Carrillo Muñoz et al. BMC Family Practice (2019) 20:156 https://doi.org/10.1186/s12875-019-1035-3 RESEARCH ARTICLE Open Access Disability perceived by primary care patients with posterior canal benign paroxysmal positional vertigo Ricard Carrillo Muñoz1, José Luis Ballve Moreno2,3* , Iván Villar Balboa1, Yolanda Rando Matos2, Oriol Cunillera Puertolas4, Jesús Almeda Ortega3,4, Estrella Rodero Perez2, Xavier Monteverde Curto2, Carles Rubio Ripollès2, Noemí Moreno Farres2, Austria Matos Mendez2, Jean Carlos Gomez Nova2, Marta Bardina Santos2, Johan Josué Villarreal Miñano2, Diana Lizzeth Pacheco Erazo2, Anabella María Hernández Sánchez5 and Grupo de estudio del vértigo en atención primaria Florida Abstract Background: Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo. Little is known on how posterior canal BPPV affects health-related quality of life in patients diagnosed and treated at primary care facilities or on whether patients with subjective and objective disease perceive the effects differently. This study was designed to describe how patients diagnosed with posterior canal BPPV in primary care perceive disability. Methods: Cross-sectional descriptive study performed at two urban primary care centers. Participants were patients aged 18 years or older with suspected posterior canal BPPV recruited for baseline evaluation in a clinical trial on the effectiveness of the Epley maneuver in primary care. The recruitment period was from November 2012 to January 2015. Perceived disability was evaluated using the Dizziness Handicap Inventory – Screening version (DHI-S). Other variables collected were age and sex, a history or diagnosis of anxiety or depression, treatment with antidepressants and/or anxiolytics, and results of the Dix-Hallpike (DH) test, which was considered positive when it triggered vertigo with or without nystagmus and negative when it triggered neither. Results: The DH test was positive in 134 patients, 40.30% of whom had objective BPPV (vertigo with nystagmus). The median age of the patients was 52 years (interquartile range [IQR], 39.00–68.50 years) and 76.1% were women. The median total score on the DHI-S was 16 out of 40 (IQR, 8.00–22.00). Scores were higher (greater perceived disability) in women (p < 0.001) and patients with subjective BPPV (vertigo without nystagmus) (p = 0.033). The items perceived as causing the greatest disability were feeling depressed (67.1%) and worsening of the condition on turning over in bed (88%). Conclusions: Patients diagnosed with posterior canal BPPV in primary care perceive their condition as a disability according to DHI-S scores, with higher levels of disability reported by women and patients with subjective BPPV. Feelings of depression and turning over in bed were associated with the greatest perceived difficulties. Trial registration: ClinicalTrials.gov Identifier: NCT01969513. Retrospectively registered. First Posted: October 25, 2013. https://clinicaltrials.gov/ct2/show/NCT01969513 Keywords: Benign paroxysmal positional vertigo, Primary care, Quality of life * Correspondence: ballvejl@gmail.com 2 Equip d’Atenció Primària Florida Nord, Institut Català de la Salut, Hospitalet de Llobregat, Barcelona, Spain 3 Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, Barcelona, Spain Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Carrillo Muñoz et al. BMC Family Practice (2019) 20:156 Page 2 of 11 Background Little is known, however, on how BPPV affects HRQOL Benign paroxysmal positional vertigo (BPPV) is the most in patients diagnosed and treated at primary care facilities common cause of vertigo. It has an annual incidence of or on whether patients with subjective and objective dis- between 10.7 and 140 cases per 100,000 inhabitants [1] ease perceive the effects differently. Moreover, very few and a lifetime prevalence of 2.4% [2]. Between 60 and studies have used the DHI-S to evaluate self-perceived 90% of cases involve the posterior canal [3]. Posterior disability in patients with BPPV, even though it is one canal BPPV can be diagnosed in primary care with a tar- of the simplest psychometric tests available [19]. As geted history, a basic physical examination, [4]. This test indicated in the recently updated Clinical Practice is considered positive when it triggers both vertigo and Guideline on BPPV, research on the impact of BPPV on nystagmus (objective BPPV), although some authors HRQOL must continue [1]. consider that a diagnosis can also be made when it trig- The aim of this study was to describe self-perceived gers vertigo only (subjective BPPV) [5]. Subjective BPPV disability using the DHI-S in patients with BPPV diag- accounts for approximately 11.5 to 48% of all cases of nosed in primary care prior to treatment with the Epley BPPV [6]. Studies comparing patients with subjective maneuver. and objective BPPV have not found differences in terms of demographics or clinical characteristics [7] Methods but little is known on how the two entities affect the We performed a cross-sectional descriptive study of two quality of life of patients seen in primary care primary care centers with 26 general practitioners (GPs) practices. serving an approximate population of 38,305 people in Patients with BPPV often have physical, functional, and L’Hospitalet de Llobregat (Barcelona, Spain). The GPs even emotional disabilities that can affect their family or received 2 h of training from an otolaryngologist in the social lives [8]. They are at an increased risk of falls [9], adequate management of patients with vertigo and the particularly if they are elderly [10], and may also experi- correct application and interpretation of the DH test. ence psychological symptoms that can affect their daily ac- Patients aged 18 years or older with a suspected diagnosis tivities [11]. The resulting distress can have a negative of BPPV recruited for a baseline visit within a randomized impact on health-related quality of life (HRQOL). clinical trial designed to demonstrate the effectiveness of Being exposed to emotional stress increases the odds the Epley maneuver for treating posterior canal BPPV in of getting an episode of Menière’s disease during the primary care were eligible for inclusion. The protocol of following hours in diagnosed patients [12, 13], and anx- the trial has been published elsewhere. [21] iety it is also a risk factor for poor prognosis in primary Patients with a positive DH test were included and care patients presenting with dizziness [13]. Dizziness those whose results suggested involvement of a portion can also be brought about by stressful events in the pre- of the semicircular canal other than the posterior canal vious year [14], and patients with BPPV have been found or vertigo of central origin were excluded and referred to score higher in depression evaluation tests [15]. to an otolaryngologist. The rest of the inclusion and ex- The impact of BPPV on HRQOL can be assessed using clusion criteria can be consulted in the trial protocol a variety of standardized questionnaires. The most widely [21] and flow chart (Fig. 1). Nineteen of the patients ini- used questionnaire is the Dizziness Handicap inventory tially recruited were subsequently excluded because they (DHI) [16]. The original version has 25 items with three met the criteria for probable vestibular migraine. This possible answers (yes, sometimes, and no) but two shorter analysis was performed retrospectively in light of in- versions have been designed: the DHI-SF (short form), creasing evidence on the high prevalence of vestibular which has 13 items each with two possible answers [17], migraine and its overlapping symptoms with BPPV [22]. and the DHI-S (screening version), which has 10 items Patients were consecutively recruited by the participat- with the same three answers as the original questionnaire ing GPs and referred for baseline evaluation within a [18]. The DHI-S is strongly correlated with the original maximum of 10 days by one of six GPs in the clinical DHI (r = 0.86) and has high internal consistency (test-re- trial team. All patients were being treated with betahis- test r = 0.95). It is a self-assessment questionnaire that can tine 8 mg 8- hourly at the initial visit, along with the be completed in about 4 to 5 min and is therefore suitable instruction of P.R.N. use (up to 3 times a day) until im- for use in settings with large volumes of patients, such as provement of symptoms. The recruitment period was primary care. It has also been validated for use in Spanish between November 2012 and January 2015. [19]. A review comparing the DHI, the DHI-SF, and the All the patients had their history taken and under- DHI-S concluded that the DHI-S was the best scale to use went a full physical examination and electronic chart because of its shorter length and close correlation with the review. Disability was assessed using the total DHI-S original questionnaire [20]. The authors also discouraged score as the dependent (outcome) variable. The DHI- the use of domain scores in favor of total score. S has 10 items that are graded with a score of 0 (for Carrillo Muñoz et al. BMC Family Practice (2019) 20:156 Page 3 of 11 Fig. 1 Flowchart of the study. DH = Dix-Hallpike the answer “no”), 2 (“sometimes”), or 4 (“yes”). The mini- We therefore studied 134 patients (40.6%). Of these, 54 mum score thus is 0 (no disability) while the maximum (40.30%) had objective BPPV (vertigo with nystagmus). score is 40 (worst possible self-perceived disability). The in- The median age for the sample was 52 years (IQR, dependent variables were age, age group (< 65 y vs ≥65 y), 39.00–68.50) and 76.12% were women. The prevalence sex, DH test result (vertigo only vs vertigo with nystag- of anxiety and depression and the use of benzodiaze- mus); a previous history of anxiety and/or depression; and pines and antidepressants are shown in Table 1. treatment with antidepressants or anxiolytics. Table 2 summarizes the responses to the DHI-S. The The distribution of DHI-S responses was studied items for which the fewest patients reported difficulties by describing the number of yes, no, and sometimes were item 6 (“Because of your problem, do you restrict answers to the 10 items for the sample as a whole your travel for business or holidays?”) and item 9 (“Be- and stratified by age, sex, presence of nystagmus, cause of your problem, have you ever been embarrassed and diagnosis of anxiety and/or depression. Total in front of others”?), with over 70% of respondents say- scores were described using medians and interquar- ing they did not experience problems in this area. By tile range (IQR) for the full sample and for sub- contrast, the areas that caused the greatest difficulties groups stratified by age, sex, nystagmus, and anxiety were items 5 (Does turning over in bed worsen your and/or depression (stratified by sex). problem?) and 1 (Because of your problem, do you feel The sample was described using median and IQR for depressed?), with 74.6% of patients answering “yes” or age and absolute and relative frequencies for presence of “sometimes” when asked if turning over in bed increased binary variables and for each of the categories in the cat- their problem and 67.1% answering “yes” or “sometimes” egorical variables. when asked if their problem made them feel depressed. Finally, the Fisher exact test was used to compare the The median DHI-S total score was 16 (IQR, 8.00– distribution of DHI-S responses according to the study 22.00) (Table 1). Statistically significant higher scores variables. The distribution of total scores by subgroup (greater perceived disability) were detected in women was compared using the Wilcoxon Rank Sum test. Stat- and in patients without nystagmus in the DH test (p < istical significance was set at a p value of 0.05 or less. 0.001 and p = 0.033, respectively). No bivariate associ- ation was detected for age or for a diagnosis of anxiety Results or depression stratified by sex with DHI score (Table 3). Of the 330 patients with suspected BPPV, 165 were ex- Responses to DHI-S items according to age, sex, objective cluded at the baseline visit (mostly because of a negative and subjective BPPV, and a history of anxiety and/or depres- DH test) and 19 were excluded retrospectively as they sion are shown in Tables 4 to 7. The distribution of re- met the criteria for probable vestibular migraine (Fig. 1). sponses was very similar in the two age groups (Table 4). Carrillo Muñoz et al. BMC Family Practice (2019) 20:156 Page 4 of 11 Table 1 Characteristics of primary care patients with Table 2 Distribution of responses to the Dizziness Handicap symptoms of benign paroxysmal positional vertigo and a Inventory – Screening version for primary care patients with positive Dix-Hallpike test benign paroxysmal positional vertigo No. of patients No Sometimes Yes Age, median (IQR), y 134 52.00 [38.25–68.00] 1. Because of your problem, 44 (32.8%) 35 (26.1%) 55 (41.0%) do you feel depressed? Age group 134 2. Does stepping off the sidewalk 63 (47.0%) 24 (17.9%) 47 (35.1%) < 65 y 92 (68.66%) worsen your problem? ≥ 65 y 42 (31.34%) 3. Because of your problem, is it 68 (50.7%) 26 (19.4%) 40 (29.9%) Sex 134 difficult to concentrate? Male 32 (23.88%) 4. Because of your problem, is it 76 (56.7%) 20 (14.9%) 38 (28.4%) difficult for you to walk around Female 102 (76.12%) the house in the dark? Nystagmus 134 5. Does turning over in bed 16 (11.9%) 18 (13.4%) 100 (74.6%) No (S-BPPV) 80 (59.70%) worsen your problem? Yes (O-BPPV) 54 (40.30%) 6. Because of your problem, 95 (70.9%) 21 (15.7%) 18 (13.4%) do you restrict your travel for Comorbidities business or holidays? Anxiety 130* 33 (25.38%) 7. Does your problem 54 (40.3%) 33 (24.6%) 47 (35.1%) Depression 130* 30 (23.08%) affect your job or household responsibilities? Drugs 8. Because of your problem, 85 (63.4%) 20 (14.9%) 29 (21.6%) Benzodiazepines 134 24 (17.91%) are you afraid to leave your Antidepressants 134 27 (20.15%) home without having someone with you? Health-related quality of life 9. Because of your problem, 96 (71.6%) 26 (19.4%) 12 (9.0%) Total DHI-S score 134 16.00 [8.00–22.00] have you ever been embarrassed in front of others? *Data missing for 4 patients Abbreviations: DHI-S Dizziness Handicap Inventory Screening version, IQR 10. Because of your problem, 83 (61.9%) 20 (14.9%) 31 (23.1%) interquartile range, O-BPPV objective benign paroxysmal positional vertigo, S- have you reduced your social BPPV subjective benign paroxysmal positional vertigo activities such as going out to dinner, going to movies, or On comparing men and women (Table 5) several significant dancing at parties? differences were detected. Women reported significantly Although we used the Spanish version of the questionnaire, we have included the original English questionnaire for comprehension purposes. Data shown as greater difficulties in stepping off the sidewalk (p = 0.015), number and percentage of respondents concentrating (p = 0.029), working and fulfilling their house- hold responsibilities (p < 0.001), and leaving their home [1] and is also similar to ages described for patients in alone (p = 0.024). specialist settings [19, 23]. In primary care settings, me- Patients with subjective BPPV (without nystagmus) dian ages of 54.9 [24] and 61 years [25] have been reported greater perceived disability in stepping off the reported. sidewalk (p = 0.038), traveling (p = 0.029), and partici- There were over three times more women than men in pating in social activities (p = 0.012) (Table 6). No sta- our series (female to male ratio, 3.19). Women are often tistically significant differences were observed between more numerous than men in studies of BPPV [2, 26–28], patients with and without a history of anxiety and/or perhaps because the disease is more prevalent in women depression for responses to the question about feeling [2, 29, 30], including those in the 18–34 bracket [31]. depressed (p = 0.217), although the former reported Anxiety and depression were common and over 20% of greater disability in relation to work and household re- the patients studied were being treated with benzodiaze- sponsibilities (p = 0.042) and feelings of embarrassment pines and/or antidepressants. These data are consistent (p = 0.035) (Table 7). with previous reports of high rates of affective disorders, such as anxiety, depression, demoralization, phobia, and Discussion somatization, in patients with BPPV [31, 32]. Kahraman This study shows that disability assessed by the DHI-S is et al. [33] recently showed that patients with BPPV may significantly affected by posterior canal BPPV, particu- experience intense anxiety and/or panic disorder at the larly in women and in patients with subjective disease initial visit that may or may not improve with treatment. (vertigo but not nystagmus in the DH test). Attempts to explain why stressful events in the preceding The median age of the patients in this series, 52 years, year can trigger BPPV include the hypothesis that the in- is within the peak range for onset of BPPV (50–70 years) crease in stress-related hormones triggered by the Carrillo Muñoz et al. BMC Family Practice (2019) 20:156 Page 5 of 11 Table 3 Total median score on the Dizziness Handicap been identified as an independent predictor of BPPV di- Inventory – Screening version by subgroups of primary care agnosed with the DH test (odds ratio, 4.36; 95% CI, patients with symptoms of benign paroxysmal positional 1.18–16.13) [36]. The second item with the highest vertigo number of “yes” responses was item 1 (“Because of your Median [IQR] P value* problem, do you feel depressed?). The median total Age group 0.187 score on the DHI-S, 16, was slightly lower than scores [< 65 y) (n = 92) 16.0 [10.0–24.0] reported for specialist settings (mean, SD: 19.79 ± 10.,14) [≥65 y) (n = 42) 12.0 [8.0–20.0] [19]; (17.19 ± 9.06) [37] although a similar score has also been reported (16,4 ± 10.71) [20]. It was also lower than Sex < 0.001 the mean scores of 17.72 (SD = 9.98) and 22.67 (12.55) Men (n = 32) 10.0 [6.0–14.0] reported for patients with unilateral and bilateral Women (n = 102) 16.0 [10.5–24.0] Ménière disease, respectively [26, 38]. Presence of nystagmus 0.033 Women perceived greater disability as a result of No (S-BPPV) (n = 80) 16.0 [10.0–24.0] BPPV than men. This finding is consistent with reports Yes (O-BPPV) (n = 54) 12.0 [8.0–18.0] by Petri et al. [26] for patients with peripheral unilateral vestibular diseases, including BPPV. We were surprised History of anxiety and/or depression in men 0.347 to see that patients with subjective posterior canal BPPV No (n = 207) 11.0 [7.5–14.0] reported greater levels of perceived disability. This ob- Yes (n = 6) 8.0 [6.0–10.0] servation, however, should be interpreted with caution History of anxiety and/or depression in women 0.648 because, as mentioned in the introduction, significant No (n = 59) 16.0 [10.0–24.0] differences between patients with subjective and object- Yes (n = 41) 16.0 [12.0–24.0] ive BPPV have not been found for demographics, clinical * Calculated using the Wilcoxon test (statistical significance: p ≤ 0.05) characteristics, or status before and after repositioning Abbreviations: IQR interquartile range, O-BPPV objective benign paroxysmal procedures [7, 39]. Just one study in Argentina reported positional vertigo, S-BPPV subjective benign paroxysmal positional vertigo higher scores (greater disability) in the physical subscale Statistically significant results are presented in bold of the original DHI for patients with nystagmus and in abnormal activation of the hypothalamus–pituitary–ad- the emotional subscale for patients without nystagmus. renal axis could interfere with inner ear blood flow and There were no significant differences, however, in total disrupt the calcium balance in the endolymph, critically scores [40]. affecting otoconial homeostasis [9, 34]. That said, higher The higher proportion of women in our study could depression scores in patients with BPPV have been attrib- be the result of inclusion bias, but it could also reflect uted to the impact of symptoms on patients’ lives [10]. It the fact that posterior canal BPPV is more common in is therefore perfectly plausible that anxiety and depression women and that in Spain, adult women are more likely are both a cause and consequence of BPPV. In our sample, to visit primary care facilities than men [41]. we found no differences in total scores on the DHI-S be- We acknowledge some limitations of this study. The tween patients with or without a history of anxiety and/or proportion of patients with subjective BPPV in our series depression, even after adjusting for sex. In brief, thus, a was also higher than that reported in the literature, pos- previous diagnosis of anxiety and/or depression was not sibly because neither Frenzel goggles nor videonystagmo- associated with worse disability results. We did, however, graphy were used to detect nystagmus in the DH test to detect a considerable percentage of patients claiming that create a more realistic primary care diagnostic environ- they felt depressed because of BPPV. Indeed, the fact that ment. However, in mild cases, nystagmus can be difficult over 40% of patients reported that they sometimes felt de- to observe, especially given the vertical nystagmus compo- pressed because of their vertigo adds to the doubts nent suppression that can occur in room light. Therefore, expressed in the recent update of the clinical BPPV guide- the study’s results of greater perceived disability in pa- lines about the adequacy of the term “benign” in benign tients with Subjective-BPPV can be challenged. Given the paroxysmal positional vertigo in reference to the disease’s complexity of interpreting nystagmus during the Dix- impact on quality of life, daily activities, and risk of falls Hallpike test, the training received may have been too [1]. short. A longer workshop could improve the diagnostic Increased vertigo due to turning over in bed was by far and therapeutic accuracy of GPs, especially to detect and the greatest problem reported by patients in the DHI-S. interpret nystagmus correctly in DHT. This is not surprising as this movement is known to Results must be interpreted in light of the descriptive trigger or increase episodes of vertigo and has a 90% nature of the paper. Significant tests were performed specificity for the diagnosis of BPPV, although its sensi- independently with no adjustment for multiple hypotheses tivity is low [35]. Onset on turning over in bed has also testing. In fact, given the large amount of contrasts, Carrillo Muñoz et al. BMC Family Practice (2019) 20:156 Page 6 of 11 Table 4 Distribution of responses to the Dizziness Handicap Inventory – Screening version for primary care patients with benign paroxysmal positional vertigo according to age group (< 65 vs ≥ 65 y) (< 65 y) (n = 92) [≥65–96 y) (n = 42) P value 1. Because of your problem, do you feel depressed? 0.588 No 28 (30.4%) 16 (38.1%) Sometimes 26 (28.3%) 9 (21.4%) Yes 38 (41.3%) 17 (40.5%) 2. Does stepping off the sidewalk worsen your problem? 0.909 No 42 (45.7%) 21 (50.0%) Sometimes 17 (18.5%) 7 (16.7%) Yes 33 (35.9%) 14 (33.3%) 3. Because of your problem, is it difficult to concentrate? 0.108 No 41 (44.6%) 27 (64.3%) Sometimes 19 (20.7%) 7 (16.7%) Yes 32 (34.8%) 8 (19.0%) 4. Because of your problem, is it difficult for you to walk around the house in the dark? 0.719 No 50 (54.3%) 26 (61.9%) Sometimes 14 (15.2%) 6 (14.3%) Yes 28 (30.4%) 10 (23.8%) 5. Does turning over in bed worsen your problem? 0.712 No 11 (12.0%) 5 (11.9%) Sometimes 14 (15.2%) 4 (9.5%) Yes 67 (72.8%) 33 (78.6%) 6. Because of your problem, do you restrict your travel for business or holidays? 0.863 No 64 (69.6%) 31 (73.8%) Sometimes 15 (16.3%) 6 (14.3%) Yes 13 (14,1%) 5 (11,9%) 7. Does your problem affect your job or household responsibilities? 0.733 No 35 (38.0%) 19 (45.2%) Sometimes 23 (25.0%) 10 (23.8%) Yes 34 (37.0%) 13 (31.0%) 8. Because of your problem, are you afraid to leave your home without having someone with you? 0.234 No 55 (59.8%) 30 (71.4%) Sometimes 17 (18.5%) 3 (7.1%) Yes 20 (21.7%) 9 (21.4%) 9. Because of your problem, have you ever been embarrassed in front of others? 0.332 No 63 (68.5%) 33 (78.6%) Sometimes 21 (22.8%) 5 (11.9%) Yes 8 (8.7%) 4 (9.5%) 10. Because of your problem, have you reduced your social activities such as going out to dinner, going to movies, or dancing at parties? 0.545 No 54 (58.7%) 29 (69.0%) Sometimes 15 (16.3%) 5 (11.9%) Yes 23 (25.0%) 8 (19.0%) Although we used the Spanish version of the questionnaire, we have included the original English questionnaire for comprehension purposes. Data shown as number and percentage of respondents Statistically significant results are presented in bold Carrillo Muñoz et al. BMC Family Practice (2019) 20:156 Page 7 of 11 Table 5 Distribution of responses to the Dizziness Handicap Inventory – Screening version for 134 primary care patients with benign paroxysmal positional vertigo according to sex Men (n=32) Women (n=102) P value 1. Because of your problem, do you feel depressed? 0.161 No 15 (46.9%) 29 (28.4%) Sometimes 7 (21.9%) 28 (27.5%) Yes 10 (31.2%) 45 (44.1%) 2. Does stepping off the sidewalk worsen your problem? 0.015 No 21 (65.6%) 42 (41.2%) Sometimes 6 (18.8%) 18 (17.6%) Yes 5 (15.6%) 42 (41.2%) 3. Because of your problem, is it difficult to concentrate? 0.029 No 23 (71.9%) 45 (44.1%) Sometimes 3 (9.4%) 23 (22.5%) Yes 6 (18.8%) 34 (33.3%) 4. Because of your problem, is it difficult for you to walk around the house in the dark? 0.827 No 20 (62.5%) 56 (54.9%) Sometimes 4 (12.5%) 16 (15.7%) Yes 8 (25.0%) 30 (29.4%) 5. Does turning over in bed worsen your problem? 0.137 No 7 (21.9%) 9 (8.8%) Sometimes 3 (9.4%) 15 (14.7%) Yes 22 (68.8%) 78 (76.5%) 6. Because of your problem, do you restrict your travel for business or holidays? 0.154 No 27 (84.4%) 68 (66.7%) Sometimes 2 (6.2%) 19 (18.6%) Yes 3 (9.4%) 15 (14.7%) 7. Does your problem affect your job or household responsibilities? 0.001 No 21 (65.6%) 33 (32.4%) Sometimes 7 (21.9%) 26 (25.5%) Yes 4 (12.5%) 43 (42.2%) 8. Because of your problem, are you afraid to leave your home without having someone with you? 0.024 No 26 (81.2%) 59 (57.8%) Sometimes 4 (12.5%) 16 (15.7%) Yes 2 (6.2%) 27 (26.5%) 9. Because of your problem, have you ever been embarrassed in front of others? 0.485 No 24 (75.0%) 72 (70.6%) Sometimes 7 (21.9%) 19 (18.6%) Yes 1 (3.1%) 11 (10.8%) 10. Because of your problem, have you reduced your social activities such as going out to dinner, going to movies, or dancing at parties? 0.453 No 23 (71.9%) 60 (58.8%) Sometimes 3 (9.4%) 17 (16.7%) Yes 6 (18.8%) 25 (24.5%) Although we used the Spanish version of the questionnaire, we have included the original English questionnaire for comprehension purposes. Data shown as number and percentage of respondents Statistically significant results are presented in bold Carrillo Muñoz et al. BMC Family Practice (2019) 20:156 Page 8 of 11 Table 6 Distribution of responses to the Dizziness Handicap Inventory – Screening version for primary care patients with symptoms of benign paroxysmal positional vertigo according to presence of nystagmus S-BPPV (n = 80) O-BPPV (n = 54) P value 1. Because of your problem, do you feel depressed? 0.485 No 23 (28.7%) 21 (38.9%) Sometimes 22 (27.5%) 13 (24.1%) Yes 35 (43.8%) 20 (37.0%) 2. Does stepping off the sidewalk worsen your problem? 0.038 No 32 (40.0%) 31 (57.4%) Sometimes 13 (16.2%) 11 (20.4%) Yes 35 (43.8%) 12 (22.2%) 3. Because of your problem, is it difficult to concentrate? 0.630 No 40 (50.0%) 28 (51.9%) Sometimes 14 (17.5%) 12 (22.2%) Yes 26 (32.5%) 14 (25.9%) 4. Because of your problem, is it difficult for you to walk around the house in the dark? 0.278 No 42 (52.5%) 34 (63.0%) Sometimes 15 (18.8%) 5 (9.3%) Yes 23 (28.7%) 15 (27.8%) 5. Does turning over in bed worsen your problem? 0.815 No 10 (12.5%) 6 (11.1%) Sometimes 12 (15.0%) 6 (11.1%) Yes 58 (72.5%) 42 (77.8%) 6. Because of your problem, do you restrict your travel for business or holidays? 0.029 No 50 (62.5%) 45 (83.3%) Sometimes 17 (21.2%) 4 (7.4%) Yes 13 (16.2%) 5 (9.3%) 7. Does your problem affect your job or household responsibilities? 0.070 No 31 (38.8%) 23 (42.6%) Sometimes 25 (31.2%) 8 (14.8%) Yes 24 (30.0%) 23 (42.6%) 8. Because of your problem, are you afraid to leave your home without having someone with you? 0.668 No 48 (60.0%) 37 (68.5%) Sometimes 13 (16.2%) 7 (13.0%) Yes 19 (23.8%) 10 (18.5%) 9. Because of your problem, have you ever been embarrassed in front of others? 0.461 No 56 (70.0%) 40 (74.1%) Sometimes 18 (22.5%) 8 (14.8%) Yes 6 (7.5%) 6 (11.1%) 10. Because of your problem, have you reduced your social activities such as going out to dinner, going to movies, or dancing at parties? 0.012 No 41 (51.2%) 42 (77.8%) Sometimes 15 (18.8%) 5 (9.3%) Yes 24 (30.0%) 7 (13.0%) Although we used the Spanish version of the questionnaire, we have included the original English questionnaire for comprehension purposes. Data shown as number and percentage of respondents Abbreviations: O-BPPV objective benign paroxysmal positional vertigo, S-BPPV subjective benign paroxysmal positional vertigo Statistically significant results are presented in bold Carrillo Muñoz et al. BMC Family Practice (2019) 20:156 Page 9 of 11 Table 7 Distribution of responses to the Dizziness Handicap Inventory – Screening version for primary care patients with symptoms of benign paroxysmal positional vertigo according to a history of anxiety and/or depression No anxiety or depression (n = 83) Anxiety and/or depression (n = 47) P value 1. Because of your problem, do you feel depressed? 0.217 No 28 (33.7%) 15 (31.9%) Sometimes 26 (31.3%) 9 (19.1%) Yes 29 (34.9%) 23 (48.9%) 2. Does stepping off the sidewalk worsen your problem? 0.660 No 36 (43.4%) 24 (51.1%) Sometimes 17 (20.5%) 7 (14.9%) Yes 30 (36.1%) 16 (34.0%) 3. Because of your problem, is it difficult to concentrate? 0.444 No 46 (55.4%) 21 (44.7%) Sometimes 15 (18.1%) 9 (19.1%) Yes 22 (26.5%) 17 (36.2%) 4. Because of your problem, is it difficult for you to walk around the house in the dark? 0.532 No 50 (60.2%) 24 (51.1%) Sometimes 12 (14.5%) 7 (14.9%) Yes 21 (25.3%) 16 (34.0%) 5. Does turning over in bed worsen your problem? 0.295 No 8 (9.6%) 8 (17.0%) Sometimes 10 (12.0%) 8 (17.0%) Yes 65 (78.3%) 31 (66.0%) 6. Because of your problem, do you restrict your travel for business or holidays? 1.000 No 59 (71.1%) 34 (72.3%) Sometimes 13 (15.7%) 7 (14.9%) Yes 11 (13.3%) 6 (12.8%) 7. Does your problem affect your job or household responsibilities? 0.042 No 37 (44.6%) 15 (31.9%) Sometimes 24 (28.9%) 9 (19.1%) Yes 22 (26.5%) 23 (48.9%) 8. Because of your problem, are you afraid to leave your home without having someone with you? 0.327 No 55 (66.3%) 26 (55.3%) Sometimes 13 (15.7%) 7 (14.9%) Yes 15 (18.1%) 14 (29.8%) 9. Because of your problem, have you ever been embarrassed in front of others? 0.035 No 58 (69.9%) 36 (76.6%) Sometimes 20 (24.1%) 4 (8.5%) Yes 5 (6.0%) 7 (14.9%) 10. Because of your problem, have you reduced your social activities such as going out to dinner, going to movies, or dancing at parties? 0.205 No 52 (62.7%) 29 (61.7%) Sometimes 9 (10.8%) 10 (21.3%) Yes 22 (26.5%) 8 (17.0%) Although we used the Spanish version of the questionnaire, we have included the original English questionnaire for comprehension purposes. Data shown as number and percentage of respondents Statistically significant results are presented in bold Carrillo Muñoz et al. BMC Family Practice (2019) 20:156 Page 10 of 11 significance corrections would have led to only two RCM,IVB,YRM, ERP, XMC, CRR, NMF, AMM, JCGN, MBS, JJVM, DLPE, OCP, JAO, tests finding statistically significant differences: DHI AMHS, CMC and RAL. All authors read and approved the final manuscript. Total Score and the 7th Item by sex. Studies designed to Funding specifically test each of the “independently significant” The project received a research grant from the Carlos III Institute of Health, Ministry contrast would be required to confirm statistical of Economy and Competitiveness (Spain), awarded on the 2013 call under the Health Strategy Action 2013–2016, within the National Research Program oriented significance. to Societal Challenges, within the Technical, Scientific and Innovation Research National Plan 2013–2016, with reference PI13/01396, co-funded with European Union ERDF funds (European Regional Development Fund). Conclusions It was also funded by the cycle XIV (2013) research grant from the Spanish BPPV had a negative impact on the quality of life of pa- Primary Care Network (REAP). The Jordi Gol Institute for Research in Primary care (IDIAP Jordi Gol): Pre- tients, particularly women and patients with subjective doctoral grant 2014/005E. disease (vertigo without nystagmus). The greatest per- The Jordi Gol Institute for research in Primary Care (IDIAP Jordi Gol) contributed ceived difficulties were related to feelings of depression financially to the translation of this article into English. and turning over in bed. The results of this study help to Availability of data and materials confirm the importance of early diagnosis and effective All data generated or analyzed during this study are included in this treatment in patients with BPPV. Both diagnosis and published article [and its supplementary information files]. treatment are possible in primary care. More research is Ethics approval and consent to participate needed on how BPPV affects the quality of life of pa- The protocol has been approved by the CEIC (Clinical Research Ethics tients attending primary care and on how repositioning Committee) of IDIAP Jordi Gol, with the number P12/69. The written consent maneuvers can help to alleviate these effects. It would states that the study follows the law contained in the Helsinki Declaration and in Title I, Article 12 of the Royal Spanish Decree 561/1993 from 16 April also be interesting to explore differences between sub- 1993. Data will be treated according to the organic law that regulates the jective and objective BPPV, particularly in terms of per- confidentiality of computerized data (Organic law 5/1992). ceived disability, and to conduct more studies using the Consent for publication shorter, simpler DHI-S scale. Not applicable. Abbreviations Competing interests BPPV: Benign paroxysmal positional vertigo; DH test: Dix Hallpike test; The authors declare that they have no competing interests. DHI: Dizziness Handicap inventory; DHI-S : Dizziness Handicap inventory screening version; DHI-SF: Dizziness Handicap inventory short form; Author details GPs: General practitioners; HRQOL: Health-related quality of life; ICS: Catalan 1 Equip d’Atenció Primària Florida Sud, Institut Català de la Salut, Hospitalet Institute of Health; IDIAP: Institute for Research in Primary Care; de Llobregat, Barcelona, Spain. 2Equip d’Atenció Primària Florida Nord, IQR: Interquartile Range; O-BPPV: Objective benign paroxysmal positional Institut Català de la Salut, Hospitalet de Llobregat, Barcelona, Spain. vertigo; PC: Primary Care; S-BPPV: Subjective benign paroxysmal positional 3 Universitat Autònoma de Barcelona, Bellaterra, Cerdanyola del Vallès, vertigo; USR: Research Support Unit Barcelona, Spain. 4Unitat de Suport a la Recerca Costa de Ponent, Institut Universitari d’Investigació en Atenció Primària Jordi Gol (IDIAPJGol), Cornellà, Acknowledgements Barcelona, Spain. 5Hospital General de Hospitalet, Hospitalet de Llobregat, The authors gratefully acknowledge the technical and scientific assistance Barcelona, Spain. provided by the Primary Healthcare Research Unit of Costa de Ponent Primary Healthcare University Research Institute IDIAP-Jordi Gol. We also thank Neus Received: 27 July 2018 Accepted: 14 October 2019 Profitós and Celsa Fernández who were responsible for safeguarding the randomization sequence list. Finally, we thank all the participants of the Grupo de estudio del vértigo en atención primaria Florida: José Luis Ballvé Moreno, Yo- References landa Rando Matos, Estrella Rodero Pérez, Xavier Monteverde Curtó, Carles 1. Bhattacharyya N, Gubbels SP, Schwartz SR, Edlow JA, El-Kashlan H, Fife T, Rubio Ripollès, Noemí Moreno Farrés, Jean Carlos Gómez Nova, Johan Josué et al. Clinical practice guideline: benign paroxysmal positional Vertigo Villarreal Miñano, Diana Lizzeth Pacheco Erazo, Raquel Adroer Martori, Anna (update) executive summary. Otolaryngol neck Surg off J am Acad Aguilar Margalejo, Olga Lucia Arias Agudelo, Silvia Cañadas Crespo, Laura Otolaryngol-head neck Surg. 2017;156(3):403–16 Available in: http://www. 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