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Rapid Systematic Review of the Epley Maneuver for Treating Posterior Canal Benign Paroxysmal
Positional Vertigo
Jeroen G. van Duijn, Liz M. Isfordink, Jenny A. Nij Bijvank, Carlijne W. Stapper, Annelies J. van Vuren, Inge Wegner,
Marlous F. Kortekaas and Wilko Grolman
Otolaryngology -- Head and Neck Surgery 2014 150: 925 originally published online 31 March 2014
DOI: 10.1177/0194599814527732

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Rapid Systematic Review
Rapid Systematic Review of the Epley
Maneuver for Treating Posterior Canal
Benign Paroxysmal Positional Vertigo
Jeroen G. van Duijn1*, Liz M. Isfordink1*, Jenny A. Nij Bijvank1*,
Carlijne W. Stapper1*, Annelies J. van Vuren1*,
Inge Wegner, MD1,2, Marlous F. Kortekaas, MD3, and
Wilko Grolman, MD, PhD1,2
No sponsorships or competing interests have been disclosed for this article.
Abstract
Objective. The aim of this study was to compare watchful
waiting to the Epley maneuver as a management option for
patients with posterior canal benign paroxysmal positional
vertigo (p-BPPV) regarding symptom relief.
Data Sources. PubMed, Embase, and The Cochrane Library.
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. Absolute risk differences and their 95% confi-
dence intervals (CIs) were extracted for the included
studies.
Results. A total of 1448 unique studies were retrieved.
Eight of these satisfied the eligibility criteria. At 1-week
follow-up, all included studies reported a clinically relevant
effect in favor of the Epley maneuver regarding symptom
relief (absolute risk differences ranging from 20% [95% CI,
5%-37%] to 59% [95% CI, 32%-76%]) or conversion to a
negative Dix–Hallpike (absolute risk differences ranging
from 17% [95% CI, –5%-37%] to 64% [95% CI, 29%-79%]).
At 1-month follow-up, the results of the included studies
diverged further. Absolute risk differences ranged from 6%
(95% CI, –24%-35%) more symptom relief in favor of watch-
ful waiting to 79% (95% CI, 56%-88%) in favor of the Epley
maneuver.
Conclusion and Recommendations. All data of the selected
studies show a benefit in favor of the Epley maneuver at 1-
week follow-up in the management of p-BPPV. The Epley
maneuver should be considered in all patients with p-BPPV.
Keywords
BPPV, Epley, systematic review, vertigo
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Otolaryngology–
Head and Neck Surgery
2014, Vol. 150(6) 925–932
Ó American Academy of
Otolaryngology—Head and Neck
Surgery Foundation 2014
Reprints and permission:
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DOI: 10.1177/0194599814527732
http://otojournal.org
Received January 17, 2014; revised February 17, 2014; accepted
February 21, 2014.
Background
Benign paroxysmal positional vertigo (BPPV) is the most
common cause of dizziness. No data are available on the
incidence of BPPV in the Netherlands. In the United States,
the incidence is 64 per 100,000.1 Patients complain of recur-
rent episodes of dizziness, often described as a ‘‘spinning
sensation.’’ Normally, there are no other neurological symp-
toms. Symptoms are provoked by sudden changes of head
position.2 The clinical diagnosis can be confirmed by the
Dix–Hallpike test, which elicits the characteristic nystag-
mus.1,2 Of the different kinds of BPPV, posterior canal
BPPV is the most common.3
One of the effective treatment options for posterior canal
BPPV is the Epley maneuver,4 first described by Epley.5
The maneuver is based on the theory that the clinical fea-
tures are triggered by the presence of free-floating particles
in the posterior semicircular canal.6 The Epley consists of a
series of head positions, which returns the particles in the
utricle, thereby removing the stimulus of the vertigo.5,7 On
the other hand, according to the AAO-HNS clinical practice
guideline,4 spontaneous resolution of symptoms occurs,
ranging from 15% to 86%, at 1 month in all kinds of BPPV.
Therefore, watchful waiting might be a considerable option
in the management of (posterior) BPPV.
1
Department of Otorhinolaryngology–Head 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, Utrecht, The
Netherlands
*
These authors contributed equally to this article.
Corresponding Author:
Inge Wegner, MD, Department of Otorhinolaryngology–Head and Neck
Surgery, University Medical Center Utrecht, Heidelberglaan 100, G05.129,
3584 CX Utrecht, The Netherlands.
Email: ENT-research@umcutrecht.nl
926 Otolaryngology–Head and Neck Surgery 150(6)

Table 1. Search for Studies on the Effect of the Epley Maneuver versus Watchful Waiting.a
Database Search Hits

PubMed #1: bppv[Title/Abstract] OR bpv[Title/Abstract] OR dizziness[MeSH Terms] OR 1048

dizziness[Title/Abstract] OR vertigo[MeSH Terms] OR vertigo[Title/Abstract] OR benign
paroxysmal positional vertigo[Supplementary Concept] OR ‘‘vestibular disease’’[Title/
Abstract] OR vestibular diseases[MeSH Terms] OR bpn[Title/Abstract] OR bppn[Title/
Abstract] OR (benign [tiab] AND paroxysmal [tiab] AND positional [tiab] AND
nystagmus [tiab]) OR canalolithiasis[Title/Abstract] OR cupulolithiasis[Title/Abstract]
#2: Epley[Title/Abstract] OR ‘‘Epley’s’’[Title/Abstract] OR canalith[Title/Abstract] OR
otolith[Title/Abstract] OR CRP[Title/Abstract] OR reposition*[Title/Abstract] OR
maneuver[Title/Abstract] OR manoeuvre[Title/Abstract] OR maneuvers[Title/Abstract]
OR manoeuvres[Title/Abstract]
#3: #1 AND #2
Embase #1: ‘dizziness’/exp OR ‘vertigo’/exp OR ‘benign paroxysmal positional vertigo’/exp OR 1320
bppv:ab,ti OR bpv:ab,ti OR dizziness:ab,ti OR vertigo:ab,ti OR ‘vestibular disease’:ab,ti OR
bpn:ab,ti OR bppn:ab,ti OR (benign:ab,ti AND paroxysmal:ab,ti AND positional:ab,ti AND
nystagmus:ab,ti) OR canalolithiasis:ab,ti OR cupulolithiasis:ab,ti
#2: epley:ab,ti OR epley*:ab,ti OR canalith:ab,ti OR otolith:ab,ti OR crp:ab,ti OR
reposition*:ab,ti OR maneuver:ab,ti OR manoeuvre:ab,ti OR maneuvers:ab,ti OR
manoeuvres:ab,ti
#3: #1 AND #2
The Cochrane Library #1: dizziness:ti OR dizziness:ab OR vertigo:ti OR vertigo:ab OR bppv:ti OR bppv:ab OR 108
bpv:ti OR bpv:ab OR ‘vestibular disease’:ti OR ‘vestibular disease’:ab OR bpn:ti OR
bpn:ab OR bppn:ti OR bppn:ab OR canalolithiasis:ti OR canalolithiasis:ab OR
cupulolithiasis:ti OR cupulolithiasis:ab OR ((benign:ti or benign:ab) AND (paroxysmal:ti or
paroxysmal:ab) AND (positional:ti or positional:ab) AND (nystagmus:ti or nystagmus:ab))
OR MeSH descriptor: [Vertigo] explode all trees or MeSH descriptor: [Dizziness]
explode all trees or MeSH descriptor: [Vestibular Diseases] explode all trees
#2: epley:ti OR epley:ab OR epley*:ti OR epley*:ab OR canalith:ti OR canalith:ab OR
otolith:ti OR otolith:ab OR crp:ti OR crp:ab OR reposition*:ti OR reposition*:ab OR
maneuver:ti OR maneuver:ab OR manoeuvre:ti OR manoeuvre:ab OR maneuvers:ti OR
maneuvers:ab OR manoeuvres:ti OR manoeuvres:ab
#3: #1 AND #2
a
The search was conducted on October 23, 2013.

Clinical Question
What is the effectiveness of watchful waiting compared to
the Epley maneuver in patients diagnosed with posterior
canal BPPV regarding symptom relief?
Methods
Retrieving Studies
A systematic search in PubMed, Embase, and The Cochrane
Library was conducted with the assistance of a clinical
librarian. Relevant synonyms for the search terms BPPV
and Epley maneuver were combined (see Table 1). Five
assessors (J.G.V.D., L.M.I., J.A.N.B., C.W.S., and A.J.V.V.)
independently excluded duplicate titles and screened the
title and abstract of the retrieved records for inclusion, fol-
lowed by screening of the full texts of eligible articles.
Studies on the effectiveness of watchful waiting versus the
Epley maneuver in patients with posterior canal BPPV were
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included. Only reports of original study data were included;
systematic reviews, opinion papers, animal or laboratory
studies, and case reports were excluded (see Figure 1 for
selection criteria). Related publications were searched in
PubMed, whereas Scopus and Web of Science were used
for cross-reference checking for studies not identified by the
initial literature search. Selected articles, related reviews,
meta-analyses, and guidelines were hand searched for rele-
vant cross-references.
Assessing Studies
Using predefined criteria, based on the PRISMA statement,8
5 reviewers (J.G.V.D., L.M.I., J.A.N.B., C.W.S., and
A.J.V.V.) independently assessed the selected studies for
their relevance and risk of bias (RoB; see Table 2).
Relevance concerned the applicability of the study findings
for answering the clinical question and involved the evalua-
tion of patients and compared treatments and outcomes: (1)
patients, notably patients diagnosed with posterior canal
van Duijn et al
Domain
BPPV
1048
PubMed
Inclusion criteria:
• Original data
• Adults
• BPPV of the posterior canal
• Compared to a control group
Exclusion criteria: Screening on title, abstract and full-text
• No posterior BPPV
• No Epley maneuver
• Systematic reviews
• Opinion papers
• Animal studies
• Laboratory studies
• Case reports
8
Figure 1. Flowchart for selection of studies on the effect of the Epley maneuver versus watchful waiting.
BPPV with the Dix–Hallpike maneuver; (2) treatment com-
parison, notably watchful waiting versus the Epley maneu-
ver; and (3) outcomes, notably our primary outcome of
interest, patient-reported symptom relief. Secondary out-
come measures were (1) disappearance of nystagmus when
performing the Dix–Hallpike maneuver, and (2) symptom
relief scored in patients without a nystagmus when perform-
ing the Dix–Hallpike maneuver. When an item was
reported, it was classified as either ‘‘satisfactory’’ or ‘‘unsa-
tisfactory.’’ When an item of the study assessment 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. With the
RoB assessment, the extent of selection and information
bias was established. Assessment of RoB involved evalua-
tion of (1) blinding, (2) concealment of treatment assign-
ment, (3) baseline comparability, (4) standardization of
treatment, (5) standardization of outcome assessment, (6)
completeness of reported data, and (7) the use of intention-
to-treat. Studies were classified as having a low risk of bias
if they satisfied all criteria and a moderate risk of bias if
they satisfied at least 3 criteria, and the remaining studies
were classified as high risk of bias. Initial discrepancies
between independent reviewers were resolved by discussion
and reported results were based on full consensus. Studies
with low relevance, high risk of bias, or both were excluded
from further review.
Data Extraction
From the included studies, 5 authors (J.G.V.D., L.M.I.,
J.A.N.B., C.W.S., and A.J.V.V.) independently extracted
descriptive data of patients and treatments. For the out-
comes of interest, absolute risks, risk differences, and their
95% confidence intervals (CIs) were extracted. Preferably,
absolute risks were extracted. If these were not given or
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927
Determinant
AND
Epley maneuver
1320 108
Embase Cochrane
2476
Removal of duplicates
1448
8
Study assessment
Suitable references
(n = 0)
could not be recalculated, findings were presented as
reported in the article. Outcome data were pooled when
study designs and methods of the included studies were con-
sidered comparable.
Results
Retrieving Studies
A total of 2476 titles were retrieved, of which 1448 were
unique studies (see Figure 1; date of last search was
October 23, 2013). One paper was excluded based on lan-
guage (Chinese).9 After selection based on title and abstract,
and subsequent full-text screening, 8 articles were initially
considered eligible for answering our clinical question.
Cross-reference checking revealed no additional articles.
Assessing Studies
The relevance was moderate in 2 studies9,10 and high in 6
studies11-16 (see Table 2). The study by Sekine et al10
included children. Waleem et al11 prescribed a placebo (a
multivitamin tablet) in the control group. Five of the 8
included studies11-15 reported the primary outcome measure
‘‘subjective symptom relief.’’ Three of the 8 studies10,16,17
reported the secondary outcome measure ‘‘disappearance of
nystagmus with the Dix–Hallpike maneuver in combination
with symptom relief,’’ and 1 study12 reported the secondary
outcome measure ‘‘disappearance of nystagmus with the
Dix–Hallpike maneuver.’’ The RoB was moderate in all of
the included studies (see Table 2). Three studies11,14,15
were prospective cohort studies. Of the randomized con-
trolled trials, only the study by Yimtae et al17 scored posi-
tive on both items of randomization: the method of
treatment allocation, and blinding of treatment allocation.
There was no completeness of data in the studies performed
by Asawavichianginda et al12 and Yimtae et al.17 None of
the included studies reported whether they analyzed results
928
Table 2. Assessment of Studies on the Effect of the Epley Maneuver versus Watchful Waiting.
Relevancea Risk of Biasb

Randomization
Sample Size Study Baseline Standardization Standardization Complete Intention-to-
Study of Study, n Design Patients Treatment Outcome Blinding Treatment Allocation Comparability (T) (O) Data Treat

Asawavichianginda 85 RCT    ? ?    s ?
et al (2000)12
Blakley (1994)13 38 RCT    ? s ?    ?
Richard et al (2005)14 81 PCS    NA NA     NA
Seo et al (2007)15 34 PCS    NA NA     ?
Sekine et al (2006)10 127 RCT s   ? ?    ? ?
Waleem et al (2008)11 44 PCS  s  NA NA     ?
Wolf et al (1999)16 41 RCT    ? ?     ?
Yimtae et al (2003)17 58 RCT         s ?
Abbreviations: ?, unclear, no information provided; NA, not applicable; PCS, prospective cohort study; RCT, randomized controlled trial.
a
Relevance—Patients:  = adults with posterior benign paroxysmal positional vertigo (p-BPPV) objected with positive Dix–Hallpike maneuver; s = children included, p-BPPV not confirmed by Dix–Hallpike maneu-
ver, other. Treatment:  = Epley maneuver compared to watchful waiting; s = Epley maneuver versus sham or other treatment, other. Outcome:  = subjective recovery of symptoms and/or recovery of nystag-
mus upon performing the Dix–Hallpike maneuver; s = other.
b
Risk of bias—Blinding:  = outcome assessors were blinded for treatment allocation; s = outcome assessors were not blinded. Treatment allocation:  = adequate concealment (eg, sealed envelopes); s = no ade-

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quate concealment. Baseline comparability:  = groups were equal; s = clinically relevant differences between patient groups. Standardization (T) of treatment with Epley maneuver:  = a protocol on the Epley
maneuver was provided; s = no protocol on the Epley maneuver was provided. Standardization (O) of outcome:  = a protocol of outcome assessment was provided and outcome was assessed at a standardized
follow-up moment; s = no protocol of outcome assessment was provided or outcome was not assessed at a standardized follow-up moment. Complete data for primary outcome:  = below 10% nonselective
missing data; s = 10% or more missing data and/or missing data were selective. Intention-to-treat:  = an intention-to-treat analysis was used; s = no intention-to-treat analysis was used.
van Duijn et al 929

Table 3. Summary of Findings at 1-Week Follow-Up.

Statistics for Each Study Recovery/Total

Risk Lower Limit Upper Limit Watchful Epley Risk Difference

Study Outcome Difference of 95% CI of 95%CI Waiting Maneuver and 95% CI

Asawavichianginda SR –0.20 –0.37 –0.05 1/39 8/35

et al (2000)12
Blakley (1994)13 NR
Richard et al (2005)14 NR
Seo et al (2007)15 SR –0.47 –0.69 –0.14 4/16 13/18
Waleem et al (2008)11 SR –0.59 –0.76 –0.32 1/22 14/22
Pooled data SR –0.39 –0.51 –0.25 6/77 35/75
Asawavichianginda et al Neg DH –0.17 –0.37 0.05 20/39 24/35
(2000)12
Sekine et al (2006)10 Neg DH and SR –0.29 –0.44 –0.13 29/60 52/67
Wolf et al (1999)16 Neg DH and SR –0.64 –0.79 –0.29 1/10 23/31
Yimtae et al (2003)17 Neg DH and SR –0.38 –0.56 –0.16 1/27 12/29

Abbreviations: CI, confidence interval; Neg DH, negative Dix–Hallpike test; NR, not reported; SR, symptom relief.

based on an intention-to-treat protocol. All 8 studies were of nystagmus with the Dix–Hallpike maneuver in combina-
characterized by moderate to high relevance and moderate tion with symptom relief’’ found a statistically significant
RoB. They were therefore included for further review. effect in favor of the Epley maneuver.

Summary of Findings 1-Month Follow-Up

1-Week Follow-Up
Three studies11,12,15 reported the primary outcome measure
at 1 week. All 3 studies found a statistically significant
effect in favor of the Epley maneuver (see Table 3). The
effects ranged from 20% to 59% less symptom relief in the
watchful waiting group. Asawavichianginda et al12 reported
complete resolution of symptoms in 23% of the patients in
the Epley group, improvement of symptoms in 66%, and no
improvement or worsening of symptoms in 11% of the
patients in the Epley group, versus 3%, 54%, and 44% in
the watchful waiting group, respectively. Waleem et al11
reported complete resolution of symptoms in 64% of the
patients in the Epley group, improvement in 18%, and no
improvement in 18%, versus 5%, 41%, and 55% in the
watchful waiting group, respectively. Seo et al15 did not
report the outcome ‘‘improvement of symptoms.’’ Pooled
data analysis displayed a significant effect in favor of the
Epley maneuver (risk difference, 39%; 95% CI, 25%-51%).
The study by Asawavichianginda et al12 was the only study
that reported both the primary outcome and the secondary
outcome ‘‘disappearance of nystagmus with the Dix–
Hallpike maneuver.’’ At 1-week follow-up, symptom relief
was reported in 1 of 39 cases in the watchful waiting group
versus 8 of 35 cases in the Epley group (risk difference,
20%; 95% CI, 5%-37%), and conversion to a negative Dix–
Hallpike was seen in 20 of 39 cases in the watchful waiting
group versus 24 of 35 cases in the Dix–Hallpike group (risk
difference, 17%; 95% CI, –5%-37%). The 3 studies10,16,17
that reported the secondary outcome measure ‘‘disappearance
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The primary outcome measure ranged from 6% in favor of
the watchful waiting group to 79% in favor of the Epley
group (see Table 4). The largest difference between the 2
treatment groups was seen in the study by Richard et al14
(risk difference, 79%; 95% CI, 56%-88%). Blakley et al13
and Seo et al15 did not report a difference in symptom relief
between both groups (6%; 95% CI, –24%-35% in favor of
watchful waiting, and 1%; 95% CI, –22%-26%, respec-
tively). Only the study by Asawavichianginda et al12
reported a larger risk difference between both groups at 1-
month follow-up, compared to 1-week follow-up.
Asawavichianginda et al12 reported improvement of symp-
toms in 47% and no improvement or worsening of symp-
toms in 6% of the patients treated with the Epley maneuver
versus 58% and 22% in the control group, respectively.
Blakley et al13 reported improvement of symptoms in 50%
and no improvement or worsening in 6% of the patients
treated with the Epley maneuver versus 36% and 14% in
the control group, respectively. Compared to the results of
Asawavichianginda et al12 at 1 week, the number of patients
in the category ‘‘no improvement’’ or ‘‘worsening of symp-
toms’’ had decreased at 1-month follow-up in both groups.
The number of patients in the control group without any
improvement of symptoms at 1 month was still larger than
the number of patients without improvement in the Epley
group.12,13 Pooled data analysis showed a statistically signif-
icant effect in favor of the Epley maneuver (risk difference,
39%; 95% CI, 23%-47%). The 4 studies that included the
Dix–Hallpike in their outcome measure reported a risk
930 Otolaryngology–Head and Neck Surgery 150(6)

Table 4. Summary of Findings at 1-Month Follow-Up.

Statistics for Each Study Recovery/Total

Risk Lower Limit Upper Limit Watchful Risk Difference

Study Outcome Difference of 95% CI of 95% CI Waiting Epley Maneuver and 95% CI

Asawavichianginda SR –0.28 –0.46 –0.06 7/36 16/34

et al (2000)12
Blakley (1994)13 SR 0.06 –0.24 0.35 11/22 7/16
Richard et al (2005)14 SR –0.79 –0.88 –0.56 2/20 54/61
Seo et al (2007)15 SR –0.01 –0.26 0.22 14/16 16/18
Waleem et al (2008)11 NR
Pooled data SR –0.39 –0.47 –0.23 34/94 93/129

Asawavichianginda Neg DH –0.27 –0.45 –0.08 23/36 31/34

et al (2000)12
Sekine et al (2006)10 Neg DH and SR –0.11 –0.24 0.01 48/60 61/67
Wolf et al (1999)16 Neg DH and SR –0.40 –0.67 –0.10 5/10 28/31
Yimtae et al (2003)17 Neg DH and SR –0.29 –0.52 0.00 7/20 16/25

Abbreviations: CI, confidence interval; Neg DH, negative Dix–Hallpike test; NR, not reported; SR, symptom relief.

difference ranging from 11% to 40% in favor of the group
treated with the Epley maneuver, although this effect was
significant only in 2 studies.12,16
Long-Term Follow-Up
Two studies12,14 provided information about symptom relief
at longer term follow-up, namely, between 3 and 6 months.
Asawavichianginda et al12 reported more symptom relief of
19% (95% CI, –6%-41%) in the Epley group at 3 months
follow-up. Two studies reported symptom relief at 6
months. Asawavichianginda et al12 showed a risk difference
of 4% (95% CI, –29%-22%) and Richard et al14 of 42%
(95% CI, 20%-62%), both in favor of the Epley group. In
both studies,12,14 there was a decrease in risk difference
compared to the results at 1 month.
Discussion
In this article, we described the results of a rapid systematic
review on the comparison between watchful waiting and the
Epley maneuver in patients with posterior canal BPPV. For
the primary outcome, a strong but variable effect of 20% to
59% in favor of the Epley maneuver was found at 1-week
follow-up. This effect decreased to some extent after a
longer follow-up period.
Some aspects need consideration when interpreting our
findings. First, the studies showed differences, which lim-
ited comparability, especially in study design; some studies
repeated (cycles of) the Epley maneuver,16,17 and others
prescribed side-medication12,17 and instructed patients to
apply different postural restrictions after treatment. As
repeated cycles of the Epley maneuver in a single session
seem to be superior to 1 single maneuver,18 this might be 1
explanation for the broad range of the results we found. On
the other hand, there is no evidence that postural restrictions
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are effective in patients treated with the Epley maneuver.4
In 1 study,12 patients in the watchful waiting group received
multivitamin tablets as a placebo. This theoretically may
have altered the results and reduced the risk difference. One
study10 included children; the age of the 127 included
patients ranged from 13 to 82 years old. The mean age was
60.1 6 14.0 years, indicating that the number of included
children was small. The differences in study population and
the use of concomitant treatment between the studies report-
ing the primary outcome of interest were considered small
and, therefore, data were pooled for this outcome. For the
secondary outcome of interest, the Dix–Hallpike maneuver
was included in the outcome measure. One study12 reported
disappearance of nystagmus with the Dix–Hallpike maneu-
ver. The other 3 studies10,16,17 reported symptom relief in
patients and conversion to a negative Dix–Hallpike maneu-
ver. This may have caused an underreporting of patients
with symptom relief, because patients with subjective symp-
tom relief and a positive Dix–Hallpike maneuver were reg-
istered as having a negative outcome. Furthermore, 2
studies16,17 performed multiple sessions of the Epley man-
euver (on a weekly basis), and 1 study17 performed repeated
cycles of the Epley maneuver in 1 session. Due to these dif-
ferences between the studies, it was considered inappropri-
ate to pool the data for the secondary outcome.
Second, it is important to note that our study focused on
complete remission of symptoms. However, a reduction of
symptoms without complete remission might be a clinically
relevant outcome for the patient as well.
Finally, although individual studies were limited by
sample size, relevance, and RoB, altogether there was suffi-
cient evidence to answer our clinical question.
Recent reviews reported the effectiveness of the Epley
maneuver up to 1-month follow-up.19-22 In contrast to our
van Duijn et al
study, these reviews included studies that used a sham man-
euver in the control group,19-22 which theoretically may
affect the natural history of posterior canal BPPV and there-
fore might be an incorrect substitute for watchful waiting.
Furthermore, these reviews used the conversion of the Dix–
Hallpike as an outcome measure, instead of ‘‘subjective
symptom relief.’’19,20 In our opinion, subjective symptom
relief is a clinically more relevant outcome measure for the
patient.
Regarding complications of treatment, the Epley maneu-
ver is associated with mild and generally self-limiting
adverse effects.23 Only 2 of the included studies reported
the occurrence of side effects of the maneuver. In the study
by Richard et al,14 researchers had not been aware of any
complications. In the study by Yimtae et al,17 complications
occurred in 14% (4/29) of the patients; 2 patients had com-
plaints of fainting, pallor, and sweating after repeated
maneuvers in 1 session, and in 2 patients, a conversion to
lateral canal BPPV occurred immediately after the Epley
maneuver was applied. Both studies did not report the
occurrence of adverse events in the control group. Because
of the mild adverse effects, the Epley maneuver should be a
considerable treatment option.
All included studies were conducted in the ENT depart-
ment. In the Netherlands, though, the majority of BPPV
patients are treated in general practice. The Dutch guideline
for general practitioners24 acknowledges the initial benefit
of the Epley maneuver but advises watchful waiting. This
recommendation is based on the occurrence of spontaneous
symptom relief and lack of experience in performing the
maneuver, as suggested by other researchers.25
The burden of BPPV is high.26 Thirty-seven percent of
the patients cannot work, and 18% avoid leaving their
homes. Health care costs for patients with BPPV are signifi-
cant.4 The costs of the Epley maneuver as a treatment mod-
ality are low. When referral to the ENT department is
required, though, this management option would be more
expensive. It might be more cost-effective to train general
practitioners in performing the Epley maneuver to avoid the
costs of referral to the ENT department.27 However, even in
the current situation in the Netherlands, the Epley maneuver
might be cost effective: sooner relief of symptoms results in
less absenteeism from work, and thus economic advantage.
Conclusion and Recommendations
All data of the selected studies show a benefit in favor of
the Epley maneuver at 1-week follow-up in the management
of BPPV of the posterior canal. At 1-month follow-up, dif-
ferences in symptom relief between watchful waiting and
the Epley maneuver decrease, although there is a tendency
toward more symptom relief after treatment with the Epley
maneuver. At longer term follow-up, the differences
between both groups decrease even further.
Because of the potential effect of the symptoms on daily
functioning, we believe that the findings in this study
should be considered in management decisions for patients
with posterior BPPV (p-BPPV). The negligible negative
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931
side effects of the maneuver and the low costs should also
be taken into account.
Translating Evidence into Practice
The Epley maneuver should be considered in every patient
diagnosed with p-BPPV, due to the proven effectiveness of
the maneuver in symptom reduction. It is important to
create facilitations that make it possible to treat all of these
patients. Exploring the possibility of training general practi-
tioners or physiotherapists might be an option, although evi-
dence on the effectiveness of the maneuver performed by
doctors other than ENT specialists is lacking.
Acknowledgment
We thank Bianca Kramer, PhD, information specialist in health
and medical sciences at Utrecht University Library, for her help
with setting up and conducting the search strategy.
Author Contributions
Jeroen G. van Duijn, writing, data collection, data analysis, inter-
pretation, drafting and revision, approval final version; Liz M.
Isfordink, writing, data collection, data analysis, interpretation,
drafting and revision, approval final version; Jenny A. Nij Bijvank,
writing, data collection, data analysis, interpretation, drafting and
revision, approval final version; Carlijne W. Stapper, writing, data
collection, data analysis, interpretation, drafting and revision,
approval final version; Annelies J. van Vuren, writing, data collec-
tion, data analysis, and interpretation, drafting and revision, approval
final version; Inge Wegner, data analysis, interpretation, drafting
and revision, approval final version; Marlous F. Kortekaas, data
analysis, interpretation, drafting and revision, approval final version;
Wilko Grolman, design, drafting and revision, approval final ver-
sion, supervision.
Disclosures
Competing interests: None.
Sponsorships: None.
Funding source: None.
References
1. Froehling DA, Bowen JM, Mohr DN, et al. The canalith repo-
sitioning procedure for the treatment of benign paroxysmal
positional vertigo: a randomized controlled trial. Mayo Clin
Proc. 2000;75:695-700.
2. Furman JM, Cass SP. Benign paroxysmal positional vertigo. N
Engl J Med. 1999;341:1590-1596.
3. Parnes LS, Agrawal SK, Atlas J. Diagnosis and management
of benign paroxysmal positional vertigo (BPPV). CMAJ. 2003;
169:681-693.
4. Bhattacharyya N, Baugh RF, Orvidas L, et al. Clinical practice
guideline: benign paroxysmal positional vertigo. Otolaryngol
Head Neck Surg. 2008;139:S47-S81.
5. Epley JM. The canalith repositioning procedure: for treatment
of benign paroxysmal positional vertigo. Otolaryngol Head
Neck Surg. 1992;107:399-404.
6. Hall SF, Ruby RR, McClure JA. The mechanics of benign par-
oxysmal vertigo. J Otolaryngol. 1979;8:151-158.
932
7. Lynn S, Pool A, Rose D, Brey R, Suman V. Randomized trial
of the canalith repositioning procedure. Otolaryngol Head
Neck Surg. 1995;113:712-720.
8. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting
items for systematic reviews and meta-analyses: the PRISMA
statement. BMJ. 2009;339:b2535.
9. Li H, Zhuang J, Zhao Z. Clinical study on canalith reposition-
ing procedure for benign paroxysmal positional vertigo of
semicircular canal. Lin Chuang Er Bi Yan Hou Ke Za Zhi.
2005;19:1029-1031.
10. Sekine K, Imai T, Sato G, Ito M, Takeda N. Natural history of
benign paroxysmal positional vertigo and efficacy of Epley
and Lempert maneuvers. Otolaryngol Head Neck Surg. 2006;
135:529-533.
11. Waleem SS, Malik SM, Ullah S, ul Hassan Z. Office manage-
ment of benign paroxysmal positional vertigo with Epley’s
maneuver. J Ayub Med Coll Abbottabad. 2008;20:77-79.
12. Asawavichianginda S, Isipradit P, Snidvongs K, Supiyaphun P.
Canalith repositioning for benign paroxysmal positional ver-
tigo: a randomized, controlled trial. Ear Nose Throat J. 2000;
79:732-737.
13. Blakley BW. A randomized, controlled assessment of the
canalith repositioning maneuver. Otolaryngol Head Neck Surg.
1994;110:391-396.
14. Richard W, Bruintjes TD, Oostenbrink P, van Leeuwen RB.
Efficacy of the Epley maneuver for posterior canal BPPV: a
long-term, controlled study of 81 patients. Ear Nose Throat J.
2005;84:22-25.
15. 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. Otol
Neurotol. 2007;28:917-919.
16. Wolf M, Hertanu T, Novikov I, Kronenberg J. Epley’s man-
oeuvre for benign paroxysmal positional vertigo: a prospective
study. Clin Otolaryngol Allied Sci. 1999;24:43-46.
Downloaded from oto.sagepub.com at SOCIEDADE BRASILEIRA DE CIRUR on July 1, 2014
Otolaryngology–Head and Neck Surgery 150(6)
17. Yimtae K, Srirompotong S, Srirompotong S, Sae-Seaw P. A
randomized trial of the canalith repositioning procedure.
Laryngoscope. 2003;113:828-832.
18. Gordon CR, Gadoth N. Repeated vs single physical maneuver
in benign paroxysmal positional vertigo. Acta Neurol Scand.
2004;110:166-169.
19. Helminski JO, Zee DS, Janssen I, Hain TC. Effectiveness of
particle repositioning maneuvers in the treatment of benign
paroxysmal positional vertigo: a systematic review. Phys Ther.
2010;90:663-678.
20. White J, Savvides P, Cherian N, Oas J. Canalith repositioning
for benign paroxysmal positional vertigo. Otol Neurotol. 2005;
26:704-710.
21. Woodworth BA, Gillespie MB, Lambert PR. The canalith
repositioning procedure for benign positional vertigo: a meta-
analysis. Laryngoscope. 2004;114:1143-1146.
22. Hilton M, Pinder D. The Epley (canalith repositioning) man-
oeuvre for benign paroxysmal positional vertigo. Cochrane
Database Syst Rev. 2004;(2):CD003162.
23. Herdman SJ, Tusa RJ. Complications of the canalith reposi-
tioning procedure. Arch Otolaryngol Head Neck Surg. 1996;
122:281-286.
24. Verheij AAA, Van Weert HCPM, Lubbers WJ, et al. NHG-
Standaard Duizeligheid. Huisarts & Wetenschap. 2002;45:
601-609.
25. Glasziou P, Heneghan C. Epley and the slow boat from
research to practice. Evid Based Med. 2008;13:34-35.
26. von Brevern M, Radtke A, Lezius F, et al. Epidemiology of
benign paroxysmal positional vertigo: a population based
study. J Neurol Neurosurg Psychiatry. 2007;78:710-715.
27. Cranfield S, Mackenzie I, Gabbay M. Can GPs diagnose
benign paroxysmal positional vertigo and does the Epley
manoeuvre work in primary care? Br J Gen Pract. 2010;60:
698-699.