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Research ArticlePractice

Evaluating the Epley maneuver

Emélie Braschi, David Ross and Christina Korownyk
Canadian Family Physician October 2015, 61 (10) 878;
Emélie Braschi
Family medicine resident at McGill University in Montreal, Que.
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David Ross
Associate Professor, Department of Family Medicine at the University of Alberta in Edmonton.
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Christina Korownyk
Associate Professor, Department of Family Medicine at the University of Alberta in Edmonton.
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Clinical question

How effective is the Epley maneuver in treating benign paroxysmal positional vertigo (BPPV)?

Bottom line

Epley maneuvers will lead to complete resolution of symptoms for 1 in every 2 to 3 patients treated. Post-Epley movement restriction does not improve symptom resolution but might promote a negative Dix-Hallpike test result for 1 in every 10 patients treated.

Evidence

Six systematic reviews of RCTs consistently supported Epley maneuvers (as classically described) despite considerable heterogeneity among trials.1–6

  • Most recent review (11 RCTs, N = 745)1:

    • -Results were statistically significant for the Epley maneuver versus control at 24 hours and 4 weeks.

      • —Resolution of symptoms (5 RCTs, n = 273): 56% versus 21% with control (NNT = 3).

      • —Positive to negative Dix-Hallpike test result (8 RCTs, n = 507): 80% versus 37% with control (NNT = 3).

  • A few small studies compare the Epley to other maneuvers and report equivalence (eg, Semont and Gans) or inferiority (eg, Brandt-Daroff) of these interventions.

Two systematic reviews looked at movement restriction after the Epley maneuver, such as a neck brace or postural advice (avoid lying on affected side for 1 to 5 days and sleep upright for 24 to 48 hours).7,8 They had slightly different inclusion criteria leading to different conclusions.7,8

  • Larger review (9 RCTs, N = 1078)7:

    • -Resolution of symptoms and negative Dix-Hallpike test result: 86% versus 85% without restriction.

  • Smaller review8:

    • -Resolution of symptoms (2 RCTs, n = 119): 52% versus 41% without restrictions (not statistically different).

    • -Negative Dix-Hallpike test result (9 RCTs, n = 528): 89% versus 78% without restrictions (statistically different).

Context

  • The natural history of BPPV is unclear.1 One small trial reported that 36.5% of patients experienced recurrence of symptoms within 48 months.9

  • Clinicians perform the classical Epley maneuver while patient self-treatment is the modified Epley maneuver.

  • Two small RCTs found that modified Epley maneuvers (3 times daily until symptoms resolved) resulted in symptom improvement in 64% to 95% of patients by 1 week.10,11 Trials that demonstrated improvement included initial supervision by an instructor.10

  • Adverse events are poorly reported but include neck discomfort, transient nausea, and disequilibrium.8

Implementation

Generally, BPPV can be diagnosed clinically; neuroimaging is rarely required. Red flags include focal deficits with numbness or weakness, cerebellar signs including severe ataxia, unilateral hearing loss or tinnitus, and direction-changing nystagmus.12 The Epley maneuver is the treatment of choice. It is best demonstrated in the office, with patient handouts13 given if symptoms recur or do not resolve. Videos demonstrating the maneuver are also available online.14,15 In a retrospective study, 47% of patients obtained symptomatic control of BPPV after a single Epley maneuver; 84% experienced symptomatic improvement after 3 maneuvers.16

Notes

Tools for Practice articles in Canadian Family Physician (CFP) are adapted from articles published on the Alberta College of Family Physicians (ACFP) website, summarizing medical evidence with a focus on topical issues and practice-modifying information. The ACFP summaries and the series in CFP are coordinated by Dr G. Michael Allan, and the summaries are co-authored by at least 1 practising family physician and are peer reviewed. Feedback is welcome and can be sent to toolsforpractice{at}cfpc.ca. Archived articles are available on the ACFP website: www.acfp.ca.

Footnotes

  • The opinions expressed in Tools for Practice articles are those of the authors and do not necessarily mirror the perspective and policy of the Alberta College of Family Physicians.

  • Copyright© the College of Family Physicians of Canada

References

  1. 1.↵
    1. Hilton MP,
    2. Pinder DK
    . The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev 2014;(12):CD003162.
  2. 2.
    1. Helminski JO,
    2. Zee DS,
    3. Janssen I,
    4. Hain TC
    . Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review. Phys Ther 2010;90:663-78.
    OpenUrlAbstract/FREE Full Text
  3. 3.
    1. Teixeira LJ,
    2. Machado JN
    . Maneuvers for the treatment of benign positional paroxysmal vertigo: a systematic review. Braz J Otorhinolaryngol 2006;72:130-9.
    OpenUrlPubMed
  4. 4.
    1. Woodworth BA,
    2. Gillespie MB,
    3. Lambert PR
    . The canalith repositioning procedure for benign positional vertigo: a meta-analysis. Laryngoscope 2004;114:1143-6.
    OpenUrlCrossRefPubMed
  5. 5.
    1. White J,
    2. Savvides P,
    3. Cherian N,
    4. Oas J
    . Canalith repositioning for benign paroxysmal positional vertigo. Otol Neurotol 2005;26:704-10.
    OpenUrlCrossRefPubMed
  6. 6.↵
    1. Hilton M,
    2. Pinder D
    . The Epley manoeuvre for benign paroxysmal positional vertigo—a systematic review. Clin Otolaryngol Allied Sci 2002;27:440-5.
    OpenUrlCrossRefPubMed
  7. 7.↵
    1. Mostafa BE,
    2. Youssef TA,
    3. Hamad AS
    . The necessity of post-maneuver postural restriction in treating benign paroxysmal positional vertigo: a meta-analytic study. Eur Arch Otorhinolaryngol 2013;270:849-52.
    OpenUrlPubMed
  8. 8.↵
    1. Hunt WT,
    2. Zimmermann EF,
    3. Hilton MP
    . Modifications of the Epley (canalith repositioning) manoeuvre for posterior canal benign paroxysmal positional vertigo (BPPV). Cochrane Database Syst Rev 2012;(4):CD008675.
  9. 9.↵
    1. Amor-Dorado JC,
    2. Barreira-Fernandez MP,
    3. Aran-Gonzalez I,
    4. Casariego-Vales E,
    5. Llorca J,
    6. González-Gay MA
    . Particle repositioning maneuver versus Brandt-Daroff exercise for treatment of unilateral idiopathic BPPV of the posterior semicircular canal: a randomized prospective clinical trial with short- and long-term outcome. Otol Neurotol 2012;33:1401-7.
    OpenUrlCrossRefPubMed
  10. 10.↵
    1. Radtke A,
    2. von Brevern M,
    3. Tiel-Wilck K,
    4. Mainz-Perchalla A,
    5. Neuhauser H,
    6. Lempert T
    . Self-treatment of benign paroxysmal positional vertigo: Semont maneuver vs Epley procedure. Neurology 2004;63:150-2.
    OpenUrlPubMed
  11. 11.↵
    1. Radtke A,
    2. Neuhauser H,
    3. von Brevern M,
    4. Lempert T
    . A modified Epley’s procedure for self-treatment of benign paroxysmal positional vertigo. Neurology 1999;53:1358-60.
    OpenUrlCrossRefPubMed
  12. 12.↵
    1. Nelson JA,
    2. Viirre E
    . The clinical differentiation of cerebellar infarction from common vertigo syndromes. West J Emerg Med 2009;10(4):273-7.
    OpenUrlPubMed
  13. 13.↵
    1. Stanford Primary Care Clinics
    . Patient information: benign paroxysmal positional vertigo. Stanford, CA: Stanford Primary Care Clinics; Available from: http://sim.stanford.edu/resources/smg_patient_info/VERTIGO03-10.pdf. Accessed 2015 Jul 4.
  14. 14.↵
    1. Chang C
    . Epley maneuver to treat BPPV vertigo [video]. YouTube; 2014. Available from: https://www.youtube.com/watch?v=9SLm76jQg3g. Accessed 2015 Jun 16.
  15. 15.↵
    1. Johns P
    . How to do the Epley maneuver [video]. YouTube; 2010. Available from: https://www.youtube.com/watch?v=9SLm76jQg3g. Accessed 2015 Jun 16.
  16. 16.↵
    1. Hughes D,
    2. Shakir A,
    3. Goggins S,
    4. Snow D
    . How many Epley manoeuvres are required to treat benign paroxysmal positional vertigo? J Laryngol Otol 2015;129(5):421-4.
    OpenUrlPubMed
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Canadian Family Physician: 61 (10)
Canadian Family Physician
Vol. 61, Issue 10
1 Oct 2015
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Evaluating the Epley maneuver
Emélie Braschi, David Ross, Christina Korownyk
Canadian Family Physician Oct 2015, 61 (10) 878;

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