Rapid Systematic Review

Rapid Systematic Review of the Epley

Maneuver versus Vestibular Rehabilitation
for Benign Paroxysmal Positional Vertigo

Otolaryngology
Head and Neck Surgery
2014, Vol. 151(2) 201207
American Academy of
OtolaryngologyHead and Neck
Surgery Foundation 2014
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0194599814534940
http://otojournal.org

Inge Wegner, MD1,2, Marlien E. F. Niesten, MD1,2,

Cornelis H. van Werkhoven, MD3, and
Wilko Grolman, MD, PhD1,2

No sponsorships or competing interests have been disclosed for this article.

Abstract
Objective. To evaluate the effectiveness of the Epley maneuver compared with vestibular rehabilitation on patientreported symptom relief and conversion of the Dix-Hallpike
from positive to negative in patients with posterior benign
paroxysmal positional vertigo (p-BPPV).
Data Sources. PubMed, Embase, and the Cochrane Library.
Review Methods. A systematic search was conducted. Studies
reporting original study data were included. Relevance and
risk of bias (RoB) of the selected articles were assessed.
Studies with low relevance, high RoB, or both were
excluded. For outcomes of interest, absolute risk differences
and their 95% confidence intervals (CIs) were extracted.
Results. A total of 373 unique studies were retrieved. Five of
these satisfied the eligibility criteria. One study with low
RoB and 3 studies with moderate RoB showed that the
Epley maneuver is more effective than vestibular rehabilitation at 1-week follow-up with regard to patient-reported
symptom relief and conversion of the Dix-Hallpike maneuver from positive to negative (risk differences range from
10% [95% CI, 30-47] to 55% [95% CI, 35-71]). There is
inconsistent evidence for the effectiveness of the Epley maneuver compared with vestibular rehabilitation at 1-month
follow-up. Most studies suggest that the Epley maneuver and
vestibular rehabilitation are equally effective at 1-month
follow-up.
Conclusion. The Epley maneuver is more effective in treating
p-BPPV than vestibular rehabilitation at 1-week follow-up.
There is inconsistent evidence for the effectiveness of the
Epley maneuver compared with vestibular rehabilitation at
1-month follow-up.

Background
Benign paroxysmal positional vertigo (BPPV) is the most
common cause of vertigo worldwide. Between 17% and
42% of patients with vertigo are diagnosed with BPPV,1-3
and the lifetime prevalence is 2.4%.4 BPPV is characterized
by repeated episodes of spinning sensations induced by
changes in head position relative to gravity. The onset of
vertigo attacks is sudden, and the attacks are usually accompanied by imbalance, nausea, and torsional nystagmus.
BPPV is thought to be caused by debris in the semicircular
canals. Most commonly, the posterior canal is affected in
approximately 85% to 95% of cases.3 Calcium carbonate
crystals (otoliths) from the utricle fall into the lumen of the
posterior canal, where they move freely and cause vertigo
when the position of the head is changed. An episode of
posterior canal BPPV (p-BPPV) can be provoked by performing the Dix-Hallpike maneuver.
There are numerous treatment options for p-BPPV.
Canalith repositioning maneuvers, such as the Epley maneuver, and vestibular rehabilitation, including Brandt-Daroff
exercises, are the main treatment options. Canalith repositioning maneuvers aim to move the debris from the posterior semicircular canal to the vestibule, thereby relieving the
stimulus from the semicircular canal.5,6 Brandt-Daroff exercises are repositioning exercises performed at home that
work in a similar way.7 Vestibular rehabilitation may also
include a combination of habituation exercises, stabilization
exercises, fall prevention training, and education.8,9

1
Department of OtorhinolaryngologyHead and Neck Surgery, University
Medical Center Utrecht, Utrecht, the Netherlands
2
Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht,
the Netherlands
3
Julius Center for Health Sciences and Primary Care, University Medical
Center Utrecht, Utrecht, the Netherlands

Keywords
BPPV, vertigo, vestibular therapy, rehabilitation therapy, CRP,
Epley, systematic review
Received March 29, 2014; accepted April 18, 2014.

Corresponding Author:
Inge Wegner, MD, Department of OtorhinolaryngologyHead and Neck
Surgery, University Medical Center Utrecht, G05.129, Heidelberglaan 100,
3584 CX Utrecht, the Netherlands
Email: ENT-research@umcutrecht.nl

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OtolaryngologyHead and Neck Surgery 151(2)

Table 1. Search for Studies on the Effect of Vestibular Rehabilitation versus the Epley Maneuver for Benign Paroxysmal Positional Vertigo
(Date of Search: March 6, 2014).
Database

Search

Hits

PubMed

(BPPV[tiab] OR BPV[tiab] OR BPPN[tiab] OR BPN[tiab] OR ((positional[tiab] OR

positioning[tiab] OR postural[tiab] OR paroxysmal[tiab] OR paroxistic[tiab] OR recurrent[tiab])
AND (vertigo[tiab] OR nystagmus[tiab] OR dizziness[tiab] OR disorder[tiab] OR
disorders[tiab])) OR cupulolithiasis[tiab] OR canalithiasis[tiab] OR canalolithiasis[tiab] OR
benign paroxysmal positional vertigo[Supplementary Concept]) AND (rehabilitat*[tiab] OR
habituat*[tiab] OR ((vestibular[tiab] OR physical[tiab] OR balanc*[tiab]) AND (therapy[tiab]
OR therapies[tiab] OR retraining[tiab] OR training[tiab])) OR physiotherapy[tiab] OR physical
therapy modalities[mesh] OR Brandt[tiab] OR Daroff[tiab]) AND (CRP[tiab] OR Epley*[tiab]
OR reposition*[tiab] OR liberatory[tiab] OR bedside[tiab] OR manoeuvre*[tiab] OR
maneuv*[tiab])
(BPPV:ti,ab OR BPV:ti,ab OR BPPN:ti,ab OR BPN:ti,ab OR ((positional:ti,ab OR positioning:ti,ab
OR postural:ti,ab OR paroxysmal:ti,ab OR paroxistic:ti,ab OR recurrent:ti,ab) AND
(vertigo:ti,ab OR nystagmus:ti,ab OR dizziness:ti,ab OR disorder:ti,ab OR disorders:ti,ab)) OR
cupulolithiasis:ti,ab OR canalithiasis:ti,ab OR canalolithiasis:ti,ab OR benign paroxysmal
positional vertigo/exp) AND (rehabilitat*:ti,ab OR habituat*:ti,ab OR ((vestibular:ti,ab OR
physical:ti,ab OR balanc*:ti,ab) AND (therapy:ti,ab OR therapies:ti,ab OR retraining:ti,ab OR
training:ti,ab)) OR physiotherapy:ti,ab OR physical therapy modalities/exp OR Brandt:ti,ab OR
Daroff:ti,ab) AND (CRP:ti,ab OR Epley*:ti,ab OR reposition*:ti,ab OR liberatory:ti,ab OR
bedside:ti,ab OR manoeuvre*:ti,ab OR maneuv*:ti,ab)
(BPPV OR BPV OR BPPN OR BPN OR ((positional OR positioning OR postural OR paroxysmal
OR paroxistic OR recurrent) AND (vertigo OR nystagmus OR dizziness OR disorder OR
disorders)) OR cupulolithiasis OR canalithiasis OR canalolithiasis) AND (rehabilitat* OR
habituat* OR ((vestibular OR physical OR balanc*) AND (therapy OR therapies OR retraining
OR training)) OR physiotherapy OR Brandt OR Daroff) AND (CRP OR Epley* OR reposition*
OR liberatory OR bedside OR manoeuvre* OR maneuv*):ti,ab,kw

262

Embase

The Cochrane Library

The aim of this systematic review is to evaluate the

effectiveness of vestibular rehabilitation in comparison with
the Epley maneuver in relieving symptoms of p-BPPV.

Methods
A rapid systematic review of the available evidence was
performed. Whereas traditional systematic reviews typically
take a minimum of 6 months to 1 year to complete, a rapid
review accelerates the process while maintaining a systematic approach.

Retrieving Studies
A systematic search in PubMed, Embase, and the Cochrane
Library was conducted with assistance of a clinical librarian
(date of last search was March 6, 2014). Relevant synonyms
for the search terms BPPV, vestibular rehabilitation, and
Epley were combined (see Table 1). Two assessors (I.W.
and M.E.F.N.) excluded duplicate titles and independently
screened the title and abstract of the retrieved records for
inclusion. Studies on p-BPPV that compared the effect of
vestibular rehabilitation to the Epley maneuver were
included. Only reports of original study data were included;
systematic reviews, animal or laboratory studies, opinion
papers, poster presentations, and case reports were excluded

274

42

(see Figure 1 for selection criteria). The same 2 reviewers

(I.W. and M.E.F.N.) screened the full texts of eligible articles using the same inclusion and exclusion criteria. Related
publications that were not identified by the initial literature
search were searched in PubMed and Scopus. Selected articles, related reviews, meta-analyses, and guidelines were
hand searched for relevant cross-references.

Assessing Studies
Using predefined criteria, 2 reviewers (I.W. and M.E.F.N.)
independently assessed the selected studies for their relevance and risk of bias (see Table 2 for assessment criteria). Relevance concerned the applicability of the study
findings for answering the clinical question and involved the
patient domain, treatments, and outcomes that were studied.
When an item of the study assessment was reported, it was
classified as either satisfactory or unsatisfactory. When
an item was not reported, it was rated unclear. Studies were
classified as having high, moderate, or low relevance if they
complied with all 3, 2, or 1 of these criteria, respectively.
Assessment of risk of bias, using the Cochrane Collaborations
tool,10 involved evaluation of (1) random and (2) concealed
treatment assignment, standardization of (3) treatment and (4)
outcome assessment, (5) completeness of reported data, and

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203
Domain
BPPV

AND
262

PubMed

Determinant
Vestibular therapy versus Epley

274
Embase

42
The Cochrane Library

578
Removal of duplicates
373
Inclusion criteria:
Therapeutic design
Original data
Corresponding domain,
determinant and outcome
Exclusion criteria:
Systematic reviews
Animal studies
Laboratory studies
Opinion papers
Poster presentations
Case reports (< 10 cases)

Screening on title and abstract

22
Screening on full-text
9
Study assessment
Suitable references
(n = 0)

5
Figure 1. Flowchart for selection of studies on the effect of vestibular rehabilitation versus the Epley maneuver for benign paroxysmal
positional vertigo (BPPV).

(6) the use of an intention-to-treat analysis. Studies were classified as having a low risk of bias if they satisfied all of these
criteria, moderate risk of bias if they satisfied at least 4 criteria,
and the remainder was classified as high risk of bias. Initial
discrepancies between independent reviewers were resolved by
discussion, and reported results are based on full consensus.
Studies with low relevance, high risk of bias, or both were
excluded from further review.

Data Extraction
For the included studies, 2 authors (I.W. and M.E.F.N.)
independently extracted descriptive data of patients and
interventions. For the outcomes of interest, absolute risk differences were extracted and their 95% confidence intervals
(95% CIs) were calculated. If these were not given or could
not be recalculated, the findings as reported in the article
were presented.

Results
Retrieving Studies
A total of 578 titles were retrieved, of which 373 were
unique studies (see Figure 1). One paper was excluded
based on language (Chinese).20 Nine articles were initially
considered eligible for answering our clinical question following title and abstract and subsequent full-text screening.
Cross-reference checking revealed no additional articles.

Assessing Studies
The relevance was found to be high for all 9 included studies11-19 (see Table 2). The risk of bias was low in only 1
study,11 moderate in 4 studies,12-15 and high in the

remaining 4 studies.16-19 Randomization, concealed treatment allocation, and blinding were either not achieved,
inadequate, or no information was provided regarding these
criteria in most of the included studies.13-19 For 3 studies,12,18,19 a large amount of outcome data was missing, and
in none of these studies was an intention-to-treat analysis
carried out. Five studies11-15 with low to moderate risk of
bias were included for further review. The study reported by
Amor-Dorado et al11 failed none of the risk of bias criteria.
Therefore, we put the most trust in the data presented in this
study.

Study Descriptives
The selected studies included a total of 258 patients with pBPPV (see Table 3). In all studies, patients were included
if they presented with symptoms of recurrent vertigo and a
characteristic torsional nystagmus when performing the DixHallpike maneuver. Patients with central nervous system
disorders were excluded in all studies. The study populations were similar with regard to age (mean age ranged
from 55 to 60 years). There are major dissimilarities
between studies regarding type of Epley maneuver, type of
vestibular rehabilitation, follow-up duration, and outcome
measures. The modified Epley maneuver was compared
with Brandt-Daroff exercises in 3 studies.11,12,15 In 1
study,13 the modified Epley maneuver was compared with
the rolling-over maneuver, and in 2 studies,12,14 the Epley
maneuver was compared with vestibular habituation exercises. Cohen and Kimball12 instructed their patients to perform 4 exercises 4 times a day: nodding the head up and
down, shaking the head right and left, rolling the head, and

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OtolaryngologyHead and Neck Surgery 151(2)

Table 2. Assessment of Studies on the Effect of Vestibular Rehabilitation versus the Epley Maneuver for Benign Paroxysmal Positional
Vertigo.a
Relevance
Study
(Year)
Amor-Dorado
et al (2012)11
Cohen and
Kimball
(2005)12
Sugita-Kitajima
et al (2010)13
Roa Castro
et al (2008)14
Radtke et al
(1999)15
Karanjai and
Saha (2010)16
Steenerson and
Cronin
(1996)17
Soto Varela
et al (2001)18
Borges Pereira
et al (2004)19

Risk of Bias

Study
Concealed
Standardi- Standardi- Complete Intention
Design Patients Treatment Outcome Randomization allocation Blinding zation (T) zation (O)
Data
to Treat
RCT

RCT

PCS

RCS

PCS

PCS

PCS

PCS

PCS

Study design: PCS = prospective cohort study; RCS = retrospective cohort study; RCT = randomized controlled trial; ? = unclear, no information provided.
Patients:  = patients with posterior benign positional paroxysmal vertigo (p-BPPV); s = patients with horizontal, anterior, or combined BPPV, other.
Treatment:  = vestibular rehabilitation therapy versus the Epley maneuver for p-BPPV; s = other. Outcome:  = subjective recovery of symptoms and/or
recovery of nystagmus upon performing the Dix-Hallpike maneuver; s = other. Randomization:  = adequate randomization (eg, random number table or
coin toss); s = no adequate randomization. Concealed allocation:  = adequate concealment of treatment allocation (eg, sealed, opaque envelopes); s = no
adequate concealment. Blinding:  = outcome assessors were blinded for treatment allocation; s = outcome assessors were not blinded for treatment allocation. Standardization (T) of treatment:  = yes, vestibular rehabilitation and the Epley maneuver were performed by the same person in all cases or operating
procedures were protocolized; s = no. Standardization (O) of outcome:  = yes, outcome was assessed by the same outcome assessor in all cases and at a
standardized follow-up moment; s = no. Completeness of outcome data for primary outcome:  = below 10% nonselective missing data; s = 10% or more
missing data and/or missing data was selective. Intention-to-treat analysis:  = an intention-to-treat analysis was performed; s = patients were not analyzed
according to intention to treat.

circumducting the head clockwise and counterclockwise.

Habituation therapy included postural control, head-eye
coordination, and habituation to vertigo exercises in the
study performed by Roa Castro et al.14 Three of the
included studies11,13,14 performed follow-up at both 1 week
and 1 month. One study15 performed follow-up at 1 week
only and 1 study at 1 month only.13 Three studies11-13
reported success rates in terms of conversion of the DixHallpike maneuver from positive to negative. Patientreported symptom relief was reported in 3 studies.12,13,15 In
the study performed by Roa Castro et al,14 the results of the
Dix-Hallpike maneuver and patient-reported symptom relief
were combined.

Data Extraction
The extracted outcome data of the 5 included studies are
described in Table 3. Risk differences are positive when
results favor the Epley maneuver and negative when they

favor vestibular rehabilitation. In the study performed by

Amor-Dorado et al,11 the difference in conversion of the DixHallpike maneuver was in favor of the modified Epley maneuver after 1 week of follow-up, with a risk difference (RD)
of 55% (95% CI, 35 to 71). Three studies12,14,15 reported success percentages at short-term follow-up of 1 week or less in
favor of the (modified) Epley maneuver. In 1 of these studies,12 which had 2 comparator groups, conversion of the DixHallpike maneuver was evaluated. This study showed an RD
in favor of the Epley maneuver of 47% (95% CI, 19 to 67)
and 55% (95% CI, 28 to 73), respectively. In another of
these studies,15 patient-reported symptom relief was evaluated (RD of 41% [15 to 62] in favor of the Epley maneuver).
In the remaining study,14 the combined results of the DixHallpike maneuver and patient-reported symptom relief were
evaluated (RD of 52% [95% CI, 13 to 78] in favor of the
Epley maneuver). In 1 of the studies,13 no difference was
found between the 2 treatment groups with regard to

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Table 3. Results of Studies on the Effect of Vestibular Rehabilitation versus the Epley Maneuver for Benign Paroxysmal Positional Vertigo.a

Study (Year)
Amor-Dorado
(2012)11
Cohen and
Kimball (2005)12

Treatment
Group 1 (n)

Treatment
Group 2 (n)

Outcome
Measure

Follow-up
Duration

Treatment
Group 1

Treatment
Group 2

Absolute Risk
Difference
(95% CI)

Modified Epley
maneuver (41)
Modified Epley
maneuver
(24/17b)

Brandt-Daroff
exercises (40)
Brandt-Daroff
exercises
(25/20b)

Negative
Dix-Hallpike (%)
Complete symptom
relief (%)
Negative
Dix-Hallpike (%)
Complete symptom
relief (%)
Negative
Dix-Hallpike (%)
Symptom
relief (%)
Negative
Dix-Hallpike (%)
Asymptomatic and
negative
Dix-Hallpike (%)
Symptom
relief (%)

1 week
1 month
Immediately
1 month
1 week
1 month
Immediately
1 month
1 week
1 month
1 week
1 month
1 week
1 month
1 week
1 month

80
93
21
35
67
76
21
35
67
76
58
83
50
75
82
88

25
43
12
55
20
60
0
70
12
71
60
100
40
100
30
90

55 (35 to 71)
50 (31 to 65)
9 (13 to 29)
20 (48 to 12)
47 (19 to 67)
16 (14 to 43)
21 (2 to 37)
35 (62 to 2)
55 (28 to 73)
6 (24 to 34)
2 (39 to 37)
17 (40 to 14)
10 (30 to 47)
25 (49 to 8)
52 (13 to 78)
2 (26 to 28)

1 week

64

23

41 (15 to 62)

Habituation
exercises
(25/17b)
Sugita-Kitajima
et al (2010)13

Modified Epley
maneuver (12)

Rolling-over
maneuver (10)

Roa Castro
et al (2008)14

Epley
maneuver (17)

Habituation
exercises (10)

Radtke
et al (1999)15

Modified Epley
maneuver (28)

Brandt-Daroff
exercises (26)

n = number of patients; 95% CI = 95% confidence interval. A positive absolute risk difference favors treatment group 1 (the [modified] Epley maneuver).
In the study performed by Cohen and Kimball,12 some patients did not return for the 1-month follow-up: 17, 20, and 17 patients did return at 1 month in
the modified Epley, Brandt-Daroff, and habituation groups, respectively.
b

conversion of the Dix-Hallpike maneuver (10% [95% CI,

30 to 47]) and patient-reported symptom relief (2% [95%
CI, 39 to 37]) at 1-week follow-up.
Four studies11-14 reported the effect of the (modified)
Epley maneuver versus vestibular rehabilitation at 1-month
follow-up. Amor-Dorado et al11 reported a statistically significant RD of 50% (95% CI, 31 to 65) in favor of the
Epley maneuver with regard to conversion of the DixHallpike maneuver. Cohen and Kimball,12 whose study had
2 comparator groups, found a statistically significant and
clinically relevant difference in favor of habituation exercises for complete symptom relief at 1-month follow-up
(RD of 35% [95% CI, 62 to 2]) compared with the
Epley maneuver. The other 3 studies12-14 did not show a difference in the effectiveness of the Epley maneuver compared with vestibular rehabilitation; the results of these
studies are not statistically significant, as the confidence
intervals contain zero. More specifically, these studies
showed no difference in effectiveness of the Epley maneuver compared with Brandt-Daroff exercises12 (RD of 16%
[95% CI, 14 to 43] for Dix-Hallpike conversion and RD of
20% [95% CI, 48 to 12] for patient-reported symptom
relief), habituation exercises (RD of 6% [95% CI, 24 to
34] for Dix-Hallpike conversion12 and RD of 2% [95% CI,
26 to 28] for the combination of Dix-Hallpike conversion
and patient-reported symptom relief14) or the rolling-over maneuver13 (RD of 25% [95% CI, 49 to 8] for Dix-Hallpike

conversion and RD of 17% [95% CI, 40 to 14] for patientreported symptom relief).4

Discussion
There is evidence from 1 study11 with low risk of bias and
3 studies12,14,15 with moderate risk of bias that the (modified) Epley maneuver is more effective than vestibular rehabilitation at short-term follow-up of 1 week or less with
regard to patient-reported symptom relief and conversion of
the Dix-Hallpike maneuver from positive to negative. There
is inconsistent evidence from 4 studies11-14 regarding the
effectiveness of the (modified) Epley maneuver compared
with vestibular rehabilitation at 1-month follow-up. Two
studies11,12 show a statistically significant RD of 50% (31
to 65) in favor of the Epley maneuver and an RD of 35%
(62 to 2) in favor of habituation exercises, respectively.12
Another 3 studies12-14 did not show a (statistically significant) difference between the 2 study groups.
Spontaneous resolution of symptoms at 1 month occurs
in 20% to 80% of patients with BPPV.3 It is likely that
symptoms resolve in patients with BPPV in a 1-month time
frame irrespective of treatment. Therefore, longer time intervals between diagnosis and treatment assessment may lead
to overestimation of treatment effects. Furthermore, this
might explain why there is no consistent evidence for the
effectiveness of the 2 therapy groups at 1-month follow-up.

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Some limitations of the available evidence need to be

considered. First, only 1 study11 satisfied all of the risk of
bias criteria. In the other 4 included studies,12-15 adequate
randomization, concealed allocation, and blinding was not
achieved or not described or a large amount of outcome
data was missing. A consequent high risk of selection bias
might lead to overestimation or underestimation of treatment effects. Second, the included studies varied with
respect to type of Epley maneuver, type of vestibular rehabilitation, follow-up duration, and outcome measure. The
heterogeneity in study characteristics made us decide to
refrain from pooling the available data. Third, the sample
sizes were rather small, yielding wide confidence intervals.
Both the (modified) Epley maneuver and vestibular rehabilitation are associated with mild adverse events. Nausea,
vomiting, fatigue, neck pain, and conversion to horizontal
canal BPPV have been reported.6,21 In the study performed
by Amor-Dorado et al,11 nausea and/or vomiting was
reported in 32% of patients treated with the Epley maneuver
and 22% of patients treated with Brandt-Daroff exercises.
Nine patients treated with Brand-Daroff exercises in this
study were switched to the Epley maneuver at 1-month
follow-up because of lack of improvement and persistence
of vertigo. In the study performed by Radtke et al,15 14% of
patients treated with the modified Epley maneuver experienced nausea compared with 38% in the Brandt-Daroff
group. One patient who was treated with the modified Epley
maneuver in this study complained of neck pain, and 1
patient complained of Brandt-Daroff exercise-related
fatigue.

Conclusion and Recommendation

There is moderate-quality evidence that the Epley maneuver
is more effective in treating p-BPPV than vestibular rehabilitation with regard to patient-reported symptom relief and
conversion of the Dix-Hallpike maneuver from positive to
negative at 1-week follow-up. There is inconsistent evidence
for the effectiveness of the Epley maneuver compared with
vestibular rehabilitation at 1-month follow-up. Most studies
suggest that the Epley maneuver and vestibular rehabilitation are equally effective at 1-month follow-up. However,
the only study with a low risk of bias did show a difference
of 50% (31 to 65) in favor of the Epley maneuver with
regard to conversion of the Dix-Hallpike maneuver. Another
study found a difference in favor of habituation exercises for
complete symptom relief at 1-month follow-up (35% [62 to
2]) compared with the Epley maneuver. We would recommend treating patients with the Epley maneuver. We would
consider vestibular rehabilitation in patients who do not tolerate the Epley maneuver or who do not respond to treatment
with the Epley maneuver.
Acknowledgments
We acknowledge and thank the following medical students for
their contribution to this systematic review: K. M. Blok, S. M.
Egger, A. V. Jong Tjien Fa, J. C. L. Notohardjo, and G. M. de
Veij Mestdagh. We thank B. M. R. Kramer, PhD, information

specialist health and medical sciences at Utrecht University

Library, for her help with setting up and conducting the search
strategy.

Author Contributions
Inge Wegner, writing, data collection, data analysis, interpretation,
drafting and revision, approval of final version; Marlien E. F.
Niesten, writing, data collection, data analysis, interpretation, drafting
and revision, approval of final version; Cornelis H. van Werkhoven,
data analysis, interpretation, drafting and revision, approval of final
version; Wilko Grolman, design, drafting and revision, approval of
final version, supervision.

Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.

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