The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo

Diagnosis and treatment of benign paroxysmal positional vertigo in common clinical practice

Aim. To analyze typical medical practice in managing patients with benign paroxysmal positional vertigo (BPPV). Subjects and methods. 33 patients (5 men and 28 women; mean age, 58 years) with BPPV who had been referred for consultation to the Medical Diagnostic Department, Clinic of Nervous Diseases, I.M. Sechenov First Moscow State Medical University, regarding for vertigo, were examined. Information about the disease before visiting the clinic, such as the duration of vertigo, its pattern, and triggers, previously established diagnoses, prescribed treatment and its efficacy, concomitant diseases, was analyzed. Results. BPPV was not timely diagnosed in 93.9% of cases. The cause of vertigo was most commonly mistakenly assumed to be cerebrovascular disease (66.6%) and cervical spine pathology (15.1%). During a primary examination, none of the patients underwent positional tests (otoneurological examination) that formed the basis for the diagnosis of BPPV. Alternatively, 90.3% of cases underwent instrumental examination: magnetic resonance imaging of the brain, X-ray of the cervical spine, and ultrasonic duplex scanning of the brachiocephalic arteries. Ineffective diagnosis led to the choice of nonoptimal treatment tactics: instead of therapeutic repositioning maneuvers (RM), the patients received therapy with drugs, such as various vasoactive agents (84.8%), nootropic and chondroprotective drugs (12%), or muscle relaxants (9.1%). After BPPV was detected, all patients underwent curative RM, which resulted in regression of the disease. One-year follow-up of the patients showed that the therapeutic effect of RM persisted. Conclusion. Lack of effective and timely diagnosis of BPPV reflects physicians’ poor awareness that this condition is the most common cause of vestibular vertigo. The role of vascular and cervicogenic factors in the development of vertigo is overestimated. Most patients with BPPV undergo unreasonable examinations and receive ineffective treatment. It is necessary to raise awareness of BPPV among of physicians and to set up specialized centers for the management of patients with dizziness.

The Epley (canalith repositioning) manoeuvre for benign paroxysmal positional vertigo

BACKGROUND

This is an update of a Cochrane Review first published in The Cochrane Library in Issue 1, 2002 and previously updated in 2004 and 2007.Benign paroxysmal positional vertigo (BPPV) is a syndrome characterised by short-lived episodes of vertigo in association with rapid changes in head position. It is a common cause of vertigo presenting to primary care and specialist otolaryngology clinics. Current treatment approaches include rehabilitative exercises and physical manoeuvres, including the Epley manoeuvre.

OBJECTIVES

To assess the effectiveness of the Epley manoeuvre for posterior canal BPPV.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 23 January 2014.

SELECTION CRITERIA

Randomised controlled trials of the Epley manoeuvre versus placebo, no treatment or other active treatment for adults diagnosed with posterior canal BPPV (including a positive Dix-Hallpike test). The primary outcome of interest was complete resolution of vertigo symptoms. Secondary outcomes were conversion of a 'positive' Dix-Hallpike test to a 'negative' Dix-Hallpike test and adverse effects of treatment.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We included 11 trials in the review with a total of 745 patients.Five studies compared the efficacy of the Epley manoeuvre against a sham manoeuvre, three against other particle repositioning manoeuvres (Semont, Brandt-Daroff and Gans) and three against a control (no treatment, medication only, postural restriction). Patients were treated in hospital otolaryngology departments in eight studies and family practices in two studies. All patients were adults aged 18 to 90 years old, with a sex ratio of 1:1.5 male to female.There was a low risk of overall bias in the studies included. All studies were randomised with six applying sealed envelope or external allocation techniques. Eight of the trials blinded the assessors to the participants' treatment group and data on all outcomes for all participants were reported in eight of the 11 studies. Complete resolution of vertigo Complete resolution of vertigo occurred significantly more often in the Epley treatment group when compared to a sham manoeuvre or control (odds ratio (OR) 4.42, 95% confidence interval (CI) 2.62 to 7.44; five studies, 273 participants); the proportion of patients resolving increased from 21% to 56%. None of the trials comparing Epley versus other particle repositioning manoeuvres reported vertigo resolution as an outcome. Conversion of Dix-Hallpike positional test result from positive to negative Conversion from a positive to a negative Dix-Hallpike test significantly favoured the Epley treatment group when compared to a sham manoeuvre or control (OR 9.62, 95% CI 6.0 to 15.42; eight studies, 507 participants). There was no difference when comparing the Epley with the Semont manoeuvre (two studies, 117 participants) or the Epley with the Gans manoeuvre (one study, 58 participants). In one study a single Epley treatment was more effective than a week of three times daily Brandt-Daroff exercises (OR 12.38, 95% CI 4.32 to 35.47; 81 participants). Adverse effects Adverse effects were infrequently reported. There were no serious adverse effects of treatment. Rates of nausea during the repositioning manoeuvre varied from 16.7% to 32%. Some patients were unable to tolerate the manoeuvres because of cervical spine problems.

AUTHORS' CONCLUSIONS

There is evidence that the Epley manoeuvre is a safe, effective treatment for posterior canal BPPV, based on the results of 11, mostly small, randomised controlled trials with relatively short follow-up. There is a high recurrence rate of BPPV after treatment (36%). Outcomes for Epley manoeuvre treatment are comparable to treatment with Semont and Gans manoeuvres, but superior to Brandt-Daroff exercises.

The evidence base for the evaluation and management of dizziness

OBJECTIVES

Dizziness presentations pose many clinical challenges. The objective of this study is to broadly summarize the evidence base that supports clinical decisions in dizziness presentations.

METHODS

MEDLINE (1966 to September 2007), Web of Science and The Cochrane Library were searched for articles with clinical relevance on topics concerning dizziness. Additional sources were also searched for clinical practice guidelines. The following information was abstracted from each article: year of publication, journal type, type of article and the topics of the article.

RESULTS

Of nearly 3000 articles identified, 1244 articles met the inclusion criteria. The most common article type was a case report or case series, followed by expert opinion or review articles, studies of medical tests and clinical trials. Meta-analyses and systematic reviews were found on benign paroxysmal positional vertigo and Meniere's disease, but only a few other topics. No clinical practice guidelines were found that focus specifically on dizziness.

CONCLUSIONS

The evidence base for the evaluation and management of dizziness seems to be weak. Future work to establish or summarize evidence in clinically meaningful ways could contribute to efforts to optimize patient care and health care utilization for one of the most common presenting symptoms.