Epley manoeuvre's efficacy for benign paroxysmal positional vertigo (BPPV) in primary-care and subspecialty settings: a systematic review and meta-analysis

BACKGROUND

Although previous studies have reported general inexperience with the Epley manoeuvre (EM) among general physicians, no report has evaluated the effect of EM on benign paroxysmal positional vertigo (BPPV) in primary care by using point estimates or certainty of evidence. We conducted this systematic review and meta-analysis and clarified the efficacy of EM for BPPV, regardless of primary-care and subspecialty settings.

METHODS

Systematic review and meta-analysis of randomised sham-controlled trials of EM for the treatment of posterior canal BPPV in primary-care and subspecialty settings. A primary-care setting was defined as a practice setting by general practitioners, primary-care doctors, or family doctors. A systematic search was conducted in January 2022 across databases, including Cochrane Central Resister of Controlled Trial, MEDLINE, Embase, Cumulative Index of Nursing and Allied Health Literature, World Health Organization International Clinical Trials Registry Platform, and ClinicalTrials.gov. Primary outcomes were the disappearance of subjective symptoms (vertigo), negative findings (Dix-Hallpike test), and all adverse events. We evaluated the certainty of evidence using the Grading of Recommendations, Assessment, Development and Evaluation approach.

RESULTS

Twenty-seven randomised controlled trials were identified. In primary-care settings, EM reduced the subjective symptoms [risk ratio (RR), 3.14; 95% confidence interval (CI), 1.96-5.02]; however, there was no applicable article for all adverse events. In the subspeciality setting, EM reduced the subjective symptoms (RR, 2.42; 95% CI, 1.64-3.56), resulting in an increase in negative findings (RR, 1.81; 95% CI, 1.40-2.34). The evidence exhibited uncertainty about the effect of EM on negative findings in primary-care settings and all adverse events in subspecialty settings.

CONCLUSIONS

Regardless of primary-care and subspecialty settings, EM for BPPV was effective. This study has shown the significance of performing EM for BPPV in primary-care settings. EM for BPPV in a primary-care setting may aid in preventing referrals to higher tertiary care facilities and hospitalisation for follow-up.

TRIAL REGISTRATION

The study was registered in protocols.io (PROTOCOL INTEGER ID: 51,464) on July 11, 2021.

Epley maneuver for benign paroxysmal positional vertigo: Evidence synthesis for guidelines for reasonable and appropriate care in the emergency department

BACKGROUND

Canalith repositioning maneuvers (such as the Epley maneuver) are recommended by specialty guidelines for management of benign paroxysmal positional vertigo (BPPV) yet are frequently underutilized in the emergency department (ED).

METHODS

We conducted a systematic review of systematic reviews to summarize the evidence of Epley maneuver for the treatment of posterior canal (pc) BPPV in any setting. We included systematic reviews of randomized controlled trials (RCTs) that compared Epley to control in adult patients with pc-BPPV. Titles, abstracts, and full texts were screened in duplicate. The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) assessment was used to rate certainty of evidence. Odds ratios (OR) and 95% confidence intervals (CI) are reported. Meta-analysis of individual studies was conducted with random and fixed effects.

RESULTS

From 2,228 titles, 7 systematic reviews were selected for quality assessment. One review was of higher methodological quality, included only RCTs, and was the most current and comprehensive. Five of the 11 RCTs of the review, including 312 patients with pc-BPPV diagnosed by Dix-Hallpike, were relevant to our question. Meta-analysis of 4 RCTs (251 patients) showed the use of Epley (as compared to control) was associated with higher complete resolution of vertigo at 1 week (OR 7.19, CI 1.52 to 33.98, moderate certainty). Meta-analysis of 3 RCTs (195 patients) showed the use of Epley was associated with higher conversion to negative Dix-Hallpike at 1 week (OR 6.67, CI 1.52 to 33.98, moderate certainty). The number-needed-to-treat was 3. Meta-analysis of the outcomes at 1 month, and when observational studies were included, showed similar results. No serious adverse effects were reported.

CONCLUSIONS

Symptoms of pc-BPPV improve with the Epley maneuver. Emergency clinicians should become familiar with performing the Epley for BPPV. Further studies on ED implementation and clinician education of Epley are needed.

Diagnostic Positional Tests and Therapeutic Maneuvers in the Management of Benign Paroxysmal Positional Vertigo

Benign Paroxysmal Positional Vertigo (BPPV), the most common vestibular disorder characterized by recurrent, brief episodes of vertigo, is attributed to the presence of otoconia in the semicircular canals. Two mechanisms contribute to its cause-canalolithiasis (otoconia freely mobile in the semicircular canal) and cupulolithiasis (otoconia adherent to the cupula). Posterior semicircular canal is the most common canal involved. Although the occurrence of BPPV in lateral and superior semicircular canal is rare, with the advancement in diagnostic techniques, their incidence is being reported in the past few years. Various diagnostic tests and therapeutic maneuvers have been described in the management of BPPV. The present report is a comprehensive review of the tests and maneuvers for BPPV written as a guide intended to help the clinicians in the accurate diagnosis and application of a canal-specific treatment maneuver for BPPV. A simplified algorithmic approach ("The Bangalore BPPV Algorithm") for the management of BPPV is described.

Assessment of a Statistical Algorithm for the Prediction of Benign Paroxysmal Positional Vertigo

Importance

Benign paroxysmal positional vertigo (BPPV) is an otologic pathologic condition defined as a sensation of spinning triggered by changes in head position relative to gravity and caused by an entrapment of fragmented endolymph debris most commonly in the posterior semicircular canal. Confirmation of diagnosis requires experience with procedures that are poorly known by those other than practitioners with advanced otologic training. The complexity in the diagnosis of BPPV inspired the design of a questionnaire-based algorithm that would be useful for determining a vestibular diagnosis and treatment options.

Objective

To assess a statistical algorithm for the diagnosis of BPPV in a busy tertiary care setting, with the long-term goal of implementing a clinical pathway to efficiently diagnose and treat patients with dizziness.

Design, Setting, and Participants

In this retrospective case series, 200 patients who visited the Department of Otolaryngology-Head and Neck Surgery at Johns Hopkins University School of Medicine for their initial vertigo symptoms from September 1, 2016, to December 31, 2016, were assessed.

Interventions

Use of a validated patient questionnaire as a tool to differentiate patients with dizziness in an electronic medical record review.

Main Outcomes and Measures

Linear predictor (LP) value based on the questionnaire for the diagnosis of BPPV.

Results

Of the 200 patient visits reviewed (132 [66%] female), 106 (53.0%; 68 [64%] female) had the information necessary to calculate the LP value and had a confirmed final diagnosis. On the basis of an LP value of 0.2 or greater, the sensitivity for a diagnosis of BPPV was 0.75 and the specificity was 1.0. The positive predictive value was 1.0, whereas the negative predictive value was 0.96. Patients with BPPV had a statistically significantly different LP value (odds ratio, 5.92; 95% CI, 2.73-12.83) than did patients without BPPV.

Conclusions and Relevance

The findings of this study suggest that the algorithm is efficient for the diagnosis of BPPV in a clinical care setting.

Management of Bilateral Benign Paroxysmal Positional Vertigo

Objective

To describe a series of patients with bilateral benign paroxysmal positional vertigo (BiBPPV), with respect to demographics, management, and outcome.

Methods

All patients who were identified and treated for BiBPPV in a previous 36-month period with a minimal follow-up period of 6 months were included. Patients were treated with Epley's maneuver (EM) on the side that was more symptomatic and that had a greater velocity and amplitude of tortional nystagmus. Patients were re-treated according to symptoms and findings on follow-up visits.

Results

Ten patients were identified with BiBPPV. Most patients complained of nonlocalized positional vertigo and unsteadiness. Four were males and 6 were females, and the mean age was 54 years. There was a positive history of recent head trauma in 4 of the patients. All patients recovered after performing a mean of 2.6 EMs during a 3-month period. One patient experienced unilateral recurrence and was re-treated successfully.

Conclusion

BiBPPV has typical characteristics and can be managed successfully with EM, performed on the more symptomatic side, followed by repeated treatments as needed.

Ebm Rating: C

© 2005 American Academy of Otolaryngology-Head and Neck Surgery Foundation, Inc. All rights reserved.

Dizziness handicap and clinical characteristics of posterior and lateral canal BPPV

PURPOSE

Benign paroxysmal positional vertigo (BPPV) is diagnosed and divided into subtypes based on positioning vertigo and nystagmus. Whether these subtypes entail any significant differences in patient-reported symptoms; is yet not known. Such differences may have clinical and therapeutic consequences. Our aim was to assess dizziness handicap and clinical characteristics of posterior and lateral canal BPPV.

METHODS

This prospective observational multicentre study analysed consecutive patients with BPPV, confirmed by standardized procedures including videonystagmography under diagnostic manoeuvres in a biaxial rotational chair. Patients were screened for other neurological and otological disorders.

OUTCOMES

Dizziness handicap inventory (DHI), posterior vs. lateral canal involvement.

FACTORS

age, gender, positional nystagmus intensity (maximum slow-phase velocity), symptom duration, 25-hydroxyvitamin D-level and traumatic aetiology.

RESULTS

132 patients aged 27-90 (mean 57, SD 13) years were included. Higher DHI scores were associated with lateral canal BPPV [95% CI (1.59-13.95), p = 0.01] and female gender [95% CI (0.74-15.52), p = 0.03]. Lateral canal BPPV was associated with longer symptom duration [OR 1.10, CI (1.03-1.17), p = 0.01] and lower 25-hydroxyvitamin D-levels [OR 0.80, CI (0.67-0.95), p = 0.03]. There was no correlation between DHI scores and nystagmus intensity.

CONCLUSIONS

This study suggests that patients with lateral canal BPPV have increased patient-perceived disability, lower vitamin D-levels and longer duration of symptoms. This subtype might therefore require closer follow-up. Patient-perceived disability is not related to positional nystagmus intensity.

Hemorrhagic stroke after Epley maneuver: a case report

BACKGROUND

This is the first case to our knowledge of a serious adverse event following the Epley maneuver, which is the treatment of choice for benign paroxysmal positional vertigo (BPPV), the most common vestibular disorder in adults.

CASE PRESENTATION

A 77 year old female presented for outpatient evaluation of vertigo at a tertiary otolaryngology clinic. She was found to have BPPV clinically, and elected to have a particle repositioning maneuver (Epley maneuver) performed in clinic. Immediately following Epley maneuver, she had severe nausea and vomiting, with evolving visual changes. A CT angiogram of the brain was performed urgently through the emergency department and demonstrated an acute intraparenchymal hemorrhage in the occipital lobe. After medical stabilization and rehabilitation, the patient continues to have a permanent visual field deficit.

CONCLUSION

The Epley maneuver is safe and effective, and there are no prior reports of serious adverse events associated with its use. This case, in which a patient experienced a hemorrhagic stroke after undergoing the Epley maneuver, is the first and sole case in the medical literature of an Epley-associated serious adverse event. The indirect causation and extreme rarity of this event do not warrant any change to patterns of practice.

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)

Objective

This update of a 2008 guideline from the American Academy of Otolaryngology—Head and Neck Surgery Foundation provides evidence-based recommendations to benign paroxysmal positional vertigo (BPPV), defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo. Changes from the prior guideline include a consumer advocate added to the update group; new evidence from 2 clinical practice guidelines, 20 systematic reviews, and 27 randomized controlled trials; enhanced emphasis on patient education and shared decision making; a new algorithm to clarify action statement relationships; and new and expanded recommendations for the diagnosis and management of BPPV.

Purpose

The primary purposes of this guideline are to improve the quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing such as radiographic imaging, and increasing the use of appropriate therapeutic repositioning maneuvers. The guideline is intended for all clinicians who are likely to diagnose and manage patients with BPPV, and it applies to any setting in which BPPV would be identified, monitored, or managed. The target patient for the guideline is aged ≥18 years with a suspected or potential diagnosis of BPPV. The primary outcome considered in this guideline is the resolution of the symptoms associated with BPPV. Secondary outcomes considered include an increased rate of accurate diagnoses of BPPV, a more efficient return to regular activities and work, decreased use of inappropriate medications and unnecessary diagnostic tests, reduction in recurrence of BPPV, and reduction in adverse events associated with undiagnosed or untreated BPPV. Other outcomes considered include minimizing costs in the diagnosis and treatment of BPPV, minimizing potentially unnecessary return physician visits, and maximizing the health-related quality of life of individuals afflicted with BPPV.

Action Statements

The update group made strong recommendations that clinicians should (1) diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down, and (2) treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure. The update group made a strong recommendation against postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV. The update group made recommendations that the clinician should (1) perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV if the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus; (2) differentiate, or refer to a clinician who can differentiate, BPPV from other causes of imbalance, dizziness, and vertigo; (3) assess patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling; (4) reassess patients within 1 month after an initial period of observation or treatment to document resolution or persistence of symptoms; (5) evaluate, or refer to a clinician who can evaluate, patients with persistent symptoms for unresolved BPPV and/or underlying peripheral vestibular or central nervous system disorders; and (6) educate patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The update group made recommendations against (1) radiographic imaging for a patient who meets diagnostic criteria for BPPV in the absence of additional signs and/or symptoms inconsistent with BPPV that warrant imaging, (2) vestibular testing for a patient who meets diagnostic criteria for BPPV in the absence of additional vestibular signs and/or symptoms inconsistent with BPPV that warrant testing, and (3) routinely treating BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines. The guideline update group provided the options that clinicians may offer (1) observation with follow-up as initial management for patients with BPPV and (2) vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV.

Natural History of Benign Paroxysmal Positional Vertigo and Efficacy of Epley and Lempert Maneuvers

We assessed the efficacy of Epley maneuver in patients with posterior canal benign paroxysmal positional vertigo (P-BPPV) and Lempert maneuver in patients with horizontal canal BPPV (H-BPPV). In patients with P-BPPV, positional vertigo in patients treated by Epley maneuver was significantly resolved more quickly than that in untreated patients. But in patients with H-BPPV, there were no significant differences of time course in remission of positional vertigo between untreated patients and patients treated by Lempert maneuver. Among the untreated patients, the positional vertigo in patients with H-BPPV was significantly resolved more quickly than that in patients with P-BPPV. Epley maneuver was effective for the treatment of patients with P-BPPV, whereas the efficacy of Lempert maneuver for the treatment of patients with H-BPPV was limited. The natural courses in remission of positional vertigo in untreated patients with H-BPPV showed significantly faster resolution than that in patients with P-BPPV.

Classification, diagnostic criteria and management of benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vertigo and the posterior and/or lateral semicircular canals are usually affected. BPPV is characterized by brief attacks of rotatory vertigo associated with positional and/or positioning nystagmus, which are elicited by specific head positions or changes in head position relative to gravity. In patients with the posterior-canal-type of BPPV, torsional nystagmus is induced by the Dix-Hallpike maneuver. In patients with the lateral-canal-type of BPPV, horizontal geotropic or apogeotropic nystagmus is induced by the supine roll test. The pathophysiology of BPPV is canalolithiasis comprising free-floating otoconial debris within the endolymph of a semicircular canal, or cupulolithiasis comprising otoconial debris adherent to the cupula. The observation of positional and/or positioning nystagmus is essential for the diagnosis of BPPV. BPPV is treated with the canalith repositioning procedure (CRP). Through a series of head position changes, the CRP moves otoconial debris from the affected semicircular canal to the utricle. In this review, we provide the classification, diagnostic criteria, and examinations for the diagnosis, and specific and non-specific treatments of BPPV in accordance with the Japanese practical guidelines on BPPV published by the Japan Society for Equilibrium Research.

Diagnosis and Treatment of Anterior-Canal Benign Paroxysmal Positional Vertigo: A Systematic Review

Background and Purpose

In contrast to the posterior- and horizontal-canal variants, data on the frequency and therapeutic management of anterior-canal benign paroxysmal positional vertigo (AC-BPPV) are sparse. To synthesize the existing body of evidence into a systematic review regarding the incidence and treatment of AC-BPPV.

Methods

Systematic search of medical databases employing predefined criteria, using the term "anterior canal benign paroxysmal positional vertigo."

Results

The electronic search retrieved 178 unique citations, 31 of which were considered eligible for further analysis. Analysis of the collected data revealed an estimated occurrence of AC-BPPV among benign paroxysmal positional vertigo patients of 3% (range 1-17.1%). No controlled therapeutic trials could be identified, and so the analysis was focused on uncontrolled case series. Treatment was categorized into three groups: Epley maneuver, Yacovino maneuver, and specific, nonstandard maneuvers described in individual articles. All three categories demonstrated success rates of over 75%, and the overall sample-size-weighted mean was 85.6%.

Conclusions

The present analysis demonstrated that AC-BPPV comprises about 3% of all BPPV cases. It can be treated safely using the Epley, Yacovino, and other maneuvers with rates of symptom resolution lying in the range of that reported for the other, more frequent canal variants. Multicenter controlled trials are needed in order to develop evidence-based guidelines for the treatment of AC-BPPV.

The Epley (canalith repositioning) manoeuvre for benign paroxysmal 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 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 of Dix-Hallpike positional test result from positive to negative 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 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.

Rapid Systematic Review of Repeated Application of the Epley Maneuver for Treating Posterior BPPV

Objective

To evaluate the effect of repeated application of the Epley maneuver on patient-reported symptom relief and resolution of nystagmus in patients with posterior benign paroxysmal positional vertigo (p-BPPV).

Data Sources

PubMed, Embase, and the Cochrane Library.

Methods

A systematic search was conducted. Studies reporting original study data were included. Relevance and risk of bias (RoB) of the selected articles were assessed. Studies with low relevance, high RoB, or both were excluded. Success percentages and mean values were extracted.

Results

A total of 955 unique studies were retrieved. Fourteen of these satisfied the eligibility criteria. All of the included studies carried a high relevance and a moderate RoB. The majority of studies were 1-armed trials, in which the Epley was repeated only in case previous attempt(s) had failed. The maneuver was not repeated if it was successful. In 32% to 90% of patients, the first treatment session was successful. Reported cumulative success percentages ranged from 40% to 100% after the second session, 67% to 98% after the third session, 87% to 100% after the fourth session, and 100% in the studies in which patients received 5 sessions. One study evaluating the effect of multiple maneuvers in a single session showed a rise in success percentages from 84% for 1 maneuver to 90% after 2 maneuvers and 92% after 3 maneuvers.

Conclusion

Multiple studies with moderate RoB show a beneficial effect of multiple sessions of the Epley maneuver in p-BPPV patients who are not fully cleared of symptoms after the first session.

Rapid Systematic Review of the Epley Maneuver for Treating Posterior Canal Benign Paroxysmal Positional Vertigo

OBJECTIVE

The aim of this study was to compare watchful waiting to the Epley maneuver as a management option for patients with posterior canal benign paroxysmal positional vertigo (p-BPPV) regarding symptom relief.

DATA SOURCES

PubMed, Embase, and The Cochrane Library.

METHODS

A systematic search was conducted. Studies reporting original study data were included. Relevance and risk of bias (RoB) of the selected articles were assessed. Studies with low relevance, high RoB, or both were excluded. Absolute risk differences and their 95% confidence intervals (CIs) were extracted for the included studies.

RESULTS

A total of 1448 unique studies were retrieved. Eight of these satisfied the eligibility criteria. At 1-week follow-up, all included studies reported a clinically relevant effect in favor of the Epley maneuver regarding symptom relief (absolute risk differences ranging from 20% [95% CI, 5%-37%] to 59% [95% CI, 32%-76%]) or conversion to a negative Dix-Hallpike (absolute risk differences ranging from 17% [95% CI, -5%-37%] to 64% [95% CI, 29%-79%]). At 1-month follow-up, the results of the included studies diverged further. Absolute risk differences ranged from 6% (95% CI, -24%-35%) more symptom relief in favor of watchful waiting to 79% (95% CI, 56%-88%) in favor of the Epley maneuver.

CONCLUSION AND RECOMMENDATIONS

All data of the selected studies show a benefit in favor of the Epley maneuver at 1-week follow-up in the management of p-BPPV. The Epley maneuver should be considered in all patients with p-BPPV.

Canalith repositioning variations for benign paroxysmal positional vertigo

OBJECTIVE

To determine if variations in common treatments for benign paroxysmal positional vertigo (BPPV) affected efficacy.

STUDY DESIGN

Prospective, pseudo-randomized study.

SETTING

Outpatient practice in a tertiary care facility.

SUBJECTS AND METHODS

Patients (n = 118) with unilateral BPPV of the posterior canal, including 13 patients with BPPV of the lateral canal, were tested at a tertiary care center on one of five interventions: canalith repositioning maneuver (CRP), CRP plus home exercise, modified CRP, CRP for patients with involvement of two semicircular canals, and self-CRP home exercise. Self-CRP was also compared to previously published data on efficacy of the Brandt Daroff exercise. Main outcome measures were vertigo intensity and frequency, presence/absence of Dix-Hallpike responses, Vestibular Disorders Activities of Daily Living Scale (VADL), and computerized dynamic posturography.

RESULTS

Vertigo intensity and frequency and Dix-Hallpike responses decreased significantly, and posturography and VADL improved significantly from pre- to post tests. No other significant changes were found. The groups did not differ significantly. Vertigo intensity and frequency were not strongly related at pretest but were related at post-test. Length of illness and age did not influence the results.

CONCLUSION

However the head is moved, as long as it is moved rapidly enough and through the correct planes in space, repositioning treatments are likely to be effective. Therefore, clinicians have a range of choices in selecting the treatment best suited for each patient's unique needs.

Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review

BACKGROUND

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo.

PURPOSE

The purpose of this systematic review was to determine whether patients diagnosed with posterior canal (PC) BPPV, based on positional testing, and treated with a particle repositioning maneuver will show the resolution of benign paroxysmal positional nystagmus (BPPN) on the Dix-Hallpike Test performed 24 hours or more after treatment.

DATA SOURCES

Data were obtained from an electronic search of the MEDLINE, EMBASE, and CINAHL databases from 1966 through September 2009.

STUDY SELECTION

The study topics were randomized controlled trials (RCTs), quasi-RCTs, the diagnosis of PC BPPV, treatment with the particle repositioning maneuver, and outcome measured with a positional test 24 hours or more after treatment.

DATA EXTRACTION

Data extracted were study descriptors and the information used to code for effect size.

DATA SYNTHESIS

In 2 double-blind RCTs, the odds in favor of the resolution of BPPN were 22 times (95% confidence interval=3.41-141.73) and 37 times (95% confidence interval=8.75-159.22) higher in people receiving the canalith repositioning procedure (CRP) than in people receiving a sham treatment. This finding was supported by the results reported in 8 nonmasked quasi-RCTs. Studies with limited methodological quality suggested that a liberatory maneuver (LM) was more effective than a control intervention; there was no significant difference in the effectiveness of the LM and the effectiveness of the CRP; the self-administered CRP was more effective than the self-administered LM; and the CRP administered together with the self-administered CRP was more effective than the CRP administered alone. The Brandt-Daroff exercises were the least effective self-administered treatments.

LIMITATIONS

The limitations included the methodological quality of the studies, the lack of quality-of-life measures, and confounding factors in reporting vertigo.

CONCLUSIONS

Randomized controlled trials provided strong evidence that the CRP resolves PC BPPN, and quasi-RCTs suggested that the CRP or the LM performed by a clinician or with proper instruction at home by the patient resolves PC BPPN. There were no data on the effects of the maneuvers on outcomes relevant to patients.

Retrospective comparison of outcomes for patients with benign paroxysmal positional vertigo based on length of postural restrictions

PURPOSE

Benign paroxysmal positional vertigo (BPPV) is the most common cause of vertigo in older adults. The effectiveness of the repositioning maneuver as an intervention has been established in the literature; however, the efficacy of the posttreatment instructions has not been established. The purpose of this retrospective study was compare treatment outcomes for patients receiving 24 hour postural restrictions posttreatment versus 48 hour restrictions.

METHODS

Medical records of 76 patients diagnosed with BPPV at an outpatient physical therapy practice were reviewed. The average age was 61.05 years (SD 16.16). A positive outcome was determined by partial or complete resolution of symptoms, defined as a reduction in the number of special tests or positions that provoked symptoms from initial examination to discharge, as well as a reduction in vertigo intensity ratings.

RESULTS

Patients in both groups experienced significant reductions in the number of symptom provoking positions, positive special tests, and ratings of vertigo intensity following treatment. Mean ratings of vertigo intensity on a 10 point scale were 5.71 pre and 1.83 post for the 24 hour group, and 6.75 pre and 3.00 post for the 48 hour group. Positive treatment outcomes were experienced by 95.4% of patients in the 24 hour group (n=63), with 53% (n=35) achieving complete resolution.

CONCLUSION

Patients experienced positive treatment outcomes regardless of the length of postural restrictions following repositioning maneuver for BPPV. Therapists can reduce the length of postural restrictions to 24 hours upright following a repositioning maneuver without adversely affecting patient outcomes.

Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo

Objectives:

This guideline provides evidence-based recommendations on managing benign paroxysmal positional vertigo (BPPV), which is the most common vestibular disorder in adults, with a lifetime prevalence of 2.4 percent. The guideline targets patients aged 18 years or older with a potential diagnosis of BPPV, evaluated in any setting in which an adult with BPPV would be identified, monitored, or managed. This guideline is intended for all clinicians who are likely to diagnose and manage adults with BPPV.

Purpose:

The primary purposes of this guideline are to improve quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary tests such as radiographic imaging and vestibular testing, and to promote the use of effective repositioning maneuvers for treatment. In creating this guideline, the American Academy of Otolaryngology—Head and Neck Surgery Foundation selected a panel representing the fields of audiology, chiropractic medicine, emergency medicine, family medicine, geriatric medicine, internal medicine, neurology, nursing, otolaryngology–head and neck surgery, physical therapy, and physical medicine and rehabilitation.

Results

The panel made strong recommendations that 1) clinicians should diagnose posterior semicircular canal BPPV when vertigo associated with nystagmus is provoked by the Dix-Hallpike maneuver. The panel made recommendations against 1) radiographic imaging, vestibular testing, or both in patients diagnosed with BPPV, unless the diagnosis is uncertain or there are additional symptoms or signs unrelated to BPPV that warrant testing; and 2) routinely treating BPPV with vestibular suppressant medications such as antihistamines or benzodiazepines. The panel made recommendations that 1) if the patient has a history compatible with BPPV and the Dix-Hallpike test is negative, clinicians should perform a supine roll test to assess for lateral semicircular canal BPPV; 2) clinicians should differentiate BPPV from other causes of imbalance, dizziness, and vertigo; 3) clinicians should question patients with BPPV for factors that modify management including impaired mobility or balance, CNS disorders, lack of home support, and increased risk for falling; 4) clinicians should treat patients with posterior canal BPPV with a particle repositioning maneuver (PRM); 5) clinicians should reassess patients within 1 month after an initial period of observation or treatment to confirm symptom resolution; 6) clinicians should evaluate patients with BPPV who are initial treatment failures for persistent BPPV or underlying peripheral vestibular or CNS disorders; and 7) clinicians should counsel patients regarding the impact of BPPV on their safety, the potential for disease recurrence, and the importance of follow-up. The panel offered as options that 1) clinicians may offer vestibular rehabilitation, either self-administered or with a clinician, for the initial treatment of BPPV and 2) clinicians may offer observation as initial management for patients with BPPV and with assurance of follow-up. The panel made no recommendation concerning audiometric testing in patients diagnosed with BPPV.

Disclaimer:

This clinical practice guideline is not intended as a sole source of guidance in managing benign paroxysmal positional vertigo. Rather, it is designed to assist clinicians by providing an evidence-based framework for decision-making strategies. The guideline is not intended to replace clinical judgement or establish a protocol for all individuals with this condition, and may not provide the only appropriate approach to diagnosing and managing this problem. ® 2008 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.

Long-term follow up after Epley's manoeuvre in patients with benign paroxysmal positional vertigo

Objective:

To assess the long-term efficacy of Epley's manoeuvre performed to treat benign paroxysmal positional vertigo.

Patients and methods:

Two hundred and sixty-nine patients suffering benign paroxysmal positional vertigo were offered Epley's manoeuvre. After five years, follow up was arranged. One hundred and three patients attended for follow up (58 women and 45 men; age range 19–65 years). As mentioned 269 patients were offered the EM and 103 of them were available for follow up. Prior to initial Epley's manoeuvre treatment, these patients' duration of benign paroxysmal positional vertigo had ranged from four to 96 weeks.

Results:

Five years after treatment of benign paroxysmal positional vertigo with Epley's manoeuvre, 65 per cent of patients reported no further attacks. Kaplan–Meier testing showed that the time to recurrence was significantly longer in patients aged less than 40 years, those with a duration of attacks of less than three years prior to initial Epley's manoeuvre treatment, and those suffering less than six exacerbations prior to initial Epley's manoeuvre treatment. Gender had no effect on time to recurrence. Duration of illness before receiving Epley's manoeuvre was the only independent predictor of recurrence.

Conclusion:

Epley's manoeuvre remains an effective modality for treatment of benign paroxysmal positional vertigo. A patient age of less than 40 years and duration of attacks of less than three years are good prognostic factors. Exacerbation number and gender do not affect the probability of benign paroxysmal positional vertigo recurrence after five years; however, these factors do affect the duration of time free from the condition.

Clinical features of benign paroxysmal positional vertigo in Western Turkey

BACKGROUND

It was the aim of this study to analyze the clinical manifestations, the incidence of each variant and the comorbid conditions of benign paroxysmal positional vertigo (BPPV) as well as the response to treatment.

METHODS

One hundred and fifty-seven patients with BPPV were reviewed prospectively. An extensive neurotologic examination was performed. All patients were treated with an appropriate canalith repositioning maneuver (CRM).

RESULTS

In 138 patients, the posterior canal (PC) was involved, in 14 patients, the horizontal canal (HC), in 2 patients, the anterior canal (AC), and in 3 patients, both the PC and HC. A history of head trauma was identified in 17 patients. In 1 patient sensorineural hearing loss on the affected side and in another bilateral peripheral vestibular loss was present. A history of migraine was reported in 21 cases. A resolution attributable to the first CRM was achieved in 132 patients.

CONCLUSIONS

PC involvement was the most frequent type constituting 87.9% of all BPPV cases. HC, AC and mixed canal types were relatively rare constituting 8.9, 1.3 and 1.9% of the cases, respectively. Response to the first CRM was recorded in 84.1%. Association with migraine was recorded in 13.4% of the patients.

Manobras para o tratamento da vertigem posicional paroxística benigna: revisão sistemática da literatura

A Vertigem Posicional Paroxística Benigna (VPPB) é uma das mais freqüentes patologias do sistema vestibular e é caracterizada por episódios de vertigens recorrentes desencadeados por movimentos da cabeça ou mudanças posturais. Há várias opções para o seu tratamento, porém as efetividades terapêuticas das mesmas permanecem controversas. OBJETIVO: Avaliar a efetividade terapêutica das manobras específicas disponíveis para o tratamento da VPPB. METODOLOGIA: Realizou-se uma busca eletrônica nas principais bases de dados, selecionando-se estudos clínicos randomizados envolvendo adultos com diagnóstico de VPPB confirmado com o teste de Dix-Hallpike e tratamento com manobras específicas (Epley ou Semont, por exemplo). Considerou-se como desfecho clínico a negativação do teste de Dix-Hallpike e a melhora das queixas subjetivas. Agruparam-se em metanálise os estudos com Escala de Jadad igual ou superior a três. RESULTADOS: Cinco estudos clínicos preencheram os critérios de inclusão, ou seja, ensaios randomizados de fase I comparando a manobra de Epley com placebos e controles. A metanálise mostra evidência dos efeitos benéficos da manobra de Epley para o tratamento do canal semicircular posterior (magnitude do efeito de 0,11 [IC 95% 0.05, 0.26] de melhora objetiva (Dix-Halpike) após uma semana, 0.24 [IC 95% 0.13, 0.45] após um mês e 0.16 [IC 95% 0.08, 0.33] de melhora referida pelos pacientes após a primeira semana). CONCLUSÃO: Evidencia-se boa eficácia clínica da manobra de Epley para o tratamento da VPPB do canal semicircular posterior. Contrariamente, trabalhos com a manobra de Semont e as propostas de manejo dos demais canais semicirculares não obtiveram qualidade metodológica satisfatória, não sendo possível demonstrar a efetividade dos mesmos.

Maneuvers for the treatment of benign positional paroxysmal vertigo: a systematic review

Benign Paroxysmal Positional Vertigo (BPPV) is one of the most frequent diseases of the vestibular system and it is characterized by episodes of recurrent vertigo triggered by head movements or position changes. There are several approaches for treatment, but efficacy is still being discussed.

Aim

To asses the effectiveness of the specific maneuvers available to the treatment of BPPV.

Methodology

An electronic search at the main databases, including MEDLINE, LILACS, PEDro, Cochrane Collaborations Database was performed, and we selected only randomized clinical trials studying adults with diagnosis of BPPV confirmed by the Dix-Hallpike test. The trials should have included physical maneuvers such as Epley and Semont. The main outcome was Dix-Hallpike negative test and the changes to subjective complaints. The trials were assessed using Jadad's scale and only studies with quality scores equal or above 3 were pooled on a meta-analyses to assess their effectiveness.

Results

We found five controlled clinical trials phase I comparing the Epley's maneuver with controls or placebo. The metaanalysis showed positive evidence of Epley's maneuver to the posterior semicircular canal (effect size = 0.11 [CI 95% 0.05, 0.26] of objective improvement [Dix-Halpike] within one week, 0.24 [CI 95% 0.13, 0.45] within one month and 0.16 [CI 95% 0.08, 0.33] of improvement reported by the patients within one week. There are no studies about the efficacy of Semont's maneuver.

Conclusion

There is scientific evidence showing good efficacy of Epley's maneuver in the treatment.

Epley's canalith-repositioning manoeuvre for benign paroxysmal positional vertigo

The efficacy of the Epley's canalith-repositioning manoeuvre in the treatment of BPPV was assessed in this prospective study of 62 patients. Patients were selected based on symptoms of positional vertigo and positive Dix-Hallpike's positional test. Patients were divided into two groups; first group comprising 34 patients underwent Epley's manoeuvre alone where as the other group comprising 28 patients underwent Epley's manoeuvre along with mastoid oscillator. At the end of 1 month patients were assessed subjectively by visual analogue scale (VAS) and objectively by Dix-Hallpike's positional test. On VAS, 85.7% patients had complete resolution of symptoms of BPPV in both the groups. Objectively 88.2% did not have positional nysfagmus after 1 month in first group whereas in the second group 86% had complete response at the end of 1 month of therapy. Follow up of 6 months could be done in 38 patients, out of which 7 (18.4%) had recurrence of their symptom of vertigo and positive Dix-Hallpike's positional test, whereas one patient continued to have no relief by Epley's manoeuvre. There was no difference in subjective and objective parameters even when CRP was performed using mastoid vibrator.

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.

Canalith Repositioning for Benign Paroxysmal Positional Vertigo

OBJECTIVE

To evaluate the efficacy of canalith repositioning maneuvers (Semont, Epley, and modified maneuvers) in the treatment of posterior canal benign paroxysmal positional vertigo (BPPV) in comparison to the rate of resolution in the untreated control cohort.

DATA SOURCES

Source articles were identified by a MEDLINE search of English language sources before 2004 plus manual crosschecks of bibliographies from identified articles, selected national meeting abstracts, review article references, and textbook chapters.

STUDY SELECTION

Each controlled trial that compared canalith repositioning patients to untreated control subjects in posterior canal benign positional vertigo (blinded and unblinded) was reviewed for inclusion.

DATA EXTRACTION

Data were abstracted systematically, scaled on validity and comparability, and cross-checked independently by another author.

DATA SYNTHESIS

Studies were combined with fixed effects meta-analysis to estimate spontaneous resolution, 95% confidence intervals (CI) of effect size, and heterogeneity.

CONCLUSION

Canalith repositioning is more effective than observation alone for the treatment of benign paroxysmal positional vertigo, despite spontaneous resolution rates of one in three at 3 weeks. Public health implications are discussed, based on the high frequency of unrecognized BPPV reported in elderly patients, and the improvements after canalith repositioning in postural control and health-related quality of life (SF 36 Health Survey) documented in the literature.

Effectiveness of treatment techniques in 923 cases of benign paroxysmal positional vertigo

OBJECTIVE

To present treatment effectiveness of 923 consecutive cases of benign paroxysmal positional vertigo (BPPV) using canalith repositioning, liberatory, and log roll maneuvers combined with redistribution exercises.

STUDY DESIGN

Retrospective case review.

METHODS

Patients presented with either posterior semicircular canal (P-SCC) BPPV or horizontal semicircular canal (H-SCC) BPPV. Diagnosis was based on patient history of transient paroxysmal vertigo and a positive Dix-Hallpike response with either torsional or horizontal nystagmus. Patients with P-SCC BPPV numbered 840, and 83 patients had H-SCC BPPV. In the original study, there were 1,000 patients; however, 77 patients were dropped from the study because of lack of follow-through. Intervention was canalith repositioning, liberatory maneuvers, log roll maneuvers, and redistribution exercises. Patients numbering 607 were treated with canalith repositioning, 233 patients had liberatory maneuvers, and 83 received log roll maneuvers. All patients received redistribution exercises before treatment maneuvers. After intervention, patients were reassessed at 6 months.

RESULTS

There were 601 women and 322 men from ages 12 to 94 (median 55) years. The average duration of symptoms before intervention was 30 months. Outcome measures were considered met when symptoms of BPPV had abated and patients demonstrated a negative Dix-Hallpike response. In the repositioning group, 94% of patients were symptom free or improved, 98% in the liberatory maneuver group and 100% in the log roll group. The average number of sessions was three for all groups. Recurrence of symptoms was demonstrated in 140 (16%) patients at 6 months.

CONCLUSIONS

Treatment of BPPV can be effective using either repositioning, liberatory, or log roll maneuvers in combination with redistribution exercises.

Restrições posturais não interferem nos resultados da manobra de reposição canalicular

A Vertigem Posicional Paroxística Benigna (VPPB) é uma das mais comuns doenças da orelha interna que cursam com tontura, porém o seu tratamento ainda é algo de inúmeras controvérsias. OBJETIVO: Avaliar a influência das orientações posturais na evolução precoce de pacientes com diagnóstico de VPPB de canal semicircular posterior, submetidos à manobra de Epley. FORMA DE ESTUDO: Prospectivo randomizado. MATERIAL E MÉTODO: Foram avaliados 50 pacientes com diagnóstico de VPPB de canal semicircular posterior submetidos à manobra de reposição canalicular de Epley, divididos em Grupo de Estudo - 23 pacientes - que receberam orientações de restrição postural pós-manobra e Grupo Controle - 27 pacientes - que não receberam orientações. RESULTADOS: Não houve diferença estatisticamente significante entre os grupos estudados quanto à resolução dos sintomas da VPPB independentemente de sexo e idade. CONCLUSÃO: A eficácia da Manobra de Reposição Canalicular de Epley não é influenciada pelo uso ou não das restrições posturais.

Posture restrictions do not interfere in the results of canalith repositioning maneuver

Benign Paroxysmal Positional Vertigo (BPPV) is a frequent cause of dizziness and despite of the excellent results with its treatment, there is some controversy about management.

Aim

To assess the efficacy of Epley Maneuver with and without post-maneuver restrictions.

Study design

Prospective randomized.

Material and Method

Fifty patients presenting BPPV of the posterior semicircular canal, treated with Epley Maneuver and divided into two groups: study group – 23 patients – with post-maneuver restrictions, and control group – 27 patients – without post-maneuver restrictions.

Results

No significant difference was found between the studied and the control group.

Conclusion

Post-maneuver restrictions do not influence the efficacy of Epley Maneuver for BPPV management.

The Canalith Repositioning Procedure for Benign Positional Vertigo: A Meta-Analysis

OBJECTIVE

To review the effectiveness of the canalith repositioning procedure (CRP) in the treatment of benign paroxysmal positional vertigo (BPPV) with a critical review of the literature and meta-analysis.

STUDY DESIGN

Meta-analysis.

METHODS

Studies eligible for inclusion were randomized, controlled trials of the CRP performed on clearly defined cases of BPPV. A total of nine studies meeting inclusion criteria were identified by two independent literature searches of Medline. Treatment and control groups were compared for symptom resolution and elimination of a positive Dix-Hallpike test.

RESULTS

Patients treated with CRP were more likely to demonstrate symptom resolution (odds ratio [OR] 4.6; 95% confidence interval [CI] 2.8-7.6) and negative Dix-Hallpike (OR 5.2; 95% CI 3.0-8.8) at the time of first follow-up. The effect of CRP for symptom improvement was strongest within the first month after treatment (OR 4.1; 95% CI 3.1-5.2) with some decline thereafter (OR 2.8; 95% CI 1.7-3.9). Conversely, the ability of CRP to produce a negative Dix-Hallpike strengthened between the first month after treatment (OR 3.0; 95% CI 1.8-4.0) and later follow-up times (OR 5.0; 95% CI 3.9-6.1).

CONCLUSIONS

The CRP is more effective than control in resolving vertigo and positive Dix-Hallpike associated with BPPV. This finding was consistent among a variety of studies using different study designs. Untreated patients may demonstrate symptom improvement with time; however, many will continue to have a positive Dix-Hallpike when examined. Resolution of vertigo in untreated patients is therefore most likely because of avoidance of provocative positions.

The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo

BACKGROUND

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 compared to other treatments available for posterior canal benign paroxysmal positional vertigo, or no treatment.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library Issue 1, 2004), MEDLINE (1966 to 2004), EMBASE (1974 to 2004) and reference lists of identified publications. Date of the most recent search was January 2004.

SELECTION CRITERIA

Randomised trials of adults diagnosed with posterior canal BPPV (including a positive Dix-Hallpike test). Comparisons sought: Epley manoeuvre versus placebo Epley manoeuvre versus untreated controls Epley manoeuvre versus other active treatment Outcome measures that were considered include: frequency and severity of attacks of vertigo; proportion of patients improved by each intervention; and conversion of a "positive" Dix-Hallpike test to a "negative" Dix-Hallpike test

DATA COLLECTION AND ANALYSIS

Both reviewers independently extracted data and assessed trials for quality.

MAIN RESULTS

Fifteen trials were identified but twelve studies were excluded because of a high risk of bias, leaving three trials in the review. Trials were mainly excluded because of inadequate concealment during randomisation, or failure to blind outcome assessors. The studies included in the review (Lynn 1995; Froehling 2000; Yimtae 2003) addressed the efficacy of the Epley manoeuvre against a sham manoeuvre or control group by comparing the proportion of subjects in each group who had complete resolution of their symptoms, and who converted from a positive to negative Dix-Hallpike test. Individual and pooled data showed a statistically significant effect in favour of the Epley manoeuvre over controls. There were no serious adverse effects of treatment.

REVIEWERS' CONCLUSIONS

There is some evidence that the Epley manoeuvre is a safe effective treatment for posterior canal BPPV, although this is based on the results of only three small randomised controlled trials with relatively short follow up. There is no good evidence that the Epley manoeuvre provides a long term resolution of symptoms. There is no good evidence comparing the Epley manoeuvre with other physical, medical or surgical therapy for posterior canal BPPV.

Pathology of benign paroxysmal positional vertigo revisited

The pathophysiology of benign paroxysmal positional vertigo (BPPV) is not completely understood. Although the concept of degenerated otoconia transforming the posterior canal (PC) crista into a gravity-sensitive sense organ has gained popular support, several temporal bone (TB) series have revealed similar deposits in normal TBs, suggesting they are a normal change in the aging labyrinth. Furthermore, some TBs from patients with BPPV do not contain particles in the posterior canal. Five TBs from patients with BPPV were studied quantitatively and qualitatively. A small PC cupular deposit was found in 1 TB, while none was seen in the other 4 TBs. The major pathological changes were 1) a 50% loss of ganglion cells in the superior vestibular division of all 5 TBs and 2) a 50% loss of neurons in the inferior division of 3 TBs, and a 30% loss in 2 TBs that contained abnormal saccular ganglion cells. These observations support a concept in the pathophysiology of BPPV that includes loss of the inhibitory effect of otolith organs on canal sense organs.

A randomized trial of the canalith repositioning procedure

OBJECTIVE

To compare the effectiveness and complications of our adaptation of the canalith repositioning procedure (CRP) with the expectation treatment for benign paroxysmal positional vertigo.

STUDY DESIGN

A randomized, controlled trial in the setting of a neurotological clinic in Thailand.

METHODS

Fifty-eight patients with posterior benign paroxysmal positional vertigo were randomly assigned to treatment and control groups using a block of four. The treatment group was treated with the modified CRP technique until the nystagmus disappeared. A mastoid oscillator was not used, nor were any instructions given for patients after the maneuver. Both groups recorded the daily grading of symptoms and the amount of anti-vertiginous drugs (cinnarizine) taken. Objective and subjective assessments were made weekly until the nystagmus disappeared or until 4 weeks had passed since treatment began.

RESULTS

The rates of effectiveness of CRP treatment and the control treatment for benign paroxysmal positional vertigo were 75.9% and 48.2%, respectively. There was a significant difference in the treatment outcomes of the CRP and control groups (P =.03). The CRP group used significantly fewer drugs than the control group (P =.001). Complications in the CRP group, such as lateral canalithiasis and fainting, were observed in 13.8% of the patients.

CONCLUSIONS

The CRP was more effective than the expectation treatment for benign paroxysmal positional vertigo insofar as it provided faster recovery and required less dependence on medication. Complications of CRP were limited to 13.8% of patients.

The Epley manoeuvre for benign paroxysmal positional vertigo--a systematic review

Benign paroxysmal positional vertigo (BPPV) is a syndrome characterized by short-lived episodes of vertigo in association with rapid changes in head position. Current treatment approaches include rehabilitative exercises and physical manoeuvres including the Epley manouevre. Randomized clinical trials of the Epley manoeuvre were identified. Outcome measures that were considered include: frequency and severity of attacks of vertigo; proportion of patients improved by each intervention; and conversion of a 'positive' Dix-Hallpike test to a 'negative' Dix-Hallpike test. Patients who received the Epley manoeuvre were more likely to have complete resolution of their symptoms [odds ratio 4.92 (95% C.I. 1.84-13.16)], and more likely to convert from a positive to negative Dix-Hallpike test [odds ratio 5.67 (95% C.I. 2.21-14.56)]. There were no serious adverse effects of treatment. There is some evidence that the Epley manouevre is a safe effective treatment for posterior canal BPPV.

The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo

BACKGROUND

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 compared to other treatments available for posterior canal benign paroxysmal positional vertigo, or no treatment.

SEARCH STRATEGY

The Cochrane Controlled Trials Register (Cochrane Library, Issue 2 2001), MEDLINE (1966 onwards), EMBASE (1974 onwards), and reference lists of identified publications. Date of the most recent search was June 2001.

SELECTION CRITERIA

Randomised trials of adults diagnosed with posterior canal BPPV (including a positive Dix-Hallpike test). Comparisons sought: - Epley manoeuvre versus placebo. - Epley manoeuvre versus untreated controls. Epley manoeuvre versus other active treatment. Outcome measures that were considered include: frequency and severity of attacks of vertigo; proportion of patients improved by each intervention; and conversion of a "positive" Dix-Hallpike test to a "negative" Dix-Hallpike test

DATA COLLECTION AND ANALYSIS

Both reviewers independently extracted data and assessed trials for quality.

MAIN RESULTS

Eleven trials were identified but nine studies were excluded because of a high risk of bias, leaving two trials in the review. Trials were mainly excluded because of inadequate concealment during randomisation, or failure to blind outcome assessors. Both studies included in the review (Lynn 1995, Froehling 2000) addressed the efficacy of the Epley manoeuvre against a sham manoeuvre by comparing the proportion of subjects in each group who had complete resolution of their symptoms, and who converted from a positive to negative Dix-Hallpike test. Individual and pooled data showed a statistically significant effect in favour of the Epley manoeuvre over controls. There were no serious adverse effects of treatment.

REVIEWER'S CONCLUSIONS

~bullet~There is some evidence that the Epley manoeuvre is a safe effective treatment for posterior canal BPPV, although this is based on the results of only two small randomised controlled trials with relatively short follow up. ~bullet~There is no good evidence that the Epley manoeuvre provides a long term resolution of symptoms. ~bullet~There is no good evidence comparing the Epley manoeuvre with other physical, medical or surgical therapy for posterior canal BPPV.