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Benign Paroxysmal Positional Vertigo: is there evidence for the Epley maneuver?

It is fairly well accepted that Epley’s maneuver (Epley 1992) is an effective in-office treatment for Benign Paroxysmal Positional Vertigo (BPPV), at least in the short-term. 1 But before I get ahead of myself, here is a brief overview of BPPV.

Estimates are that between 11 and 64 people per 100,000 in the United States suffer from idiopathic BPPV each year, occurring most commonly between the ages of 50 and 70.2,3 BPPV is characterized by brief episodes of dizziness, sometimes with accompanying nausea, following changes in head position. The most common cause, idiopathic, is more common in females. Other causes include head trauma, vestibular neuritis or labyrinthitis from inflammation or infection, vertebrobasilar ischemia, and prolonged bed rest. 4 The Epley maneuver includes 4 distinct movements of the head and body thought to coax debris (or canaliths) from the posterior semicircular canal to the vestibule, where it no longer influences position sensory cells.

I recently read a systematic review authored by Hunt and colleagues,4 which studied clinical trials investigating modifications to the Epley maneuver. Modifications designed to improve effectiveness include vibrating the mastoid bone while performing the Epley maneuver, prescribing specific balance exercises after treatment, and restricting positions such as sleeping upright and avoiding head tilt in key directions for several days following treatment. The review was performed to answer the question: Do any modifications to the Epley maneuver result in a more efficacious treatment?

The authors analyzed results from 11 clinical trials concluding that only post Epley positional restrictions improved outcomes significantly from a statistical standpoint. However, the number needed to treat was calculated as 10, meaning that the statistical significance may not be all that clinically relevant. A number needed to treat of 10 roughly suggests that 10 patients need to undergo postural restrictions for every 1 person that shows more improvement than patients treated only with the basic Epley maneuver. So should we recommend postural restrictions in addition to utilizing the Epely maneuver? I suspect that decision is best made individually with each patient, but the evidence suggests that most patients with BPPV will improve following the Epley maneuver and won’t need additional postural restrictions following care.5,6

If you are unfamiliar with performing the Epley maneuver, there are plenty of scientific literature and video-based resources available to demonstrate it. The systematic review authored by Hunt and colleagues contains a reprint of the original description that can be easily followed.
Reference List

1. Hilton M, Pinder D. The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo. Cochrane Database Syst Rev. 2004;CD003162.
2. Froehling DA, Silverstein MD, Mohr DN, Beatty CW, Offord KP, Ballard DJ. Benign positional vertigo: incidence and prognosis in a population-based study in Olmsted County, Minnesota. Mayo Clin Proc. 1991;66:596-601.
3. Mizukoshi K, Watanabe Y, Shojaku H, Okubo J, Watanabe I. Epidemiological studies on benign paroxysmal positional vertigo in Japan. Acta Otolaryngol Suppl. 1988;447:67-72.
4. Hunt WT, Zimmermann EF, Hilton MP. Modifications of the Epley (canalith repositioning) manoeuvre for posterior canal benign paroxysmal positional vertigo (BPPV). Cochrane Database Syst Rev. 2012;4:CD008675.
5. Kaski D, Bronstein AM. Epley and beyond: an update on treating positional vertigo. Pract Neurol. 2014;14:210-221.
6. Wegner I, Niesten ME, van Werkhoven CH, Grolman W. Rapid Systematic Review of the Epley Maneuver versus Vestibular Rehabilitation for Benign Paroxysmal Positional Vertigo. Otolaryngol Head Neck Surg. 2014;151:201-207.

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