Monthly Archives: December 2014

Epley maneuver for benign positional vertigo

BACKGROUND: This is an update of a Cochrane Review first published in The Cochrane Library in Issue 1, 2002 and previously updated in 2004 and 2007.Benign paroxysmal positional vertigo (BPPV) is a syndrome characterised by short-lived episodes of vertigo in association with rapid changes in head position. It is a common cause of vertigo presenting to primary care and specialist otolaryngology clinics. Current treatment approaches include rehabilitative exercises and physical manoeuvres, including the Epley manoeuvre.

OBJECTIVES: To assess the effectiveness of the Epley manoeuvre for posterior canal BPPV.

SEARCH METHODS: We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 23 January 2014.
SELECTION CRITERIA: Randomised controlled trials of the Epley manoeuvre versus placebo, no treatment or other active treatment for adults diagnosed with posterior canal BPPV (including a positive Dix-Hallpike test). The primary outcome of interest was complete resolution of vertigo symptoms. Secondary outcomes were conversion of a `positive` Dix-Hallpike test to a `negative` Dix-Hallpike test and adverse effects of treatment.

DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS: We included 11 trials in the review with a total of 745 patients.Five studies compared the efficacy of the Epley manoeuvre against a sham manoeuvre, three against other particle repositioning manoeuvres (Semont, Brandt-Daroff and Gans) and three against a control (no treatment, medication only, postural restriction). Patients were treated in hospital otolaryngology departments in eight studies and family practices in two studies. All patients were adults aged 18 to 90 years old, with a sex ratio of 1:1.5 male to female.There was a low risk of overall bias in the studies included. All studies were randomised with six applying sealed envelope or external allocation techniques. Eight of the trials blinded the assessors to the participants` treatment group and data on all outcomes for all participants were reported in eight of the 11 studies.

Complete resolution of vertigo occurred significantly more often in the Epley treatment group when compared to a sham manoeuvre or control (odds ratio (OR) 4.42, 95% confidence interval (CI) 2.62 to 7.44; five studies, 273 participants); the proportion of patients resolving increased from 21% to 56%. None of the trials comparing Epley versus other particle repositioning manoeuvres reported vertigo resolution as an outcome.

Conversion from a positive to a negative Dix-Hallpike test significantly favoured the Epley treatment group when compared to a sham manoeuvre or control (OR 9.62, 95% CI 6.0 to 15.42; eight studies, 507 participants). There was no difference when comparing the Epley with the Semont manoeuvre (two studies, 117 participants) or the Epley with the Gans manoeuvre (one study, 58 participants). In one study a single Epley treatment was more effective than a week of three times daily Brandt-Daroff exercises (OR 12.38, 95% CI 4.32 to 35.47; 81 participants).

Adverse effects were infrequently reported. There were no serious adverse effects of treatment. Rates of nausea during the repositioning manoeuvre varied from 16.7% to 32%. Some patients were unable to tolerate the manoeuvres because of cervical spine problems.

AUTHORS’ CONCLUSIONS: There is evidence that the Epley manoeuvre is a safe, effective treatment for posterior canal BPPV, based on the results of 11, mostly small, randomised controlled trials with relatively short follow-up. There is a high recurrence rate of BPPV after treatment (36%). Outcomes for Epley manoeuvre treatment are comparable to treatment with Semont and Gans manoeuvres, but superior to Brandt-Daroff exercises.

Updated prostate cancer screening guidelines from Canada

Bell N, Gorber SC, Shane A, et al. Recommendations on screening for prostate cancer with the prostate-specific antigen test.CMAJ. 2014 Nov 4;186(16):1225-1234. Epub 2014 Oct 27. (Review) PMID: 25349003


Prostate cancer is the most commonly diagnosed non–skin cancer in men and the third leading cause of cancer-related death among men in Canada. The current estimated lifetime risk of diagnosis is 14.3%, whereas the lifetime risk of death from prostate cancer is 3.6%. The prevalence of undiagnosed prostate cancer at autopsy is high and increases with age (> 40% among men aged 40–49 yr to > 70% among men aged 70–79 yr). Most cases of diagnosed prostate cancer have a good prognosis; the 10-year estimated relative survival ratio is now 95%, the highest among all cancers in men. In Canada, the age-standardized rate of death from prostate cancer rose from 1969 to 1991, followed by a decline of 37.5% from 1992 to 2009, at an average rate of 2.6% per year. In 1990, the estimated age-standardized mortality was 30 cases per 100 000, and in 2010 it was just below 20 per 100 000. However, over the same period, the number of cases and the age-standardized incidence of prostate cancer both increased. Subsequent to the introduction and adoption of prostate-specific antigen (PSA) testing, the incidence of prostate cancer increased rapidly from 1990 to a peak in 1993 and a second, less-pronounced peak in 2001. Much of the excess incidence represents overdiagnosis, that is, the detection of cancers that would not progress to cause symptoms or death. There is no conclusive evidence to determine what proportion of the decline in prostate cancer mortality is due to screening versus improved treatment, or other factors; it is likely that both screening and treatment have contributed. If PSA screening were the primary reason for the decrease in mortality, the steep increase in incidence due to early case detection associated with screening should have been followed by a sharp reduction in mortality. Instead, the reduction in prostate cancer mortality over time has been relatively steady and began too soon after the test’s introduction to be attributed mainly to PSA screening. This guideline provides recommendations on screening for prostate cancer using the PSA test with or without digital rectal examination in men in the general population. The guideline updates a prior guideline by the task force that was last published in 1994.11

Walking your dog helps you both lose weight

Owners and Pets Exercising Together: Canine Response to Veterinarian-Prescribed Physical Activity

Authors: Byers, Christopher G.; Wilson, Cindy C.; Stephens, Mark B.; Goodie, Jeffrey L.; Netting, F. Ellen; Olsen, Cara H.


Using a prospective, randomized, single-blinded clinical design, we enrolled dog owners (DOs) and their dogs presenting to a veterinary referral hospital in a two-phase trial to determine whether veterinarian-initiated counseling increases physical activity and leads to secondary health benefits for DOs and their dogs. In Phase I, self-reported health measures, height, and weight were assessed for DOs. Body condition scores (BCS) for their dogs were also determined. Owners of overweight and obese dogs (BCS > 6) were recruited for Phase II in which a baseline serum biochemical profile was obtained for DOs and dogs. Participants were randomly assigned to either a physical activity (PA) or standard care (SC) group. All DOs were provided a pedometer to determine their baseline daily step count. The PA group was counseled by a veterinarian using a standard scripted handout to encourage increased physical activity with their dogs. The veterinarian also reviewed common barriers to activity, encouraged increased levels of physical activity, and delivered a specific exercise prescription for the dog. The stated goal was for the DO to spend at least 30 minutes a day engaged in physical activity with their dog. All owners and dogs returned in three months, and biochemical and anthropometric measurements were taken again. Seventy-five DOs completed Phase I. At the completion of Phase I, 46 DOs enrolled in Phase II. Of these, 32 completed all required elements. For all participants with complete Phase I and Phase II data, there was a significant reduction in mean BCS (6.7 to 6.4; t (31) = 2.88, p = 0.007). BCS and weight decreased similarly in both groups. Glucose increased over time in the SC group but not in the PA group, yielding a significant mean group difference at followup (113 mg/dL vs. 103 mg/dL; p = 0.01). Based on our findings, both groups increased physical activity and BCS decreased significantly, and veterinarian-based counseling may have impacted these changes. No other significant biochemical changes were noted.