FOSTER MANEUVER TREATMENT OF BPPV

Timothy C. Hain, MD • Page last modified: August 2, 2022 •

Introduction

There are many methods of treating BPPV at home. These have many advantages over seeing a doctor, getting diagnosed, and then treated based on a rational procedure of diagnosis-- The home maneuvers are quick, they often work, and they are free. We now have a great analysis tool -- the Teixido BPPV viewer, and we are going to analyze the Foster Maneuver using this.

Before getting started, 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 most home maneuvers requires knowledge of the "bad" side. Sometimes this can be tricky to establish.
Complications such as conversion to another canal, or severe vomiting 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 maneuver (usually the Epley) performed in a doctors office where appropriate action can be taken in this eventuality.

This is an analysis of the "Foster" maneuver for PC BPPV

In 2012, Dr. Carol Foster reported another self-treatment maneuver for posterior canal BPPV, that she subsequently popularized with an online video 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 (actually 45 deg), and then back to sitting upright. Biomechanically, this is another way to get a series of positions similar to the Epley maneuver. The trick of it is that instead of putting the head far backward (as in the Epley), one puts the head very far forward.

We have attempted to recreate the positions above using the Teixido BPPV viewer -- it uses anatomically correct positions.

In position "A", the head is 45 degrees back. We are trying to treat the R PC (on the left above). This is a good position as the yellow otoconia go about 1/3 of the way around the posterior canal, no matter which ear. This posion should not affect debris in the AC (the blue ones), but might move debris around in the lateral canal (the red ones). The PC is green.

In position B, the head is upside down. Again a good position. For either ear, the otoconia should be about 2/3 around the canal. Almost done already. Note if there was debris in the anterior canal, this might get it about half-way around the canal.

In position C, the head, while upside down, is turned to 45 deg to the right around the carried head axis. This should do nothing at all with respect to moving around debris in either posterior canals. It does no harm, and one shouldn't be dizzy.

In position D, the trunk (with head on it), is moved to rotate the head 90 degrees up from it's carried position. This should help the otoconia move further into the area of the common crus, where it might enter the anterior canal. Again, a good position. This position would not be so good for the anteior canal (the blue one), as otoconia might just go back to where they came from.

Position E is back to upright. Otoconia should fall out of the AC if present, and hopefully fall into the common crus and vestibule. This is also a point where debris might fall back into the posterior canal.

Bottom Line:

Overall, the Foster maneuver is a logical maneuver from the biomechanics, and should be as good as the Epley or Semont.

The Foster maneuver appears to require a bit more strength and flexibility to perform than the self-Epley maneuver reported by Radke (1999), 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. Other problems might be insufficient flexibilty to attain position A (with the head far back), or danger of falling over when one is dizzy in positions B-E.

One might wonder if the Foster maneuver, which looks pretty close to the head-forward maneuver for anterior canal BPPV, might not also treat anterior canal BPPV. The answer is no, the head is in the wrong place during position D.

Dr. Foster, in her published article (2012), stated that her half-sumersault maneuver is not as effective as the regular Epley maneuver, but patients prefer it anyway. Although it looks like a good arm workout, 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), as they all put the ear through very similar positions.

References

Foster CA, Ponnapan A, Zaccaro K, Strong D. A comparison of two home exercises for benign positional vertigo: Half somersault versus Epley Maneuver. Audiol Neurotol Extra 2012;2:16-23
Furman, J. M. and T. C. Hain (2004). ""Do try this at home": self-treatment of BPPV." Neurology63(1): 8-9.
Radtke, A., et al. (1999). "A modified Epley's procedure for self-treatment of benign paroxysmal positional vertigo." Neurology 53(6): 1358-1360.
Radtke, A., et al. (2004). "Self-treatment of benign paroxysmal positional vertigo: Semont maneuver vs Epley procedure." Neurology 63(1): 150-152.