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What Doctors Don't Tell You, hepatitis E, vertigo

Duration:
28 minutes
First broadcast:
Tuesday 02 October 2012

The latest addition to the burgeoning ranks of health magazines on the newsagent's shelves is called What Doctors Don't Tell You. The headlines on the front of this month's edition promise to help you sunbathe your diabetes away, end your child's wheezing without drugs, reverse bone loss for good, and avoid hysterectomy by changing your diet. Lynne McTaggart who edits the magazine with her husband responds to the views of Inside Health's resident GP, Dr Margaret McCartney.

The commonest cause of hepatitis in the UK isn't A,B or even C - it's Hepatitis E. Although it may not have the profile of the better known strains it is causing more than its fair share of problems. Dr Harry Dalton who's a consultant gastroenterologist at The Royal Cornwall Hospital is a senior lecturer at the European Centre for Environment and Human Health and a world authority on Hepatitis E. He says we still don't fully understand what the long term effects of hepatitis E may be, particularly on the brain and nervous system.

A listener contacted Inside Health about unpleasant dizziness that happens when she turns over in bed or straightens up after bending down. She wanted to know whether it was likely to be low blood pressure, or a problem with her ears. Dr Mike Jeffreys, a Consultant physician in the Department of Healthcare for Older People at the Royal Devon and Exeter Hospital explains how benign paroxysmal positional vertigo, or BPPV could be behind her symptoms. And how it can be effectively treated with a simple series of movements to the head called the Epley manoeuvre.

  • Programme Transcript - Inside Health

    Downloaded from www.bbc.co.uk/radio4
    THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT. BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.


    INSIDE HEALTH

    TX: 02.10.12 2100-2130

    PRESENTER: MARK PORTER

    PRODUCER: PAULA MCGRATH


    Porter
    Hello and welcome to Inside Health - in today's programme: Viral hepatitis - you will have probably heard of hepatitis A, B or C, you're unlikely to be that familiar with D, but I bet you didn't even know there was a hepatitis E. Well there is - and it's now the most common cause of hepatitis in the UK.

    Dalton
    The received wisdom for many years about this condition is that it was a backpackers' disease, a disease that you picked up when travelling in an underdeveloped country. And there's a paradigm shift now, we realise this is not just a disease of developing countries, it's right here in the UK and the rest of Europe.

    Porter
    And vertigo - why pills don't work for one of the most common causes of dizziness, but the Epley manoeuvre - a simple series of movements of the head - often does. And if you have access to YouTube you can teach yourself how to do it.

    But first, the latest addition to the burgeoning ranks of health magazines - only this one takes a rather different approach to the likes of Men's Health and Top Sante. The cover of this month's edition of What Doctors Don't Tell You promises to help you sunbathe your diabetes away, end your child's wheezing without drugs, reverse bone loss for good, and avoid hysterectomy by changing your diet. Lynne McTaggart edits the magazine with her husband. So Lynne, who's this magazine aimed at?

    McTaggart
    It's really aimed at intelligent, primarily, women between 35 and 55, the caretakers, who have to make some decisions about their healthcare for their family. Although we - I like to call it a girly magazine with bite because it's providing a lot of evidence based information about what works and doesn't work in both conventional and alternative medicine.

    Porter
    Now you've had a website and a newsletter for some time and I presume you see there's a hole in the market because people aren't getting this sort of information already do you feel?

    McTaggart
    Yeah and they're getting it less and less, the kind of critical stuff that used to come out when we were first starting, which was 23 years ago.

    Porter
    Looking at this edition - October's - I'm left - maybe I'm being oversensitive but it does feel anti-doctor.

    McTaggart
    We're not anti-doctor, despite our title - What Doctors Don't Tell You - I'm anti the over-reliance on pharmaceutical drugs now and procedures that haven't properly been tested.

    Porter
    Well let me pick you up on that because there are some pretty extravagant claims that you make on the cover - I know that that's just to catch people's eye, the story's a little more complicated than that but who researchers and writes these articles and what level of evidence do you demand to support claims? I mean, for instance, such as the one saying you can sunbathe your diabetes away?

    McTaggart
    Well actually that was a government report about the importance of sunbathing, that's how we first got on to the story but if you actually look at the story you'll see there are tons of medical references to that and every story in this, even though the magazine is written in a very consumery way. Who do we require writes this? People who are experienced journalists. We also have a team of sub-editors who know how to research medical literature, who are backing up and checking every single claim and reference made.

    Porter
    I can understand you wanting doctors like me to be more cynical, more sceptical, how critical are you about the people who are funding your publication in terms of adverts, I mean this month's edition carries adverts for instance for an electrical device that suggests it can be used to treat everything from allergies to osteoporosis or a company - and I quote: "... that will teach you to harness quantum physics to increase your performance."? Now if you're talking about evidence based it's very difficult to provide evidence for that surely?

    McTaggart
    Well I think some of those have - I mean we do vet our ads, there are plenty I've turned down, advertising is a very small part of our income, we've always been completely reliant on subscribers and I have signs all over my desk that say Not For Sale.

    Porter
    Okay, well GP Margaret McCartney's been reviewing this month's edition of What Doctors Don't Tell You for Inside Health, Margaret what did you make of it?

    McCartney
    I mean I'm absolutely astounded that Lynne thinks this is an evidence based publication, it's anything but. The problem with evidence is that sometimes it'll tell you things that you would rather not know and a lot of the time medicine does do harm, it doesn't do any good, that's why doctors and scientists are duty bound to put their research findings out there and to stop doing things that cause harm. But what we shouldn't do is just abandon the medicine and scientific method and go straight for alternative medicine with no good evidence that that works either.

    Porter
    What did you like - did you like anything about the magazine?

    McCartney
    Well there was a couple of things that I think that they were getting close to correct, although I would still pick them up on some details, for example they mention that there's a problem with over-diagnosis and over-treatment of thyroid cancer, now they're saying the magazine's called What Doctors Don't Tell You, in fact it was doctors that found that out, it's doctors that published it and it's doctors that put that out for peer review, so to kind of imagine that this is something that's been kept back from the public is just nonsense.

    McTaggart
    I notice in your blog, and I'm actually quite a fan of a lot of what you write, because you're writing all the time about the problems with pharmaceutical evidence and how biased it is and how patients and doctors have to work together. The problem is ....

    McCartney
    ... but the way to do that Lynne is not to produce a publication full of rubbish, which is what your publication essentially is.

    McTaggart
    ...Margaret, Margaret our studies are actually from...

    McCartney
    No they're not.

    McTaggart
    ... medical literature.

    McCartney
    Well let's have a look at some of the things you've got in your magazine. For example, popular sunscreens cause skin cancer - now that was actually a study that was not actually published, it's not been published anywhere yet, that looked at lung cancer cells in a scientific experiment on the bench, it was not a human study and yet the conclusions were actually this is a first step, we can draw no firm conclusions, further research must be needed and you've actually put your headline - popular sunscreens cause skin cancer - which is absolute rubbish.

    McTaggart
    Margaret, I think that's a real misrepresentation of what we have in our article. We have always talked about promising research, research in the lab, research in test tubes, research on animals - we indicated it's preliminary; we're very even-handed, we try to say what works and what doesn't in both conventional and alternative medicine, that's been our stance for 23 years.

    McCartney
    Do you not feel slightly worried, Lynne, about one of your articles in your magazine claiming that CIN3, which can be a precursor to cervical cancer, can be treated with a chiropractor, a nutrition, herbal tinctures, homeopathy, green tea, organic food and hydrogen peroxide to be taken orally, which is bleach? Does that not concern you?

    McTaggart
    Well it certainly can be - it certainly worked for this woman. I - the article... excuse me...

    McCartney
    ...scientific method, and that does not - that does not move forward the interests of any women on this planet to..... such a non-scientific approach.

    McTaggart
    ...you're misrepresenting - you're misrepresenting the article of course because it was a personal story, it was simply a case study but this month is all about the problems of the jab that's being given for cervical cancer.

    Porter
    Well let me pick you up on that, I've got both of you here. First of all you've done a big piece on Gardasil and the quote is that it's the most dangerous vaccine in the world and having read the whole article it's obvious that you're not very impressed with the contribution that it's making. First of all, can I ask you Margaret what you felt about reading about that article?

    McCartney
    I thought it was ridiculously alarmist, I thought it was loose with the facts, I thought it didn't explain any of the science behind the launch of a new vaccine and how it should be monitored and rolled out in the UK or the USA. I thought it was likely to put people off having the vaccine for reasons that were nothing to do with the facts about it. So I was extremely concerned to read this basically because I don't think women will be making an informed choice about having the vaccine, I think we're getting facts that were alarmist and frankly wrong.

    Porter
    Lynne, in this case Margaret thinks you've skewed - skewed the data.

    McTaggart
    Okay, I am in the most - in most of that article, which was written by me, actually mirroring the position of Diane Harper who actually invented the vaccine. I am simply quoting the American experience, the American experience demonstrates on government studies that this is the vaccine with the most side effects for this teenage group. I'm also talking about India which rejected this vaccine after being given it free because of so many side effects and deaths. I have a 15 year old daughter and like every other mum around the country I want to make an informed choice, I can only do that if I'm given the full story.

    Porter
    Okay, so one of the things that you mention in the article is that the introduction here in the UK would only save 40 lives a year - where did that figure come from?

    McTaggart
    It came from Merck's own data because the problem is the vaccine doesn't cover every kind of HPV - Human Papilloma Virus - it only covers four and it showed in its own studies that were done post-marketing, post-launch, that it only covers a certain percentage of those lesions.

    McCartney
    In your article you say your doctor and your school nurse are not likely to tell you about the hundred plus American girls who suddenly died after receiving an HPV vaccine - but we know that all data that's taken and collected was looked at by the FDA, they went back and they went very carefully back to every single adverse incident that was shown or there was anyone suspicious of and they did not find a link. It's alarmist, Lynne, to say that your daughter might die of this vaccine and not provide any evidence whatsoever that that might be the case.

    McTaggart
    Well that's rubbish Margaret because...

    Porter
    No to be fair - to be fair Lynne that's not rubbish, the suggestion in your article, whether you meant it or not, was that the vaccine caused those hundred deaths.

    McTaggart
    The real point of what doctors don't tell you is there is a conspiracy of silence and it's growing and there is a problem with conventional medicine, it's not the carpenter I have truck with it's his tools. And we are going to continue to over-burden the NHS with a lot of treatments that are less than good unless we open this debate and we all realise that we have to work together to look at what works and we need conventional medicine to open its mind to other potential treatments.

    Porter
    I personally do not have a problem with that and I'm sure Margaret doesn't but I mean equally at the other end of the spectrum we don't want a conspiracy of quackery essentially and it's very important that if alternatives are being put forward that they have some sort of science behind them, Margaret would you agree with that?

    McCartney
    Oh more than agree, I'm increasingly horrified, Lynne, to hear you sort of say that you think that somehow medicine is a conspiracy of silence, I mean look at the Cochrane collaboration for example, look at the doctors that are out there trying their best to publish things, get them out there for full open access, the journal editors of the world that are coming together to say we must make sure that everyone gets to read everything. There's a huge amount of doctors out there who want to make treatments better for their patients and want to work with patients to do that but that does not mean throwing out the scientific method, that doesn't not mean embracing all kinds of weird quackery waste of time nonsense that just puts us back 20 or 30 years. I have to...

    McTaggart
    Yes I agree with you Margaret, I agree with you...

    McCartney
    ... but you must not throw out the scientific method because otherwise you do active harm to people.

    Porter
    Margaret McCartney, Lynne McTaggart we're not going to settle this debate today on Inside Health, it's going to rumble on for some time but thank you very much for your views, I'll let listeners make their own minds up. But for the sake of balance, I approached the manufacturer of Gardasil - Sanofi Pasteur MSD - about the article and received a long and detailed reply, but here a couple of points made by the spokesman:

    First, the statement that Gardasil is the most dangerous vaccine in the world is not reflective, he says, of the statements on the US Food and Drug Administration and the Centres for Disease Control and Prevention websites. And, second, the Department of Health estimates that the vaccine will save as many as 400 lives a year in the UK, not 40, as suggested in the article.

    Now, from a new magazine to a new virus, and the most common cause of hepatitis in the UK. Hepatitis E may not have the profile of its better known relatives - hepatitis A, B and C - but it is causing more than its fair share of problems, and we still don't fully understand what the long term effects may be, particularly on the brain and the nervous system. As I discovered when I met Dr Harry Dalton, a consultant gastroenterologist at The Royal Cornwall Hospital, senior lecturer at the European Centre for Environment and Human Health and a world authority on hepatitis E.

    Dalton
    The story starts back in India in the 1950s and 1960s and what they observed was large outbreaks of hepatitis involving tens of thousands of cases, usually affecting young people and they couldn't work out exactly what was causing them. In fact it wasn't until the early 1980s that the virus was discovered and in fact it was discovered in Afghanistan. And what happened there was there was an outbreak of hepatitis amongst the Soviet military, who were then of course in Afghanistan, and couldn't work out what was going on. And so it was investigated by a Russian scientist, he got a mixture of the stool of six Russian squaddies and mixed it with some yoghurt and he drank it and he became really very sick.

    Porter
    He must had had - he had an inkling that this...

    Dalton
    Yes, he, yes...

    Porter
    ...he knew what he was doing.

    Dalton
    It was behaving like a virus, he assumed it was an unidentified virus. And he became very sick, he got hepatitis and his stool was examined under electron microscopy and they found hepatitis E. Then they went back and looked at the old epidemics in the past in India and places in Asia and they found that those epidemics were caused by the same virus.

    Porter
    So using the retrospectoscope to look back at the samples?

    Dalton
    Exactly, exactly.

    Porter
    What's the situation here in the UK?

    Dalton
    Well until relatively recently it was assumed not to be a problem and it was occasionally seen, very rarely seen, in travellers who'd travelled to one of the endemic areas in the developing world where the virus is very common. And so it was regarded like a backpackers' disease but in fact that's proved not to be the case.

    Patient
    It started off with sort of flu-like symptoms which was a bit confusing at first because I had had some immunisations as we were hoping to travel to India. But these symptoms escalated, I had headaches, I had sickness, I had chronic pains and cramps, pains in my back and it all became quite scary. Eventually after about three weeks I was feeling so ill I went to my GP...

    Porter
    After three weeks?

    Patient
    Yes because it was confusing because...

    Porter
    You thought it was immunisation did you?

    Patient
    I thought it was the immunisation. And he immediately said he didn't think it was and did some blood tests and five o'clock the next day he phoned me with the results of the blood tests and said go straight to Trelisk. It was again very scary because nobody seemed to know what was going on - frequent blood tests and then after about four days Dr Dalton came to see me and said - I know what's wrong with you - and he told me it was hepatitis E.

    Porter
    What did you think when you were told you had hepatitis?

    Patient
    I was very cross because it meant that we couldn't go to India and I had this infection anyway which I'd caught in this country.

    Porter
    Had you ever heard of hepatitis E?

    Patient
    Never.

    Dalton
    Our studies have shown that hepatitis E is in fact the commonest cause of viral hepatitis here in the UK. The incidence of the infections, that's new infections every year, is 0.2% of the population, so that's a 120,000 infections every year, now that's an awful lot. In our Cornish population we estimate that about 30% of Cornish men and Cornish women over the age of 80 have been exposed to this virus at some stage in their life. And it's a slightly different strain of virus to the one found in the developing world but it's very closely related and this particular virus is what's called a zoonotic infection derived from animals and in the case of hepatitis E the primary host is the pig. They're perfectly happy pigs, they're not ill in any way, they just carry the virus and it's been estimated that about 85% of the pigs in the UK, for example, show evidence of infection and at one time 20% of the pigs in Britain are excreting this virus in their stool in very large quantities. And then somehow the virus is making its way from the pig population to human beings. There are various theories about how this might happen, the best evidence is it's contracted by eating pig meat - sausages, liver, that kind of thing - that haven't been cooked properly and they cause infection in that way. The key thing about it is the cooking temperature to kill this virus is 71 degrees centigrade but for 20 minutes, so that's quite a long time to cook a sausage.

    Porter
    Can hepatitis E be spread by contaminated blood products too?

    Dalton
    Yes it can.

    Porter
    And are our blood stocks routinely tested for hepatitis E?

    Dalton
    No our blood stocks aren't routinely tested and that's obviously a worry. They're certainly worried about it in the United States. The Food and Drug Administration are actively looking at this problem because they're very concerned about if they've got it in their blood supply - and they're not sure, they don't know in fact - and what implications that might have.

    Porter
    What are the implications if you have the virus and you're in contact - does it spread easily from person to person, I mean I'm thinking of families living together?

    Dalton
    No it doesn't. No, it's quite unlike hepatitis A where often you get several family members coming down with it at the same time, it's extremely uncommon with hepatitis E and we don't know why.

    Porter
    How did you first get involved in this field?

    Dalton
    Well I do this jaundice clinic every week, after two or three years we realised that we had patients with hepatitis and we had no diagnosis. In retrospect we went back and tested some of those patients and we found a few cases of hepatitis E and then we started testing prospectively and now - well we've found a whole load.

    Bentham
    My name is Richard Bentham, I'm a consultant medical microbiologist and this is the laboratory where the samples are tested for hepatitis E.

    Dalton
    So Richard, the samples arrive here, what are you actually looking for?

    Bentham
    We're looking for antibodies in the blood of patients to the virus and we do that using a rapid test, a bit like a pregnancy test, which will tell us whether there are antibodies specific for hepatitis E in their blood,

    Porter
    So you've got one here and basically instead of dropping urine on as you do with a pregnancy test, you're dropping blood presumably?

    Bentham
    That's right yes.

    Porter
    So this isn't detecting the virus itself, it's detecting the patient's reaction to that virus?

    Bentham
    Exactly that yes.

    Porter
    This turns positive when?

    Bentham
    We don't know exactly but we assume probably within a few weeks of infection.

    Porter
    How accurate is this test?

    Bentham
    This test is fairly accurate for acute cases and we know that it's important to use an accurate test because studies that we've done have shown the rate of antibodies to vary almost four fold depending on which test that you use. For instance colleagues of ours in Toulouse in Southern France found that their rate of hepatitis E antibodies jumped from 16% to over 50% when they used a more accurate test.

    Porter
    Fifty per cent, I mean that's a huge number, what's special about Toulouse?

    Bentham
    Well we suspect it's the diet, they're very keen there on pork products and they're not always very thoroughly cooked.

    Patient
    I did recover from the hepatitis fairly quickly, within about another three weeks...

    Porter
    And you basically got better on your own, you didn't need any specific treatment?

    Patient
    No none at all.

    Porter
    And has it had any long term effect on you - you look well?

    Patient
    Yes I am well, yes, fine, no I recovered completely.

    Dalton
    The vast majority of patients who are exposed to this virus in fact don't have any symptoms at all, it's only a small minority who become sick after they've been exposed. Other patients get full blown hepatitis with yellow jaundice, malaise, aching in their joints, sickness and that illness usually lasts about six weeks, generally followed by full recovery, except patients who've got a previously damaged liver and in those patients the mortality's very high we think, it may be approaching 70%. So if you've got a damaged liver and you're exposed to this virus that's really bad news.

    Porter
    And when you say damaged liver that would mean what?

    Dalton
    Patients who've got cirrhosis of the liver due to alcohol or another form of viral hepatitis, such as chronic hepatitis C or chronic hepatitis B, we think these patients at increased risk. There's also a small minority of patients - this virus can cause neurological symptoms, it can upset the nervous system with pain and weakness in the arms and limbs, some of those patients take a long time to recover, we don't know quite how frequently this occurs, nor do we fully understand the full range of neurological syndromes that this virus can cause but we think it's neuro-pathogenic, in other words some strains of it directly damage the nervous system. How does it do that? How often does it do that? We just don't know.

    Porter
    What about the risk during pregnancy?

    Dalton
    The risk during pregnancy in India and the developing countries - high mortality if you're pregnant. In this country we don't see that, it's a different strain of virus, it means that most cases that we see are not in women of childbearing age.

    Porter
    Is the emergence of hepatitis E here in the UK, is this a new disease or is it a disease that we've only just come to recognise?

    Dalton
    I think it's almost certainly been here for well over 200 years and we've only just clocked on to it. We were misled by poor quality initial diagnostics and a perceived wisdom which said hepatitis E is just a problem in the developing world and that became the mantra and it was really very badly wrong.

    Porter
    How do we know that hepatitis E is the last viral type of hepatitis that we'll discover, could there be another one out there?

    Dalton
    Well we think there is and the reason we think there is is that in patients who develop hepatitis we test them for all the viruses that we know about, all the other conditions that can cause hepatitis, including hepatitis E, and we're left with a group of patients where we don't have a diagnosis, we don't have a cause for the hepatitis and I think there's at least one more hepatitis virus that is yet to be discovered.

    Porter
    Dr Harry Dalton suggesting the hepatitis saga is far from over, and if you would like to know more about hepatitis E you will find some useful links on our website. Go to bbc.co.uk/radio4 and click on I for Inside Health.

    If you'd like us to look into a health issue that's confusing you then please do get in touch. You can send a tweet, including the hashtag insidehealth or e-mail me via insidehealth@bbc.co.uk.

    Which is what Helen Curtis did with her query about vertigo. Helen asks: "Can you please enlighten me with regards to an unpleasant dizziness that happens when turning over in bed, getting out of bed, or straightening up after bending down? Is it likely to be low blood pressure, or a problem with my ears?" Questions I put to Dr Mike Jeffreys, a consultant physician in the Department of Healthcare for Older People at the Royal Devon and Exeter Hospital.

    Jeffreys
    Dizziness means different things to different people. Sometimes people think it means unsteadiness, sometimes they think it means a feeling of imbalance and sometimes they think it means a feeling that the room is spinning round.

    Porter
    This is an interesting one as a doctor reading this story because there's two possible causes here, I mean first of all getting up from lying in a warm bath or getting out of bed - that's not unusual to feel a bit lightheaded when that happens.

    Jeffreys
    No and that phenomenon which we call orthostatic hypotension is very common in people as they grow older and that's cause by a drop in blood pressure on standing, which means that you have less blood getting to those areas of the brain that are interpreting your balance sensations as you get up. And that's slightly different from the sort of rotational vertigo that we sometimes get people complaining about as well.

    Porter
    And herein lies another clue and this is that she gets the symptoms when she rolls over in bed and what would that make you think of when somebody says that?

    Jeffreys
    That sort of situation is a good trigger for something that we call benign paroxysmal positional vertigo, which we shorten to BPPV because it's easier to say.

    Porter
    For obvious reasons yes.

    Jeffreys
    And that's a condition characterised by short episodes of rotational dizziness or vertigo that is triggered off by a movement of the head in an angular direction. The underlying problem in that situation is a disturbance in the semi-circular canals in the inner ear. As we get older sometimes we get calcium deposits in the fluid within the inner ear and movement of the head produces a turbulence in the sensitive nerve endings in that area which makes the brain think that we're moving when we're not.

    Porter
    And it's that that creates this sensation of dizziness or vertigo?

    Jeffreys
    When we were kids we all did that thing of jumping off a roundabout and feeling giddy for a while and that's great when you're a young person and you're fit and strong but when you're in your seventies and eighties that feeling can be very disturbing and very disabling.

    Porter
    Imagine a patient like Helen was there in front of you, is there some simple test you can do to prove that it's a BPPV?

    Jeffreys
    There is a manoeuvre called the Hallpike's test which is a reasonably accurate specific test for BPPV. We sit the patient on a plinth or a bed, we get them to turn their head to one side and then we lie them down very quickly backwards so that the level of their head is just below their shoulders and that can sometimes trigger off this disturbance in the inner ear and produce quite significant vertigo and disturbance of eye movements.

    Porter
    If people have been having trouble for a few weeks does it get better on its own or do we need to intervene?

    Jeffreys
    It depends very much on the level of symptoms and the people that I tend to see in clinic are the people who have had repeated vertigo over a period of time and it's not going away. And they're the people who need intervention. This isn't a situation that responds to tablets or medicines.

    Porter
    And yet many people are put on tablets aren't they for this condition?

    Jeffreys
    There seems to be a kneejerk reaction, without wanting to seem too critical, that if someone has vertigo that giving them labyrinthine sedatives - drugs that calm the labyrinth down - are going to be helpful. This really is a mechanical physical problem that responds best to mechanical physical treatment. What we do with these patients is we carry out something called Epley manoeuvre which is a series of gradual gentle movements involving moving the head and body to try and relive the space in the inner ear from the debris that's causing the problem.

    Porter
    I've heard it once described as one of those little games where you have to get the ball bearings in the hole but by manipulating the patient you're actually getting the bits of calcium down a cul-de-sac so they don't cause any trouble - it's a simplistic view.

    Jeffreys
    It's a good analogy but unfortunately it's not quite that much fun in clinic. And it's difficult to do sometimes because these patients are sometimes quite frail and they're quite disabled with other conditions, so it's usually best done with two people. And we know that if you do it with a therapist with you and you do it gently then it's well tolerated. And you can sometimes teach the patients to do it on their own at home and you can back up that education with leaflets. And we know that if we do that we're more likely to be successful.

    Porter
    If you Google Epley manoeuvre there's YouTube demonstrations from doctors doing it, it's not the most complicated of treatments but how successful is it?

    Jeffreys
    I would say that 89% of the people that we carry out Epley manoeuvres on become free of symptoms over a week or so. Once you're free of symptoms there's no point in carrying on doing the manoeuvres, some people do it because it makes them feel confident but there's no evidence that it helps in the long term. We do know that this is a condition that comes back and the recurrence rate over three years or so is something in the order of 25 to 30%. If it does come back you can do the Epley manoeuvres again and they can be just as helpful the second time round.

    Porter
    Dr Mike Jeffreys and you will find more on BPPV and the Epley manoeuvre on the Inside Health page at bbc.co.uk/radio4.

    Next week I will be looking at how doctors decide whether someone with epilepsy can come off their medication. And Margaret McCartney explores the murky world of medically unexplained symptoms - what should doctors do if all the tests come back negative and nothing appears to be wrong, but their patient still feels ill? Join us next week to find out.

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