Efficacy of particle repositioning maneuver in BPPV: a prospective study

PURPOSE: A single blinded prospective randomized controlled trial was conducted in 40 patients with benign paroxysmal positional vertigo (BPPV) to determine the efficacy of particle repositioning maneuver (PRM). MATERIALS AND METHODS: Out of 40 patients, 20 underwent PRM with the rest receiving a placebo treatment. Postprocedural instructions were given to all the patients who underwent PRM. Follow-up was for 1 year at regular intervals. Analysis was based on the symptomatic status and the Hallpike maneuver at each visit. RESULTS: After the initial week, 95% showed complete resolution of symptoms with none reporting a recurrence after PRM. On the contrary, only 15% of the controls had complete resolution with 14 out of 20 reporting a recurrence of BPPV. Results remained more or less the same at the end of 4 weeks. Six months after PRM, 19 of 20 patients had no vertigo with a meager 5% showing recurrence versus 75% of controls reporting a recurrence with only 3 of 20 reporting a favorable symptom status. At the end of 1 year, 18 of 20 patients had complete relief from symptoms with only 10% showing Hallpike maneuver positive in the study group compared with 3 of 20 reporting a relief from symptoms with 90% turning out to be Hallpike maneuver positive in the control group. CONCLUSIONS: This study establishes the efficacy of PRM in short- and long-term management of BPPV; the procedure is easy and simple.     

Effectiveness of the particle repositioning maneuver in subtypes of benign paroxysmal positional vertigo

OBJECTIVES: To assess the efficacy of the particle repositioning maneuver (PRM) in patients presenting with idiopathic benign paroxysmal positional vertigo (BPPV) compared with those with evidence of additional peripheral vestibulopathies. METHODS: Retrospective administration of the Dizziness Handicap Inventory (DHI) to 41 patients with primary BPPV and 31 patients with secondary BPPV to subjectively evaluate their symptoms before and after the PRM. RESULTS: Both groups indicated a marked improvement in symptoms after the PRM. Only two patients reported an increase in their symptoms after the PRM and both had secondary BPPV. CONCLUSIONS: The PRM was found to be highly effective in all forms of BPPV, but careful history and judicious testing may identify patients requiring additional intervention to relieve their symptoms.     

颗粒复位法治疗后半规管良性阵发位置性眩晕

目的 评价颗粒复位法治疗良性阵发性位置性眩晕的效果。方法 对１９９６年７月－１９９８年６月间治疗的３１一半规管性良性性位置性眩晕患者进行回顾分析。地规管耳右症假说,患者接受１次颗粒复位法治疗。治疗结束２周后复查并评价疗效。结果 ２１例患者的眩晕和眼一立刻或在１－２周内逐渐消失。６例改善,４例无效。总有效率８７．１％。结论 颗粒复位法对大多数良性阵发性位置性眩晕患者有效,推荐作为治疗该的首选方法。     

Effect of mastoid oscillation on the outcome of the canalith repositioning procedure

OBJECTIVE: The canalith repositioning procedure (CRP), as described by Epley, is a well-established method of treatment for benign paroxysmal positional vertigo (BPPV). Debate exists as to whether simultaneous application of a mastoid oscillator confers any added benefit. The aim of this study was to examine this question. STUDY DESIGN: Prospective randomized study. METHOD: Eighty-four subjects with unilateral posterior canal BPPV were randomized into two groups. The oscillator group was treated by CRP with mastoid oscillation and the nonoscillator group was treated by CRP alone. Positive outcome was regarded as complete resolution of symptoms and a negative Dix-Hallpike's test after a 4 to 6 week follow-up period. RESULTS: Five patients were lost to follow-up. Twenty-eight (72%) patients from the oscillator group and 26 (65%) patients from the nonoscillator group had a positive outcome. This difference was not significant (chi = 0.17, P =.68) CONCLUSION: For the treatment of posterior canal BPPV, concurrent mastoid oscillation with CRP does not significantly alter the short-term outcome.     

Effectiveness of treatments for benign paroxysmal positional vertigo of the posterior canal.

OBJECTIVE: To determine which common, nonpharmacological, nonsurgical treatments are most effective for treatment of benign paroxysmal positional vertigo (BPPV). STUDY DESIGN: Prospective, randomized, sham-controlled. PATIENTS: Patients (n = 124) with BPPV of the posterior semicircular canal. SETTING: Tertiary care center. INTERVENTIONS: Random assignment to one of five groups: modified canalith repositioning maneuver (CRP), modified liberatory maneuver (LM), sham maneuver, Brandt and Daroff's exercise, and vertigo habituation exercises. Subjects received a standard educational lecture about BPPV and the purpose of the intervention. No vestibular-suppressant medication or special instructions for head positioning were used. Post-tests were given at 1 week after treatment and at approximately 3 months and 6 months later. MAIN OUTCOME MEASURES: Vertigo intensity and frequency. RESULTS: Multilevel analyses showed that vertigo decreased significantly after LM, CRP, and Brandt-Daroff exercise; those three groups did not differ significantly. The habituation group did not differ from sham, Brandt-Daroff, LM, or CRP groups. Changes in scores were maintained throughout the 6-month follow-up period. CONCLUSION: LM, CRP, and exercises are all effective interventions; patient education plus the sham maneuver, however, had some beneficial effect. These results support two possible mechanisms of BPPV: displaced otoconia and a neural mechanism affecting interpretation of semicircular canal signals.     

特发性良性阵发性位置性眩晕患者双温试验的分析

目的：探讨特发性良性阵发性位置性眩晕（BPPV）患者双温试验以及双温试验异常的可能机制。方法：2005—2008年诊断明确的96例特发性BPPV患者,随机分为2组：第1组52例,在诊断明确后复位治疗前进行双温试验;第2组44例,在复位治疗后变位试验阴性后进行双温试验。以半规管轻瘫指数作为比较参数,χ^2检验比较2组半规管轻瘫异常的比例。结果：2组患者比较,除第1组年龄较第2组低,性别比例、受累半规管比例、侧别、病程、是否反复发作各个因素之间没有明显差别。双温试验的比较以半规管轻瘫作为比较参数,2组患者温度试验半规管轻瘫异常的比例进行χ^1检验（t=0．654,P〈0．05）,2组半规管轻瘫出现的比例相似,管石复位前后温度试验异常出现的比例差别没有统计学意义。结论：双温试验异常的原因可能是因为前庭系统存在广泛病变,飘动的耳石对内淋巴液的流动影响不大。     

良性阵发性位置性眩晕患者复位后残余症状的干预策略:单中心随机对照试验

目的比较不同干预策略处理良性阵发性位置性眩晕(benign paroxysmal positional vertigo, BPPV)复位成功后残余症状的临床疗效。方法采用平行、随机对照试验设计,2019年1—7月期间复旦大学附属眼耳鼻喉科医院收治的129例BPPV复位后有残余症状的患者在线完全随机化分至前庭康复组、倍他司汀组及对照组(空白),每组43例。前庭康复组接受为期4周的康复训练;倍他司汀组口服甲磺酸倍他司汀(12 mg/次,每日3次)4周;对照组无特殊处理。入组后4周、8周时随访,主要结局指标为日常活动与社会参与功能,采用前庭活动与参与量表(vestibular activities and participation measure,VAP)测量,次要指标为基于感觉统合试验(sensory organization test, SOT)的平衡功能以及残余症状的持续天数。采用STATA15.0软件进行统计学分析。结果三组患者VAP量表得分随时间推移均呈下降趋势,但前庭康复组下降幅度更为显著。分组比较,前庭康复组与对照组差异有统计学意义(B=-3.88,χ2=18.29,P<0.01);倍他司汀组与对照组差异无统计学意义(B=-0.96,χ2=1.16,P=0.28)。三组患者平衡功能随时间呈现恢复趋势,组间差异无统计学意义(χ2=1.37,df=2,P>0.05);前庭康复组和倍他司汀组残余症状持续时间的中位数均为14 d,对照组为19 d,三组间差异无统计学意义[Log-rank (Mantel-Cox)test;χ2=1.82,df=2,P=0.40]。结论前庭康复可以显著改善BPPV复位后残余症状患者的日常活动与社会参与功能,对缩短残余症状持续时间和促进平衡功能恢复的效果尚不确定。     

Efficacy of BPPV diagnosis and treatment system for benign paroxysmal positional vertigo

ObjectivesTo evaluate the efficacy of automatic benign paroxysmal positional vertigo (BPPV) diagnosis and treatment system for BPPV compared with the manual repositioning group.MethodsTwo hundred thirty patients diagnosed as idiopathic BPPV who were admitted from August 2018 to July 2019 in Zhejiang Hospital were included. Among them, 150 patients of posterior semicircular canal BPPV(pc-BPPV), 53 patients of horizontal semicircular canal BPPV(hc-BPPV), and 27 patients of horizontal semicircular canal calculus (hc-BPPV-cu) were randomly treated with BPPV diagnosis and treatment system(the experimental group) or manual repositioning (the control group). Resolution of vertigo and nystagmus on the Dix-Hallpike and Roll test on day 3,day 7,day 14 and day 28 follow-up after first treatment was the main outcome measure to assess the efficacy of treatment.ResultsAt 3-day and 7-day follow-up after treatment with BPPV diagnosis and treatment system, 79%, 91%had complete resolution of vertigo and nystagmus, the effective rate in the experimental group were significantly higher than those in the control group, the differences were statistically significant(P < .05). On day 14, the effective rate in the experimental group (96%) was slightly higher than that in the control group(91%), but there was no significant difference between the two groups. And at 28-day after the first treatment, the effective rate was 100% in the experimental group and the control group. The repositioning efficiency of pc-BPPV (the first, second, third treatment), hc-BPPV (the first, second, third treatment), hc-BPPV-cu(the first, second treatment) in the experimental group were higher than the control group, and the secondary reposition of pc-BPPV in the experimental group was significantly higher than the control group(96%vs.84%; P < .05). While for the hc-BPPV-cu patients, the effective rate of the third treatment in the experimental group was slightly lower than that of the control group, but the differences were not statistically significant.ConclusionsBPPV diagnosis and treatment system is effective for the treatment of BPPV, with a better effective rate than those treated with manual maneuver, and is safe and easy to perform on patients.     

前庭功能诊治系统SRM-Ⅳ在良性阵发性位置性眩晕中的应用

目的观察全自动前庭功能诊治系统（SRM-Ⅳ）诊治良性阵发性位置性眩晕的临床效果。方法回顾分析了56例良性阵发性位置性眩晕患者,其中36例采用SRM-Ⅳ进行诊断和治疗,20例采用手法诊治,对其疗效进行比较。结果采用SRM-Ⅳ治疗的患者中第1次治疗后有32例患者（89%）治愈,4例患者经过第2次治疗痊愈;采用手法复位的患者中第1次治疗后有17例患者（85%）治愈,3例患者经过第2次治疗痊愈。应用χ2检验二者的差异没有统计学意义。结论应用全自动前庭功能诊治系统诊治良性阵发性位置性眩晕临床效果可靠,弥补了手法复位的缺陷,效果直观,可重复性强。     

鼻咽癌放疗致位置性眩晕(附3例报告)

目的：探讨电离辐射对内耳前庭的影响。方法：报道鼻咽癌（ＮＰＣ）放疗致发作性位置性眩晕（ＢＰＰＶ）伴听力减退患者３例。采用耳石微粒复位法（ＰＲＭ）治疗ＢＰＰＶ,针对听力减退给予丹参治疗。结果：３例ＢＰＰＶ,２例痊愈,１例显效,听力下降的４耳语音频率平均提高１０ｄＢ。结论：ＢＰＰＶ可能与辐射所致的前庭损害有关,ＰＲＭ是治疗ＢＰＰＶ是一种有效方法。     

Long-term outcome and health-related quality of life in benign paroxysmal positional vertigo

A prospective cohort study was designed to evaluate the long-term outcome and health-related quality of life (HRQoL) in patients with posterior canal benign paroxysmal positional vertigo (PC-BPPV) treated by the particle repositioning maneuver (PRM) in the outpatient clinic of a general community hospital. Fifty individuals with PC-BPPV were included, and 45 (90%) completed the study. The diagnosis was based on the history of short episodes of vertigo and a positional nystagmus during the Dix-Hallpike test (DHT). All patients were treated by a single PRM, and relapses were evaluated by DHT at 30, 180 and 360 days post-treatment; a new PRM was performed if the DHT was positive. The main outcome measures were: percentage of patients with a negative DHT after treatment, scores obtained on the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) and the Dizziness Handicap Inventory Short Form (DHI-S) before and 30, 180 and 360 days post-treatment. The DHT was found negative in 80% (40/50) of individuals at 30 days. Ten, seven and five patients presented a positive DHT at 30, 180 and 360 days, respectively. Persistent BPPV was observed in 5% (2/50) of patients at 360 days, despite repeated PRM. Relapses (DH+ after successful PRM) were observed in 7.5% (3/50) at 180 days and 360 days. Both questionnaires showed a reliability Cronbachs alpha >0.7. The average standardized score for each SF-36 scale was compared with the reference population normative data, showing differences with norms for all scales except for vitality. After PRM, patients improved their scores with both instruments, indicating a restoration of HRQoL at 30 days. Physical dimension scores of the SF-36 improved from day 30 to 360. DHI-S scores were statistically better after PRM (P<0.001). Our results show that the effectiveness of PRM is 88% after 1 year of follow-up. Patients with BPPV experienced a decrease in HRQoL, which was restored after PRM. Although relapses were observed in 7.5% of individuals, they did not affect HRQoL.This study was presented at the Research Forum of the AAO-HNSF and the Association for Research in Otolaryngology (ARO) Annual Meeting held in Orlando, FL, on September, 23, 2003     

Recurrence of symptoms following treatment of posterior semicircular canal benign positional paroxysmal vertigo with a particle repositioning manoeuvre

A consecutive series of 51 patients (34 females and 17 males) with posterior semicircular canal benign positional paroxysmal vertigo (BPPV) were treated with the modified Epley particle positioning manoeuvre (PRM). Follow-up data were available on all 51 patients. After one manoeuvre, 42 patients had a negative Dix-Hallpike test, and after a second manoeuvre, 8 of the remaining 9 patients had a negative Dix-Hallpike test (testing was conducted 1 to 2 weeks after the PRM was performed). Therefore, the overall short-term success rate after two manoeuvres was 50 of 51 patients (98%), which is similar to other series. A follow-up questionnaire to determine the incidence of recurrence of symptoms was administered after a minimum period of 30 weeks. Twenty-three patients reported a recurrence (or, in the case of the one treatment failure, persistence) of their symptoms (45%). Therefore, although virtually all patients can be treated successfully with the PRM, almost half of these patients can be expected to experience a further recurrence of symptoms. This long-term recurrence rate is higher than has previously been reported and is a significant factor clinicians must be aware of in their treatment of this condition. In particular, this finding emphasizes the need for patient counselling with regard to the likelihood of recurrence and access to follow-up treatment if recurrence occurs.     

Comparison between objective and subjective benign paroxysmal positional vertigo: clinical features and outcomes

Conclusions: Objective benign paroxysmal positional vertigo (O-BPPV) and subjective BPPV (S-BPPV) have similar demographic and clinical features. Canalith repositioning manoeuvres (CRMs) can be an effective treatment for patients with S-BPPV, and a diagnosis of positional nystagmus is not essential for considering CRMs. This study supports the use of CRMs as the primary treatment for S-BPPV.

Objective: To examine differences in demographic and clinical features, as well as treatment outcomes, between O-BPPV and S-BPPV.

Methods: The medical records of 134 patients with BPPV were reviewed for demographic characteristics, past medical history, associated symptoms, response to CRMs, interval between symptom onset and the first medical visit, and recurrence rate. The O-BPPV group (n?=?101) comprised patients who experienced vertigo and accompanying autonomic symptoms, and showed typical nystagmus. The S-BPPV group (n?=?33) comprised patients who, when subjected to a provoking manoeuvre, showed all of the classic BPPV symptoms but did not show nystagmus. All patients had at least 3 years of follow-up.

Results: The demographics (age and sex ratio), past medical history, and associated symptoms were not significantly different between the two groups. Posterior semi-circular canal BPPV appeared more than twice as often as horizontal semi-circular canal BPPV in patients with S-BPPV. However, both canals were affected to a similar proportion in patients with O-BPPV, and the difference was marginally significant (p?=?0.073). Overall improvement was better in O-BPPV than in S-BPPV; however, there was no significant difference. The total numbers of manoeuvres for recovery and the interval between symptom onset and the first medical visit also did not show any significant inter-group differences. During a 3-year follow-up, the recurrence rate was 13.8% for O-BPPV and 21.2% for S-BPPV.     

Efficacy of postural restriction in treating benign paroxysmal positional vertigo

OBJECTIVE: To investigate the efficacy of postural restriction after canalith repositioning in treating benign paroxysmal positional vertigo (BPPV). DESIGN: Prospective trial of patients with postural restriction vs those without postural restriction after treatment. PATIENTS: Patients with classic BPPV and with BPPV without nystagmus were treated using the modified Epley canalith repositioning procedure. Patients were randomly separated into 2 groups. The first group was instructed to wear a cervical collar and to maintain an upright head position for 2 days. The second group had no motion restriction. After 5 days, the patients were followed up and evaluated using the Dix-Hallpike test. RESULTS: In the first group, 56 of 62 ears healed after the first maneuver, and the remaining ears healed after the second. In the second group, 45 of 57 ears healed after the first maneuver, 6 after the second, and 5 (with subsequent postural restriction) after the third (1 ear did not improve). Five patients in the first group and 3 patients in the second group had BPPV without nystagmus; all of these patients healed after a single maneuver. The difference between the 2 groups in the number of maneuvers required for treatment was statistically significant (P<.05). The number of patients who required a third maneuver was significantly higher in the second group (P<.05). CONCLUSIONS: Postural restriction enhances the therapeutic effect of canalith repositioning in the treatment of posterior semicircular canal BPPV. The long-term efficacy of postural restriction in preventing BPPV recurrence has not been demonstrated.     

Vibration does not improve results of the canalith repositioning procedure

OBJECTIVE: To determine whether, in patients with benign paroxysmal positional vertigo (BPPV), the canalith repositioning procedure performed with vibration applied over the mastoid bone of the affected ear is more effective in resolving the symptoms and preventing recurrence of BPPV than the procedure performed without vibration. DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Ninety-four patients diagnosed as having BPPV involving the posterior semicircular canal. INTERVENTIONS: Patients were assigned to one of 2 treatment groups: the canalith repositioning procedure with vibration (n=44) and with no vibration (n=50). MAIN OUTCOME MEASURES: Effectiveness of treatment was determined through clinical reevaluation or reported through a telephone interview 1 week after treatment. Intensity of symptoms was quantified on a scale of 1 to 3 (mild, moderate, or severe); effectiveness of treatment was categorized on a scale of 1 to 4 (cure, much better, better, or no change). Rate of recurrence was determined through later clinical reevaluation or a telephone interview. RESULTS: At 1 week, 57 of the 94 patients were cured and 16 were much better, providing a 78% overall success rate. There was no significant difference in effectiveness of the treatment or the frequency of reoccurrence of BPPV between the vibration and no-vibration groups as determined from the Kaplan-Meier product-limit method and log-rank test. Rate of recurrence was 47% at a maximum follow-up of 5.25 years. CONCLUSIONS: Our results suggest that, while the canalith repositioning procedure is effective in the treatment of BPPV, vibration applied during the maneuver does not significantly affect short-term or long-term outcomes.     

Approach to bilateral benign paroxysmal positioning vertigo

BACKGROUND: Bilateral benign paroxysmal positioning vertigo (bBPPV) is rather rare, accounting for up to 10% in the reported benign paroxysmal positioning vertigo (BPPV) series. Inappropriate head positioning during testing in unilateral BPPV causes the otolith debris in the uppermost ear to move toward the cupula, resulting in an inhibitory nystagmus and mimicking bBPPV. PURPOSE: We analyzed the clinical data of patients with bilaterally positive Dix-Hallpike maneuver and compared them with the characteristics of patients with unilateral BPPV. We further tried to propose a simple schematic approach to the treatment of patients with bilaterally positive Dix-Hallpike maneuver. MATERIALS AND METHODS: Medical records of 232 patients treated for BPPV at our dizziness clinic during 1999 to 2003 were reviewed. An algorithm used for the treatment of patients with bilaterally positive BPPV is discussed. RESULTS: Twenty-eight patients with bilaterally positive Dix-Hallpike test were found. Sixteen were diagnosed with bBPPV, and 12 were diagnosed with unilateral mimicking bBPPV. Thirty patients with unilateral posterior canal BPPV served as control subjects. No difference in age, sex distribution, duration of symptoms, number of treatments per ear, and recurrence was found between bBPPV and unilateral BPPV. The female sex appeared to be predisposed for more treatments. The total duration of BPPV symptoms obtained by history was found to correlate with the number of recurrences after treatment. CONCLUSIONS: We conclude that bBPPV can be readily distinguished from unilateral mimicking bBPPV. Patients with bBPPV do not differ from patients with unilateral BPPV in clinical characteristics. The mechanism of otolith debris dislodgment appears to be the main cause of bilaterality, trauma being a more common trigger than other known causes of BPPV.     

Benign paroxysmal positional vertigo after intense physical activity: a report of nine cases

The aim of this study was to report some clinical cases suggesting a possible correlation between benign paroxysmal positional vertigo (BPPV) and intense physical activity. Out of 430 BPPV cases referred to our out-patients clinic, 9 patients, showing symptoms of BPPV arising after an intense period of physical activity, were selected for this study. The posterior semicircular canal was affected in all the nine patients. The canalith repositioning procedure was successful and eliminated vertigo and nystagmus in all patients. During the follow-up period (12 months) all patients continued with the usual physical activity; four of the nine patients showed a recurrence of the BPPV symptoms after a new intense period of exercises: all were successfully treated by a new single Epley repositioning procedure. BPPV due to intense physical activity is a rare condition (9/430) and it may be caused by repeated vibratory vertical accelerations of a minor degree associated with metabolic variations during strenuous exercise.     

Brandt-Daroff康复练习对半规管良性阵发性位置性眩晕患者的疗效

目的探讨Brandt-Daroff康复练习对半规管良性阵发性位置性眩晕(benign paroxysmal positional vertigo,BPPV)患者的疗效。方法选取2016年9月~2018年3月就诊于我院的60例半规管BPPV患者,根据随机数字表法将其分为观察组和对照组各30例,对照组采取手法复位进行治疗,观察组在其基础上行Brandt-Daroff康复练习,连续治疗1个月并随访半年。治疗前后采用眩晕障碍评分量表(dizziness handicap inventory,DHI),不良反应发生率、半年复发率,比较两组临床疗效。结果与对照组比较,观察组临床总有效率(93.33%)显著升高,差异有统计学意义(P<0.05);治疗后,两组DHI评分显著降低,且观察组降低幅度显著大于对照组,差异有统计学意义(P<0.05);两组在不良发生率的比较中差异无统计学意义(P>0.05);与对照组(20.00%)比较,观察组半年复发率(6.67%)显著降低,差异有统计学意义(P<0.05)。结论Brandt-Daroff康复练习不仅可有效提高半规管BPPV患者临床疗效,减轻其功能障碍,而且复发率低,安全性高,值得临床参考。     

Home particle repositioning maneuver to prevent the recurrence of posterior canal BPPV

Objective

To check the value of home particle repositioning maneuver in the prevention of the recurrence of posterior canal benign paroxysmal positional vertigo (pc-BPPV).

Evaluation of a particle repositioning maneuver Web-based teaching module

OBJECTIVES/HYPOTHESIS: To compare the pass rate of residents performing the Particle Repositioning Maneuver (PRM) after one of three interventions: 1) small group PRM instruction (SG); 2) standard classroom instruction (CI); and 3) Web-based learning module (WM). We hypothesize that our Web-based learning module is more effective than CI and as effective as SG.Study Design: Prospective randomized control trial. METHODS: The study population includes all family medicine residents at the University of Western Ontario. On day 0, all subjects were tested. Residents were then randomized to one of three intervention groups: 1) SG, 2) CI, or 3) WM. On day 7, the residents were again tested. Observers were blinded to the intervention type. Testing (day 0 and day 7) was performed using the DizzyFIX (Clearwater Clinical Ltd., London, Ontario, Canada), a pass/fail test, and evaluation by a trained observer (correct or incorrect). RESULTS: There were no statistically significant differences in pass rates between the three groups before the interventions (DizzyFIX: P = .2096, observer: P = .3710). After the interventions, DizzyFIX testing pass rates were 50.0% SG, 60.0% CI and 100.0% WM (P = .3564). Observer testing pass rates were 85.7% SG, 28.6% CI, and 83.3% WM (P = .0431). CONCLUSIONS: This study demonstrated that our Web-based learning module for the PRM is comparable to small-group clinical instruction, and superior to standard classroom instruction for teaching the PRM when evaluated by a trained observer.