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

Malcolm P Hilton; Darren K Pinder

doi:10.1002/14651858.CD003162.pub2

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

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Referencias

References to studies included in this review

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estudios excluidos
otras referencias

Froehling DA, Bowen JM, Mohr DN, Brey RH, Beatty CW, Wollan PC, et al. The canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo: a randomized controlled trial. Mayo Clinic Proceedings 2000;75(7):695‐700.

Lynn S, Pool A, Rose D, Brey R, Suman V. Randomized trial of the canalith repositioning procedure. Otolaryngology ‐ Head and Neck Surgery 1995;113(6):712‐20.

Munoz J, Miklea J, Howard M, Springate R, Kaczorowski J. Canalith repositioning maneuver for benign paroxysmal positional vertigo. Canadian Family Physician 2007;53:1048‐53.

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von Brevern M, Seelig T, Radtke A, Tiel‐Wilck K, Neuhauser H, Lempert T. Short‐term efficacy of Epley's manoeuvre: a double‐blind randomised trial. Journal of Neurology, Neurosurgery and Psychiatry 2006;77:980‐2.

Yimtae K, Srirompotong S, Srirompotong S, Sae‐seaw P. A randomized trial of the canalith repositioning procedure. Laryngoscope 2003;113:828‐32.

References to studies excluded from this review

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estudios incluidos
otras referencias

Angeli S, Hawley R, Gomez O. Systematic approach to benign paroxysmal positional vertigo in the elderly. Otolaryngology ‐ Head and Neck Surgery 2003;128:719‐25.

Asawavichianginda S, Isipradit P, Snidvongs K, Supiyaphun P. Canalith repositioning for benign paroxysmal positional vertigo: a randomized, controlled trial. Ear, Nose, and Throat Journal 2000;79(9):732‐4, 736‐7.

Blakley BW. A randomized, controlled assessment of the canalith repositioning maneuver [see comments]. Otolaryngology ‐ Head and Neck Surgery 1994;110(4):391‐6.

Cohen HS, Jerabek J. Efficacy of treatments for posterior canal benign paroxysmal positional vertigo. Laryngoscope 1999;109(4):584‐90.

Cohen HS, Kimball KT. Effectiveness of treatments for benign paroxysmal positional vertigo of the posterior canal. Otology and Neurotology 2005;26(5):1034‐40.

Herdman SJ, Tusa RJ, Zee DS, Proctor LR, Mattox DE. Single treatment approaches to benign paroxysmal positional vertigo. Archives of Otolaryngology ‐ Head and Neck Surgery 1993;119(4):450‐4.

Li JC. Mastoid oscillation: a critical factor for success in the canalith repositioning procedure. Otolaryngology ‐ Head and Neck Surgery 1995;112:670‐5.

Massoud EA, Ireland DJ. Post‐treatment instructions in the nonsurgical management of benign paroxysmal positional vertigo. Journal of Otolaryngology 1996;25(2):121‐5.

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Radtke A, Neuhauser H, von Brevern M, Lempert T. A modified Epley's procedure for self‐treatment of benign paroxysmal positional vertigo. Neurology 1999;53(6):1358‐60.

Sekine K, Imai T, Sato G, Ito M, Takeda N. Natural history of benign paroxysmal positional vertigo and efficacy of Epley and Lempert maneouvres. Otolaryngology ‐ Head and Neck Surgery 2006;135:529‐33.

Seo T, Miyamoto A, Saka N, Shimano K, Sakagami M. Immediate efficacy of the canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo. Otology & Neurotology 2007;28(7):917‐19.

Sherman D, Massoud E. Treatment outcomes of benign paroxysmal positional vertigo. Journal of Otolaryngology 2001;30(5):295‐9.

Soto Varela A, Bartual Magro J, Santos Perez S, Velez Regueiro M, Lechuga Garcia R, Perez‐Carro Rios TA, et al. Benign paroxysmal vertigo: a comparative prospective study of the efficacy of Brandt and Daroff exercies, Semont and Epley manoeuvre [Vertige positionnel paroxystique benin: etude comparative prospective sur l'efficacite des exercises de Brandt et Daroff, la manoeuvre de Semont et las manoeuvre d'Epley]. Revue de Laryngologie, Otologie, Rhinologie 2001;122(3):179‐83.

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Sridhar S, Panda N, Raghunathan M. Efficacy of particle repositioning maneuver in BPPV: a prospective study. American Journal of Otolaryngology 2003;24(6):355‐60.

Steenerson RL, Cronin GW. Comparison of the canalith repositioning procedure and vestibular habituation training in forty patients with benign paroxysmal positional vertigo. Otolaryngology ‐ Head and Neck Surgery 1996;114(1):61‐4.

Waleem SSU, Malik SM, Ullah S, Hassan Z. Office management of benign paroxysmal positional vertigo with Epley's manoeuvre. Journal of Ayub Medical College, Abbottabad 2008;20(1):77‐9.

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Wolf M, Hertanu T, Novikov I, Kronenberg J. Epley's manoeuvre for benign paroxysmal positional vertigo: a prospective study. Clinical Otolaryngology 1999;24(1):43‐6.

Additional references

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estudios incluidos
estudios excluidos

Baloh RW, Honrubia V, Jacobson K. Benign positional vertigo: clinical and oculographic features in 240 cases. Neurology 1987;37(3):371‐8.

Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, et al. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngology ‐ Head and Neck Surgery 2008;139:S47‐S81.

Brandt T, Daroff RB. Physical therapy for benign paroxysmal positional vertigo. Archives of Otolaryngology 1980;106(8):484‐5.

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Helminski JO, Zee DS, Janssen I, Hain TC. Effectiveness of particle repositioning maneuvers in the treatment of benign paroxysmal positional vertigo: a systematic review. Physical Therapy 2010;90(5):663‐78.

Hunt WT, Zimmermann EF, Hilton MP. Modifications of the Epley (canalith repositioning) manoeuvre for posterior canal benign paroxysmal positional vertigo (BPPV). Cochrane Database of Systematic Reviews 2012, Issue 4. [DOI: 10.1002/14651858.CD008675.pub2]

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Mizukoshi K, Watanabe Y, Shojaku H, Okubo J, Watanabe I. Epidemiological studies on benign paroxysmal positional vertigo in Japan. Acta Oto‐Laryngologica. Supplement 1988;447:67‐72.

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Characteristics of studies

Characteristics of included studies [ordered by study ID]

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estudios excluidos

Froehling 2000

Methods	Prospective randomised controlled trial; randomisation stratified by age and sex
Participants	50 patients greater than 18 years old (18 males, 32 females) Median symptom duration 43 days for the experimental group, 35 days for the sham group
Interventions	Modified Epley manoeuvre versus sham manoeuvre (lying on the affected side for 5 minutes)
Outcomes	1. Conversion of Dix‐Hallpike test from positive to negative 2. Subjective improvement by question, "Do you feel your dizziness has completely resolved?"
Notes	Follow up only at 1 to 2 weeks after treatment; no long‐term assessment
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Age/sex stratification suggests appropriate sequence generation
Allocation concealment (selection bias)	Unclear risk	—
Blinding (performance bias and detection bias) All outcomes	Low risk	Assessor blinded to treatment. Patients received realistic sham treatment
Incomplete outcome data (attrition bias) All outcomes	Low risk	No missing outcome data
Selective reporting (reporting bias)	Low risk	All outcomes reported
Other bias	Low risk	—

Lynn 1995

Methods	Prospective randomised controlled trial; sealed envelope randomisation strategy
Participants	36 patients between 23 years and 90 years (9 males, 24 females) Symptom duration for minimum 2 months
Interventions	Modified Epley manoeuvre versus sham manoeuvre (lying in the first lateral position of the Semont manoeuvre for 5 minutes)
Outcomes	1. Conversion of Dix‐Hallpike test from positive to negative 2. Daily diary of symptoms. Report of vertigo in the 7 days prior to reassessment at 1 month was "failure".
Notes	Follow up only at 1 month after treatment; no long‐term assessment
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Block randomisation
Allocation concealment (selection bias)	Low risk	Sealed envelopes
Blinding (performance bias and detection bias) All outcomes	Low risk	Assessor blinded. Patients experienced realistic, comparable sham treatment
Incomplete outcome data (attrition bias) All outcomes	Low risk	3 of 36 patients with incomplete data. Appropriate explanation of drop‐out, spread between groups.
Selective reporting (reporting bias)	Low risk	All outcomes reported
Other bias	Low risk	—

Munoz 2007

Methods	Prospective, double‐blind, randomised controlled trial
Participants	81 patients over 18 years of age. Eligible if self‐report of positional vertigo with a positive unilateral Dix‐Hallpike test. Patients excluded: central nervous system disease, otitis media, otosclerosis, inability to tolerate the manoeuvre, severe cervical spine or cardiac disease Higher proportion of female patients in the treatment group than control (81% versus 61%)
Interventions	Standard Epley treatment versus sham treatment (the sham treatment was an Epley manoeuvre performed as if opposite ear was affected)
Outcomes	1. Conversion of Dix‐Hallpike test from positive to negative 2. Subjective resolution of symptoms on Dix‐Hallpike testing
Notes	The patients were immediately re‐tested with a Dix‐Hallpike test after the treatment. It is this result reported in the outcome. We contacted the senior author for clarification. Patients were tested prior to their second treatment, i.e. 1 week following their first treatment (and before the 2nd treatment). Results for these tests were requested but have not been provided. The full trial report details include 2 follow‐up visits. However, patients in the sham treatment group all had conventional Epley treatment at the 2nd visit (if still symptomatic) and data from these subsequent visits are not included in the analysis.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer‐generated
Allocation concealment (selection bias)	Low risk	Central telephone allocation
Blinding (performance bias and detection bias) All outcomes	Low risk	Testing and assessment by a physician who had not administered the treatment, and was blind to study group
Incomplete outcome data (attrition bias) All outcomes	Low risk	Test results were immediately post‐treatment, and available for all patients
Selective reporting (reporting bias)	Unclear risk	Both outcomes are reported for the immediate post‐test assessment. It is unclear why results performed before the 2nd intervention were not included
Other bias	Low risk	—

von Brevern 2006

Methods	Prospective, double‐blind, randomised controlled trial
Participants	67 patients, 19 to 86 years; no baseline difference in groups Entry criteria were a typical history of positional vertigo combined with a typical pattern and latency of associated nystagmus on Dix‐Hallpike testing
Interventions	Epley manoeuvre versus sham treatment (the sham treatment was an Epley manoeuvre performed as if opposite ear was affected)
Outcomes	1. Change of Dix‐Hallpike test from positive to negative at 24 hours 2. Absence of symptoms on repeat Dix‐Hallpike testing after 24 hours
Notes	Follow‐up period and testing was only 24 hours. Stated aim was to reduce likelihood of any spontaneous resolution in the control (sham) group.
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Low risk	Computer‐generated randomised numbers
Allocation concealment (selection bias)	Low risk	Sealed envelope allocation
Blinding (performance bias and detection bias) All outcomes	Low risk	The assessor at 24 hours was blinded to the treatment group. Patients were unaware if they were in treatment or sham group.
Incomplete outcome data (attrition bias) All outcomes	Low risk	1 drop‐out in study
Selective reporting (reporting bias)	Low risk	Both stated outcomes fully reported
Other bias	Low risk	—

Yimtae 2003

Methods	Prospective randomised controlled trial; block randomisation by symptom duration
Participants	58 patients greater than 18 years old
Interventions	Modified Epley manoeuvre versus untreated controls
Outcomes	1. Conversion of Dix‐Hallpike test from positive to negative 2. Subjective resolution of symptoms 3. Medication (cinnarizine) taken during study period
Notes	Follow up weekly for 1 month
*Risk of bias*
Bias	Authors' judgement	Support for judgement
Random sequence generation (selection bias)	Unclear risk	Block randomisation strongly implies robust strategy. Stratified by duration of symptoms
Allocation concealment (selection bias)	Unclear risk	—
Blinding (performance bias and detection bias) All outcomes	Low risk	Assessor blinded to treatment group
Incomplete outcome data (attrition bias) All outcomes	Low risk	No missing data
Selective reporting (reporting bias)	Low risk	All outcomes reported
Other bias	Unclear risk	Small potential for bias ‐ patients in control group were untreated, and did not therefore have similar experience of receiving "therapeutic" intervention

All five trials applied a modified Epley manoeuvre: the sequence of positioning was as originally described by Epley 1992, but without the addition of mastoid oscillation or premedication.

Characteristics of excluded studies [ordered by study ID]

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estudios incluidos

Study	Reason for exclusion
Angeli 2003	ALLOCATION: Randomised, controlled PARTICIPANTS: 47 patients (>/= 70 years old) with the diagnosis of unilateral posterior semicircular canal BPPV INTERVENTIONS: The canalith repositioning manoeuvre described is fundamentally different from the Epley manoeuvre
Asawavichianginda 2000	ALLOCATION: 1. No blinding of outcome assessors 2. Performance bias: control group received no exposure to clinical staff during the trial other than assessments, compared to frequent attendance in experimental group PARTICIPANTS: Short duration of symptoms: 62% of cohort reported symptoms of less than 2 weeks duration
Blakley 1994	ALLOCATION: 1. Inadequate randomisation strategy 2. No blinding of outcome assessors 3. Performance bias: control group received less exposure to clinical staff OUTCOME MEASURES: Outcome only by subjective measures
Cohen 1999	ALLOCATION: 1. Inadequate randomisation strategy ‐ sequential allocation 2. No blinding of outcome assessors 3. Risk of attrition bias: complete follow up for only 58 of 87 subjects OUTCOME MEASURES: Outcome only by subjective measures
Cohen 2005	ALLOCATION: Randomisation was a computer‐generated spreadsheet, but patients were then sequentially allocated to groups as they attended (see similar, Cohen 1999)
Herdman 1993	ALLOCATION: 1. Unclear randomisation strategy 2. No blinding of outcome assessors OUTCOME MEASURES: Objective outcome measures (Dix‐Hallpike test) reported in only 48% of subjects
Li 1995	ALLOCATION: 1. Unclear randomisation strategy 2. No blinding of outcome assessors
Massoud 1996	ALLOCATION: 1. Unclear randomisation strategy 2. No blinding of outcome assessors
Radtke 1999	ALLOCATION: 1. Inadequate randomisation: 20% of the study population were allocated to receive the Epley manoeuvre because they had previously failed with rehabilitation exercises, which was the control treatment. Remaining patients were allocated alternately. 2. No blinding of outcome assessors
Sekine 2006	ALLOCATION: 1. No randomisation or concealed allocation. Patients were allocated to treatment group according to which of 2 institutions they attended. 2. Patients and researchers were not blinded to intervention group.
Seo 2007	ALLOCATION: Sequential allocation to groups. High risk of bias ‐ no allocation concealment
Sherman 2001	ALLOCATION: 1. Inadequate randomisation; allocation by date of clinic visit 2. High drop‐out rate
Soto Varela 2001	ALLOCATION: 1. No description of randomisation strategy 2. Assessors not blinded to treatment group
Sridhar 2003	ALLOCATION: Assessors were not blinded to treatment group of patient
Steenerson 1996	ALLOCATION: 1. Inadequate randomisation: alternative allocation to 2 treatment groups. Control group were patients who refused active treatment. 2. No blinding of outcome assessors OUTCOME MEASURES: No objective outcome measure
Waleem 2008	ALLOCATION: High risk of bias in assignment of patients to study groups. Patients were allocated by non‐probability convenience sampling.
Wolf 1999	ALLOCATION: 1. Inadequate randomisation: first 22 patients allocated by date of examination (odd/even). Remaining 19 patients all received active treatment. 2. No blinding of outcome assessors 3. Performance bias: control group received less exposure to clinical staff

BPPV: benign paroxysmal positional vertigo

Data and analyses

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Comparison 1. Epley versus placebo manoeuvre: subjective symptom resolution

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Subjective report of complete symptom resolution Show forest plot	5	273	Odds Ratio (M‐H, Fixed, 95% CI)	4.42 [2.62, 7.44]
Open in figure viewer Analysis 1.1 Comparison 1 Epley versus placebo manoeuvre: subjective symptom resolution, Outcome 1 Subjective report of complete symptom resolution.

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Comparison 2. Epley versus placebo manoeuvre: conversion of positive to negative Dix‐Hallpike test

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Conversion of positive to negative Dix‐Hallpike test Show forest plot	5	273	Odds Ratio (M‐H, Fixed, 95% CI)	6.40 [3.63, 11.28]
Open in figure viewer Analysis 2.1 Comparison 2 Epley versus placebo manoeuvre: conversion of positive to negative Dix‐Hallpike test, Outcome 1 Conversion of positive to negative Dix‐Hallpike test.

Figure 1

Reprinted from Otolaryngology ‐ Head and Neck Surgery, 107(3), Epley JM, The canalith repositioning procedure: for treatment of benign paroxysmal positional vertigo, 399‐404, Copyright (1992), with permission from the American Academy of Otolaryngology ‐‐ Head and Neck Surgery Foundation, Inc."

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Figure 2

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

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Analysis 1.1

Comparison 1 Epley versus placebo manoeuvre: subjective symptom resolution, Outcome 1 Subjective report of complete symptom resolution.

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Analysis 2.1

Comparison 2 Epley versus placebo manoeuvre: conversion of positive to negative Dix‐Hallpike test, Outcome 1 Conversion of positive to negative Dix‐Hallpike test.

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Comparison 1. Epley versus placebo manoeuvre: subjective symptom resolution

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Subjective report of complete symptom resolution Show forest plot	5	273	Odds Ratio (M‐H, Fixed, 95% CI)	4.42 [2.62, 7.44]

Comparison 1. Epley versus placebo manoeuvre: subjective symptom resolution

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Comparison 2. Epley versus placebo manoeuvre: conversion of positive to negative Dix‐Hallpike test

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Conversion of positive to negative Dix‐Hallpike test Show forest plot	5	273	Odds Ratio (M‐H, Fixed, 95% CI)	6.40 [3.63, 11.28]

Comparison 2. Epley versus placebo manoeuvre: conversion of positive to negative Dix‐Hallpike test

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Referencias

References to studies included in this review

Froehling 2000 {published data only}

Lynn 1995 {published data only}

Munoz 2007 {published data only (unpublished sought but not used)}

von Brevern 2006 {published data only}

Yimtae 2003 {published data only}

References to studies excluded from this review

Angeli 2003 {published data only}

Asawavichianginda 2000 {published data only}

Blakley 1994 {published data only}

Cohen 1999 {published data only}

Cohen 2005 {published data only}

Herdman 1993 {published data only}

Li 1995 {published data only}

Massoud 1996 {published data only}

Radtke 1999 {published data only}

Sekine 2006 {published data only}

Seo 2007 {published data only}

Sherman 2001 {published data only}

Soto Varela 2001 {published data only}

Sridhar 2003 {published data only}

Steenerson 1996 {published data only}

Waleem 2008 {published data only}

Wolf 1999 {published data only}

Additional references

Baloh 1987

Bhattacharyya 2008

Brandt 1980

Brandt 1999

Dix 1952

Epley 1992

Froehling 1991

Handbook 2009

Helminski 2010

Hunt 2012

Katsarkas 1978

Mizukoshi 1988

Norre 1995

Semont 1988

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Characteristics of excluded studies [ordered by study ID]

Data and analyses

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