | − 8.544 | 0.0001 |
| Physical functioning | 43.8 (16.5) | 70.7 (15.3) | − 6.707 | 0.0001 |
| Role limitation due to physical health problems | 35.8 (29.1) | 68.3 (23.6) | − 4.187¥ | 0.0001¥ |
| Bodily pain | 39.2 (15.9) | 70.7 (14.2) | − 9.056 | 0.0001 |
| Emotional well-being | 31.2 (20.5) | 68.7 (18.9) | − 7.636 | 0.0001 |
| Role limitation due to emotional problems | 34.4 (34.4) | 71.1 (33.6) | − 3.635¥ | 0.0001¥ |
| Social functioning | 47.8 (16.6) | 55.1 (26.4) | − 1.186 | 0.245 |
| DHI | 59.8 (21.6) | 29.9 (14) | − 6.531 | 0.0001 |
*Paired t-test or Wilcoxon
¥Wilcoxon test
Table 3.
SF-36 categories and DHI scores in patient who received betahistine before and after treatment
| Variables | Mean (SD) | Test statistics* | P-value | |
|---|---|---|---|---|
| Before treatment | After treatment | |||
| Categories in SF-36 | ||||
| General health perceptions | 44.3 (17.4) | 69 (15.5) | − 4.536¥ | 0.0001¥ |
| Vitality | 50.3 (14.5) | 73.7 (15.5) | − 7.547 | 0.0001 |
| Physical functioning | 48 (16.4) | 69 (13.8) | − 6.5 | 0.0001 |
| Role limitation due to physical health problems | 37.5 (31.3) | 57.5 (22.9) | − 3.839¥ | 0.0001¥ |
| Bodily pain | 45.5 (22.3) | 61 (15.5) | − 3.586 | 0.0001 |
| Emotional well-being | 37.5 (24.9) | 54.4 (16.6) | − 2.853 | 0.008 |
| Role limitation due to emotional problems | 21.1 (29.6) | 52.2 (38.8) | − 3.558 | 0.001 |
| Social functioning | 42.3 (21.2) | 62.2 (22.6) | − 3.694 | 0.001 |
| DHI | 63.5 (25.5) | 33.2 (16.3) | − 6.314 | 0.001 |
*Paired t-test or Wilcoxon
¥Wilcoxon test
Table 4.
SF-36 categories and DHI scores in patient who received Epley maneuver before and after treatment
| Variables | Mean (SD) | Test statistics* | P-value | |
|---|---|---|---|---|
| Before treatment | After treatment | |||
| Categories in SF-36 | ||||
| General health perceptions | 41.8 (18.4) | 79.9 (16.4) | − 10.717 | 0.0001 |
| Vitality | 46.5 (12.6) | 71.5 (15.9) | − 8.863 | 0.0001 |
| Physical functioning | 46.3 (14.9) | 67.2 (12) | − 6.703 | 0.0001 |
| Role limitation due to physical health problems | 34.2 (26.6) | 67.5 (28.7) | − 3.870¥ | 0.0001¥ |
| Bodily pain | 35 (14.2) | 72 (15.3) | − 9.310 | 0.0001 |
| Emotional well-being | 28.3 (21.9) | 75.5 (21.1) | − 7.604 | 0.0001 |
| Role limitation due to emotional problems | 22.2 (34.3) | 68.8 (28.9) | − 3.688¥ | 0.0001¥ |
| Social functioning | 41.3 (21) | 65.3 (24.3) | − 4.076 | 0.0001 |
| DHI | 60.9 (24.2) | 27.6(23.9) | − 5.252 | 0.0001 |
*Paired t-test or Wilcoxon
¥Wilcoxon test
Table 5.
frequency of imbalance severity according to the DHI scores before and after treatment
| Groups | Dizziness severity before treatment (%) | Dizziness severity after treatment (%) | ||||
|---|---|---|---|---|---|---|
| Mild | Moderate | Severe | Mild | Moderate | Severe | |
| Dimenhydrinate | 10 | 46.67 | 43.33 | 53.33 | 46.67 | − |
| Betahistine | 10 | 40 | 50 | 46.67 | 53.33 | − |
| Epley maneuver | 6.67 | 50 | 43.33 | 66.67 | 20 | 13.33 |
| Total | 8.89 | 45.56 | 45.55 | 55.5 | 40 | 4.50 |
Discussion
Here, we presented the data of 90 adult patients with BPPV, a vertigo only triggered by positional changes confirmed by the Dix-Hallpike maneuver. There were more female patients (54.4%), consistent with the other studies [15–18]. The mean age of the patients was 47.9 (8.7) years. We showed an increase in the total score of SF-36 after treatment in all groups, although not statistically significant. Despite this, we indicated a significant increase in each category of scores in the Epley maneuver and betahistine groups and significant differences in each category in the dimenhydrinate group except for social activities. To our knowledge, there is no similar study comparing these treatments. In addition, we evaluated the effects of gender and age.
Comparing betahistine and dimenhydrinate groups, the dimenhydrinate group showed marginally significantly better results in terms of role limitation due to physical health problems. The Epley maneuver group had better outcomes in the categories of role limitation due to physical health problems, bodily pain, and emotional well-being scores compared to the betahistine group. Emotional well-being was improved in the Epley maneuver group compared to the others.
Dizziness caused by BPPV mainly affects the quality of life in the aspects of physical functions [18]. To resolve the symptoms, canalith repositioning maneuvers are suggested [19, 20]. A previous study showed a single-stage maneuver to be more effective than several consecutive maneuvers. However, they suggested that a possible reason for a lower cure rate in their patients might be the older age of their participants [17]. The rate of success reported for these maneuvers is above 80%. However, persistent cases with prolonged symptoms and disabilities exist [15]. In the current study, we didn’t assess the treatment success rate. However, we noticed a significant quality of life improvement after treatment.
Pereira et al. [16] studied the effects of repositioning in 21 patients with BPPV. Similar to our study, they had more female patients compared to males. They required a mean number of approximately two maneuvers to resolve the symptoms. Most patients reported physical complaints according to the DHI scores. They reported that the mean (SD) DHI score before the treatment was 48.05 (19.47), and after treatment, it reached 10.90 (16.33), which showed a significant difference. In the current study, 13% of the patients in the Epley maneuver group suffered severe dizziness based on the DHI scores. Patients who received betahistine or dimenhydrinate no longer had scores indicating moderate or severe dizziness. Another study also used SF-36 to assess the quality of life of the patients who received repositioning maneuvers and showed that after 30 days, the quality of life was improved significantly [21]. However, they included patients aged above 60 in their study.
Although repositioning procedures are efficient in resolving the acute symptoms [1], residual vertigo caused by the remaining debris in the canal may remain. Repeating the repositioning and vestibular rehabilitation is effective [22]. Studies show that up to half of the patients may experience recurrence [23].
Mir Mohammad Jalali et al. compared the effect of betahistine and dimenhydrinate on adult patients with BPPV. On logistic regression, betahistine superiority over placebo in improving the quality of life [10]. In the current study, we demonstrated that patients in the groups Epley mauver or betahistine had significantly better scores in all aspects. In the dimenhydrinate group, there were significant improvements except for social activities.
Another study randomized the patients into two groups: Epley maneuver plus betahistine, and sham maneuver. After one year, they didn’t observe any significant difference between the two groups in vertigo and positive Dix-Hallpike test. They showed that betahistine use and nystagmus shown on the Dix-Hallpike test before allocation were correlated with better results [24].
It is shown that older age is associated with a higher prevalence of the disorder. In our study, the mean age of the patients was around 50 years, considered middle-aged. In addition, advanced age is associated with a longer time needed for healing. In the current study, there were no significant differences between the two age groups, but older individuals had better social performance after receiving betahistine than younger patients. Gender seems to have no significant effect on the quality of life of patients with BPPV [25]. In the current study, male patients had better outcomes in terms of emotional well-being in the dimenhydrinate group, and in terms of role limitation due to physical health problems in the Epley maneuver group, female patients showed better results.
Wu et al. designed a clinical trial to investigate the effects of betahistine and vestibular rehabilitation exercises on residual vertigo in BPPV patients. One group will be assigned to rehabilitation programs only, one group to betahistine only, and the third group will receive both interventions [26].
It is shown that older patients have a higher rate of hospitalization due to BPPV. In addition, female patients have more emergency department visits [27]. In the current study, we didn’t observe advanced age to be associated with worse outcomes following the treatment.
Kim et al. showed that after repositioning, medications with suppressing action on the vestibular system, such as dimenhydrinate, are associated with better results. Although there was no significant difference between the groups in terms of DHI scores, they observed that in the group who received medications, there was a significantly lower number of individuals suffering residual symptoms compared to the other groups who received placebo or no medications [28].
In our study, comparing the three groups, the quality of life improved with the superiority of the Epley maneuver only in the mental health area. No study has compared different treatments in terms of the SF-36 areas.
The quality of life of the group treated with betahistine and the Epley maneuver improved in general health status, energy, physical function, physical pain, mental health, and social activities. The quality of life of the group treated with dimenhydrinate improved in all areas except social activities. So far, no similar study with dimenhydrinate and betahistine exists. Comparing the betahistine and the Epley maneuver, the quality of life after treatment in 3 areas of physical function, physical pain, and mental health was significantly improved with the superiority of the therapeutic maneuver. There was no significant difference in any areas of SF-36 and DHI comparing dimenhydrinate and Epley maneuver. However, in the field of social activities, there was an improvement shown in the Epley maneuver group, unlike dimenhydrinate. In the present study, there was a significant difference in the quality of life between dimenhydrinate and betahistine only in the physical performance area, and the dimenhydrinate group had better outcomes. Also, in the betahistine group, unlike dimenhydrinate, the social activities area improves, but in the comparison of these two treatments, no significant difference was observed in improving social activities. So far, no study has compared the effect of dimenhydrinate and betahistine.
We found a significant difference in the DHI scores before and after treatment. However, in the comparison of the three groups, no significant difference was found, but in the dimenhydrinate and betahistine groups, there were no patients with scores indicating severe dizziness. Therefore, betahistine or dimenhydrinate could be effective in severe forms of BPPV.
This study had several limitations; first, the relatively small sample size. Second, we only evaluated the patients in our city. Multi-center prospective studies with a greater sample size are needed.
Conclusion
In severe forms of BPPV, betahistine or dimenhydrinate addition to the treatment might be effective in reducing the symptoms. We showed some differences by gender in terms of the efficacy of the treatment in different areas of SF-36. Older patients had similar outcomes to younger patients. They even showed better outcomes in terms of social activities after treatment with betahistine plus therapeutic maneuver.
Appendix
Dimenhydrinate group + Epley maneuver (male and female)
| Test statistic P-value | Mean ± SD | Study groups | Variable | |
|---|---|---|---|---|
| Post-treatment | Pre-treatment | |||
|
ANCOVA P-VALUE = 0/560 |
74/5 ± 16/4 | 45/2 ± 16/7 | Female | General health perceptions |
| 77/1 ± 21/9 | 46/2 ± 20/8 | Male | ||
|
ANCOVA P-VALUE = 0/691 |
77/0 ± 15/4 | 47/2 ± 13/5 | Female | Vitality |
| 69/5 ± 13/2 | 44/0 ± 17/3 | Male | ||
|
ANCOVA P-VALUE = 0/118 |
70/7 ± 15/4 | 47/5 ± 16/1 | Female | Physical functioning |
| 70/5 ± 16/1 | 36/5 ± 14/4 | Male | ||
|
ANCOVA P-VALUE = 0/297 |
62/5 ± 19/0 | 32/5 ± 20/0 | Female | Role limitation due to physical health problems |
| 80/0 ± 28/4 | 42/5 ± 42/6 | Male | ||
|
ANCOVA P-VALUE = 0/777 |
71/5 ± 15/8 | 39/7 ± 13/4 | Female | Bodily pain |
| 69/2 ± 11/1 | 38/0 ± 20/4 | Male | ||
|
ANCOVA P-VALUE = 0/014 |
62/2 ± 18/0 | 28/2 ± 18/7 | Female | Emotional well-being |
| 81/6 ± 14/0 | 37/2 ± 23/6 | Male | ||
|
ANCOVA P-VALUE = 0/076 |
76/6 ± 30/8 | 31/6 ± 31/5 | Female | Role limitation due to emotional problems |
| 60/0 ± 37/8 | 40/0 ± 41/0 | Male | ||
|
ANCOVA P-VALUE = 0/878 |
61/6 ± 29/1 | 43/6 ± 15/0 | Female | Social functioning |
| 42/0 ± 12/8 | 56/2 ± 17/2 | Male | ||
|
ANCOVA P-VALUE = 0/450 |
31/2 ± 14/8 | 56/1 ± 18/3 | Female | DHI |
| 27/4 ± 12/7 | 67/2 ± 26/5 | Male | ||
Betahistine + Epley maneuver group (male and female)
| Test statistic P-value | Mean ± SD | Study groups | Variable | |
|---|---|---|---|---|
| Post-treatment | Pre-treatment | |||
| ANCOVA P-VALUE = 0/381 | 64/8 ± 17/1 | 42/1 ± 17/1 | Female | General health perceptions |
| 75/3 ± 10/6 | 47/5 ± 18/1 | Male | ||
| ANCOVA P-VALUE = 0/941 | 72/2 ± 15/1 | 51/7 ± 13/5 | Female | Vitality |
| 75/8 ± 16/5 | 48/3 ± 16/3 | Male | ||
| ANCOVA P-VALUE = 0/384 | 66/9 ± 16/6 | 44/4 ± 17/1 | Female | Physical functioning |
| 72/1 ± 7/8 | 53/3 ± 14/2 | Male | ||
| ANCOVA P-VALUE = 0/438 | 59/7 ± 21/2 | 41/7 ± 30/9 | Female | Role limitation due to physical health problems |
| 54/2 ± 25/7 | 31/2 ± 32/2 | Male | ||
| ANCOVA P-VALUE = 0/490 | 59/2 ± 16/0 | 39/9 ± 18/8 | Female | Bodily pain |
| 63/7 ± 15/1 | 54/0 ± 25/3 | Male | ||
| ANCOVA P-VALUE = 0/440 | 57/3 ± 16/6 | 26/3 ± 22/2 | Female | Emotional well-being |
| 50/0 ± 16/1 | 54/3 ± 18/9 | Male | ||
| ANCOVA P-VALUE = 0/321 | 51/8 ± 40/0 | 12/9 ± 20/2 | Female | Role limitation due to emotional problems |
| 52/7 ± 38/8 | 33/3 ± 37/5 | Male | ||
| ANCOVA P-VALUE = 0/564 | 62/9 ± 22/6 | 41/2 ± 12/8 | Female | Social functioning |
| 61/0 ± 23/5 | 44/0 ± 30/3 | Male | ||
| ANCOVAP-VALUE = 0/759 | 34/6 ± 16/5 | 56/0 ± 24/2 | Female | DHI |
| 31/2 ± 16/4 | 74/8 ± 23/9 | Male | ||
The Epley maneuver alone (female and male)
| Test statistic P-value | Mean ± SD | Study groups | Variable | |
|---|---|---|---|---|
| Post-treatment | Pre-treatment | |||
| ANCOVA P-VALUE = 0/846 | 89/0 ± 12/3 | 41/6 ± 13/9 | Female | General health perceptions |
| 74/7 ± 16/5 | 41/9 ± 20/5 | Male | ||
| ANCOVA P-VALUE = 0/837 | 69/5 ± 17/8 | 42/3 ± 11/0 | Female | Vitality |
| 72/6 ± 15/2 | 48/9 ± 13/0 | Male | ||
| ANCOVA P-VALUE = 0/651 | 69/5 ± 10/3 | 48/4 ± 14/0 | Female | Physical functioning |
| 65/8 ± 12/9 | 45/0 ± 15/7 | Male | ||
| ANCOVA *P-VALUE = 0/022 | 75/0 ± 22/4 | 34/1 ± 32/1 | Female | Role limitation due to physical health problems |
| 63/2 ± 31/6 | 34/2 ± 23/9 | Male | ||
| ANCOVA P-VALUE = 0/103 | 72/3 ± 16/2 | 34/3 ± 13/3 | Female | Bodily pain |
| 71/8 ± 15/1 | 35/4 ± 15/0 | Male | ||
| ANCOVA P-VALUE = 0/275 | 70/9 ± 26/5 | 22/5 ± 21/7 | Female | Emotional well-being |
| 78/1 ± 19/5 | 31/6 ± 22/0 | Male | ||
| ANCOVA P-VALUE = 0/105 | 51/5 ± 37/6 | 15/1 ± 31/1 | Female | Role limitation due to emotional problems |
| 78/9 ± 16/5 | 26/3 ± 36/1 | Male | ||
| ANCOVA P-VALUE = 0/849 | 67/3 ± 25/4 | 38/4 ± 15/5 | Female | Social functioning |
| 64/2 ± 24/3 | 43/0 ± 23/9 | Male | ||
| ANCOVA P-VALUE = 0/665 | 40/2 ± 27/5 | 62/2 ± 28/1 | Female | DHI |
| 20/3 ± 18/6 | 60/1 ± 22/4 | Male | ||
Dimenhydrinate + Epley maneuver group (age groups below and above 40)
| Test statistic P-value | Mean ± SD | Study groups | Variable | |
|---|---|---|---|---|
| Post-treatment | Pre-treatment | |||
| ANCOVA P-VALUE = 0/423 | 77/3 ± 17/8 | 49/2 ± 17/9 | 20 to 40 years | General health perceptions |
| 74/1 ± 18/6 | 43/4 ± 17/9 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/715 | 69/5 ± 12/7 | 44/5 ± 15/4 | 20 to 40 years | Vitality |
| 77/4 ± 15/7 | 47/1 ± 14/6 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/739 | 70/9 ± 14/3 | 49/1 ± 15/8 | 20 to 40 years | Physical functioning |
| 70/5 ± 16/3 | 40/8 ± 16/5 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/469 | 70/4 ± 21/8 | 29/5 ± 21/8 | 20 to 40 years | Role limitation due to physical health problems |
| 67/1 ± 25/1 | 39/5 ± 32/6 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/480 | 69/5 ± 13/9 | 36/1 ± 15/5 | 20 to 40 years | Bodily pain |
| 71/4 ± 14/7 | 40/9 ± 16/3 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/540 | 70/5 ± 20/3 | 28/7 ± 18/3 | 20 to 40 years | Emotional well-being |
| 67/6 ± 18/7 | 32/6 ± 22/0 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/368 | 72/7 ± 32/7 | 30/3 ± 27/7 | 20 to 40 years | Role limitation due to emotional problems |
| 70/2 ± 34/9 | 36/8 ± 38/3 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/993 | 52/7 ± 25/2 | 50/2 ± 20/6 | 20 to 40 years | Social functioning |
| 56/5 ± 27/7 | 46/5 ± 14/3 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/375 | 35/4 ± 14/6 | 61/1 ± 21/3 | 20 to 40 years | DHI |
| 26/7 ± 13/0 | 59/1 ± 22/3 | 40 to 60 years | ||
Betahistine + Epley maneuver group (age groups below and above 40 years)
| Test statistic P-value | Mean ± SD | Study groups | Variable | |
|---|---|---|---|---|
| Post-treatment | Pre-treatment | |||
| ANCOVA P-VALUE = 0/806 | 63/3 ± 11/7 | 42/5 ± 21/2 | 20 to 40 years | General health perceptions |
| 71/8 ± 16/6 | 45/2 ± 15/8 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/249 | 79/0 ± 13/5 | 54/5 ± 13/6 | 20 to 40 years | Vitality |
| 71/0 ± 16/0 | 48/2 ± 14/8 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/788 | 65/0 ± 16/0 | 48/0 ± 19/0 | 20 to 40 years | Physical functioning |
| 71/0 ± 12/6 | 48/0 ± 15/4 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/638 | 52/5 ± 14/2 | 42/5 ± 23/7 | 20 to 40 years | Role limitation due to physical health problems |
| 60/0 ± 26/2 | 35/0 ± 34/8 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/849 | 58/5 ± 10/4 | 36/5 ± 24/5 | 20 to 40 years | Bodily pain |
| 62/2 ± 17/7 | 50/0 ± 20/4 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/226 | 60/0 ± 19/8 | 36/4 ± 25/5 | 20 to 40 years | Emotional well-being |
| 51/6 ± 14/4 | 38/1 ± 25/3 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/359 | 56/6 ± 38/6 | 30/0 ± 29/1 | 20 to 40 years | Role limitation due to emotional problems |
| 50/0 ± 39/7 | 16/7 ± 29/6 | 40 to 60 years | ||
| ANCOVA *P-VALUE = 0/048 | 59/5 ± 24/2 | 42/5 ± 15/1 | 20 to 40 years | Social functioning |
| 63/5 ± 22/3 | 42/3 ± 24/0 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/172 | 37/4 ± 12/1 | 57/6 ± 24/7 | 20 to 40 years | DHI |
| 31/1 ± 17/9 | 66/5 ± 26/0 | 40 to 60 years | ||
The Epley maneuver alone group (age groups below and above 40 years)
| Test statistic P-value | Mean ± SD | Study groups | Variable | |
|---|---|---|---|---|
| Post-treatment | Pre-treatment | |||
| ANCOVA P-VALUE = 0/869 | 77/5 ± 20/7 | 42/9 ± 17/4 | 20 to 40 years | General health perceptions |
| 81/2 ± 14/2 | 41/2 ± 19/3 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/803 | 71/0 ± 16/8 | 48/0 ± 10/3 | 20 to 40 years | Vitality |
| 71/7 ± 16/0 | 45/7 ± 13/8 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/832 | 67/0 ± 13/4 | 50/0 ± 18/4 | 20 to 40 years | Physical functioning |
| 67/2 ± 11/6 | 44/5 ± 13/1 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/592 | 62/5 ± 31/7 | 35/0 ± 21/1 | 20 to 40 years | Role limitation due to physical health problems |
| 70/0 ± 27/6 | 33/7 ± 29/5 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/608 | 76/0 ± 14/1 | 34/2 ± 16/0 | 20 to 40 years | Bodily pain |
| 70/0 ± 15/8 | 35/4 ± 13/6 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/144 | 80/0 ± 22/5 | 30/8 ± 18/7 | 20 to 40 years | Emotional well-being |
| 73/2 ± 22/2 | 27/0 ± 23/8 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/948 | 63/3 ± 29/2 | 30/0 ± 39/9 | 20 to 40 years | Role limitation due to emotional problems |
| 71/6 ± 29/2 | 18/3 ± 31/5 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/968 | 60/0 ± 23/8 | 31/0 ± 18/0 | 20 to 40 years | Social functioning |
| 68/0 ± 24/7 | 46/5 ± 20/9 | 40 to 60 years | ||
| ANCOVA P-VALUE = 0/473 | 21/0 ± 19/2 | 55/2 ± 22/5 | 20 to 40 years | DHI |
| 30/6 ± 25/9 | 63/7 ± 25/1 | 40 to 60 years | ||
Authors' Contribution
All authors contributed the same in this manuscript.
Funding
N/A.
Declarations
Conflict of interest
The authors declare that there are no conflicts of interest.
Declaration of Generative AI and AI-Assisted Technologies in the Writing Process
The authors confirm that no Generative AI and AI-assisted technologies are used in the writing process.
Consent to Participate and Publish
Informed consent was obtained from all individual participants included in the study prior to participation and publication.
Ethical Approval
The study protocol was approved by the university. However, at the time the manuscript was done, an ethical code was not needed (ethical approval letter is sent).
Footnotes
Publisher's Note
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