Timothy C. Hain, MD •Page last modified: August 2, 2020
|The positions of the Epley maneuver.||Positions 1-4 correspond to positions B-E.|
The Epley maneuver, named after Dr. John Epley, is both intended to move debris or "ear rocks" out of the sensitive part of the ear (posterior canal) to a less sensitive location. It is also sometimes called the "canalith repositioning maneuver" or CRP. The Epley maneuver takes about 15 minutes to complete. It has a cure rate of roughly an 80% cure rate, the first time it is applied ( Herdman et al, 1993; Helminski et al, 2010). Others don't do as well however, and Hughes et al reported only a 47% cure rate the first time (Hughes et al, 2015). It took them 3 maneuvers to get to 84% cure.
The Epley consists of sequential movement of the head into four positions (positions B-D), staying in each position for roughly 30 seconds. The positions of the Epley are illustrated in figure 1. According to Kahraman et al, 2017, there is no difference in success rate between short maneuvers (i.e. 15 seconds in each position) and long maneuvers (i.e. 120 sec in each position). Nevertheless, we think it is more logical to use short duration for strong nystagmus, and longer duration for weak nystagmus or refractory cases.
Here are some movies:
- Click here for a low bandwidth animation.
- Animation of Epley Maneuver. Note that this maneuver is done faster in the animation than in the clinic. Usually one allows 30 seconds between positions.
If one can observe the eyes, as shown in a recording in the figure above, there should be a burst of upbeating/torsional nystagmus for at least positions B (the conventional Dix-Hallpike position), and D (the 180 degree from DH position). There may not be much nystagmus in position B (2)
When performing the Epley maneuver, caution is advised should neurological symptoms (for example, weakness, numbness, visual changes other than vertigo) occur. Occasionally such symptoms are caused by compression of the vertebral arteries (Sakaguchi et al, 2003), and if one persists for a long time, a stroke could occur. If the exercises are being performed without medical supervision, we advise stopping the exercises and consulting a physician. If the exercises are being supervised, given that the diagnosis of BPPV is well established, in most cases we modify the maneuver so that the positions are attained with body movements rather than head movements.
After the Epley, you should provide your patient with the instructions below, which are aimed at reducing the chance that debris might fall back into the sensitive back part of the ear.
INSTRUCTIONS FOR PATIENTS AFTER OFFICE TREATMENTS (Epley or Semont maneuvers)
1. Wait for 10 minutes after the maneuver is performed before going home. This is to avoid "quick spins," or brief bursts of vertigo as debris repositions itself immediately after the maneuver. Don't drive yourself home.
2. Sleep semi-recumbent for the next night. This means sleep with your head halfway between being flat and upright (a 45 degree angle). This is most easily done by using a recliner chair or by using pillows arranged on a couch (see figure 3). During the day, try to keep your head vertical. You must not go to the hairdresser or dentist. No exercise which requires head movement. When men shave under their chins, they should bend their bodies forward in order to keep their head vertical. If eye drops are required, try to put them in without tilting the head back. Shampoo only under the shower. Some authors suggest that no special sleeping positions are necessary (Cohen, 2004; Massoud and Ireland, 1996). We, as do others, think that there is some value (Cakir et al, 2006)
3. For at least one week, avoid provoking head positions that might bring BPPV on again.
- Use two pillows when you sleep.
- Avoid sleeping on the "bad" side.
- Don't turn your head far up or far down.
Be careful to avoid head-extended position, in which you are lying on your back, especially with your head turned towards the affected side. This means be cautious at the beauty parlor, dentist's office, and while undergoing minor surgery. Try to stay as upright as possible. Exercises for low-back pain should be stopped for a week. No "sit-ups" should be done for at least one week and no "crawl" swimming. (Breast stroke is OK.) Also avoid far head-forward positions such as might occur in certain exercises (i.e. touching the toes). Do not start doing the Brandt-Daroff exercises immediately or 2 days after the Epley or Semont maneuver, unless specifically instructed otherwise by your health care provider.
4. At one week after treatment, put yourself in the position that usually makes you dizzy. Position yourself cautiously and under conditions in which you can't fall or hurt yourself. Let your doctor know how you did.
The recurrence rate for BPPV after these maneuvers is about 30 percent at one year, and in some instances a second treatment may be necessary.
Comment: Massoud and Ireland (1996) stated that post-treatment instructions were not necessary. While we respect these authors, at this writing (2002), we still feel it best to follow the procedure recommended by Epley.
While some authors advocate use of vibration in the Epley maneuver, we have not found this useful in a study of our patients (Hain et al, 2000). Use of an antiemetic prior to the maneuver may be helpful if nausea is anticipated. Ondansetron is the one we stock in our practice for this.
Some authors suggest that position 'D' in the figure above is not necessary (e.g. Dr. Helen Cohen as in Cohen et al. 1999; Cohen et al. 2004 ). In our opinion, this is a mistake as mathematical modeling of BPPV suggests that position 'D' is the most important position (Squires et al, 2004). Mathematical modeling also suggests that position 'C' is probably not needed. In our opinion, position 'C' has utility as it gives patients a chance to regroup between position 'B' and 'D'.
Before we get going with this discussion -- note that there is really only one geometric way to roll rocks out of a circle, and thus all of these maneuvers are just variants on the same thing (the Epley maneuver). Also note that there are many "home treatment" maneuvers published (Furman and Hain, 2004).
The Semont maneuver -- this is discussed in detail elsewhere, but it is very clear that it is just another way to get the head positioned so that gravity moves otoconia out of the posterior canal. There are both clinic and home versions. We don't use it much in our clinic.
The "Gans" maneuver. This is another little used treatment maneuver, called the "Gans maneuver by it's inventor (R. Gans, Ph.D.), that is a hybrid between the Epley and Semont maneuvers (Roberts, 2006). It incorporates the head orientations to gravity of "B" and "D" in the Epley figure above, using the body positions of the Semont maneuver. It leaves out position 'C' in the figure above. There is too little published experience with this maneuver to say whether it is as effective as the Epley/Semont but we suspect that it has the same efficacy, as it uses the same head orientations with respect to gravity.
The Epley and/or Semont maneuvers as described above can be done at home (Radke et al, 1999; Furman and Hain, 2004). We often recommend the home-Epley to our patients who have a clear diagnosis. This procedure seems to be even more effective than the in-office procedure, perhaps because it is repeated every night for a week.
The method (for the left side) is performed as shown on the figure to the right. One stays in each of the supine (lying down) positions for 30 seconds, and in the sitting upright position (top) for 1 minute. Thus, once cycle takes 2 1/2 minutes. Typically 3 cycles are performed just prior to going to sleep. It is best to do them at night rather than in the morning or midday, as if one becomes dizzy following the exercises, then it can resolve while one is sleeping. The mirror image of this procedure is used for the right ear.
There are several problems with the "do it yourself" method. If the diagnosis of BPPV has not been confirmed, one may be attempting to treat another condition (such as a brain tumor or stroke) with positional exercises -- this is unlikely to be successful and may delay proper treatment. A second problem is that the home-Epley requires knowledge of the "bad" side. Sometimes this can be tricky to establish. Complications such as conversion to another canal (see below) can occur during the Epley maneuver, which are better handled in a doctor's office than at home. Finally, occasionally during the Epley maneuver neurological symptoms are provoked due to compression of the vertebral arteries. In our opinion, it is safer to have the first Epley performed in a doctors office where appropriate action can be taken in this eventuality.
Positions of the Foster maneuver (from Foster et al, 2012) Logic of the Foster maneuver (from her article)
The "Foster" maneuver. In 2012, Dr. Carol Foster reported another self-treatment maneuver for posterior canal BPPV, that she subsequently popularized with online videos on Youtube. In this maneuver, using the illustrations above that she published in her 2012 article, one begins with head up, then flips to upside down, comes back up into a push-up position with the head turned laterally, and then back to sitting. Biomechanically, this is just another way to get a series of positions similar to the Epley maneuver. It appears to require a bit more strength and flexibility and strength than the self-Epley maneuver reported by Radke (2004), or for that matter, nearly any of the other maneuvers. Of course, it doesn't really matter how you get your head into these positions - -as they all do the same thing. Dr. Foster, in her article, states that her maneuver is not as effective as the regular Epley maneuver, but patients prefer it anyway. Although it looks like a good arm workout, to get rid of BPPV, we don't see any particular reason to use or not use Dr. Foster's maneuver over any of the other recent home treatment BPPV maneuvers (i.e. home Epley, home Semont, Gans), as they all put the ear through very similar positions. We don't recommend the Brandt-Daroff exercises however.
Many patients have been reported in controlled studies. The median response in treated patients was 81%, compared to 37.% in placebo or untreated subjects. A metanalysis published in 2010 indicated that there is very good evidence that the Epley maneuver (CRP) is effective (Helminski et al, 2010). See here for the details.
Compared to the Epley/Semont maneuvers, there is almost no proof that either the Gans or the Foster maneuvers work. However, as they are doing almost the same thing as the other maneuvers do to the head, they should.
While the Epley maneuver works roughly 75% of the time on the first occasion they are used, this means the other 25% are either not "fixed", or just partially better, or perhaps even worse (about 5%). For this reason, in persons who have continued dizziness, a follow-up visit is scheduled and another nystagmus test with video-Frenzel goggles is done. It is common to have a follow-up visit once/week for roughly a month.
There are several possible reasons for continued dizziness after a physical treatment for BPPV:
- Maneuver didn't work (should keep treating for a reasonable number -- about 4 is usually reasonable-- attempts)
- Canal conversion (should change treatment to the new canal)
- Another problem in addition to BPPV (e.g. Migraine -- should change treatment)
- Canal Jam
- Other complications
The office maneuvers for BPPV, perhaps provided on 2 or 3 occasions, are effective in about 95% of patients with BPPV. If you are among the other remainder, or your symptoms are mild enough that the trouble of travelling is more than it is worth, or you live far away, your doctor may wish you to proceed with the home Epley exercises, as described below. If a maneuver works but symptoms recur or the response is only partial (about 40% of the time according to Smouha, 1997), another trial of the maneuver might be advised. When all maneuvers have been tried, the diagnosis is clear, and symptoms are still intolerable, surgical management (posterior canal plugging) may be offered. This is exceedingly rare.
Occasional patients travel to a facility where a device is available to position the head and body to make the maneuvers more effective. See this page for more information about this option.
BPPV often recurs. About 1/3 of patients have a recurrence in the first year after treatment, and by five years, about half of all patients have a recurrence (Hain et al, 2000; Nunez et al; 2000; Sakaida et al, 2003). If BPPV recurs, in our practice we usually retreat with one of the maneuvers above. While daily use of exercises would seem sensible, we did not find it to prevent recurrence (Helminski et al, 2005; Helminski and Hain, 2008).
In some persons, the positional vertigo can be eliminated but imbalance persists. This may be related to utricular damage (Hong et al, 2008). See this page for some other ideas. In these persons it may be reasonable to undertake a course of generic vestibular rehabilitation, as they may still need to compensate for a changed utricular mass or a component of persistent vertigo caused by cupulolithiasis. Conventional vestibular rehabilitation has some efficacy, even without specific maneuvers. (Angeli, Hawley et al. 2003; Fujino et al ,1994) )