Tools for Practice


#144 Evaluating the Epley Maneuver: When one good turn deserves another


CLINICAL QUESTION
How effective are Epley maneuvers in the treatment of Benign Paroxysmal Positional Vertigo (BPPV)?


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



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EVIDENCE
  • Six systematic reviews of Randomized Controlled Trials (RCTs): Consistently support Epley maneuvers (as classically described) despite considerable heterogeneity.1-6 
    • Most recent (11 RCTs, 745 patients):1 
      • Epley versus controat 24 hours to four weeks, results statistically significant: 
        • Resolution of symptoms (five RCTs, 273 patients)56% versus 21% with control, Number Needed to Treat (NNT)=3 
        • Conversion from Positive to Negative Dix-Hallpike (eight RCTs, 507 patients)80% versu37% with control, NNT=3. 
      • Few small studies compare Epley to other maneuvers and report equivalence (example Semont and Gans Maneuvers) or inferiority of these interventions (example Brandt-Droff). 
  • Post-Epley movement restriction such as neck brace or postural advice (avoiding lying on affected side for 1-5 days and sleeping upright for 24-48 hours).7,8 Two systematic reviews of RCTs: Slightly different inclusion criteria leading to different conclusions:7,8 
    • Largest:7 
      • Resolution of symptoms and negative Dix-Hallpike (nine RCTs, 1,078 patients): 86% versus 85% without restriction 
    • Smallest:8 
      • Resolution of symptoms (two RCTs, 119 patients)Not statistically different 52% versus 41% without restrictions. 
      • Negative Dix-Hallpike (nine RCTs, 528 patients): Statistically different 89% versu78% without restrictions.  
Context:   
  • Natural history of BPPV unclear.1 One small trial reported that 36.5% of patients experienced recurrence of symptoms over 48 months.9 
  • Classical Epley maneuver is performed by clinicianOnline examples are available.10,11  
  • Two small RCTs demonstrated that self treatment with the modified Epley maneuver (three times daily until symptoms resolve) can result in significant symptom improvement.12,13 
    • Examples available online;14 however, trials that demonstrated improvement included initial supervision of the maneuver by an instructor.12  
  • Adverse events poorly reported. Most commonlyNeck discomfort, transient nausea, and disequilibrium.8 


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Author(s):

  • Christina Korownyk MD CCFP
  • Emelie Braschi PhD MD

1. Hilton MP, Pinder DK. Cochrane Database Syst Rev. 2014; 12:CD003162.

2. Helminski JO, Zee DS, Janssen I, et al. Phys Ther. 2010; 90:663-78.

3. Teixeira LJ, Machado JN. Braz J Otorhinolaryngol. 2006; 72:130-9.

4. Woodworth BA, Gillespie MB, Lambert PR. Laryngoscope. 2004; 114:1143-6.

5. White J, Savvides P, Cherian N, et al. Otol Neurotol. 2005; 26:704-10.

6. Hilton M, Pinder D. Clin Otolaryngol Allied Sci. 2002; 27:440-5.

7. Mostafa BE, Youssef TA, Hamad AS. Eur Arch Otorhinolaryngol. 2013; 270:849-52.

8. Hunt WT, Zimmermann EF, Hilton MP. Cochrane Database Syst Rev. 2012; 4:CD008675.

9. Amor-Dorado JC, Barreira-Fernandez MP, Aran-Gonzalez I, et al. Otol Neurotol. 2012; 33:1401-7.

10. Fauquier ENT. Epley maneuver to treat BPPV Vertigo. Available at: https://www.youtube.com/watch?v=9SLm76jQg3g. Accessed June 16, 2015.

11. Johns P. How to do the Epley maneuver. Available at: https://www.youtube.com/watch?v=7ZgUx9G0uEs. Accessed June 16, 2015.

12. Radtke A, von Brevern M, Tiel-Wilck K, et al. Neurology. 2004; 63:150-2.

13. Radtke A, Neuhauser H, von Brevern M, et al. Neurology. 1999; 53:1358-60.

14. Kerber KA, Burke JF, Skolarus LE, et al. Neurology. 2012; 79:376-80.

Authors do not have any conflicts to disclose.