Маневр Эпли (репозиционирование отолитов канала) при доброкачественном пароксизмальном позиционном головокружении (ДППГ)
Referencias
References to studies included in this review
References to studies excluded from this review
References to studies awaiting assessment
Additional references
References to other published versions of this review
Characteristics of studies
Characteristics of included studies [ordered by study ID]
| Methods | Allocation: prospective randomised controlled trial Design: parallel | |
| Participants | Number: 81 patients Age: mean age 59 Gender: not reported Setting: hospital otolaryngology department Eligibility criteria: minimum duration of symptoms 1 week. Typical symptoms with positive Dix‐Hallpike test and no prior treatment for BPPV Baseline characteristics: symptoms present for mean of 50/57 days prior to treatment. Greater proportion of men in Epley group (62%) versus Brandt‐Daroff group (39%) (P value = 0.05) | |
| Interventions | Intervention group: modified Epley manoeuvre n = 40 Comparator group: Brandt‐Daroff exercises (5 cycles, TDS for 1 week) n = 41 Use of additional interventions: not reported | |
| Outcomes | Primary outcome: percentage of patients with a negative Dix‐Hallpike test after treatment 1. Short‐ and long‐term recurrence of symptoms, assessed at 7 days, then 1, 6, 12, 24, 36 and 48 months 2. Adverse effects of treatment | |
| Notes | — | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated |
| Allocation concealment (selection bias) | Low risk | Remote external allocation of group |
| Blinding (performance bias and detection bias) | Low risk | Assessor blind to treatment group |
| Incomplete outcome data (attrition bias) | Unclear risk | Data are reported only for patients who had 48 months of follow‐up. It is unclear whether there was complete follow‐up, or whether this represented only a proportion of patients who were entered into the trial |
| Selective reporting (reporting bias) | Low risk | All outcomes reported |
| Other bias | Low risk | — |
| Methods | Allocation: randomised, double‐blind, sham‐controlled trial Design: parallel allocation | |
| Participants | Number: 44 patients Age: mean age 59, all over 18 Gender: 18 male, 26 female Setting: multidisciplinary dizziness clinic in teaching hospital Eligibility criteria: typical history and classic Dix‐Hallpike test Exclusion criteria; previous Epley treatment, cervical disc herniation, severe communication problem Baseline characteristics: sham patients slightly older than Epley group (62.5 versus 55.7 years; P value = 0.08) and patients in Epley group had lower median DHI score (23 (range 8 to 66) versus 33 (range 16 to 72); P value = 0.08) | |
| Interventions | Intervention group: modified Epley manoeuvre, repeated up to 2 times if persistent positive Dix‐Hallpike test Control group: sham manoeuvre (similar to Semont diagnostic manoeuvre), repeated up to 2 times All patients advised to sleep propped up for 48 hours and to avoid lying on affected side for 48 hours | |
| Outcomes | Primary: proportion of patients with negative Dix‐Hallpike test at 12 months Secondary: 1. Proportion of patients with negative Dix‐Hallpike test at 1, 3, 6 months 2. DHI 3. Adverse events | |
| Notes | Sham manoeuvre is the same as a single Brandt‐Daroff manoeuvre | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Computer‐generated random sequence prior to study start |
| Allocation concealment (selection bias) | Low risk | Sealed envelope allocation |
| Blinding (performance bias and detection bias) | Low risk | Assessors and patients both blind to treatment group |
| Incomplete outcome data (attrition bias) | Low risk | Losses accounted for; last observation carried forward method |
| Selective reporting (reporting bias) | Low risk | Outcomes pre‐defined and all reported |
| Other bias | Low risk | — |
| Methods | Allocation: prospective randomised controlled trial Design: parallel | |
| Participants | Number: 88 patients Age: 32 to 80 years Gender: 40 males, 48 females Setting: 2 tertiary hospital otolaryngology departments Eligibility criteria: provocation test for BPPV was side‐lying manoeuvre, rather than Dix‐Hallpike test Baseline characteristics: symptom duration from 5 days to 2 months | |
| Interventions | Intervention group: modified Epley n = 27 Comparator group: Semont versus 'hybrid' manoeuvre (defined in text) n = 30/31 Treatment repeated in the initial session if persisting symptoms/signs on retesting Use of additional interventions: patients retested immediately after treatment and manoeuvre performed again if needed | |
| Outcomes | Primary outcome: persistence of nystagmus on repeat provocation testing at 1 week 1. Number of manoeuvres performed to clear symptoms at first visit 2. Adverse effects: discomfort of the manoeuvre(s) | |
| Notes | Side‐lying test is applied less commonly than the Dix‐Hallpike test but applies the same physiological principles to the diagnosis in terms of individually challenging the posterior semicircular canals in turn (Halker 2008). The hybrid manoeuvre is an alternative particle repositioning manoeuvre (Roberts 2006). The trial report also includes data on a cohort of patients who were allocated (not randomised) to receive the hybrid manoeuvre because of co‐morbidity (e.g. obesity, neck problems). Data from these patients are presented separately in the paper and have not been included or addressed further in this review | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Unclear risk | States randomisation, but no details. Author contacted for clarification but no response |
| Allocation concealment (selection bias) | Unclear risk | As above |
| Blinding (performance bias and detection bias) | Low risk | Assessors blinded to treatment group |
| Incomplete outcome data (attrition bias) | Low risk | No loss to follow‐up |
| Selective reporting (reporting bias) | High risk | Discomfort levels for Epley and Semont manoeuvres are not reported |
| Other bias | Low risk | — |
| Methods | Allocation: prospective randomised controlled trial; randomisation stratified by age and sex Design: parallel | |
| Participants | Number: 50 patients Age: greater than 18 years old Gender: 18 males, 32 females Setting: hospital otolaryngology department Eligibility criteria: positional vertigo and nystagmus on Hallpike testing Baseline characteristics: median symptom duration 43 days for the experimental group, 35 days for the sham group | |
| Interventions | Intervention group: modified Epley manoeuvre n = 24 Comparator group: sham manoeuvre (lying on the affected side for 5 minutes) n = 26 Use of additional interventions: not reported | |
| Outcomes | Primary outcome: Subjective improvement by question, "Do you feel your dizziness has completely resolved?" Conversion of Dix‐Hallpike test from positive to negative | |
| 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) | Low risk | — |
| Blinding (performance bias and detection bias) | Low risk | Assessor blinded to treatment; patients received realistic sham treatment |
| Incomplete outcome data (attrition bias) | Low risk | No missing outcome data |
| Selective reporting (reporting bias) | Low risk | All outcomes reported |
| Other bias | Low risk | — |
| Methods | Allocation: randomised controlled trial Design: parallel | |
| Participants | Number: 87 patients Age: 43/42 mean age for treatment/control Gender: 50 female, 37 male Setting: hospital otolaryngology department Eligibility criteria: patients included with a typical history of BPPV and positive Dix‐Hallpike test Baseline characteristics: symptom duration not specified | |
| Interventions | Intervention group: Epley treatment plus medication n = 43 Comparator group: medication only n = 44 Use of additional interventions: not reported | |
| Outcomes | Primary outcome: resolution of BPPV, categorical assignment as composite measure of symptom resolution and Dix‐Hallpike testing ‐ Cured (no vertigo, Dix‐Hallpike negative) ‐ Improved (vertigo improved, Dix‐Hallpike positive) ‐ No response Secondary outcomes: none reported | |
| Notes | For the purpose of analysis, the outcomes were collated to a dichotomous variable of 'resolved' (cured outcome group) or persisting symptoms ('improved' and 'no response' groups) | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Randomised, although no details |
| Allocation concealment (selection bias) | Unclear risk | No description of technique for allocation |
| Blinding (performance bias and detection bias) | Unclear risk | Not mentioned |
| Incomplete outcome data (attrition bias) | Low risk | All patients included in analysis |
| Selective reporting (reporting bias) | Low risk | All results reported |
| Other bias | Low risk | — |
| Methods | Allocation: prospective randomised controlled trial Design: parallel | |
| Participants | Number: 36 patients Age: between 23 and 90 years Gender: 9 males, 24 females Setting: hospital otolaryngology department Eligibility criteria: symptom duration for minimum 2 months Baseline characteristics: no difference between groups in sex, median age, self report of dizziness severity, amount of time counselled | |
| Interventions | Intervention group: modified Epley manoeuvre n = 18 Comparator group: sham manoeuvre (lying in the first lateral position of the Semont manoeuvre for 5 minutes) n = 15 Use of additional interventions: patients already taking medication for dizziness were allowed to continue | |
| Outcomes | Primary outcome: resolution of symptoms. Daily diary of symptoms. Report of vertigo in the 7 days prior to reassessment at 1 month was "failure" Conversion of Dix‐Hallpike test from positive to negative | |
| 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) | Low risk | Assessor blinded. Patients experienced realistic, comparable sham treatment |
| Incomplete outcome data (attrition bias) | 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 | — |
| Methods | Allocation: randomised controlled trial Design: parallel | |
| Participants | Number: 60 patients Age: 20 to 75 years Gender: 35 female, 25 male Setting: hospital otolaryngology department Eligibility criteria: typical history of BPPV and positive Dix‐Hallpike test Baseline characteristics: no minimum symptom duration stated | |
| Interventions | Intervention group: modified Epley manoeuvre n = 30 Comparator group: Semont manoeuvre n = 30 Use of additional interventions: not reported | |
| Outcomes | Primary outcome: negative Dix‐Hallpike test at day 3, 7 and 30 Secondary outcome: adverse effects of treatment | |
| Notes | — | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Random number tables |
| Allocation concealment (selection bias) | High risk | Report states "allocated using random number tables". It is not clear from the paper whether the allocation and sequence from the tables was concealed |
| Blinding (performance bias and detection bias) | High risk | None |
| Incomplete outcome data (attrition bias) | Low risk | All reported |
| Selective reporting (reporting bias) | Low risk | All reported |
| Other bias | Low risk | — |
| Methods | Allocation: prospective, double‐blind, randomised controlled trial Design: parallel | |
| Participants | Number: 81 patients Age: over 18 years of age Gender: 56 female, 23 male Setting: academic family practice in Canada Eligibility criteria: eligible if self report of positional vertigo with a positive unilateral Dix‐Hallpike test Baseline characteristics: higher proportion of female patients in the treatment group than control (81% versus 61%) | |
| Interventions | Intervention group: standard Epley treatment n = 38 Comparator group: sham treatment (the sham treatment was an Epley manoeuvre performed as if opposite ear was affected) n = 41 Use of additional interventions: not reported | |
| Outcomes | Primary outcome: Subjective resolution of symptoms on Dix‐Hallpike testing Conversion of Dix‐Hallpike test from positive to negative | |
| 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) | 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) | 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 | — |
| Methods | Allocation: prospective, double‐blind, randomised controlled trial Design: parallel | |
| Participants | Number: 67 patients Age: 19 to 86 years Gender: 19 male, 47 female Setting: hospital otolaryngology department Eligibility criteria: a typical history of positional vertigo combined with a typical pattern and latency of associated nystagmus on Dix‐Hallpike testing Baseline characteristics: no baseline difference in groups | |
| Interventions | Intervention group: Epley manoeuvre n = 36 Comparator group: sham treatment (the sham treatment was an Epley manoeuvre performed as if opposite ear was affected) n = 31 | |
| Outcomes | Primary outcome: Absence of symptoms on repeat Dix‐Hallpike testing after 24 hours Change of Dix‐Hallpike test from positive to negative at 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) | Low risk | The assessor at 24 hours was blinded to the treatment group. Patients were unaware if they were in the treatment or sham group |
| Incomplete outcome data (attrition bias) | Low risk | 1 drop‐out in study |
| Selective reporting (reporting bias) | Low risk | Both stated outcomes fully reported |
| Other bias | Unclear risk | No explanation for disparity in number of patients in treatment versus control groups (58 versus 45) |
| Methods | Allocation: randomised controlled trial Design: parallel | |
| Participants | Number: 103 patients Age: range 20 to 84 Gender: 65 female, 38 male Setting: family practice Eligibility criteria: a typical history of BPPV and positive Dix‐Hallpike test Baseline characteristics: symptom duration not specified | |
| Interventions | Intervention group: modified Epley treatment plus postural restrictions n = 58 Comparator group: postural restrictions only n = 45 Use of additional interventions: not reported | |
| Outcomes | Primary outcome: resolution of BPPV, categorical assignment as composite measure of symptom resolution and Dix‐Hallpike testing ‐ Cured (no vertigo, Dix‐Hallpike negative) ‐ Improved (vertigo improved, Dix‐Hallpike positive) ‐ No response Secondary outcomes: none reported | |
| Notes | For the purpose of analysis, the outcomes were collated to a dichotomous variable of 'resolved' (cured outcome group) or persisting symptoms ('improved' and 'no response' groups) | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | States randomised but no details |
| Allocation concealment (selection bias) | High risk | No details given of methods to conceal allocation |
| Blinding (performance bias and detection bias) | High risk | No blinding of assessors mentioned |
| Incomplete outcome data (attrition bias) | Low risk | Patient data all reported |
| Selective reporting (reporting bias) | Low risk | Results all reported |
| Other bias | Low risk | — |
| Methods | Allocation: prospective randomised controlled trial; block randomisation by symptom duration Design: parallel | |
| Participants | Number: 58 patients Age: greater than 18 years old Gender: 43 female, 15 male Setting: hospital neuro‐otology department Eligibility criteria: typical history of vertigo with positive Dix‐Hallpike test Baseline characteristics: 31 versus 39 days of symptoms. No other group difference | |
| Interventions | Intervention group: modified Epley manoeuvre n = 29 Comparator group: untreated control n = 29 Use of additional interventions: not reported | |
| Outcomes | Primary outcome: resolution of vertigo Conversion of Dix‐Hallpike test from positive to negative | |
| Notes | Follow‐up weekly for 1 month | |
| Risk of bias | ||
| Bias | Authors' judgement | Support for judgement |
| Random sequence generation (selection bias) | Low risk | Block randomisation strongly implies robust strategy. Stratified by duration of symptoms |
| Allocation concealment (selection bias) | Low risk | — |
| Blinding (performance bias and detection bias) | Low risk | Assessor blinded to treatment group |
| Incomplete outcome data (attrition bias) | Low risk | No missing data |
| Selective reporting (reporting bias) | Low risk | All outcomes reported |
| Other bias | Low risk | Small potential for bias ‐ patients in the control group were untreated, and did not therefore have a similar experience of receiving 'therapeutic' intervention |
All 10 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.
BPPV: benign paroxysmal positional vertigo
CNS: central nervous system
DHI: Dizziness Handicap Inventory
TDS: three times a day
Characteristics of excluded studies [ordered by study ID]
| Study | Reason for exclusion |
| ALLOCATION: PARTICIPANTS: INTERVENTIONS: | |
| ALLOCATION: Patients were allocated to groups; strategy unclear but randomisation not mentioned in text and authors did not reply to request for information | |
| ALLOCATION: PARTICIPANTS: | |
| ALLOCATION: OUTCOME MEASURES: | |
| ALLOCATION: OUTCOME MEASURES: | |
| ALLOCATION: Randomisation was a computer‐generated spreadsheet, but patients were then sequentially allocated to groups as they attended (see similar, Cohen 1999) | |
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BPPV: benign paroxysmal positional vertigo
Characteristics of studies awaiting assessment [ordered by study ID]
| Methods | Randomised controlled trial |
| Participants | 38 patients (22 female, 16 male) aged 23 to 56 years |
| Interventions | Epley versus Semont manoeuvre |
| Outcomes | Primary outcome measure: resolution of vertigo and negative Dix‐Hallpike test |
| Notes | Reference not obtainable Abstract details insufficient for data analysis. No detail of inclusion/exclusion criteria. Recovery rates expressed as percentages, not numbers of patients with no indication of loss to follow‐up |
| Methods | Randomised controlled trial |
| Participants | 130 patients (65:65) |
| Interventions | Epley treatment versus Semont manoeuvres |
| Outcomes | Primary outcome measure: resolution of vertigo and negative Dix‐Hallpike test Secondary outcome measure: simplicity of performing the manoeuvre |
| Notes | Reference not obtainable Abstract details insufficient for data analysis. No detail of inclusion/exclusion criteria. Recovery rates expressed as percentages, not numbers of patients with no indication of loss to follow‐up |
Data and analyses
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Complete resolution of vertigo symptoms (subjective report) Show forest plot | 5 | 273 | Odds Ratio (M‐H, Fixed, 95% CI) | 4.42 [2.62, 7.44] |
| Analysis 1.1  Comparison 1 Epley versus control or placebo manoeuvre, Outcome 1 Complete resolution of vertigo symptoms (subjective report). | ||||
| 2 Conversion of a positive to a negative Dix‐Hallpike test Show forest plot | 8 | 507 | Odds Ratio (M‐H, Fixed, 95% CI) | 9.62 [6.00, 15.42] |
| Analysis 1.2  Comparison 1 Epley versus control or placebo manoeuvre, Outcome 2 Conversion of a positive to a negative Dix‐Hallpike test. | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Resolution of symptoms and nystagmus on Dix‐Hallpike test Show forest plot | 1 | 81 | Odds Ratio (M‐H, Fixed, 95% CI) | 12.38 [4.32, 35.47] |
| Analysis 2.1  Comparison 2 Epley versus Brandt‐Daroff exercises, Outcome 1 Resolution of symptoms and nystagmus on Dix‐Hallpike test. | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Resolution of nystagmus on provocation testing, at 7 days Show forest plot | 2 | 117 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.78 [0.32, 1.88] |
| Analysis 3.1  Comparison 3 Epley versus Semont manoeuvre, Outcome 1 Resolution of nystagmus on provocation testing, at 7 days. | ||||
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Resolution of nystagmus on provocation testing, at 7 days Show forest plot | 1 | 58 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.67 [0.18, 2.52] |
| Analysis 4.1  Comparison 4 Epley versus hybrid (Gans) manoeuvre, Outcome 1 Resolution of nystagmus on provocation testing, at 7 days. | ||||
Study flow diagram.
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
Comparison 1 Epley versus control or placebo manoeuvre, Outcome 1 Complete resolution of vertigo symptoms (subjective report).
Comparison 1 Epley versus control or placebo manoeuvre, Outcome 2 Conversion of a positive to a negative Dix‐Hallpike test.
Comparison 2 Epley versus Brandt‐Daroff exercises, Outcome 1 Resolution of symptoms and nystagmus on Dix‐Hallpike test.
Comparison 3 Epley versus Semont manoeuvre, Outcome 1 Resolution of nystagmus on provocation testing, at 7 days.
Comparison 4 Epley versus hybrid (Gans) manoeuvre, Outcome 1 Resolution of nystagmus on provocation testing, at 7 days.
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Complete resolution of vertigo symptoms (subjective report) Show forest plot | 5 | 273 | Odds Ratio (M‐H, Fixed, 95% CI) | 4.42 [2.62, 7.44] |
| 2 Conversion of a positive to a negative Dix‐Hallpike test Show forest plot | 8 | 507 | Odds Ratio (M‐H, Fixed, 95% CI) | 9.62 [6.00, 15.42] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Resolution of symptoms and nystagmus on Dix‐Hallpike test Show forest plot | 1 | 81 | Odds Ratio (M‐H, Fixed, 95% CI) | 12.38 [4.32, 35.47] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Resolution of nystagmus on provocation testing, at 7 days Show forest plot | 2 | 117 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.78 [0.32, 1.88] |
| Outcome or subgroup title | No. of studies | No. of participants | Statistical method | Effect size |
| 1 Resolution of nystagmus on provocation testing, at 7 days Show forest plot | 1 | 58 | Odds Ratio (M‐H, Fixed, 95% CI) | 0.67 [0.18, 2.52] |
