BPPV and post-maneuver restrictions
Timothy C. Hain, MD •Bart Tulicki, DPT. Page last modified:
March 7, 2021
Given that the core assumption of BPPV treatment is correct, debris is moved back into the insensitive part of the ear, one would suppose that "what goes up can also go down", and that it might also just move right back where it came from. This is the reason that in the original work on BPPV treatment, there were "post-maneuver restrictions" given, usually involving instructions to avoid positions thought to be likely to allow loose debris to go back into the posterior canal. This mainly boils down to sleeping partially upright.
Although this makes perfect sense, a very large number of studies have suggested that this is not needed.
The use of different post maneuver precautions has been researched for several years now.
- Nuti et al (2000) found no need for restrictions.
- Moon et al (2005) reported that "Based on our results, we do not recommend this therapy since there was no significant benefit for the patients who utilized postural restrictions."
- Roberts et al (2005) reported: Results indicated that postmaneuver restrictions do not improve treatment efficacy.
- Simoceli et al (2005) reported: "Post-maneuver restrictions do not influence the efficacy of Epley Maneuver for BPPV management. "
- Casqueiro et al (2008) suggested that there was no difference in efficacy of the Epley maneuver, depending on use of postural restrictions or not.
- McGinnis et al suggested that 24 hours of restrictions is sufficient.
- DiStefano et al (2011) suggested that postural restrictions were not helpful in 74 patients.
- Fyrmpas (2009) suggested that the restrictions do not result in more negative positional tests, but patients report subjective improvement.
- In a meta-analysis study from 2010 by Devaiah et al. the researchers compared 6 studies in order to determine if specific restrictions hold a significant improvement over another. The study of 523 patients concluded that postural restrictions have no significant effects on the outcome of canalith repositioning maneuvers for BPPV.
- In a more recent study by Papacharalampous et al. from 2012 authors looked effects of postmaneuver restrictions for both treatment and possible recurrence rates. Again, there was no significant differences found between groups that used precautions to the ones that did not.
- Mostafa et al (2012) reported "in conclusion, post-maneuver restrictions do not add to the success of the treatment of BPPV and there is no reason to submit patients to these impractical instructions."
At Chicago Dizziness and Hearing, we have treated more than 4000 patients with BPPV. In other words, we have in a single practice, more experience than any of these analyses above, even including meta-analyses. We do continue to advise some restrictions. This is based on wanting to "stick to what works". We do not think that these restrictions are "impractical", and we also think that if we can avoid one or two extra recurrences per 100 patients, it is worth doing.
We continue to recommend after maneuvers that patients sleep with their head elevated (45 deg angle -- i.e. 2 pillows) and to avoid the sleeping with the affected side down for 12-24 hours post treatment. We would suggest avoiding supine exercises (such as Pilates or Yoga) for a week, and also (if practical) defer going to the beauty parlor, or for massages where there is prolonged supine or prone positioning for a week. Other activities we think best avoided would be teeth cleaning by the dental hygeinist, or other dental procedures as these often involve being positioned with the head backwards, vibration, and head turning.
- Casqueiro, J. C., et al. (2008). "No more postural restrictions in posterior canal benign paroxysmal positional vertigo." Otol Neurotol 29(5): 706-709.
- Devaiah, A. K. and S. Andreoli (2010). "Postmaneuver restrictions in benign paroxysmal positional vertigo: an individual patient data meta-analysis." Otolaryngol Head Neck Surg 142(2): 155-159.
- De Stefano, A., et al. (2011). "Are postural restrictions necessary for management of posterior canal benign paroxysmal positional vertigo?" Ann Otol Rhinol Laryngol 120(7): 460-464.
- Fyrmpas, G., et al. (2009). "Are postural restrictions after an Epley maneuver unnecessary? First results of a controlled study and review of the literature." Auris Nasus Larynx.
- McGinnis, P. Q., et al. (2009). "Retrospective comparison of outcomes for patients with benign paroxysmal positional vertigo based on length of postural restrictions." J Geriatr Phys Ther 32(4): 168-173.
- Moon, S. J., et al. (2005). "The effect of postural restrictions in the treatment of benign paroxysmal positional vertigo." Eur Arch Otorhinolaryngol 262(5): 408-411.
- Mostafa, B. E., et al. (2012). "The necessity of post-maneuver postural restriction in treating benign paroxysmal positional vertigo: a meta-analytic study." Eur Arch Otorhinolaryngol.
- Nuti, D., et al. (2000). "Treatment of benign paroxysmal positional vertigo: no need for postmaneuver restrictions." Otolaryngol Head Neck Surg 122(3): 440-444.
- Papacharalampous, G. X., et al. (2012). "The Role of Postural Restrictions after BPPV Treatment: Real Effect on Successful Treatment and BPPV's Recurrence Rates." Int J Otolaryngol 2012: 932847.
- Roberts, R. A., et al. (2005). "Treatment of benign paroxysmal positional vertigo: necessity of postmaneuver patient restrictions." J Am Acad Audiol 16(6): 357-366.
- Simoceli, L., et al. (2005). "Posture restrictions do not interfere in the results of canalith repositioning maneuver." Braz J Otorhinolaryngol 71(1): 55-59.