Abstract
To evaluate the effects of the modified Epley maneuver during Posterior Canal Benign Paroxysmal Positional Vertigo (BPPV) on patients’ anxiety and comfort levels. The study, organized as a prospective, worked with 72 patients who were diagnosed with Posterior Canal BPPV through Dix-Hallpike maneuver. The data for the study was collected through Descriptive Characteristics Form, General Comfort Questionnaire Short Form, and Beck Anxiety Inventory. It was found that that 63.9% of the patients experienced average-level anxiety before the implementation of the Epley maneuver and received a total of 3.07 ± .37 (1–6) from the General Comfort Questionnaire. Before applying the modified Epley maneuver and I and IV When the score changes after the week were examined, it was determined that there was a statistically significant difference in all scale scores, as comfort levels increased, anxiety levels decreased. Anxiety was identified as the most important predictor of patients’ comfort level before and after the implementation of the modified Epley maneuver. In light of these findings, it can be said that modified Epley maneuver can safely be used to increase the comfort of patients with Posterior Canal BPPV. Considering that patients with BPPV can consult to emergency rooms, family clinics along with polyclinics, it is recommended to organize regular trainings on BPPV and the implementation of the Epley maneuver. It is believed that evaluation of BPPV patients for their anxiety and offer support when needed is important for the prognosis and patients’ comfort.
Keywords: Benign paroxysmal positional vertigo, Epley maneuver, Comfort, Anxiety
Introduction
Benign Paroxysmal Positional Vertigo (BPPV) is the most commonly seen type of peripheral vertigo and is generally associated with the symptoms of nausea and vomiting [1]. From BPPV cases, in 60–90% of them the posterior canal is affected, frequent spontaneous remission and relapse is exhibited. The annual recurrence rate is approximately 15%. BPPV prevalence is between 10.7 and 64.0 in 100.000 and its lifelong prevalence is 2.4% [2–5].
The vertigo attacks in BPPV occur in position such as lying down on the bed, turning in the bed, hyperextending the head as it looks above. Most patients complain about loss of balance and unbalance walking during paroxysmal vertigo attacks. During BPPV, patient undergo a discomforting process and patients, comfort can be affected negatively. Comfort is at the center of patient experience and ensuring patient comfort became a main component of patient-centered care framework [6]. Comfort is a dynamic and multi-dimensional concept. For example, Kolcaba defines comfort as being relieved, resting easy and overcoming problems [7]. Many factors may affect patients’ comfort. Studies highlight that anxiety negatively affects patients’ comfort levels [6, 8]. Anxiety is a common case in BPPV and while in many studies, a dual relationship between anxiety and vertigo are stated, anxiety is also reported as a risk factor for bad prognosis in patients of first stage who consult with dizziness [9].
Canalith repositioning maneuvers are commonly used, effective and safe method used in the treatment of BPPV patients [10–12]. The aim of these maneuvers is to move the canaliths within the semicircular canal in appropriate angles so they drop to the utricle and end dizziness attacks by preventing them from causing endolymph movements [10, 13]. Epley’s modified particle reposition maneuver is the most frequently used maneuver in the treatment and its success rate reaches up to 90% [10, 14]. The efficiency of the Epley maneuver in comparison to other maneuvers and medication treatments is reported in many studies [10, 15–19]. Also, in some studies, it was found that Epley maneuver has a positive and significant effect on the emotional, physical and functional aspects of the lives of BPPV patients [15, 19, 20] and reduce patients’ anxiety levels [21, 22]. However, to the best of authors’ knowledge, the effects of Epley maneuver on patients’ comfort levels is yet to be studied. Yet, patient experience is a fundamental indicator of health quality, especially patient-centered care. Thus, the aim of this study is to evaluate the effects of the modified Epley maneuver implementation on the anxiety and comfort levels of patients diagnosed with Posterior Canal BPPV.
Method
Study Design and Sample
The study which was designed as a prospective, involved 72 patients who consulted the Ear Nose Throat polyclinic of a state hospital with dizziness between -September 2020; were diagnosed with Posterior Canal BPPV through Dix-Hallpike maneuver; were above the age of 18 and agreed to participate in the study. Post-hoc analysis was conducted to calculate the strength of the study on the basis of a similar study [21] and the strength of the study was found as 97.3%. Patients with the following characteristics were excluded from the study: those who did not wish to get the Epley maneuver after Dix-Hallpike Maneuver; patients with cervical and lumber pathological conditions that prevent Epley maneuver; with systematic diseases; history of psychiatric medication use; cervical hernia and those with neurological complaints excluding other otologic symptoms; hearing loss; and patients with anomalies in their hemogram, biochemistry and hormone tests.
Data Collection
The instruments were implemented during the 15 min rest period to patients who were diagnosed with BPPV after Dix-Hallpike maneuvers, accepted to receive Epley maneuver and volunteered to participate in the study. Then, information on the Epley maneuver was provided by the doctor from the research team and the maneuver was implemented. All patients who are implemented the modified Epley maneuver were called in for check-up on the first and the fourth weeks. Dix-Hallpike maneuver was repeated to patients one week after Epley implementation for control purposes and those with positive Dix-Hallpike were repeated the modified Epley maneuver by the same doctor. The instruments were implemented again to the patients on the I and IV weeks.
Instruments
Descriptive Characteristics Form
The forms prepared by the researchers on the basis of current literature includes questions that evaluate patients’ demographic characteristics.
General Comfort Questionnaire Short Form
It was developed by Kolcaba in 2006. It consists of the comfort, relief (9 items), ease (9 items), and transcendence (10 items) sub-dimensions. The minimum score of I represents low comfort and the maximum score of 6 indicated high level of comfort. The adaptation into Turkish study of the General Comfort Questionnaire Short Form was conducted in 2018 by Çıtlık-Sarıçam et al. [23]. The overall Cronbach Alpha coefficient of the scale during the adaptation study was found as 0.82, and in this study, it was calculated as 0.84.
Beck Anxiety Inventory (BAI)
The inventory was developed by Beck et al. [24] and Turkish adaptation was done by Ulusoy. Each item receives a score between 0 and 3 and high scores from the inventory indicate high levels of anxiety. The individual’s scores between 0 and 17 represent low, between 18 and 24 represent average, and 25 and above represent high levels of anxiety. The Cronbach Alpha coefficient of the inventory was reported as 0.92 [25] and in this study, it was calculated as 0.91.
Dix-Hallpike maneuver
The maneuver defined by Dix and Hallpike in the year 1952 is used for the diagnosis of BPPV. For this maneuver, the patient in the sitting position is turned 45° to the direction of the right ear which will be hung down and the posterior canal is brought to the sagittal level of the body. Then, in quick movements, the patient is laid down in a way that the patient’s head is held with two hands and is hung down about 30 degrees from the edge of the examination table and kept in this position for 30 s. In this position, what is typical for dizziness or posterior canal BPPV, is to observe whether there is torsional nystagmus that hit the side or top and if there is, it is waited until the symptoms are gone. Later on, the patient is sit up. The same procedure is applied to the other side after 30 s and the sick side is found so, that side is accepted as BPPV. Patients with no symptoms or nystagmus are accepted as negative [10, 26].
Modified Epley maneuver
The method was named as Epley Maneuver as it was first coined by Epley in 1992. With the first Epley maneuver, patients were required to be sedated before the maneuver, use mastoid vibrator during the maneuver and make patients stand upright for 48 h after the maneuver. Later on, this maneuver was modified by Parnes and Price Jones. The modified Epley maneuver is launched when the patient is in the sitting position with his head facing the opposite on the examination table. Patient’s head is supported by the person implementing the maneuver. Patient’s head is turned 45 degrees to the side of the lesion and is hung down from the examination table by giving extension position at 30 degrees. Then, while keeping the extension position of the head, the head is turned 90 degrees to the side of the lesion. Later on, the patient is turned 90 degrees to the opposite direction of the lesion with his head and the body and, while facing down, the head is positioned in a way that a 135 degree angle is formed from the facing up position. At the end of the procedure, the patient is sit up with 45 degrees to the opposite of the lesion. Lastly, the head is brought to flexion. There is a waiting period of 30 s in all positions or in case of nystagmus formation, it is waited until nystagmus and the patient’s symptoms are resolved [10, 26].
Data Analysis
The statistical analysis of the data collected from the study was done by using SPSS 21.0 Statistical Package software. The data was evaluated through descriptive statistics (frequency, percentage, mean, standard deviation). Friedman test was implemented to determine the difference between the scale scores changing through time before and on the I and IV weeks after the implementation of the modified Epley maneuver. Pearson Correlation Test was used to determine the direction of the relation of the comfort level with the other instruments; Linear Regression analysis was conducted to determine the level of relationship of the predictors affecting the comfort level. The results were evaluated between the 95% confidence range and statistical significance at p < 0.05 rate.
Research Ethics
Faculty of Medicine Clinical Research Ethics Board approval of a state university (Decision No: KAEK-361) and informed consent was received from all voluntary participants were received prior to launching the study.
Findings
Descriptive Characteristics
The mean age of BPPV patients in the study was found as 53.73 ± 13.74 (28–81) and 61.1% of the patients were above the age of 50. From the participating patients, 59.7% are female, 95.8% are married, 63.9% are working, all of them have social security, 37.5% have equal income and expense rate, 38.9% are high school graduates, 65.3% have no chronic disease, and in 51.4% of them, the vertigo is on the left side. It was seen that 80.5% of the patients’ symptoms improved in the I week after modified Epley maneuver implementation (Table 1).
Table 1.
Patients’ characteristics
| n = 72 | % | ||
|---|---|---|---|
|
Age 53.73 ± 13.74 (28–81) |
50 ≤ | 28 | 38.9 |
| 50 > | 44 | 61.1 | |
| Gender | Female | 43 | 59.7 |
| Male | 29 | 40.3 | |
| Marital status | Married | 69 | 95.8 |
| Single | 3 | 4.2 | |
| Employment status | Working | 46 | 63.9 |
| Not working | 26 | 36.1 | |
| Social security | Yes | 72 | 100.0 |
| Economic status | Income < expense | 21 | 29.2 |
| Income = expense | 27 | 37.5 | |
| Income > expense | 24 | 33.3 | |
| Educational level | Literate | 8 | 11.1 |
| Primary education | 26 | 36.1 | |
| Secondary education | 28 | 38.9 | |
| Higher education | 10 | 13.9 | |
| Chronic disease | Yes | 25 | 34.7 |
| No | 47 | 65.3 | |
| Vertigo direction | Right | 35 | 48.6 |
| Left | 37 | 51.4 | |
| I. Week after Epley Maneuver application | symptoms improved | 58 | 80.5 |
| symptoms not improved | 14 | 19.5 | |
| IV. Week after Epley Maneuver application | symptoms improved | 68 | 95.5 |
| symptoms not improved | 4 | 5.5 | |
Anxiety and Comfort Scores Before and I and IV weeks after the Implementation of Modified Epley Maneuver
It was found that prior to the implementation of modified Epley maneuver, 63.9% of the BPPV patients experience average level of anxiety (Table 2); while, patients received a mean score of 22.00 ± 4.402 from Beck Anxiety Inventory; gathered a total score of 3.07 ± 0.37 from the General Comfort Questionnaire Short Form, 2.86 ± 0.450 points from the relief sub-dimension, 3.03 ± 0.358 points from the ease sub-dimension, 3.30 ± 0.535 points from the transcendence sub-dimension (Table 3).
Table 2.
Anxiety levels before and I and IV weeks after the implementation of modified Epley Maneuver
| Before implementation of modified Epley Maneuver | I. week after the implementation of modified Epley Maneuver | IV. week after the implementation of modified Epley Maneuver | χ2 | p | ||
|---|---|---|---|---|---|---|
| n (%) | n (%) | n (%) | ||||
| Beck ansiyete total | Low anxiety | 13 (18.1) | 58 (80.6Ç) | 64 (88.9) | 84.740 | 0.000 |
| Moderate anxiety | 46 (63.9) | 11 (15.3) | 1 (1.4) | |||
| High anxiety | 13 (18.1) | 3 (4.2) | 2 (2.8) | |||
Table 3.
Anxiety and comfort scores before and I and IV weeks after the ımplementation of modified Epley Maneuver
| Before implementation of modified Epley Maneuver X ± SD | I. week after the implementation of modified Epley Maneuver X ± SD | IV. week after the implementation of modified Epley Maneuver X ± SD | χ2 | p | ||
|---|---|---|---|---|---|---|
| Beck anxiety | Inventory | 22.00 ± 4.402 | 11.72 ± 6.857 | 8.39 ± 5.335 | 107.558 | .000 |
| GCQ | Relief | 2.86 ± .450 | 3.36 ± .356 | 3.87 ± .420 | 49.000 | .000 |
| Ease | 3.03 ± .358 | 3.18 ± .396 | 3.18 ± .351 | 9.256 | .010 | |
| Transcendence | 3.30 ± .535 | 3.87 ± .545 | 3.84 ± .524 | 59.788 | .000 | |
| GCQ-total | 3.07 ± .377 | 3.49 ± .339 | 3.51 ± .371 | 76.383 | .000 | |
GCQ general comfort questionnaire short form
When the score changes of BPPV patients’ scores from the instruments before the implementation of the modified Epley maneuver and I and IV week scores after the implementation are reviewed, a statistically significant different was observed in the scores of all instruments; and it was found that while comfort levels increased, patients’ anxiety levels decreased (Table 3).
The Relationship between the Anxiety and Comfort Scores before and I and IV Weeks after the Implementation of Modified Epley Maneuver
A negative correlational relation was determined between the Beck Anxiety Inventory before the implementation of the modified Epley maneuver, I, IV weeks after the implementation with the GCQ scores. A medium-level relation between the relief and ease comfort levels of patients’ GCQ before the Epley maneuver implementation and Beck anxiety levels; high relationship between GCQ total and transcendence sub-dimension; high relationship between GCQ total with all sub-dimension and anxiety in the I week after the implementation; low relationship with GCQ’s ease sub-dimension at the 4 week after the implementation; and a medium relationship between GCQ’s other sub-dimensions and total score have found (Table 4).
Table 4.
The relationship between the anxiety and comfort scores before and I and IV Weeks after the ımplementation of modified Epley Maneuver
| Before implementation | I. week after implementation | IV. week after implementation | |||
|---|---|---|---|---|---|
| anxiety | anxiety | anxiety | |||
| Before Implementation of modified Epley Maneuver | Relief | r | −.470 | ||
| p | .000 | ||||
| Ease | r | −.476 | |||
| p | .000 | ||||
| Transcendence | r | −.518 | |||
| p | .000 | ||||
| GCQ Total | r | −.634 | |||
| p | .000 | ||||
| I. week after the implementation of modified Epley Maneuver | Relief | r | −.798 | ||
| p | −.000 | ||||
| Ease | r | −.616 | |||
| p | .000 | ||||
| Transcendence | r | −.751 | |||
| p | .000 | ||||
| GCQ Total | r | −.866 | |||
| p | .000 | ||||
| IV. week after the implementation of modified Epley Maneuver | Relief | r | −.543 | ||
| p | .000 | ||||
| Ease | r | −.307 | |||
| p | .009 | ||||
| Transcendence | r | −.572 | |||
| p | .000 | ||||
| GCQ Total | r | −.594 | |||
| p | .000 | ||||
GCQ general comfort questionnaire short form
The Investigation of the Comfort Level Predictors through Stepwise Multiple Linear Regression Model
Stepwise Multiple Linear Regression analysis was used to evaluate the variables determined with statistically significant difference in the single-variable analyses and Beck anxiety score in the prediction of patients’ comfort levels. The best model in the GCQ-Total score was found at the 2nd step before the implementation of the maneuver; at the 3rd step in the I. week after the implementation; and at the I st step in the IV week after the implementation (Table 4). The Durbin-Watson value ensured the validity of the model for GCQ-Total (DI. interview = 1.610, DII. interview = 1.746, DIII. interview = 1.120). Tolerance and VIF values showed that there is no equity of variables.
It was also determined that a one-unit increase in the standard deviation of Beck anxiety decreases standards deviation of GCQ-Total by 0.575 before the implementation of the modified Epley maneuver. Also, a one-unit increase in the unemployed characteristic from the descriptive information decreases the standard deviation of GCQ-Total by 0.223 (Table 5).
Table 5.
The investigation of the comfort level predictors through stepwise multiple linear regression model
| R | R2 | Adjusted R2 | Change statistics standard error of estimation | Change in R2 | Change in F | Sig. of change in F | Durbin–Watson | ||
|---|---|---|---|---|---|---|---|---|---|
| Before implementation | 1 | .634 | .402 | .394 | .264 | .402 | 47.104 | .000 | 1.610 |
| 2 | .670 | .449 | .433 | .255 | .046 | 5.813 | .019 | ||
| Model 2 | Unstandardized coefficients | Standardized coefficients | Collinearity statistics | ||||||
| B | Std. Error | Beta | t | Sig | Tolerance | VIF | |||
| Constant | 2.611 | .175 | 14.892 | .000 | |||||
| anxiety I | −.044 | .007 | −.575 | −6.205 | .000 | .930 | 1.075 | ||
|
Employment status (Not Working) |
−.157 | .065 | −.223 | −2.411 | .019 | .930 | 1.075 | ||
| I. week after implementation | Model | R | R2 | Adjusted R2 | Change statistics standard error of estimation | Change R2 | Change in F | Sig. of change in F | Durbin–Watson |
|---|---|---|---|---|---|---|---|---|---|
| 1 | .866 | .749 | .746 | .190 | .749 | 209.232 | .000 | 1.746 | |
| Model 3 | Unstandardized coefficients | Standardized coefficients | Collinearity statistics | ||||||
| B | Std. Error | Beta | t | Sig | Tolerance | VIF | |||
| (Constant) | 2.234 | .109 | 20.428 | .000 | |||||
| Anxiety2 | −.046 | .003 | −.846 | −14.887 | .000 | .976 | 1.025 | ||
| Economic status (Income < expense) | .131 | .047 | .159 | 2.785 | .007 | .970 | 1.031 | ||
| Marital status (Married)) | .262 | .108 | .140 | 2.423 | .018 | .947 | 1.056 |
| IV. week after implementation | Model | R | R2 | Adjusted R2 | Change statistics standard error of estimation | Change in R2 | Change in F | Sig. of change in F | Durbin–Watson |
|---|---|---|---|---|---|---|---|---|---|
| 1 | .594 | .353 | .344 | .300 | .353 | 38.181 | .000 | 1.120 | |
| Model 1 | Unstandardized coefficients | Standardized coefficients | Collinearity statistics | ||||||
| B | Std. Error | Beta | t | Sig | Tolerance | VIF | |||
| (Constant) | 2.725 | .066 | 41.114 | .000 | |||||
| Anxiety3 | −.041 | .007 | −.594 | −6.179 | .000 | 1.00 | 1.00 | ||
A one-unit increase in the standard deviation of Beck anxiety results in the decrease of GCQ standard deviation by 0.846 in the I. week after the implementation of the modified Epley maneuver. From the descriptive information, in case of income perceiver lower than expenses an increase of 0.159 is observed, and in cases of being married, compared to being single, an increase of 0.140 in observed in the standard deviation of GCQ-Total (Table 5).
It was found that one unit increase in the Beck anxiety standard deviation decreases GCQ-Total standard deviation by 0.594 at the 4 after the implementation of the modified Epley maneuver (Table 5).
Discussion
As comfort is seen as a significant disease outcome, it is an important quality indicator in health care systems [6]. Hence, in recent years, comfort in surgical and chronic diseases became a concept receiving high interest and curiosity. In this study, the effects of the modified Epley maneuver, as the most frequently used method in posterior BPPV treatment, on patient comfort and anxiety are studied for the first time. It is believed that this study would be beneficial in terms of raising awareness in health professionals regarding the implementation of the modified Epley maneuver and its importance for patients.
It was shown that BPPV patients experience anxiety due to reasons such as falling down, having another attack, and the unknown cause of the disease [1, 27, 28]. On the other hand, some studies reported that patients with anxiety disorders experience increase in vestibular dysfunction incidents and so, vestibular dysfunction is accepted as one of the pathogenesis for BPPV [22, 29, 30]. In another group of studies argue that vestibular vertigo might trigger anxiety symptoms through the neuronal channels in the partially shared parabrachial nuclei [31, 32]. In short, studies indicate that the relationship between vertigo and anxiety can be two-way and frequently occur together. In this study, it was seen that more than half of the patients had medium-level anxiety before the implementation of the modified Epley maneuver. In this regard, it is important for health professionals to be aware of the anxiety patients’ experience, evaluate and observe it, and intervene when necessary.
Considering the maximum score patients can receive from the comfort scale, it is understood that BPPV patients’ comfort levels were affected prior to the Epley maneuver. According to the comfort theory, relief is the situation felt when the individual’s comfort needs are started to be met; ease is the condition of peace, tranquility and sense of ease; and transcendence is explained as individuals overcoming the pain or problems [33]. The lowest score patients received from the comfort questionnaire is from the relief sub-dimension. Noting that patients experience discomforting symptoms such as dizziness and nausea accompanying it, it is surprising that they received low scores from the relief sub-dimension. The review of relevant literature revealed no studies investigating the comfort levels of BPPV patients. However, in studies, quality of life, which can indirectly affect comfort was found low in BPPV patients [4, 16, 20, 27].
Anxiety levels of the patients decreased significantly in the I and IV weeks after the implementation of the modified Epley maneuver. The limited number of studies also found that anxiety levels of patients with Posterior Canal BPPV decreased after implementing the Epley maneuver [21, 34]. Although a significant decrease in noted in the anxiety levels of the patients and almost all patients had no symptoms in the 4 week, it was observed that more than half of the patients still experienced mild levels of anxiety. Considering the relationship between anxiety and vertigo, patients worry on the question of whether they might experience relapses. However, the study was ended at the end of the first month, so the patients were not followed-up any further.
Patients’ comfort levels significantly increased at the I and IV weeks following the implementation of the Epley maneuver. While the lowest score patients received from the comfort questionnaire prior to the Epley maneuver implementation is from the relief sub-dimensions; it became the source of the highest scores at the IV week. This implies the recovering, comfort-increasing effect of Epley maneuver on the symptoms experienced by the patients. The sub-dimension with the lowest scores after the Epley maneuver implementation is the ease sub-dimension. This can be due to fact that more than half of the patients were experiencing anxiety at the IV week. Although the overall mean score of the patients from the comfort instrument increased after the Epley maneuver implementation, it was still found to be at medium-level. When the comfort level predictors before and after the Epley maneuver implementation is examined through Linear Regression analysis, anxiety level was found as the most important predictor. Considering that vestibular disorders may cause psychiatric disorders [31, 32], psychiatric disorders may also cause dizziness [22, 29, 30], patients who undergo epley maneuver should be evaluated in terms of anxiety even if symptoms improve, and a multidisciplinary approach should be followed when necessary.
This study has certain limitations. Lack of control group is a major limitation of the study. Another limitation is that while short-term results of patients after the modified Epley maneuver are evaluated, the long-term results are yet to the studied. It is recommended to replicate the same study with a control group by having long-term observations.
Conclusion
It is reported that in addition to high levels of recovery the implementation of the modified Epley maneuver to BPPV patients also increases patients’ comfort levels and reduce their anxiety levels. Although recovery was observed in the symptoms of almost all patients following the implementation of Epley maneuver, it was notes that more than half of them experienced mild levels of anxiety. Anxiety before and after the maneuver was determined as the most important predictor of comfort. In light of these findings, it can be said that modified Epley maneuver can safely be used to increase the comfort of patients with Posterior Canal BPPV. Considering that patients with BPPV can consult to emergency rooms, family clinics along with ENT polyclinics, it is recommended to organize regular trainings on BPPV and the implementation of the Epley maneuver. It is believed that evaluation of BPPV patients for their anxiety and offer support when needed is important for the prognosis and patients’ comfort.
Acknowledgements
We here with declare that the manuscript is not submitted to any other journal for review at present and that a professional has reviewed its language. Each author listed on the manuscript has seen and approved the submission of this version of the manuscript and takes full responsibility for the manuscript.
Declarations
Conflict of interest
The authors declare that there is no conflict of interest that involves the authors of the manuscript.
Ethics Approval
The ethics board approval for the study was collected from Akdeniz University Clinical Research Ethics Board (Decision No: KAEK-361). Patients’ written and oral consent was collected after informing them.
Footnotes
Publisher's Note
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Contributor Information
Murat Kar, Email: drmuratkar@gmail.com.
İlknur Özkan, Email: ilknurozkan@akdeniz.edu.tr.
Seçil Taylan, Email: seciltaylan@akdeniz.edu.tr.
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